Review

How Does Streptococcus

pneumoniae Invade the Brain?
Federico Iovino,1,2,* Jolien Seinen,3
Birgitta Henriques-Normark,1,2,4 and Jan Maarten van Dijl3,4

Streptococcus pneumoniae (the pneumococcus) is the major cause of bacterial

Trends
meningitis. The mechanisms by which pneumococci from the bloodstream
Streptococcus pneumoniae, the main
penetrate the blood–brain barrier to reach the brain are not fully understood. causative agent of bacterial meningitis,
Receptor-mediated adhesion of the bacteria to the brain endothelium is con- penetrates the blood–brain barrier by
binding to PECAM-1 and pIgR expressed
sidered a key event leading to meningitis development. The aim of this review is by brain vascular endothelial cells.
to discuss recent advances and perspectives related to the interactions of
S. pneumoniae with the blood–brain barrier during the events leading to men- Overall, recent findings suggest that
PECAM-1 and pIgR, together with pla-
ingitis. Altogether, the available data suggest that, by precisely defining the telet-activating factor receptor (PAFR),
pathways and ligands by which S. pneumoniae adheres to specific receptors, it another receptor thought to be more
involved in signaling rather than physi-
may be possible to interfere with the respective mechanisms and develop
cal binding, might cooperate during
strategies to prevent or even cure pneumococcal meningitis. adhesion of pneumococci to brain
endothelial cells.
Streptococcus pneumoniae, the Blood–Brain Barrier, and Pneumococcal
The passage of S. pneumoniae across
Meningitis the blood–brain barrier is a crucial
The Gram-positive bacterium Streptococcus pneumoniae (the pneumococcus) is an important step for meningitis development. The
commensal resident of the human nasopharynx. Although carriage is usually asymptomatic, knowledge of how S. pneumoniae
penetrates the blood–brain barrier
S. pneumoniae can become invasive and spread from the upper respiratory tract to other
can be used to develop strategies
organs, leading to serious diseases such as pneumonia, sepsis, or meningitis [1,2]. S. pneumoniae aimed at interfering with the respective
is the major etiological cause of bacterial meningitis, responsible for two-thirds of meningitis pathways in order to prevent the entry
cases in Europe and in the USA [3–5]. of the pathogen into the brain.

Bacterial meningitis is a disease with high morbidity and mortality worldwide despite the
implementation of several vaccination programs and antimicrobial agents [3–6]. A major route
for bacteria to reach the meninges is through the bloodstream [7]. Having reached the blood
vessels in the brain, bacteria present in the bloodstream have to cross the blood–brain barrier
to enter the brain and cause infection. This view is supported by recent immunofluorescent
analyses combined with high-resolution confocal microscopy, where blood-borne S. pneumo-
niae was clearly shown to adhere to the brain vascular endothelium prior to invasion of the
brain [8]. 1
Department of Microbiology, Tumor
and Cell Biology, Karolinska Institutet,
The blood–brain barrier is a specialized vasculature system that separates the brain from SE 171 77, Stockholm, Sweden
2
Department of Clinical Microbiology,
circulating blood and has critical functions in both protection and nutrient supply of the brain Karolinska University Hospital, SE 171
[9–11]. Endothelial cells form the layer that lines the interior surface of the blood vessels [12,13]. 76, Stockholm, Sweden
3
Pathogens can invade the brain only after crossing the endothelial cell layer of the blood–brain Department of Medical Microbiology,
University of Groningen, University
barrier and, therefore, they must develop strategies to pass this barrier. The inflammatory Medical Center Groningen, Groningen,
features and clinical complications following bacterial meningitis normally observed in humans The Netherlands
4
can be reproduced using animal models. Notably, most in vivo models that examine the These authors contributed equally to
this work.
pathophysiology of bacterial meningitis involve the direct injection of pneumococci into
the brain of mice or rats [14–18]. Administration of bacteria directly into the brain bypasses *Correspondence:
the need for blood–brain barrier translocation. In order to study the interaction of blood-borne federico.iovino@ki.se (F. Iovino).

