1
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Dias AL, Groarke EM, Hickstein D, Patel B. Role of allogeneic hematopoietic cell transplantation in VEXAS syndrome. Ann Hematol 2024:10.1007/s00277-024-05942-2. [PMID: 39168911 DOI: 10.1007/s00277-024-05942-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a newly diagnosed syndrome comprising severe systemic inflammatory and hematological manifestations including myelodysplastic syndrome and plasma cell dyscrasia. Since its discovery four years ago, several groups have identified pleomorphic clinical phenotypes, but few effective medical therapies exist which include Janus Kinase (JAK) inhibitors, interleukin inhibitors (IL-1 and IL-6), and hypomethylating agents. Prospective trials are lacking at this time and most patients remain corticosteroid dependent. VEXAS has a high morbidity from frequent life threatening inflammatory symptoms and risk of progression to hematological malignancies and has an overall survival of 50% at 10 years. Allogeneic stem cell transplant (allo-HCT) is a curative option for this disease caused by somatic mutations in the UBA1 gene. Here we outline the role of allo-HCT in treating patients with VEXAS syndrome, highlighting the outcomes from several single-institution studies and case reports. Prospective trials will be required to precisely define the role of allo-HCT in the management of VEXAS syndrome.
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Affiliation(s)
- Ajoy L Dias
- Immune Deficiency - Cellular Therapy Program, National Cancer Institute, National Institute of Health, Building 10 CRC/Room 3-3150, 10 Center Drive MSC 1102, Bethesda, MD, 20892, USA.
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, USA
| | - Dennis Hickstein
- Immune Deficiency - Cellular Therapy Program, National Cancer Institute, National Institute of Health, Building 10 CRC/Room 3-3150, 10 Center Drive MSC 1102, Bethesda, MD, 20892, USA
| | - Bhavisha Patel
- Hematology Branch, National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, USA
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2
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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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3
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Lim JWW, Chua CKT. Case report: Lower limb pseudocellulitis due to calf myositis in VEXAS syndrome. Int J Rheum Dis 2024; 27:e15270. [PMID: 39045896 DOI: 10.1111/1756-185x.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Accepted: 07/12/2024] [Indexed: 07/25/2024]
Affiliation(s)
- Julian W W Lim
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Cheryl K T Chua
- Division of Rheumatology, Department of Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
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4
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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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5
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Nakajima H, Kunimoto H. VEXAS syndrome. Int J Hematol 2024:10.1007/s12185-024-03799-9. [PMID: 38819628 DOI: 10.1007/s12185-024-03799-9] [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: 02/19/2024] [Revised: 05/12/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
VEXAS syndrome is a recently identified, adult-onset autoinflammatory disease caused by somatic mutations in UBA1. UBA1 is an X-linked gene encoding E1 ubiquitin activating enzyme and its mutation in hematopoietic stem and progenitor cells leads to their clonal expansion and myeloid-skewed differentiation. UBA1 mutations in VEXAS are clustered at the second methionine (p.Met41), eliminating UBA1b isoform translated from p.Met41. Loss of UBA1b impairs ubiquitination and activates innate immune pathways, leading to systemic autoinflammation manifested as recurrent fever, chondritis, pulmonary involvement, vasculitis, or neutrophilic dermatitis. VEXAS syndrome is frequently associated with hematological disorders such as myelodysplastic syndrome (MDS), plasma cell dyscrasia and venous thromboembolism. Macrocytic anemia/macrocytosis and vacuoles in myeloid/erythroid precursors are prominent features of VEXAS syndrome, and their presence in patients with autoinflammatory symptoms prompts physicians to screen for UBA1 variant. Treatment of VEXAS syndrome is challenging and no consistently effective therapies have been established. Anti-inflammation therapies including glucocorticoids and anti-interleukin-6 have shown limited efficacy, while azacytidine and JAK inhibitors such as ruxolitinib were found to induce favorable, mid-term responses. Hematopoietic stem cell transplantation is the only curative option for VEXAS and should be considered for younger, fit patients with poor prognostic factors or recalcitrant symptoms.
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Affiliation(s)
- Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fuku-Ura, Kanazawa-Ku, Yokohama, 236-0004, Japan.
| | - Hiroyoshi Kunimoto
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fuku-Ura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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6
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Martínez-Diaz L, Morales-Angulo C. VEXAS syndrome and otolaryngology. Am J Otolaryngol 2024; 45:104216. [PMID: 38199001 DOI: 10.1016/j.amjoto.2024.104216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024]
Affiliation(s)
- Lucía Martínez-Diaz
- Departamento de Ciencias Médicas y Quirúrgicas, Facultad de Medicina, Santander, Cantabria, Spain
| | - Carmelo Morales-Angulo
- Departamento de Ciencias Médicas y Quirúrgicas, Facultad de Medicina, Santander, Cantabria, Spain; Department of Otolaryngology, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain; IDIVAL, Santander, Cantabria, Spain.
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7
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Bellman P, Gonzalez-Lugo JD, Shahzad M, Amin MK, Khalid MF, Suleman N, Ahmed N, Singh AK, Yacoub A, Zhang D, McGuirk JP, Mushtaq MU. Successful treatment with fludarabine and cyclophosphamide in a VEXAS syndrome patient with associated myelodysplastic syndrome: a case report and systematic review. Front Oncol 2024; 14:1383730. [PMID: 38665946 PMCID: PMC11043578 DOI: 10.3389/fonc.2024.1383730] [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] [Received: 02/07/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Vacuoles, E1 syndrome, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a chronic inflammatory disorder that affects various organ systems. It is associated with hematologic malignancies and is generally refractory to therapies. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) may be considered for selected patients. We report a case wherein systemic and hematological manifestations completely resolved in a patient with VEXAS and associated myelodysplastic syndrome (MDS), following the administration of fludarabine and cyclophosphamide as part of the preparation for allo-HSCT. We conducted a systematic literature review and included 86 patients with VEXAS syndrome and associated MDS. Most cases presented with musculoskeletal involvement (71%) and anemia (72%) with lower-risk MDS. Most patients responded to corticosteroids (CS) but had a recurrence of symptoms with CS taper and were refractory to other immunosuppressive agents. Hypomethylating agents and Janus kinase inhibitors achieved a complete response in some cases. Further research is needed to develop more effective treatment strategies.
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Affiliation(s)
- Polina Bellman
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Jesus D. Gonzalez-Lugo
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Moazzam Shahzad
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
- Division of Hematology and Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL, United States
| | - Muhammad Kashif Amin
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Muhammad Fareed Khalid
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Nahid Suleman
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Nausheen Ahmed
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Anurag K. Singh
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Abdulraheem Yacoub
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Da Zhang
- Division of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Joseph P. McGuirk
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
| | - Muhammad Umair Mushtaq
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
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8
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Low M, Gray BH. Refining Vascular Care Through Science Without Losing the Art. Ann Vasc Surg 2024; 101:11-14. [PMID: 38110077 DOI: 10.1016/j.avsg.2023.12.007] [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: 12/03/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023]
Abstract
The science of medicine involves the incorporation of data from evidence-based medicine (collecting, analyzing, conducting clinical trials), medical knowledge (learned patterns of health and disease), diagnostic testing (objective evidence), treatment protocols (guidelines based on scientific evidence and/or expert consensus), and pharmacology (prescribing safely and effectively). The art of medicine involves clinical judgment (learn to interpret clinical signs, symptoms, and histories often relying on intuition and gut feelings), bedside manner (understanding patient needs), customization of care (artistic touch to meet each person's unique circumstances including values, preferences, and social determinants of health), complex decision-making (decision-making based on experience or expertise when confronted with limited or conflicting data), and managing uncertainty (making decisions keeping "doors open" when faced with limited objective confirmation). The delivery of healthcare is not "either science or art" but rather "both science and art" proposition. So, how do we wrestle with this potential paradox?
