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Doolan BJ, Lavallee ME, Hausser I, Schubart JR, Michael Pope F, Seneviratne SL, Winship IM, Burrows NP. Extracutaneous features and complications of the Ehlers-Danlos syndromes: A systematic review. Front Med (Lausanne) 2023; 10:1053466. [PMID: 36756177 PMCID: PMC9899794 DOI: 10.3389/fmed.2023.1053466] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction The Ehlers-Danlos syndromes (EDS) comprise a group of inherited connective tissue disorders presenting with variable fragility to skin, soft tissue, and certain internal organs, which can cause significant complications, particularly arterial rupture, bowel perforation and joint difficulties. Currently, there are 14 proposed subtypes of EDS, with all except one subtype (hypermobile EDS) having an identified genetic etiology. An understanding of the extracutaneous features and complications within each subtype is key to maximizing clinical care and reducing the risk of further complications. Methods A systematic review of EDS-related extracutaneous features and complications was undertaken. Results We identified 839 EDS cases that met the inclusion criteria. We noted a high prevalence of joint hypermobility amongst kyphoscoliotic (39/39, 100%), spondylodysplastic (24/25, 96.0%), and hypermobile (153/160, 95.6%) EDS subtypes. The most common musculoskeletal complications were decreased bone density (39/43, 90.7%), joint pain (217/270, 80.4%), and hypotonia/weakness (79/140, 56.4%). Vascular EDS presented with cerebrovascular events (25/153, 16.3%), aneurysm (77/245, 31.4%), arterial dissection/rupture (89/250, 35.5%), and pneumothorax/hemothorax. Chronic pain was the most common miscellaneous complication, disproportionately affecting hypermobile EDS patients (139/157, 88.5%). Hypermobile EDS cases also presented with chronic fatigue (61/63, 96.8%) and gastrointestinal complications (57/63, 90.5%). Neuropsychiatric complications were noted in almost all subtypes. Discussion Understanding the extracutaneous features and complications of each EDS subtype may help diagnose and treat EDS prior to the development of substantial comorbidities and/or additional complications. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022308151, identifier CRD42022308151.
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Affiliation(s)
- Brent J. Doolan
- School of Basic and Medical Biosciences, St. John’s Institute of Dermatology, King’s College London, London, United Kingdom,*Correspondence: Brent J. Doolan,
| | - Mark E. Lavallee
- Department of Orthopedics, University of Pittsburgh Medical Center of Central PA, Pittsburgh, PA, United States
| | - Ingrid Hausser
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jane R. Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, United States
| | - F. Michael Pope
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust (West Middlesex University Hospital), London, United Kingdom
| | - Suranjith L. Seneviratne
- Institute of Immunity and Transplantation, Royal Free Hospital and University College London, London, United Kingdom,Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo, Sri Lanka
| | - Ingrid M. Winship
- Department of Genetic Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Nigel P. Burrows
- Department of Dermatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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2
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Cavitating Lung Disease Associated With Sudden Death. Chest 2022; 161:e279-e285. [PMID: 35526897 DOI: 10.1016/j.chest.2021.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/10/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
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Fett J, Dimori M, Carroll JL, Morello R. Haploinsufficiency of Col5a1 causes intrinsic lung and respiratory changes in a mouse model of classical Ehlers-Danlos syndrome. Physiol Rep 2022; 10:e15275. [PMID: 35439366 PMCID: PMC9017971 DOI: 10.14814/phy2.15275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 11/24/2022] Open
Abstract
The Ehlers-Danlos syndromes (EDS) are inherited connective tissue diseases with primary manifestations that affect the skin and the musculoskeletal system. However, the effects of EDS on the respiratory system are not well understood and are described in the literature as sporadic case reports. We performed histological, histomorphometric, and the first in-depth characterization of respiratory system function in a mouse model of classical EDS (cEDS) with haploinsufficiency of type V collagen (Col5a1+/-). In young adult male and female mice, lung histology showed reduced alveolar density, reminiscent of emphysematous-like changes. Respiratory mechanics showed a consistent increase in respiratory system compliance accompanied by increased lung volumes in Col5a1+/- compared to control mice. Flow-volume curves, generated to mimic human spirometry measurements, demonstrated larger volumes throughout the expiratory limb of the flow volume curves in Col5a1+/- compared to controls. Some parameters showed a sexual dimorphism with significant changes in male but not female mice. Our study identified a clear respiratory phenotype in the Col5a1+/- mouse model of EDS and indicated that intrinsic respiratory and lung changes may exist in cEDS patients. Their potential impact on the respiratory function during lung infections, other respiratory disease processes, or insults may be significant and justify further clinical evaluation.
