J Hematol

Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Hematol and Elmer Press Inc

Journal website https://www.thejh.org

Case Report

Volume 11, Number 6, December 2022, pages 216-222

Synchronous Presentation of Autoimmune Hepatitis and Multiple Myeloma

Figure 1. Hematoxylin and eosin stain showing panlobular hepatitis with sheets of lymphoplasmacytic portal and periportal inflammation (× 400 magnification) (a). CD138 immunohistochemical stain highlighting portal and periportal plasma cells (× 400 magnification) (b). Kappa (c) and lambda (d) immunohistochemical stains highlighting polyclonal portal and periportal plasma cells (× 400 magnification).

Figure 2. (a) Hematoxylin and eosin stain showing hypercellular marrow and trilineage hematopoiesis with numerous (about 5-20%) plasma cells (× 400 magnification). (b) CD138 immunohistochemical stain highlighting aggregates of plasma cells in the hypercellular bone marrow (× 400 magnification). (c) The flow cytometry image above demonstrating plasma cells which are CD138 positive with a kappa/lambda ratio of 15, indicating a monotypic kappa light chain restriction.

Figure 3. (a) Sagittal T2-weighted imaging (T2W1) of the spine with fat suppression showing L2 vertebral body T2 hyperintense focal lesion (red arrow). (b) Coronal diffusion-weighted imaging (DWI) with b value of 1,000 s/mm² (in color scale) through the lumbar spine showing marked restricted diffusion of L2 vertebral body focal lesion (red arrow).

**Table 1.** Admission Laboratory Test Results
CBC and CMP	Admission	HD 7	HD 14	HD 21 (discharge)	60 days later	6 months after discharge	Reference range
CBC: complete blood count; CMP: comprehensive metabolic panel; HD: hemodialysis; WBC: white blood cell; AST: aspartate transaminase; ALT: alanine transaminase; ALP: alkaline phosphatase; INR: international normalized ratio.
WBC	8	19	27	9.8	10		4.5 - 11 × 10³/µL
Hemoglobin	8.8	8.4	8	8	9.6		12.1 - 15.1 g/dL
Platelets	316	90	244	378	210		150 - 400 × 10⁹/L
Creatinine	1.2	4.5	8	7.7	2.2	1.4	0.59 - 1.04 mg/dL
Total protein	8.5	7.4	7.3	7.4	8.9	8	6 - 8 g/dL
Albumin	2.2	2.8	2.1	2.5	3.3	3.4	3.4 - 5.4 g/dL
Globulin	6.3	4.6	5.2	4.9	5.6	4.6	2.0 - 3.5 g/dL
AST	1,118	353	103	46	16	25	10 - 40 U/L
ALT	552	176	34	45	29	24	4 - 36 U/L
ALP		69	211	145	59	70	44 - 147 IU/L
Total bilirubin	24	22	12	4.4	0.6	0.3	0.1 - 1.2 mg/dL
Direct bilirubin	21	18	9.7	2.1			< 0.3 mg/dL
Prothrombin time	18	24	14	14	13	14	11.0 - 12.5 s
INR	1.5	2.1	1.0	1.09	1.06	1.0	≤ 1.1

Table 1. Admission Laboratory Test Results

CBC and CMP

Admission

HD 7

HD 14

HD 21 (discharge)

60 days later

6 months after discharge

Reference range

CBC: complete blood count; CMP: comprehensive metabolic panel; HD: hemodialysis; WBC: white blood cell; AST: aspartate transaminase; ALT: alanine transaminase; ALP: alkaline phosphatase; INR: international normalized ratio.

WBC

9.8

4.5 - 11 × 10³/µL

Hemoglobin

8.8

8.4

9.6

12.1 - 15.1 g/dL

Platelets

316

244

378

210

150 - 400 × 10⁹/L

Creatinine

1.2

4.5

7.7

2.2

1.4

0.59 - 1.04 mg/dL

Total protein

8.5

7.4

7.3

7.4

8.9

6 - 8 g/dL

Albumin

2.2

2.8

2.1

2.5

3.3

3.4

3.4 - 5.4 g/dL

Globulin

6.3

4.6

5.2

4.9

5.6

4.6

2.0 - 3.5 g/dL

AST

1,118

353

103

10 - 40 U/L

ALT

552

176

4 - 36 U/L

ALP

211

145

44 - 147 IU/L

Total bilirubin

4.4

0.6

0.3

0.1 - 1.2 mg/dL

Direct bilirubin

9.7

2.1

< 0.3 mg/dL

Prothrombin time

11.0 - 12.5 s

INR

1.5

2.1

1.0

1.09

1.06

1.0

≤ 1.1

**Table 2.** Autoimmune Conditions Reported in Association With MM
Organ system
Hematological	Autoimmune hemolytic anemia [6]
	Pernicious anemia [7]
	Pure red cell aplasia [8]
	Immune thrombocytopenia [9]
	Evan’s syndrome [10]
	Autoimmune neutropenia [11]
Neurological	Myasthenia gravis [12]
	Autoimmune autonomic gangliopathy [13]
Gastrointestinal	Inflammatory bowel disease [14]
	Primary biliary cholangitis [15]
	Primary sclerosing cholangitis [16]
	Autoimmune hepatitis [17]
Renal	Tubulointerstitial nephritis [18]
	Membranous glomerulonephritis [19]
Musculoskeletal	Dermatomyositis [20]
	Polymyositis [21]
	Ankylosing spondylitis [22]
Endocrine	Grave’s disease [23]
	Autoimmune polyendocrinopathy [24]
Cutaneous	Paraneoplastic pemphigus [25]
	Cutaneous leukocytoclastic vasculitis
	Urticaria pigmentosa [26]
Others	Systemic lupus erythematosus [27]
	Sjogren syndrome [28]

Table 2. Autoimmune Conditions Reported in Association With MM

Organ system

Hematological

Autoimmune hemolytic anemia [6]

Pernicious anemia [7]

Pure red cell aplasia [8]

Immune thrombocytopenia [9]

Evan’s syndrome [10]

Autoimmune neutropenia [11]

Neurological

Myasthenia gravis [12]

Autoimmune autonomic gangliopathy [13]

Gastrointestinal

Inflammatory bowel disease [14]

Primary biliary cholangitis [15]

Primary sclerosing cholangitis [16]

Autoimmune hepatitis [17]

Renal

Tubulointerstitial nephritis [18]

Membranous glomerulonephritis [19]

Musculoskeletal

Dermatomyositis [20]

Polymyositis [21]

Ankylosing spondylitis [22]

Endocrine

Grave’s disease [23]

Autoimmune polyendocrinopathy [24]

Cutaneous

Paraneoplastic pemphigus [25]

Cutaneous leukocytoclastic vasculitis

Urticaria pigmentosa [26]

Others

Systemic lupus erythematosus [27]

Sjogren syndrome [28]