Exploring Alice in Wonderland syndrome in adults with persistent headache after COVID-19: a cross-sectional study in Latin America, 2025, Carrión-Ness

SNT Gatchaman

SNT Gatchaman

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Exploring Alice in Wonderland syndrome in adults with persistent headache after COVID-19: a cross-sectional study in Latin America
Carrión-Nessi, Fhabián S; Ascanio, Luis C; Omaña-Ávila, Óscar D; Regalado-Gutiérrez, Oriana A; Mendoza-Millán, Daniela L; Camejo-Ávila, Natasha A; Forero-Peña, David A; Paniz-Mondolfi, Alberto E

BACKGROUND
Alice in Wonderland syndrome (AIWS) is a neuropsychiatric disorder characterized by sensory perception distortions, including altered body image perception and distortions of shape, size, motion, color, and speed. Migraine and infectious diseases are among the most common etiologies of AIWS. However, it has not been studied in individuals with persistent headache after COVID-19.

METHODS
This cross-sectional study included a subset of individuals with AIWS symptoms derived from a survey conducted in Latin America to identify adults with persistent headache after COVID-19. For data analysis, AIWS individuals were characterized by sex and analyzed using univariable tests. Subsequently, the entire study cohort was stratified into two groups: the AIWS group and the non-AIWS group. Binomial logistic regression using the backward stepwise selection method was performed to identify the factors associated with AIWS after COVID-19.

RESULTS
Out of 421 participants with persistent headache after COVID-19, 106 (25.2%) reported at least one AIWS symptom. The AIWS group was significantly younger (median age 36 vs. 39 years, p = 0.011) and had a higher proportion of pre-existing migraine (40.6% vs. 29.5%, p = 0.035) compared to the non-AIWS group. The most common post-COVID-19 AIWS symptoms were time distortion (32.1%), derealization/depersonalization (24.5%), and hyperchromatopsia (20.8%). Logistic regression analysis revealed that experiencing any AIWS symptom during acute COVID-19 was the strongest predictor for post-acute AIWS (OR = 9.937, 95% CI = 5.603–17.62, p <0.001). Other significant predictors included phonophobia (OR = 2.322, 95% CI = 1.288–4.185, p = 0.005) and depressive symptoms (OR = 1.937, 95% CI = 1.099–3.413, p = 0.022) during acute COVID-19.

CONCLUSION
In this cohort, AIWS was a notable feature in adults with persistent headache after COVID-19, particularly in younger individuals with a history of migraine. Experiencing AIWS symptoms during acute infection increased the odds of post-acute AIWS symptoms nearly tenfold, suggesting SARS-CoV-2 may be a potent trigger. Clinicians should be aware of this association and screen for perceptual disturbances in patients with post-COVID-19 neurological sequelae.

Web | PDF | BMC Neurology | Open Access
 
I have a tiny bit of experience of this. For me, it has felt like suddenly being in Lilliput, where I'm huge and everything else is tiny. Or finding yourself in a doll's house. And it's just benignly odd/funny, not distressing.

The first time was about 5 hours before the symptoms of my triggering infection (not covid-19, but neurological) appeared - or you could argue, I suppose, that it was the first symptom. I walked into an empty room and felt suddenly felt like I was on stilts, very very tall and gangly and wobbly. According to the Cleveland Clinic site, this would be:
  • Changes in your perception of your body. This can cause part of your body to feel too big (partial macrosomatognosia) or too small (partial microsomatognosia). This effect can also cause your whole body to feel unusually tall (total macrosomatognosia) or unusually short (total microsomatognosia).
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It resolved within an hour.

The other times have been where I walk into a bathroom and everything in the bathroom looks comically small, so like this:
  • Changes in size. Objects may appear larger (macropsia) or smaller (micropsia) than they actually are.
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and maybe a bit of this:
  • Changes in distance. Objects may appear closer (pelopsia) or farther away (teleopsia) than they actually are.
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and they've been very brief, as in they have resolved within 10 seconds. I just start using the tiny little doll-house furniture and it becomes normal.

I'm lucky that in my case it's been very limited and has resolved, and it's been amusing rather than distressing or debilitating.

I haven't had the symptoms that were most common in this covid-19 group - time distortion, derealization/depersonalization, and hyperchromatopsia, and I did not have depressive symptoms during my infection (which was not covid-19). But I did have prominent phonophobia during my triggering infection and still have that. So it's interesting that they found that was a predictor.
 
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