Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

The Vibrio cholerae Cytolysin Promotes Chloride Secretion from Intact Human Intestinal Mucosa

  • Lucantonio Debellis ,

    Contributed equally to this work with: Lucantonio Debellis, Anna Diana

    Affiliation Department of General and Environmental Physiology, University of Bari, Bari, Italy

  • Anna Diana ,

    Contributed equally to this work with: Lucantonio Debellis, Anna Diana

    Affiliation Department of General and Environmental Physiology, University of Bari, Bari, Italy

  • Diletta Arcidiacono,

    Affiliation Venetian Institute of Molecular Medicine, Padua, Italy

  • Romina Fiorotto,

    Affiliation Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America

  • Piero Portincasa,

    Affiliation Clinica Medica “A. Murri”, Department of Internal and Public Medicine, University Medical School, Bari, Italy

  • Donato Francesco Altomare,

    Affiliation Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Units, University of Bari, Policlinico, Bari, Italy

  • Carlo Spirlì,

    Affiliation Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, United States of America

  • Marina de Bernard

    marina.debernard@unipd.it

    Affiliations Venetian Institute of Molecular Medicine, Padua, Italy, Department of Biology, University of Padua, Padua, Italy

The Vibrio cholerae Cytolysin Promotes Chloride Secretion from Intact Human Intestinal Mucosa

  • Lucantonio Debellis, 
  • Anna Diana, 
  • Diletta Arcidiacono, 
  • Romina Fiorotto, 
  • Piero Portincasa, 
  • Donato Francesco Altomare, 
  • Carlo Spirlì, 
  • Marina de Bernard
PLOS
x

Abstract

Background

The pathogenicity of the Vibrio cholerae strains belonging to serogroup O1 and O139 is due to the production of virulence factors such as cholera toxin (CT) and the toxin-coregulated pilus (TCP). The remaining serogroups, which mostly lack CT and TCP, are more frequently isolated from aquatic environmental sources than from clinical samples; nevertheless, these strains have been reported to cause human disease, such as sporadic outbreaks of watery diarrhoea and inflammatory enterocolitis. This evidence suggested the possibility that other virulence factor(s) than cholera toxin might be crucial in the pathogenesis of Vibrio cholerae-induced diarrhoea, but their nature remains unknown. VCC, the hemolysin produced by virtually all Vibrio cholerae strains, has been proposed as a possible candidate, though a clear-cut demonstration attesting VCC as crucial in the pathogenesis of Vibrio cholerae-induced diarrhoea is still lacking.

Methodology/Principal Findings

Electrophysiological parameters and paracellular permeability of stripped human healthy colon tissues, obtained at subtotal colectomy, mounted in Ussing chamber were studied in the presence or absence of VCC purified from culture supernatants of V. cholerae O1 El Tor strain. Short circuit current (ISC) and transepithelial resistance (RT) were measured by a computerized voltage clamp system. The exposure of sigmoid colon specimens to 1 nM VCC resulted in an increase of ISC by 20.7%, with respect to the basal values, while RT was reduced by 12.3%. Moreover, increase in ISC was abolished by bilateral Cl reduction.

Conclusion/Significance

Our results demonstrate that VCC, by forming anion channels on the apical membrane of enterocytes, triggers an outward transcellular flux of chloride. Such an ion movement, associated with the outward movement of Na+ and water, might be responsible for the diarrhoea caused by the non-toxigenic strains of Vibrio cholerae.

Introduction

Cholera is an acute diarrhoeal infection caused mostly by ingestion of Vibrio cholerae O1 and O139 and it represents one of the most outbreak-prone diseases that continue to strike fear in the population wherever it occurs. Although the advent of oral rehydration therapy (ORT) has substantially improved the cholera case fatality rates, it is believed that as much as 120000 deaths may be attributed to cholera every year [1].

The patogenicity of the Vibrio cholerae strains belonging to serogroup O1 and O139 is due to the production of virulence factors such as cholera toxin (CT) and the toxin-coregulated pilus (TCP); CT is essential for full-blown cholera whereas TCP is crucial for the adherence of bacteria to the intestinal epithelium [2], [3]. The remaining serogroups, referred to as non-O1 and non-O139, which mostly lack CT and TCP, are more frequently isolated from aquatic environmental sources than from clinical samples; nevertheless, these strains have been reported to evoke fluid accumulation in the ligated rabbit ileal loop assay [4][6] and to cause human disease, such as sporadic outbreaks of watery diarrhoea and inflammatory enterocolitis, despite the absence of CT. Nontoxigenic O1 strains have also been isolated from cases of diarrhoea [7][9]. All these evidence suggested the possibility that other virulence factor(s) than CT might be crucial in the pathogenesis of Vibrio cholerae-induced diarrhoea, but their nature remains still unknown.

El Tor hemolysin (ETH), also known as V. cholerae cytolysin (VCC) consists of two major toxin groups, namely V. cholerae O1 (VCC1) and V. cholerae non-O1 (VCC2) and is produced by all strains. It is a water soluble toxin secreted as a 79 kDa inactive pro-hemolysin by V. cholerae [10], [11]. A proteolytic cleavage by different proteases, that remove a N-terminal segment [12], generates the mature toxin of 63 kDa. In cholesterol-and ceramides-rich membranes VCC forms heptameric channels [13], [14] with a moderate anion preference, responsible for vacuolization and eventual lysis of several cell types in culture [15][18]. Recently, the vacuolization associated to VCC intoxication has been demonstrated to be an autophagic response of the cells against the toxin [19]. VCC has been proposed as virulence factor causing diarrhoea [6], [20], although the ability of non-haemolytic strains of V. cholerae to cause fluid accumulation, suggests that it is not the sole etiologic factor involved [21].

On the basis of its channel property and considering that the majority of the diarrheagenic toxins affect chloride secretion in the intestine [22], we have investigated whether VCC was able to promote an efflux of chloride from intestinal epithelial cells either by using an intestinal cell line or by administrating the toxin on a human intestinal mucosal sheet.

Here we demonstrate for the first time that VCC is capable of inducing a chloride efflux from whole human intact intestinal epithelium and in virtue of such an activity we suggest that VCC might be the major diarrheagenic factor for the non producing cholera toxin strains, or contribute to cause diarrhoea when the toxin is present.

