1
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Rosemary essential oil and its components 1,8-cineole and α-pinene induce ROS-dependent lethality and ROS-independent virulence inhibition in Candida albicans. PLoS One 2022; 17:e0277097. [DOI: 10.1371/journal.pone.0277097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
The essential oil from Rosmarinus officinalis L., a composite mixture of plant-derived secondary metabolites, exhibits antifungal activity against virulent candidal species. Here we report the impact of rosemary oil and two of its components, the monoterpene α-pinene and the monoterpenoid 1,8-cineole, against Candida albicans, which induce ROS-dependent cell death at high concentrations and inhibit hyphal morphogenesis and biofilm formation at lower concentrations. The minimum inhibitory concentrations (100% inhibition) for both rosemary oil and 1,8-cineole were 4500 μg/ml and 3125 μg/ml for α-pinene, with the two components exhibiting partial synergy (FICI = 0.55 ± 0.07). At MIC and 1/2 MIC, rosemary oil and its components induced a generalized cell wall stress response, causing damage to cellular and organelle membranes, along with elevated chitin production and increased cell surface adhesion and elasticity, leading to complete vacuolar segregation, mitochondrial depolarization, elevated reactive oxygen species, microtubule dysfunction, and cell cycle arrest mainly at the G1/S phase, consequently triggering cell death. Interestingly, the same oils at lower fractional MIC (1/8-1/4) inhibited virulence traits, including reduction of mycelium (up to 2-fold) and biofilm (up to 4-fold) formation, through a ROS-independent mechanism.
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2
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Álvarez S, Leiva-Sabadini C, Schuh CMAP, Aguayo S. Bacterial adhesion to collagens: implications for biofilm formation and disease progression in the oral cavity. Crit Rev Microbiol 2021; 48:83-95. [PMID: 34270375 DOI: 10.1080/1040841x.2021.1944054] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Collagen is the most abundant structural protein in the body and the main component of the extracellular matrix of most tissues, including dentine and periodontal tissues. Despite the well-characterized role of collagen and specifically type-I collagen, as a ligand for host cells, its role as a substrate for bacterial adhesion and biofilm formation is less explored. Therefore, the purpose of this review is to discuss recent findings regarding the adhesion of oral bacteria to collagen surfaces and its role in the progression and severity of oral and systemic diseases. Initial oral colonizers such as streptococci have evolved collagen-binding proteins (cbp) that are important for the colonization of dentine and periodontal tissues. Also, periodontal pathogens such as Porphyromonas gingivalis and Tannerella forsythia utilise cbps for tissue sensing and subsequent invasion. The implications of bacteria-collagen coupling in the context of collagen biomaterials and regenerative dentistry approaches are also addressed. Furthermore, the importance of interdisciplinary techniques such as atomic force microscopy for the nanocharacterization of bacteria-collagen interactions is also considered. Overall, understanding the process of oral bacterial adhesion onto collagen is important for developing future therapeutic approaches against oral and systemic diseases, by modulating the early stages of biofilm formation.
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Affiliation(s)
- Simón Álvarez
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile.,Dentistry School, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Camila Leiva-Sabadini
- Dentistry School, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Christina M A P Schuh
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Sebastian Aguayo
- Dentistry School, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
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3
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Pimenta AI, Kilcoyne M, Bernardes N, Mil-Homens D, Joshi L, Fialho AM. Burkholderia cenocepacia BCAM2418-induced antibody inhibits bacterial adhesion, confers protection to infection and enables identification of host glycans as adhesin targets. Cell Microbiol 2021; 23:e13340. [PMID: 33822465 DOI: 10.1111/cmi.13340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/18/2022]
Abstract
Trimeric Autotransporter Adhesins (TAA) found in Gram-negative bacteria play a key role in virulence. This is the case of Burkholderia cepacia complex (Bcc), a group of related bacteria able to cause infections in patients with cystic fibrosis. These bacteria use TAAs, among other virulence factors, to bind to host protein receptors and their carbohydrate ligands. Blocking such contacts is an attractive approach to inhibit Bcc infections. In this study, using an antibody produced against the TAA BCAM2418 from the epidemic strain Burkholderia cenocepacia K56-2, we were able to uncover its roles as an adhesin and the type of host glycan structures that serve as recognition targets. The neutralisation of BCAM2418 was found to cause a reduction in the adhesion of the bacteria to bronchial cells and mucins. Moreover, in vivo studies have shown that the anti-BCAM2418 antibody exerted an inhibitory effect during infection in Galleria mellonella. Finally, inferred by glycan arrays, we were able to predict for the first time, host glycan epitopes for a TAA. We show that BCAM2418 favoured binding to 3'sialyl-3-fucosyllactose, histo-blood group A, α-(1,2)-linked Fuc-containing structures, Lewis structures and GM1 gangliosides. In addition, the glycan microarrays demonstrated similar specificities of Burkholderia species for their most intensely binding carbohydrates.
