Aspects of the pathogenesis, immunity and treatment of Buruli ulcer

Buruli ulcer (BU) is a neglected tropical disease of the skin and subcutaneous tissue caused by infection with Mycobacterium ulcerans. The disease has been reported from over 30 countries worldwide with the highest prevalence in rural areas of West African countries. Clinically, M. ulcerans disease presents in different forms, ranging from small non-ulcerative nodules to large ulcers. The pathology of BU is largely attributable to the production of mycolactone, a lipid-like macrolide exotoxin with cytotoxic and immunosuppressive characteristics. Although mycolactone-induced cytotoxicity and tissue necrosis are the key elements of BU pathogenesis, the molecular mechanisms underlying these processes remained to be elucidated. Within the framework of this PhD thesis, we could show that mycolactone binds to the 12-kDa FK506-binding protein and acts as a potent inhibitor of both mTORC1 and mTORC2. Inhibition of mTORC2 results in inactivation of Akt and dephosphorylation and activation of the Akt-targeted transcription factor FoxO3. Subsequent up-regulation of the FoxO3 target gene Bim, a pro-apoptotic member of the Bcl-2 protein family, was observed both in vitro and in human BU lesions. Moreover, Bim knockout mice were able to contain M. ulcerans infection and did not develop necrotic lesions with large clusters of extracellular bacilli typical for BU, highlighting the pivotal role of Bim-promoted apoptosis for BU pathogenesis. In addition, we aimed at characterizing the nature of immune defense mechanisms conferring protection against BU. Specifically, we focused on the role of interferon-γ and of cellular immune effector mechanisms during the early intracellular stage of M. ulcerans infection. We could show that interferon-γ is critical for early host immunity against M. ulcerans, since mice lacking this cytokine showed a faster increase in bacterial burden and an accelerated pathogenesis, indicative of a reduced capacity to kill the bacilli during the early intracellular stage of the infection. Finally, we evaluated the activity of the new tuberculosis drug candidate Q203 against M. ulcerans using the BU mouse foot pad infection model. In this project, we were able to demonstrate that Q203 has a higher activity against M. ulcerans than rifampicin, and might therefore be suited to replace rifampicin as the first line therapeutic option in the future

Antibody-Mediated Neutralization of the Exotoxin Mycolactone, the Main Virulence Factor Produced by Mycobacterium ulcerans

Mycolactone, the macrolide exotoxin produced by Mycobacterium ulcerans, causes extensive tissue destruction by inducing apoptosis of host cells. In this study, we aimed at the production of antibodies that could neutralize the cytotoxic activities of mycolactone.; Using the B cell hybridoma technology, we generated a series of monoclonal antibodies with specificity for mycolactone from spleen cells of mice immunized with the protein conjugate of a truncated synthetic mycolactone derivative. L929 fibroblasts were used as a model system to investigate whether these antibodies can inhibit the biological effects of mycolactone. By measuring the metabolic activity of the fibroblasts, we found that anti-mycolactone mAbs can completely neutralize the cytotoxic activity of mycolactone.; The toxin neutralizing capacity of anti-mycolactone mAbs supports the concept of evaluating the macrolide toxin as vaccine target

Paralemmin-1 is expressed in lymphatic endothelial cells and modulates cell migration, cell maturation and tumor lymphangiogenesis

