Seasonal Hyperacute Panuveitis in Nepal: A Review over 40 Years of Surveillance

Seasonal Hyperacute Panuveitis (SHAPU) in Bhutan

PURPOSE

To report the first series of Seasonal Hyperacute Pan Uveitis (SHAPU) from Bhutan.

METHODS

We retrospectively analyzed the patients with clinically diagnosed SHAPU treated in the referral center in the last 5 years. Data included demographics (age, sex, laterality), region, time of presentation (year, season) and treatment received.

RESULTS

The series included 3 males and 2 females. The mean age was 16 years. Three patients had presented in autumn of 2021, and two in autumn of 2019. Four patients presented within 2 weeks of the onset of symptoms. All patients had either exposure or contact with white moths. All patients presented with unilateral sudden painless reduction in vision and low Intraocular pressure. Four patients required vitrectomy. The final visual acuity of 3 patients was >6/36, and one patient was 6/60.

CONCLUSIONS AND IMPORTANCE

The time of presentation and early treatment intervention are crucial in achieving good visual prognosis in SHAPU.

Seasonal Hyperacute Panuveitis (SHAPU) Outbreak Amidst COVID-19 Pandemic

PURPOSE

To document the demographic profile of the SHAPU outbreak amidst the COVID-19 pandemic.

METHODS

A multicentric cross-sectional study of the 2021 SHAPU outbreak during the second phase of the COVID-19 outbreak.

RESULTS

A total of 135 patients were diagnosed with SHAPU from August to December 2021, 77 (57%) were children <16 years, males 54.8% and 34.8% had direct physical contact with white moths and 41.5% had severe type of SHAPU. Dramatic increment in the moth abundance was noted in these outbreak sites. Few cases presented with atypical ocular findings, unlike past outbreaks. Due to the ongoing COVID-19 pandemic with restrictions on travel and transportation, timely management was difficult and good visual outcome was achieved only in mild-moderate cases with an early presentation.

CONCLUSION

The surge in the number of SHAPU patients, its occurrence in areas previously unreported, and some atypical presentation added raised suspicion of a possible link between COVID-19 and SHAPU.

Classification of Seasonal Hyperacute Panuveitis (SHAPU)

INTRODUCTION

Classification are essential part of scientific methodology and has important role in medical reporting system. Even after having 46 years long history, Seasonal Hyperacute Panuveitis (SHAPU), the blinding diseases reported mainly from Nepal lacks a standard classification system. Thus, we aim to contribute in the ophthalmic nosology by purposing a classification system for SHAPU.

METHODOLOGY

The classification is suggested on the background of prolonged experience of this entity by the group of investigators who have dedicated years of research on this topic.

CONCLUSION

We are optimistic that the proposed classification system will help in effective planning and evaluation of this ocular emergency condition and deliver the appropriate and reliable information for timely management and prevention of complications.

Sporadic summer outbreak of SHAPU in even years: Does the pattern match with the usual autumn outbreak?

Purpose

Seasonal Hyperacute Panuveitis (SHAPU), is a mysterious blinding disease seen only in Nepal with a higher prevalence among children usually seen in autumn every alternate odd year since 1975. This report highlights the sporadic summer outbreak in the even years with atypical presentation.

Observations

Three patients were diagnosed as SHAPU in the summer (May) of 2020. All of them noted the presence of white moths (Gazalina species) in their environment with or without direct physical contact. The clinical patterns were severe in nature including corneal melting. Two out of three patients (66.6%) developed phthisis bulbi and lost their vision.

Conclusions and importance

White moth has been associated as a risk factor for SHAPU. Despite the known natural history of appearance after monsoon of every odd year, the few unhatched eggs of the moths may hatch under the favorable circumstances in the summer of the even years and may lead to the sporadic outbreak of SHAPU. Though less in numbers, the clinical presentation of such sporadic SHAPU cases may be atypical with less favorable outcome.