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Affiliation(s)
- Jordan Fett
- Department of PediatricsUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Milena Dimori
- Department of Physiology & Cell BiologyUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - John L. Carroll
- Department of PediatricsUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
- Department of Physiology & Cell BiologyUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Roy Morello
- Department of Physiology & Cell BiologyUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
- Department of Orthopaedic SurgeryUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
- Division of GeneticsUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
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4
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Bascom R, Dhingra R, Francomano CA. Respiratory manifestations in the Ehlers-Danlos syndromes. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2021; 187:533-548. [PMID: 34811894 DOI: 10.1002/ajmg.c.31953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 10/16/2021] [Indexed: 06/13/2023]
Abstract
Persons with the Ehlers-Danlos syndromes (EDS) report a wide range of respiratory symptoms, most commonly shortness of breath, exercise limitation, and cough. Also reported are noisy breathing attributed to asthma, difficulty with deep inhalation, and inspiratory thoracic pain. The literature consists of case reports and small cross-sectional and cohort studies. One case-control study estimated twofold to threefold greater respiratory disease burden among persons with EDS as compared to controls. The differential diagnosis for symptoms is broad. Structural alterations include pectus deformities, scoliosis, recurrent rib subluxations, and tracheobronchomalacia, associated with varying degrees of physiologic impairment. Those with vascular EDS have an increased risk of pneumothorax, intrapulmonary bleeding, cysts, and nonmalignant fibrous nodules. Functional aerodigestive manifestations such as inducible laryngeal obstruction may be misdiagnosed as asthma, with gastro-esophageal dysmotility and reflux as common contributing factors. Inflammatory manifestations include costochondritis, bronchiectasis, and localized respiratory allergic and nonallergic mast cell activation. Cranio-cervical instability can dysregulate respiratory control pathways. There is a need for careful phenotyping using standardized clinical tools and patient-reported outcomes and continuing collaboration with aerodigestive specialists including otolaryngologists and gastroenterologists. Also needed is further evaluation of respiratory symptoms in persons with hypermobility spectrum disorders. Personalized monitoring strategies are invaluable for interpretation and long-term management of respiratory symptoms.
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Affiliation(s)
- Rebecca Bascom
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Penn State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Radha Dhingra
- Division of Epidemiology, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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5
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Bascom R, Dhingra R, Francomano CA, Schubart JR. A case-control study of respiratory medication and co-occurring gastrointestinal prescription burden among persons with Ehlers-Danlos syndromes. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:549-560. [PMID: 34766427 DOI: 10.1002/ajmg.c.31947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/25/2021] [Accepted: 10/16/2021] [Indexed: 11/07/2022]
Abstract
We previously reported increased pain and gastrointestinal (GI) medication prescription claims among persons with Ehlers-Danlos syndromes (EDS) and peripubertal increase in opioid and anti-emetic claims among women with EDS. Herein, we hypothesized a higher proportion of respiratory and co-occurring respiratory and GI medication prescription claims among persons with EDS compared to their matched controls with increases among peripubertal women with EDS. We compared the proportions of respiratory and co-occurring respiratory and GI medication prescription claims among persons with EDS (aged 5-62) against their age-, sex-, state of residence-, and earliest claim date-matched controls using 10 years of private prescription claims data. Prescription claims among persons with EDS versus matched controls were increased for eight medication classes (p < .0001): intranasal/inhaled corticosteroids (ICS) (30.8% vs. 19.0%), oral steroids (30.0% vs. 16.5%), H1-antihistamines (26.2% vs. 12.2%), short-acting beta agonists (22.7% vs. 11.6%), decongestants (21.6% vs. 15.9%), leukotriene modifiers (8.9% vs. 3.6%), ICS/long-acting beta agonists (5.7% vs. 2.9%), muscarinic antagonists (2.5% vs. 0.9%), and co-occurring prescriptions (29% vs. 10%). Our results suggest a critical time window for peripubertal intervention and research and a need to focus on the pathogenesis and clinical evaluation of EDS-specific respiratory and aerodigestive disorders.
