See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/267745772

Pathogenesis of Post Primary Tuberculosis: Immunity and Hypersensitivity in

the Development of Cavities

Article  in  Annals of clinical and laboratory science · November 2014

Source: PubMed

CITATIONS READS
31 505

5 authors, including:

Robert L Hunter Jeffrey Actor

University of Texas Health Science Center at Houston University of Texas Health Science Center at Houston
74 PUBLICATIONS   4,725 CITATIONS    161 PUBLICATIONS   3,605 CITATIONS   

SEE PROFILE SEE PROFILE

Shen-An Hwang Chinnaswamy Jagannath

Myriad RBM Houston Methodist Research Institute
47 PUBLICATIONS   986 CITATIONS    102 PUBLICATIONS   5,179 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Autophagy as a mechanism to enhance vaccines and adjuvants View project

Lactoferrin anti-inflammatory View project

All content following this page was uploaded by Shen-An Hwang on 04 April 2018.

The user has requested enhancement of the downloaded file.

 Available online at www.annclinlabsci.org

Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014

365

Pathogenesis of Post Primary Tuberculosis:

Immunity and Hypersensitivity in the Development of Cavities
Robert L. Hunter1, Jeffrey K. Actor1, Shen-An Hwang1, Vadim Karev2, and Chinnaswamy Jagannath1
1Department of Pathology and Laboratory Medicine, University of Texas-Houston Medical School Houston, Texas,
USA, and 2Scientific-Research Institute of Childhood Diseases of the Federal Medical and Biological Agency, Saint
Petersburg, Russia

Abstract. M. Tuberculosis (MTB) is an obligate human parasite even though humans are more resistant
than any of the animals used for study. It is a human parasite because only humans develop post primary
tuberculosis (TB) in their lungs that mediates transmission of infection to new hosts. The extreme paucity
of human lung tissue with post primary TB has forced scientists to study animal models and human tissues
that do not have the disease. Consequently, the unique features of post primary TB remain largely unknown
and misconceptions are widely accepted. This manuscript presents a revised pathogenesis of post primary
TB based on studies of lung tissues of thousands of patients by multiple authors and related literature. Pri-
mary TB stimulates systemic immunity that kills organisms and heals granulomas resulting in both protec-
tion from disseminated TB and resistance to new infection. Post primary TB, in contrast, requires systemic
immunity that it subverts to produce local susceptibility in the apex of the lung. It begins in the part of lung
with the lowest ventilation, perfusion and movement and then proceeds to paralyze alveolar macrophages,
block the exits and suppress inflammation to further isolate the area with post obstructive pneumonia.
This provides a safe place for a small number of MTB to drive prolonged accumulation of host lipids and
mycobacterial antigens in an otherwise immune person. After many months, the affected lung suddenly
undergoes caseation necrosis with vanishingly few MTB. The necrotic tissue fragments to produce a cavity
or hardens to develop fibrocaseous disease. Evidence suggests that this is triggered by a hypersensitivity reac-
tion against cord factor and then progresses as the Koch phenomenon against many antigens. MTB grow in
perfusion only in dead tissue or on a cavity wall. We anticipate that a more accurate understanding of the
pathogenesis of post primary TB will facilitate focusing modern technologies to produce rapid advances in
understanding and combating TB.

Keywords: Pulmonary tuberculosis, Mycobacterium tuberculosis, Pathogenesis, Pathology, Cavity and

Lung

Introduction Immunity to TB is different from that of any other

Tuberculosis (TB) remains an urgent global health
problem with approximately 9 million new cases
and 1.4 million deaths each year [1]. A very large
number of people are latently infected with
Mycobacterium tuberculosis (MTB) and at risk of
developing disease in coming decades. The dual
pandemic of TB and HIV/AIDS and the emer-
gence of increasingly drug-resistant strains severely
aggravate the problem and hamper control efforts.
Address correspondence to Robert L Hunter MD, PhD; Professor;
Department of Pathology and Laboratory Medicine, MSB 2.034,
University of Texas-Houston Medical School, 6431 Fannin Street,
Houston, TX 77030; phone: 713 500 5301; fax: 713 500 0730;
e-mail: Robert.L.Hunter@uth.tmc.edu
infection. The enigma of MTB is that it is an obli-
gate human parasite even though humans are more
resistant than any of the animals used for study. It is
a human parasite because only humans develop
post primary disease in their lungs [2,3]. Post pri-
mary TB produces cavities that support prolifera-
tion of vast numbers of MTB in an otherwise im-
mune host. Transmission is accomplished by
coughing MTB into the environment.
While much progress has been made in under-
standing granulomas produced by animals, little or
no progress has been made in understanding the
peculiarities of post primary TB that occur only in
humans [4]. Unanswered questions include: What

0091-7370/14/0400-365. © 2014 by the Association of Clinical Scientists, Inc.

366 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
is the nature of immunity that protects 95% of
people from disease? Why does recovery from post
primary TB make people more susceptible to new
post primary infections, but not to other types of
TB? [5,6]. Why does it occur only in the lung?
What is the role of hypersensitivity?
Recent research has served to deepen the mystery.
Unlike HIV that modifies its antigens to evade im-
mune responses, MTB keeps its antigens remark-
ably constant with even less variation than essential
structural genes [7]. Why does TB need exactly
these epitopes? Failure to answer these questions
has frustrated leaders in the field who increasingly
believe that TB can never be eliminated without a
vaccine that prevents transmission of infection [8].
Lack of understanding of the immunology and
pathogenesis of late stage TB is widely regarded as
the major impediment to vaccine development.
One can neither rationally design nor test vaccine
candidates without knowledge of the type of im-
munity needed for protection.
Since human lung tissue with developing cavitary
TB has seldom been available since the introduc-
tion of antibiotics in the 1940’s, researchers have
been forced to rely on animal models. Unfortunately,
nearly all animals eventually die of primary infec-
tion that most humans clear in weeks. Consequently,
research on animals is producing a detailed under-
standing of the early phases of TB. However, with-
out human tissues for reference, modern science
has not been able to develop models or studies to
approach the late stages of infection that account
for 80% of clinical disease and nearly 100% of
transmission to new hosts.
The pathology of pulmonary TB has a long history.
Two distinct types of pathology, ‘productive’ and
‘exudative’, were recognized by Laennec in 1821
and confirmed by virtually all investigators through
the mid 20th century [9-14]. In modern terms ‘pro-
ductive’ refers to nodular tubercles or granulomas
and ‘exudative’ refers to pneumonia. Multiple at-
tempts to explain the pathogenesis of these process-
es were published in the late 19th and early 20th
centuries. Some investigators proposed the mecha-
nism that is widely accepted today, that cavities de-
velop by erosion of granulomas into bronchi
followed by discharge of infected necrotic material
into the airways. Recognizing that this is an apt de-
scription of the disease produced by M. bovis,
Medlar examined thousands of tubercles looking
for evidence of a similar pathogenesis in humans.
He found none [12]. Once formed, all human
MTB granulomas remained small.
In the pre antibiotic era, multiple investigators,
each of whom had studied over 1000 cases of adult
TB, reported that MTB spread through bronchi to
produce tuberculous pneumonia that underwent
caseation and then cavitation [9-14]. Rich reported
“It has been found by all who have studied early
pulmonary lesions that they represent areas of case-
ous pneumonia rather than nodular tubercles.”
[10]. There was much speculation as to what seeded
the pneumonia [15]. Rich believed that small erod-
ed granulomas released MTB into bronchi.
However, it was universally recognized that devel-
oping post primary TB was a pneumonic, not a
granulomatous process.
Interest in TB declined with the introduction of an-
tibiotics in the 1950s. It resumed with resurgence
of the disease in the 1980’s with a new generation
of investigators armed with new technologies and
animal models. The rabbit infected with M. bovis
was the only common laboratory animal in which
chronic fibrosing TB with cavities could be readily
produced [15]. However, the lesions and life cycle
of M. bovis are different from those of MTB. M.
bovis must be transmitted to new hosts during the
lifetime of a cow, not the 10-30 years of MTB in
people. M. bovis does not produce post primary TB
[3,16]. It remains a particularly aggressive form of
primary TB with widespread development of case-
ating granulomas that erode into surfaces of the
pharynx, bronchi, pleura, GI, urinary tracks and
mammary glands to discharge organisms [17]. The
differences between lesions produced by MTB and
M. bovis were forgotten [3]. As a consequence, the
concept that the caseating granuloma is the charac-
teristic lesion of both primary and post primary TB
became the bed rock paradigm that has guided TB
research throughout the rise of cellular immunolo-
gy, molecular microbiology and genetics. This pa-
per challenges that paradigm.
 Pathogenesis of Post Primary Tuberculosis 367
Figure 1. Characteristics
of primary and post pri-
mary TB [3, 21]. A.
X-ray of primary TB as a
discrete round lesion in
an upper lobe of lung. B.
Cluster of caseating gran-
ulomas of primary TB
that were mistaken for
cancer and resected
(H&E 3x). C. Caseating
granuloma of miliary TB
composed primarily of
macrophages and lym-
phocytes with central ca-
seous necrosis (H&E
40x). D. X-ray of acute
post primary TB showing
diffuse infiltrate of tuber-
culous pneumonia in an
upper lobe. E. Section of
lung with caseous pneu-
monia and developing
cavities. No active granu-
lomas were present any
place in this persons body
(H&E 3x). F. Endogenous
lipid pneumonia of early
post primary TB. The in-
fection is confined to al-
veolar spaces and has very
few AFB (H&E 100x).
Reproduced in part from
Hunter et al [21]

Our investigations in this area were initiated by the
chance observation that injections of cord factor
(trehalose 6, 6’-dimycolate (TDM)) into sensitized
mice produced caseating granulomas [18]. This was
a surprise since the literature had stated or decades
that mice are a poor model of human TB because
they do not produce caseating granulomas. Further
studies revealed that variations in the protocols
could produce a spectrum of caseating granulomas
each of which resembled a manifestation of human
disease [18]. The granulomas were found to be de-
pendent on CD1d and CD4+ T cell responses
against TDM [19,20].
In an effort to determine if these observations had
relevance for humans, we initiated investigation of
the histopathology of developing human pulmo-
nary TB. Very few papers on the pathology of pul-
monary TB had been published since the 1950s.
The older literature proved exceedingly difficult to
understand because the nomenclature had changed
and there were few pictures. This began a prolonged
search for histologic slides of untreated pulmonary
TB. Once we located slides so that we could see
what the earlier investigators had described, the
pieces began falling together. Post primary TB be-
gins as an endogenous lipid pneumonia, not as a
caseating granuloma, Figure 1 [21]. In continuing
studies, we looked for exceptions. This involved
study of histologic sections of infants, people with
immunosuppression, the aged and HIV patients
who had died of pulmonary TB and comparisons
between disease produced by M. bovis and MTB
[3]. These investigations confirmed and extended
our previous observations as detailed in Figure 2.
TB develops as a necrotizing pneumonia and dis-
seminates widely in the bodies of infants and im-
munosuppressed people. The pulmonary lesions of
these people are different from those of post pri-
mary TB. They have little lipid, many more MTB
both in alveoli and in the interstitium, and an acute
inflammatory response. Immunocompetent people
infected with MTB for the first time develop case-
ating granulomas that contain the organisms and
368 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014

