# Real-world evidence: Risdiplam in a patient with spinal muscular atrophy type I with a novel splicing mutation and one SMN2 copy

## TL;DR

This paper reports a case of a patient with spinal muscular atrophy type I who showed improvement after treatment with risdiplam, despite having only one SMN2 gene copy.

## Contribution

The study is the first to report risdiplam treatment in a patient with only one SMN2 copy in a real-world setting.

## Key findings

- The patient had a novel splice mutation in SMN1 that led to a mild clinical phenotype despite having only one SMN2 copy.
- Risdiplam treatment resulted in significant clinical improvement in the patient over 7 months.
- The mutation caused alternative splicing, which explains the milder SMA phenotype.

## Abstract

Spinal muscular atrophy (SMA), which results from the deletion or/and mutation in the SMN1 gene, is an autosomal recessive neuromuscular disorder that leads to weakness and muscle atrophy. SMN2 is a paralogous gene of SMN1. SMN2 copy number affects the severity of SMA, but its role in patients treated with disease modifying therapies is unclear. The most appropriate individualized treatment for SMA has not yet been determined. Here, we reported a case of SMA type I with normal breathing and swallowing function. We genetically confirmed that this patient had a compound heterozygous variant: one deleted SMN1 allele and a novel splice mutation c.628-3T>G in the retained allele, with one SMN2 copy. Patient-derived sequencing of 4 SMN1 cDNA clones showed that this intronic single transversion mutation results in an alternative exon (e)5 3′ splice site, which leads to an additional 2 nucleotides (AG) at the 5′ end of e5, thereby explaining why the patient with only one copy of SMN2 had a mild clinical phenotype. Additionally, a minigene assay of wild type and mutant SMN1 in HEK293T cells also demonstrated that this transversion mutation induced e5 skipping. Considering treatment cost and goals of avoiding pain caused by injections and starting treatment as early as possible, risdiplam was prescribed for this patient. However, the patient showed remarkable clinical improvements after treatment with risdiplam for 7 months despite carrying only one copy of SMN2. This study is the first report on the treatment of risdiplam in a patient with one SMN2 copy in a real-world setting. These findings expand the mutation spectrum of SMA and provide accurate genetic counseling information, as well as clarify the molecular mechanism of careful genotype–phenotype correlation of the patient.