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Phan L, Hammond D, Wilson NR, Groarke EM, Patnaik MM, Pemmaraju N. VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic): clinical review in a rapidly emerging field. Leuk Lymphoma 2024; 65:1245-1257. [PMID: 38770970 DOI: 10.1080/10428194.2024.2349950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/22/2024]
Abstract
VEXAS syndrome is a recently described entity characterized by systemic inflammatory and hematologic manifestations. The disease was first characterized by Beck et al. in 2020 in a study characterizing 25 patients with undiagnosed adult-onset inflammatory syndromes. While the literature regarding VEXAS syndrome has grown exponentially since 2020, there is still much to be understood. This lack of information leads to challenges in both the diagnosis and treatment of patients with VEXAS syndrome. Patients will often have a variety of clinical symptoms that can lead to missed or delayed diagnoses. Additionally, awareness of VEXAS syndrome is still developing among clinicians. In this comprehensive review, we summarize the current literature regarding VEXAS syndrome, and explore clinical updates of this emerging disease state. Our aim of this review is to increase awareness regarding this new disease state and identify research areas to better understand future treatment approaches for patients with VEXAS syndrome.
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Affiliation(s)
- Luan Phan
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Danielle Hammond
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nathaniel R Wilson
- Department of Internal Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mrinal M Patnaik
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Berger M, Schumacher F, Wollsching-Strobel M, Kroppen D, Stanzel SB, Majorski DS, Fricke K, Plath I, Windisch W, Zimmermann M. A clinical phenotype of VEXAS syndrome with pleural effusion, infiltrates, and systemic inflammation in a 76-year-old patient: a case report. J Med Case Rep 2024; 18:392. [PMID: 39180090 PMCID: PMC11344313 DOI: 10.1186/s13256-024-04688-9] [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: 04/10/2024] [Accepted: 07/08/2024] [Indexed: 08/26/2024] Open
Abstract
INTRODUCTION VEXAS syndrome, characterized by a UBA1 gene mutation, is a rare and severe systemic inflammatory disease predominantly affecting men. Since its initial description in 2020, it has been noted for its broad clinical phenotype and frequent misdiagnosis. CASE PRESENTATION A 76-year-old Caucasian male patient diagnosed with VEXAS syndrome is presented in this case report. He presented with typical symptoms including pulmonary manifestations (infiltrates and effusions), systemic inflammation, and haematological abnormalities. The diagnosis was challenging due to the disease's heterogeneous presentation, often resembling autoimmune or haematological diseases. This patient's case featured ground-glass opacities and pleural effusions, underlining the significant pulmonary involvement seen in 50-67% of VEXAS patients. His condition was further complicated by recurrent fever and systemic inflammation affecting multiple organs. CONCLUSION VEXAS syndrome demands an aggressive treatment approach due to its high mortality rate and refractory nature. This case underscores the importance of including VEXAS syndrome in differential diagnoses, particularly for patients with systemic inflammation and pulmonary symptoms, and calls for multidisciplinary management and extensive research to understand its full range of clinical phenotypes.
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Affiliation(s)
- Melanie Berger
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany.
| | - Falk Schumacher
- Department Humanmedizin, Universität Witten/Herdecke, Witten, Germany
- Klinik für Rheumatologie, Krankenhaus Porz am Rhein gGmbH, Cologne, Germany
| | - Maximilian Wollsching-Strobel
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Doreen Kroppen
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Sarah B Stanzel
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Daniel S Majorski
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Kathrin Fricke
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Ilka Plath
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Wolfram Windisch
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
| | - Maximilian Zimmermann
- Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University, Ostmerheimer Strasse 200, 51109, Cologne, Germany
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Dias AL, Groarke EM, Hickstein D, Patel B. Role of allogeneic hematopoietic cell transplantation in VEXAS syndrome. Ann Hematol 2024:10.1007/s00277-024-05942-2. [PMID: 39168911 DOI: 10.1007/s00277-024-05942-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a newly diagnosed syndrome comprising severe systemic inflammatory and hematological manifestations including myelodysplastic syndrome and plasma cell dyscrasia. Since its discovery four years ago, several groups have identified pleomorphic clinical phenotypes, but few effective medical therapies exist which include Janus Kinase (JAK) inhibitors, interleukin inhibitors (IL-1 and IL-6), and hypomethylating agents. Prospective trials are lacking at this time and most patients remain corticosteroid dependent. VEXAS has a high morbidity from frequent life threatening inflammatory symptoms and risk of progression to hematological malignancies and has an overall survival of 50% at 10 years. Allogeneic stem cell transplant (allo-HCT) is a curative option for this disease caused by somatic mutations in the UBA1 gene. Here we outline the role of allo-HCT in treating patients with VEXAS syndrome, highlighting the outcomes from several single-institution studies and case reports. Prospective trials will be required to precisely define the role of allo-HCT in the management of VEXAS syndrome.
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Affiliation(s)
- Ajoy L Dias
- Immune Deficiency - Cellular Therapy Program, National Cancer Institute, National Institute of Health, Building 10 CRC/Room 3-3150, 10 Center Drive MSC 1102, Bethesda, MD, 20892, USA.
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, USA
| | - Dennis Hickstein
- Immune Deficiency - Cellular Therapy Program, National Cancer Institute, National Institute of Health, Building 10 CRC/Room 3-3150, 10 Center Drive MSC 1102, Bethesda, MD, 20892, USA
| | - Bhavisha Patel
- Hematology Branch, National Heart, Lung, Blood Institute, National Institute of Health, Bethesda, MD, USA
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Aalbers AM, van Daele PLA, Dalm VASH, Valk PJM, Raaijmakers MHGP. Long-term genetic and clinical remissions after cessation of azacitidine treatment in patients with VEXAS syndrome. Hemasphere 2024; 8:e129. [PMID: 39081801 PMCID: PMC11287193 DOI: 10.1002/hem3.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/29/2024] [Accepted: 06/17/2024] [Indexed: 08/02/2024] Open
Affiliation(s)
- Anna M. Aalbers
- Department of Hematology, Erasmus MC Cancer InstituteUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Paul L. A. van Daele
- Department of Internal Medicine, Division of Allergy & Clinical Immunology, and Department of Immunology, Erasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Virgil A. S. H. Dalm
- Department of Internal Medicine, Division of Allergy & Clinical Immunology, and Department of Immunology, Erasmus MCUniversity Medical Center RotterdamRotterdamthe Netherlands
| | - Peter J. M. Valk
- Department of Hematology, Erasmus MC Cancer InstituteUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marc H. G. P. Raaijmakers
- Department of Hematology, Erasmus MC Cancer InstituteUniversity Medical Center RotterdamRotterdamThe Netherlands
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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] [MESH Headings] [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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Langlois V, Curie A, Demas A, Etancelin P, Sauvètre G, Leclancher A, Mekinian A. Central nervous system vasculitis in VEXAS syndrome: A rare involvemen. Clin Neurol Neurosurg 2024; 242:108351. [PMID: 38801808 DOI: 10.1016/j.clineuro.2024.108351] [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: 03/06/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION VEXAS (Vacuoles, E1 Enzyme, X-linked, autoinflammatory, Somatic) syndrome is a recently described severe adult-onset autoinflammatory disorder mediated by X-linked gene UBA1 somatic mutations, responsible of recurrent fever, skin involvement, chondritis, macrocytic anemia and inflammatory syndrome. Neurological manifestations are rarely described, and predominantly involve peripheral nervous system (PNS) impairment. RESULTS We report the first central nervous system (CNS) vasculitis in VEXAS syndrome, characterized by headache, cognitive dysfunction and focal signs (cerebellar ataxia). Magnetic resonance imaging (MRI) revealed multifocal white-matter lesions corresponding to recent ischemic strokes, combined with cortical hemorrhagic lesions and gadolinium enhancement of the distal wall vessels. Treatment with methylprednisone, ruxolitinib and tocilizumab led to clinical improvement and a decrease of the inflammatory syndrome. The patient died few months after due to infectious complications. CONCLUSION CNS vasculitis, occurring as a manifestation of the systemic auto-inflammatory state of VEXAS syndrome, might be a rare but severe complication. We suggest that it be added to the list of inflammatory vasculopathies. More prospective studies are needed to optimize the treatment.
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Affiliation(s)
- V Langlois
- Service de médecine interne et maladies infectieuses, Groupe Hospitalier du Havre, France.
| | - A Curie
- Service de médecine interne et maladies infectieuses, Groupe Hospitalier du Havre, France; Service de médecine interne, Centre Hospitalier Eure Seine, Evreux, France
| | - A Demas
- Service de neurologie, Groupe hospitalier du Havre, France
| | - P Etancelin
- Laboratoire de génétique oncologique, Centre de lutte contre le cancer Henri Becquerel, Rouen, France
| | - G Sauvètre
- Service de médecine interne, CHU de Rouen, France
| | - A Leclancher
- Service de neurologie, Groupe hospitalier du Havre, France
| | - A Mekinian
- Service de médecine interne, Hôpital Saint Antoine, Paris, France
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Mertz P, Costedoat-Chalumeau N, Ferrada MA, Moulis G, Mekinian A, Grayson PC, Arnaud L. Relapsing polychondritis: clinical updates and new differential diagnoses. Nat Rev Rheumatol 2024; 20:347-360. [PMID: 38698240 DOI: 10.1038/s41584-024-01113-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/05/2024]
Abstract
Relapsing polychondritis is a rare inflammatory disease characterized by recurrent inflammation of cartilaginous structures, mainly of the ears, nose and respiratory tract, with a broad spectrum of accompanying systemic features. Despite its rarity, prompt recognition and accurate diagnosis of relapsing polychondritis is crucial for appropriate management and optimal outcomes. Our understanding of relapsing polychondritis has changed markedly in the past couple of years with the identification of three distinct patient clusters that have different clinical manifestations and prognostic outcomes. With the progress of pangenomic sequencing and the discovery of new somatic and monogenic autoinflammatory diseases, new differential diagnoses have emerged, notably the vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome, autoinflammatory diseases and immune checkpoint inhibitor-related adverse events. In this Review, we present a detailed update of the newly identified clusters and highlight red flags that should raise suspicion of these alternative diagnoses. The identification of these different clusters and mimickers has a direct impact on the management, follow-up and prognosis of patients with relapsing polychondritis and autoinflammatory syndromes.
