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Kouranloo K, Dey M, Almutawa J, Myall N, Nune A. Clinical characteristics, disease trajectories and management of vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome: a systematic review. Rheumatol Int 2024; 44:1219-1232. [PMID: 38129348 DOI: 10.1007/s00296-023-05513-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly discovered autoinflammatory condition characterised by somatic mutation of the UBA1 gene. The syndrome leads to multi-system inflammation affecting predominantly the skin, lungs and bone marrow. METHODS We undertook a systematic review of the multisystem features and genotypes observed in VEXAS syndrome. Articles discussing VEXAS syndrome were included. Medline, Embase and Cochrane databases were searched. Information was extracted on: demographics, type and prevalence of clinical manifestations, genetic mutations and treatment. Meta-analysis using a random effects model was used to determine pooled estimates of serum markers. RESULTS From 303 articles, 90 were included, comprising 394 patients with VEXAS. 99.2% were male, with a mean age of 67.1 years (SD 8.5) at disease onset. The most frequent diagnoses made prior to VEXAS were: relapsing polychondritis (n = 59); Sweet's syndrome (n = 24); polyarteritis nodosa (n = 11); and myelodysplastic syndrome (n = 10). Fever was reported in 270 cases (68.5%) and weight loss in 79 (20.1%). Most patients had haematological (n = 342; 86.8%), dermatological (n = 321; 81.5%), pulmonary (n = 297; 75.4%%) and musculoskeletal (n = 172; 43.7%) involvement, although other organ manifestations of varying prevalence were also recorded. The most commonly reported mutations were "c.122T > C pMET41Thr" (n = 124), "c.121A > G pMET41Val" (n = 62) and "c.121A > C pMet41Leu" (n = 52). Most patients received glucocorticoids (n = 240; 60.9%) followed by methotrexate (n = 82; 20.8%) and IL-6 inhibitors (n = 61, 15.4%). One patient underwent splenectomy; 24 received bone marrow transplants. CONCLUSION VEXAS syndrome is a rare disorder affecting predominantly middle-aged men. This is the first systematic review to capture clinical manifestations, genetics and treatment of reported cases. Further studies are needed to optimise treatment and subsequently reduce morbidity and mortality.
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Affiliation(s)
- Koushan Kouranloo
- Department of Rheumatology, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH, UK.
- School of Medicine, Cedar House, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK.
| | - Mrinalini Dey
- Centre for Rheumatic Diseases, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
| | - Jude Almutawa
- Liverpool University NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Nikki Myall
- British Medical Association Library, BMA House, Tavistock Square, London, WC1H 9JP, UK
| | - Arvind Nune
- Department of Rheumatology, Southport & Ormskirk Hospital NHS Trust, Town Lane, Kew, Southport, PR8 6PN, UK
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2
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Lacombe V, Hadjadj J, Georgin-Lavialle S, Lavigne C, Geneviève F, Kosmider O. Vacuoles in bone marrow progenitors: VEXAS syndrome and beyond. Lancet Haematol 2024; 11:e160-e167. [PMID: 38302223 DOI: 10.1016/s2352-3026(23)00375-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024]
Abstract
The presence of vacuoles in myeloid and erythroid progenitor cells in bone marrow aspirates is a key feature of vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. The mere observation of vacuolated progenitor cells is not specific to VEXAS syndrome; in this Viewpoint, we point out the causes to be considered in this situation. Vacuoles, in particular, can be observed in individuals with wild-type UBA1 and with persistent inflammatory features or myelodysplastic syndromes. However, several clues support the diagnosis of VEXAS syndrome in the presence of vacuolated bone marrow progenitors: a high number of vacuolated progenitors and of vacuoles per cell, the predominance of vacuoles in early rather than late progenitors, and the vacuolisation of both myeloid and erythroid progenitors with predominance of myeloid ones. Some criteria derived from these observations have been proposed with great diagnostic performances. However, the absence or a low proportion of vacuolated cells should not prevent UBA1 gene sequencing.
