- Open Access
Phenotypic and molecular insights into CASK-related disorders in males
- Ute Moog1,
- Tatjana Bierhals†2,
- Kristina Brand†2,
- Jan Bautsch2,
- Saskia Biskup3,
- Thomas Brune4,
- Jonas Denecke5,
- Christine E de Die-Smulders6,
- Christina Evers1,
- Maja Hempel2,
- Marco Henneke7,
- Helger Yntema8,
- Björn Menten9,
- Joachim Pietz10,
- Rolph Pfundt8,
- Jörg Schmidtke11,
- Doris Steinemann12,
- Constance T Stumpel6,
- Lionel Van Maldergem13 and
- Kerstin Kutsche2Email author
© Moog et al.; licensee BioMed Central. 2015
- Received: 13 January 2015
- Accepted: 20 March 2015
- Published: 12 April 2015
Heterozygous loss-of-function mutations in the X-linked CASK gene cause progressive microcephaly with pontine and cerebellar hypoplasia (MICPCH) and severe intellectual disability (ID) in females. Different CASK mutations have also been reported in males. The associated phenotypes range from nonsyndromic ID to Ohtahara syndrome with cerebellar hypoplasia. However, the phenotypic spectrum in males has not been systematically evaluated to date.
We identified a CASK alteration in 8 novel unrelated male patients by targeted Sanger sequencing, copy number analysis (MLPA and/or FISH) and array CGH. CASK transcripts were investigated by RT-PCR followed by sequencing. Immunoblotting was used to detect CASK protein in patient-derived cells. The clinical phenotype and natural history of the 8 patients and 28 CASK-mutation positive males reported previously were reviewed and correlated with available molecular data.
CASK alterations include one nonsense mutation, one 5-bp deletion, one mutation of the start codon, and five partial gene deletions and duplications; seven were de novo, including three somatic mosaicisms, and one was familial. In three subjects, specific mRNA junction fragments indicated in tandem duplication of CASK exons disrupting the integrity of the gene. The 5-bp deletion resulted in multiple aberrant CASK mRNAs. In fibroblasts from patients with a CASK loss-of-function mutation, no CASK protein could be detected. Individuals who are mosaic for a severe CASK mutation or carry a hypomorphic mutation still showed detectable amount of protein.
Based on eight novel patients and all CASK-mutation positive males reported previously three phenotypic groups can be distinguished that represent a clinical continuum: (i) MICPCH with severe epileptic encephalopathy caused by hemizygous loss-of-function mutations, (ii) MICPCH associated with inactivating alterations in the mosaic state or a partly penetrant mutation, and (iii) syndromic/nonsyndromic mild to severe ID with or without nystagmus caused by CASK missense and splice mutations that leave the CASK protein intact but likely alter its function or reduce the amount of normal protein. Our findings facilitate focused testing of the CASK gene and interpreting sequence variants identified by next-generation sequencing in cases with a phenotype resembling either of the three groups.
- Pontocerebellar hypoplasia
- X-linked intellectual disability
In 2008, we found the X-linked CASK gene (MIM 300172) to be mutated in female patients with a severe neurodevelopmental disorder and distinct brain anomalies which comprised progressive microcephaly, pontocerebellar hypoplasia and severe developmental delay (DD), named microcephaly with pontine and cerebellar hypoplasia (MICPCH, MIM 300749) . Subsequently, the MICPCH phenotype has been well delineated by several groups [2-5]. Affected females show primary or rapidly postnatally evolving microcephaly, and typically (moderate to) severe DD/intellectual disability (ID) with no or very limited language. Facultative features are axial hypotonia and/or peripheral hypertonia, movement and behavioral disorders, and seizures . These patients inconsistently show short stature, various eye anomalies, sensorineural hearing loss, and possibly a recognizable facial phenotype, whereas congenital malformations are rarely associated [2,4]. MRI findings are characteristic and allow differentiation of other microcephalic disorders, in particular of the different types of pontocerebellar hypoplasia (PCH). In MICPCH, cerebellar hypoplasia is diffuse affecting the hemispheres and vermis equally, and pontine hypoplasia can show relative sparing of the pontine bulging. Both pontine and cerebellar hypoplasia can be mild to severe without correlation to the severity of clinical manifestations [4,5]. The corpus callosum (CC) is of normal or low-normal size, exhibits a low cerebrum/CC ratio , and supratentorial anomalies are subtle and non-specific possibly showing a rarefication of gyri in the frontal region. Females with MICPCH carry heterozygous loss-of-function mutations in CASK including nonsense, frameshift, and splice site mutations as well as partial or complete deletions/duplications of CASK [1-5].
So far, only six males with likely loss-of-function alterations of CASK have been reported [2,5,8,9], all presenting with a severe neurological phenotype except for one who had a mosaic mutation. In addition, familial cases of male patients with missense and splice mutations in CASK have also been described. They exhibit mild to severe ID with or without nystagmus or were diagnosed with the so-called FG-syndrome [10-12]. It has been hypothesized that CASK loss-of-function mutations are associated with reduced male viability or in utero lethality , while hypomorphic mutations are associated with a different phenotypic spectrum . However, the phenotype in males associated with different CASK mutation types has not been systematically evaluated.
