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Annu. Rev. Med. 2001. 52:259–74

Copyright
c 2001 by Annual Reviews. All rights reserved

SALMONELLA: A Model for Bacterial

Pathogenesis

Michael E. Ohl and Samuel I. Miller

Department of Medicine, Division of Infectious Diseases, University of Washington,
1959 NE Pacific Street, Seattle, Washington 98195; e-mail: millersi@u.washington.edu
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Key Words innate immunity, type III secretion, antimicrobial peptide,

macrophage
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■ Abstract Salmonellae are gram-negative bacteria that cause gastroenteritis and

enteric fever. Salmonella virulence requires the coordinated expression of complex
arrays of virulence factors that allow the bacterium to evade the host’s immune sys-
tem. All Salmonella serotypes share the ability to invade the host by inducing their
own uptake into cells of the intestinal epithelium. In addition, Salmonella serotypes
associated with gastroenteritis orchestrate an intestinal inflammatory and secretory res-
ponse, whereas serotypes that cause enteric fever establish systemic infection through
their ability to survive and replicate in mononuclear phagocytes. This review explores
the molecular basis of selected Salmonella virulence strategies, with an emphasis on
general themes of bacterial pathogenesis as exemplified by Salmonella.

INTRODUCTION
Salmonellae are significant not only as an ongoing threat to worldwide public
health, but also as a fruitful model system for the study of fundamental mech-
anisms of bacterial pathogenesis. Salmonella typhimurium has long served as a
model organism for genetic studies, and a wide variety of classical and mole-
cular genetic tools exist for the identification and characterization of potential
Salmonella virulence genes. In addition, the availability of in vitro tissue culture
and small-animal models of infection facilitates study of complex interactions
between host and pathogen during various stages of infection. Although these
models do not perfectly reflect human infection, they provide insight into general
mechanisms of microbial pathogenesis and host immunity. This review summa-
rizes current understanding of selected mechanisms of Salmonella pathogenesis,
with emphasis on general themes of bacterial pathogenesis as exemplified by
Salmonella.

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GENERAL THEMES OF BACTERIAL PATHOGENESIS

As the pathogen enters and moves through its animal host, it encounters a series
of unique environments. Each host environment possesses distinct chemical and
physical properties, such as temperature, pH, osmolarity, and nutrient availability.
In each new environment the pathogen also confronts various components of the
host innate immune system. Elements of innate immunity range from the anatomi-
cal barrier functions of epithelia to the microbicidal activities of antimicrobial
peptides, complement, and phagocytes. Pathogens must sense these changing sur-
roundings and respond with coordinated programs of gene expression that provide
an adaptive advantage in each new host environment. These responses must in-
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clude adaptation to newly encountered environmental stresses, such as nutrient

deprivation, as well as activation of specific virulence mechanisms that allow the
pathogen to resist, evade, or even systematically manipulate the effectors of innate
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immunity.
Simultaneously, the host innate immune system detects the presence of micro-
bial pathogens using receptors capable of sensing and distinguishing conserved
elements of microbial structure (1). In gram-negative bacteria, these elements in-
clude lipopolysaccharide and lipoproteins of the outer membrane. Interaction of
these microbial signature molecules with specific host receptors ultimately leads
to stimulation of innate immune functions of epithelia and phagocytes. Most of-
ten, activation of these innate immune functions eliminates the microbe from the
host, leading to an asymptomatic resolution of infection. Alternatively, bacterial
pathogens that survive the innate immune effectors may persist in the host, allow-
ing continued recognition of microbial signature molecules and ongoing activation
of cytokine production and inflammation. These persistent host responses lead to
signs and symptoms of disease. In Salmonella, we are beginning to understand
the molecular interactions that determine the outcome of this dynamic encounter
between host and pathogen.

