Tumor necrosis factor blockade and the risk of viral infection

Nat Rev Rheumatol. 2010 Mar;6(3):165-74. doi: 10.1038/nrrheum.2009.279. Epub 2010 Feb 9.


Tumor necrosis factor (TNF) blockers are widely used to treat rheumatoid arthritis and other chronic inflammatory diseases. Many studies have demonstrated an increased risk of opportunistic infections such as tuberculosis and fungal infection in patients treated with TNF blockers, which is thought to be related to the primary role of TNF both in host defense and in the immune response. Little is known, however, about the association between TNF blockade and the development of viral infection. Owing to the critical role of TNF in the control of viral infection, depletion of this cytokine with TNF blockers could facilitate the development or reactivation of viral infection. A number of large observational studies have found an increased risk of herpes zoster in patients receiving TNF blockers for the treatment of rheumatoid arthritis. This Review draws attention to the risk of several viral infections, including HIV, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, and human papillomavirus, in patients receiving TNF-blocking therapy for chronic inflammatory conditions. In addition, implications for clinical practice and possible preventative approaches are discussed.

Publication types

  • Review

MeSH terms

  • Antibodies, Monoclonal / adverse effects*
  • Antirheumatic Agents / adverse effects*
  • Arthritis, Rheumatoid / complications
  • Arthritis, Rheumatoid / drug therapy*
  • Humans
  • Immunosuppressive Agents / adverse effects*
  • Opportunistic Infections / etiology
  • Opportunistic Infections / immunology
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors*
  • Tumor Necrosis Factor-alpha / physiology
  • Virus Activation
  • Virus Diseases / etiology*
  • Virus Diseases / immunology


  • Antibodies, Monoclonal
  • Antirheumatic Agents
  • Immunosuppressive Agents
  • Tumor Necrosis Factor-alpha