• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of amjpatholAmerican Journal of Pathology For AuthorsAmerican Journal of Pathology SubscribeAmerican Journal of Pathology SearchAmerican Journal of Pathology Current IssueAmerican Journal of Pathology About the JournalAmerican Journal of Pathology
Am J Pathol. Aug 2006; 169(2): 433–444.
PMCID: PMC1698797

Sepsis and Pathophysiology of Anthrax in a Nonhuman Primate Model

Abstract

Studies that define natural responses to bacterial sepsis assumed new relevance after the lethal bioterrorist attacks with Bacillus anthracis (anthrax), a spore-forming, toxigenic gram-positive bacillus. Considerable effort has focused on identifying adjunctive therapeutics and vaccines to prevent future deaths, but translation of promising compounds into the clinical setting necessitates an animal model that recapitulates responses observed in humans. Here we describe a nonhuman primate (Papio c. cynocephalus) model of B. anthracis infection using infusion of toxigenic B. anthracis Sterne 34F2 bacteria (5 × 105 to 6.5 × 109 CFU/kg). Similar to that seen in human patients, we observed changes in vascular permeability, disseminated intravascular coagulation, and systemic inflammation. The lung was a primary target organ with serosanguinous pleural effusions, intra-alveolar edema, and hemorrhagic lesions. This animal model reveals that a fatal outcome is dominated by the host septic response, thereby providing important insights into approaches for treatment and prevention of anthrax in humans.

Bacillus anthracis, a zoonotic toxigenic gram-positive, spore-forming rod, is the cause of clinical anthrax disease. There has been a significant resurgence in biomedical anthrax-related research because of the bioterrorism attacks in the United States.1–6 As a result, the genomic sequence of B. anthracis has been completed,7 exotoxin crystal structures solved,8,9 and cellular toxin receptors identified.10,11 The virulence of B. anthracis bacilli is primarily governed by products of two large plasmids that code for secreted exotoxins and an exterior capsule.12,13 The capsule, composed of poly-γ-d-glutamic acid, has anti-phagocytic properties and contributes to bacterial dissemination.14 Under the control of the atxA gene product,15 the bacteria produce exotoxin components: protective antigen (PA) serves as a conduit for translocation of lethal factor (metalloprotease) and edema factor (adenylate cyclase) into the cell for toxicity and injury.16

However, the pathophysiology of anthrax as a septic disease is less well defined. Sepsis is defined as a host systemic inflammatory response to infection and is complicated in severe sepsis with organ dysfunction, hypoperfusion, and coagulation abnormalities.17 Clinical and pathology data from the victims of anthrax bioterrorism,1,18 as well as a 1979 inadvertent release of military-grade anthrax spores in Russia,19,20 show evidence of concomitant pulmonary edema, inflammation, and disseminated intravascular coagulation (DIC). To mimic anthrax, considerable work in animal models, including rhesus monkeys and chimpanzees, has been done using administration of spores by various routes, including aerosol.21–24 These studies investigated important spore dose-response relationships and subsequent pathology observations were consistent with a general consensus that B. anthracis introduced by the respiratory route results in a fulminating septicemia rather than a primary pulmonary infection.22 However, a consistent picture of pathophysiology progression is difficult to ascertain from these inhalational models. There is significant individual variation in gross and microscopic pathology of rhesus monkeys after challenge,24 probably attributable to dose-response issues because it is difficult to know how many of the inhaled spores actually result in infection. Although organ hemorrhage, edema, and inflammatory infiltrates were noted in some animals, a systematic analysis of inflammatory or coagulation biomarkers was not available. These observations are further compounded by the current paradigm, based on toxic murine models, which describes anthrax pathogenesis as being governed by exotoxin bioactivities and host inflammatory or coagulopathic responses as playing little role.25–27 These disparities gain importance when extrapolating experimental data to patients because vaccine development and clinical management decisions are based on an understanding of disease pathogenesis.

The current study addresses whether the pathogenesis of the bacteremic phase of anthrax is governed by predominately noninflammatory pathways as suggested by toxic murine models or is represented by uncompensated inflammation and coagulation responses to the infection. We have adapted our nonhuman primate model of E. coli sepsis that has been extensively characterized28,29 and has served as the basis30 for clinical studies that culminated in Food and Drug Administration approval of an adjunct therapy for patients with severe sepsis.31 We chose infection by infusion of bacteria for reproducible dosing, because with a high B. anthracis spore infection dose, the onset of bacteremia is rapid, with dissemination within 24 ~ 48 hours,14,32 and overwhelming.23 This approach mimics the bacteremia stage during which patients become sick and seek medical attention. Unencapsulated B. anthracis 34F2 Sterne strain was used because this strain produces toxin in quantities similar to the natural fully virulent strains.33 The results illustrate the physiological, hemostatic, cellular, and inflammatory responses to anthrax, as well as distinctive lung pathology that may be a unique feature of anthrax.

Materials and Methods

Animals

Infusion methods were essentially identical to those used for E. coli34 and Shiga toxin 1.35Papio c. cynocephalus or Papio c. anubis baboons were purchased from the breeding colony maintained at the University of Oklahoma Health Sciences Center (Dr. Gary White, Director). Baboons were free of tuberculosis, weighed 6 to 8 kg, had leukocyte concentrations of 5000/mm3 to 14,000/mm3, and hematocrits exceeding 36%. T0-hour blood samples were drawn from the cephalic vein catheter followed by bacteria infusion for 2 hours. Levofloxacin infusion (7 mg/kg) was initiated at T4 hours and repeated daily. Infusion studies were performed at the University of Oklahoma Health Sciences Center. All experiments were approved by the Institutional Animal Care and Use Committee and the Institutional Biosafety Committee of the Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center.

Bacteria

Vegetative bacteria germinated from Bacillus anthracis 34F2 Sterne strain spores (Colorado Serum Co., Boulder, CO) were washed and resuspended in sterile saline for infusion. Live bacteria were quantitated using the Bac-Titer-Glo microbial cell viability assay (Promega, Madison, WI). In preliminary studies, a standard curve of viable bacteria (BacTiter-Glo) versus viable bacteria obtained by traditional plating methods (CFU/ml) was established. This relationship was very reproducible (r = 0.99; n = 3), permitting use of the luminescence assay for determining viable bacteria counts, rather than counting colonies on plates, which can be difficult with B. anthracis because of chaining. CFU/kg dosage was calculated by reference to this standard curve.

