A 2-year-old boy was admitted with a 2-week history of lethargy, abdominal distension, and peripheral edema. Two months before admission, he had undergone abdominal surgery for removal of a 13×12-cm mass demonstrated on computed tomography that was located on the left side of his abdomen (Fig 1). This was a 620-g tumor of the left kidney. Histologic examination showed a Wilms' tumor, and the child was referred for further evaluation and treatment.
On admission the child was ill, with malar flush, eyelid edema, and distended jugular veins. Continuous nodding of the head was apparent. His heart rate was 120 beats per minute, the heart sounds were weak, and a 2/6 systolic murmur was heard over the precordium. The abdomen was distended, and a scar of the left flank was present. Ascites was observed, and pitting edema was noticed on the lower extremities. The liver was palpated 3 cm below the