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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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Abumanhal M, Leibovitch I, Zisapel M, Eviatar T, Edel Y, Ben Cnaan R. Ocular and orbital manifestations in VEXAS syndrome. Eye (Lond) 2024; 38:1748-1754. [PMID: 38548942 PMCID: PMC11156927 DOI: 10.1038/s41433-024-03014-3] [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: 08/25/2023] [Revised: 01/10/2024] [Accepted: 02/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a hematoinflammatory disease that typically affects adults. It results from a somatic mutation of the E1 ubiquitin conjugating enzyme encoded by the UBA1 gene. VEXAS is frequently accompanied by myelodysplastic syndrome (MDS). The purpose of this study is to describe the ocular and orbital manifestations of VEXAS patients in a case series in our medical centre. METHODS A retrospective chart review was performed for all patients who were diagnosed with VEXAS syndrome in a tertiary medical centre over two years. RESULTS Eight patients were identified with VEXAS. In six patients, the diagnosis was confirmed by genomic sequencing. Two patients were identified based on their phenotype. All patients were males. The mean age at diagnosis was 78.7 years. In two patients, the ocular manifestation was the presenting symptom for VEXAS. Seven patients (87.5%) had history of MDS. Systemic inflammation manifestations include: skin rash (n = 5), recurrent fevers (n = 2), relapsing polychondritis (n = 2), pleuritis and pleural effusion (n = 2), poly arteritis nodosa- PAN (n = 1) and thrombophlebitis (n = 1). Seven (87%) patients were presented with periorbital oedema. Three patients showed orbital inflammation. Dacryoadenitis was observed in two patients, and extraocular muscle (EOM) myositis was detected in two patients. Four patients demonstrated ocular inflammation such as: episcleritis, scleritis and anterior uveitis. CONCLUSION ocular manifestations in VEXAS include orbital inflammation, dacryoadenitis, myositis, uveitis, scleritis, episcleritis and periorbital oedema. We recommend that in old male patients, with history of haematological disorder, presenting with ocular symptom, VEXAS investigation should be taken into consideration.
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Affiliation(s)
- Muhammad Abumanhal
- Oculoplastic, Orbital and Lacrimal Institute, Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Igal Leibovitch
- Oculoplastic, Orbital and Lacrimal Institute, Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Zisapel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Department, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Tali Eviatar
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Department, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yonatan Edel
- Department of Internal Medicine 'B', Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Health Science, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran Ben Cnaan
- Oculoplastic, Orbital and Lacrimal Institute, Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Adachi S, Kirino Y, Higashitani K, Hirahara L, Maeda A, Horita N, Takase-Minegishi K, Yoshimi R, Nakajima H. Targeting enhanced cell death represents a potential therapeutic strategy for VEXAS syndrome. Rheumatol Adv Pract 2024; 8:rkae065. [PMID: 38854419 PMCID: PMC11157137 DOI: 10.1093/rap/rkae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/08/2024] [Indexed: 06/11/2024] Open
Abstract
Objectives To unravel the mechanisms underlying cell death in the vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome using peripheral blood samples and to assess the clinical value of this knowledge. Methods Nine patients undergoing treatment for VEXAS syndrome at Yokohama City University Hospital were included in this study. Monocytes and neutrophils were isolated from peripheral blood and then monocytes were differentiated into polarized macrophages. Viable cell counts, cell death assays and measurements of various indicators such as high mobility group box 1 (HMGB1) concentration, extracellular adenosine triphosphate (ATP) concentration, annexin V level and caspase 1, 3 and 7 activities were performed. Results Elevated cell death of monocytes and neutrophils was observed in VEXAS syndrome patients, as indicated by cultured cell counts and cell death assays. Annexin V assays and measurements of caspase 1, 3 and 7 activities suggested increased apoptosis and pyroptosis in these cells. Serum HMGB1 levels were significantly elevated in VEXAS syndrome patients and decreased after prednisolone (PSL) dose escalation. Monocytes and neutrophils from the VEXAS group exhibited heightened extracellular ATP secretion, which was significantly reduced by soluble PSL co-culture. Conclusion This study confirms increased cell death of monocytes and neutrophils and damage-associated molecular patterns in VEXAS syndrome, and these findings may be valuable for drug screening, therapeutic strategies and as biomarkers.
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Affiliation(s)
- Soichiro Adachi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kana Higashitani
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Lisa Hirahara
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ayaka Maeda
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Hospital, Yokohama, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Clinical Laboratory Department, Yokohama City University Hospital, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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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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Cardoneanu A, Rezus II, Burlui AM, Richter P, Bratoiu I, Mihai IR, Macovei LA, Rezus E. Autoimmunity and Autoinflammation: Relapsing Polychondritis and VEXAS Syndrome Challenge. Int J Mol Sci 2024; 25:2261. [PMID: 38396936 PMCID: PMC10889424 DOI: 10.3390/ijms25042261] [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: 01/15/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Relapsing polychondritis is a chronic autoimmune inflammatory condition characterized by recurrent episodes of inflammation at the level of cartilaginous structures and tissues rich in proteoglycans. The pathogenesis of the disease is complex and still incompletely elucidated. The data support the important role of a particular genetic predisposition, with HLA-DR4 being considered an allele that confers a major risk of disease occurrence. Environmental factors, mechanical, chemical or infectious, act as triggers in the development of clinical manifestations, causing the degradation of proteins and the release of cryptic cartilage antigens. Both humoral and cellular immunity play essential roles in the occurrence and perpetuation of autoimmunity and inflammation. Autoantibodies anti-type II, IX and XI collagens, anti-matrilin-1 and anti-COMPs (cartilage oligomeric matrix proteins) have been highlighted in increased titers, being correlated with disease activity and considered prognostic factors. Innate immunity cells, neutrophils, monocytes, macrophages, natural killer lymphocytes and eosinophils have been found in the perichondrium and cartilage, together with activated antigen-presenting cells, C3 deposits and immunoglobulins. Also, T cells play a decisive role in the pathogenesis of the disease, with relapsing polychondritis being considered a TH1-mediated condition. Thus, increased secretions of interferon γ, interleukin (IL)-12 and IL-2 have been highlighted. The "inflammatory storm" formed by a complex network of pro-inflammatory cytokines and chemokines actively modulates the recruitment and infiltration of various cells, with cartilage being a source of antigens. Along with RP, VEXAS syndrome, another systemic autoimmune disease with genetic determinism, has an etiopathogenesis that is still incompletely known, and it involves the activation of the innate immune system through different pathways and the appearance of the cytokine storm. The clinical manifestations of VEXAS syndrome include an inflammatory phenotype often similar to that of RP, which raises diagnostic problems. The management of RP and VEXAS syndrome includes common immunosuppressive therapies whose main goal is to control systemic inflammatory manifestations. The objective of this paper is to detail the main etiopathogenetic mechanisms of a rare disease, summarizing the latest data and presenting the distinct features of these mechanisms.
