Thesis (MScMedSc)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Setting This study was conducted in the Tygerberg district, Cape Town, in the Western Cape, South Africa Background The evaluation of early tuberculosis (TB) treatment response is based on month 2 sputum culture status. This method of evaluation has a number of limitations: the test requires relatively advanced laboratory infrastructure and procedures, it takes several weeks to obtain results and is a relatively a poor marker at predicting treatment response. The discovery of potential host markers which reflect the efficacy of early treatment would be of great importance for clinical management of individual patients. The treatment failure would be detectable earlier than at week 8 of treatment. The duration of clinical trials of new anti-tuberculosis drugs may also be substantially reduced by such markers if these would be measurable earlier than at week 8 of therapy. Objectives 1) To evaluate diluted, 7-day whole blood cultures stimulated with live Mycobacterium tuberculosis (M.tb) for the presence of host markers of early TB treatment response 2) To evaluate an overnight, undiluted, M.tb antigen stimulated whole blood culture Quantiferon Gold In Tube (QFT-GIT) supernatants for host markers of early TB treatment response The study designs were as follows: In study one, baseline samples and samples from week 1, week 2 and week 4 of treatment from 30 cured TB patients were selected from a larger biomarker study, in which whole blood was stimulated with live M.tb or left unstimulated. Fifty seven host markers were measured in supernatants by multiplex cytokine arrays. In study two, baseline samples and samples from week 2 and week 8 of treatment from 19 cured TB patients were randomly selected from the placebo group in a micronutrient supplement study. QFT-GIT supernatants from these participants were assessed through multiplex cytokine arrays for levels of fifty seven host markers. All of the participants in both studies were Human Immunodeficiency Virus (HIV) negative. Changes in marker expression over time and between fast and slow responders to treatment were evaluated. Comparability between the two culture methods was assessed for markers that were evaluated in both studies. Results In study one, the majority of host markers showed significant changes over time in the unstimulated supernatants. Only GRO and IL-1beta changed significantly in an antigen-specific manner (background levels subtracted). No significant changes were observed between fast and slow responders. In study two, the majority of host markers showed significant changes over time in the unstimulated supernatants whereas only MDC and IL-4 changed during the observation period in antigen stimulated levels. Significant differences were observed between fast and slow responders at pre-treatment for IL-13 Ag-Nil and IL-1betaAg-Nil . Conclusion This study revealed, antigen-specific responses showed only limited potential for early TB treatment response monitoring, but may have potential in differentiating between treatment outcomes. Future investigations may have to include later time points during treatment as these were not included in the present assessment. The QFT-GIT samples do not appear to be equivalent to live M.tb stimulated 7-day whole blood assays. / AFRIKAANSE OPSOMMING: Instelling Die studie is uitgevoer in die Tygerbergdistrik, Kaapstad, Wes-Kaap, Suid-Afrika. Agtergrond Die evaluering van die respons op vroeë tuberkulose (TB) behandeling word gebaseer op die status van maand 2 sputum kulture. Hierdie evalueringsmetode het ‘n paar beperkinge: die toets benodig relatief gevorderde laboratorium infrastruktuur en prosedures, die toetsuitslae is eers na ‘n paar weke beskikbaar en dit is n relatiewe swak merker om repons op behandeling te voorspel. Die ontdekking van potensiële selfmerkers wat die doeltreffendheid van vroeë behandeling weerspieël sal van groot belang wees vir die kliniese bestuur van individuele pasiënte. Mislukking van die behandeling sal sodoende voor week 8 van behandeling waargeneem kan word. Die tydsduur van kliniese proewe van nuwe anti-tuberkulose medikasie mag ook baie verkort word met sulke merkers as dit voor week 8 van behandeling gemeet kan word. Doelwitte 1) Om verdunde, 7-dae oue volbloedkulture, met lewende Mikobakterium tuberkulosis (M.tb) gestimuleer, te evalueer vir die teenwoordigheid van vroeë TB behandeling respons selfmerkers. 2) Om die supernatant van oornag, onverdunde, M.tb antigeen gestimuleerde volbloedkulture Quantiferon Gold In Tube (QFT-GIT) vir vroeë behandeling respons selfmerkers te evalueer. Die studie-ontwerpe was soos volg: Met studie een is basislynmonsters en monsters verkry na week 1, week 2 en week 4 van behandeling van 30 geneesde TB-pasiënte geselekteer uit ‘n groter biomerkerstudie waarin die volbloed met lewende M.tb gestimuleer is of ongestimuleer gelaat is. Sewe-en-vyftig selfmerkers is in die supernatante gemeet deur middel van multipleks sitokine arrays. Met studie twee is basislynmonsters en monsters verkry na week 2 en week 8 van behandeling van 19 geneesde TB-pasiënte lukraak uit die plasebo-groep in ‘n mikrovoedingstowwe-aanvullingstudie geselekteer. Vlakke van 57 selfmerkers is in die QFT-GIT supernatante van hierdie deelnemers, deur middel van die multipleks sitokine arrays, bepaal. Al die deelnemers van beide studies was HIV negatief. Veranderinge in merker-uitdrukking oor tyd, asook tussen vinnige en stadige respons tot behandeling, is ge-evalueer. Die vergelykbaarheid van die twee kultuurmetodes is geassesseer ten opsigte van die ge-evalueerde merkers in albei studies. Resultate Met studie een het die meerderheid van die selfmerkers in die ongestimuleerde supernatante kenmerkende verandering oor tyd gewys. Slegs GRO en IL-1beta het aansienlik verander in die antigeenspesifieke wyse (agtergrond vlakke afgetrek). Geen kenmerkende veranderinge was waargeneem tussen die vinnige en stadige respons pasiënte nie. Met studie twee het die meerderheid van die selfmerkers aansienlike veranderinge oor tyd in die ongestimuleerde supernatante gewys, in vergelyking waar net die MDC en IL-4 veranderinge gedurende die observasie periode in antigeen gestimuleerde vlakke getoon het. Kenmerkende verskille is tussen die vinnige en stadige respons pasiënte in voorbehandeling vir IL-13 Ag-Nil en IL-1betaAg-Nil waargeneem. Gevolgtrekking Die studie bewys dat antigeenspesifieke response slegs beperkte potensiaal vir vroeë TB behandeling respons monitering het, maar mag die potensiaall vir onderskeidende behandeling uitkomste hê. Toekomstige ondersoeke sal dalk latere tydpunte gedurende die behandeling moet insluit aangesien dit nie in hierdie evaluasie ingesluit is nie. Die QFT-IT monsters verskyn nie as gelykwaardig met die lewendig M.tb gestimuleerde 7-dae volbloed toetse nie.

