Outcomes of CSF spectrophotometry in cases of suspected subarachnoid haemorrhage with negative CT: two years retrospective review in a Birmingham hospital.

AIM: The aim of this study was to evaluate the adherence to current guidelines for the investigation of suspected subarachnoid haemorrhage and the prevalence and outcome of computed tomography (CT)-negative aneurysmal subarachnoid haemorrhage. DESIGN: A retrospective review in a single large tertiary referral centre. SUBJECTS: A total of 796 patients, aged 16-90 years, who underwent lumbar puncture (LP) for suspected subarachnoid haemorrhage (SAH) following a negative or equivocal CT scan between January 2012 and November 2013 (23 months). METHODS: Xanthochromia reports were obtained using the hospital's department of biochemistry database and clinical data for these patients were reviewed using patient notes. RESULTS: Of 796 CSF reports reviewed, 728 (91%) were negative for xanthochromia, 31 (4%) were positive and 37 (5%) were equivocal. Only 2 out of the 31 patients with positive spectrophotometry results were subsequently found to have an underlying aneurysm on CT angiography. A further 9 out of these 31 patients underwent digital subtraction angiography, with no cerebral aneurysms being detected. Amongst the 37 patients with equivocal xanthochromia reports, 13 underwent CT angiography and only 1 cerebral aneurysm was detected. CONCLUSIONS: In patients with clinically suspected SAH but who have negative or questionable CT findings, CSF analysis is likely to be negative in the vast majority of cases, which was 91% in our series. In patients yielding positive or equivocal CSF results the likelihood of an aneurysm being detected is low, amounting to three out of 68 or approximately one in 23 (approximately 4%). Overall in suspected SAH cases where CT scan has been negative, the rate for the detection of cerebral aneurysm is three out of 796 cases (0.4%).

Family tracing to identify patients with familial hypercholesterolaemia: the second audit of the Department of Health Familial Hypercholesterolaemia Cascade Testing Project.

BACKGROUND: Family tracing is a method recognized to find new patients with familial hypercholesterolaemia (FH). We have implemented family tracing led by FH Nurses and have determined acceptability to patients, feasibility and costs. METHODS: Nurses were located at five National Health Service (NHS) Trusts; they identified FH patients and offered them family tracing. Responses and test results were recorded on a database and summarized on a family pedigree. RESULTS: The majority ( approximately 70%) of index cases participated; the proportion was lower when patients had been discharged from the clinics and in metropolitan areas. On average, 34% (range 13-50%) of relatives lived outside the catchment area of the clinics and could not attend the nurse-led FH clinics. Of the previously untested relatives, 76% who lived in the catchment area of the clinic came forward to be tested. One-third of the relatives who came forward for testing were children

Are patients with familial hypercholesterolaemia well managed in lipid clinics? An audit of eleven clinics from the Department of Health Familial Hypercholesterolaemia Cascade Testing project.

BACKGROUND: Familial hypercholesterolaemia (FH) is an autosomal co-dominant disorder which is relatively common, leads to high levels of LDL-cholesterol and if untreated to early coronary heart disease. An audit of current practice at National Health Service Trusts in England was undertaken to determine whether FH patients meet the diagnostic criteria for FH; are being offered appropriate advice and treatment; and to what extent their families are contacted and offered testing for the disorder. METHODS: Medical records of known FH patients (over 18 years of age and diagnosed before 31 December 2003) were accessed to obtain information on diagnosis, treatment and family tracing. RESULTS: The records of 733 FH patients were examined, 79% met the UK 'Simon Broome' register criteria for the diagnosis of definite or possible FH. Analyses showed that patients were usually offered appropriate advice and treatment, with 89% being on a statin. However, the audit indicated a high variability in family tracing between the sites, with significant differences in the frequency of inclusion of a family pedigree in the notes (range 1-71%, mean 35%); the general practitioner (GP) being advised that first-degree relatives should be tested (range 4-52%, mean 27%); and the proportion of relatives contacted and tested (range 6-50%, mean 32%). CONCLUSION: FH patients are well cared for in lipid clinics in England, are being given appropriate lifestyle advice and medication, but an increase in recording of LDL-cholesterol levels may lead to improvements in their management. Practice in family tracing appears to vary widely between clinics.

