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Bai X, Yu R, Wang Z. Laryngeal involvement in relapsing polychondritis: clinical and CT findings in 173 patients. RMD Open 2025; 11:e005397. [PMID: 40345708 PMCID: PMC12067797 DOI: 10.1136/rmdopen-2024-005397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Accepted: 04/22/2025] [Indexed: 05/11/2025] Open
Abstract
INTRODUCTION/OBJECTIVES Relapsing polychondritis (RP) is a rare autoimmune disorder primarily affecting cartilaginous structures. We aimed to characterise the clinical features and CT findings of laryngeal involvement in RP, hypothesising that specific CT patterns correlate with clinical manifestations. METHODS We retrospectively analysed 173 patients with confirmed RP. Demographic and clinical data were collected, and laryngeal, tracheal, and bronchial CT findings were reviewed. Statistical analyses identified factors associated with laryngeal involvement and airway stenosis. RESULTS Notably, 66% of asymptomatic patients displayed CT evidence of airway damage, with laryngeal involvement in 41.1% (44/107), tracheal involvement in 80.9% (140/173), and bronchial involvement in 36.4% (63/107). Cricoid erosion and broadening with mucosal hyperplasia were the predominant laryngeal findings. Significant associations with laryngeal involvement included younger age at disease onset (p<0.05), longer disease duration (p<0.01) and multiorgan manifestations (p<0.01). CONCLUSIONS Laryngeal involvement is common in RP patients with airway manifestations, second only to tracheal involvement. CT findings of cricoid erosion and broadening are characteristic. Vigilant clinical monitoring is recommended for RP patients with identified risk factors to facilitate early detection and management. Future research should focus on developing targeted interventions for this high-risk subgroup of RP patients.
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Affiliation(s)
- Xiao Bai
- Department of Rheumatology and Immunology, Beijing Tsinghua Changgung Hospital, Beijing, China
| | - Ruohan Yu
- Department of Rheumatology and Immunology, Peking University International Hospital, Beijing, China
| | - Zhengang Wang
- Department of Rheumatology and Immunology, Beijing Tsinghua Changgung Hospital, Beijing, China
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Bello F, Fagni F, Bagni G, Hill CL, Mohammad AJ, Moiseev S, Olivotto I, Seyahi E, Emmi G. Arterial and venous thrombosis in systemic and monogenic vasculitis. Nat Rev Rheumatol 2025:10.1038/s41584-025-01252-7. [PMID: 40329108 DOI: 10.1038/s41584-025-01252-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2025] [Indexed: 05/08/2025]
Abstract
Systemic vasculitis, common forms of which include anti-neutrophil cytoplasmic antibody-associated small-vessel vasculitis, large-vessel vasculitis and Behçet syndrome, are frequently complicated by arterial or venous thrombotic events (AVTEs). Newly identified entities such as DADA2 (deficiency of adenosine deaminase 2) and VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, which are driven by genetic mutations, also exhibit vasculitic features and are associated with a high risk of AVTEs. AVTEs in systemic vasculitis, including monogenic forms of vasculitis, are due to the complex interaction of inflammation and coagulation. New insights into the pathogenetic mechanisms implicate endothelial dysfunction, immune complex deposition and the interplay of pro-inflammatory cytokines with prothrombotic factors, which collectively promote thrombus formation. AVTEs impose a substantial disease burden, complicate diagnosis and negatively affect prognosis by increasing the risk of morbidity and mortality. Early diagnosis and treatment are crucial to prevent lasting damage. Management strategies should target both thrombosis and underlying inflammation. Antithrombotic therapies, including low-dose aspirin, or oral anticoagulants should be used on the basis of individual thrombotic risk assessment. Immunosuppressive therapy is the cornerstone of treatment for arterial and venous thrombosis, particularly in Behçet syndrome, in which vascular inflammation has a crucial role in thrombotic complications.
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Affiliation(s)
- Federica Bello
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Filippo Fagni
- Department of Internal Medicine 3, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Giacomo Bagni
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Catherine L Hill
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Rheumatology, Lund University, Lund, Sweden
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Sergey Moiseev
- Tareev Clinic of Internal Disease, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Meyer Children's Hospital IRCCS, Florence, Italy
| | - Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine and Behçet's Disease Research Centre, Istanbul University-Cerrahpasa, School of Medicine, Istanbul, Turkey
| | - Giacomo Emmi
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
- Clinical Medicine and Rheumatology Unit, Cattinara University Hospital, Trieste, Italy.
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, Victoria, Australia.
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Singh A, Chaudhary R. VEXAS syndrome: A newly identified X-Linked hematoinflammatory disorder - A comprehensive overview of its genetic, molecular, inflammatory, and clinical landscape. J Autoimmun 2025; 154:103425. [PMID: 40306028 DOI: 10.1016/j.jaut.2025.103425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2025] [Revised: 04/16/2025] [Accepted: 04/22/2025] [Indexed: 05/02/2025]
Abstract
VEXAS (Vacuoles, E1 Enzyme, X-linked, Auto-inflammatory, Somatic) syndrome is a recently identified auto-inflammatory disorder predominantly affecting males over the age of 50. It arises due to somatic mutations in the UBA1 gene, an X-linked gene essential for initiating the ubiquitin-proteasome system, leading to dysregulated protein degradation and immune dysfunction. Clinically, VEXAS presents with a diverse array of inflammatory manifestations, including persistent fever, neutrophilic dermatosis, auricular and nasal chondritis, pulmonary infiltrates, ocular inflammation, and venous thrombosis, along with significant haematological abnormalities such as macrocytic anemia, thrombocytopenia, myeloid and erythroid precursor vacuolization, and bone marrow dysplasia. These systemic complications contribute to high morbidity and mortality. Currently, therapeutic strategies remain largely undefined, with treatment focusing on two primary approaches, which are modulating inflammation through corticosteroids, JAK inhibitors, or IL-6 blockade and targeting the mutant hematopoietic clone or allogeneic hematopoietic stem cell transplantation (AHSCT) therapies. Supportive interventions, including red blood cell and platelet transfusions, erythropoiesis-stimulating agents, thromboprophylaxis, and antimicrobial prophylaxis, are crucial in managing disease-associated complications. This review aims to present a comprehensive analysis of VEXAS syndrome, focusing on its genetic underpinnings, pathophysiology, clinical manifestations, diagnostic criteria, and evolving therapeutic strategies. By integrating current findings from the literature and identifying gaps in ongoing research, this review seeks to equip clinicians and researchers with a comprehensive understanding of VEXAS syndrome. Additionally, it aims to guide future investigations toward refining diagnostic strategies, optimizing therapeutic approaches, and ultimately improving patient care and clinical outcomes.
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Affiliation(s)
- Alpana Singh
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Vidya Vihar, Raebareli Road, Lucknow, 226025, (U.P.), India
| | - Rishabh Chaudhary
- Department of Pharmaceutical Sciences, Babasaheb Bhimrao Ambedkar University, Vidya Vihar, Raebareli Road, Lucknow, 226025, (U.P.), India.
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Molteni R, Fiumara M, Campochiaro C, Alfieri R, Pacini G, Licari E, Tomelleri A, Diral E, Varesi A, Weber A, Quaranta P, Albano L, Gaddoni C, Basso-Ricci L, Stefanoni D, Alessandrini L, Degl'Innocenti S, Sanvito F, Bergonzi GM, Annoni A, Panigada M, Cantoni E, Canarutto D, Xie SZ, D'Alessandro A, Di Micco R, Aiuti A, Ciceri F, De Luca G, Dagna L, Matucci-Cerinic M, Merelli I, Cenci S, Scala S, Cavalli G, Naldini L, Ferrari S. Mechanisms of hematopoietic clonal dominance in VEXAS syndrome. Nat Med 2025:10.1038/s41591-025-03623-9. [PMID: 40195449 DOI: 10.1038/s41591-025-03623-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 02/28/2025] [Indexed: 04/09/2025]
Abstract
Clonal dominance characterizes hematopoiesis during aging and increases susceptibility to blood cancers and common nonmalignant disorders. VEXAS syndrome is a recently discovered, adult-onset, autoinflammatory disease burdened by a high mortality rate and caused by dominant hematopoietic clones bearing somatic mutations in the UBA1 gene. However, pathogenic mechanisms driving clonal dominance are unknown. Moreover, the lack of disease models hampers the development of disease-modifying therapies. In the present study, we performed immunophenotype characterization of hematopoiesis and single-cell transcriptomics in a cohort of nine male patients with VEXAS syndrome, revealing pervasive inflammation across all lineages. Hematopoietic stem and progenitor cells (HSPCs) in patients are skewed toward myelopoiesis and acquire senescence-like programs. Humanized models of VEXAS syndrome, generated by inserting the causative mutation in healthy HSPCs through base editing, recapitulated proteostatic defects, cytological alterations and senescence signatures of patients' cells, as well as hematological and inflammatory disease hallmarks. Competitive transplantations of human UBA1-mutant and wild-type HSPCs showed that, although mutant cells are more resilient to the inflammatory milieu, probably through the acquisition of the senescence-like state, wild-type ones are progressively exhausted and overwhelmed by VEXAS clones, overall impairing functional hematopoiesis and leading to bone marrow failure. Our study unveils the mechanism of clonal dominance and provides models for preclinical studies and preliminary insights that could inform therapeutic strategies.
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Affiliation(s)
- Raffaella Molteni
- Vita-Salute San Raffaele University, Milan, Italy.
- Inflammation Fibrosis and Ageing Initiative (INFLAGE), Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Martina Fiumara
- Vita-Salute San Raffaele University, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Campochiaro
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberta Alfieri
- National Research Council, Institute for Biomedical Technologies, Segrate, Italy
| | - Guido Pacini
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eugenia Licari
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Tomelleri
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisa Diral
- Unit of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angelica Varesi
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, Ontario, Canada
| | - Alessandra Weber
- Vita-Salute San Raffaele University, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pamela Quaranta
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luisa Albano
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Gaddoni
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Basso-Ricci
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Stefanoni
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Alessandrini
- Vita-Salute San Raffaele University, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Degl'Innocenti
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Sanvito
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gregorio Maria Bergonzi
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Annoni
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maddalena Panigada
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eleonora Cantoni
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daniele Canarutto
- Vita-Salute San Raffaele University, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Pediatric Immunohematology Unit and BMT Program, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stephanie Z Xie
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver, Denver, CO, USA
| | - Raffaella Di Micco
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- University School of Advanced Studies IUSS, Pavia, Italy
| | - Alessandro Aiuti
- Vita-Salute San Raffaele University, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Pediatric Immunohematology Unit and BMT Program, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Matucci-Cerinic
- Vita-Salute San Raffaele University, Milan, Italy
- Inflammation Fibrosis and Ageing Initiative (INFLAGE), Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ivan Merelli
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
- National Research Council, Institute for Biomedical Technologies, Segrate, Italy
| | - Simone Cenci
- Vita-Salute San Raffaele University, Milan, Italy
- Inflammation Fibrosis and Ageing Initiative (INFLAGE), Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Serena Scala
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Translational Medicine, Novartis Pharma, Basel, Switzerland
| | - Luigi Naldini
- Vita-Salute San Raffaele University, Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Samuele Ferrari
- Vita-Salute San Raffaele University, Milan, Italy.
