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Infection and Immunity, March 2007, p. 1272-1279, Vol. 75, No. 3
0019-9567/07/$08.00+0 doi:10.1128/IAI.01153-06
Copyright © 2007, American Society for Microbiology. All Rights Reserved.

Department of Pathobiology, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, Pennsylvania 19104
Received 23 July 2006/ Returned for modification 5 October 2006/ Accepted 29 November 2006
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To determine the role of Psa in pneumonic plague, we have recently analyzed its interaction with three human respiratory tract epithelial cells (19). All three studied cell lines, and particularly the type II alveolar epithelial cell line A549, showed a significantly higher interaction when the bacteria expressed Psa. In the present study, we searched for the A549 cell receptor for Psa. We found that Psa bound specifically to the phosphatidylcholine (PC) of cell lipid extracts, as well as to commercial PC preparations. Since PC is the principal component of pulmonary surfactant, which is secreted by type II alveolar epithelial cells, we also studied the Psa interaction with pulmonary surfactant. Psa bound to the PC present on type I and type II alveolar epithelial cells and in pulmonary surfactant. This adhesion was blocked by phosphorylcholine (ChoP), indicating that the interaction of Psa with the polar moiety of PC is essential for binding.
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Bacterial strains, human cells, and growth conditions. The nonfimbriated Escherichia coli host strain SE5000 (MC4100 recA56 Fim) was used (30). Plasmid pCS267 is a pBR322 derivative which carries the psaA, psaB, and psaC genes, encoding the pH 6 antigen subunit and chaperone and usher proteins, respectively (19). Bacteria were routinely grown at 37°C in Luria-Bertani (LB) medium (22), supplemented with ampicillin (200 µg/ml) when appropriate. Cells of the human type II alveolar epithelial line A549 (ATCC CCL185) and type I alveolar epithelial line WI-26 VA4 (ATCC CCL95.1; American Type Culture Collection, Rockville, MD) were cultured in Dulbecco's modified Eagle's medium (DMEM; Invitrogen, Rockville, MD) high-glucose formulation with GlutaMAX supplemented with 10% inactivated fetal bovine serum (FBS) at 37°C in 5% CO2.
Isolation of fimbriae. It was observed that recombinant pH 6 antigen (Psa) was present in significant amounts in the culture supernatant of E. coli SE5000/pCS267 grown overnight in LB medium at 37°C. Thus, Psa was isolated from spent culture medium after removal of the bacteria by centrifugation at 8,000 x g for 30 min. A saturated solution of ammonium sulfate was added to the supernatant to a final concentration of 30%. After overnight incubation on ice, the supernatant was centrifuged at 10,000 x g for 30 min, and the pellet was resuspended in Tris-buffered saline (TBS; 10 mM Tris-HCl [pH 7.4], 154 mM NaCl). Excess ammonium sulfate was removed by extensive dialysis against TBS, and the protein concentration was determined to be 0.28 mg/ml culture supernatant (21). The purity of the fimbriae was confirmed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and silver staining, showing essentially only the 15-kDa PsaA subunit band (>95% purity).
Preparation of cellular lipids. A549 cells grown to confluence were washed with phosphate-buffered saline (PBS; 10 mM NaHPO4, 1.8 mM KH2PO4, 2.7 mM KCl, 137 mM NaCl [pH 7.5]) and harvested mechanically. Lipids from cells (equivalent to 1.5 mg total cellular protein content) were successively extracted with 1.0 ml chloroform-methanol-water (4:8:3 [vol/vol/vol]) and chloroform-methanol (1:1 [vol/vol]) for 30 min. Lipid extracts were pooled, dried under N2, and resuspended in chloroform-methanol-water (60:30:4.5 [vol/vol/vol]). In order to remove glycerophospholipids from the cellular lipid extract, a mild alkaline methanolysis was done (5). After drying, a lipid aliquot was incubated in 1.0 ml of 0.25 M NaOH (in methanol) at 50°C for 10 min. Acetic acid (0.05 ml) was added followed by chloroform (2.0 ml) and water (0.67 ml). After two phases appeared, the upper phase was removed and the lower phase was washed with methanol-water (1:1 [vol/vol]) and applied to thin-layer chromatography (TLC) plates.
