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Pseudoxanthoma elasticum
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <h3>Dermatological manifestations</h3> <p>Usually, pseudoxanthoma elasticum affects the skin first, often in childhood or early adolescence.<a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> Small, yellowish papular lesions form and cutaneous laxity mainly affect the neck, <a href="/facts/Armpit/Q0EaYG2p">axillae</a> (armpits), groin, and flexural creases (the inside parts of the elbows and knees).<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a><a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> Skin may become lax and redundant. Many individuals have "oblique mental creases" (horizontal grooves of the chin).<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> The lesions are asymptomatic and have a stochastic pattern of growth and spread.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a> </p> <h3>Ocular manifestations</h3> <p>PXE first affects the retina through a dimpling of the <a href="/facts/Bruch%2527s_membrane/VCpPBoRU">Bruch membrane</a> (a thin membrane separating the blood vessel-rich layer from the pigmented layer of the <a href="/facts/Retina/v0ISNX2S">retina</a>), that is only visible during <a href="/facts/Ophthalmologic/024hdTWF">ophthalmologic</a> examinations.<a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> This is called <a href="/facts/Peau_d%2527orange/RrQCdUlA">peau d'orange</a> (a French term meaning "skin of the orange"). Eventually the mineralization of the elastic fibers in the Bruch membrane create cracks called <a href="/facts/Angioid_streaks/AFVhHNeF">angioid streaks</a> that radiate out from the optic nerve. Angioid streaks themselves do not cause distortion of vision, even if they cross into the foveal area. This symptom is present in almost all PXE patients and is usually noticed a few years after the onset of cutaneous lesions. These cracks may allow small blood vessels that were originally held back by Bruch's membrane to penetrate the retina. These blood vessels sometimes leak, and these <a href="/facts/Retinal_hemorrhage/MgfT9u2H">retinal hemorrhages</a> may lead to the loss of central vision. Vision loss is a major issue in many PXE patients.<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a><a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a><a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a> </p><p>Additionally, patients with PXE are at a greater risk of developing optic nerve head (ONH) drusen, which are calcified lesions within the optic nerve. Careful monitoring should be considered to prevent further complication, such as retinal artery occlusion and optic neuropathy.<a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a> </p> <h3>Cardiovascular manifestations</h3> <p>PXE is caused by mineralization in connective tissues in mainly the skin, eyes, and blood vessels.<a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> As a result of mineralized buildup in the vascular wall, patients may be at a greater risk for <a href="/facts/Intermittent_claudication/WJkG14tJ">intermittent claudication</a>, a condition in which cramping pain in the leg is induced by exercise,<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a> and peripheral artery disease.<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a> Occlusions in cerebral arteries can lead to reduced or blocked blood flow, resulting in serious complications including <a href="/facts/Transient_ischemic_attack/7eM1EYCg">transient ischemic attack</a> (TIA) and <a href="/facts/Stroke/DwpjdzY0">stroke</a>. Similarly, blockages in the coronary circulatory system, also called <a href="/facts/Coronary_artery_disease/szCt0nVx">coronary artery disease</a> may develop, leading to <a href="/facts/Angina_pectoris/rT1brdwS">angina</a> and <a href="/facts/Myocardial_infarction/xoGw0qcG">myocardial infarction</a> (heart attack).<a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> Cerebral ischemia in PXE is caused by small vessel occlusive disease. </p> <h3>Other manifestations</h3> <p>Although not much is known about potential gastroenterological manifestations, <a href="/facts/Gastrointestinal_bleeding/ynYL5PXm">gastrointestinal bleeding</a> is a rare symptom and usually involved bleeding from the <a href="/facts/Stomach/Q4PPDGT6">stomach</a>. </p><p>Other rare neurological complications may include intracranial aneurysms, subarachnoid and intracerebral hemorrhages.