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Hadjadj J, Nguyen Y, Mouloudj D, Bourguiba R, Heiblig M, Aloui H, McAvoy C, Lacombe V, Ardois S, Campochiaro C, Maria A, Coustal C, Comont T, Lazaro E, Lifermann F, Le Guenno G, Lobbes H, Grobost V, Outh R, Campagne J, Dor-Etienne A, Garnier A, Jamilloux Y, Dossier A, Samson M, Audia S, Nicolas B, Mathian A, de Maleprade B, De Sainte-Marie B, Faucher B, Bouaziz JD, Broner J, Dumain C, Antoine C, Carpentier B, Castel B, Lartigau-Roussin C, Crickx E, Volle G, Fayard D, Decker P, Moulinet T, Dumont A, Nguyen A, Aouba A, Martellosio JP, Levavasseur M, Puigrenier S, Antoine P, Giraud JT, Hermine O, Lacout C, Martis N, Karam JD, Chasset F, Arnaud L, Marianetti P, Deligny C, Chazal T, Woaye-Hune P, Roux-Sauvat M, Meyer A, Sujobert P, Hirsch P, Abisror N, Fenaux P, Kosmider O, Jachiet V, Fain O, Terrier B, Mekinian A, Georgin-Lavialle S. Efficacy and safety of targeted therapies in VEXAS syndrome: retrospective study from the FRENVEX. Ann Rheum Dis 2024:ard-2024-225640. [PMID: 38777378 DOI: 10.1136/ard-2024-225640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic (VEXAS) syndrome is an adult-onset autoinflammatory disease associated with somatic ubiquitin-like modifier-activating enzyme 1 (UBA1) mutations. We aimed to evaluate the efficacy and safety of targeted therapies. METHODS Multicentre retrospective study including patients with genetically proven VEXAS syndrome who had received at least one targeted therapy. Complete response (CR) was defined by a clinical remission, C-reactive protein (CRP) ≤10 mg/L and a ≤10 mg/day of prednisone-equivalent therapy, and partial response (PR) was defined by a clinical remission and a 50% reduction in CRP levels and glucocorticoid dose. RESULTS 110 patients (median age 71 (68-79) years) who received 194 targeted therapies were included: 78 (40%) received Janus kinase (JAK) inhibitors (JAKi), 51 (26%) interleukin (IL)-6 inhibitors, 33 (17%) IL-1 inhibitors, 20 (10%) tumour necrosis factor (TNFα) blockers and 12 (6%) other targeted therapies. At 3 months, the overall response (CR and PR) rate was 24% with JAKi, 32% with IL-6 inhibitors, 9% with anti-IL-1 and 0% with TNFα blockers or other targeted therapies. At 6 months, the overall response rate was 30% with JAKi and 26% with IL-6 inhibitors. Survival without treatment discontinuation was significantly longer with JAKi than with the other targeted therapies. Among patients who discontinued treatment, causes were primary failure, secondary failure, serious adverse event or death in 43%, 14%, 19% and 19%, respectively, with JAKi and 46%, 11%, 31% and 9%, respectively, with IL-6 inhibitors. CONCLUSIONS This study shows the benefit of JAKi and IL-6 inhibitors, whereas other therapies have lower efficacy. These results need to be confirmed in prospective trials.
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Affiliation(s)
- Jerome Hadjadj
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Yann Nguyen
- Service de médecine interne, Hôpital Beaujon, AP-HP.Nord, Université Paris Cité, Clichy, France
| | - Dalila Mouloudj
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Rim Bourguiba
- Médecine Interne, CEREMAIA, Sorbonne Université, Hospital Tenon, Paris, France
- Université Tunis el Manar, Faculté de médecine de Tunis, Tunis, Tunisia
| | - Mael Heiblig
- Hématologie, Hôpital Lyon Sud - HCL, Pierre-Bénite, France
| | - Hassina Aloui
- Médecine Interne, CEREMAIA, Sorbonne Université, Hospital Tenon, Paris, France
| | - Chloe McAvoy
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Valentin Lacombe
- Department of Internal Medicine, University Hospital Centre Angers, Angers, Pays de la Loire, France
| | | | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy ad Rre Disesaes. IRCCS San Raffaele Hospital. Vita-Salute Vita-Salute San Raffaele University, Milan, Italy
| | - Alexandre Maria
- Department of Internal Medicine - Multi-organ Diseases, St Eloi Hospital, Montpellier University Hospital, Univ Montpellier, Montpellier, France
| | - Cyrille Coustal
- Department of Internal Medicine - Multi-organ Diseases, St Eloi Hospital, Montpellier University Hospital, Univ Montpellier, Montpellier, France
| | - Thibault Comont
- Service de médecine interne IUCT-Oncopole, CHU Toulouse, Université Paul Sabatier, Toulouse, France
| | - Estibaliz Lazaro
- Internal Medicine, CHU de Bordeaux, Bordeaux, Nouvelle-Aquitaine, France
| | - Francois Lifermann
- Service de médecine interne, Centre Hospitalier Dax, Dax, Nouvelle-Aquitaine, France
| | - Guillaume Le Guenno
- Médecine Interne, CHU Estaing, Clermont-Ferrand, Auvergne-Rhône-Alpes, France
| | - Hervé Lobbes
- Médecine Interne, CHU Estaing, Clermont-Ferrand, Auvergne-Rhône-Alpes, France
| | - Vincent Grobost
- Médecine Interne, CHU Estaing, Clermont-Ferrand, Auvergne-Rhône-Alpes, France
| | - Roderau Outh
- Service de médecine interne et générale, Perpignan University, Perpignan, France
| | | | | | - Alice Garnier
- Hematology Department, Nantes University Hospital, Nantes, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital Universitaire de la Croix-Rousse, Hospices Civils de Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Antoine Dossier
- Service de Médecine Interne, Hôpital Bichat-Claude-Bernard, APHP, Paris, France
| | - Maxime Samson
