Case#: 33 year-old female; first cardiologic evaluation at age 24 (LV wall thickness 13 mm); re-evaluated at 33 after recurrent palpitations

DiseaseAssertion: Noonan syndrome (PTPN11) with sarcomeric hypertrophic cardiomyopathy (MYBPC3); non-obstructive HCM, mild phenotype

FamilyInfo: Father carries the MYBPC3 c.1790G>A variant and has HCM; the PTPN11 variant was absent in both parents, consistent with de novo. Both parents and the proband's brothers underwent full cardiologic evaluation, no cardiovascular disease in the other family members. Parents declined genetic testing of the underage siblings. Grandparents (I-1, I-2) and II-2, II-3 have unknown phenotypes (pedigree Fig. 2).

ParentalTesting: Both parents genotyped for the two proband variants (Table 1). Father heterozygous for MYBPC3 c.1790G>A; neither parent carries PTPN11 c.1510A>G, supporting de novo status. Phase between the two variants therefore established as in trans (different genes).

CasePresentingHPOs: HP:0001639 (Hypertrophic cardiomyopathy); HP:0001962 (Palpitations); HP:0004322 (Short stature); HP:0000271 (Abnormality of the face); HP:0001647 (Hypertelorism); HP:0000508 (Ptosis)

CaseHPOFreeText: Regular psychophysical development. First echo at 24 showed mild increase in LV wall thickness (13 mm). At 33, presented with several episodes of palpitations; exam showed mild facial dysmorphisms (wide mouth, sloping forehead, prominent nasal bridge, prominent nose, low-set ears), short stature, and a systolic heart murmur. Echo: asymmetric LV hypertrophy, maximum wall thickness 16 mm at the anterior interventricular septum, mild mitral regurgitation, non-obstructive. No other cardiovascular signs.

CaseNotHPOs: HP:0001635 (Congestive heart failure); HP:0001650 (Aortic valve stenosis); HP:0001642 (Pulmonic stenosis); HP:0001250 (Seizure)

CaseNotHPOFreeText: No heart failure, no LV outflow obstruction, no pulmonary stenosis, no other congenital heart defect. No intellectual disability; psychophysical development was regular. No other signs of cardiovascular disease on examination.

CasePreviousTesting: NGS panel of 325 cardiomyopathy-associated genes (Supplementary Table S1); MAF threshold 5%; variants validated by Sanger sequencing; cascade testing restricted to the two proband variants.

Genotyping Method: NGS targeted panel (Maxwell 16 DNA extraction, Agilent Alyssa analysis, Illumina Variant Interpreter, in-house pipeline) with Sanger validation; parental Sanger genotyping for the same two variants.

FunctionalAnalysis: None performed by the authors. They cite prior HeLa cell work showing the MYBPC3 c.1790G>A change causes exon 18 inclusion in the transcript and an almost undetectable 248 bp product.

Variant 1: PTPN11 NM_002834.3:c.1510A>G (p.Met504Val); heterozygous missense; de novo; classified pathogenic, explains Noonan syndrome

ClinVar: Not stated in the paper; verify the current record before submitting.

CAID: Not reported.

gnomAD: Not reported in the paper; I have not checked gnomAD for this variant.

Variant 2: MYBPC3 NM_000256.3:c.1790G>A (p.Arg597Gln); heterozygous missense; exon 18, last nucleotide of the exon, affecting a highly conserved residue and causing a splicing variation; inherited from the father

ClinVar: Not stated in the paper; authors note it is classified pathogenic/likely pathogenic for HCM in several genetic databases.

CAID: Not reported.

gnomAD: Not reported in the paper

PMID: 32824488

Gene: MYBPC3

AdditionalInfo: Authors describe this as the first reported young adult with HCM and mild NS carrying variants in both PTPN11 and MYBPC3. Note the terminology problem: the abstract calls them "compound heterozygous," but the variants are in different genes on different chromosomes, so this is digenic (double heterozygosity), not compound heterozygosity. The authors argue the mild phenotype contrasts with the usual expectation that multiple sarcomeric hits worsen the disease, and that red flags justified the broad panel.

Case#: 64-year-old male, non-smoker, first admitted June 2014; Russian family; died 2019 at age 69

DiseaseAssertion: MYBPC3-related cardiomyopathy with a predominantly restrictive phenotype in combination with left ventricular noncompaction (LVNC) and cardiac sarcoidosis

FamilyInfo: Son (39) and daughter (35) both heterozygous for the same variant and both have non-obstructive asymmetric HCM, with no LVNC on cardiac CT; both essentially asymptomatic on beta-blocker monotherapy. Five-year SCD risk 4.82% (son) and 2.07% (daughter); ICD implanted in the son, no shocks in three years. Authors mention another family of theirs with a father who died suddenly young and children with HCM and LVNC.

ParentalTesting: Not performed; the proband is the index case; his parents were not evaluated. Transmission to both children confirmed by Sanger.

CasePresentingHPOs:HP:0001639 (Hypertrophic cardiomyopathy)

CaseNotHPOs: Not reported

CasePreviousTesting: Not reported

Genotyping Method: Next-generation sequencing panel; variants confirmed by Sanger.

FunctionalAnalysis: None performed.

Variant 1: MYBPC3 NM_000256.3:c.278delA; heterozygous frameshift

Variant 2: KCNJ5 c.464G>A; heterozygous missense

ClinVar: Not reported.

CAID:Not reported.

gnomAD: No reported?

Gene:MYBPC3

PMID:36011256

Case#: Single proband ; 63-year-old female; palpitations at presentation July 2025; HCM diagnosis established at age 63

DiseaseAssertion: Hypertrophic cardiomyopathy (HCM) complicated by apical left ventricular aneurysm and mid-ventricular obstruction⁠

FamilyInfo: No family history of cardiac disease or sudden cardiac death at a young age reported. Both parents deceased (one of cancer, one of natural causes at age 92), neither with reported cardiovascular disease; proband has no siblings. Only first-degree relative is her son, who carries the KCNJ5 c.464G>A variant but not the MYBPC3 c.278delA variant, and has a normal echocardiogram with no myocardial hypertrophy. No pedigree beyond the son (Fig. 3B).⁠

ParentalTesting: Not performed; both parents deceased, no DNA available; authors state a valid familial segregation analysis could not be performed. Only one family member (son) was available for cascade Sanger screening.⁠

CasePresentingHPOs: HP:0001639 (Hypertrophic cardiomyopathy); HP:0001649 (Tachycardia), palpitations; HP:0001712 (Left ventricular hypertrophy).

