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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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Vandersteen AM, Weerakkody RA, Parry DA, Kanonidou C, Toddie-Moore DJ, Vandrovcova J, Darlay R, Santoyo-Lopez J, Meynert A, Kazkaz H, Grahame R, Cummings C, Bartlett M, Ghali N, Brady AF, Pope FM, van Dijk FS, Cordell HJ, Aitman TJ. Genetic complexity of diagnostically unresolved Ehlers-Danlos syndrome. J Med Genet 2024; 61:232-238. [PMID: 37813462 DOI: 10.1136/jmg-2023-109329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The Ehlers-Danlos syndromes (EDS) are heritable disorders of connective tissue (HDCT), reclassified in the 2017 nosology into 13 subtypes. The genetic basis for hypermobile Ehlers-Danlos syndrome (hEDS) remains unknown. METHODS Whole exome sequencing (WES) was undertaken on 174 EDS patients recruited from a national diagnostic service for complex EDS and a specialist clinic for hEDS. Patients had already undergone expert phenotyping, laboratory investigation and gene sequencing, but were without a genetic diagnosis. Filtered WES data were reviewed for genes underlying Mendelian disorders and loci reported in EDS linkage, transcriptome and genome-wide association studies (GWAS). A genetic burden analysis (Minor Allele Frequency (MAF) <0.05) incorporating 248 Avon Longitudinal Study of Parents and Children (ALSPAC) controls sequenced as part of the UK10K study was undertaken using TASER methodology. RESULTS Heterozygous pathogenic (P) or likely pathogenic (LP) variants were identified in known EDS and Loeys-Dietz (LDS) genes. Multiple variants of uncertain significance where segregation and functional analysis may enable reclassification were found in genes associated with EDS, LDS, heritable thoracic aortic disease (HTAD), Mendelian disorders with EDS symptomatology and syndromes with EDS-like features. Genetic burden analysis revealed a number of novel loci, although none reached the threshold for genome-wide significance. Variants with biological plausibility were found in genes and pathways not currently associated with EDS or HTAD. CONCLUSIONS We demonstrate the clinical utility of large panel-based sequencing and WES for patients with complex EDS in distinguishing rare EDS subtypes, LDS and related syndromes. Although many of the P and LP variants reported in this cohort would be identified with current panel testing, they were not at the time of this study, highlighting the use of extended panels and WES as a clinical tool for complex EDS. Our results are consistent with the complex genetic architecture of EDS and suggest a number of novel hEDS and HTAD candidate genes and pathways.
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Affiliation(s)
- Anthony M Vandersteen
- Maritime Medical Genetics Service, IWK Health Centre, Halifax, Nova Scotia, Canada
- Faculty of Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Ruwan A Weerakkody
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Institute of Clinical Sciences, Imperial College London, London, UK
- Department of Vascular Surgery, Royal Free Hospital, London, UK
| | - David A Parry
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Christina Kanonidou
- Department of Clinical Biochemistry, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Daniel J Toddie-Moore
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Jana Vandrovcova
- Department of Neuromuscular Diseases, UCL Queen Street Institute of Neurology, University College London, London, UK
| | - Rebecca Darlay
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Alison Meynert
- MRC Human Genetics Unit, University of Edinburgh, Edinburgh, UK
| | - Hanadi Kazkaz
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rodney Grahame
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Carole Cummings
- Ehlers-Danlos Syndrome National Diagnostic Service, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- Department of Metabolism, Digestion and Reproduction Section of Genetics and Genomics, Imperial College London, London, UK
| | - Marion Bartlett
- Ehlers-Danlos Syndrome National Diagnostic Service, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- Department of Metabolism, Digestion and Reproduction Section of Genetics and Genomics, Imperial College London, London, UK
| | - Neeti Ghali
- Ehlers-Danlos Syndrome National Diagnostic Service, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- Department of Metabolism, Digestion and Reproduction Section of Genetics and Genomics, Imperial College London, London, UK
| | - Angela F Brady
- Ehlers-Danlos Syndrome National Diagnostic Service, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- Department of Metabolism, Digestion and Reproduction Section of Genetics and Genomics, Imperial College London, London, UK
| | - F Michael Pope
- Ehlers-Danlos Syndrome National Diagnostic Service, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- Department of Metabolism, Digestion and Reproduction Section of Genetics and Genomics, Imperial College London, London, UK
| | - Fleur S van Dijk
- Ehlers-Danlos Syndrome National Diagnostic Service, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- Department of Metabolism, Digestion and Reproduction Section of Genetics and Genomics, Imperial College London, London, UK
| | - Heather J Cordell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Timothy J Aitman
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
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Guedry SE, Langley BO, Schaefer K, Hanes DA. Integrative medicine for hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndromes (EDS): a feasibility study. Disabil Rehabil 2024:1-14. [PMID: 38353245 DOI: 10.1080/09638288.2024.2314713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE Hypermobility spectrum disorders (HSD) and Ehlers-Danlos syndromes (EDS) are multisystem conditions marked by dysfunctional connective tissue. This feasibility study evaluated a 9-week integrative medicine program in this population. METHODS Using a single-arm study design, adults with HSD or EDS were given recommendations for an anti-inflammatory Mediterranean diet and self-management with additional behavioral and psychosocial support. Preliminary data on feasibility based on recruitment and retention, adherence to the diet, mobile app tracking, changes to perceived well-being via health outcomes, and satisfaction with care were obtained. RESULTS Thirteen participants were enrolled within a 4-month timeframe. Eight participants completed the study. Three participants met dietary tracking requirement in at least 4 of 8 intervention weeks and met the macronutrient requirements in at least half of the weeks tracked. No decreases in VAS pain scores after 5 and 9 weeks were noted; however, 62.5% (n = 5) of participants had decreased pain at 9 weeks, compared to baseline. There were significant improvements (p<.05) in six of twelve measurements of satisfaction with care at the end of the intervention. CONCLUSION This study provides a foundation for future research on patient experience and introduces a novel treatment paradigm focused on nutrition and self-management. Trial Registration: National Institutes of Health clinicaltrials.gov; identifier: NCT04734041. IMPLICATIONS FOR REHABILITATION Lifestyle and dietary interventions are relatively safe and well tolerated in the hypermobility spectrum disorder (HSD) and Ehlers-Danlos disorder (EDS) population.Participants in our 9-week integrative medicine program actively engaged in self-management of their condition and showed promising adherence to dietary and tracking requirements.Effective treatment of the intricacies and dynamics of these highly variable and clinically heterogeneous disorders may require a network of healthcare providers, integrative healthcare, as well as behavioral and psychosocial support.Dietary tracking through mobile apps might help promote self-efficacy and adherence to dietary changes.Symptom tracking might be an effective way for patients to track changes to their health and could provide valuable information for health professionals engaged in managing the disorders.
