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Anti-TNF-induced lupus — SCE Rheumatology MCQ

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HardRheumatoid arthritisAnti-TNF-induced lupusSCE Rheumatology

A 45-year-old woman with rheumatoid arthritis develops photosensitive rash and pleuritic chest pain 5 months after starting adalimumab. Examination shows mild synovitis but no renal signs. Investigations show ANA positive, anti-dsDNA positive and complement normal. What is the most likely diagnosis?

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Correct answer: E — Anti-TNF-induced lupus

The best answer is “Anti-TNF-induced lupus”. New lupus-like features after anti-TNF treatment, with ANA and anti-dsDNA positivity, indicate anti-TNF-induced lupus. Idiopathic SLE is possible but the temporal relationship to adalimumab and absence of renal disease make drug-induced disease more likely. The key management step is usually withdrawal of the offending biologic and reassessment of the RA strategy. The competing options represent related diagnoses, tests or treatments, but they do not match the decisive phenotype, safety constraint or management point in this stem.

Reference: BSR biologic DMARD safety guideline: https://academic.oup.com/rheumatology/article/58/2/e3/5076446