Summary
Clinical characteristics.
The current (but limited) understanding of the WARS2 deficiency phenotypic spectrum, based on 29 individuals from 24 families reported to date, can be viewed as a clustering of hallmark features within the broad phenotypes of epilepsy and movement disorder.
The epilepsy spectrum encompasses neonatal- or infantile-onset developmental and epileptic encephalopathy (DEE) and other less well described seizure types. DEE manifests mostly in the neonatal period or within the first year of life. Seizures are generally difficult to control and may lead to status epilepticus and death. Over time the following become evident: global developmental delay, mild-to-severe intellectual disability, speech impairment (slurred and slow speech, dysarthria or no speech production but preserved receptive speech), weakness and muscle atrophy, motor hyperactivity with athetosis, and neuropsychiatric manifestations including aggressiveness and sleep disorders.
The movement disorder spectrum encompasses the overlapping phenotypes of levodopa-responsive parkinsonism/dystonia and progressive myoclonus-ataxia/hyperkinetic movement disorder and is primarily associated with childhood or early adulthood onset.
Of note, the continua within and between the epilepsy spectrum and the movement disorder spectrum remain to be determined pending reporting of more individuals with WARS2 deficiency.
Diagnosis/testing.
The diagnosis of WARS2 deficiency is established in a proband with suggestive findings and biallelic pathogenic variants in WARS2 identified by molecular genetic testing. Of note, to date all individuals with a childhood- or early adulthood-onset movement disorder have the hypomorphic WARS2 variant c.37T>G (p.Trp13Gly) in trans with a WARS2 pathogenic variant.
Management.
Treatment of manifestations: There is no known cure for WARS2 deficiency. Supportive care to improve quality of life, maximize function, and reduce complications is recommended. Supportive treatment of WARS2-related DEE ideally involves multidisciplinary care by specialists in child neurology (treatment of seizures), nutrition/feeding, pulmonology, physical therapy, developmental pediatrics, social work, medical ethics, and medical genetics. Supportive treatment of WARS2-related movement disorders ideally involves multidisciplinary care by specialists in neurology (treatment of movement disorders), physiatry, physical therapy, occupational therapy, speech-language pathology (including consideration of augmentative and alternative communication), developmental pediatrics, mental health, social work, and medical genetics. Of note, individuals with parkinsonism show an overall good response to dopaminergic therapy, mostly to levodopa (alternatively, dopamine receptor agonists).
Surveillance: Because most infants and young children with WARS2-related DEE are severely affected and may be hospitalized for prolonged periods, it is recommended that they be reviewed regularly by senior clinical specialists when hospitalized. For individuals with a WARS2-related movement disorder, it is recommended that monitoring of existing manifestations, the individual's response to supportive care, and the emergence of new manifestations follow the recommendations of the treating specialists.
Agents/circumstances to avoid: Valproic acid has caused severe hepatopathy and neurologic deterioration in one individual with WARS2-related DEE.
Genetic counseling.
WARS2 deficiency is inherited in an autosomal recessive manner. If both parents are known to be heterozygous for a WARS2 pathogenic variant or hypomorphic variant, each sib of an affected individual has at conception a 25% chance of inheriting biallelic variants, a 50% chance of inheriting one variant, and a 25% chance of inheriting neither of the familial WARS2 variants. Sibs who inherit:
- Biallelic loss-of-function pathogenic variants are likely to have WARS2-related epilepsy;
- A WARS2 loss-of-function pathogenic variant in trans with the hypomorphic WARS2 variant are likely to have a WARS2-related movement disorder;
- One variant (either a pathogenic variant or a hypomorphic variant) are asymptomatic and are not at risk of developing WARS2 deficiency;
- Neither of the familial WARS2 variants are unaffected and not carriers.
Once the WARS2 deficiency-related variants have been identified in an affected family member, carrier testing for at-risk relatives and prenatal and preimplantation genetic testing are possible.
GeneReview Scope
WARS2 Deficiency: Phenotypic Spectrum outlines the current (but limited) understanding of the clustering of distinctive features in the two broad phenotypic spectra (epilepsy and movement disorder) and their associated genotype-phenotype correlations. Of note, the continua within and between these two major phenotypic spectra remain to be determined pending reporting of more individuals with WARS2 deficiency.
