Herpesvirus and neurological manifestations in patients with severe coronavirus disease

doi:10.21203/rs.3.rs-1534929/v1

Background

.Certain clinical manifestations of coronavirus disease (COVID-19) mimic those associated with human herpesvirus (HHV) infection. In this study, we estimated the prevalence of herpesvirus in patients with COVID-19 and determined if coinfection is associated with poorer outcomes and neurological symptoms.

Methods

We analyzed samples of 53 patients diagnosed with COVID-19. The samples were evaluated for the presence of alphaherpesviruses, betaherpesviruses, and gammaherpesviruses, and the viral loads were quantified using quantitative polymerase chain reaction (qPCR) method.

Results

Among the patients, in 73.6% had detection at least one type of herpesvirus. HHV-6 (47.2%), cytomegalovirus (43.3%), and HHV-7 (39.6%) showed the highest detection rates. Patients with a high severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 ) load were more likely to show herpes simplex virus 1 detection (p = 0.037). Among patients coinfected with SARS-CoV-2 and HHVs, 26.4% showed central nervous system-associated neurological symptoms and herpetic manifestations. A statistically significant association was observed between neurological changes and HHV-6 detection (p = 0.034).

Conclusions

The findings showed a high prevalence of herpesvirus in patients with COVID-19. Furthermore,even though SARS-CoV-2 and HHV coinfection was not associated with poorer outcomes, the findings demonstrated the association between neurological symptoms and HHV-6 detection.

SARS-CoV-2 infection

herpesvirus

neurological manifestations

People infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) commonly present mild symptoms, such asfever, cough, and fatigue. However, in certaincases, the manifestations include pneumonia, multiple organ failure, and death [1]. Some patients with coronavirus disease (COVID-19) develop other clinical manifestations, such as cutaneous lesions and neurological disorders, in addition to respiratory symptoms[2,3]. A significant percentage (80%) of patients develop neurological complications during SARS-CoV-2 infection, such asstroke, headache, dizziness, mental confusion, ageusia, anosmia, myelitis, and encephalitis [2, 4, 5, 6]. During the COVID-19 pandemic, cases of COVID-19 with human herpesvirus (HHV) reactivation were reported, which were related to lymphocytopenia owing to SARS-CoV-2 infection, or even to drug reactions [7,8]. Studies have suggested that patients with neurological manifestations of SARS-CoV-2 infection should undergo detection tests for opportunistic neurotropic viruses, such as HHVs, since therapeutic strategies are available for such infections, which can help reduce morbidity and mortality or improve disease prognosis [9, 10].

To date, the issue of neurological symptoms in patients with COVID-19 has been discussed extensively [5]. Studies have shown that SARS-CoV-2 can infect cells of the nervous system, even neurons with low expression of angiotensin converting enzyme-2, which plays an important role in viral entry [11, 6, 10]. Nervous system involvement appears to occur early, and the neurofilament content is elevated in patients with more severe outcomes [12]. However, other studies in patients with COVID-19 and neurological disorders have reported low levels or absence of viral RNA in the cerebrospinal fluid (CSF) [13, 14]. Therefore, the association between SARS-CoV-2 and neurological disorders is still not well understood [6, 15].

Although neurological disorders have been associated with infections caused by other opportunistic and neurotropic viruses [16], HHV coinfections in patients with COVID-19 remain poorly investigated. There are nine HHV species: human alphaherpesvirus 1 (herpes simplex virus (HSV)-1), human alphaherpesvirus 2 (HSV-2), human alphaherpesvirus 3 (varicella-zoster virus (VZV)-3), human gammaherpesvirus 4 (Epstein–Barr virus, EBV), human betaherpesvirus 5 (cytomegalovirus, CMV), human betaherpesvirus 6A, 6B, and 7 (HHV-6A, HHV-6B, and HHV-7), and human gammaherpesvirus8 (HHV-8) [17]. All of the viruses are double-stranded DNA viruses belonging to family Herpesviridae and are capable of establishing latency in their hosts, with the potential for reactivation in immunocompromised patients, which can lead to several complications [18, 19]. Neurological disorders have been reported in patients with herpesvirus reactivation [20]. HHV-1 is considered the main cause of viral encephalitis, which is associated with epileptic seizures in most cases [21]. Futhermore, HHV-1 has been reported as a trigger for NMDA receptor autoimmune encephalitis, as recently reported in a patient after SARS-CoV-2 infection [22] which could be attributed to molecular mimicry between the SARS-CoV-2 and NMDA receptors [23]. Except for HHV-8, all herpesviruses can cause encephalitis [21, 24, 25]. Furthermore, active infection by HHVs may also be associated with myelitis, stroke, and transient ischemic attack [26, 27, 28].

