EMBO Molecular Medicine

Spinal muscular atrophy (SMA) is an oft-fatal infantile-onset neuromuscular disease caused by low SMN protein. Administration of SMN-inducing agents to SMA newborns prevents early mortality, but therapeutic outcomes vary considerably, and disease mechanisms remain poorly understood. Genetic modifiers can provide clues to disease mechanisms and serve as targets for novel treatments. Here, we describe how one such modifier suppresses SMA in model mice. We show that the modifier, an Hspa8G470R synaptic chaperone variant we previously identified, functions beyond an already defined role as an SMN2 splice-switcher. Even in mice lacking the SMN2 gene, the modifier, whether expressed genetically or exogenously, potently suppressed disease, preventing motor neuron degeneration, ameliorating neuromuscular dysfunction and extending lifespan more than ten-fold. Unexpectedly, this was once again associated with incremental SMN increase - an outcome we discovered is linked to Hspa8G470R-mediated autophagy, effects of the modifier on autophagy-associated intermediate complexes and, ultimately, reduced SMN turnover. Interestingly, however, Hspa8G470R also stimulated neuromuscular transmission significantly, raising the effective, functional readily releasable pool of motor neuronal synaptic vesicles. This effect was not limited to mutants alone but apparent in healthy controls too and did not correlate with mere increase in SMN. Combined, these outcomes suggest that Hspa8 governs neuromuscular function in several ways including direct effects on synapses. Mechanisms revealed here shed additional light on pathways gone awry in SMA - ones that might be modulated to develop or refine therapies for neuromuscular disorders at large.

Neuronopathic Gaucher disease (nGD) is a lysosomal storage disorder caused by GBA1 mutations, leading to defective acid {beta}-glucosidase (GCase) and accumulation of glycosphingolipid substrates, causing inflammation and neurodegeneration. Patients with nGD manifest severe neurological symptoms, but current animal models fail to fully recapitulate human condition, posing a major barrier to the development of effective therapies targeting the brain. To bridge this gap, we have developed midbrain-like organoids (MLOs) from human induced pluripotent stem cells (hiPSCs) of nGD patients with GBA1L444P/P415R and GBA1L444P/RecNcil mutations to model nGD brain pathogenesis. These nGD MLOs exhibited GCase deficiency, resulting in diminished enzymatic function, accumulation of lipid substrates, widespread transcriptomic changes, and impaired dopaminergic neuron differentiation, mirroring nGD pathology. GBA1 mutation correction mediated by CRISPR/Cas9 restored GCase activity, normalized lipid substrate levels, and rescued dopaminergic neuron function, confirming the causal role of GBA1 mutations during early brain development. Using this novel platform, we further evaluated therapeutic strategies, including SapC-DOPS nanovesicles delivering GCase, AAV9-GBA1 gene therapy, and substrate reduction therapy with GZ452, a glucosylceramide synthase inhibitor currently under clinical investigation. These treatments either restored GCase activity, reduced lipid substrate accumulation, improved autophagic and lysosomal abnormalities, or ameliorated dysregulated genes involved in neural development. These patient-specific, 3D neural models offer a transformative, physiologically relevant platform for unravelling disease mechanisms and accelerating the discovery of therapies for patients with nGD.

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis and is characterised by an extensive pro-tumorigenic stroma. Although most PDAC cases occur in older patients, the impact of ageing on malignant-stromal interactions and therapy response remains poorly understood. Here, we established orthotopically-grafted organoid-derived PDAC models across three murine age groups to characterise changes in the PDAC stroma and malignant cells with ageing. Cross-species analyses of tumour transcriptomes using a graph-embedding approach showed that integrating mouse models of different ages better captures the diversity of human PDAC, and that aged models more faithfully recapitulate the biology of older patients with PDAC. We also demonstrated that aged PDAC models have a more inflammatory stroma than that of younger tumours, shaping the malignant cell transcriptome. Finally, graph-embedding identified IRAK4 as a candidate therapeutic vulnerability in aged, but not young, KRAS- and p53-mutant PDAC, which we validated in preclinical drug studies. These findings highlight how ageing is a critical determinant of PDAC biology and associated therapeutic vulnerabilities, which should be an important consideration when designing disease models for preclinical development of precision therapies.