We here report on eight unrelated male individuals, seven sporadic and one familial case, with different CASK alterations (nonsense and splice mutations, mutation of the start codon, partial gene duplications and deletions, also in mosaic state), and evaluate the clinical, genetic and molecular data of these novel subjects and the male individuals published previously. We also review the current knowledge on pathogenic mechanisms and genotype-phenotype correlation in individuals with a CASK mutation.
Male individuals with CASK mutations
Birth OFC/W/L (SD)
OFC a (SD)
Height a (SD)
Weight a (SD)
Other neurologic anomalies
Sensorineural hearing loss
c.704_708del p.K236Efs*10 ex 7 dn
w 37 +3 -4.2/-3.2/?
† at 7 m
−5.9 (4.5 m)
−4.8 (6 m)
−1 (6 m)
profound, no development
apnoeas, inability to swallow
ASD, bil. clubfeet
dolichocephaly, puffy eyelids, broad nasal bridge, bulbous tip of nose, severe retromicrognathia, ear dysplasia, fleshy ear lobes
severe hypo CBL + pons + medulla, simplified gyri, cortical atrophy
MICPCH Severe epilepsy
Dup ex 10–16 dn
w 37 +3 -2.5/-1.9/-1.5
10 m † at 21 m
probably Ohtahara s., burst suppression
macropapilla, optic atrophy?
long convex fingernails, overriding 2nd toes, linear blisters right leg, needed PEG
retrognathia, fleshy uplifted ear lobules
significant hypo CBL + pons
MICPCH Severe epilepsy
c.1A > G ex 1 dn
−5 (3 y)
profound, no development
AVSD, tapering fingers, edema of the dorsum of hands and feet, needed PEG
long eyelashes, short nose, large ears with fleshy uplifted ear lobules
small brain, hypo CBL + pons
MICPCH Severe epilepsy
−3.7 (5 y)
c.79C > T p.R27* ex 2 dn
w 33 +2 -2.57/-1.14/-1.73
intractable seizures, burst suppression
apnoea-bradycardy-syndrome, inability to swallow
VSD, short limbs, contractures of fingers
plagiocephaly, metopic ridge
severe hypo CBL + pons, progressive cortical atrophy, progressive hypomyelination
MICPCH Severe epilepsy
Dup ex 4–20 mos
w 36 +1 -1.8/0/0.3
−7.8 (9 m)
−2.1 (9 m)
−0.6 (9 m)
spasms and myoclonic seizures, no hypsarrhythmia
sparse hair, broad nasal bridge, epicanthal folds, long philtrum, retromicrognathia, fleshy uplifted ear lobules
small brain, hypo CBL + pons
Del ex 1 mos
−6 (11 m)
−2 (11 m)
−1.6 (11 m)
hypertonia of limbs
broad nasal bridge, epicanthal folds, long philtrum, prominent premaxilla, mild retrognathia, simple/thin auricle
hypo CBL + pons
Del ex 3–9 mos
−3.56 (29 m) -2.55 (5;3 y)
−3.5 (29 m) -2.42 (5;3 y)
−1.97 (29 m) -1.45 (5;3 y)
tonus regulation disorder
prominent nasal bridge, thin upper lip, pointing chin
mild hypo CBL + pons mildly simplified gyri
Dup ex 1–5 mat
Mild to moderate DD
long flat philtrum
mildly smaller frontal lobes, small CC (frontal), CBL and otherwise normal
MIC + DD
c.1061T > C p.L354Pc ex 12
profound, no development
West s., intractable seizures
large eyes, large ears, broad nasal bridge, broad nasal tip, epicanthal foldsd
MICPCH Severe epilepsy
Del ex 2 matf
−2.7 (1.4 y)
Long slender fingers, micropenis, needed tracheostomy + PEG
micrognathia, short neck
severe hypo CBL, hypo ponsd
MICPCH Severe epilepsy
c.1A > G ex 1 dn
hypertonia of limbs
short upper arms, overlapping fingers, clinodactyly
micrognathia, high arched palate
severe CBL hypo, hypo ponsd
MICPCH Severe epilepsy
c.227_228del p.E76Vfs*6 ex 3 dn
early myoclonic encephalopathy (EME)
CP, tetralogy of Fallot, AMC, hydronephrosis, VUR, needed tracheostomy
severe hypo CBL + pons
MICPCH Severe epilepsy
c.278 + 1G > A in 3 dn
intractable seizures, spasms + tonic seizures, suppression-burst
spastic tetraparesis, dystonia
long slender fingers with contractures, needed PEG
retrognathia, high arched palate, low-set ears with prominent lobules, down-slanted palpebral fissures, broad nasal bridge
very severe hypo CBL, hypo pons
MICPCH Severe epilepsy
c.316C > T p.R106* ex 4 mos
well-arched eyebrows, broad nasal bridge, hypertelorism?, anteverted nares, full lipsd
mild hypo CBL
c.915G > A p.(=) ex 9 dn
† at 2 w
severe hypo CBL + pons, thin and unmyelinated CC
Pat II 4j
Fam V c.2183A > G p.Y728C ex 23 (2 ♂)
N, strabism, optic atrophy
synophris, high nasal bridge, upslanted palpebral fissures, short columellad
hypo CBL, pachygyria
MICPCH + N
Pat II 2j
similar to II 4
MIC + Moderate ID + N
Pat IV 1j,l
Fam 74 c.2129A > G p.D710G ex 22 (4 ♂)
Mild ID + N
Pat III 3j,l
tremor, unsteady gait
Mild ID + N
Pat III 12j,l
Mild ID + N
Pat III 6j,l
Pat IV 1j,l
Fam 16 c.802T > C p.Y268H ex 8 (4 ♂, 1 without clinical description)
Pat III 4j,l
Pat II 3j,l
Fam 123 c.2756T > C p.W919R ex 27 (3 ♂)
+, in one of three patients at age 17 y
All 3: Mild ID + N
Pat III 1j,l
Fam 245 (K8919) c.1186C > T p.P396S ex 13 (4 ♂, 2 without clinical description)
short stature, 152 cm
tremor, unsteady gait
flat mid face, open mouth, eversion of lower lip
