Essential Documents for Buying a Boat in Florida: What You Need to Know
Buying a boat in Florida is an exciting venture. With so many waterways to explore, it’s no wonder that many people are drawn to this state’s boating lifestyle. But before you hit the open water, there are some essential documents you need to have in order. This isn’t just about keeping things legal; it’s about ensuring your investment is protected and that you can fully enjoy your new vessel.
Understanding the Importance of a Bill of Sale
The bill of sale is one of the most crucial documents you’ll need when buying a boat. This legal document serves as proof of the transaction and outlines the details of the sale. Think of it as your receipt, but with far more detail. It should include information such as the buyer’s and seller’s names, the boat’s hull identification number (HIN), and the purchase price.
Without a bill of sale, you might face challenges when it comes to registering your boat or proving ownership. In Florida, a bill of sale is essential, especially for motorized boats. You can find a reliable template for this document online, such as the one available at https://doctemplatehub.com/florida-boat-bill-of-sale-template/. Having this document properly filled out protects both you and the seller.
Title Transfer: The Key to Ownership
Next up is the title transfer. When you buy a boat, you need to ensure that the title is transferred from the seller to you. This is how you officially become the owner of the vessel. In Florida, the seller must sign the title over to the buyer, and this must be completed before you can register the boat in your name.
Make sure to double-check that the title is free of any liens. If the seller owes money on the boat, you could inherit that debt. To avoid complications later, it’s best to verify this before finalizing your purchase.
Registration: Making It Official
After securing the title, the next step is registration. In Florida, all boats must be registered with the Florida Department of Highway Safety and Motor Vehicles. This is where you’ll need to present your bill of sale, the signed title, and proof of identity. The registration fee varies depending on the length of the boat.
Keep in mind, if you’re buying a used boat, the previous owner’s registration will not transfer to you. You’ll need to start fresh. This is a critical step that many new boat owners overlook. Without proper registration, you risk fines and legal issues.
Insurance: Protecting Your Investment
Insurance might not be a document in the traditional sense, but it’s a vital part of owning a boat. Florida is known for its unpredictable weather and waterways, making insurance a must-have. Depending on your boat’s size and usage, you may need different levels of coverage.
When shopping for insurance, consider factors like liability coverage, physical damage coverage, and additional protections for towing or personal belongings. For example, if you’re planning to boat in areas with heavy traffic, adequate liability coverage is especially important.
Other Important Documents to Consider
Beyond the bill of sale and title, there are several other documents you might need. Here’s a quick list to keep in mind:
Proof of identity (driver’s license or state ID)
Previous registration documents (if applicable)
Inspection reports for used boats
Manufacturer’s Certificate of Origin (for new boats)
Having these documents in order can save you a lot of headaches down the line. Each piece plays a role in ensuring that your purchase goes smoothly.
Understanding Local Regulations
Florida has specific regulations that can affect your boat ownership. For instance, certain waterways may have restrictions regarding boat size, type, or even the necessity of life jackets. Familiarizing yourself with local laws can prevent unpleasant surprises.
Additionally, if you’re considering taking your boat into international waters, be aware of customs regulations. Every detail matters, especially if you plan to travel far from home.
Final Thoughts on Document Preparation
Preparing the necessary documents for buying a boat in Florida might seem daunting, but it’s a straightforward process once you know what to expect. From the bill of sale to title transfer and registration, each step is vital for ensuring a smooth transition into boat ownership. Take the time to gather all required documents and avoid rushing through the process.
Your journey into boat ownership should be enjoyable, not stressful. With the right preparations, you can spend less time worrying about paperwork and more time creating unforgettable memories on the water.
Guide complet du casino en ligne – Tout ce que vous devez savoir pour jouer en toute sécurité et maximiser vos gains
Le jeu en ligne connaît une explosion sans précédent : des millions de joueurs se connectent chaque jour pour tenter leur chance sur des plateformes qui offrent bien plus que les salles terrestres classiques. Cette montée en puissance s’explique par la facilité d’accès depuis un smartphone, la diversité des jeux disponibles et la possibilité de profiter de bonus généreux dès le premier dépôt.
Dans cet univers très concurrentiel, il est essentiel de s’appuyer sur des sources fiables pour choisir le nouveau casino en ligne qui correspond à vos attentes. Basketnews.Net se positionne comme le guide indépendant qui teste chaque offre, analyse les licences et classe les sites selon leurs performances réelles. Vous y trouverez des revues détaillées du meilleur casino en ligne France et des comparatifs mis à jour chaque semaine.
Ce guide vous propose un panorama complet : comment vérifier la licence d’un opérateur, quels jeux privilégier selon votre profil, décryptage des bonus d’accueil et promotions courantes, méthodes de paiement sécurisées et délais de retrait. Nous aborderons également le jeu responsable ainsi que les mesures de cybersécurité indispensables pour protéger vos données personnelles pendant votre session de jeu.