Owing to the high HHV prevalence worldwide and the complex course of infection, characterized by lifelong infection with periods of latency interspersed with periodic episodes of reactivation, the diagnosis of coinfections is necessary to help establish potential associations with neurological manifestations, which may affect the prognosis of SARS-CoV-2-infected patients.

This is the first study to investigate the frequency of the detection of all types of herpesviruses in critically ill patients with COVID-19, and thus, to evaluate if SARS-CoV-2 infection could be a risk factor for Herpesviridae reactivation. In addition, we aimed to investigate the association between HHV detection and neurological manifestations in patients with COVID-19.

Patients and samples

In this study, we analyzed nasopharyngeal swab samples collected from 53 patients admitted to the intensive care unit of the Clementino Fraga Filho University Hospital (HUCFF) located in Rio de Janeiro City, Brazil. All patients underwent follow-up till they were discharged. The study was approved by the Ethics Committee of the HUCFF (protocol number 4.103.725). The inclusion criteria were: 1) patients with COVID-19 diagnosis confirmed by RT-PCR [29] and 2) availability of consent forms signed by the patient or guardian/legal representative. Pregnant women were excluded from the study. The clinical evolution and demographic data of patients were collected from medical records. The assessment and interpretation of the findings of neurological examinations were reviewed by neurologists who collaborated in the study.

Virus detection

Viral DNA was extractedfrom the nasal swab samples usinga viral DNA extraction kit (Qiagen, Valencia, CA, USA), according to the manufacturer's recommendations. The viral loads of alphaherpesviruses (HSV-1, HSV-2, and VZV), betaherpesviruses (CMV, HHV-6, and HHV-7), and gammaherpesviruses (EBV and HHV-8) were quantified using real-time TaqMan PCR, as described previously [30,31,32,33, 34].

Statistical analysis

Kendall's Tau-b Correlation was used to determine the correlation between the COVID-19 load viral with the herpesvirus load viral to determine the association of the variables corticosteroid use, lymphocytopenia, outcomes, and neurological symptoms with herpesvirus detection, Pearson's Chi-square or Fisher's exact tests were used, and the viral load was evaluated using the Mann–Whitney test (Kolmogorov-Smirnov, p < 0.05). A 5% significance level was used. Statistic alanalyses were performed using SPSS version 20.0 (SPSS, Inc., Chicago, IL, USA).

All 53 patients diagnosed and hospitalized with COVID-19 underwent follow-upfrom hospital evolution till the outcome (discharge or death). The average hospital stay was of 24.36±16.65 days, ranging from 3 to 70 days. Most patients were male (50.9%), with age ranging between 17 and 95 years, and a mean age of 63.51±15.68 years. Patients were classified using the Sequential Organ Failure Assessment (SOFA) score (a SOFA score>9 was considered to represent severe cases). Among the patients, 39.6% were considered to have severe disease (SOFA>9), and 58.5% of the patients evolved to hospital discharge. Almost all patients (98.1%) had at least one comorbidity, the most common ones being systemic arterial hypertension, diabetes mellitus, and chronic kidney disease (Table 1).

Table 1. Clinical and demographic characteristics of patients admitted to the intensive care unit

Variable		N	%
Gender	Male	27	50.9
Gender	Female	26	49.1
Pulmonary impairment	<10%	20	37.8
	10%–50%	27	50.9
	>50%	6	11.3
Support O₂	None	12	22.6
	Nasal catheter	16	30.2
	Orotracheal intubation	25	47.2
Outcome	Discharge	31	58.5
Outcome	Death	21	41.5
SOFA score	≤9 (mild to moderate)	32	60.4
SOFA score	>9 (severe)	21	39.6
Comorbidities*	Yes	52	98.1
Comorbidities*	No	1	1.9
TOTAL		53	100
SOFA = Sequential Organ Failure Assessment Comorbidities*
Systemic arterial hypertension – 81.1% (43/53)
Diabetes mellitus – 45.3%(24/53)
Chronic kidney disease – 24.5% (13/53)
Cardiovascular disease– 20.8% (11/53)
Pulmonary disease–11.3% (6/53)
Immunodeficiency– 11.3% (6/53)
Maglinities– 7.5% (4/53)

*The patient may have had more than one comorbidity.

With respect to the prevalence of herpesviruses, 79.2% (42/53) of the patients tested positive for at least one herpesvirus. Of the 40 patients, 75.0% showed coinfection with two or more viral subtypes. The most prevalent herpes viruses were HHV-6 (47.2%), CMV (43.4%), HHV-7 (39.6%), and HHV-8 (17%). The HSV-1 load correlated with the SARS CoV-2 load (p=0.037). Of the patients, 33.3% showed alterations in the central nervous system (CNS), and 22.2% in the peripheral nervous system (PNS). The other correlations were weak and without statistical association, with positive tests for CMV, HHV-7 and HHV-8 and negative tests for EBV and HHV-6 (Table 2). The outcomes and viral load were not found to be associated with herpesvirus detection (using the Mann–Whitney test, p>0.05). Additionally, we evaluated the association of corticosteroid use and lymphocytopenia with herpesvirus detection (Pearson's Chi-squareor Fisher's exacttest, p>0.05), but no statistically significant associations were found between any variable and herpesvirus detection (Table 3).