Diagnosis
No consensus clinical diagnostic criteria for WARS2 deficiency have been published.
Suggestive Findings
WARS2 deficiency should be considered in a proband with the following clinical, laboratory and imaging findings, and family history.
Epilepsy Spectrum – Neonatal or Infantile Onset
Clinical findings
- Initial manifestations:
- Seizures ranging from developmental and epileptic encephalopathy (DEE) to other seizure types.Note: For the purposes of this GeneReview, DEE is defined as severe seizure onset shortly after birth (often called infantile epileptic spasms syndrome).
- Hypotonia with or without peripheral spasticity
- Global developmental delay
- Poor suck
- Manifestations over time:
- Intellectual disability
- Speech impairment (no speech, slurred and slow speech) with receptive language relatively spared
- Often movement disorder (e.g., mild ataxia, dystonia, athetosis) and/or neuropsychiatric findings
Laboratory findings. Lactic acidosis may be present in early life, and serum lactate can reach 31 mmol/L [Wortmann et al 2017]. However, lactate can also be normal.
Brain MRI. Nonspecific findings can include:
- Cerebral and cerebellar volume loss
- White matter abnormalities (including absent myelination, nonspecific periventricular signal changes)
- Thin corpus callosum
- Hypoplastic cerebellar vermis, cerebellar peduncles, and brain stem
- Hypoxemic-ischemic basal ganglia lesions
Family history is consistent with autosomal recessive inheritance (e.g., affected sibs and/or parental consanguinity). Absence of a known family history does not preclude the diagnosis.
Movement Disorder Spectrum – Childhood or Early Adulthood Onset
Clinical findings
- Initial manifestations:
- Action tremor of the hand, unilateral leg tremor, occasional jerks
- Tremor
- Distal limb myoclonus
- Ataxia
- Ballistic and dystonic movements
- Axial hypotonia with trunk instability
- Developmental delay
- Manifestations over time:
- Movement disorders, such as parkinsonism (rigidity, bradykinesia, akinesia, dysarthria, dysphagia, hypomimia); other movement disorders such as dystonia, myoclonus, ataxia, tremor (resting, action, and postural), and chorea; and ocular disorders such as oculogyric crisis (spasmodic movements of the eyeballs into a fixed position, usually upward), ptosis, supranuclear gaze palsy, and exotropia
- Mild-to-moderate developmental delay / intellectual disability
- Versive seizures (a forced and involuntary turning of the head and eyes in one direction with an associated neck extension resulting in a sustained unnatural position of both)
- Neuropsychiatric manifestations such as social phobia, anxiety, depression, aggressive behavior, psychosis, and apathy
- Spasticity, peripheral hypertonia
Neuroimaging
- Brain MRI. Often normal; in some individuals, patchy or nonspecific periventricular T2 hyperintensities, cerebellar atrophy, and variable global brain atrophy can be seen. In one individual pallidal T2 hyperintensity was described.
- DaTscan® (specific type of single-photon emission computed tomography). Abnormalities of the dopaminergic striatal pathways are seen.
Family history is consistent with autosomal recessive inheritance (e.g., affected sibs and/or parental consanguinity). Absence of a known family history does not preclude the diagnosis.
Establishing the Diagnosis
The diagnosis of WARS2 deficiency is established in a proband with suggestive findings and biallelic pathogenic (or likely pathogenic) variants in WARS2 identified by molecular genetic testing (see Table 1).
Note: (1) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variant" and "likely pathogenic variant" are synonymous in a clinical setting, meaning that both are considered diagnostic and can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include likely pathogenic variants. (2) Identification of biallelic WARS2 variants of uncertain significance (or of one known WARS2 pathogenic variant and one WARS2 variant of uncertain significance) does not establish or rule out the diagnosis. (3) The common WARS2 variant c.37T>G (p.Trp13Gly) is a hypomorphic variant that is disease causing only when in trans with a WARS2 loss-of-function variant. This variant is not disease causing in the homozygous state.
Molecular genetic testing approaches can include a combination of gene-targeted testing (multigene panel) and comprehensive genomic testing (exome sequencing, genome sequencing). Gene-targeted testing requires that the clinician determine which gene(s) are likely involved (see Option 1), whereas comprehensive genomic testing does not (see Option 2).
