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SAEM Clinical Images Series: An Unusual Appearing Umbilicus

umbilicus

The patient is a 70-year-old female with a remote history of breast cancer who presents to the Emergency Department with family due to frequent falls and disorientation. Her family reports that she previously walked independently. However, over the last several months, she has had worsening weakness and has become wheelchair-bound. Nonetheless, she frequently attempts to walk and loses her balance, leading her to falling. She is brought in today due to another fall along with worsening confusion over the past few weeks. The family does not believe the patient suffered any significant injury today, but brings here in due to her worsening condition. The patient has no complaints at this time.

Vitals: All vital signs are normal.
General: The patient is disheveled, but in no acute distress.
HEENT: No signs of trauma. Normal exam.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmur.
Abdomen: Non-tender, moderately distended, bowel sounds present. The umbilicus appears unusual- see image provided.This area in the umbilicus is a firm raised nodular density that appears crusted-over. There is no organomegaly present.
Neurologic: Patient is oriented to person and family. She has diffuse weakness and poor effort, but there are no focal deficits noted.
Skin: Relevant findings as shown.

Sister Mary Joseph’s nodule

Underlying malignancy with metastasis to the umbilicus.

This patient’s umbilical abnormality is consistent with Sister Mary Joseph’s nodule, which is a metastatic lesion from an intra-abdominal or pelvic malignancy. This finding is named for Sister Mary Joseph Dempsey, a nurse at St. Mary’s Hospital in Rochester, Minnesota, who first recognized the association between periumbilical nodules and metastatic intra-abdominal malignancies. The most common culprit is gastric malignancy, but Sister Mary Joseph’s nodule may also be seen in ovarian, endometrial, colorectal, and pancreatic cancers. As part of our patient’s traumatic workup, a CT abdomen/pelvis was performed, which revealed a large retroperitoneal mass encasing the aorta and iliac arteries, extensive lymphadenopathy, a markedly enlarged uterus, and multiple soft-tissue implants including the one within the umbilicus. Imaging was also notable for a cirrhotic liver with multiple hypodense lesions. During her hospitalization, she underwent lymph node biopsy, which revealed small cell carcinoma concerning for high-grade neuroendocrine cancer. The prognosis for patients with Sister Mary Joseph’s nodule is generally poor, as this finding indicates advanced cancer that is already metastatic.

Take-Home Points

  • Sister Mary Joseph’s nodule is a rare but serious physical exam finding that is concerning for advanced metastatic cancer.
  • A thorough physical exam is important in all patients presenting to the ED- more may be missed by not looking than by not knowing.

  • Dar IH, Kamili MA, Dar SH, Kuchaai FA. Sister Mary Joseph nodule-A case report with review of literature. J Res Med Sci. 2009 Nov;14(6):385-7. PMID: 21772912; PMCID: PMC3129082.
  • Abu-Hilal M, Newman JS. Sister Mary Joseph and her nodule: historical and clinical perspective. Am J Med Sci. 2009;337(4):271-273. doi:10.1097/MAJ.0b013e3181954187

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2026-02-06T11:36:28-08:00Feb 16, 2026|SAEM Clinical Images|
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SAEM Clinical Images Series: Bilateral Leg Swelling with a Uterine Twist

The patient is a 40-year-old female who presents to the Emergency Department with bilateral leg swelling. Her symptoms started six days prior and have progressively worsened. Her symptoms are associated with shortness of breath with no chest pain. The patient has taken an over-the-counter diuretic, which has helped with her symptoms. She also reports intermittent vaginal bleeding for the past two months, with a LMP that was two months prior. She is not currently on contraceptives, and does endorse unprotected intercourse over this time. The patient denies headache, blurry vision, nausea or vomiting, abdominal pain, urinary complaints, diarrhea or constipation. She has no other complaints at this time.

 

Vitals: BP 140/86; HR 97; R 14; T 99°F; O2 sat 99% on room air.

General: Well appearing, no acute distress.

Respiratory: Clear to auscultation.

Cardiovascular: Regular rate and rhythm, no murmur.

Abdomen: Soft, nondistended, nontender.

Extremities: Trace bilateral pitting edema. Normal range of motion, neurovascularly intact, equal pulses bilaterally.

Neurological: No focal neurological deficits.

Hgb: 9.6 (previously 13.3 two years prior)

Creatinine: Normal

BNP: 706 pg/mL

Serum ꞵ-HCG: 874,342 mIU/ml

This patient has a complete molar pregnancy.

