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. 2019 Apr 30;4(2):e00299-18. doi: 10.1128/mSystems.00299-18

Type E Botulinum Neurotoxin-Producing Clostridium butyricum Strains Are Aerotolerant during Vegetative Growth

Serena Camerini a,#, Lucia Marcocci b,#, Lara Picarazzi c, Egidio Iorio a, Irene Ruspantini a, Paola Pietrangeli b, Marco Crescenzi a, Giovanna Franciosa c,
Editor: David Fenyod
PMCID: PMC6495232  PMID: 31058231

Botulinum neurotoxins, the causative agents of the potentially fatal disease of botulism, are produced by certain Clostridium strains during vegetative growth, usually in anaerobic environments. Our findings indicate that, contrary to current understanding, the growth of neurotoxigenic C. butyricum strains and botulinum neurotoxin type E production can continue upon transfer from anaerobic to aerated conditions and that adaptation of strains to oxygenated environments requires global changes in proteomic and metabolic profiles. We hypothesize that aerotolerance might constitute an unappreciated factor conferring physiological advantages on some botulinum toxin-producing clostridial strains, allowing them to adapt to otherwise restrictive environments.

KEYWORDS: Clostridium butyricum, botulinum neurotoxin, oxidative stress

ABSTRACT

Clostridium butyricum, the type species of the genus Clostridium, is considered an obligate anaerobe, yet it has been shown to grow in the presence of oxygen. C. butyricum strains atypically producing the botulinum neurotoxin type E are the leading cause of type E human botulism in Italy. Here, we show that type E botulinum neurotoxin-producing C. butyricum strains growing exponentially were able to keep growing and producing toxin in vitro upon exposure to air, although less efficiently than under ideal oxygen-depleted conditions. Bacterial growth in air was maintained when the initial cell density was higher than 103 cells/ml. No spores were detected in the cultures aerated for 5 h. To understand the biological mechanisms allowing the adaptation of vegetative cells of C. butyricum type E to oxygen, we compared the proteome and metabolome profiles of the clostridial cultures grown for 5 h under either aerated or anaerobic conditions. The results indicated that bacterial cells responded to oxygen stress by slowing growth and modulating the expression of proteins involved in carbohydrate uptake and metabolism, redox homeostasis, DNA damage response, and bacterial motility. Moreover, the ratio of acetate to butyrate was significantly higher under aeration. This study demonstrates for the first time that a botulinum neurotoxin-producing Clostridium can withstand oxygen during vegetative growth.

IMPORTANCE Botulinum neurotoxins, the causative agents of the potentially fatal disease of botulism, are produced by certain Clostridium strains during vegetative growth, usually in anaerobic environments. Our findings indicate that, contrary to current understanding, the growth of neurotoxigenic C. butyricum strains and botulinum neurotoxin type E production can continue upon transfer from anaerobic to aerated conditions and that adaptation of strains to oxygenated environments requires global changes in proteomic and metabolic profiles. We hypothesize that aerotolerance might constitute an unappreciated factor conferring physiological advantages on some botulinum toxin-producing clostridial strains, allowing them to adapt to otherwise restrictive environments.

INTRODUCTION

Bacteria of the genus Clostridium are conventionally defined as obligate anaerobes, i.e., they have an oxygen-independent metabolism and could be killed by exposure to oxygen or form resistant spores that germinate into vegetative cells when the conditions become favorable. During vegetative growth, the toxigenic clostridial species produce toxins. Therefore, although clostridial spores are commonly isolated from environments and food products in normal atmospheric oxygen tensions, spore germination and vegetative growth—and toxin production by toxigenic species—occur only in the absence of oxygen (1).

However, while the germination of clostridial spores is rare in the presence of low oxygen concentrations, evidence suggests that vegetative cells may display considerable ability to tolerate oxygen (2, 3).

Based on current approaches, different levels of oxygen tolerance during the vegetative stage have been reported in strains of Clostridium butyricum (2, 4), which is the type species of the genus, as well as in other nontoxigenic Clostridium species, including C. acetobutylicum, C. aminovalericum, C. bifermentans, C. puniceum, C. ljungdahlii, C. tertium, and C. glycolicum (512), and—of critical importance to human health—in toxigenic species such as C. difficile and C. perfringens (1315).

Oxygen tolerance among clostridia has been attributed to the enzymatic ability of strains to consume oxygen from the medium and to defend themselves against the toxic effects of the reactive oxygen species (ROS) (2, 4, 16). Recently, a strategy based on the synthesis of aromatic polyketides (clostrubins) has been proposed for the plant pathogen C. puniceum to survive and grow in aerated environments; nonetheless, the antioxidant role of clostrubins has not been determined (9).

Certain clostridial strains produce the botulinum neurotoxin (BoNT): this protein toxin usually causes severe paralysis in humans when it is synthesized by BoNT-producing clostridia in the colonized intestine, especially in infants younger than 1 year (infant botulism); in infected wounds (wound botulism); or in contaminated food products before consumption (foodborne botulism) (17). Oxygen may not be completely absent from these environments. The newborn intestine is known to be aerobic until it is made anaerobic by oxygen-reducing aerobes (18), wounds come in contact with ambient air, and even the contaminated food products at risk of botulism may be subject to air infiltration. Therefore, studying the responses of BoNT-producing clostridia to oxygen exposure, especially in the vegetative growth phase when they produce BoNT, is imperative for better understanding the within-host dynamics and implementing food safety control measures.

Type E BoNT (BoNT/E), i.e., one of the antigenically different BoNT types causing human botulism, is usually synthesized by C. botulinum type E strains but can also be produced by atypical neurotoxigenic C. butyricum type E strains (17). In Italy, where neurotoxigenic C. butyricum type E strains were first isolated from infants with botulism and then repeatedly recovered from cases of human botulism, these strains appear to be clinically more relevant than C. botulinum type E strains (19). Moreover, neurotoxigenic C. butyricum type E strains have been associated with human botulism in Asia, the United Kingdom, and the United States, contributing to the reemergence of this microorganism as a causative agent of botulism (2023).

Although it has been reported that nonneurotoxigenic C. butyricum strains grow in oxygen-containing environments, little is known about the behavior of neurotoxigenic C. butyricum type E strains upon oxygen exposure. The present study aimed to investigate the effects of atmospheric oxygen exposure on the vegetative growth of neurotoxigenic C. butyricum type E strains and BoNT/E production and characterize the strategic defense mechanisms adopted by these microorganisms upon air exposure.

