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Virulence factors of Helicobacter pylori

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ORIGINAL ARTICLE

Virulence Factors of Helicobacter pylori

Luigina Cellini 1 and Gianfranco Donelli2
From the 1Laboratory of Medical Bacteriology, Department of Biomedical Sciences, Universita `G.
DAnnunzio, Chieti and 2Laboratory of Ultrastructures, Istituto Superiore di Sanita, Rome, Italy
Correspondence to: Dr. Luigina Cellini, Dept. Biomedical Sciences, Universita `G. DAnnunzio, Via dei Vestini,
66100 Chieti, Italy. Fax 39 0871 3555282; E-mail: l.cellini@dsb.unich.it

Microbial Ecology in Health and Disease 2000; Suppl 2: 259 262

This review focuses on the main virulence factors characterizing Helicobacter pylori strains. Several pathogenic factors are important for
the establishment and maintenance of H. pylori infection. Among those present in all isolates are the production of urease and
phospholipases, the presence of agella, the ability to attract neutrophils, the expression of iceA gene and a number of adhesins that
ensure tissue-specic colonization. In addition, a subset of H. pylori strains is characterized by: i) a potent toxin (VacA) able to cause
vacuolar degeneration of target cells by interfering with intracellular membrane fusion; and ii) the pathogenicity island (PAI), named
CagPAI that encodes for a putative secretory mechanism in which the cagA gene encodes an immunodominant antigen that is associated
with cytotoxin expression.

INTRODUCTION
Helicobacter pylori colonizes the human stomach early in
life even if only decades later the related pathology may be
expressed. Both the spiral-shaped bacterium and its coccoid form (1 5) persist in a unique biological niche within
the gastric mucus layer (6) and are able to cause a strong
inammatory state and lesions of the gastric mucosa (7)
and to drive a relevant immune response in a restricted
percentage of hosts (8, 9). In fact, disease occurs only in
about 15% of people infected, with the development of
gastritis, gastric glandular athrophy, duodenal and gastric
ulcers, gastric adenocarcinoma or MALT lymphoma (10).
Genomic and phenotipic features of different strains, presumably together with the transient condition of the gastric microenvironment, allow the expression of virulence
factors which enable some strains, rather than others, to
cause disease (7, 10). H. pylori expresses its pathogenicity
through: (i) adhesion to gastric epithelium; (ii) colonization of the mucous gel layer increasing the permeability to
hydrogen ions and pepsin; (iii) penetration in and distruction of intercellular junctions; (iv) invasion of gastric
glands and canaliculi of parietal cells; (v) evasion of host
immune defences; (vi) secretion of enzymes and production
of cytotoxins (11).
Several virulence factors (Table I) contribute to the
pathogenicity of H. pylori.
UREASE
Urease is an important virulence factor for H. pylori and is
critical for bacterial colonization of the human gastric
Taylor & Francis 2000. ISSN 1403-4174

mucosa. H. pylori urease metabolizes urea producing ammonia to neutralise the microenvironment in which the
bacterium resides (12). The presence of cytoplasmatic urease activity suggests a role of this enzyme in assimilation
of organic nitrogen (12, 13). The ammonia production can
damage the gastric mucosa through the disruption of tight
junctions and the alteration of permeability of gastric
epithelium. Moreover, urease stimulates activation of
mononuclear phagocytes and production of inammatory
cytokines (14). The native H. pylori urease consists of a
nickel-containing hexameric molecule with a molecular
mass of approximately 540 kDa made up of two subunits:
UreA [30 kDa] and UreB [62 kDa]. The urease gene
cluster contains nine genes, including ureA and ureB structural genes (15).
PHOSPHOLIPASES
H. pylori phospholipases induce generation of products
such as lysolecithin which disrupt the protective phospholipid-rich layer on the apical membrane of mucus cells
(16).
FLAGELLA
The presence of agella is an essential factor of colonization in H. pylori. Aagellate strains are not able to colonize gnotobiotic piglets (17). H. pylori possesses two to six
polar agella characterized by two types of agellin
proteins coded by aA and aB genes that are required for
full motility and persistent infection of the gastric mucosa
(18). A recent study demonstrated that agellar biosynthesis and urease activity may be linked (19).
Microbial Ecology in Health and Disease

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L. Cellini and G. Donelli

NEUTROPHIL ACTIVATING PROTEIN

H. pylori is able to activate neutrophils and to increase
neutrophil adherence to endotelial cells through the expression of a 150 kDa activating protein (Hp-Nap), made
up of 10 identical subunits, coded by the napA gene (20).
ADHESINS
It is widely accepted that H. pylori adheres to receptors in
the gastric epithelium by means of adhesins. Several specic receptors are involved in these mechanisms including
lipids, gangliosides and sulfated carbohydrates, and different types of adhesins have been characterized (21). An
interesting study revealed the presence of a protein (coded
by babA and babB genes) able to bind the human blood
group antigen Lewis b (Leb) to human gastric epithelial
cells (22).
Furthermore, the chemical structure of LPS of some
strains of H. pylori has been found to mimic Lewis x and
Lewis y blood group antigens expressed in the gastric
mucosa; this may serve to downregulate the immune response in patients with acute and chronic infections (23).
IceA
The gene encoding IceA has been identied in isolates
from patients with peptic ulcer, independently of the vacA
and cagA genotype (24) (see below). The expression of
iceA is induced by adherence of H. pylori to gastric
ephitelium (25). DNA sequencing has revealed the presence of two families: iceA1 and iceA2. Strains with the
iceA1 gene are most frequently associated with peptic
ulceration and increase the production of IL-8 (26).
VACUOLATING CYTOTOXIN (VacA)
One of the primary virulence factors described for H.
pylori is VacA (27). VacA is an oligomeric toxin composed
of 87 kDa active subunits obtained by treatment at low
pH. An antiserum produced against these puried proteins
neutralizes the cytotoxic activity (27). All strains of H.

