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Abstract
As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic spreads, it is becoming increasingly evident that coronavirus disease 2019 (COVID-19) is not limited to the respiratory system, and that other organs can be affected. In particular, virus-related neurological manifestations are being reported more and more frequently in the scientific literature. In this article, we review the literature on the association between COVID-19 and neurological manifestations, present evidence from preclinical research suggesting that SARS-CoV-2 could be responsible for many of these manifestations, and summarize the biological pathways that could underlie each neurological symptom. Understanding the mechanisms that lead to neurological manifestations in patients with COVID-19 and how these manifestations correlate with clinical outcomes will be instrumental in guiding the optimal use of targeted therapeutic strategies.
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Affiliation(s)
- Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy.
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
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de Sousa AK, Magalhães DDA, Ferreira JDS, Barbosa ALDR. SARS-CoV-2-mediated encephalitis: Role of AT2R receptors in the blood-brain barrier. Med Hypotheses 2020; 144:110213. [PMID: 33254519 PMCID: PMC7449115 DOI: 10.1016/j.mehy.2020.110213] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 12/23/2022]
Abstract
At the end of 2019, there was an outbreak of a new Coronavirus 2019 (COVID-19 disease). Studies suggest that SARS-CoV-2 can cause infection in the central nervous system (CNS) and trigger neurological symptoms that include headache, nausea and vomiting, mental confusion and loss of smell or taste. These findings reveal that Coronaviruses have neurological tropism and neuroinvasive capacity. The spread of SARS-CoV-2 in the brain tissue possibly occurs through the systemic circulation as reported in patients affected by SARS-CoV. Evidence highlights similarity between the SARS-CoV genome and SARS-CoV-2 and that both interact with the angiotensin-converting enzyme type 2 (ACE2) located in the brain tissue of infected patients. Hence, the presence of ACE2 is likely in the CNS to mediate the entry of the SARS-CoV-2 virus into neural tissue. Our hypothesis suggests that SARS-CoV-2 can cause encephalitis through the production of inflammatory mediators and activation of immune system cells resulting from the interaction of the ACE2 receptor with the viral Spike protein that causes an increase in angiotensin II. This mechanism has the ability to activate immune system cells by exacerbating stimuli at the angiotensin 2 receptor (AT2R). Thus, it leads to a status of brain injury preceded by vascular damage and destruction of the blood-brain barrier, making it responsible for the installation of acute inflammation.
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Affiliation(s)
- Antônio Kleiton de Sousa
- Laboratory of Experimental Physiopharmacology (LAFFEX), Federal University of the Delta of Parnaíba, Parnaíba, PI, Brazil
| | - Diva de Aguiar Magalhães
- Laboratory of Experimental Physiopharmacology (LAFFEX), Federal University of the Delta of Parnaíba, Parnaíba, PI, Brazil; The Northeast Biotechnology Network, Federal University of Piauí, Teresina, Brazil
| | - Jayro Dos Santos Ferreira
- Laboratory of Experimental Physiopharmacology (LAFFEX), Federal University of the Delta of Parnaíba, Parnaíba, PI, Brazil
| | - André Luiz Dos Reis Barbosa
- Laboratory of Experimental Physiopharmacology (LAFFEX), Federal University of the Delta of Parnaíba, Parnaíba, PI, Brazil; The Northeast Biotechnology Network, Federal University of Piauí, Teresina, Brazil.
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Neurological complications of coronavirus infection; a comparative review and lessons learned during the COVID-19 pandemic. J Neurol Sci 2020; 417:117085. [PMID: 32871412 PMCID: PMC7413162 DOI: 10.1016/j.jns.2020.117085] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Coronavirus disease-19 (COVID-19) pandemic continues to grow all over the world. Several studies have been performed, focusing on understanding the acute respiratory syndrome and treatment strategies. However, there is growing evidence indicating neurological manifestations occur in patients with COVID-19. Similarly, the other coronaviruses (CoV) epidemics; severe acute respiratory syndrome (SARS-CoV-1) and Middle East respiratory syndrome (MERS-CoV) have been associated with neurological complications. METHODS This systematic review serves to summarize available information regarding the potential effects of different types of CoV on the nervous system and describes the range of clinical neurological complications that have been reported thus far in COVID-19. RESULTS Two hundred and twenty-five studies on CoV infections associated neurological manifestations in human were reviewed. Of those, 208 articles were pertinent to COVID-19. The most common neurological complaints in COVID-19 were anosmia, ageusia, and headache, but more serious complications, such as stroke, impairment of consciousness, seizures, and encephalopathy, have also been reported. CONCLUSION There are several similarities between neurological complications after SARS-CoV-1, MERS-CoV and COVID-19, however, the scope of the epidemics and number of patients are very different. Reports on the neurological complications after and during COVID-19 are growing on a daily basis. Accordingly, comprehensive knowledge of these complications will help health care providers to be attentive to these complications and diagnose and treat them timely.
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Neurological Complications Associated with the Blood-Brain Barrier Damage Induced by the Inflammatory Response During SARS-CoV-2 Infection. Mol Neurobiol 2020; 58:520-535. [PMID: 32978729 PMCID: PMC7518400 DOI: 10.1007/s12035-020-02134-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/16/2020] [Indexed: 01/08/2023]
Abstract
The main discussion above of the novel pathogenic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has focused substantially on the immediate risks and impact on the respiratory system; however, the effects induced to the central nervous system are currently unknown. Some authors have suggested that SARS-CoV-2 infection can dramatically affect brain function and exacerbate neurodegenerative diseases in patients, but the mechanisms have not been entirely described. In this review, we gather information from past and actual studies on coronaviruses that informed neurological dysfunction and brain damage. Then, we analyzed and described the possible mechanisms causative of brain injury after SARS-CoV-2 infection. We proposed that potential routes of SARS-CoV-2 neuro-invasion are determinant factors in the process. We considered that the hematogenous route of infection can directly affect the brain microvascular endothelium cells that integrate the blood-brain barrier and be fundamental in initiation of brain damage. Additionally, activation of the inflammatory response against the infection represents a critical step on injury induction of the brain tissue. Consequently, the virus’ ability to infect brain cells and induce the inflammatory response can promote or increase the risk to acquire central nervous system diseases. Here, we contribute to the understanding of the neurological conditions found in patients with SARS-CoV-2 infection and its association with the blood-brain barrier integrity.
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Murta V, Villarreal A, Ramos AJ. Severe Acute Respiratory Syndrome Coronavirus 2 Impact on the Central Nervous System: Are Astrocytes and Microglia Main Players or Merely Bystanders? ASN Neuro 2020; 12:1759091420954960. [PMID: 32878468 PMCID: PMC7476346 DOI: 10.1177/1759091420954960] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
With confirmed coronavirus disease 2019 (COVID-19) cases surpassing the 18 million mark around the globe, there is an imperative need to gain comprehensive understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although the main clinical manifestations of COVID-19 are associated with respiratory or intestinal symptoms, reports of neurological signs and symptoms are increasing. The etiology of these neurological manifestations remains obscure, and probably involves several direct pathways, not excluding the direct entry of the virus to the central nervous system (CNS) through the olfactory epithelium, circumventricular organs, or disrupted blood–brain barrier. Furthermore, neuroinflammation might occur in response to the strong systemic cytokine storm described for COVID-19, or due to dysregulation of the CNS rennin-angiotensin system. Descriptions of neurological manifestations in patients in the previous coronavirus (CoV) outbreaks have been numerous for the SARS-CoV and lesser for Middle East respiratory syndrome coronavirus (MERS-CoV). Strong evidence from patients and experimental models suggests that some human variants of CoV have the ability to reach the CNS and that neurons, astrocytes, and/or microglia can be target cells for CoV. A growing body of evidence shows that astrocytes and microglia have a major role in neuroinflammation, responding to local CNS inflammation and/or to disbalanced peripheral inflammation. This is another potential mechanism for SARS-CoV-2 damage to the CNS. In this comprehensive review, we will summarize the known neurological manifestations of SARS-CoV-2, SARS-CoV and MERS-CoV; explore the potential role for astrocytes and microglia in the infection and neuroinflammation; and compare them with the previously described human and animal CoV that showed neurotropism to propose possible underlying mechanisms.
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Affiliation(s)
- Veronica Murta
- Laboratorio de Neuropatología Molecular, Instituto de Biología Celular y Neurociencia "Prof. E. De Robertis," Facultad de Medicina, UBA-CONICET, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Alejandro Villarreal
- Laboratorio de Neuropatología Molecular, Instituto de Biología Celular y Neurociencia "Prof. E. De Robertis," Facultad de Medicina, UBA-CONICET, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Alberto J Ramos
- Laboratorio de Neuropatología Molecular, Instituto de Biología Celular y Neurociencia "Prof. E. De Robertis," Facultad de Medicina, UBA-CONICET, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
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Chaná-Cuevas P, Salles-Gándara P, Rojas-Fernandez A, Salinas-Rebolledo C, Milán-Solé A. The Potential Role of SARS-COV-2 in the Pathogenesis of Parkinson's Disease. Front Neurol 2020; 11:1044. [PMID: 33041985 PMCID: PMC7527541 DOI: 10.3389/fneur.2020.01044] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/10/2020] [Indexed: 12/19/2022] Open
Abstract
Considering their current burden and epidemiological projections, nowadays Parkinson's disease and the COVID-19 pandemic are two key health problems. There is evidence of the pathogenic role of neurotropic viruses in neurodegenerative diseases and coronaviruses are neurotropic, with some of them selectively targeting the basal ganglia. Moreover, some authors demonstrated the longevity of these viruses in the affected cells of the nervous system for long periods. Coronavirus was detected in brain autopsies and SARS-CoV-2 has been isolated from the CSF of affected patients. The marked inflammatory response in some particular patients with COVID-19 with a consequent increase of pro-inflammatory cytokines is considered a prognostic factor. Immunologic changes are observed in patients with Parkinson's disease, possibly having a role in its pathogenesis. A dynamic pro-inflammatory state accompanies α-synuclein accumulation and the development and progression of neurodegeneration. Also, some viral infectious diseases might have a role as triggers, generating a cross autoimmune reaction against α-synuclein. In the past Coronaviruses have been related to Parkinson's disease, however, until now the causal role of these viruses is unknown. In this paper, our focus is to assess the potential relationship between SARS-CoV-2 infection and Parkinson's disease.
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Affiliation(s)
- Pedro Chaná-Cuevas
- Movement Disorders Center, CETRAM, Santiago, Chile
- Faculty of Medical Science, University of Santiago of Chile, Santiago, Chile
| | | | - Alejandro Rojas-Fernandez
- Institute of Medicine & Center for Interdisciplinary Studies on the Nervous System (CISNe), Universidad Austral de Chile, Valdivia, Chile
| | - Constanza Salinas-Rebolledo
- Institute of Medicine & Center for Interdisciplinary Studies on the Nervous System (CISNe), Universidad Austral de Chile, Valdivia, Chile
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Mishra R, Banerjea AC. Neurological Damage by Coronaviruses: A Catastrophe in the Queue! Front Immunol 2020; 11:565521. [PMID: 33013930 PMCID: PMC7511585 DOI: 10.3389/fimmu.2020.565521] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022] Open
Abstract
Neurological disorders caused by neuroviral infections are an obvious pathogenic manifestation. However, non-neurotropic viruses or peripheral viral infections pose a considerable challenge as their neuropathological manifestations do not emerge because of primary infection. Their secondary or bystander pathologies develop much later, like a syndrome, during and after the recovery of patients from the primary disease. Massive inflammation caused by peripheral viral infections can trigger multiple neurological anomalies. These neurological damages may range from a general cognitive and motor dysfunction up to a wide spectrum of CNS anomalies, such as Acute Necrotizing Hemorrhagic Encephalopathy, Guillain-Barré syndrome, Encephalitis, Meningitis, anxiety, and other audio-visual disabilities. Peripheral viruses like Measles virus, Enteroviruses, Influenza viruses (HIN1 series), SARS-CoV-1, MERS-CoV, and, recently, SARS-CoV-2 are reported to cause various neurological manifestations in patients and are proven to be neuropathogenic even in cellular and animal model systems. This review presents a comprehensive picture of CNS susceptibilities toward these peripheral viral infections and explains some common underlying themes of their neuropathology in the human brain.