Materials and Methods

Reagents

Vibrio cholerae cytolysin (VCC) was purified from culture supernatants of V. cholerae O1 El Tor 8731 [23]. The cleaved and active form of VCC was obtained by ethanol precipitation (final concentration, 40%), preparative isoelectric focusing in a sucrose density gradient, and hydroxyapatite chromatography [13], [24]. Figure 1 shows the purity of the VCC used for the experiments. Cell culture media and FBS were from Invitrogen/Gibco. MEQ was from Molecular Probes. Krebs buffer, Staphylococcus aureus α-Hemolysin, 4,4′-diisothiocyanatostilbene-2,2′-disulphonic acid (disodium salt) (DIDS), protamine, amiloride, papain, L-cysteine, FITC and Na-Isethionate were from Sigma. Caco-2 cells were from Istituto Zooprofilattico Sperimentale (Brescia, Italy).

thumbnail
Figure 1. SDS-PAGE of VCC preparation.

0.5 and 1 µg (left and right lane respectively) of VCC, purified as described in Materials and Methods, were applied to SDS-PAGE and stained with Comassie-blue.

https://doi.org/10.1371/journal.pone.0005074.g001

Caco-2 cells culture

Caco-2 cells, obtained from human colon adenocarcinoma, were grown in DMEM supplemented with 10% FBS. For chloride measurements cells were harvested the day before and seeded on 24 mm-glass coverslips (4×105cells).

Intracellular Cl measurements

Changes of intracellular Cl concentration were measured with the chloride indicator, 6-methoxy-N-ethylquinolinium iodide (MEQ) [25]. MEQ fluorescence is quenched by collision with halide ions, thus an increase in the fluorescent signal represents a decrease in the intracellular Cl concentration. Caco-2 cells, seeded on coverslips, were loaded with 50 µM diH-MEQ in solution #1 (NaCl 135 mM, KCl 4.7 mM, KH2PO4 1.2 mM, MgSO4•7H2O 1 mM, CaCl2 1.2 mM, HEPES 10 mM, glucose 5 mM, pyruvic acid-sodium salt 1 mM, pH 7.4) for 50 min before washing and visualizing on an Olympus inverted microscope. The incubation with VCC or PBS (as control) was carried out during the last 30 min of the dye loading. Cells were maintained in continuous perfusion with the chloride-containing buffer (solution #1): after 340 sec, solution 1 was substituted with a Cl free buffer (solution # 2) containing NaNO3 140 mM, KNO3 5 mM , gluconic acid 3 mM, MgSO4•7H2O 1 mM, glucose 5 mM, HEPES 20 mM, pH 7.4. After 500 sec, cells were re-exposed to solution 1 for 500 sec. For each experiment, fluorescence (excitation at 360 nm; emission at 420 nm) from microscopic fields, containing an average of 2–3 cells, was recorded (1 recording every 10 sec) and quantified.

To quantify changes in cellular fluorescence, the total quenchable signal of the dye was determined in each experiment, and expressed as the difference between the fluorescence signal when the cells were perfused with chloride-free buffer and the signal obtained after maximum quenching by perfusion with 150 mM potassium thiocyanate (KSCN). In the histogram representation the change in fluorescence from baseline (ΔF) was calculated by the equation ΔF = (1−F/Fb)×100, where Fb is the basal fluorescence at time = 0 sec. Using this method, each experiment was able to serve as its own control [26].

Experiments on human colon

Sigmoid colon tissues were obtained from patients undergoing subtotal colectomy for colon cancer. Before surgery, all patients had given their fully informed and written consent about the aims of the surgical intervention. Upon removal of the tissue and before inclusion in buffered formaline for routine pathology examination, a strip (about 5×1.5 cm) of full thickness colonic wall was isolated within the redundant healthy area surrounding the tumor and kept for electrophysiological studies. During dissection and experiments tissues were continuously bathed with Krebs bicarbonate/phosphate buffer, containing in mM: 107 NaCl, 4.5 KCl, 25 NaHCO3, 0.2 NaH2PO4, 1.8 Na2HPO4, 1.25 CaCl2, 1 MgCl2, and 12 D-glucose, continually gassed with O2/CO2 (95%/5%) to yield pH 7.2, and warmed up to 37°C. After removal of serosal and circular muscle layers, the stripped mucosae were mounted vertically as flat sheet between the two halves of Ussing chambers (Mussler Scientific Instruments, Aachen, Germany), having an exposed area of 1 cm2. Each half-chamber had a circular fluid canal of 3.0 ml total volume filled with Krebs solution that was constantly recirculated by means of gas bubble lift. Two pairs of Ag/AgCl electrodes were used to monitor either the transepithelial potential difference (VT, mV) and the tissue resistance (RT, Ω cm2) under open-circuit condition, or the short circuit current (ISC, µA/cm2) with the transepithelial potential clamped to zero at fixed intervals of 5 min. Offset of voltage electrodes pairs and fluid resistance were evaluated prior to the onset of each experiment and systematically subtracted. At fixed intervals of 1 min a transepithelial bipolar current pulse (I) of 1 µA amplitude and 200 msec duration was applied to the tissue and the RT was automatically calculated from the change in open-circuit voltage (ΔVT) according to Ohm's law (RT = ΔVT/I).

Experiments were conducted simultaneously on one to three specimen from the same tissue. Electrical parameters were measured in the computer-controlled chambers (software Clamp v. 2.14, Aachen, Germany) in the basal state (i.e. an equilibration time of 30 to 40 min), during incubation with VCC, α-Hemolysin or drugs added to the mucosal side and after removing the agonists. In some experiments Na-Isethionate was used to completely replace the NaCl when Cl was reduced from 116 to 9 mM in the luminal and mucosal bath. In order to avoid Ag/AgCl electrode offset change during Cl substitution, the tissues were incubated in low-Cl solution from the beginning of the experiment.

To enhance VCC interaction with mucosal colon surface, the layer of mucus was removed by incubation in a mucolytic solution containing papain (5 U/100 ml) plus L-cysteine (5 mM) [27], [28], for 25 min. The luminal mucolytic containing solution was then substituted with Krebs solution 5 min prior the addition of the toxin. The enzyme concentration and the exposure time were kept low to avoid damage to colon mucosa. In order to prevent cysteine formation and precipitation, the mixture was freshly prepared prior each experiment.

VCC, α-Hemolysin and drugs were added directly to the mucosal bath, while solution replacing after the mucolytic treatment or drug addition was obtained within about 40 sec by continuous gravity perfusion from a reservoir and suction of the mucosal bath excess by a vacuum pump.