Note: Single-gene testing (sequence analysis of WARS2, followed by gene-targeted deletion/duplication analysis) is rarely useful and typically NOT recommended.
Option 1
A mitochondrial, intellectual disability, genetic epilepsy syndrome, or inborn error of metabolism multigene panel that includes WARS2 and other genes of interest (see Differential Diagnosis) is most likely to identify the genetic cause of the condition while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.
For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.
Option 2
Comprehensive genomic testing does not require the clinician to determine which genes is likely involved. Exome sequencing is most commonly used; genome sequencing is also possible.
For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.
Clinical Characteristics
Clinical Description
The current (but limited) understanding of the WARS2 deficiency phenotypic spectrum can be viewed as a clustering of hallmark features within the broad phenotypes of epilepsy and movement disorder. The epilepsy spectrum encompasses neonatal- or infantile-onset developmental and epileptic encephalopathy (DEE) and other seizure types. The movement disorder spectrum encompasses levodopa-responsive parkinsonism/dystonia and progressive myoclonus-ataxia/hyperkinetic movement disorder. Of note, the continua within and between the epilepsy spectrum and the movement disorder spectrum remain to be determined pending reporting of more individuals with WARS2 deficiency.
To date, 29 individuals from 24 families with biallelic variants in WARS2 have been reported [Bowling et al 2017, Musante et al 2017, Theisen et al 2017, Wortmann et al 2017, Burke et al 2018, Vantroys et al 2018, Hübers et al 2019, Maffezzini et al 2019, Nogueira et al 2019, Virdee at al 2019, Martinelli et al 2020, Ilinca et al 2022, Skorvanek et al 2022, Pauly et al 2023].
Epilepsy Spectrum
Developmental and epileptic encephalopathy (DEE) has been reported in the medical literature in 13 individuals [Bowling et al 2017, Musante et al 2017, Theisen et al 2017, Wortmann et al 2017, Vantroys et al 2018, Maffezzini et al 2019, Nogueira et al 2019, Virdee at al 2019]. Epilepsy was described in 6/13 individuals, with infantile spasms syndrome (previously termed West syndrome) described in two of the six individuals [Musante et al 2017]. However, information on other types of seizures observed is limited. In one individual seizures were described as long lasting with decreased awareness, lateral eye deviation, and eyelid twitching [Vantroys et al 2018].
DEE manifests mostly in the neonatal period or within the first year of life. Seizures are generally difficult to control and may lead to status epilepticus and death.
Evolution of manifestations over time include global developmental delay, mild-to-severe intellectual disability, speech impairment (slurred and slow speech, dysarthria, or no speech production but preserved receptive speech), muscle weakness, muscle atrophy, motor hyperactivity with athetosis, and neuropsychiatric manifestations including aggressiveness and sleep disorders. Other findings are dysmorphic features.
Developmental delay and intellectual disability were observed in 12/13 individuals with WARS2-related DEE. One neonate died at age three weeks; therefore, developmental delay could not be evaluated.
In early childhood, delay is especially in expressive language, whereas receptive language is relatively spared. Some individuals never speak [Theisen et al 2017]; in some individuals speech is slurred and slow [Musante et al 2017].
Global motor delay, especially in the first year of life, has been reported [Wortmann et al 2017, Maffezzini et al 2019]. Children, however, usually achieve independent ambulation. One child did not acquire motor abilities until age 7.5 years [Wortmann et al 2017]. Another individual was not able to walk [Theisen et al 2017].
Intellectual disability ranges from mild to severe, usually in the moderate-to-severe range. Except for information that one child attended a special school [Maffezzini et al 2019], no data are available about the level of independence in other older individuals.
Hypotonia (7/13) was axial. Additional findings were brisk reflexes, upgoing toes, and limb spasticity [Theisen et al 2017, Wortmann et al 2017, Vantroys et al 2018, Maffezzini et al 2019].
Movement disorders in WARS2-related DEE are usually milder than in those observed in the movement disorder spectrum and do not interfere with daily activities. The common movement disorders are ataxia (5/13) and dystonia (4/13). Ataxia is rarely severe and, in most instances, mild [Musante et al 2017, Theisen et al 2017, Wortmann et al 2017, Maffezzini et al 2019]. Although reported, choreiform movements, tremor, and athethosis are rare [Musante et al 2017, Vantroys et al 2018].