Serum lipid and lipoprotein profile of patients with glycogen storage disease types I, III and IX.

With current dietary therapy, life expectancy in glycogen storage disease (GSD) has improved considerably and more children reach adulthood. Notwithstanding intensive dietary therapy, moderate to severe hyperlipidaemia is still observed frequently. There is limited information about the type and extent of hyperlipidaemia. We studied the lipid profile in 20 patients, aged 8-54 years, of the three (types I, III and IX) most common forms of adult GSD. Hyperlipidaemia was shown to be type-specific, affecting predominantly patients with GSD type Ia, who showed marked combined hypercholesterolaemia and hypertriglyceridaemia. By contrast, a heterogeneous distribution of HDL was found in patients with GSD I and III. There was no significant difference in Apo Al and Apo B concentrations between groups. In addition, mass measurements of the fractions of VLDL1, VLDL2 and IDL were raised in all patients with GSD Ia by comparison with all other patients with GSD. Patients with GSD type Ia have lipid concentrations and individual mass measurements that are consistent with ranges found in patients who have a significant risk of atherosclerosis. Accumulated evidence, however, suggest GSD type Ia patients do not have an increased risk of atherosclerotic cardiovascular disease (CVD) but the reason remains unknown. Intervention to reduce their lipid levels could therefore be on the basis of seeking to prevent the risk of pancreatitis rather than that of CVD.

Insulin and C-peptide levels after oral and intravenous glucose. Contribution of enteroinsular axis to insulin secretion.

Peripheral venous plasma insulin and C-peptide concentrations were measured in 10 healthy volunteers, given either 100 g glucose orally or sufficient intravenous (i.v.) glucose to produce similar glucose concentrations when measured in arterialized blood. The incremental areas under both the insulin and C-peptide curves were significantly increased after oral as compared with i.v. glucose administration by 229% and 138%, respectively. Arteriovenous plasma glucose differences were higher after oral glucose administration and were positively correlated with plasma insulin concentrations. Plasma gastric inhibitory polypeptide (GIP) and insulin concentrations were measured in seven healthy volunteers given oral glucose loads ranging from 25 to 200 g. Both the magnitude and duration of the GIP and insulin responses after oral glucose ingestion were dose dependent. These results suggest that the main cause of the increase in peripheral insulin levels after large oral carbohydrate loads is augmented insulin secretion rather than reduced hepatic extraction, indicating the possibility that an enteroinsular factor does exist, in accordance with the "incretin" concept. They also emphasize the need to document both arterial and venous glucose concentrations for the correct interpretation of experiments investigating glucose homeostasis.

Metabolic effects of cyclosporin A and FK 506 in liver transplant recipients.

Postoperative diabetes is a reported feature of the immunosuppressive agents cyclosporin A and FK 506. To date, however, no randomized comparative studies of the metabolic effects of these two drugs have been performed. In this study, extended (300 min) oral glucose tolerance tests (75 g) were performed a median of 8 mo (range 5-9 mo) postoperatively in 20 clinically stable liver transplant recipients randomly allocated to maintenance immunosuppression with either cyclosporin A (with or without azathioprine) or FK 506. None of the patients had clinically overt diabetes antedating transplantation. To avoid the confounding effects of corticosteroids, prednisolone was withdrawn at least 6 wk beforehand in each case. Ten healthy volunteers matched for age and body mass index served as control subjects. Overall blood glucose concentrations after the glucose challenge were significantly elevated in both groups of transplant recipients (P < 0.005 and P < 0.001 for cyclosporin A and FK 506 treatment groups, respectively) compared with the healthy control subjects. Venous whole-blood glucose concentration (mean +/- SE) 120 min after the ingestion of oral glucose was significantly higher in both the cyclosporin A (P < 0.05) and FK 506 (P < 0.01) treatment groups compared with the control subjects (6.6 +/- 0.5 vs. 8.8 +/- 0.9 vs. 5.2 +/- 0.2 mM, respectively). According to 1985 WHO criteria, 4 of 10 cyclosporin A-treated patients had impaired glucose tolerance, whereas 3 of 10 FK 506-treated patients had diabetes with 4 others having impaired glucose tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired copper deficiency following prolonged jejunostomy feeds.

