Caracterização genética de micobactérias não tuberculosas isoladas de espécimes clínicos pulmonares no estado do Pará

Nos últimos anos tem sido observado um aumento de relatos de infecções causadas por micobactérias não tuberculosas (MNT). No entanto, dados sobre frequência e espécies envolvidas em infecções pulmonares no Brasil são limitados, principalmente em estados da Região Norte do Brasil. O conhecimento das espécies de MNT associadas às infecções pulmonares tem importância clínica e epidemiológica, sendo as técnicas moleculares ferramentas capazes de oferecer um diagnóstico espécie-específico, o qual é necessário para a instituição de terapia adequada. O presente trabalho descreve a diversidade de MNT isoladas de espécimes pulmonares encaminhados ao Instituto Evandro Chagas entre 1999 e 2011 para pesquisa de micobactérias. As MNT foram inicialmente caracterizadas por PCR-restriction analysis (PRA-hsp65) e reidentificadas por sequenciamento dos genes RNAr 16S, hsp65, rpoB e região ITS1. De acordo com os achados, o método de PRA-hsp65 mostrou-se uma ferramenta prática para identificação MNT, permitindo a distinção de uma grande variedade de espécies de forma rápida, simples e barata, em comparação com o sequenciamento. Além disso, como sugerido no presente estudo, de acordo com a diversidade de espécies local, este método pode ser passível de modificações para proporcionar maior poder discriminatório. Para isolados do complexo Mycobacterium avium (MAC), a aplicação da análise de sequência do gene rpoB não se mostrou como alternativa adequada para discriminação de isolados do Estado do Pará, gerando resultados discrepantes com baixa resolução taxonômica. Um espectro particular de MNT foi associado aos casos de infecção pulmonar na região, representado principalmente por espécies dos complexos M. chelonae-M. abscessus (M. abscessus, M. massiliense e M. bolletii), M. avium (M. avium, M. intracellulare e M. colombiense) e M. simiae (M. simiae e taxa não nomeados). Dentre esse último, duas potenciais espécies foram detectadas, M. paraensis sp. nov. e M. amazoniensis sp. nov., sendo propostas como novos membros do complexo M. simiae. Entre os indivíduos afetados, as principais características encontradas foram sexo feminino, a idade superior a 50 anos, etnia parda e história de infecção prévia por tuberculose. Embora este estudo não demonstre a real magnitude de infecções pulmonares por MNT no Estado do Pará, ele descreve a diversidade de espécies e claramente retrata a importância desse grupo na região, chegando a representar 13,5% dos isolamentos micobacterianos em um laboratório de referência. Conjuntamente a esse achado, a identificação de casos de MNT em indivíduos presuntivamente diagnosticados com TB, indica a necessidade de confirmação bacteriológica, especialmente nos casos de resistência primária ao esquema básico da tuberculose.

Micobacteriose não tuberculosa pulmonar em hospital de referência no Estado do Pará: espécies mais frequentes, apresentação radiológica e evolução clínica

As micobactérias não tuberculosas (MNT) estão amplamente presentes no ambiente, tendo sido isoladas em águas naturais, sistemas de distribuição de água, solo e animais. Caracterizam-se pela presença de ácido micólico na parede celular. Em geral, são adquiridas através de inalação de gotículas de água contendo micobactérias. Podem causar formas variadas de doença como linfadenite, pulmonar, cutânea e disseminada. São patógenos oportunistas, com patogenicidade variável, que requerem defeitos na imunidade local ou sistêmica, congênitos ou adquiridos para causar doenças em humanos. Foram avaliados aspectos epidemiológicos, clínicos e radiológicos de 44 casos de micobacteriose não tuberculosa na forma pulmonar no Hospital João de Barros Barreto (HUJBB) através de estudo retrospectivo e foram tratados e acompanhados 21/44 (47,7%) pacientes durante um período de seis a dezessete meses através de estudo do tipo coorte prospectivo. Os dados mostraram um incremento de mais de 100% no número de casos a partir do ano de 2010 em relação aos anos anteriores no HUJBB. As micobactérias mais isoladas foram M. intracellulare (22,7%) e M. massiliense (20,5%). As condições mais frequentemente associadas à doença incluíram tratamento prévio para tuberculose (93,2%), bronquiectasias (59%), HIV (11,4%), asma (9,1%) e doença pulmonar obstrutiva crônica (9,1%). Não foram observadas diferenças nos aspectos radiológicos entre as espécies, exceto na análise das radiografias de tórax, onde atelectasias foram mais frequentes nos grupo M. massiliense do que no grupo de M. abscessus. A resposta ao tratamento de acordo com a análise das culturas para micobactérias mostrou que em 58,8% dos casos ocorreu negativação, persistência da positividade em 11,7% e positividade após negativação inicial em 11,7%. Durante o período de acompanhamento, a taxa de óbito foi de 17,7%. Os dados sugerem que a forma pulmonar da micobacteriose não tuberculosa tem se tornado uma doença com importância cada vez maior em nossa região. Adicionalmente, a resposta ao tratamento tem sido bastante satisfatória quando comparada à literatura. Entretanto, é necessário um seguimento desses pacientes por período mais prolongado para estabelecer o real desfecho da nossa abordagem terapêutica.