Trends in Microbiology, April 2016, Vol. 24, No. 4 http://dx.doi.org/10.1016/j.tim.2015.12.012 307

© 2016 Elsevier Ltd. All rights reserved.
S. pneumoniae with the brain vascular endothelium in vivo, prior to the onset of meningitis, a so-
called bacteremia-derived meningitis model was established in recent years [8,19]. This model,
where bacteria are injected into the bloodstream instead of the brain, has allowed the visualiza-
tion of successive steps from bacteremia to brain invasion. The aim of the present review is to
discuss recent advances in our understanding how blood-borne S. pneumoniae interacts with
the blood–brain barrier endothelium during the events leading up to meningitis, and how to use
such knowledge to develop new therapeutic strategies to fight the disease.

Receptor-Mediated Transcytosis
How bacterial pathogens cross the blood–brain barrier is still subject of debate. Several possible
mechanisms have been implicated in this process, such as: (i) destruction of the endothelial cell
layers in case of, for example, Neisseria meningitidis [20]; (ii) traversal of the blood–brain barrier in
between the endothelial cells by disruption of tight junctions in case of group A streptococci [21];
and (iii) receptor-mediated transcytosis across endothelial and epithelial cell layers in case of
S. pneumoniae [22,23]. The view that pneumococci pass the blood–brain barrier via transcytosis
rather than pericellularly is supported by experiments, showing a continuous and homogeneous
staining of VE-Cadherin in the brain of infected mice [8]. This implies that blood-borne
S. pneumoniae does not cause a disruption of the endothelial tight junctions. In this context,
it should be noted that bacterial pathogens such as pneumococci have the capability to bind to
certain receptors on the plasma membrane of epithelial and endothelial cells, and this receptor-
mediated binding facilitates bacterial invasion into and translocation over human cell layers. The
passage of bacterial pathogens across such layers is a fundamental step for development of
invasive diseases and it is necessary for S. pneumoniae to cross the blood–brain barrier to
develop bacterial meningitis [22,23].

The Platelet-Activating Factor Receptor (PAFR)

The first reported receptor implicated in adhesion to, invasion of, and also transcytosis through
endothelial cells is the PAFR. PAFR is a G-protein-coupled receptor with seven transmembrane
domains and its natural ligand is the platelet-activating factor (PAF). PAF is a mediator in diverse
pathologic processes, such as allergy, asthma, septic shock, arterial thrombosis, and inflam-
mation [24–26]. Binding of PAF to the PAFR stimulates numerous signal transduction pathways
including phospholipase C, D, A2, mitogen-activated protein kinases (MAPKs), and the phos-
phatidylinositol-calcium second messenger system [25]. PAFR has been proposed to bind
S. pneumoniae, thereby facilitating adhesion to, uptake by, and transcytosis through endothelial
cells leading to invasive disease [23,27,28]. However, while in vitro and in vivo studies indicate
that PAFR is involved in the development of invasive pneumococcal disease (IPD), there is so far
no unequivocal published evidence that a direct binding between S. pneumoniae and PAFR
occurs [24]. A recent study suggests that PAFR plays a role in pneumococcal adhesion to
endothelial cells, even though pneumococci do not directly bind to PAFR [29]. After immuno-
fluorescent microscopy analysis, colocalization of PAFR and S. pneumoniae was not observed
in vivo in mouse brain tissue nor in endothelial cells in vitro. Nevertheless, upon blockade of
PAFR, adhesion of pneumococci to human endothelial cells was significantly reduced, indicating
that PAFR most likely has an indirect role in IPD [29]. When the PAFR was genetically deleted or
chemically inhibited, S. pneumoniae was still able to adhere to human cells in vitro, and to cause
invasive disease in vivo [23,27].

