TRMOME 2058 No.

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Trends in
Molecular Medicine
Forum
from gut to brain via neural afferent con- Diagnostic potential of gut
New insights on gut nections, (ii) microbial derived endocrine microbiota
microbiome and autism and metabolic signals directly affecting A broad spectrum of studies across di-
1,2,3,5 1,2,5 brain function, and (iii) microbiota-induced verse geographical regions and popula-
Yating Wan , Qi Su , and neuroimmune responses in the central tions have characterized a distinct gut
1,2,4,
Siew C. Ng * nervous system (CNS). Gut microbiota microbiota profile associated with ASD
disruption related to an overgrowth of (Table 1). Amongst these, an increased
pathogenic microbes and increased gut abundance of bacteria of the genus
Autism spectrum disorder (ASD) is permeability impairs the integrity of the Clostridium, specifically Clostridium
a complex neurodevelopmental blood–brain barrier (BBB). This compro- bolteae and Clostridium botulinum, has
condition that often coincides with mise allows peripheral neurotoxic pro- been reported in individuals with ASD.
gut dysbiosis. Studies show that teins or microbial metabolites to enter By contrast, there appears to be a re-
alterations in gut microbiota influ- the brain, leading to neuronal damage or duction in the genera Prevotella and
ence brain function and could neuroinflammation. Observational stud- Roseburia. Using these bacterial bio-
serve as diagnostic biomarkers ies have consistently reported that indi- markers, machine-learning models have
and therapeutic targets. This forum viduals with ASD have a distinct gut achieved an accuracy of 70–80% in dis-
article discusses the role of gut bacterial community compared with tinguishing individuals with ASD from
neurotypical children, characterized by neurotypical peers [1,2]. Beyond composi-
microbiota in ASD pathogenesis
reduced species diversity, altered bacte- tional differences, dysfunctions in the
and its diagnostic and therapeutic
rial composition, impaired synthesis microbial metabolism of amino acids, car-
potential. pathways for neuroactive metabolites, bohydrate, and lipid profiles have also
and a lagged bacterial developmental tra- been observed and accompanied analo-
jectory [1,2]. Infants with a higher risk of gous brain metabolism differences in indi-
The role of gut microbiota in ASD developing ASD showed lower levels of viduals with ASD [6]. The combination of
ASD is a prevalent neurodevelopmental Bifidobacterium spp. and higher levels of microbial metabolic functions and bacterial
condition characterized by impairments Clostridium and Klebsiella spp. at 5 months biomarkers has demonstrated superior di-
in reciprocal social interaction and ste- of age [3]. The critical role of gut microbiota agnostic accuracy compared with the bac-
reotyped repetitive behaviors. Typically in ASD development has also been evi- terial markers alone [1]. This suggests that
diagnosed during preschool years, denced in animal studies. Transplantation a complex neurodevelopmental disorder
ASD places a considerable burden on of ASD-associated gut microbiota into like ASD requires a more comprehensive
families and society. Despite extensive germ-free mice resulted in social behavioral characterization of other multi-kingdom
research into genetics, immunology, deficits, as well as ASD-related gene up- microbiota, including viruses, fungi, and
and perinatal factors, the exact etiology regulation in the brain [4]. Mice treated archaea.
of ASD is still not fully understood. How- with antibiotics manifested anxiety-like be-
ever, with advancements in sequencing haviors and reduced social interactions, Gut viruses directly or indirectly affect
technologies, more and more research which is associated with accumulated mi- human health, either by infecting human
has noted the involvement of gut micro- crobial derived aromatic compounds and cells or by interacting with other gut micro-
biota in pathogenesis and its clinical disrupted hippocampal dysfunction. More- organisms. Administration of microbiota
value in the diagnosis and therapeutics over, offspring of mice fed a high-fat diet with a higher level of Caudovirales in mice
of ASD (Figure 1). exhibited social behavior abnormalities, enhances novel object recognition capac-
which could be reversed by co-housing ity and memory as well as upregulating
Gut microbiota and ASD with offspring from mothers fed a normal memory-involved genes in the brain [7].
development diet [5]. Overall, both preclinical and clinical Research has identified an association be-
The gut–brain axis elucidates the bidirec- evidence suggests that alterations in the tween ASD and higher levels of several
tional communication between gut micro- gut microbiota contribute to the symptoms bacteriophages, including those that infect
biota and the brain, which can also affect of ASD. Therefore, ASD-associated micro- Clostridium spp., Bacillus spp., and
host behaviors. This interaction acts bial signatures hold significant promise enterobacteria. Gut phage dysbiosis
through neuronal and chemical signaling for clinical use, both as diagnostic bio- disrupted the homeostasis of bacterial
pathways (Figure 1), including (i) the vagus markers and as targets for therapeutic in- and viral communities, potentially impairing
nerve that transmits sensory information tervention. functional pathways responsible for

Trends in Molecular Medicine, Month 2024, Vol. xx, No. xx 1

 Trends in Molecular Medicine

Gut–brain axis Diagnosis archaea are associated with worsened

Signaling through the gut permeability and inflammation, leading
afferent vagus nerve
Microbiota induced
to pathogenic factors crossing the gut bar-
BBB rier, and increasing the risk of neuroinflam-
Bacteria
Other microbes Bacterial markers
Combined markers
mation. The involvement of each microbial
kingdom – bacteria, viruses, fungi, and
P P P