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Affiliation(s)
- Andreia I Pimenta
- iBB-Institute for Bioengineering and Biosciences, and Department of Bioengineering, Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal
| | - Michelle Kilcoyne
- Carbohydrate Signalling Group, Microbiology, School of Natural Sciences, National University of Ireland Galway, Galway, Ireland
| | - Nuno Bernardes
- iBB-Institute for Bioengineering and Biosciences, and Department of Bioengineering, Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal
| | - Dalila Mil-Homens
- iBB-Institute for Bioengineering and Biosciences, and Department of Bioengineering, Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal
| | - Lokesh Joshi
- Glycoscience Group, School of Natural Sciences, National University of Ireland Galway, Galway, Ireland
| | - Arsenio M Fialho
- iBB-Institute for Bioengineering and Biosciences, and Department of Bioengineering, Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal
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4
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Phenotypic characterization of trimeric autotransporter adhesin-defective bcaC mutant of Burkholderia cenocepacia: cross-talk towards the histidine kinase BCAM0218. Microbes Infect 2020; 22:457-466. [DOI: 10.1016/j.micinf.2020.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 11/22/2022]
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5
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Khalil HS, Øgaard J, Leo JC. Coaggregation properties of trimeric autotransporter adhesins. Microbiologyopen 2020; 9:e1109. [PMID: 32864901 PMCID: PMC7568254 DOI: 10.1002/mbo3.1109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/24/2020] [Accepted: 07/30/2020] [Indexed: 12/19/2022] Open
Abstract
Trimeric autotransporter adhesins (TAAs) comprise a group of virulence‐related proteins in Gram‐negative bacteria. Members of this family bind to extracellular matrix components such as collagen and fibronectin, but also they exhibit several other functions, such as conferring serum resistance and autoaggregation. Autoaggregation promoted by TAAs is homotypic and mediated by the sticky, globular head domains of these lollipop‐like molecules. However, whether TAAs mediate heterotypic interactions (i.e., coaggregation) has not been studied. To address this question, we investigated the coaggregation of two model TAA groups: YadA from the enteropathogenic Yersiniae and the immunoglobulin‐binding Eib proteins from Escherichia coli. To study TAA coaggregation, we coexpressed a fluorescent label together with a particular TAA and followed the aggregative interactions using fluorescence microscopy and quantified the interactions using a novel script implemented in Fiji. Our results show that there is coaggregation between some populations expressing different TAAs, which can be explained by relatively high sequence similarity between the interacting TAAs. Generally, the level of coaggregation correlated with the sequence similarity. However, some TAAs did not interact despite high sequence similarity, showing exclusion of bacteria producing a noncompatible TAA. These data demonstrate that TAAs can mediate bacterial coaggregation, but in some cases prevent coaggregation of bacteria with disparate TAAs. Our results have implications for the ecology of TAA‐producing bacteria, where coaggregation may promote co‐operation whereas exclusion might be an indication of competition.
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Affiliation(s)
- Hawzeen S Khalil
- Section for Evolution and Genetics, Department of Biosciences, University of Oslo, Oslo, Norway
| | - Jonas Øgaard
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Jack C Leo
- Section for Evolution and Genetics, Department of Biosciences, University of Oslo, Oslo, Norway.,Antimicrobial Resistance, Omics and Microbiota Group, Department of Biosciences, School of Science and Technology, Nottingham Trent University, Nottingham, UK
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6
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Abstract
Microbial adhesion and biofilm formation are usually studied using molecular and cellular biology assays, optical and electron microscopy, or laminar flow chamber experiments. Today, atomic force microscopy (AFM) represents a valuable addition to these approaches, enabling the measurement of forces involved in microbial adhesion at the single-molecule level. In this minireview, we discuss recent discoveries made applying state-of-the-art AFM techniques to microbial specimens in order to understand the strength and dynamics of adhesive interactions. These studies shed new light on the molecular mechanisms of adhesion and demonstrate an intimate relationship between force and function in microbial adhesins.
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7
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Pimenta AI, Mil‐Homens D, Fialho AM. Burkholderia cenocepacia-host cell contact controls the transcription activity of the trimeric autotransporter adhesin BCAM2418 gene. Microbiologyopen 2020; 9:e998. [PMID: 32097539 PMCID: PMC7142374 DOI: 10.1002/mbo3.998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 12/11/2022] Open
Abstract
Cell-to-cell early contact between pathogens and their host cells is required for the establishment of many infections. Among various surface factors produced by bacteria that allow an organism to become established in a host, the class of adhesins is a primary determinant. Burkholderia cenocepacia adheres to the respiratory epithelium of cystic fibrosis patients and causes chronic inflammation and disease. Cell-to-cell contacts are promoted by various kinds of adhesins, including trimeric autotransporter adhesins (TAAs). We observed that among the 7 TAA genes found in the B. cenocepacia K56-2 genome, two of them (BCAM2418 and BCAS0236) express higher levels of mRNA following physical contact with host cells. Further analysis revealed that the B. cenocepacia K56-2 BCAM2418 gene shows an on-off switch after an initial colonization period, exhibits a strong expression dependent on the host cell type, and enhances its function on cell adhesion. Furthermore, our analysis revealed that adhesion to mucin-coated surfaces dramatically increases the expression levels of BCAM2418. Abrogation of mucin O-glycans turns BCAM2418 gene expression off and impairs bacterial adherence. Overall, our findings suggest that glycosylated extracellular components of host membrane might be a binding site for B. cenocepacia and a signal for the differential expression of the TAA gene BCAM2418.
