eMedicine Specialties > Neurology > Movement and Neurodegenerative Diseases

Neuroacanthocytosis

Eric Dinnerstein, MD, Consulting Staff Neurologist, Maine Neurology
Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center; Maritza Arroyo-Muñiz, MD, Associate Program Director, Professor of Neurology, Department of Neurology, University of Puerto Rico

Updated: Sep 14, 2006

Introduction

Background

Neuroacanthocytosis is a group of phenotypically and genetically heterogenous neurologic disorders characterized by 2 types of problems, neurologic problems and acanthocytosis. Neurologic problems usually consist of either movement disorders or ataxia, personality changes, cognitive deterioration, axonal neuropathy, and seizures. At some point during the course of the disease, most patients manifest acanthocytosis on the peripheral blood smear, ie, a certain percentage of the patients' erythrocytes (typically 10-30%) have an unusual starlike appearance with spiky- or thorny-appearing projections.

There has been, and there continues to be, considerable disagreement about which specific diseases should be included under the general term neuroacanthocytosis. This is the understandable result of gradually accumulating knowledge of the molecular biological bases of these disorders.

The first form of neuroacanthocytosis to be well described in the medical literature is Bassen-Kornzweig disease, or abetalipoproteinemia (1950), which is an autosomal recessive abnormality of lipoprotein metabolism resulting in ataxia combined with acanthocytosis. In the early descriptions, Bassen-Kornzweig disease was compared with a better known condition, Friedreich ataxia. The two are rather similar except that patients with Bassen-Kornzweig disease have acanthocytosis. In fact, the term acanthocyte was originated by the authors of the seminal Bassen-Kornsweig paper.

The second type of neuroacanthocytosis was described in 1960 by Levine and later in 1968 by Critchley. Just as Bassen-Kornsweig disease looks much like Friedreich ataxia, the Levine-Critchley syndrome, as it came to be called, resembles Huntington disease (HD) with prominent choreiform or choreoathetoid movements, progressive dementia, and, in the original descriptions, autosomal dominant inheritance. One notable difference from HD is that Levine-Critchley syndrome manifests acanthocytosis. When it was originally described, it was also frequently compared with Bassen-Kornzweig disease in that both combined neurologic abnormalities with acanthocytosis but the Levine-Critchley syndrome had normal lipoproteins as well as a later age of onset. What today is recognized as the Levine-Critchley syndrome is caused by a mutation in a specific gene called chorein (also called VPS13A). Interestingly, it is not clear that the original cases reported by Levine and Critchley had that mutation.

Most genetic diseases for the term neuroacanthocytosis is appropriate exhibit phenotypes similar to either Bassen-Kornsweig disease or Levine-Critchley syndrome:

• Similar to Bassen-Kornsweig disease, ie, a hereditary lipoprotein disorder that causes a predominantly sensory ataxia involving the dorsal root ganglia and the ensuing spinocerebellar pathways and projections combined with acanthocytosis:
  • Bassen-Kornsweig disease (abetalipoproteinemia)
  • Familial hypobetalipoproteinemia
  • Other lipoprotein disorders of uncertain significance
• Similar to Levine-Critchley syndrome, ie, a movement disorder with choreiform or Parkinsonlike features combined with dementia, various other neurologic abnormalities, and acanthocytosis:
  • Chorea-acanthocytosis (ChAc) McLeod syndrome (MLS)
  • McLeod syndrome (MLS)
  • Huntington disease–like2 (HDL2)
  • Pantothenate kinase–associated neurodegeneration (PKAN)
  • A number of individual cases and families have been reported that do not seem to fit the existing genetic patterns and which may represent new genetic syndromes yet to be elucidated or perhaps sporadic diseases.

