|Year : 2020 | Volume
| Issue : 1 | Page : 66-67
Fluorodeoxyglucose positron emission tomography/computed tomography imagıng in pseudo Sister Mary Joseph's nodule
Sabahat Inanir, Ceren Ozge Engur
Department of Nuclear Medicine, Pendik Research and Training Hospital, Marmara University, Istanbul, Turkey
|Date of Submission||02-Sep-2019|
|Date of Acceptance||03-Oct-2019|
|Date of Web Publication||31-Dec-2019|
Dr. Ceren Ozge Engur
Department of Nuclear Medicine, Marmara University, Istanbul Pendik Training and Research Hospital, Muhsin Yazicioglu Street, TR-34899, Üstkaynarca, Pendik, Istanbul
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Sister Mary Joseph's nodule (SMJN) refers to umbilical metastatic lesions and indicates widespread intra-abdominal malignancy. The most common primary sites are gastrointestinal and genital tract. Benign umbilical nodules are called pseudo-SMJN (PSMJN) and have been also reported in nonmalignant lesions such as endometriosis, fibroma, papillomas, myxoma, keloid, omphalith, nevi, foreign-body granulomas, and epidermoid cysts. We report a case with PSMJN as an extremely rare manifestation of intra-abdominal tuberculosis.
Keywords: Fluorodeoxyglucose positron emission tomography/computed tomography, peritoneal tuberculosis, pseudo Sister Mary's Joseph nodule
|How to cite this article:|
Inanir S, Engur CO. Fluorodeoxyglucose positron emission tomography/computed tomography imagıng in pseudo Sister Mary Joseph's nodule. Indian J Nucl Med 2020;35:66-7
|How to cite this URL:|
Inanir S, Engur CO. Fluorodeoxyglucose positron emission tomography/computed tomography imagıng in pseudo Sister Mary Joseph's nodule. Indian J Nucl Med [serial online] 2020 [cited 2020 Sep 26];35:66-7. Available from: http://www.ijnm.in/text.asp?2020/35/1/66/274367
A 40-year-old male patient was presented with a 2-month history of abdominal swelling, night sweating, and 8 kg of weight loss. He had been treated with antitumor necrosis factor (anti-TNF) drug for ankylosing spondylitis for 3 years. Abdominal computed tomography (CT) showed the presence of ascites, peritoneal thickening, and omental cake sign, and peritonitis carcinomatosa was suspected. Fluorodeoxyglucose positron emission tomography/CT (FDG PET/CT) revealed massive peritoneal involvement with high-FDG uptake (maximum standardized uptake value [SUVmax], 6.3; arrows) and a hypermetabolic nodular lesion in the periumbilical region (SUVmax, 3.3; arrowheads) [Figure 1]. Multiple hypermetabolic lymph nodes, pleural effusion, and mild FDG uptake in pleural surfaces were also seen. The albumin concentration of ascitic fluid was 2.72 g/dl, and no malignant cell was present. Ascitic fluid analysis revealed a predominance of lymphocytes and elevated adenosine deaminase level (138 U/l: normal below 50 U/l). A peritoneal biopsy was reported as necrotizing granulomatous peritonitis and panniculitis. No acid-fast bacilli were detected and cultures were negative. The QuantiFERON test gave positive result. Four-drug antituberculosis (TB) therapy was started and significantly improved the patient's symptoms within 2 months.
|Figure 1: Abdominal computed tomography showed the presence of ascites, peritoneal thickening, and omental cake sign, and peritonitis carcinomatosa was suspected. Fluorodeoxyglucose positron emission tomography/computed tomography revealed massive peritoneal involvement with high-fluorodeoxyglucose uptake (maximum standardized uptake value, 6.3; arrows) and a hypermetabolic nodular lesion in the periumbilical region (maximum standardized uptake value, 3.3, arrowheads) [Figure 1]. Multiple hypermetabolic lymph nodes, pleural effusion, and mild fluorodeoxyglucose uptake in pleural surfaces were also seen. Maximum intensity projection (a), coronal (b), axial (c), and sagittal (d) positron emission tomography/computed tomography images are given in the figure|
Click here to view
Similar laparoscopic and imaging findings can be observed in tuberculous peritonitis and peritoneal carcinomatosis. Abdominal TB constitutes 3%–6.7% of cases with extrapulmonary TB, and peritoneal involvement is common., An increased risk of TB has been demonstrated with the use of TNF-α antagonist. Anti-TNF drugs can cause the breakdown of granulomas in latent infection. A case of umbilical nodule caused by abdominal TB has been reported. The anatomic and embryologic peculiarities of the umbilicus make it a weak point for disease spread.,, In addition to umbilical metastases, umbilical nodules have been reported in benign tumors or lesions (such as omphalitis, granulomas, cutaneous endometriosis, and psoriasis).,, Benign umbilical nodules are called pseudo Sister Mary Joseph nodule and have been rarely reported with FDG PET/CT., This case highlights the need to consider TB in the differential diagnosis of hypermetabolic umbilical nodules, and careful clinical correlation of imaging findings is recommended.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mandavdhare HS, Singh H, Sharma V. Recent advances in the diagnosis and management of abdominal tuberculosis. EMJ Gastroenterol 2017;6:52-60.
Sanai FM, Bzeizi KI. Systematic review: Tuberculous peritonitis – Presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005;22:685-700.
Xie X, Li F, Chen JW, Wang J. Risk of tuberculosis infection in anti-TNF-α biological therapy: From Bench to bedside. J Microbiol Immunol Infect 2014;47:268-74.
Sharma V, Ahmed SU, Mandavdhare HS. A benign cause of sister Mary Joseph's nodule: Abdominal tuberculosis. Int J Mycobacteriol 2017;6:321.
Wronski M, Klucinski A, Krasnodebski IW. Sister Mary Joseph nodule: A tip of an iceberg. J Ultrasound Med 2014;33:531-4.
Ching AS, Lai CW. Sonography of umbilical metastasis (Sister Mary Joseph's nodule): From embryology to imaging. Abdom Imaging 2002;27:746-9.
Inanir S, Oksuzoglu K. FDG PET/CT imaging of calcified sister Mary Joseph nodule. Clin Nucl Med 2016;41:e458-9.
Calista D, Fiorentini C, Landi G. Umbilical metastasis from ovarian carcinoma: Sister Mary Joseph's nodule. J Eur Acad Dermatol Venereol 2002;16:84-5.
Coll DM, Meyer JM, Mader M, Smith RC. Imaging appearances of sister Mary Joseph nodule. Br J Radiol 1999;72:1230-3.
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;17:78-81.
Amaro R, Goldstein JA, Cely CM, Rogers AI. Pseudo sister Mary Joseph's nodule. Am J Gastroenterol 1999;94:1949-50.
Metser U, Tau N. Benign cutaneous and subcutaneous lesions on FDG-PET/CT. Semin Nucl Med 2017;47:352-61.