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Affiliation(s)
- Sara E Guedry
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
| | - Blake O Langley
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
- School of Nursing, University of WA, Seattle, WA, USA
| | - Kerry Schaefer
- Co-investigator, Healthy Living Community Clinic, Portland, OR, USA
| | - Douglas A Hanes
- Helfgott Research Institute, National University of Natural Medicine, Portland, OR, USA
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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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Wang TJ, Stecco A, Schleip R, Stecco C, Pirri C. Change in gliding properties of the iliotibial tract in hypermobile Ehlers-Danlos Syndrome. J Ultrasound 2023; 26:809-813. [PMID: 36802027 PMCID: PMC10632250 DOI: 10.1007/s40477-023-00775-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/11/2023] [Indexed: 02/23/2023] Open
Abstract
PURPOSE Fascial changes in hypermobile Ehlers-Danlos syndrome (hEDS), a heritable connective tissue disorder, can be used visualized with sonoelastography. The purpose of this study was to explore the inter-fascial gliding characteristics in hEDS. METHODS In 9 subjects, the right iliotibial tract was examined with ultrasonography. Tissue displacements of the iliotibial tract were estimated from ultrasound data using cross-correlation techniques. RESULTS In hEDS subjects, shear strain was 46.2%, lower than those with lower limb pain without hEDS (89.5%) and in control subjects without hEDS and without pain (121.1%). CONCLUSION Extracellular matrix changes in hEDS may manifest as reduced inter-fascial plane gliding.
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Affiliation(s)
- Tina J Wang
- Department of Physical Medicine & Rehabilitation, Loma Linda University School of Medicine, Loma Linda, CA, USA.
- , 429 N Central Ave, Upland, CA, 91786, USA.
| | - Antonio Stecco
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Robert Schleip
- Department of Conservative and Rehabilitive Orthopaedics, Technical University of Munich, Munich, Germany
| | - Carla Stecco
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, Padua, Italy
| | - Carmelo Pirri
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, Padua, Italy
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Plaut S. “Long COVID-19” and viral “fibromyalgia-ness”: Suggesting a mechanistic role for fascial myofibroblasts (Nineveh, the shadow is in the fascia). Front Med (Lausanne) 2023; 10:952278. [PMID: 37089610 PMCID: PMC10117846 DOI: 10.3389/fmed.2023.952278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/27/2023] [Indexed: 04/08/2023] Open
Abstract
The coronavirus pandemic has led to a wave of chronic disease cases; “Long COVID-19” is recognized as a new medical entity and resembles “fibromyalgia” which, likewise, lacks a clear mechanism. Observational studies indicate that up to 30%–40% of convalescent COVID-19 patients develop chronic widespread pain and fatigue and fulfill the 2016 diagnostic criteria for “fibromyalgia.” A recent study suggested a theoretical neuro-biomechanical model (coined “Fascial Armoring”) to help explain the pathogenesis and cellular pathway of fibromyalgia, pointing toward mechanical abnormalities in connective tissue and fascia, driven by contractile myo/fibroblasts and altered extracellular matrix remodeling with downstream corresponding neurophysiological aberrations. This may help explain several of fibromyalgia’s manifestations such as pain, distribution of pain, trigger points/tender spots, hyperalgesia, chronic fatigue, cardiovascular abnormalities, metabolic abnormalities, autonomic abnormalities, small fiber neuropathy, various psychosomatic symptoms, lack of obvious inflammation, and silent imaging investigations. Pro-inflammatory and pro-fibrotic pathways provide input into this mechanism via stimulation of proto/myofibroblasts. In this hypothesis and theory paper the theoretical model of Fascial Armoring is presented to help explain the pathogenesis and manifestations of “long COVID-19” as a disease of immuno-rheumo-psycho-neurology. The model is also used to make testable experimental predictions on investigations and predict risk and relieving factors.
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Plaut S. Suggesting a mechanism for acupuncture as a global percutaneous needle fasciotomy that respects tensegrity principles for treating fibromyalgia. Front Med (Lausanne) 2023; 9:952159. [PMID: 36777160 PMCID: PMC9911817 DOI: 10.3389/fmed.2022.952159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/30/2022] [Indexed: 01/28/2023] Open
Abstract
Acupuncture is a minimally invasive therapeutic method that uses small caliber needles while inserting them through the skin into various areas of the body. Some empirical studies find evidence to support the use of acupuncture as a treatment for certain medical conditions, however, this peculiar practice is widely considered as the domain of alternative and non-evidence-based medicine. Several mechanisms have been suggested in an attempt to explain the therapeutic action of acupuncture, but the way in which acupuncture alleviates chronic non-cancer pain or psychosomatic and psychiatric disorders is not fully understood. A recent study suggested a theoretical model (coined "Fascial Armoring") with a cellular pathway to help explain the pathogenesis of myofascial pain/fibromyalgia syndrome and functional psychosomatic syndromes. It proposes that these syndromes are a spectrum of a single medical entity that involves myofibroblasts with contractile activity in fascia and aberrant extracellular matrix (ECM) remodeling, which may lead to widespread mechanical tension and compression. This can help explain diverse psycho-somatic manifestations of fibromyalgia-like syndromes. Fascia is a continuous interconnected tissue network that extends throughout the body and has qualities of bio-tensegrity. Previous studies show that a mechanical action by needling induces soft tissue changes and lowers the shear modulus and stiffness in myofascial tissue. This hypothesis and theory paper offers a new mechanism for acupuncture therapy as a global percutaneous needle fasciotomy that respects tensegrity principles (tensegrity-based needling), in light of the theoretical model of "Fascial Armoring." The translation of this model to other medical conditions carries potential to advance therapies. These days opioid overuse and over-prescription are ubiquitous, as well as chronic pain and suffering.
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Affiliation(s)
- Shiloh Plaut
- *Correspondence: Shiloh Plaut, , ; orcid.org/0000-0001-5823-3390
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Nutritional knowledge, attitudes and dietary behaviours amongst individuals with hypermobility syndromes and associations with co-morbid gastrointestinal symptoms and fatigue; an observational study. Eur J Integr Med 2023. [DOI: 10.1016/j.eujim.2023.102231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Wang K, Wen D, Xu X, Zhao R, Jiang F, Yuan S, Zhang Y, Gao Y, Li Q. Extracellular matrix stiffness-The central cue for skin fibrosis. Front Mol Biosci 2023; 10:1132353. [PMID: 36968277 PMCID: PMC10031116 DOI: 10.3389/fmolb.2023.1132353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Skin fibrosis is a physiopathological process featuring the excessive deposition of extracellular matrix (ECM), which is the main architecture that provides structural support and constitutes the microenvironment for various cellular behaviors. Recently, increasing interest has been drawn to the relationship between the mechanical properties of the ECM and the initiation and modulation of skin fibrosis, with the engagement of a complex network of signaling pathways, the activation of mechanosensitive proteins, and changes in immunoregulation and metabolism. Simultaneous with the progression of skin fibrosis, the stiffness of ECM increases, which in turn perturbs mechanical and humoral homeostasis to drive cell fate toward an outcome that maintains and enhances the fibrosis process, thus forming a pro-fibrotic "positive feedback loop". In this review, we highlighted the central role of the ECM and its dynamic changes at both the molecular and cellular levels in skin fibrosis. We paid special attention to signaling pathways regulated by mechanical cues in ECM remodeling. We also systematically summarized antifibrotic interventions targeting the ECM, hopefully enlightening new strategies for fibrotic diseases.
