Reduced diversity and increased virulence-gene carriage in intestinal enterobacteria of coeliac children
© Sánchez et al; licensee BioMed Central Ltd. 2008
Received: 14 May 2008
Accepted: 04 November 2008
Published: 04 November 2008
Coeliac disease is an immune-mediated enteropathology triggered by the ingestion of cereal gluten proteins. This disorder is associated with imbalances in the composition of the gut microbiota that could be involved in its pathogenesis. The aim of the present study was to determine whether intestinal Enterobacteriaceae populations of active and non-active coeliac patients and healthy children differ in diversity and virulence-gene carriage, so as to establish a possible link between the pathogenic potential of enterobacteria and the disease.
Enterobacteriaceae clones were isolated on VRBD agar from faecal samples of 31 subjects (10 active coeliac patients, 10 symptom-free coeliac patients and 11 healthy controls) and identified at species level by the API 20E system. Escherichia coli clones were classified into four phylogenetic groups A, B1, B2 and D and the prevalence of eight virulence-associated genes (type-1 fimbriae [fimA], P fimbriae [papC], S fimbriae [sfaD/E], Dr haemagglutinin [draA], haemolysin [hlyA], capsule K1 [neuB], capsule K5 [KfiC] and aerobactin [iutA]) was determined by multiplex PCR.
A total of 155 Enterobacteriaceae clones were isolated. Non-E. coli clones were more commonly isolated in healthy children than in coeliac patients. The four phylogenetic E. coli groups were equally distributed in healthy children, while in both coeliac patients most commensal isolates belonged to group A. Within the virulent groups, B2 was the most prevalent in active coeliac disease children, while D was the most prevalent in non-active coeliac patients. E coli clones of the virulent phylogenetic groups (B2+D) from active and non-active coeliac patients carried a higher number of virulence genes than those from healthy individuals. Prevalence of P fimbriae (papC), capsule K5 (sfaD/E) and haemolysin (hlyA) genes was higher in E. coli isolated from active and non-active coeliac children than in those from control subjects.
This study has demonstrated that virulence features of the enteric microbiota are linked to coeliac disease.
The human gastrointestinal tract is a complex ecosystem integrated by up to 1014 bacteria. These microorganisms may belong to more than 500 different bacterial species, although 99% of the total community consists of only 30–40 species. The intestinal microbiota plays an important role in human health as they contribute to inhibiting pathogen colonization, boosting the immune system, and metabolising nutrients [1–3]. Alterations in the intestinal microbiota have also been linked to inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn's disease, as well as to other immune-related disorders. IBD patients have been shown to carry higher concentrations of mucosa-associated bacteria than control groups. In addition, the gut microbiota of these patients was characterized by a decrease in protective bacteria, such as Bifidobacterium and Lactobacillus, and an increase in harmful bacterial groups like Bacteroides and Escherichia coli. This phenomenon has been named "dysbiosis" [4, 5].
Escherichia coli was the first bacterial specie to be identified in human gastrointestinal samples. This widespread commensal Gram-negative bacterium found in the intestinal tract of healthy individuals can occasionally cause intestinal and extraintestinal diseases. The pathogenic potential of E. coli stains could be influenced by host endogenous factors, as well as by the genetic structure and ecological distribution of the strains in a particular host. Human infections by E. coli strains commonly occur in immuno-compromised individuals or when the normal gastrointestinal barrier is broken , enabling opportunistic pathogens to evade host surveillance mechanisms. Phylogenetic studies based on the analysis of 38 metabolic enzymes, have shown that E. coli strains fall into four main phylogenetic groups, denominated "A", "B1", "B2" and "D" . Strains causing extra-intestinal infections mainly belong to group B2, and to a lesser extent to group D, whereas commensal E. coli strains mostly belong to A and B1 groups . E. coli strains belonging to B2 and D groups carry more virulence-associated genes than strains from A and B1 groups [9, 10]. Therefore, the presence or absence of certain E. coli strains or an altered distribution of their relative abundance can enhance the pathogenic potential of the enteric population in predisposed individuals.