En suivant ces conseils avisés, vous pourrez naviguer sereinement entre les différents nouveaux sites de casino en ligne tout en augmentant vos chances de gains durables et sécurisés.
Section 1 – Comprendre les licences et la régulation des casinos en ligne (≈ 260 mots)
Une licence de jeu est le passe‑port légal qui autorise un opérateur à proposer ses services dans une juridiction donnée. Sans elle, aucun paiement ne peut être garanti et aucune protection du joueur n’est assurée ; c’est pourquoi la licence constitue le premier critère d’évaluation sur Basketnews.Net.
Parmi les autorités les plus reconnues figurent la Malta Gaming Authority (MGA), réputée pour son cadre fiscal attractif mais strict sur le RTP moyen ; l’UK Gambling Commission (UKGC), qui impose des exigences élevées en matière de lutte contre le blanchiment d’argent ; ainsi que Curaçao eGaming, souvent utilisée par les nouveaux sites mais avec un niveau de supervision moindre. D’autres juridictions comme l’Autorité Nationale des Jeux (ANJ) en France ou la Commission des Jeux de Gibraltar gagnent également du terrain auprès du meilleur casino en ligne 2026.
Pour vérifier la validité d’une licence, rendez‑vous sur le site officiel de l’autorité concernée et saisissez le numéro fourni dans le pied‑de‑page du casino choisi. Un lien direct vers le registre public doit apparaître ; l’absence de cette transparence est immédiatement signalée par Basketnews.Net comme un facteur négatif majeur.
La régulation influence directement la protection financière : une licence solide oblige l’opérateur à séparer les fonds joueurs dans des comptes bancaires distincts et à soumettre régulièrement ses rapports financiers aux auditeurs indépendants. Ainsi, lorsqu’un gain est déclaré – par exemple un jackpot progressif de €150 000 sur Mega Fortune – le joueur bénéficie d’une garantie légale d’encaissement dans les délais prévus par la loi locale.
Section 2 – Les différents types de jeux proposés en ligne (≈ 285 mots)
Les machines à sous restent le pilier du divertissement numérique grâce à leurs thèmes variés et leurs mécaniques simples à comprendre. On distingue trois grandes catégories :
– Classiques : trois rouleaux inspirés des premières machines mécaniques ; idéal pour ceux qui recherchent un taux de redistribution élevé (RTP souvent >96%).
– Vidéo : cinq rouleaux avec animations haute définition et multiples lignes gagnantes ; exemples populaires « Starburst » ou « Gonzo’s Quest ».
– Jackpots progressifs : chaque mise alimente un pot commun pouvant atteindre plusieurs millions d’euros ; « Mega Moolah » a déjà offert plus de $23 M à ses joueurs fidèles.
Les jeux de table offrent quant à eux une dimension stratégique plus prononcée. La roulette européenne reste favorite grâce à son seul zéro qui réduit l’avantage maison à seulement 2,7 %. Le blackjack “Perfect Blackjack” propose un RTP proche de 99 % lorsqu’on suit la stratégie optimale ; plusieurs variantes comme “Spanish 21” ou “Double Exposure” sont répertoriées sur Basketnews.Net avec leurs taux respectifs d’avantage du croupier. Le baccarat “Punto Banco” attire surtout les high rollers grâce à ses mises minimales élevées mais son edge minime (<1%).
Le poker en ligne a connu une renaissance grâce aux salles live‑streaming où les parties sont commentées par des pros internationaux ; cela crée une expérience spectateur‑joueur unique similaire aux tournois télévisés traditionnels. Des plateformes telles que PokerStars ou partypoker offrent également des cash games instantanés avec buy‑in dès €10 pour toucher une audience large tout en conservant une forte liquidité du pool prize‑pool .
Enfin les jeux avec croupier réel (« Live Dealer ») reproduisent l’ambiance d’un vrai casino via un flux vidéo HD sécurisé . Les critères essentiels sont la qualité du streaming (minimum Full HD), la rapidité du chat texte/voix et la disponibilité multilingue des dealers français ou anglais selon votre préférence.
Section 3 – Les bonus d’accueil et promotions : comment les évaluer intelligemment (≈ 250 mots)
Le welcome bonus constitue souvent le premier argument commercial d’un nouveau site de casino en ligne ; il se décline généralement sous trois formes distinctes :
– Bonus dépôt : généralement « 100 % jusqu’à €500 + 200 tours gratuits », conditionné à un dépôt minimum souvent fixé à €20 .
– Tours gratuits : attribués sans dépôt préalable mais soumis à un plafond mensuel limité ; ils permettent d’essayer des slots spécifiques sans risquer son capital initial .