Pat III 4j,l
short stature, 147 cm
flat nasal bridge, anteverted nares, wide mouth, broad palate, broad grooved tongue, short broad neck
Pat III 3j
Fam 683 c.2521-2 A > T in 25 (4 ♂)
N, high myopia
Mild ID + N
Pat II 3j
N, strabism, myopia, astigmatism
Mild ID + N
Pat II 4j
N, high myopia, optic atrophy, retinal pigment anomalies
Mild ID + N
Pat II 5j
Mild ID + N
Pat III 26m
c.83G > T p.R28L ex 2 (3 ♂)
EEG mildly abnormal
hyperactivity, aggressive behaviour, constipation
prominent forehead, frontal upsweep, hypertelorism, depressed nasal bridge, long philtrum, micrognathiad
normal (on CT)
Pat II 11m
hypotonia in infancy
aggressive behaviour, constipation
prominent forehead, hypertelorism, broad long philtrumd
Pat II 17m
hypotonia in infancy
hyperactivity, constipation, cryptorchidism
prominent forehead, frontal upsweep, long philtrum, epicanthal foldsd
Patient 2 was the 7th child of an unrelated Pakistani couple. The pregnancy was complicated by polyhydramnios, gestational diabetes controlled by a diet and IUGR. He was born in week 37 with mild microcephaly (−2.5 SD), small for gestational age, and required cardiopulmonary reanimation because of cyanosis and lack of spontaneous breathing. He was severely hypotonic and developed myoclonic seizures from his 1st month of life, later tonic and infantile seizures which were difficult to treat. His EEG showed a burst-suppression-pattern and a probable diagnosis of Ohtahara syndrome was established. Because of swallowing difficulties he was fed by a PEG tube but continued to be dystrophic. He showed nearly no development, and was last seen at the age of 10 months. Dysmorphic features consisted of retrognathia, fleshy uplifted ear lobules, long convex fingernails, and overriding 2nd toes (Figure 1). He died at the age of 21 months, probably from pneumonia. MRI brain showed significant hypoplasia of the pons and all parts of the cerebellum. No supratentorial anomalies were seen except a retardation of myelination (Figure 2).
Patient 3 was born as the 1st child of Dutch parents. The pregnancy was established with IVF/ICSI with frozen sperm which was obtained before the start of chemotherapy because of a hematologic malignancy in the father, and proceeded uneventfully. An ASD with bicuspid aortic valve was diagnosed shortly after birth. OFC at birth was within the normal range but rapidly decreased to −2.5 SD at the age of 3 months and −5 SD at age 3 years. He showed minor dysmorphic facial features with fleshy earlobes (Figure 1). From the age of 2 weeks on epileptic attacks were noted. Despite antiepileptic treatment he persisted having severe intractable seizures. He was severely hypotonic and had feeding problems, needing a PEG tube at age 2 years. He showed virtually no motor or cognitive development. He was able to recognize his parents in periods when his epilepsy was more or less under control. He was last seen when he was 5 years old and lived with his parents. He was frequently hospitalized because of complications related to his epilepsy. Ophthalmologic examination showed optic hypoplasia and nearly no visual reactions could be aroused. Cranial MRI showed significant hypoplasia of the pons and cerebellum (Figure 2).
Patient 4 was born as the 1st child of a German couple in week 34 by Cesarean section following a pregnancy complicated by IUGR and preeclampsia/maternal edema with primary microcephaly (−2.57 SD) and relevant VSD. He suffered from respiratory and cardiac insufficiency (apnoe-bradycardy-syndrome), showed severe hypotonia from the beginning and was tube fed due to inability to swallow. He developed different types of seizures with burst suppression EEG from 2 months on. On examination at 6 months of age, microcephaly corresponded to −7.7 SD (corrected for prematurity), his skull was asymmetric and had a metopic ridge. He showed disproportionate short stature with a broad thorax, rhizomelic shortening of limbs, and slender lower legs. He had flexion contractures of fingers 2 and 4 on the left, and 4 on the right side, a high palate, broad alveolar ridges, mildly protruding ears of normal length with overfolded helices (Figure 1), undescended testes, mild shawl scrotum and a hemangioma on his back. At the same age, he received surgery for inguinal hernia and a PEG. At 15 months, he was still severely hypotonic and showed little psychomotor development. His seizures responded partly to levetiracetam and vigabatrin. Serial MRI at the age of 2 and 10 months showed severe pontocerebellar hypoplasia affecting particularly the cerebellar hemispheres, progressive cerebral atrophy and progressive hypomyelination (additional effects of complicated premature birth cannot be excluded) (Figure 2).
