[A case of Alice in Wonderland syndrome after Epstein-Barr virus (EBV) encephalitis: a mimicry of focal epileptic seizure].

A 30-year-old man who received infliximab for treatment of Crohn's disease developed Epstein-Barr virus (EBV) encephalitis, which responded well to therapy; however, he had left lower visual field loss following treatment. The patient noticed peculiar symptoms 9 months after recovery from encephalitis; objects in his view appeared smaller or larger than their actual size (micropsia/macropsia). Moreover, it appeared that objects outside moved faster or slower than their actual speed of movements and moving objects appeared as a series of many consecutive snap shots. His vision was blurred, and he had visual difficulties and a sensation that his body was floating. These symptoms mainly appeared following fatigue and persisted over approximately 10 years. Based on cerebrospinal fluid analysis, brain MRI, N-isopropyl-p-123I-iodoamphetamine with single photon emission computed tomography, fluorodeoxyglucose positron emission tomography, and electroencephalography, we excluded both recurrent encephalitis and focal epileptic seizures. By taking all symptoms and other evaluation findings into account, the patient most likely suffered from "Alice in Wonderland syndrome" which is primarily associated with cortical dysfunction in the right temporo-parieto-occipital area as the consequence of previous acute EBV encephalitis.

Síndrome de Alicia en el País de las Maravillas e infección por virus de Epstein-Barr / Alice in Wonderland syndrome and Epstein-Barr virus infection

La infección por el virus de Epstein-Barr (VEB) es habitual y generalmente ocurre en la infancia o en la adultez temprana. El VEB es la etiología de la mononucleosis infecciosa, generalmente asociada con fiebre, dolor de garganta, inflamación de los ganglios linfáticos en el cuello y en ocasiones esplenomegalia. El síndrome de Alicia en el País de las Maravillas (SAPM) o síndrome de Todd es una afección rara, que principalmente afecta la integración visual y somatoestética. El SAPM sigue siendo un síndrome poco conocido y probablemente mal diagnosticado, puede ocurrir a cualquier edad, pero sobre todo en los niños en los que se asocia principalmente con la migraña y la infección por VEB. Presentamos a una paciente de diez años que acudió al servicio de urgencias con distorsión visual de la forma corporal y comportamiento extraño, sospechado inicialmente como una patología psiquiátrica pero posteriormente diagnosticado con mononucleosis infecciosa e infección por VEB confirmada serológicamente. Este caso refleja la importancia de reconocer este síndrome por parte de los médicos de urgencias y evitar derivaciones inadecuadas al servicio psiquiátrico

Infection with Epstein-Barr virus (EBV) is common and usually occurs in childhood or early adulthood. EBV is the cause of infectious mononucleosis, usually associated with fever, sore throat, swollen lymph nodes in the neck, and sometimes an enlarged spleen. Alice in Wonderland Syndrome (AIWS), also called Todd's syndrome, is a rare condition, principally involving visual and somesthetic integration. AIWS remains a poorly known and probably misdiagnosed syndrome, can occur at any age but mostly in children is mostly associated with migraine and EBV infection. We present a 10-year-old patient who went to the emergency department with visual distortion of corporal form and bizarre behaviour, initially suspected as a psychiatric pathology but subsequently diagnosed with infectious mononucleosis and serologically confirmed Epstein-Barr virus (EBV) infection. This case reflects the importance of recognizing this syndrome by emergency physicians in order to avoid inadequate referrals to the psychiatric service

Primary care challenges of an obscure case of "Alice in Wonderland" syndrome in a patient with severe malaria in a resource-constrained setting: a case report.

BACKGROUND: "Alice in Wonderland" syndrome (AIWS) is a rare neurological abnormality characterized by distortions of visual perceptions, body schema and experience of time. AIWS has been reported in patients with various infections such as infectious mononucleosis, H1N1 influenza, Cytomegalovirus encephalitis, and typhoid encephalopathy. However, AIWS occurring in a patient with severe malaria is less familiar and could pose serious primary care challenges in a low-income context. CASE PRESENTATION: A 9-year-old male of black African ethnicity was brought by his parents to our primary care hospital because for 2 days he had been experiencing intermittent sudden perceptions of his parents' heads and objects around him either "shrinking" or "expanding". The visual perceptions were usually brief and resolved spontaneously. One week prior to the onset of the visual problem, he had developed an intermittent high grade fever that was associated with other severe constitutional symptoms. Based on the historical and clinical data that were acquired, severe malaria was suspected and this was confirmed by hyperparasitaemia on blood film analysis. The patient was treated with quinine for 10 days. Apart from a single episode of generalized tonic-clonic seizures that was observed on the first day of treatment, the overall clinical progress was good. The visual illusions completely resolved and no further abnormalities were recorded during 3 months of follow-up. CONCLUSION: Symptoms of AIWS usually resolve spontaneously or after treatment of an underlying cause. In our case, the successful treatment of severe malaria coincided with a complete regression of AIWS whose aetiology was poorly-elucidated given the resource constraints. In any case, the good outcome of our patient aligns with previous reports on acute AIWS that highlight a limited need for excessive investigation and treatment modalities which are, in passing, predominantly unaffordable in resource-limited primary care settings.

