Investigation of dermal collagen nanostructures in Ehlers-Danlos Syndrome (EDS) patients

Ehlers-Danlos syndromes (EDS) represent a group of rare genetic disorders affecting connective tissues. Globally, approximately 1.5 million individuals suffer from EDS, with 10,000 reported cases in Canada alone. Understanding the histological properties of collagen in EDS has been challenging, but advanced techniques like atomic force microscopy (AFM) have opened up new possibilities for label-free skin imaging. This approach, which explores Type I collagen fibrils at the nanoscale, could potentially enhance EDS diagnosis and our knowledge of collagen type I-related connective tissue disorders. In the current study, we have employed AFM to examine ex-vivo skin biopsies from four individuals: one with classical EDS (cEDS), one with hypermobile EDS (hEDS), one with hEDS and Scleroderma (hEDS-Scleroderma), and one healthy control. Picrosirius red (PS) staining was used to highlight collagen differences in the samples. For each case, 14 images and 1400 force curves were obtained, with seven images and 700 force curves representing healthy collagen (PS-induced red staining) and the rest showcasing disrupted collagen (yellow staining). The results showed that PS staining was uniform throughout the control section, while cEDS and hEDS displayed localized areas of yellow staining. In the case of hEDS-Scleroderma, the yellow staining was widespread throughout the section. AFM images revealed irregular collagen fibrils in the disrupted, yellow-stained areas, contrasting with aligned and well-registered collagen fibrils in healthy, red-stained regions. Additionally, the study assessed the ability of non-AFM specialists to differentiate between healthy and disrupted collagen in AFM images, yielding substantial agreement among raters according to Fleiss's and Cohen's kappa scores (0.96 and 0.79±0.1, respectively). Biomechanical analysis revealed that normal healthy collagen exhibited a predominant population at 2.5 GPa. In contrast, EDS-affected collagen displayed subpopulations with lower compressive elastic modulus, indicating weaker collagen fibrils in EDS patients. Although these findings pertain to a limited number of cases, they offer valuable insights into the nanoscale collagen structure and biomechanics in individuals with EDS. Over time, these insights could be developed into specific biomarkers for the condition, improving diagnosis and treatment for EDS and related connective tissue disorders.

Lower urinary tract involvement in Ehlers-Danlos and Joint Hypermobility syndromes: Review of the literature

INTRODUCTION

Ehlers-Danlos syndrome (EDS) and Joint Hypermobility syndrome (JHS) are still poorly understood, with a prevalence of 1/5000 for EDS and 1/500 for JHS. They are characterized by multisystem involvement. Urological involvement has been little studied. The aim was to carry out a review of the literature on the urological involvement of EDS and JHS.

METHOD

A review of the literature was carried out using the following databases: Pubmed, Canadian Hospitals and EMBASE. Search terms were "Ehlers-Danlos" or "Joint Hypermobility" associated with "Urology", "Bladder", "Pelvic Organ Prolapse", "Urinary Retention", "Leak", "Leakage", "Urinary Incontinence", "Urinary Tract Infection" and "Urdodynamic", no filters were added.

RESULTS

Seventy-three articles were included for a total of 259 found. The prevalence of urinary incontinence in EDS is estimated at 50-60%, and that of pelvic organ prolapse (POP) at 29-75%. Bladder diverticula are also frequently reported. For JHS, the prevalence of urinary incontinence is estimated between 40 and 73%, that of POP increased with 73% of stage greater than 2, g-JHS patients are almost 3 times more affected by prolapses (OR=2.37) which seem more severe. Patients with vesicoureteral reflux, most often severe, are more affected by joint hypermobility (OR=2.79). Few studies have been carried out on urological assessment and treatment modalities.

CONCLUSION

EDS patients often have urinary incontinence, pelvic organ prolapse or bladder diverticula. JHS patients frequently have urinary incontinence, pelvic organ prolapse and vesicoureteral reflux.

Patient and Parent Knowledge, Understanding, and Concerns After a New Diagnosis of Ehlers Danlos Syndrome

Introduction

After diagnosis of Ehlers Danlos Syndrome (EDS), it is unclear what information patients and parents need and understand about EDS. The objective of this study is to characterize patient and parent knowledge and concerns about EDS after a diagnosis of EDS is made to determine patient and parent concerns and identify barriers that cause discomfort with the diagnosis.

Methods

A convenience sample of patient and parent dyads were recruited after new diagnosis of EDS. Patients and parents completed questionnaires that assessed knowledge, comfort, and barriers of EDS before and after diagnosis, EDS education materials accessed, and additional clinical needs and concerns.

Results

Seventy-two dyads completed the survey.