La capacité d'adaptation des bactéries à leur environnement repose, entre autres choses, sur des mécanismes de transduction du signal. Ces mécanismes leur permettent de percevoir la nature et les modifications du milieu dans lequel elles évoluent et d'adapter en conséquence leur métabolisme et leur physiologie. L'un de ces mécanismes identifié chez les procaryotes repose sur un processus de régulation impliquant, suite à un stimulus extérieur, une modification réversible des protéines au niveau de résidus séryles et thréonyles par phosphorylation via les sérine/thréonine protéine-kinases (STPK). Chez les bactéries pathogènes, notamment Mycobacterium tuberculosis et Staphylococcus aureus, les STPKs sont impliquées dans la régulation du métabolisme central, de la division cellulaire, de la composition de la paroi et de la virulence. Mes travaux de thèse ont eu pour objectif d'approfondir les connaissances sur la régulation post-traductionnelle des protéines via les STPKs chez ces deux pathogènes humains. Nous avons ainsi identifié de nouveaux substrats des STPKs chez M. tuberculosis et S. aureus et caractérisé l'effet de la phosphorylation sur l'activité de ces substrats. L'ensemble de mes travaux de thèse met en avant le rôle important de la régulation par les STPKs de voies métaboliques diverses chez ces deux pathogènes. / To overcome the stressful conditions imposed during host infections, pathogens have evolved various protective and offensive responses that could be achieved through cascades of phosphorylation. Many of the encountered external stimuli are transduced via sensor kinases embeded within the bacterial membrane, allowing the pathogen to adapt and survive in hostile environments. In addition to the classical two-component systems, Staphylococcus aureus and Mycobacterium tuberculosis possess eukaryotic-like Serine/Threonine Protein-Kinases (STPK). It is becoming clear that in these two human pathogens, many of the STPKs are involved in the regulation of metabolic processes, division, cell wall composition, virulence, etc. Therefore, signalling through STPK phosphorylation has recently emerged as a key regulatory mechanism in pathogenic bacteria. Thus, to investigate the mechanisms of STPK-dependent regulation in M. tuberculosis and S. aureus, we identified and characterized novel endogenous phosphorylated substrates, and analyzed the impact of phosphorylation on their specific activity. Overall, the results presented herein emphasize the important role of STPK-dependent mechanisms in various metabolic pathways in these two pathogens.

La tuberculose reste l'une des maladies les plus meurtrières dans le monde et de nouvelles stratégies sont urgemment demandées pour combattre Mycobacterium tuberculosis (Mtb), l'agent éthiologique de la maladie. Les lipides jouent un rôle important dans le cycle de vie de la bactérie et sont largement présents dans sa membrane et son cytoplasme, où ils peuvent servir en tant que sources de carbone et d'énergie pour favoriser la pathogénicité et la survie pendant les phases d'infection et de persistance. Dans ce contexte, les rôles des enzymes lipolytiques restent mal définis et demandent à être davantage caractérisés. La première partie de ce travail de thèse a été consacrée à l'étude des douze enzymes de Mtb homologues à la lipase hormono-sensible humaine. Les effets du MmPPOX, un composé oxadiazolone très sélectif de cette famille de protéines, ont été évalués sur les enzymes recombinantes et directement in vivo sur Mtb et M. bovis BCG. Cet inhibiteur a démontré une activité antimycobactérienne, suggérant des rôles métaboliques importants pour ces enzymes. La seconde partie de ce travail a été consacrée à l'étude des mécanismes physico-chimiques dont dépendent fortement les inhibitions des lipases et des carboxylestérases in vivo, comme la présence de substrats et/ou de détergents. La spectrométrie de masse a également été introduite en tant qu'outil rapide et puissant pour caractériser les adduits [enzyme-inhibiteur]. Enfin, nous avons développé une approche de chimie protéomique pour capturer sélectivement des hydrolases à sérine à partir de milieux biologiques complexes. / Tuberculosis remains one of the deadliest diseases in the world and new strategies are urgently needed to combat Mycobacterium tuberculosis (Mtb), its etiologic agent. Lipids play an important part in the lifetime of the bacterium, as they are widely present in the membrane and stored in the cytoplasm, where they could be used as carbon and energy sources to promote pathogenicity and survival during infection and persistence. In this context, roles of lipolytic enzymes are still poorly understood and remain to be characterized. The first part of my work was devoted to the study of twelve Mtb enzymes homologous to the human hormone-sensitive lipase. Effects of MmPPOX, an oxadiazolone compound highly selective for this family of proteins, were investigated using recombinant enzymes and directly tested in vivo using Mtb and M. bovis BCG. This inhibitor demonstrated antimycobacterial activities, suggesting important metabolic roles for these enzymes. The second part of this work was devoted to the study of physico-chemical mechanisms on which lipase and carboxylesterase inhibition could strongly depend in vivo, like presence of substrates and/or detergents. Mass spectrometry was also introduced as a direct and powerful tool to characterize [enzyme-inhibitor] adducts. Finally, we developed chemical proteomics approaches to specifically capture serine hydrolases from complex biological media. We aimed to synthesize a grafted alkylphosphonate inhibitor on a solid support by assaying several grafting strategies and matrices of various chemical natures.

