Viral infections of the autonomic nervous system and its target organs: pathogenetic mechanisms

Investigating the possible mechanisms of autonomic dysfunction post-COVID-19

Patients with long COVID suffer from many neurological manifestations that persist for 3 months following infection by SARS-CoV-2. Autonomic dysfunction (AD) or dysautonomia is one complication of long COVID that causes patients to experience fatigue, dizziness, syncope, dyspnea, orthostatic intolerance, nausea, vomiting, and heart palpitations. The pathophysiology behind AD onset post-COVID is largely unknown. As such, this review aims to highlight the potential mechanisms by which AD occurs in patients with long COVID. The first proposed mechanism includes the direct invasion of the hypothalamus or the medulla by SARS-CoV-2. Entry to these autonomic centers may occur through the neuronal or hematogenous routes. However, evidence so far indicates that neurological manifestations such as AD are caused indirectly. Another mechanism is autoimmunity whereby autoantibodies against different receptors and glycoproteins expressed on cellular membranes are produced. Additionally, persistent inflammation and hypoxia can work separately or together to promote sympathetic overactivation in a bidirectional interaction. Renin-angiotensin system imbalance can also drive AD in long COVID through the downregulation of relevant receptors and formation of autoantibodies. Understanding the pathophysiology of AD post-COVID-19 may help provide early diagnosis and better therapy for patients.

Herpes Simplex Virus 2 in Autonomic Ganglia: Evidence for Spontaneous Reactivation

Herpes simplex virus 2 (HSV-2) can be transmitted in the presence or absence of lesions, allowing efficient spread among the general population. Recurrent HSV genital lesions are thought to arise from reactivated latent virus in sensory cell bodies of the dorsal root ganglia (DRG). However, HSV-2 has also been found latent in autonomic ganglia. Spontaneous reactivation or a low level of chronic infection could theoretically also occur in these peripheral nervous tissues, contributing to the presence of infectious virus in the periphery and to viral transmission. Use of a recently described, optimized virus with a monomeric mNeonGreen protein fused to viral capsid protein 26 (VP26) permitted detection of reactivating virus in explanted ganglia and cryosections of DRG and the sacral sympathetic ganglia (SSG) from latently infected guinea pigs. Immediate early, early, and late gene expression were quantified by droplet digital reverse transcription-PCR (ddRT-PCR), providing further evidence of viral reactivation not only in the expected DRG but also in the sympathetic SSG. These findings indicate that viral reactivation from autonomic ganglia is a feature of latent viral infection and that these reactivations likely contribute to viral pathogenesis.IMPORTANCE HSV-2 is a ubiquitous important human pathogen that causes recurrent infections for the life of its host. We hypothesized that the autonomic ganglia have important roles in viral reactivation, and this study sought to determine whether this is correct in the clinically relevant guinea pig vaginal infection model. Our findings indicate that sympathetic ganglia are sources of reactivating virus, helping explain how the virus causes lifelong recurrent disease.

Viral Spread to Enteric Neurons Links Genital HSV-1 Infection to Toxic Megacolon and Lethality

Herpes simplex virus 1 (HSV-1), a leading cause of genital herpes, infects oral or genital mucosal epithelial cells before infecting the peripheral sensory nervous system. The spread of HSV-1 beyond the sensory nervous system and the resulting broader spectrum of disease are not well understood. Using a mouse model of genital herpes, we found that HSV-1-infection-associated lethality correlated with severe fecal and urinary retention. No inflammation or infection of the brain was evident. Instead, HSV-1 spread via the dorsal root ganglia to the autonomic ganglia of the enteric nervous system (ENS) in the colon. ENS infection led to robust viral gene transcription, pathological inflammatory responses, and neutrophil-mediated destruction of enteric neurons, ultimately resulting in permanent loss of peristalsis and the development of toxic megacolon. Laxative treatment rescued mice from lethality following genital HSV-1 infection. These results reveal an unexpected pathogenesis of HSV associated with ENS infection.