Patient 5 was one of dizygotic twins, born as the 1st child in week 36 after a pregnancy established by egg cell donation and ICSI, and complicated by maternal diabetes and polyhydramnios. Decelerated growth of head circumference in fetus 1 was mentioned prenatally beginning at 20 weeks of pregnancy. OFC at birth corresponded to the 3rd centile. Patient 5 showed progressive microcephaly up to −6.5 SD during the first half year of life. He developed epileptic spasms at the age of 3 months but his EEG did not show hypsarrhythmia. The treatment could reduce the frequency of seizures. His psychomotor development was moderately retarded at the age of 6 weeks. Hearing impairment was suspected but could not be validated. Myopia was diagnosed at 6 months. Examination at age 7 months revealed severe global developmental delay with severe muscular hypertonia and absence of social interaction, reflective smiling or visual fixation. Dysmorphic signs comprised a broad nasal bridge, epicanthal folds, a long philtrum, retromicrognathia, and fleshy uplifted ear lobules (Figure 1). MR images showed a small brain with significant pontocerebellar hypoplasia affecting the cerebellar vermis and hemispheres equally (Figure 2).
Patient 6 was born at term following an uneventful pregnancy as the 2nd child of an Iranian mother and a German father with microcephaly (−2.9 SD). His mother reported two previous miscarriages. He showed progressive microcephaly during his 1st year of life and global developmental delay from the beginning. At the age of 11 months, his motor development corresponded to 3 months and his Developmental Mental Index was < 50. He had an afebrile seizure but otherwise normal EEG, and his tonus was increased. He exhibited subtle facial dysmorphism (broad nasal bridge, epicanthal folds, long philtrum, prominent premaxilla, mild retrognathia, simple/thin auricle, normal ear length) (Figure 1) reminiscent of the facial phenotype described in CASK-mutation positive females . MRI of the brain showed moderate pontocerebellar hypoplasia affecting the cerebellar hemispheres and vermis equally, but no further anomalies (Figure 2).
Patient 7 was born with a normal OFC as the 2nd child of a nonconsanguineous German couple at 36 + 1 weeks of gestation. On examination at the age of 29 months, he showed microcephaly (−3.56 SD), short stature (−3.5 SD), global developmental delay, and a tonus regulation disorder. Facial dysmorphism included a prominent nasal bridge, thin upper lip, and a small pointed chin (Figure 1). He walked at the age of 30 months and learnt some words, however, he could not use them appropriately. At the age of 5;3 years, OFC and height corresponded to −2.5 SD approximately, he was able to run but fell frequently due to mild ataxia. He was restless, constantly moving and reported to be normotonic. He uttered sounds, no words and could not yet be trained in sign language. His development had not been tested formally. Brain MRI performed at 10 months showed mild hypoplasia of the pons, cerebellar vermis and hemispheres, and mildly simplified gyri (Figure 2).
Patient 8 was born at term to a 40-year-old Belgian mother. OFC corresponded to −2 SD at birth. He showed failure to thrive, rapidly progressive secondary microcephaly up to −5 SD at age 20 months, and mild to moderate developmental delay without further neurologic signs. The only physical anomaly consisted of a flat smooth philtrum (Figure 1). Brain MRI at the age of 18 months showed mildly smaller frontal lobes and a small frontal part of the corpus callosum. Cerebellum and pons were normal (Figure 2). The mother of patient 8 had a history of special education for learning difficulties, her OFC being 53 cm (3rd centile). She had three girls and a boy from a previous marriage, two of the girls required special education; the boy and a full sister of patient 8 were healthy.
DNA was isolated from leukocytes, lymphoblastoid, fibroblast and buccal cells by standard procedures. Copy number profiling for patient 7 was performed using the SurePrint G3 Custom CGH Microarray, 4x180K (G4125A, Agilent Technologies, Santa Clara, CA, USA), a high resolution 60-mer oligonucleotide based microarray with median overall probe spacing of about 13 kb. Labelling and hybridization of genomic DNA were performed according to the protocol provided by Agilent without enzymatic restriction. Data visualization and analysis was performed as described . Copy number profiling for patient 8 was performed on a 60K oligonucleotide array (Agilent Technologies, Diegem, Belgium) according to the manufacturer’s instructions with minor modifications as described . CNV evaluation was performed using the in-house developed software tool arrayCGHbase .
