Síndrome de Alicia en el País de las Maravillas secundario a infección por SARS-CoV-2 / Alice in Wonderland syndrome in SARS-CoV-2 infection

El síndrome de Alicia en el País de las Maravillas es un conjunto de trastornos complejos de la percepción visual con múltiples etiologías, siendo las infecciones las más frecuentes en Pediatría. Es un cuadro poco frecuente, pero es importante conocerlo por su carácter generalmente autolimitado. Presentamos el caso de un niño de 11 años que, a las 48 horas de infección por SARS-CoV-2, inició distorsión visual de la forma corporal, micropsias y macropsias. Se descartaron otras causas orgánicas, manteniéndose actitud expectante dada su evolución benigna. Se destaca la aparición de este síndrome en contexto clínico de infección por SARS-CoV-2, no habiendo sido descrita hasta ahora su asociación en la literatura. (AU)

The Alice in Wonderland syndrome is defined by the presence of visual perception disorders with several etiologies, being infectious the most frequent in pediatrics. It is a rare clinical condition, but it is important to recognize it because of the generally self-limited nature. We present an 11 years old child who presented visual body distortions, micropsia and macropsia 48 after SARS-CoV-2 infection. Other organic causes were discarded, maintaining an expectant treatment because of its benign evolution. It is noteworthy that this syndrome associated with SARS-CoV-2 infection has not yet been published. (AU)

[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.

A CASE OF MIGRAINE WITH SYMPTOMS OF PERCEPTION DISORDERS INCLUDING A FAMILY HISTORY.

Alice in Wonderland Syndrome is characterized by distortions in perception, especially with signs of micropsia or macropsia, peropia, teleopsia.The etiology of this syndrome includes migraine attacks, epilepsy, infections or substance abuse.In this case study, a 15-year-old adolescent girl was admitted to our child and adolescent psychiatry clinic with complaints of seeing objects and people as larger or smaller than they are and/or perceiving objects closer or farther than they are, before her migraine attacks.It was also stated that his father had similar complaints during his adolescence..In this case report, we present a case of migraine with aura.

Jean-Martin Charcot (1825-1893) and the "Alice in Wonderland syndrome".

The "Alice in Wonderland syndrome" (AIWS) is a neurological disorder characterized by altered body schema perception, visual, or somesthetic symptoms, which is frequently associated with migraine. In this article, we present the earliest known description of symptoms attributable to AIWS in the medical literature. During a lecture held on November 22, 1887, at the Salpêtrière, Jean-Martin Charcot (1825-1893) examined a patient with somesthetic symptoms (partial macrosomatognosia) in the context of migraine with aura. Although this condition was not known at the time, Charcot tried to provide an accurate semiological and nosographic framework of this case, attributing the complex of symptoms to migraine with aura and epilepsy with sensory symptoms. With intellectual honesty and clinical prudence, Charcot correctly pointed to a disturbance in the excitability of cortical areas responsible for processing and perceiving sensory stimuli.

Síndrome de Alicia en el país de las maravillas secundario a consumo de montelukast. Presentación de caso / Alice in wonderland syndrome secondary to medication with montelukast. Case presentation

RESUMEN La condición neurológica definida por la aparición de alteraciones en la percepción, usualmente interpretada como fenómenos extraños de metamorfosis y despersonalización, se reconoce como síndrome de Alicia en el país de las maravillas. Se presenta el caso de una paciente femenina de 9 años de edad, con el diagnóstico de síndrome de Alicia en el país de las maravillas secundario a medicación crónica con montelukast. El diagnóstico del síndrome psiquiátrico se realizó teniendo en consideración los antecedentes patológicos personales y el examen físico. El síndrome de Alicia en el país de las maravillas tiene un carácter benigno, sumamente infrecuente, y aunque su etiología no es del todo conocida, su aparición como reacción adversa a medicamentos es una opción que debe ser siempre considerada por el médico actuante (AU).