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Affiliation(s)
- Matthew Low
- Department of Vascular Surgery, Kootenai Health, Coeur d'Alene, ID.
| | - Bruce H Gray
- Department of Surgery/Vascular Medicine, University of South Carolina School of Medicine/Greenville, Greenville, SC
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9
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Saad AJ, Patil MK, Cruz N, Lam CS, O'Brien C, Nambudiri VE. VEXAS syndrome: A review of cutaneous findings and treatments in an emerging autoinflammatory disease. Exp Dermatol 2024; 33:e15050. [PMID: 38469984 DOI: 10.1111/exd.15050] [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: 05/09/2023] [Revised: 08/08/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic mutation) syndrome is a novel autoinflammatory, late-onset, disorder first identified in 2020. It is caused by mutations in the UBA1 gene. The most prominent clinical features reported by VEXAS patients are cutaneous and haematological, having characteristic skin features reported as the initial presenting findings of the disease. VEXAS is a severe and treatment-resistant condition with high morbidity and mortality rates. Here, we examine all case reports and case series of VEXAS syndrome through March 2023 focusing on those presenting cutaneous manifestations. We discuss these manifestations and their reported treatment strategies. In many cases, it might be first suspected and diagnosed by dermatologists, highlighting their vital role in initiating timely multidisciplinary care.
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Affiliation(s)
- Anis J Saad
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mihir K Patil
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Carle Illinois College of Medicine at the University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Nicolas Cruz
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chloe S Lam
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Connor O'Brien
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Sharmeen S, Christopher-Stine L, Salvemini JN, Gorevic P, Clark R, Yao Q. Amyopathic dermatomyositis may be on the spectrum of autoinflammatory disease: A clinical review. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2024; 5:42-48. [PMID: 38571935 PMCID: PMC10985708 DOI: 10.1515/rir-2024-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 06/13/2023] [Indexed: 04/05/2024]
Abstract
Systemic autoinflammatory diseases (SAIDs) are distinct from autoimmune diseases. The former primarily results from abnormal innate immune response and genetic testing is crucial for disease diagnosis. Similar cutaneous involvement is a main feature for both SAID and dermatomyositis (DM), so they can be confused with each other. A literature search of PubMed and MEDLINE was conducted for relevant articles. The similarities and differences between these two types of diseases were analyzed. We found phenotypic similarities between these two types of disorders. Accumulating data supports a major role of the innate immune system and a similar cytokine profile. Molecular testing using an autoinflammatory disease gene panel may help identify SAID patients from the DM population and may offer therapeutic benefit using interleukin-1 (IL-1) inhibitors. A subset of DM, notably amyopathic dermatomyositis in the absence of autoantibodies may be on the spectrum of autoinflammatory disease.
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Affiliation(s)
- Saika Sharmeen
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | | | - Joann N. Salvemini
- Department of Dermatology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Peter Gorevic
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Richard Clark
- Department of Dermatology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Qingping Yao
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
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11
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Kreutzinger V, Pankow A, Boyadzhieva Z, Schneider U, Ziegeler K, Stephan LU, Kübke JC, Schröder S, Oberender C, le Coutre P, Stintzing S, Jelas I. VEXAS and Myelodysplastic Syndrome: An Interdisciplinary Challenge. J Clin Med 2024; 13:1049. [PMID: 38398362 PMCID: PMC10889042 DOI: 10.3390/jcm13041049] [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: 01/07/2024] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently recognized systemic autoinflammatory disease caused by somatic mutations in hematopoietic progenitor cells. This case series of four patients with VEXAS syndrome and comorbid myelodysplastic syndrome (MDS) aims to describe clinical, imaging, and hematologic disease presentations as well as response to therapy. Four patients with VEXAS syndrome and MDS are described. A detailed analysis of imaging features, hemato-oncological presentation including bone marrow microscopy and clinical-rheumatological disease features and treatment outcomes is given. All patients were male; ages ranged between 64 and 81 years; all were diagnosed with MDS. CT imaging was available for three patients, all of whom exhibited pulmonary infiltrates of varying severity, resembling COVID-19 or hypersensitivity pneumonitis without traces of scarring. Bone marrow microscopy showed maturation-disordered erythropoiesis and pathognomonic vacuolation. Somatic mutation in the UBA1 codon 41 were found in all patients by next-generation sequencing. Therapy regimes included glucocorticoids, JAK1/2-inhibitors, nucleoside analogues, as well as IL-1 and IL-6 receptor antagonists. No fatalities occurred (observation period from symptom onset: 18-68 months). Given the potential underreporting of VEXAS syndrome, we highly recommend contemporary screening for UBA1 mutations in patients presenting with ambiguous signs of systemic autoinflammatory symptoms which persist over 18 months despite treatment. The emergence of cytopenia, especially macrocytic hyperchromic anemia, should prompt early testing for UBA1 mutations. Notably conspicuous, pulmonary alterations in CT imaging of patients with therapy-resistant systemic autoinflammatory symptoms should be discussed in interdisciplinary medical teams (Rheumatology, Hematology, Radiology and further specialist departments) to facilitate timely diagnosis during the clinical course of the disease.
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Affiliation(s)
- Virginie Kreutzinger
- Department of Radiology, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Anne Pankow
- Department of Rheumatology and Clinical Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Zhivana Boyadzhieva
- Department of Rheumatology and Clinical Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Udo Schneider
- Department of Rheumatology and Clinical Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Katharina Ziegeler
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Lars Uwe Stephan
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Jan Carl Kübke
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Sebastian Schröder
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Christian Oberender
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Philipp le Coutre
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Sebastian Stintzing
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Ivan Jelas
- Department of Hematology, Oncology, and Cancer Immunology, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
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12
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Chen KR. Cutaneous vasculitis in autoinflammatory diseases. J Dermatol 2024; 51:150-159. [PMID: 37955334 DOI: 10.1111/1346-8138.17030] [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: 10/01/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023]
Abstract
Autoinflammatory diseases (AIDs) characterized by recurrent episodes of localized or systemic inflammation are disorders of the innate immune system. Skin lesions are commonly found in AIDs and cutaneous vasculitis can coexist with AIDs and even present as the most striking feature. This review aims to focus on the frequent cutaneous vasculitis association in three monogenic AIDs including familial Mediterranean fever (FMF), deficiency of adenosine deaminase type 2 (DADA2), and the recently identified adult-onset VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Cutaneous vasculitis in FMF is characterized by: (1) small-vessel vasculitis similar to IgA vasculitis with palpable purpura but increased intussusception complication and less vascular IgA deposit, and (2) cutaneous arteritis-like vasculitis presenting as subcutaneous nodules most often with higher glomerular involvement. DADA2 has a wide spectrum of clinical presentations ranging from fatal systemic vasculitis with multiple strokes, especially in pediatric patients, to limited cutaneous disease in middle-aged patients. DADA2 shares similar clinical and histopathological features with polyarteritis nodosa (PAN). As a result, DADA2 is commonly initially misdiagnosed as childhood PAN. Livedo racemosa reveals the most common cutaneous manifestation of cutaneous vasculitis in patients with DADA2. VEXAS syndrome is a life-threatening disease. A diagnosis of VEXAS syndrome should be strongly considered or could be made in patients with skin lesions characterized by Sweet syndrome-like eruption, livedo racemosa, concomitant relapsing polychondritis, deep venous thrombosis, pulmonary involvement, and progressive hematologic abnormalities such as myelodysplastic syndrome with a unique finding of cytoplasmic vacuoles in myeloid and erythroid precursor cells from bone marrow aspirate smear. As skin involvement is common in AIDs and may present as the most frequent manifestation, especially in DADA2 (70% to 90%) and VEXAS syndrome (83% to 91%), dermatologists play a crucial role in contributing to the early diagnosis of these AIDs with early initiation of the appropriate therapy to avoid progressing fatal outcomes.
