Biallelic variants in the non-coding RNA gene RNU4-2 cause a recessive neurodevelopmental syndrome with distinct white matter changes

Genetic variants in RNU4-2, which encodes U4, a key non-coding small nuclear RNA (snRNA) component of the major spliceosome, were recently shown to cause a prevalent neurodevelopmental disorder (NDD) called ReNU syndrome. These variants, which almost exclusively arise de novo, act in a dominant fashion and are clustered within 18 nucleotides (nt) in the centre of RNU4-2. Here we describe a novel recessive NDD associated with homozygous and compound heterozygous variants in RNU4-2. We identified 32 individuals with biallelic variants outside of the 18 nt ReNU syndrome region, that cluster within other functionally important elements of U4, including the Stem II region, the k-turn motif, and the Sm protein binding site. We characterise the clinical phenotype in 27 of these individuals, demonstrating that the recessive disorder is clinically distinct from dominant ReNU syndrome and is associated with distinctive white matter abnormalities, including enlarged perivascular spaces. Together, these findings expand the genotypic and phenotypic spectrum of RNU4-2-associated NDDs.