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Doolan BJ, Lavallee M, Hausser I, Pope FM, Seneviratne SL, Winship IM, Burrows NP. Dermatologic manifestations and diagnostic assessments of the Ehlers-Danlos syndromes: A clinical review. J Am Acad Dermatol 2023; 89:551-559. [PMID: 36764582 DOI: 10.1016/j.jaad.2023.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The Ehlers-Danlos syndromes (EDSs) comprise a group of connective tissue disorders that manifest with skin hyperextensibility, easy bruising, joint hypermobility and fragility of skin, soft tissues, and some organs. A correct assessment of cutaneous features along with the use of adjunct technologies can improve diagnostic accuracy. OBJECTIVES To systematically review the cutaneous features and adjunct investigations of EDS. METHODS A search of PubMed and Web of Science for EDS-related cutaneous features and additional investigations was undertaken from publication of the 2017 International Classification of EDS until January 15, 2022. RESULTS One-hundred-and-forty studies involved 839 patients with EDS. The EDS female-to-male ratio was 1.36:1 (P < .001). A high prevalence of skin hyperextensibility, bruising, and soft skin were noted. Most patients with vascular Ehlers-Danlos syndrome showed venous visibility, skin fragility, and acrogeria. Classical EDS showed subcutaneous spheroids and molluscoid pseudotumours. In patients that underwent skin biopsies, only 30.3% and 71.4% showed features suggestive of EDS using light microscopy and transmission electron microscopy, respectively. LIMITATIONS Retrospective study and small cases numbers for some EDS-subtypes. CONCLUSIONS An accurate clinical diagnosis increases the chances of a molecular diagnosis, particularly for rarer EDS subtypes, whilst decreasing the need for genetic testing where there is a low clinical suspicion for a monogenic EDS-subtype.
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Affiliation(s)
- Brent J Doolan
- St John's Institute of Dermatology, School of Basic and Medical Biosciences, King's College London, London, UK; St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Mark Lavallee
- Department of Orthopedics, University of Pittsburgh Medical Center of Central PA, Pittsburgh, Pennsylvania
| | - Ingrid Hausser
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - F Michael Pope
- Department of Dermatology, Chelsea and Westminster Hospital NHS Foundation Trust (West Middlesex University Hospital), London, UK
| | - Suranjith L Seneviratne
- Institute of Immunity and Transplantation, Royal Free Hospital and University College London, London, UK; Nawaloka Hospital Research and Education Foundation, Nawaloka Hospitals, Colombo, Sri Lanka
| | - Ingrid M Winship
- Department of Genetic Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel P Burrows
- Department of Dermatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Ritelli M, Cinquina V, Venturini M, Colombi M. Identification of the novel COL5A1 c.3369_3431dup, p.(Glu1124_Gly1144dup) variant in a patient with incomplete classical Ehlers-Danlos syndrome: The importance of phenotype-guided genetic testing. Mol Genet Genomic Med 2020; 8:e1422. [PMID: 32720758 PMCID: PMC7549590 DOI: 10.1002/mgg3.1422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/02/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023] Open
Abstract
Background Classical Ehlers–Danlos syndrome (cEDS) is a connective tissue disorder mainly caused by heterozygous COL5A1 or COL5A2 variants encoding type V collagen and rarely by the p.(Arg312Cys) missense substitution in COL1A1 encoding type I collagen. The current EDS nosology specifies that minimal suggestive criteria are marked skin hyperextensibility plus atrophic scarring together with either generalized joint hypermobility or at least three minor criteria comprising additional cutaneous and articular signs. To reach a final diagnosis, molecular testing is required. Herein, we report on a 3‐year‐old female who came to our attention with an inconclusive next generation sequencing (NGS) panel comprising all cEDS‐associated genes. Methods Despite the patient did not formally fulfill the nosological criteria because the skin was only slightly hyperextensible, we made a cEDS diagnosis, mainly for the presence of typical atrophic scars. We investigated COL5A1 intragenic deletions/duplications by Multiplex Ligation‐dependent Probe Amplification (MLPA), excluded the recessive classical‐like EDS type 2 by AEBP1 Sanger analysis, and retested COL5A1 with the Sanger method. Results Molecular analyses revealed the novel COL5A1 c.3369_3431dup p.(Glu1124_Gly1144dup) intermediate‐sized duplication with a predicted dominant negative effect that was missed both by NGS and MLPA. Conclusions This report highlights that some cEDS patients might not display overt skin hyperextensibility and the importance of clinical expertise to make such a diagnosis in patients with an incomplete presentation. Our results also exemplify that NGS is not a fool‐proof technology and that Sanger sequencing achieves the diagnostic goal when there is a sufficiently clear phenotypic indication.