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Affiliation(s)
- Ko-Ron Chen
- Meguro Chen Dermatology Clinic, Tokyo, Japan
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13
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Koster MJ, Lasho TL, Olteanu H, Reichard KK, Mangaonkar A, Warrington KJ, Patnaik MM. VEXAS syndrome: Clinical, hematologic features and a practical approach to diagnosis and management. Am J Hematol 2024; 99:284-299. [PMID: 37950858 DOI: 10.1002/ajh.27156] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/13/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is a newly identified disease caused by somatic alterations in UBA1 which produce a recalcitrant inflammatory state along with hematologic disturbances. Patients with VEXAS can have a wide spectrum of clinical symptoms and providers should be familiar with the heterogeneity of associated clinical features. While hematologic parameters may be generally non-specific, peripheral blood features of macrocytosis, monocytopenia, and/or thrombocytopenia coupled with bone marrow vacuolization of erythroid or myeloid precursors should raise suspicion for this condition. Due to an increased mortality, prompt recognition and accurate diagnosis is paramount. Access to testing for confirmation of UBA1 variants is not yet universally available but clinicians should understand the current available options for genetic confirmation of this disease. Treatment options are limited due to lack of prospective clinical trials but cytokine directed therapies such as interleukin-6 inhibitors and JAK-STAT inhibitors as well as hypomethylating agents such as azacitidine have shown evidence of partial effect. Though cases are limited, allogeneic stem cell transplantation holds promise for durable response and potential cure. The intent of this review is to outline the pathophysiology of VEXAS syndrome and to provide a practical approach to diagnosis and treatment.
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Affiliation(s)
- Matthew J Koster
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Terra L Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Horatiu Olteanu
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kaaren K Reichard
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhishek Mangaonkar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Diral E, Campochiaro C, Tomelleri A, Bergonzi GM, Pizzano U, Ponzoni M, Bongiovanni L, Ronchi P, Tresoldi C, Rigamonti S, Scarfò F, Latino GM, Rinaldi E, Bernardi M, Dagna L, Ciceri F. Case report: Cytopenias in VEXAS syndrome - a WHO 2022 based approach in a single-center cohort. Front Immunol 2024; 15:1354130. [PMID: 38333211 PMCID: PMC10850384 DOI: 10.3389/fimmu.2024.1354130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/08/2024] [Indexed: 02/10/2024] Open
Abstract
VEXAS syndrome is an acquired autoinflammatory disease characterized in most cases by cytopenias and macrocytic anemia. Dyshematopoiesis is a frequent finding in chronic inflammatory conditions and therefore, cytopenias are not easily classified in VEXAS patients. Here we report a series of 7 patients affected by VEXAS associated cytopenias, treated at our center. The use of NGS, together with morphological assays, integrated with the WHO 2022 criteria, allowed to identify three subsets of VEXAS associated cytopenias: ICUS (idiopathic cytopenia of uncertain significance), CCUS (clonal cytopenia of uncertain significance) at high risk of clonal evolution, and MDS. This approach could help to better understand the nature of VEXAS associated cytopenias and to guide the use of specific targeted treatments in order to achieve long lasting responses.
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Affiliation(s)
- Elisa Diral
- Unit of Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Gregorio M. Bergonzi
- Unit of Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Umberto Pizzano
- Unit of Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Maurilio Ponzoni
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lucia Bongiovanni
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Ronchi
- Unit of Immunohaematology and Transfusion Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Tresoldi
- Unit of Immunohaematology and Transfusion Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Rigamonti
- Unit of Immunohaematology and Transfusion Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Scarfò
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gloria M. Latino
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Emma Rinaldi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Bernardi
- Unit of Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabio Ciceri
- Unit of Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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15
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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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16
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Loeza-Uribe MP, Hinojosa-Azaola A, Sánchez-Hernández BE, Crispín JC, Apodaca-Chávez E, Ferrada MA, Martín-Nares E. VEXAS syndrome: Clinical manifestations, diagnosis, and treatment. REUMATOLOGIA CLINICA 2024; 20:47-56. [PMID: 38160120 DOI: 10.1016/j.reumae.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is an adult-onset autoinflammatory syndrome characterized by somatic mutations in the UBA1 gene and is considered the prototype of hematoinflammatory diseases. Patients with VEXAS syndrome exhibit inflammatory and hematological manifestations that can lead to clinical diagnoses such as relapsing polychondritis, polyarteritis nodosa, Sweet syndrome, and myelodysplastic syndrome. Diagnosis requires bone marrow evaluation to identify cytoplasmic vacuoles in myeloid and erythroid precursors. However, genetic confirmation of mutations in UBA1 is necessary. Treatment is challenging and often involves glucocorticoids and immunosuppressants with variable responses. Hypomethylating agents and allogenic haemopoietic stem cell transplant are considered promising therapies. Prognosis is influenced by genetic and clinical factors. The aim of this review is to provide an overview of the pathogenesis, clinical presentation, treatment, and prognosis of VEXAS syndrome for the Latin American medical community.
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Affiliation(s)
- Michelle Patricia Loeza-Uribe
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Beatriz E Sánchez-Hernández
- Departamento de Patología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - José C Crispín
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Elia Apodaca-Chávez
- Departamento de Hematología y Oncología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
| | - Eduardo Martín-Nares
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
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17
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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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18
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Tsourveloudis I, Georgiadi EC, Vatalis G, Kotsi P. Case report of a patient with VEXAS syndrome. Medicine (Baltimore) 2023; 102:e36738. [PMID: 38206689 PMCID: PMC10754568 DOI: 10.1097/md.0000000000036738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 11/30/2023] [Indexed: 01/13/2024] Open
Abstract
RATIONALE Hematological malignancies have always been a challenge for scientists because there is a constant need to better define these entities. Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders characterized by ineffective hematopoiesis. Cytogenetics and molecular findings are a prerequisite for these syndromes as they confirm the clonal nature of the disease. However, MDS is often linked to autoimmunity and inflammation as part of its pathogenesis. Recently, VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) linked these two in a single mutation, suggesting that the heterogeneity among hematological malignancies often demands a more personalized medicine by tailoring medical treatment to the individual characteristics of each patient. PATIENT CONCERNS We present a case of VEXAS syndrome regarding a 63-year-old male patient who initially presented with episodes of low fever, polyarthritis of the knees and ankles, polymyalgia, and fatigue. His laboratory examinations revealed increased levels of serum inflammatory markers. DIAGNOSES Diagnosis was based on high clinical suspicion, laboratory findings, and vacuolization of the erythroid and myeloid precursors in the bone marrow evaluation. Mutational status of ubiquitin-like modifier activating enzyme 1 gene was positive with a 68.8% allelomorph frequency (rs782416867). INTERVENTIONS Therapy was based on controlling inflammation with the use of glucocorticoids and treating MDS-related anemia with the use of erythropoietin. OUTCOMES Currently, the patient visits our department regularly. He is still receiving the aforementioned treatment. He did not mention any new incidents for the time being. LESSONS VEXAS syndrome as a newly identified entity might be often underestimated since its clinical presentation is notably diverse.
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Affiliation(s)
| | - Eleni C. Georgiadi
- Transfusion Department, University General Hospital of Larissa, Larissa, Greece
| | | | - Paraskevi Kotsi
- Transfusion Department, University General Hospital of Larissa, Larissa, Greece
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19
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Chiaramida A, Obwar SG, Nordstrom AEH, Ericsson M, Saldanha A, Ivanova EV, Griffin GK, Khan DH, Belizaire R. Sensitivity to targeted UBA1 inhibition in a myeloid cell line model of VEXAS syndrome. Blood Adv 2023; 7:7445-7456. [PMID: 38091008 PMCID: PMC10758730 DOI: 10.1182/bloodadvances.2023010531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/09/2023] [Indexed: 12/18/2023] Open
Abstract
Somatic UBA1 mutations in hematopoietic cells are a hallmark of Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) syndrome, which is a late-onset inflammatory disease associated with bone marrow failure and high mortality. The majority of UBA1 mutations in VEXAS syndrome comprise hemizygous mutations affecting methionine-41 (M41), leading to the expression of UBA1M41T, UBA1M41V, or UBA1M41L and globally reduced protein polyubiquitination. Here, we used CRISPR-Cas9 to engineer isogenic 32D mouse myeloid cell lines expressing hemizygous Uba1WT or Uba1M41L from the endogenous locus. Consistent with prior analyses of patients with VEXAS syndrome samples, hemizygous Uba1M41L expression was associated with loss of the UBA1b protein isoform, gain of the UBA1c protein isoform, reduced polyubiquitination, abnormal cytoplasmic vacuoles, and increased production of interleukin-1β and inflammatory chemokines. Vacuoles in Uba1M41L cells contained a variety of endolysosomal membranes, including small vesicles, multivesicular bodies, and multilamellar lysosomes. Uba1M41L cells were more sensitive to the UBA1 inhibitor TAK243. TAK243 treatment promoted apoptosis in Uba1M41L cells and led to preferential loss of Uba1M41L cells in competition assays with Uba1WT cells. Knock-in of a TAK243-binding mutation, Uba1A580S, conferred TAK243 resistance. In addition, overexpression of catalytically active UBA1b in Uba1M41L cells restored polyubiquitination and increased TAK243 resistance. Altogether, these data indicate that loss of UBA1b underlies a key biochemical phenotype associated with VEXAS syndrome and renders cells with reduced UBA1 activity vulnerable to targeted UBA1 inhibition. Our Uba1M41L knock-in cell line is a useful model of VEXAS syndrome that will aid in the study of disease pathogenesis and the development of effective therapies.