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Affiliation(s)
- Rebecca Bascom
- Department of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.,Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Radha Dhingra
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jane R Schubart
- Department of Public Health Sciences, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.,Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Lindsay ME, Dudzinski DM, Yoon BC, Jaff MR, Thakuria JV. Case 30-2021: A 47-Year-Old Man with Recurrent Unilateral Head and Neck Pain. N Engl J Med 2021; 385:1317-1325. [PMID: 34587390 DOI: 10.1056/nejmcpc2107347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Mark E Lindsay
- From the Departments of Medicine (M.E.L., D.M.D.), Pediatrics (M.E.L., J.V.T.), Radiology (B.C.Y.), and Surgery (M.R.J.), Massachusetts General Hospital, and the Departments of Medicine (M.E.L., D.M.D., M.R.J.), Pediatrics (M.E.L., J.V.T.), and Radiology (B.C.Y.), Harvard Medical School - both in Boston
| | - David M Dudzinski
- From the Departments of Medicine (M.E.L., D.M.D.), Pediatrics (M.E.L., J.V.T.), Radiology (B.C.Y.), and Surgery (M.R.J.), Massachusetts General Hospital, and the Departments of Medicine (M.E.L., D.M.D., M.R.J.), Pediatrics (M.E.L., J.V.T.), and Radiology (B.C.Y.), Harvard Medical School - both in Boston
| | - Byung C Yoon
- From the Departments of Medicine (M.E.L., D.M.D.), Pediatrics (M.E.L., J.V.T.), Radiology (B.C.Y.), and Surgery (M.R.J.), Massachusetts General Hospital, and the Departments of Medicine (M.E.L., D.M.D., M.R.J.), Pediatrics (M.E.L., J.V.T.), and Radiology (B.C.Y.), Harvard Medical School - both in Boston
| | - Michael R Jaff
- From the Departments of Medicine (M.E.L., D.M.D.), Pediatrics (M.E.L., J.V.T.), Radiology (B.C.Y.), and Surgery (M.R.J.), Massachusetts General Hospital, and the Departments of Medicine (M.E.L., D.M.D., M.R.J.), Pediatrics (M.E.L., J.V.T.), and Radiology (B.C.Y.), Harvard Medical School - both in Boston
| | - Joseph V Thakuria
- From the Departments of Medicine (M.E.L., D.M.D.), Pediatrics (M.E.L., J.V.T.), Radiology (B.C.Y.), and Surgery (M.R.J.), Massachusetts General Hospital, and the Departments of Medicine (M.E.L., D.M.D., M.R.J.), Pediatrics (M.E.L., J.V.T.), and Radiology (B.C.Y.), Harvard Medical School - both in Boston
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7
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Vascular Ehlers-Danlos syndrome (vEDS): CT and histologic findings of pleural and lung parenchymal damage. Eur Radiol 2021; 31:6275-6285. [PMID: 33651202 DOI: 10.1007/s00330-021-07710-6] [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: 07/19/2020] [Revised: 12/17/2020] [Accepted: 01/21/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To describe CT features of lung involvement in patients with vascular Ehlers-Danlos syndrome (vEDS), a rare genetic condition caused by pathogenic variants within the COL3A1 gene, characterized by recurrent arterial, digestive, and pulmonary events. MATERIAL AND METHODS All consecutive vEDS patients referred to the national tertiary referral center for vEDS, between 2004 and 2016, were included. Chest CT scans obtained during the initial vascular work-up were reviewed retrospectively by two chest radiologists for lung involvement. Five surgical samples underwent histologic examination. RESULTS Among 136 enrolled patients (83 women, 53 men; mean age 37 years) with molecularly confirmed vEDS, 24 (17.6%) had a history of respiratory events: 17 with pneumothorax, 4 with hemothorax, and 3 with hemoptysis that required thoracic surgery in 11. CT scans detected lung parenchymal abnormalities in 78 (57.3%) patients: emphysema (mostly centrilobular and paraseptal) in 44 (32.3%), comparable for smokers and non-smokers; clusters of calcified small pulmonary nodules in 9 (6.6%); and cavitated nodules in 4 (2.9%). Histologic examination of surgical samples found arterial abnormalities, emphysema with alveolar ruptures in 3, accompanied by diffuse hemorrhage and increased