Figure 2. Stages of TB in humans. Disseminated: TB develops as a disseminated infection in the lungs and many other
organs in people without competent immune systems such as infants and adults with AIDS (H&E 40x).Primary: Primary
TB develops in response to the first infection of immunocompetent individuals. Many animals die of primary TB in
months, but most humans heal it within weeks. It produces cell-mediated immunity that effectively mediates life long pro-
tection from disease in all parts of the body except the vulnerable parts of the lung (H&E 40x). Post primary TB begins
as an endogenous lipid pneumonia in the apices of the lung. Approximately 95% of such lesions resolve spontaneously. The
other 5% go on to produce caseous pneumonia that can either soften and fragment to produce a cavity or harden to produce
caseating granulomas and fibrocaseous disease. Greater detail of the pathology of post primary TB is presented in the refer-
ences [3, 21]. Reproduced in part from Hunter et al [3, 21].

systemic immunity sufficient to control the infec-
tion in weeks1. MTB, however, remain dormant in
their bodies. The location and properties of dor-
mant MTB are controversial [22]. Much of the lit-
erature assumes that they reside in granulomas.
However, multiple studies found that granulomas
are sterile after 5 years and organisms are more
commonly isolated from normal appearing lung
and fat cells [10,11,23-25]. In any case, post pri-
mary TB begins by reactivation of dormant MTB
or new infection from the environment. It typically
begins after all granulomas have healed. It starts
with infection of alveolar cells in persons who
maintain effective immunity to protect the entire
rest of their bodies. The lesions develop as an en-
dogenous lipid pneumonia [21,26]. Most such le-
sions regress spontaneously so that progression to
clinical disease is a rare event. If they do not regress,
the lesions undergo necrosis to produce a caseous
pneumonia that may fragment and be expelled to
leave a cavity or remain as a mass that induces gran-
ulomas and fibrocaseous disease.

1The terms granuloma and pneumonia require definition since the term granuloma is frequently used incorrectly to describe any lesion produced
by TB.
Granuloma: A granuloma is a localized nodular inflammation found in tissues. In TB, a granuloma is a nodular delimited aggregation of
mononuclear inflammatory cells within tissue. It is a collection of modified macrophages resembling epithelial cells that are usually surrounded
first by a rim of lymphocytes and later by fibroblasts.

Pneumonia is an infection of the alveoli (air sacs) of the lungs. It is typically diffuse within the air spaces of a lobule and does not penetrate into
the lung tissue. The alveoli may fill with fluid and/or inflammatory cells in addition to infectious organisms.
 Pathogenesis of Post Primary Tuberculosis 369
hypothesize that bringing these
reactive components together
in a lung with endogenous lipid
pneumonia triggers the sudden
onset of caseation necrosis that
further develops into cavities or
fibrocaseous TB. The lesions
are completely reversible and
largely asymptomatic prior the
onset of caseation pneumonia,
but are irreversible and highly
toxic afterwards. The evidence
for each of the stages in this
process will be presented and
discussed.

Early post primary TB: Post pri-

mary TB begins when a virulent
organism reaches the vulnerable
area in the apex of the lung of a
person who has immunity suffi-
cient to heal caseating granulomas
and prevent new infection in all
other parts of the body. For over
100 years, multiple authors have
reported that the disease dispro-
portionately kills immunocompe-
tent young adults [27-29]. “The
higher the resistance of an individ-
ual, the greater the tendency to
apical localization and death” [10].
It is widely believed that organisms
preferentially grow in the apex of
the lung because it has increased
Figure 3. The pathogenesis of post primary TB. Post primary TB begins in oxygen tension [30]. However, the
the most isolated part of the lung and proceeds to isolate it further with bronchial idea that oxygen is the key factor is
obstruction and paralysis of macrophages. It accumulates host lipids and myco- contradicted by comparison of the
bacterial products before eventually regressing or suddenly undergoing caseous
necrosis that then leads to cavitation and/or fibrocaseous disease. distribution of primary and post
primary lesions, Figure 4. The le-
sions of primary TB are distribut-
Most of the contemporary literature depicts post ed in the same pattern as dust particles that are randomly
primary TB as a war of attrition whereby a battle distributed in proportion to ventilation. One would thus
rages between macrophages that must be recruited have to explain why primary and post primary MTB
and activated to contain and kill MTB, and MTB have different oxygen requirements and why the apices
of the lungs are more susceptible to smoke and other
that tries to divide and kill the macrophages. While
toxins [30,31].
this is a reasonable explanation of primary TB, post
primary TB is different. This manuscript presents In 1983, Goodwin challenged the hypothesis that high
studies on the pathogenesis of post primary TB oxygen tension causes TB to localize in the apices of the
from both the modern and older literature, Figure lung [30]. He proposed that lymph stasis and impaired
3. A very small number of organisms isolate a sec- clearance of antigenic substances are more important de-
tion of lung and suppress inflammation while they terminants of apical localization. The apex is the most
quietly accumulate MTB antigens and host lipids isolated part of the lung. It has the lowest ventilation,
for a sudden massive necrotizing reaction that de- perfusion and lymphatic drainage. More recent investi-
stroys lung tissue to produce a cavity. We gations support this hypothesis. Blood flow in the apex
370 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
Figure 4. Distribution of lesions in primary and post primary TB. The localization of
lesions of primary and post primary TB of many people were plotted on an X-ray. Each dot
marks the location of an individual’s lesion. The distribution of primary TB is consistent with
chance distribution of air-borne infection while most post primary lesions were apical.
(Reproduced with permission from Medlar 1948 [87]).
of the lung is very low and frequently zero because the
pressure within alveoli is lower than the pulmonary ar-
tery pressure in upright people. The pressure in the pul-
monary artery of ~10-12 mm Hg is insufficient to raise
blood from the heart to the apex of the lung of people in
the upright position. Consequently the pressure within
the alveoli of ~2 mm Hg is sufficient to completely
Figure 5. MTB localization in alveolar macrophages
in early post primary TB. AFB are found in alveolar
macrophages and nowhere else in the bodies of people with
early post primary TB. Similar localization of AFB is
found in mice with slowly progressing pulmonary TB or
reactivated TB. This is a section of mouse with reactivated
TB induced by an i.p. injection of 100 ug of TDM as an
oil-in-water emulsion (AFB Stain, 1000x).
occlude perfusion.
The oxygen tension
in the apices is high-
er even though ven-
tilation is lower, be-
cause there is
insufficient blood
flow to carry it away.
Several pieces of evi-
dence support the
hypothesis that re-
duced blood flow is
a factor in pathogen-
esis of early post pri-
mary TB. First, bed
rest was the main-
stay of therapy for
TB for many years
before introduction
to antibiotics [27,32]. Bed rest increases blood flow in
the apex of the lung because the right heart does not
have to overcome the effect of gravity of a recumbent
person. Second, there are reports that this effect could be
further increased by raising the foot of the bed to pro-
duce still greater blood flow in the apex [33]. In addi-
tion, pulmonary TB frequently improves when the pa-
tients reside in high altitudes where the rarefied air
requires more vigorous respiratory efforts. Finally, TB
was very rare in people with high pulmonary artery pres-
sure due to mitral valve stenosis and devastating in peo-
ple with decreased pulmonary artery pressure due to
pulmonic valve stenosis [30].
The technologies for measuring the effects of respiration
and heart beat motion of individual portions of the lung
have become highly sophisticated because of the needs of
radiation oncology. When treating lung cancer with ra-
diation, it is important to deliver the maximal dose to
the tumor while minimizing radiation of normal tissues.
This becomes a difficult feat for a tumor in a moving
lung. Four-dimensional CAT scans (4 DCT) visualize
the lung in three dimensions plus time to show move-
ment [34]. The movement of the lung is greatest at the
base where the diaphragm moves, moderate in the lower
chest where the ribcage moves but nonexistent in the
apices where the ribs are fixed. The ventilation at the api-
ces is very low in both upright and recumbent positions
because the lungs don’t expand and contract with respi-
ration. Ventilation is driven only by pressure changes in
the lung [35]. These data suggests that post primary TB
begins in the apices because they do not move, have low
ventilation and perfusion and, as discussed later, can be
further isolated by obstruction of bronchi.
 Pathogenesis of Post Primary Tuberculosis 371
reported that TB
pneumonia can de-
velop within one day
after surgery for TB
[13]. Similar large
numbers of foamy
macrophages in alveo-
li have been observed
in BCG immunized
mice at 24 hours after
iv challenge with viru-
lent MTB [43].
Finally, we observed
that injections of cord
Figure 6. TDM stimulates foamy alveolar macrophages in murine TB. C57Bl/6 mice factor into mice in-
were infected i.v. with 106 MTB and injected i.p. one day later with 100ug TDM in an o/w fected with MTB pro-
emulsion or the emulsion alone and examined on day 36.A. In the control animal, infection is duces a reduction of
confined to small non caseating granulomas in the lung (H&E, 100x).B. In the TDM injected nodular granulomas
animal, granulomas are smaller and much of the lung shows tuberculous pneumonia with
foamy macrophages in alveoli (H&E, 100x). Most AFB are seen in foamy alveolar macro- and an increased in
phages (Insert AFB, 100x). infected alveolar mac-
rophages, Figure 6.
Alveolar Macrophages: A characteristic of early post pri- Collectively, these data suggest that TB infects the least
mary TB is that MTB are located exclusively in alveolar active part of the lung and then manipulates the macro-
macrophages [3,11,21]. They do not enter the intersti- phages in order to prevent formation of granulomas and
tium to produce granulomas or infect any other part of to inhibit their normal functions.
the body. Alveolar macrophages have dual functions of
collecting and eliminating innocuous dust particles and Surfactant: Pulmonary surfactant is a critical regulator
recognizing and reacting appropriately to pathogens. It of inflammatory and immune functions within alveoli
appears as if MTB are treated as innocuous particles in and very likely has a role in early post primary TB [44].
immune individuals whereas they are treated as patho- Modulation of surfactant function has major effects on
gens that are carried into tissue where they induce granu- both macrophage function and fluid balance in alveoli.
lomas in immunologically naïve subjects [36]. While Mice with genetic modifications affecting surfactant are
much is unknown about this phenomenon, several piec- unable to remove MTB from alveoli to interstitial granu-
es of evidence may be relevant. Both innate and adaptive lomas. This results in rapidly progressive tuberculous
immune responses have been implicated in this response pneumonia [45]. Peripheral cell wall lipids of MTB are
[37]. Killed mycobacterial or purified mycolic acids directly inhibitory to surfactant function [46]. Finally,
cause macrophages to become foamy and to accumulate surfactant has been used with chemotherapy in patients
lipids [38]. Oxygenated mycolic acids cause differentia- with pulmonary TB. Patients received surfactant inhala-
tion of monocyte-derived macrophages into foamy mac- tions for 8 weeks during chemotherapy while the control
rophages [39,40]. MTB persisted in these cells in a non- patients received only chemotherapy. The surfactant in-
replicative state. Electron microscopy demonstrated creased sputum production, diminished cough, and has-
bacilli in the lipid droplets [41]. tened both elimination of MTB from sputum and clo-
sure of cavities. Cavernous closure was achieved in
The mouse model seems particularly relevant for this 72.9% of the surfactant treated group and in 41.4% of
phase of infection [21,42]. In primary TB, alveolar mac- the controls at 4 months [47].
rophages containing MTB migrate into tissue to form
small granulomas. In contrast, infected alveolar macro- Bronchial Obstruction: There is much evidence that
phages in immune mice remain in alveoli, Figure 5. bronchial obstruction is an essential component of early
Acid fast bacilli (AFB) are found only within foamy al- post primary TB [33]. In 1901, Hektoen reported find-
veolar macrophages and no place else in the entire body. ing obstruction of bronchi in 100% of lesions of pulmo-
MTB may be detected by culture in other organs, but nary TB [48]. Medlar proposed that post primary TB
they are too few in number to be detected by AFB stain- should be called bronchogenic TB because it characteris-
ing. This preferential localization of AFB in alveolar tically spreads through the bronchi to produce obstruc-
macrophages happens only in animals with sufficient tion and TB pneumonia [12]. This is also supported by
systemic immunity to prevent infection in all other parts the modern radiologic literature. TB frequently presents
of the body. Lesions of foamy alveolar macrophages can radiologically as a wedge shaped lesions in an upper lobe.
develop very rapidly in sensitized individuals. Levine The point of the wedge is an obstructed bronchus
372 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
Figure 7. Bronchial obstruction of post primary TB. A. CAT Scan showing tree-in-bud pattern characteristic of TB
with obstructed small bronchiole (large arrow) and ground glass in lobular alveoli (small arrow). Reproduced in part from
Hunter et al [62]. B,C. Histologic sections of human lung showing bronchial obstruction that is a characteristic of early
post primary TB (H&E 40X).
Figure 8. Abnormal cilia in post primary TB. Electron micrographs
show lesions in cilia. Reproduced with permission from Ahonen and
Valavirta [55]. A. Cross section of a normal cilia of a control patient (x 52
000). B. Cross section of one cilia with 10+0 microtubular arrangement.
Dynein arms are partially lost. The other cilia is enlarged, deformed and
dark stained (x104 000).
Figure 9. Endogenous lipid pneumonia produced by cancer and
TB. The lesions both have lipid rich foamy alveolar macrophages with
apoptosis and interstitial lymphocytic inflammation. Those caused by can-
cer are similar but do not have Langhans giant cells and contain fewer
lymphocytes. A. Cancer, B. TB (H&E 200x).
[10,49]. The characteristic CT finding of
early postprimary pulmonary TB is the
tree-in-bud pattern formed by branching
linear structures and centrilobular nod-
ules, Figure 7 [50,51]. Histopathologic
analysis indicates that these centrilobular
‘tree’ lesions occur as a result of obstruc-
tion of the terminal or respiratory bron-
chioles and sometimes the alveolar ducts.
The ‘buds’ are foci of pneumonia in the
alveoli of the obstructed ducts.
Centrilobular nodules may grow and co-
alesce into lobular consolidation that con-
sists of centrally located lesions that con-
tain caseation necrosis and surrounding
perifocal inflammation. Cavitation, when
it occurs, is centrilobular. Several centri-
lobular cavities may progressively coalesce
into a larger cavity.
Epituberculosis: A particular type of TB,
known as epituberculosis, provides addi-
tional evidence of the role of bronchial
obstruction in developing post primary
TB [52]. Epituberculosis usually presents
as a wedge shaped lesion associated with
bronchial obstruction that almost always
heals completely [10]. It is more common
in children with a bronchus obstructed by
a node with TB [52]. Some physicians
were unsure if such lesions were TB.
However, needle biopsy produced MTB
and Langhans type giant cells, with no ca-
seation [53]. Removal of bronchial ob-
struction causes epituberculosis to heal. In
one case, an epituberculosis shadow had
remained stationary for a month.
Bronchoscopy demonstrated an ulcerated
and plugged bronchus leading to the area.
The obstruction was removed and found
to be tuberculous. The shadow cleared in
 Pathogenesis of Post Primary Tuberculosis 373

