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Fig. 1 Pla subfamily OmpT subfamily Copyright © 2011, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved. Infect. Immun. doi:10.1128/IAI.01165-10 IAI Accepts, published online ahead of print on 18 January 2011 on March 29, 2020 by guest http://iai.asm.org/ Downloaded from

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Page 1: Downloaded from · 25 Cronobacter spp. are emerging neonatal pathogens in humans, associated with 26 outbreaks of meningitis and sepsis. To cause disease, they must survive in blood

Fig. 1

Pla subfamily

OmpT subfamily

Copyright © 2011, American Society for Microbiology and/or the Listed Authors/Institutions. All Rights Reserved.Infect. Immun. doi:10.1128/IAI.01165-10 IAI Accepts, published online ahead of print on 18 January 2011

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*

*

* * *

L1

L2

L3

L4

L5

Fig. 2

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Cpa

Fig. 3.

43

3020

kDa 1 2 3 4 5

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Fig. 4.

A)

B)

0.01

0.1

1

10

100

1000

Lo

g %

su

rviv

al

12% NHS

25% NHS

BAA-894 BAA894∆cpa BAA894∆cpa/

pMMB66EH::cpa

DH5α/

pMMB66EH::cpa

0.01

0.1

1

10

100

1000

Log %

surv

ival

25% NHS

25% CCPIS

25% ACPIS

BAA-894 BAA894∆cpa

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1 2 3 4 5 6

C3α

C3β

Fig. 5.

110

75

kDa

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1 2 3 4 5 6

LAR SNLDEDIIAEENS N

CpA

C3 convertase

C3a C3b

A)

C) D)

C3 α-chain

C3α

C3β

C3α

C3β

C3a

1 2 3 4 5 6

Fig. 6.

110

75

kDa

9

kDa

110

75

kDa

43

B)

30

1 2 3 4 5 6

*

*

*

*20

*

* * *

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Fig. 7.

* *

C4bα’C4bβ

C4bγ

kDa

94

67

43

30

20

1 2 3 4 5 6

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A1)

B1)

Fig. 8

A2) A3)

B2) B3)

3 x 108 bacteria 3 x 107 bacteria 3 x 108 bacteria

3 x 108 bacteria 3 x 107 bacteria

0

0.5

1

1.5

2

2.5

0 50 100 150 200 250 300 350 400

Time (minutes)

A (

40

5 n

m)

Plasmin Plasmi (α2-AP)

0

0.5

1

1.5

0 100 200 300 400 500 600

Time (minutes)

A (

405 n

m)

BAA-894 BAA894∆cpa

BAA894∆cpa/pMMB66EH::cpa BAA-884 (No Plg)

BAA894∆cpa (No Plg) BAA894∆cpa/pMMB66EH::cpa (No Plg)

0

0.5

1

1.5

2

2.5

0 500 1000 1500

Time (minutes)

A (

40

5 n

m)

BAA-894 BAA894∆cpa

BAA894∆cpa/pMMB66EH::cpa BAA-894 (No Plg)BAA894∆cpa (No Plg) BAA894∆cpa/pMMB66EH::cpa (No Plg)

0

0.5

1

1.5

0 100 200 300 400

Time (minutes)

A (

40

5 n

m)

BAA894∆cpa/pMMB66EH::cpa DH5α/pMMB66EH::cpa DH5α/PMMB66EH

0

0.5

1

1.5

0 100 200 300 400 500 600

Time (minutes)

A (

40

5 n

m)

BAA-894 + α2-AP BAA894∆cpa + α2-AP BAA894∆cpa/pMMB66EH::cpa + α2-AP

0

0.5

1

1.5

2

0 500 1000 1500

Time (minutes)

A (

40

5 n

m)

BAA-894 + α2-AP BAA894∆cpa + α2-AP BAA894∆cpa/pMMB66EH::cpa + α2-AP

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1

Cpa, the Outer Membrane Protease of Cronobacter sakazakii Activates Plasminogen 1

and Mediates Resistance to Serum Bactericidal Activity 2

3

A.A. Franco1*, M. H. Kothary

1, G. Gopinath

1, K. G. Jarvis

1,2, C. J. Grim

1,2, L. Hu

1, A. R. 4

Datta1, B. A. McCardell

1, and B. D. Tall

1 5

1CFSAN, FDA, Laurel, MD and

2Oak Ridge Institute for Science and Education, Oak 6

Ridge, TN 7

8

Key words: Cronobacter spp. Serum resistance, outer membrane protease, Cronobacter 9

plasminogen activator, complement components cleavage, plasminogen activity 10

Running title: Resistance of C. sakazakii to Serum and Plasminogen Activity 11

12

Please send reviewers' comments and galley proofs to: 13

Augusto A. Franco, Ph. D., Lab #: 3410, MOD 1 Facility, Virulence Mechanisms 14

Branch, (HFS-025), Division of Virulence Assessment, OARSA, Center for Food Safety 15

and Applied Nutrition, U. S. Food and Drug Administration, 8301 MuirKirk Rd, Laurel, 16

Maryland 20708, Phone #: 301-210-5169; E-mail: [email protected]. 17

* Denotes Corresponding Author. 18

19

20

21

22

23

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ABSTRACT 24

Cronobacter spp. are emerging neonatal pathogens in humans, associated with 25

outbreaks of meningitis and sepsis. To cause disease, they must survive in blood and 26

invade the central nervous system by penetrating the blood-brain barrier. C. sakazakii 27

BAA-894 possesses a ~131 kb plasmid (pESA3) that encodes for an outer membrane 28

protease (Cpa) that has significant identity to proteins that belong to the Pla subfamily of 29

omptins. Members of this subfamily of proteins degrade a number of serum proteins, 30

including circulating complement, providing protection from the complement-dependent 31

serum killing. Moreover, proteins of the Pla subfamily can cause uncontrolled plasmin 32

activity by converting plasminogen to plasmin and inactivating the plasmin inhibitor α2- 33

antiplasmin (α2-AP). These reactions enhance the spread and invasion of bacteria in the 34

host. In this study, we found that an isogenic cpa mutant showed reduced resistance to 35

serum in comparison to its parent C. sakazakii BAA-894 strain. Over-expression of Cpa 36

in C. sakazakii or E. coli DH5α showed that Cpa proteolytically cleaved complement 37

components C3, C3a and C4b. Furthermore, a strain of C. sakazakii over-expressing 38