Conclusion

Many respondents actively seek information on the diagnosis and management of EDS. Parents and patients look for information about EDS differently. Parents have more concerns after diagnosis and both want well-constructed, empirically supported educational materials delivered via multiple modalities, which makes clinical guidelines more essential.

Orthognathic Surgery in Ehlers-Danlos Syndrome: Review of the Literature and Case Report

EDS (Ehlers-Danlos Syndrome) is a heterogenous group of inheritable connective tissue disorders that commonly precludes patients from being elective surgical candidates. Patients with EDS are at a higher risk of increased bleeding, delayed wound healing, and temporomandibular joint pain refractory to treatment. Historically, patients with EDS and TMJ disorders are considered inappropriate surgical candidates due to a higher risk of delayed wound healing, increased risk for uncontrolled post-surgical bleeding, and unsubstantiated outcomes in regards to elective orthognathic surgery. A review of the literature demonstrates a paucity of data accounting the use of orthognathic surgery and maxillary-mandibular advancement in patients with EDS. The present study reports on the use of orthognathic double jaw surgery in a patient with a known diagnosis of hypermobile EDS, history of TMJ subluxation and pain. This case describes a 47-year-old woman with a history of hypermobile EDS who presented with Angle Class II malocclusion, Class II skeletal pattern, and clockwise rotation of the occlusal plane associated with pain at the bilateral TMJs. She underwent maxillary-mandibular advancement with counterclockwise rotation of the occlusal plane and genioplasty. The surgery was without complications, and at 22 months follow up, the patient healed uneventfully with improvement of pain and range of motion. This case report demonstrates that with diligent patient selection, orthognathic surgery in patients with EDS can be safe and effective and should not be an absolute contraindication.

No Increase in Acute or Late Radiation Toxicities in Patients With Ehlers-Danlos Syndrome Receiving Adjuvant Breast Radiation Therapy: A Report of Four Cases With Extended Follow-Up

Ehlers-Danlos syndrome (EDS) consists of a heterogeneous group of congenital collagen formation disorders characterised by skin hyperextensibility, atrophic scarring, and generalized joint hypermobility. Collagen vascular disorders have been implicated in increased incidence and severity of radiation toxicities; however, there are limited reports on the safety of radiation therapy with EDS. We identified all patients with EDS who received adjuvant conventional and hypofractionated breast radiation therapy at our institution and reviewed patient, treatment, and toxicity characteristics. Four patients were identified with a median follow-up of 13.2 months. Acute toxicities were limited to grade 1 dermatitis in all four patients. No late toxicities were seen. In this report, radiation therapy to the breast with conventional and hypofractionated regimens resulted in no significant acute or late toxicity.

Barriers to the Diagnosis, Care, and Management of Pediatric Patients With Ehlers-Danlos Syndrome in the United States: A Qualitative Analysis

Objectives: Ehlers-Danlos Syndromes (EDS) are a family of heritable connective tissue diseases. Primary practitioners are capable of diagnosing and managing EDS; however, few are knowledgeable and comfortable enough to see patients with EDS, resulting in delays in diagnosis and care. This study explores the barriers physicians experience with diagnosing, managing, and caring for patients with EDS, and potential resolutions to those barriers. Methods: As part of a larger online study, providers (n = 107) in the United States were asked to specify "What information would improve (their) comfort" in diagnosing, caring for, and managing EDS via open-ended questions. Results: Providers reported wanting clinical practice guidelines, in formats that were easily accessible and usable, information on their roles in the management of EDS, the best ways to coordinate with specialty care, and available specialty consultation. Conclusions: Providers overall are willing to diagnose and treat EDS; however, additional supports and training are needed.

Ankle Skin Defects with Vascular Ehlers-Danlos Syndromes Treated by Posterior Tibial Artery Perforator Flap: A Case Report

CASE

A 46-year-old man with vascular Ehlers-Danlos syndrome (EDS) had an open ankle fracture with a 10 × 5-cm skin defect on the medial side of the ankle. The patient underwent open reduction and internal fixation, as well as coverage of the skin defect with a posterior tibial artery perforator flap, which led to successful outcomes.

CONCLUSION

We present the successful implementation of a posterior tibial artery perforator flap for the reconstruction of skin defects in a patient with vascular EDS. Despite the fragility of soft tissues, favorable surgical outcomes were observed.

