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We present a case of a 34-year-old male on pre-exposure prophylaxis (PrEP) for HIV with prior negative syphilis screening presenting with epigastric pain and constitutional symptoms. He endorsed anal sex practices with a monogamous male partner. Laboratory testing revealed elevated aminotransferases, alkaline phosphatase, and bilirubin, along with positive smooth muscle antibodies. A rapid plasma reagin and treponemal antibodies were reactive. He was treated with benzathine penicillin G with resolution of liver function derangements and autoimmune titer elevations.<\/jats:p>","DOI":"10.1093\/milmed\/usaf631","type":"journal-article","created":{"date-parts":[[2025,12,24]],"date-time":"2025-12-24T13:03:28Z","timestamp":1766581408000},"page":"e2194-e2196","source":"Crossref","is-referenced-by-count":1,"title":["The Great Imitator: Syphilitic Hepatitis Presenting as a Mimic to Autoimmune Liver Disease"],"prefix":"10.1093","volume":"191","author":[{"given":"John","family":"Stanavage","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, Brooke Army Medical Center , San Antonio, TX 78234,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jared S","family":"Magee","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Walter Reed National Military Medical Center , Bethesda, MD 20814,","place":["United States"]},{"name":"Uniformed Services University of the Health Sciences , Bethesda, MD 20814,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adam M","family":"Tritsch","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Walter Reed National Military Medical Center , Bethesda, MD 20814,","place":["United States"]},{"name":"Uniformed Services University of the Health Sciences , Bethesda, MD 20814,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,1,22]]},"reference":[{"key":"2026090403532596500_usaf631-B1","first-page":"1132","volume-title":"Harrison\u2019s Principles of Internal Medicine","author":"Lukehart","year":"2015","edition":"19th ed"},{"key":"2026090403532596500_usaf631-B2","first-page":"269","volume-title":"Schaechter\u2019s Mechanisms of Microbial Disease","author":"Ebright","year":"2013","edition":"5th"},{"key":"2026090403532596500_usaf631-B3","volume-title":"Sexually Transmitted Infections Surveillance, 2023","author":"Centers for Disease Control and Prevention","year":"2025"},{"key":"2026090403532596500_usaf631-B4","first-page":"379","volume-title":"Robbins and Cotran Pathologic Basis of Disease","author":"McAdam","year":"2015","edition":"9th"},{"key":"2026090403532596500_usaf631-B5","doi-asserted-by":"publisher","first-page":"e100","DOI":"10.1086\/425501","article-title":"Syphilitic hepatitis in HIV-infected patients: a report of 7 cases and review of the literature","volume":"39","author":"Mullick","year":"2004","journal-title":"Clin Infect Dis"},{"key":"2026090403532596500_usaf631-B6","doi-asserted-by":"publisher","first-page":"867","DOI":"10.5858\/arpa.2014-0123-RA","article-title":"Hepatic granulomas: a review with emphasis on infectious causes","volume":"139","author":"Lamps","year":"2015","journal-title":"Arch Pathol Lab Med"},{"key":"2026090403532596500_usaf631-B7","doi-asserted-by":"publisher","first-page":"604794","DOI":"10.1155\/2014\/604794","article-title":"Hepatic lesions with secondary syphilis in an HIV-infected patient","volume":"2014","author":"Solari","year":"2014","journal-title":"Case Rep Med"},{"key":"2026090403532596500_usaf631-B8","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1186\/s12876-019-1112-z","article-title":"Syphilitic hepatitis: a case report and review of the literature","volume":"19","author":"Huang","year":"2019","journal-title":"BMC Gastroenterol"},{"key":"2026090403532596500_usaf631-B9","doi-asserted-by":"publisher","first-page":"79","DOI":"10.1007\/978-1-4613-0347-3_4","volume-title":"Microorganisms and \u00adAutoimmune Diseases. 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