ABSTRACT The neurological condition defined by the appearance of alterations in perception usually interpreted as strange phenomena of metamorphosis and depersonalization is recognized as Alice in wonderland syndrome. The case of a 9-year-old female patient is presented, with the diagnosis of Alice in Wonderland syndrome secondary to chronic medication with montelukast. The diagnosis of the psychiatric syndrome was made taking into account personal pathological history and physical examination. Alice in Wonderland syndrome has a benign, extremely rare character and although its etiology is not fully known, its appearance, as an adverse reaction to medications, is an option that should always be considered by the acting physician (AU).

[Alice in Wonderland-syndrome may be confused with anxiety].

This case report describes a seven-year-old girl with autism and nightly "anxiety" attacks. A diagnosis of Alice in Wonderland syndrome (AIWS) presumably associated to migraine was made, and the girl was successfully treated with lamotrigine. Effective treatment of the AIWS depends on correct diagnosis. Symptoms are bizarre and affect the senses of vision, sensation, touch and hearing, as well as one's own body image. AIWS is associated with epilepsy, migraine, certain infectious diseases and rarely cerebral tumours.

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

Síndrome de Alice no país das maravilhas e reativação de infeção por Epstein-Barr / Alice in wonderland syndrome and reactivation of infection by Epstein-Barr

INTRODUÇÃO: O síndrome de Alice no País das Maravilhas (SAPM) é uma entidade rara que pode ocorre no contexto de várias condições clínicas, sendo a infeção por vírus Epstein-barr (EBV) a mais comum nas causas infeciosas. Apresenta-se um caso de SAPM associado a infeção a EBV alertando para a necessidade de investigação etiológica destes casos. RELATO DE CASO: Criança de 8 anos, com síndrome de Asperger que, no contexto de amigdalite aguda e febre, surgiu com episódios paroxísticos de alguns minutos de metamorfopsias (macro e micropsia), distorção da perceção das vozes e sensação de medo. A ressonância magnética e o eletroencefalograma foram normais, e o exame citoquímico do líquor foi normal mas a polimerase chain reaction (PCR) foi positiva para vírus EBV. As serologias para EBV, repetidas 3 e 10 semanas após a avaliação inicial, confirmaram uma reativação da infeção por este agente. O doente ficou assintomático após 2 semanas e não houve recidivas. CONCLUSÕES: A investigação de metamorfopsias ou síndrome de SAPM é mandatória pois podem indiciar patologia grave, nomeadamente lesão cerebral ou epilepsia focal. Embora a doença seja rara a etiologia infecciosa deve ser excluída mesmo em doentes com perturbação prévia do comportamento.

INTRODUCTION: Alice in wonderland syndrome (AWS) is a rare condition which may occur as a sign of multiple conditions, with the most frequent infectious etiology being Epstein-barr virus (EBV) infection. We present a case of an AWS caused by EBV infection to alert for the need to investigate these cases. CASE REPORT: 8-year-old boy with Asperger syndrome who developed, in the context of tonsillitis and fever, brief paroxystic episodes of metamorfopsias (macro and micropsia), with voice perception distortion and fear. Physical exam was otherwise normal. Brian magnetic resonance and electroencephalogram were normal, liquor cytochemical exam was normal but Epstein-barr virus (EBV) polimerase chain reaction was positive. EBV blood serologies, repeated 3 and 10 weeks after the initial evaluation, confirmed the reactivation of this agent's infection. Symptoms succumbed 2 weeks after its beginning, with no relapses. CONCLUSIONS: Metamorfopsias or AWS impose etiological investigation because they may occur due to severe disease, namely cerebral lesion or focal epilepsy. Although it is a rare disease, infectious causes should be excluded, even in patients with previous disturbed behavior.

[Aura without migraine or Alice in Wonderland syndrome: Pediatric clinical case]. / Aura sin migraña o síndrome de Alicia en el País de las Maravillas: Caso clínico pediátrico.