Paracellular permeability evaluation in intact intestinal epithelia

The mucosal-to-serosal flux of fluorescein isothiocyanate (FITC; MW: 376.3) in human colon specimen mounted in Ussing chamber was assessed as described by Mayol and colleagues [29]. Tissue were incubated in Krebs buffer and exposed to mucolytic solution as described above. After mucolytic cocktail removal, FITC was added in the mucosal bath (140 µM final concentration), with or without VCC (1 nM) or protamine (100 mg/l). Serosal buffer aliquots were collected at 0, 5, 15, 30 and 60 min after FITC addition and replaced with identical PBS amount. The fluorescent emission at 520 nm after excitation at 480 nm was measured twice for each aliquot with a fluorescence spectrophotometer equipped with microplate reader (Cary Eclipse, Varian Inc. Palo Alto, CA, USA). A calibration curve obtained with fluorescence intensity (expressed as arbitrary units of the optical density measured at 480 nm) vs FITC concentration was generated to calculate the FITC concentration in the serosal chamber. The apparent permeability coefficient (Papp) was calculated using the equation Papp (cm/sec) = ΔCs×Cm−1×V×A−1×T−1, where ΔCs is the increase in FITC concentration in the serosal chamber during the interval T (sec), Cm is the FITC concentration in the mucosal chamber, V is the volume (ml) of either the mucosal or serosal compartment and A is the exposed surface of the colon specimen (cm2). Serosal (Cs) and mucosal (Cm) FITC concentrations were corrected respectively for dilution and flux.

Statistical analyses

Data are expressed as means±S.E.M. Student's t-test was used for statistical analysis of differences between experimental groups. In experiments on human colon each data set represents independent measurements on separate specimen (n) obtained from stripped mucosal preparation (m), were one to three tissue specimen were obtained from the same colon. Student's t-test for paired data was performed between results obtained on separate specimen (n) in treated vs untreated condition. A p-value equal or below 0.05 was defined as a significant difference. Calculations were performed with the NCSS2007 software (Hintze J. Kaysville, UT, USA, www.NCSS.com).

Results

VCC induces chloride efflux from Caco-2 cells

Diarrheagenic toxins affect Cl secretion in the intestine. Based on its channel properties, as discussed above, we first evaluated whether VCC was able to promote a chloride efflux in the Caco-2 intestinal cell line. Chloride movement was monitored using the chloride-sensitive fluorescent dye MEQ, whose increase in fluorescence indicates chloride efflux from the cytoplasm. Cells loaded with diH-MEQ were incubated with PBS (control) or with 500 pM VCC for 30 minutes before each experiment. After a basal record of fluorescence in Cl-containing HEPES buffer, cells were perfused with a chloride-free buffer to induce a chloride efflux from the cytoplasm and subsequently exposed to HEPES buffer to allow the chloride readmission. As shown in Fig. 2A this manoeuvre induced in the control cells an increase in fluorescence followed by a decrease, suggesting the presence of functional chloride channels on the plasma membrane. In cells treated with VCC the extent of increased fluorescence was significantly higher suggesting an increase in chloride permeability. This effect could be mediated by the activation of endogenous channels by the toxin or by the toxin itself. To discriminate between these two alternative possibilities the effect of the chloride channel inhibitor DIDS, an efficient blocker of the VCC-formed channels [18], was evaluated on control and VCC-treated cells. As shown in Fig. 2B, incubation with 100 µM DIDS did not affect the fluorescence signal of control cells, demonstrating that the endogenous channels were not blocked by DIDS at the concentration used. In contrast, DIDS completely abrogated the enhanced fluorescence signal of toxin-treated cells. These data strongly suggest that VCC forms chloride channels in the plasma membrane of the cells.

thumbnail
Figure 2. Chloride efflux induced by VCC in Caco-2 cells.

A) Caco-2 cells, loaded with MEQ were incubated with (thick line) or without (thin line) 500 pM VCC. Fluorescence was estimated upon sequential buffer substitution with Cl- containing medium (# 1) followed by Cl-free medium (# 2). Substitution of solution (#1) by solution (#2) led to an increase of MEQ fluorescence (dequenching). Subsequent substitution by solution #1 induced an influx of Cl ions, thus quenching MEQ fluorescence. Values are normalized with respect to the base line. B) Effect of 100 µM DIDS on VCC-induced chloride efflux. ΔF has been calculated as reported in the Material and Methods section. Each histogram represents an average of thirteen independent experiments with a recording of 2–3 cells in each assay. Significance, determined by Student's t test, was compared to non-treated cells (Ctrl); ***, p<0.001.

https://doi.org/10.1371/journal.pone.0005074.g002

VCC determines short circuit current (Isc) increase and transepithelial resistance (RT) decrease in the whole intact intestinal epithelium

In subsequent experiments, we assessed whether VCC acts as Cl channel also in a human model of the natural anatomical site of the bacterial colonization. V. cholerae infection affects both small and large bowel [30], however, the possibility to obtain human jejunum rather than colon specimen is scanty, whilst large intestine specimens are more common. Accordingly, we used human healthy sigmoid colon mucosal sheets, obtained from 47 patients (28 male and 19 female; ages between 32 and 84) undergoing subtotal colectomy for colon cancer. A total of 62 specimens (n) from 37 tissues (m), mounted in Ussing chambers at 37°C and bathed in oxygenated Krebs solution, exhibited a basal VT value of −7.28±(S.E.M.) 0.49 mV, lumen negative; RT was 149.24±5.22 Ω cm2 and ISC was 37.16±1.57 µA/cm2. Topical exposure to VCC (0.2, 0.5, 1 nM) did not elicit significant changes within 90 min (n = 8; m = 6), data not shown. The inefficacy of VCC in these experiments could be related to the presence of the protective mucus layer coating the gut lumen [31], [32], which is however penetrated by vibrions. Therefore, in order to improve VCC interaction with the apical membranes of colon enterocytes, the luminal mucus layer was removed by enzymatic exposure (as explained in the Material and Methods section).

Following removal of the enzyme cocktail, exposure to 1 nM VCC (n = 10; m = 7) within 90 min increased significantly ISC by 20.7% (p<0.05 vs control) and reduced RT by 12.3% (p<0.05) while VT decreased by about 7% but not significantly, as reported in Fig. 3. Following the same protocol, the exposure to 0.5 nM VCC (n = 5; m = 2) elicited similar responses but with smaller significance (Fig. 3). RT reduction and ISC increase reflect alteration of the epithelial permeability and enhancement of the ion flux which might be related to VCC-dependent channel formation. In order to test the sensitivity of the human colon epithelial model to pore-forming bacterial toxins, a series of comparative experiments was performed using α-Hemolysin of Staphylococcus aureus [33], [34]. Following similar protocol for mucus layer removal by enzymatic treatment, exposure to 120 nM α-Hemolysin within 90 min increased significantly ISC by 46.3% (p<0.02 vs control), while VT became more negative by 49.9% (p<0.02 vs control) and RT was reduced by 8.7%, albeit not significantly (Fig. 4). Similar, although minor, responses were observed with 60 and 90 nM α-Hemolysin.. Alteration of the epithelial parameters points to a correlation with toxin-dependent channel formation.

thumbnail
Figure 3. Effect of mucosal exposure to VCC.