RESULTS

Effects of air exposure on the vegetative growth of neurotoxigenic C. butyricum type E strains and BoNT/E production.

The broth cultures of the C. butyricum type E strains ISS-21 and ISS-190 in the mid-exponential-growth phase were analyzed in parallel during a 5-h incubation either under anaerobic (AN) conditions or following ambient air exposure (aerated [AE] conditions).

At the end of the experiments, the average concentrations of dissolved oxygen in AE cultures were 5.2 ± 1 ppm, whereas oxygen was not detectable in AN cultures. The average pH was 5.35 ± 0.15 in both AN and AE cultures.

The two strains exhibited similar OD600 growth curves under AN and AE conditions over the 5-h culture period, with an overall ∼2-fold increase in the OD600 values and no significant differences between each tested time point (Fig. 1A and B). As the OD600 values measure the turbidity of bacterial suspensions regardless of cell viability, the viable cells in the starting (mid-exponential-growth-phase) cultures and final cultures in AN and AE environments were counted. The average cell count of strains ISS-190 and ISS-21 in the starting cultures was ∼103 and 104 cells/ml, respectively (Fig. 1A and B). After 5 h of incubation under AN conditions, the average viable cell count in strains ISS-190 and ISS-21 was 9.4 × 105 cells/ml and 1.5 × 107 cells/ml, respectively; in contrast, the average viable cell count in strains ISS-190 and ISS-21 after a 5-h incubation under AE conditions was 6.5 × 104 and 1.2 × 106 cells/ml, respectively. Therefore, the number of viable cells at the end of the experiments was higher in AN cultures than in AE cultures, and the difference in the average viable cell count under AN and AE conditions was significant only for strain ISS-21 (P < 0.05) (Fig. 1A and B). In addition, the average cell count at the end of the experiments was significantly higher in strain ISS-21 than in strain ISS-190 in the AN environment, whereas there was no statistically significant difference between the strains in the AE environment.

FIG 1.

FIG 1

Growth of neurotoxigenic C. butyricum type E strains ISS-21 and ISS-190 under anaerobic (AN) or aerated (AE) conditions. (A and B) Growth curves of strains ISS-21 (A) and ISS-190 (B) were generated by measuring the OD600 values. The number of viable cells (symbols) was determined in the starting (mid-exponential-phase) broth cultures and after a 5-h incubation under AN or AE conditions. (C) At the end of the experiments, foam was visible in the AN broth cultures but not in the AE broth cultures. (D) Net growth of the C. butyricum type E strains ISS-21 and ISS-190 at different initial bacterial densities after a 5-h incubation under AN or AE conditions. Under AE conditions, net growth was observed only when the initial densities were >103 cells/ml. The errors were calculated by determining the standard deviation from the mean for three independent experiments for each strain. *, P < 0.05 according to Student’s t test.

Of note is that, at the end of the growth period, gas bubbles were visible in strains cultivated under AN conditions but were not visible in strains grown under AE conditions (Fig. 1C). Importantly, no spores were detected by staining or heat shock in both neurotoxigenic C. butyricum type E strains in the AE environment (data not shown).

Since it is known that bacteria respond to changes in environmental conditions in a cell-density-dependent manner (24), we determined the minimum initial bacterial density necessary to promote growth under AE conditions. The results indicated that both C. butyricum type E strains could grow under AE conditions when the initial density was at least 103 cells/ml of bacteria growing exponentially (Fig. 1D).

With regard to BoNT/E production, BoNT/E protein and toxicity levels were measured in the starting cultures of both strains and in the cultures maintained in the AN environment for 24 h (when the BoNT/E levels should be highest) (25) or incubated in the AE environment for the same time. As expected, BoNT/E protein levels determined by an immuno-ELISA were low in the starting cultures, with no significant differences between the two strains (Fig. 2). The production of BoNT/E protein was increased approximately 58-fold and 36-fold in strains ISS-21 and ISS-190, respectively, after culturing under AN conditions for 24 h and approximately 25-fold and 20-fold in the same strains under AE conditions for 24 h. Therefore, the increase in BoNT/E protein levels in the AE environment was significantly lower than in the AN environment for both strains (P < 0.05). Furthermore, while the BoNT/E protein levels were significantly higher in strain ISS-21 than in strain ISS-190 under AN conditions for 24 h (P < 0.05), the BoNT/E protein levels were similar between the two strains under AE conditions for 24 h (Fig. 2). The BoNT/E toxicity levels measured using a mouse bioassay were increased 32-fold and 8-fold in strains ISS-21 and ISS-190 cultured under AN conditions for 24 h, respectively, and 4-fold and 2-fold in the same strains under AE conditions for 24 h, respectively (Fig. 2). The increase in BoNT/E protein and toxicity levels was more evident in strain ISS-21 than in strain ISS-190, especially in the AN environment, and this result is consistent with the significantly higher growth rate of the former strain under these culture conditions.

FIG 2.

FIG 2

BoNT/E protein and toxicity levels in the starting (mid-exponential-phase) broth cultures of C. butyricum type E strains ISS-21 and ISS-190 and in the cultures after 24 h of incubation under AN or AE conditions. BoNT/E protein levels (ng/ml) were measured by ELISA (histogram bars); BoNT/E toxicity levels (mouse lethal dose [MLD]/ml) were assayed by mouse test (symbols). Data are the mean values from two independent experiments for each strain, with samples assayed in duplicate in each ELISA. Columns that do not share the same letter are statistically different according to Student’s t test (P < 0.05).

Effects of air exposure on protein expression.

As C. butyricum type E strain ISS-190 appeared less affected by air exposure than strain ISS-21, considering the more similar growth characteristics and BoNT/E production under AE and AN conditions, strain ISS-190 was selected for the comparative proteomics analysis. The C. butyricum type E strains ISS-190 and ISS-21 are clonally related, with most of the genetic diversity between the strains consisting of an ∼168-kb genetic region that is present in the ISS-190 genome but missing from the ISS-21 genome (26).

