Journal of Alzheimer’s Disease 54 (2016) 1273–1281 1273

DOI 10.3233/JAD-160607
IOS Press

Review

Herpes and Alzheimer’s Disease:

Subversion in the Central Nervous System
and How It Might Be Halted
Ruth F. Itzhaki∗
Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK

Accepted 4 July 2016

Abstract. The last 8 or so years have seen a large increase in the number of studies supporting the concept of a major role
for herpes simplex virus type 1 (HSV1) in Alzheimer’s disease (AD). The main advances have been made through studies
in humans and in mice, investigating the likelihood of reactivation of the latent virus in brain. Others have aimed to explain
the mechanisms in cells whereby the increase in amyloid-beta (A␤) production on HSV1 infection of cells and mouse brains
occurs, and the reason that infected cells make this increase. The possibility that other herpesviruses are involved in the
development of AD has been explored, and human herpesvirus type 6, Epstein-Barr virus, and cytomegalovirus, in particular,
have been implicated. Epidemiological studies have further supported the role specifically of HSV1 and its reactivation
in the disease. Antiviral studies have continued, comparing those acting by different mechanisms, such as restricting viral
replication, or blocking viral entry into cells, to treat HSV1-infected cell cultures, and then examining the extent to which
the virus-induced increases in A␤ and AD-like tau are reduced. All the studies support the usage of antiviral treatment to
slow or halt the progression of AD.

Keywords: Alzheimer’s disease, amyloid-beta, antivirals, brain, epidemiology, herpes simplex virus type 1, virus reactivation

In the last eight years, there have been many major The concept of a viral role in AD states that in
findings in research on the possible links between the HSV1-infected people (who comprise 80–90% of
common virus, herpes simplex virus type 1 (HSV1), the population by the age of 60, in most countries),
and Alzheimer’s disease (AD), and hence a large the decline of the immune system with age enables
increase in the number of publications, which now HSV1 to travel from the peripheral nervous system
total about one hundred, while relevant reviews num- (PNS) to the CNS (or possibly instead, it enters the
ber at least twenty. All these new articles support brain as a new infection via the olfactory route).
either directly or indirectly the concept of a major HSV1 then remains in brain in a latent state, but
role for HSV1 in AD, and are especially convincing can be reactivated, as in the periphery, by events
as they are based on widely differing types of exper- such as immunosuppression and stress. During each
imental approach. Those published up till 2014 have reactivation, the virus infection becomes productive,
been described in detail in a recent review [1], so this though presumably very localized–in effect a type
article will concentrate mainly on articles published of “mild” encephalitis (see below), with consequent
subsequently. neuronal damage. Recurrent reactivation results in
accumulation of damage, leading eventually to the
∗ Correspondence to: Ruth F. Itzhaki, Nuffield Department of
development of AD in the brain of those who carry
Clinical Neurosciences, University of Oxford Level 6, West Wing,
John Radcliffe Hospital, Oxford, UK. Tel.: +44 01865 250853;
an APOE-␧4 allele, accounting for some 60% of AD
E-mail: [email protected]. sufferers [2]. Similarly in the PNS, HSV1 reactivation

ISSN 1387-2877/16/$35.00 © 2016 – IOS Press and the authors. All rights reserved
1274 R.F. Itzhaki / Herpes and Alzheimer’s Disease