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Affiliation(s)
- Marco Ritelli
- 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
| | - 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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Ueda K, Kawai T, Senoo H, Shimizu A, Ishiko A, Nagata M. Histopathological and electron microscopic study in dogs with patellar luxation and skin hyperextensibility. J Vet Med Sci 2018; 80:1309-1316. [PMID: 29984735 PMCID: PMC6115261 DOI: 10.1292/jvms.18-0115] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Patellar luxation is abnormal displacement of the patella from the femoral trochlear
groove. It is seen primarily in small breed dogs and causes pain and limited mobility of
the stifle joint. This study aimed to investigate the relationship among patellar
luxation, skin extension, and skin collagen fibril diameter. Nine dogs with patellar
luxation and five clinically normal dogs were enrolled in the study. We measured the skin
extension and investigated the ultrastructure of the skin and patellofemoral ligament by
histopathology and transmission electron microscopy. The mean skin extension in dogs with
patellar luxation was 18.5 ± 5.5% which is greater than the reference value (14.5%). Mean
skin extension in controls was 8.8 ± 1.7% and was within the normal range. In dogs with
patellar luxation, histopathology of the skin and patellofemoral ligament showed sparse
and unevenly distributed collagen fibers. Transmission electron microscopy identified
poorly organized, irregularly shaped, thin collagen fibrils. Collagen fibril thickness in
dogs with patellar luxation was significantly less than fibril thickness in controls
(P<0.001). There was a significant negative correlation (ρ= −0.863;
P<0.001) between skin collagen fibril diameter and skin extension.
Skin extension was correlated with patellar luxation and disease severity. Dogs with
patellar luxation, joint dysplasia, and hyperextensible skin appear to be pathologically
related. This might represent a phenotype of the Ehlers–Danlos syndrome, a hereditary
connective tissue disorder in humans.
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Affiliation(s)
- Kazunori Ueda
- Yokohama Yamate Dog & Cat Medical Center, 27-4 Kashiwaba, Naka, Yokohama, Kanagawa 231-0866, Japan
| | - Tomoyuki Kawai
- Yokohama Yamate Dog & Cat Medical Center, 27-4 Kashiwaba, Naka, Yokohama, Kanagawa 231-0866, Japan
| | - Haruki Senoo
- Department of Cell Biology and Histology, Akita University School of Medicine, 1-1-1 Hondo Akita, Akita 010-8543, Japan
| | - Atsushi Shimizu
- Shimizu Animal Hospital, 1747-1 Kaisuka, Kamogawa-shi, Chiba 296-0004, Japan.,Department of Dermatology, School of Medicine, Faculty of Medicine, Toho University, 6-11-1 Ohmori-Nishi, Ohta, Tokyo 143-8541, Japan
| | - Akira Ishiko
- Department of Dermatology, School of Medicine, Faculty of Medicine, Toho University, 6-11-1 Ohmori-Nishi, Ohta, Tokyo 143-8541, Japan
| | - Masahiko Nagata
- Synergy Animal General Hospital, 815 Ishigami Kawaguchi, Saitama 333-0823, Japan
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Colombi M, Dordoni C, Venturini M, Ciaccio C, Morlino S, Chiarelli N, Zanca A, Calzavara-Pinton P, Zoppi N, Castori M, Ritelli M. Spectrum of mucocutaneous, ocular and facial features and delineation of novel presentations in 62 classical Ehlers-Danlos syndrome patients. Clin Genet 2017; 92:624-631. [PMID: 28485813 DOI: 10.1111/cge.13052] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/06/2017] [Accepted: 05/04/2017] [Indexed: 11/27/2022]
Abstract
Classical Ehlers-Danlos syndrome (cEDS) is characterized by marked cutaneous involvement, according to the Villefranche nosology and its 2017 revision. However, the diagnostic flow-chart that prompts molecular testing is still based on experts' opinion rather than systematic published data. Here we report on 62 molecularly characterized cEDS patients with focus on skin, mucosal, facial, and articular manifestations. The major and minor Villefranche criteria, additional 11 mucocutaneous signs and 15 facial dysmorphic traits were ascertained and feature rates compared by sex and age. In our cohort, we did not observe any mandatory clinical sign. Skin hyperextensibility plus atrophic scars was the most frequent combination, whereas generalized joint hypermobility according to the Beighton score decreased with age. Skin was more commonly hyperextensible on elbows, neck, and knees. The sites more frequently affected by abnormal atrophic scarring were knees, face (especially forehead), pretibial area, and elbows. Facial dysmorphism commonly affected midface/orbital areas with epicanthal folds and infraorbital creases more commonly observed in young patients. Our findings suggest that the combination of ≥1 eye dysmorphism and facial/forehead scars may support the diagnosis in children. Minor acquired traits, such as molluscoid pseudotumors, subcutaneous spheroids, and signs of premature skin aging are equally useful in adults.
