Open Access

Mutation spectra and genotype‑phenotype analysis of congenital hypothyroidism in a neonatal population

  • Authors:
    • Xiang Huang
    • Qiaoyi Shao
    • Shi Weng
    • Wenfang Chen
    • Weixi Yuan
    • Jiayu Tan
    • Xuexi Yang
    • Xi Su
  • View Affiliations

  • Published online on: December 9, 2024     https://doi.org/10.3892/br.2024.1908
  • Article Number: 30
  • Copyright: © Huang et al. This is an open access article distributed under the terms of Creative Commons Attribution License.

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Abstract

Congenital hypothyroidism (CH) is a common neonatal endocrine disorder that is characterized by irreversible neurodevelopmental and growth retardation due to insufficient biosynthesis of thyroid hormones at birth. Determining the causative genetic variants in infants is important for neonatal management. It was aimed to evaluate the variant frequencies and spectrum of CH in the neonatal population of Foshan, China. A total of 105 unrelated patients with CH and 138 controls from a neonatal screening program in Foshan, China were selected. A multiplex PCR amplification‑based capture panel was performed which targeted the exon regions of 30 CH‑related genes. Next‑generation sequencing data were processed using an in‑house bioinformatics system. A total of 91 variants distributed across 16 genes were identified in 74.29% (78/105) of the patients, of which 16 were novel variants and 75 were known variants. The most frequently mutated gene was DOUX2, followed by TG, TSHR and TPO. Specifically, DUOX2 variants p.Lys530Ter, p.Arg683Leu, p.Arg1110Gln, and IVS28 + 1G>T were highly recurrent in the cohort of the present study. Bi‑allelic variants in DUOX2, TSHR and TPO were identified in 24.76% (26/105) of the patients. Monoallelic variants were identified in 28.57% (30/105) of the patients. Oligogenic variants were identified in 19.05% (20/105) of the patients. The most common variant combinations of oligogenic variants were DUOX2 and TG, and DUOX2 and SLC26A4. In addition, 2 patients harbored tri‑allelic and tetra‑allelic variants in DUOX2, respectively. In conclusion, DUOX2, TG, TSHR and TPO variants were the most common genetic defects in patients with CH in the neonatal population of Foshan. Specifically, biallelic DUOX2 variants were highly prevalent in the cohort. Further, the investigation provided a variant spectrum of CH‑related genes and identified novel variants, which may allow for an improved understanding of the underlying genetic etiology of CH and provide evidence for further molecular epidemiological investigations that can guide preventive and therapeutic programs.

Introduction

Congenital hypothyroidism (CH) is a common neonatal endocrine disorder that is characterized by irreversible neurodevelopmental and growth retardation due to insufficient biosynthesis of thyroid hormones. The incidence of CH is estimated to be between 1:2,000 and 1:4,000(1), based on newborn screening programs for CH that measure thyroid-stimulating hormone (TSH) and/or thyroxine (T4) levels. In China, the incidence of CH is estimated to be 5.77 per 10,000 live births (2). Previous studies have indicated an increase in the diagnosis of CH, particularly in cases of glands in situ (GIS) (3,4), which can be attributed to lower cut-off values for TSH during newborn screening (5). However, the etiology of CH remains unclear.

The majority of CH cases (80-85%) are attributed to thyroid dysgenesis (TD), which may manifest as athyreosis, hypoplasia, ectopic thyroid tissue, or a small thyroid gland. The remaining CH cases (15-20%) are attributed to thyroid dyshormonogenesis (DH), which presents with a normally located intact thyroid gland and, in some cases, compensatory goiter (6). Genetic defects in DUOX2, TG, TPO, SLC26A4, SLC5A5, DUOXA2 and IYD have been associated with inadequate thyroid hormone biosynthesis (7,8). Although TD is typically regarded as a sporadic disease, variants in 5 genes (GLIS3, TSHR, NKX2-1, PAX8 and FOXE1) have been reported as monogenic causes of TD (9). Additionally, genetic factors play a significant role in the etiology of some familial forms of TD (10-12). Furthermore, isolated central CH is associated with genes involved in hypothalamic-pituitary-thyroid axis regulation, including TRHR, TSHB and IGSF1 (13).

Next-generation sequencing (NGS) has enabled the genetic screening of patients with CH and comprehensive analysis of CH-related genes, which may reveal the complex genetic etiology and inheritance patterns of CH. Variants in CH-related genes have been identified in populations of different ethnicities from different regions (14-16). In China, multigenic screening of patients with CH and systematic analysis of genotype-phenotype correlations have been conducted in several provinces (17-19). However, little is known about the variant characteristics of CH-related genes in Foshan, China.

In the present study, an NGS panel containing 30 candidate genes was established for multigenic screening of 105 patients with CH, diagnosed through newborn screening programs in Foshan, China. Variant frequencies and the variant spectrum of CH in the neonatal population of Foshan were evaluated.