Human sigmoid colon specimens mounted in Ussing chamber were sequentially monitored for transepithelial potential difference (VT, mV) and tissue resistance (RT, Ω cm2) changes under open-circuit condition, and for short circuit current (ISC, µA/cm2) with voltage clamped to zero. Electrical parameters were measured in the basal state (Ctrl) and during incubation (Treated) with VCC 1 nM (filled circles: n = 10; m = 7) or 0.5 nM (empty squares: n = 5; m = 2). All tissues were treated with mucolytic solution (ML) containing papain (5 U/100 ml) plus L-cysteine (5 mM) prior exposure to VCC. Each data point represents the average±S.E.M. of measurements in n specimen from m mucosae. Significance was determined by Student's t test for paired data of treated vs control (time = 0); *, p<0.05.

https://doi.org/10.1371/journal.pone.0005074.g003

thumbnail
Figure 4. Effect of mucosal exposure to Staphylococcus aureus α-hemolysin.

Human sigmoid colon specimens in the basal state (Ctrl) and during mucosal incubation (Treated) with α-hemolysin 60 nM (filled triangles: n = 5; m = 4), 90 nM (empty squares: n = 3; m = 3) and 120 nM (filled circles: n = 6; m = 6). Electrical parameters were measured as reported in legend of Fig. 3. Each data point represents the average±S.E.M. of measurements in n specimen from m mucosae. Significance was determined by Student's t test for paired data of treated vs control (time = 0); *, p<0.05; **, p<0.02.

https://doi.org/10.1371/journal.pone.0005074.g004

VCC did not affect paracellular permeability

It is widely accepted that trans-epithelial resistance is an accurate marker of epithelial viability and correlates with selective mucosal permeability [35], [36]. In order to investigate whether a paracellular ion flux could contribute to the VCC-induced RT reduction, the permeability of colon mucosa was assessed by mucosal-to-serosal FITC flux [29]. Fig. 5 shows that FITC apparent permeability after mucosal exposure to VCC (1 nM) for 60 min was 1.3×10−5±4.4×10−6 cm/sec (n = 4), a value not significantly different from 1.1×10−5±5.5×10−6 cm/sec (n = 4), observed in the presence of VCC vehicle (PBS). Dissimilarly, mucosal exposure to the polyamine protamine increased significantly epithelial permeability up to 3.2×10−5±6.9×10−6 cm/sec (n = 4; p<0.05 vs control), as observed in other substrates [37].

thumbnail
Figure 5. Effect of VCC on paracellular permeability.

Paracellular permeability of human colon specimen (0.8 cm2) mounted in Ussing chamber to mucosal-to-serosal flux of fluorescein isothiocyanate (FITC 140 µM) was measured in the presence or absence of mucosal VCC (1 nM) or protamine (100 mg/ml). Data are expressed as apparent permeability (Papp) calculated as reported in the Material and Methods. Each data point represents the average of 4 independent experiments. T-test for paired data was performed vs control (PBS exposed mucosa): * p<0.05.

https://doi.org/10.1371/journal.pone.0005074.g005

VCC-induced effects on intestinal epithelium depend on chloride channels

Correlation between the observed effects and putative VCC chloride channels was tested by lowering Cl in the mucosal and serosal solution from 116 mM to 9 mM (NaCl replaced with Na-Isethionate). If chloride channels are functional in the cell plasma membrane this manoeuvre should lead to diminution of the VCC effect on ISC but not on RT since Cl reduction would affect the ion transport but not channel formation. Fig. 6 shows that in 4 specimen from 3 tissues bilateral incubation with low-Cl reduced VT by 60.9% (p<0.02) and ISC by 86.8% (p<0.02) up to current polarity inversion. RT was reduced only by 4.9%. These changes could be interpreted as a consequence of the reduced Cl secretion from the crypts [30]. Exposure to 1 nM VCC during bilateral chloride diminution (n = 3; m = 3), reduced ISC and VT by 46.8% (p<0.02) and 22.0% (p<0.05) respectively, while RT was reduced by 9.1%. The variations reflect the increase of the epithelial permeability related to chloride channel formation and its influence on ion transport in both the crypt and surface epithelial cells.

thumbnail
Figure 6. Effect of VCC during bilateral incubation in low-Cl solution.

The colon specimens mounted in Ussing chamber were incubated in low-Cl (9 mM) solution, from the beginning to the end of the experiment, in the presence or in the absence of mucosal VCC 1 nM. Electrical parameters were measured as reported in legend of Fig. 2. Filled circles refer to toxin-exposed tissues (n = 3; m = 3), while empty circles refer to non-treated tissues (n = 4; m = 3). Significance was determined by Student's t test for paired data of control (time = 0) and treated; *, p<0.05;**, p<0.02.

https://doi.org/10.1371/journal.pone.0005074.g006

VCC-induced effects are independent on Na+ transport

Since VCC-induced current increase could depend either on the Cl secretion or on the electrogenic Na+ absorption, the potential relationship between the VCC-induced current increase and Na+ transport was tested using the Na+ channel blocker amiloride [38], [39]. Fig. 7 shows that in 4 specimen from 3 tissues amiloride (0.1 mM) significantly reduced the ISC and the VT by 41.1% (p<0.02) and 16.5% (p<0.05) respectively, while RT increased by 9.8% (p<0.02). Subsequent exposure to 1 nM VCC in 1 hour increased ISC and VT toward control levels up to 28% and 14% respectively, while RT was reduced by 7.5%. Replacing the mucosal bath with Krebs solution removed the effects of amiloride restoring the ISC almost to the control value, while dropped the RT to about 9.3% below control value. The latter effect was probably due to the formation of VCC-induced channels.

thumbnail
Figure 7. Effect of amiloride on VCC-induced Isc.

