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Pliego-Arreaga R, Cervantes-Montelongo JA, Silva-Martínez GA, Tristán-Flores FE, Pantoja-Hernández MA, Maldonado-Coronado JR. Joint Hypermobility Syndrome and Membrane Proteins: A Comprehensive Review. Biomolecules 2024; 14:472. [PMID: 38672488 PMCID: PMC11048254 DOI: 10.3390/biom14040472] [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: 02/28/2024] [Revised: 04/03/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Ehlers-Danlos syndromes (EDSs) constitute a heterogeneous group of connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Asymptomatic EDSs, joint hypermobility without associated syndromes, EDSs, and hypermobility spectrum disorders are the commonest phenotypes associated with joint hypermobility. Joint hypermobility syndrome (JHS) is a connective tissue disorder characterized by extreme flexibility of the joints, along with pain and other symptoms. JHS can be a sign of a more serious underlying genetic condition, such as EDS, which affects the cartilage, bone, fat, and blood. The exact cause of JHS could be related to genetic changes in the proteins that add flexibility and strength to the joints, ligaments, and tendons, such as collagen. Membrane proteins are a class of proteins embedded in the cell membrane and play a crucial role in cell signaling, transport, and adhesion. Dysregulated membrane proteins have been implicated in a variety of diseases, including cancer, cardiovascular disease, and neurological disorders; recent studies have suggested that membrane proteins may also play a role in the pathogenesis of JHS. This article presents an exploration of the causative factors contributing to musculoskeletal pain in individuals with hypermobility, based on research findings. It aims to provide an understanding of JHS and its association with membrane proteins, addressing the clinical manifestations, pathogenesis, diagnosis, and management of JHS.
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Affiliation(s)
- Raquel Pliego-Arreaga
- Escuela de Medicina, Universidad de Celaya, Celaya 38080, Guanajuato, Mexico; (J.A.C.-M.); (M.A.P.-H.); (J.R.M.-C.)
| | - Juan Antonio Cervantes-Montelongo
- Escuela de Medicina, Universidad de Celaya, Celaya 38080, Guanajuato, Mexico; (J.A.C.-M.); (M.A.P.-H.); (J.R.M.-C.)
- Departamento de Ingeniería Bioquímica, Tecnológico Nacional de México en Celaya, Celaya 38010, Guanajuato, Mexico;
| | | | | | | | - Juan Raúl Maldonado-Coronado
- Escuela de Medicina, Universidad de Celaya, Celaya 38080, Guanajuato, Mexico; (J.A.C.-M.); (M.A.P.-H.); (J.R.M.-C.)
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Conway AE, Verdi M, Shaker MS, Bernstein JA, Beamish CC, Morse R, Madan J, Lee MW, Sussman G, Al-Nimr A, Hand M, Albert DA. Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00281-2. [PMID: 38499084 DOI: 10.1016/j.jaip.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/23/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.
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Affiliation(s)
| | | | - Marcus S Shaker
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Claire C Beamish
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard Morse
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Pediatric Neurology, Children's Hospital at Dartmouth, Lebanon, NH
| | - Juliette Madan
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Pediatrics, Division of Child Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Psychiatry, Division of Child Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Michael W Lee
- Department of Medical Education, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Gordon Sussman
- Division of Immunology, University of Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Amer Al-Nimr
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Pediatric Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Matthew Hand
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Pediatric Nephrology and Integrative Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Daniel A Albert
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Rheumatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Ritelli M, Chiarelli N, Cinquina V, Vezzoli M, Venturini M, Colombi M. Looking back and beyond the 2017 diagnostic criteria for hypermobile Ehlers-Danlos syndrome: A retrospective cross-sectional study from an Italian reference center. Am J Med Genet A 2024; 194:174-194. [PMID: 37774134 DOI: 10.1002/ajmg.a.63426] [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: 07/07/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Abstract
The most common conditions with symptomatic joint hypermobility are hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD). Diagnosing these overlapping connective tissue disorders remains challenging due to the lack of established causes and reliable diagnostic tests. hEDS is diagnosed applying the 2017 diagnostic criteria, and patients with symptomatic joint hypermobility but not fulfilling these criteria are labeled as HSD, which is not officially recognized by all healthcare systems. The 2017 criteria were introduced to improve diagnostic specificity but have faced criticism for being too stringent and failing to adequately capture the multisystemic involvement of hEDS. Herein, we retrospectively evaluated 327 patients from 213 families with a prior diagnosis of hypermobility type EDS or joint hypermobility syndrome based on Villefranche and Brighton criteria, to assess the effectiveness of the 2017 criteria in distinguishing between hEDS and HSD and document the frequencies of extra-articular manifestations. Based on our findings, we propose that the 2017 criteria should be made less stringent to include a greater number of patients who are currently encompassed within the HSD category. This will lead to improved diagnostic accuracy and enhanced patient care by properly capturing the diverse range of symptoms and manifestations present within the hEDS/HSD spectrum.
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Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marika Vezzoli
- Unit of Biostatistics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
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Gagnon H, Lunde CE, Wu Z, Novais EN, Borsook D, Sieberg CB. Exploring Comorbidities in Adolescent and Young Adults with Hypermobile Ehlers-Danlos Syndrome with and without a Surgical History: A Preliminary Investigation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1562. [PMID: 37761523 PMCID: PMC10528958 DOI: 10.3390/children10091562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
Ehlers-Danlos Syndrome (EDS) is a rare disease affecting the skin, joints, vasculature, and internal organs. Approximately 85% of those affected are categorized as the hypermobile type (hEDS), which is associated with numerous medical and psychiatric comorbidities, including chronic pain. Additionally, approximately 71% of patients with hEDS undergo at least one surgical procedure; however, indicators for surgery and pain outcomes after surgery are poorly understood. This preliminary study used a medical chart review to identify the frequency and nature of comorbidities in a cohort of adolescents and young adult patients with hEDS and a surgical history compared to those without a surgical history. Results showed that patients diagnosed with hEDS who underwent surgery reported significantly more comorbidities (e.g., CRPS, IBS, Fibromyalgia, POTS, hypothyroidism, etc.) than those who did not have surgery. Seventy percent of individuals who presented for surgery fell within the categories of orthopedic, gastrointestinal, or laparoscopic/endometriosis-related surgeries. Identifying patients with hEDS who are at risk for needing surgery will help identify the mechanisms contributing to risk factors for poor surgical outcomes. The results of this study may be instructive in the management and care of hEDS patients undergoing surgery.
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Affiliation(s)
- Haley Gagnon
- Biobehavioral Pain Innovations Laboratory, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, MA 02115, USA; (H.G.); (C.E.L.); (Z.W.)
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Claire E. Lunde
- Biobehavioral Pain Innovations Laboratory, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, MA 02115, USA; (H.G.); (C.E.L.); (Z.W.)
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford OX3 9DU, UK
| | - Ziyan Wu
- Biobehavioral Pain Innovations Laboratory, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, MA 02115, USA; (H.G.); (C.E.L.); (Z.W.)
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Eduardo N. Novais
- Department of Orthopedic Surgery, Boston Children’s Hospital, Boston, MA 02115, USA;
- Department of Orthopedic Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - David Borsook
- Departments of Psychiatry and Radiology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Anesthesiology, Harvard Medical School, Boston, MA 02115, USA
| | - Christine B. Sieberg
- Biobehavioral Pain Innovations Laboratory, Department of Psychiatry & Behavioral Sciences, Boston Children’s Hospital, Boston, MA 02115, USA; (H.G.); (C.E.L.); (Z.W.)
- Pain and Affective Neuroscience Center, Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
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Gullapalli PA, Javed S. Multidisciplinary chronic pain management strategies in patients with Ehlers-Danlos syndromes. Pain Manag 2023; 13:5-14. [PMID: 36305215 DOI: 10.2217/pmt-2022-0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Ehlers-Danlos syndromes (EDS) are a group of disorders characterized by abnormal connective tissue affecting several organ systems. Patients with the hypermobile type of EDS (hEDS) commonly experience chronic pain which can present as musculoskeletal pain, fibromyalgia, neuropathic pain or abdominal pain. The effective management of chronic pain in hEDS patients is a challenge. This study reviews two cases of chronic pain in hEDS patients and the multimodal treatment regimen used along with peripheral nerve stimulation for shoulder and knee pains, never before reported in hEDS patients. Since hEDS associated chronic pain is multifactorial in origin, treatment requires a multidisciplinary approach which includes physical therapy, psychotherapy, pharmacotherapy and interventional pain procedures such as trigger point injections, peripheral nerve block, radiofrequency ablation and peripheral nerve stimulation.
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Affiliation(s)
| | - Saba Javed
- Department of Anesthesiology, University of Texas at Houston, Division of Chronic Pain Medicine, Houston, TX 77030, USA
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Marathe N, Lohkamp LN, Fehlings MG. Spinal manifestations of Ehlers-Danlos syndrome: a scoping review. J Neurosurg Spine 2022; 37:783-793. [PMID: 35986728 DOI: 10.3171/2022.6.spine211011] [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: 07/26/2021] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since its initial description, the definition of Ehlers-Danlos syndrome (EDS) has notably changed. At present, it broadly refers to disorders of the connective tissue that are heritable and have similar features including joint hypermobility, dermal dysplasia, and vascular as well as internal organ fragility. There has been no comprehensive review of spinal manifestations of EDS in the recent literature. That has led to controversies in management protocols of this so-called orphan disease. METHODS The authors used the latest version of the EDS classification from 2017, in which 13 subtypes were recognized. EDS has 19 different causal genes, mainly associated with collagen synthesis. Of these, 5 subtypes have associated spinal manifestations. RESULTS Some of the spinal pathologies associated with EDS include Chiari malformation, craniocervical instability, kyphoscoliosis, segmental instability and kyphosis, spontaneous CSF leaks, Tarlov cyst syndrome, tethered cord, and problems associated with wound healing. Here, the authors briefly discuss the demographics, etiology, pathophysiology, clinical features, management strategies, and directions for further research for each of these manifestations. CONCLUSIONS EDS belongs to the group of orphan diseases, with the total patient population being below 200,000. Further research on spinal manifestations of EDS is the need of the hour to establish clinical practice guidelines and close the significant knowledge gaps that currently exist.
