Defect of GTPBP3, the human mitochondrial tRNA-modifying enzyme, can lead to Combined Oxidative Phosphorylation Deficiency 23 (COXPD23). Up to now, about 20 different variants of the GTPBP3 gene have been reported; however, genotype–phenotype analysis has rarely been described. Here, we reported a 9-year-old boy with COXPD23 who presented with hyperlactatemia, hypertrophic cardiomyopathy, seizures, feeding difficulties, intellectual disability and motor developmental delay, and abnormal visual development. Biallelic pathogenic variants of the GTPBP3 gene were identified in this boy, one novel variant c.1102dupC (p. Arg368Profs*22) inherited from the mother and the other known variant c.689A>C (p. Gln230Pro) inherited from father. We curated 18 COXPD23 patients with GTPBP3 variants to investigate the genotype–phenotype correlation. We found that hyperlactatemia and cardiomyopathy were critical clinical features in COXPD23 and the average onset age was 1.7 years (3 months of age for the homozygote). Clinical classification of COXPD23 for the two types, severe and mild, was well described in this study. We observed arrhythmia and congestive heart failure frequently in the severe type with early childhood mortality, while developmental delay was mainly observed in the mild type. The proportion of homozygous variants (71.4%) significantly differed from that of compound heterozygous variants (18.1%) in the severe type. Compared with the variants in gnomAD, the proportion of LOFVs in GTPBP3 was higher in COXPD23 patients (48.6% versus 8.9%, p < 0.0001 ****), and 31% of them were frameshift variants, showing the LOF mechanism of GTPBP3. Additionally, the variants in patients were significantly enriched in the TrmE-type G domain, indicating that the G domain was crucial for GTPBP3 protein function. The TrmE-type G domain contained several significant motifs involved in the binding of guanine nucleotides and Mg²⁺, the hydrolysis of GTP, and the regulation of the functional status of GTPases. In conclusion, we reported a mild COXPD23 case with typical GTPBP3-related symptoms, including seizures and abnormal visual development seldom observed previously. Our study provides novel insight into understanding the clinical diagnosis and genetic counseling of patients with COXPD23 by exploring the genetic pathogenesis and genotype–phenotype correlation of COXPD23.

β-propeller protein-associated neurodegeneration (BPAN) is characterized by global developmental delay, intellectual disability, and epileptic encephalopathies in infancy or early childhood caused by WDR45/WIPI4 gene mutations. WDR45 depletion disrupted autophagy, leading to iron accumulation in the brain and contributing to neuronal apoptosis. The impact on neuron performance remains unknown. Our previous study established the iPSC cell line derived from a girl patient with a de novo variant c.344 + 5G > T in WDR45 (FDHPIi001). This study demonstrated that this intron 6 mutation impairs RNA splicing, resulting in a 28 bp insertion and nonsense-mediated mRNA decay (NMD) of truncated WDR45. Upon differentiating the iPSCs into dopaminergic neurons, we observed significantly shorter neuronal axons using high-intensity imaging analysis. Additionally, there was significant ferritin accumulation in the induced neurons but not in the iPSCs from the same patient. This research has elucidated the pathogenicity of a non-canonical splice site mutation in WDR45 and has provided deeper insights into the pathologies of neurodegenerative diseases caused by WDR45 defects.