VEXAS syndrome: a Spanish national research project to better understand this rare disease.

Article title : VEXAS syndrome through a rheumatologist's lens: insights from a Spanish national cohortservices de rhumatologie espagnols

First author: García-Escudero P

First author: Rheumatology

Lien vers l'article: https://pubmed.ncbi.nlm.nih.gov/39937690/

Auteur du résumé: Philippe Mertz

Introduction

VEXAS syndrome (Vacuoles, E1 enzyme, X‑linked, Autoinflammatory, Somatic) is a recently described, severe autoinflammatory disease associated with somatic variants in the UBA1 gene. It primarily affects men over 50 and combines systemic inflammatory manifestations with hematologic abnormalities. The aim of this study was to describe the clinical and genetic features of VEXAS seen in patients followed in Spanish rheumatology departments and to analyze genotype–phenotype correlations.

Methods

This was a multicenter retrospective study conducted in 126 Spanish hospitals, including 39 patients diagnosed between December 2020 and January 2024. Clinical, laboratory, and genetic data were collected and analyzed.

Key results

All patients were men, with a mean age of 73 years (range 40–92) at diagnosis. Initial working diagnoses included seronegative polyarthritis (9/39), relapsing polychondritis (6/39), Sweet’s syndrome (4/39), polymyalgia rheumatica (4/39), systemic lupus, and medium‑vessel vasculitis (3/39 each). The most frequent clinical features were skin involvement (87%), followed by polyarthritis (82%) and fever (79%). Renal involvement affected 20% of patients, a higher rate than previously reported cohorts, and polyarthritis also appeared more frequent than in earlier series.

Genetically, notable correlations emerged. The UBA1 M41V variant was significantly associated with renal involvement, whereas M41T correlated with thrombocytopenia and an increased rate of thromboembolic events. The study also identified a potentially pathogenic novel UBA1 variant (c.209T>A; p.L70H).

Regarding treatment, all patients received corticosteroids, with better responses observed after diagnostic confirmation and dose adjustments. Interleukin‑6 inhibitors and JAK inhibitors, notably ruxolitinib, showed the highest response rates, reaching 75% and 76% respectively. In contrast, anti‑TNF agents and hypomethylating agents were largely ineffective.

Conclusion

This study confirms that VEXAS remains under‑recognized in rheumatology, particularly among older men presenting with polyarthritis, unexplained cytopenias, or steroid dependence. It also underscores that genotype influences clinical expression, with certain variants associated with more severe disease or specific complications such as renal or thromboembolic involvement. Finally, the results support JAK and IL‑6 inhibitors as key therapeutic strategies in this condition.

In clinical practice, these findings support considering VEXAS promptly in any man over 50 with seronegative polyarthritis and atypical systemic features, cytopenias, or steroid dependence, to avoid diagnostic delay and better tailor therapy.

Le syndrome VEXAS une recherche nationale espagnole pour mieux comprendre cette maladie r.

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VEXAS syndrome as a new differential diagnosis of late onset spondyloarthritis

Article title: Syndrome VEXAS comme nouveau diagnostic différentiel de la spondyloarthrite du sujet âgé

First author: Jain H

Journal: MEDITERRANEAN JOURNAL OF RHEUMATOLOGY

Link to the article: https://pubmed.ncbi.nlm.nih.gov/39463879/

Author of the abstract: Philippe Mertz

VEXAS syndrome (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) is an autoinflammatory disease associated with somatic mutations in the UBA1 gene, mainly observed in people over the age of 50. This gene encodes a key enzyme in the ubiquitination process, whose dysfunction leads to the activation of several inflammatory pathways. Signs suggestive of VEXAS syndrome include macrocytic anemia, neutrophilic dermatoses (such as Sweet's syndrome), pulmonary and ophthalmological involvement, thrombosis, and various rheumatological manifestations. The latter often present as arthralgia or mono-, oligo-, or polyarthritis.

Spondyloarthritis in older individuals is a rare condition that can be axial and/or peripheral, with an inflammatory component that is often more pronounced than in younger individuals. It requires the elimination of certain specific differential diagnoses, including microcrystalline rheumatism, rhizomelic pseudo-polyarthritis, giant cell arteritis, and paraneoplastic rheumatism.