Materials and methods

Patients

The present retrospective study included 105 unrelated patients with CH and 138 controls at the Foshan Women and Children Hospital between December 2018 and September 2022 (Foshan, China). The inclusion and exclusion criteria for patients were as follows: Subjects with elevated TSH levels and decreased free thyroxine (FT4) levels who were born to non-consanguineous parents. The control subjects were healthy newborns with no detectable inherited metabolic disorders at newborn screening. Of the 105 patients, 56 were males and 49 were females. The median age of the patient cohort at diagnosis was 16 days, with a range of 6 to 355 days. CH diagnosis was based on TSH levels and FT4 levels in the neonatal screening program. Heel prick samples were collected on filter paper and TSH levels were analyzed by a time-resolved fluorescence-based assay using an Auto TRFIA-4 automatic fluorescence immunoassay analyzer (Guangzhou Fenghua Biotechnology Co., Ltd.; http://www.bio-fenghua.com/index.asp). Patients with high TSH (≥10 µIU/ml) levels were called back for further testing. Subsequently, serum TSH, FT4, free triiodothyronine, T4 and triiodothyronine levels were measured on the Roche Cobas e602 analyzer (Roche Diagnostics GmbH) using electrochemiluminescence immunoassays. Thyroid ultrasonography was performed to assess thyroid morphology whenever possible. The present study was approved (approval no. FSFY-MEC-2021-041) by the Medical Ethics Committee of the Foshan Women and Children Hospital, and written informed consent was obtained from the parents of all patients in accordance with the Declaration of Helsinki.

DNA extraction and sequencing

Genomic DNA was extracted from blood spot cards using Nucleic Acid Isolation or Purification Reagent (cat. nos DR-HS-004; Guangzhou Darui Biotechnology Co., Ltd.) according to the manufacturer's protocols. The NGS panel consisted of 30 candidate genes (BCHE, DUOX2, EZH2, GLI3, GLIS3, IYD, IGSF1, KAT6B, NEFL, NEFM, NKX2-1, NKX2-5, NSD1, PAX8, PHTF1, POU1F1, SERPINA7, TG, UBR1, SH2B3, SLC26A4, SLC5A5, SECISBP2, TPO, DUOXA2, FOXE1, LHX4, TRHR, TSHB and TSHR). Custom primers were designed to generate 687 amplicons. The target gene exon regions comprised 396 regions, and all exons along with 20 bp of the flanking introns of these regions were amplified by multiplex PCR. The total coverage of the target genes was >98% (Table SI). The Ion AmpliSeq Library Kit Plus and Ion Xpress Barcode Adapters Kits (cat. nos. A35907 and 4474517, respectively; both from Thermo Fisher Scientific, Inc.) were used to prepare DNA libraries for sequencing. The library was then quantified using the Equalbit 1X dsDNA HS Assay Kit (cat. no. EQ121-01; Vazyme, Biotech Co., Ltd.) and the Qubit Fluorometer 3.0 (Thermo Fisher Scientific, Inc.). Targeted sequencing was performed using a single-end 250 bp sequencing method on the DA8600 sequencer (Guangzhou Darui Biotechnology Co., Ltd.) with the Universal Sequencing Kit (semiconductor sequencing; cat. no. DR-CX-A001; Guangzhou Darui Biotechnology Co., Ltd.).

Bioinformatic analysis and classification of variants

The raw data generated by sequencing were analyzed using Torrent Suite Software (v.4.4.3) (Thermo Fisher Scientific, Inc.). Reads were aligned to the human reference genome (hg19) using the Torrent Mapping Alignment Program (v.4.4.11) (Thermo Fisher Scientific, Inc.). The coverage analysis plugin (v.4.4.2.2) (Thermo Fisher Scientific, Inc.) was used to assess the level of sequence coverage and overall quality of the targeted regions. The Variant Caller plugin (v.4.4.3.3) (Thermo Fisher Scientific, Inc.) was used to evaluate variants, and the called variants were annotated using Ensemble's Variant Effect Predictor (v.102) (grch37.ensembl.org/info/docs/tools/vep) based on the 1000 Genomes Project (http://www.1000genomes.org), dbSNP (http://www.ncbi.nlm.nih.gov/), Exome Aggregation Consortium (http://exac.broadinstitute.org/), ClinVar (http://www.ncbi.nlm.nih.gov/clinvar), Human Gene Mutation Database (http://www.hgmd.cf.ac.uk/), Genome Aggregation Database (http://gnomad.broadinstitute.org/), ESP6500 (http://evs.gs.washington.edu/EVS/), Ensembl (http://plants.ensembl.org/index.html), Refseq (http://www.ncbi.nlm.nih.gov/refseq/rsg), OMIM (https://omim.org/), and UCSC (https://genome.ucsc.edu). Functional predictions of the variants were evaluated using dbNSFP (v.4.1) (https://sites.google.com/site/jpopgen/dbNSFP) to obtain prediction scores based on Sorting Intolerant from Tolerant (http://sift-dna.org), Mutation Taster (http://www.mutationtaster.org/), Mutation Assessor (http://mutationassessor.org/r3/), ClinPred (https://sites.google.com/site/clinpred/), CADD (https://cadd.gs.washington.edu/), Polymorphism Phenotyping-2 (http://genetics.bwh.harvard.edu/pph2/), FATHMM (http://fathmm.biocompute.org.uk/), REVEL (https://sites.google.com/site/revelgenomics/), MetaSVM (http://genomics.usc.edu/members/15-member-detail/36-coco-dong), PROVEAN (http://provean.jcvi.org/index.php), LRT (http://www.genetics.wustl.edu/jflab/lrt_query.html), GERP (http://mendel.stanford.edu/SidowLab/downloads/gerp/), and SpliceAI (https://spliceailookup.broadinstitute.org/). The detected variants were classified into 5 categories according to the guidelines of the American College of Medical Genetics and Genomics, namely pathogenic, likely pathogenic, variants of uncertain significance, likely benign, or benign. Each pathogenic criterion was weighted as very strong (PVS1), strong (PS1-4), moderate (PM1-6), or supporting (PP1-5), while each benign criterion was weighted as stand-alone (BA1), strong (BS1-4), or supporting (BP1-6). The criteria were selected based on the evidence observed for the variants and then combined to choose a classification from the five categories (20). Variants classified as likely benign or benign were excluded from the subsequent analysis.

