OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
C HA P TER 9
Infection and pathogenesis
After a host is encountered, the parasite has to infect and
establish. The parasite has, furthermore, to grow and
multiply inside the host, and achieve transmission to the
next host. In completing these steps in the life-cycle, the
parasite inicts some damage to its host. In this chapter,
we take a look at two main elementsthe infection step,
and the way in which damage is done to the host.
9.1 Infection and dose
Macroparasites, like helminths or parasitoids, typically
invade and establish the infection as single individuals.
But in microparasites, such as bacteria, viruses, or pro-
tozoa, an infection typically occurs with a dose; that is,
many pathogens (cells, spores, virions, etc.) are needed.
Not surprisingly, the processes of infection and establish-
ment vary widely among parasites. In particular, there is
a remarkable variation in the number of pathogen cells
necessary to start an infection. This number is known as
the infective dose, and it is a statistically inferred quan-
tity ( Table 9.1). Some parasites can start an infection with
a minimum infective dose of only a few cells, as in the
example of enteropathogenic bacteria (Shigella spp.;
Health_Canada 2003), protozoan infections of humans
(Cryptosporidium parvum; Englehardt and Swartout 2004),
or for viral infections in mice (Gammaherpes; Tibbetts
et al. 2003) and cattle (foot and mouth disease; Schijven
et al. 2005). On the other hand, many parasites are only
infective at high doses, such as the bacteria Campylobacter,
Staphylococcus, or Salmonella (Sewell 1995). It is still quite
unclear why infective dose varies that much, with some-
times drastic differences, even between closely related
pathogens ( Table 9.1).
Before we scrutinize why infective dose might vary, it
should be remembered that the route of infection is an
important factor that determines how many pathogens
are needed to infect. Parasites can, for example, infect via
wounds in the skin, they can be inhaled, or they can
infect per os (i.e. when imbibed by the host). Most para-
sites can use more than one route of infection ( Table 9.2),
and the respective doses differ between these routes
(Figure 9.1). Furthermore, dose is a statistical concept
that is derived from the probability of infection when dif-
ferent numbers of pathogens are used in an inoculum,
i.e. a set of parasites administered to the host in a given
way. This procedure typically yields a doseresponse
curve that relates the inoculum size (the dose) to the
eventual effect of interest (Figure 9.1). The effect of inter-
est (the response) can be measured in very different ways;
for example, as the infection status or infection intensity
(the density of parasites in the host), antibody titre after
infection, the number of lesions on a plant leaf (the
symptoms of the disease), or host mortality rate (for the
lethal dose). Because the effect of interest varies accord-
ing to the question or problem under scrutiny, a number
of denitions have been suggested, but each of them
uses the concept of a doseresponse curve (Box 9.1).
Dose (the inoculum size) is typically measured as the
number of parasitic cells administered to the host, but it
can also mean a given amount of infectious material
(such as mg of toxin), and so on.
219
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
220 INFECTION AND PATHOGENESIS
Table 9.1 Minimum infective doses for various human bacterial pathogens.
Bacterium
Bacillus anthracis
Campylobacter jejuni
Clostridium perfringens
Coxiella burnettii
E. coli, enterohaemorrhagic
(EHEC)
Escherichia coli, enterotoxic
(ETEC)
E. coli, enteropathogenic
(EPEC)
E. coli, enteroinvasive (EIEC),
Shigella
Francisella tularensis
Listeria monocytogenes
Mycobacterium tuberculosis
Salmonella paratyphi
Salmonella typhi (enterica,
typhimurium)
Salmonella spp.
Shigella exneri
Staphylococcus aureus
Streptococcus A (pyogenes)
Streptococcus D (Enterococcus)
Treponema pallidum
Vibrio cholerae (serotypes
O139, O1)
Vibrio parahaemolyticus
Vibrio vulnicus
Yersinia enterocolitica
Yersinia pseudotuberculosis
1
FDA: from The Bad Bug Book (Food and Drug Administration 2003).
Disease, clinical symptoms
Anthrax disease.
Campylobacteriosis (enteritis,
gastroenteritis).
Food-borne illness. Diarrhea,
necrosis of intestines.
Q fever.
Diarrhea (common serotype is
O157:H7).
Gastroenteritis.
Childrens diarrhoea.
Bacillary dysentery.
Tularemia, rabbit fever, Oharas
fever.
Septicemia, meningitis,
encephalitis, uterine infections.
Tuberculosis.
Paratyphoid fever, enteric fever.
Gastroenteritis (salmonellosis).
Nausea, abdominal pain. Arthritic
symptoms may result in the
longer term.
Bacillary dysentery. Flexner.
Shigellosis.
Food poisoning. Nausea,
abdominal pain.
Sore throat, scarlet fever,
septicaemia.
Baceteraemia, endocarditis.
Syphillis
Cholera.
Gastroenteritis, diarrhea,
abdominal cramps.
Wound infections, gastroenteritis,
primary septicemia.
Gastro-enteritis, diarrhea, fever,
abdominal pain.
Tuberculosis-like symptoms,
diarrhea, fever, abdominal pain.
Dose1 (pathogen cells) Source
8103 . . . 50103 ( 103 by Sewell 1995; Casadevall and Pirofski
inhalation) 2003; Health Canada 2003
102 . . . 105 (50% infection) Sewell 1995; Teunis et al. 1999; Food
(FDA: 400500) by and Drug Administration 2003
ingestion
> 108 Food and Drug Administration 2003
10 by inhalation Sewell 1995)
10 Salyers and Whitt 2002; Food and
Drug Administration 2003; Health
Canada 2003
108 . . . 1010 Food and Drug Administration 2003;
Health Canada 2003
Adults: 108 . . . 1010 Children: Levine et al. 1983; Food and Drug
very low Administration 2003; Health
Canada 2003
10 Levine et al. 1983; Food and Drug
Administration 2003; Health
Canada 2003
10 by inhalation Sewell 1995
< 103 Salyers and Whitt 2002; Food and
Drug Administration 2003
10 by inhalation Sewell 1995; Salyers and Whitt 2002;
Food and Drug Administration
2003; Health Canada 2003
> 103, perhaps lower Health Canada 2003
105 (50% infection), perhaps Levine et al. 1983; Mims 1987; Health
lower Canada 2003
102 . . . 103 FDA: 15 . . . 20 Sewell 1995; Food and Drug
Administration 2003; Health
Canada 2003
180, by ingestion Sewell 1995
105 per gram of food Food and Drug Administration 2003
< 103, perhaps lower Food and Drug Administration 2003
> 107, perhaps higher Food and Drug Administration 2003
57 intradermal (Sewell 1995
102 . . . 1011; 108 by ingestion Levine et al. 1983; Sewell 1995; Food
(FDA: 106) and Drug Administration 2003;
Health Canada 2003
> 106 Food and Drug Administration 2003
< 100 Food and Drug Administration 2003
106 Health Canada 2003
106 Health Canada 2003
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

INFECTION AND DOSE 221

Table 9.2 Routes of infection based on hazards encountered in laboratory work. From Sewell (1995).

Parasite Route

Injured skin, mucosa Inhalation Ingestion Animal contact

Viruses
Hantavirus x x x x
Hepatitis viruses (HBV, HCV) x
Herpes simplex virus x
Herpesvirus simiae x x
HIV x
Lassa virus x x x x
Lymphocytic choriomeningitis virus x x x x
Marburg and Ebola viruses x x
Parvovirus x x
Rabies virus x x x
Venezuelan equine encephalitis virus x x x
Vesicular stomatitis virus x x x

Bacteria
Bacillus anthracis x x x
Bordetella pertussis x x
Borrelia spp. x x
Brucella spp x x x
Campylobacter spp. x x x
Chlamydia spp. x x
Coxiella burnetii x x x
Francisella tularensis x x x x
Leptospira spp. x x x
Mycobacterium tuberculosis x x
Burkholderia (Pseudomonas) pseudomallei x x
Rickettsia spp. x x x
Salmonella typhi x x
Other Salmonella spp. x x x
Treponema pallidum x x
Vibrio cholerae x x
Other Vibrio spp. x x x
Yersinia pestis x x x x

Fungi
Blastomyces dermatitidis x
Coccidioides immitis x x
Cryptococcus neoformans x x
Histoplasma capsulatum x x
Sporothrix schenckii x x
Dermatophytes x x

Protozoa
Leishmania spp. x x
Plasmodium spp. x
Toxoplasma gondii x x x
Trypanosoma spp x x
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222 INFECTION AND PATHOGENESIS

100%
Oral to
sterile gut
Subcutaneous
75%

Percent infected ~2 cfu ~400 cfu ~2 Mio cfu

50%

Orally (per os)

25%

0
0.1 1 1000 100000 10000000
Dose (bacterial cells)

Figure 9.1 The doseresponse curve. In this example, the percentage of mice infected with Salmonella enteritidis 3 weeks
post-infection is shown in relation to dose (log-scale). The presence of bacteria was measured as the number of colony-forming
units (cfu) that were present in faecal samples. The curves differ according to the mode of administering the inoculumorally to
a mice with sterilized gut, subcutaneously, or orally to a normal mouse. Redrawn from Johnson (2003) with permission from
American Biological Safety Association.