Although it has been known for over 30 years that CAG trinucleotide repeat expansions in the HTT gene are the cause of Huntingtons disease (HD), it is still not understood how these mutations lead to the loss of striatal spiny projection neurons (SPNs) and other vulnerable neuronal cell types in HD. Here we show that SCN4B, a gene that is enriched in neurons that influence motor function, including striatal SPNs, modulates HD-associated phenotypes in vivo. Loss of Scn4b in wild-type mice mimics and Scn4b overexpression in an HD mouse model rescues several HD-associated phenotypes, including motor and cognitive deficits. Single nucleus RNA sequencing (snRNA-seq) analysis reveals that loss of Scn4b replicates several HD-associated gene expression signatures in the striatum. Conversely, overexpression of Scn4b rescues HD gene expression signatures and improves various SPN electrophysiological properties in HD model mice. Taken together, our results implicate loss of Scn4b expression as an important contributor to HD pathogenesis and therapeutic target in HD.

Niemann-Pick disease, type C is an autosomal recessive, fatal, neurodegenerative disorder caused by pathological variants in NPC1 or NPC2. Dysfunction of either NPC1 or NPC2 results in impaired intracellular cholesterol transport and subsequent storage of unesterified cholesterol in endolysosomal compartments. Earlier cell-based studies utilized patient fibroblasts to study this disease; however, neuronal cells allow for investigation of the neurodegenerative aspect of NPC1. Expression of neurogenin in induced pluripotent stem cells leads to the generation of i3Neurons (integrated, isogenic, and inducible), allowing for rapid, synchronized growth of homogenous neurons. In this study, we report the development and characterization of a human iPSC-derived NPC1I1061T/I1061Ti3Neuronal model system. NPC1I1061Tis a missense variant resulting in a misfolded protein targeted for proteasomal degradation in the ER. NPC1I1061T/I1061T i3Neurons phenocopied the cellular pathological features of NPC1 disease including endolysosomal cholesterol accumulation, lysosomal morphological changes, and response to the proteostasis modulator, mo56HC. The NPC1 phenotype was alleviated by 2-hydroxypropyl-{beta}-cyclodextrin treatment, a drug demonstrating efficacy both in vitro and in vivo. This NPC1I1061T/I1061T i3Neuronal cell line can facilitate future high-throughput drug and genomic screens, particularly those aimed at identifying proteostasis regulators that improve the expression/stability of the mutant NPC1 protein.

Methylmalonic acidemia (MMA) is a recessive genetic disease caused by variants in the MMUT (mitochondrial enzyme methylmalonyl-CoA mutase) gene or by defects in transport or metabolism of MMUT cofactor (5 deoxyadenosylcobalamin), including variants in the MMAB gene. For the most recurrent pathogenic MMAB variant, c.556C>T (R186W), we identified a corrective editing strategy using adenine base editing. Deploying an adenine base editor mRNA and optimized hybrid guide RNA with lipid nanoparticles, we observed efficient in vitro corrective editing of the variant to wild-type, with minimized bystander editing and off-target editing in hepatocytes. These observations lay the groundwork for a gene editing therapy for patients with MMA resulting from at least one copy of the MMAB c.556C>T (R186W) variant, as well as a platform of similar therapies for patients with MMA caused by other variants amenable to adenine base editing.

Despite considerable advances, the emergence of treatment resistance to tyrosine kinase inhibitors (TKIs) therapy remains a significant challenge in chronic myeloid leukemia (CML). Here, we report the first clinical case of resistance to combined ponatinib and asciminib therapy in a CML patient who relapsed with B lymphoblastic blast crisis. While at presentation the patient harbored the canonical e13a2 BCR::ABL1 fusion, at relapse his disease harbored the T315I mutation together with a novel e6a3 BCR::ABL1 fusion, arisen by internal deletion in the original translocated allele. Structural modeling and biochemical analyses demonstrated that deletion of exon 2-encoded residues of ABL1 destabilizes the autoinhibited conformation, resulting in a hyperactive kinase with increased propensity for B-cell differentiation. Functional studies revealed that both BCR::ABL1e6a3 and BCR::ABL1e6a3/T315I conferred resistance to ponatinib and asciminib, alone or in combination. BCR::ABL1e6a3 demonstrated enhanced sensitivity to active-state selective inhibitors dasatinib and bosutinib, whereas BCR::ABL1e6a3/T315I remained resistant. Combined drug sensitivity assays showed that axitinib restored inhibitory activity when combined with ponatinib or asciminib. Strikingly, a combination of axitinib and asciminib with low dose ponatinib fully suppressed enzymatic activity of BCR::ABL1e6a3/T315I and cellular proliferation. These data show that treatment with asciminib and ponatinib can select for mutations with notably elevated enzymatic activity, effectively targeted by an axitinib-based triple combination. These data highlight the remarkable mutability of the BCR::ABL1 kinase, including through novel isoforms and provides a strong rationale for the clinical assessment of a triple inhibitor combination as a strategy to overcome resistance to dual ponatinib and asciminib therapy.

