Pathogenesis of Shigella dysenteriae 1 (Shiga) dysentery

Incorporating model uncertainties along with data uncertainties in microbial risk assessment

Much research on food safety has been conducted since the National Food Safety Initiative of 1997. Risk assessment plays an important role in food safety practices and programs, and various dose-response models for estimating microbial risks have been investigated. Several dose-response models can provide reasonably good fits to the data in the experimental dose range, but yield risk estimates that differ by orders of magnitude in the low-dose range. Hence, model uncertainty can be just important as data uncertainty (experimental variation) in risk assessment. Although it is common in risk assessment to account for data uncertainty, it is uncommon to account for model uncertainties. In this paper we incorporate data uncertainties with confidence limits and model uncertainties with a weighted average of an estimate from each of various models. A numerical tool to compute the maximum likelihood estimates and confidence limits is addressed. The proposed method for incorporating model uncertainties is illustrated with real data sets.

Fate of Shigella sonnei on parsley and methods of disinfection

Outbreaks of shigellosis associated with chopped parsley used as a garnish for foods occurred in four states in the United States and in two Canadian provinces in 1998. This prompted a study to determine survival and growth characteristics of Shigella sonnei inoculated onto raw parsley. Two inoculum levels (approximately 10(3) and 10(6) CFU/g) were applied to parsley leaves, portions of which were then chopped. Inoculated whole and chopped parsley leaves were held at 4 degrees C or 21 degrees C for up to 14 days. Initial populations of the organism on chopped parsley receiving high or low levels of inoculum increased by approximately 3 log10 CFU/g, within 1 day at 21 degrees C. Populations of S. sonnei on inoculated chopped or whole parsley leaves held at 4 degrees C decreased by 2.5 to 3.0 log10 CFU/g during a 14-day storage period. The pathogen multiplied, without a lag phase, on inoculated (2.72 log10 CFU/g) chopped parsley held at 21 degrees C, exceeding 6 log10 CFU/g within 24 h. Treatment of inoculated whole parsley leaves with vinegar containing 5.2% (vol/vol) acetic acid or 200 ppm free chlorine for 5 min at 21 degrees C reduced the population of S. sonnei by more than 6 log10 CFU/g, whereas treatment with vinegar containing 7.6% acetic acid or 250 ppm free chlorine reduced initial populations of 7.07 and 7.26 log10 CFU/g, respectively, to undetectable levels (<0.6 log10 CFU/g). These studies revealed that S. sonnei can grow rapidly on chopped parsley held at ambient temperature and remain viable for at least 14 days at 4 degrees C. Treatment of contaminated parsley with vinegar or chlorinated water offers a simple method to reduce markedly or eliminate the pathogen in food-service or home settings.

Comparison of six dose-response models for use with food-borne pathogens

Food-related illness in the United States is estimated to affect over six million people per year and cost the economy several billion dollars. These illnesses and costs could be reduced if minimum infectious doses were established and used as the basis of regulations and monitoring. However, standard methodologies for dose-response assessment are not yet formulated for microbial risk assessment. The objective of this study was to compare dose-response models for food-borne pathogens and determine which models were most appropriate for a range of pathogens. The statistical models proposed in the literature and chosen for comparison purposes were log-normal, long-logistic, exponential, beta-Poisson and Weibull-Gamma. These were fit to four data sets also taken from published literature, Shigella flexneri, Shigella dysenteriae, Campylobacter jejuni, and Salmonella typhosa, using the method of maximum likelihood. The Weibull-gamma, the only model with three parameters, was also the only model capable of fitting all the data sets examined using the maximum likelihood estimation for comparisons. Infectious doses were also calculated using each model. Within any given data set, the infectious dose estimated to affect one percent of the population ranged from one order of magnitude to as much as nine orders of magnitude, illustrating the differences in extrapolation of the dose response models. More data are needed to compare models and examine extrapolation from high to low doses for food-borne pathogens.

Population-based study of the incidence of Shigella diarrhea and causative serotypes in Santiago, Chile

BACKGROUND

Shigella is an important cause of diarrheal disease in children in developing countries. The increasing prevalence of antibiotic-resistant strains has stimulated interest in the use of multivalent Shigella vaccines. Because Shigella vaccines under development are based on eliciting immunity to O antigens, monitoring the distribution of serotypes in defined target populations is critical. We initiated health center-based surveillance in a poor semirural community in Colina, Santiago (7489 children <60 months of age) to determine the age-specific incidence of Shigella disease and the responsible serotypes.

FINDINGS

Surveillance was maintained at the 2 health centers during warm seasons (November 1 through April 30) for 4 successive years (1994 to 1998). Shigella was recovered from 54 of 243 cases of dysentery (22%) and from 215 of 3966 cases of nondysenteric diarrhea (5.4%) (P < 0.001). The peak mean annual incidence of shigellosis occurred among children 12 to 47 months of age (9.0 to 12.6 cases/10(3) children), although the incidence in infants (5.2/10(3)) and children 48 to 59 months of age (6.2/10(3)) was also substantial. During the 1995 through 1996 season, an age-matched healthy control was cultured for every child <60 months of age with diarrhea. Shigella isolation from cases (34 of 576, 5.9%) was >8-fold higher than controls (4 of 576, 0.7%) (P < 0.01). Four serotypes, Shigella sonnei (45%), Shigella flexneri 2b (19%), S. flexneri 2a (14%) and S. flexneri 6 (11%), accounted for 89% of all cases.

INTERPRETATION

Shigella remains an important pediatric pathogen in Santiago. The serotype distribution from Colina, which closely resembles data from a population-based surveillance study in Santiago in the mid-1980s, demonstrates a remarkable degree of serotype stability in Santiago during a 15-year period.

