NCBIBookshelf.AserviceoftheNationalLibraryofMedicine,NationalInstitutesofHealth.

BaronS,editor.MedicalMicrobiology.4thedition.Galveston(TX):UniversityofTexasMedical
BranchatGalveston1996.

Chapter7 BacterialPathogenesis
JohnnyW.Peterson.

GeneralConcepts
HostSusceptibility
Resistancetobacterialinfectionsisenhancedbyphagocyticcellsandanintactimmunesystem.Initial
resistanceisduetononspecificmechanisms.Specificimmunitydevelopsovertime.Susceptibilityto
someinfectionsishigherintheveryyoungandtheveryoldandinimmunosuppressedpatients.
BacterialInfectivity
Bacterialinfectivityresultsfromadisturbanceinthebalancebetweenbacterialvirulenceandhost
resistance.Theobjectiveofbacteriaistomultiplyratherthantocausediseaseitisinthebestinterest
ofthebacterianottokillthehost.
HostResistance
Numerousphysicalandchemicalattributesofthehostprotectagainstbacterialinfection.Thesedefenses
includetheantibacterialfactorsinsecretionscoveringmucosalsurfacesandrapidrateofreplacementof
skinandmucosalepithelialcells.Oncethesurfaceofthebodyispenetrated,bacteriaencounteran
environmentvirtuallydevoidoffreeironneededforgrowth,whichrequiresmanyofthemtoscavenge
forthisessentialelement.Bacteriainvadingtissuesencounterphagocyticcellsthatrecognizethemas
foreign,andthroughacomplexsignalingmechanisminvolvinginterleukins,eicosanoids,and
complement,mediateaninflammatoryresponseinwhichmanylymphoidcellsparticipate.
GeneticandMolecularBasisforVirulence
Bacterialvirulencefactorsmaybeencodedonchromosomal,plasmid,transposon,ortemperate
bacteriophageDNAvirulencefactorgenesontransposonsortemperatebacteriophageDNAmay
integrateintothebacterialchromosome.
HostmediatedPathogenesis
Incertaininfections(e.g.,tuberculosis),tissuedamageresultsfromthetoxicmediatorsreleasedby
lymphoidcellsratherthanfrombacterialtoxins.
IntracellularGrowth
Somebacteria(e.g.,Rickettsiaspecies)cangrowonlywithineukaryoticcells,whereasothers(e.g.,
Salmonellaspecies)invadecellsbutdonotrequirethemforgrowth.Mostpathogenicbacteriamultiply
intissuefluidsandnotinhostcells.
VirulenceFactors
Virulencefactorshelpbacteriato(1)invad
ethehost,(2)causedisease,and(3)evadehostdefenses.
Thefollowingaretypesofvirulencefactors:
AdherenceFactors:Manypathogenicbacteriacolonizemucosalsitesbyusing
pili(fimbriae)toadhere
tocells.
InvasionFactors:Surfacecomponentsthatallowthebacteriumtoinvadehostcellscanbeencodedon
plasmids,butmoreoftenareonthechromosome.

Capsules:Manybacteriaaresurroundedbycapsulesthatprotectthemfromopsonizationand
phagocytosis.
Endotoxins:ThelipopolysaccharideendotoxinsonGramnegativebacteriacausefever
,changesin
bloodpressure,inflammation,lethalshock,andmanyothertoxicevents.
Exotoxins:Exotoxinsincludeseveraltypesofproteintoxinsandenzymesproducedand/orsecreted
frompathogenicbacteria.Majorcategoriesincludecytotoxins,neurotoxins,andenterotoxins.
Siderophores:Siderophoresareironbindingfactorsthatallowsomebacteriatocompetewiththehost
foriron,whichisboundtohemoglobin,transferrin,andlactoferrin.

Introduction
Infectionistheinvasionofthehostbymicroor
ganisms,whichthenmultiplyincloseassociationwiththe
host'stissues.Infectionisdistinguishedfromdisease,amorbidprocessthatdoesnotnecessarilyinvolve
infection(diabetes,forexample,isadiseasewithnoknowncausativeagent).Bacteriacancausea
multitudeofdif
ferentinfections,ranginginseverityfrominapparenttofulminating.
Table71liststhese
typesofinfections.
Table71

TypesofBacterialInfections.

Thecapacityofabacteriumtocausediseasereflectsitsrelativepathogenicity
.Onthisbasis,bacteria
canbeorganizedintothreemajorgroups.Whenisolatedfromapatient,frankorprimarypathogensare
consideredtobeprobableagentsofdisease(e.g.,whenthecauseofdiarrhealdiseaseisidentifiedby
thelaboratoryisolationof
Salmonellaspp.fromfeces).Opportunisticpathogensarethoseisolated
frompatientswhosehostdefensemechanismshavebeencompromised.Theymaybetheagentsof
disease(e.g.,inpatientswhohavebeenpredisposedtourinarytractinfectionswith
Escherichiacoliby
catheterization).Finally
,somebacteria,suchasLactobacillusacidophilus,areconsideredtobe
nonpathogens,becausetheyrarelyornevercausehumandisease.Theircategorizationasnonpathogens
maychange,however
,becauseoftheadaptabilityofbacteriaandthedetrimentalef
fectofmodern
radiationtherapy
,chemotherapy,andimmunotherapyonresistancemechanisms.Infac
t,somebacteria
previouslyconsideredtobenonpathogensarenowknowntocausedisease.
Serratiamarcescens,for
example,isacommonsoilbacteriumthatcausespneumonia,urinarytractinfections,andbacteremiain
compromisedhosts.
Virulenceisthemeasureofthepathogenicit
yofanorganism.Thedegreeofvirulenceisrelateddirectly
totheabilityoftheor
ganismtocausediseasedespitehostresistancemechanismsitisaf
fectedby
numerousvariablessuchasthenumberofinfectingbacteria,routeofentryintothebody
,specificand
nonspecifichostdefensemechanisms,andvirulencefactorsofthebacterium.V
irulencecanbe
measuredexperimentallybydeterminingthenumberofbacteriarequiredtocauseanimaldeath,illness,
orlesionsinadefinedperiodafterthebacteriaareadministeredbyadesignatedroute.Consequently
,
calculationsofalethaldoseaf
fecting50percentofapopulationofanimals(LD
50 )oraneffectivedose
causingadiseasesymptomin50percentofapopulationofanimals(ED
50 )areusefulincomparingthe
relativevirulenceofdif
ferentbacteria.
Pathogenesisrefersbothtothemechanismofinfectionandtothemechanismbywhichdisease
develops.Thepurposeofthischapteristoprovideanoverviewofthemanybacterialvirulencefactors
and,wherepossible,toindicatehowtheyinteractwithhostdefensemechanismsandtodescribetheir
roleinthepathogenesisofdisease.Itshouldbeunderstoodthatthepathogenicmechanismsofmany
bacterialdiseasesarepoorlyunderstood,whilethoseofothershavebeenprobedatthemolecularlevel.
Therelativeimportanceofaninfectiousdiseasetothehealthofhumansandanimalsdoesnotalways
coincidewiththedepthofourunderstandingofitspathogenesis.Thisinformationisbestacquiredby
readingeachoftheensuingchaptersonspecificbacterialdiseases,infectiousdiseasetexts,andpublic
healthbulletins.

