Masomeh Askari, Svetlana A. Yatsenko, Robin Lovell-Badge, Tiphanie Merel-Chali, Balázs Gellén, Nitzan Gonen, Leila Fusee, Rana Mainpal, Mariana Costanzo, Inas Mazen, Anu Bashamboo, Anahita Mohseni Meybodi, Esperanza Berensztein, Joelle Bignon-Topalovic, Caroline Eozenou, Natalia Perez Garrido, Alicia Belgorosky, Andrea J. Berman, Roberta Migale, Ken McElreavey, Rita Bertalan, Alaa K. Kamel, Mona K. Mekkawy, Maria Sol Touzon, Priti Singh, Pablo Ramirez, Gabriela Guercio, Aleksandar Rajkovic, Mehdi Totonchi, Selma F. Witchel, Roxana Marino, John C. Schimenti, Anne Jørgensen, Génétique du développement humain, Institut Pasteur [Paris], The Francis Crick Institute [London], The Mina & Everard Goodman Faculty of Life Sciences [Ramat Gan, Israël], Université Bar-Ilan [Israel], Hospital Nacional de Pediatría Prof. Dr Juan P. Garrahan [Buenos Aires], Copenhagen University Hospital, University of Pittsburgh (PITT), Pennsylvania Commonwealth System of Higher Education (PCSHE), National Research Centre - NRC (EGYPT), University of Szeged [Szeged], Cornell University [New York], Children's Hospital of Pittsburgh of UPMC [Etats-Unis], Royan Institute for Reproductive Biomedicine [Tehran, Iran], Semmelweis University [Budapest], University of California, Génétique du Développement humain - Human developmental genetics, Institut Pasteur [Paris]-Centre National de la Recherche Scientifique (CNRS), This work is supported by the European Cooperation in Science and Technology (COST) Action DSDnet BM1303 (to A. Bashamboo and K.M.). N.G and R.L.-B. are funded by the Francis Crick Institute. The Francis Crick Institute receives its core funding from Cancer Research UK Grant FC001107, UK Medical Research Council Grant FC001107, Wellcome Grant FC001107, and by UK Medical Research Council Grant U117512772. M.S.T. and A. Belgorosky are supported by PIDC-20160028 Fondo Nacional de Ciencia y Tecnologia, Argentina, Grant PICT-2013-0181y PICT2016-0214, Agencia Nacional para Ciencia y Tecnologia, Argentina, and Consejo Nacional de Investigaciones Cientificas y Tecnologicas, Argentina. A.R. is funded by NIH Grants R01HD070647 and R21HD074278. A.J. is funded by a research grant from the Svend Andersen Foundation and the Danish Government’s support to Department of Growth and Reproduction for the International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC) programme. A.J.B. is supported by NIH Grant GM116889 and American Cancer Society Research Scholar Grant RSG-17-1.97-01-RMC, We are grateful to the Biological Research Facility, Genetic Modification Service, and Experimental Histopathology Facilities of the Francis Crick Institute. We acknowledge Dr. László Tiszlavicz (Pathological Department, University of Szeged, Hungary) for the histological examination of Patients 5a and 5b and Dr. Alejandro Suárez-Bonnet (Experimental Histopathology at Francis Crick Institute) for pathology report on mouse embryonic kidneys., Institut Pasteur [Paris] (IP), Bar-Ilan University [Israël], University of California (UC), Institut Pasteur [Paris] (IP)-Centre National de la Recherche Scientifique (CNRS), and ANR-17-CE14-0038,MGonDev,Etude des mécanismes du développement des gonades chez l'homme(2017)
International audience; Sex determination in mammals is governed by antagonistic interactions of two genetic pathways, imbalance in which may lead to disorders/differences of sex development (DSD) in human. Among 46,XX individuals with testicular DSD (TDSD) or ovotesticular DSD (OTDSD), testicular tissue is present in the gonad. Although the testis-determining gene SRY is present in many cases, the etiology is unknown in most SRY-negative patients. We performed exome sequencing on 78 individuals with 46,XX TDSD/OTDSD of unknown genetic etiology and identified seven (8.97%) with heterozygous variants affecting the fourth zinc finger (ZF4) of Wilms' tumor 1 (WT1) (p.Ser478Thrfs*17, p.Pro481Leufs*15, p.Lys491Glu, p.Arg495Gln [x3], p.Arg495Gly). The variants were de novo in six families (P = 4.4 × 10-6), and the incidence of WT1 variants in 46,XX DSD is enriched compared to control populations (P < 1.8 × 10-4). The introduction of ZF4 mutants into a human granulosa cell line resulted in up-regulation of endogenous Sertoli cell transcripts and Wt1 Arg495Gly/Arg495Gly XX mice display masculinization of the fetal gonads. The phenotype could be explained by the ability of the mutated proteins to physically interact with and sequester a key pro-ovary factor β-CATENIN, which may lead to up-regulation of testis-specific pathway. Our data show that unlike previous association of WT1 and 46,XY DSD, ZF4 variants of WT1 are a relatively common cause of 46,XX TDSD/OTDSD. This expands the spectrum of phenotypes associated with WT1 variants and shows that the WT1 protein affecting ZF4 can function as a protestis factor in an XX chromosomal context.