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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ehlers-Danlos syndrome &#40;EDS&#41; is a heterogeneous group of congenital connective tissue diseases caused by mutations in genes involved in the synthesis or processing of collagen fibers&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The phenotypic manifestations of EDS vary greatly&#44; and mild cases can go unnoticed until late in life&#46; We present the case of a girl who was diagnosed with classic EDS in our hospital based on clinical and ultrasound findings&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 8-year-old girl was referred from the emergency department for evaluation of a painful lesion on the left leg that had appeared several weeks earlier after a fall from a ladder&#46; Physical examination revealed a subcutaneous bulge of about 4<span class="elsevierStyleHsp" style=""></span>cm in diameter in the left pretibial region with yellowish-purpuric overlying skin and a strikingly gummy consistency&#46; The patient had reticulated erythematous-violaceous lesions on the right leg and dehiscent and atrophic scars on the right leg and left knee &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; High-frequency ultrasound &#40;18&#160;MHz&#41; of the left pretibial lesion revealed an anechogenic collection delimited by a thin pseudocapsule&#44; compatible with an organized hematoma &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Septal edema compatible with traumatic panniculitis was evident in the surrounding hyperechogenic subcutaneous tissue&#46; Doppler signal was absent&#46; In the directed anamnesis the patient&#39;s mother reported that the girl had been born preterm due to premature rupture of membranes and had muscular hypotonia during the neonatal period&#46; The patient was undergoing tests in the endocrinology department of another hospital for short stature and disproportion between the trunk and limbs&#46; The family history provided by the mother included joint hyperlaxity&#44; abnormal scarring&#44; and early osteoarthritis&#46; The patient also presented with skin hyperextensibility&#44; joint hypermobility&#44; and Gorlin sign &#40;ability to reach the nose with the tip of the tongue&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Based on these data a suspected diagnosis of classic EDS was established&#46; A cardiological examination&#44; including electrocardiogram and echocardiography&#44; revealed no findings of interest&#44; and the results of a laboratory workup&#44; including a complete blood count and coagulation tests&#44; were normal apart from slightly elevated D-dimer levels&#46; A second ultrasound examination performed 1 month later revealed a reduction in the hematoma of approximately 50&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Classic EDS is inherited in an autosomal dominant manner and is caused by mutations in <span class="elsevierStyleItalic">COL5A1</span> or <span class="elsevierStyleItalic">COL5A2</span>&#44; which encode the alpha-1 and alpha-2 chains&#44; respectively&#44; of collagen type V&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The disease is characterized by skin hyperextensibility&#44; joint hypermobility and associated complications &#40;luxations&#44; pain&#44; early osteoarthritis&#41;&#44; and other clinical characteristics that are reviewed in a recent international consensus paper&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Dermatologic manifestations of classic EDS include skin hyperextensibility and abnormal scarring&#44; which results the formation of atrophic scars with a cigarette-paper-like appearance&#46; Patients have thin&#44; velvety skin that bruises in response to minimal trauma&#46; Other potential lesions include nodular molluscoid pseudotumors secondary to calcification and fibrosis of hematomas&#59; spheroids &#40;hard spherical nodules on the forearms and pretibial areas&#41;&#59; and piezogenic pedal papules&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Our patient fulfilled the diagnostic criteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; No genetic study was performed as this was not essential for confirmation of the diagnosis&#46; Classic EDS is usually diagnosed when affected individuals begin to stand and walk&#44; as this period coincides with the appearance of lacerations and bruising that tend to alarm parents&#46; The main clinical differential diagnosis in childhood is bruising caused by child abuse&#44; potentially distinguishing features of which include lesions located in areas not exposed to accidental trauma &#40;e&#46;g&#46;&#44; backs of the legs or abdomen&#41;&#44; peculiar morphology &#40;e&#46;g&#46;&#44; imprints caused by fingers&#44; the dental arch&#44; belts&#44; etc&#46;&#41;&#44; and the time course of lesion appearance&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#44;5</span></a> In rarer cases extensive bruising may constitute the initial manifestation of coagulopathies that can be detected by laboratory analyses&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">High-resolution ultrasound is a useful tool for diagnostic confirmation of bruising and differentiation from other causes of subcutaneous lesions on the legs&#44; including erythema nodosum&#44; abscesses&#44; and benign &#40;lipoma&#41; or malignant &#40;rhabdomyosarcoma&#44; fibrosarcoma&#41; soft-tissue tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Hematomas present as anechoic collections that may become hypoechoic or heterogeneous over days or weeks&#44; without peripheral hypervascularization&#46; These lesions can be compressed with the ultrasound probe only in early stages&#44; after which the fluid within is replaced with fibrous tissue&#46; Another feature&#44; which is less well characterized in the literature&#44; is the presence of a thin pseudocapsule that corresponds to the fibrin and peripheral granulation tissue produced as the hematoma organizes&#46; In contrast to hematomas&#44; the aforementioned subcutaneous lesions tend to have more irregular borders and usually differ in terms of the degree of vascularization&#46; Ultrasound also allows measurement of the depth of the hematoma and confirmation of its regression&#44; allowing distinction from hemorrhagic soft-tissue tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; classic EDS should be suspected in children with joint and skin hyperlaxity and easy bruising&#46; High-resolution ultrasound is very useful for the diagnosis and follow-up of hematomas associated with EDS&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Classic Ehlers-Danlos Syndrome: Clinical and Ultrasound Findings
Síndrome de Ehlers-Danlos clásico: hallazgos clínicos y ecográficos
M. Herrero-Moyanoa, L. Noguera-Morelb, A. Torrelob, A. Hernández-Martínb,
Corresponding author
ahernandez@aedv.es

Corresponding author.
a Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, España
b Servicio de Dermatología, Hospital Universitario del Niño Jesús, Madrid, España
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    "titulo" => "Classic Ehlers-Danlos Syndrome&#58; Clinical and Ultrasound Findings"
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        "titulo" => "S&#237;ndrome de Ehlers-Danlos cl&#225;sico&#58; hallazgos cl&#237;nicos y ecogr&#225;ficos"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristic clinical signs of classic Ehlers-Danlos syndrome&#46; A&#44; Joint hypermobility with hyperextension of the fingers&#46; B&#44; Atrophic scars with a cigarette-paper-like appearance&#46; C&#44; Skin hyperlaxity&#46; D&#44; Hyperextension of the tongue &#40;Gorlin sign&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ehlers-Danlos syndrome &#40;EDS&#41; is a heterogeneous group of congenital connective tissue diseases caused by mutations in genes involved in the synthesis or processing of collagen fibers&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The phenotypic manifestations of EDS vary greatly&#44; and mild cases can go unnoticed until late in life&#46; We present the case of a girl who was diagnosed with classic EDS in our hospital based on clinical and ultrasound findings&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 8-year-old girl was referred from the emergency department for evaluation of a painful lesion on the left leg that had appeared several weeks earlier after a fall from a ladder&#46; Physical examination revealed a subcutaneous bulge of about 4<span class="elsevierStyleHsp" style=""></span>cm in diameter in the left pretibial region with yellowish-purpuric overlying skin and a strikingly gummy consistency&#46; The patient had reticulated erythematous-violaceous lesions on the right leg and dehiscent and atrophic scars on the right leg and left knee &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; High-frequency ultrasound &#40;18&#160;MHz&#41; of the left pretibial lesion revealed an anechogenic collection delimited by a thin pseudocapsule&#44; compatible with an organized hematoma &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Septal edema compatible with traumatic panniculitis was evident in the surrounding hyperechogenic subcutaneous tissue&#46; Doppler signal was absent&#46; In the directed anamnesis the patient&#39;s mother reported that the girl had been born preterm due to premature rupture of membranes and had muscular hypotonia during the neonatal period&#46; The patient was undergoing tests in the endocrinology department of another hospital for short stature and disproportion between the trunk and limbs&#46; The family history provided by the mother included joint hyperlaxity&#44; abnormal scarring&#44; and early osteoarthritis&#46; The patient also presented with skin hyperextensibility&#44; joint hypermobility&#44; and Gorlin sign &#40;ability to reach the nose with the tip of the tongue&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Based on these data a suspected diagnosis of classic EDS was established&#46; A cardiological examination&#44; including electrocardiogram and echocardiography&#44; revealed no findings of interest&#44; and the results of a laboratory workup&#44; including a complete blood count and coagulation tests&#44; were normal apart from slightly elevated D-dimer levels&#46; A second ultrasound examination performed 1 month later revealed a reduction in the hematoma of approximately 50&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Classic EDS is inherited in an autosomal dominant manner and is caused by mutations in <span class="elsevierStyleItalic">COL5A1</span> or <span class="elsevierStyleItalic">COL5A2</span>&#44; which encode the alpha-1 and alpha-2 chains&#44; respectively&#44; of collagen type V&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The disease is characterized by skin hyperextensibility&#44; joint hypermobility and associated complications &#40;luxations&#44; pain&#44; early osteoarthritis&#41;&#44; and other clinical characteristics that are reviewed in a recent international consensus paper&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Dermatologic manifestations of classic EDS include skin hyperextensibility and abnormal scarring&#44; which results the formation of atrophic scars with a cigarette-paper-like appearance&#46; Patients have thin&#44; velvety skin that bruises in response to minimal trauma&#46; Other potential lesions include nodular molluscoid pseudotumors secondary to calcification and fibrosis of hematomas&#59; spheroids &#40;hard spherical nodules on the forearms and pretibial areas&#41;&#59; and piezogenic pedal papules&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2&#44;3</span></a> Our patient fulfilled the diagnostic criteria &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; No genetic study was performed as this was not essential for confirmation of the diagnosis&#46; Classic EDS is usually diagnosed when affected individuals begin to stand and walk&#44; as this period coincides with the appearance of lacerations and bruising that tend to alarm parents&#46; The main clinical differential diagnosis in childhood is bruising caused by child abuse&#44; potentially distinguishing features of which include lesions located in areas not exposed to accidental trauma &#40;e&#46;g&#46;&#44; backs of the legs or abdomen&#41;&#44; peculiar morphology &#40;e&#46;g&#46;&#44; imprints caused by fingers&#44; the dental arch&#44; belts&#44; etc&#46;&#41;&#44; and the time course of lesion appearance&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#44;5</span></a> In rarer cases extensive bruising may constitute the initial manifestation of coagulopathies that can be detected by laboratory analyses&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">High-resolution ultrasound is a useful tool for diagnostic confirmation of bruising and differentiation from other causes of subcutaneous lesions on the