Variants of the Ehlers-Danlos syndrome. Clinical, biochemical, haematological, and chromosomal features of 100 patients

Ehlers-Danlos syndromes: importance of defining the type

Ehlers-Danlos syndromes (EDS) is an umbrella term describing 14 types, of which 13 are rare and monogenic, with overlapping features of joint hypermobility, skin, and vascular fragility, and generalised connective tissue friability. Hypermobile EDS currently has no identified genetic cause. Most of the rare monogenic EDS types can have neurological features, which are often part of major or minor diagnostic criteria for each type. This review aims to highlight the neurological features and other key characteristics of these EDS types. This should improve recognition of these features, enabling more timely consideration and confirmation or exclusion through genetic testing. In practice, many healthcare professionals still refer to patients as having 'EDS'. However, the different EDS types have distinct clinical features as well as different underlying genetic causes and pathogenic mechanisms, and each requires bespoke management and surveillance. Defining the EDS type is therefore crucial, as EDS is not in itself a diagnosis.

Diagnostic outcomes for molecular genetic testing in children with suspected Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders characterized by hyperextensible skin, hypermobile joints, easy bruisability, and fragility of the connective tissues. The diagnosis is based on clinical assessment and phenotype-guided genetic testing. Most EDS subtypes can be confirmed by genetic testing except for hypermobile EDS. This study explored the utility of applying the 2017 EDS classification criteria and molecular genetic testing in establishing an EDS diagnosis in children. In this retrospective study, we reviewed 72 patients referred to a tertiary care center for evaluation of EDS who underwent one or more forms of genetic testing. Eighteen patients (18/72, 25%) met the clinical criteria for one of the EDS subtypes and of these, 15 (15/18, 83%) were confirmed molecularly. Fifty-four patients (54/72, 75%) had features that overlapped EDS and other syndromes associated with joint hypermobility but did not fully meet clinical criteria. Twelve of them (12/54, 22%) were later shown to have a positive molecular genetic diagnosis of EDS. Different molecular genetic tests were performed on the cohort of 72 patients (EDS panel, n = 44; microarray, n = 25; whole exome sequencing [WES], n = 9; single gene sequencing, n = 3; familial variant testing, n = 10; other genetic panels n = 3). EDS panel was completed in 44 patients (61%), and a molecular diagnosis was confirmed in nine of the patients who satisfied criteria for one of the EDS subtypes (9/12, 75%) and in nine of the patients who did not fully meet criteria (9/32, 28%). We observed a correlation between generalized joint hypermobility, poor healing, easy bruising, atrophic scars, skin hyperextensibility, and developmental dysplasia of the hip with a positive molecular result. This study provides guidance for the use of molecular genetic testing in combination with the 2017 clinical diagnostic criteria in children presenting with EDS characteristics.

Subtle differences in autonomic symptoms in people diagnosed with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders

The hypermobile Ehlers-Danlos syndrome (hEDS) GENE study is a multicenter, cohort study with the goal to identify genes associated with hypermobile EDS. Of the 148 people enrolled in the hEDS GENE study, 98 meet the 2017 hEDS criteria, 27 have a hypermobility spectrum disorder (HSD) and 23 are asymptomatic family members. More than 80% of participants are female with an average age of 41 years. Each participant has completed seven questionnaires to quantify disease-related symptomatology. People with hypermobility experience a variety of physical and somatic symptoms, especially in the areas of fatigue, kinesiophobia, gastrointestinal, and autonomic function. These cause a significant decrease in health-related quality of life. The frequency and severity of most symptoms were indistinguishable between participants with hEDS and HSD; however, there were significant differences in autonomic symptoms. Less than 20% of participants had autoantibodies known to be associated with dysautonomia. Subtle symptomatic differences in people meeting the 2017 diagnostic criteria suggest focusing further etiologic studies on autonomic pathways.

Lingual Frenulum Phenotypes in Brazilian Infants With Congenital Zika Syndrome

Objective:

The present study aimed to evaluate lingual frenulum in children affected by congenital Zika syndrome (CZS) and to analyze the association of lingual frenulum phenotypes with other variables.

Design:

This present work had a cross-sectional, descriptive study design.

Setting:

This study was carried out in Fortaleza (Brazil). The health professionals provided tertiary level of care. Data collection occurred during a multidisciplinary task force for evaluating infants affected by CZS in December 2 to 3, 2016.

Patients:

Fifty-four patients with CZS (1-12 months old; 32 girls and 22 boys) were recruited from a population of 70 infants.

Interventions:

A multidisciplinary group comprised of speech-language pathologist/audiologists and pediatric dentists evaluated all patients through an intraoral examination and a specific tongue maneuver protocol for infants.

Main Outcome Measures:

Lingual frenulum visibility was the primary outcome measure. Before initiating the study, we hypothesized that children with CZS had an absent lingual frenulum.