La tuberculose est une maladie d'urgence dans le monde, l'apparition de souches résistantes au traitement a produit l'utilisation de produits naturels comme alternative. Des études ont montré que les extraits de Leucophyllum frutescens présentaient un effet antimicrobien, mais l'inconvénient est que les extraits sont récupérés dans un véhicule qui contient des solvants organiques. La préparation de nanoparticules polymériques (NP) implique l'élimination du solvant dans lequel l'actif est solubilisé, ce qui permet les utiliser comme véhicules pour l'administration des extraits. Par conséquent, le but de cette étude a été design et développer des formulations de NP avec un extrait de L. frutescens et de la rifampicine (RIF), afin d'évaluer l'activité biologique in vitro contre M. tuberculosis. Premièrement, l'extrait méthanolique de feuilles et de racines de L. frutescens et ses fractions a été obtenu. L'activité contre M. tuberculosis a été déterminée, l'extrait de racines (EMR) et ses fractions hexanique (FHR et RF1) ont été les plus actives avec une CMI de 100, 40 et 40 μg/mL, respectivement. RIF, EMH, FHR et RF1 ont été incorporés dans NP par nanoprécipitation. Des NP de ≈180 nm avec une distribution de taille homogène ont été obtenus. Les NP ont été évaluées sur M. tuberculosis, les formulations de NP-PLGA-RIF (CMI=0,10 μg/mL) et NP-PLGA-RF1 (CMI=80 μg/mL) ont montré la meilleure activité. Finalement, l'activité des formulations combinées contre M. tuberculosis a été évaluée, la combinaison de RIF avec NP-PLGA-RF1 a produit le meilleur comportement, réduisant la CMI des deux sans montrer un effet toxique. Les études réalisées dans ce travail ont montré l'utilisation potentielle d'une formulation de NP contient une fraction végétale de L. frutescens en combinaison avec le RIF comme alternative contre M. tuberculosis / Tuberculosis is an emergency disease worldwide, the emergence of resistant strains to the treatment has produced the use of natural products as alternative. Studies have shown that Leucophyllum frutescens extracts present antimicrobial effect, but the disadvantage is that the extracts are recovered in a vehicle that contains organic solvents. The preparation of polymeric nanoparticles (NP) involves the elimination of the solvent in which the active is solubilized, which makes possible to use them as vehicles for the administration of the extracts. Therefore, the aim of this study was to design and develop formulations of NP with an extract of L. frutescens, and rifampicin (RIF), in order to evaluate the in vitro biological activity against M. tuberculosis. Firstly, the methanolic extract of leaves and roots of L. frutescens and its fractions were obtained. The anti-M. tuberculosis activity was determined, being the root extract (EMR) and its hexane fractions (FHR and RF1) the most actives with a MIC of 100, 40 and 40 μg/mL, respectively. RIF, EMH, FHR and RF1 were incorporated into NP by nanoprecipitation. NP of ≈180 nm with homogeneous size distribution were obtained. The NP were evaluated on M. tuberculosis, being the formulation of NP-PLGA-RIF (MIC=0.10 μg/mL) and NP-PLGA-RF1 (CMI=80 μg/mL) with better activity. Finally, the anti-M. tuberculosis activity of the combined form formulations was evaluated, the combination of RIF with NP-PLGA-RF1 produced better behavior, reducing the MIC of both without showing toxic effect. The studies carried out in this work showed the potential use of an NP formulation contains a vegetable fraction of L. frutescens in combination with RIF as an alternative against M. tuberculosis

Como entre 25-50% dos isolados de Mycobacterium tuberculosis resistentes à INH não apresentam mutações nos genes katG, inhA, ahpC e kasA que possam justificar sua resistência, foi proposta a influência de mutações específicas no gene nat nos mecanismos de resistência e atividade da NAT. Todos os isolados obtidos (n=125) foram identificados e caracterizados através da amplificação pela PCR da IS6110 e por MIRU-VNTR, respectivamente. A determinação da concentração inibitória mínima (CIM) foi realizada pelo método REMA. Após triagem de mutações nos genes caracteristicamente envolvidos com resistência pela PCR-SSCP, seguida de seqüenciamento de DNA, foram selecionados 45 isolados para o estudo de mutações específicas (pela PCR e sequenciamento) e expressão gênica do mRNA do gene nat através da RT-PCR em tempo real. Confirmou-se que mutação no gene katG é a mais correlacionada com a resistência à INH, pois 68,4% das cepas resistentes apresentaram mutação neste gene. Mutações na região promotora do gene inhA, na região intergênica oxyR-ahpC e no gene kasA foram encontradas em 8,8%, 5,6% e 21,6% dos isolados, respectivamente. Mutações no gene nat, das quais 4 não haviam sido descritas previamente, foram encontradas em 40,0% dos isolados. Apesar dessas mutações causarem alterações na proteína, não foi observada uma relação direta com aumento na CIM. Também não foi observada relação entre a variação da expressão do mRNA do gene nat com os valores de CIM e com o número de mutações, tanto específicas do gene nat como em outros genes caracteristicamente relacionados com resistência à INH. / Since around 25-50% of the Mycobacterium tuberculosis strains resistant to INH do not present any mutation in katG, inhA, ahpC and kasA genes that could explain their resistance, we proposed to evaluate the influence of specific mutations in the nat gene in the mechanisms of resistance and in the activity of NAT. All strains were identified and characterized molecularly by the amplification by PCR of the IS6110 region and by MIRU-VNTR, respectively. The minimal inhibitory concentration (MIC) was performed using the REMA method. After screening of mutations in the resistant-related genes by PCR-SSCP followed by DNA sequencing, 45 strains were selected to be evaluated for specific mutations (by PCR and sequencing) and mRNA expression of nat by real time RT-PCR. It was showed that mutations in the katG gene were the most frequent and related to INH resistance since 68.4% of all resistant strains presented mutation in this gene. Mutations in the promoter region of inhA gene, oxyR-ahpC intergenic region and kasA gene were found in 8.8%, 5.6% and 21.6% of the strains, respectively. Mutations in the nat gene, four of them not previously described, were found in 40.0% of the strains. Although those mutations influence in the protein produced it was not observed a direct relation in an increase in CIM. It was also noted no relation between the expression of mRNA of nat gene neither with the MIC values nor with the number of mutations, both specific of nat gene as well in the other genes characteristically related to INH resistance.

