Synopses

Bacterial Toxins: Friends or Foes?

Clare K. Schmitt, Karen C. Meysick, and Alison D. O’Brien
Uniformed Services University of the Health Sciences,
Bethesda, Maryland, USA

Many emerging and reemerging bacterial pathogens synthesize toxins that serve
as primary virulence factors. We highlight seven bacterial toxins produced by well-
established or newly emergent pathogenic microbes. These toxins, which affect
eukaryotic cells by a variety of means, include Staphylococcus aureus α-toxin, Shiga
toxin, cytotoxic necrotizing factor type 1, Escherichia coli heat-stable toxin, botulinum
and tetanus neurotoxins, and S. aureus toxic-shock syndrome toxin. For each, we
discuss the information available on its synthesis and structure, mode of action, and
contribution to virulence. We also review the role certain toxins have played in
unraveling signal pathways in eukaryotic cells and summarize the beneficial uses of
toxins and toxoids. Our intent is to illustrate the importance of the analysis of bacterial
toxins to both basic and applied sciences.

Since diphtheria toxin was isolated by Roux ways, inhibiting the release of neurotransmit-
and Yersin in 1888 (1), microbial toxins have ters, or activating the host immune response. We
been recognized as the primary virulence also describe in detail seven toxins: Staphylococ-
factor(s) for a variety of pathogenic bacteria. cus aureus α-toxin, Shiga toxin (Stx), cytotoxic
Bacterial toxins have been defined as “soluble necrotizing factor type 1 (CNF1), E. coli heat-
substances that alter the normal metabolism of stable toxin (ST), botulinum and tetanus
host cells with deleterious effects on the host” (2). neurotoxins, and toxic-shock syndrome toxin
Indeed, the major symptoms associated with (TSST) produced by S. aureus. We emphasize
disease caused by Corynebacterium diphtheriae these toxins because they are produced by
(diphtheria), Bordetella pertussis (whooping emerging (Stx of enterohemorrhagic E. coli) or
cough), Vibrio cholerae (cholera), Bacillus reemerging (α-toxin of multidrug-resistant
anthracis (anthrax), Clostridium botulinum S. aureus) pathogens or illustrate different
(botulism), Clostridium tetani (tetanus), and structures or modes of action (ST, CNF1,
enterohemorrhagic Escherichia coli (bloody neurotoxins, and TSST).
diarrhea and hemolytic uremic syndrome) are all
related to the activities of the toxins produced by When It Rains, It Pores
these organisms. With the recognition of the Many bacterial exotoxins have the capacity
central role of toxin in these and other diseases to damage the extracellular matrix or the plasma
has come the application of inactive toxins membrane of eukaryotic cells. The damage not
(toxoids) as vaccines. Such toxoid vaccines have only may result in the direct lysis of cells but also
had an important positive impact on public can facilitate bacterial spread through tissues.
health. Toxins that mediate this cellular damage do so by
In this review, we provide a summary either enzymatic hydrolysis or pore formation.
overview (Table) of a variety of bacterial toxins Bacterial hyaluronidases, collagenases, and
categorized according to mode of action: phospholipases have the capacity to degrade
damaging cell membranes, inhibiting protein cellular membranes or matrices. Specific
synthesis, activating second messenger path- examples of these types of toxins include the
α-toxin of Clostridium perfringens, which has
Address for correspondence: Alison D. O’Brien, Uniformed
phospholipase C activity; Streptococcus pyogenes
Services University of the Health Sciences, Department of
Microbiology and Immunology, 4301 Jones Bridge Road, streptokinase, which can hydrolyze plasminogen
Bethesda, MD 20814, USA; fax: 301-295-3773; e-mail: to plasmin and dissolve clots; and the clostridial
aobrien@mxb.usuhs.mil. collagenases (3-5). Pore-forming toxins, as the

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Table. Characteristics of bacterial toxinsa