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Affiliation(s)
- Anca Cardoneanu
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Irina Rezus
- Discipline of Radiology, Surgery Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania;
| | - Alexandra Maria Burlui
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Patricia Richter
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Bratoiu
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Ioana Ruxandra Mihai
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Luana Andreea Macovei
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Elena Rezus
- Discipline of Rheumatology, Medical Department II, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (A.C.); (A.M.B.); (P.R.); (I.B.); (I.R.M.); (L.A.M.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania
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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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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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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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Ding Y, Dulau-Florea AE, Groarke EM, Patel BA, Beck DB, Grayson PC, Ferrada MA, Young NS, Calvo KR, Braylan RC. Use of flow cytometric light scattering to recognize the characteristic vacuolated marrow cells in VEXAS syndrome. Blood Adv 2023; 7:6151-6155. [PMID: 37477595 PMCID: PMC10582370 DOI: 10.1182/bloodadvances.2023010456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023] Open
Affiliation(s)
- Yanna Ding
- Laboratory of Pathology, Hematopathology Section, Center for Cancer Research, National Cancer Institute, Bethesda, MD
- Department of Laboratory Medicine, Hematology Section, Clinical Center, Bethesda, MD
| | - Alina E. Dulau-Florea
- Department of Laboratory Medicine, Hematology Section, Clinical Center, Bethesda, MD
| | - Emma M. Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bhavisha A. Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - David B. Beck
- Center for Human Genetics and Genomics, New York University Grossman School of Medicine, New York, NY
| | - Peter C. Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health, Bethesda, MD
| | - Marcela A. Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Disease, National Institutes of Health, Bethesda, MD
| | - Neal S. Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Katherine R. Calvo
- Department of Laboratory Medicine, Hematology Section, Clinical Center, Bethesda, MD
| | - Raul C. Braylan
- Department of Laboratory Medicine, Hematology Section, Clinical Center, Bethesda, MD
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10
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Pan FY, Fan HZ, Zhuang SH, Pan LF, Ye XH, Tong HJ. Severe inflammatory disorder in trisomy 8 without myelodysplastic syndrome and response to methylprednisolone: A case report. World J Clin Cases 2023; 11:6206-6212. [PMID: 37731580 PMCID: PMC10507565 DOI: 10.12998/wjcc.v11.i26.6206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Patients with trisomy 8 consistently present with myeloid neoplasms and/or auto-inflammatory syndrome. A possible link between myelodysplastic syndromes (MDS) with trisomy 8 (+8-MDS) and inflammatory disorders is well recognized, several cases having been reported. However, inflammatory disorders in patients without MDS have been largely overlooked. Generally, Behçet's disease is the most common type in +8-MDS. However, inflammatory disorders with pulmonary involvement are less frequent, and no effective treatment has been established. CASE SUMMARY A 27-year-old man with recurrent fever, fatigue for > 2 mo, and unconsciousness for 1 day was admitted to our emergency department with a provisional diagnosis of severe pneumonia. Vancomycin and imipenem were administered and sputum collected for metagenomic next-generation sequencing. Epstein-Barr virus and Mycobacterium kansasii were detected. Additionally, chromosomal analysis showed duplications on chromosome 8. Two days later, repeat metagenomic next-generation sequencing was performed with blood culture. Cordyceps portugal, M. kansasii, and Candida portugal were detected, and duplications on chromosome 8 confirmed. Suspecting hematological disease, we aspirated a bone marrow sample from the iliac spine, examination of which showed evidence of infection. We added fluconazole as further antibiotic therapy. Seven days later, the patient's condition had not improved, prompting addition of methylprednisolone as an anti-inflammatory agent. Fortunately, this treatment was effective and the patient eventually recovered. CONCLUSION Severe inflammatory disorders with pulmonary involvement can occur in patients with trisomy 8. Methylprednisolone may be an effective treatment.
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Affiliation(s)
- Fei-Yan Pan
- Intensive Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Hao-Zhe Fan
- Intensive Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Shun-Hong Zhuang
- Department of Clinical Laboratory, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Li-Fei Pan
- Intensive Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Xiang-Hong Ye
- Administration Division, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Hong-Jie Tong
- Intensive Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
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11
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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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12
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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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13
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Zhang X, Yang X, Ma L, Zhang Y, Wei J. Immune dysregulation and potential targeted therapy in myelodysplastic syndrome. Ther Adv Hematol 2023; 14:20406207231183330. [PMID: 37547364 PMCID: PMC10399277 DOI: 10.1177/20406207231183330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 06/02/2023] [Indexed: 08/08/2023] Open
Abstract
Myelodysplastic syndrome (MDS) is a heterogeneous group of clonal hematological diseases and a high risk for transformation to acute myeloid leukemia (AML). The identification of key genetic alterations in MDS has enhanced our understanding of the pathogenesis and evolution. In recent years, it has been found that both innate and adaptive immune signaling are activated in the hematopoietic niche of MDS with aberrant cytokine secretion in the bone marrow microenvironment. It is also clear that immune dysregulation plays an important role in the occurrence and progression of MDS, especially the destruction of the bone marrow microenvironment, including hematopoiesis and stromal components. The purpose of this review is to explore the role of immune cells, the immune microenvironment, and cytokines in the pathogenesis of MDS. Insights into the mechanisms of these variants may facilitate the development of novel effective treatments to prevent disease progression.
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Affiliation(s)
- Xiaoying Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xingcheng Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ling Ma
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei 430030, China
- Key Laboratory of Organ Transplantation, Ministry of Education
- National Health Commission (NHC)
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei 430030, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, Hubei 430030, China
- Key Laboratory of Organ Transplantation, Ministry of Education
- National Health Commission (NHC)
- Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, Hubei 430030, China
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, and Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi 030032, China
- Sino-German Joint Oncological Research Laboratory, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Taiyuan, Shanxi 030032, China
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14
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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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15
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Kataoka A, Mizumoto C, Kanda J, Iwasaki M, Sakurada M, Oka T, Fujimoto M, Yamamoto Y, Yamashita K, Nannya Y, Ogawa S, Takaori-Kondo A. Successful azacitidine therapy for myelodysplastic syndrome associated with VEXAS syndrome. Int J Hematol 2023; 117:919-924. [PMID: 36641501 DOI: 10.1007/s12185-023-03532-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is caused by UBA1 somatic mutations and is characterized by late-onset systemic autoimmune inflammation and blood abnormalities such as cytopenia, vacuolation of myeloid/erythroblastic cells, and myelodysplastic syndrome (MDS). It is often resistant to immunosuppressive therapy, and no treatment strategy has been established. A 65-year-old man presented with palpable erythema, fever, macrocytic anemia, and arthralgia. He was subsequently diagnosed with MDS complicated by Sweet's disease. Treatment with azacitidine was initiated due to suspected skin invasion by MDS cells and resistance of the skin rash to steroid therapy. Next-generation sequencing of bone marrow samples prior to treatment initiation revealed the presence of UBA1 p.M41L (VAF 0.38) and DNMT3A p.L605fs mutations (VAF 0.184). Based on the findings of systemic inflammation, a diagnosis of VEXAS syndrome was made. The fever and skin rash improved with azacitidine therapy. In conclusion, somatic mutations in UBA1 should be explored in patients with MDS exhibiting systemic autoimmune inflammation. Furthermore, azacitidine may be a good treatment option for systemic autoinflammation in MDS associated with VEXAS syndrome.