A doença infecciosa que causa o maior número de mortes no mundo é a tuberculose, causada pelo bacilo Mycobacterium tuberculosis. Um dos fatores de risco que aumenta três vezes o desenvolvimento de tuberculose é a diabetes, sendo a obesidade associada com predisposição à diabetes. A obesidade gera inflamação de baixo grau que agrava a progressão de doenças crônicas. Estudos que avaliaram a associação da obesidade com tuberculose são controversos, e o tema merece maior investigação. No presente estudo, usamos um modelo experimental para determinar a interface da obesidade e da tuberculose. Camundongos C57BL/6 foram alimentados com dieta hiperlipídica (HFD - High Fat Diet) durante 60 dias, quando foram infectados com M. tuberculosis (HFD/Mtb) por via intra-traqueal. Como controles experimentais, animais foram alimentados com dieta padrão (LFD - Low Fat Diet) e infectados (LFD/Mtb). Paralelamente, um grupo recebeu HFD e outro LFD, e seguiram sem infecção. Após 30 dias de infecção, totalizando 90 dias de dieta, os diferentes grupos foram avaliados. Os animais obesos e infectados (HFD/Mtb) apresentaram aumento do peso corporal e do peso dos tecidos adiposos, aumento da expressão gênica de IL-1? no tecido adiposo, intolerância à glicose, deficiência na produção de insulina e aumento dos níveis séricos de IFN-? comparados aos animais LFD/Mtb. Além disso, o grupo HFD/Mtb foi mais suscetível e apresentou maior inflamação pulmonar comparado ao grupo LFD/Mtb. A inflamação foi caracterizada por aumento na expressão gênica para IL-17, IFN-?, TNF, IL-1?, IL-1?, NLRP3, caspase-1, IL-18, IL-6, aumento de células CD4+ produtoras de IFN-? e/ou IL-17 nos pulmões, e foi também acompanhada por aumento de células CD8+ e células CD4+Foxp3+ quando comparado ao grupo LFD/Mtb. Como NLRP3 é uma molécula chave na metainflamação induzida pela obesidade, mas seu papel ainda não está bem definido na tuberculose, animais deficientes de NLRP3 receberam HFD e foram infectados (NLRP3-/- HFD/Mtb). Esse grupo NLRP3-/- HFD/Mtb foi mais resistente e exibiu redução da inflamação pulmonar comparado ao grupo WT (Wild Type) HFD/Mtb. Sabendo que a obesidade está associada à disbiose e que produtos bacterianos derivados da dieta alimentar ou da microbiota podem estimular a liberação de IL-1? pela ativação de NLRP3, avaliamos o papel da microbiota na comorbidade obesidade e tuberculose. Encontramos disbiose intestinal, caracterizada por aumento do Filo Firmicutes e redução dos Filos Bacteroidetes e Proteobacteria, além do aumento de butirato e redução de acetato e propionato nos intestinos do grupo HFD/Mtb comparado ao grupo LFD/Mtb. O aumento na expressão de claudina-2 sugere alteração na permeabilidade intestinal e possível translocação bacteriana, caracterizada pela disbiose nos pulmões, nos quais foi detectado aumento de Firmicutes, Bacteroidetes e Actinobacteria, e redução de Proteobacteria no grupo HFD/Mtb. Em conclusão, a obesidade aumenta a magnitude da inflamação pulmonar e a suscetibilidade à infecção por M. tuberculosis por um mecanismo dependente de NLRP3. Ambos, aumento da suscetibilidade à infecção e da inflamação pulmonar estão associadas com disbiose intestinal e pulmonar, e aumento da permeabilidade intestinal. / The infectious disease that causes the largest number of deaths in the word is tuberculosis, caused by Mycobacterium tuberculosis bacilli. One of the risk factors that increases the devolpment of tuberculosis three times is diabetes. Obesity generates lowgrade inflammation that magnify the progression of chronic disease. Studies that have evaluated the association between obesity and tuberculosis are controversial, and the issue requires further investigation. In this study, we used an experimental model to determine the interface between obesity and tuberculosis. C57BL/6 mice were fed a highfat diet (HFD) for 60 days and infected by M. tuberculosis (HFD/Mtb) via intratracheal. As experimental control, animals were fed a light-fat diet (LFD) and were infected (LFD/Mtb). In parallel, one group was fed with HFD and another LFD, and they remained without infection. After 30 days of diet completing 90 days of feeding, the different groups were evaluated. Obese and infected animals (HFD/Mtb) showed increased body mass and adipose tissue weight, increased of IL-1? gene expression in adipose tissue, glucose intolerant, impaired insulin production and increased of serum levels of IFN-? compared to LFD/Mtb animals. In addition to, HFD/Mtb animals were more susceptible and exhibited higher lung inflammation compared to LFD/Mtb animals. The inflammation was characterized by increased of IL-17, IFN-?, TNF, IL-1?, IL-1?, NLRP3, caspase-1, IL-18, IL-6 gene expression and increase of IFN-? and/ or IL-17- producing CD4+ cells in the lungs, and was also accompanied by increased CD8+ and CD4+Foxp3+ cells compared to the LFD/Mtb group. As NLRP3 is a key molecule in obesity-induced meta-inflammation, but its role is still not well defined in tuberculosis, NLRP3 deficient animals fed with HFD and were infected (NLRP3-/- HFD/Mtb). This NLRP3-/- HFD/Mtb group was more resistant and exhibited reduction of lung inflammation compared to the WT (Wild Type) HFD/ Mtb group. Considerate that obesity-associated dysbiosis and that bacterial products derived from diet or microbiota can stimulate the release of IL-1? by the activation of NLRP3, we evaluated the microbiota role in obesity and tuberculosis comorbidity. We found intestinal dysbiosis characterized by increased Firmicutes phylum and reduction of Bacteroidetes and Proteobacteria phylum, as well as increased butyrate and diminished acetate and propionate in the intestine of the HFD/Mtb group compared to the LFD/Mtb group. An increase of claudin-2 expression suggests an alteration in intestinal permeability and a possible bacterial translocation characterized by dysbiosis in the lungs, with increased of Firmicutes, Bacteroidetes and Actinobacteria and diminished of Proteobacteria in the HFD/Mtb group. In conclusion, obesity increases the magnitude of pulmonary inflammation and susceptibility to M. tuberculosis infection by an NLRP3-depedent mechanism. Both increased susceptibility to infection and pulmonary inflammation are associated with intestinal and pulmonary dysbiosis, and increased intestinal permeability.

