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Quantitative Assessment of Vacuolization of Myeloid Precursors in VEXAS Syndrome. Hemasphere 2023; 7:e828. [PMID: 36751512 PMCID: PMC9894342 DOI: 10.1097/hs9.0000000000000828] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/12/2022] [Indexed: 01/28/2023] Open
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Beck DB, Bodian DL, Shah V, Mirshahi UL, Kim J, Ding Y, Magaziner SJ, Strande NT, Cantor A, Haley JS, Cook A, Hill W, Schwartz AL, Grayson PC, Ferrada MA, Kastner DL, Carey DJ, Stewart DR. Estimated Prevalence and Clinical Manifestations of UBA1 Variants Associated With VEXAS Syndrome in a Clinical Population. JAMA 2023; 329:318-324. [PMID: 36692560 PMCID: PMC10408261 DOI: 10.1001/jama.2022.24836] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/26/2022] [Indexed: 01/25/2023]
Abstract
IMPORTANCE VEXAS (vacuoles, E1-ubiquitin-activating enzyme, X-linked, autoinflammatory, somatic) syndrome is a disease with rheumatologic and hematologic features caused by somatic variants in UBA1. Pathogenic variants are associated with a broad spectrum of clinical manifestations. Knowledge of prevalence, penetrance, and clinical characteristics of this disease have been limited by ascertainment biases based on known phenotypes. OBJECTIVE To determine the prevalence of pathogenic variants in UBA1 and associated clinical manifestations in an unselected population using a genomic ascertainment approach. DESIGN, SETTING, AND PARTICIPANTS This retrospective observational study evaluated UBA1 variants in exome data from 163 096 participants within the Geisinger MyCode Community Health Initiative. Clinical phenotypes were determined from Geisinger electronic health record data from January 1, 1996, to January 1, 2022. EXPOSURES Exome sequencing was performed. MAIN OUTCOMES AND MEASURES Outcome measures included prevalence of somatic UBA1 variation; presence of rheumatologic, hematologic, pulmonary, dermatologic, and other findings in individuals with somatic UBA1 variation on review of the electronic health record; review of laboratory data; bone marrow biopsy pathology analysis; and in vitro enzymatic assays. RESULTS In 163 096 participants (mean age, 52.8 years; 94% White; 61% women), 11 individuals harbored likely somatic variants at known pathogenic UBA1 positions, with 11 of 11 (100%) having clinical manifestations consistent with VEXAS syndrome (9 male, 2 female). A total of 5 of 11 individuals (45%) did not meet criteria for rheumatologic and/or hematologic diagnoses previously associated with VEXAS syndrome; however, all individuals had anemia (hemoglobin: mean, 7.8 g/dL; median, 7.5 g/dL), which was mostly macrocytic (10/11 [91%]) with concomitant thrombocytopenia (10/11 [91%]). Among the 11 patients identified, there was a pathogenic variant in 1 male participant prior to onset of VEXAS-related signs or symptoms and 2 female participants had disease with heterozygous variants. A previously unreported UBA1 variant (c.1861A>T; p.Ser621Cys) was found in a symptomatic patient, with in vitro data supporting a catalytic defect and pathogenicity. Together, disease-causing UBA1 variants were found in 1 in 13 591 unrelated individuals (95% CI, 1:7775-1:23 758), 1 in 4269 men older than 50 years (95% CI, 1:2319-1:7859), and 1 in 26 238 women older than 50 years (95% CI, 1:7196-1:147 669). CONCLUSIONS AND RELEVANCE This study provides an estimate of the prevalence and a description of the clinical manifestations of UBA1 variants associated with VEXAS syndrome within a single regional health system in the US. Additional studies are needed in unselected and genetically diverse populations to better define general population prevalence and phenotypic spectrum.
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Affiliation(s)
- David B. Beck
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
- Center for Human Genetics and Genomics, New York University School of Medicine
- Division of Rheumatology, Department of Medicine, New York University School of Medicine
| | | | - Vandan Shah
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Uyenlinh L. Mirshahi
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Jung Kim
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Yi Ding
- Department of Laboratory Medicine, Geisinger, Danville, Pennsylvania
| | - Samuel J. Magaziner
- Center for Human Genetics and Genomics, New York University School of Medicine
| | - Natasha T. Strande
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Anna Cantor
- Center for Human Genetics and Genomics, New York University School of Medicine
- Division of Rheumatology, Department of Medicine, New York University School of Medicine
| | - Jeremy S. Haley
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Adam Cook
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Wesley Hill
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Alan L. Schwartz
- Department of Pediatrics, Washington University in St Louis, Missouri
| | - Peter C. Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Marcela A. Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | - Daniel L. Kastner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - David J. Carey
- Department of Molecular and Functional Genomics, Geisinger, Danville, Pennsylvania
| | - Douglas R. Stewart
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
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Vitale A, Caggiano V, Bimonte A, Caroni F, Tosi GM, Fabbiani A, Renieri A, Bocchia M, Frediani B, Fabiani C, Cantarini L. VEXAS syndrome: a new paradigm for adult-onset monogenic autoinflammatory diseases. Intern Emerg Med 2023; 18:711-722. [PMID: 36662445 PMCID: PMC10082120 DOI: 10.1007/s11739-023-03193-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is a recently described pathological entity. It is an acquired monogenic autoinflammatory disease caused by somatic mutations of the UBA1 gene in blood cells precursors; the gene encodes one of the two E1 enzyme isoforms that initiates ubiquitylation in cell's cytoplasm. VEXAS syndrome leads to systemic inflammation, with all organs and tissues potentially involved. The clinical picture may be extremely heterogenous, mimicking different other systemic rheumatologic entities coexisting with haematological disorders, especially myelodysplastic syndrome. This new disease represents a very intriguing clinical condition in several respects: it accounts for the paradigm of adult-onset monogenic autoinflammatory diseases determined by a genetic mosaicism resulting in the development of a challenging multiorgan inflammatory condition. Moreover, VEXAS syndrome is perhaps not an exceptionally rare condition and represents an example of a systemic genetic autoinflammatory disease drawing its origin in bone marrow disorders. VEXAS syndrome should be strongly considered in each adult patient with an unexplained systemic inflammatory condition, especially when recurrent fevers, neutrophilic dermatosis, relapsing polychondritis, ocular inflammation and other systemic inflammatory symptoms accompanying myelodysplastic syndrome or other haematological disorders. The syndrome deserves a multidisciplinary approach to reach the diagnosis and ensure the best management of a potentially very challenging condition. To quickly describe the clinical course, long-term outcomes, and the optimal management of this new syndrome it is essential to join forces internationally. To this end, the international AutoInflammatory Disease Alliance (AIDA) registry dedicated to VEXAS syndrome has been developed and is already active.
