David Adams spent half a decade battling an illness he couldn’t name. He was in and out of the hospital several times a year. His inflamed joints made his hands feel like they had been squeezed into gloves – and he could no longer play his beloved classical and jazz guitars.
He had constant fever and fatigue. He even developed genital pain and swelling, which was his first sign that something was really wrong.
“At the turn of 2016, I started having some really painful effects in the male anatomy,” said Adams, now 70. “Then again, a lot of fatigue — my primary care doctor at the time had blood work done, and my white blood cell count was very, very low .”
Next, Adams, who lives in Alexandria, Virginia, saw a hematologist, a pulmonologist, a urologist, a rheumatologist and then a dermatologist. Some of them thought he might have cancer.
Adams’ symptoms continued with even more fatigue, pneumonia and a large rash below his waist. He tried at least a dozen medications, saw about two dozen doctors, and nothing helped.
In 2019, worsening symptoms forced him to retire early from his decades-long career in clinical data systems. But he remained in the dark about what was causing the problems.
Finally, in 2020, researchers at the National Institutes of Health discovered and named a rare genetic disorder: VEXAS syndrome, which wreaks havoc on the body through inflammation and blood problems.
Adams had an appointment with his rheumatologist at the time, and when he walked into the office, he saw that his doctor was “as giddy as a little kid.”
In his doctor’s hands was a copy of a paper in the New England Journal of Medicine describing the discovery of VEXAS syndrome.
Adams had his answer.
“For the first time there was a one-to-one correlation of symptoms,” he said. “It was quite a shock.”
An estimated 1 in about 13,500 people in the U.S. may have VEXAS syndrome, a new study suggests, meaning the mysterious and sometimes fatal inflammatory disorder may be more common than previously thought.
In comparison, the genetic disorder spinal muscular atrophy affects about 1 in 10,000 people, and Huntington’s disease occurs in about 1 in every 10,000 to 20,000 people.
Since its discovery, occasional VEXAS cases have been reported in medical research, but the study reveals new estimates of its prevalence.
The research, published Tuesday in the journal JAMA, suggests that about 1 in 13,591 people in the United States have mutations in the UBA1 gene that develop later in life and cause VEXAS syndrome.
“This study shows that there are probably tens of thousands of patients in the United States who have this disease, and the vast majority of them are probably not being recognized because doctors don’t really consider this a diagnosis more broadly,” said Dr. David Beck, an assistant professor in the Department of Medicine at NYU Langone Health and a lead author of the study.
VEXAS syndrome is not hereditary, so people who have it do not pass the disease on to their children. But the UBA1 gene is on the X chromosome, so the syndrome is an X-linked disease. It predominantly affects men who carry only one X chromosome. Females have two X chromosomes, so if they have a mutation in a gene on one X chromosome but not the other, they are generally unaffected.
“It’s present in 1 in 4,000 men over the age of 50. So we think it’s a disease that should be considered in terms of testing for people who have the symptoms,” said Beck, who also led the federal research team , who identified shared UBA1 mutation among VEXAS patients in 2020.
“The advantage of VEXAS syndrome is that we have a test. We have a genetic test that can directly help make the diagnosis,” he said. “It’s just a matter of patients who meet the criteria — who are older individuals with systemic inflammation, low blood counts that really don’t respond to anything but steroids—and then urge their doctors to get genetic testing to get a diagnosis.”
Adams, who became a patient of Beck’s, said getting a diagnosis — and understanding the cause of his symptoms — was life-changing.
“It was really incredibly liberating to get the diagnosis,” he said.
“You cannot fight your enemy unless your enemy has a name,” he added. “We finally had something we could point to and say, ‘OK, we understand what’s going on. This is VEXAS.’ ”
For the new study, Beck and his colleagues at the NIH, New York University, Geisinger Research and other institutions analyzed data on 163,096 patients in a health system in central and northeastern Pennsylvania, from January 1996 to January 2022, including electronic health records and blood samples.
Eleven of the patients had a disease-causing UBA1 variant, and a 12th person had a “highly suspicious” variant.
Only three of the 12 are still alive. A five-year survival rate of 63% has previously been reported with VEXAS.
Among the 11 patients in the new study who had pathogenic variants in UBA1, only two were women. Seven had arthritis as a symptom, and four had been diagnosed with rheumatological diseases, such as psoriasis of the skin or sarcoidosis, which causes swollen lumps in the body. All had anemia or low blood cell counts.
“No one had previously been clinically diagnosed with VEXAS syndrome,” Beck said.
The finding “underscores how important it is to be able to pick these patients out, give them the diagnosis and start the aggressive therapies or aggressive treatments to keep their inflammation in check,” he said.
VEXAS — an acronym for five clinical characteristics of the disease — has no standardized treatment or cure, but Beck said symptoms can be managed with medications such as the steroid prednisone or other immunosuppressants.
“But the toxicity of prednisone over years is challenging. There are other anti-inflammatory drugs that we use, but they are only partially effective at the moment,” he said. “One treatment for individuals that we’ve seen that is very effective is bone marrow transplantation. That comes with its own risks, but that just underscores the serious nature of the disease.”
While the new study helps provide estimates of the prevalence and symptoms of VEXAS syndrome, the data is not representative of the entire United States, and Beck said more research needs to be done on a larger, more diverse group of people.
Some men may hesitate to seek medical attention for VEXAS symptoms, but Adams said it could save their lives.
“Eventually it’s going to get so bad that you end up like my first hospitalization, where you’re at death’s door,” Adams said. “You don’t want to be in that situation.”
Adams has been taking prednisone to relieve his symptoms and it has helped. But because steroid use can have side effects such as cataracts and weight gain, he has worked with his doctors to find other forms of treatment so he can reduce his intake of the medication.
Beck and his colleagues are studying targeted therapies for VEXAS syndrome as well as conducting stem cell bone marrow transplant trials at the NIH.
“There are many different facets of the disease,” said Dr. Bhavisha Patel, a hematologist and researcher in the National Heart, Lung and Blood Institute’s Hematopoiesis and Bone Marrow Defects Laboratory, in an NIH news release last month.
“I think that’s what’s challenging when we think about treatment because it’s so heterogeneous,” said Patel, who was not involved in the new study.
“Both at NIH and worldwide, the groups dedicated to VEXAS are looking for medical treatments to offer other patients who do not qualify for a bone marrow transplant,” she said. “We continue to collaborate on many projects to further categorize this disease and ultimately come up with the best treatment options.”