A case of secondary phase of syphilis possibly associated with syphilitic hepatitis

A 68-year-old man presented to our hospital with a generalized non-pruritic red rash. He was taking 4 different oral medications, including antibiotics prescribed by his local physician for sore throat from 2 weeks before. Medical examination revealed red papules on his entire body, including his palms, redness and swelling of the pharynx, soft palate enanthema, and enlarged cervical lymph nodes. No rash was found on the external genitalia or anus. A drug eruption was most suspected. Blood test revealed biliary enzyme-dominant liver dysfunction. Of the hepatitis viral markers, only hepatitis B had an already-infected pattern, while other hepatitis viral markers and antinuclear and antimitochondrial antibodies were absent. Abdominal CT revealed no organic hepatobiliary disease. Syphilis serum reaction was strongly positive, and detailed questioning revealed a history of sexual intercourse with an unspecified number of partners. He was diagnosed as having secondary syphilis. The generalized rash was diagnosed as syphilis papulosa, while the soft palate enanthema was thought to be syphilitic angina. Pathohistology of the abdominal papules revealed perivascular inflammatory cell infiltration in the upper dermis, consistent with syphilis. The skin rash started to disappear, and the syphilis serological antibody values immediately declined after initiating oral amoxycillin administration. The liver dysfunction also started to improve, however, the hepatobiliary enzyme levels plateaued, so the amoxycillin dose was increased and liver supporting therapy was added to the treatment regimen. Immediately the liver function normalized. This clinical course suspected that not only syphilitic hepatitis was together developed, but drug-induced liver injury was associated with the secondary phase of syphilis.With the current rapid increase in the incidence of syphilis in Japan, it must be considered when patients present with symptoms such as sore throat, rash, swollen lymph nodes, and liver dysfunction.