Multiplex ligation-dependent probe amplification (MLPA)
SALSA MLPA P398 CASK probemix (version A1) (MRC-Holland, Amsterdam, The Netherlands) was used according to the manufacturer’s instructions to detect single and multiple exon deletions/duplications in the CASK gene (exons 1–23 and 25–27). MLPA results were analysed with the Sequence Pilot algorithm, version 4.0.1 (JSI Medical Systems, Kippenheim, Germany). A relative probe signal of 1 (100%) in a male sample DNA reflected one copy of target sequence of the CASK-specific probe. Mosaic deletions of a probe’s recognition sequence led to a significant reduction in relative peak area (by 35-50% or higher). Relative signals of 1.5 (150%) of CASK-specific probes indicated two copies of the respective target sequences.
Sequencing of CASK
The coding region of the CASK gene (27 exons) [GenBank:NM_003688] was amplified from genomic DNA. Primer sequences are available on request. Amplicons were directly sequenced using the ABI BigDye Terminator Sequencing Kit (Applied Biosystems, Darmstadt, Germany) and an automated capillary sequencer (ABI 3500; Applied Biosystems). Sequence electropherograms were analysed using Sequence Pilot software (JSI Medical Systems).
Fluorescence in situ hybridization (FISH)
Metaphase spreads from peripheral blood lymphocytes were prepared by standard procedure and counterstained using 4′,6-diamidino-2-phenylindole (DAPI). BAC (RP11 human BAC library) and fosmid clones (WIBR-2 human fosmid library [G248P8]) were received from the BACPAC Resource Center, Children’s Hospital Oakland, CA, USA. BAC and fosmid DNA preparation and labelling as well as fluorescence microscopy and analysis of images was performed as previously described .
Fibroblast cells were cultured in Dulbecco’s modified Eagle medium (DMEM; Life Technologies, Darmstadt, Germany) and lymphoblastoid cell lines in Roswell Park Memorial Institute 1640 medium (RPMI 1640; Life Technologies), both supplemented with 10% (v/v) fetal bovine serum (FBS; PAA Laboratories, Cölbe, Germany) and penicillin-streptomycin (100 U/ml and 100 μg/ml, respectively; Life Technologies) and incubated at 37°C in a humidified atmosphere with 5% CO2.
Transcript analysis and cloning
Total RNA of patient 5 and three healthy males was extracted by using the PAXgene Blood RNA Kit (PreAnalytiX/QIAGEN, Hilden, Germany) according to the manufacturer’s instructions. Total RNA was extracted from cultured primary fibroblasts of patients 1, 2 and 5 and three healthy individuals as well as from lymphoblastoid cells of patient 8 and one healthy individual (RNeasy Mini Kit, QIAGEN). 1 μg of RNA was reverse transcribed into cDNA (Superscript II®; Invitrogen, Karlsruhe, Germany) using random hexanucleotides (Invitrogen) according to the manufacturer’s protocol. RT-PCR fragments were obtained by using different primer combinations according to standard PCR protocols (see online Additional file 1: Table S1). PCR products were cloned into pCR2.1 TOPO TA Cloning® Vector (Invitrogen). E.coli clones were subjected to colony PCR and PCR products from individual clones were sequenced.
Antibodies and reagents
The following primary antibodies and dilutions were used: rabbit anti-CASK antibody (named anti-CASK2 antibody; WB 1:500; Cell Signaling Technology, Danvers, MA, USA), mouse anti-CASK antibody (named anti-CASK1 antibody; WB 1:1000; Millipore, Schwalbach, Germany), mouse anti-α-tubulin antibody (clone DM 1A; WB 1:7500; Sigma-Aldrich, Taufkirchen, Germany). As secondary antibodies, horseradish peroxidase-conjugated anti-mouse and anti-rabbit antibodies (1:1000–1:10000 dilution; GE Healthcare, Munich, Germany) were used.
Cells were washed with ice-cold 1x PBS and harvested in modified RIPA buffer (150 mM NaCl, 50 mM Tris–HCl, pH 8.0, 0.5% sodium desoxycholate [w/v], 1% Nonidet P40 [v/v], 0.1% sodium dodecyl sulfate [w/v]) containing protease inhibitor cocktail (Roche, Mannheim, Germany). Cell debris was removed by centrifugation at 14000 rpm for 10 minutes at 4°C and protein solutions were supplemented with sample buffer. Proteins were separated on SDS-polyacrylamide gels and transferred to PVDF membranes. Following blocking (20 mM Tris–HCl, pH 7.4; 150 mM NaCl; 0.1% Tween-20; 4% non-fat dry milk) and washing (20 mM Tris–HCl, pH 7.4; 150 mM NaCl; 0.1% Tween-20), membranes were incubated in primary antibody solution (20 mM Tris–HCl, pH 7.4; 150 mM NaCl; 0.1% Tween-20; 5% BSA or 0.5% non-fat dry milk) containing the appropriate antibody. Next, membranes were washed and incubated with the peroxidase-coupled secondary antibody. After final washing, immunoreactive proteins were visualized using the Immobilon Western Chemiluminescent HRP Substrate (Millipore).
