cell biology 5 Flashcards
(116 cards)
Epidemiology of cholera
Cholera is an acute intestinal infection caused by toxigenic Vibrio cholerae . The main areas of the world in which cholera is present are Africa, Asia and parts of the Middle East. There are more than 100 types of cholera. However, there are only two types of cholera that affect humans: Vibrio cholerae O1 and Vibrio cholerae O139. We are currently in the 7th Cholera Pandemic, caused by the El Tor biotype of V. cholerae O1. It was first identified in 1905 at a quarantine camp on the Siniai Peninsula in El-Tor, Egypt from a group of pilgrims returning from Mecca. El Tor reappeared in an outbreak in Indonesia in 1937, but the pandemic did not arise until the 1960’s when El Tor spread through Bangladesh and India. It then arose in parts of Africa and Italy in the 1970’s. Spreading through parts of Europe in the 1980’s, it then affected 21 countries in Latin America in the 1990’s. It is responsible now for over 1 million cases worldwide. In 1992, a second serotype was discovered in Bangladesh, designated O139 (“Bengal”), and is now endemic in the region. The strain currently in Haiti since 2010 is the O1 Ogawa serotype.
Vibrio cholerae O1
there are two subtypes (Classical and El Tor). There are 3 serotypes of O1: Inaba, Ogawa and Hikojima.
Vibrio cholerae O139
first described in Bangladesh in 1992, now considered endemic in the region.
Global trend (taken from WHO) for cholera
Globally for 2013, there was an estimated 1.4 to 4.3 million cases accounting for 28,000 to 142,000 deaths. The true number is not known due to limitations in surveillance systems and lack of diagnostic capacities in some areas, leading to both over- and under-reporting. “In 2013, 43% of cases were reported from Africa whereas between 2001–2009, 93% to 98% of total cases worldwide were reported from that continent. This proportion changed in 2010 with the outbreak in the island of Hispaniola. A higher proportion of cases started to be reported from Haiti and the Dominican Republic. Globally, cases reported from Africa have also decreased since 2012. However many people still die of the disease notably in Sub-Saharan Africa, Asia and in Hispaniola, clearly showing that cholera remains a significant public health problem.”
Cholera Symptoms
Voluminous (up 1 liter per hour) watery feces with bits of mucus - this is sometimes called ‘rice water’ stools since it looks like water in which rice has been washed, Vomiting, Severe and rapid dehydration. An infected individual could die within hours if left untreated from dehydration. If you lived in a developing country before the 1970’s and were infected with cholera, you had a 30-50% chance of dying. Due to oral rehydration therapy (ORT), the mortality is reduced to about 1%.
Pathophysiology of cholera
Vibrio cholerae is spread by the fecal-oral route. Therefore, it is most commonly spread contaminated food or water. Good sanitation is crucial to control cholera transmission.. The infectious dose of V. cholera is stated to be 108 cfu. The required dose is lower in the presence of reduced gastric acidity. On the other hand as few as 100,000 rods for Salmonella subspecies and 10 bacilli for Shigella subspecies are required for infection. Therefore, you need a good dose of contaminated food to be infected. Vibrio cholerae is a noninvasive species. The mechanism of diarrhea is through a “virulence cassette” composed of 3 genes encoding for the 3 toxins that result in diarrhea: ctx (cholera toxin), zot (zonulin occludens toxin), and ace (accessory cholera enterotoxin).
ctx (cholera toxin)
The primary mechanism of disease is through the actions of cholera toxin (Ctx). Ctx consists of an A subunit and B subunit. The A subunit is the active site while the B subunit is the transport molecule. Intestinal crypt cells, the primary secretory cells found in the small intestinal mucosa, respond to numerous secretagogues including acetylcholine, prostaglandins, and vasoactive intestinal peptide. The second messengers Ca2+ and cAMP lead to chloride secretion through the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR), located on the apical (luminal) side of the cells. Ctx binds to the GM1 ganglioside receptor on surface of the enterocyte via the B subunit. At the cell surface, the A subunit is then cleaved off and endocytosed. It subsequently binds to G protein intracellularly, and then stimulates adenylate cyclase to produce cAMP. cAMP leads to the continuous activation of CFTR, resulting in a massive efflux of chloride ions, followed by water, resulting in massive watery diarrhea high in electrolyte content.
zot (zonulin occludens toxin)
Zonulin occludens toxin (Zot) is located on the bacterial membrane and binds to a Zot receptor, resulting in an alteration of intestinal permeability through a cascade of intracellular events that lead to subsequent tight junction disassembly. It is believed to mimic Zonulin, the naturally occurring endogenous modulator of tight junctions. This results in lossening the tight junctions and an increased efflux of salt and water in the gut.
ace (accessory cholera enterotoxin)
Accessory cholera enterotoxin (Ace) affects the potential differences across cells, contributing to the diarrhea, but the precise mechanism is still unknown.