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Affiliation(s)
- Andreia I. Pimenta
- iBB‐Institute for Bioengineering and BiosciencesInstituto Superior Técnico, University of LisbonLisbonPortugal
| | - Dalila Mil‐Homens
- iBB‐Institute for Bioengineering and BiosciencesInstituto Superior Técnico, University of LisbonLisbonPortugal
| | - Arsenio M. Fialho
- iBB‐Institute for Bioengineering and BiosciencesInstituto Superior Técnico, University of LisbonLisbonPortugal
- Department of BioengineeringInstituto Superior TécnicoUniversity of LisbonLisbonPortugal
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8
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Fibrinogen binding is affected by amino acid substitutions in C-terminal repeat region of fibronectin binding protein A. Sci Rep 2019; 9:11619. [PMID: 31406152 PMCID: PMC6690874 DOI: 10.1038/s41598-019-48031-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 07/29/2019] [Indexed: 11/14/2022] Open
Abstract
Fibronectin-binding protein A (FnBPA), a protein displayed on the outer surface of Staphylococcus aureus, has a structured A-domain that binds fibrinogen (Fg) and a disordered repeat-region that binds fibronectin (Fn). Amino acid substitutions in Fn-binding repeats (FnBRs) have previously been linked to cardiovascular infection in humans. Here we used microtiter and atomic force microscopy (AFM) to investigate adhesion by variants of full-length FnBPA covalently anchored in the outer cell wall of Lactococcus lactis, a Gram-positive surrogate that otherwise lacks adhesins to mammalian ligands. Fn adhesion increased in five of seven FnBPA variants under static conditions. The bond targeting Fn increased its strength with load under mechanical dissociation. Substitutions extended bond lifetime (1/koff) up to 2.1 times for FnBPA-Fn. Weaker adhesion was observed for Fg in all FnBPA variants tested with microtiter. However, mechanical dissociation with AFM showed significantly increased tensile strength for Fg interacting with the E652D/H782Q variant. This is consistent with a force-induced mechanism and suggests that the dock, lock, and latch (DLL) mechanism is favored for Fg-binding under mechanical stress. Collectively, these experiments reveal that FnBPA exhibits bimodal, ligand-dependent adhesive behavior. Amino acid substitutions in the repeat-region of FnBPA impact binding to both ligands. This was unexpected for Fg since all variants have the same A-domain sequence, and the Fg-binding site is distant from the repeat region. This indicates that FnBRs may fold back on the A-domain in a way that impacts the DLL binding mechanism for Fg.
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9
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Yoo H, Lee DJ, Kim D, Park J, Chen X, Hong S. Magnetically-focusing biochip structures for high-speed active biosensing with improved selectivity. NANOTECHNOLOGY 2018; 29:265501. [PMID: 29624503 DOI: 10.1088/1361-6528/aabc4d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We report a magnetically-focusing biochip structure enabling a single layered magnetic trap-and-release cycle for biosensors with an improved detection speed and selectivity. Here, magnetic beads functionalized with specific receptor molecules were utilized to trap target molecules in a solution and transport actively to and away from the sensor surfaces to enhance the detection speed and reduce the non-specific bindings, respectively. Using our method, we demonstrated the high speed detection of IL-13 antigens with the improved detection speed by more than an order of magnitude. Furthermore, the release step in our method was found to reduce the non-specific bindings and improve the selectivity and sensitivity of biosensors. This method is a simple but powerful strategy and should open up various applications such as ultra-fast biosensors for point-of-care services.
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Affiliation(s)
- Haneul Yoo
- Department of Physics and Astronomy, and Institute of Applied Physics, Seoul national University, Seoul 08826, Republic of Korea
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10
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Shahina Z, El-Ganiny AM, Minion J, Whiteway M, Sultana T, Dahms TES. Cinnamomum zeylanicum bark essential oil induces cell wall remodelling and spindle defects in Candida albicans. Fungal Biol Biotechnol 2018; 5:3. [PMID: 29456868 PMCID: PMC5807769 DOI: 10.1186/s40694-018-0046-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 01/16/2018] [Indexed: 12/01/2022] Open
Abstract
Background Cinnamon (Cinnamomum zeylanicum) bark extract exhibits potent inhibitory activity against Candida albicans but the antifungal mechanisms of this essential oil remain largely unexplored. Results We analyzed the impact of cinnamon bark oil on C. albicans RSY150, and clinical strains isolated from patients with candidemia and candidiasis. The viability of RSY150 was significantly compromised in a dose dependent manner when exposed to cinnamon bark oil, with extensive cell surface remodelling at sub inhibitory levels (62.5 μg/mL). Atomic force microscopy revealed cell surface exfoliation, altered ultrastructure and reduced cell wall integrity for both RSY150 and clinical isolates exposed to cinnamon bark oil. Cell wall damage induced by cinnamon bark oil was confirmed by exposure to stressors and the sensitivity of cell wall mutants involved in cell wall organization, biogenesis, and morphogenesis. The essential oil triggered cell cycle arrest by disrupting beta tubulin distribution, which led to mitotic spindle defects, ultimately compromising the cell membrane and allowing leakage of cellular components. The multiple targets of cinnamon bark oil can be attributed to its components, including cinnamaldehyde (74%), and minor components (< 6%) such as linalool (3.9%), cinamyl acetate (3.8%), α-caryophyllene (5.3%) and limonene (2%). Complete inhibition of the mitotic spindle assembly was observed in C. albicans treated with cinnamaldehyde at MIC (112 μg/mL). Conclusions Since cinnamaldehyde disrupts both the cell wall and tubulin polymerization, it may serve as an effective antifungal, either by chemical modification to improve its specificity and efficacy or in combination with other antifungal drugs. Electronic supplementary material The online version of this article (10.1186/s40694-018-0046-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zinnat Shahina