Effect of VCC (1 nM) on Na+ conductance was tested on amiloride (0.1 mM) pretreated human sigmoid colon (n = 4; m = 3). Electrical parameters were measured in the basal state (Ctrl), followed by incubation with mucosal amiloride (30 min), successive addition of VCC (60 min) and after removing the agonists (Ctrl). Significance was determined by Student's t test for paired data of control (time = 0) and treated; *, p<0.05;**, p<0.02.

https://doi.org/10.1371/journal.pone.0005074.g007

VCC contributes to the endogenous chloride movement through the intestinal epithelium

In order to better analyze the Cl ion movement that occurred through the VCC-formed pores we used the chloride channel inhibitor DIDS, on both control tissue and toxin-treated colon, at a concentration able to block chloride transport in apical membrane vesicles from human distal colon [40], and in the whole rat colon [41]. As reported in Fig. 8, DIDS (1 mM), after 90 min of incubation, increased significantly RT by 14.4% (p<0.02; n = 7; m = 5). ISC and VT were both altered transiently in the first 30 min: ISC decreased with a maximal reduction of 22.9%, while VT increased by 5.9%, albeit both changes were not significant. RT increase is suitable with apical endogenous anionic channel blockage, while transient VT increase and ISC decrease could probably be related to the progressive reduction of both the basolateral Na+-K+-2Cl cotransport activity and the K+ recirculation through the basolateral K+ channels following blockage of apical Cl exit [30], [41], [42]. Exposure to 1 nM VCC at the same time of DIDS transiently increased VT within 30 min by 33.1% (p<0.02) and ISC by 8.2% (n = 7; m = 4). The increase could be probably interpreted as progressive appearance and blockage of VCC-formed channels. The VCC-induced RT drop was partially inhibited by DIDS. An analysis comparing the three sets of experiments (exposure to VCC, DIDS and VCC+DIDS) and converting the epithelial resistance into conductance indicates that DIDS inhibits by about 70% the toxin anion channels. Taken together, these findings suggest that VCC-formed channels can support additional apical chloride efflux from human colon tissue samples.

thumbnail
Figure 8. Effect of DIDS on VCC-induced Isc.

Effect of VCC on human sigmoid colon Cl conductance was tested by mucosal exposure to DIDS (1 mM) in the presence (n = 7; m = 4) or in the absence (n = 7; m = 5) of VCC 1 nM. Filled circles refer to toxin-exposed tissues while empty circles refer to non-treated tissues. Electrical parameters were measured in the basal state (Ctrl), during incubation with DIDS or DIDS plus VCC added to the mucosal side (Treated) and after removing the agonists (Ctrl). Significance was determined by Student's t test for paired data of control (time = 0) and treated; *, p<0.05;**, p<0.02.

https://doi.org/10.1371/journal.pone.0005074.g008

Discussion

The mechanism involved in the pathogenesis of human enteritis consequent to infections sustained by non-toxigenic Vibrio cholerae strains remains still unclear [9], [43], [44] and no single virulence factor has yet been identified to explain their enterotoxicity [45]. VCC, the hemolysin produced by virtually all Vibrio cholerae strains, has been proposed as a possible candidate: Hichinose and colleagues, first reported the enterotoxicity of El Tor-like hemolysin from non-O1 V. cholerae in 1987 [20], a finding that was later confirmed [6], [46]. However, although collectively these data suggest a crucial role for VCC as an enterotoxic virulence factor, a clear-cut demonstration is still lacking.

Considering that one of the mechanisms of toxin-induced diarrhoea depends on direct effects on ion transport in intestinal epithelial cells [22], we examined the effects of purified VCC on human healthy sigmoid colon mucosal sheets. The sensitivity of the human colon epithelial model to pore-forming bacterial toxins was also assessed by comparative experiments using α-Hemolysin of Staphylococcus aureus.

The exposure to the VCC significantly reduced RT up to 12.3% and increased ISC up to 20.7% within 90 min.

The RT decrease could be the result of change either in the epithelial cell membrane conductance or in the paracellular pathway. Evaluation of the mucosal-to-serosal flux of fluorescein isothiocyanate demonstrated that paracellular pathway is not affected by the VCC, thus the RT decrease could be related to modification of the transcellular resistance and represents the major evidence that VCC forms pores. The analysis of time course for RT and ISC changes upon VCC exposure suggests that, for the concentrations used in our experiments, the channel formation is a gradual process that reaches its maximum within one hour.

In the absence of VCC, and with a null mucosal vs serosal ionic gradient, the polarization of the whole epithelium depends either on the Cl secretion or on the electrogenic Na+ absorption. In the distal colon the Cl secretion occurs mainly through the cystic fibrosis transmembrane conductance regulator channels (CFTR), which is expressed throughout the entire colonic epithelium but dominates in the lower part of the crypts [30]. The Na+ transport relies mainly on amiloride-sensitive Na+ channels (ENaC) expressed in the surface epithelium and upper crypts [30]. On the basis of these considerations, the ISC increase consequent to the VCC exposure could be compatible with the enhancement of either the Cl secretion or the Na+ absorption.

If, by hypothesis, VCC forms cation channels, as suggested in a previous report [24], we would expect a rise of the ISC associated to an increased electrogenic Na+ flux. Our experiments with amiloride, a typical inhibitor of the Na+ conductance [39], showed that the VCC-dependent ISC increase, as well as the RT decrease, are not affected by the loop diuretic, excluding the Na+ flux involvement in the VCC-induced effects.

In order to confirm that the ISC increase, observed upon VCC exposure, was due to the Cl ion passage through VCC-formed channels, we evaluated the effects of the toxin after reducing Cl concentration in the incubation milieu. Mucosal VCC addition elicited a large drop of the RT compatible with channel formation in the apical membrane and responsible for a conductance increment which is virtually independent from the ion concentration. In contrast, the ISC, which remained almost constant during the first 30 minutes, probably because of progressive VCC-channel formation, subsequently started to decrease reaching 50% of the initial value. This demonstrated that the ISC increment induced by the toxin (Fig. 3) is principally related to the Cl movement. Treatment with the chloride channel inhibitor DIDS also confirmed that the ion movement occurs through VCC-formed pores.

Altogether these results represent the first in vivo evidence that VCC could be a diarrhogenic factor. Indeed, abnormal secretion of Cl across the intestinal apical membrane would increase the outward movement of Na+ and water, leading to the accumulation of fluid in the gastro-intestinal tract.

Acknowledgments

The authors thank Prof. G. Teti (Department of Pathology and Experimental Microbiology, University of Messina) for valuable advice, Prof. G. Palasciano (Clinica Medica “A. Murri”, University of Bari) for instrumentation availability, Dr. B. Cetera, Dr. G. Busco and Dr. A. Garbetta for joining some measurements. The authors also thank Prof. F. Prete, Dr. L. Scoppetta (Surgical Unit) and Dr. V.L. Troilo (Department of Emergency and Organ Transplantation) - Policlinico of Bari, for kindly supplying the human colon tissues.

Author Contributions

Conceived and designed the experiments: LD AD DA CS MDB. Performed the experiments: LD AD DA RF. Analyzed the data: LD CS MDB. Contributed reagents/materials/analysis tools: LD PP DFA MDB. Wrote the paper: LD MDB.

