For REF/REF entries the ALT is '.'
wget https://ftp.ncbi.nlm.nih.gov/pub/clinvar/vcf_GRCh38/clinvar.vcf.gz
gunzip -c "clinvar.vcf.gz" | grep -v "^#" | awk -F'\t' '$5=="." {print}' | grep Pathogenic | head -n 1
1 161629781 242687 T . . . AF_EXAC=0.66256;ALLELEID=45585;CLNHGVS=NC_000001.11:g.161629781%3D;CLNREVSTAT=no_classification_for_the_single_variant;CLNSIG=no_classification_for_the_single_variant;CLNVC=single_nucleotide_variant;CLNVCSO=SO:0001483;CLNVI=OMIM:610665.0001;GENEINFO=FCGR3B:2215;MC=SO:0002073|no_sequence_alteration;ONC=no_classification_for_the_single_variant;ONCREVSTAT=no_classification_for_the_single_variant;RS=2290834;SCI=no_classification_for_the_single_variant;SCIREVSTAT=no_classification_for_the_single_variant;CLNDISDBINCL=MedGen:C4017227;CLNDNINCL=Neutrophil-specific_antigens_NA1/NA2;CLNSIGINCL=36924:Pathogenic