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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 2024:1-13. [PMID: 38770970 DOI: 10.1080/10428194.2024.2349950] [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: 03/06/2024] [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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2
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Chien KS, Ong F, Kim K, Li Z, Kanagal‐Shamanna R, DiNardo CD, Takahashi K, Montalban‐Bravo G, Hammond D, Sasaki K, Pierce SA, Kantarjian HM, Garcia‐Manero G. Cancer patients with clonal hematopoiesis die from primary malignancy or comorbidities despite higher rates of transformation to myeloid neoplasms. Cancer Med 2024; 13:e7093. [PMID: 38497538 PMCID: PMC10945882 DOI: 10.1002/cam4.7093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/25/2024] [Accepted: 02/28/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND The occurrence of somatic mutations in patients with no evidence of hematological disorders is called clonal hematopoiesis (CH). CH, whose subtypes include CH of indeterminate potential and clonal cytopenia of undetermined significance, has been associated with both hematologic cancers and systemic comorbidities. However, CH's effect on patients, especially those with concomitant malignancies, is not fully understood. METHODS We performed a retrospective evaluation of all patients with CH at a tertiary cancer center. Patient characteristics, mutational data, and outcomes were collected and analyzed. RESULTS Of 78 individuals included, 59 (76%) had a history of cancer and 60 (77%) had moderate to severe comorbidity burdens. DNMT3A, TET2, TP53, and ASXL1 were the most common mutations. For the entire cohort, the 2-year overall survival rate was 79% (95% CI: 70, 90), while the median survival was not reached. Of 20 observed deaths, most were related to primary malignancies (n = 7, 35%), comorbidities (n = 4, 20%), or myeloid neoplasms (n = 4, 20%). Twelve patients (15%) experienced transformation to a myeloid neoplasm. According to the clonal hematopoiesis risk score, the 3-year transformation rate was 0% in low-risk, 15% in intermediate-risk (p = 0.098), and 28% in high-risk (p = 0.05) patients. By multivariate analysis, transformation was associated with variant allele frequency ≥0.2 and hemoglobin <10 g/dL. CONCLUSIONS In a population including mostly cancer patients, CH was associated with comorbidities and myeloid transformation in patients with higher mutational burdens and anemia. Nevertheless, such patients were less likely to die of their myeloid neoplasm than of primary malignancy or comorbidities.
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Affiliation(s)
- Kelly S. Chien
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Faustine Ong
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Kunhwa Kim
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ziyi Li
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Rashmi Kanagal‐Shamanna
- Department of HematopathologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Courtney D. DiNardo
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Koichi Takahashi
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Danielle Hammond
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Koji Sasaki
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sherry A. Pierce
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Hagop M. Kantarjian
- Department of LeukemiaThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Podvin B, Cleenewerck N, Nibourel O, Marceau-Renaut A, Roynard P, Preudhomme C, Duployez N, Terriou L. Three UBA1 clones for a unique VEXAS syndrome. Rheumatology (Oxford) 2024; 63:e48-e50. [PMID: 37698981 DOI: 10.1093/rheumatology/kead472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Affiliation(s)
- Benjamin Podvin
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | | | - Olivier Nibourel
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | - Alice Marceau-Renaut
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | | | - Claude Preudhomme
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | - Nicolas Duployez
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | - Louis Terriou
- CHU Lille, Internal Medicine and Immunology, Centre de Reference des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
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4
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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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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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Craven KE, Ewalt MD. Premalignant Clonal Hematopoiesis (Clonal Hematopoiesis of Indeterminate Potential and Clonal Cytopenia of Undetermined Significance). Clin Lab Med 2023; 43:565-576. [PMID: 37865503 DOI: 10.1016/j.cll.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Premalignant clonal hematopoiesis is the presence of somatic alterations in the blood of otherwise healthy individuals. Although the condition is not considered as a cancer, it carries an increased risk of developing a hematologic malignancy, particularly in those with large neoplastic clones, multiple pathogenic mutations, and high-risk mutations. In addition to the increased risk of malignancy, clonal hematopoiesis carries a markedly increased risk of cardiovascular events and death. Appropriate identification of this entity is critical to mitigate cardiovascular risk factors and ensure appropriate monitoring for the emergence of blood cancer.
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Affiliation(s)
- Kelly E Craven
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 36, New York, NY 10065, USA
| | - Mark D Ewalt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 36, New York, NY 10065, USA.
