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Duodenal and liver lesions in an adult with generalised weakness
  1. David Szafron1,
  2. Hyun-seok Kim1,2,
  3. Christie G Turin1,
  4. Eduardo Benzi3,
  5. Natalia Khalaf1,2,4,
  6. Ruben Hernaez2,4,5
  1. 1Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
  2. 2Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
  3. 3Department of Pathology, Baylor College of Medicine, Houston, Texas, United States
  4. 4Gastroenterology and Hepatology, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
  5. 5Houston VA Health Services Research and Development Center of Excellence, Michael E Debakey Veterans Affairs Medical Center, Houston, Texas, United States
  1. Correspondence to Dr David Szafron, Baylor College of Medicine, Houston, TX 77030-3411, USA; dszafron{at}bcm.edu

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Clinical presentation

A 73-year-old man with a history of heart failure and hypertension presented with a several-week history of generalised weakness, anorexia, 5 kg weight loss, intermittent small volume hematochezia and right upper quadrant abdominal pain. He denied fever, chills, dysphagia, nausea, vomiting, diarrhoea and constipation. He had no previous endoscopy or colorectal cancer screening.

His admission vital signs were normal. He was anaemic (haemoglobin 8.6 g/dL reference 12–18 g/dL), with mean corpuscular volume 83 (81–100 fL/cell), ferritin 321.9 (11–336 ng/mL), alkaline phosphatase 174 (38–127 IU/L), albumin 2.4 (3.5–4.9 g/dL), total bilirubin 0.8 (0.2–1.2 mg/dL) and aspartate aminotransferase/alanine aminotransferase 28/21 (10–40 U/L, 7–56 U/L). Serological tests for hepatitis and HIV were negative. RPR was negative 1 month previously. CT imaging with intravenous contrast (figure 1) revealed six target-like liver lesions (0.7 to 1 cm) with peripheral arterial enhancement and several enlarged coeliac lymph nodes (largest 0.8 cm). Due to anaemia/hematochezia, upper and lower endoscopy were performed. His oesophagogastroduodenoscopy showed a 1 cm elevated round lesion with clear margins and depressed centre with no clear ulceration in the duodenum (figure 2), and biopsy of the lesion was obtained. Colonoscopy was normal. PET/CT showed several areas of FDG-avid uptake in the liver (figure 1) and retroperitoneal lymph node enhancement. Liver biopsy was obtained.

Figure 1

Venous (A) and arterial (B) phase CT image and 18F-FDG PET (C).

Figure 2

White-light and narrow-band imaging of duodenal lesion on oesophagogastroduodenoscopy.

Question

What is the most likely diagnosis?

Discussion

Liver biopsy showed a dense population of S100-positive spindle cells in nests and fascicles with dense inflammatory infiltrate, abscess formation and focal granulomata (figure 3). The immunohistochemical profile was not consistent with vascular, hepatocellular or melanocytic neoplasms. Stains for acid-fast bacillus and fungal organisms were negative. An initial diagnosis of inflammatory pseudotumour was rendered. Duodenal biopsy showed severe acute and chronic mucosal inflammation, but no Helicobacter pylori. He was discharged but readmitted after 4 days with fever (temperature 39°C) and leucocytosis (white blood cells 16 (x10ˆ9/L) with 86% neutrophils). Rapid plasma reagin (RPR) was positive (1:64) with confirmation by microhemagglutination assay for Treponema pallidum antibodies. Steiner stain of the liver (figure 4) and duodenal biopsies showed spirochetes and he was diagnosed with secondary syphilis. On learning the diagnosis, the patient admitted recent oral sexual behaviour with one female partner but no high-risk sexual behaviours. Follow-up CT 2 weeks after a 3-week course of penicillin injections showed interval decrease in the size of his liver lesions and resolution of lymphadenopathy with complete resolution of symptoms and an expectation of full recovery.

Figure 3

H&E stain showing focal granulomatous inflammation.

Figure 4

Steiner treponemal stain.

This case describes a now rare manifestation of secondary syphilis presenting as liver and duodenal lesions. GI manifestations typically appear as mucosal oedema, erosions, superficial ulceration, nodularity or hypertrophy of gastric folds that are most often reported in the stomach but may also be present in the duodenum.1 2 Direct infection of the mucosal surface by treponemal organisms is the mechanism for lesion formation as seen in figure 4. Inflammatory pseudotumours of the liver are another rare manifestation of secondary syphilis.3 4 Given recent CDC data showing a resurgence in the incidence of syphilis, non-specific complaints with systemic manifestations within the GI tract should prompt a thorough sexual history and a low threshold for serological testing for syphilis.5

Acknowledgments

We thank Dr David Y Graham for his support.

References

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Footnotes

  • Contributors DS performed background research and assisted in drafting and reviewing the manuscript, as well as in drafting reviewer responses. DS submitted the finalised work. H-sK performed background research and assisted in drafting and reviewing the manuscript. CGT assisted in drafting and reviewing the manuscript, as well as drafting reviewer responses. EB provided discussion of pathology and assisted in drafting and reviewing the manuscript. NK assisted in drafting and reviewing the manuscript. RH assisted in drafting and reviewing the manuscript, as well as in drafting reviewer responses. RH assisted in submitting the finalised work.

  • Funding This material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

  • Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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