The lymphatic system, the network of lymphatic vessels and lymphoid organs, maintains the body fluid balance and ensures the immunological surveillance of the body. In the adult organism, the de novo formation of lymphatic vessels is mainly observed in pathological conditions. In contrast to the molecular mechanisms governing the generation of the lymphatic vasculature during embryogenesis, the processes underlying pathological lymphangiogenesis are less well understood. A genome-wide screen comparing the transcriptome of tumor-derived lymphatic endothelial cells with that of blood vessel endothelial cells identified paralemmin-1 as a protein prominently expressed in lymphatic endothelial cells. Paralemmin-1 is a lipid-anchored membrane protein that in fibroblasts and neurons plays a role in the regulation of cell shape, plasma membrane dynamics and cell motility. Here, we show that paralemmin-1 is expressed in tumor-derived lymphatic endothelial cells as well as in lymphatic endothelial cells of normal, non-tumorigenic tissue. Paralemmin-1 represses cell migration and delays the formation of tube-like structures of lymphatic endothelial cells in vitro by modulating cell-substrate adhesion, filopodia formation and plasma membrane blebbing. While constitutive genetic ablation of paralemmin-1 expression in mice has no effect on the development and physiological function of the lymphatic system, the loss of paralemmin-1 impaired tumor-associated lymphangiogenesis. Together, these results newly identify paralemmin-1 as a protein highly expressed in lymphatic endothelial cells. Similar to its function in neurons, it may link the cytoskeleton to the plasma membrane and thereby modulate lymphatic endothelial cell adhesion, migration and lymphangiogenesi

The HeMoVal study protocol: a prospective international multicenter cohort study to validate cerebrospinal fluid hemoglobin as a monitoring biomarker for aneurysmal subarachnoid hemorrhage related secondary brain injury.

INTRODUCTION Preclinical studies provided a strong rationale for a pathophysiological link between cell-free hemoglobin in the cerebrospinal fluid (CSF-Hb) and secondary brain injury after subarachnoid hemorrhage (SAH-SBI). In a single-center prospective observational clinical study, external ventricular drain (EVD) based CSF-Hb proved to be a promising biomarker to monitor for SAH-SBI. The primary objective of the HeMoVal study is to prospectively validate the association between EVD based CSF-Hb and SAH-SBI during the first 14 days post-SAH. Secondary objectives include the assessment of the discrimination ability of EVD based CSF-Hb for SAH-SBI and the definition of a clinically relevant range of EVD based CSF-Hb toxicity. In addition, lumbar drain (LD) based CSF-Hb will be assessed for its association with and discrimination ability for SAH-SBI. METHODS HeMoVal is a prospective international multicenter observational cohort study. Adult patients admitted with aneurysmal subarachnoid hemorrhage (aSAH) are eligible. While all patients with aSAH are included, we target a sample size of 250 patients with EVD within the first 14 day after aSAH. Epidemiologic and disease-specific baseline measures are assessed at the time of study inclusion. In patients with EVD or LD, each day during the first 14 days post-SAH, 2 ml of CSF will be sampled in the morning, followed by assessment of the patients for SAH-SBI, co-interventions, and complications in the afternoon. After 3 months, a clinical follow-up will be performed. For statistical analysis, the cohort will be stratified into an EVD, LD and full cohort. The primary analysis will quantify the strength of association between EVD based CSF-Hb and SAH-SBI in the EVD cohort based on a generalized additive model. Secondary analyses include the strength of association between LD based CSF-Hb and SAH-SBI in the LD cohort based on a generalized additive model, as well as the discrimination ability of CSF-Hb for SAH-SBI based on receiver operating characteristic (ROC) analyses. DISCUSSION We hypothesize that this study will validate the value of CSF-Hb as a biomarker to monitor for SAH-SBI. In addition, the results of this study will provide the potential base to define an intervention threshold for future studies targeting CSF-Hb toxicity after aSAH. STUDY REGISTRATION ClinicalTrials.gov Identifier NCT04998370 . Date of registration: August 10, 2021

The HeMoVal study protocol: a prospective international multicenter cohort study to validate cerebrospinal fluid hemoglobin as a monitoring biomarker for aneurysmal subarachnoid hemorrhage related secondary brain injury