The Laminin Receptor (LR)

The LR is an important molecule involved both in cell adhesion to the basement membrane
and in signal transduction following this binding event. The LR on endothelial cells was found
to interact with neurotropic viruses, including Sindbis virus [30], Dengue virus [31], adeno-
associated virus [32], tick-borne encephalitis virus, and Venezuelan equine encephalitis virus
[33]. LR was identified to be a common receptor for both S. pneumoniae and N. meningitidis on

308 Trends in Microbiology, April 2016, Vol. 24, No. 4

the surface of rodent and human brain microvascular endothelial cells [19]. Fluorescent beads
coated with the pneumococcal choline-binding protein (Cbp) A [34–36] that were injected
intravascularly into mice adhered to the cerebral endothelium. Pretreatment with anti-LR anti-
body led to an inhibition of the adherence of the CbpA–beads to the endothelium in mice, thus
suggesting that the LR interacts with the bacteria facilitating translocation of intracellular
pneumococci across the blood–brain barrier endothelium, from the basolateral side of endo-
thelial cells to the brain tissue [19].

The Poly Immunoglobulin Receptor (pIgR)

The pIgR transports immunoglobulins across mucosal epithelial barriers (e.g., in the respiratory
tract) as a first line of defense to antigens from pathogenic bacteria [37–39]. S. pneumoniae has
been shown to bind to pIgR expressed by human nasopharyngeal epithelial cells and this
binding facilitates pneumococcal translocation through the nasopharyngeal epithelium [22].
When human nasopharyngeal epithelial (Detroit) cells were treated with an antibody against pIgR
prior to pneumococcal challenge, adherence was reduced [22]. This implies that pIgR is
functionally involved in pneumococcal adhesion to nasopharyngeal epithelium. Furthermore,
immunoblotting analyses showed that pneumococcal CbpA binds to human pIgR, indicating
that CbpA may be required to mediate binding of S. pneumoniae to this receptor [22]. PIgR is
not only present on the epithelium of the respiratory tract, but can also be found on the plasma
membrane of endothelial cells, especially brain endothelial cells [29]. Due to its presence on the
blood–brain barrier endothelium, the possible involvement of pIgR in pneumococcal adhesion to
brain endothelial cells was recently investigated [29]. Notably, immunofluorescent analyses of
brain tissue of infected mice showed that most pneumococci adhering to the brain vasculature
were colocalized with pIgR [29]. Furthermore, by incubating pneumococci with human endo-
thelial cell lysates, it was shown that S. pneumoniae can directly bind to pIgR [29]. The combined
results therefore suggest that pIgR is a direct adhesion receptor for S. pneumoniae on the
blood–brain barrier endothelium.

Even though the main route of brain invasion seems to be the bloodstream, pneumococci may
also reach the brain through skull fractures that tear the dura mater, or directly from the
nasopharynx. In fact, it was recently reported that S. pneumoniae can transmigrate from the
nasopharyngeal epithelium to the olfactory nerves that anatomically connect the upper respira-
tory tract with the central nervous system [40]. Although it was not shown experimentally, an
intriguing hypothesis is that the pIgR on the nasopharyngeal epithelium could mediate the
passage of the bacteria from the epithelial cells to the olfactory nerve. Clearly, once this passage
has occurred the bacteria can travel along the nerve and reach the brain.

Platelet Endothelial Cell Adhesion Molecule-1 (PECAM-1)

The PECAM-1 (also known as CD31) is a pan-endothelial protein present in the intercellular
junctions of the endothelial cells, that is involved in leukocyte migration, angiogenesis, and
integrin activation [41–43]. In particular, the involvement of PECAM-1 in leukocyte–endothelium
interaction and leukocyte trans-endothelial migration in the vascular system makes PECAM-1 a
key molecule in inflammation and neuroinflammation [43]. Recently, PECAM-1 was implicated in
gastrointestinal infection caused by Salmonella enterica serovar Typhimurium [44], suggesting
an active role of PECAM-1 in host–pathogen interactions. This raised the question whether
PECAM-1 might also play a role in host–pneumococcal interactions. Indeed, for the first time it
was recently shown that, in brain tissue from intravenously infected mice, most pneumococci did
colocalize with PECAM-1 [45]. Blockade of PECAM-1 with a specific antibody in human brain
endothelial cells led to a significant reduction of bacterial adhesion, indicating that PECAM-1 is
functionally involved in S. pneumoniae adhesion to the brain vascular endothelium [45]. Using a
biochemical approach, it was demonstrated that S. pneumoniae can directly bind PECAM-1
expressed by human endothelial cells [45]. Importantly, PECAM-1 colocalized with pIgR on the