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Affiliation(s)
- Ritu Mishra
- Laboratory of Virology, National Institute of Immunology, New Delhi, India
| | - Akhil C. Banerjea
- Laboratory of Virology, National Institute of Immunology, New Delhi, India
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Rahman A, Niloofa R, De Zoysa IM, Cooray AD, Kariyawasam J, Seneviratne SL. Neurological manifestations in COVID-19: A narrative review. SAGE Open Med 2020; 8:2050312120957925. [PMID: 32974019 PMCID: PMC7491214 DOI: 10.1177/2050312120957925] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/20/2020] [Indexed: 01/05/2023] Open
Abstract
COVID-19, a respiratory viral infection, has affected more than 10 million individuals worldwide. Common symptoms include fever, dry cough, fatigue and shortness of breath. Some patients show neurological manifestations such as headache, dizziness, cerebrovascular disease, peripheral nerve and muscle symptoms and smell and taste impairment. In previous studies, SARS-CoV-1 and MERS-CoV were found to affect the nervous system. Given the high similarity between SARS-CoV-1 and SARS-CoV-2, effects on the nervous system by SARS-CoV-2 are a possibility. We have outlined the common neurological manifestations in COVID-19 (information are up-to-date as of June 2020) and discussed the possible pathogenetic mechanisms and management options.
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Affiliation(s)
- Asma Rahman
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Roshan Niloofa
- Department of Zoology and Environment Sciences, Faculty of Science, University of Colombo, Colombo, Sri Lanka
| | - Ishan M De Zoysa
- Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Akila D Cooray
- Department of Zoology and Environment Sciences, Faculty of Science, University of Colombo, Colombo, Sri Lanka
| | - Jayani Kariyawasam
- Institute of Biochemistry, Molecular Biology and Biotechnology, University of Colombo, Colombo, Sri Lanka
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Santerre M, Arjona SP, Allen CN, Shcherbik N, Sawaya BE. Why do SARS-CoV-2 NSPs rush to the ER? J Neurol 2020; 268:2013-2022. [PMID: 32870373 PMCID: PMC7461160 DOI: 10.1007/s00415-020-10197-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/15/2020] [Accepted: 08/27/2020] [Indexed: 12/18/2022]
Abstract
SARS-CoV-2, which led to the 2020 global pandemic, is responsible for the Coronavirus Disease 2019 (COVID-19), a respiratory illness, and presents a tropism for the central nervous system. Like most members of this family, the virus is composed of structural and non-structural proteins (NSPs). The non-structural proteins are critical elements of the replication and transcription complex (RTC), as well as immune system evasion. Through hijacking the endoplasmic reticulum (ER) membrane, NSPs help the virus establish the RTC, inducing ER stress after membrane rearrangement and causing severe neuronal disturbance. In this review, we focus on the role of Nsp3, 4, and 6 in intracellular membrane rearrangement and evaluate the potential disruption of the central nervous system and the neurodegeneration which it could trigger. Studies of these NSPs will not only bring to light their specific role in viral infection but also facilitate the discovery of novel targeted drugs.
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Affiliation(s)
- Maryline Santerre
- Molecular Studies of Neurodegenerative Diseases Lab, Lewis Katz School of Medicine, Fels Institute for Cancer Research, Temple University, 3307 North Broad Street, Philadelphia, PA, 19140, USA.
| | - Sterling P Arjona
- Molecular Studies of Neurodegenerative Diseases Lab, Lewis Katz School of Medicine, Fels Institute for Cancer Research, Temple University, 3307 North Broad Street, Philadelphia, PA, 19140, USA
| | - Charles Ns Allen
- Molecular Studies of Neurodegenerative Diseases Lab, Lewis Katz School of Medicine, Fels Institute for Cancer Research, Temple University, 3307 North Broad Street, Philadelphia, PA, 19140, USA
| | - Natalia Shcherbik
- Department for Cell Biology and Neuroscience, School of Osteopathic Medicine, Rowan University, 2 Medical Center Drive, Stratford, NJ, 08084, USA
| | - Bassel E Sawaya
- Molecular Studies of Neurodegenerative Diseases Lab, Lewis Katz School of Medicine, Fels Institute for Cancer Research, Temple University, 3307 North Broad Street, Philadelphia, PA, 19140, USA. .,Department of Neurology, Lewis Katz School of Medicine - Temple University Philadelphia, Philadelphia, PA, 19140, USA.
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60
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Riederer P, Ter Meulen V. Coronaviruses: a challenge of today and a call for extended human postmortem brain analyses. J Neural Transm (Vienna) 2020; 127:1217-1228. [PMID: 32725545 PMCID: PMC7386201 DOI: 10.1007/s00702-020-02230-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 01/08/2023]
Abstract
While there is abounding literature on virus-induced pathology in general and coronavirus in particular, recent evidence accumulates showing distinct and deleterious brain affection. As the respiratory tract connects to the brain without protection of the blood-brain barrier, SARS-CoV-2 might in the early invasive phase attack the cardiorespiratory centres located in the medulla/pons areas, giving rise to disturbances of respiration and cardiac problems. Furthermore, brainstem regions are at risk to lose their functional integrity. Therefore, long-term neurological as well as psychiatric symptomatology and eventual respective disorders cannot be excluded as evidenced from influenza-A triggered post-encephalitic Parkinsonism and HIV-1 triggered AIDS-dementia complex. From the available evidences for coronavirus-induced brain pathology, this review concludes a number of unmet needs for further research strategies like human postmortem brain analyses. SARS-CoV-2 mirroring experimental animal brain studies, characterization of time-dependent and region-dependent spreading behaviours of coronaviruses, enlightening of pathological mechanisms after coronavirus infection using long-term animal models and clinical observations of patients having had COVID-19 infection are calling to develop both protective strategies and drug discoveries to avoid early and late coronavirus-induced functional brain disturbances, symptoms and eventually disorders. To fight SARS-CoV-2, it is an urgent need to enforce clinical, molecular biological, neurochemical and genetic research including brain-related studies on a worldwide harmonized basis.
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Affiliation(s)
- Peter Riederer
- Clinic and Policlinic for Psychiatry, Psychosomatics and Psychotherapy, University Hospital Würzburg, Margarete-Hoeppel-Platz 1, 97080, Würzburg, Germany.
- University of Southern Denmark Odense, J.B. Winslows Vey 18, 5000, Odense, Denmark.
| | - Volker Ter Meulen
- Institut für Virologie und Immunbiologie, Universität Würzburg, Versbacherstraße Straße 7, 97078, Würzburg, Germany
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Cataldi M, Pignataro G, Taglialatela M. Neurobiology of coronaviruses: Potential relevance for COVID-19. Neurobiol Dis 2020; 143:105007. [PMID: 32622086 PMCID: PMC7329662 DOI: 10.1016/j.nbd.2020.105007] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 12/18/2022] Open
Abstract
In the first two decades of the 21st century, there have been three outbreaks of severe respiratory infections caused by highly pathogenic coronaviruses (CoVs) around the world: the severe acute respiratory syndrome (SARS) by the SARS-CoV in 2002-2003, the Middle East respiratory syndrome (MERS) by the MERS-CoV in June 2012, and Coronavirus Disease 2019 (COVID-19) by the SARS-CoV-2 presently affecting most countries In all of these, fatalities are a consequence of a multiorgan dysregulation caused by pulmonary, renal, cardiac, and circulatory damage; however, COVID patients may show significant neurological signs and symptoms such as headache, nausea, vomiting, and sensory disturbances, the most prominent being anosmia and ageusia. The neuroinvasive potential of CoVs might be responsible for at least part of these symptoms and may contribute to the respiratory failure observed in affected patients. Therefore, in the present manuscript, we have reviewed the available preclinical evidence on the mechanisms and consequences of CoVs-induced CNS damage, and highlighted the potential role of CoVs in determining or aggravating acute and long-term neurological diseases in infected individuals. We consider that a widespread awareness of the significant neurotropism of CoVs might contribute to an earlier recognition of the signs and symptoms of viral-induced CNS damage. Moreover, a better understanding of the cellular and molecular mechanisms by which CoVs affect CNS function and cause CNS damage could help in planning new strategies for prognostic evaluation and targeted therapeutic intervention.
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Affiliation(s)
| | | | - Maurizio Taglialatela
- Division of Pharmacology, Department of Neuroscience, University of Naples "Federico II", 80131 Naples, Italy.
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Sanclemente-Alaman I, Moreno-Jiménez L, Benito-Martín MS, Canales-Aguirre A, Matías-Guiu JA, Matías-Guiu J, Gómez-Pinedo U. Experimental Models for the Study of Central Nervous System Infection by SARS-CoV-2. Front Immunol 2020; 11:2163. [PMID: 32983181 PMCID: PMC7485091 DOI: 10.3389/fimmu.2020.02163] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The response to the SARS-CoV-2 coronavirus epidemic requires increased research efforts to expand our knowledge of the disease. Questions related to infection rates and mechanisms, the possibility of reinfection, and potential therapeutic approaches require us not only to use the experimental models previously employed for the SARS-CoV and MERS-CoV coronaviruses but also to generate new models to respond to urgent questions. DEVELOPMENT We reviewed the different experimental models used in the study of central nervous system (CNS) involvement in COVID-19 both in different cell lines that have enabled identification of the virus' action mechanisms and in animal models (mice, rats, hamsters, ferrets, and primates) inoculated with the virus. Specifically, we reviewed models used to assess the presence and effects of SARS-CoV-2 on the CNS, including neural cell lines, animal models such as mouse hepatitis virus CoV (especially the 59 strain), and the use of brain organoids. CONCLUSION Given the clear need to increase our understanding of SARS-CoV-2, as well as its potential effects on the CNS, we must endeavor to obtain new information with cellular or animal models, with an appropriate resemblance between models and human patients.
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Affiliation(s)
- Inmaculada Sanclemente-Alaman
- Laboratory of Neurobiology, Department of Neurology, Institute of Neurosciences, San Carlos Institute for Health Research, Universidad Complutense de Madrid, Madrid, Spain
| | - Lidia Moreno-Jiménez
- Laboratory of Neurobiology, Department of Neurology, Institute of Neurosciences, San Carlos Institute for Health Research, Universidad Complutense de Madrid, Madrid, Spain
| | - María Soledad Benito-Martín
- Laboratory of Neurobiology, Department of Neurology, Institute of Neurosciences, San Carlos Institute for Health Research, Universidad Complutense de Madrid, Madrid, Spain
| | - Alejandro Canales-Aguirre
- Preclinical Evaluation Unit, Medical and Pharmaceutical Biotechnology, CIATEJ-CONACYT, Guadalajara, Mexico
| | - Jordi A. Matías-Guiu
- Laboratory of Neurobiology, Department of Neurology, Institute of Neurosciences, San Carlos Institute for Health Research, Universidad Complutense de Madrid, Madrid, Spain
| | - Jorge Matías-Guiu
- Laboratory of Neurobiology, Department of Neurology, Institute of Neurosciences, San Carlos Institute for Health Research, Universidad Complutense de Madrid, Madrid, Spain
| | - Ulises Gómez-Pinedo
- Laboratory of Neurobiology, Department of Neurology, Institute of Neurosciences, San Carlos Institute for Health Research, Universidad Complutense de Madrid, Madrid, Spain
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Zubair AS, McAlpine LS, Gardin T, Farhadian S, Kuruvilla DE, Spudich S. Neuropathogenesis and Neurologic Manifestations of the Coronaviruses in the Age of Coronavirus Disease 2019: A Review. JAMA Neurol 2020; 77:1018-1027. [PMID: 32469387 PMCID: PMC7484225 DOI: 10.1001/jamaneurol.2020.2065] [Citation(s) in RCA: 615] [Impact Index Per Article: 153.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in December 2019, causing human coronavirus disease 2019 (COVID-19), which has now spread into a worldwide pandemic. The pulmonary manifestations of COVID-19 have been well described in the literature. Two similar human coronaviruses that cause Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV-1) are known to cause disease in the central and peripheral nervous systems. Emerging evidence suggests COVID-19 has neurologic consequences as well. Observations This review serves to summarize available information regarding coronaviruses in the nervous system, identify the potential tissue targets and routes of entry of SARS-CoV-2 into the central nervous system, and describe the range of clinical neurological complications that have been reported thus far in COVID-19 and their potential pathogenesis. Viral neuroinvasion may be achieved by several routes, including transsynaptic transfer across infected neurons, entry via the olfactory nerve, infection of vascular endothelium, or leukocyte migration across the blood-brain barrier. The most common neurologic complaints in COVID-19 are anosmia, ageusia, and headache, but other diseases, such as stroke, impairment of consciousness, seizure, and encephalopathy, have also been reported. Conclusions and Relevance Recognition and understanding of the range of neurological disorders associated with COVID-19 may lead to improved clinical outcomes and better treatment algorithms. Further neuropathological studies will be crucial to understanding the pathogenesis of the disease in the central nervous system, and longitudinal neurologic and cognitive assessment of individuals after recovery from COVID-19 will be crucial to understand the natural history of COVID-19 in the central nervous system and monitor for any long-term neurologic sequelae.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Lindsay S McAlpine
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Tova Gardin
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Shelli Farhadian
- Division of Infectious Disease, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Division of Neurological Infections and Global Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Deena E Kuruvilla
- Division of Headache and Facial Pain, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Serena Spudich
- Division of Neurological Infections and Global Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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SARS-CoV-2 and the Nervous System: From Clinical Features to Molecular Mechanisms. Int J Mol Sci 2020. [PMID: 32751841 DOI: 10.3390/ijms21155475.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Increasing evidence suggests that Severe Acute Respiratory Syndrome-coronavirus-2 (SARS-CoV-2) can also invade the central nervous system (CNS). However, findings available on its neurological manifestations and their pathogenic mechanisms have not yet been systematically addressed. A literature search on neurological complications reported in patients with COVID-19 until June 2020 produced a total of 23 studies. Overall, these papers report that patients may exhibit a wide range of neurological manifestations, including encephalopathy, encephalitis, seizures, cerebrovascular events, acute polyneuropathy, headache, hypogeusia, and hyposmia, as well as some non-specific symptoms. Whether these features can be an indirect and unspecific consequence of the pulmonary disease or a generalized inflammatory state on the CNS remains to be determined; also, they may rather reflect direct SARS-CoV-2-related neuronal damage. Hematogenous versus transsynaptic propagation, the role of the angiotensin II converting enzyme receptor-2, the spread across the blood-brain barrier, the impact of the hyperimmune response (the so-called "cytokine storm"), and the possibility of virus persistence within some CNS resident cells are still debated. The different levels and severity of neurotropism and neurovirulence in patients with COVID-19 might be explained by a combination of viral and host factors and by their interaction.