Analysis of cellular lipids separated by TLC. Cellular lipids were separated on TLC aluminum-backed silica gel G plates (Merck, Darmstadt, Germany) with chloroform-methanol-water (65:25:4 [vol/vol/vol]) used as a solvent system (8, 28, 36). Glycolipids were stained with orcinol-sulfuric acid reagent (29) and phospholipids were detected with molybdenum blue reagent (Sigma). For the overlay assay, the plates were sequentially treated with polyisobutylmethacrylate (0.4% in n-hexane), blocked in 0.5% bovine serum albumin (BSA) in PBS for 1 h at room temperature, overlaid with purified Psa fimbriae (50 µg/ml in 1% BSA-PBS) for 1 h, and washed three times with PBS-0.02% Tween 20. Bound fimbriae were visualized with rabbit anti-Psa antiserum (19) in combination with a horseradish peroxidase (HRP)-conjugated anti-rabbit IgG (Cappel, MP Biomedicals, Aurora, Ohio), with 4-chloro-1-naphthol and H2O2 as the substrate.
Determination of binding by ELISA. Binding was determined by enzyme-linked immunosorbent assay (ELISA) as follows. The wells of polyvinyl chloride microtiter plates (96 wells; Falcon, Becton Dickinson, Franklin Lakes, NJ) were coated with 1 µg (each) of phospholipids (PC, phosphatidylserine [PS], phosphatidylethanolamine [PE], phosphatidylinositol [PI], or sphingomyelin [SM]) or galactosylceramide (GalCer) in methanol (100%) or chloroform-methanol (1:1 [vol/vol]), as described previously (12). Both coating methods gave comparable binding results. The lipids were dried at 37°C, the wells were blocked with 0.5% BSA-PBS for 1 h, and dilution rows of Psa fimbriae in 0.5% BSA-PBS were prepared. After incubation at room temperature for 1 h and washing with PBS, bound fimbriae were detected with rabbit anti-Psa antiserum as described above, except that o-phenylenediamine was used as the chromophore. For the binding inhibition assays, Psa fimbriae (0.25 to 1.0 µg/ml in 0.5% BSA-TBS) were preincubated with twofold serially diluted ChoP, phosphorylserine (SerP), galactose, lactose, or glucose (starting at a concentration of 500 mM in TBS) for 30 min at room temperature. The mixtures were transferred to the lipid-coated plates, and fimbrial binding was determined with rabbit anti-Psa antiserum in combination with HRP-conjugated anti-rabbit IgG and o-phenylendiamine (A450). For the pulmonary surfactant studies, polyvinyl chloride plates were coated with Survanta (1.0 µg of phospholipids/ml) or rat surfactant (includes approximately 80 µg/ml PC and 0.16 mg/ml protein; diluted 1/10 in PBS) overnight at 37°C. Psa binding and ChoP inhibitory effect were assayed as previously described for lipids. Determination of the 50% inhibitory concentration (IC50) was done using the Hill equation (KaleidaGraph 4.0; Synergy Software, Reading, PA).
Preparation of polymeric inhibitors.
ChoP, SerP, or
-lactose 1-phosphate (LacP) were cross-linked to polylysine (molecular weight [MW], 15,000 to 30,000) by using EDC [1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride] to form stable phosphoramidate bonds. Briefly, ChoP (165.0 mg/ml, or SerP [45 mg/ml] or LacP [275 mg/ml]), EDC (143.8 mg/ml), and polylysine (1.0 mg/ml) were dissolved and mixed in 0.1 M imidazole (pH 6.0) and incubated for 5 h at 37°C, followed by extensive dialysis against TBS. The presence of cross-linked molecules was confirmed by nondenaturing PAGE (40), mass spectrometry (DNA & Proteomics Core Facility, School of Veterinary Medicine, University of Pennsylvania), and ELISA with specific anti-ChoP (monoclonal antibody [MAb] TEPC15; Sigma) or SerP (MAb clone 1H6; Upstate) antibodies. The efficiency of cross-linking was quantified by phosphorus analysis (39). Polymerized ChoP-polylysine (200 µg/ml) was digested with trypsin from Sigma (2 µg/ml; 9,800 BAEE [N-
-benzoyl-L-arginine ethyl ester] units per mg of protein) overnight at 37°C in 25.0 mM ammonium bicarbonate (pH 8.0).