Molar pregnancy is part of a spectrum of gestational trophoblastic tumors that include benign hydatidiform moles, locally invasive moles, and choriocarcinoma. Patients classically present with painless first or early second trimester vaginal bleeding with uterine size larger than expected gestational age and excessively high β-hcg levels. Some patients develop anemia, hyperemesis gravidarum, clinical hyperthyroidism, and signs of preeclampsia including hypertension, headaches, proteinuria and edema. Acute respiratory distress can occur due to embolization of trophoblastic tissue into the pulmonary vasculature, thyrotoxicosis, or simple fluid overload. Management involves removal of molar tissue through D&C or dilation and suction evacuation. Histopathologic examination of the products of conception is the gold standard for the diagnosis of a molar pregnancy. β-hcg levels are then monitored to ensure complete resolution and to detect any signs of persistent trophoblastic disease. In some cases, adjunct chemotherapy or even hysterectomy may be needed.

Take-Home Points

  • Molar pregnancy can be diagnosed with excessively high β-hcg levels and an ultrasound that shows a classic “snowstorm” or “bunches of grapes” finding.

  • Consider gestational trophoblastic disease in any patient with signs and symptoms of preeclampsia prior to 20 weeks gestation.

  • Cavaliere A, Ermito S, Dinatale A, Pedata R. Management of molar pregnancy. J Prenat Med. 2009 Jan;3(1):15-7. PMID: 22439034; PMCID: PMC3279094.
  • Soper, John T. MD. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics & Gynecology 137(2):p 355-370, February 2021. | DOI: 10.1097/AOG.0000000000004240

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-01-31T19:31:26-08:00Feb 6, 2026|Ob/Gyn, SAEM Clinical Images|
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SAEM Clinical Images Series: A Curious Case of Abdominal Pain

The patient is a 22-year-old G0P0 female who presents to the Emergency Department with two days of left lower quadrant abdominal pain. The patient rates her pain as 10/10 in intensity, sharp in character, and states the pain radiates to her lower back. She notes similar intermittent pain over the past few months, but the pain became persistent over the past two days and has worsened. She also reports decreased appetite with nausea and vomiting. Her pain is exacerbated by movement. She began her menstrual period three days before presentation and denies being sexually active. She was previously prescribed oral contraception for treatment of menorrhagia, but discontinued it five months ago. She denies any fever, chills, chest pain, shortness of breath, urinary frequency, dysuria, vaginal discharge, bleeding, or vaginal pain.

 

Vitals: BP 132/84; HR 89; R 17; T 98.6°F; O2 sat 100% on room air

General: Appears uncomfortable due to pain.

Cardiovascular: Normal rate, regular rhythm.

Abdominal: Soft, non-distended, LLQ tenderness to palpation without rebound or guarding, bowel sounds present.

Genitourinary: No active bleeding or discharge, no signs of infection. No masses palpated.

WBC: 4.8

Hgb: 13.2

BMP: Normal

LFT’s: Normal

Urinalysis: Normal

Urine pregnancy test: Negative

This patient has a mature cystic teratoma (Dermoid Cyst).

Mature cystic teratomas (MCTs), also known as dermoid cysts, are benign ovarian germ cell tumors. While MCTs can occur in women of any age, they are found primarily in patients of reproductive age, with a median age of mid-30s. Patients may present asymptomatically, or with symptoms including nausea/vomiting, abdominal pain, and vaginal bleeding. Pelvic ultrasound or abdominal CT are first-line imaging studies, as well as laboratory testing to include ruling out pregnancy. In this patient with a negative UA and urine pregnancy test, abdominal CT was obtained and showed a large pelvic mass containing bony structures. Intraoperatively, the patient was found to have a large left ovarian dermoid cyst with evidence of torsion. The cyst contained multiple teeth and brown hair, and the diagnosis was confirmed with surgical pathology. Ovarian torsion is a serious complication of MCT and occurs in 3% to 21% of cases. If concomitant ovarian torsion is suspected, emergent gynecologic consultation is warranted.

Take-Home Points

  • Dermoid cysts are benign ovarian germ cell tumors that may grow large, cause significant pain, and often contain teeth and hair.

  • Ovarian torsion is an emergent potential complication of dermoid cysts and may require emergent consultation and surgical intervention.