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Affiliation(s)
- Philippe Mertz
- Department of Rheumatology, National Reference Center for Rare Autoimmune Diseases (RESO), INSERM UMR-S 1109, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Nathalie Costedoat-Chalumeau
- National Referral Centre for Rare Autoimmune and Systemic Diseases, Department of Internal Medicine, Hôpital Cochin, AP-HP Centre, Université Paris Cité, Paris, France
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Arsène Mekinian
- Service de Médecine Interne, DHUi2B, Hôpital Saint-Antoine, Paris, France
| | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Rare Autoimmune Diseases (RESO), INSERM UMR-S 1109, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
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8
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Pankow A, Krusche M. [The most frequent febrile syndromes and autoinflammatory diseases in adulthood]. Z Rheumatol 2024; 83:363-375. [PMID: 38802504 DOI: 10.1007/s00393-024-01522-x] [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] [Accepted: 04/24/2024] [Indexed: 05/29/2024]
Abstract
Autoinflammatory diseases are characterized by inflammatory manifestations in various organ systems, whereby recurrent febrile episodes, musculoskeletal complaints, gastrointestinal and cutaneous symptoms frequently occur accompanied by serological signs of inflammation. Autoinflammatory diseases include rare monogenic entities and multifactorial or polygenic diseases, which can manifest as a variety of symptoms in the course of time. Examples of monogenic autoinflammatory diseases are familial Mediterranean fever (FMF), cryopyrin-associated periodic syndrome (CAPS), tumor necrosis factor (TNF) receptor-associated periodic syndrome (TRAPS) and the recently described VEXAS (vacuoles, E1 enzyme, X‑linked, autoinflammatory and somatic) syndrome. For non-monogenically determined autoinflammatory diseases, the most important representatives in adulthood are adult-onset Still's disease (AOSD) and the Schnitzler syndrome, in which a polygenic susceptibility and epigenetic factors are more likely to play a role.
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Affiliation(s)
- Anne Pankow
- Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Martin Krusche
- Nephrologie, Rheumatologie, Endokrinologie, III. Medizinische Klinik und Poliklinik, Martinistr. 52, 20251, Hamburg, Deutschland
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Nakajima H, Kunimoto H. VEXAS syndrome. Int J Hematol 2024:10.1007/s12185-024-03799-9. [PMID: 38819628 DOI: 10.1007/s12185-024-03799-9] [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: 02/19/2024] [Revised: 05/12/2024] [Accepted: 05/21/2024] [Indexed: 06/01/2024]
Abstract
VEXAS syndrome is a recently identified, adult-onset autoinflammatory disease caused by somatic mutations in UBA1. UBA1 is an X-linked gene encoding E1 ubiquitin activating enzyme and its mutation in hematopoietic stem and progenitor cells leads to their clonal expansion and myeloid-skewed differentiation. UBA1 mutations in VEXAS are clustered at the second methionine (p.Met41), eliminating UBA1b isoform translated from p.Met41. Loss of UBA1b impairs ubiquitination and activates innate immune pathways, leading to systemic autoinflammation manifested as recurrent fever, chondritis, pulmonary involvement, vasculitis, or neutrophilic dermatitis. VEXAS syndrome is frequently associated with hematological disorders such as myelodysplastic syndrome (MDS), plasma cell dyscrasia and venous thromboembolism. Macrocytic anemia/macrocytosis and vacuoles in myeloid/erythroid precursors are prominent features of VEXAS syndrome, and their presence in patients with autoinflammatory symptoms prompts physicians to screen for UBA1 variant. Treatment of VEXAS syndrome is challenging and no consistently effective therapies have been established. Anti-inflammation therapies including glucocorticoids and anti-interleukin-6 have shown limited efficacy, while azacytidine and JAK inhibitors such as ruxolitinib were found to induce favorable, mid-term responses. Hematopoietic stem cell transplantation is the only curative option for VEXAS and should be considered for younger, fit patients with poor prognostic factors or recalcitrant symptoms.
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Affiliation(s)
- Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fuku-Ura, Kanazawa-Ku, Yokohama, 236-0004, Japan.
| | - Hiroyoshi Kunimoto
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fuku-Ura, Kanazawa-Ku, Yokohama, 236-0004, Japan
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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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Bica BERG, de Souza AWS, Pereira IA. Unveiling the clinical spectrum of relapsing polychondritis: insights into its pathogenesis, novel monogenic causes, and therapeutic strategies. Adv Rheumatol 2024; 64:29. [PMID: 38627861 DOI: 10.1186/s42358-024-00365-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/21/2024] [Indexed: 04/19/2024] Open
Abstract
Relapsing polychondritis is a rare multisystem disease involving cartilaginous and proteoglycan-rich structures. The diagnosis of this disease is mainly suggested by the presence of flares of inflammation of the cartilage, particularly in the ears, nose or respiratory tract, and more rarely, in the presence of other manifestations. The spectrum of clinical presentations may vary from intermittent episodes of painful and often disfiguring auricular and nasal chondritis to an occasional organ or even life-threatening manifestations such as lower airway collapse. There is a lack of awareness about this disease is mainly due to its rarity. In 2020, VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, a novel autoinflammatory syndrome, was described. VEXAS syndrome is attributed to somatic mutations in methionine-41 of UBA1, the major E1 enzyme that initiates ubiquitylation. This new disease entity connects seemingly unrelated conditions: systemic inflammatory syndromes (relapsing chondritis, Sweet's syndrome, and neutrophilic dermatosis) and hematologic disorders (myelodysplastic syndrome or multiple myeloma). Therefore, this article reviews the current literature on both disease entities.
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Affiliation(s)
- Blanca E R G Bica
- Reumatology Division of Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Rio de Janeiro, Rua Esteves Junior 62, CEP 22231-160, Laranjeiras, Rio de Janeiro, RJ, Brazil.
| | | | - Ivânio Alves Pereira
- Reumatologia da Universidade do Sul de Santa Catarina-UNISUL, Florian?polis, RJ, Brazil
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12
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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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Zeisbrich M, Schindler V, Krausz M, Proietti M, Mrovecova P, Voll RE, Glaser C, Röther F, Warnatz K, Venhoff N. [Macrocytic anemia and polychondritis: VEXAS syndrome]. Z Rheumatol 2024; 83:229-233. [PMID: 36735069 PMCID: PMC10973061 DOI: 10.1007/s00393-023-01318-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 02/04/2023]
Abstract
An adult-onset autoinflammatory syndrome caused by somatic mutations in the UBA1 gene on the X chromosome was first reported in 2020. This VEXAS syndrome (acronym for vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) is characterized by an overlap of rheumatic inflammatory diseases with separate hematologic abnormalities. A substantial number of affected patients suffer from treatment refractory relapsing polychondritis and nearly always show signs of macrocytic anemia. This case report illustrates the diagnostic key points to recognizing patients with VEXAS syndrome.
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Affiliation(s)
- Markus Zeisbrich
- Klinik für Rheumatologie und Klinische Immunologie, Vaskulitis-Zentrum Freiburg, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.
- Klinik für Rheumatologie und Klinische Immunologie, Universitätsklinikum Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| | - Viktoria Schindler
- Klinik für Rheumatologie und Klinische Immunologie, Vaskulitis-Zentrum Freiburg, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Máté Krausz
- Centrum für chronische Immundefizienz, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
- Biologische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Michele Proietti
- Centrum für chronische Immundefizienz, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Pavla Mrovecova
- Centrum für chronische Immundefizienz, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Reinhard E Voll
- Klinik für Rheumatologie und Klinische Immunologie, Vaskulitis-Zentrum Freiburg, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Cornelia Glaser
- Klinik für Rheumatologie und Klinische Immunologie, Vaskulitis-Zentrum Freiburg, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Fabian Röther
- Praxis für Rheumatologie in Donaueschingen, Sonnenhaldenstr. 2, 78166, Donaueschingen, Deutschland
| | - Klaus Warnatz
- Klinik für Rheumatologie und Klinische Immunologie, Vaskulitis-Zentrum Freiburg, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
- Centrum für chronische Immundefizienz, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - Nils Venhoff
- Klinik für Rheumatologie und Klinische Immunologie, Vaskulitis-Zentrum Freiburg, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
- Klinik für Rheumatologie und Klinische Immunologie, Universitätsklinikum Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland
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14
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Sockel K, Götze K, Ganster C, Bill M, Georgi JA, Balaian E, Aringer M, Trautmann-Grill K, Uhlig M, Bornhäuser M, Haase D, Thiede C. VEXAS syndrome: complete molecular remission after hypomethylating therapy. Ann Hematol 2024; 103:993-997. [PMID: 38214707 PMCID: PMC10866742 DOI: 10.1007/s00277-023-05611-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
The VEXAS syndrome, a genetically defined autoimmune disease, associated with various hematological neoplasms has been attracting growing attention since its initial description in 2020. While various therapeutic strategies have been explored in case studies, the optimal treatment strategy is still under investigation and allogeneic cell transplantation is considered the only curative treatment. Here, we describe 2 patients who achieved complete molecular remission of the underlying UBA1 mutant clone outside the context of allogeneic HCT. Both patients received treatment with the hypomethylating agent azacitidine, and deep molecular remission triggered treatment de-escalation and even cessation with sustained molecular remission in one of them. Prospective studies are necessary to clarify which VEXAS patients will benefit most from hypomethylating therapy and to understand the variability in the response to different treatment strategies.
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Affiliation(s)
- Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany.
