We recently reported a severe deficiency in collagen type VI, resulting from recessive mutations of the COL6A2 gene, in patients with Ullrich congenital muscular dystrophy. Their parents, who are all carriers of one mutant allele, are unaffected, although heterozygous mutations in collagen VI caused Bethlem myopathy. Here we investigated the consequences of three COL6A2 mutations in fibroblasts from patients and their parents in two Ullrich families. All three mutations lead to nonsense-mediated mRNA decay. However, very low levels of undegraded mutant mRNA remained in patient B with compound heterozygous mutations at the distal part of the triple-helical domain, resulting in deposition of abnormal microfibrils that cannot form extensive networks. This observation suggests that the C-terminal globular domain is not essential for triple-helix formation but is critical for microfibrillar assembly. In all parents, the COL6A2 mRNA levels are reduced to 57-73% of the control, but long term collagen VI matrix depositions are comparable with that of the control. The almost complete absence of abnormal protein and nearnormal accumulation of microfibrils in the parents may account for their lack of myopathic symptoms.Congenital atonic-sclerotic muscular dystrophy (MIM 254090), first described by Ullrich in 1930 (1) and later referred to as Ullrich syndrome, delineates a distinct subtype of congenital muscular dystrophy, characterized by muscle weakness and hypotonia starting at birth or in early infancy (2). The salient clinical features of Ullrich congenital muscular dystrophy (UCMD) 1 are multiple joint contractures associated with distal hyperextensibility. Patients frequently display additional skeletal deformities, including scoliosis and kyphosis, and suffer from respiratory difficulties early in life. The mode of inheritance is consistent with an autosomal recessive pattern (3). We and others (4 -6) have recently shown that a deficiency in collagen type VI, resulting from homozygous or compound heterozygous mutations in COL6A2, which encodes one of the three collagen VI chains, causes UCMD. Subsequently, three homozygous mutations in another collagen VI gene, COL6A3, have been shown to cause severe and mild forms of UCMD with complete or partial deficiency in collagen VI (7).Several distinctive clinical features of UCMD are also observed in Bethlem myopathy, a mild, dominantly inherited congenital disorder characterized by muscle wasting and multiple joint contractures (8). Missense and splicing mutations in all three collagen VI genes have been reported in patients with Bethlem myopathy (9 -12). In addition, functional haploinsufficiency of the COL6A1 gene has been demonstrated in three Bethlem myopathy patients (13-15). All the known mutations show a high penetrance. Recently, in three families the dominant limb-girdle muscular dystrophy has also been shown to be caused by missense mutations in the COL6A1 and COL6A2 genes (16). Thus, abnormalities in collagen VI can lead to a wide spectrum of clinical phenotypes...