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> </p> <h2 id="genetics">Genetics</h2> <p>80% of clinical cases of pseudoxanthoma elasticum have detectable mutations in the <i>ABCC6</i> gene.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a><a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a><a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a><a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> Mutations in almost all parts of the gene have been described, of all types (missense, nonsense, splice alteration, insertion, small deletion or large deletion). Although there have been reports of <a href="/facts/Dominance_relationship/DsvtPyQU">autosomal dominant</a> inheritance, the inheritance is typically autosomal recessive (both parents need to be carriers, and there is a 25% chance that a child will inherit <i>both</i> abnormal copies of the gene and therefore develop the condition).<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> </p><p>Strong genetic linkage was found with mutations in the <i><a href="/facts/ABCC6/woTx7Hjr">ABCC6</a></i> gene, which codes for the ABCC6 protein, which is a membrane transporter from the large <a href="/facts/ATP-binding_cassette_transporter_genes/aXPf4sA9">ATP-binding cassette transporter</a> family. The protein is expressed in most organs, but mainly in the <a href="/facts/Liver/Rtp4Fk2b">liver</a> and <a href="/facts/Kidney/HBspPrv9">kidney</a>. ABCC6 mediates ATP release in the liver. This is the main source of circulating pyrophosphate (PPi), and individuals affected by PXE have strongly reduced plasma PPi levels, explaining their mineralization disorder.<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a> One study suggested that mutations causing total absence of an ABCC6 protein caused a more severe disease,<a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a> but this could not be confirmed in a subsequent case series.<a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a> Given the variations in age of onset and severity it is likely that other unknown risk factors (genetic, environmental, and lifestyle) may be involved.<a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> </p><p>Premature <a href="/facts/Atherosclerosis/WIS8QQ6v">atherosclerosis</a> is also associated with mutations in the <i><a href="/facts/ABCC6/woTx7Hjr">ABCC6</a></i> gene, even in those without PXE.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> A syndrome almost indistinguishable from hereditary PXE has been described in patients with <a href="/facts/Hemoglobinopathy/ztfHkna3">hemoglobinopathies</a> (<a href="/facts/Sickle-cell_disease/93LT7ATq">sickle-cell disease</a> and <a href="/facts/Thalassemia/NF7GIJsJ">thalassemia</a>) through a poorly understood mechanism.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a> In addition, there appears to be another PXE-like syndrome with a similar phenotype but as a result of problems with another gene, <a href="/facts/Gamma-glutamyl_carboxylase/hzrNbCYg">gamma-glutamyl carboxylase</a>.<a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> Mutations in <i>ABCC6</i> can also cause generalized arterial calcification of infancy.<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a> In some cases of PXE, mutations in <i>ABCC6</i> cannot be found, and other genes such as <i>ENPP1</i> may be implicated.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> </p> <h2 id="pathophysiology">Pathophysiology</h2> <p>In PXE, there is mineralization (accumulation of <a href="/facts/Calcium_in_biology/wgUxKej5">calcium</a> and other minerals) and fragmentation of the <a href="/facts/Elastin/9S2w5thw">elastin</a>-containing fibers in <a href="/facts/Connective_tissue/mal3fc7k">connective tissue</a>, but primarily in the midlaminar layer of the dermis, Bruch's membrane and the midsized <a href="/facts/Artery/Y1Yj0jat">arteries</a>.<a class="footnote-ref" id="fnref:36" href="#fn:36"><sup>36</sup></a> Recent studies have confirmed that PXE is a metabolic disease, and that its features arise because metabolites of vitamin K cannot reach peripheral tissues.<a class="footnote-ref" id="fnref:37" href="#fn:37"><sup>37</sup></a> Low levels of PPi cause mineralization in peripheral tissues.