COVID-19 is a novel zoonotic disease that causes severe flu-like symptoms and respiratory distress (1–3). The novel coronavirus causes COVID-19 termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), similar to the coronavirus-induced SARS (4). Since the discovery of SARS-CoV-2 in early 2020, incalculable social and economic damage has been caused (5). COVID-19 is thought to be spread through aerosols and/or droplets. Since more than 97 percent of these droplets are smaller than 50 μm, the virus spreads more easily and is more difficult to prevent (6, 7). After an incubation period of 4–14 days, most infected people have symptoms of varying degrees that range from mild to severe, including cough, fever, lethargy, anorexia, and muscle pain (8, 9). Besides, the temporary loss of smell and taste are also common symptoms in patients with COVID-19 (10). Researchers worldwide are using various techniques to develop drugs against SARS-CoV-2 infections, such as Remdesivir and Lopinavir, which previously have been chosen for human clinical trials (11, 12). In addition, several different types of COVID-19 vaccines have been approved globally to battle with COVID-19. However, the number of patients with COVID-19 is still rising rapidly (13, 14).

The World Health Organization considers epidemic hemorrhagic fever, Ebola virus Disease, influenza, SARS-CoV-2, SARS, and other diseases with epidemic or epidemic potential impacting human society substantially (15–17). The Hantavirus-caused epidemic hemorrhagic fever significantly influences public health, which primarily affected Asia and Europe. The incubation period for epidemic hemorrhagic fever is around 14-21 days. Headache and fever are the most common symptoms, often accompanied by lack of appetite, bleeding tendency, and renal failure (18). Fever, hypotension, oliguria, diuresis, and recovery are the five main clinical stages of epidemic hemorrhagic fever(EHF). Recently, both EHF and COVID-19 have outbroken simultaneously in some regions. It warns the possibility of co-infection of EHF and COVID-19. Thus, it also drives us to consider the strategies to treat this potential co-infection in advance. Although the type of pathogen and pathophysiology vary, several studies have shown that thrombosis in COVID-19 is associated with hemorrhage in viral hemorrhagic fever. Since the thrombogenic phase always precedes the bleeding phase, it can be considered a sequential change in the timing of acute infectious events (19). The two infections share similar symptoms and laboratory features early, posing challenges for accurate diagnosis and treatment. Due to the globalization of the economy and public transportation, many diseases have exceeded the limit of original geographic origins and are now affecting people worldwide (20). Previously, COVID-19 and dengue co-infection had placed a heavy burden on healthcare systems in dengue-endemic areas (21, 22). Therefore, to prevent the linked attacks of Hantavirus and COVID-19, we need more studies into treatments for these transmitted diseases.

Puerarin is the main biologically active ingredient extracted from Pueraria Lobata, widely used in the therapy of various diseases such as diabetes, Parkinson’s disease, Alzheimer’s disease, and cancer (23). Studies have shown that puerarin may play important roles by regulating different pathways, including oxidative stress, cell cycle, inflammation, and autophagy (24). Puerarin may treat EHF/COVID-19 by modulating the immune system to enhance the induction of Tregs and modulate immune tolerance (25, 26). In conclusion, puerarin has potential therapeutic value in treating viral infections. Therefore, as shown in Figure 1, we analyzed genes regulated by puerarin, EHF, and COVID-19, through bioinformatic methods and obtained common core targets and common key pathways to explore whether puerarin could be a potential drug candidate for EHF/COVID-19.

COVID-19, a rapidly expanding disease, is still spreading over the world. However, specific treatments for COVID-19 are still in development. COVID-19 has caused economic, social, health, and personal lifestyle difficulties across the globe. According to the most recent figures issued by Johns Hopkins University in the United States on January 7, 2022, the number of confirmed cases of COVID-19 worldwide has surpassed 300 million. While it takes only five months for the total number of infected people to reach to 300 million from 200 millions. As a global emerging zoonotic pathogen, Hantavirus causes EHF in Asia and Europe. Each year, more than 20,000 hantavirus cases are reported worldwide, most of which come from Asia (27). The number of Hantavirus cases has rapidly increased in recent years, posing a major threat to human health. EHF patients can also be infected with COVID-19; however, no effective anti-hantavirus/COVID-19 medications are available. The combination of traditional Chinese and Western medicine therapy modalities has been widely employed in the clinical therapy of patients with COVID-19. Traditional Chinese medicine can decrease the risk of severe disease of COVID-19 positive patients (28). The potential therapeutic value and molecular mechanism of puerarin in the therapy of EHF/COVID-19 were investigated. We found 69 possible therapeutic targets and molecular mechanisms by using bioinformatics for puerarin’s role in COVID-19 and EHF.

Various pharmacological studies against the SARS-CoV-2 and the host are currently being carried out. The narrow antiviral spectrum of antiviral drugs and the rapid evolution of drug resistance have led to a limited therapeutic effect on patients with COVID-19. Natural products are a key source for antiviral drug research and development, and puerarin has exhibited antiviral properties as a natural product. Studies showed that the mechanism of puerarin in inhibiting HIV-1 replication might be connected to limiting viral particles’ initial attachment to the cell surface of T lymphocytes and macrophages (29). Recent studies have shown that puerarin has antiviral effects and can inhibit neuraminidase in vivo and vitro (30). In addition, puerarin is a potential drug for treating Staphylococcus aureus-mediated infections, preventing Staphylococcus aureus from damaging human alveolar epithelial cells (31).