A 19-year-old man who developed extensive oesophageal lye (Alkali) stricture and received long-term enteral nutrition (eight months) with a jejunostomy tube developed macrocytic anaemia (Hb: 41 g/L) with leucopenia (white blood cell [WBC]: 3.0 x 10(9)/L). The patient's serum vitamin B12, folate, iron and liver function tests were normal. Bone marrow examination revealed gross erythroid hyperplasia and cytoplasmic vacuolization of erythroid and myeloid elements. Further investigations revealed low serum copper (0.3 micromol/L) and ceruloplasmin concentrations (<30 mg/L) with marginally low normal serum concentration of red cell peroxidase (13 U/gHb), establishing the diagnosis of copper deficiency anaemia. The anaemia and leucopenia responded intermittently to intravenous copper therapy, but the serum copper concentration dropped when intravenous copper therapy was withdrawn. Enteral jejunostomy copper supplementation failed to maintain adequate serum copper concentrations. After stabilizing the general condition of the patient, a pharyngo-gastric anastamosis was performed and normal oral diet commenced, which restored normal serum copper concentration. This case report suggests that copper supplements in the form of copper sulphate are not adequately absorbed when administered through a jejunostomy tube.

Investigation of low density lipoprotein subfractions as a coronary risk factor in normotriglyceridaemic men.

There is an increasing interest in low density lipoprotein (LDL) subfractions since some of them are associated with a higher risk for coronary artery disease (CAD). Small LDL particles are particularly atherogenic and more of those are produced in hypertriglyceridaemia. However, high triglyceride concentrations are not the only explanation for the predominance of small LDL particles and other influences, including genetic factors, are also responsible for LDL particle size. We investigated LDL subfraction profiles in two groups: 46 men with and 21 men without CAD proven angiographically. For the separation of LDL subfractions, we used continuous disc polyacrylamide gel electrophoresis (PAGE) that is rapid and easier to perform than the other methods usually used which, although more precise in terms of measuring particle diameter, are much more demanding of time and equipment. The described method is suitable for routine use in assessing large numbers of patients. All studied men had triglyceride concentrations below 2.3 mmol/l. LDL scores were calculated on the basis of all LDL subfractions present in a particular profile; the higher the score, the greater the proportion of small LDL particles. LDL cholesterol (P < 0.05) and LDL score (P < 0.001) were the only significant discriminators between two groups. LDL score was significantly correlated with CAD, even after adjusting for triglyceride and HDL cholesterol concentrations and it was the best discriminant factor for the presence of CAD.

Particle size: the key to the atherogenic lipoprotein?

Using different analytical methods, up to 12 low-density lipoprotein (LDL) subfractions can be separated. LDL particle size decreases with increasing density. Smaller, denser LDL particles seem more atherogenic than the larger, lighter particles, based on the experimental findings that smaller LDL particles are more susceptible for oxidation in vitro, have lower binding affinity for the LDL receptors and lower catabolic rate, have a higher concentration of polyunsaturated fatty acids, and potentially interact more easily with proteoglycans of the arterial wall. Clinical studies have shown that a smaller LDL subfraction profile is associated with an increased risk of heart disease, even when total cholesterol level is only slightly raised. There is a strong inverse association between LDL particle size and triglyceride concentrations. Although LDL particle size is genetically determined, its phenotypic expression may also be affected by environmental factors such as drugs, diet, obesity, exercise or disease. Factors that shift the LDL subfractions profile towards larger particles may reduce the risk of heart disease.