OVERVIEW OF SALMONELLA CLINICAL SYNDROMES

AND PATHOPHYSIOLOGY
The principal clinical syndromes associated with Salmonella infection are enteric
(typhoid) fever and gastroenteritis (2). Enteric fever is a protracted systemic ill-
ness that results from infection with the exclusively human pathogens, S. typhi
and S. paratyphi. Clinical manifestations include fever, abdominal pain, transient
diarrhea or constipation, and occasionally a maculopapular rash. The pathologi-
cal hallmark of enteric fever is mononuclear cell infiltration and hypertrophy of
the reticuloendothelial system, including the intestinal Peyer’s patches, mesenteric
lymph nodes, spleen, and bone marrow. Without treatment, mortality is 10%–15%.
In contrast, the many nontyphoidal Salmonella strains, such as S. enteriditis and
S. typhimurium, infect a wide range of animal hosts, including poultry, cattle, and
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pigs, and usually cause a self-limited enteritis in humans. In certain inbred mouse
strains, however, S. typhimurium infection produces an illness resembling enteric
fever that serves as an experimental model for systemic Salmonella infections.
All Salmonella infections begin with the ingestion of organisms in contaminated
food or water. Conditions that increase gastric pH reduce the Salmonella infectious
dose, which suggests that gastric acidity represents a significant initial barrier to in-
fection (3). Interestingly, salmonellae exhibit an adaptive acid-tolerance response
on exposure to low pH, possibly promoting survival in acidic host environments
such as the stomach (4). After entering the small bowel, salmonellae must tra-
verse the intestinal mucus layer before encountering and adhering to cells of the
intestinal epithelium. Salmonellae express several fimbriae that contribute to their
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ability to adhere to intestinal epithelial cells (5).

Microscopic studies reveal that salmonellae invade epithelial cells by a mor-
phologically distinct process termed bacterial-mediated endocytosis (6). Shortly
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after bacteria adhere to the apical epithelial surface, profound cytoskeletal rear-
rangements occur in the host cell, disrupting the normal epithelial brush border
and inducing the subsequent formation of membrane ruffles that reach out and en-
close adherent bacteria in large vesicles (see Figure 1). This process resembles the
membrane ruffling and macropinocytosis induced in many cells by growth factors,
and it is morphologically and functionally distinct from receptor-mediated endo-
cytosis, the mechanism by which many other pathogens enter nonphagocytic cells.
Bacterial-mediated endocytosis requires coordinated synthesis of multiple bacte-
rial proteins, and is prevented by inhibition of specific host-cell signal-transduction
pathways that govern cytoskeletal organization (7, 8). Following bacterial inter-
nalization, a fraction of the Salmonella-containing vesicles transcytose to the
basolateral membrane, and the apical epithelial brush border reconstitutes.
In mice, salmonellae appear to preferentially adhere to and enter the micro-
fold cells (M cells) of the intestinal epithelium, although invasion of normally
nonphagocytic enterocytes also occurs (9). M cells are specialized epithelial cells
that sample intestinal antigens through pinocytosis and transport these antigens
to lymphoid cells that underlie the epithelium in Peyer’s patches (10). This acti-
vity is important in the priming of mucosal immunity. In bovine epithelium, how-
ever, salmonellae do not appear to interact preferentially with M cells, and the
relative roles of M cell and enterocyte invasion in different animal hosts and
Salmonella disease syndromes require further study (11). Recent data demon-
strate that salmonellae may also passively cross the intestinal epithelial barrier
following phagocytosis by migrating CD18-positive phagocytes (12).
In addition to invasion of the intestinal epithelial barrier, Salmonella serotypes
clinically associated with enteritis induce a secretory response in the intestinal
epithelium and initiate recruitment and transmigration of neutrophils into the in-
testinal lumen (13). In in vitro tissue culture models, recruitment of neutrophils
across the epithelial surface requires protein synthesis in both bacteria and the
epithelial cell and is associated with production of several cytokines (14). Specifi-
cally, epithelial cell production of the potent neutrophil chemokine interleukin-8
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Figure 1 Scanning electron micrograph showing Salmonella typhimurium entering a

Hep-2 cell through bacterial mediated endocytosis. Membrane ruffles extend from the cell
surface, enclosing and internalizing adherent bacteria. (Electron micrograph in collabora-
tion with Dr. Carol Wells, University of Minnesota.)

appears important in recruiting neutrophils to the submucosal space, and factors

not yet defined promote transmigration of neutrophils across the epithelial barrier.
Once across the intestinal epithelium, salmonellae encounter another obstacle
of innate immunity, the submucosal macrophage. Salmonella serotypes that cause
systemic infection enter macrophages, again apparently by induced macropinocy-
tosis, and subsequently activate virulence mechanisms that allow evasion of the
microbicidal functions of the phagocyte, permitting survival and replication in the
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SALMONELLA PATHOGENESIS 263

intracellular environment (15). Migration of infected phagocytes to other organs

of the reticuloendothelial system probably facilitates dissemination of bacteria in
the host. Figure 2 shows selected events in the pathogenesis of gastroenteritis and
enteric fever, along with associated virulence genes.