– Bonus sans dépôt : rare chez les opérateurs régulés mais très attractif (« €10 offerts dès inscription ») avec conditions de mise élevées (>30x) afin d’éviter l’abus .
Les conditions de mise constituent le véritable piège : elles déterminent combien vous devez miser avant pouvoir retirer votre gain net provenant du bonus ou des tours gratuits . Par exemple un bonus €200 avec wagering ×35 exige €7 000 de mises totales – ce qui peut rapidement devenir coûteux si vous jouez principalement aux slots à volatilité élevée . Il faut donc comparer non seulement le montant offert mais aussi le ratio wagering / valeur réelle du bonus .
Les programmes fidélité diffèrent largement entre plateformes : certains proposent un cashback quotidien allant jusqu’à 12 % sur vos pertes nettes tandis que d’autres organisent des tournois hebdomadaires où chaque euro misé génère des points échangeables contre gadgets ou crédits freebet . Selon nos tests sur Basketnews.Net , les programmes combinant cashback progressif + points VIP offrent généralement le meilleur rendement global pour le joueur moyen.
Section 4 – Méthodes de paiement sécurisées et rapidité des retraits (≈ 295 mots)
Choisir une méthode adaptée dépend avant tout du montant envisagé ainsi du délai souhaité pour recevoir vos gains :
Cartes bancaires – Visa et MasterCard restent acceptées partout ; dépôt instantané tandis que retrait nécessite généralement entre 24 et48 heures après validation KYC . Frais éventuels autour de €0‑€2 selon la banque émettrice .
Portefeuilles électroniques – Skrill & Neteller offrent un traitement quasi immédiat tant côté dépôt que retrait (<15 minutes). Les plafonds varient toutefois selon votre statut KYC : jusqu’à €25 000/mois pour les comptes vérifiés .
Cryptomonnaies – Bitcoin ou Ethereum permettent anonymat renforcé et frais minimes (<0,5 %) mais peuvent subir une volatilité importante au moment du change EUR/crypto . Les retraits prennent habituellement entre quelques minutes et deux heures selon l’encombrement du réseau .
Virements bancaires – Solution classique pour gros montants (>€5 000) car elle assure traçabilité totale ; toutefois temps moyen =3‑5 jours ouvrés et frais pouvant atteindre €15 .
Astuces pour limiter ces coûts :
– Privilégiez toujours une méthode offrant dépot gratuit afin d’éviter une double facturation bancaire.
– Convertissez vos fonds dans une devise stable avant retrait crypto afin d’échapper aux spreads défavorables.
– Utilisez une carte prépayée liée directement au portefeuille électronique afin d’obtenir instantanément votre argent disponible sans passer par l’étape bancaire traditionnelle .
Basketnews.Net compare régulièrement chaque option sur chaque site testé afin que vous puissiez choisir celui qui combine sécurité maximale et délais optimaux correspondant au meilleur casino en ligne adapté à votre profil.
Le jeu responsable commence par fixer clairement ses limites financières :
Dépôt quotidien/hebdomadaire : définissez un plafond maximal (€100/jour ou €500/semaine) via votre compte utilisateur.
Limite temporelle : activez l’alarme session après X minutes jouées afin d’éviter l’épuisement mental.
Mise maximale : choisissez un montant maximum par pari qui ne dépasse pas <5 % de votre capital total .
La plupart des opérateurs agréés proposent aujourd’hui une fonction auto‑exclusion permettant bloquer définitivement ou temporairement l’accès au compte pendant six mois voire plusieurs années . Sur Basketnews.Net vous pouvez comparer rapidement chaque politique RGS/GRS — certaines plateformes offrent même l’option « pause illimitée » directement depuis leur tableau “Outils responsables”.
Reconnaître les signaux avant-coureurs est crucial : perte constante malgré augmentation des mises, sentiment d’anxiété avant chaque session ou recours fréquent aux crédits supplémentaires sont autant d’indicateurs qu’il faut prendre au sérieux . En cas besoin , plusieurs associations nationales telles que Joueurs.info ou Addiction Help Line proposent lignes téléphoniques gratuites ouvertes24/7 ainsi que forums anonymes où partager son expérience sans jugement.
Le chiffrement SSL/TLS représente la première barrière protectrice entre votre navigateur et le serveur du casino ; il se reconnaît facilement grâce au petit cadenas vert affiché dans la barre URL ainsi au préfixe “https://”. Sans ce protocole toutes vos informations – identifiants login , coordonnées bancaires , historiques de jeu – pourraient être interceptées par un tiers malveillant .
L’authentification à deux facteurs (2FA) renforce considérablement ce périmètre sécurisé : après saisie habituelle du mot‑de‑passe vous recevez un code unique via SMS ou application authentificatrice (Google Authenticator). L’activation ne prend quelques clics dans les paramètres “Sécurité” du compte utilisateur mais ajoute une couche supplémentaire indispensable surtout lors d’opérations importantes comme gros retraits (>€10 000).