Table 2. Prevalence of herpesvirus reactivation, viral load, and correlation of herpesvirus reactivation with the SARS-CoV-2 load

virus	Prevalence n (%)	SARS-CoV-2 load (mean+ DP)	Kendall’s Tau-b Correlation coefficient (coefficient; p value)
HSV-1	9/53 (17)	3.54E+9 + 1.0E+10	0.556; p=0.037*
HSV-2	1/53 (1.9)	1930	-
EBV	15/53 (28.3)	1.52E+12 + 3.99E+12	-0.162; p=0.400
CMV	23/53 (43.4)	1.31E+11 + 3.28E+11	0.020; p=0.895
VZV	4/53 (7.5)	1.32E+10 + 2.26E+10	-
HHV-6	25/53 (47.2)	8.52E+11 + 2.14E+12	-0.223; p=0.102
HHV-7	21/53 (39.6)	2.83E+11 + 6.57E+11	0.181; p=0.251
HHV-8	9/53 (17)	9.50E+5 + 2.40E+6	0,355; p=0,139

^aKendall’s Tau-b coefficient indicates the association of the SARS-CoV-2 load with the load viral of each herpesvirus. Missing values indicate that the test could not be conducted owing to a small sample size. *Statistical significance. SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; HSV, herpes simplex virus; VZV, varicella zoster virus; EBV, Epstein–Barr virus; CMV, cytomegalovirus; HHV, human herpesvirus.

Table 3. Association of corticosteroid use and lymphocytopenia with herpesvirus reactivation

Viral type	Corticosteroid use		p	Lymphocytopenia		p	TOTAL
Viral type	Yes N(%)	No N(%)	p	Yes N(%)	No N(%)	p	TOTAL
HSV-1
Yes	8 (88.9)	1 (11.1)	0.129⁽¹⁾	6 (66.7)	3 (33.3)	0.474⁽¹⁾	9 (100)
No	25 (56.8)	19 (43.2)	0.129⁽¹⁾	22 (50)	22 (50)	0.474⁽¹⁾	44 (100)

HSV-2
Yes	1 (100)	0 (0)	1.000⁽¹⁾	1 (100)	0 (0)	1.000⁽¹⁾	1 (100)
No	32 (61.5)	20 (38.5)	1.000⁽¹⁾	27 (51.9)	25 (48.1)	1.000⁽¹⁾	52 (100)

EBV
Yes	11 (73.3)	4 (26.7)	0.296⁽²⁾	10 (66.7)	5 (33.3)	0.205⁽²⁾	15 (100)
No	22 (57.9)	16 (42.1)	0.296⁽²⁾	18 (47.4)	20 (52.6)	0.205⁽²⁾	38 (100)

CMV
Yes	12 (52.2)	11 (47.8)	0.185⁽²⁾	11 (47.8)	12 (52.2)	0.523⁽²⁾	23 (100)
No	21 (70)	9 (30)	0.185⁽²⁾	17 (56.7)	13 (43.3)	0.523⁽²⁾	30 (100)

VZV
Yes	2 (50)	2 (50)	0.627⁽¹⁾	3 (75)	1 (25)	0.613⁽¹⁾	4 (100)
No	31 (63.3)	18 (36.7)	0.627⁽¹⁾	25 (51)	24 (49)	0.613⁽¹⁾	49 (100)

HHV-6
Yes	14 (56)	11 (44)	0.374⁽²⁾	12 (48)	13 (52)	0.506⁽²⁾	25 (100)
No	19 (67.9)	9 (32.1)	0.374⁽²⁾	16 (57.1)	12 (42.9)	0.506⁽²⁾	28 (100)

HHV-7
Yes	14 (66.7)	7 (33.3)	0.592⁽²⁾	8 (381)	13 (61.9)	0.082⁽²⁾	21 (100)
No	19 (59.4)	13 (40.6)	0.592⁽²⁾	20 (62.5)	12 (37.5)	0.082⁽²⁾	32 (100)

HHV-8
Yes	5 (55.6)	4 (44.4)	0.715⁽²⁾	2 (22.2)	7 (77.8)	0.087⁽²⁾	9 (100)
No	28 (63.6)	16 (36.4)	0.715⁽²⁾	26 (59.1)	18 (40.9)	0.087⁽²⁾	44 (100)

Fisher's exact test; ⁽²⁾ Pearson's Chi-square test; * Statistical significance. HSV, herpes simplex virus; VZV, varicella zoster virus; EBV, Epstein–Barr virus; CMV, cytomegalovirus; HHV, human herpesvirus