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Affiliation(s)
- Asami Kataoka
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Makoto Iwasaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Maki Sakurada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tomomi Oka
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kohei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yasuhito Nannya
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Division of Hematopoietic Disease Control, Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Seishi Ogawa
- Department of Pathology and Tumor Biology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
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16
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Kobak S. What the genes tell us in the VEXAS syndrome? A rheumatologist's perspective. Int J Rheum Dis 2023; 26:827-830. [PMID: 37126393 DOI: 10.1111/1756-185x.14646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Senol Kobak
- Department of Internal Medicine and Rheumatology, Istinye University Faculty of Medicine, Liv Hospital, Istanbul, Turkey
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17
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Borie R, Debray MP, Guedon AF, Mekinian A, Terriou L, Lacombe V, Lazaro E, Meyer A, Mathian A, Ardois S, Vial G, Moulinet T, Terrier B, Jamilloux Y, Heiblig M, Bouaziz JD, Zakine E, Outh R, Groslerons S, Bigot A, Flamarion E, Kostine M, Henneton P, Humbert S, Constantin A, Samson M, Bertrand NM, Biscay P, Dieval C, Lobbes H, Jeannel J, Servettaz A, Adelaide L, Graveleau J, de Sainte-Marie B, Galland J, Guillotin V, Duroyon E, Templé M, Bourguiba R, Georgin Lavialle S, Kosmider O, Audemard-Verger A, Pha M, Hie M, Meghit K, Rondeau-Lutz M, Weber JC. Pleuropulmonary Manifestations of Vacuoles, E1 Enzyme, X-Linked, Autoinflammatory, Somatic (VEXAS) Syndrome. Chest 2023; 163:575-585. [PMID: 36272567 DOI: 10.1016/j.chest.2022.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a newly identified autoinflammatory disorder related to somatic UBA1 mutations. Up to 72% of patients may show lung involvement. RESEARCH QUESTION What are the pleuropulmonary manifestations in VEXAS syndrome? STUDY DESIGN AND METHODS One hundred fourteen patients were included in the French cohort of VEXAS syndrome between November 2020 and May 2021. Each patient included in the study who had an available chest CT scan was discussed in an adjudication multidisciplinary team and classified as showing potentially pleuropulmonary-specific involvement of VEXAS syndrome or others. RESULTS Fifty-one patients had a CT scan available for review and 45 patients (39%) showed pleuropulmonary abnormalities on chest CT scan that were considered related to VEXAS syndrome after adjudication. Most patients were men (95%) with a median age 67.0 years at the onset of symptoms. Among these 45 patients, 44% reported dyspnea and 40% reported cough. All 45 patients showed lung opacities on chest CT scan (including ground-glass opacities [87%], consolidations [49%], reticulation [38%], and septal lines [51%]) and 53% of patients showed pleural effusion. Most patients showed improvement with prednisone, but usually required > 20 mg/d. The main clinical and biological features as well the median survival did not differ between the 45 patients with pleuropulmonary involvement and the rest of the cohort, suggesting that the prevalence of pleuropulmonary involvement might have been underdiagnosed in the rest of the cohort. INTERPRETATION Pulmonary manifestations are frequent in VEXAS syndrome, but rarely are at the forefront. The initial outcome is favorable with prednisone and does not seem to lead to pulmonary fibrosis.
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Affiliation(s)
- Raphael Borie
- Service de Pneumologie A, Hôpital Bichat, APHP, Paris, France; INSERM, Unité 1152, Université de Paris, Paris, France.
| | - Marie Pierre Debray
- Service de Radiologie, Hôpital Bichat, APHP, Paris, France; INSERM, Unité 1152, Université de Paris, Paris, France
| | - Alexis F Guedon
- Service de Médecine Interne, Hôpital St. Antoine, APHP, Paris, France
| | - Arsene Mekinian
- Service de Médecine Interne, Hôpital St. Antoine, APHP, Paris, France
| | | | - Valentin Lacombe
- Service de Médecine Interne et Immunologie Clinique, CHU d'Angers, Angers, France
| | - Estibaliz Lazaro
- Médecine Interne et Maladies Infectieuses, Hôpital Haut l'Evêque, CHU de Bordeaux, Pessac, France
| | - Aurore Meyer
- Service d'Immunologie Clinique et Médecine Interne, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France
| | - Alexis Mathian
- Service de Médicine Interne 2, Hôpital de la Pitié Salpêtrière, APHP, Paris, France
| | - Samuel Ardois
- Service de Médecine Interne et Immunologie Clinique, Hôpital Pontchaillou, Renne, France
| | - Guillaume Vial
- Médecine Interne et Immunologie Clinique, Hôpital Saint André, CHU Bordeaux, Bordeaux, France
| | - Thomas Moulinet
- Département de Médecine Interne et Immunologie Clinique, CHU Nancy, UMR 7365, IMoPA, University of Lorraine, CNRS, Nancy, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, APHP, Paris, France
| | - Yvan Jamilloux
- Service de Médecine Interne, Hôpital de la Croix Rousse, Hématologie, Centre Hospitalier de Lyon Sud, Pierre Bénite, Lyon, France
| | - Mael Heiblig
- Service de Médecine Interne, Hôpital de la Croix Rousse, Hématologie, Centre Hospitalier de Lyon Sud, Pierre Bénite, Lyon, France
| | | | - Eve Zakine
- Service de Dermatologie, Hopital St. Louis, APHP, Paris, France
| | - Roderau Outh
- Service de Médecine Interne, CHG Perpignan, Perpignan, France
| | | | - Adrien Bigot
- Service de Médecine Interne et Immunologie Clinique, CHU Bretonneau, Tours, France
| | - Edouard Flamarion
- Service de Médecine Interne, Hôpital Européen Georges Pompidou, APHP-Centre, Université de Paris Cité, Paris, France
| | - Marie Kostine
- Service de Rhumatologie, CHU Bordeaux, Bordeaux, France
| | - Pierrick Henneton
- Service de Médecine Vasculaire, CHU de Montpellier, Montpellier, France
| | | | - Arnaud Constantin
- Department of Rheumatology, Pierre-Paul Riquet University Hospital, and Toulouse III-Paul Sabatier University, Toulouse, France
| | - Maxime Samson
- Service de Médecine Interne et Immunologie Clinique, CHU de Dijon, Dijon, France
| | | | - Pascal Biscay
- Clinique Mutualiste Pessac Médecine Interne, Pessac, France
| | - Celine Dieval
- Service de Médecine Interne, CHU Rochefort, Rochefort, France
| | - Herve Lobbes
- Service de Médecine Interne, CHU de Clermont-Ferrand, Hôpital Estaing, Clermont-Ferrand, France
| | - Juliette Jeannel
- Service de Médecine Interne, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France
| | - Amelie Servettaz
- Service de Médecine Interne, Maladies Infectieuses, Immunologie Clinique, CHU de Reims, Reims, France
| | - Leo Adelaide
- Service de Médecine Interne, CHU Lucien Hussel, Vienne, France
| | - Julie Graveleau
- Service de Médecine Interne, CHU Saint-Nazaire, Saint-Nazaire, France
| | | | - Joris Galland
- Service de Médecine Interne, Centre Hospitalier de Bourg-en-Bresse, Bourg-en-Bresse, France
| | - Vivien Guillotin
- Médecine Interne et Maladies Infectieuses, Hôpital Haut l'Evêque, CHU de Bordeaux, Pessac, France
| | - Eugénie Duroyon
- Laboratoire d'Hématologie, Hôpital Cochin, APHP, Paris, France
| | - Marie Templé
- Laboratoire d'Hématologie, Hôpital Cochin, APHP, Paris, France
| | - Rim Bourguiba
- Service de Médecine Interne, Hôpital Tenon, APHP, Paris, France
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Abstract
ABSTRACT VEXAS (vacuoles, E1 enzyme, X-LINKED, autoinflammatory, somatic) syndrome is a complex inflammatory disease associated with somatic mutations of the ubiquitin-like modifier activating enzyme 1 (UBA1) gene. A 75-year-old man with a medical history of thrombophlebitis, leukocytoclastic vasculitis, chronic inflammatory arthralgia, elevated inflammatory markers, and anemia was diagnosed with VEXAS syndrome. 18F-FDG PET/CT showed thoracic aortitis, a rare involvement during VEXAS syndrome. Corticosteroid therapy monitored with 18F-FDG PET/CT led to a complete metabolic response.
