Sister Mary Joseph Nodule.

Submitted December 19, 2019; revision received March 5, 2020; accepted March 20, 2020. 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. On ultrasound, which may be used to assist in biopsy, the nodule may appear as a hypoechoic mass. A Sister Mary Joseph nodule should raise suspicion for metastatic or recurrent visceral malignancy and is a marker of poor prognosis. (doi:10.7556/ jaoa.2020.131)