Results

Variant frequency in the study population

In total, 91 variants were identified in 78 of the 105 cases (74.29%). These variants were distributed across 16 genes (DUOX2, TG, TPO, DUOXA2, SLC26A4, SLC5A5, IYD, TSHR, GLIS3, KAT6B, NKX2-5, LHX4, POU1F1, SECISBP2, IGSF1 and TRHR). The most frequently mutated gene was DOUX2 (50.55%, 46/91), followed by TG (10.99%; 10/91), TSHR (8.79%; 8/91) and TPO (6.59%; 6/91). Two variants [p.Lys530Ter (DUOX2) and p.Gly132Arg (TSHR)] were homozygous, while the other variants were heterozygous (Table I). The clinical, biochemical and variant information of the 78 patients is shown in Table SII.

Table I

Spectrum of 91 variants in 16 genes.

Table I

Spectrum of 91 variants in 16 genes.

GeneNucleotide changeAmino acid changeExon/Intron positiondbSNP numberVariant typeStatusZygosityAllele frequency (gnomAD)Evidence of classificationVariant classificationNumbers of patients(Refs.)
DUOX2c.1588A>Tp.Lys530 TerExon 14rs180671269Stop gainedKnownHet/Hom0.0092PVS1_VeryStrong + PM2_SupportingLP20(21)
DUOX2c.3329G>Ap.Arg1110 GlnExon 25rs368488511MissenseKnownHet0.00244645PM3_VeryStrong + PM2_Supporing + PP1 + PS3_Supporting + PP3_ModerateP8(22)
DUOX2c.3693+ 1G>TIVS28+ 1G>TIntron 28rs200717240Splice donorKnownHet0.001413PM3_VeryStrong + PM2_Supporting + PM3_StrongP5(23)
DUOX2c.2654G>Ap.Arg885 GlnExon 20rs181461079MissenseKnownHet0.0011PM3_Strong + PM2_Supporting + PM5_Moderate + PP3 + PP1 + PS3 SupportingP3(21)
DUOX2c.596delp.Ser199 TrpfsTer122Exon 6rs766103168Frame-shiftKnownHet0.0002PVS1_VeryStrong + PM2_SupportingLP2(24)
DUOX2c.3616G>Ap.Ala1206 ThrExon 28rs762588205MissenseKnownHet0.0002PM3_Strong + PM2_Supporting + PS3_SupportingP1(25)
DUOX2c.1300C>Tp.Arg434 TerExon 12rs119472026Stop gainedKnownHet0.00010873PVS1_VeryStrong + PM3_VeryStrong + PM2_SupportingP1(26)
DUOX2c.2101C>Tp.Arg701 TerExon 17rs201109959Stop gainedKnownHet0.00010874PVS1_VeryStrong + PM3_Strong + PM2_SupportingP1(26)
DUOX2c.1708C>Tp.Gln570 TerExon 15rs1332668133Stop gainedKnownHet0.0003PVS1_VeryStrong + PM2_SupportingLP1(27)
DUOX2c.477delp.Glu160 ArgfsTer16Exon 5rs1480917996Frame-shiftKnownHetNAPVS1_VeryStrong + PM2_SupportingLP1(28)
DUOX2c.602dupp.Gln202 ThrfsTer99Exon 6rs567500345Frame shiftKnownHet0/0.001285PVS1_VeryStrong + PM3_VeryStrong + PM2_Supporting + PP1P1(29)
DUOX2c.2635G>Ap.Glu879LysExon 20rs774556391MissenseKnownHet0.00092421 PM3_Strong+PM2_Supporting + PP3_Moderate + PP1 + Supporting + PS3_SupportingLP3(21)
DUOX2c.2104_2106delp.Gly702delExon 17rs779340990Inframe deletionKnownaHet0.001033PM2_Supporting + PM4VUS2NA
DUOX2c.3285_3286delp.Ile1097 LeufsTer24Exon 25NAFrame-shiftNovelHetNAPVS1_VeryStrong + PM2_SupportingLP1NA
DUOX2c.2048G>Tp.Arg683 LeuExon 17rs8028305MissenseKnownHet0.00462107BS1_StrongVUS10(17)
DUOX2c.1268C>Tp.Thr423IleExon 12rs201197899MissenseKnownHet0.0016PM2_SupportingVUS3(30)
DUOX2c.3632G>Ap.Arg1211 HisExon 28rs141763307MissenseKnownHet0.0003262PP3_Strong + PM2_SupportingVUS3(23)
DUOX2c.1310G>Cp.Gly437AlaExon 12rs769796932MissenseKnownHet0.0017PP3 + PM2 SupportingVUS3(19)
DUOX2c.3689C>Tp.Ala1230 ValExon 28rs557220354MissenseKnownaHet0.0002175PM2_Supporting + BP4gVUS2NA
DUOX2c.505C>Tp.Arg169TrpExon 5rs201590426MissenseKnownHet0.001935PM2_Supporting + PM5VUS2(31)
DUOX2c.364C>Ap.Pro122ThrExon 5rs200265605MissenseKnownHet0.0004PM2_Supporting + BP4gVUS1(19)
