Extraordinary Hyperbilirubinemia in a Patient With Multiple Myeloma

Abstract

Multiple myeloma (MM) is a hematologic malignancy that classically manifests with hypercalcemia, renal insufficiency, anemia, and bone disease. Liver dysfunction is a less known complication that usually occurs through liver infiltration by plasma cells, amyloid deposition, or iron deposition. We present a case of a 49 year old Female patient with MM and extreme hyperbilirubinemia. This was a 49 year old female who presented to the emergency room with profound fatigue, progressive jaundice, and pruritus. She had a history of relapsed refractory stage III MM that was being treated with bendamustine. The patient was transfusion dependent, requiring blood transfusions twice a week. Vital signs revealed tachycardia. Her physical exam was remarkable for dry mucous membranes, jaundice, scleral icterus, diffuse abdominal tenderness, and hepatosplenomegaly. Labs were significant for a Hgb of 10 g/dL, platelets of 40,000/mL, total bilirubin of 49.5 mg/dL, direct bilirubin of 30 mg/dL, AST of 18 U/L, ALT of 51 U/L, alkaline phosphatase of 80 U/L, albumin of 3.8 g/dL, INR of 1.3, ferritin of 15,000, and iron of 206. Further work-up, including a hepatitis panel, autoimmune workup, hemolytic workup, toxicology screen, US, MRCP, etc., did not yield a diagnosis.. Transjugular hepatic biopsy was performed to assess the etiology of the hyperbilirubinemia. It showed infiltration of plasma cells, extensive iron deposition in hepatocytes, and Kupffer cells with pericellular fibrosis in the areas infiltrated by plasma cells (figures 1, 2). The patient's liver dysfunction was attributed to secondary hemochromatosis and malignant infiltration of MM. The patient was treated with supportive care. Given her poor prognosis, goals of care were discussed, and she was eventually discharged with home hospice. It is important to recognize liver dysfunction in patients with Multiple Myeloma. Up to 40% of individuals with multiple myeloma have some plasma cell infiltration of the liver. Involvement of the liver in MM carries a poor prognosis. The literature search found that the total bilirubin usually ranges from 3.2 to 17.3 mg/dL in these cases. Our case demonstrated a staggering total bilirubin of 49.5mg/dL. This was multifactorial due to plasma cell infiltration of the liver and secondary hemochromatosis from numerous transfusions. It is important to keep in mind that Bendamustine has also been documented to cause an unconjugated hyperbilirubinemia secondary to hemolytic anemia.2257_A Figure 1. Medium power photomicrograph of a transjuglar liver biopsy with hemosiderin-laden hepatocytes and sinusoidal plasma cell infiltrate with associated fibrosis.2257_B Figure 2. Strong expression of kappa IgG by infiltrating cells.