Tuberculosis control: the relevance of classic principles in an era of acquired immunodeficiency syndrome and multidrug resistance

A Rare Case of Tubercular Osteomyelitis of Maxilla: A Case Report

Tuberculosis (TB) is a chronic granulomatous infection which primarily affects lungs. It is caused by Mycobacterium tuberculosis which was discovered by Dr Robert Koch. It can also affect other organs. Tuberculosis is a major cause of morbidity and mortality in developing countries. Early detection and initiation of antitubercular therapy are important in the management of TB. Extrapulmonary TB might not exhibit same features as pulmonary tuberculosis. Tuberculosis of maxilla is an extremely rare entity which can be misdiagnosed as carcinoma of maxillary sinus or other infectious conditions. We are presenting a case of tuberculous osteomyelitis of maxilla in a 14-year-old female who came with a discharging sinus over the right cheek. She underwent endoscopic debridement of sinuses and histopathological examination was suggestive of Koch's infection. Patient was further treated with antitubercular therapy and showed significant improvement at four weeks follow up.

An overview of mechanism and chemical inhibitors of shikimate kinase

Tuberculosis is a highly infectious disease other than HIV/AIDS and it is one of the top ten causes of death worldwide. Resistance development in the bacteria occurs because of genetic alterations, and the molecular insights suggest that the accumulation of mutation in the individual drug target genes is the primary mechanism of multi-drug resistant tuberculosis. Chorismate is an essential structural fragment for the synthesis of aromatic amino acids and synthesized biochemically by a number of bacteria, including Mycobacterium tuberculosis, utilizing the shikimate pathway. This shikimate kinase is the newer possible target for the generation of novel antitubercular drug because this pathway is expressed only in mycobacterium and not in Mammals. The discovery and development of shikimate kinase inhibitors provide an opportunity for the development of novel selective medications. Multiple shikimate kinase inhibitors have been identified via insilico virtual screening and related protein-ligand interactions along with their in-vitro studies. These inhibitors bind to the active site in a similar fashion to shikimate. In the current review, we present an overview of the biology and chemistry of the shikimate kinase protein and its inhibitors, with special emphasis on the various active scaffold against the enzyme. A variety of chemically diversified synthetic scaffolds including Benzothiazoles, Oxadiazoles, Thiobarbiturates, Naphthoquinones, Thiazoleacetonitriles, Hybridized Pyrazolone derivatives, Orthologous biological macromolecule derivatives, Manzamine Alkaloids derivatives, Dipeptide inhibitor, and Chalcones are discussed in detail. These derivatives bind to the specific target appropriately proving their potential ability through different binding interactions and effectively explored as an effective and selective Sk inhibitor.Communicated by Ramaswamy H. Sarma.

Rv1268c protein peptide inhibiting Mycobacterium tuberculosis H37Rv entry to target cells

Tuberculosis (TB) remains one of the most worrying infectious diseases affecting public health around the world; 8.7 million new TB cases were reported in 2011. The search for an Mycobacterium tuberculosis H37Rv protein sequence which is functionally important in host-pathogen interaction has been proposed for developing a new vaccine which will allow efficient and safe control of the spread of this disease. The present study thus reports the results obtained for the Rv1268c protein described in the M. tuberculosis H37Rv genome as a hypothetical unknown, probably secreted, protein based on a highly robust, specific, sensitive and functional approach to the search for potential epitopes to be included in an anti-tuberculosis vaccine. Rv1268c presence was determined by immunoblotting after obtaining polyclonal sera against mycobacterial total sonicate or subcellular fractions. Such sera were used in electron immunomicroscopy (EIM) for confirming protein localisation on the M. tuberculosis envelop by recognising colloidal gold-labelled immunoglobulin. Screening assays revealed the presence of two sequences having high binding activity: one binding A549 alveolar epithelial cells ((141)TGMAALEQYLGSGHAVIVSI(160)) and other binding U937 monocyte-derived macrophages ((21)AVALGLASPADAAAGTMYGD(40)). Such sequences' ability to inhibit mycobacterial entry during in vitro assays was analysed. The structure of synthetic peptides binding to target cells was also determined, bearing in mind the structure-function relationship. These results, together with those obtained for other proteins, have been involved in selecting peptides which might be included in a subunit-based anti-tuberculosis vaccine.