Infusion Procedures

Briefly, the baboons were fasted for 24 hours before the study, with free access to water. They were immobilized the morning of the experiment with ketamine (14 mg/kg, i.m.) and sodium pentobarbital administered through a percutaneous catheter in the cephalic vein of the forearm to maintain a light level of surgical anesthesia (2 mg/kg, approximately every 20 to 40 minutes). This catheter was also used to infuse the B. anthracis bacteria and sterile saline to replace insensible loss. An additional percutaneous catheter was inserted into the saphenous vein in one hind limb and the catheter advanced to the inferior vena cava; this catheter was used for sampling blood. Baboons were orally intubated and positioned on their left side on a heat pad. Our typical infusion protocol involved blood draw at T0, followed immediately by bacteria infusion at the appropriate concentration for 2 hours, typically at 0.2 ml/minute.

Monitoring and Sampling Procedures

Blood samples were taken at various time points for assay purposes and to confirm bacteremia. Except for samples taken for colony counts, blood samples were collected into 1/100 vol of 5000 U/ml penicillin and 500 μg/ml streptomycin to kill circulating vegetative bacteria. Bacteremia was confirmed by traditional plating methods using blood obtained at T+2 hours just after finishing the infusion and T+4 hours before antibiotics. Colony counts varied according to the loading dose. For a 108 CFU/kg challenge, colony counts were near 104 CFU/ml at T+2 hours and 200 CFU/ml at T+4 hours. Colony counts on blood sampled between days 2 to 7 were consistently negative. Blood pressure and rectal temperature were measured with a Critikon monitor (Critikon, Inc., Tampa, FL) and a YSI thermometer (Yellow Springs Instrument Co., Yellow Springs, OH), respectively.

Metabolic and Cytokine Assays

Complete blood counts and hematocrits were determined and blood smears were done for differential counts. Routine blood chemistries, fibrinogen, fibrin degradation products (FDP), and activated partial thromboplastin times (APTT) were determined.34,36,37 Fibrin degradation products and APTT assays were run on-line during the experiments. Plasma interleukin (IL)-1β levels were determined by enzyme-linked immunosorbent assay (ELISA) using the hIL-1Beta/IL-1F2 DuoSet kit (R&D Systems, Minneapolis, MN). Plasma IL-6 levels were determined by ELISA.36 D-dimer levels were determined by ELISA (Diagnostica Stago, Asnières, France). Other cytokines were quantitated by flow cytometry-based Multiplex assay (Dr. J. Connolly, Ph.D., Baylor Institute for Immunology Research, Dallas, TX).

Tumor Necrosis Factor (TNF)-α ELISA

Microtiter plates were coated with 50 μl of 1 μg/ml of goat anti-human TNF-α (anti-hTNF-α/TNFSF1A, R&D Systems), washed, and blocked. Plasma samples were diluted at least 1:50 and incubated in the wells for 2 hours at room temperature. Wells were washed, and bound antigen was detected with 0.2 μg/ml of biotinylated goat anti-human TNF-α (R&D Systems) followed by streptavidin-horseradish peroxidase and TMB substrate (1 Step Ultra TMB; Pierce, Rockford, IL). The reaction was stopped with 2 mol/L H2SO4 and OD450nm was determined. Linear standard curves were prepared using recombinant human TNF-α (R&D Systems); the assay was sensitive to 15 pg/ml TNF-α.

Protein C ELISA

Wells of 96-well microtiter plates were coated with 50 μl of 10 μg/ml goat anti-human protein C polyclonal antibody as a capture antibody, and an anti-human protein C HPC4 murine monoclonal antibody conjugated with biotin (EX-Link Sulfo-NHS-LC-biotin, final 4 μg/ml; Pierce) was the detection antibody. Antibodies were obtained from Dr. Charles Esmon (Cardiovascular Biology Research, Oklahoma Medical Research Foundation). Wells were coated overnight, washed, and blocked, and samples (50 μl of 1:2000) were incubated at 37°C for 1 hour. Wells were washed, incubated with detection antibody (4 μg/ml, 1.5 hours, room temperature) followed by streptavidin-horseradish peroxidase (1:8000, 1 hour, AMDEX streptavidin-horseradish peroxidase; Amersham Pharmacia Biotech, Arlington Heights, IL). Color was developed with TMB substrate. The reaction was stopped with 2 mol/L H2SO4 and the OD450nm was determined. Standard curves were made from dilution of normal human plasma or baboon pooled plasma and results expressed as percentage of normal for that species. The human and baboon standard curves were parallel and linear (data not shown). Baboons have slightly lower protein C levels compared to humans; the protein C antigen in a normal baboon plasma pool (from five animals) was 66.5 ± 1.2% of the human protein C level.

PA ELISA

Anthrax PA was quantitated by standard ELISA methods using goat anti-PA as coating antibody (1 μg/ml), biotinylated-goat anti-PA as detection antibody (1 μg/ml), and purified recombinant PA as standards (0 to 25 ng/ml; List Biologicals, Campbell, CA). Bound antigen from plasma (1:50) was detected with streptavidin-horseradish peroxidase and TMB substrate (450 nm). The assay was sensitive to 3 ng/ml PA antigen.

Terminal dUTP Nick-End Labeling (TUNEL) Assay

Apoptotic cells were visualized using an in situ fluorescence TUNEL assay (Roche, Indianapolis, IN), according to the manufacturer’s instructions.

Histopathology

At necropsy, the gross appearance of the major organs was examined, and specimens were collected within 1 hour of death. Tissues were fixed in 10% neutral buffered formalin for at least 24 hours, processed by standard methods, and embedded in paraffin. Sections were stained with hematoxylin and eosin (H&E) or phosphotungstic acid (PTAH) for routine histopathology. Congestion, white cell influx, hemorrhage, thrombosis, and necrosis on blinded samples were quantified by Dr. Stanley Kosanke (Department of Pathology, School of Medicine, University of Oklahoma Health Sciences Center) as described.38 Tissues were rated according to the severity of the histopathological lesions. The scale ranged from 0 to + 4, with 4 being the most severe.