References

  1. 1. World Health Organization (2001) Cholera vaccines. Wkly Epidemiol Rec 76: 117–124.World Health Organization2001Cholera vaccines.Wkly Epidemiol Rec76117124
  2. 2. Faruque SM, Albert MJ, Mekalanos JJ (1998) Epidemiology, genetics, and ecology of toxigenic Vibrio cholerae. Microbiol Mol Biol Rev 62: 1301–1314.SM FaruqueMJ AlbertJJ Mekalanos1998Epidemiology, genetics, and ecology of toxigenic Vibrio cholerae.Microbiol Mol Biol Rev6213011314
  3. 3. Karaolis DK, Johnson JA, Bailey CC, Boedeker EC, Kaper JB, et al. (1998) A Vibrio cholerae pathogenicity island associated with epidemic and pandemic strains. Proc Natl Acad Sci U S A 95: 3134–3139.DK KaraolisJA JohnsonCC BaileyEC BoedekerJB Kaper1998A Vibrio cholerae pathogenicity island associated with epidemic and pandemic strains.Proc Natl Acad Sci U S A9531343139
  4. 4. Sanyal SC, Huq MI, Neogy PK, Alam K, Kabir MI, et al. (1984) Experimental studies on the pathogenicity of Vibrio mimicus strains isolated in Bangladesh. Aust J Exp Biol Med Sci 62: 515–521.SC SanyalMI HuqPK NeogyK. AlamMI Kabir1984Experimental studies on the pathogenicity of Vibrio mimicus strains isolated in Bangladesh.Aust J Exp Biol Med Sci62515521
  5. 5. Saha DR, Pal A, Rajendran K, Dutta P (2006) Histopathological changes in experimental cholera with a non toxigenic non- O1 non-O139 Vibrio cholerae strain isolated from Kolkata, India. Indian J Exp Biol 44: 221–227.DR SahaA. PalK. RajendranP. Dutta2006Histopathological changes in experimental cholera with a non toxigenic non- O1 non-O139 Vibrio cholerae strain isolated from Kolkata, India.Indian J Exp Biol44221227
  6. 6. Saka HA, Bidinost C, Sola C, Carranza P, Collino C, et al. (2008) Vibrio cholerae cytolysin is essential for high enterotoxicity and apoptosis induction produced by a cholera toxin gene-negative V. cholerae non-O1, non-O139 strain. Microb Pathog 44: 118–128.HA SakaC. BidinostC. SolaP. CarranzaC. Collino2008Vibrio cholerae cytolysin is essential for high enterotoxicity and apoptosis induction produced by a cholera toxin gene-negative V. cholerae non-O1, non-O139 strain.Microb Pathog44118128
  7. 7. Coelho A, Andrade JR, Vicente AC, Salles CA (1995) New variant of Vibrio cholerae O1 from clinical isolates in Amazonia. J Clin Microbiol 33: 114–118.A. CoelhoJR AndradeAC VicenteCA Salles1995New variant of Vibrio cholerae O1 from clinical isolates in Amazonia.J Clin Microbiol33114118
  8. 8. Saha PK, Koley H, Mukhopadhyay AK, Bhattacharya SK, Nair GB, et al. (1996) Nontoxigenic Vibrio cholerae O1 serotype Inaba biotype El Tor associated with a cluster of cases of cholera in southern India. J Clin Microbiol 34: 1114–1147.PK SahaH. KoleyAK MukhopadhyaySK BhattacharyaGB Nair1996Nontoxigenic Vibrio cholerae O1 serotype Inaba biotype El Tor associated with a cluster of cases of cholera in southern India.J Clin Microbiol3411141147
  9. 9. Ninin E, Caroff N, El Kouri D, Espaze E, Richet H, et al. (2000) Nontoxigenic Vibrio cholerae O1 bacteremia: case report and review. Eur J Clin Microbiol Infect Dis 19: 489–491.E. NininN. CaroffD. El KouriE. EspazeH. Richet2000Nontoxigenic Vibrio cholerae O1 bacteremia: case report and review.Eur J Clin Microbiol Infect Dis19489491
  10. 10. Alm RA, Stroeher UH, Manning PA (1988) Extracellular proteins of Vibrio cholerae: nucleotide sequence of the structural gene (hlyA) for the haemolysin of the haemolytic El Tor strain 017 and characterization of the hlyA mutation in the non-haemolytic classical strain 569B. Mol Microbiol 2: 481–488.RA AlmUH StroeherPA Manning1988Extracellular proteins of Vibrio cholerae: nucleotide sequence of the structural gene (hlyA) for the haemolysin of the haemolytic El Tor strain 017 and characterization of the hlyA mutation in the non-haemolytic classical strain 569B.Mol Microbiol2481488
  11. 11. Yamamoto K, Ichinose Y, Shinagawa H, Makino K, Nakata A, et al. (1990) Two-step processing for activation of the cytolysin/hemolysin of Vibrio cholerae O1 biotype El Tor: nucleotide sequence of the structural gene (hlyA) and characterization of the processed products. Infect Immun 58: 4106–4116.K. YamamotoY. IchinoseH. ShinagawaK. MakinoA. Nakata1990Two-step processing for activation of the cytolysin/hemolysin of Vibrio cholerae O1 biotype El Tor: nucleotide sequence of the structural gene (hlyA) and characterization of the processed products.Infect Immun5841064116
  12. 12. Nagamune K, Yamamoto K, Honda T (1997) Intramolecular chaperone activity of the pro-region of Vibrio cholerae El Tor cytolysin. J Biol Chem 10: 1338–1343.K. NagamuneK. YamamotoT. Honda1997Intramolecular chaperone activity of the pro-region of Vibrio cholerae El Tor cytolysin.J Biol Chem1013381343
  13. 13. Zitzer A, Zitzer O, Bhakdi S, Palmer M (1999) Oligomerization of Vibrio cholerae cytolysin yields a pentameric pore and has a dual specificity for cholesterol and sphingolipids in the target membrane. J Biol Chem 274: 1375–1380.A. ZitzerO. ZitzerS. BhakdiM. Palmer1999Oligomerization of Vibrio cholerae cytolysin yields a pentameric pore and has a dual specificity for cholesterol and sphingolipids in the target membrane.J Biol Chem27413751380
  14. 14. Krasilnikov OV, Merzlyak PG, Lima VL, Zitzer AO, Valeva A, et al. (2007) Pore formation by Vibrio cholerae cytolysin requires cholesterol in both monolayers of the target membrane. Biochimie 89: 271–277.OV KrasilnikovPG MerzlyakVL LimaAO ZitzerA. Valeva2007Pore formation by Vibrio cholerae cytolysin requires cholesterol in both monolayers of the target membrane.Biochimie89271277
