Alice in Wonderland Syndrome as a Presenting Symptom of EBV Infection Shii-Ben Liaw, MD and Ein-Yiao Shen, MD
Four Chinese patients (2 boys, 2 girls), ages 4-9 years, who had episodes of perception error of body schema and objects are reported. The metamorphopsia, which had been named Alice in Wonderland syndrome, is the major presentation. All of them were proved to have acute Epstein-Barr virus infection, as documented by positive heterophii antibody test and/or positive IgM antibody to Epstein-Barr virus capsid antigen. The duration of the perception disorder ranged from 1 week to 3 months. We believe that any young child presenting with Alice in Wonderland syndrome should undergo examination for Epstein-Barr virus infection; complete recovery from the disorder can be expected. L i a w S - B , S h e n E - Y . A l i c e in W o n d e r l a n d s y n d r o m e as a presenting symptom
of EBV
infection. Pediatr Neurol
1991 ;7:464-6.
Introduction A l i c e in W o n d e r l a n d s y n d r o m e ( A W S ) w a s p r o p o s e d b y T o d d in 1955 to e n c o m p a s s t h e c o m p l e x s y m p t o m s o f bizarre perceptual distortions, including personal body i m a g e a n d size, as w e l l as t h e d i s t a n c e o f o b j e c t s [1]. T h e experiences
of metamorphopsia
in t h e s e p a t i e n t s w e r e
s i m i l a r to t h o s e o f t h e 9 - y e a r - o l d c h a r a c t e r , A l i c e , in The
A d v e n t u r e s o f A l i c e in W o n d e r l a n d . T h i s p e r c e p t u a l d i s t o r tion is f r i g h t e n i n g to t h o s e a f f e c t e d . W e r e p o r t 4 p a t i e n t s w i t h A W S , the c o u r s e s o f w h i c h w e r e b e n i g n a n d t e m p o r a r y . All p a t i e n t s h a d d o c u m e n t e d E p s t e i n - B a r r - v i r u s induced infection.
Case Reports Methods. The mechanism of the procedures utilized for serologic diagnosis involves the serum of EBV-infected patients which will agglutinate with horse erythrocyte cells treated with glutaraldehyde. Heterophil antibody titers are positive in the acute stages of EBV infection, especially in children older than 4 years, and are elevated 3-6
From the Department of Pediatrics; Mackay Memorial Hospital; Taipei, Taiwan, Republic of China.
464
PEDIATRIC NEUROLOGY
Vol. 7 No. 6
months. The IgM and IgG antibodies to EBV capsid antigen (IgMEBVCA and IgG-EBVCA) are detected by using the indirect fluorescent antibody method. The IgM response is transient for 1-2 months but the lgG response is lifelong for those patients with EBV infection. Patient I. This 5-year-old girl was referred to our hospital lor evaluation of episodes of bizarre behavior. She complained that witches and policemen came into her home; occasionally, she perceived that her mother alternately became larger or smaller. She talked to herself, had incoherent speech, and sometimes was puzzled by seeing objects around her changing in size and shape. She had an upper respiratory tract infection and fever 4 days prior to this episode. On physical examination, the patient appeared confused and disoriented; however, the other neurologic findings, including cranial nerve function, muscle power, deep tendon reflexes, cerebellar function, and autonomic nerve function, were normal. No organomegaly was present. The leukocyte count was 10,900/ram 3 with 44% neutrophils and 44% lymphocytes and an erythrocyte sedimentation rate of 15 rnm/hr. The biochemical studies were noruaal except for mild liver dysfunction; the SGOT was 81 U/L (normal: 5-12 U/L) and SGPT was 48 U/L (normal: 3-23 U/L). lgG antibody titer to EBV capsid antigen was 1:320 and the lgM antibody titers to EBV capsid antigen was positive. Cerebrospinal fluid (CSF) examination revealed 24 erythrocytes/mm3, 30 leukocytes/mm 3 - all were lymphocytes; glucose was 63 mg/dl and protein 40 mg/dl. Culture of the CSF and blood revealed no bacterial growth. Electroencephalography (EEG), which was performed on the day of admission, disclosed diffuse, slow waves (1-2 Hz, 80-150 jaV~ in both hemispheres. Cranial computed tomography (CT) was normal. No medications were administered except haloperidol which was given occasionally. During the next 3 months, the subjective complaints diminished spontaneously and later ceased. Patient 2. A 4-year-old girl was in excellent health until she