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Phan L, Hammond D, Wilson NR, Groarke EM, Patnaik MM, Pemmaraju N. VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic): clinical review in a rapidly emerging field. Leuk Lymphoma 2024; 65:1245-1257. [PMID: 38770970 DOI: 10.1080/10428194.2024.2349950] [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: 03/06/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
VEXAS syndrome is a recently described entity characterized by systemic inflammatory and hematologic manifestations. The disease was first characterized by Beck et al. in 2020 in a study characterizing 25 patients with undiagnosed adult-onset inflammatory syndromes. While the literature regarding VEXAS syndrome has grown exponentially since 2020, there is still much to be understood. This lack of information leads to challenges in both the diagnosis and treatment of patients with VEXAS syndrome. Patients will often have a variety of clinical symptoms that can lead to missed or delayed diagnoses. Additionally, awareness of VEXAS syndrome is still developing among clinicians. In this comprehensive review, we summarize the current literature regarding VEXAS syndrome, and explore clinical updates of this emerging disease state. Our aim of this review is to increase awareness regarding this new disease state and identify research areas to better understand future treatment approaches for patients with VEXAS syndrome.
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Affiliation(s)
- Luan Phan
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mrinal M Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Czech M, Cuellar-Rodriguez J, Patel BA, Groarke EM, Cowen EW, Turturice B, Beck DB, Wilson L, Goodspeed W, Darden I, Young NS, Hickstein D, Ombrello A, Hoffman P, Arikan EA, Sinaii N, Hathaway L, Castelo-Soccio L, Fike A, Kastner DB, Grayson PC, Ferrada MA. Opportunistic Infections, Mortality Risk, and Prevention Strategies in Patients With Vacuoles, E1 Enzyme, X-Linked, Autoinflammatory, Somatic (VEXAS) Syndrome. Open Forum Infect Dis 2024; 11:ofae405. [PMID: 39077052 PMCID: PMC11285395 DOI: 10.1093/ofid/ofae405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/14/2024] [Indexed: 07/31/2024] Open
Abstract
Background VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a genetic disorder characterized by bone marrow failure and systemic inflammation, putting patients at risk for infections. This study comprehensively examines the prevalence of opportunistic infections in patients with VEXAS, evaluating their impact on clinical outcomes and potential preventive measures. Methods Patients with confirmed VEXAS were included. Survival analysis and logistic regression were used to identify associations between opportunistic infections and mortality. Infection rates (IRs) for Pneumocystis jirovecii pneumonia (PJP) and alphaherpesviruses were calculated over a prospective 8-month observation period in relationship to prophylaxis. Results Of 94 patients with VEXAS, 6% developed PJP; 15% had alphaherpesvirus reactivation, with varicella zoster virus (VZV) being the most common herpesvirus; and 10% contracted a nontuberculous mycobacterial (NTM) infection. Risk of death was significantly increased per month following a diagnosis of PJP (hazard ratio [HR], 72.41 [95% confidence interval {CI}, 13.67-533.70]) or NTM (HR, 29.09 [95% CI, 9.51-88.79]). Increased odds for death were also observed in patients with a history of herpes simplex virus (HSV) reactivation (odds ratio [OR], 12.10 [95% CI, 1.29-114.80]) but not in patients with VZV (OR, 0.89 [95% CI, .30-2.59]). Prophylaxis for PJP (IR, 0.001 vs 0 per person-day, P < .01) and VZV (IR, 0.006 vs 0 per person-day, P = .04) markedly decreased infection rates with a number needed to treat of 4 and 7, respectively. Conclusions Opportunistic infections are common in patients with VEXAS. Patients who develop PJP, HSV, or NTM are at increased risk for death. Prophylaxis against PJP and VZV is highly effective.