CaseNotHPOFreeText: No history of hypertension, diabetes, or hyperlipidemia. Phenocopies excluded: no extra-cardiac manifestations of Fabry disease and GLA testing negative; cardiac amyloidosis excluded (no apical sparing, normal serum free light chains, negative serum protein electrophoresis and immunofixation); no significant coronary stenosis on coronary CT angiography. No QT prolongation or features of Andersen–Tawil syndrome on ECG.

CasePreviousTesting: Whole exome sequencing identified both variants; all rare and known variants validated by Sanger sequencing, with cascade Sanger screening in available one family member. No prior genetic testing reported before this episode.

Genotyping Method: Targeted region capture with next-generation high-throughput sequencing (whole exome, exonic plus flanking regions); variants confirmed by bidirectional Sanger sequencing. Cascade screening by Sanger in the son. MYBPC3 variant absent from 1000 Genomes, ESP6500, ExAC, and the Besuper local database. KCNJ5 variant absent from 1000 Genomes and ESP6500, ExAC frequency, absent from local Basenhall controls.⁠

FunctionalAnalysis: None performed; authors list absence of functional studies and lack of mRNA-level validation as limitations. MYBPC3 frameshift predicted to trigger nonsense-mediated decay.⁠

Variant: MYBPC3 NM_000256.3:c.278delA (p.Lys93ArgfsTer3); heterozygous; exon 2; novel, not in ClinVar or HGMD; classified Likely Pathogenic by ACMG (PVS1, PM2). Second variant: KCNJ5 NM_000256.3:c.464G>A (p.Arg155Gln); heterozygous; exon 2; novel, not in ClinVar or HGMD; classified VUS (PM2, PP3). Note the paper's KCNJ5 accession is written as NM_000256.3, which is the MYBPC3 transcript, most likely a typo in the article Pepper please conform for me the correct KCNJ5 accession

ClinVar: No ClinVar record for either variant; nearby KCNJ5 missense variants c.451G>A, c.452G>A, c.470T>G, and c.473C>G are documented as pathogenic/likely pathogenic for long QT syndrome or aldosteronism, and downstream frameshift/nonsense variants at the MYBPC3 locus are classified pathogenic or likely pathogenic.

CAID:Not found.

gnomAD: No allele frequency available, so no MAF to report.

PMID: 42428486

Gene: MYBPC3

HGNC: HGNC:7551

AdditionalInfo:Single-case report, no case numbering system used. Treated with dapagliflozin, metoprolol, rivaroxaban, and recombinant human BNP for 13 days, discharged on the first three; mexiletine added at 1-week follow-up for persistent palpitations. ICD recommended but declined due to financial constraints; 3-month follow-up showed good adherence with occasional palpitations and no serious arrhythmic events. Authors conclude MYBPC3 c.278delA is likely pathogenic for HCM, while the KCNJ5 variant shows no clinical phenotype in the proband or her son and may be incidental or a modifier.⁠

Case#: Pedigree III:2; male; HCM diagnosed clinically at age 39 (1998); heart transplant after progression to end-stage heart failure

DiseaseAssertion: Hypertrophic cardiomyopathy (HCM), progressed to end-stage heart failure with systolic dysfunction

FamilyInfo: No family history of heart disease reported at diagnosis; no known consanguinity. Parents deceased and unavailable for testing. 12 relatives genotyped: one brother (III:3) homozygous, seven first- and second-degree relatives heterozygous. All heterozygotes have normal ECG, normal echo, and no cardiac symptoms. Three children of generation IV (IV:7, IV:8, IV:9) still awaiting results.⁠

ParentalTesting: Not performed; both parents deceased. Absence of consanguinity stated but not genetically confirmed; parental phase therefore inferred rather than tested.

CasePresentingHPOs:HP:0001639 (Hypertrophic cardiomyopathy); HP:0002094 (Dyspnea); HP:0001658 (Myocardial infarction);HP:0001678 (Atrioventricular block)

CaseHPOFreeText: Exertional dyspnea at age 39 with systolic murmur; IVS 26 mm, posterior wall >16 mm, LVOT peak velocity 2.8 m/s. Pacemaker 1999, extracted 2010 for infection. 2013 circumflex occlusion treated with stent (cholesterol 6.8 mmol/L, LDL 4.6 mmol/L; former smoker). Septum 27 mm, moderate systolic dysfunction, NSVT on Holter → ICD. 2014 AF with severe dyspnea; on beta-blocker, ACE inhibitor, and aldosterone antagonist. 2016 VO₂max 14 mL/kg/min; LVEDP 24 mmHg rising to 38 with exercise, pulmonary pressure 56/27 rising to 70/… systolic. Biopsy: moderate interstitial fibrosis, focal hypertrophy and atrophy, no infiltrative disease.

CaseNotHPOs: HP:0000822 (Hypertension); HP:0000819 (Diabetes mellitus)

CaseNotHPOFreeText: BP normal throughout, no hypertension. No storage or infiltrative disease on biopsy. Spirometry normal. Narrow QRS, so CRT not indicated.

CasePreviousTesting: 84-gene cardiomyopathy NGS panel (MYBPC3 100% coverage); MLPA confirmed true homozygosity rather than hemizygous deletion; Sanger cascade in 12 relatives.

Genotyping Method: NGS panel followed by MLPA confirmation of homozygosity; Sanger for family cascade.

FunctionalAnalysis: None performed. Biopsy showed interstitial fibrosis with hypertrophy and atrophy, no infiltrative disease. Dominant-negative mechanism proposed, untested.