Infections with the protozoan parasite Trypanosoma cruzi are widespread in the Americas and can lead to severe cardiac and/or gastrointestinal pathology. Current treatments are limited to monotherapies characterised by prolonged dosing regimens, disputed efficacy and toxic side-effects. Here, we demonstrate that short duration co-administration of well-tolerated sub-efficacious oral doses of the parasite-selective proteasome inhibitor GNF6702 and the pro-drug benznidazole produce parasitological cure in an experimental model of chronic Chagas disease.

Three-dimensional (3D) organotypic cultures recapitulate key structural features of oral tumours and provide controlled, ethical, and reproducible research platforms. However, their ability to faithfully recapitulate in vivo tissue composition and their translational relevance require rigorous validation. Here, we characterised a head and neck squamous cell carcinoma (HNSCC) model using single-cell RNA sequencing to assess maturation, cellular heterogeneity, functionality, and inter- and intra-tissue interactions within epithelial and stromal compartments. The epithelial layer of the model differentiated into populations closely resembling the tissue of tumour origin, including dividing and precursor cells, heterogeneous basal layer, suprabasal cells, and metabolically specialised populations. All epithelial lineages emerged from proliferative progenitors, driven by dynamic transcription factor programmes. The collagen-rich stroma contained functionally diverse fibroblasts reflecting the heterogeneity of cancer-associated fibroblasts in vivo, including dividing, matrix-producing, immune-responsive, and tumour-like populations. Importantly, extensive epithelial-stromal communication networks developed, essential for cancer epithelium maintenance and tumour microenvironment regulation. Matrix-derived signals, particularly fibronectin, osteopontin, and laminins, constituted dominant inputs to CD44-expressing cancer cells and are associated with patient survival in HNSCC, highlighting potential therapeutic targets. Overall, this organotypic HNSCC model exhibits high functional fidelity, captures key tumour elements relevant for therapy and resistance and brings confidence in non-animal drug testing.

Targeting mitochondrial Complex I (CI) is a currently emerging anti-cancer strategy, with several enzyme inhibitors entering clinical trials. Among others, aggressive high-grade serous tubo-ovarian cancer (HGSOC) may particularly benefit from this therapeutic approach due to the scarce response to first- and second-line treatments, with consequent high mortality, such as the anti-angiogenic bevacizumab. We here show that CI represents a vulnerability in HGSOC, which can be exploited for therapeutic intervention. Indeed, ablating CI function in OV-90 HGSOC cells led to significant in vivo tumor growth decrease, smaller masses, and lower KI-67 proliferative index. This was confirmed in a switch-off system in which CI deprivation was induced during tumor progression to mimic pharmacologic treatment, suggesting this result can be achieved in growing neoplasms. We also show that abolishing CI in HGSOC cells leads to failure in stabilizing the hypoxia inducible factor-1a and to respond to hypoxia through the transcriptional activation of its target genes, ultimately lowering vascular endothelial growth factor (VEGF) and generating an immature intratumor vascular system accompanied by a decreased blood flow. Last, we demonstrate that targeting CI sets the biological basis for increased sensitivity to anti-angiogenics, as CI-deprived tumors displayed growth arrest when bevacizumab was administered, unlike their CI-competent counterpart. Our findings point to CI inhibition as a booster for anti-VEGF therapies and pave the way for combined protocols in treatment of HGSOC.