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Affiliation(s)
- Kang Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dongsheng Wen
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuewen Xu
- Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui Zhao
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Feipeng Jiang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Shengqin Yuan
- School of Public Administration, Sichuan University, Chengdu, Sichuan, China
| | - Yifan Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Yifan Zhang, ; Ya Gao, ; Qingfeng Li,
| | - Ya Gao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Yifan Zhang, ; Ya Gao, ; Qingfeng Li,
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Yifan Zhang, ; Ya Gao, ; Qingfeng Li,
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RNA-Seq of Dermal Fibroblasts from Patients with Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders Supports Their Categorization as a Single Entity with Involvement of Extracellular Matrix Degrading and Proinflammatory Pathomechanisms. Cells 2022; 11:cells11244040. [PMID: 36552803 PMCID: PMC9777098 DOI: 10.3390/cells11244040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD) are clinically overlapping connective tissue disorders of unknown etiology and without any validated diagnostic biomarker and specific therapies. Herein, we in-depth characterized the cellular phenotype and gene expression profile of hEDS and HSD dermal fibroblasts by immunofluorescence, amplicon-based RNA-seq, and qPCR. We demonstrated that both cell types show a common cellular trait, i.e., generalized extracellular matrix (ECM) disarray, myofibroblast differentiation, and dysregulated gene expression. Functional enrichment and pathway analyses clustered gene expression changes in different biological networks that are likely relevant for the disease pathophysiology. Specifically, the complex gene expression dysregulation (mainly involving growth factors, structural ECM components, ECM-modifying enzymes, cytoskeletal proteins, and different signal transducers), is expected to perturb many ECM-related processes including cell adhesion, migration, proliferation, and differentiation. Based on these findings, we propose a disease model in which an unbalanced ECM remodeling triggers a vicious cycle with a synergistic contribution of ECM degradation products and proinflammatory mediators leading to a functional impairment of different connective tissues reflecting the multisystemic presentation of hEDS/HSD patients. Our results offer many promising clues for translational research aimed to define molecular bases, diagnostic biomarkers, and specific therapies for these challenging connective tissue disorders.
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Royer SP, Han SJ. Mechanobiology in the Comorbidities of Ehlers Danlos Syndrome. Front Cell Dev Biol 2022; 10:874840. [PMID: 35547807 PMCID: PMC9081723 DOI: 10.3389/fcell.2022.874840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
Ehlers-Danlos Syndromes (EDSs) are a group of connective tissue disorders, characterized by skin stretchability, joint hypermobility and instability. Mechanically, various tissues from EDS patients exhibit lowered elastic modulus and lowered ultimate strength. This change in mechanics has been associated with EDS symptoms. However, recent evidence points toward a possibility that the comorbidities of EDS could be also associated with reduced tissue stiffness. In this review, we focus on mast cell activation syndrome and impaired wound healing, comorbidities associated with the classical type (cEDS) and the hypermobile type (hEDS), respectively, and discuss potential mechanobiological pathways involved in the comorbidities.
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Affiliation(s)
- Shaina P. Royer
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, United States
| | - Sangyoon J. Han
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, United States
- Department of Mechanical Engineering, Michigan Technological University, Houghton, MI, United States
- Health Research Institute, Michigan Technological University, Houghton, MI, United States
- *Correspondence: Sangyoon J. Han,
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Plaut S. Scoping review and interpretation of myofascial pain/fibromyalgia syndrome: An attempt to assemble a medical puzzle. PLoS One 2022; 17:e0263087. [PMID: 35171940 PMCID: PMC8849503 DOI: 10.1371/journal.pone.0263087] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 01/11/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Myofascial Pain Syndrome (MPS) is a common, overlooked, and underdiagnosed condition and has significant burden. MPS is often dismissed by clinicians while patients remain in pain for years. MPS can evolve into fibromyalgia, however, effective treatments for both are lacking due to absence of a clear mechanism. Many studies focus on central sensitization. Therefore, the purpose of this scoping review is to systematically search cross-disciplinary empirical studies of MPS, focusing on mechanical aspects, and suggest an organic mechanism explaining how it might evolve into fibromyalgia. Hopefully, it will advance our understanding of this disease. METHODS Systematically searched multiple phrases in MEDLINE, EMBASE, COCHRANE, PEDro, and medRxiv, majority with no time limit. Inclusion/exclusion based on title and abstract, then full text inspection. Additional literature added on relevant side topics. Review follows PRISMA-ScR guidelines. PROSPERO yet to adapt registration for scoping reviews. FINDINGS 799 records included. Fascia can adapt to various states by reversibly changing biomechanical and physical properties. Trigger points, tension, and pain are a hallmark of MPS. Myofibroblasts play a role in sustained myofascial tension. Tension can propagate in fascia, possibly supporting a tensegrity framework. Movement and mechanical interventions treat and prevent MPS, while living sedentarily predisposes to MPS and recurrence. CONCLUSIONS MPS can be seen as a pathological state of imbalance in a natural process; manifesting from the inherent properties of the fascia, triggered by a disrupted biomechanical interplay. MPS might evolve into fibromyalgia through deranged myofibroblasts in connective tissue ("fascial armoring"). Movement is an underemployed requisite in modern lifestyle. Lifestyle is linked to pain and suffering. The mechanism of needling is suggested to be more mechanical than currently thought. A "global percutaneous needle fasciotomy" that respects tensegrity principles may treat MPS/fibromyalgia more effectively. "Functional-somatic syndromes" can be seen as one entity (myofibroblast-generated-tensegrity-tension), sharing a common rheuma-psycho-neurological mechanism.
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Affiliation(s)
- Shiloh Plaut
- School of Medicine, St. George’s University of London, London, United Kingdom
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Matrix Metalloproteinases Inhibition by Doxycycline Rescues Extracellular Matrix Organization and Partly Reverts Myofibroblast Differentiation in Hypermobile Ehlers-Danlos Syndrome Dermal Fibroblasts: A Potential Therapeutic Target? Cells 2021; 10:cells10113236. [PMID: 34831458 PMCID: PMC8621259 DOI: 10.3390/cells10113236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 12/17/2022] Open
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS) is the most frequent type of EDS and is characterized by generalized joint hypermobility and musculoskeletal manifestations which are associated with chronic pain, and mild skin involvement along with the presence of more than a few comorbid conditions. Despite numerous research efforts, no causative gene(s) or validated biomarkers have been identified and insights into the disease-causing mechanisms remain scarce. Variability in the spectrum and severity of symptoms and progression of hEDS patients’ phenotype likely depend on a combination of age, gender, lifestyle, and the probable multitude of genes involved in hEDS. However, considering the clinical overlap with other EDS forms, which lead to abnormalities in extracellular matrix (ECM), it is plausible that the mechanisms underlying hEDS pathogenesis also affect the ECM to a certain extent. Herein, we performed a series of in vitro studies on the secretome of hEDS dermal fibroblasts that revealed a matrix metalloproteinases (MMPs) dysfunction as one of the major disease drivers by causing a detrimental feedback loop of excessive ECM degradation coupled with myofibroblast differentiation. We demonstrated that doxycycline-mediated inhibition of MMPs rescues in hEDS cells a control-like ECM organization and induces a partial reversal of their myofibroblast-like features, thus offering encouraging clues for translational studies confirming MMPs as a potential therapeutic target in hEDS with the expectation to improve patients’ quality of life and alleviate their disabilities.