- 1Department of Chemistry and Biochemistry, University of Regina, 3737 Wascana Parkway, Regina, SK Canada
| | - Amira M El-Ganiny
- 2Microbiology and Immunology Department, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
| | | | - Malcolm Whiteway
- 4Centre for Structural and Functional Genomics, Concordia University, Montreal, QC Canada
| | - Taranum Sultana
- 1Department of Chemistry and Biochemistry, University of Regina, 3737 Wascana Parkway, Regina, SK Canada
| | - Tanya E S Dahms
- 1Department of Chemistry and Biochemistry, University of Regina, 3737 Wascana Parkway, Regina, SK Canada.,3Regina Qu'Appelle Health Region, Regina, SK Canada
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11
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Defining the Mechanical Determinants of Kingella kingae Adherence to Host Cells. J Bacteriol 2017; 199:JB.00314-17. [PMID: 28874408 DOI: 10.1128/jb.00314-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/23/2017] [Indexed: 12/17/2022] Open
Abstract
Kingella kingae is an important pathogen in young children and initiates infection by colonizing the posterior pharynx. Adherence to pharyngeal epithelial cells is an important first step in the process of colonization. In the present study, we sought to elucidate the interplay of type IV pili (T4P), a trimeric autotransporter adhesin called Knh, and the polysaccharide capsule in K. kingae adherence to host cells. Using adherence assays performed under shear stress, we observed that a strain expressing only Knh was capable of higher levels of adherence than a strain expressing only T4P. Using atomic force microscopy and transmission electron microscopy (TEM), we established that the capsule had a mean depth of 700 nm and that Knh was approximately 110 nm long. Using cationic ferritin capsule staining and thin-section transmission electron microscopy, we found that when bacteria expressing retractile T4P were in close contact with host cells, the capsule was absent at the point of contact between the bacterium and the host cell membrane. In a T4P retraction-deficient mutant, the capsule depth remained intact and adherence levels were markedly reduced. These results support the following model: T4P make initial contact with the host cell and mediate low-strength adherence. T4P retract, pulling the organism closer to the host cell and displacing the capsule, allowing Knh to be exposed and mediate high-strength, tight adherence to the host cell surface. This report provides the first description of the mechanical displacement of capsule enabling intimate bacterial adherence to host cells.IMPORTANCE Adherence to host cells is an important first step in bacterial colonization and pathogenicity. Kingella kingae has three surface factors that are involved in adherence: type IV pili (T4P), a trimeric autotransporter adhesin called Knh, and a polysaccharide capsule. Our results suggest that T4P mediate initial contact and low-strength adherence to host cells. T4P retraction draws the bacterium closer to the host cell and causes the displacement of capsule. This displacement exposes Knh and allows Knh to mediate high-strength adherence to the host cell. This work provides new insight into the interplay of T4P, a nonpilus adhesin, and a capsule and their effects on bacterial adherence to host cells.
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12
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Casillas-Ituarte NN, Cruz CHB, Lins RD, DiBartola AC, Howard J, Liang X, Höök M, Viana IFT, Sierra-Hernández MR, Lower SK. Amino acid polymorphisms in the fibronectin-binding repeats of fibronectin-binding protein A affect bond strength and fibronectin conformation. J Biol Chem 2017; 292:8797-8810. [PMID: 28400484 DOI: 10.1074/jbc.m117.786012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/08/2017] [Indexed: 11/06/2022] Open
Abstract
The Staphylococcus aureus cell surface contains cell wall-anchored proteins such as fibronectin-binding protein A (FnBPA) that bind to host ligands (e.g. fibronectin; Fn) present in the extracellular matrix of tissue or coatings on cardiac implants. Recent clinical studies have found a correlation between cardiovascular infections caused by S. aureus and nonsynonymous SNPs in FnBPA. Atomic force microscopy (AFM), surface plasmon resonance (SPR), and molecular simulations were used to investigate interactions between Fn and each of eight 20-mer peptide variants containing amino acids Ala, Asn, Gln, His, Ile, and Lys at positions equivalent to 782 and/or 786 in Fn-binding repeat-9 of FnBPA. Experimentally measured bond lifetimes (1/koff) and dissociation constants (Kd = koff/kon), determined by mechanically dissociating the Fn·peptide complex at loading rates relevant to the cardiovascular system, varied from the lowest-affinity H782A/K786A peptide (0.011 s, 747 μm) to the highest-affinity H782Q/K786N peptide (0.192 s, 15.7 μm). These atomic force microscopy results tracked remarkably well to metadynamics simulations in which peptide detachment was defined solely by the free-energy landscape. Simulations and SPR experiments suggested that an Fn conformational change may enhance the stability of the binding complex for peptides with K786I or H782Q/K786I (Kdapp = 0.2-0.5 μm, as determined by SPR) compared with the lowest-affinity double-alanine peptide (Kdapp = 3.8 μm). Together, these findings demonstrate that amino acid substitutions in Fn-binding repeat-9 can significantly affect bond strength and influence the conformation of Fn upon binding. They provide a mechanistic explanation for the observation of nonsynonymous SNPs in fnbA among clinical isolates of S. aureus that cause endovascular infections.
