Leprechaunism is an autosomal recessive disorder caused by mutations in the insulin receptor gene and characterized by intrauterine and postnatal growth restriction, abnormal glucose homeostasis, and severe insulin-resistance. Here we report the biochemical and molecular characterization of a male patient, NZ, who died at 2 yr of age with this syndrome. 125I-Insulin binding to fibroblasts from the proband, his mother, father, and unaffected sister was reduced to 8, 53, 38, and 35% of controls, respectively. Analysis of the insulin receptor gene by polymerase chain reaction amplification using primers flanking each of the 22 exons and direct DNA sequencing identified 2 different mutations in the proband. The paternal mutation was an in-frame deletion of base pairs 1159-1161 in exon 3, which resulted in the loss of the codon for Asn-281. The maternal mutation was a G-->A transition in the first nucleotide of the splice-donor junction in intron 13. The maternal mutation activated a cryptic splice site 27 base pairs upstream in exon 13 and caused an in-frame deletion of amino acids 859-867 of the extracellular domain of the insulin receptor beta subunit. Identification of both mutations enabled prenatal diagnosis in 2 subsequent pregnancies. In the first pregnancy, DNA from cells cultured from chorionic villus (CV) biopsies carried both mutations in the insulin receptor gene. In the second pregnancy, DNA from the CV biopsy cells was negative for both mutations, indicating that the fetus was unaffected by leprechaunism. Insulin binding could not be used in prenatal diagnosis because cells cultured from some control CV biopsies failed to bind insulin. These data indicate that patient NZ with leprechaunism was a compound heterozygote for 2 novel mutations in the insulin receptor gene and that direct DNA sequencing enables prenatal diagnosis for this lethal disorder.