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14
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Wang TJ, Stecco A. Fascial thickness and stiffness in hypermobile Ehlers-Danlos syndrome. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:446-452. [PMID: 34741592 DOI: 10.1002/ajmg.c.31948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/23/2021] [Accepted: 10/16/2021] [Indexed: 11/05/2022]
Abstract
There is a high prevalence of myofascial pain in people with hypermobile Ehlers-Danlos Syndrome (hEDS). The fascial origin of pain may correspond to changes in the extracellular matrix. The objective of this study was to investigate structural changes in fascia in hEDS. A series of 65 patients were examined prospectively-26 with hEDS, and 39 subjects with chronic neck, knee, or back pain without hEDS. The deep fascia of the sternocleidomastoid, iliotibial tract, and iliac fascia were examined with B-mode ultrasound and strain elastography, and the thicknesses were measured. Stiffness (strain index) was measured semi-quantitatively using elastography comparing fascia to muscle. Differences between groups were compared using one-way analysis of variance. hEDS subjects had a higher mean thickness in the deep fascia of the sternocleidomastoid compared with non-hEDS subjects. There was no significant difference in thickness of the iliac fascia and iliotibial tract between groups. Non-hEDS subjects with pain had a higher strain index (more softening of the fascia with relative stiffening of the muscle) compared with hEDS subjects and non-hEDS subjects without back or knee pain. In myofascial pain, softening of the fascia may occur from increase in extracellular matrix content and relative increase in stiffness of the muscle; this change is not as pronounced in hEDS.
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Affiliation(s)
- Tina J Wang
- Department of Physical Medicine & Rehabilitation, Loma Linda University School of Medicine, Upland, California, USA
| | - Antonio Stecco
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, New York, USA
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15
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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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16
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Tassanakijpanich N, McKenzie FJ, McLennan YA, Makhoul E, Tassone F, Jasoliya MJ, Romney C, Petrasic IC, Napalinga K, Buchanan CB, Hagerman P, Hagerman R, Casanova EL. Hypermobile Ehlers-Danlos syndrome (hEDS) phenotype in fragile X premutation carriers: case series. J Med Genet 2021; 59:687-690. [PMID: 34193467 DOI: 10.1136/jmedgenet-2020-107609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/08/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND While an association between full mutation CGG-repeat expansions of the Fragile X Mental Retardation 1 (FMR1) gene and connective tissue problems are clearly described, problems in fragile X premutation carriers (fXPCs) CGG-repeat range (55-200 repeats) of the FMR1 gene may be overlooked. OBJECTIVE To report five FMR1 fXPCs cases with the hypermobile Ehlers-Danlos syndrome (hEDS) phenotype. METHODS We collected medical histories and FMR1 molecular measures from five cases who presented with joint hypermobility and loose connective tissue and met inclusion criteria for hEDS. RESULTS Five cases were female and ranged between 16 and 49 years. The range of CGG-repeat allele sizes ranged from 66 to 150 repeats. All had symptoms of hEDS since early childhood. Commonalities in molecular pathogenesis and coexisting conditions between the fXPCs and hEDS are also presented. The premutation can lead to a reduction of fragile X mental retardation protein, which is crucial in maintaining functions of the extracellular matrix-related proteins, particularly matrix metallopeptidase 9 and elastin. Moreover, elevated FMR1 messenger RNA causes sequestration of proteins, which results in RNA toxicity. CONCLUSION Both hEDS phenotype and premutation involvement may co-occur because of related commonalities in pathogenesis.
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Affiliation(s)
- Nattaporn Tassanakijpanich
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand.,UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA
| | - Forrest J McKenzie
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Yingratana A McLennan
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Elisabeth Makhoul
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Flora Tassone
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Mittal J Jasoliya
- Department of Biochemistry and Molecular Medicine, University of California, Davis, School of Medicine, Sacramento, California, USA
| | | | - Ignacio Cortina Petrasic
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Kaye Napalinga
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,MedMom Institute for Human Development, Pasig City, Philippines
| | | | - Paul Hagerman
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA.,Department of Biochemistry and Molecular Medicine, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Randi Hagerman
- UC Davis MIND Institute, UC Davis Health, Sacramento, California, USA .,Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Emily L Casanova
- Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
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17
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Malek S, Köster DV. The Role of Cell Adhesion and Cytoskeleton Dynamics in the Pathogenesis of the Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders. Front Cell Dev Biol 2021; 9:649082. [PMID: 33968931 PMCID: PMC8097055 DOI: 10.3389/fcell.2021.649082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/22/2021] [Indexed: 12/26/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of 13 disorders, clinically defined through features of joint hypermobility, skin hyperextensibility, and tissue fragility. Most subtypes are caused by mutations in genes affecting the structure or processing of the extracellular matrix (ECM) protein collagen. The Hypermobility Spectrum Disorders (HSDs) are clinically indistinguishable disorders, but are considered to lack a genetic basis. The pathogenesis of all these disorders, however, remains poorly understood. Genotype-phenotype correlations are limited, and findings of aberrant collagen fibrils are inconsistent and associate poorly with the subtype and severity of the disorder. The defective ECM, however, also has consequences for cellular processes. EDS/HSD fibroblasts exhibit a dysfunctional phenotype including impairments in cell adhesion and cytoskeleton organization, though the pathological significance of this has remained unclear. Recent advances in our understanding of fibroblast mechanobiology suggest these changes may actually reflect features of a pathomechanism we herein define. This review departs from the traditional view of EDS/HSD, where pathogenesis is mediated by the structurally defective ECM. Instead, we propose EDS/HSD may be a disorder of membrane-bound collagen, and consider how aberrations in cell adhesion and cytoskeleton dynamics could drive the abnormal properties of the connective tissue, and be responsible for the pathogenesis of EDS/HSD.
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Affiliation(s)
- Sabeeha Malek
- Division of Biomedical Sciences, Centre for Mechanochemical Cell Biology, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Darius V Köster
- Division of Biomedical Sciences, Centre for Mechanochemical Cell Biology, Warwick Medical School, University of Warwick, Coventry, United Kingdom
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18
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Gensemer C, Burks R, Kautz S, Judge DP, Lavallee M, Norris RA. Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes. Dev Dyn 2021; 250:318-344. [PMID: 32629534 PMCID: PMC7785693 DOI: 10.1002/dvdy.220] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 12/14/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.
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Affiliation(s)
- Cortney Gensemer
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Randall Burks
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
| | - Steven Kautz
- Department of Health Sciences and Research, Medical University of South Carolina, Charleston, South Carolina
| | - Daniel P. Judge
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Mark Lavallee
- Department of Family Medicine, Wellspan Health, York, Pennsylvania
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina
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19
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Chiarelli N, Zoppi N, Ritelli M, Venturini M, Capitanio D, Gelfi C, Colombi M. Biological insights in the pathogenesis of hypermobile Ehlers-Danlos syndrome from proteome profiling of patients' dermal myofibroblasts. Biochim Biophys Acta Mol Basis Dis 2020; 1867:166051. [PMID: 33383104 DOI: 10.1016/j.bbadis.2020.166051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 02/07/2023]
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS), mainly characterized by generalized joint hypermobility and its complications, minor skin changes, and apparently segregating with an autosomal dominant pattern, is still without a known molecular basis. Hence, its diagnosis is only clinical based on a strict set of criteria defined in the revised EDS nosology. Moreover, the hEDS phenotypic spectrum is wide-ranging and comprises multiple associated signs and symptoms shared with other heritable or acquired connective tissue disorders and chronic inflammatory diseases. In this complex scenario, we previously demonstrated that hEDS patients' skin fibroblasts show phenotypic features of myofibroblasts, widespread extracellular matrix (ECM) disarray, perturbation of ECM-cell contacts, and dysregulated expression of genes involved in connective tissue architecture and related to inflammatory and pain responses. Herein, the cellular proteome of 6 hEDS dermal myofibroblasts was compared to that of 12 control fibroblasts to deepen the knowledge on mechanisms involved in the disease pathogenesis. Qualitative and quantitative differences were assessed based on top-down and bottom-up approaches and some differentially expressed proteins were proofed by biochemical analyses. Proteomics disclosed the differential expression of proteins principally implicated in cytoskeleton organization, energy metabolism and redox balance, proteostasis, and intracellular trafficking. Our findings offer a comprehensive view of dysregulated protein networks and related pathways likely associated with the hEDS pathophysiology. The present results can be regarded as a starting point for future in-depth investigations aimed to decipher the functional impact of potential bioactive molecules for the development of targeted management and therapies.
