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The dormant blood microbiome in chronic, inflammatory diseases

The dormant blood microbiome in chronic, inflammatory diseases Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 FEMS Microbiology Reviews, fuv013, 39, 2015, 567–591 doi: 10.1093/femsre/fuv013 Advance Access Publication Date: 4 May 2015 Review Article REVIEW ARTICLE The dormant blood microbiome in chronic, inflammatory diseases 1 1 2,∗ 1 Marnie Potgieter , Janette Bester ,DouglasB.Kell and Etheresia Pretorius Department of Physiology, Faculty of Health Sciences, University of Pretoria, Arcadia 0007, South Africa and School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK Corresponding author: School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK. Tel: (+44)161 306 4492; E-mail: dbk@manchester.ac.uk One sentence summary: Atopobiosis of microbes (the term describing microbes that appear in places other than where they should be), as well as the products of their metabolism, seems to correlate with, and may contribute to, the dynamics of a variety of inflammatory diseases. Editor: Prof. Antoine Danchin ABSTRACT Blood in healthy organisms is seen as a ‘sterile’ environment: it lacks proliferating microbes. Dormant or not-immediately-culturable forms are not absent, however, as intracellular dormancy is well established. We highlight here that a great many pathogens can survive in blood and inside erythrocytes. ‘Non-culturability’, reflected by discrepancies between plate counts and total counts, is commonplace in environmental microbiology. It is overcome by improved culturing methods, and we asked how common this would be in blood. A number of recent, sequence-based and ultramicroscopic studies have uncovered an authentic blood microbiome in a number of non-communicable diseases. The chief origin of these microbes is the gut microbiome (especially when it shifts composition to a pathogenic state, known as ‘dysbiosis’). Another source is microbes translocated from the oral cavity. ‘Dysbiosis’ is also used to describe translocation of cells into blood or other tissues. To avoid ambiguity, we here use the term ‘atopobiosis’ for microbes that appear in places other than their normal location. Atopobiosis may contribute to the dynamics of a variety of inflammatory diseases. Overall, it seems that many more chronic, non-communicable, inflammatory diseases may have a microbial component than are presently considered, and may be treatable using bactericidal antibiotics or vaccines. Keywords: ‘sterile’ blood microbiome; culturability; dormancy; dysbiosis; atopobiosis; Parkinson’s disease; Alzheimer disease INTRODUCTION (Marshall and Warren 1984) being a particularly well-known ex- ample. There have also been hints for a microbial component to ‘Overall, it seems inevitable that the availability of these meth- many other non-communicable diseases, but culturing the rele- ods will cause the catalog of disease states recognized as having vant organisms has rarely been successful. However, there is in- a microbial contribution to their etiology to expand enormously creasing recognition that microbes may be present in forms that in the short term, particularly as improved methods for resusci- are not easily culturable, and a number of recent articles have tation of small cell numbers are found’ (Davey and Kell 1996). brought these possibilities more sharply into focus. Our aim is to Over the years, a variety of diseases that were previously con- review these developments. The manuscript structure is shown sidered non-communicable have been found to have a micro- in Fig. 1. bial component, the role of Helicobacter pylori in ulcerogenesis Received: 26 January 2015; Accepted: 2 March 2015 FEMS 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 567 Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 568 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 Figure 1. An overview figure summarizing the contents of this manuscript. Table 1. Operational definitions of viable, non-viable and dormant A note on terminology: viable, culturable, dormant and microbes. These are the three terms we consider best suited to de- sterile scribe the macroscopic physiological states of microbes as regards their ability to replicate. We note that the terms ‘not immediately In this field, much confusion has arisen historically because of culturable’ (NIC) and ‘active but not culturable’ (ABNC) can also have a failure to recognize that most microbes reproduce by binary some utility (Kell et al. 1998), while dormant cells are sometimes fission and that this reproduction must be a minimal property referred to as ‘persisters’. Other variants of ‘dormancy’ that have or hallmark of a microbial cell that possesses ‘life’ or is ‘alive’ been used include ‘anabiosis’ (Keilin 1959) and ‘cryptobiosis’ (e.g. (Proal, Albert and Marshall 2011). Thus, as with Schroding ¨ er’s cat Clegg 2001;Neuman 2006); all these terms imply a reversible state between the appearance of being living and non-living in differ- (e.g. Primas 1981; Gribbin 1985), we cannot say that an individ- ent circumstances. This definition of dormancy also likely includes ual microbial cell ‘is’ alive, only (if true) that it ‘was’ alive, since cells that may operationally be ‘injured’, and possibly wall-less L- it will by then have become two cells. This implies that being forms (Domingue and Woody 1997; Mattman 2001; Allan, Hoischen alive is not best treated as though it were an innate property of a and Gumpert 2009;Dom´ınguez-Cuevas et al. 2012; Errington 2013; cell, but the definition must be operational, and include both the Mercier, Kawai and Errington 2013, 2014) provided they are or may cell and the ‘environment’ (experiment) used to detect the status become culturable. ‘Sterile’ refers to an absence of operationally vi- able organisms as defined in this table. a posteriori (Kell et al. 1998). Thus, as with Postgate (e.g. Postgate 1967, 1969, 1976), we equate viability with culturability, and stress that culturability— Term Properties the ability to reproduce—is to be determined operationally. Other methods that do not determine culturability are not tests Viable Capable of observable replication, i.e. of viability per se, but merely measure what they measure (e.g. culturable, by any stated means. the content of a chemical such as ATP, membrane permeability Non-viable Incapable of observable replication by any to a dye, enzymatic activity, macromolecular sequences and so stated means normally capable of effecting on). In addition, it is impossible in principle to (cor)relate macro- replication in the relevant organism. scopic measurements of a culture with the ability of individual Dormant Not viable in the sense of not being more or cells to divide (Kell et al. 1991; Davey and Kell 1996). In other less immediately culturable, but may be words, if the macroscopic ATP content of say a starving culture returned to a state of viability or culturability were to decrease by 50%, we would not know if all of the cells by preincubation under suitable conditions. had lost half their ATP or half of the cells had lost all of their ATP (or anything in between). The culturability of the former would likely be 50% and of the latter 100%, despite the same macro- scopic ATP content. scathing about the term ‘unculturable’ (Gest 2008), noting that A lack of culturability may mean that a cell is non-viable one just needs to try harder to culture organisms. Table 1 shows under the circumstances tested, but viability or non-viability the three terms best suited to discuss these issues, while Fig. 2 are not the only two possible states here. An apparent non- shows a diagrammatic representation of the macroscopic phys- culturability of a surviving cell also admits another possibility, iological microbial states we mostly consider. for which the natural term is ‘dormant’ (Kaprelyants, Gottschal The assessment of replication potential (culturability) of in- and Kell 1993;Epstein 2013). This is that the cell is not presently dividual cells may be done microscopically (e.g. by microscopic culturable (viable), but it is not ‘dead’ (in the sense of an oper- counts) or macroscopically (e.g. via colony formation on an agar ationally irreversible loss of viability) in that it may be induced plate or through the ‘most probable number’ technique). The to return to a state of culturability (by a process or processes latter has the advantage of potentially assessing dormancy in typically referred to as ‘resuscitation’). This also means that the the absence of any contaminating culturable cells that might term ‘viable-but-non-culturable’, while quite common in use, is proliferate during the assay (Kaprelyants, Mukamolova and Kell in fact an oxymoron that is to be discouraged (Kell et al. 1998). 1994; Votyakova, Kaprelyants and Kell 1994;Kell et al. 1998). For The eminent microbial physiologist Howard Gest is similarly assessing culturability (=viability), we do not therefore include Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 569 Figure 2. A diagrammatic representation of the major macroscopic physiological states of microbes and their interrelationships. other strategies in which cells do not actually divide, such as the diseased humans and from 7% of supposedly healthy humans, so-called direct viable count of Kogure, Simidu and Taga (1979). when RBCs were lysed (Domingue and Schlegel 1977). A year Thus, we here highlight the point that the possibility of micro- later, corynebacteria-like microorganisms developing in hemo- bial dormancy means that a system that appears to be devoid cultures were shown within RBCs (Tedeschi et al. 1978), and in of culturable microbes may still contain dormant cells or forms 2001 it was found that even ‘healthy’ blood specimens can con- that may become culturable. tain bacterial 16S ribosomal DNA (Nikkari et al. 2001). Domingue and Woody (1997) and Domingue (2010) summarizes much of this earlier literature. L-forms are bacterial variants that lack The ‘sterile’ blood microbiome brought into question some or all of a cell wall. Nonetheless they can divide, especially in osmotically stabilized media, by processes that variously in- The circulation is a closed system and the blood in healthy or- volve membrane blebbing, tubulation, vesiculation and fission ganisms was first believed to be a sterile environment (Drennan (Allan, Hoischen and Gumpert 2009; Errington 2013; Mercier, 1942; Proal, Albert and Marshall 2014). This definition is used Kawai and Errington 2014). While it remains unclear whether in the most usual sense of an absence of culturable microbes, what was seen in these earlier studies (Domingue and Woody since blood can of course provide a suitable growth medium 1997; Domingue 2010) may have been L-forms (Mattman 2001), for microbes (as in blood culture; Wilson and Weinstein 1994; that could in time revert to normal bacteria under the correct Weinstein 1996; Schroeter et al. 2012; cf. Valencia-Shelton and conditions (Casadesus ´ 2007), L-forms are becoming a topic of Loeffelholz 2014), and any bacteraemia or sepsis, even at 1– −1 considerable current research (Devine 2012;Dom´ınguez-Cuevas 10 cells mL (Murray 2015), is potentially life-threatening (e.g. et al. 2012; Mercier, Kawai and Errington 2013, 2014). Vincent et al. 2009; Eleftheriadis et al. 2011; Havey, Fowler and The presence of a blood bacterial microbiome has also been Daneman 2011; Montassier et al. 2013). However, the principle associated with a variety of infectious, as well as non-infectious of the presence of truly sterile blood in healthy humans has disease states (Huang et al. 2006; Thwaites and Gant 2011; been challenged, as operationally it does not mean that dormant Nielsen et al. 2012; Prajsnar et al. 2012;Wang et al. 2012a; Ki- or non-culturable forms of organisms are absent (Kaprelyants, bru et al. 2014;Sato et al. 2014). It is, for example, known that Gottschal and Kell 1993;Kell et al. 1998; McLaughlin et al. 2002) H. pylori can exist not only in the gastric mucosa but also in (see Table 1). Nearly 50 years ago, the existence of a novel bacte- peripheral blood, where it could cause bacteremia (Huang et al. riological system was noted in 71% of blood samples taken from Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 570 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 2006), and could contribute to Parkinson’s disease (PD) or related (II) A second argument is that the morphological type of organ- pathologies that precede motor symptoms (Nielsen et al. 2012). ism (e.g. coccus versus bacillus) seems to be characteristic Helicobacter pylori was also previously implicated in the develop- of particular diseases. ment of anemia (Wang et al. 2012b; Kibru et al. 2014). Staphylo- (III) A third argument is that in many cases (see below) relevant coccus aureus can also use neutrophils as ‘Trojan horses’ to dis- organisms lurk intracellularly, which is hard to explain by seminate infection (Thwaites and Gant 2011; Prajsnar et al. 2012), contamination. while many other pathogens, such as Listeria monocytogenes (Xa- (IV) A fourth argument is that there are just too many diseases yarath and Freitag 2012), Salmonella typhimurium (Eisenreich et al. where bacteria have been found to play a role in the patho- 2010; Claudi et al. 2014; Holden 2015)and Yersinia pestis (Isberg genesis, that all of them may be caused by contamination. 1991), are well known to persist intracellularly; Gest (2008)gives (V) Finally, the actual numbers of cells involved seem far too other historical examples. The same is true for viruses, which great to be explicable by contamination; given that blood 9 −1 are not discussed here. contains more than 10 erythrocytes mL , if there was The presence of an aberrant blood microbiota (as assessed by just one bacterial cell per 100 000 erythrocytes (see below 4 −1 sequencing) has been implicated in type II diabetes and cardio- and Amar et al. 2011), this will equate to 10 bacteria mL . vascular disease (Amar et al. 2011, 2013;Sato et al. 2014). There These are not small numbers. is also growing evidence that periodontal disease and gingivi- It is important to point out that molecular methods have been tis are closely linked to cardiovascular disease (Yang et al. 2013; used frequently to detect active sepsis. These selfsame meth- Ram´ırez et al. 2014). Oral bacterial translocation into the blood ods are also used in environmental biology (as we pointed has been implicated in the development of periodontal disease- out in this review), without undue concern about the poten- induced endocarditis and myocardial and/or cerebral infarction, tial for contamination. Contamination will always be a concern, especially in patients with heart valve dysfunction (Koren et al. of course, as noted by Nikkari et al. (2001), but many papers 2011; Amar and Engelke 2014;Seringec et al. 2014). since 2001 have documented strategies for detecting prokaryotic We will argue in the next sections that the existence of poten- DNA in blood and serum using appropriate and careful controls tially viable (but possibly non-proliferating) pleomorphic bac- (Anthony et al. 2000; Mylotte and Tayara 2000;Jiang et al. 2009; teria in the blood of healthy humans (McLaughlin et al. 2002) Varani et al. 2009;Mancini et al. 2010; Chang et al. 2011; Grif et al. may therefore be of some significance in pathology. If such a 2012a;Fernandez-Cruz ´ et al. 2013;Gaibani et al. 2013). Also, de- microbiome can disrupt homeostasis, it can ultimately play a tecting bacteria in blood cultures during sepsis is considered the fundamental role in disease development and progression. It standard diagnostic tool for blood stream infections (Munoz ˜ et al. has therefore been proposed that the blood microbiota might 2008; Varani et al. 2009), and some laboratories consider that e.g. therefore represent or contribute to the first step in the kinetics PCR testing should always be a complement for the traditional of atherosclerosis (Sato et al. 2014), cardiovascular disease and blood culture test (Grif et al. 2012b). type II diabetes (Amar et al. 2011), and therefore ultimately serve as biomarkers for cardiovascular disease risk (Amar et al. 2013). Theroleofdormancy However, in the quest to use the blood microbiota as biomarkers, the question of detectability and cultivability are key concepts. Dormancy in microbiology is of course well known, even for non- In particular, the existence of a blood microbiome is