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Affiliation(s)
- Valentin Lacombe
- Service de Médecine interne et immunologie clinique, Centre Hospitalier Universitaire d'Angers, Angers, France; Centre de Référence des Maladies auto-immunes et auto-inflammatoires systémiques de l'adulte Nord, Nord-ouest, Méditerranée et Guadeloupe (CeRAINOM), Angers, France; Mitolab, unité MitoVasc, INSERM U1083, CNRS UMR6015, Université d'Angers, Angers, France.
| | - Jérome Hadjadj
- Service de Médecine interne, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Georgin-Lavialle
- Service de Médecine interne, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de référence constitutif des maladies auto-inflammatoires et de l'amylose inflammatoire (CEREMAIA), Paris, France
| | - Christian Lavigne
- Service de Médecine interne et immunologie clinique, Centre Hospitalier Universitaire d'Angers, Angers, France; Centre de Référence des Maladies auto-immunes et auto-inflammatoires systémiques de l'adulte Nord, Nord-ouest, Méditerranée et Guadeloupe (CeRAINOM), Angers, France
| | - Franck Geneviève
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire d'Angers, Angers, France; Fédération Hospitalo-Universitaire Grand Ouest Against Leukemia (FHU GOAL), Angers, France
| | - Olivier Kosmider
- Laboratoire d'Hématologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
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3
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Fan BE, Sum CLL, Leung BPL, Ang MK, Lim XR, Lee SSM, Koh LW, Goh LL, Chan WL, Wang LD, Wong SL, Tay SH. VEXAS Syndrome and Thrombosis: Findings of Inflammation, Hypercoagulability, and Endothelial Dysfunction. Semin Thromb Hemost 2024. [PMID: 38181815 DOI: 10.1055/s-0043-1778105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Affiliation(s)
- Bingwen E Fan
- Department of Haematology, Tan Tock Seng Hospital, Singapore
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christina L L Sum
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore
| | - Bernard P L Leung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
- Health and Social Sciences, Singapore Institute of Technology, Singapore
| | - Mui K Ang
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore
| | - Xin R Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Samuel S M Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Li W Koh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Liuh L Goh
- Molecular Diagnostic Laboratory, Tan Tock Seng Hospital, Singapore
| | - Wee L Chan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Liang D Wang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Siu L Wong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Tan Tock Seng Hospital, Singapore
| | - Sen H Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
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4
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Nicholson LT, Cowen EW, Beck D, Ferrada M, Madigan LM. VEXAS Syndrome-Diagnostic Clues for the Dermatologist and Gaps in Our Current Understanding: A Narrative Review. JID INNOVATIONS 2024; 4:100242. [PMID: 38130326 PMCID: PMC10733701 DOI: 10.1016/j.xjidi.2023.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 12/23/2023] Open
Abstract
Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome is a newly recognized, acquired autoinflammatory disorder with broad systemic implications and a poor global prognosis. Because cutaneous lesions are present in the majority of those affected, it is necessary that dermatologists are equipped to recognize this important disease. Through identification, there is a greater opportunity for disease stratification, surveillance for systemic involvement, and selection of the best available therapies. As our understanding of this disease develops, dermatologists should also play a role in addressing the knowledge gaps that exist.
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Affiliation(s)
| | - Edward W. Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, Maryland, USA
| | - David Beck
- Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Marcela Ferrada
- Rheumatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, Maryland, USA
| | - Lauren M. Madigan
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
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5
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Padureanu V, Marinaș CM, Bobirca A, Padureanu R, Patrascu S, Dascalu AM, Bobirca F, Tribus L, Alexandru C, Serboiu C, Dumitrascu C, Musetescu A. Clinical Manifestations in Vacuoles, E1 Enzyme, X-Linked, Autoinflammatory, Somatic (VEXAS) Syndrome: A Narrative Review. Cureus 2024; 16:e53041. [PMID: 38410307 PMCID: PMC10895688 DOI: 10.7759/cureus.53041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/28/2024] Open
Abstract
The newly identified refractory adult-onset autoinflammatory syndrome known as VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is brought on by somatic mutations in the ubiquitin-like modifier-activating enzyme 1 (UBA1) gene in hematopoietic stem and progenitor cells that change the expression of the UBA1 isoform. As a result, patients have a variety of hematologic and systemic inflammatory symptoms. All types of medical professionals should treat VEXAS syndrome seriously due to the high fatality rate. To better comprehend the condition and enhance the prognosis for VEXAS syndrome, this review article describes the essential traits and clinical signs of the condition. The discussion of future directions in the study of systemic inflammatory disorders brought on by somatic mutations concludes.