Neuropsychiatric manifestations, including aggressive behavior and sleep disorders, were described in 4/13 individuals [Musante et al 2017, Maffezzini et al 2019].
Other findings
- Gastrointestinal manifestations seen in WARS2-related DEE include intestinal pseudo-obstruction and obstipation [Wortmann et al 2017, Maffezzini et al 2019]. Pseudo-obstruction was reported in one neonate who required an ileostomy [Wortmann et al 2017].One child developed acute hepatopathy at age 6.5 years after the administration of valproic acid [Vantroys et al 2018], and one had an episode of severe liver failure at age four months [Bowling et al 2017].
- Hypoglycemia was reported in three neonates [Theisen et al 2017, Wortmann et al 2017] and one child at age six years [Vantroys et al 2018].
- Dysmorphic and musculoskeletal features can include long philtrum, thin upper lip, low-set ears, broad nasal bridge, hypertelorism, narrow and high-arched palate, and equinus foot [Musante et al 2017, Vantroys et al 2018]. Clench fist was also described.
- Ocular involvement can include optic nerve atrophy, visual impairment, retinitis pigmentosa, strabismus, nystagmus, and amblyopia [Bowling et al 2017, Wortmann et al 2017, Maffezzini et al 2019, Skorvanek et al 2022].
- Cardiac involvement is rare. One individual with WARS2-related DEE had mild cardiomyopathy [Wortmann et al 2017].
Prognosis. To date, at least seven of 13 children with WARS2-related DEE have died in the neonatal period or early childhood due to epileptic seizures [Theisen et al 2017, Wortmann et al 2017], respiratory insufficiency following infection, or multiorgan failure [Bowling et al 2017, Wortmann et al 2017].
Movement Disorder Spectrum
The movement disorder spectrum is primarily comprised of an early-onset levodopa-responsive parkinsonism/dystonia phenotype (12/16 individuals) [Burke et al 2018, Nogueira et al 2019, Virdee et al 2019, Martinelli et al 2020, Ilinca et al 2022, Skorvanek et al 2022, Pauly et al 2023]; however, a few (4/16) individuals do not have parkinsonism and instead have progressive myoclonus-ataxia/hyperkinetic movement disorder (4/16) [Hübers et al 2019, Skorvanek et al 2022].
Onset. Onset can be as early as in the first year of life but is more commonly in childhood [Skorvanek et al 2022].
Parkinsonism. Most individuals with WARS2-related movement disorder have parkinsonism (11/16) that may include moderate-to-severe bradykinesia or akinesia that is often – but not always – associated with rigidity [Burke et al 2018, Martinelli et al 2020, Skorvanek et al 2022]. Further manifestations may include dysarthria, dysphagia, and hypomimia. Parkinsonism has not been reported in individuals with myoclonus-ataxia/hyperkinetic movement disorder.
Tremor can be seen in almost all individuals (15/16). At disease onset asymmetric action tremor of the hand is seen; it can be exacerbated by excitement and physical activity. Tremor can further progress to bilateral resting and postural tremor. In one individual, unilateral leg tremor was the first manifestation, which progressed to the other limbs during the disease course [Burke et al 2018]. Tremor was levodopa responsive in all individuals [Burke et al 2018, Skorvanek et al 2022].
Dystonia is common (10/16) and can be focal-cervical, axial, in the upper limb, or generalized [Skorvanek et al 2022].
Myoclonus was observed in 7/16 individuals, four of whom had levodopa-responsive parkinsonism/dystonia and three of whom had progressive myoclonus-ataxia/hyperkinetic movement disorder. Myoclonus typically involves the distal limbs, is severe, and increases with action and intention, as well as during excitement or fever. It is slowly progressive and can progress to continuous myoclonus [Skorvanek et al 2022].
Occasional myoclonic limb jerks have also been reported [Skorvanek et al 2022, Pauly et al 2023].
Ataxia, described in 5/16 individuals with both movement disorder phenotypes, is mild and is not present at disease onset but develops later in the disease course [Skorvanek et al 2022].
Other movement disorders
- Choreiform movements are rare but have been described [Skorvanek et al 2022].
- A hyperkinetic movement disorder with uncontrollable ballistic and dystonic movements and loss of already acquired skills has been described in one individual to date [Hübers et al 2019].