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Affiliation(s)
- Nandan Marathe
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and
| | - Laura-Nanna Lohkamp
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Baeza-Velasco C, Hamonet C, Montalescot L, Courtet P. Suicidal Behaviors in Women With the Hypermobile Ehlers-Danlos Syndrome. Arch Suicide Res 2022; 26:1314-1326. [PMID: 33596399 DOI: 10.1080/13811118.2021.1885538] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypermobile Ehlers-Danlos syndrome (hEDS) is the most frequent heritable disorder of the connective tissue. This is characterized by a generalized fragility of tissues leading to chronic pain, disability and high levels of psychological distress. Suicidal behaviors in those affected are not uncommon but they have not been well studied. We aimed to explore aspects of suicidality and related factors in a group of patients with hEDS. METHOD Thirty-five women with hEDS were included in this cross-sectional study. They were assessed with the Mini-International Neuropsychiatric Interview for Axis 1 DSM-IV mental disorders and suicidality. They also responded to self-questionnaires assessing health (pain, BMI, and diagnosis delay) and psychosocial variables (social support, physical functioning, coping strategies, personality disturbances, and resilience). RESULTS Eleven patients (31.4%) had attempted suicide in the past. Fifteen patients (42.9%) had some degree of suicide risk at the time of evaluation, mainly mild risk (60%). Compared with patients without a history of suicide attempt, those who had attempted suicide were younger, scored higher on personality disturbances, especially on depressive, avoidant, antisocial, and borderline trait subscores, and had an increased prevalence of lifetime major depression, mania/hypomanic episodes, and anxiety disorders (p < .05). Binary logistic regression showed that personality disturbances and anxiety disorders increase the probability of belonging to the attempters group. CONCLUSIONS Consistent with previous reports, these data highlight the high frequency of suicidal behaviors in hEDS patients as well as the importance to explore psychopathology in those affected in order to identify vulnerable individuals and provide specific support.HIGHLIGHTSAttempted suicide in patients with hEDS is not uncommon.Age and the presence of psychopathology are associated with suicide attempt in hEDS patients.Personality disturbances and lifetime anxiety disorders predicted suicide attempted in this sample.
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Madiyeva M, Rymbaeva T. Congenital Heart Disease in Children Living Close to the Former Semipalatinsk Nuclear Test Site: Frequency, Structure, and Links with Connective Tissue Dysplasia. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Congenital heart disease (CHD) is the most common serious congenital disorder. CHD is the leading cause of death in the first year of life. One of the factors influencing the incidence of CHD is collagen structural abnormalities such as connective tissue dysplasia (CTD).
Aim: To study the prevalence of CHD and its subtypes, to determine the combination of CHD and CTD with minor cardiac abnormalities (MCA).
Methods: A retrospective study on the prevalence of CHD in the Republic of Kazakhstan and Semey city and a case-control study in the pediatric clinic of the Medical University Hospital was conducted.
With CHD, CTD, and healthy children were included in the study. Children of all groups were examined according to the methodology, which included a collection of medical and family history; clinical examination; assessment of CHD severity. The collected data were then analyzed using SPSS software.
Results: The prevalence of CHD in Semey was 6.9 per 1,000 live births. Atrial septal defect and ventricular septal defect were the most common CHD subtypes. The phenotype was represented by the asthenic physique, joint hypermobility, ear anomalies, and scoliosis. MCAs were in children with CHD and CTD. Mitral valve prolapse and left ventricular false tendons were detected most frequently.
Conclusion: MCAs detected in children with CTD. CTD is a factor influencing the severity of CHD.
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Santos TS, Marçal R, Moldovan O, Carvalho L, Ducla-Soares J. Cardiovascular manifestations of type IV Ehlers-Danlos syndrome – A case report. Rev Port Cardiol 2022; 41:425-430. [DOI: 10.1016/j.repc.2019.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 05/11/2019] [Indexed: 11/30/2022] Open
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Bailleux S, Collins P, Nikkels AF. The Relevance of Skin Biopsies in General Internal Medicine: Facts and Myths. Dermatol Ther (Heidelb) 2022; 12:1103-1119. [PMID: 35430724 PMCID: PMC9110592 DOI: 10.1007/s13555-022-00717-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Non-dermatology medical specialties may refer patients for skin biopsies, searching for a particular diagnosis. However, the diagnostic impact of the skin biopsy is not clearly established. This article aims to assess the indications for, and evaluate the clinical relevance of, skin biopsies in non-dermatology medical specialties. Methods A questionnaire was sent to 23 non-dermatology specialty departments in a university medical center, requesting a list of indications for skin biopsies, as well as to 10 staff dermatologists to collect the indications of skin biopsies requested by non-dermatology specialties. Once the indications were collected, a literature search was performed to evaluate their clinical value and relevance. Results Eleven non-dermatology specialties provided a list of skin biopsy indications, to which staff dermatologists added seven more indications. A literature search revealed evidence-based medicine data for six diseases, that is, amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, and chronic graft-versus-host disease. Results were questionable concerning infectious endocarditis, acute graft-versus-host-disease, and the lupus band test. Skin biopsy were not evidenced as useful for the diagnosis of calciphylaxis, systemic scleroderma, Behçet’s disease, or hypermobile Ehlers–Danlos syndrome. For the diagnosis of Alport’s syndrome, pseudoxanthoma elasticum, and vascular Ehlers–Danlos syndrome, skin biopsy is currently outperformed by genetic analyses. For diagnoses such as Henoch–Schönlein purpura and Sjögren’s syndrome, skin biopsy represents an additional item among other diagnostic criteria. Conclusion The usefulness of skin biopsy as requested by non-dermatology specialties is only evidenced for amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, chronic graft-versus-host-disease, Henoch–Schönlein purpura, and Sjögren’s syndrome.
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Affiliation(s)
- Sophie Bailleux
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium
| | - Patrick Collins
- Department of Dermatopathology, University Hospital Centre, CHU du Sart Tilman, Liège, Belgium
| | - Arjen F Nikkels
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium.
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Butler MG, Moreno-De-Luca D, Persico AM. Actionable Genomics in Clinical Practice: Paradigmatic Case Reports of Clinical and Therapeutic Strategies Based upon Genetic Testing. Genes (Basel) 2022; 13:genes13020323. [PMID: 35205368 PMCID: PMC8872067 DOI: 10.3390/genes13020323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/29/2022] [Accepted: 02/07/2022] [Indexed: 12/13/2022] Open
Abstract
In clinical settings, the information provided by genetic testing can explain the triggers and processes underlying clinical presentations, such as neurodevelopmental disorders, in up to one third of affected individuals. However, translating this knowledge into better and more personalized clinical management to many appears a distant target. This article presents three paradigmatic cases to exemplify how this translational effort can, at least in some instances, be undertaken today with very positive results: (a) a young girl carrying a chr. 16p11.2 duplication can be screened using targeted exams and undertake therapeutic/preventive interventions related to her genetic diagnosis; (b) a 13-year-old boy with intellectual disability and autism spectrum disorder carries a chr. 11q14.1 deletion, partly spanning the DLG2 gene important for synaptic function, and gained over 20 I.Q. points ostensibly due to carbolithium, prescribed in the absence of affective symptoms, exclusively following the pathophysiology pointed out by the genetic results; (c) a 58-year-old woman carries a COL3A1 gene variant responsible for the vascular form of Ehler–Danlos syndrome with colon rupture. Detection of this variant in six members of her extended family allows for better clinical management of the proband and targeted genetic counselling for family members at risk of this connective tissue disorder. The unprecedented flow of genetic information available today through new technologies, if interpreted in the light of current knowledge in clinical diagnosis and care of those with connective tissue disorders and neurodevelopmental disturbances, in biology and in neuropsychopharmacology, can promote better clinical and pharmacological treatment, disease surveillance, and management provided and incorporated into the clinical setting.
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Affiliation(s)
- Merlin G. Butler
- Departments of Psychiatry & Behavioral Sciences and Pediatrics, University of Kansas Medical Center, Kansas City, KS 66160, USA;
| | - Daniel Moreno-De-Luca
- Genomic Psychiatry Consultation Service, Verrecchia Clinic for Children with Autism and Developmental Disabilities, Bradley Hospital, East Providence, RI 02915, USA;
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Antonio M. Persico
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, I-41125 Modena, Italy
- Child and Adolescent Neuropsychiatry Program, Modena University Hospital, I-41125 Modena, Italy
- Correspondence:
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Tapasak BE, Malis DJ. The Mystery of Ehlers-Danlos Syndrome: An Autobiographical Case Report. Cureus 2022; 14:e21601. [PMID: 35228959 PMCID: PMC8869278 DOI: 10.7759/cureus.21601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/06/2022] Open
Abstract
Ehlers-Danlos syndrome (EDS) most often presents with the classic symptoms of skin hyperelasticity, hypermobility of joints, atrophic scarring, and fragility of blood vessels. However, EDS can also have uncommon presentations which are much more insidious. This case report details the author’s lifelong experience living with EDS, which was diagnosed after many seemingly unrelated afflictions including fatigue, spontaneous pneumothorax, and gastroesophageal reflux disease. Studies indicate that these complications warrant investigation of the connective tissue disorder with further lifelong follow-up of disease progression. Extra care should be taken to differentiate the disorder from other heritable connective tissue disorders as well as consider the psychosocial issues these patients experience.
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Considerations for lactation with Ehlers-Danlos syndrome: a narrative review. Int Breastfeed J 2022; 17:4. [PMID: 34983567 PMCID: PMC8725515 DOI: 10.1186/s13006-021-00442-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background Ehlers-Danlos syndrome (EDS) is a rare genetic connective tissue condition that is poorly understood in relation to lactation. As diagnostic methods improve, prevalence has increased. EDS, a disorder that impacts connective tissue, is characterized by skin extensibility, joint hypermobility, and fragile tissue which can affect every organ and body system leading to complications during pregnancy, delivery, and the postpartum period. Traits of this disease can cause mild to severe physiologic and functional obstacles during lactation. Unfortunately, there is little clinical evidence and minimal guidance for lactation management, and providers may feel uncomfortable and hesitant to address these concerns with patients due to a lack of readily available resources on the subject and inexperience with such patients. This narrative review describes and discusses the types of EDS, identifying symptoms, considerations, and precautions for care providers to implement during lactation and breastfeeding. Methods An electronic search of relevant citations was conducted using the databases Cochrane, PubMed, and Google Scholar from 1 January 2000 to 1 November 2021. Search terms used were Ehlers-Danlos syndrome, Hypermobility Syndrome, breastfeeding, lactation, breastmilk expression, breastmilk collection, human milk expression, human milk collection, and infant feeding. The search of these databases yielded zero results. As no research articles on EDS were directly related to lactation, this narrative review includes articles found that related to the health of mothers relevant to maternal function during lactation. Discussion For the healthcare provider, identifying characteristics of EDS can improve the management of lactation challenges. Mothers may experience generalized symptoms from gastrointestinal distress to fatigue or chronic pain, while they also may suffer from more specific joint complaints and injuries, such as dislocations / subluxations, or skin fragility. Such obstacles can generate impediments to breastfeeding and create unique challenges for breastfeeding mothers with EDS. Unfortunately, new mothers with these symptoms may have them overlooked or not addressed, impacting a mother’s ability to meet her breastfeeding intentions. While there are some published research manuscripts on EDS and pregnancy, there is a lack of information regarding breastfeeding and lactation. Additional research is needed to help guide EDS mothers to achieve their breastfeeding intentions.
