Clinical characteristics.

EFEMP2-related cutis laxa, or autosomal recessive cutis laxa type 1B (ARCL1B), is characterized by cutis laxa and systemic involvement, most commonly arterial tortuosity, aneurysms, and stenosis; retrognathia; joint laxity; and arachnodactyly. Severity ranges from perinatal lethality as a result of cardiopulmonary failure to manifestations limited to the vascular and craniofacial systems.

Diagnosis/testing.

The diagnosis of EFEMP2-related cutis laxa is established in a proband with suggestive findings and biallelic pathogenic variants in EFEMP2 identified by molecular genetic testing.

Management.

Treatment of manifestations: Treatment of aortic root dilatation with beta-blockers or angiotensin receptor inhibitors can be considered. Aortic aneurysm replacement has been performed successfully. Symptomatic treatment of pulmonary emphysema; muscle-reinforcing physical therapy for joint hypermobility; routine repair of hernias. Tracheostomy may be necessary when retrognathia leads to upper-airway obstruction.

Surveillance: Follow-up evaluations with a cardiologist and pulmonologist at least annually starting from the time of diagnosis. Annual MR angiography from head to pelvis.

Agents/circumstances to avoid: Sun tanning to avoid damaging the skin; cigarette smoking to avoid worsening of emphysema.

Genetic counseling.

EFEMP2-related cutis laxa is inherited in an autosomal recessive manner. If both parents are known to be heterozygous for an EFEMP2 pathogenic variant, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier. Once the EFEMP2 pathogenic variants have been identified in an affected family member, carrier testing for at-risk relatives, prenatal testing for a pregnancy at increased risk, and preimplantation genetic testing are possible.

Suggestive Findings

The diagnosis of EFEMP2-related cutis laxa should be considered in individuals with the following clinical characteristics:

• Vascular involvement
  • Arterial and aortic tortuosity
  • Aortic and arterial aneurysms. The ascending aorta and aortic arch are typically most dilated.
  • Aortic stenosis. The isthmus aorta in particular is often stenotic.
  • Stenosis and dilatation of pulmonary arteries
  • Pulmonary hypertension
  • Hemorrhagic stroke
• Cutis laxa. Furrowing of the skin of the whole body that can be displaced more than normal skin and shows abnormal recoil; the skin has a "doughy" consistency. It does not display redundancy as in the Ehlers-Danlos syndromes.
• Respiratory involvement. Diaphragmatic hernia or hypoplasia
• Craniofacial involvement
  • Retrognathia
  • Widely spaced eyes
  • High palate
  • Long philtrum
  • Sagging cheeks
  • Dysplastic ears
• Other evidence of a generalized connective disorder
  • Joint laxity or contractures
  • Arachnodactyly
  • Pectus excavatum
  • Inguinal hernias
  • Hypotonia
  • Bone fragility

Establishing the Diagnosis

The diagnosis of EFEMP2-related cutis laxa is established in a proband with suggestive findings and biallelic pathogenic (or likely pathogenic) variants in EFEMP2 identified by molecular genetic testing (see Table 1).

Note: (1) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variants" and "likely pathogenic variants" are synonymous in a clinical setting, meaning that both are considered diagnostic and both can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include any likely pathogenic variants. (2) Identification of biallelic EFEMP2 variants of uncertain significance (or identification of one known EFEMP2 pathogenic variant and one EFEMP2 variant of uncertain significance) does not establish or rule out the diagnosis.

Because the phenotype of EFEMP2-related cutis laxa is indistinguishable from many other inherited disorders with cutis laxa and/or arterial abnormalities (tortuosity, aneurysm, and/or stenosis), recommended molecular genetic testing approaches include use of a multigene panel or comprehensive genomic testing.

Note: Single-gene testing (sequence analysis of EFEMP2, followed by gene-targeted deletion/duplication analysis) is rarely useful and typically NOT recommended.

• A cutis laxa or arteriopathy multigene panel that includes EFEMP2 and other genes of interest (see Differential Diagnosis) is most likely to identify the genetic cause of the condition while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.
  For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.
• Comprehensive genomic testing does not require the clinician to determine which gene is likely involved. Exome sequencing is most commonly used; genome sequencing is also possible.
  If exome sequencing is not diagnostic, exome array (when clinically available) may be considered to detect (multi)exon deletions or duplications that cannot be detected by sequence analysis. Note: To date such variants have not been identified as a cause of this disorder.
  For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.