Immunohistochemistry

Tissues were processed as described.39 Tissues from saline-treated control animals37 were treated identically to those obtained in the current anthrax study. Tissues were fixed (4% paraformaldehyde), cryoprotected (5% sucrose, mounted in Tissue-Tek OCT compound), and snap-frozen in liquid nitrogen-cooled isopentane. Tissue cryosections were treated with 0.1 mol/L glycine in phosphate-buffered saline (PBS) for 15 minutes to block free aldehyde groups and with 3% bovine serum albumin and 5% normal goat serum in PBS plus 0.1% saponin, for 30 minutes at room temperature to block nonspecific binding sites. For double-immunofluorescence labeling, specimens were incubated with mixtures of monoclonal (mAb; 10 μg/ml) and polyclonal antibodies (20 μg/ml) for 1 hour at 20°C or overnight at 4°C. The following antibodies were used: anti-tissue factor mAb, (clone TF9-10H10; gift from Dr. James H. Morrissey, Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, IL), anti-nitrotyrosine mAb (LabVision Corp., Fremont, CA), anti-CD68 mAb (DAKO, Carpinteria, CA), rabbit polyclonal IgGs against human tissue factor pathway inhibitor (TFPI), and human inducible nitric oxide synthetase (iNOS; NeoMarkers Inc., Fremont, CA). The sections were washed 3 × 10 minutes in PBS/saponin and incubated for 1 hour at 20°C with combinations of appropriate detection antibodies conjugated with fluorescein isothiocyanate or Cy3 (Jackson ImmunoResearch Laboratories, West Grove, PA) diluted 1:100 in 1% bovine serum albumin in the same buffer. After washing as above, segments were mounted in Vectashield (Vector Laboratories, Burlingame, CA) containing TO-PRO-3 iodine (Molecular Probes, Eugene, OR) as a nuclear counterstain.

As negative controls for polyclonal antibody staining, primary antibodies were replaced with equivalent amounts of rabbit nonimmune serum. The anti-nitrotyrosine antibody specificity was confirmed by control experiments showing loss of antibody recognition after competition with excess (10 mmol/L) 3-nitrotyrosine (not shown). Anti-digoxigenin mAb, a hapten antigen that occurs only in plants, was used as negative control for mAb staining.

Specimens were examined using a Nikon C1 confocal laser-scanning unit equipped with a three-laser launcher (488, 543, and 633 nm emission lines) installed on an Eclipse TE200-U inverted microscope (Nikon, Melville, NY). Images were taken with either a ×20 plan achromat objective (NA 0.46) or a ×60 apochromat oil immersion objective (NA 1.4).

Statistical Analyses

Data were analyzed for differences between dosage groups using the Student’s t-test, assuming equal variance. APTT, d-dimer, elastase, and cyto/chemokine data were transformed to natural log before analysis to account for unequal variances. A P value <0.05 was considered to be significantly different.

Results

In all animals, except those that received the lowest doses, we observed coagulopathy, increased vascular permeability, and inflammation, in which the severity of the response was commensurate with the extent of the bacterial challenge. Eleven animals were studied; data are grouped according to the log10 bacterial load.

Mortality

Survival times after challenge with B. anthracis Sterne strain were dose-dependent (Figure 1). A 7-day survivor was considered to be a permanent survivor. Infusion of 5 × 105 and 5 × 107 CFU/kg was sublethal, and the upper limit of a sublethal dose was near 6 × 107 CFU/kg. Bacterial exotoxin production was confirmed by increases in PA (Figure 2), which is required for cellular intoxication.40 PA antigen decreased to baseline after antibiotic treatment began.

Figure 1-6932
Mortality. Animals were infused with B. anthracis Sterne bacteria in doses ranging from 5 × 105 CFU/kg to 6.5 × 109 CFU/kg. All animals except two (*1.6 × 109 and *3.8 × 109 CFU/kg) received antibiotic treatment ...
Figure 2-6932
Toxemia. Plasma levels of anthrax toxin PA were determined by ELISA after infusion of bacteria. Challenge dose in CFU/kg: 105 to 106 ([down-pointing small open triangle], n = 2); 107 (□, n = 3); 108 (•, n = 3); and 109 ([filled triangle], n = ...

Lung Pathology

Pathological changes in the lungs after ≥107 CFU/kg were consistent with acute lung injury. Macroscopic findings (Figure 3, A and B) included widespread hemorrhagic lesions and frothy edematous fluid from the trachea. Large volumes of serosanguinous pleural fluid (40 ~ 60 ml) were found at necropsy in all animals that received a lethal challenge. Microscopic findings included congestion, hemorrhage, intra-alveolar edema, fibrin, neutrophilic influx, and hyaline membrane formation (Figure 3, C–F), with the severity being proportionate to the challenge dose (Figure 3G).

Figure 3-6932
Lung pathology. A: Pleural cavities contained prominent serosanguinous pleural effusions (arrow). B: Hemorrhagic lesions and frothy edematous fluid from the trachea (arrow) is consistent with permeability edema. C: Widespread capillary leakage in lung ...

Coagulopathy

Early aggressive hemostatic changes were apparent by loss of fibrinogen, prolongation of APTT clotting times, elevated D-dimer, and decreased platelets (Figure 4, A–D). D-dimer changes indicated fibrin formation and fibrinolysis, and the sensitivity of this marker was indicated by continuing elevated levels after 105 to 106 CFU/kg when the animals appeared to be otherwise normal. Fibrinogen increases by 24 hours reflected the acute phase response. A consumptive coagulopathy typical of overt DIC41 was evident at 12 to 24 hours (≥107 CFU/kg) when fibrinogen levels recovered to ≈80%, but APTT clotting times remained prolonged (45 to 65 seconds) and platelets low.

Figure 4-6932
Coagulopathy. Hemostatic changes are apparent by loss of fibrinogen (A), prolongation of APTT clotting times (B), elevated D-dimer (C), and reduced platelets (D). Mean ± SEM. Challenge dose in CFU/kg: 105 to 106 ([down-pointing small open triangle], n = 2); 10 ...

The protein C pathway down-modulates coagulation and inflammation,42 and reduced protein C levels are associated with a poor prognosis in patients.31,43 In the B. anthracis-challenged baboons, protein C levels decreased, indicating consumption (Figure 5). The early rise in protein C antigen was likely due to hemoconcentration, not increased synthesis.

Figure 5-6932
Protein C levels. Citrated plasma was collected at the times indicated, and protein C antigen levels were determined by ELISA as described in the Materials and Methods. Normal (100%) was defined using pooled normal baboon plasma. Challenge dose in CFU/kg: ...

Vascular Permeability

Increased vascular permeability was reflected by changes in mean systemic arterial pressure, respiration, and hematocrit (Figure 6, A–C). Hemoconcentration attributable to fluid exiting from the vasculature to extravascular spaces was accompanied by increased respiration rates.