- German Cancer Consortium (DKTK), CHOICE Consortium, Partner Sites, MunichDresden, Germany.
| | - Katharina Götze
- German Cancer Consortium (DKTK), CHOICE Consortium, Partner Sites, MunichDresden, Germany
- Department of Medicine III, Klinikum rechts der Isar, Technical University of Munich (TUM), Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Christina Ganster
- Clinics of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Marius Bill
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Julia-Annabell Georgi
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Ekaterina Balaian
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | | | - Maria Uhlig
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
| | - Martin Bornhäuser
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
- German Cancer Consortium (DKTK), CHOICE Consortium, Partner Sites, MunichDresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Detlef Haase
- Clinics of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Christian Thiede
- Medical Clinic and Policlinic I, University Hospital Dresden, TU Dresden, Dresden, Germany
- AgenDix GmbH, Dresden, Germany
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15
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de Valence B, Delaune M, Nguyen Y, Jachiet V, Heiblig M, Jean A, Riescher Tuczkiewicz S, Henneton P, Guilpain P, Schleinitz N, Le Guenno G, Lobbes H, Lacombe V, Ardois S, Lazaro E, Langlois V, Outh R, Vinit J, Martellosio JP, Decker P, Moulinet T, Dieudonné Y, Bigot A, Terriou L, Vlakos A, de Maleprade B, Denis G, Broner J, Kostine M, Humbert S, Lifermann F, Samson M, Pechuzal S, Aouba A, Kosmider O, Dion J, Grosleron S, Bourguiba R, Terrier B, Georgin-Lavialle S, Fain O, Mekinian A, Morgand M, Comont T, Hadjadj J. Serious infections in patients with VEXAS syndrome: data from the French VEXAS registry. Ann Rheum Dis 2024; 83:372-381. [PMID: 38071510 DOI: 10.1136/ard-2023-224819] [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: 08/07/2023] [Accepted: 10/22/2023] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is an acquired autoinflammatory monogenic disease with a poor prognosis whose determinants are not well understood. We aimed to describe serious infectious complications and their potential risk factors. METHODS Retrospective multicentre study including patients with VEXAS syndrome from the French VEXAS Registry. Episodes of serious infections were described, and their risk factors were analysed using multivariable Cox proportional hazards models. RESULTS Seventy-four patients with 133 serious infections were included. The most common sites of infection were lung (59%), skin (10%) and urinary tract (9%). Microbiological confirmation was obtained in 76%: 52% bacterial, 30% viral, 15% fungal and 3% mycobacterial. Among the pulmonary infections, the main pathogens were SARS-CoV-2 (28%), Legionella pneumophila (21%) and Pneumocystis jirovecii (19%). Sixteen per cent of severe infections occurred without any immunosuppressive treatment and with a daily glucocorticoid dose ≤10 mg. In multivariate analysis, age >75 years (HR (95% CI) 1.81 (1.02 to 3.24)), p.Met41Val mutation (2.29 (1.10 to 5.10)) and arthralgia (2.14 (1.18 to 3.52)) were associated with the risk of serious infections. JAK inhibitors were most associated with serious infections (3.84 (1.89 to 7.81)) compared with biologics and azacitidine. After a median follow-up of 4.4 (2.5-7.7) years, 27 (36%) patients died, including 15 (56%) due to serious infections. CONCLUSION VEXAS syndrome is associated with a high incidence of serious infections, especially in older patients carrying the p.Met41Val mutation and treated with JAK inhibitors. The high frequency of atypical infections, especially in patients without treatment, may indicate an intrinsic immunodeficiency.
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Affiliation(s)
| | - Marion Delaune
- Médecine interne, Université Toulouse III-Paul Sabatier Faculté de santé, Centre Hospitalier Universitaire de Toulouse Pole IUC de Toulouse Oncopole CHU, Toulouse, France
| | - Yann Nguyen
- Médecine interne, Université Paris Cité, Hôpital Beaujon, Clichy, France
| | - Vincent Jachiet
- Médecine Interne, Sorbonne université, Hopital Saint-Antoine, Paris, France
| | - Mael Heiblig
- Hématologie clinique, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon-Sud, Pierre-Benite, France
| | - Alexis Jean
- Médecine interne, CHU de Bordeaux, Bordeaux, France
| | | | - Pierrick Henneton
- Service de Médecine Interne A, Hôpital Saint Eloi, CHRU de Montpellier, Montpellier, France
| | - Philippe Guilpain
- Service de Médecine Interne A, Hôpital Saint Eloi, CHRU de Montpellier, Montpellier, France
| | - Nicolas Schleinitz
- Médecine interne, Aix-Marseille Universite, Hôpital de la Timone, Marseille, France
| | | | - Hervé Lobbes
- Médecine interne, CHU Estaing, Clermont-Ferrand, France
| | - Valentin Lacombe
- Médecine interne et immunologique clinique, CHU Angers, Angers, France
| | | | | | - Vincent Langlois
- Médecine interne et infectieuse, Hospital Group Le Havre, Le Havre, France
| | - Roderau Outh
- Service de médecine interne et générale, CH Perpignan, Perpignan, France
| | - Julien Vinit
- Médecine interne, Hospital Centre Chalon-sur-Saon, Chalon-sur-Saone, France
| | | | - Paul Decker
- Médecine interne et immunologie clinique, CHU de Nancy, Nancy, France
| | - Thomas Moulinet
- Médecine interne et immunologie clinique, CHU de Nancy, Nancy, France
| | - Yannick Dieudonné
- Immunologie Clinique et Médecine Interne, CHU de Strasbourg, Strasbourg, France
| | | | - Louis Terriou
- Médecine interne - hématologie, CHU Lille, Lille, France
| | - Alexandre Vlakos
- Médecine interne, Haute-Saône Hospital Group Vesoul Site, Vesoul, France
| | | | - Guillaume Denis
- Médecine interne et hématologie, Centre Hospitalier de Rochefort, Rochefort, France
| | | | - Marie Kostine
- Rhumatologie, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
| | - Sebastien Humbert
- Hématologie, Centre Hospitalier Universitaire de Besancon, Besancon, France
| | | | | | - Susann Pechuzal
- Médecine interne-polyvalente, Hôpitaux Drôme Nord, Romans, France
| | | | - Olivier Kosmider
- Service d'Hématologie Biologique, DMU BioPhyGen, APHP, Paris, France
| | - Jeremie Dion
- Médecine interne, Université Toulouse III-Paul Sabatier Faculté de santé, Centre Hospitalier Universitaire de Toulouse Pole IUC de Toulouse Oncopole CHU, Toulouse, France
| | | | - Rim Bourguiba
- Médecine interne, CEREMAIA, Sorbonne Université, Hospital Tenon, Paris, France
| | - Benjamin Terrier
- Médecine interne, Université Paris Cité, Hospital Cochin, Paris, France
| | | | - Olivier Fain
- Médecine Interne, Sorbonne université, Hopital Saint-Antoine, Paris, France
| | - Arsène Mekinian
- Médecine Interne, Sorbonne université, Hopital Saint-Antoine, Paris, France
| | - Marjolaine Morgand
- Médecine Interne, Sorbonne université, Hopital Saint-Antoine, Paris, France
| | - Thibault Comont
- Médecine interne, Université Toulouse III-Paul Sabatier Faculté de santé, Centre Hospitalier Universitaire de Toulouse Pole IUC de Toulouse Oncopole CHU, Toulouse, France
| | - Jerome Hadjadj
- Médecine Interne, Sorbonne université, Hopital Saint-Antoine, Paris, France
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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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18
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Lacombe V, Hadjadj J, Georgin-Lavialle S, Lavigne C, Geneviève F, Kosmider O. Vacuoles in bone marrow progenitors: VEXAS syndrome and beyond. Lancet Haematol 2024; 11:e160-e167. [PMID: 38302223 DOI: 10.1016/s2352-3026(23)00375-7] [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: 11/03/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024]
Abstract
The presence of vacuoles in myeloid and erythroid progenitor cells in bone marrow aspirates is a key feature of vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. The mere observation of vacuolated progenitor cells is not specific to VEXAS syndrome; in this Viewpoint, we point out the causes to be considered in this situation. Vacuoles, in particular, can be observed in individuals with wild-type UBA1 and with persistent inflammatory features or myelodysplastic syndromes. However, several clues support the diagnosis of VEXAS syndrome in the presence of vacuolated bone marrow progenitors: a high number of vacuolated progenitors and of vacuoles per cell, the predominance of vacuoles in early rather than late progenitors, and the vacuolisation of both myeloid and erythroid progenitors with predominance of myeloid ones. Some criteria derived from these observations have been proposed with great diagnostic performances. However, the absence or a low proportion of vacuolated cells should not prevent UBA1 gene sequencing.
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Affiliation(s)
- Valentin Lacombe
- Service de Médecine interne et immunologie clinique, Centre Hospitalier Universitaire d'Angers, Angers, France; Centre de Référence des Maladies auto-immunes et auto-inflammatoires systémiques de l'adulte Nord, Nord-ouest, Méditerranée et Guadeloupe (CeRAINOM), Angers, France; Mitolab, unité MitoVasc, INSERM U1083, CNRS UMR6015, Université d'Angers, Angers, France.
| | - Jérome Hadjadj
- Service de Médecine interne, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sophie Georgin-Lavialle
- Service de Médecine interne, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de référence constitutif des maladies auto-inflammatoires et de l'amylose inflammatoire (CEREMAIA), Paris, France
| | - Christian Lavigne
- Service de Médecine interne et immunologie clinique, Centre Hospitalier Universitaire d'Angers, Angers, France; Centre de Référence des Maladies auto-immunes et auto-inflammatoires systémiques de l'adulte Nord, Nord-ouest, Méditerranée et Guadeloupe (CeRAINOM), Angers, France
| | - Franck Geneviève
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire d'Angers, Angers, France; Fédération Hospitalo-Universitaire Grand Ouest Against Leukemia (FHU GOAL), Angers, France
| | - Olivier Kosmider
- Laboratoire d'Hématologie, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
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19
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Podvin B, Cleenewerck N, Nibourel O, Marceau-Renaut A, Roynard P, Preudhomme C, Duployez N, Terriou L. Three UBA1 clones for a unique VEXAS syndrome. Rheumatology (Oxford) 2024; 63:e48-e50. [PMID: 37698981 DOI: 10.1093/rheumatology/kead472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Affiliation(s)
- Benjamin Podvin
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | | | - Olivier Nibourel
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | - Alice Marceau-Renaut
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | | | - Claude Preudhomme
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | - Nicolas Duployez
- Univ. Lille, CNRS, Inserm, CHU Lille, IRCL, UMR9020-UMR1277 - Canther-Cancer Heterogeneity, Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Laboratory of Hematology, Lille, France
| | - Louis Terriou
- CHU Lille, Internal Medicine and Immunology, Centre de Reference des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Lille, France
- U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
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20
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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: 7] [Impact Index Per Article: 7.0] [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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21
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Kosmider O, Possémé C, Templé M, Corneau A, Carbone F, Duroyon E, Breillat P, Chirayath TW, Oules B, Sohier P, Luka M, Gobeaux C, Lazaro E, Outh R, Le Guenno G, Lifermann F, Berleur M, Le Mene M, Friedrich C, Lenormand C, Weitten T, Guillotin V, Burroni B, Boussier J, Willems L, Aractingi S, Dionet L, Tharaux PL, Vergier B, Raynaud P, Ea HK, Ménager M, Duffy D, Terrier B. VEXAS syndrome is characterized by inflammasome activation and monocyte dysregulation. Nat Commun 2024; 15:910. [PMID: 38291039 PMCID: PMC10828464 DOI: 10.1038/s41467-024-44811-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/02/2024] [Indexed: 02/01/2024] Open
Abstract
Acquired mutations in the UBA1 gene were recently identified in patients with severe adult-onset auto-inflammatory syndrome called VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic). However, the precise physiological and clinical impact of these mutations remains poorly defined. Here we study a unique prospective cohort of VEXAS patients. We show that monocytes from VEXAS are quantitatively and qualitatively impaired and display features of exhaustion with aberrant expression of chemokine receptors. In peripheral blood from VEXAS patients, we identify an increase in circulating levels of many proinflammatory cytokines, including IL-1β and IL-18 which reflect inflammasome activation and markers of myeloid cells dysregulation. Gene expression analysis of whole blood confirms these findings and also reveals a significant enrichment of TNF-α and NFκB signaling pathways that can mediate cell death and inflammation. This study suggests that the control of the nflammasome activation and inflammatory cell death could be therapeutic targets in VEXAS syndrome.