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Affiliation(s)
| | - Sandra G. Obwar
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Maria Ericsson
- Department of Cell Biology, Harvard Medical School, Boston, MA
| | - Aisha Saldanha
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, MA
| | - Elena V. Ivanova
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Dilshad H. Khan
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA
| | - Roger Belizaire
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA
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20
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Baur V, Stoevesandt J, Hueber A, Hüffmeier U, Kneitz H, Morbach H, Schultz E, Goebeler M. VEXAS-Syndrome, a newly described autoinflammatory systemic disease with dermatologic manifestations. J Dtsch Dermatol Ges 2023; 21:1456-1463. [PMID: 37953404 DOI: 10.1111/ddg.15227] [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: 04/02/2023] [Accepted: 07/27/2023] [Indexed: 11/14/2023]
Abstract
VEXAS syndrome is a recently identified autoinflammatory systemic disease caused by an acquired somatic mutation of the X-linked UBA1 gene, the key enzyme of the first step of ubiquitylation. The acronym VEXAS stands for the characteristics Vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic. The disease occurs in advanced adulthood preferentially in men and is characterized by hematological, rheumatological and dermatological symptoms. The latter include neutrophil-rich lesions reminiscent of Sweet's syndrome, erythema nodosum- and panniculitis-like skin manifestations and recurrent polychondritis of the nose and auricles. The presence of cytoplasmic vacuoles in myeloid and erythroid precursors in the bone marrow is characteristic. In up to half of the cases, VEXAS syndrome is associated with myelodysplastic syndrome. Dermatologists should be familiar with the clinical picture, as skin symptoms are often the first indicator of the disease. Molecular diagnostics are essential for confirming the diagnosis and risk stratification of affected patients. In this minireview we provide an overview of the pathophysiology, diagnosis and therapy of VEXAS syndrome and illustrate its clinical picture with two own cases.
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Affiliation(s)
- Vera Baur
- Department of Dermatology, Paracelsus Medical Private University, Nuremberg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Axel Hueber
- Department of Rheumatology, Paracelsus Medical Private University, Nuremberg, Germany
| | - Ulrike Hüffmeier
- Institute of Human Genetics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Hermann Kneitz
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Henner Morbach
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Erwin Schultz
- Department of Dermatology, Paracelsus Medical Private University, Nuremberg, Germany
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
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Baur V, Stoevesandt J, Hueber A, Hüffmeier U, Kneitz H, Morbach H, Schultz E, Goebeler M. VEXAS-Syndrom, eine neu beschriebene autoinflammatorische Systemerkrankung mit dermatologischen Manifestationen. J Dtsch Dermatol Ges 2023; 21:1456-1464. [PMID: 38082529 DOI: 10.1111/ddg.15227_g] [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: 04/02/2023] [Accepted: 07/27/2023] [Indexed: 12/18/2023]
Abstract
ZusammenfassungDas VEXAS‐Syndrom ist eine kürzlich erstbeschriebene autoinflammatorische Systemerkrankung, die auf einer erworbenen, somatischen Mutation des X‐chromosomal lokalisierten UBA1‐Gens, dem Schlüsselenzym des ersten Schritts der Ubiquitinierung, beruht. Das Akronym VEXAS steht für die Charakteristika Vacuoles, E1 enzyme, X‐linked, autoinflammatory und somatic. Die Erkrankung tritt im fortgeschrittenen Erwachsenenalter vorzugsweise bei Männern auf und ist insbesondere durch hämatologische, rheumatologische und dermatologische Symptome gekennzeichnet. Letztere umfassen unter anderem neutrophilenreiche, an das Sweet‐Syndrom erinnernde Läsionen, Erythema nodosum‐ und Pannikulitis‐artige Hauterscheinungen sowie rezidivierende Polychondritiden an Nase und Ohrmuscheln. Das Vorliegen zytoplasmatischer Vakuolen in myeloiden und erythroiden Vorläuferzellen des Knochenmarks ist charakteristisch. In bis zur Hälfte der Fälle ist das VEXAS‐Syndrom mit einem myelodysplastischen Syndrom vergesellschaftet. Dermatologen sollten das Krankheitsbild kennen, da Hauterscheinungen oft der erste Indikator für die Erkrankung sind. Eine molekulare Diagnostik ist essenziell für die Diagnosesicherung und die Risikostratifizierung betroffener Patienten. In dieser Arbeit geben wir einen Überblick über die Pathophysiologie, Diagnostik und Therapie des VEXAS‐Syndroms und illustrieren das klinische Spektrum anhand zweier eigener Fälle.
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Affiliation(s)
- Vera Baur
- Klinik für Dermatologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Johanna Stoevesandt
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Axel Hueber
- Abteilung für Rheumatologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Ulrike Hüffmeier
- Humangenetisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Hermann Kneitz
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Henner Morbach
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Erwin Schultz
- Klinik für Dermatologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Matthias Goebeler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
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22
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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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Lokhande A, Jarmale S, Vaishnav YJ, Schaefer J. An Orbital Manifestation of VEXAS Syndrome. Ophthalmic Plast Reconstr Surg 2023; 39:e194-e197. [PMID: 37405738 DOI: 10.1097/iop.0000000000002450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is an adult-onset autoinflammatory disorder characterized by systemic inflammation (vasculitis, arthritis, chondritis, dermatosis) and hematologic abnormalities (thrombosis, cytopenia, vacuolization of marrow precursors). The patient demonstrated some of the adult-onset inflammatory and hematologic features, in addition to recurrent eye pain, chemosis and orbital inflammation. This case describes an instance of VEXAS syndrome in a patient with uncommon orbital symptoms such as scleritis and myositis.
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Affiliation(s)
| | | | - Yash J Vaishnav
- The Warren Alpert Medical School of Brown University
- Division of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
| | - Jamie Schaefer
- The Warren Alpert Medical School of Brown University
- Division of Ophthalmology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, U.S.A
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24
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Myint K, Patrao N, Vonica O, Vahdani K. Recurrent superior orbital fissure syndrome associated with VEXAS syndrome. J Ophthalmic Inflamm Infect 2023; 13:39. [PMID: 37673972 PMCID: PMC10482812 DOI: 10.1186/s12348-023-00362-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023] Open
Abstract
PURPOSE To describe a case of recurrent orbital inflammation and superior orbital fissure syndrome associated with VEXAS (vacuoles, E1 enzyme, X-linked, auto-inflammatory, somatic) syndrome. CASE PRESENTATION VEXAS syndrome is a recently identified multi-system inflammatory disease of late adult onset. The authors describe the case of a 76-year-old man who presented with recurrent episodes of orbital inflammation, with superior orbital fissure syndrome, dacryoadenitis and orbital myositis. He had a constellation of systemic disorders including recurrent chest infections, congestive cardiac failure, pulmonary emboli and skin rashes. The underlying diagnosis of VEXAS syndrome was confirmed by genetic testing, which revealed the UBA1 mutation. CONCLUSION VEXAS syndrome should be considered in the differential diagnosis of orbital inflammatory disease associated with multi-system inflammatory disorders.
