Recurrent fever and association with severe organ involvement, mortality and treatment outcomes in VEXAS syndrome: data from the AIDA Network.

Valeria Caggiano, Jessica Sbalchiero, Micol Frassi, Francesca Crisafulli, Ilaria Cavazzana, Andrea Hinojosa-Azaola, Eduardo Martín-Nares, Guillermo Arturo Guaracha-Basañez, Jiram Torres-Ruiz, Ewa Wiesik-Szewczyk, Anna Nowakowska-Plaza, Paolo Sfriso, Sara Bindoli, Samuele Rizzo, José Hernández-Rodríguez, Verónica Gómez-Caverzaschi, Olga Araújo, Henrique A Mayrink Giardini, Andrés González-García, Giuseppe Lopalco, Ombretta Viapiana, Riccardo Bixio, Abdurrahman Tufan, Pravin Hissaria, Mark Beecher, Alicia Callisto, Amato De Paulis, Lorenzo Dagna, Corrado Campochiaro, Alessandro Tomelleri, Serena Bugatti, Alessandra Milanesi, Guillermo Ruiz-Irastorza, Adriana Soto-Peleteiro, Matteo Piga, Alberto Cauli, Fabrizio Conti, Chiara Cardamone, Paola Triggianese, Carmelo Gurnari, Rosetta Vitetta, Marcella Prete, Vito Racanelli, Rosaria Talarico, Francesco Ferro, Federica di Cianni, Maria Chiara Cuccaro, Adrián Mayo-Juanatey, Alessandra Renieri, Vincenzo Sorrentino, Mehmet Ali Ergun, Alberto Balistreri, Bruno Frediani, Monica Bocchia, Claudia Fabiani, Luca Cantarini, Antonio Vitale

Journal: Frontiers in immunology 2026;17():1753412

PMID: 41909650

Abstract

INTRODUCTION

Recurrent febrile episodes account for one of the most frequent symptoms observed in Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) syndrome and a key target for therapeutic intervention. Therefore, this study aims at investigating the association between recurrent febrile episodes and specific clinical manifestations, mortality and response to treatment.

METHODS

Data were obtained from the international AutoInflammatory Disease Alliance (AIDA) Network registry and analyzed using a Bayesian statistical approach. Posterior probabilities [P(β)] were calculated to assess the likelihood that fever was associated with clinical, laboratory, genetic, and therapeutic features.

RESULTS

In total, 87 VEXAS patients were enrolled, 65 (74.7%) of whom suffered from recurrent fever episodes. Fever episodes showed a significant association with patients' mortality [P(β): 99.41%], as well as with major inflammatory organ involvement, including cardiac [P(β): 99.99%], lung [P(β): 99.98%], and gastrointestinal [P(β): 97.5%] involvement. The occurrence of recurrent fever episodes was associated with a negligible probability of both complete response and treatment failure [P(β) <2.5%], instead favoring a partial response [P(β) >97.5%] to conventional disease modifying anti-rheumatic drugs, Janus Kinases inhibitors, and tocilizumab. For temperatures exceeding 40 °C, using anti-interleukin-1 agents was associated with a high probability of treatment failure [P(β): 99.3%].

CONCLUSIONS

febrile episodes are associated with more severe pattern of organ involvement and, accordingly, to death. Furthermore, febrile episodes could correlate with differential therapeutic responsiveness, thereby potentially serving as a valuable marker to guide the treatment strategies in VEXAS patients.

Copyright © 2026 Caggiano, Sbalchiero, Frassi, Crisafulli, Cavazzana, Hinojosa-Azaola, Martín-Nares, Guaracha-Basañez, Torres-Ruiz, Wiesik-Szewczyk, Nowakowska-Plaza, Sfriso, Bindoli, Rizzo, Hernández-Rodríguez, Gómez-Caverzaschi, Araújo, Mayrink Giardini, González-García, Lopalco, Viapiana, Bixio, Tufan, Hissaria, Beecher, Callisto, De Paulis, Dagna, Campochiaro, Tomelleri, Bugatti, Milanesi, Ruiz-Irastorza, Soto-Peleteiro, Piga, Cauli, Conti, Cardamone, Triggianese, Gurnari, Vitetta, Prete, Racanelli, Talarico, Ferro, di Cianni, Cuccaro, Mayo-Juanatey, Renieri, Sorrentino, Ergun, Balistreri, Frediani, Bocchia, Fabiani, Cantarini and Vitale.

Address: Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, University of Siena, Siena, Italy.; Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy.; 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.; Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.; Department of Internal Medicine, Pneumonology, Allergology, Clinical Immunology and Rare Diseases, Military Institute of Medicine, National Research Institute, Warsaw, Poland.; Rheumatology Unit, Department of Medicine, University of Padua, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Padua, Italy.; 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.; Rheumatology Division, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil.; Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.; Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J) Policlinic Hospital, University of Bari, Bari, Italy.; Rheumatology Unit, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.; Rheumatology Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy.; Department of Internal Medicine, Division of Rheumatology, Gazi University Hospital, Ankara, Türkiye.; Department of Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, SA, Australia.; Department of Immunopathology, SA Pathology, Adelaide, SA, Australia.; Department of Translational Medical Sciences, Section of Clinical Immunology, University of Naples Federico II, Naples, Italy.; Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Naples, Italy.; 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.; Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy.; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Pavia, Italy.; Faculty of Medicine and Nursery, University of the Basque Country, Euskal Herriko Unibertsitatea (UPV/EHU), Leioa, Biscay, Spain.; Autoimmune Diseases Unit, Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Spain.; Rheumatology Unit, Department of Medical Sciences and Public Health, University and Azienda Ospedaliero Universitaria (AOU) of Cagliari, Cagliari, Italy.; Department of Internal Medicine and Medical Specialties, Rheumatology Unit, Azienda Ospedaliero Universitaria (AOU) Policlinico Umberto I, Sapienza University of Rome, Rome, Italy.; Unità Operativa Complessa (UOC) of Internal Medicine - Rheumatology Outpatients Unit, Azienda Ospedaliero-Universitaria San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, Salerno, Italy.; Unità Operativa Complessa (UOC) Medicina Interna - UOSD Geriatria, Università di Roma Tor Vergata, Rome, Italy.; Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.; 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, United States.; Unit of Rheumatology, Azienda Sanitaria Locale di Vercelli (ASL VC) Sant' Andrea Hospital, Vercelli, Italy.; Rheumatic and Systemic Autoimmune Diseases Unit, Department of Interdisciplinary Medicine (DIM), University of Bari Medical School, Bari, Italy.; Centre for Medical Sciences, University of Trento and Internal Medicine Division, Santa Chiara Hospital, Provincial Health Care Agency (APSS), Trento, Italy.; Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.; Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy.; Hematology, Azienda Ospedaliera Universitaria Senese, University of Siena, Siena, Italy.; Department of Rheumatology, Doctor Peset University Hospital, Valencia, Spain.; 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.; Molecular Medicine Section, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy.; Department of Medical Genetics, Faculty of Medicine, Gazi University, Ankara, Türkiye.; Bioengineering and Biomedical Data Science Lab, Department of Medical Biotechnologies, University of Siena, Siena, Italy.; Azienda Ospedaliero-Universitaria Senese [European Reference Network (ERN) for Rare Immunodeficiency, Autoinflammatory and Autoimmune Diseases (RITA) Center], Siena, Italy.; Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy.
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