Toxin implicated
Organism/toxin Mode of action Target Disease in diseaseb
Damage membranes
Aeromonas hydrophila/aerolysin Pore-former Glycophorin Diarrhea (yes)
Clostridium perfringens/ Pore-former Cholesterol Gas gangrenec ?
perfringolysin O
Escherichia coli/hemolysind Pore-former Plasma membrane UTIs (yes)
Listeria monocytogenes/ Pore-former Cholesterol Foodborne systemic (yes)
listeriolysin O illness, meningitis
Staphyloccocus aureus/α-toxin Pore-former Plasma membrane Abcessesc (yes)
Streptococcus pneumoniae/ Pore-former Cholesterol Pneumoniac (yes)
pneumolysin
Streptococcus pyogenes/ Pore-former Cholesterol Strep throat, Sfc ?
streptolysin O
Inhibit protein synthesis
Corynebacterium diphtheriae/ ADP-ribosyltransferase Elongation factor 2 Diphtheria yes
diphtheria toxin
E. coli/Shigella dysenteriae/ N-glycosidase 28S rRNA HC and HUS yes
Shiga toxins
Pseudomonas aeruginosa/ ADP-ribosyltransferase Elongation factor 2 Pneumoniac (yes)
exotoxin A
Activate second messenger
pathways
E.coli
CNF Deamidase Rho G-proteins UTIs ?
LT ADP-ribosyltransferase G-proteins Diarrhea yes
STd Stimulates guanylate cyclase Diarrhea yes
guanylate cyclase receptor
CLDTd G2 block Unknown Diarrhea (yes)
EAST ST-like? Unknown Diarrhea ?
Bacillus anthracis/edema factor Adenylate cyclase ATP Anthrax yes
Bordetella pertussis/
dermonecrotic toxin Deamidase Rho G-proteins Rhinitis (yes)
pertussis toxin ADP-ribosyltransferase G-protein(s) Pertussis yes
Clostridium botulinum/C2 toxin ADP-ribosyltransferase Monomeric G-actin Botulism ?
C. botulinum/C3 toxin ADP-ribosyltransferase Rho G-protein Botulism ?
Clostridium difficile/
toxin A Glucosyltransferase Rho G-protein(s) Diarrhea/PC (yes)
toxin B Glucosyltransferase Rho G-protein(s) Diarrhea/PC ?
Vibrio cholerae/cholera toxin ADP-ribosyltransferase G-protein(s) Cholera yes
Activate immune response
S. aureus/
enterotoxins Superantigen TCR and MHC II Food poisoningc yes
exfoliative toxins Superantigen (and TCR and MHC II SSS c yes
serine protease?)
toxic-shock toxin Superantigen TCR and MHC II TSSc yes
S. pyogenes/pyrogenic exotoxins Superantigens TCR and MHC II SF/TSS c yes
Protease
B. anthracis/lethal factor Metalloprotease MAPKK1/MAPKK2 Anthrax yes
C. botulinum/neurotoxins A-G Zinc-metalloprotease VAMP/synaptobrevin, Botulism yes
SNAP-25, syntaxin
Clostridium tetani/tetanus toxin Zinc-metalloprotease VAMP/synaptobrevin Tetanus yes
a
Abbreviations: CNF, cytotoxic necrotizing factor; LT, heat-labile toxin; ST, heat-stable toxin; CLDT, cytolethal distending toxin;
EAST, enteroaggregative E. coli heat-stable toxin; TCR, T-cell receptor; MHC II, major histocompatibility complex class II;
MAPKK, mitogen-activated protein kinase kinase; VAMP, vesicle-associated membrane protein; SNAP-25, synaptosomal-
associated protein; UTI, urinary tract infection; HC, hemorrhagic colitis; HUS, hemolytic uremic syndrome; PC, antibiotic-
associated pseudomembranous colitis; SSS, scalded skin syndrome; SF, scarlet fever; TSS, toxic-shock syndrome.
b
Yes, strong causal relationship between toxin and disease; (yes), role in pathogenesis has been shown in animal model or
appropriate cell culture; ?, unknown.
c
Other diseases are also associated with the organism.
d
Toxin is also produced by other genera of bacteria.