Coeliac disease is an immune-mediated enteropathology triggered by the ingestion of wheat-gluten and similar proteins of rye, barley and, probably, oats. Coeliac disease can be present at any age with a variety of clinical features; however, typical cases manifest in early childhood with gastrointestinal symptoms . In coeliac patients, the inflammatory milieu caused by gluten antigens could lead to imbalances in gut microbial composition, characterised by higher numbers of Gram-negative bacteria and decreased numbers of beneficial Gram-positive bacteria, as compared to healthy individuals. In previous studies, E. coli proportions were significantly higher in duodenal biopsies of active coeliac patients than in controls ; moreover, a similar trend was detected in faeces although the differences were not so remarkable . However, little is known about the possible association between enterobacterial population and coeliac disease pathogenesis.
The aim of the present study was to determine whether intestinal Enterobacteriaceae populations of active and non-active coeliac patients and healthy children differ in diversity and virulence-gene carriage, so as to establish a possible link between the pathogenic potential of enterobacteria and the disease.
Subjects and sampling
Thirty-one children were included in this study, 10 active coeliac patients, on a normal gluten-containing diet, showing clinical symptoms of the disease, positive coeliac serology markers and signs of severe enteropathy by duodenal biopsy examination (mean age 3.86 years, range 1.0–8.86 years); 10 symptom-free coeliac patients (non-active coeliac), who had been on a gluten-free diet for 1–2 years (mean age 6.2 years, range 1.0–12.0 years); and 11 healthy children without known food intolerance (mean age 3.51 years, range 0.1–7.75 years). None of the children included in the study had been treated with antibiotics for at least 1 month before the sampling time. Faecal samples were collected and immediately stored at 4°C, under anaerobic conditions (AnaeroGen, Oxoid, Hampshire, UK), and analysed in less than 12 hours. The study protocol was approved by the local Ethics Committee, and children were enrolled in the study after written informed consent was obtained from their parents.
Isolation and identification of Enterobacteriaceaeclones from faeces
Faecal samples (2 g wet weight) were 10-fold diluted in phospahate-buffered saline (PBS, 130 mM sodium chloride, 10 mM sodium phosphate, [pH 7.2]), and homogenized in a Lab Blender 400 Stomacher (Seward Medical, London, UK). Serial dilutions were made in PBS and aliquots were plated on Violet Red Bile Dextrose Agar, VRBD (Scharlau, Barcelona, Spain) and incubated under aerobic conditions at 37°C for 48 hours. Then, five individual Enterobacteriaceae-like colonies differing in size, shape, colour or mucoid appearance on VRBD agar were isolated and subcultured in Plate Count Agar (Scharlau, Barcelona, Spain) under aerobic conditions at 37°C for 24 hours. The identity of the presumptive Enterobacteriaceae isolates was confirmed by conventional microbiological methods, including colony and cellular morphology and Gram staining. The selected isolates were further identified at species level by using the API20E system (BioMerieux, Lyon, France), in order to select E. coli clones and non-E. coli clones.
Phylogenetic classification and virulence-associated gene carriage of E. coliisolates
Escherichia coli isolates were assigned to one of the four phylogenetic groups A, B1, B2 or D by a triplex PCR technique as previously described . The 25 μl PCR mixture consisted of 10 mM Tris-HCl (pH 8.3), 2.5 mM MgCl2, 1 μM of each primer pair for the genes ChuA, YjaA and TspE4C2, 200 μM, dNTPs and 2.5 U of Taq polymerase (Ecotaq, ECOGEN, Spain). A piece of a bacterial colony was collected directly from a plate and added to the reaction mixture as a source of DNA. The PCR programme was as follows: initial denaturalization at 94°C for 4 min; and 30 cycles of 5 s at 94°C, 10 s at 59°C; and a final extension step of 5 min at 72°C. The PCR products were separated in a 2% agarose gel electrophoresis and visualised by ethidium-bromide staining. The isolates were assigned to phylogenetic groups as follows: ChuA+ YjaA+, group B2; ChuA+YjaA-, group D; ChuA- TspE4C2+ group B1; ChuA- TspE4C2- group A.
