D-2-hydroxyglutaric aciduria (D-2-HGA) is a rare neurometabolic disease with two main subtypes, caused by either inactivating variants in D2HGDH (type I) or germline gain of function variants in IDH2 (type II), that result in accumulation of the same toxic metabolite,
D-2-hydroxyglutarate. The main clinical features of both are neurologic, including developmental delay,
hypotonia, and
seizures.
Dilated cardiomyopathy is a unique feature thus far only reported in type II. As somatic variants in IDH2 are frequently identified in several different types of
cancer, including
acute myeloid leukemia (AML), a link between
cancer and this
metabolic disease has been proposed; however, there is no reported
cancer in patients with either type of
D-2-HGA. Murine models have demonstrated how
D-2-hydroxyglutarate alters metabolism and epigenetics, a potential mechanism by which this metabolite may cause
cancer and
cardiomyopathy. Here, we report the first case of both AML and
dilated cardiomyopathy in a pediatric patient with
D-2-HGA type I, who was treated with an
anthracycline-free regimen. This report may expand the clinical spectrum of this rare
metabolic disease and provide insight on long-term surveillance and care. However, this case is complicated by the presence of a complex chromosomal rearrangement resulting in a 25.5 Mb duplication of 1q41 and a 2.38 Mb deletion of 2q37.3. Thus, the direct causal relationship between
D-2-HGA and leukemogenesis or
cardiomyopathy warrants further scrutiny.