microorganisms

Communication
The Microbiota–Gut–Brain Axis–Heart Shunt Part II:
Prosaic Foods and the Brain–Heart Connection in
Alzheimer Disease
Mark Obrenovich 1,2,3,4,5, *, Shams Tabrez 6,7 , Bushra Siddiqui 8 , Benjamin McCloskey 3 and
George Perry 9
1 Research Service, Louis Stokes Cleveland, Department of Veteran’s Affairs Medical Center, Cleveland,
OH 44106, USA
2 Department of Chemistry, Case Western Reserve University, Cleveland, OH 44106, USA
3 The Gilgamesh Foundation for Medical Science and Research, Cleveland, OH 44116, USA;
[email protected]
4 Department of Medicinal and Biological Chemistry, College of Pharmacy and Pharmaceutical Sciences,
University of Toledo, Toledo, OH 43606, USA
5 Departments of Chemistry and Biological and Environmental Sciences, Cleveland State University,
Cleveland, OH 44115, USA
6 King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
[email protected]
7 Department of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz
University, Jeddah 21589, Saudi Arabia
8 North East Ohio College of Medicine, Rootstown, OH 44272, USA; [email protected]
9 Department of Biology, University of Texas at San Antonio, San Antonio, TX 78249, USA;
[email protected]
* Correspondence: [email protected]




Received: 31 December 2019; Accepted: 26 March 2020; Published: 31 March 2020


Abstract: There is a strong cerebrovascular component to brain aging, Alzheimer disease, and vascular
dementia. Foods, common drugs, and the polyphenolic compounds contained in wine modulate
health both directly and through the gut microbiota. This observation and novel findings centered
on nutrition, biochemistry, and metabolism, as well as the newer insights we gain into the
microbiota-gut-brain axis, now lead us to propose a shunt to this classic triad, which involves
the heart and cerebrovascular systems. The French paradox and prosaic foods, as they relate to the
microbiota-gut-brain axis and neurodegenerative diseases, are discussed in this manuscript, which is
the second part of a two-part series of concept papers addressing the notion that the microbiota and
host liver metabolism all play roles in brain and heart health.

Keywords: French paradox; polyphenol; cerebrovascular; heart; brain; microbiota-gut-brain axis;

trimethylamine-N-oxide (TMANO/TMAO); co-metabolism; Alzheimer disease; Parkinson’s disease;
prosaic foods; red wine

1. Introduction
We know that what is good for the heart is also good for the brain, most likely involving the shared
cerebrovascular system. It is well established that a vegetarian and polyphenol-rich diet, including
fruits, vegetables, teas, juices, wine, indigestible fiber, and whole grains, provides health-promoting
phytochemicals and phytonutrients that are beneficial for the heart and brain. What is not well
characterized is the effect these foods have when co-metabolized within our dynamic gut and its
colonizing flora. The concept of a heart shunt within the microbiota-gut-brain axis underscores the

Microorganisms 2020, 8, 493; doi:10.3390/microorganisms8040493 www.mdpi.com/journal/microorganisms

Microorganisms 2020, 8, 493 2 of 18

close association between brain and heart health, and the so-called “French paradox” offers clues
for understanding neurodegenerative and cerebrovascular diseases. Moreover, oxidation–reduction
reactions and redox properties of so-called brain- and heart-protective foods are underappreciated
with respect to their enhanced or deleterious mechanisms of action. Focusing on prodromal stages,
and the common mechanisms underlying heart, cerebrovascular, and neurodegenerative diseases,
we may unmask an understanding of the means to better treat these related diseases. Part I, in a
two-part series of concept papers, focuses on novel findings involving nutrition, biochemistry,
microbiology, and metabolism to suggest a heart shunt within the microbiota-gut-brain axis. Here,
we explore the bacterial species that contribute to disease and health; we suggest that oxidative and
inflammatory mechanisms drive heart and brain disease, and that wine polyphenols help protect
us from bacterial-derived deleterious metabolites. Exploring aspects of co-metabolism within the
microbiota-gut-brain axis and metabolites from prosaic foods could lead to a unifying hypothesis
for age-related diseases and advance our understanding of vascular dementia, neurodegeneration,
and heart disease. To simplify our understanding of the two most common and extremely complex
diseases in the world today, namely, coronary heart disease (CHD) and Alzheimer disease (AD),
we describe a shunt between the heart and the brain, where commensal microorganisms though the
microbiota-gut-brain (MGB) axis do affect both the heart and the brain, which are coupled through the
vasculature, and oxidative and inflammatory stressors are key propagators of disease pathogenesis for
the brain and the heart.
There are many competing theories surrounding the pathogenesis of Alzheimer disease and
other neurologic degenerative states. Unfortunately, little is accomplished in regard to curbing
age-related diseases and neuronal degeneration. Several alternative hypotheses that do not support
or refute current dogma are not mutually exclusive either. Alois Alzheimer described neuronal
changes in a multifactorial, memory-robbing, and complex disease, which we call Alzheimer disease.
However, he did not suffer from the illness and this is why it is not apostrophized in the medical
nomenclature system. The disease itself has early manifestations and later ones as well, depending on
the particular protein involved or the underlying genetic constitution of affected individuals. AD is
characterized by hallmark lesions, namely, extracellular amyloid deposits or plaques and intracellular
microtubule-associated proteins called tau within neurofibrillary inclusions or tangles. When we say
that amyloid plaques and neurofibrillary tangles cause the disease, we look at end-stage lesions to make
that statement. While correlation does not imply causation, it does offer clues into the pathogenesis
of the disease. Answers to the pathogenesis of AD and many neurodegenerative diseases lie in
understanding that they are largely a result of a protracted process, which many believe begins decades
before any prodromal stages or pathology become evident. Our efforts to directly target extracellular
amyloid deposits or the intracellular neurofibrillary tangles does not cure the disease nor does it give
effective treatments or patient and care-giver relief. While plaques and inclusions are not benign,
they are hallmark end-stage lesions, and we must search ahead of prodromal changes if we expect to
develop a cure. The Alzheimer Association estimates that five million Americans live with AD in all
its forms and, in the United States, every 66 s, a new case develops on their website. This number is
expected to rise to as high as 16 million by 2050, since AD is an age-related disease.
Because the current hypotheses do not address the full scope of the disease, and due to lower
funding levels, particular for young investigators, we made little progress in efforts to cure or halt the
disease through drugs and treatments. Scientists work diligently to find means to not only treat AD but
prevent it from developing in the first place. Unfortunately, there is little success in the approaches that
modern science undertakes. Over the last four decades, we explored the lesions involved but did not
fully address the underpinnings or precipitating events and mechanisms. New and growing evidence
links the trillions of microbes that inhabit the human gastrointestinal tract to neurological conditions
and diseases. What is good for the heart is good for the brain, and the concept of a heart shunt
within the microbiota-gut-brain axis underscores the close association between brain and heart health.
Moreover, oxidation–reduction reactions and redox properties of so-called brain and heart-protective
Microorganisms 2020, 8, 493 3 of 18