Cpa caused a rapid activation of plasminogen and inactivation of α2-AP. These results 39

strongly suggest that Cpa may be an important virulence factor involved in serum 40

resistance, as well as spread and invasion of C. sakazakii. 41

42

43

44

45

46

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3

INTRODUCTION 47

Cronobacter spp., formerly known as Enterobacter sakazakii, are Gram-negative 48

rod-shaped bacteria within the family Enterobacteriaceae. The genus, Cronobacter 49

comprises five species, C. sakazakii, C. malonaticus, C. turicensis, C. muytjensii, and C. 50

dublinensis, and genomospecies group 1. They are emerging pathogens that cause severe 51

meningitis, septicemia, or necrotizing enterocolitis in neonates and infants (22, 38, 61). 52

Although the disease frequency is very low, the mortality rate ranges from 40% to as high 53

as 80% (12, 38, 61). Meningitis caused by Cronobacter spp. occurs both as sporadic 54

cases and as outbreaks, and contaminated powdered infant formulas have been 55

epidemiologically implicated as the source of the pathogen in most cases (2, 16, 32, 51). 56

In order to cause meningitis, it is expected that Cronobacter spp. express virulence 57

factors that help in colonization of the mucosal surfaces, allow for the translocation into 58

the blood stream and overcome host defense mechanisms. 59

Little is known about the virulence factors of Cronobacter spp. and the 60

pathogenic mechanisms involved in neonatal infections. Using suckling mice, it was 61

demonstrated that Cronobacter spp. produce an enterotoxin when orally fed; however, 62

the genes encoding the putative toxin have yet to be identified (39, 42). Kothary et al. 63

(23) found that all Cronobacter spp. produce a zinc-containing metalloprotease that 64

causes rounding of CHO cells. It has also been shown that the outer membrane protein A 65

(OmpA) of Cronobacter spp. is involved in the colonization of the gastrointestinal tract 66

and invasion of human intestinal epithelial and brain endothelial cells, as well as 67

subsequent survival in blood to cause meningitis (36, 37, 53). Recently, it was reported 68

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that the outer membrane protein, OmpX together with OmpA are involved in the 69

basolateral invasion of enterocyte-like human epithelial cells by C. sakazakii (21). 70

Whole genome sequencing of C. sakazakii BAA-894 showed that this strain 71

possesses two plasmids, pESA2 and pESA3 (24). By using in silico analysis, we 72

determined that pESA3 encodes an outer membrane protease with significant identity to 73

proteins that belong to the omptin family. The omptins include a family of aspartate 74

proteases which are surface orientated outer membrane proteins expressed by many 75

members of the Enterobacteriaceae (26, 18). Most of the known omptins are bacterial 76

virulence factors and function as proteases, adhesins, or invasins (14, 18, 26). 77

Amino acid sequence analyses of known omptin proteins predict that there are 78

two groups within the family. The first group, called the Pla subfamily, consists of the 79

PgtE of Salmonella enterica, Pla of Yersinia pestis, and PlaA of Erwinia spp. The second 80

subfamily, designated as OmpT, contains OmpT and OmpP of Escherichia coli and SopA 81

of Shigella flexneri (14, 26). Moreover, studies have shown that the members in each 82

subfamily are functionally similar (14, 26). PgtE and Pla are involved in uncontrolled 83

plasmin activity by efficient conversion of human proenzyme, plasminogen to plasmin, 84

inactivation of the plasmin inhibitors α2 antiplasmin (α2-AP) and plasminogen activator 85

inhibitor 1 (PAI-1) (13, 27, 29, 56). These properties enhance the spread and 86

multiplication of Y. pestis and S. enterica in the host (26, 27, 28, 49, 55). Pla and PgtE 87

also degrade a number of serum proteins, including circulating complement, providing Y. 88

pestis and S. enterica protection from complement-dependent serum killing (44, 55). 89

PlaA is likely to play an important role in bacteria-plant interactions. Members of the 90

OmpT subfamily, including OmpT and SopA, slowly cleave plasminogen (33, 34) to 91

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plasmin, which is then quickly inhibited by α2-AP (27). OmpT and SopA have also been 92

found to play a role in bacterial virulence in ways that are unrelated to plasminogen 93

activation. OmpT of E. coli causes the cleavage of protamine and other cationic peptides 94

that possess antibiotic activity (11, 57) and SopA of S. flexneri cleaves IcsA, which is an 95

important requirement in the intercellular spread of shigellae into adjacent host cells by 96

means of actin-based motility (5, 50). 97

Alignment of the amino acid sequence of the C. sakazakii outer membrane 98

protease with different members of omptin family indicates that the protease belong to 99

Pla subfamily. Due to the high similarity with Pla, we named this outer membrane 100

protease ‘Cpa’, which stands for ‘Cronobacter plasminogen activator’. In this study, we 101

investigated the role of Cpa in providing protection to C. sakazakii from complement-102

dependent serum killing, as well as in activating plasminogen and inactivating α2-AP. 103

MATERIALS AND METHODS 104

Bacterial strains, plasmids, and culture conditions. The bacterial strains and 105

plasmids used in this study are described in Table 1. A strain of C. sakazakii BAA-894 106

which was resistant to nalidixic acid (BAA894NA) was isolated as a spontaneous mutant 107

using the method described by Johnson et al. (20). Cronobacter spp. and E. coli strains 108

were grown at 37oC in Luria-Bertani (LB) broth with shaking (175 rpm) or on LB agar. 109

Antibiotics were added when required at the following concentrations: ampicillin (100 110

µg/ml) and nalidixic acid (256 µg/ml). 111

Construction of cpa isogenic mutant. Nucleotide sequence of plasmid pESA3 112

was obtained from the GenBank database 113

(http://www.ncbi.nlm.nih.gov/Genbank/index.html; Accession NC_009780). Sequence of 114

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the gene ESA_pESA3p05434 (named cpa in this study) and flanking regions were used 115

to design primers for isolation of a cpa mutant and cloning of cpa (24). A cpa isogenic 116

mutant was created in C. sakazakii BAA-894 using the method previously described for 117

the mutation of the Bacteroides fragilis toxin gene (46). Briefly, a primer internal to and 118

orientated upstream of cpa (primer mut2; XhoI, 5'-119

gcggatgactcgagtgttacagaagaagcggcattcgc) was used in a PCR reaction with primer mut1 120

