Nanoscopy Reveals Heparan Sulfate Clusters as Docking Sites for SARS-CoV-2 Attachment and Entry

Reviewer #1 (Public review):

This paper investigates how heparan sulfate (HS) engagement functions in the cellular entry of SARS-CoV-2. A prevailing model that has been developed over the last five years by work from many laboratories using a variety of biochemical, structural, and microscopic approaches is that HS acts a co-receptor for SARS-CoV-2; its binding to SARS-CoV-2 both concentrates virus on the surface of target cells and allosterically alters the spike protein to promote an "up/open" RBD conformation that enables engagement of the proteinaceous receptor human ACE2 on the cell surface (PMID: 32970989, 35926454, 38055954, 39401361, 40548749). These two events enable plasma membrane fusion (after a cleavage event promoted by plasma membrane TMPSS2) or endocytosis and subsequent pH-dependent fusion (which requires a cathepsin L-mediated cleavage of the spike).

The authors in this study used a series of microscopy techniques, labeled pseudoviruses and authentic SARS-CoV-2 strains, and cells lacking or expressing HS and/or hACE2 to re-examine the specific stage(s) HS and hACE2 function in the entry process. They suggest that HS mediates SARS-CoV-2 cell-surface attachment and endocytosis, and that hACE2 functions "downstream" of this to facilitate productive infection. Their results also suggest that SARS-CoV-2 binds clusters of HS molecules projecting 60-410 nm, which act as docking sites for viral attachment. Blocking HS binding with pixantrone, a drug under clinical evaluation for cancer (due to its anti-topoisomerase II activity), inhibited SARS-CoV-2 Omicron JN.1 variant from attaching to and infecting human airway cells. The authors conclude that their work establishes a revised entry paradigm in which HS clusters mediate SARS-CoV-2 attachment and endocytosis, with ACE2 acting at some stage downstream. They speculate this idea might apply broadly to other viruses known to engage HS and has translational implications for developing antiviral agents that target HS interactions.

The strengths of the interesting and technically well-executed study include the use of multiple high-resolution microscopy modalities, the tracking of labelled viruses, the use of both pseudoviruses and authentic SARS-CoV-2, and the use of primary airway cells. Nonetheless, there are issues that need to be addressed to buttress the proposed model compared to earlier ones. These include: (a) the distinction between macropinocytosis and receptor-mediated endocytosis and what this might mean for productive SARS-CoV-2 infection; (b) the need to account for TMPRSS2 expression and plasma membrane fusion; (c) addition of genetic studies in which hACE2 is expressed in cells lacking HS; (d) an unclear picture of exactly where downstream hACE2 functions; and (e) and a need for comparative/additional study of earlier SARS-CoV-2 variants, which preferentially fuse at the plasma membrane.

Reviewer #2 (Public review):

In this manuscript by Han et al, the authors assess the binding of SARS-CoV-2 to heparan sulfate clusters via advanced light microscopy of viral particles. The authors claim that the SARS-CoV-2 spike (in the context of pseudovirus and in authentic virus) engages heparan sulfate clusters on the cell surface, which then promotes endocytosis and subsequent infection. The finding that HSPGs are important for SARS-CoV-2 entry in some cell types is well-described, but the authors attempt to make the claim here that HS represents an alternative "receptor" and that HS engagement is far more important than the field appreciates. The data itself appears to be of appropriate quality and would be of interest to the field, but the overly generalized conclusions lack adequate experimental support. This significantly diminishes enthusiasm for this manuscript as written. The manuscript is imprecise and far overstates the actual findings shown by the data. Additional controls would be of great benefit.

Further, it is this reviewer's opinion that the findings do not represent a novel paradigm as claimed. HS has been well described for SARS-CoV-2 and other viruses to serve as attachment factors to promote initial virus attachment. While the manuscript provides new insight into the details of this process, the manuscript attempts to oversell this finding by applying new words rather than new molecular details. The authors would be better served by presenting a more balanced and nuanced view of their interesting data. In this reviewer's opinion, the salesmanship significantly detracts from the data and manuscript.