developed cough, rhinorrhea, and lever. She had speech incoherence, personality changes, and tear one week prior to admission. She would say strange things, such as "Why are you dead?". "'Why is your face so distorted?", and "Why are you grimacing'?". She also told her mother that their house was getting smaller and beginning to fall down. Through the entire hospital course, she did not complain of headache or have seizures. There was no hepatosplenomegaly and the remaining physical exanlination was normal except for occasional confused episodes and indifference. EEG was performed soon after admission and revealed intermittent bursts of regional slow waves (3-4 Hz, 50-100 ~aV) in both parieto-occipital areas. The leukocyte count was 6,900/ram 3 with 62% neutrophils and 31~} lymphocytes. The biochemical examinations of glucose, SGOT, SGPT, and electrolytes were within normal limits. The IgG antibody to EBV capsid antigen was 1:640; heterophil antibody test was also positive on the first trial, but the lgM antibody titer was negative. We repeated the serologic tests 2 weeks later and the titer of lgG antibody to the EBV capsid antigen decreased to 1:320. No specific treatment was given during hospitalization: during the next 3 weeks, the subjective complaints disappeared spontaneously. Patient 3. A 9-year-old boy was brought to our pediatric neurology outpatient department because of peculiar behaviors for 2 days. He had fever and symptoms of upper respiratory tract infections about 4 days prior to consultation. He then began complaining about seeing objects that appeared to be undergoing changes in size and shape. He appeared to be amused with his present condition in seeing "a giant mother" and "a miniature TV." This illness in an excellent student prior to the episode, thereby caused anxiety for the parents. On examination, the patient was well nourished, well developed, and appeared to be very amused by this
Communications should be addressed to: Dr. Liaw; Department of Pediatrics: Sin-Lau Christian Hospital; No. 57, Sec 1. Don-Mon Road; Tainan, Taiwan, Republic of China. Received October 25, 1990; accepted February 13, 1991.
bizarre experience. He had no history of headache, seizures, or drug abuse. Neurologic findings were normal. The leukocyte count of peripheral blood smear was 6,800/mm3 with 50% lymphocytes; the anti-EBVCA IgM was positive and the IgG titer to anti-EBVCA was 1:320. EEG performed at the height of his symptoms was normal. We explained the probable benign course of this perception disorder to his family. He was not given any medications and the subjective complaints disappeared 3 days later. Patient 4. A 5-year-old boy was admitted because of visual hallucinations and was very frightened. He had experienced high fever, cough, and rhinorrhea for about 4-5 days prior to admission. Since early morning on the day of admission, he refused to move his body and all extremities were kept rigid simulating a robot posturing. He believed that witches were living in his legs, resulting in expansion of his body, and refused to be dressed because the clothes would not fit his enlarged form. He also saw things around him in distorted shapes and sizes, such as a miniature television and a huge air conditioner. On physical examination, he was a well-developed, well-nourished boy who was in a frightened state because of the bizarre appearance of objects around him. He was alert and well-oriented with no lymphadenopathy or hepatosplenomegaly. He followed commands during neurologic testing with relative ease. EEG, which was performed soon after admission, was normal. The leukocyte count was 8,700/mm3 with 35% neutrophils and 60% lymphocytes. Liver function tests were normal (i.e., SGOT 20 U/L, SGPT 17 U/L). The lgG antibody to EBVCA was 1:320; lgM titer was negative, but the heterophil antibody test was positive. He did not receive medications and was discharged 5 days later after full recovery; however, the same episodes recurred 3 days after di~harge. Cranial CT was ordered with an incidental finding of a retrocerebellar arachnoid cyst. The symptoms resolved within 2 weeks and there has been no recurrence. Discussion
