P2450 - Isolated Hyperbilirubinemia - A Rare Initial Presentation of Multiple Myeloma

Kishore Karri, MD¹, Nimish Thakral, MD¹, Vijay Aluru, MD¹, Kshitij Thakur, MD, MSc¹, Pradeep Yarra, MD, MSc^2
1University of Kentucky, Lexington, KY; ²Saint Louis University Hospital, St. Louis, MO

Introduction: Multiple Myeloma is a primary neoplasm of plasma cells . The diagnosis of MM is often suspected because of one (or more) of the following clinical presentations:
1.Bone pain with lytic lesions
2.Systemic signs or symptoms such as unexplained Fatigue, weight loss or anemia
3.Hypercalcemia, which is either symptomatic or discovered incidentally
4. Renal Failure
Jaundice (or) Isolated hyperbilirubinemia as an initial first presentation of multiple myeloma is extremely rare and has been seldom reported in literature .

Case Description/Methods: A 51 year old female presented to clinic with new onset jaundice . Lab were significant for serum bilirubin of 14.9, AST 54 and ALT 65 and alkaline phosphatase of 130 . Work up for chronic liver disease including Infectious hepatitis, HIV, Autoimmune Hepatitis, cholestatic liver diseases & Wilson Disease was negative. Imaging studies, including MRCP, CT Abdomen pelvis , and duplex US of liver did not show any identifiable pathology. Subsequent liver biopsy showed clonal plasma cell infiltrate and parenchymal injury. On Hematological evaluation patient was noted to have patient's kappa light chain was 707, lambda light chain was 1.23, and kappa lambda ratio was 574.8. The patient underwent bone marrow biopsy which then confirmed the diagnosis of kappa light chain multiple myeloma with extramedullary hepatic involvement. The patient completed induction treatment with high dose IV dexamethasone and subsequently was treated with Lenalidomide in the outpatient hematology clinic .

Discussion: Isolated Hyperbilirubinemia as a first presentation of multiple myeloma is extremely rare . On literature review, plasma cell infiltration of the liver can be detected in up to 45% of patients with multiple myeloma (MM) at autopsy. However, only rare cases have been reported of massive plasma cell infiltration of the liver that leads to non-obstructive cholestasis with possible progression to liver failure. Gastroenterologists must harbor a high index of suspicion for this presentation so as to avoid delayed diagnosis and treatment.


Disclosures:


Kishore Karri, MD¹, Nimish Thakral, MD¹, Vijay Aluru, MD¹, Kshitij Thakur, MD, MSc¹, Pradeep Yarra, MD, MSc². P2450 - Isolated Hyperbilirubinemia - A Rare Initial Presentation of Multiple Myeloma, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.