Alice in Wonderland.

This article is the first one of what I plan to be a long-term series of posts under the umbrella Medicine: a Fascinating Puzzle. Not sure where it will go in time, if anywhere, but my aim, initially, at least, is to share special clinical cases, syndromes or situations, from medical literature or even movies 🙂

This is not a medical advice in any way, nor does it concern my own clinical experience. It is just a way of contemplating together the complex magic of science.

I am so excited that I even used my very lame artistic skills and came up with this:

Yes, I know, this looks as designed by a very bored and sleepy baby, but bare with me, I shall do my best to improve and make this section more esthetically pleasing. I make no promises, though.

Clinical case presentations are one of the most poetic, if I might say so, parts of the medical work, although writing and submitting them to peer-reviewed publications is anything but lyrical for many. I’ll try to put an additional layer of literature to the presentations, hoping that will make them more entertaining, but I will not alter the medical content in that process.

Here we go with the first one. The source is Vilela M, Fernandes D, Salazar T Sr, Maio C, Duarte A. When Alice Took Sertraline: A Case of Sertraline-Induced Alice in Wonderland Syndrome. Cureus. 2020 Aug 30;12(8):e10140. doi: 10.7759/cureus.10140. PMID: 33005552; PMCID: PMC7524018. Accessed on 06 Jan 201.

The full article can be found here:

Imagine you are Anne *with an e*, a 67-year-old woman and you have quite a few medical issues, including thyroid problems, altered lipid values and a difficult depressive syndrome. For this you need treatment and you are taking sertraline, a drug that helped you before.

After about a week of treatment, you start to present some weird episodes, with strange body sensations. You feel your hands enlarged and then smaller, albeit knowing that was not really possible and seeing them in their normal size. You also feel sometimes that your body levitates towards the ceiling.

Once, you even had the impression that an outside force diminished you. Meanwhile, some objects in the room seemed to have reduced their size and you noticed them far, far away. Luckily, these episodes are short, lasting only a few minutes. Unfortunately, they were recurrent.

You consulted an ophthalmologist, but the results came back normal. Your attending physician examined you and saw no alterations. Your neurological examination was normal. Lab investigations were also clear. The great news, though, was that your symptoms resolved within a week. Yay!

What was it, though? What made you experience all that? As the saying goes, it’s never lupus :), but in this case, it was sertraline. As ever, there is not a substance which only benefits us, for everything there is a risk. Although sertraline turned Anne’s depression in a more stable condition, being a psychoactive drug it apparently also caused a (drug-induced) Alice in Wonderland syndrome.

Alice in wonderland GIF on GIFER - by Faera

It has a pretty name, but it surely does not look like a pretty situation to be put in. It is, as Anne saw for herself, a disorder which alters the perception of your own body dimensions and its position in time and space.

It also distorts perception of external objects. It was described in 1952, but some of us still hear of it for the first time in 2021, or even never, since it is quite rare. The English psychiatrist John Todd chose the name as an homage to the book Alice’s Adventures in Wonderland. Those were the times of fantasy in medicine, not now when not only do we face a pandemic with tragic consequences but it also has such an uninspired name! 🙂

The cause is, apparently, unknown, although there are some potential clues regarding the neurological pathways involved. It has been associated with migraine in adult patients or with some infections in children. As Anne found out, it can also be drug-induced.

The bad news: there is not an actual treatment. The good news: it generally resolves by itself.

While for scientists this can look like a fascinating syndrome, I am sure that it must be terrifying to be the patient in this scenario.

Medicine is, indeed, such a fascinating puzzle. Scary, but equally mesmerizing puzzle. Be honest, though: Are you still evaluating the size of your hands after reading all this?

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