Results:

Lingual frenula were visible in 34 (63%) infants, whereas in 20 (37%) infants lingual frenula visibility required a specific maneuver to retract the tongue. Six of 20 infants presented posteriorly positioned lingual frenula that were visible after maneuver. Lingual frenula were covered by mucous tissue in 14 infants. Presence of posterior frenulum was associated with dysphagia ( P = 0.038). However, the presence of dysphagia in a multivariate model did not associate with the presence of a posterior lingual frenulum ( P = .069) or neurologic symptoms ( P = .056).

Conclusion:

Children with CZS showed predominance of a posterior lingual frenula covered by an overlapping curtain-like mucous membrane.

EDS IV (Acrogeria): New Autosomal Dominant and Recessive Types

Evidence is presented that type IV of the Ehlers-Danlos syndrome (EDS IV) is genetically variable. A benign autosomal dominant form and two autosomal recessive variants are described with clinical and biochemical features that are distinct from classical acrogeria.

Skeletal muscle morphology, protein synthesis, and gene expression in Ehlers-Danlos syndrome

Patients with Ehlers-Danlos syndrome (EDS) are known to have genetically impaired connective tissue and skeletal muscle symptoms in form of pain, fatigue, and cramps; however earlier studies have not been able to link these symptoms to morphological muscle changes. We obtained skeletal muscle biopsies in patients with classic EDS [cEDS; n = 5 (Denmark)+ 8 (The Netherlands)] and vascular EDS (vEDS; n = 3) and analyzed muscle fiber morphology and content (Western blotting and muscle fiber type/area distributions) and muscle mRNA expression and protein synthesis rate (RT-PCR and stable isotope technique). The cEDS patients did not differ from healthy controls (n = 7-11) with regard to muscle fiber type/area, myosin/α-actin ratio, muscle protein synthesis rate, or mRNA expression. In contrast, the vEDS patients demonstrated higher expression of matrix proteins compared with cEDS patients (fibronectin and MMP-2). The cEDS patients had surprisingly normal muscle morphology and protein synthesis, whereas vEDS patients demonstrated higher mRNA expression for extracellular matrix remodeling in skeletal musculature compared with cEDS patients.NEW & NOTEWORTHY This study is the first of its kind to systematically investigate muscle biopsies from Ehlers-Danlos patients, focusing on muscle structure and function. These patients suffer from severe muscle symptoms, but in our study they show surprisingly normal muscle findings, which points toward indirect muscle symptoms originating from the surrounding connective tissue. These findings have basal physiological importance and implications for future physiotherapeutic treatment options for these patients.

Voermans N. Neurological manifestations of Ehlers-Danlos syndrome(s): A review

The term "Ehlers-Danlos syndrome" (EDS) groups together an increasing number of heritable connective tissue disorders mainly featuring joint hypermobility and related complications, dermal dysplasia with abnormal skin texture and repair, and variable range of the hollow organ and vascular dysfunctions. Although the nervous system is not considered a primary target of the underlying molecular defect, recently, increasing attention has been posed on neurological manifestations of EDSs, such as musculoskeletal pain, fatigue, headache, muscle weakness and paresthesias. Here, a comprehensive overview of neurological findings of these conditions is presented primarily intended for the clinical neurologist. Features are organized under various subheadings, including pain, fatigue, headache, stroke and cerebrovascular disease, brain and spine structural anomalies, epilepsy, muscular findings, neuropathy and developmental features. The emerging picture defines a wide spectrum of neurological manifestations that are unexpectedly common and potentially disabling. Their evaluation and correct interpretation by the clinical neurologist is crucial for avoiding superfluous investigations, wrong therapies, and inappropriate referral. A set of basic tools for patient's recognition is offered for raising awareness among neurologists on this underdiagnosed group of hereditary disorders.

The Pinch Rhytidectomy: A Safe, Effective, "Low SMAS" Variation on the Theme

BACKGROUND

The competitive efficacy of the superficial musculoaponeurotic system (SMAS) rhytidectomy (SMASectomy) facelift has been well established. However, the outcomes after an associated open necklift have not been as reliable; the persistent incidence of recurrent bands and iatrogenic deformities has prompted a change in technique.

OBJECTIVES

The author conducted a long-term retrospective review to evaluate a variation on the SMASectomy facelift technique. A solely lateral, "low SMAS" approach was substituted for direct necklift in all patients.

METHODS

Patients who were candidates for a facelift underwent this laterally based, SMASectomy technique. Those who underwent concomitant full-face CO2 laser resurfacing were excluded from the review. A total of 198 patients treated consecutively during a 7-year period (2006-2012) were included in the study.

RESULTS

Postoperative follow-up ranged from 1 to 7 years. All patients' neck deformities were fully corrected by the solely lateral SMASectomy technique. In addition, the patients recovered more rapidly than with traditional direct necklift, with no nerve injuries, skin compromise, or hypertrophic scarring.

