Morning Report

Nicholas Whipple March 25, 2013

CC: Vision Problems HPI: 6 year old male presents to continuity clinic Beginning >3 weeks ago, began to complain of a unique vision disturbance

1-2x/day, people, though not objects, began to seem to move farther away from the patient this annoys him mildly

Teachers at school have not reported any noticed change in behavior or difficulty seeing the board No witnessed falls or clumsiness There is no impetus for this disturbance such as light, stress, or food

HPI: Often, during an event, patient will Stare strongly as though he is trying to somehow resolve the visual disturbance

This staring is mild and almost unnoticed

He saw an Optometrist at 2 weeks ago who performed dilated exam and reported normalcy of all tested fields

It does not appear that pressure was evaluated, per report

HPI: There was a preceding viral illness with mild subjective fever About 1 week after events began occurring, patient had accident at school.

Slipped on ice, hit back of head on ground. Was drowsy afterwards. Teachers informed but did not take note of subsequent abnormal behavior and did not think it serious enough to call or inform parents. No LOC Did not fall asleep or take nap afterwards Father called school and spoke with teacher who reported no noticed change in patient on day of injury

ROS: negative for headache, vomiting, developmental regression, or delay. No sleep disturbance. Not photophobia or phonophobia. Patient does complain of dysuria x 2 days
Past Medical Hx: Born 36 weeks after uncomplicated pregnancy Phototherapy for jaundice hospitalized day 2 of life for febrile infant workup (negative) No surgeries Immunizations: UTD Allergies: NKDA, no food allergies known Medications: none Family Hx: there are maternal aunts and maternal GM with migraine. Mother has epilepsy Social Hx: lives with family

Weight: 16.6 kg, T 36.7, HR 64, BP 90/52 Vision Screen: Left eye: 20/30, Right eye: 20/30, Both: 20/30
GEN: alert, active, well appearing, no distress HEENT: AT/NC, TMS clear, no LAD, bilateral red reflex, normal appearing iris and sclera, can read board across room with ease RESP: CTAB CV: RRR, no Murmur or rub ABD: soft, nd, no HSmegaly SKIN: no petechiae, purpura, or bruising. GU: circumcised, descended testicles, right hydrocele

NEURO: Mental status: alert Cranial Nerves: CN 2-12 intact, PERRL, no nystagmus, can see in all visual fields, no diplopia, EOMI, conjugate gaze Motor: 5/5 upper and lower extremity strength, no pronator drift, no tremor, tone is normal, moves all extremities equally, no dysdiadochokinesia Reflex: trace patellar reflex bilaterally Gait: normal gait without ataxia, normal tiptoe and heel walk, normal jump

Labs

UA: completely normal

Plan

RTC in one week with diary of visual symptoms Email Neurology to discuss case and need for referral No imaging at this time Refer to Urology for Hydrocele

One week later

HPI

No headache Visual events persist

Diary indicates 1x/day, 2-3 minutes, no change in quality or duration Not associated with pain, accident, headache, time of day, light, or other

What would you do ?

What is the Diagnosis ?

What Did Neurology Think ?

Alice in Wonderland syndrome

Alice in Wonderland Syndrome represents the spectrum of migraine with aura, but the visual aura is quite atypical and may include bizarre visual illusions and spatial distortions preceding an otherwise nondescript headache. Affected patients describe distorted visual perceptions similar to those experienced by Alice.such as micropsia, macropsia, metamorphopsia.most commonly seen in children
Unusual Headache Syndrome in Children. Current Pain and Headache Reports

Alice in Wonderland syndrome

Migraine with aura

A typical visual aura may consists of scotoma, transient blurry vision, zig-zag lines, or scintillations, but more complex visual changes such as those seen in Alice in Wonderland syndrome (visual distortions that include sensation that objects are bigger or smaller than they are; objects appear to be moving when they are still.) can occur.
Pediatric Headache: A Review. Pediatrics in Review

Alice in Wonderland syndrome

Perceptual distortions of sizes, shapes, and spatial relationships, known as the Alice in Wonderland syndrome (metamorphopsia).
Nelson Textbook of Pediatrics