Detection and confirmation of alkaloids in leaves of Justicia adhatoda and bioinformatics approach to elicit its anti-tuberculosis activity

The extraction and determination of alkaloids was performed and confirmed by phytochemical analysis. Six different quinazoline alkaloids (vasicoline, vasicolinone, vasicinone, vasicine, adhatodine and anisotine) were found in the leaf of Justicia adhatoda (J. adhatoda). The presence of the peaks obtained through HPLC indicated the diverse nature of alkaloid present in the leaf. The enzyme β-ketoacyl-acyl-carrier protein synthase III that catalyses the initial step of fatty acid biosynthesis (FabH) via a type II fatty acid synthase has unique structural features and universal occurrence in Mycobacterium tuberculosis (M. tuberculosis). Thus, it was considered as a target for designing of anti-tuberculosis compounds. Docking simulations were conducted on the above alkaloids derived from J. adhatoda. The combination of docking/scoring provided interesting insights into the binding of different inhibitors and their activity. These results will be useful for designing inhibitors for M. tuberculosis and also will be a good starting point for natural plant-based pharmaceutical chemistry.

Antiretroviral treatment as prevention: impact of the 'test and treat' strategy on the tuberculosis epidemic

Antiretroviral therapy (ART) has been remarkably effective in ameliorating Human Immunodeficiency Virus (HIV)-associated morbidity and mortality. The rapid decline in viral load during ART also presents an opportunity to develop a “treatment as prevention” strategy in order to reduce HIV transmission at a population level. Modelling exercises have demonstrated that for this strategy to be effective, early initiation of ART with high coverage of the HIV-infected population will be required. The HIV epidemic has fueled a resurgence of tuberculosis (TB) particularly in sub-Saharan Africa and widespread early initiation of ART could also impact this epidemic via several mechanisms. The proportion of patients with low CD4 cell counts who are at high risk of TB disease from progression of both latent and new TB infection would be greatly reduced. Entry into a life-long ART program provides an ongoing opportunity for intensified TB case finding among the HIV-infected population. Regular screening for HIV infection also presents an opportunity for intensified TB case finding in the general population. The combined effect of reduced progression of infection to disease and intensified case finding could reduce the overall prevalence of infectious TB, thereby further decreasing TB transmission. In addition, decreasing prevalence of HIV infection would reduce the TB-susceptible pool within the population. The ‘test and treat’ strategy therefore has potential to reduce the TB risk at both an individual and a population level. In this paper we explore the expected “TB dividend” of wider access to ART and also explore the potential of the “test and treat” strategy to impact on TB transmission, particularly in the heavily burdened setting of sub-Saharan Africa.

Oxidizing substrate specificity of Mycobacterium tuberculosis alkyl hydroperoxide reductase E: kinetics and mechanisms of oxidation and overoxidation

Alkyl hydroperoxide reductase E (AhpE), a novel subgroup of the peroxiredoxin family, comprises Mycobacterium tuberculosis AhpE (MtAhpE) and AhpE-like proteins present in many bacteria and archaea, for which functional characterization is scarce. We previously reported that MtAhpE reacted ~10(3) times faster with peroxynitrite than with hydrogen peroxide, but the molecular reasons for that remained unknown. Herein, we investigated the oxidizing substrate specificity and the oxidative inactivation of the enzyme. In most cases, both peroxidatic thiol oxidation and sulfenic acid overoxidation followed a trend in which those peroxides with the lower leaving-group pK(a) reacted faster than others. These data are in agreement with the accepted mechanisms of thiol oxidation and support that overoxidation occurs through sulfenate anion reaction with the protonated peroxide. However, MtAhpE oxidation and overoxidation by fatty acid-derived hydroperoxides (~10(8) and 10(5) M(-1) s(-1), respectively, at pH 7.4 and 25°C) were much faster than expected according to the Brønsted relationship with leaving-group pK(a). A stoichiometric reduction of the arachidonic acid hydroperoxide 15-HpETE to its corresponding alcohol was confirmed. Interactions of fatty acid hydroperoxides with a hydrophobic groove present on the reduced MtAhpE surface could be the basis of their surprisingly fast reactivity.

A truncated lipoglycan from mycobacteria with altered immunological properties

Maintenance of cell-wall integrity in Mycobacterium tuberculosis is essential and is the target of several antitubercular drugs. For example, ethambutol targets arabinogalactan and lipoarabinomannan (LAM) biosynthesis through the inhibition of several arabinofuranosyltransferases. Apart from their role in cell-wall integrity, mycobacterial LAMs also exhibit important immunomodulatory activities. Here we report the isolation and detailed structural characterization of a unique LAM molecule derived from Mycobacterium smegmatis deficient in the arabinofuranosyltransferase AftC (AftC-LAM). This mutant LAM expresses a severely truncated arabinan domain completely devoid of 3,5-Araf-branching residues, revealing an intrinsic involvement of AftC in the biosynthesis of LAM. Furthermore, we found that ethambutol efficiently inhibits biosynthesis of the AftC-LAM arabinan core, unambiguously demonstrating the involvement of the arabinofuranosyltransferase EmbC in early stages of LAM-arabinan biosynthesis. Finally, we demonstrate that AftC-LAM exhibits an enhanced proinflammatory activity, which is due to its ability to activate Toll-like receptor 2 (TLR2). Overall, our efforts further describe the mechanism of action of an important antitubercular drug, ethambutol, and demonstrate a role for specific arabinofuranosyltransferases in LAM biosynthesis. In addition, the availability of sufficient amounts of chemically defined wild-type and isogenic truncated LAMs paves the way for further investigations of the structure-function relationship of TLR2 activation by mycobacterial lipoglycans.