The story of Alice in Wonderland, written by Lewis Carroll in 1865, related a peculiar journey of a 9-year-old girl, Alice, into Wonderland. The experience of Alice has been applied in adolescent psychology as a good example of cognitive, social, physical, and moral development [2,3]. Todd proposed the term, Alice in Wonderland syndrome, to encompass the complex symptoms o f perceptual distortion of body image, and of size, position, and distance of objects (metamorphopsia) [ 1]. The illustrations in the story book, drawn by Sir John Tenniel, were typical examples o f perceptual distortions. According to the report by Todd, the perception disturbance has been observed in patients with migraine, epilepsy, hypnotic states, drug intoxication with LSD or marijuana, hyperpyrexia, cerebral lesions, and schizophrenia [l]. In addition, in 1977 Copperman described 3 affected patients presenting with AWS as a symptom of infectious mononucleosis [4]. All 4 o f our patients had AWS perceptual defects as described by Todd [3]. They experienced distortions in sizes, shapes o f body schema and objects, causing variable degrees of anxiety and fear except for Patient 3 who had a cheerful mood about the unusual perceptions. None of them had a history of migraine or epilepsy and all denied any ingestion of hallucinogens. Because previous reports suggested that AWS may be an early sign of EBV infection, we performed serologic testing on all of our patients. All 4 patients were diagnosed as having acute EBV infection by one of the following serologic criteria: posi-
tive heterophil antibody or positive IgM antibody to EBVCA; and the IgG antibody titer to E B V C A were equal or more than 1:320 [6,7]. They all were proved to have acute EBV infection associated with AWS. The duration of symptoms of these 4 patients ranged from 5 days to 3 months (average: 1 month) and all had complete recovery without neurologic sequelae. During acute episodes, no specific therapy was instituted. The AWS caused by EBV infection appeared to be benign and transient. EBV produces a wide and expanding spectrum of clinical manifestations varying in intensity and duration; each manifestation has its own special problems (e.g., infectious m o n o n u c l e o s i s , p n e u m o n i a , airway obstruction, thrombocytopenia, hemolytic anemia, jaundice, glomerulonephritis, and neurologic and psychiatric disorders) [5]. The neurologic manifestations o f EBV infection comprise a wide and variable spectrum and reviews have reported meningoencephalitis, encephalitis, Guillain-Barr6 syndrome, seizures, chorea, and acute psychotic reaction [810]. The incidence of central nervous system involvement with EBV infection varies from 1-10%. AWS is one o f the unusual neurologic manifestations of EBV infection. The diagnosis of probable EBV encephalitis was made in Patient I by C S F examination (i.e., 24 erythrocytes/mm 3, 30 leukocytes/mm 3 - all lymphocyte cells). No C S F examinations were performed on the other 3 patients. EEG demonstrated abnormalities in 2 patients, including intermittent bursts o f slow waves (1-4 CPS, 50-100 ~tV) in bilateral hemispheres with predominance in the parieto-occipital areas. The neuroanatomic origin of A W S perhaps is in the parietal lobe [8,11]; the presence of formed visual hallucination may be associated with temporal or occipital lobe pathology [ 12]. Encephalitis or encephalopathy may occur in young children with EBV infection; if the involved area were localized in the parietal lobe, then AWS may be a major manifestation. Although there are no prospective, statistical reports, we believe the association of AWS with EBV infection in young children is not infrequent. Misinterpretation of perception errors and its short course may underestimate the incidence o f AWS. AWS may be the first and major symptom o f EBV infection; therefore, we suggest that all children with AWS symptoms have serologic tests for EBV performed prior to any other invasive or expensive examinations. The course of AWS is self-limited and transitory; therefore, reassurance and understanding will lessen the anxiety and concern of the patient and family. Although there is no specific treatment for these complex symptoms, it is essential to recognize this self-limiting condition. References
[ll Todd J. "Alice in Wonderland" syndrome. Can Med Assoc J 1955;73:701-4. [2l Lough GJ. Alice in Wonderland and cognitive development: Teaching with examples. J Adolesc 1983;6-305-15.
