Tuberculosis

Tuberculosis (TB) is fast becoming incurable affecting millions globally. Mycobacterium tuberculosis (Mtb), causative agent of TB, has evolved elusive survival strategies through point mutations in the drug targets leading to a daunting scenario of resistance towards first-line TB drugs, exacerbated by global differences in mutation patterns. Drug resistance studies have focussed only on few mutations; however, hundreds of mutations have been reported in the last three decades. WHOs goal of global eradication of TB therefore now requires a deep understanding of mechanisms of drug resistance, involving many mutations, addressed in a global context. This study addresses bacterial survival strategies by following bacteria-drug interaction to probe into how bacteria evolve drug resistance mechanisms through mutations. We hypothesise that bacteria favour mutations that protect them from a drug while making the drug ineffective. To test the hypothesis, we quantify the impact of mutations on both bacterial function and drug binding affinity to get to the root of drug resistance revealing how bacteria may evolve an arsenal of mutations towards an optimal survival strategy. This first comprehensive and systematic in-depth study global patterns of mutation and drug resistance mechanisms from mutation data for Mtb reported over the last 30 years. These were collected for 31,073 drug-resistant Mtb isolates from 149 published studies for the four first line drugs isoniazid (INH), pyrazinamide (PZA), rifampicin (RIF), and ethambutol (EMB). We found 821 single frequency non-synonymous mutations for INH (n= 202), RIF (n=120), EMB (n=226) and PZA (n=273). We then investigated the prevalence and diversity of these mutations in the drug targets across the globe. We found S315T in the target katG (60%) to be the most prevalent mutation in INH resistance followed by S450L in rpoB (56%) and M306V in embB (29%) associated with RIF and EMB resistance, respectively; these were also the highly occurring mutations across the six WHO regions, except for the most common mutation Q10P in pncA (1.4%) (PZA resistance; with shorter exposure to drug) showing a variable pattern of occurrence globally. We found the highest mutational burden in the Western Pacific and South-East Asia regions for INH and RIF resistance. Frequent mutations had also undergone frequent amino acid substitutions. Accordingly, we developed a comprehensive atlas of mutation spread across the globe and their evolution over the last 30 years. We then probed into the impact of mutations on TB bacteria and drug binding with a comprehensive bioinformatics analysis for understanding crucial changes caused by mutation at the molecular level affecting function and structural stability of bacteria and the drug binding affinity. We found that the most prevalent mutations occur in non-conserved areas in the drug binding region indicating a choice of a less dramatic level of change in target protein function and stability. All mutations reduced drug binding affnity. For characterising drug resistance mechanisms, we introduced a new concept of ranking drug-resistant TB mutations into lethal, moderate, mild and neutral considering the combined effect on Mtb viability and drug binding. We identified 340 mutations as lethal, 284 as moderate, 185 as mild and 12 as neutral. We observed that frequently occurring mutations occur in non-conserved regions causing a mild effect on target proteins (such as S315T of katG, S450L of rpoB and M306V in embB), while reducing drug binding affinity. With these we uncovered a universal strategy of drug resistance and bacterial survival: Mtb favours less harmful mutations in the drug binding region without compromising conservancy while destabilising the drugs, thus striking a balance between fitness and drug resistance. This ingenuous strategy seems successful and reasonable persisting globally over three decades and provides a holistic understanding of drug resistance and a strong foundation for designing efficacious drugs and therapies towards global eradication of TB.

Intravital microscopy enables direct visualization of dynamic cellular processes within intact tissues, but its application to Mycobacterium tuberculosis (Mtb) has been limited by Biosafety Level 3 (BSL-3) containment requirements and the technical challenges of stabilizing the lung for high-resolution imaging. Here, we present a protocol that combines the thoracic Window for High-Resolution Imaging of the murine Lung (WHRIL) with a genetically defined, triple-auxotrophic Mtb strain (mc27902) approved for use under BSL-2 conditions. We describe the construction of a tdTomato-expressing derivative (mc28471) preparation of bacteria for intravenous infection and intravital imaging in reporter mice. This system enables visualization of rapid bacterial entry into the pulmonary vasculature, subsequent aggregation, and vascular occlusion, dissemination into the lung parenchyma, and macrophage uptake over three days post-infection. This protocol provides the first practical platform for real-time intravital imaging of mycobacteria in the lung and establishes a foundation for mechanistic studies of bacterial physiology, host recognition, and immune-mediated clearance using safe Mtb surrogates. SummaryThis protocol describes a biosafety level 2 (BSL-2)-compatible intravital imaging platform for visualizing Mycobacterium tuberculosis (Mtb) in the intact murine lung at single cell resolution. By combining the Window for High-Resolution Imaging of the murine Lung (WHRIL) with a fluorescently labeled, genetically defined triple auxotrophic Mtb strain (mc27902), this approach overcomes long-standing biosafety and technical barriers that have prevented real-time imaging of mycobacterial infection in vivo. The method enables direct visualization of early bacterial localization, aggregation, vascular interactions, and macrophage uptake during the initial hours to days following infection, providing a practical foundation for mechanistic studies of host-pathogen interactions under safe experimental conditions.