A case of recurrent depressive disorder presenting with Alice in Wonderland syndrome: psychopathology and pre- and post-treatment FDG-PET findings.

BACKGROUND: Alice in Wonderland syndrome (AIWS) is a rare neuropsychiatric syndrome that typically manifests in distortion of extrapersonal visual image, altered perception of one's body image, and a disturbed sense of the passage of distance and time. Several conditions have been reported to contribute to AIWS, although its biological basis is still unknown. Here, we present the first case demonstrating a clear concurrence of recurrent depressive disorder and AIWS. The clinical manifestations and pre- and post-treatment fluorodeoxyglucose positron-emission tomographic (FDG-PET) images provide insights into the psychopathological and biological basis of AIWS. CASE PRESENTATION: We describe a 63-year-old Japanese male who developed two distinct episodes of major depression concurrent with AIWS. In addition to typical AIWS perceptual symptoms, he complained of losing the ability to intuitively grasp the seriousness of news and the value of money, which implies disturbance of high-order cognition related to estimating magnitude and worth. Both depression and AIWS remitted after treatment in each episode. Pre-treatment FDG-PET images showed significant hypometabolism in the frontal cortex and hypermetabolism in the occipital and parietal cortex. Post-treatment images showed improvement of these abnormalities. CONCLUSIONS: The clinical co-occurrence of depressive episodes and presentation of AIWS can be interpreted to mean that they have certain functional disturbances in common. In view of incapacity, indifference, devitalization, altered perception of one's body image, and disturbed sense of time and space, the features of AIWS analogous to those of psychotic depression imply a common psychopathological basis. These high-order brain dysfunctions are possibly associated with the metabolic abnormalities in visual and parietotemporal association cortices that we observed on the pre- and post-treatment FDG-PET images in this case, while the hypometabolism in the frontal cortex is probably associated with depressive symptoms.

Alice in Wonderland Syndrome: A real life version of Lewis Carroll's novel.

Alice in Wonderland Syndrome was originally coined by Dr. John Todd in 1955. The syndrome is named after the sensations experienced by the character Alice in Lewis Carroll's novel Alice's Adventures in Wonderland. Alice in Wonderland Syndrome consists of metamorphopsia (seeing something in a distorted fashion), bizarre distortions of their body image, and bizarre perceptual distortions of form, size, movement or color. Additionally, patients with Alice in Wonderland Syndrome can experience auditory hallucinations and changes in their perception of time. Currently, there is no known specific cause of Alice in Wonderland Syndrome. However, theories point to infections such as the Epstein-Barr virus, medications such as topiramate and associated migraines. Neuroimaging studies have revealed brain regions involved with the manifestation of symptoms. These include the temporo-parietal junction within the temporal lobe and the visual pathway, specifically the occipital lobe. There are no current treatments for Alice in Wonderland Syndrome. Further research is needed to find better treatments for Alice in Wonderland Syndrome and to elucidate the exact cause or causes of Alice in Wonderland Syndrome.

Síndrome de Alicia en el país de las maravillas en patología cerebrovascular / Alice in Wonderland syndrome in cerebrovascular disease

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Síndrome de Alicia en el País de las Maravillas como pródromo de faringoamigdalitis estreptocócica / Alice in Wonderland syndrome as a prodrome of streptococcal tonsillopharyngitis

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Migrainous Aura, Visual Snow, and "Alice in Wonderland" Syndrome in Childhood.

Migraine is a condition that is common in the pediatric and adolescent population. Among children with migraine, visual aura can consist of either negative or positive features or both. Reports of sensory auras can also be elicited with a careful history. The understanding of the types of aura, as well as their relation to the more typical features of migraine, are discussed. The similar phenomena of visual snow and Alice in Wonderland syndrome in children are also described in detail.

Alice in Wonderland Syndrome associated with a temporo-parietal cavernoma.

Alice in Wonderland Syndrome (AIWS) is characterized by a rare constellation of perceptual disturbances including distorted body image, metamorphopsia, and visual hallucinations. In this report, we relate a unique case of AIWS in a woman with a right temporo-parietal cavernoma. AIWS in this patient may be secondary to epileptiform activity associated with the cavernoma and improved with anti-epileptic treatment.