Received: 3 April 2019 Revised: 20 September 2019 Accepted: 27 December 2019

DOI: 10.1002/ajmg.a.61483

ORIGINAL ARTICLE

Expanding the genotype–phenotype correlation of

de novo heterozygous missense variants in YWHAG as a
cause of developmental and epileptic encephalopathy

Farah Kanani1 | Hannah Titheradge2 | Nicola Cooper2 | Frances Elmslie3 |

4 5 6 6
Melissa M. Lees | Jane Juusola | Laura Pisani | Carolyn McKenna |
Cyril Mignot7 | Stephanie Valence8 | Boris Keren9 | Katherine Lachlan10 |
DDD Study11 | Meena Balasubramanian1,12

1
Sheffield Clinical Genetics Service, Sheffield
Children's NHS Foundation Trust, Abstract
Sheffield, UK Developmental and Epileptic encephalopathies (DEE) describe heterogeneous epi-
2
Clinical Genetics, Birmingham Women's and
lepsy syndromes, characterized by early-onset, refractory seizures and developmental
Children's NHS Foundation Trust,
Birmingham, UK delay (DD). Several DEE associated genes have been reported. With increased access
3
South West Thames Regional Genetics to whole exome sequencing (WES), new candidate genes are being identified
Service, St George's, University of London, UK
4
although there are fewer large cohort papers describing the clinical phenotype in
North East Regional Genetics Service, Great
Ormond Street Hospital, London, UK such patients. We describe 6 unreported individuals and provide updated information
5
Clinical Genomics and Research Programs, on an additional previously reported individual with heterozygous de novo missense
Gaithersburg, Maryland
6
variants in YWHAG. We describe a syndromal phenotype, report 5 novel, and a recur-
Human Genetics & Genomics, Northwell
Health System, New York, USA rent p.Arg132Cys YWHAG variant and compare developmental trajectory and treat-
7
Assistance Publique–Hôpitaux de Paris, ment strategies in this cohort. We provide further evidence of causality in YWHAG
Département de Génétique and Centre de
variants. WES was performed in five patients via Deciphering Developmental Disor-
Référence Déficiences Intellectuelles de
Causes Rares, Groupe Hospitalier ders Study and the remaining two were identified via Genematcher and AnnEX data-
Pitié-Salpêtrière, France
bases. De novo variants identified from exome data were validated using Sanger
8
Assistance Publique–Hôpitaux de Paris,
Service de Neuropédiatrie, Hôpital Armand sequencing. Seven out of seven patients in the cohort have de novo, heterozygous
Trousseau missense variants in YWHAG including 2/7 patients with a recurrent c.394C > T, p.
9
Département de génétique, hôpital Pitié-
Arg132Cys variant; 1/7 has a second, pathogenic variant in STAG1. Characteristic
Salpêtrière, Assistance publique-Hôpitaux de
Paris, France features included: early-onset seizures, predominantly generalized tonic–clonic and
10
Wessex Clinical Genetics Service, Princess absence type (7/7) with good response to standard anti-epileptic medications; mod-
Anne Hospital, Southampton, UK
11
erate DD; Intellectual Disability (ID) (5/7) and Autism Spectrum Disorder (3/7). De
Wellcome Trust Sanger Institute,
Cambridge, UK novo YWHAG missense variants cause EE, characterized by early-onset epilepsy, ID
12
Academic Unit of Child Health, University of and DD, supporting the hypothesis that YWHAG loss-of-function causes a neurologi-
Sheffield, Sheffield, UK
cal phenotype. Although the exact mechanism of disease resulting from alterations in
Correspondence YWHAG is not fully known, it is possible that haploinsufficiency of YWHAG in devel-
Meena Balasubramanian and Farah Kanani,
oping cerebral cortex may lead to abnormal neuronal migration resulting in DEE.
Sheffield Clinical Genetics Service, Sheffield
Children's Hospital NHS Foundation Trust,
Western Bank, Sheffield S10 2TH. KEYWORDS
Email: meena.balasubramanian@nhs.net (M. B.) developmental delay, early-onset seizures, epileptic encephalopathy, intellectual disability,
and farah.kanani@nhs.net (F. K)
YWHAG

