Efficacy and Mechanisms of Alkaloids Against Enterovirus A71: A Systematic Review and Meta-Analysis of Preclinical Evidence Integrated with Network Pharmacology and Molecular Docking

Figures

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  Figure 1. PRISMA flowchart and study selection.

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  Figure 2. The risk of bias assessment of the 9 studies included in this meta-analysis based on the SYRCLE’s Risk of Bias tool. “+”, low risk of bias; “?”, unclear risk of bias. (A) Risk of bias graph; (B) Risk of bias summary [30,32,33,34,47,48,49,50,51].

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  Figure 3. Forest plot of the effect of alkaloid intervention on survival rate in EV-A71-infected animal models [30,32,33,34,47,48,50,51].

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  Figure 4. Forest plots of the effect of alkaloid intervention on clinical outcomes in EV-A71-infected animal models. (A) Clinical score [30,32,33,34,47,48,50,51]. (B) Body weight [30,33,34,50].

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  Figure 5. Forest plots of the effect of alkaloid intervention on viral replication in EV-A71-infected animal models. (A) Viral load in brain tissue [30,33,47]. (B) Viral load in hind limb muscle tissue [30,32,34,47,50,51]. (C) VP1 protein expression [33,34].

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  Figure 6. Subgroup analyses of the effect of alkaloid intervention on outcomes based on alkaloid type (isoquinoline alkaloids vs. quinolizidine alkaloids). (A) Survival rate [30,32,33,34,47,48,50,51]. (B) Clinical severity score [30,32,33,34,47,48,50,51]. (C) Body weight [30,33,34,50]. (D) Viral load in hind limb muscle tissue [30,32,34,47,50,51].

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  Figure 7. Subgroup analyses of the effect of alkaloid intervention on outcomes based on dose (low dose: ≤5 mg/kg vs. high dose: >5 mg/kg). (A) Survival rate [30,32,33,34,47,48,50,51]. (B) Clinical severity score [30,32,33,34,47,48,50,51]. (C) Body weight [30,33,34,50]. (D) Viral load in hind limb muscle tissue [30,32,34,47,50,51].

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  Figure 8. Sensitivity analysis chart. (A) Survival rate [30,32,33,34,47,48,50,51]. (B) Clinical score [30,32,33,34,47,48,50,51]. (C) Body weight [30,33,34,50]. (D) Viral load in brain tissue [30,33,47]. (E) Viral load in hind limb muscle tissue [30,32,34,47,50,51].

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  Figure 9. Network pharmacology analysis of the 7 active compounds against EV-A71 infection. (A) Venn diagram showing the intersection of disease genes, drug targets, and core targets. (B) Compound–target–disease network. The diamond nodes represent 7 active compounds (lycorine, berberine, matrine, emetine, cepharanthine, oxysophocarpine, harmine), the circular nodes represent the target genes, and the square node represents EV-A71 infection. (C) Target–pathway network. The circular nodes represent the core target genes, and the rectangular nodes represent the key KEGG signaling pathways. (D) Sankey diagram visualizing the flow relationship between compounds, core targets, and key pathways. (E) Venn diagram of the intersection of 4 centrality metrics (MCC, BC, CC_net, DC) for screening core targets from the PPI network. (F) GO enrichment analysis of the 155 intersection targets. The bar length represents the −log10 (p-value), and the color indicates the GO category (BP: biological process, CC_GO: cellular component, MF: molecular function). (G) PPI network of the core targets. The node size is proportional to the degree value, and the edge color represents the interaction confidence. (H)…

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  Figure 10. Molecular docking validation of core active compounds with key target proteins. (A,B) 3D binding mode and 2D interaction diagram of berberine with MAPK1 (binding affinity: −9.3 kcal/mol). (C,D) 3D binding mode and 2D interaction diagram of berberine with MAPK3 (binding affinity: −9.1 kcal/mol). (E,F) 3D binding mode and 2D interaction diagram of matrine with JUN (binding affinity: −6.8 kcal/mol). (G,H) 3D binding mode and 2D interaction diagram of lycorine with MAPK1 (binding affinity: −7.6 kcal/mol). (I,J) 3D binding mode and 2D interaction diagram of emetine with AURKB (binding affinity: −7.9 kcal/mol). (K,L) 3D binding mode and 2D interaction diagram of harmine with MAPK8 (binding affinity: −6.7 kcal/mol). All the 2D diagrams illustrate detailed non-covalent interactions.