Variant: MYBPC3 NM_000256.3:c.2618C>A (p.Pro873His); homozygous missense; C7 domain. (Paper writes "c.2618 G>A" once, C>A is correct.)

ClinVar: Not stated; conflicting interpretations noted in the literature. Pepper please verifiy for me!

CAID: Not reported

gnomAD: AF 0.00006781 (14/206,446; 13/97,288 European non-Finnish) per the authors.

AdditionalInfo: ACMG Class 2 (likely pathogenic) heterozygous. Authors argue homozygosity drove progression to end-stage failure; alternative triggers considered, prior myocarditis (1989) and the 2013 infarct; but judged insufficient to explain severity.

PMID: 29663722 Gene: MYBPC3 HGNC: HGNC:7551

Case: Patient III-3 (proband's granduncle; father of IV-2 and IV-3) DiseaseAssertion: Type 2A VWD, based on low plasma VWF:Ag and activity and lack of plasma HMW VWF multimers (diagnosis explicitly extended to this patient along with proband and IV-2, IV-3, IV-4). FamilyInfo: Granduncle of proband V-2; father of IV-2 and IV-3 (both also affected); part of 5-affected-member pedigree (Fig. 1). ParentalGenotype(s): NA — his own parents' (generation II) genotype status not reported. CasePresentingHPOs: HP:0012147 (Reduced quantity of VWF; VWF:Ag 21.6 U/dL), HP:0030129 (Impaired VWF:RCo; VWF:Rco 5.0 U/dL), HP:0030132 (Absence of large VWF multimers — plasma), HP:0003645 (Prolonged partial thromboplastin time; APTT 45.5 sec) CaseHPOFreeText: Described only generically as having "abnormal bleedings" / "similar clinical symptoms" to the proband — no itemized bleeding symptoms given for this individual specifically. FVIII:C 28.0 U/dL (nv 50-150). RIPA not tested (N/A). TT 16.7 sec and PT 14.0 sec both within normal range. CaseNOTHPOs: NA CaseNOTHPOFreeText: Platelet-associated VWF multimers normal (HMW multimers present) per the group finding covering this patient. CasePreviousTesting: Targeted confirmation of the familial VWF variant; not genome-wide. GenotypingMethod: Sanger sequencing/allele-specific analysis, same platform as proband. PreviouslyPublished: NA Gene: VWF Variant: Same novel heterozygous in-frame 6-bp deletion, exon 28, ΔD1529V1530 (VWF A2 domain) HGVS: c.4585_4590del (p.Asp1529_Val1530del) ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient V-2, Male, 9 years old (proband) DiseaseAssertion: Type 2A VWD, based on history of abnormal bleeding, low plasma VWF:Ag and activity, low FVIII:C, and lack of plasma HMW VWF multimers. FamilyInfo: Proband of a pedigree (Fig. 1) with 5 affected individuals (V-2, III-3, IV-2, IV-3, IV-4) across multiple generations, all carrying the same variant; unaffected father (IV-5) does not carry it. ParentalGenotype(s): Mother (IV-4) heterozygous for the variant, affected. Father (IV-5) does not carry the variant, unaffected (normal VWF:Ag 95.2 IU/dL, normal multimer pattern). CasePresentingHPOs: HP:0000421 (Epistaxis), HP:0001934 (Persistent bleeding after trauma — "prolonged bleedings from small wounds"), HP:0012147 (Reduced quantity of VWF; VWF:Ag 20.5 U/dL), HP:0030129 (Impaired VWF:RCo; VWF:Rco 6.2 U/dL), HP:0030132 (Absence of large VWF multimers — plasma), HP:0011871 (Impaired RIPA; 28.5%), HP:0003645 (Prolonged partial thromboplastin time; APTT 58.1 sec) CaseHPOFreeText: Frequent bruising, delayed wound healing (no matching HPO code in the approved list); FVIII:C 25.0 U/dL (nv 50-150); TT 16.7 sec and PT 14.2 sec both within normal range. CaseNOTHPOs: NA CaseNOTHPOFreeText: Platelet-associated VWF multimers were normal (HMW multimers present, indistinguishable from controls) despite the plasma multimer defect — supports a secretion defect rather than a synthesis defect. CasePreviousTesting: Not genome-wide; targeted VWF gene analysis — Sanger sequencing of all 52 exons and intron-exon boundaries of VWF using published primers, followed by allele-specific cloning (pMD18-T vector) and sequencing to resolve the heterozygous deletion. GenotypingMethod: Direct Sanger sequencing (Applied Biosystems 310 DNA analyzer) of all VWF exons/boundaries; PCR amplification and cloning of individual alleles into pMD18-T vector to confirm and characterize the heterozygous deletion. PreviouslyPublished: NA — first report of this variant/family. Gene: VWF Variant: Novel heterozygous in-frame 6-bp deletion in exon 28, removing residues D1529 and V1530 (ΔD1529V1530) in the VWF A2 domain. Functional studies (HEK293 transfection) showed the mutant is expressed but its secretion is markedly impaired (42±4% of WT in conditioned medium, p<0.01) with intracellular retention (174±29% of WT in cell lysate, p<0.05) and ER colocalization (PDI co-staining); co-transfection with WT VWF reduced WT secretion (61±16% of WT alone, p<0.05), indicating a dominant-negative effect. Classified as a "Group I" type 2A mechanism (impaired intracellular transport/secretion). HGVS: c.4585_4590del (p.Asp1529_Val1530del) — confirmed against the authors' GenBank