Connective tissue disorders and eye: A review and recent updates

Collagen vascular disorders (CVDs), also known as connective tissue diseases (CTDs), are a heterogeneous group of entities that affect the connective tissues and are capable of causing end-organ damage to multiple systems, primarily cardiopulmonary and musculoskeletal. However, the occurrence and severity are highly variable among patients. Ocular involvement occurs in a significant number of these disorders and may precede the onset of other extraocular features, thereby serving as an important marker in the diagnosis of these diseases. A timely and accurate diagnosis enables the management of complications. CTDs are primarily immune-mediated inflammatory diseases; however, classifications have encompassed heritable disorders affecting collagen-containing structures and disorders of vascular development. A review of literature published until 25 January 2022 and collected from various databases using the relevant keywords was conducted. All publications (original articles, review articles, as well as case reports) describing the ocular features in CTDs were studied in detail. The objective of this review is to recognize the common ophthalmic presentations of various autoimmune and heritable CTDs, distinguish them from overlapping diseases, elaborate on the prognosis and management of these varied eye presentations, and deliberate on their impact on other ophthalmic surgeries.

Chiari I malformation management in patients with heritable connective tissue disorders

Background

Chiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges.

Objective

This study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD.

Methods

Patients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26).

Results

38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001).

Conclusions

Patients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.

Development of a Multidisciplinary Clinic for Patients with Ehlers Danlos Syndromes: Considerations and Strategies

Ehlers-Danlos Syndromes (EDS) is a group of connective tissue disorders often encountered within rheumatology clinics and is associated with several overlapping symptoms, which may require attention from other medical subspecialities. Barriers exist to implementing multidisciplinary care for EDS, including a lack of knowledge, comfort, and time managing EDS. In the absence of multidisciplinary care, patients are often forced to self-coordinate care. This can lead to gaps in care and a lack of clarity of medical ownership over the patient's care. Integrated multidisciplinary clinics are sorely needed, but the development and implementation of such clinics is limited by resources and personnel. As such, the development of a multidisciplinary clinic can be daunting and may serve to discourage providers with competencies in EDS from attempting to develop this service. In this editorial, we share our experiences in developing a multidisciplinary clinic for EDS at a moderately-sized children's hospital, relying on several core disciplines with established EDS clinical loads (ie, rheumatology, cardiology, genetics, and psychology). We discuss considerations for the expansion of this service, pitfalls, and barriers throughout the development of the clinic, and our rationale underlying our process-related decisions. Development of a greater number of multidisciplinary EDS clinics, even in the potential absence of larger institutional support, is both possible and imperative for improving EDS care globally.

Gender dysphoria in adolescents with Ehlers-Danlos syndrome

Objectives

Ehlers-Danlos Syndrome represents a family of heritable connective tissue disorders that include joint hypermobility, tissue fragility, and skin hyperextensibility. Ehlers-Danlos Syndrome presents with clinical sequela across multiple body systems that require multidisciplinary care. Little is known about adolescents with Ehlers-Danlos Syndrome who are transgender and gender diverse. To date, there have been no reports of transgender and gender diverse youth in pediatric patients with Ehlers-Danlos Syndrome. The objective of this study was to characterize transgender and gender diverse adolescents with Ehlers-Danlos Syndrome seen in a pediatric multidisciplinary specialty clinic.

Methods

A retrospective chart review was performed and it was found that 28 patients were seen in the Ehlers-Danlos Syndrome multidisciplinary clinic were reported being transgender and gender diverse. Chart review included analysis of all documents in the electronic medical record, including demographic data, gender identity, chosen pronouns, specialty care previously received for Ehlers-Danlos Syndrome, symptoms and conditions related to it, and medications.

Results

Of the 166 total adolescents seen in the pediatric multidisciplinary Ehlers-Danlos Syndrome clinic during the study period, 17% reported gender dysphoria. The average age at Ehlers-Danlos Syndrome diagnosis was 13.5 years (range 8-17 years). Most (61%) reported their gender identity as transgender, followed by nonbinary (14%). Most had preferred male (he/him) pronouns (47%), followed by nonbinary (they/them) pronouns (39%). The vast majority reported fatigue (75%), musculoskeletal issues (96%), psychiatric issues (86%), cardiac issues (71%), gastrointestinal issues (68%), and neurologic issues (79%).

Conclusions

Here we report the first cohort of transgender and gender diverse adolescents in the Ehlers-Danlos syndrome population and show an association between the two. This report increases awareness for providers who care for patients with Ehlers-Danlos Syndrome. As care for those with Ehlers-Danlos Syndrome is often complex and multidisciplinary, providers should adopt practices of gender-affirming medical care that contribute to improved care and outcomes.