- San Raffaele Telethon Institute for Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Quigley C, Pietris J, Ang T, Zgaga L, Selva D. Ocular Features of VEXAS Syndrome: A Systematic Review and Meta-analysis. Am J Ophthalmol 2025; 276:50-63. [PMID: 40157447 DOI: 10.1016/j.ajo.2025.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Revised: 03/12/2025] [Accepted: 03/19/2025] [Indexed: 04/01/2025]
Abstract
PURPOSE To identify and analyze ocular features seen in Vacuoles, E1-ligase, X-linked Auto-inflammatory, Somatic (VEXAS) syndrome. DESIGN A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: ID 566167). METHODS Article inclusion criteria comprised genetic confirmation VEXAS syndrome that included eye involvement. Exclusion criteria included lack of genetic testing, or ocular feature reporting. A systematic search of the PubMed/MEDLINE, Embase, and CENTRAL databases was performed from January 2020 to September 2024. Data were collected and risk of bias assessed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis, specific UBA1 mutation and systemic feature data were also included. An association between severity of ocular features, presence of specific ophthalmic or systemic features, with age or causative mutation was investigated using Kruskal-Wallis rank sum testing and Fisher exact test, respectively, using R. RESULTS Fifty-two articles were included, amounting to 204 individuals (1 female). Mean age of VEXAS symptom onset was 67 ± 5 years (range: 46-87). Orbital inflammation was the most common ocular manifestation, comprising periorbital edema (n = 83, 40.7%), orbital myositis (n = 14, 6.9%), dacryoadenitis (n = 6, 2.9%), and orbital compartment syndrome (n = 1, 0.5%). Other features included episcleritis (n = 28, 13.7%), scleritis (n = 28, 13.7%), uveitis (n = 25, 12.3%), and retinal vasculitis (n = 2, 1%), among others. Visual acuity reporting was limited (n = 4, 2%). Meta-analysis was conducted on 32 articles (n = 48) with genotype and ocular feature data. The most commonly reported UBA1 mutation was the missense mutation p.Met41Thr (n = 24, 50%), followed by p.Met41Val (n = 17, 35%), p.Met41Leu (n = 4, 8%), and splice site mutations or deletions (n = 3, 6%). There was an association for more severe ophthalmic features in the splice site mutation group vs methionine 41 missense mutations (P = .04). The most commonly associated systemic features included dermatologic manifestations (n = 41, 85%), recurrent fever (n = 38, 79%), and pulmonary involvement (n = 30, 63). CONCLUSION There is notable variation in the ophthalmic features of VEXAS. Ophthalmic review is advised for VEXAS patients who develop eye symptoms, given the risk of sight-threatening disease.
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Affiliation(s)
- Clare Quigley
- From the Department of Ophthalmology, Royal Adelaide Hospital (C.Q., J.P., T.A., D.S.), Adelaide, South Australia, Australia.
| | - James Pietris
- From the Department of Ophthalmology, Royal Adelaide Hospital (C.Q., J.P., T.A., D.S.), Adelaide, South Australia, Australia
| | - Terence Ang
- From the Department of Ophthalmology, Royal Adelaide Hospital (C.Q., J.P., T.A., D.S.), Adelaide, South Australia, Australia
| | - Lina Zgaga
- Department of Public Health and Primary Care (L.Z.), Trinity College Dublin, Ireland
| | - Dinesh Selva
- From the Department of Ophthalmology, Royal Adelaide Hospital (C.Q., J.P., T.A., D.S.), Adelaide, South Australia, Australia
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Devaux M, Jachiet V, Hirsch P, Georgin-Lavialle S, Mekinian A, Salmeron G, Sep-Hieng S, Flandrin-Gresta P, Chretiennot A, Ghit L, Masson H, Le Lostec Z, Veyssier-Belot C. [VEXAS-like auto inflammatory syndrome: 2 cases]. Rev Med Interne 2025; 46:139-145. [PMID: 39721820 DOI: 10.1016/j.revmed.2024.12.003] [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: 05/15/2024] [Revised: 12/05/2024] [Accepted: 12/12/2024] [Indexed: 12/28/2024]
Abstract
INTRODUCTION VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic), recently described, due to a somatic mutation of the UBA1 gene and often associated with hemopathy, is characterized by systemic symptoms close to those described in Still's disease or relapsing polychondritis. There are also patients with hemopathy, presenting inflammatory symptoms reminiscent of those of VEXAS syndrome but without mutation of the UBA1 gene. CASE/DISCUSSION Two male patients consulted for general signs, dermatological symptoms, arthralgia, chondritis and venous thrombosis, like patients in the French cohort suffering from VEXAS syndrome. The myelogram found vacuoles in the myeloid and erythroid precursors, with a diagnosis of chronic myelomonocytic leukemia for one and myelodysplastic syndrome for the other. The search for a mutation of the UBA1 gene by the sanger technique, the next-generation sequencing (NGS) analysis of a myeloid panel and the complete sequencing was negative, not allowing the diagnosis of VEXAS syndrome to be retained. There were other somatic mutations, indicating clonal hematopoiesis associated with this systemic inflammatory state. Initial corticosteroid therapy was effective but corticosteroid dependence required sparing treatment with hypomethylating agents or Janus Kinase inhibitors. CONCLUSION The role of somatic mutations in the pathophysiology of autoinflammatory diseases associated with hematologic diseases must be better understood in order to better characterize them and develop targeted treatments.
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Affiliation(s)
- Mathilde Devaux
- Service de médecine interne, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France.
| | - Vincent Jachiet
- Service de medicine interne and inflammation-immunopathology-biotherapy department (DMU i2), Sorbonne Université, AP-HP, Hôpital Saint-Antoine, 75012 Paris, France
| | - Pierre Hirsch
- Département d'hématologie biologique, hématologie chromosomique et moléculaire, Sorbonne université, AP-HP, hôpital Saint-Antoine, 75012, Paris, France
| | | | - Arsene Mekinian
- Service de medicine interne and inflammation-immunopathology-biotherapy department (DMU i2), Sorbonne Université, AP-HP, Hôpital Saint-Antoine, 75012 Paris, France
| | - Geraldine Salmeron
- Service d'hématologie, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
| | - Sonnthida Sep-Hieng
- Laboratoire d'hématologie, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
| | | | - Andrea Chretiennot
- Service de médecine interne, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
| | - Lilia Ghit
- Service de médecine interne, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
| | - Helene Masson
- Service de médecine interne, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
| | - Zoe Le Lostec
- Service de médecine interne, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
| | - Catherine Veyssier-Belot
- Service de médecine interne, CHI Poissy-St Germain, 10, rue du Champs Gaillard, 78300 Poissy, France
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Mallo-Miranda MV, Morales-Angulo C. Otorhinolaryngological manifestations of autoinflammatory diseases. Systematic review. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2025; 76:116-129. [PMID: 39341593 DOI: 10.1016/j.otoeng.2024.09.005] [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: 05/09/2024] [Accepted: 09/17/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVES To detail the main otorhinolaryngological manifestations of autoinflammatory diseases, aiming to contribute to early diagnosis and treatment. DATA SOURCES Searches were conducted in PubMed, LILACS, Cochrane Library. REVIEW METHODS A systematic review of the medical literature on autoinflammatory diseases was conducted to identify characteristic head and neck manifestations, using PRISMA criteria. Observational studies or systematic reviews with a minimum of 10 cases per disease were included. Qualitative synthesis and a risk assessment were carried out. RESULTS Our review included 29 articles that met the inclusion criteria, with 10 to 486 patients per study. Autoinflammatory diseases with characteristic head and neck manifestations included VEXAS syndrome (auricular, nasal, or laryngotracheal chondritis), NPRL3-AID (hearing loss), NPRL12-AID (cervical lymphadenopathies, hearing loss and oral ulcers), HIDSs syndrome (painful cervical nodes and oral ulcers), haploinsufficiency A20 (oral ulcers), TRAPS (pharyngitis, aphthous stomatitis, periorbital edema, and cervical lymphadenopathies), Behcet's disease (oral and pharyngeal ulcers), PFAPA syndrome (recurrent tonsillitis, oral ulcers, and painful cervical adenopathies), Kawasaki disease (cervical nodes, pharyngitis and changes in oral mucosa) and undefined periodic fever (pharyngitis, oral ulcers, and painful cervical nodes). CONCLUSION Given their complex diagnosis and unique head and neck manifestations, otolaryngologists must be well-versed in these diseases for early detection and treatment. ENT specialists should consider the possibility of an autoinflammatory disease when encountering symptoms such as auricular, nasal, or laryngeal chondritis, recurrent oral ulcers, painful inflammatory lymphadenopathies, periorbital edema, recurrent pharyngitis, or hearing loss within the context of compatible systemic conditions.
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Affiliation(s)
| | - Carmelo Morales-Angulo
- Faculty of Medicine, University of Cantabria, Santander, Cantabria, Spain; Department of Otolaryngology and Head and Neck Surgery, Marqués de Valdecilla University Hospital, Santander, Spain; Cell Cycle, Stem Cell Fate and Cancer Laboratory, Institute for Research Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain.