submission (JN625247) and cross-validated against a real ClinVar-confirmed exon 28 variant ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient IV-3 (son of III-3; first cousin of proband's mother IV-4) DiseaseAssertion: Type 2A VWD, based on low plasma VWF:Ag and activity and lack of plasma HMW VWF multimers. FamilyInfo: Son of III-3 (proband's granduncle); first cousin of IV-4 (proband's mother); part of 5-affected-member pedigree (Fig. 1). ParentalGenotype(s): Father (III-3) heterozygous for the variant, affected. Mother's genotype not reported. CasePresentingHPOs: HP:0012147 (Reduced quantity of VWF; VWF:Ag 19.5 U/dL), HP:0030129 (Impaired VWF:RCo; VWF:Rco 7.6 U/dL), HP:0030132 (Absence of large VWF multimers — plasma), HP:0003645 (Prolonged partial thromboplastin time; APTT 45.2 sec) CaseHPOFreeText: Described only generically as having "abnormal bleedings" / "similar clinical symptoms" — no itemized bleeding symptoms given specifically for this individual. FVIII:C 29.0 U/dL (nv 50-150). RIPA not tested (N/A). TT 18.6 sec and PT 13.4 sec both within normal range. CaseNOTHPOs: NA CaseNOTHPOFreeText: Platelet-associated VWF multimers normal (HMW multimers present) per the group finding covering this patient. CasePreviousTesting: Targeted confirmation of the familial VWF variant; not genome-wide. GenotypingMethod: Sanger sequencing/allele-specific analysis, same platform as proband. PreviouslyPublished: NA Gene: VWF Variant: Same novel heterozygous in-frame 6-bp deletion, exon 28, ΔD1529V1530 (VWF A2 domain) HGVS: c.4585_4590del (p.Asp1529_Val1530del) ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient IV-4, Female (mother of proband V-2) DiseaseAssertion: Type 2A VWD, based on history of abnormal bleeding, low plasma VWF:Ag and activity, and lack of plasma HMW VWF multimers. FamilyInfo: Mother of proband V-2; part of 5-affected-member pedigree (Fig. 1). ParentalGenotype(s): Not described (her own parents' genotype status not reported in extracted text — see Figure 1). CasePresentingHPOs: HP:0000421 (Epistaxis), HP:0000132 (Menorrhagia), HP:0012147 (Reduced quantity of VWF; VWF:Ag 21.7 U/dL), HP:0030129 (Impaired VWF:RCo; VWF:Rco 5.0 U/dL), HP:0030132 (Absence of large VWF multimers — plasma), HP:0011871 (Impaired RIPA; 3.0%), HP:0003645 (Prolonged partial thromboplastin time; APTT 46.1 sec) CaseHPOFreeText: Anemia (secondary to menorrhagia; no matching HPO code in the approved list); FVIII:C not tested (N/A); TT 18.1 sec and PT 14.1 sec both within normal range. CaseNOTHPOs: NA CaseNOTHPOFreeText: Platelet VWF multimer status NOT tested for this patient ("Platelet samples were not available from IV-4") — do not assume the "normal platelet multimers" finding reported for the other four affected members applies here. CasePreviousTesting: Targeted confirmation of the familial VWF variant (not described as independent full 52-exon screening for this individual specifically); not genome-wide. GenotypingMethod: Sanger sequencing/allele-specific analysis, same platform as proband (Applied Biosystems 310 DNA analyzer). PreviouslyPublished: NA Gene: VWF Variant: Same novel heterozygous in-frame 6-bp deletion, exon 28, ΔD1529V1530 (VWF A2 domain) HGVS: c.4585_4590del (p.Asp1529_Val1530del) ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient IV-2 (daughter of III-3; first cousin of proband's mother IV-4) DiseaseAssertion: Type 2A VWD, based on low plasma VWF:Ag and activity and lack of plasma HMW VWF multimers. FamilyInfo: Daughter of III-3 (proband's granduncle); first cousin of IV-4 (proband's mother); part of 5-affected-member pedigree (Fig. 1). ParentalGenotype(s): Father (III-3) heterozygous for the variant, affected. Mother's genotype not reported. CasePresentingHPOs: HP:0012147 (Reduced quantity of VWF; VWF:Ag 30.4 U/dL), HP:0030129 (Impaired VWF:RCo; VWF:Rco 8.4 U/dL), HP:0030132 (Absence of large VWF multimers — plasma), HP:0003645 (Prolonged partial thromboplastin time; APTT 45.8 sec) CaseHPOFreeText: Described only generically as having "abnormal bleedings" / "similar clinical symptoms" — no itemized bleeding symptoms given specifically for this individual. FVIII:C 50.0 U/dL — at the exact lower limit of normal (nv 50-150), notably higher than the other affected members. RIPA not tested (N/A). TT 15.6 sec and PT 13.8 sec both within normal range. CaseNOTHPOs: NA CaseNOTHPOFreeText: Platelet-associated VWF multimers normal (HMW multimers present) per the group finding covering this patient. CasePreviousTesting: Targeted confirmation of the familial VWF variant; not genome-wide. GenotypingMethod: Sanger sequencing/allele-specific analysis, same platform as proband. PreviouslyPublished: NA Gene: VWF Variant: Same novel heterozygous in-frame 6-bp deletion, exon 28, ΔD1529V1530 (VWF A2 domain) HGVS: c.4585_4590del (p.Asp1529_Val1530del) ClinVarID: NA CAID: NA gnomAD: NA