(XbaI, 5'-cgacggactctagactggagtgtggactgggcgctttatg) located approximately 3 kb 121

upstream of primer mut2 (restriction sites are underlined). A second PCR reaction used a 122

primer within cpa oriented downstream (primer mut3; XhoI, 5'-123

gcgcgactctcgagatgattaataacgcgaccggaacgtc) with a primer located approximately 3 kb 124

downstream of primer 3 (primer mut4; XbaI, 5'-125

gcgccacttctagatctggtgcgcacctttgatgcgctgc); the restriction sites are underlined. PCR 126

reactions with primers mut1 and mut2 and primers mut3 and mut4 were performed with 127

AccuPrime Taq DNA Polymerase High Fidelity (Invitrogen). The PCR products were 128

digested with XbaI and XhoI and cloned by three-way ligation into the suicide vector 129

pCVD442 at the XbaI site (4). Ligation of the XhoI sites created an in-frame deletion, 130

removing 87% of the 936 bp of cpa. E. coli DH5α גpir was transformed with the ligated 131

DNA sample and a plasmid containing the PCR products in the correct orientation was 132

selected (pCVD442::∆cpa) by PCR and sequenced to demonstrate mutation of cpa. Then 133

pCVD442::∆ cpa was transformed into E. coli SM10 גpir and then mobilized into C. 134

sakazakii BAA894NA. Single homologous recombination clones were selected in LB-135

agar containing ampicillin and nalidixic acid and, subsequently, double homologous 136

recombination mutants were selected in LB-agar containing 10% sucrose as described by 137

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Donnenberg and Kaper (4). cpa deleted clones which were sucrose resistant and 138

ampicillin sensitive were confirmed by PCR, sequence analyses and Western blot 139

analysis using rabbit anti-His6-Cpa antiserum as described below. 140

Complementation. For complementation of cpa mutant, the cpa gene was 141

amplified by PCR using primers Cpafw (EcoRI, 5’-142

gcctggcggaattcaatggaataatatatgaataagaaacttattgtcg) and Cparv (PstI, 5’- 143

gatcaaagctgcagtcagaaacggtactgaagacctgcgg), digested with EcoRI and PstI and cloned 144

into the Ptac expression vector pMMB66EH (10). The resultant plasmid 145

pMMB66EH::cpa was transformed into E. coli SM10גpir and then mobilized into 146

BAA894∆cpa by conjugation. Expression of Cpa by pMMB66EH::cpa using 147

BAA894∆cpa or DH5α as hosts was induced by 1 mM IPTG; and confirmed by Western 148

blot analysis using rabbit anti-His6-Cpa antiserum as described below. 149

Cpa purification and production of anti-Cpa antiserum. In order to produce 150

antibodies against CpA, a His6-Cpa fusion protein was cloned and expressed in E. coli. 151

Briefly, cpa was cloned into pET30(+) T7 promoter-based expression vector (Novagen, 152

San Diego, CA) by PCR amplification using primers EcoRI, (5’-153

gcctggcggaattcatgaataagaaacttattgtcgtggcga) and XhoI (5’- 154

cggctcgcctcgagtcagaaacggtactgaagacctgcgg). The recombinant plasmid was transformed 155

into E. coli BL21 and the over-expressed His6-Cpa fusion protein was purified under 156

denaturing conditions by chromatography using the Ni-NTA kit according the 157

manufacturer’s instructions (Qiagen, Valencia, CA). Antibodies against His6-Cpa 158

protein were prepared by injecting 1 mg of fusion proteins emulsified with RIBI adjuvant 159

system (Corixa, Hamilton, MT) into rabbits according to FDA/IACUC protocol number 160

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013X. A booster of 500 µg of fusion protein and adjuvant was injected 4 weeks after the 161

first injection. Anti-Cpa antibodies titers were measured using a standard ELISA 162

procedure using Protein A-peroxidase, hydrogen peroxide, and 2, 2′-Azino-bis (3-163

ethylbenzothiazoline-6-sulfonic acid). 164

Identification of Cpa. C. sakazakii and E. coli cultures grown for18 h in LB 165

broth were collected by centrifugation and suspended in PBS (pH 7.4). Bacterial cells 166

were lysed by sonication and cell debris were pelleted by centrifugation. Whole-cell 167

lysates (4 µg) were separated by SDS-PAGE using 8-25% gradient PhastGels (GE 168

Healthcare, Piscataway, NJ), and electro-blotted onto nitrocellulose membranes. Cpa 169

expression was confirmed by using anti-His6-Cpa antisera (1:500 dilution) as the primary 170

antibody, goat anti-rabbit IgG-alkaline phosphatase conjugate as the second antibody 171

(1:3000 dilution), and an alkaline phosphatase substrate detection kit (BioRad, Hercules, 172

CA). 173

Serum survival assay. Wild-type and recombinant C. sakazakii and E. coli 174

strains were grown to mid-logarithmic phase, collected by centrifugation, washed and 175

diluted in phosphate-buffered saline (PBS, pH 7.4). C. sakazakii (106

CFU) and E. coli 176

(107 CFU) cultures were suspended in 12% and 25% of normal human serum (NHS) and 177

incubated at 37oC for 1 h. The bacteria were then serially diluted and plated on LB-agar 178

for quantitative determination. Serum heated at 56oC for 30 min (heat-inactivated serum; 179

HIS) was used as control in all experiments. To differentiate which potential 180

complement activation pathway may be involved in serum resistance, NHS was 181

incubated with 20 mM EGTA plus 5mM MgCl2 for 30 min at 25oC for classical and 182

lectin pathway inactivation (classical and lectin-dependent complement pathway 183

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inactivated serum; CCPIS) (3, 8); or heated at 47oC for 20 min for alternative pathway 184

inactivation (alternative complement pathway inactivated serum; ACPIS) (35). The 185

percentage survival was calculated as follows: average numbers of bacteria that survive 186

exposure to NHS or partially inactivated serum at 1 h divided by number of bacteria that 187

survive exposure to HIS at 1 h multiplied by 100. 188

Proteolysis of complement proteins C3, C3a, and C4b. Two ml of wild-type 189

and recombinant C. sakazakii and E. coli cultures grown to mid-logarithmic phase were 190

collected by centrifugation and resuspended in 0.2 ml of PBS (pH 7.4). To determine 191

proteolysis of purified C3, C3a, and C4b, 6 µl of the bacterial suspension (6 x 107 cells) 192

was added to 4 µl of PBS (pH 7.4) containing 1.8 µg of purified human C3, C3a, or C4b 193