Topics in microbial risk assessment: dynamic flow tree process

Microbial risk assessment is emerging as a new discipline in risk assessment. A systematic approach to microbial risk assessment is presented that employs data analysis for developing parsimonious models and accounts formally for the variability and uncertainty of model inputs using analysis of variance and Monte Carlo simulation. The purpose of the paper is to raise and examine issues in conducting microbial risk assessments. The enteric pathogen Escherichia coli O157:H7 was selected as an example for this study due to its significance to public health. The framework for our work is consistent with the risk assessment components described by the National Research Council in 1983 (hazard identification; exposure assessment; dose-response assessment; and risk characterization). Exposure assessment focuses on hamburgers, cooked a range of temperatures from rare to well done, the latter typical for fast food restaurants. Features of the model include predictive microbiology components that account for random stochastic growth and death of organisms in hamburger. For dose-response modeling, Shigella data from human feeding studies were used as a surrogate for E. coli O157:H7. Risks were calculated using a threshold model and an alternative nonthreshold model. The 95% probability intervals for risk of illness for product cooked to a given internal temperature spanned five orders of magnitude for these models. The existence of even a small threshold has a dramatic impact on the estimated risk.

Shigellosis on Indian reserves in Manitoba, Canada: its relationship to crowded housing, lack of running water, and inadequate sewage disposal

OBJECTIVES

This study compares incidence and hospitalization rates for shigellosis between Indians and the rest of the population in Manitoba, Canada. It examines the relationship between shigellosis and environmental conditions on reserves.

METHODS

Rates were calculated with surveillance data and a survey of environmental infrastructure was done.

RESULTS

Indians had shigellosis incidence and hospitalization rates that were 29 and 12 times as high, respectively, as those of the rest of the population. Household crowding, lack of piped water, and inadequate sewage disposal were significantly associated with an increased incidence of shigellosis on reserves.

CONCLUSIONS

Many cases of shigellosis may be prevented by improving living conditions on Indian reserves.

Of four murine, anti-Shigella dysenteriae type 1 O-polysaccharide antibodies, three employ V-genes that differ extensively from those of the fourth

Three murine, monoclonal antibodies, IgM 5286 F2, IgM 5297 C1, and IgG 5338 H4 were generated against Shigella dysenteriae type 1 O-specific polysaccharide (O-SP)-conjugate. They are specific for the O-SP, which is a poly-[alpha-L-rhamnopyranosyl-(1-->3)-alpha-L-rhamnopyranosyl-(1-->2)-al pha-D-galactopyranosyl-(1-->3)-2-deoxy-2-amino-N-acetyl-alpha-D-glucopyr anosyl]. The VH and VL genes of these antibodies were cloned and their sequences determined. They showed 93% homology, but were quite different to the primary sequence of IgM 3707 E9, of the same O-SP-specificity, previously reported. The fine-specificities of both IgG 5338 H4 and IgM 3707 E9 were for the same disaccharide moiety in the O-SP, while IgMs 5286 F2 and 5297 C1 showed fine-specificity for the entire repeating unit of the O-SP. Therefore, divergent sequences can confer upon antibodies similar-, or even identical-carbohydrate-epitope fine-specificity. In addition, close primary sequence-homology does not preclude differences in antibody fine-specificity.

Prevalence of shigellosis in the U.S.: consistency with dose-response information

Every year there are estimated 300000 cases of Shigella in the United States (Bennett et al., 1987, Am. J. Prev. Med. 3, 102-114). A beta-poisson model was fit to human dose-response information on pathogenic Shigella using the Maximum Likelihood Estimation technique (Haas, 1983, Am. J. Epidemiol. 118, 573-582). Pooled and separate data sets for the Shigella species were fit to the beta-Poisson model and 95% confidence limits and regions were calculated. Shigella dysentariae and Shigella flexneri confidence regions and limits overlapped with each other and with the pooled data set, suggesting that this model can describe Shigella in general. The pooled Shigella model as well as the upper and lower confidence limits of the three data sets showed average exposures based on the estimated U.S. caseload of pathogenic Shigella of 0.01 to 0.014 organisms (confidence limits 0.001-0.05) for a 7-day per annum period of exposure and ranges from 0.07 to 0.1 organisms (confidence limits 0.006-0.4). for a 1-day per annum period of exposure. The plausibility of the pooled dose-response model was then evaluated by comparison with two known cruise ship outbreaks. The pooled model estimated that the two outbreaks studied could have been due to ingestion of 344 (confidence limits 72-915) Shigella cells per meal and 10.5-12 (confidence limits 1-44) Shigella cells per glass of water by passengers.

Secretory diarrhea in children: newly recognized toxins and hormone-secreting tumors

This review of bacterial toxins and hormones that stimulate diarrhea shows that we have learned much concerning the pathophysiology of these diarrheal states; however, we have much yet to learn. It is hoped that research will continue to enlighten us with regard to the pathophysiology, diagnosis, and treatment for these disease processes.

A modified Shigella volunteer challenge model in which the inoculum is administered with bicarbonate buffer: clinical experience and implications for Shigella infectivity

In the absence of a definitive immunologic correlate of protection against shigellosis, promising Shigella vaccine candidates have been selected based on their ability to confer resistance against experimental challenge with wild-type Shigella in healthy adult volunteers. A limitation of this model has been the low and often variable attack rate of illness among controls, necessitating repeated inpatient studies to demonstrate statistically significant results. In this study, the Shigella challenge model was modified by using bicarbonate buffer instead of skimmed milk as the delivery vehicle to enhance survival of the ingested challenge inoculum. To determine the ability of the modified model to detect protective efficacy, 11 veteran volunteers (previously challenged with S. flexneri 2a in bicarbonate buffer) and 12 immunologically naive control subjects were challenged with 1.4 x 10(3) c.f.u. S. flexneri 2a. Shigellosis occurred in 3 veterans and 11 control subjects (27 vs 92%, p = 0.003), yielding a protective efficacy of 70%. Dose response was evaluated in an additional seven naive subjects who were inoculated with a log lower (1.4 x 10(2) c.f.u.) S. flexneri 2a and had a significantly diminished attack rate of shigellosis (317 (43%) vs 11/12 (92%), p = 0.04). These findings indicate that the modified bicarbonate challenge model using an inoculum of 10(3) c.f.u. is a safe, repeatable, and valid method of selecting Shigella vaccines and other immunoprophylactic agents that are likely to confer protection against natural shigellosis.