Trends in Microbiology, April 2016, Vol. 24, No. 4 309

Key Figure
Cooperation of Platelet-Activating Factor Receptor (PAFR), pIgR, and
PECAM-1 in Pneumococcal Adhesion to Endothelial Cells: A Proposed
New Model

(A) (B)
S. pneumoniae

Inflammation Inflammatory
cytokines

Pneumococcal PAF
Blood components

More adhering pneumococci

S. pneumoniae More S. pneumoniae
binding sites binding sites
PAFR activation

plgR
plgR

PAFR

PAFR
before acvaon plgR-PECAM-1
upregulation

Endothelial cell

Brain

Figure 1. (A) Under normal physiological conditions, PAFR is present on the plasma membrane of endothelial cells in its
non-activated state, while pIgR and PECAM-1 are forming a double receptor displaying binding sites that can potentially be
used as anchors for the adhesion of bacterial pathogens. (B) Upon pneumococcal infection, inflammation develops and
PAFR is activated by pneumococcal components, such as pneumolysin and choline-binding proteins, and PAF. Activation
of PAFR may lead to the upregulation of pIgR–PECAM-1. This enhanced expression of pIgR–PECAM-1 would make more
potential binding sites available for Streptococcus pneumoniae and, ultimately, this would lead to more pneumococci
adhering to endothelial cells, allowing them to enter the brain.

brain endothelium and, moreover, the two receptors directly interacted with each other as
demonstrated by co-immunoprecipitation experiments suggesting the possible formation of a
double receptor that facilitates the passage of S. pneumoniae across the blood–brain barrier [45]
(Figure 1, Key Figure). Nevertheless, to unequivocally demonstrate the joint role of PECAM-1 and
pIgR in pneumococcal meningitis, S. pneumoniae should be intravenously administered to
PECAM-1 / and pIgR / mice. In the case of a direct role, as suspected, one would expect
that only few bacteria can translocate the blood–brain barrier in the knock-out mice. Although
current literature still lacks such experimental evidence, it was previously shown that adhesion
of bacteria to the brain vasculature endothelium represents a crucial moment for invasion of
meningeal pathogens in the brain. In addition, the observation that blood-borne pneumococci
colocalize with both PECAM-1 and pIgR in vivo strongly indicates that the two receptors jointly
facilitate the passage of the bacteria from the bloodstream into the brain [29,45].

Cooperation of PAFR, pIgR and PECAM-1 during Pneumococcal Adhesion

to Endothelial Cells: A New Model
From the current literature [24], it remains unclear what the exact role of PAFR is in IPD. The
involvement of PAFR in S. pneumoniae adhesion to endothelial cells might well be exerted
through the binding of PAF or pneumococcal cell-wall components to the receptor and the
subsequent inflammatory consequences of its activation [24]. Inflammation leads to an upre-
gulation of receptors expressed on the plasma membrane of the apical side of the cells [7,27,46],
and PECAM-1 and pIgR may be among them. In the presence of more pIgR and PECAM-1,