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Sharp HEC, Critchley HD, Eccles JA. Connecting brain and body: Transdiagnostic relevance of connective tissue variants to neuropsychiatric symptom expression. World J Psychiatry 2021; 11:805-820. [PMID: 34733643 PMCID: PMC8546774 DOI: 10.5498/wjp.v11.i10.805] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/12/2021] [Accepted: 08/18/2021] [Indexed: 02/06/2023] Open
Abstract
The mind is embodied; thoughts and feelings interact with states of physiological arousal and physical integrity of the body. In this context, there is mounting evidence for an association between psychiatric presentations and the expression variant connective tissue, commonly recognised as joint hypermobility. Joint hypermobility is common, frequently under-recognised, significantly impacts quality of life, and can exist in isolation or as the hallmark of hypermobility spectrum disorders (encompassing joint hypermobility syndrome and hypermobile Ehlers-Danlos syndrome). In this narrative review, we appraise the current evidence linking psychiatric disorders across the lifespan, beginning with the relatively well-established connection with anxiety, to hypermobility. We next consider emerging associations with affective illnesses, eating disorders, alongside less well researched links with personality disorders, substance misuse and psychosis. We then review related findings relevant to neurodevelopmental disorders and stress-sensitive medical conditions. With growing understanding of mind-body interactions, we discuss potential aetiopathogenetic contributions of dysautonomia, aberrant interoceptive processing, immune dysregulation and proprioceptive impairments in the context of psychosocial stressors and genetic predisposition. We examine clinical implications of these evolving findings, calling for increased awareness amongst healthcare professionals of the transdiagnostic nature of hypermobility and related disorders. A role for early screening and detection of hypermobility in those presenting with mental health and somatic symptoms is further highlighted, with a view to facilitate preventative approaches alongside longer-term holistic management strategies. Finally, suggestions are offered for directions of future scientific exploration which may be key to further delineating fundamental mind-body-brain interactions.
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Affiliation(s)
- Harriet Emma Clare Sharp
- Department of Medical Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, East Sussex, United Kingdom
- Department of Psychiatry, Sussex Partnership NHS Foundation Trust, Worthing, BN13 3EP, West Sussex, United Kingdom
| | - Hugo D Critchley
- Department of Medical Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, East Sussex, United Kingdom
- Department of Psychiatry, Sussex Partnership NHS Foundation Trust, Worthing, BN13 3EP, West Sussex, United Kingdom
| | - Jessica A Eccles
- Department of Medical Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, East Sussex, United Kingdom
- Department of Psychiatry, Sussex Partnership NHS Foundation Trust, Worthing, BN13 3EP, West Sussex, United Kingdom
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15
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Aubry-Rozier B, Schwitzguebel A, Valerio F, Tanniger J, Paquier C, Berna C, Hügle T, Benaim C. Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different? Rheumatol Int 2021; 41:1785-1794. [PMID: 34398260 PMCID: PMC8390400 DOI: 10.1007/s00296-021-04968-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/06/2021] [Indexed: 01/04/2023]
Abstract
Diagnosing hypermobile Ehlers–Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18–73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18–26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.
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Affiliation(s)
| | | | - Flore Valerio
- Rheumatology, HFR Fribourg, Villars-sur-Glâne, Switzerland
| | - Joelle Tanniger
- Physiotherapy, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Célia Paquier
- Physiotherapy, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Chantal Berna
- Center for Integrative and Complementary Medicine & Pain Center, Division of Anesthesiology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Hügle
- Rheumatology and Rehabilitation, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Charles Benaim
- Rheumatology and Rehabilitation, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland. .,Department of Medical Research, Clinique Romande de Réadaptation, Sion, Switzerland.
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16
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Scicluna K, Formosa MM, Farrugia R, Borg I. Hypermobile Ehlers-Danlos syndrome: A review and a critical appraisal of published genetic research to date. Clin Genet 2021; 101:20-31. [PMID: 34219226 DOI: 10.1111/cge.14026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/08/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022]
Abstract
The Ehlers-Danlos syndromes (EDS) are a collection of rare hereditary connective tissue disorders with heterogeneous phenotypes, usually diagnosed following clinical examination and confirmatory genetic testing. Diagnosis of the commonest subtype, hypermobile Ehlers-Danlos Syndrome (hEDS), relies solely on a clinical diagnosis since its molecular aetiology remains unknown. We performed an up-to-date literature search and selected 11 out of 304 publications according to a set of established criteria. Studies reporting variants affecting collagen proteins were found to be hindered by cohort misclassification and subsequent lack of reproducibility of these genetic findings. The role of the described variants affecting Tenascin-X and LZTS1 is yet to be demonstrated in the majority of hEDS cases, while the functional implication of associated signaling pathways and genes requires further elucidation. The available literature on the genetics of hEDS is scant, dispersed and conflicting due to out-dated nosology terminology. Recent literature has suggested the role of several promising candidate mechanisms which may be linked to the underlying molecular aetiology. Knowledge of the molecular genetic basis of hEDS is expected to increase in the near future through the mainstream use of high-throughput sequencing combined with the updated classification of EDS, and the upcoming Hypermobile Ehlers-Danlos Genetic Evaluation (HEDGE) study.
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Affiliation(s)
- Kirsty Scicluna
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta
| | - Melissa M Formosa
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.,Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Rosienne Farrugia
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.,Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta
| | - Isabella Borg
- Centre for Molecular Medicine and Biobanking, University of Malta, Msida, Malta.,Medical Genetics Unit, Department of Pathology, Mater Dei Hospital, Msida, Malta.,Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
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17
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Lorenz D, Kress W, Zaum AK, Speer CP, Hebestreit H. Report of two siblings with spondylodysplastic Ehlers-Danlos syndrome and B4GALT7 deficiency. BMC Pediatr 2021; 21:293. [PMID: 34193099 PMCID: PMC8243911 DOI: 10.1186/s12887-021-02767-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/07/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The spondylodysplastic Ehlers-Danlos subtype (OMIM #130070) is a rare connective tissue disorder characterized by a combination of connective tissue symptoms, skeletal features and short stature. It is caused by variants in genes encoding for enzymes involved in the proteoglycan biosynthesis or for a zinc transporter. PRESENTATION OF CASES We report two brothers with a similar phenotype of short stature, joint hypermobility, distinct craniofacial features, developmental delay and severe hypermetropia indicative for a spondylodysplastic Ehlers-Danlos subtype. One also suffered from a recurrent pneumothorax. Gene panel analysis identified two compound heterozygous variants in the B4GALT7 gene: c.641G > A and c.723 + 4A > G. B4GALT7 encodes for galactosyltransferase I, which is required for the initiation of glycosaminoglycan side chain synthesis of proteoglycans. CONCLUSIONS This is a first full report on two cases with spondylodysplastic Ehlers-Danlos syndrome and the c.723 + 4A > G variant of B4GALT7. The recurrent pneumothoraces observed in one case expand the variable phenotype of the syndrome.
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Affiliation(s)
- Delia Lorenz
- Center for Rare Diseases, University Hospital Würzburg, University of Würzburg, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
- University Children's Hospital Würzburg, University of Würzburg, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Wolfram Kress
- Department of Human Genetics, University of Würzburg, Biozentrum, Am Hubland, 97074, Würzburg, Germany
| | - Ann-Kathrin Zaum
- Department of Human Genetics, University of Würzburg, Biozentrum, Am Hubland, 97074, Würzburg, Germany
| | - Christian P Speer
- University Children's Hospital Würzburg, University of Würzburg, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany
| | - Helge Hebestreit
- Center for Rare Diseases, University Hospital Würzburg, University of Würzburg, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany.
- University Children's Hospital Würzburg, University of Würzburg, Josef-Schneider-Strasse 2, 97080, Würzburg, Germany.
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18
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Holick MF, Shirvani A, Charoenngam N. Fetal Fractures in an Infant with Maternal Ehlers-Danlos Syndrome, CCDC134 Pathogenic Mutation and a Negative Genetic Test for Osteogenesis Imperfecta. CHILDREN-BASEL 2021; 8:children8060512. [PMID: 34204301 PMCID: PMC8235512 DOI: 10.3390/children8060512] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
Intrauterine fractures are a rare clinical finding caused by abnormal early-life osteogenesis. In this case report, we reported a male infant with twenty-three intrauterine/fetal fractures resembling osteogenesis imperfecta and tested negative for COL1A1 and COL1A2 mutations. The infant’s mother had Ehlers–Danlos syndrome, hypermobility type. Whole-genome sequencing revealed that there were no pathologic mutations previously documented to be associated with intrauterine fracture. Genetic mutations reported to be associated with fragility fractures were identified. These include the pathogenic homozygous mutation in the CCDC134 gene. Other genetic variants that might be responsible for variable expressivity of the skeletal manifestation include the homozygous variants of the genes CCDC134, COL15A1 and ZFPM1, and the heterozygous variants of the genes MYH3, BCHE, AUTS2. This is the first reported case of in utero fractures, that was confirmed by X-ray after birth, in an infant who had no genetic evidence for osteogenesis imperfecta, had a homozygous pathogenic mutation of an osteogenesis gene and whose mother had Ehlers-Danlos syndrome hypermobility type. Therefore, we have identified a new genetic cause for in utero fractures. If after birth, this infant were found to have these fractures in various stages of healing with a negative genetic test for osteogenesis imperfecta he would have been misdiagnosed as due to nonaccidental trauma.
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Affiliation(s)
- Michael F. Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (A.S.); (N.C.)
- Correspondence: ; Tel.: +1-617-358-6139
| | - Arash Shirvani
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (A.S.); (N.C.)
| | - Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA; (A.S.); (N.C.)
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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19
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Almatrafi A, Hashmi JA, Fadhli F, Alharbi A, Afzal S, Ramzan K, Basit S. Further Evidence of a Recessive Variant in COL1A1 as an Underlying Cause of Ehlers-Danlos Syndrome: A Report of a Saudi Founder Mutation. Glob Med Genet 2021; 7:109-112. [PMID: 33693443 PMCID: PMC7938939 DOI: 10.1055/s-0041-1722873] [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] [Indexed: 11/09/2022] Open
Abstract
Ehlers–Danlos syndrome (EDS) is a group of clinically and genetically heterogeneous disorder of soft connective tissues. The hallmark clinical features of the EDS are hyperextensible skin, hypermobile joints, and fragile vessels. It exhibits associated symptoms including contractures of muscles, kyphoscoliosis, spondylodysplasia, dermatosparaxis, periodontitis, and arthrochalasia. The aim of this study is to determine the exact subtype of EDS by molecular genetic testing in a family segregating EDS in an autosomal recessive manner. Herein, we describe a family with two individuals afflicted with EDS. Whole exome sequencing identified a homozygous missense mutation (c.2050G > A; p.Glu684Lys) in the
COL1A1
gene in both affected individuals, although heterozygous variants in the
COL1A1
are known to cause EDS. Recently, only one report showed homozygous variant as an underlying cause of the EDS in two Saudi families. This is the second report of a homozygous variant in the
COL1A1
gene in a family of Saudi origin. Heterozygous carriers of
COL1A1
variant are asymptomatic. Interestingly, the homozygous variant identified previously and the one identified in this study are same (c.2050G > A). The identification of a unique homozygous mutation (c.2050G > A) in three Saudi families argues in favor of a founder effect.