O Fator de Necrose Tumoral-alfa (TNF-alfa) possui um importante papel na imunopatogênese da psoríase e agentes biológicos, como os inibidores de TNF-alfa, têm apresentado bons resultados no tratamento desta. No entanto, estes agentes foram associados ao aumento de casos de reativação de tuberculose entre os pacientes que os utilizaram. Este estudo foi realizado com o intuito de avaliar a resposta imune de pacientes com psoríase grave, ativa, sem tratamento, frente a antígenos de Mycobacterium tuberculosis (Mtb), e o efeito dos inibidores de TNF-alfa nesta resposta. Estudamos 24 pacientes com psoríase grave divididos em 2 grupos: não reatores (n = 14) e reatores (n = 10) ao teste intradérmico com PPD. Como controle, utilizamos um total de 26 indivíduos sadios, também separados em 2 grupos segundo a reatividade ao PPD (PPD-, n = 13; PPD+, n = 13). Em uma segunda etapa estudamos 11 pacientes com psoríase leve a moderada, também sem tratamento, PPD (-) para avaliarmos a importância da gravidade da psoríase na resposta aos antígenos micobacterianos. Avaliamos a resposta imunológica in vitro através da linfoproliferação, quantificação da produção de IFN-gama (ELISA) e quantificação de células produtoras de IFN-gama (ELISPOT), na presença e ausência dos inibidores de TNF-alfa (infliximab e etanercepte), utilizando os antígenos purificados ESAT-6, Ag85B e o antígeno bruto sonicado da cepa H37Rv (AgSMtb), e o mitógeno fitohemaglutinina (PHA). Os pacientes com psoríase grave PPD (-) apresentaram reposta linfoproliferativa e níveis de IFN-gama menores que nos controles PPD (-). Os pacientes com psoríase leve a moderada apresentaram resposta imune intermediária entre controles e pacientes graves. Em relação aos inibidores de TNF- alfa, verificou-se que infliximab e etanercepte apresentaram diferença em suas capacidades de inibição, sendo que somente o infliximab ocasionou a inibição total de TNF-alfa. Em contrapartida o etanercept manteve a produção de TNF-alfa, e em alguns casos elevou sua produção. Estes diminuíram apenas parcialmente a reatividade in vitro dos pacientes com psoríase, uma vez que a secreção de IFN-gama e o número de células produtoras de IFN-gama não foram alterados na presença dos inibidores. A secreção de IL-10 foi diminuída tanto na presença do infliximab, quanto na presença do etanercepte. Os dados obtidos permitem concluir que (a) os pacientes com psoríase grave PPD (-) apresentam uma baixa reatividade in vitro, principalmente das respostas que avaliam linfócitos T de memória central, aos antígenos de Mtb, sendo que essa baixa reatividade não está totalmente relacionada com a gravidade da doença, uma vez que os pacientes com psoríase leve a moderada apresentaram resposta intermediária a dos controles e pacientes com psoríase grave; (b) e que apesar dos inibidores de TNF- alfa promoverem uma inibição parcial da resposta imune, a reativação da tuberculose estaria mais relacionada à própria ausência de TNF-alfa, não compensada pela atuação isolada, e provavelmente insuficiente, de IFN-gama na manutenção do granuloma, do que a outras substanciais modificações na resposta imunológica frente aos antígenos micobacterianos. / Tumor necrosis factor alpha (TNF-alpha) has a pivotal role in psoriasis pathogenesis and biologic agents, such as TNF-alpha inhibitors, have provided good results in its treatment. However, the use of these agents has been associated with an increase in the number of cases of tuberculosis reactivation. This study aimed to evaluate the immune response of severe psoriasis patients, with active, untreated disease to relevant Mycobcterium tuberculosis antigens, and the effect of the TNF-alpha inhibitors (infliximab and etanercept) in this response. Twenty four severe psoriasis patients were enrolled and divided in two groups according to their reactivity to the tuberculin skin test: TST (n= 14) and TST + (n=10). As controls, we studied 26 healthy donors, also divided in two groups to the TST reactivity (TST -, n=13; TST+, n=13). Eleven mild to moderate psoriasis patients, untreated, TST (-) were studied to evaluated the role of psoriasis severity in the immune response to the mycobacterial antigens. Immune responses were evaluated in vitro by the lymphocyte proliferative response (LPR) assay, ELISA for IFN-? secretion by peripheral blood mononuclear cells and enumeration of IFN-? secreted cells (ELISPOT) induced in response to the purified antigens ESAT-6, Ag85B and a crude sonicated antigen preparation from H37Rv Mtb strain (AgSMtb), as well as to the mitogen phytohemagglutinin (PHA), in the presence or absenceinflimab/etanercept. The LPR and IFN-g secretion to Mtb antigens were lower in TST- severe psoriasis patients than TST- controls. Mild to moderate psoriasis patients had intermediate responses, between controls and severe psoriasis patients. The TNF-a inhibitors infliximab and etanercept showed differences in their inhibitiory activity, since only infliximab was capable to neutralize all TNF-a. On the other hand, etanercept kept TNF-alpha production, and in some cases even increased its production. The TNF-alpha inhibitors diminished partially the in vitro patients immune responses, since the IFN-? secretion and enumeration of IFN-? secreted cells were not affected. IL-10 secretion was diminished with both TNF-a inhibitors. In conclusion: (a) TST(-) severe psoriasis patients have decreased in vitro reactivity, mainly in those responses that evaluate central memory T-cell responses, to Mtb antigens, and this decrease could not be fully explained by disease severity, since mild psotiasis patients had intermediate responses; (b) and despite the fact that TNF-alpha inhibitors promote a partial immune response inhibition, tuberculosis reactivation could be related more with the lack of TNF-alpha, which was probably not compensated by the IFN-g activity alone, probably insufficient, to the support granuloma formation, than other defects of the immune response to Mtb antigens.

Etwa ein Drittel der Weltbevölkerung ist mit Mycobacterium tuberculosis (Mtb), der Erreger der Tuberkulose (TB), infiziert. Daher ist es unbedingt notwendig vorhandenen Behandlungsstrategien weiter zu verbessern. Diese Study beschäftigt sich mit dem Mtb Protein Ag85C, einer Mycolyltransferase, als ein neues Ziel für die medikamentöse Behandlung der TB. Ag85C ist eines von drei verwandten Proteinen, Ag85A, B und C, welche zusammen an der Biogenese der Zellwand von Mtb beteiligt sind. Eine Gruppe von chemischen Molekülen mit den Namen Ag85C-1 bis -4 wurde als Inhibitoren von Ag85C getestet. Alle Verbindungen waren in der Lage das Wachstum von Mtb in Flüssigkulturen zu inhibieren, aber nur Ag85C-3 hatte ebenfalls einen Effekt auf intrazelluläre Bakterien, welches in einem Makrophagen-Infektions-System getestet wurde. Hervorzuheben ist, dass Ag85C-3 darüber hinaus auch das in vitro Überleben eines MDR Stammes inhibierte. Dies macht dieses Molekül zu einem interessanten Kandidaten für neue anti-mycobakterielle Therapieansätze. Desweiteren wurden detaillierte, funktionelle Charakterisierungen der Effekte von Ag85C-3 auf Mtb durchgeführt. Die Verbindung modifiziert die Lipide der mykolischen Säuren in der Zellwand durch die Blockierung der Ag85 Funktionen. Dieser Effekt führt dann zu einer Veränderung in der Durchlässigkeit der Außenhülle von Mtb. Mit Hilfe der microarray Analyse wurden die Regulierungen der Signalwege durch Ag85C-3 umfassend untersucht. Es konnte gezeigt werden, dass lebensnotwendige Siderophore durch das Molekül modifiziert werden, was auf mehrere Wirkungsmechanismen schließen lässt. Diese Erkenntnisse machen Ag85C, als Ziel, und Ag85C-3, als Inhibitor, zu vielversprechende Kandidaten für zukünftige Medikamentenforschung auf dem Gebiet der TB-Therapien. Diese Studie hebt zudem die zielbasierte Identifizierung von chemischen Inhibitoren als wichtigen und wertvollen Ansatz für die Medikamentenentwicklung hervor. / Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB) infects about one-third of the world’s population. Therefore there is an urgent need to improve existing intervention strategies. This study evaluated the Mtb Ag85C protein, a mycolyl transferase, as a novel target for drug mediated intervention. Ag85C belongs to a family of three cognate proteins, Ag85A, B and C. They are involved in the final steps of Mtb cell envelope biogenesis. A panel of chemical molecules, Ag85C-1-4, which bind to Ag85C were utilized as inhibitors of Ag85C. All compounds inhibited growth of Mtb in vitro in liquid medium cultures but only Ag85C-3 had an effect on intracellular bacteria in macrophage infection system. Importantly, Ag85C-3 can inhibit in vitro survival of a MDR strain of Mtb making it a relevant molecule in the search for novel classes of anti-mycobacterial compounds. Furthermore a detailed functional characterization of Ag85C-3 effect on Mtb was performed. It modified the cell wall mycolic acid containing lipid amounts by blocking Ag85 function that led to changes in permeability of Mtb envelope. A comprehensive analysis of Mtb signalling pathways regulated by Ag85C-3 was investigated through microarray analysis. It showed modification of vital siderophore biosynthesis indicating multiple mechanisms of action. Thus the target, Ag85C and the inhibitor, Ag85C-3 are promising candidates for future TB drug research aimed at combating broad spectrum resistance development. This study also reinforces target based identification of chemical inhibitors as a valid and valuable approach in drug development.