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Cáceres-Nazario B, Rivenbark J, Saha MK, Mathews S, Rubinstein SM. Novel use of Siltuximab in a patient with VEXAS Syndrome. Ann Hematol 2025; 104:1259-1267. [PMID: 39417832 PMCID: PMC11971123 DOI: 10.1007/s00277-024-06037-8] [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: 08/21/2024] [Accepted: 10/04/2024] [Indexed: 10/19/2024]
Abstract
VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is an increasingly recognized disorder that occurs due to somatic mutations of a ubiquitin-activating enzyme encoded by ubiquitin-like modifier activating enzyme 1 gene, UBA1. Clinical findings associated with VEXAS syndrome include recurrent fevers, polychondritis, periorbital edema, pleural effusions, myocarditis and/or pericarditis, hepatosplenomegaly, myelodysplastic syndrome, cytopenias, inflammatory arthritis, neutrophilic dermatosis, and deep venous thrombosis. Novel renal manifestations like interstitial nephritis are infrequent, and to our knowledge, acute renal failure due to C3 glomerulonephritis (C3GN) has not yet been reported. Overwhelming systemic inflammation can result in morbid end-organ damage and death. While there is no formal guideline or established protocol for its management, treatment of VEXAS syndrome with tocilizumab, an interleukin-6 (IL-6)-directed therapy, has been described in the literature. Here, we report a case of a 71-year-old male patient presenting with C3GN as an initial manifestation of VEXAS syndrome and explore the rationale for our approach to treatment with IL-6 blockade. Our patient was initially treated with two inpatient doses of tocilizumab with successful transition to siltuximab in the outpatient setting. He continues to benefit from ongoing siltuximab treatment for more than one year to date without any safety issues or relapse of VEXAS syndrome.
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Affiliation(s)
- Beatriz Cáceres-Nazario
- Department of Medicine, Hematology Division, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joshua Rivenbark
- Department of Medicine, Hematology Division, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manish K Saha
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie Mathews
- School of Medicine, Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel M Rubinstein
- Department of Medicine, Hematology Division, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
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9
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Grandière L, Vicaire H, Pop G, Didier M, Freynet O, Alexandre M, Clero D, Mathian A, Martinod E, Brillet PY, Gille T, Uzunhan Y. Relapsing polychondritis: tracheobronchial involvement and differential diagnoses. J Thorac Dis 2025; 17:461-475. [PMID: 39975747 PMCID: PMC11833600 DOI: 10.21037/jtd-24-1603] [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: 09/25/2024] [Accepted: 11/22/2024] [Indexed: 02/21/2025]
Abstract
This review is describing the diagnostic and therapeutic approach to tracheobronchial involvement in relapsing polychondritis (RP), with a focus on differential diagnoses of inflammatory origin. RP is a systemic auto-immune disease that mainly affects cartilage structures, progressing through inflammatory flare-ups between phases of remission and ultimately leading to deformation of the involved cartilages. Besides the damage of auricular or nasal cartilage, tracheobronchial and cardiac involvement are the most severe, and can seriously alter the prognosis. Tracheobronchial lesions are assessed through a multimodal approach. Mapping of tracheal lesions is achieved using dynamic thoracic imaging and flexible bronchoscopy. Measurement of pulmonary function (with new emphasis on pulse oscillometry) is useful to diagnose obstructive ventilatory impairment, and can be used to follow RP patients, after therapeutics implementation. Diagnosis can be difficult in the absence of specific diagnostic tools, especially because there is a large number of differential diagnoses, in particular inflammatory diseases. Nuclear imaging can help with detection of metabolic activity on involved cartilages, leading to sharpen the final diagnosis. The prognosis has improved, thanks to the upgraded interventional bronchoscopy techniques, and the development of immunosuppressant including targeted therapies, such as tumor necrosis factor-α (TNF-α) inhibitors, offering patients several treatment options, in addition to supportive care.
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Affiliation(s)
- Louis Grandière
- Pulmonology Department, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Hugues Vicaire
- Pulmonology Department, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Gabriel Pop
- Nuclear Medicine Department, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Morgane Didier
- Pulmonology Department, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Olivia Freynet
- Pulmonology Department, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Marina Alexandre
- Dermatology Department, Reference Center for Auto-immune Bullous Diseases (MALIBUL), Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Dominique Clero
- Ear, Nose and Throat Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique – Hôpitaux de Paris – Sorbonne Université, Paris, France
| | - Alexis Mathian
- Internal Medicine Department No. 2, Regional Reference Center for Rare Systemic Auto-Immune and Rare Auto-Inflammatory, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupement Hospitalier Pitié-Salpêtrière, Institut E3M, Paris, France
- Sorbonne Université, Inserm, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Emmanuel Martinod
- Thoracic and Vascular Surgery Department, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
- INSERM UMR_1272 Hypoxie et Poumon, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord, Bobigny, France
| | - Pierre-Yves Brillet
- Radiology Department, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Thomas Gille
- INSERM UMR_1272 Hypoxie et Poumon, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord, Bobigny, France
- Physiology and Functional Explorations Department, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - Yurdagül Uzunhan
- Pulmonology Department, Reference Center for Rare Pulmonary Diseases, Hôpital Avicenne, Assistance Publique – Hôpitaux de Paris – Hôpitaux Universitaires de Paris Seine-Saint-Denis, Bobigny, France
- INSERM UMR_1272 Hypoxie et Poumon, UFR SMBH Léonard de Vinci, Université Sorbonne Paris Nord, Bobigny, France
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10
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Kötter I, Krusche M. VEXAS syndrome: an adult-onset autoinflammatory disorder with underlying somatic mutation. Curr Opin Rheumatol 2025; 37:21-31. [PMID: 39470174 DOI: 10.1097/bor.0000000000001068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2024]
Abstract
PURPOSE OF REVIEW VEXAS syndrome (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) was first described in 2020, where in a cohort of adults with unexplained fever or inflammation, systematic genetic testing was performed and 25 men with a median age of 64 years and somatic mutations in the UBA1 gene were identified. In the current review, we aim to discuss the relevant literature from January 2023 until July 2024 to give new insights into the pathophysiology, epidemiology, diagnosis and treatment of VEXAS. RECENT FINDINGS VEXAS affects 1 : 4269 in men over the age of 50. Janus-Kinase-inhibitors (JAKi) and IL-6-inhibitors are more effective immunosuppressants against hyperinflammation. Ruxolitinib is more effective than other JAKi. Azacitidine induces remission in many patients, but only few MDS-associated patients were treated. Allogeneic stem cell transplantation is feasible for selected cases. Infections are the major cause of death. Prognosis is still poor with a 5-year mortality rate of 18-40%. SUMMARY In the current review, we discuss the novelties for VEXAS, including pathogenic pathways, epidemiological data, diagnostic criteria and algorithms, treatment options and complications. We hope that this review may improve rheumatologists understanding of VEXAS. We strongly recommend enrolling VEXAS patients in registries and clinical trials, to improve prognosis of VEXAS in the future.
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Affiliation(s)
- Ina Kötter
- University Hospital Eppendorf, Department Internal Medicine III, Division of Rheumatology and Inflammatory Systemic Autoimmune Diseases, Hamburg
- Clinic for Rheumatology and Immunology, Bad Bramstedt, Germany
| | - Martin Krusche
- University Hospital Eppendorf, Department Internal Medicine III, Division of Rheumatology and Inflammatory Systemic Autoimmune Diseases, Hamburg
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11
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Bixio R, Bindoli S, Morciano A, Padoan R, Aldegheri F, Mastropaolo F, Bertoldo E, Rotta D, Appoloni M, Orsolini G, Gatti D, Adami G, Viapiana O, Rossini M, Sfriso P, Fassio A. The role of 18FDG-PET imaging in VEXAS syndrome: a multicentric case series and a systematic review of the literature. Intern Emerg Med 2024; 19:2331-2345. [PMID: 39251478 PMCID: PMC11582098 DOI: 10.1007/s11739-024-03763-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 08/28/2024] [Indexed: 09/11/2024]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, and somatic) syndrome is characterized by heterogeneous clinical manifestations. Due to the inflammatory nature of this condition, 18-FDG-PET (18-fluorodeoxyglucose-positron emission tomography) might be used to diagnose and monitor the disease. However, no data are available about the most common findings of PET imaging in this disease. For this reason, we summarised all the available reports of patients with VEXAS who underwent at least one PET scan and described 8 additional patients' PET from our centres. Overall, we described 35 patients' PET findings. All patients were male, with a median age of 70 years. The most frequent hypermetabolic sites on PET scans were the bone marrow (77.1%), lymph nodes (35.3%), lungs (28.6%), spleen and large vessels (22.9%), and cartilage (20%). Six patients underwent a PET scan 2.7 ± 1.5 years before VEXAS diagnosis, showing nonspecific uptake in the bone marrow. Four patients had a follow-up PET scan, showing a decrease or a disappearance of the previously identified hypermetabolic areas. In conclusion, although no specific uptake site has been found for VEXAS syndrome, PET imaging could help detect inflammatory foci that are not clinically evident. In addition, high metabolic activity in bone marrow might precede the clinical onset of the disease, shedding light on the pathogenesis of VEXAS.
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Affiliation(s)
- Riccardo Bixio
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy.
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Andrea Morciano
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Federico Aldegheri
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Francesca Mastropaolo
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Eugenia Bertoldo
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
- Internal Medicine Department, Hospital Mater Salutis, Legnago, Verona, Italy
| | - Denise Rotta
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Matteo Appoloni
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Giovanni Orsolini
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Davide Gatti
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Giovanni Adami
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Ombretta Viapiana
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Maurizio Rossini
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy
| | - Angelo Fassio
- Rheumatology Unit, Department of Medicine, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
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12
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Dantas JG, Biegelmeyer E, Zarur EB, Pinheiro FAG. Rare primary vasculitis: update on multiple complex diseases and the new kids on the block. Adv Rheumatol 2024; 64:79. [PMID: 39385260 DOI: 10.1186/s42358-024-00421-8] [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: 03/04/2024] [Accepted: 09/26/2024] [Indexed: 10/12/2024] Open
Abstract
Systemic vasculitis is a group of rare diseases that share an essential characteristic: inflammation of blood vessel walls. This injury occurs during the disease course, but specific features vary for each entity. In this paper, we will address relevant aspects of the newest monogenic mutation vasculitis, such as deficiency of adenosine deaminase 2 (ADA2) and VEXAS syndrome (UBA1), and other relevant vasculitis, such as Cogan syndrome and Susac syndrome that may share some similarities with them.