DUOX2c.1428C>Ap.Asn476 LysExon 13rs199918362MissenseKnownHet0.0053BS1_Strong + BP4gVUS1(16)
DUOX2c.4537G>Cp.Gly1513 ArgExon 34rs748262140MissenseKnownHetNA/0.000002052PP3_Strong + PM2_SupportingVUS1(23)
DUOX2c.2291G>Ap.Arg764 GlnExon 18rs201884203MissenseKnownHet0.00010873PM2_SupportingVUS1(27)
DUOX2c.4561G>Tp.Gly1521 TerExon 34rs765781255Stop gainedKnownHet0.001PVS1_Moderate + PM2_SupportingVUS1(23)
DUOX2c.1946C>Ap.Ala649GluExon 17rs748793969MissenseKnownHet5.44E-05PM3_Strong + PM2_SupportingVUS1(21)
DUOX2c.1295G>Ap.Arg432HisExon 12rs530736554MissenseKnownHet0.0006PM2_SupportingVUS1(23)
DUOX2c.3251G>Ap.Arg1084 GlnExon 25rs558919433MissenseKnownHet0.0004PP3_Moderate + PM2_SupportingVUS1(32)
DUOX2c.4348T>Cp.Tyr1450 HisExon 32rs753591292MissenseKnownHet0.0004PP3 + PM2_SupportingVUS1(33)
DUOX2c.3595C>Gp.Leu1199 ValExon 28NAMissenseNovelHetNAPM2_SupportingVUS1NA
DUOX2 c.2335-25T>CIVS18-25T>CIntron 18NAIntronNovelHetNABP7_Supporting + PM2_SupportingVUS1NA
DUOX2c.1304A>Gp.Asp435 GlyExon 12rs772040742MissenseKnownHet0.00043492PP3 + PM2_SupportingVUS1(23)
DUOX2c.4408C>Tp.Arg1470 TrpExon 33rs200785525MissenseKnownHet0.0022PM2_Supporting + PP3_ModerateVUS1(18)
DUOX2c.1855G>Tp.Val619LeuExon 16rs768447406MissenseKnownaHet0.0007068BP4g + PM2_SupportingVUS1NA
DUOX2c.903G>Tp.Trp301CysExon 8rs568196384MissenseKnownHet0.0003263PP3 + PM2 SupportingVUS1(17)
DUOX2c.2412C>Gp.Cys804 TrpExon 19NAMissenseNovelHetNAPP3 + PM2_SupportingVUS1NA
DUOX2c.655_656 delinsTCp.Leu219 SerExon 6NAMissenseNovelHetNAPM2_SupportingVUS1NA
DUOX2c.646_647 insTTTCC CCCGp.Gln216 delinsLeu SerProGluExon 6rs1894400616Protein alteringKnownaHetNA/0.000016PM4 + PM2_SupportingVUS1NA
DUOX2c.647_658 del p.Gln216_Leu219delExon 6NAInframe deletionNovelHetNAPM4 + PM2_SupportingVUS1NA
DUOX2c.2921G>Ap.Arg974HisExon 22rs778216481MissenseKnownHet0.0013PP3 + PM2_SupportingVUS1(19)
DUOX2c.1127G>Ap.Arg376 GlnExon 10rs778729877MissenseKnownaHet0.00005437PM5 + PM2_SupportingVUS1NA
DUOX2c.514-2A>GIVS5-2A>Gintron 5NASplice acceptorKnownHetNAPVS1_VeryStrong + PM2_SupporingLP1(28)
DUOX2c.3374A>Gp.Asp1125 GlyExon 25NAMissenseNovelHetNAPP3_Moderate + PM2_SupportingVUS1NA
DUOX2c.4375G>Ap.Asp1459 AsnExon 32rs199546504MissenseKnownHet0.0005PM2_SupportingVUS1(27)
DUOX2c.2894C>Tp.Ser965LeuExon 22rs144153950MissenseKnownHet0.0005PM2_SupportingVUS1(18)
DUOX2c.1393C>Ap.Pro465ThrExon 12rs774177514MissenseKnownaHetNABP4 + PM2_SupportingVUS1NA
DUO- XA2c.738C>Gp.Tyr246TerExon 5rs4774518Stop gainedKnownHet0.0019PVS1_Strong + PM3_Strong + PM2_Supporting + PS3_SupportingP1(34)
DUO XA2c.413dupp.Tyr138TerExon 4rs778410503Frame-shiftKnownHet0.0033PVS1_VeryStrong + PM2_SupporingLP1(35)
GLIS3c.1982delp.Lys661 SerfsTer145Exon 6NAFrameshiftNovelHetNAPVS1_VeryStrong + PM2_SupporingLP2NA
GLIS3c.1843G>Ap.Ala615ThrExon 5rs752946704MissenseKnownaHet0.000054371PM2_SupportingVUS1NA
GLIS3c.2723C>Tp.Ala908ValExon 11rs140101069MissenseKnownHet0.004245BP4 + PM2_SupportingVUS1(36)
IGSF1c.584G>Cp.Gly195AlaExon 5rs745841814MissenseKnownaHet0.0003PM2_SupportingVUS1NA
IYDc.688-7G>AIVS4-7G>AIntron 4rs1778273239Splice regionKnownaHetNA/0.000001446 BP4+PM2_SupportingVUS1NA
IYDc.380C>Tp.Pro127LeuExon 3rs372196319MissenseKnownaHet0.0001089PP3_Moderate + PM2_SupportingVUS1NA
KAT6Bc.1025T>Cp.Ile342ThrExon 7rs182392778MissenseKnownaHet0.0028BS1_StrongVUS2NA
LHX4c.970G>Ap.Ala324ThrExon 6rs544059210MissenseKnownHet0.00005437PM2_SupportingVUS1(37)