Sequence analysis of the 27 coding exons of CASK was performed on six male patients and revealed three pathogenic mutations: the nonsense mutation c.79C > T (p.R27*) in patient 4, the 5-bp deletion c.704_708delATAAG in patient 1 and a transition affecting the start codon, c.1A > G, in patient 3 (Table 1). The A-to-G change of the first ATG codon has previously been reported in a male with Ohtahara syndrome and cerebellar hypoplasia . These three hemizygous CASK alterations were not present in the mothers of the patients and therefore occurred de novo.
MLPA for the CASK gene on the remaining three patients identified two intragenic duplications, one of exons 10–16 in patient 2 (Figure 3A) and one of exons 4–20 in patient 5 (Figure 3A). In patient 6, the relative peak area of the two probes for exon 1 was reduced by 50-60% indicating a mosaic deletion of this CASK exon (Figure 3A). Somatic mosaicism of the exon 1 deletion was confirmed in buccal cell-derived DNA of patient 6 by MLPA as the dosage of this exon was reduced by ~60% (data not shown). The two duplications were also detected in DNA isolated from the patients’ fibroblasts as well as in a third tissue (buccal cells) of individual 5 (data not shown). The mother of patient 2 did not carry the exon 10–16 duplication (data not shown), while the biological mother of patient 5 was not available.
CASK transcript analysis
In individuals 2 and 5, we amplified specific mRNA junction fragments that were not obtained in healthy individuals indicating an intragenic in tandem duplication (Figure 4B and C). Sequencing of the aberrant CASK transcript in patient 2, who carried the exon 10–16 duplication, revealed that exon 16 was spliced to exon 10, followed by exons 12 and 13. This out-of-frame CASK transcript was found in both RNA isolated from leukocytes and fibroblasts and contained a premature termination codon in exon 10 (Figure 4B). Cloning and sequencing of the junction fragments obtained from leukocyte- and fibroblast-derived RNA of patient 5 detected aberrant splicing of exon 17 or exon 18 to exons 4 and 5 indicating that exons 19 and 20 were skipped in the majority of transcripts, and exons 18–20 in some of them (Figure 4C). Both CASK transcript variants (exon 17-4-5 and exon 18-4-5) contained a premature stop codon in exon 4 (Figure 4C).
The 5-bp deletion c.704_708delATAAG in patient 1 leads to a frameshift and introduction of a premature termination codon (p.(K236Efs*10)). However, this deletion affects the last five nucleotides of exon 7 suggesting that recognition of the adjacent splice donor site in the pre-mRNA could be disturbed by the spliceosome. We tested this hypothesis by performing RT-PCR on RNA isolated from fibroblasts of patient 1 that yielded multiple amplicons of different sizes compared with a single PCR product generated from control RNA (Figure 4D). Amplicon cloning followed by sequencing of a total of 53 clones revealed five different CASK transcript variants in fibroblasts of patient 1: in the major transcript form exon 7 was skipped; minor forms included transcripts containing exons 5 to 8 with the 5-bp deletion in exon 7, transcripts lacking both exons 7 and 8 as well as transcripts with a shortened exon 7 (skipping of 39 bp or of 97 bp at the 3′ end) (Figure 4D and Additional file 1: Figure S3). Three out of the five CASK mRNA variants harboured a premature termination codon in exon 8 (Figure 4D).
CASK protein analysis
sporadic male patients with MICPCH and severe epileptic encephalopathy:
This group includes ten individuals so far (patients 1–5 reported here and five patients reported previously, Table 1). CASK alterations in these patients likely represent germline mutations, except for patient 5, and include a missense mutation, a nonsense mutation, a splice site mutation, a mutation affecting the start codon in two individuals, a 2 bp and a 5 bp deletion, two intragenic duplications of multiple exons and a deletion of exon 2 (this report and refs. [2,5,8,9]). Transcript analysis in our patients 1, 2 and 5 and the patient with the exon 2 deletion revealed that the mutations severely disturb the integrity of the CASK gene as aberrant mRNAs with a premature termination codon were produced (this report and ref. ). In addition, wild-type CASK protein was absent in cells of patients 1 and 2 (this report) and the two patients with c.1A > G and the exon 2 deletion , further indicating that these males carry a CASK null allele. Patient 5 also has an inactivating CASK mutation, however, by immunoblotting we demonstrated a small amount of CASK protein with a molecular mass corresponding to that of wildtype in his fibroblasts. To confirm expression of wild-type CASK, we tried to amplify a CASK transcript harboring exons 3–21 from RNA isolated from leukocytes and fibroblasts of patient 5 and indeed generated an RT-PCR product from his fibroblast-derived RNA. This finding indicates that patient 5 has a high level somatic mosaicism of the exon 4–20 duplication. In accordance with this interpretation, no exon 3-to-21 transcript was amplified from leukocyte-derived RNA of patient 5 suggesting that expression of CASK is generally low in blood and/or the degree of somatic mosaicism of the exon 4–20 duplication is higher in leukocytes than in fibroblasts.