Finally, a number of systemic diseases (usually sporadic) exist in which the combination of neurologic findings and acanthocytosis may actually be incidental. Examples of this type of neuroacanthocytosis include case reports of patients with hepatic encephalopathy, myxedema, or certain types of vasculitis who at some point in their disease show choreiform features plus acanthocytosis. It is not known why such diseases show these features as an occasional manifestation and, in the authors' opinion, it is not correct to call these diseases forms of neuroacanthocytosis per se. However, for the sake of completeness, diseases that have been known to occasionally exhibit features of neuroacanthocytosis will be listed.

Pathophysiology

Multisystem pathology is evident, including severe atrophy of the caudate and putamen with loss of small and medium-sized neurons and an associated astrocytic reaction. Less severe changes are seen in the pallidum.

Neuronal loss and mild gliosis can be seen in the thalamus, substantia nigra, and anterior horn of the spinal cord.

Acanthocytes are seen in peripheral blood smears. Creatine phosphokinase (CPK) level, and occasionally serum transaminases level, are elevated.

Serum vitamin E and lipoprotein levels typically are normal in the neuroacanthocytoses that do not involve abetalipoproteinemia or hypobetalipoproteinemia.

In the few cases for which neurochemical data are available, dopamine was decreased in almost the entire brain, norepinephrine levels were elevated in the putamen and globus pallidus, substance P levels were decreased in the striatum and substantia nigra, and serotonin levels were decreased in the caudate nucleus and substantia nigra. These findings are difficult to interpret because of severe caudate atrophy, concurrent medications, and small sample sizes.

Frequency

United States

Neuroacanthocytosis is a rare disease for which insufficient epidemiological data are available to draw conclusions about frequency.

Mortality/Morbidity

Reported causes of death include the following:

• Emaciation due to progressive weakness and dysphagia
• Tracheobronchial aspiration
• Suicide

Race

This disease has been reported in several races, but epidemiological data are insufficient to report prevalences.

Sex

Data are insufficient, but the condition may be more common in males than in females.

Age

Mean age of onset is 32 years (range, 8-62 y).

Clinical

History

• Involuntary movements
  • Chorea and dystonia, features of hyperkinetic movement disorders, are more frequent than tics and parkinsonism. Several of these disorders may be present simultaneously.
  • Parkinsonism eventually may replace the hyperkinetic state.
  • Orolingual dystonia causes eating problems, dysarthria, and dysphagia (ie, the tongue involuntarily pushes food out of the mouth).
• Personality changes occur, including impulsivity, distractibility, anxiety, depression, apathy, loss of introspection, and compulsivity.
• A peculiar gait is characterized by lurching with long strides and quick, involuntary knee flexion.
• Seizures, generally tonic-clonic (ie, grand mal), occur in 30-40% of patients; they are infrequent and relatively easy to treat.

Physical

• The following signs are observed, in order of frequency: chorea, dystonia (including eating dystonia), other orolinguofacial dyskinesias (with lip biting and dysarthria), vocal and/or motor tics, and parkinsonism.
• Subcortical dementia with executive skill problems of the frontal lobe has been reported.
  • Executive skill problems include perseverative errors, excessive vulnerability to external intrusion, and inability to inhibit immediate and inappropriate responses to stimuli.
  • Visuopraxic disorders, anomia, and verbal as well as nonverbal memory retrieval problems may be noted.
• Axonal neuropathy may present with the following signs:
  • Decreased or absent deep tendon reflexes
  • Muscle wasting (amyotrophy)

Causes

Each major type of neuroacanthocytosis appears to have its own basic etiology, ie, the specific gene in which a mutation is present. The known mutant genes are listed with their respective diseases below.