Migraine with aura in children is often reported, typical aura without headache is reported sometimes, but persistent aura and Alice in Wonderland syndrome is exceptionally reported. We present a case corresponding to the last one mentioned in a 6-year-old patient who had at least two episodes with the typical characteristics of aura without migraine before developing more frequently the complete clinical picture of aura and subsequently headache. The complementary studies systematically done to the patient were normal and she improved with conventional therapy.It is important to emphasize that the syndrome should be suspected in any patient who presents the described manifestations in order to approach to the diagnosis of aura without migraine, to discard either organic pathology or another cause and to indicate adequate therapeutic measures.

La migraña con aura en pacientes pediátricos es reportada con frecuencia; el aura típica sin migraña, en raras ocasiones, y el aura persistente asociada al denominado síndrome de Alicia en el País de las Maravillas, excepcionalmente.El objetivo de este reporte es presentar un caso clínico correspondiente a la última variedad mencionada. Se trata de una paciente de 6 años de edad, quien tuvo, al menos, dos episodios con estas características antes de presentar un cuadro clínico completo de aura y, consecutivamente, cefalea con más frecuencia. Los estudios complementarios practicados de manera sistemática a la paciente fueron normales, con mejoría clínica con el tratamiento convencional.Se debe sospechar el síndrome en todo paciente que se presente con las características descritas a fin de aproximarse al diagnóstico de aura sin migraña, descartar patologías orgánicas o de otra naturaleza e instaurar la terapéutica adecuada.

Transient Episode of Alice in Wonderland Syndrome After Ventriculoatrial Shunt Revision.

BACKGROUND: Visual misperceptions as a result of neurosurgical disorders are well documented. Alice in Wonderland syndrome (AWS) typically is reported in neurologic and psychiatric disorders. We present a patient who developed symptoms of AWS postoperatively. CASE DESCRIPTION: A 48-year-old man presented in shunt failure, attributed to a proximal catheter occlusion. Operative revision with replacement of the proximal catheter was performed without incident. Postoperatively, he complained of visual disturbances, including the perception that people had small heads on full-sized bodies. Symptoms resolved postoperatively. The patient's symptoms were diagnosed as a transient episode of AWS. This was attributed to manipulation of the parieto-occipital cortex during the revision. The local inflammatory response from manipulation of that area is thought to have caused our patient's symptoms. CONCLUSIONS: Visual disturbances caused by lesions along the optic radiations are common findings for neurosurgery patients, although AWS after surgical intervention has not been reported previously.

The Alice-in-Wonderland Syndrome.

In 1955, English psychiatrist John Todd defined the Alice-in-Wonderland syndrome (AIWS) as self-experienced paroxysmal body-image illusions involving distortions of the size, mass, or shape of the patient's own body or its position in space, often accompanied by depersonalization and/or derealization. AIWS had been described by American Neurologist Caro Lippman in 1952, but Todd's report was the most influential. Todd named the syndrome for the perceptual disorder of altered body image experienced by the protagonist in Alice's Adventures in Wonderland (1865) by Lewis Carroll (Charles Lutwidge Dodgson). In Carroll's original story, Alice experienced several dramatic changes in body size and shape (e.g., shrinking to 10 inches high, growing unnaturally tall but not any wider, and growing unnaturally large). Todd reported 6 cases of AIWS, all of whom had episodic body-image distortions like those experienced by Lewis Carroll's Alice character; some also had visual perceptual disturbances, but none had visual perceptual disorders without body-image distortions. Therefore, AIWS may be accompanied by visual perceptual disorders (e.g., micropsia, macropsia, telopsia, pelopsia), but basing the diagnosis of AIWS on isolated visual perceptual disorders, as has subsequently been done by a number of authors, is inaccurate and misleading. Cases of isolated visual illusions without self-perceived distortions of body size, shape, or form, do not meet Todd's original criteria, nor are they commensurate with the experiences of the protagonist in Alice's Adventures in Wonderland. Furthermore, such cases differ by age and etiology from those that involve somesthetic perceptual disorders. Therefore, the use of the term AIWS for isolated visual illusions is problematic and should be discouraged. Although Todd's and Lippman's cases were adolescents or adults, AIWS is most commonly reported in children. Reported causes include infection (especially with Epstein Barr virus), migraine, epilepsy, depression, and toxic and febrile delirium.

The Alice in Worderland Syndrome.