Box 9.1 Definitions of dose

A dose is typically the number of infective parasites
administered to a host in a dened way, e.g. para-
sites fed per os, or host exposed to infective spores.
Various infective doses are dened as follows:
ID50 (the 50%-infective dose): dose needed to
infect 50% of the tested hosts.
LD50 (the 50%-lethal dose): dose needed to kill
50% of the tested hosts.
LD10, LD99, etc.: dose needed to kill 10%, 99% of
hosts, etc.
LD50/30, LD50/60: dose needed to kill 50% of the
tested hosts during a period of up to 30 (or 60)
days. Mostly used for studies of radiation eects.
LDLo: lowest published dose needed to infect a host.
EID50 (the egg 50%-infective dose): dose needed
to infect 50% of the tested eggs. Used when test-
ing the infectivity of viruses on fertilized chicken
eggs (e.g. to produce vaccines).
ELD50 (the egg 50%-lethal dose): dose needed to
kill 50% of the tested eggs.
TCID50 (the tissue culture 50%-infectious dose):
dose needed to produce a pathogenic eect in 50%
of the cultures inoculated.
To test for a lethal dose in the standard way, usually
many host individuals are needed. Fewer test indi-
viduals are necessary with the xed-dose procedure
(usually used for tests of toxicity of a parasite when
infected orally). For this test, a xed number of host
individuals are tested, and the lethal dose is extrapo-
lated from the results.
In medical practice, a number of further meas-
ures are used. These are not necessarily referring to
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
parasitic infections but often refer to drug treat-
ment or to protection from radiation, toxins, and
poisons.
Booster dose: dose of an active immunizing agent,
usually smaller than the initial dose, which is
needed to maintain immunity.
Eective dose (ED): dose of a drug producing the
desired eect.
Fractionated dose: fraction of the total quantity of
a drug needed for the eect, and which is given at
intervals.
Maximum dose (safe dose): largest dose that can
safely be given.
Median curative dose (CD50): dose removing the
infection symptoms in 50% of subjects.
Median lethal dose: same as LD50.
9.1.1 Analysing infective dose
If we knew how the infection process actually unfolds, it
would be possible to reconstruct the resulting dosere-
sponse curve and thus the infective dose, D. Consider the
simplest case: every single parasite has the same probabil-
ity, p, to infect a host. If all hosts were equally susceptible
and all pathogens fully infectious, then, obviously p = 1,
that is, every parasite would infect with certainty. We
would, therefore, observe an infective dose of D = 1 para-
site. But rst complication arises because D is a random
variable in a given situation. For example, for any given
inoculum, the actual number of parasites it contains var-
ies in practice around a mean of D. Box 9.2 shows how
dose, D, can be analysed and predicted under explicit
assumptions for a specic infection model. Two major
models that are commonly considered are as follows.
9.1.1.1 Individual effective dose (threshold model)
In this model, infection occurs when the inoculum contains
more than the individual effective dose (IDE) for a given
host to cause infection. IDE is dened as the number of
INFECTION AND DOSE 223
Minimum lethal dose (MLD, minimum fatal dose):
smallest dose that is capable of killing a host. This
depends on body mass.
Median eective dose (ED50): dose producing
eect in 50% of subjects.
Median immunizing dose: vaccine or antigen dose
to generate immunity in 50% of subjects.
Median toxic dose (TD50): dose producing the
toxic eect in 50% of subjects.
Minimum dose (threshold dose): smallest dose
producing the eect.
Minimum lethal dose (MLD): smallest dose needed
to kill a host.
Priming dose: dose needed to establish an eect
(in drug treatments).
Tolerance dose: The largest dose that can be admin-
istered without eect.
parasites, n, such that numbers below IDE cause no infec-
tion, and numbers at least, or above, IDE cause full infec-
tion. Hence, the probability of infection is p = 0 for n < IDE,
and p = 1 for n IDE. These conditions dene a step func-
tion, such that the value of p is zero below IDE but jumps
to p = 1 at IDE (Figure 9.2a). However, the actual number of
parasites in a given dose varies randomly, and, therefore,
the doseresponse curve observed in practice becomes sig-
moidal (Figure 9.2a). Alternatively, the IDE can vary among
hosts. Such variation also causes the doseresponse curve
to depart from a step function (with a step at varying levels
of IDE corresponding to each individual host) and thus to
become more gradual (Figure 9.2b). Hence, although the
individual effective dose-model is essentially a threshold
model, the threshold does not become visible because
doses and individual subjects vary in a population.
9.1.1.2 Independent action model
In this scenario, infection is assumed to result from the
independently acting parasites in an inoculum. The inde-
pendent- action models are, therefore, characterized by
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

224 INFECTION AND PATHOGENESIS

(a) Constant

Probability of infection
Random

IDE Dose

(b)
Probability of infection
Frequency

Host IDE

Dose

Figure 9.2 Individual effective dose (IDE) model. (a) All hosts are homogeneous and have the same IDE. As a result, the
infection succeeds if the dose is at least or above the IDE, but fails if the dose is below IDE; the doseresponse curve is a step
function (dotted line). In practice, inoculum size (administered dose) deviates randomly from the mean and, hence, the
observed curve is sigmoidal (solid line). (b) Hosts vary in their IDEs as shown by the distribution given by the dotted line. The
observed doseresponse curve (solid line) is a gradual function reecting the variation in individual IDEs in the population.

the probability, p, per parasite to cause an infection inde-
pendent of dose, D. This probability is considered to be a
biological characteristic of the parasite and/or the host it
encounters. Box 9.2 shows how this model can be analy-
sed more formally. Infection occurs when at least one
parasite hits the right site or the right conditions (sin-
gle-hit models), or when at least one parasite survives a
population dynamics process of births and deaths as it is
entering and colonizing the host (birthdeath models).
1. Single-hit models assume that a single parasite is
able to start an infection. At the same time, it is
assumed that an inoculum consists of a mixture
of infectious and non-infectious parasites. Hence,
the capacity of an inoculum to cause infection
varies with its size, D, and depending on what
determines the infection process. Alternatively,
the parasites of an inoculum might all be
infectious, but accidentally end up at different
sites within the host, some sites being favourable
for infection and some sites not. For example,
penetrating the gut wall might be easier for a
parasite than penetrating the skin. With a
specication of the infection process, the overall
infection probability can be formalized by using
probability distributions for the chances that a
parasite happens to be infective, or at the right
place (see Box 9.2).
2. Birthdeath process models assume that the
parasite population, which has just entered a host,
grows over time, a process that is governed by
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
Box 9.2 Theory of infectious dose
For any practical consideration, dose, D, is a random
variable because it is rarely possible to administer
exactly the same number of parasites to a given host.
Hence, the number of parasites in a given inoculum
varies around a mean number, D. Because parasites
occur in discrete numbers, mean and variance of
parasite numbers in a dose can be described with a
Poisson distribution. More precisely, P(k, D) is the
probability that any given dose being administered
contains k parasites, provided the average dose is D.
This Poisson-distributed probability can be formally
written as
Dk e -D
P(k,D) = . (1)
k!
With this distribution, the fraction of hosts not
receiving any parasite at all, Q, is:
Q = e(D).
Therefore, the fraction of hosts receiving at least
one parasite is given by:
D
R=1Q=1e . (2)
Assuming every parasite is fully infectious, there-
fore, infection starts when at least one parasite
(k 1) is administered, then, R is also the fraction of
hosts responding with an infection when a dose, D,
is used. At the point where R = Q = 0.5 we have, by
denition, the value ED50 (the eective dose for 50%
infection; see Box 9.1). Using eqn 2 this corresponds
to a dose D = 0.69 parasites (recall that D is a mean).
Consideration of probabilities thus allows a predic-
tion of the expected dose, D, under explicit assump-
tions, as made above.
With the independent action model, at least one
parasite is needed to start an infection. The model
can, therefore, be characterized by a probability, p,
per parasite to start an infection independent of
dose, D. If all hosts are homogeneous and respond to
INFECTION AND DOSE 225
the parasite in the same way, then p assumes a con-
stant value. If hosts are heterogeneous, then p is a
random variable with a given distribution, e.g. a dis-
tribution similar to Figure 9.2b.
With homogeneous hosts and assuming that dose,
D, is a random variable with a Poisson-distribution,
the probability of not becoming infected with a dose
of size, D, is:
P(not responding) = (1 p)D. (3)
Because p is generally small, while D is large, one
can approximate the fraction of host subjects not
becoming infected (i.e. not responding), Q, and the
fraction becoming infected (responding), R, with:
Q = (1 p)D eDp R = 1 Q 1 eDp (4)
similar to eqn 2 above. Using the results of eqn 2
for the 50%-eective dose, ED50 = 0.69, we nd
that:
R 1 e 0.69/ ED50 . (5)
When hosts are heterogeneous, p varies. In this
case, the fraction of hosts not becoming infected
has to be summed over a distribution of p-values
in the population, which are given by the distribu-
tion of values over all hostparasite interactions.
This distribution is similar to the distribution of
IDEs, as shown in Figure 9.2b. If p is continuous,
then:
1
Q e -Dp f(p)dp, , (6)
0
where f(p) is the probability distribution for the
dierent values of p in a population of hosts (0 p
1). As before, the fraction becoming infected is
R = 1 Q.
Birthdeath process models assume that a popu-
lation of parasites starts growing in a host with
(Continued )
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
226 INFECTION AND PATHOGENESIS
Box 9.2 Continued
births (at rate, ) and deaths (at rate, ). The parasite
population will eventually grow to a population size
that is considered to be the infective threshold, C.
After reaching C, the infection is established.
Obviously, C can be reached when > . If < ,
infection does not occur. When = the parasite
population uctuates, and infection or failure can
result. Obviously, the chances of having > does
increase with dose, D. If the value of D is large, the
growth of the parasite population can be approxi-
mated by the standard exponential growth of classi-
cal population biology as:
Dl = D0e(l)t, (7)
where D0 is the infecting dose at the start of the
infection process, and Dt is the size of the parasite
Box 9.3 Modelling doseresponse curves
The doseresponse curve is a key element of under-
standing hostparasite relationships. Furthermore,
doseresponse curves are essential tools for quanti-
tative risk assessments in medical or agricultural
practice. For example, when the response is a health-
relevant parameter, such as the probability of devel-
oping symptoms of the disease, the doseresponse
curve shows how exposure to a potentially danger-
ous pathogen can result in detrimental health
eects.
Modelling the doseresponse curve involves t-
ting a particular mathematical function to the
observed data (Figure 1), where the quality of the t
is determined by a likelihood function. For a dose
response curve this is assuming a likelihood func-
tion, f(D, S), where f denotes the response that is a
function of dose, D, and S is a set of parameters that
population at time t. With a birthdeath process, the
fraction of non-infected host subjects is expected to
decrease with dose as:
Q = e pD (8)
With birthdeath processes the establishment of
an infection occurs with some time delay. This time
can be estimated depending on how the model is for-
mulated. In the simplest case, the time delay to
infection decreases with 1/log(D) above a given
threshold, i.e. above the individually eective dose.
Additional complications arise when the values of
and are themselves not constant but change with
either the duration (time-dependence) or the size
(number-dependence) of the infection (Ercolani
1984).
characterizes this function. The tting procedure
consists of nding a set of parameter values, S*, that
maximizes the likelihood that D is accurately mapped
into the response with the assumed function f().
Dierent functions of this kind can be compared.
Most statistical packages (such as SAS, SPSS, R) pro-
vide routines that can be used for such non-linear
optimization and curve tting. The curves can fur-
thermore be equipped with condence intervals that
are estimated in dierent ways. For example, boot-
strapping or Monte Carlo methods embedded in a
Bayesian framework can generate condence inter-
vals if more than one estimated parameter is used to
dene the doseresponse function.
An important application of modelling dosere-
sponse curves is to extrapolate infection risks for
values of doses that had not been observed. In this
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

