Rheumatological diseases are multi systemic in nature and syndromic approach will help to elucidate the cause. Unusual manifestations and orphan diseases do get referred to rheumatologists and when we evaluate these diseases it’s important to also think out of the box scenarios. Here I would like to share these 3 cases with learning points that would help physicians to remember when dealing with similar unusual manifestations in clinical practice. Postgraduates during their 3 year training period should get exposed to all complex and rare manifestations of common and orphan diseases and hence it’s imperative for the budding physicians to learn and keep in memory.