Platensimycin activity against mycobacterial beta-ketoacyl-ACP synthases

Background

There is an urgent need for the discovery and development of new drugs against Mycobacterium tuberculosis, the causative agent of tuberculosis, especially due to the recent emergence of multi-drug and extensively-drug resistant strains. Herein, we have examined the susceptibility of mycobacteria to the natural product platensimycin.

Methods and Findings

We have demonstrated that platensimycin has bacteriostatic activity against the fast growing Mycobacterium smegmatis (MIC = 14 µg/ml) and against Mycobacterium tuberculosis (MIC = 12 µg/ml). Growth in the presence of paltensimycin specifically inhibited the biosynthesis of mycolic acids suggesting that the antibiotic targeted the components of the mycolate biosynthesis complex. Given the inhibitory activity of platensimycin against β-ketoacyl-ACP synthases from Staphylococcus aureus, M. tuberculosis KasA, KasB or FabH were overexpressed in M. smegmatis to establish whether these mycobacterial KAS enzymes were targets of platensimycin. In M. smegmatis overexpression of kasA or kasB increased the MIC of the strains from 14 µg/ml, to 30 and 124 µg/ml respectively. However, overexpression of fabH on did not affect the MIC. Additionally, consistent with the overexpression data, in vitro assays using purified proteins demonstrated that platensimycin inhibited Mt-KasA and Mt-KasB, but not Mt-FabH.

Significance

Our results have shown that platensimycin is active against mycobacterial KasA and KasB and is thus an exciting lead compound against M. tuberculosis and the development of new synthetic analogues.

Synthesis and biological evaluation of NAS-21 and NAS-91 analogues as potential inhibitors of the mycobacterial FAS-II dehydratase enzyme Rv0636

The identification of potential new anti-tubercular chemotherapeutics is paramount due to the recent emergence of extensively drug-resistant strains of Mycobacterium tuberculosis (XDR-TB). Libraries of NAS-21 and NAS-91 analogues were synthesized and evaluated for their whole-cell activity against Mycobacterium bovis BCG. NAS-21 analogues 1 and 2 demonstrated enhanced whole-cell activity in comparison to the parental compound, and an M. bovis BCG strain overexpressing the dehydratase enzyme Rv0636 was resistant to these analogues. NAS-91 analogues with ortho-modifications gave enhanced whole-cell activity. However, extension with biphenyl modifications compromised the whole-cell activities of both NAS-21 and NAS-91 analogues. Interestingly, both libraries demonstrated in vitro activity against fatty acid synthase II (FAS-II) but not FAS-I in cell-free extracts. In in vitro assays of FAS-II inhibition, NAS-21 analogues 4 and 5 had IC₅₀ values of 28 and 19 μg ml⁻¹, respectively, for the control M. bovis strain, and the M. bovis BCG strain overexpressing Rv0636 showed a marked increase in resistance. In contrast, NAS-91 analogues demonstrated moderate in vitro activity, although increased resistance was again observed in FAS-II activity assays with the Rv0636-overexpressing strain. Fatty acid methyl ester (FAME) and mycolic acid methyl ester (MAME) analysis of M. bovis BCG and the Rv0636-overexpressing strain revealed that the effect of the drug was relieved in the overexpressing strain, further implicating and potentially identifying Rv0636 as the target for these known FabZ dehydratase inhibitors. This study has identified candidates for further development as drug therapeutics against the mycobacterial FAS-II dehydratase enzyme.

Biosynthesis of mycobacterial arabinogalactan: identification of a novel alpha(1-->3) arabinofuranosyltransferase

The cell wall mycolyl-arabinogalactan–peptidoglycan complex is essential in mycobacterial species, such as Mycobacterium tuberculosis and is the target of several antitubercular drugs. For instance, ethambutol targets arabinogalactan biosynthesis through inhibition of the arabinofuranosyltransferases Mt-EmbA and Mt-EmbB. A bioinformatics approach identified putative integral membrane proteins, MSMEG2785 in Mycobacterium smegmatis, Rv2673 in Mycobacterium tuberculosis and NCgl1822 in Corynebacterium glutamicum, with 10 predicted transmembrane domains and a glycosyltransferase motif (DDX), features that are common to the GT-C superfamily of glycosyltransferases. Deletion of M. smegmatis MSMEG2785 resulted in altered growth and glycosyl linkage analysis revealed the absence of AG α(1→3)-linked arabinofuranosyl (Araf) residues. Complementation of the M. smegmatis deletion mutant was fully restored to a wild-type phenotype by MSMEG2785 and Rv2673, and as a result, we have now termed this previously uncharacterized open reading frame, arabinofuranosyltransferase C (aftC). Enzyme assays using the sugar donor β-d-arabinofuranosyl-1-monophosphoryl-decaprenol (DPA) and a newly synthesized linear α(1→5)-linked Ara₅ neoglycolipid acceptor together with chemical identification of products formed, clearly identified AftC as a branching α(1→3) arabinofuranosyltransferase. This newly discovered glycosyltransferase sheds further light on the complexities of Mycobacterium cell wall biosynthesis, such as in M. tuberculosis and related species and represents a potential new drug target.