Liposome-mediated bacterial agglutination. Bacterial recognition of phospholipids was also determined by assessment of the aggregation of bacteria with various phospholipid vesicles. The following liposome vesicles were prepared: PC-containing liposomes with PC-dicetylphosphate (DP)-cholesterol (CHO) at a molar ratio of 5:1:4, PE-containing liposomes with PE-DP-CHO at a molar ratio of 5:1:4, PC- and GalCer-containing liposomes with PC-DP-CHO-GalCer at a molar ratio of 5:1:4:0.5, and PE- and GalCer-containing liposomes with PE-DP-CHO-GalCer at a molar ratio of 5:1:4:0.5. For liposome preparations, lipids dissolved in methanol-chloroform (1:1 [vol/vol]) were mixed and dried under N2 gas and then vacuum dried for 30 min. The dried pellets were resuspended in isopropanol (50 µl), and PBS (450 µl) was added while mixing. For bacterial agglutination tests, slide agglutinations were performed by mixing 2.5 µl of liposomes (0.2 mg/ml) with 10 µl of E. coli psa+ (SE5000/pCS267) or lacking psa (SE5000/pBR322) grown overnight at 37°C and washed three times in PBS.
Psa fimbria binding to A549 cells. Binding of purified Psa fimbriae was performed on monolayer of A549 cells cultured in 96-well tissue culture plates. Cells were washed with PBS and fixed with 1% formaldehyde in PBS for 20 min at room temperature. All of the experimental conditions used to assay Psa binding were the same as those described for the ELISA experiments. Negative controls without addition of fimbriae to cells gave A450 values of approximately 0.05 (similar to those of controls without cells).
Recombinant E. coli psa+ cell binding to alveolar epithelial cells and pulmonary surfactant. Bacterial binding assays were done essentially as described previously (11, 19). Briefly, A549 and WI-26 VA4 cells cultured to confluence in 24-well tissue culture plates were washed three times with PBS and DMEM without FBS was added. E. coli psa+ (SE5000/pCS267) or E. coli lacking psa (SE5000/pBR322) was grown as described earlier, washed with PBS, retaken in DMEM without FBS, and added to the cells at a multiplicity of infection of 10. After incubation at 37°C for 1 h, duplicate wells of infected cell monolayer were washed five times with PBS and 0.1% Triton X-100 in water was added. After 15 min, cell lysates were collected and serially diluted 10-fold in PBS, and aliquots were inoculated onto LB agar plates with suitable antibiotics to assess viable bacterial CFU. For the binding inhibition assays with water-soluble inhibitors (ChoP, SerP, galactose, choline, and the polylysine polymers), the inhibitors were added to the cells at the same time as the bacteria. For the binding inhibition assays with pulmonary surfactant (Survanta), three approaches were used. Survanta was added to the epithelial cells, the plates were centrifuged (600 x g, 10 min) and incubated for 10 min at 37°C, and the supernatant was removed or not removed before the bacteria were added. For the third alternative, Survanta was incubated for 30 min at 37°C with the bacteria before addition of the mixture to the epithelial cells. The range of the concentrations of Survanta in the wells was from 0.05 to 6.25 mg phospholipids per ml. The statistical analyses were conducted using Student's t test.
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FIG. 1. Psa binding to lipids from A549 cells on TLC plates. (A) Psa fimbriae were overlaid on TLC-separated lipids, and binding was detected with rabbit polyclonal anti-Psa antibody followed by incubation with HRP-conjugated anti-rabbit IgG. (B) Detection of phospholipids by molybdenum blue staining. (C) Detection of glycolipids with orcinol. Lane 1, A549 cell lipid extract corresponding to 300 µg of cellular protein; lane 2, A549 cell lipid extract after alkali methanolysis. Lane 3 contained commercial PE, PC, PS, PI, and SM (5.0 µg each) for panels A and B and neutral glycosphingolipid Qualimix (4.0 µg) containing GalCer, lactosylceramide (LacCer), globotriaosylceramide (Gb3Cer), and globotetraosylceramide (Gb4Cer) for panel C.