Occurrence of Mycobacterium bovis and non-tuberculous mycobacteria (NTM) in raw and pasteurized milk in the northwestern region of Paraná, Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Reliable identification of mycobacterial species by PCR-restriction enzyme analysis (PRA)-hsp65 in a reference laboratory and elaboration of a sequence-based extended algorithm of PRA-hsp65 patterns

Abstract Background Identification of nontuberculous mycobacteria (NTM) based on phenotypic tests is time-consuming, labor-intensive, expensive and often provides erroneous or inconclusive results. In the molecular method referred to as PRA-hsp65, a fragment of the hsp65 gene is amplified by PCR and then analyzed by restriction digest; this rapid approach offers the promise of accurate, cost-effective species identification. The aim of this study was to determine whether species identification of NTM using PRA-hsp65 is sufficiently reliable to serve as the routine methodology in a reference laboratory. Results A total of 434 NTM isolates were obtained from 5019 cultures submitted to the Institute Adolpho Lutz, Sao Paulo Brazil, between January 2000 and January 2001. Species identification was performed for all isolates using conventional phenotypic methods and PRA-hsp65. For isolates for which these methods gave discordant results, definitive species identification was obtained by sequencing a 441 bp fragment of hsp65. Phenotypic evaluation and PRA-hsp65 were concordant for 321 (74%) isolates. These assignments were presumed to be correct. For the remaining 113 discordant isolates, definitive identification was based on sequencing a 441 bp fragment of hsp65. PRA-hsp65 identified 30 isolates with hsp65 alleles representing 13 previously unreported PRA-hsp65 patterns. Overall, species identification by PRA-hsp65 was significantly more accurate than by phenotype methods (392 (90.3%) vs. 338 (77.9%), respectively; p < .0001, Fisher's test). Among the 333 isolates representing the most common pathogenic species, PRA-hsp65 provided an incorrect result for only 1.2%. Conclusion PRA-hsp65 is a rapid and highly reliable method and deserves consideration by any clinical microbiology laboratory charged with performing species identification of NTM.

Novel screening tools for latent tuberculosis: time to leave an old friend?

PURPOSE OF REVIEW: Therapeutic inhibition of tumour necrosis factor-alpha strongly increases the risk of reactivation in latent tuberculosis infection. Recent blood tests based on antigen-specific T cell response and measuring production of interferon-gamma, so called interferon-gamma release assays (IGRAs), are promising novel tools to identify infected patients. The performance of diagnostic testing for latent tuberculosis infection in patients with rheumatic diseases will be discussed. RECENT FINDINGS: In patients with rheumatoid arthritis, IGRAs are more sensitive and more specific than traditional tuberculin skin testing. They are unaffected by Bacillus-Calmette-Guérin vaccination and most nontuberculous mycobacteria. Most comparative studies show a better performance of the IGRAs than tuberculin skin testing in terms of a higher specificity. The rate of indeterminate results may be affected by glucocorticoids and the underlying disease but appears independent of disease-modifying antirheumatic drugs. Despite using identical Mycobacterium tuberculosis antigens, the two commercially available tests show differences in clinical performance. SUMMARY: The current information about the performance of the tuberculin skin testing and the IGRAs in the detection of latent tuberculosis infection in patients with rheumatic diseases strongly suggest a clinically relevant advantage of the IGRAs. Their use will help to reduce overuse and underuse of preventive treatment in tumour necrosis factor inhibition.

