P3.217: Through the Viral Looking Glass: EBV Meningitis and Alice in Wonderland Syndrome

Introduction: Epstein-Barr Virus (EBV) is a ubiquitous virus that typically causes mild or asymptomatic infections in children but can occasionally lead to more severe complications. While EBV-related mononucleosis is well-documented, central nervous system (CNS) involvement is rare and presents diagnostic challenges. Alice in Wonderland Syndrome (AIWS), characterized by distorted sensory perception, is a less common manifestation linked to EBV. Here, we report a case of EBV meningitis in an 8-year-old girl who presented with AIWS.

Case Description: An 8-year-old previously healthy female presented with a one-week history of fever, night sweats, abdominal pain, headache, and fatigue. Initial laboratory tests showed elevated liver enzymes (AST 285, ALT 256), elevated CRP (13.5), and a positive monospot test for EBV. Imaging at the referring hospital revealed severe pericholecystic fluid and splenomegaly. Upon admission, her condition worsened with visual disturbances described as seeing objects “far away,” nuchal rigidity, lethargy, and persistent fevers.

A sepsis workup included cerebrospinal fluid (CSF) analysis, revealing mononuclear cell predominance and positive EBV DNA by PCR. Blood and CSF cultures were negative. CT imaging of the head was normal. Neurological symptoms and visual distortions, later identified as AIWS, became less frequent with acyclovir therapy. Additional evaluations, including abdominal ultrasounds and chest imaging, indicated fluid overload with pleural effusions and ascites, which slowly improved with supportive care and diuretics. The patient completed a five-day course of acyclovir and was discharged with instructions to avoid contact sports due to hepatosplenomegaly.

Discussion: EBV typically presents fatigue, fever, lymphadenopathy, and hepatosplenomegaly, but neurologic complications occur in only 0.5–7% of cases. CNS manifestations include meningoencephalitis, acute psychosis, and AIWS. AIWS is characterized by altered perceptions of time, space, and body image, often linked to EBV infection.

EBV may access the CNS via infected lymphocytes crossing the blood-brain barrier or through direct viral invasion. Testing includes serologic markers (IgM/IgG to viral capsid antigen) and CSF PCR for EBV DNA, which confirmed the diagnosis in this case. Neuroimaging is often unremarkable, but MRI can rule out alternative diagnoses like herpes simplex virus encephalitis.

Treatment remains controversial. Antivirals like acyclovir and ganciclovir are often used to reduce viral replication, with variable outcomes. This patient improved clinically with acyclovir, supporting its utility in managing EBV meningitis.

Conclusion: This case underscores the importance of considering EBV-associated CNS infections in children presenting with fever, altered mental status, and visual disturbances. AIWS may serve as a diagnostic clue for EBV meningitis. Early recognition and treatment with antivirals may improve outcomes, though further studies are needed to establish definitive guidelines.