In this group, the affected males have the most severe clinical presentation. Developmental delay is severe to profound; the eldest reported patients are 5 years of age and hardly show any development (patient 3 in Table 1 and patient 16 in ref. ). Similar to females with MICPCH, microcephaly is congenital or evolves rapidly during the first months of life and later becomes significant (up to −9 SD). MRI consistently shows significant or severe pontocerebellar hypoplasia. Other brain malformations include rarefication of gyri, (progressive) cortical atrophy and progressive hypomyelination but no further supratentorial involvement. Seizures manifest as Ohtahara syndrome, West syndrome, early myoclonic encephalopathy or just as unspecified intractable seizures. We conclude that CASK loss-of-function alterations cause severe epileptic encephalopathy in males but do not specifically underlie e.g. Ohtahara syndrome. Affected individuals frequently need a percutaneous endoscopic gastrostomy (PEG) for feeding and/or tracheostomy because of apnea. Congenital heart defects, in particular septal defects, are present in 4/10 patients and contractures, long slender fingers or shortening of limbs in two. 8 of 10 show retro-/micrognathia and fleshy uplifted ear lobules are seen in five patients (Figure 1).
Male individuals with a severe CASK mutation clinically manifest with unspecific early epileptic encephalopathy and congenital or early postnatal and rapidly progressing microcephaly. Thus, the brain imaging findings are the major diagnostic clue and should prompt CASK testing, however, the differential diagnosis of other pontocerebellar hypoplasia (PCH) forms can be challenging . For example, the CASK-mutation positive patient reported by Nakamura et al.  had been previously described with a clinical diagnosis of PCH type 3 , and it cannot be excluded that additional individuals with PCH may have been misclassified and are without a molecular diagnosis up to date.
MICPCH and a severe developmental disorder but without severe epilepsy:
The CASK alterations in this group of five individuals (patients 6–7 reported here and three patients reported previously, Table 1) include severe mutations in mosaic state (nonsense mutation, exon 1 deletion and exon 3–9 deletion) as well as a partly penetrant splice mutation (c.915G > A, affecting the last nucleotide of exon 9) and a missense mutation (c.2183A > G, p.Y728C), both in the hemizygous state (this report and refs. [1,2,10]). The three patients with somatic mosaicism of the CASK mutation produce wild-type protein in a significant percentage of their cells, most likely reducing clinical severity in these cases.
The phenotype of the males in this group is comparable to MICPCH in females. DD/ID (if specified) is severe, microcephaly is variable and the degree of pontocerebellar hypoplasia on MRI does not necessarily correlate with the degree of DD. Seizures have not been described in the five individuals, however, patient 5 reported in Najm et al.  deceased shortly after birth. The interpretation of clinical data of this patient group is limited by the small sample size and restricted data on patient 5 . One individual, patient II-4 of family V in Hackett et al. , presented with nystagmus besides severe ID and cerebellar hypoplasia. His brother (patient II-2) shows a similar but milder phenotype, with nystagmus and mild microcephaly but no imaging of the brain has been reported.
mild to severe ID with or without nystagmus:
The 21 cases of this group (patient 8 reported here and 20 cases published previously) are all familial and carry splice mutations or missense variants affecting amino acid residues in different CASK protein domains (Figure 6) [10-12]. Patient 8 harbors a duplication of exon 1 to 5 which was inherited from his mother. We identified multiple aberrant CASK transcripts in lymphoblastoid cells of this individual, however, we also amplified a CASK mRNA which contained exons 1 to 6 in the correct order, including part of the 5' untranslated region. Consistently, we detected a small amount of wild-type CASK protein in the patient’s cells indicating that some CASK transcripts are efficiently translated.
In this group, microcephaly is documented only in individual 8 and in patient II.2 of family V . Pontocerebellar hypoplasia or other brain anomalies can only be excluded in a minority of patients because imaging of the brain has often not been performed or reported. Various seizure disorders have been reported for seven males from four families, in none of them being severe. Nystagmus was observed in 12 patients. Short stature, facial dysmorphism, behavioural problems, tremor and/or hypotonia may be associated. Intrafamilial variability seems to be small, in particular with regard to eye findings and the degree of ID. In the family with the segregating c.83G > T mutation, the affected males have been described as having FG syndrome (FGS) [11,19], which is a heterogeneous X-linked condition initially described by Opitz and Kaveggia (Opitz-Kaveggia syndrome, MIM 305450) . FGS1 is caused by a recurrent mutation in MED12 (MIM 300188) , and has a well-defined phenotype consisting of DD/ID, hypotonia, dolichomacrocephaly, characteristic facies including small ears and hypertelorism, and congenital anomalies of the corpus callosum, heart and/or skeleton. The phenotype of the other FGS types, however, is poorly defined. Thus, we propose the clinical diagnosis of the males with the CASK mutation c.83G > T should be syndromic ID rather than FGS.
Restricted clinical data are available for 13 carrier females from seven families. No abnormalities are reported in seven of these females, deriving from three families. Four carriers showed mild to severe ID, one had absence seizures, two tremor, and three nystagmus. MRI findings are given for one carrier only (no anomalies) who presented with ID and nystagmus.
The three phenotypic groups, however, represent a clinical continuum and at least two males link the groups: patient 5 with a high level mosaicism for the duplication of exons 4 to 20 and a less severe form of epilepsy links group I to II; and patient II.4 from family V with the missense mutation c.2183A > G (p.Y728C) , who represents the interface to group (iii) as he and his brother who carried the same mutation both had nystagmus.