Moth hair in cornea in a case of seasonal hyperacute panuveitis

Seasonal Hyperacute Panuveitis (SHAPU) is a seasonal and cyclic uveitic disease reported only from Nepal occurring every odd year. Untreated eyes go blind and phthisis within a week. Circumstantial evidence for the role of moths has been reported earlier. Herein for the first time, we describe a SHAPU case in a healthy young Nepalese patient where the exposure to white moth was followed by the development of the uveitis and the moth hair particles was detected in the corneal and presence was confirmed with anterior segment optical coherence topography.

Recent Advances in Diagnosis and Treatment of Infectious Uveitis Prevalent in Asia-Pacific Region

ABSTRACT

The role of infections in intraocular inflammation is being increasingly recognized across the world. The Asia-Pacific region, being the single largest and most populous geographical entity on the planet, is home to a wide variety of such infections. Not surprisingly, there has been an explosion in the literature on infectious uveitis emerging from Asia-Pacific countries. In this review, we have covered recent advances in the diagnosis, treatment, and pathogenesis of common forms of infectious uveitis from the Asia-Pacific region. Much of the literature is focussed on the diagnosis of these infections by clinical criteria and laboratory investigations. There has also been an increased emphasis on the application of newer modes of ocular imaging and understanding pathomechanisms of ocular inflammation in these infections. Together this research has significantly improved our understanding of the diagnosis and management of infectious uveitis.

The Risk Factors of Seasonal Hyperacute Panuveitis

BACKGROUND

Seasonal Hyperacute Panuveitis (SHAPU) is an eye disease of unclear aetiology occurring cyclically during the autumn in odd years in Nepal causing blindness within a week. This study is the first of its type to investigate the risk factors of SHAPU.

METHODS

A multicentric national level case-control study was performed during the 2017 SHAPU outbreak. Cases were matched to controls in a 1:3 ratio based on age, sex and geographic area.Questionnaire-based personal interview was used and risk factors were categorized as biological and behavioral. For univariate analysis, frequency, median and interquartile range was calculated. Chi-squared test with/without continuity correction and Fisher's exact test were used. Multivariate conditional logistic regressions were used for all the independent variables for p <0.1 in the univariate analyses.

RESULTS

We identified 35 cases and 105 controls; 71.4% were children≤16 years (38-day infant to 50-year-old). All were immunocompetent individuals, males were 57.1% and females 42.9%. Potential risks such as visible moths/butterfly activity, contact with livestock, and attending mass gatherings of people were not reported more frequently in cases vs controls in univariate analyses. Differences in possibly protective factors such as self-reported mosquito net use, light off at night while sleeping, and habit of hands/face washing after physical contact/touch with any insects/butterflies/birds were not statistically significant between both groups. In multivariate model, SHAPU cases were significantly more likely than controls to report physical contact with butterflies/white moths (Adjusted OR:6.89; CI:2.79-17.01,p < .001).

CONCLUSIONS

Direct physical contact with butterflies/moths was associated with significantly increased odds of SHAPU cases.

Youngest reported Seasonal Hyperacute Panuveitis case

Purpose

Seasonal Hyperacute Panuveitis (SHAPU) is a mysterious but rapidly devastating intraocular inflammatory disease reported only from Nepal during odd years after monsoon. Though it predominantly affects children, it has been reported between 9 months and 50 years age. But herein, we report a case of SHAPU in a 38-days-baby during 2017 SHAPU outbreak.

Observations

Parents of a 38-days-healthy male baby from Pokhara noticed redness in child's right eye since 5 days (October 2017). They noticed the fall of a white moth from the tubelight over the child's face 1-day prior to symptom onset. On examination, both eyes followed and fixated at light. The right eye was congested with dense anterior chamber reaction and white pupillary reflex obscuring the glow of the retina. Ultrasonography showed hyperechoic vitreous shadows with choroidal thickening. Left eye was normal. The child underwent vitreous tap with core vitrectomy + lensectomy with intravitreal antibiotics and steroid ↓GA. The blood investigations were normal and the vitreous sample yielded no organism growth. Viral PCR analysis was negative. The intraocular inflammation decreased and fundal glow was visible.

Conclusions

AND IMPORTANCE: SHAPU can occur in a child as young as 38 days. Link with moth remains the strongest suspect.