Case: Female, 19 y.o., ethnicity unknown.

DiseaseAssertion: VWD2N

FamilyInfo: Proband has one older symptomatic sister who shares an identical compound heterozygous genotype, presenting with a mild bleeding tendency, reduced FVIII activity (20-30%), and severely reduced FVIII binding (<2%). The family features one younger unaffected sister who tested negative for both variants, and an unaffected carrier mother. Both parents had normal factor VIII, and there was no male relative with reduced factor VIII or bleeding symptoms.

ParentalGenotype(s): Mother is heterozygous for the c.2561G>A (p.R854Q) variant, negative for the c.2402G>A (p.S801N) variant, and has normal baseline factor VIII levels, confirming the sisters' variants are in trans. Father unavailable/not tested.

CasePresentingHPOs: HP:0004846 (Prolonged bleeding after surgery), HP:0003645 (Prolonged partial thromboplastin time).

CaseHPOFreeText: Index patient experienced bleeding complications following wisdom tooth surgery. Factor VIII binding activity is reduced at 32%. Reduced coagulation factor VIII activity (30%). Prolonged activated partial thromboplastin time (aPTT) of 37 seconds.

CaseNOTHPOs: HP:0001873 (Thrombocytopenia), HP:0012147 (Reduced quantity of von Willebrand factor), HP:0030130 (Impaired von Willebrand factor collagen binding activity).

CaseNOTHPOFreeText: Normal vWF antigen (vWF:Ag) levels (101%), normal vWF activity (116%), normal vWF-collagen-binding activity (104%), normal vWF multimer distribution structures, normal hemoglobin level (128 g/L), and normal Prothrombin Time (PT/QUICK) of 83%.

CasePreviousTesting: Siblings did not carry any known mutations in the F8 gene or the LMAN1 and MCFD2 genes (which encode for endoplasmic reticulum carrier proteins of coagulation factors V and VIII).

GenotypingMethod: Direct sequence analysis of VWF exons 18-20.

PreviouslyPublished: NA.

Gene: VWF

HGNCID: HGNC:12726

Variant: Heterozygous c.2561G>A (p.R854Q) and heterozygous c.2402G>A (p.S801N).

HGVS: (1) NM_000552.5:c.2561G>A (p.Arg854Gln) (2) NM_000552.5:c.2402G>A (p.Ser801Asn)

ClinVarID: (1) 296 (2) NA

CAID: (1) NA (2) CA383522023

gnomAD: (1) MAF of 0.005974 in the European (non-Finnish) population https://gnomad.broadinstitute.org/variant/12-6034812-C-T?dataset=gnomad_r4

(2) MAF of 0.00001098 in the South Asian population https://gnomad.broadinstitute.org/variant/12-6044331-C-T?dataset=gnomad_r4

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-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: 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: IP-2

DiseaseAssertion: VWD3

FamilyInfo: The mother reported no history of bleeding episodes and the laboratory data were in the border line of the normal range.

ParentalGenotype(s): mother is heterozygous for the p.Gln2551AlafsX16 in the VWF gene

CasePresentingHPOs: HP:0000421

CaseHPOFreeRext: VWF:Ag <6%, VWF:RCo <6% and FVIII:C 2%. Clinically, repetitive severe epistaxis and subcutaneous hematomas were observed.

CaseNOTHPOs:

CaseNOTHPOFreeText:

CasePreviousTesting: Direct sequencing of exons 2–52 including exon/intron boundaries of the VWF gene

GenotypingMethod: multiple ligation‐dependent probe amplification (MLPA; using kit P011 and P012; MRC Holland, Amsterdam, the Netherlands) according to the manufacturer’s instructions. The PCR products were run on an ABI PRISM 3130XL sequencer with the GeneScan 500 LIZ size standard and analyzed using GeneMapper Software 5.0 (Applied Biosystems, Darmstadt, Germany).

PreviouslyPublished: NA

Gene: VWF

Variant: p.Gln2551AlafsX16

HGVS:

ClinVarID:

CAID:

gnomAD:

MultipleGeneVariants:

GeneName: VWF

Variant: whole gene deletion

ClinVarID or CAID:

gnomAD:

Gene:VWF

HGNCID:12726

Case:Preterm female newborn delivered by C/S

DiseaseAssertion:VWD Type 2B

FamilyInfo:Fig. 1 Father with VWD 2B and two paternal half-brothers diagnosed with hematomas after birth

ParentalGenotype(s):heterozygous carrier p.(Val1316Met) confirmed in the father, half-brothers were not tested

CasePresentingHPOs: HP:0001873, HP:0012147

CaseHPOFreeRext:Multiple hematomas, no cerebral hemorrhage

CaseNOTHPOs:HP:0030130

CaseNOTHPOFreeText:analyses showed reduced VWF activity levels (40% at postnatal day 7), whereas VWF antigen was normal (146% at postnatal day 7)

CasePreviousTesting:No . Gene:VWF

Variant:p.Val1316Met

HGVS:NM_000552.4:c.3946G>A

ClinVarID:290

CAID:CA114127

gnomAD:6.20e-7

Case:Patient 1, Male, 4 y/o, German and Thai

DiseaseAssertion:FOXG1 syndrome

FamilyInfo: Non-consanguineous parents. De novo. Patient 1 has maternally inherited duplications at 15q21.12(47292250-47309868)x3 and Xp22.31(6451676-8115124)x3 of unknown clinical significance.

ParentalGenotype:Not provided

CasePresentingHPOs:HP:0002197, HP:0005484, HP:0011344, HP:0001252, HP:0020045,HP:0000540, HP:0010808, HP:0002019, HP:0003781, HP:0012741, HP:0002421, HP:0000748, HP:0003763, HP:5200017, HP:0025112, HP:0000957

CaseHPOFreeText: At 19 months, could not sit independently and no speech development. Stereotypic hand and head movements. High pain tolerance. X-ray at age 2 showed broad ribs. Improved head control by age 4.

CaseNotHPO:HP:0410263, HP:0002376

CaseNotHPOFreeText:Dysmorphic features. breathing abnormalities

CasePreviousTesting:No previous testing

PreviouslyPublished:Not previously published

GenotypingMethod:Mate-pair sequencing, Sanger sequencing

Gene:FOXG1

Variant:46,XY,t(9;14)(q22.3;q11.2)dn

HGVS:Not provided

ClinVarID:426096

gnomAD:Not provided

Case#:Patient 7, male, 5 years old

DiseaseAssertion:Neonatal/Infantile Epileptic Encephalopathy (NIEE)

FamilyInfo:The family is French/Chinese

ParentalGenotype:The variant was inherited from Patient 7's asymptomatic mother.

CasePresentingHPOs:HP:0010864, HP:0012758, HP:0000729, HP:0007359, HP:0002069, HP:0032794, HP:0001250, HP:0000252.

CaseHPOFreeText:Patient 7 presents with severe intellectual disability, developmental slowdown, and various seizure types. Patient 7 has Autistic Spectrum Disorder (ASD) and microcephaly.

Patient History

@ 12 months - Patient 7 presented with seizures.

Patient 7 developed additional seizure types including: focal seizures with/without generalization, generalized tonic/clonic/tonic-clonic seizures, myoclonic seizures, and hypomotor seizures.

Patient 7 was on two antiepileptic drugs at most recent followup 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:SLC9A6

Variant:Hemizygous splice site NM_001042537.1 c. 794-2A>G was assessed by the authors to be likely pathogenic.

HGVS:Not provided

ClinVarID:Not found

CAID:CA414750320

gnomAD:Not found

MultipleGeneVariants:Not provided