Identification of the dehydratase component of the mycobacterial mycolic acid-synthesizing fatty acid synthase-II complex

Mycolic acids are vital components of the Mycobacterium tuberculosis cell wall and are essential for survival. While most components of the fatty acid synthase-II (FAS-II) enzymic machinery that synthesizes these long chain alpha-alkyl, beta-hydroxy fatty acids have been identified, the gene encoding the beta-hydroxyacyl-acyl carrier protein (ACP) dehydratase activity has remained elusive. Recent bioinformatics-based studies and drug inhibition experiments have identified the M. tuberculosis gene Rv0636 as a promising candidate for this role. Using a recently described, specialized transduction-based genetic tool we now demonstrate that MSMEG1341, the Mycobacterium smegmatis homologue of Rv0636, is an essential gene; null mutants of the gene could only be generated in a merodiploid strain which contained a second integrated acetamide-inducible copy of MSMEG1341. Growth of the conditional mutant in the absence of acetamide resulted in loss of mycolic acid biosynthesis and eventually loss of viability due to cell lysis. Null MSMEG1341 mutants could also be generated in a M. smegmatis strain containing an integrated copy of Rv0636, indicating that Rv0636 was the functional counterpart of MSMEG1341 in M. tuberculosis. Our results demonstrate that MSMEG1341 is an essential gene involved in mycolic acid biosynthesis and encodes the FAS-II beta-hydroxyacyl-ACP dehydratase.

Flavonoid inhibitors as novel antimycobacterial agents targeting Rv0636, a putative dehydratase enzyme involved in Mycobacterium tuberculosis fatty acid synthase II

Flavonoids comprise a large group of bioactive polyphenolic plant secondary metabolites. Several of these possess potent in vivo activity against Escherichia coli and Plasmodium falciparum, targeting enzymes involved in fatty acid biosynthesis, such as enoyl-ACP-reductase, beta-ketoacyl-ACP reductase and beta-hydroxyacyl-ACP dehydratase. Herein, we report that butein, isoliquirtigenin, 2,2',4'-trihydroxychalcone and fisetin inhibit the growth of Mycobacterium bovis BCG. Furthermore, in vitro inhibition of the mycolic-acid-producing fatty acid synthase II (FAS-II) of Mycobacterium smegmatis suggests a mode of action related to those observed in E. coli and P. falciparum. Through a bioinformatic approach, we have established the product of Rv0636 as a candidate for the unknown mycobacterial dehydratase, and its overexpression in M. bovis BCG conferred resistance to growth inhibition by butein and isoliquirtigenin, and relieved inhibition of fatty acid and mycolic acid biosynthesis in vivo. Furthermore, after overexpression of Rv0636 in M. smegmatis, FAS-II was less sensitive to these inhibitors in vitro. Overall, the data suggest that these flavonoids are inhibitors of mycobacterial FAS-II and in particular Rv0636, which represents a strong candidate for the beta-hydroxyacyl-ACP dehydratase enzyme of M. tuberculosis FAS-II.

X-ray crystal structure of Mycobacterium tuberculosis beta-ketoacyl acyl carrier protein synthase II (mtKasB)

Mycolic acids are long chain alpha-alkyl branched, beta-hydroxy fatty acids that represent a characteristic component of the Mycobacterium tuberculosis cell wall. Through their covalent attachment to peptidoglycan via an arabinogalactan polysaccharide, they provide the basis for an essential outer envelope membrane. Mycobacteria possess two fatty acid synthases (FAS); FAS-I carries out de novo synthesis of fatty acids while FAS-II is considered to elongate medium chain length fatty acyl primers to provide long chain (C(56)) precursors of mycolic acids. Here we report the crystal structure of Mycobacterium tuberculosis beta-ketoacyl acyl carrier protein synthase (ACP) II mtKasB, a mycobacterial elongation condensing enzyme involved in FAS-II. This enzyme, along with the M. tuberculosis beta-ketoacyl ACP synthase I mtKasA, catalyzes the Claisen-type condensation reaction responsible for fatty acyl elongation in FAS-II and are potential targets for development of novel anti-tubercular drugs. The crystal structure refined to 2.4 A resolution revealed that, like other KAS-II enzymes, mtKasB adopts a thiolase fold but contains unique structural features in the capping region that may be crucial to its preference for longer fatty acyl chains than its counterparts from other bacteria. Modeling of mtKasA using the mtKasB structure as a template predicts the overall structures to be almost identical, but a larger entrance to the active site tunnel is envisaged that might contribute to the greater sensitivity of mtKasA to the inhibitor thiolactomycin (TLM). Modeling of TLM binding in mtKasB shows that the drug fits the active site poorly and results of enzyme inhibition assays using TLM analogues are wholly consistent with our structural observations. Consequently, the structure described here further highlights the potential of TLM as an anti-tubercular lead compound and will aid further exploration of the TLM scaffold towards the design of novel compounds, which inhibit mycobacterial KAS enzymes more effectively.

