Comprehensively identifying and validating the implications of NR5A1 and DHX37 variants for 46,XY disorders of sex development diagnosis

Background: The clinical phenotype and pathogenic mechanism of 46,XY disorders of sex development (DSD) are complex, and several pathogenic variants are identified by next-generation sequencing. However, these variants currently require additional interpretation and validation prior to their application in 46,XY DSD diagnosis and clinical guidance. Results: Here, we identified three genetic variants in two 46,XY DSD patients by whole exome sequencing screening and Sanger sequencing validation. The pathogenicity of three genetic variants was identified by in silico analysis and functional experiments. One patient carrying the reported pathogenic variant (c.319 C > T) of NR5A1 showed a phenotype of 46,XY complete gonadal dysgenesis, which was different from the reported 46,XY partial gonadal dysgenesis. These findings suggested that the variant (c.319 C > T) of NR5A1 contributes to the clinical phenotypic heterogeneity of 46,XY DSD. The other patient carried two genetic variants, among which the c.1252 C > T variant of NR5A1 produced truncated protein and lost the transcriptional activation of NR5A1 to the targeted genes. The other c.769G > A variant of DHX37 had no significant effect on the expression level and cellular localization of DHX37, and the downstream signaling pathway of DHX37. Moreover, the in silico and structural analysis identified the c.769G > A variant of DHX37 as a deleterious variant that may affect DHX37 function. According to the American College of Medical Genetics and Genomics guidelines and relevant literature reports, combined with the patient’s clinical phenotype and pedigreed analysis, it is proposed that the likely pathogenic variant identified in this patient is the c.1252 C > T variant of NR5A1. Nonetheless, the potential pathogenicity of the DHX37 (c.769G > A) variant of this patient also merits further investigation and consideration. Conclusions: Our results have expanded the clinical phenotype spectrum and genetic diagnosis spectrum of 46,XY DSD, which will contribute to the accurate diagnosis and treatment guidance for 46,XY DSD patients and provide evidence-based genetic counseling for 46,XY DSD family fertility.