SALMONELLA VIRULENCE MECHANISMS

Pathogenicity Islands: Pathogen Evolution
through Horizontal Gene Transfer
Analysis of the genetic structure of bacterial pathogens reveals that virulence
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genes often cluster in localized regions of the chromosome, termed pathogenicity

islands (16). Three observations suggest that pathogens have acquired these gene
clusters through horizontal gene transfer: (a) pathogenicity islands often have a
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GC content that differs significantly from the rest of the bacterial chromosome,
(b) pathogenicity islands are often flanked by genes that are contiguous in closely
related but nonpathogenic bacteria, and (c) remnants of bacteriophage or transpo-
son insertion sequences often lie near the borders of pathogenicity islands, sug-
gesting a possible mechanism for acquisition of these genes (16). Pathogenicity
islands often contain multiple functionally related genes necessary for a specific
virulence phenotype, suggesting that acquisition of a pathogenicity island during
evolution may in one “quantum leap” open up new host niches or lifestyles for the
pathogen. For example, Salmonella pathogenicity island 1 (SPI-1) encodes genes
necessary for invasion of intestinal epithelial cells and induction of intestinal secre-
tory and inflammatory responses (11, 13). In contrast, Salmonella pathogenicity
island 2 (SPI-2) encodes genes essential for intracellular replication, and, in the
mouse enteric fever model, is necessary for establishment of systemic infection
beyond the intestinal epithelium (17, 18). Many pathogenicity islands, including
SPI-1 and SPI-2, encode specialized devices for the delivery of virulence proteins
into host cells, termed type III secretion systems (TTSSs).

Type III Secretion Systems—Manipulating

the Host Cell with a Molecular Syringe
TTSSs are specialized virulence devices that have evolved to modify host-cell
function through the direct translocation of bacterial virulence proteins into the
host-cell cytoplasm (19). These translocated bacterial proteins alter such basic
host-cell functions as signal transduction, cytoskeletal architecture, membrane
trafficking, and cytokine gene expression. The delivery of bacterial proteins into
the host cell clearly represents a complex task, as translocated proteins must cross
the bacterial inner and outer membrane as well as the host-cell plasma membrane.
The precise structure, function, and regulation of the TTSS is a subject of ongoing
study (for an in-depth review, see 19). In brief, the inner and outer membrane
components of the secretion apparatus are homologous to the bacterial flagellar
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Figure 2 Selected events in Salmonella pathogenesis and associated virulence genes.

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SALMONELLA PATHOGENESIS 265

export apparatus and PulD family of type II secretion proteins, respectively. By

analogy to these well-studied systems, it is deduced that these TTSS components
probably assemble to form a secretion channel across the inner and outer bacte-
rial membranes. Electron micrographs of a supramolecular structure associated
with a Salmonella TTSS support this model (Figure 3) (20). These images reveal
an elongated structure spanning the inner and outer membranes, referred to as
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Figure 3 Electron micrograph showing purified needle complexes. The two ring-shaped
structures at the complex base associate with the bacterial inner and outer membranes and
are homologous to the basal body of the flagellar export apparatus. The needle portion is
unique to the type three secretion apparatus and is thought to bridge the bacterium and host
cell during secretion of effector proteins. (Micrograph courtesy of T Kimbrough.)
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the needle complex. As expected, the inner-membrane–associated components of

this complex resemble the flagellar export apparatus. The mechanism of protein
translocation across the host-cell membrane is less clear but is thought to involve
a set of secreted “translocase” proteins that may associate to form a translocation
pore in the host-cell membrane (19).
Although the TTSS itself is highly conserved in a wide variety of plant and
animal pathogens, the effector proteins translocated into the host cell are unique
to each pathogen. These unique sets of effector proteins contribute to the distinct
virulence phenotype of each pathogen. Genes encoding these effector proteins may
lie in the same pathogenicity island that encodes the secretion apparatus, or they
may reside elsewhere in the chromosome (19). Interestingly, the genes for several
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Salmonella TTSS targets lie within temperate bacteriophages, which suggests that
horizontal gene transfer may provide for mixing and matching of individual TTSS
effector proteins, thus allowing fine tuning of virulence phenotypes (21, 22).
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Virulence Factors Involved in Epithelial Cell