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65
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Pennisi M, Lanza G, Falzone L, Fisicaro F, Ferri R, Bella R. SARS-CoV-2 and the Nervous System: From Clinical Features to Molecular Mechanisms. Int J Mol Sci 2020; 21:E5475. [PMID: 32751841 PMCID: PMC7432482 DOI: 10.3390/ijms21155475] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Increasing evidence suggests that Severe Acute Respiratory Syndrome-coronavirus-2 (SARS-CoV-2) can also invade the central nervous system (CNS). However, findings available on its neurological manifestations and their pathogenic mechanisms have not yet been systematically addressed. A literature search on neurological complications reported in patients with COVID-19 until June 2020 produced a total of 23 studies. Overall, these papers report that patients may exhibit a wide range of neurological manifestations, including encephalopathy, encephalitis, seizures, cerebrovascular events, acute polyneuropathy, headache, hypogeusia, and hyposmia, as well as some non-specific symptoms. Whether these features can be an indirect and unspecific consequence of the pulmonary disease or a generalized inflammatory state on the CNS remains to be determined; also, they may rather reflect direct SARS-CoV-2-related neuronal damage. Hematogenous versus transsynaptic propagation, the role of the angiotensin II converting enzyme receptor-2, the spread across the blood-brain barrier, the impact of the hyperimmune response (the so-called "cytokine storm"), and the possibility of virus persistence within some CNS resident cells are still debated. The different levels and severity of neurotropism and neurovirulence in patients with COVID-19 might be explained by a combination of viral and host factors and by their interaction.
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Affiliation(s)
- Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 97–95123 Catania, Italy; (M.P.); (F.F.)
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78–95123 Catania, Italy
- Oasi Research Institute–IRCCS, Via Conte Ruggero, 73–94018 Troina, Italy;
| | - Luca Falzone
- Epidemiology Unit, IRCCS Istituto Nazionale Tumori “Fondazione G. Pascale”, Via Mariano Semmola, 53 –80131 Naples, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 97–95123 Catania, Italy; (M.P.); (F.F.)
| | - Raffaele Ferri
- Oasi Research Institute–IRCCS, Via Conte Ruggero, 73–94018 Troina, Italy;
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 87–95123 Catania, Italy;
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66
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Yachou Y, El Idrissi A, Belapasov V, Ait Benali S. Neuroinvasion, neurotropic, and neuroinflammatory events of SARS-CoV-2: understanding the neurological manifestations in COVID-19 patients. Neurol Sci 2020; 41:2657-2669. [PMID: 32725449 PMCID: PMC7385206 DOI: 10.1007/s10072-020-04575-3] [Citation(s) in RCA: 212] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/02/2020] [Indexed: 12/19/2022]
Abstract
Respiratory viruses are opportunistic pathogens that infect the upper respiratory tract in humans and cause severe illnesses, especially in vulnerable populations. Some viruses have neuroinvasive properties and activate the immune response in the brain. These immune events may be neuroprotective or they may cause long-term damage similar to what is seen in some neurodegenerative diseases. The new “Severe Acute Respiratory Syndrome Coronavirus 2” (SARS-CoV-2) is one of the Respiratory viruses causing highly acute lethal pneumonia coronavirus disease 2019 (COVID-19) with clinical similarities to those reported in “Severe Acute Respiratory Syndrome Coronavirus”(SARS-CoV) and the “Middle East Respiratory Syndrome Coronavirus”(MERS-CoV) including neurological manifestation. To examine the possible neurological damage induced by SARS-CoV-2, it is necessary to understand the immune reactions to viral infection in the brain, and their short- and long-term consequences. Considering the similarities between SARS-CoV and SARS-CoV-2, which will be discussed, cooperative homological and phylogenetical studies lead us to question if SARS-CoV-2 can have similar neuroinvasive capacities and neuroinflammatiory events that may lead to the same short- and long-term neuropathologies that SARS-CoV had shown in human and animal models. To explain the neurological manifestation caused by SARS-CoV-2, we will present a literature review of 765 COVID-19 patients, in which 18% had neurological symptoms and complications, including encephalopathy, encephalitis and cerebrovascular pathologies, acute myelitis, and Guillain-Barré syndrome. Clinical studies describe anosmia or partial loss of the sense of smell as the most frequent symptom in COVID19 patients, suggesting that olfactory dysfunction and the initial ultrarapid immune responses could be a prognostic factor.
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Affiliation(s)
- Yassine Yachou
- Neurology Department, Astrakhan State Medical University, Astrakhan, Russia.
| | - Abdeslem El Idrissi
- Center for Developmental Neuroscience, City University of New York, College of Staten Island, New York, USA
| | - Vladimir Belapasov
- Neurology Department, Astrakhan State Medical University, Astrakhan, Russia
| | - Said Ait Benali
- Neurosurgery Department, Mohammed VI University Hospital Center, Cadi Ayyad University, Marrakech, Morocco
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67
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Badrfam R, Zandifar A. From encephalitis lethargica to COVID-19: Is there another epidemic ahead? Clin Neurol Neurosurg 2020; 196:106065. [PMID: 32659638 PMCID: PMC7347327 DOI: 10.1016/j.clineuro.2020.106065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Rahim Badrfam
- Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Atefeh Zandifar
- Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran.
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68
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Nuzzo D, Picone P. Potential neurological effects of severe COVID-19 infection. Neurosci Res 2020; 158:1-5. [PMID: 32628969 PMCID: PMC7333632 DOI: 10.1016/j.neures.2020.06.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
Coronaviruses (CoVs) are large positive stranded enveloped RNA viruses that generally cause enteric and respiratory diseases in humans and in animals. Most human CoVs have recently attracted global attention to their lethal potential and great infectious capacity. A highly pathogenic CoV, called COVID-19 or SARS-CoV-2, dramatically emerged in December 2019 in Wuhan, China. This new CoV has caused severe pneumonia in China and rapidly spreads around the world, the COVID-19 pandemic. Growing evidence pieces show that viruses, such as CoVs, can enter the central nervous system from different pathways and inducing neurotoxicity. Therefore, it is urgent to make clear whether SARS-CoV-2 has access to the central nervous system and can cause direct neuronal effects. Moreover, a brain-lung-brain axis is been proposed from the scientific community where severe neurological dysfunction and injury are associated with lung injury, and vice versa. In this axis, virus-induced inflammation and oxidative stress could be the common mechanisms responsible for CoV neurological symptoms. Therefore, is important to make clear whether SARS-CoV-2 lung damage can cause direct or indirect neuronal effects.
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Affiliation(s)
- Domenico Nuzzo
- Consiglio Nazionale delle Ricerche, Istituto per la Ricerca e l'Innovazione Biomedica, Palermo, Italy.
| | - Pasquale Picone
- Consiglio Nazionale delle Ricerche, Istituto per la Ricerca e l'Innovazione Biomedica, Palermo, Italy.
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69
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Vallamkondu J, John A, Wani WY, Ramadevi SP, Jella KK, Reddy PH, Kandimalla R. SARS-CoV-2 pathophysiology and assessment of coronaviruses in CNS diseases with a focus on therapeutic targets. Biochim Biophys Acta Mol Basis Dis 2020; 1866:165889. [PMID: 32603829 PMCID: PMC7320676 DOI: 10.1016/j.bbadis.2020.165889] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023]
Abstract
The novel Coronavirus disease of 2019 (nCOV-19) is a viral outbreak noted first in Wuhan, China. This disease is caused by Severe Acute Respiratory Syndrome (SARS) Coronavirus (CoV)-2. In the past, other members of the coronavirus family, such as SARS and Middle East Respiratory Syndrome (MERS), have made an impact in China and the Arabian peninsula respectively. Both SARS and COVID-19 share similar symptoms such as fever, cough, and difficulty in breathing that can become fatal in later stages. However, SARS and MERS infections were epidemic diseases constrained to limited regions. By March 2020 the SARS-CoV-2 had spread across the globe and on March 11th, 2020 the World Health Organization (WHO) declared COVID-19 as pandemic disease. In severe SARS-CoV-2 infection, many patients succumbed to pneumonia. Higher rates of deaths were seen in older patients who had co-morbidities such as diabetes mellitus, hypertension, cardiovascular disease (CVD), and dementia. In this review paper, we discuss the effect of SARS-CoV-2 on CNS diseases, such as Alzheimer's-like dementia, and diabetes mellitus. We also focus on the virus genome, pathophysiology, theranostics, and autophagy mechanisms. We will assess the multiorgan failure reported in advanced stages of SARS-CoV-2 infection. Our paper will provide mechanistic clues and therapeutic targets for physicians and investigators to combat COVID-19. SARS-CoV-2 and Dementia, Multiple Sclerosis, Encephalitis, and Parkinson's disease SARS-CoV-2 and Diabetes Mellitus Coronaviruses and Autophagy Protease Inhibitors and Repurposed Drugs for SARS-CoV-2 USFDA approved drugs-HCQ and Remdesivir. SARS-CoV-2 diagnostics
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Affiliation(s)
| | - Albin John
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Willayat Yousuf Wani
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States
| | | | | | - P Hemachandra Reddy
- Professor of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA; Internal Medicine, Neuroscience & Pharmacology, Texas Tech University Health Sciences Center, Lubbock, TX, USA; Neurology, Departments of School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA; Public Health Department of Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA; Department of Speech, Language and Hearing Sciences, School Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Ramesh Kandimalla
- Department of Biochemistry, Kakatiya Medical College, Warangal 506007, Telangana, India; Applied Biology, CSIR-Indian Institute of Technology, Uppal Road, Tarnaka, Hyderabad 500007, Telangana, India.
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70
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Domingues RB, Mendes-Correa MC, de Moura Leite FBV, Sabino EC, Salarini DZ, Claro I, Santos DW, de Jesus JG, Ferreira NE, Romano CM, Soares CAS. First case of SARS-COV-2 sequencing in cerebrospinal fluid of a patient with suspected demyelinating disease. J Neurol 2020; 267:3154-3156. [PMID: 32564153 PMCID: PMC7305694 DOI: 10.1007/s00415-020-09996-w] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 12/27/2022]
Abstract
The association between coronaviruses and central nervous system (CNS) demyelinating lesions has been previously shown. However, no case has been described of an association between the novel coronavirus (SARS-COV-2) and CNS demyelinating disease so far. SARS-COV-2 was previously detected in cerebrospinal fluid (CSF) sample of a patient with encephalitis. However, the virus identity was not confirmed by deep sequencing of SARS-COV-2 detected in the CSF. Here, we report a case of a patient with mild respiratory symptoms and neurological manifestations compatible with clinically isolated syndrome. The viral genome of SARS-COV-2 was detected and sequenced in CSF with 99.74-100% similarity between the patient virus and worldwide sequences. This report suggests a possible association of SARS-COV-2 infection with neurological symptoms of demyelinating disease, even in the absence of relevant upper respiratory tract infection signs.