(Calbiochem, San Diego, CA) and then incubated for 45 min and 18 h at 37oC. To 194

determine proteolysis of C3 in NHS, 10 µl of bacterial suspension (1 x 108 cells) was 195

mixed with 5 µl of PBS and 5 µl of NHS (final concentration NHS 25%) and then 196

incubated for 30 min and 18 h at 37oC. After incubation, the samples were centrifuged 197

and supernatants were separated by SDS-PAGE using either 12.5% homogeneous (to 198

identify cleavage of C3) or 8-25% gradient gels (to identify cleavage of C3a, and C4b), 199

electro-blotted to nitrocellulose membrane and probed with goat anti-human C3, or C4b 200

(Calbiochem, San Diego, CA) antibodies. Alkaline phosphatase-conjugated rabbit anti-201

goat antibody was used as a secondary antibody to detect the cleaved complement 202

proteins. 203

Plasminogen activation. Kinetic measurement of plasminogen activation was 204

performed by incubating 3 x 107-8

bacteria, 4 µg of human-Glu-plasminogen 205

(Haematologic Technologies Inc., River Road, VT) and the chromogenic plasmin 206

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substrate Val-Leu-Lys-p-nitroaniline dihydrochloride (0.5 mM S-2251; Chromogenix) in 207

a total volume of 200 µl at 37°C. Plasmin formation was measured every 20 min at 405 208

nm by using a microtiter plate reader (Molecular Devices, Sunnyvale, CA). Plasmin 209

(Sigma-Aldrich) was used as a positive control at a final concentration of 20 µg/ml. The 210

effect of α2-AP on plasmin activity was assayed at a final concentration of 25 µg/ml. 211

Phylogenetic analysis. Phylogenetic analyses of omptins nucleotide sequences 212

were conducted in MEGA4 (60). The evolutionary history was inferred using the 213

Neighbor-Joining method (48). The bootstrap consensus tree inferred from 500 replicates 214

(7) is taken to represent the evolutionary history of the taxa analyzed (7). The percentage 215

of replicate trees in which the associated taxa clustered together in the bootstrap test (500 216

replicates) are shown next to the branches (7). The tree is drawn to scale, with branch 217

lengths in the same units as those of the evolutionary distances used to infer the 218

phylogenetic tree. The evolutionary distances were computed using the Poisson 219

correction method (63) and are in the units of the number of amino acid substitutions per 220

site. All positions containing gaps and missing data were eliminated from the dataset. 221

There were a total of 309 positions in the final dataset. 222

N-terminal Amino Acid Sequencing. The ~100 kDa protein band produced by 223

proteolysis of the C3α was excised from a Western blotted Problott membrane, stained 224

with Coomassie brilliant blue R250, and the N-terminal amino acid sequence was 225

determined by Edmand degradation using a Procise model 492 protein Sequencer 226

(Applied Biosystems, Foster City, CA). 227

Accession numbers. NCBI accession numbers of the nucleotide and proteins 228

sequences used in this study are as follows: Pla, NP_857784; PgtE, AF239770; PlaA, 229

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NP_857613; OmpT, AP_001210; OmpP, X74278; and SopA, NP_858404. NCBI 230

accession number of pESA3 is NC_009780, and cpa has the gene number 231

ESA_pESA3p05434. 232

RESULTS 233

In silico sequence analysis of Cpa. Phylogenetic cluster analysis of the 234

nucleotide sequence of C. sakazakii cpa revealed that cpa clusters with the Pla 235

subfamily of omptins (Fig. 1). The omptins proteases contain a conserved barrel 236

structure with 10 transmembrane β-strands and five surface-exposed loops (L1–L5) (26, 237

27, 62). Mutagenesis scanning, loop swapping, and substitution analyses showed that the 238

differing polypeptide substrate selectivity of omptins is dictated by sequence variation in 239

the surface-exposed loops of the β-barrel (15, 27, 43). Alignment of the amino acid 240

sequence of Cpa with those of Pla, PgtE and OmpT showed that the predicted Cpa 241

surface-exposed loops share a higher identity with those of Pla and PgtE than with OmpT 242

(Fig. 2). A recent study showed that the most variable surface residues between Pla and 243

OmpT subfamilies are T36, L213, I260, D266 and D273 suggesting that these amino 244

acids are important for substrate specificity (13; J. Haiko, personal communication). 245

Sequence alignment of Cpa with Pla and PgtE showed that all of these predicted substrate 246

specific amino acids, except for D266, are conserved in Cpa (Fig. 2). The sequence 247

similarity of Cpa with members of the Pla subfamily of omptins led to our hypothesis that 248

Cpa may have similar functions to those of Pla and/or PgtE. 249

Generation of a C. sakazakii cpa deletion mutant. In order to determine 250

whether Cpa is required for serum resistance and virulence of C. sakazakii, a cpa isogenic 251

mutant, BAA894∆cpa, was constructed. To confirm that the deletion was in-frame 252

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deletion PCR with specific primers targeting internal and flanking regions of cpa was 253

performed and the PCR product was sequenced (data not shown). Western blot analysis 254

using antibodies against the His6-Cpa fusion protein revealed the presence of Cpa (~ 33 255

kDa) in wild-type (WT) strain BAA-894, but not in mutant strain BAA894∆cpa (Fig. 3, 256

lanes 1 and 2). 257

Cpa is required for resistance to complement-mediated killing. The C. 258

sakazakii BAA894∆cpa mutant and WT BAA-894 were tested for survival in the 259

presence of NHS and HIS. Figure 4A shows that incubation for 1 h with 12% NHS, 2% 260

of mutant BAA894∆cpa survived compared to 70% survival rate of WT BAA-894. When 261

serum concentration was increased to 25%, the survival rate declined to 0.16% for 262

BAA894∆cpa and 17% for BAA-894 (Fig. 4A). 263

The cpa mutation was complemented by cloning the cpa gene into the expression 264

vector pMMB66EH and mobilizing this construct into BAA994∆cpa. IPTG induction of 265

