Case Report Safe ECT in a Patient With the Ehlers–Danlos Syndrome *†Pascal Sienaert, MD, †Marc De Hert, MD, PhD, †Martine Houben, *Filip Bouckaert, MD, *Sabien Wyckaert, MD, *‡Bénédicte Hagon, MD, *André Hagon, MD, and †Jozef Peuskens, MD, PhD Abstract The Ehlers–Danlos syndrome is an inheritable dis- order caused by genetic defects of collagen. Hyper- extensibility and fragility of the skin, joint hyper- laxity, and generalized fragility of the connective tissues, involving the hollow organs and arteries, are the cardinal features of this syndrome. Low bone density has also been reported. Theoretically, these patients can have an increased risk of rup- ture of blood vessels and of bone fractures. A pa- tient with a schizo-affective disorder and Ehlers– Danlos Type I who received bifrontal ECT for a depressive episode is described. Even without spe- cific measures to lower blood pressure, a course of ECT was finished without any complication. Key Words: electroconvulsive therapy, schizoaffec- tive disorder, Ehlers–Danlos syndrome ( J ECT 2003;19:230–233) E hlers–Danlos syndrome (EDS) is the most prevalent heritable disorder of connective tissue 1 caused by genetic defects of type I, III, or V collagen. 2 EDS is a relatively rare disorder, with current estimates placing the prevalence at about 1 in 20,000. 3 Six differ- ent types of this disorder are recognized: the classic type (EDS I and II), the hypermobility type (EDS III), the vascular type (EDS IV), the kyphoscoliosis type (EDS VI), the arthrocha- lasia type (EDS VIIB), and the dermatospar- axis type (EDS VIIC). 4 Individuals diagnosed with EDS types I, II, and III comprise approxi- mately 90% of those diagnosed with this syn- drome. 3 The different types of this syndrome share as cardinal features hyperextensibility and fragility of the skin, joint hyperlaxity, and generalized fragility of the connective tissues, involving the hollow organs and arteries. 4 Musculoskeletal problems include joint pain, swelling and instability, and spinal deformi- ty. 1 The classic type of EDS is characterized by abnormal scarring, fragility of skin and blood vessels, frequent varicose veins, and joint laxity. 2,5 In patients with the vascular type, severe fragility of the blood vessels leads to excessive bruising and spontaneous ruptures of middle-sized and large arteries, causing catastrophic bleeding. 2,6 Life expec- tancy can be shortened in the vascular type, whereas in the other types life expectancy is normal. 4 Bone is an important part of the connective tissue group, but very little is known about bone involvement in EDS. EDS and osteogenesis imperfecta are closely re- lated and are known to co-exist. The available data suggest that some people with EDS could have osteoporosis. 7,8 A recent study identified a tendency of EDS patients to frac- ture, have low bone mass, and have abnormal bone structure. 9 Coelho and colleagues 10 found low bone density in the lumbar spine (but not in the hip) in 4 patients with type I EDS. Given these theoretical data, we had to weigh the possible benefits of ECT in a se- verely depressed schizoaffective patient and the possible higher risk of rupture of blood vessels and bone fractures as a result of his comorbid EDS. Apart from some reports on complications during anesthetic and somatic procedures in patients with different types of EDS, 11 we did not find any publications to guide our decision. Received June 18, 2003; accepted August 29, 2003. From the *ECT Department, University Centre Sint-Jozef, Leuvensesteenweg, Kortenberg; †Department of Psychotic Disorders, University Centre Sint-Jozef, Leuvensesteenweg, Kortenberg; and ‡Department of Anaesthesiology, CHU Brugmann, Brussels, Belgium. Reprints: Dr. P. Sienaert, University Centre Sint-Jozef, Leuvensesteenweg 517, 3070 Kortenberg, Belgium (e-mail: pascal.sienaert@uc-kortenberg.be). Copyright © 2003 by Lippincott Williams & Wilkins 230 The Journal of ECT Volume 19, Number 4 December 2003