Alice in Wonderland syndrome

Causes *****Migraine*****(most common) virus

EBV

First described by Copperman in 1977

Coxsackie Influenza

encephalitic process seizures drug ingestion (e.g. LSD) psychiatric illness (e.g. schizophrenia) cerebral lesion

AWS: history

The picturesque term Alice in Wonderland syndrome was first applied to this symptom complex by Lippman in 1952 Alice in Wonderland Syndrome: described by Todd in 1955 One of Lippmans patients spontaneously states that she felt short and wide as she walked along, and she called this a Tweedle Dum or Tweedle Dee feeling

AWS: common symptoms

Repeated events

Usually a few each day May last a few weeks to a few months Have been known to resolve, then recur a few years later

Usually last only a few minutes Always <10 minutes Patients remain lucid and oriented during events Age: mostly childhood to 20s The sufferer can become alarmed, frightened, even panic-stricken b/c of the visual disturbance

AWS: common symptoms

Micropsia: objects are perceived to be smaller than they actually are Macropsia: objects are perceived to be larger than they actually are Hallucinations and distortions of body image

Parts of body have become distorted in shape or size

Impairment in time sense

Time is slowing down Time is speeding up

Micropsia: Alices Adventures in Wonderland

Macropsia: Alices Adventures in Wonderland

AWS: history

Book #1: Alices Adventures in Wonderland Book #2: Through the Looking Glass, and What Alice Found There

Alice changes size.

AWS: history

Shrinks

After drinking from a bottle marked DRINK ME (Ch 1) While fanning herself with the White Rabbits fan (Ch 2) After eating a pebble which has turned into a cake (Ch 3) After eating a cake marked EAT ME (Ch 1) After drinking from an unmarked bottle (Ch 3) During the trial of the Knave of Hearts (Ch 11&12)

Grows

Alice Liddell, age 7, photographed by Lewis Carroll in 1860

Alice in Wonderland shrink and growth scenes

Lewis Carroll

Wrote Alices Adventures in Wonderland, published 1865 Charles Lutwidge Dodgson

(Lewis Carroll is pseudonymn)

Suffered from migraines

he called bilious headaches had component of visual phenomena Likely fortification spectra

Small hole of light or bright geometrical lines/shapes in visual field that grow and expand

Some scholars wonder if Carrolls personal migraine symptoms contributed to some of Alices experiences

Pathophysiology

Migraine with aura Vasoconstrictive phase of migraine

Timing of event is not usually reported to be concomitant with headache Often, there is no headache involved

Metamorphopsia that arises primarily in the posterior parietal lobe, especially in the nondominant hemisphere Transient focal decreased cerebral perfusion

AWS & Family History

Common for family members to have history of migraines On at least one occasion, a relative had previous symptoms of AWS

Case symptoms

A corridor appeared to be longer than it actually was The ground appears too close I got up to go to the bathroom. As I was leaving the bathroom, I felt as if I was going too fast. I grabbed my doorit felt about one foot thick in my hand. As I went through the hall, it felt as if I was going too fast. I have a giant mother and a miniature TV

Case symptoms

There were episodes during which he suddenly felt as if everyone was talking too fast and that he was moving too fast. His left hand also felt as if it was carrying a heavy rock. Half of my body is 2x larger than the other My left ear was ballooning out 6 inches the people I look at become smaller and smaller to me My house is getting smaller

Diagnostic workup

EEG

May be warranted if visual symptoms involve entire visual field, there are seizure-like activities Rule out occipital lobe epilepsy Some experts feel this should always be ordered Encephalitis, intoxication

EBV panel

Rule out serious pathology

Full Neurological exam, including fundoscopic exam to assess ICP

Treatment

Prophylactic migraine therapy

if migraine is the cause

Reassurance and Follow up as needed The condition is self-limited and transitory Serious Sequelae to come?

There has never been a reported case of AWS that then progressed to brain tumor or mental disorder

Neuroimaging ???

Sleep related headache Confusion Abnormal neurologic findings Vomiting Headache with cough, urination, defecation Recurrent and focal headache Exclusively occipital headache Change in headache type Progressive increase in headache frequency or severity