1. Università
degli
Studi
di
Perugia
Facoltà
di
Medicina
e
Chirurgia
Lucio
Casali
Mariano
E.
Crapa
Ca<edra
di
Mala=e
dell’Apparato
Respiratorio
Storia
naturale
della
Tubercolosi
Milano,
21
marzo
2014

2. Genetic epidemiology of TB
The analysis of the epidemic wave of tuberculosis observed in Europe
in the XVIII and XIX centuries, have shown mortality frequencies that
reach the 2% per year. In particular, in absence of chemotherapy, a
spike can be observed in the first 50-100 years, followed by a slow
decline in the next 200-250 years.
These data support the hypothesis,
developped by E.R.N. Grigg, that in
the first phase of the epidemic wave
the most susceptible portion of
population has been eliminated
(rappresenting up to 20% of the
whole population).
Grigg ERN. Am Rev Tuberc 1958; 78: 426-53

4. –

5. The
life
cycle
of
M.
tuberculosis.
The
infecLon
is
iniLated
when
Mtb
bacilli,
present
in
exhaled
droplets
or
nuclei,
are
inhaled
and
phagocytosed
by
resident
alveolar
macrophages.
The
resulLng
proinflammatory
response
triggers
the
infected
cells
to
invade
the
subtending
epithelium.
This
response
also
leads
to
the
recruitment
of
monocytes
from
the
circulaLon,
as
well
as
extensive
neovascularizaLon
of
the
infecLon
site.
The
macrophages
in
the
granulomas
differenLate
to
form
epithelioid
cells,
mulLnucleate
giant
cells,
and
foam
cells
filled
with
lipid
droplets.
The
granuloma
can
become
further
straLfied
by
the
formaLon
of
a
fibrous
cuff
of
extracellular
matrix
material
that
is
laid
down
outside
the
macrophage
layer.
Lymphocytes
appear
to
be
restricted
primarily
to
this
peripheral
area.
Many
of
the
granulomas
persist
in
this
balanced
state,
but
progression
toward
disease
is
characterized
by
the
loss
of
vascularizaLon,
increased
necrosis,
and
the
accumulaLon
of
caseum
in
the
granuloma
center.
UlLmately,
infecLous
bacilli
are
released
into
the
airways
when
the
granuloma
cavitates
and
collapses
into
the
lungs.

6. Fact
and
ficLon
in
tuberculosis
vaccine
research:
10
years
later

9. Percentage
of
CD4CD25high
T
cells
from
PBMC
of
21
healthy
control
subjects
and
24
paLents
with
acLve
TB.

13. Fact
and
ficLon
in
tuberculosis
vaccine
research:
10
years
later
Targets
and
effectors
of
protecLve
immunity
in
tuberculosis
T
cells
parLcipate
in
protecLon.
Cytokines
acLvate
macrophages,
killer
molecules
lyse
target
cells
and
Mycobacterium
tuberculosis.
The
role
of
B
cells
is
unknown.
Th=T
helper,
CTL=cytolyLc
T
lymphocytes,
TNF=tumour
necrosis
factor.

14. Mycobacterium
tuberculosis
evades
host
immunity
by
recruiLng
mesenchymal
stem
cells
S.
Raghuvanshi
et
Al.www.pnas.org/cgi/doi/10.1073/pnas.1007967107
Infusion
of
MSCs
converts
a
mouse
strain
resistant
to
M.
tb
infecCon
to
disease
suscepCbility.
TGF-­‐βRIIDN
transgenic
mice
were
infused
with
5
×
106
MSCs
derived
from
C57BL/6
mice
infected
for
30
d
with
M.
tb,
followed
by
M.
tb
challenge
(∼110
bacilli)
by
the
aerosol
route.
(A)
Bacterial
loads
in
lungs
and
spleens
of
mice
at
different
days
aUer
infecCon.
(B)
Histological
secCons
of
spleens.
(C)
Numbers
of
granuloma-­‐like
structures
per
cross-­‐secCon
evaluated
by
examining
30
slides
of
each
sample.
(D)
Bacterial
loads
in
MSC-­‐treated
C57BL/6
mice
at
different
Cme
points
aUer
M.
tb
infecCon.
(E)
Sorted
CD4+Thy1.2+FoxP3−
cells
from
FoxP3
knock-­‐in
mice
were
adopCvely
transferred
to
Thy1.1+
mice
along
with
MSCs,
followed
by
infecCon
with
H37Rv.
Conversion
to
cells
with
a
Treg
phenotype
was
followed
in
the
spleens
by
analyzing
Thy1.2+CD4+FoxP3+
cells.
Results
presented
here
are
representaCve
of
three
independent
experiments.