from latency is known to cause cold sores (herpes [chronic psychiatric illness]”? Cases of recurrent
labialis), but mainly in those carrying an apoE-␧4 HSE are still quite often reported, but of course they
allele [2] (a result later confirmed by Koelle et al. would not be seen by neuropathologists, who exam-
[3]), paralleling the HSV1-APOE-␧4 connection in ine only fatal cases, i.e., the most severe, and who
the CNS. might well conclude therefore that “mild” encephali-
tis does not exist.
In mice, HSV1 latency in brain is established a
REACTIVATION OF HSV1 IN BRAIN few weeks after inoculation of the virus. Many early
investigations indicated that its reactivation in brain
One of the most important aspects of the concept was far rarer than in the trigeminal ganglia (TG),
is that of reactivation of HSV1 in brain. Several stud- as determined by assays of dissociated and minced
ies were described in detail in the recent review [1], tissue such as the ex vivo (explant) assay of reac-
including a finding that provides major direct evi- tivation frequency (in which latently infected cells
dence of reactivation in brain: an examination of CSF are cultured with susceptible uninfected ones). How-
samples sent to a reference laboratory for HSV testing ever, two recent very interesting studies indicate that
[4], revealed, unexpectedly, that 26 of the 3200 sam- HSV1 in mouse brain can in fact be reactivated rel-
ples were positive for the viral DNA. HSV DNA is atively easily. Yao et al. [7] examined the brain stem
present in CSF of herpes simplex encephalitis (HSE) and TG of HSV1-infected animals during latency
patients but the disease could not explain the rela- and unexpectedly found in brain a greater number
tively very high proportion of samples that were viral of copies of the viral genome, and also more frequent
DNA-positive (8 per thousand) as the prevalence of reactivation, than in the TG. They attributed this dif-
HSE in the population is much lower, only ∼2 per ference from previous results to a more rapid loss of
million. A further reason why HSE could not account viability of brain stem cells than of TG cells after
for the results is that after HSE, HSV1 DNA remains dissociation, and especially after mincing, so that
in the CSF only briefly, for about a week (in contrast ex vivo measurements would not accurately assess
to the long life of intrathecal antibodies to HSV). The viral reactivation in brain. The data of Ramakrishna
data thus not only confirm HSV1 presence in brain et al. [8] were equally striking: they investigated
but also suggest that HSV1 reactivation in brain is HSV1-infected immunodeficient mice (lacking B
not so infrequent. The finding is consistent with an and T cells) which were treated with intravenous
earlier study using in situ hybridization, which sug- immunoglobulin (IVIG) to promote long-term sur-
gested that immunosuppression causes latent HSV to vival (via IVIG’s immunomodulatory and antiviral
reactivate and that subsequent replication leads to its activities). After high dose HSV1 inoculation, mice
amplification [5]: HSV DNA was detectable in post- in which viral latency had been established in brain
mortem brain specimens of subjects who had been showed spontaneous reactivation of the virus; this
immunosuppressed and were seropositive for HSV, was suppressed by T cells but not B cells. Hyper-
but not in those who were seronegative or who had thermic stress caused HSV1 reactivation in brain of
not been immunosuppressed. most of the animals, with subsequent occurrence of
Another relevant early study [6] described cases HSE.
of “mild” encephalitis: patients’ symptoms were less Productive HSV1 infection causes damage via
severe than usual and recovery was almost com- inflammatory processes as well as by direct viral
plete, with only minor sequelae, even though the action. Some of these processes can occur also
patients were not treated with antivirals. In the days during latency [9]: in HSV1-infected mice, several
before antiviral treatment became routine, most cases inflammatory markers such as toll-like receptor-4,
of HSE were usually fatal, and those who sur- interferon ␣/␤, and p-IRF3, characteristic of viral
vived often suffered severe neurological problems, replication, were all detectable in brain at a time
including memory loss. Klapper et al. referred also well after virus inoculation, and therefore after the
to recurrent HSE, i.e., reactivation of latent HSV1 establishment of viral latency in brain, thus indicating
present in brain, and they suggested that other recur- that reactivation had occurred. The authors con-
rences might not always have been recognized. They cluded that HSV-1 presence in the CNS could cause
presciently speculated: “Is it possible that one or more chronic neuroinflammation through recurrent reacti-
reactivation events [of HSV1] resulting in mild dis- vation, leading to activation of toll-like receptors and
ease could play an etiological role in such conditions thence to cumulative neuronal dysfunction. All these
 R.F. Itzhaki / Herpes and Alzheimer’s Disease 1275

