our patient presented with accelerated silicosis starting as gradually progressive shortness of breath for about 1 year , progressing to chronic type 1 respiratory failure . this was followed by development of full blown mctd , with combined features of rheumatoid arthritis , scleroderma and systemic lupus erythematosus with severe arthritis , myositis and joint contractures . this was a case report of a 32-year - old stone crusher presented with gradually progressive breathlessness , initially on exertion and later , also at rest for 1 year . at the same time , he also noticed raynaud 's phenomenon involving the fingers and toes . over the next 6 months , he developed a gradual binding down of the skin over the dorsa of hands , forearms , face and leg . the patient also had severe joint pains predominantly involving all joints of the hands , including the wrist joint and the knees bilaterally . patient had been working as a stone crusher for the past 6 years . on examination , the patient had diffuse hyperpigmentation , visible respiratory distress with a respiratory rate of 34/min with mild pallor . arterial blood gas analysis revealed type 1 respiratory failure with pao2- 54 mmhg , ph - 7.38 , paco2- 38 mmhg . testing for immune markers revealed antinuclear antibody ( ana ) positive-9 ( if assay ) , anti - double stranded - deoxyribonucleic acid positive , anti - scl70 igg antibody positive  86 u / l , anti - u1 ribonucleoprotein ( rnp ) antibodies positive in high titers , anti - cyclic citrullinated peptide and rheumatoid factor positive . contrast enhanced computed tomography of the chest was suggestive of diffuse intra and interlobular septal thickening with fibrosis and randomly situated nodules [ figure 1 ] . transbronchial lung biopsy was compatible with silicosis and revealed focal interstitial fibrosis interspersed with pigment laden macrophages and refractile material . low dose prednisonolone ( 20 mg od ) was given in view of the arthritis . methotrexate at a dose of 25 mg weekly was also started along with proton pump inhibitors and physiotherapy . his hypoxia has also improved on therapy , but he continues to be on supplemental oxygen . some patients have features of more than one rheumatic disease and thus do not fit into traditional classification . patients with combination of clinical finding similar to those of systemic lupus erythematosus , progressive systemic sclerosis , polymyositis , rheumatoid arthritis and with unusually high titers of circulating ana with specificity for nuclear rnp are considered to have mctd . hypotheses implicating modified self - antigens and/or infectious agents in the pathogenesis of mctd have been advanced , but none have been proven yet . crystalline silica ( quartz ) particles less than 1  are the most pathogenic in silicosis . this constitutes a permanent stimulus for the fibroblasts , which increase their production of collagen leading to cutaneous sclerosis , vascular occlusion and pulmonary fibrosis , which explains the myriad clinical features of scleroderma and mctd .