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Affiliation(s)
- Olivier Kosmider
- Université de Paris Cité, Institut Cochin, CNRS UMR8104, INSERM U1016, Paris, France.
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France.
| | - Céline Possémé
- Institut Pasteur, Université de Paris Cité, Translational Immunology Unit, Paris, France
| | - Marie Templé
- Université de Paris Cité, Institut Cochin, CNRS UMR8104, INSERM U1016, Paris, France
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Aurélien Corneau
- Sorbonne Université, Faculté de Médecine, UMS037, PASS, Plateforme de Cytométrie de la Pitié-Salpêtrière CyPS, Paris, France
| | - Francesco Carbone
- Université de Paris Cité, Imagine Institute, Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Atip-Avenir Team, INSERM UMR 1163, Paris, France
- Labtech Single-Cell@Imagine, Imagine Institute, INSERM UMR 1163, Paris, France
| | - Eugénie Duroyon
- Université de Paris Cité, Institut Cochin, CNRS UMR8104, INSERM U1016, Paris, France
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Paul Breillat
- Université de Paris Cité, INSERM, U970, PARCC, F-, Paris, France
- Department of Internal Medicine, National Reference Center for Rare Systemic Autoimmune Diseases, AP-HP, APHP-CUP, Hôpital Cochin, Paris, France
| | | | - Bénédicte Oules
- Department of Pathology, AP-HP, APHP-CUP, Hôpital Cochin, Paris, France
| | - Pierre Sohier
- Department of Pathology, AP-HP, APHP-CUP, Hôpital Cochin, Paris, France
| | - Marine Luka
- Université de Paris Cité, Imagine Institute, Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Atip-Avenir Team, INSERM UMR 1163, Paris, France
- Labtech Single-Cell@Imagine, Imagine Institute, INSERM UMR 1163, Paris, France
| | - Camille Gobeaux
- Biochemistry Laboratory, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Estibaliz Lazaro
- Department of Internal Medicine, Bordeaux University Hospital-Haut-Lévêque, Pessac, France
| | - Roderau Outh
- Department of Internal Medicine, Centre Hospitalier de Perpignan, Perpignan, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | | | - Marie Berleur
- Department of Internal Medicine, AP-HP, APHP-NUP, Hôpital Bichat, Paris, France
| | - Melchior Le Mene
- Université de Paris Cité, Institut Cochin, CNRS UMR8104, INSERM U1016, Paris, France
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Chloé Friedrich
- Université de Paris Cité, Institut Cochin, CNRS UMR8104, INSERM U1016, Paris, France
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Cédric Lenormand
- Université de Strasbourg, Department of Dermatology, CHRU Strasbourg, Strasbourg, France
| | - Thierry Weitten
- Department of Internal Medicine, Centre Hospitalier (CHICAS), Gap, France
| | - Vivien Guillotin
- Department of Internal Medicine, Bordeaux University Hospital-Saint-André, Bordeaux, France
| | - Barbara Burroni
- Department of Pathology, AP-HP, APHP-CUP, Hôpital Cochin, Paris, France
| | - Jeremy Boussier
- Sorbonne University - 47-83 Boulevard de l'Hopital, Paris, France
| | - Lise Willems
- Université de Paris Cité, Institut Cochin, CNRS UMR8104, INSERM U1016, Paris, France
- Hematology Department, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Selim Aractingi
- Dermatology Department, Assistance Publique-Hôpitaux de Paris, Centre-Université de Paris Cité, Cochin Hospital, Paris, France
| | - Léa Dionet
- Université de Paris Cité, INSERM, U970, PARCC, F-, Paris, France
| | | | - Béatrice Vergier
- Pathology Department, Bordeaux University Hospital-Haut-Lévêque, Pessac, France
| | - Pierre Raynaud
- Pathology Department, Centre Hospitalier de Perpignan, Perpignan, France
| | - Hang-Korng Ea
- Université de Paris Cité, INSERM, UMR-S 1132 BIOSCAR, Paris, France
- Rheumatology Department, AP- HP, Lariboisière Hospital, Paris, France
| | - Mickael Ménager
- Université de Paris Cité, Imagine Institute, Laboratory of Inflammatory Responses and Transcriptomic Networks in Diseases, Atip-Avenir Team, INSERM UMR 1163, Paris, France
- Labtech Single-Cell@Imagine, Imagine Institute, INSERM UMR 1163, Paris, France
| | - Darragh Duffy
- Institut Pasteur, Université de Paris Cité, Translational Immunology Unit, Paris, France
| | - Benjamin Terrier
- Université de Paris Cité, INSERM, U970, PARCC, F-, Paris, France.
- Department of Internal Medicine, National Reference Center for Rare Systemic Autoimmune Diseases, AP-HP, APHP-CUP, Hôpital Cochin, Paris, France.
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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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23
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Zuo Z, Zhou Z, Chang Y, Liu Y, Shen Y, Li Q, Zhang L. Ribonucleotide reductase M2 (RRM2): Regulation, function and targeting strategy in human cancer. Genes Dis 2024; 11:218-233. [PMID: 37588202 PMCID: PMC10425756 DOI: 10.1016/j.gendis.2022.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/26/2022] [Accepted: 11/14/2022] [Indexed: 12/29/2022] Open
Abstract
Ribonucleotide reductase M2 (RRM2) is a small subunit in ribonucleotide reductases, which participate in nucleotide metabolism and catalyze the conversion of nucleotides to deoxynucleotides, maintaining the dNTP pools for DNA biosynthesis, repair, and replication. RRM2 performs a critical role in the malignant biological behaviors of cancers. The structure, regulation, and function of RRM2 and its inhibitors were discussed. RRM2 gene can produce two transcripts encoding the same ORF. RRM2 expression is regulated at multiple levels during the processes from transcription to translation. Moreover, this gene is associated with resistance, regulated cell death, and tumor immunity. In order to develop and design inhibitors of RRM2, appropriate strategies can be adopted based on different mechanisms. Thus, a greater appreciation of the characteristics of RRM2 is a benefit for understanding tumorigenesis, resistance in cancer, and tumor microenvironment. Moreover, RRM2-targeted therapy will be more attention in future therapeutic approaches for enhancement of treatment effects and amelioration of the dismal prognosis.
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Affiliation(s)
- Zanwen Zuo
- Innovative Drug R&D Center, College of Life Sciences, Huaibei Normal University, Huaibei, Anhui 235000, China
- National “111” Center for Cellular Regulation and Molecular Pharmaceutics, Key Laboratory of Fermentation Engineering (Ministry of Education), Hubei Key Laboratory of Industrial Microbiology, Cooperative Innovation Center of Industrial Fermentation (Ministry of Education & Hubei Province), and School of Food and Biological Engineering, Hubei University of Technology, Wuhan, Hubei 430068, China
| | - Zerong Zhou
- Innovative Drug R&D Center, College of Life Sciences, Huaibei Normal University, Huaibei, Anhui 235000, China
- National “111” Center for Cellular Regulation and Molecular Pharmaceutics, Key Laboratory of Fermentation Engineering (Ministry of Education), Hubei Key Laboratory of Industrial Microbiology, Cooperative Innovation Center of Industrial Fermentation (Ministry of Education & Hubei Province), and School of Food and Biological Engineering, Hubei University of Technology, Wuhan, Hubei 430068, China
| | - Yuzhou Chang
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH 43210, USA
| | - Yan Liu
- School of Agriculture and Biology, and Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Yuping Shen
- College of Chemistry and Bioengineering, Hunan University of Science and Engineering, Yongzhou, Hunan 425199, China
| | - Qizhang Li
- Innovative Drug R&D Center, College of Life Sciences, Huaibei Normal University, Huaibei, Anhui 235000, China
- National “111” Center for Cellular Regulation and Molecular Pharmaceutics, Key Laboratory of Fermentation Engineering (Ministry of Education), Hubei Key Laboratory of Industrial Microbiology, Cooperative Innovation Center of Industrial Fermentation (Ministry of Education & Hubei Province), and School of Food and Biological Engineering, Hubei University of Technology, Wuhan, Hubei 430068, China
| | - Lei Zhang
- Innovative Drug R&D Center, College of Life Sciences, Huaibei Normal University, Huaibei, Anhui 235000, China
- Department of Pharmaceutical Botany, School of Pharmacy, Naval Medical University, Shanghai 200433, China
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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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Kim HY, Yoo KH, Jung CW, Kim HJ, Kim SH. Genetic Characteristics of Patients with Young-Onset Myelodysplastic Neoplasms. J Clin Med 2023; 12:7651. [PMID: 38137719 PMCID: PMC10743392 DOI: 10.3390/jcm12247651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/15/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Myelodysplastic neoplasm (MDS) is a heterogeneous group of myeloid neoplasms affected by germline and somatic genetic alterations. The incidence of MDS increases with age but rarely occurs at a young age. We investigated the germline and somatic genetic alterations of Korean patients with young-onset MDS (<40 years). Among the thirty-one patients, five (16.1%) had causative germline variants predisposing them to myeloid neoplasms (three with GATA2 variants and one each with PGM3 and ETV variants). We found that PGM3 deficiency, a subtype of severe immunodeficiency, predisposes patients to MDS. Somatic mutations were identified in 14 patients (45.2%), with lower rates in patients aged < 20 years (11.1%). Nine (29%) patients had U2AF1 S34F/Y mutations, and patients with U2AF1 mutations showed significantly worse progression-free survival (p < 0.001) and overall survival (p = 0.006) than those without U2AF1 mutations. A UBA1 M41T mutation that causes VEXAS syndrome was identified in a male patient. In conclusion, a germline predisposition to myeloid neoplasms occurred in ~16% of young-onset MDS patients and was largely associated with primary immunodeficiencies, including GATA2 deficiency. Furthermore, the high frequency of somatic U2AF1 mutations in patients with young-onset MDS suggests the presence of a distinct MDS subtype.