foods are underappreciated, as are any enhanced or deleterious mechanisms of action involving such
small molecular compounds.
Previously, we reported a commensal co-metabolic relationship between the microbiota and the
host [1–3]. Some consider only symbionts to be the holobiome; however, when we discuss the microbiota,
we consider all microorganisms as a microbiome and include all bionts within a host. This relationship
goes well beyond simple nutrition and metabolism and includes the prospect for bugs as drugs, as we
call them. Furthermore, in the case of mental and brain disease, we include all microorganismal bionts,
which engage as generators of beneficial co-metabolism, to be psychosymbiotics. This powerful concept
will one day change our interpretation of lab results, patient histories, and genomic testing, and it will
become a key component of what will be truly known as personalized medicine. We propose that this
novel concept will lead to better treatment, diagnostic, and management approaches, which could one
day prevent disease or, conversely, contribute to research and understanding of disease pathobiology [1].
Our microbiome affects the microbiota-gut-brain axis both directly and indirectly. Multiple routes
of gut–brain communication are established. One pathway is through neural networks that
control the enteric nervous system independently or through the central nervous system (CNS)
via sympathetic efferent prevertebral ganglia. Others include parasympathetic efferent nerve signaling
through the vagus nerve [2]. It is at these nodes where the microbiota has indirect action on
the hypothalamic–pituitary–adrenal (HPA) axis and brain through chemical messengers acting as
neurotransmitters and secondary messengers [3] (see Figure 1). We are currently classifying small
molecules from the microbiota, which originate distal to the brain and yet reach brain compartments.
This happens via diverse indirect routes like the vagus nerve, as well as directly and systemically
when the gut-derived or liver-modified compounds cross immune barriers to enter the brain and other
immune-privileged compartments [4]. Whether these compounds are beneficial or deleterious,
they need to reach a level that possibly can affect the brain to result in physiologic changes.
We now suggest a new pathway for the MGB axis, which we now consider to be coupled, namely,
the microbiota-gut-brain–heart shunt. In simplest terms, the shunt is any connection or opening
or coupling of systems and organs that allows for movement within or from one part of the body
to another. Shunting, in biochemical terms, is usually bidirectional and reversible. For example,
enzymatic processes and enzymes, like transketolase, which drives the hexose monophosphate shunt,
are analogous to the MGB axis, and flux depends on precursor levels or mass action. When shunts act
similarly to anatomic shunting, such as congenital heart defects or when used to bypass organs or other
systems, shunting is usually directional. Nevertheless, we describe a shunt that affects metabolite flux,
which is easily shared between the coupled systems and has similar effects on both conjoined organs.
In describing the tight coupling between the heart and the brain, Obrenovich and colleagues
found common AD and heart protein expression that led to the development of a unifying theory
for AD, which helped explain cerebrovascular aspects of the most common neurodegenerative
disease. AD has components of dementia, as well as cognitive and neuropsychiatric manifestations.
Neural communication pathways within the enteric nervous system, a main division of the autonomic
nervous system, affect gastrointestinal function and are coupled with the vagal afferent nerves
that transmit sensory information from the visceral organs to the CNS. Thus, the gut is a major
communication route to the brainstem and CNS, and the vast majority of vagal nerve fibers are
afferent [5], which sense regulatory gut signals and peptides, such as leptin, ghrelin, and others [3].
Nevertheless, we know that what is good for the heart is also good for the brain, most likely
involving the shared cerebrovascular system, as in a shunt. It is well established that a vegetarian
and polyphenol-rich diet, including fruits, vegetables, teas, juices, wine, indigestible fiber, and whole
grains, provides health-promoting phytochemicals and phytonutrients that are beneficial for the heart
and brain. What is not well characterized is the effect these foods have when co-metabolized within
our dynamic gut and its colonizing flora.
Microorganisms 2020, 8, 493 4 of 18
Microorganisms 2020, 8, x FOR PEER REVIEW 4 of 17

Figure
Figure 1. 1.Action
Actionofofmicrobiota
microbiota through
through hypothalamic–pituitary–adrenal
hypothalamic–pituitary–adrenal (HPA) axis
(HPA) and
axis brain
and brainviavia
chemical messengers. Depicted here is the microbiota-gut-brain axis–heart shunt and the intersection
chemical messengers. Depicted here is the microbiota-gut-brain axis–heart shunt and the intersection
between the gut-derived messengers vs. liver and bacterial toxins or metabolites and the effect that
between the gut-derived messengers vs. liver and bacterial toxins or metabolites and the effect that
stress and short-chain fatty acids (SCFAs) have on the system. This can arise form prosaic foods, drug
stress and short-chain fatty acids (SCFAs) have on the system. This can arise form prosaic foods, drug
action, or co-metabolism between the microbiota and the host.
action, or co-metabolism between the microbiota and the host.

