As genetic testing has become more accessible and affordable, variants of uncertain significance (VUS) are increasingly identified, and determining whether these variants play causal roles in disease is a major challenge. The known disease-associated Annexin A11 (ANXA11) mutations result in ANXA11 aggregation, alterations in lysosomal-RNA granule co-trafficking, and TDP-43 mis-localization and present as amyotrophic lateral sclerosis or frontotemporal dementia. We identified a novel VUS in ANXA11 (P93S) in a kindred with corticobasal syndrome (CBS) and unique radiographic features that segregated with disease. We then queried neurodegenerative disorder clinic databases and mutations in ANXA11 were found in association with clinically diagnosed CBS, thereby establishing CBS as part of ANXA11 clinical spectrum. In iPSC-derived neurons expressing mutant ANXA11 we investigated the impact of this variant on known ANXA11 function and found decreased colocalization of lysosomes and decreased neuritic RNA as well as decreased nuclear TDP-43 and increased formation of cryptic exons compared to controls. Single-cell sequencing and proteomic analysis of the P93S variant in iPSC-derived neurons and microglia reveal that immune dysregulation and interferon signaling pathways in microglia are central to disease. Collectively, these findings identify a new pathogenic variant in ANXA11, expand the range of clinical syndromes caused by ANXA11 mutations, and implicate both neuronal and microglia dysfunction in ANXA11 pathophysiology. This work illustrates the potential for iPSC-derived cellular models to revolutionize the variant annotation process and provides a generalizable approach to determining the causality of novel variants across genes.
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