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Phan L, Hammond D, Wilson NR, Groarke EM, Patnaik MM, Pemmaraju N. VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic): clinical review in a rapidly emerging field. Leuk Lymphoma 2024; 65:1245-1257. [PMID: 38770970 DOI: 10.1080/10428194.2024.2349950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
VEXAS syndrome is a recently described entity characterized by systemic inflammatory and hematologic manifestations. The disease was first characterized by Beck et al. in 2020 in a study characterizing 25 patients with undiagnosed adult-onset inflammatory syndromes. While the literature regarding VEXAS syndrome has grown exponentially since 2020, there is still much to be understood. This lack of information leads to challenges in both the diagnosis and treatment of patients with VEXAS syndrome. Patients will often have a variety of clinical symptoms that can lead to missed or delayed diagnoses. Additionally, awareness of VEXAS syndrome is still developing among clinicians. In this comprehensive review, we summarize the current literature regarding VEXAS syndrome, and explore clinical updates of this emerging disease state. Our aim of this review is to increase awareness regarding this new disease state and identify research areas to better understand future treatment approaches for patients with VEXAS syndrome.
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Affiliation(s)
- Luan Phan
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mrinal M Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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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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Sockel K, Götze K, Ganster C, Bill M, Georgi JA, Balaian E, Aringer M, Trautmann-Grill K, Uhlig M, Bornhäuser M, Haase D, Thiede C. VEXAS syndrome: complete molecular remission after hypomethylating therapy. Ann Hematol 2024; 103:993-997. [PMID: 38214707 PMCID: PMC10866742 DOI: 10.1007/s00277-023-05611-w] [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: 12/10/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
The VEXAS syndrome, a genetically defined autoimmune disease, associated with various hematological neoplasms has been attracting growing attention since its initial description in 2020. While various therapeutic strategies have been explored in case studies, the optimal treatment strategy is still under investigation and allogeneic cell transplantation is considered the only curative treatment. Here, we describe 2 patients who achieved complete molecular remission of the underlying UBA1 mutant clone outside the context of allogeneic HCT. Both patients received treatment with the hypomethylating agent azacitidine, and deep molecular remission triggered treatment de-escalation and even cessation with sustained molecular remission in one of them. Prospective studies are necessary to clarify which VEXAS patients will benefit most from hypomethylating therapy and to understand the variability in the response to different treatment strategies.
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Affiliation(s)
- Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany.
- German Cancer Consortium (DKTK), CHOICE Consortium, Partner Sites, MunichDresden, Germany.
| | - Katharina Götze
- German Cancer Consortium (DKTK), CHOICE Consortium, Partner Sites, MunichDresden, Germany
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christina Ganster
- Clinics of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Marius Bill
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Julia-Annabell Georgi
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Ekaterina Balaian
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | | | - Maria Uhlig
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Martin Bornhäuser
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), CHOICE Consortium, Partner Sites, MunichDresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Detlef Haase
- Clinics of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Christian Thiede
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
- AgenDix GmbH, Dresden, Germany
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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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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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