Observations on recovery from and recurrence of HSV-2 infections in adult mice that were rescued from lethal vaginal infection by antiviral therapy

An adult mouse model for studies of latency and recurrence after vaginal HSV-2 infection is not available at present, largely because the infection kills most mice within 14 days. We describe here an antiviral therapy that rescues most vaginally infected mice from death. Vaginally infected mice were nearly all rescued by combined treatment with one dose of monoclonal anti-HSV glycoprotein D 3 days after infection plus valacyclovir in the drinking water on days 3, 4, 5, 7, 9, 11, 13, and 15 after infection. At 60 days after infection, PCR measurements revealed that most rescued mice had viral DNA in their lumbosacral dorsal root ganglia, lumbosacral spinal cords, and paracervical autonomic ganglia, consistent with the possibility that latent infections were established. At this time, immunolabeling revealed CD45+ lymphoid cells in these neural tissues in rescued mice but not in normal control mice. In vivo depletion of T lymphocytes with monoclonal antibodies caused a recurrence of herpes illness symptoms earlier and in a larger proportion of rescued mice than was observed in non-depleted rescued mice. Interestingly, many rescued mice (46/114) spontaneously developed a syndrome of typical herpes illness symptoms that began with ruffled fur on a mouse that previously had sleek fur and progressed to arched backs, feeble gait, hindlimb paralysis, and death or euthanasia, or in some cases to recovery to health. This high incidence of apparent spontaneous recurrence of HSV-2 infection in rescued mice suggests that it may be possible, with some refinement of the procedure, to obtain an effective adult mouse model for studies of therapeutic vaccination to inhibit or prevent HSV-2 recurrence after genital tract infection.

Intravaginal administration of herpes simplex virus type 2 to mice leads to infection of several neural and extraneural sites

Female mice have been used extensively to study mucosal immunity against herpes simplex virus type 2 (HSV-2) infection of the vagina, but comparatively little is known about the spread of this virus to other tissues. Here the authors have used immunolabeling to demonstrate that HSV-2 infected the vaginal epithelium; the epithelium covering the vulva, perineum, and anal canal; and perineal hair follicles and sebaceous glands. The kinetics and basal localization of the immunolabeling indicated that the virus spread horizontally within the epithelial layer, starting in the vagina and then proceeding to the distal epithelial sites. HSV-2 also spread from the vagina to multiple neuronal sites including the paracervical ganglia (PCG), which are the major autonomic ganglia of the pelvis. The authors demonstrated both sympathetic and parasympathetic neurons in the PCG by labeling of acetylcholinesterase and tryosine hydroxlyase, and noted that infection was limited mainly or entirely to parasympathetic neurons. Infection of the PCG was correlated with the presence of virus in the autonomic ganglia in the walls of the rectum and urinary bladder, which in turn correlated with distention of these organs and retention of urine and feces. HSV-2 infection was also detected in cell bodies and axons in the lumbosacral sympathetic chain, in lumbosacral dorsal root ganglia, and in the dorsal portions of the lumbar spinal cord. Collectively, the data show that vaginal HSV-2 infection in mice leads to subsequent infection of multiple neural and epithelial sites. This information should be useful for development of a mouse model that can be used to study HSV-2 latency and for development of therapeutic vaccines to prevent recurrent infections.

Is herpes simplex virus associated with peptic ulcer disease?

To test the hypothesis that herpes simplex virus type 1 (HSV-1) may be associated with peptic ulcer disease, we examined ulcerative lesions of the distal stomach and proximal duodenum for the presence of nucleic acids and antibodies specific for HSV-1. Utilizing in situ hybridization, immunocytochemistry, and polymerase chain reaction with sequencing, gastric or duodenal tissues from 4 of 22 patients (18%) with documented peptic ulcer disease demonstrated the presence of both specific HSV-1 nucleic acid sequences and proteins. HSV-1 was found restricted in clusters of cells near the margin of the ulcer but was absent at sites distal to the lesion. Several of such HSV-1-infected cells also contained cholecystokinin. These cholecystokinin-containing cells are of neuroendocrine origin and receive contact from the vagal nerve. Campylobacter pylori bacteria were not found in three of the four peptic ulcer tissues that harbored HSV-1. Further, none of the stomach or duodenal tissue samples from 33 patients undergoing clinical evaluation, but having no evidence of peptic ulcer disease, had HSV-1 materials. Thus, our data suggest that a subset of peptic ulcer disease may be associated with HSV-1 and raise the possibility that some peptic ulcers may be caused by this virus.