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7
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Nathan DI, Dougherty M, Bhatta M, Mascarenhas J, Marcellino BK. Clonal hematopoiesis and inflammation: A review of mechanisms and clinical implications. Crit Rev Oncol Hematol 2023; 192:104187. [PMID: 37879493 DOI: 10.1016/j.critrevonc.2023.104187] [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: 06/03/2023] [Revised: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
Clonal hematopoiesis (CH) is defined by the presence of somatic mutations in hematopoietic stem and progenitor cells (HSPC). CH is associated primarily with advancing age and confers an elevated risk of progression to overt hematologic malignancy and cardiovascular disease. Increasingly, CH is associated with a wide range of diseases driven by, and sequelae of, inflammation. Accordingly, there is great interest in better understanding the pathophysiologic and clinical relationship between CH, aging, and disease. Both observational and experimental findings support the concept that CH is a potential common denominator in the inflammatory outcomes of aging. However, there is also evidence that local and systemic inflammatory states promote the growth and select for CH clones. In this review, we aim to provide an up-to-date summary of the nature of the relationship between inflammation and CH, which is central to unlocking potential therapeutic opportunities to prevent progression to myeloid malignancy.
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Affiliation(s)
- Daniel I Nathan
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Max Dougherty
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Manasa Bhatta
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bridget K Marcellino
- Tisch Cancer Institute, Division of Hematology and Medical Oncology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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8
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Foucar K, Bagg A, Bueso-Ramos CE, George T, Hasserjian RP, Hsi ED, Orazi A, Tam W, Wang SA, Weinberg OK, Arber DA. Guide to the Diagnosis of Myeloid Neoplasms: A Bone Marrow Pathology Group Approach. Am J Clin Pathol 2023; 160:365-393. [PMID: 37391178 DOI: 10.1093/ajcp/aqad069] [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: 03/17/2023] [Accepted: 05/18/2023] [Indexed: 07/02/2023] Open
Abstract
OBJECTIVES The practicing pathologist is challenged by the ever-increasing diagnostic complexity of myeloid neoplasms. This guide is intended to provide a general roadmap from initial case detection, often triggered by complete blood count results with subsequent blood smear review, to final diagnosis. METHODS The integration of hematologic, morphologic, immunophenotypic, and genetic features into routine practice is standard of care. The requirement for molecular genetic testing has increased along with the complexity of test types, the utility of different testing modalities in identifying key gene mutations, and the sensitivity and turnaround time for various assays. RESULTS Classification systems for myeloid neoplasms have evolved to achieve the goal of providing a pathology diagnosis that enhances patient care, outcome prediction, and treatment options for individual patients and is formulated, endorsed, and adopted by hematologists/oncologists. CONCLUSIONS This guide provides diagnostic strategies for all myeloid neoplasm subtypes. Special considerations are provided for each category of testing and neoplasm category, along with classification information, genetic testing requirements, interpretation information, and case reporting recommendations based on the experience of 11 Bone Marrow Pathology Group members.
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Affiliation(s)
- Kathryn Foucar
- Department of Pathology, University of New Mexico, Albuquerque, NM, US
| | - Adam Bagg
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Carlos E Bueso-Ramos
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Tracy George
- Department of Pathology, University of Utah, Salt Lake City, UT, US
| | | | - Eric D Hsi
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, US
| | - Attilio Orazi
- Department of Pathology, Texas Tech University, El Paso, TX, US
| | - Wayne Tam
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine, Hofstra/Northwell, Greenvale, NY, US
| | - Sa A Wang
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, US
| | - Olga K Weinberg
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, US
| | - Daniel A Arber
- Department of Pathology, University of Chicago, Chicago, IL, US
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Vu KT, Wolfe RM, Lambird JE, Maracaja DLV. A case of VEXAS syndrome presenting with unusual bone marrow granulomas: a diagnostic dilemma. BMC Rheumatol 2023; 7:18. [PMID: 37430338 DOI: 10.1186/s41927-023-00343-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND VEXAS is a recently described inflammatory disease caused by mutations in the UBA1 gene. Symptoms are diverse and include fevers, cartilaginous inflammation, lung inflammation, vasculitis, neutrophilic dermatoses, and macrocytic anemia. Cytoplasmic inclusions in myeloid and erythroid progenitors in the bone marrow are a hallmark feature. Here we report the first case of VEXAS with non-caseating granulomas in the bone marrow. CASE PRESENTATION A 62-year-old Asian male presented with fevers, erythema nodosum, inflammatory arthritis, and periorbital inflammation. Labs were significant for persistently elevated inflammatory markers and macrocytic anemia. Over the years his symptoms and inflammatory markers only improved with glucocorticoids and recurred when prednisone dose was lowered below 15-20 mg daily. He underwent bone marrow biopsy showing non-caseating granulomas and PET scan showing hilar/mediastinal lymphadenopathy. He was initially diagnosed with IgG4-related disease (treated with rituximab) and later sarcoidosis (treated with infliximab). After failing these agents, the possibility of VEXAS was considered and later confirmed by molecular testing. CONCLUSIONS To the best of our knowledge, this is the first observation of non-caseating granulomas in VEXAS, a cautionary reminder of its non-specificity since misinterpretation can lead to diagnostic delay. VEXAS should be in the differential in patients with symptoms of chronic inflammation responding positively to steroids (but not to B-cell depletion or TNF inhibition), which is in line with previous literature.