Figure 10. Bronchial obstruction by cancer and chemotherapy produced a TB like cavity. A. Anterior view CAT
scan showing a large mass in the left side of the mediastinum measuring approximately 8.2 x 9 x 9.5 cm (arrow). It encases
the left upper lobe bronchi, pulmonary artery and pulmonary vessels. Although it does not show well in this reproduction,
the pulmonary parenchyma of the left upper lobe had a ground glass appearance characteristic of obstructive pneumonia.
(Reproduced with permission in part from Hunter et al [62]). B. Repeat CAT scan 5 weeks later showing a large cavity in
the left upper lobe measuring 12 x 8 cm where the ground glass area had been (arrow). The radiologist’s report stated “Given
its rapid development and the presence of numerous tree-in-bud opacities … the patient needs to be assessed for possible
TB.” C. Posterior photograph of both lungs of the patient at autopsy showing a large thin walled cavity in the left upper
lobe (arrow). This cavity, like those caused by TB, extended to the pleural surface, but did not penetrate. D. Section of the
wall of the cavity of our cancer case showing a layer of necrotic lung overlying granulation tissue and lipid pneumonia. The
detached, necrotic fragment of lung (arrow) resembles the fragments of lung that are coughed up by people with developing
cavitary TB (H&E Stain 40). E. Giant cell resembling a Langhans Giant cell. (H&E stain 400x). F. Area on necrosis
resembling caseation necrosis with cholesterol crystals. (H&E stain 100x).

six days by x-ray. There are multiple other reports in the
pre antibiotic literature where surgical relief of bronchial
obstruction produced resolution of pulmonary TB [10].
Finally, the role of bronchial obstruction in developing
post primary TB is illustrated by the observation that
extensive unilateral pulmonary TB has been reported
with segmental atresia of a bronchus [54].
Cilia: Obstruction of small bronchi by developing TB
may be viewed as a failure of ciliary clearance. Most par-
ticles that reach alveoli are ingested by alveolar macro-
phages that migrate to small bronchi where they contact
cilia. The cilia then carry the macrophages and particles
into the trachea and up to the mouth where they are
swallowed. In patients with pulmonary TB, the bron-
chial mucosal is generally intact although there may be
areas of ulcerated infected tissue extending into the sub-
mucosal glands. Ahonen and Valavirta studied cilia of
TB patients by electron microscopy [55]. They demon-
strated loss of some ciliary components and major
distortion and swelling of other cilia, Figure 8. These
unique changes suggest that MTB has a specific effect on
cilia.
The effects of tobacco smoke support an important role
for cilia in the pathogenesis of developing TB [31]. In
epidemiologic studies, cigarette smoking has been con-
sistently reported to markedly increase the risk of devel-
oping pulmonary TB. It is well established that cigarette
smoke inhibits cilia action. Thus it is likely that paralysis
of cilia by the smoke contributes to the pathogenesis of
post primary TB [56,57].
Post obstructive pneumonia: We reported that post pri-
mary TB begins as an endogenous lipid pneumonia
[3,21]. We now know that bronchial obstruction from
any cause produces post-obstructive pneumonia charac-
terized by gradual accumulation lipid rich foamy macro-
phages in alveoli behind the obstruction [58]. The lipid
has been identified as neutral lipids and cholesterol that
374 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014

Figure 11. MTB anti-

gen in immunocompe-
tent and immune com-
promised people. A.
Immunohistochemical
stain for MTB (IHC) in
alveolar macrophages of
an immunocompetent
person with developing
post primary TB (IHC
Stain 200x). B. Higher
power of same section
showing that the antigen
is entirely intracellular.
(IHC 1000x). These sec-
tions were negative by
AFB stain demonstrating
a paucibacillary infec-
tion. C. Many AFB in a
patient with HIV and
disseminated TB (AFB
stain, 1000x). D. IHC
stain for MTB of section
C reflects AFB in number
and distribution of
MTB. (IHC Stain
1000x).

are probably derived from action of macrophages on sur-
factant. In 1925, Pagel used fat stains to access the
amount of lipid in alveoli during the course of develop-
ing post primary TB. He found that stainable lipid in-
creased progressively with time [59].
Today, cancer is the most common cause of post obstruc-
tive pneumonia [60]. It is an endogenous lipid pneumo-
nia with many similarities to early post primary TB. The
disease produced by cancer has fewer lymphocytes and
no Langhans type giant cells, but has a similar pattern of
lipid rich foamy macrophages filling alveoli, Figure 9.
The lipid is derived from surfactant and is similar to that
found in tuberculous pneumonia. Post obstructive pneu-
monia due to cancer can undergo necrosis resembling
the caseous necrosis of TB and cavitation. One study
found cavities in 13% of patients with post obstructive
pneumonia caused by squamous cell carcinomas [61]. In
one case, chest x-ray demonstrated ground glass appear-
ance of post obstructive pneumonia immediately before
initiation of chemotherapy. A similar x-ray one week
later demonstrated a very large cavity, Figure 10 [62].
The patient subsequently died. An autopsy revealed lipid
pneumonia with multinucleated giant cells and necrosis
resembling caseation in the wall of the cavity with strik-
ing similarities to that of recently formed human tuber-
culous cavities. Others have reported similar cases [63].
These results demonstrate that post obstructive pneumo-
nia establishes conditions for the development of caseous
necrosis and cavitation [60].
Accumulation of mycobacterial antigens:
Immunohistochemical staining tissues with polyclonal
antiserum against whole killed MTB has been developed
as a diagnostic test for TB [64]. The amount and distri-
bution of MTB antigen staining in tissues varies with the
type of infection. In tissues from people with rapidly
progressive TB associated with HIV, the staining of
MTB antigen is similar to that of acid fast staining. The
staining of early post primary TB is different. It typically
demonstrates far larger amounts mycobacterial antigen
than can be accounted for by organisms observed with
acid fast stains. In fact, there is frequently intense stain-
ing for mycobacterial products in tissues with no detect-
able AFB, Figure 11. The finding of MTB antigens in
tissues with no AFB is the justification for use of immu-
nohistochemistry for diagnosis [64-66]. The staining for
MTB antigens in immunocompetent patients is typical-
ly diffuse within the cytoplasm of foamy alveolar macro-
phages. It is not found extracellularly except in necrosis.
These studies demonstrate that mycobacterial antigens
accumulate with the lipid in foci of endogenous lipid
pneumonia of post primary TB.
Our earlier studies demonstrated that slowly progressive
pulmonary TB in the mouse has many similarities to
early post primary TB in humans [3,21]. This includes
obstruction of bronchi an accumulation of foamy mac-
rophages containing lipid, few AFB and mycobacterial
antigens in portions of the lung distal to the obstruction.
In this model, ManLAM, MPT64 and polyclonal
 Pathogenesis of Post Primary Tuberculosis 375
mycobacterial antigens were all
shown to progressively accu-
mulate in alveolar macro-
phages over several months
[80]. ManLAM has anti-in-
flammatory properties that in-
hibit production of TNF-α
and IL-12 by human dendritic
cells and macrophages and
modulates MTB-induced
apoptosis via binding to mac-
rophage mannose receptors.
This is particularly important
in deactivating host macro- Figure 12. Perifocal inflammation and pulmonary alveolar proteinosis. A.
Perifocal inflammation of TB is a lipid rich edematous inflammatory response that sur-
phages to allow the bacteria to rounds active TB sites of infection. While it typically has few or no AFB, perifocal inflam-
survive within them [67,68]. mation contributes significantly to caseation, cavitation and morbidity of TB (H&E
Despite the low numbers of 100X). B. Pulmonary alveolar proteinosis (PAP) has many similarities to perifocal inflam-
AFB, the MTB were metaboli- mation. TB (H&E 100X).
cally active during chronic TB
in murine lungs and they have
a unique transcriptome signa-
ture [69,70].

