Surface protrusions of Plasmodium falciparum-infected erythrocytes, called knobs, display focal aggregates of P falciparum erythrocyte membrane protein 1 (PfEMP1), the adhesion ligand binding endothelial-cell receptors. The resulting sequestration of infected erythrocytes in tissues represents an important factor in the course of fatalities in patients with malaria. The main component of knobs is the knob-associated histidine-rich protein (KAHRP), and it contributes to altered mechanical properties of parasiteinfected erythrocytes. The role of KAHRP domains in these processes is still elusive. We generated stable transgenic P falciparum-infected erythrocytes expressing mutant versions of KAHRP. Using atomic force and electron microscopy we show that the C-terminal repeat region is critical for the formation of functional knobs. Elasticity of the membrane differs dramatically between cells with different KAHRP mutations. We propose that the 5 repeat region of KAHRP is important in cross-linking to the host-cell cytoskeleton and this is required for knob protrusion and efficient adhesion under physi-
IntroductionPlasmodium falciparum is the most lethal malaria parasite of humans. 1 An important aspect in virulence of P falciparum is the ability of infected erythrocytes to sequester in and obstruct the microvasculature of different organs. 2 These abnormal circulatory properties of erythrocytes involve parasite-induced alterations in their biomechanical and adhesive properties and are important for survival and pathogenicity of P falciparum. 3 Cytoadhesion is mediated by the antigenically variant P falciparum erythrocyte membrane protein-1 (PfEMP1), which can bind to host receptors including CD36 and chondroitin sulfate A (CSA). 4 PfEMP1 is concentrated on electron-dense elevations of the membrane referred to as knobs, 5-7 providing a platform for adherence under physiologic flow conditions. 8 Increased erythrocyte rigidity and adhesiveness result in dramatically augmented hemodynamic resistance observed in microvasculature perfused with P falciparum-infected erythrocytes. 9 Knobs consist predominantly of the knob-associated histidine-rich protein (KAHRP), 10,11 assembling on the cytoplasmic face of the membrane. KAHRP is required for knob formation. 8 KAHRP has a signal sequence with a recessed hydrophobic core that directs the protein into the parasitophorous vacuole via the endomembrane system. 12 A second signal, we termed the "Plasmodium export element" (PEXEL), 13 is required for transfer across the parasitophorous vacuole membrane to the erythrocyte cytosol. 13,14 The PEXEL is followed by a histidine-rich region containing sequences responsible for interaction with Maurer clefts, 15 structures assembled in the P falciparum-infected erythrocyte cytosol important in protein sorting and trafficking. 12 There are also 2 blocks of highly charged repeats, designated the 5Ј and 3Ј repeats according to their location. 10,11 Current evidence suggests KAHRP interacts with various cytoskeletal components of the erythr...