Exploring the Tapestry of Everyday Life: From Hobbies to Global Events
Life, in its magnificent complexity, is a tapestry woven with threads of countless experiences, interests, and events. From the mundane to the extraordinary, each thread contributes to the rich and vibrant picture that represents our individual and collective existence. Exploring this tapestry involves delving into a diverse range of topics, from personal hobbies and passions to significant global events that shape our world. Let’s embark on a journey to unravel some of these fascinating threads.
The Joy of Hobbies and Personal Pursuits
At the heart of a fulfilling life lie personal passions and hobbies. These activities, pursued for pleasure and self-enrichment, provide a much-needed respite from the demands of daily life. Whether it’s the intricate art of knitting, the exhilarating rush of rock climbing, or the quiet contemplation of bird watching, hobbies offer a unique opportunity to express creativity, learn new skills, and connect with like-minded individuals.
Consider the world of online gaming. It’s more than just entertainment; it’s a thriving community where people from all walks of life come together to share their passion for virtual worlds and strategic challenges. Platforms like jojobet offer a variety of games and opportunities for interaction, fostering a sense of camaraderie and shared experience. Engaging in such activities can boost cognitive function, improve problem-solving skills, and even alleviate stress. The key is to find a hobby that resonates with your interests and provides a sense of enjoyment and accomplishment.
Furthermore, hobbies often lead to unexpected discoveries and personal growth. Learning a new language can open doors to different cultures and perspectives, while mastering a musical instrument can unlock hidden talents and emotional expression. The possibilities are endless, and the journey of exploration is just as rewarding as the destination.
Navigating the Complexities of Global Events
Beyond our personal spheres, the world stage is constantly evolving, shaped by significant global events that impact communities and nations. From political upheavals and economic shifts to environmental crises and technological advancements, these events demand our attention and understanding. Staying informed about current affairs is crucial for responsible citizenship and informed decision-making.
Understanding the nuances of global events requires critical thinking and a willingness to consider multiple perspectives. Relying on diverse and reputable news sources is essential to avoid misinformation and bias. Engaging in respectful dialogue with others who hold different viewpoints can broaden our understanding and foster empathy.
Moreover, recognizing the interconnectedness of global events is crucial. A political crisis in one region can have ripple effects on economies and social structures worldwide. Understanding these connections allows us to better anticipate challenges and contribute to solutions.
The Ever-Evolving Landscape of Technology
Technology is an undeniable force shaping our modern world. From the smartphones in our pockets to the complex algorithms that drive artificial intelligence, technology permeates every aspect of our lives. Its impact is both transformative and disruptive, offering unprecedented opportunities while also raising ethical and societal concerns.
Keeping abreast of technological advancements is essential for navigating the modern world. Understanding the basics of coding, data analysis, and cybersecurity can empower individuals to participate in the digital economy and protect themselves from online threats. Furthermore, exploring the ethical implications of emerging technologies like artificial intelligence and biotechnology is crucial for ensuring that these technologies are used for the benefit of humanity.
The rapid pace of technological change requires a commitment to lifelong learning and adaptation. Embracing new skills and staying curious about emerging trends will be essential for navigating the future workplace and contributing to innovation.
Finding Balance and Meaning in a Multifaceted World
In a world filled with diverse interests, complex events, and rapidly evolving technologies, finding balance and meaning is paramount. It requires a conscious effort to prioritize our well-being, cultivate meaningful relationships, and contribute to something larger than ourselves. This could involve volunteering in our communities, supporting causes we believe in, or simply being present and engaged in our daily interactions.
Ultimately, the tapestry of life is a work in progress, constantly being woven with new experiences, challenges, and opportunities. By embracing the diversity of life and cultivating a sense of curiosity and purpose, we can create a rich and fulfilling existence that contributes to the greater good.
The Enduring Appeal of Hobbies: Finding Joy and Growth in Leisure
In the hustle and bustle of modern life, it’s easy to get caught up in work, responsibilities, and the constant pursuit of achievement. However, amidst all the obligations, it’s crucial to carve out time for activities that bring joy, relaxation, and personal growth. These activities, often referred to as hobbies, play a vital role in our overall well-being and can significantly enrich our lives. From creative pursuits like painting and writing to physical activities like hiking and sports, the range of hobbies is vast and diverse, offering something for everyone.