Morphologic evaluation of the pathogenesis of bacterial enteric infections

Current advances in the understanding of the pathogenicity of the agents of diarrheal infections, Vibrio cholerae, diarrheagenic E. coli, Shigella, Salmonella, and enteropathogenic Yersinia, have, to a great extent, become possible due to morphological studies of host-pathogen interactions in natural and experimental infections. Despite a multigenic nature and a diversity of pathogenic features in the bacterial species and even in serogroups of the same species, it is now possible to delineate four major patterns of interaction of enteric pathogens with their cellular targets, the enterocytes, and with the immune apparatus of the gut. These patterns, epicellular cytotonic, epicellular restructuring cytotonic, invasive intraepithelial cytotonic and cytotoxic, and invasive transcellular cytotonic and cytotoxic bacteremic, underlie early pathogenesis and clinical manifestations in the respective diarrheal diseases. In this review, the results of the morphological analyses of these patterns over the last 3 decades as well as some methodological problems encountered in the interpretation of morphological observations are discussed.

Use of the polymerase chain reaction and fluorescent-antibody methods for detecting viable but nonculturable Shigella dysenteriae type 1 in laboratory microcosms

Epidemiological studies of shigellosis in Bangladesh have demonstrated that surface-water sources can act as foci of infection. Studies of laboratory microcosms have shown that shigellae become nonculturable but remain viable when exposed to environmental samples of water. The present study was carried out to detect viable but nonculturable Shigella dysenteriae 1 from laboratory microcosms by the polymerase chain reaction and the fluorescent-antibody techniques. S. dysenteriae 1 was inoculated into laboratory microcosms consisting of water samples collected from ponds, lakes, rivers, and drains in Bangladesh. The survival of S. dysenteriae in microcosms was assessed by viable counting on MacConkey agar. After 2 to 3 weeks, S. dysenteriae 1 became nonculturable but remained viable. After 6 weeks, this nonculturable but viable S. dysenteriae 1 was detected by both the polymerase chain reaction and the fluorescent-antibody methods. The viable but nonculturable state of S. dysenteriae 1 demonstrated in this study may be important for understanding the epidemiology of shigellosis.

Growth and survival of Shigella flexneri in common Bangladeshi foods under various conditions of time and temperature

Survival and growth of Shigella flexneri were assessed in various foods, including boiled rice, lentil soup, milk, cooked beef, cooked fish, mashed potato, mashed brinjal, and raw cucumber. Growth at 25 and 37 degrees C and survival at 5 degrees C were observed by viable counts on MacConkey agar. The organism grew well in all tested foods and growth increased from 10(5) to 10(8) to 10(10) cells per ml or g within 6 to 18 h after inoculation at 25 and 37 degrees C.

Antibodies to shiga holotoxin and to two synthetic peptides of the B subunit in sera of patients with Shigella dysenteriae 1 dysentery

Acute- and convalescent-phase sera from 18 Thai patients and convalescent-phase sera from two Israeli patients and one Bangladeshi patient with Shigella dysenteriae 1 (Shiga) dysentery were tested by enzyme-linked immunosorbent assay to detect antibodies that bind S. dysenteriae lipopolysaccharide (LPS), Shiga holotoxin, or two synthetic peptides representing epitopes from the B subunit of Shiga toxin. Paired sera from 24 Maryland adults with Shigella flexneri 2a or Shigella sonnei diarrhea served as negative controls. Of the 16 paired Thai serum samples tested for immunoglobulin G LPS antibody, 10 had greater than or equal to 4-fold rises (the two subjects with the highest convalescent-phase titers exhibited toxin-neutralizing activity); acute-phase specimens from four of the remaining six individuals already had elevated Shiga LPS titers in their acute specimens ranging from 1:800 to 1:12,800. Similarly, convalescent-phase sera from the two Israeli patients and the Bangladeshi patient revealed LPS titers of 1:800 to 1:3,200. In contrast, none of the Maryland volunteers with S. flexneri or S. sonnei diarrhea manifested rises in Shiga anti-LPS (P less than 0.00001 versus 10 of 16 Thai patients). Only 4 of the 18 Thai patients had significant rise in antibody to purified Shiga toxin, while one of the two Israeli patients and the one Bangladeshi patient had elevated convalescent-phase titers. None of the sera that reacted with Shiga holotoxin had antibody that bound to the peptides. This report, which describes a search for serum antibodies that bind Shiga toxin in patients with Shiga dysentery, demonstrates such antibodies in only a minority of patients with bacteriologically confirmed disease. During Shiga dysentery, Shiga toxin may be elaborated in such small quantities in vivo that it fails to elicit an immune response in most patients even though it may exert biological effects. In this behavior Shiga toxin resembles tetanus toxin, another potent exotoxin that fails to elicit antitoxic responses in people who recover from clinical tetanus.

