T HE J OU RNAL Of INVt!STIGATIVt: DEKMATOLOGl'. 66:59- 79. 1976 Vol. 66. No.

2
CopyriJ.(l1t@ 1976 by Tl1e William s & Wilkins Co. Prmled In U.S.A .

REVIEW ARTICLE
James H. Herndon. Jr .. M.D.
Reuiew A rticle Editor

DEFECTS IN THE BIOCHEMISTRY OF COLLAGEN IN DISEASES OF

CONNECTIVE TISSUE

JOUN I UI'ITo. M.D.. PH .D .. AND JACK R. LI CHTENSTIZIN , M.D .'"

D iul.~ion of Dermat ology. Departm ent of M edicine. Wa ... hinpton UniuersLty School of Med Icine. St. Louis,
M i.'i,·muri. l '. S . .4.

The collage ns are the major stru ctural g-lycoproteins of connecti\'e ti ss ues. A unique
primar~' struct ure a nd a multiplicit~· of post -tran slational modification reactions are required
for normal f'ibrillol:{enesis. The post-tra nsla ti onal modifi cations include hydroxylation of
prolyl a nd Iysyl residues. glycosylation. fold ing of the molecule into triple-helical confo rma-
tion. proteolytic conversion of precu rso r procollagen to collagen. a nd oxidative deami nation
of certain lysyJ and hydroxylysyl residues. Any defec t in the normal mechanism s responsible
for the synthesis and secretion of collagen molecules or the deposition of these molecules into
extracellular fibers could res ult in ab normal fibrillogenesis: suc h defects could resul t in a
co nn ecti\'e t issue disease. Recentl y. defects in the regul ation of the types of collagen
sy nth e~ized a nd in the enzymes in\'oh'ed in the post-translational modifications have been
found in he ritable diseases of' connective ti!;sue. Thus far. the prima ry heritable disorders of
collagen metabolism in man include I~'syl h~' droxylase deficiency in Ehle rs- Danlos !;yndrome
type VI. p-collagen peptidase deficienc\' in Ehle rs- Danlo. syndrome type VII. decreased
sy nthe~i s of type III ('ollagen in Ehlers- Danlos s~ 'n d ro me l~' PE' C\ '. Jysyi oxidase defi cie ncy in
X +linked cutis lax a and Ehle rs- Danlos sy ndrome t~'pe \' . and decreased synthesis of type 1
collagen in osteoge nesis impe rfec t a.

DEFI~ITIO~ OF " COLLAGES DISEASE"
The lerm "colJaJ!en disease" a priori implies that
th e clinical condi t io n in\'olve~ an abnormality in
the structu re. synthesis. or de~radation of col\agen.
Toda~· . howe\'er. the te rm collagen disease is fre-
quentl~· used to cha racterize a limited group of
clinically heterogeneou!; disorders wh ich include
disseminated lupu~ er~·thematosu , progress-h'e
s ~' stemic sclerosis. dermatomyositis. and periarte r-
itis nodosa . In the classical se nse as it was origi -
nally introduced by Klemperer et al III . the use of
the term in these diseases is based on the m or-
ph ologic observati on wh ic h is kn own as "fibrinoid
degenerati on " and whi c h implies changes in the
collagen fibers. In considering: these diseases on the
basis of the a\'ailable e\'idence it seems tha t
scle roderm a is the only clinical condition among:
the classical coilage n diseases whi ch invoh'es any
detec table abnormality in the structu re or metabo-
lism of collagen .
Man uscript received Ju ly 23, 1975: in rev ised form
September 26. 19i5: accepLed for publication OC[.Qber 1.
19i5.
Thi s work was su pported in parl by NIH Grants fROI
AM 185150t and TOI AM 05611. and b\' Grant 1357 from
the National Foundation. . clinical conditions which are true collagen diseases
• Howard Hughes inves ti~ato r .
Reprint requests to: Dr. J Ui tlo, Division of Dermc tol.
ogy. Depa rtment of Medi cine. Washington University
School of Medicine, 51.. Louis, Missouri 63110
Collagen is the most abu ndant st ru ctural protein
in connecti\'e t issues of orga ns such a50 skin . bone.
tendon. and c8rtilag-e. In skin. collage n re prese nts
\\lel! over 70 e; of the dry weight (see [2]). Collagen
is an unusual protei n in many respect s. and its
s tru ClU re and metabolism in\'oJ\'e a number of
unique features wh ich are criti cal for deposition of
normal collage n fibers. Based on ou r information of
the normal biochemistry of collagen, it is now
possible to specify distinct le\'els at whi ch defects
could be introduced into collagen molecules a nd
the fibers they form. A defect at anyone of these
le\'e ls could produce a t rue disease of collage n .
Thus. it has been proposed recently that the term
collagen disease shou ld be rese rved for conditions
in wh ich a defec i in collagen ca n bE' clearly
dem onstrated at the molecular le\'el 13).
In a primary collagen disease. such a defect
could be an inherited abnormality either in the
st r ucture of collagen Or procollagen or in the
acti\'ity of enzymes participating in the biosynthe-
sis a n d degradation of collagen. In a seco ndary,
acquired type of collagen disease. changes in colla-
gen may be seconda ry to initially un related meta-
bolic changes. According to this definition . several
are known . In this review the clinical. genetic, and
biochemical aspects of such diseases a re elucidated
and an accou n t of t he recent advances in the
60 UITrO AND LlCI-tTENSTE IN Vol. 66. No.2

biochemistry of normal collagen is given. An out-
line of t he steps in collagen sy nthes is and degrada-
ti o n as well as the known si t.es of coilage n defects in
various clinical and experimental conditions are
presented in Figure 1 a nd Table 1. For more
co mplete reviews of the progress made in the
biochemistry , biosynthesis. and degradation of
collage n. see 12- 91 .
THE BIOCHEMISTRY OF NORMAL COLLAGEN
General Structure
Exa minatio n of co nnective tis sues demonstrates
that collagen is deposit ed as la rge bundles of
regul arl y oriented fibers which o n furt her e xamin a·
ti o n can be sho wn to be com posed of small er fibrils
and microfi brils. These microfi brils are alig ned in
a parallel ma nner whi ch res ults in a regu la r
patt.ern of cross-striations o r bands when the ti ss ue
is visual ized by electron micro sco p~l . Th is banding
patt.e rn is due to t he stainin ~ of c h ar ~ed amino
acids in the mo lecule. The most pro mine nt cross-
str iat ions appear as repeating bands approxi-
mat.ely 700 A apa rt.
The basic co llagen molec ule is composed of t.hree
polypeptide chains. ca lled ,,-chaine (see 12.4. 61l.
Ea ch of the a-cha in s is coiled in a helix which
differs from 1 he a -helix found in most 0 1 her pro-
teins in that the axial distance from one amino
aci d t.o the next i:o mo re ext.ended. the distan ce
being abou t 2.9 A ins tead of' 1.5 A in an ,,- helix .
Three a -chai ns are in turn coiled on each o th er.
much like th e strands of' a rope. to form a tripl e-
helical stru cture. This unusual heli cal co nfo rm s-

lntfQceHutof Steps
I. Assembly of 3 polypept ide
chains of ~1,30 0 aa 's each.
2. Synlhesis of peplidyl Hypro
and Hylys.
3. Addition of sugars (Glc-Gal- )
'" 10 Hylys.
Gal 4. Synthesis of intefchain
~ S- S- bonds.
~ 5. Formohonof 3-hel\J..
I
~I( $ecre1 ion of Pr ecursor { " Procollogen ")
\ Ga l .

~ O~ 0.; 0 101

Removal of Peptide Extensions

by Peplidose (5)

--
M...
.,,-

CroSS-lm kino of Fi ber

Deom inati on of Hy lys and Lys to

gn1e a ldehydes
2. Cross-l ink formolion by reoclion Of
either tal 2 aldehyde s or tb)
I a ldehyde" I NH - on ad j acent
2
molecules

