Functional assay for analysis of variants of uncertain significance in maple syrup urine disease

Abstract

Introduction: Enhanced molecular characterisation using high-throughput sequencing has significantly improved patient diagnosis and management. However, the identification of variants of uncertain significance (VUS) limits its use for clinical decision making, such as prenatal diagnosis in subsequent pregnancies. Case report: We report a female infant who presented with mild gross motor delay at 4 months and developed seizures with hypoglycaemia at 5 months. Plasma amino acid and urine organic acid findings were consistent with Maple syrup urine disease (MSUD), despite a normal newborn screening test for this condition. MSUD results in deficiency of branched-chain alpha-ketoacid dehydrogenase, responsible for leucine, isoleucine, and valine degradation, caused by biallelic pathogenic variants in BCKDHA, BCKDHB, or DBT genes. Results: Molecular analysis in this patient identified two VUS, c.434-15_434-4del and c.365A>G (p. Tyr122Cys) in the DBT gene. Functional testing, in the form of leucine decarboxylation studies in fibroblasts revealed deficient function and mRNA splicing studies provided additional data that permitted variant reclassification and subsequent prenatal testing. Conclusion: This case reinforces the need for specialist biochemical genetic laboratories to retain their ability to perform functional assays to aid the resolution of VUS.