Case: Rotz Proband, female, reported at birth

DiseaseAssertion: VWD2b

FamilyInfo: Mother was 30yo reported with new onset thrombocytopenia during labor, diagnosed with maternal ITP; mother also had history of menorrhagia and excessive bleeding with minor trauma; VWF profile revealed a Factor VIII activity=49 IU/dL, VWF antigen=32 IU/dL, and undetectable RCo

ParentalGenotype(s): mother also carried c.3964G>A unregistered variant

CasePresentingHPOs: HP:0001873, HP:0030132, HP:0000967, HP:0000421, HP:0001892, HP:0001903, HP:0001981

(thrombocytopenia, Absence of large von Willebrand factor multimers, Petechiae, epistaxis, abnormal bleeding, anemia, schistocyte)

CaseHPOFreeText: small hematoma at IV puncture site, platelet count was 9×109/L, ultrasound showed no hemorrhage, hemoglobin=7.6 g/dL

CaseNOTHPOs: HP:0012147, HP:0030129

(Reduced quantity of VWF, impaired ristocetin cofactor assay activity)

CaseNOTHPOFreeText: no unusual findings on physical exam

CasePreviousTesting: NA

GenotypingMethod: Sequencing of VWF exon 28

PreviouslyPublished: NA

Gene: VWF

Variant: c.3964G>A unregistered variant

HGVS: NA

ClinVarID: NA

CAID: NA

gnomAD: NA

Case4: (Proband CabGT-4), Female, age not specified, Caucasian

DiseaseAssertion: Glanzmann thrombasthenia

FamilyInfo: N/A

ParentalGenotype: N/A

CasePresentingHPOs: N/A

CaseHPOFreeText: N/A

CaseNotHPOs: N/A

ProteinExpression: Flow cytometry showed surface expression as 53% GPIIb and 66% GPIIIa

Platelet Aggregation: N/A

CasePreviousTesting: Promoter and exon sequences of aIIb and b3 genes were amplified and directly sequence

Gene: ITGA2B

Variant: c.1442-13_1442-1del (This variant does not show up in the CAR or ClinVar)

LegacyVariant: N/A

ClinVar: N/A

CAiD: N/A

gnomAD N/A

Case: Patient III-1, Male, 43 years (as of Dec 2010 follow-up) DiseaseAssertion: VWD type 2A, phenotype IIC ("VWD2AIIC-Miami"). Bleeding score 9 (elevated; nv <4). FamilyInfo: Son of II-3; part of 4-member, 2-generation pedigree, dominant transmission. ParentalGenotype(s): Mother (II-3) heterozygous for the variant, affected. Father's genotype not tested/not reported. CasePresentingHPOs: HP:0000421 (Epistaxis), HP:0001934 (Persistent bleeding after trauma — bleeding from minor wounds), HP:0004846 (Prolonged bleeding after surgery — post-surgical bleeding, bleeding at tooth extraction), HP:0030130 (Impaired VWF collagen binding activity; VWF:CB/Ag ratio 0.14, nv ≥0.8), HP:0030129 (Impaired VWF:RCo; VWF:RCo/Ag ratio 0.18, nv ≥0.8), HP:0030132 (Absence of large VWF multimers) CaseHPOFreeText: VWF:Ag markedly ELEVATED at 2.72× normal (nv 0.5-1.6) — highest of the four patients. Absolute VWF:RCo 0.40 and VWF:CB 0.37 (both below the ≥0.5 absolute threshold, so reduced in both absolute and ratio terms, unlike II-3). VWF:GPIbα binding 0.55 absolute / 0.20 ratio. FVIII:C 0.99 (normal, nv ≥0.6) with reduced FVIII-binding ratio (F8Br 0.49, nv ≥0.6). VWF propeptide:Ag ratio (ppr) 0.32, markedly reduced (nv 0.8-2.2). PFA-100 closure times markedly prolonged (both >300 sec). Hematoma and oral cavity bleeding also reported. No menorrhagia (not applicable, male). CaseNOTHPOs: NA CaseNOTHPOFreeText: NA CasePreviousTesting: Same family-wide testing history as Patient II-3 (extensive prior negative Sanger sequencing, causative variant found only via MLPA); not genome-wide. GenotypingMethod: Same as Patient II-3 — MLPA plus confirmatory RT-PCR/sequencing. PreviouslyPublished: PMID 8324222 (Ledford et al. 1993) — same family as originally reported. Gene: VWF Variant: Heterozygous complex in-frame duplication of VWF exons 9-10 (same variant as Patient II-3). HGVS: NM_000552.3:c.998_1156dup (p.Glu333_Pro385dup) ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient III-5, Female, 37 years (as of Dec 2010 follow-up) DiseaseAssertion: VWD type 2A, phenotype IIC ("VWD2AIIC-Miami"). Bleeding score not done (nd). FamilyInfo: Daughter of II-3; part of 4-member, 2-generation pedigree, dominant transmission. ParentalGenotype(s): Mother (II-3) heterozygous for the variant, affected. Father's genotype not tested/not reported. CasePresentingHPOs: HP:0030130 (Impaired VWF collagen binding activity; VWF:CB/Ag ratio 0.14, nv ≥0.8), HP:0030129 (Impaired VWF:RCo; VWF:RCo/Ag ratio 0.15, nv ≥0.8), HP:0030132 (Absence of large VWF multimers) CaseHPOFreeText: Specific bleeding symptoms not individually itemized in the text for this patient (her bleeding score was not done, and the itemized symptom list in the Results section explicitly covers only the three patients with bleeding scores recorded). Text states only that "all studied patients" including this one have "a significant bleeding tendency with typical mucocutaneous bleeding symptoms." VWF:Ag ELEVATED at 2.01× normal (nv 0.5-1.6). Absolute VWF:RCo 0.30 and VWF:CB 0.29 (both below the ≥0.5 absolute threshold). VWF:GPIbα binding 0.39 absolute / 0.19 ratio. FVIII:C 0.85 (normal, nv ≥0.6) with reduced FVIII-binding ratio (F8Br 0.44, nv ≥0.6). VWF propeptide:Ag ratio (ppr) 0.61, reduced (nv 0.8-2.2). PFA-100 closure times prolonged (Epinephrine >267 sec, ADP >278 sec). CaseNOTHPOs: NA CaseNOTHPOFreeText: NA CasePreviousTesting: Same family-wide testing history as Patient II-3; not genome-wide. GenotypingMethod: Same as Patient II-3 — MLPA plus confirmatory RT-PCR/sequencing. PreviouslyPublished: PMID 8324222 (Ledford et al. 1993) — same family as originally reported. Gene: VWF Variant: Heterozygous complex in-frame duplication of VWF exons 9-10 (same variant as Patient II-3). HGVS: NM_000552.3:c.998_1156dup (p.Glu333_Pro385dup) ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient III-3, Female, 41 years (as of Dec 2010 follow-up) DiseaseAssertion: VWD type 2A, phenotype IIC ("VWD2AIIC-Miami"). Bleeding score 14 (elevated; nv <4). FamilyInfo: Daughter of II-3; part of 4-member, 2-generation pedigree, dominant transmission. ParentalGenotype(s): Mother (II-3) heterozygous for the variant, affected. Father's genotype not tested/not reported. CasePresentingHPOs: HP:0000421 (Epistaxis), HP:0000132 (Menorrhagia), HP:0001934 (Persistent bleeding after trauma — bleeding from minor wounds), HP:0004846 (Prolonged bleeding after surgery — bleeding at tooth extraction), HP:0030130 (Impaired VWF collagen binding activity; VWF:CB/Ag ratio 0.12, nv ≥0.8), HP:0030129 (Impaired VWF:RCo; VWF:RCo/Ag ratio 0.15, nv ≥0.8), HP:0030132 (Absence of large VWF multimers) CaseHPOFreeText: VWF:Ag ELEVATED at 1.78× normal (nv 0.5-1.6) — least elevated of the four, though still above range. Absolute VWF:RCo 0.27 and VWF:CB 0.22 (both below the ≥0.5 absolute threshold). VWF:GPIbα binding 0.35 absolute / 0.20 ratio. FVIII:C 0.75 (normal, nv ≥0.6) with reduced FVIII-binding ratio (F8Br 0.50, nv ≥0.6). VWF propeptide:Ag ratio (ppr) 0.57, reduced (nv 0.8-2.2). PFA-100 closure times markedly prolonged (Epinephrine >300 sec, ADP >284 sec). No explicit mention of post-surgery bleeding for this patient specifically (unlike II-3 and III-1). CaseNOTHPOs: NA CaseNOTHPOFreeText: NA CasePreviousTesting: Same family-wide testing history as Patient II-3; not genome-wide. GenotypingMethod: Same as Patient II-3 — MLPA plus confirmatory RT-PCR/sequencing. PreviouslyPublished: PMID 8324222 (Ledford et al. 1993) — same family as originally reported. Gene: VWF Variant: Heterozygous complex in-frame duplication of VWF exons 9-10 (same variant as Patient II-3. HGVS: NM_000552.3:c.998_1156dup (p.Glu333_Pro385dup) ClinVarID: NA CAID: NA gnomAD: NA

