Elucidating the Staphylococcus aureus TSST-1 Regulatory Network as a Response to Vaginal pH

Menstrual toxic shock syndrome (mTSS) is a life-threatening disease caused by the Staphylococcus aureus superantigen TSST-1. At menstruation, the typical acidic vaginal environment rises to near neutral pH, which allows for enhanced TSST-1 production. However, the regulatory network which alters toxin production in response to pH is unknown, despite the importance of this cue in the vaginal environment. To mimic the vaginal environment, we used Vaginally Defined Medium to assess TSST-1 promoter activity in the mTSS strain S. aureus MN8 and discovered a significant upregulation of tst expression occurring at pH 4.5 in a low glucose environment, referred to here as the acidic virulence surge. This increased expression was observed in several regulatory mutant backgrounds tested, including in the absence of SaeS, which has previously been thought to be required for TSST-1 production. Recent studies in non-mTSS S. aureus strains have identified GraXRS as a pH sensor, in addition to its function in cationic antimicrobial peptide sensing. We therefore hypothesized that GraXRS alters TSST-1 expression at low pH. Deletion of the sensor-kinase graS gene resulted in the loss of TSST-1 surge at pH 4.5, indicating that GraXRS is required for the acidic virulence surge. We also found expression from the SaeRS P1 and SarA promoters to be significantly attenuated in the ∆graS background. At low pH, the absence of GraS resulted in reduced T cell activation from S. aureus supernatants when compared to other regulatory mutants, suggesting that GraXRS is the dominant activator at pH 4.5. Finally, we developed an in vivo murine model to measure tst expression using luciferase expression. Our results demonstrate a complex sequence of events that occur in response to changes in pH and further suggests that GraXRS is the main activator of TSST-1 expression at low pH.