EDITORIAL COMMENTARY
How Does Mycobacterium tuberculosis Establish
Infection?
Suman Laal
NYU School of Medicine, New York, New York
(See the article by Barrios-Payán et al, on pages 1194–205.)
On 16 January 1924, Allen Krause gave
an address entitled “The spread of tuber-
culous infection in the body” before the
Bronx County Medical Society, under
the auspices of the New York Tuberculo-
sis (TB) Association [1]. He said “few of
us, it would seem, think of the possibility
of a more general distribution of infec-
tion as perhaps the mode of tuberculosis;
of bacilli nesting in many places
throughout the body, once entrance is
made, and causing only minimal or mi-
croscopic, in other words, unnoticed
changes in many tissues, with only a
single visible focus, or a few here and
there, to indicate infection; with, maybe,
a rather free and frequent moving about
of small numbers of germs along the
various avenues of dissemination and a
consequent repeated new focalization
that is widespread, the early focus of rel-
atively many bacilli and of native tissue
reaction remaining the only visible
process and numerous minute foci of
few bacilli remaining concealed with
their growth kept in abeyance by the im-
munity of the body, as long as this
Received 6 March 2012; accepted 20 March 2012; elec-
tronically published 25 June 2012.
Correspondence: Suman Laal, PhD, NYU School of Medi-
cine, c/o VA Medical Center, 423 East 23rd Street, Room
18123N, New York, NY 10010 (suman.laal@nyumc.org).
The Journal of Infectious Diseases 2012;206:1157–9
© The Author 2012. Published by Oxford University Press
on behalf of the Infectious Diseases Society of America. All
rights reserved. For Permissions, please e-mail: journals.
permissions@oup.com.
DOI: 10.1093/infdis/jis382
holds.” Nearly 90 years later, in the study
by Barrios-Payán et al [1a] reported in
this issue of The Journal, multiple sensi-
tive techniques were used to probe the
presence, location, and viability of Myco-
bacterium tuberculosis (Mtb) in immu-
nocompetent individuals in Mexico. All
subjects died from reasons unrelated to
TB and had no evidence or history of
clinical TB. The authors provide evi-
dence of latent Mtb infection not only in
the lungs but also in the liver, spleen,
and kidneys of these individuals. As ex-
pected from a TB-endemic setting, a ma-
jority of these individuals were latently
infected, with Mtb DNA demonstrable
in the lungs of approximately 70%. Of
importance, almost all of the individuals
also had bacterial DNA in the spleen,
kidney, and/or liver. Whereas Mtb DNA
was present in only extrapulmonary lo-
cations in many subjects, none showed
infection restricted to only the lungs.
Different individuals were infected with
different strains of Mtb. Thus, dissemi-
nation from the lungs and infection in
multiple organs appear fundamental to
the establishment of Mtb infection and,
as Krause postulated, may indeed be “the
mode” of spread of Mtb in the body.
Although the BCG-vaccination status
of the subjects is not provided, BCG
vaccination is routine in Mexico. Barrios-
Payán et al were unable to detect Myco-
bacterium bovis BCG DNA in any
specimen. Reactivation of BCG in HIV-
positive patients occurs, but it is far less
EDITORIAL COMMENTARY
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frequent than reactivation of latent Mtb.
BCG has been shown to be attenuated
for dissemination in animal models
[2–4]. Moreover, latently infected indi-
viduals exhibit immune responses to
ESAT6. Although the mechanism under-
lying attenuated dissemination of BCG
is unclear, ESAT6, which is one of the
RD1-encoded proteins secreted via ESX-
1, may play a role in bacterial dissemina-
tion from the lungs [2–5]. ESAT6 is a
pore-forming toxin that causes cytolysis
of both type 1 and type 2 alveolar epi-
thelial cells in vitro, and it is also an
adhesin which binds to laminin [5, 6].
Laminin is synthesized by pneumocytes
and is a major component of the base-
ment membrane on which these cells
rest. It is possible that Mtb organisms
replicating in alveolar epithelial cells use
ESAT6 for anchoring onto the basolater-
al laminin-expressing surfaces and cause
damage to the cells and the basement
membrane, thus participating in their
dissemination via the alveolar wall.
While the presence of >1 clinical
strain in TB patients was reported
earlier, Barrios-Payán et al provide evi-
dence for latent infection with multiple
Mtb strains in the same individual [7, 8].
Thus, adaptive immune responses elicit-
ed by the first infection (which was
driven to latency) could not inhibit a
second or even a third strain of Mtb
from infecting and disseminating. Even
robust immune responses, which in most
individuals can prevent reactivation of
• JID 2012:206 (15 October) • 1157
latent Mtb infection throughout the life-
time, cannot protect against new infec-
tion. Development of vaccines should
include consideration of the importance
of both eliciting sterilizing immunity
that can eliminate latent bacteria and/or
protect against new infection. This is im-
portant because the risk for reactivation
will exist as long as latent infection lurks
anywhere in the body.