2. 2. ModulatingAD
Modulating ADthrough
throughProsaic
Prosaic Foods
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and Drugs
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When
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one considerswayswaysto toaffect
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and modulate
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one’sownownhealth,
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onemust
muststart
startwith diet
with and
diet and
lifestyle. Beyond our immediate dietary choices and variable consortium of gut
lifestyle. Beyond our immediate dietary choices and variable consortium of gut bacteria with which we bacteria with which
we are colonized, higher education and exercise positively affect and modulate the risk and
are colonized, higher education and exercise positively affect and modulate the risk and progression
progression of AD. Furthermore, oxidative and inflammatory stressors also modulate AD and many
of AD. Furthermore, oxidative and inflammatory stressors also modulate AD and many age-related
age-related disease risks. Thus, antioxidant foods and anti-inflammatory agents are expected to
disease risks. Thus, antioxidant foods and anti-inflammatory agents are expected to provide the most
provide the most impact. As it turns out, other common things also do this, including prosaic items
impact. As it turns out, other common things also do this, including prosaic items such as wine, tea
such as wine, tea (phenolic acids), some spices, select nonsteroidal anti-inflammatory drugs
(phenolic acids), some spices, select nonsteroidal anti-inflammatory drugs (NSAIDS), statins, some
(NSAIDS), statins, some antidepressants, nootropics [6], and euglycemic medications or insulin
antidepressants,
sensitizers [7] tonootropics
name a few. [6],Other
and euglycemic medications
attempts to improve or insulin
function targetedsensitizers [7] to nameand
cellular mechanisms a few.
Other attempts to improve function targeted cellular mechanisms and neuronal stimulation
neuronal stimulation to treat or delay AD. These include things such as caffeine, nicotine, nootropics, to treat
or other
delaypsychostimulants,
AD. These include things such as caffeine, nicotine, nootropics, other psychostimulants,
vasodilators, and opiate antagonists [8]. Nootropics, so-called smart drugs,
vasodilators, and opiate
display anti-hypoxic andantagonists
anti-amnestic[8]. effects,
Nootropics,
prevent so-called
memorysmart drugs, display
impairment, anti-hypoxic
and facilitate cognitiveand
anti-amnestic effects, prevent memory impairment, and facilitate cognitive
function, which we know occurs with brain aging, insult, trauma, and in various diseases. This function, which we know
occurs within
happens, brain
part,aging,
throughinsult,
both trauma,
stimulatoryandand
in various diseases.
cholinergic This happens, in part, through both
mechanisms.
stimulatory and cholinergic
For Alzheimer research,mechanisms.
the French paradox is an interesting consideration. There is not yet a
clear
Formechanism
Alzheimerfor how thethe
research, French
French enjoy high-fat
paradox foods
is an with heart
interesting disease-sparing
consideration. Theremechanism,
is not yet and
a clear
more work is necessary to address these aspects. Taken together, we argue
mechanism for how the French enjoy high-fat foods with heart disease-sparing mechanism, and more that oxidative stress
through
work microbial
is necessary action these
to address and aspects.
metabolism
Takencouldtogether,contribute
we argueto thattrimethylamine-N-oxide
oxidative stress through
(TMANO/TMAO)
microbial action andformation,
metabolism but could
other factors may to
contribute be trimethylamine-N-oxide
more important in modulating heart and
(TMANO/TMAO)
cerebrovascular disease forms of AD or vascular dementia (VaD) (see
formation, but other factors may be more important in modulating heart and cerebrovascular Figure 1 for an overview).
Microorganisms 2020, 8, 493 5 of 18

disease forms of AD or vascular dementia (VaD) (see Figure 1 for an overview). Prosaic foods,
such as red wine, its constituents, or its co-metabolized chemicals, have intriguing properties
that include acting on endothelial cells and the cerebrovascular system [9]. Endothelin-1 (ET-1)
is important in AD, since it is a highly potent peptide and vasoconstrictor [10]. It is associated
with atherosclerosis, and we showed that ET-1 has a strong relationship with AD pathogenesis and
cytokine stress [11], while high expression of ET-1 is known to contribute to the development of
cerebrovascular disease, AD, and cancer. Prosaic foods, including red wine, were shown to inhibit
ET-1 synthesis. Conversely, prosaic foods, such as eggs and those containing phosphatidylcholine
(PC), are associated with CHD but this does not involve the cholesterol theory. Rather, it involves
absorption, where host enzymes convert trimethylamine (TMA) to trimethylamine-N-oxide [12].
TMANO formation in humans is poorly understood but may contribute to bacterial pathobiology of
clot formation. This illustrates a well-supported notion of a heart–brain shunt, and it allows exploring
the microbiota-gut-brain axis–heart shunt, whereby microbe-derived metabolites not only reach the
brain and brain compartments but also have an effect on the heart. Incredibly powerful, this supports
our premise and demands a call for greater funding levels if more progress is expected to happen with
AD research.
All of the aforementioned prosaic drugs and foods show efficacy in both treating and delaying AD
or they helped to elucidate its pathogenesis. For instance, diabetes has an incredibly adverse effect on
the heart and brain. Recently, a newer form of AD, called type 3 diabetes, was described. Using diabetes
drugs, such as the insulin sensitizer metformin, which is suggested to have anti-aging and many
other positive health effects, could modulate AD and CHD risk. In diabetic mice, metformin corrected
memory impairment and abnormal transport of amyloid beta (Aβ) across the blood–brain barrier
(BBB) [13]. One human study, exploring the microbiota and metformin, compared administration in
both diabetic and non-diabetic individuals. The diabetics were found to have higher abundance of a
mucin-degrading microbe Akkermansia species. When the researchers pooled short-chain fatty acid
(SCFA)-producing and mucin-degrading microbes, they found that A. muciniphila and A. butyrivibrio
were more abundant in the gut of type 2 diabetics on metformin than in those diabetic cohorts not on
metformin. The presence of a higher number of colony-forming units of both types of bacteria suggests
that metformin seems to improve the integrity of the intestinal mucosal barrier, favoring colonization
of these species, and it explains the improved mucin layer maintenance and lower inflammation by
reducing any translocation of proinflammatory lipopolysaccharide (LPS). This could aid in controlling
adipose tissue metabolism and fat storage, as well as help improve glucose homeostasis, but perhaps
only in diabetics [14]. This group recapitulated findings with aging and antibiotic use, which offers
an explanation for reduced alpha diversity and the growth of opportunistic pathogens, such as
species of Escherichia and Shigella. Nevertheless, metformin is the most commonly prescribed drug
for type 2 diabetes and is considered quite safe when administered to healthy adults. Its putative
neuroprotective properties, when taken with meals, could reduce hyperinsulinemia by downregulating
insulin-like growth factor-binding protein and increasing free insulin-like growth factor-1 (IGF-1) [15].
AD has both an oxidative stress component and a neuro-inflammatory component to its
pathogenesis. Amyloid beta (Aβ) fragments like Aβ 1–42 form insoluble aggregates that are toxic,
whereas others are relatively harmless. When it comes to AD, anti-inflammatories like ibuprofen,
aspirin, and naproxen sodium, which lower inflammation, should reduce the risk of developing AD
through the inflammasome mechanism. However, with NSAID studies, it was found that they affect
the production of Aβ through changing the cleavage site for amyloid precursor protein (APP) in nerve
cells. Alpha, beta, and gamma secretases are the enzymes responsible for the differential production
of amyloid fibrils of various lengths through this cleavage mechanism. However, it was shown that
amyloid causes the microglia to release pro-inflammatory cytokines like interleukin (IL) 1β and tumor
necrosis factor (TNF) alpha, among others [16]. NSAIDs are believed to increase the favorable cleavage
of APP by directing APP–gamma secretase, an enzyme complex with presenillin1 (PS1), and reshaping
the protein cleavage site, thereby reducing Aβ 1–42. NSAIDs do not reduce the overall quantity
Microorganisms 2020, 8, 493 6 of 18