To identify differentially expressed proteins (DEPs) following air exposure, proteins from cells grown under AN or AE conditions were analyzed by proteomic analysis. A total of 953 proteins were detected; however, only 598 proteins were consistently identified in at least 3 of 5 replicates and were therefore selected for further analyses (see Table S1 in the supplemental material). Among them, 8 and 11 proteins were uniquely expressed in either the AE or AN environment, whereas 579 were identified in both environments and were subjected to quantitative analysis. Of these, 76 proteins were upregulated and 24 were downregulated under AE conditions compared to AN conditions (Fig. 3). The analysis of proteins modulated by air exposure indicated that protein-protein interactions were enriched (P value of 6.3e−10), suggesting that specific protein complexes and/or networks were likely affected by oxygen (Fig. S1).

FIG 3.

FIG 3

Distribution of C. butyricum type E strain ISS-190 proteins identified by proteomic analysis. Diagram showing the distributions of the cellular proteins identified in Clostridium butyricum strain ISS-190 uniquely in aerobiosis (AE), in anaerobiosis (AN), or under both conditions (common proteins). On the right, the diagram shows how many common proteins were found up- or downexpressed in AE (|FC| > 0.6, respectively; P values < 0.05) or were not affected by the oxygen concentration.

FIG S1

Protein-protein interaction (PPI) network of DEPs. PPI network of proteins found up- or downrepresented or uniquely identified under the AE or AN condition constructed and visualized by STRING. The PPI enrichment P value was 6.3e−10. Download FIG S1, TIF file, 2.0 MB (2MB, tif) .

Copyright © 2019 Camerini et al.

This content is distributed under the terms of the Creative Commons Attribution 4.0 International license.

TABLE S1

C. butyricum type E strain ISS-190 cell proteins identified under both AE and AN conditions or uniquely under the AE or AN condition. Download Table S1, DOCX file, 0.09 MB (97.1KB, docx) .

Copyright © 2019 Camerini et al.

This content is distributed under the terms of the Creative Commons Attribution 4.0 International license.

The DEPs were categorized by function (Table 1 and Fig. 4). The results indicate that the modulation of biological processes depends on the AE/AN growth conditions (Fig. 5). The most affected biological processes were membrane transport, redox homeostasis, carbohydrate metabolism, sulfur metabolism, and protein translation. The expression of ribosomal proteins was decreased under AE conditions. On the other hand, proteins involved in cell redox homeostasis, antioxidant defense, and sulfur metabolism and some proteins involved in the transport of solutes across membranes, particularly sugars and proteins, were overexpressed after air exposure. Similarly, several proteins involved in DNA damage responses and flagellum-associated proteins were more abundant under AE conditions.

TABLE 1.

Clostridium butyricum ISS-190 proteins up- or downexpressed under the AE condition