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Affiliation(s)
- Vlad Padureanu
- Department of Internal Medicine, Emergency County Hospital of Craiova, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | | | - Anca Bobirca
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Rodica Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Stefan Patrascu
- Department of Surgery, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Ana Maria Dascalu
- Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Florin Bobirca
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Laura Tribus
- Department of Gastroenterology, Faculty of Oral Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Cristina Alexandru
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Crenguta Serboiu
- Department of Histology, Cellular and Molecular Biology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Catalin Dumitrascu
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Anca Musetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, Craiova, ROU
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6
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Sterling D, Duncan ME, Philippidou M, Salisbury JR, Kulasekararaj AG, Basu TN. VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) for the dermatologist. J Am Acad Dermatol 2023; 89:1209-1214. [PMID: 35121074 DOI: 10.1016/j.jaad.2022.01.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/06/2022] [Accepted: 01/14/2022] [Indexed: 11/16/2022]
Abstract
In 2020, Beck et al1 described a novel adult autoinflammatory syndrome entitled VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic), a newly-discovered disorder that connected previously unrelated inflammatory syndromes and a prototype for a new class of hematoinflammatory diseases.2 Eighty-nine percent of published cases have documented skin involvement, but despite the high incidence and diagnostic accessibility of skin manifestations, there has been little focus on the dermatological features of VEXAS syndrome thus far. A PubMed search of all published case reports of VEXAS syndrome to date was performed, with inclusion of all cases confirmed by genetic sequencing, and this review summarizes the reported dermatological signs. There have already been 141 confirmed published cases since original publication, 126 of which had documented cutaneous signs.1-34 A wide range of skin presentations are reported, including Sweet-like urticated and tender erythematous nodules, cartilaginous involvement with chondritis, cutaneous vasculitis, and periorbital angiodema.1-34 Many patients had been diagnosed with Sweet syndrome, relapsing polychondritis, polyarteritis nodosa, or erythema nodosum.1-34 Hallmarks of skin histopathology are a neutrophilic dermatosis with coexisting or exclusive leukocytoclastic vasculitis.1 The new classification therefore helps link previously disparate inflammatory skin conditions into a unifying pathophysiological pathway.
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Affiliation(s)
- David Sterling
- Department of Dermatology, King's College Hospital, London, United Kingdom.
| | - Mhairi E Duncan
- Department of Dermatology, King's College Hospital, London, United Kingdom
| | | | | | | | - Tanya N Basu
- Department of Dermatology, King's College Hospital, London, United Kingdom.
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7
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Tosato F, Pelloso M, Zuin J, Basso D. Peripheral blood cells vacuoles in VEXAS syndrome. Am J Hematol 2023; 98:1663-1664. [PMID: 37073682 DOI: 10.1002/ajh.26931] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Francesca Tosato
- Department of Laboratory Medicine, Padua University Hospital, Padova, Italy
| | - Michela Pelloso
- Department of Laboratory Medicine, Padua University Hospital, Padova, Italy
| | - Jenny Zuin
- Department of Laboratory Medicine, Padua University Hospital, Padova, Italy
| | - Daniela Basso
- Department of Laboratory Medicine, Padua University Hospital, Padova, Italy
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8
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Hines AS, Mohandesi NA, Lehman JS, Koster MJ, Cantwell HM, Alavi A, Warrington KJ, Mangaonkar AA, Go RS, Patnaik MM, Sartori-Valinotti JC. Cutaneous involvement in VEXAS syndrome: clinical and histopathologic findings. Int J Dermatol 2023. [PMID: 36890121 DOI: 10.1111/ijd.16635] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/25/2023] [Accepted: 02/21/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is an autoinflammatory disease with frequent cutaneous manifestations. METHODS We conducted a retrospective study of all patients with genetically confirmed VEXAS syndrome seen at our institution. Available clinical photographs and skin biopsy slides were reviewed. RESULTS Cutaneous manifestations developed in 22/25 (88%) patients with VEXAS syndrome. From this group, 10/22 (45%) developed skin involvement before or at the time of other clinical features of VEXAS. Twenty distinct dermatologic presentations of VEXAS from 14 patients were reviewed, and histopathologic patterns were classified as follows: neutrophilic urticarial dermatosis (n = 5, 25%), leukocytoclastic/urticarial vasculitis (n = 4, 20%), urticarial tissue reaction (n = 4, 20%), neutrophilic dermatosis (n = 3, 15%), neutrophilic panniculitis (n = 2, 10%), and nonspecific chronic septal panniculitis (n = 2, 10%). Common systemic findings included macrocytic anemia (96%), fever (88%), thrombocytopenia (76%), weight loss (76%), ocular inflammation (64%), pulmonary infiltrates (56%), deep venous thrombosis or pulmonary embolism (52%), and inflammatory arthritis (52%). CONCLUSIONS Cutaneous involvement is a common feature of VEXAS syndrome, and histopathologic findings exist on a spectrum of neutrophilic inflammatory dermatoses.