Clinical Description

EFEMP2-related cutis laxa (autosomal recessive cutis laxa type 1B, ARCL1B) is a highly variable disorder ranging from perinatal lethality caused by cardiopulmonary failure [Hoyer et al 2009, Letard et al 2018] to manifestations limited to the vascular and craniofacial systems [Renard et al 2010]. The most common shared features besides cutis laxa include arterial tortuosity, aneurysms, and stenosis; retrognathia; joint laxity; and arachnodactyly.

To date, 49 individuals have been identified with a pathogenic variant in EFEMP2 [Hucthagowder et al 2006, Dasouki et al 2007, Hoyer et al 2009, Renard et al 2010, Al-Hassnan et al 2012, Erickson et al 2012, Iascone et al 2012, Kappanayil et al 2012, Sawyer et al 2013, Hebson et al 2014, Hibino et al 2018, Letard et al 2018, Mauger et al 2019, Yetman et al 2019]. The following description of the phenotypic features associated with this condition is based on these reports.

Cardiovascular. The most typical cardiovascular findings are marked aortic dilatation, aortic and arterial tortuosity, isthmic aortic narrowing, and dilatation/stenosis of the pulmonary arteries. Aberrant branching of the right pulmonary artery is also a frequent finding. Additional cardiovascular findings that have been described occasionally include cardiac hypertrophy, bradycardia [Dasouki et al 2007, Hoyer et al 2009], pulmonary hypertension, and tricuspid insufficiency [Dasouki et al 2007]. In a cohort of 16 affected individuals from India, almost all died from cardiopulmonary failure in the neonatal period [Nampoothiri et al 2010]. Other individuals underwent successful aortic surgery and survived [Sawyer et al 2013, Hebson et al 2014, Hibino et al 2018, Yetman et al 2019].

Lung. Most common lung problems are related to diaphragmatic hypoplasia or hernia. Developmental emphysema has been described in one individual [Hoyer et al 2009], but emphysema is more typical for FBLN5-associated cutis laxa.

Skin. Although EFEMP2-related cutis laxa is classified within the cutis laxa group, skin findings can be minor or even normal. If present, pertinent skin findings include cutis laxa and thin translucent or velvety skin.

Craniofacial. The most recurrent characteristics are mirognathia or retrognathia, long philtrum, widely spaced eyes, high palate, and dysplastic ears. Additional features include thin vermilion of the upper lip and prominent eyes. A single individual has been reported with keratoglobus [Mauger et al 2019].

Musculoskeletal. Individuals with EFEMP2-related cutis laxa usually present with muscle hypotonia. Other common findings are joint laxity or contractures, arachnodactyly, and pectus deformities (carinatum or excavatum). Fractures also appear to be common [Hoyer et al 2009]. Additional skeletal observations include soft cranial bones, bowing and elongation of the long bones, and flaring of the metaphyses.

Other. Inguinal/umbilical hernias may be present.

Genotype-Phenotype Correlations

Survival analysis comparing four individuals with at least one truncating EFEMP2 pathogenic variant with 22 individuals with biallelic missense EFEMP2 pathogenic variants showed a shorter median survival in the first group (9.45 months vs 36 months) [Letard et al 2018].

Prevalence

Very few reliable estimates of the prevalence of cutis laxa exist. The prevalence at birth for all types of cutis laxa is 1:4,000,000 according to the Rhone-Alps Eurocat Registry [E Robert, personal observation].

Evaluations Following Initial Diagnosis

To establish the extent of disease and needs in an individual diagnosed with EFEMP2-related cutis laxa, the evaluations summarized in Table 4 (if not performed as part of the evaluation that led to the diagnosis) are recommended.

Treatment of Manifestations

Surveillance

Agents/Circumstances to Avoid

Avoid the following:

• Sun tanning, which can damage skin
• Cigarette smoking, which can worsen emphysema

Evaluation of Relatives at Risk

It is appropriate to clarify the genetic status of older and younger sibs of an affected individual in order to identify as early as possible those who should undergo regular cardiovascular and pulmonary surveillance to allow prompt initiation of treatment and preventive measures.

