Neuroacanthocytosis

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Background

Neuroacanthocytosis encompasses a group of genetically heterogenous disorders characterized by neurologic signs and symptoms associated with acanthocytosis, an abnormality of red blood cells.[1, 2, 3] Neurologic problems usually consist of either movement disorders or ataxia, personality changes, cognitive deterioration,[4, 5] axonal neuropathy, and seizures[6] . 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.[7]

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 and 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),[1] 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[8, 9] and later in 1968 by Critchley[10] . 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 which the term neuroacanthocytosis is appropriate exhibit phenotypes similar to either Bassen-Kornsweig disease or Levine-Critchley syndrome:

As in many other diseases, there is considerable clinical heterogeneity in these syndromes, which may be caused by environmental interactions as well as the background of other genes and other diseases in the patient.[22]

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 are 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.[23]

Epidemiology

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:

Race

Neuroacanthocytosis 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).

History

See the list below:

Physical

See the list below:

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.

Table 1. Most Common Neuroacanthocytosis Syndromes



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See Table

See the list below:

Table 2. Extremely Rare or Uncertain Causes of Neuroacanthocytosis



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See the list below:

Laboratory Studies

See the list below:

Imaging Studies

See the list below:

Other Tests

See the list below:

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. Some dyskinesias may respond to carbamazepine.[43]

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.

Surgical Care

Deep brain stimulation was used to help two French patients with neuroacanthocytosis. One of them had a specific diagnosis of choreoacanthocytosis with an intronic mutation in the CHaC gene. The other had a diagnosis of McLeod syndrome (MLS) with weak Kell antigen expression and a mutation in the KX gene. Both had an extremely severe movement disorder with a combination of chorea and dystonia. One patient also had severe dysarthria, involuntary belching, and involuntary tongue biting. The other had hypotonia, postural instability, and cognitive deterioration. Both patients received bilateral globus pallidus stimulators. After extensive adjustment, blinded evaluation of "before" and "after" video by two independent movement disorder specialists showed significant improvement in each patient's chorea. The first patient also had an improvement in belching. However, the other aspects of their problems were not significantly improved.[44]

An earlier study of a single patient by a different group failed to show improvement in a patient with choreoacanthocytosis.[45] However, this was completed 6 years previously and technical knowledge of the details of positioning and regulating the stimulators has improved. The adjustments made in the two partially successful cases were very delicate, and small changes in stimulation parameters made major differences. Although these results are preliminary, they should be regarded as promising for future developments.

Consultations

See the list below:

Diet

See the list below:

Activity

See the list below:

Medication Summary

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

In one case describing a 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.[47]

Haloperidol (Haldol)

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

Class Summary

These agents improve psychiatric symptoms and may improve chorea.

OnabotulinumtoxinA (BOTOX©)

Clinical Context:  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.

Class Summary

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

Prognosis

See the list below:

Author

Stephen A Berman, MD, PhD, MBA, Professor of Neurology, University of Central Florida College of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Nestor Galvez-Jimenez, MD, MSc, MHA, The Pauline M Braathen Endowed Chair in Neurology, Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Ceribell, Eisai, Greenwich, Growhealthy, LivaNova, Neuropace, SK biopharmaceuticals, Sunovion<br/>Serve(d) as a speaker or a member of a speakers bureau for: Eisai, Greenwich, LivaNova, Sunovion<br/>Received research grant from: Cavion, LivaNova, Greenwich, Sunovion, SK biopharmaceuticals, Takeda, UCB.

Additional Contributors

Paula K Rauschkolb, DO, Assistant Professor of Neurology and Medicine, Geisel School of Medicine at Dartmouth; Consulting Staff Physician, Department of Neurology, Department of Medicine, Section of Hematology/Oncology, Dartmouth-Hitchcock Medical Center

Disclosure: Nothing to disclose.

Roberta J Seidman, MD, Associate Professor of Clinical Pathology, Stony Brook University School of Medicine; Director of Neuropathology, Department of Pathology, Stony Brook University Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Maritza Arroyo-Muñiz, MD, to the development and writing of this article.

References

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OMIM# Name Mode Gene, Locus, and Protein Onset age Description Pathology
#200150 ChAc or Levine-Critchley syndrome[8, 9, 10, 15] Autosomal recessiveVPS13A 9q21



chorein[15]



Adult onset; early to middle age (20-50 y)Features include choreoathetosis, dystonia, parkinsonism, orofacial dyskinesias, seizures, and neuropathy. Whether the original index cases (ie, Levine, 1960 and 1968; Critchley, 1967 and 1970) were part of the Levine-Critchley syndrome as understood genetically today remain unknown.[8, 9, 10] Atrophy of the caudate, putamen, globus pallidus, and substantia nigra
+314850 MacLeod Syndrome or MLS[16] X-linkedKell blood group gene, XK



Xp21 locus



XK protein



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 Huntington's Disease-Like 2, HDL2[17, 18] Autosomal dominant



(CAG repeat expansion)



JPH3



16q24.3



Junctophilin-3



Onset earlier as repeat size increases (usually 30-40 y)Features include choreoathetosis, dystonia, parkinsonism, hyperreflexia, dementia, and weight loss.Atrophy of the caudate and putamen
#234200 PKAN or PANK2 deficiency (previously termed Hallervorden-Spatz disease)[19] Autosomal recessivePANK2; 20p13Childhood onset (by 4-6 y); adult onset subtypes existFeatures include choreoathetosis, dystonia, dysarthria, rigidity, spasticity, and dementia. PKAN also includes the HARP (hypoprebeta-lipoproteinemia, acanthocytosis, retinitis pigmentosa, and pallidal degeneration) subtype.Iron deposition in the globus pallidus (causes "eye-of-the-tiger" sign on MRIs
#200100 Abeta-lipoprotein-emia[11, 12, 13, 14] Autosomal recessiveMTP; 4q22- q24Infancy / childhoodFeatures 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, spinocere-bellar projections; possibly some direct cerebellar involvement; retinitis pigmentosa
+107730 FHBL1[27, 28, 29, 30, 31] Autosomal recessiveAPOB; 2p24Infancy / childhoodFeatures 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, spinocere-bellar projections; possibly some direct cerebellar involvement; retinitis pigmentosa.
%605019 FHBL2[32, 33] Possibly autosomal recessive3p22-p21.2 for some, for others linkage not knownInfancy / childhoodFeatures are same as for FHBL1.Same as FHBL1
OMIM Name Mode Locus Description
#540000 Mitochondrial encephalopathy, lactic acidosis, and stroke (MELAS) with acanthocytosis[34] Mitochondrial for MELAS but this case is not provenMitochondrial genome for MELAS but this case is not provenThis 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/AFamilial acanthocytosis with paroxysmal exertion-induced dyskinesias and epilepsy (FAPED)[35] 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.
#246700 Anderson disease, now part of chylomicron retention disease (CMRD)Autosomal recessiveSar1B gene, 5q31.1[36] Severe intestinal fat malabsorption with diarrhea, steatorrhea, hypobetalipoproteinemia, low cholesterol, triglyceride and phospholipid levels, and failure to secrete chylomicrons after a fatty meal. Typically lacks acanthocytes, retinitis pigmentosa, and ataxia. Rare cases may be associated with acanthocytes and some neurologic problems and so may be considered neuroacanthocytosis. A single mention of features of neuroacanthocytosis is found in book chapter[37] and reference to same chapter[38] .
+278000 or 278100Atypical Wolman disease[39] 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)[39] . 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 neurologic problems. This single case has now been given its own number (OMIM #278100). Whether this case is truly Wolman disease is uncertain.