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Affiliation(s)
| | - Maria Cássia Mendes-Correa
- Virology Section (LIM-52), Instituto de Medicina Tropical, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Ingra Claro
- Instituto de Medicina Tropical de São Paulo, São Paulo, SP, Brazil
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71
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Huang J, Zheng M, Tang X, Chen Y, Tong A, Zhou L. Potential of SARS-CoV-2 to Cause CNS Infection: Biologic Fundamental and Clinical Experience. Front Neurol 2020; 11:659. [PMID: 32625165 PMCID: PMC7314941 DOI: 10.3389/fneur.2020.00659] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/02/2020] [Indexed: 02/05/2023] Open
Abstract
SARS-CoV-2 is a novel coronavirus leading to serious respiratory disease and is spreading around the world at a raging speed. Recently there is emerging speculations that the central nervous system (CNS) may be involved during SARS-CoV-2 infection, contributing to the respiratory failure. However, the existence of viral replication in CNS has not been confirmed due to the lack of evidence from autopsy specimens. Considering the tropism of SARS-CoV-2, ACE2, is prevailing in CNS, and the neuro-invasive property of human coronavirus was widely reported, there is a need to identified the possible complications during COVID-19 for CNS. In this review, we conduct a detailed summary for the potential of SARS-CoV-2 to infect central nervous system from latest biological fundamental of SARS-CoV-2 to the clinical experience of other human coronaviruses. To confirm the neuro-invasive property of SARS-CoV-2 and the subsequent influence on patients will require further exploration by both virologist and neurologist.
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Affiliation(s)
- Jianhan Huang
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Meijun Zheng
- Department of Otolaryngology, Head and Neck Surgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Xin Tang
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Yaxing Chen
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Aiping Tong
- State Key Laboratory of Biotherapy, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Liangxue Zhou
- Department of Neurosurgery, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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72
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Farhadian S, Glick LR, Vogels CBF, Thomas J, Chiarella J, Casanovas-Massana A, Zhou J, Odio C, Vijayakumar P, Geng B, Fournier J, Bermejo S, Fauver JR, Alpert T, Wyllie AL, Turcotte C, Steinle M, Paczkowski P, Dela Cruz C, Wilen C, Ko AI, MacKay S, Grubaugh ND, Spudich S, Barakat LA. Acute encephalopathy with elevated CSF inflammatory markers as the initial presentation of COVID-19. BMC Neurol 2020; 20:248. [PMID: 32552792 PMCID: PMC7301053 DOI: 10.1186/s12883-020-01812-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/01/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND COVID-19 is caused by the severe acute respiratory syndrome virus SARS-CoV-2. It is widely recognized as a respiratory pathogen, but neurologic complications can be the presenting manifestation in a subset of infected patients. CASE PRESENTATION We describe a 78-year old immunocompromised woman who presented with altered mental status after witnessed seizure-like activity at home. She was found to have SARS-CoV-2 infection and associated neuroinflammation. In this case, we undertake the first detailed analysis of cerebrospinal fluid (CSF) cytokines during COVID-19 infection and find a unique pattern of inflammation in CSF, but no evidence of viral neuroinvasion. CONCLUSION Our findings suggest that neurologic symptoms such as encephalopathy and seizures may be the initial presentation of COVID-19. Central nervous system inflammation may associate with neurologic manifestations of disease.
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Affiliation(s)
- Shelli Farhadian
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA.
- Department of Neurology, Yale School of Medicine, New Haven, CT, 06510, USA.
| | - Laura R Glick
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Chantal B F Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Jared Thomas
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Jennifer Chiarella
- Department of Neurology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Arnau Casanovas-Massana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | | | - Camila Odio
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Pavithra Vijayakumar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Bertie Geng
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - John Fournier
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Santos Bermejo
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Joseph R Fauver
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Tara Alpert
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Anne L Wyllie
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | | | | | | | - Charles Dela Cruz
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Craig Wilen
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Albert I Ko
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | | | - Nathan D Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Lydia Aoun Barakat
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA
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73
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Cheng Q, Yang Y, Gao J. Infectivity of human coronavirus in the brain. EBioMedicine 2020; 56:102799. [PMID: 32474399 PMCID: PMC7255711 DOI: 10.1016/j.ebiom.2020.102799] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/18/2020] [Accepted: 04/29/2020] [Indexed: 01/08/2023] Open
Abstract
A new strain of human coronaviruses (hCoVs), Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has been identified to be responsible for the current outbreak of the coronavirus disease 2019 (COVID-19). Though major symptoms are primarily generated from the respiratory system, neurological symptoms are being reported in some of the confirmed cases, raising concerns of its potential for intracranial invasion and neurological manifestations, both in the acute phase and in the long-term. At present, it remains unclear the extent to which SARS-CoV-2 is present in the brain, and if so, its pathogenic role in the central nervous system (CNS). Evidence for neuroinvasion and neurovirulence of hCoVs has been recognised in animal and human studies. Given that SARS-CoV-2 belongs to the same family and shares characteristics in terms of receptor binding properties, it is worthwhile exploring its potential CNS manifestations. This review summarises previous findings from hCoVs in relation to the CNS, and compares these with the new strain, aiming to provide a better understanding of the effects of SARS-CoV-2 on the CNS.
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Affiliation(s)
- Qi Cheng
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia; Stroke and Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Yue Yang
- Brain and Mind Centre, Central Clinical School, the University of Sydney, Sydney, Australia
| | - Jianqun Gao
- Brain and Mind Centre, Central Clinical School, the University of Sydney, Sydney, Australia.
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74
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Ahmed MU, Hanif M, Ali MJ, Haider MA, Kherani D, Memon GM, Karim AH, Sattar A. Neurological Manifestations of COVID-19 (SARS-CoV-2): A Review. Front Neurol 2020; 11:518. [PMID: 32574248 PMCID: PMC7257377 DOI: 10.3389/fneur.2020.00518] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/11/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been associated with many neurological symptoms but there is a little evidence-based published material on the neurological manifestations of COVID-19. The purpose of this article is to review the spectrum of the various neurological manifestations and underlying associated pathophysiology in COVID-19 patients. Method: We conducted a review of the various case reports and retrospective clinical studies published on the neurological manifestations, associated literature, and related pathophysiology of COVID-19 using PUBMED and subsequent proceedings. A total of 118 articles were thoroughly reviewed in order to highlight the plausible spectrum of neurological manifestations of COVID 19. Every article was either based on descriptive analysis, clinical scenarios, correspondence, and editorials emphasizing the neurological manifestations either directly or indirectly. We then tried to highlight the significant plausible manifestations and complications that could be related to the pandemic. With little known about the dynamics and the presentation spectrum of the virus apart from the respiratory symptoms, this area needs further consideration. Conclusion: The neurological manifestations associated with COVID-19 such as Encephalitis, Meningitis, acute cerebrovascular disease, and Guillain Barré Syndrome (GBS) are of great concern. But in the presence of life-threatening abnormal vitals in severely ill COVID-19 patients, these are not usually underscored. There is a need to diagnose these manifestations at the earliest to limit long term sequelae. Much research is needed to explore the role of SARS-CoV-2 in causing these neurological manifestations by isolating it either from cerebrospinal fluid or brain tissues of the deceased on autopsy. We also recommend exploring the risk factors that lead to the development of these neurological manifestations.
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Affiliation(s)
- Muhammad Umer Ahmed
- Ziauddin University and Hospital, Ziauddin Medical College, Karachi, Pakistan
| | - Muhammad Hanif
- Khyber Medical College Peshawar, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Mukarram Jamat Ali
- Department of Internal Medicine, King Edward Medical University Lahore, Lahore, Pakistan
| | | | | | | | - Amin H Karim
- Houston Methodist Hospital, Houston, TX, United States.,Baylor College of Medicine, Houston, TX, United States
| | - Abdul Sattar
- Southside Hospital Northwell Health, New York, NY, United States
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75
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Neurological manifestations associated with COVID-19: a review and a call for action. J Neurol 2020; 267:1573-1576. [PMID: 32436101 PMCID: PMC7238392 DOI: 10.1007/s00415-020-09896-z] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 01/15/2023]
Abstract
While the epidemic of Coronavirus disease 2019 (COVID-19) continues to spread globally, more and more evidences are collected about the presence of neurological manifestations and symptoms associated with it. A systematic review has been performed of papers published until 5 April 2020. 29 papers related to neurological manifestations associated with COVID-19 were examined. The results show presence of central and peripheral nervous system manifestations related to coronavirus. Neurological manifestations, or NeuroCOVID, are part of the COVID-19 clinical picture, but questions remain regarding the frequency and severity of CNS symptoms, the mechanism of action underlying neurological symptoms, and the relationship of symptoms with the course and severity of COVID-19. Further clinical, epidemiological, and basic science research is urgently needed to understand and address neurological sequalae of COVID-19. Concomitant risk factors or determinants (e.g. demographic factors, comorbidities, or available biomarkers) that may predispose a person with COVID-19 to neurological manifestations also need to be identified. The review shows that although more and more papers are reporting neurological manifestations associated with COVID-19; however, many items remain unclear and this uncertainty calls for a global action that requires close coordination and open-data sharing between hospitals, academic institutions and the fast establishment of harmonised research priorities and research consortia to face the NeuroCOVID-19 complications.
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76
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Turtle L. Respiratory failure alone does not suggest central nervous system invasion by SARS-CoV-2. J Med Virol 2020; 92:705-706. [PMID: 32246782 DOI: 10.1002/jmv.25828] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/31/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Lance Turtle
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Tropical and Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
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77
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Matías-Guiu J, Gomez-Pinedo U, Montero-Escribano P, Gomez-Iglesias P, Porta-Etessam J, Matias-Guiu JA. Should we expect neurological symptoms in the SARS-CoV-2 epidemic? Neurologia 2020; 35:170-175. [PMID: 32299636 PMCID: PMC7136883 DOI: 10.1016/j.nrl.2020.03.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION There is growing evidence that SARS-CoV-2 can gain access to the central nervous system (CNS). We revise the literature on coronavirus infection of the CNS associated with neurological diseases. DEVELOPMENT Neurological symptoms were rarely reported in the SARS-CoV and MERS-CoV epidemics, although isolated cases were described. There are also reports of cases of neurological symptoms associated with CoV-OC43 and CoV-229E infection. The presence of neurological lesions, especially demyelinating lesions in the mouse hepatitis virus model, may explain the mechanisms by which coronaviruses enter the CNS, particularly those related with the immune response. This may explain the presence of coronavirus in patients with multiple sclerosis. We review the specific characteristics of SARS-CoV-2 and address the question of whether the high number of cases may be associated with greater CNS involvement. CONCLUSION Although neurological symptoms are not frequent in coronavirus epidemics, the high number of patients with SARS-CoV-2 infection may explain the presence of the virus in the CNS and increase the likelihood of early- or delayed-onset neurological symptoms. Follow-up of patients affected by the SARS-CoV-2 epidemic should include careful assessment of the CNS.
