A Case of a Rheumatoid Arthritis Patient on Newly Initiated Tumor Necrosis Factor Inhibitor Treatment Developing Granulomatosis With Polyangiitis Vasculitis: A Conundrum About Disease Overlap or Drug-Induced Vasculitis

Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitides subset of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAVs) that involves small-sized arteries affecting multisystemic organs. Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammatory polyarthritis involving the small joints. GPA and RA can have overlapping clinical presentations, including vasculitis, ocular inflammation, interstitial lung disease, and arthritis, but existing evidence indicates they are distinct conditions. Vasculitis-induced biologic tumor necrosis factor (TNF) inhibitors have been reported, particularly cutaneous vasculitis and lupus-like syndromes. We retrospectively review a case of a patient with rheumatoid arthritis with a newly diagnosed GPA with RA on anti-TNF therapy. The coexistence of RA with GPA is rare, and cases of TNF inhibitors have been reported; it becomes a conundrum when a patient faces this presentation.