Clinical correlation between Treponema pallidum infection and agenesis of the gallbladder

LETTER TO THE EDITOR

Clinical correlation between Treponema pallidum infection and agenesis of the gallbladder

Gianluca Stanzani, Edoardo Virgilio^*; Marco Badiali

Department of General Surgery Unit 2, Faculty of Medicine and Psychology, University of Rome "La Sapienza", St. Andrea Hospital

Dear Editor,

A 40-year-old previously healthy woman experienced a four-week history of recurrent postprandial epigastric pain. Following medical investigation, the patient was diagnosed with an ultrasound-documented cholelithiasis, as well as syphilis, since the specific blood tests (venereal disease laboratory research and Treponema pallidum hemagglutination assays) were positive. After a three-week course of intramuscular benzathine penicillin, the patient, free from peritoneal signs, was scheduled for laparoscopic cholecystectomy at our surgical department. During the operation, there was no evidence of the gallbladder on the inferior side of the liver. Therefore, after inspecting the liver and its ligaments, gallbladder heterotopy was excluded and the intraoperative diagnosis of agenesis of the gallbladder was made. The day after the intervention, a magnetic resonance cholangiopancreatography confirmed the gallbladder agenesis and excluded further biliary abnormalities or choledocholithiasis. Hence, the patient was discharged. After two years and four months of follow-up, she remains asymptomatic.

Through the centuries, syphilis has proven to affect any organ of the human body, including the hepato-biliopancreatic system. In fact, late and congenital syphilis may determine hepatitis and obstructive jaundice through the development of hepatic or cephalopancreatic gumma and hepar lobatum, which is the syphilitic cirrhosis of the liver, while early syphilis may cause periportal inflammation.^1,2 Conversely, congenital agenesis of the gallbladder (CAGB) is a very rare condition (0.01%-0.04%) that is one of the numerous disorders affecting the gallbladder. Usually asymptomatic, it sometimes manifests with dyspepsia, biliary colic, or jaundice.³ It is known that ultrasound can misdiagnose such an anomaly, thus rendering the diagnosis of CAGB without a laparoscopic intervention somewhat difficult. ⁴ T he pertinent literature consists of approximately 400 cases of CAGB; none of these were associated with syphilis. Although there is no certain explanation as to why and how a previously dormant CAGB became symptomatic after a Treponema pallidum infection, our patient's long asymptomatic stage (28 months with no biliary colic) following specific antibiotic treatment is a relevant fact, and prompts the speculation on a potentially underlying immunologic mechanism. Given the unprecedented concurrence of these two conditions, this clinical dilemma could remain indefinitely unresolved.

Conflict of interest

All authors declare to have no conflict of interest.

Received 15 March 2012

Accepted 18 March 2012

Available online 7 September 2012

• 1. Haburchak DR, Davidson H. Anorectal lesions and syphilitic hepatitis. West J Med. 1978;128:64-7.
• 2. Sobel HJ, Wolf EH. Liver involvement in early syphilis. Arch Pathol. 1972;93:565-8.
• 3. Bittner 4th JG, Patterson GK. Agenesis of the gallbladder in a symptomatic adult. Am Surg. 2010;76:546-8.
• 4. Watemberg S, Rahmani H, Avrahami R, Nudelman IL, Deutsch AA. Agenesis of the gallbladder found at laparoscopy for cholecistectomy: an unpleasant surprise. Am J Gastroenterol. 1995;90:1020-1.

Publication Dates

• Publication in this collection
  17 Oct 2012
• Date of issue
  Oct 2012