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A 41-year-old healthy female underwent cholecystectomy due to symptomatic gallstone related acute cholecystitis. A week later she was readmitted with fatigue, low grade fever, worsening pallor, generalized edema including bilateral leg swelling and abdominal distension with pain. Laboratory evaluation showed mild normocytic anemia (Hgb 7 g/dL [12–16 g/dL]), mean corpuscular volume 92 fL (80–100 fL), mild leukocytosis with WBC count 12,000/µL (4000–11,000/µL), thrombocytopenia (platelet count 55,000/µL [150,000–400,000/µL]). Comprehensive metabolic panel showed normal serum electrolytes, blood urea nitrogen, creatinine, and liver profile, except for low serum total protein of 5.1 g/dL (6.1–8.2 g/dL) and hypoalbuminemia (albumin 2.4 g/dL [3.4–4.7 g/dL]). Urinalysis showed proteinuria and an elevated random protein-to-creatinine ratio of 3.8. A 24-h urine collection revealed an elevated total protein of 3.1 gm/24 h, consistent with nephrotic range proteinuria. A contrast computerized scan (CT) of chest, abdomen and pelvis showed moderate bilateral pleural effusions, and moderate ascites: no other abnormality was noted in the chest, abdomen, or pelvis. Diagnostic and therapeutic paracenteses were performed draining about 3000 ml of straw-colored fluid. Analysis showed a serum-ascites-albumin gradient (SAAG) of 1.9 g/dL with a normal cell count and negative cytology.