It’s the story of an eight-year-old Italian girl. admitted to the emergency room of a children’s hospital for repeated episodes of visual and auditory hallucinations. The girl does not suffer from any psychiatric disorder and has no personal or family history of migraine or epilepsy.
Three days previously, she began to have visual hallucinations during an infectious episode manifested by fever (up to 38.9°C) and vomiting.
The erroneous perceptions last a few minutes and disappear spontaneously. She then perceives objects and people smaller than they are or, conversely, larger than in reality. It presents what specialists call micropsia and macropsia. That’s not all: the size of her body seems smaller than it is (microsomatognosia) and she experiences the sensation that objects appear much further away than they really are (teleopsia). These episodes of visual distortions are sometimes associated with headaches. The little girl has no disturbance of consciousness at any time, nor alteration of the perception of time.
She also presents with auditory hallucinations, which the doctors do not detail in their article published in their article published in the issue dated January 2025 in the journal Pediatric Neurology.
She was admitted to the Bambino Gesù pediatric hospital in Rome due to the persistence of these curious symptoms even though the fever had broken. The clinical examination does not show any localized neurological deficit. The biological examinations carried out during his hospitalization were all negative, with the exception of one. An antigen test reveals that she is infected with SARS-CoV-2, the coronavirus responsible for Covid-19, which is confirmed by a PCR test.
This little girl’s fundus is normal. The electroencephalogram coupled with a video recording (EEG-video) shows normal brain activity, without any epileptic discharge. During this examination, the little girl felt these visual distortions, which were not accompanied by epileptic discharges on the video-EEG. Doctors therefore ruled out that the little girl could suffer from epilepsy.
Magnetic resonance imaging of the brain (brain MRI) also showed no significant abnormalities.
Based on the clinical symptoms, normal neurological and ophthalmological examinations and the results of the EEG and MRI, the doctors conclude that the visual perception abnormalities of their young patient are compatible with Alice in Land syndrome. wonders linked to SARS-CoV-2 infection. The visual phenomena persisted for another month, therefore well after the disappearance of the SARS-CoV-2 infection. However, they were less frequent. The complete disappearance of visual symptoms occurred approximately two months after the onset of the disturbances.
This little girl presents what neurologists call “Alice in Wonderland syndrome,” a distortion of a part of the body. This disorder takes its name from the novel by Lewis Carroll, pseudonym of Charles Lutwidge Dodgson, professor of mathematics at Oxford and himself a migraine sufferer. We remember the incessant metamorphoses of Alice, who goes from tiny after drinking the contents of a vial to gigantic after eating a piece of cake.
First described in 1952, this syndrome is characterized by a set of visual hallucinations, distortions of body image as well as an alteration in the perception of space and time, often accompanied by headaches. Three years later, in 1955, the British psychiatrist John Todd named this phenomenon Alice in Wonderland syndrome (SAPM), to designate these transient bodily changes. In addition to the body schema disorders felt by the patient, this syndrome can sometimes include derealization (impression of strangeness affecting the perception of the surrounding world), an alteration of the flow of time, visual illusions concerning size, shape, the distance of objects.
Susanna Staccioli and her pediatric neurologist colleagues report in the same article a second case of transient SAPM associated with SARS-CoV-2 infection. This concerns a six-year-old girl referred to the emergency room for repeated episodes of visual hallucinations in a context of symptomatic SARS-CoV-2 infection. Unlike the previous case, this young patient does not present any hearing symptoms. She has no personal or family history of migraine, epilepsy, or other neurological disorder, nor any recent history of infectious disease.
The child’s visual illusions relate to the shape and size of objects or people, what specialists call metamorphopsia. She also presents with chromatopsia, characterized by abnormal color perception. These visual symptoms started about three weeks ago, within a few minutes, and disappeared spontaneously. These episodes are not accompanied by any neurological deficit or disturbance of consciousness. Laboratory tests are normal, with the exception of a nasal antigen test which is positive for SARS-CoV-2. The fundus examination is normal, as are the brain MRI and video-EEG performed during wakefulness and sleep.
Doctors concluded that the little girl developed transient Alice in Wonderland syndrome associated with SARS-CoV-2 infection. During her hospitalization, the child did not have a new episode during which she perceived her body or part of her body larger than it was. She had no further symptoms after the SARS-CoV-2 infection resolved.
Italian pediatricians point out that these two children were not vaccinated against Covid-19.
