but its occurrence in pediatric patients is rare , especially associated with moderate to severe hypoproteinemia . it was first described in 1886 and occurs in 4% of total and less than 1% of newly diagnosed cases in adults . most of these patients undergo unnecessary procedures such as multiple paracentesis , gastrointestinal ( gi ) and liver biopsies before the actual diagnosis is made often leading to unnecessary delay in diagnosis . therefore in patients presenting as ascites of unknown etiology with physical and developmental delay , hypothyroidism should be kept as differential , as treatment leads to fast recovery . we report a case of 4-year - old female child , who presented to us with history of progressively increasing abdominal distension and minimal pedal edema for 2 months . there was no preceding history of fever , oliguria , orthopnea , jaundice , bleeding , any cough , h / o koch 's contact or recurrent diarrhea suggestive of malabsorption syndrome . she had these symptoms intermittently for past 2 years for which she was treated with diuretics . she was first live issue born at term by vaginal delivery following uncomplicated pregnancy and was immunized for age . she had a history of developmental delay , with developmental age corresponding to 2 years . she was documented to have hypoproteinemia without proteinuria on multiple occasions and had undergone liver and even cardiac biopsy for possibility of some restrictive cardiomyopathy , both of which reported as normal . her weight and height were both below 3 centiles . on examination , she was afebrile with pulse rate 64/min , respiratory rate 34/min and blood pressure of 80/60 mm of hg . there was mild periorbital puffiness , minimal pedal edema , pallor and normal jugular venous pressure . abdominal examination revealed grossly distended abdomen with liver palpable 3 cm below right costal margin , non - tender with smooth surface and sharp margins . her complete blood count revealed hemoglobin of 10.2 , white blood cells ( wbc ) 12,700 ( p56 , l40 , m3 , e1 ) , platelets 4.13 lakhs / cmm with macrocytosis on peripheral blood smear . total serum protein was 3.1 mg / dl with 2.2 mg / dl of albumin and normal liver function tests . her renal functions , electrolytes , calcium , urine for albumin and chest x - ray were normal . echocardiogram ( echo ) revealed intrinsically normal heart with normal ejection fraction and minimal pericardial effusion . diagnostic paracentesis revealed 58 cells/l , with 82% lymphocytes , 68 mg% sugar , 148 mg% cholesterol and 2.8 mg / dl of total proteins , 1.9 mg / dl of albumin with serum - ascites - albumin gradient ( saag ) of 0.3 mg / dl . thyroid profile was suggestive of hypothyroidism with total serum t3 = 0.84 nmol / l , t4 = 48 nmol / l and thyroid - stimulating hormone ( tsh ) = 30 miu / l . on treating with thyroxine replacement at 4 g / kg / day , ascites started decreasing 3 weeks following treatment [ figure 2 ] . nmol / l , t4 = 79 nmol / l and tsh = 4.3 miu / l . this is potentially curable with thyroxin replacement unlike chronic hepatic and renal diseases where little can be offered to patients . in evaluation of new cases of ascites , the study of ascitic fluid , especially total protein and saag may curtail the list of different invasive and expensive investigations . chronic liver disease , congestive cardiac failure , chronic renal disease , nephrotic syndrome , malnutrition or hypoalbuminemia of any other cause produces transudate . of various causes , tubercular peritonitis , pyogenic peritonitis , peritoneal malignancies and pancreatic causes can all lead to high protein ascites . however , hypothyroidism is a rare possibility that should be kept considered in evaluation of exudative ascites . ascitic fluid in case of hypothyroidism reveals high protein ( > 2.5 g / dl ) and saag value is usually low although it may vary . review of literature revealed 52 documented cases of myxedema ascites in adults . a very consistent finding was high total protein level ( > 2.5 g / dl ) in almost all cases with mean saag of 1.5 g / dl with a range of 0.8 - 2.3 g / dl . wbc counts were rather low , usually with a lymphocytic predominance with a mean of 60 cells/l and 81% lymphocytes . in our patient , one is that low levels of circulating thyroid hormones cause increased extravasations of plasma proteins because of abnormal capillary permeability with a lack of a compensatory increase in lymph flow and protein return rate which also accounts for hypoproteinemia in the case of hypothyroidism . the second hypothesis is that hyaluronic acid accumulated in the skin produces edema by direct hygroscopic effect . however , hyaluronic acid has only been found in minute quantities in patients with myxedema ascites , not large enough to exert a direct hygroscopic effect . but it could interact with albumin to form complexes that prevent the lymphatic drainage of extravasated albumin . prompt recognition of hypothyroid ascites prevents the inappropriate use of diuretics and unnecessary procedures , including repeated paracenteses and liver biopsies . once routine evaluation of ascites excludes common causes , thyroid function tests should be performed on patients with clinical features suggestive of hypothyroidism and high protein levels in the ascitic fluid .
hypothyroidism is frequently encountered condition to a pediatrician . passive effusions into serous cavities , sometimes to considerable amount are frequently noted . 
 however , the significant ascites caused by this is rare in a child and in no instance , it is too excessive . 
 so diagnosis is frequently delayed and patient frequently receive unnecessary procedures such as liver , even gastrointestinal biopsies . 
 analysis of ascitic fluid shows exudative nature with high protein . 
 the case we present here is a 4-year - old female child with recurrent ascites , developmental delay and hypoproteinemia . 
 high index of suspicion can lead to diagnosis . over all prognosis 
 is excellent after stating replacement therapy with l - thyroxine .