While there is undeniable evidence to link endosomal acid-base homeostasis to viral pathogenesis, the lack of druggable molecular targets has hindered translation from bench to bedside. The recent identification of variants in the interferon-inducible endosomal Na + /H + exchanger 9 associated with severe coronavirus disease-19 (COVID-19) has brought a shift in the way we envision aberrant endosomal acidification. Is it linked to an increased susceptibility to viral infection or a propensity to develop critical illness? This review summarizes the genetic and cellular evidence linking endosomal Na + /H + exchangers and viral diseases to suggest how they can act as a broad-spectrum modulator of viral infection and downstream pathophysiology. The review also presents novel insights supporting the complex role of endosomal acid-base homeostasis in viral pathogenesis and discusses the potential causes for negative outcomes of clinical trials utilizing alkalinizing drugs as therapies for COVID-19. These findings lead to a pathogenic model of viral disease that predicts that nonspecific targeting of endosomal pH might fail, even if administered early on, and suggests that endosomal Na + /H + exchangers may regulate key host antiviral defence mechanisms and mediators that act to drive inflammatory organ injury.Abbreviations APOE4, apolipoprotein 4 allele; COVID-19, coronavirus disease 19; CTD, C-terminal cytoplasmic domain; EBOV, Ebolavirus; eNHE, endosomal Na + /H + exchanger; EV, extracellular vesicles; GP, glycoproteins; GWAS, genome-wide association studies; HA, haemagglutinin; HCV, hepatitis C virus; IFNAR2, interferon alpha and beta receptor subunit 2; IFN, interferon b; NHE6, Na + /H + exchanger 6; NHE7, Na + /H + exchanger 7; NHE9, Na + /H + exchanger 9; NHP, nonhuman primate; N-Ras, neuroblastoma RAS viral oncogene homolog; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; TM, transmembrane segment; V-ATPase, vacuolar-type ATPase; VPS10, vacuolar protein sorting 10; WNV, West Nile virus.