INFECTION AND DOSE 227

context, predictions for low doses are of particular
practical interest, since the low doses will be impor-
tant to estimate the risks of infection and to dene
limits of exposure for most practical purposes. At
low doses, the widely applicable independent action
models (which assume no infection threshold) can
be approximated by a linear doseresponse relation-
ship. On the log-scale, these models generate a slope
of one at low doses, but models might dier consid-
erably in their respective intercepts (Figure 1).

1.0 1.0
Max risk Max risk
0.8 0.8

Prob. infection
Prob. infection

0.6 0.6

0.4 Max likelihood 0.4 Max likelihood

0.2 0.2

0 0
103 100 103 106 109 103 100 103 106 109
Dose (cells) Dose (cells)

Figure 1 Observed doseresponse relationship (probability of infection, dots) and two models tted to the data (lines) for
experimental infections of human volunteers by the bacterium Campylobacter jejuni, strain A3249. Left: A Beta-Poisson
model for dose is tted (solid line) and the corresponding 95%-condence intervals (upper and lower dotted line)
estimated by bootstrapping. In addition, the maximum risk curve is calculated by assuming infection probability per
parasite, p = 1 (broken line). The maximum risk curve estimates infection probability at low doses. Right: A hypergeometric
model tted to the same data. Redrawn from Teunis and Havelaar (2000) with permission from John Wiley & Sons, Inc.

births and a deaths of individual parasites. An

infection is established when the parasite
population reaches a certain infective threshold
size. Box 9.2 shows how this process can be
formally analysed. A particularly interesting aspect
of the birthdeath process scenario is that the
establishment of an infection occurs with some
time delay. This time can be estimated depending
on how the model is formulated (Box 9.2).
Single-hit models and independent-action processes
seem to be widely applicable. Which of these models
might be appropriate is veried by analysing the dose
response curves; for example, by checking the slope of
the curve at the point of ED50 (Ercolani 1984) (Figure
9.2; Box 9.3). In practice, a range of different mathe-
matical functions can often be tted to a given dataset.
Even though they might reect similar scenarios for the
actual infection process, doses predicted for values
outside the measurements can be very different. This
poses a problem, since predictions for doses beyond
the observed or tested values are the ones that are the
most valuable ones.
If host and parasite individuals vary in their properties
in a population, the doseresponse curve can be dened
for a particular combination of host and parasite types.
Therefore, the overall infection characteristic emerges as a
result of various single combinations, i.e. across a host
parasite infection matrix. This distinction is helpful, since a
subset of a population might, for example, consist of hosts
that have already encountered the parasite and now are
partially immunized. Another subset of hosts might still
be susceptible instead. In practice, the compilation of
such data is not easy. Compilation is typically hampered
by the heterogeneity of the respective studies that are
using different doses, different sensitivities of the tests,
different administration routes ( Table 9.2), sample sizes,
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

228 INFECTION AND PATHOGENESIS

and so forth. Stratied statistical analyses and the tools of
meta-analysis might be a solution to this problem.
9.1.2 The manipulation hypothesis
Doseresponse relationships are affected, among other
things, by the molecular mechanisms that govern the
infection process. Mechanisms that parasites use to
manipulate the host and facilitate their infection (see
Chapter 8) might be particularly important in this respect.
For example, if the parasite secretes modulator mol-
ecules into its environment to gain entrance into a host
(a distant action method), then the parasite might be in
a numerical race against the host. The parasites succeed
if the parasite population can grow fast enough to allow
production of sufficient quantities of immune modula-
tors before the immune system clears the infection. With
such distant action, therefore, at least some of the varia-
tion in doseresponse curves arises from the degree to
which the successful infection depends on the collective
action of parasites in an inoculum. By contrast, parasites
that depend on a direct transfer of modulatory proteins
into host cells (local action) do not have this numerical
constraint. Even a single parasite could manage to infect
and initiate a population of daughter parasites that sub-
sequently spreads inside the host. Hence, the number of
parasites needed for an infection might depend on the
way in which parasites manipulate the host defences to
gain entrance into the host (the manipulation hypoth-
esis). This distinction is reminiscent (but not equal to) of
the distinction into a frontal attack strategy and a stealth
strategy made by parasitologists, based on the observa-
tion of how aggressively parasites attack the host and its
immune system (Merrell and Falkow 2004). Considering
bacterial parasites, for example, they can approximately
be classied according to whether the initial steps of the
infection are facilitated by direct injection of proteins into
the host cell (e.g. via a type III secretion system; Figure
8.1), or whether parasites gain entrance by secreting
molecules with a distant effect. The manipulation hypoth-

log (Dose) (number of bacterial cells)

0 1 2 3 4 5 6 7 8 9 10 11 12

Enteroinvasive E.coli, Shigella

US Food and Drug Admin.
Enterohaemorrhagic E.coli Health Canada
Enteropathogenic E.coli Other sources

Listeria monocytogenes

Mycobacterium tuberculosis
Bacteria using
Salmonella enterica
local actions
Streptococcus pyogenes
Yersinia spp.

Bacillus anthracis
Staphylococcus aureus
Bacteria using
Streptococcus pneumoniae
distant actions
Vibrio cholerae

Figure 9.3 Infective dose for bacteria and mode of host manipulation. Local action: bacteria that directly interact with the host
cell, either by injection of manipulative proteins, or by deploying such proteins on their surfaces. Distant action: bacteria
interact indirectly by secretion of manipulative proteins into their surrounding. These take effect when binding to a receptor on
the host surface. The manipulative proteins ensure entry of the parasite into the host cell, e.g. by manipulating the host cell
cytoskeleton. Dose information is taken from the US Food and Drug Administration (USFDA; Food and Drug Administration
2003), from Health Canada (Health Canada 2003), and from various other sources. Redrawn from Schmid-Hempel and Frank
(2007).
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
esis suggests that this classication affects the infectious
dose, with low doses expected for local action and high
doses for distant action. Comparing the published infec-
tious doses for various bacterial pathogens, it is indeed
found that bacteria using direct injection of modulating
molecules (local action) have lower infectious doses than
those that are secreting molecules into their surround-
ings (the distant action) (Figure 9.3). Manipulation strat-
egy might, therefore, be another important determinant
of infectious dose in some cases.
9.2 Similar parasites cause different
pathologies
One of the most obvious properties of hostparasite
systems is that the outcome of the infection varies
widely between different parasitic infections. To illustrate
the point, consider the following two examples.
9.2.1 The common cold
The common cold is caused by infections with human rhi-
novirus (HRV). HRV is a small ssRNA-virus (Picornaviridae)
of which more than 100 different serotypes have been
described. Transmission occurs by droplets (aerosol), or
by direct contact with infected hosts (hand-to-hand).
In Europe or North America, for example, most people
are infected at least once a yearespecially children
and young adultswith a peak of infections during the
autumn months ( Arruda et al. 1997). The primary site of
infection is the nasal mucosa, but infection of the con-
juctiva (the skin covering the eye around the pupil) and
of the lower respiratory tract, including the lungs (espe-
cially in combination with asthma attacks), is not uncom-
mon, too. One reason for this restriction of the parasite to
peripheral tissues is the fact that the virus cannot replicate
well beyond a temperature of 3335C; hence, the virus
would not be very viable under normal body tempera-
tures (37C). A common cold typically starts with a sore
throat and either a runny or stuffy nose. These symp-
toms are associated with sleep disturbance and a gen-
eral feeling of malaise that interferes with normal daily
activities. There is no specic cure known, but the symp-
SIMILAR PARASITES CAUSE DIFFERENT PATHOLOGIES 229
2.5
2.0
Symptom severity (score)
1.5
runny nose
1.0
0.5 sore throat
0 5 10 14
Days post-infection
Figure 9.4 Symptoms of a common cold. The curves show
the change over time after two of the characteristic
symptoms (runny nose, sore throat) are rst noticed by the
patients. All cases shown here are self-diagnosed. The
presence of the rhinovirus was conrmed by molecular
markers, and the overall rate of documented infections was
83% for a total of 346 patients. Redrawn from Arruda et al.
(1997) with permission from University of Chicago.
toms typically subside 1012 days post-infection, and
the patient fully recovers (Figure 9.4) ( Arruda et al. 1997).
Complications associated with HRV infections, such as
middle-ear infections (otitis media), or lung infections,
may occur but are generally rare. Hence, the pathogenic
effects of HRV are generally benign and up to 40% of
infections are asymptomatic altogether (Heikkinen and
Jarvinen 2003; Kirchberger et al. 2007).
9.2.2 Inuenza
This condition is due to an infection by Inuenza virus
(also a small ssRNA-virus; Orthomyxoviridae). In con-
trast to HRV, inuenza virus can cause severe patho-
logical symptoms that can be life-threatening. Similar
to HRV, infection occurs by aerosol or by direct contact
with infected hosts. A few hours, or days, post-infection
the symptoms appear relatively suddenly, such as a dry
throat, headache, muscle pains, weakness, and fatigue
as well as high fever. These symptoms last for 714 days.
Sometimes, the infection leads to pneumonia (a lung
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