Figure 6-6932
Vascular permeability. A–C: Increased vascular permeability led to reduced mean systemic arterial pressure (A) accompanied by corresponding increases in respiration (B) and hematocrit (C). Responses were dose-dependent. Mean ± SEM. Challenge ...

Cellular Responses

Cellular responses were typical of a septic challenge, were less dose-dependent, and were similar to our previous studies in the E. coli baboon model29(Figure 7). Changes in white cell populations reflected the expected margination of white cells and subsequent granulopoietic responses to the infection.

Figure 7-6932
Cellular responses. A–C: The changes in WBC counts (A) reflect ongoing neutropenia (B) and lymphocytopenia (C). D: The increase in bands is a typical granulopoietic response to septic challenge. There was no clear dose dependence, but the magnitude ...

Inflammation

Similar to patients and most animal models, there was an early, transient hyperinflammatory response to B. anthracis with increased cytokine and neutrophil elastase levels (Figure 8). Some differences were observed from comparison of cytokine/chemokine data from B. anthracis-treated baboons (Figure 9) and from earlier experiments with baboons that received 108 CFU/kg (low sublethal), 109 CFU/kg (high sublethal), or 1010 CFU/kg (lethal) E. coli 086:K61H. Analyses from E. coli-treated baboons were performed on stored samples; no new animals were challenged with E. coli for this study. After B. anthracis, IL-8 responses were less dose-dependent, MCP-1 levels were up to sevenfold higher, and MIP-1 increases were more transient.

Figure 8-6932
Systemic inflammatory responses. A–D: Increases in TNF-α (A), IL-1β (B), IL-6 (C), and neutrophil elastase (D) occurred after bacterial challenge. Changes were relatively early, transient, and similar to responses observed in other ...
Figure 9-6932
B. anthracis versus E. coli challenge in the baboon. Plasma levels of IL-8 (A, B), MCP-1 (C, D), MIP-1 (E, F), IL-12p70 (G, H), and IL-12p40 (I, J) were determined by assays from baboons challenged with B. anthracis (top) or E. coli (bottom). Challenge ...

There were interesting differences in IL-12 levels, a heterodimer of p40 and p35 that functions in innate and adaptive immunity. IL-12p70 levels were similar after B. anthracis or E. coli challenge (Figure 9, G and H), indicating similar p35 production.44 IL-12p40 is typically overexpressed after inflammatory stimuli, as was observed in the baboons after E. coli challenge (Figure 9J) with an inverse dose-dependent relationship, in agreement with earlier data.45 However, little IL-12p40 was generated in B. anthracis animals (Figure 9I), suggesting a profound immune dysfunction at this level.

Immunohistochemistry

Molecular changes at the tissue level provide insight into pathways that respond to B. anthracis. Compared to a saline-treated control, expression of tissue factor (TF), the tightly regulated initiator of extrinsic coagulation,46 was higher on lung mononuclear cells after B. anthracis (Figure 10, A and B; green). In contrast, expression of tissue factor pathway inhibitor (TFPI), the constitutively available inhibitor of extrinsic coagulation, was markedly lower (Figure 10, A and B; red). Both hemostatic molecules are modulated by inflammatory cytokines.46,47 Elevated TF expression with concomitant decreases in TFPI inhibitory capacity is consistent with the DIC indicated by the cellular and physiological markers.

Figure 10-6932
Immunohistochemistry. Lung tissues from a baboon that received 3.8 × 109 CFU/kg B. anthracis Sterne intravenously (right) or a saline-challenged baboon (control, left) were processed for immunohistochemistry as described in the Materials and Methods. ...

Pulmonary oxidative damage was indicated by marked expression of inducible nitric oxide synthetase (iNOS, red) on CD68+ mononuclear infiltrates (Figure 10, C and D; green) and increased protein tyrosine nitration (Figure 10, E and F; red). Little cellular apoptosis was observed in the lung (not shown), despite infiltration of CD68+ cells. Moderate apoptosis was observed in the spleen (Figure 10, G and H; green) and splenic capsule, similar to that observed previously in macaques.48

Discussion

The current data demonstrate that infection with toxigenic B. anthracis elicits many features of a septic disease; therefore, the lethal role of the host response to the septic challenge with anthrax has likely been underestimated. When infected, people do not die from spores or toxin alone. They die from complications elicited by the vegetative bacteria; this includes exotoxin activities as well as their own uncompensated inflammatory and coagulopathic responses to the septic challenge.

Massive volumes of serosanguinous pleural effusions were observed in all fatal cases in the 2001 attacks1,18 and in our baboon model, the lung was also severely affected. The hemorrhagic lesions, intra-alveolar edema, and hyaline membrane formation were consistent with acute lung injury, and large volumes of serosanguinous pleural fluid were found at necropsy in all animals after a lethal challenge. In three communities of wild chimpanzees in the Tai National Park, Ivory Coast, eight of which died of anthrax,49 histopathology also revealed lung edema and significant hemorrhages presenting as ecchymoses in multiple organs, including the lungs. In macaques exposed to aerosolized spores of virulent B. anthracis Ames strain, hemorrhagic lesions in the lung were prominent, although it was not clear whether lung injury was of airway origin or from the bloodstream.48 The current data demonstrate that the acute lung injury and pulmonary effusions can be directly attributed to blood-borne B. anthracis bacteria.

Prominent pleural effusions observed both in the baboon model and in bioterrorism-associated cases are not normally predominant features of sepsis and are likely a unique result of B. anthracis. The lung pathology also differs considerably from our experience with the intravenous lethal E. coli model, in which acute lung injury is an inconsistent finding and pleural effusions are rarely observed (<5 ml, if at all), even at high bacteria doses.38 The mechanism for this difference is not apparent with the current experimental approach. Dissemination would be expected to be similar between the intravenous E. coli and B. anthracis models because bacteria are infused similarly via the cephalic vein and the lung is the first capillary bed encountered; the lung is also an early target of bacteria germinated from inhaled B. anthracis spores.50 There are also considerable differences in the nature of the bacteria, and gram-negative E. coli would be expected to propagate inflammation through Toll-like receptors with a specificity different from that recognized by toxigenic gram-positive B. anthracis.51 However, there is overlap because heat-killed B. anthracis52 and anthrolysin-O from B. anthracis Sterne strain53 can activate Toll-like receptor 4, which is ordinarily associated with activation by lipopolysaccharide from gram-negative bacteria. Whether these differences contribute to the distinct lung pathology and cytokine profiles after B. anthracis challenge is not yet known.

