Methylphenidate-associated Alice in Wonderland syndrome

We describe the case of a child affected by typical symptoms of Alice in Wonderland syndrome (AIWS), related to the methylphenidate treatment he was taking for an attention deficit hyperactivity disorder (ADHD). To our knowledge, this is the first case of methylphenidate-associated AIWS.

Retrospective single center observational case report.

A 12-year-old boy was complaining of micropsias and macropsias. Except a disruptive ADHD treated by methylphenidate for 2 years, his medical history was banal. His symptoms coincided with a change in his treatment regimen and ceased with methylphenidate discontinuation. Unfortunately, they recurred when the medication was reimplemented by his psychiatrist. The ophthalmological examination was unremarkable. We concluded to an AIWS and prescribed ancillary testing (including blood work, electroencephalogram, and brain MRI) to rule out conditions known to be associated with this syndrome. In the meanwhile, the methylphenidate dosage was readapted, and the symptoms disappeared again. Seen this clear dechallenge and rechallenge effect and the fact that all additional tests returned normal results, we deduced that our patient's symptoms were associated to methylphenidate.

AIWS could be a potential side effect of methylphenidate. Given the frequency of methylphenidate prescription for ADHD and its widespread misuse, it is important to consider this peculiar adverse effect. Every physician should be aware of the condition to offer reassurance and to prescribe the appropriate additional examinations, as life-threatening disorders can cause this syndrome.