230 INFECTION AND PATHOGENESIS

infection associated with oedema) and the patients may
virtually drown in their own body uids. There are three
types of inuenza virus (each with many serotypes), of
which inuenza A and B are the most common ones, and
where type A is the most dangerous form for humans.
The 1918 inuenza strain (type A) caused the big pan-
demic at the end of the First World War and is considered
one of the most deadly viral infections to ever have swept
through the human population.
So, why do these two viruses with seemingly similar
life-styles cause such different pathologies? This ques-
tion has many answers. Looking at the mechanisms, the
biochemical and molecular processes involved deter-
mine the actual effect. Looking at the evolutionary
processes, differences in the effect on the host will also
have different consequences for the success and further
transmission of the parasite. We will discuss this latter
problem, i.e. the evolution of parasite virulence, in
Chapter 12. Here, we rst focus on the different mecha-
nisms that can generate detrimental effects on the host
(the pathogenesis).
9.3 Pathogenesis: the mechanisms of
virulence
Pathogenicity1 is the ability of a pathogen to cause dam-
age and to generate disease in its host. This covers a large
range of biochemical, molecular, and physiological pro-
cesses that all can do harm. Pathogenicity is often used
interchangeably with the term virulence, but the latter
should be reserved for denoting the degree of damage
done to the host, especially the reduction in host tness
(Figure 9.5). In the context of theories, virulence has, for
example, been dened in terms of host mortality rate
(May and Anderson 1983b). Even though a denition
based on host mortality rate is simple and easy to mea-
sure, it clearly falls short of covering the full spectrum of
possible outcomes of a parasitic infection. So, what are
the mechanisms of pathogenesis? Pathological effectsin
their widest sensecan be caused by a wide range of dif-
ferent mechanisms, some relating to the hosts physi-
ology, some to the action of the parasites, and others
due to interactions between both parties. The quest for

Reproductive
success (Host)

Virulence
(on Host)

Pathogenesis

Host

Parasite
- multiplication
- growth
Infection by parasite

Transmission
(Parasite)

Figure 9.5 Pathogenesis and virulence. A healthy host individual becomes exposed to a parasite. The parasite infects, estab-
lishes, and invades tissues where it starts to grow and multiply. These steps are typically associated with pathogenesis, a process
that damages the host. The consequences of pathogenesis can be macroscopically summarized and quantied as virulence.
Virulence is measured as a reduction in host tness (reproductive success), e.g. a reduction in the number of surviving offspring.
The parasite gains tness by being able to survive inside the host and by achieving transmission to new hosts.

1
The word pathogen is a composite from the Greek pathos (suffering) and gennan (to generate), while virulence stems from the
Latin word virulentus, which is derived from virus (poison, i.e. full of poison).
Table 9.3 Mechanisms of pathogenesis.

Mechanism Description Pathogenic effect Source

Impairing capacities Presence of parasite leads to loss of fullMites lodging in one ear of nocturnal moths Ebert and Herre 1996; Moore 2002; Reed
functionality for important capacity. impair hearing of hunting bats. Trematodes et al. 2002
Associated tissue damage not a main on gills of sh reduce water ow and
effect. generate respiratory failure.
Many parasites induced behavioural Phototactic behaviour that leads to host death
changes that impair the hosts capacity by predators acting as next host of the
to function normally. parasite.
Destruction of tissue Parasite destroys critical or a large mass of
Parasitoids consuming internal tissues or Godfray 1994; Mahany and Bray 2004
tissue, which leads to failure of organs organs of the host.
and eventual host death. Haemorrhagic viruses cause necrosis and
failure of vascular system.
Virulence factors Mainly described from bacteria and Various mechanisms, such as disruption of Dustin and Rice 2006; Rappleye and Goldman
viruses, but also known from protozoa host cell cytoskeleton, cytokine signalling, 2006; Wilson et al. 2007
and fungi. This general category includes neutralization of host defences. Often
the toxins (below). associated with severe necrosis of tissues or
inammatory processes. Pathogenic effect
correlated with presence and expression of
virulence factor.
Toxins Secreted proteins (exotoxins) or Cytotoxins lead to apoptosis and tissue Fukao 2004; Moayeri and Leppla 2004;
components of cell walls (endotoxins, necrosis. Disruption of cytokine functioning Abrami et al. 2005; Lapaque et al. 2005;
enterotoxins) that allow pathogen to causes fatal septic shock. Wilson et al. 2007
invade and spread within the host.
Toxins have high biological activity and
act like enzymes.
Proteases Enzymes described from all major parasitic Similar role as toxins. Proteases are antigenic McKerrow et al. 2006
groups aid in breaking into tissues and and can induce inammation and other
across cell membranes. severe pathogenic effects.
Response exhaustion (secondary Parasites deplete host immune response in Host is forced to respond to continuously Rall 2003; Deitsch and Hviid 2004; Dustin and
infections) various ways. changing parasite antigenic surface. Rice 2006; Picker 2006
Antigenic variation a major mechanism Eventually, defence breaks down and
where pathogen persistently changes progression to disease follows.
epitopes recognized by the host.
Escape mutations produce new variants in In many cases, weakening of the immune
an infecting population. response allows secondary infections by
Opportunistic infections damage the host. other pathogens that lead to sever
pathogenesis.
Self-damage (immunopathology) Parasite induces host immune response that Immune response with cytotoxic lymphocytes Pawlotsky 2004; Graham et al. 2005a ; Bray
causes damage to own tissue. (This destroys own, uninfected tissue. Continuous 2006; Guidotti and Chisari 2006
OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

PATHOGENESIS: THE MECHANISMS OF VIRULENCE

general process applies to many of the destruction leads to pathogenesis.