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Affiliation(s)
- J Matías-Guiu
- Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España.
| | - U Gomez-Pinedo
- Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - P Montero-Escribano
- Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - P Gomez-Iglesias
- Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - J Porta-Etessam
- Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
| | - J A Matias-Guiu
- Servicio de Neurología, Instituto de Neurociencias, Hospital Clínico San Carlos, San Carlos, IdISSC, Madrid, España
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Matías-Guiu J, Gomez-Pinedo U, Montero-Escribano P, Gomez-Iglesias P, Porta-Etessam J, Matias-Guiu J. Should we expect neurological symptoms in the SARS-CoV-2 epidemic? NEUROLOGÍA (ENGLISH EDITION) 2020. [PMCID: PMC7164915 DOI: 10.1016/j.nrleng.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction There is growing evidence that SARS-CoV-2 can gain access to the central nervous system (CNS). We revise the literature on coronavirus infection of the CNS associated with neurological diseases. Development Neurological symptoms were rarely reported in the SARS-CoV and MERS-CoV epidemics, although isolated cases were described. There are also reports of cases of neurological symptoms associated with CoV-OC43 and CoV-229E infection. The presence of neurological lesions, especially demyelinating lesions in the mouse hepatitis virus model, may explain the mechanisms by which coronaviruses enter the CNS, particularly those related with the immune response. This may explain the presence of coronavirus in patients with multiple sclerosis. We review the specific characteristics of SARS-CoV-2 and address the question of whether the high number of cases may be associated with greater CNS involvement. Conclusion Although neurological symptoms are not frequent in coronavirus epidemics, the high number of patients with SARS-CoV-2 infection may explain the presence of the virus in the CNS and increase the likelihood of early- or delayed-onset neurological symptoms. Follow-up of patients affected by the SARS-CoV-2 epidemic should include careful assessment of the CNS.
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79
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Wang LL, Swevers L, Van Meulebroek L, Meeus I, Vanhaecke L, Smagghe G. Metabolomic Analysis of Cricket paralysis virus Infection in Drosophila S2 Cells Reveals Divergent Effects on Central Carbon Metabolism as Compared with Silkworm Bm5 Cells. Viruses 2020; 12:v12040393. [PMID: 32244654 PMCID: PMC7232303 DOI: 10.3390/v12040393] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/06/2020] [Accepted: 03/31/2020] [Indexed: 12/24/2022] Open
Abstract
High-throughput approaches have opened new opportunities for understanding biological processes such as persistent virus infections, which are widespread. However, the potential of persistent infections to develop towards pathogenesis remains to be investigated, particularly with respect to the role of host metabolism. To explore the interactions between cellular metabolism and persistent/pathogenic virus infection, we performed untargeted and targeted metabolomic analysis to examine the effects of Cricket paralysis virus (CrPV, Dicistroviridae) in persistently infected silkworm Bm5 cells and acutely infected Drosophila S2 cells. Our previous study (Viruses 2019, 11, 861) established that both glucose and glutamine levels significantly increased during the persistent period of CrPV infection of Bm5 cells, while they decreased steeply during the pathogenic stages. Strikingly, in this study, an almost opposite pattern in change of metabolites was observed during different stages of acute infection of S2 cells. More specifically, a significant decrease in amino acids and carbohydrates was observed prior to pathogenesis, while their abundance significantly increased again during pathogenesis. Our study illustrates the occurrence of diametrically opposite changes in central carbon mechanisms during CrPV infection of S2 and Bm5 cells that is possibly related to the type of infection (acute or persistent) that is triggered by the virus.
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Affiliation(s)
- Luo-Luo Wang
- Guangdong Provincial Key Laboratory of Insect Developmental Biology and Applied Technology, Institute of Insect Science and Technology, School of Life Sciences, South China Normal University, Guangzhou 510631, China;
- Department of Plants and Crops, Faculty of Bioscience Engineering, Ghent University, 9000 Ghent, Belgium;
| | - Luc Swevers
- Insect Molecular Genetics and Biotechnology, Institute of Biosciences and Applications, National Centre for Scientific Research “Demokritos”, 153 10 Athens, Greece;
| | - Lieven Van Meulebroek
- Laboratory of Chemical Analysis, Department of Veterinary Public Health and Food Safety, Ghent University, 9000 Ghent, Belgium; (L.V.M.); (L.V.)
| | - Ivan Meeus
- Department of Plants and Crops, Faculty of Bioscience Engineering, Ghent University, 9000 Ghent, Belgium;
| | - Lynn Vanhaecke
- Laboratory of Chemical Analysis, Department of Veterinary Public Health and Food Safety, Ghent University, 9000 Ghent, Belgium; (L.V.M.); (L.V.)
| | - Guy Smagghe
- Department of Plants and Crops, Faculty of Bioscience Engineering, Ghent University, 9000 Ghent, Belgium;
- Correspondence:
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81
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Li H, Xue Q, Xu X. Involvement of the Nervous System in SARS-CoV-2 Infection. Neurotox Res 2020; 38:1-7. [PMID: 32399719 PMCID: PMC7220627 DOI: 10.1007/s12640-020-00219-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 02/07/2023]
Abstract
As a severe and highly contagious infectious disease, coronavirus disease 2019 (COVID-19) has caused a global pandemic. Several case reports have demonstrated that the respiratory system is the main target in patients with COVID-19, but the disease is not limited to the respiratory system. Case analysis indicated that the nervous system can be invaded by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and that 36.4% of COVID-19 patients had neurological symptoms. Importantly, the involvement of the CNS may be associated with poor prognosis and disease worsening. Here, we discussed the symptoms and evidence of nervous system involvement (directly and indirectly) caused by SARS-CoV-2 infection and possible mechanisms. CNS symptoms could be a potential indicator of poor prognosis; therefore, the prevention and treatment of CNS symptoms are also crucial for the recovery of COVID-19 patients.
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Affiliation(s)
- Hao Li
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China
| | - Qun Xue
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China.
| | - Xingshun Xu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, 215004, Jiangsu, China.
- Institute of Neuroscience, Soochow University, Suzhou, 215123, Jiangsu, China.
- Jiangsu Key Laboratory of Neuropsychiatric Diseases, Soochow University, Suzhou, 215123, Jiangsu, China.
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82
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Human Coronaviruses and Other Respiratory Viruses: Underestimated Opportunistic Pathogens of the Central Nervous System? Viruses 2019; 12:v12010014. [PMID: 31861926 PMCID: PMC7020001 DOI: 10.3390/v12010014] [Citation(s) in RCA: 650] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 11/16/2022] Open
Abstract
Respiratory viruses infect the human upper respiratory tract, mostly causing mild diseases. However, in vulnerable populations, such as newborns, infants, the elderly and immune-compromised individuals, these opportunistic pathogens can also affect the lower respiratory tract, causing a more severe disease (e.g., pneumonia). Respiratory viruses can also exacerbate asthma and lead to various types of respiratory distress syndromes. Furthermore, as they can adapt fast and cross the species barrier, some of these pathogens, like influenza A and SARS-CoV, have occasionally caused epidemics or pandemics, and were associated with more serious clinical diseases and even mortality. For a few decades now, data reported in the scientific literature has also demonstrated that several respiratory viruses have neuroinvasive capacities, since they can spread from the respiratory tract to the central nervous system (CNS). Viruses infecting human CNS cells could then cause different types of encephalopathy, including encephalitis, and long-term neurological diseases. Like other well-recognized neuroinvasive human viruses, respiratory viruses may damage the CNS as a result of misdirected host immune responses that could be associated with autoimmunity in susceptible individuals (virus-induced neuro-immunopathology) and/or viral replication, which directly causes damage to CNS cells (virus-induced neuropathology). The etiological agent of several neurological disorders remains unidentified. Opportunistic human respiratory pathogens could be associated with the triggering or the exacerbation of these disorders whose etiology remains poorly understood. Herein, we present a global portrait of some of the most prevalent or emerging human respiratory viruses that have been associated with possible pathogenic processes in CNS infection, with a special emphasis on human coronaviruses.
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The S2 Subunit of QX-type Infectious Bronchitis Coronavirus Spike Protein Is an Essential Determinant of Neurotropism. Viruses 2019; 11:v11100972. [PMID: 31652591 PMCID: PMC6832359 DOI: 10.3390/v11100972] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 01/23/2023] Open
Abstract
Some coronaviruses (CoVs) have an extra furin cleavage site (RRKR/S, furin-S2′ site) upstream of the fusion peptide in the spike protein, which plays roles in virion adsorption and fusion. Mutation of the S2′ site of QX genotype (QX-type) infectious bronchitis virus (IBV) spike protein (S) in a recombinant virus background results in higher pathogenicity, pronounced neural symptoms and neurotropism when compared with conditions in wild-type IBV (WT-IBV) infected chickens. In this study, we present evidence suggesting that recombinant IBV with a mutant S2′ site (furin-S2′ site) leads to higher mortality. Infection with mutant IBV induces severe encephalitis and breaks the blood–brain barrier. The results of a neutralization test and immunoprotection experiment show that an original serum and vaccine can still provide effective protection in vivo and in vitro. This is the first demonstration of IBV-induced neural symptoms in chickens with encephalitis and the furin-S2′ site as a determinant of neurotropism.
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84
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Double-stranded viral RNA persists in vitro and in vivo during prolonged infection of porcine reproductive and respiratory syndrome virus. Virology 2018; 524:78-89. [DOI: 10.1016/j.virol.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 12/31/2022]
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85
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Dello Russo C, Cappoli N, Coletta I, Mezzogori D, Paciello F, Pozzoli G, Navarra P, Battaglia A. The human microglial HMC3 cell line: where do we stand? A systematic literature review. J Neuroinflammation 2018; 15:259. [PMID: 30200996 PMCID: PMC6131758 DOI: 10.1186/s12974-018-1288-0] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/21/2018] [Indexed: 02/08/2023] Open
Abstract
Microglia, unique myeloid cells residing in the brain parenchyma, represent the first line of immune defense within the central nervous system. In addition to their immune functions, microglial cells play an important role in other cerebral processes, including the regulation of synaptic architecture and neurogenesis. Chronic microglial activation is regarded as detrimental, and it is considered a pathogenic mechanism common to several neurological disorders. Microglial activation and function have been extensively studied in rodent experimental models, whereas the characterization of human cells has been limited due to the restricted availability of primary sources of human microglia. To overcome this problem, human immortalized microglial cell lines have been developed. The human microglial clone 3 cell line, HMC3, was established in 1995, through SV40-dependent immortalization of human embryonic microglial cells. It has been recently authenticated by the American Type Culture Collection (ATCC®) and distributed under the name of HMC3 (ATCC®CRL-3304). The HMC3 cells have been used in six research studies, two of which also indicated by ATCC® as reference articles. However, a more accurate literature revision suggests that clone 3 was initially distributed under the name of CHME3. In this regard, several studies have been published, thus contributing to a more extensive characterization of this cell line. Remarkably, the same cell line has been used in different laboratories with other denominations, i.e., CHME-5 cells and C13-NJ cells. In view of the fact that "being now authenticated by ATCC®" may imply a wider distribution of the cells, we aimed at reviewing data obtained with the human microglia cell line clone 3, making the readers aware of this complicated nomenclature. In addition, we also included original data, generated in our laboratory with the HMC3 (ATCC®CRL-3304) cells, providing information on the current state of the culture together with supplementary details on the culturing procedures to obtain and maintain viable cells.
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Affiliation(s)
- Cinzia Dello Russo
- Institute of Pharmacology, Università Cattolica del S. Cuore, L.go F Vito 1, 00168, Rome, Italy. .,Pharmacology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Natalia Cappoli
- Institute of Pharmacology, Università Cattolica del S. Cuore, L.go F Vito 1, 00168, Rome, Italy
| | - Isabella Coletta
- Angelini RR&D (Research, Regulatory & Development) - Angelini S.p.A., Rome, Italy
| | - Daniele Mezzogori
- Institute of Human Physiology, Università Cattolica del S. Cuore, Rome, Italy
| | - Fabiola Paciello
- Institute of Otolaryngology, Università Cattolica del S. Cuore, Rome, Italy
| | - Giacomo Pozzoli
- Institute of Pharmacology, Università Cattolica del S. Cuore, L.go F Vito 1, 00168, Rome, Italy.,Pharmacology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierluigi Navarra
- Institute of Pharmacology, Università Cattolica del S. Cuore, L.go F Vito 1, 00168, Rome, Italy.,Pharmacology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandra Battaglia
- Immunology Laboratory, Department of Oncological Gynecology, Università Cattolica del S. Cuore, Rome, Italy
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Axonal Transport Enables Neuron-to-Neuron Propagation of Human Coronavirus OC43. J Virol 2018; 92:JVI.00404-18. [PMID: 29925652 DOI: 10.1128/jvi.00404-18] [Citation(s) in RCA: 305] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/08/2018] [Indexed: 02/08/2023] Open
Abstract
Human coronaviruses (HCoVs) are recognized respiratory pathogens for which accumulating evidence indicates that in vulnerable patients the infection can cause more severe pathologies. HCoVs are not always confined to the upper respiratory tract and can invade the central nervous system (CNS) under still unclear circumstances. HCoV-induced neuropathologies in humans are difficult to diagnose early enough to allow therapeutic interventions. Making use of our already described animal model of HCoV neuropathogenesis, we describe the route of neuropropagation from the nasal cavity to the olfactory bulb and piriform cortex and then the brain stem. We identified neuron-to-neuron propagation as one underlying mode of virus spreading in cell culture. Our data demonstrate that both passive diffusion of released viral particles and axonal transport are valid propagation strategies used by the virus. We describe for the first time the presence along axons of viral platforms whose static dynamism is reminiscent of viral assembly sites. We further reveal that HCoV OC43 modes of propagation can be modulated by selected HCoV OC43 proteins and axonal transport. Our work, therefore, identifies processes that may govern the severity and nature of HCoV OC43 neuropathogenesis and will make possible the development of therapeutic strategies to prevent occurrences.IMPORTANCE Coronaviruses may invade the CNS, disseminate, and participate in the induction of neurological diseases. Their neuropathogenicity is being increasingly recognized in humans, and the presence and persistence of human coronaviruses (HCoV) in human brains have been proposed to cause long-term sequelae. Using our mouse model relying on natural susceptibility to HCoV OC43 and neuronal cell cultures, we have defined the most relevant path taken by HCoV OC43 to access and spread to and within the CNS toward the brain stem and spinal cord and studied in cell culture the underlying modes of intercellular propagation to better understand its neuropathogenesis. Our data suggest that axonal transport governs HCoV OC43 egress in the CNS, leading to the exacerbation of neuropathogenesis. Exploiting knowledge on neuroinvasion and dissemination will enhance our ability to control viral infection within the CNS, as it will shed light on underlying mechanisms of neuropathogenesis and uncover potential druggable molecular virus-host interfaces.
