Alice in Wonderland Syndrome in a Child Following Epstein-Barr Virus Infection: A Case Report

Abstract

Alice in Wonderland syndrome (AIWS) is a rare and often underrecognized neuropsychiatric phenomenon characterized by transient episodes of visual and somatosensory perceptual distortions, including micropsia, macropsia, altered body image, derealization, and disrupted perception of time. It most commonly affects children and adolescents and can be triggered by various conditions, including migraine, epilepsy, medications, and infections. We present the case of a 10-year-old previously healthy girl who developed intermittent episodes of micropsia, time distortion, and depersonalization shortly after recovering from a self-limited febrile illness. Her history and symptoms were classic for AIWS, and serologic testing confirmed an acute Epstein-Barr virus (EBV) infection, with positive viral capsid antigen (VCA) IgM and IgG and negative EBNA-1 IgG, indicating a primary EBV infection. Extensive diagnostic workup, including basic metabolic panel, inflammatory markers, autoimmune screening, neuroimaging (MRI), and electroencephalography (EEG), revealed no abnormalities, effectively ruling out structural, epileptic, or metabolic causes. The patient retained full orientation and insight throughout the episodes, and her symptoms gradually resolved over the course of four weeks without pharmacologic intervention. Supportive care, patient and family reassurance, and close outpatient follow-up were sufficient for full recovery. This case reinforces the strong association between AIWS and post-infectious states, particularly EBV, and emphasizes the importance of early recognition and appropriate evaluation to avoid unnecessary interventions. Increased clinician awareness of AIWS is crucial in guiding timely diagnosis, alleviating anxiety, and ensuring optimal management in affected pediatric patients.

Keywords: alice in wonderland syndrome; body image distortion; derealization; epstein-barr virus; macropsia; micropsia; perceptual distortion; post-infectious neuropsychiatric syndrome; transient perceptual disorder; visual illusions.