A Not So Pleasant Fairy Tale

Background: Alice in Wonderland Syndrome (AiWS) is a neurological condition defined by the presence of perception disorders which translate into an imbalance between the self-representation and/or the perception of the real world. Several conditions have been associated with this syndrome, such as infections, brain injuries, psychoactive drug abuse and epilepsy.

Clinical Case: A 13 year-old male was observed in a general pediatric appointment due to visual distortion. According to his mother, this happened for the first time when he was 5 years old, and it occurred once or twice per year ever since, lasting no longer than 10 minutes. He usually wakes up frightened, claiming he sees everything bigger (macropsia) and sometimes he also refers that the objects seem to run away from him (teleopsia). Physical examination was unremarkable. The following investigation revealed compatible signs of cerebral anoxia at the MRI, probably due to neonatal asphyxia, and a normal initial sleep electroencephalogram (EEG). When repeated 7 months later it showed epileptiform activity. Zonisamide was indicated to be initiated in case of a new seizure.

Discussion: Visual distortions are the hallmark of AiWS, but body image and time distortion can also occur. Patients may have an erroneous perception of their body size or a distortion of the size and shape of the objects around them. This condition may be caused by epilepsy which, in turn, and although unusual, may be a later manifestation of neonatal asphyxia. So, it is important to be aware of these associations so that an early and accurate diagnosis can be made, and proper treatment and follow-up be performed.