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<StructureSection load=1bcp size='500' side='right' caption='Pertussis Toxin-ATP complex ([[1bcp]])' scene=''>[[Image:230px-Pertussis.jpg|left|thumb|A young boy coughing due to pertussis.]]
<StructureSection load=1bcp size='500' side='right' caption='Pertussis Toxin-ATP complex ([[1bcp]])' scene=''>[[Image:230px-Pertussis.jpg|left|thumb|A young boy coughing due to pertussis.]]
==Introduction==
==Introduction==
'''Pertussis Toxins''' (PT) is a protein-based exotoxin and major virulence factor produced by the bacterium [http://en.wikipedia.org/wiki/Bordetella_pertussis ''Bordetella pertussis''].<ref name=Hazes>PMID: 8637000</ref> PT causes [http://en.wikipedia.org/wiki/Whooping_cough pertussis], which is also known at whooping cough and is highly contagious bacterial disease.  The disease is caused by the bacterium colonizing the respiratory tract where it then establishes an infection. This disease had been characterized by severe coughing that can last up to six weeks and in some countries lasting nearly 100 days. It has been documented in some cases that PT can cause subconjunctival hemorrhages, rib fractures, hernias, fainting and vertebral artery dissection.
'''Pertussis Toxins''' (PT) is a protein-based exotoxin and major virulence factor produced by the bacterium [http://en.wikipedia.org/wiki/Bordetella_pertussis ''Bordetella pertussis''].<ref name=Hazes>PMID: 8637000</ref> PT causes [http://en.wikipedia.org/wiki/Whooping_cough pertussis], which is also known at [http://www.youtube.com/watch?v=1PajbAKd8Kg whooping cough] and is highly contagious bacterial disease.  The disease is caused by the bacterium colonizing the respiratory tract where it then establishes an infection.<ref name=Carbonetti>PMID: 14573656</ref> This disease had been characterized by severe coughing that can last up to six weeks and in some countries lasting nearly 100 days.<ref name=Carbonetti>PMID: 17418639</ref>It has been documented in some cases that PT can cause [http://en.wikipedia.org/wiki/Subconjunctival_hemorrhage subconjunctival hemorrhages], [http://en.wikipedia.org/wiki/Rib_fracture rib fractures], [http://en.wikipedia.org/wiki/Hernias hernias], fainting and [http://en.wikipedia.org/wiki/Vertebral_artery_dissection vertebral artery dissection].<ref name=cornia>PMID: 20736473</ref>


As of 2010, the worldwide incidence of whooping cough has been estimated to 48.5 million cases and nearly 295,000 deaths per year. With that in mind, whooping cough can affect people of any age; however, before vaccines were available the disease was most common in infants and young children but now children are immunized and the high percentage of cases are seen among adolescents.
As of 2010, the worldwide incidence of whooping cough has been estimated to 48.5 million cases and nearly 295,000 deaths per year.<ref name=Bettiol>PMID: 20091541</ref> With that in mind, whooping cough can affect people of any age; however, before vaccines were available the disease was most common in infants and young children but now children are immunized and the high percentage of cases are seen among adolescents.


