Respiratory Involvement in HIST1H1E-Related Rahman Syndrome: A Case of Severe Mixed Apnea

Rahman syndrome (HIST1H1E-related neurodevelopmental syndrome, OMIM #617537) is a rare autosomal-dominant condition caused by truncating variants in the C-terminal domain of the HIST1H1E gene. It is characterized by macrocephaly, hypotonia, craniofacial anomalies, and multisystem anomalies. Although multisystem involvement has been increasingly described, respiratory manifestations remain sparsely documented. We report a female infant with mosaic HIST1H1E truncation (c.435dupC; p.Thr146Hisfs*50) who presented with severe mixed sleep apnea secondary to laryngomalacia, requiring two airway surgeries and multidisciplinary management. Despite surgical intervention, polysomnography demonstrated persistent mixed apneas, suggesting both structural and central components. Brain MRI revealed nonspecific ischemic changes that could contribute to the neurological phenotype. To contextualize this observation, we reviewed 70 published cases of Rahman syndrome. Respiratory involvement was reported in only 13.5% (neonatal respiratory distress), 2.8% (upper-airway anomalies), and 1.4% (sleep-disordered breathing), frequencies comparable to those in the general population, although most reports lacked systematic respiratory evaluation. These findings suggest that respiratory morbidity may be under-evaluated rather than absent in Rahman syndrome. The combination of hypotonia, craniofacial restriction, and possible brain-stem dysregulation provides a plausible pathophysiologic substrate for both central and obstructive apnea. We recommend considering airway assessment and polysomnography in affected individuals presenting with stridor, desaturations, or sleep-related breathing difficulties. This case further expands the phenotypic spectrum of HIST1H1E-related disorders and represents the first documented example of mosaicism associated with this condition.