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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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Sofi FA, Naqati SM, Ahmad M, Bindroo M. VEXAS syndrome presenting as diffuse alveolar haemorrhage. BMJ Case Rep 2024; 17:e259474. [PMID: 38538102 PMCID: PMC10982693 DOI: 10.1136/bcr-2023-259474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
We report the case of a man in his late 30s who presented with a history of breathlessness and cough with haemoptysis. Complete blood counts revealed pancytopenia. High-resolution CT showed diffuse bilateral ground glass opacities. Sequential bronchoalveolar lavage confirmed alveolar haemorrhage. Bone marrow aspiration showed vacuoles in erythroid and myeloid precursor cells. The genome was sequenced, and the UBA1 gene revealed a c.121 A>G mutation (p.Met41Val), confirming vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome. The patient was managed with high-dose prednisolone pulse therapy. He improved with the complete resolution of the alveolar haemorrhage and an improvement in lung function and cytopenias.
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Affiliation(s)
- Fayaz Ahmad Sofi
- General Medicine, Division of Rheumatology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Shaariq Mehraj Naqati
- General Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Mushtaq Ahmad
- General Medicine, Division of Rheumatology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Muzaffar Bindroo
- General Medicine, Division of Rheumatology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
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Oka H, Sumitomo S, Nishikubo M, Yamashita D, Maruoka H, Shiroishi Y, Shimizu H, Kanamori M, Nishioka H, Ohmura K. VEXAS syndrome with granulomatosis with polyangiitis manifestation: retained in remission using methotrexate and infliximab. Rheumatology (Oxford) 2024; 63:e110-e112. [PMID: 37792501 DOI: 10.1093/rheumatology/kead536] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/06/2023] Open
Affiliation(s)
- Hideki Oka
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Shuji Sumitomo
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Masashi Nishikubo
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Daisuke Yamashita
- Department of Pathology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hayato Maruoka
- Department of Clinical Laboratory, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Yumi Shiroishi
- Department of Clinical Laboratory, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hayato Shimizu
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Maki Kanamori
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hiroaki Nishioka
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Koichiro Ohmura
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
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Chen KR. Cutaneous vasculitis in autoinflammatory diseases. J Dermatol 2024; 51:150-159. [PMID: 37955334 DOI: 10.1111/1346-8138.17030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023]
Abstract
Autoinflammatory diseases (AIDs) characterized by recurrent episodes of localized or systemic inflammation are disorders of the innate immune system. Skin lesions are commonly found in AIDs and cutaneous vasculitis can coexist with AIDs and even present as the most striking feature. This review aims to focus on the frequent cutaneous vasculitis association in three monogenic AIDs including familial Mediterranean fever (FMF), deficiency of adenosine deaminase type 2 (DADA2), and the recently identified adult-onset VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Cutaneous vasculitis in FMF is characterized by: (1) small-vessel vasculitis similar to IgA vasculitis with palpable purpura but increased intussusception complication and less vascular IgA deposit, and (2) cutaneous arteritis-like vasculitis presenting as subcutaneous nodules most often with higher glomerular involvement. DADA2 has a wide spectrum of clinical presentations ranging from fatal systemic vasculitis with multiple strokes, especially in pediatric patients, to limited cutaneous disease in middle-aged patients. DADA2 shares similar clinical and histopathological features with polyarteritis nodosa (PAN). As a result, DADA2 is commonly initially misdiagnosed as childhood PAN. Livedo racemosa reveals the most common cutaneous manifestation of cutaneous vasculitis in patients with DADA2. VEXAS syndrome is a life-threatening disease. A diagnosis of VEXAS syndrome should be strongly considered or could be made in patients with skin lesions characterized by Sweet syndrome-like eruption, livedo racemosa, concomitant relapsing polychondritis, deep venous thrombosis, pulmonary involvement, and progressive hematologic abnormalities such as myelodysplastic syndrome with a unique finding of cytoplasmic vacuoles in myeloid and erythroid precursor cells from bone marrow aspirate smear. As skin involvement is common in AIDs and may present as the most frequent manifestation, especially in DADA2 (70% to 90%) and VEXAS syndrome (83% to 91%), dermatologists play a crucial role in contributing to the early diagnosis of these AIDs with early initiation of the appropriate therapy to avoid progressing fatal outcomes.