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name suggests, disrupt the selective influx and staphylococcal accessory gene regulator (agr)
efflux of ions across the plasma membrane by locus (6,7). The α-toxin is synthesized as a 319
inserting a transmembrane pore. This group of amino acid precursor molecule that contains an
toxins includes the RTX (repeats in toxin) toxins N-terminal signal sequence of 26 amino acids.
from gram-negative bacteria, streptolysin O The secreted mature toxin, or protomer, is a
produced by S. pyogenes, and the S. aureus hydrophilic molecule that lacks cysteine resi-
α-toxin (described below). dues and has a molecular mass of approximately
S. aureus α-toxin can be considered the 33 kDa (6-8). Recently, the crystallographic
prototype of oligomerizing pore-forming cytotox- structure of the fully assembled α-toxin pore was
ins. The α-toxin gene resides as a single copy on solved (9). On the plasma membrane, seven toxin
the chromosome of most pathogenic S. aureus protomers assemble to form a 232-kDa mush-
strains, and its expression is environmentally room-shaped heptamer comprising three distinct
regulated at the transcriptional level by the domains (Figure 1A) (9,10). The cap and rim

Figure 1. Diagrammatic representation of the mode of action of several bacterial toxins. A. Damage to cellular
membranes by Staphylococcus aureus α-toxin. After binding and oligomerization, the stem of the mushroom-
shaped α-toxin heptamer inserts into the target cell and disrupts membrane permeability as depicted by the
influx and efflux of ions represented by red and green circles. B. Inhibition of protein synthesis by Shiga toxins
(Stx). Holotoxin, which consists of an enzymatically active (A) subunit and five binding (B) subunits, enters cells
through the globotriasylceramide (Gb3) receptor. The N-glycosidase activity of the A subunit then cleaves an
adenosine residue from 28S ribosomal RNA, which halts protein synthesis. C. Examples of bacterial toxins that
activate secondary messenger pathways. Binding of the heat-stable enterotoxins (ST) to a guanylate cyclase
receptor results in an increase in cyclic GMP (cGMP) that adversely effects electrolyte flux. By ADP-
ribosylation or glucosylation respectively, the C3 exoenzyme (C3) of Clostridium botulinum and the Clostridium
difficile toxins A and B (CdA & CdB) inactivate the small Rho GTP-binding proteins. Cytotoxic necrotizing
factor (CNF) of E. coli and the dermonecrotic toxin (DNT) of Bordetella species activate Rho by deamidation.