Submitted by PPG Pediatria e Sa?de da Crian?a (pediatria-pg@pucrs.br) on 2018-02-16T18:56:46Z No. of bitstreams: 1 Tese Doutorado - Tatiana Kurtz -FINAL (1).pdf: 3145488 bytes, checksum: 8d9c7ca2d5630d7d9e3c1060cce48762 (MD5) / Approved for entry into archive by Caroline Xavier (caroline.xavier@pucrs.br) on 2018-02-22T16:58:20Z (GMT) No. of bitstreams: 1 Tese Doutorado - Tatiana Kurtz -FINAL (1).pdf: 3145488 bytes, checksum: 8d9c7ca2d5630d7d9e3c1060cce48762 (MD5) / Made available in DSpace on 2018-02-22T17:05:19Z (GMT). No. of bitstreams: 1 Tese Doutorado - Tatiana Kurtz -FINAL (1).pdf: 3145488 bytes, checksum: 8d9c7ca2d5630d7d9e3c1060cce48762 (MD5) Previous issue date: 2017-08-31 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / Introduction and Objectives: Tuberculosis (TB) is a complex infectious disease that can occur in any age group. When the host comes in contact with Mycobacterium tuberculosis (MTB) the immune response of the organism may be sufficient to prevent the disease, resulting in total destruction of the bacteria or establishment of latency, termed latent tuberculosis (TBL). Due to the difficulty in demonstrating MTB in the clinical specimens of the child, the diagnosis of TB disease is based on the clinical, epidemiological and radiological bases associated with the interpretation of the cutaneous tuberculin (TT) test. In this context, Mycobacterium tuberculosis infection, mostly latent, represents an important reservoir for reactivation of the disease. This contingent is sufficient to continue generating new cases for many decades, even if the chain of transmission is interrupted. Thus, the precise definition of the criteria for diagnosis of latent TB has great relevance and TT is an important tool. The objective of the study is to evaluate the effect of the neonatal BCG vaccine on the tuberculin skin test cutaneous reaction and to define cutoff points to detect tuberculosis in the first two years of life. Methods: A cross-sectional study was carried out in children from the municipality of Santa Cruz do Sul, who met the inclusion criteria of the study: infants up to 2 years of age who received BCG vaccine during the neonatal period. Exclusion criteria were birth weight <2,000 grams, being the mother of HIV positive mother, or mother with persistence of tuberculosis in the perinatal period, or cases where there was evidence of primary immunodeficiency, absence of BCG vaccine scar after 6 months of life, in addition to TB research and TB contact. The children were identified and included through the authorization of the person responsible, explaining the project and accepting the consent term. The project was approved by the Research Ethics Committee of the Santa Cruz Hospital, where patient data were collected and the University of Santa Cruz do Sul (UNISC). The variable under study was the cutaneous induration reaction of the tuberculin test, in the first two years post-vaccination, using different cutoff points. A descriptive analysis of the variables was performed. Numerical variables were represented by mean and standard deviation and categorical variables by means of absolute number and percentage. To describe the data, we used means and standard deviation, or median and interquartile range for the quantitative variables; percentage for qualitative variables. For analysis of the Tuberculin Test, the sample was submitted to the analysis of variance (ANOVA), with significance level of p?0.05. The data analyzed in the SPSS Program 17.0. Results: Potentially eligible participants totaled 808, of which 90 were selected from the inclusion / exclusion criteria. Data collected included demographic characteristics, nutritional indexes, vaccination status and previous exposure to TB. TTs were administered and induration measured after 48-72 hours. The selected ones were of both sexes, with ages varying between 3 and 24 months. Of these, eleven were excluded because they did not attend the reading of the tuberculin test (TT), resulting in a sample of 79 patients. The median age was 9.5 months for boys and 11 months for girls. It was divided into 3 groups according to the age range: between 3-9 months (group 1), 10-18 months (group 2) and 19-24 months of age (group 3). We found that, when comparing the 3 groups, we showed a decrease in the mean response to tuberculin as the age group progresses, presenting statistical significance (p = 0.041). Considering the probable absence of Mycobacterium tuberculosis infection in the sample of patients included in the study, we observed that the tuberculin test with the highest reaction occurs in group 1. From the age of 10 months, no patient shows a reaction to the tuberculin test above 5 mm. The finding shows the decline in the tuberculin reaction curve in the first year of life. A complementary analysis was performed excluding patients who did not present an induration reaction (TT = 0 mm), and 28 patients were excluded from the interpretation. The 51 patients with Test Tuberculin reactor were divided into the same 3 groups according to age group. Between 3-9 months (group 1), 10-18 months (group 2) and 19-24 months of age (group 3), we found that when comparing the 3 groups, again we showed a decrease in the reaction to tuberculin according to age progresses, presenting significance (p = 0.031). We found that there were no adverse effects, described in the literature, in patients who underwent the Tuberculin Test. Conclusions: Based on the data from the study, we demonstrated that the induration reaction occurs in the tuberculin test in the first 12 months of age in previously healthy and BCG-vaccinated patients in the neonatal period. Therefore our results suggest that the cutoff point could