Connective tissue diseases — Medicine Library

Summary

Connective tissue is an important biological tissue composed of an extracellular matrix that binds, anchors, and supports organs. There are various types of connective tissue, all of which consist of varying combinations of fibers, cells, and intercellular substance. Over 200 conditions, which may be inherited or autoimmune, affect connective tissue, and they are collectively known as connective tissue diseases (CTDs). Inherited CTDs are caused by mutations that affect one of the two fibers (collagen and fibrillin). Autoimmune CTDs have no clear etiology, but the incidence is higher in women and among genetically predisposed individuals. As the name suggests, in autoimmune CTDs, the immune system develops antibodies against components of connective tissue. Individual conditions can affect a vast range of bodily structures (including cartilage, blood vessels, bone, tendons, and organs) and thus present with a wide array of clinical findings.

Autoimmune connective tissue diseases

Systemic lupus erythematosus
Rheumatoid arthritis
Inflammatory myopathies (e.g., polymyositis; , dermatomyositis)
Systemic sclerosis
Sjogren syndrome
Mixed connective tissue disease (Sharp's syndrome)
Relapsing polychondritis

Inherited connective tissue diseases

Ehlers-Danlos syndrome
Marfan syndrome
Osteogenesis imperfecta
Alport syndrome
Loeys-Dietz syndrome
[1]
- Autosomal dominant inheritance
- Caused by mutations in TGFβ receptor
- Features shared with Marfan syndrome: marfanoid habitus, increased risk of ascending aortic aneurysms and aortic dissection
- Distinct features: hypertelorism, bifid uvula, cleft palate, easy bruising and keloids, arterial tortuosity (winding course of arteries)
Kniest syndrome
- Autosomal dominant inheritance
- Caused by mutations in COL2A1 gene leading to impaired production of type 2 collagen
- Clinical features
  - Short stature
  - Ocular disorders (e.g., myopia, cataracts)
  - Hearing impairment

Clinical manifestations of connective tissue disorders

Clinical features vary greatly among individual diseases. The table below provides a general overview of the more common features.

Overview of manifestations of connective tissue disorders
Features	Autoimmune CTDs	Inherited CTDs
General	Fever, weight loss, fatigue	Fatigue, weakness
Musculoskeletal	Polyarthritis, myositis	Joint hypermobility, curved spine, brittle bones, bone deformities, growth abnormalities (short or tall stature)
Skin	Erythema, Raynaud's phenomenon	Hyperextensive, fragile skin
Other organ manifestations	Heart: pericarditis Lungs: scarring (pulmonary fibrosis), pleurisy Kidneys: nephritis (e.g., glomerulonephritis) CNS: depressive moods	Heart: valve weakness/prolapse Lungs: weakness, difficulty breathing, tendency to develop emphysema Blood vessels: aneurysms, ruptures Eye abnormalities

References:[2][3][4][5]

Connective tissue disorders

Non-autoimmune

Overview of inherited and acquired connective tissue disorders
Condition	Etiology	Pathophysiology	Clinical features (examples)
Marfan syndrome	Autosomal dominant disease caused by mutation of fibrillin-1 gene (FBN1) on chromosome 15	Defective fibrillin → defective elastin → defective connective tissue throughout the body	Tall stature with disproportionately long extremities; joint hypermobility Arachnodactyly Aortic aneurysm and dissection Lens subluxation superiorly and temporally Heart valve defects (mitral valve prolapse) Skin hyperelasticity
Ehlers-Danlos syndrome	Heterogeneous group of six connective tissue disorders with variable inheritance (autosomal recessive or dominant) Mutation in genes controlling synthesis of collagen Classic type: mutations in COL5A1, COL5A2 → type V collagen defect Vascular type: type III procollagen defect	Defective collagen cross-linking and fibril synthesis	Varying degrees of: Joint hypermobility (most common) Skin hyperextensibility Heart valve defects (particularly mitral valve prolapse) Aneurysms/dissections of the iliac, splenic, renal arteries, or the aorta
Menkes disease [6]	X-linked recessive neurodegenerative disease caused by a mutation in the gene ATP7A (coding for Menkes protein, copper-transporting ATPase 1)	Defective copper-transporting ATPase 1 → impaired copper absorption and transport → reduced activity of copper-dependent enzymes (e.g., lysyl oxidase, tyrosinase)→ defective collagen crosslinking and fibril synthesis	Sparse, fragile, kinky hair Hypopigmented skin and hair Failure to thrive Developmental retardation Epilepsy Hypotonia Increased risk of cerebral aneurysm Decreased copper and ceruloplasmin levels
Osteogenesis imperfecta	Rare, autosomal dominant inherited bone disorder due to mutation in COL1A1 or COL1A2 genes	Mutation in type I collagen gene → decreased synthesis of type 1 collagen	Brittle bones and frequent and/or multiple fractures from minimal trauma Growth retardation Skeletal deformities Blue sclera Progressive hearing loss (due to abnormal ossicles)
Scurvy	Vitamin C deficiency	Defect in hydroxylation of proline and lysine residues in procollagen → production of abnormal collagen with decreased tensile strength	Swollen gums Mucosal bleeding Poor wound healing Curly body hair Follicular hyperkeratosis Hemarthrosis Generalized weakness/fatigue

A for Absent copper and B for a Bunch of copper: In Menkes disease, the ATP7A gene is defective, resulting in decreased copper levels. In Wilson disease, the ATP7B gene is defective, which leads to high copper levels.