data support the proposal that HSV1 reactivates–not down-regulated. GSK3␤ level and activity remained
just in the periphery, but also in the brain. almost constant, although at late stages of infection
the enzyme was inactivated through being phospho-
rylated at Ser9. However, a second study by the
CELL BIOLOGICAL STUDIES same group [22] showed that HSV1 caused acti-
vation of phosphorylated GSK3. The activation of
In another type of approach–cell biological pGSK3 was Ca2+-dependent and was essential for
studies aiming to find if the characteristic abnor- the HSV-1-dependent phosphorylation of APP at
mal molecules found in AD brains can be Thr668, leading then to its subsequent degradation
produced by HSV1 infection–HSV1-infected cell and to the intraneuronal accumulation of A␤. A
cultures revealed accumulation of amyloid-beta (A␤) very significant finding was that HSV-1 infection
[10–12], and of AD-like tau (P-tau) occurs [13–16]. reduced the expression of the presynaptic proteins
Implicating HSV1 further in AD was the discov- synapsin-1 and synaptophysin, and depressed synap-
ery that in AD brains, most of the HSV1 DNA is tic transmission. By using 4G8 antibody which binds
very specifically localized in amyloid plaques [17]: to A␤, and also by infecting APP-knockout mice, the
in brain of elderly controls, a much lower proportion authors showed that these inhibitory effects on synap-
of the viral DNA is present in plaques, presumably tic function were dependent on GSK-3 activation and
reflecting a lower extent of synthesis of A␤, or else intraneuronal accumulation of A␤.
a more efficient removal of the peptide. The HSV1- The increase in A␤ that HSV1 causes raised the
induced increases in A␤ and P-tau were accounted for possibility that at least initially, the peptide at low
by increases in the relevant enzymes via, in the case levels might function as part of the innate immune
of BACE, HSV1-induced PKR activation followed system, acting protectively as a “bioflocculant”, i.e.,
by phosphorylation of eukaryotic translation initi- binding neurotoxic agents, as previously suggested
ation factor 2-alpha (eIF-2␣) [18]; eIF2␣ shuts off by Robinson and Bishop [23], or as an anti-microbial
general protein synthesis, but reverses the inhibitory peptide [10]; however, in the latter study, although A␤
effect of the BACE1 5’ untranslated region (5’UTR) appeared to have antiviral activity, it was attributable
in the BACE promoter on BACE expression. The to its toxic effect on the cells. Furthermore, virucidal
PKR polymorphisms in AD patients discovered by assays, which assess the capacity of the test molecule
Bullido et al. [19] could affect this process, thereby to inactivate virus particles, showed no effect on viral
leading to the observed high level of activated PKR infectivity. However, in view of recent positive find-
in AD brains. ings (see below), the antiviral activity is probably
Santana et al. [20] investigated the effects of mild determined by the method of its preparation and its
oxidative stress combined with HSV1 infection of state of aggregation. In any case, though, A␤ even-
cells (which itself causes oxidation). They found that tually becomes toxic when over-produced and when
oxidative stress significantly augmented the HSV1- oligomerization occurs.
induced accumulation of A␤ and its secretion, as well
as the inhibition of autophagy, although it did not
increase the degradation of long-lived proteins. These DOES A␤ HAVE ANTIMICROBIAL
oxidative effects were not attributable to enhanced PROPERTIES?
virus replication as, surprisingly, oxidation reduced
viral DNA replication and reduced even more the for- There is now evidence that A␤, which structurally
mation that leads to the neurodegeneration seen in resembles antimicrobial peptides (AMPs) and, like
AD. them, can cause activation of immune cells, does
Civitelli et al. [21] found that HSV-1 infection indeed have antiviral activity. A number of stud-
of cultured mouse cortical neurons and SH-SY5Y ies have implicated certain bacteria–spirochetes [24]
neuroblastoma cells causes the production of sev- and Chlamydia pneumoniae (C. pneumoniae) [25], as
eral APP fragments, including the APP intracellular well as HSV1, in the development of AD. Both types
domain (AICD). AICD binds the promoter region of bacteria elicit the formation of A␤ and P-tau, and
of both neprilysin (NEP), the major A␤-degrading components of both colocalize with AD pathology.
enzyme, and GSK3␤, the enzyme causing hyperphos- The antibacterial activity of A␤ was detected first by
phorylation of tau. NEP level and enzyme activity Soscia et al. [26] and is discussed later in this section
were initially stimulated by infection but later were together with a recent study from the same group.
1276 R.F. Itzhaki / Herpes and Alzheimer’s Disease