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Maladies Auto-immunes et Auto-inflammatoires Rares de l'adulte, CHU Dijon-Bourgogne, Dijon,France; Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Sylvain Audia
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Maladies Auto-immunes et Auto-inflammatoires Rares de l'adulte, CHU Dijon-Bourgogne, Dijon,France; Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Barbara Nicolas
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Maladies Auto-immunes et Auto-inflammatoires Rares de l'adulte, CHU Dijon-Bourgogne, Dijon,France; Université de Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, RIGHT Interactions Greffon-Hôte-Tumeur/Ingénierie Cellulaire et Génique, Dijon, France
| | - Alexis Mathian
- French National Referral Center for Systemic Lupus Erythematosus, Antiphospholipid Antibody Syndrome and Other Autoimmune Disorders, Service de Médecine Interne 2, Institut E3M, Inserm UMRS, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
| | | | - Benjamin De Sainte-Marie
- Department of Internal Medicine, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Benoit Faucher
- Department of Internal Medicine, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | | | - Jonathan Broner
- Internal Medicine Department, University Hospital Centre Nimes, Nimes, France
| | - Cyril Dumain
- Internal Medicine Department, University Hospital Centre Nimes, Nimes, France
| | - Carole Antoine
- Internal Medicine, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azu, France
| | - Benjamin Carpentier
- Hématologie clinique, Universite Catholique de Lille Hopital Saint-Vincent de Paul, Lille, Hauts-de-France, France
| | - Brice Castel
- Service de Médecine Interne et d'Immunologie clinique, Centre Hospitalier de Lourdes, Lourdes, France
| | | | - Etienne Crickx
- Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Geoffroy Volle
- Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Damien Fayard
- University Hospital Centre Gabriel Montpied, Clermont-Ferrand, Auvergne-Rhône-Alpes, France
| | - Paul Decker
- Médecine interne et immunologie clinique, CHU de Nancy, UMR 7365, IMoPA, Université de Lorraine, CNRS, Nancy, France
| | - Thomas Moulinet
- Médecine interne et immunologie clinique, CHU de Nancy, UMR 7365, IMoPA, Université de Lorraine, CNRS, Nancy, France
| | - Anael Dumont
- Department of Internal Medicine, University Hospital Centre Caen, Caen, Basse-Normandie, France
| | - Alexandre Nguyen
- Department of Internal Medicine, University Hospital Centre Caen, Caen, Basse-Normandie, France
| | - Achille Aouba
- Department of Internal Medicine, University Hospital Centre Caen, Caen, Basse-Normandie, France
| | | | | | - Sebastien Puigrenier
- Department of Internal Medicine, Centre hospitalier de Boulogne-sur-Mer, Boulogne-sur-Mer, France
| | - Pascale Antoine
- Department of Internal Medicine, Centre hospitalier de Boulogne-sur-Mer, Boulogne-sur-Mer, France
| | | | | | - Carole Lacout
- Department of Internal Medicine, University Hospital Centre Angers, Angers, Pays de la Loire, France
| | - Nihal Martis
- Internal Medicine Department, University Hospital of Nice, Archet 1 Hospital, Nice, France
| | - Jean-Denis Karam
- Department of Internal Medicine Amiens University Hospital, Amiens, France
| | - Francois Chasset
- Sorbonne Université, Faculté de Médecine, AP-HP, Service de Dermatologie et Allergologie, Paris, France
| | - Laurent Arnaud
- Department of Rheumatology. National reference Center for rare diseases (RESO). Hôpitaux Universitaires de Strasbourg et INSERM UMR-S 1109, Strasbourg, France
| | - Paola Marianetti
- Service de médecine interne, maladies infectieuses, immunologie clinique, Reims Champagne-Ardenne University, Reims, France
| | - Christophe Deligny
- Service de Médecine Interne, University Hospital of Martinique, Fort-de-France, Martinique
| | - Thibaud Chazal
- Internal Medicine, The Fondation Adolphe de Rothschild Hospital, Paris, France
| | | | - Murielle Roux-Sauvat
- Service de médecine interne, Pierre Oudot Hospital of Bourgoin-Jallieu, Bourgoin-Jallieu, France
| | - Aurore Meyer
- Service d'immunologie clinique et médecine interne, Hopitaux universitaires de Strasbourg, Strasbourg, Alsace, France
| | - Pierre Sujobert
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'hématologie biologique, Pierre Bénite, France
| | - Pierre Hirsch
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, AP-HP, SIRIC8 CURAMUS, Hôpital Saint-Antoine, Service d'Hématologie Biologique, Paris, France
| | - Noemie Abisror
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Pierre Fenaux
- Hématologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Olivier Kosmider
- Service d'Hématologie Biologique, DMU BioPhyGen, APHP, Paris, France
| | - Vincent Jachiet
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Olivier Fain
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Benjamin Terrier
- Médecine interne, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France
| | - Arsène Mekinian
- Sorbonne Université, service de médecine interne, Hôpital Saint-Antoine, AP-HP, Paris, France
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Phan L, Hammond D, Wilson NR, Groarke EM, Patnaik MM, Pemmaraju N. VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic): clinical review in a rapidly emerging field. Leuk Lymphoma 2024:1-13. [PMID: 38770970 DOI: 10.1080/10428194.2024.2349950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
