Extracellular bacteria are capable of replicating outside host cells, for example, in the blood, in connective tissues, and in tissue spaces such as the lumens of the airways and gastrointestinal tract. Many different species of extracellular bacteria are pathogenic, and disease is caused by two principal mechanisms. First, these bacteria induce inflammation, which results in tissue destruction at the site of infection. Second, many of these bacteria produce toxins, which have diverse pathologic effects. The toxins may be endotoxins, which are components of bacterial cell walls, or exotoxins, which are actively secreted by the bacteria. The endotoxin of gram-negative bacteria, also called lipopolysaccharide (LPS), has been mentioned in earlier chapters as a potent activator of macrophages and dendritic cells. Many exotoxins are cytotoxic, and they kill cells by various biochemical mechanisms. Other exotoxins interfere with normal cellular functions without killing cells, and yet other exotoxins stimulate the production of cytokines that cause disease.
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