The Fascinating Coat Surrounding Mycobacteria

The mycobacterial cell envelope is fascinating in several ways. First, its composition is unique by the exceptional lipid content, which consists of very long-chain (up to C90) fatty acids, the so-called mycolic acids, and a variety of exotic compounds. Second, these lipids are atypically organized into a Gram-negative-like outer membrane (mycomembrane) in these Gram-positive bacteria, as recently revealed by CEMOVIS, and this mycomembrane also contains pore-forming proteins. Third, the mycolic acids esterified a holistic heteropolysaccharide (arabinogalacan), which in turn is linked to the peptidoglycan to form the cell wall skeleton (CWS). In slow-growing pathogenic mycobacterial species, this giant structure is surrounded by a capsular layer composed mainly of polysaccharides, primarily a glycogen-like glucan. The CWS is separated from the plasma membrane by a periplasmic space. A challenging research avenue for the next decade comprises the identification of the components of the uptake and secretion machineries and the isolation and biochemical characterization of the mycomembrane.

Direct visualization of the outer membrane of mycobacteria and corynebacteria in their native state.

The cell envelope of mycobacteria, which include the causative agents of tuberculosis and leprosy, is crucial for their success as pathogens. Despite a continued strong emphasis on identifying the multiple chemical components of this envelope, it has proven difficult to combine its components into a comprehensive structural model, primarily because the available ultrastructural data rely on conventional electron microscopy embedding and sectioning, which are known to induce artifacts. The existence of an outer membrane bilayer has long been postulated but has never been directly observed by electron microscopy of ultrathin sections. Here we have used cryo-electron microscopy of vitreous sections (CEMOVIS) to perform a detailed ultrastructural analysis of three species belonging to the Corynebacterineae suborder, namely, Mycobacterium bovis BCG, Mycobacterium smegmatis, and Corynebacterium glutamicum, in their native state. We provide new information that accurately describes the different layers of the mycobacterial cell envelope and challenges current models of the organization of its components. We show a direct visualization of an outer membrane, analogous to that found in gram-negative bacteria, in the three bacterial species examined. Furthermore, we demonstrate that mycolic acids, the hallmark of mycobacteria and related genera, are essential for the formation of this outer membrane. In addition, a granular layer and a low-density zone typifying the periplasmic space of gram-positive bacteria are apparent in CEMOVIS images of mycobacteria and corynebacteria. Based on our observations, a model of the organization of the lipids in the outer membrane is proposed. The architecture we describe should serve as a reference for future studies to relate the structure of the mycobacterial cell envelope to its function.

EPIDEMIOLOGIC TRENDS OF LUNG DISEASE DUE TO MYCOBACTERIA KANSASII AND AVIUM-INTRACELLULARE IN TEXAS, 1977-1983

This study compared the reported isolations of Mycobacterium kansasii (MK) and Myobacterium avium-intracellulare (MAI) with Mycobacterium tuberculosis (MTB) between 1977-1983 in Texas. A total of 15,395 mycobacterial cases were identified of which 1,352 (8.8%) were MK or MAI. The incidence of MK was higher in urban areas than nonurban areas (p < .005). The incidence of MAI has increased in the Dallas metroplex from 34 cases to 251 for the same time period. Although the number of MK cases previously reported has always exceeded those of MAI, the numbers were equal in the last year (1983) of the study.^ More than 75% of patients with MK or MAI were Caucasians compared to only 18% of patients with MTB. Male to female ratios for MK and MAI are 3:1 and 3:2, respectively. The age distribution of MK patients were an average of 5 years younger than patients with MAI, a finding which concurs with previous studies. MK and MAI pulmonary infections continue to be absent among children and relatively absent among Hispanics.^ MK appears to be associated with occupations in construction, whereas MAI is more often associated with farm work. ^