<a class="footnote-ref" id="fnref:38" href="#fn:38"><sup>38</sup></a> </p> <h2 id="diagnosis">Diagnosis</h2> <p>The diagnostic criteria for PXE are the typical skin biopsy appearance and the presence of <a href="/facts/Angioid_streaks/AFVhHNeF">angioid streaks</a> in the retina. Criteria were established by consensus of clinicians and researchers at the 2010 biennial research meeting of the PXE Research Consortium.<a class="footnote-ref" id="fnref:39" href="#fn:39"><sup>39</sup></a> and confirmed at the 2014 meeting<a class="footnote-ref" id="fnref:40" href="#fn:40"><sup>40</sup></a> These consensus criteria state that definitive PXE is characterized by two pathogenic mutations in the <i>ABCC6</i> or ocular findings – angioid streaks > 1 DD or peau d'orange in an individual <20 years of age together with skin findings: </p> <ul><li>Characteristic pseudoxanthomatous papules and plaques on the neck or flexural creases.</li> <li>Diagnostic histopathological changes in lesional skin: Calcified elastic fibers in the mid and lower dermis, confirmed by positive calcium stain</li></ul> <h3>Differential diagnosis</h3> Pseudoxanthoma elasticum versus histopathological differential diagnoseson light microscopy (LM) and <a href="/facts/Electron_microscopy/XtaBktwF">electron microscopy</a> (EM)<a class="footnote-ref" id="fnref:41" href="#fn:41"><sup>41</sup></a><table><tbody><tr><td>Pseudoxanthoma elasticum</td><td>LM: Mid-dermal calcification and fragmentation of elastic fibersEM: Mineralization in elastic fiber core</td></tr><tr><td>PXE-like disease with coagulation deficiency</td><td>LM: Middermal calcification and fragmentation of elastic fibersEM: Mineralization in elastic fiber periphery</td></tr><tr><td><a href="/facts/Hemoglobinopathies/ztfHkna3">Hemoglobinopathies</a></td><td>LM: Middermal calcification and fragmentation of elastic fibersEM: Mineralization in elastic fiber core</td></tr><tr><td>PXE-like papillary dermal elastolysis</td><td>LM: Selective elastic tissue elimination in the papillary dermis and presence of melanophages</td></tr><tr><td>White fibrous papulosis of the neck</td><td>LM: Dermal fibrosis in papillary and mid-reticular dermis</td></tr><tr><td>Late-onset focal dermal elastosis</td><td>EM: Decrease of elastic fibers; fragmentation of remaining fibersLM: Accumulation of elastic fibers in mid- and reticular dermis without fragmentation or calcification</td></tr><tr><td><a href="/facts/Perforating_calcific_elastosis/Ml827the">Perforating calcific elastosis</a></td><td>LM: Middermal calcification and degeneration of elastic fibers with transepidermal elimination</td></tr><tr><td><a href="/facts/Buschke%25E2%2580%2593Ollendorff_syndrome/Egvjkqr6">Buschke–Ollendorff syndrome</a></td><td>LM: Increased amount of hypertrophic elastic fibers in dermisEM: Altered translucent elastic fibers</td></tr><tr><td><a href="/facts/Elastosis_perforans_serpiginosa/EpJFNmwq">Elastosis perforans serpiginosa</a></td><td>LM: Transepidermal or perifollicular perforating canals</td></tr><tr><td>Papular elastorrhexis</td><td>LM: Thickening of collagen bundles next to loss and fragmentation of elastic fibers</td></tr><tr><td>Upper dermal elastolysis</td><td>LM: Complete loss of elastic fibers in the upper dermis</td></tr><tr><td>Middermal elastolysis</td><td>LM: Complete absence of elastic fibers in the middermis</td></tr><tr><td><a href="/facts/Linear_focal_elastosis/11FEjMSN">Linear focal elastosis</a></td><td>LM: Massive basophilic fibers; clumping of elastic fibers in papillary dermis</td></tr><tr><td>Elastoderma</td><td>LM: Increased, intertwining thin elastic fibers in papillary and upper reticular dermis</td></tr><tr><td><a href="/facts/Calcinosis_cutis/sNKTwz8E">Calcinosis cutis</a></td><td>LM: Deposits of calcium in the dermis</td></tr></tbody></table> <h2 id="treatment">Treatment</h2> <p>There is no confirmed treatment that directly interferes with the disease process.<a class="footnote-ref" id="fnref:42" href="#fn:42"><sup>42</sup></a><a class="footnote-ref" id="fnref:43" href="#fn:43"><sup>43</sup></a> </p><p>Cosmetic surgery to remove excessive skin has been used to improve aesthetic appearance in PXE patients<a class="footnote-ref" id="fnref:44" href="#fn:44"><sup>44</sup></a> but because of the non-life-threatening nature of these symptoms, should be used with caution.