Vascular Ehlers-Danlos Syndrome: Pathological Variants, Recent Discoveries, and Theoretical Approaches

Vascular Ehlers-Danlos syndrome (vEDS) is a rare autosomal dominant genetic disorder. It is the most fatal among all types of EDS. In addition to typical EDS characteristics, vEDS patients are at risk of blood vessel rupture due to possession of pathogenic variants of the COL3A1 gene, which encodes type III collagen. Type III collagen is a major component of humans' vascular walls. The management of this disease is possible; however, there is no cure as of present. Recently, discoveries with potential impact on the management of vEDS have been elucidated. Mice with vEDS traits treated with a beta-blocker celiprolol showed significant improvements in their thoracic aorta biomechanical strength. Moreover, it has been demonstrated that the specifically designed small interference RNAs (siRNA) can effectively silence the pathogenic variant allele. To enhance the normal allele expression, an intracellularly expressed lysyl oxidase is shown to regulate the transcription rate of the COL3A1 promoter. Similarly, an embryonic homeobox transcription factor Nanog upregulates the wild-type COL3A1 expression through activation of the transforming growth factor-beta pathway, which increases type III collagen synthesis. Despite numerous advancements, more studies are to be performed to incorporate these discoveries into clinical settings, and eventually, more personalized treatments can be created.

Resource utilization and multidisciplinary care needs for patients with Ehlers-Danlos syndrome

BACKGROUND

Ehlers-Danlos syndrome (EDS) represents a family of heritable connective tissue disorders with overlapping phenotypic features, frequently including joint hypermobility, tissue fragility, and skin hyperextensibility. Comorbid symptoms are common for patients with EDS and include multiple body systems marked by neurologic, cardiovascular, gastrointestinal, musculoskeletal issues, chronic pain, headaches, and anxiety and depression. The many comorbidities lead to high disease burden, which requires greater healthcare utilization.

METHODS

This survey of families examines healthcare utilization, of adults and minors, through evaluation of subspecialty care appointments across many healthcare systems in one region.

RESULTS

There were 155 adults and 83 minors with a diagnosis of EDS with a total of 693 unique visits across 27 different specialties at over 20 different hospitals or clinics in the surveyed area. Cardiology, neurology, and gastroenterology were the most utilized subspecialties for adults, while rheumatology, cardiology, and neurology were most utilized by minors. Many respondents (67%) reported their medical care needs are not being met, and 87% reported interest in a multidisciplinary clinic for EDS with the most interest in pain management, physical and occupational therapy, and rheumatology.

CONCLUSION

Understanding healthcare utilization and needs of those with EDS can provide the foundation for improved care for those with EDS through a coordinated multidisciplinary care model.

Into the Tissues: Extracellular Matrix and Its Artificial Substitutes: Cell Signalling Mechanisms

The existence of orderly structures, such as tissues and organs is made possible by cell adhesion, i.e., the process by which cells attach to neighbouring cells and a supporting substance in the form of the extracellular matrix. The extracellular matrix is a three-dimensional structure composed of collagens, elastin, and various proteoglycans and glycoproteins. It is a storehouse for multiple signalling factors. Cells are informed of their correct connection to the matrix via receptors. Tissue disruption often prevents the natural reconstitution of the matrix. The use of appropriate implants is then required. This review is a compilation of crucial information on the structural and functional features of the extracellular matrix and the complex mechanisms of cell-cell connectivity. The possibilities of regenerating damaged tissues using an artificial matrix substitute are described, detailing the host response to the implant. An important issue is the surface properties of such an implant and the possibilities of their modification.

Patients With Ehlers-Danlos Syndromes Experience Higher Rates of Prosthetic Dislocation After Total Hip Arthroplasty and Worse Implant Survival at 5 Years

INTRODUCTION

Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after total hip arthroplasty in this cohort remain poorly characterized.

METHODS

Data were abstracted from the 2010 to 2018 PearlDiver Mariner administrative database. Patients with EDS undergoing total hip arthroplasty for osteoarthritis were identified and matched 1:10 to patients without a diagnosis of EDS. Ninety-day incidence of postoperative complications and hospital readmission were identified and compared. Odds of 90-day adverse events were compared using multivariate logistic regression. Finally, 5-year implant survival was compared using a log-rank test. Significance was set at P < 0.005 after Bonferroni correction.

RESULTS

Matching was done for 354 patients with EDS to 3,518 patients without EDS. Patients with EDS had markedly higher rates of periprosthetic dislocation within 90 days of surgery (4.2% dislocation rate in EDS vs. 1.7% in matched control subjects, P = 0.001). On multivariate analysis, patients with EDS continued to have increased odds of dislocation in the 90-day postoperative period (Odds Ratio=2.64, P = 0.001), whereas the rates of the other studied adverse events were not markedly different between groups. At 5 years, 92.7% of patients with EDS and 96.1% of the matched control subjects remained unrevised (significant log rank difference, P = 0.004).

CONCLUSION

Compared with patients without EDS, patients with EDS were found to have a higher rate of perioperative dislocation and markedly lower implant survival at 5 years. These findings are consistent with the increased connective tissue laxity associated with EDS.