==structure==
==Structure==
The [http://en.wikipedia.org/wiki/Pertussis_toxin pertussis toxin] has been characterized as being an AB toxin meaning that there are 2 subunits: A subunit possesses the enzyme activity and the B possesses it the receptor binding portion.  PT in particular is an AB5 toxin consisting of a six-component protein complex. With that in mind, this protein is a hexamer containing a catalytic (S1) subunit that is tightly associated with the pentameric cell-binding component (B-oligomer). The S1 component is a single subunit <scene name='Pertussis_Toxin-ATP_Complex/Subunit_1/3'>S1 (chains A,G)</scene> while the B-oligomer is a pentamer composed of four types of subunits: <scene name='Pertussis_Toxin-ATP_Complex/Subunit_2/3'>S2 (chains B,H)</scene>,  
The [http://en.wikipedia.org/wiki/Pertussis_toxin pertussis toxin] has been characterized as being an AB toxin meaning that there are 2 subunits: A subunit possesses the enzyme activity and the B subunit possesses the receptor binding portion.  PT in particular is an AB5 toxin consisting of a six-component protein complex, and the multiple subunits of the complex are not identical in composition.<ref name=Hazes>PMID: 8637000</ref> With that in mind, this protein is a hexamer containing a catalytic (S1) subunit that is tightly associated with the pentameric cell-binding component (B-oligomer).<ref name=Hazes>PMID: 8637000</ref> The S1 component is a single subunit <scene name='Pertussis_Toxin-ATP_Complex/Subunit_1/3'>S1 (chains A,G)</scene> while the B-oligomer is a pentamer composed of four types of subunits: <scene name='Pertussis_Toxin-ATP_Complex/Subunit_2/3'>S2 (chains B,H)</scene>, <scene name='Pertussis_Toxin-ATP_Complex/Subunit_3/5'>S3 (chains C,I)</scene>, two copies of <scene name='Pertussis_Toxin-ATP_Complex/Subunit_4/3'>S4 (chains D,E,J,K)</scene>, and <scene name='Pertussis_Toxin-ATP_Complex/Subunit_5/4'>S5 (chains F,L)</scene>.<ref name=Hazes>PMID: 8637000</ref>  The overall structure of PT <scene name='Pertussis_Toxin-ATP_Complex/Whole_monomer/2'>multisubunit complex</scene>. These subunits are encoded by ptx genes, which are encoded on a large PT [http://en.wikipedia.org/wiki/Operon operon] that includes additional genes as well such as Pti genes.  Together the PT and Pti proteins form the PT secretion complex and toxin itself.<ref name=Weiss>PMID: 8464913</ref>
<scene name='Pertussis_Toxin-ATP_Complex/Subunit_3/5'>S3 (chains C,I)</scene>, two copies of <scene name='Pertussis_Toxin-ATP_Complex/Subunit_4/3'>S4 (chains D,E,J,K)</scene>, and <scene name='Pertussis_Toxin-ATP_Complex/Subunit_5/4'>S5 (chains F,L)</scene>.<ref name=Hazes>PMID: 8637000</ref>  These subunits are encoded by a ptx genes, which are encoded on a large PT [http://en.wikipedia.org/wiki/Operon operon] that includes additional genes as well such as Pti genes.  Together the PT and Pti proteins form the PT secretion complex.


==Pertussis Toxin activation==
==Pertussis Toxin activation==
'''Pertussis Toxin''' by itself is harmless unless activated.  From multiple studies, it has became clear that there is a direct interaction between [http://en.wikipedia.org/wiki/Adenosine_triphosphate Adenosine triphosphate] (ATP) and pertussis toxin which leads to activation. The direct effect of ATP is to destabilize the interaction between the S1 subunit and the B-oligomer by binding to the B-oligomer. This interaction relaxes the toxin by facilitating the subsequent reduction of  a disulphide bond in the S1 subunit.  The main interaction that leads to the destabilization is the favorable hydrogen bonding and electrostatic interaction between the triphosphate moiety and five positively charged amino acids:<scene name='Pertussis_Toxin-ATP_Complex/5_amino_acid_interaction/2'>Arg S2:150, Lys S2-151, Arg S3-150, and Arg S4b-69</scene>. In contrast, the negatively charged carboxyl terminus of subunit S1 interacts unfavorably with the negative charges of the triphosphate moiety, causing a displacement of the C-terminal of <scene name='Pertussis_Toxin-ATP_Complex/Repulsion_of_subunit_s1/3'>Tyr 233:A and Phe 235:A</scene> therefore,  the repulsion between the triphosphate moiety and the C terminus of subunit S1 forms the mechanism by which the interaction between S1 and the B-Oligomer is destabilized.
'''Pertussis Toxin''' by itself is harmless unless activated.  From multiple studies, it has became clear that there is a direct interaction between [http://en.wikipedia.org/wiki/Adenosine_triphosphate Adenosine triphosphate] (ATP) and pertussis toxin which leads to activation.<ref name=Hazes>PMID: 8637000</ref><ref name=Kaslow>PMID: 1612292</ref>The direct effect of ATP is to destabilize the interaction between the S1 subunit and the B-oligomer by binding to the B-oligomer.<ref name=Hazes>PMID: 8637000</ref> This interaction relaxes the toxin by facilitating the subsequent reduction of  a disulphide bond in the S1 subunit.   
 
