Heritable connective tissue disorders (CTDs) include a heterogeneous group of conditions affecting extracellular matrix structure, collagen and elastin biology, glycosaminoglycan (GAG) synthesis, and signaling pathways that regulate vascular and skeletal development. Clinical presentations range from isolated features (e.g., joint hypermobility, skin laxity, early-onset osteoarthritis, congenital scoliosis) to life-threatening complications such as thoracic aortic aneurysm and dissection or severe skeletal fragility. Many CTDs overlap phenotypically and may be under-recognized without molecular confirmation.
The PreCheck Health Services Comprehensive Connective Tissue Disorders Panel (84 genes) is a germline, targeted exome assay intended to support diagnosis and management of suspected heritable CTDs, including Marfan spectrum disorders, Loeys-Dietz and related TGF-beta pathway conditions, Ehlers-Danlos syndromes (EDS), osteogenesis imperfecta and collagenopathies, cutis laxa syndromes, and selected skeletal dysplasia syndromes with connective tissue involvement.
❖ Individuals with features suggestive of heritable aortopathy (aortic root dilation/aneurysm, arterial tortuosity, early dissection, family history of thoracic aortic disease).
❖ Individuals with suspected Ehlers-Danlos syndrome or related hypermobility/skin/connective tissue phenotypes (skin hyperextensibility, atrophic scarring, joint instability, easy bruising).
❖ Individuals with bone fragility, recurrent fractures, dentinogenesis imperfecta, or skeletal features consistent with osteogenesis imperfecta/collagenopathy spectrum.
❖ Individuals with cutis laxa, craniofacial dysmorphism, congenital contractures, or multisystem CTD phenotypes.
❖ Individuals with unexplained congenital skeletal abnormalities where a defined CTD diagnosis would change management and recurrence risk counseling.
This panel targets germline variants in genes that encode extracellular matrix (ECM) components, collagen processing enzymes, proteoglycan/glycosaminoglycan (GAG) biosynthesis factors, elastic fiber and microfibril proteins, and key developmental signaling pathways (TGF-β/SMAD) that collectively maintain connective tissue structure and function. Genes are organized into biologic and clinical pathways relevant to heritable connective tissue disorders, including (but not limited to) Ehlers–Danlos syndromes, Marfan/Loeys–Dietz spectrum, osteogenesis imperfecta, cutis laxa, skeletal dysplasias, and corneal/fragility phenotypes.
1. Fibrillar Collagens and Collagen Fibrillogenesis (Structural ECM)
Core structural collagens and related ECM proteins that determine tissue tensile strength; variants are associated with classic/vascular EDS, osteogenesis imperfecta, Stickler spectrum, and other skeletal/connective phenotypes.
❖ COL1A1, COL1A2, COL2A1, COL3A1, COL5A1, COL5A2, COL11A1, COL11A2, COL12A1, COL6A2, COL6A3, COL9A1, COL9A2, COL9A3, TNXB, SPARC
2. Collagen Post-Translational Modification and Cross-Linking
Genes required for collagen hydroxylation, folding, secretion, and stable cross-link formation; disruptions commonly produce severe tissue fragility, congenital contractures, and skeletal dysplasia phenotypes.
❖ CRTAP, P3H1, PLOD1, PLOD2, PLOD3, FKBP14, ALDH18A1, PYCR1
3. Proteoglycan and GAG Biosynthesis/Remodeling (Dermatan/Chondroitin Sulfate Pathways)
Genes involved in synthesis and modification of proteoglycans and GAG chains important for skin, ligament, and skeletal integrity; variants are linked to EDS subtypes and spondylodysplastic phenotypes.
❖ B3GALT6, B3GAT3, B4GALT7, CSGALNACT1, CHST14, CHST3, DSE, BPNT2, BGN
4. Elastic Fiber, Microfibril, and ECM Adhesion Complex
Genes governing elastic fiber assembly and microfibrillar architecture; variants can cause Marfan spectrum, congenital contractural arachnodactyly, and cutis laxa–like presentations with vascular/skin involvement.