The same isolates were also characterized by two sets of multiplex PCR as described by Nowrouzian et al. (2001) . The first PCR detected the presence of the following virulence-associated genes: fimA (type-1 fimbriae), papC (P fimbriae), sfaD/E (S fimbriae) and draA (Dr haemagglutinin). The second PCR detected the presence of the following genes: hlyA (haemolysin), neuB (capsule K1), KfiC (capsule K5) and iutA (aerobactin). The 25 μl PCR reaction mixture consisted of 10 mM Tris HCl (pH 8.3), 1.5 mM of MgCl2 for the first multiplex PCR and 2.0 mM MgCl2 for the second multiplex PCR, 0.45 μM of each primer, 100 μM dNTPs and 2.5 U of Taq polymerase (Ecotaq, ECOGEN, Spain). A piece of a bacterial colony was used as a source of DNA as indicated above.
Differences in prevalence of different species, phylogenetic groups or virulence genes were established by applying the chi-square test, and when appropriate by the two-tailed Fisher's exact test and Kolmogorov-Smirnof test. In each case, analyses were carried out with the Statgraphics software (Manugistics, Rockville, MD), and statistical differences were established at P value below 0.05.
Diversity of Enterobacteriaceae and E. coliclones from coeliac and healthy children
Of the 31 individuals analyzed in this study, only 14 (45%) carried Enterobacteriaceae species other than E. coli. The latter species was always recovered in healthy individuals and in eight of them (73%) at least one other non-E. coli species was detected. Non-E. coli species were detected in only four (40%) active and two non-active coeliac patients (20%). Non-E. coli clones were recovered more abundantly in healthy children than in non-active coeliac patients (P = 0.03).
Citrobacter freundii, Enterobacter agglomerans, Klebsiella oxytoca and Escherichia vulneris were identified in healthy children harbouring non-E. coli species. Klyuvera spp, Enterobacter cloacae, Citrobacter freundii, Shigella spp, Chryseomonas luteola and Klebsiella oxytoca were also isolated in active coeliac disease children and Klebsiella oxytoca, Aeromonas hydrophila/caviae and Klebsiella pneumoniae were identified in non-active coeliac patients.
Phylogenetic classification of E. coliclones from coeliac and healthy children
Virulence-associated gene carriage in E. coliclones from coeliac and healthy children
Prevalence of virulence-associated genes in A+B1 (commensal) and B2+D (virulent) E. coli clones isolated from active and non-active coeliac disease patients and healthy children
Virulence factor (gene)
Virulent B2 + D clones (%)*
Commensal A + B1 clones (%)*
(n = 23)
(n = 23)
(n = 21)
(n = 17)
(n = 19)
(n = 19)
Type 1 fimbriae
6 (35) b
1 (5) a
10 (59) b
12 (63) b
Significant differences were revealed in the diversity and virulence-gene carriage of Enterobacteriaceae and E. coli clones isolated from faeces of active and non-active coeliac patients and healthy controls, suggesting that this bacterial group could be primarily or secondarily involved in coeliac disease.
E. coli was the most common member of the Enterobacteriaceae family isolated from human faecal samples of healthy and coeliac disease children. This result is consistent with a previous study of 49 coeliac and healthy children, in which the main Enterobacteriaceae species detected was E. coli. In the aforementioned study, the ratio of E. coli to Enterobacteriaceae was greater in active coeliac children than in healthy controls . Furthermore, biopsy specimens taken from paediatric patients with inflammatory bowel disease also revealed that E. coli was the most common Enterobacteriaceae species detected in MacConkey agar . Thus, a reduction in the relative abundance of non-E. coli species is associated with coeliac disease and could favour the predominance of harmful clones in the gut ecosystem.
Although several Enterobacteriaceae colonies were often selected from a sample, because they differed morphology and were suspected to represent different strains, they often turned out to be identical regarding their phylogenetic classification and virulence-associated gene patterns, usually some of them represented the same clone. This can be explained by the fact that only one clone usually dominates human gastrointestinal gut so that the other clones are not detectable .