The first paper on the antiviral properties of A␤ in number of infectious viruses, and much greater
[27] investigated its effect on influenza virus A during subsequent mortality, compared with wild-type and
infection of several human and canine epithelial cell heterozygous litter mates. The authors suggested
cultures, used as model systems. The authors found that WNV-induced Asyn inhibits viral replication,
that the activity of A␤42 was much greater than that growth, and injury in the CNS and that the peptide
of A␤40 , and that the maximum antiviral effect of has a novel and important functional role in the devel-
A␤42 was achieved when it was pre-incubated with opment of Parkinson’s disease.
the virus, thereby indicating that it acts on the virus Both the influenza and the HSV1 studies tested
rather than on the cell. Also, A␤ caused aggrega- A␤ efficacy as an antiviral by assaying virus level,
tion of the virus, reduced viral protein synthesis, and using quantitative PCR on viral DNA extracted from
modulated its interaction with phagocytes. the cell cultures. However, PCR has the disadvan-
As to the effect of A␤ on HSV1, Bourgade et al. tage of measuring DNA not only from “live” but also
[28] infected cell cultures with the virus and found from inactivated virus, thereby over-estimating the
that both A␤40 and A␤42 inhibited HSV1 DNA repli- virus level. Also, in the HSV1 studies, the A␤ con-
cation when added to the cultures. This occurred centration used was high (20 ␮g/ml) probably very
either when the peptides were added before the virus much greater than the levels in brain cells. It would
or when added together with it, but not when added therefore be well worth extending the studies using
after virus addition. Also, in a cell-free system, A␤ a much lower A␤ concentration and assaying virus
interacted directly with HSV1 (as A␤42 did with levels by standard virological methods, such as the
influenza virus), indicating that in the cell cultures, plaque assay (the method used by Beatman et al.
it prevented HSV1 entry into cells. Both this and [30]).
the influenza virus study showed also that A␤ acts Further strong evidence for the protective role of
selectively against enveloped viruses as opposed to A␤, although unexpectedly in its oligomeric form,
non-enveloped viruses, and Bourgade et al suggested has been obtained in an interesting, very detailed
that this might reflect A␤ insertion into the viral enve- study by Kumar et al. [31]. This followed work
lope. In a second study, Bourgade et al. [29] used by the same group examining the effect of syn-
co-cultures of neuroglioma (H4) and glioblastoma thetic A␤ on the growth of eight pathogens, the
(U118-MG) cells as an in vitro model, and found yeast Candida albicans (C.albicans) and seven com-
that the H4 cells secreted A␤42 in response to HSV- mon types of bacteria, in culture, which indicated
1 challenge, and that U118-MG cells could rapidly that A␤ has a protective role in innate immunity
internalize A␤42 . Extraneous A␤42 induced strong [26]. In the more recent study, the microbes investi-
production of cytokines in the cell lines, and a com- gated were the bacterium, Salmonella typhimurium
bination of A␤42 and HSV-1 induced the production (S. typhimurium), and the yeast C. albicans. The
of the pro-inflammatory cytokines TNF␣ and IL-1␤, targets were transfected human neuroglioma cells
and IFN␣ in the cell lines. A␤42 -conditioned medium (H4) over-expressing A␤, transgenic (Tg) nematodes,
from HSV-1-infected H4 cells, when added to cul- Caenorhabditis elegans (C. elegans), expressing A␤
tures of H4 cells, conferred A␤-dependent protection in body wall muscle, and Tg mice overexpressing
against HSV-1 replication when the cells were chal- A␤. The authors showed that A␤ protected the cul-
lenged with HSV-1. The authors proposed that in tures of transfected cells and also the Tg nematodes,
human brain, A␤42 acts as an AMP against neu- greatly increasing their survival when infected by C.
rotropic enveloped viruses such as HSV1; also, in albicans. Similarly, the Tg mice survived infection
agreement with the present author’s suggestions, they with S. Typhimurium for a far longer time period than
considered that eventual overproduction of A␤ pep- did wild-type and APP knock-out mice. To examine
tide might contribute to amyloid plaque formation. the protective mechanism, the authors compared A␤
Intriguingly, ␣-synuclein (Asyn), another AMP- with an antimicrobial peptide (AMP), LL-37, which
like peptide, has very recently been shown by is known to protect against microbes by oligomeriz-
Beatman et al. [30] to have antiviral activity against ing and binding to their surface, thereby preventing
certain enveloped RNA viruses. Infection of pri- their attachment to the target cells, and then forming
mary neurons with West Nile virus (WNV) or fibrils round them so that they are immobilized. On
with Venezuelan equine encephalitis virus caused infecting the transfected H4 cells with C. albicans,
an increase in Asyn expression, and infection of the authors found that the transfected cells bound
Asyn knock-out mice resulted in a huge increase fewer yeasts than did non-transfected H4 cells, and
 R.F. Itzhaki / Herpes and Alzheimer’s Disease 1277

