To identify Mycobacterium tuberculosis virulence factors, we integrated comparative genomics and epidemiologic data analysis to investigate the relationship between certain genomic insertions and deletions in the phospholipase-C gene D (plcD) with the clinical presentation of tuberculosis (TB). Four hundred ninety-six wellcharacterized M. tuberculosis clinical isolates were studied. Approximately 30% (147) of the isolates had an interruption of the plcD gene. Patients infected with the plcD mutant were twice as likely to have extrathoracic disease as those infected by a strain without an interruption (adjusted odds ratio, 2.19; 95% confidence interval, 1.27, 3.76). When we limited the analysis to the 275 isolates with distinct DNA fingerprint patterns, we observed the same association (adjusted odds ratio, 2.74; 95% confidence interval, 1.35, 5.56). Furthermore, the magnitude of the association appeared to differ with the type of extrathoracic TB. Our findings suggest that the plcD gene of M. tuberculosis is potentially involved in the pathogenesis of TB, and the clinical presentation of the disease may be influenced by the genetic variability of the plcD region.
Keywords: extrathoracic tuberculosis; pathogenesis; virulence factorsTuberculosis (TB) is a major cause of morbidity and mortality worldwide (1). The lack of an effective vaccine to prevent those who are latently infected with Mycobacterium tuberculosis from developing active disease, the variable results obtained in bacillus Calmette-Gué rin vaccine efficacy trials, the emergence of multidrug-resistant TB worldwide, and the increasing coinfection of HIV with M. tuberculosis in many regions of the world (2-4) highlight the need for a highly effective vaccine and new antimicrobial agents. Identification of the M. tuberculosis factors that contribute to the pathogenesis of TB is necessary if the goal to develop a more effective vaccine is to be reached.To date, identification of M. tuberculosis virulence factors has been based primarily on in vitro and animal studies (5). Although these studies have increased our understanding of the function of a number of M. tuberculosis genes and the impact of gene products on the organisms' behavior in various in vitro and in vivo models, correlation of in vitro findings and animal studies with the pathogenesis of human disease remains challenging (5). An alternative strategy to identify M. tuberculosis virulence factors (6-11) combines comparative genomics to identify genome alteration with epidemiologic methods, to assess associations between genetic polymorphisms and clinical characteristics of the disease. Previous comparative genomic studies have identified large sequence deletions in multiple regions of the M. tuberculosis genome (6,11,12). However, the epidemiologic and clinical phenotypes of these genomic alterations remain largely unknown. Of the previously reported genomic deletions, the region containing the phospholipase-C gene D (plcD) (6) is of particular interest because of the role of plc in the pathog...