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Clinical Images  |   December 2020
Sister Mary Joseph Nodule
Author Notes
  • From the Department of Internal Medicine at John H. Stroger, Jr. Hospital of Cook County in Chicago, Illinois. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Parth Desai, DO, John H. Stroger, Jr. Hospital of Cook County, 1969 Ogden Ave, Chicago, IL 60612-3765. Email: parth.desai@cookcountyhhs.org
     
Article Information
Clinical Images   |   December 2020
Sister Mary Joseph Nodule
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 940. doi:https://doi.org/10.7556/jaoa.2020.131
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 940. doi:https://doi.org/10.7556/jaoa.2020.131
A 59-year-old woman with ductal carcinoma in situ status post-bilateral mastectomy presented to the emergency department with two weeks of jaundice. Vital signs were normal and examination revealed marked scleral icterus, jaundice, and a palpable subcutaneous umbilical nodule. Laboratory investigation revealed direct hyperbilirubinemia with direct bilirubin of 16.2 mg/dL (Ref: 0-0.2 mg/dL), total bilirubin of 22.3 mg/dL (Ref: 0.2-1.2 mg/dL), and alkaline phosphatase 323 U/L (Ref: 20-120 U/L). Contrast enhanced abdominal computed tomography scan demonstrated thickening and fat stranding of the gallbladder neck, concomitant intrahepatic biliary ductal dilatation, and an umbilical soft tissue deposit (image A and image B). Endoscopic retrograde cholangiopancreatography with common bile duct brushings revealed gallbladder adenocarcinoma. The patient was not a candidate for chemotherapy and died during the hospitalization from septic shock due to a bilioma and ARDS. 
Sister Mary Joseph nodule is an uncommon clinical finding which may be noted on computed tomography imaging as a well-defined subcutaneous enhancing lesion. It can be either well-defined or demonstrate indefinite margins.1,2 On ultrasound, which may be used to assist in biopsy, the nodule may appear as a hypoechoic mass.1 A Sister Mary Joseph nodule should raise suspicion for metastatic or recurrent visceral malignancy and is a marker of poor prognosis.3 
References
Bashir O, Prince N, Ahmad S, Coveney E. Sister Joseph's nodule: imaging of a clinical sign. Appl Radiol. 2012;41(5):27-28.
Larentzakis A, Theodorou D, Fili K, et al Sister Mary Joseph's nodule: three case reports. Cases J. 2008;1(1):182. doi: 10.1186/1757-1626-1-182 [CrossRef] [PubMed]
Palaniappan M, Jose WM, Mehta A, Kumar K, Pavithran K. Umbilical metastasis: a case series of four Sister Joseph nodules from four different visceral malignancies. Curr Oncol. 2010;17(6):78-81. doi: 10.3747/co.v17i6.684 [CrossRef] [PubMed]