[Tertiary syphilis with liver gummata].

Sonography revealed multiple echo-poor lesions in the liver of a 51-year-old man with nonspecific symptoms (fatigue, drop in performance, pressure sensation in the upper abdomen), increased blood sedimentation rate (68/110 mm) and evidence of cholestasis (gamma-GT 126 U/l, alkaline phosphatase 444 U/l, leucine-aminopeptidase 64 U/l). Under the diagnosis of liver metastases the primary tumour was looked for. These investigations and a fine-needle biopsy having proved unsuccessful, laparoscopy was performed. The biopsies so obtained showed whitish yellow, tight elastic structures indicating gummas of the liver in tertiary syphilis. Treponema-specific IgM antibodies in serum characterized active syphilis requiring treatment. Administration of antibiotics (penicillin 1 mega U daily i.m.; because of allergy replaced after four days by erythromycin 2 g daily for six weeks) resulted in complete normalization of all biochemical findings and, some time later, regression of the gummas. The patient has now been symptom-free for three years. This case illustrates the need even to-day of including syphilis in the differential diagnosis of unclear space-occupying lesions of the liver.