only sporulating bacteria, and has been defined as a stable but re- really meaningful and of scientific interest if it represents an versible nonreplicating state (Mariotti et al. 2013; see also Table 1 undisturbed state, and is not, for instance, an artefact caused and Kaprelyants, Gottschal and Kell 1993;Kell et al. 1998, 2003). by the external introduction of microbes through human in- The importance of dormant or non-cultured (as opposed to ‘non- tervention, reagent contamination (Schroeter et al. 2012;Salter culturable’) organisms has long been recognized in environmen- et al. 2014) and so forth. We therefore rehearse the evidence tal microbiology (e.g. Mason, Hamer and Bryers 1986; Amann, that while such artefacts are certainly possible, and must be Ludwig and Schleifer 1995; Eilers et al. 2000; Hugenholtz 2002; excluded rigorously, the phenomenon of a human blood micro- Keller and Zengler 2004; Pham and Kim 2012;Epstein 2013), be- biome cannot be dismissed as such an artefact in toto. cause of the 100-fold or greater difference between microscopi- cally observable cells and those capable of forming a colony on Evidence that these observations are not due to an agar plate (‘the great plate count anomaly’, see below). contamination Of the four main possibilities, what we do not know in gen- eral is whether the ‘missing’ cells While contamination from reagents (e.g. Schroeter et al. 2012; Salter et al. 2014), or simply poor sterile technique with nee- (i) are incapable of growth on the enrichment/isolation media, dles and so on, can lead to an artefactual appearance of a blood (ii) are killed by the enrichment/isolation media (e.g. Tanaka microbiome, we consider that the following arguments, taken et al. 2014), together, exclude the thought that the entire (and consider- (iii) have lost viability irreversibly (i.e. are operationally dead) or able) literature on a blood microbiome can be explained via (iv) are in a dormant or not-immediately-culturable state from contamination. which we might resuscitate them (to effect culturability) if only we knew how. The fact that typical isolation media and incubation conditions (I) The first argument is that there are significant differences do not admit the measurable growth of all strains is certainly between the blood microbiomes of individuals harboring well known (indeed it is the basis for selective isolation media!), disease states and nominally healthy controls, despite the and it took a good while to learn how to culture pathogens such fact that samples are treated identically (see later). Some as H. pylori (Marshall and Warren 1984; Marshall 2006), Legionella similar arguments apply to the assessment of drug trans- pneumophila (Feeley et al. 1978;Saito et al. 1981;Meyer 1983), porters under different conditions (Kell and Oliver 2014). Tropheryma whipplei (Maiwald and Relman 2001;Maiwald et al. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 571 2003; Renesto et al. 2003) and so on (Singh et al. 2013). The major- The development of sequence-based methods for microbes ity of bacteria that persist in a ‘non-culturable’ form in wounds (and especially non-eukaryotes) owes much to the pioneering (e.g. Dowd et al. 2008;Percival et al. 2012), or in diseases such work of Carl Woese and colleagues, who recognized the util- as cystic fibrosis (Lewis 2010) or tuberculosis (Young, Stark and ity of small subunit ribosomal RNA (based on both its essen- Kirschner 2008; Zhang, Yew and Barer 2012), and even simply tiality and the small but significant sequence variations) and in conventional cultures of Escherichia coli (e.g. Koch 1987;Bal- applied it with great effect in molecular phylogenetics (Woese aban et al. 2004; Keren et al. 2004a,b; Gerdes and Maisonneuve and Fox 1977; Woese, Kandler and Wheelis 1990). Notwithstand- 2012; Amato, Orman and Brynildsen 2013; Germain et al. 2013; ing modern reinterpretations of the taxonomic details derived Maisonneuve, Castro-Camargo and Gerdes 2013; Maisonneuve therefrom (e.g. Williams et al. 2013), there can be little doubt and Gerdes 2014; Holden 2015), where phenotypic culture dif- that this work drew the attention of microbiologists to the po- ferentiation is well established (Koch 1971), are also ‘normally tential of sequence-based methods for detecting microbes that culturable’ by established means. Thus, the existence of oper- were then invisible to methods based solely on culture, e.g. in ationally ‘non-culturable’ forms of only moderately fastidious clinical microbiology (Didelot et al. 2012; Loman et al. 2012;Proal bacteria is very well established, and more and more bacteria et al. 2013; Fricke and Rasko 2014). rRNA remains a widely used previously thought ‘unculturable’ are being brought into culture strategy for detecting specific microbes. This has of course led to (e.g. Zengler et al. 2002; Keller and Zengler 2004; Stevenson et al. metagenomics, the large-scale sequencing of macromolecules 2004; Gich et al. 2005; Kamagata and Tamaki 2005; D’Onofrio et al. and indeed (statistically) entire genomes from complex (non- 2010; Nichols et al. 2010; Vartoukian, Palmer and Wade 2010; axenic) environments, increasing the requirement for a full set Dedysh 2011; Pham and Kim 2012; Puspita et al. 2012, 2013; Stew- of complete reference sequences (Kyrpides et al. 2014) and not art 2012; Allen-Vercoe 2013; Narihiro and Kamagata 2013;Singh just those of 16S rRNA (Yarza et al. 2013). Even the coupling of et al. 2013;Walker et al. 2014;Lagier et al. 2015a,b;Ling et al. 2015). sequences to activities has now become possible (e.g. Radajew- In environmental microbiology, some bacteria pass through ski et al. 2000;Wang et al. 2012c). the usual 0.2 μm filters, and have been referred to as ‘ultrami- crobacteria’ (Macdonell and Hood 1982; Morita 1997). It was pro- Microbiome analyses: latest technologies employed posed (Kaprelyants, Gottschal and Kell 1993) that rather than More recently, gut metagenomics has been systematized with being small (starved) forms of normal bacteria they were more likely to be normal forms of small bacteria, and this seems to NIH’s Human Microbiome project (HMP) and the European MetaHIT project aiming to deciphering the structure and func- have been accepted (Lysak et al. 2010;Sahin et al. 2010; Duda et al. tion of the human gut microbiota (Fredricks 2013; Robles-Alonso 2012;Soina et al. 2012). and Guarner 2014). The HMP has developed a reference collec- The ability to culture certain kinds of soil bacteria by prein- tion of 16S ribosomal RNA gene sequences collected from sites cubation in weak broth is also well established (e.g. Bakken and across the human body (Koren et al. 2013; Ding and Schloss 2014). Olsen 1987; Kaprelyants, Gottschal and Kell 1993), and our own This information can be used to associate changes in the micro- experiments showed very high levels of resuscitability of dor- biome with changes in health, and particularly also the blood mant cells of Micrococcus luteus (e.g. Kaprelyants and Kell 1993; microbiome. The Integrative Human Microbiome Project (iHMP, Kaprelyants, Mukamolova and Kell 1994; Kaprelyants et al. 1996, http://hmp2.org), the second phase of the NIH HMP, aims to 1999;Kell et al. 1998, 2003; Mukamolova et al. 1998a,b, 1999, study the interactions by analyzing microbiome and host ac- 2002a,b). In a similar way, substrate-accelerated death of non- or slowly growing microorganisms has been known for decades tivities in longitudinal studies of disease-specific cohorts and by creating integrated data sets of microbiome and host func- (Postgate 1967; Calcott and Postgate 1972; Calcott and Calvert 1981). tional properties (The Integrative HMP (iHMP) Research Network Consortium 2014), ultimately allowing us to analyze host and Thus, any of several well-established mechanisms may con- microbial DNA (genome) and RNA (transcriptome) sequences tribute to the (often) large differences observable between mi- (Morgan and Huttenhower 2014). However, in the HMP study, croscopic counts and the number of operationally culturable the main anatomic sites where samples are collected are skin, microbes, with the greatest likelihood being that we simply mouth, nose, colon and vagina (ElRakaiby et al. 2014). So far as we have to develop more and better methods to bring these strains are aware, these projects do not focus on the blood microbiome back into culture, i.e. to resuscitate them. In particular, however, (which is probably unsurprising when most commentators as- this ‘great plate count anomaly’ has, of course, been brought sume that it does not exist). into much sharper focus because of the advent of culture- independent, sequence-based means for detecting and (to a cer- The gut microbiome is by far the largest numerically, and our purpose here is not to review it in any detail, since this has been tain extent) enumerating microbes (though not, of course, of as- sessing their culturability). done very well in terms of Sequence-based methods for detecting (i) its constitution (Lozupone et al. 2012;Weinstock 2012), non-proliferating microbes (ii) temporal variation (Caporaso et al. 2011;Flores et al. 2014; Thaiss et al. 2014), The vast majority of microbial species remain uncultivated and, (iii) changes associated with diet (Muegge et al. 2011), until recently, about half of all known bacterial phyla were iden- (iv) obesity (Turnbaugh et al. 2006, 2009), tified only from their 16S ribosomal RNA gene sequence (Lasken (v) age and geography (Delzenne and Cani 2011; Delzenne and McLean 2014). Also, single-cell genomics is a powerful tool et al. 2011; Yatsunenko et al. 2012), for accessing genetic information from uncultivated microor- (vi) inflammation (Cani et al. 2008, 2012), ganisms (Lasken 2012;Rinke et al. 2013;Cavanagh et al. 2014; (vii) the immune system (Kau et al. 2011; McDermott and Huff- Clingenpeel et al. 2014). Bacterial single-cell genome sequenc- nagle 2014) ing and bioinformatics are, however, challenging (Pallen, Loman (viii) and various pathologies (Pflughoeft and Versalovic 2012; and Penn 2010;Didelot et al. 2012; Loman et al. 2012;Frickeand Schulz et al. 2014). Rasko 2014). Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 572 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 It was implied that a better understanding of microbiome- inflammation leading to tissue injury, organ failure, etc. (Stein- encoded pathways for xenobiotic metabolism might also have berg 2003; Wiest and Rath 2003;Balzan et al. 2007). We stress implications for improving the efficacy of pharmacologic inter- that they may be found in both infectious and non-infectious ventions with neuromodulatory agents (Gonzalez et al. 2011), diseases as well as being translocated during surgery, and and that the exploration of microbiome and metagenome might that atopobiosis of bacteria originating in the oral cavity, e.g. give us insightful new perspectives regarding human genet- in periodontal disease, may also be significant in rheumatoid ics and how the microbiota contribute to immunity, as well as arthritis, for instance (see below). Fig. 3 provides a schematic to metabolic and inflammatory diseases (Cho and Blaser 2012; representation of dysbiosis, bacterial translocation and Blaser et al. 2013; Blaser 2014; Leslie and Young 2015). This atopobiosis. is because it is assumed in such studies that it is the small- molecule products of the gut microbiome that can appear in How do gut bacteria escape into blood? the human serum metabolome, and thus influence the rest of If the gut microbiome is seen as the main source of the blood the human body (e.g. Wikoff et al. 2009; Holmes et al. 2011; microbiome, it is necessary to establish which kinds of condi- Le Chatelier et al. 2013, and see Table 2). Here we also need tions might permit this in the absence of real physical damage to mention lipopolysaccharide (LPS), a main constituent of the (as may, for instance, be caused by surgery) leading to micro- Gram-negative outer membrane that induces the production of bial translocation. Wiest, Lawson and Geuking (2014) mention cytokines and/or chemokines, which in turn regulate inflamma- three possible points of entrance for bacteria into the surround- tory and innate and subsequent adaptive immune responses ing (sterile) tissue: (Glaros et al. 2013;Rhee 2014; Ronco 2014). The release of LPS may therefore change gut homeostasis, may play a role in e.g. (i) by dendritic cells via processes between epithelial cells, not inflammatory bowel disease and necrotizing enterocolitis (Rhee 2014), and may certainly act as an acute phase protein in sepsis affecting tight junction function, (ii) via injured/inflamed epithelium with dysfunctional epithe- (Ding and Jin 2014). By contrast, our theme here is that it is additionally the mi- lial barrier, crobes themselves that can pass from the gut (and other ‘exter- (iii) and via M cells overlying Peyer’s patches as specialized cells providing access of microbial products to antigen- nal’ surfaces) into the human body, a phenomenon sometimes known as ‘dysbiosis’, albeit this term is more commonly used presenting cells. with another meaning. We here need to discriminate a changed (pathologic) microbiota in the place of origin from the results of a We discuss bacterial translocation in this context in the fol- translocation of microbiota to other areas of the body. In the fol- lowing sections. lowing sections, we use the term dysbiosis to describe changes in a microbiome in its main origin (typically the gut), and we The role of M cells and Peyer’s patches in gut microbial coin the term ‘atopobiosis’ to describe microbes that appear in translocation and atopobiosis places other than where they should be. While the gut epithelium represents the largest mucosal tissue, the mechanisms underlying the interaction between the micro- The origin of detectable but non-proliferating microbes biome and the epithelial cells remain poorly understood (Math- appears to be mainly via ‘atopobiosis’ of the gut ias et al. 2014). Although this is a vast and complex field that microbiome warrants a review of its own, we briefly argue that gut dysbio- Dysbiosis, also known as dysbacteriosis, particularly referring to sis results in an atypical interaction of both the microbiota, as microbial imbalance in the digestive tract, has been widely dis- well as their secretory products, with the gut epithelial layer. cussed (e.g. Scher and Abramson 2011;Scanlan et al. 2012; Amar This results in an altered barrier function, which may also lead et al. 2013; Bested, Logan and Selhub 2013; Duytschaever et al. to changed mucosal immunity and ultimately to atopobiosis. 