CONCLUSIONS

Results indicate that midline open necklift can be replaced by the low SMASectomy.

LEVEL OF EVIDENCE

4.

Tenascin-X, collagen, and Ehlers-Danlos syndrome: tenascin-X gene defects can protect against adverse cardiovascular events

Long thought to be two separate syndromes, Ehlers-Danlos syndrome hypermobility type (EDS-HT) and benign joint hypermobility syndrome (BJHS) appear on close examination to represent the same syndrome, with virtually identical clinical manifestations. While both EDS-HT and BJHS were long thought to lack the genetic loci of other connective tissue disorders, including all other types of EDS, researchers have discovered a genetic locus that accounts for manifestations of both EDS-HT and BJHS in a small population of patients. However, given the modest sample size of these studies and the strong correlation between serum levels of tenascin-X with clinical symptoms of both EDS-HT and BJHS, strong evidence exists for the origins of both types of hypermobility originating in haploinsufficiency or deficiency of the gene TNXB, responsible for tenascin-X. Tenascin-X regulates both the structure and stability of elastic fibers and organizes collagen fibrils in the extra-cellular matrix (ECM), impacting the rigidity or elasticity of virtually every cell in the body. While the impacts of tenascin-X insufficiency or deficiency on the skin and joints have received some attention, its potential cardiovascular impacts remain relatively unexplored. Here we set forth two novel hypotheses. First, TNXB haploinsufficiency or deficiency causes the range of clinical manifestations long identified with both EDS-HT and BJHS. And, second, that haploinsufficiency or deficiency of TNXB may provide some benefits against adverse cardiovascular events, including heart attack and stroke, by lowering levels of arterial stiffness associated with aging, as well as by enhancing accommodation of accrued atherosclerotic plaques. This two-fold hypothesis provides insights into the mechanisms underlying the syndromes previous identified with joint hypermobility, at the same time the hypothesis also sheds light on the role of the composition of the extracellular matrix and its impacts on endothelial sheer stress in adverse cardiovascular events.

Joint hypermobility as a distinctive feature in the differential diagnosis of myopathies

Congenital and adult-onset inherited myopathies represent a wide spectrum of syndromes. Classification is based upon clinical features and biochemical and genetic defects. Joint hypermobility is one of the distinctive clinical features that has often been underrecognized so far. We therefore present an overview of myopathies associated with joint hypermobility: Ullrich congenital muscular dystrophy, Bethlem myopathy, congenital muscular dystrophy with joint hyperlaxity, multi-minicore disease, central core disease, and limb girdle muscular dystrophy 2E with joint hyperlaxity and contractures. We shortly discuss a second group of disorders characterised by both muscular features and joint hypermobility: the inherited disorders of connective tissue Ehlers-Danlos syndrome and Marfan syndrome. Furthermore, we will briefly discuss the extent and pattern of joint hypermobility in these myopathies and connective tissue disorders and propose two grading scales commonly used to score the severity of joint hypermobility. We will conclude focusing on the various molecules involved in these disorders and on their role and interactions in muscle and tendon, with a view to further elucidate the pathophysiology of combined hypermobility and myopathy. Hopefully, this review will contribute to enhanced recognition of joint hypermobility and thus be of aid in differential diagnosis.

[Ehlers-Danlos syndrome and bilateral, dystrophic breast calcifications]

Diagnostic investigations of mammary glands, which are routinely undertaken prior to a planned liver transplantation, can place high demands on the radiologist. The article describes a case of known Ehlers-Danlos syndrome, where it was essential that the radiologist was sufficiently informed over the past history, possible previously made images and typical presentation forms of microcalcification for corresponding findings from the breast diagnostics.

Ehlers-Danlos Syndrome in Athletes

Ehlers-Danlos syndrome (EDS) should be considered in the evaluation of the hypermobile athlete. EDS is a group of inheritable connective tissue disorders affecting collagen and is characterized by articular hypermobility, skin extensibility, and tissue fragility. The most common findings in the active athlete are joint pain or instability, tissue fragility, or joint dislocations. Other common findings include "cigarette paper" scarring over bony prominences, pes planus, mitral valve prolapse, hyperelastic thin skin, and internal organ involvement. The vascular type has an increased risk of sudden death secondary to catastrophic events such as aortic or visceral rupture. Although there are some genetic laboratory tests currently available, a careful history and physical examination are most helpful in diagnosing athletes with this disorder. Previous classification systems were confusing, but the 1997 revised nosology simplified the classification of EDS into six types (three major, three minor). Preparticipation cardiothoracic and orthopedic screening is highly recommended for athletes with EDS, and appropriate cardiovascular, orthopedic, gastrointestinal, neurologic, and dermatologic management can often allow patients with EDS to remain active.