Perifocal inflammation is a
toxic edema or desquamating
pneumonia near tuberculous
lesions that is thought to be a
manifestation of hypersensitiv-
ity because it has few or no
MTB detectable by acid fast
staining [11,12]. It can occur
with both primary and post Figure 13. Spontaneous regression of post primary TB. Only about 5% of people
develop symptomatic post primary TB. However, many have apical scars and other evi-
primary TB and has been dence of asymptomatic infection suggesting that most lesions resolve spontaneously. These
identified as a major contribu- sections are from a resolving lesion were found incidentally at autopsy. A. Low magnifica-
tor to mortality in miliary TB tion showing encapsulated lesion measuring 3/8 inch in diameter (H&E 4x). B. Higher
[71]. The morphology of a magnification of the same lesion showing alveoli filled with fibrin and macrophages (H&E,
perifocal reaction is essentially 20x).
that of an exudative tubercu-
lous tissue reaction [72]. It is
composed mainly of blood
plasma, fibrin, red blood cor-
puscles, relatively few poly-
morphonuclear leukocytes,
many lymphocytes, and des-
quamated foamy alveolar mac-
rophages. The histological
character of a perifocal reac-
tion, however, will vary from
purely hemorrhagic perifocal
zones to zones of leukocyte in- Figure 14. Histopathology formation of cavities. A typical case showed tuberculous
pneumonia and perifocal inflammation undergoing caseation necrosis and fragmentation
filtrations with marked des- to form cavities. No granulomas were present any place in her body. All of the lesions ap-
quamation and proliferation peared consistent with the 10-day history. MTB was identified in tissue by PCR. AFB were
of alveolar cells with lympho- present, but extremely rare. Only three were found by acid fast staining in all of her lung
cytes and plasma. Or there sections. There were also signs of acute vasculitis and intravascular blood coagulation,
may be merely an exudation of sludging of erythrocytes in capillaries, and microthrombi in small vessels, in larger branches
of the pulmonary artery and in veins resulting in the lung tissue infarction. A. Section
plasma with a little fibrin and a showing necrotic lung (top) surrounded by granulation tissue and caseous tuberculous
few lymphocytes. Erokhin pneumonia (H&E 1x).B. A nearby area where the necrotic tissue has been coughed out to
used electron microscopy to leave a cavity traversed by a blood vessel (arrow) (H&E 1x).
 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
376
demonstrate destruction of alveolar epithelium, particu-
larly Type 2 cells [29]. Tissue with perifocal inflamma-
tion is seldom seen in surgical resections since it clears
rapidly with antibiotic therapy [10,12]. Reversal of peri-
focal inflammation may be observed in X-rays within 72
hours of the initiation of therapy [73].
Perifocal inflammation, at first glance, appears to be an
epiphenomenon: something that takes place as a result
of TB, not a primary contributor to it. However, several
pieces of information suggest that it may be central to he
pathogenesis of TB. First, perifocal inflammation under-
goes caseous necrosis to contribute a major portion of
lung afflicted with caseous pneumonia. Next, it can be
induced in tuberculous people by injections of tubercu-
lin and is associated with clinical exacerbation of disease.
This is the Koch phenomenon to be discussed later.
Finally, the fact that it resolves quickly with therapy in-
dicates that it requires live MTB.
Histologically, perifocal inflammation of TB resembles
pulmonary alveolar proteinosis (PAP), Figure 12. This is
a condition in which alveoli are filled with lipid rich
fluid and foamy macrophages and lymphocytes but few
other inflammatory cells. It can be caused by a deficiency
in surfactant protein B or by an autoimmune disease
with altered GM-CSF signaling [74,75]. PAP can be
caused by a number of infections including TB. We sus-
pect that some of these were cases of perifocal inflamma-
tion of TB rather than cases of alveolar proteinosis com-
plicated by TB [76,77]. The disease can frequently be
treated simply by lavage that washes out the lipid rich
material from alveoli.
PAP frequently occurs in association with endogenous
lipid pneumonia [78]. Most cases analyzed showed mor-
phological features of both PAP and endogenous lipid
pneumonia. Type II pneumocytes, macrophages, and
neutrophils play a significant part in the pathogenesis of
both. Historically, endogenous lipid pneumonia has
been reported to be caused by bronchial obstruction by
cancer, but it also can occur with infection and other
diseases that are not associated with bronchial obstruc-
tion. Additionally, in PAP, the alveoli are usually filled
with protein and lipid material resembling surfactant
[78,79].
Regression of post primary TB: The large majority of
early post primary TB cases regress prior to development
of symptoms. Only about 5% of people develop disease
[42]. Since some people resolve infections repeatedly, it
is likely that over 99% of early post primary infections
resolve spontaneously. Consequently, it is a rare event for
the process to progress to clinical disease. Scars found in
the apices of the lungs of people born in the preantibi-
otic era have been attributed to healed TB that regressed
in the very early stages, Figure 13.
Onset of clinical disease: Patients with post primary TB who
develop disease typically do so within one or two years follow-
ing infection [42,80]. The onset of clinical pulmonary TB is
extraordinarily diverse causing much difficulty with diagnosis
[27]. It can present as acute pneumonia, chronic dyspeptic and
anemic symptoms or bronchitic with so little symptoms or fe-
ver that TB is discovered only accidentally by sputum. The
most instructive cases, however, are those who undergo a rapid
onset of caseous pneumonia, Figure 14. Investigators from
Laennec in the early 19th century through Erokhin in the early
21st century described this mode of presentation [29,81].
Available evidence suggests that the disease process is similar,
but less extensive and less well synchronized, in patients with
less severe onset.
Caseous pneumonia typically begins with sudden acute onset
of chill, fever, and rapidly advancing symptoms of severe in-
toxication [27,29]. Patients often complain of pain in the
chest, dyspnea and coughing with expectoration of sometimes
rust-colored sputum. Physical examination in the first days of
disease reveals intensive deadening of percussion sounds, bron-
chial breathing with crackling rales of high pitch and sonority.
The disease at this early stage is typically indistinguishable from
community acquired bacterial pneumonia [29,82]. The X-rays
show only diffuse density of lung lobes or lobules, which be-
comes intensive over a few days. Diagnosis is especially difficult
because of the lack of AFB in sputum [83]. In a recent study,
only 12.8% of caseous pneumonia cases had AFB in their spu-
tum in first two weeks of the disease [29]. This number in-
creased to 39.2% by the end of the first month, and to 67% by
the end of the second month.
Patients with caseous pneumonia did have two characteristic
laboratory findings [29]. The first was profound hyper coagula-
tion with development of disseminated intravascular coagula-
tion (DIC). This is a well known complication of tuberculosis
[84]. The second was lymphopenia of CD4+ cells. Patients
with caseous pneumonia had significant relative and absolute
decrease in CD4+-lymphocytes versus patients with chronic
pulmonary TB and age matched controls. At the same time,
the numbers of CD8+ cells in caseous pneumonia patients did
not differ from those found in patients with chronic pulmo-
nary TB. The CD4+/CD8+ ratio was 0.7±0.03 for patients
with caseous pneumonia versus 1.4±0.09 for patients with
chronic pulmonary TB and 1.4±0.07 for normal controls.
The Koch Phenomenon: The clinical presentation of caseous
pneumonia has striking resemblance to the Koch phenomenon
[85]. Koch proposed that tuberculin could be a specific cure
for TB. In early attempts at therapy, large doses of tuberculin
were injected subcutaneously. The treatment caused severe lo-
cal and systemic reactions in patients with relatively mild dis-
ease. It induced perifocal reactions that progressed rapidly to
caseation and cavitation. Of the 230 patients with advanced
cavitary disease who received this treatment, 30 died [86].
Koch, himself, had a severe constitutional reaction following
the injection of old tuberculin [72].