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 Synopses

domains of the α-toxin heptamer are situated at Stxs are potent cytotoxins that can be
the surface of the plasma membrane, while the divided into two antigenically distinct groups
stem domain serves as the transmembrane that share 50% to 60% homology: Stx/Stx1 and
channel. Stx2 (15-17). Stx and Stx1 are elaborated by
Alpha-toxin is cytolytic to a variety of cell S. dysenteriae serotype 1 and E. coli,
types, including human monocytes, lympho- respectively, and differ at only one amino acid.
cytes, erythrocytes, platelets, and endothelial Stx2-type toxins have been found only in E. coli
cells (6,8). For α-toxin to damage cellular isolates and are quite diverse. While Stx2 is
membranes, three sequential events are re- considered the prototype of this group, variants
quired. Toxin protomers must first bind to target have been found that differ antigenically, in
membranes by either unidentified high-affinity receptor specificity and in activation by
receptors or through nonspecific absorption to intestinal mucus. Some of these attributes are
substances such as phosphotidylcholine or the result of only one or two nucleotide
cholesterol on the lipid bilayer (6-8). Second, differences in the toxin genes.
membrane-bound protomers must oligomerize The stx of S. dysenteriae is invariably
into a nonlytic prepore heptamer complex. Third, chromosomally located. The genes that encode
the heptamer must undergo a series of Stx1 and Stx2 are carried chromosomally or by
conformational changes that create the stem lysogenic bacteriophages. The genes that code
domain of the toxin, which is then inserted into for the A and B subunits of Stxs, stxA and stxB,
the membrane (9,10). The α-toxin pore allows the are organized within an operon. The operator
influx and efflux of small molecules and ions that region of Stx/Stx1 (but not Stx2) contains a
eventually lead to the swelling and death of consensus fur box that is responsible for the iron-
nucleated cells and the osmotic lysis of regulation of Stx and Stx1 production. Neither
erythrocytes. Pore formation has also been iron nor any other environmental factors
shown to trigger secondary events that could examined affect the expression of Stx2. However,
promote development of pathologic sequelae. intestinal mucus enhances the activity of some
These events include endonuclease activation, Stx2 variants (18). The Stxs, which carry typical
increased platelet exocytosis, release of cytokines N-terminal leader sequences, are not actively
and inflammatory mediators, and production of secreted from the bacterial cell and are thought
eicosanoids (6,8). Several animal models have to be released into the milieu during cell lysis.
demonstrated that α-toxin is required for Stxs display an AB-toxin structure; an
S. aureus virulence in these systems (6,8); enzymatically active A subunit is noncovalently
however, the precise role of α-toxin in associated with a binding, or B, component. The
staphylococcal diseases in humans remains crystal structures of the Stx1 B pentamer (19)
unclear. and the Stx holotoxin have been solved (20)
(Figure 2). Other toxins that share this AB
Stop, in the Name of Toxin structure are the E. coli heat-labile toxin (21),
A second class of toxins intoxicates target cholera toxin, and pertussis toxin (22) (Figure 2).
cells by inhibiting protein synthesis. Substrates The molecular masses of mature Stx A and B
for toxins in this group are elongation factors and monomeric subunits are approximately 35 kDa
ribosomal RNA. Diphtheria toxin and Pseudomo- and 7.5 kDa, respectively, although holotoxin
nas exotoxin A act by ADP-ribosylating contains five B subunit molecules. The B subunit
elongation factor 2 (EF2) (11,12). The modified pentamer directs the binding of the holotoxin to
EF2 is no longer able to function in protein sensitive eukaryotic cells via specific glycolipid
synthesis. Stxs, also called verotoxins, are receptors. Once internalized, the A polypeptide
produced by Shigella dysenteriae serotype 1 and is cleaved into an enzymatically active A1 portion
the emerging pathogens designated Stx-produc- and an A2 portion; these fragments remain
ing E. coli (STEC). Stxs inactivate ribosomal associated through a disulfide bond. The A2
RNA (by a mechanism described below) so that portion serves to link the A1 fragment and the B
the affected ribosome can no longer interact with pentamer.
elongation factors (13,14). The inhibition of The enzymatic A subunit acts as a
protein synthesis by this group of toxins specific N-glycosidase to cleave a single adenine
ultimately results in death of the target cell. residue from 28S ribosomal RNA (13,14). This

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Figure 2. Ribbon crystal structures of Shigella dysenteriae Shiga toxin (20), Escherichia coli heat-labile toxin I
(LT-I) (21), and pertussis toxin (22). The Shiga toxin figure was contributed by Marie Frasier. The LT-I and
pertussis figures were contributed by Ethan Merritt. The figures were drawn in MOLSCRIPT (75).