Whole-exome sequencing facilitates the differential diagnosis of Ehlers-Danlos syndrome (EDS)

Ehlers-Danlos syndromes (EDSs) are a group of rare monogenic conditions with strong heterogeneity and can be caused by 20 genes associating with the essence of the extracellular matrix (ECM). This study enrolled three cases with various subtypes of EDS. Clinical evaluation and genetic testing with whole-exome sequencing (WES) were performed. The clinical manifestations of all three patients were thoroughly monitored; and three de novo diagnostic variants, namely COL5A1: NM_001278074.1: c.4609-2A>C, COL3A1: NM_000090.3: c.3554G>T(p.Gly1185Val), and COL1A1: NM_000088.3: c.545G>T(p.Gly182Val) were identified from them, respectively. The findings in this study expanded the mutation spectrum of EDS and strengthened the efficiency of WES in the differential diagnosis on disorders with overlapping phenotypes and various pathogenesis.

Establishing an Ehlers-Danlos Syndrome Clinic: Lessons Learned

In a large academic medical center, patient requests from the community and internal referrals for evaluation of suspected hypermobility conditions were being denied consultation because services specific to this condition were not available. We identified this gap and developed a comprehensive evaluation for this unique patient population. The objective of this paper is to demonstrate a solution for improving outcomes in a neglected patient population by establishing an innovative outpatient clinic specifically tailored for patients with EDS. We describe the lessons learned on establishing a specialty clinic for treating patients with hypermobility syndromes including hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobile syndrome disorder (HSD). Findings were collected from a patient focus group that was instrumental in understanding common care gaps. We document the firsthand perspective of three patients presenting with hypermobility accompanied by joint pain and denote the complicated state of healthcare in recognizing and treating this condition. A summary of patient demographics and characteristics was collected from patients seen in the clinic from November 14, 2019 to April 13, 2021. The firsthand accounts illustrate the challenges faced in treating this condition and the need for, and success of, this clinic using a coordinated care model. Demographics reveal a primarily white female population under the age of 50 with many comorbidities. Genetic testing was largely negative, with more patients diagnosed with HSD than hEDS. Our shared experience of launching a successful EDS clinic may assist other clinicians in establishing similar care models.

Pediatrics for Disability: A Comprehensive Approach to Children with Syndromic Psychomotor Delay

Intellectual disability is the impairment of cognitive, linguistic, motor and social skills that occurs in the pediatric age and is also described by the term "mental retardation". Intellectual disability occurs in 3-28 % of the general population due to a genetic cause, including chromosome aberrations. Among people with intellectual disabilities, the cause of the disability was identified as a single gene disorder in up to 12 %, multifactorial disorders in up to 4 %, and genetic disorders in up to 8.5 %. Children affected by a malformation syndrome associated with mental retardation or intellectual disability represent a care challenge for the pediatrician. A multidisciplinary team is essential to manage the patient, thereby controlling the complications of the syndrome and promoting the correct psychophysical development. This requires continuous follow-up of these children by the pediatrician, which is essential for both the clinical management of the syndrome and facilitating the social integration of these children.

Management of invasive ductal carcinoma in hypermobile Ehlers-Danlos syndrome: a case report

Literature is sparse regarding the management and long-term outcomes of breast cancer in patients with Ehlers-Danlos syndrome (EDS). Of the EDS subtypes, hypermobile Ehlers-Danlos Syndrome (hEDS) is associated with cardiovascular dysautonomia which manifests as spontaneous episodes of tachycardia and hypotension. Given this clinical autonomic system impact, hEDS is known to have significant intraoperative risk and postoperative complications. However, outcomes of hEDS patients have not been specifically studied in the field of breast cancer surgery. Here we present a case of a 62-year-old female with hEDS and node-positive invasive ductal breast carcinoma. Given the patient's medical history of hEDS, close attention was given to the patient's intraoperative vital signs and predisposition for poor wound healing. The patient underwent left Goldilocks mastectomy with left axillary lymph node dissection. Due to cardiac comorbidities, she was not a candidate for neoadjuvant or adjuvant chemotherapy. The patient tolerated adjuvant radiation and endocrine therapy without side effects, and has remained free of local, regional, and distant cancer recurrence following treatment. This case report highlights a literature gap in the surgical and radiation therapy management of breast cancer in patients with hEDS. Although breast surgery and radiation therapy in patients with invasive breast cancer and hEDS can be a safe management option, we discuss how perioperative complications must be cautiously navigated and how treatment must be tailored to individuals' specific hEDS variant to ensure optimal patient safety and positive long-term outcomes.