LHX4c.1127C>Tp.Thr376IleExon 6rs1334926032MissenseKnownaHetNAPM2_SupportingVUS1NA
NKX2-5c.773G>Cp.Gly258AlaExon 2NAMissenseNovelHetNAPP2 + PM2_SupportingVUS1NA
POU 1F1c.744-6C>AIVS5-6C>AIntron 5NAIntronNovelHetNAPP3_Moderate + PM2_SupportingVUS1NA
SECIS BP2c.1212+ 4C>TIVS8+4C>TIntron8NAIntronNovelHetNABP4 + PM2_SupportingVUS1NA
SLC26 A4c.919-2A>GIVS7-2A>GIntron 7rs111033313Splice acceptorKnownHet0.0048PVS1_VeryStrong + PM3_VeryStrong + PM2_Supporting + PP1 + PS3_SupportingP1(38)
SLC26 A4c.2086C>Tp.Gln696TerExon 18rs752807925Stop gainedKnownHet0.0002PVS1_VeryStrong + PM3_VeryStrong + PM2_SupportingP1(39)
SLC26 A4c.269C>Tp.Ser90LeuExon 3rs370588279MissenseKnownHet0.00005437PM3_VeryStrong + PM1 + PP2 + PM2_Supporting + PP3 + PS3_SupportingP1(40)
SLC26 A4c.-3-46C>TIVS1-46C> TIntron 1NAIntronNovelHetNABP7 + PM2_SupportingVUS1NA
SLC26 A4c.697G>Cp.Val233LeuExon 6rs397516431MissenseKnownHet0.0014135PM3_Strong + PM1 + PP2 + PM2_Supporting + PP3VUS1(41)
SLC5A5c.1499C>Tp.Pro500LeuExon 12rs531134045MissenseKnownaHet0.0003PM2_SupportingVUS1NA
TGc.5512delp.Asp1838 ThrfsTer14Exon 29NAFrame-shiftNovelHetNAPVS1_VeryStrong + PM2_SupporingLP1NA
TGc.5854C>Tp.Arg1952 TrpExon 31rs369705913MissenseKnownaHet0.00010903PM2_SupportingVUS1NA
TGc.3641G>Ap.Arg1214 GlnExon 17rs200877580MissenseKnownaHet0.0002BP4 + PM2_SupportingVUS1NA
TGc.635A>Gp.Asn212 SerExon 5rs187737243MissenseKnownaHet0.0021BP4VUS1NA
TGc.1597G>Ap.Gly533 ArgExon 9NAMissenseNovelHetNAPM2_SupportingVUS1NA
TGc.958C>Tp.Arg320 CysExon 8rs138561283MissenseKnownaHet0.0008PM2_SupportingVUS1NA
TGc.7753C>Tp.Arg2585 TrpExon 44rs114211101MissenseKnownHet0.00513651BS1VUS1(18)
TGc.8205delp.Gln2736 SerfsTer10Exon 48rs758002273Frame-shiftKnownaHet0.0014PVS1_Moderate + PM2_SupporingVUS1NA
TGc.925A>Gp.Thr309AlaExon 8rs199712883MissenseKnownHet0.001BP4 + PM2_SupportingVUS1(16)
TGc.3040G>Ap.Asp1014 AsnExon 12rs114772213MissenseKnownHet0.0005BP4 + PM2_SupportingVUS1(42)
TPOc.2268dupp.Glu757TerExon 13rs770781635Frame-shiftKnownHet0.0016PVS1_VeryStrong + PM3_VeryStrong + PM2_SupportingP1(43)
TPOc.2146G>Tp.Glu716TerExon 12NAStop gainedNovelHetNAPVS1_VeryStrong + PM2_SupporingLP1NA
TPOc.2017G>Ap.Glu673 LysExon 12rs201193196MissenseKnownHet0.0007PP3 + PM2_SupportingVUS1(44)
TPOc.2603C>Tp.Thr868 MetExon 15rs201576336MissenseKnownaHet0.0009PM2_SupportingVUS1NA
TPOc.2536C>Tp.Arg846 TrpExon 15rs28913014MissenseKnownHet0.0017BS1 + BS2_SupportingVUS1(45)
TPOc.1367G>Ap.Arg456 LysExon 9rs1329337261MissenseKnownaHet0PM2_SupportingVUS1NA
TRHRc.504T>Gp.Ile168MetExon 2rs13306060MissenseKnownHet0.0024 BP4+PM2_SupportingVUS1(46)
TSHRc.2272G>Ap.Glu758 LysExon 10rs746522401MissenseKnownHet0.0003262PM2_SupportingVUS1(32)
TSHRc.740T>Cp.Val247AlaExon 2NAMissenseNovelHetNABP4 + PM2_SupportingVUS1NA
TSHRc.394G>Cp.Gly132 ArgExon 5rs760874290MissenseKnownHom0.00054413PS4+PM2_Supporting + PP3_SupportingVUS1(47)
TSHRc.823G>Ap.Ala275ThrExon 9rs180762551MissenseKnownHet0.0003262PP3 + PM2_SupportingVUS1(48)
TSHRc.915T>Ap.Ser305ArgExon 10rs142122217MissenseKnownHet0.0033NAVUS1(48)
TSHRc.1492G>Ap.Gly498SerExon 10rs1376842882MissenseKnownHetNAPM2_Supporting + PP3_Moderate + PM1VUS1(49)
TSHRc.694G>Cp.Asp232HisExon 9rs752791414MissenseKnownaHet0.00005437PP3_Moderate + PM2_SupportingVUS1NA
TSHRc.1960A>Tp.Ile654PheExon 10rs767239688MissenseKnownaHet0.0002PP3_Strong + PS4 + PM2_SupportingP1NA