  • Cong L, Wang S, Yeung SY, et al. Mature Cystic Teratoma: An Integrated Review. Int J Mol Sci. 2023;24(7):6141. doi: 10.3390/ijms24076141. PMID: 37047114.
  • Ahmed A, Lotfollahzadeh S. Cystic Teratoma. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. PMID: 33231995.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-01-31T19:24:41-08:00Feb 2, 2026|Ob/Gyn, SAEM Clinical Images|
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SAEM Clinical Images Series: Quirky Quincke’s

The patient is a 38-year-old male with no past medical history who presents to the Emergency Department with chief complaint of “swollen uvula” that started 4 hours ago. The patient reports that he woke up this morning with pain in his throat and associated shortness of breath secondary to swelling. States he looked in his mouth in the mirror and saw that his uvula was swollen, prompting his visit to the ED. He states that he took Benadryl and Tylenol at onset of symptoms with no relief. The patient denies fever, cough, runny nose, nausea, vomiting, or drooling and has had no known sick contacts, changes in diet, or new medications. He denies smoking or any illicit drug use. He reports that this happened to him once before years ago when he was in his 20s, when he had similar presentation with edema of his uvula that was treated with Benadryl and a “shot” that he received 1 time in the emergency department with significant improvement and resolution of symptoms. He has no other complaints at this time.

 

quincke

Vitals: BP 115/69 HR 86 R 17 T 98.2 O2sat 100% room air.

General: Well appearing, no acute distress, normal voice.
HEENT: Relevant findings as shown. There is no drooling, pooling of secretions, muffled voice, lip swelling, or trismus. No signs of
peritonsillar abscess.
Neck: Non-tender to palpation. No swelling or adenopathy present.
Respiratory: Clear to auscultation bilaterally, breathing comfortably.

Influenza, COVID, Rapid Strep: negative

Quincke’s Disease (isolated angioedema of the uvula)

Quincke’s disease is an uncommon clinical diagnosis with unknown incidence; there are multiple causes reported in the literature. The most commonly reported cause is Type 1 hypersensitivity reaction. Other reported causes include hereditary angioedema, inhalation exposure, thermal injuries, and infections. In our particular case, we suspect hereditary angioedema given the patient’s prior history of the same issue. The ED management of uvular angioedema should include treatment with antihistamines, corticosteroids, NSAIDs and/or epinephrine in severe cases. Antibiotics are indicated if infection suspected. In cases of hereditary angioedema, patients may benefit from recombinant C1 esterase inhibitors. Patients with uvular angioedema should be closely monitored for signs of worsening respiratory compromise. If the patient worsens, admission for close observation should be considered or in severe cases, intubation for airway protection may be necessary. If the edema is not progressing, mild or uncomplicated, and/or resolved after treatment, patients can be safely discharged home. Our patient was monitored in the ED for over 2 hours without worsening and was discharged home with close follow up.

Take-Home Points

  • Quincke’s disease is an uncommon phenomenon of isolated uvular edema with multiple possible etiologies.
  • Airway patency is the primary concern when managing uvular angioedema.

  • Gabriel Atan Sanchez, Madison Boot, Abdul Lathif, Quincke’s disease: an unusual pathology, Journal of Surgical Case Reports, Volume 2023, Issue 3, March 2023, rjad085, https://doi.org/10.1093/jscr/rjad085
  • Mohammadi, Ladan1,; Miller, Anthony2; Ashurst, John V.3. Quincke’s disease. Journal of Family Medicine and Primary Care 5(3):p 677-679, Jul–Sep 2016. | DOI: 10.4103/2249-4863.197308
  • Gonçalves FMF, Costa M, Campos AL, Cotter J. Quincke’s Disease Presenting After Cocaine Exposure. Cureus. 2022 Oct 21;14(10):e30536. doi: 10.7759/cureus.30536. PMID: 36415441; PMCID: PMC9675901.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-01-25T20:55:37-08:00Jan 30, 2026|ENT, SAEM Clinical Images|
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SAEM Clinical Images Series: Pain, Paralysis, and Rash

The patient is an 81-year-old female with a history of asthma and hypertension who presents to the Emergency Department with right-sided abdominal swelling for five days. Five days ago, the right side of her abdomen appeared to protrude more than the left. This protrusion then increased over the next 2-3 days. The patient was diagnosed with shingles to the right lower abdomen earlier that month, but her rash has now nearly resolved. She continues to have “electric” pain in the region of the prior shingles infection. She denies any fevers, abdominal trauma, vomiting, or changes in bowel or bladder habits. She has never had anything like this before.

 

Vitals: All vital signs are normal.

Abdomen: See image provided. There is a firm unilateral distention of the right lower abdomen without shifting dullness or fluid wave. No palpable masses are present. There is moderate tenderness over the protruding region but no rebound or guarding. Bowel sounds are present.

Skin: See image provided. Moderate tenderness to palpation over region.

CBC and CMP are unremarkable.

CT scan of the abdomen and pelvis: No evidence of acute abnormality. Normal appendix. Moderate stool burden.

This patient has a Zoster pseudohernia.

Varicella-Zoster Virus (Shingles).

