Sister Mary Joseph’s nodule is a rare manifestation, found as a deposit in the umbilicus, that results from a metastasis of late-stage, intra-abdominal or pelvic malignancy. Clinical knowledge of its presence is important as it can be overlooked as a benign skin lesion, especially since little racial diversity of this physical exam finding exists for skin images in medical texts. We report a case of a 53-year-old Black man who was found to have an exophytic, ulcerated umbilicus with serous drainage and computed tomography of the abdomen confirming a Sister Mary Joseph’s nodule.

Case Presentation: A 53-year-old Black man previously diagnosed with heart failure and alcohol use disorder, presented in the emergency department with a chronic umbilical wound and worsening, sharp abdominal pain (I). Labs obtained demonstrated transaminitis. He was diagnosed with an omphalolith secondary to inadequate hygiene and discharged with instructions for wound care and alcohol cessation. He then represented to the emergency department after a syncopal episode where an electrocardiogram revealed unstable atrial flutter prompting cardioversion and initiation of an amiodarone drip. Once normal sinus rhythm was restored, a thorough history revealed persistent periumbilical pain. Physical examination revealed abdominal distention with tenderness, hypoactive bowel sounds, and an ulcerated umbilical protrusion with serous drainage. Hepatic panel redemonstrated transaminitis with cholestasis and clinical suspicion included a malignancy with a Sister Mary Joseph Nodule (SMJ). Computed tomography of the abdomen revealed a centrally hypodense mass with irregular rim enhancement at the umbilicus compatible with a SMJ (II). Multiple hypoattenuating hepatic lesions with increased, enhancing rims and a hypodense mass at the pancreatic tail indicated metastatic pancreatic cancer. The rarity of this neoplastic marker and the lack of representation of Sister Mary Joseph’s nodule in medical images for persons with darker skin can exacerbate under-recognition by clinicians. Exposure to pathologic findings on multiple different skin tones and awareness of clinicians’ implicit biases can help address racial disparities in medicine and prevent diagnostic delays.