Toxins

Toxinsproducedbybacteriaaregenerallyclassifiedintotwogroups:exotoxins
andendotoxins.Exotoxinsareproteinsthataremostoftenexcretedfromthecell.
Howeversomeexotoxinsaccumulateinsidethecellandareeitherinjecteddirectly
intothehostorarereleasedbycelllysis.Endotoxinsarelipidmoleculesthatare
componentsofthebacterialcellmembrane.Theprimaryfeaturesofthetwo
groupsarelistedinTable94.

A.Exotoxins
Manygrampositiveandgramnegativebacteriaproduceexotoxinsof
considerablemedicalimportance.Someofthesetoxinshavehadmajorrolesin
worldhistory.Forexample,tetanuscausedbythetoxinofCtetanikilledasmany
as50,000soldiersoftheAxispowersinWorldWarII;theAlliedforces,however,
immunizedmilitarypersonnelagainsttetanus,andveryfewdiedofthatdisease.
Vaccineshavebeendevelopedforsomeoftheexotoxinmediateddiseasesand
continuetobeimportantinthepreventionofdisease.Thesevaccinescalled
toxoidsaremadefromexotoxins,whicharemodifiedsothattheyarenolonger
toxic.ManyexotoxinsconsistofAandBsubunits.TheBsubunitgenerally
mediatesadherenceofthetoxincomplextoahostcellandaidsentranceofthe
exotoxinintothehostcell.TheAsubunitprovidesthetoxicactivity.Examples
ofsomepathogeneticmechanismsassociatedwithexotoxinsaregivenbelow.
Othertoxinsofspecificbacteriaarediscussedinthechapterscoveringthose
bacteria.
Cdiphtheriaeisagrampositiverodthatcangrowonthemucousmembranesof
theupperrespiratorytractorinminorskinwounds(seeChapter12).StrainsofC
diphtheriaethatcarryalysogenic,temperatecorynebacteriophage( phageor
phage)withthestructuralgeneforthetoxinaretoxigenicandproduce
diphtheriatoxinandcausediphtheria.Manyfactorsregulatetoxinproduction;
whentheavailabilityofinorganicironisthefactorlimitingthegrowthrate,then
maximaltoxinproductionoccurs.Thetoxinmoleculeissecretedasasingle
polypeptidemolecule(molecularweight[MW],62,000).Thisnativetoxinisenzy
maticallydegradedintotwofragments,AandB,linkedtogetherbyadisulfide
bond.FragmentB(MW,40,700)bindstospecifichostcellreceptorsand
facilitatestheentryoffragmentA(MW,21,150)intothecytoplasm.FragmentA
inhibitspeptidechainelongationfactorEF2bycatalyzingareactionthatattaches
anadenosinediphosphateribosylgrouptoEF2,yieldinganinactiveadenosine
diphosphateriboseEF2complex.Arrestofproteinsynthesisdisruptsnormal
cellularphysiologicfunctions.Diphtheriatoxinisverypotent.

Ctetaniisananaerobicgrampositiverodthatcausestetanus(seeChapter11).C
tetanifromtheenvironmentcontaminateswounds,andthesporesgerminatein
theanaerobicenvironmentofthedevitalizedtissue.Infectionoftenisminorand
notclinicallyapparent.ThevegetativeformsofCtetaniproducethetoxin
tetanospasmin(MW,150,000)thatiscleavedbyabacterialproteaseintotwo
peptides(MW,50,000and100,000)linkedbyadisulfidebond.Thetoxininitially
bindstoreceptorsonthepresynapticmembranesofmotorneurons.Itthen
migratesbytheretrogradeaxonaltransportsystemtothecellbodiesofthese
neuronstothespinalcordandbrainstem.Thetoxindiffusestoterminalsof
inhibitorycells,includingbothglycinergicinterneuronsand aminobutyricacid
(GABA)secretingneuronsfromthebrainstem.Thetoxindegradessynaptobrevin,
aprotein
requiredfordockingofneurotransmittervesiclesonthepresynapticmembrane.
ReleaseoftheinhibitoryglycineandGABAisblocked,andthemotorneuronsare
notinhibited.Spasticparalysisresults.Extremelysmallamountsoftoxincanbe
lethalforhumans.Tetanusistotallypreventableinimmunologicallynormal
peoplebyimmunizationwithtetanustoxoid.
Cbotulinumcausesbotulism.Thisanaerobic,grampositivesporeforming
organismisfoundinsoilorwaterandmaygrowinfoods(eg,canned,vacuum
packed)iftheenvironmentisappropriatelyanaerobic.Anexceedinglypotent
toxin(themostpotenttoxinknown)isproduced.Itisheatlabileandisdestroyed
bysufficientheating.Therearesevendistinctserologictypesoftoxin.TypesA,
B,E,andFaremostcommonlyassociatedwithhumandisease.Thetoxinisvery
similartotetanustoxin,witha150,000MWproteinthatiscleavedinto100,000
MWand50,000MWproteinslinkedbyadisulfidebond.Botulinumtoxinis
absorbedfromthegutandbindstoreceptorsofpresynapticmembranesofmotor
neuronsoftheperipheralnervoussystemandcranialnerves.Proteolysis,bythe
lightchainofbotulinumtoxin,oftargetproteinsintheneuronsinhibitstherelease
ofacetylcholineatthesynapse,resultinginlackofmusclecontractionand
flaccidparalysis.
SporesofCperfringensareintroducedintowoundsbycontaminationwithsoilor
feces.Inthepresenceofnecrotictissue(ananaerobicenvironment),spores
germinate,andvegetativecellscanproduceseveraldifferenttoxins.Manyofthese
arenecrotizingandhemolyticandtogetherwithdistentionoftissuebygas
formedfromcarbohydratesand
interferencewithbloodsupplyfavorthespreadofgasgangrene.Thealpha
toxinofCperfringensisalecithinasethatdamagescellmembranesbysplitting