BackgroundTuberculosis (TB) remains a major global health concern, posing a substantial burden in Pakistan. Genetic factors play a pivotal role in individual susceptibility to TB. Surfactant protein A and surfactant protein D are essential components of the innate immune system, contributing to pulmonary host defense against Mycobacterium tuberculosis (MTB). AimThis study aimed to investigate the association between single nucleotide polymorphisms (SNPs) in the SP-A1gene at rs1059047 (+1101 C/T) and the SP-D gene at rs3088308 (911 T/A) and TB susceptibility in the Pakistani population. MethodA case-control study was conducted, comprising 350 individuals, including 150 healthy controls, 100 TB patients, and 100 TB contacts. Genotyping was performed using tetra ARMS-PCR. GraphPad Prism v.10 was used for statistical analysis. ResultsOur results revealed no significant association between the SP-A1 gene polymorphism at rs1059047 (+1101 C/T) and SP-D gene polymorphism at rs3088308 (911 T/A) and TB susceptibility in the Pakistani population (p>0.5). Interestingly, concerning the rs3088308 polymorphism in the SP-D gene, a comparison between healthy controls and TB contacts indicated that the homozygous TT genotype was significantly associated with protection against LTBI (73.53% vs. 82.35%; p=0.00, OR=0.19, 95% CI=0.08-0.51).

BackgroundTuberculosis (TB) is the second-leading cause of deaths from infectious agents and remains a global health threat. Ethionamide (ETH) is a prodrug used in regimens for multidrug-resistant TB, and, partly due to side effects that can lead to low treatment adhesion, resistance arises. Changes in EthA, the monooxygenase that activates ETH, are the main mechanism of resistance. Yet, of hundreds of EthA substitutions found in resistant isolates, only a handful have been annotated as resistance determinants. ResultsAn in silico analysis was carried out on a previously described panel of Mycobacterium tuberculosis clinical isolates for which genomes and ETH susceptibility testing results were available. EthA substitutions were mapped, revealing the existence of hotspots in its sequence. Visualization of the hotspots in the EthA structural model shows that they cluster in three regions, including ligand binding pockets. Models were built of twenty-three variants found in resistant isolates and changes in local configuration was mapped to identify investigate impact on ETH activation. Information from these models contributed to establishing five criteria for scoring whether substitutions are most likely to lead to resistance. Using these criteria, EthA D58G was selected and its expression is shown to increase growth in high ETH concentrations. ConclusionFunctionally relevant regions of EthA are revealed and point out priority substitutions for functional studies, enhancing identification and detection of substitutions not been previously associated with resistance.

Phage therapy offers promise to combat antimicrobial resistance, including drug-resistant tuberculosis (TB). Understanding phage activity against Mycobacterium tuberculosis (Mtb) adapted to physiologic microenvironments, such as hypoxia and acidity in granulomas, is essential since these conditions induce non-replicating states. We evaluated a phage combination against Mtb under hypoxic, acidic (pH 5.5), and stationary-phase conditions in vitro. In planktonic Mtb growth conditions, phage concentrations increased around day seven followed by a significant reduction in Mtb H37Rv load, which was maintained over 31 days. Phage addition prevented regrowth was observed with rifampicin and isoniazid alone. Individual phage stability was differentially affected by acidic media conditions, resulting in variability of antimycobacterial activity. In hypoxic conditions and stationary growth experiments, phage titers remained stable over time with no change in mycobacterial load compared to controls. Model-based predictions were able to adequately capture phage-mycobacterial interactions with and without rifampicin. The lack of antimycobacterial activity in assays with non-replicating mycobacteria suggest that phages need actively replicating mycobacteria to exert lytic activity. Stable phage concentrations in assays with non-replicating mycobacteria suggests low grade phage replication in these conditions. Established models can support future study design through simulations of different experimental scenarios.