FIG. 1. Schematic presentation of the steps involved in the intracel lula r biosynthes is of procollagen and the asse mbly
of collagen molecu les into extracellular fibers. Abbrevia ti ons: mRNA . messenger RNA ; aa' .~ , amino aci ds: Hy pro .
hydroxyproline: Hylys , hydroxylysi ne: GLc-GaJ-, glu cosy l~a la c tose attached to th e hydroxyl group of hydroxylysi ne;
Lys. lysine; NH'I.-' amino-te rm inal ends of pol ypeptide chains. and also the {-amino group on either hydroxy lysine or
lysine. The scheme is modified from a similar one published else where (3 ]. (Reproduced with permission . Ui tlo and
Prockop. 1975 (31 .)
Feb. 1976
T"ULE I. PQ.lisibiLit ies for d efect •.;; in col/agen biology and exa mple!> of clinical and experimental conditions inuoluinJ!
Level and natu re of the defl:!cl
51 ruc(Ure of co llagen molecul e
Transc ription and lramilslinn
Change in amino ac id sequen ce
Cha nge in types of t'o Il8 ~en synthesized
PO~ l · l ram;lational m odificali()n~
Syn lh ~is of hyd roxy proline
Symhe-is of h~' droxylysine
Addition of ~alaclOse and glucose 10 hy-
d roxylysine
Cha in association. disulfide hond in,e- .a nd
helix formation
Con version of procollagen to collagen
Ox idatin deaminal ion nfhy droxylysine and
lysi ne
FDrmslion and stabiliz8t ion of cross-link!>.
Ra te of ('oilagen synthesis and deg radation
Change in rate of synt hesis
Change in rate of deJ!:radat ion
tion g-i\'es the molecule a riJtid . rodlike shape with
dimensions of approximately J5 .. 3000 A.
The unique natu re of the collagen t riple helix i::.
l a r g-el~' explai ned by the unu sual amino acid com-
posi tion of the polypeptide chains ITab . II I 11. 141.
Each 01 the a-chai ns conlain~ app roximately 1,000
amino acids a nd each c hain ha s a molec ular \..'eig-h t
of about 95.000 daltons . Glyci ne accounts for
one -thi rd of the total amino acid com positio n. and
sequencing of collagen c hain s has dem onst rated
that ~l~'c ine is evenly di stributed throughout the
m olec ule a t e,·ery th ird posi tion Isee 16. 15]) .
Consequenth-. the polypeptide chains of colla~e n
can be considered as a repeating- trip let rep re-
sented as IX -Y-Glyl",. The X - and Y-posi tions of
thi s repea l ing triplet can be occ upied by a va riety
of amino acids but most frequen tl y the X -po ition
is occu pied by proline and the V-posi t io n is oc-
cu p ied by hydroxyp roline with th ese 1\\'0 imi no
acids forming about 22 c( of' th e lotal amino acid
com posi t ion of rolla ~en IT ab. Il l. The rela t ivel)'
high content of the imino acids a nd the character -
istic d is tribut ion of glycine a re n ece5sa r~' for the
t riple-heli cal con fo r mation of th e collagen m ole-
cu le 141. In the absence of the tr iple-helical confor-
mation . no collagen fibers would be deposited in
ti ssues and th e conn ec ti ve t issue wo uld appea r
defect ive.
No clinical condition de riving from a subst itu-
ti o n of glycine . proline, or hyd roxyproli ne in colla-
Ke n has been reported. e\'e n though it is t o be
expected that with polypeptide chains of ove r 1.000
ami no acids, mutations result. ing in amino acid
COLLAGE!\. IS Ul SEASE 61
such defects
Clin ical or experimental condition
None kn own
Ehl ers- Danl os synd ro me type 1\': one fo r m of o~teog enesis
imperfects : osteoarthritis
Scu r,,\, : anoxia
Ehle r!'! - Danlo~ syndrome type \"l
None known
J'one known
Ehl e r~ - Danlo~ syndrome type vn : dermat ospa raxis in catt le
and sheep
Cu tis la xa : Eh len-- Danlos s\'nd rome type \ ': M enkes kinky
hair ~ ynd ro me: lathyri s m
Ho mocyst inuri a: the M arfan syndrome ('?): o -penicillamine-in-
du('ed changes in skin and ot her tissues
Act ive :-tlernde rma : kel oid fMmation: hype rtrophic scars: pul -
munary fibrosis : liver cirrhosis: syno\'ial tissue proliferatio n
in in namrnatory stages of rheumat o id arthriti s
Ca rt ilage dest ruct ion in rheumat oid arthritis : epide rm olysis
bullosa d ystrophica: hor monal disturban ces
substitut ions would be frequent occu rre nces, Be-
cau se su bst.itu t ion of a glycine or a proline residue
co uld inte rfe re with the fo r mati on of th e nor mal
t riple helix. the collagen in suc h a case might be so
se ri ously d efecti\'e that th e disease would be le t hal
in ute ro. However. because of the large number of
amino acids and the repetitious nature of the
sequence in collagen . it would be difficult to detect
si ngJe amin o acid subslitutions wit h presen t tech-
n iques.
Types of Col/agen
Alt hough collagens in higher animals conta in
about the same amou nt of imino acids and gl ~· ci ne.
there are considerable \'arialions in the seque nce of
amino acid~ which occupy the X - a nd Y-positions
of the repeating tr iple t -stru ctu re X- Y-GI),. Some of
these diffe rences ca n be explained b~' th e extent t o
whi ch the p oJypeptides are mndified afte r tran sla -
tion of colla ge n messen ge r·R:-.JA (see below). So me
of the differences. howe\'e r. indicate that there are
several distinct ge nes giving rise to synthesis of
collagen polypept ides with slightly \'a riable amino
aci d sequences ITable 11 1. Bone. tendon. and the
bulk of skin collage n a re composed of a collage n
whi ch consists of th ree a·chains of fWO different
k.inds. This t ype I collage n contains two identical
a-chai ns designated as a 1(l), and a t hird chain
called a 2 which is clearly different from al{D in
its amino a c id co mposition 116,17J. In cartilage,
the collagen m olecules are composed of three
identical, genetically distinct a-chains. a1(IT),
whi ch again have an am ino acid composi tio n
 62 U1ITO AND l.1CHTENSTEIN Vol . 66, No.2

TABLE n. Genetically distinct forms of collagen

Relative amount$ of amino

acids preselll in thf' molecul(>"
Type
of col. Chain (residues per 1(00)
la~en·
comj:lOSition --------------------------
Hydroxy.
Hydro~'-
Distribution among tillsues
Glycine Proline Lysine lysinE.'
proline
lal(1) j,a2° 330 129 96 30 4 Dermis. tendons. bones. and other
limes
a laHID j, 320 lOS 100 13 21 Cartilage
m lal(no I, 360 109 112 35 5 Dermis. cardiovascular and ~as.-
trointesli nai systems
IV lalllVl J, 325 60 163 5 42 Base ment membranes

C Values for type I and 111 collagens Bre from ral skin [10 J: value~ for ty pe II collage n Bfe from chick ste rnal cart ilages
[11 J; values for type IV collagen are from canine glomerular basement membrane /12.131.
b These Bfe the major types of colla~e ns reco~nized in tissues ()f vertehrat.e a nimals tada:.. but further research may

disclose the existence of add it ional (ype~ .

~ The designation implies that type I collagen molecule is composed of two a I-chains characteristic to type I collagen
and of one a2-chain. Collagen molecules of type H. Ut and rv are composed of three identical Q-chains.