Am J Med Genet. 2020;1–8. wileyonlinelibrary.com/journal/ajmga © 2020 Wiley Periodicals, Inc. 1

2 KANANI ET AL.
1 | I N T RO DU CT I O N
Developmental and Epileptic Encephalopathies (DEE) are a group of
severe childhood epilepsy disorders; genetics is believed to play an
important role in epilepsy syndromes with an increasing number of
candidate genes being identified via whole genome and exome
sequencing. Specific genes are still only discovered in a small propor-
tion of cases.
YWHAG is one such gene that has been implicated in DEE.
YWHAG (*605356) on Chr 7q11.23 encodes for YWHAG, a member
of 14–3-3 protein family, which are involved in intracellular signaling
pathways, playing an important role in signal transduction leading to
mitosis and cellular proliferation. Given their role, they are prevalent
in several human diseases (Aghazadeh & Papadopoulos, 2016).
YWHAG is highly expressed in brain, skeletal muscle and heart;
mouse models suggest an alteration in Ywhag level lead to delayed
neuronal migration in developing brain (Cornell, Wachi, Zhukarev, &
Toyo-Oka, 2016). ywhag1 knockdown in zebrafish show reduced
brain size, cardiomegaly and increased cardiac arrhythmia. Interstitial
deletions at Chr 7q11.23 have led to infantile seizures and cardio-
myopathy in patients with Williams-Beuren syndrome, suggesting
haploinsufficiency of YWHAG as likely explanation (Komoike
et al., 2010).
2 | METHOD
We present six previously unreported patients with de novo missense
variants in YWHAG and provide updated information on one previ-
ously reported individual to expand further on this patient's clinical
phenotype. WES was performed in five patients via Deciphering
Developmental Disorders Study. Recruitment to this study was via
UK regional Clinical Genetics centers after routine referral. Two
patients were identified via Genematcher and AnnEX databases.
De novo variants identified from exome data were validated using
Sanger sequencing.
3 | CLINICAL REPORTS
3.1 | Patient 1: NM_012479 YWHAG: c.169C > G
(p.Arg57Gly) Decipher ID- 280332
A 15-year-old female who presented with absence, focal, and
generalized tonic–clonic seizure activity with onset at 10 months-
of-age (Tables 1 and 2). Seizure control had been established with
Levetiracetam and Ethosuximide. She also had moderate global
developmental delay, intellectual disability, and a diagnosis of
autism spectrum disorder (ASD). Neuroimaging was unremarkable.
With regards to facial dysmorphism, she had downslanting
palpebral fissures, an upturned nose, absent Cupid's bow and
small ears.
T A B L E 1 YWHAG mutations found in patient series, with
predicted protein change shown
Patient Predicted protein
number YWHAG variant change
1 c.169C > G p.Arg57Gly
2 c.398A > C p.Tyr133Ser
3 c.532A > G p.Asn178Asp
4 c.394C > T p.Arg132Cys
5 c.394C > T p.Arg132Cys
6 c.169C > T p.Arg57Cys
7 c.529C > A p.Leu177Ile
3.2 | Patient 2: NM_012479 YWHAG: c.398A > C
(p.Tyr133Ser) Decipher ID- 276784
A 16-year-old male with a history of a single generalized tonic–clonic
seizure recently. He had global developmental delay, intellectual dis-
ability, and ASD. Neuroimaging was unremarkable. Dysmorphic facial
features included: downslanting palpebral fissures, downturned cor-
ners of mouth, ptosis, and a bulbous nose.
3.3 | Patient 3: NM_012479 YWHAG: c.532A > G
(p.Asn178Asp) Decipher ID- 299681
A 7-year-old male in whom a de novo variant has also been identified
in STAG1. He was diagnosed with absence seizures at the age of
2 years. There had been no particular developmental concerns prior
to that time. He was initially treated with sodium valproate, but this
had little effect. The addition of Lamotrigine resulted in a change of
personality and was ceased, and Ethosuximide then added. This
resulted in some improvement in seizure control. Since the sodium
valproate was stopped, seizure control improved further, and he has
remained seizure-free on Ethosuximide, with a plan to wean this. He
was also reported to have moderate global developmental delay, and
a diagnosis of autism was made at the age of 6 years; he has a number
of sensory issues. Neuroimaging was unremarkable.
3.4 | Patient 4: NM_012479 YWHAG: c.394C > T
(p.Arg132Cys) Decipher ID- 269359
This patient was previously reported by Guella et al. (Subject E) but is
included here as further phenotypic information has become available
since the time of last reporting. A 23-year-old female with moderate–
severe developmental delay, significant speech delay, moderate ID
and ASD. Characteristic facial features included: hypertelorism, down-
slanting palpebral fissures and small ears. She has experienced gener-
alized tonic–clonic, myoclonic, and absence seizures. Age of onset
was reported to be less than six months-of-age. She has had a partial
response to Stiripentol and Sodium Valproate. Electroencephalogram
 KANANI ET AL.
TABLE 2 Genotype and phenotypic features of patients within our cohort