Progress and new directions in genetics of tuberculosis: an NHLBI working group report

Tuberculosis (TB), along with AIDS and malaria, is one of the three major killers among infectious diseases. New approaches to preventing, diagnosing, and curing TB are needed, which depend on a better understanding of Mycobacterium tuberculosis and the host. The National Heart, Lung, and Blood Institute convened a working group to develop recommendations for future TB research, including genetic aspects of the disease. The following areas were identified: (1) animal model research to improve understanding of persistence, reactivation, and granulomatous reactions; (2) preclinical studies aimed at shortening treatment of TB; (3) new resources for manipulating and characterizing the M. tuberculosis genome, proteome chips for more specific diagnoses, and studies of genes that appear to be essential but whose functions are not known; (4) prospective studies associated with clinical trials in populations with or at risk of TB to advance development of diagnostics and prognostics; (5) new quantitative and bioinformatic approaches to study the interaction between M. tuberculosis and the infected host and how this influences the infection process; (6) molecular characterization of M. tuberculosis genome diversity and phylogenetic analysis; (7) coordinated studies of human genome scans; (8) genetic epidemiology studies; (9) activities to foster knowledge dissemination, education, and training; and (10) coordination between the National Institutes of Health, the Gates Foundation, the Global Alliance for Tuberculosis Drug Development, and other organizations.

Probing the mechanism of the Mycobacterium tuberculosis beta-ketoacyl-acyl carrier protein synthase III mtFabH: factors influencing catalysis and substrate specificity

Mycolic acids are the dominant feature of the Mycobacterium tuberculosis cell wall. These alpha-alkyl, beta-hydroxy fatty acids are formed by the condensation of two fatty acids, a long meromycolic acid and a shorter C(24)-C(26) fatty acid. The component fatty acids are produced via a combination of type I and II fatty acid synthases (FAS) with FAS-I products being elongated by FAS-II toward meromycolic acids. The beta-ketoacyl-acyl carrier protein (ACP) synthase III encoded by mtfabH (mtFabH) links FAS-I and FAS-II, catalyzing the condensation of FAS-I-derived acyl-CoAs with malonyl-acyl carrier protein (ACP). The acyl-CoA chain length specificity of mtFabH was assessed in vitro; the enzyme extended longer, physiologically relevant acyl-CoA primers when paired with AcpM, its natural partner, than with Escherichia coli ACP. The ability of the enzyme to use E. coli ACP suggests that a similar mode of binding is likely with both ACPs, yet it is clear that unique factors inherent to AcpM modulate the substrate specificity of mtFabH. Mutation of proposed key mtFabH residues was used to define their catalytic roles. Substitution of supposed acyl-CoA binding residues reduced transacylation, with double substitutions totally abrogating activity. Mutation of Arg(46) revealed its more critical role in malonyl-AcpM decarboxylation than in the acyl-CoA binding role. Interestingly, this effect was suppressed intragenically by Arg(161) --> Ala substitution. Our structural studies suggested that His(258), previously implicated in malonyl-ACP decarboxylation, also acts as an anchor point for a network of water molecules that we propose promotes deprotonation and transacylation of Cys(122).

Tuberculosis in New York city: recent lessons and a look ahead

In the late 1980s and early 1990s, after decades of decline, the incidence of tuberculosis began to rise in New York city, reaching a peak of 3811 cases by 1992. The epidemic took root in a setting of inadequate treatment regimens, homelessness, a diminished public-health system, and the onset of the HIV/AIDS epidemic. In addition, a subepidemic of drug-resistant tuberculosis occurred throughout New York city, most notably in a series of well documented nosocomial outbreaks. By 1994, using broadened initial treatment regimens, directly observed therapy, and improved US Centers for Disease Control and Prevention guidelines for hospital control and disease prevention, New York city began to effectively halt the progression of the epidemic. By 2002, tuberculosis rates in New York city reached an historic low of 1084. However, given the presence of a large reservoir of latently infected individuals in the city and an ongoing tuberculosis pandemic, New York city continues to face significant challenges from this persistent pathogen.