Charcot-Marie-Tooth Type 4B3 (CMT4B3) is a genetic disorder leading to peripheral axon degeneration and clinical manifestations of distal weakness and gait impairment. CMT4B3 is caused by mutations in SBF1/MTMR5, a negative regulator of phosphoinositide signaling and autophagy. Although SBF1 mutations are ubiquitously expressed, how and why loss of SBF1/MTMR5 exerts deleterious effects predominantly in neurons of the peripheral nervous system (PNS) is unknown. To investigate the effects of mutant SBF1/MTMR5 on PNS neurons compared to non-neurons, we engineered a novel and unique model system of CMT4B3 using human induced pluripotent stem cells (iPSCs) differentiated into key components of the PNS: motor neurons (iMNs), sensory neurons (iSNs), or skeletal muscle (iMuscle). To model CMT4B3, we used iPSCs derived from a CMT43B patient, or genetically knocked down SBF1 in WT cells. Strikingly, CMT4B3 iMNs showed the highest degree of cell degeneration among all cell types, concordant with the clinical phenotype of patients. We also found that CMT4B3 iMNs and iSNs showed attenuated expression of MTMR5 and related paralogs MTMR2 and MTMR13. Knockdown of SBF1 most significantly augmented autophagy in iMNs than other cell types. Finally, we tested treatment with VPS34-IN1, a pharmacologic inhibitor of the Class III PI3-Kinase functioning in opposition to MTMR5 in regulating phosphoinositides, and found that VPS34-IN1 rescued cell death in CMT4B3 iMNs. Together, our results for the first time confirm PNS cell type-specific differences in myotubularin expression, autophagy, and vulnerabilities to SBF1 mutations, and identify a novel therapeutic strategy of high disease-modifying potential for CMT4B3.

Loss of neuronal regenerative capacity is a common feature of neurodegenerative disease and axonal injury, yet the transcriptional programs governing this state remain poorly defined. Stathmin-2 (STMN2), a tubulin-binding protein essential for axon maintenance and repair, is profoundly depleted following loss of nuclear TDP-43 in neurodegenerative disease. Here, we identify statins as potent inducers of STMN2 expression. Pharmacological and genetic suppression of the mevalonate pathway, and subsequent prevention of protein geranylgeranylation, restored STMN2 levels in TDP-43 deficient cells and promoted neurite growth. STMN2 induction was abrogated when using a statin analogue unable to interact with HMG-CoA reductase, and through co-administration of mevalonate or geranylgeranyl diphosphate substrates. RNA-seq revealed that statins induce a coordinated pro-regenerative transcriptional response, including activation of the AP-1 transcription factor complex gene, ATF3. Loss of ATF3 attenuated STMN2 induction in vitro, and diminished injury-induced Stmn2 upregulation in spinal motor neurons in vivo. These results demonstrate statins as modulators of ATF3 and STMN2 expression and highlight their therapeutic potential in neurodegenerative disease.

Nutrient availability is a critical environmental factor that influences the metabolism and adaptability of cancer cells, including acute lymphoblastic leukaemia (ALL) cells, prone to relapse in the central nervous system (CNS). Currently available cell culture media contain supraphysiological nutrient levels and do not represent the restricted metabolic environment of CNS-ALL which resides in the leptomeninges surrounded by cerebrospinal fluid (CSF). Therefore, we formulated a novel physiological CSF-like cell culture medium (CSFmax) that recapitulates the unique metabolite composition of the CSF. Through in vitro and in vivo metabolic and functional studies, we demonstrate that ALL cells cultured in CSFmax rewire their metabolism, closely mimicking the metabolic phenotype of CNS-ALL, including their metabolic activity and redox state. Utilising CSFmax, in comparison to conventional nutrient-rich culture media, we identified an essential role for autophagy in ALL adaptation to the CNS niche. This was evident by increased autophagic activity and selective sensitisation of ALL cells to pharmacological inhibition of autophagy and genetic knockout of Unc-51 Like Autophagy Activating Kinase 1 (ULK1) or autophagy related 7 (ATG7). Importantly, using a robust preclinical in vivo model, mice xenografted with ULK1 and ATG7 deficient ALL cells exhibited reduced CNS disease burden when compared to mice xenografted with control cells. Overall, our findings provide strong evidence that physiological CSFmax is superior to current in vitro culture systems in recapitulating the metabolic signature of CNS resident ALL cells. By exploiting this system, we revealed for the first time autophagy as a targetable therapeutic vulnerability in CNS-ALL. Key PointsO_LICulturing ALL cells in bespoke CSF-like medium (CSFmax) recapitulates the metabolic adaptation of ALL cells in the CNS niche C_LIO_LIAutophagy is critical for metabolic adaptation and survival of CNS resident ALL cells C_LI