Invasion and Induction of Enteritis
Salmonellae induce a complex array of cytoplasmic and nuclear responses in
host intestinal epithelial cells. They initiate cytoskeletal rearrangements that lead
to membrane ruffling and bacterial internalization, induction of transmembrane
fluid and electrolyte fluxes, and synthesis of cytokine and prostaglandin medi-
ators of inflammation (7, 23–26). Over the past decade, extensive research has
focused on identifying Salmonella virulence genes involved in the induction of
these responses. In in vitro models, Salmonella mutants lacking a functional SPI-1
TTSS are unable to invade epithelial cells or induce cytokine synthesis (11, 25).
Moreover, these mutants are attenuated for virulence in the mouse typhoid-fever
model when inoculated orally, but not when inoculated intravenously, and they
fail to produce significant secretory or inflammatory responses in the bovine lig-
ated ileal loop model of Salmonella enteritis (24, 27). Accordingly, attention has
turned to identifying the virulence proteins translocated into the epithelial cell by
the SPI-1 TTSS and delineating the host-cell functions these proteins target.
Two effector proteins translocated by the SPI-1 TTSS, SopE and SptP, appear to
target members of the Rho family of monomeric GTP-binding proteins (G proteins)
(28, 29). Members of the Rho family, including cdc42, rac, and rho, play a central
role in regulating the actin cytoskeleton (30). In addition, Rho-family G proteins
regulate gene transcription, mainly via their ability to stimulate signaling through
members of the mitogen-activated protein kinase family (MAP kinases) (30). Seve-
ral observations indicate that at least one member of the Rho family, cdc42, plays
a central role in mediating the host-cellular response to Salmonella infection.
Microinjection of a cdc42 dominant negative mutant into epithelial cells inhibits
both bacterial internalization via macropinocytosis and Salmonella-dependent in-
duction of epithelial-cell cytokine synthesis (8). This is consistent with previ-
ous work showing that induction of epithelial-cell IL-8 synthesis in response to
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SALMONELLA PATHOGENESIS 267

Salmonella infection requires the MAP kinase p38, a known downstream target of
cdc42 (25). Furthermore, microinjection of a constitutively active cdc42 mutant
into epithelial cells induces membrane ruffling and provokes internalization of
invasion-incompetent Salmonella mutants (8). Recently, Hardt et al demonstrated
that microinjection of purified SopE into epithelial cells induces membrane ruffling
in a cdc42-dependent manner and that SopE directly activates cdc42 and rac-1 in
vitro by acting as a GDP/GTP exchange factor (28).
As described above, the normal intestinal epithelial-cell brush border recovers
its form shortly after Salmonella invades. Interestingly, this recovery of the epithe-
lial brush-border morphology requires the function of the Salmonella SptP protein,
another known SPI-1 effector protein (29). SptP appears to functionally oppose
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the activity of SopE, as simultaneous injection of the SptP protein with SopE
eliminates the membrane-ruffling response induced by injection of SopE alone.
Indeed, in vitro experiments demonstrate that SptP directly inactivates cdc42 and
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rac-1 by acting as a GTPase-activating protein (29). These findings suggest that