Adverse change in low-density lipoprotein subfractions profile with oestrogen-only hormone replacement therapy.

In a prospective longitudinal study in 17 women, we investigated the effects of surgical menopause and subsequent oestrogen-only hormone replacement therapy (HRT) on plasma concentrations of total cholesterol, HDL cholesterol, LDL cholesterol, triglyceride and LDL subfractions profile. Plasma LDL is a heterogeneous population of particles of varying size, density and chemical composition. The predominance of small LDL particles is a newly-recognized risk factor for coronary artery disease. The LDL score is used to describe LDL subfractions profile and the greater the score, the higher the proportion of small LDL particles. Six weeks after hysterectomy and bilateral oopherectomy, total cholesterol and triglyceride concentrations were significantly increased (p < 0.01) as well as the LDL score (p < 0.05). After 6 weeks of oestrogen-only HRT, total cholesterol concentration was significantly lower and HDL cholesterol concentration significantly higher than before the treatment (p < 0.05). At the same time, mean LDL score significantly increased and in none of the women did LDL subfractions profile change favourably.

Statin-fibrate combination: therapy for hyperlipidemia: a review.

Statins and fibrates are well-established treatments for hyperlipidaemias and the prevention of vascular events. However, fibrate + statin therapy has been restricted following early reports of rhabdomyolysis that mainly involved gemfibrozil, originally with bovastatin, and recently, with cerivastatin. Despite this limitation, several reports describing combination therapy have been published. This review considers these studies and the relevant indications and contraindications. Statin + fibrate therapy should be considered if monotherapy or adding other drugs (e.g. cholesterol absorption inhibitors, omega-3 fatty acids ornicotinic acid) did not achieve lipid targets or is impractical. Combination therapy should be hospital-based and reserved for high-risk patients with a mixed hyperlipidaemia characterised by low density lipoprotein cholesterol (LDL) >2.6 mmol/l(100 mg/dl, high density lipoprotein cholesterol (HDL) <1.0 mmol/l (40 mg/dl) and/or triglycerides> 5.6 mmol/l (500 mg/dl. These three 'goals' are individually mentioned in guidelines. Patients should have normal renal, liver and thyroid function tests and should not be receiving therapy with cyclosporine, protease inhibitors or drugs metabolised through cytochrome P450 (especially 3A4). Combination therapy is probably best conducted using drugs with short plasma half-lives; fibrates should be prescribed in the morning and statins at night to minimise peak dose interactions. Both drug classes should be progressively titated from low doses. Regular (3-monthly) monitoring of liver function and creatine kinase is required. In conclusion, fibrate + statin therapy remains an option in high-risk patents. However, long-term studies involving safety monitoring and vascular endpoints are required to demonstrate the efficacy of this regimen.

Cyclosporin: revisions in monitoring guidelines and review of current analytical methods.

This article summarizes the main changes that have occurred in cyclosporin (ciclosporin) monitoring and measurement since the previous review in this journal. Cyclosporin has been reformulated to reduce variability in its absorption, leading to fewer post-transplant rejection episodes. Monitoring has mostly utilized the measurement of pre-dose blood levels of the drug, but more recently the potential benefit of using samples collected during the first few hours post-dose has been evaluated. Calculating the area under the cyclosporin concentration-time curve may be the ideal, but is not viable in the routine clinical situation and 2-h post-dose sampling seems likely to offer a practical clinical solution. Analytical methods based on high-performance liquid chromatography (HPLC) and immunoassay are available for the determination of whole blood cyclosporin concentrations. HPLC is specific but rarely used for routine monitoring, although HPLC-tandem mass spectrometry is making the technique more viable. New immunoassays have been introduced, but none are completely specific for the parent drug and all exhibit cross-reactivity towards cyclosporin metabolites. Immunoassays were originally designed for the lower cyclosporin concentrations seen in pre-dose samples, but are being evaluated and modified for determination of the higher concentrations seen 2 h post-dose.

Clinical evaluation of sodium ion selective field effect transistors for whole blood assay.

