We report a 9-year-old Spanish boy with severe psychomotor developmental delay, short stature,
microcephaly and abnormalities of the brain morphology, including cerebellar
atrophy. Whole-exome sequencing (WES) uncovered two novel de novo variants, a hemizygous variant in CASK (
Calcium/
Calmodulin Dependent
Serine Protein Kinase) and a heterozygous variant in EEF2 (Eukaryotic Translation
Elongation Factor 2). CASK gene encodes the peripheral plasma membrane
protein CASK that is a scaffold
protein located at the synapses in the brain. The c.2506-6 A > G CASK variant induced two alternative splicing events that account for the 80% of the total transcripts, which are likely to be degraded by NMD. Pathogenic variants in CASK have been associated with severe
neurological disorders such as
mental retardation with or without nystagmus also called
FG syndrome 4 (FGS4), and intellectual developmental disorder with
microcephaly and pontine and cerebellar hypoplasia (
MICPCH). Heterozygous variants in EEF2, which encodes the
elongation factor 2 (eEF2), have been associated to
Spinocerebellar ataxia 26 (SCA26) and more recently to a childhood-onset
neurodevelopmental disorder with benign external
hydrocephalus. The yeast model system used to investigate the functional consequences of the c.34 A > G EEF2 variant supported its pathogenicity by demonstrating it affects translational fidelity. In conclusion, the phenotype associated with the CASK variant is more severe and masks the milder phenotype of EEF2 variant.