Protein expression
type, category,
and no.
NCBI
accession
no.
Gene name Protein name FCa Notesb Biological
process
Upexpressed
    Biological process
not assigned
        1 489509402 CLP_2689 Phage major tail protein 1.89 Biol GO not assigned
        2 489502155 CLP_3314 Metallophosphoesterase 0.69 Biol GO not assigned
        3 488646122 CLP_3861 Outer surface protein * Biol GO not assigned
        4 489502201 CLP_3345 Uncharacterized protein 1.55 Biol GO not assigned
        5 489504250 CLP_1280 Uncharacterized protein 1.16 Biol GO not assigned
        6 489504278 CLP_1290 Uncharacterized protein 1.28 Biol GO not assigned
        7 489504289 CLP_1282 Uncharacterized protein * Biol GO not assigned
        8 489504297 CLP_1288 Uncharacterized protein 1.31 Biol GO not assigned
        9 489504751 CLP_2775 Putative lipoprotein 2.24 Biol GO not assigned
        10 489503695 CLP_3097 Putative lipoprotein 0.70 Biol GO not assigned
        11 489509462 CLP_1648 Major capsid protein * Biol GO not assigned
        12 489504253 CLP_1279 Uncharacterized protein 1.54 Biol GO not assigned:
likely phage
        13 489504296 CLP_1287 Baseplate J family protein 1.29 Biol GO not assigned:
likely phage
        14 237656561 CLP_1654 Uncharacterized protein * Biol GO not assigned:
likely PTS
    Carbohydrate
metabolism
        15 488642402 CLP_0032 N-Acetylneuraminate lyase (NanA) 2.89 Carbohydrate metabolism:
sialic acid catabolism
        16 489505355 CLP_0171 N-Acetylmannosamine-6-
phosphate 2-epimerase (NanE)
4.50 Carbohydrate metabolism:
sialic acid catabolism
        17 489503203 CLP_0041 Beta-glucosidase * Glycoside hydrolase Carbohydrate metabolism
        18 489502642 CLP_0871 Alpha,alpha-phosphotrehalase 1.32 Glycoside hydrolase Carbohydrate metabolism
        19 489505662 CLP_1017 Alpha amylase, catalytic region 1.64 Glycoside hydrolase Carbohydrate metabolism
        20 489502184 CLP_3347 Glycosyl hydrolase family 32, N
domain protein
3.15 Glycoside hydrolase Carbohydrate metabolism
        21 488644093 CLP_1327 Hydroxyacylglutathione hydrolase 1.57 Carbohydrate metabolism
        22 488646082 CLP_3906 Ribose-5-phosphate isomerase B 3.45 Carbohydrate metabolism
        23 489502147 CLP_3305 dTDP-4-dehydrorhamnose
3,5-epimerase
1.35 Carbohydrate metabolism
        24 489503814 CLP_3464 UDP-N-acetylglucosamine
4,6-dehydratase
* Carbohydrate metabolism
        25 489507281 CLP_4271 Aldose 1-epimerase 0.65 Carbohydrate metabolism
    Peptidoglycan
metabolism
        26 489504484 CLP_3010 Penicillin-binding protein 2.12 Peptidoglycan metabolism
        27 489502929 CLP_0014 Cell wall hydrolase/autolysin 4.04 Peptidoglycan metabolism
    Redox homeostasis
        28 488644028 CLP_1392 FAD-dependent oxidoreductase 0.94 Fe-S Redox homeostasis
        29 488644495 CLP_1011 ArsC family protein 2.63 Redox homeostasis
        30 488644556 CLP_0948 Redoxin 1.37 Redox homeostasis
        31 489501807 CLP_2414 NADH oxidase 2.89 NADH→NAD Redox homeostasis
        32 489503213 CLP_0082 Oxidoreductase NAD-binding
domain protein
2.16 NAD→NADH Redox homeostasis
        33 489505820 CLP_3877 FAD-linked oxidase domain
protein
1.58 FAD→FADH Redox homeostasis
        34 489506590 CLP_0595 Thioredoxin-disulfide reductase 3.25 FAD→FADH,
NAD→NADH
Redox homeostasis
        35 489506753 CLP_0519 MviM protein NAD(P)-dependent
oxidoreductase
3.25 NADP→NADPH Redox homeostasis
        36 489507464 CLP_4064 Thioredoxin reductase 1.74 NADP→NADPH Redox homeostasis
        37 489510856 CLP_0102 Rubrerythrin 1.45 Fe Redox homeostasis
        38 488644026 CLP_1394 Zinc finger protein 0.67 Redox homeostasis
        39 489502510 CLP_2859 Ribosome-binding ATPase YchF 3.21 Redox homeostasis
    Sulfur metabolism
        40 489504716 CLP_1763 Cystathionine beta-lyase, MetC 2.10 Sulfur metabolism: amino
acid metabolism
        41 489507701 CLP_3701 S-Adenosylmethionine synthase,
MetK
1.02 Sulfur metabolism: Cys
and Met metabolism
        42 489505568 CLP_1012 Sulfite reductase 1.25 Fe-S Sulfur metabolism: H2S
biosynthesis—redox
homeostasis
        43 237656426 CLP_2257 Sulfate adenylyltransferase
subunit 1-bifunctional
enzyme CysN/CysC
2.93 Sulfur metabolism: H2S
biosynthesis—sulfate
reduction
        44 489501666 CLP_2258 Sulfate adenylyltransferase
subunit 2-bifunctional
enzyme CysN/CysC
* Sulfur metabolism: H2S
biosynthesis—sulfate
reduction
        45 488642894 CLP_2741 Cysteine desulfurase IscS 1.18 Fe-S Sulfur metabolism: (Fe-S)
cluster biosynthesis
    Transport
        Protein
transport
            46 488644099 CLP_1321 Protein translocase subunit SecD 1.20 P-P hydrolase Protein transport
            47 489510437 CLP_1322 Protein-export membrane
protein SecF
0.64 P-P hydrolase Protein transport
            48 489504061 CLP_3432 Chemotaxis protein MotA 0.69 Protein transport
        Sugar transport
            49 488646019 CLP_3984 Phosphoenolpyruvate-protein
phosphotransferase
1.19 Sugar PTS Sugar transport
            50 489503218 CLP_0055 PTS, lactose/cellobiose family
IIB component
2.05 Sugar PTS Sugar transport
            51 489505845 CLP_3908 PTS enzyme IIC component,
galactitol transporter
2.57 Sugar PTS Sugar transport
            52 489505963 CLP_3910 PTS enzyme IIBC component,
fructose transporter
2.96 Sugar PTS Sugar transport
            53 489507776 CLP_3760 Lichenan-specific phosphotransferase
enzyme IIA component,
cellobiose transporter
3.21 Sugar PTS Sugar transport
            54 489508885 CLP_3296 CspC, N-acetylmuramoyl-
l-alanine amidase family
protein
0.88 Hydrolase Sugar transport:
peptidoglycan
amidohydrolase
            55 489501903 CLP_2323 Putative sugar-binding secreted
protein
4.50 ABC transporter Sugar transport:
peptidoglycan
amidohydrolase
        Transmembrane
transport
            56 489510211 CLP_2264 Sulfate transporter subunit,
sulfate starvation-induced
protein 2
1.86 ABC transporter Transmembrane transport
            57 489507313 CLP_4206 ABC transporter, ATP-binding protein 2.04 ABC transporter Transmembrane transport
            58 489502974 CLP_2166 Amino acid permease-
associated region
3.44 Transmembrane transport
            59 489504117 CLP_2003 Efflux transporter, RND family 3.09 Transmembrane transport
            60 488644700 CLP_0371 Extracellular solute-binding
protein family 3
0.91 Transmembrane transport
            61 489506027 CLP_3956 Extracellular solute-binding
protein, family 1
0.77 Transmembrane transport
            62 489502966 CLP_2159 Spermidine/putrescine import
ATP-binding protein PotA
0.86 Transmembrane transport
        Membrane
protein
            63 489505750 CLP_1031 ErfK/YbiS/YcfS/YnhG family
protein
1.22 Membrane protein
            64 488645963 CLP_4057 PilT protein domain protein 1.47 Membrane protein
            65 489502814 CLP_1221 V-type ATP synthase subunit D 3.67 Plasma membrane ATP-
coupled proton transport
    Nucleotide/
nucleoside biosynthesis
        66 489510278 CLP_1207 Pseudouridine synthase, RluA family 0.86 Nucleoside synthesis
        67 488642701 CLP_3018 Nucleoside diphosphate kinase (NDK) 2.09 Nucleotide biosynthesis
        68 488644020 CLP_1400 Uridine kinase (UDK) 1.27 Pyrimidine biosynthesis
        69 488646320 CLP_4393 Oxidoreductase FAD/NAD 1.46 Fe-S
(oxidoreductase)
Pyrimidine biosynthesis
        70 489502503 CLP_2848 Dihydroorotate dehydrogenase
B [NAD(+)], PyrK
0.84 Fe-S
(electron transfer)
Pyrimidine biosynthesis
        71 488642810 CLP_2846 Orotate
phosphoribosyltransferase, PyrE
0.26 Pyrimidine biosynthesis
    Translation
        72 489504979 CLP_2730 GTP-binding protein TypA/BipA 2.16 Translation
        73 489502964 CLP_2156 Helicase domain protein 3.82 Translation
        74 488645666 CLP_3735 Peptide chain release factor 1 1.05 Translation
        75 489506025 CLP_3829 Asparaginyl/glutamyl-tRNA
amidotransferase GatC
0.92 Translation
        76 489503907 CLP_3482 Flagellar assembly factor FliW 1.25 Translation
    Other
        77 489503965 CLP_3434 Flagellar basal body protein * Bacterial-type flagellum
motility
        78 489505096 CLP_2731 RNase J 1.10 rRNA processing
        79 488642929 CLP_2579 GTPase Der 1.98 Ribosome biogenesis
        80 489509514 CLP_1938 Chemotaxis response regulator 1.04 Stimulus response
        81 488644530 CLP_0974 UspA domain protein 1.89 Stress response
        82 489502173 CLP_3317 DegT/DnrJ/EryC1/StrS
aminotransferase
0.85 Transferase
aminotransferase
        83 489510263 CLP_2488 Protein RecA 0.79 DNA repair
        84 489505855 CLP_3987 Ribonucleoside-diphosphate
reductase
1.54 Oxidoreductase DNA replication
Downexpressed
    Biological process
not assigned
        1 488644185 CLP_1269 Uncharacterized protein −0.64 Biol GO not assigned
        2 489503664 CLP_3067 Uncharacterized protein −3.20 Biol GO not assigned
        3 489504941 CLP_2749 p-47 protein −2.11 Biol GO not assigned
        4 489505689 CLP_1082 Uncharacterized protein * Biol GO not assigned
        5 489501399 CLP_1582 TPR repeat protein * Biol GO not assigned
        6 489507297 CLP_4257 Uncharacterized protein * Biol GO not assigned
        7 489510276 CLP_2354 Uncharacterized protein −1.42 Biol GO not assigned
    Carbohydrate
metabolism
        8 489509381 CLP_1388 Propionate CoA-transferase −2.21 Likely uses butyryl-
CoA as the
substrate
Carbohydrate metabolism
        9 489502979 CLP_0779 Transaldolase −1.55 Carbohydrate metabolism
        10 488644944 CLP_0793 Pyruvate formate-lyase-activating
enzyme
−1.85 Fe-S Carbohydrate metabolism
        11 489505871 CLP_3853 Butyryl-CoA dehydrogenase −0.95 Carbohydrate metabolism:
butyrate synthesis
pathway
        12 489506129 CLP_3852 Electron transfer flavoprotein,
beta subunit
−1.13 Electron transfer Carbohydrate metabolism:
butyrate synthesis
pathway
        13 906848776 CLP_3850 3-Hydroxybutyryl-CoA dehydrogenase −1.24 Carbohydrate metabolism:
butyrate synthesis
pathway
    Translation
        14 488643005 CLP_2502 30S ribosomal protein S15 −0.78 Translation
        15 488645977 CLP_4028 30S ribosomal protein S19 −1.16 Translation
        16 488645980 CLP_4025 50S ribosomal protein L16 −0.72 Translation
        17 488645984 CLP_4021 50S ribosomal protein L24 * Translation
        18 488645990 CLP_4015 30S ribosomal protein S5 −0.77 Translation
        19 488645998 CLP_4006 30S ribosomal protein S13 −1.66 Translation
        20 488646007 CLP_3997 50S ribosomal protein L13 −0.87 Translation
        21 488646008 CLP_3996 30S ribosomal protein S9 −0.77 Translation
        22 488646514 CLP_4041 50S ribosomal protein L10 −0.84 Translation
        23 489502574 CLP_2872 50S ribosomal protein L25 −1.72 Translation
        24 489503008 CLP_2520 Ribosome-recycling factor * Translation
        25 488646138 CLP_3844 60-kDa chaperonin −0.94 Protein refolding Translation
    rRNA processing
        26 488642944 CLP_2563 Probable dual-specificity RNA
methyltransferase RlmN
* Fe-S rRNA processing
        27 489508929 CLP_3179 rRNA small-subunit methyltransferase * rRNA processing
    Nucleotide/
nucleoside biosynthesis
        28 489507369 CLP_4280 Ribose-phosphate pyrophosphokinase * Nucleotide biosynthesis
        29 488642862 CLP_2788 5-(Carboxyamino)imidazole
ribonucleotide mutase, PurE
* Nucleotide biosynthesis
    Other
        30 488642931 CLP_2577 Stage IV sporulation protein A −3.09 Sporulation
        31 653633918 AWN73_
11055
Serine protease −2.83 Protein kinase
        32 488643856 CLP_1581 Heat shock protein Hsp20 −2.40 Stress response
        33 489507712 CLP_3749 Peptidoglycan-binding LysM −2.19 Peptidoglycan
metabolism
        34 488643009 CLP_2498 Aspartokinase * Amino acid biosynthesis
        35 489504328 CLP_3792 N-Acetylgalactosamine permease
IID component
* PTS Sugar transport
a

