A long-standing hypothesis in neurology, sometimes termed the "pathogen hypothesis" of
neurodegeneration, proposes that chronic or reactivating neurotropic infections contribute to the pathogenesis of several age-related neurodegenerative conditions such as
Alzheimer's disease (AD). This hypothesis was first articulated in the 1990s and has gained renewed attention since a series of mechanistic and epidemiological studies were published from 2018 onward. The best-studied candidate pathogen for this hypothesis is
herpes simplex virus type 1 (HSV-1), which establishes latency in the
trigeminal ganglion and has been detected by
PCR in the brains of both AD patients and age-matched controls. The viral concept of AD proposes that latent HSV-1 in the brains of carriers of the ε4 allele of
APOE undergoes episodic reactivation triggered by inflammation or immunosuppression, producing cumulative neuronal damage,
amyloid-β (Aβ) deposition, and
tau protein hyperphosphorylation, which are all classic hallmarks of AD. In cell culture and mouse models, HSV-1 infection upregulates
BACE1 and alters
amyloid precursor protein processing, producing intracellular accumulation of Aβ and hyperphosphorylated tau. It has also been found that antiviral drugs such as
acyclovir reduce levels of HSV-1-induced Aβ accumulation by 70% and inhibit abnormal tau phosphorylation. Epidemiological data also provide evidence for this hypothesis. A 2025 study used the age-based eligibility cutoff of the Welsh
herpes zoster vaccination program as a
natural experiment and reported that receipt of the live-attenuated zoster vaccine reduced the probability of a new
dementia diagnosis over seven years by approximately 20%. Nationwide cohort studies from Taiwan have also found that antiherpetic treatment following symptomatic HSV or
varicella-zoster virus infection is associated with a reduced subsequent incidence of dementia. However, this viral hypothesis of AD has been contested as well. Reviewers have noted that a large majority of adults harbor latent herpesviruses without developing dementia, implying that infection is at most one of several interacting risk factors, rather than a standalone cause. Additionally, a concrete causal mechanism has not yet been established. A direct causal role will likely require confirmation through
randomized controlled trials (RCTs) of antiviral or vaccine interventions. == Research use ==