HostSusceptibility

HostSusceptibility
Susceptibilitytobacterialinfectionsdependsonthephysiologicandimmunologicconditionofthehost
andonthevirulenceofthebacteria.BeforeincreasedamountsofspecificantibodiesorTcellsare
formedinresponsetoinvadingbacterialpathogens,thenonspecificmechanismsofhostresistance
(suchaspolymorphonuclearneutrophilsandmacrophageclearance)mustdefendthehostagainstthe
microbes.Developmentofef
fectivespecificimmunity(suchasanantibodyresponsetothebacterium)
mayrequireseveralweeks(
Fig.71).Thenormalbacterialfloraoftheskinandmucosalsurfacesalso
servestoprotectthehostagainstcolonizationbybacterialpathogens.Inmosthealthyindividuals,
bacteriafromthenormalflorathatoccasionallypenetratethebody(e.g.,duringtoothextractionor
routinebrushingofteeth)areclearedbythehost'scellularandhumoralmechanisms.Incontrast,
individualswithdefectiveimmuneresponsesarepronetofrequent,recurrentinfectionswitheventhe
leastvirulentbacteria.Thebestknownexampleofsuchsusceptibilityisacquiredimmunedeficiency
+
syndrome(AIDS),inwhichtheCD4
helperlymphocytesareprogressivelydecimatedbyhuman
immunodeficiencyvirus(HIV).However
,resistancemechanismscanbealteredbyma
nyother
processes.Forexample,agingoftenweakensbothnonspecificandspecificdefensesystemssothat
theycannolongeref
fectivelycombatthechallengeofbacteriafromtheenvironment.Infantsarealso
especiallysusceptibletocertainpathogens(suchasgroupBstreptococcibecausetheirimmunesystems
arenotyetfullydevelopedandcannotmountaprotectiveimmuneresponsetoimportantbacterial
antigens.Inaddition,someindividualshavegeneticdefectsofthecomplementsystemorcellular
defenses(e.g.,inabilityofpolymorphonuclearneutrophilstokillbacteria).Finally
,apatientmaydevelop
granulocytopeniaasaresultofapredisposingdisease,suchascancer
,orimmunosuppressive
chemotherapyfororgantransplantsorcancer
.
Figure71

Serumantibodyresponseto
Salmonellatyphiduringtyphoid
feveranditsrelationshiptosepticemia.
Hostresistancecanbecompromisedbytraumaandbysomeunderlyingdiseases.Anindividual
becomessusceptibletoinfectionwithavarietyofbacteriaiftheskinormucosaisbreached,particularly
inthecaseofseverewoundssuchasburnsorcontaminatedsur
gicalwounds.Cysticfibrosispatients,
whohavepoorciliaryfunctionandconsequentlycannotclearmucusef
ficientlyfromtherespiratory
tract,areabnormallysusceptibletoinfectionwithmucoidstrainsof
Pseudomonasaeruginosa,resulting
inseriousrespiratorydistress.Ascendingurinarytractinfectionswith
Escherichiacoliarecommonin
womenandareparticularlytroublesomeinpatientswithurinarytractobstructions.Avarietyofroutine
medicalprocedures,suchastrachealintubationandcatheterizationofbloodvesselsandtheurethra,
increasetheriskofbacterialinfection.Theplasticdevicesusedintheseproceduresarereadily
colonizedbybacteriafromtheskin,whichmigratealongtheoutsideofthetubetoinfectdeepertissues
orenterthebloodstream.Becauseofthisproblem,itisstandardpracticetochangecathetersfrequently
(e.g.,every72hoursforperipheralintravenouscatheters).
Manydrugshavebeendevelopedtotreatbacterialinfections.Antimicrobialagentsaremostef
fective,
however,whentheinfectionisalsobeingfoughtbyhealthyphagocyticandimmunede
fenses.Some
reasonsforthissituationarethepoordif
fusionofantibioticsintocertainsites(suchastheprostate
gland),theabilityofmanybacteriatomultiplyorsurviveinsidecells(wheremanyantimicrobialagents
havelittleornoef
fect),thebacteriostaticratherthanbactericidalactionofsomedrugs,andthecapacity
ofsomeorganismstodevelopresistancetomultipleantibiotics.
Manybacterialpathogensaretransmittedtothehostbyavector
,usuallyanarthropod
.Forexample,
RockyMountainspottedfeverandL
ymediseasearebothvectoredbyticks,andbubonicplagueis
spreadbyfleas.Susceptibilitytothesediseasesdependspartlyonthehost'scontactwiththevector
.

