Reconsidering the etiology of Beethoven's deafness: A cautionary perspective on chronic HBV infection

•HBV infection as a cause of Beethoven's deafness: uncertainties persist.•Limited reported cases of severe hearing impairment directly attributed to HBV.•Detection of HBV DNA in Beethoven's hair samples indicates a recent infection.•Chronic lead poisoning hypothesis was support by high lead in the hair and skull. Dear Editor, We read with great interest the article entitled "Could chronic HBV infection explain Beethoven's hearing loss? Implications for patients currently living with hepatitis B" recently published in this journal.1Rzymski P. Zarębska-Michaluk D. Flisiak R. Could chronic HBV infection explain Beethoven's hearing loss? Implications for patients currently living with hepatitis B.J Infect. 2023; 87: 171-176Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar While the hypothesis presented in the article suggests that chronic HBV infection is a cause of Beethoven's deafness and cirrhosis, there are still uncertainties surrounding the link between chronic HBV infection and deafness. The article proposes three potential mechanisms through which HBV infection could lead to hearing loss. Firstly, it suggests that polyarteritis nodosa associated with viral hepatitis may affect various organs, including the ears, resulting in conductive or sensorineural hearing loss.2Peitersen E. Carlson B.H. Hearing impairment as the initial sign of polyarteritis nodosa.Acta Otolaryngol. 1966; 61: 189-195Crossref PubMed Scopus (47) Google Scholar Secondly, it theorizes that HBV infection directly affects the endothelial cells and neurons of the inner ear. Lastly, it suggests that elevated release of proinflammatory cytokines due to HBV infection can ultimately lead to cochlear malfunction.3So H. Kim H. Lee J.H. Park C. Kim Y. Kim E. et al.Cisplatin cytotoxicity of auditory cells requires secretions of proinflammatory cytokines via activation of ERK and NF-kappaB.J Assoc Res Otolaryngol. 2007; 8: 338-355Crossref PubMed Scopus (198) Google Scholar If indeed HBV infection can cause hearing impairment through these pathways, the effects should be more apparent. However, there have been very few reported cases of severe hearing impairment or deafness directly attributed to HBV infection since its discovery. It has also been hypothesized that Beethoven had chronic HBV infection, and his hearing loss at the age of 28 was a result of the immune clearance period. Nonetheless, the detection of HBV DNA in Beethoven's hair samples only indicates a recent infection shortly before his death, and there is insufficient evidence to support the notion that Beethoven contracted HBV early on.4Begg T.J.A. Schmidt A. Kocher A. Larmuseau M.H.D. Runfeldt G. Maier P.A. et al.Genomic analyses of hair from Ludwig van Beethoven.Curr Biol. 2023; 33: 1431-1447.e22Abstract Full Text Full Text PDF PubMed Google Scholar Furthermore, the article suggests that elevated interferon levels during the immune clearance period may have contributed to Beethoven's hearing loss and mentions that interferon-based treatments for HBV and HCV infection have occasionally induced this symptom.3So H. Kim H. Lee J.H. Park C. Kim Y. Kim E. et al.Cisplatin cytotoxicity of auditory cells requires secretions of proinflammatory cytokines via activation of ERK and NF-kappaB.J Assoc Res Otolaryngol. 2007; 8: 338-355Crossref PubMed Scopus (198) Google Scholar However, the amount of interferon naturally produced by the body in response to viral infection is significantly lower than the dosage used in treatment. Therefore, even if interferon levels increase during the immune clearance period, the resulting hearing damage would be minimal. In conclusion, the hypothesis proposing chronic HBV infection as the cause of Beethoven's deafness should be approached with caution. In recent years, the hypothesis of chronic lead poisoning has gained traction and has been supported by reliable analyses and evidence. For instance, high concentrations of lead, 40 times higher than usual, were detected in Beethoven's hair and the top of his skull. The chronic consumption of lead-contaminated wine could explain repeated exposure over the years, and some of Beethoven's clinical symptoms align with those of chronic lead poisoning.5Brotto D. Fellin R. Sorrentino F. Gheller F. Trevisi P. Bovo R. A modern case sheds light on a classical enigma: Beethoven's deafness.Laryngoscope. 2021; 131: 179-185Crossref PubMed Scopus (14) Google Scholar Therefore, we believe that the hypothesis of chronic lead poisoning provides a more plausible explanation for the etiology of Beethoven's deafness. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This work was supported by Taishan Scholars Program (tstp20221142) and Academic Promotion Program of Shandong First Medical University (2019LJ001). All data relevant to this work are included in this paper. Beethoven’s deafness more likely linked to viral infection than lead poisoningJournal of InfectionVol. 88Issue 2PreviewDear Editor, Full-Text PDF Open Access