Fatal splenic rupture in Ehlers-Danlos syndrome

Unexpected death involving the spleen - an overview

The spleen is located in the left upper quadrant of the abdominal cavity and has both immunological and haematological functions. A variety of quite different entities may be associated with sudden death due to splenic involvement. These range from simple traumatic disruption of the parenchyma of a normal spleen with marked intra-abdominal haemorrhage, to conditions such as malaria and infectious mononucleosis where splenomegaly predisposes to rupture. Haematological diseases such as malignancies and haemoglobinopathies may causes sudden death due to haemorrhage or red cell sequestration. Asplenia or polysplenia may be associated with significant congenital heart disease. Hyposplenia, both structural and functional, may also result in rapid demise from sometimes unusual bacterial infections. Vascular abnormalities causing death include entities such as splenic artery aneurysms. Thus, deaths from splenic pathology may be due to localised issues or may be part of more generalised disease. For this reason the autopsy in cases of splenic-associated deaths must be comprehensive and include special testing such as microbiological screening and/or haematologic/genetic evaluation.

Splenic artery pathology presentation, operative interventions, and outcomes in 88 patients with Vascular Ehlers Danlos Syndrome

BACKGROUND

Vascular Ehlers-Danlos Syndrome (VEDS) is rare and associated with arteriopathies. The aim of this study is to investigate the presentation, operative interventions, and outcomes of splenic arterial pathology in a population of more than 1,500 individuals with genetically confirmed VEDS due to pathogenic COL3A1 variants.

METHODS

Cross-sectional analysis of 1,547 individuals was performed. The data were assembled by harmonizing data from three overlapping cohorts with genetically confirmed VEDS: the VEDS Collaborative Natural History Study (N=242), a single center cohort (N=75), and the UW Collagen Diagnostic Lab cohort (N=1,231). Duplicates were identified and removed. Patients were selected for analysis if they had splenic artery aneurysm (SAA), pseudoaneurysm, dissection, thrombosis, or rupture. Demographics, COL3A1 variants, interventions, and outcomes were analyzed. Comparisons by splenic artery rupture were made.

RESULTS

A total of 88 patients presented between 1992 and 2021 with splenic artery pathology (5.7% of the cohort, Mean age at diagnosis 37+11.1 years, 50% male). One third were diagnosed with VEDS prior to the splenic artery pathology diagnosis and 17% were diagnosed post-mortem. Most had a positive family history (61%). Most had COL3A1 variants associated with minimal normal collagen production (71.589.7%). Median follow up was 8.5 (IQR 0.9-14.7) years. Initial presentation was rupture in 47% of the cases. Splenic artery rupture overall was 51% (N=45) including 4 cases of splenic rupture. There were no major differences in VEDS related manifestations or COL3A1 variant type by rupture status. SAA was noted in 39% of the cases. Only 12 patients had splenic artery diameter documented in 12 cases with a median diameter of 12 (IQR 10.3-19.3) mm. A total of 34 (38.6%) patients underwent 40 splenic arterial interventions: 21 open surgical, 18 embolization, and 1 unknown procedure. More than one splenic artery intervention was performed in 5 (14.7%) cases. Open repair complications included arteriovenous fistula (n=1), intestinal or pancreatic injury (1 each), and four intraoperative deaths. There were no deaths or access site complications related to splenic artery embolization. Four (23.5%) developed a new SAA in the remaining splenic artery post embolization. All-cause mortality was 35% (n=31) including 22 related to a ruptured splenic artery.

CONCLUSIONS

Splenic arteriopathy in VEDS is associated with variants that affect the structure and secretion of type III collagen and frequently present with rupture. Rupture and open repair are associated with high morbidity and mortality while embolization is associated with favorable outcomes. Suggest repair considerations at SAA diameter of 15 mm. Long term follow up is indicated as secondary splenic arteriopathy can occur.