different from that in aI(D [18. 19\. This type of
collagen is found exclusi\'ely in cartilagi nous tis-
sues and is designated as t~lpe LI . More recentl~· .
skin. gastrointestinal. and \'ascu lar connective tis-
sues have been dem onstrated to contain an addi-
tional geneticall;' distinct type of collagen. type 1lI
[20- 22\. Type III collagen is composed of three
identical a-chains which display distinct chem ical
features such as relatively high contents of hydroxy-
proline and glycine. and the presence of cystine
(Tab. rn. In fetal skin. type III coliagen accounts
for more than half of the total collagen. while in
adult skin less than 20Sf of the total collagen is
type III [21\. Type III collagen has been. therefore.
suggested to represe nt a fetal form of collagen.
According 10 the cu rrent nomenclature. the spe-
cific type of collagen present in basement mem-
branes is designated as type I", Type IV col lagen i!';
relatively poorly cha ra cterized but it seems to be
synthesized by epithelial Or end othelial cells and it
has a relatively high content of hydroxyproline and
hydroxylysine (Tab. II) [23.24J.
Translation of Pracalla~en Poly peptides
Among the characteristic features. of collagen is
the observation that under physiologic co nditions
collagen molecules spontaneously assemble into
insoluble fibers . This obse r\'ation previously pre -
sented a problem in that it was difficult to \'isual-
ize how the collagen molecule could be synthesized
inside the cell and secreted into t.he extracellular
milieu without the molecule prematurely assem-
bling into insoluble fibers. This question has been
now ans.wered by the demonstration t.hat coHagen
is initially synthesized as a higher-molec ular-
weight precursor , This precursor molecule, procol-
lagen. is soluble under physiologic conditions in
which collagen molecules form fibers . (For recent
rev iews on procaliagen, see [5, 8. 9, 25 J.)
Procollagen polypeptides, like several other pro-
teins destined for secretion out of the cells (261. a rE
s),nthesized on the memb rane-bound ribosomes
and t.he ne\"'ly syn thesized chains are fed into
cisternae of the rough endoplasmic reti culum (Fig.
2) [271. The initialiy-s;'nthesized polypeptides of
procollagen are larger than a -c hain::; because they
co nta in addit io nal amino acids both at the amino-
term inal and carboxy-te rm inal end s of the p()I~'.
pept ide chains , These larger precursor fo rm ~ of
a-chains are called pr(l -a c hain s ( F'l~ . :;1. The
amino acid composition of the extens ion peptides
is different from the collagenous porti on of the
molecule in lhat the exten sio n ~ are co rnparath-e ty
ri ch in acidic amino acids. relat ive ly poor in
glycine. proline. and h~ · drux y pro line . and th e ~'
contain cysleine and tryptophan which are not
present in tvpe I or type II collagens (see /8.25J).
Recent immunologic. chemical. and eleclTonmicro-
scopic evidence has dem onstrated that the m ajor
peptide extension in procollagen is located at the
carboxy-terminal end of the polypeptide chain [29.
301. The carboxy-terminal extensions have also
been shown to contain interchain disulfide bonds
which link three pro-a chains together /31J.
The carboxy-terminal peptide extension isolated
from the pro-a chai ns of t~' pe I or t~' pe II procol la -
gen consist s of approximatel~' 200 1O :l00 amin o
acids and the amino-terminal extension contains
an additional 100 or so amin o acids ~o that each
pro-a chai n is some 30 to 4OC;:;: longer than an
a-chain in its fully extended form (see [25]) . it
should be emphasized that the term procollagen
should be applied onl y to precutsor molecules
whi ch contain peptide extensions on both ends and
in which the chains are disulfide bonded. An
intermediate form of precu rsor molecule. without
the carboxy-terminal extensions and consequently
containing no interchain disulfide links but st ill
having amino-te rmin al extensions present. is
termed p·coJJagen .
Feb . 1976
Post- Tran slational M odific ations of Peptide
Chains
After t h e ribosomal assemb1y of amino acids into
pro-a c hains, the polypeptides u nd ergo several
modifica tions which are characteri stic of the bio-
sy nthesis of collagen (see Fi g. 1) . These events are
frequently termed a post-translational modifica -
tion rea ctions to emp hasize t hat these rea ctions are
not directly controlled by the information in mes-
senger-R NA bUI that th ey occ ur a ft er the amino
acids have been linked togel her b y pe ptide bonds.
The post -tra nslational modifi ca ti on rea ctions in-
clude: (a) hydrox ylalion of selecled prolv l residu es;
(b) hydroxyla ti on of selected Iysy l res idues; (c )
attachment or su gar s. ga lactose and gl u cose. int o
- -- f-----
Flc. 2. Schematic pre1'ent81ion 01 the synthesi~ and
secretiun ot" lJrucu!!agen b) a fihrob/nsf. The enla rg-ed
a rea demonstrates events occur ring: in rough endoplasmic
reI icu lum (RER , of cell~ du ring: the s~'lthesis of procalla-
~en. The polypeptide chains of procollagen a re syn-
thesized on membrane-bound ribosomes and the nas-cent
chains a re fed in lo the cistern ae of HER. The hyd roxyla -
tions of prol~· 1 and iysyl residues a nd the glycosylation of
hyd ro x: .\"!.\'s~' / residues a re init ialed on g-rowing pol.,·pep-
t ides a nd these reactions a re completed after the release
of full -size chains from ribosomes. Three pro-o chai ns a re
lin ked loge th er by the formal ion of interchain disulfide
bonds a nd the molecule assumes a triple -helical confor-
mation which is requi red for procollagen to pass fr om
RER to G{)l~d vesicles; the molecules are t.hen secreted in
these \'es icJes into extracellular mili eu. (Reprodu cf'd wi lh
pe rmi ssion. Prockop et a1. 19i5 [9].)
CO LLAGE N IN DISEASE 63
A B
II J I I Jill II If 11I1
"'a,, --
FIG. 3. Demonstration tha I t he polypept ides of procol-
lagen a re larger than the a-chai ns of collagen. Procolla-
gen synthesized and secreted by freshly isolated connec-
tive tissue celis was preci pitated by ammoniltrn sulfa te
and the protei n was electrophoresed on polyacrylamide
disc gels afte r denaturation in sodium dodecyl sulfate
and reduction with mercaptoethanol. The two ba nd s
corresponding to prO-a 1 and pto-a2 cha ins of procollagen
1ge1 Bl have a slower mobility t han the al and a2 chai ns
of collagen on control gel (gel A l. ind icating- that the
pro-a chains a re larger tha n the collagen a-cha ins . (Re-
produced with pe rmission. L-ia o and Proekop. 19i4
[28J.)
ce rtain hydroxylysyl residues: (d) chain associa-
ti on . disulfide bonding. a nd triple helix fo rm ation:
(el proLeolytic conversion of procollagen 1.0 colla-
gen; (0 oxidati\'e deamination of cenain lysyl and
hyd rox ~' lysy l residues.
Synthesis of hydroxy proline. One of the unusual
features of collagen is the presence of h~'d roxyp ro­
line {Fig. -l l.t The biologic role of hyd roxyp roline
in collagen was for a long time unknown but it is
now well established that a critical amount of
hy·d roxyproline is requi re d to stabilize the triple-
helical conformation at ph~'siologic temperatures.
The tr iple helix in turn is required fo r the secretion
of p r oco ll Agpn molecules out of the cell!'; at an
optimal rate. and the rigid triple -helical st ructure
is a necessar~' requi rement fo r the extracellula r
deposition of func tionally adequa te collagen fibe rs
(see 19]1. T herefore. in lhe absen ce of hydrox;·pro-
li n e. the collagen polypept.ides would nOt acquire
[he critical tripl e~helical structure under physio-
t Small a mounts of hyd roxyproline are also found in
elastin (3:3]. Clq. a protei n componen t of the com pl ement
system. has been shown LO ha\,(' an ami no acid composi-
Tion similar to collagen in thai it contai ns relatively large
amounts of glycine. h~·dro xyproline. and hydroxy /ysi ne
(34 J.
 64 UITTO AND LICHTENSTEIN
H H
L - PROLI NE ~- 4 - HYDROXY - L- PROLI NE
-Gly -Pro - Y - Gly- X- ?ro- Giy- X - Y -
Prol yl hydrox ylase
02,Fe2+,a: - KG, As .Ac.
-Gly - Pro - Y- Gly - X -Hypro -Gl y -X - Y-
Flc. . 4. Structures of proline and hydroxyproline. and
schematic presentation of the enzymatic hydroxylation of
proly} residues in the Y· position of the repeatinJ{ X -Y-Gly
sequence of collagen polypeptides. (Reprodu ced wilh
pe rmission. Uitto and Prockop. 1975 (32].)
logic co nditi ons and no collagen fibe rs would
appear in the ext racellular space.
Even tho ugh hydroxyp roline accountS for about
lO cr of the amino acids in collagen. lhere is no
genetic code o r transfer-R~A for this particular
amino acid. and. therefore. free hydroxyproline is
not incorporated into collagen. Hydroxyproiinp in
col1ag-en is s~'nthesized by h~'d roxylatio n of' certain
prolyl residues which a re in peptide linkages. The
hydroxylation reacti on i~ catal~'zed by an enzyme.
pro!yl hydroxylase. which re co~nizes pro lyl resi-
dues only in the Y-pos-i lion of the repealing- tripl et
sequence X-Y-Gly of collagen. Prolyl h)'droxyla;e
requires m olecula r oxygen. ferrous iron. a -keto-
glutarate, and a reducing agent such as ascorbate
as cosubstrates or cofactors for the react ion (Fig.
4). ( Fo r an extensive review on prolyl hydroxylase.
see {3o \I. Various studies ha\'e demo nstrated that
the hyrlroxylation of appropriate prolyl residues
begins while the peptide chain s are growing 011 the