❖ FBN1, FBN2, ELN, EFEMP2, FBLN5, LTBP2, LTBP3, LTBP4
5. TGF-β Signaling and Aortopathy/Connective Tissue Dysregulation (Marfan/Loeys–Dietz Spectrum)
Genes in canonical TGF-β signaling and downstream transcriptional regulation; variants are associated with syndromic aortopathy, craniofacial, skeletal, and skin findings.
❖ TGFB1, TGFB2, TGFB3, TGFBR1, TGFBR2, SMAD2, SMAD4, SMAD6, SKI, NOTCH1
6. Developmental Patterning and Skeletal Morphogenesis
Genes influencing bone and joint development, vertebral segmentation, craniofacial patterning, and connective tissue formation; variants contribute to skeletal dysplasia and multisystem CTD phenotypes.
❖ NOG, KIF22, SLC26A2, MED12, LEMD3, GORAB, ROBO3
7. Mineralization and Bone Matrix Homeostasis
Genes involved in bone mineralization and vitamin K–dependent protein modification; variants can present with osteopenia, fractures, and mineralization defects that overlap CTD presentations.
❖ ALPL, GGCX
8. Cytoskeletal/Nuclear Architecture and Smooth Muscle Contractility (Syndromic CTD Overlap)
Genes affecting cellular structural integrity or smooth muscle function, relevant to CTD overlap phenotypes including vascular complications and multisystem presentations.
❖ ACTA2, FLNA, FLNB, ATP7A, ABCC6, AEBP1, ATP6AP1, ATP6V0A2, ATP6V1A, ATP6V1E1, C1R, C1S, ABL1, ADAMTS2, ADAMTS10, ADAMTS17, ADAMTSL2, ADAMTSL4, LOXL3, SLC2A10, SLC39A13, ZNF469
Parameter Description
Genes Analyzed 84 Connective tissue-related genes.
Technology Platform Illumina NGS (Hybrid-Capture Target Enrichment).
Coverage Metrics >98% bases at ≥20× read depth.
Variant Types Detected SNVs and small indels (≤20 bp) within coding exons ±10 bp intronic boundaries.
Reference Genome GRCh38/hg38.
Bioinformatics Pipeline SeqOne™, ACMG/AMP compliant.
Confirmatory Testing Sanger sequencing or orthogonal method as indicated.
Turnaround Time ~10 calendar days.
Quality Metrics Read quality ≥Q30; allelic balance ≥0.3; minimum coverage 20×.
1. Diagnostic Clarity and Prognosis
❖ Provides a molecular explanation for “idiopathic” connective tissue presentations (e.g., joint hypermobility with complications, unexplained arterial dilation/dissection, early-onset scoliosis, recurrent dislocations, spontaneous organ/skin fragility), reducing the diagnostic odyssey for patients and families.
❖ Distinguishes between overlapping heritable connective tissue disorders with different natural histories and surveillance needs, including:
* Marfan spectrum (FBN1) vs Loeys–Dietz spectrum (TGFB2, TGFB3, TGFBR1, TGFBR2, SMAD2, SMAD4, SMAD6, SKI) for aortopathy risk stratification and monitoring cadence.
* Vascular EDS (COL3A1) vs classic EDS (COL5A1, COL5A2) vs TNXB-related hypermobility/EDS overlap, impacting counseling on vascular/organ rupture risk and procedural planning.
* Osteogenesis imperfecta (COL1A1, COL1A2, CRTAP, P3H1) vs other skeletal dysplasia/connective phenotypes, informing fracture risk and orthopedic strategy.
2. Management Planning, Surveillance, and Risk Reduction
❖ Enables gene-informed surveillance and anticipatory management, including:
* Aortopathy/arterial disease monitoring for FBN1, ACTA2, TGFB1/2/3, TGFBR1/2, SMAD2/4/6, SKI, NOTCH1, with earlier referral to cardiology and tailored imaging intervals.
* Procedure/anesthesia and surgical risk planning in conditions with tissue fragility (e.g., COL3A1, severe collagen-processing disorders such as PLOD1/PLOD2/PLOD3, FKBP14).
* Ophthalmology integration where relevant (e.g., corneal fragility phenotypes in ZNF469, microfibril-associated ectopia lentis risk in FBN1).
❖ Supports avoidance of potentially higher-risk activities or exposures based on phenotype/genotype (e.g., individualized counseling for contact sports, heavy lifting, and high-impact activities in high-risk vascular phenotypes).