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Affiliation(s)
- M Colombi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Italy
| | - C Dordoni
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Italy
| | - M Venturini
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Italy
| | - C Ciaccio
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Italy
| | - S Morlino
- Division/Laboratory of Medical Genetics, Department of Molecular Medicine, Sapienza University, San Camillo-Forlanini Hospital, Italy
| | - N Chiarelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Italy
| | - A Zanca
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Italy
| | - P Calzavara-Pinton
- Division of Dermatology, Department of Clinical and Experimental Sciences, Spedali Civili University Hospital, Italy
| | - N Zoppi
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Italy
| | - M Castori
- UOC Genetica Medica, IRCCS Casa "Sollievo della Sofferenza", San Giovanni Rotondo (Foggia), Italy
| | - M Ritelli
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, School of Medicine, University of Brescia, Italy
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Rosato S, Syx D, Ivanovski I, Pollazzon M, Santodirocco D, De Marco L, Beltrami M, Callewaert B, Garavelli L, Malfait F. RIN2 syndrome: Expanding the clinical phenotype. Am J Med Genet A 2016; 170:2408-15. [PMID: 27277385 DOI: 10.1002/ajmg.a.37789] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/22/2016] [Indexed: 01/12/2023]
Abstract
Biallelic defects in the RIN2 gene, encoding the Ras and Rab interactor 2 protein, are associated with a rare autosomal recessive connective tissue disorder, with only nine patients from four independent families reported to date. The condition was initially termed MACS syndrome (macrocephaly, alopecia, cutis laxa, and scoliosis), based on the clinical features of the first identified family; however, with the expansion of the clinical phenotype in additional families, it was subsequently coined RIN2 syndrome. Hallmark features of this condition include dysmorphic facial features with striking, progressive facial coarsening, sparse hair, normal to enlarged occipitofrontal circumference, soft redundant and/or hyperextensible skin, and scoliosis. Patients with RIN2 syndrome present phenotypic overlap with other conditions, including EDS (especially the dermatosparaxis and kyphoscoliosis subtypes). Here, we describe a 10th patient, the first patient of Caucasian origin and the oldest reported patient so far, who harbors the previously identified homozygous RIN2 mutation c.1878dupC (p. (Ile627Hisfs*7)). Besides the hallmark features, this patient also presents problems not previously associated with RIN2 syndrome, including cervical vertebral fusion, mild hearing loss, and colonic fibrosis. We provide an overview of the clinical findings in all reported patients with RIN2 mutations and summarize some of the possible pathogenic mechanisms that may underlie this condition. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Simonetta Rosato
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Delfien Syx
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Ivan Ivanovski
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy.,Department of Surgical, Medical, Dental and Morphological Sciences with Interest in Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marzia Pollazzon
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Daniela Santodirocco
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Loredana De Marco
- Anatomic Pathology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Marina Beltrami
- Department of Internal Medicine, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Bert Callewaert
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Livia Garavelli
- Clinical Genetics Unit, Department of Obstetrics and Pediatrics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Fransiska Malfait
- Center for Medical Genetics, Ghent University and Ghent University Hospital, Ghent, Belgium
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