Consider acute hepatitis C, syphilis, and HIV in MSM with hepatitis

Although Pratsides and colleagues correctly identified drug induced hepatitis as the cause of the clinical hepatitis in their case report, readers should be aware of three other differential diagnoses in men who have sex with men (MSM) who present with acute transaminitis.1 Firstly, there is an ongoing epidemic of acute hepatitis C in these men in the UK (particularly Brighton and London) and other parts of the developed world.2 This may not be detected by routine serology during the acute phase because antibody seroconversion can take weeks to months,3 so polymerase chain reaction for hepatitis C would be recommended in this scenario. Secondly, international outbreaks of syphilis have been reported in MSM, including in the UK.4 Syphilis, particularly in the secondary stage, should be considered as a differential diagnosis in MSM who have abnormal liver function tests. Thirdly, a test for HIV infection should have been recommended. Although HIV itself rarely produces abnormal liver function tests, it is more common in people with other causes of abnormal liver function (including hepatitis C and syphilis). Furthermore, current guidelines from the National Institute for Health and Clinical Excellence and British HIV Association recommend that all MSM attending healthcare services should be offered HIV testing.5