Microbiology and Immunology 2500

Tuberculosis and Leprosy

Dr. Idowu Olawoye

Dr. (He-doh-wu Or-lah-wor-yay)
iolawoye@uwo.ca
Lyme Disease (Lyme Borreliosis)
• prototype emerging infectious disease
Learning Objectives
• a multisystemic disorder
• commonly presents
• Understand unique as skin lesions
properties of the mycobacteria cell envelope
(erythema migrans)
• Understand transmission and progression of tuberculosis and
leprosy
• if untreated, can lead to arthritis, carditis
• Recognize methods and limitations for TB testing
and• nervous
Distinguishsystem manifestations
key differences between leprosy
• mostandcommon vector-borne disease in
tuberculosis

North America
Mycobacteria
• M. tuberculosis
– causative agent of Tuberculosis in humans
– often called "TB" for tubercle bacilli
• M. leprae
– causative agent of Leprosy in humans
• M. bovis
– causes tuberculosis in cows, rarely in humans
– humans can be infected by the consumption of
unpasteurized milk leading to extrapulmonary
tuberculosis
• M. avium
– can cause a tuberculosis-like illness in humans,
particularly in patients with AIDS
Tuberculosis
• Infection by M. tuberculosis can be latent or active
• Approximately 2 Billion people (1/4 of the world’s population)
likely have latent TB
• TB is contagious and spread through the air by people with
active TB
• ~10% of people infected with latent TB will develop active TB
in their lifetime
• ~1.6 million people die from TB each year
Latent TB Infection

Houbet and Dodd, 2018. PLoS Medicine

Mycobacterium tuberculosis
• An intracellular pathogen (lives within
macrophages)
• Slow generation time of >15 h
• M. tuberculosis can be grown in the lab on
specialized media but takes 4-6 weeks to
get small colonies
 Mycobacterium tuberculosis
• Mycobacteria have an unusual cell envelope with high
concentrations of mycolic acid – ‘waxy’
• Impermeability to stains and dyes
- ‘Gram positive’ Acid fast stain (a Hallmark of Mycobacteria)
• The unusual cell envelope is
associated with resistance to:
- some antibiotics
- osmotic lysis via complement
deposition
- lethal oxidative stress promoting
survival inside of macrophages
The pathogen: Mycobacterium tuberculosis
• the "waxy", lipid-rich cell envelope (very
hydrophobic) resists common strains –
(i.e. Gram strain)
• “acid-fastness” is due to the presence
of mycolic acid
• Acid fast stain
- stained with carbol-fuchsin dye with
slow heating (to melt the wax)
- washed with ethanol and HCl
- counter stained with methylene blue
- acid-fast organisms appear red
whereas non-acid fast organisms
appear blue
Spread and progression of tuberculosis
• Stage 1:
– transmission is from inhalation of droplets from an infected
host, usually by coughing or sneezing
– coughing/sneezing can generate 3000 droplet nuclei; droplet
nuclei can contain <10 bacteria
– small diameter droplets (~5 μm) can stay airborne for
extended periods of time
– airborne droplets can be
inhaled directly into
the lungs
Spread and progression of tuberculosis
• Stage 2:
– phagocytosis of TB cells by lung (alveolar) macrophages
– TB blocks acidification of the phagosome
– TB inhibits the fusion of the lysosome to the phagosome
– TB multiplies in macrophages
– macrophages lyse and release TB cells to infect more
macrophages
– TB delays dendritic cell migration to lymph nodes
 ESX secretion systems

• 5 ESX systems exist

in Mtb
• enable the transport
of select bacterial
molecules across the thick
Mtb cell envelope
• multiple functions including
damage to the phagosome
membrane
• other functions that inhibit
the immune responses