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Affiliation(s)
- Hyun-Young Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (H.-Y.K.); (H.-J.K.)
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea;
| | - Chul Won Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea;
| | - Hee-Jin Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (H.-Y.K.); (H.-J.K.)
| | - Sun-Hee Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (H.-Y.K.); (H.-J.K.)
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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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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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Mascaro JM, Rodriguez-Pinto I, Poza G, Mensa-Vilaro A, Fernandez-Martin J, Caminal-Montero L, Espinosa G, Hernández-Rodríguez J, Diaz M, Rita-Marques J, Sanmarti R, Castañeda S, Colunga D, Coto-Hernández R, Fanlo P, Elejalde JI, Bujan S, Figueras I, Marco FM, Andrés M, Suárez S, Gonzalez-Garcia A, Fustà-Novell X, Garcia-Belando C, Granados A, Fernandez-Figueras MT, Quilis N, Orriols-Caba M, Gómez de la Torre R, Cid MC, Espígol-Frigolé G, Alvarez-Abella A, Labrador E, Rozman M, Lopez-Guerra M, Castillo P, Alamo-Moreno JR, Gonzalez-Roca E, Plaza S, Fabregat V, Lara R, Vicente-Rabaneda EF, Tejedor-Vaquero S, Magri G, Bonet N, Solis-Moruno M, Cerutti A, Fornas O, Casals F, Yagüe J, Aróstegui JI. Spanish cohort of VEXAS syndrome: clinical manifestations, outcome of treatments and novel evidences about UBA1 mosaicism. Ann Rheum Dis 2023; 82:1594-1605. [PMID: 37666646 PMCID: PMC10646843 DOI: 10.1136/ard-2023-224460] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND The vacuoles, E1-enzyme, X linked, autoinflammatory and somatic (VEXAS) syndrome is an adult-onset autoinflammatory disease (AID) due to postzygotic UBA1 variants. OBJECTIVES To investigate the presence of VEXAS syndrome among patients with adult-onset undiagnosed AID. Additional studies evaluated the mosaicism distribution and the circulating cytokines. METHODS Gene analyses were performed by both Sanger and amplicon-based deep sequencing. Patients' data were collected from their medical charts. Cytokines were quantified by Luminex. RESULTS Genetic analyses of enrolled patients (n=42) identified 30 patients carrying UBA1 pathogenic variants, with frequencies compatible for postzygotic variants. All patients were male individuals who presented with a late-onset disease (mean 67.5 years; median 67.0 years) characterised by cutaneous lesions (90%), fever (66.7%), pulmonary manifestations (66.7%) and arthritis (53.3%). Macrocytic anaemia and increased erythrocyte sedimentation rate and ferritin were the most relevant analytical abnormalities. Glucocorticoids ameliorated the inflammatory manifestations, but most patients became glucocorticoid-dependent. Positive responses were obtained when targeting the haematopoietic component of the disease with either decitabine or allogeneic haematopoietic stem cell transplantation. Additional analyses detected the UBA1 variants in both haematopoietic and non-haematopoietic tissues. Finally, analysis of circulating cytokines did not identify inflammatory mediators of the disease. CONCLUSION Thirty patients with adult-onset AID were definitively diagnosed with VEXAS syndrome through genetic analyses. Despite minor interindividual differences, their main characteristics were in concordance with previous reports. We detected for the first time the UBA1 mosaicism in non-haematopoietic tissue, which questions the previous concept of myeloid-restricted mosaicism and may have conceptual consequences for the disease mechanisms.
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Affiliation(s)
- Jose Manuel Mascaro
- Department of Dermatology, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | | | - Gabriela Poza
- Department of Internal Medicine, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Anna Mensa-Vilaro
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Immunology, Hospital Clínic, Barcelona, Spain
| | | | - Luis Caminal-Montero
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Gerard Espinosa
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Jose Hernández-Rodríguez
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Marina Diaz
- Department of Haematology, Hospital Clínic, Barcelona, Spain
| | - Joana Rita-Marques
- Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Raimon Sanmarti
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Rheumatology, Hospital Clínic, Barcelona, Spain
| | - Santos Castañeda
- Department of Rheumatology, Hospital Universitario La Princesa, Madrid, Spain
- Instituto de Investigaciones Sanitarias Princesa (IIS-Princesa), Madrid, Spain
- Cátedra UAM-Roche, EPID-Future, Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Dolores Colunga
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Rubén Coto-Hernández
- Department of Internal Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Patricia Fanlo
- Department of Internal Medicine, Hospital Universitario de Navarra, Pamplona, Spain
| | | | - Segundo Bujan
- Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Ignasi Figueras
- Department of Dermatology, Hospital de Bellvitge, Barcelona, Spain
| | - Francisco Manuel Marco
- Department of Immunology, Hospital General Universitario de Alicante Dr Balmis, Alicante, Spain
- Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Mariano Andrés
- Alicante Institute for Health and Biomedical Research, Alicante, Spain
- Seccion de Reumatologia, Hospital General Universitario de Alicante, Alicante, Spain
- Department of Clinic Medicine, Universidad Miguel Hernandez de Elche, Elche, Spain
| | - Silvia Suárez
- Department of Internal Medicine, Hospital Valle del Nalón, Langreo, Spain
| | - Andres Gonzalez-Garcia
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitario Ramón y Cajal | IRYCIS, Madrid, Spain
| | | | - Clara Garcia-Belando
- Department of Rheumatology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Ana Granados
- Department of Internal Medicine, Hospital Universitari Parc Taulí, Sabadell, Spain
| | | | - Neus Quilis
- Department of Rheumatology, Hospital Universitari de Vinalopo, Elche, Spain
| | - Maria Orriols-Caba
- Department of Internal Medicine, Hospital comarcal Alt Penedès, Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedès, Spain
| | | | - Maria Cinta Cid
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Georgina Espígol-Frigolé
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Autoimmune Diseases, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | | | - Maria Rozman
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Haematology, Hospital Clínic, Barcelona, Spain
| | - Monica Lopez-Guerra
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Pathology, Hospital Clínic, Barcelona, Spain
| | - Paola Castillo
- Department of Pathology, Hospital Clínic, Barcelona, Spain
| | | | - Eva Gonzalez-Roca
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Department of Immunology, Hospital Clínic, Barcelona, Spain
| | - Susana Plaza
- Department of Immunology, Hospital Clínic, Barcelona, Spain
| | | | - Rocio Lara
- Department of Immunology, Hospital Clínic, Barcelona, Spain
| | - Esther F Vicente-Rabaneda
- Department of Rheumatology, Hospital Universitario La Princesa, Madrid, Spain
- Instituto de Investigaciones Sanitarias Princesa (IIS-Princesa), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Giuliana Magri
- Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
- Immunology Unit, Department of Biomedical Sciences, Faculty of Medicine and Health Science, University of Barcelona, Barcelona, Spain
| | - Nuria Bonet
- Genomics Core Facility, Departament de Medicina i Ciències de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Manuel Solis-Moruno
- Genomics Core Facility, Departament de Medicina i Ciències de la Vida, Universitat Pompeu Fabra, Barcelona, Spain
| | - Andrea Cerutti
- Hospital del Mar Medical Research Institute, PRBB, Barcelona, Spain
- Catalan Institute for Research and Advanced Studies (ICREA), Barcelona, Spain
| | - Oscar Fornas
- Flow Cytometry Unit, Universitat Pompeu Fabra - Center of Genomic Regulation, Barcelona, Spain
| | - Ferran Casals
- Departament de Genètica, Microbiologia i Estadística, Faculty of Biology, University of Barcelona, Barcelona, Spain
- Institut de Biomedicina de la Universitat de Barcelona (IBUB), Universitat de Barcelona, Barcelona, Spain
| | - Jordi Yagüe
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Immunology, Hospital Clínic, Barcelona, Spain
| | - Juan I Aróstegui
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- School of Medicine, Universitat de Barcelona, Barcelona, Spain
- Department of Immunology, Hospital Clínic, Barcelona, Spain
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Wolff L, Horisberger A, Moi L, Karampetsou MP, Comte D. Polyarteritis Nodosa: Old Disease, New Etiologies. Int J Mol Sci 2023; 24:16668. [PMID: 38068989 PMCID: PMC10706353 DOI: 10.3390/ijms242316668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
Polyarteritis nodosa (PAN), also known as panarteritis nodosa, represents a form of necrotizing vasculitis that predominantly affects medium-sized vessels, although it is not restricted to them and can also involve smaller vessels. The clinical presentation is heterogeneous and characterized by a significant number of patients exhibiting general symptoms, including asthenia, fever, and unintended weight loss. Although PAN can involve virtually any organ, it preferentially affects the skin, nervous system, and the gastrointestinal tract. Orchitis is a rare but specific manifestation of PAN. The absence of granulomas, glomerulonephritis, and anti-neutrophil cytoplasmic antibodies serves to distinguish PAN from other types of vasculitis. Major complications consist of hemorrhagic and thrombotic events occurring in mesenteric, cardiac, cerebral, and renal systems. Historically, PAN was frequently linked to hepatitis B virus (HBV) infection, but this association has dramatically changed in recent years due to declining HBV prevalence. Current epidemiological research often identifies a connection between PAN and genetic syndromes as well as neoplasia. This article provides a comprehensive review of PAN, specifically focusing on the progression of its clinical manifestations over time.
