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The patients' clinical data, nerve conduction studies, magnetic resonance imaging (MRI), and intraepidermal nerve fiber density in skin biopsies were reviewed.<\/jats:p><\/jats:sec>Results<\/jats:title>The mean age at onset was 9.5\u2009years; the intrinsic hand muscles were affected before or at the same time as the distal leg musculature. The clinical examination revealed greater weakness of the distal muscles, with a more pronounced involvement of the thenar complex and the first dorsal interosseous in upper limbs. Electrophysiological studies were concordant with an exclusively motor axonal neuropathy. A pathologic split hand index was found in six patients. Muscle MRI showed predominant fatty infiltration and atrophy of the anterolateral and superficial posterior compartment of the legs. Most patients reported distal pinprick sensory loss. A reduced intraepidermal nerve fiber density was evident in skin biopsies from proximal and distal sites in nine patients.<\/jats:p><\/jats:sec>Conclusions<\/jats:title>GARS1<\/jats:italic> variants may produce a dHMN phenotype with \u201csplit hand\u201d and sensory disturbances, even when sensory nerve conduction studies are normal. This could be explained by a dysfunction of sensory neurons in the dorsal ganglion that is reflected as a reduction of dermal nerve endings in skin biopsies without a distal gradient.<\/jats:p><\/jats:sec>","DOI":"10.1111\/ene.16416","type":"journal-article","created":{"date-parts":[[2024,7,25]],"date-time":"2024-07-25T11:50:42Z","timestamp":1721908242000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Insights into phenotypic variability caused by GARS1<\/i> pathogenic variants"],"prefix":"10.1111","volume":"31","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-3687-258X","authenticated-orcid":false,"given":"Jes\u00fas","family":"Jim\u00e9nez\u2010Jim\u00e9nez","sequence":"first","affiliation":[{"name":"Neuromuscular Diseases Unit, Department of Neurology Hospital Universitari i Polit\u00e8cnic La Fe Valencia Spain"},{"name":"Neuromuscular and Ataxias Research Group Instituto de Investigaci\u00f3n Sanitaria La 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