A previously healthy 10-year-old boy presents to the emergency department (ED) for new-onset anasarca and laboratory test result abnormalities. One week before presentation he developed periorbital edema on awakening in the morning that would resolve by the afternoon. Three days before presentation he had abdominal swelling without pain and subsequently developed peripheral edema. He presented to the pediatrician’s office, where a 10-lb (4.5-kg) unintentional weight gain and progressive fatigue (described as frequent naps by his mother) over 2 months were noted. Serum chemistries were significant for a low total protein level (3.8 g/dL [38 g/L]) and hypoalbuminemia (album level, 2.7 g/dL [27 g/L]). Abdominal ultrasonography was ordered to further assess the abdominal swelling and demonstrated a small amount of ascites, mildly heterogenous liver echotexture, mild splenomegaly, and a mildly distended inferior vena cava. The patient’s review of symptoms at the time of presentation is otherwise negative, including no diarrhea, dyspnea...
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