2013; Vaarala 2013). Core to this literature is the idea that factors The gut epithelium is necessarily normally quite impermeable that lead to significant changes in the gut microbiota composi- to microbes, but there is increasing evidence that direct chem- tion (dysbiosis) ultimately result in pathology (Larsen et al. 2010; ical communication between the microbiota and the epithelial Amar et al. 2011, 2013; Bested, Logan and Selhub 2013; Burcelin cells regulates mucosal integrity (Venkatesh et al. 2014). A pos- et al. 2013; De Angelis et al. 2013; Fremont et al. 2013; Lanter, Sauer sible point of entry is by direct cellular uptake, and there is and Davies 2014; Petriz et al. 2014;Power et al. 2014; Tojo et al. one type of cell that can take up microbes, and these are the 2014). Table 3 gives a list of diseases, largely inflammatory dis- M cells overlaying the Peyer’s patches (Kerneis ´ et al. 1997;Jep- eases, which have been associated with gut dysbiosis. son and Clark 1998; Clark and Jepson 2003; Corr, Gahan and In addition, we argue here that as well as gut dysbiosis, a Hill 2008; Lelouard et al. 2010; Fukuda, Hase and Ohno 2011). derangement of the gut microbiome, what we are seeing here, Peyer’s patches are seen as the ‘immune sensors’ of the gut ep- often called ‘translocation’ in the context of surgery (Swank ithelium. Considerable evidence exists that they provide a pri- and Deitch 1996;MacFie 2004) and various diseases (Berg 1995) mary route for the limited translocation of microbes between (see Table 4 that lists diseases and conditions where bacterial the gut epithelium and the blood system (Jung, Hugot and Bar- translocation is specifically implicated), is what might better be reau 2010). These interactions with the cells of the gut may called atopobiosis (Greek ατ ¨ oπoς or atopos, in the wrong place), suggest that changes in the intestinal microbiota also influ- i.e. an appearance of members of the gut (or other) microbiome ence mucosal immunity (Sato, Kiyono and Fujihashi et al. 2014). in the wrong place. Bacterial translocation is therefore discussed This is indeed the case, and gut dysbiosis has been shown to in the context of the movement of gut origin microbes [that play a significant role in the development of autoimmune dis- changed from normal (dysbiosis)] that moved across the ‘intact’ eases, in particular inflammatory bowel diseases (Clemente et al. gastrointestinal tract into normally sterile tissues, including 2012; Morgan et al. 2012; Hold et al. 2014; Kostic, Xavier and blood, where the organisms may then directly cause infection or Gevers 2014;Owyangand Wu 2014;Ma et al. 2015). It was also Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 573 Table 2. Some examples of small molecule gut metabolites whose secretion has been implicated in various disease states. Role in health and Metabolite Intermediates/products Synthesis disease References Amino acids The gut microbiota is not itself an important source Faure et al. (2006); Devaraj, of amino acids during periods of adequate protein Hemarajata and Versalovic intake. Some commensal members produce biolog- (2013); Bergen (2014) ically active components from amino acids. Amino acid supplementation in a mouse model of ulcerative colitis has been shown to promote overall growth of commensal microbiota. The effect was considered to be mediated via the stimulatory effect on mucin pro- duction by amino acid supplementation. Benzoates Benzoic acid, hippurate, Gut microbiota in mice with active colitis displayed Rechner et al. (2002); 2-hydroxyhippurate enrichment for genes involved in benzoate degrada- Aronov et al. (2011); De tion. Hippurate derives from plant food polyphenols Preter and Verbeke (2013); and is a conjugate of benzoic acid with glycine. In Rooks et al. (2014) humans a large portion of hippurate is believed to be derived from precursors absorbed in the small in- testines. It is reliably decreased in IBD. Bile acids Bile acids are synthesized from cholesterol in the Martin et al. (2007); Bennett liver and further metabolized into secondary bile et al. (2013); Ger ´ ard (2013); acids by the gut microbiota. The amino acid sides Kakiyama et al. (2013); chain of glyco- and tauro-conjugated bile acids are Mart´ınez et al. (2013); Sayin cleaved by bacterial bile salt hydrolase (BSH) enzyme et al. (2013); Joyce et al. to yield unconjugated bile acids (cholic and chen- (2014) odeoxycholic acids). These products will then be fur- ther modified by gut bacteria to produce secondary bile acids. A decrease in this conversion is positively correlated with liver cirrhosis. Bile acids can mod- ulate the composition of the microbiota in the gut, where they function as signaling molecules and may constitute a mechanism of quorum sensing. In turn, the microbiota strongly affect bile acid metabolism by promoting deconjugation, dehydrogenation and dehydroxylation. It can also inhibit bile acid synthe- sis in the liver by alleviation of farnesoid X receptor inhibition in the ileum. Bile acids can induce FMO3 expression by an FXR-dependent mechanism. Lipids Cholesterol The gut microbiota impact on the host systemic lipid Martin et al. (2007); metabolism. When administered as probiotics Bifi- Mart´ınez et al. (2009, 2013); dobacteria and Lactobacillus can enhance dyslipidemia Yu et al. (2013); Joyce et al. and insulin resistance. Microbiota have an influence (2014 on cholesterol metabolism and weight gain in the host via the bacterial BSH mechanism. Methylamines and Methylamine, Cleavage of choline and phosphatidylcholine (PC) by Wang et al. (2011); Craciun products of choline dimethylamine, the gut microbiota via the enzyme choline TMA-lyase and Balskus (2012); Koeth metabolism dimethylglycine, produces TMA. Oxidation of TMA by hepatic flavin- et al. (2013); Tang et al. trimethylamine (TMA) and containing monooxygenase 3 (FMO3) forms TMAO. (2013); Zhu et al. (2014) trimethylamine N-oxide Microbial metabolism of L-carnitine also produces (TMAO) TMA via a novel Rieske-type protein. Risk for major adverse cardiovascular events coincides with higher levels of TMAO. Neurotransmitters Serotonin, melatonin, It was recently discovered that gut microbiota pro- Desbonnet et al. (2008); glutamate, GABA, duce tryptophan decarboxylase, the enzyme respon- Bravo et al. (2011); Rooks noradrenaline, dopamine sible for decarboxylasing tryptophan to tryptamine. et al. (2014); Williams et al. and acetylcholine Tryptamine promotes the release of serotonin by en- (2014); O’Mahony et al. terochromaffincells.Inaratmodelitwas shownthat (2015) Bifidobacteria treatment resulted in increased tryp- tophan and kynurenic acid levels. Another study in mice showed the potential of Lactobacillus rhamnosus to modulate the GABAergic system. Decreased levels of dopamine were measured in fecal samples from active colitis mice. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 574 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 Table 2. (Continued.) Role in health and Metabolite Intermediates/products Synthesis disease References Phytochemicals, Chlorogenic acids, A significant amount of polyphenols reaches the Tomas-Barberan et al. particularly hydrolysable tannins and colon and is believed to contribute to gut health (2014); Kahle et al. (2006); polyphenolic flavonoids by promoting the growth of some commen- Aronov et al. (2011); van compounds sals. Polyphenolic bioconversion by microbiota Duynhoven et al. (2011); is paramount in the production of a large range Cardona et al. (2013); Mar´ın of bioactive molecules. The exact roles of these et al. (2015) molecules in health and disease are yet to be fully understood. Nonetheless epidemiological stud- ies have tied polyphenols to health benefits such as antioxidative, anticarinogenic, antiadipogenic, antidiabetic and neuroprotective properties. Gut microbiota can also convert dietary polyphenols to benzoate. Polyunsaturated Omega3and 6 L. plantarum has genes encoding for the enzyme in- Kishino et al. (2013) fatty acids (PUFA) volved in saturation metabolism of PUFA. Short-chain fatty Most abundant acetate, The SCFAs are produced from bacterial fermentation Bergman (1990); Maslowski acids (SCFAs) propionate, butyrate; to a of non-digestible polysaccharides. They play a role in et al. (2009); den Besten et al. lesser extent—formate, metabolic syndrome prevention and treatment. Evi- (2013); Kimura et al. (2013); fumarate, malonate, dence point to their potential to promote metabolic Natarajan and Pluznick succinate, caproate and control in type 2 diabetes. SCFAs are a major source (2014); Puddu et al. (2014) valerate of energy for colonocytes and also contribute up to 10% of the host’s daily caloric requirements. They are further involved in the control of energy utiliza- tion and maintenance of metabolic homeostasis via the G Protein coupled Receptor 43 (GPR43) receptor. SCFA products also dampen inflammatory response through this receptor. SCFAs have also been shown to affect cell proliferation and apoptosis (in cancer cells), and in epigenetic machinery such as histone acetylation by butyrate. Vitamins B-group vitamins, vitamin It is well established that the gut microbiota synthe- Hill (1997); Cooke, Behan B12; vitamin C, biotin, size a large number of vitamins de novo.Thisisim- and Costello (2006); vitamin K portant since humans lack biosynthetic pathways for Arumugam et al. (2011); vitamins. The deleterious effects of vitamin deficien- LeBlanc et al. (2013); cies are well known. It has only recently been sug- Degnan, Taga and gested that vitamin B12 may also contribute to shap- Goodman (2014) ing the structure and function of microbial commu- nities in the human gut. Other noteworthy bioactives Conjugated linoleic acid (CLA), bacteriocin CLA is associated with a diverse array of biological Bowdish, Davidson and activities, and predominantly associated with acti- Hancock (2005); Ross et al. vation of peroxisome proliferator activated receptors (2010) (PPARs) and the associated switching on and off of genes. Some Bifidobacteria and Lactobacillus species have been shown to produce CLA. Bacteriocins are peptides synthesized by bacteria and have narrow (same species) or broad (across genera) spectrum ac- tivity against other bacteria. A large number of ar- chaea and bacteria are believed to produce at least one bacteriocin. Tetrathionate and nitric oxide Tetrathionate and nitric oxide are produced in an in- Winter et al. (2010); Bergen flammatory environment and are central to the fit- (2014); Rooks et al. (2014) ness of several Enterobacteriaceae. Tetrathionate uti- lization positively correlated with active colitis in a mouse model. Bacterial growth depends on the pres- ence of nitrogen. Synthesis of amino acids by the mi- crobiome depends on the recycling of nitrogen back into gastrointestinal organs. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 575 Table 3. Various pathologies that have been associated with dysbiosis of the gut. Condition References Asthma Abrahamsson et al. (2014) AD Karri, Martinez and Coimbatore (2010); Alam et al. (2014) Atherosclerosis Koren et al. (2011) Autism spectrum disorders Parracho et al. (2005); Finegold et al. (2010); Adams et al. (2011); Williams et al. (2011, 2012); De Angelis et al. (2013); Kang et al. (2013) β-Cell autoimmunity de Goffau et al. (2014) Cardiovascular disease Amar et al. (2011) Crohn’s disease Seksik et al. (2003) Chronic fatigue syndrome Sheedy et al. (2009); Proal et al. (2013) Cystic fibrosis Scanlan et al. (2012); Bruzzese et al. (2014);Sanc ´ hez-Calvo et al. (2008); Duytschaever et al. (2011, 2013); Madan et al. (2012) HIV/AIDS Lozupone et al. (2013); McHardy et al. (2013); Vujkovic-Cvijin et al. (2013) IgE-associated eczema Abrahamsson et al. (2012) Inflammation Cani et al. (2008, 2012); Delzenne and Cani (2011); Delzenne et al. (2011) Inflammatory bowel disease Conte et al. (2006); Clemente et al. (2012); Manichanh et al. (2012); Morgan et al. (2012); Nagalingam and Lynch (2012); Bakhtiar et al. (2013) Iron deficiency Balamurugan et al. (2010); Zimmermann et al. (2010); Dostal et al. (2012, 2014) Liver disease Schnabl and Brenner (2014) Multiple sclerosis Berer et al. (2011) Obesity Delzenne and Cani (2011); Geurts et al. (2014) Rheumatoid arthritis Detert et al. (2010); Berer et al. (2011); Scher and Abramson (2011); Bingham and Moni (2013); Brusca, Abramson and Scher (2014); Catrina, Deane and Scher (2014); Cenit ´ et al. (2014); Demoruelle, Deane and Holers (2014); Taneja (2014) Parkinson’s Disease Scheperjans et al. (2015); Vizcarra et al. (2015) Sarcoidosis Almenoff et al. (1996) Systemic lupus erythematosus Hevia et al. (2014); Zhang et al. (2014a) Symptomatic atherosclerosis/stroke Karlsson et al. (2012) Type 1 diabetes Brown et al. (2012); Owen and Mohamadzadeh (2013); Petersen and Round (2014) Type 2 diabetes Larsen et al. (2010); Brown et al. (2012); Qin et al. (2012); Karlsson et al. (2013); Everard et al. (2014) Table 4. Diseases and conditions where bacterial translocation (of gut or oral origin) and consequent chronic infection are specifically implicated Diseases and conditions where translocation of bacteria are present References Communicable diseases Fibrosis stage in HIV/HCV coinfection Balagopal et al. (2008); Montes-de-Oca et al. (2011); Page, Nelson and Kelleher (2011); Lin, Weinberg and Chung (2013); Sacchi et al. (2015) Hepatitis C virus (HCV) infection French et al. (2013); Munteanu et al. (2014) HIV/AIDS infection Sandler and Douek (2012); Klatt, Funderburg and Brenchley (2013); Vazquez-Castellanos et al. (2014) Pneumonia in immunocompromised Sawa (2014) patients Diseases usually seen as non-communicable Abdominal compartment syndrome Mifkovic et al. (2013) Alcoholic liver disease Chen and Schnabl (2014); Malaguarnera et al. (2014) Allergic disease: bacterial translocation Abrahamsson Wu and Jenmalm (2015) during pregnancy Atherosclerosis Epstein, Zhou and Zhu (1999); Kozarov et al. (2006); Erridge (2008); Renko et al. (2008); Epstein et al. (2009); Nagata, de Toledo and Oho (2011); Rosenfeld and Campbell (2011); Hopkins (2013); Dinakaran et al. (2014); Rogler and Rosano (2014); Trøseid et al. (2014) Burn wounds Macintire and Bellhorn (2002); Sharma (2007); Aboelatta et al. (2013) Cirrhosis Wiest and Garcia-Tsao (2005); Jun et al. (2010); Giannelli et al. (2014); Wiest, Lawson and Geuking (2014) Chronic kidney disease Anders, Andersen and Stecher (2013); Sabatino et al. (2014) Metabolic syndrome Festi et al. (2014) Non-alcoholic fatty liver disease Bieghs and Trautwein (2014) Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 576 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 Table 4. (Continued.) Diseases and conditions where translocation of bacteria are present References Obesity Vajro, Paolella and Fasano (2013); Sanz and Moya-Per ´ ez (2014) Pancreatitis Mifkovic et al. (2009); Guo et al. (2014); Olah ´ and Romics (2014) Rheumatoid arthritis Ogrendik (2009b, 2013b); Ebringer and Rashid (2014); Koziel, Mydel and Potempa (2014) Schizophrenia Severance et al. (2013); Severance, Yolken and Eaton (2014) Sepsis and Septic shock Tsujimoto, Ono and Mochizuki (2009); Wallet et al. (2011); Deitch (2012); Leli et al. (2014) Stroke Syrjanen ¨ et al. (1988); Emsley and Tyrrell (2002); Emsley et al. (2003); Emsley and Hopkins (2008); McColl, Allan and Rothwell (2009); Emsley and Chamorro (2010); Grau, Urbanek and Palm (2010); Wang et al. (2012a); Chien et al. (2013); Dalager-Pedersen et al. (2014); Fugate et al. (2014) Surgical procedures Bariatric surgery Festi et al. (2014) Cardiac surgery Allen (2014) Multiple organ failure (MOF) Swank and Deitch (1996) Sepsis due to surgery MacFie (2004); Puleo et al. (2011) ‘Sepsis’ is widely used to imply living microbes, but as is now well known it can also occur in the absence of any culturable microbes, including those incapable of proliferation due to antibiotic activity. Sepsis may commonly result simply from the effects of molecules such as LPS on the generation of inflammator y cytokines (Kotsaki and Giamarellos-Bourboulis 2012; Balakrishnan et al. 2013). suggested that a changed gut microbiota represents the initial well as other microorganisms can reside inside RBCs (e.g. Mi- site of autoimmunity generation, and might be a critical epige- nasyan 2014), and thus able to cross the RBC membrane some- netic factor in autoimmune diseases such as rheumatoid arthri- how (see Table 5). Transmission electron microscopy (TEM) anal- tis (Scher and Abramson 2011; Luckey et al. 2013; Brusca, Abram- ysis showing bacteria inside cells would also tend to imply that son and Scher 2014; Catrina, Deane and Scher 2014;Cenit ´ et al. the bacteria were not externally introduced artefactually during 2014; Taneja 2014). There is also evidence that regulatory T cells the preparation of the samples. in the gut are influenced by microbial factors, and that a changed For the current paper, we have revisited our AD and PD microbiota (dysbiosis) may influence the induction and suppres- samples and figures from Pretorius et al. (2014a) and Lipinski sor functions of these cells, in turn leading to a changed gut mu- and Pretorius (2013) and noted the prevalence of bacteria in al- cosal immunity (Kinoshita and Takeda 2014). most all of the AD and PD samples, in numbers much in ex- We have earlier reviewed the literature that suggests that cess of those seen in our database of thousands micrographs dysbiosis can cause gut epithelial barrier dysfunction, and from healthy individuals. Here we show additional micrographs thereby provide a point of entry into the body, including the from the previously published samples (see Figs 5 and 6). In blood, resulting in atopobiosis. This is supported by recent re- both conditions (see Figs 5AD and 6PD), microbes were noted search that has suggested that blood microbiota might be impli- in close proximity to RBCs, and in some cases RBCs extended cated in various (cardiovascular and other) diseases. Sequence- pseudopodia-like projections towards the microbiota. SEM anal- based techniques provided evidence for the presence of such ysis of AD whole blood (Fig. 5) shows that mostly coccus-shaped a blood microbiome. The question now arises as to whether bacteria are present. White blood cells are seen in close proxim- such a microbiome’s presence can be directly measured by e.g. ity to these bacteria in AD patients (see Fig. 5A–C). SEM anal- ultrastructural (microscopic) methods, since a consequence of yses of PD patients (Fig. 6) show both coccus- and bacillus- any translocation of microbes between the gut microbiome and shaped bacteria in close proximity to RBCs. We also observed blood is that they should then be observable in blood. The next that RBCs extend pseudopodia towards these bacteria and this sections will provide visual evidence of the presence of such might be part of the mechanism by which the bacteria en- a microbiota in Alzheimer’s disease (AD) and PD. As shown in ter the RBCs (see Fig. 6C–F). We also note possibly dividing Table 3, these conditions are known to be associated with the coccus-shaped bacteria in both these conditions, indicated with presence of dysbiosis. blue arrows on Fig. 5A (AD patient) and Fig. 6D (PD patient). This might suggest that these bacteria may be(come) cultur- able under appropriate conditions (see also Soina et al. 2012; Direct measurement by ultrastructural (microscopic) Epstein 2013). methods TEM analysis of the samples from Lipinski and Pretorius Direct measurement by ultrastructural (microscopic) methods of (2013) and Pretorius et al. (2014a) showed the presence in- side RBCs of cells that appeared to be microbial in nature analysis shows that microbes are in fact common constituents of blood in inflammatory diseases [previously seen in PD—Fig. 8 (unpublished data). These internalized cells further provide evidence for a sustained presence of such a blood micro- in (Pretorius et al. 2014a and in AD—Fig. 2 in (Lipinski and Pre- biota (and one hardly explained by contamination) (see Fig. 7A torius 2013). We show and annotate selected micrographs from and B: AD and C and D: PD). Bacteria are shown with ar- these papers in Fig. 4]. An important concern that needs to be rows in the micrographs. No bacterial membrane was noted; addressed, as is also the case with sequence-based methods, is therefore, the bacteria may be L-forms. There seems to be whether the presence of microbiota in whole blood is indeed bacterial species selectivity for a given disease, as our pre- not the result of introduced external contamination. There is liminary observations suggest a prevalence for bacillus-type in fact considerable evidence in the literature that bacteria as Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 577 Figure 3. Schematic representation of dysbiosis, bacterial translocation and atopobiosis. (A) When intestinal microbiota are associated with dysbiosis,(B) the gut barrier (1 and 2) becomes compromised; this leads to (C), a route of entry via the gut epithelia causing (D) bacterial translocation. Bacterial translocation is also associated with a compromised systemic immune system barrier (3). Therefore, intestinal microbiota dysbiosis (A) followed by bacterial translocation (D) results in (E) atopobiosis. (F) The results of bacterial translocation are seen in various conditions (see Table 4). bacteria in AD, but both coccus- and bacillus-shaped bacteria however, dormancy and viability versus non-viability issues per- in PD patients. tain (as discussed above). Our observations suggest that the presence of bacteria in We found a definite association between RBCs and bacteria, these two diseases occurs in only a small fraction of the RBC with RBCs (see Figs 6 and 7) forming pseudopodia-like extension, population, which is why we had not really noted them in our as if in the process of engulfing bacteria. Both coccoid (round) previous studies (e.g. Bester et al. 2013; Pretorius et al. 2013, and bacillary (elongated) bacteria were found in PD whole blood 2014a,b; Pretorius and Kell 2014), and SEM and TEM analysis con- SEM micrographs, but only coccoid forms in AD whole blood firms this observation. We have never (or not yet) found bacte- SEM micrographs. Samples from 25 diagnosed AD patients were ria inside RBCs from healthy controls (these without overt, diag- studied and bacteria were detected in 14 individuals from this nosed diseases) when studying blood smears using TEM analy- AD sample, while samples from 30 PD patients were studied, sis. The microscopy preparation methods involve a washing pro- in 21 of whom we detected bacteria. Obviously, the type of bac- cess, and this may wash away some of the bacteria, or RBCs and teria cannot be identified from ultrastructural observations. As white blood cells associated with bacteria. Therefore, the actual with the timeline of established cases such as the role of H. quantification of the bacteria can only be done by other means; pylori in ulcers and colon cancer, the next tasks are to bring Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 578 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 these microscopically observed bacteria into culture and to carry out sequence-based studies to establish their role (if any) in non-communicable diseases. However, to illustrate that the bac- teria may indeed be engulfed by the RBCs, and to confirm that the phenomenon is not due to external contamination, we show TEM micrographs from both of the studied diseases (see Fig. 7, AD and PD). CONCLUDING REMARKS AND PROSPECTIVE EXPERIMENTS ‘Non-culturable’ (which should be called ‘not-easily-culturable’ or ‘not-yet-cultured’) microbes are commonplace in the ‘envi- ronmental microbiology’ of soil and water, and the blood cer- tainly represents an ‘environment’. As we show here, there is a large and scattered literature, increasing in size, to the effect that there might be a (mainly dormant) microbial component Figure 4. Micrographs taken from previously published manuscripts. (A–C)Bac- in a variety of chronic diseases that are normally considered to terial presence in PD, originally shown in Fig. 8A, C and G in Pretorius et al. (2014a). (D) Bacterial presence in AD, originally shown in Fig. 2 in Lipinski and be non-microbial or non-communicable in nature, even when Pretorius (2013). microbes appear absent by culturability criteria. Our previous Table 5. Some microorganisms that are known to invade red blood cells. Pathogen Type of microorganism Mechanism of invasion References Anaplasma marginale A tick-borne pathogen that causes Via major surface protein 1a (MSP1a) Kocan et al. the disease anaplasmosis in cattle. (2004) Bartonella bacilliformis Bartonella species are fastidious The Trw T4SS mediates attachment of Bartonella to Iwaki-Egawa and B.quintana Gram-negative bacteria, which red blood cells in Bartonella lineage 4. Bartonella is Ihler (1997); belong to the alpha group of the collected in pits and trenches that form as a result Coleman and domain Proteobacteria. of deformation factor. Invaginations supposedly Minnick (2001); pinch off to carry the content in a vacuole structure Rolain et al. to the cytoplasm of the red blood cell where the (2003); Eicher organism persists. and Dehio (2012) Brucella melitensis Facultative intracellular Invasion shown in mouse erythrocytes. Mechanism Vitry et al. (2014) Gram-negative coccobacilli. to be identified. Francisella tularensis Highly infectious bacterium, Via serum complement-dependent and Conlan (2011); which can cause severe disease independent mechanisms. Horzempa et al. tularemia with an infection of (2011) fewer than 10 bacteria Mycoplasma suis A member or the hemotrophic Invasion occurs in a similar manner to that of P. Groebel et al. mycoplasma group that parasitize falciparum and B. bacilliformis. Attachment via MSG1 (2009); Zhang erythrocytes in pigs. (GAPDH) protein. et al. (2014c) M. bovis Small cell wall-less bacterium that Undetermined. van der Merwe, contributes to a number of chronic Prysliak and inflammatory diseases in dairy Perez-Casal and feedlot cattle. (2010) M. gallisepticum Mycoplasmas are small cell Not known. Vogl et al. (2008) wall-less prokaryotes. Plasmodium falciparum The main malaria parasite, part of Recognition of surface receptors precedes a Cowman and whose life cycle involves reorientation where the apical end is adjusted to Crabb (2006) inhabiting RBCs. the erythrocyte. A tight junction that involves high-affinity ligand receptor interactions is formed. The tight junction moves from the apical to posterior pole and is powered by the actin-myosin motor of the parasite. The adhesive proteins at the junction are proteolytically removed when the posterior pole is reached, most likely by a rhomboid resident protease in a process that facilitates membrane resealing. The invasion process produces a parasitophorous vacuole containing the merozoite. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 579 Table 5. (Continued.) Pathogen Type of microorganism Mechanism of invasion References Streptococcus pneumoniae Gram-positive bacterium which LPXTG motif-containing pneumococcal proteins, Yamaguchi et al. causes infection-related diseases. erythrocyte lipid rafts and erythrocyte actin (2013) remodeling are involved in the invasion mechanism. Theileria sporozites Intracellular protozoan Occurs in a similar manner to sporozoite entry. Shaw (2003); transmitted by ixodid ticks. Infect Bishop et al. wild and domesticated ruminants. (2004) Phylogenetically most closely related to Babesia. Figure 6. RBCs with microbiota from patients with diagnosed PD (additional mi- crographs from sample used in Pretorius et al. 2014a). These micrographs are rep- Figure 5. RBCs with microbiota from patients with diagnosed AD (additional mi- resentative of bacteria found in smears of 21 of the 30 PD individuals. (A) A col- crographs from sample used in Lipinski and Pretorius 2013). These micrographs lection of coccus- and bacillus-shaped bacteria; (B) coccus- and bacillus-shaped are representative of bacteria found in smears of 14 of the 30 AD individuals. bacteria associated with erythrocyte; (C) bacillus-shaped bacteria in close prox- (A and B) coccus-shaped bacteria associated with white blood cell; (B) coccus- imity with erythrocyte. Erythrocyte forms extensions towards bacteria; (D and E) shaped bacteria associated with an erythrocyte and white blood cell; (C)two bacillus-shaped bacteria associated with elongated erythrocytes; (F) coccus- and white blood cells associated with coccus-shaped bacteria; (D) a string of cocci- bacillus-shaped bacteria close to erythrocyte that extends pseudopodia towards blue arrow shows possibly dividing coccoid bacteria; (E) an erythrocyte associ- the bacteria. Coccus-shaped bacteria shown with pink arrows; bacillus-shaped ated with coccus-shaped bacteria; (F) a high machine magnification of a coccus- bacteria shown with white arrows. Dividing coccus-shaped bacteria shown with shaped bacteria associated with a dense matted fibrin deposit. Scale bar: 1 μm. blue arrow. Scale bar: 1 μm. work (e.g. Bester et al. 2013; Pretorius et al. 2013, 2014a;Kelland Pretorius 2014, 2015; Pretorius and Kell 2014) has implied iron dysregulation as a regular accompaniment to, and probable con- We have here pointed up the likelihood of a steady crop tributory factor for, a variety of similar diseases, all of which of effectively dormant microbes being a feature of blood bi- have an inflammatory component. We argue here that there is ology in chronically diseased humans, including those with also a microbial contribution to this in the blood, and it is not un- non-communicable diseases. As with any complex system, the reasonable that the microbial requirement for iron means that, magnitude of any component is affected by the kinetics of every despite the oxidative stress it can entail (Touati 2000;Kell 2009, relevant step; while the precise nature of all the interactions is 2010), microbes may be anticipated to increase in prevalence uncertain, Fig. 8 describes the general network—the first step in when iron is free (e.g. Ratledge 2007; Clifton, Corrent and Strong any systems analysis (Kell 2006; Kell and Knowles 2006). 2009; Sia, Allred and Raymond 2013; Chu et al. 2014) and avail- Consequently, we recognize that the analysis above has able (D’Onofrio et al. 2010), probably behaving in a social manner largely been qualitative (the ‘presence’ of a microbial compo- (Kell, Kaprelyants and Grafen 1995; West and Buckling 2003;Dig- nent in a specific disease is a qualitative statement). However, gle et al. 2007; Harrison and Buckling 2009). chronic, non-communicable diseases are very far from being Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 580 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 tectable blood microbiome in this and other diseases that show such flares. As with H. pylori and stomach ulcers (and cancer), the simple prediction is that bactericidal antibiotics should be of value in the treatment of such supposedly non-communicable diseases. Indeed, this prediction is borne out for diseases such as rheumatoid arthritis (Ogrendik 2009a, 2013a; Kwiatkowska and Masli ´ nska ´ 2012) and multiple sclerosis (Ochoa-Repar ´ az et al. 2009; 2011), while antipneumococcal vaccination has shown ef- ficacy in preventing stroke (Vila-Corcoles et al. 2014). Of course, events such as heart attacks and strokes (and see Table 4)may also be seen as sudden increases in severity of an underlying condition, and in some cases (such as the much increased like- lihood of strokes after subarachnoid haemorrhages; McMahon et al. 2013), analysis of changes in the blood microbiome might prove predictive. The obvious next tasks are thus to relate the number and nature of blood microbes observed in cases such as the above to microbial sequences and antigens that can be detected in aliquots of the same samples (e.g. Salipante et al. 2013, 2015), to determine the physiological state of the various microbes (in- Figure 7. TEM confirming the presence of bacteria inside erythrocytes of ( A and cluding e.g. whether they are L-forms), and to establish methods B)AD,(C and D) PD. (Additional micrographs from sample used in Lipinski and to bring them (back) into culture. Since microbes, inflammation Pretorius (2013) and Pretorius et al. (2014a). Arrows in each micrograph show the and various syndromes are such common co-occurrences (as presence of cellular inclusions, without visible membranes. Inclusions are not typically noted in erythrocytes. We suggest that these inclusions are bacteria, are coagulopathies; Kell and Pretorius 2015), longitudinal stud- possibly as L-forms. Scale bar = 1 μm (A, C, D); 200 nm (D). ies will have a specially important role, as they will both show the dynamics and be able to help discriminate cause and ef- fect during the time evolution of chronic, non-communicable diseases in ageing populations. The immunogenicity of per- static (and thousands of human genes change their expression sisters, and their ability to induce various kinds of inflamma- at least 2-fold even on a diurnal basis; Zhang et al. 2014b). Thus, a tion, must be rather different from that of replicating organ- clear further issue is to seek to understand how the blood micro- isms, and this must be investigated. Armed with such collec- biome may co-vary with the day-to-day dynamics of chronic dis- tive knowledge, we might be better placed to develop thera- eases. For example, rheumatoid arthritis has circadian rhythms peutics such as pre- and probiotics and bactericidal antibiotics (Straub and Cutolo 2007) and is well known to provide signifi- for use in such cases previously thought to lack a microbial cant variations (‘flares’; Flurey et al. 2014) in severity at different contribution. times. A reasonable strategy is thus to look for changes in a de- Figure 8. Relationships between a dormant blood microbiome and chronic disease dyamics. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 581 FUNDING Phylogenetics: a discipline of evolutionary biology that stud- ies the relationships between organisms based on how closely We thank the Biotechnology and Biological Sciences Research similar some of their macromolecular sequences are. Council (grant BB/L025752/1) as well as the National Re- Pleomorphic: possessing the ability to change shape or size search Foundation (NRF) of South Africa for supporting this in response to environmental stimuli. collaboration. Resuscitation: induction of apparently non-culturable cells to a state of culturability. Conflict of interest. None declared. Sterile: refers to an absence of operationally viable organ- isms. Viable: capable of observable replication, i.e. culturable, by any stated means. GLOSSARY 16S ribosomal RNA: a component of the 30S small subunit of REFERENCES prokaryotic ribosomes. 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The dormant blood microbiome in chronic, inflammatory diseases