The occurrence of neurological symptoms was investigated in patients with COVID-19. Symptoms related to the CNS were detected in 26.4% of the patients, where assymptoms related to the PNS where observed in 7.5% of the patients (Table 4). CNS symptoms were more prevalent in patients with herpesvirus detection, with statistically significant values obtained for HHV-6 (40% in patients with HHV-6 detection vs 14.3% in patients without HHV-6 detection). Of note, there was detection the CMV and HHV-7 in multiple patients neurological symptoms, but the findings were not of statistical significance. HSV-1, HSV-2, VZV, HHV-8 and EBV were also detected in patients who showed CNS-associated neurological symptoms. There was no association of herpesvirus detection with PNS-related symptoms (Table 5).

Table 4. Frequency of neurological symptoms

Symptoms	n	%
Central nervous system*	14/53	26.4
Impaired consciousness	8/53	15.1
Headache	5/53	9.4
Dizziness	1/53	1.9
Acute cerebrovascular disease	1/53	1.9
Seizure	1/53	1.9

Peripheral nervous system*	4/53	7.5
Hypo/ageusia	2/53	3.8
Hypo/anosmia	1/53	1.9
Vision impairment	1/53	1.9
Peripheral neuropathy	1/53	1.9

* The patient may have had more than one symptom

Table 5. Association of neurological symptoms with herpesvirus reactivation

Virus	Central nervous system		p	Peripheral nervous system		p	TOTAL
Virus	Yes N(%)	No N(%)	p	Yes N(%)	No N(%)	p	TOTAL
HSV-1
Yes	3 (33.3)	6 (66.8)	0.684⁽¹⁾	2 (22.2)	7 (77.8)	0.129⁽¹⁾	9(100)
No	11 (25)	33 (75)	0.684⁽¹⁾	2 (4.5)	42 (95.5)	0.129⁽¹⁾	44(100)

HSV-2
Yes	1 (100)	0 (0)	0.264⁽¹⁾	0 (0)	1 (100)	0.999⁽¹⁾	1(100)
No	13 (25)	39 (75)	0.264⁽¹⁾	4 (7.7)	48 (92.3)	0.999⁽¹⁾	52(100)

EBV
Yes	5 (33.3)	10 (66.7)	0.504⁽¹⁾	0 (0)	15 (100)	0.568⁽¹⁾	15(100)
No	9 (23.7)	29 (76.3)	0.504⁽¹⁾	4 (10.5)	34 (89.5)	0.568⁽¹⁾	38(100)

CMV
Yes	9 (39.1)	14 (60.9)	0.066⁽²⁾	0 (0)	23 (100)	0.124⁽¹⁾	23(100)
No	5 (16.7)	25 (83.3)	0.066⁽²⁾	4 (13.3)	26 (86.7)	0.124⁽¹⁾	30(100)

VZV
Yes	2 (50)	2 (50)	0.282⁽¹⁾	0 (0)	4 (100)	0.999⁽¹⁾	4 (100)
No	12 (24.5)	37 (75.5)	0.282⁽¹⁾	4 (8.2)	45 (91.8)	0.999⁽¹⁾	49(100)

HHV-6
Yes	10 (40)	15 (60)	0.034^(2)*	0 (0)	25 (100)	0.113⁽¹⁾	25(100)
No	4 (14.3)	24 (85.7)	0.034^(2)*	4 (14.3)	24 (85.7)	0.113⁽¹⁾	28(100)

HHV-7
Yes	8 (38.1)	13 (61.9)	0.118⁽²⁾	1 (4.8)	20 (95.2)	0.999⁽¹⁾	21(100)
No	6 (18.8)	26 (81.2)	0.118⁽²⁾	3 (9.4)	29 (90.6)	0.999⁽¹⁾	32(100)

HHV-8
Yes	3 (33.3)	6 (66.7)	0.684⁽²⁾	0 (0)	9 (100)	0.999⁽¹⁾	9 (100)
No	11 (25.0)	33 (75.0)	0.684⁽²⁾	4 (9.1)	40 (90.9)	0.999⁽¹⁾	44(100)

Fisher's exact test; ⁽²⁾ Pearson's Chi-square test; * Statistical significance.SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; HSV, herpes simplex virus; VZV, varicella zoster virus; EBV, Epstein–Barr virus; CMV, cytomegalovirus; HHV, human herpesvirus.