The main interaction that leads to the destabilization is the favorable hydrogen bonding and electrostatic interaction between the triphosphate moiety and five positively charged amino acids:<scene name='Pertussis_Toxin-ATP_Complex/5_amino_acid_interaction/4'>Arg S2-150, Arg S3-150, Arg S3-151, Arg S4b-69, and Lys S2-151</scene>. In contrast, the negatively charged carboxyl terminus of subunit S1 interacts unfavorably with the negative charges of the triphosphate moiety, causing a displacement of the C-terminal of <scene name='Pertussis_Toxin-ATP_Complex/Real_repulsion/3'>Phe 235:A</scene> therefore,  the repulsion between the triphosphate moiety and the C terminus of subunit S1 forms the mechanism by which the interaction between S1 and the B-Oligomer is destabilized.<ref name=Hazes>PMID: 8637000</ref>The details of the [http://proteopedia.org/wiki/images/9/94/PT_ATP_complex.png protein-ATP interactions] can also be seen here.<ref name=Hazes>PMID: 8637000</ref>


==Mechanism of pathogenesis==
==Mechanism of pathogenesis==
Following the pertussis toxin binding to the cell membrane (B subunit binds to terminal sialic acid residues), the toxin is taken up by an endosome and transported from the plasma membrane via the Golgi apparatus to the endoplasmic reticulum (ER) where finally membrane translocation occurs.  The destabilization of PT occurs in the ER prior to membrane translocation.  After binding of ATP, cleavage of the single disulphide bond by [http://en.wikipedia.org/wiki/Protein_disulfide_isomerase protein disulphide isomerase] (PDI) occurs in subunit S1 <scene name='Pertussis_Toxin-ATP_Complex/Disulphide_bonds_breaking/1'>(Cys 41-Cys 201)</scene> and is believed to trigger a conformational change necessary to expose the active site to its substrates. The reducation step takes place after interaction of PT with ATP.  After destabilization, the S1 becomes active and catalyzes the [http://en.wikipedia.org/wiki/ADP_ribosylation ADP-ribosylation] of the alpa-subunit of regulatory trimeric [http://en.wikipedia.org/wiki/G_proteins G-proteins] (Giα). This then prevents Giα from inhibiting adenylate cyclase and leads to an increase in intracellular levels of [http://en.wikipedia.org/wiki/Cyclic_adenosine_monophosphate Cyclic adenosine monophosphate] (cAMP).  The increase in cAMP affects normal biological signaling and causes severe effects such as hypoglycemia.
 
The disease pertussis has two stages.  The first stage is colonization of the upper respiratory tract where ''B. pertussis'' adheres by using filamentous hemagglutinin (FHA) and cell bound pertussis toxin PTx.  This can be visualized in the following image of [http://www.proteopedia.org/wiki/images/3/3e/B.pertussis.jpeg the colonization of tracheal epithelial cells by ''Bordetella pertussis'' ].
<ref>Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html</ref>
 
The second stage is the toxemic stage which follows the colonization stage.  The PT B subunit oligomer uses S2 and S3 as adhesins, and they  bind the bacteria to host cell receptors. S2 and S3 utilize different receptors on host cells. S2 binds specifically to a glycolipid, which is found primarily on the ciliated epithelial cells. S3 binds to a glycoprotein found mainly on phagocytic cells.  After binding, the toxin is taken up by an endosome and transported from the plasma membrane via the Golgi apparatus to the endoplasmic reticulum (ER) where finally membrane translocation occurs.<ref name=Plaut>PMID: 18201245</ref> The destabilization of PT occurs in the ER prior to membrane translocation.  After binding of ATP, cleavage of the single disulphide bond by [http://en.wikipedia.org/wiki/Protein_disulfide_isomerase protein disulphide isomerase] (PDI) occurs in subunit S1 <scene name='Pertussis_Toxin-ATP_Complex/Disulphide_bonds_breaking/1'>(Cys 41-Cys 201)</scene> and is believed to trigger a conformational change necessary to expose the active site to its substrates.<ref name=Hazes>PMID: 8637000</ref> The reducation step takes place after interaction of PT with ATP.   
 
