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Clostridium difficile toxins induce VEGF-A and vascular permeability to promote disease pathogenesis

Nature Microbiology volume 4, pages 269–279 (2019)Cite this article

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Abstract

Clostridium difficile infection (CDI) is mediated by two major exotoxins, toxin A (TcdA) and toxin B (TcdB), that damage the colonic epithelial barrier and induce inflammatory responses. The function of the colonic vascular barrier during CDI has been relatively understudied. Here we report increased colonic vascular permeability in CDI mice and elevated vascular endothelial growth factor A (VEGF-A), which was induced in vivo by infection with TcdA- and/or TcdB-producing C. difficile strains but not with a TcdA−TcdB− isogenic mutant. TcdA or TcdB also induced the expression of VEGF-A in human colonic mucosal biopsies. Hypoxia-inducible factor signalling appeared to mediate toxin-induced VEGF production in colonocytes, which can further stimulate human intestinal microvascular endothelial cells. Both neutralization of VEGF-A and inhibition of its signalling pathway attenuated CDI in vivo. Compared to healthy controls, CDI patients had significantly higher serum VEGF-A that subsequently decreased after treatment. Our findings indicate critical roles for toxin-induced VEGF-A and colonic vascular permeability in CDI pathogenesis and may also point to the pathophysiological significance of the gut vascular barrier in response to virulence factors of enteric pathogens. As an alternative to pathogen-targeted therapy, this study may enable new host-directed therapeutic approaches for severe, refractory CDI.

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Fig. 1: CDI increases colonic vascular permeability in mice.
Fig. 2: C. difficile toxins induce VEGF-A production, mediated by the HIF-α, p38-MAPK and MEK1/2 signalling pathways, in human colonocytes.
Fig. 3: Toxins induce the production of VEGF-A in CDI mice in vivo and in human colonic mucosa ex vivo.
Fig. 4: Human colonocytes pre-exposed to TcdA or TcdB stimulate HIF signal-mediated HIMEC proliferation.
Fig. 5: Both VEGFR-2 kinase inhibition and anti-VEGF-A treatment attenuates vascular permeability and protects mice from CDI.
Fig. 6: Enhanced serum levels of VEGF-A in CDI patients and reduced VEGF-A levels in follow-up sera after standard treatment.

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Data availability

All data reported in this study are available from the corresponding author on reasonable request.

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Acknowledgements

We thank W.-R. Lie (EMD Millipore) for help with the cytokine assays and T. Fei (Dana Farber Cancer Institute) for technical help. This work was supported by an Irving W. and Charlotte F. Rabb Award (to X.C.), Crohn’s and Colitis Foundation of America Career Development Award (to X.C.), Young Investigator Award for Probiotic Research (to X.C.), NIH/NIDDL grant no. P30 DK 41301 (to C.P.), NIH/NIDDK grant no. U01 DK110003 (to C.P.), NIH/NIAID R01 grant no. DK60729 (to C.P.), fellowship from the Crohn’s and Colitis Foundation of America (to K.B.), Foundation of China National Key Clinical Discipline (to J.W.), Foundation of China Scholarship Council (to J.Huang), National Health and Medical Research Council of Australia grant no. 1107812 (to D.L.), Australian Research Council Future Fellowship grant no. FT120100779 (to D.L.) and NIH/NIAID R01 grant nos AI116596 (to C.P.K.) and U19 AI 109776 (to C.P.K.).

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Authors and Affiliations

  1. Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Jun Huang, Ciarán P. Kelly, Javier A. Villafuerte Gálvez, Hua Xu, Xiaotong Yang, Kelsey S. Shields, Yi Zhang, Ishan J. Patel, Joshua Hansen, Alan C. Moss & Xinhua Chen

  2. Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China

    Jun Huang, Meijin Huang & Jianping Wang

  3. Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China

    Jun Huang

  4. Division of Digestive Diseases, Inflammatory Bowel Disease Center, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA

    Kyriaki Bakirtzi

  5. Infection and Immunity Program, Monash Biomedicine Discovery Institute and Department of Microbiology, Monash University, Clayton, Victoria, Australia

    Dena Lyras, Steven J. Mileto, Sarah Larcombe & Charalabos Pothoulakis

  6. Institute of Microbiology and Immunology, Life and Environment Science College, Shanghai Normal University, Shanghai, China

    Xiaotong Yang

  7. Mucosal Immunology and Biology Research Center, Massachusetts General Hospital for Children and Harvard Medical School, Charlestown, MA, USA

    Weishu Zhu

  8. Department of Gastrointestinal Surgery, The Third Xiangya Hospital, Central South University, Changsha, China

    Yi Zhang

  9. Department of Pathology, Children’s Hospital Boston and Harvard Medical School, Boston, MA, USA

    Jeffrey D. Goldsmith

  10. Icahn School of Medicine at Mount Sinai (Elmhurst) Program, New York, NY, USA

    Ishan J. Patel

  11. Department of Biotechnology and Molecular Medicine, A.I. Virtanen Institute, University of Eastern Finland and Science Service Center and Gene Therapy Unit, Kuopio University Hospital, Kuopio, Finland

    Seppo Yla-Herttuala

  12. Microbiota-Host Interactions and Clostridia Research Group, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile

    Daniel Paredes-Sabja

  13. Departments of Molecular and Integrative Physiology, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA

    Yatrik M. Shah

  14. Guangdong Institute of Gastroenterology, Guangzhou, China

    Jianping Wang

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Contributions

X.C., C.P.K., J.Huang, D.L., C.P. and J.W. were involved in study design, analysis and interpretation of data, drafted the manuscript and obtained funding. J.Huang, J.A.V.G., Y.M.S., K.B., H.X., X.Y., W.Z., Y.Z., J.D.G., S.J.M., S.L., D.P.-S., K.S.S., I.J.P. and J.Hansen contributed towards the acquisition of data. C.P., Y.M.S., A.C.M., M.H. and S.Y.-H. provided material support.

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Correspondence to Jianping Wang or Xinhua Chen.

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Huang, J., Kelly, C.P., Bakirtzi, K. et al. Clostridium difficile toxins induce VEGF-A and vascular permeability to promote disease pathogenesis. Nat Microbiol 4, 269–279 (2019). https://doi.org/10.1038/s41564-018-0300-x

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