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Affiliation(s)
- Ahmad Almatrafi
- Department of Biology, College of Science, Taibah University, Almadinah Almunawwarah, Saudi Arabia
| | - Jamil A Hashmi
- Center for Genetics and Inherited Diseases, Taibah University Almadinah Almunawwarah, Medina, Kingdom of Saudi Arabia
| | - Fatima Fadhli
- Department of Genetics, Madinah Maternity and Children Hospital, Medina, Kingdom of Saudi Arabia
| | - Asma Alharbi
- Center for Genetics and Inherited Diseases, Taibah University Almadinah Almunawwarah, Medina, Kingdom of Saudi Arabia
| | - Sibtain Afzal
- Faculty of Allied and Health Sciences, Imperial College of Business Studies, Lahore, Pakistan
| | - Khushnooda Ramzan
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Sulman Basit
- Center for Genetics and Inherited Diseases, Taibah University Almadinah Almunawwarah, Medina, Kingdom of Saudi Arabia
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20
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Ehlers-Danlos Syndrome: Immunologic contrasts and connective tissue comparisons. J Transl Autoimmun 2021; 4:100077. [PMID: 33437956 PMCID: PMC7786113 DOI: 10.1016/j.jtauto.2020.100077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/12/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022] Open
Abstract
Ehlers-Danlos Syndrome (EDS) is a family of multisystemic hereditary connective tissue disorders now comprised of 13 recognized subtypes, classical, classical-like, cardiac-valvular, vascular, hypermobile, arthrochlasia, dermosparaxis, kyphoscoliotic, brittle cornea syndrome, spondylodysplastic, musculocontractural, myopathic, and periodontal, as designated by the most recent 2017 International classification system. Clinical presentation of this disease can range from mild manifestations including skin hyperextensibility and joint hypermobility, to more severe complications such as vascular and organ rupture. While there may be accompanying inflammation in some of the subtypes of EDS, the pathogenic mechanisms have not been clearly defined. Thorough evaluation incorporates clinical examination, family history, laboratory testing, and imaging. In recent years, studies have identified multiple gene variants involved in the pathogenesis of specific EDS subtypes as well as elaborate clinical diagnostic criteria and classification models used to differentiate overlapping conditions. The differential diagnosis of EDS includes hypermobility spectrum disorders, Marfan syndrome, Loey-Dietz syndrome, Cutis laxa syndromes, autosomal dominant polycystic kidney disease, osteogenesis Imperfecta Type 1, fibromyalgia, depression, and chronic fatigue syndrome. Surgical treatment is reserved for complications, or emergencies involving vascular or orthopedic injury because of the risk of poor wound healing. Management techniques each have their own consequences and benefits, which will also be discussed in this review article. Patients affected by this spectrum of disorders are impacted both phenotypically and psychosocially, diminishing their quality of life. There are 13 of EDS as defined by the International EDS Consortium, some with an identified genetic etiology. Skin hyperextensibility, joint hypermobility, easy bruising, and organ rupture are common features of EDS. Hypermobile EDS is a poorly defined entity that has been associated with MCAS and POTs. The association of hEDS, MCAS and POTS has not been confirmed. There is a paucity of evidence for an immunological mechanism for EDS.
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21
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Biology and Biomechanics of the Heart Valve Extracellular Matrix. J Cardiovasc Dev Dis 2020; 7:jcdd7040057. [PMID: 33339213 PMCID: PMC7765611 DOI: 10.3390/jcdd7040057] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/02/2020] [Accepted: 12/13/2020] [Indexed: 02/06/2023] Open
Abstract
Heart valves are dynamic structures that, in the average human, open and close over 100,000 times per day, and 3 × 109 times per lifetime to maintain unidirectional blood flow. Efficient, coordinated movement of the valve structures during the cardiac cycle is mediated by the intricate and sophisticated network of extracellular matrix (ECM) components that provide the necessary biomechanical properties to meet these mechanical demands. Organized in layers that accommodate passive functional movements of the valve leaflets, heart valve ECM is synthesized during embryonic development, and remodeled and maintained by resident cells throughout life. The failure of ECM organization compromises biomechanical function, and may lead to obstruction or leaking, which if left untreated can lead to heart failure. At present, effective treatment for heart valve dysfunction is limited and frequently ends with surgical repair or replacement, which comes with insuperable complications for many high-risk patients including aged and pediatric populations. Therefore, there is a critical need to fully appreciate the pathobiology of biomechanical valve failure in order to develop better, alternative therapies. To date, the majority of studies have focused on delineating valve disease mechanisms at the cellular level, namely the interstitial and endothelial lineages. However, less focus has been on the ECM, shown previously in other systems, to be a promising mechanism-inspired therapeutic target. Here, we highlight and review the biology and biomechanical contributions of key components of the heart valve ECM. Furthermore, we discuss how human diseases, including connective tissue disorders lead to aberrations in the abundance, organization and quality of these matrix proteins, resulting in instability of the valve infrastructure and gross functional impairment.
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22
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Ritelli M, Venturini M, Cinquina V, Chiarelli N, Colombi M. Multisystemic manifestations in a cohort of 75 classical Ehlers-Danlos syndrome patients: natural history and nosological perspectives. Orphanet J Rare Dis 2020; 15:197. [PMID: 32736638 PMCID: PMC7393722 DOI: 10.1186/s13023-020-01470-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022] Open
Abstract
Background The Ehlers-Danlos syndromes (EDS) are rare connective tissue disorders consisting of 13 subtypes with overlapping features including joint hypermobility, skin and generalized connective tissue fragility. Classical EDS (cEDS) is principally caused by heterozygous COL5A1 or COL5A2 variants and rarely by the COL1A1 p.(Arg312Cys) substitution. Current major criteria are (1) skin hyperextensibility plus atrophic scars and (2) generalized joint hypermobility (gJHM). Minor criteria include additional mucocutaneous signs, epicanthal folds, gJHM complications, and an affected first-degree relative. Minimal criteria prompting molecular testing are major criterion 1 plus either major criterion 2 or 3 minor criteria. In addition to these features, the clinical picture also involves multiple organ systems, but large-scale cohort studies are still missing. This study aimed to investigate the multisystemic involvement and natural history of cEDS through a cross-sectional study on a cohort of 75 molecularly confirmed patients evaluated from 2010 to 2019 in a tertiary referral center. The diagnostic criteria, additional mucocutaneous, osteoarticular, musculoskeletal, cardiovascular, gastrointestinal, uro-gynecological, neuropsychiatric, and atopic issues, and facial/ocular features were ascertained, and feature rates compared by sex and age. Results Our study confirms that cEDS is mainly characterized by cutaneous and articular involvement, though none of their hallmarks was represented in all cases and suggests a milder multisystemic involvement and a more favorable natural history compared to other EDS subtypes. Abnormal scarring was the most frequent and characteristic sign, skin hyperextensibility and gJHM were less common, all without any sex and age bias; joint instability complications were more recurrent in adults. Some orthopedic features showed a high prevalence, whereas the other issues related to the investigated organ systems were less recurrent with few exceptions and age-related differences. Conclusions Our findings define the diagnostic relevance of cutaneous and articular features and additional clinical signs associated to cEDS. Furthermore, our data suggest an update of the current EDS nosology concerning scarring that should be considered separately from skin hyperextensibility and that the clinical diagnosis of cEDS may be enhanced by the accurate evaluation of orthopedic manifestations at all ages, faciocutaneous indicators in children, and some acquired traits related to joint instability complications, premature skin aging, and patterning of abnormal scarring in older individuals.
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Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Brescia, Italy
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Viale Europa 11, I-25123, Brescia, Italy.
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23
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Ritelli M, Cinquina V, Venturini M, Colombi M. Identification of the novel COL5A1 c.3369_3431dup, p.(Glu1124_Gly1144dup) variant in a patient with incomplete classical Ehlers-Danlos syndrome: The importance of phenotype-guided genetic testing. Mol Genet Genomic Med 2020; 8:e1422. [PMID: 32720758 PMCID: PMC7549590 DOI: 10.1002/mgg3.1422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/02/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023] Open
Abstract
Background Classical Ehlers–Danlos syndrome (cEDS) is a connective tissue disorder mainly caused by heterozygous COL5A1 or COL5A2 variants encoding type V collagen and rarely by the p.(Arg312Cys) missense substitution in COL1A1 encoding type I collagen. The current EDS nosology specifies that minimal suggestive criteria are marked skin hyperextensibility plus atrophic scarring together with either generalized joint hypermobility or at least three minor criteria comprising additional cutaneous and articular signs. To reach a final diagnosis, molecular testing is required. Herein, we report on a 3‐year‐old female who came to our attention with an inconclusive next generation sequencing (NGS) panel comprising all cEDS‐associated genes. Methods Despite the patient did not formally fulfill the nosological criteria because the skin was only slightly hyperextensible, we made a cEDS diagnosis, mainly for the presence of typical atrophic scars. We investigated COL5A1 intragenic deletions/duplications by Multiplex Ligation‐dependent Probe Amplification (MLPA), excluded the recessive classical‐like EDS type 2 by AEBP1 Sanger analysis, and retested COL5A1 with the Sanger method. Results Molecular analyses revealed the novel COL5A1 c.3369_3431dup p.(Glu1124_Gly1144dup) intermediate‐sized duplication with a predicted dominant negative effect that was missed both by NGS and MLPA. Conclusions This report highlights that some cEDS patients might not display overt skin hyperextensibility and the importance of clinical expertise to make such a diagnosis in patients with an incomplete presentation. Our results also exemplify that NGS is not a fool‐proof technology and that Sanger sequencing achieves the diagnostic goal when there is a sufficiently clear phenotypic indication.