Introduction: Preclinical studies provided a strong rationale for a pathophysiological link between cell-free hemoglobin in the cerebrospinal fluid (CSF-Hb) and secondary brain injury after subarachnoid hemorrhage (SAH-SBI). In a single-center prospective observational clinical study, external ventricular drain (EVD) based CSF-Hb proved to be a promising biomarker to monitor for SAH-SBI. The primary objective of the HeMoVal study is to prospectively validate the association between EVD based CSF-Hb and SAH-SBI during the first 14 days post-SAH. Secondary objectives include the assessment of the discrimination ability of EVD based CSF-Hb for SAH-SBI and the definition of a clinically relevant range of EVD based CSF-Hb toxicity. In addition, lumbar drain (LD) based CSF-Hb will be assessed for its association with and discrimination ability for SAH-SBI. Methods: HeMoVal is a prospective international multicenter observational cohort study. Adult patients admitted with aneurysmal subarachnoid hemorrhage (aSAH) are eligible. While all patients with aSAH are included, we target a sample size of 250 patients with EVD within the first 14 day after aSAH. Epidemiologic and disease-specific baseline measures are assessed at the time of study inclusion. In patients with EVD or LD, each day during the first 14 days post-SAH, 2 ml of CSF will be sampled in the morning, followed by assessment of the patients for SAH-SBI, co-interventions, and complications in the afternoon. After 3 months, a clinical follow-up will be performed. For statistical analysis, the cohort will be stratified into an EVD, LD and full cohort. The primary analysis will quantify the strength of association between EVD based CSF-Hb and SAH-SBI in the EVD cohort based on a generalized additive model. Secondary analyses include the strength of association between LD based CSF-Hb and SAH-SBI in the LD cohort based on a generalized additive model, as well as the discrimination ability of CSF-Hb for SAH-SBI based on receiver operating characteristic (ROC) analyses. Discussion: We hypothesize that this study will validate the value of CSF-Hb as a biomarker to monitor for SAH-SBI. In addition, the results of this study will provide the potential base to define an intervention threshold for future studies targeting CSF-Hb toxicity after aSAH

Targeting the Mycobacterium ulcerans cytochrome bc1:aa3 for the treatment of Buruli ulcer

Mycobacterium ulcerans is the causative agent of Buruli ulcer, a neglected tropical skin disease that is most commonly found in children from West and Central Africa. Despite the severity of the infection, therapeutic options are limited to antibiotics with severe side effects. Here, we show that M. ulcerans is susceptible to the anti-tubercular drug Q203 and related compounds targeting the respiratory cytochrome bc; 1; :aa; 3; . While the cytochrome bc; 1; :aa; 3; is the primary terminal oxidase in Mycobacterium tuberculosis, the presence of an alternate bd-type terminal oxidase limits the bactericidal and sterilizing potency of Q203 against this bacterium. M. ulcerans strains found in Buruli ulcer patients from Africa and Australia lost all alternate terminal electron acceptors and rely exclusively on the cytochrome bc; 1; :aa; 3; to respire. As a result, Q203 is bactericidal at low dose against M. ulcerans replicating in vitro and in mice, making the drug a promising candidate for Buruli ulcer treatment

Laboratory diagnosis of Buruli ulcer : challenges and future perspectives

Current options to control Buruli ulcer (BU) are limited, as no effective vaccine is available and knowledge on transmission mechanisms of the causative agent, Mycobacterium ulcerans, is incomplete. Early case detection and rapid initiation of treatment are key elements to prevent the development of large, disfiguring ulcers often associated with permanent physical disability and stigma. BU has been reported from 34 countries, with the greatest disease burden in West Africa and steadily increasing case numbers in south-eastern Australia. The disease can present in a variety of clinical manifestations, including relatively unspecific, painless nodules, plaques, and edema, which may eventually progress to chronic, ulcerative lesions. The clinical diagnosis of BU is therefore complicated by a broad differential diagnosis, particularly in tropical areas, where the prevalence of other skin conditions with a similar appearance is high. With the introduction of combination antibiotic therapy, replacing excision surgery as the standard treatment for BU, pre-treatment confirmation of the clinical diagnosis has further gained in importance to avoid the redundant use of anti-mycobacterial drugs. At present, available confirmatory diagnostic tests either lack sufficient sensitivity/specificity or are centralized and thus often not accessible to patients living in remote, rural areas of Africa. In recognition of this disparity, WHO and other stakeholders have called for new diagnostic tools for BU that can be applied at district hospitals or primary healthcare facilities. This chapter highlights challenges, advances and future prospects for the necessary decentralization of the diagnosis of BU