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
CFTR functions as an ATP-gated anion channel, increasing the conductance for certain anions (e.g. Cl–) to flow down their electrochemical gradient. ATP-driven conformational changes in CFTR open and close a gate to allow transmembrane flow of anions down their electrochemical gradient. This in contrast to other ABC proteins, in which ATP-driven conformational changes fuel uphill substrate transport across cellular membranes. Essentially, CFTR is an ion channel that evolved as a ‘broken’ ABC transporter that leaks when in open conformation. The CFTR is found in the epithelial cells of many organs including the lung, liver, pancreas, digestive tract, reproductive tract, and skin. Normally, the protein moves chloride and thiocyanate[17] ions (with a negative charge) out of an epithelial cell to the covering mucus. Positively charged sodium ions follow passively, increasing the total electrolyte concentration in the mucus, resulting in the movement of water out of cell by osmosis.
Osmotic Diarrhea
Osmotic diarrhea is diarrhea driven by an osmotically active agent in the intestinal lumen which pulls water into the intestine. Lactose intolerance is one example where malabsorbed lactose causes water to be drawn into the colon leading to diarrhea. An osmotic diarrhea can also occur in the setting of malabsorptive conditions such as from celiac disease or following a particularly severe case of gastroenteritis, where malabsorbed carbohydrates can lead to an osmotic diarrhea. Medications such as polyethylene glycol (used to treat constipation) which is not absorbed, can result in more watery stools. This type of diarrhea will improve when you remove the osmotic source.
Secretory Diarrhea
If a patient has a secretory diarrhea, the watery stools will continue even they are fasting. This is because the intestine is actively secreting fluids and electrolytes into the lumen. Cholera is the prototypic secretory diarrhea. In the small intestines, you have villi (the long fingerlike projections in the musocsa) that serve to increase the absorptive capacity of the intestine, and you have crypts (located at the base of each villi) that serve to secrete fluids and electrolytes. In normal conditions, the villi outperform the crypts, so that you have a net fluid and electrolyte absorption. In the case of cholera, the crypts secrete so much that it overwhelms the absorptive capacity of the villi, even though there is no histological injury to the intestinal epithelium. Therefore, the fluid lost from a secretory diarrhea can have an electrolyte content that is close to that found in your serum!
How is cholera treated?
The treatment for cholera is rehydration, focusing on both volume repletion and replacing ongoing fluid losses. Antibiotics are not generally indicated in mild-moderate cases of cholera, but can be used to treat severely affected individuals. Antibiotics will shorten the duration of disease and reduce the risk of further infectivity by killing the organisms. Anti-diarrheal medications are not indicated for cholera, as while it may slow down intestinal motility, it will not affect the secretory component of the diarrhea (in fact, it may make you feel worse!). In the United States, it is convenient to deliver fluids intravenously. However, in regions where IV fluids are inaccessible, oral rehydration therapy (ORT) is cheap and easily accessible, either in the form of a package or homemade. More importantly, it is lifesaving. The fundamental principle of oral rehydration solutions is to take advantage of the sodium transporters in the apical surface of the intestinal epithelial cell. This is done by coupling glucose or starch with sodium in the intestinal lumen, to promote sodium absorption and hence chloride and water flow away from the lumen. Not only can oral rehydration replace lost fluids in an individual, it even has the potential to actually reduce the volume of diarrhea. For more than 25 years, UNICEF and WHO had recommended a single formulation of glucose-based ORS to prevent or treat dehydration from diarrhea. This product, which provides a solution containing 90 mEq/l of sodium with a total osmolarity of 311 mOsm/l, had proven to be effective. However, concerns about its use in non-cholera causes of diarrhea (although it has been shown to also be effective in rotavirus-induced diarrhea) and also about the high osmolarity (possibility of driving an osmotic-induced diarrhea) resulted in a new improved formulation. Therefore, in 2003, a “reduced osmolarity” formulation had been developed, with lower glucose and sodium concentrations. While there are some concerns about biochemical hyponatremia in individuals receiving the reduced osmolarity formula, it has not been associated with serious consequences and appears to be better tolerated by patients. There is now an additional recommendation of zinc supplementation for the management of diarrheal