be modified from 10mm to 5mm of induration after 12 months of age, improving the specificity of the TT diagnostic test to identify cases of TB infection. This reevaluation of the lowest cutoff point in the first two years of life may prevent inappropriate management in patients with tuberculosis. / Introdu??o e Objetivos: A tuberculose (TB) ? uma doen?a infecciosa complexa, podendo ocorrer em qualquer faixa et?ria. Quando o hospedeiro entra em contato com o Mycobacterium tuberculosis (MTB) a resposta imunit?ria do organismo pode ser suficiente para evitar a doen?a, ocorrendo destrui??o total das bact?rias ou estabelecimento de um estado de lat?ncia, denominado de tuberculose latente (TBL). Devido ? dificuldade em demonstrar MTB nos esp?cimes cl?nicos da crian?a, o diagn?stico da TB doen?a ? fundamentado em bases cl?nicas, epidemiol?gicas e radiol?gicas associados ? interpreta??o do teste tubercul?nico (TT) cut?neo. Neste contexto, verifica-se que a infec??o pelo Mycobacterium tuberculosis, na sua maioria forma latente, representa um importante reservat?rio de reativa??o da doen?a. Este contingente ? suficiente para continuar gerando novos casos por muitas d?cadas, mesmo que a cadeia de transmiss?o seja interrompida. Dessa forma, a defini??o precisa dos crit?rios para diagn?stico de TB latente tem grande relev?ncia e o TT ? uma importante ferramenta. O objetivo do estudo ? avaliar o efeito da vacina BCG neonatal na rea??o de endura??o cut?nea do Teste Tubercul?nico e definir pontos de corte para detectar tuberculose nos dois primeiros anos de vida. M?todos: Estudo transversal, em crian?as do munic?pio de Santa Cruz do Sul, que se adequaram aos crit?rios de inclus?o do estudo: lactentes at? 2 anos de idade que receberam vacina BCG durante o per?odo neonatal. Crit?rios de exclus?o foram: peso ao nascimento <2,000 gramas, ser filho de m?e HIV positiva, ou m?e com vig?ncia de tuberculose no per?odo perinatal, ou ainda os casos em que houve evid?ncia de imunodefici?ncia prim?ria, aus?ncia de cicatriz vacinal de BCG ap?s 6 meses de vida, al?m de investiga??o de TB e contato de TB. As crian?as foram identificadas e inclu?das atrav?s de autoriza??o do respons?vel, mediante explica??o do projeto e aceita??o do termo de consentimento. O projeto foi aprovado pela Comiss?o de ?tica em Pesquisa do Hospital Santa Cruz, onde foi realizada a coleta de dados dos pacientes e Universidade de Santa Cruz do Sul (UNISC). A vari?vel em estudo foi a rea??o de endura??o cut?nea do teste tubercul?nico, nos dois primeiros anos p?s-vacina??o, utilizando diferentes pontos de corte. Realizada uma an?lise descritiva das vari?veis. As vari?veis num?ricas foram representadas por meio de m?dia e desvio padr?o e as categ?ricas por meio de n?mero absoluto e porcentagem. Para descri??o dos dados, foram utilizados m?dias e desvio padr?o, ou mediana e intervalo interquartil para as vari?veis quantitativas; porcentagem para as vari?veis qualitativas. Para an?lise do Teste Tubercul?nico a amostra foi submetida ao teste de an?lise de vari?ncia (ANOVA), com n?vel de signific?ncia de p?0,05. Os dados analisados no Programa SPSS 17.0. Resultados: Os participantes potencialmente eleg?veis totalizaram 808, desses 90 foram selecionados a partir dos crit?rios de inclus?o/exclus?o. Dados coletados inclu?ram caracter?sticas demogr?ficas, ?ndices nutricionais, estado de vacina??o e exposi??o pr?via ? TB. TTs foram administrados e a endura??o medida ap?s 48-72 horas. Os selecionados foram de ambos os sexos, com idade variando entre 3 e 24 meses. Destes, onze foram exclu?das, pois n?o compareceram a leitura do teste tubercul?nico (TT), resultando em amostra final de 79 pacientes. A mediana das idades foi de 9,5 meses, entre os meninos, e 11 meses entre as meninas. Realizada divis?o em 3 grupos conforme faixa et?ria: entre 3-9 meses (grupo 1), 10-18 meses (grupo 2) e 19-24 meses de idade (grupo 3). Constatamos que, quando comparados os 3 grupos, evidenciamos queda na m?dia de rea??o ? tuberculina conforme a faixa et?ria progride, apresentando signific?ncia estat?stica (p= 0.041). Considerando a prov?vel aus?ncia de infec??o por Mycobacterium tuberculosis na amostra de pacientes inclu?dos no estudo, observamos que o teste tubercul?nico com rea??o mais elevada ocorre no grupo 1. A partir dos 10 meses de idade nenhum paciente demonstra rea??o ao teste tubercul?nico acima de 5 mm. O achado evidencia o decl?nio na curva de rea??o ? tuberculina j? no primeiro ano de vida. Realizada an?lise complementar excluindo os pacientes que n?o apresentaram rea??o de endura??o (TT= 0 mm), sendo exclu?dos da interpreta??o 28 pacientes. Os 51 pacientes com Teste Tubercul?nico reator foram divididos nos mesmos 3 grupos conforme faixa et?ria. Entre 3-9 meses (grupo 1), 10-18 meses (grupo 2) e 19-24 meses de idade (grupo 3), onde constatamos que quando comparados os 3 grupos, novamente evidenciamos queda na rea??o ? tuberculina conforme a faixa et?ria progride, apresentando signific?ncia (p= 0.031). Constatamos que n?o ocorreram efeitos adversos, descritos em literatura, nos pacientes que se submeteram a aplica??o do Teste Tubercul?nico. Conclus?es: A partir dos dados do estudo demonstramos que ocorre queda da rea??o de endura??o no teste tubercul?nico nos primeiros 12 meses de idade em pacientes previamente h?gidos e vacinados com BCG no per?odo neonatal. Portanto nossos resultados sugerem que o ponto de corte poderia ser modificado de 10mm para 5mm de endura??o ap?s os 12 meses de idade, melhorando a especificidade do teste diagn?stico TT para identifica??o dos casos de TB infec??o. Esta reavalia??o do ponto de corte menor nos dois primeiros anos de vida pode evitar manejos inadequados nos pacientes com contato com tuberculose.