riboso mes. and the hyd roxyl at ion appears to be
completed soon after the full-size pro-a chains a re
released from the ribosomes (see {281L The en-
zyme prolyl hydroxyla e has been localized in the
rough endoplasmic reticulum {36- 391 and. there-
fo re. the hydroxylation seems to sta rt when the
amino-terminal ends of the growing po l~'pep tides
enter the cisternae of the rough endoplasmic re-
ticulum (see Fig. 2).
A yet. no inhe rited disease has been reporlpd in
which collagen is deficient in hydroxyproline or in
which there is deficiency in prolyl hydroxylase . It
seems, howe\-er. that mos t of the clinical manifes-
tation s of scurvy o n connective tiss ue could be
explained on the basis of deficient hydroxylation of
prolyl re sidues in collagen. As noted above , prol yl
hydrQxylase requires 8 redu tin):'!: agent such as
ascorbate for its activity. Ascorbic acid deficienc\"
leads to decreased form~tion of collagen fibers. and
reduced fibrillogenesis could well explain so me of
the clinical manifestations such as poor wound
Vol _ 66. No. 2
healing a n d decreased tensile stren~lh of connec-
tive tissues obse rved in SCUf\'~' [40j. An analog-ous
situation may exist in tissues with relative a noxia.
since molecular oxygen is a specific requirement
for the fo r mation of hyd roxyl f;! r(lups in hydroxy.
proline _ Studies with animal models have demon -
strated t ha t the heali ng of wounds is relatively poor
unde r hypobaric conditions and in suc h 8 situation
the low O. levels may we ll limit the synthesis of
hydroxyproline (see 141 - 43 j). This obse rvation
may also explain th e decreased healing tendency of
wounds and ulcer~ in peripheral tissues which are
anoxic due to relati\'e ly scant blood supplies.
Synlhesi:." of hydro).::rlysine. H ydrox~' I~lsine IS a
second amino add characteri!:ilic uf collagen 1Pig .
5). Ac{'ording t.o current knowl edge. the pre~ence of
hydr ox~l ly si ne in collagen has little s ignificance to
the int racellul ar proce~sin~ or secretion of the
procollagen. but it plays a critical role in the
formation of cros!-':-li nks which s tahil ize the extra-
cellular colla!!en matrix. The ~y nthe ~is of h~' dr()xy ­
lysine is simi lar to hydroxyproline in that free
hydroxylysine if' not incorporated into na ~ce nt
polypeptide chai n ~. In ~tead. ce rtain l,\'s.\·1 residues
in peptide linka~e::. are convened to hydroxyl:vsinl' .
The hydr()x~' lat ion reaction is catalyzed b~' the
enzyme. lysyl h~·droxylase. which . like prolyl hy -
droxylas€', require~ O 2 , Fe 2 -, a -keto/!Iutarate, a nd
ascorbate as cofacto rs and co~ubstrate~. It !-hould
be emphasized th at these hydroxyla se~ a re two
different enz~' me protein!" which ha \·e heen clearly
sepa rated from eath o ther during purific atio n H-t
45 j. Lysy l hydroxylase. lik e prol ,\"! hydr o x~· la=,e.
hydroxy1ate~ 1~'s~'1 residues only in the Y - po ~itio n
01 the X -Y-GI.\' :-equence . Even thou g- h h~' droxyla ­
li on of 1.\'5,\"1 residu es in collal!en i~ in itiated while
the po\ypept ide!-- a re :-li\1 as:--f:'mh\ed o n the ribo·
so mes. it seems that fhe formation of h~'droxyl~' ­
sine continues for some l ime afte r the relea ~e 01
peptide:; from the ribosomes 1:281.
NH2 NH2
1 I ~O
CH2 CH 2 C
1 I I'H
CH2 CHOH CH z
1 I I
CH 2 CH 2 CH z
1 1 I
CH2 CH 2 CHz
I 1 I
CH CH CH
/ \ / \ / \
H2N COOH H2N COOH HzN COOH
LYSINE 8-HYDROXY- ALLYSINE
LYSINE
FIG . 5. Structures of lysine. hydroxylysine. and ally-
sine. the aldehyde derivative of lys ine.
Feb . /976
The extent to which lysyJ residues in t he Y-posi-
tion of the X -Y-G ly sequences are hydroxylated
varies greatly arnon~ the collagens from differen t
sources (Tab. III. In particular_ collagens of type I
a nd type III are frequently hyd roxylated to a lower
degree so that t hese collagen~ nu rma ll y contain 4 to
8 residues of hydroxylysine pe r 1,000 amino acids
whereas collagen of type II ha s about 4 to 5 times as
many hydroxy lysi ne residues . In type IV collagen.
most of t he Jysyl resid ues are convened to hydrox y-
lysi ne .
GlycQ.,,'yiation. Collagen has galaclOsyl residues
and gJucm;~dgatac[osyl residues attached to the
molecule (see [2.91). During intracellular biosyn-
thesis the sugar residues a re attached sequentially
so that a galacLOsyl residue is first attached to col·
lagen polypeptides and then a glucose molecule is
added t o this galaclOsyl residue ( Fig. I). The link
between the ca rbohyd rat e and the protein is an
O-glycosidic bond through the hydroxyl group of
h~'droxylysine. Therefore. the synthesis of hy-
droxylysine is a prerequisi t e for the glycosylation of
co lla~e n , Both glycosylatlon reactions are ca t a-
lyzed by separate. specific enzymes called collage n
galactosyitransfe rase and collagen glucnsyltransfe-
rase [46.471. Both enzymes utilize UDP-sugars as
a Sou rce of the ca rbohydrate, and they requi re
Mil " as a cofacto r. Rec'ent studies indicate that
the triple -helical confo rm ation prevents the addi·
tion of the second suga r. glucose. to the molecule
(see [9 J). It appears. therefore, that glycosylation
begins on nascent polypeptides after the sy nthesis
of hydroxy lysyl residues and is complete before the
procollagen chai ns fold into triple -heli cal co nforma-
tion. In addition to sugars attached to hydroxy lysyl
residues on the collage nous part of the molecule.
ca rboxy-terminal extensio n of procollagen may con-
lain carbohydrates 1481. The quantity and nature
of these residues are. however. unknown at the
present time. In gene ral. the function of suga rs in
collagen is not known .
Chain aSi'Dcialion. disulfide bondinp. and helix
{ormation, One of the nitieal ,!-;teps in the in trace l-
lular synthesis of procollagen is the association of
three pro-a chains and subsequent folding of the
po!ypeptide50 into tr iple - helical co nform ation
(Figs . 1. 2), Re('ent obse rvations ha\'e sugges ted
that th e peptide extensions 011 the indi\'idual
p ro-a chains assume a globular confor mation soon
after th ei r translation and this conformation con-
tains the specifi c information which dirE'cts the
correCl association of the three pro·a chains 19.
25 J. Such a mechanism is particularly attractive
because it would explain the association of p ro-a 1
and pro-a2 chains in a proper 2:J ratio du ring the
synthesis of type I procollage n . It would also
explain the rapid and efficient association of the
prO·a chains and t he foldin~ of t he molecule into
the triple helix in a biologically adequate time .
This laller point is emphasized b~1 thE' observation
that isolated collagen a-chains renature into a
triple-helical conformation ve ry slowly so r har 2-1
COLLAGt:N IN DI SEA SE 65
-;
x - ·_ - --x---·--- · --- 50 ;--'
~ 15 I
/ .
,'0-- --l-----i ;'"
~ / :' I Helicity 40 ~~
i"
>< . I I.&.J -
~ /--:J " Disulf ide Bond ing 9 ::
~:I: ,I S
10 I/Hydroxylatloo
,I
~_ Uw:J
30 ~
~ X I o::r;
,
: ii
~
~ 1//
5
I
"" O~! 0 .
I : 0
o 3 9 18 27 36
CHASE TI ME ( MINI
FIG. 6. Hyd roxylation of prolyl residues . synthesis of
interchain disulfide bonds and the formation of triple
helix during the intracellular biosynthesis of procollagen .
Freshly isolated cart ila,l:1:€ cells were pulse-labeled for 4
min with jl4C jproline and the label was then chased by
addition of I!2C jproline into incubation medium . Newly
synthesized j l4 C jprocollagen polypeptides were isolated
at different time points by gel filtration on agarose in
sodium dodecyJ sulfate. and the degree of hydroxylation,
disulfide bondin~. and helicity were measured. The
results demonstrate that the hydroxylation of prolyl
residues i maximal well before the s\'nthesis of inter-
chain disulfide bonds and. therefore. the cha in associa-
ti on and disulfide bonding appear to limit the folding of
the procollagen into triple-helical conformat ion under
"optimal " incubation condit ions. (Reprodu ced with per,
mission. Uitlo and Prockop. 19,4 [511.)
hr o r more is required for about 50(:( of the
molecules to become heli cal 1491. In contrast. pro-a
chains synthesized by freshly isolated con nect i\'e
tissue cells associate and fold into the triple-heLi-
cal conformati on within 5 to 10 min from the time
they are sy nthesized on the ribosomes 150. 51] (Fig .
6). It appears. therefore. that the association of the
extension parts eit her at the amino- or ca rboxy -ter-
minal ends of the ptJlypeptide chains facilitates the
folding of the molecules into triple-helical confor-
mation. perhaps by prO\'iding 8 nucleation site
from which the formation of triple helix is propa-
gated th roughout the collagenous port ion of the
molecule.
Du ring the process of chain association . the
half-cys tine residues on the extension peptides of
the pro-a chains form inlerchain disulfide bonds
linking three pro-a chai ns together IFigs. 2. 6) 152J.
Experiments with freshly isolated connective tis-
sue cells ha\'e demonst rated that the synthesis of
interchain disulfide bonds closely parallels the rate
at which the procollagon molecu les fold into triple -
helical con fo rmation 150,51 ] (F ig. 6). On th e basis
of th is observation and other experimental evi-
dence 1531_ it seems possible that the formation of
interchain disulfide bonds may playa role in helix
formation during the biosynthesis of procollagen.
Conversion of procollagen to collagen. As dis-
66 unTO AND LICHTENSTfW, Vol . 66, No.2

