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

Abstract

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 presentationA 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.ConclusionSymptoms 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.

Prevalence and characteristics of Alice in Wonderland Syndrome in adult migraineurs: Perspectives from a tertiary referral headache unit

“…In this regard, one notable example is Alice in Wonderland Syndrome (AIWS), a syndrome characterised by visual and somatosensory misperceptions (5–7). The association between AIWS and migraine is mostly anecdotal, since it has been investigated only by case reports or small studies (8–15). Moreover, while migraine is the first cause of AIWS in adults (6,16), most of the studies on AIWS have focused on children (6,17,18).…”

"Um mundo em câmera lenta" como manifestação da Síndrome de Alice no País das Maravilhas: um relato de caso

“…A base do diagnóstico consiste em excluir outras condições clínicas que justifiquem alucinações visuais ou auditivas. (35)(36)(37)(38)(39)(40)(41) e tentar identificar a condição clínica que esteja associada com o surgimento dos sintomas e se essa associação de causalidade é verdadeira, já que há relatos de experimentação dos sintomas de alucinação ou distorção da realidade na população geral. É necessário pesquisar se há lesões cerebrais subjacentes, fazendo-se este rastreio por meio de RM, pesquisa de LCR e EEG, que normalmente encontram-se sem alterações significativas.…”

Metamorphopsia in neurological practice

“…[4,32]. Хотя ключевым признаком синдрома Алисы в Стране чудес признаны не зрительные искажения, а пароксизмальные ощущения изменения размеров, массы, формы, положения своего тела в пространстве, сочетающиеся с явлениями деперсонализации/дереализации и чувством изменения течения времени, однако метаморфопсии в большинстве случаев сопутствуют кинестетическим иллюзиям [31,33,34]. Всего в рамках синдрома Алисы в Стране чудес описано 42 зрительных симптома и 16 симптомов, относящихся к телесным и другим ощущениям [9,23].…”

“…Также этот синдром описан при остром рассеянном энцефаломиелите, тромбозе церебральных вен, инсульте с вовлечением медиальных отделов правой височной доли, апоплексии гипофиза, опухолях и травмах головного мозга, психических заболеваниях (шизофрения, депрессивное расстройство), сенсорной депривации, интоксикациях, употреблении ряда лекарственных препаратов (антагонисты 5-HT2A-рецепторов, декстрометорфан, рисперидон, топирамат, осельтамивир и др.) и запрещенных наркотических веществ [4,9,23,30,31,[34][35][36].…”

“…Для уменьшения эффекта Пульфриха, если он сильно мешает повседневной активности, перед здоровым глазом больного размещают плотный фильтр, который вставляют в оправу для очков [21]. Синдром Алисы в Стране чудес обычно регрессирует после устранения его причины и специального симптоматического лечения не требует [4,33,34].…”