Salmonella regulates the relative activities of TTSS effector proteins at different
times during invasion, although the mechanisms of this regulation are mysterious.
SptP also contains a domain with potent tyrosine phosphatase activity, but the in
vivo significance of this activity is unclear (29).
Other SPI-1 TTSS effectors interact directly with the host-cell actin cytoskele-
ton. SipA is a translocated effector protein that binds actin in vitro and acts to
stabilize actin filaments and decrease the critical concentration for actin poly-
merization (31). Salmonella mutants lacking sipA invade cultured epithelial cells
with slightly decreased efficiency at early time points, and they induce diffuse
actin rearrangements in the host cell, in contrast to the more localized cytoskeletal
alterations induced by wild-type bacteria (31). In addition, Hayward et al recently
reported that SipC, a component of the putative translocase apparatus that mediates
entry of other TTSS effectors into the host cell, directly binds actin in vitro and
both nucleates actin polymerization and directly stimulates filament bundling (32).
It is difficult to use targeted gene disruption to isolate the role of SipC in inducing
membrane ruffling, since sipC null mutants are unable to translocate other SPI-1
TTSS effectors, producing pleiotropic phenotypes. Nonetheless, several observa-
tions suggest SipC may play a central role in inducing the actin rearrangements
that underlie bacterial-mediated endocytosis. SipC enters the host-cell membrane
at the site of initial bacterial contact and probably binds actin directly through
its cytoplasmic domain. Also, SipC is homologous to the Shigella invasion pro-
tein, IpaC. Inert beads coated with IpaC and a related Shigella invasion protein,
IpaB, stimulate membrane ruffling in cultured cells in the absence of other bac-
terial proteins (33). Overall, it seems plausible that SipA and SipC act in concert
with downstream cellular effectors of Rho GTPases to initiate and localize the
actin rearrangements associated with membrane ruffling and bacterial-mediated
endocytosis.
Additional studies have focused on identification of SPI-1 TTSS effectors
involved in inducing the intestinal secretory and inflammatory responses that
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268 OHL ¥ MILLER

accompany infection with nontyphoidal Salmonella strains. Galyov et al iden-

tified the SopB protein and went on to demonstrate its translocation by the SPI-1
TTSS (13). Mutants lacking sopB show normal invasion of epithelial cells in
vitro but induce significantly less fluid secretion and neutrophil accumulation in
a bovine ligated ileal loop model of Salmonella enteritis. Analysis of the sopB
sequence revealed two motifs homologous to eukaryotic inositol polyphosphate
4-phosphatases. This was an intriguing finding, since previous studies had shown
that Salmonella infection of epithelial cells leads to a several-fold increase in the
intracellular concentration of a specific inositol polyphosphate, D-myo-inositol
1,4,5,6 tetrakisphosphate [Ins (1,4,5,6)P4] (23). The increased concentration of
this compound ultimately leads to an increase in cellular basal chloride secretion,
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with associated fluid flux. Indeed, SopB functions as an inositol polyphosphate

4-phosphatase in vitro (34). Furthermore, a point mutation in the sopB gene that
abolishes inositol phosphatase activity in vitro produces a mutant strain that does
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not induce increased Ins (1,4,5,6)P4 levels in Hela cells. In animals, this mutant in-
duces the same intestinal secretion and inflammation as the sopB null mutant (34).
Taken together, these findings indicate that SopB promotes intestinal inflammation
and fluid secretion by subverting inositol phosphate signaling pathways.
Despite these many intriguing results, our understanding of the molecular basis
of Salmonella interactions with the epithelial cell is quite incomplete. For exam-
ple, even though the in vitro biochemical functions of SopE and SptP suggest
important roles for these proteins in invasion, Salmonella mutants lacking sopE or
sptP display only mildly decreased invasion, and many clinical isolates altogether
lack the bacteriophage that carries the sopE gene (22, 28, 35). Conceivably, some
of the effector protein functions observed in vitro may be artifacts of the high
levels of these proteins present in transfection and microinjection experiments,
and conversely, our current in vitro and animal models of infection may not be
sensitive measures of all the Salmonella virulence functions that are important
in nature. Several identified SPI-1 effector proteins lack a known function, and
it seems likely that multiple effector proteins contribute to the ability to cause
gastroenteritis.