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Abstract

Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 FEMS Microbiology Reviews, fuv013, 39, 2015, 567–591 doi: 10.1093/femsre/fuv013 Advance Access Publication Date: 4 May 2015 Review Article REVIEW ARTICLE The dormant blood microbiome in chronic, inflammatory diseases 1 1 2,∗ 1 Marnie Potgieter , Janette Bester ,DouglasB.Kell and Etheresia Pretorius Department of Physiology, Faculty of Health Sciences, University of Pretoria, Arcadia 0007, South Africa and School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK Corresponding author: School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK. Tel: (+44)161 306 4492; E-mail: dbk@manchester.ac.uk One sentence summary: Atopobiosis of microbes (the term describing microbes that appear in places other than where they should be), as well as the products of their metabolism, seems to correlate with, and may contribute to, the dynamics of a variety of inflammatory diseases. Editor: Prof. Antoine Danchin ABSTRACT Blood in healthy organisms is seen as a ‘sterile’ environment: it lacks proliferating microbes. Dormant or not-immediately-culturable forms are not absent, however, as intracellular dormancy is well established. We highlight here that a great many pathogens can survive in blood and inside erythrocytes. ‘Non-culturability’, reflected by discrepancies between plate counts and total counts, is commonplace in environmental microbiology. It is overcome by improved culturing methods, and we asked how common this would be in blood. A number of recent, sequence-based and ultramicroscopic studies have uncovered an authentic blood microbiome in a number of non-communicable diseases. The chief origin of these microbes is the gut microbiome (especially when it shifts composition to a pathogenic state, known as ‘dysbiosis’). Another source is microbes translocated from the oral cavity. ‘Dysbiosis’ is also used to describe translocation of cells into blood or other tissues. To avoid ambiguity, we here use the term ‘atopobiosis’ for microbes that appear in places other than their normal location. Atopobiosis may contribute to the dynamics of a variety of inflammatory diseases. Overall, it seems that many more chronic, non-communicable, inflammatory diseases may have a microbial component than are presently considered, and may be treatable using bactericidal antibiotics or vaccines. Keywords: ‘sterile’ blood microbiome; culturability; dormancy; dysbiosis; atopobiosis; Parkinson’s disease; Alzheimer disease INTRODUCTION (Marshall and Warren 1984) being a particularly well-known ex- ample. There have also been hints for a microbial component to ‘Overall, it seems inevitable that the availability of these meth- many other non-communicable diseases, but culturing the rele- ods will cause the catalog of disease states recognized as having vant organisms has rarely been successful. However, there is in- a microbial contribution to their etiology to expand enormously creasing recognition that microbes may be present in forms that in the short term, particularly as improved methods for resusci- are not easily culturable, and a number of recent articles have tation of small cell numbers are found’ (Davey and Kell 1996). brought these possibilities more sharply into focus. Our aim is to Over the years, a variety of diseases that were previously con- review these developments. The manuscript structure is shown sidered non-communicable have been found to have a micro- in Fig. 1. bial component, the role of Helicobacter pylori in ulcerogenesis Received: 26 January 2015; Accepted: 2 March 2015 FEMS 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 567 Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 568 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 Figure 1. An overview figure summarizing the contents of this manuscript. Table 1. Operational definitions of viable, non-viable and dormant A note on terminology: viable, culturable, dormant and microbes. These are the three terms we consider best suited to de- sterile scribe the macroscopic physiological states of microbes as regards their ability to replicate. We note that the terms ‘not immediately In this field, much confusion has arisen historically because of culturable’ (NIC) and ‘active but not culturable’ (ABNC) can also have a failure to recognize that most microbes reproduce by binary some utility (Kell et al. 1998), while dormant cells are sometimes fission and that this reproduction must be a minimal property referred to as ‘persisters’. Other variants of ‘dormancy’ that have or hallmark of a microbial cell that possesses ‘life’ or is ‘alive’ been used include ‘anabiosis’ (Keilin 1959) and ‘cryptobiosis’ (e.g. (Proal, Albert and Marshall 2011). Thus, as with Schroding ¨ er’s cat Clegg 2001;Neuman 2006); all these terms imply a reversible state between the appearance of being living and non-living in differ- (e.g. Primas 1981; Gribbin 1985), we cannot say that an individ- ent circumstances. This definition of dormancy also likely includes ual microbial cell ‘is’ alive, only (if true) that it ‘was’ alive, since cells that may operationally be ‘injured’, and possibly wall-less L- it will by then have become two cells. This implies that being forms (Domingue and Woody 1997; Mattman 2001; Allan, Hoischen alive is not best treated as though it were an innate property of a and Gumpert 2009;Dom´ınguez-Cuevas et al. 2012; Errington 2013; cell, but the definition must be operational, and include both the Mercier, Kawai and Errington 2013, 2014) provided they are or may cell and the ‘environment’ (experiment) used to detect the status become culturable. ‘Sterile’ refers to an absence of operationally vi- able organisms as defined in this table. a posteriori (Kell et al. 1998). Thus, as with Postgate (e.g. Postgate 1967, 1969, 1976), we equate viability with culturability, and stress that culturability— Term Properties the ability to reproduce—is to be determined operationally. Other methods that do not determine culturability are not tests Viable Capable of observable replication, i.e. of viability per se, but merely measure what they measure (e.g. culturable, by any stated means. the content of a chemical such as ATP, membrane permeability Non-viable Incapable of observable replication by any to a dye, enzymatic activity, macromolecular sequences and so stated means normally capable of effecting on). In addition, it is impossible in principle to (cor)relate macro- replication in the relevant organism. scopic measurements of a culture with the ability of individual Dormant Not viable in the sense of not being more or cells to divide (Kell et al. 1991; Davey and Kell 1996). In other less immediately culturable, but may be words, if the macroscopic ATP content of say a starving culture returned to a state of viability or culturability were to decrease by 50%, we would not know if all of the cells by preincubation under suitable conditions. had lost half their ATP or half of the cells had lost all of their ATP (or anything in between). The culturability of the former would likely be 50% and of the latter 100%, despite the same macro- scopic ATP content. scathing about the term ‘unculturable’ (Gest 2008), noting that A lack of culturability may mean that a cell is non-viable one just needs to try harder to culture organisms. Table 1 shows under the circumstances tested, but viability or non-viability the three terms best suited to discuss these issues, while Fig. 2 are not the only two possible states here. An apparent non- shows a diagrammatic representation of the macroscopic phys- culturability of a surviving cell also admits another possibility, iological microbial states we mostly consider. for which the natural term is ‘dormant’ (Kaprelyants, Gottschal The assessment of replication potential (culturability) of in- and Kell 1993;Epstein 2013). This is that the cell is not presently dividual cells may be done microscopically (e.g. by microscopic culturable (viable), but it is not ‘dead’ (in the sense of an oper- counts) or macroscopically (e.g. via colony formation on an agar ationally irreversible loss of viability) in that it may be induced plate or through the ‘most probable number’ technique). The to return to a state of culturability (by a process or processes latter has the advantage of potentially assessing dormancy in typically referred to as ‘resuscitation’). This also means that the the absence of any contaminating culturable cells that might term ‘viable-but-non-culturable’, while quite common in use, is proliferate during the assay (Kaprelyants, Mukamolova and Kell in fact an oxymoron that is to be discouraged (Kell et al. 1998). 1994; Votyakova, Kaprelyants and Kell 1994;Kell et al. 1998). For The eminent microbial physiologist Howard Gest is similarly assessing culturability (=viability), we do not therefore include Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 569 Figure 2. A diagrammatic representation of the major macroscopic physiological states of microbes and their interrelationships. other strategies in which cells do not actually divide, such as the diseased humans and from 7% of supposedly healthy humans, so-called direct viable count of Kogure, Simidu and Taga (1979). when RBCs were lysed (Domingue and Schlegel 1977). A year Thus, we here highlight the point that the possibility of micro- later, corynebacteria-like microorganisms developing in hemo- bial dormancy means that a system that appears to be devoid cultures were shown within RBCs (Tedeschi et al. 1978), and in of culturable microbes may still contain dormant cells or forms 2001 it was found that even ‘healthy’ blood specimens can con- that may become culturable. tain bacterial 16S ribosomal DNA (Nikkari et al. 2001). Domingue and Woody (1997) and Domingue (2010) summarizes much of this earlier literature. L-forms are bacterial variants that lack The ‘sterile’ blood microbiome brought into question some or all of a cell wall. Nonetheless they can divide, especially in osmotically stabilized media, by processes that variously in- The circulation is a closed system and the blood in healthy or- volve membrane blebbing, tubulation, vesiculation and fission ganisms was first believed to be a sterile environment (Drennan (Allan, Hoischen and Gumpert 2009; Errington 2013; Mercier, 1942; Proal, Albert and Marshall 2014). This definition is used Kawai and Errington 2014). While it remains unclear whether in the most usual sense of an absence of culturable microbes, what was seen in these earlier studies (Domingue and Woody since blood can of course provide a suitable growth medium 1997; Domingue 2010) may have been L-forms (Mattman 2001), for microbes (as in blood culture; Wilson and Weinstein 1994; that could in time revert to normal bacteria under the correct Weinstein 1996; Schroeter et al. 2012; cf. Valencia-Shelton and conditions (Casadesus ´ 2007), L-forms are becoming a topic of Loeffelholz 2014), and any bacteraemia or sepsis, even at 1– −1 considerable current research (Devine 2012;Dom´ınguez-Cuevas 10 cells mL (Murray 2015), is potentially life-threatening (e.g. et al. 2012; Mercier, Kawai and Errington 2013, 2014). Vincent et al. 2009; Eleftheriadis et al. 2011; Havey, Fowler and The presence of a blood bacterial microbiome has also been Daneman 2011; Montassier et al. 2013). However, the principle associated with a variety of infectious, as well as non-infectious of the presence of truly sterile blood in healthy humans has disease states (Huang et al. 2006; Thwaites and Gant 2011; been challenged, as operationally it does not mean that dormant Nielsen et al. 2012; Prajsnar et al. 2012;Wang et al. 2012a; Ki- or non-culturable forms of organisms are absent (Kaprelyants, bru et al. 2014;Sato et al. 2014). It is, for example, known that Gottschal and Kell 1993;Kell et al. 1998; McLaughlin et al. 2002) H. pylori can exist not only in the gastric mucosa but also in (see Table 1). Nearly 50 years ago, the existence of a novel bacte- peripheral blood, where it could cause bacteremia (Huang et al. riological system was noted in 71% of blood samples taken from Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 570 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 2006), and could contribute to Parkinson’s disease (PD) or related (II) A second argument is that the morphological type of organ- pathologies that precede motor symptoms (Nielsen et al. 2012). ism (e.g. coccus versus bacillus) seems to be characteristic Helicobacter pylori was also previously implicated in the develop- of particular diseases. ment of anemia (Wang et al. 2012b; Kibru et al. 2014). Staphylo- (III) A third argument is that in many cases (see below) relevant coccus aureus can also use neutrophils as ‘Trojan horses’ to dis- organisms lurk intracellularly, which is hard to explain by seminate infection (Thwaites and Gant 2011; Prajsnar et al. 2012), contamination. while many other pathogens, such as Listeria monocytogenes (Xa- (IV) A fourth argument is that there are just too many diseases yarath and Freitag 2012), Salmonella typhimurium (Eisenreich et al. where bacteria have been found to play a role in the patho- 2010; Claudi et al. 2014; Holden 2015)and Yersinia pestis (Isberg genesis, that all of them may be caused by contamination. 1991), are well known to persist intracellularly; Gest (2008)gives (V) Finally, the actual numbers of cells involved seem far too other historical examples. The same is true for viruses, which great to be explicable by contamination; given that blood 9 −1 are not discussed here. contains more than 10 erythrocytes mL , if there was The presence of an aberrant blood microbiota (as assessed by just one bacterial cell per 100 000 erythrocytes (see below 4 −1 sequencing) has been implicated in type II diabetes and cardio- and Amar et al. 2011), this will equate to 10 bacteria mL . vascular disease (Amar et al. 2011, 2013;Sato et al. 2014). There These are not small numbers. is also growing evidence that periodontal disease and gingivi- It is important to point out that molecular methods have been tis are closely linked to cardiovascular disease (Yang et al. 2013; used frequently to detect active sepsis. These selfsame meth- Ram´ırez et al. 2014). Oral bacterial translocation into the blood ods are also used in environmental biology (as we pointed has been implicated in the development of periodontal disease- out in this review), without undue concern about the poten- induced endocarditis and myocardial and/or cerebral infarction, tial for contamination. Contamination will always be a concern, especially in patients with heart valve dysfunction (Koren et al. of course, as noted by Nikkari et al. (2001), but many papers 2011; Amar and Engelke 2014;Seringec et al. 2014). since 2001 have documented strategies for detecting prokaryotic We will argue in the next sections that the existence of poten- DNA in blood and serum using appropriate and careful controls tially viable (but possibly non-proliferating) pleomorphic bac- (Anthony et al. 2000; Mylotte and Tayara 2000;Jiang et al. 2009; teria in the blood of healthy humans (McLaughlin et al. 2002) Varani et al. 2009;Mancini et al. 2010; Chang et al. 2011; Grif et al. may therefore be of some significance in pathology. If such a 2012a;Fernandez-Cruz ´ et al. 2013;Gaibani et al. 2013). Also, de- microbiome can disrupt homeostasis, it can ultimately play a tecting bacteria in blood cultures during sepsis is considered the fundamental role in disease development and progression. It standard diagnostic tool for blood stream infections (Munoz ˜ et al. has therefore been proposed that the blood microbiota might 2008; Varani et al. 2009), and some laboratories consider that e.g. therefore represent or contribute to the first step in the kinetics PCR testing should always be a complement for the traditional of atherosclerosis (Sato et al. 2014), cardiovascular disease and blood culture test (Grif et al. 2012b). type II diabetes (Amar et al. 2011), and therefore ultimately serve as biomarkers for cardiovascular disease risk (Amar et al. 2013). Theroleofdormancy However, in the quest to use the blood microbiota as biomarkers, the question of detectability and cultivability are key concepts. Dormancy in microbiology is of course well known, even for non- In particular, the existence of a blood microbiome is only sporulating bacteria, and has been defined as a stable