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Affiliation(s)
- Joao Gabriel Dantas
- Rheumatology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, 3° andar, São Paulo, SP, 04023-062, Brazil
| | - Erika Biegelmeyer
- Rheumatology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, 3° andar, São Paulo, SP, 04023-062, Brazil
| | - Eduarda Bonelli Zarur
- Rheumatology Division, Universidade Federal de São Paulo, Rua Botucatu, 740, 3° andar, São Paulo, SP, 04023-062, Brazil
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13
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Echerbault R, Bourguiba R, Georgin-Lavialle S, Lavigne C, Ravaiau C, Lacombe V. Comparing clinical features between males and females with VEXAS syndrome: data from literature analysis of patient reports. Rheumatology (Oxford) 2024; 63:2694-2700. [PMID: 38407378 DOI: 10.1093/rheumatology/keae123] [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: 08/23/2023] [Revised: 12/14/2023] [Accepted: 02/01/2024] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVES VEXAS syndrome is an autoinflammatory disease associated with a somatic mutation of the X-linked UBA1 gene in haematopoietic progenitor cells. This disorder was originally described as a disease affecting men, but rare cases of VEXAS syndrome in women have since been reported. The theoretical existence of phenotypic sex differences in this X-linked disease is debated. We compared the features of VEXAS syndrome between males and females to better understand this disorder and to improve its diagnostic accuracy in females. METHODS From previously published clinical descriptions of VEXAS syndrome, we included studies that described patients with precise, individual VEXAS-related features. We formed a literature-based cohort of patients by collecting their clinical and biological data and compared the characteristics of male and female patients. RESULTS We gathered 224 patient descriptions from 104 articles: 9 women and 215 men. Among the women, 1 had a constitutional 45,X karyotype and 4 had an acquired X monosomy in the bone marrow karyotype, while the marrow karyotype was not provided for the others. No difference was observed in the clinical or biological features according to sex. We also observed no difference in the type of UBA1 mutation or the association with myelodysplastic syndrome. CONCLUSIONS Our results supported the hypothesis that the UBA1 mutation should be sought under the same conditions in both sexes. As UBA1 is not subject to X-chromosome inactivation, VEXAS syndrome in females requires both UBA1 mutation and X monosomy, thus explaining the similarity between male and female VEXAS-related features and the lower prevalence of VEXAS syndrome in females.
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Affiliation(s)
- Robin Echerbault
- Department of Internal Medicine and Clinical Immunology, Angers University Hospital, Angers, France
| | - Rim Bourguiba
- Department of Internal Medicine, National Reference Centre for Auto-inflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA), Tenon Hospital, AP-HP, Paris, France
- Sorbonne Université, Inserm U938, Paris, France
| | - Sophie Georgin-Lavialle
- Department of Internal Medicine, National Reference Centre for Auto-inflammatory Diseases and Inflammatory Amyloidosis (CEREMAIA), Tenon Hospital, AP-HP, Paris, France
- Sorbonne Université, Inserm U938, Paris, France
| | - Christian Lavigne
- Department of Internal Medicine and Clinical Immunology, Angers University Hospital, Angers, France
| | - Camille Ravaiau
- Department of Internal Medicine and Clinical Immunology, Angers University Hospital, Angers, France
| | - Valentin Lacombe
- Department of Internal Medicine and Clinical Immunology, Angers University Hospital, Angers, France
- University of Angers, Inserm, CNRS, MITOVASC, Equipe MitoLab, SFR ICAT, Angers, France
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14
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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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15
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Burgei J, Alsheimer KM, Lantry J, Hehn B. Mediastinal lymphadenopathy due to VEXAS syndrome. BMJ Case Rep 2024; 17:e261179. [PMID: 39122375 DOI: 10.1136/bcr-2024-261179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2024] Open
Abstract
Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome is a rare disease first reported in 2020, most commonly seen in men aged 56-75 years old. Common clinical features include skin lesions (83.5%), fever (63.6%), relapsing chondritis (36.4%), venous thrombosis (34.7%) and lymph node enlargement (33.9%). The patient is a man in his 40s who presented with testicular and lower extremity pain, followed by a rash and bicytopenia. He was initiated on corticosteroids and sulfasalazine. He was found to have mediastinal lymphadenopathy and underwent an endobronchial ultrasound and transbronchial needle aspiration followed by a video-assisted thoracic surgery biopsy which were unrevealing. Eventually, an ubiquitin-like modifier activating enzyme (UBA-1) gene analysis was performed that was consistent with VEXAS syndrome. Patients with VEXAS syndrome usually present with a red or violaceous rash and dyspnoea. Laboratory abnormalities include anaemia, elevated mean corpuscular volume, thrombocytopenia and elevated inflammatory markers. Diagnosis is based on the genetic mutation and associated symptoms. The treatment includes steroids and Janus kinase (JAK) inhibitors, specifically ruxolitinib.
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Affiliation(s)
| | | | - Julia Lantry
- Pulmonary, Guthrie Health, Sayre, Pennsylvania, USA
| | - Boyd Hehn
- Pulmonary, Guthrie Health, Sayre, Pennsylvania, USA
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16
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Heeney A, Wu R, Fitzgerald C, Orfali N, Akasheh N, Magee C. VEXAS syndrome as a cause for multifocal, relapsing head and neck inflammation. Clin Case Rep 2024; 12:e9126. [PMID: 38947541 PMCID: PMC11213686 DOI: 10.1002/ccr3.9126] [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: 05/15/2024] [Accepted: 06/20/2024] [Indexed: 07/02/2024] Open
Abstract
VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is a novel autoinflammatory syndrome. We describe a case of VEXAS syndrome with upper airway and oral cavity involvement which are not well described in the literature.
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Affiliation(s)
- Aoife Heeney
- Department of General Internal MedicineSt James's HospitalDublinIreland
| | - Rachael Wu
- Department of Otolaryngology, Head and Neck SurgerySt James's HospitalDublinIreland
| | - Conall Fitzgerald
- Department of Otolaryngology, Head and Neck SurgerySt James's HospitalDublinIreland
| | - Nina Orfali
- Department of HaematologySt James's HospitalDublinIreland
| | - Nadim Akasheh
- Department of General Internal MedicineSt James's HospitalDublinIreland
| | - Conor Magee
- Department of General Internal MedicineSt James's HospitalDublinIreland
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17
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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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18
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Kouranloo K, Dey M, Almutawa J, Myall N, Nune A. Clinical characteristics, disease trajectories and management of vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome: a systematic review. Rheumatol Int 2024; 44:1219-1232. [PMID: 38129348 DOI: 10.1007/s00296-023-05513-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly discovered autoinflammatory condition characterised by somatic mutation of the UBA1 gene. The syndrome leads to multi-system inflammation affecting predominantly the skin, lungs and bone marrow. METHODS We undertook a systematic review of the multisystem features and genotypes observed in VEXAS syndrome. Articles discussing VEXAS syndrome were included. Medline, Embase and Cochrane databases were searched. Information was extracted on: demographics, type and prevalence of clinical manifestations, genetic mutations and treatment. Meta-analysis using a random effects model was used to determine pooled estimates of serum markers. RESULTS From 303 articles, 90 were included, comprising 394 patients with VEXAS. 99.2% were male, with a mean age of 67.1 years (SD 8.5) at disease onset. The most frequent diagnoses made prior to VEXAS were: relapsing polychondritis (n = 59); Sweet's syndrome (n = 24); polyarteritis nodosa (n = 11); and myelodysplastic syndrome (n = 10). Fever was reported in 270 cases (68.5%) and weight loss in 79 (20.1%). Most patients had haematological (n = 342; 86.8%), dermatological (n = 321; 81.5%), pulmonary (n = 297; 75.4%%) and musculoskeletal (n = 172; 43.7%) involvement, although other organ manifestations of varying prevalence were also recorded. The most commonly reported mutations were "c.122T > C pMET41Thr" (n = 124), "c.121A > G pMET41Val" (n = 62) and "c.121A > C pMet41Leu" (n = 52). Most patients received glucocorticoids (n = 240; 60.9%) followed by methotrexate (n = 82; 20.8%) and IL-6 inhibitors (n = 61, 15.4%). One patient underwent splenectomy; 24 received bone marrow transplants. CONCLUSION VEXAS syndrome is a rare disorder affecting predominantly middle-aged men. This is the first systematic review to capture clinical manifestations, genetics and treatment of reported cases. Further studies are needed to optimise treatment and subsequently reduce morbidity and mortality.
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Affiliation(s)
- Koushan Kouranloo
- Department of Rheumatology, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH, UK.
- School of Medicine, Cedar House, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK.
| | - Mrinalini Dey
- Centre for Rheumatic Diseases, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK
| | - Jude Almutawa
- Liverpool University NHS Foundation Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Nikki Myall
- British Medical Association Library, BMA House, Tavistock Square, London, WC1H 9JP, UK
| | - Arvind Nune
- Department of Rheumatology, Southport & Ormskirk Hospital NHS Trust, Town Lane, Kew, Southport, PR8 6PN, UK
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19
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Grandière L, Gille T, Brillet PY, Didier M, Freynet O, Vicaire H, Clero D, Martinod E, Mathian A, Uzunhan Y. [Tracheobronchial involvement in relapsing polychondritis and differential diagnoses]. Rev Mal Respir 2024; 41:421-438. [PMID: 38762394 DOI: 10.1016/j.rmr.2024.03.009] [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: 01/17/2024] [Accepted: 03/22/2024] [Indexed: 05/20/2024]
Abstract
Relapsing polychondritis is a systemic auto-immune disease that mainly affects cartilage structures, progressing through inflammatory flare-ups between phases of remission and ultimately leading to deformation of the cartilages involved. In addition to characteristic damage of auricular or nasal cartilage, tracheobronchial and cardiac involvement are particularly severe, and can seriously alter the prognosis. Tracheobronchial lesions are assessed by means of a multimodal approach, including dynamic thoracic imaging, measurement of pulmonary function (with recent emphasis on pulse oscillometry), and mapping of tracheal lesions through flexible bronchoscopy. Diagnosis can be difficult in the absence of specific diagnostic tools, especially as there may exist a large number of differential diagnoses, particularly as regards inflammatory diseases. The prognosis has improved, due largely to upgraded interventional bronchoscopy techniques and the development of immunosuppressant drugs and targeted therapies, offering patients a number of treatment options.