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Affiliation(s)
| | | | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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9
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van Leeuwen-Kerkhoff N, de Witte MA, Heijstek MW, Leavis HL. Case report: Up-front allogeneic stem cell transplantation in a patient with the VEXAS syndrome. Br J Haematol 2022; 199:e12-e15. [PMID: 36039520 DOI: 10.1111/bjh.18424] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Nathalie van Leeuwen-Kerkhoff
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Moniek A de Witte
- Department of Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marloes W Heijstek
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Helen L Leavis
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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10
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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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UBA1 gene mutation in giant cell arteritis. Clin Rheumatol 2022; 41:1257-1259. [DOI: 10.1007/s10067-021-06022-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/29/2021] [Accepted: 12/12/2021] [Indexed: 01/30/2023]
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Abstract
VEXAS syndrome, an autoinflammatory syndrome due to a Ubiquitin Like Modifier Activating Enzyme 1 (UBA1) somatic mutation, has a high thrombotic burden. We report a case of a 69-year-old male that was diagnosed with VEXAS syndrome who developed venous thromboembolism (VTE). Review of literature of existing VEXAS syndrome cases showed a high thrombotic burden, with the reported incidence of VTE (36.4%) being markedly higher than arterial thrombosis (1.6%), with deep vein thrombosis being more common than pulmonary embolism. Somatic mutation in the UBA1 gene results in decreased ubiquitylation which is a key driver in the development of thrombosis in VEXAS syndrome, due to chronic inflammation and cytokine release from abnormal crosstalk between the intrinsic effector mechanism of innate immune cells, platelets and endothelium resulting in dysregulated haemostasis and endothelial dysfunction. Targeting endothelial dysfunction and reducing inflammatory milieu causing hypercoagulability with immunosuppressants and immunomodulatory agents, together with anticoagulation may be the strategy to prevent recurrent thrombotic events.
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Affiliation(s)
- Thet Mon Oo
- Department of General Medicine, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jie Tian Jeanette Koay
- Department of Haematology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Siew Fen Lee
- Department of General Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Shang Ming Samuel Lee
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Xin Rong Lim
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bingwen Eugene Fan
- Lee Kong Chian School of Medicine, Singapore, Singapore.
- Yong Loo Lin School of Medicine, Singapore, Singapore.
- Department of Haematology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore.
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore, Singapore.
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13
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Patel N, Dulau-Florea A, Calvo KR. Characteristic bone marrow findings in patients with UBA1 somatic mutations and VEXAS syndrome. Semin Hematol 2021; 58:204-211. [PMID: 34802541 DOI: 10.1053/j.seminhematol.2021.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a newly characterized syndrome with underlying somatic UBA1 mutations in myeloid cells linking hematologic disease with autoinflammatory rheumatologic disorders. Hematologic abnormalities, particularly peripheral blood cytopenia(s) may prompt bone marrow evaluation in patients with known or unrecognized VEXAS syndrome. This review highlights key findings and diagnostic considerations encountered during bone marrow examination in patients with this disorder. Frequently reported hematologic changes include macrocytic anemia, cytoplasmic vacuoles in myeloid and erythroid precursors, marrow hypercellularity, and varying degrees of dysplasia. Myelodysplastic syndrome and plasma cell neoplasms have been diagnosed in patients with VEXAS syndrome. Macrophage activation syndrome and/or hemophagocytic lymphohistiocytosis and monoclonal B-cell lymphocytosis have also been reported. The bone marrow is a target organ in VEXAS syndrome. Heightened awareness of the bone marrow features and hematologic complications may aid in identifying individuals with VEXAS who may benefit from increased disease surveillance or alternative therapeutic strategies.