of Aβ molecules but change the PS1 confirmation, shifting APP toward shorter fragments like Aβ
1–38 [17]. Unfortunately, trials were halted due to cardiovascular problems observed with frequent
use of many NSAIDS [17]. It is possible that NSAIDs, many of which contain one or more benzene
rings and food-derived phenols, when processed or co-metabolized with gut bacteria, could also affect
APP cleavage.
Importantly, amyloid in all of its forms has an unknown function, but it is known to bind toxins,
metals, and compounds through a bioflocculant or precipitation mechanism, resulting in phagocytic
presentation to microglia for clearance [18]. This mechanism is similar to salivary proline-rich proteins,
particularly the basic ones, which form insoluble complexes with compounds like condensed tannins
and lignans, thereby also acting effectively as a type of bioflocculant. Moreover, in AD, iron and
copper distribution is altered [19], and amyloid binds these divalent cations directly and, depending
on the metal species bound, either propagates or dismutate oxidative stress by quenching hydroxyl
free radical activity [18]. Metal-catalyzed oxidation is involved in aging, in age-related diseases,
in aerobic metabolism, and in diabetic complications. These include glyocoxidative stress (oxidative
stress coupled with glycation), one of the many redox-active mechanisms that propagate protein, lipid,
and nucleic acid damage [20–22]. Furthermore, Aβ was recently recognized as part of the innate
immune system as an antimicrobial peptide [23,24]. This finding both supports the bioflocculant
concept and hypothesis for Aβ protection and illustrates that microbes and viruses could be responsible
for initiating AD pathogenesis long after the initial infection or occurrence and after precipitating
events resolve. It is important to note that not all bacteria are harmful. Intrinsically, empirically, and by
definition, commensal and pathogenic bacteria have very clear differences, and an important difference
is their localization when breaching barriers or breaching host defenses [25].
This brings us to the point of a leaky gut, celiac disease (CD), and the possible downstream
consequence of a leaky gut begetting a leaky brain [25]. Growing attention is focused on the involvement
of the gut–brain axis and microbiota dysbiosis in CD, which is commonly known as a systemic disorder
with multifactorial pathogenesis and multifaceted symptomatology. CD, so-called “celiac brain”,
is now shedding light onto the fast-growing importance of microbiota dysbiosis and its involvement
in brain function. In an attempt to assess neurological changes such as so-called “brain fog” and
dementia, which are known to occur in adult celiac patients, transcranial magnetic stimulation (TMS),
a non-invasive neurophysiological technique, is now being used to assess and monitor such neurological
changes [26].
In this framework, TMS studies carried out so far in CD patients seem to converge on an impaired
central motor conductivity and a hyperexcitable celiac brain to TMS, which partially reverts after a
long-term gluten restriction [27]. Notably, a clear hyperexcitability is a stably reported feature of both
degenerative and vascular dementia, which also partially share an impairment of the central cholinergic
pathways, now found to be more evident in AD and mildly cognitively impaired patients compared to
those with vascular cognitive impairment [28]. Therefore, given its potential neuroprotective effect,
assessment for gluten sensitivity or a gluten-free diet could be introduced in patients with celiac disease
or sensitivities, although the overall response in neurological symptoms (and cognition in particular) is
still controversial [26]. Nevertheless, identifying new and possibly modifiable risk factors, like gluten
intolerance or gut sensitivity, may especially be of crucial importance to those patients with CD.
Gut dysbiosis seems to play a crucial role in depression and some mental disorders. Along with
possible implications for the antimicrobial effects of antidepressant drugs, antidepressant effectiveness
may be modulated by the microbiota [29]. An altered microbiota is linked to neuropsychological
disorders, such as depression and autistic spectrum disorder (ASD). Gastrointestinal disorders like
inflammatory bowel disease and irritable bowel syndrome are associated with mental disorders [30].
In combination with a leaky gut, a leaky brain could lead to potential negative neurological consequences,
such as increased severity of depression, anxiety, or a host of other neurological diseases [25].
Antibiotic interventions are very disruptive for the gut flora and often lead to dysbiosis, which can
impact the metabolites produced by the gut microbiota [31,32]. This could ultimately have negative
Microorganisms 2020, 8, 493 7 of 18

consequences for patients with an infection and also for those who have depression or anxiety due to
alterations in gut-produced metabolites or hormones [33]. Therefore, new methods are needed for
treating patients, while protecting their microbiota, if antibiotics are to be used.