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Affiliation(s)
- Khiem T Vu
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA.
| | - Rachel M Wolfe
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Jonathan E Lambird
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
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10
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Estes J, Malus M, Wilson L, Grayson PC, Maz M. A Case of VEXAS: Vacuoles, E1 Enzyme, X-linked, Autoinflammatory, Somatic Syndrome With Co-existing DNA (Cytosine-5)-Methyltransferase 3A Mutation Complicated by Localized Skin Reaction to Tocilizumab and Azacitidine. Cureus 2023; 15:e39906. [PMID: 37404435 PMCID: PMC10317045 DOI: 10.7759/cureus.39906] [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: 06/03/2023] [Indexed: 07/06/2023] Open
Abstract
Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a recently identified autoinflammatory condition with a correlating missense somatic mutation of the X chromosome. Here we present a unique case of a patient with VEXAS syndrome with coinciding ubiquitin-like modifier activating enzyme 1 (UBA1) and DNA (cytosine-5)-methyltransferase 3A (DNMT3A) mutations who developed cutaneous and systemic reactions to tocilizumab and azacitidine therapy, respectively.
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Affiliation(s)
- Jordan Estes
- Department of Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Matthew Malus
- Department of Medicine, Division of Allergy, Clinical Immunology, and Rheumatology, University of Kansas Medical Center, Kansas City, USA
| | - Lorena Wilson
- National Human Genome Research Institute, National Institutes of Health, Bethesda, USA
| | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA
| | - Mehrdad Maz
- Department of Medicine, Division of Allergy, Clinical Immunology, and Rheumatology, University of Kansas Medical Center, Kansas City, USA
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11
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Mendez LM, Patnaik MM. Clonal Hematopoiesis: Origins and determinants of evolution. Leuk Res 2023; 129:107076. [PMID: 37075557 DOI: 10.1016/j.leukres.2023.107076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 04/21/2023]
Abstract
The accrual of somatic mutations is a byproduct of aging. When a clone bearing a somatic genetic alteration, conferring comparative competitive advantage, displays sufficient outgrowth to become detectable amongst an otherwise polyclonal background in the hematopoietic system, this is called clonal hematopoiesis (CH). Somatic genetic alterations observed in CH include point mutations in cancer related genes, mosaic chromosomal alterations or a combination of these. Interestingly, clonal hematopoiesis (CH) can also occur with somatic variants in genes without a known role in cancer and in the absence of a somatic genetic alteration through a process that has been described as 'genetic drift'. Clonal hematopoiesis of indeterminate significance (CHIP), is age-related and defined by the presence of somatic point mutations in cancer related genes, in the absence of cytopenias or a diagnosis of hematologic neoplasm, with a variant allele fraction ≥ 2 %. Remarkably, the increased mortality associated with CHIP is largely due to cardiovascular disease. Subsequently, CHIP has been associated with a myriad of age-related conditions such as Alzheimer's Disease, osteoporosis, CVA and COPD. CHIP is associated with an increased risk of hematologic malignancies, particularly myeloid neoplasms, with the risk rising with increasing clone size and clonal complexity. Mechanisms regulating clonal evolution and progression to hematologic malignancies remain to be defined. However, observations on context specific CH arising in the setting of bone marrow failure states, or on exposure to chemotherapy and radiation therapy, suggest that CH reflects context specific selection pressures and constraint-escape mechanisms.
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Affiliation(s)
- Lourdes M Mendez
- Section of Hematology, Department of Internal Medicine, Yale Cancer Center and Smilow Cancer Hospital, Yale University School of Medicine, CT, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, MN, USA.