VEXAS syndrome is a recently described entity characterized by systemic inflammatory and hematologic manifestations. The disease was first characterized by Beck et al. in 2020 in a study characterizing 25 patients with undiagnosed adult-onset inflammatory syndromes. While the literature regarding VEXAS syndrome has grown exponentially since 2020, there is still much to be understood. This lack of information leads to challenges in both the diagnosis and treatment of patients with VEXAS syndrome. Patients will often have a variety of clinical symptoms that can lead to missed or delayed diagnoses. Additionally, awareness of VEXAS syndrome is still developing among clinicians. In this comprehensive review, we summarize the current literature regarding VEXAS syndrome, and explore clinical updates of this emerging disease state. Our aim of this review is to increase awareness regarding this new disease state and identify research areas to better understand future treatment approaches for patients with VEXAS syndrome.
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Affiliation(s)
- Luan Phan
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mrinal M Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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3
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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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4
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Gurnari C, Koster L, Baaij L, Heiblig M, Yakoub-Agha I, Collin M, Passweg J, Bulabois CE, Khan A, Loschi M, Carnevale-Schianca F, Crisà E, Caravelli D, Kuball J, Saraceni F, Olivieri A, Rambaldi A, Kulasekararaj AG, Hayden PJ, Badoglio M, Onida F, Scheid C, Franceschini F, Mekinian A, Savic S, Voso MT, Drozd-Sokolowska J, Snowden JA, Raj K, Alexander T, Robin M, Greco R, McLornan DP. Allogeneic hematopoietic cell transplantation for VEXAS syndrome: results of a multicenter study of the EBMT. Blood Adv 2024; 8:1444-1448. [PMID: 38330178 PMCID: PMC10955646 DOI: 10.1182/bloodadvances.2023012478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024] Open
Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | | | | | - Mael Heiblig
- Department of Hematology, Centre Hospitalier Lyon Sud, Lyon, France
| | | | | | | | | | - Anjum Khan
- Yorkshire Blood & Marrow Transplant Program, Leeds, United Kingdom
| | | | | | - Elena Crisà
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | | | - Jürgen Kuball
- Department of Haematology, University Medical Centre, Utrecht, The Netherlands
| | | | | | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan and Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Patrick J. Hayden
- Department of Haematology, Trinity College Dublin, St. James’s Hospital, Dublin, Ireland
| | | | - Francesco Onida
- ASST Fatebenefratelli-Sacco, University of Milan, Milan, Italy
| | | | - Franco Franceschini
- Rheumatology and Clinical Immunology, ASST Spedali Civili of Brescia and Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Arsène Mekinian
- Sorbonne Université, Assistance Publique–Hôpitaux de Paris, Hôpital Saint Antoine, Service de médecine interne et Inflammation-Immunopathology-Biotherapy Department, Paris, France
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Kavita Raj
- University College London Hospitals NHS Trust, London, United Kingdom
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | | | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Donal P. McLornan
- University College London Hospitals NHS Trust, London, United Kingdom
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5
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Khitri MY, Hadjadj J, Mekinian A, Jachiet V. VEXAS syndrome: An update. Joint Bone Spine 2024; 91:105700. [PMID: 38307404 DOI: 10.1016/j.jbspin.2024.105700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
VEXAS (Vacuoles, E1 Enzyme, X-linked, Autoinflammatory, Somatic) syndrome is a recently described autoinflammatory syndrome, mostly affecting men older than 50 years, caused by somatic mutation in the UBA1 gene, a X-linked gene involved in the activation of ubiquitin system. Patients present a broad spectrum of inflammatory manifestations (fever, neutrophilic dermatosis, chondritis, pulmonary infiltrates, ocular inflammation, venous thrombosis) and hematological involvement (macrocytic anemia, thrombocytopenia, vacuoles in myeloid and erythroid precursor cells, dysplastic bone marrow) that are responsible for a significant morbidity and mortality. The therapeutic management is currently poorly codified but is based on two main approaches: controlling inflammatory symptoms (by using corticosteroids, JAK inhibitor or tocilizumab) or targeting the UBA1-mutated hematopoietic population (by using azacitidine or allogeneic hematopoietic stem cell transplantation). Supportive care is also important and includes red blood cell or platelet transfusions, erythropoiesis stimulating agents, thromboprophylaxis and anti-infectious prophylaxis. The aim of this review is to provide a current overview of the VEXAS syndrome, particularly focusing on its pathophysiological, diagnostic and therapeutic aspects.
