The NM_000203.5:c.1855C>T (p.Arg619Ter) variant in IDUA is a nonsense variant predicted to cause a premature stop codon in the last exon of the gene and therefore to escape nonsense mediated decay. Less than 10% of the protein is predicted to be removed. (PVS1_Moderate; PMID: 24480078). At least 4 patients with this variant had documented IDUA deficiency within the affected range in leukocytes or plasma, and clinical features specific to MPS I including dysostosis multiplex, hepatosplenomegaly, arthropathy, and corneal involvement (PP4). This variant has been detected in at least 12 individuals with MPS I. Of those individuals, 6 were compound heterozygous for the variant and a pathogenic or likely pathogenic variant (Variants: 1163C>G (p.Thr388Arg), 1598C>G (p.Pro533Arg), 1205G>A (p.Trp402Ter), 386-2A>G, 208C>T (p.Gln70Ter)) and none of those were confirmed in trans (PMIDs: 28752568, 11735025). 6 individuals were homozygous for the variant (PMID: 28752568, PMID: 27146977) (PM3_very strong). The highest population minor allele frequency in gnomAD v4.1.0. is 0.00002881 (34/1179960 alleles) in the European non-Finnish population, which is lower than the ClinGen Lysosomal Diseases VCEP’s threshold for PM2_Supporting (<0.00025), meeting this criterion (PM2_Supporting). To our knowledge, the results of functional assays have not been reported for this variant. There is a ClinVar entry for this variant (Variation ID: 280976, 2 star review status) with 6 submitters classifying the variant as pathogenic. In summary, this variant meets the criteria to be classified as pathogenic for MPS I based on the IDUA-specific ACMG/AMP criteria applied, as specified by the ClinGen Lysosomal Diseases Variant Curation Expert Panel (Specifications Version 1.0.0): PM3_very strong, PVS1_moderate, PP4, PM2_supporting. (Classification approved by the ClinGen Lysosomal Diseases Variant Curation Expert Panel on December 6, 2024)