Data from case reports of the 2001 bioterrorism victims were consistent with either overt2,5 or probable DIC.3 These clinical observations strongly indicate that procoagulant and inflammatory responses coincide with bacteremia and toxemia. In the baboons, we observed a significant increase in vascular permeability coincident with hemostatic imbalances manifested by thrombocytopenia, transient leucopenia, and an aggressive DIC. Histopathology confirmed the coagulopathy and fibrin deposition in the lungs. Loss of circulating protein C and cell-associated TFPI, coupled with increased tissue factor expression presents a potential molecular basis for the severe hemostatic dysfunction in the baboons and suggests that anti-coagulant adjunctive therapies may influence mortality or morbidity due to B. anthracis infection.

A systemic inflammatory response ensued with early transient increases in proinflammatory cytokines/chemokines. Although this hyperinflammatory response is typical after most infectious challenges, changes in IL-12p40 were notably different between E. coli- and B. anthracis-treated animals. IL-12 is a proinflammatory cytokine that bridges innate and adaptive immune responses and skews T-cell reactivity toward a Th1 response.54 Antigen-presenting cells, such as dendritic cells and macrophages, are the primary producers of IL-12, a heterodimeric cytokine consisting of p40 and p35 subunits that arise as two different gene products.55 p35 is constitutively transcribed, is regulated posttranslationally,56 and is not secreted independently. In contrast, p40 production is regulated by inflammatory effectors, often to high levels, including during infection with Neisseria meningitides57 or in autoimmune disease.58 The lack of p40 in the anthrax animals may have multiple consequences because p40 homodimers antagonize IL-1259 and p40/p19 heterodimers (IL-23) have overlapping, yet distinct, functions to those of IL-12.60 The mechanism for the paucity of p40 in the anthrax animals is not known. It may be related to whether the bacteria is gram-negative or -positive.61 Alternatively, anthrax lethal toxin (lethal factor + PA) inhibits dendritic cell maturation62 and kills macrophages,63 which would selectively compromise immune responsiveness and favor bacterial survival.

Tissue inflammation was demonstrated by pulmonary CD68+ mononuclear infiltrates and iNOS expression by CD68+ cells and other cell types (presumably endothelial and/or pulmonary epithelial cells). Production of nitric oxide by iNOS is important for vascular tone and antibacterial defense, but overproduction is cytotoxic, so iNOS expression is tightly regulated.64 Increased protein tyrosine nitration in the lung reflects a shift from the signal transducing physiological actions of ·NO to peroxynitrate-mediated oxidative stress and injury.65

The relative contribution of anthrax exotoxins toward death of the baboons remains to be established in our model. MCP-1 levels were up to sevenfold higher in the anthrax baboons compared with E. coli-challenged animals, and MCP-1 is induced similarly from vascular cells by both gram-positive and gram-negative bacteria,66 suggesting that this preferential increase by B. anthracis may be attributable to the primate vasculature reacting to exotoxin(s). With high bacterial load, the baboons died within 10 to 12 hours when PA levels are detectable. Like patients, our primates receive antibiotics, and PA antigen was low to undetectable after 24 hours, yet animals challenged with 0.5 to 1.6 × 109 CFU/kg still succumbed in 3 to 4 days. Edema toxin will induce necrosis in a zebra fish model,67 and high doses of edema toxin induce multiple organ failure secondary to vascular permeability changes in mice.68 In the baboons, necrosis was not observed in the lungs but was present in the adrenals and in kidneys secondary to microthrombosis (not shown). However, we cannot ascribe this pathology to B. anthracis or exotoxins because it is also observed in baboons after challenge with E. coli. Species differences or choice of infective agent may contribute to these differing observations. Data from our ongoing experiments with B. anthracis strains defective in toxin production as well as purified toxin challenges will contribute to elucidating the relative contributions of anthrax toxins toward host mortality. Because most current vaccine approaches target the PA toxin component, understanding the in vivo role of anthrax toxins becomes critically important.

Collectively, the current data demonstrate that host responses to anthrax infection include compromised innate immunity coupled with uncompensated inflammatory and coagulopathic responses. Our model does not discriminate between effects of anthrax exotoxins or nontoxin bacterial products. Although the B. anthracis Sterne strain produces exotoxin levels approximately equivalent to naturally virulent strains,33 it does not have the external bacterial capsule that is believed to play a role in delaying uptake by macrophages and subsequent cytokine responses.69 Thus, the study design may not precisely replicate the kinetics of disease progression associated with infection by spores of fully virulent B. anthracis. Additional baboon models are in progress to determine the effect of kinetics on disease development.

In summary, interpretation of responses to challenge with anthrax spores, toxins, or bacteria in animal models should be viewed from the perspective of human victims of anthrax in whom toxemia and bacteremia coincide. This larger perspective will accelerate development of clinically relevant animal models for rapid transition of vaccines, immunotherapeutics, and adjunct therapeutics for treatment and prevention of anthrax in humans.

Acknowledgments

We thank Glenn Peer, Brett Clough, Jamie Talbert, Kandice Swindle, Scott Freeman, and Valta Collins for their dedicated expertise; Dr. D.J. Flournoy (VA Medical Center, Oklahoma City, OK) and Dr. Gary White (Director, University of Oklahoma Health Sciences Center Baboon Research Resource, Oklahoma City, OK) for helpful discussions; and Dr. J. Donald Capra (President, Oklahoma Medical Research Foundation, Oklahoma City, OK) for his support and critical reading of the manuscript.

Footnotes

Address reprint requests to Shinichiro Kurosawa, M.D., Ph.D., Free Radical Biology and Aging Research, Oklahoma Medical Research Foundation, 825 NE 13th St., Oklahoma City, OK 73104. .ude.cshuo.frmo@awasoruk-orihcinihs :liam-E

Supported by the National Institutes of Health (grants 1R01 AI058107 and 1U19 AI062629 to S.K., and RR020143 to D.J.S.-K.).

The work was performed at: Oklahoma Medical Research Foundation and the University of Oklahoma Health Sciences Center.