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Mode of Inheritance

EFEMP2-related cutis laxa is inherited in an autosomal recessive manner.

Risk to Family Members

Parents of a proband

• The parents of an affected child are obligate heterozygotes (i.e., presumed to be carriers of one EFEMP2 pathogenic variant based on family history).
• Molecular genetic testing is recommended for the parents of a proband to confirm that both parents are heterozygous for an EFEMP2 pathogenic variant and to allow reliable recurrence risk assessment. (De novo variants are known to occur at a low but appreciable rate in autosomal recessive disorders [Jónsson et al 2017].)
• Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.

Sibs of a proband

• If both parents are known to be heterozygous for an EFEMP2 pathogenic variant, each sib of an affected individual has at conception a 25% chance of being affected, a 50% chance of being an asymptomatic carrier, and a 25% chance of being unaffected and not a carrier.
• In general, similar clinical manifestations are observed in sibs with EFEMP2 pathogenic variants, but exceptions exist.
• Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.

Offspring of a proband. The offspring of an individual with EFEMP2-related cutis laxa are obligate heterozygotes (carriers) for a pathogenic variant in EFEMP2.

Other family members. Each sib of the proband's parents has a 50% risk of being a carrier of an EFEMP2 pathogenic variant.

Carrier Detection

Carrier testing for at-risk relatives requires prior identification of the EFEMP2 pathogenic variants in the family.

Related Genetic Counseling Issues

See Management, Evaluation of Relatives at Risk for information on evaluating at-risk relatives for the purpose of early diagnosis and treatment.

Family planning

• The optimal time for determination of genetic risk, clarification of carrier status, and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
• It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are carriers, or are at risk of being carriers.

DNA banking. Because it is likely that testing methodology and our understanding of genes, pathogenic mechanisms, and diseases will improve in the future, consideration should be given to banking DNA from probands in whom a molecular diagnosis has not been confirmed (i.e., the causative pathogenic mechanism is unknown). For more information, see Huang et al [2022].

Prenatal Testing and Preimplantation Genetic Testing

Once the EFEMP2 pathogenic variants have been identified in an affected family member, prenatal testing and preimplantation genetic testing are possible.

Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.

Molecular Pathogenesis

Different mechanisms have been suggested for the pathogenetic consequences of EFEMP2 mutation [Papke & Yanagisawa 2014, Papke et al 2015, Sasaki et al 2016]. Biallelic pathogenic variants in EFEMP2 lead to diminished secretion or stability of the fibulin-4 protein into the extracellular matrix. This leads to decreased activity of lysyl oxidase (important for collagen and elastin cross-linking) and other extracellular matrix components such as collagen IV, fibrillin-1, and elastin. Finally, a role in transforming growth factor-beta (TGFß) signaling has been proposed based on interactions with LTBP1 and LTBP4 (latent transforming growth factor beta binding protein).

Mechanism of disease causation. EFEMP2-related cutis laxa occurs via a loss-of-function mechanism, leading to impaired collagen and elastin function [Papke et al 2015].

Author Notes

Bart Loeys, MD, PhD
Center for Medical Genetics, Antwerp University Hospital

Anne De Paepe, MD, PhD
Center for Medical Genetics, Ghent University Hospital

Zsolt Urban, PhD
Graduate School of Public Health, Department of Human Genetics, University of Pittsburgh

Acknowledgments

This work was funded in part by the University of Antwerp (GOA, Methusalem-OEC grant "Genomed" FFB190208), the Fund for Scientific Research, Flanders (FWO, Belgium, G.0356.17, G.0447.20), the Dutch Heart Foundation (2013T093), and the Marfan Foundation. Dr Loeys, senior clinical investigator of the Fund for Scientific Research, Flanders, holds a consolidator grant from the European Research Council (Genomia – ERC-COG-2017-771945) and is a member of European Reference Network on rare vascular disorders (VASCERN).

Revision History

• 15 June 2023 (aa) Revision: added EMILIN1-related cutis laxa to Differential Diagnosis
• 22 October 2020 (ha) Comprehensive update posted live
• 23 July 2015 (me) Comprehensive update posted live
• 12 May 2011 (me) Review posted live
• 9 July 2010 (bl) Original submission

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