hemosiderin resorption. CONCLUSION In vEDS patients, identification of lung parenchymal abnormalities is common on CT. The most frequently observed CT finding was emphysema suggesting alveolar wall rupture which might facilitate the diagnostic screening of the disease in asymptomatic carriers of a genetic COL3A1 gene mutation. The prognostic value and evolution of these parenchymal abnormalities remain to be evaluated. KEY POINTS • Patients with vEDS can have lung parenchymal changes on top of or next to thoracal vascular abnormalities and that these changes can be present in asymptomatic cases. • The presence of these parenchymal changes is associated with a slightly higher incidence of respiratory events (although not statistically significant). • Identification of the described CT pattern by radiologists and chest physicians may facilitate diagnostic screening.
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Abstract
Systemic diseases often manifest with cutaneous findings. Many pediatric conditions with prominent skin findings also have significant pulmonary manifestations. These conditions include both inherited multisystem genetic disorders such as yellow-nail syndrome, neurofibromatosis type 1, tuberous sclerosis complex, hereditary hemorrhagic telangiectasia, Klippel-Trénaunay-Weber syndrome, cutis laxa, Ehlers-Danlos syndrome, dyskeratosis congenita, reactive processes such as mastocytosis, and aquagenic wrinkling of the palms. This overview discusses the pulmonary manifestations of skin disorders.
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Affiliation(s)
- Bernard A Cohen
- Division of Pediatric Dermatology, Johns Hopkins Medical Institutions, 200 N. Wolfe Street, Baltimore, MD 21287, USA.
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9
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Mendonça Almeida L, Sousa C, Vilares Morgado P, Fernandes P, Amado J, Paiva JA, Marinho A, Oliveira JP. Massive Pulmonary Thrombosis Following Haemoptysis in Type IV Ehlers-Danlos Syndrome. Arch Bronconeumol 2020; 57:309-311. [PMID: 33478827 DOI: 10.1016/j.arbres.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Célia Sousa
- Radiology Department, Centro Hospitalar e Universitário São João, Porto, Portugal
| | | | - Pedro Fernandes
- Cardiothoracic Surgery Department, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - José Amado
- Intensive Care Medicine Department, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - José Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar e Universitário São João, Porto, Portugal; Internal Medicine Department, Faculty of Medicine of University of Porto, Portugal
| | - Anabela Marinho
- Pulmonology Department, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - João Paulo Oliveira
- Medical Genetics Department, Centro Hospitalar e Universitário São João, Porto, Portugal; Unit of Genetics, Department of Pathology, Faculty of Medicine of University of Porto, Portugal; i3S - Institute for Research and Innovation in Health/Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Portugal
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10
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Yonker LM, Hawley MH, Moschovis PP, Lu M, Kinane TB. Recognizing genetic disease: A key aspect of pediatric pulmonary care. Pediatr Pulmonol 2020; 55:1794-1809. [PMID: 32533909 PMCID: PMC7384240 DOI: 10.1002/ppul.24706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/12/2020] [Indexed: 12/19/2022]
Abstract
Advancement in technology has improved recognition of genetic etiologies of disease, which has impacted diagnosis and management of rare disease patients in the pediatric pulmonary clinic. This review provides an overview of genetic conditions that are likely to present with pulmonary features and require extensive care by the pediatric pulmonologist. Increased familiarity with these conditions allows for improved care of these patients by reducing time to diagnosis, tailoring management, and prompting further investigation into these disorders.
