Fig. 1: Bi-allelic variants in ATG4D segregate with a neurodevelopmental disorder in three individuals from two unrelated families.

a Neuroimaging of Individual 1 showing mild cerebellar atrophy disproportionately involving the superior cerebellar hemispheres and vermis at 5 years 3 months (arrowhead in T2-weighted sagittal view image, left panel). There were no remarkable neuroimaging findings for Individual 2 at 1 year 3 months (arrow in T1-weighted sagittal view image, right panel). b Photographs of the affected individuals showing a common facial gestalt characterized by almond-shaped eyes, a depressed nasal bridge, and a prominent Cupid’s bow. Age at the time of the photos is 5 years 3 months for Individual 1, 4 years 8 months for Individual 2, and 3 years 5 months for Individual 3. Written consent was obtained for the publication of photographs. c The pedigrees of two unrelated families with at least one affected individual exhibiting a neurodevelopmental disorder show segregation of compound heterozygous ATG4D variants with disease. d Schematic of the ATG4D gene showing the relative location of each variant (asterisks). The schematic is to scale, while the variant position is approximate. e Schematic of the ATG4D cysteine protease and its functional domains including the peptidase family C54 domain (dark gray), a cryptic mitochondrial signal peptide (light green), a BH3 domain (green), and a caspase 3 cleavage site (arrowhead). The location of the predicted amino acid changes is indicated (asterisks). The schematic and variant position are to scale. f Alignment of missense variants in ATG4D across multiple species including human (Homo sapiens), chimpanzee (Pan troglodytes), mouse (Mus musculus), dog (Canine familiaris), African clawed frog (Xenopus laevis), zebrafish (Danio rerio), fruit fly (Drosophila melanogaster), nematode (Caenhabdoritis elegans), and budding yeast (Saccharomyces cerevisiae). The amino acid residue of interest is indicated by the arrowhead and the level of conservation is indicated by the intensity of the color.