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Affiliation(s)
- Nicola Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marco Ritelli
- 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
| | - Daniele Capitanio
- Department of Biomedical Sciences for Health, University of Milan, Milano, Italy
| | - Cecilia Gelfi
- Department of Biomedical Sciences for Health, University of Milan, Milano, Italy; IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.
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20
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Ali A, Andrzejowski P, Kanakaris NK, Giannoudis PV. Pelvic Girdle Pain, Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review. J Clin Med 2020; 9:jcm9123992. [PMID: 33317183 PMCID: PMC7764306 DOI: 10.3390/jcm9123992] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/27/2020] [Accepted: 12/04/2020] [Indexed: 01/04/2023] Open
Abstract
Pelvic girdle pain (PGP) refers specifically to musculoskeletal pain localised to the pelvic ring and can be present at its anterior and/or posterior aspects. Causes such as trauma, infection and pregnancy have been well-established, while patients with hypermobile joints are at greater risk of developing PGP. Research exploring this association is limited and of varying quality. In the present study we report on the incidence, pathophysiology, diagnostic and treatment modalities for PGP in patients suffering from Hypermobility Spectrum Disorder (HSD) and Hypermobility-Type Ehlers-Danlos Syndrome (hEDS). Recommendations are made for clinical practice by elaborating on screening, diagnosis and management of such patients to provide a holistic approach to their care. It appears that this cohort of patients are at greater risk particularly of mental health issues. Moreover over, they may require a multidisciplinary approach for their management. Ongoing research is still required to expand our understanding of the relationship between PGP, HSD and hEDS by appropriately diagnosing patients using the latest updated terminologies and by conducting randomised control trials to compare outcomes of interventions using standardised patient reported outcome measures.
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Affiliation(s)
- Ahmed Ali
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Floor D, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Paul Andrzejowski
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Floor D, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Floor D, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Floor D, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds LS7 4SA, UK
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21
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Li J, Ritelli M, Ma CS, Rao G, Habib T, Corvilain E, Bougarn S, Cypowyj S, Grodecká L, Lévy R, Béziat V, Shang L, Payne K, Avery DT, Migaud M, Boucherit S, Boughorbel S, Guennoun A, Chrabieh M, Rapaport F, Bigio B, Itan Y, Boisson B, Cormier-Daire V, Syx D, Malfait F, Zoppi N, Abel L, Freiberger T, Dietz HC, Marr N, Tangye SG, Colombi M, Casanova JL, Puel A. Chronic mucocutaneous candidiasis and connective tissue disorder in humans with impaired JNK1-dependent responses to IL-17A/F and TGF-β. Sci Immunol 2020; 4:4/41/eaax7965. [PMID: 31784499 DOI: 10.1126/sciimmunol.aax7965] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/01/2019] [Indexed: 12/12/2022]
Abstract
Genetic etiologies of chronic mucocutaneous candidiasis (CMC) disrupt human IL-17A/F-dependent immunity at mucosal surfaces, whereas those of connective tissue disorders (CTDs) often impair the TGF-β-dependent homeostasis of connective tissues. The signaling pathways involved are incompletely understood. We report a three-generation family with an autosomal dominant (AD) combination of CMC and a previously undescribed form of CTD that clinically overlaps with Ehlers-Danlos syndrome (EDS). The patients are heterozygous for a private splice-site variant of MAPK8, the gene encoding c-Jun N-terminal kinase 1 (JNK1), a component of the MAPK signaling pathway. This variant is loss-of-expression and loss-of-function in the patients' fibroblasts, which display AD JNK1 deficiency by haploinsufficiency. These cells have impaired, but not abolished, responses to IL-17A and IL-17F. Moreover, the development of the patients' TH17 cells was impaired ex vivo and in vitro, probably due to the involvement of JNK1 in the TGF-β-responsive pathway and further accounting for the patients' CMC. Consistently, the patients' fibroblasts displayed impaired JNK1- and c-Jun/ATF-2-dependent induction of key extracellular matrix (ECM) components and regulators, but not of EDS-causing gene products, in response to TGF-β. Furthermore, they displayed a transcriptional pattern in response to TGF-β different from that of fibroblasts from patients with Loeys-Dietz syndrome caused by mutations of TGFBR2 or SMAD3, further accounting for the patients' complex and unusual CTD phenotype. This experiment of nature indicates that the integrity of the human JNK1-dependent MAPK signaling pathway is essential for IL-17A- and IL-17F-dependent mucocutaneous immunity to Candida and for the TGF-β-dependent homeostasis of connective tissues.
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Affiliation(s)
- Juan Li
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Cindy S Ma
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales 2010, Australia.,St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales 2010, Australia
| | - Geetha Rao
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales 2010, Australia
| | | | - Emilie Corvilain
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | | | - Sophie Cypowyj
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Lucie Grodecká
- Molecular Genetics Laboratory, Centre for Cardiovascular Surgery and Transplantation, Brno 65691, Czech Republic
| | - Romain Lévy
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | - Vivien Béziat
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | - Lei Shang
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Kathryn Payne
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales 2010, Australia
| | - Danielle T Avery
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales 2010, Australia
| | - Mélanie Migaud
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | - Soraya Boucherit
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | | | | | - Maya Chrabieh
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | - Franck Rapaport
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Benedetta Bigio
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA
| | - Yuval Itan
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA.,The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.,Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Bertrand Boisson
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | - Valérie Cormier-Daire
- University of Paris, Imagine Institute, 75015 Paris, France.,Department of Medical Genetics, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France
| | - Delfien Syx
- Center for Medical Genetics, Ghent University Hospital, 9000 Ghent, Belgium
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University Hospital, 9000 Ghent, Belgium
| | - Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Laurent Abel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA.,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
| | - Tomáš Freiberger
- Molecular Genetics Laboratory, Centre for Cardiovascular Surgery and Transplantation, Brno 65691, Czech Republic.,Faculty of Medicine and Central European Institute of Technology, Masaryk University, Brno 62500, Czech Republic
| | - Harry C Dietz
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.,Howard Hughes Medical Institute, Baltimore, MD 21205, USA
| | - Nico Marr
- Sidra Medicine, P.O. Box 26999, Doha, Qatar.,College of Health and Life Sciences, Hamad Bin Khalifa University, P.O. Box 34110, Doha, Qatar
| | - Stuart G Tangye
- Immunology Division, Garvan Institute of Medical Research, Darlinghurst, New South Wales 2010, Australia.,St. Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales 2010, Australia
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy
| | - Jean-Laurent Casanova
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA. .,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France.,Pediatric Hematology-Immunology Unit, Necker Hospital for Sick Children, 75015 Paris, France.,Howard Hughes Medical Institute, New York, NY 10065, USA
| | - Anne Puel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, The Rockefeller University, New York, NY 10065, USA. .,Laboratory of Human Genetics of Infectious Diseases, Necker Branch, INSERM U1163, Necker Hospital for Sick Children, 75015 Paris, France.,University of Paris, Imagine Institute, 75015 Paris, France
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22
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Beckers AB, Vork L, Fikree A, de Ridder R, Aziz Q, Masclee A, Keszthelyi D. Colonoscopy is safe and not associated with higher pain scores in patients with hypermobility spectrum disorder: results from an exploratory prospective study. Therap Adv Gastroenterol 2020; 13:1756284820927310. [PMID: 32733599 PMCID: PMC7370544 DOI: 10.1177/1756284820927310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patient perception of colonoscopy varies greatly. Young slender women and patients with irritable bowel syndrome (IBS) appear to be at risk for periprocedural pain. Recent evidence suggests a high prevalence of joint hypermobility related connective tissue disorders in this population. Therefore, we aimed to investigate whether hypermobility spectrum disorder (HSD) is associated with increased pain during colonoscopy. METHODS We prospectively included patients undergoing routine colonoscopy. Subjects were assessed for HSD using the 2017 criteria, and IBS and functional dyspepsia using the Rome III criteria. After colonoscopy and recovery from sedation, patients were asked to report pain scores on a 100-mm visual analogue scale (VAS). In addition, caecal intubation time was measured, endoscopists scored the difficulty of the procedure (100-mm VAS) and procedure-related adverse events were registered. RESULTS Of 200 included patients, 22 (11%) met criteria for HSD. A female predominance was observed in patients with HSD (86.4% versus 49.4%, p < 0.001). A crude linear regression model demonstrated that pain scores were 13.30 mm higher in patients with HSD versus non-HSD patients (95% CI 0.07 - 26.53, p = 0.049). When subsequently correcting for possible confounding factors, however, this difference in pain scores could be explained by a confounding effect of female gender. Caecal intubation time, perceived procedural difficulty and complication rate did not differ significantly between groups. CONCLUSION HSD does not seem to be a predictor of painful colonoscopy, probably due to female gender as a confounding factor. In addition, performing colonoscopy is not more complicated in patients with HSD versus non-HSD patients, nor is it associated with more adverse events.