Developmental delay (DD) and intellectual disability (ID). Individuals with WARS2-related movement disorder have mostly mildly impaired intellect (7/16); however, details are limited [Skorvanek et al 2022, Pauly et al 2023].
Neuropsychiatric manifestations (5/16 individuals) include anxiety, depression, aggressive behavior, psychosis, apathy, social phobia, and unsociable character [Skorvanek et al 2022, Pauly et al 2023].
Other findings
- Seizures were reported in two individuals with WARS2-related movement disorder: one with versive seizures with paroxysmal epileptic alterations in the frontal lobe [Martinelli et al 2020] and the other with neonatal seizures followed by persistent generalized and complex partial seizures [Ilinca et al 2022].
- Ocular involvement can include ptosis, slow saccades, and exotropia [Bowling et al 2017, Wortmann et al 2017, Maffezzini et al 2019, Skorvanek et al 2022].
- Cardiac involvement is rare. Sinus tachycardia was documented in one individual with WARS2-related movement disorder [Skorvanek et al 2022].
- Increased limb tone. No details provided [Skorvanek et al 2022, Pauly et al 2023].
Genotype-Phenotype Correlations
Several genotype-phenotype correlations have been observed.
Biallelic loss-of-function WARS2 pathogenic variants are typically associated with neonatal- or infantile-onset DEE. However, at least two individuals with biallelic loss-of-function WARS2 variants had levodopa-responsive parkinsonism/dystonia [Virdee et al 2019, Ilinca et al 2022].
p.Trp13Gly. Evidence suggests that the common WARS2 variant c.37T>G (p.Trp13Gly) is a hypomorphic variant that is disease causing only when in trans with a loss-of-function variant. While individuals with the hypomorphic p.Trp13Gly variant in trans with a loss-of-function variant typically have the milder childhood- or early adulthood-onset movement disorder phenotype, this genotype has also been identified in at least one individual with infantile-onset DEE (between age six and nine months) [Martinelli et al 2020].
In general, clinically significant intrafamilial clinical variability has not observed among sibs who have the same biallelic WARS2 variants [Musante et al 2017, Wortmann et al 2017, Maffezzini et al 2019, Skorvanek et al 2022]. However, in one family with early-onset levodopa-responsive parkinsonism/dystonia, a sister had less severe manifestations than her affected brother. She had slowly progressive distal myoclonus and borderline intellectual ability, whereas her brother had severe distal myoclonus, intermittent cervical and axial dystonia, and mild-to-moderate intellectual disability [Skorvanek et al 2022].
Nomenclature
The title of this GeneReview, WARS2 deficiency, encompasses the full phenotypic spectrum reported in individuals with pathogenic WARS2 genotypes – that is, individuals with WARS2-related epilepsy, typically caused by biallelic WARS2 pathogenic variants, and individuals with WARS2-related movement disorder, typically caused by compound heterozygosity for a WARS2 pathogenic variant in trans with the hypomorphic variant c.37T>G (p.Trp13Gly).
Other designations used in the literature to refer to individuals with phenotypes within the WARS2 deficiency spectrum include:
Prevalence
To date, 29 individuals from 24 families have been identified with WARS2 deficiency (see Clinical Description).
Genetically Related (Allelic) Disorders
No phenotypes other than those discussed in this GeneReview are known to be associated with germline pathogenic variants in WARS2.
Differential Diagnosis
Epilepsy Spectrum
Developmental and epileptic encephalopathy (DEE). Because the phenotype of WARS2-related DEE is indistinguishable from many other inherited disorders with neonatal- or infantile-onset encephalopathy, all neurodevelopmental disorders, epileptic encephalopathy syndromes, and mitochondrial disorders should be considered in the differential diagnosis. See the Primary Mitochondrial Disorders Overview and the following OMIM Phenotypic Series:
- Intellectual disability without other distinctive findings: OMIM Autosomal Dominant, Autosomal Recessive, and Syndromic X-linked Intellectual Developmental Disorder Phenotypic Series.
- DEE: OMIM Developmental and Epileptic Encephalopathy Phenotypic Series
Additionally, the infantile-onset disorders in Table 2a have overlapping phenotypic features with WARS2-related DEE, including increased serum lactate, developmental delay, intellectual disability, seizures, and muscle involvement.