La politique de confidentialité doit préciser quels types de données sont collectés (nom complet , adresse IP , habitudes de jeu) ainsi expliquer comment elles sont stockées conformément au RGPD européen*. Les joueurs européens disposent alors d’un droit à l’oubli complet pouvant être exercé via formulaire dédié ; aucune donnée résiduelle ne doit subsister après suppression définitive demandée par l’utilisateur .
Utiliser un VPN fiable lors d’une connexion depuis un pays où le jeu est restreint offre deux avantages majeurs :
1️⃣ Masquage efficace votre adresse IP réelle évitant géoblocages imposés par certaines autorités locales.
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En résumé , combiner SSL/TLS natif , activation systématique du 2FA, lecture attentive des clauses RGPD ainsi qu’une navigation VPN sécurisée constitue aujourd’hui la meilleure pratique recommandée par Basketnews.Net pour protéger vos fonds et votre identité numérique.
Section 7 – Choisir le meilleur casino en ligne selon vos critères personnels (≈ 260 mots)
Critère
Questions à se poser
Exemple d’évaluation sur Basketnews.Net
Budget
Quel est mon capital initial ?
Classement “Meilleurs bonus low‑budget”.
Type de jeu préféré
Slots vs Live dealer vs Poker
Filtre “Top jeux vidéo slots”.
Rapidité des retraits
Ai‑je besoin d’argent immédiatement ?
Tableau “Temps moyen retrait”.
Support client
Langue parlée ? Disponibilité chat/phone ?
Avis utilisateurs “Service client”.
Mobile / App
Je joue principalement sur smartphone ?
Test “Compatibilité mobile”.
Après avoir complété ce tableau mental, pondérez chaque critère selon son importance relative :
Si votre priorité est rapidité, donnez plus poids au temps moyen retrait indiqué dans notre comparatif annuel.
Pour les amateurs mobile, privilégiez uniquement les casinos certifiés compatibles iOS/Android avec application native fluide.
Lorsque votre budget reste limité (<€50), orientez-vous vers ceux proposant bonus sans dépôt modérés couplés à faibles exigences wagering.
En croisant ces éléments avec nos évaluations détaillées — notamment celles concernant nouveau site de casino online récemment lancé — vous serez capable de sélectionner précisément celui qui maximise plaisir tout en limitant risques financiers.
Conclusion – (≈ 180 mots)
Nous avons parcouru ensemble toutes les facettes essentielles permettant d’aborder sereinement l’univers du gambling digital : choisir un opérateur doté d’une licence fiable délivrée par une autorité reconnue ; sélectionner judicieusement ses jeux parmi slots volatiles ou tables stratégiques ; analyser minutieusement chaque promotion afin d’en extraire réellement la valeur ajoutée ; opter pour des méthodes financières sûres tout en maîtrisant délais et frais associés ; adopter quotidiennement bonnes pratiques responsables ainsi qu’une hygiène numérique rigoureuse grâce au chiffrement SSL/TLS voire au VPN lorsqu’il faut contourner restrictions géographiques.
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Diabetic myonecrosis or diabetic muscle infarction, was first described by Angervall and Stener in 1965. It is a very rare, under-recognised complication of poorly controlled long-standing diabetes mellitus with associated complications like nephropathy, retinopathy and neuropathy. Fewer than 200 cases have been reported in literature.
Case presentation
A 59-year-old male, with poorly controlled type 2 diabetes mellitus (T2DM) for the last ten years, and hypertension for five years, presented with three months’ history of insidious onset bilateral thigh pains. Intensity of pain gradually increased, making the patient bed-bound for ten days prior to presentation. He also had diabetic nephropathy for the previous year, bilateral diabetic retinopathy for four months, and diabetic mononeuropathy of the left ulnar nerve for one month. He had a history of similar pain in his right thigh three years before, which had improved gradually over two months with low-dose oral steroids and analgesics received elsewhere.
Examination revealed mild swelling all over both thighs, with overlying cutaneous erythema and tenderness of the thigh muscles. Muscle power at the hips and knees could not be assessed due to pain; however, it was normal at the lower legs, upper limbs and neck. The possibility of idiopathic inflammatory myositis (IIM) was considered in view of symmetrical myalgia and muscle tenderness of the proximal groups of lower limbs.
