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TABLE 1 Frequency of Signs and Symptoms in HBoV-Positive TABLE 2 Rates of HBoV Coinfection With Common Respiratory
Group (n = 11) in Comparison With the General Study Group Viruses for Each of the 11 Detections of HBoV, in Comparison With
(n = 95) the Total Number of Detections of Each Virus in the Total Study
Number and Number and Population of 95 Subjects
Percentage in Bocavirus- Percentage in Total Number and Number and
Signs/Symptoms Positive Subjects Study Population Percentage in Bocavirus- Percentage in Total
Cough 11 (100%) 87 (92%) Virus Positive Subjects Study Population
(n = 95)
(n = 11)
Earache/trouble 1 (0.9%) 7 (7%)
hearing Influenza A 2 (18%) 43 (45%)
Has the patient 6 (55%) 29 (30%) HPIV1 9 (82%) 12 (13%)
been hospitalized? HPIV3 2 (18%) 5 (5%)
Stiff neck 1 (0.9%) 13 (10%) HPIV4 1 (9%) 1 (1%)
Eye pain 6 (55%) 49 (52%) Respiratory 1 (9%) 1 (1%)
Muscle aches 8 (73%) 69 (73%) syncytial virus
Runny eyes 2 (18%) 7 (7%) Enteroviruses 1 (9%) 0 (0%)
Wheezing 0 (0%) 0 (0%) Rhinovirus 1 (9%) 10 (11%)
Hoarseness 5 (45) 21 (22%) Human
metapneumovirus 7 (64%) 10 (11%)
Trouble breathing 1 (0.9%) 2 (2%) A/B
Ringing in ears 3 (27%) 7 (7%) HPIV = human parainfluenza virus.
Fever 11 (100%) 93 (98%)
Malaise 9 (82%) 57 (60%)
Dizziness 7 (64%) 53 (56%) The military population of Georgia predominantly consists of
Sinus pain 6 (55%) 26 (27%) young adults, and because HBoV is more common in children,
Sore throat 8 (73%) 73 (77%) it is possible that younger people are at a higher risk for coin-
Runny/stuffy nose 6 (55%) 50 (53%) fection with this virus than are older people. A possible pos-
Headache 11 (100%) 87 (92%) itive correlation was detected between the presence of HBoV
Photophobia 2 (18%) 17 (18%) and the development of pneumonia. This finding may indicate
Pneumonia 4 (36%) 6 (6%) that HBoV tends to increase the severity of acute respiratory
Vaccinated against 0 (0%) 0 (0%) illness, a phenomenon that might also be reflected in the in-
influenza creases in the presence of cough, runny eyes, ringing in the
ears, malaise, dizziness, and sinus pain that was also observed.
Although the mechanism of HBoV pathogenesis is not cur-
rently known, it is possible that HBoV pathogenesis synergizes
increased in subjects that were coinfected with HBoV in com- with the pathologic processes of coinfecting viruses, thus lead-
parison with the total study population. One notable differ- ing to an enhancement of the overall pathologic process and
ence between the HBoV-positive group and the general study an increase in disease symptomology.
population was the presence of pneumonia, which was more
common in the HBoV-positive group than in the general study Significantly, the symptoms and the seasonality of HBoV
group (33% vs 6%). overlap with those of the novel SARS-CoV-2 virus that is the
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causative agent of the COVID-19 pandemic. It is therefore
Coinfections were detected in every HBoV-positive case. Coin- possible that HBoV infection can confound the diagnosis of
fecting viruses included some of the most common respiratory respiratory disease in Georgia. This may be especially true in
pathogens, including influenza, human parainfluenza virus, regions of the country that do not have access to a robust clin-
respiratory syncytial virus, human metapneumovirus, entero- ical laboratory infrastructure and molecular diagnostics.
virus, and rhinovirus. The highest rate of coinfection was de-
tected with human parainfluenza virus 1, which was detected There are several limitations to this study. The major limitation
in nine cases of coinfection, followed by human metapneumo- is that this was purely a molecular study with a small sample
virus A/B, which was detected in seven cases of coinfection size and that the virus was not isolated or directly observed; it
(Table 2). is therefore impossible to determine whether the positive PCR
results were indicative of active infections or whether they re-
Discussion sulted from the amplification of the fragmented DNA released
from inactive virus. Another limitation is that Koch’s postu-
HBoV is a newly discovered virus and, to our knowledge, it lates for HBoV have not been fulfilled, and because the role
has not previously been detected in the country of Georgia. of this virus in respiratory disease has not been completely
In this study, we detected 11 positive cases of HBoV of a total elucidated, it is impossible to determine whether the respira-
95 tested subjects who reported to the Georgian Military Hos- tory symptoms identified in this study are a direct result of
pital with acute respiratory disease. Consistent with existing the HBoV infection of whether they result primarily from the
literature, all the positive cases were also positive for one or coinfecting virus or bacteria. A further limitation is that the
more coinfecting respiratory pathogens. The role of HBoV in age range of the study population does not match the typical
the pathogenesis of respiratory disease is not fully understood. age of Special Operations personnel. It is hoped that, despite
Our data support the notion that this virus often coexists with these limitations, the data presented in this report will serve
other respiratory viruses and that it may participate in the to inform members of the military medical community about
pathologic process. the presence of HBoV in Georgia. It is also hoped that this

102 | JSOM Volume 20, Edition 4 / Winter 2020