Background: With the emergence of drug-resistant strains and an unprecedented threat to control initiatives, tuberculosis remains to be a major public health risk in Ethiopia. Resistance to rifampicin (RR) is an important indicator, since RR is an acceptable surrogate for multidrug-resistant TB (MDR-TB). Over 95% of RR is based on mutations in an 81base pair segment of the rpoB gene, detected using rapid molecular assays. Despite this, detailed molecular epidemiological information is scarce. This study characterized the specific rpoB gene mutation patterns among patients in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted in 753 Mycobacterium tuberculosis complex (MTBC) clinical samples, corroborated as positive for MTBC from 2020 to 2024; respective probe mutation patterns were generated by the Xpert MTB/RIF platform. Demographic and clinical variables were also assessed for detecting the potential risk factors. Results: The overall RR-TB rate was 2.3% (17/753). Molecular analysis showed a distinct pattern of mutation, with codon 526 mutations being the most frequent, occurring in 54.3% of the resistance mechanisms. This was followed by those at codons 531 (21.7%) and 533 (15.2%). Most significant was the fact that 100% of RR-TB was observed among treatment-naive patients, providing unequivocal evidence that primary transmission is the exclusive cause of resistance in this population. Moreover, there were no statistically significant correlations between RR-TB and demographic factors, including sex, age, or HIV co-infection. Conclusion: The study demonstrates a steady, low-grade epidemic of RR-TB in Addis Ababa, dominated by a virulent bacterial strain with a distinctive mutation at codon 526. These observations highlight the imperative necessity for a strategic shift from a reactive, clinically-oriented model to proactive public health measures. To effectively break the chains of transmission, we recommend the universal application of drug susceptibility testing, enhanced and socially-directed contact tracing, and integrating molecular surveillance into the TB control program.

The lack of a reliable chronic murine model limits drugs evaluation against Mycobacterium abscessus. Models show discrepancies, especially regarding host factors (mouse strain, sex and age). Using beads-model, we compared BALB/cJRJ and C57BL/6NCrl across sexes and ages. BALB/cJRJ showed more sustained infection and lower variability, with no significant sex- or age-related differences. Considering these results and the higher prevalence of NTM pulmonary infections in female patients, 5-6 weeks-old female BALB/cJRJ are appropriate for M. abscessus beads-model.

Background: Tuberculosis (TB) remains the leading infectious cause of death worldwide, with India accounting for nearly one-fourth of global TB cases. Ni-kshay, the countrys digital case-based TB notification platform is rich in data pertaining to the continuum of care of TB patients. This study aims to develop a standardized analytical approach to programmatic data to identify predictors of unfavourable treatment outcomes and mortality among adult drug-sensitive TB patients at the state level for Maharashtra during 2021 and 2022. Methods: Two separate analyses were undertaken comparing treatment success with: (1) unfavourable outcomes (death, treatment failure, loss to follow-up, regimen change, or not evaluated); and (2) mortality. Multivariate logistic regression was used to compute adjusted odds ratios (aOR) for key risk factors, adjusting for age, gender, and weight. Results: The final cohort included 323,124 cases for unfavourable outcome analysis and 315,579 cases for mortality analysis. Increasing age, male gender, lower body weight, known HIV and diabetes comorbidities, tobacco and alcohol consumption, and "unknown" status for behavioural risks and comorbidity status were significantly associated with increased odds of both unfavourable outcomes and mortality. Conclusions: This study highlights the utility of programmatic data in identifying high-risk TB patients and offers a reproducible analytic framework.

Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), has regained its position as the worlds leading killer among infectious diseases. Despite extensive research progress across epidemiology, diagnosis, drug development, treatment regimens, vaccines, drug resistance, virulence factors, and immune mechanisms, MTB-related knowledge remains fragmented across thousands of publications, limiting its effective use. To address this gap, we present MTB-KB, a literature-curated knowledgebase that systematically integrates high-impact findings from eight major sections of TB research. The current release contains 75,170 associations from 1,246 publications, covering 18,439 entities standardized using authoritative databases and WHO-endorsed classifications. A central feature is the interactive knowledge graph, which links cross-section associations to reveal and infer MTB-host interactions, treatment strategies, and vaccine development opportunities. MTB-KB also provides a user-friendly interface with browsing, advanced search, and statistical visualization. Overall, by consolidating dispersed MTB knowledge into a structured and accessible platform, MTB-KB provides a valuable resource for researchers, clinicians, and policymakers, supporting both basic and clinical TB research, enabling evidence-based TB prevention, diagnosis, and treatment, and contributing to global elimination efforts. MTB-KB is accessible at https://ngdc.cncb.ac.cn/mtbkb/.