Patient 1 Patient 2 Patient Patient 4 Patient 6

DDD-280332 DDD-276784 3 DDD-299681 DDD-269359 Patient 5 DDD-283758 Patient 7
Variant
Variant YWHAG YWHAG YWHAG YWHAG YWHAG YWHAG YWHAG
c.169C > G,p. c.398A > C,p. c.532A > G,p. c.394C > T,p. c.394C > T,p. c.169C > T,p.Arg57Cys c.529C > A,p.Leu177Ile
Arg57Gly Tyr133Ser Asn178Asp Arg132Cys Arg132Cys
Type Missense Missense Missense Missense Missense Missense Missense
Inheritance De novo De novo De novo De novo De novo De novo De novo
Other variants - - Class 5 de novo STAG1 - - - -
variant
Demographics
Sex F M M F M F F
Age 15 16 7 23 4 10 7.5
Birth
Gestation at 40 40 40 - 40 39 40
delivery (weeks)
Birth weight 3.74 kg (77th) 4.08 kg (86th) 3.35 kg (34th) - 3.6 kg (25th) (0.Fourth) 3.02 kg (ninth)
(percentile)
Growth & development
Height (centile) 165 cm (75th) 173.4 cm (25-50th) 129 cm (50th centile) 105 cm (50-75th) (<0.Fourth) 120 cm (9-25th)
Weight (centile) 92.5 kg (>99.Sixth) 76.1 kg (75-91st) 30.85Kg (75th-91st 19.5 kg (91st) (ninth) 20 kg (ninth)
centile)
OFC - - 52.5 cm (ninth-25th 52 cm (<0.Fourth)
centile)
Walking (months) 15 23 24–30 16 21 22 18
First words 17 9 9 16 12 >24
(months)
Speech/ language Normal Normal Speech delay, echolalia Delayed Mild delay Requires support. unclear Delayed
speech. Short simple
sentences
Developmental Moderate global Global Global Moderate–severe Mild global Global Mild global
delay
ID Mild–moderate Mild–moderate Moderate Moderate Mild Moderate Mild–moderate
ASD Present - Present Present - - -
Learning & Special needs school Learning disability, Special needs Mild delay Moderate learning Special needs school
Education dyslexia, dyspraxia education disability
(Continues)

3
TABLE 2

4
(Continued)