FC is reported as log2 AE/AN ratio, as described in Materials and Methods. * indicates proteins for which FC has not been calculated because they have been detected only in aerobic or anaerobic conditions.

b

Notes column reports some specific relevant functional protein features discussed in the text.

FIG 4.

FIG 4

Functional categorization of DEPs under AE conditions. Functional categorization of the C. butyricum type E strain ISS-190 proteins modulated under AE conditions (P values < 0.05). The numbers in the graph indicate the percentage of the proteins involved in the described biological process.

FIG 5.

FIG 5

Frequency of DEPs under AE conditions in the different biological processes. Number of C. butyricum type E strain ISS-190 proteins up- or downmodulated under AE conditions (P values < 0.05) in each biological process. Arrows indicate the most-affected biological processes depending on AE/AN condition.

With respect to carbohydrate metabolism, some proteins related to polysaccharide catabolic processes were upregulated in the AE environment, whereas three enzymes responsible for converting acetoacetyl-CoA to butyryl-CoA (3-hydroxybutyryl-CoA dehydrogenase, acyl-CoA dehydrogenase, and electron transfer flavoprotein subunit beta) were downregulated in the AE environment. Of note, the pyruvate formate lyase (PFL)-activating protein was also decreased in the AE environment.

Effects of air exposure on extracellular metabolism evaluated by 1H NMR spectroscopy.

Nuclear magnetic resonance (NMR) spectroscopy was used to identify and quantify fermentation products in the extracellular medium for both strains after a 5-h incubation under either AN or AE conditions (Fig. 6).

FIG 6.

FIG 6

Extracellular metabolite concentrations from pooled ISS strains (n = 6). Relative concentrations (%) of the individual metabolites versus all extracellular metabolites investigated are shown on the y axis. *, P < 0.05 according to Student’s t test.

The formate levels were significantly lower (P = 0.004) in the AE extracellular medium than in the AN extracellular medium, whereas the acetate content was significantly higher in the AE medium than in the AN medium (P = 0.003). Moreover, there was a significant increase in the acetate/butyrate ratio (P = 0.004) in the media of both strains under AE conditions compared to the strains grown under AN conditions. There were no other significant differences in the levels of metabolites linked to pyruvate metabolism (lactate, ethanol, and alanine).