Cpa expression in BAA994∆cpa /pMMB66EH::cpa resulted in 99% and 73% survival in 266

the presence of 12% and 25% NHS, respectively (Fig. 4A). Western blot analysis using 267

antibodies against the His6-Cpa fusion protein showed that the BAA994∆cpa 268

/pMMB66EH::cpa complemented strain expressed Cpa at a higher level than WT 269

BBAA-894 (Fig.3, lanes 1 and 3), which could explain the higher level of serum 270

resistance exhibited by BAA994∆cpa/pMMB66EH::cpa compared to WT BAA-894. 271

Also, E. coli DH5α transformed with pMMB66EH::cpa expressed Cpa at a higher 272

level than WT BAA-894 (Fig. 3, lanes 1 and 5). This construct was used to determine if 273

Cpa alone is sufficient to mediate the serum resistance. After 1 h incubation, 38% and 274

0.2% of DH5α/pMMB66EH::cpa survived in the presence of 12% and 25% NHS, 275

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respectively (Fig. 4A). In contrast, DH5α and DH5α carrying the vector pMMB66EH 276

was rapidly killed by 12% and 25% NHS, but not by HIS (data not shown) indicating 277

that Cpa was able to impart serum resistance to E. coli expressing C. sakazakii Cpa 278

protein. These results support our hypothesis that Cpa plays a role in the serum resistance 279

of C. sakazakii. Furthermore, the higher level of serum resistance of 280

BAA894∆cpa/pMMB66EH::cpa than DH5α/ pMMB66EH::cpa suggests that in addition 281

to Cpa there are additional Cronobacter factors that may be involved in serum resistance. 282

Complement pathways involved. The complement cascade is a complex system 283

of 25 to 30 plasma proteins and plays an innate role in the resistance against microbial 284

infections (31, 45). Three pathways can activate the complement system: the classical, 285

the alternative, and the lectin dependent. To determine which complement activation 286

pathways are involved in the Cpa mediated serum resistance, WT BAA-894 and 287

BAA894∆cpa were incubated with 25% of classical and lectin-dependent complement 288

pathway inactivated serum (CCPIS) or 25% of alternative complement pathway 289

inactivated serum (ACPIS). Both the WT and Cpa mutant strains were resistant to 290

CCPIS. However, BAA894∆cpa was more sensitive than WT BAA-894 to ACPIS (Fig. 291

4B) suggesting that Cpa is required for resistance to complement and the resistance is 292

activated selectively by the classical and/or lectin pathways. 293

Proteolytic cleavage of complement components. Component C3 plays a 294

central role in the three complement activation pathways (31, 45). In order to investigate 295

whether Cpa is involved in serum resistance by cleaving C3, NHS was incubated with 296

WT BAA-894 and recombinant C. sakazakii and E. coli strains expressing Cpa and then 297

analyzed by immunoblotting using anti-human C3 antibody (Fig. 5). Human C3 298

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comprises of α and β chains of 110 and 75 kDa, respectively (47). Immunoblot analysis 299

of NHS treated with the WT BAA-894 or one of the Cpa-negative strains, 300

BAA894∆cpa, or DH5α /pMMB66EH, showed intact 110 kDa α and 75 kDa β-chains of 301

C3 (Fig. 5, lanes 1, 2, and 4), whereas the 110 kDa α-chain band disappeared in NHS 302

incubated with that BAA894∆cpa/pMMB66EH::cpa and DH5α/pMMB66EH::cpa (Fig. 303

5, lanes 3 and 5). These data suggest that over-expression of Cpa resulted in the 304

proteolytic cleavage of the C3 α-chain. 305

In order to determine whether strains expressing Cpa directly cleave C3, purified 306

C3 was incubated with the bacterial cells followed by SDS-PAGE and immunoblot 307

analysis using anti-human C3 antibodies. After 45 min incubation at 37oC, the α-chain 308

band was observed at a position (~100 kDa) lower than that of the intact C3 when the 309

protein was incubated with Cpa-expressing strains BAA994∆cpa /pMMB66EH::cpa and 310

DH5α/pMMB66EH::cpa suggesting proteolysis of the α-chain band (Fig. 6A, lanes 3 and 311

5). The 110 kDa α-chain and 100 kDa bands were observed wit WT BAA-894 suggesting 312

that these strains caused partial proteolysis of the α-chain band (Fig. 6A, lane 1), 313

compared to the reaction mixture of intact C3 with the cpa mutant where the α-chain 314

band remained unaltered (Fig. 6A, lane 2). After 18 h of incubation at 37oC, further 315

proteolytic cleavage of C3 was observed in the presence of either BAA894∆cpa 316

/pMMB66EH::cpa, or DH5α/ pMMB66EH::cpa, but not with WT BAA-894 or the cpa-317

mutant strains (Fig. 6B). In addition to the 100 kDa protein, DH5α/pMMB66EH::cpa 318

yielded proteins of approximately 60 and 43 kDa (Fig. 6B, lane 5), whereas the 100 kDa 319

protein was completely degraded to yield proteins of sizes ~ 60, 43, and 20 kDa when C3 320

was incubated with BAA994∆cpa/pMMB66EH::cpa (Fig. 6B lane 3). These results 321

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showed that BAA994∆cpa/pMMB66EH::cpa could proteolytically cleavage the110 kDa-322

C3α chain protein better than DH5α/pMMB66EH::cpa. 323

During activation of the complement, C3 convertase catalyzes the proteolytic 324

cleavage of C3α into C3b and C3a of sizes 101 kDa and 9 kDa, respectively (47). The 325

~100 kDa band resulting from the cleavage of C3 by Cpa-expressing strains (Fig. 6A 326

lanes 1 and 3) appears to be equivalent in size to the C3b α-chain. N-terminal amino acid 327

sequence analysis of this band showed same C3α cleavage pattern for both CpA and C3 328

convertase (Fig. 6C). Further, SDS-PAGE analysis showed that WT BAA-894 and Cpa-329

expressing BAA894∆cpa/pMMB66EH::cpa and DH5α/ pMMB66EH::cpa, but not the 330

mutant BAA894∆cpa, degraded C3a (Fig. 6D). 331

Complement component C4 is the second most abundant component of the 332

complement system and is crucial for activation of both classical and lectin pathways (31, 333

45). C4b molecule composes of three disulfide-linked polypeptides chains C4 α`, β, and γ 334