3. Oxidation–Reduction Reactions Involving the Brain and Mammalian Gut

Reactive oxygen (ROS) or nitrogen species (RNS) are implicated in oxidative stress and
damage, which is a paradoxical component of aerobic metabolism [34]. Since we cannot escape
oxidative metabolism, and oxidation is a very common enzymatic mechanism, one must consider
oxidation–reduction pairs in every system explored. Oxidation–reduction or redox potential (Eh) is
measured in millivolts and represents the affinity of electron transfer to or from a chemical species in
solution. The ability to either gain or lose electrons in that particular environment is concentration-
and temperature-dependent. Chemical species with higher, i.e., more positive, reduction potentials
than a particular species introduced into the system tend to gain electrons from the new species and
become themselves reduced by the oxidizing species, whereas solutions with lower, i.e., more negative,
reduction potential tend to lose electrons to the new species and become themselves oxidized by
reducing the new species [35].
The brain responds to distressful physiological stimuli like oxidative stress, infection, neuronal
injury, or trauma through astrocyte and microglia activation, which then secrete a host of inflammatory
mediators and cytokines. The author elucidated a downstream consequence in AD, whereby massive
nitric oxide (NO) production, largely from expression of the inducible form of nitric oxide synthase
(iNOS), contributes to pathogenesis in AD. NO is an important vasodilator but reacts rapidly with
the superoxide anion to form the RNS peroxynitrite anion. Nitric oxide-dependent oxidative stress
results in ultrastructural cellular alterations and damage to mitochondrial DNA in AD cases [11].
With a greater focus on oxidative stress, rather than on cholesterol alone, as the French paradox
would suggest, colleagues at Case Western Reserve University USA elucidated how NO, which is
secreted by gut bacteria, was able completely change nematodes’ ability to regulate their own
gene expression. This study was the first to demonstrate how gut bacteria could affect ubiquitous
mammalian NO networks and offer a possible mechanism in mammals, including humans [36].
Of course, the researchers did force the microbial mechanism by feeding NO-producing bacteria to the
worms and, via mass action, they were able to affect DNA-silencing proteins and impair healthy worm
development. We could extrapolate this to any fetus overexposed in utero to excess NO, or we could
consider NO and reactive nitrogen free radicals as possibly being gut-derived, contributing to the RNS
aspect of the disease. However, we must not ignore the many beneficial aspects of NO as a signaling
molecule, when targeting this process.
Further support for an antioxidant hypothesis and mechanism for inhibiting bacterial-derived
oxidation products comes from previous studies using selective mitochondrial antioxidants. To explore
mechanisms for age-dependent protection on cerebral blood flow in apolipoprotein E (ApoE4)
transgenic mice and in rats, administration of acetyl-l-Carnitine (ALCAR) and R-alpha-lipoic acid (LA)
was performed [25]. Comparing ApoE4 mice vs. age-matched wild-type controls, 14 C and iodinated
anti-pyrene autoradiography demonstrated gradual brain hypoperfusion. Treatment with ALCAR plus
LA was reported to prevent ischemic damage in rats and ApoE4 mice. Transmission electron microscopy
showed ultrastructural damage in young and aged microvessel endothelia, perivascular cells,
perivascular nerve terminals, hippocampal neurons, and glial cells, which coexist with mitochondrial
structural alteration and mitochondrial DNA overproliferation and deletion in all brain cellular
compartments. Temporal and spatial memory tests showed a trend in improving cognitive function
when ALCAR antioxidant was used in combination. This suggests that a mitochondrial redox potential
shift is important in brain protection with these compounds. Previous studies reported the abolishment
of oxidative stress-induced structural changes in brain parenchymal cells (neurons, vascular wall cells,
and glia) and restored cognitive performance by the same mitochondrial antioxidants, i.e., ALCAR +
LA, in a two-vessel occlusion model of vascular dementia (VaD) aged rats [37,38].
Microorganisms 2020, 8, 493 8 of 18

More support for a bacterial role in redox mechanisms and diseases, possibly including ulcerative
colitis, comes from the formation of hydrogen sulfide gas (H2 S), which at neutral pH is ionized to sulfide
anion [39]. High concentrations of H2 S are correlated with sulfate-reducing bacteria, meat-rich diets,
or the high fecal sulfide concentration derived from the bacterial degradation of cysteine, methionine,
and sulfated gut-proteins [39]. H2 S comes from oxidized sulfur-containing foods (meat or wine)
and food additives, such as sulfite, sulfate, and sulfur dioxide, which was shown to inhibit butyrate
oxidation in colonocytes [39]. The toxicity or protective aspect of hydrogen gas or H2 S is not well
understood, but the chemoprotective aspect of butyrate in the gut is well known. So is the danger and
toxicity from heavy metals, such as mercury, lead, and arsenic, which are among the top 10 United
States Department of Agriculture poisons and toxins due to frequent human exposure and the disease
burden following acute and chronic exposure [13]. Among their common characteristics is the chemical
affinity to proteins and non-protein thiols. Moreover, amines and intestinal bacteria are expected to
react with nitrite to form nitrosamines and other nitrogen-containing toxic compounds, which are
implicated in AD [25].

4. Statins, Other Natural Statin-Like Compounds, Small G-Proteins, and G-Protein Coupled
Receptor and Cognate Kinase 2 (GRK2) in AD
Some statins, which are cholesterol-lowering drugs also show efficacy against AD, but by diverse
means. In that regard, late-onset AD is associated with the ApoE gene involved in cholesterol and
triglyceride transport and metabolism. Patients with one or more copies of the ApoE 4 allele are
more likely to have Aβ aggregation and deposition and are more likely to get AD. Statins, like Lipitor
(atorvastatin) and Zocor (simvastatin), also affect APP cleavage in ways similar to NSAIDs. This occurs
through the Rho small guanosine triphosphate (GTP)-binding protein pathway and the activation
of Rho-associated kinases (ROCK) 1, which promote the aberrant cleavage of APP and increase the
production of Aβ 1–42 [40].
G-proteins in AD involve G-protein coupled receptor (GPCR) and cognate kinase (GRK)
2 activation, which Obrenovich and coworkers first identified in AD brains, observing its role
in early AD pathobiology and before any prodromal stages. At that time, Obrenovich and colleagues
postulated a brain–heart connection for AD pathogenesis as this kinase bridged our understanding of
disease in both organs [41]. Others went on to include GRK5 in this process [42]. It is the overexpression
of GRK2, and to a lesser extent GRK5, which the author, and others, found in the cytosolic fractions of
hippocampal and cortical brain homogenates. This overexpression increased with age and with amyloid
plaque deposition and began before any prodromal stages of AD were evident. This observation
was also expected to occur in within microglia. We described the subcellular localization of GRK2 in
neurons and the earlier involvement of vascular lesions in vivo as a key event in the neuropathogenesis
and early development of human AD and AD-like pathology. Furthermore, we described the ectopic
localization and expression of cell-cycle markers in AD [43], and we showed that GRK2 modulates
cell-cycle progression [44].
Our understanding of the early activation of GPCRs, with their cognate kinases, is that they control
many cellular functions, including cytoskeletal organization and post-translational modifications
such as phosphorylation and gene expression, among others. Moreover, multiple drugs target
GPCRs and some are likely neuroprotective. When researchers examined Rho, a small GTP-binding
protein, and its pathway and activation in AD and APP cleavage in culture, they found that Rho
activated ROCK1 [40] and perhaps ROCK2. Importantly, statins like Lipitor and Zocor can inhibit
ROCK1 activity and favor good APP cleavage. This finding does not preclude an indirect mechanism,
whereby ROCK1 phosphorylates an accessory molecule, which then interacts with alpha secretase.
Our colleagues, when at Case Western Reserve University USA, noted that amyloid deposits activated
pro-inflammatory cytokines and that statins inhibited amyloid-stimulated monocyte and microglial
activation, as well as the subsequent release of pro-inflammatory cytokines like TNF-alpha and IL1-β,
and they demonstrated a new function for statins other than or independent of their anti-inflammatory
Microorganisms 2020, 8, 493 9 of 18

