Clonal hematopoiesis meets an autoinflammatory disease: the new paradigm of VEXAS syndrome

Abstract

Introduction: VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is an acquired autoinflammatory disorder caused by somatic mutations in the UBA1 gene. Predominantly affecting males over 50, the disease presents with systemic inflammation, hematologic abnormalities, and features of clonal hematopoiesis, with nearly half of patients developing myelodysplastic syndromes (MDS). The interaction between inflammation and clonal expansion defines disease progression, emphasizing the need for a comprehensive understanding of its pathogenesis and management.

Areas covered: This review discusses the clinical spectrum, genetic landscape, and pathogenic mechanisms of VEXAS syndrome. The correlation between UBA1 mutations and disease severity is explored, alongside the role of clonal hematopoiesis and inflammatory pathways. Current treatments, including corticosteroids, immunosuppressants, JAK inhibitors, and azacitidine, are evaluated for efficacy and limitations. The potential of allogeneic hematopoietic stem cell transplantation (allo-HSCT) as a curative approach is also addressed. Literature search was conducted from January 2020 to present using PubMed and Scopus databases to identify relevant studies.

Expert opinion: VEXAS syndrome reflects a complex interaction between autoinflammation and clonal hematopoiesis. While targeted therapies offer symptomatic control, responses remain variable. Future strategies should focus on genotype-driven, personalized treatments and optimizing allo-HSCT protocols to improve patient outcomes and offer disease-modifying potential.

Keywords: UBA1; VEXAS syndrome; bone marrow failure; clonal hematopoiesis; hematology; inflammation; myelodysplastic syndrome; ubiquitylation.