(1). Western blot analysis showed that Cpa-expressing strain 335

BAA894∆cpA/pMMB66EH::cpa completely degraded the C4b α`-chain and partially 336

degraded C4b β-chain resulting in a protein band of approximately 60 kDa, whereas the 337

wild-type and cpa mutant strains did not cleave C4b (Fig. 7, lanes 1, 2, and 3). In 338

addition to the C4 α`, β, and γ bands, a 60 kDa protein band was observed when C4b was 339

incubated with DH5α/pMMB66EH::cpa suggesting a partial proteolysis of the C4 α’ 340

and/or C4 β chains (Fig. 7, lane 5). 341

Plasminogen activation. We studied the capability of Cpa to convert 342

plasminogen to plasmin and to inactivate the plasmin inhibitor α2-AP. Our previous 343

results indicated that the proteolytic activity of Cpa on complement components is 344

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influenced by Cpa expression levels. To test whether Cpa at different expression levels 345

could activate plasminogen, WT BAA-894, BAA894∆cpa and 346

BAA894∆cpa/pMMB66EH::cpa was evaluated using different bacterial cell 347

concentrations. In the presence of 3 x 108 cells of Cpa over-expressing strain 348

BAA894∆cpa/pMMB66EH::cpa, we observed a rapid activation of plasminogen 349

compared to WT BAA-894, which had a slow plasmin formation, while, no plasminogen 350

activity was detected for the Cpa mutant strain BAA-894∆copa (Fig. 8A1). No activity 351

was detected when WT BAA-894 or BAA894∆cpa/pMMB66EH::cpa were incubated in 352

absence of plasminogen (Fig. 8A1) indicating that the plasminogen activity detected in 353

these strains was not due to direct hydrolysis of the chromogenic substrate S-2224 by 354

CpA. Plasminogen activity of BAA-894 and BAA894∆cpa/pMMB66EH::cpa decreased 355

when plasminogen was incubated with 3 x 107

bacteria (Fig. 8A2) showing that 356

plasminogen activity depends on Cpa concentration. In line with the results observed 357

from the serum-resistance assay and the proteolysis analysis of complement components 358

C3 and C4b, the pMMB66EH::cpa recombinant plasmid expressed in BAA894∆cpa 359

produced higher plasminogen activity than when it was expressed in E. coli DH5α (Fig. 360

8A3). This result suggested that Cpa is proteolytically more active when it is expressed 361

in its native C. sakazakii than when it is heterologously expressed in E. coli. 362

We observed that the plasmin inhibitor, α2-AP, did not inhibit the plasmin 363

activity induced by Cpa over-expressing strain, BAA894∆cpa/pMMB66EH::cpa, in the 364

presence of 3 x 108

bacterial cells, and only transiently inhibited the plasmin activity in 365

the presence of 3 x 107

cells (Fig. 8B1 and B2). In contrast, α2-AP permanently 366

inactivated free plasmin and plasmin activity of WT BAA-894 in presence of both 3 x 367

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108

and 3 x 107 bacteria (Fig.8B1, B2, and B3). These results indicate that the proteolytic 368

inactivation of α2-AP is also dependent upon the concentration of Cpa. 369

DISCUSSION 370

The success of the opportunistic pathogen Cronobacter spp. to cause meningitis is 371

dependent upon its ability to survive in blood and the subsequent invasion of the central 372

nervous system by breaching the blood-brain barrier. In order to achieve these 373

objectives, the bacterial cells must be resistant to complement-dependent killing and must 374

degrade fibrin, collagen and other structural components of the extracellular matrix (28, 375

30). Pla and PgtE have the capacity to activate plasminogen to plasmin and inactivate the 376

plasmin inhibitor α2-AP (27, 29, 56). Plasmin is a broad-specific serine protease that 377

degrades fibrin and collagen, in addition to other structural proteins (41). Plasmin also 378

activates other proteolytic enzymes, such as matrix metalloproteinases (MMPs) that 379

degrade the tight junction components of microvascular endothelial cells (28). This latter 380

function is critical for plasmin-mediated mechanisms of intercellular migration that allow 381

passage of bacterial cells across the vasculature into either peripheral tissues or otherwise 382

privileged compartments such as the central nervous system. Inactivation of α2-AP 383

promotes uncontrolled proteolysis contributing to the invasion of the bacteria (26, 28, 29, 384

49, 55). Pla and PgtE also mediate serum resistance by proteolytic cleavage of 385

complement components (44, 55). 386

In this study, we found that Cpa of C. sakazakii, just like PgtE and Pla, provides 387

resistance against the bactericidal activity of serum by cleaving complement components 388

C3 and C4b as well as the activation of plasminogen and inactivation of α2-AP. Our 389

results showed that the proteolytic activities of Cpa are influenced by the level of its 390

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expression. Over-expression of Cpa in recombinant C. sakazakii or E. coli strains 391

increased the efficiency of plasminogen activation, α2-AP inactivation and cleavage of 392

complement components compared to Cpa expressed by WT BAA-894. The low 393

proteolytic activity identified in BAA-894 strain might be due to inhibition by the O-394

antigen. It has been reported that a long O-antigen component of a smooth LPS sterically 395

inhibits the proteolytic activity of omptin proteins (25, 29). Similar results were observed 396

for PgtE, where PgtE expressed in a smooth S. enterica strain lacked plasminogen 397

activity, but E. coli harboring pgtE cloned in a multicopy plasmid had plasminogen 398

activity (56). Y. pestis is genetically rough and possesses a short-chain LPS (54); thus, 399

Pla-mediated proteolytic functions are fully active in Y. pestis. 400

Interestingly, our results showed that even though C. sakazakii cpa mutant and 401

DH5α strains harboring recombinant vector plasmid pMMB66EH::cpa expressed Cpa at 402

the same levels (Fig. 3), BAA894∆cpa/pMMB66EH::cpa was more resistant to NHS, 403

and had higher proteolytic activity towards complement components C3 and C4b, 404

plasminogen and α2-AP than the activity observed with DH5α/pMMB66EH::cpa. It is 405

possible that structural differences in the LPS expressed by C. sakazakii BAA-894 and E. 406

coli allowed Cpa expressed in C. sakazakii to be more proteolytically active than when it 407

is expressed in E. coli. LPS has a dual function on omptins; these proteins need to 408

interact with lipid A to be proteolytically active but also the presence of O-antigen 409

repeats sterically hinders access of exogenous macromolecular substrates to the omptin 410

active site (25, 29). It is known that natural LPS molecules are intrinsically 411

heterogeneous in structure and molecular mass (e.g., differences in oligosaccharide chain 412

lengths and levels of acylation and substitution) (58). Recent studies have demonstrated 413