3. Reproductive Planning and Cascade Testing
❖ Defines inheritance patterns (autosomal dominant, autosomal recessive, X-linked), enabling accurate recurrence risk counseling and family planning.
❖ Facilitates targeted cascade testing for at-risk relatives and reproductive partners when appropriate, and enables earlier monitoring for gene-positive relatives who may develop progressive manifestations (e.g., aortic dilation, scoliosis, joint instability).
Comprehensive connective tissue disorder genetic testing provides clinically actionable information across medical genetics, cardiology, vascular surgery, orthopedics, rheumatology, ophthalmology, maternal–fetal medicine, physical therapy, and primary care. Results directly influence diagnostic clarification, risk stratification, surveillance planning, and family counseling.
Risk Stratification and Diagnostic Clarification
Identify pathogenic or likely pathogenic variants underlying heritable connective tissue disorders, distinguishing genetic etiologies from acquired or multifactorial causes of hypermobility, aneurysm/dissection, scoliosis, recurrent dislocations, early hernias, skin fragility, or unusual scarring. Molecular results refine differential diagnoses generated by clinical criteria and imaging (e.g., echocardiography/CTA/MRA), enabling transition from a “suspected” connective tissue disorder to a definitive, gene-based diagnosis with appropriately scaled systemic surveillance (e.g., FBN1 vs TGFBR2/SMAD2/SKI vs COL3A1).
Family Risk Assessment, Cascade Testing, and Reproductive Counseling
Clarify recurrence risk and identify at-risk relatives once a pathogenic variant is identified—particularly for dominant aortopathy and CTD genes (e.g., FBN1, ACTA2, TGFBR1, TGFBR2, TGFB2, TGFB3, SMAD2, SMAD4, SMAD6, SKI, COL3A1) and recessive connective tissue/skeletal dysplasia genes (e.g., B3GALT6, B3GAT3, B4GALT7, CHST14, DSE, FKBP14, PLOD1, CRTAP, P3H1). Support partner testing when indicated for recessive disorders to assess couple-level reproductive risk and provide anticipatory guidance for gene-positive relatives who may be at risk for progressive manifestations (e.g., aortic enlargement, orthopedic complications).
Personalized Management and Multidisciplinary Care
Use molecular findings to guide individualized management, including selection and timing of surveillance (e.g., vascular imaging intervals for FBN1/TGFBR1/2/SMAD2/3-pathway genes, orthopedic monitoring in collagen and proteoglycan pathway disorders), referral prioritization (cardiology/vascular surgery/orthopedics/ophthalmology), and procedural planning for fragile tissue phenotypes (notably COL3A1 and severe collagen-processing defects). Gene-informed care can reduce avoidable complications by aligning monitoring and interventions to the expected natural history for the specific disorder.
Pharmacogenetics Testing (for drug metabolism and gene-drug interactions)
Match treatments to the patient’s metabolic phenotype (e.g., CYP2D6, CYP2C19, CYP3A5, CYP2C9), reducing the risk of adverse drug reactions and improving efficacy.
Together, these tools enable precision medicine teams to offer a fully customized, data-driven treatment plan for each patient.
Germline testing for heritable connective tissue disorders has become an essential tool in precision medicine, enabling clinicians to identify the molecular causes of syndromic and non-syndromic connective tissue disease, including aortopathies, arterial tortuosity and dissection risk, joint hypermobility with complications, skeletal dysplasias, skin fragility, and multisystem overlap phenotypes. When combined with clinical evaluation and appropriate imaging (e.g., echocardiography, CTA/MRA, and orthopedic assessments), a targeted gene panel provides diagnostic clarity that surpasses clinical assessment alone—particularly in disorders with overlapping features and variable expressivity.
With high analytic performance and curated gene–disease evidence, PreCheck Health Services delivers genomic insights that refine diagnosis, guide risk-stratified surveillance (especially for vascular complications in genes such as FBN1, ACTA2, TGFB2/TGFB3, TGFBR1/TGFBR2, SMAD2/SMAD4/SMAD6, and SKI), and support management decisions across cardiology, vascular surgery, orthopedics, ophthalmology, and rehabilitation. Molecular findings also enable targeted cascade testing and appropriate partner evaluation when indicated.
