PMC9595653_01
Observed clinical features of the patient, (A): Thin Nose, lobe less ear (red arrow), thin skin with visible chest veins (white arrow), (B): Acrogeria (red arrow) with club foot (white arrow), (C): Easy bruising and thin skin, varicose veins, (D): Hypermobility of small joints (shown in distal phalange of index finger). Digital subtraction angiography images of bilateral common carotid arteries showing dissection of left internal carotid artery (E,F). Right internal carotid artery was normal. Axial (G) and coronal (H) maximum intensity projection (MIP) CT images showing aneurysmal dilatation of left hepatic artery. Coronal MIP images (I,J) of contrast enhanced CT show dissection involving left renal artery with multiple infarcts of renal parenchyma. Axial (K) and coronal (L) MIP CT images show dissection involving right renal artery and right common iliac artery.
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On examination the patient had a thin face with prominent nose and lobeless ears (Figure 1A) along with fragile and thin skin over the extremities suggestive of Acrogeria (Figure 1B). Presence of varicose veins with some ecchymotic patches were observed over the lower limbs (Figure 1C). Chest veins were also found to be prominent (Figure 1A). Hypermobility of small joints of the hands (Figure 1D) and clubbing of feet were observed (Figure 1B). Digital Subtraction Angiography (DSA) was suggestive of dissection with sub occlusive narrowing in the left internal carotid artery in the skull base region (Figures 1E,F). Computed tomography (CT) angiography showed aneurysmal dilatation of left hepatic artery (Figures 1G,H) along with multiple arterial dissections involving left renal artery (Figures 1I,J) and multiple infarcts in right renal artery and proximal right common iliac artery (Figures 1K,L). Visualization of this variant in Integrative Genome Viewer (IGV) suggested heterozygosity (Supplementary Data 1 in Supplementary Figure 1).
Primary culture of skin derived fibroblasts from (A) age matched control (B) suspected vEDS patient. Immunofluorescence analysis of fibroblasts show (C) presence of Col3A1(Red) control fibroblasts whereas (D) patient fibroblasts show absence of Col3A1. Transmission electron microscopy of (E) control fibroblasts with normal morphology, (F) vEDS fibroblasts with altered morphology, arrows show intracytoplasmic lamellar vacuolar bodies. (G) Sequences of wild-type (1340-G) and mutant (1340-A) COL3A1 cDNA derived from patient skin fibroblasts. As vEDS patient is heterozygous for COL3A1 c.1340G > A mutation, sequencing of the region harboring the mutation results in detection of both guanine and adenine at position 1340. The G > A mutation leads to an exchange from glycine to aspartic acid at the protein level.
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Patient and control fibroblasts were cultured from skin biopsy (Figures 2A,B) and analysis of protein expression of COL3A1 was done using immunofluorescence. There was a complete absence of COL3A1 production in the patient fibroblasts compared to the control fibroblasts (Figures 2C,D). Fibroblasts derived from skin biopsy of patient with exon19:c. 1340G > A variant were larger in size as compared to the control fibroblasts (Figures 2C,D). We observed lamellar vacuolar bodies in the cytoplasm of vEDS fibroblasts which were not present in control fibroblasts (Figures 2E,F). A variant obtained from Whole exome sequencing was confirmed by Sanger sequencing (Figure 2G). All methodology provided in Supplementary Data 2.