2). A 6.3 Mb region of homozygosity on chromosome 16 (25,073063-31,378235) that was shared by the proband and her affected cousin but not with the unaffected cousin harbored an excellent candidate gene,

HSD3B7. We PCR-amplified and sequenced Enzalutamide cell line the coding region of HSD3B7 in the proband using flanking oligonucleotides to amplify each of the nine exons of the gene.3 The proband and her affected first cousin (III.5) were both homozygous for a 2-basepair deletion in exon 1 of HSD3B7 (c.45_46del AG, p.T15Tfsx27) that was not present in the unaffected cousin. Exon 1 of HSD3B7 was then sequenced in the other family members. Both parents of the affected first cousin (III.5) were heterozygous CH5424802 order for the mutation. The proband’s parents were not available for sampling but four of their siblings were heterozygous for the mutation (II.2, II.4, II.7, and II.14) (Fig. 1). We confirmed the diagnosis of 3β-HSD deficiency by using negative ion FAB-MS21 to analyze the bile acids in the serum of family member III.5. The results definitively established a defect in bile acid synthesis consistent with a deficiency in the activity

of 3β-HSD (formally called 3β-hydroxy-Δ5-C27 steroid dehydrogenase/isomerase). The negative ion mass spectrum of the serum (Fig. 3) was remarkable in revealing the presence of ions consistent with an array of atypical bile acids not normally detected in serum by FAB-MS. The triplets of ions at m/z 453, 469, and 485 (sulfate conjugates) and m/z 510, 526, and 542 (glyco-sulfate conjugates) are characteristic of monohydroxy, dihydroxy, and trihydroxy bile acids, respectively, with a structural feature of a 3β-hydroxy-Δ5 structure (i.e., unsaturated C24 bile acids), respectively, and these are signature metabolites for this genetic defect Low-density-lipoprotein receptor kinase in bile acid synthesis.2, 21 There was a complete absence of the glycine and taurine conjugates of the primary bile acids of cholic (m/z 498 and 514) and chenodeoxycholic acids (m/z 448 and 464), typically observed

in patients with cholestasis when bile acid synthesis is intact. Family member III.5 was referred to a hepatologist to commence treatment with bile acids. Here we report the identification of a family with 3β-HSD deficiency in which affected individuals show striking phenotypic variability. The proband had chronic liver disease from childhood, but survived without medical care into her early 20s and then died at age 24. Her paternal first cousin (III.1) died at age 6 years of liver disease. The sister of III.1 (III.5) had an apparently self-limited liver disorder in childhood that was severe enough to require multiple hospitalizations and yet she has been asymptomatic for the last 22 years. We confirmed that she was homozygous for a null allele of HSD3B7, yet her liver function tests were normal at age 32 years. The lack of 3β-HSD activity was biochemically confirmed by FAB-MS analysis of the serum.