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Review 1: "SARS-CoV-2 infects brain choroid plexus and disrupts the blood-CSF-barrier"

This pre-print investigates SARS-CoV-2 tropism in a brain organoid model and claims infection primarily targets the choroid plexus with limited infection of astrocytes and neurons. While compelling, orthogonal validation in alternative models is needed.

Published onOct 02, 2020
Review 1: "SARS-CoV-2 infects brain choroid plexus and disrupts the blood-CSF-barrier"
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key-enterThis Pub is a Review of
SARS-CoV-2 infects brain choroid plexus and disrupts the blood-CSF-barrier
SARS-CoV-2 infects brain choroid plexus and disrupts the blood-CSF-barrier

Abstract Coronavirus disease-19 (COVID-19), caused by the SARS-CoV-2 virus, leads primarily to respiratory symptoms that can be fatal, particularly in at risk individuals. However, neurological symptoms have also been observed in patients, including headache, seizures, stroke, and fatigue. The cause of these complications is not yet known, and whether they are due to a direct infection of neural cells, such as neurons and astrocytes, or through indirect effects on supportive brain cells, is unknown. Here, we use brain organoids to examine SARS-CoV-2 neurotropism. We examine expression of the key viral receptor ACE2 in single-cell RNA sequencing (scRNA-seq) revealing that only a subset of choroid plexus cells but not neurons or neural progenitors express this entry factor. We then challenge organoids with both SARS-CoV-2 spike protein pseudovirus and live virus to demonstrate high viral tropism for choroid plexus epithelial cells but not stromal cells, and little to no infection of neurons or glia. We find that infected cells of the choroid plexus are an apolipoprotein and ACE2 expressing subset of epithelial barrier cells. Finally, we show that infection with live SARS-CoV-2 leads to barrier breakdown of the choroid plexus. These findings suggest that neurological complications may result from effects on the choroid plexus, an important barrier that normally prevents entry of immune cells and cytokines into the cerebrospinal fluid (CSF) and brain.

RR:C19 Evidence Scale rating by reviewer:

  • Reliable. The main study claims are generally justified by its methods and data. The results and conclusions are likely to be similar to the hypothetical ideal study. There are some minor caveats or limitations, but they would/do not change the major claims of the study. The study provides sufficient strength of evidence on its own that its main claims should be considered actionable, with some room for future revision.



The paper by Pellegrini et al. investigates SARS-CoV-2 tropism in brain in organoid systems. The authors have provided convincing evidence that choroid-plexus epithelial cells exhibit a significant degree of susceptibility to SARS-CoV-2 infection, whereas neurons and glia cells appear to be highly refractory of SARS-CoV-2. The authors identified an apoliprotein and ACE2 expressing subset of epithelial barrier cells within the choroid plexus as the main target of SARS-CoV-2. The authors have also provided evidence that SARS-CoV-2 can infect the choroid plexus epithelium from the basal side and that infection was associate with altered cell-cell junctions suggesting that SARS-CoV-2 infection can lead to a breakdown of the blood-CSF-barrier.

The paper is well-written, and the experimental section has been well executed. The results have been clearly presented and nicely illustrated and support the central message of the paper, namely that a subpopulation of choroid plexus epithelial cells, rather than neurons or glia, is a main target of SARS-CoV-2 under the experimental conditions of the study.

As with other studies using brain organoid systems to study the effect of infectious agent on the brain, there is the general limitation of whether organoids accurate reflect the environment of infections, like SARS-CoV-2, resulting in neurological symptoms observed in adults. Nevertheless, regardless of this limitation, this study is interesting and can provide insights into cell type specific susceptibility to infection.

The authors have convincingly shown that SARS-CoV-2 infection causes alterations in cell-cell junctions contributing to the blood-CSF-barrier. This finding would be strengthened by the incorporation of RNAseq studies to examine whether the observed physical injury to the blood-CSF-barrier is associate with changes in gene expression that have been linked to neurological symptoms. The observation by the authors of an apoliprotein and ACE2 expressing subset of choroid plexus cells as the main target of SARS-CoV-2 would be further enhanced by confirming that blocking of the ACE2 receptor prevents SARS-CoV-2 infection of these cells.

Based on their finding of abundant infection from the basal side of the choroid plexus epithelium, the authors suggest that the vascular compartment of the choroid plexus could be the SARS-CoV-2 entry point to the central nervous system. Although this a plausible scenario, there is very limited evidence of viremia in COVID-19 patients. The discussion section could incorporate comments and comparison with other known neurotropic viruses that target the choroid plexus.


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