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Affiliation(s)
- Lael M Yonker
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Megan H Hawley
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, Massachusetts
| | - Peter P Moschovis
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mengdi Lu
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - T Bernard Kinane
- Pulmonary Division, Massachusetts General Hospital for Children, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Boone PM, Scott RM, Marciniak SJ, Henske EP, Raby BA. The Genetics of Pneumothorax. Am J Respir Crit Care Med 2019; 199:1344-1357. [PMID: 30681372 PMCID: PMC6543724 DOI: 10.1164/rccm.201807-1212ci] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 01/23/2019] [Indexed: 12/21/2022] Open
Abstract
A genetic influence on spontaneous pneumothoraces-those occurring without a traumatic or iatrogenic cause-is supported by several lines of evidence: 1) pneumothorax can cluster in families (i.e., familial spontaneous pneumothorax), 2) mutations in the FLCN gene have been found in both familial and sporadic cases, and 3) pneumothorax is a known complication of several genetic syndromes. Herein, we review known genetic contributions to both sporadic and familial pneumothorax. We summarize the pneumothorax-associated genetic syndromes, including Birt-Hogg-Dubé syndrome, Marfan syndrome, vascular (type IV) Ehlers-Danlos syndrome, alpha-1 antitrypsin deficiency, tuberous sclerosis complex/lymphangioleiomyomatosis, Loeys-Dietz syndrome, cystic fibrosis, homocystinuria, and cutis laxa, among others. At times, pneumothorax is their herald manifestation. These syndromes have serious potential extrapulmonary complications (e.g., malignant renal tumors in Birt-Hogg-Dubé syndrome), and surveillance and/or treatment is available for most disorders; thus, establishing a diagnosis is critical. To facilitate this, we provide an algorithm to guide the clinician in discerning which cases of spontaneous pneumothorax may have a genetic or familial contribution, which cases warrant genetic testing, and which cases should prompt an evaluation by a geneticist.
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Affiliation(s)
- Philip M. Boone
- Harvard Genetics Training Program, Boston, Massachusetts
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rachel M. Scott
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
| | - Stefan J. Marciniak
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, United Kingdom
- Division of Respiratory Medicine, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Elizabeth P. Henske
- Pulmonary Genetics Center, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Benjamin A. Raby
- Pulmonary Genetics Center, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Shalhub S, Neptune E, Sanchez DE, Dua A, Arellano N, McDonnell NB, Milewicz DM. Spontaneous pneumothorax and hemothorax frequently precede the arterial and intestinal complications of vascular Ehlers-Danlos syndrome. Am J Med Genet A 2019; 179:797-802. [PMID: 30793832 DOI: 10.1002/ajmg.a.61094] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 09/26/2018] [Accepted: 12/11/2018] [Indexed: 11/08/2022]
Abstract
Vascular Ehlers-Danlos syndrome (vEDS) is a connective tissue disorder due to defective type III collagen production and is associated with arterial rupture, spontaneous intestinal perforation, and gravid uterine rupture. Spontaneous pneumothorax and/or hemothorax (P/HTX) also occurs in vEDS patients. The temporal relation of pulmonary manifestations to arterial and intestinal complications in vEDS has not been well described. This was investigated in a multi-institutional retrospective case series of vEDS patients with confirmatory testing for COL3A1 mutation between 2000 and 2012. Data abstracted included demographics, family histories, presentation, and management of associated complications. Ninety-six cases (39% males, mean age 38.6 ± 15.5 years, range 8-79) had confirmatory testing for vEDS. P/HTX was documented in 17 (17.7%) cases. Most P/HTX preceded the diagnosis of vEDS (81%). Diagnosis of vEDS was made after arterial or intestinal complications at a mean of 7 years (range 0-26) post the initial P/HTX. In conclusion, spontaneous P/HTX is an early manifestation of vEDS frequently preceding an arterial complication or intestinal perforation. Thus, a spontaneous P/HTX in a young patient should trigger a differential diagnosis that includes vEDS. This should lead to an investigation of other vEDS features and subsequent genetic testing if vEDS features are present.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Enid Neptune
