Case presentation A 23-month-old boy presents to a pulmonology clinic with hoarseness of voice and a respiratory workup. Past history At four months, hoarseness of voice & stridor was first observed Swollen peripheral joints Poor weight gain Born to consanguineous Indian parents No family history of rheumatoid arthritis or other pathological inheritance On examination Vitals were stable, and oxygen saturation maintained Failure to thrive Biphasic stridor with horse cries and intermittent subcostal retractions present The interphalangeal joints, wrists, knees, and ankles: swollen and tender Subcutaneous nodules present on the wrist and ankles (Figure 1, cover image) No erythema or warmth X-rays: soft tissue swelling of both hands, irregular borders of metacarpals with scalloping of the distal ulna (Figure 2, cover image) Ultrasound: Hyperemic synovium, tenosynovitis of the phalangeal…