The politics of 'branding' in policy transfer: the case of DOTS for tuberculosis control

How and why policies are transferred between countries has attracted considerable interest from scholars of public policy over the last decade. This paper, based on a larger study, sets out to explore the processes involved in policy transfer between international and national levels. These processes are illustrated by looking at a particular public health policy--DOTS for the control and treatment of tuberculosis. The paper demonstrates how, after a long period of neglect, resources were mobilised to put tuberculosis back on international and national public policy agendas, and then how the policy was 'branded' and marketed as DOTS, and transferred to low and middle income countries. It focuses specifically on international agenda setting and policy formulation, and the role played by international organisations in those processes. It shows that policy communities, and particular individuals within them, may take political rather than technical positions in these processes, which can result in considerable contestation. The paper ends by suggesting that while it is possible to raise the profile of a policy dramatically through branding and marketing, success also depends on external events providing windows of opportunity for action. Second, it warns that simplifying policy approaches to 'one-size-fits-all' carries inherent risks, and can be perceived to harm locally appropriate programmes. Third, top-down internationally driven policy changes may lead to apparent policy transfer, but not necessarily to successfully implemented programmes.

Mycobacterium tuberculosis pathogenesis and molecular determinants of virulence

Tuberculosis (TB), one of the oldest known human diseases. is still is one of the major causes of mortality, since two million people die each year from this malady. TB has many manifestations, affecting bone, the central nervous system, and many other organ systems, but it is primarily a pulmonary disease that is initiated by the deposition of Mycobacterium tuberculosis, contained in aerosol droplets, onto lung alveolar surfaces. From this point, the progression of the disease can have several outcomes, determined largely by the response of the host immune system. The efficacy of this response is affected by intrinsic factors such as the genetics of the immune system as well as extrinsic factors, e.g., insults to the immune system and the nutritional and physiological state of the host. In addition, the pathogen may play a role in disease progression since some M. tuberculosis strains are reportedly more virulent than others, as defined by increased transmissibility as well as being associated with higher morbidity and mortality in infected individuals. Despite the widespread use of an attenuated live vaccine and several antibiotics, there is more TB than ever before, requiring new vaccines and drugs and more specific and rapid diagnostics. Researchers are utilizing information obtained from the complete sequence of the M. tuberculosis genome and from new genetic and physiological methods to identify targets in M. tuberculosis that will aid in the development of these sorely needed antitubercular agents.

[Risk factors associated to tuberculosis patients with positive sputum microscopy]

OBJECTIVE

The main factor responsible for producing new cases of tuberculosis by exogen transmission is the existence of Mycobacterium tuberculosis in the sputum of tuberculosis patients. The objective of this study was to determine the risk factors associated to positive smear tuberculosis cases in Lleida (Spain).

METHODS

We studied new cases of tuberculosis over the period 1992-1998. The variables considered were: age, gender, coinfection with HIV, injection drug use (IDU), consumption of alcohol, existence of caverns in thorax X-ray, and laboratory results of direct smear examination. We calculated the incidence rates for 100,000 persons-year. The association between the dependent variable case of tuberculosis with positive Mycobacterium tuberculosis smear and the remaining independent variables were assessed obtaining odds ratios (OR) and 95% confidence intervals (CI) (crude cOR and adjusted aOR by non conditional logistic regression).

RESULTS

We detected 905 new cases of tuberculosis. The rates in the period 1992-1998 decreased from 38.8 to 30.8. 44.9% of cases (n = 406) presented a positive direct smear. There was a positive association between the risk of being a positive smear patient and having caverns in thorax x-ray (aOR = 6.8; 95% CI, 4.8-95), being male (aOR = 1.8; 95% CI, 1.3-2.6) and consuming alcohol (aOR = 1.6; 95% CI,1.1-2.3) and this risk was significant lower in those under 15 years old (aOR = 0.2; 95% CI, 0.1-0.5), and coinfection with HIV (aOR = 0.5; 95% CI, 0.3-0.9).

CONCLUSIONS

HIV infection implies a reduced impact in endemecity of tuberculosis. Study of contacts and the implementation of directly observed treatment must be considered not only for coinfected HIV cases and IDU but also for adult males, especially those who consume alcohol, particularly when they have caverns.

Predictors of tuberculosis transmission in prisons: an analysis using conventional and molecular methods

OBJECTIVE

To determine the tuberculosis (TB) transmission patterns within the prison system in Catalonia, conventional epidemiological techniques were combined with DNA fingerprinting of Mycobacterium tuberculosis.