The phylogenetic groups A, B1, B2 and D were found in different proportions in healthy, active coeliac and non-active coeliac patients. This fact also suggests links between lower diversity of intestinal E. coli population and coeliac disease. In healthy children, isolates of each of the four groups were found in equal proportions. By contrast, isolates belonging to groups A and B2, followed by those of group D dominated the composition of E. coli microbiota in active coeliac children, while integrants of group B1 were not isolated; group D was the most common in non-active coeliac disease, followed by groups A, B2, and B1. These results reflect imbalances in the composition of the four E. coli phylogenetic groups in coeliac disease children, revealing the most remarkable differences between non-active coeliac patients and healthy controls. In patients with IBD, such as Crohn's disease and ulcerative colitis, B2 and D phylogenetic groups were more prevalent than in the control group. Moreover, a relationship was established between the presence of serine protease autotransporter proteins (SPATE) or adhesins in B2+D-positive E. coli isolates . In active coeliac patients, the dominance of group B2 virulent clones could provide pathogenic inflammatory factors either causative or consequence of the inflammatory status associated with gluten intake in the active phase of this disorder creating a vicious circle. Nowrouzian et al.  concluded that group D strains preferentially colonize infants with less complex intestinal microbiota, since this group is more abundant than others in one-year-old infants. Both genetic make-up and gluten-free diet could contribute to changes in the gut milieu of non-active coeliac patients, leading to a predominant colonization of the virulent D group in detriment to the others. In fact, lower total bacterial populations have been detected in duodenal samples taken from this population group when compared with active coeliac patients and controls .
Overall, E coli clones of the virulent phylogenetic groups (B2+D) isolated from active and non-active coeliac patients, carried a higher number virulent genes than those from healthy controls. A higher prevalence of P fimbriae gene (papC) was found in coeliac patients as compared to healthy children, regardless of the phase of this disorder; however, the association of type-1 fimbriae (fimA) and S fimbriae (sfaD/E) gene carriage with coeliac disease was not so evident. Significant differences in the carriage of type-1 fimbriae (fimA) gene were not detected in the group of children under study but E. coli clones from active and non-active coeliac disease isolates tended to carry fewer type-1 fimbriae (fimA) genes than those from healthy children. Previous studies have indicated that the proportion of type-1 fimbriated E. coli is lower in IgA-deficient subjects than in control individuals [20, 21] and this may also be the case for coeliac disease patients since this disease is associated with IgA deficiency. E. coli adhesins, including P fimbriae, confer mannose-resistant (MR) adherence to intestinal epithelial cells. MR adhesions are well-know virulence factors in urinary-tract infection, septicaemia and meningitis. Strains that persist in the human intestinal microbiota (resident strains) are more often P fimbriated, whereas S fimbriated E. coli are not associated with long-term persistence in the gut of healthy individuals [20, 22]. Thus, the significantly higher prevalence of P fimbriae E. coli clones in treated and untreated coeliac patients constitutes a novel link between gut microbiota and coeliac disease, and revealed that gut health may be compromised in these subjects, even when subjected to a gluten-free diet.
A higher prevalence of capsular K5 gene (kfiC) of E. coli clones belonging to the virulent groups was associated with active coeliac disease, while a similar but less remarkable trend was found in non-active coeliac patients, as compared to controls. Capsular polysaccharides are known to render bacterial surfaces hydrophilic and negatively charged, making the bacterium resistant to entrapment in mucus. In addition, capsules contribute to virulence by protecting bacteria from phagocytosis and possibly from serum killing, in part by blocking activation of the alternative complement pathway [23, 15].
Moreover, a higher prevalence of the haemolysin (hlyA) gene in E coli clones of the virulent groups was associated with non-active coeliac patients in particular. α-Haemolysin is the most common cytolytic protein secreted by haemolytic E. coli strains. Haemolysin activity might contribute to persistence by attacking enterocytes and releasing nutrients for the bacteria. In fact, E. coli appears to use membrane lipids as its main nutrient source in the large intestine [23, 24].
It has also been confirmed that E. coli clones of the virulent groups (B2 + D) carried more virulent-associated genes than those of commensal groups (A + B1), with the exception of the aerobactin gene (iutA). Remarkably, genes for S (sfaD/E) and P fimbriae (papC), K5 capsule (kfiC) and haemolysin (hlyA) were significantly more common in virulent E. coli clones than in commensal strains of our population groups. In agreement, genes coding for virulence-associated genes have been found more frequently in pathogenic strains than in commensal strains [8, 23]. In addition, virulent E. coli isolates (B2 + D) have previously been shown to carry virulence-associated genes more commonly than commensal clones [10, 25, 26]. Virulence-associated genes are usually encoded on pathogenicity islands (PAIs) providing a mechanism for coordinated horizontal transfer of virulence genes, thus favouring dissemination of pathogenic determinants, as could be the case in the gut ecosystem of coeliac patients .