Other seizure types. All genetic epilepsy syndromes without other distinctive findings should be considered in the differential diagnosis.
Movement Disorder Spectrum
For a general review of the clinical characteristics and causes of monogenic Parkinson disease, see Parkinson Disease Overview.
Myoclonus-ataxia predominate phenotypes should further be differentiated from:
- Myoclonus epilepsy syndromes (See Progressive Myoclonic Epilepsy Type 1.)
- Neuraminidase deficiency (OMIM 256550)
- Neuronal ceroid lipofuscinosis (OMIM Phenotypic Series: Ceroid lipofuscinoses)
Management
No clinical practice guidelines for WARS2 deficiency have been published.
Evaluations Following Initial Diagnosis
The evaluations recommended to determine the extent of disease and needs of an individual diagnosed with WARS2-related epilepsy are summarized in Table 3a and of an individual with WARS2-related movement disorder in Table 3b. Note: It is often not necessary to repeat evaluations performed as part of the evaluation that led to the diagnosis.
Treatment of Manifestations
To date, there is no known cure for WARS2 deficiency.
Supportive care to improve quality of life, maximize function, and reduce complications is recommended. This ideally involves multidisciplinary care by specialists in relevant fields (see Table 4a for WARS2-related epilepsy; see Table 4b for WARS2-related movement disorder).
Developmental Delay / Intellectual Disability Management Issues
The following information represents typical management recommendations for school-age individuals with developmental delay / intellectual disability in the United States; standard recommendations may vary from country to country.
All ages. Consultation with a developmental pediatrician is recommended to ensure the involvement of appropriate community, state, and educational agencies (US) and to support parents in maximizing quality of life. Some issues to consider:
- Individualized education plan (IEP) services:
- An IEP provides specially designed instruction and related services to children who qualify.
- IEP services will be reviewed annually to determine whether any changes are needed.
- As required by special education law, children should be in the least restrictive environment feasible at school and included in general education as much as possible and when appropriate.
- Vision consultants should be a part of the child's IEP team to support access to academic material.
- PT, OT, and speech services will be provided in the IEP to the extent that the need affects the child's access to academic material. Beyond that, private supportive therapies based on the affected individual's needs may be considered. Specific recommendations regarding type of therapy can be made by a developmental pediatrician.
- As a child enters the teen years, a transition plan should be discussed and incorporated in the IEP. For those receiving IEP services, the public school district is required to provide services until age 21.
- A 504 plan (Section 504: a US federal statute that prohibits discrimination based on disability) can be considered for those who require accommodations or modifications such as front-of-class seating, assistive technology devices, classroom scribes, extra time between classes, modified assignments, and enlarged text.
- Developmental Disabilities Administration (DDA) enrollment is recommended. DDA is a US public agency that provides services and support to qualified individuals. Eligibility differs by state but is typically determined by diagnosis and/or associated cognitive/adaptive disabilities.
- Families with limited income and resources may also qualify for supplemental security income (SSI) for their child with a disability.
Surveillance
Because most infants and young children with WARS2-related developmental and epileptic encephalopathy are severely affected and may be hospitalized for prolonged periods from the onset of disease manifestations, they should be reviewed regularly by senior clinical specialists if they are hospitalized.
The recommendations regarding frequency of follow up in Table 5a (for WARS2-related epilepsy) and Table 5b (for WARS2-related movement disorder) pertain to outpatient visits only.
Agents/Circumstances to Avoid
Valproic acid can cause severe hepatopathy and neurologic deterioration, as reported in one individual with WARS2-related DEE [Vantroys et al 2018].
Evaluation of Relatives at Risk
See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.
Therapies Under Investigation
Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.
Genetic Counseling
Genetic counseling is the process of providing individuals and families with information on the nature, mode(s) of inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members; it is not meant to address all personal, cultural, or ethical issues that may arise or to substitute for consultation with a genetics professional. —ED.
Mode of Inheritance
WARS2 deficiency is inherited in an autosomal recessive manner. To date:
- Most individuals with WARS2-related epilepsy have the disorder as the result of biallelic WARS2 loss-of-function pathogenic variants;
- Most individuals with WARS2-related movement disorder have the disorder as the result of compound heterozygosity for a WARS2 loss-of-function pathogenic variant in trans with the hypomorphic WARS2 variant c.37T>G (p.Trp13Gly).
