Sister Mary Joseph Nodule
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Parth Desai
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
1. BashirO, PrinceN, AhmadS, CoveneyE.Sister Joseph's nodule: imaging of a clinical sign.Appl Radiol. 2012;41(5):27-28.10.37549/AR1898Search in Google Scholar
2. LarentzakisA, TheodorouD, FiliK, et al.Sister Mary Joseph's nodule: three case reports.Cases J.2008;1(1):182. doi:10.1186/1757-1626-1-182Search in Google Scholar PubMed PubMed Central
3. PalaniappanM, JoseWM, MehtaA, KumarK, PavithranK. 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.v17i6.684Search in Google Scholar PubMed PubMed Central
© 2020 American Osteopathic Association
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