Vagus nerve

P P
Microbial archaea – in shaping phenotypes of neuro-
Proinflammatory pathways
cytokines logical disorders has become increasingly
Treatment evident. Hence, integrated analysis of the
multi-kingdom gut microbiota warrants
Core ASD behavior and consideration as a novel biomarker panel
co-occurring medical
Microbial metabolites
conditions improved in ASD diagnosis. In addition, different geo-
graphic regions involving various popula-
Microbial metabolites cross
the gut barrier and BBB tions, diets, and lifestyles may contribute
Gut lumen
to variations in gut ecology (Table 1), indi-
Trends in Molecular Medicine cating a need to eliminate/assess the con-
Figure 1. Microbiota gut–brain axis and gut microbiota potential in diagnosis and therapeutics of founders’ effects on ASD models.
autism spectrum disorder (ASD). The communication between gut microbes and the brain through the
gut–brain axis involves the vagus nerve pathway, microbially derived endocrine and metabolic signaling, and
Therapeutic potential of gut
the immune system (left panel). The ASD-associated microbial markers have promising value for aiding
diagnosis (right top panel) and as targets for therapeutic intervention (right bottom panel). Abbreviations: AUC, microbiota
area under the curve; BBB, blood–brain barrier. Figure created with BioRender. Until now, no pharmaceuticals have been
officially and widely approved to treat
ASD. The strong connection between
neuroactive metabolite synthesis in individ- consortium of mucosa-associated fungi gut microbiota and ASD has highlighted
uals with ASD [8]. The extraintestinal effects have a significantly increased social prefer- the potential approach of modifying the
of gut fungi and archaea have also been re- ence, which is mediated by the interleukin gut microbiome to improve behavioral
vealed in the gut–brain axis. Transfer of gut (IL)-17R-dependent signaling pathway of symptoms associated with ASD. Fecal
fungi from stressed to non-stressed mice neuroimmune modulation [10]. Individuals microbiota transplantation (FMT) has
has been shown to induce irritable bowel with ASD have higher levels of gut fungi been evaluated in ASD. There was a
syndrome-like symptoms, which can be re- (Candida and Saccharomyces cerevisiae) marked improvement in both the severity
stored by administration of Saccharomyces but a lower level of Aspergillus versicolor. of autism and gastrointestinal (GI) symp-
boulardii [9]. Mice colonized with a specific Furthermore, the altered gut methanogenic toms in individuals with ASD after FMT,

Table 1. Microbial markers associated with ASD

Distinct microbial signatures from healthy controls Biomarkers AUC based on biomarkers Refs
Veillonella, Enterobacteriaceae increase Two taxa and 17 microbial metabolic functions Discovery cohort: 0.86 [1]
Microbial glutamate degradation and acetate synthesis Validation cohort 1: 0.78
decrease and 15 other microbial metabolism changes Validation cohort 2: 0.82
Validation cohort 3: 0.67
Faecalibacterium decrease Five bacteria species Discovery cohort: 0.83 [2]
Clostridium, Dialister, Coprobacillus, Alistipes indistinctus, Validation cohort: 0.76
candidate division_TM7_ isolate_TM7c, Streptococcus
cristatus, Eubacterium limosum and Streptococcus
oligofermentans increase
Eubacterium decrease Three differentially abundant gut or oral genera and Oral marker: 0.71 [13]
Paraprevotella, Granulicatella, Peptoniphilus increase dysbiosis markers Gut marker: 0.72
Dysbiosis marker: 0.69
Sutterella, Prevotella, and Bacteroides decrease 24 bacterial genera Discovery cohort: 0.93 [14]
Bifidobacterium longum, Prevotella copri decrease Five detoxification pathways Discovery cohort: 0.88 [15]
Veillonella parvula and Lactobacillus rhamnosus increase
Microbial detoxification enzymes decrease

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Trends in Molecular Medicine

and a long-term benefit was shown [11]. in personalized microbial interventions to suit References
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cytokines. These interventions not only
1
Microbiota I-Center (MagIC), Hong Kong
improve core autism-like behavior but 2
Department of Medicine and Therapeutics, The Chinese
also alleviate the highly prevalent co- University of Hong Kong, Hong Kong
3
The D.H. Chen Foundation Hub of Advanced Technology for
occurring medical conditions: GI symp- Child Health (HATCH), The Chinese University of Hong Kong,
toms, anxiety, irritability, and sleep distur- Hong Kong
4
Li Ka Shing Institute of Health Sciences, State Key Laboratory
bance. This suggests a potential shared of Digestive Disease, Institute of Digestive Disease, The Chinese
etiology of genetic and environmental University of Hong Kong, Hong Kong
5
These authors contributed equally to this work
factors between these comorbidities
and ASD, as well as shared pathways *Correspondence:
through which gut microbial interventions [email protected] (S.C. Ng).
can modulate brain function and host https://doi.org/10.1016/j.molmed.2024.06.010

phenotypes. There is no universal © 2024 Elsevier Ltd. All rights are reserved, including those for
remedy for ASD; thus, the challenge remains text and data mining, AI training, and similar technologies.

Trends in Molecular Medicine, Month 2024, Vol. xx, No. xx 3