Risk to Family Members
Parents of a proband
- The parents of an affected individual are presumed to be heterozygous for a WARS2 pathogenic variant or hypomorphic variant.
- Molecular genetic testing is recommended for the parents of the proband to confirm that both parents are heterozygous for a WARS2 pathogenic variant or hypomorphic variant and to allow reliable recurrence risk assessment..
- If a pathogenic variant or hypomorphic variant is detected in only one parent and parental identity testing has confirmed biological maternity and paternity, it is possible that one of the variants identified in the proband occurred as a de novo event in the proband or as a postzygotic de novo event in a mosaic parent [Jónsson et al 2017]. If the proband appears to have homozygous pathogenic variants (i.e., the same two pathogenic variants), additional possibilities to consider include:
- A single- or multiexon deletion in the proband that was not detected by sequence analysis and that resulted in the artifactual appearance of homozygosity;
- Uniparental isodisomy for the parental chromosome with the pathogenic variant that resulted in homozygosity for the pathogenic variant in the proband.
- Heterozygotes (carriers) are asymptomatic and are not at risk of developing the disorder.
Sibs of a proband
- If both parents are known to be heterozygous for a WARS2 pathogenic variant or hypomorphic variant, each sib of an affected individual has at conception a 25% chance of inheriting biallelic variants, a 50% chance of inheriting one variant, and a 25% chance of inheriting neither of the familial WARS2 variants. Sibs who inherit:
- Biallelic loss-of-function pathogenic variants are likely to have WARS2-related epilepsy;
- A WARS2 loss-of-function pathogenic variant in trans with the hypomorphic WARS2 variant are likely to have WARS2-related movement disorder;
- One variant (either a pathogenic variant or a hypomorphic variant) are asymptomatic and are not at risk of developing WARS2 deficiency;
- Neither of the familial WARS2 variants are unaffected and not carriers.
- In all but one family, clinically significant intrafamilial clinical variability has not been observed among sibs who have the same biallelic WARS2 variants [Musante et al 2017, Wortmann et al 2017, Maffezzini et al 2019, Skorvanek et al 2022] (see Genotype-Phenotype Correlations).
- Note: Individuals who are homozygous for the hypomorphic WARS2 variant are predicted to be asymptomatic [Ilinca et al 2022, Skorvanek et al 2022].
Offspring of a proband
- To date, individuals with WARS2-related developmental and epileptic encephalopathy are not known to reproduce.
- The offspring of an individual with a WARS2-related movement disorder are obligate heterozygotes (carriers) for either a WARS2 pathogenic variant or the WARS2 hypomorphic variant.
Other family members. Each sib of the proband's parents is at a 50% risk of being a carrier of a WARS2 deficiency-related variant.
Carrier detection. Carrier testing for at-risk relatives requires prior identification of the WARS2 deficiency-related variants in the family.
Related Genetic Counseling Issues
Family planning
- The optimal time for determination of genetic risk and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
- It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are carriers, or are at risk of being carriers.
- Carrier testing for reproductive partners of individuals known to be carriers should be considered, particularly if consanguinity is likely and/or if both partners are of the same ethnic background.
Prenatal Testing and Preimplantation Genetic Testing
Once the WARS2 deficiency-related variants have been identified in an affected family member, prenatal and preimplantation genetic testing are possible.
Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.
Resources
GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.
- American Parkinson Disease Association (APDA)Phone: 800-223-2732Fax: 718-981-4399Email: apda@apdaparkinson.org
- Fox Trial Finder
- MedlinePlus
- Michael J. Fox Foundation for Parkinson's ResearchPhone: 800-708-7644 (toll-free)Email: info@michaeljfox.org
- Mito FoundationAustraliaPhone: 61-1-300-977-180Email: info@mito.org.au
- National Institute of Neurological Disorders and Stroke (NINDS)
- Parkinson’s Disease Society (UK)United KingdomPhone: 0808 800 0303Email: hello@parkinsons.org.uk
- Parkinson's FoundationPhone: 800-4PD-INFO (473-4636)Email: contact@parkinson.org
- The Charlie Gard FoundationUnited KingdomEmail: hello@thecharliegardfoundation.org
- United Mitochondrial Disease FoundationPhone: 888-317-UMDF (8633)Email: info@umdf.org
- RDCRN Patient Contact Registry: North American Mitochondrial Disease Consortium
Molecular Genetics
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.