properties [45]. Since cholesterol could not reverse the suppression, it was concluded that the action
was also independent of any cholesterol-lowering properties. Moreover, in rodent models, bacteria
through the MGB do control neuroinflammation [46], and other aspects of brain inflammation in terms
of motor deficits are being elucidated.
There is no question that cholesterol in the neuronal cell membrane influences the activity of
secretases. Candidate AD drugs are also a cardiovascular disease drug targets, such as inhibitors of
acyl-coenzyme A, cholesterol acyltransferase (ACAT), like Avasimibe, which regulates cholesterol
distribution. Inhibiting ACAT lowers the production of Aβ. Kovacs and colleagues found that
lowering cholesterol with ACAT inhibitors also improved learning in mice independent of cholesterol
distribution [47]. Thus, it appears that what is good for the heart is also directly good for the brain,
and the author maintained this for decades arguing for a strong cerebrovascular component to AD.
Cholesterol fits into the French paradox story at several nodes, but microglia are central in this
discussion, as NSAIDs and statins both share the APP cleavage mechanism, and aberrant cleavage is
decreased when inflammation is suppressed in microglia.

5. Oligomers, Aβ-Derived Diffusible Ligands (ADDLS), Amyloid Fibrils, and Conformational

Protein Changes
Amyloid beta plaque deposition does not correlate well with the severity of AD symptoms.
Obrenovich, Perry, and coworkers speculated that Aβ is not in fact entirely toxic and has useful
function, some even protective, and they argued that the protracted course of the disease has in fact an
earlier mechanism of pathogenesis. Therefore, amyloid theorists began to further split the questionably
toxic species Aβ into smaller species called Aβ-derived diffusible ligands (ADDLS) and amyloid
oligomers [48]. The convention here is that not all fibrils are created equally, and different forms are
differentially dangerous, such as proto-filaments of Aβ that have two isoforms, one toxic the other not.
The resulting oligomers of the proto-filaments are suspected of being neurotoxic by configuration and
conformational mechanisms, similar to prion disease pathogenesis in structure [49]. In that regard,
Obrenovich and coworkers and others studied polyphenolic antioxidants and glycation mechanisms
in diabetes and AD pathogenesis, suggesting that a protracted form of AD might be first initiated
through a conformational change in protein structure [50,51]. Furthermore, a preventive mechanism
to address confirmation changes, analogous to Congo red staining and birefringence, could hold the
answer to protecting neurons from forming beta pleated sheet conformational changes in globular
or other proteins and preventing subsequent glycation-mediated filamentous changes considered to
be pathogenic.
In that regard, curcumin, tea, and other spices could bind to suspect proteins and either prevent
conformational changes or suppress their toxicity, since these epitopes are suspected of mediating
toxicity in conformational disease. Curcumin is an antioxidant that we speculated would be important
for inhibiting or quenching oxidative stress in AD pathogenesis [50,52]. However, another beneficial
mechanism of action could be at work here, as curcumin was shown to break up Aβ plaques in mouse
brain models and differentially bind fibrillar amyloid forms in in vitro systems [53]. The curcumin
studies that showed inhibition of Aβ and fibril formation were done in vitro, illustrating that absorption
and brain delivery present hurdles to approaches using beta pleated sheet-binding substances. In that
regard, curcumin and turmeric are difficult to absorb in dietary form and they do not cross the
blood–brain barrier. Moreover, the stain and dye Congo red is most likely toxic to cells and,
thus, its therapeutic use is questionable. Yet, other similar functioning compounds from food or
co-metabolism may exist. New and safer compounds could be synthesized with this mechanism of
action. The bioavailability of prosaic foods could also be improved or modified to cross immune
barriers, thereby having an effect on aspects of conformational states or enhancing clearance of
deleterious structural modifications suspected in precipitating disease pathogenesis. Efforts to improve
bioavailability should be studied and proven before we can advocate supplementing or dosing spices
and foods to treat disease. However, there is one study which demonstrated that adding curcumin
Microorganisms 2020, 8, 493 10 of 18

to the mouse diet did break up Aβ plaques in rodent brains [54]. Unfortunately, it is unclear if this
system mimics human physiology. While mice are the best current model we have to recapitulate
human diseases, they often do not always mimic them fully or recapitulate all aspects of human disease.
Nevertheless, when we consider dietary-derived phenomenon or mechanisms, we must then add
in the microbiota aspect, as bacteria and/or microorganisms outnumber human cells by factors of 10
to 100-fold due to their abundance and size and ability to change biochemistry through mass action.
These are contributing factors and potential sources for confounders, especially when findings involve
transformation, modification, or formation of new compounds not derived from the host metabolism
that could indeed reach brain compartments. Modified compounds possessing new beta pleated
sheet-binding properties could perhaps offer potential clues about conformational disease mechanisms
or explain variant and equivocal findings in this regard. When considering any natural product
claim or mechanism for monitoring or treating diseases, like AD or other neurodegenerative diseases,
one must exercise caution, while expecting purity and integrity, and we should insist on some clinical
proof or peer-reviewed support from those monetizing supplements for these results in the production
of unknown protective metabolites. Furthermore, whether the aim is to treat conformational disease,
dissipate aberrant protein aggregates, or attenuate aberrant signaling, we must explore all possible
contributions from enteric gut bacteria.