The Benefits of Engaging in Hobbies
The advantages of having a hobby extend far beyond mere entertainment. Engaging in activities we enjoy can have a profound impact on our mental, emotional, and even physical health. Here are some of the key benefits:
Stress Reduction: Hobbies provide a much-needed escape from the pressures of daily life. When we immerse ourselves in an activity we love, our minds focus on the present moment, allowing us to forget our worries and anxieties. This can lead to a significant reduction in stress levels and an overall sense of calm.
Enhanced Creativity and Problem-Solving Skills: Many hobbies, such as playing a musical instrument, writing, or painting, stimulate creativity and require us to think outside the box. These activities can help us develop our problem-solving skills and approach challenges with a fresh perspective.
Increased Self-Esteem and Confidence: Mastering a new skill or achieving a goal in a hobby can boost our self-esteem and confidence. Whether it’s learning to knit a sweater, completing a challenging hike, or winning a local chess tournament, these accomplishments provide a sense of pride and accomplishment.
Improved Social Connections: Many hobbies offer opportunities to connect with like-minded individuals. Joining a book club, a hiking group, or a pottery class can lead to new friendships and a sense of community. Sharing our passions with others can be incredibly rewarding and fulfilling.
Cognitive Stimulation: Engaging in mentally stimulating hobbies, such as learning a new language, playing strategy games, or reading, can help keep our minds sharp and improve cognitive function. These activities can also help prevent age-related cognitive decline.
Improved Physical Health: Physical hobbies, such as dancing, swimming, or gardening, can contribute to improved physical health and fitness. These activities can help us maintain a healthy weight, strengthen our muscles and bones, and improve our cardiovascular health.
Exploring Different Types of Hobbies
With such a wide variety of hobbies to choose from, finding the right one can feel overwhelming. However, the key is to explore different options and experiment with activities that pique your interest. Here are some broad categories of hobbies to consider:
Creative Hobbies: These hobbies involve expressing yourself through art, music, writing, or other creative mediums. Examples include painting, drawing, sculpting, playing a musical instrument, singing, writing poetry or fiction, photography, and filmmaking.
Physical Hobbies: These hobbies involve physical activity and can range from leisurely pursuits to more strenuous sports. Examples include hiking, biking, swimming, dancing, gardening, yoga, playing team sports, and martial arts.
Intellectual Hobbies: These hobbies involve mental stimulation and learning. Examples include reading, learning a new language, playing strategy games, solving puzzles, coding, and studying history or science.
Collecting Hobbies: These hobbies involve collecting and organizing items of interest. Examples include stamp collecting, coin collecting, antique collecting, and collecting sports memorabilia. Some people even enjoy collecting things online, and for those looking for exciting online platforms, jojobet offers diverse options.
Crafting Hobbies: These hobbies involve creating things with your hands. Examples include knitting, crocheting, sewing, quilting, woodworking, pottery, and jewelry making.
Tips for Finding the Right Hobby
Finding a hobby that you truly enjoy and that fits your lifestyle can take some time and effort. Here are some tips to help you in your search:
Reflect on Your Interests and Passions: What activities do you naturally gravitate towards? What subjects do you enjoy learning about? What skills do you admire in others? Consider these questions to identify potential hobbies that align with your interests.
Experiment with Different Activities: Don’t be afraid to try new things. Take a class, attend a workshop, or borrow a book from the library to explore different hobbies.
Start Small: You don’t have to commit a lot of time or money to a hobby right away. Start with a small project or a short trial period to see if you enjoy it.
Be Patient: It takes time to develop skills and see progress in a hobby. Don’t get discouraged if you don’t see results immediately.
Don’t Be Afraid to Quit: If you try a hobby and don’t enjoy it, don’t feel obligated to continue. There are plenty of other options to explore.
Find a Community: Connecting with other people who share your interests can make a hobby more enjoyable and rewarding. Join a club, take a class, or participate in online forums to connect with fellow enthusiasts.
Making Time for Hobbies in a Busy Life
One of the biggest challenges of engaging in hobbies is finding the time. With so many competing demands on our time, it can be difficult to prioritize leisure activities. However, making time for hobbies is essential for our well-being, and with a little planning, it’s possible to incorporate them into even the busiest of schedules.
Schedule Time for Hobbies: Treat your hobbies like any other important appointment and schedule time for them in your calendar.
Start Small: Even 15-30 minutes a day can make a difference.
Combine Hobbies with Other Activities: Listen to audiobooks while you exercise, or knit while you watch TV.
Reduce Screen Time: Limit your time on social media and other online activities to free up time for hobbies.