CASK encodes the calcium/calmodulin (CaM)-dependent serine protein kinase which belongs to the membrane-associated guanylate kinase (MAGUK) protein family, the most prominent family of multidomain scaffolding proteins . CASK has been shown to control synapse formation and activity by (i) presynaptic organization and regulation of neurotransmitter release, (ii) maintaining the morphology of dendritic spines and trafficking of ion channels to the postsynaptic site, and (iii) regulating the transcription of genes involved in cortical development by entering the nucleus [23,24]. However, the exact pathomechanism underlying the clinical spectrum ranging from MICPCH with severe epilepsy to mild ID is still unclear. In general, hemizygous CASK variants in males of phenotype group (iii) have been suggested to represent hypomorphic alleles [10,11], altering one or more of the multiple CASK functions while preserving others. An impact on protein structure and/or function has been demonstrated for the pathogenic CASK alterations p.Y728C and p.W919R, while the nature of the deleterious impact on CASK function remains to be determined for p.R28L, p.Y268H and p.P396S [25,26]. The two splice mutations c.2129A > G and c.2521-2A > T likely lead to the production of CASK proteins lacking several amino acid residues [10,11]. These mutant proteins may misfold, mislocalize, loose their capacity to bind CASK interaction partners and/or have a changed function. For example, the constitutively active CaM-kinase domain in the N-terminus of CASK  could be affected by the amino acid alteration p.R28L.
The nature of the CASK mutations found in males of phenotypic groups (i) and (ii) is quite different from that of group (iii) and corresponds to the mutation types found in females [2-5]. Indeed, germline and mosaic alterations consistently found in group (i) likely are null alleles as has been shown by CASK transcript analysis and immunoblotting demonstrating the absence of CASK protein in different cell types of severely affected individuals (Figures 4 and 5; ref. ). The non-synonymous CASK mutation c.1061T > C/p.L354P found in a 5-year-old male patient of this group is possibly a loss-of-function mutation in view of his severe phenotype, but the functional consequences of this alteration have not been investigated . The small amount of normal CASK protein in patient 5 correlated well with the presence of CASK wild-type transcript in his fibroblasts (Figure 4C). Somatic mosaicism for a severe CASK mutation attenuates the phenotype in males, as shown for patients 6 and 7 in our cohort and patient 12 described by Burglen et al. . However, the level of somatic mosaicism can be high, as in patient 5, and may mimic a germline mutation. Patients who are somatic mosaics of a CASK inactivating mutation are expected to produce wild-type CASK protein in a small percentage of their cells, as demonstrated for patient 5. Obviously, this scenario did not protect them from developing pontocerebellar hypoplasia that can readily be detected on brain imaging. Interestingly, in lymphoblastoid cells of patient 8 who carried the CASK exon 1–5 duplication, a small amount of wild-type CASK protein was observed. However, in contrast to somatic mosaics, this patient still produces some wild-type CASK in all of his cells and not only in a portion of cells. It can be hypothesized that the small amount of functional CASK was sufficient for an apparently normal structural development of the brain in patient 8, but led to microcephaly and ID, similar to the missense and splicing mutations described in males with X-linked non-syndromic/syndromic ID.
In summary, we describe three phenotypic groups forming an overlapping spectrum of CASK-related disorders in males: group (i) includes the most severely affected males, group (ii) is a mitigation of group (i), and group (iii) includes males with variable ID and facultative clinical features. Our detailed analysis of the impact of mutations on CASK pre-mRNA splicing and protein expression indicates a genotype-phenotype correlation: inactivating CASK germline mutations are associated with the most severe phenotype (MICPCH with severe epileptic encephalopathy), while in the mosaic state these mutations result in an attenuated phenotype (MICPCH) that can also be caused by partly penetrant CASK mutations. CASK alterations leaving the protein intact, but with a reduced functionality or a reduction in protein level, are found in males with highly variable X-linked ID. We recommend CASK testing in male patients with the combination of DD/ID or epileptic encephalopathy, postnatal microcephaly (< −3 SD) and pontocerebellar hypoplasia. Sequencing of exons 22–27 may also be considered in patients with ID and nystagmus.
The authors declare that they have no conflict of interest. We are grateful to the patients and their families who contributed to this study. We thank Inka Jantke, Marika Pusch, Marcel Tauscher and Inga Ziemer for skilful technical assistance, Jessica Hoffmann und Isabelle Prehl (CeGaT GmbH) for CASK mutation analysis, Maja Kopic (Klinik für Kinder- und Jugendmedizin, Klinikum Lippe, Detmold, Germany) for collecting clinical data of patient 2, and William B. Dobyns (Center for Integrative Brain Research, Seattle, WA, USA) and Gökhan Uyanik (Medizinische Genetik, Hanusch-Krankenhaus, Vienna, Austria) for reviewing MR images of patient 8 and 7, respectively. This work was supported by a grant from the Landesforschungsförderung Hamburg (“Molekulare Mechanismen der Netzwerkmodifizierung: Anpassung von Synapsen und Netzwerken für neuronale Plastizität”) to K.K.
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