but re- really meaningful and of scientific interest if it represents an versible nonreplicating state (Mariotti et al. 2013; see also Table 1 undisturbed state, and is not, for instance, an artefact caused and Kaprelyants, Gottschal and Kell 1993;Kell et al. 1998, 2003). by the external introduction of microbes through human in- The importance of dormant or non-cultured (as opposed to ‘non- tervention, reagent contamination (Schroeter et al. 2012;Salter culturable’) organisms has long been recognized in environmen- et al. 2014) and so forth. We therefore rehearse the evidence tal microbiology (e.g. Mason, Hamer and Bryers 1986; Amann, that while such artefacts are certainly possible, and must be Ludwig and Schleifer 1995; Eilers et al. 2000; Hugenholtz 2002; excluded rigorously, the phenomenon of a human blood micro- Keller and Zengler 2004; Pham and Kim 2012;Epstein 2013), be- biome cannot be dismissed as such an artefact in toto. cause of the 100-fold or greater difference between microscopi- cally observable cells and those capable of forming a colony on Evidence that these observations are not due to an agar plate (‘the great plate count anomaly’, see below). contamination Of the four main possibilities, what we do not know in gen- eral is whether the ‘missing’ cells While contamination from reagents (e.g. Schroeter et al. 2012; Salter et al. 2014), or simply poor sterile technique with nee- (i) are incapable of growth on the enrichment/isolation media, dles and so on, can lead to an artefactual appearance of a blood (ii) are killed by the enrichment/isolation media (e.g. Tanaka microbiome, we consider that the following arguments, taken et al. 2014), together, exclude the thought that the entire (and consider- (iii) have lost viability irreversibly (i.e. are operationally dead) or able) literature on a blood microbiome can be explained via (iv) are in a dormant or not-immediately-culturable state from contamination. which we might resuscitate them (to effect culturability) if only we knew how. The fact that typical isolation media and incubation conditions (I) The first argument is that there are significant differences do not admit the measurable growth of all strains is certainly between the blood microbiomes of individuals harboring well known (indeed it is the basis for selective isolation media!), disease states and nominally healthy controls, despite the and it took a good while to learn how to culture pathogens such fact that samples are treated identically (see later). Some as H. pylori (Marshall and Warren 1984; Marshall 2006), Legionella similar arguments apply to the assessment of drug trans- pneumophila (Feeley et al. 1978;Saito et al. 1981;Meyer 1983), porters under different conditions (Kell and Oliver 2014). Tropheryma whipplei (Maiwald and Relman 2001;Maiwald et al. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 571 2003; Renesto et al. 2003) and so on (Singh et al. 2013). The major- The development of sequence-based methods for microbes ity of bacteria that persist in a ‘non-culturable’ form in wounds (and especially non-eukaryotes) owes much to the pioneering (e.g. Dowd et al. 2008;Percival et al. 2012), or in diseases such work of Carl Woese and colleagues, who recognized the util- as cystic fibrosis (Lewis 2010) or tuberculosis (Young, Stark and ity of small subunit ribosomal RNA (based on both its essen- Kirschner 2008; Zhang, Yew and Barer 2012), and even simply tiality and the small but significant sequence variations) and in conventional cultures of Escherichia coli (e.g. Koch 1987;Bal- applied it with great effect in molecular phylogenetics (Woese aban et al. 2004; Keren et al. 2004a,b; Gerdes and Maisonneuve and Fox 1977; Woese, Kandler and Wheelis 1990). Notwithstand- 2012; Amato, Orman and Brynildsen 2013; Germain et al. 2013; ing modern reinterpretations of the taxonomic details derived Maisonneuve, Castro-Camargo and Gerdes 2013; Maisonneuve therefrom (e.g. Williams et al. 2013), there can be little doubt and Gerdes 2014; Holden 2015), where phenotypic culture dif- that this work drew the attention of microbiologists to the po- ferentiation is well established (Koch 1971), are also ‘normally tential of sequence-based methods for detecting microbes that culturable’ by established means. Thus, the existence of oper- were then invisible to methods based solely on culture, e.g. in ationally ‘non-culturable’ forms of only moderately fastidious clinical microbiology (Didelot et al. 2012; Loman et al. 2012;Proal bacteria is very well established, and more and more bacteria et al. 2013; Fricke and Rasko 2014). rRNA remains a widely used previously thought ‘unculturable’ are being brought into culture strategy for detecting specific microbes. This has of course led to (e.g. Zengler et al. 2002; Keller and Zengler 2004; Stevenson et al. metagenomics, the large-scale sequencing of macromolecules 2004; Gich et al. 2005; Kamagata and Tamaki 2005; D’Onofrio et al. and indeed (statistically) entire genomes from complex (non- 2010; Nichols et al. 2010; Vartoukian, Palmer and Wade 2010; axenic) environments, increasing the requirement for a full set Dedysh 2011; Pham and Kim 2012; Puspita et al. 2012, 2013; Stew- of complete reference sequences (Kyrpides et al. 2014) and not art 2012; Allen-Vercoe 2013; Narihiro and Kamagata 2013;Singh just those of 16S rRNA (Yarza et al. 2013). Even the coupling of et al. 2013;Walker et al. 2014;Lagier et al. 2015a,b;Ling et al. 2015). sequences to activities has now become possible (e.g. Radajew- In environmental microbiology, some bacteria pass through ski et al. 2000;Wang et al. 2012c). the usual 0.2 μm filters, and have been referred to as ‘ultrami- crobacteria’ (Macdonell and Hood 1982; Morita 1997). It was pro- Microbiome analyses: latest technologies employed posed (Kaprelyants, Gottschal and Kell 1993) that rather than More recently, gut metagenomics has been systematized with being small (starved) forms of normal bacteria they were more likely to be normal forms of small bacteria, and this seems to NIH’s Human Microbiome project (HMP) and the European MetaHIT project aiming to deciphering the structure and func- have been accepted (Lysak et al. 2010;Sahin et al. 2010; Duda et al. tion of the human gut microbiota (Fredricks 2013; Robles-Alonso 2012;Soina et al. 2012). and Guarner 2014). The HMP has developed a reference collec- The ability to culture certain kinds of soil bacteria by prein- tion of 16S ribosomal RNA gene sequences collected from sites cubation in weak broth is also well established (e.g. Bakken and across the human body (Koren et al. 2013; Ding and Schloss 2014). Olsen 1987; Kaprelyants, Gottschal and Kell 1993), and our own This information can be used to associate changes in the micro- experiments showed very high levels of resuscitability of dor- biome with changes in health, and particularly also the blood mant cells of Micrococcus luteus (e.g. Kaprelyants and Kell 1993; microbiome. The Integrative Human Microbiome Project (iHMP, Kaprelyants, Mukamolova and Kell 1994; Kaprelyants et al. 1996, http://hmp2.org), the second phase of the NIH HMP, aims to 1999;Kell et al. 1998, 2003; Mukamolova et al. 1998a,b, 1999, study the interactions by analyzing microbiome and host ac- 2002a,b). In a similar way, substrate-accelerated death of non- or slowly growing microorganisms has been known for decades tivities in longitudinal studies of disease-specific cohorts and by creating integrated data sets of microbiome and host func- (Postgate 1967; Calcott and Postgate 1972; Calcott and Calvert 1981). tional properties (The Integrative HMP (iHMP) Research Network Consortium 2014), ultimately allowing us to analyze host and Thus, any of several well-established mechanisms may con- microbial DNA (genome) and RNA (transcriptome) sequences tribute to the (often) large differences observable between mi- (Morgan and Huttenhower 2014). However, in the HMP study, croscopic counts and the number of operationally culturable the main anatomic sites where samples are collected are skin, microbes, with the greatest likelihood being that we simply mouth, nose, colon and vagina (ElRakaiby et al. 2014). So far as we have to develop more and better methods to bring these strains are aware, these projects do not focus on the blood microbiome back into culture, i.e. to resuscitate them. In particular, however, (which is probably unsurprising when most commentators as- this ‘great plate count anomaly’ has, of course, been brought sume that it does not exist). into much sharper focus because of the advent of culture- independent, sequence-based means for detecting and (to a cer- The gut microbiome is by far the largest numerically, and our purpose here is not to review it in any detail, since this has been tain extent) enumerating microbes (though not, of course, of as- sessing their culturability). done very well in terms of Sequence-based methods for detecting (i) its constitution (Lozupone et al. 2012;Weinstock 2012), non-proliferating microbes (ii) temporal variation (Caporaso et al. 2011;Flores et al. 2014; Thaiss et al. 2014), The vast majority of microbial species remain uncultivated and, (iii) changes associated with diet (Muegge et al. 2011), until recently, about half of all known bacterial phyla were iden- (iv) obesity (Turnbaugh et al. 2006, 2009), tified only from their 16S ribosomal RNA gene sequence (Lasken (v) age and geography (Delzenne and Cani 2011; Delzenne and McLean 2014). Also, single-cell genomics is a powerful tool et al. 2011; Yatsunenko et al. 2012), for accessing genetic information from uncultivated microor- (vi) inflammation (Cani et al. 2008, 2012), ganisms (Lasken 2012;Rinke et al. 2013;Cavanagh et al. 2014; (vii) the immune system (Kau et al. 2011; McDermott and Huff- Clingenpeel et al. 2014). Bacterial single-cell genome sequenc- nagle 2014) ing and bioinformatics are, however, challenging (Pallen, Loman (viii) and various pathologies (Pflughoeft and Versalovic 2012; and Penn 2010;Didelot et al. 2012; Loman et al. 2012;Frickeand Schulz et al. 2014). Rasko 2014). Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 572 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 It was implied that a better understanding of microbiome- inflammation leading to tissue injury, organ failure, etc. (Stein- encoded pathways for xenobiotic metabolism might also have berg 2003; Wiest and Rath 2003;Balzan et al. 2007). We stress implications for improving the efficacy of pharmacologic inter- that they may be found in both infectious and non-infectious ventions with neuromodulatory agents (Gonzalez et al. 2011), diseases as well as being translocated during surgery, and and that the exploration of microbiome and metagenome might that atopobiosis of bacteria originating in the oral cavity, e.g. give us insightful new perspectives regarding human genet- in periodontal disease, may also be significant in rheumatoid ics and how the microbiota contribute to immunity, as well as arthritis, for instance (see below). Fig. 3 provides a schematic to metabolic and inflammatory diseases (Cho and Blaser 2012; representation of dysbiosis, bacterial translocation and Blaser et al. 2013; Blaser 2014; Leslie and Young 2015). This atopobiosis. is because it is assumed in such studies that it is the small- molecule products of the gut microbiome that can appear in How do gut bacteria escape into blood? the human serum metabolome, and thus influence the rest of If the gut microbiome is seen as the main source of the blood the human body (e.g. Wikoff et al. 2009; Holmes et al. 2011; microbiome, it is necessary to establish which kinds of condi- Le Chatelier et al. 2013, and see Table 2). Here we also need tions might permit this in the absence of real physical damage to mention lipopolysaccharide (LPS), a main constituent of the (as may, for instance, be caused by surgery) leading to micro- Gram-negative outer membrane that induces the production of bial translocation. Wiest, Lawson and Geuking (2014) mention cytokines and/or chemokines, which in turn regulate inflamma- three possible points of entrance for bacteria into the surround- tory and innate and subsequent adaptive immune responses ing (sterile) tissue: (Glaros et al. 2013;Rhee 2014; Ronco 2014). The release of LPS may therefore change gut homeostasis, may play a role in e.g. (i) by dendritic cells via processes between epithelial cells, not inflammatory bowel disease and necrotizing enterocolitis (Rhee 2014), and may certainly act as an acute phase protein in sepsis affecting tight junction function, (ii) via injured/inflamed epithelium with dysfunctional epithe- (Ding and Jin 2014). By contrast, our theme here is that it is additionally the mi- lial barrier, crobes themselves that can pass from the gut (and other ‘exter- (iii) and via M cells overlying Peyer’s patches as specialized cells providing access of microbial products to antigen- nal’ surfaces) into the human body, a phenomenon sometimes known as ‘dysbiosis’, albeit this term is more commonly used presenting cells. with another meaning. We here need to discriminate a changed (pathologic) microbiota in the place of origin from the results of a We discuss bacterial translocation in this context in the fol- translocation of microbiota to other areas of the body. In the fol- lowing sections. lowing sections, we use the term dysbiosis to describe changes in a microbiome in its main origin (typically the gut), and we The role of M cells and Peyer’s patches in gut microbial coin the term ‘atopobiosis’ to describe microbes that appear in translocation and atopobiosis places other than where they should be. While the gut epithelium represents the largest mucosal tissue, the mechanisms underlying the interaction between the micro- The origin of detectable but non-proliferating microbes biome and the epithelial cells remain poorly understood (Math- appears to be mainly via ‘atopobiosis’ of the gut ias et al. 2014). Although this is a vast and complex field that microbiome warrants a review of its own, we briefly argue that gut dysbio- Dysbiosis, also known as dysbacteriosis, particularly referring to sis results in an atypical interaction of both the microbiota, as microbial imbalance in the digestive tract, has been widely dis- well as their secretory products, with the gut epithelial layer. cussed (e.g. Scher and Abramson 2011;Scanlan et al. 2012; Amar This results in an altered barrier function, which may also lead et al. 2013; Bested, Logan and Selhub 2013; Duytschaever et al. to changed mucosal immunity and ultimately to atopobiosis. 