UCLA

Tumor necrosis factor-alpha (TNF-α) inhibitors are effective biologic disease-modifying antirheumatic drugs (bDMARDs) commonly used to treat various inflammatory conditions. While generally considered safe, these agents have been associated with paradoxical immune-mediated adverse effects, including sarcoid-like reactions. We present the case of a 24-year-old male with juvenile idiopathic arthritis (JIA) who developed pulmonary manifestations of a sarcoid-like reaction while on adalimumab therapy. The patient presented with progressive dyspnea, and imaging revealed diffuse bilateral ground-glass opacities with hilar lymphadenopathy. Endobronchial ultrasound-guided biopsy confirmed non-necrotizing granulomas with giant cells and eosinophils, consistent with a sarcoid-like reaction. Following discontinuation of adalimumab and initiation of methotrexate and prednisone therapy, the patient showed significant clinical and radiological improvement. This case highlights the importance of considering paradoxical drug reactions in patients on TNF-α inhibitors who present with respiratory symptoms and emphasizes the need for prompt diagnosis and appropriate management.