Shiga toxin-associated hemolytic uremic syndrome: combined cytotoxic effects of shiga toxin and lipopolysaccharide (endotoxin) on human vascular endothelial cells in vitro

This study explores the in vitro relationship between Shiga toxin-producing Shigella spp. and Escherichia coli and the development of vascular complications in humans following bacillary dysentery. We propose that lipopolysaccharide (LPS; endotoxin) may combine with Shiga toxin to facilitate vascular damage characteristic of hemolytic uremic syndrome. We have examined the direct cytotoxic effects of Shiga toxin and LPS on human umbilical vein endothelial cells (HUVEC) in culture. Shiga toxin alone was cytotoxic to HUVEC, whereas LPS was noncytotoxic at concentrations at or below 10 micrograms/ml. Combinations of LPS with Shiga toxin resulted in a synergistic cytotoxic effect. The synergistic cytotoxic response of HUVEC to Shiga toxin plus LPS was dose dependent for both agents and was maximal at 24 h of exposure. This synergistic response was enhanced by preincubation of HUVEC with LPS. LPS (1 micrograms/ml) alone depressed HUVEC protein synthesis in a transient manner and enhanced the protein synthesis-inhibiting activity of Shiga toxin. The synergistic cytotoxic activity of LPS analogs was as follows, in decreasing order: complete LPS = diphosphoryl lipid A greater than monophosphoryl lipid A greater than deacylated LPS. These results are consistent with a role for Shiga toxin and LPS in the development of hemolytic uremic syndrome at the level of the vascular endothelium in humans.

Auxotrophic live oral Shigella flexneri vaccine protects monkeys against challenge with S. flexneri of different serotypes

The aromatic-dependent live Shigella flexneri Y strain SFL114, attenuated by a Tn10-inactivated aroD gene, was given as an oral vaccine to 14 Macaca fascicularis monkeys. A significant clinical attenuation of SFL114 was seen (p = 0.0058) as all vaccinated monkeys tolerated 2 x 10(10)-1 x 10(11) bacteria of SFL114, whereas four out of seven monkeys orally given 1 x 10(11) of the virulent parent strain SFL1 developed shigellosis. The average excretion time for SFL114 and SFL1 were 2 and 18 days, respectively. As seen endoscopically SFL1 caused colonic lesions, whereas SFL114 did not. Histopathologic examination of colonic biopsies showed that SFL114 induced only slight acute inflammation, whereas SFL1 caused severe acute inflammation (p less than 0.01). The vaccine strain SFL114 elicited significant species-specific serum immune responses (p less than 0.005) as seen in enzyme immune assays using lipopolysaccharides from S. flexneri serotypes Y, 1b, and 2a and Escherichia coli K-12 as antigens. The titres were comparable to those seen in monkeys given virulent S. flexneri strains. Western blot analyses showed that many prevaccination sera contained antibodies directed against the invasion plasmid-coded polypeptides. However, after vaccination with SFL114 increased amounts of such anti-polypeptide antibodies were seen, particularly in sera from monkeys having a low prevaccination antibody level. SFL114 also elicited a significant species-specific (p less than 0.025) local intestinal sIgA response against the homologous lipopolysaccharide antigen. Vaccinated monkeys were clinically protected against an oral challenge with 1-2 x 10(11) live, virulent S. flexneri strains of any of serotypes Y (strain SFL1), 1b (strain SFL27), or 2a (strain M4243).(ABSTRACT TRUNCATED AT 250 WORDS)

Preparation, characterization, and immunogenicity of conjugates composed of the O-specific polysaccharide of Shigella dysenteriae type 1 (Shiga's bacillus) bound to tetanus toxoid

The background for developing conjugate vaccines for shigellosis composed of the O-specific polysaccharide (O-SP) bound to a protein is described elsewhere (C. Y. Chu, R. Schneerson, and J. B. Robbins, submitted for publication). Briefly, there is direct evidence for type (lipopolysaccharide [LPS])-specific protection after infection with the wild type or with attenuated strains of shigellae. Prospective studies of Israeli armed forces recruits show a correlation between preexisting serum immunoglobulin G (IgG) LPS antibodies and resistance to shigellosis (D. Cohen, M. S. Green, C. Block, R. Slephon, and I. Ofek, J. Clin. Microbiol. 29:386-389, 1991). In order to elicit IgG LPS-specific antibodies to Shigella dysenteriae type 1, the O-SP of this pathogen was purified and bound to tetanus toxoid (TT) by three schemes. The most immunogenic used a modification of a published method (C. Y. Chu, R. Schneerson, J. B. Robbins, and S. C. Rastogi, Infect. Immun. 40:245-256, 1983). The resultant O-SP-TT conjugates were stable and elicited high levels of IgG O-SP antibodies and booster responses in young mice when injected subcutaneously in saline at 1/10 the proposed human dose. Adsorption onto alum or concurrent administration with monophosphoryl lipid A enhanced both the IgG and IgM antibody responses to the O-SP of the conjugate; both the nonadsorbed and adsorbed conjugates elicited higher rises of IgG than of IgM antibodies. Clinical evaluations of S. dysenteriae type 1 O-SP-TT conjugates are planned.

Shiga toxin-associated hemolytic-uremic syndrome: combined cytotoxic effects of Shiga toxin, interleukin-1 beta, and tumor necrosis factor alpha on human vascular endothelial cells in vitro

This study explores the relationship between Shiga toxin-producing Shigella or Escherichia coli strains and the development of vascular complications in humans following bacillary dysentery. We propose that endotoxin-elicited interleukin-1 or tumor necrosis factor alpha (TNF) may combine with Shiga toxin to facilitate vascular damage characteristic of hemolytic-uremic syndrome. This study examines the cytotoxic effects of Shiga toxin, interleukin-1, and TNF on cultured human umbilical vein endothelial cells (HUVEC). Both Shiga toxin and TNF were cytotoxic to HUVEC, although HUVEC obtained from individual umbilical cords differed in their sensitivities to these agents. With Shiga toxin-sensitive HUVEC, combinations of TNF with Shiga toxin resulted in a synergistic cytotoxic effect. In contrast, interleukin-1 was not cytotoxic to HUVEC, nor did it enhance cell death in combination with Shiga toxin. The synergistic cytotoxic response of HUVEC to Shiga toxin and TNF was dose and time dependent for both agents and could be neutralized by monoclonal antibodies directed against either Shiga toxin or TNF. This synergistic response was delayed, being maximal on day 2. Preincubation (24 h) of HUVEC with TNF sensitized the cells to Shiga toxin. TNF alone had no effect on HUVEC protein synthesis but enhanced the inhibitory activity of Shiga toxin. These results are consistent with a role for Shiga toxin in the development of hemolytic-uremic syndrome at the level of the vascular endothelium in humans.

