A Case of Rheumatoid Arthritis on Newly Initiated TNF- Inhibitor Developing GPA Vasculitis- Conundrum About an Overlap or Drug-Induced Vasculitis

Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitides subset of 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 TNF inhibitors have been reported (1-3), 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.