This study has demonstrated changes in Enterobacteriaceae diversity and increases in virulence-gene carriage in E. coli clones isolated from coeliac patients when compared to those from healthy controls. Thus, the results support the hypothesis that dysbiosis may constitute a virulence factor contributing to pathogenesis and full expression of coeliac disease. Further studies should be carried out to correlate the virulence gene carriage with specific pathogenic roles that E. coli clones could play in this disorder.
This work was supported by grants AGL2005-05788-C02-01 and Consolider Fun-C-Food CSD2007-00063 from the Spanish Ministry of Science and Education (MEC). The scholarship to E. Sánchez from Danone S.A. is fully acknowledged.
- Wang M, Ahrné S, Jeppsson B, Molin G: Comparison of bacterial diversity along the human intestinal tract by direct cloning and sequencing of 16S rRNA genes. FEMS Microbiol Ecol. 2005, 54 (2): 219-31. 10.1016/j.femsec.2005.03.012.View ArticlePubMed
- Flint HJ, Duncan SH, Scott KP, Louis P: Interactions and competition within the microbial community of the human colon: links between diet and health. Environ Microbiol. 2007, 9 (5): 1101-11. 10.1111/j.1462-2920.2007.01281.x.View ArticlePubMed
- Rajiliæ-Stojanoviæ M, Smidt H, de Vos WM: Diversity of the human gastrointestinal tract microbiota revisited. Environ Microbiol. 2007, 9 (9): 2125-36. 10.1111/j.1462-2920.2007.01369.x.View Article
- Neut C, Bulois P, Desreumaux P, Membré JM, Lederman E, Gambiez L, Cortot A, Quandalle P, van Kruiningen H, Colombel JF: Changes in the bacterial flora of the neoterminal ileum after ileocolonic resection for Crohn's disease. Am J Gastroenterol. 2002, 97 (4): 939-46. 10.1111/j.1572-0241.2002.05613.x.View ArticlePubMed
- Swidsinski A, Weber J, Loening-Baucke V, Hale LP, Lochs H: Spatial organization and composition of the mucosal flora in patients with inflammatory bowel disease. J Clin Microbiol. 2005, 43 (7): 3380-9. 10.1128/JCM.43.7.3380-3389.2005.PubMed CentralView ArticlePubMed
- Rolhion N, Darfeuille-Michaud A: Adherent-invasive Escherichia coli in inflammatory bowel disease. Inflamm Bowel Dis. 2007, 13 (10): 1277-83. 10.1002/ibd.20176.View ArticlePubMed
- Herzer PJ, Inouye S, Inouye M, Whittam TS: Phylogenetic distribution of branched RNA-linked multicopy single-stranded DNA among natural isolates of Escherichia coli. J Bacteriol. 1990, 172 (11): 6175-81.PubMed CentralPubMed
- Picard B, Garcia JS, Gouriou S, Duriez P, Brahimi N, Bingen E, Elion J, Denamur E: The link between phylogeny and virulence in Escherichia coli extraintestinal infection. Infect Immun. 1999, 67 (2): 546-53.PubMed CentralPubMed
- Nowrouzian FL, Adlerberth I, Wold AE: Enhanced persistence in the colonic microbiota of Escherichia coli strains belonging to phylogenetic group B2: role of virulence factors and adherence to colonic cells. Microbes Infect. 2006, 8 (3): 834-40. 10.1016/j.micinf.2005.10.011.View ArticlePubMed
- Sabaté M, Moreno E, Pérez T, Andreu A, Prats G: Pathogenicity island markers in commensal and uropathogenic Escherichia coli isolates. Clin Microbiol Infect. 2006, 12 (9): 880-6. 10.1111/j.1469-0691.2006.01461.x.View ArticlePubMed
- Fasano A, Catassi C: Coeliac disease in children. Best Pract Res Clin Gastroenterol. 2005, 19 (3): 467-78. 10.1016/j.bpg.2005.01.008.View ArticlePubMed
- Nadal I, Donat E, Ribes-Koninckx C, Calabuig M, Sanz Y: Imbalance in the composition of the duodenal microbiota of children with coeliac disease. J Med Microbiol. 2007, 56 (Pt 12): 1669-74. 10.1099/jmm.0.47410-0.View ArticlePubMed