cussed above, the intracellular biosynthesis of A

collagen involves an elaboration of a precursor
molecule. procollagen, which is secreted in triple-
helical form out of the cells. Procollag-en molecules
a re then converted to collag-en molecules by lim -
ited proteolysis which rem oves the peptide exten- 0
sions on the molecule (Fig. 1). At the moment. it is e-9 + H,N C=N
'H H
not conclusively established whether this conve r-
sion is a result of cleavage catalyzed by a single
specific en zy me or whether several successi\'e steps
and several enzymes are required to produ ce I he
final collagen molecule . It should be mentioned
that se\"eraJ preteases. suc h as;. pepsin and ch,vIno-
trypsin. will nonspecifically cleave the extension$.
from procollagen. It is unlikely. howe ve r. that they
have a physiologic role since the coHagen formed
upon such digestion has a different amino-t.erminal
amino acid than present in ,·ivo. and the collag-en
also lacks the 1~ls ine-derived cross- links whi ch (II lIT I (ill l
normally occ ur at the amino-terminal end of the
molecule.
Endopeptidases which cIea"e the precursor ex - B eH, CH,
\ / ,
CH, CH,
/
t.ensi on peptides have been found for bot h procolla-
gen and p-collagen . An enzyme has been found in
calf connective tissues that conve rts p-coUagen to
C
,,0
'H
+
HS-C
I
H,N- CH
I
- C/
S-C
I
H'N - CH
H I
collagen [54J. This enz;'me requires Ca- - for its
COOH eOOH
acti,·iry. The purified peptidase cleaves the amino-
terminal peptide extension en bloc from pro('oll a-
gen, and leaves the amino-terminal lysine-derived
cross-links intact. suggesting a specifici ty of ac ti on
[55J. A similar peptidase also has been found in rat
calvaria [56J . Thisenzyme has been termed procol -
lagen peptidase but this a ppea rs to be a misnomer
since the enzyme will not cleave the carboxy-te r-
minal extension from procollagen: it co nverts p-
collagen but not procollagen to collagen [57 J. This II I ITIl I Ill i
enzyme should. therefore. be called p-collagen or
PIG. 7. A schem atic presentation of the formati on of
amino-terminal peptidase. An other endopeptidase inter molecular cross- links of collagen a nd a proposed
bas been isolated from the fibroblast cell culture mechanism by wb ich D-penicillam in e blocks tbe cross-
medium [58]. This enzyme rem oves the large car- link formation. In the upper frame IAJ. an aldehyde
~roup derived from oxidative deamination of either a
boxy-terminal, disulfide-linked trimer en bloc. and
iysyl or hydroxyl~,sy l residue in a collagen molecule In
the enzyme should probably be referred to as car- reaClS with an H tmino group on a Jysyl or hydruxylysyl
boxy-terminal peptidase. The two enzymes. amin o- resid ue in an adjacent molecule (If) to form a Schiff-base
terminal and carboxy-termin al peptidases. are both type cross-li nk (lIf) . In the lower frame (BL a D-penic il -
required for complete conversion of procollagen to lami ne molecule (IV) reacts " 'ith the aldehyde to rorm a
rela t ivelv stable thia1.olidine compou nd l V ) which effec-
collagen. tively blocks the participation of t he aldehyde group in
cross-lin k form ation. (Ada pted from lhe presentation hy
Fib er Formation and Cross- Linking Desmukh and Nimni . 1969 !61 J.)
After the re moval of extension peptides. the
collagen molecules spontaneously align to form unmodified lysine o r hyciroxylysine to form a
fibers. These fibers. however. do not attai n the Schiff-base ty pe cova lent cross- link . The second
necessary tensile strength until the molecul es are type of reaclion is a n a ldol condensation between
linked togethe r by specific cova lent bonds kn ow n two aldehydes. In addition to these t ypes of cross-
as cross-links (for review, see [6.59.60]) . The mos t links. collagen contains several more complex
common forms of cross-links in collagen are de- cross-links which also involve Iysvl or hydroxyl,·syl
rived from lysine or hydroxylysi ne. The first step in residues (see [6i1 . The Iys ine- and hydroxylysi ne -
the cross-linking of collagen is the enzymatic deri ved cross-links can be eit.her intram olecular
synthesis of a ldehyde derivatives by removal of the occurrin g between two adjacent a-chains in th e
. -amino groups of some of the Iysyl and hydrox yly- same collagen molecule or int.ermolecular stabiliz-
syl residues (Figs. 5. 7, see a lso Fig. l l. The ing the alignment of two collagen molecules a long
aldehydes then form cross-links by two kinds of the microfibril. The intra molecular cross-links are
reactions. One reaction involves co ndensat.ion of mainly products of aldol condensation whereas the
an aldehyde with an f-amin o group still present in intermolecular cross-links are primarily of Schiff-
Feb. 1976
base type. Both types of cross-links seem w involve
an aldehyde from 8 specific Iysyl residue which is
located at the amino-terminal end of the collagen
molecule.
The first step in collagen cross· linking, the
oxidative deamination of ce rtain JysyJ and hydroxy-
Iysyl resrdues. is catalyzed by Iysyl oxidase
162-64]. This enzyme requires copper as a cofactor
and its activi t y is readil y inhibited by nitriles
which are known to produce lathyris m in animals.
LysyJ oxidase functions in the extracellular space
and it has high activity with coliagen which has
been precipitated as native fibrils as compared to
denatured collagen or isolated a-chains [64 J. It
appears. t h e rdore. thl::lllhe formcnion ofaldehyde~
occurs primarily after the onset of fibril formation
in vivo. Even though partially purified lysvi oxi-
dase preparations produce aldehydes b~t h from
lys ine and hydroxyiysine in collagen. it is no t clear
whethe r two se parat.e enzymes are required for
dearnination of lysi_ne and hydrox.dysine. respec-
tively. The cross· linking of elastin also involves
aldehydes which form quarternary cross-links
known as desmosine and isodesmosine and which
are derived from JysyJ residues. It is not known
whether th e ~ame enzyme ha~ activity both with
collagen and elastin molecules, Because the cross-
links of collagen prov ide the t.ensile strength re-
qui red in a runctionjn~ ti~sue. a defect in the
formation of these co\'ale nt bonds can lead to a
disturbance in connecti\'e tissue.
Cuntrol uf Col/a~en Synthesis
One of the most intri~uing problems in collagen
biolog~- is the question of mechanisms regulating
[he amou nr :-:; t)f collagen being deposited infO the
extracellular fibers, E\'en though the discrete steps
of the intracellular bios~,nthesis of procollagen a nd
the mechanistic details of collagen degradation arE'
l ar~el~' unden;lOod. th e knowledge of the factors
cont rol ling these processes and prO\-iding a balance
between the synthesis and breakdown of colla~en is
minimal.
The regulation of collagen sy nthesis on a tran-
scriptional or translational le\'el may in\'oke con-
trul mechanisms which are applicable to the syn-
thesis of any protein_ Such factors include_ for
instance. the amount of messenger-R:\A, the pool
size of transfer-RNA. and the presence of specifi c
initiation and elongation factors_ One t.heory sug-
gests that the intracellular pool of a specific amino
acid such as proline may control the rate of
ribosomal assembly of pro-a chains [651. This
hypothesis is supported b:v th e observation that the
free proline pool is increased in certain clinical and
experimental situations with increased collaf!en
synthesis. e.g.. liver ci rrhosis 166.67). Another
specific suggestion as to the control mechanism of
the translation of collagen messenger-RNA re·
valves around the fate of pept ide extensions after
they have been removed from the procollagen
moJecuJes, This suggestion was originally based on
the obse rva tion that the rate of collagen synthesis
COU.AGEN IN DISEASE 67
in the skin fib roblasts of patients with defective
conversion of procollagen to collagen was higher
than in control skin fibroblasts [68]. It was sug-
gested that the peptide fragments after their re -
lease from the rest of the molecule could partici-
pate in feedback inhibition of further procollagen
synthesis by the cells. This interesting- hypothesis
is cu rrently being tested in several laborat.ories_
In addit.ion to possible control mechanisms ex-
isting at the transcriptional or t.ranslational level.
fibriJlogenesis could also be regulated at the level
of post-t ranslational modification reacti ons, such
as the hydroxylation of prolyl residues to hydroxy-
proline or the folding of the prolein into a triple-
helical conformation (!See \9]), The possilJilily that
prolyl hydroxylation might be a rate-limiting step
in the synthesis of a procollagen molecule has been
supported by the observati on that the actidlY of
prol)'l hydroxylase in tissues parallels the rate of
collagen formation, E\'en though the hydroxylation
of prolyl residues may be a rate-limiting step for
collagen synthesis in canditons such as scu rvy or
anoxia. recent experiments \...·ith isolated connec-
tive tissue cells have demonstrated that in the
presence of optimal levels of oxyge n. ascorbic acid,
and other cofactors of prolyl hydroxylase. the
prolyl hydroxylation is maximal before triple. helix
formation takes place, and, therefore_ the folding
or the protein into a helical conformation seems to
be rate limiting under such conditions [50.51.69]
(Fig. 6). The mechansims which regula te the
association and disulfide bonding of the pro-a
chains and subsequent helix formation are un-
known at present. Besides triple-helix formation,
a l her factors in\'oh'ed in secretion of procollagen
may regulare fibrill o1!enesis, Since procolJagen
polypeptides are initiall~· synthesized in the roug-h
endoplasmic ret.iculum and then secreted in Golgi
vesicles. such factors include the assem bl~· of
microrubules and (he rale of intracellular translo-
cation of the molecule (F ig. 2: see 1911.
Degradation of Collagen
Colla~en was once considered to be a metaboli-
cally inert protein which remained in the tissues
for the lifetime of the animal. It is now known that
the bulk of the coliagen in the body is conr.inuously
turned ove r and even the most stable fibers are
slowly replaced by those newly synthesized. Colla-
gen consists of molecules at different stages of
maturation, and these differem fractions have
metabolic half·li\'es \'ar~·ing from a few hours to
several years, In particular. t he paoloI' newly
synthesized collagen molecules. which are readily
soluble in neutral salt solu cions or in weak aceric
acid.ha~ahal~li~~2w3hrS=e~~~
soluble molecules are converted to insoluble and
more slowly metabolized forms by cross-link for-
mation. or the molecu les are degraded to smaller
peptides (see [70)).
Mamma lian collagenoses. Although the com-
plete breakdown of collagen probably involves
several enzymic steps_ it is now well established
68 UITrO AND L ICHTENSTEI N Vol. 66, No.2