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Affiliation(s)
- Mary Czech
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Cuellar-Rodriguez
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Bhavisha A Patel
- National Heart, Blood, and Lung Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Emma M Groarke
- National Heart, Blood, and Lung Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward W Cowen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Benjamin Turturice
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David B Beck
- Department of Medicine and Department of Biochemistry and Molecular Pharmacology, New York University, New York, New York, USA
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lorena Wilson
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Wendy Goodspeed
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ivana Darden
- National Heart, Blood, and Lung Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Neal S Young
- National Heart, Blood, and Lung Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Dennis Hickstein
- National Heart, Blood, and Lung Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Amanda Ombrello
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Patrycjia Hoffman
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Evsen Apaydin Arikan
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ninet Sinaii
- Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Londa Hathaway
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Leslie Castelo-Soccio
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alice Fike
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Daniel B Kastner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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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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Adachi S, Kirino Y, Higashitani K, Hirahara L, Maeda A, Horita N, Takase-Minegishi K, Yoshimi R, Nakajima H. Targeting enhanced cell death represents a potential therapeutic strategy for VEXAS syndrome. Rheumatol Adv Pract 2024; 8:rkae065. [PMID: 38854419 PMCID: PMC11157137 DOI: 10.1093/rap/rkae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Objectives To unravel the mechanisms underlying cell death in the vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome using peripheral blood samples and to assess the clinical value of this knowledge. Methods Nine patients undergoing treatment for VEXAS syndrome at Yokohama City University Hospital were included in this study. Monocytes and neutrophils were isolated from peripheral blood and then monocytes were differentiated into polarized macrophages. Viable cell counts, cell death assays and measurements of various indicators such as high mobility group box 1 (HMGB1) concentration, extracellular adenosine triphosphate (ATP) concentration, annexin V level and caspase 1, 3 and 7 activities were performed. Results Elevated cell death of monocytes and neutrophils was observed in VEXAS syndrome patients, as indicated by cultured cell counts and cell death assays. Annexin V assays and measurements of caspase 1, 3 and 7 activities suggested increased apoptosis and pyroptosis in these cells. Serum HMGB1 levels were significantly elevated in VEXAS syndrome patients and decreased after prednisolone (PSL) dose escalation. Monocytes and neutrophils from the VEXAS group exhibited heightened extracellular ATP secretion, which was significantly reduced by soluble PSL co-culture. Conclusion This study confirms increased cell death of monocytes and neutrophils and damage-associated molecular patterns in VEXAS syndrome, and these findings may be valuable for drug screening, therapeutic strategies and as biomarkers.
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Affiliation(s)
- Soichiro Adachi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kana Higashitani
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Lisa Hirahara
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ayaka Maeda
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Hospital, Yokohama, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Clinical Laboratory Department, Yokohama City University Hospital, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Bica BERG, de Souza AWS, Pereira IA. Unveiling the clinical spectrum of relapsing polychondritis: insights into its pathogenesis, novel monogenic causes, and therapeutic strategies. Adv Rheumatol 2024; 64:29. [PMID: 38627861 DOI: 10.1186/s42358-024-00365-z] [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: 03/01/2024] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
Relapsing polychondritis is a rare multisystem disease involving cartilaginous and proteoglycan-rich structures. The diagnosis of this disease is mainly suggested by the presence of flares of inflammation of the cartilage, particularly in the ears, nose or respiratory tract, and more rarely, in the presence of other manifestations. The spectrum of clinical presentations may vary from intermittent episodes of painful and often disfiguring auricular and nasal chondritis to an occasional organ or even life-threatening manifestations such as lower airway collapse. There is a lack of awareness about this disease is mainly due to its rarity. In 2020, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, a novel autoinflammatory syndrome, was described. VEXAS syndrome is attributed to somatic mutations in methionine-41 of UBA1, the major E1 enzyme that initiates ubiquitylation. This new disease entity connects seemingly unrelated conditions: systemic inflammatory syndromes (relapsing chondritis, Sweet's syndrome, and neutrophilic dermatosis) and hematologic disorders (myelodysplastic syndrome or multiple myeloma). Therefore, this article reviews the current literature on both disease entities.