above cases.)
231
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
232 INFECTION AND PATHOGENESIS
understanding the tness-reducing effects unites studies
on pathogenesis and virulence. And, even though under-
lying mechanisms are involved, it is nevertheless possible
to identify some major categories of pathogenesis ( Table
9.3), which we will discuss in turn.
9.3.1 Impairing host capacities
Parasitic infection typically leads to the loss of some func-
tion for the host. For example, parasites that need trans-
mission into their nal host, reduce the hosts normal
capacity to avoid its natural predators. Such strategies
have been discussed above in the context of parasites
manipulating the behaviour of their hosts (see Chapter
8). In fact, parasites can lodge in places where they affect
the hosts capacity to hear, see, or breathe. For example,
mites of the genus Dicrocheles occupy one ear in their
host (nocturnal moths) and often destroy the ear as a
consequence of the infection. Therefore, the hearing of
the moth is impaired, even though the host is not com-
pletely deafened (Ebert and Herre 1996). In addition to
this direct pathological effect on the ears, impairment also
increases the chances that the moth is eaten by acousti-
cally searching bats, a predator that a healthy moth nor-
mally would hear and avoid. Similarly, many trematodes
specialize in attaching to the gills of sh ( Valtonen et al.
1997; Morozinska-Gogol 2006). A heavy load of such
external parasites will reduce water ow through the gills
and damage the ne gill structure, leading to swollen gills
and respiratory diseases (Reed et al. 2002). Hence, the
impairment of vital functions is a generic principle that is
characteristic of parasite-induced damage, even though
the detailed effects vary among different systems.
9.3.2 Destruction of tissue
Some parasites destroy the hosts tissue very directly.
Examples are the parasitoidstypically arthropods,
whose immature stages (larvae, nymphs) live inside, or
on, a host (Godfray 1994). For example, females of ich-
neumonid wasps (which is a group of probably more
than 80,000 species) lay eggs into a hosts body, typically
larvae of other insects. After hatching, the growing larva
starts to consume the hosts body uids and, increas-
ingly, the hosts tissues and internal organs. Eventually,
the critical organs are consumed and the host dies, at
which point the parasite larva pupates and later devel-
ops into the adult parasitoid. Several other groups of
hymenopteran insects, besides the Ichneumonidae, have
evolved this parasitic habitat; it is also known from the
true ies (Diptera). Conopid ies, for instance, attack for-
aging workers of bumblebees that y among owers to
collect nectar and pollen. The egg is a 12 mm long and
is injected into the hosts abdomen. The parasite then
develops to a pupa that lls half of the abdominal cavity.
Within 1012 days the host is killed (Schmid-Hempel and
Schmid-Hempel 1996).
In cases such as those illustrated by parasitoids, the
destruction of tissues and organs is the main process of
pathogenesis and the cause of eventual host death. Host
death is often (but not always) essential for the comple-
tion of the parasites life-cycle. In this case, the parasite is
an obligate killer. During the development of the parasite,
additional mechanisms also contribute to a negative
impact on the host. For example, symbiotic viruses help
many parasitoid species to evade the hosts immune
response and to guarantee successful hatching of the eggs
(Schmidt et al. 2001). The parasitoid larva can also actively
change the hormone prole of the host and so affect its
behaviour to the advantage of the parasite ( Joiner et al.
1973). All of these processes contribute to pathogenesis.
Destruction of tissue as a generic element of pathogenesis
is not restricted to macroparasites, but can also be found
in viruses or bacteria. A drastic example is hemorrhagic
viruses, where the destruction of tissue in the course of
infection is a major factor of pathogenesis and host death
(Mahany and Bray 2004; Bray 2006).
9.3.3 Virulence factors
The study of mutant bacteria or viruses that are unable
to infect, or that show attenuated virulence, has led to
the identication of genetic elements and particular
molecules whose presence is needed for the develop-
ment of the full pathogenic effects. The elements have
been named virulence factors. Virulence factors typi-
cally reside as specic genetic elements on pathogenicity
islands ( Table 10.2). More generally, virulence factor is a
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
generic term that refers to any factor critical for a patho-
gens success, regardless of whether it causes pathogenic
effects in the more narrow sense. In particular, virulence
factors also govern the parasites ability to enter into host
cells, to persist, and to transmit from the host. Using the
example of bacteria, the classication of virulence factors
can further refer to the functional role they play in the
parasites life-cycle.
9.3.3.1 Adhesion factors (adhesins)
Many bacteria must first attach to a surface of the host,
such as to skin, mucosa (in the alimentary, respiratory,
or urogenital tracts), and to other tissues inside the host
body. Bacteria promote their attachment by molecules
that mediate adhesion on cell surfaces. Because this
step is essential for a bacterium to become pathogenic
at all, an adhesion factor is considered a virulence
factor whose absence renders the bacterium non-
virulent. Adhesins are typically proteins or polysac-
charides. For example, the capacity of different strains
of E. coli to cause diarrhoea-related deaths (mainly in
infants) is tightly linked to the capacity of the bacteria
to attach to the cell lining of the gut (Kaper et al. 2004;
Dean et al. 2005).
9.3.3.2 Colonization factors
These molecules serve the bacterium to survive in a hos-
tile host environment. For example, Helicobacter pylori
produce the enzyme urease that allows it to survive in
the acid environment of the stomach. H. pylori can even-
tually cause gastric ulcers and cancer. Among the various
strains of H. pylori, the pathogenic effects correlate with
the production of urease.
9.3.3.3 Invasion factors (invasins)
The parasite invasion step can depend on how well the
pathogen spreads through the extra-cellular space in a
hosts body. Such spreading is important, for example,
in Staphylococcus aureus and Pseudomonas aeruginosa
( Wilson et al. 2007). To spread outside the cells, spe-
cialized bacterial enzymes cleave proteins in connective
tissue, degrade the extra-cellular matrix, and facilitate
tissue invasion, which eventually results in the patho-
genic effects of tissue necrosis. Bacterial invasion factors
PATHOGENESIS: THE MECHANISMS OF VIRULENCE 233
may also induce the host cell to endocytose the patho-
gen and thus to transport it into the cell interior. A num-
ber of bacterial species have toxins that generate pores
in the host cell membranes, which subsequently leads
to cell lysis and damage ( Wilson et al. 2007). Salmonella
species possess a large variety of proteins that are
secreted to penetrate and destroy the cells of the intes-
tinal mucosa at specic locations (the M-cells in the
Peyers patches; the lymphoid follicles). Penetration into
the cell is an essential step in the pathogenesis of these
infections ( Jones and Falkow 1996). For some bacteria,
residence inside a host cell is obligatory (e.g. Chlamydia,
Rickettsia, Mycobacterium leprae); for others, cell entry
can provide a means of being spread and transported
to other host tissues, but it is not an essential step in the
life-cycle ( Wilson et al. 2007). In recent years, many of
the genes underlying these invasion factors have been
identied.
9.3.3.4 Immune evasion factors
A number of virulence factors can be traced back to mol-
ecules that inhibit the hosts immune defences ( Table
10.2). For example, many parasites (bacteria, viruses) can
lodge in phagocytic host cells that normally are able to
engulf a pathogen and subsequently destroy it. For this
purpose, the host cells produce reactive oxygen radicals,
change the pH in the parasite-holding vacuoles, or mobi-
lize degrading proteases. Immune evasion factors play a
prominent role in allowing the parasites to overcome
these defence mechanisms. These evasion factors thus
allow the parasite to become pathogenic.
9.3.3.5 Toxins
Many virulence factors are toxins that poison host cells.
Toxins are discussed in more detail in the next section.
The example of bacteria is often cited, but such virulence
factors are also known from viruses. Viruses must enter
the host cell where they usurp the replication machinery
of the host. Typically, viral entry is achieved by binding
to receptor proteins on the hosts cell surface. The virus
then enters the host cell, as the membrane is altered. Viral
elements that facilitate this process are virulence factors,
as they determine whether or not a virus can enter and
eventually cause pathogenic effects.
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
234 INFECTION AND PATHOGENESIS
9.3.4 Toxins
Bacteria are well known for producing toxins that dam-
age the host. They come in two types:
1. Exotoxins are typically proteins released from the
bacterial cells. Exotoxins penetrate into the hosts
body and can take effect far from the site of
bacterial growth.
2. Endotoxins are compounds that are associated
with the bacterial cells themselves.
Often, endotoxins are components of the cell wall that,
under normal circumstances, are not released into the
host. Endotoxins can become released when the host
cells are lysed as a result of host defence or, perhaps,
as a by-product of antibiotic treatment that destroys
the cells ( Wilson et al. 2007). Some toxins play a major
role at the site of infection and invasion. Chemically,
bacterial toxins are often lipopolysaccharides (associ-
ated with the cell walls of Gram-negative bacteria) or
proteins that can be released into the external environ-
ment. Bacterial toxins are among the most potent tox-
ins for mammals, including humans, known in nature
( Table 9.4). For example, botulinum and tetanus tox-
ins are ten million times (a factor of 107) more potent
than strychnine and even a hundred thousand times
(a factor of 105) more toxic than the most powerful
snake venoms.
Both Gram-negative and Gram-positive bacteria are
able to produce toxins. Typically, virulent strains of the
bacteria produce the toxin, whereas the non-virulent
strains produce far less or no toxin. The toxin itself is the
major determinant of the pathogenic effects on the host.
Toxins have a high biological activity, even at low concen-
trations, but are typically denatured by heat, acids, or
proteolytic enzymes. Toxins thus act like enzymes and are
more or less specic regarding which host functions they
affect. Consequently, toxins are also classied as neuro-
toxins (acting on the nervous system), leukocidins (acting
on leukocytes), or haemolysins (acting on the blood).
Some toxins are specically cytotoxic, i.e. attack specic
cells of the host (such as tetanus or botulinum toxins that
attack nerve cells), while others are broadly cytotoxic for
a variety of cells (e.g. toxins produced by Staphylococci
such as Clostridia). For example, toxins (chemically, phos-
pholipases) can cut the phospholipids out of many cell
membranes, which leads to the loss of a stable host cell
structure and to cell death and tissue damage. The same
effect results from the action of hameolysins and
leukocidins.
A serious pathogenic condition resulting from bacte-
rial infections is septic shock, which results from the
combined action of cytokines, components of the com-
plement, and the coagulation cascade as the hosts
immune system responds. Typically, constituents of the
cell wall, notably lipopolysaccharides (LPS), of Gram-
negative bacteria (e.g. from E. coli, Pseudomonas aerugi-
nosa), can activate these events and lead to septic shock
(Lapaque et al. 2005; Wilson et al. 2007). In the process,
Lipid A (the toxic component of LPS) stimulates the
release of inammation-triggering cytokines and acti-
vates the immune cascades. Also, Gram-positive bacteria
(e.g. Staphylococcus aureus, S. epidermalis) can induce a
septic shock, even though they lack such endotoxins.
Instead, peptidoglycan fragments and other molecules
(teichoic acids) induce the same responses as LPS
( Wilson et al. 2007).
Bacterial protein toxins are highly antigenic; in the
host, antibodies are able to neutralize their effect.
Because toxins are proteins they lose their stability over
time, even though they remain antigenic. This degener-
ated product is called a toxoid. Toxins can also be arti-
cially de-toxied and turned into a toxoid by various
reagents (e.g. formalin, iodine, etc.). As they remain anti-
genic yet non-toxic, toxoids are used for immunization
against diseases caused by toxin-producing bacteria.
Classical vaccinations based on this principle are those
against diphtheria (caused by Corynebacterium diphthe-
riae) and tetanus (Clostridium tetani) ( Table 9.4).
Some bacterial toxins are based on a two-component
system (e.g. those in Vibrio cholerae, Corynebacterium
diphtheriae, Bordetella pertussis; Wilson et al. 2007). In
this case, one component (subunit A) generates the
enzymatic (toxic) activity by a variety of mechanisms,
and another component (subunit B) is responsible for
the binding of the entire complex to a receptor on the
host cell membrane (typically a glycoprotein) and for its
transport into the cell interior. Neither of the two subu-
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

PATHOGENESIS: THE MECHANISMS OF VIRULENCE 235

Table 9.4 Extra-cellular bacterial toxins and lethal doses for mice, from Gill (1982).