310 Trends in Microbiology, April 2016, Vol. 24, No. 4

S. pneumoniae has more sites to adhere to on the endothelial cells. It has been repeatedly
shown that blocking PAFR with a specific antibody or antagonist leads to a significant reduction
of pneumococcal adhesion to endothelial cells in vitro [23,27,29]. We therefore hypothesize that,
due to PAFR blocking, the upregulation of pIgR and PECAM-1 may be prohibited. Possibly, the
presence of pneumococci may trigger the autocrine production of PAF, directly or indirectly,
which activates PAFR, leading to an upregulation of pIgR and PECAM-1. This would increase
pneumococcal adherence to pIgR and PECAM-1 and, in turn, more adherent bacteria would
increase the chances of bacterial invasion into the cells (Figure 1). Whether PAFR activation
leads, directly or indirectly, to pIgR-PECAM-1 upregulation still remains an open question.
Besides PAF, secreted pneumococcal components, such as pneumolysin [47,48] and CbpA,
could bind to PAFR and activate this receptor [49]. Clearly, this idea still needs to be experi-
mentally validated. Accordingly, an in-depth investigation of secreted and surface-attached
pneumococcal proteins, including proteomics and structural analyses, will be required to identify
any protein(s) of S. pneumoniae that could be recognized and bound by PAFR. Interesting
candidate proteins for such studies were recently identified by Pribyl et al. in a proteomics-based
survey of the pneumococcal surface-bound and secreted proteins [50]. An important recent
finding was that if pIgR and PECAM-1 are blocked simultaneously, pneumococcal adhesion to
endothelial cells is reduced even more than when the two receptors are blocked individually [45].
Bacteria cannot adhere to pIgR and PECAM-1 after blocking with their respective antibodies,
but PAFR activation may still be possible and could thus lead to upregulation of PECAM-1 and
pIgR expression.

Humans Deficient in Receptors PAFR, pIgR, and PECAM-1 Have Not Been
Identified, but Mice Survive without Them
Humans deficient in PAFR have not been identified. However PAFR–/– mice have been gener-
ated [51]. In PAFR–/– mice, modifications of known angiogenic factors, such as vascular
endothelial growth factor (VEGF), have not been observed, but a sustained rise in the chemo-
kines CXCL2 and CCL2 has been detected, which may compensate for the absence of PAFR
as an important molecule in maintaining immunological surveillance [52]. These findings indicate
that the absence of PAFR in mice is compatible with health, although it has to be noted that this
was observed under controlled conditions. Mice lacking pIgR were of normal size and fertility as
well, but displayed increased IgG levels in their sera, suggesting a triggering of systemic
immunity [53]. These findings indicate that absence of pIgR is not lethal either, but at the same
time it seems that absence of pIgR is sensed as a potential danger by the systemic immune
system [38,53]. PECAM-1 is expressed not only by endothelial cells but also by platelets,
neutrophils, and macrophages, and its signaling pathways might mediate resistance to
apoptosis and promote cell survival [41,42]. Absence of PECAM-1 may therefore lead to several
cellular dysfunctions. Interestingly, PECAM-1 was reported not to be required for embryogene-
sis, fetal maturation, or fertility in mice, and, furthermore, PECAM-1 expression on platelets is not
essential for platelet–platelet aggregation [54]. PECAM-1–/– animals develop normally and do not
show any signs of an abnormal physiology under normal baseline conditions. However, as the
animals age they can develop an autoimmune lupus-like syndrome and, when stressed, a variety
of abnormal responses have also been noticed. In particular, PECAM-1–/– animals exhibited a
prolonged bleeding time [55]. Thus, although the absence of the PAFR, pIgR, or PECAM-1
receptors did not cause serious problems in mice during certain circumstances, dysfunctions
and abnormalities due to a lack of these receptors cannot be excluded.

Blockade of S. pneumoniae Receptors: A New Avenue for the Prevention

and Cure of Pneumococcal Meningitis
Knowledge of the mechanisms by which the pneumococcus interacts with the blood–brain
barrier before invading the brain is fundamental in order to develop therapeutic strategies to
avoid adhesion of S. pneumoniae to the blood–brain barrier and, thus, invasion of the pathogen