• The hereditary lipoprotein (typically betalipoprotein) disorders
  • Bassen-Kornsweig disease (abetalipoproteinemia) - Microsomal triglyceride transfer protein (MTP)
  • Familial hypobetalipoproteinemia (FHBL)
    • FHBL1 - Apolipoprotein B (APOB)
    • FHBL2 - Gene not known
  • Other lipoprotein disorders of unknown etiology
• Hereditary movement disorders (choreiform or Parkinsonlike)
  • Chorea-acanthocytosis (ChAc) - Chorein (VPS13A)
  • McLeod syndrome (MLS) - Kell blood group protein
  • Huntington disease–like2 (HDL2) - Junctophilin-3 (JPH3)
  • Pantothenate kinase–associated neurodegeneration (PKAN) - Pantothenatekinase 2 (PANK2)
  • Other genetic and sporadic disorders - Genes not yet elucidated, or multigenetic, or due to sporadic conditions
• Although the ultimate basic etiology of the genetic conditions that cause most of the cases of acanthocytosis is known, it is generally not known how the gene defect produces the pathophysiological abnormalities.
• The etiology is best understood for the betalipoprotein deficiencies. Lack of microsomal triglyceride transfer protein (MTP) or a direct mutation in the gene for betapolipoprotein leads to a decreased absorption of vitamin E as well as other vitamins and possibly other cofactors. This leads to damage to the dorsal root ganglia, spinocerebellar tracts, retina, and cerebellum. It also leads to a defect in the conformation and/or fluidity of the erythrocyte membrane. Band three of the membrane appears to be one of the components significantly involved.
• For the other genetic disorders, the connections between the gene defects and the pathophysiological changes are not known. Again, changes in erythrocyte membrane conformation and/or fluidity (possibly via band three) may be involved in the changes underlying the acanthocytosis.
• In order to better understand the many different types of neuroacanthocytosis, the most common varieties have been organized into a table. The first column lists the Online Mendelian Inheritance in Man number (OMIM#). The Mendelian Inheritance in Man (MIM) catalog (not online) was developed by Dr. Victor McKusick and colleagues at Johns Hopkins University, and the OMIM is hosted by the US National Center for Biotechnology Information on what is essentially the same Web site as PubMed. Also provided in the table are the name, mode of inheritance, locus (including the chromosomal region and the names of the gene and protein if available), onset age, description of the condition, and the pathology. Table 1. Most Common Neuroacanthocytosis Syndromes

  OMIM#	Name	Mode	Locus	Onset age	Description	Pathology
  #200150	ChAc or Levine-Critchley syndrome	Autosomal recessive	VPS13A (chorein); 9q21	Adult onset; early to middle age (20-50 y)	Features include choreoathetosis, dystonia, parkinsonism, orofacial dyskinesias, seizures, and neuropathy. Interestingly, whether the original the index cases (ie, Levine, 1960 and 1968; Critchley, 1967 and 1970) were part of the Levine-Critchley syndrome as understood genetically today remains unknown.	Atrophy of the caudate, putamen, globus pallidus, and substantia nigra
  +314850	MLS	X-linked	Kell blood group protein; Xp21	Adult onset middle to late age (40-70 y)	Features include choreoathetosis, dystonia, parkinsonism, seizures, neuropathy, myopathy, and cardiomyopathy	Atrophy of the caudate, putamen, and globus pallidus; substantia nigra not involved
  #606438	HDL2	Autosomal dominant	JPH3; 16q24.3	Onset earlier as repeat size increases (usually 30-40 y)	Features include choreoathetosis, dystonia, parkinsonism, hyperreflexia, dementia, weight loss.	Atrophy of the caudate and putamen
  #234200	PKAN or PANK2 deficiency (previously termed Hallervordan-Spatz disease)	Autosomal recessive	PANK2; 20p13	Childhood onset (by 4-6 y); adult-onset subtypes exist	Features include choreoathetosis, dystonia, dysarthria, rigidity, spasticity, and dementia. PKAN also includes the HARP (hypoprebetalipoproteinemia, acanthocytosis, retinitis pigmentosa, and pallidal degeneration) subtype.	Iron deposition in the globus pallidus (causes "eye-of-the-tiger" sign on MRIs
  #200100	Abeta-lipoproteinemia	Autosomal recessive	MTP; 4q22- q24	Infancy/childhood	Features include ataxia (sensory ataxia with some cerebellar features), visual loss, mental retardation/dementia, low vitamin E level, high cholesterol level, and abnormal lipoprotein electrophoresis.	Dorsal root ganglia, ascending sensory tracts, cuneate and gracile nuclei of cord, spinocerebellar projections; possibly some direct cerebellar involvement; retinitis pigmentosa
  +107730	FHBL1	Autosomal recessive	APOB; 2p24	Infancy/childhood	Features include ataxia (sensory ataxia with some cerebellar features), visual loss, and mental retardation/dementia.	Dorsal root ganglia, ascending sensory tracts, cuneate and gracile nuclei of cord, spinocerebellar projections; possibly some direct cerebellar involvement; retinitis pigmentosa.
  %605019	FHBL2	Possibly autosomal recessive	Unknown (possibly other types as well); 3p22-p21.2	Infancy/childhood	Features are same as for FHBL1.	Same as FHBL1