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Affiliation(s)
| | - Carlos H B Cruz
- the Aggeu Magalhães Institute, Oswaldo Cruz Foundation, Recife, PE, 50.740-465, Brazil, and
| | - Roberto D Lins
- the Aggeu Magalhães Institute, Oswaldo Cruz Foundation, Recife, PE, 50.740-465, Brazil, and
| | | | | | - Xiaowen Liang
- the Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas 77030
| | - Magnus Höök
- the Center for Infectious and Inflammatory Diseases, Institute of Biosciences and Technology, Texas A&M Health Science Center, Houston, Texas 77030
| | - Isabelle F T Viana
- the Aggeu Magalhães Institute, Oswaldo Cruz Foundation, Recife, PE, 50.740-465, Brazil, and
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13
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Feuillie C, Formosa-Dague C, Hays LMC, Vervaeck O, Derclaye S, Brennan MP, Foster TJ, Geoghegan JA, Dufrêne YF. Molecular interactions and inhibition of the staphylococcal biofilm-forming protein SdrC. Proc Natl Acad Sci U S A 2017; 114:3738-3743. [PMID: 28320940 PMCID: PMC5389287 DOI: 10.1073/pnas.1616805114] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Staphylococcus aureus forms biofilms on indwelling medical devices using a variety of cell-surface proteins. There is growing evidence that specific homophilic interactions between these proteins represent an important mechanism of cell accumulation during biofilm formation, but the underlying molecular mechanisms are still not well-understood. Here we report the direct measurement of homophilic binding forces by the serine-aspartate repeat protein SdrC and their inhibition by a peptide. Using single-cell and single-molecule force measurements, we find that SdrC is engaged in low-affinity homophilic bonds that promote cell-cell adhesion. Low-affinity intercellular adhesion may play a role in favoring biofilm dynamics. We show that SdrC also mediates strong cellular interactions with hydrophobic surfaces, which are likely to be involved in the initial attachment to biomaterials, the first stage of biofilm formation. Furthermore, we demonstrate that a peptide derived from β-neurexin is a powerful competitive inhibitor capable of efficiently blocking surface attachment, homophilic adhesion, and biofilm accumulation. Molecular modeling suggests that this blocking activity may originate from binding of the peptide to a sequence of SdrC involved in homophilic interactions. Our study opens up avenues for understanding the role of homophilic interactions in staphylococcal adhesion, and for the design of new molecules to prevent biofilm formation during infection.
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Affiliation(s)
- Cécile Feuillie
- Institute of Life Sciences, Université Catholique de Louvain, B-1348 Louvain-la-Neuve, Belgium
| | - Cécile Formosa-Dague
- Institute of Life Sciences, Université Catholique de Louvain, B-1348 Louvain-la-Neuve, Belgium
| | - Leanne M C Hays
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin 2, Ireland
| | - Ophélie Vervaeck
- Institute of Life Sciences, Université Catholique de Louvain, B-1348 Louvain-la-Neuve, Belgium
| | - Sylvie Derclaye
- Institute of Life Sciences, Université Catholique de Louvain, B-1348 Louvain-la-Neuve, Belgium
| | - Marian P Brennan
- Molecular and Cellular Therapeutics, Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Timothy J Foster
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin 2, Ireland
| | - Joan A Geoghegan
- Department of Microbiology, Moyne Institute of Preventive Medicine, School of Genetics and Microbiology, Trinity College Dublin, Dublin 2, Ireland;
| | - Yves F Dufrêne
- Institute of Life Sciences, Université Catholique de Louvain, B-1348 Louvain-la-Neuve, Belgium;
- Walloon Excellence in Life Sciences and Biotechnology (WELBIO), 1300 Wavre, Belgium
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14
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Mil‐Homens D, Pinto SN, Matos RG, Arraiano C, Fialho AM. Burkholderia cenocepacia
K56‐2 trimeric autotransporter adhesin BcaA binds TNFR1 and contributes to induce airway inflammation. Cell Microbiol 2016; 19. [DOI: 10.1111/cmi.12677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 09/22/2016] [Accepted: 09/24/2016] [Indexed: 01/10/2023]
Affiliation(s)
- Dalila Mil‐Homens
- Institute for Bioengineering and Biosciences (iBB), Instituto Superior Técnico University of Lisbon Lisbon Portugal
| | - Sandra N. Pinto
- Centro de Química Física Molecular and Institute of Nanoscience and Nanotechnology, Instituto Superior Técnico University of Lisbon Lisbon Portugal
| | - Rute G. Matos
- Instituto de Tecnologia Química e Biológica – ITQB Universidade Nova de Lisboa Oeiras Portugal
| | - Cecília Arraiano
- Instituto de Tecnologia Química e Biológica – ITQB Universidade Nova de Lisboa Oeiras Portugal
| | - Arsenio M. Fialho
- Institute for Bioengineering and Biosciences (iBB), Instituto Superior Técnico University of Lisbon Lisbon Portugal
- Department of Bioengineering, Instituto Superior Técnico University of Lisbon Lisbon Portugal
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King JE, Roberts IS. Bacterial Surfaces: Front Lines in Host-Pathogen Interaction. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 915:129-56. [PMID: 27193542 DOI: 10.1007/978-3-319-32189-9_10] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
All bacteria are bound by at least one membrane that acts as a barrier between the cell's interior and the outside environment. Surface components within and attached to the cell membrane are essential for ensuring that the overall homeostasis of the cell is maintained. However, many surface components of the bacterial cell also have an indispensable role mediating interactions of the bacteria with their immediate environment and as such are essential to the pathogenesis of infectious disease. During the course of an infection, bacterial pathogens will encounter many different ecological niches where environmental conditions such as salinity, temperature, pH, and the availability of nutrients fluctuate. It is the bacterial cell surface that is at the front-line of these host-pathogen interactions often protecting the bacterium from hostile surroundings but at the same time playing a critical role in the adherence to host tissues promoting colonization and subsequent infection. To deal effectively with the changing environments that pathogens may encounter in different ecological niches within the host many of the surface components of the bacterial cell are subject to phenotypic variation resulting in heterogeneous subpopulations of bacteria within the clonal population. This dynamic phenotypic heterogeneity ensures that at least a small fraction of the population will be adapted for a particular circumstance should it arise. Diversity within the clonal population has often been masked by studies on entire bacterial populations where it was often assumed genes were expressed in a uniform manner. This chapter, therefore, aims to highlight the non-uniformity in certain cell surface structures and will discuss the implication of this heterogeneity in bacterial-host interaction. Some of the recent advances in studying bacterial surface structures at the single cell level will also be reviewed.