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Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
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24
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Yasukawa S, Uehara M, Suzuki T, Nakano M, Kosho T, Nakamura Y, Takahashi J. The first experience of denosumab therapy on patients with Ehlers-Danlos syndrome and osteoporosis: detailed observation of two patients. Mod Rheumatol Case Rep 2020; 5:377-383. [PMID: 32692295 DOI: 10.1080/24725625.2020.1799493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Previous studies have shown decreased bone mineral density (BMD) due to an unknown mechanism in Ehlers-Danlos Syndrome (EDS) patients and described approaches to treatment for osteoporosis in EDS. To date, however, there is no established method of treatment. In this study, we investigated two patients with EDS to clarify the efficacy and safety of denosumab treatment in EDS patients with osteoporosis. We retrospectively enrolled two EDS patients with osteoporosis who underwent denosumab therapy. Patient 1 was a 59-year-old male with classical EDS and osteoporosis who received a 48-month course of denosumab therapy. His lumbar BMD and total hip BMD were 1.335 g/cm2 and 0.762 g/cm2 before treatment, respectively. Forty-eight months later, the lumbar and total hip BMD showed gains of 1.6% and 11.4%, respectively. Patient 2 was a 42-year-old male with vascular EDS and osteoporosis who received an 18-month course of denosumab therapy. His lumbar BMD and total hip BMD were 0.763 g/cm2 and 0.583 g/cm2 before treatment, respectively. Eighteen months later, the lumbar and total hip BMD showed gains of 5.0% and 1.8%, respectively. No fractures or other complications were recorded during the observational period in both cases. This is the first experience of denosmab therapy on patients with EDS and osteoporosis. Denosumab, administered safely with no serious adverse effects such as fractures, exerted a fluctuating but probably positive effect regarding BMD and could be a treatment option on these patients.
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Affiliation(s)
- Sako Yasukawa
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takako Suzuki
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masaki Nakano
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoki Kosho
- Department of Medical Genetics, Shinshu University Hospital, Matsumoto, Japan.,Center for Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | - Yukio Nakamura
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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25
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Ritelli M, Colombi M. Molecular Genetics and Pathogenesis of Ehlers-Danlos Syndrome and Related Connective Tissue Disorders. Genes (Basel) 2020; 11:genes11050547. [PMID: 32414079 PMCID: PMC7288446 DOI: 10.3390/genes11050547] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 12/21/2022] Open
Abstract
Ehlers–Danlos syndromes (EDS) are a group of heritable connective tissue disorders (HCTDs) characterized by a variable degree of skin hyperextensibility, joint hypermobility and tissue fragility. The current EDS classification distinguishes 13 subtypes and 19 different causal genes mainly involved in collagen and extracellular matrix synthesis and maintenance. EDS need to be differentiated from other HCTDs with a variable clinical overlap including Marfan syndrome and related disorders, some types of skeletal dysplasia and cutis laxa. Clinical recognition of EDS is not always straightforward and for a definite diagnosis, molecular testing can be of great assistance, especially in patients with an uncertain phenotype. Currently, the major challenging task in EDS is to unravel the molecular basis of the hypermobile EDS that is the most frequent form, and for which the diagnosis is only clinical in the absence of any definite laboratory test. This EDS subtype, as well as other EDS-reminiscent phenotypes, are currently investigated worldwide to unravel the primary genetic defect and related pathomechanisms. The research articles, case report, and reviews published in this Special Issue focus on different clinical, genetic and molecular aspects of several EDS subtypes and some related disorders, offering novel findings and future research and nosological perspectives.
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26
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Warring SK, Castillo R, Klaas K, Taggart N, Fischer PR. Visual Diagnosis: A Case of Stretchy Skin and Vascular Abnormalities. Pediatr Rev 2020; 41:e16-e20. [PMID: 32358036 DOI: 10.1542/pir.2017-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Kelsey Klaas
- Department of General Pediatric and Adolescent Medicine, and
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27
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Abstract
PURPOSE OF REVIEW To summarize the bone findings, mainly bone mass and fracture risk, in Ehlers-Danlos syndromes (EDS). RECENT FINDINGS Low bone mineral density and fractures seem to be frequent in some of the rare EDS types (kyphoscoliotic, arthrochalasia, spondylodysplastic, and classic-like EDS). For the more prevalent hypermobile and classic EDS types, some case-control studies found mildly decreased bone mineral density, but it was not clear that fracture rates were increased. Nevertheless, abnormalities in vertebral shape seem to be common in classical and hypermobile EDS types. In a cohort of individuals with EDS followed since birth, no fractures were observed during infancy. Bone mineral density varies widely among the different types of EDS, and vertebral abnormalities seem to be common in classical and hypermobile EDS. It might be justified to perform spine radiographs and bone mineral density assessments in newly diagnosed EDS.
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Affiliation(s)
- Shuaa Basalom
- Shriners Hospital for Children, 1003 Boulevard Decarie, Montreal, Québec, Canada
| | - Frank Rauch
- Shriners Hospital for Children, 1003 Boulevard Decarie, Montreal, Québec, Canada.
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Pope MK, Ratajska A, Johnsen H, Rypdal KB, Sejersted Y, Paus B. Diagnostics of Hereditary Connective Tissue Disorders by Genetic Next-Generation Sequencing. Genet Test Mol Biomarkers 2019; 23:783-790. [DOI: 10.1089/gtmb.2019.0064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | | | - Hilde Johnsen
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | | | - Yngve Sejersted
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Benedicte Paus
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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29
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Adham S, Dupuis‐Girod S, Charpentier E, Mazzella J, Jeunemaitre X, Legrand A. Classical Ehlers‐Danlos syndrome with a propensity to arterial events: A new report on a French family with a
COL1A1
p.(Arg312Cys) variant. Clin Genet 2019; 97:357-361. [DOI: 10.1111/cge.13643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/23/2019] [Accepted: 09/06/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Salma Adham
- Assistance‐Publique Hôpitaux de Paris, Hôpital européen Georges Pompidou, Centre de référence des maladies vasculaires raresService de génétique Paris France
- Faculté de SantéUniversité de Paris Paris France
| | - Sophie Dupuis‐Girod
- Hospices Civils de Lyon, Hôpital Femme Mère EnfantService de Génétique, Centre de compétence des maladies vasculaires rares Bron France
- Inserm, CEA, BIG‐Biologie du Cancer et de l'InfectionUniversité de Grenoble Alpes Grenoble France
| | - Etienne Charpentier
- Faculté de SantéUniversité de Paris Paris France
- Assistance‐Publique Hôpitaux de Paris, Hôpital européen Georges PompidouService de radiologie Paris France
| | - Jean‐Michaël Mazzella
- Assistance‐Publique Hôpitaux de Paris, Hôpital européen Georges Pompidou, Centre de référence des maladies vasculaires raresService de génétique Paris France
| | - Xavier Jeunemaitre
- Assistance‐Publique Hôpitaux de Paris, Hôpital européen Georges Pompidou, Centre de référence des maladies vasculaires raresService de génétique Paris France
- Faculté de SantéUniversité de Paris Paris France
- INSERM, UMRS 970, Paris – Centre de recherche cardiovasculaire PARCC Paris France
| | - Anne Legrand
- Assistance‐Publique Hôpitaux de Paris, Hôpital européen Georges Pompidou, Centre de référence des maladies vasculaires raresService de génétique Paris France
- Faculté de SantéUniversité de Paris Paris France
- INSERM, UMRS 970, Paris – Centre de recherche cardiovasculaire PARCC Paris France
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30
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Further Defining the Phenotypic Spectrum of B3GAT3 Mutations and Literature Review on Linkeropathy Syndromes. Genes (Basel) 2019; 10:genes10090631. [PMID: 31438591 PMCID: PMC6770791 DOI: 10.3390/genes10090631] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 11/29/2022] Open
Abstract
The term linkeropathies (LKs) refers to a group of rare heritable connective tissue disorders, characterized by a variable degree of short stature, skeletal dysplasia, joint laxity, cutaneous anomalies, dysmorphism, heart malformation, and developmental delay. The LK genes encode for enzymes that add glycosaminoglycan chains onto proteoglycans via a common tetrasaccharide linker region. Biallelic variants in XYLT1 and XYLT2, encoding xylosyltransferases, are associated with Desbuquois dysplasia type 2 and spondylo-ocular syndrome, respectively. Defects in B4GALT7 and B3GALT6, encoding galactosyltransferases, lead to spondylodysplastic Ehlers-Danlos syndrome (spEDS). Mutations in B3GAT3, encoding a glucuronyltransferase, were described in 25 patients from 12 families with variable phenotypes resembling Larsen, Antley-Bixler, Shprintzen-Goldberg, and Geroderma osteodysplastica syndromes. Herein, we report on a 13-year-old girl with a clinical presentation suggestive of spEDS, according to the 2017 EDS nosology, in whom compound heterozygosity for two B3GAT3 likely pathogenic variants was identified. We review the spectrum of B3GAT3-related disorders and provide a comparison of all LK patients reported up to now, highlighting that LKs are a phenotypic continuum bridging EDS and skeletal disorders, hence offering future nosologic perspectives.
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31
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Chiarelli N, Ritelli M, Zoppi N, Colombi M. Cellular and Molecular Mechanisms in the Pathogenesis of Classical, Vascular, and Hypermobile Ehlers‒Danlos Syndromes. Genes (Basel) 2019; 10:E609. [PMID: 31409039 PMCID: PMC6723307 DOI: 10.3390/genes10080609] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/30/2019] [Accepted: 08/09/2019] [Indexed: 12/12/2022] Open
Abstract
The Ehlers‒Danlos syndromes (EDS) constitute a heterogenous group of connective tissue disorders characterized by joint hypermobility, skin abnormalities, and vascular fragility. The latest nosology recognizes 13 types caused by pathogenic variants in genes encoding collagens and other molecules involved in collagen processing and extracellular matrix (ECM) biology. Classical (cEDS), vascular (vEDS), and hypermobile (hEDS) EDS are the most frequent types. cEDS and vEDS are caused respectively by defects in collagen V and collagen III, whereas the molecular basis of hEDS is unknown. For these disorders, the molecular pathology remains poorly studied. Herein, we review, expand, and compare our previous transcriptome and protein studies on dermal fibroblasts from cEDS, vEDS, and hEDS patients, offering insights and perspectives in their molecular mechanisms. These cells, though sharing a pathological ECM remodeling, show differences in the underlying pathomechanisms. In cEDS and vEDS fibroblasts, key processes such as collagen biosynthesis/processing, protein folding quality control, endoplasmic reticulum homeostasis, autophagy, and wound healing are perturbed. In hEDS cells, gene expression changes related to cell-matrix interactions, inflammatory/pain responses, and acquisition of an in vitro pro-inflammatory myofibroblast-like phenotype may contribute to the complex pathogenesis of the disorder. Finally, emerging findings from miRNA profiling of hEDS fibroblasts are discussed to add some novel biological aspects about hEDS etiopathogenesis.
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Affiliation(s)
- Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy
| | - Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy
| | - Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25121 Brescia, Italy.