DISCUSSION

Anaerobically cultured C. butyricum type E strains continued to grow and produce BoNT/E in liquid medium during the transition from anaerobic to aerated conditions, although aeration for 5 h resulted in a dissolved oxygen concentration in the final cultures of ∼5 ppm, which does not support aerobic life (27) but is not the oxygen-free conditions required for vegetative growth of anaerobic clostridia.

While the OD600 data indicated similar growth rates under AN and AE conditions over 5 h, viable cell counts were lower in the AE environment than in the AN environment at the end of the culture period, suggesting that bacterial growth was decreased under the stress conditions of aeration compared to the ideal conditions of anaerobiosis. The lack of complete correlation between OD and viable cell count data under stress conditions has been reported for other bacteria (28) and may be because OD values are affected by light scattering due to cell debris and stress-induced bacterial cell damage.

C. butyricum type E strains continued to grow upon air exposure only when the starting exponentially growing cultures contained at least 103 cells/ml. The absence of growth at lower initial bacterial densities could be a result of either oxygen toxicity or decreased cell-to-cell signaling (24). The absence of spores in the cultures of C. butyricum type E strains after a 5-h aeration indicates that sporulation did not occur in the evaluated period and that aerotolerance was not due to spore formation. Sporulation in clostridia has been reported to be strain dependent (29).

Of note, our results indicated that even BoNT/E production was maintained during the transition from AN to AE conditions. BoNT/E protein and toxicity levels were increased in the cultures transferred to AE conditions for 24 h, although the levels were significantly lower than those in cultures maintained under AN conditions for the same period. The significantly lower BoNT/E protein and toxicity levels detected in the AE environment than those in the AN environment can be attributed to the decreased growth rates under the former conditions. Moreover, our proteomics analysis revealed that the abundance of several ribosomal proteins was lower under AE conditions, evidencing that the overall protein synthesis could be downregulated in the presence of oxygen, which is a general adaptive response to acute stress in bacteria (30). Additional effects due to downregulation of BoNT/E synthesis under AE conditions cannot be excluded. Little is known on the toxin synthesis regulation in BoNT/E-producing clostridial strains. We recently hypothesized that production of BoNT/E in C. butyricum type E strains might be controlled at the posttranscriptional and/or posttranslational levels (i.e., protein folding, secretion, and degradation) (31); accordingly, since oxygen is known to modify the structure and function of proteins, BoNT/E inactivation by oxidative damage could be expected (32). Recently, it was shown that BoNT/E expression in C. botulinum type E strains is positively regulated by the sporulation regulator Spo0A (33); our proteomics results showed similar Spo0A protein levels in the C. butyricum type E broth cultures incubated for 5 h under AN and under AE conditions (see Table S1 in the supplemental material). The absence of significant differences in the BoNT/E protein levels under AN and AE conditions in the proteomics analysis may be due to only cellular proteins being analyzed whereas BoNT/E protein is an exotoxin secreted by clostridia in the medium (34). Nevertheless, cellular levels of the protein P-47 were decreased under AE conditions (Table 1); this protein is encoded in the bont/e toxin gene cluster and coexpressed with BoNT/E, although the two proteins might not be secreted together (35).

Our proteomics analyses indicated that membrane transport was one of the most affected processes under AE conditions: many proteins overexpressed in AE contain or interact with ATP-binding cassettes (ABC transporters) and are involved in transporting solutes across membranes. Other overexpressed proteins are involved in sugar transport, especially five proteins (Table 1) from the phosphoenolpyruvate (PEP)-dependent phosphotransferase system (PTS), which is a major mechanism used by bacteria for carbohydrate uptake and conversion into phosphoesters during transport (36). Moreover, the proteomic analysis indicated that acetylmuramoyl-l-alanine amidase and cell wall hydrolase, which are involved in peptidoglycan catabolism, were upregulated under AE conditions.

Other proteins involved in protein transport, including SecD and SecF, which are members of the Sec protein translocase complex, were overexpressed in the AE environment. These results indicate that molecular trafficking through the cellular membrane and carbohydrate metabolism are enhanced under AE conditions, suggesting that energy requirements are higher.

Aeration also induced the expression of proteins involved in redox homeostasis, including NADH oxidase, rubrerythrin, peroxiredoxin, and thioredoxin reductase. In this respect, Kawasaki et al. (4) detected the activity of NAD(P)H peroxidase and superoxide dismutase (SOD) in nonneurotoxigenic C. butyricum strains exposed to air. It is known that rubrerythrin has a strong NAD(P)H peroxidase activity (10). Moreover, enzymes homologous to peroxiredoxin and thioredoxin reductase prevent the inactivation of manganese-SOD (Mn-SOD) of Saccharomyces cerevisiae under oxidative stress, contributing to the antioxidant defense in yeast (37). Since an Mn-SOD gene is carried in the genome of three closely related neurotoxigenic C. butyricum type E strains, we speculate that peroxiredoxin and thioredoxin reductase in these strains may protect Mn-SOD.

The proteomic analysis indicated that proteins involved in sulfur metabolism were upregulated under AE conditions, including two subunits of the bifunctional enzyme CysN/CysC sulfate adenylyltransferase and sulfite reductase: these enzymes are involved in cysteine production, and this sulfur-containing amino acid strongly inhibits toxin production in C. difficile (38). Furthermore, several cysteine-containing proteins, often required for protein folding or involved in cellular response to oxidative stress, and (Fe-S) cluster-containing proteins are sensitive to oxidization, and many of these proteins were overexpressed under AE conditions (Table 1), suggesting the need to restore the pool of these proteins in their active state. In contrast, the PFL-activating enzyme, an oxygen-sensitive Fe-S binding protein, responsible for the conversion of pyruvate into acetyl-CoA and formate in anaerobic metabolism (Fig. 7), was downregulated under AE conditions. In accordance, the formate content was significantly lower in the supernatants from aerated C. butyricum type E cells than in those from anaerobic cells. Formate is ultimately converted to carbon dioxide and hydrogen in the metabolic pathways of clostridial species (Fig. 7). Therefore, the lower levels of formate resulting from the decreased expression of the PFL-activating enzyme, together with the upregulation of hydrogen-consuming enzymes, may partially explain the decreased formation of gas in the cultures upon aeration.

FIG 7.