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Affiliation(s)
- L Grandière
- Service de pneumologie, centre de référence constitutif des maladies pulmonaires rares, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - T Gille
- Service de physiologie-explorations fonctionnelles, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France; Inserm UMR 1272 hypoxie et poumon, UFR SMBH Léonard de Vinci, université Sorbonne Paris Nord, 125, rue de Stalingrad, 93000 Bobigny, France
| | - P-Y Brillet
- Service de radiologie, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - M Didier
- Service de pneumologie, centre de référence constitutif des maladies pulmonaires rares, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - O Freynet
- Service de pneumologie, centre de référence constitutif des maladies pulmonaires rares, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - H Vicaire
- Service de pneumologie, centre de référence constitutif des maladies pulmonaires rares, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France
| | - D Clero
- Service d'oto-rhino-laryngologie, hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris - Sorbonne université, Paris 13(e), France
| | - E Martinod
- Service de chirurgie thoracique et vasculaire, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France; Inserm UMR 1272 hypoxie et poumon, UFR SMBH Léonard de Vinci, université Sorbonne Paris Nord, 125, rue de Stalingrad, 93000 Bobigny, France
| | - A Mathian
- Centre de référence pour le lupus, le syndrome des anti-phospholipides et autres maladies auto-immunes rares, service de médecine interne 2, Institut E3M, Assistance publique-Hôpitaux de Paris (AP-HP), groupement hospitalier Pitié-Salpêtrière, Paris, France
| | - Y Uzunhan
- Service de pneumologie, centre de référence constitutif des maladies pulmonaires rares, hôpital Avicenne, Assistance publique-Hôpitaux de Paris - Hôpitaux universitaires de Paris Seine-Saint-Denis, Bobigny, France; Inserm UMR 1272 hypoxie et poumon, UFR SMBH Léonard de Vinci, université Sorbonne Paris Nord, 125, rue de Stalingrad, 93000 Bobigny, France.
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20
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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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21
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Abumanhal M, Leibovitch I, Zisapel M, Eviatar T, Edel Y, Ben Cnaan R. Ocular and orbital manifestations in VEXAS syndrome. Eye (Lond) 2024; 38:1748-1754. [PMID: 38548942 PMCID: PMC11156927 DOI: 10.1038/s41433-024-03014-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/10/2024] [Accepted: 02/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is a hematoinflammatory disease that typically affects adults. It results from a somatic mutation of the E1 ubiquitin conjugating enzyme encoded by the UBA1 gene. VEXAS is frequently accompanied by myelodysplastic syndrome (MDS). The purpose of this study is to describe the ocular and orbital manifestations of VEXAS patients in a case series in our medical centre. METHODS A retrospective chart review was performed for all patients who were diagnosed with VEXAS syndrome in a tertiary medical centre over two years. RESULTS Eight patients were identified with VEXAS. In six patients, the diagnosis was confirmed by genomic sequencing. Two patients were identified based on their phenotype. All patients were males. The mean age at diagnosis was 78.7 years. In two patients, the ocular manifestation was the presenting symptom for VEXAS. Seven patients (87.5%) had history of MDS. Systemic inflammation manifestations include: skin rash (n = 5), recurrent fevers (n = 2), relapsing polychondritis (n = 2), pleuritis and pleural effusion (n = 2), poly arteritis nodosa- PAN (n = 1) and thrombophlebitis (n = 1). Seven (87%) patients were presented with periorbital oedema. Three patients showed orbital inflammation. Dacryoadenitis was observed in two patients, and extraocular muscle (EOM) myositis was detected in two patients. Four patients demonstrated ocular inflammation such as: episcleritis, scleritis and anterior uveitis. CONCLUSION ocular manifestations in VEXAS include orbital inflammation, dacryoadenitis, myositis, uveitis, scleritis, episcleritis and periorbital oedema. We recommend that in old male patients, with history of haematological disorder, presenting with ocular symptom, VEXAS investigation should be taken into consideration.
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Affiliation(s)
- Muhammad Abumanhal
- Oculoplastic, Orbital and Lacrimal Institute, Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Igal Leibovitch
- Oculoplastic, Orbital and Lacrimal Institute, Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Zisapel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Department, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Tali Eviatar
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Department, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yonatan Edel
- Department of Internal Medicine 'B', Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Health Science, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Ran Ben Cnaan
- Oculoplastic, Orbital and Lacrimal Institute, Division of Ophthalmology, Tel Aviv Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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22
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Vitale A, Caggiano V, Martin-Nares E, Frassi M, Dagna L, Hissaria P, Sfriso P, Hernández-Rodríguez J, Ruiz-Irastorza G, Monti S, Tufan A, Piga M, Giardini HAM, Lopalco G, Viapiana O, De Paulis A, Triggianese P, Vitetta R, de-la-Torre A, Fonollosa A, Caroni F, Sota J, Conticini E, Sbalchiero J, Renieri A, Casamassima G, Wiesik-Szewczyk E, Yildirim D, Hinojosa-Azaola A, Crisafulli F, Franceschini F, Campochiaro C, Tomelleri A, Callisto A, Beecher M, Bindoli S, Baggio C, Gómez-Caverzaschi V, Pelegrín L, Soto-Peleteiro A, Milanesi A, Vasi I, Cauli A, Antonelli IPDB, Iannone F, Bixio R, Casa FD, Mormile I, Gurnari C, Fiorenza A, Mejia-Salgado G, Kawakami-Campos PA, Ragab G, Ciccia F, Ruscitti P, Bocchia M, Balistreri A, Tosi GM, Frediani B, Cantarini L, Fabiani C. Orbital/ocular inflammatory involvement in VEXAS syndrome: Data from the international AIDA network VEXAS registry. Semin Arthritis Rheum 2024; 66:152430. [PMID: 38554594 DOI: 10.1016/j.semarthrit.2024.152430] [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: 11/28/2023] [Revised: 01/24/2024] [Accepted: 03/07/2024] [Indexed: 04/01/2024]
Abstract
VEXAS syndrome is a recently described monogenic autoinflammatory disease capable of manifesting itself with a wide array of organs and tissues involvement. Orbital/ocular inflammatory manifestations are frequently described in VEXAS patients. The objective of this study is to further describe orbital/ocular conditions in VEXAS syndrome while investigating potential associations with other disease manifestations. In the present study, twenty-seven out of 59 (45.8 %) VEXAS patients showed an inflammatory orbital/ocular involvement during their clinical history. The most frequent orbital/ocular affections were represented by periorbital edema in 8 (13.6 %) cases, episcleritis in 5 (8.5 %) patients, scleritis in 5 (8.5 %) cases, uveitis in 4 (6.8 %) cases, conjunctivitis in 4 (6.8 %) cases, blepharitis in 3 (5.1 %) cases, orbital myositis in 2 (3.4 %) cases. A diagnosis of systemic immune-mediated disease was observed in 15 (55.6 %) cases, with relapsing polychondritis diagnosed in 12 patients. A significant association was observed between relapsing polychondritis and orbital/ocular involvement in VEXAS syndrome (Relative Risk: 2.37, 95 % C.I. 1.03-5.46, p = 0.048). Six deaths were observed in the whole cohort of patients after a median disease duration of 1.2 (IQR=5.35) years, 5 (83.3 %) of which showed orbital/ocular inflammatory involvement. In conclusion, this study confirms that orbital/ocular inflammatory involvement is a common finding in VEXAS patients, especially when relapsing polychondritis is diagnosed. This makes ophthalmologists a key figure in the diagnostic process of VEXAS syndrome. The high frequency of deaths observed in this study seems to suggest that patients with orbital/ocular involvement may require increased attention and more careful follow-up.
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Affiliation(s)
- Antonio Vitale
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy
| | - Valeria Caggiano
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy
| | - Eduardo Martin-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Micol Frassi
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Brescia, Italy
| | - Lorenzo Dagna
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Milan, Italy
| | - Pravin Hissaria
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia; Department of Immunopathology, SA Pathology, Adelaide, Australia
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine, University of Padua, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Padua, Italy
| | - José Hernández-Rodríguez
- Clinical Unit of Autoinflammatory Diseases, Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic of Barcelona [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], University of Barcelona, Barcelona, Spain
| | - Guillermo Ruiz-Irastorza
- Faculty of Medicine and Nursery, University of the Basque Country, UPV/EHU, Leioa, Biscay, Spain; Autoimmune Diseases Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Spain
| | - Sara Monti
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Pavia, Italy; Department of Internal Medicine and Therapeutics, Università di Pavia, Italy
| | - Abdurrahman Tufan
- Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Turkiye
| | - Matteo Piga
- Rheumatology Unit, Department of Medical Sciences, University and AOU of Cagliari, Cagliari, Italy
| | - Henrique A Mayrink Giardini
- Rheumatology Division, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Giuseppe Lopalco
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Policlinic Hospital, University of Bari, Bari, Italy
| | - Ombretta Viapiana
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Italy
| | - Amato De Paulis
- Department of Translational Medical Sciences, Section of Clinical Immunology, University of Naples Federico II, Naples, Italy; Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Rosetta Vitetta
- Unit of Rheumatology, ASL VC Sant' Andrea Hospital, Vercelli 13100, Italy
| | - Alejandra de-la-Torre
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Alex Fonollosa
- Department of Ophthalmology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
| | - Federico Caroni
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena 53100, Italy
| | - Jurgen Sota
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy
| | - Edoardo Conticini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy
| | - Jessica Sbalchiero
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy
| | - Alessandra Renieri
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy; Department of Medical Biotechnologies, Med Biotech Hub and Competence Center, University of Siena, Siena, Italy; Genetica Medica, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Giulia Casamassima
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy; Department of Medical Biotechnologies, Med Biotech Hub and Competence Center, University of Siena, Siena, Italy; Genetica Medica, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Ewa Wiesik-Szewczyk
- Department of Internal Medicine, Pneumonology, Allergology and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine, National Research Institute, Warsaw, Poland
| | - Derya Yildirim
- Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Turkiye
| | - Andrea Hinojosa-Azaola
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Francesca Crisafulli
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Brescia, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology, Spedali Civili and Department of Clinical and Experimental Sciences, University of Brescia, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Brescia, Italy
| | - Corrado Campochiaro
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Milan, Italy
| | - Alessandro Tomelleri
- Division of Immunology, Transplants and Infectious Diseases, Università Vita-Salute San Raffaele, Milan, Italy; Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS Ospedale San Raffaele, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Milan, Italy
| | - Alicia Callisto
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark Beecher
- Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, Australia
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine, University of Padua, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Padua, Italy
| | - Chiara Baggio
- Rheumatology Unit, Department of Medicine, University of Padua, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Padua, Italy
| | - Verónica Gómez-Caverzaschi
- Clinical Unit of Autoinflammatory Diseases, Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Hospital Clínic of Barcelona [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], University of Barcelona, Barcelona, Spain
| | - Laura Pelegrín
- Department of Ophthalmology, Institut Clínic d'Oftalmologia (ICOF), Hospital Clinic de Barcelona, University of Barcelona, Institut de Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Adriana Soto-Peleteiro
- Faculty of Medicine and Nursery, University of the Basque Country, UPV/EHU, Leioa, Biscay, Spain; Autoimmune Diseases Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Spain
| | - Alessandra Milanesi
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Pavia, Italy; Department of Internal Medicine and Therapeutics, Università di Pavia, Italy
| | - Ibrahim Vasi
- Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Turkiye
| | - Alberto Cauli
- Rheumatology Unit, Department of Medical Sciences, University and AOU of Cagliari, Cagliari, Italy
| | | | - Florenzo Iannone
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Policlinic Hospital, University of Bari, Bari, Italy
| | - Riccardo Bixio
- Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Italy
| | - Francesca Della Casa
- Department of Translational Medical Sciences, Section of Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Ilaria Mormile
- Department of Translational Medical Sciences, Section of Clinical Immunology, University of Naples Federico II, Naples, Italy
| | - Carmelo Gurnari
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alessia Fiorenza
- Unit of Rheumatology, ASL VC Sant' Andrea Hospital, Vercelli 13100, Italy
| | - Germán Mejia-Salgado
- Neuroscience Research Group (NEUROS), NeuroVitae Center, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - Perla Ayumi Kawakami-Campos
- Department of Ophthalmology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gaafar Ragab
- Internal Medicine Department, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Cairo University, Giza, Egypt; Faculty of Medicine, Newgiza University, 6th of October City, Egypt
| | - Francesco Ciccia
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Piero Ruscitti
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Monica Bocchia
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Hematology Unit, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena 53100, Italy
| | - Alberto Balistreri
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Gian Marco Tosi
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy; Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy.
