Discussion 
Rhupus is one of the overlap syndromes in CTD( connective tissue disease) in which patients present with criteria satisfying both RA and SLE. The prevalence varies from 0.01% to 2%.(3,4). The coexistence of  RA and SLE, Rhupus syndrome,  is very rare. The absence of specific diagnostic criteria to make a diagnosis makes it very difficult to identify such patients. reports showed the presentation first comes with clinical features of RA followed by SLE, and it is more common in women. 5
RA is an autoimmune inflammatory illness involving joints and other organ system. There is no known etiology but genetic and environmental factors are contributory.  Synovial inflammation orchestrated by T-cells, and B-cells, along with the release of pro-inflammatory cytokines by TH1 cells is the key pathophysiologic process.
The exact etiology and pathology of SLE remains unclear. But complicated interaction of environmental, genetic, and immunologic factors is probably involved. The loss of immune tolerance increases the antigenic load, and shifting of Th1 to Th2 immune responses leads to B-cell hyperactivity and the production of pathogenic autoantibodies. The coexistence of these two diseases with different pathophysiologies makes it unique. (6)Previous studies have shown that patients with rhupus were found to have a lower incidence of malar rash, hemolytic anemia, and renal and neurological involvement compared with the SLE. The rhupus group also had a rare incidence of severe renal disorders such as nephrotic syndrome and renal failure. (7)Previous studies have also shown a lower incidence of visceral organ involvement compared with SLE alone. (8)
For nearly 10 years our patient had erosive polyarthritis with episodes of flare-ups. She was on treatment for RA, and after 10 years of treatment, she presented with an erythematous non-itchy patch on both cheeks, alopecia, and oral ulcers on the buccal mucosa bilaterally which are evidence of SLE (systematic lupus erythematosus).
The rare coexistence of those two diseases and the co-occurrence of some of the symptoms such as arthralgia makes it difficult to pick it early.
Management of rhupus is not yet established and is primarily an expert’s recommendation. The majority of reports of rhupus had been managed based on the predominating features. Recent preliminary findings showed the promising effect of Bacitracin along with other DMARDs, regarding reducing disease activity and improving quality of life. Further investigation is needed with a larger sample size to confirm the efficacy and safety of bacitracin in rhupus (9)