The Alice in Wonderland syndrome

Q: In which type of toxicity do patients develop "Alice in Wonderland-like" syndrome?

Answer: Anticholinergic intoxication 

Anticholinergic toxicity is common, particularly with over-the-counter and commonly prescribed medications such as antihistamines, tricyclic antidepressants, sleep aids (doxylamine), cold syrups, scopolamine patches, and mydriatic & cycloplegic eye drops.

The usual side effects are tachycardia, constipation, anxiety, agitation, dysarthria, confusion, disorientation, visual hallucinations, bizarre behavior, delirium, psychosis, paranoia, coma, and seizures.

A few famous terms described are

• "Red as a beet" (peripheral) due to cutaneous vasodilation 
• "Dry as a bone" as Sweat glands are innervated by muscarinic receptors
• "Hot as a hare" - hyperthermia is common
• "Blind as a bat" due to ineffective ocular accommodation
• "Mad as a hatter" - CNS symptoms as described above
• "Full as a flask"  due to urinary retention

Hallucinations are often described as "Alice in Wonderland-like" or "Lilliputian type," in which people appear to become larger and smaller to a patient. Patients may appear to grab invisible objects from the air.

#toxicity

References:

1. Lanska DJ, Lanska JR. The Alice-in-Wonderland Syndrome. Front Neurol Neurosci. 2018;42:142-150. doi: 10.1159/000475722. Epub 2017 Nov 17. PMID: 29151098.

2. Mantingh MR. Het 'Alice in Wonderland'-syndroom [The Alice in Wonderland syndrome]. Ned Tijdschr Geneeskd. 2014;158:A7225. Dutch. PMID: 24666533.

3. Broderick ED, Metheny H, Crosby B. Anticholinergic Toxicity. 2023 Apr 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 30521219.