that in hi gher animals th e degradation process is one prevents the appearance of collagenase in
initiated by a single cleavage cataly·ted by a cu ltures of involuting rat uterus 181 J. Furthermore,
specifi c ma mma lia n collagenase (for rev iew of parat.hyroid horm one a nd heparin stimulat.e colla-
collagenases. see \6.71.72]). This proteolytic genase p roduction in bone cultures. a nd bacterial
enzyme seems to ac t at a specific peptide ~ bond site toxi ns a nd lymphocyte extracts can increase colla -
in the collap;en molecule. which is approxim at ely genase produ ction by macrophages in cullure 16,
three. quBrters of the distan ce away from the 82,83]. It appears. t herefore. that the acti vity of
amino- term inal end of the molecule \73] . Recent collagenolytic enzymes a nd t he ove ra ll ra te of
st.udies have also demonstrated t ha t the enzyme collagen degradat.ion is under relat ive ly com plex
operat.es more efficiently on collagen m olecules co nt rol by several fact.ors present in se rum and
that are in the triple-heli cal conform at ion \74] tissues.
and . therefore. the specific cleavage produces two
hel ical molec ules whi ch represe nt abou t 75 ,* a nd DISEASES OF CO LLA GE:>i
25 % of the size of the origi na l collagen molecule. Heritab le Connective Tissue Disorders
Because the triple.helical s tructure of these
shorter molecules is unstable at body tempera- The clinical, nosoiogic. a nd genet ic aspects of
tu res. t he molecules are rend ered nonhelica l and the heritable disorde rs of con nec t ive tissue ha ve
the released polypeptides are furthe r degrad ed been rollated by M cKusick 184). Th is rei"e rence
into small peptides or free ami no acids by less should be consult.ed for more- detailE'd descripti on
specific peptidases. . of the diseases di !iicussed here. M cKu sick has
The natu re of the collagen substrate innuences proposed that severa l of the conne ct ive tissue
th e rat e at which the molecules are degraded b~1 disord ers ar e her it able diseases of collagen metab-
mammalia n collagenase. In parti cu lar, increased olism : among these are the Ehlers- Dan los svn-
cross-linking of collagen appears to diminish lhe drame. osteogenesis impe rfecta. and the Ma ri'an
rat e at which the fib ri ls a re degraded \i5]. Also. syndrome. Here we will emph asize th ese a nd ot her
the rat e at which the cleavage of the molecules sy ndromes whe re a biochemical d efect in coll ag-e n
occu rs seems io d epend on the type of co llage n has been de monstra ted. a nd discuss e\'idence for
since cartila~e coH agen or type 11 collagen is defectiyE' collagen biosynt hesis or degrada tion in
degraded at a co n si d erabl~' s lower rat.e than type Iot her con ne-c li ve- ti ssue diseases. such as sc lero-
collagen (see \76}) . derm a and epide-rmo\ysis h ullosa.
Urinary hydroxyproline as a marker of collagen \"'iIb man~' genetic- s~·nd ro m es. cli nical and
degradation. Since h.vdrox.vproline is a n amino genetic heteru~eneity have preceded the- demon-
acid that is abundant in colla~en and since this stration of biochemical h e l e rogeneit ~· . For exam ple,
amino aci d cann ot be reutili zed by th e cells for the the mucopu\vsaccharidose-s were initiall\' clas:;;ified
synthesis of new collagen polvpeptides. urinan' int o six diffe'rent s~'nd r(lme$; nn the ba~i~ or clinical
hydroxyproline ca n be rneasur~d a~ a marker ~f and gene-tiC' evidE'nce. and separate hiochemica\
collagen deg-radation in \·ivo. Although urinary defects in muco polysaccha rid e degra dation were
h ydroxyproli ne is not a pa rticularly sensiti\'e index subsequentl y elucidated \84 j. In heritable disor-
of collagen degradation since relatively la r~e ders of collage n metabol ism. such as th e Ehl eT'-
amounts of degrada t ion are req ui red to produce- Danlos syndrome a nd osteogenesis impe- rfecla.
""here clinical a nd ge netic helerog'e- neiry ha\'e been
rneasureable cha nges. assa~' of u r i n a r~' hydroxypro-
\ine is a useful laborato ry lest in diagnosing ::;orne recogni zed. a co rresponding bioche-mical heleroge--
clini cal states wilh ma rked ly increased col lagen nei l.\" has bee n demonstrated .
degradation (see \70.i7]). The list of such condi- Ehlers- Dan/os syndrome tE- Dl. This syndrome
tions includes hy perthyroidism . hyperpa rat hywid- has been subdi " ided into se \'en fo rms on the ba5is
ism. Paget 's disease of bones. and also mal igna nt of clinical. genet ic. and more r ecentl~· . biochemica l
tu mors whi ch metastasize int o bones. In creased information (T ab. 111 ). The ('ommon clin ical fea -
urinary hyd roxyp rol ine values han> also been re- tures are soft. vel\'e (~:. a nd stret chable skin. wh ich
ported in some patients with psoriasis. sa rcoidosis. is eas ily torn a nd which heals '\-'it h at rophic sca rs.
and extensive infl amma tory p rocesses a ffec ting There is easy bruisabi lity and frequently a blee-d -
skin (see [70JI. These changes. howe,·er. are rela- ing diathesis. The joints a re hypermobile and
tively small and a re of little if any sign ifica nce in easily dislocated . Less freque- nt findings inclu de
the d iagnosis of clinical evaluation of these disease inguinal hernias. t1opp~' mitral valve synd rome.
processes \78.79 ]. molluscu m pse ud otum ors. and myopia . Remarka·
bl y. the bones are- not in vo lved in th e Ehlers- Dan -
Cuntrol of Col/a#en Degrada tion los syndrome.
The mecha nisms whi ch may regulate the ratc of E- D ty pes 1. 11 . a nd II I: The most common form,
deb'Tadation of collagen fibers a re poorl~r und er- 01' thi s syndrome. ty pe, !. 11 . a nd 111. are inherited
stood . The production of collagenase appears to be in a n au tosoma l dominant pa t lern a nd are dis tin -
under horm onal con trol since hydrocortisone in guished by the exten t a nd severity of the sy mp-
p hysiologic co n ce nlratio n ~ has been shown to pre - to ms (Tab. fil l. :-10 precise bioc hemical defe ct has
ve nt the appea ra nce or ac tive collagenase in cul- been detected as ye t bu t a n ab norm a l patte rn of
tures of norm al human skin \80]. Also. progester - collagen intermolec u lar cross -links has been d e-
Feb, 1976 COLLAGEN IN DI S EA.S E 69
TABLE lil . Clinical. genetic:. and bioch em ical heterogeneity in the Eh lers-Danlos syndrome (E- Dl