After destabilization, the S1 becomes active and catalyzes the [http://en.wikipedia.org/wiki/ADP_ribosylation ADP-ribosylation] of the alpa-subunit of regulatory trimeric [http://en.wikipedia.org/wiki/G_proteins G-proteins] (Giα) host protein.<ref name=Hazes>PMID: 8637000</ref><ref name=Kaslow>PMID: 1612292</ref> This then prevents Giα from inhibiting [http://en.wikipedia.org/wiki/Adenylate_cyclase adenylate cyclase] and leads to an increase in intracellular levels of [http://en.wikipedia.org/wiki/Cyclic_adenosine_monophosphate Cyclic adenosine monophosphate] (cAMP).  The conversion of [http://proteopedia.org/wiki/images/b/bb/500px-Adenylate_kinase.png ATP to cyclic AMP] cannot be stopped and intracellular levels of cAMP increase.<ref>Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html</ref>This has the effect to disrupt cellular function/signaling, and in the case of phagocytes, to decrease their phagocytic activities such as chemotaxis, engulfment, the oxidative burst, and bacteridcidal killing.<ref>Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html</ref>


==Treatment==
==Treatment==
Early treatment of pertussis is the only effective way to treat the bacterial infection.  If treatment for pertussis is started early in the course of illness during the 1 to 2 weeks before severe coughing occurs, the symptoms may be lessened. If the diagnosed to late, antibiotics will not alter the course of the illness since the bacteria is already producing the PT toxin. The preferred antibiotics are [http://en.wikipedia.org/wiki/Erythromycin Erythromycin], [http://en.wikipedia.org/wiki/Clarithromycin Clarithromycin], and [http://en.wikipedia.org/wiki/Azithromycin Azithromycin].
Early treatment of pertussis is the only effective way to treat the bacterial infection.  If treatment for pertussis is started early in the course of illness during the 1 to 2 weeks before severe coughing occurs, the symptoms may be lessened.<ref>Centers for Disease Control and Prevention. http://www.cdc.gov/pertussis/clinical/treatment.html</ref>The preferred antibiotics are that inhibit protein synthesis such as: [http://en.wikipedia.org/wiki/Erythromycin Erythromycin], [http://en.wikipedia.org/wiki/Clarithromycin Clarithromycin], and [http://en.wikipedia.org/wiki/Azithromycin Azithromycin].<ref name=Altunaiji>PMID: 17636756</ref> If the diagnosed to late, antibiotics will not alter the course of the illness since the bacteria is already producing the PT toxin.


The primary method of prevention for pertussis is [http://en.wikipedia.org/wiki/Vaccination vaccination].  The [http://en.wikipedia.org/wiki/DPT_vaccine DTaP vaccine] vaccine is used and this vaccine is composed of diphtheria, tetanus, and pertussis.  The pertussis component is acellular; this acellular component are selected antigens of pertussis that induces [http://en.wikipedia.org/wiki/Adaptive_immune_system adaptive immunity].
The primary method of prevention for pertussis is [http://en.wikipedia.org/wiki/Vaccination vaccination].  The [http://en.wikipedia.org/wiki/DPT_vaccine DTaP vaccine] is used and this vaccine is composed of diphtheria, tetanus, and pertussis.  The pertussis component is acellular; this acellular component are selected antigens (inactivated pertussis toxin (toxoid) and filamentous hemagglutinin) of pertussis that induces [http://en.wikipedia.org/wiki/Adaptive_immune_system adaptive immunity].<ref>Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html</ref>


==Conclusion==
==Conclusion==
This paper was significant since it gave a clear understanding of the PT activation as well as a better understanding to the pathogenesis of the toxin. The key features of this proposal is that ATP binding signals the arrival of the PT in the endoplasmic reticulum and at the same time triggers dissociation of the holotoxin prior to membrane translocation. Therefore, the dissociation is due to ATP binding destabilization and reduction by protein disulphide isomerase.
The findings of PT activation was significant since it illustrated a better understanding for the pathogenesis of the toxin. The key features of this proposal is that ATP binding signals the arrival of the PT in the endoplasmic reticulum by acting as a molecular sensor.<ref name=Hazes>PMID: 8637000</ref> This detection of the PT in the ER at the same time triggers dissociation of the holotoxin prior to membrane translocation.<ref name=Hazes>PMID: 8637000</ref> Therefore, the dissociation is due to ATP binding destabilization, reduction by protein disulphide isomerase, and proteolytic cleavage.<ref name=Hazes>PMID: 8637000</ref>


</StructureSection>


</StructureSection>
==3D structures of Pertussis toxin==
 
[[Pertussis toxin]]


==References==
==References==
<references/>
<references/>

Latest revision as of 15:05, 31 January 2012

A young boy coughing due to pertussis.