To our knowledge, this study is the first to provide a broad overview of all HHV infections in patients with severe COVID-19. Interestingly, we observed the detection of one more types of herpesviruses in patients. Coinfection by two or more viruseswas observed in 39 patients, whereas some patients showed the detection of up to four types of herpesviruses concurrently. These data indicate that the state of immunosuppression in SARS-CoV-2 infection, characterized by symptoms such as lymphocytopenia, may possibly trigger a cycle of opportunistic virus reactivations, which makes it necessary to monitor the influence of these viruses on the course of COVID-19 [35, 10]. These findings reiterate the importance of further studies on family Herpesviridae that investigate their reactivation frequency in the population and interference with other pathogens [36]. Interestingly, we detected HHV-8 in 17% of patients. Previous studies have observed the low prevalence of HHV-8 in the Brazilian population compared to other herpesviruses [37]. However, a considerable detection rate of HHV-8 in our study cohort suggests that the prevalence of HV-8 may be underestimated by serological detection methods curreent.

Herpesviruses are considered pathogens of importance in immunocompromised individuals. This state of immunodeficiency plays a potential role in viral reactivation. Some studies have shown the high incidence of herpetic reactivation in patients with COVID-19, reporting a significantly longer duration of mechanical ventilation in patients with CMV and HSV-1 reactivation, and showing that EBV reactivation is associated with aprolonged ICU stay [35, 38]. However, despite the high level of herpesvirus detection in our study, only HSV-1 showed a viral load correlation with SARS CoV-2 (p = 0.037) (Table 2), indicating that patients with a high viral load of SARS-CoV-2 tend to show HSV-1 reactivation. These data represent an important finding. According to some reported cases, patients coinfected with SARS-CoV-2 and HSV-1 can develop complications such as acute liver failure, neurological symptoms, and septic shock [39, 9, 10]. This information highlights the importance of the early screening of HSV-1 reactivation in patients with COVID-19-related complications and the necessity of appropriate treatment and avoidance of worse outcomes. We did not find any significant association between the detection of other herpesviruses and worse outcomes, as reported in previous studies [40, 38, 35].

In hospitalized patients with COVID-19, a high prevalence of some viral subtypes of Herpesviridae, such as HSV-1 and EBV, has been reported [ 41, 35]. In our study, both HSV-1 and EBV showed detected in 17% and 28.3% of the patients, respectively; however, the gammaherpesviruses HHV-6, CMV, and HHV-7 showed the highest DNA loads.

HSV-1, HSV-2, VZV, and EBV are important pathogens associated with neurological manifestations and have a prevalence of more than 60% in adults. HSV can reactivate in the peripheral ganglion with axonal transport to the temporal lobe, and it is estimated that 70% of HSV encephalitis cases are caused by reactivation, which is also the most common cause of encephalitis [42, 20]. With respect to the effects on the CNS, HSV-1 and SARS-COV-2 share the potential for acting as viral triggersfor NMDA receptor encephalitis [22, 23]. VZV, which also establishes latency in the ganglia upon reactivation, can cause several neurological symptoms, such as encephalitis and ischemic stroke [20]. Conversely, EBV reactivation has been associated with several potentially long-term neurological complications, such as psychoneurosis/brain fog and headaches [43].

Although our study population showed a high rate of herpesvirus detection, a limitation of the study was the lack of information about the exact date of symptom onset and the time of sample collection. Seeßle et al. (2021) recently showed that the HSV-1 reactivation rate increased 11 days after the onset of symptoms in patients with COVID-19; therefore, possibly, there activation rate of some herpesviruses may be higher than that observed in our study, because the time between symptom onset and sample collection may vary.

In 26.4% of the patients, we observed CNS-associated neurological symptoms, such as impaired consciousness, headache, dizziness, acute cerebrovascular disease, and seizure. Similarly, a recent study confirmed SARS-CoV-2/HSV-1 coinfection in a patient with loss of consciousness, disorientation, and dizziness [9], which are symptoms suggestive of herpetic infection. EBV reactivation has also been associated with persistent symptoms observed in patients with COVID or long COVID,including some neurological manifestations, such as confusion and headache, which were observed in our patient group as well [44]. The most commonly detected herpesviruses in patients with neurological changes were HHV-6, CMV, and HHV-7. Although a statistically significant association between neurological changes and herpesvirus detection was only observed for HHV-6, CMV also showed detection in several patients, and the reactivation of this virus is also associated with neurological changes in immunocompromised patients. The immunosuppressive condition triggered by SARS-CoV-2 infection may play a role in CMV reactivation, which may cause diffuse encephalitisand myelitis [20]. This is similar to how HHV-7 reactivation can trigger CNS-related manifestations [45]. In addition, our findings also suggested an association between neurological changes and HSV-1 detection in patients with a high SARS-CoV-2 load. In this group of patients, 33.3% (3/9) showed changes in the CNS and 22.2% (2/9) in the PNS. Given the strong association between HSV-1 reactivation and neurological changes, further investigation of this association is necessary.