Trends in Microbiology, April 2016, Vol. 24, No. 4 311

into the central nervous system. Adhesion of pneumococci to the blood–brain barrier is
spatiotemporally controlled at different sites throughout the brain, and the local immune system
in the brain is activated immediately as soon as bacteria in the bloodstream interact with the
blood–brain barrier [8]. The bacteremia-derived meningitis model is used to investigate the
interactions of bacteria with the blood–brain barrier, including the events preceding meningitis
[8,19,29,45]. To study meningitis itself, intracisternal administration of bacteria was previously
used to induce meningitis in vivo [14–18]. Using this model, neutrophil influx into the brain was
detected only at 30 hours after challenge, indicating that white blood cells can be detected in the
brain only at late stages of the disease [14]. A high count of white blood cells in the cerebrospinal
fluid (CSF) is often used as a clinical test for diagnosis of meningitis [56]. Moreover, classic
symptoms of meningitis, such as rash, neck stiffness, photophobia, severe headache, and
impaired consciousness develop late [56–58]. While these symptoms represent the classical
picture of suspected meningitis, the disease may be already at an advanced stage in patients
displaying them. Thus, it is not really surprising that, at this stage, the risks of brain damage are
considerable even if the infection is successfully fought with antibiotics. World Health Organiza-
tion (WHO) data indicate that, even if the disease is diagnosed early and adequate treatment is
started immediately, 5–10% of the patients will die, typically within 24–48 hours after occurrence
of the first symptoms. When left untreated, up to 50% of the patients may die. In case of
recovery, brain damage, hearing loss, or a learning disability appears in 10–20% of the survivors
(http://www.who.int/topics/meningitis/en/). It is therefore crucial to start interventions before
bacteria have invaded the brain in order to optimize the survival chances of patients and to
prevent permanent damage. Treatment with antibiotics is the clinically used way to cure
meningitis, and routine vaccination against pneumococcal infections with the pneumococcal
conjugate vaccine (PCV), which is active against seven to thirteen common capsular serotypes
of this pathogen, has significantly reduced the incidence of invasive pneumococcal disease in
vaccinated children [59–61]. Knowing that PAFR, pIgR, and PECAM-1 mediate the first adhe-
sion of blood-borne S. pneumoniae to the vascular endothelium of the blood–brain barrier opens
a complementary approach to antibiotics and vaccines for curing or preventing pneumococcal
meningitis by developing therapies that interfere with these receptors. This could, for example,
be achieved by blocking PAFR, pIgR, and PECAM-1 with specific antibodies which would limit
the adhesion of pneumococci to the blood–brain barrier and then observing whether the
systemic administration of blocking antibodies leads to less severe disease symptoms. Alter-
natively, blockade of the receptors can be achieved by using either chemical antagonists, such
as, for instance, L659989 or WEB2086 previously used to successfully block the PAFR in vitro
[24], or the pneumococcal proteins that should specifically anchor to the receptors, such as
CbpA that was reported to bind to pIgR in the respiratory epithelium [22,62]. Another alternative,
but technically more challenging approach, is to prevent binding of S. pneumoniae to PAFR,
pIgR, and PECAM-1 on the blood–brain barrier endothelium by blocking the respective ligands
on the pneumococcal cell surface with engineered soluble derivatives of these receptors. This
would have the potential advantage of minimal interference with the physiological functions of
these three receptors. Such studies could be aided by targeted infection-imaging approaches,
for instance, with positron emission tomography (PET) tracers that bind well to S. pneumoniae
[63]. However, while blocking of these pneumococcal receptors could provide protection
against meningitis, it will be crucial to develop strategies to avoid possible dysfunctions caused
by their blocking before this approach can be implemented in the clinic. Based on literature data,
mutated PAFR in mice is not likely to cause serious dysfunctions [51]. However, mutated pIgR
may interfere with the normal transport of immunoglobulins across cells. It has been shown that
treatment with phorbol myristyl acetate (PMA) activates isozymes of protein kinase C (PKC), a
downstream protein in the signaling cascade of pIgR [64]. This activation stimulates not only
pIgR transcytosis, but more generally the pathway of a variety of molecules in the transcytotic
pathways [64]. Thus, treatment with PMA can stimulate cells to use other transcytotic systems
and their receptors, in case immunoglobulin transfer mediated by pIgR is altered. In this way