Liaw and Shen: Alice in Wonderland Syndrome 465
[3] Maharajh H, Alice in Wonderland: The multi-racial small group on clinical practice. Int J Soc Psychiatry 1984;30:85-8. [4] Copperman SM. "Alice-in-Wonderland" syndrome as a presenting symptom of infectious mononucleosis in children. Clin Pediatr 1977;16:143-9. [5] Symaya CV, Ench Y. Epstein-Barr virus infectious mononucleosis in children, I. Clinical and general laboratory findings. Pediatrics 1985;75:1003-10. [61 Wu WH, Chyou SC, Huang FY, et al. Clinical observation of primary Epstein-Barr virus infection in children. Acta Paediatr Sin 1988;29:145-51. [7] Symaya CV, Ench Y. Epstein-Barr virus infectious mononucleosis in children, II. Heterophil antibody and viral-specific responses. Pediatrics 1985;75:1011-9.
466
PEDIATRIC NEUROLOGY
Vol, 7 No. 6
[8] Gross C. The many faces of infectious mononucleosis: The spectrum of Epstein-Barr virus infection in children. Pediatr Rev 1985; 7:35-44. [9] Hender N, Leahy W. Psychiatric and neurologic sequelae of infectious mononucleosis. Am J Psychiatry 1978;135:842-4. [10] Schlesinger RD, Crelinsten GL. Infectious mononucleosis dominated by neurologic symptoms and signs. Can Med Assoc J 1977; 117:652-3. [11] Sanguineti G. "Alice in Wonderland" syndrome in a patient with infectious mononucleosis. J Infect Dis 1983;147:782. [12] Golden GS. The Alice in Wonderland syndrome in juvenile migraine. Pediatrics 1979;63:517-9.
Four Chinese patients (2 boys, 2 girls), ages 4-9 years, who had episodes of perception error of body schema and objects are reported. The metamorphopsia, which had been named Alice in Wonderland syndrome, is the major presentation. All of them were proved to have acute Epstein-Barr virus infection, as documented by positive heterophii antibody test and/or positive IgM antibody to Epstein-Barr virus capsid antigen. The duration of the perception disorder ranged from 1 week to 3 months. We believe that any young child presenting with Alice in Wonderland syndrome should undergo examination for Epstein-Barr virus infection; complete recovery from the disorder can be expected. L i a w S - B , S h e n E - Y . A l i c e in W o n d e r l a n d s y n d r o m e as a presenting symptom
of EBV
infection. Pediatr Neurol
1991 ;7:464-6.
Introduction A l i c e in W o n d e r l a n d s y n d r o m e ( A W S ) w a s p r o p o s e d b y T o d d in 1955 to e n c o m p a s s t h e c o m p l e x s y m p t o m s o f bizarre perceptual distortions, including personal body i m a g e a n d size, as w e l l as t h e d i s t a n c e o f o b j e c t s [1]. T h e experiences
of metamorphopsia
in t h e s e p a t i e n t s w e r e
s i m i l a r to t h o s e o f t h e 9 - y e a r - o l d c h a r a c t e r , A l i c e , in The
A d v e n t u r e s o f A l i c e in W o n d e r l a n d . T h i s p e r c e p t u a l d i s t o r tion is f r i g h t e n i n g to t h o s e a f f e c t e d . W e r e p o r t 4 p a t i e n t s w i t h A W S , the c o u r s e s o f w h i c h w e r e b e n i g n a n d t e m p o r a r y . All p a t i e n t s h a d d o c u m e n t e d E p s t e i n - B a r r - v i r u s induced infection.