METHODS

IS6110- and polymorphic GC-rich repeat sequence (PGRS)-based restriction fragment length polymorphism (RFLP) were combined with epidemiological studies to assess the relatedness of isolates from all patients with confirmed TB at five prisons in the province of Barcelona (Catalonia, Spain), between 1 July 1994 and 31 December 1996. Risk factors for transmission were analysed to a logistic regression. The extent of drug-resistant TB was also assessed.

RESULTS

The incidence of TB during the study period was 2775 cases per 100,000 inmate years. Of the 247 culture-positive cases, 126 (51%) appeared to have active TB as a result of recent transmission. Using conventional epidemiological methods, 14 active chains of transmission were identified in prison involving 65 isolates (52% of clustered patients). A lengthy history of imprisonment [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.52-5.11] and pulmonary TB (OR 2.36, 95% CI 1.17-4.75) were independently associated with clustering. Low rates of both initial (2.9%) and acquired drug resistance (5.8%) were identified and there was no evidence of the transmission of drug-resistant TB.

CONCLUSION

In the prison system studied, the recent transmission of TB contributes substantially to the overall incidence of the disease. Both lengthy incarcerations and delays in identifying inmates with pulmonary symptoms play a key role in this recent transmission. Directly observed therapy (DOT) is a critical control strategy for reducing the emergence of drug resistance and for avoiding the transmission of resistant organisms.

Treatment and prevention of multidrug-resistant tuberculosis

Multidrug-resistant tuberculosis (MDRTB), which is defined as combined resistance to isoniazid and rifampicin, is a 'man-made' disease that is caused by improper treatment, inadequate drug supplies or poor patient supervision. Patients with MDRTB face chronic disability and death, and represent an infectious hazard for the community. Cure rates of 96% have been achieved but require prompt recognition of the disease, rapid accurate susceptibility results, and early administration of an individualised re-treatment regimen. Such regimens are usually based on a quinolone and an injectable agent (i.e. an aminoglycoside or capreomycin) supplemented by other 'second-line' drugs. This therapy is prolonged (e.g. 24 months), expensive, and has multiple adverse effects. Prevention of MDRTB is therefore of paramount importance. The World Health Organization (WHO) has recommended a multifaceted programme, known by the acronym DOTS (directly observed therapy, short-course), that promotes effective treatment of drug-susceptible TB as the prime method of limiting drug resistance. DOTS was part of a successful MDRTB control programme in New York City, which also included treatment of prevalent MDRTB cases, streamlined laboratory testing, effective infection control procedures and wider application of screening and preventive therapy (although the optimal chemotherapy for MDRTB infection remains undefined). Industrialised countries have the resources to treat patients with MDRTB and to mount these extensive control programmes. Unfortunately, MDRTB is also prevalent in Asia, South America and the former Soviet Union. First world countries have a vested interest, as well as a moral responsibility, to assist in controlling MDRTB in these 'hot spots'.

[Anti-tuberculosis drug consumption as an indicator of the epidemiological situation of tuberculosis in Spain]

OBJECTIVES

To describe anti-tuberculosis drug consumption in Spain for the period, 1985-1995, compare the associated time trend and geographical pattern against case reports of tuberculosis (TB), and estimate the number of persons undergoing anti-tuberculosis therapy in 1995.

METHODS

The official Drug Database was used to ascertain consumption of anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) in Spain during the period, 1985-1995. The technical units of measurement used for comparison purposes were daily defined dose (DDD) and DDD rate per day per 100,000 population. Annual trends and geographical patterns of consumption were plotted. The respective numbers of persons treated in 1995 with each of the four drugs were first estimated and then compared against TB case reports.

RESULTS

There was an overall decline in the consumption of isoniazid, rifampicin and ethambutol over the period, 1985-1995, though the former two registered rises in 1991 and 1992. Pyrazinamide consumption showed growth throughout the study period. The highest 1995 consumption rates were registered by Galicia, Cantabria, Asturias, the Basque Country, Ceuta and Melilla, and the lowest by the Canary Islands and Navarre. Comparisons run against TB case reports revealed a greater degree of underreporting in certain provinces. In 1995, approximately 18,858 persons (48 per 100,000 population) must be assumed to have undergone pyrazinamide therapy in Spain, indicating that the reported TB rate of 22 per 100,000 population could well represent underreporting in excess of 100%.

CONCLUSIONS

The trend in anti-tuberculosis drug consumption reflects shifts in treatment guidelines and is compatible with a rise in TB incidence in recent years. Major underreporting of TB marked by wide inter-regional and -provincial differences was in evidence. Pyrazinamide consumption is probably the best indicator for estimating minimum TB incidence.