Interferon-γ is a crucial activator of early host immune defense against Mycobacterium ulcerans infection in mice

Buruli ulcer (BU), caused by infection with Mycobacterium ulcerans, is a chronic necrotizing human skin disease associated with the production of the cytotoxic macrolide exotoxin mycolactone. Despite extensive research, the type of immune responses elicited against this pathogen and the effector functions conferring protection against BU are not yet fully understood. While histopathological analyses of advanced BU lesions have demonstrated a mainly extracellular localization of the toxin producing acid fast bacilli, there is growing evidence for an early intra-macrophage growth phase of M. ulcerans. This has led us to investigate whether interferon-γ might play an important role in containing M. ulcerans infections. In an experimental Buruli ulcer mouse model we found that interferon-γ is indeed a critical regulator of early host immune defense against M. ulcerans infections. Interferon-γ knockout mice displayed a faster progression of the infection compared to wild-type mice. This accelerated progression was reflected in faster and more extensive tissue necrosis and oedema formation, as well as in a significantly higher bacterial burden after five weeks of infection, indicating that mice lacking interferon-γ have a reduced capacity to kill intracellular bacilli during the early intra-macrophage growth phase of M. ulcerans. This data demonstrates a prominent role of interferon-γ in early defense against M. ulcerans infection and supports the view that concepts for vaccine development against tuberculosis may also be valid for BU

IFNγ-deficient mice have a significantly higher bacterial burden 5 weeks after infection.

<p>WT and IFNγ^-/- mice were infected with <i>M</i>. <i>ulcerans</i> and the bacterial load was determined by IS2404-specific qPCR (A). The distribution of AFB in the footpads was assessed by histopathological analysis at week 3 (B) and week 5 (C). (A) IFNγ^-/- mice showed a significantly stronger increase in the bacterial burden between week 3 and 5 (1) and had a significantly higher bacterial burden as compared to WT animals 5 weeks after infection with <i>M</i>. <i>ulcerans</i> (2). Values are displayed as mean, the error bars represent the S.D. (n = 3 per genotype). P values were calculated using non-parametric regression models according to the Brunner-Langer method. *, P ≤ 0.05. (B and C) 5 μm tissue sections of foot pads from representative WT (left) and IFNγ^-/- (right) mice stained with ZN for visualization of AFB after 3 (B) or 5 (C) weeks of infection. AFB were predominantly intracellular at week 3 (B1 and B2, black arrows) whereas a mix of intra- and extracellular bacilli was found after 5 weeks of infection (C). At week 5, more AFB were present in IFNγ^-/- foot pads (C2 and C4), no difference in the total immune cell infiltration between the two groups was observed (C1 and C3). Scale bars represent 8 μm (B1 and B2), 160 μm (C1 and C3) and 40 μm (C2 and C4).</p

Extensive tissue necrosis and oedema formation in mice lacking IFNγ.

<p>HE stained histologic sections of foot pads from representative WT (A) and IFNγ^-/- (B) mice 1, 5 and 8 weeks after infection with <i>M</i>. <i>ulcerans</i>. Scale bars represent 5 mm (A1, A4, A7, B1, B4 and B7, left), 1 mm (A1, A4, A7, B1, B4 and B7, box), 150 μm (A2, A5, A8, B2, B5 and B8) and 80 μm (A3, A6, A9, B3, B6 and B9).</p