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that Pla and LPS interact and consequently Pla activity is enhanced by the presence of 414

low amounts of aminoarabinose and low acylation levels of LPS (58). 415

Our results clearly showed that WT BAA-894 is more resistant to serum killing 416

than the cpa mutant strain. These results suggest that the proteolytic activity of Cpa 417

expressed in WT BAA-894 increases the resistance of the bacteria to serum. Moreover, 418

C. sakazakii is an opportunistic pathogen that causes meningitis especially in neonates 419

and infants. Neonates do not have a mature immune system and are often unable to 420

mount an effective immune response. The levels of complement components, including 421

C3 and C4, in neonatal plasma are limited when compared with those in adults, and 422

generally range from ~10-70% of the adult levels (9). The level of Cpa activity expressed 423

by WT BAA-894 would be adequate to afford resistance to complement mediated-killing 424

given that neonatal levels of serum complement components are significantly less than 425

that of an adult. 426

It is also possible that during infection with C. sakazakii, the LPS structure and 427

CpA expression are modified in such way that the activity of Cpa is maximized. In fact, 428

during growth of S. enterica within mouse macrophages, the LPS structure is altered and 429

the length and the amount of the O-antigen are strongly reduced (6, 29). The same studies 430

also showed that the expression levels of PgtE are increased during growth of the bacteria 431

inside of the macrophage. Recently, Suomalainen et. al. (58) have shown that 432

temperature induces changes in Y. pestis LPS, which in turn would lead to an increase in 433

Pla-mediated proteolysis. Studies using in vivo models are necessary to further determine 434

the role of Cpa in the virulence of C. sakazakii. 435

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On the other hand, we showed that even though E. coli recombinant strain 436

DH5α/pMMB66EH::cpa cleaves complement components C3 and C4b more efficiently 437

than WT BAA894, this strain is more resistant to NHS. These results suggest that in 438

addition to Cpa there are other Cronobacter factors involved in serum resistance. This is 439

further supported by our results showing that BAA894∆cpa is more resistant to NHS than 440

DH5α. Mittal et al. (36), using neonatal rat serum, found that outer membrane protein 441

OmpA is necessary for the survival of Cronobacter spp. in serum. 442

Complement component C3 plays a central role in the activation of the 443

complement system (47). Its activation is required for classical, lectin and alternative 444

pathways. In all three pathways, a C3-convertase cleaves C3 into C3a and C3b. C3b 445

binds to the surface of the pathogen causing a cascade of further complement protein 446

cleavage and activation events that culminate in the formation of the membrane attack 447

complex (MAC). C3b binding to the surface of pathogens also leads to greater 448

internalization of a pathogen by phagocytic cells via opsonization. Our data demonstrate 449

that Cpa proteolytically cleaves C3 α-chain when it is incubated with NHS or purified C3 450

for 18 h. Similar activity has been reported for the elastase of Pseudomonas aeruginosa 451

(17, 59). This protease was shown to degrade the C3 α-chain without affecting the C3 β-452

chain. 453

Interestingly, incubation of Cpa-expressing C. sakazakii and recombinant DH5α 454

strains with purified C3 for only 45 min cleaved C3α-chain protein at the same site where 455

C3 convertase cleaves C3 α protein to produce C3a and C3b. This activity of Cpa against 456

C3 is reminiscent of that of gelatinase, GelE, produced by Enterococcus faecalis (40). 457

Purified GelE cleaved C3 into a C3b-like molecule, which was inactivated rapidly via 458

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reaction with water. This C3 convertase-like activity of GelE was shown to result in the 459

depletion of C3, and thus inhibiting the activation of the complement system (40). 460

Alternatively, it is possible that the presence of Cpa in BAA-894 and recombinant C. 461

sakazakii and E. coli strains induces a spontaneous cleavage of C3 in a short period of 462

time to produce C3b and C3a. To determine whether Cpa induces this spontaneous or the 463

C3b-100 kb band is produced by Cpa proteolytic activity, it would be necessary to 464

incubate purified C3 with a C. sakazakii strain expressing a proteolytic inactivated Cpa. 465

Our results also indicate that Cpa expressed by WT BAA-894 or recombinant C. 466

sakazakii and E. coli DH5α completely degrades the small molecular weight C3a protein. 467

C3a is an anaphylatoxin that serves as a mediator of inflammation by inducing mast cell 468

degranulation, histamine release and increased vascular permeability (31, 45). 469

Degradation of C3a by Cpa may cause paralysis of a variety of C3a-mediated immune 470

reactions occurring in the human serum. 471

Our finding also showed that inactivation of the classic and lectin pathway of the 472

complement restored viability of cpa mutant at the same level as the WT strain. 473

Furthermore, inactivation of the alternative pathway did not restore viability of cpa 474

mutant indicating that the cpa mutant is killed by classical/lectin pathway only; thus, 475

indicating that Cpa is required for exerting resistance to complement activation by the 476

classical and/or lectin pathways. Activation of the classical pathway is initiated by the 477

binding of C1 complex to antibodies bound to an antigen on the bacterial surface. C1s, in 478

the complex, activates C4 by cleaving C4 to C4a and C4b, which bind to the microbial 479

surface (3, 8, 19). Our results indicate that Cpa provides resistance to the classical 480

complement pathway by proteolytically cleaving C4b α and C4 β-chains (Fig. 7). We do 481

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not rule out the possibility that in addition to cleaving C3, C3a and C4b, Cpa may 482

proteolytically degrade other components of the complement cascade, such as C5. 483

In conclusion, we have shown that Cpa expressed by WT C. sakazakii BAA-894 484

slowly cleaves plasminogen and increases survival in serum in comparison to a Cpa 485

deletion mutant. The low proteolytic activity of BAA-894 may be due to Cpa inhibition 486

by BAA-894-smooth LPS. Over-expression of Cpa in recombinant C. sakazakii 487

produces a rapid activation of plasminogen and inactivation of α2-AP as well as enhances 488

proteolytic cleavage of complement components that in turn increase resistance to serum 489

bactericidal activity. In vivo studies are necessary to further determine the role of Cpa in 490

the virulence of C. sakazakii. 491

ACKNOWLEDGMENT 492

We thank Carmen Fernandez-Prada, Cynthia L. Sears and Prasad Rallabhandi, for review 493

the manuscript. L. Hu is a FDA Commissioner’s Fellow. K. G. Jarvis and C. J. Grim are 494

Oak Ridge Institute for Science and Education fellows and the authors wish to thank the 495