Alzheimers disease (AD) is one of the most common age-related causes of death, with limited effective disease-modifying treatments. Although metformin shows promise as a disease-modifying agent for AD, its molecular mechanism--specifically how it confers neuroprotection despite potentially increasing amyloid-beta (A{beta}) load--remains obscure. Here, we demonstrate that metformin functions as a pharmacological activator of the ubiquitin-binding protease rngo/DDI2. Through a genetic screen in Drosophila, we identified rngo/DDI2 as a potent suppressor of A{beta} toxicity. We provide in silico and genetic evidence that metformin interacts with the conserved D257 residue of the rngo/DDI2 RVP domain, inducing homodimerisation and subsequent protein stabilisation. This activation boosts proteasome activity in the presence of A{beta} preferentially clearing highly abundant proteins to preserve proteostasis. Crucially, this intervention is broadly effective; rngo/DDI2 upregulation robustly suppresses toxicity in models of TDP-43 and C9orf72-repeat expansion pathology, indicating a generalised mechanism of neuroprotection. Supported by human iPSC data and evidence of DDI2 depletion in AD patient brains, our results identify rngo/DDI2 as a conserved regulator of neuronal resilience. We propose that directly targeting DDI2 stabilisation represents a novel, broadly applicable therapeutic strategy to counteract proteotoxic stress across a broad spectrum of neurodegenerative diseases.

Diabetes mellitus (DM) and obesity frequently coexist. Both are associated with adipose dysfunction, yet the contribution of DM remains uncertain. Using bulk transcriptomics of subcutaneous and visceral adipose tissue (SAT and VAT, respectively), we show that DM is associated with shared and distinct patterns of differential gene expression in these depots. Gene ontology analysis of hits across depots highlighted extracellular matrix, inflammatory pathways, metabolism, axon guidance and endoplasmic reticulum stress. Histology revealed larger SAT adipocytes in people with DM, but only in the overweight category. Body mass index (BMI)-stratified transcriptomic analyses of SAT identified DM-associated hits present only in the overweight group. These were validated in plasma protein form using UK Biobank, informing our development of an adipose risk score that predicted incident DM in overweight people beyond a clinical risk score. Hence, molecular signatures of diabetic SAT can define high-risk adiposity, which may aid the targeting of clinical interventions.

Mutations in the CDKL5 gene cause CDKL5 deficiency disorder (CDD), a severe neurodevelopmental encephalopathy characterized by a broad range of symptoms, including early-onset seizures, profound motor impairment and dysmorphic facial features. Current treatment options remain limited and largely focus on seizure management, which is often challenging to control, underscoring the critical need for new effective therapies. To identify potential novel candidate molecules for the treatment of CDD, we performed the first in vivo drug screening using a cdkl5 mutant zebrafish model. Recapitulating key features of the human disorder, cdkl5-/- larvae exhibit reduced locomotor behavior, providing a robust readout to assess therapeutic efficacy. By screening 170 compounds from MAPK Inhibitor and Histone Modification Libraries, both implicated in CDKL5 dysfunction, we identified 18 and 12 small molecules that partially or fully restored locomotor activity, respectively. Among these, fisetin, divalproex, resveratrol, and VX-702 were further evaluated for their capacity to rescue cdkl5-/- craniofacial defects and altered gene expression. Fisetin demonstrated the most consistent phenotypic improvement, including partial restoration of craniofacial abnormalities and normalization of gene expression levels. Future research aimed at elucidating the molecular mechanisms underlying the observed rescue effects will be critical to understand their mode of action. Overall, our study demonstrates the utility of this rapid and scalable zebrafish-based screening approach for therapeutic discovery in CDD and identifies promising therapeutic molecules that warrant further validation in complementary preclinical systems.

PrP lowering is a validated therapeutic hypothesis in prion disease. To identify small molecules that reduce PrP levels, we performed phenotypic screening in cultured cells. To prioritize PrP specificity in our primary screen, we generated mouse N2a cells stably expressing GFP and used high content imaging analysis to select compounds that lowered PrP without affecting GFP signal or cell viability. Screening a curated library of 3,492 compounds with annotated mechanisms of action identified two small molecules, EYH (PubChem CID: 71678945) and LCZ (PubChem CID: 24970350), that selectively and dose-dependently lowered PrP. Proteomics on whole cell lysates identified PrP as the #1 or #2 most potently downregulated out of 8,722 proteins detected. Both compounds minimally affected Prnp mRNA, reduced expression of exogenously transfected PrP, and remained potent in non-dividing primary cells, consistent with a post-translational mechanism. Co-treatment with the proteasome inhibitor MG132 yielded accumulation of unglycosylated PrP, demonstrating proteasome clearance of PrP. However, both compounds showed limited or no activity in human cell lines, and failed to reduce PrP in vivo after 14 days of treatment. These findings highlight the challenges associated with mechanism-agnostic phenotypic screening for PrP-lowering compounds and support prioritizing compounds with known mechanisms of action.