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32
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VanderJagt K, Butler MG. Ehlers-Danlos syndrome and other heritable connective tissue disorders that impact pregnancies can be detected using next-generation DNA sequencing. Arch Gynecol Obstet 2019; 300:491-493. [PMID: 31250196 DOI: 10.1007/s00404-019-05226-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/19/2019] [Indexed: 10/26/2022]
Abstract
Ehlers-Danlos syndromes (EDS) are a genetically heterogeneous group of inherited connective tissue disorders classified into six major types with a variable collection of findings and different inheritance patterns. Although complications occur in about one-half of pregnancies in women with EDS, the majority can have a good outcome if managed appropriately. Classic EDS is characterized by joint hypermobility, loose skin with poor healing and easy bruising, musculoskeletal problems with chronic pain and at risk for pre-term delivery. In addition, the vascular form of EDS can have cardiac anomalies, aneurysms, gastrointestinal perforation and uterine rupture during pregnancy. Due to overlapping features among the connective tissue disorders, it is difficult to categorize the disorder into specific types without detailed genetic testing which is now available through advanced genomic technology using next-generation DNA sequencing, searching genomic databases and bioinformatics approach. Therefore, obstetrical complications are variable but relate to specific connective tissue disorders requiring an exact diagnosis. There are several dozen genes causing connective tissue disorders that are currently available for testing using next-generation sequencing and bioinformatics to provide pertinent care, treatment and surveillance of the affected pregnant woman but also for her at-risk fetus related to the specific heritable condition.
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Affiliation(s)
- Krystal VanderJagt
- Departments of Psychiatry and Behavioral Sciences and Pediatrics, Medical Center, University of Kansas, Kansas City, KS, USA.
| | - Merlin G Butler
- Departments of Psychiatry and Behavioral Sciences and Pediatrics, Medical Center, University of Kansas, Kansas City, KS, USA
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33
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Kalisch L, Hamonet C, Bourdon C, Montalescot L, de Cazotte C, Baeza-Velasco C. Predictors of pain and mobility disability in the hypermobile Ehlers-Danlos syndrome. Disabil Rehabil 2019; 42:3679-3686. [PMID: 31060411 DOI: 10.1080/09638288.2019.1608595] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aim: Among the Ehlers-Danlos syndromes, the hypermobile subtype (hEDS) is the most common. The variety, accumulation and duration of the painful symptoms make hEDS a chronic and highly disabling condition. Identifying drivers of pain and mobility disability in hEDS is necessary to provide adapted prevention and intervention programs.Methods: A cross-sectional sample of 75 adults with hEDS according to Villefranche criteria (67 women; 36 years, SD = 11.2) responded to self-assessment questionnaires regarding psychological (negative thoughts and emotions), health (pain, fatigue, diagnostic delay, body mass index, and mobility disability) and socio-demographic variables.Results: Forty-three percent of the participants suffer from severe pain, and two thirds suffer from a high level of mobility disability. Multivariate analyses show that delay of diagnosis, being professionally active and thoughts of helplessness are variables that increase the likelihood of severe pain, whereas age, fatigue, and body mass index predict mobility disability.Conclusion: These results confirm previous research concerning the high disease burden observed in hEDS patients, and highlight the importance of multidisciplinary management that includes nutritional and psychological advice to address this pathology. Increasing awareness of the clinical aspects of hEDS among physicians is necessary to reduce diagnostic delay and minimize negatives outcomes.Implications for RehabilitationA high proportion of patients with hypermobile Ehlers-Danlos syndrome suffer from severe pain (>42%) and a high level of mobility disability (>65%).Different psychosocial and health variables predict pain and mobility disability in patients with hypermobile Ehlers-Danlos syndrome.Awareness concerning the clinical picture of hypermobile Ehlers-Danlos syndrome among health care professionals is necessary to reduce diagnosis delay and the burden of the disease.
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Affiliation(s)
- Larissa Kalisch
- Department of Psychology, Anglia Ruskin University, Cambridge, UK
| | - Claude Hamonet
- Faculty of Medecine, University Paris-Est Créteil, Créteil, France
| | | | - Lucile Montalescot
- Laboratory of Psychopathology and Health Processes (EA 4057), University Paris Descartes-Sorbonne Paris Cité, Boulogne-Billancourt, France
| | - Cécile de Cazotte
- Laboratory of Psychopathology and Health Processes (EA 4057), University Paris Descartes-Sorbonne Paris Cité, Boulogne-Billancourt, France
| | - Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes (EA 4057), University Paris Descartes-Sorbonne Paris Cité, Boulogne-Billancourt, France.,Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France
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34
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Rolfes MC, Deyle DR, King KS, Hand JL, Graff AH, Derauf C. Fracture incidence in Ehlers-Danlos syndrome - A population-based case-control study. CHILD ABUSE & NEGLECT 2019; 91:95-101. [PMID: 30856599 PMCID: PMC7064152 DOI: 10.1016/j.chiabu.2019.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/31/2018] [Accepted: 03/04/2019] [Indexed: 06/01/2023]
Abstract
BACKGROUND The differential diagnosis of non-accidental injury during childhood includes medical conditions that predispose to skeletal fragility. Ehlers-Danlos syndrome (EDS) has been proposed as one such condition despite little objective evidence in the medical literature. OBJECTIVE To investigate if EDS causes increased bone fragility during infancy and childhood. PARTICIPANTS AND SETTING Residents of an 8-county region in southern Minnesota using the Rochester Epidemiology Project (REP) medical records-linkage system. METHODS This retrospective, population-based, case-control study identified subjects with EDS from 1976 to 2015 who had complete records for at least their first year of life. Validity of diagnosis was ascertained using the 2017 International Classification of the Ehlers-Danlos Syndromes. Records were reviewed for fracture diagnoses that were characterized by age, location, type and mechanism. RESULTS Of 219 potential cases, 21 had complete records for the first year of life and sufficient evidence in the medical record to support an EDS diagnosis. Of these 21, there were 14 hypermobile, 2 classical, 4 vascular, and 1 arthrochalasia EDS subtypes. 11 of 21 EDS cases (52.4%) and 15 of 63 controls (23.8%) had one or more fractures during childhood. No fractures were identified in the first year of life. Comparing cases to controls, EDS was associated with having any fractures during childhood with an odds ratio of 3.4 (95% CI: 1.20-9.66). CONCLUSIONS We found no evidence that infants with common forms of EDS are predisposed to more frequent fractures. Ambulatory subjects with these EDS subtypes may have a higher incidence of fractures during childhood.
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Affiliation(s)
- Mary C Rolfes
- Mayo Clinic School of Medicine - Minnesota Campus, 200 First Street SW, Rochester, MN 55905, USA.
| | - David R Deyle
- Departments of Clinical Genomics and Pediatric and Adolescent Medicine, 200 First Street SW, Rochester, MN 55905, USA.
| | - Katherine S King
- Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jennifer L Hand
- Departments of Dermatology, Clinical Genomics, and Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Arne H Graff
- Departments of Pediatric and Adolescent Medicine and Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Chris Derauf
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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35
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Velvin G, Wilhelmsen JE, Johansen H, Bathen T, Geirdal AØ. Systematic review of quality of life in persons with hereditary thoracic aortic aneurysm and dissection diagnoses. Clin Genet 2019; 95:661-676. [DOI: 10.1111/cge.13522] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Gry Velvin
- TRS National Resource Centre for Rare DisordersSunnaas Rehabilitation Hospital Nesodden Norway
| | - Jan E. Wilhelmsen
- TRS National Resource Centre for Rare DisordersSunnaas Rehabilitation Hospital Nesodden Norway
| | - Heidi Johansen
- TRS National Resource Centre for Rare DisordersSunnaas Rehabilitation Hospital Nesodden Norway
| | - Trine Bathen
- TRS National Resource Centre for Rare DisordersSunnaas Rehabilitation Hospital Nesodden Norway
| | - Amy Ø. Geirdal
- Departments of Social Work, Child Welfare and Social Policy, Faculty of Social SciencesMetropolitan University of Oslo Norway
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36
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Wasim S, Suddaby JS, Parikh M, Leylachian S, Ho B, Guerin A, So J. Pain and gastrointestinal dysfunction are significant associations with psychiatric disorders in patients with Ehlers-Danlos syndrome and hypermobility spectrum disorders: a retrospective study. Rheumatol Int 2019; 39:1241-1248. [PMID: 30923956 DOI: 10.1007/s00296-019-04293-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/20/2019] [Indexed: 12/20/2022]
Abstract
In this retrospective study, we investigate the frequency and types of psychiatric disorders and their relationship to systemic manifestations in a cohort of 391 Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorder (HSD) patients based on the current 2017 International Classification of EDS diagnostic criteria. A detailed, systematic retrospective chart review was undertaken for patients assessed for HSD or EDS at two Canadian health centres. Patients were diagnosed according to the Villefranche criteria and reclassified for this study according to the 2017 International Classification of EDS. Data validation and statistical analyses were conducted. Psychiatric disorders were very common, with 49.4% of the total cohort affected; 28.9% reported multiple psychiatric diagnoses. Mood (34.5%) and somatoform (28.6%) disorders were most common. Interestingly, attention-deficit/hyperactivity disorder (ADHD) was significantly enriched in the HSD, but not EDS cohort (p = 0.0002, 95% CI 3.48-9.00) compared to the general population. There were no differences in the systemic associations with having psychiatric manifestations in the HSD compared to the EDS subsets. Muscle/body pain (OR 1.99) and gastrointestinal dysfunction (OR 2.07) were significantly associated with having mood disorders, and gastrointestinal dysfunction (OR 2.61) and nerve-related pain (OR 3.27) were associated with having somatoform disorders across the cohort. The common systemic associations with the presence of psychiatric manifestations in both HSD and EDS reaffirm that the conditions should be treated as a spectrum rather than as wholly separate entities, particularly with respect to psychiatric management. EDS and HSD patients share common psychiatric presentations, though ADHD is more common with HSD.
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Affiliation(s)
- S Wasim
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, 60 Murray Street, Box 34, 3rd Floor, Room 400, Toronto, ON, M5T 3L9, Canada
| | - J S Suddaby
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, 60 Murray Street, Box 34, 3rd Floor, Room 400, Toronto, ON, M5T 3L9, Canada
| | - M Parikh
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, 60 Murray Street, Box 34, 3rd Floor, Room 400, Toronto, ON, M5T 3L9, Canada
| | - S Leylachian
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, 60 Murray Street, Box 34, 3rd Floor, Room 400, Toronto, ON, M5T 3L9, Canada
| | - B Ho
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, 60 Murray Street, Box 34, 3rd Floor, Room 400, Toronto, ON, M5T 3L9, Canada.,Department of Pediatrics, Division of Medical Genetics, Queen's University, Kingston, Canada
| | - A Guerin
- Department of Pediatrics, Division of Medical Genetics, Queen's University, Kingston, Canada
| | - J So
- Fred A. Litwin Family Centre in Genetic Medicine, University Health Network and Mount Sinai Hospital, 60 Murray Street, Box 34, 3rd Floor, Room 400, Toronto, ON, M5T 3L9, Canada. .,Centre for Addiction and Mental Health, Toronto, Canada. .,Departments of Medicine, Psychiatry, and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
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Ritelli M, Cinquina V, Venturini M, Pezzaioli L, Formenti AM, Chiarelli N, Colombi M. Expanding the Clinical and Mutational Spectrum of Recessive AEBP1-Related Classical-Like Ehlers-Danlos Syndrome. Genes (Basel) 2019; 10:E135. [PMID: 30759870 PMCID: PMC6410021 DOI: 10.3390/genes10020135] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/28/2019] [Accepted: 02/08/2019] [Indexed: 12/26/2022] Open
Abstract
Ehlers-Danlos syndrome (EDS) comprises clinically heterogeneous connective tissue disorders with diverse molecular etiologies. The 2017 International Classification for EDS recognized 13 distinct subtypes caused by pathogenic variants in 19 genes mainly encoding fibrillar collagens and collagen-modifying or processing proteins. Recently, a new EDS subtype, i.e., classical-like EDS type 2, was defined after the identification, in six patients with clinical findings reminiscent of EDS, of recessive alterations in AEBP1, which encodes the aortic carboxypeptidase⁻like protein associating with collagens in the extracellular matrix. Herein, we report on a 53-year-old patient, born from healthy second-cousins, who fitted the diagnostic criteria for classical EDS (cEDS) for the presence of hyperextensible skin with multiple atrophic scars, generalized joint hypermobility, and other minor criteria. Molecular analyses of cEDS genes did not identify any causal variant. Therefore, AEBP1 sequencing was performed that revealed homozygosity for the rare c.1925T>C p.(Leu642Pro) variant classified as likely pathogenetic (class 4) according to the American College of Medical Genetics and Genomics (ACMG) guidelines. The comparison of the patient's features with those of the other patients reported up to now and the identification of the first missense variant likely associated with the condition offer future perspectives for EDS nosology and research in this field.