The oac gene encoding a lipopolysaccharide O-antigen acetylase maps adjacent to the integrase-encoding gene on the genome of Shigella flexneri bacteriophage Sf6

Lysogens of Shigella flexneri harbouring the temperate bacteriophage, Sf6, have been previously shown to undergo a serotype conversion due to O-acetylation of the O-antigen of the lipopolysaccharide. A partial physical map of the phage genome has been constructed. Analysis of the phage DNA suggests that the phage packages by a headful mechanism and that the mature DNA molecules are terminally redundant. Cloning of the PstI fragments of Sf6 enabled the region encoding the serotype conversion to be localized, showing that this was clearly phage-encoded. The gene was further localized by mutagenesis with Tn5 and the nucleotide sequence of the entire 2693-bp PstI fragment was determined. Two major open reading frames (ORFs) were found capable of encoding proteins of 44.1 and 37.2 kDa. The latter corresponds to the O-antigen acetylase and its gene has been designated oac. The oac gene is capable of converting Sh. flexneri serotypes X, Y, 1a and 4a to 3a, 3b, 1b and 4b, respectively. The Oac protein bears a high degree of homology to the NodX protein of Rhizobium leguminosarum suggesting that it, too, may be a sugar acetylase. The second ORF immediately upstream from oac corresponds to the bacteriophage Sf6 integrase responsible for chromosomal integration and is highly homologous to the integrases of Escherichia coli bacteriophages P4 and phi 80, but less closely related to those of P1, P2, P22, 186 and lambda.

Nucleotide sequence of the ipaBCD structural genes of Shigella dysenteriae

A 9 kb EcoRI and two PstI fragments from the virulence plasmid of Shigella dysenteriae CG097 were shown to contain all ipa genes by probing with Shigella flexneri ipaB, -C, -D and -A gene probes. The DNA sequences of S. dysenteriae ipaBC genes were very similar to those of S. flexneri M90T and S. flexneri YSH6000, but ipaD differed by 22 codons from that of S. flexneri. The differences in ipaD may account for the different in vitro host specificities shown by S. dysenteriae and S. flexneri. The nucleotide composition of ipa genes revealed an unusually large number of codons that are rarely used in Escherichia coli chromosomal genes, indicating a different origin.

The pathogenic mechanisms of Shiga toxin and the Shiga-like toxins

It is now well documented that some enteric bacteria which cause diarrhoeal and/or dysenteric disease produce, at high levels, one or more of a family of protein toxins referred to as Shiga toxin and Shiga-like toxins (SLTs; alternatively called verocytotoxins or VTs). Within the past few years, there have been considerable advancements made in our understanding of the biochemistry and molecular biology of Shiga toxin and SLTs. However, the precise role of the toxins in mediating colonic disease, as well as their contribution to the development of extra-intestinal sequelae (e.g. the haemolytic uraemic syndrome and neurological disorders), remain less clear. In this MicroReview, we will briefly summarize recent progress in Shiga toxin- and SLT-related research and present evidence supporting the concept that these toxins contribute to pathogenesis by directly damaging vascular endothelial cells, thereby disrupting the homeostatic properties of these cells. We will also discuss data which suggest that toxin-mediated damage in the kidney may not be limited to glomerular endothelial cells but may include tubular epithelial cells. Thus, the role of the toxins in renal disease may not be limited to the glomeruli, as was initially hypothesized when the association of infection with toxin-producing strains and the development of acute renal failure was established.

Potentials of Shigella flexneri Y strain TSF21 as a candidate vaccine against shigellosis: safety, immunogenicity and protective efficacy in Bonnet monkeys

A thymine-requiring and temperature-sensitive mutant of Shigella flexneri Y was tested in Bonnet monkeys for safety, immunogenicity and protective efficacy. A dose of 10(11) cells when fed orally mimicked natural infection in having invaded epithelial cells, but was otherwise clinically non-reactogenic. Animals immunized with two oral doses, each dose consisting of 1 x 10(11) mutant bacteria, were fully protected when challenged, with respect to the lack of any clinical symptoms or detectable histological abnormalities in the intestinal mucosa. Unimmunized animals when similarly challenged developed frank dysentery and the intestinal mucosa showed severe histological abnormalities. Titres of serum antibodies increased by about 11-fold of the base level in animals immunized with a dose of 10(11) cells, but not with lower doses. The challenge bacteria appeared to be phagocytised by macrophages. In some monkeys of a particular group, congestive patches were seen in the stomach, but not in any other part of the gut, after the animals were fed with the virulent parent strain. The lesions were relatively severe in the immunized groups of animals.