[i] aVariants recorded in database of dbSNP or gnomAD. NA, data not available; Het, heterozygous; Hom, homozygous; P, pathogenic; LP, likely pathogenic; VUS, variants of uncertain significance.

Biallelic variants were identified in 24.76% (26/105) of patients with CH: In DUOX2 (24 cases), TSHR (1 case) and TPO (1 case). In addition, monoallelic variants were identified in 28.57% (30/105) of the patients: In DUOX2 (18 cases), TSHR (3 cases), TG (2 cases), GLIS3 (2 cases), SLC5A5 (1 case), DUOXA2 (1 case), IYD (1 case), TPO (1 case) and KAT6B (1 case). Oligogenic variants were identified in 19.05% (20/105) of the patients. The most common variant combinations of oligogenic variants were DUOX2 and TG (2 cases), and DUOX2 and SLC26A4 (2 cases). In total, 2 patients harbored tri-allelic and tetra-allelic variants in DUOX2, respectively. Notably, 71.43% (75/105) of the patients harbored variants in at least one gene involved in thyroid hormone biosynthesis (9) (DUOX2, TG, TPO, DUOXA2, SLC26A4, SLC5A5, IYD and TSHR) (Table SII).

Analysis of pathogenicity

Of the 91 variants across 16 genes, 16 were novel variants, while 75 variants had been previously reported in literature and databases. A total of 13 of the known variants were classified as pathogenic, including 7 variants in DUOX2 (p.Arg1110Gln, IVS28+1G>T, p.Arg885Gln, p.Ala1206Thr, p.Arg434Ter, p.Arg701Ter and p.Gln202ThrfsTer99), 3 in SLC26A4 (IVS7-2A>G, p.Gln696Ter and p.Ser90Leu), 1 in TPO (p.Glu757Ter), 1 in TSHR (p.Ile654Phe) and 1 in DUOXA2 (p.Tyr246Ter). A total of 7 known variants were likely pathogenic, including 6 DUOX2 variants (p.Lys530Ter, p.Ser199TrpfsTer122, p.Gln570Ter, p.Glu160ArgfsTer16, p.Glu879Lys and IVS5-2A>G) and 1 of DUOXA2 (p.Tyr138Ter). A total of 4 novel variants were likely pathogenic [p.Ile1097LeufsTer24 (DUOX2), p.Lys661SerfsTer145 (GLIS3), p.Asp1838ThrfsTer14 (TG) and p.Glu716Ter (TPO)]. Furthermore, 67 variants were classified as variants of uncertain significance (Table I).