PathogenicMechanisms
BacterialInfectivity

Factorsthatareproducedbyamicroor
ganismandevokediseasearecalledvirulencefactors.Examples
aretoxins,surfacecoatsthatinhibitphagocytosis,andsurfacereceptorsthatbindtohostcells.Most
frank(asopposedtoopportunistic)bacterialpathogenshaveevolvedspecificvirulencefactorsthat
allowthemtomultiplyintheirhostorvectorwithoutbeingkilledorexpelledbythehost'sdefenses.
Manyvirulencefactorsareproducedonlybyspecificvirulentstrainsofamicroor
ganism.Forexample,
onlycertainstrainsof
E.colisecretediarrheacausingenterotoxins.
Virulencefactorsshouldneverbeconsidere
dindependentlyofthehost'sdefensestheclinicalcourseof
adiseaseoftendependsontheinteractionofvirulencefactorswiththehost'sresponse.Aninfection
beginswhenthebalancebetweenbacterialpathogenicityandhostresistanceisupset.Inessence,we
liveinanenvironmentthatfavorsthemicrobe,simplybecausethegrowthrateofbacteriafarexceeds
thatofmosteukaryoticcells.Furthermore,bacteriaaremuchmoreversatilethaneukaryoticcellsin
substrateutilizationandbiosynthesis.Thehighmutationrateofbacteriacombinedwiththeirshort
generationtimeresultsinrapidselectionofthebestadaptedstrainsandspecies.Ingeneral,bacteriaare
muchmoreresistanttotoxiccomponentsintheenvironmentthaneukaryotes,particularlywhenthe
majorbarriersofeukaryotes(skinandmucousmembranes)arebreached.
Fromapracticalstandpoint,bacteriacanbesaidtohaveasingleobjective:tomultiply
.Onlyafewof
thevastnumberofbacterialspeciesintheenvironmentconsistentlycausediseaseinagivenhost.From
ateleologicstandpoint,itisnotinthebestinterestofthepathogentokillthehost,becauseinmostcases
thedeathofthehostmeansthedeathofthepathogen.Themosthighlyevolvedoradaptedpathogens
aretheonesthatacquirethenecessarynutritionalsubstancesforgrowthanddisseminationwiththe
smallestexpenditureofener
gyandleastdamagetothehost.Forexample,
Rickettsiaakari,the
etiologicagentofrickettsialpox,causesamild,selflimitedinfectionconsistingofheadache,fever
,anda
papulovesicularrash.Othermembersoftherickettsialgroup,suchas
R.rickettsii,theagentofRocky
Mountainspottedfever
,elicitmoresevere,lifethreateninginfections.Somebacteriath
atarepoorly
adaptedtothehostsynthesizevirulencefactors(e.g.,tetanusanddiphtheriatoxin)sopotentthatthey
threatenthelifeofthehost.
HostResistance
Althougheasilydamaged,theskinrepresentsoneofthemostimportantbarriersofthebodytothe
microbialworld,whichcontainsadiversearrayofbacteriainenormousnumbers.Fortunately
,most
bacteriaintheenvironmentarerelativelybenigntoindividualswithnormalimmunesystems.However
,
patientswhoareimmunosuppressed,suchasindividualsreceivingcancerchemotherapyorhaveAIDS,
opportunisticmicrobialpathogenscanestablishlifethreateninginfections.Normally
,microbesinthe
environmentarepreventedfromenteringthebodybytheskinandmucousmembranes.Theoutermost
surfaceoftheskinconsistsofsquamouscellepithelium,lar
gelycomprisedofdeadcellsthatare
sloughedoffasnewcellsareformedbelowthem.Inadditiontotheskinbarrier
,mucousmembranesof
therespiratory,gastrointestinal,andurogen
italsystemsrepresentotherportalsthroughwhichbacteria
cangainaccesstothebody
.Likethesquamousepithelialcellsoftheskin,themucosalepithelialcells
dividerapidly
,andasthecellsmature,they
arepushedlaterallytowardtheintestinallumenandshed.
Theentireprocessisreportedtorequireonly3648hoursforcompletereplacementoftheepithelium,
whichdiminishesthenumberofbacteriaassociatedwiththeepithelium.Theskinsurfaceisadry
,acidic
environment,andthetemperatureislessthan37C.Theporesandcrevicesoftheskinalsoare
colonizedbythenormalbacterialflora,whichensurecompetitionforpathogenstowhichtheskinis
exposed.Similarly
,themucouslayerthatco
verstheepitheliacontainshostilesubstancestomicrobial
colonization.Protectivelevelsoflysozyme,lactoferrin,andlactoperoxidaseinthemucuseitherkill
bacteriaorrestricttheirgrowth.Inaddition,themucuscontainssecretoryimmunoglobulins
(predominantlysIgA)synthesizedbyplasmacellsresidentinthesubmucosaltissueDuringthenormal
courseoflife,individualsdeveloplocalantibodiesspecificforavarietyofintestinalbacteriathatcolonize
mucosalsurfaces.
Anothermechanismofrestrictinggrowthofbacteriathatpenetratetheskinandmucousmembranesis
competitionforiron.T
ypically,theamountoffreeironintissuesandbloodavailabletobacteriaisvery
low,sinceplasmatransferrinbindsvirtually
allironintheblood.Similarly
,hemoglobinintheerythrocytes
bindsiron.Withoutfreeiron,bacterialgrowthisrestrictedunlessthebacteriasynthesiz
esiderophoresor