- Pulmonary and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Desiree E Sanchez
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Anahita Dua
- Department of Surgery, Stanford University, Stanford, California
| | - Nelson Arellano
- Department of surgery, Centro Clinico Quirurgico Hospital Del Dia Norte, Guayaquil, Ecuador
| | | | - Dianna M Milewicz
- Division of Medical Genetics, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Texas
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13
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The Many Radiological Presentations of Pulmonary Nodules in Type IV Ehlers-Danlos Syndrome. Arch Bronconeumol 2018; 54:626. [PMID: 29980309 DOI: 10.1016/j.arbres.2018.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 11/20/2022]
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14
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Park MA, Shin SY, Kim YJ, Park MJ, Lee SH. Vascular Ehlers-Danlos syndrome with cryptorchidism, recurrent pneumothorax, and pulmonary capillary hemangiomatosis-like foci: A case report. Medicine (Baltimore) 2017; 96:e8853. [PMID: 29381997 PMCID: PMC5708996 DOI: 10.1097/md.0000000000008853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 10/27/2017] [Accepted: 11/02/2017] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Vascular Ehlers-Danlos syndrome (vEDS) is a rare autosomal dominant inherited collagen disorder caused by defects or deficiency of pro-alpha 1 chain of type III procollagen encoded by COL3A1. vEDS is characterized not only by soft tissue manifestations including hyperextensibility of skin and joint hypermobility but also by early mortality due to rupture of arteries or vital organs. Although pulmonary complications are not common, vEDS cases complicated by pneumothorax, hemothorax, or intrapulmonary hematoma have been reported. When a patient initially presents only with pulmonary complications, it is not easy for clinicians to suspect vEDS. PATIENT CONCERNS We report a case of an 18-year-old high school student, with a past history of cryptorchidism, presenting with recurrent pneumothorax. DIAGNOSES Routine laboratory findings were unremarkable. Chest high resolution computed tomographic scan showed age-unmatched hyperinflation of both lungs, atypical cystic changes and multifocal ground glass opacities scattered in both lower lobes. His slender body shape, hyperflexible joints, and hyperextensible skin provided clue to suspicion of a possible connective tissue disorder. INTERVENTIONS The histological examination of the lung lesions showed excessive capillary proliferation in the pulmonary interstitium and pleura allowing the diagnosis of pulmonary capillary hemangiomatosis (PCH)-like foci. Genetic study revealed COL3A1 gene splicing site mutation confirming his diagnosis as vEDS. OUTCOMES Although his diagnosis vEDS is notorious for fatal vascular complication, there was no evidence of such complication at presentation. Fortunately, he has been followed up for 10 months without pulmonary or vascular complications. LESSONS To the best of our knowledge, both cryptorchidism and PCH-like foci have never been reported yet as complications of vEDS, suggesting our case might be a new variant of this condition. This case emphasizes the importance of comprehensive physical examination and history-taking, and the clinical suspicion of a possible connective tissue disorder when we encounter cases with atypical presentation and/or unique chest radiologic findings especially in young patients.