depurination ultimately results in the inhibition that are regulators of the actin cytoskeleton
of protein synthesis within intoxicated cells (28,29). Most members of this toxin family, which
(Figure 1B). Prokaryotic ribosomes are as includes the large clostridial cytotoxins and the
sensitive to the N-glycosidase activity of Stx as C3 exoenzyme of C. botulinum, inactivate Rho
eukaryotic ribosomes (23). (29). CNF1, CNF2, and the dermonecrotic toxins
STEC are considered emerging pathogens from Bordetella species form a unique subset in
(24) because they were first described less than this family, since these toxins have the capacity
20 years ago, during a 1983 outbreak of to activate Rho (Figure 1C) (29-32). CNF1 and
hemorrhagic colitis associated with undercooked CNF2 share 99% amino acid similarity; however,
hamburger (25,26). STEC O157:H7 causes we will discuss only CNF1 in detail because of
approximately 20,000 cases of hemorrhagic its association with extraintestinal E. coli
colitis each year in the United States (27). infections in humans, most notably urinary
Approximately 1,000 cases of the life-threaten- tract infections.
ing sequelae hemolytic uremic syndrome and The gene for CNF1 is chromosomally
approximately 100 deaths are also attributed to encoded and resides on a pathogenicity island in
E. coli O157:H7 annually in the United States (27). uropathogenic E. coli (33,34). The toxin is
synthesized as a hydrophilic polypeptide of
Don’t Shoot the Messenger approximately 115 kDa that remains primarily
Bacterial toxins can also target and alter the cytoplasmic because of the lack of a signal
function of a variety of cellular proteins without sequence (33). Recent structure and function
directly killing the intoxicated cell. Toxin analysis of CNF1 indicates that the toxin has
activation or modification of secondary messen- distinct binding and enyzmatic domains (35).
gers can cause dramatic alterations to signal The N-terminal half of CNF1, which includes two
transduction pathways critical in maintaining a potential transmembrane domains, contains the
variety of cellular functions. To demonstrate the cellular binding domain. This region of the
diversity among the toxins that belong to this molecule shows amino acid similarity to the
category, we will describe CNF type 1 and the Pasteurella multicoda toxin, a potent mitogen
heat-stable enterotoxins. thought to be the etiologic agent of progressive
atrophic rhinitis in pigs (33,35). The C-terminal
Cytotoxic Necrotizing Factor (CNF) portion of CNF1 represents the toxin’s enzymatic
CNF types 1 and 2 (CNF1/2) from E. coli domain and shows homology with dermonecrotic
belong to a group of bacterial toxins that modify toxins in a 100-amino acid stretch that may
Rho, a subfamily of small GTP-binding proteins represent the active site of the toxin (33,35).

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Eukaryotic cells intoxicated with CNF1 Heat-Stable Toxin (ST)

exhibit membrane ruffling; the formation of focal Two families of diarrheagenic STs have been
adhesions and actin stress fibers; and DNA described: STa (or STI) and STb (or STII).
replication in the absence of cell division, a Distinct STas are produced by a variety of
phenomenon that results in enlarged multi- enteric pathogenic organisms: enterotoxinogenic
nucleated cells (Figure 3). The drastic changes E. coli (ETEC) (the focus of this section),
apparent in CNF1-treated cells are a result of the V. cholerae, Vibrio mimicus, Yersinia
toxin’s capacity to modify Rho (29,30,32). This enterocolitica, Citrobacter freundii, and Kleb-
modification has recently been identified as a siella.
deamidation of the glutamine residue at position Strains of ETEC associated with human
63 of Rho to a glutamic acid. This amino acid disease may produce either STa, heat-labile
change produces a dominant active Rho protein toxin I, or both. STas from ETEC isolates are
unable to hydrolyze bound GTP (30,32). In vivo, related but distinct toxins (38). STh is produced
CNF1 causes necrosis in rabbit skin following by strains of human origin, while STp is found
intradermal injection and persistent inflamma- predominantly in porcine strains. The STa genes
tion in a mouse footpad assay (36). Epidemiologic (estA) of ETEC are encoded within a transpos-
data support the role of CNF1 as a virulence able element and have been found on a variety of
factor in human extraintestinal infections, replicons (39,40). STa is translated as a
although direct proof of the toxin’s role in disease precursor molecule of 72 amino acids and
remains to be determined (29,37). undergoes two cleavage events before the
secretion of the mature form into the culture
supernatant. Mature STs are small peptides that
range from 17 to 53 amino acids. STh and STp
contain 19 and 18 residues, respectively. STas
share a conserved C-terminal region of 13 amino
acids essential for toxicity and the heat-stable
nature of the toxin. Six cysteine residues are
present within this domain, and the three
disulphide bonds formed between the cysteine
residues are necessary for toxicity of the
molecule. Binding of STa to its cellular receptor
results in the stimulation of membrane-bound
guanylate cyclase, which in turn leads to an
increase in intracellular cyclic GMP (Figure 1C)
(41). This increase in cyclic GMP affects
electrolyte flux in the bowel; sodium absorption
is inhibited and chloride secretion is stimulated.
These ion flux changes result in the secretory
diarrhea characteristic of ETEC infection. ETEC
cause traveler’s diarrhea and are a major source
of childhood diarrhea in many parts of the world.