Generalized Joint Hypermobility and Its Relationship to Injury Patterns Among NCAA Lacrosse Players

OBJECTIVE

To prospectively observe and compare injury patterns between hypermobile and nonhypermobile NCAA athletes.

DESIGN AND SETTING

Athletes were screened for generalized joint hypermobility before the 1995 lacrosse season. Injuries were recorded through the end of the postseason and compared in hypermobile and nonhypermobile athletes.

SUBJECTS

A total of 310 male and female volunteers from 17 lacrosse teams participated in the study.

MEASUREMENTS

Hypermobility was evaluated with the technique of Carter and Wilkinson (as modified by Beighton and colleagues), which uses 9 joint measurements to assess global joint mobility. For an athlete to be considered hypermobile, 5/9 of these measurements must have been positive. Next, certified athletic trainers prospectively recorded injuries and hours of practice and game participation on a standard form. After the season, all data forms were returned to us for analysis. Significance was set at P = .05, and x(2) and independent t tests were used to compare injuries between groups.

RESULTS

Twenty of 147 men (13.6%) and 54 of 163 women (33.1%) were hypermobile, yielding an overall hypermobility prevalence of 23.8%. One hundred athletes sustained 134 injuries. There were no significant differences in overall injury rate among hypermobile (2.29/1000 hours) compared with nonhypermobile (3.54/1000 hours) athletes. Nonhypermobile athletes suffered contact injuries at a higher rate (1.38/1000 hours) than hypermobile athletes (0.52/1000 hours). Hypermobile athletes showed an increased rate of ankle injuries, and nonhypermobile athletes showed a trend toward an increased rate of strains. Multiple approaches to analysis of the data revealed no other significant findings.

CONCLUSIONS

There was no difference in overall injury rates between hypermobile and nonhypermobile athletes in this sample. This finding is somewhat surprising in light of significant evidence that hypermobility appears to be a factor in joint complaints among nonathletes. Additional research is needed to clearly determine whether a relationship exists between hypermobility and injury rates among athletes.

The early results of the Brunelli procedure for trapeziometacarpal instability

We report the results of Brunelli's abductor pollicis longus transfer for symptomatic instability of the trapeziometacarpal joint in 15 hands (14 patients) at a mean follow-up of 21 months. Patients were assessed subjectively, and objectively by an independent observer. All but one of the patients were very satisfied with the result of the operation, including the six patients who had significant degeneration of the carpometacarpal joint surface preoperatively. Four patients said they had no pain and the mean pain score overall on a visual analogue scale was 1.2 (out of a maximum of 10). Overall the outcome was rated good or excellent in 11 of the 15 thumbs.

Hereditary epidermolytic palmoplantar keratoderma (Vörner type) in a family with Ehlers-Danlos syndrome

We describe a kindred in whom epidermolytic palmoplantar keratoderma occurred in association with Ehlers-Danlos syndrome type III (benign hypermobility syndrome). This kindred consisted of 27 members of four generations, 14 of whom had palmoplantar keratoderma (PPK). Of those who had palmoplantar keratoderma, 6 had Ehlers-Danlos type III (EDS II). The proband presented with diffuse, symmetrical hyperkeratotic plaques that were yellow and sharply demarcated, covering the entire palms and soles, in addition to marked large and small joint flexibility and skin hyperextensibility. A biopsy specimen from the palm revealed features of epidermolytic hyperkeratosis with acanthosis. To our knowledge, this is the first report of PPK in a family with Ehlers-Danlos syndrome. Linkage analysis of these two clinical traits showed that the genes responsible for PPK and EDS III are not closely linked, and therefore are not immediately adjacent. However, linkage at greater genetic distances could not be excluded.

Polycystic kidney disease, biliary dysgenesis in a patient with Larsen's syndrome

Larsen's syndrome is characterised by multiple joint dislocations, flat face and talipes equinovarus. There is an autosomal dominant form and also a more severe autosomal recessive form. Several types of polycystic kidney disease have been reported in children. In this report we present an infant with a severe form of Larsen's syndrome (thought to be lethal Larsen-like), infantile-type polycystic kidney disease, biliary dysgenesis and osteosclerosis.

