Germline gain-of-function mutations in SOS1 cause Noonan syndrome

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Abstract
Noonan syndrome, the most common single-gene cause of congenital heart disease, is characterized by short stature, characteristic facies, learning problems and leukemia predisposition1. Gain-of-function mutations in PTPN11, encoding the tyrosine phosphatase SHP2, cause ∼ 50% of Noonan syndrome cases. SHP2 is required for RAS-ERK MAP kinase (MAPK) cascade activation2, and Noonan syndrome mutants enhance ERK activation ex vivo3,4 and in mice5. KRAS mutations account for 6, but the gene(s) responsible for the remainder are unknown. We identified missense mutations in SOS1, which encodes an essential RAS guanine nucleotide-exchange factor (RAS-GEF), in ∼ 20% of cases of Noonan syndrome without PTPN11 mutation. The prevalence of specific cardiac defects differs in SOS1 mutation–associated Noonan syndrome. Noonan syndrome–associated SOS1 mutations are hypermorphs encoding products that enhance RAS and ERK activation. Our results identify SOS1 mutants as a major cause of Noonan syndrome, representing the first example of activating GEF mutations associated with human disease and providing new insights into RAS-GEF regulation.