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Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy.
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy.
| | - Marina Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, 25123 Brescia, Italy.
| | - Letizia Pezzaioli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy.
- Spedali Civili of Brescia, 25123 Brescia, Italy.
| | | | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy.
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy.
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38
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Formenti AM, Doga M, Frara S, Ritelli M, Colombi M, Banfi G, Giustina A. Skeletal fragility: an emerging complication of Ehlers-Danlos syndrome. Endocrine 2019; 63:225-230. [PMID: 30554346 DOI: 10.1007/s12020-018-1822-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/21/2018] [Indexed: 12/31/2022]
Abstract
Ehlers-Danlos syndrome (EDS) is an emerging cause of skeletal fragility. Mechanism of bone damage are probably multifactorial in line with the different skeletal phenotypes that can be found in clinical practice. A structured approach to clinical management of bone metabolic complication in EDS is proposed.
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Affiliation(s)
| | - Mauro Doga
- Vita-Salute San Raffaele University, Milano, Italy
| | | | - Marco Ritelli
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marina Colombi
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Giuseppe Banfi
- IRCCS, Istituto Ortopedico Galeazzi, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
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39
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Fragkos KC, Keetarut K, Cox A, Eady J, Emmanuel AV, Zarate-Lopez N. Joint Hypermobility Syndrome Affects Response to a Low Fermentable Oligosaccharide, Disaccharide, Monosaccharide and Polyol Diet in Irritable Bowel Syndrome Patients: A Retrospective Study. Gastroenterology Res 2019; 12:27-36. [PMID: 30834032 PMCID: PMC6396789 DOI: 10.14740/gr1133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 01/16/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet causes significant clinical improvement in patients with irritable bowel syndrome (IBS). Joint hypermobility syndrome (JHS), defined as musculoskeletal symptoms in a hypermobile individual in the absence of systemic rheumatological disease, may be associated with functional gastrointestinal symptoms, including IBS. The aim of this study is to examine whether JHS can affect the response to the low FODMAP diet in patients with IBS. METHODS In this retrospective study, we included patients with IBS according to Rome III criteria who had followed a low FODMAP diet. Symptoms scores were measured before and after the low FODMAP diet. RESULTS A total of 165 patients (130 females, age 44 ± 14 years) were included. Diarrhea predominant IBS (IBS-D) was present in 40.6% of our patients while JHS was present in 21.2%. The score for abdominal pain was higher for JHS compared to non-JHS prior to intervention (P = 0.011). Symptoms improved in both groups of patients after a low FODMAP diet (P < 0.0001). The largest effects were shown with significant decreases of the average score and bloating. When broken down by JHS and IBS type, a low FODMAP diet significantly improved pain, bloating, diarrhea, constipation, and the average score with the largest effect in JHS/constipation predominant IBS (IBS-C), JHS/mixed IBS and unclassified IBS (IBS-M), JHS/IBS-D, non-JHS/IBS-C and JHS/IBS-M, respectively. CONCLUSIONS Our study suggests that a low FODMAP diet has a greater effect on IBS symptoms in JHS than non-JHS patients.
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Affiliation(s)
- Konstantinos C. Fragkos
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Katie Keetarut
- Dietetics Department, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Anna Cox
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Johanna Eady
- Dietetics Department, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Anton V. Emmanuel
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
| | - Natalia Zarate-Lopez
- GI Physiology Unit, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK
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Baeza-Velasco C, Cohen D, Hamonet C, Vlamynck E, Diaz L, Cravero C, Cappe E, Guinchat V. Autism, Joint Hypermobility-Related Disorders and Pain. Front Psychiatry 2018; 9:656. [PMID: 30581396 PMCID: PMC6292952 DOI: 10.3389/fpsyt.2018.00656] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Autism Spectrum Disorder (ASD) and Joint Hypermobility-Related Disorders are blanket terms for two etiologically and clinically heterogeneous groups of pathologies that usually appears in childhood. These conditions are seen by different medical fields, such as psychiatry in the case of ASD, and musculoskeletal disciplines and genetics in the case of hypermobility-related disorders. Thus, a link between them is rarely established in clinical setting, despite a scarce but growing body of research suggesting that both conditions co-occur more often than expected by chance. Hypermobility is a frequent sign of hereditary disorders of connective tissue (e.g., Ehlers-Danlos syndromes, Marfan syndrome), in which the main characteristic is the multisystem fragility that prone to proprioceptive and motor coordination dysfunction and hence to trauma and chronic pain. Considering the high probability that pain remains disregarded and untreated in people with ASD due to communication and methodological difficulties, increasing awareness about the interconnection between ASD and hypermobility-related disorders is relevant, since it may help identify those ASD patients susceptible to chronic pain.
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Affiliation(s)
- Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, University Paris Descartes-Sorbonne Paris Cité, Boulogne-Billancourt, France
- INSERM U1061, Neuropsychiatry: Epidemiological and Clinical Research, Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France
| | - David Cohen
- Department of Child and Adolescent Psychiatry, Reference Center for Rare Psychiatric Diseases, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France
- Institut des Systèmes Intelligents et Robotiques, CNRS UMR 7222, Université Sorbonne, Paris, France
| | | | | | - Lautaro Diaz
- Department of Child and Adolescent Psychiatry, Reference Center for Rare Psychiatric Diseases, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Cora Cravero
- Department of Child and Adolescent Psychiatry, Reference Center for Rare Psychiatric Diseases, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Emilie Cappe
- Laboratory of Psychopathology and Health Processes, University Paris Descartes-Sorbonne Paris Cité, Boulogne-Billancourt, France
| | - Vincent Guinchat
- Department of Child and Adolescent Psychiatry, Reference Center for Rare Psychiatric Diseases, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France
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Zylberberg HM, Lebwohl B, Green PHR. Celiac Disease-Musculoskeletal Manifestations and Mechanisms in Children to Adults. Curr Osteoporos Rep 2018; 16:754-762. [PMID: 30350261 DOI: 10.1007/s11914-018-0488-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW We aim to review the current literature on the association of musculoskeletal disorders and celiac disease that is a common disorder, affecting about 1% of the population. Extra-intestinal symptoms and presentations predominate. RECENT FINDINGS While the literature supports an association with reduced bone mineral density and increased fracture risk and celiac disease, there is little evidence supporting associations with other rheumatological conditions. Patients frequently report musculoskeletal symptoms; however, studies of specific disease entities suffer from a lack of standardization of testing for celiac disease and a lack of control groups. Well-controlled, preferably population-based studies are required to further explore a relationship between celiac disease and musculoskeletal disorders.
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Affiliation(s)
- Haley M Zylberberg
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA
| | - Peter H R Green
- Celiac Disease Center, Columbia University Medical Center, 180 Fort Washington Ave, New York, NY, 10032, USA.
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Sulli A, Talarico R, Scirè CA, Avcin T, Castori M, Ferraris A, Frank C, Grunert J, Paolino S, Bombardieri S, Schneider M, Smith V, Cutolo M, Mosca M, Malfait F. Ehlers-Danlos syndromes: state of the art on clinical practice guidelines. RMD Open 2018; 4:e000790. [PMID: 30402275 PMCID: PMC6203099 DOI: 10.1136/rmdopen-2018-000790] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/12/2018] [Accepted: 09/22/2018] [Indexed: 01/17/2023] Open
Abstract
Objective To report the effort of the European Reference Network for Rare and Complex CONnective tissue and musculoskeletal diseases NETwork working group on Ehlers-Danlos syndromes (EDS) and related disorders to assess current available clinical practice guidelines (CPGs) specifically addressed to EDS, in order to identify potential clinician and patient unmet needs. Methods Systematic literature search in PUBMED and EMBASE based on controlled terms (MeSH and Emtree) and keywords of the disease and publication type (CPGs). All the published articles were revised in order to identify existing CPGs on diagnosis, monitoring and treatment of EDS. Results Literature revision detected the absence of papers reporting good quality CPGs to optimise EDS patient care. The current evidence-based literature regarding clinical guidelines for the EDS was limited in size and quality, and there is insufficient research exploring the clinical features and interventions, and clinical decision-making are currently based on theoretical and limited research evidences. Conclusions Many clinician and patient unmet needs have been identified.