2013; Vaarala 2013). Core to this literature is the idea that factors The gut epithelium is necessarily normally quite impermeable that lead to significant changes in the gut microbiota composi- to microbes, but there is increasing evidence that direct chem- tion (dysbiosis) ultimately result in pathology (Larsen et al. 2010; ical communication between the microbiota and the epithelial Amar et al. 2011, 2013; Bested, Logan and Selhub 2013; Burcelin cells regulates mucosal integrity (Venkatesh et al. 2014). A pos- et al. 2013; De Angelis et al. 2013; Fremont et al. 2013; Lanter, Sauer sible point of entry is by direct cellular uptake, and there is and Davies 2014; Petriz et al. 2014;Power et al. 2014; Tojo et al. one type of cell that can take up microbes, and these are the 2014). Table 3 gives a list of diseases, largely inflammatory dis- M cells overlaying the Peyer’s patches (Kerneis ´ et al. 1997;Jep- eases, which have been associated with gut dysbiosis. son and Clark 1998; Clark and Jepson 2003; Corr, Gahan and In addition, we argue here that as well as gut dysbiosis, a Hill 2008; Lelouard et al. 2010; Fukuda, Hase and Ohno 2011). derangement of the gut microbiome, what we are seeing here, Peyer’s patches are seen as the ‘immune sensors’ of the gut ep- often called ‘translocation’ in the context of surgery (Swank ithelium. Considerable evidence exists that they provide a pri- and Deitch 1996;MacFie 2004) and various diseases (Berg 1995) mary route for the limited translocation of microbes between (see Table 4 that lists diseases and conditions where bacterial the gut epithelium and the blood system (Jung, Hugot and Bar- translocation is specifically implicated), is what might better be reau 2010). These interactions with the cells of the gut may called atopobiosis (Greek ατ ¨ oπoς or atopos, in the wrong place), suggest that changes in the intestinal microbiota also influ- i.e. an appearance of members of the gut (or other) microbiome ence mucosal immunity (Sato, Kiyono and Fujihashi et al. 2014). in the wrong place. Bacterial translocation is therefore discussed This is indeed the case, and gut dysbiosis has been shown to in the context of the movement of gut origin microbes [that play a significant role in the development of autoimmune dis- changed from normal (dysbiosis)] that moved across the ‘intact’ eases, in particular inflammatory bowel diseases (Clemente et al. gastrointestinal tract into normally sterile tissues, including 2012; Morgan et al. 2012; Hold et al. 2014; Kostic, Xavier and blood, where the organisms may then directly cause infection or Gevers 2014;Owyangand Wu 2014;Ma et al. 2015). It was also Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 573 Table 2. Some examples of small molecule gut metabolites whose secretion has been implicated in various disease states. Role in health and Metabolite Intermediates/products Synthesis disease References Amino acids The gut microbiota is not itself an important source Faure et al. (2006); Devaraj, of amino acids during periods of adequate protein Hemarajata and Versalovic intake. Some commensal members produce biolog- (2013); Bergen (2014) ically active components from amino acids. Amino acid supplementation in a mouse model of ulcerative colitis has been shown to promote overall growth of commensal microbiota. The effect was considered to be mediated via the stimulatory effect on mucin pro- duction by amino acid supplementation. Benzoates Benzoic acid, hippurate, Gut microbiota in mice with active colitis displayed Rechner et al. (2002); 2-hydroxyhippurate enrichment for genes involved in benzoate degrada- Aronov et al. (2011); De tion. Hippurate derives from plant food polyphenols Preter and Verbeke (2013); and is a conjugate of benzoic acid with glycine. In Rooks et al. (2014) humans a large portion of hippurate is believed to be derived from precursors absorbed in the small in- testines. It is reliably decreased in IBD. Bile acids Bile acids are synthesized from cholesterol in the Martin et al. (2007); Bennett liver and further metabolized into secondary bile et al. (2013); Ger ´ ard (2013); acids by the gut microbiota. The amino acid sides Kakiyama et al. (2013); chain of glyco- and tauro-conjugated bile acids are Mart´ınez et al. (2013); Sayin cleaved by bacterial bile salt hydrolase (BSH) enzyme et al. (2013); Joyce et al. to yield unconjugated bile acids (cholic and chen- (2014) odeoxycholic acids). These products will then be fur- ther modified by gut bacteria to produce secondary bile acids. A decrease in this conversion is positively correlated with liver cirrhosis. Bile acids can mod- ulate the composition of the microbiota in the gut, where they function as signaling molecules and may constitute a mechanism of quorum sensing. In turn, the microbiota strongly affect bile acid metabolism by promoting deconjugation, dehydrogenation and dehydroxylation. It can also inhibit bile acid synthe- sis in the liver by alleviation of farnesoid X receptor inhibition in the ileum. Bile acids can induce FMO3 expression by an FXR-dependent mechanism. Lipids Cholesterol The gut microbiota impact on the host systemic lipid Martin et al. (2007); metabolism. When administered as probiotics Bifi- Mart´ınez et al. (2009, 2013); dobacteria and Lactobacillus can enhance dyslipidemia Yu et al. (2013); Joyce et al. and insulin resistance. Microbiota have an influence (2014 on cholesterol metabolism and weight gain in the host via the bacterial BSH mechanism. Methylamines and Methylamine, Cleavage of choline and phosphatidylcholine (PC) by Wang et al. (2011); Craciun products of choline dimethylamine, the gut microbiota via the enzyme choline TMA-lyase and Balskus (2012); Koeth metabolism dimethylglycine, produces TMA. Oxidation of TMA by hepatic flavin- et al. (2013); Tang et al. trimethylamine (TMA) and containing monooxygenase 3 (FMO3) forms TMAO. (2013); Zhu et al. (2014) trimethylamine N-oxide Microbial metabolism of L-carnitine also produces (TMAO) TMA via a novel Rieske-type protein. Risk for major adverse cardiovascular events coincides with higher levels of TMAO. Neurotransmitters Serotonin, melatonin, It was recently discovered that gut microbiota pro- Desbonnet et al. (2008); glutamate, GABA, duce tryptophan decarboxylase, the enzyme respon- Bravo et al. (2011); Rooks noradrenaline, dopamine sible for decarboxylasing tryptophan to tryptamine. et al. (2014); Williams et al. and acetylcholine Tryptamine promotes the release of serotonin by en- (2014); O’Mahony et al. terochromaffincells.Inaratmodelitwas shownthat (2015) Bifidobacteria treatment resulted in increased tryp- tophan and kynurenic acid levels. Another study in mice showed the potential of Lactobacillus rhamnosus to modulate the GABAergic system. Decreased levels of dopamine were measured in fecal samples from active colitis mice. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 574 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 Table 2. (Continued.) Role in health and Metabolite Intermediates/products Synthesis disease References Phytochemicals, Chlorogenic acids, A significant amount of polyphenols reaches the Tomas-Barberan et al. particularly hydrolysable tannins and colon and is believed to contribute to gut health (2014); Kahle et al. (2006); polyphenolic flavonoids by promoting the growth of some commen- Aronov et al. (2011); van compounds sals. Polyphenolic bioconversion by microbiota Duynhoven et al. (2011); is paramount in the production of a large range Cardona et al. (2013); Mar´ın of bioactive molecules. The exact roles of these et al. (2015) molecules in health and disease are yet to be fully understood. Nonetheless epidemiological stud- ies have tied polyphenols to health benefits such as antioxidative, anticarinogenic, antiadipogenic, antidiabetic and neuroprotective properties. Gut microbiota can also convert dietary polyphenols to benzoate. Polyunsaturated Omega3and 6 L. plantarum has genes encoding for the enzyme in- Kishino et al. (2013) fatty acids (PUFA) volved in saturation metabolism of PUFA. Short-chain fatty Most abundant acetate, The SCFAs are produced from bacterial fermentation Bergman (1990); Maslowski acids (SCFAs) propionate, butyrate; to a of non-digestible polysaccharides. They play a role in et al. (2009); den Besten et al. lesser extent—formate, metabolic syndrome prevention and treatment. Evi- (2013); Kimura et al. (2013); fumarate, malonate, dence point to their potential to promote metabolic Natarajan and Pluznick succinate, caproate and control in type 2 diabetes. SCFAs are a major source (2014); Puddu et al. (2014) valerate of energy for colonocytes and also contribute up to 10% of the host’s daily caloric requirements. They are further involved in the control of energy utiliza- tion and maintenance of metabolic homeostasis via the G Protein coupled Receptor 43 (GPR43) receptor. SCFA products also dampen inflammatory response through this receptor. SCFAs have also been shown to affect cell proliferation and apoptosis (in cancer cells), and in epigenetic machinery such as histone acetylation by butyrate. Vitamins B-group vitamins, vitamin It is well established that the gut microbiota synthe- Hill (1997); Cooke, Behan B12; vitamin C, biotin, size a large number of vitamins de novo.Thisisim- and Costello (2006); vitamin K portant since humans lack biosynthetic pathways for Arumugam et al. (2011); vitamins. The deleterious effects of vitamin deficien- LeBlanc et al. (2013); cies are well known. It has only recently been sug- Degnan, Taga and gested that vitamin B12 may also contribute to shap- Goodman (2014) ing the structure and function of microbial commu- nities in the human gut. Other noteworthy bioactives Conjugated linoleic acid (CLA), bacteriocin CLA is associated with a diverse array of biological Bowdish, Davidson and activities, and predominantly associated with acti- Hancock (2005); Ross et al. vation of peroxisome proliferator activated receptors (2010) (PPARs) and the associated switching on and off of genes. Some Bifidobacteria and Lactobacillus species have been shown to produce CLA. Bacteriocins are peptides synthesized by bacteria and have narrow (same species) or broad (across genera) spectrum ac- tivity against other bacteria. A large number of ar- chaea and bacteria are believed to produce at least one bacteriocin. Tetrathionate and nitric oxide Tetrathionate and nitric oxide are produced in an in- Winter et al. (2010); Bergen flammatory environment and are central to the fit- (2014); Rooks et al. (2014) ness of several Enterobacteriaceae. Tetrathionate uti- lization positively correlated with active colitis in a mouse model. Bacterial growth depends on the pres- ence of nitrogen. Synthesis of amino acids by the mi- crobiome depends on the recycling of nitrogen back into gastrointestinal organs. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 575 Table 3. Various pathologies that have been associated with dysbiosis of the gut. Condition References Asthma Abrahamsson et al. (2014) AD Karri, Martinez and Coimbatore (2010); Alam et al. (2014) Atherosclerosis Koren et al. (2011) Autism spectrum disorders Parracho et al. (2005); Finegold et al. (2010); Adams et al. (2011); Williams et al. (2011, 2012); De Angelis et al. (2013); Kang et al. (2013) β-Cell autoimmunity de Goffau et al. (2014) Cardiovascular disease Amar et al. (2011) Crohn’s disease Seksik et al. (2003) Chronic fatigue syndrome Sheedy et al. (2009); Proal et al. (2013) Cystic fibrosis Scanlan et al. (2012); Bruzzese et al. (2014);Sanc ´ hez-Calvo et al. (2008); Duytschaever et al. (2011, 2013); Madan et al. (2012) HIV/AIDS Lozupone et al. (2013); McHardy et al. (2013); Vujkovic-Cvijin et al. (2013) IgE-associated eczema Abrahamsson et al. (2012) Inflammation Cani et al. (2008, 2012); Delzenne and Cani (2011); Delzenne et al. (2011) Inflammatory bowel disease Conte et al. (2006); Clemente et al. (2012); Manichanh et al. (2012); Morgan et al. (2012); Nagalingam and Lynch (2012); Bakhtiar et al. (2013) Iron deficiency Balamurugan et al. (2010); Zimmermann et al. (2010); Dostal et al. (2012, 2014) Liver disease Schnabl and Brenner (2014) Multiple sclerosis Berer et al. (2011) Obesity Delzenne and Cani (2011); Geurts et al. (2014) Rheumatoid arthritis Detert et al. (2010); Berer et al. (2011); Scher and Abramson (2011); Bingham and Moni (2013); Brusca, Abramson and Scher (2014); Catrina, Deane and Scher (2014); Cenit ´ et al. (2014); Demoruelle, Deane and Holers (2014); Taneja (2014) Parkinson’s Disease Scheperjans et al. (2015); Vizcarra et al. (2015) Sarcoidosis Almenoff et al. (1996) Systemic lupus erythematosus Hevia et al. (2014); Zhang et al. (2014a) Symptomatic atherosclerosis/stroke Karlsson et al. (2012) Type 1 diabetes Brown et al. (2012); Owen and Mohamadzadeh (2013); Petersen and Round (2014) Type 2 diabetes Larsen et al. (2010); Brown et al. (2012); Qin et al. (2012); Karlsson et al. (2013); Everard et al. (2014) Table 4. Diseases and conditions where bacterial translocation (of gut or oral origin) and consequent chronic infection are specifically implicated Diseases and conditions where translocation of bacteria are present References Communicable diseases Fibrosis stage in HIV/HCV coinfection Balagopal et al. (2008); Montes-de-Oca et al. (2011); Page, Nelson and Kelleher (2011); Lin, Weinberg and Chung (2013); Sacchi et al. (2015) Hepatitis C virus (HCV) infection French et al. (2013); Munteanu et al. (2014) HIV/AIDS infection Sandler and Douek (2012); Klatt, Funderburg and Brenchley (2013); Vazquez-Castellanos et al. (2014) Pneumonia in immunocompromised Sawa (2014) patients Diseases usually seen as non-communicable Abdominal compartment syndrome Mifkovic et al. (2013) Alcoholic liver disease Chen and Schnabl (2014); Malaguarnera et al. (2014) Allergic disease: bacterial translocation Abrahamsson Wu and Jenmalm (2015) during pregnancy Atherosclerosis Epstein, Zhou and Zhu (1999); Kozarov et al. (2006); Erridge (2008); Renko et al. (2008); Epstein et al. (2009); Nagata, de Toledo and Oho (2011); Rosenfeld and Campbell (2011); Hopkins (2013); Dinakaran et al. (2014); Rogler and Rosano (2014); Trøseid et al. (2014) Burn wounds Macintire and Bellhorn (2002); Sharma (2007); Aboelatta et al. (2013) Cirrhosis Wiest and Garcia-Tsao (2005); Jun et al. (2010); Giannelli et al. (2014); Wiest, Lawson and Geuking (2014) Chronic kidney disease Anders, Andersen and Stecher (2013); Sabatino et al. (2014) Metabolic syndrome Festi et al. (2014) Non-alcoholic fatty liver disease Bieghs and Trautwein (2014) Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 576 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 Table 4. (Continued.) Diseases and conditions where translocation of bacteria are present References Obesity Vajro, Paolella and Fasano (2013); Sanz and Moya-Per ´ ez (2014) Pancreatitis Mifkovic et al. (2009); Guo et al. (2014); Olah ´ and Romics (2014) Rheumatoid arthritis Ogrendik (2009b, 2013b); Ebringer and Rashid (2014); Koziel, Mydel and Potempa (2014) Schizophrenia Severance et al. (2013); Severance, Yolken and Eaton (2014) Sepsis and Septic shock Tsujimoto, Ono and Mochizuki (2009); Wallet et al. (2011); Deitch (2012); Leli et al. (2014) Stroke Syrjanen ¨ et al. (1988); Emsley and Tyrrell (2002); Emsley et al. (2003); Emsley and Hopkins (2008); McColl, Allan and Rothwell (2009); Emsley and Chamorro (2010); Grau, Urbanek and Palm (2010); Wang et al. (2012a); Chien et al. (2013); Dalager-Pedersen et al. (2014); Fugate et al. (2014) Surgical procedures Bariatric surgery Festi et al. (2014) Cardiac surgery Allen (2014) Multiple organ failure (MOF) Swank and Deitch (1996) Sepsis due to surgery MacFie (2004); Puleo et al. (2011) ‘Sepsis’ is widely used to imply living microbes, but as is now well known it can also occur in the absence of any culturable microbes, including those incapable of proliferation due to antibiotic activity. Sepsis may commonly result simply from the effects of molecules such as LPS on the generation of inflammator y cytokines (Kotsaki and Giamarellos-Bourboulis 2012; Balakrishnan et al. 2013). suggested that a changed gut microbiota represents the initial well as other microorganisms can reside inside RBCs (e.g. Mi- site of autoimmunity generation, and might be a critical epige- nasyan 2014), and thus able to cross the RBC membrane some- netic factor in autoimmune diseases such as rheumatoid arthri- how (see Table 5). Transmission electron microscopy (TEM) anal- tis (Scher and Abramson 2011; Luckey et al. 2013; Brusca, Abram- ysis showing bacteria inside cells would also tend to imply that son and Scher 2014; Catrina, Deane and Scher 2014;Cenit ´ et al. the bacteria were not externally introduced artefactually during 2014; Taneja 2014). There is also evidence that regulatory T cells the preparation of the samples. in the gut are influenced by microbial factors, and that a changed For the current paper, we have revisited our AD and PD microbiota (dysbiosis) may influence the induction and suppres- samples and figures from Pretorius et al. (2014a) and Lipinski sor functions of these cells, in turn leading to a changed gut mu- and Pretorius (2013) and noted the prevalence of bacteria in al- cosal immunity (Kinoshita and Takeda 2014). most all of the AD and PD samples, in numbers much in ex- We have earlier reviewed the literature that suggests that cess of those seen in our database of thousands micrographs dysbiosis can cause gut epithelial barrier dysfunction, and from healthy individuals. Here we show additional micrographs thereby provide a point of entry into the body, including the from the previously published samples (see Figs 5 and 6). In blood, resulting in atopobiosis. This is supported by recent re- both conditions (see Figs 5AD and 6PD), microbes were noted search that has suggested that blood microbiota might be impli- in close proximity to RBCs, and in some cases RBCs extended cated in various (cardiovascular and other) diseases. Sequence- pseudopodia-like projections towards the microbiota. SEM anal- based techniques provided evidence for the presence of such ysis of AD whole blood (Fig. 5) shows that mostly coccus-shaped a blood microbiome. The question now arises as to whether bacteria are present. White blood cells are seen in close proxim- such a microbiome’s presence can be directly measured by e.g. ity to these bacteria in AD patients (see Fig. 5A–C). SEM anal- ultrastructural (microscopic) methods, since