A case of SARS-CoV-2/HHV-6 coinfection associated with myelitis has also been reported previously, with the presence of HHV-6 in the CSF. The findings of this case provided evidence of HHV-6 reactivation in the CNS associated with the immunocompromised status acquired during SARS-CoV-2 infection [46]. Although neurological disorders are commonly associated with human alphaherpesvirus infection, the two viral species, HHV-6A and B, are neurotropic and cause neurological disorders such as dizziness, epilepsy, and encephalitis [27]. HHV-6 has a high prevalence in the population and can infect neuronal cells and disrupt cellular functions and metabolic processes essential for maintaining a healthy environment in the CNS [47]. Increasing evidence has indicated the association of HHV-6 infection with various neurological alterations in immunocompromised and immunocompetent individuals [48, 49]. Based on our findings and the ability of HSV-1 and HHV-6 to cause neurological disorders during reactivation, we suggest that this viral subtype should be investigated as a possible cause of neurological changes in SARS-CoV-2-infected individuals. However, although the detection of herpesvirus in body fluids of patients in an immunosuppressed state is strongly suggestive of a reactivation, we cannot determine ifthat it is a reactivation or a primary infection. A limitation of the study that should be considered, is the size of the study cohort, and the inability of examining the CSF for viral DNA because of the clinical status of the patients, and the overload on the public health system during the peak of the pandemic.

Another limitation of this study was that the size of the study population may have interfered with the result of the association between lymphocytopenia and the use of corticosteroids, since corticosteroids, such as steroids and immunomodulatory drugs, have been identified as triggers for the reactivation of latent herpesviruses in the host [50, 7].

in this study, we reported a high prevalence (73.6%) of herpesvirus detection in patients with COVID-19. We also showed the association between HHV-6 detection and neurological disorders. Our findings showed that HHV detection may be underestimated, and that herpesviruses other than HSV-1, EBV, and CMV may also be associated with neurological manifestations. The results highlight the importance of investigating the role of opportunistic viruses, such as herpesviruses, in the context of COVID-19, and their influence on the prognosis and neurological manifestations in patients infected with SARS-CoV-2. In addition, future investigations should focus on the role of herpesviruses in modulating the immune system via the regulation of gene expression during SARS-CoV-2 infection in critically ill patients, since herpesviruses harbor several mechanisms for regulating the host immune system.

Ethics approval and consent to participate

The study is of accordance with ethical principles (Declaration of Helsinki), approved by the Ethics Committee of the HUCFF (CAAE: 31240120.0.0000.5257).

Consent for publication

Informed written consent was obtained from the patient or legal guardian/representative was obtained.

Availability of data and materials

The data analyzed during the study are available from the corresponding author on reasonable request.

Competing interests

The authors report no potential competing interest.

Funding

This work was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) – Finance Code 001, Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), and Oswaldo Cruz Institute, which approved the project and funded the research with Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Author’s contribuitions

VCSC, VSP and LAAL conceived and designed the study. VCSC, VSP, OCM and WLCNPC performed all the experiments.DJSS performed statistical analysis of data. SVAL performed clinical analysi of patients. ALS, CHFR, CHFRF, CABM, and JPCG performed collection the material and of patients information.. All authors read and approved the fnal manuscript.

Acknowledgments

We thank all health professionals form Hospital Universitário Clementino Fraga Filho for supporting the patients included in this study.

Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun 2020; 109(102433):102433.
Chou SH-Y, Beghi E, Helbok. Global incidence of neurological manifestations among patients hospitalized with COVID-19-A report for the GCS-NeuroCOVID consortium and the ENERGY consortium. JAMA Netw Open 2021 ;4(5):e2112131.
Recalcati S. Cutaneous manifestations in COVID-19: a first perspective. J Eur Acad Dermatol Venereol 2020; 34(5):e212–3.
Sarı E, UygurKülcü N, Erdede O, UyurYalçın E, SezerYamanel RG. New-onset dizziness associated with COVID-19. Pediatr Neurol 2021;115:72.
Mao L, Jin H, Wang M, et al. Neurologic manifestations of hospitalized patients with Coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020; 77(6):683–90.
Moriguchi T, Harii N, Goto J, et al. A first case of meningitis/encephalitis associated with SARS-Coronavirus-2. Int J Infect Dis 2020; 94:55–8.
Grandolfo M, Romita P, Bonamonte D, et al. Drug reaction with eosinophilia and systemic symptoms syndrome to hydroxychloroquine, an old drug in the spotlight in the COVID-19 era. Dermatol Ther 2020; 33(4):e13499
Llamas-Velasco M, Rodríguez-Jiménez P, Chicharro P, De Argila D, Muñoz-Hernández P, Daudén E. Reply to “Varicella-like exanthem as a specific COVID-19-associated skin manifestation: Multicenter case series of 22 patients”: To consider varicella-like exanthem associated with COVID-19, virus varicella zoster and virus herpes simplex must be ruled out. J Am AcadDermatol 2020; 83(3):e253–4.
Herlinge AL, Monteiro FLL, D’arc M, et al. Identification and characterisation of SARS-CoV-2 and Human alphaherpesvirus 1 from a productive coinfection in a fatal COVID-19 case. Mem Inst Oswaldo Cruz . 2022;116:e210176.
Xu R, Zhou Y, Cai L, et al. Co-reactivation of the human herpesvirus alpha subfamily (herpes simplex virus-1 and varicella zoster virus) in a critically ill patient with COVID-19. Br J Dermatol 2020; 183(6):1145–7.
Ramani A, Müller L, Ostermann PN, Gabriel E, Abida-Islam P, Müller-Schiffmann A, et al. SARS-CoV-2 targets neurons of 3D human brain organoids. EMBO J 2020; 39(20):e106230.
Aamodt AH, Høgestøl EA, Popperud TH et al. Blood neurofilament light concentration at admittance: a potential prognostic marker in COVID-19 . bioRxiv. 2020. p. 2020.09.07.20189415
Kremer S, Lersy F, Anheim M, et al. Neurologic and neuroimaging findings in patients with COVID-19: A retrospective multicenter study: A retrospective multicenter study. Neurology 2020; 95(13):e1868–82.
Espíndola OM, Brandão CO, Gomes YCP, et al. Cerebrospinal fluid findings in neurological diseases associated with COVID-19 and insights into mechanisms of disease development. Int J Infect Dis 2021; 102:155–62
Neumann B, Schmidbauer ML, Dimitriadis K, et al. Cerebrospinal fluid findings in COVID-19 patients with neurological symptoms. J Neurol Sci 2020; 418(117090):117090.
Koyuncu OO, Hogue IB, Enquist LW. Virus infections in the nervous system. Cell Host Microbe 2013; 13(4):379–93.
Walker PJ, Siddell SG, Lefkowitz EJ, et al. Changes to virus taxonomy and the International Code of Virus Classification and Nomenclature ratified by the International Committee on Taxonomy of Viruses (2019). Arch Virol 2019; 164(9):2417–29.
Zarrouk K, Piret J, Boivin G. Herpesvirus DNA polymerases: Structures, functions and inhibitors. Virus Res 2017; 234:177–92.
Hirsch MS. Herpes group virus infections in the compromised host. In: Clinical Approach to Infection in the Compromised Host. Boston, MA: Springer US; 1994. p. 379–96.
Sousa IP Jr, Dos Santos FB, de Paula VS, et al. Viral and prion infections associated with central nervous system syndromes in Brazil. Viruses 2021;13(7):1370.
Roos KL. ENCEPHALITIS. Neurol Clin. 1999; 17(4):813–833
Sarigecili E, Arslan I, Ucar HK, Celik U. Pediatric anti-NMDA receptor encephalitis associated with COVID-19. ChildsNervSyst . 2021; 37(12):3919–3922.
Vasilevska V, Guest PC, Bernstein H-G, Schroeter ML, Geis C, Steiner J. Molecular mimicry of NMDA receptors may contribute to neuropsychiatric symptoms in severe COVID-19 cases. J Neuroinflammation. 2021; 18(1):245.
Kleinschmidt-DeMasters BK, Gilden DH. The expanding spectrum of herpesvirus infections of the nervous system. Brain Pathol 2001;11(4):440–51.
Parra M, Alcala A, Amoros C, et al. Encephalitis associated with human herpesvirus-7 infection in an immunocompetent adult. Virol J 2017; 14(1):97
Donati D, Akhyani N, Fogdell-Hahn A, Cermelli C, Cassiani-Ingoni R, Vortmeyer A, et al. Detection of human herpesvirus-6 in mesial temporal lobe epilepsy surgical brain resections. Neurology 2003; 61(10):1405–11.
Bartolini L, Theodore WH, Jacobson S, Gaillard WD. Infection with HHV-6 and its role in epilepsy. Epilepsy Res 2019; 153:34–9.