Rationale: Sputum-based testing using Xpert MTB/RIF Ultra (Xpert) is the most common molecular testing method for diagnosing tuberculosis (TB). Objectives: To evaluate whether sputum quality influences Xpert positivity and diagnostic accuracy. Methods: We screened consecutive people for presumptive TB in India, the Philippines, Vietnam, Nigeria, South Africa, Uganda, and Zambia as part of the R2D2 TB Network and ADAPT studies. Participants provided 2-3 sputum samples for Xpert and culture reference testing. The quality of the first sputum sample was graded following standardized procedures by trained research staff and used for Xpert testing. We performed logistic regression to evaluate whether sputum grade was independently associated with Xpert positivity, and calculated sensitivity and specificity of Xpert against a culture-based microbiological reference standard (MRS). Measurements and Main Results: Among 1,855 participants, 798 (43%) were female, 348 (19%) were living with HIV (PLHIV), and 1795 (97%) had a cough of [≥]2 weeks. Overall, 313 (17%) had a positive Xpert result. Most sputum samples were salivary (83%). Xpert positivity was lowest among salivary samples (16.1%) and highest among purulent samples (31.2%). After adjusting for demographic and clinical variables, there was no significant association between any sputum grade and Xpert positivity. Xpert sensitivity (salivary: 89%, mucoid: 91%, mucopurulent: 87%, purulent: 100%) and specificity (>98%) were high across sputum grades. Conclusions: Sputum quality was not independently associated with Xpert positivity and Xpert sensitivity was high across all sputum grades. These findings support molecular testing of all sputum samples for TB diagnosis regardless of macroscopic appearance.

BackgroundMoxifloxacin is a key component of current MDR-TB therapy regimens. The choice to include it in therapy at standard or higher doses is based on the lack or presence of resistance mutations conferring low-level or high-level resistance to moxifloxacin, as detected by the Line probe assay (LPA). Due to inherent phenotypic and genotypic discordance, such resistance must be reconfirmed phenotypically using liquid culture and drug susceptibility testing (LC-DST) at critical concentration and clinical breakpoint of the drug. This takes several weeks, delaying the therapeutic decision. The current study intends to shorten this time by performing phenotypic DST directly on sputum samples. MethodsA cross-sectional study was conducted for 18 months from October 2023 to April 2025, in which smear positive sputum samples that were resistant to Rifampicin or Isoniazid or both were subjected to Direct Moxifloxacin DST, irrespective of patient characteristics. Results obtained by Direct DST were compared against Indirect LC-DST as the gold standard as well as with LPA to evaluate the diagnostic accuracy and time savings with direct DST. ResultsDirect DST exhibited high accuracy of 98.18%, high sensitivity (90.91%), high specificity (98.99%), excellent concordance (98.18%) and almost perfect agreement (kappa value - 0.901) when compared to Indirect DST. It saved an average of 10 {+/-} 3.20 days over Indirect DST to obtain the valid results. Similar performance was also observed in comparison to LPA with good sensitivity (90.91%), specificity (98.99%) and accuracy (98.18%). Significant discordance was however noted in classification of resistance by both direct and indirect DST compared to LPA. Few error rates and minimal cost advantages were some of the disadvantages of Direct-DST. ConclusionDirect DST demonstrated excellent performance characteristics, making it a reliable and rapid alternative to the gold standard, saving significant time in guiding therapeutic decisions for effective patient management.

Background: Host genetics alone explains limited susceptibility to tuberculosis (TB), particularly in people with HIV (PWH). Protein quantitative trait loci (pQTLs), genetic variants that regulate plasma protein levels, may bridge genetic and immunological mechanisms underlying TB progression. Methods: We conducted cis-pQTL mapping in 60 PWH who progressed to active TB and 194 matched controls from the Swiss HIV Cohort Study. Plasma proteomes were quantified via high-resolution mass spectrometry (dia-PASEF), and genotype-protein associations were analyzed separately in TB and control groups. Results: TB progressors harbored 26 cis-pQTLs linked to 12 proteins uniquely enriched in immune pathways (antigen presentation, complement activation, phagocytosis, and T-cell regulation). Controls showed 107 cis-pQTLs linked to 14 targets. Gene Ontology enrichment revealed 46 immune biological processes in TB versus only 1 in controls, with HLA-C, C4B, and CHIT1 as key TB-specific proteins. Conclusions: Integrating proteomics with genomics suggests differential regulation of immune proteins associated with TB progression in PWH. hese genetically anchored protein candidates support follow-up studies and future biomarker evaluation for TB risk prediction.