On evaluation, deep vein thrombosis (DVT) was ruled out. Creatine phosphokinase (CPK) was 354 IU/l (normal range is 20–200IU/l). MRI of the thighs, performed during a previous episode in 2015, showed increased bulk of the right vastus lateralis muscle with hyperintense signal on short tau inversion recovery (STIR) images (arrow in Figure 1a,1b) and hypointense signal on T1-weighted images. MRI of the thighs during the present episode demonstrated similar changes, but this time with symmetrical involvement of multiple muscle groups (hip adductors, abductors, quadriceps and hamstrings) (arrows in Figure 1c). Review of histopathology slides of muscle biopsy from the right vastus lateralis performed in 2015 (Figure 2), showed ischaemic necrosis of muscle fibres (arrows) with scattered lymphocytes (arrowheads). Antinuclear antibody and anticardiolipin antibodies were negative. Other laboratory data are summarised in Table 1. CPK during the previous episode was 308IU/l, with a normal range of 39–300IU/l.
Figure 1a MRI of the right thigh in 2015 showing increased bulk of the right vastus lateralis muscle with hyperintense signal on STIR image (arrow) in coronal plane
Figure 1b MRI of the thighs in 2015 showing increased bulk of the right vastus lateralis muscle with hyperintense signal on STIR image (arrow) in transverse plane
Figure 1c MRI of the thighs during present episode, showing increased bulk of the bilateral multiple muscles with hyperintense signal on STIR image (arrows) in coronal plane
Table 1 Laboratory data
White blood cell count (4000–11000 /mm3)
9700
Erythrocyte sedimentation rate (0–20 mm/hr)
63
Aspartate aminotransferase (7–40 IU/l)
27
Creatine phosphokinase (20–200 IU/l)
354
Lactate dehydrogenase (200–400 IU/l)
235
Serum creatinine (0.9–1.4 mg/dl)
3.0
Haemoglobin A1C (4–6 %)
8.6
24 hour urine proteins (< 0.15 grams/day)
3.7
Taking into consideration the following points: long-standing poorly controlled diabetes, concomitant presence of other microvascular complications of diabetes, past history of similar myalgia in the right thigh with myonecrosis on muscle histopathology, normal muscle power at the upper limbs and neck, absence of cutaneous and other manifestations of IIM, CPK being just above the normal upper limit, the absence of antinuclear antibodies and the poor general condition of the patient, muscle biopsy was deferred and a diagnosis of recurrent DMI was made. The hypertension was treated appropriately, blood glucose was controlled with insulin and bed rest was advised with DVT-prophylaxis measures. The patient also received opioid analgesics and aspirin. He had minimal pain relief during his hospital stay, but over the next two months the pain gradually decreased and he was able to ambulate with support. This clinical improvement without the use of any immunosuppressant strongly supported the diagnosis of DMI.
Figure 2 Histopathology of muscle biopsy from the right vastus lateralis in 2015 showing ischaemic necrosis of muscle fibres (arrows) with scattered lymphocytes (arrowheads)
Discussion
DMI is a rare complication of DM. It presents with acute onset of spontaneous muscular pain and swelling, most commonly unilaterally in the thighs.2
A systematic review of DMI found 126 cases reported in the literature over 48 years, of which 54% were females. Half of the patients had T2DM, with a mean age of 52.2 years, whereas the mean age in patients with type 1 diabetes mellitus (T1DM) was 35.9 years. The mean duration of T2DM at the time of DMI diagnosis was 11 years, and for T1DM it was 18.9 years. Concurrent retinopathy, nephropathy and neuropathy was seen in 46.6% of patients. The mean HBA1c value at the time of DMI diagnosis was 9.34%. Nephropathy, which is the most common microvascular complication of DM, was seen in 75% of cases.2 Bilateral involvement is seen in 8% to 33% of cases.3,4 The most frequently affected muscles reported are the vastus medialis and vastus lateralis, though many other muscles can be affected.2,4 Laboratory investigations for DMI are relatively non-specific.3 CPK may be normal or increased.
The pathogenesis of DMI is unknown. Thromboembolic events secondary to microvascular endothelial damage may cause tissue ischaemia and trigger an inflammatory response. Generation of free radicals due to reperfusion injury, and increased pressure within the fascial compartment due to tissue oedema, may lead to local hypoxia culminating in infarction. The presence of hypercoagulable state in diabetes, due to alteration of coagulation-fibrinolysis system, with increased levels of factor VII, fibrinogen, thrombomodulin, and decreased levels of antithrombin and tissue plasminogen activator may also contribute.2,3,4,5
Idiopathic inflammatory myositis was considered due to presentation in bilateral thighs. The classic unilateral presentation of DMI may be confused with DVT, pyomyositis, cellulitis, necrotising fasciitis or malignancy.6 Though weakness is the most prominent symptom in IIM, sometimes myalgia may be the only presentation.7,8 MRI is the imaging modality of choice in either condition, but does not differentiate these two conditions. In both the affected muscles show hyperintensities on T2-weighted and STIR images, and hypointensities on T1-weighted images, with associated perifascial, perimuscular and/or subcutaneous oedema.9 Muscle biopsy can provide a definitive diagnosis in such cases. The tissue is pale and large areas of muscle fibre necrosis are seen under the microscope. If the diagnosis is certain on the basis of non-invasive investigations, muscle biopsy is not recommended, since mean time to symptom resolution may be increased in patients undergoing this procedure.2
DMI resolves spontaneously over a few weeks to months in most patients.5 Management is mainly supportive, consisting of aspirin, analgesics, bed rest and controlling blood glucose levels. Onyenemezu and Capitle compared surgery, physiotherapy and bed rest in the treatment of DMI and found that the patients undergoing surgery (muscle excision biopsy ) had significantly prolonged symptom recovery time when compared to those managed by physiotherapy or bed rest.10 Horton et al. also showed that time to recovery was numerically lower in patients who received supportive care (glycaemic control and pain management/best rest) plus a nonsteroidal anti-inflammatory drug, than those who were managed only by bed rest.2 The recurrence rate of DMI is found to be lowest with bed rest followed by physiotherapy and was highest in those who underwent surgery.10
Patients with DMI are at high risk of recurrence, which is reported to be from 34.9% to 45.0% in different studies, and in about two-thirds of patients these recurrences are noted in a different location or muscle group than in the initial presentation.2,3 Our patient had recurrence of DMI after three years with current involvement of multiple muscle groups.