lecithintophosphorylcholineanddiglyceride.Thetatoxinalsohasanecro
tizingeffect.CollagenasesandDNAsesareproducedbyclostridiaeaswell.
SomeSaureusstrainsgrowingonmucousmembranes(eg,thevaginain
associationwithmenstruation)orinwounds,elaboratetoxicshocksyndrome
toxin1(TSST1),whichcausestoxicshocksyndrome(Chapter13).Theill
nessischaracterizedbyshock,highfever,andadiffuseredrashthatlater
desquamates;multipleotherorgansystemsareinvolvedaswell.TSST1isasuper
antigenandstimulatesTcellstoproducelargeamountsofinterleukin2(IL2)
andtumornecrosisfactor(TNF)(seeChapter8).Themajorclinical
manifestationsofthediseaseappeartobesecondarytotheeffectsofthe
cytokines.ManyofthesystemiceffectsofTSST1aresimilartothoseoftoxicity
causedbylipopolysaccharide(LPS;seediscussionbelow).
SomestrainsofgroupA hemolyticstreptococciproducepyrogenicexotoxin
Athatissimilartoorthesameasstreptococcalerythrogenictoxin,whichresults
inscarletfever.Rapidlyprogressivesofttissueinfectionbystreptococcithat
producethepyrogenicexotoxinAhasmanyclinicalmanifestationssimilarto
thoseofstaphylococcaltoxicshocksyndrome.ThepyrogenicexotoxinAalsoisa
superantigenthatactsinamannersimilartoTSST1.

B.ExotoxinsAssociatedwithDiarrhealDiseasesandFood
PoisoningExotoxinsassociatedwithdiarrhealdiseasesarefrequentlycalled
enterotoxins.(SeealsoTable483.)Characteristicsofsomeimportant
enterotoxinsarediscussedbelow.

Vcholeraehasproducedepidemicdiarrhealdisease(cholera)inmanypartsofthe
world(seeChapter17)andisanothertoxinproduceddiseaseofhistoricaland
currentimportance.Afterenteringthehostviacontaminatedfoodordrink,V
choleraepenetratestheintestinalmucosaandattachestomicrovilliofthebrush
borderofgutepithelialcells.Vcholerae,usuallyoftheserotypeO1(andO139),
canproduceanenterotoxinwithaMWof84,000.Thetoxinconsistsoftwo
subunitsA,whichissplitintotwopeptides,A1andA2,linkedbyadisulfide
bond,andB.SubunitBhasfiveidenticalpeptidesandrapidlybindsthetoxinto
cellmembranegangliosidemolecules.SubunitAentersthecellmembraneand
causesalargeincreaseinadenylatecyclaseactivityandintheconcentrationof
cAMP.Theneteffectisrapidsecretionofelectrolytesintothesmallbowellumen,
withimpairmentofsodiumandchlorideabsorptionandlossofbicarbonate.Life
threateningmassivediarrhea(eg,2030L/day)canoccur,andacidosisdevelops.
Thedeleteriouseffectsofcholeraareduetofluidlossandacidbaseimbalance;
treatment,therefore,isbyelectrolyteandfluidreplacement.

SomestrainsofSaureusproduceenterotoxinswhilegrowinginmeat,dairy
products,orotherfoods.Intypical
cases,thefoodhasbeenrecentlypreparedbutnotproperlyrefrigerated.Thereare
atleastsevendistincttypesofthestaphylococcalenterotoxin.Afterthe
preformedtoxinisingested,itisabsorbedinthegut,whereitstimulatesvagus
nervereceptors.Thestimulusistransmittedtothevomitingcenterinthecentral
nervoussystem.Vomiting,oftenprojectile,resultswithinhours.Diarrheaisless
frequent.Staphylococcalfoodpoisoningisthemostcommonformoffood
poisoning.Saureusenterotoxinsaresuperantigens.
EnterotoxinsarealsoproducedbysomestrainsofYenterocolitica(seeChapter
19),Vibrioparahaemolyticus(seeChapter17),Aeromonasspecies(seeChapter
17),andotherbacteria,buttheroleofthesetoxinsinpathogenesisisnotaswell
defined.TheenterotoxinproducedbyCperfringensisdiscussedinChapter11.

