Alveolar Bile and Light Chain Immunoglobulin Depositions as an Unusual Complication of Transjugular Liver Biopsy Resulting in Bilhemia in a Patient with Multiple Myeloma

<b>Background:</b> A 69-year-old man with multiple myeloma and left-sided heart failure presented to the hospital with a two-month fever. <b>Method:</b> A transjugular liver biopsy was performed due to the rapid progression of liver failure. The procedure was complicated by an intraperitoneal hemorrhage. The bleeding was managed expectantly. <b>Result:</b> Significantly elevated serum bilirubin levels occurred on the 13th day after liver biopsy. Increasing serum bilirubin levels were observed until the patient's death due to a biliovenous fistula at the liver biopsy site. Simultaneously, his slightly elevated liver enzymes returned to normal. The patient died 23 days after liver biopsy due to acute respiratory distress syndrome. Fistulous communication between the biliary tree and the hepatic venous system with subsequent bile leakage into the venous system (bilhemia) can lead to bile deposition in the lungs. Bile deposition in the lungs may potentiate and accelerate the development of diffuse alveolar damage with hyaline membranes. <b>Conclusions:</b> Lambda and kappa light chain deposition in the pulmonary alveoli in patients with multiple myeloma can mimic typical hyaline membranes.