receptorsforironcontainingmoleculesthatcompetefortransferrinboundiron.Suchsiderophoresstrip
ironfromtransferrinandpresentittothebacteria,whichenablesthemtogrow
.Thephagocyticcellsof
thebodypatrolthebloodandtissuesforforeignsubstances,includingbacteria.Thistaskisassumed
predominantlybypolymorphonuclearneutrophilshowever
,monocytes,macrophages
,andeosinophils
alsoparticipate.Afterphagocytosis,thesebacterialcellsusuallyarekilledunlesstheirnumbersare
excessiveortheypossessvirulencefactors,thatenablethemtosurvivethelysosomalenzymesand
acidicpH.Insomeinstances,thebacteriakillthephagocyteormultiplywithinthemacrophage,
escapingthehostileextracellularenvironment.Wheninflammationoccurs,phagocyticcells,alongwith
lymphocytes,playanimportantroleininnateimmunitytobacterialinfections.Duringtheinteractionof
bacterialcellswithmacrophages,Tcells,andBcells,specificantibodyresponsesand/orcellmediated
immunitydeveloptoprotectagainstreinfection.
GeneticandMolecularBasisforVirulence
Virulencefactorsinbacteriamaybeencod
edonchromosomalDNA,bacteriophageDNA,plasmids,
ortransposonsineitherplasmidsorthebacterialchromosome(
Fig.72Table72).Forexample,the
capacityoftheShigellaspeciestoinvadecellsisapropertyencodedinpartona140megadalton
plasmid.Similarly
,theheatlabileenterotox
in(LTI)ofE.coliisplasmidencoded,whereastheheat
labiletoxin(L
TII)isencodedonthechromosome.Othervirulencefactorsareacquiredbybacteria
followinginfectionbyaparticularbacteriophage,whichintegratesitsgenomeintothebacterial
chromosomebytheprocessoflysogeny(
Fig.72).Temperatebacteriophagesoftenserveasthebasis
oftoxinproductioninpathogenicbacteria.Examplesincludediphtheriatoxinproductionby
Corynebacteriumdiphtheriae,erythrogenictoxinformationby
Streptococcuspyogenes,Shigalike
toxinsynthesisby
E.coli,andproductionofbotulinumtoxin(typesCandD)by
Clostridium
botulinum.Othervirulencefactorsareencodedonthebacterialchromosome(e.g.,choleratoxin,
Salmonellaenterotoxin,andYersiniainvasionfactors).
Figure72

Mechanismsofacquiringbacterialvirulencegenes.

Table72

GeneticBasisforV
irulenceofSelectedBa
cterialPathogens.

Thetransferofgenesforantibioticresistanceamongbacteriaisasignificantmedicalproblem,although
noneofthesepropertiesactuallyconfersincreasedvirulencetothebacterium.Rather
,theyprovidethe
opportunityforresistantbacteriatoproliferateandproduceothervirulencefactorsinpatientswhoare
beingtreatedwithaninappropriateantibiotic.Resistancefactorsarediscussedfullyin
Chapter5.
Anintriguingquestionregardingmostbacterialproteintoxinsisthepurposetheyserveforthe
bacteriophageorthebacteriumcarryingthem.Severalbacterialtoxinsareenzymes.Forexample,
+
choleratoxin,diphtheriatoxin,
PseudomonasexotoxinA,andpertussistoxinallareNAD
glycohydrolasesthatalsoactasADPribosyltransferases.Thetoxicef
fectofthesebacterialenzymeson
thehostisintegraltothepathogenesisofthebacterialinfections,butthefunctionoftheenzymesinthe
normalbacterialphysiologyisnotknown.Ofalltheproteintoxinssynthesizedbypathogenicbacteria,
therearefewinstancesinwhichthefunctionoftheproteintothebacteriumisknown.Itwouldbe
unlikelyforthebacteriumorinfectingbacteriophagetoexpendtheener
gynecessarytosynthesizethese
relativelyhighmolecular
weightandcomplexmoleculesiftheyof
fereditnoadvantage.Frequentlythe
toxicityofthesesubstancesisunintentionalasfarasthebacteriaareconcerned,consideringthatthe
primarygoalofthemicroor
ganismsistoacquirenutrientsandmultiplyratherthantoharmthehost.
HostmediatedPathogenesis

Thepathogenesisofmanybacterialinfectionscannotbeseparatedfromthehostimmuneresponse,for
muchofthetissuedamageiscausedbythehostresponseratherthanbybacterialfactors.Classic
examplesofhostresponsemediatedpathogenesisareseenindiseasessuchasGramnegativebacterial
sepsis,tuberculosis,andtuberculoidleprosy
.Thetissuedamageintheseinfectionsiscausedbytoxic
factorsreleasedfromthelymphocytes,macrophages,andpolymorphonuclearneutrophilsinfiltratingthe
siteofinfection(
Fig.73).Oftenthehostresponseissointensethathosttissuesaredestroyed,allowing
resistantbacteriatoproliferate.Inlepromatousleprosy
,incontrast,theabsenceofacellularresponseto
Mycobacteriumlepraeallowsthebacteriatomultiplytosuchlar
genumbersintheskinthatthey
becometightlypackedandreplacehealthytissue.Themolecularbasisforthisspecificimmuneaner
gyis
poorlyunderstood.
Figure73

Generalizedmechanismsofbacterialpathogenesis.bacteria
inducedtoxicityorhostmediateddamage.
IntracellularGrowth
Ingeneral,bacteriathatcanenterandsurvivewithineukaryoticcellsareshieldedfromhumoral
antibodiesandcanbeeliminatedonlybyacellularimmuneresponse.However
,thesebacteriamust
possessspecializedmechanismstoprotectthemfromtheharshef
fectsofthelysosomalenzymes
encounteredwithinthecell(see
Ch.1).Pathogenicbacteriacanbegroupedintothreecategoriesonthe
basisoftheirinvasivepropertiesforeukaryoticcells(
Fig.74Table73).Althoughsomebacteria
(e.g.,Rickettsia,Coxiella,andChlamydia)growonlyinsidehostcells,others(e.g.,
Salmonella,
Shigella,andYersinia)arefacultativeintracellularpathogens,invadingcellswhenitgivesthema
selectiveadvantageinthehost.
Figure74

Examplesofpathogenicbacteria,indicatingtheirpreferredgrowth
phasewithinthehost.(ETEC:enterotoxigenic
E.coli)
Table73