Sodium ion selective field effect transistors (ISFETs) were evaluated for their performance in measurement of sodium ions in whole blood for 'near patient' analysis in operating theatres and intensive care units. Performance was evaluated in comparison with a standard clinical laboratory sodium/potassium ion analyser (Radiometer KNA1) and with sodium and potassium assays using flame photometry on the plasma from each whole blood specimen. The imprecisions (coefficients of variation) of three ISFETs for sodium ion assay were 1.08, 1.56 and 1.10%, respectively. Robust bivariate linear regression (reweighted least squares preceded by least median of squares) of the ISFET versus KNA1 sodium ion activity yielded a regression coefficient of 1.08 and an intercept of -18.2 mM. The influence of potassium, protein and lipid on the measurement of sodium ions by both ISFETs and the KNA1 was assessed using robust multiple regression (also based on reweighted least squares preceded by least median of squares). In the regression versus flame photometry, protein was found to be more influential for the KNA1 (glass sodium ion selective electrode) than for the ISFET. Potassium had no influence on assays using the ISFET, but had a weak negative influence on assays using the KNA1. Two ISFETs lasted for more than 200 assays each demonstrating their robustness in the assay of whole blood.

Comparison of potassium ISFETs with the Radiometer KNA1 and the Corning 902 ion selective electrode analysers for whole blood potassium ion estimation.

Evaluation of the performance of potassium ion sensitive field effect transistors (K+ ISFETs), developed by Thorn EMI in a form suitable for mass production and for incorporation in 'near the patient' analysers, showed only very small constant and proportional biases against the Radiometer KNA1 and the Corning 902 for whole blood potassium ion estimation. Between batch imprecision tests with whole blood showed the K+ ISFET was comparable in performance to the Corning 902 but inferior to the Radiometer KNA1. The evaluation demonstrated that ISFET manufacturing technology has now reached a stage of development at which ISFETs should be considered seriously for use in clinical chemical analysers.

The cardiovascular and oncotic effects of albumin infusion in premature infants.

We determined the oncotic and cardiovascular effects of a standardised infusion of human albumin (1.2 g/kg over 2 h as a 20% solution) in 12 premature infants on 18 occasions when hypovolaemia was suspected on clinical grounds. Blood volume increased by a median value of 15.5%, and fell to preinfusion values by 3 h post infusion in all but four cases. Albumin concentration and colloid osmotic pressure rose during infusion and remained raised even when blood volume had fallen to preinfusion levels. Blood pressure rose in 3 cases only and heart rate fell by greater than 5 beats/min in 6 cases. Indices of long- and short-term heart rate variability were unchanged, but blood pressure variability fell in the second hour of infusion (P = 0.03), an effect which was independent of changes in lung inflation. No changes in blood gases or oxygenation occurred during infusion and no evidence of pulmonary oedema was found. There were wide variations in oncotic and cardiovascular responses to the standardised infusion both between and within subjects. When human albumin is infused in this manner some protection against respiration-induced variability in blood pressure can result, but the circulatory response may prove difficult to predict in the individual.

Worsening lipid profile is associated with progression of carotid artery stenosis.

BACKGROUND: To determine if uncontrolled hypercholesterolaemia predisposes to progression of carotid artery stenosis. METHODS: Fasting blood samples were collected from 76 patients referred for carotid duplex ultrasound for investigation of transient ischaemic attacks or recent stroke. Patients were grouped depending on the severity of the stenosis found. Patients on lipid lowering agents were excluded. The data were analysed using one way analysis of variance and the c2 test as appropriate. RESULTS: There were more men in the 70-99% group (15 vs 6, c2 = 10.6, p < 0.001, Table I). The total cholesterol was raised in all three groups. Patients with carotid stenosis of 70-99% had significantly elevated triglycerides (2.4 mmol vs 1.47 mmol and 1.37 mmol, p < 0.003), low HDL (1.14 mmol vs 1.45 mmol and 1.18 mmol, p < 0.003) and a higher cholesterol/HDL ratio (5.56 vs 4.29 and 4.71, p < 0.014) compared with the other two groups. There was no difference in lipoprotein(a) in the three groups. CONCLUSIONS: Increased triglycerides and low HDL cholesterol seen in the 70-99% group suggest that a worsening lipid profile is associated with progression of carotid artery stenosis.