Prevalence of Scoliosis in Hypermobile Ehlers-Danlos Syndrome

Objective: The main purpose of this study was to evaluate the prevalence, form, and severity of scoliosis in a population of adults meeting the 2017 criteria for hypermobile Ehlers-Danlos syndrome (hEDS). The second objective was to compare the prevalence of scoliosis versus other criteria at initial hEDS diagnosis. Methods: A retrospective study looking at the frequency and severity of scoliosis in adults (N=28) meeting the 2017 diagnostic criteria for hEDS through analysis of a full spine EOS® X-ray (EOS imaging, Paris, France) performed at the initial diagnosis. Severity was defined by the Cobb angle. Results: At the initial diagnosis, the mean age was 30.1 years (standard deviation [SD]: ±10.18 years). Twenty-nine percent (n=8/28) of patients fulfilling hEDS criteria presented with scoliosis. Thirty-two percent (n=9/28) of patients had scoliotic inflection and 39% (n=11/28) had no scoliosis. Scoliosis was mild-to-moderate with a mean Cobb angle of 13.6° (SD: ±3.5°). None of the patients had severe scoliosis requiring surgery. Compared to the 2017 diagnostic criteria, it is noteworthy that scoliosis prevalence in this present study population ranks at the level of the most frequent ones. Conclusion: This study provides interesting information regarding frequency of scoliosis and scoliotic inflection in a group of patients with hEDS. Although the patients did not present with severe forms of scoliosis at initial diagnosis, the results highlight the importance of systematically looking for scoliosis in adult and young patients, in order to follow progression and ensure appropriate management.

ADAMTSL2 gene variant in patients with features of autosomal dominant connective tissue disorders

Ehlers-Danlos syndrome (EDS) consists of a heterogeneous group of genetically inherited connective tissue disorders. A family with three affected members over two generations with features of Dermatosparaxic EDS (dEDS) autosomal dominant transmission was reported by Desai et al. and having a heterozygous nonsynonymous missense variant of ADAMTSL2 (c.1261G > A; p. Gly421Ser). Variation in this gene is also reported to cause autosomal recessive geleophysic dysplasia. We report five unrelated patients with the Gly421Ser variant identified from a large series of patients presenting with features of connective tissue disorders, each with a positive family history consistent with autosomal dominant transmission. Clinical features of a connective tissue disorder included generalized joint hypermobility and pain with fragility of internal and external tissues including of skin, dura, and arteries. Overall, our analyses including bioinformatics, protein modeling, and gene-protein interactions with the cases described would add evidence for the Gly421Ser variant in ADAMTSL2 as causative for variable expressivity of autosomal dominant connective tissue disorders.

Pregnancy outcomes in women with Ehlers-Danlos Syndrome

PURPOSE

Ehlers-Danlos Syndrome (EDS) is an inherited connective tissue disorder caused by abnormal collagen synthesis. Little is known about its effects on pregnancy. The purpose of this study was to evaluate the pregnancy outcomes in women with EDS.

MATERIALS AND METHODS

We conducted a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from the United States. The study included women who delivered between 1999 and 2014. We measured the prevalence of EDS over time, and compared the baseline, obstetrical, and neonatal outcomes among women with EDS to the general obstetrical population without EDS. Unconditional logistic regression models were used to calculate the adjusted effect of EDS on maternal and neonatal outcomes.

RESULTS

The overall prevalence of EDS in pregnancy was 7 per 100,000 births, with the trend increasing over the 16 year study period (p < .0001). Women with EDS were more likely to be Caucasian, belong to a higher income quartile, and smoke. Pregnancies in women with EDS were associated with prematurity, 1.47 (1.18-1.82), cervical incompetence, 3.11 (1.99-4.85), antepartum hemorrhage, 1.71 (1.16-2.50), placenta previa, 2.26 (1.35-3.77) and maternal death, 9.04 (1.27-64.27). Pregnant women with EDS were more likely to be delivered by cesarean section, 1.55 (1.36-1.76), have longer postpartum stays (>7 days), 2.82 (2.08-3.85), and have a neonate with intra-uterine growth restriction, 1.81 (1.29-2.54).

CONCLUSIONS

EDS in pregnancy is a high-risk condition with increased maternal morbidity and mortality, as well as newborn morbidity. Consideration should be given to prematurity preventative measures and high-risk pregnancy consultation.

Appendiceal torsion in Ehlers-Danlos syndrome: A case report of a rare phenomenon in a rare disease

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Appendiceal torsion, a rare phenomenon, may be seen in Ehlers-Danlos syndrome.

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Appendiceal torsion is clinically indistinguishable from acute appendicitis.

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Ehlers-Danlos syndrome contributes to surgical problems due to fragility of tissue.

Introduction

Appendiceal torsion is a rare phenomenon with only a few reported cases and never in a patient with Ehlers-Danlos syndrome (EDS). We present the first case of appendiceal torsion leading to acute appendicitis in a patient with EDS.