IntracellularofExtracellularGrowthPreferenceRelativeto
EukaryoticCells.
Somebacteriasurvivetheintracellularmilieubyproducingphospholipasestodissolvethephagocytic
vesiclesurroundingthem.Thisappearstobethecasefor
R.rickettsii,whichdestroysthephagosomal
membranewithwhichthelysosomesfuse.
Legionellapneumophila,whichpreferstheintracellular
environmentofmacrophagesforgrowth,appearstoinduceitsownuptakeandblockslysosomalfusion
byundefinedmechanisms.OtherbacteriahaveevolvedtothepointthattheypreferthelowpH
environmentwithinthelysosomalgranules,asmaybethecasefor
Coxiellaburnetii,ahighlyresistant
memberoftherickettsialgroup.
SalmonellaandMycobacteriumspeciesalsoappeartobevery
resistanttointracellularkillingbyphagocyticcells,buttheirmechanismsofresistancearenotyetfully
understood.Certainly
,thecapacityofbacteriatosurviveandmultiplywithinhostcellshasgreatimpact
onthepathogenesisoftherespectiveinfections.
Mostbacterialpathogensdonotinvadecells,proliferatinginsteadintheextracellularenvironment
enrichedbybodyfluids.Someofthesebacteria(e.g.,
V.choleraeandBordetellapertussis)donot
evenpenetratebodytissues,but,rather
,adheretoepithelialsurfacesandcausediseas
ebysecreting
potentproteintoxins.Althoughbacteriasuchas
E.coliandP.aeruginosaaretermednoninvasive,they
frequentlyspreadrapidlytovarioustissuesoncetheygainaccesstothebody
.Allbacteriacouldat
somepointbeconsideredintracellularoncetheybecomeingestedbypolymorphonuclearneutrophils
andmacrophages,buttheseor
ganismsarenotrenownedfortheircapacitytosurvivetheintracellular
environmentortoinducetheirownuptakebymosthostcells.

SpecificVirulenceFactors

Thevirulencefactorsofbacteriacanbedividedintoanumberoffunctionaltypes.Thesearediscussed
inthefollowingsections:
AdherenceandColonizationFactors
Tocauseinfection,manybacteriamustfirstadheretoamucosalsurface.Forexample
,thealimentary
tractmucosaiscontinuallycleansedbythereleaseofmucusfromgobletcellsandbytheperistalticflow
ofthegutcontentsovertheepithelium.Similarly
,ciliatedcellsintherespiratorytractsweepmucusand
bacteriaupward.Inaddition,theturnoverofepithelialcellsatthesesurfacesisfairlyrapid.Theintestinal
epithelialcellmonolayeriscontinuallyreplenished,andthecellsarepushedfromthecryptstothevillar
tipsinabout48hours.T
oestablishaninfectionatsuchasite,abacteriummustadhere
totheepithelium
andmultiplybeforethemucusandextrudedepithelialcellsaresweptaway
.Toaccomplishthis,bacteria
haveevolvedattachmentmechanisms,suchaspili(fimbriae),thatrecognizeandattachthebacteriato
cells(seeCh.2).Colonizationfactors(astheyareoftencalled)areproducedbynumerousbacterial
pathogensandconstituteanimportantpartofthepathogenicmechanismofthesebacteria.Some
examplesofpiliated,adherentbacterialpathogensare
V.cholerae,E.coli,Salmonellaspp.,N.
gonorrheae,N.meningitidis,andStreptococcuspyogenes.
InvasionFactors
Mechanismsthatenableabacteriumtoinvadeeukaryoticcellsfacilitateentryatmucosalsurfaces.
Someoftheseinvasivebacteria(suchas
RickettsiaandChlamydiaspecies)areobligateintracellular
pathogens,butmostarefacultativeintracellularpathogens(
Fig.74).Thespecificbacterialsurface
factorsthatmediateinvasionarenotknowninmostinstances,andoften,multiplegeneproductsare
involved.SomeShigellainvasionfactorsareencodedona140megadaltonplasmid,which,when
conjugatedintoE.coli,givesthesenoninvasivebacteriathecapacitytoinvadecells.Otherinvasion
geneshavealsorecentlybeenidentifiedinSalmonellaand
Yersiniapseudotuberculosis.The
mechanismsofinvasionof
Rickettsia,andChlamydiaspeciesarenotwellknown.
CapsulesandOtherSurfaceComponents
Bacteriahaveevolvednumerousstructuralandmetabolicvirulencefactorsthatenhancetheirsurvival
rateinthehost.Capsuleformationhaslongbeenrecognizedasaprotectivemechanismforbacteria
(seeCh.2).Encapsulatedstrainsofmanybacteria(e.g.,pneumococci)aremorevirulentandmore
resistanttophagocytosisandintracellularkillingthanarenonencapsulatedstrains.Or
ganismsthatcause
bacteremia(e.g.,Pseudomonas)arelesssensitivethanmanyotherbacteriatokillingbyfreshhuman
serumcontainingcomplementcomponents,andconsequentlyarecalledserumresistant.Serum
resistancemayberelatedtotheamountandcompositionofcapsularantigensaswellastothestructure
ofthelipopolysaccharide.Therelationshipbetweensurfacestructureandvirulenceisimportantalsoin
Borreliainfections.Asthebacteriaencounteranincreasingspecificimmuneresponsefromthehost,the
bacterialsurfaceantigensarealteredbymutation,andtheprogeny
,whicharenolongerrecognizedby
theimmuneresponse,expressrenewedvirulence.
Salmonellatyphiandsomeoftheparatyphoid
organismscarryasurfaceantigen,the
Viantigen,thoughttoenhancevirulence.Thisantigenis
composedofapolymerofgalactosamineanduronicacidin1,4linkage.Itsroleinvirulencehasnot
beendefined,butantibodytoitisprotective.
Somebacteriaandparasiteshavetheabilitytosurviveandmultiplyinsidephagocyticcells.Aclassic
exampleisMycobacteriumtuberculosis,whosesurvivalseemstodependonthestructureand
compositionofitscellsurface.Theparasite
Toxoplasmagondiihastheremarkableabilitytoblockthe
fusionoflysosomeswiththephagocyticvacuole.Thehydrolyticenzymescontainedinthelysosomesare
unable,therefore,tocontributetothedestructionoftheparasite.Themechanism(s)bywhichbacteria
suchasLegionellapneumophila,Brucellaabortus,andListeriamonocytogenesremainunharmed
insidephagocytesarenotunderstood.
Endotoxins
EndotoxiniscomprisedoftoxiclipopolysaccharidecomponentsoftheoutermembraneofGram
negativebacteria(see
Ch.2).Endotoxinexertsprofoundbiologicef
fectsonthehostandmaybelethal.