  15. 15. Pantano S, Montecucco C (2006) A molecular model of the Vibrio cholerae cytolysin transmembrane pore. Toxicon 47: 35–40.S. PantanoC. Montecucco2006A molecular model of the Vibrio cholerae cytolysin transmembrane pore.Toxicon473540
  16. 16. Coelho A, Andrade JR, Vicentem AC, Dirita VJ (2000) Cytotoxic cell vacuolating activity from Vibrio cholerae hemolysin. Infect Immun 68: 1700–1705.A. CoelhoJR AndradeAC VicentemVJ Dirita2000Cytotoxic cell vacuolating activity from Vibrio cholerae hemolysin.Infect Immun6817001705
  17. 17. Figueroa-Arredondo P, Heuser JE, Akopyants NS, Morisaki JH, Giono-Cerezo S, et al. (2001) Cell vacuolation caused by Vibrio cholerae hemolysin. Infect Immun 69: 1613–1624.P. Figueroa-ArredondoJE HeuserNS AkopyantsJH MorisakiS. Giono-Cerezo2001Cell vacuolation caused by Vibrio cholerae hemolysin.Infect Immun6916131624
  18. 18. Moschioni M, Tombola F, de Bernard M, Coelho A, Zitzer A, et al. (2002) The Vibrio cholerae haemolysin anion channel is required for cell vacuolation and death. Cell Microbiol 4: 397–409.M. MoschioniF. TombolaM. de BernardA. CoelhoA. Zitzer2002The Vibrio cholerae haemolysin anion channel is required for cell vacuolation and death.Cell Microbiol4397409
  19. 19. Saka HA, Gutiérrez MG, Bocco JL, Colombo MI (2007) The autophagic pathway: a cell survival strategy against the bacterial pore-forming toxin Vibrio cholerae cytolysin. Autophagy 3: 363–365.HA SakaMG GutiérrezJL BoccoMI Colombo2007The autophagic pathway: a cell survival strategy against the bacterial pore-forming toxin Vibrio cholerae cytolysin.Autophagy3363365
  20. 20. Hichinose Y, Yamamoto K, Nakasone N, Tanabe MJ, Takeda T, et al. (1987) Enterotoxicity of El Tor-like hemolysin of non-O1 Vibrio cholerae. Infect Immun 55: 1090–1093.Y. HichinoseK. YamamotoN. NakasoneMJ TanabeT. Takeda1987Enterotoxicity of El Tor-like hemolysin of non-O1 Vibrio cholerae.Infect Immun5510901093
  21. 21. Singh DV, Matte MH, Matte GR, Jiang S, Sabeena F, et al. (2001) Molecular analysis of Vibrio cholerae O1, O139, non-O1, and non-O139 strains: clonal relationships between clinical and environmental isolates. Appl Environ Microbiol 67: 910–921.DV SinghMH MatteGR MatteS. JiangF. Sabeena2001Molecular analysis of Vibrio cholerae O1, O139, non-O1, and non-O139 strains: clonal relationships between clinical and environmental isolates.Appl Environ Microbiol67910921
  22. 22. Laohachai KN, Bahadi R, Hardo MB, Hardo PG, Kourie JI (2003) The role of bacterial toxins in the induction of changes in membrane transport: implications for diarrhoea. Toxicon 42: 687–707.KN LaohachaiR. BahadiMB HardoPG HardoJI Kourie2003The role of bacterial toxins in the induction of changes in membrane transport: implications for diarrhoea.Toxicon42687707
  23. 23. Hall RH, Drasar BS (1990) Vibrio cholerae HlyA hemolysin is processed by proteolysis. Infect Immun 58: 3375–3379.RH HallBS Drasar1990Vibrio cholerae HlyA hemolysin is processed by proteolysis.Infect Immun5833753379
  24. 24. Zitzer A, Palmer M, Weller U, Wassenaar T, Biermann C, et al. (1997) Mode of primary binding to target membranes and pore formation induced by Vibrio cholerae cytolysin (hemolysin). Eur J Biochem 247: 209–216.A. ZitzerM. PalmerU. WellerT. WassenaarC. Biermann1997Mode of primary binding to target membranes and pore formation induced by Vibrio cholerae cytolysin (hemolysin).Eur J Biochem247209216
  25. 25. Spirlì C, Nathanson MH, Fiorotto R, Duner E, Denson LA, et al. (2001) Proinflammatory cytokines inhibit secretion in rat bile duct epithelium. Gastroenterology 121: 156–169.C. SpirlìMH NathansonR. FiorottoE. DunerLA Denson2001Proinflammatory cytokines inhibit secretion in rat bile duct epithelium.Gastroenterology121156169
  26. 26. Biwersi J, Verkman AS (1991) Cell-permeable fluorescent indicator for cytosolic chloride. Biochemistry 30: 7879–7883.J. BiwersiAS Verkman1991Cell-permeable fluorescent indicator for cytosolic chloride.Biochemistry3078797883
  27. 27. Flemström G, Hällgren A, Nylander O, Engstrand L, Wilander E, et al. (1999) Adherent surface mucus gel restricts diffusion of macromolecules in rat duodenum in vivo. Am J Physiol 277: G375–G382.G. FlemströmA. HällgrenO. NylanderL. EngstrandE. Wilander1999Adherent surface mucus gel restricts diffusion of macromolecules in rat duodenum in vivo.Am J Physiol277G375G382
  28. 28. Debellis L, Papini E, Caroppo R, Montecucco C, Curci S (2001) Helicobacter pylori cytotoxin VacA increases alkaline secretion in gastric epithelial cells. Am J Physiol Gastrointest Liver Physiol 281: G1440–G1448.L. DebellisE. PapiniR. CaroppoC. MontecuccoS. Curci2001Helicobacter pylori cytotoxin VacA increases alkaline secretion in gastric epithelial cells.Am J Physiol Gastrointest Liver Physiol281G1440G1448
  29. 29. Mayol JM, Adame-Navarrete Y, Alarma-Estrany P, Molina-Roldan E, Huete-Toral F, et al. (2006) Luminal oxidants selectively modulate electrogenic ion transport in rat colon. World J Gastroenterol 12: 5523–5527.JM MayolY. Adame-NavarreteP. Alarma-EstranyE. Molina-RoldanF. Huete-Toral2006Luminal oxidants selectively modulate electrogenic ion transport in rat colon.World J Gastroenterol1255235527
  30. 30. Kunzelmann K, Mall M (2002) Electrolyte transport in the mammalian colon: mechanisms and implications for disease. Physiol Rev 82: 245–289.K. KunzelmannM. Mall2002Electrolyte transport in the mammalian colon: mechanisms and implications for disease.Physiol Rev82245289
  31. 31. Atuma C, Strugala V, Allen A, Holm L (2001) The adherent gastrointestinal mucus gel layer: thickness and physical state in vivo. Am J Physiol Gastrointest Liver Physiol 280: G922–G929.C. AtumaV. StrugalaA. AllenL. Holm2001The adherent gastrointestinal mucus gel layer: thickness and physical state in vivo.Am J Physiol Gastrointest Liver Physiol280G922G929