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Affiliation(s)
- Jane E King
- Faculty of Life Sciences, University of Manchester, Manchester, M13 9PT, UK
| | - Ian S Roberts
- Faculty of Life Sciences, University of Manchester, Manchester, M13 9PT, UK.
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16
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Qin W, Wang L, Lei L. New findings on the function and potential applications of the trimeric autotransporter adhesin. Antonie van Leeuwenhoek 2015; 108:1-14. [PMID: 26014492 DOI: 10.1007/s10482-015-0477-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/08/2015] [Indexed: 11/27/2022]
Abstract
Trimeric autotransporter adhesins (TAAs) are located on the surface of many pathogenic Gram-negative bacteria. TAAs belong to the autotransporter protein family and consist of three identical monomers. These obligate homotrimeric proteins are secreted through the bacterial type Vc secretion system and share a common molecular organization that each monomer consists of a N-terminal "passenger" domain and a C-terminal translocation domain. TAAs are important virulence factors that are involved in bacterial life cycle and participate in mediating infection, invasion, dissemination and evasion of host immune responses. TAAs have also proved to be useful for many applications, such as vaccines and disease biomarkers. We here mainly focused on new findings on bio-function and application of TAAs in addition to their common structure and secretion mechanisms.
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Affiliation(s)
- Wanhai Qin
- College of Veterinary Medicine, Jilin University, Xi'an Road 5333, Changchun, China,
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Staphylococcus aureus Fibronectin-Binding Protein A Mediates Cell-Cell Adhesion through Low-Affinity Homophilic Bonds. mBio 2015; 6:e00413-15. [PMID: 26015495 PMCID: PMC4447249 DOI: 10.1128/mbio.00413-15] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Staphylococcus aureus is an important opportunistic pathogen which is a leading cause of biofilm-associated infections on indwelling medical devices. The cell surface-located fibronectin-binding protein A (FnBPA) plays an important role in the accumulation phase of biofilm formation by methicillin-resistant S. aureus (MRSA), but the underlying molecular interactions are not yet established. Here, we use single-cell and single-molecule atomic force microscopy to unravel the mechanism by which FnBPA mediates intercellular adhesion. We show that FnBPA is responsible for specific cell-cell interactions that involve the FnBPA A domain and cause microscale cell aggregation. We demonstrate that the strength of FnBPA-mediated adhesion originates from multiple low-affinity homophilic interactions between FnBPA A domains on neighboring cells. Low-affinity binding by means of FnBPA may be important for biofilm dynamics. These results provide a molecular basis for the ability of FnBPA to promote cell accumulation during S. aureus biofilm formation. We speculate that homophilic interactions may represent a generic strategy among staphylococcal cell surface proteins for guiding intercellular adhesion. As biofilm formation by MRSA strains depends on proteins rather than polysaccharides, our approach offers exciting prospects for the design of drugs or vaccines to inhibit protein-dependent intercellular interactions in MRSA biofilms. IMPORTANCE Staphylococcus aureus is a human pathogen that forms biofilms on indwelling medical devices, such as central venous catheters and prosthetic joints. This leads to biofilm infections that are difficult to treat with antibiotics because many cells within the biofilm matrix are dormant. The fibronectin-binding proteins (FnBPs) FnBPA and FnBPB promote biofilm formation by clinically relevant methicillin-resistant S. aureus (MRSA) strains, but the molecular mechanisms involved remain poorly understood. We used atomic force microscopy techniques to demonstrate that FnBPA mediates cell-cell adhesion via multiple, low-affinity homophilic bonds between FnBPA A domains on adjacent cells. Therefore, FnBP-mediated homophilic interactions represent an interesting target to prevent MRSA biofilms. We propose that such homophilic mechanisms may be widespread among staphylococcal cell surface proteins, providing a means to guide intercellular adhesion and biofilm accumulation.
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Fatal attraction: how bacterial adhesins affect host signaling and what we can learn from them. Int J Mol Sci 2015; 16:2626-40. [PMID: 25625516 PMCID: PMC4346855 DOI: 10.3390/ijms16022626] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 12/25/2014] [Accepted: 01/19/2015] [Indexed: 12/20/2022] Open
Abstract
The ability of bacterial species to colonize and infect host organisms is critically dependent upon their capacity to adhere to cellular surfaces of the host. Adherence to cell surfaces is known to be essential for the activation and delivery of certain virulence factors, but can also directly affect host cell signaling to aid bacterial spread and survival. In this review we will discuss the recent advances in the field of bacterial adhesion, how we are beginning to unravel the effects adhesins have on host cell signaling, and how these changes aid the bacteria in terms of their survival and evasion of immune responses. Finally, we will highlight how the exploitation of bacterial adhesins may provide new therapeutic avenues for the treatment of a wide range of bacterial infections.