Case Reports Methods. The mechanism of the procedures utilized for serologic diagnosis involves the serum of EBV-infected patients which will agglutinate with horse erythrocyte cells treated with glutaraldehyde. Heterophil antibody titers are positive in the acute stages of EBV infection, especially in children older than 4 years, and are elevated 3-6
From the Department of Pediatrics; Mackay Memorial Hospital; Taipei, Taiwan, Republic of China.
464
PEDIATRIC NEUROLOGY
Vol. 7 No. 6
months. The IgM and IgG antibodies to EBV capsid antigen (IgMEBVCA and IgG-EBVCA) are detected by using the indirect fluorescent antibody method. The IgM response is transient for 1-2 months but the lgG response is lifelong for those patients with EBV infection. Patient I. This 5-year-old girl was referred to our hospital lor evaluation of episodes of bizarre behavior. She complained that witches and policemen came into her home; occasionally, she perceived that her mother alternately became larger or smaller. She talked to herself, had incoherent speech, and sometimes was puzzled by seeing objects around her changing in size and shape. She had an upper respiratory tract infection and fever 4 days prior to this episode. On physical examination, the patient appeared confused and disoriented; however, the other neurologic findings, including cranial nerve function, muscle power, deep tendon reflexes, cerebellar function, and autonomic nerve function, were normal. No organomegaly was present. The leukocyte count was 10,900/ram 3 with 44% neutrophils and 44% lymphocytes and an erythrocyte sedimentation rate of 15 rnm/hr. The biochemical studies were noruaal except for mild liver dysfunction; the SGOT was 81 U/L (normal: 5-12 U/L) and SGPT was 48 U/L (normal: 3-23 U/L). lgG antibody titer to EBV capsid antigen was 1:320 and the lgM antibody titers to EBV capsid antigen was positive. Cerebrospinal fluid (CSF) examination revealed 24 erythrocytes/mm3, 30 leukocytes/mm 3 - all were lymphocytes; glucose was 63 mg/dl and protein 40 mg/dl. Culture of the CSF and blood revealed no bacterial growth. Electroencephalography (EEG), which was performed on the day of admission, disclosed diffuse, slow waves (1-2 Hz, 80-150 jaV~ in both hemispheres. Cranial computed tomography (CT) was normal. No medications were administered except haloperidol which was given occasionally. During the next 3 months, the subjective complaints diminished spontaneously and later ceased. Patient 2. A 4-year-old girl was in excellent health until she developed cough, rhinorrhea, and lever. She had speech incoherence, personality changes, and tear one week prior to admission. She would say strange things, such as "Why are you dead?". "'Why is your face so distorted?", and "Why are you grimacing'?". She also told her mother that their house was getting smaller and beginning to fall down. Through the entire hospital course, she did not complain of headache or have seizures. There was no hepatosplenomegaly and the remaining physical exanlination was normal except for occasional confused episodes and indifference. EEG was performed soon after admission and revealed intermittent bursts of regional slow waves (3-4 Hz, 50-100 ~aV) in both parieto-occipital areas. The leukocyte count was 6,900/ram 3 with 62% neutrophils and 31~} lymphocytes. The biochemical examinations of glucose, SGOT, SGPT, and electrolytes were within normal limits. The IgG antibody to EBV capsid antigen was 1:640; heterophil antibody test was also positive on the first trial, but the lgM antibody titer was negative. We repeated the serologic tests 2 weeks later and the titer of lgG antibody to the EBV capsid antigen decreased to 1:320. No specific treatment was given during hospitalization: during the next 3 weeks, the subjective complaints disappeared spontaneously. Patient 3. A 9-year-old boy was brought to our pediatric neurology outpatient department because of peculiar behaviors for 2 days. He had fever and symptoms of upper respiratory tract infections about 4 days prior to consultation. He then began complaining about seeing objects that appeared to be undergoing changes in size and shape. He appeared to be amused with his present condition in seeing "a giant mother" and "a miniature TV." This illness in an excellent student prior to the episode, thereby caused anxiety for the parents. On examination, the patient was well nourished, well developed, and appeared to be very amused by this
Communications should be addressed to: Dr. Liaw; Department of Pediatrics: Sin-Lau Christian Hospital; No. 57, Sec 1. Don-Mon Road; Tainan, Taiwan, Republic of China. Received October 25, 1990; accepted February 13, 1991.