legs&#44; including erythema nodosum&#44; abscesses&#44; and benign &#40;lipoma&#41; or malignant &#40;rhabdomyosarcoma&#44; fibrosarcoma&#41; soft-tissue tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Hematomas present as anechoic collections that may become hypoechoic or heterogeneous over days or weeks&#44; without peripheral hypervascularization&#46; These lesions can be compressed with the ultrasound probe only in early stages&#44; after which the fluid within is replaced with fibrous tissue&#46; Another feature&#44; which is less well characterized in the literature&#44; is the presence of a thin pseudocapsule that corresponds to the fibrin and peripheral granulation tissue produced as the hematoma organizes&#46; In contrast to hematomas&#44; the aforementioned subcutaneous lesions tend to have more irregular borders and usually differ in terms of the degree of vascularization&#46; Ultrasound also allows measurement of the depth of the hematoma and confirmation of its regression&#44; allowing distinction from hemorrhagic soft-tissue tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion&#44; classic EDS should be suspected in children with joint and skin hyperlaxity and easy bruising&#46; High-resolution ultrasound is very useful for the diagnosis and follow-up of hematomas associated with EDS&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Herrero-Moyano M&#44; Noguera-Morel L&#44; Torrelo A&#44; Hern&#225;ndez-Mart&#237;n A&#46; S&#237;ndrome de Ehlers-Danlos cl&#225;sico&#58; hallazgos cl&#237;nicos y ecogr&#225;ficos&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;83&#8211;85&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Extensive purpuric lesion on the anterior aspect of the middle and distal third of the left leg&#44; and reticulated erythematous-violaceous lesions on the contralateral leg&#46; Note the presence of 2 atrophic scars on the distal third of the right leg and on the left knee&#46;</p>"
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                  \t\t\t\t" scope="col">Major Criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46; Marked skin hyperextensibility and atrophic scarring2&#46; Generalized joint hypermobility&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46; Easy bruising2&#46; Soft&#44; velvety skin3&#46; Skin fragility4&#46; Molluscoid pseudotumors5&#46; Subcutaneous spheroids6&#46; Hernia &#40;or history thereof&#41;7&#46; Epicanthic folds8&#46; Complications associated with joint hypermobility &#40;e&#46;g&#46;&#44; sprains&#44; subluxation&#47;dislocation&#44; pain&#44; flat feet&#41;9&#46; First-degree relative who fulfils the clinical criteria&nbsp;\t\t\t\t\t\t\n
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                    0 => array:2 [
                      "titulo" => "Ehlers-Danlos syndrome&#44; classical type"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Bowen"
                            1 => "G&#46;J&#46; Sobey"
                            2 => "N&#46;P&#46; Burrows"
                            3 => "M&#46; Colombi"
                            4 => "M&#46;E&#46; Lavallee"
                            5 => "F&#46; Malfait"
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                    0 => array:2 [
                      "doi" => "10.1002/ajmg.c.31548"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med Genet C Semin Med Genet"
                        "fecha" => "2017"
                        "volumen" => "175"
                        "paginaInicial" => "27"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28192633"
                            "web" => "Medline"
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              "identificador" => "bib0040"
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                    0 => array:2 [
                      "titulo" => "Clinical and molecular characterization of 40 patients with classic Ehlers-Danlos syndrome&#58; Identification of 18 <span class="elsevierStyleItalic">COL5A1</span> and 2 <span class="elsevierStyleItalic">COL5A2</span> novel mutations"
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                          "autores" => array:6 [
                            0 => "M&#46; Ritelli"
                            1 => "C&#46; Dordoni"
                            2 => "M&#46; Venturini"
                            3 => "N&#46; Chiarelli"
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                            "web" => "Medline"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Piezogenic papules in Ehlers-Danlos syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46; Poppe"
                            1 => "H&#46; Hamm"
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.jpeds.2013.07.035"
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                      "titulo" => "Ehlers-Danlos syndrome&#40;s&#41; mimicking child abuse&#58; Is there an impact on clinical practice&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
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                    0 => array:2 [
                      "doi" => "10.1002/ajmg.a.37733"
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                        "fecha" => "2016"
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                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "Unexplained facial scar&#58; child abuse or Ehlers-Danlos syndrome&#63;"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "B&#46; Abtahi-Naeini"
                            1 => "J&#46; Shapouri"
                            2 => "M&#46; Masjedi"
                            3 => "A&#46; Saffaei"
                            4 => "M&#46; Pourazizi"
                          ]
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        "fecha" => "2014"
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Article information
ISSN: 15782190
Original language: English
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Idiomas
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