{'fraction_non_alphanumeric': 0.035667107001321, 'fraction_numerical': 0.02509907529722589, 'mean_word_length': 4.6255572065378905, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A 47-year-old woman with persistent watery diarrhea, proteinuria, proximal weakness and monoclonal gammopathy.

Case report A 47-year old woman was admitted to our hospital because of severe watery diarrhea, edema and profound weakness. The patient had been well until 5 months earlier when progressive, prominent, proximal weakness developed. The patient had difficulty in walking, rising from a chair and raising her arms. Gradually pedal edema developed. Three months earlier the patient was complaining of intermittent pain in both temporomandibular joint regions with radiation to the teeth and progressive difficulty in opening her mouth. Twenty days before admission she had an abrupt onset of nausea, vomiting, cramping abdominal pain and watery diarrhea. The patient passed approximately 15 watery stools daily without blood. Three days before her admission she began to have dysphagia. The patient was a medical doctor and the mother of two children, with a normal menstrual cycle and a history free of disease, tobacco smoking, and alcohol consumption. Her temperature was 37°C, pulse 110/min and respirations 20/min. Her blood pressure was 120/80 mmHg without signs of orthostatic hypotension. The patient appeared lethargic and had dysphonia. The lungs and heart were found to be normal. The skin was pale without abnormal pigmentation or rash. No lymphadenopathy was found. The neck was supple and the thyroid gland was not palpable. Attempts to open the patient’s jaw by applying pressure to the chin were unsuccessful (lockjaw) and she was unable to protrude her tongue. The abdomen was tense but not tender and the liver and spleen were not palpable. A subcutaneous nodule was palpable in the upper right part of the abdomen. There was 3+ edema in the feet and legs and trace edema in the hands. The joints were normal. Rectal examination was negative; a greenish watery liquid was present within the rectum and gave a negative test for occult blood. The genitalia were normal. There was a reduction of strength (grade 3/5) in the proximal muscles of both limbs. Tendon reflexes, vibration, joint position, pin prick and temperature sensations were normal. There was marked wasting of both masseter muscles. The optic fundi appeared normal; the pupils were normal in size and shape, and reacted normally to light and accommodation. No other neurological abnormalities were detected. The patient’s hematocrit was 37% and her white cell count was 6,800/mm3 with 57% neutrophils, 14% lymphocytes, and 24% monocytes. The platelet count was 320,000/mm3 and the ESR 75 mm/hr. Creactive protein was 268 mg/dl. Urinalysis gave a ++ positive test for protein; the sediment contained 8 red cells per high power field; no red cell casts were seen. In a 24-hr urine specimen the protein was 1 gr. The prothrombin time and partial thromboplastin time were normal. The urea nitrogen was 51 mg/dl, creatine 1.5 mg/dl, bilirubin 1 mg/dl, calcium 11.5 mg/dl, uric acid 8.8 mg/dl and protein 4.8 g/dl (albumin 2.8 g and globulin 2 g/dl). The sodium was 147 mmol and the potassium 4.4 mmol/L. ASAT was 17 U/L, ALAT 20 U/L, LDH 300 U/L, creatinophosphokinase 48 U/L, amylase 92 U/L and alkaline phosphatase 229 U/ L. Tests for hepatitis B surface antigen and human immunodeficiency virus antibodies were negative. Rheumatoid factor and cryoglobulins were negative. C3 was 104 mg/dl and C4 was 46 mg/dl. A thyroid function test was normal. Serum protein electrophoresis revealed a discrete band in the region of the γ-globulins and severe hypoglobulinemia. Immunofixation of the serum showed a 1Hematologist MD, Department of Internal Medicine, Evgenidio Hospital; 2Pathologist MD, Department of Pathology, Evgenidio Hospital; 3Professor of Internal Medicine, Harokopio University, Athens.