Figure 15. AFB in viable and necrotic lung. Section of
lung of a person with necrotizing tuberculous pneumonia.
In immunocompetent people, very few and frequently no
AFB are ever found in viable tissue (Right). Large numbers
of AFB are found only in newly necrotic tissue (Arrow
Left). However, AFB in necrotic tissue seldom grow in cul-
ture [11, 12]. Their numbers decline as the nuclear debris
is removed (AFB Stain 100x).
More recent studies have confirmed and extended these
results. Perifocal reactions occur only around existing ac-
tive tuberculous lesions. The systemic symptoms include
fever often up to 40°C or higher with toxemia [85].
Injections of tuberculin have the potential to increase the
severity of TB markedly [72]. The morphology of an in-
flammatory reaction induced by tuberculin around a tu-
berculous focus is essentially that of a perifocal reaction
of active TB. It is composed mainly of blood plasma, fi-
brin, red blood corpuscles, relatively few polymorpho-
nuclear leucocytes, many lymphocytes, desquamated al-
veolar epithelial cells and alveolar macrophages.
Growth and cultivability of MTB in tissue: The litera-
ture frequently states that massive numbers of MTB
overwhelm host defenses to produce caseation necrosis
[15]. This is at odds with the observations that the onset
of caseous pneumonia is a pauci bacillary process with
very few MTB. Many papers report that some early le-
sions are paucibacillary while others have many AFB
[11,12]. A likely explanation is that most of these inves-
tigators are reporting on chronic pulmonary TB that has
multiple stages simultaneously. In addition, MTB do
grow in massive numbers producing necrosis in immune
compromised people such as those with HIV. This is not
the case in immunocompetent people. Canetti and
Medlar who independently examined thousands of cases
report that AFB are found in large numbers only in re-
cently necrotic tissue or on cavity walls [11,12,87]. They
are never found in large numbers in viable tissue of im-
munocompetent people. This is our observation as well,
Figure 15. An unexplained, but consistent finding, is
that the vast majority of AFB in closed necrotic tissues
will not grow in culture nor will they infect guinea pigs
[11,88]. In contrast, nearly 100% of AFB present in
Pathogenesis of Post Primary Tuberculosis 377
cavities will grow in culture [11,12,89]. It has been as-
sumed that MTB that do not grow in culture are dead.
Recent investigations demonstrate that many such or-
ganisms can be resuscitated and that proliferation of
MTB is tightly controlled by both host and parasite
[135]. Organisms that proliferate massively in any part
of the body except a cavity endanger their host and
thereby themselves. Increasing data indicates that MTB
controls its proliferation to insure our survival and to
develop conditions for its transmission to new hosts.
Production of cavities: Once a lesion develops caseous
pneumonia, it may further develop in one of two direc-
tions. First, it may soften and fragment to the point that
pieces of lung can be coughed out to produce a cavity.
The fragmentation and removal of necrotic lung may be
nearly complete in some patients. In these cases, the re-
sultant cavities begin with a shaggy wall of debris. Over
time this resolves and they develop a thin fibrous wall
with little or no inflammation and bacteria grow only on
the inner surface of the cavity. Laennec noticed that such
cavities are always centered on bronchi and that they are
lined with a smooth waxy material that pushes its way
into the bronchi. Histologically, the inner surface is a
mass of organisms that grow as a pellicle [3,90]. MTB
grown in liquid media without surfactants grows prefer-
entially as a surface pellicle which forces its way across
the surface and climbs the sides of the vessel, Figure 16.
This is due to rigidity of the monolayer of TDM [90].
Fibrocaseous TB: The caseous pneumonic material that
is not coughed out will dehydrate and become surround-
ed by granulomatous inflammation [11]. However, un-
like granulomas of primary TB in which caseation ne-
crosis develops within granulomas, the granulomas in
post primary TB develop around preexisting foci of case-
ous pneumonia. If a caseous pneumonic lesion is small,
it forms the nidus of a caseating granuloma superficially
similar to those of primary TB, Figure 17. However, the
underlying alveolar structure can be observed with con-
nective tissue stains. If a caseous pneumonic is large, the
formation of granuloma around it results in fibrocaseous
TB that is the most common type of chronic disease.
TB is the largest cause of pulmonary fibrosis worldwide
[91,92]. It has been reported that the rabbit is the only
animal model that will produce fibrocaseous TB.
However, such lesions can be produced in mice by injec-
tions of mycobacteria in an oil emulsion of TDM [18].
In addition, it appears that fibrocaseous TB is a reaction
to dehydrated caseous necrosis; a lipid matrix containing
mycobacterial antigens. Freund’s complete adjuvant
consisting of mycobacteria in an oil-in-water emulsion
reproduces this rather well [93].
378 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
Discussion
For generations, the metaphor of host resistance to
TB has been a war of attrition. Can the host recruit
and activate macrophages fast enough to contain
and kill MTB or can the MTB divide and kill the
macrophages to produce an enlarging lesion.
Evidence presented herein demonstrates that this
metaphor is inappropriate. A better one is the ex-
plosive reaction produced by dropping pure sodi-
um into water. Two reactive components, host T
cells and MTB antigens, are produced and stored
separately in developing post primary TB. When
brought together, they react violently to produce
caseous pneumonia that evolves to cavities and/or
fibrocaseous TB. Live MTB are not necessary for
this process, but are standing by to move in and
populate the cavity as the violence subsides.
The Streetlight effect. “Many, and possibly most,
scientists spend their careers looking for answers
where the light is better rather than where the truth
is more likely to lie. They don’t always have much
choice. It is often extremely difficult or even impos-
sible to cleanly measure what is really important, so
scientists instead cleanly measure what they can,
hoping it turns out to be relevant.” David H.
Freedman [94]. While surrogate measurements
Figure 16. Maturation of
Cavities. A. A cavity in the
upper lobe of the lung with
connection to a bronchus. The
disease was largely asymptom-
atic and the patient died of
unrelated illness. The wall of
the cavity was composed of fi-
brous tissue and a layer of ne-
crotic debris [10]. Reproduced
in part from Rich & Hunter
[3]. B. The surface of this cav-
ity demonstrated massive
numbers of acid-fast organ-
isms. No organisms or evi-
dence of active TB were pres-
ent anywhere else in the body
(AFB Stain, 200x). C. Other
areas of the lung demonstrated
scars of healed TB with no evi-
dence of recent activity (H &
E Stain 100 x). D. MTB
growing as a pellicle in a petri
dish. The layer of MTB grow-
ing on a cavity wall has the
characteristics of a pellicle that
spreads and climbs the walls
due to the pressure of the ex-
panding layer of TDM [9,
90].
yield clean numbers, they frequently throw off the re-
sults, sometimes dramatically. Post primary TB is an
extreme example of the streetlight effect. It is a disease
that occurs only in human lungs. Unfortunately, lung
tissue suitable for study has not been available to re-
searchers since the dawn of the antibiotic age in the
1950’s before the development of cellular immunolo-
gy, molecular microbiology or genetics. Researchers
have been forced to use animal models and human
tissues that do not have post primary TB. As a conse-
quence, generations of scientists have been led to
adopt an erroneous conception of the pathogenesis of
post primary TB. The new sciences of cellular immu-
nology and molecular genetics were unable to focus
light on phenomena they could not see.
Stimulated by inconsistencies in the literature, our in-
vestigations began with searching literature from the
preantibiotic era. This proved to be of little value be-
cause the nomenclature and concepts were so differ-
ent from what we had been taught and there were few
pictures. Progress was made only when we gained ac-
cess to slides from autopsies of adults who died of un-
treated acute pulmonary TB. Their lungs showed ca-
seous pneumonia with very few organisms and no
granulomas. With this, the pieces began to fall into
place suggesting plausible answers to long standing
questions.

Figure 17. Chronic Fibrocaseous TB. Aging caseous
pneumonia that fails to fragment becomes surrounded by
granulomatous tissue and fibrosis. The central necrotic core
retains the structure of alveoli. It became surrounded by an
active granulomatous process with epitheloid cells, giant cells
and lymphocytes, but no foamy macrophages. Fibrosis devel-
ops gradually. This is a characteristic lesion of late post pri-
mary TB (Trichrome Stain, 40 x magnification).
Primary TB stimulates systemic immunity. This ac-
tivates macrophages to ingest and kill MTB and to
contain them within granulomas that eventually
heal. The result is protection from disseminated TB
and effective resistance to new infection.
Granulomas don’t occur in developing post prima-
ry TB because, there is sufficient immunity from
primary TB to prevent growth of MTB in viable
tissue. This protects the entire body except for the
vulnerable region of the lung that has special mech-
anisms to facilitate transmission of MTB to new
hosts.
Post primary TB does not result from a lack of sys-
temic immunity, but rather from local susceptibili-
ty in the apex of the lung. It begins in the part of
lung with the lowest ventilation, perfusion and
movement and proceeds to paralyze alveolar micro-
phages, blockade the exits and suppress inflamma-
tion to further isolate the area in order to provide a
place for prolonged accumulation of host lipids and
mycobacterial products. At some point, there is a
sudden onset of a necrotizing hypersensitivity reac-
tion to the accumulated products. This appears to
be a combination of perifocal inflammation due to
protein antigens and caseous necrosis due to cord
factor. Once induced, the caseous pneumonia may
either fragment to produce cavities or harden to
produce fibrocaseous TB. There has been much
Pathogenesis of Post Primary Tuberculosis 379
speculation as to what causes the softening and
fragmentation of caseous material [15]. Granulomas
in post primary TB occur only in response to case-
ous pneumonia that fails to fragment [11,12].
This conception of the pathogenesis of TB is based
upon a mixture of facts, correlations and specula-
tions. While some of the ideas presented in this pa-
per will surely change with advancing knowledge,
the facts will remain and must be considered. The
following statements are supported by multiple in-
vestigations each of which involves hundreds or
thousands of patients and should be considered to
be facts.
1. In post primary TB, granulomas develop in re-
sponse to caseation necrosis and are not the cause of
it [10-12].
2. Cavities develop from fragmentation of case-
ous pneumonia, not from eroding granulomas
[10-13].
3. Caseous pneumonia with developing cavities is
typically paucibacillary (contains very few MTB)
[11,12,27,29].
4. Developing post primary TB is characterized
by bronchial obstruction that produces post ob-
structive pneumonia that can cavitate [12,13,48,
51,95,96].
5. TB antigens accumulate within cells in areas
with very few AFB [21,64-66,97].
The value of scientific theory is often judged by
how well it explains natural phenomena. The pro-
posed pathogenesis of post primary TB suggests
answers to long standing questions.
• How can MTB be an obligate human para-
site when people are more resistant than any of
the animals studied? MTB is an obligate human
parasite because it can only be transmitted to new
hosts by people. Humans are more resistant to TB
because most develop effective immunity against
primary TB in weeks whereas most animals die
within months of progressive disease. This benefits
the organism because it maintains the health of the
host who can then spread infection frequently for
decades [27,98]. Only humans develop post pri-
mary TB that progresses to pulmonary cavities
from which infection can be transmitted to new
hosts.
380 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
• What is the nature of the immunity that pro-
tects most people from post primary TB? People
do not develop post primary TB unless they have
sufficient immunity to heal primary TB and pre-
vent new infection in every part of their bodies ex-
cept the vulnerable area in the apex of the lung. The
appropriate question, therefore, is: How do MTB
manipulate an otherwise effective host responses in
this particular part of the lung? MTB selects the
least active part of lung and uses an otherwise effec-
tive immune response to isolate it further and mod-
ulate macrophages to accumulate host and myco-
bacterial products quietly in preparation for an
abrupt and massive necrotizing reaction. Since pro-
gression to disease is a rare event, resistance can be
due to any of the many factors that could prevent
developing conditions for the necrotizing reaction.
• How can multiple pulmonary lesions in a
single lung act independently as if the others did
not exist? Patients with chronic TB frequently have
multiple stages of TB lesions in their lungs that de-
velop independently of one another [10,11,15,27].
Many stages of lesions in post primary TB may co-
exist in a single lung because they are controlled
locally, particularly by bronchial obstruction that
produces stasis and facilitates storage of lipids and
antigens. Obstruction is a local process that can be-
gin in different parts of the lung at different times.
In contrast, the lesions in persons with primary
(miliary) or disseminated TB all look similar to one
another because they are controlled by systemic
immunity.
• Why doesn’t recovery from post primary TB
produce immunity? Recovery from most infections
results in immunity. TB is different. “To have
passed through a period of high mortality risk con-
fers not protection, but added hazard in later life.”
(The White Plague, Dubos [28]). Recent studies
report that people who have recovered from TB are
highly susceptible to new infections rather than re-
activation of previous infections [5,99]. Such peo-
ple are only susceptible to new post primary TB,
and not to primary or disseminated TB. Immunity
typically remains sufficient to protect the rest of
their bodies. Susceptibility in such persons is prob-
ably due to production of more vulnerable areas of
lung due to disruption of bronchial structures and
clearance mechanisms by the previous lesions.
Damage to bronchi probably facilitates mainte-
nance of bronchial obstruction by TB. Modified
immune responses may contribute, but there is lit-
tle data.
• What is the role of immunosuppression in
post primary TB? Suppression of T cell function
by steroid drugs, HIV or old age reactivates latent
infection and increases susceptibility to disseminat-
ed TB. This is frequently extrapolated to imply that
all reactivation of TB is initiated by immunosup-
pression. However, there is little evidence that peo-
ple with pulmonary TB are immunosuppressed.
They are not more susceptible to other viral or bac-
terial infections. They are not even more susceptible
to other intracellular bacterial infections [100]. In
addition, people with suppression of T cell func-
tion are less likely to develop cavities and spread the
disease to others than immunocompetent young
adults [101-103]. In fact, young adults with the
strongest immune responses are the most likely to
have apical localization of infection, to produce
cavities and to die of acute disease [10,27]. A strong
immune response is necessary to produce a cavity.
Once a cavity is produced, a strong immune re-
sponse is needed to keep the massive number of
MTB produced in the cavity from spreading infec-
tion to the rest of the body and killing its host.
Immunosuppression may be necessary to reactivate
latent MTB and to get organisms to the apex of the
lung. From then on its role is unclear.
• What are the roles of hypersensitivity and
immunity? It has long been known that much of
the tissue damage in TB cannot be attributed di-
rectly to the organisms, but is a hypersensitivity
that resembles the Koch phenomenon [10,72,86,
104]. Possible roles of hypersensitivity in immunity
have been widely discussed [15,37]. The studies
presented herein suggest that hypersensitivity and
immunity are separate and distinct phenomena.
Primary TB stimulates immunity, the ability to re-
cruit and activate macrophages sufficiently to con-
trol and kill MTB and prevent new infection. This
immunity may be weakened by immunosuppres-
sion such as HIV to allow disseminated infection.
However, it typically persists and protects the body
from new infection in every place except for the
vulnerable region of the lung where MTB has es-
tablished a unique environment for production of

