Alice in Wonderland Syndrome and Covid-19: A Report of Three Cases

Introduction: “Alice In Wonderland Syndrome” (AIWS) is characterized by episodes of distorted perceptions or temporal/spatial changes. The pathophysiological mechanism is not well defined. However, some authors argue that it is a rare perceptive disturbance, which affects mainly associative sensorial cortex integration mechanisms, involved in internal-external relationship development. It was initially described in migraine and/or epilepsy patients. Infections are considered the main cause of AIWS in children, and it can occur before, during or after the contact with the microorganism. COVID-19 is the disease caused by the SARS-CoV-2 virus, which can be linked with neurological manifestations. Clinical case reports: Three children, between 6 and 11 years of age, previously healthy and without personal or familiar history of migraine and/or epilepsy, were observed in Neuropediatrics consultations because of visual changes, described as corresponding to macropsia, micropsia, teleopsia and pelopsia. In two of the cases, symptoms began during SARS-CoV-2 infection and, in the other one, a week after the disease. Every episode lasted a few minutes and resolved spontaneously in a few days. Discussion: No complementary exams are needed to diagnose AIWS. Nevertheless, when paroxysmic visual changes are present, other aetiologies frequently need to be excluded. Generally, episodes are self-limited, and symptoms completely resolve, with a long-term good prognosis. Until this moment, AIWS has not been linked to COVID-19. However, in this case reports, SARS-CoV-2 was the only identified trigger. Similarly to other viruses, like EBV or H1N1, cerebral hypoperfusion by hypoxemia and/or by pro-inflammatory cytokines action in response to SARS-CoV-2 are possible underlying pathophysiological mechanisms.