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Jacquot A, Sakamoto C, Razafitianamarahavo A, Caillet C, Merlin J, Fahs A, Ghigo JM, Duval JFL, Beloin C, Francius G. The dynamics and pH-dependence of Ag43 adhesins' self-association probed by atomic force spectroscopy. NANOSCALE 2014; 6:12665-12681. [PMID: 25208582 DOI: 10.1039/c4nr03312d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Self-associating auto-transporter (SAAT) adhesins are two-domain cell surface proteins involved in bacteria auto-aggregation and biofilm formation. Antigen 43 (Ag43) is a SAAT adhesin commonly found in Escherichia coli whose variant Ag43a has been shown to promote persistence of uropathogenic E. coli within the bladder. The recent resolution of the tri-dimensional structure of the 499 amino-acids' β-domain in Ag43a has shed light on the possible mechanism governing the self-recognition of SAAT adhesins, in particular the importance of trans-interactions between the L shaped β-helical scaffold of two α-domains of neighboring adhesins. In this study, we use single-molecule force spectroscopy (SMFS) and dynamic force spectroscopy (DFS) to unravel the dynamics of Ag43-self association under various pH and molecular elongation rate conditions that mimic the situations encountered by E. coli in its natural environment. Results evidenced an important stretchability of Ag43α with unfolding of sub-domains leading to molecular extension as long as 150 nm. Nanomechanical analysis of molecular stretching data suggested that self-association of Ag43 can lead to the formation of dimers and tetramers driven by rapid and weak cis- as well as slow but strong trans-interaction forces with a magnitude as large as 100-250 pN. The dynamics of cis- and trans-interactions were demonstrated to be strongly influenced by pH and applied shear force, thus suggesting that environmental conditions can modulate Ag43-mediated aggregation of bacteria at the molecular level.
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Affiliation(s)
- Adrien Jacquot
- Université de Lorraine, Laboratoire de Chimie Physique et Microbiologie pour l'Environnement, UMR 7564, Villers-lès-Nancy, F-54601, France
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Beaussart A, Baker AE, Kuchma SL, El-Kirat-Chatel S, O’Toole GA, Dufrêne YF. Nanoscale adhesion forces of Pseudomonas aeruginosa type IV Pili. ACS NANO 2014; 8:10723-10733. [PMID: 25286300 PMCID: PMC4212785 DOI: 10.1021/nn5044383] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/30/2014] [Indexed: 05/30/2023]
Abstract
A variety of bacterial pathogens use nanoscale protein fibers called type IV pili to mediate cell adhesion, a primary step leading to infection. Currently, how these nanofibers respond to mechanical stimuli and how this response is used to control adhesion is poorly understood. Here, we use atomic force microscopy techniques to quantify the forces guiding the adhesion of Pseudomonas aeruginosa type IV pili to surfaces. Using chemical force microscopy and single-cell force spectroscopy, we show that pili strongly bind to hydrophobic surfaces in a time-dependent manner, while they weakly bind to hydrophilic surfaces. Individual nanofibers are capable of withstanding forces up to 250 pN, thereby explaining how they can resist mechanical stress. Pulling on individual pili yields constant force plateaus, presumably reflecting conformational changes, as well as nanospring properties that may help bacteria to withstand physiological shear forces. Analysis of mutant strains demonstrates that these mechanical responses originate solely from type IV pili, while flagella and the cell surface localized and proposed pili-associated adhesin PilY1 play no direct role. We also demonstrate that bacterial-host interactions involve constant force plateaus, the extension of bacterial pili, and the formation of membrane tethers from host cells. We postulate that the unique mechanical responses of type IV pili unravelled here enable the bacteria to firmly attach to biotic and abiotic surfaces and thus maintain attachment when subjected to high shear forces under physiological conditions, helping to explain why pili play a critical role in colonization of the host.
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Affiliation(s)
- Audrey Beaussart
- Institute of Life Sciences, Université catholique de Louvain, Croix du Sud, 1, bte L7.04.01., B-1348 Louvain-la-Neuve, Belgium
| | - Amy E. Baker
- Department of Microbiology & Immunology, Geisel School of Medicine, Dartmouth Medical School, Hanover, New Hampshire 03755, United States
| | - Sherry L. Kuchma
- Department of Microbiology & Immunology, Geisel School of Medicine, Dartmouth Medical School, Hanover, New Hampshire 03755, United States
| | - Sofiane El-Kirat-Chatel
- Institute of Life Sciences, Université catholique de Louvain, Croix du Sud, 1, bte L7.04.01., B-1348 Louvain-la-Neuve, Belgium
| | - George A. O’Toole
- Department of Microbiology & Immunology, Geisel School of Medicine, Dartmouth Medical School, Hanover, New Hampshire 03755, United States
| | - Yves F. Dufrêne
- Institute of Life Sciences, Université catholique de Louvain, Croix du Sud, 1, bte L7.04.01., B-1348 Louvain-la-Neuve, Belgium
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Atomic force microscopy in microbiology: new structural and functional insights into the microbial cell surface. mBio 2014; 5:e01363-14. [PMID: 25053785 PMCID: PMC4120197 DOI: 10.1128/mbio.01363-14] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Microbial cells sense and respond to their environment using their surface constituents. Therefore, understanding the assembly and biophysical properties of cell surface molecules is an important research topic. With its ability to observe living microbial cells at nanometer resolution and to manipulate single-cell surface molecules, atomic force microscopy (AFM) has emerged as a powerful tool in microbiology. Here, we survey major breakthroughs made in cell surface microbiology using AFM techniques, emphasizing the most recent structural and functional insights.
