Peptidoglycan--an endotoxin in its own right?

Studies aimed at dissecting the complex pathophysiology of sepsis with multiple organ failure have traditionally focused on lipopolysaccharide of gram-negative bacteria, which is widely regarded as the classical endotoxin. However, gram-positive sepsis now accounts for up to 50% of all cases, calling for a shift of focus. Peptidoglycan (PepG) is the major cell wall component of gram-positive bacteria and has been increasingly recognized as an important proinflammatory molecule. During gram-positive infections, PepG reaches the circulation by bacterial breakdown or translocation from the intestine. Administration of PepG induces all the classical features of infectious illness and endotoxemia and may cause systemic inflammation with organ failure in animal models. Its potency, however, is crucially dependent on various features of its complex structure. PepG interacts with the innate immune system through receptors mainly expressed on monocytes/macrophages but may induce inflammatory changes in other cell types as well. Among the most extensively studied receptor systems are the nucleotide-binding oligomerization domains, the toll-like receptors, and the PepG recognition proteins. Based on the current available literature, we would like to propose that PepG must be regarded as an endotoxin in its own right and to encourage further work in the field of PepG signaling.