Gröschel et al., 2016 Nature Reviews Microbiology

Spread and progression
of tuberculosis
• Stage 3:
– infected macrophages may
form granulomas
– TB granulomas are "tubercles"
of immune cells that try to
destroy invading pathogens
(typically formed by
macrophages)
– the granuloma represents a
"balance" between the
pathogen and the host à
latent infection
Spread and progression
of tuberculosis
• Stage 3:
– T cell activated
macrophages can kill TB
– activated T cells can secrete
cytokines (IFN-gamma) to
activate the macrophages
– macrophages at the center
of the granuloma remain
harder to activate by T cells
– chronic inflammation cause
“cheese-like” necrosis à
caseous necrosis
Spread and progression
of tuberculosis
• Stage 4:
– some macrophages remain
unactivated and infected
– the tubercle grows
– erosion of the granuloma into
the airway provides the route of
transmission
– deterioration of host immunity
can result in a life-threatening
infection à active tuberculosis
– the caseous center can liquefy
leading to cavitation
Extrapulmonary Tuberculosis
• Infection outside the lungs
• Can infect multiple organ systems (bone, joints, liver, spleen,
gastrointestinal tract and brain)
• More likely to occur in immunocompromised (e.g. HIV-
infected patients) individuals and young children
• Widespread dissemination, called miliary tuberculosis, is
almost always fatal
Testing and Diagnosis
• Tuberculin test (PPD = purified protein
derivative from M. tuberculosis)
• T cell-mediated response
• a positive result is a red and swollen circle at 48h
• a person is considered infected
if they convert from negative to positive on a TB skin
test
• a positive result could mean:
- latent or active TB, BCG vaccinated, previously
infected
• a negative result could mean:
- not infected, immune compromised (e.g. AIDS),
not infected long enough
Testing and Diagnosis
• A positive tuberculin test would
likely mean a careful history and
a chest X-ray
• X-ray: typical upper lobe
“shadowing” = lesions
• calcified granulomas may be
seen on an X-ray
• staining of sputum for acid fast
bacilli and culturing
• Interferon-gamma response assay
Treatment
• active TB can kill ~2 out of 3 people if untreated
• six months of antibiotics for the short treatment
– slow growth means long treatments
• generally, multiple types of antibiotics are used:
– Rifampin (inhibits RNA polymerase)
– Isoniazid (inhibits mycolic acid synthesis)
– others…
• why give two or more drugs?
Drug Resistant TB
• multi-drug resistant TB (MDR-TB)
– defined as being resistant to the two most effective
first-line therapeutic drugs, isoniazid and rifampin
• extensively-drug resistant TB (XDR-TB)
– also resistant to the most effective second-line therapeutic drugs
used commonly to treat MDR-TB
– XDR-TB has been found in all regions of the world
• BUT:
– new drugs are being developed
– drug combinations and reduced treatment regimes
BCG
• “bacille Calmette-Guérin”
• a living vaccine prepared from
attenuated M. bovis
• lacks the ESX-1 secretion system
• BCG shares antigenicity with TB
• controversial due to variable efficacy (~80% or much less) for
pulmonary TB
• effective against miliary TB
• vaccinated individuals can give a false positive for the tuberculin
test
• vaccination leaves large scars
• recommended for individuals with high risk to exposure
Leprosy
• a chronic disease caused by Mycobacterium leprae
• Leprosy is also sometimes called Hansen’s disease
• very slow progression – incubation period of ~5 years
• can cause permanent damage to skin, nerves, limbs and eyes
• Leprosy is very rare in high-income countries
• ~ 2 million people are permanently disabled by leprosy, mainly
in tropical developing countries (this may be a low estimate)
Mycobacterium leprae
• “Gram-positive” acid fast, rod shaped, waxy cell envelope
(mycolic acid)
• cannot be cultivated in vitro (less well-studied than M.
tuberculosis)
• M. leprae infects macrophages of skin and Schwann cells in
nerves
• can grow in the foot pads of mice (low numbers)
• causes systemic infection in the armadillo (1010 organisms
per gram of infected tissue)
Leprosy
• historically, victims of leprosy have been ostracized
– rejected by family and friends
– driven out of communities
• lesions in tuberculosis are “hidden”
• lesions in leprosy are “visible”
• BUT, leprosy is much less infectious that TB
Leprosy
• two major forms: Tuberculoid and Lepromatous
Tuberculoid Leprosy
• cell-mediated immunity present
• macrophage can contain
the bacteria
• light coloured lesions with
“anesthetic” areas
• sometimes loss of hair and
pigmentation
• patients become tuberculin positive
(active T cell-mediated responses)
• bacterial cells are generally not
recoverable from lesions
• Tuberculoid Leprosy can be
self-limiting
Lepromatous Leprosy
• cell-mediated immune responses are absent
• macrophages are not ac4vated
• M. leprae survives and mul4ples in macrophages and Schwann
cells
• Schwann cells provide myelin insula4on to peripheral nerves
• due to nerve damage and loss of sensa4on leads to inadvertent
trauma4c lesions on the face and extremi4es
• can cause loss of eyebrows, thickening and enlarged nares, ears
and cheeks à “lion like” appearance
• lesions can become secondarily infected, eventually resul4ng in
bone resorp4on, disfigurements and mu4la4on
Early versus Late Lepromatous Leprosy
 A Macrophage Response to Mycobacterium leprae
Phenolic Glycolipid Initiates Nerve Damage in Leprosy
Spread and progression of leprosy
• transmission is not well understood
• probably close and direct contact is required for extended
periods of time - inhaled droplets?
• most exposed individuals do not develop disease – host
genetics likely plays an important role
Leprosy is treatable with antibiotics
• multidrug therapy (MDT) with 3 antibiotics (same treatments
since the 1980s)
• 6 months to 1 year
• patients are thought to no longer transmit the disease after one
dose of MDT
• ultimate goal is elimination of leprosy