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Kufs disease, an adult-onset neuronal ceroid lipofuscinosis, is challenging to diagnose and genetically heterogeneous. Mutations in  CLN6  were recently identified in recessive Kufs disease presenting as progressive myoclonus epilepsy (Type A), whereas the molecular basis of cases presenting with dementia and motor features (Type B) is unknown. We performed genome-wide linkage mapping of two families with recessive Type B Kufs disease and identified a single region on chromosome 11 to which both families showed linkage. Exome sequencing of five samples from the two families identified homozygous and compound heterozygous missense mutations in  CTSF  within this linkage region. We subsequently sequenced  CTSF  in 22 unrelated individuals with suspected recessive Kufs disease, and identified an additional patient with compound heterozygous mutations.  CTSF  encodes cathepsin F, a lysosomal cysteine protease, dysfunction of which is a highly plausible candidate mechanism for a storage disorder like ceroid lipofuscinosis.  In silico  modeling suggested the missense mutations would alter protein structure and function. Moreover, re-examination of a previously published mouse knockout of  Ctsf  shows that it recapitulates the light and electron-microscopic pathological features of Kufs disease. Although  CTSF  mutations account for a minority of cases of type B Kufs,  CTSF  screening should be considered in cases with early-onset dementia and may avoid the need for invasive biopsies.

Cathepsin F mutations cause Type B Kufs disease, an adult-onset neuronal ceroid lipofuscinosis