FIG 7

Fermentation pathways of glucose under AE and AN conditions detected by MS and NMR analyses. End products from pyruvate metabolism detected by NMR analysis from the extracellular medium are shown out of the box: red and green arrows indicate down- and upmodulation, respectively, under the AE condition. Enzymes involved in butyrate production and detected by proteomic analysis are shown inside the box with a red arrow indicating their downmodulation. (CLP_0793, pyruvate formate-lyase-activating enzyme; CLP_3850, 3-hydroxybutyryl-CoA dehydrogenase; CLP_3853, butyryl-CoA dehydrogenase; CLP_3852, electron transfer flavoprotein, beta subunit).

Furthermore, the proteomics analysis showed that three enzymes of the butyrate metabolic pathway were downregulated under AE conditions, suggesting that oxygen induced a decrease in butyrate biosynthesis. In line with this result, butyrate content was decreased, although not significantly, in the aerated supernatants compared to nonaerated supernatants; concomitantly, the acetate levels were significantly higher in the aerated supernatants, suggesting that oxygen caused a shift in electron flow toward acetate formation instead of butyrate formation in these C. butyricum type E strains. The acetate/butyrate ratio in nonneurotoxigenic C. butyricum strains is increased as the hydrogen partial pressure is decreased in the medium (39). Moreover, the higher levels of several proteins putatively involved in DNA replication and repair and nucleotide biosynthesis and flagellum-related proteins under AE conditions suggest that the DNA damage response may be activated and proton-driven bacterial motility enhanced. The improved bacterial motility may increase proton consumption and consequently decrease the generation of ROS (40). Furthermore, our finding that a protein involved in an early stage of sporulation was down-expressed in the AE environment is consistent with the absence of spores in C. butyricum type E cultures after a 5-h exposure to ambient air.

In conclusion, the enhanced aerotolerance of neurotoxigenic C. butyricum type E strains that we report here may have public health significance. First, it may increase the opportunities for these microorganisms to colonize the newborn intestine, because the intestine at birth is aerobic and gradually becomes anaerobic (18); in addition, the ability to inactivate the ROS generated by inflammatory processes in the gut may be advantageous to intestine-colonizing neurotoxigenic C. butyricum type E strains. To date, most neurotoxigenic C. butyricum type E strains have been involved in infant intestinal toxemia botulism (2123, 41, 42). It is of interest that Cassir et al. (43) recently found a significant association between oxidized gut environment and the presence of cytotoxic (nonneurotoxigenic) C. butyricum strains in preterm neonates with necrotizing enterocolitis. Furthermore, the studies on aerotolerance may improve the isolation and identification of BoNT-producing clostridia, considering that other clostridial strains have been misidentified because of their aerotolerance features (11).

To our knowledge, this study is the first to demonstrate vegetative growth and toxin production upon air exposure for BoNT-producing clostridial strains. The results point to the need for further research on the aerotolerance of other BoNT-producing clostridial strains, especially C. botulinum strains, which are more frequently involved in botulism.

MATERIALS AND METHODS

Bacterial strains and growth conditions.

Two neurotoxigenic C. butyricum type E strains (ISS-21 and ISS-190) isolated from distinct infant botulism cases in Italy were used in this study (41, 42). The effect of atmospheric oxygen on the vegetative growth of these strains was analyzed by using a culture approach similar to that used by other authors for similar purposes (6, 14, 15), with modifications. Tryptone-peptone-glucose-yeast extract (TPGY) broth (pH 7.0) (Oxoid) without the addition of reducing agents was used to grow the strains. Clostridial growth was monitored by measuring the optical densities of the cell suspensions at 600 nm (OD600) at regular time intervals (Biophotometer; Eppendorf). The strains were grown to the mid-exponential phase (OD600 of ∼1) at 37°C in a jar with an anaerobic gas generator (Anaerogen; Oxoid) (starting cultures). Then, 50% of the exponentially growing cultures were transferred to flasks (flask-to-medium ratio, 1:10) and incubated in ambient air (aerated or AE conditions) in an incubator shaker (New Brunswick Scientific; model G25) at 200 rpm and 37°C for 5 h; the remaining volumes of the starting cultures were overlaid with sterile Vaseline oil to produce oxygen-depleted (anaerobic or AN) conditions and were incubated at 37°C for 5 h. The experimental time of 5 h was empirically chosen in order to assay the differences between the vegetative cultures under the AN and AE conditions before sporulation occurred. Growth curves were generated using the OD600 values. These experiments were repeated three times.

The AE cultures were streaked on nonselective tryptone soy agar (TSA) plates, and the plates were incubated at 37°C for 24 h to detect contamination with aerobic bacteria at the end of culturing. To assess the presence of spores, slides from the AE cultures were examined microscopically; in addition, aliquots of the AE cultures grown for 5 h were treated at 70°C for 10 min and streaked on egg yolk agar plates, and bacterial growth was assessed after a 48-h incubation at 37°C under anaerobiosis. The pH values of the cultures were determined using a pH meter (Mettler Toledo). The dissolved oxygen levels were measured using a dissolved oxygen meter (model HI9146; Hanna Instruments). Viable bacteria were counted using the three-tube most probable number (MPN) method as previously described (31). The average number of viable cells was measured by combining the data from three separate experiments.

Student’s t test was used to perform all pairwise comparisons between OD600 values or viable cell counts under AN and AE conditions. All calculations were performed using GraphPad Prism software version 6 (GraphPad Software, San Diego, CA), and P values < 0.05 were considered statistically significant.

Quantification of BoNT/E protein and toxicity levels.

BoNT/E protein and toxicity levels were measured in the starting (mid-exponential-growth-phase) cultures and in cultures grown under AN or AE conditions for 24 h. The cultures were centrifuged at 12,000 × g for 20 min at 4°C.

BoNT/E protein levels in the supernatants from two assays were quantified in duplicate using a commercial BoNT/E enzyme-linked immunosorbent assay (ELISA) kit (Tetracore). Absorbance was measured at 405 nm using a Multiskan Go microplate spectrophotometer (Thermo Scientific). The BoNT/E concentrations (ng/ml) were determined using the standard toxin concentration curve provided by the manufacturer, and the mean and standard deviation were calculated. Student’s t test was used to perform pairwise comparisons, with statistical significance at P < 0.05.

A mouse bioassay was used for determining BoNT/E toxicity. The culture supernatants were treated with 0.5% trypsin at 1:250 for 20 min at room temperature, 2-fold diluted in phosphate buffer (pH 6.4) containing 0.2% gelatin, and injected intraperitoneally into groups of two male CD1 mice (weight of 25 g). The mice were monitored over 4 days for signs of botulism (44), the number of deaths was recorded, and the results were expressed as mouse lethal dose (MLD) per ml. The mouse bioassay was done twice.