The types of variants identified in our cohort are shown in Fig. 1. Most variants were missense variants (69.23%; 63/91), followed by frameshift variants (9.89%; 9/91), stop gained variants (8.79%; 8/91) and intron variants (4.40%; 4/91). Inframe deletion, splice acceptor, protein altering, splice donor and splice region variants were also identified in the present study. In addition, 7 known missense variants in DUOX2 [p.Arg683Leu (n=10), p.Arg1110Gln (n=8), p.Arg885Gln (n=3), p.Glu879Lys (n=3), p.Thr423Ile (n=3), p.Arg1211His (n=3) and p.Gly437Ala (n=3)] were highly prevalent in the cohort (Table I). A total of 20 patients harbored a stop gained variant in DUOX2 (p.Lys530Ter). A known splice donor variant (IVS28 + 1G>T) in DUOX2 was detected in 5 patients (Table SII).

Genotype-phenotype correlation in patients with CH

Of the 78 patients (34 females and 44 males) with variants, 73 patients had normal or goitrous thyroid glands, which may be associated with GIS. Only 1 patient had athyreosis with a monoallelic GLIS3 mutation (p.Ala908Val). Thyroid morphology was not detected in 4 patients. A total of 7 patients (patients 5,12, 30, 37, 40, 62 and 63) were preterm infants with normal thyroid glands, 5 of whom harbored rare variants in SLC5A5, GLIS3, POU1F1, DUOXA2, or KAT6B. Furthermore, 10 patients had a family history of thyroid disease, of which 7 (patients 8, 29, 48, 50, 64, 73 and 74) harbored biallelic or monoallelic DUOX2 variants with eutopic thyroid glands of normal size, and goiter was noted in only 1 case (patient 10) with monoallelic TG mutations (p.Asn212Ser). Notably, patient 54 harbored tetra-allelic variants in DUOX2 (p.Arg683Leu, p.Leu219Ser, p.Gln216delinsLeuSerProGlu and p.Gln216_Leu219del).

Discussion

In the present study, a cohort of 105 patients with CH was comprehensively screened using NGS to analyze the variant frequencies and variant spectrum of CH in the neonatal population of Foshan. Variants in CH-related genes were identified in 74.29% (78/105) of patients. DUOX2, TG, TSHR and TPO were the most frequently mutated genes, similar to a previous study in Chinese patients with CH (48).

Variants in DUOX2 have been reported to be a common cause of CH in patients of Chinese and East Asian ethnicities, often resulting in DH with a normal-sized eutopic or goitrous thyroid gland owing to decreased H2O2 production in the thyroid (33,50). Among the 105 patients, 46 different DUOX2 variants were identified in 61 patients (58.10%; 61/105), reflecting the high prevalence of DUOX2 variants in patients in the present study, which is consistent with previous studies in Chinese populations (17,19). Moreover, 4 known DUOX2 variants, p.Lys530Ter, p.Arg683Leu, p.Arg1110Gln, and IVS28 + 1G>T, were highly recurrent in the cohort of the present study. The most common variant detected in the present study was p.Lys530Ter. Consistent with the findings of the present study, Tan et al (28) and Fu et al (17) reported p.Lys530Ter to be the most common variant in Chinese populations. In the present study, 25.71% (27/105) of the patients had monoallelic variants in DUOX2, 29.52% (31/105) had biallelic variants in DUOX2 and 1.90% (2/105) had tri-allelic variants in DUOX2 (patients 13 and 69). In addition, 1 patient (patient 54) with tetra-allelic variants in DUOX2, whose brother was also diagnosed with CH was also identified. However, additional information regarding patients 13, 54 and 69 has not been collected, which limited the evaluation of their types or inheritance patterns of CH.

TG variants have been reported to affect the synthesis and storage of thyroid hormones, resulting in hypothyroidism with compensatory goiter (51). The variant frequency for TG in the cohort of the present study was 9.52% (10/105), which was higher than that reported for Japanese patients (2.82%) (52). In total, 8/10 patients with TG variants in the cohort harbored monoallelic heterozygous TG variants in combination with other CH-related genes, suggesting that oligogenic involvement may contribute to the genetic etiology of some patients with CH. The TG variant p.Arg2585Trp has been reported in both Chinese and Japanese populations (24,53).

Inactivating variants in TSHR cause TSH resistance, which negatively affects thyroid growth, and stimulates thyroid hormone synthesis and release (7). Monoallelic TSHR variants were identified in 6 patients (5.71%; 6/105), and DUOX2 or TG variants were found along with TSHR variants in 3/6 patients with TSHR variants. Biallelic variants in TSHR were identified in 1 patient whose sister also had CH. In contrast to Chinese populations, TSHR variants are the most common genetic defects in patients with CH (10.9%) in Saudi Arabia (54). In the present study, TSHR variants-p.Glu758Lys, p.Ala275Thr and p.Ser305Arg-were reported in the Chinese population (32,48,55). p.Gly132Arg has been frequently reported in patients with CH of Chinese (50), Japanese (47) and Korean (14) ethnicities. In total, 1 patient in the cohort has a homozygous TSHR variant p.Gly132Arg. p.Gly498Ser has been previously reported in the Japanese population, and its low expression is likely to affect the functions of the TSH receptor (49).