Genetic basis of virulence in Shigella species

Shigella species and enteroinvasive strains of Escherichia coli cause disease by invasion of the colonic epithelium, and this invasive phenotype is mediated by genes carried on 180- to 240-kb plasmids. In addition, at least eight loci on the Shigella chromosome are necessary for full expression of virulence. The products of these genes can be classified as (i) virulence determinants that directly affect the ability of shigellae to survive in the intestinal tissues, e.g., the aerobactin siderophore (iucABCD and iutA), superoxide dismutase (sodB), and somatic antigen expression (rfa and rfb); (ii) cytotoxins that contribute to the severity of disease, e.g., the Shiga toxin (stx) and a putative analog of this toxin (flu); and (iii) regulatory loci that affect the expression of plasmid genes, e.g., ompR-envZ, which mediates response to changes in osmolarity, virR (osmZ), which mediates response to changes in temperature, and kcpA, which affects the translation of the plasmid virG (icsA) gene which is associated with intracellular bacterial mobility and intracellular bacterial spread. A single plasmid regulatory gene (virF) controls a virulence-associated plasmid regulon including virG (icsA) and two invasion-related loci, i.e., (i) ipaABCD, encoding invasion plasmid antigens that may be structural components of the Shigella invasion determinant; and (ii) invAKJH (mxi), which is necessary for insertion of invasion plasmid antigens into the outer membrane.

The pathology of Shigella flexneri infection in rhesus monkeys: an endoscopic and histopathological study of colonic lesions

Twenty-two Rhesus monkeys were orally fed 1 x 10(11) live virulent Shigella flexneri of either serotypes 1b, 2a, 4a or Y. On the basis of colonoscopic findings they were classified into: group A - normal endoscopic picture (10 monkeys), and group B - pathological endoscopic picture (12 monkeys). Pathological findings, distributed over the entire colon, were seen as either red patches (+/- erosions) or diffuse lesions, i.e. fragile red mucosa, mucosal bleeding and broad edemas. Histopathological examination of concomitant biopsies showed an acute inflammation restricted to the mucosa in 8/12 of group B as compared to 2/10 of group A. The Shigellae were most commonly demonstrated in the surface epithelium and more rarely in the deep layer of the lamina propria. Immunohistochemical staining, using monoclonal antibodies directed against Shigella flexneri O-antigenic polysaccharide, showed a high correlation with histopathological findings. Clinically all 10 monkeys in group A remained healthy, whereas 7/12 (all displaying histopathological signs of acute inflammation) in group B developed dysenteric symptoms. Colonoscopy should be combined with histopathological and immunohistochemical examinations of biopsies to study the pathological events taking place in the colon tissue during the course of a Shigella infection and will be of great value to assess the protective efficacy of S. flexneri vaccine candidates.

General considerations in the management of typhoid fever and dysentery

Typhoid fever is diagnosed on the basis of isolation of Salmonella typhi from blood, bone marrow, or bile. S. typhi found in stool or urine may reflect chronic asymptomatic carriage. Although antimicrobial therapy may not eliminate carriage, it is effective for the treatment of clinically evident acute disease. Among the drugs currently available, chloramphenicol is the most widely used. Chloramphenicol is effective and inexpensive, but it is associated with a 3% rate of chronic carriage, a high relapse rate, and, in rare cases, aplastic anemia. For these reasons, and because of the emergence of chloramphenicol-resistant strains of S. typhi, alternative drugs need to be considered. Dysentery is characterized by the passage of unformed stools that commonly contain blood and mucus and in which large numbers of leukocytes can be detected on microscopic examination. Invasion of the intestinal epithelium is the distinguishing characteristic, and Shigella sp are the most frequent cause. Although oral rehydration is useful in dehydrated patients, dehydration is not a common problem in acute dysentery, and antimicrobial treatment is indicated for this disease. An antimicrobial agent should be selected on the basis of knowledge of the susceptibility patterns of locally isolated Shigella strains.

Role of Shiga toxin in the pathogenesis of bacillary dysentery, studied by using a Tox- mutant of Shigella dysenteriae 1

A Tox- mutant of Shigella dysenteriae 1, SC501, was genetically engineered by cloning the Shiga toxin operon, inserting a cassette into the A subunit gene, and exchanging this in vitro-mutagenized sequence with the wild-type gene. SC501 produced a low amount of residual cytotoxicity which was not neutralized by a rabbit immune serum directed against Shiga toxin. Invasion of cultured cells demonstrated that Shiga toxin had no effect on the rate of intracellular growth of bacteria or on the rapid killing of invaded host cells. On the other hand, several significant differences were observed in macaque monkeys infected intragastrically with either the wild-type strain or its mutant. The production of Shiga toxin by the invading strain was correlated with the presence of blood within stools, a sharp drop in blood polymorphonuclear cells, and histopathological alterations, such as the destruction of capillary vessels within the connective tissue of the colonic mucosa, severe inflammatory vasculitis of the peritoneal mesothelium, and major efflux of inflammatory cells to the intestinal lumen. It is proposed that Shiga toxin influences the severity of bacillary dysentery by inducing colonic vascular damage, which accounts for bloody stools, intestinal ischemia, and inflation of a polymorphonuclear intestinal compartment during the infectious process.

Synthetic peptides of Shiga toxin B subunit induce antibodies which neutralize its biological activity

Shiga toxin B chain, the binding subunit of Shiga toxin, was recently purified; and the amino acid sequence of this 7,716-dalton polypeptide was determined (N.G. Seidah, A. Donohue-Rolfe, C. Lazure, F. Auclair, G. T. Keusch, and M. Chretien, J. Biol. Chem. 261:13928-13931, 1986). In the present study, synthetic peptides corresponding to three overlapping sequences from the N-terminal region of this subunit were prepared. The peptides synthesized consisted of residues 5 to 18, 13 to 26, and 7 to 26. This region coincides with the major peak of hydrophilicity and surface area residues predicted from a computer analysis. For the purpose of immunization, the peptides either were conjugated with a protein or synthetic carrier or were polymerized with glutaraldehyde. Antisera against these peptide derivatives raised in rabbits reacted not only with the respective homologous peptide but also to a comparable extent with the intact Shiga toxin. The anti-peptide antisera effectively neutralized the various biological activities of the Shiga toxin, namely, cytotoxicity to HeLa cells, enterotoxic activity (the fluid secretion into ligated ileal loops in rats), and neurotoxicity in mice. Furthermore, active immunization with the peptide conjugates was found to protect mice against the lethal effect of Shiga toxin.