Virulence Factors Involved in Macrophage

Survival and Systemic Infection
Salmonella serotypes that cause enteric fever must survive and replicate within
the host macrophage to establish systemic infection (36). Although residence in
the macrophage shields the bacterium from elements of humoral immunity, it
also exposes the bacterium to the nutrient-poor and microbicidal environment of
the phagosome. Antimicrobial activities of the macrophage include production
of reactive oxygen and nitrogen species, as well as the antimicrobial peptides
and hydrolytic enzymes that enrich the mature phagolysosome. Salmonellae must
sense the phagosomal environment and activate virulence mechanisms that allow
it to resist or evade these antimicrobial effectors.
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SALMONELLA PATHOGENESIS 269

Among the Salmonella genes necessary for survival in the macrophage are con-
stituents of a two-component response regulator termed PhoP/PhoQ (37). Found
in a wide variety of bacteria, two-component regulators are simple signal trans-
duction systems that often regulate bacterial gene expression in response to envi-
ronmental cues (38). In their simplest form, they consist of a membrane-spanning
sensor/kinase protein (in this case, PhoQ) that transfers a phosphate to the second,
cytoplasmic component (PhoP) in response to environmental stimuli. Following
phosphorylation, the cytoplasmic component usually serves as a transcriptional
regulator. The PhoP/PhoQ system regulates over 40 genes, inducing the expres-
sion of so-called PhoP-activated genes ( pag) and repressing expression of other
genes, termed PhoP-repressed genes ( prg) (37). PhoP-activated genes are ex-
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pressed within the macrophage phagosome, and are required for survival within
the macrophage. Conversely, PhoP-repressed genes switch off in the phagosome,
and include components of the SPI-1 TTSS (39). Both PhoP null and PhoP consti-
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tutive mutants are avirulent, which implies that proper timing of both pag and prg
gene expression is essential in the host (37, 40). Although magnesium depletion
activates pag expression in vitro, the precise signals that the PhoP/PhoQ system
senses to discern host environments in vivo remain a matter of speculation. The
PhoP/PhoQ regulon exemplifies a common theme in bacterial pathogens: Rela-
tively recently acquired virulence genes are controlled by more evolutionarily an-
cient regulators, thus exploiting the ability of these regulators to sense simple
physical and chemical cues to discriminate between host environments.
Activation of the PhoP regulon leads to widespread modifications in the protein
and lipopolysaccharide components of the bacterial inner and outer membranes.
These surface modifications promote Salmonella survival in the stressful environ-
ment of the phagosome, in part by conferring resistance to the activity of antimicro-
bial peptides (41). Antimicrobial peptides are small, amphipathic molecules that
reside at epithelial surfaces and within phagocytes. Antimicrobial peptides kill bac-
teria by disrupting the bacterial membrane (42). At least in part, PhoP-activated
genes promote resistance to antimicrobial peptides by catalyzing covalent modifi-
cations of the lipid A component of lipopolysaccharide (41). These modifications
probably discourage antimicrobial peptide insertion into the outer membrane by al-
tering membrane fluidity and surface charge density. In addition, PhoP-regulated
lipid A modifications produce a lipopolysaccharide molecule with significantly
less proinflammatory potential, as measured by induction of tumor necrosis factor
synthesis in monocytes and synthesis of E-selectin in endothelial cells (43). It is
intriguing to speculate that Salmonella may benefit from this ability to modify its
own intrinsic inflammatory potential in response to specific host environments.
More recently, several investigators have described a second Salmonella TTSS
that is necessary for survival in the macrophage and establishment of systemic
infection in the host (44–46). Located in Salmonella pathogenicity island 2, this
system activates within the phagosome and translocates bacterial effector proteins
from the phagosome into the macrophage cytosol (44–47). Although the precise
functions of the effector proteins translocated by the SPI-2 TTSS are currently
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270 OHL ¥ MILLER

unknown, they appear to interfere with maturation of the Salmonella-containing

phagosome, preventing phagosome-lysosome fusion and allowing Salmonella to
physically avoid microbicidal effectors within the macrophage (47). A recent report
shows that an intact SPI-2 TTSS prevents colocalization of Salmonella-containing
vacuoles with the NADPH-dependent oxidase that catalyzes production of reactive
oxygen species within the phagocyte. Consistent with this finding, Salmonella
mutants lacking a functional SPI-2 TTSS regain virulence in knockout mice lacking
a functional NADPH oxidase (48).
Salmonellae also express several enzymes that directly inactivate reactive
oxygen and nitrogen species produced by the macrophage. Salmonella’s resis-
tance to nitric oxide (NO) and related reactive nitrogen compounds found in the
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macrophage is mediated partly by synthesis of homocysteine, an antagonist of NO