Major Comments:

The authors need to rigorously define a "receptor" vs an "attachment factor." They also should avoid ambiguous terms such as "receptor underlying ...attachment" and "attachment receptor" (or at least clearly define them). Much of their argument hinges on the specific definition of these terms. This reviewer would argue that a receptor is a host factor that is necessary and sufficient for active promotion of viral entry (genome release into the cytoplasm), while an attachment factor is a host factor that enhances initial viral attachment/endocytosis but is neither necessary nor sufficient. The evidence does NOT implicate HS as a receptor under this fairly textbook definition. This is proven in Figure 1 (and elsewhere) in which ACE2 is absolutely required for viral entry.

The authors should genetically perturb HS biosynthesis in their key assays to demonstrate necessity. HS biosynthesis genes have been shown to be important for SARS-CoV-2 entry into some cells but not others (Huh7.5 cells PMID 33306959, but not in Vero cells PMID 33147444, Calu3 cells 35879413, A549 cells 33574281, and others 36597481. The authors need to discuss this important information and reconcile it with their data and model if they want to claim that HS is broadly important.

Is targeting HS really a compelling anti-viral strategy? The data show a ~5-fold reduction, which likely won't excite a drug company. The strengths and limitations of HS targeting should be presented in a more balanced discussion. Animal data showing anti-viral activity of PIX is warranted. This would enhance this claim and also provide key evidence of a relevant role for HS in a more physiologic model.

The authors provide little discussion of the fact that these studies rely exclusively on cell lines (which also happen to be TMPRSS2-deficient). The role of proteases in the role of HS should be tested in the cell lines and primary cells used, as protease expression is a key determinant of the site of fusion.

The claim that "SARS-CoV2 JN.1 variant binds to heparan sulfate, not hACE2, in primary human airway cells" is extraordinary and thus requires extraordinary evidence.

First, PIX reduces attachment by 5-fold, which is not the same as "nearly abolished." Also, anti-ACE2 "nearly abolished" entry in 7D, while PIX did not. If the authors want to make these claims, an alternative method to disrupt HS (other than PIX) is needed in primary airway cells. A genetic approach would be much more convincing. The authors should also demonstrate whether entry in their primary cell assays is TMPRSS2 vs Cathepsin L dependent (using E64d and camostat, for instance) as mentioned above.

Each figure should clearly state how many independent experiments and replicates per experiment were performed. What does "3 experiments" mean? Are these three independent experiments or three wells on one day?

Reviewer #3 (Public review):

Summary:

In this manuscript, the authors define a new paradigm for the attachment and endocytosis of SARS-CoV-2 in which cell surface heparan sulfate (HS) is the primary receptor, with ACE2 having a downstream role within endocytic vesicles. This has implications for the importance of targeting virion-HS interactions as a therapeutic strategy.

Strengths:

The authors show that viruses are internalized via dynamin-dependent endocytosis and that endocytic internalization is the major pathway for pseudotyped SARS-CoV-2 genome expression. They show that HS-mediated viral attachment is a critical step preceding viral endocytosis and also subsequent genome expression. Further, they show that hACE2 acts downstream of endocytosis to promote viral infection, and may be co-internalised with virions after HS attachment. Pseudotyped virus and authentic SARS-CoV-2 provide similar results. In addition, the authors demonstrate that remarkable clusters of multiple HS chains exist on the cell surface, visualised by a number of elegant microscopy methods, and that these represent the docking sites for virions. These visualisations are an important general contribution in themselves to understanding the nanoscale interactions of HS at the cell surface.

The use of a complementary range of methods, virus constructs, and cell models is a strength, and the results clearly support the conclusions.

Overall, the results convincingly demonstrate a different model to the currently accepted mechanism in which the ACE2 protein is regarded as the cell surface receptor for SARS-CoV-2. Here, the authors provide compelling evidence that cell surface clusters of HS are the primary docking site, with ACE2 interactions occurring later, after endocytosis (whilst still being essential for viral genome expression). This is an exciting and important landmark evidence which supports the view that HS-virion interactions should be viewed as a key site for anti-viral drug targeting, likely in strategies that also target the downstream ACE2-based mechanism of viral entry within endosomes.

Weaknesses:

This reviewer identified only minor points regarding citing and discussing other studies and typos, which can be corrected.