that the A␤ bound to the yeast cell walls, but only patients and elderly controls, compared to HSV1,
if it was in oligomeric form; then, like LL-37, the apart from human herpesvirus type 6 (HHV6) which,
A␤ wrapped up the yeast. Similarly, on infection of in the author’s laboratory was detected in brain of
the nematodes, the yeasts became entrapped and the 70% and 40% of AD patients and age-matched con-
clumps thus formed were stainable with thioflavin S, trols respectively [28]. It was suggested that as there
as are amyloid plaques in human brain. Further, in Tg was considerable overlap of HHV6 and HSV1 in
mice–animals that normally develop amyloid plaques brain, HHV6 might act together with HSV1 in the
only at a later age–plaques were seen in young mice at development of AD. Previously, the same laboratory
just 2 days after infection with S. Typhymurium. The found no varicella zoster virus (VZV) in brain [34],
authors commented that the same features, oligomer- but detected HSV2 in 13% and 20%, respectively,
ization, fibrillization, and carbohydrate binding, are of patients and controls, cytomegalovirus (CMV) in
associated also with the pathophysiological effect of 36% and 34%, respectively [33], and in 93% of vas-
A␤, and they suggest that dysregulation of the normal cular dementia patients [35].
protective activity of A␤ leads to AD pathology. Carbone et al. [36] sought the presence of the DNA
Unfortunately, the authors did not investigate of CMV, Epstein Barr virus (EBV), and HHV6 in
infection with HSV1 in either study, despite its being peripheral blood leucocytes (PBL) and in brain. No
the pathogen most frequently implicated in AD, CMV was detected in any samples, but EBV was
and implicated via diverse approaches. In fact their detected in 45% of PBL from AD patients, 31% from
immobilized pathogen model strikingly resembles controls, and in 6% of AD brains. HHV6 was detected
the pictures of HSV1 DNA embedded within amy- in 23% PBL from AD patients, 4% from controls, and
loid plaques in AD brains, a finding published in in 17% of AD brains. In subjects followed for 5 years,
2009 [17], and the bioflocculent model proposed by the percentage positive for EBV and HHV6 increased
Robinson and Bishop in 2002 [23]. Further, the bacte- in those who developed AD, as did serum IgG lev-
ria and the yeast investigated in the studies described els for CMV and HHV6. They considered that the
above have never been associated in any way with non-detection of CMV DNA, in contrast to their anti-
AD, yet the two types of bacteria that are strongly CMV antibody detection and to the data of Lin et al.
implicated in the disease (spirochetes and C. pneu- [33], possibly reflected the inability of their technique
moniae) both of which, significantly, are intracellular, to detect low levels of CMV DNA. They concluded
were not investigated. that EBV, HHV6, and perhaps CMV might all be
implicated in the progression to AD.
In a later study [37], the authors examined AD
HSE AND A␤
patients and elderly controls over a five-year period
for cognitive performance and for clinical diagnosis
Interestingly, a link between HSE and A␤ was
of AD, investigating genetic factors regulating antivi-
discovered by Bearer et al. [32], who investigated
ral response, such as IFN-λ3. They found that the
autopsy brain tissue from three HSE patients: a
genes responsible were associated with increased risk
9-day-old, a 8-year-old, and a 76-year-old (the lat-
of cognitive decline and AD, again implicating EBV
ter showing no evidence of AD). They detected A␤
and HHV6, and they proposed that impaired immu-
but no P-tau in brain of each subject. A␤ was not
nity against persistent viruses, such as herpesviruses,
detected in cases of non-herpetic viral encephalitis.
in genetically predisposed elderly people might cause
They concluded that HSV can induce the formation
recurrent virus reactivation from latency, hence acti-
of A␤ deposits, and recommended future follow-up
vating brain microglia, and increasing A␤ production
of HSE patients who survive to find if the plaques and
and accumulation. An earlier publication, by Carter
HSV1 infection persist, i.e., if more A␤ is deposited.
[38] had discussed putative antiviral host responses,
specifically to HSV1, which could affect its infectiv-
ARE THERE OTHER HERPESVIRUSES IN ity or replication; these included nitric oxide, cysteine
THE ELDERLY BRAIN? protease inhibitor cystatin C and certain cytokines,
namely, IL1A, IL2, IL1RN, IL6, IL18, and TNF and
There have been very few studies on the pos- as Carter commented, their effects would be influ-
sible involvement of other herpes viruses in AD. enced by any polymorphisms.
Most of these viruses, if detected at all in brain, Recently, the effects of HSV2, another herpes virus
were found in a relatively low proportion of AD highly homologous to HSV1, have been studied in
1278 R.F. Itzhaki / Herpes and Alzheimer’s Disease