cavities that facilitate transmission to new hosts.
Immunity protects the host from systemic infec-
tion. Hypersensitivity reactions destroy lung tissue
to produce a cavity. The organism needs both in
order to survive. If there is no cavity, MTB can
never escape to a new host. If here is no systemic
immunity, MTB will produce disseminated infec-
tion and kill the host thereby killing itself.
MTB is an obligate human parasite because it can
only be transmitted from host to host by humans.
Consequently, all of its genes have been selected to
enhance survival and transmission in people.
Everything that it makes or does has been selected
for that one purpose. MTB is an ancient human
pathogen that can persist indefinitely in very small
populations of as little as 200 people [105]. The
lifecycle of MTB is to infect a person, frequently a
child, and then hide for 10-30 years before reacti-
vating to produce a cavity in the lung from which
organisms are coughed up over a period of decades
to infect new individuals.
Highly conserved immunologic epitopes. Many
microbial antigens are highly variable in order to
evade immune responses. MTB is different. Musser
reported remarkably little variation in antibody epi-
topes of MTB [106]. In 2012, Comas et al reported
that the T epitopes of MTB are hyper conserved.
[7]. More than 95% of the 491 individual epitopes
analyzed had identical amino acid sequences. The
researchers speculated that MTB needs these epit-
opes because they induce particularly toxic reac-
tions that are necessary for tissue destruction and
the formation of cavities that mediate transmission
of infection.
Several pieces of evidence support this hypothesis.
First, infected humans are much more sensitive to
tuberculin than the guinea pig or other animals
[85]. Tuberculin test sites in humans with TB fre-
quently become necrotic. Necrosis does not occur
in animals or in people with positive skin-tests in-
duced by BCG or tuberculoid leprosy [107]. MTB
shares epitopes with some saprophytic mycobacte-
ria. These shared mycobacterial epitopes evoke mild
skin-test reactivity in TB patients [107]. Cases have
been reported in which tuberculin skin tests pro-
duced pulmonary perifocal inflammation that was
Pathogenesis of Post Primary Tuberculosis 381
fatal [72]. Tuberculous pneumonia has developed
overnight following surgery for TB [13]. Perifocal
reactions in the form of a sudden increase in the
size of pulmonary lesions were probably the result
of dissemination of tuberculoprotein. [72]. Cord
factor produced by MTB is far more toxic that that
produced by other mycobacteria [108]. MTB cord
factor also has hypersensitivity epitopes that are not
present on BCG [109]. Furthermore, mixing the
MTB with oil in Freund’s adjuvant induces a far
more severe and long lasting toxicity in tuberculous
humans than that the MTB materials alone. This is
probably relevant since caseation necrosis consists
of mycobacterial antigens in a lipid matrix.
Given the nature of natural selection, epitopes are
hyper conserved because they help the organism
survive in their only natural host, people. To do
this, they must have two properties. The first is to
produce particularly necrotizing tissue reactions.
The second is that they must remain hidden until
needed. Premature release of MTB antigens would
not stimulate a large enough reaction to produce a
cavity from which MTB could escape to infect new
hosts. There is evidence that hiding of antigens is
accomplished via multiple mechanisms. First, the
isolation and blockade of sections of the lung pro-
vides a protected environment for MTB. Second,
antigens detectable by immunohistochemistry are
located exclusively in live cells in alveoli. Third, the
mycobacteria produce anti-inflammatory agents
like man-LAM and sulfolipid [80, 110]. Finally, as
will be discussed later, cord factor is non-toxic until
its toxicity is activated by interaction with appro-
priate lipids. It seems reasonable to hypothesize,
therefore, that the ability to cause sudden onset of
caseous pneumonia depends both on the toxicity of
the hypersensitivity reactions and the ability to hide
the antigens until sufficient quantities are available
to produce a cavity able to mediate transmission of
infection to new hosts.
Cord factor as the trigger for caseous pneumonia:
In the 1950’s, Middlebrook identified two proper-
ties of virulent MTB that distinguished them from
avirulent mycobacteria [111]. The first was forma-
tion of elongated aggregates of organisms, called
serpentine cords. The second was staining with
neutral red. Cord formation is due to cord factor or
382 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
trehalose 6’6 dimycolate (TDM) [112,113].
Neutral red staining is largely due to sulfolipid that
is an inhibitor of the toxicity of cord factor
[110,114,115]. It is probably more than coinci-
dence that two long recognized characteristics of
virulent MTB, cord formation and neutral red
staining relate to TDM and its sulfolipid inhibitor.
TDM is the leading candidate for triggering sud-
den onset of caseous necrosis because its potent
ability to stimulate release of TNF from macro-
phages depends on its physical conformation.
While it is found in all mycobacteria, the quantities
excreted, chemical structure, toxicity and antigenic-
ity of that produced by MTB are unique. TDM is
the only chemically defined substance ever to be
shown to produce caseation necrosis [18]. It is the
most abundant and by orders of magnitude most
the toxic lipid of MTB [116]. While MTB contains
many lipids, TDM is unique in being free on the
bacterial surface in large quantity. Extraction of lip-
ids from the surface of viable virulent MTB yields
nearly pure TDM [116,117]. Removal of TDM
from the surface of MTB reduces virulence for
mice. Adding purified TDM back restores the viru-
lence [118]. TDM generated controversy immedi-
ately after its discovery because its toxic effects were
only demonstrable when it was injected with oil
that was considered ‘unphysiologic’ [117,119].
More recent studies have suggested that rather than
being unphysiologic, interactions of TDM with
lipids are central to the pathogenesis of TB [90].
The most striking feature of TDM is that it has
multiple distinct sets of biologic activities that de-
pend upon its physical configuration. TDM is so
large and insoluble that it remains as a thick coat on
the organisms. As such, it prevents phagosome lyso-
some fusion, prevents acidification of phagosomes,
protects organisms from killing by macrophages
and impedes antigen presentation [120,121]. In sa-
line, TDM is nontoxic; the LD50 for mice is great-
er than 50,000 µg, the highest dose ever injected.
TDM removed from MTB and placed as a single
molecular monolayer on the surface of lipid drop-
lets has a completely different physical structure
and set of biologic activities [122,123]. It spontane-
ously forms a two dimensional crystalline mono-
layer on oil-water interfaces that is the most rigid
lipid monolayer known [122-125]. The monolayer
spontaneously forms on any interface of water with
a hydrophobic surface. When virulent MTB con-
tact lipid droplets, they instantly enter the droplet
shedding the TDM that assumes the monolayer
configuration on the water-lipid interface. The
monolayer of TDM is stable with a half life of 4
days as a single molecular monolayer in mice
[123,124]. It is highly toxic with an LD50 of 30 µg
and produces foreign body granulomas in naïve
mice and hypersensitive granulomas in immunized
mice [19,126,127]. The hypersensitivity reactions
are dependent on CD1d and CD4+ T cells [19].
Injections of 10 µg of TDM emulsion every other
day induce hemorrhagic pneumonitis, cachexia and
death of C57BL1/6 mice [117]. Much larger doses,
50-100 µg are rarely lethal.
The key property of TDM that makes it a candidate
trigger for caseous pneumonia is its ability to
change configuration to suddenly stimulate release
of large amounts of TNF. Geisel et al demonstrated
that the ability of TDM to induce release of TNF
from macrophages increases with particle size
[128]. TDM on the surface of 90 micron diameter
beads induced release over 2600 pg/ml TNF while
the same amount on the same surface area of 1 mi-
cron beads induces less than 100 pg/ml. In retro-
spect, similar observations had been made earlier.
Bloch demonstrated that injection of TDM in oil is
far more toxic than injection of the same materials
as an oil-in -water emulsion [112,116]. Yarkoni
demonstrated that oil emulsions of TDM with
large particle size were far more effective as cancer
immunotherapeutic agents than those with the
same qualities in small droplets [129]. We demon-
strated that small beads coated with TDM are in-
gested by macrophages and induced non-allergic
granulomas. TDM on a plate (very large bead), in
contrast, causes macrophages to adhere, spread and
lyse within minutes [130].
The hypothesis is that post primary TB isolates a
section of lung to facilitate the buildup of host lip-
ids and mycobacterial products to generate condi-
tions for a hypersensitive reaction that produces
caseation pneumonia and cavitation [107,131].
Lipid progressively accumulates with increasing
droplet size in post obstructive pneumonia. The
trigger for initiating caseous pneumonia may be an
increase in the size of lipid droplets coated with
TDM to the point that they activate release of large
amounts of TNF that drives a positive feedback for

