## Clinical Context This patient has **drug-induced interstitial lung disease (ILD)** secondary to TNF-α inhibitor therapy. TNF-α inhibitors are a recognized cause of **non-infectious pneumonitis**, especially in patients on concurrent methotrexate. ## Key Point: **When a TNF-α inhibitor-associated ILD is suspected:** 1. **Discontinue the biologic immediately** — continuation risks progressive respiratory failure 2. **Exclude infection** (TB, PCP, fungal) — already done (TB negative, clinical picture atypical for PCP) 3. **Initiate corticosteroids** — the standard anti-inflammatory therapy for drug-induced ILD 4. **Continue or adjust csDMARD** based on severity; methotrexate may be continued at lower dose or held temporarily ## High-Yield: TNF-α inhibitor–associated ILD occurs in ~0.5–2% of RA patients and is a **medical emergency**. The diagnosis is clinical + radiological (interstitial pattern, exclusion of infection). **Immediate biologic withdrawal + corticosteroids** is the standard management; most patients improve within weeks. ## Mnemonic: **STOP-ILD** = **S**top the TNF inhibitor, **T**reat with corticosteroids, **O**xygenate, **P**revent infection, **I**nvestigate for other causes, **L**ow-dose methotrexate continuation (if tolerated), **D**isease monitoring. ## Clinical Pearl: TNF-α inhibitors suppress Th1 immunity and paradoxically can trigger **autoimmune-like pulmonary toxicity**. Unlike infection (which requires antimicrobials), drug-induced ILD responds to **immunosuppression withdrawal + corticosteroids**. Continuing the offending agent while treating empirically with antibiotics is dangerous and delays recovery. [cite:Harrison 21e Ch 313; Uptodate RA and Interstitial Lung Disease]
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