Prioritize and Say No: Learn to say no to commitments that don’t align with your priorities, and make time for activities that bring you joy.
In conclusion, hobbies are not just frivolous pastimes; they are essential for our overall well-being. By engaging in activities we enjoy, we can reduce stress, enhance creativity, boost self-esteem, improve social connections, and maintain cognitive and physical health. So, take some time to explore different hobbies, find something that resonates with you, and make it a part of your life. You’ll be glad you did.
The Enduring Appeal of Hobbies: Why We Need Them More Than Ever
In today’s fast-paced world, it’s easy to get caught up in the whirlwind of work, family responsibilities, and endless to-do lists. We often prioritize productivity and achievement, leaving little room for activities that bring us joy and relaxation. However, neglecting our hobbies can have a detrimental effect on our overall well-being. Hobbies offer a much-needed escape from the pressures of daily life, providing opportunities for creativity, personal growth, and social connection. They are not just frivolous pastimes; they are essential for a balanced and fulfilling life.
The Mental and Emotional Benefits of Hobbies
The psychological benefits of engaging in hobbies are numerous and well-documented. Hobbies can act as stress relievers, providing a healthy outlet for pent-up emotions and anxieties. When we immerse ourselves in an activity we enjoy, our brains release endorphins, natural mood boosters that can alleviate stress and improve our overall sense of well-being. This is especially important in today’s world, where stress and anxiety are increasingly prevalent. Whether it’s painting, gardening, playing a musical instrument, or sekabet giriş to a different kind of game, engaging in a hobby allows us to disconnect from the digital world and reconnect with ourselves.
Furthermore, hobbies can enhance our cognitive function. Activities that require problem-solving, critical thinking, and creativity can stimulate our brains and improve our memory, concentration, and overall cognitive abilities. Learning a new skill, such as a new language or a complex craft, can also challenge our brains and help us stay mentally sharp as we age. The sense of accomplishment we feel when we master a new skill or complete a challenging project can also boost our self-esteem and confidence.
Exploring Different Types of Hobbies
The beauty of hobbies is that there is something for everyone. Whether you’re an introvert or an extrovert, a creative type or a logical thinker, there’s a hobby out there that can suit your interests and personality. Some popular hobbies include:
Creative Arts: Painting, drawing, sculpting, writing, photography, music. These hobbies allow us to express ourselves creatively and explore our artistic talents.
Outdoor Activities: Hiking, camping, fishing, gardening, birdwatching. These hobbies connect us with nature and provide opportunities for physical exercise and fresh air.
Collecting: Stamps, coins, antiques, books. Collecting can be a fascinating way to learn about history, culture, and different subjects.
Games and Puzzles: Board games, card games, video games, jigsaw puzzles, crossword puzzles. These hobbies can provide mental stimulation and social interaction.
DIY and Crafts: Knitting, crocheting, sewing, woodworking, jewelry making. These hobbies allow us to create something with our own hands and express our creativity.
Learning and Education: Learning a new language, taking online courses, reading, attending lectures. These hobbies expand our knowledge and keep our minds active.
The key is to find a hobby that you genuinely enjoy and that aligns with your interests and values. Don’t be afraid to experiment with different activities until you find something that resonates with you. You might be surprised at what you discover.
Making Time for Hobbies in a Busy Schedule
One of the biggest challenges people face when it comes to hobbies is finding the time to pursue them. With busy work schedules, family responsibilities, and other commitments, it can feel impossible to carve out time for personal interests. However, making time for hobbies is an investment in your well-being, and it’s worth prioritizing. Here are some tips for fitting hobbies into a busy schedule:
Schedule it in: Treat your hobby like any other important appointment and schedule it into your calendar. Even if it’s just for 30 minutes a day, dedicating specific time to your hobby can help you stay consistent.
Multitask strategically: Combine your hobby with other activities. For example, listen to audiobooks while you’re commuting or doing chores.
Involve others: Turn your hobby into a social activity by involving friends or family members. This can make it more enjoyable and provide accountability.
Be flexible: Don’t be afraid to adjust your schedule as needed. If you can’t find time during the week, try dedicating a few hours on the weekend.
Be realistic: Start small and gradually increase the amount of time you spend on your hobby as you become more comfortable.
The Social Benefits of Shared Hobbies
Beyond the individual benefits, hobbies can also provide valuable opportunities for social connection. Joining a club, taking a class, or participating in online communities related to your hobby can connect you with like-minded individuals who share your passion. These social connections can provide support, encouragement, and a sense of belonging. Sharing your hobby with others can also lead to new friendships and expand your social circle.