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19
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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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20
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Shimizu T, Ide H, Tsuji Y, Koga T, Kawakami A. VEXAS syndrome complicated with severe infection. Rheumatology (Oxford) 2022; 61:e374-e376. [PMID: 35723601 DOI: 10.1093/rheumatology/keac364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Toshimasa Shimizu
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroyuki Ide
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Yoshika Tsuji
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences
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21
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Abstract
Myelodysplastic syndromes (MDS) are a family of myeloid cancers with diverse genotypes and phenotypes characterized by ineffective haematopoiesis and risk of transformation to acute myeloid leukaemia (AML). Some epidemiological data indicate that MDS incidence is increasing in resource-rich regions but this is controversial. Most MDS cases are caused by randomly acquired somatic mutations. In some patients, the phenotype and/or genotype of MDS overlaps with that of bone marrow failure disorders such as aplastic anaemia, paroxysmal nocturnal haemoglobinuria (PNH) and AML. Prognostic systems, such as the revised International Prognostic Scoring System (IPSS-R), provide reasonably accurate predictions of survival at the population level. Therapeutic goals in individuals with lower-risk MDS include improving quality of life and minimizing erythrocyte and platelet transfusions. Therapeutic goals in people with higher-risk MDS include decreasing the risk of AML transformation and prolonging survival. Haematopoietic cell transplantation (HCT) can cure MDS, yet fewer than 10% of affected individuals receive this treatment. However, how, when and in which patients with HCT for MDS should be performed remains controversial, with some studies suggesting HCT is preferred in some individuals with higher-risk MDS. Advances in the understanding of MDS biology offer the prospect of new therapeutic approaches.
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22
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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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23
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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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24
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González García A, Fernández-Martín J, Robles Marhuenda Á. Idiopathic multicentric Castleman disease and associated autoimmune and autoinflammatory conditions: practical guidance for diagnosis. Rheumatology (Oxford) 2022; 62:1426-1435. [PMID: 35997567 PMCID: PMC10070070 DOI: 10.1093/rheumatology/keac481] [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: 06/30/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is an infrequent and life-threatening disorder characterised by systemic inflammatory symptoms, generalised lymphadenopathy, polyclonal lymphocyte proliferation, and organ dysfunction caused by a hyperinflammatory state. It accounts for one third to one half of all multicentric Castleman disease (MCD) cases. iMCD is often associated with autoimmune manifestations that may precede the iMCD diagnosis, be identified at the same time or follow it. In addition, iMCD may also coincide with a number of autoimmune diseases (such as psoriasis or myasthenia gravis) or autoinflammatory diseases (such as familial Mediterranean fever). Moreover, diverse inflammatory disorders, such as rheumatoid arthritis, systemic lupus erythematosus, adult-onset Still disease, systemic juvenile idiopathic arthritis, immunoglobulin (IgG4) related disease, or the recently described VEXAS syndrome, can present clinical features or lymphadenopathy with histopathological "Castleman-like" findings compatible with those of iMCD. Given the iMCD clinical heterogeneity and the overlap with other autoimmune or autoinflammatory disorders, iMCD diagnosis can be challenging. In this review, we explore the overlap between iMCD and inflammatory diseases and provide practical guidance on iMCD diagnosis in order to avoid misdiagnosis and confusion with other autoimmune or autoinflammatory conditions.
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Affiliation(s)
- Andrés González García
- Systemic Autoimmune and Orphan Diseases Unit, Department of Internal Medicine, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Julián Fernández-Martín
- Internal Medicine Department, Hospital Álvaro Cunqueiro, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Ángel Robles Marhuenda
- Autoimmune Diseases Unit of the Internal Medicine Service, Hospital La Paz, Madrid, Spain
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25
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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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26
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The VEXAS syndrome from rheumatology perspective: genomic DNA sequencing as available blueprint for diagnosing rheumatic diseases with overlapping haematological or dermatological findings. Clin Rheumatol 2022; 41:2917-2918. [PMID: 35578121 DOI: 10.1007/s10067-022-06211-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 04/22/2022] [Accepted: 05/13/2022] [Indexed: 11/03/2022]
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27
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Islam S, Cullen T, Sumpton D, Damodaran A, Heath D, Bosco A, Doo NW, Kidson-Gerber G, Cheong A, Lawford R, Walsh R, Sammel A. VEXAS syndrome: lessons learnt from an early Australian case series. Intern Med J 2022; 52:658-662. [PMID: 35419965 DOI: 10.1111/imj.15742] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/07/2021] [Indexed: 01/10/2023]
Abstract
VEXAS is a newly recognised adult-onset autoinflammatory syndrome resulting from a somatic mutation in the UBA1 gene. Herein, we present three cases of VEXAS syndrome in Sydney, Australia, that capture key clinical features and the refractory nature of the condition. They highlight the importance of multidisciplinary collaboration for early diagnosis and the need for new therapeutic options.