References

  • Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M, Tapper M, Fisk TL, Zaki S, Popovic T, Meyer RF, Quinn CP, Harper SA, Fridkin SK, Sejvar JJ, Shepard CW, McConnell M, Guarner J, Shieh WJ, Malecki JM, Gerberding JL, Hughes JM, Perkins BA. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis. 2001;7:933–944. [PMC free article] [PubMed]
  • Freedman A, Afonja O, Chang MW, Mostashari F, Blaser M, Perez-Perez G, Lazarus H, Schacht R, Guttenberg J, Traister M, Borkowsky W. Cutaneous anthrax associated with microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant. JAMA. 2002;287:869–874. [PubMed]
  • Borio L, Frank D, Mani V, Chiriboga C, Pollanen M, Ripple M, Ali S, DiAngelo C, Lee J, Arden J, Titus J, Fowler D, O’Toole T, Masur H, Bartlett J, Inglesby T. Death due to bioterrorism-related inhalational anthrax: report of 2 patients. JAMA. 2001;286:2554–2559. [PubMed]
  • Barakat LA, Quentzel HL, Jernigan JA, Kirschke DL, Griffith K, Spear SM, Kelley K, Barden D, Mayo D, Stephens DS, Popovic T, Marston C, Zaki SR, Guarner J, Shieh WJ, Carver HW, Meyer RF, Swerdlow DL, Mast EE, Hadler JL. Fatal inhalational anthrax in a 94-year-old Connecticut woman. JAMA. 2002;287:863–868. [PubMed]
  • Mina B, Dym JP, Kuepper F, Tso R, Arrastia C, Kaplounova I, Faraj H, Kwapniewski A, Krol CM, Grosser M, Glick J, Fochios S, Remolina A, Vasovic L, Moses J, Robin T, DeVita M, Tapper ML. Fatal inhalational anthrax with unknown source of exposure in a 61-year-old woman in New York City. JAMA. 2002;287:858–862. [PubMed]
  • Bush LM, Abrams BH, Beall A, Johnson CC. Index case of fatal inhalational anthrax due to bioterrorism in the United States. N Engl J Med. 2001;345:1607–1610. [PubMed]
  • Read TD, Peterson SN, Tourasse N, Baillie LW, Paulsen IT, Nelson KE, Tettelin H, Fouts DE, Eisen JA, Gill SR, Holtzapple EK, Okstad OA, Helgason E, Rilstone J, Wu M, Kolonay JF, Beanan MJ, Dodson RJ, Brinkac LM, Gwinn M, DeBoy RT, Madpu R, Daugherty SC, Durkin AS, Haft DH, Nelson WC, Peterson JD, Pop M, Khouri HM, Radune D, Benton JL, Mahamoud Y, Jiang L, Hance IR, Weidman JF, Berry KJ, Plaut RD, Wolf AM, Watkins KL, Nierman WC, Hazen A, Cline R, Redmond C, Thwaite JE, White O, Salzberg SL, Thomason B, Friedlander AM, Koehler TM, Hanna PC, Kolsto AB, Fraser CM. The genome sequence of Bacillus anthracis Ames and comparison to closely related bacteria. Nature. 2003;423:81–86. [PubMed]
  • Santelli E, Bankston LA, Leppla SH, Liddington RC. Crystal structure of a complex between anthrax toxin and its host cell receptor. Nature. 2004;430:905–908. [PubMed]
  • Drum CL, Yan SZ, Bard J, Shen YQ, Lu D, Soelaiman S, Grabarek Z, Bohm A, Tang WJ. Structural basis for the activation of anthrax adenylyl cyclase exotoxin by calmodulin. Nature. 2002;415:396–402. [PubMed]
  • Wigelsworth DJ, Krantz BA, Christensen KA, Lacy DB, Juris SJ, Collier RJ. Binding stoichiometry and kinetics of the interaction of a human anthrax toxin receptor, CMG2, with protective antigen. J Biol Chem. 2004;279:23349–23356. [PubMed]
  • Bradley KA, Mogridge J, Mourez M, Collier RJ, Young JA. Identification of the cellular receptor for anthrax toxin. Nature. 2001;414:225–229. [PubMed]
  • Green BD, Battisti L, Koehler TM, Thorne CB, Ivins BE. Demonstration of a capsule plasmid in Bacillus anthracis. Infect Immun. 1985;49:291–297. [PMC free article] [PubMed]
  • Mikesell P, Ivins BE, Ristroph JD, Dreier TM. Evidence for plasmid-mediated toxin production in Bacillus anthracis. Infect Immun. 1983;39:371–376. [PMC free article] [PubMed]
  • Drysdale M, Heninger S, Hutt J, Chen Y, Lyons CR, Koehler TM. Capsule synthesis by Bacillus anthracis is required for dissemination in murine inhalation anthrax. EMBO J. 2005;24:221–227. [PMC free article] [PubMed]
  • Dai Z, Sirard JC, Mock M, Koehler TM. The atxA gene product activates transcription of the anthrax toxin genes and is essential for virulence. Mol Microbiol. 1995;16:1171–1181. [PubMed]
  • Collier RJ, Young JA. Anthrax toxin. Annu Rev Cell Dev Biol. 2003;19:45–70. [PubMed]
  • Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31:1250–1256. [PubMed]
  • Guarner J, Jernigan JA, Shieh WJ, Tatti K, Flannagan LM, Stephens DS, Popovic T, Ashford DA, Perkins BA, Zaki SR. Pathology and pathogenesis of bioterrorism-related inhalational anthrax. Am J Pathol. 2003;163:701–709. [PMC free article] [PubMed]
  • Abramova FA, Grinberg LM, Yampolskaya OV, Walker DH. Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979. Proc Natl Acad Sci USA. 1993;90:2291–2294. [PMC free article] [PubMed]
  • Meselson M, Guillemin J, Hugh-Jones M, Langmuir A, Popova I, Shelokov A, Yampolskaya O. The Sverdlovsk anthrax outbreak of 1979. Science. 1994;266:1202–1208. [PubMed]
  • Gleiser CA, Berdjis CC, Hartman HA, Gochenour WS. Pathology of experimental respiratory anthrax in Macaca mulatta. Br J Exp Pathol. 1963;44:416–426. [PMC free article] [PubMed]
  • Albrink WS, Goodlow RJ. Experimental inhalation anthrax in the chimpanzee. Am J Pathol. 1959;35:1055–1065. [PMC free article] [PubMed]
  • Lincoln RE, Hodges DR, Klein F, Mahlandt BG, Jones Jr WI, Haines BW, Rhian MA, Walker JS. Role of the lymphatics in the pathogenesis of anthrax. J Infect Dis. 1965;115:481–494. [PubMed]