312 Trends in Microbiology, April 2016, Vol. 24, No. 4

transport of immunoglobulins can be maintained through other transcytotic pathways. Regard- Outstanding Questions
ing the vascular role of PECAM-1, it is important to bear in mind that endothelial cells express a How exactly does the signaling recep-
vast range of endothelial adhesion factors (such as VECAM-1 and ICAM-1) that perform similar tor PAFR cooperate with the binding
receptors pIgR and PECAM-1 during
functions as PECAM-1 [65,66]. Therefore, is conceivable that such adhesion molecules could the adhesion of S. pneumoniae to brain
complement for PECAM-1's role in case PECAM-1 is blocked. In principle, it should thus be endothelial cells?
possible to develop monoclonal antibodies blocking the pneumococcal binding site of the
Does an absence of adhesion recep-
PECAM-1 receptor.
tors lead to less bacterial invasion into
the brain in animal meningitis models?
While the blocking of pIgR and PECAM-1 showed only a partial reduction of pneumococcal
adherence to endothelial cells [45], the blocking of the PAFR, pIgR, and PECAM-1 receptors at the Is the treatment with blocking antibod-
ies/antagonists/receptor ligands a valid
same time could be a potential way to completely preclude the adhesion of S. pneumoniae to the
way to block the adhesion receptors
blood–brain barrier endothelium and, therefore, prevent completely pneumococcal invasion into and prevent bacterial passage across
the brain. This, however, remains to be assessed experimentally. Clearly, an important advantage the blood–brain barrier? If so, can such
of conceivable therapies based on monoclonal antibodies against PAFR, pIgR, and PECAM-1 treatment be applied in humans?

would be that these antibodies need to be administered only as long as pneumococci are
detectable in the blood. Once these have been fought successfully with regular antibiotics, the
antibody therapy can be stopped, which will limit possible unwanted side effects to a minimum.

Lastly, it has been demonstrated that pneumococci in the blood can reach and adhere to the
blood–brain barrier endothelium after which they may invade the brain [8]. Bacteremia is present
in 20–30% of cases with pneumococcal pneumonia, which can occur when an infection of the
lungs grows out of control [67–69]. Patients with bacteremia and pneumonia can be considered
‘high-risk’ for progression towards brain infection and, for this reason, it could be valuable for
them to receive innovative treatments that block pneumococcal receptors. This would prevent
pneumococci from adhering to the blood–brain barrier and invading the brain. Such a treatment
would even be of relevance for patients who are hospitalized with meningitis as it would still
reduce the numbers of bacteria adhering to the blood–brain barrier and, in combination with
antibiotic therapy, both the blood-borne bacteria and the bacteria that have already reached the
brain could be eliminated.

Concluding Remarks
What is the ultimate goal of knowing how S. pneumoniae invades the brain? Clearly, if
pneumococci cannot adhere to endothelial cells, bacterial invasion will most likely be prevented.
Therefore, by precisely defining the pathways by which S. pneumoniae adheres to specific
receptors, it may be possible to develop drugs that interfere with these mechanisms and to
develop strategies to prevent or even cure pneumococcal meningitis, as this still remains a very
serious disease with high mortality and morbidity worldwide (see Outstanding Questions).
Judged by our current understanding of pneumococcal brain invasion, this is a highly ambitious
but potentially achievable objective.

Acknowledgments
We thank Staffan Normark, Jetta Bijlsma and Ingrid Molema for their critical feedback. F.I. and B.H.-N. were supported by
grants from the Swedish Research Council, ALF grant from Stockholm County Council, the Foundation for Strategic
Research (SSF), and Knut and Alice Wallenberg foundation. F.I. and J.S. were supported in part by grants from the
Graduate School of Medical Sciences of the University of Groningen. J.S. and J.M.v.D. acknowledge the Deutsche
Forschungsgemeinschaft Research Training Group GRK1870 for support.

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