the rest of the lesions. In support of this, we have
observed that injection of a TDM emulsion into
mice with slowly progressive pulmonary TB induc-
es production of larger lipid droplets, greater in-
flammation, necrosis and proliferation of
organisms.
Animal Experimental Models: Most studies using
animal models of TB have focused on understand-
ing the early stages of granuloma formation. A ma-
jor gap is a failure to address later stages leading to
transmission [132]. This gap cannot be addressed
without a better understanding of pathogenesis.
Our observations suggest that most, if not all, ani-
mals develop components of both primary and post
primary TB. For example, the late stages of TB in
rabbits, mice and guinea pigs are all similar to hu-
man TB in that disease is not driven by increasing
numbers of MTB, but by a host response to myco-
bacterial products [104]. Humans, however, are
the only species in which the lesions progress to
produce cavities that mediate transmission of infec-
tion to new hosts. Most current literature assumes
that caseating granulomas are the characteristic le-
sion of both primary and post primary TB.
A central point of this paper is that granulomas are
characteristic of primary TB, but are not involved
in developing post primary disease. The concept
that the TB in guinea pigs is more human like than
that in mice because it develops large caseating
granulomas is incorrect. Large caseating granulo-
mas are characteristic only of progressive primary
TB in infants. Mice are regularly criticized because
they fail to produce caseating granulomas when, in
fact, slowly progressive TB in mice is a rather good
model of parts of the early stages of post primary
TB. In addition, many reviewers and funding agen-
cies insist that animals be infected by low dose aero-
sol infection to reproduce the conditions of human
infection. This reproduces only the first few weeks
of infection and has little or no relevance for post
primary TB that occurs decades later. As exempli-
fied by our studies with caseating granulomas in
mice, one can develop protocols to reproduce in
animals the conditions and lesions that exist in hu-
mans at different stages of infection [18]. A recent
publication used this approach to produce cavitary
lesions in rabbits [133]. While there is no complete
animal model of post primary TB, we believe that
Pathogenesis of Post Primary Tuberculosis 383
many models could yield valuable insights into par-
ticular aspects the disease. The challenge is to de-
fine models that address relevant aspects of the hu-
man disease.
Vaccine candidates: Many investigators believe
that a vaccine that acts against pulmonary TB is the
only hope of eventually eradicating MTB [8]. The
current vaccine, BCG, provides a degree of protec-
tion against disseminated TB, saving the lives of ap-
proximately 50 thousand children every year.
However, it has no measurable impact on post pri-
mary TB or transmission of infection. The funda-
mental problem is that one can’t rationally develop
an effective vaccine for post primary TB without
understanding protective immunity [134].
Vaccine development projects typically focus on re-
ducing the numbers of MTB in tissue and prolong-
ing the life of animals. This is appropriate for pri-
mary TB, but not for post primary disease because
the disease has very few MTB during developmen-
tal stages and needs none to produce disease. There
has long been realization that the immune response
is responsible for tissue damage as well as control-
ling proliferation of MTB. Targeting latent MTB
or those active in early post primary disease could
be effective. However, current, animal models of
protection from primary TB are not helpful. They
only serve to try to induce animals to produce the
type of response that most humans develop sponta-
neously in weeks. The challenge for preventing post
primary TB is to find ways to prevent MTB from
co-opting and using our strongest response for its
advantage. This may be possible since progression
of developing post primary TB is a rare event. At
least 95% of early infections regress spontaneously.
The people who develop disease do not have weaker
or less effective immune responses. MTB uses and
subverts immunity to produce an isolated area of
lung in which it can slowly accumulate host lipids
and mycobacterial antigens necessary to produce a
necrotizing hypersensitivity reaction. A vaccine that
blocks any one of multiple factors required for this
process could produce regression.
The Streetlight Effect states that one can only ef-
fectively study things that can be seen [94]. The
capabilities of modern science have increased phe-
nomenally since tissues with post primary TB
384 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
ceased to be readily obtainable due to introduction
of antibiotics and declining autopsy rates. This pa-
per presents a synthesis of old and new investiga-
tions to produce a revised conception of the patho-
genesis of post primary TB. Progression of infection
from implantation of MTB in a lung to clinical
disease is a rare event because most infections re-
solve spontaneously. Examination of the process
suggests many places where it might be interrupted
thereby preventing clinical disease and transmission
of infection to new hosts. We anticipate that this
will move the streetlight to facilitate use of modern
technologies to rapidly address previously refracto-
ry questions of the world’s most lethal bacterial
pathogen.
Acknowledgements
Supported in part by USPHS grants HL 68537, AI78420,
AI49534, HL080313.
References
1. World_Health_Organization. Global tuberculosis report
2013. 2013.
2. Russell, D. G., C. E. Barry, 3rd, and J. L. Flynn. Tuberculosis:
what we don’t know can, and does, hurt us. Science 2010. 328:
852-856.
3. Hunter, R. L. Pathology of post primary tuberculosis of the
lung: An illustrated critical review. Tuberculosis (Edinb) E
publication ahead of print July 4, 2011.
4. Russell, D. G. Who puts the tubercle in tuberculosis? Nat Rev
Microbiol 2007. 5: 39-47.
5. den Boon, S., S. W. van Lill, M. W. Borgdorff, D. A. Enarson,
S. Verver, E. D. Bateman, E. Irusen, C. J. Lombard, N. W.
White, C. de Villiers, and N. Beyers. High prevalence of tuber-
culosis in previously treated patients, Cape Town, South
Africa. Emerg Infect Dis 2007. 13: 1189-1194.
6. van Rie, A., T. C. Victor, M. Richardson, R. Johnson, G. D.
van der Spuy, E. J. Murray, N. Beyers, N. C. Gey van Pittius,
P. D. van Helden, and R. M. Warren. Reinfection and Mixed
Infection Cause Changing Mycobacterium tuberculosis Drug-
resistance Patterns. Am J Respir Crit Care Med 2005.
7. Comas, I., J. Chakravartti, P. M. Small, J. Galagan, S.
Niemann, K. Kremer, J. D. Ernst, and S. Gagneux. Human T
cell epitopes of Mycobacterium tuberculosis are evolutionarily
hyperconserved. Nature genetics 2010. 42: 498-503.
8. Brennan, M. J., and J. Thole. Tuberculosis vaccines: a strategic
blueprint for the next decade. Tuberculosis (Edinb) 2012. 92
Suppl 1: S6-13.
9. Laennec, R. A treatise on diseases of the chest in which they are
described according to their anatomical characters, and their
diagnosis established on a new principle by means of acoustick
instruments. 1821 T&G Underwood, London (reprinted 1979
by The Classics of Medicine Library. Birmingham AL).
10. Rich, A. The Pathogenesis of Tuberculosis, Second Edition.
1951 Charles C Thomas, Springfield, Illinois.
11. Canetti, G. The tubercle bacillus in the pulmonary lesion of
man. Histobacteriology and its bearing on the therapy of pul-
monary tuberculosis. 1955 Springer Publishing Compani Inc.,
New Yoyk.
12. Medlar, E. M. The behavior of pulmonary tuberculous lesions;
a pathological study. Am Rev Tuberc 1955. 71: 1-244.
13. Levine, E. R. Chapter 7, Classification of reinfection pulmo-
nary tuberculosis. In The Fundamentals of Pulmonary
Tuberculosis and its Complications for Students, Teachers and
Practicing Physicians. E. Hayes, ed. Charles C Thomas,
Springfield. 1949. 97-113.
14. Pagel, W., F. Simmonds, N. MacDonald, and E. Nassau.
Chapter 3. The Morbid Anatomy and Histology of Tuberculosis,
An Introduction in Simple Terms. In In Pulmonary
Tuberculosis, Bacteriology, Pathology, Management,
Epidemiology and Prevention. Oxford University Press,
London. 1964. 36-63.
15. Dannenberg, A. M., Jr. Pathogenisis of human pulmonary tu-
berculosis. Insights from the rabbit model. 2006 ASM press,
Washington, DC.
16. Creighton, C. Bovine Tubercuosis in Man: An account of the
Pathology of Suspected Cases. 1881 MacMillan and Co.,
London.
17. Liebana, E., L. Johnson, J. Gough, P. Durr, K. Jahans, R.
Clifton-Hadley, Y. Spencer, R. G. Hewinson, and S. H.
Downs. Pathology of naturally occurring bovine tuberculosis
in England and Wales. Vet J 2008. 176: 354-360.
18. Hunter, R. L., M. Olsen, C. Jagannath, and J. K. Actor.
Trehalose 6,6’-dimycolate and lipid in the pathogenesis of case-
ating granulomas of tuberculosis in mice. Am J Pathol 2006.
168: 1249-1261.
19. Guidry, T. V., R. L. Hunter, Jr., and J. K. Actor. Mycobacterial
glycolipid trehalose 6,6’-dimycolate-induced hypersensitive
granulomas: contribution of CD4+ lymphocytes. Microbiology
2007. 153: 3360-3369.
20. Guidry, T. V., M. Olsen, K. S. Kil, R. L. Hunter, Jr., Y. J. Geng,
and J. K. Actor. Failure of CD1D-/- mice to elicit hypersensi-
tive granulomas to mycobacterial cord factor trehalose 6,6’-di-
mycolate. J Interferon Cytokine Res 2004. 24: 362-371.
21. Hunter, R. L., C. Jagannath, and J. K. Actor. Pathology of
postprimary tuberculosis in humans and mice: contradiction
of long-held beliefs. Tuberculosis (Edinb) 2007. 87: 267-278.
22. Ehlers, S. Lazy, dynamic or minimally recrudescent? On the
elusive nature and location of the mycobacterium responsible
for latent tuberculosis. Infection 2009. 37: 87-95.
23. Lin, P. L., C. B. Ford, M. T. Coleman, A. J. Myers, R.
Gawande, T. Ioerger, J. Sacchettini, S. M. Fortune, and J. L.
Flynn. Sterilization of granulomas is common in active and la-
tent tuberculosis despite within-host variability in bacterial
killing. Nat Med 2014. 20: 75-79.
24. Neyrolles, O., R. Hernandez-Pando, F. Pietri-Rouxel, P.
Fornes, L. Tailleux, J. A. Barrios Payan, E. Pivert, Y. Bordat, D.
Aguilar, M. C. Prevost, C. Petit, and B. Gicquel. Is adipose
tissue a place for Mycobacterium tuberculosis persistence? PloS
one 2006. 1: e43.
25. Agarwal, P., S. R. Khan, S. C. Verma, M. Beg, K. Singh, K.
Mitra, A. N. Gaikwad, M. S. Akhtar, and M. Y. Krishnan.
Mycobacterium tuberculosis persistence in various adipose de-
pots of infected mice and the effect of anti-tubercular therapy.
Microbes Infect 2014. 16: 571-580.
26. Hadda, V., and G. C. Khilnani. Lipoid pneumonia: an over-
view. Expert review of respiratory medicine 2010. 4: 799-807.
27. Osler, W. Chapter 26, Tuberculosis. In The principles and
practice of medicine. D. Appleton and Company, New York.
1892. 184-255.
28. Dubos, R., and G. Dubos. The White Plague. Tuberculosis,
Man, and Society. 1987 Rutgers Univesity Press, Brunswick,
NJ.
29. Erokhin, V. V., V. Y. Mishin, V. I. Chukanov, and D. V.
Guiller. Caseous pneumonia, Pathologic anatomy, pathogene-
sis, diagnosis, clinical course and treatment, A manual for prac-
titioners 2008 Meditsina Publishers, Moscow.
30. Goodwin, R. A., and R. M. Des Prez. Apical localization of
pulmonary tuberculosis, chronic pulmonary histoplasmosis,
and progressive massive fibrosis of the lung. Chest 1983. 83:
801-805.

