A novel variant of NOTCH2 causes skeletal fragility

A 2-month-old female child presented with a low-trauma femoral fracture, low bone mass, bowing of long bones, loss of height of a thoracic vertebra, and Wormian bones. Exome sequencing revealed the presence of a novel heterozygous 4006G > C pG1336R mutation in exon 25 of NOTCH2 in the child and her father. In silico analysis considered the variant as likely deleterious. CRISPR/Cas9 was used to introduce the Notch2^4006G>C mutation into Notch2 to create Notch2^em1Ecan mutant mice. Homozygous Notch2^em1Ecan mutant mice were active, appeared healthy, had normal femoral length, but lower weights than controls. μCT of the distal femur revealed a 25 % decrease in trabecular bone volume, and a decrease in total, bone and marrow area, in periosteal perimeter and polar moment of inertia, revealing the presence of small and potentially fragile bones. Three-point bend testing demonstrated decreased toughness in Notch2^em1Ecan femurs. Cancellous bone histomorphometry demonstrated decreased eroded surface, and Raman spectroscopy revealed normal mineral to matrix ratios, carbonate:phosphate and collagen peak ratios. A structure homology model of NOTCH2 EGF33-36 repeats suggests that the G1336R mutation may disrupt the local structure, reducing the flexibility of the extracellular domain and thereby affecting receptor activation and signaling. Indeed, there was a modest decrease in Notch canonical target genes in osteoblasts from Notch2^em1Ecan mice. Osteoblast and osteoclast differentiation were diminished in cells from Notch2^em1Ecan mice. In conclusion, a novel mutation affecting the NOTCH2 extracellular domain is associated with small and apparently fragile bones, possibly due to altered Notch signaling.