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Affiliation(s)
- Ko-Ron Chen
- Meguro Chen Dermatology Clinic, Tokyo, Japan
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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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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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Boyadzhieva Z, Ruffer N, Kötter I, Krusche M. How to treat VEXAS syndrome: a systematic review on effectiveness and safety of current treatment strategies. Rheumatology (Oxford) 2023; 62:3518-3525. [PMID: 37233149 DOI: 10.1093/rheumatology/kead240] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES To evaluate the effectiveness and safety of current treatment strategies for the vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. METHODS A protocolized systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Three databases were searched for reports on treatment strategies for VEXAS. Data from the included publications was extracted and a narrative synthesis was performed. Treatment response was recorded as complete (CR), partial (PR) or none (NR) depending on changes in clinical symptoms and laboratory parameters. Patient characteristics, safety data and previous treatments were analysed. RESULTS We identified 36 publications with a total of 116 patients; 113 (98.3%) were male. The identified reports included azacytidine (CR 9/36, 25%; PR 14/36, 38.9%), Janus kinase inhibitors (JAKi) (CR 11/33, 33%; PR 9/33, 27.3%), tocilizumab (CR 3/15, 20%; PR 6/15, 40%), allogeneic stem cell transplantation (CR 6/7, 85.7%; one patient died), anakinra (CR 4/5, 80%; NR 1/5, 20%), canakinumab (CR 1/2, 50%; PR 1/2, 50%) and glucocorticoid monotherapy (CR 1/6, 16.7%; PR 4/6, 66.7%). Individual reports were available for TNF inhibitors, rituximab and MTX. Data on adverse events were available for 67 patients (67/116, 57.8%) and included: pneumonia (12/67, 17.9%), other infections (9/67, 13.4%), venous thromboembolisms (6/67, 8.9%), cytopenias (4/67, 5.9%), and acute (4/67, 5.9%) and chronic graft-vs-host-disease (2/67, 2.9%). CONCLUSION Current data on VEXAS treatment are limited and inhomogeneous. Treatment decisions should be individualized. For the devolvement of treatment algorithms clinical trials are needed. Adverse events remain a challenge, especially an elevated risk for venous thromboembolism associated to JAKi treatment should be carefully considered.
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Affiliation(s)
- Zhivana Boyadzhieva
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nikolas Ruffer
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ina Kötter
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Rheumatology and Immunology, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Martin Krusche
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Watanabe R, Kiji M, Hashimoto M. Vasculitis associated with VEXAS syndrome: A literature review. Front Med (Lausanne) 2022; 9:983939. [PMID: 36045928 PMCID: PMC9420898 DOI: 10.3389/fmed.2022.983939] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Vasculitis is an inflammatory disorder of the blood vessels that causes damage to a wide variety of organs through tissue ischemia. Vasculitis is classified according to the size (large, medium, or small) of the blood vessels. In 2020, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, a novel autoinflammatory syndrome, was described. Somatic mutations in methionine-41 of UBA1, the major E1 enzyme that initiates ubiquitylation, are attributed to this disorder. This new disease entity connects seemingly unrelated conditions: inflammatory syndromes (relapsing chondritis, Sweet's syndrome, or neutrophilic dermatosis) and hematologic disorders (myelodysplastic syndrome or multiple myeloma). Notably, such patients sometimes develop vasculitis, such as giant cell arteritis and polyarteritis nodosa, and fulfill the corresponding classification criteria for vasculitis. Thus, vasculitis can be an initial manifestation of VEXAS syndrome. In this research topic exploring the link between autoinflammatory diseases and vasculitis, we first provide an overview of the disease mechanisms and clinical phenotypes of VEXAS syndrome. Then, a literature review using the PubMed database was performed to delineate the clinical characteristics of vasculitis associated with VEXAS syndrome. Finally, the therapeutic options and unmet needs of VEXAS syndrome are discussed.
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Alcedo PE, Gutierrez-Rodrigues F, Patel BA. Somatic mutations in VEXAS Syndrome and Erdheim-Chester Disease: Inflammatory Myeloid Diseases. Semin Hematol 2022; 59:156-166. [DOI: 10.1053/j.seminhematol.2022.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 12/27/2022]
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