C.LipopolysaccharidesofGramNegativeBacteria
TheLPS(endotoxin)ofgramnegativebacteriaarebacterialcellwall
componentsthatareoftenliberatedwhenthebacterialyse.Thesubstancesare
heatstable,haveMWsbetween3000and5000(lipooligosaccharides,LOS)and
severalmillion(lipopolysaccharides)andcanbeextracted(eg,withphenol
water).Theyhavethreemainregions(seeFigure219).
ThepathophysiologiceffectsofLPSaresimilarregardlessoftheirbacterial
originexceptforthoseofBacteroidesspecies,whichhaveadifferentstructureand
arelesstoxic(seeChapter21).LPSinthebloodstreamisinitiallyboundto
circulatingproteins,whichtheninteractwithreceptorsonmacrophages
neutrophilsandothercellsofthereticuloendothelialsystem.Proinflammatory
cytokinessuchasIL1,IL6,IL8,TNF,andothercytokinesarereleased,and
thecomplementandcoagulationcascadesareactivated.Thefollowingcanbe
observedclinicallyorexperimentally:fever,leukopenia,andhypoglycemia;
hypotensionandshockresultinginimpairedperfusionofessentialorgans(eg,
brain,heart,kidney);intravascularcoagulation;anddeathfrommassiveorgan
dysfunction.
InjectionofLPSproducesfeverafter6090minutes,thetimeneededforthebody
toreleaseIL1.InjectionofIL1producesfeverwithin30minutes.Repeated
injectionofIL1producesthesamefeverresponseeachtime,butrepeated
injectionofLPScausesasteadilydiminishingfeverresponsebecauseoftolerance
partlycausedbyreticuloendothelialblockadeandpartlycausedbyIgMantibodies

toLPS.
InjectionofLPSproducesearlyleukopenia,asdoesbacteremiawithgram
negativeorganisms.Secondaryleukocytosisoccurslater.Theearlyleukopenia
coincideswiththeonsetoffevercausedbyliberationofIL1.LPSenhances
glycolysisinmanycelltypesandcanleadtohypoglycemia.
HypotensionoccursearlyingramnegativebacteremiaorafterinjectionofLPS.
Theremaybewidespreadarteriolarandvenularconstrictionfollowedby
peripheralvasculardilatation,increasedvascularpermeability,decreasein
venousreturn,loweredcardiacoutput,stagnationinthe
CHAPTER9PathogenesisofBacterialInfection157
158SECTIONIIIBacteriology
microcirculation,peripheralvasoconstriction,shock,andimpairedorganperfusion
anditsconsequences.Disseminatedintravascularcoagulation(DIC)also
contributestothesevascularchanges.
LPSisamongthemanydifferentagentsthatcanactivatethealternativepathway
ofthecomplementcascade,precipitatingavarietyofcomplementmediated
reactions(eg,anaphylatoxins,chemotacticresponses,membranedamage)anda
dropinserumlevelsofcomplementcomponents(C3,C5C9).
Disseminatedintravascularcoagulationisafrequentcomplicationofgram
negativebacteremiaandcanalsooccurinotherinfections.LPSactivatesfactor
XII(Hagemanfactor)thefirststepoftheintrinsicclottingsystemandsetsinto
motionthecoagulationcascade,whichculminatesintheconversionoffibrinogen
tofibrin.Atthesametime,plasminogencanbeactivatedbyLPStoplasmin(a
proteolyticenzyme),whichcanattackfibrinwiththeformationoffibrinsplit
products.Reductioninplateletandfibrinogenlevelsanddetectionoffibrinsplit
productsareevidenceofDIC.Heparincansometimespreventthelesions
associatedwithDIC.
LPScausesplateletstoadheretovascularendotheliumandocclusionofsmall
bloodvessels,causingischemicorhemorrhagicnecrosisinvariousorgans.
Endotoxinlevelscanbeassayedbythelimulustest:Alysateofamebocytesfrom
thehorseshoecrab(limulus)gelsorcoagulatesinthepresenceof0.0001 g/mLof
endotoxin.Thistestisrarelyusedinclinicallaboratoriesbecauseitisdifficultto
performaccurately.

D.PeptidoglycanofGramPositiveBacteria
Thepeptidoglycanofgrampositivebacteriaismadeupofcrosslinked
macromoleculesthatsurroundthebacterialcells(seeChapter2andFigure215).
Vascularchangesleadingtoshockmayalsooccurininfectionscausedbygram
positivebacteriathatcontainnoLPS.Grampositivebacteriahaveconsiderably
morecellwallassociatedpeptidoglycanthandogramnegativebacteria.
Peptidoglycanreleasedduringinfectionmayyieldmanyofthesamebiologic
activitiesasLPS,althoughpeptidoglycanisinvariablymuchlesspotentthanLPS.