Introduction: Zhu-Tokita-Takenouchi-Kim (ZTTK) syndrome is a rare multisystemic congenital disorder caused by SON gene variants. This study aimed to present the results of whole exome sequencing, and describe some rare findings observed in the proband. Case Presentation: An 11-year-old boy exhibited hypotonia, poor growth, short stature, and microcephaly. The patient displayed various neurological symptoms, such as developmental delay, seizures, hydrocephalus, and brain abnormalities. He presented with strabismus, urinary problems, and facial dysmorphism. A history of stroke, obsession, insomnia, self-injurious behavior, and hearing loss was also noted. Based on the patient’s clinical findings, whole exome sequencing was performed. A novel variant in the SON gene was identified. This variant was confirmed by Sanger sequencing. Notably, the parents tested normal for the variant. Conclusion: This study presents a patient who exhibited a wide range of behavioral abnormalities, stroke, and recurrent urolithiasis – features that are rarely reported in ZTTK syndrome – and includes a review of the literature.

1.
Gilissen
C
,
Hehir-Kwa
JY
,
Thung
DT
,
van de Vorst
M
,
van Bon
BW
,
Willemsen
MH
, et al
.
Genome sequencing identifies major causes of severe intellectual disability
.
Nature
.
2014
;
511
(
7509
):
344
7
.
2.
Tokita
MJ
,
Braxton
AA
,
Shao
Y
,
Lewis
AM
,
Vincent
M
,
Küry
S
, et al
.
De novo truncating variants in SON cause intellectual disability, congenital malformations, and failure to thrive
.
Am J Hum Genet
.
2016
;
99
(
3
):
720
7
.
3.
Takenouchi
T
,
Miura
K
,
Uehara
T
,
Mizuno
S
,
Kosaki
K
.
Establishing SON in 21q22. 11 as a cause a new syndromic form of intellectual disability: possible contribution to Braddock–Carey syndrome phenotype
.
Am J Med Genet
.
2016
;
170
(
10
):
2587
90
.
4.
Kim
J-H
,
Shinde
DN
,
Reijnders
MR
,
Hauser
NS
,
Belmonte
RL
,
Wilson
GR
, et al
.
De novo mutations in SON disrupt RNA splicing of genes essential for brain development and metabolism, causing an intellectual-disability syndrome
.
Am J Hum Genet
.
2016
;
99
(
3
):
711
9
.
5.
Zhu
X
,
Petrovski
S
,
Xie
P
,
Ruzzo
EK
,
Lu
Y-F
,
McSweeney
KM
, et al
.
Whole-exome sequencing in undiagnosed genetic diseases: interpreting 119 trios
.
Genet Med
.
2015
;
17
(
10
):
774
81
.
6.
Kim
J-H
,
Park
EY
,
Chitayat
D
,
Stachura
DL
,
Schaper
J
,
Lindstrom
K
, et al
.
SON haploinsufficiency causes impaired pre-mRNA splicing of CAKUT genes and heterogeneous renal phenotypes
.
Kidney Int
.
2019
;
95
(
6
):
1494
504
.
7.
Richards
S
,
Aziz
N
,
Bale
S
,
Bick
D
,
Das
S
,
Gastier-Foster
J
, et al
.
Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of medical genetics and genomics and the association for molecular Pathology
.
Genet Med
.
2015
;
17
(
5
):
405
24
.
8.
Kushary
ST
,
Revah-Politi
A
,
Barua
S
,
Ganapathi
M
,
Accogli
A
,
Aggarwal
V
, et al
.
ZTTK syndrome: clinical and molecular findings of 15 cases and a review of the literature
.
Am J Med Genet
.
2021
;
185
(
12
):
3740
53
.
9.
Tang
S
,
You
J
,
Liu
L
,
Ouyang
H
,
Jiang
N
,
Duan
J
, et al
.
Expanding the mutational spectrum of ZTTK syndrome: A de novo variant with global developmental delay and malnutrition in a Chinese patient
.
Mol Genet Genomic Med
.
2023
;
11
(
8
):
e2188
.
10.
Yang
Y
,
Xu
L
,
Yu
Z
,
Huang
H
,
Yang
L
.
Clinical and genetic analysis of ZTTK syndrome caused by SON heterozygous mutation c.394C>T
.
Mol Genet Genomic Med
.
2019
;
7
(
11
):
e953
.
11.
Quintana Castanedo
L
,
Sánchez Orta
A
,
Maseda Pedrero
R
,
Santos Simarro
F
,
Palomares Bralo
M
,
Feito Rodríguez
M
, et al
.
Skin and nails abnormalities in a patient with ZTTK syndrome and a de novo mutation in SON
.
Pediatr Dermatol
.
2020
;
37
(
3
):
517
9
.
12.
Yang
L
,
Yang
F
.
