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Background HSD10 mitochondrial disease (HSD10MD), originally described as a deficiency of 2‐methyl‐3‐hydroxybutyryl‐CoA dehydrogenase (MHBD), is a rare X‐linked disorder of a moonlighting protein encoded by the HSD17B10. The diagnosis is usually first suspected on finding elevated isoleucine degradation metabolites in urine, reflecting decreased MHBD activity. However, it is now known that clinical disease pathogenesis reflects other independent functions of the HSD10 protein; particularly its essential role in mitochondrial transcript processing and tRNA maturation. The classical phenotype of HSD10MD in affected males is an infantile‐onset progressive neurodegenerative disorder associated with severe mitochondrial dysfunction. Patients, Methods, and Results In four unrelated families, we identified index patients with MHBD deficiency, which implied a diagnosis of HSD10MD. Each index patient was independently investigated because of neurological or developmental concerns. All had persistent elevations of urinary 2‐methyl‐3‐hydroxybutyric acid and tiglylglycine. Analysis of HSD17B10 identified a single missense variant, c.364C>G, p.Leu122Val, in each case. This rare variant (1/183336 alleles in gnomAD) was previously reported in one Dutch patient and was described as pathogenic. The geographic origins of our families and results of haplotype analysis together provide evidence of a founder effect for this variant in Quebec. Notably, we identified an asymptomatic hemizygous adult male in one family, while a second independent genetic disorder contributed substantially to the clinical phenotypes observed in probands from two other families. Conclusion The phenotype associated with p.Leu122Val in HSD17B10 currently appears to be attenuated and nonprogressive. This report widens the spectrum of phenotypic severity of HSD10MD and contributes to genotype–phenotype correlation. At present, we consider p.Leu122Val a “variant of uncertain significance.” Nonetheless, careful follow‐up of our patients remains advisable, to assess long‐term clinical course and ensure appropriate management. It will also be important to identify other potential patients in our population and to characterize their phenotype., HSD10 mitochondrial disease (HSD10MD) is a rare X‐linked disorder, with a classical phenotype of infantile‐onset progressive neurodegeneration associated with severe mitochondrial dysfunction. We describe patients from four unrelated families, showing an unusually mild clinical phenotype. All patients have the p.Leu122Val variant in the HSD17B10, reflecting a founder effect.