Becauseitisomnipresentintheenvironment,endotoxinmustberemovedfromallmedicalsupplies
destinedforinjectionoruseduringsur
gicalprocedures.Thetermendotoxinwascoinedin1893by
Pfeiffertodistinguishtheclassoftoxicsubstancesreleasedafterlysisofbacteriafromthetoxic
substances(exotoxins)secretedbybacteria.Few
,ifany,othermicrobialproductshavebeenas
extensivelystudiedasbacterialendotoxins.Perhapsitisappropriatethatamoleculewithsuchimportant
biologiceffectsonthehost,andoneproducedbysomanybacterialpathogens,shouldbethesubjectof
intenseinvestigation.
StructureofEndotoxin
Figure75illustratesthebasicstructureofendotoxin.Endotoxinisamolecularcomplexoflipidand
polysaccharidehence,thealternatenamelipopolysaccharide.Thecomplexissecuredtotheouter
2+
membranebyionicandhydrophobicforces,anditsstrongnegativechar
geisneutralizedbyCa
and
2+
Mg ions.
Figure75

Basicstructureofendotoxin(lipopolysaccharide)fromGram
negativebacteria.
Thestructureofendotoxinmoleculesfrom
Salmonellaspp.andE.coliisknownindetail.Enoughdata
onendotoxinfromotherGramnegativeor
ganismshavebeengatheredtorevealacommonpatternwith
genusandspeciesdiversity
.Althoughallen
dotoxinmoleculesaresimilarinchemicalstructureand
biologicactivity
,somediversityhasevolved
.Purifiedendotoxinappearsaslar
geaggregates.The
molecularcomplexcanbedividedintothreeregions(
Fig.75):(1)theOspecificchains,whichconsist
ofavarietyofrepeatingoligosaccharideresidues,(2)thecorepolysaccharidethatformsthebackbone
ofthemacromolecule,and(3)lipidA,composedusuallyofaglucosaminedisaccharidewithattached
longchainfattyacidsandphosphate.Thepolysaccharideportionsareresponsibleforantigenic
diversity,whereasthelipidAmoietyconfer
stoxicity.Dissociationofthecomplexhasrevealedthatthe
polysaccharideisimportantinsolubilizingthetoxiclipidAcomponent,andinthelaboratoryitcanbe
replacedbycarrierproteins(e.g.,bovineserumalbumin).
MembersofthefamilyEnterobacteriaceaeexhibitOspecificchainsofvariouslengths,whereas
N.
gonorrhoeae,N.meningitidis,andB.pertussiscontainonlycorepolysaccharideandlipidA.Some
investigatorsworkingonthelatterformsofendotoxinprefertocallthemlipooligosaccharidesto
emphasizethechemicaldif
ferencefromtheendotoxinoftheentericbacilli.Nevertheless,thebiologic
activitiesofallendotoxinpreparationsareessentiallythesame,withsomebeingmorepotentthan
others.

BiologicActivityofEndotoxin
Thebiologicef
fectsofendotoxinhavebeenextensivelystudied.PurifiedlipidA(conjugatedtobovine
serumalbumin)andendotoxinelicitthesamebiologicresponses.
Table74listssomeofthebiologic
effectsofendotoxin.Themorepertinenttoxicef
fectsincludepyrogenicity
,leukopeniafollowedby
leukocytosis,complementactivation,depressioninbloodpressure,mitogenicity
,inductionof
prostaglandinsynthesis,andhypothermia.Theseeventscanculminateinsepsisandlethalshock.
However,itshouldbenotedfrom
Table74thatnotallef
fectsofendotoxinarenecessarilydetrimental
severalinduceresponsespotentiallybeneficialtothehost,assumingthestimulationisnotexcessive.
Theseinclude:
Table74

MultipleBiologicActivitiesExhibitedbytheLipidAComponent
ofEndotoxin.
1. mitogenicef
fectsonBlymphocytesthatincreaseresistancetoviralandbacterialinfections
2.

inductionofgammainterferonproductionbyTlymphocytes,whichmayenhancetheantiviralstate,
promoterejectionoftumorcells,andactivatemacrophagesandnaturalkillercells
3. activationofthecomplementcascadewiththeformationofC3aandC5a
4. inductionoftheformationofinterleukin1bymacrophagesandinterleukin2andothermediatorsby
Tlymphocytes.
Currentresearchfocusesonexploitingsomeofthepotentialbeneficialef
fectsofnontoxicendotoxin
derivativesandholdspromisefordevelopmentoffuturetreatmentregimensforstimulatingtheimmune
response.Forexample,thetoxicityofendotoxinislar
gelyattributedtolipidA,attachedtoa
polysaccharidecarrier
.ThetoxicityoflipidAismarkedlyreducedafterhydrolysisofaphosphategroup
ordeacylationofoneormorefattyacidsfromthelipidAmolecule.Clinicaltrialsareinprogresstotest
amonophosphoryllipidAforitspotentialofinducinglowdosetolerancetoendotoxin.T
oleranceto
endotoxincanbeachievedbypretreatmentofananimalwithlowdosesofendotoxinoradetoxified
lipidAderivativebeforechallengewithhighdosesofendotoxin.Experimentalstudieshave
demonstratedthatinductionoftolerancetoendotoxinreducesthedangerousef
fectsofendotoxin.Itis
hopedthattheserelativelynontoxiclipidAderivativesmaybeusefulinreducingtheseverityofbacterial
sepsisinwhichbacterialendotoxinproducesalifethreateningclinicalcourse.
Endotoxin,whichlar
gelyaccumulatesintheliverfollowinginjectionofasublethaldosebythe
intravenousroute,canbedevastatingbecauseofitsabilitytoaf
fectavarietyofcellandhostproteins.
Kupffercells,granulocytes,macrophages,platelets,andlymphocytesallhaveacellreceptorontheir
surfacecalledCD14,whichbindsendotoxin.EndotoxinbindingtotheCD14receptoronmacrophages
isenhancedbyinteractionwithahostproteinmadeintheliver(i.e.,LPSbindingprotein).Theextentof
involvementofeachcelltypeprobablydependsonthelevelofendotoxinexposure.Theef
fectsof
endotoxinonsuchawidevarietyofhostcellsresultinacomplexarrayofhostresponsesthatcan
culminateintheseriousconditiongramnegativesepsis,whichoftenleadstoshockanddeath.The
effectsofendotoxinonhostcellsareknowntostimulateprostaglandinsynthesisandtoactivatethe
kallikreinsystem,thekininsystem,thecomplementcascadeviathealternativepathway
,theclotting
system,andthefibrinolyticpathways.Whenthesenormalhostsystemsareactivatedandoperateoutof
control,itisnotsurprisingthatendotoxincanbelethal.Althoughitisdif
ficulttocomprehendthe
mechanismsofallthecellresponsesandthemyriadsequelaeofthecellmediatorsreleasedrather
indiscriminatelyinthehostfollowingexposuretoendotoxin,itdoesseemclearthatthehostcellular
responsetoendotoxin,ratherthanadirecttoxicef
fectofendotoxin,playsthemajorroleincausing
tissuedamage(Fig.73).