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Affiliation(s)
- Louis Wolff
- Department of Internal Medicine, Hôpital Universitaire de Bruxelles (H.U.B.), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium;
| | - Alice Horisberger
- Department of Medicine, Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Department of Medicine, Division of Immunology and Allergy, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Laura Moi
- Immunology and Allergology, Institut Central des Hôpitaux, Valais Hospital, 1951 Sion, Switzerland;
| | | | - Denis Comte
- Department of Medicine, Division of Internal Medicine, Lausanne University Hospital, University of Lausanne, 1005 Lausanne, Switzerland
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30
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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: 16] [Impact Index Per Article: 16.0] [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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31
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Jachiet V, Hadjadj J, Zhao LP, Chasset F, Fain O, Fenaux P, Mekinian A. [Dysimmune manifestations associated with myelodysplastic neoplasms and chronic myelomonocytic leukaemias]. Bull Cancer 2023; 110:1147-1155. [PMID: 37414632 DOI: 10.1016/j.bulcan.2023.02.023] [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: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 07/08/2023]
Abstract
Systemic inflammatory or autoimmune diseases (SIAD) are observed in up to a quarter of patients with myelodysplastic syndromes (MDS) or chronic myelomonocytic leukemia (CMML), with a broad clinical spectrum including asymptomatic biological abnormalities, isolated inflammatory clinical manifestations (recurrent fever, arthralgia, neutrophilic dermatoses…) or identified systemic diseases (giant cell arteritis, recurrent polychondritis…). Recent advances in molecular biology have shed new light on the pathophysiological mechanisms that link inflammatory manifestations and myeloid hemopathies, particularly in VEXAS syndrome following the identification of somatic mutations in the UBA1 gene, or in neutrophilic dermatoses with the concept of myelodysplasia cutis. Although the presence of SIAD does not seem to affect overall survival or the risk of transformation into acute myeloid leukemia, their treatment remains a challenge given the frequent high level of corticosteroid dependence as well as the poor efficacy and tolerance (cytopenias, infections) of conventional immunosuppressive agents. Recent prospective data supports the interest of a therapeutic strategy using demethylating agents and notably azacitidine to target the pathological clone.
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Affiliation(s)
- Vincent Jachiet
- Sorbonne université, Assistance publique-Hôpitaux de Paris, centre hospitalo-universitaire Saint-Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Paris, France
| | - Jérôme Hadjadj
- Sorbonne université, Assistance publique-Hôpitaux de Paris, centre hospitalo-universitaire Saint-Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Paris, France
| | - Lin-Pierre Zhao
- Université de Paris Cité, AP-HP, hôpital Saint-Louis, service d'hématologie, 75010 Paris, France
| | - François Chasset
- Sorbonne université, faculté de médecine, Assistance publique-Hôpitaux de Paris, centre hospitalo-universitaire Tenon, service de dermatologie, Paris, France
| | - Olivier Fain
- Sorbonne université, Assistance publique-Hôpitaux de Paris, centre hospitalo-universitaire Saint-Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Paris, France
| | - Pierre Fenaux
- Université de Paris Cité, AP-HP, hôpital Saint-Louis, service d'hématologie, 75010 Paris, France
| | - Arsène Mekinian
- Sorbonne université, Assistance publique-Hôpitaux de Paris, centre hospitalo-universitaire Saint-Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Paris, France.
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Kunimoto H, Miura A, Maeda A, Tsuchida N, Uchiyama Y, Kunishita Y, Nakajima Y, Takase-Minegishi K, Yoshimi R, Miyazaki T, Hagihara M, Yamazaki E, Kirino Y, Matsumoto N, Nakajima H. Clinical and genetic features of Japanese cases of MDS associated with VEXAS syndrome. Int J Hematol 2023; 118:494-502. [PMID: 37062784 DOI: 10.1007/s12185-023-03598-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 04/18/2023]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a new disease entity with autoinflammatory disorders (AID) driven by somatic variants in UBA1 that frequently co-exists with myelodysplastic syndromes (MDS). Clinicopathological and molecular features of Japanese cases with VEXAS-associated MDS remain elusive. We previously reported high prevalence of UBA1 variants in Japanese patients with relapsing polychondritis, in which 5 cases co-occurred with MDS. Here, we report clinicopathological and variant profiles of these 5 cases and 2 additional cases of MDS associated with VEXAS syndrome. Clinical characteristics of these cases included high prevalence of macrocytic anemia with marked cytoplasmic vacuoles in myeloid/erythroid precursors and low bone marrow (BM) blast percentages. All cases were classified as low or very low risk by the revised international prognostic scoring system (IPSS-R). Notably, 4 out of 7 cases showed significant improvement of anemia by treatment with prednisolone (PSL) or cyclosporin A (CsA), suggesting that an underlying inflammatory milieu induced by VEXAS syndrome may aggravate macrocytic anemia in VEXAS-associated MDS. Targeted deep sequencing of blood samples suggested that MDS associated with VEXAS syndrome tends to involve a smaller number of genes and lower risk genetic lesions than classical MDS.
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Affiliation(s)
- Hiroyoshi Kunimoto
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Ayaka Miura
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Ayaka Maeda
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Naomi Tsuchida
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Rare Disease Genomics, Yokohama City University Hospital, Yokohama, Japan
| | - Yuri Uchiyama
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Rare Disease Genomics, Yokohama City University Hospital, Yokohama, Japan
| | - Yosuke Kunishita
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Yuki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Takuya Miyazaki
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Maki Hagihara
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Etsuko Yamazaki
- Clinical Laboratory Department, Yokohama City University Hospital, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, 236-0004, Japan.
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33
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Bonnekoh H, Krusche M, Feist E, Wagner AD, Pankow A. [Autoinflammatory syndromes]. Z Rheumatol 2023; 82:678-687. [PMID: 37672064 DOI: 10.1007/s00393-023-01428-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
The concept of autoinflammation includes a heterogeneous group of monogenic and polygenic diseases. These are characterized by excessive activation of the innate immune system without antigen-specific T cells or autoantibodies. The diseases are characterized by periodic episodes of fever and increased inflammation parameters. Monogenic diseases include familial Mediterranean fever (FMF) and the newly described VEXAS (vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) syndrome. Heterogeneous diseases include adult-onset Still's disease and Schnitzler syndrome. Treatment is aimed at preventing the excessive inflammatory reaction in order to avoid long-term damage, such as amyloid A (AA) amyloidosis.
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Affiliation(s)
- Hanna Bonnekoh
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Hindenburgdamm 27, 12203, Berlin, Deutschland
- Allergologie und Immunologie, Fraunhofer-Institut für Translationale Medizin und Pharmakologie (ITMP), Berlin, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik für Nephrologie, Rheumatologie und Endokrinologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Eugen Feist
- Klinik für Rheumatologie, Helios Fachklinik Vogelsang-Gommern, Sophie-von-Boetticher-Straße 1, 39245, Vogelsang, Deutschland
| | - Annette Doris Wagner
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - Anne Pankow
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
- Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Myint K, Patrao N, Vonica O, Vahdani K. Recurrent superior orbital fissure syndrome associated with VEXAS syndrome. J Ophthalmic Inflamm Infect 2023; 13:39. [PMID: 37673972 PMCID: PMC10482812 DOI: 10.1186/s12348-023-00362-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023] Open
Abstract
PURPOSE To describe a case of recurrent orbital inflammation and superior orbital fissure syndrome associated with VEXAS (vacuoles, E1 enzyme, X-linked, auto-inflammatory, somatic) syndrome. CASE PRESENTATION VEXAS syndrome is a recently identified multi-system inflammatory disease of late adult onset. The authors describe the case of a 76-year-old man who presented with recurrent episodes of orbital inflammation, with superior orbital fissure syndrome, dacryoadenitis and orbital myositis. He had a constellation of systemic disorders including recurrent chest infections, congestive cardiac failure, pulmonary emboli and skin rashes. The underlying diagnosis of VEXAS syndrome was confirmed by genetic testing, which revealed the UBA1 mutation. CONCLUSION VEXAS syndrome should be considered in the differential diagnosis of orbital inflammatory disease associated with multi-system inflammatory disorders.
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Affiliation(s)
- Katie Myint
- Adnexal Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
| | - Namritha Patrao
- Royal Eye Unit, Kingston Hospital NHS Foundation Trust, Surrey, UK
| | - Oana Vonica
- Royal Eye Unit, Kingston Hospital NHS Foundation Trust, Surrey, UK
| | - Kaveh Vahdani
- Adnexal Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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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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Rohmer J, Nguyen Y, Trefond L, Agard C, Allain JS, Berezne A, Charles P, Cohen P, Gondran G, Groh M, Huscenot T, Lacout C, Lazaro E, London J, Maurier F, Mekinian A, Mesbah R, Nubourgh I, Perard L, Puéchal X, Pugnet G, Puyade M, Queyrel V, Roux A, Rouzaud D, Durel CA, Guillevin L, Terrier B. Clinical features and long-term outcomes of patients with systemic polyarteritis nodosa diagnosed since 2005: Data from 196 patients. J Autoimmun 2023; 139:103093. [PMID: 37536165 DOI: 10.1016/j.jaut.2023.103093] [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: 03/04/2023] [Revised: 06/19/2023] [Accepted: 07/11/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The landscape of polyarteritis nodosa (PAN) has substantially changed during the last decades. Recent data regarding causes, characteristics, and prognosis of systemic PAN in the modern era are lacking. METHODS This retrospective study included patients with systemic PAN referred to the French Vasculitis Study Group between 2005 and 2019. Characteristics, associated conditions and outcomes were collected, and predictors of relapse and death were analyzed. RESULTS 196 patients were included. Main clinical symptoms were constitutional (84%), neurological (59%), skin (58%) and musculoskeletal (58%) manifestations. Secondary PAN accounted for 55 (28%) patients, including myelodysplastic syndrome (9%), solid cancer (7%), lymphoma (4%) and autoinflammatory diseases (4%). No patient had active HBV infection. All treated patients (98.5%) received glucocorticoids (GCs), alone (41%) or in combination with immunosuppressants (59%), with remission achieved in 90%. Relapses were independently associated with age >65 years (HR 1.85; 95% CI1.12-3.08), gastrointestinal involvement (1.95; 95% CI1.09-3.52) and skin necrotic lesions (HR 1.95; 95%CI 1.24-3.05). One-, 5- and 10-year overall survival rates were 93%, 87% and 81%, respectively. In multivariate analyses, age >65 years (HR 2.80; 95%CI 1.23-6.37), necrotic purpura (HR 4.16; 95%CI 1.62-10.70), acute kidney injury (HR 4.89; 95% 1.71-13.99) and secondary PAN (HR 2.98; 95%CI 1.29-6.85) were independently associated with mortality. CONCLUSION Landscape of PAN has changed during the last decades, with the disappearance of HBV-PAN and the emergence of secondary PAN. Relapse rate remains high, especially in aged patients with gastrointestinal and cutaneous necrosis, as well as mortality.