Patient 1 Patient 2 Patient Patient 4 Patient 6

DDD-280332 DDD-276784 3 DDD-299681 DDD-269359 Patient 5 DDD-283758 Patient 7
Dysmorphic Down slanting Ptosis, down slanting Upturned nose with Hypertelorism, down - Upslanting palpebral Bulbous nose, thin
features palpebral fissures, palpebral fissures, thickened alae nasi, slanting palpebral fissures, short upper lip,
upturned nose, downturned corners wide mouth fissures, small ears columella, broad mouth hypertelorism,
absent Cupid's bow, of mouth prominent forehead
small ears,
prominent forehead
Seizure history
Seizure phenotype Absence, focal and Isolated generalized Absence Generalized Generalized Frontal lobe epilepsy Absence
generalized tonic–clonic tonic–clonic, tonic–clonic
tonic–clonic generalized
myoclonic, absence
Age of onset 10 months 16 years 2 years <6 months 2 years < 5 years -
Anti-epileptic Levetiracetam, None Ethosuximide Stiripentol and Sodium valproate Sodium valproate and None
medication Ethosuximide divalproex sodium carbamazepine
Treatment No N/a No response to Partial response No No N/a
resistant? Lamotrigine
Investigations
EEG - Not performed Prolonged burst of Generalized polyspike - - Normal
generalized 2.5 Hz wave and slow wave
spike and wave discharges
activity noted
Cranial MRI Normal Normal Normal Normal Focus of Subtle signal changes in Normal
hyperintensity frontal subcortical
frontal lobe white matter
Additional - Irlen syndrome Joint hypermobility Ataxia, thoracolumbar Tremors Routine bound, limited -
scoliosis diet, sensory
sensitivities, flapping
behaviour, short
attention span

Note: One patient previously reported by Guella et al. 2017 (Patient 4) is included here, as further phenotypic information has been obtained since time of last reporting.