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Affiliation(s)
- Katie Myint
- Adnexal Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
| | - Namritha Patrao
- Royal Eye Unit, Kingston Hospital NHS Foundation Trust, Surrey, UK
| | - Oana Vonica
- Royal Eye Unit, Kingston Hospital NHS Foundation Trust, Surrey, UK
| | - Kaveh Vahdani
- Adnexal Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly defined refractory adult-onset autoinflammatory syndrome caused by somatic mutations in the ubiquitin-like modifier-activating enzyme 1 (UBA1) gene in hematopoietic stem and progenitor cells, resulting in a shift in UBA1 isoform expression. Thus, patients develop a spectrum of systemic inflammatory manifestations and hematologic symptoms. To date, patients respond poorly to immune suppressive drugs, except high-dose glucocorticoids, and no treatment guidelines have been established. Given the high mortality rate, VEXAS syndrome needs to be taken seriously by physicians in all specialties. This article aims to describe the key features, pathogenesis, and clinical manifestations of VEXAS syndrome to better understand the targeted treatment and improve the prognosis of VEXAS syndrome.
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Affiliation(s)
- Yue Zhang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Xifeng Dong
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Huaquan Wang
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
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26
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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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27
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Koster MJ, Ghaffar U, Kermani TA, Patnaik MM, Go RS, Mangaonkar AA, Reichard KK, Olteanu H, Warrington KJ. Antineutrophil cytoplasmic antibody-associated vasculitis and VEXAS syndrome: comment on the article by Muratore et al. Arthritis Rheumatol 2023; 75:1490-1492. [PMID: 36716119 DOI: 10.1002/art.42466] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/27/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Matthew J Koster
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Umar Ghaffar
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Tanaz A Kermani
- Division of Rheumatology, Department of Internal Medicine, University of California, Los Angeles, Santa Monica, CA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Kaaren K Reichard
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Horatiu Olteanu
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Kobak S. VEXAS syndrome: Current clinical, diagnostic and treatment approaches. Intractable Rare Dis Res 2023; 12:170-179. [PMID: 37662628 PMCID: PMC10468411 DOI: 10.5582/irdr.2023.01020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/30/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023] Open
Abstract
VEXAS syndrome, is a hemato-inflammatory chronic disease characterized with predominantly rheumatic and hematologic systemic involvement. It was first described in 2020 by a group of researchers in the United States. VEXAS syndrome is a rare condition that primarily affects adult males and is caused by a mutation in the UBA1 gene located on the X chromosome. Its pathogenesis is related to the somatic mutation affecting methionine-41 (p.Met41) in UBA1, the major E1 enzyme that initiates ubiquitylation. Mutant gene lead to decreased ubiquitination and activated innate immune pathways and systemic inflammation occur. The specific mechanism by which the UBA1 mutation leads to the clinical features of VEXAS syndrome is not yet fully understood. VEXAS is a newly define adult-onset inflammatory syndrome manifested with treatment-refractory fevers, arthritis, chondritis, vasculitis, cytopenias, typical vacuoles in hematopetic precursor cells, neutrophilic cutaneous and pulmonary inflammation. Diagnosing VEXAS syndrome can be challenging due to its rarity and the overlap of symptoms with other inflammatory conditions. Genetic testing to identify the UBA1 gene mutation is essential for definitive diagnosis. Currently, there is no known cure for VEXAS syndrome, and treatment mainly focuses on managing the symptoms. This may involve the use of anti-inflammatory medications, immunosuppressive drugs, and supportive therapies tailored to the individual patient's needs. Due to the recent discovery of VEXAS syndrome, ongoing research is being conducted to better understand its pathogenesis, clinical features, and potential treatment options. In this review article, the clinical, diagnostic and treatment approaches of VEXAS syndrome were evaluated in the light of the latest literature data.
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Affiliation(s)
- Senol Kobak
- Department of Internal Medicine and Rheumatology, Istinye University Faculty of Medicine, Liv Hospital, WASOG Sarcoidosis Clinic, Istanbul,Turkey
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Stiburkova B, Pavelcova K, Belickova M, Magaziner SJ, Collins JC, Werner A, Beck DB, Balajkova V, Salek C, Vostry M, Mann H, Vencovsky J. Novel Somatic UBA1 Variant in a Patient With VEXAS Syndrome. Arthritis Rheumatol 2023; 75:1285-1290. [PMID: 36762418 PMCID: PMC10821773 DOI: 10.1002/art.42471] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/19/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Somatic mutations in UBA1 have recently been causally linked to a severe adult-onset inflammatory condition referred to as VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Ubiquitin-activating enzyme E1 (UBA-1) is of fundamental importance to the modulation of ubiquitin homeostasis and to the majority of downstream ubiquitylation-dependent cellular processes. Direct sequencing analysis of exon 3 containing the prevalent variants p.Met41Leu, p.Met41Val, and/or p.Met41Thr is usually used to confirm the disease-associated mutations. METHODS We studied the clinical, biochemical, and molecular genetic characteristics of a 59-year-old man with a 2-year history of arthritis, fever, night sweats, nonspecific skin rash, lymphadenopathy, and myelodysplastic syndrome with multilineage dysplasia. RESULTS The mutational analysis revealed a previously undescribed sequence variant c.1430G>C in exon 14 (p.Gly477Ala) in the gene UBA1. In vitro enzymatic analyses showed that p.Gly477Ala led to both decreased E1 ubiquitin thioester formation and E2 enzyme charging. CONCLUSION We report a case of a patient of European ancestry with clinical manifestations of VEXAS syndrome associated with a newly identified dysfunctional UBA-1 enzyme variant. Due to the patient's insufficient response to various immunosuppressive treatments, allogeneic hematopoietic stem cell transplantation was performed, which resulted in significant improvement of clinical and laboratory manifestations of the disease.
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Affiliation(s)
- Blanka Stiburkova
- Institute of Rheumatology and Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Katerina Pavelcova
- Institute of Rheumatology and Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Monika Belickova
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Samuel J. Magaziner
- Center for Human Genetics and Genomics, New York University School of Medicine, New York, New York, United States
| | - Jason C. Collins
- National Institute for Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - Achim Werner
- National Institute for Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, United States
| | - David B. Beck
- Center for Human Genetics and Genomics, New York University School of Medicine, New York, New York, United States
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York, United States
| | - Veronika Balajkova
- Institute of Rheumatology and Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Cyril Salek
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
- Institute of Clinical and Experimental Haematology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Vostry
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Herman Mann
- Institute of Rheumatology and Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiri Vencovsky
- Institute of Rheumatology and Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
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30
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Chabrun F, Lacombe V, Dieu X, Geneviève F, Urbanski G. Accurate stratification between VEXAS syndrome and differential diagnoses by deep learning analysis of peripheral blood smears. Clin Chem Lab Med 2023; 61:1275-1279. [PMID: 36722042 DOI: 10.1515/cclm-2022-1283] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 01/17/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVES VEXAS syndrome is a newly described autoinflammatory disease associated with UBA1 somatic mutations and vacuolization of myeloid precursors. This disease possesses an increasingly broad spectrum, leading to an increase in the number of suspected cases. Its diagnosis via bone-marrow aspiration and UBA1-gene sequencing is time-consuming and expensive. This study aimed at analyzing peripheral leukocytes using deep learning approaches to predict VEXAS syndrome in comparison to differential diagnoses. METHODS We compared leukocyte images from blood smears of three groups: participants with VEXAS syndrome (identified UBA1 mutation) (VEXAS); participants with features strongly suggestive of VEXAS syndrome but without UBA1 mutation (UBA1-WT); participants with a myelodysplastic syndrome and without clinical suspicion of VEXAS syndrome (MDS). To compare images of circulating leukocytes, we applied a two-step procedure. First, we used self-supervised contrastive learning to train convolutional neural networks to translate leukocyte images into lower-dimensional encodings. Then, we employed support vector machine to predict patients' condition based on those leukocyte encodings. RESULTS The VEXAS, UBA1-WT, and MDS groups included 3, 3, and 6 patients respectively. Analysis of 33,757 images of neutrophils and monocytes enabled us to distinguish VEXAS patients from both UBA1-WT and MDS patients, with mean ROC-AUCs ranging from 0.87 to 0.95. CONCLUSIONS Image analysis of blood smears via deep learning accurately distinguished neutrophils and monocytes drawn from patients with VEXAS syndrome from those of patients with similar clinical and/or biological features but without UBA1 mutation. Our findings offer a promising pathway to better screening for this disease.