(49). Salmonella mutants unable to synthesize homocysteine due to a mutation in
the metL gene are hypersensitive to S-nitrosothiol NO-donor compounds and are
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less virulent. In addition, salmonellae produce at least one, and in certain highly
virulent strains two, superoxide dismutases that can inactivate reactive oxygen
species (50). Inactivation of either enzyme leads to decreased macrophage sur-
vival and attenuated virulence. Production of one superoxide dismutase, SodCII,
relies on synthesis of the alternate RNA polymerase sigma factor encoded by the
rpoS gene (50). The alternate RpoS sigma factor is necessary for transcription of
multiple Salmonella genes involved in adaptation to stressful environments, such
as acid shock, nutrient starvation, and oxidative stress, and disruption of the rpoS
gene significantly attenuates virulence (51).
Adapting to the nutrient limitation encountered within the phagosome requires
induction of multiple biosynthetic genes necessary for de novo synthesis of es-
sential metabolites, including aromatic amino acids and purines. Auxotrophic mu-
tants lacking these enzymes are avirulent and may constitute effective Salmonella
vaccines (52, 53).

APPLICATION OF GENOMICS TO THE STUDY

OF BACTERIAL PATHOGENESIS
Over the past few years, the entire DNA sequences of several human pathogens
have become available, and sequences of many more pathogens, including S. ty-
phimurium and S. typhi, near completion (54). The ability to analyze and compare
the entire genetic content and organization of pathogens promises insight into
fundamental mechanisms of microbial virulence and host adaptation. Analysis of
pathogen genomes may identify potential virulence genes by sequence homology
to known virulence factors. In addition, comparison of pathogen genomes may
identify specific genes or pathogenicity islands absent in related species, or other
strains of the same pathogen. In conjunction with genome databases, new tech-
nologies such as DNA microarrays allow rapid analysis of bacterial gene expres-
sion profiles under different environmental conditions (54). For example, DNA
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SALMONELLA PATHOGENESIS 271

microarrays will permit comprehensive analysis of Salmonella gene expression

within the host cell phagosome, identifying virulence genes necessary for in-
tracellular survival. Great hope exists that genome-based strategies will rapidly
identify novel targets for vaccines and antimicrobial agents.

CONCLUSION
The long-standing availability of genetic methods in Salmonella has allowed the
identification of the majority of genes required for Salmonella virulence, and the
upcoming completion of the S. typhimurium and S. typhi genome projects promises
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to further hasten the identification of virulence genes. Despite this wealth of infor-
mation, our understanding of the intricacies of the host-pathogen interactions that
determine the outcome of Salmonella infections remains rudimentary. The current
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challenge is to unravel the function and regulation of these virulence genes in the
proper host contexts. Fundamental questions remain: What determines the host
range and specific disease syndrome associated with a given Salmonella serotype?
What are the host-cellular targets of the TTSS effectors involved in invasion, in-
duction of enteritis, and intracellular survival? What factors does Salmonella sense
to determine its location in the host, and how are these signals integrated to regu-
late virulence gene expression? Further study of these questions promises to teach
us much, not only about Salmonella but also about fundamental aspects of euka-
ryotic cell biology and host immunity. Moreover, while our current antibiotics
rather nonspecifically target basic aspects of bacterial metabolism, elucidation
of pathogen-specific virulence mechanisms may allow design of more specific,
pathogen-directed antimicrobial therapies. Such new agents may induce less dis-
ruption of normal flora and selection for drug resistance. In this era of emerging
antibiotic resistance, the development of such agents is increasingly important.