Department of Energy for their support. 496

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H.J. Vogel. Academic Press, New York. 691

FIGURES 692

FIG. 1. Phylogenetic tree of omptin family members. Phylogenetic analyses 693

were conducted in MEGA4 (60). The evolutionary history was inferred using the 694

Neighbor-Joining method (48). 695

FIG. 2. Protein sequence alignment of C. sakazakii Cpa with known omptins. 696

Pla of Y. pestis, OmpT of E. coli, and PgtE of S. enterica. Sequences were aligned using 697

the MEGA4 program (60). Residues important for proteolytic activity are in bold, 698

putative important residues for Pla subfamily substrate specificity are in marked by an 699

asterix (13), and the predicted surface-exposed loops determined for OmpT are indicated 700

by L1 to L5 (62). Amino acid residues are numerated according to Pla sequence. 701

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FIG. 3. Immunoblot of Cpa. Similar amounts (4 µg) of whole-cell lysate 702

preparations of C. sakazakii and E. coli strains were analyzed by Western blotting using a 703

rabbit anti-His6-Cpa serum. Lanes: 1) BAA-894; 2) BAA894∆cpa; 3) 704

BAA894∆cpa/pMMB66EH::cpa; 4) DH5α/pMMB66EH; and 5) 705

DH5α/pMMB66EH::cpa. Molecular weights (in kDa) are indicated on the left. 706

FIG. 4. C. sakazakii Cpa is required for survival in NHS. A) C. sakazakii and 707

recombinant DH5α strains were incubated with 12% and 25% of NHS. B) C. sakazakii 708

BAA-894 and BAA894∆cpa strains were incubated with 25% CCPIS and 25% ACPIS. 709

Serum survival assay was performed as described in Materials and Methods section. The 710

percentage survivals shown are the means ± standard deviations of three different assays. 711

The P value was < 0.05 for comparison of BAA-894 and BAA894∆cpa survival in 25% 712

and 12% NHS as calculated by Student’s t test. 713

FIG. 5. Proteolysis of the complement factor C3α chain in NHS by C. 714

sakazakii and recombinant DH5α strains expressing Cpa. 25% NHS was incubated 715

with 1) BAA-894; 2) BAA894∆cpa; 3) BAA894∆cpa/pMMB66EH::cpa; 4) 716

DH5α/pMMB66EH; 5) DH5α/pMMB66EH::cpa; and 6) PBS. C3 proteolytic cleavage 717

was identified by immunoblotting using anti-human C3 antibodies. 718

FIG. 6. Proteolysis of purified complement factor C3 and C3a by C. 719

sakazakii strains expressing Cpa. A) Purified C3 was incubated for 45 min with 1) 720

BAA-894; 2) BAA894∆cpa; 3) BAA894∆cpa/pMMB66EH::cpa; 4) 721

DH5α/pMMB66EH; 5) DH5α/pMMB66EH::cpa; and 6) PBS. B) Purified C3 was 722

incubated for 18 h (same lanes as in A). Proteolytic cleavage of C3 was identified by 723

immunoblotting using anti-human C3 antibodies. Major Cpa mediated cleavage products 724

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of C3 are indicated with asterisks. C) Schematic view of C3 cleavage site by Cpa after 725

45 min incubation. The arrow shows the cleavage site. D) Purified C3a was incubated 726

with 1) BAA-894; 2) BAA894∆cpa; 3) BAA894∆cpa/pMMB66EH::cpa; and 4) 727

DH5α/pMMB66EH; 5) DH5α/pMMB66EH::cpa; and 6) PBS for 18 h. C3a proteolytic 728

cleavage was detected by SDS-PAGE using 8-25% gradient gel. The gel was stained with 729

Coomassie blue. 730

FIG. 7. Proteolysis of purified complement factor C4b by C. sakazakii strains 731

expressing Cpa. A) Purified C4b was incubated with 1) BAA-894; 2) BAA894∆cpa; 3) 732

BAA894∆cpa/pMMB66EH::cpa; 4) DH5α/pMMB66EH; 5) DH5α/pMMB66EH::cpa; 733

and 6) PBS for 18 h. C4b proteolytic cleavage was identified by immunoblotting using 734

anti-human C4 antibodies. Major Cpa mediated cleavage products of C4b are indicated 735

with asterisks. 736

FIG. 8. Plasminogen activation and α2-AP inactivation by C. sakazakii BAA-737

894 and recombinant C. sakazakii and E. coli DH5α strains. Bacteria and plasminogen 738

were incubated in PBS without (A) and with α2-AP (B), and plasmin activity was 739

measured with the chromogenic plasmin substrate S-2251 as described in Materials and 740

Methods. The assays were repeated three times; means in a representative assay with 741

triplicate samples are shown. 742

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Table 1. Bacteria and plasmids used in this study

Strain or plasmid Relevant characteristic(s) Reference

C. sakazakii

BAA-894 Isolated from powdered infant formula associated with

NICU*outbreak, obtained from ATCC (Manassas, VA)

16

BAA894NA BAA-894 nalidixic acid resistant spontaneous mutant This study

BAA894∆cpa BAA-894 cpa isogenic mutant This study

BAA894∆cpa

/pMMB66EH::cpa

BAA894 ∆cpa complemented with pMMB66EH::cpA This study

E. coli

BL21 F- dcm ompT hsdS(rB- mB-) gal [malB+]K-12(λ

S) Novagen

DH5α F- φ80lacZ∆M15 ∆(lacZYA-argF) U169 recA1 endA1

hsdR17 (rk-, mk+) phoA supE44 λ- thi-1 gyrA96 relA1

Invitrogen

DH5α /pMMB66EH DH5α containing plasmid pMMB66EH This study

DH5α/pMMB66EH::cpa DH5α containing pMMB66EH::cpa This study

DH5α גpir DH5α containing גpir 52

SM10 גpir thi thr leu tonA lacY supE recA::RP4-2-Tc::Mu Km גpir 4

Plasmids

pET30(+) Expression vector, T7 promoter-drive system Novagen

pET30::cpa Plasmid expressing His6-CpA fusion protein This study

pCVD442 Suicide vector, R6K ori, mobRP4, bla, sacB 4

pMMB66EH Broad-host-range Ptac expression vector 10

pMMB66EH::cpa cpa cloned into pMMB66EH This study

pCVD442::∆cpa ∆cpa and flanking region cloned into pCVD442 This study

* NICU: Neonatal intensive care units.

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