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Affiliation(s)
- Sadia Islam
- Rheumatology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Taylor Cullen
- Rheumatology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Daniel Sumpton
- Rheumatology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Arvin Damodaran
- Rheumatology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David Heath
- Rheumatology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Annmarie Bosco
- Haematology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Haematology Department, NSW Health Pathology Randwick, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicole W Doo
- Haematology Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Giselle Kidson-Gerber
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Haematology Department, NSW Health Pathology Randwick, Sydney, New South Wales, Australia
| | - Anthony Cheong
- Royal Prince Alfred Hospital, New South Wales Health Pathology, Sydney, New South Wales, Australia.,Institute of Precision Medicine and Bioinformatics, Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ron Lawford
- Rheumatology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Rebecca Walsh
- Haematology Department, New South Wales Health Pathology Randwick, Sydney, New South Wales, Australia
| | - Anthony Sammel
- Rheumatology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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28
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Matsumoto H, Asano T, Tsuchida N, Maeda A, Yoshida S, Yokose K, Fujita Y, Temmoku J, Matsuoka N, Yashiro-Furuya M, Sato S, Irie K, Norikawa N, Yamamoto T, Endo M, Fukuchi K, Ohkawara H, Ikezoe T, Uchiyama Y, Kirino Y, Matsumoto N, Watanabe H, Migita K. Behçet's disease with a somatic UBA1 variant: Expanding spectrum of autoinflammatory phenotypes of VEXAS syndrome. Clin Immunol 2022; 238:108996. [DOI: 10.1016/j.clim.2022.108996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/31/2022] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
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29
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Lacombe V, Beucher A, Urbanski G, Le Corre Y, Cottin L, Croué A, Bouvier A. Distinction between clonal and paraclonal cutaneous involvements in VEXAS syndrome. Exp Hematol Oncol 2022; 11:6. [PMID: 35172893 PMCID: PMC8848791 DOI: 10.1186/s40164-022-00262-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/06/2022] [Indexed: 12/21/2022] Open
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, auto-inflammatory, somatic) syndrome is an inflammatory disorder with hematological and systemic features. A recent study demonstrated that the dermal infiltrate in neutrophilic dermatosis from VEXAS patients is derived from the pathological UBA1-mutated myeloid clone. Neutrophilic dermatosis is, however, only one of the various skin involvements observed in VEXAS syndrome. We analyzed 10 formalin-fixed paraffin-embedded skin biopsies from genetically confirmed VEXAS syndrome. UBA1 mutation was found in the biopsies related to neutrophilic dermatitis but in none of the other histological patterns (leukocytoclastic vasculitis and septal panniculitis). This could lead to a distinction between clonal and paraclonal cutaneous involvements in VEXAS syndrome, which could in turn improve therapeutic outcomes.
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Affiliation(s)
- Valentin Lacombe
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire, 4 rue Larrey, Angers, France. .,Mitolab Team-CNRS 6214-INSERM 1083-MITOVASC Institute, University of Angers, Angers, France.
| | - Annaelle Beucher
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire, Angers, France.,Fédération Hospitalo-Universitaire 'Grand Ouest Against Leukemia' (FHU GOAL), Angers, France
| | - Geoffrey Urbanski
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire, 4 rue Larrey, Angers, France.,Mitolab Team-CNRS 6214-INSERM 1083-MITOVASC Institute, University of Angers, Angers, France
| | - Yannick Le Corre
- Service de Dermatologie, Centre Hospitalier Universitaire, Angers, France
| | - Laurane Cottin
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire, Angers, France.,CRCINA, INSERM, SFR ICAT, Universités d'Angers, Angers, France
| | - Anne Croué
- Département de Pathologie Cellulaire et Tissulaire, Centre Hospitalier Universitaire, Angers, France
| | - Anne Bouvier
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire, Angers, France.,Fédération Hospitalo-Universitaire 'Grand Ouest Against Leukemia' (FHU GOAL), Angers, France
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30
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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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31
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Patel N, Dulau-Florea A, Calvo KR. Characteristic bone marrow findings in patients with UBA1 somatic mutations and VEXAS syndrome. Semin Hematol 2021; 58:204-211. [PMID: 34802541 DOI: 10.1053/j.seminhematol.2021.10.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a newly characterized syndrome with underlying somatic UBA1 mutations in myeloid cells linking hematologic disease with autoinflammatory rheumatologic disorders. Hematologic abnormalities, particularly peripheral blood cytopenia(s) may prompt bone marrow evaluation in patients with known or unrecognized VEXAS syndrome. This review highlights key findings and diagnostic considerations encountered during bone marrow examination in patients with this disorder. Frequently reported hematologic changes include macrocytic anemia, cytoplasmic vacuoles in myeloid and erythroid precursors, marrow hypercellularity, and varying degrees of dysplasia. Myelodysplastic syndrome and plasma cell neoplasms have been diagnosed in patients with VEXAS syndrome. Macrophage activation syndrome and/or hemophagocytic lymphohistiocytosis and monoclonal B-cell lymphocytosis have also been reported. The bone marrow is a target organ in VEXAS syndrome. Heightened awareness of the bone marrow features and hematologic complications may aid in identifying individuals with VEXAS who may benefit from increased disease surveillance or alternative therapeutic strategies.
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Affiliation(s)
- Nisha Patel
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Alina Dulau-Florea
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD.
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32
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Koster MJ, Warrington KJ. VEXAS within the spectrum of rheumatologic disease. Semin Hematol 2021; 58:218-225. [PMID: 34802543 DOI: 10.1053/j.seminhematol.2021.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/15/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
The identification of the VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome as a myeloid-driven inflammatory disease resulting from somatic mutations in the UBA1 gene further exposes the increasingly recognized overlap between hematologic disturbances and auto-immunity and/or auto-inflammatory presentations. Although single or multi-lineage cytopenias are a unifying aspect of VEXAS, patients with this condition can present with a wide array of inflammatory findings affecting the skin, lung, joints, eye, vascular system, and cartilaginous structures. As such, it is paramount that generalists, and subspecialty providers familiarize themselves with the clinical characteristics of this condition. This review summarizes the reported clinical symptoms of VEXAS syndrome with a particular focus on its non-hematologic inflammatory features.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN.
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
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33
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Groarke EM, Dulau-Florea AE, Kanthi Y. Thrombotic manifestations of VEXAS syndrome. Semin Hematol 2021; 58:230-238. [PMID: 34802545 DOI: 10.1053/j.seminhematol.2021.10.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 11/11/2022]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described autoinflammatory syndrome characterized by diffuse inflammatory manifestations, predisposition to hematological malignancy, and an association with a high rate of thrombosis. VEXAS is attributed to somatic mutations in the UBA1 gene in hematopoietic stem and progenitor cells with myeloid restriction in mature forms. The rate of thrombosis in VEXAS patients is approximately 40% in all reported cases to date. Venous thromboembolism predominates thrombotic events in VEXAS. These are classified as unprovoked in etiology, although systemic and vascular inflammation are implicated. Here, we review the clinical and laboratory characteristics in VEXAS that provide insight into the possible mechanisms leading to thrombosis. We present knowledge gaps in the mechanisms and management of VEXAS-associated thromboinflammation and propose areas for future investigation in the field.