<a class="footnote-ref" id="fnref:45" href="#fn:45"><sup>45</sup></a> </p><p>One of the most critical symptom of PXE is <a href="/facts/Choroidal_neovascularization/AL9YMNFu">choroidal neovascularization</a> which can lead to deterioration of central vision. <a href="/facts/Photodynamic_therapy/qHIQzT5K">Photodynamic therapy</a> has been used as a treatment, but this has been replaced with <a href="/facts/Endothelial_growth_factor/kNDc0Xj0">endothelial growth factor</a> (VEGF) inhibitors (such as <a href="/facts/Bevacizumab/CXXMF9rL">bevacizumab</a>, <a href="/facts/Ranibizumab/oUvts4E1">ranibizumab</a>, and <a href="/facts/Aflibercept/sPDlQ7tR">aflibercept</a>)<a class="footnote-ref" id="fnref:46" href="#fn:46"><sup>46</sup></a> with efficacy similar to their use in treatment of <a href="/facts/Macular_degeneration/9pFARaka">age-related macular degeneration</a>.<a class="footnote-ref" id="fnref:47" href="#fn:47"><sup>47</sup></a> </p><p>To limit cardiovascular symptoms, reduction of cardiovascular risk factors through lifestyle changes is recommended.<a class="footnote-ref" id="fnref:48" href="#fn:48"><sup>48</sup></a> Generally clinicians recommend avoidance of non-steroidal anti-inflammatory drugs (NSAIDS) that increase bleeding risk, such as <a href="/facts/Aspirin/opMK4qLk">aspirin</a>, and <a href="/facts/Ibuprofen/vsKBTfVl">ibuprofen</a> to prevent eye and gastrointestinal bleeding.<a class="footnote-ref" id="fnref:49" href="#fn:49"><sup>49</sup></a> </p><p>Formerly, dietary restriction of calcium was tried with no benefit, and in fact accelerated mineralization in mice.<a class="footnote-ref" id="fnref:50" href="#fn:50"><sup>50</sup></a> There are a number of potential treatments that are currently being tested or have just undergone testing including magnesium,<a class="footnote-ref" id="fnref:51" href="#fn:51"><sup>51</sup></a> etidronate,<a class="footnote-ref" id="fnref:52" href="#fn:52"><sup>52</sup></a> PPi,<a class="footnote-ref" id="fnref:53" href="#fn:53"><sup>53</sup></a> and tissue-nonspecific alkaline phosphatase inhibitors.<a class="footnote-ref" id="fnref:54" href="#fn:54"><sup>54</sup></a> </p><p>Given that ABCC6 <a href="/facts/Heterozygous/XzEJ5gPp">heterozygous</a> mutations result in few symptoms of PXE, this disease is a candidate for <a href="/facts/Gene_therapy/CaxRLfKM">gene therapy</a>. Some initial proof-of-principle experiments have been done in mice that have relieved some of symptoms of PXE, but as with all gene therapy treatments, there are many hurdles that must be overcome including insuring that the treatment will be long-lasting and reducing the risk of insertional <a href="/facts/Mutagenesis/kQtI5zT1">mutagenesis</a> and severe immune reactions.<a class="footnote-ref" id="fnref:55" href="#fn:55"><sup>55</sup></a> </p> <h2 id="epidemiology">Epidemiology</h2> <p>The reported prevalence of pseudoxanthoma elasticum is about 1:25,000. Females are twice as likely to be affected as males. The disease occurs in all ethnicities, but <a href="/facts/Afrikaner/MNKWNlDV">Afrikaners</a> are more likely to have PXE as a result of a <a href="/facts/Founder_effect/5hRhkbSF">founder effect</a> (i.e., higher prevalence in the small group of people from whom Afrikaners descend).<a class="footnote-ref" id="fnref:56" href="#fn:56"><sup>56</sup></a> </p> <h2 id="history">History</h2> <p>The first description of PXE that distinguished it from other <a href="/facts/Xanthoma/kkdJksvS">xanthoma</a> conditions was by Dr Ferdinand-Jean Darrier in 1896.<a class="footnote-ref" id="fnref:57" href="#fn:57"><sup>57</sup></a> The eponym "Grönblad-Strandberg syndrome" is used in older literature, after two physicians who made further discoveries in the disease manifestations.<a class="footnote-ref" id="fnref:58" href="#fn:58"><sup>58</sup></a> </p><p>PXE has the distinction of being the only disease for which a layperson is the discover of the mutated gene. The <i>ABCC6</i> gene mutation was discovered simultaneously by four research teams, all of which published at the same time. The principal investigators were (in order of the date of publication): Jouni Uitto,<a class="footnote-ref" id="fnref:59" href="#fn:59"><sup>59</sup></a> Arthur Bergen,<a class="footnote-ref" id="fnref:60" href="#fn:60"><sup>60</sup></a> Charles Boyd,<a class="footnote-ref" id="fnref:61" href="#fn:61"><sup>61</sup></a> and Klaus Lindpainter.