Background: In Rwanda, genomic surveillance identified a dominant multidrug-resistant tuberculosis (MDR-TB) strain, the R3clone, responsible for approximately 70% of rifampicin-resistant TB cases. Its presence beyond Rwanda remains unexplored. Methods: Unique genetic signatures of the R3clone were defined using whole-genome sequencing of MDR-TB isolates from Rwanda. We developed a targeted qPCR assay detecting a clone-specific single-nucleotide polymorphism. With these tools, we screened isolates from neighbouring countries and public genomic repositories. Results: We identified 375 R3clone isolates, including 264 from historical Rwandan collections (1991-2021), 49 from recent Rwandan diagnostic routine (2021-2024), 25 from historical Burundi isolates (2002-2013), and 37 among public repositories from several countries. The R3clone-specific qPCR showed 100% specificity in distinguishing the R3clone from other MTBC (sub-)lineages. Transmission analysis revealed cross-border transmission of the R3clone within the Great Lakes Region. Conclusion: This study comprehensively assesses cross-border transmission of a dominant MDR-TB strain, highlighting the need for coordinated international surveillance.

BackgroundEstimating bacterial load in clinical samples has important applications in tuberculosis (TB) management, including assessment of disease severity, treatment response, and baseline genome copies required for sequencing. However, rapid and affordable tools for quantifying Mycobacterium tuberculosis (M. tuberculosis) remain limited. MethodsWe developed a high-resolution melt (HRM) based quantitative PCR assay using molecular beacon chemistry targeting the single-copy RD9 region of M. tuberculosis. Analytical performance was assessed using 10-fold serial dilutions of H37Rv DNA. Clinical validation included DNA from 100 M. tuberculosis culture isolates and 40 sputum samples from Xpert MTB/RIF- and culture-positive pulmonary TB patients. To evaluate specificity, we tested 30 non-tuberculous mycobacterium (NTM) culture isolates from patients infected with Mycobacterium abscessus (n=25) and Mycobacterium fortuitum (n=5) and DNA from saliva samples of 10 healthy controls. ResultsThe HRM-qPCR assay showed a linear dynamic range from 101 to 106 genome copies per reaction, with a lower limit of detection of 10 copies. Standardized melt-curve analysis yielded a single target-specific peak at 73.7{+/-}0.12{degrees}C across dilutions, confirming specific amplification. Sensitivity for M. tuberculosis detection was 100% in culture isolates and 95.0% (38/40) in sputum, with no false positives among M. tuberculosis-negative controls. Assay specificity was 100% in both culture isolates and sputum, with no additional melt peaks. We did not observe any peaks indicative of non-specific binding in NTMs. Amplification was observed in two NTM samples whose Tm matched M. tuberculosis RD9 (median M. tuberculosis copies=678.5), suggesting possible co-infection or contamination. No amplification or specific melt peaks were observed in saliva samples, indicating high probe specificity. ConclusionsMolecular beacon-based HRM-qPCR assay enables rapid, highly specific quantification of M. tuberculosis genome copies in clinical samples and has potential utility for treatment monitoring, triaging specimens for sequencing, and assessing transmission risk in high-burden settings.

Despite multiple treatment strategies and extensive research on resistance mechanisms, tuberculosis (TB) remains a major global health threat, largely because of the rise of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. Among various mechanisms complicating the situation, active antibiotic export via efflux pumps is particularly significant, yet largely unexplored. Mycobacterium sp. encodes numerous transporters, many of which are overexpressed in clinical isolates or under drug stress. Here, we examined the possible role of Rv0783c, a putative transporter that is reportedly overexpressed in drug-stressed conditions. Rv0783c conferred resistance to multiple structurally diverse antibiotics, fluoroquinolones and anti-TB drugs in the heterologous hosts, namely, Escherichia coli and Mycobacterium smegmatis. Reduced drug accumulation and active efflux of ethidium bromide (EtBr) confirmed its transport activity, which in turn gets nullified upon using the proton-motive force blocker, CCCP. On the other hand, its expression enhanced biofilm formation, linking antibiotic resistance to persistence-associated phenotype. Furthermore, site-directed mutagenesis confirmed the presence of crucial interacting residues with antibiotics that were identified by in silico analysis. Overall, we demonstrate the role of Rv0783c in the extrusion of first and second-line anti-TB drugs and enhancing biofilm formation.