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Affiliation(s)
- Mohamed-Yacine Khitri
- Service de médecine interne, AP-HP, hôpital Saint-Antoine, Sorbonne université, 184, rue du faubourg, 75012 Paris, France
| | - Jérôme Hadjadj
- Service de médecine interne, AP-HP, hôpital Saint-Antoine, Sorbonne université, 184, rue du faubourg, 75012 Paris, France
| | - Arsène Mekinian
- Service de médecine interne, AP-HP, hôpital Saint-Antoine, Sorbonne université, 184, rue du faubourg, 75012 Paris, France
| | - Vincent Jachiet
- Service de médecine interne, AP-HP, hôpital Saint-Antoine, Sorbonne université, 184, rue du faubourg, 75012 Paris, France.
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6
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Gurnari C, Pascale MR, Vitale A, Diral E, Tomelleri A, Galossi E, Falconi G, Bruno A, Crisafulli F, Frassi M, Cattaneo C, Bertoli D, Bernardi M, Condorelli A, Morsia E, Poloni A, Crisà E, Caravelli D, Triggianese P, Brussino L, Battipaglia G, Bindoli S, Sfriso P, Caroni F, Dragani M, Mallegni F, Pilo F, Firinu D, Curti A, Papayannidis C, Olivieri A, Kordasti S, Albano F, Pane F, Musto P, Bocchia M, Lugli E, Breccia M, Frigeni M, Dagna L, Greco R, Franceschini F, Campochiaro C, Cantarini L, Voso MT. Diagnostic capabilities, clinical features, and longitudinal UBA1 clonal dynamics of a nationwide VEXAS cohort. Am J Hematol 2024; 99:254-262. [PMID: 38108611 DOI: 10.1002/ajh.27169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023]
Abstract
VEXAS is a prototypic hemato-inflammatory disease combining rheumatologic and hematologic disorders in a molecularly defined nosological entity. In this nationwide study, we aimed at screenshotting the current diagnostic capabilities and clinical-genomic features of VEXAS, and tracked UBA1 longitudinal clonal dynamics upon different therapeutics, including allogeneic hematopoietic cell transplant. We leveraged a collaboration between the Italian Society of Experimental Hematology and of Rheumatology and disseminated a national survey to collect clinical and molecular patient information. Overall, 13/29 centers performed UBA1 genomic testing locally, including Sanger sequencing (46%), next-generation sequencing (23%), droplet digital polymerase chain reaction (8%), or combination (23%). A total of 41 male patients were identified, majority (51%) with threonine substitutions at Met41 hotspot, followed by valine and leucine (27% and 8%). Median age at VEXAS diagnosis was 67 years. All patients displayed anemia (median hemoglobin 9.1 g/dL), with macrocytosis. Bone marrow vacuoles were observed in most cases (89%). The most common rheumatologic association was polychondritis (49%). A concomitant myelodysplastic neoplasm/syndrome (MDS) was diagnosed in 71% of patients (n = 28), chiefly exhibiting lower Revised International Prognostic Scoring System risk profiles. Karyotype was normal in all patients, except three MDS cases showing -Y, t(12;16)(q13;q24), and +8. The most frequently mutated gene was DNMT3A (n = 10), followed by TET2 (n = 3). At last follow-up, five patients died and two patients progressed to acute leukemia. Longitudinal UBA1 clonal dynamics demonstrated mutational clearance following transplant. We collected a nationwide interdisciplinary VEXAS patient cohort, characterized by heterogeneous rheumatologic manifestations and treatments used. MDS was diagnosed in 71% of cases. Patients exhibited various longitudinal UBA1 clonal dynamics.