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 Annual Review of Medicine
Volume 52, 2001

CONTENTS
REGULATION OF LEUKOTRIENES IN THE MANAGEMENT OF
ASTHMA: Biology and Clinical Therapy, Alan R. Leff 1
PATHOPHYSIOLOGICAL ROLE OF CYTOKINES IN CONGESTIVE
HEART FAILURE, Arnon Blum, Hylton Miller 15
CURRENT TREATMENT STRATEGIES FOR CHRONIC HEPATITIS
B AND C, Otto S. Lin, Emmet B. Keeffe 29
HEALTH CARE WORKFORCE FOR THE TWENTY-FIRST
CENTURY: The Impact of Nonphysician Clinicians, Richard A. Cooper
51
ADVANCES IN THE TREATMENT OF LUPUS NEPHRITIS, Robert
Zimmerman, Jai Radhakrishnan, Anthony Valeri, Gerald Appel 63
BIOMEDICAL ETHICS AND THE WITHDRAWAL OF ADVANCED
Annu. Rev. Med. 2001.52:259-274. Downloaded from www.annualreviews.org

LIFE SUPPORT, Noreen R. Henig, John L. Faul, Thomas A. Raffin

79
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MOLECULAR GENETICS AND PATHOGENESIS OF AUTOSOMAL

DOMINANT POLYCYSTIC KIDNEY DISEASE, M. Amin Arnaout
93
ANTIBODY-TARGETED IMMUNOTHERAPY FOR TREATMENT
OF MALIGNANCY, Christine A. White, Robin L. Weaver, Antonio J.
Grillo-López 125
LIVER TRANSPLANTS FROM LIVING RELATED DONORS,
Benjamin Samstein, Jean Emond 147
NOVEL PLATELET INHIBITORS, Joel S. Bennett 161
LUNG TRANSPLANTATION AT THE TURN OF THE CENTURY,
Dawn L. DeMeo, Leo C. Ginns 185
PREVENTION OF UREMIC BONE DISEASE USING
CALCIMIMETIC COMPOUNDS, Klaus Olgaard, Ewa Lewin 203
ACUTE RESPIRATORY DISTRESS SYNDROME: Physiology and
New Management Strategies, Ann B. Weinacker, Laszlo T. Vaszar 221
NEW ORAL THERAPIES FOR TYPE 2 DIABETES MELLITUS: The
Glitazones or Insulin Sensitizers, Sunder Mudaliar, Robert R. Henry 239
SALMONELLA: A Model for Bacterial Pathogenesis, Michael E. Ohl,
Samuel I. Miller 259
RISK-ADJUSTED SURGICAL OUTCOMES, Jennifer Daley, William
G. Henderson, Shukri F. Khuri 275
THE ROLE OF INFLAMMATION AND INFECTION IN CORONARY
ARTERY DISEASE, Anton E. Becker, Onno J. de Boer, Allard C. van
der Wal 289
EVOLVING TREATMENT STRATEGIES FOR INFLAMMATORY
BOWEL DISEASE, Stephen B. Hanauer, Themistocles Dassopoulos
299
IRRITABLE BOWEL SYNDROME, Yehuda Ringel, Ami D. Sperber,
Douglas A. Drossman 319
EFFECTS OF NEUROPEPTIDES AND LEPTIN ON NUTRIENT
PARTITIONING: Dysregulations in Obesity, Bernard Jeanrenaud,
Françoise Rohner-Jeanrenaud 339
MIXED CHIMERISM AND TRANSPLANTATION TOLERANCE,
Thomas Wekerle, Megan Sykes 353
GENETIC TESTING FOR CANCER PREDISPOSITION, Charis Eng,
Heather Hampel, Albert de la Chapelle 371
 CURRENT CONCEPTS IN THE POLYCYSTIC OVARY
SYNDROME, Andrea Dunaif, Abraham Thomas, 401
RENAL ARTERY STENOSIS: A Common, Treatable Cause of Renal
Failure, Stephen C. Textor, Christopher S. Wilcox 421
TISSUE ENGINEERING: Current State and Prospects, Ulrich A. Stock,
Joseph P. Vacanti 443
KAPOSI''S SARCOMA-ASSOCIATED HERPESVIRUS: A New DNA
Tumor Virus, C. Boshoff, Y. Chang 453
HEREDITARY DISTAL RENAL TUBULAR ACIDOSIS: New
Understandings, Daniel Batlle, Hrishikesh Ghanekar, Sheeja Jain, Amit
Mitra 471
GENE TRANSFER FOR ANGIOGENESIS IN CORONARY ARTERY
DISEASE, Roger J. Laham, Michael Simons, Frank Sellke 485
ATYPICAL ANTIPSYCHOTICS: New Directions and New Challenges
in the Treatment of Schizophrenia, Shitij Kapur, Gary Remington
503
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