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Affiliation(s)
- Blanca E R G Bica
- Reumatology Division of Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Rio de Janeiro, Rua Esteves Junior 62, CEP 22231-160, Laranjeiras, Rio de Janeiro, RJ, Brazil.
| | | | - Ivânio Alves Pereira
- Reumatologia da Universidade do Sul de Santa Catarina-UNISUL, Florian?polis, RJ, Brazil
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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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Boyadzhieva Z, Ruffer N, Kötter I, Krusche M. How to treat VEXAS syndrome: a systematic review on effectiveness and safety of current treatment strategies. Rheumatology (Oxford) 2023; 62:3518-3525. [PMID: 37233149 DOI: 10.1093/rheumatology/kead240] [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: 03/11/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES To evaluate the effectiveness and safety of current treatment strategies for the vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. METHODS A protocolized systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Three databases were searched for reports on treatment strategies for VEXAS. Data from the included publications was extracted and a narrative synthesis was performed. Treatment response was recorded as complete (CR), partial (PR) or none (NR) depending on changes in clinical symptoms and laboratory parameters. Patient characteristics, safety data and previous treatments were analysed. RESULTS We identified 36 publications with a total of 116 patients; 113 (98.3%) were male. The identified reports included azacytidine (CR 9/36, 25%; PR 14/36, 38.9%), Janus kinase inhibitors (JAKi) (CR 11/33, 33%; PR 9/33, 27.3%), tocilizumab (CR 3/15, 20%; PR 6/15, 40%), allogeneic stem cell transplantation (CR 6/7, 85.7%; one patient died), anakinra (CR 4/5, 80%; NR 1/5, 20%), canakinumab (CR 1/2, 50%; PR 1/2, 50%) and glucocorticoid monotherapy (CR 1/6, 16.7%; PR 4/6, 66.7%). Individual reports were available for TNF inhibitors, rituximab and MTX. Data on adverse events were available for 67 patients (67/116, 57.8%) and included: pneumonia (12/67, 17.9%), other infections (9/67, 13.4%), venous thromboembolisms (6/67, 8.9%), cytopenias (4/67, 5.9%), and acute (4/67, 5.9%) and chronic graft-vs-host-disease (2/67, 2.9%). CONCLUSION Current data on VEXAS treatment are limited and inhomogeneous. Treatment decisions should be individualized. For the devolvement of treatment algorithms clinical trials are needed. Adverse events remain a challenge, especially an elevated risk for venous thromboembolism associated to JAKi treatment should be carefully considered.
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Affiliation(s)
- Zhivana Boyadzhieva
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nikolas Ruffer
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ina Kötter
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Martin Krusche
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Koster MJ, Samec MJ, Warrington KJ. VEXAS Syndrome-A Review of Pathophysiology, Presentation, and Prognosis. J Clin Rheumatol 2023; 29:298-306. [PMID: 36251488 DOI: 10.1097/rhu.0000000000001905] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT VEXAS ( V acuoles, E 1 enzyme, X -linked, A utoinflammatory, S omatic) syndrome is a newly identified disease caused by somatic mutations in the UBA1 gene resulting in refractory autoinflammatory features, frequently accompanied by cytopenias. Although the prevalence of this syndrome is yet unknown, understanding the clinical phenotype can assist clinicians in prompt recognition of cases among patients with glucocorticoid-responsive but immunosuppressive-resistant inflammatory symptoms. The pathophysiology, clinical presentation, diagnostic methods, treatment, and prognosis of VEXAS are herein reviewed.