6. AD-Protective Foods and the Microbiota

Other protective mechanisms involving the aforementioned compounds, including curcumin and
phenolic acids and their modification to smaller compounds, have many mechanisms of action, some
of which may come from digestion or breakdown of these prosaic products by bacterial metabolism or
when co-metabolized with the host. One thing needed in the discovery process is a battery of tests
involving either fecal culture or select bacterial clones isolated and studied in regard to metabolism,
building a new database for bacterial co-metabolism. This approach can serve to identify the chemical
metabolic compounds within these digestive systems, and this may lead to new drugs, drug targets,
and enzyme inhibitors. For example, in AD, a primary early degenerative process leads to the damage
of cholinergic neurons in the brain, resulting in cognitive impairment. The level of neurotransmitter
acetylcholine (ACh), a small molecule important in cognition and memory, is low in the brains of
AD patients, and some speculate that reduced synthesis of acetylcholine in the brain is the cause of
AD. However, dietary choline, phosphatidyl choline, lecithin, and betaine all can be converted into
trimethylamine-N-oxide (TMANO/TMAO) via the metabolic enzymatic action of anaerobic bacteria and
the liver [55]. Prior to absorption, dietary choline, a nutrient found largely in eggs, organs, and other
animal foods, and carnitine are metabolized in the large intestine by gut microbiota to trimethylamine
(TMA), as well as to dimethylamine and methylamine, albeit in lesser amounts [56]. After absorption,
host enzymes convert TMA to TMANO in the liver via liver flavin monooxygenases [57].
One promising treatment approach is to enhance ACh levels by selectively targeting the
enzyme which breaks down acetylcholine in the cholinergic synapses to acetate and choline.
Acetylcholinesterase (AChE) is the enzyme largely responsible for the hydrolysis of ACh, but nonspecific
cholinesterases hydrolyze ACh as well. One such enzyme, which is a plasma choline esterase,
is the pseudo-cholinesterase known as butyryl cholinesterase (BChE). There are potent AChE drugs
that are readily absorbed, such as AChE inhibitors esolerineare, phenserine, and tolserine [58,59].
While inhibiting the AChE enzymes could offer insight into protective mechanisms, nothing yet
found is quite perfect. Nevertheless, several investigations reported that a reduction in AChE activity
compensates for BChE activity, and they explored plant-derived phytochemicals for their AChE
inhibitory activity. Natural compounds are of great interest in drug discovery. In that regard, natural
cholinesterase AChE inhibitors lead the search for compounds for AD treatment, as they should
have significant inhibitory activities against both AChE enzymes [60], but few studies reported the
co-metabolism aspects surrounding acetyl cholinesterase inhibitory activity.
Microorganisms 2020, 8, 493 11 of 18

Many natural product compounds have AChE inhibitory activity. For example, resveratrol,
quercetin, and curcumin all inhibit AChE and BChE. However, those products that inhibit AChE
alone include the tea catechins, namely, the gallocatechins, such as epigallocatechin, epicatechin,
epicatechin-3-gallate, and epigallocatechin-3-gallate, as well as the cinnamic acids and caffeic acid [60].
Moreover, nootropic and stimulating chemicals like caffeine also inhibit AChE and improve memory
and cognition. Again, we postulate that the same or other plant compounds could also yield similar,
even more effective, treatments. Furthermore, novel compounds from the metabolism of these
prosaic foods through bacterial or microorganism-derived modification may yield beneficial effects.
For example, Hwangryunhaedok-tang (HT), an Asian herb, when fermented with Lactobacillus spp.,
has enhanced anti-inflammatory effects through suppression of mitogen-activated protein kinase
signaling in LPS-stimulated RAW264.7 cells in vitro [61]. HT also exerts neuroprotective effects
on memory impairment by reducing cholinergic system dysfunction and inflammatory response
in vascular dementia in a rat model [62]. HT, as well as black tea, green tea, and coffee, contains
compounds which inhibit acetylcholinesterase, but they may contain many other enzymes, such as
thiaminases, which degrade thiamin(e) (vitamin B1), another important compound in brain health
and energy homeostasis. It is transketolase and the diversion of glycolytic intermediates to the
hexose monophosphate shunt that protect against glycation damage in diabetes and perhaps even type
3 diabetes [63] or AD. Moreover, green tea metabolites inhibit beta secretase and could prevent the release
of Aβ peptides from APP. However, coffee is a less effective inhibitor of acetylcholinesterase, having
no butyryl cholinesterase or beta secretase inhibitory activity [64]. Finally, Hwangryunhaedok-tang
was shown to have anti-inflammatory, antiplatelet, and antithrombotic activity [65]. This herb is but
one example of prosaic foods having activity after metabolism or bacterial fermentation processes.

7. Microorganisms Found in Alzheimer Disease

During the course of aging, the gastrointestinal tract epithelial barrier and the blood–brain
barrier become significantly more permeable, which would make the CNS more susceptible to
potential neurotoxins generated by microbiome-resident or environmental pathogens (see Figure 1).
The contribution of pathogenic microbial populations to the progression of AD is being established
and altered microbiome signaling from other disease-inducing agents, such as fungal infection of the
CNS and viral infections, may contribute to the development of AD [3]. Chronic fungal infections
and disseminated diffuse mycoses found in the peripheral blood of AD patients may help explain
increase AD risk from the mycobiota. In that regard, yeast and fungal proteins like (1,3)-β-glucan or
high levels of fungal polysaccharides are associated with increased AD risk [66]. A number of viral
agents, common viruses, and latent viral infections can establish lifelong latency in the CNS, and they
are linked to the development of AD. For example, Herpesviridae and Herpes simplex virus-1 (HSV-1),
human cytomegalovirus, and hepatitis C infections were shown to significantly increase the risk of
AD, especially in the elderly [3]. Chlamydophila pneumoniae is another pathogenic Gram-negative,
obligate intracellular bacteria associated with AD and coronary artery disease [67]. Chagas disease
caused by the protozoan Trypanosoma cruzi mainly affects the nervous system, digestive system,
and heart. Enteric nervous system impairment caused by T. cruzi infection also has an association with
Helicobacter pylori infection [68]. Toxoplasma species such as several intracellular protozoan parasites,
specifically, Toxoplasma gondii, cross the BBB to cause neurological dysfunction and encephalitis by
promoting chronic inflammation of the brain, meninges, and CNS. Moreover, AD is associated with
significantly increased anti-T. gondii antibodies, which suggests a possible mechanistic link between
T. gondii infection and AD via household pets [3,69].
Interestingly, red wine constituents may reverse some of the action of pathogens in various
models. In Chagas disease, for example, resveratrol in mice was effective in reversing functional
heart disease [70], and heart function was improved by sirtuin 1 (SIRT-1) targeted therapy for
Trypanosoma cruzi infection [71]. In neuronal progenitor cells, resveratrol mediated a reversal in
purinergic signaling and toxoplasma T. gondii immune responses [72]. Antibiotics, such as ofloxacin
Microorganisms 2020, 8, 493 12 of 18