The experimental animal protocol adhered to Directive 2010/63/EU on the protection of animals used for scientific purposes of the European Parliament and was approved by the Italian Ministry of Health (authorization no. 291/2015).

Harvesting and lysis of bacterial cells.

Fifty milliliters of the AE and AN cultures grown for 5 h was centrifuged at 5,000 × g for 15 min. Each culture supernatant (2 ml) was mixed with 18 ml of 80% ethanol and stored at −80°C until analysis of metabolites. For cell protein extraction, the pellets were washed twice with 50 mM phosphate buffer (pH 7.8) containing 0.1 mM EDTA and suspended in 500 μl of a solution containing 25 mM Tris, pH 7.4, 0.1 mM EDTA, 0.2% Triton X-100, 0.2 mg/ml lysozyme, 0.1 mg/ml RNase, 0.1 mg/ml DNase, and 1× protease inhibitor cocktail (Sigma-Aldrich). After 30 min at 37°C, the suspensions were subjected to ultrasound treatment (10 cycles of 45 s on and 2 min off at a frequency of 20 kHz) (Sonics VCX 500) on ice. Samples were centrifuged at 25,000 × g for 10 min at 4°C, and the protein concentration in the supernatants was estimated using the Bio-Rad protein assay kit with bovine serum albumin used as a standard. The supernatants were stored at −80°C until proteomic analyses.

Proteomic analysis.

Proteins were separated on a 1-D gel, 4 to 12%, and colored by Coomassie blue staining. Each gel lane was cut in 12 to 15 contiguous slices, treated with DTT and iodoacetamide, and digested with trypsin (Promega Corporation), as described by Shevchenko et al. (45). The peptide mixtures were analyzed by nanoflow reversed-phase liquid chromatography–tandem mass spectrometry (nLC-MS/MS) using an Ultimate 3000 HPLC (Dionex) coupled online with a linear ion trap (LTQ; Thermo). Peptides were desalted in a trap column and separated in a 10-cm silica capillary as previously described (46). Tandem mass spectra were acquired in data-dependent mode (top five) and searched against Clostridium proteins (C. butyricum type E strain BL5262 taxonomy identity 632245) from the NCBI database using Proteome Discoverer version 1.4 (Thermo Electron) filtering spectral matches with a Percolator node with a q-value based false-discovery rate (FDR) of 0.01. Specific trypsin cleavages were admitted, with two possible missed cleavages. Only proteins identified with at least two peptides were considered, and only proteins detected in at least three replicates were considered for further analysis. The analyses were performed in quintuplicates. A label-free quantitative analysis was performed to identify DEPs in proteomic analyses, comparing AE and AN conditions. Only proteins identified in at least three replicates were selected for identification of DEPs. The proteins expressed under one condition were excluded from the statistical analysis but used for the successive analysis step. Protein abundances were estimated using normalized spectral abundance factor (NSAF) values calculated normalizing the spectral counts against the protein length and the sum of spectral counts in the corresponding run. Identification of DEPs was performed using the method proposed by Pavelka et al. (47), effectively applied in spectral-count-based proteome quantification (48), showing a good sensitivity-specificity tradeoff. The method consists of signal-to-noise-ratio (STN) statistics improved using protein-specific estimates of standard deviation (SD) derived by the power-law global error model (PLGEM), which well describes the SD-versus-mean dependence in NSAF data sets. A resampling-based algorithm is then used for multiple testing adjustment to control the false-positive rate (FPR). The PLGEM-STN method was applied using the ‘plgem’ Bioconductor (49) package in step-by-step mode. Further details on the method are reported in the work of Pavelka et al. (47). Our NSAF data set showed a good fitting to the PLGEM (adjusted r2 = 0.996); PLGEM-STN was thus used to compare NSAF values under AE and AN conditions; multiple testing correction was applied, setting in ‘plgem’ a 1,000-iteration resampling and a ‘delta’ (parameter for FPR estimate) of 0.05. The fold change (FC) for each protein was estimated as the log2 of the average NSAF(AE)/average NSAF(AN) ratio. The proteins showing both adjusted P values of <0.05 and |FC| of >0.6 were predicted as differentially expressed in our data set. The proteins up- or downrepresented and those uniquely identified under AE or AN conditions were grouped by biological function as retrieved from the UniProt database and analyzed by the STRING tool, version 10.5 (http://www.string-db.org), with a minimum required interaction score of 0.7.

High-resolution NMR spectroscopy.

High-resolution NMR (Bruker Avance spectrometer; Karlsruhe, Germany) analyses were performed on extracellular medium at 25°C and 400 MHz. 1H magnetic resonance spectroscopy (MRS) spectra were acquired and analyzed as previously described (50). Metabolite quantification was expressed as the percentage of metabolite concentration versus all investigated metabolites. Differences in the metabolite concentration under AE and AN conditions were evaluated using the Wilcoxon signed-rank test at a significance level of P < 0.01.

Availability of data.

The mass spectrometry proteomics data have been deposited in the ProteomeXchange Consortium (http://proteomecentral.proteomexchange.org) via the PRIDE partner repository with the data set identifier PXD013383.

ACKNOWLEDGMENTS

L.M. and P.P. received financial supports from Regione Lazio of Italy (FILAS-RU-2014-1020). The study was also supported by internal ISS research funding. The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.

We thank Concetta Scalfaro, Claudia D’Agostino, and Carlo Giovannelli for technical assistance.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

FIG S1

Protein-protein interaction (PPI) network of DEPs. PPI network of proteins found up- or downrepresented or uniquely identified under the AE or AN condition constructed and visualized by STRING. The PPI enrichment P value was 6.3e−10. Download FIG S1, TIF file, 2.0 MB (2MB, tif) .

Copyright © 2019 Camerini et al.

This content is distributed under the terms of the Creative Commons Attribution 4.0 International license.

TABLE S1

C. butyricum type E strain ISS-190 cell proteins identified under both AE and AN conditions or uniquely under the AE or AN condition. Download Table S1, DOCX file, 0.09 MB (97.1KB, docx) .

Copyright © 2019 Camerini et al.

This content is distributed under the terms of the Creative Commons Attribution 4.0 International license.


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