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Affiliation(s)
- Floris Chabrun
- University of Angers, Inserm 1083, CNRS 6015, Mitolab Team, MITOVASC Institute, SFR ICAT, Angers, France
- Laboratoire de Biochimie et Biologie Moléculaire, Centre Hospitalier Universitaire, Angers, France
| | - Valentin Lacombe
- University of Angers, Inserm 1083, CNRS 6015, Mitolab Team, MITOVASC Institute, SFR ICAT, Angers, France
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire, Angers, France
| | - Xavier Dieu
- University of Angers, Inserm 1083, CNRS 6015, Mitolab Team, MITOVASC Institute, SFR ICAT, Angers, France
- Laboratoire de Biochimie et Biologie Moléculaire, Centre Hospitalier Universitaire, Angers, France
| | - Franck Geneviève
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire Angers, Angers, France
- Fédération Hospitalo-Universitaire 'Grand Ouest Against Leukemia' (FHU GOAL), Angers, France
| | - Geoffrey Urbanski
- University of Angers, Inserm 1083, CNRS 6015, Mitolab Team, MITOVASC Institute, SFR ICAT, Angers, France
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire, Angers, France
- Department of Orofacial Sciences, School of Dentistry, University of California, San Francisco, CA, USA
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31
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Kucharz EJ. VEXAS syndrome: a newly discovered systemic rheumatic disorder. Reumatologia 2023; 61:123-129. [PMID: 37223371 PMCID: PMC10201379 DOI: 10.5114/reum/163090] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/05/2023] [Indexed: 05/25/2023] Open
Abstract
VEXAS syndrome is an adult-onset autoinflammatory disease associated with hematologic symptoms. The disease affects primarily males, and leads to death of a significant proportion of the patients. VEXAS syndrome is caused by a somatic mutation of the UBA1 gene in hematopoietic progenitor cells. The clinical picture of the syndrome consists of a number of organ manifestations including those akin to rheumatic diseases, arthritis, myalgia, vasculitis and chondritis.
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Affiliation(s)
- Eugenisz J Kucharz
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Medical University of Silesia, Katowice, Poland
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Casal Moura M, Yi ES, Koster MJ, Ryu JH, Baqir M. A 79-Year-Old Man With Recurrent Respiratory and Constitutional Symptoms, Elevated Acute Phase Reactants, and Pancytopenia. Chest 2023; 163:e207-e210. [PMID: 37164584 DOI: 10.1016/j.chest.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/21/2022] [Accepted: 12/17/2022] [Indexed: 05/12/2023] Open
Abstract
CASE PRESENTATION A 79-year-old man was examined because of recurrent dyspnea and constitutional symptoms that included malaise, fatigue, fevers, and arthralgias over the past 7 years. He was a nonsmoker who was a retired farmer. Elevated levels of acute phase reactants and C-reactive protein and a high erythrocyte sedimentation rate were noted often in his health records. However, an extensive rheumatologic evaluation, which included serologic studies (antinuclear antibodies, cyclic citrullinated peptide antibodies, antineutrophil cytoplasmic antibodies) and temporal artery biopsy, had not shown an identifiable autoimmune disease. The patient had been treated intermittently with prednisone, with partial symptomatic improvement. Various cytopenias had been present over the preceding years; however, three bone marrow biopsy specimens showed moderately hypercellular bone marrow with no diagnostic findings.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | | | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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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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34
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Aluri J, Cooper MA. Somatic mosaicism in inborn errors of immunity: Current knowledge, challenges, and future perspectives. Semin Immunol 2023; 67:101761. [PMID: 37062181 PMCID: PMC11321052 DOI: 10.1016/j.smim.2023.101761] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/18/2023]
Abstract
Inborn errors of immunity (IEI) are a diverse group of monogenic disorders of the immune system due to germline variants in genes important for the immune response. Over the past decade there has been increasing recognition that acquired somatic variants present in a subset of cells can also lead to immune disorders or 'phenocopies' of IEI. Discovery of somatic mosaicism causing IEI has largely arisen from investigation of seemingly sporadic cases of IEI with predominant symptoms of autoinflammation and/or autoimmunity in which germline disease-causing variants are not detected. Disease-causing somatic mosaicism has been identified in genes that also cause germline IEI, such as FAS, and in genes without significant corresponding germline disease, such as UBA1 and TLR8. There are challenges in detecting low-level somatic variants, and it is likely that the extent of the somatic mosaicism causing IEI is largely uncharted. Here we review the field of somatic mosaicism leading to IEI and discuss challenges and methods for somatic variant detection, including diagnostic approaches for molecular diagnoses of patients.
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Affiliation(s)
- Jahnavi Aluri
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Megan A Cooper
- Department of Pediatrics, Division of Rheumatology/Immunology, Washington University in St. Louis, St. Louis, MO 63110, USA.
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35
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R Pinto F, Lamas A, G Oliveira D, E Oliveira M, Faria R. VEXAS Syndrome: A Call for Diagnostic Awareness Based on a Case Series of Seven Patients. ACTA MEDICA PORT 2023; 36:379-380. [PMID: 37071935 DOI: 10.20344/amp.19687] [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: 01/28/2023] [Accepted: 03/17/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Filipe R Pinto
- Serviço de Hematologia Clínica. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - António Lamas
- Serviço de Medicina Interna. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Daniel G Oliveira
- Unidade de Imunologia Clínica. Centro Hospitalar Universitário de Santo António. Porto; Immunobiology Group. i3S - Instituto de Investigação e Inovação em Saúde. Universidade do Porto; Unidade Multidisciplinar de Investigação Biomédica. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Márcia E Oliveira
- Unidade Multidisciplinar de Investigação Biomédica. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto; Unidade de Genética Molecular. Centro de Genética Médica Jacinto de Magalhães. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica. Centro Hospitalar Universitário de Santo António. Porto; Unidade Multidisciplinar de Investigação Biomédica. Instituto de Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto; Unidade de Genética Molecular. Centro de Genética Médica Jacinto de Magalhães. Centro Hospitalar Universitário de Santo António. Porto. Portugal
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36
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Moura MC, Baqir M, Tandon YK, Samec MJ, Hines AS, Reichard KK, Mangaonkar AA, Go RS, Warrington KJ, Patnaik MM, Koster MJ, Ryu JH. Pulmonary manifestations in VEXAS syndrome. Respir Med 2023; 213:107245. [PMID: 37062498 DOI: 10.1016/j.rmed.2023.107245] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a recently recognized multisystem disorder caused by somatic mutations in the UBA1 gene. METHODS A retrospective cohort study was conducted on all patients with VEXAS syndrome evaluated at our institution from June 2020 through May 2022. Medical records and chest imaging studies were reviewed. RESULTS We identified 45 subjects with median age of 68 years (range, 57-89), all men. Prior to VEXAS diagnosis, most patients had been diagnosed with various hematologic, rheumatologic, and dermatologic disorders. Most patients (84%) demonstrated canonical UBA1 methionine-41 (p.Met41) somatic mutations in hematopoietic cells. Fever (82%), skin lesions (91%), and respiratory symptoms (93%) were common presenting features. Chest CT manifested abnormalities in 91% of patients including parenchymal opacities in 25 (74%), most commonly ground-glass opacities (47%), along with mediastinal lymphadenopathy (29%), airway abnormalities (29%), and pleural effusion (24%). Pulmonary function test results available in 18 (40%) patients demonstrated mild restrictive impairment or normal results. Bronchoalveolar lavage and lung biopsy performed in a minority of patients demonstrated neutrophilic alveolitis and parenchymal inflammation, respectively. All patients received glucocorticoid therapy with at least partial response, but relapses were common and other immunosuppressive agents were employed in most patients. Pulmonary involvement appeared to improve in patients who received tocilizumab and JAK inhibitors. CONCLUSION The pulmonary manifestations in VEXAS are relatively nonspecific and nonsevere, occur in the context of systemic inflammation and are responsive to escalation in glucocorticoid dosing.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yasmeen K Tandon
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Matthew J Samec
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Alexander S Hines
- Division of Dermatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kaaren K Reichard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Abhishek A Mangaonkar
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ronald S Go
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mathew J Koster
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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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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Abstract
PURPOSE OF REVIEW Two years after the recognition of VEXAS (for Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, we propose an extensive review of the current understanding of VEXAS pathophysiology and therapeutic options. RECENT FINDINGS Among the nearly 150 articles published about VEXAS, some have provided determinant insights into VEXAS pathophysiology and treatment. Clinical data from retrospective series support the JAK inhibitor ruxolitinib as the most efficient strategy to control inflammation, and interesting results were also described with azacytidine. Allogeneic stem cell transplantation remains the only curative option, but should be proposed to carefully selected patients. SUMMARY Although waiting for more robust evidence from prospective clinical trials, therapeutic options emerge from retrospective studies. We propose a set of criteria that should be systematically reported to harmonize the evaluation of therapeutic outcomes. This will allow the collection of high-quality data and facilitate their subsequent meta-analysis with the overall aim of improving the management of VEXAS patients.