cultured human neuroblastoma cells [39]. HSV2 was HSV1 reactivations were the events leading to the
found, like HSV1, to cause increased accumulation of development of AD, However, a second study by
abnormally phosphorylated tau and A␤, altered APP Lovheim et al. [49] found, surprisingly, an associ-
processing, and impaired autophagy. The authors ation of IgG, but not IgM, with AD, thus implicating
suggested that HSV2 (and other herpesviruses) might HSV1 presence rather than activity in AD. This result
play a role in AD as it remains latent in sensory neu- contradicted the authors’ previous data and those of
rons but is capable of reactivating, and it can infect others, so to explain the difference they suggested that
the brain and cause neurological symptoms, just as it might result from the different approaches used–the
HSV1 infection does. However, they acknowledged previous ones being cohort studies, and their present
that HSV2 usually causes HSE only in neonates, not one a case-control study. Alternatively, it could be
in adults, and that serological data show that the virus because of HSV1 affecting an early stage in AD
infects a much lower proportion of the population, development, or perhaps it reflected their paucity of
and resides in far fewer elderly human brains than IgM-positive subjects.
does HSV1. Two investigations have been made on the possi-
All these results, together with the discovery that in ble association, in young subjects, of infection by a
AD brains, almost all the HSV1 DNA resides within specific virus, or of infectious burden (I.B. – seroposi-
amyloid plaques [17], suggests that in many AD tivity to several microbes), with cognition or AD. One
patients, HSV1 in brain is responsible for the abnor- study investigated 612 soldiers in the Israeli military
mal processing of amyloid precursor protein (APP), (59% male and 41% female, aged 19–21) for HSV-
for the formation of A␤, its toxic aggregates, and of 1 infection and possible association with cognitive
plaques, for abnormal phosphorylation of tau, and functioning and language abilities [50]. After con-
for synaptic dysfunction: the major features of AD. trolling for education, immigration status, and sex
Whether the other herpesviruses contribute remains (although not for socio-economic status), and remov-
to be confirmed; possibly in the case of CMV, its ing those with mild to moderate mental illness, the
action might be through immune dysregulation, as 62% who were seropositive for HSV-1 infection were
proposed by Stowe et al. [40]. found to have lower IQ and lower language skills.
The second study on young to middle aged subjects
[51] examined serum IgG antibodies to toxocariasis,
EPIDEMIOLOGICAL STUDIES toxoplasmosis, hepatitis A, hepatitis B, and hepatitis
C, CMV, HSV1, and HSV2, in over 5,000 subjects
There have been further epidemiological investiga- aged 20–59 years. Cognition was assessed by three
tions on anti-HSV1 IgG and IgM antibodies in serum tests: the Third National Health and Nutrition Exam-
from AD patients. The rationale for the serum anti- ination Survey computer-based simple reaction time
body work is that while the presence of IgG shows (SRT), symbol-digit substitution (SDS), and serial-
that the person has been infected with HSV1, the digit learning (SDL) tasks. The infectious burden
presence of IgM indicates that recent reactivation of index was found to be associated with two of the
HSV1 has occurred. However, serum antibody lev- three cognitive function measures, SDS and SDL, on
els reflect the response to the virus in the periphery; controlling for age, sex, race-ethnicity, educational
whether or not they reflect response to the virus in attainment, and the poverty-to-income ratio (an esti-
brain is unknown because at present, no imaging mate of socioeconomic status). HSV1, CMV, and
method can detect either latent HSV1 in brain, or hepatitis A were the main contributors to the asso-
reactivated virus if present at very low levels. It does ciation, that of hepatitis C was very low, and those of
seem likely though that events that cause reactivation HSV2, toxoplasmosis, toxocariasis, and hepatitis B
in the periphery, such as stress and immunosuppres- were intermediate.
sion, would cause reactivation also in the brain, but Possible microbial associations with cognition or
perhaps less severely. with AD in older subjects have recently been inves-
Many antibody studies have shown an association tigated in three studies. D’Aiuto et al. [52] used
between systemic infections and cognitive decline, functional MRI to evaluate brain activation during
with HSV1 as the main suspect [41–46] – but see a working memory task, and found an associa-
comment on [46] by Itzhaki and Klapper [47]. Leten- tion between “nonencephalitic HSV-1 infection”,
neur et al. [44], Feart et al. [45], and Lovheim et al. assessed by serum IgG, and functional brain changes
[46] mainly implicated IgM, thereby suggesting that linked with working memory impairment. Barnes
 R.F. Itzhaki / Herpes and Alzheimer’s Disease 1279