Type" of E- D Inheritance Biochemical defect

I - Gravis type Aul ~omal dominant Unknown
rr - Mitis l y pe Autuso mal dominant Unknown
If] - Benign hypermohile t,y pe Autoso mal dominant Unknown
IV - Ecchymot ic. arterial o r Sack type Autosomal re(,essive Absen ce of ty pe 111 coll agen
V - X · linked l ype X -linked recessive Lysy i oxidase deficiency
VI - Ocula r lype Au tosomal recessive LysyJ hydroxylase deficien cy
vn - Arthrocalas is multiplex congenita Autosomal recessive p-Collagen peptidase deficiency
-------------------------------------------------
teeted in th e skin from one patient with E- D t ype 1
185 1, Howeve r, in ot her patients with E- D th is
abnormalit y has not been verified 1601, Dermal
histopathology in these cases is usua Uy unrema rk4
able. alt houg h an increase in elastin staining has
been deseri bed .
An autosomally dominant. in herited connective
tiss ue disease which resembles E- D has been
desc ribed in d ogs and minks [861, In these animals
the s kin is fragile and heals with at rophic scars. and
is unusually stret chable, The biochemical defect in
t.hese a nim a ls is unkn ov·m . Beca use of the strik ing
si milarit y to the hum an Ehle rs- Danlos syndrom e.
thi s di sease may prese nt an animal mode l for the
human disease.
E- O type IY : This syndrome is a lso known as the
Sack. arterial. or ecchymotic fo rm. Pa tients with
thi s fo rm of the disease have the highest mortali ty
a nd rarel~' Ih-e beyond the second decade. Unlike
ot her fo r ms of E - D, the skin is not \·eket." a nd
stretchable a nd th ere is no joi nt h.\.' perm obi li t~·.
Rather, th ese patients have extremely friable tis-
sues. The skin is thin and translucent with th e
underlyin~ ven ous network easily \'isible (Fi.e:. 81.
The ~ kin is prone t o lacerations. freq ue ntl~' is
unable to hold s titches, and heals ponrly wi t h
at rop hic scars, Ecchymoses are extremely corn·
man . A common skin Jesion in this syndro me is
elastosis perfo rans, These patients are prone to
FIG. 8. The thin t ranslucent skin of Ehlers- Danlos
gastroi ntestinal ruptures especially in the colon . synd rome type r\" . The abdominal sca r is from su rgery for
and to large arte ria l ruptures. resulting in thei r colonic rupture . (The pi cture is cou rtesy of Dr. V. A.
demise. Ligh r microscopy of th eir tissues demon- Mc Kusick. )
strat e~ a reduced amou nt of collaJ[en in the dermis .
aorta, a nd submucosa of the gut. Amino acid X·linked recessi"e inheri tance pattern, The dini-
a na lyses of hyd rolysat es of t he aon a from these cal featu res are sim il ar to th ose in the type I or the
patienls shm.\· a decreased conlent of gJ~"("ine. gra \'is fo rm of E - D. except t h a t joilll hyperm obiJ·
hydroxyp roline. and h~· droxylysine. amino acids it\' is mild 1881, A fami!\- with E - O type \ ' has
characterist ic of collagenous protein 1871. C~·a n o· recentl~' been reported with defpcti\'e lysyl oxidase
gen bromide peptide mapping of th e collagenou~ ac t ivity [891. In this family, two affected maternal
prote ins of th e skin. aort a. gasrrointes t inal t rBcl. cousins had stretchable skin. joint hypermobilit y.
and lungs has revea led an absence of type III and flopp~' mitral \'ake syndrome. Cultured skin
collagen. Fu rtherm ore. no type III collagen or fib roblasts from the propositus demonstrated l~"syl
procollage n was synthesized in th e cul t u red skin oxidase le\'els which were 15 to ao e:;: of th ose
fibroblasts fro m these pat ie nts rBi 1. These resu lt s detected in norm al fibroblasts. The extractabilit,\'
indi ca te th a t patient s with E- O type IV fail to of collagen deposited by the patient's skin fibro-
synthesize t;'pe III colla~en, The lac k of lype III blasts was inc reased in neutral sa h solutions, but
collagen co uld re adily explain th e tendency of norm al in aci d ic soh·ents. HOWe\ler. with de-
tissues s uch as kin . aorta. a nd the gaslrol ntest inal creased intramolecular cross· li nk in g. the acidic
tra ct to rupture beca use they have a high content collagen extract should be most s trikingl~' elevated.
of this t ype of collagen, E - O t;'pe \ -1: The biochemical defect in E - O
E - O t ype Y: Th is form of the di sease has an t~' pe \"1 , a deficienc~' in lysyl hydrox~· lase. was first
70 lJlTIO AND LlCHTENSl'EIK
detected by Pinnell. Kr ane, "'en zo ra, a nd
Glimcber [90], Their patients were two sisters. 9
and 12 years of age. who were floppy babies with
retarded motor development. The pregnancy in
one case had been complicated by premature
rupture of the feta l membranes , Both patients had
soft. velvety, and st ret chable skin. joint hypermo~
bility, and foot deformities (Fig, 9). During the
first decade of life they developed severe scoliosis
which necessitated corrective surger,v in one of
them. They both had m icrocornea. and one sister
had required enucleation of the left eye after
intraocular bleeding foll owing an automobile acci-
dent. One sib had a murmur consistent with floppy
mitral \'alve. No other famil~' members had this
syndrome.
Another family with this syndrome also has been
reported 191], The propositus was a 48-year-old
woman wh o was initially diag-nosed as having E - D
type [ or the gra" is form_ She had soft . velvety.
fragile skin wh ich was easily lOrn and healed with
atrophic scars. Her joints were hyperm obi le . Dur·
ing the first decade she developed sco liosis . which
requ ired bracing . She had severe myop ia. mi -
crOCornea. and bilateral. spontaneous intraocu lar
bleeding resulting in blindness in the second
decade of life. Sbe subsequently died of a dissect-
ing aortic aneurysm.
Her brother had an identical syndrome. includ -
ing bilateral in traocu lar bleeding and blindness.
No other family membe rs were aifected : the par-
ents were seconG. cousins, suggesting autosomal
recessi\'e inheritance. Because of the ocular man i-
festations. this syndrome has also been called the
ocular form of E - D.
Amino acid analysis of the skin from th ese
patients indi cated less than one residue of h~' ­
droxylysine per 1.000 amin o acids. while the skin
from normal persons and patients with other forms
of Ehlers-Danlos syndrome had 4 or 5 residues of
hydroxy lysine per 1.000 amino acids. Yenebral
bone and fascia from these patients had a less
pronounced decrease in hydroxyiysi ne, wh ile ca rt i-
FIG . 9. Hyperextensible skin in a patient with hy-
droxylysine-deficiem collagen disease. the type VT form
of Ehlers- Danios syndrome . (Reprodu ced ..... ith permis -
sion. Pinnell el al. 1972 (90J.)
Vol. 66. No.2
lage had a norm al content of this amino acid . The
dermal collag-en from the tbree patients studied
revealed a small increase in extractability in acid
or neutral salt solutions while a marked increase in
extractability in denaturing solvents was observ ed.
Cross-link profiles of the skin and bone collagen
from the patients first report.ed by Pinnell et al
showed a deficiency of hydrox ylysine-derived
cross-links 192]. Both the studies on Lhe extract.a -
bilit~1 and cross-lin k profiles indicate a defect in
the intermolecular cross-linkjn~ of collagen in
these pat ients.
As discussed above. hydroxy-lysine is not incor-
porated in to collagen as a free amino acid but
certain lysyl res idues are hydroxylated after tran s-
lation by Iysyl hydroxylase. The activity of this
enzyme in skin fibroblasts derived from palients
with E- D type VI has been found to be defecti"e
191.93]. [n both reports. Iysyl hydroxylase activity
was found to be less than lO Ci; of that in control
cultures. while prolyl hydrox ylase activity. a dis-
tinct enzyme having similar function and cofactor
requiremenls. was found to be normal. Thus. these
patients have hydroxyl:vsine-deficient coll age n due
to defec ti ve Iysy l h~' droxyla se activity. Because the
c ross~li nks derived fro m hydroxy\ ysine are chemi-
cally more sta ble than t hose derived from lysine
[94 J. the lack of hydrox)']ysine explains the insta-
bility of collav;en with accompanying rlinical m ani·
festa l io ns .
.An at tempt has been made re(,en tl y to correr t
lhe defeel in.these patients by gh'ing larg e quan-
tities of asco rbic acid. a cofactor for lys~'1 h~' dro x ~· t­
ase. In il ial results in one pat ienl appea r promising
195J.
E- D t)'pe VII : This s)'ndrome was init ially called
arthrocalasis multiplex congeniLa. because of the
m arked loose joimednes~ (Fig'. ]0) . Th ree patients
have been reported with an identical s~'ndrome of
mul! ipl e joint dislocations. including bil ateral con·
genital hip dislocations. marked joint hype rmobil-
ity, and soft. velvety skin which is stretchab le and
heals with atrophic scars . The patients demon-
strate easy b ru isability 168.96]. The adult patie nt s
have been short with the height in two adult
pat ients being 143 Bnd 125 cm. M icrocornea and
myopia were present in two of the three patients.
Scoliosis wa s noted to develop in the teens. The
parents of one of the pat.i e nts we re second co usins.
suggesting au tosomal recess i\'e inher itan ce .
The extractability of ski n col lagen in all three
patients was in c reased in neutral sa lt and acid
aqueous solvents as well as in denat uring agents.
suggesting decreased cross· linking . Further exami-
nation of collagen extracted from the s kin and
tendon s from these patients demonstrated that the
collagen contai ned higher-molecular -weight com-
ponents. in addition to normal collagen a-c ha ins .
Amin o acid ana lys is of these components revealed
increased amounts of half·cysteine and a lower
amount of hydroxyproline than present in collagen .
These results suggested that these pat ients have a
Feb. 1976
FJG . 10 . .1\1 ark ed joint h.vperm obil ity in a patient with
Ehlers- Danlos syndrome type VII. The patie nt has had
surgica l procedu res for bilateral congenital hip disloca-
tions . (The pi cture is cou rtesy of Dr. V. A. McKusick ,J
defi ciency in conversion of procollagen to collagen .
This hypothesis \\'8S further support ed by assay s of
t.he enzyme whi ch con\'erts p-collag-en to co llagen
from the medium of cultured skin fibroblasts.
These st udies showed that the enzyme acti vi ty in
the patient 's fibroblast s was 10 to 20% of the
ac th 'i t~' found in controls. The synt hesis of coll age-
nous protein by the skin fibroblasts from these
patients was in c reased more than twice o\'er the
co ntrols . suggesting that the conve rs ion of procol-
lagen to coll agen is in-'olved in the control of
collagen synthesis [68 J.
A similar defect in t he conversion of p-co llagen
to collagen has been described in inbred cattle in
Belgium [97 J and Texas 198 J and also in sheep in
Norway [99.100J. The characteristic featu re in
these animals is extrem ely fragile s kin (Fig. 11 ).
causing the bov in e disease to be named dermato-
sparaxis or "torn skin ," Other tissues. except
bones, in these animals are also extremely friable,
Ex tracts of the skin and other tissues from these
animals co ntain primaril y higher-molecular-
weight collage nous co mponents whi ch can be iden-
tified as p-collagen [101.102 J. In caule. the derma-
tosparactic tissues lack the endopeptidase which
cleaves the am ino- terminal extension from p-col la-
COLLAGEN IN D ISEASE 71
gen , and the medium from c ultured skin fib ro-
blasts from derm atospa ractic calves contains onl y
10 to 20 % of the p-collage n endo peptidase activity
observed in norm al calves [54]. In dermatosparac-
tic cattle , th e presence of ami no-term inal exten-
sions on co llagen results in abnormal cross-linking
of collagen due to deficient fo rmation of the
intermolecular cross-links 1103 J. This abnormal
c ross -link ing results in disorganization of the der -
matosparactic collagen fibers (Fig. 12). Rem oval of
the non helical extension with the endopepti dase in
vitro results in norm al collagen fiber formation ,
indicati ng that the defic ient cross- linkin g resul ts
fro m the presence of [he nonhelical extens ion on
t he molecule.
Ost eogen.esis imperfect a (Of). This disease is
characterized by excessivel y fra gile bones. thin
skin, dentinogenesis impe rfecta, joint hypermobiJ-
ity, otosclerosis, and blue sclerae, This disease is
convenientl y classified into osteogenesis imper-
fecta conge nita (Ole) and osteogenesis imperfecta
tarda WIT ) on the basis of the onset and severity
of the clinical findings.
In Ole. the fetus is born with multiple in utero
fractures, and the disease has a high perinatal
mortalit y (Fig . 13), The cranium is soft and
membranaceous, and there are multiple wormian
bones on x-rays _ The joints are lax, hernias are
present. and the sclera are blue . Radiographically.
the bones are lucen t and ma:--- be un usually broad
or thin and gracile (Fig . 14 ). This disorder may be
ca used by a new mutat ion or may be inh erited in
autosomal dominant or in autosomaJ recessive
pattern _
In OIT, fractures are not usually present at
birth . but may occur any time after birth . The
clini ca l manifestations are sim ilar, but much less
severe. than in OI C, OIT is in\-ariably inherited in
an autosomal dominant pattern_ In both forms of
this disease the frequency of fractu res usually
diminishes after puberty _
Recentl y. a disturban ce in the types of collagen
synthesized by the skin fibroblasts from cert ain
FIG _ 11. Lamb with dermat osparaxis . The anim al is
shown on the first day of life after a small. unavoidable
trauma has produced la rge lacerations in the skin _ (The
picture reproduced with permission , Fj0istad and Helle,
1974 1100]. )
 72 UIT'l'O AND Ll CHTENSTEIl\' Vol. 66, No.2

FIG. 12. Section of the skin of a lamb with dermatosparaxis visualized by electron microscopy. Left-hand picture:
The collagen fibers in the skin of dermatosparaci ic la m b are highly irregula r in cross-sect ion and are greatly redu ced in
quantity. (The picture reproduced with permission. Fj01:otad and Helle. 1974 [1001.) Right-hand picture: Control
e lectron micrograph of the skin of a normal newborn lamb. (The photograph wa s kindly provided by Dr . Bj0rn Ol sen.
Department of Biochemistry, Rutgers Medi cal Schoo1. Colle~e ()f Medicine and Denti stry of Kew Jersey . )
Magnification in both pictures is 75.000·fold.