a consequence of yses of PD patients (Fig. 6) show both coccus- and bacillus- any translocation of microbes between the gut microbiome and shaped bacteria in close proximity to RBCs. We also observed blood is that they should then be observable in blood. The next that RBCs extend pseudopodia towards these bacteria and this sections will provide visual evidence of the presence of such might be part of the mechanism by which the bacteria en- a microbiota in Alzheimer’s disease (AD) and PD. As shown in ter the RBCs (see Fig. 6C–F). We also note possibly dividing Table 3, these conditions are known to be associated with the coccus-shaped bacteria in both these conditions, indicated with presence of dysbiosis. blue arrows on Fig. 5A (AD patient) and Fig. 6D (PD patient). This might suggest that these bacteria may be(come) cultur- able under appropriate conditions (see also Soina et al. 2012; Direct measurement by ultrastructural (microscopic) Epstein 2013). methods TEM analysis of the samples from Lipinski and Pretorius Direct measurement by ultrastructural (microscopic) methods of (2013) and Pretorius et al. (2014a) showed the presence in- side RBCs of cells that appeared to be microbial in nature analysis shows that microbes are in fact common constituents of blood in inflammatory diseases [previously seen in PD—Fig. 8 (unpublished data). These internalized cells further provide evidence for a sustained presence of such a blood micro- in (Pretorius et al. 2014a and in AD—Fig. 2 in (Lipinski and Pre- biota (and one hardly explained by contamination) (see Fig. 7A torius 2013). We show and annotate selected micrographs from and B: AD and C and D: PD). Bacteria are shown with ar- these papers in Fig. 4]. An important concern that needs to be rows in the micrographs. No bacterial membrane was noted; addressed, as is also the case with sequence-based methods, is therefore, the bacteria may be L-forms. There seems to be whether the presence of microbiota in whole blood is indeed bacterial species selectivity for a given disease, as our pre- not the result of introduced external contamination. There is liminary observations suggest a prevalence for bacillus-type in fact considerable evidence in the literature that bacteria as Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 577 Figure 3. Schematic representation of dysbiosis, bacterial translocation and atopobiosis. (A) When intestinal microbiota are associated with dysbiosis,(B) the gut barrier (1 and 2) becomes compromised; this leads to (C), a route of entry via the gut epithelia causing (D) bacterial translocation. Bacterial translocation is also associated with a compromised systemic immune system barrier (3). Therefore, intestinal microbiota dysbiosis (A) followed by bacterial translocation (D) results in (E) atopobiosis. (F) The results of bacterial translocation are seen in various conditions (see Table 4). bacteria in AD, but both coccus- and bacillus-shaped bacteria however, dormancy and viability versus non-viability issues per- in PD patients. tain (as discussed above). Our observations suggest that the presence of bacteria in We found a definite association between RBCs and bacteria, these two diseases occurs in only a small fraction of the RBC with RBCs (see Figs 6 and 7) forming pseudopodia-like extension, population, which is why we had not really noted them in our as if in the process of engulfing bacteria. Both coccoid (round) previous studies (e.g. Bester et al. 2013; Pretorius et al. 2013, and bacillary (elongated) bacteria were found in PD whole blood 2014a,b; Pretorius and Kell 2014), and SEM and TEM analysis con- SEM micrographs, but only coccoid forms in AD whole blood firms this observation. We have never (or not yet) found bacte- SEM micrographs. Samples from 25 diagnosed AD patients were ria inside RBCs from healthy controls (these without overt, diag- studied and bacteria were detected in 14 individuals from this nosed diseases) when studying blood smears using TEM analy- AD sample, while samples from 30 PD patients were studied, sis. The microscopy preparation methods involve a washing pro- in 21 of whom we detected bacteria. Obviously, the type of bac- cess, and this may wash away some of the bacteria, or RBCs and teria cannot be identified from ultrastructural observations. As white blood cells associated with bacteria. Therefore, the actual with the timeline of established cases such as the role of H. quantification of the bacteria can only be done by other means; pylori in ulcers and colon cancer, the next tasks are to bring Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 578 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 these microscopically observed bacteria into culture and to carry out sequence-based studies to establish their role (if any) in non-communicable diseases. However, to illustrate that the bac- teria may indeed be engulfed by the RBCs, and to confirm that the phenomenon is not due to external contamination, we show TEM micrographs from both of the studied diseases (see Fig. 7, AD and PD). CONCLUDING REMARKS AND PROSPECTIVE EXPERIMENTS ‘Non-culturable’ (which should be called ‘not-easily-culturable’ or ‘not-yet-cultured’) microbes are commonplace in the ‘envi- ronmental microbiology’ of soil and water, and the blood cer- tainly represents an ‘environment’. As we show here, there is a large and scattered literature, increasing in size, to the effect that there might be a (mainly dormant) microbial component Figure 4. Micrographs taken from previously published manuscripts. (A–C)Bac- in a variety of chronic diseases that are normally considered to terial presence in PD, originally shown in Fig. 8A, C and G in Pretorius et al. (2014a). (D) Bacterial presence in AD, originally shown in Fig. 2 in Lipinski and be non-microbial or non-communicable in nature, even when Pretorius (2013). microbes appear absent by culturability criteria. Our previous Table 5. Some microorganisms that are known to invade red blood cells. Pathogen Type of microorganism Mechanism of invasion References Anaplasma marginale A tick-borne pathogen that causes Via major surface protein 1a (MSP1a) Kocan et al. the disease anaplasmosis in cattle. (2004) Bartonella bacilliformis Bartonella species are fastidious The Trw T4SS mediates attachment of Bartonella to Iwaki-Egawa and B.quintana Gram-negative bacteria, which red blood cells in Bartonella lineage 4. Bartonella is Ihler (1997); belong to the alpha group of the collected in pits and trenches that form as a result Coleman and domain Proteobacteria. of deformation factor. Invaginations supposedly Minnick (2001); pinch off to carry the content in a vacuole structure Rolain et al. to the cytoplasm of the red blood cell where the (2003); Eicher organism persists. and Dehio (2012) Brucella melitensis Facultative intracellular Invasion shown in mouse erythrocytes. Mechanism Vitry et al. (2014) Gram-negative coccobacilli. to be identified. Francisella tularensis Highly infectious bacterium, Via serum complement-dependent and Conlan (2011); which can cause severe disease independent mechanisms. Horzempa et al. tularemia with an infection of (2011) fewer than 10 bacteria Mycoplasma suis A member or the hemotrophic Invasion occurs in a similar manner to that of P. Groebel et al. mycoplasma group that parasitize falciparum and B. bacilliformis. Attachment via MSG1 (2009); Zhang erythrocytes in pigs. (GAPDH) protein. et al. (2014c) M. bovis Small cell wall-less bacterium that Undetermined. van der Merwe, contributes to a number of chronic Prysliak and inflammatory diseases in dairy Perez-Casal and feedlot cattle. (2010) M. gallisepticum Mycoplasmas are small cell Not known. Vogl et al. (2008) wall-less prokaryotes. Plasmodium falciparum The main malaria parasite, part of Recognition of surface receptors precedes a Cowman and whose life cycle involves reorientation where the apical end is adjusted to Crabb (2006) inhabiting RBCs. the erythrocyte. A tight junction that involves high-affinity ligand receptor interactions is formed. The tight junction moves from the apical to posterior pole and is powered by the actin-myosin motor of the parasite. The adhesive proteins at the junction are proteolytically removed when the posterior pole is reached, most likely by a rhomboid resident protease in a process that facilitates membrane resealing. The invasion process produces a parasitophorous vacuole containing the merozoite. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 579 Table 5. (Continued.) Pathogen Type of microorganism Mechanism of invasion References Streptococcus pneumoniae Gram-positive bacterium which LPXTG motif-containing pneumococcal proteins, Yamaguchi et al. causes infection-related diseases. erythrocyte lipid rafts and erythrocyte actin (2013) remodeling are involved in the invasion mechanism. Theileria sporozites Intracellular protozoan Occurs in a similar manner to sporozoite entry. Shaw (2003); transmitted by ixodid ticks. Infect Bishop et al. wild and domesticated ruminants. (2004) Phylogenetically most closely related to Babesia. Figure 6. RBCs with microbiota from patients with diagnosed PD (additional mi- crographs from sample used in Pretorius et al. 2014a). These micrographs are rep- Figure 5. RBCs with microbiota from patients with diagnosed AD (additional mi- resentative of bacteria found in smears of 21 of the 30 PD individuals. (A) A col- crographs from sample used in Lipinski and Pretorius 2013). These micrographs lection of coccus- and bacillus-shaped bacteria; (B) coccus- and bacillus-shaped are representative of bacteria found in smears of 14 of the 30 AD individuals. bacteria associated with erythrocyte; (C) bacillus-shaped bacteria in close prox- (A and B) coccus-shaped bacteria associated with white blood cell; (B) coccus- imity with erythrocyte. Erythrocyte forms extensions towards bacteria; (D and E) shaped bacteria associated with an erythrocyte and white blood cell; (C)two bacillus-shaped bacteria associated with elongated erythrocytes; (F) coccus- and white blood cells associated with coccus-shaped bacteria; (D) a string of cocci- bacillus-shaped bacteria close to erythrocyte that extends pseudopodia towards blue arrow shows possibly dividing coccoid bacteria; (E) an erythrocyte associ- the bacteria. Coccus-shaped bacteria shown with pink arrows; bacillus-shaped ated with coccus-shaped bacteria; (F) a high machine magnification of a coccus- bacteria shown with white arrows. Dividing coccus-shaped bacteria shown with shaped bacteria associated with a dense matted fibrin deposit. Scale bar: 1 μm. blue arrow. Scale bar: 1 μm. work (e.g. Bester et al. 2013; Pretorius et al. 2013, 2014a;Kelland Pretorius 2014, 2015; Pretorius and Kell 2014) has implied iron dysregulation as a regular accompaniment to, and probable con- We have here pointed up the likelihood of a steady crop tributory factor for, a variety of similar diseases, all of which of effectively dormant microbes being a feature of blood bi- have an inflammatory component. We argue here that there is ology in chronically diseased humans, including those with also a microbial contribution to this in the blood, and it is not un- non-communicable diseases. As with any complex system, the reasonable that the microbial requirement for iron means that, magnitude of any component is affected by the kinetics of every despite the oxidative stress it can entail (Touati 2000;Kell 2009, relevant step; while the precise nature of all the interactions is 2010), microbes may be anticipated to increase in prevalence uncertain, Fig. 8 describes the general network—the first step in when iron is free (e.g. Ratledge 2007; Clifton, Corrent and Strong any systems analysis (Kell 2006; Kell and Knowles 2006). 2009; Sia, Allred and Raymond 2013; Chu et al. 2014) and avail- Consequently, we recognize that the analysis above has able (D’Onofrio et al. 2010), probably behaving in a social manner largely been qualitative (the ‘presence’ of a microbial compo- (Kell, Kaprelyants and Grafen 1995; West and Buckling 2003;Dig- nent in a specific disease is a qualitative statement). However, gle et al. 2007; Harrison and Buckling 2009). chronic, non-communicable diseases are very far from being Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 580 FEMS Microbiology Reviews, 2015, Vol. 39, No. 4 tectable blood microbiome in this and other diseases that show such flares. As with H. pylori and stomach ulcers (and cancer), the simple prediction is that bactericidal antibiotics should be of value in the treatment of such supposedly non-communicable diseases. Indeed, this prediction is borne out for diseases such as rheumatoid arthritis (Ogrendik 2009a, 2013a; Kwiatkowska and Masli ´ nska ´ 2012) and multiple sclerosis (Ochoa-Repar ´ az et al. 2009; 2011), while antipneumococcal vaccination has shown ef- ficacy in preventing stroke (Vila-Corcoles et al. 2014). Of course, events such as heart attacks and strokes (and see Table 4)may also be seen as sudden increases in severity of an underlying condition, and in some cases (such as the much increased like- lihood of strokes after subarachnoid haemorrhages; McMahon et al. 2013), analysis of changes in the blood microbiome might prove predictive. The obvious next tasks are thus to relate the number and nature of blood microbes observed in cases such as the above to microbial sequences and antigens that can be detected in aliquots of the same samples (e.g. Salipante et al. 2013, 2015), to determine the physiological state of the various microbes (in- Figure 7. TEM confirming the presence of bacteria inside erythrocytes of ( A and cluding e.g. whether they are L-forms), and to establish methods B)AD,(C and D) PD. (Additional micrographs from sample used in Lipinski and to bring them (back) into culture. Since microbes, inflammation Pretorius (2013) and Pretorius et al. (2014a). Arrows in each micrograph show the and various syndromes are such common co-occurrences (as presence of cellular inclusions, without visible membranes. Inclusions are not typically noted in erythrocytes. We suggest that these inclusions are bacteria, are coagulopathies; Kell and Pretorius 2015), longitudinal stud- possibly as L-forms. Scale bar = 1 μm (A, C, D); 200 nm (D). ies will have a specially important role, as they will both show the dynamics and be able to help discriminate cause and ef- fect during the time evolution of chronic, non-communicable diseases in ageing populations. The immunogenicity of per- static (and thousands of human genes change their expression sisters, and their ability to induce various kinds of inflamma- at least 2-fold even on a diurnal basis; Zhang et al. 2014b). Thus, a tion, must be rather different from that of replicating organ- clear further issue is to seek to understand how the blood micro- isms, and this must be investigated. Armed with such collec- biome may co-vary with the day-to-day dynamics of chronic dis- tive knowledge, we might be better placed to develop thera- eases. For example, rheumatoid arthritis has circadian rhythms peutics such as pre- and probiotics and bactericidal antibiotics (Straub and Cutolo 2007) and is well known to provide signifi- for use in such cases previously thought to lack a microbial cant variations (‘flares’; Flurey et al. 2014) in severity at different contribution. times. A reasonable strategy is thus to look for changes in a de- Figure 8. Relationships between a dormant blood microbiome and chronic disease dyamics. Downloaded from https://academic.oup.com/femsre/article/39/4/567/2467761 by DeepDyve user on 19 July 2022 Potgieter et al. 581 FUNDING Phylogenetics: a discipline of evolutionary biology that stud- ies the relationships between organisms based on how closely We thank the Biotechnology and Biological Sciences Research similar some of their macromolecular sequences are. Council (grant BB/L025752/1) as well as the National Re- Pleomorphic: possessing the ability to change shape or size search Foundation (NRF) of South Africa for supporting this in response to environmental stimuli. collaboration. Resuscitation: induction of apparently non-culturable cells to a state of culturability. Conflict of interest. None declared. Sterile: refers to an absence of operationally viable organ- isms. Viable: capable of observable replication, i.e. culturable, by any stated means. GLOSSARY 16S ribosomal RNA: a component of the 30S small subunit of REFERENCES prokaryotic ribosomes. 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