Species Toxin Effect in host Lethality1 (per kg of

Bacillus anthracis
Bacillus anthracis
Bordetella pertussis
Bordetella pertussis
Clostridium botulinum
Clostridium perfringens
Clostridium tetani
Corynebacterium
diphtheriae
Escherichia coli
Escherichia coli
Pseudomonas
Shigella dysenteriae
Staphylococcus aureus
Staphylococcus aureus
Staphylococcus aureus
Vibrio cholerae
Yersinia pestis
1
Dose refers to LD50. Abbreviations: intraperitoneally (i.p.), intravenously (i.v.), subcutaneously (s.c.), minimum lethal dose (MLD).
body mass)
Anthrax toxin (EF) Oedema factor (EF) causes increased levels of cAMP < 200 g
in phagocytes and formation of impermeable
pores in membranes, leading to host cell lysis.
Anthrax toxin (LF) Lethal factor (LF) induces cytokine release; is cytotoxic < 114 g (rat)
to host cells.
Adenylate cyclase toxin Locally increases cAMP in phagocytes and formation
of impermeable pores in membranes, leading to
host cell lysis.
Pertussis toxin (ptx) Blocks inhibition of adenylate cyclase in host cells. 15 g, 21g i.p.
Botulinum toxin Inhibits neurotransmission at neuromuscular 0.4 ng i.p.
synapses; leads to accid paralysis.
Perfringens entertoxin Activates adenylate cyclase leading to increased 81 g i.v.
cAMP in epithelial cells.
Tetanus toxin Inhibits neurotransmission at inhibitory synapses; 1 ng (MLD)
leads to spastic paralysis.
Diphtheria toxin (dtx) Ribolysation of ELF 2 (elongation factor 2), thus 1.6 mg s.c. (MLD)
leading to inhibition of protein synthesis in host
cells.
E. coli LT toxin Similar to cholera toxin. 250 g i.v.
E. coli ST toxin Promotes secretion of water and electrolytes from 250 g i.v.
intestinal epithelium.
Pseudomonas exotoxin A (A/B) Inhibits protein synthesis resulting in cell death. 3 g
Shiga toxin Cleaves rRNA, thus inhibiting protein synthesis. 1.3 g i.p., 450 ng i.v.
Staphylococcus enterotoxins A family of molecules. Diverse and massive action 20 g i.v. (monkey)
against immune system, including lymphocytes,
macrophages. Leading to emesis (vomiting).
Interact with MHC class II molecules on APC
(antigen presenting cells) and beta chains on T-cell
receptor. Leads to production of IL-1, TNF and
other lymphokines (which is used in diagnosis).
Toxic shock syndrome-toxin Acts on vascular system, causing inammation, fever,
(TSST-1) shock.
Exfoliatin toxin Cleavage in epidermal cells.
Cholera toxin Increasing level of cAMP promoting secretion of uids, 250 g
Murine toxin electrolytes in intestinal epithelium; diarrhea. < 10 g (from impure
material)

nits is active unless combined with the other part. This
happens when the two separately synthesized subunits
come together on the cell membrane, or when a single
polypeptide with structure A/B is cleaved into the two
subunits and so becomes active. Cell entry of the entire
complex can either be direct, when subunit B binds and
opens a pore in the membrane, or subunit B binds and
the entire AB-complex is transported into the cells inte-
rior by receptor-mediated endocytosis. In the process,
the toxin complex becomes enclosed in a membrane-
derived vesicle (the endosome) and is later activated
( Wilson et al. 2007).
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

236 INFECTION AND PATHOGENESIS

The synthesis of toxins by the bacteria is tightly regu-
lated and under genetic control. It is furthermore affected
by the environmental conditions that the bacterium
encounters. For instance, diphtheria toxin depends on
the availability of iron, while cholera toxin depends on
osmolarity and temperature (Beier and Gross 2006). A
pathogenic effect of bacteria, therefore, often depends
on the action of toxin, and other virulence factors, in
combination with a given environmental condition. The
advantage of toxin production for the pathogen itself was
discussed in Chapter 8, showing that these factors are
often crucial for manipulating the hosts defences. Indeed,
cytotoxic compounds are used by many highly virulent
bacteria to manipulate and evade the hosts immune
response (Rosenberger and Finlay 2003).
9.3.5 Proteases
The role of proteases is similar to that of toxins.
Proteases are enzymes able to cut other proteins into
pieces. Obviously, this property is highly relevant when
a host has to deal with invading parasites and, vice
versa, when a parasite manipulates its host. Proteases
are, therefore, one of the key elements in the hostpar-
asite interaction and are known from all major parasite
groups ( Armstrong 2001; McKerrow et al. 2006). Among
the different classes, cysteine proteases are commonly
found in protozoan and simple metazoan parasites;
they serve for tissue invasion (Entamoeba, Fasciola), to
degrade and mobilize nutrients (trypanosomes), for
immune evasion (Trypanosoma), or to modify other
proteins (Leishmania, Plasmodium). Serine proteases
are involved in processes that prevent coagulation (hel-
minths), in invasion processes (schistosomes), and in
processing other proteins (malaria). Metalloproteases
show a similar range of activities against coagulation,
for tissue invasion, and nutrient degradation. Aspartyl
proteases also affect nutrient degradation (in helminths,
and malaria) (McKerrow et al. 2006).
In many cases proteases appear to take effect by aiding
in immune evasion, rather than by direct action ( Table
9.5). For example, Trypanosoma cruzi is the etiological
agent of Chagas disease, a cause of fatal heart failure in
human populations of Latin America. It is still debated
whether the tissue damage in the heart is caused by the
parasite or by the hosts immune response. However, a
protease produced by T. cruzi (cruzain, GP75/51) is a
major proteolytic enzyme and affects different processes
at different stages of the parasites life-cycle. Among other
things, cruzain helps invade host cells. In chronic infec-
tions, cruzain is also highly antigenic. It is, therefore, sus-
pected to be a major promoter of pathogenesis
(McKerrow et al. 2006). Proteases, therefore, not only
help the parasite to overcome host defences but thereby
also induce inammation and prepare for other patho-
logic conditions ( Table 9.5).

Table 9.5 Proteases from protozoa and trematodes, and their effects. After McKerrow et al. (2006).

Parasite Protease Effect that leads to pathology Likely mechanism

Leishmania major GP63 Affects resistance provided by complement. Degradation of complement.
Leishmania GP63 Facilitates macrophage infection, migration Facilitating binding to macrophage and
amazonensis through extra-cellular matrix. survival inside. Degradation of
extra-cellular matrix.
Leishmania mexicana CPB Facilitates macrophage infection. Suppression Facilitating the entry of the promastigote
of TH1. stage. Degradation of immune
signalling components.
Entamoeba histolytica EhCP1 Induces pathological inammatory process. Dys-regulation of inammatory process.
EhCP2 Causes enteric cytopathology. Disruption of intestinal layers.
EhCP5 Causes enteric cytopathology. Induces Disruption of intestinal layers. Dys-
pathological inammatory process and regulation of inammatory process.
hepatic pathology.
Schistosoma mansoni Serine proteases Depletion of immunoglobulins. Degradation of immunoglobulins.
(trematode)
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

IMMUNOPATHOLOGY 237

9.3.6 Pathogenesis by opportunistic infections
In some cases the pathological effects are a result of the
weakening of the immune system, which allows another
infection to become established. For example, in many
infections by the measles virus, the actual dangerous
effects might be caused by secondary infections (Rall
2003). This happens because the measles virus transiently
suppresses almost the entire immune system (mainly via
suppressing dendritic cells and macrophages). This sup-
pression predisposes the host to opportunistic infections.
Only in rare cases (about 1 per 100,000 infections) does
the measles virus lead directly to an ultimately fatal, pro-
gressive, neurodegenerative disease (Rall 2003). A similar
situation probably exists in HIV infections, even though
the exact mechanisms leading to a progression to AIDS
(the pathological result of the infection) are still con-
troversial. HIV targets the CD4 cells that express CCR5
receptors. The early massive replication of the virus
leads to their depletion and impedes the regeneration of
this reservoir. As a result, the host becomes susceptible
to opportunistic infections that are the actual cause of
major pathological effects (Picker 2006). In both cases,
measles and HIV, it is the virus that evades the hosts
immune response and thereby degrades the immune
systems capacity over time. The actual cause of illness
is another infection but the ground had been prepared
through the effects of the primary infection.
9.4 Immunopathology
Severe infections are often associated with immunopa-
thology, that is, damage to the host caused by an inap-
propriate response of the immune system. Inappropriate
responses include misdirected processes of killing the
parasite, or the production of the wrong antigens, both
of which can lead to the destruction of own cells and

Table 9.6 Immunopathology associated with parasitic infections, after Sorci et al. (2009) and Graham et al. (2005a).