Table 2 Pointers for suspecting DMI
Long-standing poorly controlled DM with presence of other microvascular complications
Acute onset focal or multifocal myalgia without fever and trauma
Tenderness of involved muscle with or without overlying cutaneous erythema
T2/STIR hyperintensities with muscle oedema of one or more muscles on MRI
Though DMI is very rare, physicians who manage DM should be aware of this complication and should suspect it in the presence of the pointers listed in Table 2. In clinically suspected cases MRI helps in reaching a diagnosis, and in atypical cases muscle biopsy may help further by demonstrating muscle infarction.
Conclusion
The present case is of interest as the patient had recurrent DMI, a rare complication of T2DM, presenting with bilateral thigh myalgia which showed bilaterally symmetrical hyperintensities of multiple muscles on MRI. Increased awareness regarding this entity among physicians may help in timely diagnosis and in avoiding a battery of unnecessary investigations.
References
1 Angervall I, Sterner B. Tumoridorm focal muscular degeneration in two diabetic patients. Diabetologia 1965; 1: 39–42.
2 Horton WB, Taylor JS, Ragland TJ et al. Diabetic muscle infarction: a systematic review. BMJ Open Diabetes Res Care 2015; 3:e000082.
3 Kapur S, Brunet JA, McKendry RJ. Diabetic muscle infarction: case report and review. J Rheumatol 2004; 31: 190–4.
4 Trujilo-Santos AJ. Diabetic muscle infarction: an underdiagnosed complication of long standing diabetes. Diabetes care 2003; 26: 211–5.
5 Bhat T, Naik M, Mir MF et al. Recurrent diabetic muscle infarction, a rare complication of diabetes: a case report. Egypt Rheumatol Rehabil 2017; 44: 181–4.
6 Rastogi A, Bhadada SK, Saikia UN et al. Recurrent diabetic myonecrosis: a rare complication of a common disease. Indian J Med Sci 2011; 65: 311–5.
7 Ahmed HN, Chhaya SK, Makdissi A et al. Diabetic muscle infarction: case report of a rare complication. Am J Med 2007; 120: e3-e5.
8 Ascherman DP, Aggarwal R, Oddis CV. Classification, epidemiology, and clinical features of inflammatory muscle disease. In: Marc C, editor. Hochberg, 7th ed., Vol.2. Philadelphia: ElsevierInc.; 2019; pp. 1293–305.
9 Gupta S, Goyal P, Sharma P et al. Recurrent diabetic myonecrosis – an under-diagnosed cause of acute painful swollen limb in long standing diabetics. Ann Med Surg (Lond) 2018; 35: 141–5.
10 Onyenemezu I, Capitle E Jr. Retrospective analysis of treatment modalities in diabetic muscle infarction. Open Access Rheumatol Res Rev 2014; 6: 1–6.
DEAR EDITOR, ReA, a subtype of SpA, is a sterile inflammatory arthritis, predominantly involving the lower extremities. It usually occurs 1–3 weeks after a remote mucosal infection (gastrointestinal or genitourinary). It is also known as Reiter’s syndrome in the presence of the classical triad: urethritis in men and cervicitis in women, ocular inflammation (conjunctivitis or uveitis) and arthritis of large joints. Chlamydia trachomatis, Campylobacter, Salmonella, Shigella and Yersinia are a few of the common bacterial infections that can cause ReA [1]. A few other bacteria and viruses have also been associated with the pathogenesis of ReA. The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a cause of ReA has been reported previously in six cases [2–7]. Here, we report a case of ReA after SARS-CoV-2 infection. Written informed consent was obtained from the patient.