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Affiliation(s)
- Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Valeria Caggiano
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Antonio Bimonte
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Federico Caroni
- Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Gian Marco Tosi
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Alessandra Fabbiani
- Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alessandra Renieri
- Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy
- Department of Medical Biotechnologies, Med Biotech Hub and Competence Center, University of Siena, Siena, Italy
- Genetica Medica, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Monica Bocchia
- Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
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Al-Hakim A, Poulter JA, Mahmoud D, Rose AMS, Elcombe S, Lachmann H, Cargo C, Duncan CJA, Bishton M, Bigley V, Khan A, Savic S. Allogeneic haematopoietic stem cell transplantation for VEXAS syndrome: UK experience. Br J Haematol 2022; 199:777-781. [PMID: 36184391 DOI: 10.1111/bjh.18488] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/13/2022] [Accepted: 09/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Adam Al-Hakim
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - James A Poulter
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Dina Mahmoud
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - Ailsa M S Rose
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - Suzanne Elcombe
- Department of Immunology, Newcastle upon Tyne NHS Trust, Newcastle upon Tyne, UK
| | - Helen Lachmann
- National Amyloidosis Centre Royal Free London NHS Foundation Trust and Division of Medicine University, College London, London, UK
| | - Catherine Cargo
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - Christopher J A Duncan
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Centre for Bone Marrow Transplantation, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mark Bishton
- Department of haematology, Nottingham University Hospitals NHS Trust, UK
- Translational Medical Sciences, University of Nottingham, UK
| | - Venetia Bigley
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Centre for Bone Marrow Transplantation, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Anjum Khan
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - Sinisa Savic
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
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Lost in translation: cytoplasmic UBA1 and VEXAS syndrome. Blood 2022; 140:1455-1457. [PMID: 36173661 DOI: 10.1182/blood.2022017560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/07/2022] [Indexed: 11/20/2022] Open
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Gurnari C, McLornan DP. Update on VEXAS and role of allogeneic bone marrow transplant: Considerations on behalf of the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2022; 57:1642-1648. [PMID: 35941354 DOI: 10.1038/s41409-022-01774-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/09/2022]
Abstract
VEXAS (acronym for Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a fascinating new entity encompassing a variety of clinical manifestations, spanning from auto-inflammatory symptoms to hematologic disorders, including myelodysplastic syndromes and plasma cell dyscrasias. Genetically defined by somatic mutations of the X-linked gene UBA1 in hematopoietic stem and progenitor cells, VEXAS typically manifests in males during the fifth/sixth decade of life. Since its discovery, several groups have documented pleomorphic clinical phenotypes, in addition to a plethora of therapeutic options (e.g., JAK inhibitors, hypomethylating agents, and allogeneic stem cell transplant, allo-HCT) in retrospective case series. However, no treatment guidelines have been validated to date, VEXAS patients are typically steroid-dependent and may manifest life-threatening inflammatory symptoms refractory to multiple lines of therapy. To date, the only curative option appears to be allo-HCT in suitable individuals. Nonetheless, this procedure carries an inherent risk of morbidity and mortality that must be judiciously evaluated against a phenotypically diverse disorder where the optimal therapeutic algorithm remains ill-defined. Herein, we provide an overview of the current VEXAS data/ therapeutic evidence and discuss the curative potential of allo-HCT whilst highlighting the efforts required for generation of robust data able to inform therapeutic decisions.
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Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, USA.,Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Donal P McLornan
- Department of Stem Cell Transplantation and Haematology, University College London Hospitals, London, UK.
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Alcedo PE, Gutierrez-Rodrigues F, Patel BA. Somatic mutations in VEXAS Syndrome and Erdheim-Chester Disease: Inflammatory Myeloid Diseases. Semin Hematol 2022; 59:156-166. [DOI: 10.1053/j.seminhematol.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 12/27/2022]
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