Development of an auxotrophic oral live Shigella flexneri vaccine

An oral live attenuated Shigella flexneri vaccine candidate strain was constructed by making it auxotrophic and dependent on aromatic metabolites not available in mammalian tissues. An aroD gene of Escherichia coli K12 strain NK 5131, inactivated by insertion in it of the Tn 10 transposon, was transduced using phage P1 into a virulent S. flexneri serotype Y strain (Sfl 1) isolated from a patient with bacillary dysentery. One of the transductant strains Sfl 114 was found to invade HeLa cells in vitro, to cause plaque formation in HeLa monolayers (i.e. maintain intracellular multiplication in vitro), but to be unable to cause keratoconjunctivitis in guinea-pig eyes. When the strain was fed to Macacca fascicularis monkeys it was well tolerated, excreted for 1-4 days, and found to elicit a local intestinal sIgA and serum IgA, IgM and IgG responses. Monkeys challenged with 100 ID50 dose (1 X 10(11) bacteria) of the virulent parent Sfl 1 strain were completely protected from development of diarrhoea. Coloscopy of the monkeys and the sampling of intestinal biopsies showed that the vaccine protected against the surface epithelial erosions and ulcerations seen in unimmunized monkeys. Killing of invading virulent shigellae apparently took place intracellularly in the mucosa suggesting that cellular immune mechanisms played a role in the elicited host defence. The constructed S. flexneri Sfl 114 strain has the properties of a promising shigella vaccine and will next be the subject of studies with human volunteers.

Bacterial gastroenteritis

Acute diarrhea is a major cause of childhood morbidity. Important advances in the understanding of bacterial gastroenteritis have been made in the past two decades. This article reviews the epidemiology, pathogenesis, and methods of diagnosis of bacterial gastroenteritis. Bacterial enteric pathogens common to North America are discussed in more detail.

Role of a 60-megadalton plasmid and Shiga-like toxins in the pathogenesis of infection caused by enterohemorrhagic Escherichia coli O157:H7 in gnotobiotic piglets

Enterohemorrhagic Escherichia coli (EHEC) of serotype O157:H7 has two putative virulence factors: (i) a fimbrial adhesin, specified by a 60-megadalton (MDa) plasmid, and (ii) bacteriophage-specified cytotoxin(s), known as Shiga-like toxin (SLT) or verotoxin. The contribution of these factors to the pathogenesis of EHEC-induced disease in gnotobiotic piglets was examined. The bacterial strains included the following: two EHEC strains and their corresponding plasmid-cured derivatives; another EHEC isolate and its derivative which had spontaneously lost the ability to produce SLT; one E. coli K-12 transconjugatant containing a 60-MDa plasmid from an EHEC strain; two K-12 strains into which an SLT-producing phage had been transduced (one of these strains also carried a 60-MDa EHEC-derived plasmid); and the parent K-12 strain. Each strain was fed to four piglets, which were observed for diarrhea and examined for development of characteristic mucosal lesions 3 or 5 days after inoculation. All 24 piglets inoculated with the three EHEC strains and their respective derivatives (two plasmid cured and one SLT negative) showed the typical mucosal lesions of bacterial attachment: effacement of microvillous border and cell membrane dissolution culminating in destruction of surface and glandular epithelium in the cecum and colon. No such lesions were observed in 12 piglets inoculated with three strains of E. coli K-12, including the strain which carried both the 60-MDa plasmid and a phage which specified production of SLT. Moderate to severe diarrhea was observed in 16 piglets inoculated with two EHEC strains and their derivatives (one plasmid cured and one SLT negative). The third EHEC strain and its plasmid-cured derivative produced fewer typical mucosal lesions and no diarrhea. The reason for the reduced virulence of this strain was not clear. These results demonstrate that neither the 60-MDa plasmid nor the capacity to produce SLT is essential for expression of virulence by E. coli O157:H7 in gnotobiotic piglets.

In vitro and in vivo pathogenicity of Plesiomonas shigelloides

Epidemiologic evidence suggests that Plesiomonas shigelloides is an enteric pathogen. We conducted in vitro, animal, and volunteer studies on P. shigelloides isolates from patients with diarrhea. Five strains gave a negative keratoconjunctivitis reaction in guinea pigs and did not invade HeLa cells. Genetic probes for heat-stable enterotoxins related to those of enterotoxigenic Escherichia coli and for gene sequences common to the invasiveness plasmids of Shigella spp. and enteroinvasive E. coli were negative. Heat-labile enterotoxins were not found when a modified GM1-enzyme-linked immunosorbent assay was used. Rabbits did not develop diarrhea but were transiently colonized when inoculated with up to 10(11) P. shigelloides CFU using the reversible intestinal tie adult rabbit diarrhea model. A very large plasmid (between 118 and 312 megadaltons) was found in all isolates. Strain P012 was cured of its plasmid by novobiocin. This strain, but not its cured derivative, invaded the mucosa of the distal ileum of gnotobiotic piglets given 10(10) CFU. At a lower inoculum (10(9) CFU), strain P012 induced inflammation of the colonic mucosa and diarrhea at day 6. The same isolate was fed to 33 healthy volunteers in doses of 1 X 10(3) to 4 X 10(9) CFU. Thirty-six percent of the volunteers shed the organism, but none became ill. These data are only weakly supportive of a role for P. shigelloides in diarrheal illness and suggest the need for more studies with other strains to better understand its pathogenicity.