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Affiliation(s)
- Abraham B. Beckers
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Lisa Vork
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Asma Fikree
- Gastroenterology Department, Royal London Hospital, London, UK
| | - Rogier de Ridder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
| | - Qasim Aziz
- Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
| | - Ad Masclee
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Limburg, The Netherlands
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23
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Copetti M, Morlino S, Colombi M, Grammatico P, Fontana A, Castori M. Severity classes in adults with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders: a pilot study of 105 Italian patients. Rheumatology (Oxford) 2020; 58:1722-1730. [PMID: 30783660 DOI: 10.1093/rheumatology/kez029] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/09/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES This study is aimed at identifying discrete severity classes among adults with hypermobile Ehlers-Danlos syndrome (hEDS)/hypermobility spectrum disorders (HSD). METHODS Subjects were selected according to the old and new nomenclatures and all completed a set of questionnaires exploring pain, fatigue, dysautonomic symptoms, coordination and attention/concentration deficits and quality of life in general. Data were investigated by hierarchical clustering on principal components. Cluster comparisons were then performed by using the two-sample unpaired t test and the standardized mean difference was reported as a measure of effect size. Conditional classification tree analysis and multivariable logistic regression were carried out in order to identify the profiles that were at higher risk to belong to the more severe cluster. Weighted linear combination was used to identify a numerical score measuring this risk. RESULTS A total of 105 patients were selected and distributed in two distinct severity groups. These groups were statistically separated on the basis of 47 of 59 items/characteristics. One group featured the worse values of most questionnaire items (complex/severe cluster) and the other was dominated by the better values (simplex/milder cluster). Only three items were able to stratify patients according to their risk to belong to the complex cluster. A severity score was then constructed on these three items. CONCLUSION Adults with hEDS/HSD can be separated in two severity classes, which do not mirror either the old or new criteria for hEDS. The identified severity score could allow a bi-dimensional approach to adults with hEDS/HSD for optimal management planning.
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Affiliation(s)
- Massimiliano Copetti
- Unit of Biostatistics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo
| | - Silvia Morlino
- Laboratory of Medical Genetics, Department of Molecular Medicine, Sapienza University of Rome, San Camillo-Forlanini Hospital.,Vaclav Vojta Rehabilitation Center, Rome
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Brescia
| | - Paola Grammatico
- Laboratory of Medical Genetics, Department of Molecular Medicine, Sapienza University of Rome, San Camillo-Forlanini Hospital
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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24
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Vera AM, Peterson LE, Dong D, Haghshenas V, Yetter TR, Delgado DA, McCulloch PC, Varner KE, Harris JD. High Prevalence of Connective Tissue Gene Variants in Professional Ballet. Am J Sports Med 2020; 48:222-228. [PMID: 31765226 DOI: 10.1177/0363546519887955] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a high prevalence of hypermobility spectrum disorder (HSD) in dancers. While there is no known genetic variant for HSD, hypermobile Ehlers-Danlos syndrome is a genetic disorder that exists within HSD. There are many connective tissue disorders (CTDs) with known (and unknown) genes associated with hypermobility. Hypermobility has distinct advantages for participation in flexibility sports, including ballet. PURPOSE To determine the prevalence of gene variants associated with hypermobility in a large professional ballet company. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS In this cross-sectional investigation, 51 professional male and female dancers from a large metropolitan ballet company were eligible and offered participation after an oral and written informed consent process. Whole blood was obtained from peripheral venipuncture, and DNA was isolated. Isolated DNA was subsequently enriched for the coding exons of 60 genes associated with CTD that included hypermobility as a phenotype, including Ehlers-Danlos syndromes, osteogenesis imperfecta, Marfan syndrome, and others. Genes were targeted with hybrid capture technology. Prepared DNA libraries were then sequenced with next-generation sequencing technology. Genetic database search tools (Human Gene Mutation Database and e!Ensembl, http://useast.ensembl.org/ ) were used to query specific variants. Descriptive statistics were calculated. RESULTS Of 51 dancers, 32 (63%) agreed to participate in DNA analysis (mean ± SD age, 24.3 ± 4.4 years; 18 men, 14 women). Twenty-eight dancers had at least 1 variant in the 60 genes tested, for an 88% prevalence. A total of 80 variants were found. A variant in 26 of the 60 genes was found in at least 1 dancer. Among the 28 dancers with variants, 16 were found in the TTN gene; 10 in ZNF469; 5 in RYR1; 4 in COL12A1; 3 in ABCC6 and COL6A2; 2 in ADAMTS2, CBS, COL1A2, COL6A3, SLC2A10, TNC, and TNXB; and 1 in ATP6V0A2, B4GALT7, BMP1, COL11A1, COL5A2, COL6A1, DSE, FBN1, FBN2, NOTCH1, PRDM5, SMAD3, and TGFBR1. Nine variants found in this population have never been reported. No identified variant was identical to any other variant. No identified variant was known to be disease causing. In the general population, the prevalence of each variant ranges from never reported to 0.33%. In the study population, the prevalence of each variant was 3.13%. There was no association between hypermobility scores and genetic variants. CONCLUSION Genetic variants in CTD-associated genes are highly prevalent (88%) in professional ballet dancers. This may significantly account for the high degree of motion in this population.