The return of tuberculosis

At the end of the 20th century, tuberculosis remains a major public health issue. In developing countries tuberculosis is a leading cause of morbidity and mortality, and the spread of the HIV epidemic contributes significantly to the worsening of the situation. Coinfection with tuberculosis and HIV results in special diagnostic and therapeutic problems and uses up larger amounts of medical resources in developing countries. Outbreaks of multidrug resistant tuberculosis (MDR-TB) were first reported from US-American centers caring for HIV patients, but have now been observed in many other countries. In Western Europe the tuberculosis epidemic is under control, but increasing incidence rates in migrants raise new problems in these countries. Tuberculosis is uncontrolled in large parts of the former Soviet Union due to the socio-economic break-down in these countries. Only rigorous infection control measures on a world-wide scale will prevent further detoriation of this situation. Therefore, the extension of surveillance systems, and sufficient funding for the prevention, diagnosis, and treatment of tuberculosis by national governments and international organizations are all urgently needed.

Host resistance to intracellular infection: mutation of natural resistance-associated macrophage protein 1 (Nramp1) impairs phagosomal acidification

The mechanisms underlying the survival of intracellular parasites such as mycobacteria in host macrophages remain poorly understood. In mice, mutations at the Nramp1 gene (for natural resistance-associated macrophage protein), cause susceptibility to mycobacterial infections. Nramp1 encodes an integral membrane protein that is recruited to the phagosome membrane in infected macrophages. In this study, we used microfluorescence ratio imaging of macrophages from wild-type and Nramp1 mutant mice to analyze the effect of loss of Nramp1 function on the properties of phagosomes containing inert particles or live mycobacteria. The pH of phagosomes containing live Mycobacterium bovis was significantly more acidic in Nramp1- expressing macrophages than in mutant cells (pH 5.5 +/- 0.06 versus pH 6.6 +/- 0.05, respectively; P <0.005). The enhanced acidification could not be accounted for by differences in proton consumption during dismutation of superoxide, phagosomal buffering power, counterion conductance, or in the rate of proton "leak", as these were found to be comparable in wild-type and Nramp1-deficient macrophages. Rather, after ingestion of live mycobacteria, Nramp1-expressing cells exhibited increased concanamycin-sensitive H+ pumping across the phagosomal membrane. This was associated with an enhanced ability of phagosomes to fuse with vacuolar-type ATPase-containing late endosomes and/or lysosomes. This effect was restricted to live M. bovis and was not seen in phagosomes containing dead M. bovis or latex beads. These data support the notion that Nramp1 affects intracellular mycobacterial replication by modulating phagosomal pH, suggesting that Nramp1 plays a central role in this process.

Pulmonary and extrapulmonary tuberculosis at AIDS diagnosis in Spain: epidemiological differences and implications for control

OBJECTIVE

To ascertain the differential factors associated with pulmonary versus extrapulmonary tuberculosis (TB) at AIDS diagnosis in Spain.

DESIGN

Analysis of AIDS surveillance data.

METHODS

Data about AIDS patients, aged 12 years and over, diagnosed in 1995 were taken from the Spanish AIDS Register. The respective proportions of cases presenting with pulmonary and extrapulmonary TB at AIDS diagnosis were analysed by gender, age, HIV transmission category, prison record, province, country of origin and CD4+ lymphocyte count. A multivariate analysis was carried out using logistic regression analysis.

RESULTS

Of 6161 AIDS cases analysed, 20.1% presented with pulmonary TB and 20.4% with extrapulmonary TB. Overall, TB showed association with men, age under 30 years, injecting drug users (IDU), cases of heterosexual HIV transmission, and concurrent or past stay in prison. Frequency of TB proved no different among foreign-born patients. Pulmonary and extrapulmonary TB showed a similar distribution for most of the variables. Current prison inmates registered a high risk of pulmonary TB [adjusted odds ratio (OR), 4.2; 99% confidence interval (CI), 3.1-5.8] compared with patients without prison record, and ex-prison inmates registered an intermediate risk (OR, 2.3; 99% CI, 1.8-3.0). Among patients with TB at AIDS diagnosis, pulmonary TB was associated with subjects currently in prison (OR, 2.1; 99% CI, 1.5-3.0) and injecting drug use (OR, 1.5; 99% CI, 1.0-2.4). Pulmonary TB presented with higher CD4+ lymphocyte counts than extrapulmonary TB (P < 0.001).

CONCLUSIONS

The results suggest the importance that recent transmission of TB may be having among young adults, IDU and prison inmates in particular, and calls for a review of control strategies.

Active efflux by multidrug transporters as one of the strategies to evade chemotherapy and novel practical implications of yeast pleiotropic drug resistance

Mankind is faced by the increasing emergence of resistant pathogens, including cancer cells. An overview of the different strategies adopted by a variety of cells to evade chemotherapy is presented, with a focus on the mechanisms of multidrug transport. In particular, we analyze the yeast network for pleiotropic drug resistance and assess the potentiality of this system for further understanding of the mechanism of broad specificity and for development of novel practical applications.