Mycobacterium tuberculosis (Mtb) subverts host immune responses via modulation of host epigenome and metabolism. In this study, we underscore a role for the epigenetic modifier, Lysine Specific Demethylase 1 (LSD1), in regulating macrophage metabolism to support mycobacterial pathogenesis. In ex vivo and in vivo infection models, LSD1 inhibition reduced mycobacterial CFU alleviating lung pathology. Metabolomic analysis of Mtb infected, LSD1 deficient macrophages revealed increased levels of alpha-ketoglutarate (AKG), a crucial TCA cycle metabolite via regulating genes implicated in glutamine breakdown. Moreover, exogenous addition of AKG resulted in reduced oxidative stress and attenuated lipid peroxidation (LPO) with a consequent decrease in Mtb survival. Blocking glutamine breakdown in LSD1 deficient macrophages failed to reduce LPO and promoted Mtb intracellular survival, highlighting the role of LSD1-AKG axis in this immunomodulation. Dietary supplementation of AKG to Mtb infected mice improved lung pathology, limited Mtb dissemination and reduced the levels of oxidative Malondialdehyde adducts. Therefore, we highlight a host protective role of AKG during Mtb pathogenesis through suppression of lipid peroxidation and uncover an epigenetic-metabolic axis exploited by Mtb, thereby positing dietary supplementation of AKG as a potential therapeutic strategy against Tuberculosis.

Aminoglycoside drugs, amikacin, streptomycin, and amikacin liposome inhalation suspension are crucial for treating refractory Mycobacterium avium-intracellulare complex pulmonary disease. In Mycobacterium tuberculosis, cross-resistance occurs between amikacin and kanamycin, but not between amikacin and streptomycin in genetic drug susceptibility testing. However, the occurrence of cross-resistance among aminoglycosides remains unclear in M. avium-intracellulare complex. We aimed to evaluate cross-resistance among aminoglycosides to determine whether streptomycin or kanamycin remains effective after the development of amikacin resistance. This single-center retrospective study included 20 patients with amikacin-resistant M. avium-intracellulare complex harboring rrs mutations. Paired analyses of streptomycin and kanamycin minimum inhibitory concentration values before and after amikacin resistance development were performed. In addition, streptomycin- and kanamycin-resistant strains were generated in vitro and resistance-associated mutations were identified using whole-genome sequencing. No significant increase was observed in streptomycin minimum inhibitory concentration values following amikacin resistance. In contrast, kanamycin values uniformly increased to >256 g/mL after the acquisition of amikacin resistance. Furthermore, amikacin- and kanamycin-resistant isolates shared mutations at position 1408 in the rrs gene, whereas streptomycin-resistant isolates exhibited mutations at position 20 in the rrs gene. These results suggest that amikacin and kanamycin exhibit cross-resistance in M. avium-intracellulare complex, whereas amikacin and streptomycin may not. Two cases in our cohort in which streptomycin treatment was effective after the acquisition of amikacin resistance further support these findings. In conclusion, streptomycin may be a potential therapeutic alternative for amikacin-resistant M. avium-intracellulare complex pulmonary disease. Future studies correlating streptomycin minimum inhibitory concentration values with clinical outcomes are required.