pylori possess the vacA gene and about 5060% of them

express a fully virulent cytotoxin (28, 29) able to induce
acidic vacuoles in the cytoplasm of eukaryotic cells (11).
The toxin causes vacuolar degeneration of target cells by
interfering with intracellular membrane fusion. The vacuolation mechanism involves the stimulation of adenosinetriphosphate dependant proton pump and of a small
GTPase called rab7 (30 32). Furthermore, VacA induces
an inactivation of energy metabolism followed by mitochondrial damage, leading to impairment of the cell cycle
in gastric epithelial cells (33).
VacA is immunolocalised in the periplasm and outer
membrane of whole bacteria and also in vesicles and outer
membrane blebs (34).
Several different families of vacA alleles characterize H.
pylori and encode products with different activities. Mosaicism in vacA alleles is expressed by ve vacA subtypes of
which three concern signal sequence regions (s1a, s1b and
s2 ) and two middle region motifs (m1 and m2 ) (35, 36).
vacA genotypes are important in vivo because of the diversity-pathogenicity relationship among H. pylori strains
(36). The s1a strains produce higher levels of cytotoxin
with more severe gastric inammation and duodenal ulceration than the other two allelic s types (37). The m1 middle
region allele is more frequently associated with a higher
level of gastric damage as compared with the m2 form and
it is toxic for Hela cells (38). Moreover, the distribution of
vacA genotypes and the association with expression of
pathogenicity is also related to different geographical areas
(39, 40).
Cag PATHOGENICITY ISLAND
H. pylori strains isolated from gastric epithelium can be
classied in at least two groups, named type I and type II,
on the basis of genotypic and phenotypic differences.
Infections by type I strains are associated with the more
severe forms of disease with respect to the less virulent
type II strains (41, 42). Two type I H. pylori strains, 26695
(43) and J99 (44), have been entirely sequenced and they

Table I
Virulence factors of Helicobacter pylori
Factor

Gene

Function

Urease

ure operon

Phospholipase
Flagella
Nap
Adhesins
IceA
VacA
cag PAI

gene
flaA, aB
napA
babA1, babA2
iceA1, iceA2
vacA
31 genes coding for type IV secretion system

CagA

cagA (part of Cag PAI)

Mucosal toxicity, gastric acid neutralisation, assimilation of

organic nitrogen
Disruption of the gastric mucosal barrier
Bacterial motility
Neutrophil activation
Leb binding to gastric epithelium
Homologue of NIa III restriction endonuclease
Cytotoxicity for gastric epithelium
C-X-C chemokine family increasing neutrophilic inltration into
gastric epithelium
Immunodominant antigen

H. pylori virulence

differ from type II strains by the presence of a 40 Kb

locus, containing 31 genes, inserted into the chromosomal
glutamate-racemase gene, named Cag pathogenicity island
(abbreviated CagPAI or Cag region) (41). This secretory
system is involved in the induction of increased gastric
mucosal levels of members of the C-X-C chemokine family, which includes the neutrophil chemoattractant IL-8
(45, 46), and promotes neutrophilic inltration into the
gastric epithelium.
It has recently been demonstrated that multiple genes in
the left half of the CagPAI are required for transcription
of the IL-8 gene in gastric epithelial cells and that this is
related to the activation of protein tyrosine kinase (47).
Several CagPAI genes are homologous to genes of other
pathogens that encode for subunits of the specialized type
IV secretory system that deliver bacterial virulence factors
across the bacterial membrane to the surface or into host
cells (42).
H. pylori containing CagPAI is associated with the
development of chronic active gastritis (26), peptic ulceration (48) and atrophic gastritis with an increased risk of
gastric cancer (49). Before the characterization of CagPAI,
the development of clinical disease related to H. pylori was
associated with the expression of cagA gene (50). CagA is
described as an immunodominant antigen with a molecular mass of 120 kDa able to express the cytotoxin encoded
by vacA. This gene is at one end of the CagPAI and is
considered the marker of its presence (41). Recently, the
presence of CagA positive H. pylori infection has been
related to food allergy (51). In fact, the enhanced mucosal
and inammatory lesions could increase the epithelial permeability with a non selective passage of allergens which,
in atopic subjects, could stimulate the IgE response. The
incidence of CagPAI positive strains is 60 70% all over
the world, except in Korea and Japan where it is nearly
100% (52, 53). Recent studies (54) have demonstrated the
presence of both Cag positive and Cag negative strains in
the same patient, suggesting a dynamic equilibrium among
strains in which the prevalence of one type over the other
modulates the expression of the disease.
ACKNOWLEDGEMENTS
This review has been carried out with nancial support from the
Commission of the European Communities, Agriculture, and
Fisheries (FAIR), specic RTD programme PL98-4230 Intestinal
Flora: Colonization Resistance and Other effects. It does not
reects its views and in no way anticipates the Commissions
future policy in this area.
The careful assistance of Emanuela Di Campli and Donatella
Lombardi in preparation of the manuscript is gratefully
acknowledged.

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