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Affiliation(s)
- Nisha Patel
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Alina Dulau-Florea
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD.
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14
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Groarke EM, Dulau-Florea AE, Kanthi Y. Thrombotic manifestations of VEXAS syndrome. Semin Hematol 2021; 58:230-238. [PMID: 34802545 DOI: 10.1053/j.seminhematol.2021.10.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 11/11/2022]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described autoinflammatory syndrome characterized by diffuse inflammatory manifestations, predisposition to hematological malignancy, and an association with a high rate of thrombosis. VEXAS is attributed to somatic mutations in the UBA1 gene in hematopoietic stem and progenitor cells with myeloid restriction in mature forms. The rate of thrombosis in VEXAS patients is approximately 40% in all reported cases to date. Venous thromboembolism predominates thrombotic events in VEXAS. These are classified as unprovoked in etiology, although systemic and vascular inflammation are implicated. Here, we review the clinical and laboratory characteristics in VEXAS that provide insight into the possible mechanisms leading to thrombosis. We present knowledge gaps in the mechanisms and management of VEXAS-associated thromboinflammation and propose areas for future investigation in the field.
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Affiliation(s)
- Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Alina E Dulau-Florea
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Yogendra Kanthi
- Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
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15
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Oganesyan A, Hakobyan Y, Terrier B, Georgin-Lavialle S, Mekinian A. Looking beyond VEXAS: Coexistence of undifferentiated systemic autoinflammatory disease and myelodysplastic syndrome. Semin Hematol 2021; 58:247-253. [PMID: 34802547 DOI: 10.1053/j.seminhematol.2021.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/08/2021] [Accepted: 10/01/2021] [Indexed: 01/24/2023]
Abstract
It has been established that individuals with myelodysplastic syndromes (MDS) have a higher frequency of systemic inflammatory disorders. On the other hand, patients with autoimmune diseases are at increased risk of MDS development. Both diseases can be associated with various genetic lesions and share diverse pathogenetic mechanisms. Recently identified VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome, associated with somatic mutations in UBA1, encompasses a range of inflammatory conditions involving multiple organs along with hematological pathologies, including MDS, as well as characteristic bone marrow vacuolization of myeloid and erythroid precursors. This novel syndrome drove further attention to complex associations between MDS and adult-onset inflammatory conditions. The present narrative literature review discusses the clinical presentation, pathophysiology, management of concurrent MDS and systemic inflammatory diseases in parallel to the clinical picture of VEXAS syndrome.
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Affiliation(s)
- Artem Oganesyan
- Department of Adult Hematology, Yeolyan Hematology Center, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Adult Hematology, Yeolyan Hematology Center, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare and Systemic Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Georgin-Lavialle
- Internal Medicine Department, National Reference Center for Autoinflammatory Diseases and Amyloidosis (CEREMAIA), Sorbonne Université, INSERM U938, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arsene Mekinian
- Internal Medicine Department and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hospital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de Recherche Saint-Antoine (CRSA), Sorbonne Universités, UMPC University Paris 06, INSERM U938, Paris, France.