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12
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Bruno A, Gurnari C, Alexander T, Snowden JA, Greco R. Autoimmune manifestations in VEXAS: Opportunities for integration and pitfalls to interpretation. J Allergy Clin Immunol 2023; 151:1204-1214. [PMID: 36948992 DOI: 10.1016/j.jaci.2023.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/24/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a novel entity manifesting with a multiplicity of clinical features. Somatic mutations of the UBA1 gene in hematopoietic stem cells constitute the genetic basis of VEXAS. As an X-linked disorder, most cases occur in men, classically developing symptoms during the fifth to sixth decade of life. Considering its multidisciplinary nature involving numerous branches of internal medicine, VEXAS has elicited a wide medical interest and several medical conditions have been associated with this disease. Even so, its recognition in everyday clinical practice is not necessarily straightforward. Close collaboration between different medical specialists is mandatory. Patients with VEXAS may manifest a range of features from manageable cytopenias to disabling and life-threatening autoimmune phenomena with limited responses to therapy, with the potential for progression to hematological malignancies. Diagnostic and treatment guidelines are exploratory and include a range of rheumatological and supportive care treatments. Allogeneic hematopoietic stem cell transplantation is potentially curative, but its risks are significant and its position in the treatment algorithm is yet to be defined. Herein, we present the variegated manifestations of VEXAS, provide practice criteria for diagnostic testing of UBA1, and discuss potential treatment options, including allogeneic hematopoietic stem cell transplantation, current evidence, and future directions.
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Affiliation(s)
- Alessandro Bruno
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - John A Snowden
- Sheffield Blood & Marrow Transplant and Cellular Therapy Programme, Department of Haematology, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
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Gurnari C, Visconte V. From bone marrow failure syndromes to VEXAS: Disentangling clonal hematopoiesis, immune system, and molecular drivers. Leuk Res 2023; 127:107038. [PMID: 36841022 DOI: 10.1016/j.leukres.2023.107038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
Clonal hematopoiesis (CH) is a result of the selective expansion of hematopoietic stem and progenitor cells (HSPCs) carrying somatic mutations originating from a primary HSC. The advent of modern genomic technologies has helped recognizing that CH is common in elderly healthy subjects as a result of the aging bone marrow (BM). CH in healthy subjects without abnormalities in blood counts is known as CH of indeterminate potential. CH is also seen in BM failure (BMF) disorders. Whether CH alarms for the risk to develop malignant evolution in BMF or creates an adaptation to selective pressure is a matter of controversy. As such, a continuum might exist from pre-malignant to malignant hematopoietic diseases. This review summarizes how somatic mutations and immune derangement in HSCs shape disease evolution and describes the complexity of disorders such as VEXAS as the prototypic tetrad of somatic mutations, morphologic features, inflammatory pathways and immune overshooting. In such a view, we interconnect the axis aging and immune-hematopoietic system, which all convey important clues for the risk to develop malignancies.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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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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Gurnari C, McLornan DP. Update on VEXAS and role of allogeneic bone marrow transplant: Considerations on behalf of the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2022; 57:1642-1648. [PMID: 35941354 DOI: 10.1038/s41409-022-01774-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/09/2022]
Abstract
VEXAS (acronym for Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a fascinating new entity encompassing a variety of clinical manifestations, spanning from auto-inflammatory symptoms to hematologic disorders, including myelodysplastic syndromes and plasma cell dyscrasias. Genetically defined by somatic mutations of the X-linked gene UBA1 in hematopoietic stem and progenitor cells, VEXAS typically manifests in males during the fifth/sixth decade of life. Since its discovery, several groups have documented pleomorphic clinical phenotypes, in addition to a plethora of therapeutic options (e.g., JAK inhibitors, hypomethylating agents, and allogeneic stem cell transplant, allo-HCT) in retrospective case series. However, no treatment guidelines have been validated to date, VEXAS patients are typically steroid-dependent and may manifest life-threatening inflammatory symptoms refractory to multiple lines of therapy. To date, the only curative option appears to be allo-HCT in suitable individuals. Nonetheless, this procedure carries an inherent risk of morbidity and mortality that must be judiciously evaluated against a phenotypically diverse disorder where the optimal therapeutic algorithm remains ill-defined. Herein, we provide an overview of the current VEXAS data/ therapeutic evidence and discuss the curative potential of allo-HCT whilst highlighting the efforts required for generation of robust data able to inform therapeutic decisions.
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Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, USA.,Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Donal P McLornan
- Department of Stem Cell Transplantation and Haematology, University College London Hospitals, London, UK.