A 27-year-old female was hospitalized after 2 days of fever and body aches. On evaluation, SARS-CoV-2 RT-PCR from a nasopharyngeal swab was positive, and CT imaging of the chest showed bilateral peripheral ground glass opacities COVID-19 Reporting and Data System (CO-RADS-4). Other laboratory parameters during hospitalization showed leucopenia (3200/mm3), elevated CRP (114 mg/l) and D-dimer (three times upper normal limit), and normal levels of lactate dehydrogenase, ferritin and IL-6. She was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia and received 1 mg/kg CS in the form of oral methylprednisolone and favipiravir. Oxygen saturation was well maintained on room air throughout the disease course. Fever subsided on day 3 of hospitalization, and she was discharged on day 8 with tapering doses of CS. Two weeks after testing positive for SARS-CoV-2 infection, while on 0.25 mg/kg of CS, she developed acute onset arthritis in both lower extremities and relatively mild arthritis in the small joints of the right hand. She did not have any history of recent diarrhoea, cervicitis or uveitis.
On examination, bilateral knee, ankle and midfoot joints were extremely tender and swollen. Mild tenderness was also noted in the small joints of the right hand (wrist, MCP and PIP joints). The rest of the physical examination was normal. RT-PCR for SARS-CoV-2 was negative. RF was positive in low titres. ACPA, ANA and HLA-B27 were negative. A probable diagnosis of ReA secondary to SARS-CoV-2 infection was made. She received NSAID and additionally required oral opioid analgesic to manage the pain. CS was gradually tapered and stopped over next 3 weeks. At 4-week follow-up, the arthritis had improved significantly, allowing withdrawal of opioid analgesic and tapering of NSAID.
Although ReA causes asymmetric oligoarthritis in the lower extremities, a mild form of upper limb arthritis can also occur, as seen in our patient [6]. In contrast to this, Danssaert et al. [5] reported arthritis of unilateral hand joints without involvement of lower extremities. Liew et al. [4] described a patient with acute right knee arthritis manifesting 3 days after fever and simultaneously being positive for SARS-CoV-2 infection. Schenker et al. [6] and De Stefano et al. [7] described cases of ReA associated with cutaneous vasculitis and psoriatic skin lesions, respectively. The patient reported by Ono et al. [2] had severe respiratory distress requiring mechanical ventilation, whereas respiratory involvement was milder in the other five patients [3–7], including our patient. All these cases are summarized in Table 1.
Table 1
Reported cases of possible reactive arthritis after SARS-CoV-2 infection
Other manifestations of ReA include inflammatory back pain, dactylitis, enthesitis, tendinitis and bursitis. There are no specific laboratory tests for ReA, and diagnosis relies on the typical clinical presentation with detection of the triggering infection [8]. Arthritis persists for >6 months in 30–50% of patients [1]. The most effective treatment for ReA is NSAID. IA glucocorticoid can be used for mono- or oligoarticular disease. In chronic cases, SSZ can be effective when started within 3 months of disease onset [8].
Our patient developed lower limb predominant inflammatory arthritis, 2 weeks after SARS-CoV-2 infection. The presence of RF in low titres was possibly attributable to an immune response to the recent infection. The classical clinical picture, a preceding infection, absence of other autoantibodies, absence of autoimmunity in the family and response to NSAID, supported the diagnosis of ReA.
This case, along with previously reported cases, suggest SARS-CoV-2 infection as an aetiology in the pathogenesis of ReA. More observations are required to strengthen this association.
Key message
• ReA should be considered in patients with acute arthritis after SARS-CoV-2 infection.
Funding: No specific funding was received from any funding bodies in the public, commercial or not for-profit sectors to carry out the work described in this manuscript.
Disclosure statement: The authors have declared no conflicts of interest.
Data availability statement
The authors confirm that the data supporting the findings of this study are available within the article.
DEAREDITOR, Takayasu arteritis is a rare chronic granulomatous large-vessel vasculitis with preferential involvement of the aorta, its major branches and the pulmonary arteries [1]. Ocular involvement in Takayasu arteritis is seen as Takayasu retinopathy, which is the result of ocular hypoperfusion and chronic ischaemia [2]. Scleritis in Takayasu arteritis is extremely rare, reported in only six cases [3–6]. We report a case of previously undiagnosed asymptomatic Takayasu arteritis presenting with bilateral recurrent anterior scleritis.
A 48-year-old woman presented with redness and pain in the right eye for 15 days. Pain radiated around the eye and was exacerbated by eye movements. She had history of multiple episodes of inflamed, painful eyes for past 6 years, involving the left eye for the initial 4 years and the right eye thereafter. She received topical CSs and NSAIDs, and oral CSs at variable doses during these episodes.
