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On enquiry she gave history suggestive of photosensitivity; genital ulcerations; oral mucosal ulcerations; loss of appetite; joint pain with swelling of bilateral small joints of hand and wrist joints and elbows for last three months. [http://www.selleckchem.com/products/Semagacestat(LY450139).html Semagacestat in vivo] She denied any history suggestive of Raynaud's phenomenon, hemoptysis, menstrual irregularities, dysphagia, dryness of mouth and muscle weakness or seizures. On examination of face, there was presence of mucosal ulcerations in the lower lips with butterfly like rash over malar region [Figure 1]. Joints examination revealed tenderness with swelling of bilateral proximal and distal interphalangeal joints; metacarpophalangeal joints, wrist and elbow joints without any deformity and restriction of movement. There was absence of skin thickening, lymphadenopathy and hepato-splenomegaly but pallor present. Examination of chest revealed bilateral stony dull percussion note over infra-axillary and infra-scapular area with diminished vesicular breath sound suggestive of bilateral pleural effusion. He denied any history of anti-tubercular drug intake, treatment with corticosteroids and contact history of tuberculosis. Figure 1 Face examination showing presence of mucosal ulcerations in the lower lips with butterfly like rash over malar region Complete blood count was normal except normocytic normochromic anemia with hemoglobin 9.0 gm/dl and raised erythrocyte sedimentation rate 65 mm at 1st hour. Urine examination showed albuminuria 2+, occasional red blood cells and 24-hour urinary protein as 900 mg/day. Liver function and renal function tests were normal. The X-ray of both hands [http://en.wikipedia.org/wiki/DPEP3 DPEP3] showed lucency within bilateral triquetral bones and erosion at base of right sided 5th metacarpal bone suggestive of erosive arthritis [Figure 2]. Her chest X-ray postero-anterior view showed bilateral mild pleural effusion [Figure 3]. Her electrocardiography, echocardiography and ultrasonography of whole abdomen were normal. The pleural fluid was straw in colour and its analysis revealed total cell count 750 cells/mm3 [http://www.selleckchem.com/c-Met.html selleck] (lymphocytes 95%, and neutrophil 05%), protein 5.1 mg/dl, sugar 64 mg/dl, lactate dehydrogenase 450 U/L and adenosine deaminase 72.9 U/L (normal