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Affiliation(s)
- Julien Rohmer
- Department of Internal Medicine, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France
| | - Yann Nguyen
- Department of Internal Medicine, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France; Autoimmunity Team, Immunology of Viral Infections and Autoimmune Diseases, INSERM U1184, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Ludovic Trefond
- Department of Internal Medicine, CHU, Clermont Ferrand, France
| | - Christian Agard
- Nantes Université, CHU Nantes, Service de médecine interne, F-44000, Nantes, France
| | | | - Alice Berezne
- Department of Internal Medicine, CH, Annecy, Genevois, France
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Pascal Cohen
- Department of Internal Medicine, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France
| | - Guillaume Gondran
- Department of Internal Medicine and dermatology, CHU, Limoges, France
| | - Matthieu Groh
- Department of Internal Medicine, National Reference Center for Hypereosinophilic Syndromes, Foch Hospital, Suresnes, France; University of Lille, INSERM U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Tessa Huscenot
- Department of Internal Medicine, Hôpital Ambroise Parée, Paris, France
| | - Carole Lacout
- Department of Internal Medicine and Clinical Immunology, CHU, Angers, France
| | - Estibaliz Lazaro
- Department of Internal Medicine, Hôpital Haut Leveque, CHU, Bordeaux, France
| | - Jonathan London
- Department of Internal Medicine, Hôpital de la Croix Saint Simon, Paris, France
| | | | - Arsène Mekinian
- Department of Internal Medicine, Hôpital Saint Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Rafik Mesbah
- Department of Internal Medicine, CH, de Boulogne sur Mer, France
| | - Isabelle Nubourgh
- Department of Internal Medicine, Université libre de Bruxelles, Belgique
| | - Laurent Perard
- Department of Internal Medicine, Hôpital Saint Joseph Saint Luc, Lyon, France
| | - Xavier Puéchal
- Department of Internal Medicine, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France
| | - Gregory Pugnet
- Department of Internal Medicine and clinical immunology, CHU, Toulouse, France
| | | | | | - Arthur Roux
- Department of Nephrology, HEGP, Paris, France
| | - Diane Rouzaud
- Department of Internal Medicine, Hôpital Bichat, Paris, France
| | | | - Loïc Guillevin
- Department of Internal Medicine, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, AP-HP.Centre, Université Paris Cité, Paris, France; University Paris-Cité, F-75006, Paris, France.
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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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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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Cristiano A, Belardi R, Hajrullaj H, Fabiani E, Falconi G, Galossi E, Bernardini S, Voso MT, Nuccetelli M. Correlation analysis between auto-immunological and mutational profiles in myelodysplastic syndromes. Inflamm Res 2023; 72:1695-1707. [PMID: 37507570 PMCID: PMC10499973 DOI: 10.1007/s00011-023-01773-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 04/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE AND DESIGN Systemic-Inflammatory-Autoimmune-Diseases (SIAD) is increasingly considered in Myelodysplastic-Syndromes (MDS). In this line, we evaluated the MDS auto-immunological profile, correlating it to the mutational landscape, trying to identify a molecular-genetic trigger agent related to SIAD. METHODS AND MATERIALS Eighty-one MDS were enrolled and t-NGS was performed. Anti-Nuclear-Antibodies (ANA) were tested, and ANA-antigenic-specificity was characterized by ANA-profile, ENA-screen, anti-dsDNA. Non-Hematological-Patients (NHP) and Healthy-Donors (HD) were used as controls. RESULTS At clinically relevant cut-off (≥ 1:160), ANA was significantly more frequent in MDS, while ANA-antigenic-specificity showed a low association rate. ANA ≥ 1:160-positive MDS showed a mutational landscape similar to ANA-negative/ANA < 1:160 MDS. No significant correlations between mutational and immunological profiles were found and UBA1 mutations, related to VEXAS, were absent. CONCLUSIONS Although ANA-positivity was found to be increased in MDS, the low ANA-antigenic-specificity suggests that autoantibodies didn't recognize autoimmune-pathognomonic antigens. The lack of relationship between genetic profile and ANA-positivity, suggests that MDS genetic variants may not be the direct cause of SIAD.
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Affiliation(s)
- Antonio Cristiano
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy.
| | - Riccardo Belardi
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Hajro Hajrullaj
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
| | - Emiliano Fabiani
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
- UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Giulia Falconi
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
| | - Elisa Galossi
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
| | - Sergio Bernardini
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
- Tor Vergata University Hospital, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133, Rome, Italy
- Tor Vergata University Hospital, Rome, Italy
| | - Marzia Nuccetelli
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
- Tor Vergata University Hospital, Rome, Italy
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Belicard F, Belhomme N, Bouzy S, Saillard C, Nedelec F, Mear JB, Ardois S, Pastoret C, Reizine F, Camus C, Painvin B. Vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic syndrome in the intensive care unit: a case report. J Med Case Rep 2023; 17:314. [PMID: 37480098 PMCID: PMC10362754 DOI: 10.1186/s13256-023-04034-5] [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: 08/02/2021] [Accepted: 06/11/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic syndrome is a newly discovered inflammatory disease affecting male subjects, for which few data exist in the literature. Here, we describe the case of a patient with known Sweet's syndrome admitted to the intensive care unit and for whom a vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic syndrome was diagnosed, allowing for appropriate treatment and the patient's discharge and recovery. CASE PRESENTATION A 70-year-old male White patient was hospitalized in the intensive care unit following an intrahospital cardiac arrest. History started a year before with repeated deep vein thrombosis and episodes of skin eruption compatible with Sweet's syndrome. After a course of oral steroids, fever and inflammatory syndrome relapsed with onset of polychondritis, episcleritis along with neurological symptoms and pulmonary infiltrates. Intrahospital hypoxic cardiac arrest happened during patient's new investigations, and he was admitted in a critical state. During the intensive care unit stay, he presented with livedoid skin lesions on both feet. Vasculitis was not proven; however, cryoglobulinemia screening came back positive. Onset of pancytopenia was explored with a myelogram aspirate. It showed signs of dysmyelopoiesis and vacuoles in erythroid and myeloid precursors. Of note, new deep vein thrombosis developed, despite being treated with heparin leading to the diagnosis of heparin-induced thrombocytopenia. The course of symptoms were overlapping multiple entities, and so a multidisciplinary team discussion was implemented. Screening for UBA1-mutation in the blood came back positive, confirming the vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic syndrome. Corticosteroids and anti-IL1 infusion were started with satisfactory results supporting patient's discharge from intensive care unit to the internal medicine ward. CONCLUSIONS Vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic syndrome should be suspected in male patients presenting with inflammatory symptoms, such as fever, skin eruption, chondritis, venous thromboembolism, and vacuoles in bone marrow precursors. Patients with undiagnosed vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic syndrome may present with organ failure requiring hospitalization in intensive care unit, where screening for UBA1 mutation should be performed when medical history is evocative. Multidisciplinary team involvement is highly recommended for patient management, notably to start appropriate immunosuppressive treatments.
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Affiliation(s)
- Félicie Belicard
- Service de Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Nicolas Belhomme
- Internal Medicine Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Simon Bouzy
- Hematology Laboratory Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Clémence Saillard
- Dermatology Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Fabienne Nedelec
- Hemostasis Laboratory Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Jean-Baptiste Mear
- Hematology Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Samuel Ardois
- Internal Medicine Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Cedric Pastoret
- Hematology Laboratory Department, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Florian Reizine
- Service de Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Christophe Camus
- Service de Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France
| | - Benoit Painvin
- Service de Réanimation Médicale et des Maladies Infectieuses, Centre Hospitalier Universitaire de Rennes, Hôpital Pontchaillou, 2 rue Henri le Guilloux, 35033, Rennes Cedex 9, France.
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Bewersdorf JP, Xie Z, Bejar R, Borate U, Boultwood J, Brunner AM, Buckstein R, Carraway HE, Churpek JE, Daver NG, Porta MGD, DeZern AE, Fenaux P, Figueroa ME, Gore SD, Griffiths EA, Halene S, Hasserjian RP, Hourigan CS, Kim TK, Komrokji R, Kuchroo VK, List AF, Loghavi S, Majeti R, Odenike O, Patnaik MM, Platzbecker U, Roboz GJ, Sallman DA, Santini V, Sanz G, Sekeres MA, Stahl M, Starczynowski DT, Steensma DP, Taylor J, Abdel-Wahab O, Xu ML, Savona MR, Wei AH, Zeidan AM. Current landscape of translational and clinical research in myelodysplastic syndromes/neoplasms (MDS): Proceedings from the 1 st International Workshop on MDS (iwMDS) Of the International Consortium for MDS (icMDS). Blood Rev 2023; 60:101072. [PMID: 36934059 DOI: 10.1016/j.blre.2023.101072] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
Biological events that contribute to the pathogenesis of myelodysplastic syndromes/neoplasms (MDS) are becoming increasingly characterized and are being translated into rationally designed therapeutic strategies. Herein, we provide updates from the first International Workshop on MDS (iwMDS) of the International Consortium for MDS (icMDS) detailing recent advances in understanding the genetic landscape of MDS, including germline predisposition, epigenetic and immune dysregulation, the complexities of clonal hematopoiesis progression to MDS, as well as novel animal models of the disease. Connected to this progress is the development of novel therapies targeting specific molecular alterations, the innate immune system, and immune checkpoint inhibitors. While some of these agents have entered clinical trials (e.g., splicing modulators, IRAK1/4 inhibitors, anti-CD47 and anti-TIM3 antibodies, and cellular therapies), none have been approved for MDS. Additional preclinical and clinical work is needed to develop a truly individualized approach to the care of MDS patients.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Rafael Bejar
- Division of Hematology and Oncology, Moores Cancer Center, UC San Diego, La Jolla, CA, USA
| | - Uma Borate
- Ohio State University Comprehensive Cancer/ James Cancer Hospital, Ohio State University, Columbus, OH, USA
| | - Jacqueline Boultwood
- Blood Cancer UK Molecular Haematology Unit, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew M Brunner
- Leukemia Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Rena Buckstein
- Department of Medical Oncology/Hematology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hetty E Carraway
- Leukemia Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jane E Churpek
- Department of Hematology, Oncology, and Palliative Care, Carbone Cancer Center, The University of Wisconsin-Madison, Madison, WI, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matteo Giovanni Della Porta
- IRCCS Humanitas Clinical and Research Center & Humanitas University, Department of Biomedical Sciences, via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - Amy E DeZern
- Division of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Pierre Fenaux
- Hôpital Saint Louis, Assistance Publique Hôpitaux de Paris and Paris Cité University, Paris, France
| | - Maria E Figueroa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Steven D Gore
- National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD, USA
| | | | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | | | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, and Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD, USA
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Vijay K Kuchroo
- Evergrande Center for Immunologic Diseases, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan F List
- Precision BioSciences, Inc., Durham, NC, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ravindra Majeti
- Division of Hematology, Department of Medicine, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Olatoyosi Odenike
- Leukemia Program, University of Chicago Medicine and University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Gail J Roboz
- Weill Cornell Medical College, New York, NY, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | - Guillermo Sanz
- Health Research Institute La Fe, Valencia, Spain; Hospital Universitario y Politécnico La Fe, Valencia, Spain; CIBERONC, IS Carlos III, Madrid, Spain
| | - Mikkael A Sekeres
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Daniel T Starczynowski
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Justin Taylor
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Omar Abdel-Wahab
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mina L Xu
- Departments of Pathology & Laboratory Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Michael R Savona
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew H Wei
- Department of Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Walter and Eliza Hall Institute of Medical Research and University of Melbourne, Victoria, Australia
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA.