KANANI ET AL.
KANANI ET AL.
had shown generalized polyspike wave and slow wave discharges.
Neuroimaging was unremarkable. Additionally, she has ataxia,
thoracolumbar scoliosis with a leg length discrepancy of around 2 cm
and a lumbar lordosis.
3.5 | Patient 5: NM_012479 YWHAG: c.394C > T
(p.Arg132Cys)
A 4-year-old male with mild global delay, ID, and learning difficulties
experienced generalized tonic–clonic seizures from 2 years-of-age.
Seizure control had been achieved with sodium valproate. Cranial MRI
had shown a focus of hyperintensity of the frontal lobe.
3.6 | Patient 6: NM_012479 YWHAG: c.169C > T
(p.Arg57Cys) Decipher ID-283758
A 10-year-old female with frontal lobe epilepsy, treated with Carba-
mazepine and Sodium Valproate. There was associated global devel-
opmental delay and moderate learning disability. Cranial MRI showed
subtle signal changes in frontal subcortical white matter.
3.7 | Patient 7: NM_012479 YWHAG:c.529C > A
(p.Leu177Ile)
A 7-year-old female with mild global delay and mild–moderate ID. She
had a history of absence seizures. Age of onset and medication history
is unknown. An EEG was unremarkable. Facial dysmorphism includes:
bulbous nose, thin upper lip, hypertelorism, and a prominent forehead.
F I G U R E 1 YWHAG gene (transcript ENST00000307630). Boxes indicate exons, lines introns. First amino acid of each exon shown above.
Predicted protein change from variants from patients in this series shown below gene. Functional domain shown below gene [Color figure can be
viewed at wileyonlinelibrary.com]
5
4 | RE SU LT S
4.1 | Sequencing results
Each of the seven patients in the cohort has de novo, heterozygous
missense variants in YWHAG (Figure 1). Two patients harbor a recur-
rent c.394C > T, p.Arg132Cys variant (Patients 4 and 5). Only one
patient (Patient 3) has another variant; a second, pathogenic variant in
STAG1. None of the variants identified in this cohort are present in
the population databases-gnomAD and ExAC.
4.2 | Demographics
Four patients are female. Five are currently under the age of 16; and
two are 16 years or above.
4.3 | Seizure activity
Early-onset seizures were experienced by four patients. Average age
of seizure onset was two years, ranging from 4 months to 16 years.
Age of seizure onset was unknown for two patients. One patient
(Patient 2) had experienced only one isolated generalized tonic–clonic
seizure aged 16. Seizure type was predominantly generalized tonic–
clonic and absence.
Seizure control was typically established with Sodium Valproate,
Levetiracetam, and other standard anti-epileptic medications. At least
four patients required multiple anti-epileptic medications before control
was established; specific information regarding number of anti-
6 KANANI ET AL.
epileptics required was not available for one patient. One patient
(patient 4) achieved only partial response to anti-epileptic medication
and there were no other reports of treatment refractory seizures. Neu-
roimaging was unremarkable in five of the seven patients. Patients
5 and 6 had frontal lobe hyperintensity and subtle signal changes in
frontal subcortical white matter on cranial MRI, respectively.
4.4 | Neurodevelopment and cognition
Developmental delay was widely reported amongst our cohort with
7/7 patients having global delay ranging from mild to severe. Del-
ayed milestones were a frequent presentation with the average age
of walking being 20 months (range 15 to 30 months) and age at first
words, 15 months (range 9 to 24 months). Many patients subse-
quently went on to experience further speech and language delay.
Intellectual disability was present in six patients with additional edu-
cational support required. Autism Spectrum Disorder was reported
in three patients including the patient who additionally carried a de
novo STAG1 mutation. Other behavioral anomalies were only
reported in one patient, who had short attention span and challeng-
ing behavior.
4.5 | Facial gestalt
The most commonly noted features in our cohort included a promi-
nent forehead, long palpebral fissures, bulbous nose, and absent
Cupid's bow (Figure 2).
4.6 | Additional features
Other reported features included ataxia (1/7), thoracolumbar scoliosis
(1/7), and tremors (1/7); though no firm correlation can be made.
There were no apparent dissimilarities in the overall phenotype
F I G U R E 2 Clinical photographs showing characteristic facial features including prominent forehead, long palpebral fissures, bulbous nose,
and absent Cupid's bow [Color figure can be viewed at wileyonlinelibrary.com]
between those with the recurrent c.394C > T, p.Arg132Cys variant
and the remainder cohort.
5 | DI SCU SSION
Many causal variants in developmental and epileptic encephalopathies
arise de novo with increasing numbers of candidate genes being iden-
tified through WES. Allen et al., 2013 explored the impact of de novo
variants on neuropsychiatric disease risk, specifically on those associ-
ated with infantile spasms and Lennox–Gastaut Syndrome via the Epi-
lepsy Phenome/Genome Project (Allen et al., 2013). In this study,
Sanger sequencing confirmed 329 de novo variants in 264 trios that
were analyzed. Each trio had on average 1.25 confirmed de novo vari-
ants in several genes that have also been linked to ID and ASD.
In 2016, Vissers et al. subsequently reported that de novo point
mutations, insertions or deletions, or structural genomic variation
accounted for most cases of severe ID and that this was likely to be the
case for other related neurodevelopmental disorders (Vissers, Gilissen, &
Veltman, 2016).
YWHAG, a member of the 14–3-3 protein family, is involved in
modulating cell survival and control of apoptosis (Morrison, 2009;
Porter, Khuri, & Fu, 2006) and inhibition of 14-3-3 and ligand protein
binding causes apoptosis (Masters & Fu, 2001).
YWHAG was identified as a candidate gene for epilepsy by
Komoike et al., 2010 (Komoike et al., 2010). Here, they reported two
patients with Williams-Beuren Syndrome (WBS) who presented with
infantile spasms, a rare presentation in WBS. Subsequent arrayCGH
and FISH analysis identified atypical deletions of 7q11. In one patient,
the deletion extended to the distal telomeric region, containing
YWHAG, amongst other genes. Reduced expression of YWHAG was
seen in lymphocytes derived from the patient. Further analysis was
performed using gene knockdown of zebrafish. Knockdown of ywhag1
(zebrafish homolog of human YWHAG) resulted in reduced brain size
as well as ventricular enlargement and arrhythmia. The function of
YWHAG in cerebral and neural growth, required for normal
KANANI ET AL. 7