This integrated approach enhances long-term connective tissue and general health care by enabling earlier, more accurate, and individualized management, ultimately improving outcomes and supporting informed planning for patients and families.
The Comprehensive Connective Tissue Disorder Panel is designed to detect single-nucleotide variants (SNVs) and small insertions and deletions in 84 genes associated with inherited hearing loss. Targeted regions for this panel include the coding exons and 10 bp intronic sequences immediately to the exon-intron boundary of each coding exon in each of these genes. Extracted patient DNA is prepared using targeted hybrid capture, assignment of a unique index, and sequencing via Illumina sequencing by synthesis (SBS) technology. Data is aligned using the human genome build GRCh38. Variant interpretation is performed according to current American College of Medical Genetics and Genomics (ACMG) professional guidelines for the interpretation of germline sequence variants using SeqOne Pipeline.
ABCC6, ABL1, ACTA2, ADAMTS10, ADAMTS17, ADAMTS2, ADAMTSL2, ADAMTSL4, AEBP1, ALDH18A1, ALPL, ATP6AP1, ATP6V0A2, ATP6V1A, ATP6V1E1, ATP7A, B3GALT6, B3GAT3, B4GALT7, BGN, BPNT2, C1R, C1S, CHST14, CHST3, COG7, COL11A1, COL11A2, COL12A1, COL1A1, COL1A2, COL2A1, COL3A1, COL5A1, COL5A2, COL6A2, COL6A3, COL9A1, COL9A2, COL9A3, CRTAP, CSGALNACT1, DSE, EFEMP2, ELN, FBLN5, FBN1, FBN2, FKBP14, FLNA, FLNB, GGCX, GORAB, KIF22, LEMD3, LOXL3, LTBP2, LTBP3, LTBP4, MED12, NOG, NOTCH1, P3H1, PLOD1, PLOD2, PLOD3, PYCR1, RIN2, ROBO3, SKI, SLC26A2, SLC2A10, SLC39A13, SMAD2, SMAD4, SMAD6, SPARC, TGFB1, TGFB2, TGFB3, TGFBR1, TGFBR2, TNXB, ZNF469
This test aims to detect all clinically relevant variants within the coding regions of the genes evaluated. Pathogenic and likely pathogenic variants detected in these genes should be confirmed by orthogonal methods. Detected genetic variants classified as benign, likely benign, or of uncertain significance are not included in this report. Homopolymer regions and regions outside of the coding regions cannot be captured by the standard NGS target enrichment protocols. Currently, the assay does not detect large deletions and duplications. This analysis also cannot detect pathogenic variants within regions that were not analyzed (e.g., introns, promoter and enhancer regions, long repeat regions, and mitochondrial sequence). This assay is not designed to detect mosaicism and is not designed to detect complex gene rearrangements or genomic aneuploidy events. It is important to understand that there may be variants in these genes undetectable using current technology. Additionally, there may be genes associated with connective tissue disease whose clinical association has not yet been definitively established. The test may therefore not detect all variants associated with connective tissue disease. The interpretation of variants is based on our current understanding of the genes in this panel and is based on current ACMG professional guidelines for the interpretation of germline sequence variants. Interpretations may change over time as more information about the genes in this panel becomes available. Qualified health care providers should be aware that future reclassifications of genetic variants can occur as ACMG guidelines are updated. Factors influencing the quantity and quality of extracted DNA include, but are not limited to, collection technique, the amount of buccal epithelial cells obtained, the patient’s oral hygiene, and the presence of dietary or microbial sources of nucleic acids and nucleases, as well as other interfering substances and matrix-dependent influences. PCR inhibitors, extraneous DNA, and nucleic acid-degrading enzymes may adversely affect assay results.
This laboratory-developed test (LDT) was developed, and its performance characteristics were determined by PreCheck Health Services, Inc. This test was performed at PreCheck Health Services, Inc. (CLIA ID: 10D2210020 and CAP ID: 9101993), which is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high complexity testing.
This assay has not been cleared or approved by the U.S. Food and Drug Administration (FDA). Clearance or approval by the FDA is not required for the clinical use of this analytically and clinically validated laboratory-developed test. This assay has been developed for clinical purposes, and it should not be regarded as investigational or for research.
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