Introduction

Pertussis Toxins (PT) is a protein-based exotoxin and major virulence factor produced by the bacterium Bordetella pertussis.[1] PT causes pertussis, which is also known at whooping cough and is highly contagious bacterial disease. The disease is caused by the bacterium colonizing the respiratory tract where it then establishes an infection.[2] This disease had been characterized by severe coughing that can last up to six weeks and in some countries lasting nearly 100 days.[2]It has been documented in some cases that PT can cause subconjunctival hemorrhages, rib fractures, hernias, fainting and vertebral artery dissection.[3]

As of 2010, the worldwide incidence of whooping cough has been estimated to 48.5 million cases and nearly 295,000 deaths per year.[4] With that in mind, whooping cough can affect people of any age; however, before vaccines were available the disease was most common in infants and young children but now children are immunized and the high percentage of cases are seen among adolescents.

Structure

The pertussis toxin has been characterized as being an AB toxin meaning that there are 2 subunits: A subunit possesses the enzyme activity and the B subunit possesses the receptor binding portion. PT in particular is an AB5 toxin consisting of a six-component protein complex, and the multiple subunits of the complex are not identical in composition.[1] With that in mind, this protein is a hexamer containing a catalytic (S1) subunit that is tightly associated with the pentameric cell-binding component (B-oligomer).[1] The S1 component is a single subunit while the B-oligomer is a pentamer composed of four types of subunits: , , two copies of , and .[1] The overall structure of PT . These subunits are encoded by ptx genes, which are encoded on a large PT operon that includes additional genes as well such as Pti genes. Together the PT and Pti proteins form the PT secretion complex and toxin itself.[5]

Pertussis Toxin activation

Pertussis Toxin by itself is harmless unless activated. From multiple studies, it has became clear that there is a direct interaction between Adenosine triphosphate (ATP) and pertussis toxin which leads to activation.[1][6]The direct effect of ATP is to destabilize the interaction between the S1 subunit and the B-oligomer by binding to the B-oligomer.[1] This interaction relaxes the toxin by facilitating the subsequent reduction of a disulphide bond in the S1 subunit.

The main interaction that leads to the destabilization is the favorable hydrogen bonding and electrostatic interaction between the triphosphate moiety and five positively charged amino acids:. In contrast, the negatively charged carboxyl terminus of subunit S1 interacts unfavorably with the negative charges of the triphosphate moiety, causing a displacement of the C-terminal of therefore, the repulsion between the triphosphate moiety and the C terminus of subunit S1 forms the mechanism by which the interaction between S1 and the B-Oligomer is destabilized.[1]The details of the protein-ATP interactions can also be seen here.[1]

Mechanism of pathogenesis

The disease pertussis has two stages. The first stage is colonization of the upper respiratory tract where B. pertussis adheres by using filamentous hemagglutinin (FHA) and cell bound pertussis toxin PTx. This can be visualized in the following image of the colonization of tracheal epithelial cells by Bordetella pertussis .

[7]

The second stage is the toxemic stage which follows the colonization stage. The PT B subunit oligomer uses S2 and S3 as adhesins, and they bind the bacteria to host cell receptors. S2 and S3 utilize different receptors on host cells. S2 binds specifically to a glycolipid, which is found primarily on the ciliated epithelial cells. S3 binds to a glycoprotein found mainly on phagocytic cells. After binding, the toxin is taken up by an endosome and transported from the plasma membrane via the Golgi apparatus to the endoplasmic reticulum (ER) where finally membrane translocation occurs.[8] The destabilization of PT occurs in the ER prior to membrane translocation. After binding of ATP, cleavage of the single disulphide bond by protein disulphide isomerase (PDI) occurs in subunit S1 and is believed to trigger a conformational change necessary to expose the active site to its substrates.[1] The reducation step takes place after interaction of PT with ATP.