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87
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Beidas M, Chehadeh W. PCR array profiling of antiviral genes in human embryonic kidney cells expressing human coronavirus OC43 structural and accessory proteins. Arch Virol 2018; 163:2065-2072. [PMID: 29619598 PMCID: PMC7086905 DOI: 10.1007/s00705-018-3832-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/22/2018] [Indexed: 10/26/2022]
Abstract
Human coronavirus OC43 (HCoV-OC43) is a respiratory virus that usually causes a common cold. However, it has the potential to cause severe infection in young children and immunocompromised adults. Both SARS-CoV and MERS-CoV were shown to express proteins with the potential to evade early innate immune responses. However, the ability of HCoV-OC43 to antagonise the intracellular antiviral defences has not yet been investigated. The potential role of the HCoV-OC43 structural (M and N) and accessory proteins (ns2a and ns5a) in the alteration of antiviral gene expression was investigated in this study. HCoV-OC43M, N, ns2a and ns5a proteins were expressed in human embryonic kidney 293 (HEK-293) cells before challenge with Sendai virus. The Human Antiviral Response PCR array was used to profile the antiviral gene expression in HEK-293 cells. Over 30 genes were downregulated in the presence of one of the HCoV-OC43 proteins, e.g. genes representing mitogen-activated protein kinases, toll-like receptors, interferons, interleukins, and signaling transduction proteins. Our findings suggest that similarly to SARS-CoV and MERS-CoV, HCoV-OC43 has the ability to downregulate the transcription of genes critical for the activation of different antiviral signaling pathways. Further studies are needed to confirm the role of HCoV-OC43 structural and accessory proteins in antagonising antiviral gene expression.
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Affiliation(s)
- Meshal Beidas
- Department of Microbiology, Faculty of Medicine, Kuwait University, PO Box 24923, 13310, Safat, Kuwait
| | - Wassim Chehadeh
- Department of Microbiology, Faculty of Medicine, Kuwait University, PO Box 24923, 13310, Safat, Kuwait.
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88
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Abstract
The four endemic human coronaviruses HCoV-229E, -NL63, -OC43, and -HKU1 contribute a considerable share of upper and lower respiratory tract infections in adults and children. While their clinical representation resembles that of many other agents of the common cold, their evolutionary histories, and host associations could provide important insights into the natural history of past human pandemics. For two of these viruses, we have strong evidence suggesting an origin in major livestock species while primordial associations for all four viruses may have existed with bats and rodents. HCoV-NL63 and -229E may originate from bat reservoirs as assumed for many other coronaviruses, but HCoV-OC43 and -HKU1 seem more likely to have speciated from rodent-associated viruses. HCoV-OC43 is thought to have emerged from ancestors in domestic animals such as cattle or swine. The bovine coronavirus has been suggested to be a possible ancestor, from which HCoV-OC43 may have emerged in the context of a pandemic recorded historically at the end of the 19th century. New data suggest that HCoV-229E may actually be transferred from dromedary camels similar to Middle East respiratory syndrome (MERS) coronavirus. This scenario provides important ecological parallels to the present prepandemic pattern of host associations of the MERS coronavirus.
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Affiliation(s)
- Victor M Corman
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, Berlin, Germany; German Center for Infection Research (DZIF), Berlin, Germany
| | - Doreen Muth
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, Berlin, Germany; German Center for Infection Research (DZIF), Berlin, Germany
| | - Daniela Niemeyer
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, Berlin, Germany
| | - Christian Drosten
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Virology, Berlin, Germany; German Center for Infection Research (DZIF), Berlin, Germany.
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Morfopoulou S, Brown JR, Davies EG, Anderson G, Virasami A, Qasim W, Chong WK, Hubank M, Plagnol V, Desforges M, Jacques TS, Talbot PJ, Breuer J. Human Coronavirus OC43 Associated with Fatal Encephalitis. N Engl J Med 2016; 375:497-8. [PMID: 27518687 DOI: 10.1056/nejmc1509458] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Julianne R Brown
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - E Graham Davies
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Glenn Anderson
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alex Virasami
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Waseem Qasim
- University College London, London, United Kingdom
| | - Wui K Chong
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Le Coupanec A, Desforges M, Meessen-Pinard M, Dubé M, Day R, Seidah NG, Talbot PJ. Cleavage of a Neuroinvasive Human Respiratory Virus Spike Glycoprotein by Proprotein Convertases Modulates Neurovirulence and Virus Spread within the Central Nervous System. PLoS Pathog 2015; 11:e1005261. [PMID: 26545254 PMCID: PMC4636366 DOI: 10.1371/journal.ppat.1005261] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/16/2015] [Indexed: 11/24/2022] Open
Abstract
Human coronaviruses (HCoV) are respiratory pathogens that may be associated with the development of neurological diseases, in view of their neuroinvasive and neurotropic properties. The viral spike (S) glycoprotein is a major virulence factor for several coronavirus species, including the OC43 strain of HCoV (HCoV-OC43). In an attempt to study the role of this protein in virus spread within the central nervous system (CNS) and neurovirulence, as well as to identify amino acid residues important for such functions, we compared the sequence of the S gene found in the laboratory reference strain HCoV-OC43 ATCC VR-759 to S sequences of viruses detected in clinical isolates from the human respiratory tract. We identified one predominant mutation at amino acid 758 (from RRSR↓ G758 to RRSR↓R758), which introduces a putative furin-like cleavage (↓) site. Using a molecular cDNA infectious clone to generate a corresponding recombinant virus, we show for the first time that such point mutation in the HCoV-OC43 S glycoprotein creates a functional cleavage site between the S1 and S2 portions of the S protein. While the corresponding recombinant virus retained its neuroinvasive properties, this mutation led to decreased neurovirulence while potentially modifying the mode of virus spread, likely leading to a limited dissemination within the CNS. Taken together, these results are consistent with the adaptation of HCoV-OC43 to the CNS environment, resulting from the selection of quasi-species harboring mutations that lead to amino acid changes in viral genes, like the S gene in HCoV-OC43, which may contribute to a more efficient establishment of a less pathogenic but persistent CNS infection. This adaptative mechanism could potentially be associated with human encephalitis or other neurological degenerative pathologies. Human coronaviruses (HCoV) are respiratory pathogens involved in a sizable proportion of common colds. They have over the years been associated with the development of neurological diseases, given their demonstrated neuroinvasive and neurotropic properties. The viral spike (S) glycoprotein appears to be associated with these neurologic features and is a major factor of virulence for several coronavirus species, including HCoV-OC43. To further characterize the role of this protein in neurovirulence and virus spread within the CNS, we sought to identify amino acid residues that may be important for this function. Our data revealed that one of them, G758R, introduces a functional furin-like cleavage site in the S protein (RRSR↓R758). This change in S protein mostly impacts neurovirulence, which seems associated with a modified viral dissemination, without significantly affecting its neuroinvasive capacity. This mutation, found in all characterized contemporary human clinical respiratory isolates, underlines previous findings that naturally existing field isolates of HCoV-OC43 variants still possess the capacity to invade the CNS where they could eventually adapt and establish a persistent human CNS infection, a mechanism potentially associated with human encephalitis or neurodegenerative pathologies of unknown etiologies.
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Affiliation(s)
- Alain Le Coupanec
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Université du Québec, Laval, Québec, Canada
| | - Marc Desforges
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Université du Québec, Laval, Québec, Canada
- * E-mail: (MDe); (PJT)
| | - Mathieu Meessen-Pinard
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Université du Québec, Laval, Québec, Canada
| | - Mathieu Dubé
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Université du Québec, Laval, Québec, Canada
| | - Robert Day
- Institut de Pharmacologie de Sherbrooke, Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Nabil G. Seidah
- Laboratory of Biochemical Neuroendocrinology, Clinical Research Institute of Montreal, Montréal, Québec, Canada
| | - Pierre J. Talbot
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Université du Québec, Laval, Québec, Canada
- * E-mail: (MDe); (PJT)
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The ns12.9 Accessory Protein of Human Coronavirus OC43 Is a Viroporin Involved in Virion Morphogenesis and Pathogenesis. J Virol 2015; 89:11383-95. [PMID: 26339053 DOI: 10.1128/jvi.01986-15] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/31/2015] [Indexed: 12/20/2022] Open
Abstract
UNLABELLED An accessory gene between the S and E gene loci is contained in all coronaviruses (CoVs), and its function has been studied in some coronaviruses. This gene locus in human coronavirus OC43 (HCoV-OC43) encodes the ns12.9 accessory protein; however, its function during viral infection remains unknown. Here, we engineered a recombinant mutant virus lacking the ns12.9 protein (HCoV-OC43-Δns12.9) to characterize the contributions of ns12.9 in HCoV-OC43 replication. The ns12.9 accessory protein is a transmembrane protein and forms ion channels in both Xenopus oocytes and yeast through homo-oligomerization, suggesting that ns12.9 is a newly recognized viroporin. HCoV-OC43-Δns12.9 presented at least 10-fold reduction of viral titer in vitro and in vivo. Intriguingly, exogenous ns12.9 and heterologous viroporins with ion channel activity could compensate for the production of HCoV-OC43-Δns12.9, indicating that the ion channel activity of ns12.9 plays a significant role in the production of infectious virions. Systematic dissection of single-cycle replication revealed that ns12.9 protein had no measurable effect on virus entry, subgenomic mRNA (sgmRNA) synthesis, and protein expression. Further characterization revealed that HCoV-OC43-Δns12.9 was less efficient in virion morphogenesis than recombinant wild-type virus (HCoV-OC43-WT). Moreover, reduced viral replication, inflammatory response, and virulence in HCoV-OC43-Δns12.9-infected mice were observed compared to the levels for HCoV-OC43-WT-infected mice. Taken together, our results demonstrated that the ns12.9 accessory protein functions as a viroporin and is involved in virion morphogenesis and the pathogenesis of HCoV-OC43 infection. IMPORTANCE HCoV-OC43 was isolated in the 1960s and is a major agent of the common cold. The functions of HCoV-OC43 structural proteins have been well studied, but few studies have focused on its accessory proteins. In the present study, we demonstrated that the ns12.9 protein is a newly recognized viroporin, and the ns12.9 gene knockout virus (HCoV-OC43-Δns12.9) presents a growth defect in vitro and in vivo. We identified the important functions of the ns12.9 viroporin in virion morphogenesis during HCoV-OC43 infection. Furthermore, mice infected with HCoV-OC43-Δns12.9 exhibited reduced inflammation and virulence accompanied by a lower titer in the brain than that of wild-type-infected mice, suggesting the ns12.9 viroporin influences virus pathogenesis. Therefore, our findings revealed that the ns12.9 viroporin facilitates virion morphogenesis to enhance viral production, and these results provided a deeper understanding of HCoV-OC43 pathogenesis.