Responsible mechanisms still obscure
The pathophysiological mechanisms underlying the occurrence of SAPM during SARS-CoV-2 infection are unclear. Are they linked to discrete structural abnormalities in the brain, to cerebral metabolic abnormalities, to the persistence of viral particles in the body leading to overactivation of the immune system with increased inflammation associated with production of inflammatory molecules (cytokines), disturbances in functional cerebral connectivity, a defect in cerebral perfusion, a reduction in the activation of certain cortical visual areas?
In rare cases of infections in children and adults
There are only very rare cases of SAPM associated with SARS-CoV-2 infection in the medical literature. In 2022, a German team reported a case of SAPM in a five-year-old boy who presented with teleopsis: he had the sensation of having his arms and legs more elongated than they really were. This disorder appeared two weeks after being diagnosed positive for SARS-CoV-2 during a PCR test. The episodes, lasting 10 to 30 minutes, occurred approximately once a day.
In 2023, Portuguese pediatricians described three cases of SAPM associated with Covid-19 in children, aged 6 to 11 years, without any history of migraine or epilepsy. They exhibited macropsia, micropsia, teleopsia and pelopsia (objects appearing closer than they really are). In two cases, visual symptoms appeared during acute viral infection. In another, they occurred a week later. Each episode lasted a few minutes. The symptoms disappeared spontaneously.
SAPM is also rare in adults. It mainly manifests itself during migraines and epileptic attacks. Other causes have been identified, such as the use of hallucinogenic drugs (LSD) or psychotropic drugs, brain tumors, viral encephalitis, psychiatric disorders (schizophrenia, depression), infection with the Epstein-Barr virus (EBV). or febrile conditions, such as acute upper respiratory infections (pharyngitis, tonsillitis). In almost 20% of cases, no cause is identified. Finally, approximately 65% of SAPM cases occur in children under the age of 18.
Marc Gozlan (Follow me on XFacebook, LinkedIn, Mastodon, BlueSkyand on my other blog ‘Diabetes in all its forms’dedicated to the thousand and one facets of diabetes – already 78 posts).
To find out more:
Staccioli S, Mariani R, Bompard S, et al. Alice in Wonderland Syndrome in Children With Severe Acute Respiratory Syndrome SARS-CoV-2 Infection: A Case Series of Two Patients in an Italian Hospital. Pediatr Neurol. 2025 Jan;162:28-31. doi: 10.1016/j.pediatrneurol.2024.10.008
Figueiredo AM, Correia L, Ribeiro JA, et al. Alice in wonderland syndrome and Covid-19: a report of three cases. SVOA Neurol. 2023;4:2, 29-32. doi: 10.58624/SVOANE.2023.04.087
Piervincenzi C, Petsas N, Viganò A, et. Functional connectivity alterations in migraineurs with Alice in Wonderland syndrome. Neurol Sci. 2023 Jan;44(1):305-317. doi: 10.1007/s10072-022-06404-1
Bittmann S, Moschüring-Alieva E, Luchter E, et al. Is Covid-19 a Trigger of Alice in Wonderland Syndrome? J Clin Ped Res. 2022;1:6e8. doi: 10.37191/Mapsci-JCPR-1(1)-003
Lu Y, Li X, Geng D, Mei N, et al. Cerebral Micro-Structural Changes in COVID-19 Patients – An MRI-based 3-month Follow-up Study. EClinicalMedicine. 2020 Aug;25:100484. doi: 10.1016/j.eclinm.2020.100484
Farooq O, Fine EJ. Alice in Wonderland Syndrome: A Historical and Medical Review. Pediatr Neurol. 2017 Dec;77:5-11. doi: 10.1016/j.pediatrneurol.2017.08.008
Weissenstein A, Luchter E, Bittmann MA. Alice in Wonderland syndrome: A rare neurological manifestation with microscopy in a 6-year-old child. J Pediatr Neurosci. 2014 Sep-Dec;9(3):303-4.
Liu AM, Liu JG, Liu GW, Liu GT. « Alice in wonderland » syndrome: presenting and follow-up characteristics. Pediatr Neurol. 2014 Sep;51(3):317-20. doi: 10.1016/j.pediatrneurol.2014.04.007
Weidenfeld A, Borusiak P. Alice-in-Wonderland syndrome–a case-based update and long-term outcome in nine children. Childs Nerv Syst. 2011 Jun;27(6):893-6.
Hung KL, Liao HT, Tsai ML. Epstein-Barr virus encephalitis in children. Acta Paediatr Taiwan. 2000 May-Jun;41(3):140-6.
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