DetectionofEndotoxininMedicalSolutions
Endotoxinisomnipresentintheenvironment.Itisfoundinmostdeionizedwaterlinesinhospitalsand
laboratories,forexample,andaf
fectsvirtuallyeverybiologicassaysystemeverexamined.Ittendstobe
ascapegoatforallbiologicproblemsencounteredinthelaboratory
,and,manytimes,thisreputationis
deserved.Becauseofitspyrogenicanddestructiveproperties,extremecaremustbetakentoavoid
exposingpatientstomedicalsolutionscontainingendotoxin.Eventhoughallsuppliesshouldbesterile,
solutionsforintravenousadministrationcanbecomecontaminatedwithendotoxincontainingbacteria
aftersterilizationasaresultofimproperhandling.Furthermore,waterusedinthepreparationofsuch
solutionsmustbefilteredthroughionexchangeresinstoremoveendotoxin,becauseitisnotremoved
byeitherautoclavesterilizationorfiltrationthroughbacterialmembranefilters.Ifendotoxincontaining
solutionswereusedinsuchmedicalproceduresasrenaldialysis,heartbypassmachines,blood
transfusions,orsur
gicallavage,thepatientwouldsuf
ferimmediatefeveraccompaniedbyarapidand
possiblylethalalterationsinbloodpressure.
Solutionsforhumanorveterinaryusearepreparedundercarefullycontrolledconditionstoensure
sterilityandtoremoveendotoxin.Representativesamplesofeverymanufacturingbatcharecheckedfor
endotoxinbyoneoftwoprocedures:the
Limuluslysatetestortherabbitpyrogenicitytest.Therabbit
pyrogenicitytestisbasedontheexquisitesensitivityofrabbitstothepyrogenicef
fectsofendotoxin.A
sampleofthesolutiontobetestedusuallyisinjectedintravenouslyintotheearveinsofadultrabbits

whiletherectaltemperatureoftheanimalismonitored.Carefulmonitoringofthetemperatureresponses
providesasensitiveandreliableindicatorofthepresenceofendotoxinand,importantly
,onemeasureof
thesafetyofthesolutionforuseinpatients.
TheLimuluslysatetestismorecommonandlessexpensive.Thistest,whichisbasedontheabilityof
endotoxintoinducegelationoflysatesofamebocytecellsfromthehorseshoecrab
Limulus
polyphemus,issimple,fast,andsensitive(about1ng/ml).Itissosensitive,however
,thattrace
quantitiesofendotoxininregulardeionizedwateroftenobscuretheresults.Itcanbeusedforrapid
detectionofcertainGramnegativeinfections(e.g.,ofcerebrospinalfluid)however
,bloodcontains
inhibitorsthatpreventgelation.T
estkitsarecommerciallyavailable.Theamebocyteis
thesole
phagocyticimmunecellofthehorseshoecrab,andthegelationreactionisbelievedtobeinvolvedin
sequesteringinvadingGramnegativebacteria.
Exotoxins
Exotoxins,unlikethelipopolysaccharideendotoxin,areproteintoxinsreleasedfromviablebacteria.
Theyformaclassofpoisonsthatisamongthemostpotent,perunitweight,ofalltoxicsubstances.
Mostofthehighermolecular
sizedexotoxinproteinsareheatlabilehowever
,numerouslowmolecular

