Rhupus in a patient on biologic - medicamentous or not?

A 69-year-old woman was diagnosed with seropositive RA in 2003. having bad prognostic factors (high level of inflammatory markers and rheumatoid factor, polyarticular erosive disease). She was treated with levothyroxine from 2012. and had no other significant comorbidity. From beginning she was given methotrexate along with antimalarial and intermittent glucocorticosteroid depo intramuscular injections. In 2009. methotrexate was withdrawn because of significant transaminases elevation. She also had side effects using leflunomide and sulphasalazine. She used infliximab from 2013. to 2014. and was stopped because of psoriasis induction. From March 2015. tocilizumab was introduced as a second biologic with different mechanism and which could also be used as monotherapy. After a year of tocilizumab use she had PPD3 positivity and continued biologic along with incomplete latent tuberculosis chemoprophylaxis with izoniazide which also induced significant transaminases elevation. Her tocilizumab dosing was influenced by her neutropenias, lymphopaenias and thrombocytopaenias, so she often had less then a preplanned dose. In the winter of 2019. after clinical suspicion on drug induced lupus (DIL) based on cytopaenias, appearance of alopecia and malar rush and history of anti-TNF and izoniazide use, she had laboratory evaluation discovering homogeneous pattern antinuclear antibodies (ANA) 1/160, high level of antihistone antibody, anti-DNA antibody with low c3 component. After systemic evaluation, no other organs were affected. Patient developed overlap between old RA and newly diagnosed SEL. tocilizumab was stopped at the beginning of 2020. She had transient arthritis flare, now well controlled with baricitinib.