![]() Syphilis has various well-recognized presentations. Over the same period, the number of primary and secondary syphilis cases, 35,000, increased to the highest number reported since 1991. In the United States, from 2017 to 2018, there were over 115,000 syphilis cases, according to the Centers for Disease Control and Prevention. Syphilis cases have been increasing at a worrisome rate. Her transaminases, total bilirubin, and ALP continued trending downward, eventually reaching normal limits, along with a resolution of her symptoms. In addition to symptomatic management, the patient received her second and third doses of penicillin. Staining for spirochetes was not performed at that time. Immunostaining for Helicobacter pylori was negative. Biopsy showed evidence of erosive gastritis in the gastric antrum. The largest gastric ulcer was 4 mm (Figure (Figure1) 1) while the largest duodenal ulcer was 7 mm. Esophagogastroduodenoscopy (EGD) was performed and demonstrated multiple nonbleeding duodenal and gastric ulcers with moderate inflammation and erythema. Extensive workup for gastritis was performed at that time. However, she returned two days later with similar symptoms, notably epigastric pain, nausea, and vomiting. The patient was discharged after receiving her first dose of penicillin and after reporting improvement in abdominal pain. Three days following her first dose of penicillin there was marked improvement in her labs as follows: ALP 169 U/L, total bilirubin 1.1 mg/dL, AST 14 U/L, ALT 42 U/L, and WBC 13.40 K/µL. ![]() After the first dose of penicillin, total bilirubin, ALP, and other liver enzymes began to improve. A liver biopsy was not performed.įollowing her positive syphilis test, the patient was treated with three doses of intramuscular penicillin G 2.4 million units. However, syphilis testing was positive with a rapid plasma reagin (RPR) titer of 1:32 (normal: nonreactive). Testing for human immunodeficiency virus, Epstein-Barr virus, and cytomegalovirus among other common viral infections was negative. She was negative for anti-nuclear, anti-smooth muscle, and anti-mitochondrial antibodies. Duplex ultrasound of mesenteric vessels was unremarkable.The patient tested negative for hepatitis A, B, and C. A hepatobiliary iminodiacetic acid scan displayed patent cystic and common bile ducts. Abdominal ultrasound and CT showed cholelithiasis without gallbladder wall thickening, pericholecystic fluid, or other signs of acute cholecystitis. Initial laboratory tests were significant for a white blood cell (WBC) count of 20.55 K/µL, alanine aminotransferase (ALT) of 115 U/L, aspartate transaminase (AST) of 68 U/L, alkaline phosphatase (ALP) of 279 U/L, and total bilirubin of 4.1 mg/dL. She had erythematous, swollen, and tender proximal and distal interphalangeal joints of the hands bilaterally. There was no hepatosplenomegaly or ascites. The patient had epigastric and right upper quadrant abdominal tenderness. Oral thrush and erythema were found on oropharyngeal examination. The patient notably had scleral icterus but no jaundice of the skin or rashes. Upon initial examination, she was hemodynamically stable, but tachycardic with a pulse of 123 beats per minute and afebrile. The patient denied usage of alcohol, herbal supplements, and medications including acetaminophen, nonsteroidal anti-inflammatory drugs, and proton pump inhibitors. She was sexually active with only one male partner over the past year and was not using barrier protection. The patient had a medical history of well-controlled asthma. ![]() She also complained of dark urine and diffuse myalgias and arthralgias. A 27-year-old female presented to the hospital with a three-day history of fever, chills, vomiting, and right upper quadrant pain.
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