  32. 32. Strugala V, Allen A, Dettmar PW, Pearson JP (2003) Colonic mucin: methods of measuring mucus thickness. Proc Nutr Soc 62: 237–243.V. StrugalaA. AllenPW DettmarJP Pearson2003Colonic mucin: methods of measuring mucus thickness.Proc Nutr Soc62237243
  33. 33. Bhakdi S, Bayley H, Valeva A, Walev I, Walker B, Kehoe M, Palmer M (1996) Staphylococcal alpha-toxin, streptolysin-O, and Escherichia coli hemolysin: prototypes of pore-forming bacterial cytolysins. Arch Microbiol 165: 73–79.S. BhakdiH. BayleyA. ValevaI. WalevB. WalkerM. KehoeM. Palmer1996Staphylococcal alpha-toxin, streptolysin-O, and Escherichia coli hemolysin: prototypes of pore-forming bacterial cytolysins.Arch Microbiol1657379
  34. 34. Eichstaedt S, Gäbler K, Below S, Müller C, Kohler C, Engelmann S, Hildebrandt P, Völker U, Hecker M, Hildebrandt JP (2009) Effects of Staphylococcus aureus-hemolysin A on calcium signalling in immortalized human airway epithelial cells. Cell Calcium 45: 165–176.S. EichstaedtK. GäblerS. BelowC. MüllerC. KohlerS. EngelmannP. HildebrandtU. VölkerM. HeckerJP Hildebrandt2009Effects of Staphylococcus aureus-hemolysin A on calcium signalling in immortalized human airway epithelial cells.Cell Calcium45165176
  35. 35. Prasad M, Ito S, Silen W (1997) Functional studies of in vitro rat distal colon before and after restitution. Surgery 121: 430–439.M. PrasadS. ItoW. Silen1997Functional studies of in vitro rat distal colon before and after restitution.Surgery121430439
  36. 36. Gitter AH, Bendfeldt K, Schulzke JD, Fromm M (2000) Trans/paracellular, surface/crypt, and epithelial/subepithelial resistances of mammalian colonic epithelia. Pflugers Arch 439: 477–482.AH GitterK. BendfeldtJD SchulzkeM. Fromm2000Trans/paracellular, surface/crypt, and epithelial/subepithelial resistances of mammalian colonic epithelia.Pflugers Arch439477482
  37. 37. Peixoto EB, Collares-Buzato CB (2005) Protamine-induced epithelial barrier disruption involves rearrangement of cytoskeleton and decreased tight junction-associated protein expression in cultured MDCK strains. Cell Struct Funct 29: 165–178.EB PeixotoCB Collares-Buzato2005Protamine-induced epithelial barrier disruption involves rearrangement of cytoskeleton and decreased tight junction-associated protein expression in cultured MDCK strains.Cell Struct Funct29165178
  38. 38. Sandle GI, Wills NK, Alles W, Binder HJ (1986) Electrophysiology of the human colon: evidence of segmental heterogeneity. Gut 27: 999–1005.GI SandleNK WillsW. AllesHJ Binder1986Electrophysiology of the human colon: evidence of segmental heterogeneity.Gut279991005
  39. 39. Mall M, Bleich M, Leich M, Kuehr J, Brandis M, et al. (1999) CFTR-mediated inhibition of amiloride sensitive sodium conductance by CFTR in human colon is defective in cystic fibrosis. Am J Physiol Gastrointest Liver Physiol 277: G709–G716.M. MallM. BleichM. LeichJ. KuehrM. Brandis1999CFTR-mediated inhibition of amiloride sensitive sodium conductance by CFTR in human colon is defective in cystic fibrosis.Am J Physiol Gastrointest Liver Physiol277G709G716
  40. 40. Alrefai WA, Ramaswamy K, Dudeja PK (2001) Mechanism(s) of chloride transport in human distal colonic apical membrane vesicles. Dig Dis Sci 46: 2209–2218.WA AlrefaiK. RamaswamyPK Dudeja2001Mechanism(s) of chloride transport in human distal colonic apical membrane vesicles.Dig Dis Sci4622092218
  41. 41. Moschetta A, Portincasa P, Debellis L, Petruzzelli M, Montelli R, et al. (2003) Basolateral Ca2+ -dependent K+-channels play a key role in Cl secretion induced by taurodeoxycholate from colon mucosa. Biol Cell 95: 115–122.A. MoschettaP. PortincasaL. DebellisM. PetruzzelliR. Montelli2003Basolateral Ca2+ -dependent K+-channels play a key role in Cl secretion induced by taurodeoxycholate from colon mucosa.Biol Cell95115122
  42. 42. Greger R, Bleich M, Leipziger J, Ecke D, Mall M, et al. (1997) Regulation of ion transport in colonic crypts. News Physiol Sci 12: 62–66.R. GregerM. BleichJ. LeipzigerD. EckeM. Mall1997Regulation of ion transport in colonic crypts.News Physiol Sci126266
  43. 43. Blake PA, Weaver RE, Hollis DG (1980) Diseases of humans (other than cholera) caused by vibrios. Annu Rev Microbiol 34: 341–367.PA BlakeRE WeaverDG Hollis1980Diseases of humans (other than cholera) caused by vibrios.Annu Rev Microbiol34341367
  44. 44. Finch MJ, Valdespinom JL, Wellsm JG, Perez-Perez G, Arjona F, et al. (1987) Non-01 Vibrio cholerae infections in Cancun, Mexico. Am J Trop Med Hyg 36: 393–397.MJ FinchJL ValdespinomJG WellsmG. Perez-PerezF. Arjona1987Non-01 Vibrio cholerae infections in Cancun, Mexico.Am J Trop Med Hyg36393397
  45. 45. Faruque SM, Chowdhury N, Kamruzzaman M, Dziejman M, Rahman MH, et al. (2004) Genetic diversity and virulence potential of environmental Vibrio cholerae population in a cholera-endemic area. Proc Natl Acad Sci U S A 101: 2123–2128.SM FaruqueN. ChowdhuryM. KamruzzamanM. DziejmanMH Rahman2004Genetic diversity and virulence potential of environmental Vibrio cholerae population in a cholera-endemic area.Proc Natl Acad Sci U S A10121232128
  46. 46. Zitzer AO, Nakisbekov NO, Li AV, Semiotrokev VL, Kiseliov Y, et al. (1993) Entero-cytolysin (EC) from Vibrio cholerae non-O1 (some properties and pore-forming activity). Zentralbl Bakteriol 279: 494–504.AO ZitzerNO NakisbekovAV LiVL SemiotrokevY. Kiseliov1993Entero-cytolysin (EC) from Vibrio cholerae non-O1 (some properties and pore-forming activity).Zentralbl Bakteriol279494504