Dermatologic Problems in the Intensive Care Unit: Part II

Skin disorders are present in many patients hospitalized in the intensive care unit. They range in severity from being the reason for admission to being a nuisance during care. These cutaneous problems have been categorized into four groups: (1) serious skin diseases that may incur life-threatening complications; (2) subtle skin problems associated with systemic disorders that may be characterized by critical events; (3) prominent cutaneous manifestations that accompany life-threatening systemic diseases; and (4) skin disorders that develop as complications during intensive care. Diseases in the first category were discussed in Part I of this article [1]. In Part II, we discuss diseases in the second category. The remaining disorders will be covered in Parts III and IV.

Spontaneous Splenic Rupture in Vascular Ehlers-Danlos Syndrome

Vascular Ehlers-Danlos Syndrome (VEDS) is a rare autosomal dominant collagen vascular disorder. Different from other Ehler-Danlos Syndrome subtypes, VEDS has poor prognosis due to severe fragility of connective tissues and association with life-threatening vascular and gastrointestinal complications. Spontaneous splenic rupture is a rare but hazardous complication related to this syndrome. To date, only 2 cases have been reported in the literature. Here we present another case of this uncommon complication, occurring in a 54-year-old woman in clinical follow-up for VEDS who presented with sudden onset of abdominal pain and hypotension.

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

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

Visceroptosis of the bowel in the hypermobility type of Ehlers-Danlos syndrome: presentation of a rare manifestation and review of the literature

Gastrointestinal complications are common in patients with Ehlers-Danlos syndrome, affecting up to 50% of individuals depending on the subtype. The spectrum of gastrointestinal manifestations is broad and ranges from life threatening spontaneous perforation of the visceral organs to a more benign functional symptoms. Here we describe the clinical and radiographic manifestations of visceroptosis of the bowel, a rare complication of Ehlers-Danlos syndrome that is characterized by prolapse of abdominal organs below their natural position. We further review the literature on gastrointestinal complications in the different forms of Ehlers-Danlos syndrome.

Spontaneously ruptured splenic aneurysm in a young patient with Ehlers-Danlos syndrome

The authors describe a young patient with a history of type IV vascular Ehlers-Danlos syndrome (EDS) who underwent successful treatment for a spontaneous haemorrhage from a splenic artery aneurysm, and the authors would like to remind clinicians of the mortality and morbidity associated with vascular-type EDS.

Sudden and unexpected death in three cases of Ehlers-Danlos syndrome type IV

Ehlers-Danlos syndrome (EDS) type IV is a connective tissue disorder characterized by the inability to produce sufficient amounts of collagen or a defect in the structure of collagen. The most serious complications include a rupture of a viscus or vascular rupture with or without mural dissection. Death may result from internal hemorrhage. This report describes three cases of sudden and unexpected death caused by EDS type IV. Two cases involved hemothorax as a result of dissection of the subclavian artery and aorta, respectively. The third case represented spontaneous pulmonary rupture and hemorrhage. A detailed family history should be sought, and additional specimens collected to confirm the diagnosis, including skin fibroblasts for collagen testing and blood for DNA testing. The forensic pathologist should consider the possibility of EDS type IV upon discovery of spontaneous visceral or arterial rupture and should alert the family members of this hereditary and potentially fatal condition.

Ehlers-Danlos syndrome type IV

Ehlers-Danlos syndrome type IV, the vascular type of Ehlers-Danlos syndromes (EDS), is an inherited connective tissue disorder defined by characteristic facial features (acrogeria) in most patients, translucent skin with highly visible subcutaneous vessels on the trunk and lower back, easy bruising, and severe arterial, digestive and uterine complications, which are rarely, if at all, observed in the other forms of EDS. The estimated prevalence for all EDS varies between 1/10,000 and 1/25,000, EDS type IV representing approximately 5 to 10% of cases. The vascular complications may affect all anatomical areas, with a tendency toward arteries of large and medium diameter. Dissections of the vertebral arteries and the carotids in their extra- and intra-cranial segments (carotid-cavernous fistulae) are typical. There is a high risk of recurrent colonic perforations. Pregnancy increases the likelihood of a uterine or vascular rupture. EDS type IV is inherited as an autosomal dominant trait that is caused by mutations in the COL3A1 gene coding for type III procollagen. Diagnosis is based on clinical signs, non-invasive imaging, and the identification of a mutation of the COL3A1 gene. In childhood, coagulation disorders and Silverman's syndrome are the main differential diagnoses; in adulthood, the differential diagnosis includes other Ehlers-Danlos syndromes, Marfan syndrome and Loeys-Dietz syndrome. Prenatal diagnosis can be considered in families where the mutation is known. Choriocentesis or amniocentesis, however, may entail risk for the pregnant woman. In the absence of specific treatment for EDS type IV, medical intervention should be focused on symptomatic treatment and prophylactic measures. Arterial, digestive or uterine complications require immediate hospitalisation, observation in an intensive care unit. Invasive imaging techniques are contraindicated. Conservative approach is usually recommended when caring for a vascular complication in a patient suffering from EDS type IV. Surgery may, however, be required urgently to treat potentially fatal complications.