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Affiliation(s)
- Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maria Rosaria Pascale
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Antonio Vitale
- Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, University of Siena and Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy
| | - Elisa Diral
- Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS Ospedale San Raffaele & Vita-Salute San Raffaele University, Milan, Italy
| | - Elisa Galossi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Giulia Falconi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Alessandro Bruno
- Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Micol Frassi
- ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Chiara Cattaneo
- ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Diego Bertoli
- ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Massimo Bernardi
- Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Erika Morsia
- Hematology Department, University of Ancona, Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Antonella Poloni
- Hematology Department, University of Ancona, Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Elena Crisà
- Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | | | - Paola Triggianese
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Luisa Brussino
- Department of Medical Sciences Allergy and Clinical Immunology Unit, University of Torino & Mauriziano Hospital, Torino, Italy
| | - Giorgia Battipaglia
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Federico Caroni
- Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | | | - Flavia Mallegni
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Federica Pilo
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Davide Firinu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Antonio Curti
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Papayannidis
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Attilio Olivieri
- Hematology Department, University of Ancona, Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Sharham Kordasti
- Hematology Department, University of Ancona, Azienda Ospedaliera Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
- Haematology, Guy's Hospital & Comprehensive Cancer Centre, King's College, London, UK
| | - Francesco Albano
- Department of Precision and Regenerative Medicine and Ionian Area, "Aldo Moro" University, Bari, Italy
| | - Fabrizio Pane
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Pellegrino Musto
- Department of Precision and Regenerative Medicine and Ionian Area, "Aldo Moro" University, Bari, Italy
| | - Monica Bocchia
- Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Elisabetta Lugli
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Massimo Breccia
- Department of Translational and Precision Medicine, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Marco Frigeni
- Azienda SocioSanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS Ospedale San Raffaele & Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaella Greco
- Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS Ospedale San Raffaele & Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, University of Siena and Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
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7
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Koster MJ, Lasho TL, Olteanu H, Reichard KK, Mangaonkar A, Warrington KJ, Patnaik MM. VEXAS syndrome: Clinical, hematologic features and a practical approach to diagnosis and management. Am J Hematol 2024; 99:284-299. [PMID: 37950858 DOI: 10.1002/ajh.27156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/13/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is a newly identified disease caused by somatic alterations in UBA1 which produce a recalcitrant inflammatory state along with hematologic disturbances. Patients with VEXAS can have a wide spectrum of clinical symptoms and providers should be familiar with the heterogeneity of associated clinical features. While hematologic parameters may be generally non-specific, peripheral blood features of macrocytosis, monocytopenia, and/or thrombocytopenia coupled with bone marrow vacuolization of erythroid or myeloid precursors should raise suspicion for this condition. Due to an increased mortality, prompt recognition and accurate diagnosis is paramount. Access to testing for confirmation of UBA1 variants is not yet universally available but clinicians should understand the current available options for genetic confirmation of this disease. Treatment options are limited due to lack of prospective clinical trials but cytokine directed therapies such as interleukin-6 inhibitors and JAK-STAT inhibitors as well as hypomethylating agents such as azacitidine have shown evidence of partial effect. Though cases are limited, allogeneic stem cell transplantation holds promise for durable response and potential cure. The intent of this review is to outline the pathophysiology of VEXAS syndrome and to provide a practical approach to diagnosis and treatment.
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Affiliation(s)
- Matthew J Koster
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Terra L Lasho
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Horatiu Olteanu
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kaaren K Reichard
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhishek Mangaonkar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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8
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Kanagal-Shamanna R, Beck DB, Calvo KR. Clonal Hematopoiesis, Inflammation, and Hematologic Malignancy. ANNUAL REVIEW OF PATHOLOGY 2024; 19:479-506. [PMID: 37832948 DOI: 10.1146/annurev-pathmechdis-051222-122724] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Somatic or acquired mutations are postzygotic genetic variations that can occur within any tissue. These mutations accumulate during aging and have classically been linked to malignant processes. Tremendous advancements over the past years have led to a deeper understanding of the role of somatic mutations in benign and malignant age-related diseases. Here, we review the somatic mutations that accumulate in the blood and their connection to disease states, with a particular focus on inflammatory diseases and myelodysplastic syndrome. We include a definition of clonal hematopoiesis (CH) and an overview of the origins and implications of these mutations. In addition, we emphasize somatic disorders with overlapping inflammation and hematologic disease beyond CH, including paroxysmal nocturnal hemoglobinuria and aplastic anemia, focusing on VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Finally, we provide a practical view of the implications of somatic mutations in clinical hematology, pathology, and beyond.
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Affiliation(s)
- Rashmi Kanagal-Shamanna
- Department of Hematopathology and Molecular Diagnostics, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David B Beck
- Center for Human Genetics and Genomics, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Katherine R Calvo
- Hematology Section, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA;
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, Maryland, USA
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9
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Nicholson LT, Cowen EW, Beck D, Ferrada M, Madigan LM. VEXAS Syndrome-Diagnostic Clues for the Dermatologist and Gaps in Our Current Understanding: A Narrative Review. JID INNOVATIONS 2024; 4:100242. [PMID: 38130326 PMCID: PMC10733701 DOI: 10.1016/j.xjidi.2023.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 12/23/2023] Open
Abstract
Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome is a newly recognized, acquired autoinflammatory disorder with broad systemic implications and a poor global prognosis. Because cutaneous lesions are present in the majority of those affected, it is necessary that dermatologists are equipped to recognize this important disease. Through identification, there is a greater opportunity for disease stratification, surveillance for systemic involvement, and selection of the best available therapies. As our understanding of this disease develops, dermatologists should also play a role in addressing the knowledge gaps that exist.