• The diseases in the next table are even rarer than those listed in the previous table. In some of these, the neuroacanthocytosis appears to represent an exception and possibly idiosyncratic reaction seen in some patients with concomitant diseases; however, the full range of acanthocytosis is not yet completely understood. What in current practice may appear to be an isolated idiosyncratic case may, in the future, stand as a part of a broader syndrome. Table 2. Extremely Rare or Uncertain Causes of Neuroacanthocytosis

  OMIM	Name	Mode	Locus	Discription
  #540000	Mitochondrial encephalopathy, lactic acidosis, and stroke (MELAS) with acanthocytosis	Mitochondrial for MELAS but this case is not proven	Mitochondrial genome for MELAS but this case is not proven	This is a single case. Typically, MELAS is an A3243G mutation. (Adenine is replaced by guanosine at position 3243 in the mitochondrial genome.) This single case report did not have mitochondrial genomic sequencing. Pathology reports showed abnormalities in Betz cells, brainstem neurons, and anterior horn cells. Muscle pathology results are compatible with MELAS.
  N/A	Familial acanthocytosis with paroxysmal exertion-induced dyskinesias and epilepsy (FAPED)	Autosomal dominant (not certain; only one family)		This is characterized by intermittent attacks of cramps and involuntary movements; attacks are myoclonic and atonic epilepsy. It has been described in one family. MRI showed mild basal ganglia degeneration. Positron emission tomography scanning showed decreased glucose metabolism in the thalamus.
  #607689	Anderson disease	Autosomal recessive for Anderson disease; very rarely has features of neuroacanthocytosis; (possible coincidental association with Anderson disease or misdiagnosis)	Unknown (not the gene for ApoB), 5q31.1	Patients usually have severe intestinal fat malabsorption with diarrhea, steatorrhea, hypobetalipoproteinemia, low cholesterol levels, low triglyceride levels, low phospholipid levels, and failure to secrete chylomicrons after a fatty meal. Typically, acanthocytes, retinitis pigmentosa, and ataxia are lacking, but rare cases may be associated with acanthocytes and some neurological problems and so may be considered a neuroacanthocytosis in those instances.
  +278000 or 278100	Atypical Wolman disease	Unknown (single case)	Unknown (single case)	In 1970, Eto and Kitagawa described a patient with lipid malabsorption, vomiting, growth failure, adrenal calcification, hypolipoproteinemia, and acanthocytosis and termed it Wolman disease (OMIM #278000). The patient had hepatosplenomegaly, steatorrhea, abdominal distention, and adrenal calcification that appeared in the first weeks of life, as well as widespread accumulation of cholesterol esters and triglycerides in the internal organs. Typically, Wolman disease is not associated with acanthocytes or neurological problems. This single case has now been given its own number (OMIM #278100). Whether this case is truly Woman disease is uncertain.

• Various systemic diseases may also be accompanied by acanthocytosis and neurological findings, especially in severely ill patients. These include various cancers, thyroid disorders, patients who have had a splenectomy, cirrhosis of the liver and hepatic encephalopathy, psoriasis, and an obscure condition called Eales disease in which an idiopathic inflammatory venous occlusion primarily affects the peripheral retina in adults. In these conditions, the presentation as neuroacanthocytosis may be a coincidence in which some type of neurological insult, such as a stroke due to vasculitis, coincides with bone marrow failure in a severely ill individual; alternatively, a more fundamental connection may be present that is not currently understood.