The Alice in Wonderland Syndrome (AWS) was first described more than 60 years ago by Lippman. It refers to episodes during which an individual may variously experience (as did Alice during her time in Wonderland) somatic, visuo-perceptual and/or visuo-spatial hallucinations, as well as feelings of depersonalisation, derealisation and distorted sense of time. Although the prevalence of AWS is unknown, indirect evidence from both retrospective and prospective studies suggests that it is a rare disorder. This paper describes the case of Zoe, a right-handed, native English speaker who was age 45 years when she experienced an episode of AWS. On neuropsychological assessment, Zoe demonstrated notable impairment of attention, learning and recall (particularly for visuo-spatial information) as well as executive dysfunction (viz., impairment of planning, cognitive flexibility and abstraction), consistent with fronto-temporal dysfunction. Detailed profiles of neuropsychological impairment in the context of AWS have not previously been reported, and it is unclear if such impairment is, indeed, a central and characteristic feature of AWS.

Temporal-occipital glioblastoma presenting with Alice in Wonderland Syndrome in a patient with a long-time history of migraine without aura.

Alice in Wonderland Syndrome (AIWS) is a rare perceptual disorder characterized by an erroneous perception of the body or the surrounding space. AIWS may be caused by different pathologies, ranging from infections to migraine. We present the case of a 54-year-old man, with a long-time history of migraine without aura, diagnosed with AIWS due to a glioblastoma located in the left temporal-occipital junction. To date, this is the first case of AIWS caused by glioblastoma. This case suggests that to exclude aura-mimic phenomena, a careful diagnostic workup should always be performed even in patients with a long-time history of migraine.

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.

[Visual Snow Syndrome: Symptoms and Ophthalmological Findings]. / Das Visual-Snow-Syndrom: Symptome und ophthalmologische Befunde.

Background The symptom "visual snow" describes the continuous perception of tiny flickering dots within the whole visual field of both eyes. The diagnosis of a visual snow syndrome requires the appearance of typical additional visual symptoms and the exclusion of ophthalmological or neurological causes, or pharmacological influences. Patients and Methods Three male and four female subjects between 13 and 36 years of age referred with visual snow were investigated and asked about their symptoms. A complete ophthalmological investigation, including binocular fundoscopy, was performed in all patients. Furthermore, best corrected visual acuity, perimetry, binocular functions, colour vision (D15-test), full-field ERG, pattern-reversal VEP and SD-OCT images of macula and optic nerve (RNFL) were analysed. Results Visual acuity of at least 1.0 and normal findings for all further investigations were observed in all patients. The following additional visual symptoms were identified: illusionary palinopsia (n = 6), disturbance of night vision (n = 5), positive light phenomena (n = 7). A history of migraine with aura was reported in five patients. The intake of hallucinogenic drugs or centrally active pharmaceuticals was denied by all patients. The findings of available or initiated neurological investigations were normal. Conclusions The visual snow syndrome has to be regarded as a diagnosis of exclusion. Visual function parameters are not impaired. Apart from eye diseases, a persistent migraine aura as well as neurological diseases or the intake of hallucinogenic drugs must be excluded as possible causes of visual snow and palinopsia.

Alice in Wonderland syndrome associated with mycoplasma infection.

Alice in Wonderland syndrome (AIWS) is a rare condition in which patients report distorted size perception of objects and their own bodies. Although specific causes and pathology have not been elucidated, an association between AIWS and infection has been suggested. To our knowledge, mycoplasma-induced AIWS has not been examined. A girl aged 7 years 11 months presented with fever (temperature, 40°C) and cough. Although the fever disappeared after approximately 10 days, she complained that her mother's face suddenly appeared smaller to her. Subsequently, she complained that objects intermittently appeared smaller than normal. Particle agglutination test indicated elevated serum antibodies against Mycoplasma pneumoniae. The patient was therefore diagnosed the patient with AIWS secondary to mycoplasma infection. Although mycoplasma infection is known to cause various central nervous system symptoms, this is the first report involving AIWS, suggesting that mycoplasma could affect visual function in children.