development of brain and heart, was described and thus, YWHAG
haploinsufficiency was proposed as a cause of infantile spasms and
cardiomegaly, as seen in the subject with WBS.
Wachi et al., 2017 described the important role of 14-3-3 proteins in
neuronal migration. They identified that 14-3-3epsilon and 14-3-3zeta
are important for brain development and radial migration of pyramidal
neurons in the developing cerebral cortex. It was also reported that
14-3-3gamma-deficiency resulted in delayed neuronal migration as well
as morphological defects. Therefore, disruption of 14-3-3 proteins is
known to be associated with pathological brain development and neuro-
nal migration defects (Wachi, Cornell, & Toyo-Oka, 2017).
Previous to this, in 2013, Allen et al. described a patient with a de
novo missense variant in YWHAG c.387C > G p.Asp129Glu in associa-
tion with epileptic encephalopathy (Allen et al., 2013) and De Rubeis
et al. reported a patient with a de novo missense variant in YWHAG
c.148A > C p.Lys50Gln through WES when exploring the interplay of
common and rare genetic variation in ASD (De Rubeis et al., 2014).
In the only YWHAG series to-date, Guella et al., 2017 described
four patients with de novo variants in YWHAG and suggested it as a
cause of early-onset epilepsy, DEE and ID (Guella et al., 2017). In this
series, the de novo variants were predicted to impair dimerization and
phosphopeptide binding. Age at seizure onset was typically under
12 months; myoclonic seizure type being the most common with focal
motor, the absence and eyelid myoclonia also reported.
As demonstrated in our cohort, interestingly, seizure control was
generally established with anti-epileptic medication, monotherapy
(most often sodium valproate) though each patient did require more
than one medication at various stages in their treatment pathway, in
order to maintain seizure control. ID was a common finding in this
cohort, ranging from mild to severe and each of the patients had

TABLE 3 Genotype and phenotypic features of previously published patients (Guella et al., 2017)

(subject B) Guella et al (subject F) Guella et al (subject D) Guella et al

Variant
Variant YWHAG c.394C > T,p. YWHAG c.394C > T,p. YWHAG
Arg132Cys Arg132Cys c.44A > C,pGlu15Ala
Type Missense Missense Missense
Inheritance De novo De novo De novo
Other variants - - -
Demographics
Sex F F F
Age 19 16 11
Birth
Gestation at delivery (weeks) - - -
Birth weight (percentile) - - -
Development
Speech/language Early language delay
Developmental delay Mild–moderate Mild Global
ID Mild–moderate Mild–moderate
ASD -
Learning & education Delayed Mild delay Mild–moderate delay
Seizure history
Seizure phenotype Myoclonic, atypical absence, Absence, myoclonic, eyelid Focal motor
generalized tonic–clonic myoclonia
Age of onset <12 months <6 years 6 months
Anti-epileptic medication Clonazepam, Lamotrigine, Lamotrigine, sodium Sodium valproate
Divalproex sodium, valproate
Ethosuximide
Treatment resistant? Now seizure free on No No
divalproex sodium
Investigations
EEG Dysrhythmic background, Bilateral frontotemporal -
sharp waves in bianterior spikes, generalized spike
quadrants waves
Cranial MRI Normal Normal Generalized atrophy with
loss of white matter
Additional Coordination difficulties Thoracolumbar scoliosis Hypotonia, joint laxity
8 KANANI ET AL.