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Affiliation(s)
- Angelina M Vera
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Leif E Peterson
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - David Dong
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Varan Haghshenas
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Thomas R Yetter
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | | | | | - Kevin E Varner
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Joshua D Harris
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
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25
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Morlino S, Micale L, Ritelli M, Rohrbach M, Zoppi N, Vandersteen A, Mackay S, Agolini E, Cocciadiferro D, Sasaki E, Madeo A, Ferraris A, Reardon W, Di Rocco M, Novelli A, Grammatico P, Malfait F, Mazza T, Hakim A, Giunta C, Colombi M, Castori M. COL1-related overlap disorder: A novel connective tissue disorder incorporating the osteogenesis imperfecta/Ehlers-Danlos syndrome overlap. Clin Genet 2019; 97:396-406. [PMID: 31794058 DOI: 10.1111/cge.13683] [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] [Received: 10/11/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/19/2022]
Abstract
The 2017 classification of Ehlers-Danlos syndromes (EDS) identifies three types associated with causative variants in COL1A1/COL1A2 and distinct from osteogenesis imperfecta (OI). Previously, patients have been described with variable features of both disorders, and causative variants in COL1A1/COL1A2; but this phenotype has not been included in the current classification. Here, we expand and re-define this OI/EDS overlap as a missing EDS type. Twenty-one individuals from 13 families were reported, in whom COL1A1/COL1A2 variants were found after a suspicion of EDS. None of them could be classified as affected by OI or by any of the three recognized EDS variants associated with COL1A1/COL1A2. This phenotype is dominated by EDS-related features. OI-related features were limited to mildly reduced bone mass, occasional fractures and short stature. Eight COL1A1/COL1A2 variants were novel and five recurrent with a predominance of glycine substitutions affecting residues within the procollagen N-proteinase cleavage site of α1(I) and α2(I) procollagens. Selected variants were investigated by biochemical, ultrastructural and immunofluorescence studies. The pattern of observed changes in the dermis and in vitro for selected variants was more typical of EDS rather than OI. Our findings indicate the existence of a wider recognizable spectrum associated with COL1A1/COL1A2.
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Affiliation(s)
- Silvia Morlino
- Laboratory of Medical Genetics, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Lucia Micale
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo (Foggia), Italy
| | - Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marianne Rohrbach
- Division of Metabolism and Children's Research Centre, University Children's Hospital, Zurich, Switzerland
| | - Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | | | - Sara Mackay
- Maritime Medical Genetics Service, Dalhousie University, Halifax, Canada
| | - Emanuele Agolini
- Laboratory of Medical Genetics, IRCCS Bambino Gesù Children Hospital, Rome, Italy
| | - Dario Cocciadiferro
- Laboratory of Medical Genetics, IRCCS Bambino Gesù Children Hospital, Rome, Italy
| | - Erina Sasaki
- Department of Clinical Genetics, Children's Health Ireland (CHI) at Crumlin, Crumlin, Ireland
| | - Annalisa Madeo
- Unit of Rare Diseases, IRCCS Institute Gianna Gaslini, Genoa, Italy
| | - Alessandro Ferraris
- Laboratory of Medical Genetics, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | - Willie Reardon
- Department of Clinical Genetics, Children's Health Ireland (CHI) at Crumlin, Crumlin, Ireland
| | - Maja Di Rocco
- Unit of Rare Diseases, IRCCS Institute Gianna Gaslini, Genoa, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, IRCCS Bambino Gesù Children Hospital, Rome, Italy
| | - Paola Grammatico
- Laboratory of Medical Genetics, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Tommaso Mazza
- Unit of Bioinformatics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo (Foggia), Italy
| | - Alan Hakim
- The Platinum Medical Center, The Wellington Hospital, London, UK
| | - Cecilia Giunta
- Connective Tissue Unit, Division of Metabolism and Children's Research Centre, University Children's Hospital, Zurich, Switzerland
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS-Casa Sollievo della Sofferenza, San Giovanni Rotondo (Foggia), Italy
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26
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Rymen D, Ritelli M, Zoppi N, Cinquina V, Giunta C, Rohrbach M, Colombi M. Clinical and Molecular Characterization of Classical-Like Ehlers-Danlos Syndrome Due to a Novel TNXB Variant. Genes (Basel) 2019; 10:genes10110843. [PMID: 31731524 PMCID: PMC6895888 DOI: 10.3390/genes10110843] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/20/2019] [Accepted: 10/23/2019] [Indexed: 12/21/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) constitute a clinically and genetically heterogeneous group of connective tissue disorders. Tenascin X (TNX) deficiency is a rare type of EDS, defined as classical-like EDS (clEDS), since it phenotypically resembles the classical form of EDS, though lacking atrophic scarring. Although most patients display a well-defined phenotype, the diagnosis of TNX-deficiency is often delayed or overlooked. Here, we described an additional patient with clEDS due to a homozygous null-mutation in the TNXB gene. A review of the literature was performed, summarizing the most important and distinctive clinical signs of this disorder. Characterization of the cellular phenotype demonstrated a distinct organization of the extracellular matrix (ECM), whereby clEDS distinguishes itself from most other EDS subtypes by normal deposition of fibronectin in the ECM and a normal organization of the α5β1 integrin.
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Affiliation(s)
- Daisy Rymen
- Connective Tissue Unit, Division of Metabolism and Children’s Research Centre, University Children’s Hospital, 8032 Zürich, Switzerland; (C.G.); (M.R.)
- Correspondence:
| | - Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (M.R.); (N.Z.); (V.C.); (M.C.)
| | - Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (M.R.); (N.Z.); (V.C.); (M.C.)
| | - Valeria Cinquina
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (M.R.); (N.Z.); (V.C.); (M.C.)
| | - Cecilia Giunta
- Connective Tissue Unit, Division of Metabolism and Children’s Research Centre, University Children’s Hospital, 8032 Zürich, Switzerland; (C.G.); (M.R.)
| | - Marianne Rohrbach
- Connective Tissue Unit, Division of Metabolism and Children’s Research Centre, University Children’s Hospital, 8032 Zürich, Switzerland; (C.G.); (M.R.)
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, University of Brescia, 25123 Brescia, Italy; (M.R.); (N.Z.); (V.C.); (M.C.)
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27
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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: 40] [Impact Index Per Article: 8.0] [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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28
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Morlino S, Carbone A, Ritelli M, Fusco C, Giambra V, Nardella G, Notarangelo A, Panelli P, Mazzoccoli G, Zoppi N, Grammatico P, Wade EM, Colombi M, Castori M, Micale L. TAB2 c.1398dup variant leads to haploinsufficiency and impairs extracellular matrix homeostasis. Hum Mutat 2019; 40:1886-1898. [PMID: 31250519 DOI: 10.1002/humu.23834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 12/16/2022]
Abstract
Transforming growth factor β-activated kinase 1 (TAK1) mediates multiple biological processes through the nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB) and the mitogen-activated protein kinase (MAPK) signaling pathways. TAK1 activation is tightly regulated by its binding partners (TABs). In particular, binding with TAB2 is crucial for cardiovascular development and extracellular matrix (ECM) homeostasis. In our previous work, we reported a novel multisystem disorder associated with the heterozygous TAB2 c.1398dup variant. Here, we dissect the functional effects of this variant in order to understand its molecular pathogenesis. We demonstrate that TAB2 c.1398dup considerably undergoes to nonsense-mediated messenger RNA decay and encodes a truncated protein that loses its ability to bind TAK1. We also show an alteration of the TAK1 autophosphorylation status and of selected downstream signaling pathways in patients' fibroblasts. Immunofluorescence analyses and ECM-related polymerase chain reaction-array panels highlight that patient fibroblasts display ECM disorganization and altered expression of selected ECM components and collagen-related pathways. In conclusion, we deeply dissect the molecular pathogenesis of the TAB2 c.1398dup variant and show that the resulting phenotype is well explained by TAB2 loss-of-function. Our data also offer initial insights on the ECM homeostasis impairment as a molecular mechanism probably underlying a multisystem disorder linked to TAB2.
