Inflammation secondary to sepsis can involve multiple organs, including liver. Hepatocellular injury in sepsis results from hypoperfusion and inflammatory cytokines, manifesting as elevated alkaline phosphatase, AST, ALT and bilirubin. However right upper quadrant scans should be performed when in doubt to rule out other life threatening pathologies. We report a case of undiagnosed multiple myeloma and primary amyloidosis with liver and pancreatic involvement, admitted for sepsis secondary to meningitis. A 65-year-old male was brought to hospital after wife found him confused, diaphoretic and nonverbal. He was febrile and somnolent. Lumbar puncture confirmed bacterial meningitis for which he was treated, but later developed jaundice. His liver function tests were consistent with cholestasis. Right upper quadrant (RUQ) ultrasonography (images 1,2) and CT abdomen (image 3) did not show any tumors, stones or strictures but demonstrated massive hepatomegaly. Malignancy work-up was initiated for hypercalcemia, as PTH, PTHrP and vitamin D levels were normal. Serum protein electrophoresis (SPEP) showed abnormal band suggestive of a paraprotein in gamma region (1.00 g/dL), along with elevation of free Kappa and lambda light chains. Bone marrow biopsy revealed 10% plasma cells. Alkaline phosphatase, AST, ALT, and bilirubin, continue to trend up, peaking at 1521 U/L, 138 U/L, 129 U/L and 4.1 mg/dL (2.9 mg/dL- direct bilirubin) respectively. GGT was elevated at 1364 U/L and CA 19-9 at 3386 U/L. MCRP was negative for biliary or pancreatic duct dilatation. Liver biopsy confirmed primary amyloidosis. Hence patient was started on chemotherapy for IgG kappa multiple myeloma and primary amyloidosis, and had significant improvement in liver function tests and CA 19-9 after first cycle. Amyloidosis is a process of extracellular insoluble protein deposition that commonly involves gastrointestinal tract, with up to 90 percent liver involvement. Jaundice along with elevated alkaline phosphatase and transaminases is seen frequently with liver involvement but jaundice is associated with poor prognosis. Liver alone is almost never the sole organ affected, and in the above-reported case, later on biopsy of the pancreas was also consistent with widespread amyloid deposits. Even though amyloidosis represents a rare cause of cholestatic jaundice, it is important to consider it in differentials due to high mortality with median one-year survival of fifty percent in untreated cases.Figure: Right upper quadrant ultrasound - hepatomegaly.Figure: RUQ ultrasound showing normal CBD.Figure: CT abdomen - hepatomegaly.