“Mom, I saw dad’s head get bigger!” Such a statement made by a child would likely alarm that child’s parents. But the child might actually be describing symptoms of Alice in Wonderland syndrome (AIWS), a neurologic condition aptly named after Lewis Carroll’s famous novel. Awareness of this condition in children is important, especially because it can occur during infectious events, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This was highlighted by an Italian study published in Pediatric Neurology.
Persistent Symptoms
AIWS is characterized by visual, auditory, and/or somesthetic distortions, including:
- Macropsia: Objects appear larger than they are
- Micropsia: Objects appear smaller
- Teleopsia: Objects seem farther away
- Pelopsia: Objects seem closer
- Metamorphopsia: Patients perceive their body or body parts as enlarging or shrinking
- Chromatopsia: Altered perception of colors
Auditory distortions may also occur. When such distortions are the result of age-related limitations, that is, in elderly populations, patients are generally aware that their perceptions are not real (unless the patient has a psychiatric condition such as psychosis). However, AIWS is more commonly observed in children. 
“When not associated with lesions in the central nervous system, it can occur alongside infections or shortly thereafter,” explained Susanna Staccioli, MD, a pediatric neurologist at the Bambino Gesù Pediatric Hospital in Rome, Italy, and the lead author of the study, which presented two pediatric cases of AIWS linked to SARS-CoV-2 infection.
Two Pediatric Cases
The first case involved an 8-year-old girl with no prior history of migraines or epilepsy. She experienced visual distortions, including micropsia, macropsia, and teleopsia, and auditory hallucinations, sometimes accompanied by headaches. Her symptoms began during a febrile episode (38 °C). Despite the fever resolving, the symptoms persisted, prompting a hospital visit 3 days later. A neurologic examination revealed no issues, and the only positive test was for SARS-CoV-2. The visual and auditory phenomena gradually diminished over a month and resolved completely 2 months postinfection.
The second case involved a 6-year-old girl, also without a history of migraines or epilepsy, who experienced recurring visual distortions, including metamorphopsia and chromatopsia. These brief episodes began 3 weeks before her visit to the emergency room. Testing revealed an otherwise asymptomatic SARS-CoV-2 infection. Her symptoms disappeared with the infection’s resolution.
In both cases, EEG results were normal, and brain MRI showed no abnormalities. There was no correlation between visual phenomena and cortical activity. “In the first case, the AIWS lasted longer than usual, possibly due to SARS-CoV-2’s neurotropism and inflammatory potential, which might have prolonged inflammation,” commented Staccioli. Despite this, she noted, the condition followed a benign course.
Investigating Symptoms
“Parents often don’t take these symptoms seriously at first because they seem so bizarre,” Staccioli explained. As a result, pediatric patients with AIWS often present at the hospital days after symptom onset. Children’s descriptions may be imaginative and hard to articulate, but as the phenomena recur consistently, parents become alarmed and seek medical attention.
Diagnosis relies on well-defined symptomatology, and a detailed patient history is essential. “Sometimes we ask children to draw what they saw,” suggested Staccioli. Parents are often helpful in reporting their child’s descriptions, especially when children are shy during consultations. The parents of the two COVID-19 patients were particularly distressed. “During the pandemic, beyond the worrisome symptoms, the entire situation was challenging,” she recalled.
Differential diagnoses include epilepsy with visual symptoms or neuropsychiatric disorders. “There’s a good article on headaches with visual disturbances or central nervous system lesions,” noted Staccioli.
Neuroimaging is performed under specific circumstances, such as when symptom descriptions are unconvincing, there is no infectious episode, very early onset, or when other red-flag symptoms occur. “After an initial evaluation, the child is referred to a headache center for proper follow-up,” Staccioli added.
Raising Awareness
“AIWS is a condition that should be considered before a psychiatric disorder is suspected,” she emphasized. However, she believes awareness among primary care pediatricians is improving. “Much information is being disseminated about this,” she concluded.
This story was translated from Univadis Italy using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