Differential Diagnoses

Huntington Disease
Parkinson Disease
Parkinson Disease in Young Adults
Parkinson-Plus Syndromes
Tourette Syndrome and Other Tic Disorders
Wilson Disease

Other Problems to Be Considered

Bassen-Kornzweig disease (ie, abetalipoproteinemia)

Workup

Laboratory Studies

• Fresh blood smear for acanthocytes: Any level greater than 3% is abnormal; in neuroacanthocytosis, acanthocytes usually measure 10-30%. Liver disease, splenectomy, and hemolytic anemia must be excluded.
• Elevated creatine kinase
• Serum lipoproteins: In addition to the abetalipoproteinemia and hypobetalipoproteinemia, a case report of a patient with aprebetalipoproteinemia has also been documented. All the forms probably have not yet been discovered.
• Elevated liver enzyme levels
• Specific genetic tests
  • Bassen-Kornsweig disease (abetalipoproteinemia) -MTP gene
  • FHBL1 -APOB gene
  • ChAc - Chorein (VPS13A)
  • MLS - Kell blood group protein (XK)
  • HDL2 -JPH3 gene
  • PKAN -PANK2 gene

Imaging Studies

• Brain MRI - Caudate atrophy and increased signal in caudate and lentiform nuclei. In PKAN, a pallidal hypointensity with a central area of hyperintensity, named "eye of the tiger" sign, is observed. The hypointensity is due to iron deposition.
• Brain CT scanning - Caudate atrophy and ventricular dilatation (especially in the frontal horns of the lateral ventricles)
• Brain positron emission tomography - Hypometabolism in the neostriatum and the frontal cerebral cortical areas
• Brain single-photon emission computed tomography (SPECT) - Hypoperfusion in the neostriatum and frontal areas

Other Tests

• Electromyography (EMG) and nerve conduction study (NCS) findings are consistent with chronic denervation and a primarily axonal peripheral neuropathy.

Treatment

Medical Care

The betalipoprotein disorders of abetalipoproteinemia and the hypobetalipoproteinemias cause a malabsorption of vitamins, especially vitamin E and also vitamins A and K. Treating the patient with high doses of these vitamins, especially vitamin E, ameliorates, but does not completely cure, these diseases.

For the choreiform/parkinsonian group, no specific treatment exists for the primary diseases. No attempts have yet been made to systematically collect observations regarding response to drugs. For choreiform and choreoathetoid movements (hyperkinesias), antipsychotics, such as haloperidol (Haldol), are still helpful. Second-generation antipsychotics may also be used as well as other medications such as tetrabenazine and tiapride.

Parkinsonian symptoms may respond to dopaminergic agents such as carbidopa-levodopa, ropinirole, and pramipexole. However, such agents tend to worsen chorea and could not be used unless a given patient had predominantly parkinsonian features (such as may occur in PKAN). Tremor may respond nonspecifically to either cholinergic agents such as benztropine (Cogentin) or trihexyphenidyl (Artane) or to medications used for essential tremor such as beta-blockers or primidone. One can consider botulinum toxin injection in treating both dystonias, choreoathetoid movements, and tremor.

For possible epileptic seizures, carbamazepine, oxcarbamazepine, and gabapentin are reasonable options.

The treatment is not based on a fundamental understanding of the diseases, but treatment that may work to suppress the symptoms without undue side effects is tried.

Consultations

• Psychiatrist: Psychiatric evaluation is indicated to diagnose and treat depression and/or other psychiatric disorders.
• Nutritionist

Diet

• Maintain a balanced diet.
• Consultation with a nutritionist may be appropriate.
• In advanced cases, a soft diet and/or a GI feeding tube may become necessary.