Mutations in the COL5A1 gene are causal in the Ehlers-Danlos syndromes I and II

The Ehlers-Danlos syndrome (EDS) is a heterogeneous connective-tissue disorder of which at least nine subtypes are recognized. Considerable clinical overlap exists between the EDS I and II subtypes, suggesting that both are allelic disorders. Recent evidence based on linkage and transgenic mice studies suggest that collagen V is causally involved in human EDS. Collagen V forms heterotypic fibrils with collagen I in many tissues and plays an important role in collagen I fibrillogenesis. We have identified a mutation in COL5A1, the gene encoding the pro(alpha)1(V) collagen chain, segregating with EDS I in a four-generation family. The mutation causes the substitution of the most 5' cysteine residue by a serine within a highly conserved sequence of the pro(alpha)1(V) C-propeptide domain and causes reduction of collagen V by preventing incorporation of the mutant pro(alpha)1(V) chains in the collagen V trimers. In addition, we have detected splicing defects in the COL5A1 gene in a patient with EDS I and in a family with EDS II. These findings confirm the causal role of collagen V in at least a subgroup of EDS I, prove that EDS I and II are allelic conditions, and represent a, so far, unique example of a human collagen disorder caused by substitution of a highly conserved cysteine residue in the C-propeptide domain of a fibrillar collagen.

Dynamic swan neck deformity in a patient with Ehlers-Danlos syndrome

A patient with type I Ehlers–Danlos syndrome with a congenital hand deformity described as a “dynamic swan neck deformity” is presented and causes of the deformity are discussed.

Ehlers-Danlos syndrome: recent advances and current understanding of the clinical and genetic heterogeneity

The Ehlers-Danlos syndrome (EDS) is a heterogeneous group of generalized connective tissue disorders, the major manifestations of which are skin fragility, skin hyperextensibility, and joint hypermobility. The clinical and molecular definition of more than ten types of EDS has, more than ever, emphasized the importance of correct diagnosis because the natural history and mode of inheritance differ among the types. Unfortunately, much of the older literature does not differentiate among the types clearly, and in some instances the life-threatening complications of EDS type IV may be cited as characteristic of the syndrome as a whole. Heterogeneity in EDS began to be appreciated about 30 years ago when the core of the modern classification was developed by Barabas. Since then it was extended by Beighton et al, and then amplified with the insights provided by biochemical and molecular genetic studies. Clinical studies were sufficient initially to distinguish five types of EDS; biochemical studies identified four additional types, EDS type VI, EDS type VII, EDS type IX, and EDS type X, whereas clinical criteria distinguished EDS type VIII. In the following sections, the clinical manifestations of the different forms of EDS are summarized and the known biochemical and molecular genetic features are emphasized.

Pathomorphological and biochemical alterations in Ehlers-Danlos-syndrome type IV

We are reporting the morphological and biochemical data of a patient with the characteristic features of the Ehlers-Danlos-Syndrome Type IV (Sack-Barabas Type) who died acutely after an episode of recurrent ruptures of the bowel with subsequent septic peritonitis. Morphologically, the connective tissue of the vessel walls, the dermis and the connective tissue of internal organs, particularly that of liver and lung, showed a distinct hypoplasia of the collagenous scaffold. Collagen fibers were irregularly arranged which was also corroborated by ultrastructural examination of the collagen fibrils of the dermis and of intervertebral disc material. Immunohistochemically, a loss in the staining intensity for collagen III could be observed in all locations. In contrast, the localization of collagen I, IV, V and VI appeared normal, although with some reduced staining intensity which particularly held true for collagen I in the dermis and vessel wall. The biochemical content of collagen III in lung and liver tissue was significantly reduced when compared to control tissues. Accordingly, in the pool of newly synthesized collagen from skin fibroblasts, only minute amounts of collagen III could be found which was normally secreted and had a normal electrophoretic migration.

Diseases and disorders of muscle

Muscle may suffer from a number of diseases or disorders, some being fatal to humans and animals. Their management or treatment depends on correct diagnosis. Although no single method may be used to identify all diseases, recognition depends on the following diagnostic procedures: (1) history and clinical examination, (2) blood biochemistry, (3) electromyography, (4) muscle biopsy, (5) nuclear magnetic resonance, (6) measurement of muscle cross-sectional area, (7) tests of muscle function, (8) provocation tests, and (9) studies on protein turnover. One or all of these procedures may prove helpful in diagnosis, but even then identification of the disorder may not be possible. Nevertheless, each of these procedures can provide useful information. Among the most common diseases in muscle are the muscular dystrophies, in which the newly identified muscle protein dystrophin is either absent or present at less than normal amounts in both Duchenne and Becker's muscular dystrophy. Although the identification of dystrophin represents a major breakthrough, treatment has not progressed to the experimental stage. Other major diseases of muscle include the inflammatory myopathies and neuropathies. Atrophy and hypertrophy of muscle and the relationship of aging, exercise, and fatigue all add to our understanding of the behavior of normal and abnormal muscle. Some other interesting related diseases and disorders of muscle include myasthenia gravis, muscular dysgenesis, and myclonus. Disorders of energy metabolism include those caused by abnormal glycolysis (Von Gierke's, Pompe's, Cori-Forbes, Andersen's, McArdle's, Hers', and Tauri's diseases) and by the acquired diseases of glycolysis (disorders of mitochondrial oxidation). Still other diseases associated with abnormal energy metabolism include lipid-related disorders (carnitine and carnitine palmitoyl-transferase deficiencies) and myotonic syndromes (myotonia congenita, paramyotonia congenita, hypokalemic and hyperkalemic periodic paralysis, and malignant hyperexia). Diseases of the connective tissues discussed include those of nutritional origin (scurvy, lathyrism, starvation, and protein deficiency), the genetic diseases (dermatosparaxis, Ehlers-Danlos syndrome, osteogenesis imperfecta, Marfan syndrome, homocystinuria, alcaptonuria, epidermolysis bullosa, rheumatoid arthritis in humans, polyarthritis in swine, Aleutian disease of mink, and the several types of systemic lupus erythematosus) and the acquired diseases of connective tissues (abnormal calcification, systemic sclerosis, interstitial lung disease, hepatic fibrosis, and carcinomas of the connective tissues). Several of the diseases of connective tissues may prove to be useful models for determining the relationship of collagen to meat tenderness and its other physical properties. Several other promising models for studying the nutrition-related disorders and the quality-related characteristics of meat are also reviewed.