<a class="footnote-ref" id="fnref:62" href="#fn:62"><sup>62</sup></a> The gene was patented by Charles D. Boyd, Katalin Csiszar, Olivier LeSaux, Zsolt Urban, Sharon Terry, and assigned to PXE International by these co-inventors. Between the filing and 2013, when the Supreme Court of the United States declared that genes may not be patented.<a class="footnote-ref" id="fnref:63" href="#fn:63"><sup>63</sup></a> PXE International freely licensed the gene to any lab for clinical testing and research. PXE International continues to hold and maintain other patents (diagnosis and treatment patents).<a class="footnote-ref" id="fnref:64" href="#fn:64"><sup>64</sup></a><a class="footnote-ref" id="fnref:65" href="#fn:65"><sup>65</sup></a> </p><p>PXE International, a support organization, was founded in 1995, by Patrick and <a href="/facts/Sharon_F._Terry/AGDsmEHF">Sharon Terry</a>,<a class="footnote-ref" id="fnref:66" href="#fn:66"><sup>66</sup></a><a class="footnote-ref" id="fnref:67" href="#fn:67"><sup>67</sup></a><a class="footnote-ref" id="fnref:68" href="#fn:68"><sup>68</sup></a><a class="footnote-ref" id="fnref:69" href="#fn:69"><sup>69</sup></a> following the diagnosis of their two children. It has a registry of 4,600 affected individuals. </p> <h2 id="images">Images</h2> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/List_of_cutaneous_conditions/U58kszg2">List of cutaneous conditions</a></li></ul> <h2 id="external-links">External links</h2> <ul><li><a href="https://www.pxe.org">PXE international</a></li></ul> <ul><li><i><a href="https://www.ncbi.nlm.nih.gov/books/br.fcgi?book=gene&part=pxe">pxe</a></i> at <a href="/facts/National_Institutes_of_Health/G3Eytfcc">NIH</a>/<a href="/facts/University_of_Washington/36PG6qkG">UW</a> GeneTests</li> <li><i><a href="https://ghr.nlm.nih.gov/condition=pseudoxanthomaelasticum">Pseudoxanthoma elasticum</a></i> at <a href="/facts/U.S._National_Library_of_Medicine/Hzty0MCX">NLM</a> Genetics Home Reference</li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>Li Q, van de Wetering K, Uitto J (February 2019). "Pseudoxanthoma Elasticum as a Paradigm of Heritable Ectopic Mineralization Disorders: Pathomechanisms and Treatment Development". review. The American Journal of Pathology. 189 (2): 216–225. doi:10.1016/j.ajpath.2018.09.014. PMC 6412714. PMID 30414410. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6412714" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6412714</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>Chassaing N, Martin L, Calvas P, Le Bert M, Hovnanian A (December 2005). "Pseudoxanthoma elasticum: a clinical, pathophysiological and genetic update including 11 novel ABCC6 mutations". review. Journal of Medical Genetics. 42 (12): 881–92. doi:10.1136/jmg.2004.030171. PMC 1735972. PMID 15894595. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1735972" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1735972</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>Finger RP, Charbel Issa P, Ladewig MS, Götting C, Szliska C, Scholl HP, Holz FG (2009). "Pseudoxanthoma elasticum: genetics, clinical manifestations and therapeutic approaches". review. Survey of Ophthalmology. 54 (2): 272–85. doi:10.1016/j.survophthal.2008.12.006. PMID 19298904. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>Chassaing N, Martin L, Calvas P, Le Bert M, Hovnanian A (December 2005). "Pseudoxanthoma elasticum: a clinical, pathophysiological and genetic update including 11 novel ABCC6 mutations". review. Journal of Medical Genetics. 42 (12): 881–92. doi:10.1136/jmg.2004.030171. PMC 1735972. PMID 15894595. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1735972" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1735972</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Marconi B, Bobyr I, Campanati A, Molinelli E, Consales V, Brisigotti V, et al. (August 2015). "Pseudoxanthoma elasticum and skin: Clinical manifestations, histopathology, pathomechanism, perspectives of treatment". review. Intractable & Rare Diseases Research. 4 (3): 113–22. doi:10.5582/irdr.2015.01014. PMC 4561240. PMID 26361562. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561240" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561240</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Germain DP (May 2017). "Pseudoxanthoma elasticum". review. Orphanet Journal of Rare Diseases. 12 (1): 85. doi:10.1186/s13023-017-0639-8. PMC 5424392. 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