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Affiliation(s)
| | - Edward W. Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, Maryland, USA
| | - David Beck
- Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Marcela Ferrada
- Rheumatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, Maryland, USA
| | - Lauren M. Madigan
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
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10
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Loeza-Uribe MP, Hinojosa-Azaola A, Sánchez-Hernández BE, Crispín JC, Apodaca-Chávez E, Ferrada MA, Martín-Nares E. VEXAS syndrome: Clinical manifestations, diagnosis, and treatment. REUMATOLOGIA CLINICA 2024; 20:47-56. [PMID: 38160120 DOI: 10.1016/j.reumae.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is an adult-onset autoinflammatory syndrome characterized by somatic mutations in the UBA1 gene and is considered the prototype of hematoinflammatory diseases. Patients with VEXAS syndrome exhibit inflammatory and hematological manifestations that can lead to clinical diagnoses such as relapsing polychondritis, polyarteritis nodosa, Sweet syndrome, and myelodysplastic syndrome. Diagnosis requires bone marrow evaluation to identify cytoplasmic vacuoles in myeloid and erythroid precursors. However, genetic confirmation of mutations in UBA1 is necessary. Treatment is challenging and often involves glucocorticoids and immunosuppressants with variable responses. Hypomethylating agents and allogenic haemopoietic stem cell transplant are considered promising therapies. Prognosis is influenced by genetic and clinical factors. The aim of this review is to provide an overview of the pathogenesis, clinical presentation, treatment, and prognosis of VEXAS syndrome for the Latin American medical community.
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Affiliation(s)
- Michelle Patricia Loeza-Uribe
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Beatriz E Sánchez-Hernández
- Departamento de Patología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - José C Crispín
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Elia Apodaca-Chávez
- Departamento de Hematología y Oncología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
| | - Eduardo Martín-Nares
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
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11
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Chiaramida A, Obwar SG, Nordstrom AEH, Ericsson M, Saldanha A, Ivanova EV, Griffin GK, Khan DH, Belizaire R. Sensitivity to targeted UBA1 inhibition in a myeloid cell line model of VEXAS syndrome. Blood Adv 2023; 7:7445-7456. [PMID: 38091008 PMCID: PMC10758730 DOI: 10.1182/bloodadvances.2023010531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/09/2023] [Indexed: 12/18/2023] Open
Abstract
Somatic UBA1 mutations in hematopoietic cells are a hallmark of Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) syndrome, which is a late-onset inflammatory disease associated with bone marrow failure and high mortality. The majority of UBA1 mutations in VEXAS syndrome comprise hemizygous mutations affecting methionine-41 (M41), leading to the expression of UBA1M41T, UBA1M41V, or UBA1M41L and globally reduced protein polyubiquitination. Here, we used CRISPR-Cas9 to engineer isogenic 32D mouse myeloid cell lines expressing hemizygous Uba1WT or Uba1M41L from the endogenous locus. Consistent with prior analyses of patients with VEXAS syndrome samples, hemizygous Uba1M41L expression was associated with loss of the UBA1b protein isoform, gain of the UBA1c protein isoform, reduced polyubiquitination, abnormal cytoplasmic vacuoles, and increased production of interleukin-1β and inflammatory chemokines. Vacuoles in Uba1M41L cells contained a variety of endolysosomal membranes, including small vesicles, multivesicular bodies, and multilamellar lysosomes. Uba1M41L cells were more sensitive to the UBA1 inhibitor TAK243. TAK243 treatment promoted apoptosis in Uba1M41L cells and led to preferential loss of Uba1M41L cells in competition assays with Uba1WT cells. Knock-in of a TAK243-binding mutation, Uba1A580S, conferred TAK243 resistance. In addition, overexpression of catalytically active UBA1b in Uba1M41L cells restored polyubiquitination and increased TAK243 resistance. Altogether, these data indicate that loss of UBA1b underlies a key biochemical phenotype associated with VEXAS syndrome and renders cells with reduced UBA1 activity vulnerable to targeted UBA1 inhibition. Our Uba1M41L knock-in cell line is a useful model of VEXAS syndrome that will aid in the study of disease pathogenesis and the development of effective therapies.
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Affiliation(s)
| | - Sandra G. Obwar
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Maria Ericsson
- Department of Cell Biology, Harvard Medical School, Boston, MA
| | - Aisha Saldanha
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, MA
| | - Elena V. Ivanova
- Belfer Center for Applied Cancer Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Dilshad H. Khan
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA
| | - Roger Belizaire
- Department of Pathology, Dana-Farber Cancer Institute, Boston, MA
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12
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Baur V, Stoevesandt J, Hueber A, Hüffmeier U, Kneitz H, Morbach H, Schultz E, Goebeler M. VEXAS-Syndrome, a newly described autoinflammatory systemic disease with dermatologic manifestations. J Dtsch Dermatol Ges 2023; 21:1456-1463. [PMID: 37953404 DOI: 10.1111/ddg.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/27/2023] [Indexed: 11/14/2023]
Abstract
VEXAS syndrome is a recently identified autoinflammatory systemic disease caused by an acquired somatic mutation of the X-linked UBA1 gene, the key enzyme of the first step of ubiquitylation. The acronym VEXAS stands for the characteristics Vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic. The disease occurs in advanced adulthood preferentially in men and is characterized by hematological, rheumatological and dermatological symptoms. The latter include neutrophil-rich lesions reminiscent of Sweet's syndrome, erythema nodosum- and panniculitis-like skin manifestations and recurrent polychondritis of the nose and auricles. The presence of cytoplasmic vacuoles in myeloid and erythroid precursors in the bone marrow is characteristic. In up to half of the cases, VEXAS syndrome is associated with myelodysplastic syndrome. Dermatologists should be familiar with the clinical picture, as skin symptoms are often the first indicator of the disease. Molecular diagnostics are essential for confirming the diagnosis and risk stratification of affected patients. In this minireview we provide an overview of the pathophysiology, diagnosis and therapy of VEXAS syndrome and illustrate its clinical picture with two own cases.