TPO plays an important role in thyroid hormone biosynthesis and variants in TPO have been reported to be highly prevalent in patients with DH-associated CH of Caucasian (56) and Malaysian-Chinese (57) ethnicities. In the cohort of the present study, the variant rate for TPO was ~4.76% (5/105), which was lower than that reported in other populations. The stop gained variant p.Glu757Ter identified in the cohort of the present study has been reported as a common cause of CH in Taiwanese (43).

In addition, no definite pathogenic or likely pathogenic variants were identified in IYD, SLC5A5, LHX4, IGSF1, KAT6B, NKX2-5, POU1F1, SECISBP2, or TRHR in the cohort. Moreover, variants in these genes appear to be rare: Only 1 or 2 variants were identified for each of these genes, and are usually associated with variants in other genes, especially DUOX2 or TG.

A previous study reported that oligogenic variants are common in sporadic CH (16), suggesting that a combination of rare variations in CH-related genes may underlie the complex genetic etiology of CH. In the present study, oligogenic variants were detected in 19.05% (20/105) of the patients, and the combination of DUOX2, TG, TPO and TSHR variants was noted frequently. There is some evidence that suggests that patients with tri-allelic variants have permanent CH (17). However, one of the limitations of the present study is that the clinical phenotypes of all patients with CH in the cohort of the present study were not clearly elucidated; therefore, the association between the function of oligogenic variants and the hypothyroid phenotype remains unclear.

In conclusion, DUOX2, TG, TSHR and TPO variants were the most common genetic defects in patients with CH in the neonatal population of Foshan. Specifically, biallelic DUOX2 variants were highly prevalent in the study population. Based on the findings of the present study, the authors suggest that oligogenic variants in CH-related genes may contribute to the complex genetic etiology of CH. Further, the present investigation provides a detailed variant spectrum of CH-related genes and identifies novel variants, which may allow for an improved understanding of the underlying genetic etiology of CH and provide evidence for further molecular epidemiological investigations that can guide preventive and therapeutic programs in Foshan, China.

Supplementary Material

List and the coverage of the 30 candidate genes included in the NGS panel.
Clinical features and genotypical data in 78 patients with congenital hypothyroidism.

Acknowledgements

Not applicable.

Funding

Funding: The present study was supported by the Scientific Research Fund of Women and Children's Medical Research Center of Foshan Women and Children Hospital (grant no. FEYJZX-2020-003) and the Foshan Genetic Metabolic Disease Molecular Diagnosis and Treatment Engineering Technology Research Center (grant no. 2120001009239).

Availability of data and materials

The data generated in the present study may be found in the Genome Sequence Archive for Human under accession number HRA008474 or at the following URL: https://ngdc.cncb.ac.cn/gsa-human/s/U36l4c36.

Authors' contributions

WC collected the patients' blood samples. WC, SW and WY performed the experiments. XH, QS and JT analyzed and interpreted the data. SW, XY and XH drafted and wrote the manuscript. XH, XY and SW participated in discussing and revising the manuscript. XS and XY conceived and designed the study. XS, XH and JT contributed to overall senior mentorship and guidance and support to the project. XH and SW confirm the authenticity of all the raw data. All authors read and approved the final version of the manuscript.

Ethics approval and consent to participate

The present study was approved by the Medical Ethics Committee of the Foshan Women and Children Hospital (Foshan, China) on 12 March 2021 (approval no. FSFY-MEC-2021-041), and the renewal date of the ethics approval was 22 May 2025. Written informed consent was obtained from the parents/guardians of all patients and controls in accordance with the Declaration of Helsinki.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Huang X, Shao Q, Weng S, Chen W, Yuan W, Tan J, Yang X and Su X: Mutation spectra and genotype‑phenotype analysis of congenital hypothyroidism in a neonatal population. Biomed Rep 22: 30, 2025.
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Huang, X., Shao, Q., Weng, S., Chen, W., Yuan, W., Tan, J. ... Su, X. (2025). Mutation spectra and genotype‑phenotype analysis of congenital hypothyroidism in a neonatal population. Biomedical Reports, 22, 30. https://doi.org/10.3892/br.2024.1908
MLA
Huang, X., Shao, Q., Weng, S., Chen, W., Yuan, W., Tan, J., Yang, X., Su, X."Mutation spectra and genotype‑phenotype analysis of congenital hypothyroidism in a neonatal population". Biomedical Reports 22.2 (2025): 30.
Chicago
Huang, X., Shao, Q., Weng, S., Chen, W., Yuan, W., Tan, J., Yang, X., Su, X."Mutation spectra and genotype‑phenotype analysis of congenital hypothyroidism in a neonatal population". Biomedical Reports 22, no. 2 (2025): 30. https://doi.org/10.3892/br.2024.1908