The common targets of COVID-19, EHF, and puerarin, according to present study, are ACE, ACE2, AGTR1, AKT1, BCL2, CASP3, CASP9, EGFR, ESR1, F10, GPT, and others. We hypothesize that RELA, JUN, NF-κB1, NF-κB2, and FOS are the main targets of puerarin in the therapy of EHF/COVID-19 based on protein interactions. Most patients with severe COVID-19 have elevated inflammatory cytokines and infection-related markers. Jun, FOS, or ATF, which bind to a shared AP-1 binding site, are subunits of the dimeric transcription factor AP-1. AP-1 factors can regulate different target genes to execute a range of biological tasks. c-Jun is involved in multiple cellular biological processes, including inflammatory responses. c-Jun can mediate the human inflammatory response induced by cytokines, thereby establishing a feedback loop to enhance the inflammatory effect after viral infection (32, 33). Therefore, drugs targeting c-Jun protein can be used to treat inflammatory diseases. FOS participates in human development by modifying the structure of cells as a stress response gene. The FOS induced by bacteria can activate the downstream immune cascade to eliminate bacteria (34).In mammals, NF-κB is widely expressed and regulates multiple cellular processes, including immunity, stress responses, and apoptosis. Viruses frequently target the NF-κB pathway to improve viral replication, host cell survival, and immune evasion. The NF-κB family has five members in human cells, including NF-κB1 and NF-κB2. By regulating numerous pro-inflammatory cytokines, chemokines, and adhesion molecules, NF-κB plays a role in the activation and recruitment of inflammatory regulatory cells (35). TNF and IL-1 can also influence NF-κB activation by strengthening the immune response and lengthening the time spent in the human body (36). RELA (also known as p65) is a member of the NF-κB family of proteins. The development of many inflammatory disorders is dependent on the huge rise in active p65 and the subsequent transactivation of effector molecules (37). Although the induction and activation of p65 are usually transient, it can activate downstream target genes with various functions, influencing cell biological processes such as proliferation and apoptosis (38, 39). As a key target in the inflammatory response, new drugs have been developed targeting p65. In conclusion, the molecular mechanism of puerarin in the treatment of EHF/COVID-19 may be strongly related to immune and inflammatory responses.

The results of the GO term enrichment revealed that the process of oxidative stress and oxygen metabolism might be linked to puerarin’s therapeutic effect. The disulfide-thiol balance plays an important role in viral entry into host cells, and oxidative stress from free radicals can disrupt this balance (40). COVID-19 has been proven in recent research to cause excessive oxidative stress, which can cause respiratory illness and even death in patients (41). Antioxidant supplementation can help to keep the human immune system stable and reduce the danger of SARS-CoV-2 infection. According to the biopsy of intestinal mucosa from EHF patients, the rise in Ki67 and cell proliferation could be linked to local oxidative stress (42). Puerarin can increase the expression of Nrf2 and HO-1 in diabetic mice, reducing oxidative stress and delaying cataract progression (43).

According to KEGG pathway enrichment analysis and literature, the molecular mechanism of puerarin in the therapy of EHF/COVID-19 may be related to HIF-1, TNF, IL-17, and Toll-like receptor signaling pathway. HIF-1α induced monocyte metabolic disturbance in patients with COVID-19 directly suppresses T cell responses and reduces epithelial cell survival (44). Only the mixture of TNF-α and IFN-γ induces cell death characterized by inflammatory cell death PANoptosis in Patients with COVID-19. The specific mechanism is that TNF-α and IFN-γ jointly activate the JAK/STAT1 axis, which drives caspase-8/FADD-mediated PANoptosis (45). As a result, neutralizing drugs targeting TNF-α and IFN-γ may be used in the clinical therapy of patients with COVID-19. In EHF patients, Hantavirus can work together with TNF- to stimulate the synthesis of ERK1/2, causing proteinuria and renal failure (46). Puerarin prevents normal hepatocyte apoptosis in septic mice by inhibiting the production of TNF-, IL-6, and IL-1 (47). According to clinical research, the deterioration of EHF is generally followed by an increase in cytokines such as IL-10, IL-17, and IL-12p70 (48). Through the MyD88-independent signaling pathway, Toll-like receptor (TLR)4, a member of TLRs family, may perform an anti-infective role against Hantavirus in the host (49). TLR4-mediated inflammatory signaling molecules are upregulated in patients with COVID-19 compared to healthy individuals, suggesting that TLR4 signaling may be associated with pathological inflammation in patients with COVID-19 (50). Puerarin reduces nickel-induced oxidative stress and inflammatory reactions via modulating the TLR4/p38/CREB signaling pathway, according to research (51).

We identified 69 core COVID-19, EHF, and puerarin targets and signaling pathways, including NF-κB, IL-17, TNF, TLR, and HIF-1. It investigated puerarin’s possible molecular mechanism in treating EHF/COVID-19 and demonstrated multi-targeted characteristics in treating infections. However, there are some limitation in present study. All of the data came from databases, and there was no follow-up in vivo or in vitro trials to back up the conclusions.

In conclusion, we found that puerarin may treat patients with EHF/COVID-19 through anti-inflammatory, immunomodulatory, and antiviral, and explored potential therapeutic targets and molecular mechanisms of puerarin through bioinformatics analysis. These findings have not been tested in humans, but may demonstrate the potential value of Puerarin in the treatment of EHF/COVID-19.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Supplementary Material.

CZ developed the concept of the project. The data was collected and evaluated by WL, XL, and HW with the help of KN, QM, and JH. All authors reviewed and discussed the results and contributed to the paper preparation. CZ, WL, XL, and HW wrote the manuscript. All authors have read and approved the manuscript.

The study was supported by Shenzhen Key Laboratory Foundation (ZDSYS20200811143757022).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.