Primary intraosseous vascular malformation (VMPI, #606893) is an ultra-rare disorder caused by biallelic pathogenic variants in ELMO2 . To date, only six families with pathogenic ELMO2 variants causing a VMPI phenotype have been described. VMPI is characterized by vascular malformations that compress the facial bones, often leading to life-threatening complications, such as massive bleeding and intracranial herniation. In VMPI, vascular malformations are progressive and there is no causal therapy available. We report on four unreported individuals with classical VMPI harbouring biallelic truncating variants in ELMO2 , including a novel homozygous 25 bp duplication c.579_603dup; p.(Leu202Profs*47), detected by whole-exome sequencing. We present extensive clinical follow-up data, including a close monitoring of an individual from prenatal diagnosis onwards. Using computed tomography or magnetic resonance imaging angiography, we described the radiological characteristics of vascular malformations with fast-flow properties in the affected individuals. Additionally, we conducted a comprehensive histopathological evaluation of samples from one individual. This analysis revealed not only the similar morphological features described previously but also some atypical findings, such as increased de novo bone formation. Furthermore, we report for the first time the use of propranolol and sirolimus in VMPI. While we noted a reduction of bleeding episodes in one individual, no significant clinical improvement was observed overall in the other individuals treated with sirolimus. Moreover, sirolimus led to severe infectious complications with abscess formation in two individuals. Conversely, propranolol was relatively well tolerated, although it did not result in any notable clinical outcomes. During follow-up, one individual died due to severe bleeding.

Background: L-2-hydroxyglutaric aciduria (L2HGA) is a rare autosomal recessive neurometabolic disorder caused by biallelic loss-of-function variants in the L-2-hydroxyglutarate dehydrogenase (L2HGDH) gene, leading to accumulation of L-2-hydroxyglutarate in the brain and other tissues. While various variants have been reported, the pathogenic mechanism of specific variants remains unclear. In this study, we aimed to investigate the molecular consequences of the c.905C>T p.(Pro302Leu) variant, identified in two siblings with typical symptoms of L2HGA, by analyzing its effects on protein localization and enzymatic activity in a cell model. Methods: HA-tagged wild-type and p.(Pro302Leu) mutant L2HGDH constructs were overexpressed in HEK293T cells. We assessed protein expression, subcellular localization, and enzymatic activity using Western blot analysis, immunofluorescence microscopy, and a specific enzyme assay measuring 2,6-dichloroindophenol (DCIP) reduction to assess L2HGDH enzymatic activity. Results: Western blotting showed that wild-type L2HGDH exists primarily in the processed, mature mitochondrial form, whereas the p.(Pro302Leu) mutant remained largely in the unprocessed precursor form. Immunofluorescence and differential centrifugation revealed that wild-type protein localized to mitochondria, while the mutant protein accumulated in the cytoplasm in a diffuse or punctate pattern. Enzyme activity assays demonstrated that the mutant retained <30% of wild-type activity. Conclusions: These findings indicate that the p.(Pro302Leu) variant leads to aggregation of mislocalized protein, thereby impairing L2HGDH function rather than decreasing enzymatic function. This study provides clinical and molecular evidence supporting the pathogenicity of this previously reported mutation and highlights the importance of mitochondrial import for enzyme functionality in L2HGA.