Toll-like receptor-2 mediates mycobacteria-induced proinflammatory signaling in macrophages

The recognition of mycobacterial cell wall components causes macrophages to secrete tumor necrosis factor α (TNF-α) and other cytokines that are essential for the development of a protective inflammatory response. We show that toll-like receptors are required for the induction of TNF-α in macrophages by Mycobacterium tuberculosis. Expression of a dominant negative form of MyD88 (a signaling component required for toll-like receptor signaling) in a mouse macrophage cell line blocks TNF-α production induced by M. tuberculosis. We identify toll-like receptor-2 (TLR2) as the specific toll-like receptor required for this induction by showing that expression of an inhibitory TLR2 (TLR2-P681H) blocks TNF-α production induced by whole M. tuberculosis. Further, we show that TLR2-dependent signaling mediates responses to mycobacterial cell wall fractions enriched for lipoarrabinomannan, mycolylarabinogalactan–peptidoglycan complex, or M. tuberculosis total lipids. Thus, although many mycobacterial cell wall fractions are identified to be inflammatory, all require TLR2 for induction of TNF-α in macrophages. These data suggest that TLR2 is essential for the induction of a protective immune response to mycobacteria.

A yeast manganese transporter related to the macrophage protein involved in conferring resistance to mycobacteria.

A novel Saccharomyces cerevisiae mutant, unable to grow in the presence of 12.5 mM EGTA, was isolated by replica plating. The phenotype of the mutant is caused by a single amino acid change (Gly149 to Arg) in the essential yeast gene CDC1. The mutant could be suppressed by overexpression of the SMF1 gene, which was isolated as an extragenic high-copy suppressor. The SMF1 gene codes for a highly hydrophobic protein and its deletion renders the yeast cells sensitive to low manganese concentration. In accordance with this observation, the smf1 null mutant exhibits reduced Mn2+ uptake at micromolar concentrations. Using a specific antibody, we demonstrated that Smf1p is located in the yeast plasma membrane. These results suggest that Smf1p is involved in high-affinity Mn2+ uptake. This assumption was also tested by overexpressing the SMF1 gene in the temperature-sensitive mutant of the mitochondrial processing peptidase (MAS1). SMF1 overexpression as well as addition of 1 mM Mn2+ to the growth medium complemented this mutation. This also suggests that in vivo Mas1p is a manganese-dependent peptidase. The yeast Smf1p resembles a protein from Drosophila and mammalian macrophages. The latter was implicated in conferring resistance to mycobacteria. A connection between Mn2+ transport and resistance or sensitivity to mycobacteria is discussed.

Homing events in the gyrA gene of some mycobacteria.

The A subunit of DNA gyrase in Mycobacterium leprae, unlike its counterpart in Mycobacterium tuberculosis, is produced by protein splicing as its gene, gyrA, harbors a 1260-bp in-frame insertion encoding an intein, a putative homing endonuclease. Analysis of the gyrA locus from different mycobacterial species revealed the presence of inteins in Mycobacterium flavescens, Mycobacterium gordonae and Mycobacterium kansasii but not in 10 other pathogenic or saprophytic mycobacteria. In all four cases where intein coding sequences were found, they were localized in the same position in gyrA, immediately downstream of the codon for the key active-site residue Tyr-130. The intein products were similar, but not identical, in sequence and the splice junctions displayed all the features found in other polypeptides known to be produced by protein splicing from a precursor protein. Paired motifs, found in homing endonucleases encoded by some group I RNA introns, and inteins showing endonuclease activity, were present in the gyrA inteins as were other intein-specific signatures. Some strains of M. flavescens, M. gordonae, and M. kansasii were shown by PCR analysis to have inteinless gyrA genes, in contrast to the situation in M. leprae where all the isolates possessed insertions in gyrA. Sequencing of the corresponding regions revealed that, although the GyrA protein sequence was conserved, the nucleotide sequences differed in gyrA genes with and without inteins, suggesting that the homing endonuclease displays sequence specificity.

Disparate responses to oxidative stress in saprophytic and pathogenic mycobacteria.