Activity

• Typically, no restriction in activity is required until more advanced stages of the disease.
• Fall and balance precautions should be observed.
• In patients with advanced disease, walkers and/or wheelchairs may be appropriate.

Medication

No effective treatment exists. However, symptomatic treatment can be attempted.

In a recently described patient who presented with truncal tic as part of the symptoms of neuroacanthocytosis, the newly approved anticonvulsant, levetiracetam, was very helpful in controlling the tic. However, further studies are warranted to ensure that it is effective.

Antipsychotic agents

These agents improve psychiatric symptoms and may improve chorea.

Haloperidol (Haldol)

Useful in treatment of irregular spasmodic movements of limbs or facial muscles.

Dosing

Adult

1-5 mg PO bid/tid; increase slowly to response; not to exceed 30 mg/d
2-5 mg IM q4-8h prn

Pediatric

Not established

Interactions

May increase serum concentrations of TCAs; may increase hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects; concomitant anticholinergics may increase intraocular pressure; concurrent lithium associated with encephalopathylike syndrome

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage; toxic CNS depression or comatose state

Precautions

Pregnancy

D - Unsafe in pregnancy

Precautions

May cause severe neurotoxicity manifesting as rigidity or inability to walk or talk in patients with thyrotoxicosis; if IV/IM, watch for hypotension; caution in CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance (discontinue if it occurs); may produce neuroleptic malignant syndrome or severe cardiovascular disorders (due to hypotension or precipitation of angina pectoris); if patient has seizures, decrease threshold; may produce or worsen parkinsonian symptoms

Acetylcholine (ACh) release inhibitor

This agent is effective in mandibular dystonia, thereby improving eating.

Botulinum toxin type A (BOTOX®)

Inject into mandibular muscles that are associated with dystonic movements. Treats excessive, abnormal contractions associated with blepharospasm. Binds to receptor sites on motor nerve terminals and inhibits release of ACh, which in turn inhibits transmission of impulses in neuromuscular tissue.
Reexamine patients 7-14 d after initial dose to assess response. Increase doses 2-fold over previous dose for patients experiencing incomplete paralysis of target muscle, but do not repeat injection for at least 1 mo.

Dosing

Adult

20-60 U IM

Pediatric

Not established

Interactions

Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Understand anatomy of area to be injected; do not exceed recommended dosages and frequencies of administration; presence of antibodies to botulinum toxin type A may reduce effects of therapy

Follow-up

Prognosis

• Disease progression is poorly understood, and no cure exists.

References

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Keywords

chorea-acanthocytosis, Levine-Critchley syndrome, acanthocytosis, Bassen-Kornsweig disease, abetalipoproteinemia, familial hypobetalipoproteinemia, lipoprotein disorders, chorea-acanthocytosis McLeod syndrome, MLS, ChAc, McLeod syndrome, Huntington disease–like2, HDL2, pantothenate kinase–associated neurodegeneration, PKAN

Contributor Information and Disclosures

Author

Eric Dinnerstein, MD, Consulting Staff Neurologist, Maine Neurology
Eric Dinnerstein, MD is a member of the following medical societies: American Academy of Neurology and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center
Stephen A Berman, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Maritza Arroyo-Muñiz, MD, Associate Program Director, Professor of Neurology, Department of Neurology, University of Puerto Rico
Maritza Arroyo-Muñiz, MD is a member of the following medical societies: American Academy of Neurology and National Stroke Association
Disclosure: Nothing to disclose.

Medical Editor

Roberta J Seidman, MD, Director of Neuropathology, Clinical Associate Professor, Department of Pathology, Stony Brook University Medical Center
Roberta J Seidman, MD is a member of the following medical societies: American Academy of Neurology, American Association for the Advancement of Science, and American Association of Neuropathologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
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Managing Editor

Nestor Galvez-Jimenez, MD, Program Director of Movement Disorders, Department of Neurology, Division of Medicine, Director of Neurology Residency Training Program, Cleveland Clinic Florida
Nestor Galvez-Jimenez, MD is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
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