disease in addition to ORT, particularly for pediatric patients. There has been considerable debate over whether or not ORT should be given in prepackaged formulations or homemade. Even though the majority of mothers in developing countries affected by cholera are aware of ORT, only fewer than half will make the solution correctly. This could potentially lead to hypernatremia or continued dehydration. On the other hand, it is cheaper and more easily accessible than having to go to a local clinic to obtain prepackaged formulations, and it promotes self-sufficiency. More recently, rice-based ORT has been promoted as being able to even reduce the severity of diarrhea. From a homemade perspective, this has been made by essentially substituting glucose with rice cereal. Naturally, such a product has now been commercialized and produced as “Ceralyte.” Ceralyte-90 is designed for secretory diarrhea, and Ceralyte-70 and -50 have less sodium, and are intended for “less severe” forms of diarrhea. Nevertheless, there have been numerous studies suggesting that this rice-based ORT is actually superior to standard ORS for cholera (but not necessarily so for regular diarrhea). Rice-based and other cereal-based oral rehydration solutions are thought to reduce diarrhea by adding more substrate to the gut lumen without increasing osmolality, thus providing additional glucose molecules for glucose-mediated absorption. In addition, the amino acids in the solutions may also provide additional substrate for other cotransport mechanisms within the colon.
Mechanisms of fluid absorption by ORT
Remember, cholera results in the massive efflux of chloride out of the cell via the CFTR, in the form of salt, and is accompanied by water (it causes a secretory diarrhea). As you have likely already learned from Professor Betz’s lectures, there are several transporters that can bring sodium into a cell (and chloride will follow) from the apical side. These all rely on the sodium/potassium pump on the basolateral membrane, to create a sodium gradient favoring sodium entry into the cell. However, some will result in a net movement of a charge across the membrane (electrogenic transport) and some will not (electroneutral transport). Studies in animals and humans demonstrated that the maximum uptake of water and electrolytes occurs when the ratio of carbohydrate to sodium approaches one, and the WHO recommends a ratio of < 1.4 to 1. The WHO formulas take advantage of the sodium cotransporters on the apical side of the enterocyte, which are not affected during a cholera infection. These are in the form of sodium-glucose transporters, or sodium coupled with other substrates such as amino acids, which help in sodium reabsorption. Again, when sodium reenters a cell, chloride and water will then follow. The key to successful ORT is to start early and offer the solution continuously (small frequent sips if vomiting) in a patient with cholera. Likewise, as the patient is being rehydrated, early feeding is recommended.
Necrosis
premature death of cells. In necrosis, the organelle that suffers first seems to be the mitochondrion, which early on begins to swell. At the stage called “high-amplitude swelling” it can no longer maintain its ionic gradients or oxidative phosphorylation, and the cell runs out of energy. Starving for ATP, the plasma membrane’s ion pumps fail, water floods in, and the cell swells and bursts. Lysis releases the cell’s intracellular contents into the extracellular milieu, where they have no business being; these internal lipids, proteases, and small molecules are intensely proinflammatory. They attract white cells, primarily macrophages, from around the body. Given the extent of damage, this is usually desirable, as the local facilities for dealing with damage can be overwhelmed. The effect of the inflammatory process is debris removal, injury resolution, and, if the stroma has been damaged, scar formation.
COMMON FEATURES OF APOPTOSIS
The defining morphological feature of apoptosis is a collapse of the nucleus; chromatin, which is normally composed of mixed open and condensed regions (heterochromatin and euchromatin), becomes supercondensed, appearing as crescents around the nuclear envelope and, eventually, spherical featureless beads. The structural correlate of this morphological change is the fragmentation of DNA into units of one or several nucleosomes in length. (A nucleosome consists of a core of histone proteins wrapped by about 180 base pairs of DNA, and is the first stage of compaction of DNA.) This degradation reflects the action of an endonuclease on the DNA in the linkers between nucleosomes; this stretch of DNA is not very well protected by histones. Because a cell can only repair a few simultaneous double-stranded breaks in its DNA, the extensive DNA damage in apoptosis (up to 300,000 breaks/chromosome!) means that even if there were no other changes, the cell would certainly never divide again.
