PTS and metabolic disease: Tetrahydrobiopterin deficiency (or BH4 deficiency) is a rare inborn metabolic disorder characterized by the deficiency of tetrahydrobiopterin or BH4 and caused by mutations in one of the four genes, including GCH1, PCBD1, PTS, and QDPR. This condition is inherited by autosomal recessive pattern and has a wide spectrum of symptoms, including intellectual disability, progressive problems with development, movement disorders, difficulty swallowing, seizures, behavioral problems, and inability to control body temperature.