Tumor necrosis factor-α (TNF-α) inhibitors are considered safe and effective for treatment of rheumatoid arthritis (RA) and psoriatic arthritis (PsA) 1. Although induction of antinuclear antibodies (ANA) and lupus-like syndromes have been described in patients treated with TNF blockers1, their use was recently advocated in treatment of systemic lupus erythematosus (SLE) 2. Most reported lupus-like cases were characterized by malaise, fatigue, and increased arthritis, without major organ system involvement3. We describe 6 women who developed active SLE satisfying American College of Rheumatology diagnostic criteria (Table 1) with life-threatening manifestations after receiving TNF blockade for treatment of RA or PsA (Table 2).

The first patient was admitted for dyspnea and chest pain after 3-month treatment of RA with etanercept. She had decreased breath sounds, arthritis, malar and papular rash, leukocytosis, elevated erythrocyte sedimentation rate (ESR), and positive ANA and anticardiolipin antibodies. Chest radiograph and echocardiogram showed pleural and pericardial effusion with right ventricular compression. Two liters of fluid were drained through a pericardial window. Etanercept was discontinued and she was discharged on prednisone and mycophenolate mofetil. Within 3 months, she went into remission. She also had erosive hand arthritis and this may represent an overlap of RA and lupus, termed rhupus4. The second patient was treated with sulfasalazine and etanercept when she was admitted with headache, blurry vision, dizziness and leg numbness, unsteady gait, arthritis, and discoid and malar rash. She had elevated ESR, positive ANA and anti-DNA antibodies, and low complement concentrations. Brain imaging showed demyelinating lesions. After discontin-