Irphan Gaslightwala et al describe a 59-year-old man with a history of chronic lymphocytic leukemia; 6 months of persistent fevers, chills, and night sweats; and loss of 50 pounds.
However, biopsy and cytology analyses of the lesions showed no signs of malignancy.
Endoscopic ultrasound revealed multiple well-demarcated hypoechoic lesions. During a follow-up visit, the patient was found to have developed a rash that was limited to his palms and soles, and the sclera of his eye was red.
Based on laboratory test results and detection of spirochetes in the liver, the patient was diagnosed with gummatous syphilis—a type of tertiary syphilis caused by a delayed hypersensitivity reaction to the Treponema pallidum organism. The lesions observed were hepatic gummas (granulomas with a central area of necrosis surrounded by mononuclear, epithelioid, and giant cells); and the patient also had syphilitic episcleritis. He was treated with intravenous penicillin G.
The authors explain that gummas can appear on CT images as low-attenuation lesions with slight peripheral enhancement and rare calcifications. This appearance can be confused with that of metastates or abscesses.
Gaslightwala et al say it is therefore important for gastroenterologists to remain informed about syphilis, which is increasing in incidence. Tertiary syphilis occurs years after the initial infection, and spirochetes only rarely are identified in pathology samples. Diagnosis therefore requires serologic tests and analyses of response to therapy.