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A 46-year-old woman with a 6-year history of rheumatoid arthritis is evaluated for symmetrical worsened joint pains in the hands and feet of 1 week's duration. She also has new onset of chest pain on deep breathing, a facial rash, and purpura on the calves. For the first 5 years of her disease, she was treated with methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, and minocycline, but this regimen did not effectively control her severe erosive rheumatoid arthritis. One year ago, she was switched to a maintenance dose of methotrexate, and etanercept therapy was added to her regimen; since then, her arthritis and fatigue had significantly and rapidly improved.
On physical examination, temperature is 37.5 °C (99.5 °F), pulse rate is 110/min, and blood pressure is 140/90 mm Hg. She appears acutely ill and has a macular malar rash. Cardiac examination reveals a pericardial friction rub. There is active synovitis of the small joints of the hands and feet and palpable purpura on the shins.
Laboratory Studies
Hemoglobin
11.5 g/dL (115 g/L)
Leukocyte count
2200/μL (2.2 × 109/L)
Platelet count
165,000/µL (165 × 109/L )
Erythrocyte sedimentation rate
55 mm/h
C-reactive protein
5.0 mg/dL (50 mg/L)
Chest radiograph reveals cardiomegaly. Electrocardiogram shows ST segment elevation across the precordium.
Which of the following is the most likely diagnosis?
A Non-Hodgkin's lymphoma
B Rheumatoid arthritis flare
C Felty's syndrome
D Drug-induced systemic lupus erythematosus
E Bacterial endocarditis
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Hello Pace. How are you?
D Drug-induced systemic lupus erythematosus
Maybe!! 
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hello rammar ,
Not too bad......How abt you.
D is right.
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plz tell thedrug vch caused lupus
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pace..explanation to ths pls...i also doubt which drug cause it...
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Correct Answer = D)
Key Points
* Up to 20% of patients with rheumatoid arthritis treated with anti“tumor necrosis factor agents develop antinuclear antibody positivity.
* A small percentage of patients taking anti“tumor necrosis factor agents develop drug-induced systemic lupus erythematosus.
This patient most likely has systemic lupus erythematosus induced by the anti“tumor necrosis factor agent etanercept. Discontinuation of the inciting drug is indicated for this uncommon clinical problem. Corticosteroid therapy also may be warranted to acutely treat this patient's arthritis, pericarditis, and rash. Antinuclear antibody positivity in a previously antinuclear antibody“negative patient would strongly support this diagnosis. Up to 20% of patients with rheumatoid arthritis treated with anti“tumor necrosis factor agents develop new-onset antinuclear antibody positivity and may develop an associated lupus-like syndrome. However, a significant number of patients with rheumatoid arthritis may have positive findings on antinuclear antibody assays before initiation of anti“tumor necrosis factor therapy.
Patients with rheumatoid arthritis have an increased incidence of large B-cell, non-Hodgkin's lymphoma compared with age- and sex-matched control populations. There also is an association between methotrexate therapy for rheumatoid arthritis and development of B-cell lymphoma; tumors have even been shown to resolve in some patients on discontinuation of methotrexate. In nearly 50% of these patients, tumors contain Epstein“Barr virus, which is a cofactor in tumor development. It is uncertain whether anti“tumor necrosis factor therapy causes an increased incidence of this type of tumor. However, patients with rheumatoid arthritis with B-cell lymphoma usually do not present with joint pains, pericarditis, and the rash described in this patient.
Rheumatoid arthritis flare is possible in this setting but is unlikely because her condition was well controlled and she does not have a history of extra-articular manifestations of rheumatoid arthritis. Serum sickness is an immune complex disease triggered by drugs such as antibiotics that develops 1 to 2 weeks after initiation of the inciting agent. This condition frequently causes severe swelling of the joints, urticaria, and eosinophilia. Bacterial infection is more common in patients treated with anti“tumor necrosis factor agents, especially in the setting of concomitant use of methotrexate. Characteristic bacterial infections include upper respiratory infections; urinary tract infections; and skin infections, which are particularly common in patients with leg ulcers. Felty's syndrome causes granulocytopenia but would not cause the malar rash and pericarditis seen in this patient.
Endocarditis may cause a single joint inflammation or localized skin lesions but not the diffuse symptoms that this patient has. Pericarditis is an uncommon manifestation of endocarditis, particularly in the setting of joint flare and rash
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