Ehlers-Danlos syndrome and Menkes disease are both associated with reduced lysyl oxidase activity, resulting in defective collagen cross-linking and fibril synthesis.

Autoimmune

Overview of autoimmune connective tissue disorders
	Clinical features	Diagnostics	Management
Systemic lupus erythematosus	Constitutional symptoms Malar rash Arthritis and arthralgia Photosensitivity Serositis (pleuritis, pericarditis) Neuropsychiatric manifestations Oral ulcers Hematological abnormalities (petechiae, pallor)	Antinuclear antibodies (ANA): 98% sensitivity Anti-dsDNA antibodies Anti-Sm antibodies Complement levels: ↓ C3, ↓ C4 Renal biopsy (for lupus nephritis) CBC, ESR, CRP, urinalysis	Hydroxychloroquine (first-line) Glucocorticoids Immunosuppressants (mycophenolate mofetil, azathioprine, cyclophosphamide) Refractory disease: biologics (belimumab, rituximab)
Rheumatoid arthritis (RA)	Symmetrical polyarthralgia (MCP joints, PIP joints, wrist joints) Joint deformities (swan neck deformity, boutonniere deformity) Morning stiffness (> 30 minutes) Constitutional symptoms Rheumatoid nodules (skin and/or pulmonary) Keratoconjunctivitis sicca, episcleritis Raynaud phenomenon	Rheumatoid factor Anti-CCP antibodies X-ray: marginal erosions of cartilage and bone, joint space narrowing Inflammatory markers (↑ ESR, ↑ CRP) Ultrasound or MRI (for early disease)	Acute symptomatic management: glucocorticoids and/or NSAIDs Long-term: DMARDs (e.g., methotrexate) Refractory RA: biologic DMARDs (e.g., TNF inhibitors)
Systemic sclerosis (SSc)	Sclerodactyly Digital ulcers Raynaud phenomenon Dysphagia Clinical features of interstitial lung disease (ILD) Pulmonary arterial hypertension Scleroderma renal crisis: oliguria, hypertension	ANA Anti-Scl-70 antibodies (diffuse SSc) Anticentromere antibodies (limited SSc) HRCT chest: may show ILD Nailfold capillaroscopy Pulmonary function tests: ↓ FVC and ↓ DLCO	Organ-specific symptomatic therapy Diffuse cutaneous disease, severe organ involvement, or ILD: systemic immunomodulatory medication Scleroderma renal crisis: ACE inhibitors Raynaud phenomenon: calcium channel blockers
Sjogren syndrome	Xerostomia Xerophthalmia Eye itching and/or burning sensation Dental caries Arthralgia and/or arthritis Raynaud phenomenon Constitutional symptoms	Anti-Ro/SSA or anti-La/SSB antibodies ANA ↑ ESR Schirmer test: decreased tear production Salivary gland biopsy: criterion standard (not routinely performed)	Artificial tears Artificial saliva, salivary stimulants Musculoskeletal pain: symptomatic treatment (e.g., NSAIDs), DMARDs (e.g., hydroxychloroquine) Severe systemic symptoms: immunosuppressants
Idiopathic inflammatory myopathies (e.g., polymyositis, dermatomyositis)	Symmetrical proximal muscle weakness Dysphagia Interstitial lung disease Myalgia Dermatomyositis: cutaneous features (e.g., heliotrope rash, Gottron papules, mechanic's hands)	↑ Creatine kinase Dermatomyositis: anti-Mi-2 antibodies, anti-SRP antibodies EMG Muscle biopsy (criterion standard) Malignancy screening	Supportive therapies (e.g., physical therapy, occupational therapy) Glucocorticoids (first-line) Immunosuppressants (e.g., methotrexate) Refractory disease: IVIg
Mixed connective tissue disease	Concurrent features of at least two autoimmune connective tissue diseases	Anti-U1 RNP antibodies (required for diagnosis) ANA Immunofluorescence: speckled pattern	Treatment depends on dominant clinical features Disease flares: glucocorticoids Lupus-like features: antimalarials (e.g., hydroxychloroquine) ILD: immunosuppressants (e.g., cyclophosphamide)
Relapsing polychondritis	Chondritis: auricular, nasal, laryngotracheobronchial, and/or costal Arthropathy Sensorineural hearing loss Vertigo	Clinical diagnosis X-ray: cartilage calcification MRI: inflammation of joints and/or cartilage Cartilage biopsy (not routinely performed)	Mild disease: NSAIDs, dapsone, or colchicine Severe disease: systemic glucocorticoids Refractory disease: conventional DMARDs or biologic DMARDs

References

Choudhary S, Gadegone R, Koley S. "Menkes kinky hair disease". Indian J Dermatol. 57(5). :407. (2012)
Pauker SP. "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes". UpToDate. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-ehlers-danlos-syndromes. [2016-07-08]
Beary JF, Chines AA. "Osteogenesis imperfecta: Clinical features and diagnosis". UpToDate. UpToDate. https://www.uptodate.com/contents/osteogenesis-imperfecta-clinical-features-and-diagnosis. [2015-09-03]
Kashtan CE. "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)". UpToDate. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-diagnosis-and-treatment-of-hereditary-nephritis-alport-syndrome#H4. [2016-12-08]
Wright MJ, Connolly HM. "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders". UpToDate. UpToDate. https://www.uptodate.com/contents/genetics-clinical-features-and-diagnosis-of-marfan-syndrome-and-related-disorders#H14. [2016-11-02]
"Loeys-Dietz syndrome". https://ghr.nlm.nih.gov/condition/loeys-dietz-syndrome#synonyms. [2017-03-01]