Mutation analysis of the N-acetylgalactosamine-6-sulfate sulfatase gene was performed in a group of 35 patients with mucopolysaccharidosis type IVA from 33 families, mainly of European origin. By nonradioactive SSCP screening, 35 different gene mutations were identified, 31 of them novel. Together they account for 88.6% of the disease alleles of the patients investigated. The vast majority of the gene alterations proved to be point mutations, 23 missense, 2 nonsense, and 3 affecting splicing. Six small deletions (1-27 bp) and one insertion were also characterized. In a Polish family, two mildly affected siblings were compound heterozygotes for R94G and R259Q. Their mother was homozygous for the latter point mutation, leading to enzyme deficiency and a borderline disease phenotype.