15. Hypoxia:
a
window
into
Mycobacterium
tuberculosis
latency
Tige
R.
et
Al.
Cellular
Microbiology
(2009)
11(8),
1151–1159
Hypoxic
gene
expression
is
rapidly
dominated
by
the
Enduring
Hypoxic
Response
(EHR).
Each
bar
represents
the
total
number
of
genes
induced
at
that
hypoxic
Cme
point.
The
bars
aredivided
into
the
genes
of
the
DosR
response
(blue),
the
EHR
(red),
and
other
induced
genes
(green)

16. The
Mycobacterium
tuberculosis
DosR
Regulon
Assists
in
Metabolic
Homeostasis
and
Enables
Rapid
Recovery
from
Nonrespiring
Dormancy
Rachel
L.
et
Al.
J.
Bacteriol.
2010,
192(6):1662.
Growth
and
survival
during
anaerobic
dormancy
determined
by
recovery
on
solid
and
liquid
media.
Wild-­‐type,
DorKO
mutant,
and
complemented
bacteria
were
grown
in
glass
tubes
with
sCr
bars
and
a
culture-­‐to-­‐headspace
raCo
of
0.65.
Cultures
were
sCrred
with
magneCc
sCrrers.
(A)
CFU
were
counted
at
various
Cmes
by
plaCng
samples
from
tubes
harvested
sacrificially.
Squares,
H37Rv;
triangles,
DorKO;
circles,
DorCO.

17. The
Mycobacterium
tuberculosis
DosR
Regulon
Assists
in
Metabolic
Homeostasis
and
Enables
Rapid
Recovery
from
Nonrespiring
Dormancy
Rachel
L.
et
Al.
J.
Bacteriol.
2010,
192(6):1662.
ATP
measurement
during
early
dormancy.
Samples
from
RAD
model
cultures
were
harvested
at
various
Cme
points
in
an
anaerobic
chamber.
ATP
was
extracted
using
a
chloroform
heat-­‐
based
method
and
frozen
unCl
measurements
could
be
obtained
using
the
Promega
Enliten
ATP
assay
system.
The
values
are
the
averages
of
three
experiments.
Open
bars,
H37Rv;
black
bars,
DorKO;
gray
bars,
DorCO.
RLUs,
relaCve
light
units.

20. No
Anti
TNF
Pz
italiano
di
56
aa,
in
tra<amento
con
infliximab
da
2
se=mane,
esordio
con
stato
confusionale,
crisi
epile=che,
tanto
da
portare
a
ricovero
in
neurologia
per
sospe<a
encefalite.
Successivamente
febbre
e
grave
dispnea.
Deceduto
in
rianimazione
dopo
3
se=mane
per
shock
se=co.

21. –

22. –

23. –

24. –

25. U.
Mack
et
Al.
Eur
Respir
J
2009;
33:
956–973
Summary
of
the
dynamic
sequence
of
events
governing
the
generaCon,
persistence
and
reacCvaCon
of
granulomatous
lesions
in
the
course
of
Mycobacterium
tuberculosis
infecCon.
For
details
of
T-­‐
helper
cell
priming,
triggering
and
effector
molecules,
and
sequenCal
progress
of
lesions
to
latency
and
reacCvaCon,
please
refer
to
secCon
1
of
the
present
arCcle.
IFN:
interferon;
IL:
interleukin;
TNF:
tumour
necrosis
factor;
ESAT:
early
secreted
anCgenic
target;
CFP:
culture
filtrate
protein;
ROI:
reacCve
oxygen
intermediates.