Case: Patient II-3, Female, 67 years (as of Dec 2010 follow-up) DiseaseAssertion: VWD type 2A, phenotype IIC ("VWD2AIIC-Miami") — a historically named variant of type 2A characterized by paradoxically elevated VWF:Ag with reduced function; dominantly inherited in this family (unlike classic/most VWD2AIIC, which is recessive). Bleeding score 21 (very high; nv <4). FamilyInfo: Mother of III-1, III-3, and III-5 (all three affected); 4-member, 2-generation pedigree, dominant transmission. ParentalGenotype(s): NA — her own parents not part of this study. CasePresentingHPOs: HP:0000421 (Epistaxis), HP:0000132 (Menorrhagia), HP:0001934 (Persistent bleeding after trauma — bleeding from minor wounds), HP:0004846 (Prolonged bleeding after surgery — post-surgical bleeding, bleeding at tooth extraction), HP:0030130 (Impaired VWF collagen binding activity; VWF:CB/Ag ratio 0.18, nv ≥0.8), HP:0030129 (Impaired VWF:RCo; VWF:RCo/Ag ratio 0.22, nv ≥0.8), HP:0030132 (Absence of large VWF multimers) CaseHPOFreeText: VWF:Ag markedly ELEVATED at 2.50× normal (nv 0.5-1.6). Absolute VWF:RCo 0.54 and VWF:CB 0.46 (both near/within the lower end of normal in absolute terms, nv ≥0.5, but severely reduced relative to the elevated antigen). VWF:GPIbα binding 0.74 absolute / 0.30 ratio. FVIII:C 1.08 (normal, nv ≥0.6) with reduced FVIII-binding ratio (F8Br 0.61, at threshold, nv ≥0.6). VWF propeptide:Ag ratio (ppr) 0.71, reduced (nv 0.8-2.2) — indicates decreased clearance of mature VWF relative to propeptide. PFA-100 closure times markedly prolonged (Epinephrine and ADP both >300 sec, nv ≤165/≤118). Hematoma (bruising) and oral cavity bleeding also reported. Post-partum bleeding ultimately requiring hysterectomy. Historical DDAVP test performed in this patient specifically showed findings consistent with delayed VWF clearance. Oral contraceptive/desmopressin use not specified. CaseNOTHPOs: NA CaseNOTHPOFreeText: NA CasePreviousTesting: Extensive prior negative testing — partial sequencing in the original 1993 study plus subsequent complete Sanger sequencing of all VWF coding exons by multiple independent groups over ~20 years found no candidate mutation. The causative variant was only found via MLPA (multiplex ligation-dependent probe amplification), which detects copy-number changes that exon sequencing alone misses. Not genome-wide; VWF-targeted. GenotypingMethod: MLPA identified signal gain at exons 9-10 in all 4 family members; confirmed by duplication-junction-specific RT-PCR (sense primer in exon 10, antisense in exon 9) and by RT-PCR/sequencing across exons 8-11. Full genomic characterization (PCR primer walking, RepeatMasker, MFold in silico DNA-folding analysis) defined a complex rearrangement: a 5,047 bp duplication (intron 8 through part of intron 10, including exons 9 and 10) plus two deletions (1,348 bp and 2,301 bp) within intron 10, apparently mediated by inverted Alu repeat elements (proposed mechanism: replication slippage for the duplication, a stable Alu3/Alu4 inverted-repeat DNA secondary structure for the deletion). PreviouslyPublished: PMID 8324222 (Ledford MR, Rabinowitz I, Sadler JE, Kent JW, Civantos F. "New variant of von Willebrand disease type II with markedly increased levels of von Willebrand factor antigen and dominant mode of inheritance: von Willebrand disease type IIC Miami." Blood. 1993;82:169-75) — this is the original report of this same family. Gene: VWF Variant: Heterozygous complex in-frame duplication of VWF exons 9-10 (net transcript-level effect), D1 domain (VWF propeptide region). Recombinant expression studies (not patient-specific, applies to the variant generally): "homozygous" mutant VWF secreted only as dimers (no higher-order multimers); co-expression with WT VWF reproduced the patients' plasma multimer pattern exactly; mutant retained in unusually large intracellular granules colocalizing with PDI in the ER; ADAMTS13 proteolysis was not resistant, but an aberrant extra proteolytic band appeared in both patient plasma and recombinant mutant; infusion of recombinant mutant VWF into VWF-/- mice showed significantly prolonged half-life vs. WT (mean residence time 3.15h vs 1.90h, p=0.015), supporting decreased clearance as the mechanism for the paradoxically elevated VWF:Ag. HGVS: NM_000552.3:c.998_1156dup (p.Glu333_Pro385dup) ClinVarID: NA CAID: NA gnomAD: NA