Ehlers-Danlos syndrome type IV: phenotypic consequences of a splicing mutation in one COL3A1 allele

The features of a child with Ehlers-Danlos syndrome type IV (EDS IV) resulting from a mutation in one COL3A1 allele were studied. The child was heterozygous for a G- to A-transition at the splice donor site of intron 41. It resulted in the splicing out of the exon 41 encoded sequence from alpha 1(III) mRNA and the deletion of 36 amino acids from glycine775 to lysine810 of the triple helical domain of alpha 1(III) chains of type III collagen. The amount of type III collagen in the dermis was only about 11% of normal. The child had the acrogeric form of EDS IV. He had the characteristic facies with a pinched nose, thin lips, and prominent eyes. These facial features, his aesthenic build, thin skin, prominent subcutaneous veins, and aged hands produced a 'cachectic' appearance. These features were evident in early childhood and worsened up to 12 1/2 years when he was last reviewed. Spontaneous bruising, bleeding from the large bowel, constipation, and delayed gastric emptying were other features. In cross section, the dermal collagen fibrils were round and measured 93.3 +/- 11.5 nm in diameter which was not significantly different from control values of 102.5 +/- 13.4 nm. The serum type III procollagen amino-terminal propeptide level of 25.5 ng/ml was within the normal age matched values of 15.5 +/- 7.7 ng/ml despite the low production of type III collagen by cultured fibroblasts. The child probably had a spontaneous new mutation in one COL3A1 allele as only normal sequences were obtained from the corresponding amplified region of the parent's leucocyte DNA.

Intractable vasculitis, resorptive osteolysis, and immunity to type I collagen in type VIII Ehlers-Danlos syndrome

A unique patient with type VIII Ehlers-Danlos syndrome and cutaneous vasculitis, resorptive osteolysis, and cardiac valvular disease is described. Collagen analyses identified morphologic and physical abnormalities of type I collagen. The patient's T lymphocytes could be propagated in vitro with type I collagen and produced a 60-kd lymphokine that bound this protein. Cellular autoimmunity to type I collagen may be responsible for this patient's intractable clinical condition.

Platelet and coagulation studies in Ehlers-Danlos syndrome

Fifty-one patients with Ehlers-Danlos syndrome were investigated for abnormalities of platelets and coagulation. Thirty-eight were examined prospectively and 13 retrospectively. A bleeding history was taken from all patients; only four (8%) gave no history of a bruising or bleeding tendency. Nine patients (18%) had significant haemostatic abnormalities of whom four (8%) had a platelet release defect, three (6%) had a factor XI deficiency and two (4%) had a factor XIII deficiency. Additionally 16 patients (31%) had mild abnormalities of uncertain significance of whom four (8%) had prolonged bleeding times (three in association with platelet aggregation abnormalities), 13 (26%) had platelet aggregation abnormalities and two had a positive Hess test. Twenty-four patients (47%) had normal tests for haemostasis of whom 20 (39%) had a bleeding diathesis and four (8%) had no such tendency. Results were analysed according to the type of Ehlers-Danlos syndrome, but there was no pattern to the abnormalities. The high frequency of a bleeding tendency in Ehlers-Danlos patients with normal tests for haemostasis (83%) supports the conventional explanation for this clinical feature, that defects in the structural integrity of skin and blood vessels lead to easy bruising.

Multiple congenital aneurysms of unknown origin

A case is reported of an 18-year-old man with a syndrome of multiple aneurysms of unknown origin. Several interventions were necessary over a 30-year-period, mainly for haemodynamic reasons or compression. A review of the literature revealed seven similar cases, two of which had Ehlers-Danlos Syndrome.

Syndromology: an updated conceptual overview. X. References

Part X is the reference section for Parts I through VIII which appeared in the four previous issues of the journal and Part IX which appears in this issue. The reference section itself is divided into two parts. The first part provides general references of selected topics for the interested reader. The second part consists of an alphabetical listing of all references cited in Parts I through IX.

