"ALICE IN WONDERLAND" SYNDROME AND VARICELLA

Abstract

To The Editors: The "Alice in Wonderland" syndrome (AWS) includes an array of symptoms involving altered perception of shape (metamorphopsia) of objects or persons who appear to be smaller (micropsia) or larger (macropsia) than normal, the feeling of levitation, of impaired sense of passage of time, of zooming of the environment.1 This unusual neurologic picture, which can be mistaken for psychosis or drug intoxication, has been found to accompany cerebral lesions, mainly temporo-occipital or parieto-occipital,2 temporal epilepsy and migraine.3 In addition it is occasionally found in infectious mononucleosis4 as an initial manifestation of the disease5 or even as its only symptom. In 1996 Wang et al.6 reported a case of AWS during the course of disease caused by Coxsackievirus B1. We recently observed a patient who developed macropsia and zooming illusions at the end of varicella. Case report. A 4-year-old girl was taken to the Emergency Room of the Pediatric Department of the University of Ferrara because she had been complaining for the past 2 days that her parents were increasing and then decreasing in size and that the walls were closing down on her. She had had uncomplicated chickenpox 2 weeks before the beginning of the hallucinatory symptoms, which lasted for a few minutes and recurred several times a day. On physical examination she appeared to be an intelligent, well-oriented young girl in no distress. She was able to describe her visual illusions in detail. The only pathologic finding was the presence over her body of varicella lesions, all crusted. Neurologic and cerebrospinal fluid examinations were normal. An electroencephalogram revealed bilateral posterior slowing. Antibody titers against Epstein-Barr virus and Coxsackievirus were negative. Personal history was negative for drug ingestion, epilepsy or migraine, whereas family history (her maternal aunt) was positive for migraine without aura. The hallucinations continued, although decreasing in frequency, for 3 weeks and the electroencephalographic abnormalities for 2 weeks. She has now been asymptomatic for 1 year. We believe that AWS in this patient can probably be attributed to previous infection with varicella-zoster virus, although, less likely, it could be the first episode of isolated migrainous aura in a patient with positive family history. In a review of the literature we found only one case of AWS attributed to varicella.7 Varicella can be complicated by encephalitis at the rate of 1.7 per 100 000 cases8 and by cerebellar ataxia, but the clinical condition and normal cerebrospinal fluid parameters make both diagnoses unlikely in this patient. Varicella should be included among possible causes for AWS. Stefano Soriani, M.D. Raffaella Faggioli, M.D. Paola Scarpa, M.D. Caterina Borgna-Pignatti, M.D. Department of Clinical and Experimental Medicine; Division of Pediatrics; University of Ferrara; Ferrara, Italy