Presentation of case

A 36-year-old male with history of musculoskeletal EDS presented with one week of abdominal pain localizing to the right lower quadrant. He was evaluated in the emergency department with a complete set of labs and CT abdomen/pelvis. The CT scan showed acute appendicitis, but did not mention any appendiceal torsion. He was taken to the operating room for a standard laparoscopic appendectomy. Intraoperatively, there was inflammation at the tip of the appendix with a 270-degree torsion of the mid-appendix and mesoappendix. After untwisting, the appendix was safely removed from the base of the cecum. Patient recovered well postoperatively and no masses or tumors were identified on final pathology.

Discussion

Primary appendiceal torsion occurs without an identifiable cause and secondary torsion occurs due to pathology such as carcinoid tumor or other masses. Patients with EDS may be more prone to either torsion as they have hyperelastic skin, joints and ligaments. EDS patients require special workup prior to any operation including cardiopulmonary evaluation and may have unique postoperative complications.

Conclusion

The ligamentous hypermobility of EDS may have predisposed our patient to appendiceal torsion and acute appendicitis. This is a rare phenomenon and may be underdiagnosed in EDS patients. Practitioners should be aware of this manifestation of EDS.

Recessive marfanoid syndrome with herniation associated with a homozygous mutation in Fibulin-3

We have previously reported on a consanguineous family where 2 siblings, a girl and a boy, presented with tall stature, long and triangular faces, prominent forehead, telecanthus, ptosis, everted lower eyelids, downslanting palpebral fissures, large ears, high arched palate, long arm span, arachnodactyly, advanced bone age, joint laxity, pectus excavatum, inguinal hernia, and myopia, suggestive of a new subtype of connective tissue disorder (Megarbane et al. AJMG, 2012; 158(A)5: 1185-1189). On clinical follow-up, both patients had multiple inguinal, crural, and abdominal herniae, intestinal occlusions, several huge diverticula throughout the gut and the bladder, and rectal prolapse. In addition, the girl had a mild hearing impairment, and the boy a left diaphragmatic hernia. Here we describe the molecular characterization of this disorder using Whole Exome Sequencing, revealing, in both siblings, a novel homozygous missense variant in the EFEMP1 gene, c.163T > C; p.(Cys55Arg) whose homozygous by descent, autosomal recessive transmission was confirmed through segregation analysis by Sanger sequencing. In addition, the girl exhibited a homozygous mutation in the MYO3A gene, c.1370_1371delGA; p.(Arg457Asnfs*25), associated with non-syndromic deafness. The siblings were also found to harbor a homozygous nonsense variant in the VCPKMT gene. We review the literature and discuss our updated clinical and molecular findings that suggest EFEMP1 to be the probable candidate gene implicated in this novel connective tissue disease.

Survey of Ehlers-Danlos Patients' ophthalmic surgery experiences

Background

Ehlers‒Danlos Syndrome (EDS) is a rare disease affecting approximately 1 in 5,000 people. Although ophthalmic conditions associated with EDS have been described, little data exist concerning ophthalmic surgical outcomes experienced by EDS patients.

Methods

Patients with EDS were surveyed via the EDS Society and asked about their ophthalmic surgical experiences including procedure, complications, and the timing with respect to receiving the EDS diagnosis. Complications were confirmed as such by subspecialists.

Results

Of 579 respondents, 467 reported confirmed EDS, and 112 of those had an ophthalmic procedure, including refractive surgery, cataract/lens surgery, retinal surgery, strabismus surgery, oculoplastic surgery, corneal surgery, and laser surgery for glaucoma. The rate of confirmed complications was: 23%‐refractive, 33%‐lens/cataract, 33%‐retina, 59%‐strabismus, 23%‐ oculoplastics, 0%‐cornea, and 25%‐glaucoma laser. In addition, 76% of patients underwent surgery prior to the EDS diagnosis.

Conclusions

Patients with EDS may have elevated risk of postoperative ophthalmic surgical complications. It would seem reasonable to systemically and prospectively explore how patients with EDS respond to ophthalmic surgery. Furthermore, it would seem circumspect to ask surgical candidates patients about whether they carry a diagnosis of EDS or have signs and symptoms of EDS prior to surgery.