et al. [53], in a longitudinal study, implicated CMV is IVIG, so that treating AD patients with the fucan
in an increased risk of AD, and stated that HSV1 from Undaria together with valacyclovir (the biodrug
was not related to AD incidence. However, Itzhaki of ACV, which is far better absorbed in the body than
and Klapper [54] pointed out that Barnes et al used is ACV) would be particularly suitable, as well as
a far less sensitive assay for HSV1 than for CMV, relatively inexpensive.
detecting only a single viral glycoprotein for HSV1
whereas for CMV, all of its proteins were detectable. CONCLUSIONS
From data obtained in another longitudinal study,
Nimgaonkar et al. [55] maintained that CMV, HSV2, It is sometimes asserted that HSV1 presence in AD
or Toxoplasma gondii exposure, but not HSV1 expo- brain–the basis of the viral concept–and the effects
sure, were associated with cognitive decline in older of the virus, are a consequence either of the disease
persons; however, in their discussion they alluded to itself or of APOE-␧4 carriage conferring particular
the lack of sensitivity of their assays for HSV1, in any susceptibility to HSV1 infection of the brain. How-
case adding that not finding an association between ever, the former suggestion is rebutted by the fact that
exposure to HSV-1 and cognitive decline did not pre- the virus is present in brain of a high proportion of
clude a role for HSV1. Such differences in sensitivity elderly controls as well as AD patients, and the latter
of assays used for detecting antibodies to various by the fact that many elderly controls harbor HSV1
viruses should obviously be taken into account when in brain but only a few carry an APOE-␧4 allele [2].
comparing different viruses or estimating infectious Thus, the data strongly indicate that HSV1 is a cause,
burden. not an effect, of the disease (nor an effect of hav-
ing the “wrong” APOE allele). Also, as mentioned
above, the APOE-␧4-HSV1 association in cold sores
FURTHER ANTIVIRAL STUDIES (as well as APOE’s influence on microbial diseases
[60]) support the concept, as do the data described
Further investigations have been pursued on antivi- above and in previous reviews [1, 61], in particular,
ral treatment of cells in culture during HSV1 work on HSV1-APOE interactions [62–64]. And the
infection, following the studies on acyclovir (ACV), diversity of the types of study lends further credence
penciclovir (PCV), foscarnet [56], and BAY 57–1293 to the concept. Whether or not HSV1 acts in combina-
[57], all of which inhibit viral DNA replication. Each tion with another microbe is unknown but should be
of these agents greatly reduced HSV1-induced for- investigated. And whether HSV1 augments the effect
mation of P-tau and A␤ (and of HSV1, as expected), of a non-microbial factor is unknown also, but can-
P-tau dropping to almost zero, but A␤ decreasing not usefully be discussed, as no other factor has been
to 20–30% of the value without the antiviral. This proposed that is known to be more damaging specif-
showed that HSV1 DNA replication is needed for ically in those who will develop AD than in those
the abnormal phosphorylation of tau, but not for A␤ fortunate enough to evade it. Whatever the answers to
formation, so the decrease in the latter caused by these questions, a clinical trial treating patients with
the antivirals was attributed instead to the antivi- an antiviral to slow or halt disease progression is now
ral causing a reduction in viral spread, because of surely warranted.
reduced viral replication. Another agent, IVIG, also
reduced P-tau and A␤, probably through prevent-
ing HSV1 entry into cells, and treatment with a DISCLOSURE STATEMENT
combination of IVIG and ACV was found to be par-
ticularly effective [58]. The authors then tried a type The author’s disclosure is available online (http://
of anti-HSV1 antiviral known to prevent HSV1 entry, j-alz.com/manuscript-disclosures/16-0607r1).
namely, fucans-sulphated polysaccharides, which are
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