Golimumab (Simponi®) is a TNF-α inhibitor used for rheumatologic conditions such as rheumatoid arthritis (RA), ankylosing spondylitis, and ulcerative colitis. Neurologic side effects such as seizures, posterior reversible encephalopathy syndrome (PRES), and demyelinating disease are rare, with only 18 cases reported in the Federal Adverse Event Reporting System (FAERS). We present a case of possible PRES closely following the first subcutaneous administration of Golimumab for RA in a 71-year-old male patient.

TNF-α is a proinflammatory cytokine involved in inflammation and autoimmunity. Golimumab, a human anti-TNF-α IgG1 monoclonal antibody, can bind circulating and cell-bound TNF molecules, causing apoptosis of TNF-expressing cells. PRES is a dangerous neurologic syndrome characterized by headache, seizures, altered mentation, and visual disturbances due to vasogenic brain swelling, typically in the parietal and occipital lobes. PRES is associated with hypertension, autoimmune disease, infection, or cytotoxic medications.

A 71-year-old male with history of RA, hypothyroidism, hypertension, COPD, and type 2 diabetes presented with facial shaking and bilateral upper-extremity jerking for 20 minutes, followed by confusion. This occurred two hours after his first Golimumab injection. Blood pressure was 158/102 mmHg; heart rate 40-50 bpm. CT angiography showed no acute findings. EEG showed no epileptiform activity. MRI revealed a small right parietal infarct and scattered subcortical and periventricular FLAIR hyperintensities. Subspecialists favored PRES over infarct, hypothyroidism, or convulsive syncope given timing, imaging, and symptoms.

This case highlights possible Golimumab-induced PRES presenting with seizure-like activity, hypertension, and transient altered mentation. Though rare, PRES is a serious potential adverse effect of TNF-α inhibitors. Those prescribing TNF- α inhibitors should monitor blood pressure and neurologic status closely after initiation to ensure early recognition and prevention of complications.