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Affiliation(s)
- Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD.
| | - Alina E Dulau-Florea
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Yogendra Kanthi
- Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
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34
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Poulter JA, Savic S. Genetics of somatic auto-inflammatory disorders. Semin Hematol 2021; 58:212-217. [PMID: 34802542 DOI: 10.1053/j.seminhematol.2021.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/07/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
Systemic autoinflammatory disorders (SAIDs) encompass a heterogeneous group of monogenic disorders characterized by recurrent episodes of systemic and organ-specific inflammation. Genetic studies have facilitated the identification of Mendelian forms of SAIDs but many patients still remain without a diagnosis. Recent studies have uncovered that somatic (acquired) mutations can cause later-onset SAIDs. In this review, we will discuss the current knowledge surrounding the genetics of these acquired auto-inflammatory disorders (AAIDs), with a focus on VEXAS, NLRP3-associated AAIDs and Schnitzler's syndrome and provide suggestions for future research in this field.
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Affiliation(s)
- James A Poulter
- Leeds Institute of Medical Research, University of Leeds, UK
| | - Sinisa Savic
- Leeds Institute of Rheumatological and Musculoskeletal Medicine, University of Leeds, UK.
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35
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Oganesyan A, Hakobyan Y, Terrier B, Georgin-Lavialle S, Mekinian A. Looking beyond VEXAS: Coexistence of undifferentiated systemic autoinflammatory disease and myelodysplastic syndrome. Semin Hematol 2021; 58:247-253. [PMID: 34802547 DOI: 10.1053/j.seminhematol.2021.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/08/2021] [Accepted: 10/01/2021] [Indexed: 01/24/2023]
Abstract
It has been established that individuals with myelodysplastic syndromes (MDS) have a higher frequency of systemic inflammatory disorders. On the other hand, patients with autoimmune diseases are at increased risk of MDS development. Both diseases can be associated with various genetic lesions and share diverse pathogenetic mechanisms. Recently identified VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome, associated with somatic mutations in UBA1, encompasses a range of inflammatory conditions involving multiple organs along with hematological pathologies, including MDS, as well as characteristic bone marrow vacuolization of myeloid and erythroid precursors. This novel syndrome drove further attention to complex associations between MDS and adult-onset inflammatory conditions. The present narrative literature review discusses the clinical presentation, pathophysiology, management of concurrent MDS and systemic inflammatory diseases in parallel to the clinical picture of VEXAS syndrome.
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Affiliation(s)
- Artem Oganesyan
- Department of Adult Hematology, Yeolyan Hematology Center, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Adult Hematology, Yeolyan Hematology Center, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare and Systemic Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Georgin-Lavialle
- Internal Medicine Department, National Reference Center for Autoinflammatory Diseases and Amyloidosis (CEREMAIA), Sorbonne Université, INSERM U938, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Arsene Mekinian
- Internal Medicine Department and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hospital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de Recherche Saint-Antoine (CRSA), Sorbonne Universités, UMPC University Paris 06, INSERM U938, Paris, France.
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36
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Kusne Y, Fernandez J, Patnaik MM. Clonal hematopoiesis and VEXAS syndrome: survival of the fittest clones? Semin Hematol 2021; 58:226-229. [PMID: 34802544 DOI: 10.1053/j.seminhematol.2021.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/19/2021] [Accepted: 10/01/2021] [Indexed: 01/13/2023]
Abstract
Clonal hematopoiesis (CH) is defined by the acquisition of somatic mutations in hematopoietic stem cells (HSC) leading to enhanced cellular fitness and proliferation under positive clonal selection pressures. CH most frequently involves epigenetic regulator genes (DNMT3A, TET2 and ASXL1), with these mutations being associated with enhanced inflammation and increased all-cause mortality largely from cardiovascular disease and endothelial dysfunction. These mutations also increase the risk for hematological neoplasms. Somatic mutations in UBA1, encoding the E1 ubiquitin ligase in HSC, cause a severe adult-onset autoinflammatory disease that can be associated with myeloid and plasma cell neoplasms, termed VEXAS (vacuoles, X-linked, autoinflammatory, somatic) syndrome. Given the degree of inflammation seen, one would have expected this to be a fertile ground for CH development and propagation, however, preliminary data doesn't support this. Here in, we review the current data on CH, inflammation and VEXAS syndrome.
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Affiliation(s)
- Yael Kusne
- Division of Hematology/Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Jenna Fernandez
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN.
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Georgin-Lavialle S, Terrier B, Guedon AF, Heiblig M, Comont T, Lazaro E, Lacombe V, Terriou L, Ardois S, Bouaziz JD, Mathian A, Le Guenno G, Aouba A, Outh R, Meyer A, Roux-Sauvat M, Ebbo M, Zhao LP, Bigot A, Jamilloux Y, Guillotin V, Flamarion E, Henneton P, Vial G, Jachiet V, Rossignol J, Vinzio S, Weitten T, Vinit J, Deligny C, Humbert S, Samson M, Magy-Bertrand N, Moulinet T, Bourguiba R, Hanslik T, Bachmeyer C, Sebert M, Kostine M, Bienvenu B, Biscay P, Liozon E, Sailler L, Chasset F, Audemard-Verger A, Duroyon E, Sarrabay G, Borlot F, Dieval C, Cluzeau T, Marianetti P, Lobbes H, Boursier G, Gerfaud-Valentin M, Jeannel J, Servettaz A, Audia S, Larue M, Henriot B, Faucher B, Graveleau J, de Sainte Marie B, Galland J, Bouillet L, Arnaud C, Ades L, Carrat F, Hirsch P, Fenaux P, Fain O, Sujobert P, Kosmider O, Mekinian A. Further characterization of clinical and laboratory features occurring in VEXAS syndrome in a large-scale analysis of multicenter case-series of 116 French patients. Br J Dermatol 2021; 186:564-574. [PMID: 34632574 DOI: 10.1111/bjd.20805] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND A new autoinflammatory syndrome related to somatic mutations of UBA1 was recently described and called VEXAS syndrome. OBJECTIVE To describe clinical characteristics, laboratory findings and outcomes of VEXAS syndrome. DESIGN Case-series. SETTING Patients referred to a French multicenter registry between November 2020 and May 2021. PATIENTS 116 patients with VEXAS syndrome. MEASUREMENTS Frequency and median of parameters and vital status, from diagnosis to the end of the follow-up. RESULTS Main clinical features were skin lesions (83.5%), non-infectious fever (63.6%), weight loss (62%), lung involvement (49.6%), ocular symptoms (38.8%), relapsing chondritis (36.4%), venous thrombosis (34.7%), lymph nodes (33.9%), and arthralgia (27.3%). Hematological disease was present in 58 cases (50%), considered as myelodysplastic syndrome (MDS, n= 58) and monoclonal gammapathy of unknown significance (n=12).UBA1 mutations included p.M41T (44.8%), p.M41V (30.2%), p.M41L (18.1%), and splice mutations (6.9%). After a median follow-up of 3.0 years, 18 patients died (15.5%), from infectious origin (n=9) and MDS progression (n=3). Unsupervised analysis identified 3 clusters: cluster 1 (47%) with mild-to-moderate disease; cluster 2 (16%) with underlying MDS and higher mortality rates; cluster 3 (37%) with constitutional manifestations, higher C-reactive protein levels and less frequent chondritis. Five-year probability of survival was 84.2% in cluster 1, 50.5 % in cluster 2, and 89.6% in cluster 3. UBA1 p.Met41Leu mutation was associated with a better prognosis. CONCLUSION VEXAS syndrome displays a large spectrum of organ manifestations and shows different clinical and prognostic profiles. It also raises a potential impact of the identified UBA1 mutation.