T A B L E 4 Comparison of features in individuals with YWHAG patient 4. ML provided clinical information for patient 3. JJ, LP, and
variants compared with those reported in the literature CMcK provided clinical information for patient 5. CM, SV, and BK pro-
This study Guella Total reported vided clinical information for patient 7. KL provided clinical informa-
Clinical features cohort et al. 2017 features tion for patient 6. MB provided clinical information for patient 1 and
Seizures 7/7 3/3 10/10 was the senior supervisor of the project.
Seizure onset prior to 4/7 3/3 7/10
five years-of-age DATA AVAILABILITY STAT EMEN T
Treatment refractory 1/7 0/3 1/10 Data sharing is not applicable to this article as no new data were cre-
seizures ated or analysed in this study.
Facial dysmorphism 5/7 0/3 5/10
Developmental delay 7/7 3/3 10/10 OR CID
ID 6/7 2/3 8/10 Farah Kanani https://orcid.org/0000-0003-4388-0290
Speech impairment 4/7 1/3 5/10
Abnormal MRI brain 2/7 1/3 3/10 RE FE RE NCE S
Aghazadeh, Y., & Papadopoulos, V. (2016). The role of the 14-3-3 protein
family in health, disease, and drug development. Drug Discovery Today,
21(2), 278–287.
developmental delay. Neuroimaging was unremarkable in most cases,
Allen, A. S., Berkovic, S. F., Cossette, P., Delanty, N., Dlugos, D.,
with one patient found to have generalized atrophy with diffuse loss Eichler, E. E., … Winawer, M. R. (2013). De novo mutations in epileptic
of white matter. Facial dysmorphism was not commented upon in this encephalopathies. Nature, 501(7466), 217–221.
series. (Tables 3 and 4). Cornell, B., Wachi, T., Zhukarev, V., & Toyo-Oka, K. (2016). Regulation of
neuronal morphogenesis by 14-3-3epsilon (Ywhae) via the microtu-
bule binding protein, doublecortin. Human Molecular Genetics, 25(20),
4405–4418.
6 | C O N CL U S I O N S De Rubeis, S., He, X., Goldberg, A. P., Poultney, C. S., Samocha, K.,
Cicek, A. E., et al. (2014). DDD study, homozygosity mapping col-
laborative for autism, UK10K consortium. Synaptic, transcrip-
The phenotypic data from our cohort supports YWHAG as a DEE can-
tional and chromatin genes disrupted in autism. Nature, 515,
didate gene. Our series indicates that de novo YWHAG missense vari-
209–215.
ants cause DEE, characterized by early-onset epilepsy, ID and DD, Guella, I., McKenzie, M. B., Evans, D. M., Buerki, S. E., Toyota, E. B., Van
supporting the possible hypothesis that YWHAG loss-of-function cau- Allen, M. I., … Epilepsy Genomics Study. (2017). Deciphering develop-
ses a neurological phenotype. We report an extended phenotype and mental disorders study. De Novo mutations in YWHAG cause early-
onset epilepsy. American Journal of Human Genetics, 2, 300–310.
propose that there are similar seizure phenotypes. While multiple
Komoike, Y., Fujii, K., Nishimura, A., Hiraki, Y., Hayashidani, M.,
antiepileptic medications may be needed to establish seizure control, Shimojima, K., … Saitsu, H. (2010). Zebrafish gene knockdowns imply
treatment resistant epilepsy appears to be rare. There appears to be a roles for human YWHAG in infantile spasms and cardiomegaly. Gene-
strong association between de novo YWHAG variants, global develop- sis, 4, 233–243.
Masters, S. C., & Fu, H. (2001). 14-3-3 proteins mediate an essential anti-
mental delay, and mild–moderate ID.
apoptotic signal. The Journal of Biological Chemistry, 276,
There also appears to certain variant hotspots in YWHAG as 45193–45200.
described here, further case reports of patients with this recurrent Morrison, D. K. (2009). The 14-3-3 proteins: Integrators of diverse signal-
variant are needed to determine if these patients have a discernible, ing cues that impact cell fate and cancer development. Trends in Cell
Biology, 19, 16–23.
more specific phenotype but from our cohort, this does not appear to
Porter, G. W., Khuri, F. R., & Fu, H. (2006). Dynamic 14-3-3/client protein
the case from the data collected so far. interactions integrate survival and apoptotic pathways. Seminars in
We propose that haploinsufficiency of YWHAG in developing cere- Cancer Biology, 16, 193–202.
bral cortex leads to abnormal neuronal migration resulting in EE. Further Vissers, L. E., Gilissen, C., & Veltman, J. A. (2016). Genetic studies in intellec-
tual disability and related disorders. Nature Reviews. Genetics, 17(1), 9–18.
patients and functional studies will help determine this hypothesis.
Wachi, T., Cornell, B., & Toyo-Oka, K. (2017). Complete ablation of the
14-3-3epsilon protein results in multiple defects in neuropsychiatric
ACKNOWLEDGMENTS behaviors. Behavioural Brain Research, 319, 31–36.
Deciphering Developmental Disorders Study, Wellcome Trust Sanger
Institute, Cambridge, UK.

CONF LICT OF IN TE RE ST How to cite this article: Kanani F, Titheradge H, Cooper N,

The authors declare no potential conflict of interest.
AUTHORS C ON TRIBUTIONS
FK collected the data and wrote the manuscript. HT and NC provided
clinical information for patient 2. FE provided clinical information for
et al. Expanding the genotype–phenotype correlation of de
novo heterozygous missense variants in YWHAG as a cause of
developmental and epileptic encephalopathy. Am J Med Genet
Part A. 2020;1–8. https://doi.org/10.1002/ajmg.a.61483