3-methylglutaconic aciduria (3-MGCA) is a biochemical finding in a diverse group of inherited metabolic disorders. Conditions manifesting 3-MGCA are classified into two major categories, primary and secondary. Primary 3-MGCAs involve two inherited enzymatic deficiencies affecting leucine catabolism, whereas secondary 3-MGCAs comprise a larger heterogeneous group of conditions that have in common compromised mitochondrial energy metabolism. Here, we report 3-MGCA in two siblings presenting with sensorineural hearing loss and neurological abnormalities associated with a novel, homozygous missense variant (c.1999C>G, p.Leu667Val) in the YME1L1 gene which encodes a mitochondrial ATP-dependent metalloprotease. We show that the identified variant results in compromised YME1L1 function, as evidenced by abnormal proteolytic processing of substrate proteins, such as OPA1 and PRELID1. Consistent with the aberrant processing of the mitochondrial fusion protein OPA1, we demonstrate enhanced mitochondrial fission and fragmentation of the mitochondrial network in patient-derived fibroblasts. Furthermore, our results indicate that YME1L1L667V is associated with attenuated activity of rate-limiting Krebs cycle enzymes and reduced mitochondrial respiration, which may explain the build-up of 3-methylglutaconic and 3-methylglutaric acid due to the diversion of acetyl-CoA, not efficiently processed in the Krebs cycle, towards the formation of 3-methylglutaconyl-CoA, the precursor of these metabolites. In summary, our findings classify YME1L1 deficiency as a new type of secondary 3-MGCA, thus expanding the genetic landscape and facilitating the diagnosis of inherited metabolic disorders featuring this biochemical phenotype.

Biochemical Genetics Department The Cyprus Institute of Neurology and Genetics Nicosia Cyprus

Cytogenetics and Genomics Department The Cyprus Institute of Neurology and Genetics Nicosia Cyprus

Department of Paediatrics and Inherited Metabolic Disorders 1st Faculty of Medicine Charles University General University Hospital Prague Czech Republic

Department of Paediatrics Inborn Errors of Metabolism Clinic Archbishop Makarios 3 Hospital State Health Services Organisation Nicosia Cyprus

Karaiskakio Foundation Nicosia Cyprus and Archbishop Makarios 3 Hospital State Health Services Organisation Nicosia Cyprus

Neolab SA Medical Laboratory Athens Greece

Paediatric Neurology Clinic Archbishop Makarios 3 Hospital State Health Services Organisation Nicosia Cyprus

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