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FIG. 2. Psa binding to solid-phase-coated phospholipids. PC, SM, PS, PE, or PI was adsorbed onto polyvinyl chloride microtiter wells (1.0 µg per well) and incubated with increasing concentrations of Psa fimbria. Bound fimbria was detected with an antifimbrial antibody and an HRP-conjugated secondary antibody. The data are means ± standard error of three values and represent one of three reproducible experiments.
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TABLE 1. Inhibition of Psa binding to PC or GalCer by monomeric or polymeric inhibitors
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FIG. 3. Inhibition of Psa binding to PC. PC was adsorbed onto polyvinyl chloride microtiter wells and incubated with Psa fimbriae (0.25 µg/well) and increasing concentrations of the following inhibitors: trypsinized polylysine-ChoP (empty circles), untreated polylysine-ChoP (filled circles), trypsinized polylysine-SerP (empty diamonds), or untreated polylysine-SerP (filled diamonds). PC adsorption onto the wells and Psa detection were as described in the legend to Fig. 2. The data are means ± standard error of three values and are representative of two reproducible experiments.
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Interaction of Psa-expressing bacteria with phosphatidylcholine-containing liposomes. The accessibility of lipid receptors to ligands is more restricted when the receptors are membrane associated than when they a solid phase is coated with them. To determine whether Psa recognizes PC as a membrane constituent, PC-containing liposomes were prepared and their capacity to agglutinate Psa fimbriated E. coli was investigated. PC-containing liposomes, but not PE-containing liposome controls, mixed with E. coli expressing Psa fimbriae promoted strong bacterial agglutination (Table 2). The incorporation of GalCer into PE-liposomes resulted in the agglutination of E. coli psa+ cells. In contrast, no agglutination was observed when E. coli psa mutant cells were mixed with PC-, PE-, or PE-GalCer-containing liposomes. Incubation of the fimbriated E. coli strain with PBS did not result in the formation of autoaggregates. Thus, the Psa fimbriae allow bacteria to bind to PC-containing membranes.
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TABLE 2. Liposome-mediated bacterial agglutination
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11% inhibitions). Similarly, 50 mM serine had no inhibitory effects. Although 500 mM galactose did not efficiently inhibit binding to the A549 cells (11% inhibition), it weakly inhibited binding to the WI-26 VA4 cells (34% inhibition). |
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TABLE 3. Inhibition of adhesion of E. coli psa+ and psa mutant cells to alveolar epithelial cellsa
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0.05). Taken together, all of the results indicated that bacterial adhesion to the A549 cells conferred by the Psa fimbriae involved essentially PC. Although Psa-mediated bacterial adhesion to the WI-26 VA4 cells involved mainly PC, galactose-containing receptors were likely also involved. Interaction of pulmonary surfactant with Psa fimbria. Pulmonary surfactant is a lipoprotein complex that is synthesized and secreted by alveolar type II epithelial cells into the thin liquid layer that lines the lung epithelium. It is well established that lipids comprise over 90% of pulmonary surfactant, the remainder being made up of the surfactant proteins SP-A, -B, -C, and -D. At least 80% of the surfactant lipids are phospholipids, while the remainder are composed largely of neutral lipids such as cholesterol. Phosphatidylcholine lipids account for 70 to 80% of surfactant phospholipids (35). Considering the PC-enriched environment present in pulmonary surfactant, Psa binding to the commercial surfactant preparation Survanta and to rat surfactant from bronchoalveolar lavage was assayed. A concentration-dependent binding of purified Psa fimbriae to both surfactant preparations was observed by ELISA (Fig. 4A). Binding to Survanta reached saturation at fimbrial concentrations of 10 to 20 µg/ml, whereas binding to rat surfactant was essentially completed at 5.0 to 10 µg/ml. ChoP inhibited Psa binding to Survanta and rat surfactant in a concentration-dependent manner (Fig. 4B). The maximum blocking effect (90% inhibition) was observed for a ChoP concentration of 250 mM, when 0.5 µg/ml of Psa was added. These results indicated that the phosphorylcholine moiety of pulmonary surfactant PC interacts directly with the Psa fimbriae.
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FIG. 4. Psa binding to solid-phase-coated pulmonary surfactant. Polyvinyl chloride microtiter wells were used to adsorb rat surfactant (filled circles) or Survanta (empty squares). Binding of increasing concentrations of Psa fimbriae (A) and the inhibitory effect of ChoP on Psa binding (B) were determined as described in the legend to Fig. 2. The data are means ± standard error of three values and are representative of two reproducible experiments.
