Dermatology: Practical and Conceptual DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Letter | Dermatol Pract Concept 2013;3(4):13 53 Case A 25-year-old male patient without significant personal or fam- ily medical history was admitted to the Dermatology Depart- ment suffering from primary syphilis. He was a heterosexual man and the infective sexual contact was approximately five weeks before hospitalization. He started the specific treatment with benzathine penicillin 2.400.000 IU followed by the dis- charge from the hospital, as he tolerated the first doses of peni- cillin very well, without Jarish-Herxheimer reaction following the initiation of the antibiotic. He received advice to continue the treatment with penicillin as an outpatient. After ten days the patient returned to the emergency department having an altered general condition, low-grade fever, loss of appetite, vomiting, oliguria, generalized edema, and lumbar pain. During the medical examination we noticed pale skin, renal type generalized edema, dull pain radiating to the flanks, tender kidneys on palpation, and left side inguinal lymphadenopathy. The urine volume during 24 hours was of 900 ml. We established the diagnosis of acute glomerulone- phritis with nephrotic syndrome [1]. The investigations revealed the following abnormalities: erythrocyte sedimentation rate 100 mm/h, fibrinogen 720 mg/ dl, positive reactive C protein; hypoproteinemia 5 g/dl; hyper- cholesterolemia 371 mg/dl; hyperlipidemia 1,168 mg/dl; renal impairment: urea 64 mg/dl and creatinine 1.87 mg/dl; hepatic cytolysis: aspartate transaminase 77 IU/L; alanine transami- nase 75 IU/L with increase of alkaline phosphatase 324 IU/L; A rare case of syphilis associated with renal and hepatic involvement Alin Laurentiu Tatu1, Maria Popescu2, Radu Rotarescu3, Sanda Dorina Popescu4 1 Faculty of Medicine and Pharmacy, Dunarea de Jos University, Galati, Romania 2 Internal Medicine Department, Emergency Hospital of Galati, Galati, Romania 3 Dermatology Department, Mid Staffordshire NHS Foundation Trust, Stafford, Staffordshire, United Kingdom 4 Dermatology Department, University Hospital of North Stafffordshire, Staffordshire, United Kingdom Key words: syphilis, membranous glomerulonephritis, nephrotic syndrome, hepatic involvement Citation: Tatu AL, Popescu M, Rotarescu R, Popescu SD. A rare case of syphilis associated with renal and hepatic involvement. Dermatol Pract Conc. 2013;3(4):13. http://dx.doi.org/10.5826/dpc.0304a13. Received: June 4, 2013; Accepted: July 1, 2013; Published: October 31, 2013 Copyright: ©2013 Tatu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Dr. Alin Laurentiu Tatu, Faculty of Medicine and Pharmacy Dunarea de Jos University, Strada AL.I.CUZA NR 39 Galati, Jud Galati COD 800101,Romania. Tel. + 0336 130 217. Email: dralin_tatu@yahoo.com We present an unusual case of syphilis that despite starting treatment with penicillin has evolved with renal complications. Due to glomerulonephritis with nephrotic syndrome the case required shared care between the renal physician and dermatologist. Doctors of different specialties need to keep in mind that early syphilis can have visceral involvement and patients might need prompt, specific therapeutic intervention. ABSTRACT 54 Letter | Dermatol Pract Concept 2013;3(4):13 cific syphilis serological tests were also improved, VDRL ++ (dilution1/2) and TPHA +++. After the patient was discharged from the hospital, he continued the treatment with benzathine penicillin 2.400.000 IU/week (for two weeks) and prednisone in reducing doses with regular monitoring of the urine and renal tests. At 2-month follow-up the proteinuria was absent. At 6-month follow-up VDRL was negative and TPHA ++ had improved, remaining positive. The serological and urine tests monitoring continued every three months in the first year and every six months in the second year. After two years TPHA ++ was still positive but VDRL and RPR remained negative. Discussion This rare case is interesting from the nephrologic point of view due to the rare systemic involvement of the kidneys during the syphilis infection, leading to the presentation of membranous glomerulonephritis [1,2,3]. For dermatologists, it is important to keep in mind the possibility of early and multiple visceral involvement of syphilis that sometimes can be severe but with a rapid favorable evolution with support- ive treatment [4]. References 1. Mora Mora MT, Gallego Domínguez MS, Castellano Cerviño MI, et al. Membranous glomerulonephritis in a patient with syphilis. Nefrologia. 2011;31(3):372-3. 2. Hunte W, al-Ghraoui F, Cohen RJ- Secondary syphilis and the nephrotic syndrome. J Am Soc Nephrol. 1993;3(7):1351-5. 3. Soehardy Z, Hayati SN, Rozita M, et al. Subclinical acquired syphilis masquerading as membranous glomerulonephritis. Med J Malaysia. 2006;61(4):484-6. 4. Koenig M, Duband S, Thibaudin D, Cathébras P. Rash and ne- phrotic syndrome: consider syphilis. Presse Med. 2005;4;34(9):657. circulating immune complexes 42 IU/L. The urine examination showed proteinuria 12 g/24h, microscopic hematuria with dysmorphic red blood cells, and cylindruria hyaline cylinders. The HIV, and hepatitis B and C screenings were negative. Due to the recent history of syphilis infection, a derma- tologic consultation was requested. Examination showed in the coronal sulcus presence of ulceration with indurated basis and satellite inguinal lymphadenopathy. The clinical examination was completed by the specific serological inves- tigations that were intensely positive: VDRL++++ (venereal disease research laboratory) (dilution 1/4), positive RPR (rapid plasma reagin), and TPHA++++ (treponema pallidum hemagglutination assay). The ophthalmologic and the neuro- logic examinations showed no change. Ultrasound revealed moderate hepatomegaly, ascites and kidneys increased in size. The final and reviewed diagnosis was made: Early sec- ondary syphilis with the persistence of the primary chancre, associated with syphilitic glomerulonephritis with nephrotic syndrome and hepatic involvement [1,2]. Since the secondary stage of syphilis starts around ninth week after infection and as our patient had visceral involvement, although no exan- themas or enanthemas had been found clinically, we felt that this was an early stage of secondary syphilis and that the per- sistence of ulcus durum would be consistent with this stage. Treatment with penicillin 2.400.000 IU/day was started with oral steroid therapy, prednisone 1 mg/kg/day, and cor- rection of the hypoproteinemia (human albumin perfusions) and diuretics (furosemide and spironolactone) were initiated. After the first 10 days of treatment we noticed a favorable clinical progress: improvement of the general condition, the disappearance of the low-grade fever and of the edema, the normalization of urine volume, the remission of lymphade- nopathy, and the epithelialization of the primary chancre. At the time of discharge from the hospital we noted proteinuria < 0.5 g/24h without hematuria, the acute renal impairment had disappeared, hepatic tests had settled, and that the spe-