Furthermore, hobbies can provide opportunities to give back to the community. Many hobbies, such as knitting, crocheting, and woodworking, can be used to create items for charity. Sharing your skills and talents with others can be a rewarding experience and make a positive impact on the world.
In conclusion, hobbies are not just frivolous pastimes; they are essential for a balanced and fulfilling life. They provide numerous mental, emotional, and social benefits, helping us to relieve stress, enhance our cognitive function, connect with others, and express ourselves creatively. By making time for hobbies in our busy schedules, we can invest in our well-being and create a more meaningful and enjoyable life. So, take some time to explore your interests and discover the joy of pursuing a hobby that you love. You might be surprised at how much it enriches your life.
The Ever-Evolving Tapestry of Modern Life: Navigating the Complexities
Life in the 21st century is a whirlwind of constant change, technological advancements, and evolving social norms. It’s a tapestry woven with threads of opportunity, challenge, and a persistent pursuit of meaning. From global interconnectedness to individual self-discovery, understanding the nuances of modern life requires a broad perspective and a willingness to adapt.
The Digital Revolution: A Double-Edged Sword
The digital revolution has undoubtedly reshaped our world. The internet, smartphones, and social media have connected us in unprecedented ways, offering access to information and opportunities that were unimaginable just a few decades ago. We can communicate with people across the globe instantly, learn new skills online, and even build entire careers from the comfort of our homes.
However, this interconnectedness comes with its own set of challenges. The constant stream of information can be overwhelming, leading to information overload and a decline in attention spans. Social media, while connecting us, can also contribute to feelings of isolation, anxiety, and comparison. The spread of misinformation and the erosion of privacy are also serious concerns that we must address as a society. As technology continues to evolve, it’s crucial to develop critical thinking skills and learn to navigate the digital landscape responsibly. For those seeking entertainment and potential financial gains in the digital realm, it’s important to be aware of responsible gaming practices. You can always find helpful information for things like casibom güncel giriş and other related topics on reputable websites.
The Shifting Sands of Social Norms
Social norms are constantly evolving, reflecting changing values and beliefs. What was considered acceptable or even desirable in the past may be frowned upon today, and vice versa. This can be confusing and even unsettling for some, but it also presents an opportunity for growth and progress.
One of the most significant shifts in recent years has been the increasing acceptance of diversity and inclusion. People are more aware of the importance of treating everyone with respect, regardless of their race, ethnicity, gender, sexual orientation, or other personal characteristics. This has led to greater representation in media, politics, and other spheres of life.
Another important trend is the growing emphasis on mental health and well-being. People are becoming more open about their struggles with anxiety, depression, and other mental health issues. This has led to a greater demand for mental health services and a decrease in the stigma associated with seeking help.
Navigating these shifting social norms requires empathy, understanding, and a willingness to challenge our own biases and assumptions. It’s important to listen to different perspectives, engage in respectful dialogue, and be open to changing our minds.
The Pursuit of Meaning in a Materialistic World
In a world increasingly focused on material possessions and economic success, many people are searching for deeper meaning and purpose in their lives. They are questioning the traditional definition of success and seeking fulfillment in other areas, such as relationships, creativity, and contribution to society.
This search for meaning can take many different forms. Some people find it through their religious faith, while others find it through their work, hobbies, or relationships. Some people dedicate their lives to helping others, while others focus on personal growth and self-discovery.
There is no one-size-fits-all answer to the question of how to find meaning in life. What works for one person may not work for another. However, some common themes emerge:
* **Connection:** Building strong relationships with others is essential for well-being and a sense of belonging.
* **Purpose:** Having a sense of purpose, whether it’s through work, volunteering, or pursuing a passion, can give life meaning and direction.
* **Gratitude:** Practicing gratitude, focusing on the good things in our lives, can improve our mood and increase our sense of happiness.
* **Mindfulness:** Being present in the moment, paying attention to our thoughts and feelings without judgment, can help us appreciate the beauty of life and reduce stress.
The Future of Modern Life: Embracing Uncertainty
The only certainty about the future is that it will be uncertain. Technological advancements, climate change, political instability, and other factors are creating a complex and rapidly changing world.
To thrive in this environment, we need to be adaptable, resilient, and open to learning new things. We need to develop critical thinking skills, problem-solving abilities, and the capacity for innovation. We also need to cultivate empathy, compassion, and a sense of global citizenship.