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Affiliation(s)
- Pierre Sujobert
- Hospices Civils de Lyon. Hôpital Lyon Sud, Service d'hématologie biologique, Lyon
- Université Claude Bernard Lyon 1, Faculté de médecine et de maïeutique Lyon Sud Charles Mérieux, Lymphoma Immunobiology Team, Pierre Bénite
| | - Maël Heiblig
- Université Claude Bernard Lyon 1, Faculté de médecine et de maïeutique Lyon Sud Charles Mérieux, Lymphoma Immunobiology Team, Pierre Bénite
- Hospices Civils de Lyon. Hôpital Lyon Sud, Service d'hématologie clinique, Lyon
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service de médecine interne
- Lyon Immunopathology Federation (LIFE), Lyon University, Lyon, France
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Abstract
INTRODUCTION VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described, late-onset, acquired autoinflammatory disorder caused by mutations in the UBA1 gene. The various clinical manifestations of VEXAS broadly divided into inflammatory or haematological. VEXAS defines a new disease category - the hematoinflammatory disorders triggered by somatic mutations restricted to blood but causing systemic inflammation with multi-organ involvement and associated with aberrant bone marrow status. VEXAS causes significant morbidity and reduced life expectancy, but the optimum standard of care remains undefined. AREAS COVERED This review describes the discovery of VEXAS, relevant genetic causes and immunopathology of the disease. A detailed account of its various clinical manifestations and disease mimics is provided. Current treatment and management options are discussed. EXPERT OPINION New rare variants in UBA1 and VEXAS-like UBA1 negative cases are reported. Consensus diagnostic criteria might be required to define VEXAS and its related disorders. Investigation of sporadic, VEXAS-like cases will require the application of deep sequencing using DNA obtained from various cellular or tissue locations. Prospective studies are needed to define the optimal supportive and treatment options for patients with varying disease severity and prognosis. VEXAS-specific hematopoietic stem cell transplant selection criteria also require development.
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Affiliation(s)
- Adam Al-Hakim
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Leeds, UK.,National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, School of Medicine, University of Leeds, Leeds, UK
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VEXAS Syndrome in a Patient with Myeloproliferative Neoplasia. Case Rep Hematol 2023; 2023:6551544. [PMID: 36879894 PMCID: PMC9985496 DOI: 10.1155/2023/6551544] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 11/25/2022] [Accepted: 02/02/2023] [Indexed: 02/27/2023] Open
Abstract
VEXAS syndrome stands for vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome. The syndrome is a combined hematological and rheumatological condition caused by a somatic mutation in the UBA1. There is an association between VEXAS and hematological conditions such as myelodysplastic syndrome (MDS), monoclonal gammopathies of uncertain conditions (MGUS), multiple myeloma (MM), and monoclonal B-cell lymphoproliferative conditions. There are not many descriptions of patients having VEXAS in combination with myeloproliferative neoplasm (MPN). With this article, we want to present a case history of a man in his sixties with a JAK2V617F mutated essential thrombocythemia (ET) developing VEXAS syndrome. The inflammatory symptoms occurred three and a half years after the ET diagnosis. He started to experience symptoms of autoinflammation and an overall worsening of his health, and blood work showed high inflammatory markers, leading to repeated hospitalizations. His major complaint was stiffness and pain, and high dosages of prednisolone were necessary to obtain pain relief. He subsequently developed anemia and significantly variable levels of thrombocytes, which previously were at a steady level. To evaluate his ET, we made a bone marrow smear demonstrating vacuolated myeloid and erythroid cells. Having VEXAS syndrome in mind, genetic testing identifying the UBA1 gene mutation was performed, thus confirming our suspicion. The work-up with myeloid panel on his bone marrow identified genetic mutation in the DNMT3 too. After developing VEXAS syndrome, he experienced thromboembolic events with both cerebral infarction and pulmonary embolism. Thromboembolic events are also common in JAK2 mutated patients, but in his case, they presented first after VEXAS had developed. Throughout the course of his condition, several attempts with prednisolone tapering and steroid sparing drugs were tried. He could not get pain relief unless the combination of medications included a relatively high dose of prednisolone. Currently, the patient uses prednisolone, anagrelide, and ruxolitinib, with partial remission and fewer hospitalizations and more stabilized hemoglobin and thrombocytes.
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Legeas C, Saucereau J, Saraux A, Schoenlaub P. VEXAS syndrome: A first case without any haematological abnormalities. Joint Bone Spine 2023; 90:105473. [PMID: 36273795 DOI: 10.1016/j.jbspin.2022.105473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/23/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Cécile Legeas
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Brest teaching Hospital, Brest, France; Dermatology Unit, Hopital d'instruction des Arméees, Brest, France
| | - Justine Saucereau
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Brest teaching Hospital, Brest, France; Dermatology Unit, Hopital d'instruction des Arméees, Brest, France
| | - Alain Saraux
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Brest teaching Hospital, Brest, France; Dermatology Unit, Hopital d'instruction des Arméees, Brest, France.
| | - Patricia Schoenlaub
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Brest teaching Hospital, Brest, France; Dermatology Unit, Hopital d'instruction des Arméees, Brest, France
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Neupane K, Jayarangaiah A, Zhang Y, Kumar A. VEXAS syndrome with progression of MDS to MDS/MPN overlap syndrome. BMJ Case Rep 2022; 15:e251089. [PMID: 36549759 PMCID: PMC9791449 DOI: 10.1136/bcr-2022-251089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
VEXAS (vacuoles, E1 enzyme, X linked, autoinflammatory, somatic) syndrome is a novel inflammatory syndrome that was first described in December 2020. Patients with VEXAS syndrome have a somatic mutation in the UBA1 gene, inflammatory conditions and usually haematological conditions. Haematological conditions reported in patients with VEXAS syndrome include myelodysplastic syndrome (MDS), clonal cytopenia of undetermined significance, plasma cell neoplasm including multiple myeloma/monoclonal gammopathy of undetermined significance, haemophagocytic lymphohistiocytosis and monoclonal B-cell lymphocytosis. Here we describe a patient with VEXAS syndrome who had a progression of MDS to MDS/myeloproliferative neoplasm overlap syndrome. The ocular findings so far reported in these patients include episcleritis, uveitis, blepharitis and orbital cellulitis. Here we report retinal detachment as a clinical feature of VEXAS syndrome. This finding has a significant implication in patient management as it warrants higher vigilance for this sight-threatening complication.