The authors report the case of a 67-year-old man living in India with peripheral polyarthritis associated with chronic inflammatory low back pain. Skin lesions had also been observed for a month, and biopsy revealed neutrophilic dermatosis, which responded well to corticosteroid therapy. Rheumatological tests showed the presence of HLA B27, active bilateral sacroiliitis on MRI, synovitis of the wrists, and bilateral retrocalcaneal bursitis. Initial treatment with sulfasalazine and NSAIDs failed, and the introduction of methotrexate at 15 mg/week was also ineffective. Further investigations revealed macrocytic anemia (Hb = 8.3 g/dL, MCV = 106 fL) associated with a biological inflammatory syndrome (CRP = 38 mg/L). These abnormalities led to Sanger sequencing of the UBA1 gene, confirming the diagnosis of VEXAS syndrome due to the p.Met41Leu mutation. Corticosteroid therapy combined with sulfasalazine at 1 mg/day controlled the joint symptoms.

Two other cases of spondyloarthritis in older patients associated with VEXAS syndrome have been reported:

A 57-year-old man living in France, presenting with a similar clinical picture, including peripheral polyarthritis, bilateral sacroiliitis, HLA-B27 positivity, and biological inflammatory syndrome (2). When the first inflammatory symptoms appeared at the age of 57 in 2010, treatment with anti-TNF alpha initially provided good control of the symptoms. Subsequently, he developed acute anterior uveitis, chondritis of the ear and nose, chronic inflammatory bowel disease (IBD), and neutrophilic dermatosis. Several lines of treatment were attempted without lasting success, including methotrexate, azathioprine, cyclophosphamide, baricitinib, infliximab, tocilizumab, anakinra, and ustekinumab. Finally, a combination treatment of intravenous immunoglobulins (2 g/kg every 4 weeks) and secukinumab (300 mg every 4 weeks) proved effective. The diagnosis of VEXAS syndrome associated with the Met41Thr mutation was made retrospectively in 2020.

A 74-year-old Caucasian man with a recent history of venous thrombosis in the lower limbs presented with inflammatory low back pain with bilateral sacroiliitis on MRI, macrocytic anemia (Hb = 8.8 g/dL and MCV = 101 fL), but without significant biological inflammatory syndrome (3). He subsequently developed progressive anemia (Hb = 8.5 g/dL and MCV = 100 fL), purpura of the lower limbs, erythema nodosum, and chondritis of the ear. He was diagnosed with VEXAS syndrome associated with the Met41Thr mutation of the UBA1 gene. After several treatments failed, including tocilizumab complicated by abscessed diverticulitis, azacitidine at the standard dose of 75 mg/m²/day led to a significant reduction in corticosteroid therapy (from 40 mg/day to 5 mg/day) and clinical improvement of symptoms.

The manifestations of VEXAS syndrome are varied and still poorly defined. It appears to be one of the new differential diagnoses to consider in cases of spondyloarthritis in older patients, particularly those aged 50 and over, given the age of onset of VEXAS syndrome and especially in the presence of a biological inflammatory syndrome, hematological abnormalities with associated anemia, particularly macrocytic anemia, or other suggestive findings such as neutrophilic dermatosis. An atypical history or the appearance of new extra-rheumatological symptoms, such as venous thrombosis, inflammatory dermatoses (particularly neutrophilic), chondritis, or pulmonary involvement, should also point to this diagnosis. In addition, resistance to initial treatment with NSAIDs may be a warning sign, especially since the hematological abnormalities associated with VEXAS syndrome may appear secondarily.

REFERENCES

Jain H, Roy D, Mavidi S, Haldar S, Mondal S, Bhattacharya P, et al. Elderly Onset Spondyloarthropathy and VEXAS Syndrome: A Case Report. Mediterr J Rheumatol. 2024 Sep;35(3):490–3.

Magnol M, Couvaras L, Degboé Y, Delabesse E, Bulai-Livideanu C, Ruyssen-Witrand A, et al. VEXAS syndrome in a patient with previous spondyloarthritis with a favourable response to intravenous immunoglobulin and anti-IL17 therapy. Rheumatology (Oxford). 2021 Sep 1;60(9):e314–5.

Pereira da Costa R, Sapinho G, Bandeira M, Infante J, Marques T, Mimoso Santos C, et al. Case report: VEXAS syndrome: an atypical indolent presentation as sacroiliitis with molecular response to azacitidine. Front Immunol. 2024;15:1403808.

Syndrome VEXAS comme nouveau diagnostic différentiel de la spondyloarthrite du sujet âgé.p

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Comparing clinical features between males and females with VEXAS syndrome: data from literature analysis of patient reports

Premier auteur: Echerbault et al.

Lien vers l'article: DOI: 10.1093/rheumatology/keae123

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.

VEXAS Syndrome.pdf

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