Nagel C-H, Döhner K, Fathollahy M, et al. Nuclear egress and envelopment of herpes simplex virus capsids analyzed with dual-color fluorescence HSV1(17+). J Virol 2008; 82(6):3109–24
Ferreira BI da S, da Silva-Gomes NL, Coelho WL da CNP, et al. Validation of a novel molecular assay to the diagnostic of COVID-19 based on real time PCR with high resolution melting. PLoS One 2021; 16(11):e0260087.
Lima LRP, Silva AP da, Schmidt-Chanasit J, Paula VS de. Diagnosis of human herpes virus 1 and 2 (HHV-1 and HHV-2): use of a synthetic standard curve for absolute quantification by real time polymerase chain reaction. Mem Inst Oswaldo Cruz 2017; 112(3):220–3.
Raposo JV, Alves ADR, Dos Santos da Silva A, et al. Multiplex qPCR facilitates identification of betaherpesviruses in patients with acute liver failure of unknown etiology. BMC Infect Dis 2019; 19(1):773.
Raposo JV, Sarmento DJDS, Pinto RBDS, et al. Longitudinal study on oral shedding of human betaherpesviruses 6 and 7 in renal transplant recipients reveals active replication. J Oral Microbiol 2020; 12(1):1785801.
de Oliveira Lopes A, Spitz N, Martinelli KG, et al. Introduction of human gammaherpesvirus 8 genotypes A, B, and C into Brazil from multiple geographic regions. Virus Res 2020; 276(197828):197828.
Fellner MD, Durand K, Rodriguez M, Irazu L, Alonio V, Picconi MA. Duplex realtime PCR method for Epstein-Barr virus and human DNA quantification: its application for post-transplant lymphoproliferative disorders detection. Braz J Infect Dis 2014; 18(3):271–80.
Simonnet A, Engelmann I, Moreau A-S, et al. High incidence of Epstein-Barr virus, cytomegalovirus, and human-herpes virus-6 reactivations in critically ill patients with COVID-19. Infect Dis Now 2021; 51(3):296–9.
Hosomi S, Nishida Y, Fujiwara Y. The impact of human herpesviruses in clinical practice of inflammatory bowel disease in the era of COVID-19. Microorganisms 2021; 9(9):1870.
Lopes A de O, Lima LRP, Tozetto-Mendoza TR, et al. Low prevalence of human gammaherpesvirus 8 (HHV-8) infection among HIV-infected pregnant women in Rio De Janeiro, Brazil. J Matern Fetal Neonatal Med 2021; 34(20):3458–61.
Le Balc’h P, Pinceaux K, Pronier C, Seguin P, Tadié J-M, Reizine F. Herpes simplex virus and cytomegalovirus reactivations among severe COVID-19 patients. Crit Care 2020; 24(1):530.
Busani S, Bedini A, Biagioni E, Serio L, Tonelli R, Meschiari M, et al. Two fatal cases of acute liver failure due to HSV-1 infection in COVID-19 patients following immunomodulatory therapies. ClinInfectDis. 2021; 73(1):e252–5.
Lino K, Alves LS, Raposo JV, et al. Presence and clinical impact of human herpesvirus-6 infection in patients with moderate to critical coronavirus disease-19. J Med Virol. [Preprint] 14 Oct 2021. [cited 2022 Feb 12]. Available from: https://pubmed.ncbi.nlm.nih.gov/34647632/doi:10.1002/jmv.27392 2021;
Seeßle J, Hippchen T, Schnitzler P, Gsenger J, Giese T, Merle U. High rate of HSV-1 reactivation in invasively ventilated COVID-19 patients: Immunological findings. PLoS One 2021; 16(7):e0254129.
Tzellos S, Farrell PJ. Epstein-barr virus sequence variation-biology and disease. Pathogens. 2012; 1(2):156–74.
Häusler M, Ramaekers VT, Doenges M, Schweizer K, Ritter K, Schaade L. Neurological complications of acute and persistent Epstein-Barr virus infection in paediatric patients: Paediatric CNS EBV Infections. J Med Virol 2002; 68(2):253–63.
Gold JE, Okyay RA, Licht WE, Hurley DJ. Investigation of long COVID prevalence and its relationship to Epstein-Barr virus reactivation. Pathogens 2021;10(6):763.
Torigoe S, Koide W, Yamada M, Miyashiro E, Tanaka-Taya K, Yamanishi K. Human herpesvirus 7 infection associated with central nervous system manifestations. J Pediatr 1996; 129(2):301–5
Jumah M, Rahman F, Figgie M, et al. COVID-19, HHV6 and MOG antibody: A perfect storm. J Neuroimmunol 2021; 353(577521):577521
Meeuwsen S, Persoon-Deen C, Bsibsi M, et al. Modulation of the cytokine network in human adult astrocytes by human herpesvirus-6A. J Neuroimmunol 2005; 164(1–2):37–47.
Patel R, Mohan A, Pokharel K, Pardi M. A rare case of human Herpesvirus 6 meningitis in an immunocompetent Asian male presented with a severe intractable headache. Cureus 2021; 13(5):e15331.
Whitley RJ, Lakeman FD. Human herpesvirus 6 infection of the central nervous system: is it just a case of mistaken association? ClinInfectDis. 2005; 40(6):894–5.
Franceschini E, Cozzi-Lepri A, Santoro A, et al. Herpes simplex virus re-activation in patients with SARS-CoV-2 pneumonia: A prospective, observational study. Microorganisms 2021; 9(9):1896.

No competing interests reported.

Herpesvirus and neurological manifestations in patients with severe coronavirus disease

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Background

Materials And Methods

Statistical analysis

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1