Bi-allelic gephyrin variants impair GABAergic inhibition in a patient with epileptic encephalopathy.

Synaptic inhibition is essential for shaping the dynamics of neuronal networks, and aberrant inhibition is linked to epilepsy. Gephyrin (Geph) is the principal scaffolding protein at inhibitory synapses and is essential for postsynaptic clustering of glycine (GlyRs) and GABA type A receptors (GABAARs). Consequently, gephyrin is crucial for maintaining the relationship between excitation and inhibition in normal brain function and mutations in the gephyrin gene (GPHN) are associated with neurodevelopmental disorders and epilepsy. We identified bi-allelic variants in the GPHN gene, namely the missense mutation c.1264G > A and splice acceptor variant c.1315-2A > G, in a patient with developmental and epileptic encephalopathy (DEE). We demonstrate that the splice acceptor variant leads to nonsense-mediated mRNA decay (NMD). Furthermore, the missense variant (D422N) alters gephyrin structure, as examined by analytical size exclusion chromatography and CD-spectroscopy, thus leading to reduced receptor clustering and sensitivity towards calpain-mediated cleavage. Additionally, both alterations contribute to an observed reduction of inhibitory signal transmission in neurons, which likely contributes to the pathological encephalopathy.