Background: Without tuberculosis preventive therapy (TPT), approximately 5% of individuals infected with M. tuberculosis progress to active tuberculosis (TB) disease. Recent studies have identified body mass index (BMI) < 25 kg/m2 as a predictor of TB progression, but additional markers are needed to better identify persons at increased risk. Methods: Close contacts of patients with culture-confirmed pulmonary TB were enrolled in the Regional Prospective Observational Research in Tuberculosis (RePORT)-Brazil cohort from 2015 to 2019 and followed for up to 24 months. Analyses were restricted to interferon-{gamma} release assay (IGRA)-positive contacts who did not receive TPT or received <30 days of isoniazid. Prediction models to identify close contacts at increased TB risk were constructed using two complementary approaches: incremental models used BMI as the base predictor and evaluated whether baseline whole-blood transcriptomic signatures, human genetic polymorphism risk scores derived from low-pass whole-genome sequencing, and BMI-related plasma biomarkers improved model discrimination. Agnostic models did not impose BMI in the model and used penalized regression for predictor selection. Results: Among 285 close contacts, 15 (5%) progressed to TB. The model with BMI as unique predictor had a C-index of 0.66 (95% confidence interval [CI] 0.55; 0.77). Adding Rajan5 or Duffy9 transcriptomic signature scores to BMI improved discrimination compared with BMI alone, with C-indices of 0.78 (95% CI 0.62; 0.99) and 0.75 (95% CI 0.61; 0.89), respectively, but did not further improve discrimination after accounting for adiponectin. Adding adiponectin to BMI increased the C-index to 0.80 (95% CI 0.68; 0.91), while adiponectin alone captured most of the discriminatory performance in agnostic models (C-index, 0.80, 95% CI 0.69; 0.91). Genetic risk scores, leptin, and the adiponectin:leptin ratio did not improve model discrimination compared with the BMI-only model. In exploratory post hoc analyses, higher adiponectin was associated with increased risk of progression to TB, with each two-fold increase associated with a higher hazard of TB (HR 2.91, 95% CI 1.73; 4.91, p < 0.001). Conclusions: Baseline adiponectin strongly predicted progression to TB among close contacts and captured most of the discriminatory information contained in epidemiological and transcriptomic variables. Its consistent selection across modelling approaches supports adiponectin as a promising biomarker for TB risk stratification.

Bovine tuberculosis (bTB), due to Mycobacterium bovis (Mb) infection, is a chronic cattle disease and neglected cause of zoonotic tuberculosis. The role of neutrophils in bTB is overlooked. We recently identified a new neutrophil subset in cattle and mice with a similar morphology to conventional inflammatory neutrophils (Nconv). However, unlike Nconv, these regulatory neutrophils (Nreg) express MHC-II at their surface and can suppress lymphocyte proliferation. In this study, we compared the responses of bovine Nconv and Nreg to infection with a virulent Mb strain circulating in France and the attenuated Mb BCG vaccine. Nreg and Nconv had different transcriptional profiles and were differentially activated by Mb infection. Both Nreg and Nconv efficiently killed Mb, but Nreg had higher levels of phagocytosis activity and ROS production. Nreg had higher levels of mitochondrial activity and an ultrastructural organization different from that of Nconv. Our results provide the first insight into the functional characterization of bovine neutrophil subsets during Mb infection and highlight a new layer of complexity in their functional diversity that must be taken into account to improve our understanding of bTB pathophysiology, which is urgently required to improve the management of this costly disease.