The challenges facing us are significant, but so are the opportunities. By embracing uncertainty and working together, we can create a future that is more just, sustainable, and fulfilling for all. The key is to stay informed, engaged, and committed to making a positive difference in the world. From understanding global events to navigating the digital world, the future requires a proactive and informed citizenry.
The Everlasting Allure of Games of Chance: A Historical and Cultural Perspective
From the roll of ancient dice to the modern-day thrill of online platforms, games of chance have held a captivating power over humanity for millennia. Their appeal transcends cultural boundaries, socioeconomic strata, and even time itself. But what is it about these games that so enthralls us? Is it simply the potential for financial gain, or is there something deeper at play?
A Journey Through Time: The History of Games of Chance
The earliest evidence of games of chance dates back to ancient civilizations. Dice, crafted from bones and stones, have been unearthed in archaeological digs spanning Mesopotamia, Egypt, and the Indus Valley. These weren’t mere pastimes; they were often intertwined with religious rituals and divination practices. The outcome of a dice roll was seen as the will of the gods, a glimpse into the future, or a way to resolve disputes.
As societies evolved, so did the games. Playing cards emerged in China during the Tang Dynasty, eventually making their way to Europe in the 14th century. Card games, like poker and blackjack, introduced elements of strategy and skill alongside pure luck. The rise of casinos in 17th-century Venice marked a turning point, transforming games of chance into organized commercial activities. These early casinos were not just places to gamble; they were social hubs, centers of intrigue, and stages for high-stakes drama.
The invention of the printing press further democratized access to games of chance. Printed playing cards became more affordable, and books on gambling strategies began to circulate. This spread of information, coupled with the allure of quick riches, fueled the popularity of games of chance across all social classes.
The Psychology Behind the Thrill: Why We Gamble
The psychology of gambling is complex and multifaceted. Several factors contribute to the enduring appeal of games of chance. One key element is the element of risk. Humans are naturally drawn to situations that present a degree of uncertainty. The potential for both reward and loss triggers the release of dopamine in the brain, creating a feeling of excitement and anticipation.
Another factor is the illusion of control. Even in games based purely on chance, players often believe they can influence the outcome through strategies, superstitions, or intuition. This belief, however unfounded, provides a sense of agency and control, making the experience more engaging.
Social factors also play a significant role. Gambling can be a social activity, providing an opportunity to bond with friends and family. The shared experience of winning or losing can create a sense of camaraderie and excitement. Furthermore, the social status associated with gambling, particularly in high-stakes environments, can be a powerful motivator for some individuals. For some, the thrill comes from platforms like casibom, which offer a variety of online gaming experiences.
Games of Chance in Culture: A Reflection of Society
Games of chance have permeated popular culture, appearing in literature, film, and music. They often serve as metaphors for life’s uncertainties, the risks we take, and the rewards we seek. From the high-stakes poker games in Western films to the lottery dreams depicted in novels, games of chance reflect our hopes, fears, and aspirations.
The depiction of gambling in culture is not always positive. Stories often explore the darker side of addiction, the destructive consequences of chasing losses, and the ethical dilemmas faced by those involved in the industry. These cautionary tales serve as a reminder of the potential pitfalls associated with excessive gambling.
Furthermore, games of chance often reflect the social and economic conditions of a society. During times of economic hardship, lottery tickets and other forms of gambling may become more popular as people seek a quick escape from their financial woes. Similarly, in societies with limited opportunities for social mobility, gambling may be seen as a way to overcome class barriers and achieve upward mobility.
The Future of Games of Chance: Technology and Regulation
The advent of the internet and mobile technology has revolutionized the world of games of chance. Online casinos and sports betting platforms have made gambling more accessible than ever before. The convenience and anonymity of online gambling have attracted a wider audience, but they have also raised concerns about problem gambling and the need for stronger regulation.
As technology continues to evolve, we can expect to see even more innovative forms of games of chance emerge. Virtual reality (VR) and augmented reality (AR) technologies have the potential to create immersive and interactive gambling experiences. Cryptocurrency and blockchain technology could also transform the industry by offering greater transparency and security.
However, the future of games of chance will depend not only on technological advancements but also on effective regulation. Governments around the world are grappling with the challenge of balancing the economic benefits of gambling with the need to protect consumers and prevent problem gambling. Stricter regulations, responsible gambling initiatives, and increased public awareness are essential to ensuring that games of chance remain a form of entertainment and do not become a source of harm.
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.
