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The lighter side of myeloma: an easily overlooked diagnosis
  1. J J Feld1,
  2. M Guindi2,
  3. E J Heathcote3
  1. 1Department of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Pathology, University of Toronto, Toronto, Ontario, Canada
  3. 3Department of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to:
    Dr J J Feld
    Liver Disease Section, NIDDK, NIH, 10 Center Dr Rm 9B16, MSC 1800, Bethesda, MD 20892, USA;

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Clinical presentation

A previously healthy 61 year old man developed back pain, fatigue, and anaemia. IgG κ multiple myeloma was diagnosed and the patient was treated with vincristine, adriamycin, and dexamethasone. He tolerated chemotherapy well but began complaining of pruritus after his second cycle. He was found to have an elevated alkaline phosphatase level (ALP) of 872 IU/L (normal level <110 IU/l) with normal serum transaminases, bilirubin values, and a stable serum creatinine (125 μmol/l; normal level <99 μmol/l). An ultrasound revealed normal bile ducts and liver architecture. Persistence of pruritus and ALP elevation led to liver biopsy (fig 1). The patient began to notice increasing abdominal girth and darkening of his urine. Serum bilirubin increased rapidly to 284 μmol/l with an ALP of 1047 IU/l. He was transferred to a tertiary care facility and was found to be deeply jaundiced, mildly encephalopathic, with moderate ascites. The previously performed liver biopsy was reviewed, leading to a specific diagnosis (fig 2).

Figure 1

 Liver biopsy showing material lining sinusoids (arrows). Haematoxylin and eosin; magnification 630×.

Figure 2

 Diagnostic stain of liver biopsy tissue.


What is the diagnosis?

See page 1401 for answer

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