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Case report
Ref Number: APCP-PP-281

Leukodystrophy-Like MRI Changes and Status Epilepticus as an Initial Manifestation of L-2-Hydroxyglutaric Aciduria: A Case Report

TCMGDP Cooray¹, KCS Dalpatadu ², SAC Dalpatadu ³, S.I. Majitha⁴, De Silva D⁵
1- Faculty of Medicine, University of Colombo, Sri Lanka 2- Colombo North Teaching Hospital, Sri Lanka 3- Faculty of Medicine, General Sir John Kotelawala Defence University, Sri Lanka 4- Lady Ridgeway Hospital, Sri Lanka 5- Faculty of Medicine, University of Kelaniya, Sri Lanka
Corresponding Author: TCMGDP Cooray (amali.dalpatadu@gmail.com)
Abstract Body
Introduction: L-2-hydroxyglutaric aciduria (L-2-HGA) is a rare autosomal recessive neurometabolic disorder caused by pathogenic variants in L2HGDH, leading to accumulation of the neurotoxic metabolite L-2-hydroxyglutarate. It typically presents with progressive developmental delay , seizures, and characteristic but non-specific bilateral white-matter abnormalities on MRI. Diagnostic delay is common due to overlap with leukodystrophies and epileptic encephalopathies. Early-onset status epilepticus is an uncommon presentation. Case presentation: We report a 7-year-old boy with speech delay , learning difficulties,behavioural disturbances, and recurrent generalized tonic–clonic seizures. Notably , he experienced two episodes of status epilepticus in infancy . Neurological examination was normal. EEG demonstrated diffuse background slowing without epileptiform discharges. BrainMRI showed bilateral, symmetric confluent periventricular, deep, and subcortical white-matter signal abnormalities with relative U-fiber sparing, initially suggestive of leukodystrophy . Urine organic acid analysis revealed marked isolated elevation of 2-hydroxyglutaric acid, with only a trace increase in ethylmalonic acid. Whole-exome sequencing identified a pathogenic L2HGDHvariant, confirming L-2-HGA. Other metabolic and systemic investigations were unremarkable. Riboflavin and L-carnitine supplementation were initiated. Conclusions: This case expands the recognised clinical spectrum of L-2-HGA by highlighting early-onset status epilepticus with leukodystrophy-like MRI changes. Neuroimaging alone may be misleading; integrated metabolic and molecular evaluation is essential for accurate diagnosis. Increased awareness of this atypical presentation may facilitate earlier recognition,targeted investigation, appropriate counselling, and timely management, particularly in resource-limited settings.
Keywords: Leukodystrophy-like mri changes; Initial manifestation; Status epilepticus
Presentation Type: Case report
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