The Book of Sin

Effect

Generates a random pickup, pill, card, or rune.
- This includes (Added in Repentance)(Cracked Key) Cracked Key, (Added in Afterbirth)(Dice Shard) Dice Shard, and (Added in Afterbirth)(Emergency Contact) Emergency Contact.
- Hearts can be of any type other than Blended Hearts.
- (Penny) Pennys can be of any type, with higher value coins and (Added in Afterbirth) (Lucky Penny) Lucky Pennys being rarer.
- (Bomb) Bombs and (Key) Keys will always be singular (unless Isaac has Bogo Bombs and/or Humbling Bundle).
Each pickup seems to be equally likely, which means that there is around a 1/7 chance to get a particular type of pickup.
(Added in Afterbirth †) This item belongs to the Bookworm set. Collecting three items from this set will transform Isaac into Bookworm.

Synergies

(Added in Repentance) Book of Virtues: Grants a random wisp based on one of the Seven Deadly Sins. The wisp spawned isn't linked to the pickup dropped.
- (Pride) Pride: a blue bomb wisp in the middle ring. Unlike the Wrath ones, their tears have no effect, they don't drop troll bombs, nor a bomb pickup on death.
- (Greed) Greed: 3 yellow coin wisps in the outer ring. Their tears may petrify enemies like Midas' Touch.
- (Wrath) Wrath: an orange bomb wisp in the middle ring, which fire flaming tears. They drop troll bombs when continuously firing, and leave a bomb pickup when they die.
- (Envy) Envy: a white face-like wisp in the outer ring.
- (Lust) Lust: a randomly colored pill wisp in the inner ring, with effects that are the same as Mom's Bottle of Pills wisps.
- (Gluttony) Gluttony: a heart wisp in the middle ring, with effects that are the same as Yum Heart wisps.
- (Sloth) Sloth: a Bob's Head wisp in the middle ring. Their tears travel in an arc like Ipecac but don't always explode on impact. There is a small chance for an exploding tear.