Steroid 21-hydroxylase deficiency is the major cause ofcongenital adrenal hyperplasia (CAH), a common genetic disease. To define the relationship between gene mutations and enzyme deficiency, we generated missense mutations of the 21-hydroxylase cDNA at three different sites and characterized the mutant proteins after expressing them in cultured mammain and yeast cells. Among them, Serl and Val"' have been found to be mutated in CAH patients, whereas Cys' has been implicated as the heme ligand. Our results show mutations at these sites result in complete, partial, or no loss of the enzymatic activity. All the Cys4' mutants had neither enzymatic activity nor P450 absorption, thus supporting the notion that Cys4' is the heme ligand. All the 268-mutants exhibited the same activity as normal 21-hydroxylase, demonstrating that the clinically observed Ser2" --Thr change represents a polymorphism rather than the cause of the enzyme deficiency. The 281-mutants had normal K., but greatly reduced V.. values that also paralleled the reduction in the heme content, in the order Val" (normal, 100%) > Ile2' (50%) > Leul' (20%) > Thr"' (10%).Our findings suggest that the methyl group at the l-carbon of Val"' is required for heme incorporation and consequently enzymatic activity. (J. Clin. Invest. 1991. 88:519-523.)