Barrios-Payán et al also show that
latent infection with Mtb is present
in endothelial and/or epithelial cells in
every organ tested, in the absence of
inflammatory responses or granuloma
formation. While the role of macrophages
has been studied extensively, little atten-
tion has been paid to infection of non-
phagocytic cells in TB. Infection with
Mtb is initiated by the few bacilli in a
droplet inhaled into an alveolus. Adap-
tive immune responses are elicited
roughly 4–5 weeks later in humans (and
rabbits) and approximately 2–3 weeks
later in mice. Studies of primary infec-
tion cannot easily be done in humans
and are challenging even in animal
models because of the very low numbers
of bacteria present at early time points.
Recent studies report >20 000-fold bac-
terial replication in the lungs of Mtb-
infected mice before immune responses
are generated; this replication occurs in
a “nonmigrating compartment” that
does not induce proliferation of naive
CD4+ T cells [9]. Dissemination of Mtb
from the lungs to other organs precedes
the development of immunity [10, 11].
Is it possible that the early infection and
replication occurs in alveolar epithelial
and endothelial cells, which vastly out-
number the alveolar macrophages? Do
the bacteria then spread by hematoge-
nous routes to the endothelial cells in
different organs? Evidence exists in
guinea pigs for dissemination of Mtb
from the site of inoculation to the liver,
spleen, kidney, bone marrow, and else-
where within hours, as does evidence for
dissemination of free bacteria [12–14].
Perhaps at the very early stages of infec-
tion, Mtb organisms replicate inside
1158 • JID 2012:206 (15 October) • EDITORIAL COMMENTARY
alveolar epithelial and endothelial cells
and disseminate systemically, even as
they replicate in the lymph nodes to
reach the required antigenic threshold
for eliciting immune responses [9]. Inva-
sion and replication in nonphagocytic
cells would be advantageous since these
cells lack the killing mechanisms of
macrophages. Moreover, replication in
these cells may provide the bacteria with
an opportunity to modify their pheno-
type to better disseminate systemically
and/or to enhance survival in phagocytic
cells that eventually migrate to the site
of infection [13]. Infected epithelial/
endothelial cells may also regulate the
initiation of adaptive immune responses
[15, 16].
The extensive replication and dissemi-
nation of Mtb that results in seeding of
the body is eerily silent, with no discern-
ible signs and symptoms; the site of this
bacterial replication and the means by
which the bacteria disseminate after in-
fection are unknown. Other nonmotile,
gram-positive bacteria use cell-wall/
surface proteins called adhesins to estab-
lish infection in the cells of the relevant
mucosal barrier and to disseminate
across the barrier [17–19]. Adhesins
enable the bacteria to attach/invade/
translocate across the epithelial and en-
dothelial cells directly or by binding to 1
or more components of the host extracel-
lular matrix [17–21]. Adhesins can also
regulate the early immune responses via
induction of chemokines and cytokines
from cells of the mucosal barriers [22–
24]. Some adhesins of Mtb have been
identified in recent years, and two,
HBHA and ESAT6, contribute to Mtb
infection and dissemination from the
lungs in vivo [2–5, 14, 25–28]. A third
adhesin, PknD, also a laminin-binding
protein of Mtb, contributes to invasion
of the human brain microvascular endo-
thelial cells that form the blood-brain
barrier [27]. Considering its ability to
disseminate and infect the epithelial and
endothelial cells in multiple extrapulmo-
nary locations, Mtb may use different ad-
hesins for establishing infection in
different extrapulmonary sites. While the
role of adhesins in infection is an active
area of investigation for other gram-
positive bacteria, studies of Mtb adhesins
are still in their infancy [20, 21].
This ability to quietly disseminate and
then lie dormant is responsible for the
success of Mtb in establishing the huge
reservoir of latently infected humans: es-
timates are that one-third of the global
population, or approximately 2 billion
individuals, carry a latent infection with
Mtb. Although our knowledge of TB
pathogenesis is increasing rapidly, there
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are still many gaps in our understanding
of the simple question, How do the few
Mtb organisms that are inhaled establish
infection?
Notes
Financial support. The work cited from the
laboratory of S.L. is supported by the Research
Enhancement Award Program funded by the
Department of Veterans Affairs, a Veterans
Affairs Merit Review Award, the National Insti-
tutes of Health (NIH; grant R01 AI-056257),
and the National Institute of Allergy and Infec-
tious Diseases, NIH (contract NO1-AI-75320).
Potential conflicts of interest. S.L. certifies no
potential conflicts of interest.
The author has submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest. Con-
flicts that the editors consider relevant to the
content of the manuscript have been disclosed.
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