Early in apoptosis cells
shrink remarkably, losing about a third of their volume in a few seconds. This shrinkage is quite apparent in cell culture, and also in vivo, where apoptotic cells in tissue sections often pull away from their neighbors. As might be expected there are cytoskeletal changes that accompany shrinkage, and the result is a peculiar, vigorous “boiling” action of the plasma membrane, which has been called zeiosis.
zeiosis
a bleb is a protrusion, or bulge, of the plasma membrane of a cell, caused by localized decoupling of the cytoskeleton from the plasma membrane. During apoptosis (programmed cell death), the cell’s cytoskeleton breaks up and causes the membrane to bulge outward. These bulges may separate from the cell, taking a portion of cytoplasm with them, to become known as apoptotic bodies. Phagocytic cells eventually consume these fragments and the components are recycled.
apoptotic bodies
small sealed membrane vesicles that are produced from cells undergoing cell death by apoptosis. The formation of apoptotic bodies is a mechanism preventing leakage of potentially toxic or immunogenic cellular contents of dying cells and prevents inflammation or autoimmune reactions as well as tissue destruction. the apoptotic cell usually tears itself apart from other cells with zeiosis into apoptotic bodies, some of which contain chromatin. It is not known how, or even if, these changes lead to cell death. This is because early in apoptosis, while the cell is still fully “viable,” that is, still able to exclude vital dyes like trypan blue, it is recognized by another cell and phagocytosed; it dies within the phagocyte. So the goal of all the morphological changes is to ensure that the apoptotic cell gets taken up by a healthy cell, before it has had a chance to spill its dangerous contents.
PHAGOCYTOSIS OF APOPTOTIC CELLS
Apoptosis is also accompanied by changes in the plasma membrane, the most obvious of which involves the phospholipid phosphatidylserine (PS). All the PS in a normal plasma membrane is confined to the inner leaflet of the lipid bilayer; in fact, an enzyme (called “flippase”) ensures that any PS molecule that strays to the outer leaflet is quickly returned. Soon after apoptosis begins, the distribution of PS becomes equal on both sides of the membrane, by a “scrambling” mechanism involving “scramblase.” This means that PS is now exposed on the cell’s exterior surface. Phagocytic cells have receptors for PS, and recognize, bind to, and ingest cells that have committed to the apoptotic pathway, consuming them while they are still alive. In this way the apoptotic cell never has a chance to lyse and release inflammation-causing molecules to the extracellular space. Furthermore, a macrophage that recognizes a cell as apoptotic does not become activated. So the removal of apoptotic cells is physiological and silent, as would be appropriate for an event that occurs constantly in the normal human body. The correct removal of apoptotic cells is so vital that there are multiple mechanisms for their recognition, in addition to the PS system. The apoptotic cell dies inside the macrophage, before the membrane is permeable, preventing any inflammation.
morphogenetic death
A very important phenomenon during development that determines the final shape of body parts and organs. In limbs, the death by apoptosis of cells between the digits gives the final form to fingers and toes. In the nervous system, many more cells develop than the organism needs; those that form the correct contacts at the correct time are bathed in survival factors by the target they have innervated; if not, they are dispensable. Indeed, even the formation of as precise a structure as the brain depends on a Darwinian-style selection of cells that have chanced to make the best connections. Other local conditions could determine cell survival. For example, it has been shown very recently that cell shape, as influenced by the local tissue geometry, affects whether a cell will live or die.
Immune system and apoptosis
Apoptosis is very important in the immune system. In the thymus of the young rodent (and, we have pretty good evidence, human), 95-99% of the lymphocytes that develop there fail to be selected to mature as useful T cells, and die by apoptosis; the entire organ is replaced every 3 days. Clearly the process of generating effective, safe T cells is so exacting that most cells don’t make the cut.
cancer and apoptosis
it is thought that mutations that lead to cell growth are common, but tumors are rare. Perhaps as a small abnormal clone develops, it reaches a point where it exceeds the capacity of the microenvironment to provide growth and survival support, and involutes by apoptosis. But if, just before this critical period a second mutation or adaptation takes place, such that the cells are now more resistant to apoptosis, the clone may survive. There will be subsequent crises, and a new adaptation will be required each time; many experts estimate that it takes about 7 mutations for a cell to become fully, clinically, malignant. But this simple model stresses a key point: for cancer progression, mutations that inhibit death may be just as important as those that stimulate growth.
Bcl-2
Damage to the Bcl-2 gene has been identified as a cause of a number of cancers. Bcl-2 is specifically considered as an important anti-apoptotic protein and is thus classified as an oncogene.