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It is noteworthy that in the A549 lipid extract, carbohydrate staining allowed us to visualize some glycosphingolipids whose relative migrations corresponded to short-carbohydrate-chain glycosylceramides (including hydroxylated GalCer [not shown]). Although lactosylceramide and hydroxylated GalCer were previously reported to interact with Psa fimbriae, we did not detect this interaction under the experimental conditions used for TLC. However, weak binding of Psa to TLC-separated commercial hydroxylated GalCer could be distinguished by adding an excess of this lipid to the TLC plate. For this, it was necessary to assay at least 10 times more pure hydroxylated GalCer than the amount of cerebroside found in the A549 cellular lipid extract used to detect PC as a Psa receptor (data not shown). Similarly, we did not detect Psa binding to any other A549 glycolipid under the conditions used to identify PC as a receptor, despite a previous report which showed that pure asialo-GM1, an A549 receptor for Pseudomonas aeruginosa (10), interacts with the Psa fimbriae. Thus, it is likely that the amounts of cellular lipid extract applied to the TLC that were adequate for recognition of PC by Psa, were not sufficient for the detection of potential weak interactions of Psa with asialo-GM1 or any other glycosphingolipid.
The Psa fimbriae bound to PC and to sphingomyelin in a concentration-dependent manner, although the binding affinity to PC was significantly stronger. The Psa-PC interaction could be completely inhibited by the presence of ChoP or choline, indicating the importance of the chemical structure of choline for the binding domain of the receptor. Psa did not bind to phospholipids that lacked a ChoP or choline moiety, such as PE, PS, or PI. Since some of the fatty acids of phospholipids that are adsorbed on a solid phase are expected to be exposed and accessible to ligands, our results strongly suggest that only the ChoP or choline moiety of PC, and not its fatty acid chains, is involved in the ligand-receptor interaction. Moreover, unlike ChoP monomers that inhibited in the millimolar range, polymerized ChoP, prepared by cross-linking ChoP to polylysine molecules, was inhibitory in the nanomolar range. In contrast the SerP-polylysine was not inhibitory. These results confirmed that the ChoP domain of PC interacts specifically with Psa. They also indicated that the Psa ligand has multiple binding domains for ChoP, in agreement with the homopolymeric structure of the Psa fimbria. Although the affinity of ChoP of a Psa binding moiety might be relatively weak, it is suggested that PC headgroup proximity on host cell membranes (or arrayed on a solid phase) permits multiple simultaneous interactions with the polymeric adhesins of the Psa fimbria. This is in contrast with other well-studied fimbriae, such as the type 1 and P fimbriae of Escherichia coli, which are heteropolymers that carry only a few minor adhesive subunits with higher affinities for their monomeric soluble receptor analogues. The specificity of the PC-Psa interaction was further supported by results on binding experiments of Psa-fimbriated bacteria with PC- and PE-containing liposomes. In contrast to TLC overlay or ELISA binding assays, ligand binding to receptors that are embedded into liposomes more closely models the adhesion to cell membrane receptors. Only Psa-fimbriated E. coli cells, and not nonfimbriated E. coli cells, were aggregated by PC-containing liposomes. The absence of interactions of Psa-fimbriated E. coli cells with the PE-containing liposomes attested again to the specificity of the Psa-PC interaction.
That Psa specifically recognizes certain glycosphingolipids carrying ß1-linked galactosyl residues, such as GalCer, as previously described (24), was further confirmed with LacP- and SerP-polylysine polymers, only the former one being inhibitory at micromolar concentrations. The Psa-PC and Psa-GalCer interactions were independent of each other. Galactose and lactose, the latter one used as a monomer or polymer, interfered only with the Psa-GalCer, but not with the Psa-PC interaction. Conversely, monomeric or polymeric ChoP disturbed only Psa binding to PC, but not to GalCer. These results indicate that Psa fimbriae utilize separate domains for binding to PC and GalCer.
