Skin manifestations, multiple aneurysms, and carotid-cavernous fistula in Ehlers-Danlos syndrome type IV.

A21-year-old woman presented with left ocular pain and severe pulsatile headache. She had suffered from easy bruisability since she was young. On physical examination, ecchymoses and bruises were noticed on trauma sites (Figure 1A). The skin was so thin that subcutaneous blood vessels were visible (Figure 1B). Huge hematomas and ecchymoses occurred at the puncture sites after angiography (Figure 1C). There was no significant hyperelasticity of the skin. Mild hypermobility of the joints in the hands was observed. Angiography showed a large carotid-cavernous fistula and an aneurysm at the cervical portion of the left internal carotid artery (Figure 2A). Abdominal aortography disclosed a large ovoid aneurysm of the left renal artery with delayed nephrogram (Figure 2B). The carotid-cavernous fistula was successfully occluded by detachable balloons. This case demonstrates characteristic clinical features of type IV Ehlers-Danlos syndrome, an autosomal dominant disorder resulting from mutations in the COL3A1 gene. The gene defects alter the metabolism of type III collagen, a major constituent of the walls of blood vessels.1 Type IV EhlersDanlos syndrome is life-threatening because of its vascular manifestations, which are characterized by rupture, dissection, or aneurysm formation affecting large or medium-sized arteries.2