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Affiliation(s)
- Silvia Morlino
- Laboratory of Medical Genetics, Department of Molecular Medicine, San Camillo-Forlanini Hospital, Sapienza University, Rome, Italy
| | - Annalucia Carbone
- Division of Internal Medicine and Unit of Chronobiology, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Marco Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Universityinflammatory disorders and cancer of Brescia, Brescia, Italy
| | - Carmela Fusco
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Vincenzo Giambra
- Institute for Stem Cell Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Grazia Nardella
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy.,Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Patrizio Panelli
- Institute for Stem Cell Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Gianluigi Mazzoccoli
- Division of Internal Medicine and Unit of Chronobiology, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Nicoletta Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Universityinflammatory disorders and cancer of Brescia, Brescia, Italy
| | - Paola Grammatico
- Laboratory of Medical Genetics, Department of Molecular Medicine, San Camillo-Forlanini Hospital, Sapienza University, Rome, Italy
| | - Emma M Wade
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Marina Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Universityinflammatory disorders and cancer of Brescia, Brescia, Italy
| | - Marco Castori
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
| | - Lucia Micale
- Division of Medical Genetics, Fondazione IRCCS Casa Sollievo della Sofferenza, Foggia, Italy
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29
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Chiarelli N, Carini G, Zoppi N, Ritelli M, Colombi M. Molecular insights in the pathogenesis of classical Ehlers-Danlos syndrome from transcriptome-wide expression profiling of patients' skin fibroblasts. PLoS One 2019; 14:e0211647. [PMID: 30716086 PMCID: PMC6361458 DOI: 10.1371/journal.pone.0211647] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/17/2019] [Indexed: 12/16/2022] Open
Abstract
Classical Ehlers-Danlos syndrome (cEDS) is a dominant inherited connective tissue disorder mainly caused by mutations in the COL5A1 and COL5A2 genes encoding type V collagen (COLLV), which is a fibrillar COLL widely distributed in a variety of connective tissues. cEDS patients suffer from skin hyperextensibility, abnormal wound healing/atrophic scars, and joint hypermobility. Most of the causative variants result in a non-functional COL5A1 allele and COLLV haploinsufficiency, whilst COL5A2 mutations affect its structural integrity. To shed light into disease mechanisms involved in cEDS, we performed gene expression profiling in skin fibroblasts from four patients harboring haploinsufficient and structural mutations in both disease genes. Transcriptome profiling revealed significant changes in the expression levels of different extracellular matrix (ECM)-related genes, such as SPP1, POSTN, EDIL3, IGFBP2, and C3, which encode both matricellular and soluble proteins that are mainly involved in cell proliferation and migration, and cutaneous wound healing. These gene expression changes are consistent with our previous protein findings on in vitro fibroblasts from other cEDS patients, which exhibited reduced migration and poor wound repair owing to COLLV disorganization, altered deposition of fibronectin into ECM, and an abnormal integrin pattern. Microarray analysis also indicated the decreased expression of DNAJB7, VIPAS39, CCPG1, ATG10, SVIP, which encode molecular chaperones facilitating protein folding, enzymes regulating post-Golgi COLLs processing, and proteins acting as cargo receptors required for endoplasmic reticulum (ER) proteostasis and implicated in the autophagy process. Patients’ cells also showed altered mRNA levels of many cell cycle regulating genes including CCNE2, KIF4A, MKI67, DTL, and DDIAS. Protein studies showed that aberrant COLLV expression causes the disassembly of itself and many structural ECM constituents including COLLI, COLLIII, fibronectin, and fibrillins. Our findings provide the first molecular evidence of significant gene expression changes in cEDS skin fibroblasts highlighting that defective ECM remodeling, ER homeostasis and autophagy might play a role in the pathogenesis of this connective tissue disorder.
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Affiliation(s)
- Nicola Chiarelli
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Giulia Carini
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Nicoletta Zoppi
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Marco Ritelli
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
| | - Marina Colombi
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, University of Brescia, Brescia, Italy
- * E-mail:
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30
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Mu W, Muriello M, Clemens JL, Wang Y, Smith CH, Tran PT, Rowe PC, Francomano CA, Kline AD, Bodurtha J. Factors affecting quality of life in children and adolescents with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders. Am J Med Genet A 2019; 179:561-569. [PMID: 30703284 DOI: 10.1002/ajmg.a.61055] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/29/2018] [Accepted: 12/05/2018] [Indexed: 12/12/2022]
Abstract
Hypermobile Ehlers-Danlos syndrome (hEDS) is a hereditary disorder of connective tissue, often presenting with complex symptoms can include chronic pain, fatigue, and dysautonomia. Factors influencing functional disability in the pediatric hEDS population are incompletely studied. This study's aims were to assess factors that affect quality of life in children and adolescents with hEDS. Individuals with hEDS between the ages 12-20 years and matched parents were recruited through retrospective chart review at two genetics clinics. Participants completed a questionnaire that included the Pediatric Quality of Life Inventory (PedsQL™), PedsQL Multidimentional Fatigue Scale, Functional Disability Inventory, Pain-Frequency-Severity-Duration Scale, the Brief Illness Perception Questionnaire, measures of anxiety and depression, and helpful interventions. Survey responses were completed for 47 children and adolescents with hEDS/hypermobility spectrum disorder (81% female, mean age 16 years), some by the affected individual, some by their parent, and some by both. Clinical data derived from chart review were compared statistically to survey responses. All outcomes correlated moderately to strongly with each other. Using multiple regression, general fatigue and pain scores were the best predictors of the PedsQL total score. Additionally, presence of any psychiatric diagnosis was correlated with a lower PedsQL score. Current management guidelines recommend early intervention to prevent disability from deconditioning; these results may help identify target interventions in this vulnerable population.
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Affiliation(s)
- Weiyi Mu
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Muriello
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia L Clemens
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - You Wang
- Department of Public Health Studies, Johns Hopkins University Krieger School of Art and Science, Baltimore, Maryland
| | - Christy H Smith
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phuong T Tran
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Ho Chi Minh City University of Technology (HUTECH), Ho Chi Minh City, Vietnam
| | - Peter C Rowe
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clair A Francomano
- Harvey Institute for Human Genetics, Greater Baltimore Medical Center, Baltimore, Maryland
| | - Antonie D Kline
- Harvey Institute for Human Genetics, Greater Baltimore Medical Center, Baltimore, Maryland
| | - Joann Bodurtha
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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31
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Abstract
Efforts on recognition, diagnosis, and management of the presumed, most common connective tissue disorder hypermobile Ehlers-Danlos syndrome have been an ongoing challenge, even decades after the description of this condition. A recent international consortium proposed a revised Ehlers-Danlos syndrome classification, an update much needed since Villefranche nosology, in 1998. Hypermobile Ehlers-Danlos syndrome is the only subtype in these groups of syndromes with no known genetic cause(s). This effort brought significant attention to this often underappreciated condition. This review provides an update of the clinical and genetic aspects of hypermobile Ehlers-Danlos syndrome for clinicians and researchers.
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Affiliation(s)
- Irman Forghani
- Clinic of Clinical and Translational Genetics, Dr. John T. Macdonald Foundation Department of Human Genetics, University of Miami, Miller School of Medicine, Miami, USA
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32
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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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