The Nerve of Some Toxins

The C. botulinum neurotoxins (BoNTs,
serotypes A-G) and the C. tetani tetanus
neurotoxin (TeNT) constitute another category
of bacterial toxins on the basis of similarities in
structure, enzymatic activity, and the targeting
to cells of the nervous system. BoNTs are most
Figure 3. The effect of cytotoxic necrotizing factor type commonly associated with infant and foodborne
1 (CNF1) on eukaryotic cells. A. HEp-2 cells, botulism and exist in nature as large complexes
magnification 10X. B. HEp-2 cells intoxicated with comprised of the neurotoxin and one or more
CNF1, magnification 10X. associated proteins believed to provide protection

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and stability to the toxin molecule while in the respectively) are the direct result of the specific
gut (42,43). TeNT, which is synthesized from neurons affected and the type of neurotransmit-
vegetative C. tetani in wounds, does not appear ters blocked (45-47).
to form complexes with any other protein
components (42,43). Bacterial Superantigens: Too Much of a
The BoNTs and TeNT are either plasmid Good Thing
encoded (TeNT, BoNTs/A, G, and possibly B) or Several bacterial toxins can act directly on
bacteriophage encoded (BoNTs/C, D, E, F), and the T cells and antigen-presenting cells of the
the neurotoxins are synthesized as inactive immune system. Impairment of the immunologic
polypeptides of 150 kDa (44). BoNTs and TeNT functions of these cells by toxin can lead to
are released from lysed bacterial cells and then human disease. One large family of toxins in this
activated by the proteolytic cleavage of an category are the pyrogenic toxin superantigens
exposed loop in the neurotoxin polypeptide (45). (PTSAgs), whose hallmark biological activities
Each active neurotoxin molecule consists of a include potent stimulation of the immune cell
heavy (100 kDa) and light chain (50 kDa) linked system, pyrogenicity, and enhancement of
by a single interchain disulphide bond (42,45). endotoxin shock (49-51). These stable, secreted
The heavy chains of both the BoNTs and TeNT toxins of 22 kDa to 30 kDa include staphylococcal
contain two domains: a region necessary for enterotoxins serotypes A-E, G, and H; group A
toxin translocation located in the N-terminal streptococcal pyrogenic exotoxins serotypes A-C
half of the molecule, and a cell-binding domain and F; group A streptococcal superantigen; and
located within the C-terminus of the heavy chain staphylococcal TSST-1, which we discuss below.
(45,46). The light chains of both the BoNTs and All PTSAgs share common biological activi-
TeNT contain zinc-binding motifs required for ties, but TSST-1 is the most divergent member of
the zinc-dependent protease activities of the the toxin family, with less than 30% amino acid
molecules (45,46). homology to other family members (52-54).
The cellular targets of the BoNTs and TeNT TSST-1 is chromosomally encoded, and the tst
are a group of proteins required for docking and gene is located in a variable genetic element
fusion of synaptic vesicles to presynaptic plasma in S. aureus (49,52,55). The toxin is synthesized
membranes and therefore essential for the as a precursor molecule of 234 residues with the
release of neurotransmitters. The BoNTs bind to first 40 amino acids acting as a signal sequence
receptors on the presynaptic membrane of motor that is cleaved to generate the mature 22 kDa
neurons associated with the peripheral nervous toxin (49). Expression of TSST-1 depends on
system. Proteolysis of target proteins in these oxygen, temperature, pH and glucose levels, and
neurons inhibits the release of acetylcholine, is regulated by the S. aureus agr locus (49,51).
thereby preventing muscle contraction (47,48). On the basis of crystallographic analysis, TSST-
BoNTs/B, D, F, and G cleave the vesicle- 1 appears structurally similar to several other
associated membrane protein and synaptobrevin, PTSAgs in that the toxin consists of two distinct
BoNT/A and E target the synaptosomal- domains; however, unlike other family members,
associated protein SNAP-25, and BoNT/C TSST-1 does not require a zinc cofactor (51-54).
hydrolyzes syntaxin and SNAP-25 (42,45,46). Domain A of TSST-1 (amino acid residues 1-17
TeNT affects the central nervous system and and 90-194) exists as a ß-grasp motif, and domain
does so by entering two types of neurons. TeNT B consists of a five-stranded ß-barrel motif that
initially binds to receptors on the presynaptic forms an oligosaccharide/oligonucleotide bind-
membrane of motor neurons but then migrates ing fold.
by retrograde vesicular transport to the spinal In general, the potent immunostimulatory
cord, where the neurotoxin can enter inhibitory properties of PTSAgs are a direct result of toxin
interneurons (45,47). Cleavage of the vesicle- binding to distinct regions outside the peptide
associated membrane protein and synaptobrevin binding cleft of the major histocompatibility class
in these neurons disrupts the release of glycine II molecules (expressed on the surface of
and gamma-amino-butyric acid, which, in turn, antigen-presenting cells) and to specific
induces muscle contraction (47,48). The con- Vß elements on the T-cell receptor. In particular,
trasting clinical manifestations of BoNT or TeNT the domain B of TSST-1 binds primarily to the
intoxication (flaccid and spastic paralysis, α-chain of human leukocyte antigen-DR1