A de novo heterozygous variant in the SON gene is associated with Zhu-Tokita-Takenouchi-Kim syndrome
.
Mol Genet Genomic Med
.
2020
;
8
(
11
):
e1496
.
13.
Slezak
R
,
Smigiel
R
,
Rydzanicz
M
,
Pollak
A
,
Kosinska
J
,
Stawinski
P
, et al
.
Phenotypic expansion in Zhu-Tokita-Takenouchi-Kim syndrome caused by de novo variants in the SON gene
.
Mol Genet Genomic Med
.
2020
;
8
(
10
):
e1432
.
14.
Tan
Y
,
Duan
L
,
Yang
K
,
Liu
Q
,
Wang
J
,
Dong
Z
, et al
.
A novel frameshift variant in SON causes Zhu-Tokita-Takenouchi-Kim Syndrome
.
J Clin Lab Anal
.
2020
;
34
(
8
):
e23326
.
15.
Peng
F
,
Zhu
L
,
Hou
Y
,
Gu
R
,
Wang
Y
,
Wen
X
, et al
.
Identification of a frameshift mutation in SON gene via whole exome sequencing in a patient with ZTTK syndrome
.
Research Square
.
2021
.
16.
Dingemans
AJM
,
Truijen
KMG
,
Kim
JH
,
Alaçam
Z
,
Faivre
L
,
Collins
KM
, et al
.
Establishing the phenotypic spectrum of ZTTK syndrome by analysis of 52 individuals with variants in SON
.
Eur J Hum Genet
.
2022
;
30
(
3
):
271
81
.
17.
Yi
Z
,
Song
Z
,
Li
F
,
Yang
C
,
Xue
J
,
Li
L
, et al
.
A novel de novo frameshift variation in the SON gene causing severe global developmental delay and seizures in a Chinese female
.
Int J Dev Neurosci
.
2022
;
82
(
3
):
271
6
.
18.
Pavone
P
,
Saia
F
,
Pappalardo
X
,
Barbagallo
M
,
Prato
A
,
Rizzo
R
.
Novel malformations: chiari type 1 and hydrocephalus in Zhu-Tokita-Takenouchi-Kim syndrome and novel SON variants
.
Clin Case Rep
.
2022
;
10
(
12
):
e6529
.
19.
Eid
M
,
Bhatia
S
.
Novel de novo heterozygous variants in the SON gene causing ZTTK syndrome: a case report of two patients and review of neurological findings
.
Child Neurol Open
.
2022
;
9
:
2329048x221119658
.
20.
Hudec
J
,
Kosinova
M
.
Anesthesia of the patient with zhu-tokita-takenouchi-kim (ZTTK) syndrome: a case report
.
Children
.
2022
;
9
(
6
):
869
.
21.
El-Said
A
,
Morales
JL
,
Rossi
G
,
Longani
N
.
Metabolic stroke as a clinical manifestation of zhu-tokita-takenouchi-kim syndrome: a case series
.
Neurol Genet
.
2023
;
9
(
3
):
e200072
.
22.
Langford
J
,
Vukadin
L
,
Carey
JC
,
Botto
LD
,
Velinder
M
,
Mao
R
, et al
.
SON-related zhu-tokita-takenouchi-kim syndrome with recurrent hemiplegic migraine: putative role of PRRT2
.
Neurol Genet
.
2023
;
9
(
3
):
e200062
.
23.
Vasquez-Forero
DM
,
Masotto
B
,
Ferrer-Avargues
R
,
Moya
CM
,
Pachajoa
H
.
Case report: a novel SON mutation in a Colombian patient with ZTTK syndrome
.
Front Genet
.
2023
;
14
:
1183362
.
24.
Pietrobattista
A
,
Della Volpe
L
,
Francalanci
P
,
Figà Talamanca
L
,
Monti
L
,
Lepri
FR
, et al
.
The expanding phenotype of ZTTK syndrome due to the heterozygous variant of SON gene focusing on liver involvement: patient report and literature review
.
Genes
.
2023
;
14
(
3
):
739
.
25.
Ueda
M
,
Matsuki
T
,
Fukada
M
,
Eda
S
,
Toya
A
,
Iio
A
, et al
.
Knockdown of Son, a mouse homologue of the ZTTK syndrome gene, causes neuronal migration defects and dendritic spine abnormalities
.
Mol Brain
.
2020
;
13
(
1
):
80
.
26.
Jo
YH
,
Choi
SH
,
Yoo
HW
,
Kwak
MJ
,
Park
KH
,
Kong
J
, et al
.
Clinical use of whole exome sequencing in children with developmental delay/intellectual disability
.
Pediatr Neonatol
.
2024
;
65
(
5
):
445
50
.
27.
Vasudevan
P
,
Suri
M
.
A clinical approach to developmental delay and intellectual disability
.
Clin Med
.
2017
;
17
(
6
):
558
61
.
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