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Affiliation(s)
- Min A. Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University School of Medicine
| | - So Youn Shin
- Department of Radiology, Kyung Hee University Hospital, College of Medicine, Kyung Hee University
| | - Young Jin Kim
- Department of Laboratory Medicine, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Myung Jae Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University School of Medicine
| | - Seung Hyeun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University School of Medicine
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15
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Keschenau PR, Kotelis D, Bisschop J, Barbati ME, Grommes J, Mees B, Gombert A, Peppelenbosch AG, Schurink GWH, Kalder J, Jacobs MJ. Editor's Choice – Open Thoracic and Thoraco-abdominal Aortic Repair in Patients with Connective Tissue Disease. Eur J Vasc Endovasc Surg 2017; 54:588-596. [DOI: 10.1016/j.ejvs.2017.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/27/2017] [Indexed: 01/02/2023]
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16
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Kinane TB, Lin AE, Lahoud-Rahme M, Westra SJ, Mark EJ. Case 4-2017. A 2-Month-Old Girl with Growth Retardation and Respiratory Failure. N Engl J Med 2017; 376:562-574. [PMID: 28177866 DOI: 10.1056/nejmcpc1613465] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- T Bernard Kinane
- From the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Massachusetts General Hospital, and the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Harvard Medical School - both in Boston
| | - Angela E Lin
- From the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Massachusetts General Hospital, and the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Harvard Medical School - both in Boston
| | - Manuella Lahoud-Rahme
- From the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Massachusetts General Hospital, and the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Harvard Medical School - both in Boston
| | - Sjirk J Westra
- From the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Massachusetts General Hospital, and the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Harvard Medical School - both in Boston
| | - Eugene J Mark
- From the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Massachusetts General Hospital, and the Departments of Pediatrics (T.B.K., A.E.L.), Cardiology (M.L.-R.), Radiology (S.J.W.), and Pathology (E.J.M.), Harvard Medical School - both in Boston
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17
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Abrahamsen BJ, Kulseth MA, Paus B. A 19-Year-Old Man With Relapsing Bilateral Pneumothorax, Hemoptysis, and Intrapulmonary Cavitary Lesions Diagnosed With Vascular Ehlers-Danlos Syndrome and a Novel Missense Mutation in COL3A1. Chest 2015; 147:e166-e170. [DOI: 10.1378/chest.13-3002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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18
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Ruggeri P, Calcaterra S, Girbino G. Bullous emphysema as first presentation of Ehlers-Danlos syndrome in monozygotic twins. Respir Med Case Rep 2014; 14:40-2. [PMID: 26029576 PMCID: PMC4356030 DOI: 10.1016/j.rmcr.2014.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ehlers-Danlos syndrome, characterized by hyperextensible skin, hypermobile joints, and fragile vessels, is the most common heritable disorder of connective tissue and has an estimated prevalence of 1 in 5000. Pulmonary involvement with signs of lung destruction (bullous emphysema) as first presentation is unusual. We report a case of monozygotic twins 37 years old men with occasional evidence of bullous emphysema with previously undiagnosed Ehlers-Danlos syndrome type IV. We emphasize the importance of considering uncommon genetic causes of emphysema in young adults, discuss underlining pathophysiological mechanisms and propose a conservative management and follow-up.
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Affiliation(s)
- Paolo Ruggeri
- Department of Experimental Medicine and Surgery with Odontostomatology, Respiratory Unit, Policlinico Universitario "G.Martino", Messina, Italy
| | - Salvatore Calcaterra
- Department of Experimental Medicine and Surgery with Odontostomatology, Respiratory Unit, Policlinico Universitario "G.Martino", Messina, Italy
| | - Giuseppe Girbino
- Department of Experimental Medicine and Surgery with Odontostomatology, Respiratory Unit, Policlinico Universitario "G.Martino", Messina, Italy
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19
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Non-traumatic and spontaneous hemothorax in the setting of forensic medical examination: a systematic literature survey. Forensic Sci Int 2013; 236:22-9. [PMID: 24529771 DOI: 10.1016/j.forsciint.2013.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 12/07/2013] [Accepted: 12/15/2013] [Indexed: 01/18/2023]
Abstract
Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax.
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