Identification of Two Independent COL5A1 Variants in Dogs with Ehlers-Danlos Syndrome

The Ehlers–Danlos syndromes (EDS) are a heterogeneous group of heritable disorders affecting connective tissues. The mutations causing the various forms of EDS in humans are well characterized, but the genetic mutations causing EDS-like clinical pathology in dogs are not known, thus hampering accurate clinical diagnosis. Clinical analysis of two independent cases of skin hyperextensibility and fragility, one with pronounced joint hypermobility was suggestive of EDS. Whole-genome sequencing revealed de novo mutations of COL5A1 in both cases, confirming the diagnosis of the classical form of EDS. The heterozygous COL5A1 p.Gly1013ValfsTer260 mutation characterized in case 1 introduced a premature termination codon and would be expected to result in α1(V) mRNA nonsense-mediated mRNA decay and collagen V haploinsufficiency. While mRNA was not available from this dog, ultrastructural analysis of the dermis demonstrated variability in collagen fibril diameter and the presence of collagen aggregates, termed ‘collagen cauliflowers’, consistent with COL5A1 mutations underlying classical EDS. In the second case, DNA sequencing demonstrated a p.Gly1571Arg missense variant in the COL5A1 gene. While samples were not available for further analysis, such a glycine substitution would be expected to destabilize the strict molecular structure of the collagen V triple helix and thus affect protein stability and/or integration of the mutant collagen into the collagen V/collagen I heterotypic dermal fibrils. This is the first report of genetic variants in the COL5A1 gene causing the clinical presentation of EDS in dogs. These data provided further evidence of the important role of collagen V in dermal collagen fibrillogenesis. Importantly, from the clinical perspective, we showed the utility of DNA sequencing, combined with the established clinical criteria, in the accurate diagnosis of EDS in dogs.

The extracellular matrix as a multitasking player in disease

Extracellular matrices (ECMs) are highly specialized and dynamic three-dimensional (3D) scaffolds into which cells reside in tissues. ECM is composed of a variety of fibrillar components, such as collagens, fibronectin, and elastin, and non-fibrillar molecules as proteoglycans, hyaluronan, and glycoproteins including matricellular proteins. These macromolecular components are interconnected forming complex networks that actively communicate with cells through binding to cell surface receptors and/or matrix effectors. ECMs exert diverse roles, either providing tissues with structural integrity and mechanical properties essential for tissue functions or regulating cell phenotype and functions to maintain tissue homeostasis. ECM molecular composition and structure vary among tissues, and is markedly modified during normal tissue repair as well as during the progression of various diseases. Actually, abnormal ECM remodeling occurring in pathologic circumstances drives disease progression by regulating cell-matrix interactions. The importance of matrix molecules to normal tissue functions is also highlighted by mutations in matrix genes that give rise to genetic disorders with diverse clinical phenotypes. In this review, we present critical and emerging issues related to matrix assembly in tissues and the multitasking roles for ECM in diseases such as osteoarthritis, fibrosis, cancer, and genetic diseases. The mechanisms underlying the various matrix-based diseases are also discussed. Research focused on the highly dynamic 3D ECM networks will help to discover matrix-related causative abnormalities of diseases as well as novel diagnostic tools and therapeutic targets.

Management of chronic pain in Ehlers-Danlos syndrome: Two case reports and a review of literature

RATIONALE

Ehlers-Danlos syndromes (EDSs) are a heterogeneous group of heritable connective tissue disorders involving defective collagen synthesis. Patients with EDS are prone for chronic myofascial pain, apart from other comorbidities. Although the initial pathology is commonly nociceptive, progression of EDS leads to neuropathies and central sensitization of pain signals. Overall, approximately 90% or more EDS patients suffer from chronic pain. There are no existing guidelines to manage chronic pain in EDS patients. In this article, we illustrate 2 case reports of EDS patients with chronic pain and review the relevant literature regarding the pathological considerations and management of chronic pain in EDS.

PATIENT CONCERNS

Our first patient had worsening multiple joint pains despite treatment with medications and a recent diagnosis of EDS-type 3. The second patient had a complicated history including longstanding EDS and multiple previous surgeries. She was referred due to concern about complex regional pain syndrome (CRPS) in her upper extremity.

DIAGNOSES

For the first patient, apart from chronic pain due to her EDS, her history also revealed that she suffered from kinesiophobia. For the second patient, a detailed clinical assessment revealed no signs of CRPS but instead a generalized worsening of EDS symptoms.

INTERVENTIONS

Both patients were evaluated by the multidisciplinary team consisting of a pain physician, nurse, pain psychologist, and a kinesiologist. Their treatment involved optimization of daily medications, participation in pain self-management sessions that included cognitive behavioral therapy, graded exercises, coping, and relaxation strategies.

OUTCOMES

Both patients demonstrated significantly better pain control and achieved overall improvement in daily living.

LESSONS

EDS is a complex illness with a multitude of symptoms. As in our patients, EDS patients also suffer from panic and anxiety disorders that increase the burden of pain. Apart from optimization of medications, EDS patients are best managed by a multidisciplinary approach that includes pain education and life style changes. The caution that they are resistant to local anesthetics is unwarranted. Appropriate pain interventions in selected patients may have a role to decrease pain intensity.