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molecules, while domain A specifically binds to “magic bullets,” hybrids of the enzymatically
human T-cell receptor Vß2 elements (51-53,56). active portion of a toxin molecule and monoclonal
Binding of TSST-1 to Vß2 T-cell receptor antibodies (or a receptor), are in clinical trials for
elements results in a massive proliferation of up the treatment of persons with B-cell lymphomas,
to 20% of peripheral T cells, an event that leukemia, and bone marrow transplants.
drastically skews the T-cell Vß repertoire Several clinical applications have also been
(53,56). T cells that undergo this expansion can found for the powerful botulinum neurotoxin
subsequently exist in a state of anergy or type A (BoNT/A) (46,68). The disorders that
undergo apoptosis (56). Concomitant to T-cell respond to BoNT/A involve muscle hyperactivity.
proliferation is a massive release of both A minuscule amount of purified toxin injected
lymphocyte (interleukin [IL]-2, tumor necrosis into specific sites results in paralysis of the
factor ß, gamma interferon)-derived and mono- target muscle and ablation of the muscle spasm.
cyte (IL-1, IL-6, tumor necrosis factor α)-derived Therapy must be continual since the effect of the
cytokines (51,56). These cytokines serve as toxin usually lasts for no more than several
mediators of the hypotension, high fever, and months. The first maladies treated with BoNT/A
diffuse erythematous rash that are characteris- were eye movement abnormalities (69). How-
tic of toxic-shock syndrome. Long established as ever, the therapeutic value of BoNT/A has been
a key substance in causing staphylococcal toxic- shown for many other disorders including
shock syndrome, TSST-1 has more recently been cervical and laryngeal dystonia, writer’s cramp,
linked with Kawasaki syndrome, a leading cause hemifacial spasm, tremors, and tics (46,68). BoNT/
of acquired heart disease in children in the A is also used cosmetically to reduce deep
United States (50,54). wrinkles caused by the contraction of facial
muscles (70).
Dr. Jekyll or Mr. Hyde? Another toxic bacterial product with medical
Some of these powerful disease-causing applications is streptokinase, a potent plasmino-
toxins have been exploited to further basic gen activator produced by several pathogenic
knowledge of cell biology or for medical purposes. streptococcal strains. The proteolytic activity of
For example, cholera toxin and the related labile- streptokinase is used to clear blocked arteries in
toxin of E. coli, as well as B. pertussis toxin, have patients who have heart attacks (71,72).
been used as biologic tools to understand the
mechanism of adenylate cyclase activation and Vaccinate, Don’t Procrastinate
the role of cyclic AMP as a second messenger in Vaccines directed at the toxic component of
the eukaryotic cell (57-59). Derivatives of some of bacterial pathogens have proven quite effective
these toxins, cholera toxin and labile toxin, have in preventing certain diseases. Most licensed
also been incorporated into human vaccines toxoid vaccines are relatively crude, but
because of the adjuvant properties of these effective, preparations. These vaccines consist of
molecules (60,61). partially purified toxin preparations obtained
Similarly, the activities of several potent from culture supernatants of bacteria such as
cytotoxins have been harnessed as potential C. diphtheriae, C. tetani, or B. anthracis.
therapies for certain cancers. Such toxins can Formaldehyde treatment is used to detoxify the
either be used directly in treatment or as diphtheria and tetanus toxins for vaccine
components of immunotoxins (62-64). For formulation. The anthrax vaccine contains the
example, Stx binds to the cell surface glycolipid protective antigen and small amounts of the
CD77, which is expressed by B cells in certain lethal factor and edema factor toxins. The
B-cell lymphomas (65,66). This finding led to current botulinum vaccine is an investigational
studies that showed that Stx can purge murine drug composed of crude preparations of five
(and potentially human) bone marrow of botulinum toxoids and is distributed by the
malignant CD77+ B cells before an autologous Centers for Disease Control and Prevention to
bone marrow transplant (67). Other toxins that researchers that work with the toxin or
inhibit protein synthesis, such as diphtheria organism. Acellular pertussis vaccines that
toxin, Pseudomonas exotoxin A, or the plant contain pertussis toxoid, alone or as one of
toxin ricin, are frequently engineered as the cell- several components, are as effective as killed
killing component of immunotoxins. These whole-cell vaccines but less reactogenic (73);