or clarithromycin, together with resveratrol or quercetin, showed inhibition and lowering of IL-23
levels, which suggested that the combined treatment might show a synergistic effect when controlling
chlamydia infection [73]. Even viruses are potential treatment targets. For example, polyphenol-rich
extract from berries, with high chlorogenic acid and delphinidin-3-rutinoside content, inhibited HSV-1
replication, while demonstrating scavenging and chelating properties, decreasing ROS production,
and counteracting the catalase suicide molecule t-butyl hydroperoxide-induced cytotoxicity [74].
Moreover, the extract from the peel also increased intracellular glutathione levels, which suggests a
possible hormetic mechanism of action.
Taken together, it is clear that the human CNS is under constant assault from a wide array of
intrinsic and extrinsic neuroactive products from microbes, pathogens, viruses, and fungi found in the
environment and contained within the microbiome. When we couple treatment with select polyphenols,
many of the AD-implicated organisms are either controlled or respond to those administered
polyphenols. Virtually every type of microbe known could be implicated in contributing to AD
susceptibility and pathogenesis, which is especially true when blood immune barriers are breached [25].
This could be especially important with aging, because the innate immune system and physiological
barriers are often compromised with advancing age [75], which would enable microbes and any
neurotoxic metabolites produced to readily gain access to the CNS or other brain compartment.
Since AD is clearly a multifactorial disease, having multiple biological pathways through which
vulnerable neurons elicit dysfunction, it is not surprising that multiple and complex microbial insults
contribute to AD, which include pathological signal transmission throughout the vagus nerves to
the CNS.
From Part I to Part II, we come full circle in describing aspects of the French paradox and the
MGB axis–heart shunt. In Part I of this series, we described the metabolism of foods and carnitine
by gut microbes. In particular, we explored the enzymatic action of anaerobic bacteria and discussed
dietary sources for TMANO, from choline, phosphatidylcholine (PC), and betaine, all of which produce
trimethylamine-N-oxide [55] in Part I. In Part II, we explored gut metabolites and TMANO in possible
AD pathogenesis and protection. We and others identified TMANO in human tissues and fluids
including human cerebrospinal fluid and rodent brains. It was shown that TMANO lowers the
critical concentration of tubulin needed for tubulin assembly by modulating binding of protein kinase
A-phosphorylated microtubule-associated protein tau to form tubulin. It seems that TMANO levels are
not related to neurological disorders [76]. However, since one hallmark of AD is hyper-phosphorylation
of the microtubule-associated protein Tau, this finding offers a therapeutic implication for TMANO in
Alzheimer disease. In support of this notion, it was found that TMANO not only affects the promotion,
but also enhances the assembly of microtubules, as found experimentally with both mutant and
hyper-phosphorylated tau protein [77]. TMANO does not act by dephosphorylating tau protein; rather,
it facilitates the binding of the microtubule-associated protein tau and tubulin by reducing the critical
concentration of tubulin necessary for assembly [78]. Furthermore, TMANO stabilizes and modifies
the aggregation of Aβ peptide, and, with chaperone-like activity, it can prevent the conversion of Aβ
peptide to its β-conformation and stabilize the resulting proto-fibrils, which might prevent aggregation
and tangles [79]. TMANO may have a role in protecting the brain as discussed in Part I of this two-part
series. This makes a case for the neurotransmitter acetylcholine and PC and choline in brain health,
and the adequate intake of choline reduced the risk of dementia as it was observed that intake, mainly
from eggs and meat, was associated with reduced dementia risk [80].

8. Conclusions
In summation, it is not clear after knowing what we now know about TMANO production,
even from healthy foods with choline derivatives, how this could synergize with wine and its betaine
and alcohol content to offer an explanation for the French paradox. Moreover, how the French and their
well-known consumption of largely fatty, saturated, rich, and unhealthy foods (not unlike Americans)
can actually have less heart disease and less AD than any other group is intriguing. Some suggest
Microorganisms 2020, 8, 493 13 of 18

that smaller portions, chewing more, and less overall life stress could also help to explain differences.
We suggest that bugs could act as drugs or psychobiotics, which implies that our microbiota and the
right diet or foods may be all we need to affect many aspects of our mental, brain, and heart health.
Therefore, these findings demand that we explore the microbiota of the French and the
co-metabolism of paradoxical foods, maybe even coupled with red wine polyphenols, in rodent
and culture models. In that way, we may elucidate a mechanism and advance our understanding of
how prosaic foods, in the right combination or with wine polyphenolic acids, could serve to prevent
intractable neuronal disease. Perhaps, one day, we will consume a designer symbiotic and, thus, have
our cake and eat it too, and, if Marie Antoinette were extant, she might rephrase her famous quote to
say “Qu’ils mangent lentement et qu’ils mangent de la brioche, mais qu’ils n’oublient pas du vin!”
(translation: “Let them eat slowly and let them eat cake, but let them not forget some wine!”); however,
until such time, “à votre santé!” (translation: “to your health!”).

Funding: This research received no external funding.

Conflicts of Interest: The authors declare no conflicts of interest.

Abbreviations
hypothalamic–pituitary–adrenal HPA
trimethylamine-N-oxide TMANO/TMAO
amyloid precursor protein APP
interleukin IL
tumor necrosis factor TNF
endothelin-1 ET-1
reactive oxygen species ROS
reactive nitrogen species RNS
lipopolysaccharide LPS
nonsteroidal anti-inflammatory drugs NSAIDs
insulin-like growth factor-1 IGF-1
presenillin1 PS1
amyloid beta Aβ
peroxynitrite ONOO
nitric oxide NO
inducible nitric oxide iNOS
microbiota-gut-brain MGB
celiac disease CD
apolipoprotein E ApoE4
acetyl-l-Carnitine ALCAR
R-alpha-lipoic acid LA
vascular dementia VaD
hydrogen sulfide gas H2 S
cholesterol acyltransferase ACAT
Hwangryunhaedok-tang HT
small guanosine triphosphate GTP
G-protein coupled receptor kinase GRK
G-protein coupled receptor GPCR
amyloid-derived diffusible ligands ADDLS
acetylcholine ACh
acetylcholinesterase AChE
butyryl cholinesterase BChE
oxidation–reduction or redox potential Eh
herpes simplex virus-1 HSV-1
phosphatidylcholine PC
Microorganisms 2020, 8, 493 14 of 18

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