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92
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Arabi YM, Harthi A, Hussein J, Bouchama A, Johani S, Hajeer AH, Saeed BT, Wahbi A, Saedy A, AlDabbagh T, Okaili R, Sadat M, Balkhy H. Severe neurologic syndrome associated with Middle East respiratory syndrome corona virus (MERS-CoV). Infection 2015; 43:495-501. [PMID: 25600929 PMCID: PMC4521086 DOI: 10.1007/s15010-015-0720-y] [Citation(s) in RCA: 299] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 01/04/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since the identification of the first case of infection with the Middle East respiratory syndrome corona virus (MERS-CoV) in Saudi Arabia in June 2012, the number of laboratory-confirmed cases has exceeded 941 cases globally, of which 347 died. The disease presents as severe respiratory infection often with shock, acute kidney injury, and coagulopathy. Recently, we observed three cases who presented with neurologic symptoms. These are so far the first reported cases of neurologic injury associated with MERS-CoV infection. METHODS Data was retrospectively collected from three patients admitted with MERS-CoV infection to Intensive Care unit (ICU) at King Abdulaziz Medical City, Riyadh. They were managed separately in three different wards prior to their admission to ICU. FINDING The three patients presented with severe neurologic syndrome which included altered level of consciousness ranging from confusion to coma, ataxia, and focal motor deficit. Brain MRI revealed striking changes characterized by widespread, bilateral hyperintense lesions on T2-weighted imaging within the white matter and subcortical areas of the frontal, temporal, and parietal lobes, the basal ganglia, and corpus callosum. None of the lesions showed gadolinium enhancement. INTERPRETATION CNS involvement should be considered in patients with MERS-CoV and progressive neurological disease, and further elucidation of the pathophysiology of this virus is needed.
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Affiliation(s)
- Y. M. Arabi
- Intensive Care Department, MC-1425, Respiratory Services, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center (KAIMRC), P.O. Box 22490, Riyadh, 11426 Kingdom of Saudi Arabia
| | - A. Harthi
- Neuro Physiology Services, Neurology Division, Department of Medicine, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - J. Hussein
- Neuro Radiology Section, Medical Imaging Department, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - A. Bouchama
- Intensive Care Unit, Experimental Medicine Department, King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - S. Johani
- Microbiology, Pathology and Laboratory Medicine, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - A. H. Hajeer
- Basic Medical Sciences, Microbiology, Pathology and Laboratory Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - B. T. Saeed
- Cardiac Sciences Department, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - A. Wahbi
- Vascular Surgery, Department of Surgery, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - A. Saedy
- Infectious Disease Section, Department of Medicine, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - T. AlDabbagh
- Intensive Care Unit, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - R. Okaili
- Neuro Radiology, Nuero Interventionalist, Medical Imaging Department, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - M. Sadat
- Intensive Care Unit, King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
| | - H. Balkhy
- Infection Prevention and Control Program, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center (KAIMRC), King Abdulaziz Medical City, Riyadh, 11426 Saudi Arabia
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93
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Yang D, Leibowitz JL. The structure and functions of coronavirus genomic 3' and 5' ends. Virus Res 2015; 206:120-33. [PMID: 25736566 PMCID: PMC4476908 DOI: 10.1016/j.virusres.2015.02.025] [Citation(s) in RCA: 277] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 02/22/2015] [Accepted: 02/23/2015] [Indexed: 01/19/2023]
Abstract
Coronaviruses (CoVs) are an important cause of illness in humans and animals. Most human coronaviruses commonly cause relatively mild respiratory illnesses; however two zoonotic coronaviruses, SARS-CoV and MERS-CoV, can cause severe illness and death. Investigations over the past 35 years have illuminated many aspects of coronavirus replication. The focus of this review is the functional analysis of conserved RNA secondary structures in the 5' and 3' of the betacoronavirus genomes. The 5' 350 nucleotides folds into a set of RNA secondary structures which are well conserved, and reverse genetic studies indicate that these structures play an important role in the discontinuous synthesis of subgenomic RNAs in the betacoronaviruses. These cis-acting elements extend 3' of the 5'UTR into ORF1a. The 3'UTR is similarly conserved and contains all of the cis-acting sequences necessary for viral replication. Two competing conformations near the 5' end of the 3'UTR have been shown to make up a potential molecular switch. There is some evidence that an association between the 3' and 5'UTRs is necessary for subgenomic RNA synthesis, but the basis for this association is not yet clear. A number of host RNA proteins have been shown to bind to the 5' and 3' cis-acting regions, but the significance of these in viral replication is not clear. Two viral proteins have been identified as binding to the 5' cis-acting region, nsp1 and N protein. A genetic interaction between nsp8 and nsp9 and the region of the 3'UTR that contains the putative molecular switch suggests that these two proteins bind to this region.
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Affiliation(s)
- Dong Yang
- Department of Microbiology, Immunology & Biochemistry, The University of Tennessee Health Science Center College of Medicine, Memphis, TN 38163, USA
| | - Julian L Leibowitz
- Department of Microbial Pathogenesis and Immunology, Texas A&M University, College of Medicine, College Station, TX 77843-1114, USA.
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94
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Desforges M, Le Coupanec A, Stodola JK, Meessen-Pinard M, Talbot PJ. Human coronaviruses: viral and cellular factors involved in neuroinvasiveness and neuropathogenesis. Virus Res 2014; 194:145-58. [PMID: 25281913 PMCID: PMC7114389 DOI: 10.1016/j.virusres.2014.09.011] [Citation(s) in RCA: 236] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/22/2014] [Accepted: 09/24/2014] [Indexed: 12/15/2022]
Abstract
Human coronavirus (HCoV) are naturally neuroinvasive in both mice and humans. Both transneuronal and hematogenous route may allow virus invasion of the CNS. Infection of neurons leads to excitotoxicity, neurodegeneration and cell-death. HCoV are potentially associated with human neurological disorders.
Among the various respiratory viruses infecting human beings, coronaviruses are important pathogens, which usually infect the upper respiratory tract, where they are mainly associated with common colds. However, in more vulnerable populations, such as newborns, infants, the elderly and immune-compromised individuals, these opportunistic pathogens can also affect the lower respiratory tract, leading to pneumonia, exacerbations of asthma, and various types of respiratory distress syndrome. The respiratory involvement of human coronaviruses has been clearly established since the 1960s. Nevertheless, for almost three decades now, data reported in the scientific literature has also demonstrated that, like it was described for other human viruses, coronaviruses have neuroinvasive capacities since they can spread from the respiratory tract to the central nervous system (CNS). Once there, infection of CNS cells (neurotropism) could lead to human health problems, such as encephalitis and long-term neurological diseases. Neuroinvasive coronaviruses could damage the CNS as a result of misdirected host immune responses that could be associated with autoimmunity in susceptible individuals (virus-induced neuroimmunopathology) and/or viral replication, which directly induces damage to CNS cells (virus-induced neuropathology). Given all these properties, it has been suggested that these opportunistic human respiratory pathogens could be associated with the triggering or the exacerbation of neurologic diseases for which the etiology remains poorly understood. Herein, we present host and viral factors that participate in the regulation of the possible pathogenic processes associated with CNS infection by human coronaviruses and we try to decipher the intricate interplay between virus and host target cells in order to characterize their role in the virus life cycle as well as in the capacity of the cell to respond to viral invasion.
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Affiliation(s)
- Marc Desforges
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Institut national de la recherche scientifique, Université du Québec, 531 boulevard des Prairies, Laval, Québec, Canada H7V 1B7.
| | - Alain Le Coupanec
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Institut national de la recherche scientifique, Université du Québec, 531 boulevard des Prairies, Laval, Québec, Canada H7V 1B7
| | - Jenny K Stodola
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Institut national de la recherche scientifique, Université du Québec, 531 boulevard des Prairies, Laval, Québec, Canada H7V 1B7
| | - Mathieu Meessen-Pinard
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Institut national de la recherche scientifique, Université du Québec, 531 boulevard des Prairies, Laval, Québec, Canada H7V 1B7
| | - Pierre J Talbot
- Laboratory of Neuroimmunovirology, INRS-Institut Armand-Frappier, Institut national de la recherche scientifique, Université du Québec, 531 boulevard des Prairies, Laval, Québec, Canada H7V 1B7.
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95
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Adhikari R, Thapa S. Neuroinvasive and neurotropic human respiratory coronaviruses: potential neurovirulent agents in humans. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 807:75-96. [PMID: 24619619 PMCID: PMC7121612 DOI: 10.1007/978-81-322-1777-0_6] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In humans, viral infections of the respiratory tract are a leading cause of morbidity and mortality worldwide. Several recognized respiratory viral agents have a neuroinvasive capacity since they can spread from the respiratory tract to the central nervous system (CNS). Once there, infection of CNS cells (neurotropism) could lead to human health problems, such as encephalitis and long-term neurological diseases. Among the various respiratory viruses, coronaviruses are important pathogens of humans and animals. Human Coronaviruses (HCoV) usually infect the upper respiratory tract, where they are mainly associated with common colds. However, in more vulnerable populations, such as newborns, infants, the elderly, and immune-compromised individuals, they can also affect the lower respiratory tract, leading to pneumonia, exacerbations of asthma, respiratory distress syndrome, or even severe acute respiratory syndrome (SARS). The respiratory involvement of HCoV has been clearly established since the 1960s. In addition, for almost three decades now, the scientific literature has also demonstrated that HCoV are neuroinvasive and neurotropic and could induce an overactivation of the immune system, in part by participating in the activation of autoreactive immune cells that could be associated with autoimmunity in susceptible individuals. Furthermore, it was shown that in the murine CNS, neurons are the main target of infection, which causes these essential cells to undergo degeneration and eventually die by some form of programmed cell death after virus infection. Moreover, it appears that the viral surface glycoprotein (S) represents an important factor in the neurodegenerative process. Given all these properties, it has been suggested that these recognized human respiratory pathogens could be associated with the triggering or the exacerbation of neurological diseases for which the etiology remains unknown or poorly understood.
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Affiliation(s)
| | - Santosh Thapa
- Department of Microbiology, Tribhuvan University, Kathmandu, Nepal
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96
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Dominguez SR, Shrivastava S, Berglund A, Qian Z, Góes LGB, Halpin RA, Fedorova N, Ransier A, Weston PA, Durigon EL, Jerez JA, Robinson CC, Town CD, Holmes KV. Isolation, propagation, genome analysis and epidemiology of HKU1 betacoronaviruses. J Gen Virol 2014; 95:836-848. [PMID: 24394697 DOI: 10.1099/vir.0.059832-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
From 1 January 2009 to 31 May 2013, 15 287 respiratory specimens submitted to the Clinical Virology Laboratory at the Children's Hospital Colorado were tested for human coronavirus RNA by reverse transcription-PCR. Human coronaviruses HKU1, OC43, 229E and NL63 co-circulated during each of the respiratory seasons but with significant year-to-year variability, and cumulatively accounted for 7.4-15.6 % of all samples tested during the months of peak activity. A total of 79 (0.5 % prevalence) specimens were positive for human betacoronavirus HKU1 RNA. Genotypes HKU1 A and B were both isolated from clinical specimens and propagated on primary human tracheal-bronchial epithelial cells cultured at the air-liquid interface and were neutralized in vitro by human intravenous immunoglobulin and by polyclonal rabbit antibodies to the spike glycoprotein of HKU1. Phylogenetic analysis of the deduced amino acid sequences of seven full-length genomes of Colorado HKU1 viruses and the spike glycoproteins from four additional HKU1 viruses from Colorado and three from Brazil demonstrated remarkable conservation of these sequences with genotypes circulating in Hong Kong and France. Within genotype A, all but one of the Colorado HKU1 sequences formed a unique subclade defined by three amino acid substitutions (W197F, F613Y and S752F) in the spike glycoprotein and exhibited a unique signature in the acidic tandem repeat in the N-terminal region of the nsp3 subdomain. Elucidating the function of and mechanisms responsible for the formation of these varying tandem repeats will increase our understanding of the replication process and pathogenicity of HKU1 and potentially of other coronaviruses.