patients with 01 has been found [104 J. The cul-
tured skin fibroblasts from one patient with a
severe, lethal form of ole synthesized type I and
type III collagenous proteins in a ma rkedl,' alte red
pro portion . Normall y, the ralio of type I to type n]
collagen synthesized by skin fib roblasts in c ulture
is 5-6: I. while the skin fibroblasts from this
particular patiem synthesized these two types of
collagen in a ra tio of I: 1 [104-1061. In the s kin fibro-
blasts fTom three other patients with 01 , a decrease
in the ratio of type I to type III collagenous prot eins
was also found. while in six other stra ins of cells
from 01 patients the ratio was found \0 be norma l
[104 J. Another study of the cultured skin fibro-
blasts from a patient with OIT has found a
decreased synthesis of the ,,2-chains of type I
collagen [107J. These studies suggest that certai n
cases of osteogenesis imperfecta may resul t from
the failure of the fibroblasts to synthesize normal
amounts of type I collagen .
Cutis lax a. The primary clinical fe ature of cut is
laxa is redundant , pendulous, and stretchable sk in
(Fig . 15). The facial s kin sags into jowls and the
eye lid s droo p. giving an appearance of premature
agin g. The skin is not resilient. nor is it friable as in
the Ehlers- Danlos s:.md rome. There is usually no
joint hyperm obi lity . The primary internal man i-
festation is pulmonar~' emphysema. Other com-
plications include hernias and rectal and ut e rine
prolapses. This disorder may be inherited as an
autosomal dominant or recessive. or X -linked
recessive pattern . Acquired c utis laxa (ge neralized
elastol ys is) has been described with onset often
characteri zed by g-ene ral ized erythematous ra sh.
Hi stopathology of the !ikin shows fraJlmentation of
the elast ic fibers.
Recentl y. two male cousins with culis lax a
inherited in an apparent X -link ed recessive pat -
te rn have been reported to have deficient lysyJ
oxidase activity in th ei r cu ltured skin fibroblasts.+
The enzyme deficiency was more apparent when
collagen instead of elastin was used as 8 su bstrate
+ Byers PH , Narayanan AS. Bornstein P , Hall JG: An
X -linked form of cutis laxa due to defi ciency of JysyJ
oxidase; the collagen and elastin cross-li nking enzyme
(a bstr). Binh Defects Conferen ce, 1975, p 206
Feb. 1976
w assay the enzyme activity. 1t is not known yet
whether other cases with cutis laxa have a si milar
defect..
Homocystinuria . The prominent clinical mani ·
festations in homocys Linu ria 8re lens dislocation ,
aortic aneurysm5i. propensity fo r thrombosis. os-
teoporosis. and skeletal malformations. such as
scoliosis and pectus excavatum (Fig . 16) . The more
severely affected cases 8re mentall y retarded. The
basic defect in t.his disease is reduced activity of
cystathionine synthetase, an enzyme which con-
verts homocysteine and serine to cystathionine
with defective enzymatic activity. homocysteine.
homocystine. serine. and methioni ne accumulate
in tissues.
The skin co lla~en from palienls with homocys-
tinuria is more eXlraclable than normal [108J. This
finding and the simila rit.Y of the clinical feat ures to
lathyrism. an animal disease with defective colla-
gen cross-linking, have suggested that formation of
cross-Jin ks might be prevented by the accumula-
tion of one of the metabolites mentioned above.
Because of the similarit y of the stru ctures of
homocysteine and penicillamine. it was initially
suggested that homoc~lsteine. like penicillamine.
might bind to lysine-de rived aldehydes and pre-
FIG. 13. Stillborn fetus with osteogenesis imperfecia
congenita. Note the helmet-shaped skull and micromeJi8
due to multiple fractures.
COLLAGEN ]1'\ DISEASt: 73
FIG. 14 . Radiographs of lhe fetus shown in Fig. 13. The
picture demonstrates broad bones with multiple frac-
lures.
venl cross-linking /l09J (see Fil!_ 7). However, since
10 limes Lhe maximal amounts of homocysteine
present in the blood of homocystinuric pat ients is
requ ired to prevent the formation of aldehyde-
derived cross-links in vilro [109J. this hypothesis
seems somewhat tenuous. M ore recently it has
been demonstrated that in the presence of homo-
cysteine in quantities found in vivo there is actually
an accumulation of the aldehyde-derived collagen
cross-link_ dehydrohydroxylysinonorleucine [110J.
This suggests that homocysteine may prevent the
further stabilizat ion of the aldehyde-derh'ed cross-
links and the newly synthesized collagen fibers do
not acquire the normal tensile stren gth.
The .Marlan syndrome. The cJjni('aJ manifesta-
tions of the Marfan synd rom e include tall stature
with the span being gre ater than the height. and
(he lower segment of the body being much greater
than the upper. Skeletal malformations include
joint hypermobility. arachnodactyly. scoliosis. and
pectus exca\'at urn. Ocular abnormali ties include
myopia and lens dislocation. The cardiO\'ascular
abnormalities. the most s.e\'ere manifestations of
the disease. include aneurysms and aortic dis-
section. and vah'ular insufficiency. This disease
is inherited in an autosomal dominant pattern.
The most striking pathology is the degeneration
of the elastic fibers and accumulation of meta-
chromatica]I.'!! staining material in the aorta.
Because of the similarity of the dinical findings
of the Marfan syndrome to lathyrism. a cross-link·
ing defect has been sought in patients with the
Ma rfan syndrome. Lys~\'l oxidase activity. the en-
zyme which initiates cross·linking. has been re-
ported to be normal in cultu red skin fibroblasts
from patients with this s)'T1drome [111]. However,
the collag-en in s kin or the newly synthesized
collagen in skin fibroblast cultures from patients
with the l\1arfan s~'ndrome is more extractable in
aqueous and den at u ring buffers than collagen in
controls /112,113J. Skin fib roblasts from patients
with the Marfan syndrome also stain metachro-
maticaJly. and synthesize approximately 5 times
more hya luronic acid than control skin fibroblasts
74 UlTIO AND LI CHTENSTEI N
FIG. 15. Fa cies of a patient wi th cuti s taxa , demon-
strating prominent jowls. (The picture is courtesy of Dr.
V. A. McKusick.1
§ Since elasti n contai ns cross-link s whic h are also
formed by aldehyde derivatives of lysine. iathyrogenic
nitriles. copper defi cien cy. and other si tuations which
prevent cross-linki ng of collagen usuall y have s imilar
effects on cross-linking of elasti n [62, 64] . Because the
aorta contain s large amounts of elas tin , the devel opment
of aorti c a neu rysms and the rupture of aorta in lathyri sm
and other conditions discussed here are probably ex-
plained by inhibition of cross-linking of elastin.
Vol. 66, N o. 2
collagen and Iysyl residues in elastin. but it is not
yet known whether separate enzymes operate
physiologically on lysine and hydroxy lysine in
collagen. or whether different enzymes operate on
coHagen and elastin. It is also not known whether
there are distinct isoen zymes of iysyl oxidase in
different tissues: however. their existence could
explain the clinical differences in these three
diseases.
Two animal models have been described with
defective cross-linking. Aortic aneurysms, re-
duced tensile strength of t he s kin, curly vib ri ssae,
skelet al malformations. and reduced fitness are
present in mice with cenain alleles of the mottled
series [l16 [. The disease is inherited in an X -linked
pat tern and is , t.herefore. most severe in males,
although some females may also develop aonic
aneurysms. Biochemical studies have shown that
the collagen and elastin in these mice lack Iysine-
derived aldehydes and have abnormal cross·links
[116]. The disease in these mice is similar to
lathyrism. a disease produced by the adminis-
tration of .B-amino propionitriie, an inhibitor of
the enzyme Iysyl oxidase [62- 64]. Animals with
lathyrism have generalized connective tissue
manifestations including fragile skin, aortic
aneurysms. loose joints. and skeletal malforma ·
tions such as scoliosis (see [6]). The tissue collagen
from these animals is more extractable due to a
failure to form lysine-derived cross-links.
All of the diseases in which Iysy l oxidase ac tivity
has been suggested to be decreased ha ve been
inherit ed in an X · linked recessi ve pattern . This
suggests that the gene coding for this enzyme may
be on the X-chromosome.
Acqu ired Diseases with Abn orma l Collogen
Metab olism
D iseQ.fieS of coLLa/{en synthe.~is. In several clinical
condit io ns th ere seems to be an imbalance between
FIG . 16. Patient with the severe form of ho mocys-
tinuri a. including mental retardati on . pectus ca rinatum .
scoliosis. and stiff joints. (The picture is courtesy of Dr.
V. A. McKusic k.)
Feb . 1976 COLLAGEN I'" DISEASE 75
thesis, rather than dec reased degradation , appears
to be the critical factor leading to excessive accu -
mulation of collagen in affected tissues 111i-122].
These conditions are not. considered as primary
collagen diseases since the increased collagen syn-
thesis is clearly not the primary event in the
disease process. Nevertheless, the deposition of
collagen seems to be the major incapacitating and
life-th reatening process. and consequently a phar-
macologic app roach which could prevent the in-
creased collagen accumulation in tissues would be
desirable.
The systemic form of scleroderma or progressive
syst.emic sclerosis appears to be an accumulation
disease of collagen in that one of the most criti cal
features of this disease is the excessive deposition
of collagen in skin, subcutaneous tissues, and in a
variety of internal organs (for review, see [123}).
Biochemical studies with skin biopsies and cul-
tured skin fibroblasts from patients with active
scleroderma have demonstrated that the rate of
collagen synthesis is increased ove r co ntrols
1122-128]. At present, the mechanisms that trigger
the increased collagen synthesis aTe unknown .
•A. secon d mechanism for the pathogenesis of
certain diseases may be the production of the
ubiquitous t ypes of collagen instead of the tissue-
specific types. For example. cartilage slices from
patients with osteoarthritis synthesize type 1 colla-
gen instead of the tissue-specific type IT collagen
synthesized by normal cartil age 1129]. Such a
switch in the type of collagen synthesized from
type Il collagen to type I collagen could also be
reproduced by incubating slice of normal cart ilage
with lysosomal enzymes at acid pH [130], suggest-
ing a pathogenetic mechanism in osteoarthritis.
Disea ses of collagen degradation. At present. no
heritable diseases have been shown to be due to
defecth·e collagen degradation. H owever . in-
creased collagenase acti\·ity and increased collagen
degradat ion is probabl~' involved in the pathogen-
esis of man~' diseases. For example. cultured skin
biopsies from patients with epidermolysis bullosa
dystrophica have a sig-n ificantly increased colla-
genase production over controls. suggest ing a role
in the blister production in this disease 1131-1331.
Also in rheumatoid arthritis there is an increased
product ion of collagenase and other neutral pro-
teases contributin g: to the join t destruction (see
n·
172
riG . 17. A: Typical fac ies in Menkes kinky hair s)-'n-
drome. (The picture is courtesy of Or. V. A. McKusick.l
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