Molecular Pathogenesis
Aminoacyl-tRNA synthetases are nucleus-encoded mitochondrial enzymes involved in a broad range of cellular processes. Pathogenic variants involving aminoacyl-tRNA synthetases can affect several cellular mechanisms, mainly in tissues with a high energy demand such as the central nervous system (CNS). Accordingly, pathogenic variants in 17 of the 19 aminoacyl-tRNA synthetases have been associated with diseases of the CNS [Lott et al 2013, Moulinier et al 2017, Sissler et al 2017].
WARS2 encodes a ubiquitously expressed mitochondrial tryptophanyl-tRNA synthetase, which has a cytoplasmic (WAR) and a mitochondrial (WARS2) form vital for mitochondrial translation. Pathogenic variants in WARS2 cause different structural and kinetic changes in mitochondrial tryptophanyl-tRNA synthetase that in turn affect one or more steps in the process of transferring/charging tryptophan to its cognate tRNA in the mitochondria, thus affecting mitochondrial protein synthesis. Investigation of aminoacylation of WARS2 variants showed a clear decrease in charged mitochondrial tryptophanyl-tRNA synthetase in the fibroblasts of affected individuals, while total mitochondrial tryptophanyl-tRNA synthetase levels appeared normal, indicating that the defect in WARS2 deficiency causes improper aminoacylation of tryptophanyl-tRNA, leading to abnormalities in mitochondrial oxidative phosphorylation protein biosynthesis [Wortmann et al 2017].
Functional data show that the hypomorphic p.Trp13Gly variant diminishes (but does not abolish) transport of WARS2 protein into mitochondria [Ilinca et al 2022, Skorvanek et al 2022]. Of particular note, individuals homozygous for the hypomorphic p.Trp13Gly variant are predicted to be asymptomatic (see WARS2-specific laboratory technical considerations).
Mechanism of disease causation. Loss of function
WARS2-specific laboratory technical considerations. Evidence to date suggests that the common WARS2 variant p.Trp13Gly is a hypomorphic variant that is disease-causing only when in trans with a loss-of-function pathogenic WARS2 variant. The presence of the p.Trp13Gly variant at a relatively high frequency (922 alleles [0.33%], including six homozygotes in all populations in gnomAD v2.1.1) supports the idea that this variant is not disease causing in the homozygous state. Based on the assumption that individuals in reference databases such as gnomAD are not affected by rare severe neurologic disorders, standard algorithms used in clinical diagnostic laboratories are likely to filter out variants that are present at a high frequency in the homozygous state. Therefore, diagnostic laboratories offering testing for WARS2 need to take into consideration the relative high frequency of this hypomorphic variant and its relevance to disease causation, especially if another pathogenic WARS2 variant is detected in the heterozygous state, in which case using additional and/or modified filters to specifically confirm/exclude the presence of the p.Trp13Gly hypomorphic variant in trans is recommended [Ilinca et al 2022, Skorvanek et al 2022].
Chapter Notes
Author Notes
Contact Professor Henry Houlden (ku.ca.lcu@nedluoh.h) or Sara Nagy, MD, Msc (ku.ca.lcu@ygan.s) to inquire about review of WARS2 variants of uncertain significance.
Revision History
- 12 October 2023 (bp) Review posted live
- 18 April 2023 (sn) Original submission
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Publication Details
Author Information and Affiliations
UCL Queen Square Institute of Neurology
University College London
London, United Kingdom
UCL Queen Square Institute of Neurology
University College London
London, United Kingdom
UCL Queen Square Institute of Neurology
University College London
London, United Kingdom
UCL Queen Square Institute of Neurology
University College London
London, United Kingdom
UCL Queen Square Institute of Neurology
University College London
London, United Kingdom
University Hospital Basel
University of Basel
Basel, Switzerland
Publication History
Initial Posting: October 12, 2023.
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NLM Citation
Mroczek M, Busra A, Houlden H, et al. WARS2 Deficiency. 2023 Oct 12. In: Adam MP, Feldman J, Mirzaa GM, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2024.