Case#: 02069, Age 45, Female, Blood Type O+ (Table S3)

Disease Assertion: VWD 1

FamilyInfo: The patients was 1 of 3 members of family #0226.

Parental Genotype: Not listed

CasePresentingHPOs: N/A

CaseHPOFreeText: Bleeding Score 5, VWF:Ag: 30, VWF:RCo:27, FVIII:C: 81, VWF:CB: 40

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

Protein Expression: N/A

CasePreviousTesting: 48,48 Access-Array amplification. NGS Molecular analysis was performed. Sanger sequencing was used to validate selected mutations

Gene: VWF

Variant: NM_000552.4:c.3467C>T (p.Thr1156Met) and NM_000552.3:c.-3151T>G

ClinVar: 100264 ClinVar

CAID: CA228414 CAID

gnomAD: N/A

Case#: 03044, Age 27, Female (Table S3)

Disease Assertion: VWD 1

FamilyInfo: Patient was the only member of family #03230

Parental Genotype: not listed

CasePresentingHPOs: N/A

CaseHPOFreeText: Bleeding Score 3, VWF:Ag: 22, VWF:RCo:18, FVIIIC:29, VWF:CB: 17

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

Protein Expression: N/A

CasePreviousTesting: 48,48 Access-Array amplification. NGS Molecular analysis was performed. Sanger sequencing was used to validate selected mutations

Gene: VWF

Variant: c.6699_6702dup (p.Cys2235ArgfsTer8)

ClinVar:

CAID:

gnomAD:

Case#: 36004, Age 69, Female, Blood Type O- (Table S3)

Disease Assertion: VWD 1

FamilyInfo: The patient is the only member of Family#3603.

Parental Genotype: Not listed

CasePresentingHPOs: N/A

CaseHPOFreeText: VWF:Ag: 22, VWF:RCo:18.5, FVIII:C: 19, VWF:CB: 19

CaseNotHPOs: N/A

CaseNotHPOFreeText: Bleeding Score 3

Protein Expression: N/A

CasePreviousTesting: 48,48 Access-Array amplification. NGS Molecular analysis was performed. Sanger sequencing was used to validate selected mutations.

Gene: VWF

Variant: NM_000552.4:c.2546+55G>T (p.=)

ClinVar: N/A

CAID: N/A

gnomAD: N/A

Case#: 03035, Age 51, Male (Table S3)

Disease Assertion: VWD1

FamilyInfo: A part of family #03150 along with two other patients.

Parental Genotype: Not listed

CasePresentingHPOs: Not listed

CaseHPOFreeText: Bleeding Score 4, VWF:Ag: 34, VWF:RCo: 26, FVIII:C: 43, VWF:CB 33

CaseNotHPOs: N/A

CaseNotHPOFreeText: N/A

Protein Expression:N/A

CasePreviousTesting: 48,48 Access-Array amplification. NGS Molecular analysis was performed. Sanger sequencing was used to validate selected mutations

Gene: VWF

Variant: NM_000552.4:c.3467C>T (p.Thr1156Met) and NM_000552.3:c.-3151T>G

ClinVar: 100264 ClinVar

CAID: CA228414 CAID

gnomAD: N/A

PMID: 36468906

Gene: VWF

HGNCID: 12726

Case: 6 year old boy living in Croatia

DiseaseAssertion: type 1 VWD

FamilyInfo: family history of bleeding disorders

CasePresentingHPOs: HP:0000421, HP:0011889, HP:0000978, HP:0008151

CaseHPOFreeRext: VWF:GPIbM = 23.6% (decreased), VWF"Ag = 24.7% (decreased), VWF:GPIbM/VWF:Ag (ratio) = 0.96, FVIII = 54.0% (normal), VWF:CB = 24.2% (decreased)

GenotypingMethod: NGS, MLPA

Gene: VWF

Variant: heterozygous deletion of exons 1-6 within the VWF gene

Case: P39,Chinese, female, 21yo

DiseaseAssertion: VWD1

FamilyInfo: NA

ParentalGenotype(s): NA

CasePresentingHPOs: HP:0012147

(Reduced quantity of VWF)

CaseHPOFreeText: type O blood, bleeding score = 10; VWF:Ag (%) = 13.0, VWF:RCo (%) = 14.3, FVIII:C (%) = 32.1, VWF:CB (%) = 12.9, VWFpp (%) = 12.1, VWF:RCo/VWF:Ag = 1.1, VWF:CB/VWF:Ag = 1.0, VWFpp/VWF:Ag = 0.9, FVIII:C/VWF:Ag = 2.5

CaseNOTHPOs:

CaseNOTHPOFreeText:

CasePreviousTesting: NA

GenotypingMethod: NGS

PreviouslyPublished: NA

Gene: VWF

Variant: c.8116-2delA

HGVS: NA

ClinVarID: NA

CAID: NA

gnomAD: NA

Case: P54, Chinese, female, 30yo

DiseaseAssertion: VWD2A

FamilyInfo: both parents had mild type 1 VWD, a second undetected variant may exist in patient

