[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.

[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.

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 Wonderland syndrome. What do we know after 60 years?]

BACKGROUND

The Alice in Wonderland syndrome (AIWS) was conceptualised in 1955 as a group of distortions of visual perception, the body schema and the experience of time. Although 60 years have passed since then, very little is known yet about the syndrome. This is surprising since the AIWS has important diagnostic and therapeutic implications.

AIM

To provide an overview of the literature on the AIWS.

METHOD

For this review, a literature search was carried out in PubMed and the historical literature.

RESULTS

The search yielded 70 papers with a total of 169 case descriptions. As these papers indicate, the AIWS has many causes, the main ones being neurological, infectious and substance-related; sometimes the causes are psychiatric. Among adults and elderly patients the disorders described are mainly neurological; among young people encephalitis is fairly common. Treatment needs to be directed at the (assumed) underlying condition, although in almost half of the cases the patient's main requirement is reassurance rather than treatment. Prevalence rates are unknown, but studies in the general population indicate that the symptoms of the AIWS occur more frequently than previously assumed.

CONCLUSION

Clinical suspicion of an AIWS warrants careful auxiliary investigations and - whenever necessary - treatment. The AIWS should not be confused with schizophrenia spectrum disorders and other perceptual disorders, and it deserves to be included in the research agenda of international classifications such as the DSM and ICD.

[The Alice in Wonderland syndrome]

BACKGROUND

Alice in Wonderland syndrome (AIWS) is characterised by abnormal perception, such as metamorphopsia, macropsia, micropsia, teleopsia and pelopsia. Although brief and transient, these episodes of visual distortion may lead to great anxiety, especially in children. AIWS seems to be associated with specific viral infections, epilepsy, migraine, and brain tumours.

CASE DESCRIPTION

An 8-year-old boy had episodes of seeing persons further away than they actually were (teleopsia). These perceptual distortions occurred when he was about to go to sleep. The episodes never exceeded 10 minutes. He was referred to a paediatrician and an ophthalmologist, who found no abnormalities. Serological tests showed a positive IgG for both Epstein-Barr and varicella zoster virus.

CONCLUSION

The cause of AIWS is unclear. When occurring in the young patient, parents often become worried. In most cases no serious pathological cause is found. Usually, reassurance is sufficient. Therefore, general practitioners should be able to recognise the symptoms.