TNF alpha antagonist-induced lupus-like syndrome: report and review of the literature with implications for treatment with alternative TNF alpha antagonists

Int J Dermatol. 2011 May;50(5):619-25. doi: 10.1111/j.1365-4632.2011.04871.x.


Background: In patients with various autoimmune and rheumatic diseases, a drug-induced lupus-like syndrome (DILS) has been reported with the use of adalimumab, cerrolizumab pegol, etanercept, and infliximab.

Objective: To review clinical characteristics of patients who develop tumor necrosis factor (TNF) alpha antagonist-induced lupus-like syndrome (TAILS) and review implications for further TNF alpha antagonist therapy.

Materials and methods: We describe a 62-year-old woman with rheumatoid arthritis who developed a pruritic photo-distributed rash two months after the initiation of etanercept therapy. Her skin biopsy showed lupus erythematosus, and she had positive serum ANA, anti-Sjogren's syndrome A (SSA)/Ro, and anti-Sjogren's syndrome B (SSB)/La antibodies. Her symptoms resolved after discontinuation of the drug, topical and systemic corticosteroids, and hydroxychloroquine sulfate. Subsequently, her rheumatoid arthritis was treated with golimumab for six months without recurrence of skin lesions. Published reports of individuals who have developed TAILS and those who have continued treatment with alternative TNF alpha antagonists are reviewed.

Results: TAILS is most commonly associated with the use of etanercept and infliximab. It occurs most often in women in the fifth decade of life. Onset of symptoms ranges from less than one month to more than four years. Syndrome-associated cutaneous lesions and induction of autoantibodies are common. There is no definitively established mechanism of pathogenesis. Treatment can include discontinuation of the drug, corticosteroids, immunosuppressives, and hydroxychloroquine sulfate. To date, 10 patients with TAILS have continued therapy with an alternative TNF alpha antagonist without recurrence of lupus symptoms.

Conclusions: Development of a DILS after one TNF alpha antagonist does not preclude continued treatment with an alternative TNF alpha antagonist.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Antibodies, Antinuclear / blood
  • Antibodies, Monoclonal / adverse effects
  • Antibodies, Monoclonal / therapeutic use*
  • Antibodies, Monoclonal, Humanized
  • Antirheumatic Agents / adverse effects*
  • Antirheumatic Agents / therapeutic use
  • Arthritis, Rheumatoid / drug therapy*
  • Certolizumab Pegol
  • Etanercept
  • Female
  • Humans
  • Hydroxychloroquine / therapeutic use
  • Immunoglobulin Fab Fragments / adverse effects
  • Immunoglobulin Fab Fragments / therapeutic use
  • Immunoglobulin G / adverse effects*
  • Immunoglobulin G / therapeutic use
  • Immunosuppressive Agents / therapeutic use
  • Infliximab
  • Lupus Erythematosus, Systemic / chemically induced*
  • Lupus Erythematosus, Systemic / diagnosis
  • Lupus Erythematosus, Systemic / pathology
  • Middle Aged
  • Polyethylene Glycols / adverse effects
  • Polyethylene Glycols / therapeutic use
  • Receptors, Tumor Necrosis Factor / therapeutic use
  • Treatment Outcome
  • Tumor Necrosis Factor-alpha / antagonists & inhibitors*


  • Adrenal Cortex Hormones
  • Antibodies, Antinuclear
  • Antibodies, Monoclonal
  • Antibodies, Monoclonal, Humanized
  • Antirheumatic Agents
  • Immunoglobulin Fab Fragments
  • Immunoglobulin G
  • Immunosuppressive Agents
  • Receptors, Tumor Necrosis Factor
  • Tumor Necrosis Factor-alpha
  • Polyethylene Glycols
  • Hydroxychloroquine
  • golimumab
  • Infliximab
  • Etanercept
  • Certolizumab Pegol