Choline and ChoP monomers or polymers inhibited significantly the binding of Psa-fimbriated E. coli cells to A549 and WI-26 VA4 cells. Although galactose and LacP polymers also inhibited bacterial adhesion to the WI-26 VA4 cells, the inhibition was significantly less efficient, suggesting that the bacteria bound to the alveolar epithelial cells mainly by using receptors with the polar choline moiety. Because PC contains choline and is a major component of the outer leaflet of mammalian cell membranes, and because of the strong avidity of the Psa-fimbriated bacteria for membrane-embedded PC, PC is likely the most relevant cellular receptor for Psa. Psa-mediated binding to PC on cell membranes is consistent with our previous findings suggesting that Psa inhibits the intracellular uptake of Y. pestis by binding to a receptor that does not activate any internalization process (19). Although galactose-containing secondary receptors might modulate Psa-mediated bacterial binding, no protein receptor could be detected when total cellular membranes were analyzed by standard ligand blotting assays (40; data not shown). The relative importance of ß1-linked galactosyl- and PC-exposing receptors on the surface of the respiratory tract remains to be determined in mammals.
Type II alveolar epithelial cells secrete surfactant, which is a lipoprotein complex found in the fluid lining the alveolar surface of the lungs. Pulmonary surfactant is composed of approximately 90% lipid and 10% protein. The majority of pulmonary surfactant lipids are phospholipids; among them, the most abundant is PC (80%) (35). Thus, it was highly relevant to study potential interactions between Psa and surfactant. Two different types of pulmonary surfactants were investigated: the surfactant contained in rat broncheoalveolar lavage and Survanta, a commercial surfactant extracted from bovine lungs. As expected, considering the high percentage of PC present in pulmonary surfactant, Psa binding and inhibition of binding by ChoP were both concentration dependent for the two surfactant preparations. Since surfactant covers the pulmonary surface, surfactant might act as a protective layer that inhibits the binding of Psa-fimbriated bacteria to all of the pulmonary cells. Although the latter possibility was unlikely, since Psa-fimbriated bacteria bound efficiently to the A549 type II alveolar epithelial cells, which secrete surfactant, addition of various amounts of surfactant to the type I (WI-26 VA4) or type II (A549) cells did not interfere with the adhesive process. In the lungs, surfactant forms a surface monolayer of lipids (air-water interface) and a subphase (aqueous hypophase) consisting of lamellar bodies that unravel into tubular myelin, the source of the lipids composing the surface film (15). During the tidal breathing process, compression and expansion cycles extract or insert most lipids from or into the surface layer of the surfactant film (9). Thus there is a constant cyclical movement that thickens and thins the surfactant film. It is anticipated that bacteria bound to PC in surfactant lipids will participate in these kinetic events, bringing many bacteria into contact with alveolar cell membranes. In addition to this movement of surfactant components during breathing, the alveolar epithelial cells that produce surfactant also recycle surfactant by endocytosis, an additional process that should permit Y. pestis to come into direct contact with the cell membrane. Interestingly, the potential biological relevance of surfactant PC and recycling has also been described for adenoviral infections of alveolar epithelial cells (1).
Since surfactant covers the whole respiratory surface in the lungs, PC might play an important role for the early interactions of Psa-fimbriated Y. pestis with mammalian pulmonary cells after aerosol transmission. Thus, it is tempting to speculate that aerosol sprays containing soluble ChoP polymers might exhibit prophylactic properties by inhibiting Y. pestis contact with respiratory tract epithelial cells. However, whether aerosols and expectorates created by humans or mammals with pneumonic plague carry Psa-fimbriated Y. pestis is not known.
We have previously shown that Y. pestis binds better to three types of human respiratory tract epithelial cells if the bacteria express Psa (19). Thus, in contrast to macrophages, which don't need Psa to interact with Y. pestis (11), Psa-mediated Y. pestis binding to surfactant and respiratory tract epithelial cells might optimize the needed cell contact to activate the T3SS for the intracellular delivery of effector molecules to epithelial cells. The indirect detection of new adhesins in the absence of the pH 6 and F1 antigen also suggested the existence of additional Y. pestis ligands for respiratory tract epithelial cells (19). The relative function of each of these different pathogen-host interactions might be modulated by temporal and spatial variables during the infectious process. Moreover, the role of the alveolar epithelial cells in the early anti-inflammatory process of primary pneumonic plague (4, 16, 23, 31) remains to be determined.
This work was supported by NIH grant 1R21 AI053343-01A1.
Published ahead of print on 18 December 2006. ![]()
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