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Affiliation(s)
- S Georgin-Lavialle
- Sorbonne Université, AP-HP, Hôpital Tenon, service de médecine interne, CEREMAIA, F-75020, Paris, France
| | - B Terrier
- University of Paris, AP-HP, Cochin Hospital, Department of Internal Medicine, F-75014, Paris, France
| | - A F Guedon
- Sorbonne Université, Inserm, Institut Pierre-Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Hôpital Saint-Antoine, APHP, Paris
| | | | - T Comont
- University Hospital of Toulouse, Department of Internal Medicine and Clinical Immunology, Toulouse, France
| | - E Lazaro
- Department of Internal Medicine and Infectious Diseases, Hôpital Haut-Lévêque, Bordeaux, France
| | - V Lacombe
- Department of Internal Medicine, Angers University Hospital, Angers, France
| | - L Terriou
- Department of Internal Medicine, Lille University Hospital, Lille, France
| | - S Ardois
- Service de médecine interne, CHU de Rennes, Rennes, France
| | - J-D Bouaziz
- Université de Paris, Service de dermatologie, Hôpital Saint Louis, APHP, INSERM U944, Paris, France
| | - A Mathian
- Assistance Publique-Hôpitaux de Paris, Groupement Hospitalier Pitié-Salpêtrière, French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Paris, France
| | - G Le Guenno
- University Hospital Centre of Bordeaux, Saint Andre Hospital, Department of Internal Medicine and Clinical Immunology, F-33000 Bordeaux, France, CHU de Clermont-Ferrand, Hôpital Estaing, service de médecine interne, Clermont-Ferrand, France
| | - A Aouba
- Caen Université, Hôpital de Caen, Department of Internal Medicine, Caen, France
| | - R Outh
- Service de médecine interne et générale, Centre Hospitalier de Perpignan, Perpignan, France
| | - A Meyer
- Service d'immunologie clinique et médecine interne, Nouvel Hôpital Civil, CHU Strasbourg
| | - M Roux-Sauvat
- GHND, Centre Hospitalier Pierre Oudot, 30 avenue du Médipôle, BP 40348, 38302 Bourgoin-Jallieu Cedex
| | - M Ebbo
- Aix Marseille Université, AP-HM, Hôpital de la Timone, Department of Internal Medicine, Marseille, France
| | - L P Zhao
- APHP, Hematology department, CHU of Saint Louis, Paris, France
| | - A Bigot
- 19University of Tours, Tours, France, Department of Internal Medicine and Clinical
| | - Y Jamilloux
- University Hospital of Lyon, Hospices Civils de Lyon, Department of Internal Medicine and Clinical Immunology, Lyon, France
| | - V Guillotin
- University Hospital Centre of Bordeaux, Saint Andre Hospital, Department of Internal Medicine and Clinical Immunology, F-33000 Bordeaux, France, CHU de Clermont-Ferrand, Hôpital Estaing, service de médecine interne, Clermont-Ferrand, France
| | - E Flamarion
- Université de Paris, Service de médecine interne, HEGP Paris, France
| | - P Henneton
- Service de Médecine Vasculaire, CHU Montpellier, 80 Av Augustin Fliche, Montpellier, 34090
| | - G Vial
- University Hospital Centre of Bordeaux, Saint Andre Hospital, Department of Internal Medicine and Clinical Immunology, F-33000 Bordeaux, France, CHU de Clermont-Ferrand, Hôpital Estaing, service de médecine interne, Clermont-Ferrand, France
| | - V Jachiet
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), F-75012, Paris, France
| | - J Rossignol
- Université de Paris, Service d'hématologie, Necker Enfants Malades, Paris, France
| | - S Vinzio
- Univ. Grenoble Alpes, Inserm, U1036, CHU Grenoble Alpes, CEA, IRIG-BCI, 38000, Grenoble, France
| | - T Weitten
- Service de médecine interne, Centre Hospitalier (CHICAS), GAP, France
| | - J Vinit
- Service de médecine interne, Centre Hospitalier, Chalons, France
| | - C Deligny
- Service de Rhumatologie - Médecine Interne 5D · CHU de Martinique - Hôpital P. Zobda-Quitman, France
| | - S Humbert
- CHU de Besançon, Service de Médecine Interne, Besançon, France
| | - M Samson
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - N Magy-Bertrand
- CHU de Besançon, Service de Médecine Interne, Besançon, France
| | - T Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Systemic and Autoimmune Rare Diseases, Nancy University Hospital, UMR 7365, IMoPA, Lorraine University, CNRS, Vandoeuvre-lès-Nancy, France
| | - R Bourguiba
- Sorbonne Université, AP-HP, Hôpital Tenon, service de médecine interne, CEREMAIA, F-75020, Paris, France
| | - T Hanslik
- AP-HP, Hôpital Ambroise Paris, service de médecine interne, Paris, France
| | - C Bachmeyer
- Sorbonne Université, AP-HP, Hôpital Tenon, service de médecine interne, CEREMAIA, F-75020, Paris, France
| | - M Sebert
- APHP, Hematology department, CHU of Saint Louis, Paris, France
| | - M Kostine
- Department of Rheumatology, Hôpital Haut-Lévesque, Bordeaux, France
| | - B Bienvenu
- Hôpital Saint Joseph, service de médecine interne, Marseille, France
| | - P Biscay
- Clinique Mutualiste Pessac Médecine Interne, Pessac, France
| | - E Liozon
- Service de Médecine Interne, CHU Dupuytren, Limoges, France
| | - L Sailler
- University Hospital of Toulouse, Department of Internal Medicine, Toulouse, France
| | - F Chasset
- Sorbonne Université, Hôpital Tenon, service de dermatologie et allergologie et Inflammation-Immunopathology-Biotherapy Department (DMU i3), F-75020, Paris, France
| | - A Audemard-Verger
- 19University of Tours, Tours, France, Department of Internal Medicine and Clinical
| | - E Duroyon
- Service d'Hématologie Biologique, DMU BioPhyGen GH AP-HP. Centre-University de Paris
| | - G Sarrabay
- Laboratory of Rare and Autoinflammatory Genetic Diseases and Reference Centre for Autoinflammatory Diseases and Amyloidosis (CEREMAIA), CHU Montpellier, University of Montpellier, Montpellier, France
| | - F Borlot
- Service de médecine Interne, CH Béziers, France
| | - C Dieval
- Service de médecine interne et hématologie, CH régional, Rochefort, France
| | - T Cluzeau
- Hematology department, CHU of Nice, Cote d'Azur University, Nice, France
| | - P Marianetti
- CHU de REIMS, Service de médecine interne, maladies infectieuses, immunologie clinique
| | - H Lobbes
- University Hospital Centre of Bordeaux, Saint Andre Hospital, Department of Internal Medicine and Clinical Immunology, F-33000 Bordeaux, France, CHU de Clermont-Ferrand, Hôpital Estaing, service de médecine interne, Clermont-Ferrand, France
| | - G Boursier
- Laboratory of Rare and Autoinflammatory Genetic Diseases and Reference Centre for Autoinflammatory Diseases and Amyloidosis (CEREMAIA), CHU Montpellier, University of Montpellier, Montpellier, France
| | - M Gerfaud-Valentin
- University Hospital of Lyon, Hospices Civils de Lyon, Department of Haematology, Lyon, France
| | - J Jeannel
- Université de Paris, Service de médecine interne, HEGP Paris, France
| | - A Servettaz
- CHU de REIMS, Service de médecine interne, maladies infectieuses, immunologie clinique
