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Here we report the first familial case spread through at least three generations, genetically verified cases of Marshall-Stickler syndrome in Bulgaria. The proband, a 2-year-old girl, has craniofacial dysplasia, ocular hypertelorism, small saddle nose with a flat bridge and midface hypoplasia. The pedigree of the proband’s family showed that her father has the same clinical manifestations of the disease. In addition, her father presented with a tall, thin stature and mild hearing loss, manifested with aging. The same dysmorphological symptoms were presented by the paternal grandfather. Both patients, the 2-year-old girl and her father, have been diagnosed to carry Marshall-Stickler syndrome. The  COL2A1  gene tested negative in the family. Based on the higher percentage of mutations in the  COL2A1  gene, we analyzed this gene as the first target in the family. The  COL2A1  gene tested negative, and we sequenced the gene further. A novel splice site mutation c.3474+1G&gt;A was found in intron 44. This variant is related to the clinical presentation in the patient and her father. The c.3474+1G&gt;A mutation results in altered splicing affects at the donor splice site of intron 44, which most probably gives a nonfunctional protein. The variant affects the major triple-helical domain that represents a mutation hot-spot for the gene.

Novel mutation in the COL11A1 gene causing Marshall-Stickler syndrome in three generations of a Bulgarian family