Multiple hollow organ dysplasia in Ehlers-Danlos syndrome

We report a case of Ehlers-Danlos syndrome with a number of rare, hazard-creating organ dysplasias such as colon diverticula causing spontaneous perforation, bladder diverticula, bile duct diverticula, and multiple aneurysma formations of the arteries.

Clinico-neurological investigations in the fra(X) form of mental retardation

A clinical, neurological and electroencephalographic investigation was undertaken in 29 previously cytogenetically verified hemizygous males with the fra(X) form of mental retardation (age range 3.5 to 59 years); in addition, 6 heterozygous females were examined. All male patients displayed the known physical aspects of this syndrome together with associated abnormalities of the palate, skeleton, connective tissue and endocrine system. The most prominent neurological features were different forms of oculomotor disturbances, minor motor and pyramidal signs, incoordination, muscle hypotonia, gait and speech abnormalities. There was no increased frequency either in seizures or in epileptic EEG discharges. Some patients had a slowing of background activity in EEG. About 50% of all patients displayed autistic-like behaviour, short attention span and/or hyperactivity. In accordance with the literature, the findings indicate that there are no neurological, electroencephalographic or neuroradiological features which occur specifically in this syndrome. The need to differentiate the findings from those resulting from encephalopathic mechanisms during the gestational and perinatal period is stressed. A distinct typing of seizures and EEG changes is needed in each patient, before definite conclusions about an association of seizures and fra(X) syndrome are drawn. In view of the lack of correlation between IQ and the clinical-neurological measures, a more practical approach to quantifying the mental impairment is proposed.

Oral manifestations of Ehlers-Danlos syndrome: report of case

First described in the beginning of this century, Ehlers-Danlos syndrome is a hereditary connective tissue disorder. This case report describes an 11-year-old girl who had frequent unexplainable bruises. During an initial orthodontic evaluation, characteristic symptoms were spotted, and a subsequent diagnosis made.

Complications of pregnancy and benign familial joint hyperlaxity

A family is described in which four generations were affected by benign familial joint hyperlaxity and, in the two generations for which obstetric data were available, pregnancies were complicated by unexplained mid-trimester vaginal bleeding. This prompted a study to determine whether unexplained antepartum haemorrhage (APH) and premature rupture of the membranes (PROM) both of which might reflect the structure of fetal collagen, were associated with joint hyperlaxity in offspring. The joint hyperlaxity of children born from such pregnancies was slightly greater than that found in age matched children born from uncomplicated pregnancies.

Spontaneous carotid-cavernous fistula and multiple arterial dissections in type IV Ehlers-Danlos syndrome. Case report

A 43-year-old woman without phenotypic expression of Ehlers-Danlos syndrome developed a spontaneous unilateral carotid-cavernous fistula (CCF). Attempts at balloon occlusion of the CCF were unsuccessful, and caused multiple arterial dissections and lacerations eventually leading to massive retroperitoneal hemorrhage and death. The CCF was demonstrated during postmortem studies. In addition, the patient had independent dissections of the internal carotid artery at the site of the fistula and an intracavernous aneurysm of the contralateral internal carotid artery. Despite widespread dissections, the major arteries showed only mild histological abnormalities. Morphometric analysis of collagen from the aorta revealed an increase in large-sized fibers, consistent with deficiency of Type III collagen.

Cardiovascular complications in the Ehlers-Danlos syndrome with minimal external findings

Ehlers-Danlos syndrome (EDS) is clinically and genetically a heterogeneous disorder of connective tissue. Eleven different types of EDS have been documented, several of which have major cardiovascular complications as part of their clinical manifestations. The purpose of this report is to call attention to a form of EDS with minimal external features but severe internal vascular complications.

The differential symptomatology of errors of collagen metabolism: a tentative classification

We address the confusion in the current classification of inherited disorders of collagen and the excessive extension of the concept of the Ehlers-Danlos "syndrome" that tends to cover many facts and conditions frequently without strong clinical connection. We propose to subdivide the collagen disorders into four main classes depending on whether skin, joints, bone, or blood vessels are mainly involved. The class with mainly skin involvement includes the different forms of cutis laxa, Ehlers-Danlos syndrome types I and II (autosomal dominant), types V and IX (X-linked recessive), type VI (autosomal recessive), and type VIII (autosomal dominant). The group with mainly articular involvement includes Larsen and related syndromes and other types with a more benign course. The conditions with mainly skeletal involvement include the different forms of osteogenesis imperfecta. The class with mainly blood vessel involvement includes disorders of type III collagen and the Marfan syndrome. This tentative classification proposes a logical clinical framework that will allow easier integration of molecular biology data.

