After this patient failed to respond to multiple treatments (steroid, methotrexate, hydroxychloroquine, colchicine, and antibiotics), the use of a TNF-alpha inhibitor was employed as an alternative, previously reported to be effective in a few case reports.6, 7, 8, 9 Rarely, these drugs may present paradoxical granuloma formation, and this should be considered by clinicians. The gene discussed is TNF; the disease is Granuloma.