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Wu Z, Gao S, Gao Q, Patel BA, Groarke EM, Feng X, Manley AL, Li H, Ospina Cardona D, Kajigaya S, Alemu L, Quinones Raffo D, Ombrello AK, Ferrada MA, Grayson PC, Calvo KR, Kastner DL, Beck DB, Young NS. Early activation of inflammatory pathways in UBA1-mutated hematopoietic stem and progenitor cells in VEXAS. Cell Rep Med 2023; 4:101160. [PMID: 37586319 PMCID: PMC10439277 DOI: 10.1016/j.xcrm.2023.101160] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 04/18/2023] [Accepted: 07/21/2023] [Indexed: 08/18/2023]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a pleiotropic, severe autoinflammatory disease caused by somatic mutations in the ubiquitin-like modifier activating enzyme 1 (UBA1) gene. To elucidate VEXAS pathophysiology, we performed transcriptome sequencing of single bone marrow mononuclear cells and hematopoietic stem and progenitor cells (HSPCs) from VEXAS patients. HSPCs are biased toward myeloid (granulocytic) differentiation, and against lymphoid differentiation in VEXAS. Activation of multiple inflammatory pathways (interferons and tumor necrosis factor alpha) occurs ontogenically early in primitive hematopoietic cells and particularly in the myeloid lineage in VEXAS, and inflammation is prominent in UBA1-mutated cells. Dysregulation in protein degradation likely leads to higher stress response in VEXAS HSPCs, which positively correlates with inflammation. TCR usage is restricted and there are increased cytotoxicity and IFN-γ signaling in T cells. In VEXAS syndrome, both aberrant inflammation and myeloid predominance appear intrinsic to hematopoietic stem cells mutated in UBA1.
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Affiliation(s)
- Zhijie Wu
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Shouguo Gao
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Qingyan Gao
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Bhavisha A Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Xingmin Feng
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ash Lee Manley
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Haoran Li
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Daniela Ospina Cardona
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA; Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; Center for Human Genetics and Genomics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Sachiko Kajigaya
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Lemlem Alemu
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Diego Quinones Raffo
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Amanda K Ombrello
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD 20892, USA
| | - Daniel L Kastner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - David B Beck
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA; Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY 10016, USA; Center for Human Genetics and Genomics, New York University Grossman School of Medicine, New York, NY 10016, USA.
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
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Kouranloo K, Ashley A, Zhao SS, Dey M. Pulmonary manifestations in VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome: a systematic review. Rheumatol Int 2023; 43:1023-1032. [PMID: 36617363 PMCID: PMC10126013 DOI: 10.1007/s00296-022-05266-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND VEXAS (vacuoles, E1 enzyme, X-linked, auto-inflammatory, somatic) syndrome is a newly described auto-inflammatory disease. Many cases feature pulmonary infiltrates or respiratory failure. This systematic review aimed to summarize respiratory manifestations in VEXAS syndrome described to date. METHODS Databases were searched for articles discussing VEXAS syndrome until May 2022. The research question was: What are the pulmonary manifestations in patients with VEXAS syndrome? The search was restricted to English language and those discussing clinical presentation of disease. Information on basic demographics, type and prevalence of pulmonary manifestations, co-existing disease associations and author conclusions on pulmonary involvement were extracted. The protocol was registered on the PROSPERO register of systematic reviews. RESULTS Initially, 219 articles were retrieved with 36 ultimately included (all case reports or series). A total of 269 patients with VEXAS were included, 98.6% male, mean age 66.8 years at disease onset. The most frequently described pulmonary manifestation was infiltrates (43.1%; n = 116), followed by pleural effusion (7.4%; n = 20) and idiopathic interstitial pneumonia (3.3%; n = 9). Other pulmonary manifestations were: nonspecific interstitial pneumonia (n = 1), bronchiolitis obliterans (n = 3), pulmonary vasculitis (n = 6), bronchiectasis (n = 1), alveolar haemorrhage (n = 1), pulmonary embolism (n = 4), bronchial stenosis (n = 1), and alveolitis (n = 1). Several patients had one or more co-existing autoimmune/inflammatory condition. It was not reported which patients had particular pulmonary manifestations. CONCLUSION This is the first systematic review undertaken in VEXAS patients. Our results demonstrate that pulmonary involvement is common in this patient group. It is unclear if respiratory manifestations are part of the primary disease or a co-existing condition. Larger epidemiological analyses will aid further characterisation of pulmonary involvement and disease management.
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Affiliation(s)
- Koushan Kouranloo
- School of Medicine, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK.