Parasite Immunopathology Source

Viruses:
Inuenza virus Allergy. Dahl et al. 2004
B3 Coxsackie virus Myocarditis, Type 1 diabetes mellitus (T1DM). Rose and Mackay 2000
Herpes simplex virus Keratitis (inammation of the cornea in the eye). Zhao et al. 1998
Mouse adenovirus type I Encephalomyelitis. Moore et al. 2003
Dengue virus Haemorrhagic fever, liver damage. Libraty et al. 2002; Mongkolsapaya et al. 2003

Bacteria:
Mycobacterium tuberculosis
Borrelia burgdorferi
Staphylococcus aureus
Streptococcus pyogenes
Helicobacter
Adjuvant arthritis. Moudgil et al. 2001; Hirsch et al. 1996; Ehlers
Prolonged disease; lung damage not related to et al. 2001
bacterial load.
Lyme arthritis. Benoist and Mathis 2001
Allergy. Ennis et al. 2004
Rheumatic fever. Kirvan et al. 2003
Autoimmune gastritis. Amedei et al. 2003

Protozoa:
Leishmania major
Plasmodium yoelii
Trypanosoma brucei
Trypanosoma cruzi
Skin lesions, liver damage. Louzir et al. 1998
Disease severity. Omer et al. 2003
Damage to central nervous system. Maclean et al. 2004
Damage to heart muscle. Holscher et al. 2000

Helminths:
Nippostrongylus brasiliensis Hypersensitivity of the respiratory tract. Coyle et al. 1998
Brugia malayi Hypersensitivity of the respiratory tract. Hall et al. 1998
Schistosoma spp. Damage to liver and urinary tract. Booth et al. 2004; Wamachi et al. 2004
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
238 INFECTION AND PATHOGENESIS
tissues (auto-immunity). Inappropriate responses can
also be triggered by environmental stimuli (allergies).
Such maladaptive responses are mediated by a number
of different immunological processes. As will be dis-
cussed in Chapter 12, when the severity of the patho-
genic effects is related to the number of parasitic cells
in a host, this can be understood in a framework for the
evolution of parasite virulence. But such a relationship
is often absent with immunopathology (Graham et al.
2005a). Misguidance of immune responses is suggested,
for example, when infections by inuenza virus activate
an extensive immune activity in excess to what would
be needed to clear the virus (Hussell et al. 2001; Xu et
al. 2004). Similarly, some of the anaemia associated with
infection by malaria parasites (which destroy red blood
cells) is caused by the immune system itself, rather than
the parasite (Graham et al. 2005a). Most examples of
immunopathology are known from humans and other
mammals ( Table 9.6). So far, little is known about immu-
nopathology in invertebrates, although several studies
suggest that self-reactivity is occurring in insects, too
(Schmid-Hempel 2005; Sadd and Siva-Jothy 2006).
9.4.1 Immunopathology associated with cytokines
As illustrated in Chapter 4, TNF- is among the most
important cytokines in vertebrates. It serves to recruit
immune cells to the site of infection, to activate phago-
cytotic cells, or to induce direct killing of parasites. TNF-
also dilatates blood vessels and makes them permeable,
such that immune cells and humoral immune components
can enter neighbouring, infected tissues from the blood-
stream. One of the most severe consequences caused by
over-activity of TNF- is septic shock. Septic shock occurs
when bacteria, for example, escape from tissues into the
bloodstream, which is followed by a massive release of
TNF- that in turn results in massive loss of blood into
neighbouring tissues. Blood pressures drops dramatically,
accompanied by high heart-beat rate and rapid breath-
ing. Septic shock is a feared medical condition, as mortal-
ity rates are high. When TNF- is blocked experimentally
in test animals, mice become susceptible to minor infec-
tions that they would normally control, yet these mice do
not show shock symptoms (Pfeffer et al. 1993).
TNF- also provides an example of how pathology
resulting from the immune defence is balanced against
various other needs. For example, the expression of
TNF- defends against malaria parasites by inducing the
degradation of red blood cells, which is the target of
infection by Plasmodium. The loss of red blood cells limits
the infection by the parasites but also results in an anae-
mic state that is associated with loss of vigour. In the case
of cerebral malaria, the release of TNF- thus combats
the parasite but also leads to fever and changed blood
circulation in the brain that can lead to coma and a fatal
outcome. The response that leads to the least anaemic
condition, while still generating a response to infection,
therefore is the best response, and this happens at an
intermediate level of TNF- production (Graham et al.
2005a , 2005b).
The immune response against helminths is another
example where immunopathology can result (Graham
et al. 2005a). Typically, the response leads to encapsula-
tion, for example, of parasites and eggs, and in medical
terms to the formation of granuloma and brosis. This
simultaneously results in damage to host tissue where
the parasites infect, such as the urinary tract, the liver, or
the lungsand the response may furthermore relate to
the development of asthma. Schistosomiasis is an exam-
ple where the parasites eggs lodge in the urinary tract,
and where granuloma develop that eventually block the
organs functions. Interleukin IL-13 is instrumental in
causing such capsule (granuloma) formation. IL-13 is also
polymorphic in the human population and certain vari-
ants of this interleukin are pre-disposing more heavily to
such immunopathology (Graham et al. 2005a).
9.4.2 Immunopathology caused by immune-
evasion mechanisms
An important class of pathogenic mechanisms refers to
immune evasion by parasites ( Tables 9.6, 9.7). Whereas
the hosts own defence machinery is responsible for
the damage under immunopathology, it is important
to notice that, in perhaps most of the cases, the hosts
defence machinery is being manipulated by the parasite.
Thus, the pathogenesis might be under the control of the
parasite, rather than the host. The distinction between
Table 9.7 Modulation of pathogenic effects by immune evasion mechanisms.

Parasite Immune evasion mechanisms1 Relation to pathogenesis Source

Poxviruses All poxviruses modulate the hosts signalling network in Change in chemokine signalling is of central Alcami 2003; Seet et al.
some way; different groups use different importance to pathogenesis. In many cases, the 2003
mechanisms, e.g. targeting interferons, TNFs, respective genes have been acquired from the
interleukins, complement and chemokines. host, or homologues to host proteins are
produced.
Hepatitis C virus Various mechanisms to disrupt innate immunity, delays Progress to chronic infection strongly correlated Pawlotsky 2004; Dustin and
organization of effective response. Virus also disables with emergence of escape variants. Chronic Rice 2006; Guidotti and
interferon production and response. Escape mutants infections can lead to complications, e.g. liver Chisari 2006
accumulate in infecting population. failure, cirrhosis and carcinoma.
Cytomegalovirus A variety of viral functions target the immune response, Failure to control virus; inammation favours Mocarski Jr. 2002
mainly the cellular response, e.g. leukocyte spread of virus.
migration, apoptosis, and MHC-function.
Inuenza virus Virus produces anti-IFN protein preventing activation Immune evasion allows spread of virus and Yewdell and Garcia-Sastre
of host transcription factors. generates pathogenic effects. 2002
Filial haemorrhagic viruses (Zaire Immune suppression by a variety of mechanisms that Systemic suppression of immune defence allows Mahany and Bray 2004
Ebola) act in concert, e.g. preventing dendritic cells from dissemination within host. Infection of cells can
activating T-cells, disrupting interferon response in end with severe inammation, necrosis, release of
macrophages and dendritic cells. tissue factors that lead to intravascular coagulation,
and of cytokines and chemokines that induce
vascular dysfunction and organ failure.
Brucella Type IV-secretion system and unorthodox LPS ensure Pathogenic effects related to bacterial replication Lapaque et al. 2005
immune evasion, e.g. bacterium becoming resistant and persistence in host cells, which is directly
to macrophage attacks. dependent on capacity to evade host immune
response.
Yersinia entercolitica, Y. Invasion allows adhesion and invading host cells, Dissemination in tissue leads to potentially fatal Ellison et al. 2004
pseudotuberculosis regulated by the parasites RovA gene. pathogenesis.
Bacillus anthracis Anthrax toxin (several components) impairs host Infection in lung: bacteria can multiply because Abrami et al. 2005
immune system, e.g. via disruption of cytokine immune response impaired. Leads to host
regulation. suffocation and/or vascular collapse. Toxins also
induce cytokine-independent shock late in an
infection.
Pseudomonas syringae, Salmonella Pseudomonas: Bacterial protein targets immunity- Suppression of host immune response leads to Nomura et al. 2006
enterica associated host plant protein and destroys it by spread of pathogen and potentially devastating
usurping host proteosome. Thereby host vesicle pathogenic effects.
trafficking pathways and extra-cellular defence
disabled.
Salmonella: also usurps host proteins to maintain a
membrane-bound compartment that holds the
OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

parasite. In both cases, type III-secretion systems

IMMUNOPATHOLOGY

involved.
239

(Continued)
 240

Table 9.7 Continued

Parasite Immune evasion mechanisms1 Relation to pathogenesis Source

Neisseria, Streptococcus
Pseudomonas syringae
Extra-cellular proteinases. Cleave host
immunoglobulins (IgA1) at specic sites and inactive
host immune defence.
Usurpation of host immune proteins. Destroys host
immune protein and blocks vesicle trafficking.
Leads to infection and allows bacteria to multiply. Armstrong 2001
Suppression of innate immune response allows Nomura et al. 2006
building up the infection that destroys tissue of
the plant host.
INFECTION AND PATHOGENESIS

