Primary ovarian failure in addition to classical clinical features of Coats Plus Syndrome in a female carrying two truncating variants of CTC1.

Coats plus syndrome is an autosomal recessive multisystemic and pleiotropic disorder affecting the eyes, brain, bone, and gastrointestinal tract, usually caused by compound heterozygous variants of the Conserved Telomere maintenance Component 1 gene (CTC1), involved in telomere homeostasis and replication. So far, most reported patients are compound heterozygous for a truncating mutation and a missense variant. The phenotype is believed to result from telomere dysfunction, with accumulation of DNA damage, cellular senescence, and stem cell depletion. Here, we report a 23-year-old female with prenatal and postnatal growth retardation, microcephaly, osteopenia, recurrent fractures, intracranial calcification, leukodystrophy, parenchymal brain cysts, bicuspid aortic valve and primary ovarian failure. She carries a previously reported maternally inherited pathogenic variant in exon 5 [c.724_727del, p.(Lys242Leufs*41)] and a novel, paternally inherited splice site variant [c.1617+5G>T; p.(Lys480Asnfs*17)] in intron 9. CTC1 transcript analysis showed that the latter resulted in skipping of exon 9. A trace of transcripts was normally spliced resulting in the presence of a low level of wild-type CTC1 transcripts. We speculate that ovarian failure is caused by telomere shortening or chromosome cohesion failure in oocytes and granulosa cells, with early decrease in follicular reserve. This is the first patient carrying two truncating CTC1 variants and the first presenting primary ovarian failure.