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Affiliation(s)
- Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Carlo Alberto Scirè
- Section of Rheumatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Marco Castori
- Division of Medical Genetics, IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Alessandro Ferraris
- Medical Genetics Laboratory, Molecular Medicine Department, San Camillo Forlanini Hospital, Sapienza University, Rome, Italy
| | - Charissa Frank
- Flemish Association for Hereditary Connective Tissue Disorders, Brussels, Belgium
| | | | - Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Matthias Schneider
- Institute for Rheumatology, Hiller Research Unit for Rheumatology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marta Mosca
- Department of Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
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Zoppi N, Chiarelli N, Ritelli M, Colombi M. Multifaced Roles of the αvβ3 Integrin in Ehlers-Danlos and Arterial Tortuosity Syndromes' Dermal Fibroblasts. Int J Mol Sci 2018; 19:ijms19040982. [PMID: 29587413 PMCID: PMC5979373 DOI: 10.3390/ijms19040982] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/19/2018] [Accepted: 03/24/2018] [Indexed: 02/07/2023] Open
Abstract
The αvβ3 integrin, an endothelial cells’ receptor-binding fibronectin (FN) in the extracellular matrix (ECM) of blood vessels, regulates ECM remodeling during migration, invasion, angiogenesis, wound healing and inflammation, and is also involved in the epithelial mesenchymal transition. In vitro-grown human control fibroblasts organize a fibrillar network of FN, which is preferentially bound on the entire cell surface to its canonical α5β1 integrin receptor, whereas the αvβ3 integrin is present only in rare patches in focal contacts. We report on the preferential recruitment of the αvβ3 integrin, due to the lack of FN–ECM and its canonical integrin receptor, in dermal fibroblasts from Ehlers–Danlos syndromes (EDS) and arterial tortuosity syndrome (ATS), which are rare multisystem connective tissue disorders. We review our previous findings that unraveled different biological mechanisms elicited by the αvβ3 integrin in fibroblasts derived from patients affected with classical (cEDS), vascular (vEDS), hypermobile EDS (hEDS), hypermobility spectrum disorders (HSD), and ATS. In cEDS and vEDS, respectively, due to defective type V and type III collagens, αvβ3 rescues patients’ fibroblasts from anoikis through a paxillin-p60Src-mediated cross-talk with the EGF receptor. In hEDS and HSD, without a defined molecular basis, the αvβ3 integrin transduces to the ILK-Snail1-axis inducing a fibroblast-to-myofibroblast-transition. In ATS cells, the deficiency of the dehydroascorbic acid transporter GLUT10 leads to redox imbalance, ECM disarray together with the activation of a non-canonical αvβ3 integrin-TGFBRII signaling, involving p125FAK/p60Src/p38MAPK. The characterization of these different biological functions triggered by αvβ3 provides insights into the multifaced nature of this integrin, at least in cultured dermal fibroblasts, offering future perspectives for research in this field.
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Affiliation(s)
- Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, 25123 Brescia, Italy.
| | - Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, 25123 Brescia, Italy.
| | - Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, 25123 Brescia, Italy.
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, 25123 Brescia, Italy.
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Baeza-Velasco C, Bourdon C, Montalescot L, de Cazotte C, Pailhez G, Bulbena A, Hamonet C. Low- and high-anxious hypermobile Ehlers-Danlos syndrome patients: comparison of psychosocial and health variables. Rheumatol Int 2018; 38:871-878. [PMID: 29497845 DOI: 10.1007/s00296-018-4003-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/26/2018] [Indexed: 12/19/2022]
Abstract
Despite the frequent co-ocurrence of hypermobile Ehler-Danlos syndrome (hEDS) and pathological anxiety, little is known about the psychosocial and health implications of such comorbidity. Our aim was to explore the association between high levels of anxiety and psychosocial (catastrophizing, kinesiophobia, somatosensory amplification, social support and functioning), health (pain, fatigue, BMI, tobacco/alcohol use, depression, diagnosis delay, general health), and sociodemographic factors in people with hEDS. In this cross-sectional study, 80 hEDS patients were divided into two groups according to self-reported anxiety levels: low and high. Psychosocial, sociodemographic and health variables were compared between the groups. Forty-one participants reported a high level of anxiety (51.2%). No differences were found in the sociodemographic variables between high-anxious and low-anxious patients. The percentage of participants with severe fatigue and high depressive symptomatology was significantly higher in the high-anxious group (80.5 vs 56.4; 26.8 vs 12.8%, respectively). High-anxious hEDS patients also showed significantly higher levels of pain catastrophizing, somatosensory amplification as well as a poorer social functioning and general health. Multivariate analyses showed that somatosensory amplification, pain catastrophizing and poor social functioning are variables that increase the probability of belonging to the high-anxious group. Despite limitations, this first study comparing high-anxious versus low-anxious hEDS patients with respect to health aspects, highlight the importance of considering the psychosocial factors (many susceptible to modification), to improve the adjustment to this chronic condition and provide support to those affected through a biopsychosocial approach.
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Affiliation(s)
- Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, Institut de Psychologie, University Paris Descartes-Sorbonne Paris Cité, 71 Avenue Édouard Vaillant, 92100, Boulogne-Billancourt, France. .,INSERM U1061, Neuropsychiatry: Epidemiological and Clinical Research, Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France.
| | | | - Lucile Montalescot
- Laboratory of Psychopathology and Health Processes, Institut de Psychologie, University Paris Descartes-Sorbonne Paris Cité, 71 Avenue Édouard Vaillant, 92100, Boulogne-Billancourt, France
| | - Cécile de Cazotte
- Laboratory of Psychopathology and Health Processes, Institut de Psychologie, University Paris Descartes-Sorbonne Paris Cité, 71 Avenue Édouard Vaillant, 92100, Boulogne-Billancourt, France
| | - Guillem Pailhez
- Department of Psychiatry, Autonoma University of Barcelona, Barcelona, Spain
| | - Antonio Bulbena
- Department of Psychiatry, Autonoma University of Barcelona, Barcelona, Spain
| | - Claude Hamonet
- Department of Physical Medicine and Rehabilitation, Hôtel-Dieu Hospital, Paris, France.,University Paris-Est Créteil, Créteil, France
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Attention-deficit/hyperactivity disorder, joint hypermobility-related disorders and pain: expanding body-mind connections to the developmental age. ACTA ACUST UNITED AC 2018; 10:163-175. [PMID: 29446032 DOI: 10.1007/s12402-018-0252-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/07/2018] [Indexed: 12/17/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) and generalized joint hypermobility (JH) are two separated conditions, assessed, and managed by different specialists without overlapping interests. Recently, some researchers highlighted an unexpected association between these two clinical entities. This happens in a scenario of increasing awareness on the protean detrimental effects that congenital anomalies of the connective tissue may have on human health and development. To review pertinent literature to identify possible connections between ADHD and GJH, special emphasis was put on musculoskeletal pain and syndromic presentations of GJH, particularly the hypermobile Ehlers-Danlos syndrome. A comprehensive search of scientific databases and references lists was conducted, encompassing publications based on qualitative and quantitative research. Impaired coordination and proprioception, fatigue, chronic pain, and dysautonomia are identified as potential bridges between ADHD and JH. Based on these findings, a map of the pathophysiological and psychopathological pathways connecting both conditions is proposed. Although ADHD and JH are traditionally separated human attributes, their association may testify for the dyadic nature of mind-body connections during critical periods of post-natal development. Such a mixed picture has potentially important consequences in terms of disability and deserves more clinical and research attention.
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Baeza-Velasco C, Bulbena A, Polanco-Carrasco R, Jaussaud R. Cognitive, emotional, and behavioral considerations for chronic pain management in the Ehlers–Danlos syndrome hypermobility-type: a narrative review. Disabil Rehabil 2018; 41:1110-1118. [DOI: 10.1080/09638288.2017.1419294] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, University Paris Descartes - Sorbonne Paris Cité, Boulogne Billancourt, France
- Inserm U1061, La Colombière Hospital, Montpellier, France
| | - Antonio Bulbena
- Department of Psychiatry, Autonoma University of Barcelona, Barcelona, Spain
| | | | - Roland Jaussaud
- Department of Internal Medicine and Clinical Immunology, Medicine School, University of Lorraine, CHRU Nancy, Nancy, France
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A classical Ehlers-Danlos syndrome family with incomplete presentation diagnosed by molecular testing. Eur J Med Genet 2018; 61:17-20. [DOI: 10.1016/j.ejmg.2017.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/20/2017] [Accepted: 10/07/2017] [Indexed: 12/13/2022]
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Abstract
PURPOSE OF REVIEW Joint hypermobility is a common, although largely ignored physical sign. Joint hypermobility is often asymptomatic but may be a feature of an underlying genetic disorder with systemic manifestations. The present article presents a comprehensive approach to considering joint hypermobility and clinically related issues in children and adults. RECENT FINDINGS Ehlers-Danlos syndrome (EDS) is an umbrella term for various Mendelian connective tissue disorders sharing joint hypermobility, skin hyperextensibility, and tissue fragility. Hypermobile EDS is the default diagnosis in many individuals and still lacks of any confirmatory test. There is also a continuous spectrum of phenotypes between asymptomatic, nonsyndromic joint hypermobility, and hypermobile EDS. In 2017, a new international classification of EDSs, joint hypermobility, and related disorders was published. EDSs are now classified in 13 different variants because of mutations in 19 genes. The gap between joint hypermobility and hypermobile EDS is filled by the descriptive diagnosis of 'hypermobility spectrum disorders'. Alongside the new criteria recommendations for the assessment and management of selected issues related to joint hypermobility such as fatigue and physical therapy have also been published by expert panels. SUMMARY Asymptomatic, nonsyndromic joint hypermobility, hypermobility spectrum disorders and EDS (particularly, the hypermobile type) are the most common phenotypes in children and adults with joint hypermobility. Their prompt recognition is crucial to the appropriate application of evidence-based management and the reduction in burden of ill health.
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49
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[Ehlers-Danlos syndromes]. Ann Dermatol Venereol 2017; 144:744-758. [PMID: 29032848 DOI: 10.1016/j.annder.2017.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 02/27/2017] [Accepted: 06/12/2017] [Indexed: 11/22/2022]
Abstract
Ehlers-Danlos syndromes (EDS) are a heterogeneous group of inheritable connective tissue disorders characterized by skin hyperextensibility, joint hypermobility and cutaneous fragility with delayed wound healing. Over and above these common features, they differ in the presence or absence of various organ and tissue abnormalities, and differences in genetic causal mechanisms and degree of severity. They are complex and multisystem diseases, with the majority being highly disabling because of major joint problems and neurosensory deficiencies, and in some cases, they may be life-threatening due to associated complications, especially vascular disorders. In 1997, the Villefranche classification defined 6 subtypes of EDS. However, many other new variants have been described over the last years. The "historical" EDS were characterized by abnormalities in fibrillar collagen protein synthesis. More recently, disorders of synthesis and organization of the extracellular matrix have been shown to be responsible for other types of EDS. Thus, many EDS are in fact metabolic diseases related to enzymatic defects. While there is no curative treatment for any type of EDS, early diagnosis is of utmost importance in order to optimize the symptomatic management of patients and to prevent avoidable complications. Patients must be treated and monitored by multidisciplinary teams in highly specialized reference centers. In this article, we present the current state of knowledge on these diseases that continue to be elucidated thanks to new molecular genetic techniques.
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Ritelli M, Palit A, Giacopuzzi E, Inamadar AC, Dordoni C, Mujja A, Murgude MS, Colombi M. Clinical and molecular characterization of a 13-year-old Indian boy with cutis laxa type 2B: Identification of two novel PYCR1 mutations by amplicon-based semiconductor exome sequencing. J Dermatol Sci 2017; 88:141-143. [PMID: 28499588 DOI: 10.1016/j.jdermsci.2017.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Aparna Palit
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Edoardo Giacopuzzi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Arun C Inamadar
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Chiara Dordoni
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Ajay Mujja
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Meghana S Murgude
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy; Department of Dermatology, Venereology & Leprosy, Sri B. M. Patil Medical College, Hospital & Research Center, BLDE University, Vijayapur, Karnataka, India; Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia, Italy.
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