BackgroundNumerous studies reporting utility of microbial blood biomarkers for diagnosis and treatment monitoring of M. tuberculosis (Mtb) infection and tuberculosis disease have been conducted, but up-to-date systematic reviews and meta-analyses of these data are lacking. We aimed to evaluate diagnostic accuracy of microbial blood biomarkers for detection of tuberculosis disease and to characterise their responses to antimicrobial therapy. MethodsFor this aggregate data meta-analysis, we searched MEDLINE, EMBASE and Scopus from 1st January, 1990, to 22 October, 2025, using terms for "tuberculosis", "microbial biomarker", and "human blood" to identify studies in which participants underwent blood sampling for detection of cell-free Mtb DNA, cell-associated Mtb DNA, protein/peptide Mtb antigens and lipid/glycolipid Mtb antigens before {+/-} after initiation of antimicrobial therapy. For bivariate analyses we used hierarchical summary receiver operating characteristic (HSROC) models to calculate areas under HSROC curves (AUC) for each analyte class to evaluate diagnostic accuracy for tuberculosis disease. For longitudinal analyses, we calculated risk differences to evaluate changes in proportions of biomarker-positive individuals after vs. before initiation of antimicrobial therapy, and pooled them using random-effects meta-analysis. Findings137 eligible articles were identified in the search, of which 109 vs. 13 contributed data to bivariate vs. longitudinal analyses, respectively. For cell-free Mtb DNA targets, AUC was 0.87 (95% CI 0.84 to 0.89), with sensitivity 61.5% (51.0 to 71.0) and specificity 93.0% (88.1 to 96.1); 4,878 samples from 34 unique study/setting/biomarker combinations (investigations). For cell-associated Mtb DNA targets, AUC was 0.93 (0.90 to 0.95), with sensitivity 43.9% (29.4 to 59.4) and specificity 97.1% (94.5 to 98.5); 3,589 samples, 32 investigations. For protein/peptide targets, AUC was 0.94 (0.92 to 0.96), with sensitivity 78.9% (73.2 to 83.6) and specificity 92.9% (90.7 to 94.5%); 10,260 samples, 61 investigations. For lipid/glycolipid targets, AUC was 0.96 (0.94 to 0.97), with sensitivity 68.6% (54.1 to 80.3) and specificity 97.0% (94.0 to 98.5); 3,287 samples, 22 investigations. Pooled risk differences for proportions of individuals biomarker-positive after vs. before initiation of antimicrobial therapy were -0.44 (-0.89 to 0.01; 68 samples, 5 investigations) for cell-free Mtb DNA; -0.46 (-0.88 to -0.03; 89 samples, 5 investigations) for cell-associated Mtb DNA, and -0.24 (-0.75 to 0.28; 160 samples, 4 investigations) for protein/peptide antigens. No studies investigating responses of lipid/glycolipid antigens to antimicrobial therapy were identified. Heterogeneity was moderate (I2 25-50%) for the majority of studies. 98/109 and 11/13 studies contributing data to bivariate vs. longitudinal analyses, respectively, were assessed as being at high risk of bias. InterpretationMolecular and biochemical microbial blood biomarkers exhibit similar accuracy for detection of tuberculosis disease, with specificity consistently exceeding sensitivity. Cell-associated Mtb DNA biomarkers exhibited a statistically significant response to antimicrobial therapy, with similar trends observed for cell-free Mtb DNA and protein/peptide antigens. These findings should be interpreted cautiously in the light of high risk of bias for many of the primary studies contributing data. Higher quality studies are needed to evaluate this emerging class of tuberculosis biomarkers. FundingBarts Charity, The Medical College of Saint Bartholomews Hospital Trust, Wellcome HARP Doctoral Fellowship Scheme. RESEARCH IN CONTEXT Evidence before this studyThe World Health Organisation (WHO) has identified high-priority biomarker needs for screening, diagnosis, evaluating likelihood of disease progression and treatment monitoring for tuberculosis. Numerous studies reporting utility of microbial blood biomarkers for diagnosis and treatment monitoring of M. tuberculosis (Mtb) infection and tuberculosis disease have been conducted, but up-to-date systematic reviews and meta-analyses of these data are lacking. We performed a systematic search of MEDLINE, EMBASE and Scopus from 1st January, 1990, to 22 October, 2025, using terms for "tuberculosis", "microbial biomarker", and "human blood" to identify studies in which participants underwent blood sampling for detection of cell-free Mtb DNA, cell-associated Mtb DNA, protein/peptide Mtb antigens and lipid/glycolipid Mtb antigens before {+/-} after initiation of antimicrobial therapy. Multiple studies have investigated utility of microbial blood biomarkers for detection of tuberculosis disease and monitoring responses to antimicrobial therapy, but only three relevant systematic reviews have been conducted to date, of which two (2007, 2021) report on detection of cell-free Mtb DNA, and one (2011) reports on antigen detection tests. Numerous primary studies have been published since these meta-analyses were conducted, but up-to-date syntheses incorporating the latest data for all classes of microbial blood biomarker for tuberculosis are lacking. Added value of this studyTo our knowledge, this study is the most comprehensive systematic review and meta-analysis of data from studies of microbial blood biomarkers of Mtb infection and tuberculosis disease conducted to date. It is also the first meta-analysis to synthesise data from studies investigating detection of cell-associated Mtb DNA in blood. Bivariate analysis of data from 109 studies revealed AUC values of 0.87 to 0.96 for the four microbial biomarker classes investigated, with sensitivity vs. specificity ranging from 43.9% to 80.2% vs. 87.9% to 97.1%, respectively. Cell-associated Mtb DNA biomarkers exhibited a statistically significant response to antimicrobial therapy, with similar trends observed for cell-free Mtb DNA and protein/peptide antigens. However, most primary studies were assessed as being at high risk of bias. Implications of all the available evidenceMolecular and biochemical microbial blood biomarkers exhibit similar accuracy for detection of tuberculosis disease, with specificity consistently exceeding sensitivity. Cell-associated Mtb DNA biomarkers exhibited a statistically significant response to antimicrobial therapy, with similar trends observed for cell-free Mtb DNA and protein/peptide antigens. These findings should be interpreted cautiously in the light of high risk of bias for many of the primary studies contributing data. Higher quality studies are needed to evaluate this emerging class of tuberculosis biomarkers.