Spontaneous common iliac arteries rupture in Ehlers-Danlos syndrome type IV: report of two cases and review of the literature

Two patients with previously undiagnosed Ehlers-Danlos syndrome type IV (EDS IV) presented acutely with clinical features suggestive of hypovolemic shock. Emergency laparotomies in both of them revealed spontaneous rupture of the common iliac arteries. The clinical features, operative findings, surgical approach, outcome and implications are discussed.

Fatal vascular catastrophe in Ehlers-Danlos syndrome: a case report and review

The Ehlers-Danlos syndrome (EDS) is a group of hereditary connective tissue disorders that are characterized by abnormalities of the skin, joints, and a diversity of other phenotypic manifestations. An awareness of the disease is vital for optimal outcome in this rare group of patients who may present with a variety of life-threatening illnesses. Ehlers-Danlos type IV has been associated with vascular catastrophes, perforated viscous, ruptured uterus, and pneumothorax (1-4). We present a case of aneurysmal formation and spontaneous rupture of the great vessels in a 15-year-old male with EDS type IV, who remained undiagnosed until the time of autopsy.

Surgical pitfalls in a patient with type IV Ehlers-Danlos syndrome and spontaneous colonic rupture. Report of a case

PURPOSE

This paper intends to stress the importance of early diagnosis and discuss surgical treatment of Type IV Ehlers-Danlos syndrome (EDS-4), an autosomal dominant connective tissue disease characterized by typical features of the face and extremities, inappropriate and easy bruising, and extreme tissue fragility, which may lead to dramatic and often fatal complications, mostly spontaneous arterial or intestinal rupture.

METHODS

We report the case of a 41-year-old female who presented with spontaneous perforation of the sigmoid colon.

RESULTS

The patient was seen over a nine-year period, during which time she required six operations and presented with a great number of surgical complications including stenosis of an end-colostomy, repeated subocclusive episodes caused by intraperitoneal adhesions, and enterocutaneous fistulas, finally ending with an ileostomy and short bowel syndrome. It is only after a difficult laparotomy for ovarian cyst excision, marked by numerous adhesions and friable bowel, that the diagnosis of EDS-4 was considered and established.

CONCLUSIONS

In case of "idiopathic" spontaneous perforation of the colon in a young adult, features of EDS-4 should be thoroughly looked into and, if found, skin fibroblast culture with collagen Type III analysis performed. The surgical treatment of choice consists of subtotal colectomy and permanent end-ileostomy. In case of patient refusal, a second-stage ileorectal anastomosis can be performed but carries the high risk of anastomotic leakage.

Obstetrical problems in patients with Ehlers-Danlos syndrome type IV; a case report

The Ehlers-Danlos syndrome type IV is a heritable connective-tissue disorder characterized by thin translucent skin, pronounced bruising and scarring, and extreme tissue fragility. Obstetrical complications include premature rupture of membranes, rupture of blood vessels and gravid uterus, tearing of perineum, vagina, urethra and bladder, requesting specific prophylactic and therapeutic measurements. Hereditary transmission is usually autosomal dominant with variable expression. Histological examination of skin biopsy and biochemical analysis of collagen proteins from skin fibroblast cultures confirm the clinical diagnosis. DNA studies offer the possibility of prenatal diagnosis in suitable families. The consecutive severe obstetrical complications of a woman with Ehlers-Danlos syndrome type IV are reported here. The patient died at age 33 years from renal artery rupture.