Multiple myeloma of the liver presenting as non-obstructive jaundice

Abstract

Dear Editor, Multiple myeloma (MM) involves, mainly but not exclusively, the bone marrow. It is occasionally associated with jaundice. The underlying process may be a myeloma infiltration of the head of the pancreas or hepatic amyloid deposition or extra-hepatic biliary obstruction due to an abdominal plasmacytoma. A rare case of myeloma manifested by jaundice after hepatic myeloma infiltration is reported. A 55-year-old man was referred to our hospital because of weakness, weight loss and jaundice. Physical examination showed somnolence, jaundice and hepatomegaly 10 cm below the costal margin. Cardiovascular and respiratory examinations were normal. Results of the blood test performed on admission were as follows: calcium 3.62 mmol/l, bilirubin 203 μmol/l, alkaline phosphatase 373 IU/l (normal 100–280 UI/l), γ-glutamyltransferase 888 IU/l, lactate dehydrogenase (LDH) 727 IU/l (normal 5–270 IU/l), aspartate aminotransferase (SGOT) 145 IU/l, alanine aminotransferase (SGOT) 136 IU/l, creatinine 1395 μmol/l, haemoglobin 7.6 g/dl, white cell count 8.9× 10/l, platelets 82×10/l, prothrombin index 46% and Creactive protein 40 mg/l. Serum and urine protein studies revealed an M-component Lambda. Serological tests were negative for hepatitis B and C viruses. Blood, stool and urine cultures did not reveal any growth. A bone marrow aspirate was performed, showing 46% of atypical plasma cells with prominent nucleoli (Fig. 1). Residual normal haemopoeitic cells were markedly reduced in number. There was no evidence of lytic lesions on X-ray films. However, abdominal ultrasound scan showed hepatomegaly and ascitis. Neither biliary dilatation nor tumor nodules were seen by abdominal computerized axial tomography (Fig. 2). A liver biopsy was performed and showed dilated sinuses containing plasma cells, plasmablasts and extramedullary haemopoeitic cells. Myeloma cells also infiltrated portal tracts (Fig. 3). There was no evidence of amyloid deposition in the liver biopsy. A diagnosis of MM with liver involvement was made. The patient was treated with Dexamethasone. But unfortunately, his condition deteriorated with the onset of renal failure. He died a few days later. Extraosseous manifestations are found in less than 5% of patients with MM. Elevation of the LDH level suggest the presence of occult extraosseous disease and predict a poor prognosis [1, 2]. In our patient, the serum LDH level was very high. Myeloma causing jaundice has occasionally been reported in literature. However, all cases reported to date have been due to hepatic amyloid deposition or extrahepatic biliary tract obstruction. As far as we know, only two cases of liver dysfunction due to plasma-cell infiltration have been confirmed by biopsy [3, 4]. Liver involvement in MM is uncommon. It is frequently found at autopsy, but it is clinically manifest in a few patients. Signs of liver dysfunction are not part of the Ann Hematol (2007) 86:529–530 DOI 10.1007/s00277-007-0267-9