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Purpose: The mediator (MED) multisubunit-complex modulates the activity of the transcriptional machinery, and genetic defects in different MED subunits (17, 20, 27) have been implicated in neurologic diseases. In this study, we identified a recurrent homozygous variant in MED11 (c.325C>T; p.Arg109Ter) in 7 affected individuals from 5 unrelated families. Methods: To investigate the genetic cause of the disease, exome or genome sequencing were performed in 5 unrelated families identified via different research networks and Matchmaker Exchange. Deep clinical and brain imaging evaluations were performed by clinical pediatric neurologists and neuroradiologists. The functional effect of the candidate variant on both MED11 RNA and protein was assessed using reverse transcriptase polymerase chain reaction and western blotting using fibroblast cell lines derived from 1 affected individual and controls and through computational approaches. Knockouts in zebrafish were generated using clustered regularly interspaced short palindromic repeats/Cas9. Results: The disease was characterized by microcephaly, profound neurodevelopmental impairment, exaggerated startle response, myoclonic seizures, progressive widespread neurodegeneration, and premature death. Functional studies on patient-derived fibroblasts did not show a loss of protein function but rather disruption of the C-terminal of MED11, likely impairing binding to other MED subunits. A zebrafish knockout model recapitulates key clinical phenotypes. Conclusion: Loss of the C-terminal ofMED subunit 11 may affect its binding efficiency to otherMED subunits, thus implicating the MED-complex stability in brain development and neurodegeneration.

Introduction Peroxisomal D-bifunctional protein (DBP) deficiency is an autosomal recessive disorder historically described as a Zellweger-like syndrome comprising neonatal seizures, retinopathy, hearing loss, dysmorphic features, and other complications. The HSD17B4 gene encodes DBP which is essential for oxidation of peroxisomal substrates. We describe 4 patients - 2 unrelated female girls and 2 monozygotic twin sisters - with DBP deficiency and phenotypic diversity. Patient reports Patient 1 presented neonatally with hypotonia and seizures, and later on developed global developmental delay and regression, sensorineural hearing loss, nystagmus and cortical blindness. The brain MRI demonstrated bilateral peri-sylvian polymicrogyria. Whole exome sequencing revealed 2 mutations in the HSD17B4 gene (c.752G>A, p.(Arg251Gln); c.868 + 1delG). Patient 2 presented with hypotonia, motor delay, and sensorineural hearing loss in infancy, considerable developmental regression during her fourth year, nystagmus, and peripheral neuropathy. Brain MRI demonstrated cerebellar atrophy and abnormal basal ganglia and white matter signal, which appeared after the age of two years. Whole exome sequencing revealed 2 mutations in the HSD17B4 gene (c.14 T>G, p.(Leu5Arg); c.752G>A, p.(Arg251Gln)). Patients 3 and 4, two female monozygotic twins, presented with hypotonia, developmental delay, and macrocephaly from birth, and later on also sensorineural hearing loss, infantile spasms and hypsarrhythmia, and adrenal insufficiency. Brain MRI demonstrated delayed myelination, and an assay of peroxisomal beta oxidation suggested DBP deficiency. Sequencing of the HSD17B4 gene revealed the same 2 mutations as in patient 1. Discussion We describe 4 patients with variable and diverse clinical picture of DBP deficiency and particularly emphasize the clinical, biochemical, and neuroimaging characteristics. Interestingly, the clinical phenotype varied even between patients with the exact two mutations in the HSD17B4 gene. In addition, in two of the three patients in whom levels of VLCFA including phytanic acid were measured, the levels were within normal limits. This is expanding further the clinical spectrum of this disorder, which should be considered in the differential diagnosis of every patient with hypotonia and developmental delay especially if accompanied by polymicrogyria, seizures, sensorineural hearing loss, or adrenal insufficiency regardless of their VLCFA profile.

The normal activity of basal ganglia neurons is characterized by Poisson-like (random) firing patterns. Correlations between neurons of the same structure are weak or non-existent. By contrast, synchronous oscillations are commonly found in the basal ganglia of human patients and animal models of Parkinson’s disease. The frequency of these oscillations is often similar to that of the parkinsonian tremor, but their role in generating the tremor or other parkinsonian symptoms is still under debate. The tremor is intermittent and does not appear in all human patients. Similarly, primate models tend to develop tremor as a function of species of monkey. African green (vervet) monkeys usually demonstrate a high-amplitude, low-frequency (4–7 Hz) tremor beyond their akinesia and bradykinesia, whereas macaques tend to be akinetic rigid and rarely demonstrate a low-amplitude high-frequency (10–12 Hz) action–postural tremor. We took advantage of this fact and studied the appearance of the synchronicity and oscillations in six monkeys, three vervets and three macaques, before and after 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) systemic treatment and induction of parkinsonism. Multiple extracellular recordings were conducted in the primary motor cortex of two monkeys and in the globus pallidus (GP) of all six monkeys. All the monkeys became akinetic and bradykinetic as a result of the MPTP treatment, but only vervets demonstrated prolonged episodes of low-frequency (4–6 Hz) tremor, whereas macaques were non-tremulous. The GP population exhibited ∼5 Hz oscillatory activity in all six monkeys, whereas ∼10 Hz neural oscillations were only detected in the tremulous monkeys. The activity of the cortical neurons became strongly oscillatory at ∼10 Hz in one of these monkeys, but not the other, although both were tremulous and exhibited comparable pallidal oscillatory activity. Finally, synchronous oscillations, when present, were centred around the higher frequencies of oscillations. These findings suggest that there is a correlation between high-frequency GP neural oscillations and tremor. Furthermore, these pallidal 10 Hz oscillations are probably transferred to the periphery through cortical and brainstem pathways.