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16
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Koster MJ, Kourelis T, Reichard KK, Kermani TA, Beck DB, Cardona DO, Samec MJ, Mangaonkar AA, Begna KH, Hook CC, Oliveira JL, Nasr SH, Tiong BK, Patnaik MM, Burke MM, Michet CJ, Warrington KJ. Clinical Heterogeneity of the VEXAS Syndrome: A Case Series. Mayo Clin Proc 2021; 96:2653-2659. [PMID: 34489099 DOI: 10.1016/j.mayocp.2021.06.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
The objective of this study is to describe the clinical features and outcomes of patients with the newly defined vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. Nine men with somatic mutations in the UBA1 gene were identified; the most frequent variant was p.Met41Thr (7 of 9, 78%). The median age at VEXAS diagnosis was 74 (67, 76.5) years, and patients had a median duration of symptoms for 4 years before diagnosis. Refractory constitutional symptoms (88%), ear and nose chondritis (55%), and inflammatory arthritis (55%) were common clinical features. Vasculitis was noted in 44%. All patients had significantly elevated inflammatory markers and macrocytic anemia. Thrombocytopenia was present in 66% at diagnosis of VEXAS. Eight patients had bone marrow biopsies performed. All bone marrows were hypercellular, and there was vacuolization of the erythroid (100%) or myeloid precursors (75%). Glucocorticoids attenuated symptoms at prednisone doses ≥20 mg per day, but no other immunosuppressive agent showed consistent long-term control of disease. One patient with coexisting plasma-cell myeloma received plasma-cell-directed therapy with improvement of the inflammatory response, which is a novel finding. In conclusion, VEXAS syndrome is a clinically heterogeneous, treatment-refractory inflammatory condition caused by somatic mutation of the UBA1 gene. Patients often present with overlapping rheumatologic manifestations and persistent hematologic abnormalities. As such, internists and subspecialists, including pathologists, should be aware of this condition to avert diagnostic delay, now that the etiology of this syndrome is known.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN.
| | - Taxiarchis Kourelis
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - Kaaren K Reichard
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Tanaz A Kermani
- Department of Internal Medicine, Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, Santa Monica, CA
| | - David B Beck
- National Institutes of Health, National Human Genome Research Institute, Bethesda, MD
| | | | - Matthew J Samec
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | | | - Kebede H Begna
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - C Christopher Hook
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - Jennifer L Oliveira
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Benedict K Tiong
- Department of Internal Medicine, Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, Santa Monica, CA
| | - Mrinal M Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - Michelle M Burke
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | - Clement J Michet
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
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17
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Euvrard R, Fournier T, Georgescu D, Bourbon E, Sujobert P, Lega JC, Adelaide L. VEXAS syndrome-related AA amyloidosis: a case report. Rheumatology (Oxford) 2021; 61:e15-e16. [PMID: 34498034 DOI: 10.1093/rheumatology/keab683] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Romain Euvrard
- Service de Néphrologie, Medipôle Lyon Villeurbanne Hôpital Privé, Lyon, France
| | - Thomas Fournier
- Service de Néphrologie, Medipôle Lyon Villeurbanne Hôpital Privé, Lyon, France
| | - Dana Georgescu
- Service de Médecine Interne, Centre Hospitalier de Vienne, Vienne, France
| | - Estelle Bourbon
- Service d'Hématologie biologique, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Pierre Sujobert
- Service d'Hématologie biologique, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean Christophe Lega
- Service de Médecine Interne et vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon; Equipe Evaluation et Modélisations des Effets Thérapeutiques, UMR CRNS 5558, Université Claude Bernard Lyon 1, Lyon, France
| | - Leopold Adelaide
- Service de Médecine Interne, Centre Hospitalier de Vienne, Vienne, France
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18
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Shaukat F, Hart M, Burns T, Bansal P. UBA1 and DNMT3A Mutations in VEXAS Syndrome. A Case Report and Literature Review. Mod Rheumatol Case Rep 2021; 6:134-139. [PMID: 34480172 DOI: 10.1093/mrcr/rxab021] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/20/2021] [Accepted: 07/30/2021] [Indexed: 11/14/2022]
Abstract
VEXAS syndrome is a recently described X-linked autoinflammatory condition associated with somatic mutation of the UBA1 gene. It often coexists with MDS which can occur due to DNMT3A mutation. These patients, predominantly males, present after the fifth decade of life with unique systemic inflammatory clinical features and have hematological abnormalities and vacuolated precursor cells on bone marrow pathology. Here we describe a unique case of VEXAS syndrome in a patient harboring DNMT3A gene mutation with coexisting UBA1 mutation with a review of literature.