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Affiliation(s)
- Vera Baur
- Department of Dermatology, Paracelsus Medical Private University, Nuremberg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Axel Hueber
- Department of Rheumatology, Paracelsus Medical Private University, Nuremberg, Germany
| | - Ulrike Hüffmeier
- Institute of Human Genetics, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Hermann Kneitz
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Henner Morbach
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Erwin Schultz
- Department of Dermatology, Paracelsus Medical Private University, Nuremberg, Germany
| | - Matthias Goebeler
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
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13
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Baur V, Stoevesandt J, Hueber A, Hüffmeier U, Kneitz H, Morbach H, Schultz E, Goebeler M. VEXAS-Syndrom, eine neu beschriebene autoinflammatorische Systemerkrankung mit dermatologischen Manifestationen. J Dtsch Dermatol Ges 2023; 21:1456-1464. [PMID: 38082529 DOI: 10.1111/ddg.15227_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/27/2023] [Indexed: 12/18/2023]
Abstract
ZusammenfassungDas VEXAS‐Syndrom ist eine kürzlich erstbeschriebene autoinflammatorische Systemerkrankung, die auf einer erworbenen, somatischen Mutation des X‐chromosomal lokalisierten UBA1‐Gens, dem Schlüsselenzym des ersten Schritts der Ubiquitinierung, beruht. Das Akronym VEXAS steht für die Charakteristika Vacuoles, E1 enzyme, X‐linked, autoinflammatory und somatic. Die Erkrankung tritt im fortgeschrittenen Erwachsenenalter vorzugsweise bei Männern auf und ist insbesondere durch hämatologische, rheumatologische und dermatologische Symptome gekennzeichnet. Letztere umfassen unter anderem neutrophilenreiche, an das Sweet‐Syndrom erinnernde Läsionen, Erythema nodosum‐ und Pannikulitis‐artige Hauterscheinungen sowie rezidivierende Polychondritiden an Nase und Ohrmuscheln. Das Vorliegen zytoplasmatischer Vakuolen in myeloiden und erythroiden Vorläuferzellen des Knochenmarks ist charakteristisch. In bis zur Hälfte der Fälle ist das VEXAS‐Syndrom mit einem myelodysplastischen Syndrom vergesellschaftet. Dermatologen sollten das Krankheitsbild kennen, da Hauterscheinungen oft der erste Indikator für die Erkrankung sind. Eine molekulare Diagnostik ist essenziell für die Diagnosesicherung und die Risikostratifizierung betroffener Patienten. In dieser Arbeit geben wir einen Überblick über die Pathophysiologie, Diagnostik und Therapie des VEXAS‐Syndroms und illustrieren das klinische Spektrum anhand zweier eigener Fälle.
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Affiliation(s)
- Vera Baur
- Klinik für Dermatologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Johanna Stoevesandt
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Axel Hueber
- Abteilung für Rheumatologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Ulrike Hüffmeier
- Humangenetisches Institut, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Deutschland
| | - Hermann Kneitz
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Henner Morbach
- Kinderklinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Erwin Schultz
- Klinik für Dermatologie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Matthias Goebeler
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Würzburg, Würzburg, Deutschland
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14
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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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Moura MC, Baqir M, Tandon YK, Samec MJ, Hines AS, Reichard KK, Mangaonkar AA, Go RS, Warrington KJ, Patnaik MM, Koster MJ, Ryu JH. Pulmonary manifestations in VEXAS syndrome. Respir Med 2023; 213:107245. [PMID: 37062498 DOI: 10.1016/j.rmed.2023.107245] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a recently recognized multisystem disorder caused by somatic mutations in the UBA1 gene. METHODS A retrospective cohort study was conducted on all patients with VEXAS syndrome evaluated at our institution from June 2020 through May 2022. Medical records and chest imaging studies were reviewed. RESULTS We identified 45 subjects with median age of 68 years (range, 57-89), all men. Prior to VEXAS diagnosis, most patients had been diagnosed with various hematologic, rheumatologic, and dermatologic disorders. Most patients (84%) demonstrated canonical UBA1 methionine-41 (p.Met41) somatic mutations in hematopoietic cells. Fever (82%), skin lesions (91%), and respiratory symptoms (93%) were common presenting features. Chest CT manifested abnormalities in 91% of patients including parenchymal opacities in 25 (74%), most commonly ground-glass opacities (47%), along with mediastinal lymphadenopathy (29%), airway abnormalities (29%), and pleural effusion (24%). Pulmonary function test results available in 18 (40%) patients demonstrated mild restrictive impairment or normal results. Bronchoalveolar lavage and lung biopsy performed in a minority of patients demonstrated neutrophilic alveolitis and parenchymal inflammation, respectively. All patients received glucocorticoid therapy with at least partial response, but relapses were common and other immunosuppressive agents were employed in most patients. Pulmonary involvement appeared to improve in patients who received tocilizumab and JAK inhibitors. CONCLUSION The pulmonary manifestations in VEXAS are relatively nonspecific and nonsevere, occur in the context of systemic inflammation and are responsive to escalation in glucocorticoid dosing.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yasmeen K Tandon
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Matthew J Samec
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Alexander S Hines
- Division of Dermatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kaaren K Reichard
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Abhishek A Mangaonkar
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Ronald S Go