To persist in macrophages and in granulomatous caseous lesions, pathogenic mycobacteria must be equipped to withstand the action of toxic oxygen metabolites. In Gram-negative bacteria, the OxyR protein is a critical component of the oxidative stress response. OxyR is both a sensor of reactive oxygen species and a transcriptional activator, inducing expression of detoxifying enzymes such as catalase/hydroperoxidase and alkyl hydroperoxidase. We have characterized the responses of various mycobacteria to hydrogen peroxide both phenotypically and at the levels of gene and protein expression. Only the saprophytic Mycobacterium smegmatis induced a protective oxidative stress response analogous to the OxyR response of Gram-negative bacteria. Under similar conditions, the pathogenic mycobacteria exhibited a limited, nonprotective response, which in the case of Mycobacterium tuberculosis was restricted to induction of a single protein, KatG. We have also isolated DNA sequences homologous to oxyR and ahpC from M. tuberculosis and Mycobacterium avium. While the M. avium oxyR appears intact, the oxyR homologue of M. tuberculosis contains numerous deletions and frameshifts and is probably nonfunctional. Apparently the response of pathogenic mycobacteria to oxidative stress differs significantly from the inducible OxyR response of other bacteria.

Using new scanning electron microscopy (SEM) approaches to elucidate bacterial biofilm architecture

Healthcare-associated infections (HAI) are a major public health problem being Klebsiella pneumoniae and nontuberculous mycobacteria, both with high antibiotic resistance rates, among their etiological agent. Since biofilme assembly is pointed as one of the mechanisms involved in emergence of antibiotic resistance understanding bacteria organization within the biofilm and the identification of differences between planktonic and sessile forms of bacteria will be a step forward to fight HAI. In the present work we used SEM as a tool to characterize the internal structure of biofilm assembled on different surfaces. For SEM analysis, biofilms were allowed to form either on six-well cell culture plates, silicon or metallic disks placed inside the wells for different incubation periods at 37 °C. The biofilm assembled on the cell culture dish was for both secondary and backscattered electron analysis as described before. Biofilms assembled on silicon disks instead of being sectioned were prepared as metallographic samples, by grinding with grit SIC paper and polishing with diamond particles. Samples were cleaned (70% ethanol), dried with hot air, further coated and analysed. A preliminary study using FIB-SEM has been performed to access the ultrastructure of biofilms assembled on metallic surfaces. The results obtained showed that the same bacteria assembled biofilms with different ratios of biomass and extracellular matrix depending on the surface. SEM performed on thin sections of biofilms is a powerful tool to elucidate biofilm structure allowing the quantification of the major components. FIB-SEM is also a promising tool in this field.

Cellular impermeability and uptake of biocides and antibiotics in Gram-positive bacteria and mycobacteria

Gram-positive bacteria possess a permeable cell wall that usually does not restrict the penetration of antimicrobials. However, resistance due to restricted penetration can occur, as illustrated by vancomycin-intermediate resistant Staphylococcus aureus strains (VISA) which produce a markedly thickened cell wall. Alterations in these strains include increased amounts of nonamidated glutamine residues in the peptidoglycan and it is suggested that the resistance mechanism involves 'affinity trapping' of vancomycin in the thickened cell wall. VISA strains have reduced doubling times, lower sensitivity to lysostaphin and reduced autolytic activity, which may reflect changes in the D-alanyl ester content of the wall and membrane teichoic acids. Mycobacterial cell walls have a high lipid content, which is assumed to act as a major barrier to the penetration of antimicrobial agents. Relatively hydrophobic antibiotics such as rifampicin and fluoroquinolones may be able to cross the cell wall by diffusion through the hydrophobic bilayer composed of long chain length mycolic acids and glycolipids. Hydrophilic antibiotics and nutrients cannot diffuse across this layer and are thought to use porin channels which have been reported in many species of mycobacteria. The occurrence of porins in a lipid bilayer supports the view that the mycobacterial wall has an outer membrane analogous to that of gram-negative bacteria. However, mycobacterial porins are much less abundant than in the gram-negative outer membrane and allow only low rates of uptake for small hydrophilic nutrients and antibiotics.