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42
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Ripke A, Münchau A, von Bubnoff N, Jendrek S, Kopelke S, Kümpers C, Parschke P, Schinke S, Khandanpour C. [B symptoms in unexplained mediastinal lymphadenopathy : Case report of a 72-year-old male patient with VEXAS syndrome]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023:10.1007/s00108-023-01543-9. [PMID: 37336829 DOI: 10.1007/s00108-023-01543-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/21/2023]
Abstract
The case of a 72-year-old male patient who presented to our centre for rare diseases with recurrent fever, night sweats and weight loss with initially confirmed mediastinal lymphadenopathy is reported. Investigation of lymph node material was unrevealing. As an additional finding, the patient had a myelodysplastic syndrome. VEXAS syndrome (vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) could be confirmed on the basis of a bone marrow biopsy and genetic testing.
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Affiliation(s)
- A Ripke
- Zentrum für Seltene Erkrankungen Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - A Münchau
- Zentrum für Seltene Erkrankungen Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland
| | - N von Bubnoff
- Klinik für Hämatologie und Onkologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - S Jendrek
- Klinik für Rheumatologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - S Kopelke
- Klinik für Hämatologie und Onkologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - C Kümpers
- Institut für Pathologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - P Parschke
- Klinik für Pneumologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - S Schinke
- Klinik für Rheumatologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
| | - C Khandanpour
- Klinik für Hämatologie und Onkologie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Deutschland
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43
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Casal Moura M, Yi ES, Koster MJ, Ryu JH, Baqir M. A 79-Year-Old Man With Recurrent Respiratory and Constitutional Symptoms, Elevated Acute Phase Reactants, and Pancytopenia. Chest 2023; 163:e207-e210. [PMID: 37164584 DOI: 10.1016/j.chest.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/21/2022] [Accepted: 12/17/2022] [Indexed: 05/12/2023] Open
Abstract
CASE PRESENTATION A 79-year-old man was examined because of recurrent dyspnea and constitutional symptoms that included malaise, fatigue, fevers, and arthralgias over the past 7 years. He was a nonsmoker who was a retired farmer. Elevated levels of acute phase reactants and C-reactive protein and a high erythrocyte sedimentation rate were noted often in his health records. However, an extensive rheumatologic evaluation, which included serologic studies (antinuclear antibodies, cyclic citrullinated peptide antibodies, antineutrophil cytoplasmic antibodies) and temporal artery biopsy, had not shown an identifiable autoimmune disease. The patient had been treated intermittently with prednisone, with partial symptomatic improvement. Various cytopenias had been present over the preceding years; however, three bone marrow biopsy specimens showed moderately hypercellular bone marrow with no diagnostic findings.
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Affiliation(s)
- Marta Casal Moura
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | | | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Bonnekoh H, Krusche M, Feist E, Wagner AD, Pankow A. [Autoinflammatory syndromes]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:442-451. [PMID: 37115240 PMCID: PMC10140729 DOI: 10.1007/s00108-023-01505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 04/29/2023]
Abstract
The concept of autoinflammation includes a heterogeneous group of monogenic and polygenic diseases. These are characterized by excessive activation of the innate immune system without antigen-specific T cells or autoantibodies. The diseases are characterized by periodic episodes of fever and increased inflammation parameters. Monogenic diseases include familial Mediterranean fever (FMF) and the newly described VEXAS (vacuoles, E1 enzyme, X‑linked, autoinflammatory, somatic) syndrome. Heterogeneous diseases include adult-onset Still's disease and Schnitzler syndrome. Treatment is aimed at preventing the excessive inflammatory reaction in order to avoid long-term damage, such as amyloid A (AA) amyloidosis.
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Affiliation(s)
- Hanna Bonnekoh
- Institut für Allergieforschung, Charité - Universitätsmedizin Berlin, Hindenburgdamm 27, 12203, Berlin, Deutschland
- Allergologie und Immunologie, Fraunhofer-Institut für Translationale Medizin und Pharmakologie (ITMP), Berlin, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik und Poliklinik für Nephrologie, Rheumatologie und Endokrinologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Eugen Feist
- Klinik für Rheumatologie, Helios Fachklinik Vogelsang-Gommern, Sophie-von-Boetticher-Straße 1, 39245, Vogelsang, Deutschland
| | - Annette Doris Wagner
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - Anne Pankow
- Ambulanz für seltene entzündliche Systemerkrankungen mit Nierenbeteiligung, Abteilung für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
- Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
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Wang C, Sallman DA. Current Therapeutic Landscape in Lower Risk Myelodysplastic Syndromes. Curr Treat Options Oncol 2023; 24:387-408. [PMID: 36966266 DOI: 10.1007/s11864-023-01062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 03/27/2023]
Abstract
OPINION STATEMENT Lower risk myelodysplastic syndromes are typically characterized by an indolent disease course with a relatively low risk of transformation into acute myeloid leukemia. These patients are classically identified using the revised International Prognostic Scoring System and most likely its molecular version in the near future which may change the paradigm of treatment. The overall goals of care are symptomatic control to reduce transfusion requirements and improve quality of life. Symptomatic anemia is the most common indication to initiate disease-specific therapies after the optimization of supportive measures. Currently, erythropoiesis-stimulating agents remain the standard upfront therapy for anemia, and patients with del(5q) cytogenetic changes can benefit from lenalidomide monotherapy. Other therapeutic options after failure of upfront treatment include luspatercept, hypomethylating agents, and immunosuppressive therapies after taking into account of individualized disease features. Allogeneic hematopoietic stem cell transplant is the only potentially curative option and is usually reserved for medically fit patients with severe symptomatic cytopenias who failed all standard options and/or the disease is progressing toward higher risk categories. Fortunately, novel investigational therapies are rapidly emerging by targeting different biological processes contributing to MDS pathogenesis, and eligible patients should be managed in clinical trials if available.
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Affiliation(s)
- Chen Wang
- Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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46
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Bruno A, Gurnari C, Alexander T, Snowden JA, Greco R. Autoimmune manifestations in VEXAS: Opportunities for integration and pitfalls to interpretation. J Allergy Clin Immunol 2023; 151:1204-1214. [PMID: 36948992 DOI: 10.1016/j.jaci.2023.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/24/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a novel entity manifesting with a multiplicity of clinical features. Somatic mutations of the UBA1 gene in hematopoietic stem cells constitute the genetic basis of VEXAS. As an X-linked disorder, most cases occur in men, classically developing symptoms during the fifth to sixth decade of life. Considering its multidisciplinary nature involving numerous branches of internal medicine, VEXAS has elicited a wide medical interest and several medical conditions have been associated with this disease. Even so, its recognition in everyday clinical practice is not necessarily straightforward. Close collaboration between different medical specialists is mandatory. Patients with VEXAS may manifest a range of features from manageable cytopenias to disabling and life-threatening autoimmune phenomena with limited responses to therapy, with the potential for progression to hematological malignancies. Diagnostic and treatment guidelines are exploratory and include a range of rheumatological and supportive care treatments. Allogeneic hematopoietic stem cell transplantation is potentially curative, but its risks are significant and its position in the treatment algorithm is yet to be defined. Herein, we present the variegated manifestations of VEXAS, provide practice criteria for diagnostic testing of UBA1, and discuss potential treatment options, including allogeneic hematopoietic stem cell transplantation, current evidence, and future directions.
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Affiliation(s)
- Alessandro Bruno
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Tobias Alexander
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Rheumatology and Clinical Immunology, Berlin, Germany
| | - John A Snowden
- Sheffield Blood & Marrow Transplant and Cellular Therapy Programme, Department of Haematology, Sheffield Teaching Hospitals Foundation NHS Trust, Sheffield, United Kingdom
| | - Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
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47
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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: 21] [Impact Index Per Article: 21.0] [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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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
PURPOSE OF REVIEW Two years after the recognition of VEXAS (for Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, we propose an extensive review of the current understanding of VEXAS pathophysiology and therapeutic options. RECENT FINDINGS Among the nearly 150 articles published about VEXAS, some have provided determinant insights into VEXAS pathophysiology and treatment. Clinical data from retrospective series support the JAK inhibitor ruxolitinib as the most efficient strategy to control inflammation, and interesting results were also described with azacytidine. Allogeneic stem cell transplantation remains the only curative option, but should be proposed to carefully selected patients. SUMMARY Although waiting for more robust evidence from prospective clinical trials, therapeutic options emerge from retrospective studies. We propose a set of criteria that should be systematically reported to harmonize the evaluation of therapeutic outcomes. This will allow the collection of high-quality data and facilitate their subsequent meta-analysis with the overall aim of improving the management of VEXAS patients.
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Affiliation(s)
- Pierre Sujobert
- Hospices Civils de Lyon. Hôpital Lyon Sud, Service d'hématologie biologique, Lyon
- Université Claude Bernard Lyon 1, Faculté de médecine et de maïeutique Lyon Sud Charles Mérieux, Lymphoma Immunobiology Team, Pierre Bénite
| | - Maël Heiblig
- Université Claude Bernard Lyon 1, Faculté de médecine et de maïeutique Lyon Sud Charles Mérieux, Lymphoma Immunobiology Team, Pierre Bénite
- Hospices Civils de Lyon. Hôpital Lyon Sud, Service d'hématologie clinique, Lyon
| | - Yvan Jamilloux
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service de médecine interne
- Lyon Immunopathology Federation (LIFE), Lyon University, Lyon, France
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Austestad J, Madland TM, Sandnes M, Haslerud TM, Benneche A, Reikvam H. 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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Affiliation(s)
- Janne Austestad
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Miriam Sandnes
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
| | - Torjan Magne Haslerud
- Department of Nuclear Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Andreas Benneche
- Department of Medical Genetics, University of Bergen, N-5021 Bergen, Norway
| | - Håkon Reikvam
- Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway
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