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Year : 2005  |  Volume : 53  |  Issue : 4  |  Page : 270-272

Demonstration of varicella zoster virus in a case of presumed seasonal hyperacute panuveitis

Medical and Vision Research Foundations, Sankara Nethralaya, College Road, Chennai, India

Correspondence Address:
Jyotirmay Biswas
Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Chennai 600 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0301-4738.18911

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How to cite this article:
Kathil P, Biswas J, Gopal L. Demonstration of varicella zoster virus in a case of presumed seasonal hyperacute panuveitis. Indian J Ophthalmol 2005;53:270-2

How to cite this URL:
Kathil P, Biswas J, Gopal L. Demonstration of varicella zoster virus in a case of presumed seasonal hyperacute panuveitis. Indian J Ophthalmol [serial online] 2005 [cited 2020 Oct 22];53:270-2. Available from: https://www.ijo.in/text.asp?2005/53/4/270/18911

Seasonal hyperacute panuveitis (SHAPU) has been described as a severe form of unilateral panuveitis, which in most cases leads to blindness within hours of its onset. It has been seen only in Nepal since 1975. This disease appears with the onset of autumn in September and lasts until the December in 2-year cycles. The usual history is a that of a child in good ocular and general health, suddenly develops a red eye with mild pain, photophobia, lacrimation, and profound loss of vision to hand movements or light perception within hours of onset. Examination shows diffuse conjunctival congestion, aqueous cells, fibrinous exudation in anterior chamber, and hypopyon in more than 50% of cases. There is white pupillary reflex due to infiltration of the vitreous with inflammatory cells. The white reflex in some cases takes a yellowish tinge after few days. Some patients can develop streaks of haemorrhage on the vitreous surface during late stages. The intraocular pressure (IOP) is usually reduced or occasionally may be raised. There is hypotension within few days with shallowing of anterior chamber to virtual obliteration ultimately. This condition has been also called malignant hypotension. Aetiology of this condition is still undetermined.[1]

We report a case of SHAPU in which anterior chamber aspirate showed varicella zoster virus (VZV) by immunofluroscence and subsequent treatment with intravenous acyclovir and oral cortico steroids improved the condition. This case indicates that VZV could be implicated in the aetiology of this rare disease.

  Case Report Top

A 34-year-old male from Kathmandu (Nepal) presented to us in October 2001 with the chief complaints of noticing sudden black spots in front of right eye 5 days back followed by complete loss of vision next day associated with redness and mild pain. He was diagnosed as SHAPU by local ophthalmologist. There was no history of fever, focal sepsis, joint pain, low backache, oral or genital ulcers, injury, intravenous alimentation, drug abuse, exposure, or any systemic illness. Previous investigations revealed normal chest X-ray, normal total and differential count, negative RA factor, negative VDRL, and negative ELISA (enzyme linked immunosorbent assay) for HIV I and II. Patient was using tablet wyslone (100 mg/day), tablet acyclovir (800 mg 5 times/day), dexamethasone eye drops (10 times/day), and atropine eye drops (3 times/day)

On examination, his best corrected visual acuity was hand movement close to face in the right eye and 6/6, N6 in left eye. Slit lamp examination of the right eye revealed marked conjunctival and circumcorneal congestion, corneal stromal oedema, Descemet's folds, endothelitis, aqueous flare 3+, cells 2+, 1 mm hypopyon, and dense vitreous cells [Figure - 1]. Intraocular pressure (IOP) was 07 mm Hg in right eye. There was no view of right eye fundus. The slit lamp and fundus examination of left eye was within normal limits including IOP at 13 mm Hg. Ultrasound B scan of the right eye revealed multiple dot like and membranous echoes in the mid and posterior vitreous cavity suggestive of inflammatory debris. Complete posterior vitreous detachment was found with attached retina. Choroid was marginally thickened.

Based on the clinical and laboratory findings, provisional diagnosis of endogenous endophthalmitis was made. Anterior chamber tap was done and subjected to direct smear for bacteria and fungus as well as immunoflurescence study for herpes simplex virus (HSV), VZV, and cytomegalovirus (CMV). Immunoflurescence staining was positive has positive for VZV and negative for HSV and CMV. Patient was admitted on the same day and was started on intravenous acyclovir 500 mg every 8 times/hour for 7 days, intravenous cefotaxime 500 mg every 12 hours along with oral prednisolone 60 mg/day in tapering dose and prednisolone acetate eye drops 1 time/hour, Atropine eye drops 2 times/day, ciprofloxacin eye drops 1 time/hour and acyclovir eye ointment 5 times/day.

After 7 days of treatment, the vision improved to 1/60. Corneal oedema, Descemet's folds, and hypopyon subsided. Vitritis also decreased and disc and retina could be visualised [Figure - 2] but the anterior chamber reaction persisted. The patient was switched over to oral acyclovir 800 mg 5 times/day.

At the same time, polymerase chain reaction (PCR) for mycobacteria, fungus, HSV, VZV, and CMV genome were negative results. ELISA (serum) for anti-VZV and -CMV IgG was found highly positive while ELISA for anti-VZV and -CMV IgM, anti-HSV IgG and IgM was negative.

Patient on this treatment showed steady improvement. Three weeks later vision improved to 6/9, N36. Anterior chamber inflammation and vitritis decreased. Patient was maintained on oral acyclovir 800 mg 5 times/day for 6 weeks, oral cortico steroids in tapering doses and topical cortico steroids and cycloplegics.

The right eye visual acuity was 6/6, N6, at 6 weeks. Slit lamp examination of anterior segment was normal. IOP was normal. On fundus examination, disc showed mild pallor vitreous cavity showed presence of debris inferiorly. Rest of the fundus was normal [Figure - 3]. The patient was continued on oral acyclovir for two more weeks along with cortico steroids in tapering doses and at 1 month later visit showed further improvement with reduction in vitreous debris.

  Discussion Top

SHAPU is an entity described only in Nepal. This is mostly seen in children, but can be seen in adults.[1] Aetiology of this disease is not yet known. Previous studies have failed to show growth of bacteria and fungi in cultures of aqueous. Attempts to reproduce the disease in animals following injection of aqueous and vitreous from patients have not succeeded thus excluding microorganisms in the causation of disease. The seasonal incidence of disease would tend to implicate an agent from the environment like insects or pollens. A group of insects, moths were implicated to be the causative agent in a outbreak in 1977, though animal experiments using different varieties of moths failed to produce the disease in a study. It has been suggested that it may be a hypersensitivity response to a variety of exogenous and endogenous agents. Our case showed the presence of VZV in the aqueous and elevated antibody level in the serum, suggesting a viral aetiology. Literature shows a poor prognosis in most of the cases with poor visual potential and some eyes develop malignant hypotension. The visual recovery and prognosis in our case has been exceptionally good following intravenous acyclovir therapy.

Our study has the limitation of a single case report, though the demonstration of VZV in the aqueous and rapid resolution of inflammation following specific antiviral therapy indicates possible viral aetiology and warrants study of aqueous aspirate for VZV of larger number of cases to substantiate our observations.

  Acknowledgment Top

This work is financially supported by Vision Research Foundation, Chennai, India.

  References Top

Upadhyay MP, Rai NC, Ogg JE, Shrestha BR. Seasonal hyperacute panuveitis of unknown etiology. Ann ophthalmol 1984;16:38-44.  Back to cited text no. 1


  [Figure - 1], [Figure - 2], [Figure - 3]

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