Examination of the eyes showed temporal congestion in the right eye (Fig. 1A) and a normal left eye. Ophthalmic assessment confirmed nodular anterior scleritis of the right eye. Visual acuity, the cornea, anterior and posterior chambers were normal in both eyes. Further physical examination revealed absent pulses in the left radial, ulnar, brachial and subclavian arteries. Right radial and brachial pulses were diminished. Bruits were heard over bilateral carotid and left subclavian arteries. Blood pressure was not recordable in the left arm, 90/60 mmHg in the right arm and 130/80 mmHg in both lower limbs.
Fig. 1
Scleritis in Takayasu arteritis
(A) Anterior scleritis. (B) CT angiogram, showing circumferential wall thickening in ascending (arrow) and descending thoracic aorta (arrowhead). (C) CT angiogram, showing stenosis in right common carotid and bilateral subclavian arteries (arrowheads), with complete occlusion in proximal part of left subclavian artery (arrow).
On evaluation, ESR was 49 mm/h, CRP was 20.4 mg/l, and ANCAs (ELISA and immunofluorescence) and ANA tests were negative. Chest radiographs and echocardiographs were normal. CT angiogram showed circumferential wall thickening in the ascending (arrow in Fig. 1B), arch and descending thoracic aorta (arrowhead in Fig. 1B) and the brachiocephalic, left common carotid and left subclavian arteries. Complete occlusion was seen in the proximal part of the left subclavian artery (arrow in Fig. 1C), with collaterals filling the distal segment. Stenosis was seen in the right common carotid and bilateral subclavian arteries (arrowheads in Fig. 1C). A diagnosis of Takayasu arteritis with anterior nodular scleritis was made, and oral prednisolone was started at 1 mg/kg in combination with oral MTX 15 mg/week. Ocular symptoms improved markedly over the next few days, and gradual tapering of prednisolone dose was planned.
We have found only six published cases of Takayasu arteritis associated with scleritis [3–8]. Akhtar et al. [3] reported a case with a 10-year history of Takayasu arteritis. The patient was in prolonged remission before developing scleritis as a presenting manifestation of disease flare. Scleritis was refractory to MMF and required adalimumab for CS weaning. Scleritis as a presenting manifestation in an asymptomatic occult Takayasu arteritis was reported only once [7]. This patient succumbed to ischaemic colitis 3 weeks after presentation, and necrotizing granulomatous vasculitis of the thoracic and abdominal aorta was demonstrated on autopsy. Similar to our case, Chaudhary et al. [8] also reported a case of Takayasu arteritis with a 6-year-long history of fluctuating scleritis. But unlike their patient, our patient was asymptomatic for Takayasu arteritis and had occult vascular inflammation for an unknown duration, leading to stenosis and occlusion of vessels. This presentation makes our case extremely unusual and also emphasizes the importance of detailed physical examination even in patients presenting with isolated scleritis.
Small vessel vasculitis in Takayasu arteritis is less well described. Different cutaneous manifestations with histopathological evidence of vasculitis have been reported in Takayasu arteritis [9]. Scleritis in our patient could also be a small vessel manifestation of Takayasu arteritis. However, the possibility of these two conditions coexisting cannot be excluded.
Key message
Takayasu arteritis should be in the list of differential diagnoses in patients with isolated scleritis.
Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article.
Disclosure statement: The authors have declared no conflicts of interest.
Data availability statement
Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article.
A 70-year-old female, hypertensive and diabetic for 15 years, presented with symmetrical inflammatory polyarthritis of the small and large joints of the upper and lower limbs of 8 months duration. She had multiple tender and swollen joints and painful, restricted movement of the left knee. The ESR was elevated, and RF was negative. She was diagnosed as seronegative RA and was initiated on oral MTX and low-dose CS. She also received IA CS in the left knee in view of the severe debilitating pain. At 2 months follow-up, she continued to have left knee pain with tenderness and had no other tender or swollen joints. Radiographs of the knees showed bilateral grade three OA with chondromatosis of the left suprapatellar bursa (Fig. 1A and B, arrow). Surgical removal of cartilaginous bodies while performing a total knee arthroplasty is planned at later date.
Fig. 1
Synovial chondromatosis
Anteroposterior (A) and lateral (B) radiographic views of knees, showing synovial osteochondromatosis of left suprapatellar bursa (arrowed).
Synovial chondromatosis is a rare, tumour-like, benign lesion of the synovium, which may occur in the synovial membrane of a joint, bursa or tendon sheath. It usually presents unilaterally in large joints. The knee is the joint most commonly involved, but chondromatosis can also manifest in other joints, such as the shoulder, elbow, hip and ankle [1]. It is uncommon in RA, and only a few cases have been reported.
Funding: No specific funding was received from any funding bodies in the public, commercial or not for-profit sectors to carry out the work described in this manuscript.
Disclosure statement: The authors have declared no conflicts of interest.
