The Phenotypic Spectrum of PNKP-Associated Disease and the Absence of Immunodeficiency and Cancer Predisposition in a Dutch Cohort

Pediatr Neurol. 2020 Dec:113:26-32. doi: 10.1016/j.pediatrneurol.2020.07.014. Epub 2020 Jul 28.


Background: We aimed to expand the number of currently known pathogenic PNKP mutations, to study the phenotypic spectrum, including radiological characteristics and genotype-phenotype correlations, and to assess whether immunodeficiency and increased cancer risk are part of the DNA repair disorder caused by mutations in the PNKP gene.

Methods: We evaluated nine patients with PNKP mutations. A neurological history and examination was obtained. All patients had undergone neuroimaging and genetic testing as part of the prior diagnostic process. Laboratory measurements included potential biomarkers, and, in the context of a DNA repair disorder, we performed a detailed immunologic evaluation, including B cell repertoire analysis.

Results: We identified three new mutations in the PNKP gene and confirm the phenotypic spectrum of PNKP-associated disease, ranging from microcephaly, seizures, and developmental delay to ataxia with oculomotor apraxia type 4. Irrespective of the phenotype, alpha-fetoprotein is a biochemical marker and increases with age and progression of the disease. On neuroimaging, (progressive) cerebellar atrophy was a universal feature. No clinical signs of immunodeficiency were present, and immunologic assessment was unremarkable. One patient developed cancer, but this was attributed to a concurrent von Hippel-Lindau mutation.

Conclusions: Immunodeficiency and cancer predisposition do not appear to be part of PNKP-associated disease, contrasting many other DNA repair disorders. Furthermore, our study illustrates that the previously described syndromes microcephaly, seizures, and developmental delay, and ataxia with oculomotor apraxia type 4, represent the extremes of an overlapping spectrum of disease. Cerebellar atrophy and elevated serum alpha-fetoprotein levels are early diagnostic findings across the entire phenotypical spectrum.

Keywords: AOA4 ataxia with oculomotor apraxia type 4; DNA repair; Immunodeficiency; MCSZ microcephaly, seizures and developmental delay; PNKP Polynucleotide kinase 3′-phosphatase.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Cohort Studies
  • DNA Repair Enzymes / genetics*
  • Developmental Disabilities / genetics
  • Female
  • Genetic Association Studies
  • Humans
  • Immunologic Deficiency Syndromes / epidemiology*
  • Male
  • Microcephaly / genetics*
  • Mutation / genetics*
  • Neoplasms / epidemiology*
  • Netherlands
  • Phenotype
  • Phosphotransferases (Alcohol Group Acceptor) / genetics*
  • Seizures / genetics
  • Spinocerebellar Ataxias / congenital*
  • Spinocerebellar Ataxias / genetics
  • Young Adult


  • PNKP protein, human
  • Phosphotransferases (Alcohol Group Acceptor)
  • DNA Repair Enzymes

Supplementary concepts

  • Spinocerebellar ataxia, autosomal recessive 1