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mathew J Koster
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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Bruno A, Gurnari C, Alexander T, Snowden JA, Greco R. Autoimmune manifestations in VEXAS: Opportunities for integration and pitfalls to interpretation. J Allergy Clin Immunol 2023; 151:1204-1214. [PMID: 36948992 DOI: 10.1016/j.jaci.2023.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/24/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a novel entity manifesting with a multiplicity of clinical features. Somatic mutations of the UBA1 gene in hematopoietic stem cells constitute the genetic basis of VEXAS. As an X-linked disorder, most cases occur in men, classically developing symptoms during the fifth to sixth decade of life. Considering its multidisciplinary nature involving numerous branches of internal medicine, VEXAS has elicited a wide medical interest and several medical conditions have been associated with this disease. Even so, its recognition in everyday clinical practice is not necessarily straightforward. Close collaboration between different medical specialists is mandatory. Patients with VEXAS may manifest a range of features from manageable cytopenias to disabling and life-threatening autoimmune phenomena with limited responses to therapy, with the potential for progression to hematological malignancies. Diagnostic and treatment guidelines are exploratory and include a range of rheumatological and supportive care treatments. Allogeneic hematopoietic stem cell transplantation is potentially curative, but its risks are significant and its position in the treatment algorithm is yet to be defined. Herein, we present the variegated manifestations of VEXAS, provide practice criteria for diagnostic testing of UBA1, and discuss potential treatment options, including allogeneic hematopoietic stem cell transplantation, current evidence, and future directions.
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Affiliation(s)
- Alessandro Bruno
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - John A Snowden
- Sheffield Blood & Marrow Transplant and Cellular Therapy Programme, Department of Haematology, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
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Heiblig M, Patel B, Jamilloux Y. VEXAS syndrome, a new kid on the block of auto-inflammatory diseases: A hematologist's point of view. Best Pract Res Clin Rheumatol 2023; 37:101861. [PMID: 37652853 DOI: 10.1016/j.berh.2023.101861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023]
Abstract
The recently discovered VEXAS syndrome is caused by the clonal expansion of hematopoietic stem or progenitor cells with acquired mutations in UBA1 gene, which encodes for a key enzyme of the ubiquitylation proteasome system. As a result, a shorter cytoplasmic isoform of UBA1 is transcribed, which is non-functional. The disease is characterized by non-specific and highly heterogeneous inflammatory manifestations and macrocytic anemia. VEXAS syndrome is a unique acquired hematological monogenic disease with unexpected association with hematological neoplasms. Despite its hematopoetic origin, patients with VEXAS syndrome usually present with multi-systemicinflammatory disease and are treated by physicians from many different specialties (rheumatologists, dermatologists, hematologistis, etc.). Furthermore, manifestations of VEXAS may fulfill criteria for existing diseases: relapsing polychondritis, giant cell arteritis, polyarteritis nodosa, and myelodysplastic syndrome. The goal of this review is to depict VEXAS syndrome from a hematologic point of view regarding its consequences on hematopoiesis and the current strategies on therapeutic interventions.
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Affiliation(s)
- Maël Heiblig
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'hématologie clinique, Lyon, France; Université Claude Bernard Lyon 1, Faculté de médecine et de maïeutique Lyon Sud Charles Mérieux, Lymphoma Immunobiology Team, Pierre Bénite, France.
| | - Bhavisha Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service de médecine interne, Lyon, France
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Abstract
INTRODUCTION VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described, late-onset, acquired autoinflammatory disorder caused by mutations in the UBA1 gene. The various clinical manifestations of VEXAS broadly divided into inflammatory or haematological. VEXAS defines a new disease category - the hematoinflammatory disorders triggered by somatic mutations restricted to blood but causing systemic inflammation with multi-organ involvement and associated with aberrant bone marrow status. VEXAS causes significant morbidity and reduced life expectancy, but the optimum standard of care remains undefined. AREAS COVERED This review describes the discovery of VEXAS, relevant genetic causes and immunopathology of the disease. A detailed account of its various clinical manifestations and disease mimics is provided. Current treatment and management options are discussed. EXPERT OPINION New rare variants in UBA1 and VEXAS-like UBA1 negative cases are reported. Consensus diagnostic criteria might be required to define VEXAS and its related disorders. Investigation of sporadic, VEXAS-like cases will require the application of deep sequencing using DNA obtained from various cellular or tissue locations. Prospective studies are needed to define the optimal supportive and treatment options for patients with varying disease severity and prognosis. VEXAS-specific hematopoietic stem cell transplant selection criteria also require development.
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Affiliation(s)
- Adam Al-Hakim
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Leeds, UK.,National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, School of Medicine, University of Leeds, Leeds, UK
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