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Characterization of BCAM0224, a multifunctional trimeric autotransporter from the human pathogen Burkholderia cenocepacia. J Bacteriol 2014; 196:1968-79. [PMID: 24659767 DOI: 10.1128/jb.00061-14] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Members of the trimeric autotransporter adhesin (TAA) family play a crucial role in adhesion of Gram-negative pathogens to host cells. Moreover, these proteins are multifunctional virulence factors involved in several other biological traits, including invasion into host cells and evasion of the host immune system. In cystic fibrosis epidemic Burkholderia cenocepacia strain J2315, we identified a unique TAA (BCAM0224)-encoding gene, previously described as being implicated in virulence. Here, we characterized this multifunctional protein, trying to establish its role in B. cenocepacia pathogenicity. We show that BCAM0224 occurs on the bacterial surface and adopts a trimeric conformation. Furthermore, we demonstrated that BCAM0224 is needed for earlier stages of biofilm formation and is required for swarming motility. In addition, BCAM0224 plays an important role in evasion of the human innate immune system, providing resistance against the bactericidal activity of serum via the complement classical pathway. Finally, BCAM0224 mediates bacterial adhesion to and invasion of cultured human bronchial epithelial cells. Together, these data reveal the high versatility of the BCAM0224 protein as a virulence factor in the pathogenic bacterium B. cenocepacia.
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Sullan RMA, Beaussart A, Tripathi P, Derclaye S, El-Kirat-Chatel S, Li JK, Schneider YJ, Vanderleyden J, Lebeer S, Dufrêne YF. Single-cell force spectroscopy of pili-mediated adhesion. NANOSCALE 2014; 6:1134-1143. [PMID: 24296882 DOI: 10.1039/c3nr05462d] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Although bacterial pili are known to mediate cell adhesion to a variety of substrates, the molecular interactions behind this process are poorly understood. We report the direct measurement of the forces guiding pili-mediated adhesion, focusing on the medically important probiotic bacterium Lactobacillus rhamnosus GG (LGG). Using non-invasive single-cell force spectroscopy (SCFS), we quantify the adhesion forces between individual bacteria and biotic (mucin, intestinal cells) or abiotic (hydrophobic monolayers) surfaces. On hydrophobic surfaces, bacterial pili strengthen adhesion through remarkable nanospring properties, which - presumably - enable the bacteria to resist high shear forces under physiological conditions. On mucin, nanosprings are more frequent and adhesion forces larger, reflecting the influence of specific pili-mucin bonds. Interestingly, these mechanical responses are no longer observed on human intestinal Caco-2 cells. Rather, force curves exhibit constant force plateaus with extended ruptures reflecting the extraction of membrane nanotethers. These single-cell analyses provide novel insights into the molecular mechanisms by which piliated bacteria colonize surfaces (nanosprings, nanotethers), and offer exciting avenues in nanomedicine for understanding and controlling the adhesion of microbial cells (probiotics, pathogens).
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Affiliation(s)
- Ruby May A Sullan
- Université catholique de Louvain, Institute of Life Sciences, Croix du Sud, 1, bte L7.04.01., B-1348 Louvain-la-Neuve, Belgium.
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Travier L, Lecuit M. Listeria monocytogenes ActA: a new function for a 'classic' virulence factor. Curr Opin Microbiol 2013; 17:53-60. [PMID: 24581693 DOI: 10.1016/j.mib.2013.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/23/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
Listeria monocytogenes (Lm) is ubiquitous and widespread in the environment. It is responsible for one of the most severe human foodborne infection. Lm is a facultative intracellular bacterium that can cross the intestinal barrier, disseminate via the bloodstream and reach the liver, spleen, central nervous system and fetus. The bacterial surface protein ActA is one of the most critical and best characterized virulence factors of Lm. It fulfills many essential functions within host cells, allowing Lm escape from autophagy and recruiting an actin polymerization complex that promotes Lm actin-based motility, cell-to-cell spread and dissemination within host tissues. We have recently shown that ActA also acts extracellularly. It mediates Lm aggregation and biofilm formation in vitro and in vivo, and long-term colonization of the gut lumen. This new property of ActA favors Lm transmission and may participate in the selective pressure on Lm to maintain ActA.
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Affiliation(s)
- Laetitia Travier
- Institut Pasteur, Biology of Infection Unit, 75015 Paris, France; Inserm U1117, Paris, France
| | - Marc Lecuit
- Institut Pasteur, Biology of Infection Unit, 75015 Paris, France; Inserm U1117, Paris, France; French National Reference Center and WHO Collaborating Centre Listeria, Institut Pasteur, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Necker-Pasteur for Infectiology, Institut Imagine, Necker-Enfants Malades University Hospital, Paris, France.
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