bizarre experience. He had no history of headache, seizures, or drug abuse. Neurologic findings were normal. The leukocyte count of peripheral blood smear was 6,800/mm3 with 50% lymphocytes; the anti-EBVCA IgM was positive and the IgG titer to anti-EBVCA was 1:320. EEG performed at the height of his symptoms was normal. We explained the probable benign course of this perception disorder to his family. He was not given any medications and the subjective complaints disappeared 3 days later. Patient 4. A 5-year-old boy was admitted because of visual hallucinations and was very frightened. He had experienced high fever, cough, and rhinorrhea for about 4-5 days prior to admission. Since early morning on the day of admission, he refused to move his body and all extremities were kept rigid simulating a robot posturing. He believed that witches were living in his legs, resulting in expansion of his body, and refused to be dressed because the clothes would not fit his enlarged form. He also saw things around him in distorted shapes and sizes, such as a miniature television and a huge air conditioner. On physical examination, he was a well-developed, well-nourished boy who was in a frightened state because of the bizarre appearance of objects around him. He was alert and well-oriented with no lymphadenopathy or hepatosplenomegaly. He followed commands during neurologic testing with relative ease. EEG, which was performed soon after admission, was normal. The leukocyte count was 8,700/mm3 with 35% neutrophils and 60% lymphocytes. Liver function tests were normal (i.e., SGOT 20 U/L, SGPT 17 U/L). The lgG antibody to EBVCA was 1:320; lgM titer was negative, but the heterophil antibody test was positive. He did not receive medications and was discharged 5 days later after full recovery; however, the same episodes recurred 3 days after di~harge. Cranial CT was ordered with an incidental finding of a retrocerebellar arachnoid cyst. The symptoms resolved within 2 weeks and there has been no recurrence. Discussion
The story of Alice in Wonderland, written by Lewis Carroll in 1865, related a peculiar journey of a 9-year-old girl, Alice, into Wonderland. The experience of Alice has been applied in adolescent psychology as a good example of cognitive, social, physical, and moral development [2,3]. Todd proposed the term, Alice in Wonderland syndrome, to encompass the complex symptoms o f perceptual distortion of body image, and of size, position, and distance of objects (metamorphopsia) [ 1]. The illustrations in the story book, drawn by Sir John Tenniel, were typical examples o f perceptual distortions. According to the report by Todd, the perception disturbance has been observed in patients with migraine, epilepsy, hypnotic states, drug intoxication with LSD or marijuana, hyperpyrexia, cerebral lesions, and schizophrenia [l]. In addition, in 1977 Copperman described 3 affected patients presenting with AWS as a symptom of infectious mononucleosis [4]. All 4 o f our patients had AWS perceptual defects as described by Todd [3]. They experienced distortions in sizes, shapes o f body schema and objects, causing variable degrees of anxiety and fear except for Patient 3 who had a cheerful mood about the unusual perceptions. None of them had a history of migraine or epilepsy and all denied any ingestion of hallucinogens. Because previous reports suggested that AWS may be an early sign of EBV infection, we performed serologic testing on all of our patients. All 4 patients were diagnosed as having acute EBV infection by one of the following serologic criteria: posi-