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Affiliation(s)
- Karun Neupane
- Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
- Internal Medicine, Jacobi Medical Center, Bronx, New York, USA
| | - Apoorva Jayarangaiah
- Department of Hematology and Oncology, Jacobi Medical Center, Bronx, New York, USA
| | - Yan Zhang
- Department of Pathology, Jacobi Medical Center, Bronx, New York, USA
| | - Abishek Kumar
- Department of Hematology and Oncology, Jacobi Medical Center, Bronx, New York, USA
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Grayson PC, Beck DB, Ferrada MA, Nigrovic PA, Kastner DL. VEXAS Syndrome and Disease Taxonomy in Rheumatology. Arthritis Rheumatol 2022; 74:1733-1736. [PMID: 35696333 PMCID: PMC9617773 DOI: 10.1002/art.42258] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/26/2022] [Accepted: 06/02/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Peter C. Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - David B. Beck
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, NY, NY
- Center for Human Genetics and Genomics, New York University Grossman School of Medicine, NY, NY
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Marcela A. Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Boston, MA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA
| | - Daniel L Kastner
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
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Yildirim D, Inan MA, Akyurek N, Tufan A. Vexas Syndrome Presenting As Long Covid-19. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1887-5341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Objective VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic)
syndrome is a recently described systemic inflammatory syndrome caused by
somatic mutations of UBA1. COVID-19 is a viral infection that was described in
2019 and spread widely and quickly all around the world. Constitutional,
thrombotic and pulmonary symptoms of these two conditions are similar, which is
why cases of VEXAS syndrome may be misdiagnosed as a COVID infection.
Case report We introduced a case report of a 72-year-old male patient with
VEXAS syndrome who had fever, fatigue, deep vein thrombosis and a cough and was
thought to have a long COVID-19 infection for one year. Then we diagnosed him
with VEXAS syndrome with vacuoles in myelomonocytic cells, skin lesions and a
mutation of the UBA-1 gene.
Conclusion VEXAS and long COVID are two new conditions with overlapping
clinical presentations. Physicians must be aware of these clinical conditions
because of their different treatment strategy and prognosis.
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Affiliation(s)
- Derya Yildirim
- Rheumatology, Gazi Universitesi Tip Fakultesi, Ankara,
Turkey
| | | | - Nalan Akyurek
- pathology, Gazi Universitesi Tip Fakultesi, Ankara,
Turkey
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Rasch MNB, Szabados F, Jensen JMB, Nielsen KO, Hauge EM, Troldborg A. Patients with VEXAS diagnosed in a Danish tertiary rheumatology setting have highly elevated inflammatory markers, macrocytic anaemia and negative autoimmune biomarkers. RMD Open 2022; 8:e002492. [PMID: 38967099 PMCID: PMC9462080 DOI: 10.1136/rmdopen-2022-002492] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/23/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) is an autoinflammatory condition with overlapping features of rheumatology and haematology caused by somatic mutations in the UBA1 gene. Patients present with highly variable symptoms and their path towards diagnosis are often complicated and characterised by extensive examinations. It is, therefore, pivotal that clinicians become familiar with the clinical presentation of VEXAS to advance identification of patients with the disease. OBJECTIVES We aimed to (1) characterise patients diagnosed with VEXAS in a tertiary rheumatology referral centre, (2) identify common rheumatological biomarkers that may distinguish VEXAS from other rheumatic diseases and (3) suggest which clinical findings should motivate genetic testing for VEXAS. METHODS Patients were identified and diagnosed at the department of Rheumatology, Aarhus University Hospital (AUH), Denmark. Blood samples were examined for VEXAS-associated UBA1 variants by Sanger sequencing at the department of Clinical Immunology, AUH. Clinical and biochemical data were retrieved from the hospital electronic patient chart. RESULTS Eleven male patients with clinical suspicion of VEXAS underwent sequencing. Five of these carried known VEXAS-associated variants. Median age at diagnosis was 84 (75-87) years. All patients had significantly elevated inflammatory markers with a median C-reactive protein (CRP) of 297 (196-386) mg/L and macrocytic anaemia. None of the patients presented common biomarkers for autoimmunity. CONCLUSION Danish patients with VEXAS syndrome are men with persistent inflammation, constitutional symptoms and heterogeneous clinical presentations. Shared features for all patients in this study were highly elevated inflammatory markers, macrocytic anaemia and negative autoimmune biomarkers.
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Affiliation(s)
| | - Fruzsina Szabados
- Rheumatology, Sygehus Vendsyssel i Hjørring, Hjorring, Nordjylland, Denmark
| | - Jens Magnus Bernth Jensen
- Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
- Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ellen-Margrethe Hauge
- Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne Troldborg
- Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Biomedicine, Aarhus University, Aarhus, Denmark
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Wilke MVMB, Morava-Kozicz E, Koster MJ, Schmitz CT, Foster SK, Patnaik M, Warrington KJ, Klee EW, Pinto E Vairo F. Exome sequencing can misread high variant allele fraction of somatic variants in UBA1 as hemizygous in VEXAS syndrome: a case report. BMC Rheumatol 2022; 6:54. [PMID: 36038944 PMCID: PMC9426024 DOI: 10.1186/s41927-022-00281-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/09/2022] [Indexed: 11/11/2022] Open
Abstract
Background VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome) is a recently described syndrome caused by a somatic missense variant at the methionine-41 (p.(Met41)) position in the ubiquitin-like modifier activating enzyme 1 (UBA1) in Xp11.3. Germline pathogenic variants in UBA1 are associated with a distinct phenotype: a syndrome with severe neurologic features associated with loss of anterior horn cells and infantile death denominated X-Linked Spinal Muscular Atrophy 2 (SMAX2) (OMIM 301,830).
Case presentation We report a male individual with the phenotype of VEXAS syndrome that was initially identified through exome sequencing (ES) as having a hemizygous germline variant in UBA1 due to high variant allele frequency (VAF). Research Sanger sequencing was able to confirm the absence of the p.(Met41Val) variant in a skin biopsy and in gastric mucosa tissue sample confirming the variant happened as a postzygotic event.
Conclusions The present case exemplifies the diagnostic challenge that was imposed by the high VAF detected by ES that failed to correctly demonstrate that the variant was in a mosaic state. Sequencing of different tissues should be considered when there is conflict between the UBA1 variant status and the clinical findings. Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00281-z.
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Affiliation(s)
| | - Eva Morava-Kozicz
- Department of Clinical Genomics, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. .,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Matthew J Koster
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Christopher T Schmitz
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, 55905, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Shannon Kaye Foster
- Division of Dermatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Mrinal Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Eric W Klee
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, 55905, USA.,Department of Clinical Genomics, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Filippo Pinto E Vairo
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, 55905, USA.,Department of Clinical Genomics, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Paradigm shift in monogenic autoinflammatory diseases and systemic vasculitis: The VEXAS syndrome. Med Clin (Barc) 2022; 159:489-496. [PMID: 36049972 DOI: 10.1016/j.medcli.2022.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022]
Abstract
VEXAS syndrome was described by the end of 2020 as an autoinflammatory disease caused by post-zygotic variants in the UBA1 gene. VEXAS syndrome occurs in adult males with recurrent fever, arthralgia/arthritis, ear/nose chondritis, neutrophilic dermatosis, lung inflammation, venous thrombosis, and different types of vasculitis. Common laboratory changes include raised acute phase reactants and macrocytic anemia. The coexistence of myelodysplasia is frequent, and bone marrow vacuolization of myeloid and erythroid precursors is characteristic. Glucocorticoids are effective at medium-high doses, but the remaining immunosuppressive drugs, either conventional or biological, have showed limited or absent efficacy. Azacitidine has been associated with a good response, especially in patients with accompanying myelodysplastic syndrome. Allogeneic hematopoietic stem cell transplantation appears to be the only curative therapy by now. VEXAS syndrome has become a paradigm shift in the diagnosis and treatment of autoinflammatory diseases and systemic vasculitis.
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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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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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Wilson NR, Jain P, Gomez JA, Lu H, Pemmaraju N. Concurrent myelodysplasia and monoclonal B lymphocytosis in VEXAS syndrome. Leuk Res 2022; 120:106909. [PMID: 35820269 DOI: 10.1016/j.leukres.2022.106909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/18/2022] [Accepted: 06/25/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Preetesh Jain
- Department of Lymphoma and Myeloma, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jesus A Gomez
- Department of Hematology and Oncology, Texas Oncology, El Paso, TX, USA
| | - Huifang Lu
- Department of Rheumatology and Clinical Immunology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA.
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