Bacteria, Protozoa Microbial proteolytic enzymes (proteases) allow
invasion of host tissue and immune evasion. Effect
counteracted by host protease inhibitors.
Plasmodium falciparum Parasite erythrocyte membrane proteins (PfEMP1)
promote adhesion to endothelial receptors and
immune evasion. PfEMP1 is based on family of
antigenic variant genes (var).
Leishmania A large diversity of lipophosphoglycanes (LPGs) used to Parasite effect depends on establishment, which is Turco et al. 2001
bind to macrophages, to inhibit macrophage
signalling and host cytokine production.
Dissemination of pathogen leads to adverse McKerrow et al. 2006
effects, e.g. induction of inammation and
degradation of blood components.
Adhesion and immune evasion combine to Crabb 2006
generate pathogenic effects.
dependent on LPG.
OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

Trypanosoma cruzi Cruzain is the major parasite protease that facilitates Cruzain important for pathogenesis, e.g. by McKerrow et al. 2006
host cell invasion and permits immune evasion. triggering auto-immune responses.
Trypanosoma brucei Kinetoplastid endosomal system is crucial to evade Infection and dissemination generates pathogenic Morgan et al. 2002
host immunity, in particular, resistance to TLF and effects.
antigen recognition.
Helminths Release of proteases that inhibit host cystatins, serpins, Typically reduces inammation normally caused McKerrow et al. 2006
and may function as potent anti-coagulants. by parasite. Reduces pathogenic effects.
Fungi A fungal structure (the cryptococcal capsule) prevents Growing fungus causes pathogenic effects. Burgwyn Fuchs and
phagocytosis of fungus. Mylonakis 2006
Dimorphic fungi Proteins that facilitate attachment to host macrophages Most cause respiratory diseases. Tissue damage and Rappleye and Goldman 2006
and down-regulation of TNF. Antigenic glycopeptides fungal dissemination associated with alkalinization
on surface are actively removed by fungal proteases. of host environment by fungal ureases.
In the extra-cellular space, fungal production of
melanin provides protection against host-generated
peroxides.
1
Italics indicate names of genes.
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
self-damage as a result of parasite control (as an immedi-
ate or delayed result of evasion), as compared to dam-
age under host control (a result of over-responding or
misguidance) is, however, not easy to establish (Schmid-
Hempel 2008b).
For example, hepatitis C virus replicates within the liver
cells without pathogenic effects. The clinical syndromes
of the infection (liver cirrhoses and cancer) are primarily
due to the hosts immune defences, in particular, due to
the action of the adaptive immune response via cytotoxic
lymphocytes. This response is also responsible for the
clearance of the virus, but the recurrent immune-induced
damage nally leads to tissue failure (Pawlotsky 2004;
Guidotti and Chisari 2006). In human poliovirus, the host
receptor plays a major role, as it also induces an altered
conformation of the viral particles that subsequently
causes pathogenic damage in host tissue. The difference
in pathogenicity among viral strains in turn relates to the
viruses replication capacity (Ohka and Nomoto 2001). A
major contribution to pathogenesis by self-damage is
probably also found in haemorrhagic viruses. Many
pathogenic effects are caused by the innate immune
response. Molecules released by infected and destroyed
cells exacerbate these effects by inducing vascular leak-
age. Parasite-induced impairment of the hosts cellular
immune system thus appears to be important for the
fatality of haemorrhagic virus infections (Bray 2006). Not
always, therefore, does the host have full control over its
own immune defence machinery and can limit its detri-
mental effects ( Table 9.7).
9.5 The genetics of pathogenesis
Pathogenesis is often due to virulence factors. For many
pathogens, these virulence factors and their genetic basis
have been identied in considerable detail. Genes that
affect the pathogenesis, and thus lead to virulence, are
labelled as virulence genes. The expression of these viru-
lence genes is tightly regulated, depending on the host
environment and the stage of infection the pathogen
nds itself in. The illustration of the exact mechanisms
of gene regulation can be found elsewhere; it is not
detailed here except for special cases (Cotter and DiRita
THE GENETICS OF PATHOGENESIS 241
2000; Francis et al. 2002; Ellison et al. 2004). In bacteria,
the genes encoding for factors that cause pathogen-
esis (e.g. toxins), and eventually determine virulence,
are often found in blocks of the genome (pathogenicity
islands). These are often stretches of the genome that
harbour DNA sequences typical for mobile genes; that
is, genes that can be horizontally transferred to other
bacteria in the vicinity. In particular, the DNA sequences
are indicative of transposasesenzymes that facilitate
the copying and transfer of genetic elements within the
genome (Kjemtrup et al. 2000). The respective genes for
the virulence factors are either found on plasmids or on
sequences derived from lysogenic phages. Both elements
allow horizontal mobility of genes, which is a major pro-
cess that allows bacterial populations to evolve virulence
rather quickly. For example, the closest relatives of the
human-pathogenic Vibrio cholerae, the aetiological
agent of cholera, are found in aquatic environments. It
is thought that V. cholerae has, in several steps, acquired
its virulence genes by horizontal transfer. In particular, its
primary virulence genes are clustered in several genomic
regions and appear to have been acquired recently via
phages, or some other as yet unknown horizontal trans-
fer process. Each acquisition of new elements has been
correlated with the outbreak of major cholera epidemics
(Faruque and Mekalanos 2003) (Figure 9.6).
Many virulence genes show sequences that are con-
vergent to sequences coding for the various actors in the
hosts immune system. For example, Salmonella induces
host immune cells (CDC42) to internalize the bacterium
by forced rearrangement of its cytoskeleton (via the
pathogen-produced proteins SopE, SopE2). Once inside
the cell, the pathogen-derived protein SptP reverses this
effect and the host cell rearranges its cytoskeleton again
to the normal conguration. The sequence of SptP, for
instance, is convergent to the host GAP-enzyme that nor-
mally would induce the same effect. Similar convergent
evolution of pathogen gene sequences have been stud-
ied for Yersinia pseudotuberculosis (inavsins convergent to
host bronectin), Haemophilus inuenza (IgA1 protease
convergent to host trombin), Mycobacterium tuberculosis
(mycosin proteins convergent to host furin-binding pro-
teins), or Bacillus anthracis (anthrax toxin convergent to
host intra-cellular transport signals) (Sikora et al. 2005).
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi

242 INFECTION AND PATHOGENESIS

Vibrio cholerae
Diverse clones in
aquatic environments

O139
O1 O1
VSPs

O1 El Tor O1,ElElTor
O1 Tor Non-O1, Non-O139 O139
VSP2
VSP1
TCP TCP TCP TCP

Sporadic regional outbreaks

O1, El Tor O1,ElElTor
O1 Tor Non-O1, Non-O139 O139
VSP2
TCP TCP TCP
VSP1 TCP

CTX CTX CTX CT

CT CT
VPI2 VPI2
TCP
VPI2

O1 El
O1, El Tor
Tor Non-O1, Non-O139 O139
TCP TCP TCP
CTX CT CT CT
CTX

O1 genes replaced

Pandemic strains
with O139
VPI2 deletion
O1,ElElTor
O1 Tor VSP2 O139
VSP2 VSP1 TCP VSP1 TCP
CT CT
O1 classical
CT TCP

Pandemic VI Pandemic VII Pandemic VIII

Figure 9.6 Emergence of pandemic strains of Vibrio cholerae. The diagram shows the evolution of various strains from the
ancestral V. cholerae in aquatic environments. In particular, the gain (and loss) of virulence factors is illustrated. Boxes contain
names of the strains; boxes with solid lines are observed strains, boxes with dotted lines are conjectured. Solid arrows symbolize
horizontal gene transfer of pathogenic islands, broken lines are possible but still hypothetical transfers. The strains in the
bottom row have caused subsequent cholera pandemics (6th to 8th pandemic). Acronyms: CTX, cholera toxin phage; CT,
cholera toxin; O1 and O139, various O antigen gene clusters; TCP, toxin co-regulated pilus gene cluster also referred to as VPI;
VPI, Vibrio pathogenicity island; VPI2, the island that includes the nanH gene cluster; VSP Vibrio seventh pandemic island; VSP1
and VSP2, the islands found in seventh pandemic El Tor strains and eighth pandemic O139 strain. Redrawn from Faruque and
Mekalanos (2003) with permission from Elsevier.
 OUP CORRECTED PROOF FINALS, 01/27/2011, SPi
SUMMARY
Infection, growth, and multiplication of the established
parasite within the host are important steps in a para-
sites life-cycle. A striking observation is that the doses
needed to infect a host, and the pathogenic effects
caused by the established parasite, vary enormously.
The infective dose is derived from doseresponse
curves. Several scenarios exist to explain dosere-
sponse curves, such as individual effective dose and
independent action models (based on single-hit,
or birthdeath processes). Different strategies of
immune evasion during the rst steps of infection
might be important, too, to explain the variation in
infective dose.
Even apparently similar parasites cause very differ-
ent pathogenic effects.
Pathogenesis is the physiological process underly-
ing the development of virulence in the course of an
THE GENETICS OF PATHOGENESIS 243
infection. Pathogenesis can be caused by different
mechanisms, such as the impairment of host capac-
ities, tissue destruction, the effects of various viru-
lence factors, toxins, and proteases, or by
opportunistic secondary infections.
Immunopathology is caused by inappropriate
immune defences. Disregulation of the immune
response by cytokines is an important cause in this
context. In many cases, mechanisms of parasite
immune evasion might also lead to important
immunopathology.
Virulence factors are modulators for parasite infec-
tion and pathogenicity. In bacteria, for example,
these factors are coded by virulence genes that are
often located on pathogenicity islands. These are
genetic regions that can move horizontally among
bacteria.