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Patient Story

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A 12-year-old boy presents to his pediatrician with pain in his knees while walking. On physical examination, he is noted to be short, has hyperextensibility of the skin, and hypermobile joints (Figures 224-1 and 224-2). His mother mentions that there are family members who have hypermobile joints, and who have had problems with dislocation and sprains of their joints. The pediatrician makes a clinical diagnosis of Ehlers-Danlos Syndrome and orders an echocardiogram, which is normal.

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FIGURE 224-1

Hyperextensibility of the skin in a boy with proven Ehlers-Danlos syndrome. (Used with permission from Richard P. Usatine, MD.)

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FIGURE 224-2

Hypermobility of the fingers in the same boy with Ehlers-Danlos syndrome. (Used with permission from Richard P. Usatine, MD.)

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Introduction

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The Ehlers–Danlos syndromes (EDS) constitute a genetically heterogeneous group of conditions, characterized by fragility of the connective tissues, resulting in skin, ligament, joint, blood vessels, and visceral organ manifestations. The clinical spectrum ranges from mild skin and joint hyperlaxity to severe physical disability and life-threatening vascular complications.

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Synonyms

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Hereditary collagen dysplasia.

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Epidemiology

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  • The prevalence of EDS (all types) is estimated to be approximately one in 5,000 individuals.1

  • The most recent classification of EDS relies on clinical and biochemical criteria.2

  • Classification of the EDS types and prevalence:

    • Classic type—Affects 1 in 20,000 to 40,000 individuals.

    • Hypermobility type—Affects 1 in 10,000 to 15,000 individuals.

    • Vascular type—Affects 1 in 250,000 individuals. Accounts for about 5 percent of cases of EDS. Not often diagnosed until adulthood.

    • Kyphoscoliosis type—Very rare.

    • Arthrochalasia type—Very rare.

    • Dermatosparaxis type—Very rare

  • The vascular form of EDS is the most dangerous, because it is associated with spontaneous rupture of medium and large-sized arteries and hollow organs, especially the large intestine and uterus; vascular events typically occur between the third and fifth decade.

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Etiology and Pathophysiology

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  • Mode of inheritance is autosomal dominant for all forms of EDS except the kyphoscoliosis and dermatosparaxis types (recessive mode), and an unclassified X-linked form which is extremely rare.

  • Abnormalities of mature collagen structure in extracellular matrices of multiple tissues (skin, tendons, blood vessels, and viscera) are common to all forms of EDS.

  • Classic EDS is associated with defects in type V collagen, corresponding to mutations of COL5A genes, as well as type I collagen (COL1A1).

  • The precise etiology for the hypermobility form has not been identified.

  • Vascular EDS involves a deficiency in type III collagen and several studies suggest that mutations of gene COL3A1 lead to this deficiency.3

  • The kyphoscoliotic type of EDS is caused by a deficiency of lysyl hydroxylase (PLOD), a collagen modifying illness.

  • The arthrochalasia form of EDS results ...

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