La tuberculose (TB) reste parmi les 10 premières causes de décès dans le monde ; l’émergence/réémergence de la TB résistante aux antituberculeux aggrave la situation et représente un défi majeur pour l’éradication de la TB. Le Laos est entouré par des pays fortement touchés par la TB et la TB multi-résistante (MDR) et cette maladie représente une priorité en termes de santé publique dans ce pays. Il n’existe encore aucune donnée sur la structure génétique et la résistance aux antibiotiques de la population de M. tuberculosis au Laos.Dans ce contexte, ce travail avait pour but d’analyser la diversité génétique et la structure des populations de M. tuberculosis ainsi que les déterminants génétiques associés à la résistance à partir d’échantillons collectés lors de l’enquête de prévalence nationale de la Tuberculose (TBPS) 2010-2011, l’enquête de résistance aux antituberculeux (DRS) 2016-2017 et chez les cas suspects de MDR-TB au Laos (2010-2014). Plusieurs techniques d’analyses ont été utilisées, comprenant les tests de sensibilité aux médicaments (phénotypique et génotypique), le séquençage et le génotypage par spoligotypage et MIRU-VNTR. Les données ont été analysées par des méthodes statistiques et phylogénétiques.Premièrement, ce travail s’est focalisé sur la diversité des familles de M. tuberculosis circulant au Laos. Les familles EAI et Beijing (76.7% et 14.4% respectivement) ont été principalement observées dans les échantillons de TBPS, alors que la famille Beijing était plus fréquente dans les échantillons de DRS et chez les patients suspectés de MDR-TB (35% et 41% respectivement). La transmission récente était non-négligeable avec un taux de « clustering » global de 11.9%, et des taux pour Beijing de 20 % et EAI de 11 %. Deuxièmement, les résultats ont révélé des profils de résistance très diverses allant de la mono-résistance jusqu’à la pré-XDR (ultrarésistance). Les mutations associées aux profils de résistance ont montré une grande diversité, avec cependant certaines mutations majeures dans les gènes rpoB, katG, et rpsL. Le gène pncA a montré un pattern différent avec de la diversité sans mutations prééminentes. En plus des mutations détectées, des délétions et insertions de bases ont été également observées. Le séquençage a montré son utilité pour la détection de la résistance aux antibiotiques dans les trois échantillons à l’étude. Enfin, la famille Beijing, famille la plus problématique au niveau mondial en termes de résistance et de transmissibilité, a été identifiée de manière significative dans le groupe de patients <35 ans, principalement dans les provinces du Nord, dans les cas de transmissions récentes et chez les isolats très résistants. Tous ces points suggèrent un risque d’émergence de la MDR-TB accrue au Laos dû à la famille Beijing.En conclusion, cette étude permet d’avoir pour la première fois un aperçu de la structure des populations de M. tuberculosis au Laos. Les résultats soulignent le risque d’augmentation du nombre de cas infectés par la famille Beijing et donc des cas de résistance. Pour empêcher une dégradation de la situation, il est essentiel d’améliorer les stratégies pour le dépistage des résistances et de développer des tests moléculaires capables de couvrir un large nombre de mutations qui soit simple à implémenter dans les pays à ressources limités. Les résultats de ce travail serviront de base en termes de famille/sous-famille/génotype et de mutations associées à la résistance au Laos. Ces données pourront être comparées avec de futures études/analyses pour étudier l’évolution de la TB et de la TB résistante et ainsi d’évaluer l’efficacité des politiques de contrôle mises en place. La description des mutations associées aux résistances est utilisée pour créer une base de données régionale en collaboration avec le Vietnam et le Cambodge pour développer un outil de diagnostic basé sur la technologie des puces à ADN pour améliorer la détection de la résistance dans la région. / Tuberculosis (TB) is still one of the top 10 leading causes of death worldwide; the emergence/re-emergence of drug resistant TB aggravates the situation globally and challenges the prospect of ending TB by 2035. Lao PDR is surrounded by TB and MDR-TB high burden countries and TB continues to be one of the priority infection diseases in this country. The prevalence of TB in 2010 was almost twice as high than previous estimates and little is known about drug resistance. Up to now, M. tuberculosis population data regarding drug resistance and genetic structure are totally absent. In this context, we aimed to study the diversity and the structure of M. tuberculosis population and the genetic determinants associated to drug resistance using clinical samples collected from the TB prevalence survey (TBPS), 2010-2011; from the Drug resistance survey (DRS), 2016-2017 and from presumptive MDR-TB cases in Lao PDR (2010-2014). Various methods and analyses were used, including drug susceptibility testing (phenotypic and genotypic), DNA sequencing and genotyping of M. tuberculosis using spoligotyping and MIRU-VNTR. The data were analyzed by statistical and phylogenetic analyses.Firstly, this work was focused on the diversity of M. tuberculosis families circulating in Lao PDR. According to the result form TBPS, EAI and Beijing family (76.7% and 14.4% respectively) were mainly observed, while Beijing family was more observed in DRS, and presumptive MDR-TB cases (35% and 41% respectively). The level of recent transmission in Lao PDR was non-negligible with a global clustering rate of 11.9% and in Beijing and EAI of 20% and 11%, respectively. Secondly, the results demonstrated the diversity of drug resistant patterns from mono-resistance to pre-extensively drug resistance (pre-XDR). A high diversity of mutations associated with drug resistance was also observed, however common mutations were mainly found (e.g: mutations in rpoB gene, katG and rpsL). The pattern was different for pncA gene, we observed a diversity of mutations without preeminent ones. Besides the number of known and unknown mutations associated with anti-TB drug resistance, deletion and insertion of bases were also observed. The sequencing showed its usefulness for drug resistance detection. Lastly, Beijing family, which is the more problematic family in the world in terms of resistance and transmissibility, was observed on a significant manner in young age group, mainly in the northern provinces, in recent transmission cases and among highly drug resistant isolates, suggesting an increasing risk of highly drug resistance TB due to highly transmissible Beijing strains in Lao PDR.In conclusion, this study provides the first genetic insights into the M. tuberculosis population in Lao PDR. The results underline the risk of increase of Beijing and drug resistant TB in the country. In order to prevent a more serious situation in the future regarding drug resistance as observed in neighboring countries, there is an urgent need of effective strategy improvement for drug resistance screening and the development of rapid molecular tests that cover a large number of drug resistance simultaneously with a feasible implementation in the limited resource countries. The results of genotyping from our study will be the baseline of families/subfamilies/genotype of M. tuberculosis population and of the mutations associated with drug resistance in Lao PDR. These data will be compared with further study/analysis to evaluate the trend of TB and drug resistant TB in the country and to determine if the drug resistance is under control after the set-up of new policies. The data of drug resistance associated mutations are used to build a regional database in collaboration with Vietnam and Cambodia in order to develop a diagnostic tool based on DNA chip technology to improve the drug resistance detection in the region.