| | - Claudia Fabiani
- Rheumatology Unit, Policlinico "Le Scotte", Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center] Siena, viale Bracci 16, Siena 53100, Italy; Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy.
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23
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Martínez-Diaz L, Morales-Angulo C. VEXAS syndrome and otolaryngology. Am J Otolaryngol 2024; 45:104216. [PMID: 38199001 DOI: 10.1016/j.amjoto.2024.104216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024]
Affiliation(s)
- Lucía Martínez-Diaz
- Departamento de Ciencias Médicas y Quirúrgicas, Facultad de Medicina, Santander, Cantabria, Spain
| | - Carmelo Morales-Angulo
- Departamento de Ciencias Médicas y Quirúrgicas, Facultad de Medicina, Santander, Cantabria, Spain; Department of Otolaryngology, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain; IDIVAL, Santander, Cantabria, Spain.
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24
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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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25
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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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26
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Wolff L, Caratsch L, Lötscher F, Seitz L, Seitz P, Coattrenec Y, Seebach J, Vilinovszki O, Balabanov S, Nilsson J, Canbek A, Clottu A, Bruecker R, Efthymiou A, Regli D, Chrysoula M, Amstad A, Bonadies N, Blum S, Chitic M, Schreiber C, Comte D. VEXAS syndrome: a Swiss national retrospective cohort study. Swiss Med Wkly 2024; 155:3879. [PMID: 40132164 DOI: 10.57187/s.3879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2025] Open
Abstract
STUDY AIMS VEXAS syndrome is a recently discovered monogenic auto-inflammatory disease caused by a somatic mutation in the UBA1 gene that manifests with rheumatologic and haematologic features. In this report, we present the first Swiss cohort, detailing its manifestations and treatment outcomes among Swiss patients. METHODS Data were retrospectively collected from nine hospitals across Switzerland, representing a broad geographic distribution. Treating physicians completed a standardised case report form for each patient. The principal investigator and the co-investigators collected and analysed all case report forms. RESULTS We identified 23 patients between July 2022 and 2023, of which 17 are described. All were male. They presented with skin manifestations (88%), general symptoms (82%), venous thromboembolism (59%), ocular manifestation (59%), lung infiltrates (59%) and articular manifestations (47%). Central nervous system and kidney manifestations were very rare, and heart and digestive manifestations were absent. Macrocytic anaemia was present in all patients throughout the disease progression but only in two-thirds of patients (12/17, 71%) at the time of diagnosis. Clinical response was reached in all cases treated with ruxolitinib (4/4, 100%), upadacitinib (1/1, 100%), azacytidine (5/5, 100%) and haematopoietic stem cell transplantation (2/2, 100%). All deaths were attributed to infections (5/5, 100%). CONCLUSION This study corroborates the clinical spectrum of VEXAS syndrome described in other cohorts. It suggests that VEXAS syndrome is not limited to patients with macrocytic anaemia. In this study, azacytidine has been used effectively among patients with myelodysplastic syndrome. In addition, Janus kinase (JAK) inhibitors, particularly ruxolitinib, have been successfully used even in those without myelodysplastic syndrome. We report two successful treatments by haematopoietic stem cell transplantation.
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Affiliation(s)
- Louis Wolff
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Leo Caratsch
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Upper Valais Hospital Centre Visp (SZO), Rheumatology, Hôpital du Valais, Visp, Switzerland
| | - Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pascal Seitz
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yann Coattrenec
- Division of Immunology and Allergy, Geneva University Hospitals, Geneva, Switzerland
| | - Jörg Seebach
- Division of Immunology and Allergy, Geneva University Hospitals, Geneva, Switzerland
| | - Oliver Vilinovszki
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Balabanov
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Jakob Nilsson
- Department of Immunology, University Hospital Zurich, Zurich, Switzerland
| | - Aylin Canbek
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Aurélie Clottu
- Division of Immunology and Allergy, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Rolf Bruecker
- Rheumatology, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Anna Efthymiou
- Department of Hemato-Oncology, HFR Hôpital Fribourgeois, Fribourg, Switzerland
| | - Dena Regli
- Department of Internal Medicine, HFR Hôpital Fribourgeois, Fribourg, Switzerland
| | - Manolaraki Chrysoula
- Department of Rheumatology, University Hospital Basel and University of Basel, Basel
| | - Andrea Amstad
- Department of Rheumatology, University Hospital Basel and University of Basel, Basel
| | - Nicola Bonadies
- Oncology and Hematology Private Practice, Solothurn, Switzerland
| | - Sabine Blum
- Division of Hematology and Hematology Central Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Mariana Chitic
- Department of Medicine, Limattal Hospital, Schlieren, Switzerland
| | - Cornelia Schreiber
- Department of Oncology and Hematology, Limattal Hospital, Schlieren, Switzerland
| | - Denis Comte
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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27
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Saad AJ, Patil MK, Cruz N, Lam CS, O'Brien C, Nambudiri VE. VEXAS syndrome: A review of cutaneous findings and treatments in an emerging autoinflammatory disease. Exp Dermatol 2024; 33:e15050. [PMID: 38469984 DOI: 10.1111/exd.15050] [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: 05/09/2023] [Revised: 08/08/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory and somatic mutation) syndrome is a novel autoinflammatory, late-onset, disorder first identified in 2020. It is caused by mutations in the UBA1 gene. The most prominent clinical features reported by VEXAS patients are cutaneous and haematological, having characteristic skin features reported as the initial presenting findings of the disease. VEXAS is a severe and treatment-resistant condition with high morbidity and mortality rates. Here, we examine all case reports and case series of VEXAS syndrome through March 2023 focusing on those presenting cutaneous manifestations. We discuss these manifestations and their reported treatment strategies. In many cases, it might be first suspected and diagnosed by dermatologists, highlighting their vital role in initiating timely multidisciplinary care.
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Affiliation(s)
- Anis J Saad
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mihir K Patil
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Carle Illinois College of Medicine at the University of Illinois Urbana-Champaign, Champaign, Illinois, USA
| | - Nicolas Cruz
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chloe S Lam
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Connor O'Brien
- Transplant Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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28
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Fonollosa A, Carreño E, Vitale A, Jindal AK, Ramanan AV, Pelegrín L, Santos-Zorrozua B, Gómez-Caverzaschi V, Cantarini L, Fabiani C, Hernández-Rodríguez J. Update on ocular manifestations of the main monogenic and polygenic autoinflammatory diseases. FRONTIERS IN OPHTHALMOLOGY 2024; 4:1337329. [PMID: 38984133 PMCID: PMC11182141 DOI: 10.3389/fopht.2024.1337329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/30/2024] [Indexed: 07/11/2024]
Abstract
Autoinflammatory diseases include disorders with a genetic cause and also complex syndromes associated to polygenic or multifactorial factors. Eye involvement is present in many of them, with different extent and severity. The present review covers ophthalmological lesions in the most prevalent monogenic autoinflammatory diseases, including FMF (familial Mediterranean fever), TRAPS (TNF receptor-associated periodic syndrome), CAPS (cryopyrin-associated periodic syndromes), Blau syndrome, DADA2 (deficiency of adenosine deaminase 2), DITRA (deficiency of the interleukin-36 receptor antagonist), other monogenic disorders, including several ubiquitinopathies, interferonopathies, and the recently described ROSAH (retinal dystrophy, optic nerve edema, splenomegaly, anhidrosis, and headache) syndrome, and VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome. Among polygenic autoinflammatory diseases, ocular manifestations have been reviewed in Behçet's disease, PFAPA (periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis) syndrome, Still's disease and autoinflammatory bone diseases, which encompass CRMO (chronic recurrent multifocal osteomyelitis) and SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome.
