A 32-year-old woman delivered monozygotic female twins vaginally at 34 weeks of gestation in November, 2011. This was her fourth pregnancy. She had received antenatal care elsewhere. During the fi rst trimester she had an episode of fever and rash. The rest of the antenatal period was uneventful. Both the twins had respiratory distress and were admitted to our neonatal intensive care unit. Both were given empirical antibiotic therapy and were mechanically ventilated. Echo cardiogram showed that twin one had a patent ductus arteriosus; weight was appropriate for gestational age. Twin two was small for gestational age and was covered with diff use purpura (fi gure), and had thrombocytopenia (platelet count 39×109/L) and retinitis. Radiography showed a radiolucent humerus bilaterally and intracranial calcifi cations. In view of the clinical features and maternal history of fever in the fi rst trimester, intrauterine infection was suspected. Both twins were positive for rubella specifi c IgM (chemiluminescent microparticle immunoassay; Abbott, Ireland) and negative for antibodies against toxoplasma and cytomegalovirus (CMV). The mother tested positive for both rubella and CMV specifi c IgG. Viral cultures could not be done because of lack of resources. Twin two succumbed to pulmonary haemorrhage on day 4. Twin one developed congestive cardiac failure on day 3 and was managed conservatively; she was extubated on day 5, and eventually discharged on medication for cardiac failure on day 12 having established direct breastfeeds. When she was last seen for follow-up in January, 2012, she had appropriate weight gain, tests for vision and hearing were normal, and her cardiac failure secondary to patent ductus arteriosus was under control. More than three decades have passed since the introduction of the live attenuated rubella vaccine. With widespread immunisation against rubella, the incidence of fetal exposure to rubella has decreased drastically, particularly in developed countries. However, rubella continues to aff ect women of childbearing age and young children in developing countries where vaccination against rubella is not covered under the national immunisation schedule. In our case, the diagnosis was made on the basis of the criteria for congenital rubella syndrome proposed by the US Centers for Disease Control and Prevention. Only a few studies have reported congenital rubella syndrome in twins. Only one twin in our case was severely aff ected, supporting the view that that there can be individual variation in disease expression. One study showed that in India, 82·2% of children between 1 and 5 years of age and 13·5% between 10 and 15 years of age were susceptible to rubella. Congenital rubella syndrome is a leading cause of non traumatic cataracts and hearing loss in children in developing countries. In India, more than 50% of children who underwent surgery for cataracts associated with congenital rubella syndrome had poor visual outcomes; most also had associated hearing loss. These facts underline the need for strengthening the rubella immunisation programme in India towards universal coverage in states that have not yet implemented it. Strong political will and a change in the constitution of the immunisation advisory groups could put an end to the problem of congenital rubella syndrome, and pave the way for its elimination as is being planned in the USA and the EU.