In pleiotropic diseases, multiple organ systems are affected causing a variety of clinical manifestations. Here, we report a pleiotropic disorder with a unique constellation of neurological, endocrine, exocrine, and haematological findings that is caused by biallelic MADD variants. MADD, the mitogen-activated protein kinase (MAPK) activating death domain protein, regulates various cellular functions, such as vesicle trafficking, activity of the Rab3 and Rab27 small GTPases, tumour necrosis factor-α (TNF-α)-induced signalling and prevention of cell death. Through national collaboration and GeneMatcher, we collected 23 patients with 21 different pathogenic MADD variants identified by next-generation sequencing. We clinically evaluated the series of patients and categorized the phenotypes in two groups. Group 1 consists of 14 patients with severe developmental delay, endo- and exocrine dysfunction, impairment of the sensory and autonomic nervous system, and haematological anomalies. The clinical course during the first years of life can be potentially fatal. The nine patients in Group 2 have a predominant neurological phenotype comprising mild-to-severe developmental delay, hypotonia, speech impairment, and seizures. Analysis of mRNA revealed multiple aberrant MADD transcripts in two patient-derived fibroblast cell lines. Relative quantification of MADD mRNA and protein in fibroblasts of five affected individuals showed a drastic reduction or loss of MADD. We conducted functional tests to determine the impact of the variants on different pathways. Treatment of patient-derived fibroblasts with TNF-α resulted in reduced phosphorylation of the extracellular signal-regulated kinases 1 and 2, enhanced activation of the pro-apoptotic enzymes caspase-3 and -7 and increased apoptosis compared to control cells. We analysed internalization of epidermal growth factor in patient cells and identified a defect in endocytosis of epidermal growth factor. We conclude that MADD deficiency underlies multiple cellular defects that can be attributed to alterations of TNF-α-dependent signalling pathways and defects in vesicular trafficking. Our data highlight the multifaceted role of MADD as a signalling molecule in different organs and reveal its physiological role in regulating the function of the sensory and autonomic nervous system and endo- and exocrine glands.

Bioinformatics Core Unit University Medical Center Hamburg Eppendorf Hamburg Germany

CeGaT GmbH and Praxis für Humangenetik Tübingen Tübingen Germany

Center for Human Genetics KU Leuven Leuven Belgium

Center for Metabolic Diseases KU Leuven Leuven Belgium

Center of Medical Genetics University Hospital Antwerp Antwerp Belgium

Centre for Developmental Disabilities Department of Development and Regeneration KU Leuven Leuven Belgium

Child and Adolescent Neuropsychiatric Unit Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan Italy

Department for Neuropediatrics University Children's Hospital Ruhr University Bochum Bochum Germany

Department of Genetics and Genomic Sciences Icahn School of Medicine at Mount Sinai New York USA

Department of Medical Genetics Faculty of Medicine Mashhad University of Medical Sciences Mashhad Iran

Department of Medical Genetics University of Antwerp Antwerp Belgium

Department of Neuromuscular Diseases UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery London UK

Department of Pediatric Neurology University Hospital Antwerp Antwerp Belgium

Department of Pediatrics and Adolescent Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Czech Republic

Department of Pediatrics Icahn School of Medicine at Mount Sinai New York USA

Department of Pediatrics Prignitz Hospital Brandenburg Medical School Germany

Department of Pediatrics University Medical Center Hamburg Eppendorf Hamburg Germany

Division of Genetics and Metabolism College of Medicine University of South Florida Tampa Florida USA

Division of Genetics Department of Pediatrics King Abdullah specialized Children's Hospital King Abdulaziz Medical City Ministry of National Guard Health Affairs Riyadh Saudi Arabia

Division of Medical Genetics Department of Pediatrics Duke University Medical Center Durham North Carolina USA

Division of Medical Genetics Department of Specialized Medicine McGill University Health Centre Montreal Canada

Dr von Hauner Children's Hospital University of Munich Munich Germany

GeneDx Gaithersburg USA

Genetic Center of Khorasan Razavi Mashhad Iran

Genetics Research Centre Molecular and Clinical Sciences Institute St George's University London UK

Human Genetics Department McGill University Montreal Canada

Institute of Human Genetics Jena University Hospital Jena Germany

Institute of Human Genetics Medical Faculty RWTH Aachen University Aachen Germany

Institute of Human Genetics University Medical Center Hamburg Eppendorf Hamburg Germany

Institute of Human Genetics University Medical Center Leipzig Leipzig Germany

Instituto de Genética Médica y Molecular Hospital Universitario La Paz IdiPAZ CIBERER ISCIII Madrid Spain

King Saud Bin Abdulaziz University for Health Sciences Ministry of National Guard Health Affairs Riyadh Saudi Arabia

Klinik für Neuropädiatrie und angeborene Stoffwechselerkrankungen Klinikum Oldenburg Oldenburg Germany

Laboratorio di Genetica Medica ASST Papa Giovanni XXIII Bergamo Italy

Medical Genetic Unit Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan Italy

Medical Genetics Research Center Mashhad University of Medical Sciences Mashhad Iran

Medical Genomics Research Department King Abdullah International Medical Research Center Riyadh Saudi Arabia

Medicover Humangenetik Hannover Hanover Germany

Mindich Child Health and Development Institute Icahn School of Medicine at Mount Sinai New York USA

Next Generation Genetic Polyclinic Mashhad Iran

Research Unit for Rare Diseases Department of Pediatrics and Adolescent Medicine 1st Faculty of Medicine Charles University Prague Czech Republic

Unidad de Patología Compleja Servicio de Pediatría Hospital Universitario La Paz Madrid Spain

Universitätsklinikum Leipzig AöR University of Leipzig Hospital for Children and Adolescents Leipzig Germany

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