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such vaccines have recently been approved for Acknowledgments

use in infants as well as older children. We thank Drs. Ethan Merritt and Marie Frasier for
generating and contributing the figures on toxin crystal
New vaccines aimed at toxins are in various structures.
stages of development: research and develop- Work in Dr. O’Brien’s laboratory is supported by grants
ment, preclinical, phase I, phase II, or phase III from the National Institutes of Health (AI20148-16, AI33525-
(74). The next generation of toxoid vaccines falls 5, AI38281-3), the Department of Agriculture (97-35201-
4578), and the Uniformed Services University of the Health
into three general categories: purified toxoids Sciences (R073EQ).
that have been inactivated by chemical or
genetic means; live, attenuated strains of the Dr. Schmitt is a research assistant professor in the
causative agent that produce a genetically Department of Microbiology and Immunology, Uni-
derived toxoid; or live, attenuated unrelated formed Services University of the Health Sciences,
bacterial vector strains, such as V. cholerae or Bethesda, Maryland, USA. Research interests include
virulence factors and pathogenesis of disease caused by
Salmonella, that produce the target toxoid.
Shiga toxin-producing E. coli and regulation of Salmo-
Examples of each of these approaches and nella virulence.
progress in development of specific toxoid
vaccines are described annually in the Jordan
Report (74). References
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