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Affiliation(s)
- Samuel R Dominguez
- Departments of Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, 12800 E 19th Ave, Room P18-9403B, Aurora, CO 80045, USA.,Departments of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, 12800 E 19th Ave, Room P18-9403B, Aurora, CO 80045, USA
| | - Susmita Shrivastava
- Department of Pathology and Clinical Medicine, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Andrew Berglund
- Departments of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, 12800 E 19th Ave, Room P18-9403B, Aurora, CO 80045, USA
| | - Zhaohui Qian
- Departments of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, 12800 E 19th Ave, Room P18-9403B, Aurora, CO 80045, USA
| | - Luiz Gustavo Bentim Góes
- Interdisciplinary Graduate Program in Biotechnology, University of São Paulo, Av Prof. Lineu Prestes, 2415, ICB-III, Cidade Universitária, CEP: 05508-900, São Paulo, SP - Brazil.,J. Craig Venter Institute, 9704 Medical Center Drive, Rockville, MD 20850, USA
| | - Rebecca A Halpin
- Department of Pathology and Clinical Medicine, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Nadia Fedorova
- Department of Pathology and Clinical Medicine, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Amy Ransier
- Department of Pathology and Clinical Medicine, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Philip A Weston
- Departments of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, 12800 E 19th Ave, Room P18-9403B, Aurora, CO 80045, USA
| | - Edison Luiz Durigon
- Interdisciplinary Graduate Program in Biotechnology, University of São Paulo, Av Prof. Lineu Prestes, 2415, ICB-III, Cidade Universitária, CEP: 05508-900, São Paulo, SP - Brazil.,J. Craig Venter Institute, 9704 Medical Center Drive, Rockville, MD 20850, USA
| | - José Antonio Jerez
- Department of Microbiology, Institute of Biomedical Sciences, University of São Paulo, Av Prof. Lineu Prestes 1374, ICB-II, Cidade Universitária, CEP: 05580-900, São Paulo, SP - Brazil.,J. Craig Venter Institute, 9704 Medical Center Drive, Rockville, MD 20850, USA
| | - Christine C Robinson
- Department of Preventive Veterinary Medicine and Animal Health, Faculty of Veterinary Medicine and Animal Science, University of São Paulo, Av. Prof. Dr. Orlando Marques de Paiva, 87, Cidade Universitária, CEP: 05508-270, Sao Paulo, SP - Brazil
| | - Christopher D Town
- Department of Pathology and Clinical Medicine, Children's Hospital Colorado, 13123 E 16th Ave, Aurora, CO 80045, USA
| | - Kathryn V Holmes
- Departments of Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, 12800 E 19th Ave, Room P18-9403B, Aurora, CO 80045, USA
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97
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Novel treatment with neuroprotective and antiviral properties against a neuroinvasive human respiratory virus. J Virol 2013; 88:1548-63. [PMID: 24227863 DOI: 10.1128/jvi.02972-13] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Human coronaviruses (HCoVs) are recognized respiratory pathogens with neuroinvasive and neurotropic properties in mice and humans. HCoV strain OC43 (HCoV-OC43) can infect and persist in human neural cells and activate neuroinflammatory and neurodegenerative mechanisms, suggesting that it could be involved in neurological disease of unknown etiology in humans. Moreover, we have shown that HCoV-OC43 is neurovirulent in susceptible mice, causing encephalitis, and that a viral mutant with a single point mutation in the viral surface spike (S) protein induces a paralytic disease that involves glutamate excitotoxicity in susceptible mice. Herein, we show that glutamate recycling via the glial transporter 1 protein transporter and glutamine synthetase are central to the dysregulation of glutamate homeostasis and development of motor dysfunctions and paralytic disease in HCoV-OC43-infected mice. Moreover, memantine, an N-methyl-d-aspartate receptor antagonist widely used in the treatment of neurological diseases in humans, improved clinical scores related to paralytic disease and motor disabilities by partially restoring the physiological neurofilament phosphorylation state in virus-infected mice. Interestingly, memantine attenuated mortality rates and body weight loss and reduced HCoV-OC43 replication in the central nervous system in a dose-dependent manner. This novel action of memantine on viral replication strongly suggests that it could be used as an antiviral agent to directly limit viral replication while improving neurological symptoms in various neurological diseases with a viral involvement. Mutations in the surface spike (S) protein of human respiratory coronavirus OC43 appear after persistent infection of human cells of the central nervous system, a possible viral adaptation to this environment. Furthermore, a single amino acid change in the viral S protein modulated virus-induced neuropathology in mice from an encephalitis to a neuropathology characterized by flaccid paralysis, which involves glutamate excitotoxicity. We now show that memantine, a drug that is used for alleviating symptoms associated with neuropathology, such as Alzheimer's disease, can partially restore the physiological state of infected mice by limiting both neurodegeneration and viral replication. This suggests that memantine could be used as an antiviral agent while improving neurological symptoms in various neurological diseases with a viral involvement.
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98
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Lau SKP, Lau CCY, Chan KH, Li CPY, Chen H, Jin DY, Chan JFW, Woo PCY, Yuen KY. Delayed induction of proinflammatory cytokines and suppression of innate antiviral response by the novel Middle East respiratory syndrome coronavirus: implications for pathogenesis and treatment. J Gen Virol 2013; 94:2679-2690. [PMID: 24077366 DOI: 10.1099/vir.0.055533-0] [Citation(s) in RCA: 294] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The high mortality associated with the novel Middle East respiratory syndrome coronavirus (MERS-CoV) has raised questions about the possible role of a cytokine storm in its pathogenesis. Although recent studies showed that MERS-CoV infection is associated with an attenuated IFN response, no induction of inflammatory cytokines was demonstrated during the early phase of infection. To study both early and late cytokine responses associated with MERS-CoV infection, we measured the mRNA levels of eight cytokine genes [TNF-α, IL-1β, IL-6, IL-8, IFN-β, monocyte chemotactic protein-1, transforming growth factor-β and IFN-γ-induced protein (IP)-10] in cell lysates of polarized airway epithelial Calu-3 cells infected with MERS-CoV or severe acute respiratory syndrome (SARS)-CoV up to 30 h post-infection. Among the eight cytokine genes, IL-1β, IL-6 and IL-8 induced by MERS-CoV were markedly higher than those induced by SARS-CoV at 30 h, whilst TNF-α, IFN-β and IP-10 induced by SARS-CoV were markedly higher than those induced by MERS-CoV at 24 and 30 h in infected Calu-3 cells. The activation of IL-8 and attenuated IFN-β response by MERS-CoV were also confirmed by protein measurements in the culture supernatant when compared with SARS-CoV and Sendai virus. To further confirm the attenuated antiviral response, cytokine response was compared with human HCoV-229E in embryonal lung fibroblast HFL cells, which also revealed higher IFN-β and IP-10 levels induced by HCoV-229E than MERS-CoV at 24 and 30 h. Whilst our data supported recent findings that MERS-CoV elicits attenuated innate immunity, this represents the first report to demonstrate delayed proinflammatory cytokine induction by MERS-CoV. Our results provide insights into the pathogenesis and treatment of MERS-CoV infections.
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Affiliation(s)
- Susanna K P Lau
- Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China.,State Key Laboratory of Emerging Infectious Diseases, University of Hong Kong, Hong Kong, P.R. China.,Carol Yu Centre for Infection, University of Hong Kong, Hong Kong, P.R. China.,Research Centre of Infection and Immunology, University of Hong Kong, Hong Kong, P.R. China
| | - Candy C Y Lau
- Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China
| | - Kwok-Hung Chan
- Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China
| | - Clara P Y Li
- Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China
| | - Honglin Chen
- Research Centre of Infection and Immunology, University of Hong Kong, Hong Kong, P.R. China.,Carol Yu Centre for Infection, University of Hong Kong, Hong Kong, P.R. China.,State Key Laboratory of Emerging Infectious Diseases, University of Hong Kong, Hong Kong, P.R. China.,Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China
| | - Dong-Yan Jin
- Department of Biochemistry, University of Hong Kong, Hong Kong, P.R. China
| | - Jasper F W Chan
- Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China
| | - Patrick C Y Woo
- Carol Yu Centre for Infection, University of Hong Kong, Hong Kong, P.R. China.,Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China.,State Key Laboratory of Emerging Infectious Diseases, University of Hong Kong, Hong Kong, P.R. China.,Research Centre of Infection and Immunology, University of Hong Kong, Hong Kong, P.R. China
| | - Kwok-Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases, University of Hong Kong, Hong Kong, P.R. China.,Department of Microbiology, University of Hong Kong, Hong Kong, P.R. China.,Research Centre of Infection and Immunology, University of Hong Kong, Hong Kong, P.R. China.,Carol Yu Centre for Infection, University of Hong Kong, Hong Kong, P.R. China
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99
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Binding and repressive activities of apolipoprotein E3 and E4 isoforms on the human ApoD promoter. Mol Neurobiol 2013; 48:669-80. [PMID: 23715769 PMCID: PMC7090986 DOI: 10.1007/s12035-013-8456-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 04/09/2013] [Indexed: 11/04/2022]
Abstract
Apolipoprotein D (ApoD) gene expression is increased in several neurological disorders such as Alzheimer’s disease (AD) and multiple sclerosis. We previously showed that transgenic mice that overexpress human ApoD show a better resistance against paraquat or OC43 coronavirus-induced neurodegeneration. Here, we identified several nuclear factors from the cortex of control and OC43-infected mice which bind a fragment of the proximal ApoD promoter in vitro. Of interest, we detected apolipoprotein E (ApoE). Human ApoE consists of three isoforms (E2, E3, and E4) with the E4 and E2 alleles representing a greater and a lower risk for developping AD, respectively. Our results show that ApoE is located in the nucleus and on the ApoD promoter in human hepatic and glioblastoma cells lines. Furthermore, overexpression of ApoE3 and ApoE4 isoforms but not ApoE2 significantly inhibited the ApoD promoter activity in U87 cells (E3/E3 genotype) cultured under normal or different stress conditions while ApoE knock-down by siRNA had a converse effect. Consistent with these results, we also demonstrated by ChIP assay that E3 and E4 isoforms, but not E2, bind the ApoD promoter. Moreover, using the Allen Brain Atlas in situ hybridization database, we observed an inverse correlation between ApoD and ApoE mRNA expression during development and in several regions of the mouse brain, notably in the cortex, hippocampus, plexus choroid, and cerebellum. This negative correlation was also observed for cortex layers IV–VI based on a new Transcriptomic Atlas of the Mouse Neocortical Layers. These findings reveal a new function for ApoE by regulating ApoD gene expression.
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100
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Chan JFW, Chan KH, Choi GKY, To KKW, Tse H, Cai JP, Yeung ML, Cheng VCC, Chen H, Che XY, Lau SKP, Woo PCY, Yuen KY. Differential cell line susceptibility to the emerging novel human betacoronavirus 2c EMC/2012: implications for disease pathogenesis and clinical manifestation. J Infect Dis 2013; 207:1743-52. [PMID: 23532101 PMCID: PMC7107374 DOI: 10.1093/infdis/jit123] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The emerging novel human betacoronavirus 2c EMC/2012 (HCoV-EMC) was recently isolated from patients with severe pneumonia and renal failure and was associated with an unexplained high crude fatality rate of 56%. We performed a cell line susceptibility study with 28 cell lines. HCoV-EMC was found to infect the human respiratory tract (polarized airway epithelium cell line Calu-3, embryonic fibroblast cell line HFL, and lung adenocarcinoma cell line A549), kidney (embryonic kidney cell line HEK), intestinal tract (colorectal adenocarcinoma cell line Caco-2), liver cells (hepatocellular carcinoma cell line Huh-7), and histiocytes (malignant histiocytoma cell line His-1), as evident by detection of high or increasing viral load in culture supernatants, detection of viral nucleoprotein expression by immunostaining, and/or detection of cytopathic effects. Although an infected human neuronal cell line (NT2) and infected monocyte and T lymphocyte cell lines (THP-1, U937, and H9) had increased viral loads, their relatively lower viral production corroborated with absent nucleoprotein expression and cytopathic effects. This range of human tissue tropism is broader than that for all other HCoVs, including SARS coronavirus, HCoV-OC43, HCoV-HKU1, HCoV-229E, and HCoV-NL63, which may explain the high mortality associated with this disease. A recent cell line susceptibility study showed that HCoV-EMC can infect primate, porcine, and bat cells and therefore may jump interspecies barriers. We found that HCoV-EMC can also infect civet lung fibroblast and rabbit kidney cell lines. These findings have important implications for the diagnosis, pathogenesis, and transmission of HCoV-EMC.
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Affiliation(s)
- Jasper Fuk-Woo Chan
- Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Rd, Pokfulam, Hong Kong Special Administrative Region, China
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