After destabilization, the S1 becomes active and catalyzes the ADP-ribosylation of the alpa-subunit of regulatory trimeric G-proteins (Giα) host protein.[1][6] This then prevents Giα from inhibiting adenylate cyclase and leads to an increase in intracellular levels of Cyclic adenosine monophosphate (cAMP). The conversion of ATP to cyclic AMP cannot be stopped and intracellular levels of cAMP increase.[9]This has the effect to disrupt cellular function/signaling, and in the case of phagocytes, to decrease their phagocytic activities such as chemotaxis, engulfment, the oxidative burst, and bacteridcidal killing.[10]

Treatment

Early treatment of pertussis is the only effective way to treat the bacterial infection. If treatment for pertussis is started early in the course of illness during the 1 to 2 weeks before severe coughing occurs, the symptoms may be lessened.[11]The preferred antibiotics are that inhibit protein synthesis such as: Erythromycin, Clarithromycin, and Azithromycin.[12] If the diagnosed to late, antibiotics will not alter the course of the illness since the bacteria is already producing the PT toxin.

The primary method of prevention for pertussis is vaccination. The DTaP vaccine is used and this vaccine is composed of diphtheria, tetanus, and pertussis. The pertussis component is acellular; this acellular component are selected antigens (inactivated pertussis toxin (toxoid) and filamentous hemagglutinin) of pertussis that induces adaptive immunity.[13]

Conclusion

The findings of PT activation was significant since it illustrated a better understanding for the pathogenesis of the toxin. The key features of this proposal is that ATP binding signals the arrival of the PT in the endoplasmic reticulum by acting as a molecular sensor.[1] This detection of the PT in the ER at the same time triggers dissociation of the holotoxin prior to membrane translocation.[1] Therefore, the dissociation is due to ATP binding destabilization, reduction by protein disulphide isomerase, and proteolytic cleavage.[1]


Pertussis Toxin-ATP complex (1bcp)

Drag the structure with the mouse to rotate

3D structures of Pertussis toxin3D structures of Pertussis toxin

Pertussis toxin

ReferencesReferences

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Hazes B, Boodhoo A, Cockle SA, Read RJ. Crystal structure of the pertussis toxin-ATP complex: a molecular sensor. J Mol Biol. 1996 May 17;258(4):661-71. PMID:8637000 doi:10.1006/jmbi.1996.0277
  2. 2.0 2.1 Carbonetti NH, Artamonova GV, Mays RM, Worthington ZE. Pertussis toxin plays an early role in respiratory tract colonization by Bordetella pertussis. Infect Immun. 2003 Nov;71(11):6358-66. PMID:14573656 Cite error: Invalid <ref> tag; name "Carbonetti" defined multiple times with different content
  3. Cornia PB, Hersh AL, Lipsky BA, Newman TB, Gonzales R. Does this coughing adolescent or adult patient have pertussis? JAMA. 2010 Aug 25;304(8):890-6. PMID:20736473 doi:10.1001/jama.2010.1181
  4. Bettiol S, Thompson MJ, Roberts NW, Perera R, Heneghan CJ, Harnden A. Symptomatic treatment of the cough in whooping cough. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD003257. PMID:20091541 doi:10.1002/14651858.CD003257.pub3
  5. Weiss AA, Johnson FD, Burns DL. Molecular characterization of an operon required for pertussis toxin secretion. Proc Natl Acad Sci U S A. 1993 Apr 1;90(7):2970-4. PMID:8464913
  6. 6.0 6.1 Kaslow HR, Burns DL. Pertussis toxin and target eukaryotic cells: binding, entry, and activation. FASEB J. 1992 Jun;6(9):2684-90. PMID:1612292
  7. Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html
  8. Plaut RD, Carbonetti NH. Retrograde transport of pertussis toxin in the mammalian cell. Cell Microbiol. 2008 May;10(5):1130-9. Epub 2007 Dec 31. PMID:18201245 doi:10.1111/j.1462-5822.2007.01115.x
  9. Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html
  10. Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html
  11. Centers for Disease Control and Prevention. http://www.cdc.gov/pertussis/clinical/treatment.html
  12. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004404. PMID:17636756 doi:10.1002/14651858.CD004404.pub3
  13. Kenneth Todar, PhD. (2008). http://www.textbookofbacteriology.net/pertussis.html

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