Oncogenic potential of sexually transmitted viruses with special reference to oral cancer

Recent changes in social mores have been accompanied by a noted increase in the frequency of sexually transmitted diseases. Viruses that have been identified as causative agents for a large proportion of these diseases have also been associated with various malignant states. Concomitantly, the number of cases of oral cancer (considered to occur usually around or after the fifth decade of life) reportedly has been increasing among young adults. The oncogenic potential of several sexually transmitted viruses (HSV, HPV, CMV, and LAV/HTLV III) and their possible role in the development of malignant conditions, in particular oral cancer, are discussed in this review.

The AIDS virus as an opportunistic organism inducing a state of chronic relative cortisol excess: therapeutic implications

The AIDS virus is an opportunistic organism which requires a previously immunocompromised host for successful replication. We propose that the primary and as yet unlocalized lesion caused by the AIDS virus involves disruption of physiologically balanced responses to stressors, effectively creating a state of chronic relative cortisol excess. Such a state inhibits successful anti-pathogen strategies including those directed against the AIDS virus itself and leads to a self-sustaining downhill clinical course. Therapies based on this model are discussed.

Alteration of tyrosine hydroxylase activity in PC12 cells infected with herpes simplex virus type 1

During infection with herpes simplex virus type 1 (HSV-1) the activity of tyrosine hydroxylase (TH) in PC12 pheochromocytoma cells was initially depressed reaching a nadir at 6 hours post-inoculation, but recovered rapidly with a return to baseline activity by 8 to 9 hours post-inoculation. Subsequently, TH activity again fell with a second more variable rise in activity occurring at 24 hours post-inoculation. Studies with metabolic inhibitors and 2 temperature-sensitive viral mutants indicated that these alterations of TH activity were dissociated from morphological cytopathology and likely required expression of "late" viral gene products. Immunotitration using anti-TH antibody suggested that early depression of TH activity resulted principally from loss of enzyme protein rather than simple enzyme inactivation, and that reconstitution of activity at 9 hours was related to augmented enzyme synthesis. These observations illustrate the complexity of perturbed cellular metabolism during HSV-1 infection and suggest involvement of two unexpected processes: alteration of a specialized cell function as a result of viral genes expressed late in the replicative cycle, and augmented synthesis of a cell-coded gene product during the course of infection.

Acute autonomic and sensory neuropathy associated with elevated Epstein-Barr virus antibody titre

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Tyrosine hydroxylase activity in the superior cervical ganglion during herpes simplex virus infection: correlation with viral titers and viral antigen

The activity of tyrosine hydroxylase (TH) was measured in the superior cervical ganglion (SCG) of the mouse during herpes simplex virus (HSV) infection. TH activity remained at control levels or actually increased during acute infection at a time when viral titers of SCG homogenates were at their peak and viral antigen was detected in from one-third to one-half of ganglionic neurons. A rapid decline in TH activity followed and coincided with falling viral titers, disappearance of viral antigen and replacement of neurons by inflammatory cells. Immunization partially prevented this reduction of TH activity. In addition, when mice were immunosuppressed by cyclophosphamide, TH activity was relatively preserved early in the course of infection despite high viral titers in the ganglion and the presence of viral antigen and histopathological alterations in nearly 100% of neurons. These results suggest that a cellular 'luxury function', in this case TH activity, can be preserved and perhaps even augmented during neuronal HSV infection. Indeed, activity of this enzyme may persist until late into the acute phase of infection, perhaps up to the point of cell death induced either by immune-mediated or direct virus-induced cell lysis.