Segregation of the COL6A2 Variant (c.1817-3C>G) in a Consanguineous Saudi Family with Bethlem Myopathy.

Introduction: Bethlem myopathy is a rare genetic disease caused by a variant mapped to 21q22, which harbors the collagen type VI alpha 2 chain (COL6A2) and collagen type VI alpha 1 chain (COL6A1) genes, and 2q37, which harbors the collagen type VI alpha 3 chain (COL6A3) gene. Disease onset can occur at any age, and the symptoms are related to those of muscular dystrophy. Since Bethlem myopathy is a rare disease, no previous studies have been conducted in Arab countries, including Saudi Arabia. Its variable presentation of nonspecific muscular contractions and severity represents a diagnostic dilemma. Case presentation: Here, we report a Saudi pediatric patient, who is 9 years old (proband), brought to the pediatric clinic of King Saud's Hospital by his mother. The boy presented with difficulty standing, walking, and running with his classmates and unaffected siblings. He has a younger sibling, aged 6 years old, who reported having a limping gait and difficulty bending his right knee. Laboratory results for the proband were unremarkable except for a slight increase in creatine kinase (CK). Whole-exome sequencing (WES) was performed for five family members, including the proband and his symptomatic brother, their mother and two asymptomatic siblings. A very rare 3' splice site acceptor intronic variant, NM_001849.4: c.1817-3C>G, located three nucleotides before exon 25, was identified in COL6A2. Bioinformatics tools (SpliceAI, dbscSNV, FATHMM-MKL, and MaxEntScan) predicted this variant as pathogenic. The proband and his 6-year-old sibling presented a homozygous genotype for the variant, whereas the mother and one asymptomatic sibling were heterozygous, and the other sibling carried homozygous wild-type alleles. Conclusions: This is the first study to report a case of Bethlem myopathy confirmed by WES in Saudi Arabia and all Arab nations. The identified variant is rare, and its segregation pattern suggests autosomal recessive inheritance. The segregation pattern and bioinformatics tool results may qualify this variant to be annotated as pathogenic, addressing the reported uncertainty of its classification. Our findings contribute to linking and filling the knowledge gap of diagnosing and managing patients with collagen VI-related myopathies, providing greater clinical and genetic understanding to the existing knowledge.