As a consequence of their sizes, many loss-of-function genetic mutations fall within large genes. A major gene-therapy tool that could be used to solve large swaths of the genetic diseases that result from these inherited mutations is large-fragment knock-in. I.e. instead of attempting to create separate treatments for each and every location that these mutations occur in, large groups of patients could be aided via a single safe-harbor integration of the full-length coding sequence. Towards this goal, we have created a set of early stage gene-editing enzymes that can help mediate large cargo integration at a safe harbor locus in human cells. When expressed in stable lines, our S-SELeCT (Site-Specific Large Cargo Targeting) integrase fusions can facilitate integration of a 10 kb plasmid at frequencies up to 32%, and when delivered transiently via plasmid transfection, we were able to achieve up to 13% knock-in. These are the first serine integrase enzymes that have been evolved fully in human cells, and the first to recognize an endogenous symmetric non-pseudosite - the first true human serine integrase attachment site. GRAPHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=79 SRC="FIGDIR/small/702954v2_ufig1.gif" ALT="Figure 1"> View larger version (10K): org.highwire.dtl.DTLVardef@1385a3org.highwire.dtl.DTLVardef@1aaae1eorg.highwire.dtl.DTLVardef@8d6089org.highwire.dtl.DTLVardef@1bcc5bb_HPS_FORMAT_FIGEXP M_FIG C_FIG

Vacuole, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome (VS) is a severe autoinflammatory disease driven by somatic mutations in ubiquitin-like modifier activating enzyme 1 (UBA1), for which disease activity biomarkers and therapeutic targets are needed. We conducted longitudinal deep phenotyping of patients with VS and found that ribonuclease 1 (RNASE1) expression is most strongly correlated with the disease activity score measured by the VEXAS Current Activity Form (VEXASCAF). Single-cell RNA-sequencing showed that RNASE1 was upregulated in VS monocytes. We generated human monocytic cell lines harboring UBA1 mutations (p.Met41Val, p.Met41Leu, and p.Met41Thr). These cells exhibited varying degrees of impaired ubiquitination and subsequent pathological features such as the unfolded protein response, increased pro-inflammatory cytokine production, cell death, and RNASE1 expression, mirroring the genotype-phenotype associations observed in patients with VS. Multi-omics analyses revealed that genotypes linked to greater clinical severity were enriched in pro-inflammatory, interferon, and necroptosis signatures. Notably, functional interrogation demonstrated that inhibition of receptor-interacting protein kinase 3 (RIPK3), a key regulator of necroptosis, markedly suppressed all these pathological features, including the elevated RNASE1 expression. These results identify the RIPK3-RNASE1 axis in VS, highlighting RNASE1 as a potential biomarker and RIPK3 as an attractive therapeutic target.

Hantaviruses are globally distributed rodent-borne viruses that cause human diseases. In Europe, the Puumala orthohantavirus (PUUV) is the most prevalent hantavirus and causes a mild form of hemorrhagic fever with renal syndrome (HFRS), characterized by renal, hemorrhagic and pulmonary manifestations. To date, the mechanisms underlying pulmonary symptoms are still poorly understood, highlighting a significant gap in our knowledge of the disease. In this translational study, we investigated the role of hyaluronan (HA), an extracellular matrix glycosaminoglycan with a high water-retaining capacity, in pulmonary disease severity during PUUV infection and examined whether PUUV disrupts HA metabolism. We found that plasma HA levels increased during acute PUUV infection, normalized during convalescence, and correlated with disease severity. In lung tissue from fatal PUUV cases, HA accumulated extensively and was associated with disrupted alveolar architecture. Furthermore, in bronchoalveolar lavage fluid, high-molecular weight HA levels were elevated in patients with greater pulmonary involvement. In vitro, infecting a panel of human lung cell types, we found that PUUV infection altered HA homeostasis in a cell-type-specific manner. Infection induced an imbalance in HA metabolic pathways, with early upregulation of hyaluronan synthases followed by induction of HA degradation and receptor genes. Primary lung fibroblasts similarly showed increased HA production with pronounced donor variability in HA regulating gene expression not explained by infection levels. These findings identify dysregulated HA metabolism as a feature of PUUV infection and link pulmonary HA accumulation to disease severity, implicating HA as a potential biomarker and therapeutic target in hantavirus associated lung disease.