  • Fritz DL, Jaax NK, Lawrence WB, Davis KJ, Pitt ML, Ezzell JW, Friedlander AM. Pathology of experimental inhalation anthrax in the rhesus monkey. Lab Invest. 1995;73:691–702. [PubMed]
  • Cui X, Moayeri M, Li Y, Li X, Haley M, Fitz Y, Correa-Araujo R, Banks SM, Leppla SH, Eichacker PQ. Lethality during continuous anthrax lethal toxin infusion is associated with circulatory shock but not inflammatory cytokine or nitric oxide release in rats. Am J Physiol. 2004;286:R699–R709. [PubMed]
  • Shoop WL, Xiong Y, Wiltsie J, Woods A, Guo J, Pivnichny JV, Felcetto T, Michael BF, Bansal A, Cummings RT, Cunningham BR, Friedlander AM, Douglas CM, Patel SB, Wisniewski D, Scapin G, Salowe SP, Zaller DM, Chapman KT, Scolnick EM, Schmatz DM, Bartizal K, MacCoss M, Hermes JD. Anthrax lethal factor inhibition. Proc Natl Acad Sci USA. 2005;102:7958–7963. [PMC free article] [PubMed]
  • Moayeri M, Haines D, Young HA, Leppla SH. Bacillus anthracis lethal toxin induces TNF-alpha-independent hypoxia-mediated toxicity in mice. J Clin Invest. 2003;112:670–682. [PMC free article] [PubMed]
  • Taylor FB., Jr Staging of the pathophysiologic responses of the primate microvasculature to Escherichia coli and endotoxin: examination of the elements of the compensated response and their links to the corresponding uncompensated lethal variants. Crit Care Med. 2001;29:S78–S89. [PubMed]
  • Taylor FB, Jr, Wada H, Kinasewitz G. Description of compensated and uncompensated disseminated intravascular coagulation (DIC) responses (non-overt and overt DIC) in baboon models of intravenous and intraperitoneal Escherichia coli sepsis and in the human model of endotoxemia: toward a better definition of DIC. Crit Care Med. 2000;28:S12–S19. [PubMed]
  • Taylor FB, Jr, Chang A, Esmon CT, D’Angelo A, Vigano-D’Angelo S, Blick KE. Protein C prevents the coagulopathic and lethal effects of Escherichia coli infusion in the baboon. J Clin Invest. 1987;79:918–925. [PMC free article] [PubMed]
  • Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ., Jr Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. 2001;344:699–709. [PubMed]
  • Lyons CR, Lovchik J, Hutt J, Lipscomb MF, Wang E, Heninger S, Berliba L, Garrison K. Murine model of pulmonary anthrax: kinetics of dissemination, histopathology, and mouse strain susceptibility. Infect Immun. 2004;72:4801–4809. [PMC free article] [PubMed]
  • Leppla SH. Production and purification of anthrax toxin. Methods Enzymol. 1988;165:103–116. [PubMed]
  • Kaneko T, Stearns-Kurosawa DJ, Taylor FBJ, Twigg M, Osaki K, Kinasewitz G, Peer G, Kurosawa S. Reduced neutrophil CD10 expression in non-human primates and humans after in vivo challenge with E coli or lipopolysaccharide. Shock. 2003;20:130–137. [PubMed]
  • Taylor FB, Jr, Tesh VL, DeBault L, Li A, Chang AC, Kosanke SD, Pysher TJ, Siegler RL. Characterization of the baboon responses to Shiga-like toxin: descriptive study of a new primate model of toxic responses to Stx-1. Am J Pathol. 1999;154:1285–1299. [PMC free article] [PubMed]
  • Taylor FB, Chang AC, Peer G, Li A, Ezban M, Hedner U. Active site inhibited factor VIIa (DEGR VIIa) attenuates the coagulant and interleukin-6 and -8, but not tumor necrosis factor, responses of the baboon to LD100 Escherichia coli. Blood. 1998;91:1609–1615. [PubMed]
  • Taylor FB, Jr, Stearns-Kurosawa DJ, Kurosawa S, Ferrell G, Chang AC, Laszik Z, Kosanke S, Peer G, Esmon CT. The endothelial cell protein C receptor aids in host defense against Escherichia coli sepsis. Blood. 2000;95:1680–1686. [PubMed]
  • Randolph MM, White GL, Kosanke SD, Bild G, Carr C, Galluppi G, Hinshaw LB, Taylor FB., Jr Attenuation of tissue thrombosis and hemorrhage by ala-TFPI does not account for its protection against E coli—a comparative study of treated and untreated non-surviving baboons challenged with LD100 E coli. Thromb Haemost. 1998;79:1048–1053. [PubMed]
  • Lupu F, Heim D, Bachmann F, Kruithof EK. Expression of LDL receptor-related protein/alpha 2-macroglobulin receptor in human normal and atherosclerotic arteries. Arterioscler Thromb. 1994;14:1438–1444. [PubMed]
  • Nassi S, Collier RJ, Finkelstein A. PA63 channel of anthrax toxin: an extended beta-barrel. Biochemistry. 2002;41:1445–1450. [PubMed]
  • Levi M, de Jonge E, van der Poll T. Sepsis and disseminated intravascular coagulation. J Thromb Thrombolysis. 2003;16:43–47. [PubMed]
  • Esmon CT. Protein C anticoagulant pathway and its role in controlling microvascular thrombosis and inflammation. Crit Care Med. 2001;29:S48–S51. [PubMed]
  • Fisher CJ, Jr, Yan SB. Protein C levels as a prognostic indicator of outcome in sepsis and related diseases. Crit Care Med. 2000;28:S49–S56. [PubMed]
  • Aste-Amezaga M, Ma X, Sartori A, Trinchieri G. Molecular mechanisms of the induction of IL-12 and its inhibition by IL-10. J Immunol. 1998;160:5936–5944. [PubMed]
  • Jansen PM, van der Pouw Kraan TC, de Jong IW, van Mierlo G, Wijdenes J, Aarden L, Chang AA, Taylor FB, Jr, Hack CE. The release of interleukin-12 in Escherichia coli-induced lethal and sublethal primate sepsis. Ann NY Acad Sci. 1996;795:351–353. [PubMed]
  • Morrissey JH. Tissue factor: a key molecule in hemostatic and nonhemostatic systems. Int J Hematol. 2004;79:103–108. [PubMed]