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Alcedo PE, Gutierrez-Rodrigues F, Patel BA. Somatic mutations in VEXAS Syndrome and Erdheim-Chester Disease: Inflammatory Myeloid Diseases. Semin Hematol 2022; 59:156-166. [DOI: 10.1053/j.seminhematol.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 12/27/2022]
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Molecular Pathways in Clonal Hematopoiesis: From the Acquisition of Somatic Mutations to Transformation into Hematologic Neoplasm. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081135. [PMID: 36013314 PMCID: PMC9410004 DOI: 10.3390/life12081135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022]
Abstract
Hematopoietic stem cell aging, through the acquisition of somatic mutations, gives rise to clonal hematopoiesis (CH). While a high prevalence of CH has been described in otherwise healthy older adults, CH confers an increased risk of both hematologic and non-hematologic diseases. Classification of CH into clonal hematopoiesis of indeterminate potential (CHIP) and clonal cytopenia of undetermined significance (CCUS) further describes this neoplastic myeloid precursor state and stratifies individuals at risk of developing clinically significant complications. The sequential acquisition of driver mutations, such as DNMT3A, TET2, and ASXL1, provide a selective advantage and lead to clonal expansion. Inflammation, microbiome signatures, and external selective pressures also contribute to clonal evolution. Despite significant progress in recent years, the precise molecular mechanisms driving CH transformation to hematologic neoplasms are not well defined. Further understanding of these complex mechanisms may improve risk stratification and introduce therapeutic interventions in CH. Here we discuss the genetic drivers underpinning CH, mechanisms for clonal evolution, and transformation to hematologic neoplasm.
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A Synopsis Clonal Hematopoiesis of Indeterminate Potential in Hematology. Cancers (Basel) 2022; 14:cancers14153663. [PMID: 35954328 PMCID: PMC9367563 DOI: 10.3390/cancers14153663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Abstract
Simple Summary Mutations are not the norm, yet they exist. Having some mutations can infer information about a precancerous state. Clonal hematopoiesis of indeterminate potential is a condition of recurrent somatic mutations in the blood of otherwise healthy adults. In this review, we unravel the role of these mutations in multiple myeloma. Abstract Clonal hematopoiesis of indeterminate potential can be defined as genetic mutations that correlate in hematologic neoplasia such as myelodysplastic syndrome. Patients with cytopenia increasingly undergo molecular genetic tests of peripheral blood or bone marrow for diagnostic purposes. Recently, a new entity has been demarcated to lessen the risk of incorrect diagnoses of hematologic malignancies. This new entity is a potential precursor of myeloid diseases, analogous to monoclonal gammopathy of undetermined significance as a potential precursor of multiple myeloma.
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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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Kao RL, Jacobsen AA, Billington CJ, Yohe SL, Beckman AK, Vercellotti GM, Pearson DR. A case of VEXAS syndrome associated with EBV-associated hemophagocytic lymphohistiocytosis. Blood Cells Mol Dis 2021; 93:102636. [PMID: 34864445 DOI: 10.1016/j.bcmd.2021.102636] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/24/2021] [Indexed: 01/07/2023]
Abstract
Vacuoles, E1, X-linked, autoimmunity, somatic (VEXAS) syndrome is characterized by a pathogenic mutation in UBA1, which leads to protean complications including autoimmunity and myelodysplasia. A 56-year-old man with steroid-dependent, later steroid-refractory cutaneous polyarteritis nodosa and Sweet syndrome developed recurrent daily fever, macrocytic anemia, thrombocytopenia, acute hypoxic respiratory failure, and anasarca. He was eventually diagnosed with Epstein-Barr virus (EBV) viremia and hemophagocytic lymphohistiocytosis (HLH). He improved clinically with rituximab, ruxolitinib, and increased glucocorticoids before expiring from Pseudomonas sepsis. UBA1 exon 3 mutational analysis in myeloid enriched peripheral blood revealed a c.122T>C (p.Met41Thr) pathogenic variant, consistent with VEXAS syndrome. We describe the first case of EBV-associated HLH in a patient diagnosed with VEXAS syndrome. Early identification of this syndrome will be important in order to offer potential therapies before life-threatening complications arise.
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Affiliation(s)
- Roy L Kao
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Audrey A Jacobsen
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Department of Dermatology, University of Minnesota, Minneapolis, MN, USA
| | - Charles J Billington
- Department of Pediatrics, Division of Genetics and Metabolism, University of Minnesota, Minneapolis, MN, USA
| | - Sophia L Yohe
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Amy K Beckman
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Gregory M Vercellotti
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - David R Pearson
- Department of Dermatology, University of Minnesota, Minneapolis, MN, USA.
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