2 52 Running title: Loss of UGP2 causes a severe epileptic encephalopathy 53 54 55 Abstract: 60 Developmental and/or epileptic encephalopathies (DEEs) are a group of devastating genetic 61 disorders, resulting in early onset, therapy resistant seizures and developmental delay. Here we 62 report on 12 individuals from 10 families presenting with a severe form of intractable epilepsy, 63 severe developmental delay, progressive microcephaly and visual disturbance. Whole exome 64 sequencing identified a recurrent, homozygous variant (chr2:64083454A>G) in the essential UDP-65 glucose pyrophosphorylase (UGP2) gene in all probands. This rare variant results in a tolerable 66Met12Val missense change of the longer UGP2 protein isoform but causes a disruption of the start 67 codon of the shorter isoform. We show that the absence of the shorter isoform leads to a reduction 68 of functional UGP2 enzyme in brain cell types, leading to altered glycogen metabolism, upregulated 69unfolded protein response and premature neuronal differentiation, as modelled during pluripotent 70 stem cell differentiation in vitro. In contrast, the complete lack of all UGP2 isoforms leads to 71 differentiation defects in multiple lineages in human cells. Reduced expression of Ugp2a/Ugp2b in 72 vivo in zebrafish mimics visual disturbance and mutant animals show a behavioral phenotype. Our 73 study identifies a recurrent start codon mutation in UGP2 as a cause of a novel autosomal recessive 74 DEE. Importantly, it also shows that isoform specific start-loss mutations causing expression loss of a 75 tissue relevant isoform of an essential protein can cause a genetic disease, even when an organism-76 wide protein absence is incompatible with life. We provide additional examples where a similar 77 disease mechanism applies. 78 79 80 81 82 83 84 85 86 87 3 Introduction: 88 Developmental and/or epileptic encephalopathies (DEEs) are a heterogeneous group of genetic 89 disorders, characterized by severe epileptic seizures in combination with developmental delay or 90 regression 1 . Genes involved in multiple pathophysiological pathways have been implicated in DEEs, 91 including synaptic impairment, ion channel alterations, transporter defects and metabolic processes 92 such as disorders of glycosylation 2 . Mostly, dominant acting, de novo mutations have been identified 93 in children suffering from DEEs 3 , and only a limited number of genes with a recessive mode of 94 inheritance are known so far, with a higher occurrence rate in consanguineous populations 4 . A recent 95 cohort study on DEEs employing whole exome sequencing (WES) and copy-number analysis, 96however, found that up to 38% of diagnosed cases might be caused by recessive genes, indicating 97 that the importance of this mode of inheritance in DEEs has been underestimated 5 . 98