| | - S Audia
- Department of Internal Medicine and Clinical Immunology, Dijon University Hospital, Dijon, France
| | - M Larue
- APHP, Service de rhumatologie, Hôpital Henri Mondor, Créteil, France
| | - B Henriot
- Service de médecine interne, Centre Hospitalier René Pleven, Dinan, France
| | - B Faucher
- Aix Marseille Université, AP-HM, Hôpital de la Timone, Department of Internal Medicine, Marseille, France
| | - J Graveleau
- CHU de Nantes Hôtel Dieu, Service de Médecine Interne, Nantes, France
| | - B de Sainte Marie
- University Hospital Centre of Bordeaux, Saint Andre Hospital, Department of Internal Medicine and Clinical Immunology, F-33000 Bordeaux, France, CHU de Clermont-Ferrand, Hôpital Estaing, service de médecine interne, Clermont-Ferrand, France
| | - J Galland
- Service de médecine interne, hôpital Fleyriat, Centre hospitalier Bourg-en-Bresse, France
| | - L Bouillet
- Univ. Grenoble Alpes, Inserm, U1036, CHU Grenoble Alpes, CEA, IRIG-BCI, 38000, Grenoble, France
| | - C Arnaud
- University Hospital of Toulouse, Department of Internal Medicine, Toulouse, France
| | - L Ades
- APHP, Hematology department, CHU of Saint Louis, Paris, France
| | - F Carrat
- Sorbonne Université, Inserm, Institut Pierre-Louis d'Epidémiologie et de Santé Publique, Département de Santé Publique, Hôpital Saint-Antoine, APHP, Paris
| | - P Hirsch
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, service d'hématologie biologique, F-75012, Paris, France
| | - P Fenaux
- APHP, Hematology department, CHU of Saint Louis, Paris, France
| | - O Fain
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), F-75012, Paris, France
| | - P Sujobert
- CHU de Besançon, Service de Médecine Interne, Besançon, France
| | - O Kosmider
- Service d'Hématologie Biologique, DMU BioPhyGen GH AP-HP. Centre-University de Paris
| | - A Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), F-75012, Paris, France
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Koster MJ, Kourelis T, Reichard KK, Kermani TA, Beck DB, Cardona DO, Samec MJ, Mangaonkar AA, Begna KH, Hook CC, Oliveira JL, Nasr SH, Tiong BK, Patnaik MM, Burke MM, Michet CJ, Warrington KJ. Clinical Heterogeneity of the VEXAS Syndrome: A Case Series. Mayo Clin Proc 2021; 96:2653-2659. [PMID: 34489099 DOI: 10.1016/j.mayocp.2021.06.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
The objective of this study is to describe the clinical features and outcomes of patients with the newly defined vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. Nine men with somatic mutations in the UBA1 gene were identified; the most frequent variant was p.Met41Thr (7 of 9, 78%). The median age at VEXAS diagnosis was 74 (67, 76.5) years, and patients had a median duration of symptoms for 4 years before diagnosis. Refractory constitutional symptoms (88%), ear and nose chondritis (55%), and inflammatory arthritis (55%) were common clinical features. Vasculitis was noted in 44%. All patients had significantly elevated inflammatory markers and macrocytic anemia. Thrombocytopenia was present in 66% at diagnosis of VEXAS. Eight patients had bone marrow biopsies performed. All bone marrows were hypercellular, and there was vacuolization of the erythroid (100%) or myeloid precursors (75%). Glucocorticoids attenuated symptoms at prednisone doses ≥20 mg per day, but no other immunosuppressive agent showed consistent long-term control of disease. One patient with coexisting plasma-cell myeloma received plasma-cell-directed therapy with improvement of the inflammatory response, which is a novel finding. In conclusion, VEXAS syndrome is a clinically heterogeneous, treatment-refractory inflammatory condition caused by somatic mutation of the UBA1 gene. Patients often present with overlapping rheumatologic manifestations and persistent hematologic abnormalities. As such, internists and subspecialists, including pathologists, should be aware of this condition to avert diagnostic delay, now that the etiology of this syndrome is known.
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Affiliation(s)
- Matthew J Koster
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN.
| | - Taxiarchis Kourelis
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - Kaaren K Reichard
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Tanaz A Kermani
- Department of Internal Medicine, Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, Santa Monica, CA
| | - David B Beck
- National Institutes of Health, National Human Genome Research Institute, Bethesda, MD
| | | | - Matthew J Samec
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | | | - Kebede H Begna
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - C Christopher Hook
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - Jennifer L Oliveira
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Benedict K Tiong
- Department of Internal Medicine, Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, Santa Monica, CA
| | - Mrinal M Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN
| | - Michelle M Burke
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | - Clement J Michet
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
| | - Kenneth J Warrington
- Department of Internal Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN
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Shaukat F, Hart M, Burns T, Bansal P. UBA1 and DNMT3A Mutations in VEXAS Syndrome. A Case Report and Literature Review. Mod Rheumatol Case Rep 2021; 6:134-139. [PMID: 34480172 DOI: 10.1093/mrcr/rxab021] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/20/2021] [Accepted: 07/30/2021] [Indexed: 11/14/2022]
Abstract
VEXAS syndrome is a recently described X-linked autoinflammatory condition associated with somatic mutation of the UBA1 gene. It often coexists with MDS which can occur due to DNMT3A mutation. These patients, predominantly males, present after the fifth decade of life with unique systemic inflammatory clinical features and have hematological abnormalities and vacuolated precursor cells on bone marrow pathology. Here we describe a unique case of VEXAS syndrome in a patient harboring DNMT3A gene mutation with coexisting UBA1 mutation with a review of literature.
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Affiliation(s)
- Farah Shaukat
- Department of Oncology: Johns Hopkins Hospital, Baltimore, USA
| | - Melissa Hart
- Department of Pathology. Mayo Clinic Health System, Eau Claire, USA
| | - Timothy Burns
- Department of Hematology/Oncology. Mayo Clinic Health System, Eau Claire, USA
| | - Pankaj Bansal
- Department of Rheumatology. Mayo Clinic Health System, Eau Claire, USA
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