Pathogenesis of Shigella diarrhea: rabbit intestinal cell microvillus membrane binding site for Shigella toxin

This study examined the binding of purified 125I-labeled shigella toxin to rabbit jejunal microvillus membranes (MVMs). Toxin binding was concentration dependent, saturable, reversible, and specifically inhibited by unlabeled toxin. The calculated number of toxin molecules bound at 4 degrees C was 7.9 X 10(10) (3 X 10(10) to 2 X 10(11))/micrograms of MVM protein or 1.2 X 10(6) per enterocyte. Scatchard analysis showed the binding site to be of a single class with an equilibrium association constant, K, of 4.7 X 10(9) M-1 at 4 degrees C. Binding was inversely related to the temperature of incubation. A total of 80% of the labeled toxin binding at 4 degrees C dissociated from MVM when the temperature was raised to 37 degrees C, but reassociated when the temperature was again brought to 4 degrees C. There was no structural or functional change of MVM due to toxin as monitored by electron microscopy or assay of MVM sucrase activity. These studies demonstrate a specific binding site for shigella toxin on rabbit MVMs. The physiological relevance of this receptor remains to be determined.

Shigella dysenteriae type 1 enterocolitis

Shigella dysenteriae type 1 is much more virulent than Shigella flexneri and sonnei which are endemic in Australia. This report describes a 22 year old woman who acquired Shigella dysenteriae type 1 whilst travelling in India. During the course of her illness, she developed severe enterocolitis for which a subtotal colectomy was performed. The illness resembled fulminant ulcerative colitis and its infectious nature was difficult to establish because several fecal cultures failed to grow the pathogen. Her infection was complicated by shigella bacteremia, disseminated intravascular coagulation, and renal cortical necrosis which requires continued hemodialysis.

Pathogenesis of placentitis in the goat inoculated with Brucella abortus. II. Ultrastructural studies

Pregnant goats were inoculated intravenously or in uterine arteries with Brucella abortus, and tissues from the uterus and placenta were examined by electron microscopy. Identification of B. abortus in placentae was with antibody-coated colloidal gold. B. abortus was first seen in phagosomes of erythrophagocytic trophoblasts and in the rough endoplasmic reticulum of chorioallantoic trophoblasts. Subsequently, trophoblast necrosis and ulceration of chorioallantoic membranes were present. Coincidently, B. abortus was present in the lumen of placental capillaries. In late stages of infection, placental vasculitis was present, and placentomal trophoblasts were separated from maternal syncytial epithelium. In lesions with vasculitis, large numbers of B. abortus were in connective tissue of chorionic villi. Within the placentome, trophoblasts that lined chorionic villi contained no intracellular bacteria and were separated from B. abortus by intact basement membranes. These results suggest that bacteremic B. abortus is endocytosed by erythrophagocytic trophoblasts and that B. abortus replicates in the rough endoplasmic reticulum of chorioallantoic trophoblasts. Replication of brucellae in trophoblastic rough endoplasmic reticulum is unique; we believe that B. abortus may utilize endoplasmic reticulum for synthesis and glycosylation of bacterial membrane proteins or that B. abortus catabolizes trophoblast secretory proteins.

Experimental infection of infant rabbits with verotoxin-producing Escherichia coli

To study the pathogenesis of diarrheal disease due to verotoxin (VT)-producing Escherichia coli, 3-day-old rabbits were inoculated intragastrically with live E. coli O157:H7 (high VT producer), E. coli O113:K75:H21 (low VT producer), or O157:H45 (VT negative) and were examined for clinical symptoms, bacterial colonization, presence of detectable free VT in the intestines, and histological changes. Diarrhea developed consistently with 10(8) bacteria of E. coli O157:H7 but was observed only infrequently with even a higher dose of E. coli O113:K75:H21. VT-negative strains failed to cause diarrhea under the same experimental conditions. E. coli O157:H7 was recovered from the colon of infected animals in a significantly higher concentration than from the small intestine, and the clinical symptoms correlated with the presence of detectable free VT in the colon. Histological changes were seen mainly in the mid- and distal colon; these changes were characterized by a vast increase in apoptosis in the surface epithelium, increased mitotic activity in the crypts, mucin depletion, and a mild to moderate infiltration of neutrophils in the lamina propria and epithelium. Multiple foci of attached bacteria were seen on the surface epithelium of the gut-associated lymphoid tissue, cecum, and colon. Bacteria were never seen in epithelial cells or the lamina propria. These mucosal abnormalities as well as clinical symptoms were reproduced in infant rabbits by the intragastric administration of VT alone. These results are consistent with the hypothesis that VT plays a major role in the pathogenesis of diarrhea caused by E. coli O157:H7 and other VT-producing E. coli.

Escherichia coli diarrhoea

Ever since Escherich (1885) first isolated the organism now known asEscherichia colifrom the stools of infants, medical microbiologists have been faced with the problem of distinguishing between those strains capable of causing diarrhoea and those that are harmless gut commensals. Epidemiological investigations were greatly facilitated by the description by Kauffmann (1947) of a serotyping scheme forE. coli, and Taylor (1961) later reported that 17 0 serogroups ofE. colihad been implicated as possible causes of epidemic infantile enteritis. These infantile enteropathogenicE. coli(EPEC), having been discovered by epidemiological studies using serotyping, belonged by definition to a restricted range of serogroups. More recently it was shown that otherE. colistrains may produce enterotoxins, and these enterotoxigenicE. coli(ETEC) usually belong to particular serogroups which are different from those associated with EPEC.E. colistrains belonging to a third range of serogroups may cause an illness resembling shigella dysentery, and these may be regarded as entero-invasiveE. coli(EIEC).E. colistrains that cause diarrhoea may therefore be considered as three groups, as follows.