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Affiliation(s)
- Farah Shaukat
- Department of Oncology: Johns Hopkins Hospital, Baltimore, USA
| | - Melissa Hart
- Department of Pathology. Mayo Clinic Health System, Eau Claire, USA
| | - Timothy Burns
- Department of Hematology/Oncology. Mayo Clinic Health System, Eau Claire, USA
| | - Pankaj Bansal
- Department of Rheumatology. Mayo Clinic Health System, Eau Claire, USA
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19
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Quand la génétique permet d’expliquer 14 ans de phénomènes inflammatoires. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.03.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Rossignol J, Marzac C, Dellal A, Solary E, Jachiet V, Belfeki N, Slaoui M, Georgin-Lavialle S, Benarroche D, Hermine O, Fain O, Mekinian A. Mutation du gène UBA1 dans l’artérite à cellules géantes. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.03.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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21
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Sakuma M, Tanimura A, Yasui S, Ishiguro K, Kobayashi T, Ohshiro Y, Miyazaki H, Minamimoto R, Okafuji T, Shimozawa K, Ogura G, Miwa A, Yamashita H, Kaneko H. Case of polychondritis-onset refractory organising pneumonia with cytopaenia diagnosed as VEXAS syndrome: the disease course of seven years. Rheumatology (Oxford) 2021; 60:e356-e359. [PMID: 33839773 DOI: 10.1093/rheumatology/keab349] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/29/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023] Open
Affiliation(s)
- Maki Sakuma
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Akira Tanimura
- Department of Hematology, Tokyo-Kita Medical Center, Tokyo, Japan
| | - Satsuki Yasui
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kenji Ishiguro
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toshiaki Kobayashi
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yusuke Ohshiro
- Clinical Laboratory Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hideki Miyazaki
- Department of Clinical Pathology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryogo Minamimoto
- Department of Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takashi Okafuji
- Department of Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsuyoshi Shimozawa
- Department of Pediatrics, National Center for Global Health and Medicine, Tokyo, Japan
| | - Go Ogura
- Department of Pathology, Tokai University, Kanagawa, Japan
| | - Akiyoshi Miwa
- Department of Hematology, Tokyo-Kita Medical Center, Tokyo, Japan
| | - Hiroyuki Yamashita
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroshi Kaneko
- Division of Rheumatic Diseases, National Center for Global Health and Medicine, Tokyo, Japan
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22
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Huang H, Zhang W, Cai W, Liu J, Wang H, Qin T, Xu Z, Li B, Qu S, Pan L, Huang G, Gale RP, Xiao Z. VEXAS syndrome in myelodysplastic syndrome with autoimmune disorder. Exp Hematol Oncol 2021; 10:23. [PMID: 33741056 PMCID: PMC7976711 DOI: 10.1186/s40164-021-00217-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/12/2021] [Indexed: 11/16/2022] Open
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly-described adult-onset inflammatory syndrome characterized by vacuoles in myeloid and erythroid precursor cells and somatic mutations affecting methionine-41 (p.Met41) in UBA1. The VEXAS syndrome often overlaps with myelodysplastic syndromes (MDS) with autoimmune disorders (AD). By screening the UBA1 gene sequences derived from MDS patients with AD from our center, we identified one patient with a p.Met41Leu missense mutation in UBA1, who should have been diagnosed as MDS comorbid with VEXAS syndrome. This patient respond poorly to immune suppressive drugs. Patients with MDS and AD who have characteristic vacuoles in myeloid and erythroid precursor cells should be screened for UBA1 mutation, these patients are likely to have VEXAS syndrome and unlikely to improve with immunosuppressive drugs and should be considered for other alternative therapies.
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Affiliation(s)
- Huijun Huang
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wenjun Zhang
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wenyu Cai
- Hematologic Pathology Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jinqin Liu
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Huijun Wang
- Hematologic Pathology Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Tiejun Qin
- MDS and MPN Centre, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, 288 Nanjing Road, Tianjin, 300020, China
| | - Zefeng Xu
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, 288 Nanjing Road, Tianjin, 300020, China.,National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Bing Li
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, 288 Nanjing Road, Tianjin, 300020, China.,National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shiqiang Qu
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,MDS and MPN Centre, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, 288 Nanjing Road, Tianjin, 300020, China.,National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Lijuan Pan
- MDS and MPN Centre, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, 288 Nanjing Road, Tianjin, 300020, China.,National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Gang Huang
- Divisions of Experimental Haematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Robert Peter Gale
- Division of Experimental Medicine, Department of Medicine, Haematology Section, Imperial College London, London, UK
| | - Zhijian Xiao
- State Key Laboratory of Experimental Haematology, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China. .,MDS and MPN Centre, Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, 288 Nanjing Road, Tianjin, 300020, China. .,National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
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