Introduction: Inherited glycosylphosphatidylinositol biosynthesis defect is considered a subset of the congenital glycosylation disorder that result from mutations in the genes encoding proteins participating in glycosylphosphatidylinositol biosynthesis and modification. Glycosylphosphatidylinositol anchor proteins play important roles in numerous cellular processes including neurogenesis, cell adhesion, immune response and signalling. Hyperphosphatasia with mental retardation syndrome-3 is one of the Glycosylphosphatidylinositol anchor defects, characterized by moderate to severe intellectual disability, dysmorphic features, hypotonia, seizures and persistent hyperphosphatasia. The aim of this study was to investigating the clinical implications of the PGAP2 gene and identifying the severe phenotype. Case Presentation: A male patient with dysmorphic features, neurodevelopmental delay, seizures, hearing loss, Hirschsprung disease, central fever and elevated alkaline phosphatase was included in the study. The magnetic resonance imaging showed cerebral atrophy, corpus callosum hypoplasia. The whole exome sequencing analysis of the individual, and Sanger sequencing were performed for segregation. Additionally, next generation sequencing, whole transcriptome sequencing and homology modelling and analysis were performed. Whole exome sequencing revealed a homozygous c.651C>G (p.His217Gln) in the PGAP2 gene. The Sanger sequencing confirmed the parents were heterozygous. There is no splicing variant was detected by whole transcriptome sequencing. The AlphaFold model was interpreted hypothetically. It was observed the substitution of histidine, with glutamine and may affect the stability of protein. Discussion: Homozygous PGAP2 mutations in the patient we reported in our study resulted in a severe clinic including, severe developmental delay and intellectual disability, severe epilepsia, dysmorphic features, central fever, biochemical, hormonal and immunological abnormalities. This patient would be the youngest case published in the literatur. We showed that, the instability of mutant PGAP2 protein that cause Hyperphosphatasia with mental retardation syndrome-3 lead to more severe phenotypes.
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