# Rare Duplication in the RYR1 Gene Causing Malignant Hyperthermia and Clinical Variability

## TL;DR

A rare duplication in the RYR1 gene is linked to malignant hyperthermia and contributes to variable disease severity.

## Contribution

This study reclassifies a rare RYR1 duplication as a borderline likely pathogenic variant and explores its impact on disease severity.

## Key findings

- A rare in-frame duplication in RYR1 was found in two siblings with malignant hyperthermia.
- The duplication was associated with a 50% reduction in RYR1 mRNA expression, suggesting a hypomorphic allele.
- The study suggests that small insertions in RYR1 can lead to structural defects and severe clinical outcomes.

## Abstract

Background/Objectives: Variants in the RYR1 gene are associated mainly with Malignant Hyperthermia. Missense variants are largely the most common, while insertions and duplications account for less than 10%. We aimed to investigate the effect of a rare duplication in the RYR1 gene with the variability of the Malignant Hyperthermia susceptibility phenotype. Methods: We used exome variant screening, in vitro contracture test, anatomopathological examination of the muscle biopsy, RT-qPCR analysis for RYR1 relative expression. Results: We identified a family with two affected siblings carrying an insertion of 18 pair bases in exon 91 of the RYR1 gene, resulting in an in-frame duplication of 6 amino acids (c.12835_12852 dupGAGGGCGCGGCGGGGCTC: 162 p.G4279_T4284insAAGLEG). This variant was found at a frequency of 0.0007% in gnomAD and was absent in 1200 Brazilian controls. First classified as a Variant of Uncertain Significance (VUS), with the molecular and physiological data from our family, we were able to reclassify it, reaching 5 points, which is still a VUS but borderline likely pathogenic. Muscle relative mRNA expression of RYR1 in the two patients identified a ~50% reduction, suggesting a possible hypomorphic allele. Conclusions: The pathomechanisms of RYR1 gene variants in Malignant Hyperthermia are mainly associated with gain-of-function mechanisms, but small insertions can often lead to loss of function or improper folding protein. This study adds evidence to the possibility that duplication in this region can cause structural defects and a more severe phenotype in the patients.