- Liverpool University NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK.
| | - Athea Ashley
- Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, Yorkshire, UK
| | - Sizheng Steven Zhao
- Versus Arthritis Centre for Epidemiology, Centre for Musculoskeletal Research, The University of Manchester, Manchester, M13 9PL, UK
| | - Mrinalini Dey
- Department of Rheumatology, Queen Elizabeth Hospital, Stadium Rd, London, SE18 4QH, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Brownlow Hill, Liverpool, L69 3BX, UK
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11
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Bindoli S, Baggio C, Doria A, Bertoldo E, Sfriso P. JAK inhibitors for the treatment of VEXAS syndrome. Exp Biol Med (Maywood) 2023; 248:394-398. [PMID: 37243340 PMCID: PMC10281621 DOI: 10.1177/15353702231165030] [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] [Indexed: 05/28/2023] Open
Abstract
Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a novel described autoinflammatory entity for which the diagnosis is defined by somatic mutations of the UBA1 X-linked gene in hematopoietic progenitor cells. The clinical manifestations are heterogeneous since they range from autoinflammatory symptoms to the presence of underlying hematologic disorders such as myelodysplastic syndromes. Response to treatment in VEXAS is very poor and to date, the therapeutic strategies adopted are only partially effective. However, recently described cohorts of subjects with VEXAS treated with Janus kinase inhibitors (JAK-I) proved that these drugs can be effective in the treatment of several manifestations related to the disease. Herein, we carried out a brief literature review that includes cohorts and single cases in which JAK-I were adopted as a promising strategy to manage VEXAS patients. Subsequently, we described our experience with JAK-I in VEXAS, illustrating the first case, to our knowledge, of a 65-year-old man who was successfully treated with the selective JAK-1 inhibitor filgotinib.
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Affiliation(s)
- Sara Bindoli
- Rheumatology Unit, Department of
Medicine, University of Padova, 35128 Padova, Italy
| | - Chiara Baggio
- Rheumatology Unit, Department of
Medicine, University of Padova, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of
Medicine, University of Padova, 35128 Padova, Italy
| | - Eugenia Bertoldo
- Rheumatology Unit, Department of
Medicine, University of Verona, 37129 Verona, Italy
- Internal Medicine Unit, Department of
Medicine, Mater Salutis Hospital, 37045, Legnago, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of
Medicine, University of Padova, 35128 Padova, Italy
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12
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Bruno A, Gurnari C, Alexander T, Snowden JA, Greco R. Autoimmune manifestations in VEXAS: Opportunities for integration and pitfalls to interpretation. J Allergy Clin Immunol 2023; 151:1204-1214. [PMID: 36948992 DOI: 10.1016/j.jaci.2023.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/24/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a novel entity manifesting with a multiplicity of clinical features. Somatic mutations of the UBA1 gene in hematopoietic stem cells constitute the genetic basis of VEXAS. As an X-linked disorder, most cases occur in men, classically developing symptoms during the fifth to sixth decade of life. Considering its multidisciplinary nature involving numerous branches of internal medicine, VEXAS has elicited a wide medical interest and several medical conditions have been associated with this disease. Even so, its recognition in everyday clinical practice is not necessarily straightforward. Close collaboration between different medical specialists is mandatory. Patients with VEXAS may manifest a range of features from manageable cytopenias to disabling and life-threatening autoimmune phenomena with limited responses to therapy, with the potential for progression to hematological malignancies. Diagnostic and treatment guidelines are exploratory and include a range of rheumatological and supportive care treatments. Allogeneic hematopoietic stem cell transplantation is potentially curative, but its risks are significant and its position in the treatment algorithm is yet to be defined. Herein, we present the variegated manifestations of VEXAS, provide practice criteria for diagnostic testing of UBA1, and discuss potential treatment options, including allogeneic hematopoietic stem cell transplantation, current evidence, and future directions.