ParentalGenotype(s): NA

CasePresentingHPOs: HP:0012147

(Reduced quantity of VWF)

CaseHPOFreeText: type A blood, bleeding score = 4; VWF:Ag (%) = 27.0, VWF:RCo (%) = 1.8, FVIII:C (%) = 44.6, VWF:CB (%) = 1.1, VWFpp (%) = 11.2, VWF:RCo/VWF:Ag = 0.1, VWF:CB/VWF:Ag = 0.0, VWFpp/VWF:Ag = 0.4, FVIII:C/VWF:Ag = 1.7

CaseNOTHPOs:

CaseNOTHPOFreeText:

CasePreviousTesting: NA

GenotypingMethod: NGS

PreviouslyPublished: NA

Gene: VWF

Variant: c.875–5T>G - Unregistered Variant

HGVS: NA

ClinVarID: NA

CAID: NA

gnomAD: NA

Case: P42, Chinese, male, 10yo

DiseaseAssertion: VWD1

FamilyInfo: NA

ParentalGenotype(s): NA

CasePresentingHPOs: HP:0012147

(Reduced quantity of VWF)

CaseHPOFreeText: type O blood, bleeding score = 1; VWF:Ag (%) = 41.9, VWF:RCo (%) = 33.9, FVIII:C (%) = 54.7, VWF:CB (%) = 46.8, VWFpp (%) = 34.6, VWF:RCo/VWF:Ag = 1.0, VWF:CB/VWF:Ag = 1.1, VWFpp/VWF:Ag = 0.8, FVIII:C/VWF:Ag = 1.3

CaseNOTHPOs:

CaseNOTHPOFreeText:

CasePreviousTesting: NA

GenotypingMethod: NGS

PreviouslyPublished: NA

Gene: VWF

Variant: c.-672C>T

HGVS: NA

ClinVarID: NA

CAID: NA

gnomAD: NA

Case#: Elayaperumal_2018_V-290 , Male, 7 months (onset), origin in India

DiseaseAssertion: VWD type 3

FamilyInfo: no consanguinity reported. positive family history

ParentalGenotype: not reported

CasePresentingHPOs:

CaseHPOFreeText: bleeding score of 12, VWF:Ag 0, FVIII:C 9.2%

CaseNotHPOs:

CaseNotHPOFreeText:

CasePreviousTesting: not reported

GenotypingMethod: CSGE and Sanger sequencing of VWF gene only.

Gene: VWF

Variant: heterozygous c.6798+1G>C

HGVS: NM_000552.3:c.6798+1G>C

ClinVarID: not found

CAID: CA383489728

gnomAD: not found

MultipleGeneVariants:

Note: other allele not identified. Large deletion possible.

Case#: Case1, Sex:Female, Age:35

DiseaseAssertion: STGD

FamilyInfo: n/a

CasePresentingHPOs: n/a

CaseHPOFreeText: Clinical Notes: the patient reported an ocular trauma in the right eye, which required hospitalization and caused sudden loss of vision at the age of 9 years. In 1998, at our first observation, visual acuity was 20/1,000 in the right eye and 20/600 in the left eye.

CaseNotHPOs:n/a

CaseNotHPOFreeText: n/a

Genotyping Method: genetic analysis

PreviouslyPublished: n/a

Variant: Variant is a heterozygous mutation given as (N965S/G1961E); NM_000350.3(ABCA4):c.2894A>G (p.Asn965Ser) /NM_000350.3(ABCA4):c.5882G>A (p.Gly1961Glu)

ClinVar: Variation ID: 236096 / Variation ID: 7888

SupplementalData: n/a

Case#:Patient 52, female, 3 years old

DiseaseAssertion:Neonatal/Infantile Epileptic Encephalopathy (NIEE)

FamilyInfo:DeNovo. The family is Chinese

ParentalGenotype:The authors only conducted singleton and not trio-based exome sequencing so the parents' exomes were not sequenced.

CasePresentingHPOs:HP:0011344, HP:0002069, HP:0007359, HP:0011097, HP:0100704, HP:0001332, HP:0002072, HP:0012171.

CaseHPOFreeText:Patient 52 presents with severe global developmental delay and epilepsy.

Patient 52 has generalized tonic/clonic/tonic-clonic seizures, focal seizures and spasms. Patient 52's seizure onset occurred at 3 months old.

Patient 52 has cortical visual impairment (CVI), dystonia, chorea, and hand-washing sterotypies.

Patient History

@ 3 months - Patient 52 had generalized tonic/clonic/tonic-clonic seizures.

Patient 52 was on 3 antiepileptic drugs at most recent follow-up visit which reduced seizure frequency by >50%.

CaseNotHPOs:Not provided

CaseNotHPOFreeText:Not provided

CasePreviousTesting:The authors selected a cohort of 31 patients with seizure cryptogenic Neonatal/Infantile Epileptic Encephalopathy (NIEE) and seizure onset before 24 months.

Exclusion criteria included: (1) Patients with a definite history of brain insult, malformation of cortical development, neurocutaneous and syndromal disorders, and confirmed or highly suspected neurometabolic disorders based on clinical and biochemical markers. (2) Patients with Dravet syndrome and epilepsy at infancy with migrating focal seizure were also excluded because the majority of variants are detected in the SCN1A (>85%) and KCNT1 (approximately 50%) genes.

Formal neuropsychological testing or best clinical assessment was used to classify patient development or intelligence.

PreviouslyPublished:Not previously published

GenotypingMethod:Whole Exome Sequencing (WES) variant results were filtered in a panel of 430 epilepsy-associated genes. After selection of variants from the 430-gene panel, the synonymous variants, variants with variant frequency <10%, and variants with allele frequency >1% were removed.

Gene:CDKL5

Variant:NM_003159.2 c. 1849delC (p. Arg617Valfs*4)

The authors state that the variant is a heterozygous frameshift deletion.

The authors state that this is a novel variant and is pathogenic.

HGVS:Not provided

ClinVarID:Not found

CAID:Not found.

gnomAD:Not found

MultipleGeneVariants:Not provided