A clinical review of the hyperlaxity of joints with particular reference to osteoarthrosis

The range of observed movement at a given joint varies with a gaussian distribution throughout the population. Individuals whose joints display an unusually high degree of laxity are susceptible to a variety of rheumatic and orthopaedic symptoms. The impression that such individuals develop premature osteoarthrosis is a strong one, but hard to prove. In addition, certain individuals with inherited abnormalities of connective tissue are undoubtedly at risk of accelerated osteoarthrosis.

The observed range of movement at a joint is determined by a variety of factors. The main ones are the muscular tone, the laxity of the collagen that contributes to the joint capsule and surrounding structures, and the shape of the articulating bony surfaces. The first of these is probably neurologically mediated, the latter two are usually genetically determined. In a majority of cases it is probably the mechanical joint instability that produces the articular damage, though the alternative hypothesis is that the osteoarthrosis is initiated by genetic aberrations in the collagen that coincidentally cause lax joints. Clinical and family studies using the Leeds Hyperextensometer will help to clarify this and it remains a possibility that genetic markers may point to those individuals who will be at particular risk of osteoarthrosis should joint hyperlaxity develop.

X-linked Ehlers-Danlos syndrome type V; the next generation

Two English families with the X-linked form (Type V) of the Ehlers-Danlos syndrome (EDS) who were investigated almost 20 years ago have been re-studied. In one family, the potentially heterozygous sister of 3 affected brothers had born two sons, of whom one has EDS. The 3 brothers had all procreated, producing a total of 2 sons and 3 daughters, all of whom are clinically normal. These pedigree data provide further evidence to support the syndromic identity and X-linked mode of inheritance of this form of the EDS. In the second family, two affected brothers had both procreated; one had produced three normal offspring, while the other had a son with soft extensible skin and a daughter with articular hypermobility. The syndromic status of this kindred is uncertain. Serum copper and ceruloplasmin concentrations in affected males and obligate carrier females in both families were normal. Cytogenetic investigations, including high resolution banding, yielded normal results.

Presumed homozygous Ehlers-Danlos syndrome type I in a highly inbred kindred

While studying an extended family of individuals with the Ehlers-Danlos (ED) syndrome type I, we found an affected male who was born to 2 affected consanguineous parents. This man had a more severe condition than that of his other affected relatives. Moreover, all 6 of his children were affected. Taking the pedigree data into account, the conditional probability of homozygosity for the ED gene in that patient was calculated as 97%. Some problems of the clinical and genetic approach to the recognition of the homozygous state in the ED syndrome are discussed using this family as an example.

Orthodontic treatment in Ehlers-Danlos syndrome

The literature is briefly reviewed and the presentation and orthodontic treatment of a patient with Ehlers-Danlos syndrome is described. Surprisingly, in view of the nature of this collagen disorder, tooth movement appeared to progress normally; there was, however, a problem of mucosal ulceration which was alleviated through regular use of chlorhexidine mouthwash.

An unbalanced (6q;13q) translocation in a male with clinical features of Ehlers-Danlos type II syndrome

Ehlers-Danlos syndrome has been divided into several different types according to the variety and severity of clinical manifestations, and may follow autosomal dominant, autosomal recessive, or X linked patterns of inheritance. Only rarely have chromosome anomalies been seen in patients manifesting phenotypic features of the syndrome and most are considered insignificant. However, one case report involved a balanced t(9;17)(q34;q11) in a female with the clinical features of Ehlers-Danlos type I and IV syndromes and, as noted by McKusick: "It is possible, furthermore, that certain very rare syndromes that are transmitted in a Mendelian manner are the result of small chromosome aberrations, such as deletion or inversion, affecting the action of several genes". We present a 14 year old male with features of Ehlers-Danlos type II syndrome and an unbalanced (6q;13q) translocation.

An unusual connective tissue disease in mother and son: a "new" type of Ehlers-Danlos syndrome?

A 23-year-old woman and her 2 1/2-year-old son both had large hernias, positional foot deformities, abnormal thoracic shape, asthma, and severe eczematoid dermatitis. Their facial appearance was quite similar and included asymmetry with prominent nasal bridge and small jaw. In addition, the mother had severe thoracolumbar kyphoscolosis and "cigarette paper" scars over her legs. She died after rupture of a a thoracic aortic aneurysm and was found on postmortem examination to have cystic medionecrosis of the aorta and myxomatous degeneration and elongation of the mitral and tricuspid valves. The family history was otherwise negative; there was no consanguinity. The connective tissue disease in this mother and her son appears to be a previously unrecognized dominantly-inherited disorder with some similarity to classical Ehlers-Danlos syndrome.

Familial acrogeria (Gottron)

A mother and her oldest son suffering from acrogeria are described; in the mother the disease was complicated by elastosis perforans serpiginosa. Microscopic and ultramicroscopic details are given.