An Unusual Case of Multiple Myeloma Diagnosed due to Clinical Manifestations of Infiltration of the Disease into the Liver

Abstract

: Clinical manifestations of infiltration of multiple myeloma into the liver are extremely rare. We present a case of a 73-year-old African-American female presenting with complaints of persistent nausea and vomiting. Initial laboratory findings included BUN of 23, creatinine 2.3, AST 73, ALT 59, alkaline phosphatase 335, total bilirubin 1.3 mg/dL, and direct bilirubin 0.7mg/dL. Serologic abnormalities persisted, prompting CT-guided biopsy of the liver. Pathology demonstrated diffuse plasma cell infiltration, and further work-up confirmed the diagnosis of multiple myeloma. Case Report: A 73-year-old female presented with complaints of nausea and vomiting of three weeks' duration, with associated intermittent diarrhea. Physical examination revealed a soft, nondistended abdomen, positive for periumbilical and epigastric tenderness with no guarding or rebound. Laboratory results were significant for a BUN of 23, creatinine 2.3, AST 73, ALT 59, alkaline phosphatase 335, total bilirubin 1.3 mg/dL, direct bilirubin 0.7mg/dL, and CA 19-9 of 352.7. Abdominal ultrasound, endoscopic ultrasound, and MRI of the abdomen with and without contrast was employed, but could not explain the persistent elevation in the patient's transaminases, alkaline phosphatase, and bilirubin. CT-guided biopsy of the liver was ordered. Findings of myelomatosis, an atypical plasmacytic infiltration of the liver, was described per the pathology. Serum and urine electrophoresis showed a lambda light chain predominance, with levels found to be 930 mg/dL and 1,960 mg/dL. Bone marrow aspiration confirmed a 17% marrow plasmacytosis, lambda restricted. The patient was diagnosed with multiple myeloma and started on treatment with bortezomib and dexamethasone. Discussion: Extraosseous involvement of multiple myeloma is a well-documented manifestation of the disease. Infiltration of the liver has been described in the literature, with Walz-Mattmüller, et al. reporting liver involvement in 32% of patients with multiple myeloma (1). Although liver infiltration and abnormalities in liver function tests are common, clinical manifestations of these irregularities are exceedingly rare (2). These instances exist in the literature as case reports, such as that described by Barth, et al., involving a patient presenting with acute cholestatic hepatitis diagnosed with multiple myeloma on biopsy of the liver (3). We report a similar case, in which a patient with complaints of nausea, vomiting, and obstructive cholestasis on serology was subsequently diagnosed with multiple myeloma. Although rare, manifestations of liver infiltration can occur, and physicians should remain vigilant in the work-up of cholestatic jaundice not explained by other pathology.