tive heterophil antibody or positive IgM antibody to EBVCA; and the IgG antibody titer to E B V C A were equal or more than 1:320 [6,7]. They all were proved to have acute EBV infection associated with AWS. The duration of symptoms of these 4 patients ranged from 5 days to 3 months (average: 1 month) and all had complete recovery without neurologic sequelae. During acute episodes, no specific therapy was instituted. The AWS caused by EBV infection appeared to be benign and transient. EBV produces a wide and expanding spectrum of clinical manifestations varying in intensity and duration; each manifestation has its own special problems (e.g., infectious m o n o n u c l e o s i s , p n e u m o n i a , airway obstruction, thrombocytopenia, hemolytic anemia, jaundice, glomerulonephritis, and neurologic and psychiatric disorders) [5]. The neurologic manifestations o f EBV infection comprise a wide and variable spectrum and reviews have reported meningoencephalitis, encephalitis, Guillain-Barr6 syndrome, seizures, chorea, and acute psychotic reaction [810]. The incidence of central nervous system involvement with EBV infection varies from 1-10%. AWS is one o f the unusual neurologic manifestations of EBV infection. The diagnosis of probable EBV encephalitis was made in Patient I by C S F examination (i.e., 24 erythrocytes/mm 3, 30 leukocytes/mm 3 - all lymphocyte cells). No C S F examinations were performed on the other 3 patients. EEG demonstrated abnormalities in 2 patients, including intermittent bursts o f slow waves (1-4 CPS, 50-100 ~tV) in bilateral hemispheres with predominance in the parieto-occipital areas. The neuroanatomic origin of A W S perhaps is in the parietal lobe [8,11]; the presence of formed visual hallucination may be associated with temporal or occipital lobe pathology [ 12]. Encephalitis or encephalopathy may occur in young children with EBV infection; if the involved area were localized in the parietal lobe, then AWS may be a major manifestation. Although there are no prospective, statistical reports, we believe the association of AWS with EBV infection in young children is not infrequent. Misinterpretation of perception errors and its short course may underestimate the incidence o f AWS. AWS may be the first and major symptom o f EBV infection; therefore, we suggest that all children with AWS symptoms have serologic tests for EBV performed prior to any other invasive or expensive examinations. The course of AWS is self-limited and transitory; therefore, reassurance and understanding will lessen the anxiety and concern of the patient and family. Although there is no specific treatment for these complex symptoms, it is essential to recognize this self-limiting condition. References
[ll Todd J. "Alice in Wonderland" syndrome. Can Med Assoc J 1955;73:701-4. [2l Lough GJ. Alice in Wonderland and cognitive development: Teaching with examples. J Adolesc 1983;6-305-15.
Liaw and Shen: Alice in Wonderland Syndrome 465
[3] Maharajh H, Alice in Wonderland: The multi-racial small group on clinical practice. Int J Soc Psychiatry 1984;30:85-8. [4] Copperman SM. "Alice-in-Wonderland" syndrome as a presenting symptom of infectious mononucleosis in children. Clin Pediatr 1977;16:143-9. [5] Symaya CV, Ench Y. Epstein-Barr virus infectious mononucleosis in children, I. Clinical and general laboratory findings. Pediatrics 1985;75:1003-10. [61 Wu WH, Chyou SC, Huang FY, et al. Clinical observation of primary Epstein-Barr virus infection in children. Acta Paediatr Sin 1988;29:145-51. [7] Symaya CV, Ench Y. Epstein-Barr virus infectious mononucleosis in children, II. Heterophil antibody and viral-specific responses. Pediatrics 1985;75:1011-9.
466
PEDIATRIC NEUROLOGY
Vol, 7 No. 6
[8] Gross C. The many faces of infectious mononucleosis: The spectrum of Epstein-Barr virus infection in children. Pediatr Rev 1985; 7:35-44. [9] Hender N, Leahy W. Psychiatric and neurologic sequelae of infectious mononucleosis. Am J Psychiatry 1978;135:842-4. [10] Schlesinger RD, Crelinsten GL. Infectious mononucleosis dominated by neurologic symptoms and signs. Can Med Assoc J 1977; 117:652-3. [11] Sanguineti G. "Alice in Wonderland" syndrome in a patient with infectious mononucleosis. J Infect Dis 1983;147:782. [12] Golden GS. The Alice in Wonderland syndrome in juvenile migraine. Pediatrics 1979;63:517-9.