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Affiliation(s)
- Alex Fonollosa
- Department of Ophthalmology, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Barakaldo, Spain
- Department of Retina, Instituto Oftalmológico Bilbao, Bilbao, Spain
| | - Ester Carreño
- Department of Ophthalmology, Rey Juan Carlos University Hospital, Madrid, Spain
- Department of Ophthalmology, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Siena, Italy
| | - Ankur K Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children and Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Laura Pelegrín
- Department of Ophthalmology, Institut Clínic d'Oftalmologia (ICOF), Hospital Clinic de Barcelona, University of Barcelona, Institut de Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Borja Santos-Zorrozua
- Department of Biostatistics, Biocruces Bizkaia Health Research Institute, Bilbao, Spain
| | - Verónica Gómez-Caverzaschi
- Autoinflammatory Diseases Clinical Unit, Department of Autoimmune Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Barcelona, Spain
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Siena, Italy
| | - José Hernández-Rodríguez
- Autoinflammatory Diseases Clinical Unit, Department of Autoimmune Diseases, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Center of the European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA), Spanish Center of the Centros, Servicios y Unidades de Referencia (CSUR) and Catalan Center of the Xarxa d'Unitats d'Expertesa Clínica (XUEC) for Autoinflammatory Diseases, Barcelona, Spain
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29
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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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30
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Kishtagari A, Corty RW, Visconte V. Clonal hematopoiesis and autoimmunity. Semin Hematol 2024; 61:3-8. [PMID: 38423847 DOI: 10.1053/j.seminhematol.2024.01.012] [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: 11/06/2023] [Revised: 01/14/2024] [Accepted: 01/28/2024] [Indexed: 03/02/2024]
Abstract
Clonal hematopoiesis (CH) has been associated with aging, occurring in about 10% of individuals aged >70 years, and immune dysfunction. Aged hematopoietic stem and progenitor cells exhibit pathological changes in immune function and activation of inflammatory pathways. CH clones commonly harbor a loss of function mutation in DNMT3A or TET2, which causes increased expression of inflammatory signaling genes, a proposed mechanism connected to CH and the development of age-related diseases. Additionally, inflammation may stress the hematopoietic compartment, driving the expansion of mutant clones. While the epidemiologic overlap between CH, hematologic malignancies, and atherosclerotic cardiovascular diseases has been reported, the mechanisms linking these concepts are largely unknown and merit much further investigation. Here, we review studies highlighting the interplay between CH, inflamm-aging, the immune system, and the prevalence of CH in autoimmune diseases.
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Affiliation(s)
- Ashwin Kishtagari
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Robert W Corty
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
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31
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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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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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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: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 12/23/2023] Open
Abstract
Vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic syndrome is a newly recognized, acquired autoinflammatory disorder with broad systemic implications and a poor global prognosis. Because cutaneous lesions are present in the majority of those affected, it is necessary that dermatologists are equipped to recognize this important disease. Through identification, there is a greater opportunity for disease stratification, surveillance for systemic involvement, and selection of the best available therapies. As our understanding of this disease develops, dermatologists should also play a role in addressing the knowledge gaps that exist.
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Affiliation(s)
| | - Edward W. Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, Maryland, USA
| | - David Beck
- Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Marcela Ferrada
- Rheumatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, Maryland, USA
| | - Lauren M. Madigan
- Department of Dermatology, University of Utah, Salt Lake City, Utah, USA
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Loeza-Uribe MP, Hinojosa-Azaola A, Sánchez-Hernández BE, Crispín JC, Apodaca-Chávez E, Ferrada MA, Martín-Nares E. VEXAS syndrome: Clinical manifestations, diagnosis, and treatment. REUMATOLOGIA CLINICA 2024; 20:47-56. [PMID: 38160120 DOI: 10.1016/j.reumae.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is an adult-onset autoinflammatory syndrome characterized by somatic mutations in the UBA1 gene and is considered the prototype of hematoinflammatory diseases. Patients with VEXAS syndrome exhibit inflammatory and hematological manifestations that can lead to clinical diagnoses such as relapsing polychondritis, polyarteritis nodosa, Sweet syndrome, and myelodysplastic syndrome. Diagnosis requires bone marrow evaluation to identify cytoplasmic vacuoles in myeloid and erythroid precursors. However, genetic confirmation of mutations in UBA1 is necessary. Treatment is challenging and often involves glucocorticoids and immunosuppressants with variable responses. Hypomethylating agents and allogenic haemopoietic stem cell transplant are considered promising therapies. Prognosis is influenced by genetic and clinical factors. The aim of this review is to provide an overview of the pathogenesis, clinical presentation, treatment, and prognosis of VEXAS syndrome for the Latin American medical community.
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Affiliation(s)
- Michelle Patricia Loeza-Uribe
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Andrea Hinojosa-Azaola
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Beatriz E Sánchez-Hernández
- Departamento de Patología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - José C Crispín
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Elia Apodaca-Chávez
- Departamento de Hematología y Oncología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - Marcela A Ferrada
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA.
| | - Eduardo Martín-Nares
- Departamento de Inmunología y Reumatología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
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Padureanu V, Marinaș CM, Bobirca A, Padureanu R, Patrascu S, Dascalu AM, Bobirca F, Tribus L, Alexandru C, Serboiu C, Dumitrascu C, Musetescu A. Clinical Manifestations in Vacuoles, E1 Enzyme, X-Linked, Autoinflammatory, Somatic (VEXAS) Syndrome: A Narrative Review. Cureus 2024; 16:e53041. [PMID: 38410307 PMCID: PMC10895688 DOI: 10.7759/cureus.53041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/28/2024] Open
Abstract
The newly identified refractory adult-onset autoinflammatory syndrome known as VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is brought on by somatic mutations in the ubiquitin-like modifier-activating enzyme 1 (UBA1) gene in hematopoietic stem and progenitor cells that change the expression of the UBA1 isoform. As a result, patients have a variety of hematologic and systemic inflammatory symptoms. All types of medical professionals should treat VEXAS syndrome seriously due to the high fatality rate. To better comprehend the condition and enhance the prognosis for VEXAS syndrome, this review article describes the essential traits and clinical signs of the condition. The discussion of future directions in the study of systemic inflammatory disorders brought on by somatic mutations concludes.
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Affiliation(s)
- Vlad Padureanu
- Department of Internal Medicine, Emergency County Hospital of Craiova, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | | | - Anca Bobirca
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Rodica Padureanu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Stefan Patrascu
- Department of Surgery, University of Medicine and Pharmacy of Craiova, Craiova, ROU
| | - Ana Maria Dascalu
- Department of Ophthalmology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Florin Bobirca
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Laura Tribus
- Department of Gastroenterology, Faculty of Oral Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Cristina Alexandru
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Crenguta Serboiu
- Department of Histology, Cellular and Molecular Biology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Catalin Dumitrascu
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Anca Musetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, Craiova, ROU
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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: 1] [Impact Index Per Article: 0.5] [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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38
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Makus B, Rose T. [Relapsing polychondritis]. Z Rheumatol 2023; 82:867-876. [PMID: 38012458 DOI: 10.1007/s00393-023-01451-1] [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: 11/02/2023] [Indexed: 11/29/2023]
Abstract
Relapsing polychondritis (RP) is a rare multisystemic disease predominantly involving the extracellular matrix. Typical manifestations are chondritis of the ears, nose and trachea as well as an asymmetrical oligoarthritis or polyarthritis of small and also larger joints. Various other involvements have also been described. The treatment of RP is individually dependent on a variety of factors, e.g., organ manifestations. Glucocorticoids, immunosuppressants and targeted treatment are implemented. In the case of seronegative rheumatoid arthritis or vasculitis with an atypical course the symptoms of RP should be taken into consideration.
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Affiliation(s)
- Benjamin Makus
- Klinik für Rheumatologie und Klinische Immunologie, Charité Universitätsmedizin Berlin, Charité Platz 1, 10117, Berlin, Deutschland
| | - Thomas Rose
- Klinik für Rheumatologie und Klinische Immunologie, Charité Universitätsmedizin Berlin, Charité Platz 1, 10117, Berlin, Deutschland.
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Fanlo P, Román MLDS, Fonollosa A, Ilarramendi J, Heras H, Grayson P. Episcleritis and periorbital edema secondary to VEXAS syndrome. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2023; 98:607-610. [PMID: 37595794 DOI: 10.1016/j.oftale.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/07/2023] [Indexed: 08/20/2023]
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly described autoinflammatory entity caused by a UBA-1 gene mutation. Among the most frequent symptoms it produces fever, cytopenias, polychondritis, pulmonary infiltrates and up to 40% ocular involvement such as periorbital edema, uveitis, episcleritis, scleritis and retinal vasculitis. Patients respond to high doses of corticosteroids, however, many end up being refractory to them and to the classic immunosuppressants. We described the case of a 77-year-old male patient with ocular involvement in the form of episcleritis and periorbital edema who was later diagnosed with VEXAS Syndrome. The patient, after failing treatment with immunosuppressants, is currently receiving treatment with oral steroids and tocilizumab. Ophthalmologist must be aware of the ophthalmological affectation of autoinflammatory diseases and especially of this new entity described as the VEXAS Syndrome.
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Affiliation(s)
- P Fanlo
- Servicio de Medicina Interna, Hospital Universitario de Navarra, Pamplona, Spain.
| | - M López de San Román
- Servicio de Medicina Interna, Hospital Universitario de Navarra, Pamplona, Spain
| | - A Fonollosa
- Department of Ophthalmology, Instituto de Investigación Sanitaria de Vizcaya Biocruces, Hospital Universitario de Cruces, Universidad del País Vasco, Instituto Oftalmológico Bilbao, Bilbao, Spain
| | - J Ilarramendi
- Servicio de Hematología, Hospital Universitario de Navarra, Pamplona, Spain
| | - H Heras
- Servicio de Oftalmología, Hospital Universitario de Navarra, Pamplona, Spain
| | - P Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland, Spain
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Yin R, Zhao M, Xu D, Wang Q, Li M, Zhang W, Zhang F, Zeng X, Huo Y, Hou Y. Relapsing polychondritis: focus on cardiac involvement. Front Immunol 2023; 14:1218475. [PMID: 37771578 PMCID: PMC10523381 DOI: 10.3389/fimmu.2023.1218475] [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: 05/07/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023] Open
Abstract
Background Relapsing polychondritis (RP) with cardiac involvement may present with acute cardiovascular events, and may be associated with a negative prognosis. Herein, we analyzed the clinical characteristics of RP patients with cardiac involvement. Method RP patients, hospitalized from December 2005 to December 2021 at Peking Union Medical College Hospital (PUMCH), were screened. Univariate and multivariate logistic regression analyses were used to statistically analyze the clinical characteristics of these patients. Results The incidence of cardiac involvement in inpatients with RP was 24.1%. Univariate logistic regression analysis revealed age, central nervous system (CNS) involvement, neutrophil-to-lymphocyte ratio (NLR) > 6.41, and disease duration > 4 years as risk factors for cardiac involvement in RP. Conversely, the incidence of tracheobronchial and chest wall involvement was significantly lower in the group with cardiac involvement. Multivariate logistic regression confirmed that age, CNS involvement, NLR > 6.41, and disease duration > 4 years were independent factors for cardiac involvement. Subsequently, we identified five well-defined clinical patterns of RP, based on the involvement of different organs in our patients, and found that the heart-brain model was significantly mutually exclusive with the airway model. Conclusion Occurrence of cardiac involvement in RP is associated with age, CNS involvement, NLR, and disease duration. It is mutually exclusive with airway-related involvement. Regular echocardiography and electrocardiography are necessary for patients with RP.