Zoster pseudohernia (ZP) occurs when the zoster infection infiltrates a posterior thoracic dermatome, affecting the spinal nerve roots responsible for the motor function of the abdominal wall. ZP typically presents with a rapidly progressive unilateral outpouching of the abdomen, giving a hernia-like appearance, but with intact abdominal wall musculature. In most cases, the classic Herpes Zoster rash precedes ZP, however in up to 10% of patients ZP may be the first presenting sign of zoster. Although uncommon, the symptoms are often distressing to patients, with many presenting to emergency departments or surgical offices for initial evaluation. The diagnosis is clinical and is based on a history of zoster infection or classic zoster symptoms and lack of findings suggesting alternate pathology. Abdominal CT or other imaging is recommended to exclude tumors, true hernias, free fluid, or other possible causes of abdominal distention. Electromyography (EMG) can be used to support diagnosis and will typically be abnormal due to the dysfunction of the abdominal wall musculature. Complete recovery occurs in 70-80% of patients within about 4-5 months.

Take-Home Points

  • Zoster Pseudohernia is a rare presentation of herpes zoster infection resulting in dysfunction of the abdominal wall musculature.

  •  There is no specific treatment with most cases fully resolving within several months to one year.

  • Chernev I, Dado D. Segmental zoster abdominal paresis (zoster pseudohernia): a review of the literature. PM R. 2013 Sep;5(9):786-90. doi: 10.1016/j.pmrj.2013.05.013. PMID: 24054853.
  • Yoo J, Koo T, Park E, Jo M, Kim MS, Jue MS. Abdominal pseudohernia caused by herpes zoster: 3 case reports and a review of the literature. JAAD Case Rep. 2019 Aug 5;5(8):729-732. doi: 10.1016/j.jdcr.2019.06.019. PMID: 31440570; PMCID: PMC6698640.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-01-25T20:35:10-08:00Jan 26, 2026|Infectious Disease, Neurology, SAEM Clinical Images|
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SAEM Clinical Images Series: A Pedunculated Bone to Pick

knee

The patient is a 46-year-old male with a past medical history of chronic left knee pain, hypertension, and congestive heart failure who presents to the Emergency Department with worsening left knee pain. He had been walking more frequently of late to increase his exercise, but denies any falls or specific trauma. He noticed some swelling to the area over the past few days but there has been no redness, rash, or fever. He also denies calf pain, lower leg swelling, and shortness of breath. He has no other complaints at this time but due to his worsening
pain and mild swelling, he comes in for evaluation.

 

Vital Signs: All vital signs are normal.
General: Well appearing, no acute distress.
Cardiovascular: No murmurs, 2+ peripheral pulses in all extremities.
Extremities: Left knee exam shows a small suprapatellar effusion and mild tenderness to palpation; there is no erythema, deformity, or crepitus; he has full active and passive range of motion.

The patient has an osteochondroma.

Asymptomatic growths require no intervention. Symptomatic patients should be referred to orthopedics for consideration of resection.

Osteochondromas are the most common benign bony tumor and occur due to hamartomatous growth of cartilage. The characteristic x-ray appearance is a sessile or pedunculated bony growth located in the metaphysis projecting away from the epiphysis, as seen in this case. These lesions are more commonly seen in males and are typically diagnosed in the first four decades of life, with 75% of diagnoses occurring before the age of twenty. Patients typically present with painless masses close to tendon insertion sites, most commonly near the knee. There is a low risk of malignant transformation. Patients with Multiple Hereditary Exostoses, a rare autosomal dominant genetic condition, may present with numerous osteochondromas with a greater potential for malignant transformation. While the majority of osteochondromas are asymptomatic, symptoms may develop due to impingement on nearby structures or from fractures. If patients have persistent symptoms or cosmetic concerns, they can be referred to orthopedic surgery for consideration of resection. There have been no approved medical therapy options for osteochondroma.

Take-Home Points

  • Osteochondromas are benign bony tumors that typically present as painless masses and are also commonly found incidentally on x-ray.
  • Treatment is usually supportive; however, orthopedic surgery referral should be considered for persistent or severe symptoms.

  • Paras T, O’Donnell P. Osteochondroma & Multiple Hereditary Exostosis. Orthobullets.   Rauf A, Gaillard F. Osteochondroma. In: Radiopaedia.Org. Radiopaedia.org; 2005. doi:10.53347/rID-1799
  • Tepelenis K, Papathanakos G, Kitsouli A, et al.   Osteochondromas: an updated review of epidemiology, pathogenesis, clinical presentation, radiological features and treatment options. In Vivo. 2021;35(2):681-691. doi:10.21873/invivo.12308

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2026-01-06T10:24:09-08:00Jan 12, 2026|SAEM Clinical Images|
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