Syphilitic hepatitis in HIV-infected patients: A report of 7 cases and review of the literature

Background. A recent resurgence of primary and secondary syphilis has been observed in certain population groups, particularly among persons infected with human immunodeficiency virus (HIV). Liver involvement is an infrequently recognized complication of early syphilis, with no previous reports among HIV-infected patients. Methods. We describe 7 cases of syphilitic hepatitis in HIV-positive individuals and review the literature. Results. At our institutions, all patients presented with a rash consistent with secondary syphilis. Each case was characterized by a conspicuous increase in serum alkaline phosphatase level (mean level +/- standard deviation, 905 +/- 523.6 IU/L) and milder elevations in serum transaminase levels. The mean CD4(+) absolute T cell count was 317 cells/mm(3), and the median rapid plasma reagin (RPR) titer was 1:128. There was a significant correlation between higher CD4(+) cell counts and the RPR titers (R = 0.93; P = .002). Symptomatic resolution and biochemical improvement, particularly a significant decrease in serum alkaline phosphatase levels (P = .02), occurred following antibiotic therapy. Conclusions. Hepatic dysfunction is not uncommon in HIV-infected persons and is attributable to multiple causes. In the appropriate clinical setting, syphilitic hepatitis is an easily diagnosed and reversible etiology of liver dysfunction. The recognition of this entity will prevent unnecessary evaluation of abnormal liver enzyme levels in HIV-positive patients.