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Affiliation(s)
- Ruxue Yin
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Mengzhu Zhao
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Dong Xu
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Qian Wang
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Mengtao Li
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Wen Zhang
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Fengchun Zhang
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Xiaofeng Zeng
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
| | - Yuping Huo
- Department of Rheumatology, Jin Cheng People’s Hospital, Jincheng, Shanxi, China
| | - Yong Hou
- Key Laboratory of Rheumatology and Clinical Immunology, Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Ministry of Education, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Beijing, China
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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: 5] [Impact Index Per Article: 2.5] [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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42
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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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43
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Ruffer N, Krusche M. VEXAS syndrome: a diagnostic puzzle. RMD Open 2023; 9:e003332. [PMID: 37532466 PMCID: PMC10401208 DOI: 10.1136/rmdopen-2023-003332] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/12/2023] [Indexed: 08/04/2023] Open
Abstract
The VEXAS syndrome (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) is an adult-onset systemic autoinflammatory condition that is caused by an acquired deficiency of the UBA1 gene in hematopoietic progenitor cells. The clinical spectrum of the VEXAS syndrome currently comprises a broad range of phenotypes such as vasculitis, relapsing polychondritis and Sweet's syndrome. In the past, VEXAS patients have left clinicians puzzled and the true nature of this disease has not been captured until late 2020. This viewpoint describes the relevant clinical features of the VEXAS syndrome and reviews different approaches to establish the diagnosis. Finally, future directions within the field of systemic inflammatory diseases caused by somatic mutations are being discussed.
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Affiliation(s)
- Nikolas Ruffer
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Krusche
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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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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Kucharz EJ. VEXAS syndrome: a newly discovered systemic rheumatic disorder. Reumatologia 2023; 61:123-129. [PMID: 37223371 PMCID: PMC10201379 DOI: 10.5114/reum/163090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/05/2023] [Indexed: 05/25/2023] Open
Abstract
VEXAS syndrome is an adult-onset autoinflammatory disease associated with hematologic symptoms. The disease affects primarily males, and leads to death of a significant proportion of the patients. VEXAS syndrome is caused by a somatic mutation of the UBA1 gene in hematopoietic progenitor cells. The clinical picture of the syndrome consists of a number of organ manifestations including those akin to rheumatic diseases, arthritis, myalgia, vasculitis and chondritis.
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Affiliation(s)
- Eugenisz J Kucharz
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Medical University of Silesia, Katowice, Poland
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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: 16] [Impact Index Per Article: 8.0] [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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Mertz P, Sparks J, Kobrin D, Ogbonnaya SA, Sevim E, Michet C, Arnaud L, Ferrada M. Relapsing polychondritis: Best Practice & Clinical Rheumatology. Best Pract Res Clin Rheumatol 2023; 37:101867. [PMID: 37839908 DOI: 10.1016/j.berh.2023.101867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 10/17/2023]
Abstract
Relapsing polychondritis (RP) is an uncommon inflammatory disorder that predominantly targets cartilaginous structures. The disease frequently affects the nose, ears, airways, and joints, but it can also impact organs that aren't primarily cartilage-based, such as blood vessels, skin, inner ear, and eyes. Given its infrequent occurrence and recurrent symptoms, patients often experience delays in proper diagnosis. Lately, based on the organs involved, the disease's diverse manifestations have been categorized into specific clinical groups, based on the most likely organ involvement including auricular, nasal, pulmonary, and musculoskeletal. More recently the discovery of a new disease, called (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) VEXAS syndrome, due to mutations in UBA1 gene, identified the cause of 8 % of the patients with a clinical diagnosis of RP. VEXAS is likely the cause of a previously described "hematologic subgroup" in RP. This discovery is proof of concept that RP is likely more than one disease (Beck et al., Dec 31 2020; Ferrada et al., 2021). People diagnosed with RP face numerous hurdles, with the quality of their lives and overall prognosis being affected. Diagnosing the condition is particularly challenging due to its fluctuating symptoms, the absence of specific markers, and the lack of universally recognized classification criteria. For a correct diagnosis, it's imperative for healthcare professionals to identify its unique clinical patterns. Moreover, there are no approved metrics to gauge the disease's severity, complicating patient management. This review seeks to equip clinicians with pertinent insights to better diagnose and attend to these complex patients.
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Affiliation(s)
- Phillip Mertz
- Hôpitaux Universitaires de Strasbourg, Centre National de Référence RESO-Lupus, 67000 Strasbourg, France
| | - Joshua Sparks
- Department of Pediatrics, University of Louisville, Louisville, KY, USA
| | - Dale Kobrin
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Sandra Amara Ogbonnaya
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Ecem Sevim
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Clement Michet
- Mayo Clinic School of Medicine, Division of Rheumatology, USA
| | - Laurent Arnaud
- Hôpitaux Universitaires de Strasbourg, Centre National de Référence RESO-Lupus, 67000 Strasbourg, France
| | - Marcela Ferrada
- National Institutes of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA.
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Abstract
INTRODUCTION VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described, late-onset, acquired autoinflammatory disorder caused by mutations in the UBA1 gene. The various clinical manifestations of VEXAS broadly divided into inflammatory or haematological. VEXAS defines a new disease category - the hematoinflammatory disorders triggered by somatic mutations restricted to blood but causing systemic inflammation with multi-organ involvement and associated with aberrant bone marrow status. VEXAS causes significant morbidity and reduced life expectancy, but the optimum standard of care remains undefined. AREAS COVERED This review describes the discovery of VEXAS, relevant genetic causes and immunopathology of the disease. A detailed account of its various clinical manifestations and disease mimics is provided. Current treatment and management options are discussed. EXPERT OPINION New rare variants in UBA1 and VEXAS-like UBA1 negative cases are reported. Consensus diagnostic criteria might be required to define VEXAS and its related disorders. Investigation of sporadic, VEXAS-like cases will require the application of deep sequencing using DNA obtained from various cellular or tissue locations. Prospective studies are needed to define the optimal supportive and treatment options for patients with varying disease severity and prognosis. VEXAS-specific hematopoietic stem cell transplant selection criteria also require development.
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Affiliation(s)
- Adam Al-Hakim
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, UK
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, Leeds Teaching Hospitals, NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Leeds, UK.,National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, School of Medicine, University of Leeds, Leeds, UK
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Robert M, Berleur M, Gaudemer A, Crow YJ, Frémond ML, Sacré K. VEXAS syndrome: Expanding the clinical and molecular spectrum. Joint Bone Spine 2023; 90:105531. [PMID: 36690065 DOI: 10.1016/j.jbspin.2023.105531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/07/2022] [Accepted: 12/16/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Marie Robert
- Service de médicine interne, hôpital Bichat, Assistance publique-Hôpitaux de Paris, 46, rue Henri Huchard, 75018 Paris, France
| | - Marie Berleur
- Service de médicine interne, hôpital Bichat, Assistance publique-Hôpitaux de Paris, 46, rue Henri Huchard, 75018 Paris, France
| | - Augustin Gaudemer
- Service de radiologie, hôpital Bichat, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Yanick J Crow
- Laboratoire de neurogénétique et neuroinflammation, Inserm U1163, institut Imagine, Paris, France; MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Marie-Louise Frémond
- Laboratoire de neurogénétique et neuroinflammation, Inserm U1163, institut Imagine, Paris, France; Unité d'immuno-hématologie et rhumatologie pédiatriques, hôpital Necker-Enfants malades, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Karim Sacré
- Service de médicine interne, hôpital Bichat, Assistance publique-Hôpitaux de Paris, 46, rue Henri Huchard, 75018 Paris, France; Inserm UMR1149, centre de recherche sur l'inflammation, laboratoire d'excellence inflamex, Paris, France.
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Vitale A, Caggiano V, Bimonte A, Caroni F, Tosi GM, Fabbiani A, Renieri A, Bocchia M, Frediani B, Fabiani C, Cantarini L. VEXAS syndrome: a new paradigm for adult-onset monogenic autoinflammatory diseases. Intern Emerg Med 2023; 18:711-722. [PMID: 36662445 PMCID: PMC10082120 DOI: 10.1007/s11739-023-03193-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023]
Abstract
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is a recently described pathological entity. It is an acquired monogenic autoinflammatory disease caused by somatic mutations of the UBA1 gene in blood cells precursors; the gene encodes one of the two E1 enzyme isoforms that initiates ubiquitylation in cell's cytoplasm. VEXAS syndrome leads to systemic inflammation, with all organs and tissues potentially involved. The clinical picture may be extremely heterogenous, mimicking different other systemic rheumatologic entities coexisting with haematological disorders, especially myelodysplastic syndrome. This new disease represents a very intriguing clinical condition in several respects: it accounts for the paradigm of adult-onset monogenic autoinflammatory diseases determined by a genetic mosaicism resulting in the development of a challenging multiorgan inflammatory condition. Moreover, VEXAS syndrome is perhaps not an exceptionally rare condition and represents an example of a systemic genetic autoinflammatory disease drawing its origin in bone marrow disorders. VEXAS syndrome should be strongly considered in each adult patient with an unexplained systemic inflammatory condition, especially when recurrent fevers, neutrophilic dermatosis, relapsing polychondritis, ocular inflammation and other systemic inflammatory symptoms accompanying myelodysplastic syndrome or other haematological disorders. The syndrome deserves a multidisciplinary approach to reach the diagnosis and ensure the best management of a potentially very challenging condition. To quickly describe the clinical course, long-term outcomes, and the optimal management of this new syndrome it is essential to join forces internationally. To this end, the international AutoInflammatory Disease Alliance (AIDA) registry dedicated to VEXAS syndrome has been developed and is already active.
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Affiliation(s)
- Antonio Vitale
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Valeria Caggiano
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Antonio Bimonte
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Federico Caroni
- Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Gian Marco Tosi
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Alessandra Fabbiani
- Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Alessandra Renieri
- Medical Genetics, Department of Medical Biotechnologies, University of Siena, Siena, Italy
- Department of Medical Biotechnologies, Med Biotech Hub and Competence Center, University of Siena, Siena, Italy
- Genetica Medica, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
| | - Monica Bocchia
- Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy
| | - Bruno Frediani
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic and Rheumatology-Ophthalmology Collaborative Uveitis Center, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100, Siena, Italy.
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