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Affiliation(s)
- Alessandro Bruno
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - John A Snowden
- Sheffield Blood & Marrow Transplant and Cellular Therapy Programme, Department of Haematology, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
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13
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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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14
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Watanabe R, Kiji M, Hashimoto M. Vasculitis associated with VEXAS syndrome: A literature review. Front Med (Lausanne) 2022; 9:983939. [PMID: 36045928 PMCID: PMC9420898 DOI: 10.3389/fmed.2022.983939] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Vasculitis is an inflammatory disorder of the blood vessels that causes damage to a wide variety of organs through tissue ischemia. Vasculitis is classified according to the size (large, medium, or small) of the blood vessels. In 2020, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, a novel autoinflammatory syndrome, was described. Somatic mutations in methionine-41 of UBA1, the major E1 enzyme that initiates ubiquitylation, are attributed to this disorder. This new disease entity connects seemingly unrelated conditions: inflammatory syndromes (relapsing chondritis, Sweet's syndrome, or neutrophilic dermatosis) and hematologic disorders (myelodysplastic syndrome or multiple myeloma). Notably, such patients sometimes develop vasculitis, such as giant cell arteritis and polyarteritis nodosa, and fulfill the corresponding classification criteria for vasculitis. Thus, vasculitis can be an initial manifestation of VEXAS syndrome. In this research topic exploring the link between autoinflammatory diseases and vasculitis, we first provide an overview of the disease mechanisms and clinical phenotypes of VEXAS syndrome. Then, a literature review using the PubMed database was performed to delineate the clinical characteristics of vasculitis associated with VEXAS syndrome. Finally, the therapeutic options and unmet needs of VEXAS syndrome are discussed.
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15
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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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16
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Ramon A, Greigert H, Ornetti P, Bonnotte B, Samson M. Mimickers of Large Vessel Giant Cell Arteritis. J Clin Med 2022; 11:jcm11030495. [PMID: 35159949 PMCID: PMC8837104 DOI: 10.3390/jcm11030495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 01/27/2023] Open
Abstract
Giant cell arteritis (GCA) is a large-vessel granulomatous vasculitis occurring in patients over 50-year-old. Diagnosis can be challenging because there is no specific biological test or other diagnoses to consider. Two main phenotypes of GCA are distinguished and can be associated. First, cranial GCA, whose diagnosis is usually confirmed by the evidence of a non-necrotizing granulomatous panarteritis on temporal artery biopsy. Second, large-vessel GCA, whose related symptoms are less specific (fever, asthenia, and weight loss) and for which other diagnoses must be implemented if there is neither cephalic GCA nor associated polymyalgia rheumatica (PMR) features chronic infection (tuberculosis, Coxiella burnetti), IgG4-related disease, Erdheim Chester disease, and other primary vasculitis (Behçet disease, relapsing polychondritis, or VEXAS syndrome). Herein, we propose a review of the main differential diagnoses to be considered regarding large vessel vasculitis.
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Affiliation(s)
- André Ramon
- Rheumatology Department, Dijon-Bourgogne University Hospital, 21000 Dijon, France;
- INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, 21000 Dijon, France; (H.G.); (B.B.); (M.S.)
- Correspondence:
| | - Hélène Greigert
- INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, 21000 Dijon, France; (H.G.); (B.B.); (M.S.)
- Internal Medicine and Clinical Immunology Department, Dijon-Bourgogne University Hospital, 21000 Dijon, France
- Vascular Medicine Department, Dijon-Bourgogne University Hospital, 21000 Dijon, France
| | - Paul Ornetti
- Rheumatology Department, Dijon-Bourgogne University Hospital, 21000 Dijon, France;
- INSERM, CIC 1432, Clinical Investigation Center, Plurithematic Module, Technological Investigation Platform, Dijon-Bourgogne University Hospital, 21000 Dijon, France
- INSERM UMR 1093-CAPS, Bourgogne Franche-Comté University, UFR des Sciences et Du Sport, 21000 Dijon, France
| | - Bernard Bonnotte
- INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, 21000 Dijon, France; (H.G.); (B.B.); (M.S.)
- Internal Medicine and Clinical Immunology Department, Dijon-Bourgogne University Hospital, 21000 Dijon, France
| | - Maxime Samson
- INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, 21000 Dijon, France; (H.G.); (B.B.); (M.S.)
- Internal Medicine and Clinical Immunology Department, Dijon-Bourgogne University Hospital, 21000 Dijon, France
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