Dyspnea, Tachycardia, and New Onset Seizure as a Presentation of Wilms Tumor: A Case Report

Wilms tumor is found in 1 in 10,000 children and most commonly presents in asymptomatic toddlers whose care givers notice a nontender abdominal mass in the right upper quadrant. This case of Wilms tumor presented as a critically ill eleven-year old with significant tachypnea, dyspnea, vague abdominal pain, intermittent emesis, new onset seizure, metabolic acidosis, and hypoxemia. This is the first case in the literature of Wilms Tumor with cavoatrial involvement and seizure and pulmonary embolism resulting in aggressive resuscitation and treatment. Treatment included anticoagulation, chemotherapy, nephrectomy, and surgical resection of thrombi, followed by adjunctive chemotherapy with pulmonary radiation. 1. Introduction Wilms tumor (WT) is found in 1 in 10,000 children. The classical diagnosis of WT is through the incidental finding of a palpable abdominal mass on an otherwise asymptomatic young child. This case describes an unusual presentation in an adolescent who presented with abdominal pain, emesis, shortness of breath, tachycardia with palpitations, and new onset seizure. The patient described presented to physicians in a critical state and appeared to have a cardiac or neurologically related diagnosis. This rare presentation of Wilms tumor should be regarded when abdominal pain patients present with a myriad of symptoms. 2. Case Report An 11-year-old female presented to the emergency department after a week-long history of intermittent abdominal pain and was found to be tachycardic up to 190’s. Six days prior to arrival she had her first episode of abdominal pain with emesis. She was at school and described the pain as vague and diffuse. The episode spontaneously resolved without intervention or medication, but she still complained of residual intermittent abdominal pain throughout the following week. Similar abdominal pain and nonbloody, nonbilious emesis brought her back to the school nurse on the day of ED visit. She had difficulty walking to the office due to dyspnea. The mother witnessed the patient having 2 episodes of seizure-like activity including clenching of the hands, stretching of the feet, and foaming at the mouth with lip cyanosis and incontinence lasting a total of 15 minutes. Upon arrival at the ED, the patient was severely tachycardic with an ECG demonstrating sinus tachycardia at 190？bpm with intraventricular conduction delay. The tachycardia improved to 130？bpm after fluid resuscitation with normal saline. The patient recalled experiencing similar palpitations in the past week that worsened with activity and improved with