sizedexotoxinsareheatstablepeptides.Unlikeendotoxin,whichisastructuralcomponentofallGram
negativecells,exotoxinsareproducedbysomemembersofbothGrampositiveandGramnegative
genera.Thefunctionsoftheseexotoxinsforthebacteriaareusuallyunknown,andthegenesformost
canbedeletedwithnonoticeableef
fectonbacterialgrowth.Incontrasttotheextensivesystemicand
immunesystemef
fectsofendotoxinonthehost,thesiteofactionofmostexotoxinsismorelocalized
andisconfinedtoparticularcelltypesorcellreceptors.T
etanustoxin,forexample,af
fectsonly
internuncialneurons.Ingeneral,exotoxinsareexcellentantigensthatelicitspecificantibodiescalled
antitoxins.Notallantibodiestoexotoxinsareprotective,butsomereactwithimportantbindingsitesor
enzymaticsitesontheexotoxin,resultingincompleteinhibitionofthetoxicactivity(i.e.,neutralization).
Exotoxinscanbegroupedintoseveralcategories(e.g.,neurotoxins,cytotoxins,andenterotoxins)based
ontheirbiologicef
fectonhostcells.Neurotoxinsarebestexemplifiedbythetoxinsproducedby
Clostridiumspp.,forexample,thebotulinumtoxinformedby
C.botulinum.Thispotentneurotoxin
actsonmotorneuronsbypreventingthereleaseofacetylcholineatthemyoneuraljunctions,thereby
preventingmuscleexcitationandproducingflaccidparalysis.Thecytotoxinsconstitutealar
ger,more
heterogeneousgroupingwithawidearrayofhostcellspecificitiesandtoxicmanifestations.One
cytotoxinisdiphtheriatoxin,whichisproducedby
Corynebacteriumdiphtheriae.Thiscytotoxin
inhibitsproteinsynthesisinmanycelltypesbycatalyzingtheADPribosylationofelongationfactorII,
whichblockselongationofthegrowingpeptidechain.
Enterotoxinsstimulatehypersecretionofwaterandelectrolytesfromtheintestinalepitheliumandthus
producewaterydiarrhea.Someenterotoxinsarecytotoxic(e.g.,shigalikeenterotoxinfrom
E.coli),
whileothersperturbeukaryoticcellfunctionsandarecytotonic(e.g.,choleratoxin).Enterotoxinsalso
candisturbnormalsmoothmusclecontraction,causingabdominalcrampinganddecreasetransittime
forwaterabsorptionintheintestine.Enterotoxigenic
E.coliandV.choleraeproducediarrheaafter
attachingtotheintestinalmucosa,wheretheyelaborateenterotoxins.Neitherpathogeninvadesthe
bodyinsubstantialnumbers,exceptinthecaseof
E.colispeciesthathaveacquiredaninvasion
plasmid.Importantly
,choleratoxinand
E.coliheatlabileenterotoxinsIandIIcauseADPribosylation
ofcellproteinsinamannersimilartodiphtheriatoxin,exceptthattheprimarytar
getistheregulatory
protein(Gs_ )ofadenylatecyclase,resultinginincreasedlevelsofcyclic3,5adenosinemonophosphate
(cAMP)(seeCh.25).Incontrast,theorganismsresponsibleforshigellosis(
Shigelladysenteriae,S.
boydii,S.flexneri,andS.sonnei)penetratethemucosalsurfaceofthecolonandterminalileumto
proliferateandcauseulcerationsthatbleedintotheintestinallumen.Despitecausingextensiveulceration
ofthemucosa,thepathogensrarelyenterthebloodstream.TheShigaenterotoxinproducedby
Shigella
speciesandtheShigalikeenterotoxinelaboratedbymanyisolatesof
E.coliinhibitproteinsynthesisin
eukaryoticcells.Itisnotclearhowthiscytotoxicenterotoxincauseshypersecretionofwaterand
electrolytesfromtheintestinalepithelium.Theseenterotoxinsdif
ferfromthosesecretedby
V.cholerae
andE.coliinthattheShigatoxinsarecytotoxicandlethal,whereasthecholeratoxinlikeenterotoxins
arenot.Thelatterenterotoxinscausenostructuraldamagetocells,andaredescribedascytotonic.The

ensuinginflammatoryresponsetotheinvadingbacteriaand/ortheirtoxinsappearstoactivateneurologic
controlmechanisms(e.g.,prostaglandins,serotonin)thatnormallyregulatewaterandelectrolyte
transport.
Siderophores
Bothanimalsandbacteriarequireironformetabolismandgrowth,andthecontrolofthislimited
resourceisoftenusedasatacticintheconflictbetweenpathogenandhost.Animalshaveevolved
mechanismsofwithholdingironfromtissuefluidsinanattempttolimitthegrowthofinvadingbacteria.
Althoughbloodisarichsourceofiron,thisironisnotreadilyavailabletobacteriasinceitisnotfreein
solution.Mostoftheironinbloodisboundeithertohemoglobininerythrocytesortotransferrinin
plasma.Similarly
,theironinmilkandother
secretions(e.g.,tears,saliva,bronchialmucus,bile,and
gastrointestinalfluid)isboundtolactoferrin.Somebacteriaexpressreceptorsforeukoyoticironbinding
proteins(e.g.,transferrinbindingoutermembraneproteinsonthesurfaceof
Neisseriraspp.).Viathese
specializedreceptorsironacquisitionisfacilitated,providingtheesssentialelementforbacterialgrowth.
Otherbacteriahaveevolvedelaboratemechanismstoextracttheironfromhostproteins(
Fig.76).
Siderophoresaresubstancesproducedbymanybacteria(andsomeplants)tocaptureironfromthe
host.Theabsenceofirontriggerstranscriptionofthegenescodingfortheenzymesthatsynthesize
siderophores,aswellasforasetofsurfaceproteinreceptorsthatrecognizesiderophorescarrying
boundiron.Thebindingconstantsofthesiderophoresforironaresohighthatevenironboundto
transferrinandlactoferrinisconfiscatedandtakenupbythebacterialcells.Anexampleofabacterial
siderophoreisenterochelin,whichisproducedby
EscherichiaandSalmonellaspecies.Classic
experimentshavedemonstratedthat
Salmonellamutantsthathavelostthecapacitytosynthesize
enterochelinlosevirulenceinanassayoflethalityinmice.Injectionofpurifiedenterochelinalongwith
theSalmonellamutantsrestoresvirulencetothebacteria.Therefore,siderophoreproductionbymany
pathogenicbacteriaisconsideredanimportantvirulencemechanism.
Figure76

Competitionbetweenhostcellsandbacterialpathogensforiron,
illustratingtheimportanceofsiderophores.Sincefreeironis
scarceintissuefluidsandblood,bacterialsiderophorescompete
3+
effectivelyforFe
boundtolactoferrinandtransferrin.
(more...)

Epilogue
Manyfactorsdeterminetheoutcomeofthebacteriumhostrelationship.Thehostmustliveinan
environmentfilledwithadiversepopulationofmicroor
ganisms.Becauseofthemagnitudeofthe
infectiousdiseaseproblem,westrivetounderstandthenaturalimmunemechanismsofthehostsothat
futureimprovementsinresistancetobacterialinfectionsmaybepossible.Similarly
,massiveresearch
effortsarebeingexpendedtoidentifyandcharacterizethevirulencefactorsofpathogenicbacteriaand
henceallowustointerruptthepathogenicmechanismsofvirulentbacteria.Theavailabilityofanarrayof
antibioticsandvaccineshasprovidedthemedicalprofessionwithpowerfultoolstocontrolorcure
manyinfections.Unfortunately
,thesedrugsandvaccineshaveeliminatednobacterialdiseasefromthe
humanoranimalpopulations,andbacterialinfectionsanddrugresistanceremainaseriousmedical
problem.

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