Improving the quality of plasma cholesterol measurements in primary care.

During the last 2 years an external quality assessment (EQA) scheme has been developed for plasma cholesterol measurements made in primary care. The scheme, which is supported by the UK Department of Health and by the instrument manufacturers, now has over 300 participants, most of whom use the Boehringer Reflotron. Operators are mostly nurses, with little or no laboratory experience. To avoid matrix effects, fresh plasma specimens collected from normal volunteers and those attending a hospital lipid clinic are used. Three specimens, mostly with cholesterol concentrations in the range 5-9 mmol/L, are distributed every 2 months. The mean plasma cholesterol results show good agreement with those from 'reference' laboratories, and efforts are now being made to link these laboratories with the CDC-based reference system. The scheme uses a predominantly graphical presentation of results, with a greater element of interpretation by the organisers than is usually provided for laboratory-based participants. The distribution of results shows a higher proportion of outliers than in the UK national EQA scheme for laboratory cholesterol measurements. At present about 10% of participants in primary care obtain results which could be clinically misleading, and new approaches are needed in dealing with these 'poor performers'. This scheme could serve as a model for other assays in primary care. It illustrates the importance of training, quality assurance and education, and the need for laboratory staff to become more involved in this growing and important area of laboratory medicine.

Quality of plasma cholesterol measurements in primary care.

Three surveys were made of the quality of plasma cholesterol measurements performed with a commercial desktop analyser (BCL Reflotron) in primary care. Each survey included three specimens, and results were received from 37, 61, and 69 participants. Although many participants obtained satisfactory results, 8.6% of the results differed by 1.0 mmol/l or more from the target values, and the overall between instrument dispersion of results was 1.3 times that between hospital laboratories. It was found that common sources of error were poor technique and the use of outdated reagent strips. Users of such instruments outside the laboratory need help and advice with training, and guidelines for this are provided. The main recommendations are that users should establish contact with a local clinical chemistry laboratory for training and support and should participate in external quality assessment schemes.

Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study.

OBJECTIVE: To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. DESIGN: Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis. SETTING: Eleven primary-care practices: eight in Birmingham and three in Lambeth. PARTICIPANTS: Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs. MAIN OUTCOME MEASURES: Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) 'fatty liver' not associated with the above; and (4) the absence of detectable disease. RESULTS: Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of 'fatty liver' was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change. CONCLUSIONS: Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of 'fatty' liver. Abnormal LFTs and 'fatty' liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat. FUTURE WORK RECOMMENDATIONS: (1) the cases of 'fatty liver' and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Prevalence of hepatitis in early syphilis among an HIV cohort.

To investigate the prevalence of syphilitic hepatitis among a group of HIV-infected patients we performed a cross-sectional observational study of consecutive HIV-infected patients with early syphilis attending University Hospital Birmingham between 1 January 2005 and 31 August 2008. The AIDS Clinical Trials Group grading for abnormal liver enzymes was used to identify hepatitis. A total of 62 HIV-infected patients were diagnosed with early syphilis during the study period. Twelve (19.3%) of them demonstrated abnormal liver enzymes consistent with syphilitic hepatitis involving raised levels of alanine aminotransferase, aspartate transaminase, alkaline phosphatase or gamma-glutamyl transferase (GGT). Grade 3 hepatotoxicity was observed among five patients. None of the patients with syphilitic hepatitis had grade IV hepatitis or abnormal bilirubin levels. Liver biopsy was not carried out in any of the patients, and following completion of treatment of syphilis all abnormal liver enzymes returned to normal levels after a median of 16 weeks. Exclusion of syphilis must be considered when investigating hepatic disease in HIV-infected patients.