  • Osterud B, Bajaj MS, Bajaj SP. Sites of tissue factor pathway inhibitor (TFPI) and tissue factor expression under physiologic and pathologic conditions On behalf of the Subcommittee on Tissue factor Pathway Inhibitor (TFPI) of the Scientific and Standardization Committee of the ISTH. Thromb Haemost. 1995;73:873–875. [PubMed]
  • Vasconcelos D, Barnewall R, Babin M, Hunt R, Estep J, Nielsen C, Carnes R, Carney J. Pathology of inhalation anthrax in cynomolgus monkeys (Macaca fascicularis) Lab Invest. 2003;83:1201–1209. [PubMed]
  • Leendertz FH, Ellerbrok H, Boesch C, Couacy-Hymann E, Matz-Rensing K, Hakenbeck R, Bergmann C, Abaza P, Junglen S, Moebius Y, Vigilant L, Formenty P, Pauli G. Anthrax kills wild chimpanzees in a tropical rainforest. Nature. 2004;430:451–452. [PubMed]
  • Lyons CR, Lovchik J, Hutt J, Lipscomb MF, Wang E, Heninger S, Berliba L, Garrison K. Murine model of pulmonary anthrax: kinetics of dissemination, histopathology, and mouse strain susceptibility. Infect Immun. 2004;72:4801–4809. [PMC free article] [PubMed]
  • Basu S, Fenton MJ. Toll-like receptors: function and roles in lung disease. Am J Physiol. 2004;286:L887–L892. [PubMed]
  • Hsu LC, Mo Park J, Zhang K, Luo JL, Maeda S, Kaufman RJ, Eckmann L, Guiney DG, Karin M. The protein kinase PKR is required for macrophage apoptosis after activation of Toll-like receptor 4. Nature. 2004;428:341–345. [PubMed]
  • Park JM, Ng VH, Maeda S, Rest RF, Karin M. Anthrolysin O and other gram-positive cytolysins are toll-like receptor 4 agonists. J Exp Med. 2004;200:1647–1655. [PMC free article] [PubMed]
  • Langrish CL, McKenzie BS, Wilson NJ, de Waal MR, Kastelein RA, Cua DJ. IL-12 and IL-23: master regulators of innate and adaptive immunity. Immunol Rev. 2004;202:96–105. [PubMed]
  • Sieburth D, Jabs EW, Warrington JA, Li X, Lasota J, LaForgia S, Kelleher K, Huebner K, Wasmuth JJ, Wolf SF. Assignment of genes encoding a unique cytokine (IL12) composed of two unrelated subunits to chromosomes 3 and 5. Genomics. 1992;14:59–62. [PubMed]
  • Aste-Amezaga M, Ma X, Sartori A, Trinchieri G. Molecular mechanisms of the induction of IL-12 and its inhibition by IL-10. J Immunol. 1998;160:5936–5944. [PubMed]
  • Hazelzet JA, Kornelisse RF, van der Pouw Kraan TC, Joosten KF, van der Voort E, van Mierlo G, Suur MH, Hop WC, de Groot R, Hack CE. Interleukin 12 levels during the initial phase of septic shock with purpura in children: relation to severity of disease. Cytokine. 1997;9:711–716. [PubMed]
  • Lauwerys BR, Van Snick J, Houssiau FA. Serum IL-12 in systemic lupus erythematosus: absence of p70 heterodimers but presence of p40 monomers correlating with disease activity. Lupus. 2002;11:384–387. [PubMed]
  • Ling P, Gately MK, Gubler U, Stern AS, Lin P, Hollfelder K, Su C, Pan YC, Hakimi J. Human IL-12 p40 homodimer binds to the IL-12 receptor but does not mediate biologic activity. J Immunol. 1995;154:116–127. [PubMed]
  • Oppmann B, Lesley R, Blom B, Timans JC, Xu Y, Hunte B, Vega F, Yu N, Wang J, Singh K. Novel p19 protein engages IL-12p40 to form a cytokine, IL-23, with biological activities similar as well as distinct from IL-12. Immunity. 2000;13:715–725. [PubMed]
  • Hermann C, Spreitzer I, Schroder NW, Morath S, Lehner MD, Fischer W, Schutt C, Schumann RR, Hartung T. Cytokine induction by purified lipoteichoic acids from various bacterial species—role of LBP, sCD14, CD14 and failure to induce IL-12 and subsequent IFN-gamma release. Eur J Immunol. 2002;32:541–551. [PubMed]
  • Agrawal A, Lingappa J, Leppla SH, Agrawal S, Jabbar A, Quinn C, Pulendran B. Impairment of dendritic cells and adaptive immunity by anthrax lethal toxin. Nature. 2003;424:329–334. [PubMed]
  • Friedlander AM, Bhatnagar R, Leppla SH, Johnson L, Singh Y. Characterization of macrophage sensitivity and resistance to anthrax lethal toxin. Infect Immun. 1993;61:245–252. [PMC free article] [PubMed]
  • Aktan F. iNOS-mediated nitric oxide production and its regulation. Life Sci. 2004;75:639–653. [PubMed]
  • Schopfer FJ, Baker PR, Freeman BA. NO-dependent protein nitration: a cell signaling event or an oxidative inflammatory response? Trends Biochem Sci. 2003;28:646–654. [PubMed]
  • Frevert CW, Matute-Bello G, Skerrett SJ, Goodman RB, Kajikawa O, Sittipunt C, Martin TR. Effect of CD14 blockade in rabbits with Escherichia coli pneumonia and sepsis. J Immunol. 2000;164:5439–5445. [PubMed]
  • Voth DE, Hamm EE, Nguyen LG, Tucker AE, Salles II, Ortiz-Leduc W, Ballard JD. Bacillus anthracis oedema toxin as a cause of tissue necrosis and cell type-specific cytotoxicity. Cell Microbiol. 2005;7:1139–1149. [PubMed]
  • Firoved AM, Miller GF, Moayeri M, Kakkar R, Shen Y, Wiggins JF, McNally EM, Tang WJ, Leppla SH. Bacillus anthracis edema toxin causes extensive tissue lesions and rapid lethality in mice. Am J Pathol. 2005;167:1309–1320. [PMC free article] [PubMed]
  • Ezzell JW, Welkos SL. The capsule of bacillus anthracis, a review. J Appl Microbiol. 1999;87:250. [PubMed]

Articles from The American Journal of Pathology are provided here courtesy of American Society for Investigative Pathology
PubReader format: click here to try

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...