- Collado MC, Calabuig M, Sanz Y: Differences between the fecal microbiota of coeliac infants and healthy controls. Curr Issues Intest Microbiol. 2007, 8 (1): 9-14.PubMed
- Clermont O, Bonacorsi S, Bingen E: Rapid and simple determination of the Escherichia coli phylogenetic group. Appl Environ Microbiol. 2000, 66 (10): 4555-8. 10.1128/AEM.66.10.4555-4558.2000.PubMed CentralView ArticlePubMed
- Nowrouzian F, Adlerberth I, Wold AE: P fimbriae, capsule and aerobactin characterize colonic resident Escherichia coli. Epidemiol Infect. 2001, 126 (1): 11-8.PubMed CentralPubMed
- Conte MP, Schippa S, Zamboni I, Penta M, Chiarini F, Seganti L, Osborn J, Falconieri P, Borrelli O, Cucchiara S: Gut-associated bacterial microbiota in paediatric patients with inflammatory bowel disease. Gut. 2006, 55 (12): 1760-7. 10.1136/gut.2005.078824.PubMed CentralView ArticlePubMed
- Lidin-Janson G, Kaijser B, Lincoln K, Olling S, Wedel H: The homogeneity of the faecal coliform flora of normal school-girls, characterized by serological and biochemical properties. Med Microbiol Immunol. 1987, 164: 247-253. 10.1007/BF02125493.View Article
- Kotlowski R, Bernstein CN, Sepehri S, Krause DO: High prevalence of Escherichia coli belonging to the B2+D phylogenetic group in inflammatory bowel disease. Gut. 2007, 56 (5): 669-75. 10.1136/gut.2006.099796.PubMed CentralView ArticlePubMed
- Nowrouzian FL, Wold AE, Adlerberth I: Escherichia coli strains belonging to phylogenetic group B2 have superior capacity to persist in the intestinal microflora of infants. J Infect Dis. 2005, 191 (7): 1078-83. 10.1086/427996.View ArticlePubMed
- Friman V, Adlerberth I, Connell H, Svanborg C, Hanson LA, Wold AE: Decreased expression of mannose-specific adhesins by Escherichia coli in the colonic microflora of immunoglobulin A-deficient individuals. Infect Immun. 1996, 64 (7): 2794-8.PubMed CentralPubMed
- Friman V, Nowrouzian F, Adlerberth I, Wold AE: Increased frequency of intestinal Escherichia coli carrying genes for S fimbriae and haemolysin in IgA-deficient individuals. Microb Pathog. 2002, 32 (1): 35-42. 10.1006/mpat.2001.0477.View ArticlePubMed
- Nowrouzian FL, Friman V, Adlerberth I, Wold AE: Reduced phase switch capacity and functional adhesin expression of type 1-fimbriated Escherichia coli from immunoglobulin A-deficient individuals. Infect Immun. 2007, 75 (2): 932-40. 10.1128/IAI.00736-06.PubMed CentralView ArticlePubMed
- Johnson JR: Virulence factors in Escherichia coli urinary tract infection. Clin Microbiol Rev. 1991, 4 (1): 80-128.PubMed CentralPubMed
- Nowrouzian F, Hesselmar B, Saalman R, Strannegard IL, Aberg N, Wold AE, Adlerberth I: Escherichia coli in infants' intestinal microflora: colonization rate, strain turnover, and virulence gene carriage. Pediatr Res. 2003, 54 (1): 8-10.1203/01.PDR.0000069843.20655.EE.View ArticlePubMed
- Johnson JR, Delavari P, Kuskowski M, Stell AL: Phylogenetic distribution of extraintestinal virulence-associated traits in Escherichia coli. J Infect Dis. 2001, 183 (1): 78-88. 10.1086/317656. Epub 2000 Nov 22View ArticlePubMed
- Boyd EF, Hartl DL: Chromosomal regions specific to pathogenic isolates of Escherichia coli have a phylogenetically clustered distribution. J Bacteriol. 1998, 180 (5): 1159-65.PubMed CentralPubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/8/50/prepub
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