31. Pai, M., A. Mohan, K. Dheda, C. C. Leung, W. W. Yew, D. J.
Christopher, and S. K. Sharma. Lethal interaction: the collid-
ing epidemics of tobacco and tuberculosis. Expert review of
anti-infective therapy 2007. 5: 385-391.
32. Murray, J. F. Bill Dock and the location of pulmonary tubercu-
losis: how bed rest might have helped consumption. Am J
Respir Crit Care Med 2003. 168: 1029-1033.
33. Broch, B. L. Chapter 14, The role of the bronchial tree in the
pathogenesis of pulmonary tuberculosis. In The Fundamentals
of Pulmonary Tuberculosis and its Complications for Students,
Teachers and Practicing Physicians. E. Hayes, ed. Charles C
Thomas, Springfield. 1949. 245-253.
34. Ehrhardt, J., R. Werner, A. Schmidt-Richberg, and H.
Handels. Statistical modeling of 4D respiratory lung motion
using diffeomorphic image registration. IEEE transactions on
medical imaging 2011. 30: 251-265.
35. Du, K., J. E. Bayouth, K. Cao, G. E. Christensen, K. Ding, and
J. M. Reinhardt. Reproducibility of registration-based mea-
sures of lung tissue expansion. Medical physics 2012. 39:
1595-1608.
36. Lam, C. W., J. T. James, R. McCluskey, and R. L. Hunter.
Pulmonary toxicity of single-wall carbon nanotubes in mice 7
and 90 days after intratracheal instillation. Toxicol Sci 2004.
77: 126-134.
37. O’Garra, A., P. S. Redford, F. W. McNab, C. I. Bloom, R. J.
Wilkinson, and M. P. Berry. The immune response in tubercu-
losis. Annu Rev Immunol 2013. 31: 475-527.
38. Korf, J., A. Stoltz, J. Verschoor, P. De Baetselier, and J. Grooten.
The Mycobacterium tuberculosis cell wall component mycolic
acid elicits pathogen-associated host innate immune responses.
Eur J Immunol 2005. 35: 890-900.
39. Peyron, P., J. Vaubourgeix, Y. Poquet, F. Levillain, C. Botanch,
F. Bardou, M. Daffe, J. F. Emile, B. Marchou, P. J. Cardona, C.
de Chastellier, and F. Altare. Foamy macrophages from tuber-
culous patients’ granulomas constitute a nutrient-rich reservoir
for M. tuberculosis persistence. PLoS Pathog 2008. 4:
e1000204.
40. Korf, J. E., G. Pynaert, K. Tournoy, T. Boonefaes, A. Van
Oosterhout, D. Ginneberge, A. Haegeman, J. A. Verschoor, P.
De Baetselier, and J. Grooten. Macrophage reprogramming by
mycolic acid promotes a tolerogenic response in experimental
asthma. Am J Respir Crit Care Med 2006. 174: 152-160.
41. Melo, R. C., and A. M. Dvorak. Lipid body-phagosome inter-
action in macrophages during infectious diseases: host defense
or pathogen survival strategy? PLoS Pathog 2012. 8: e1002729.
42. North, R. J., and Y. J. Jung. Immunity to tuberculosis. Annu
Rev Immunol 2004. 22: 599-623.
43. Nuermberger, E. L., T. Yoshimatsu, S. Tyagi, W. R. Bishai, and
J. H. Grosset. Paucibacillary tuberculosis in mice after prior
aerosol immunization with Mycobacterium bovis BCG. Infect
Immun 2004. 72: 1065-1071.
44. Kondo, A., N. Oketani, M. Maruyama, Y. Taguchi, Y.
Yamaguchi, H. Miyao, I. Mashima, M. Oono, K. Wada, T.
Tsuchiya, H. Takahashi, and S. Abe. [Significance of serum
surfactant protein-D (SP-D) level in patients with pulmonary
tuberculosis]. Kekkaku 1998. 73: 585-590.
45. Chroneos, Z. C., K. Midde, Z. Sever-Chroneos, and C.
Jagannath. Pulmonary surfactant and tuberculosis.
Tuberculosis (Edinb) 2009. 89 Suppl 1: S10-14.
46. Wang, Z., U. Schwab, E. Rhoades, P. R. Chess, D. G. Russell,
and R. H. Notter. Peripheral cell wall lipids of Mycobacterium
tuberculosis are inhibitory to surfactant function. Tuberculosis
(Edinb) 2008. 88: 178-186.
47. Lovacheva, O. V., V. V. Erokhin, N. V. Chernichenko, G. V.
Evgushchenko, L. N. Lepekha, and O. A. Rozenberg. [Results
of use of surfactant in complex therapy of patients with de-
structive pulmonary tuberculosis]. Probl Tuberk Bolezn Legk
2006. 12-17.
Pathogenesis of Post Primary Tuberculosis 385
48. Hektoen, L., and D. Reisman. A Text-Book of Pathology for
the use of students and practitoners of medicine and surgery.
1901 W.B. Saunders & Company, London and Philadelphia.
49. Coats, J., and L. K. Sutherland. Manual Of Pathology, Chapter
5. Healing Of Phthisis. 1900 Longmans, Green, And Co,
London.
50. Im, J. G., H. Itoh, K. S. Lee, and M. C. Han. CT-pathology
correlation of pulmonary tuberculosis. Crit Rev Diagn Imaging
1995. 36: 227-285.
51. Lee, J. Y., K. S. Lee, K. J. Jung, J. Han, O. J. Kwon, J. Kim, and
T. S. Kim. Pulmonary tuberculosis: CT and pathologic correla-
tion. J Comput Assist Tomogr 2000. 24: 691-698.
52. Kondo, S., T. Miyagawa, and M. Ito. [Reevaluation of patho-
genesis of epituberculosis in infants and children with tubercu-
losis]. Kekkaku 2007. 82: 569-575.
53. Fish, R., and W. Pagel. The morbid anatomy of epituberculosis.
J Path Bact 1938. 47: 593-601.
54. Amita, R., S. Sandhyamani, and M. Unnikrishnan. Extensive
unilateral pulmonary tuberculosis with segmental atresia of
principal bronchus. Lung India : official organ of Indian Chest
Society 2014. 31: 94-95.
55. Ahonen, A., and K. Valavirta. Ultrastructure of cilia in pulmo-
nary tuberculosis. European journal of respiratory diseases.
Supplement 1983. 128 (Pt 2): 460-463.
56. Reed, G. W., H. Choi, S. Y. Lee, M. Lee, Y. Kim, H. Park, J.
Lee, X. Zhan, H. Kang, S. Hwang, M. Carroll, Y. Cai, S. N.
Cho, C. E. Barry, 3rd, L. E. Via, and H. Kornfeld. Impact of
diabetes and smoking on mortality in tuberculosis. PloS one
2013. 8: e58044.
57. Davies, P. D., W. W. Yew, D. Ganguly, A. L. Davidow, L. B.
Reichman, K. Dheda, and G. A. Rook. Smoking and tubercu-
losis: the epidemiological association and immunopathogene-
sis. Trans R Soc Trop Med Hyg 2006. 100: 291-298.
58. Farver, C., A. E. Fraire, and J. F. Tomashefski. Dail and
Hammar’s Pulmonary Pathology, Volume 1: Nonneoplastic
Lung Disease 1998 Springer Verlag New York
59. Pagel W, and P. W. Zur Histochemie der Lungentuberkulose,
mit besonderer Berucksichtung der Fettsubstanzen und
Lipoide. (Fat and lipoid content to tuberculous tissue.
Histochemical investigation.). . Virchows Arch Pathol Anat
1925. 256: 629-640.
60. Johnson, J. L., and J. J. Ellner. Chapter 57. Cavitary Pulmonary
Disease. In Clinical Infectious Diseases: A Practical Approach.
R. K. Root, ed. Oxford University Press, New Hork. 1999.
539-549.
61. Akinosoglou, K. S., K. Karkoulias, and M. Marangos.
Infectious complications in patients with lung cancer.
European review for medical and pharmacological sciences
2013. 17: 8-18.
62. Hunter, R. L. On the pathogenesis of post primary tuberculo-
sis: the role of bronchial obstruction in the pathogenesis of
cavities. Tuberculosis (Edinb) 2011. 91 Suppl 1: S6-10.
63. Pattnaik, M. K., P. C. Majhi, A. K. Nayak, and D. Senapati. A
rare presentation of a huge mature mediastinal teratoma with
right lung cavitation. BMJ case reports 2014. 2014.
64. Humphrey, D. M., and M. H. Weiner. Mycobacterial antigen
detection by immunohistochemistry in pulmonary tuberculo-
sis. Hum Pathol 1987. 18: 701-708.
65. Ridley, M. J., and D. S. Ridley. Histochemical demonstration
of mycobacterial antigen, specific antibody and complement in
the lesions of tuberculosis. The Histochemical journal 1986.
18: 551-556.
66. Pedersen, J. S., I. Clarke, and J. Mills. Improved detection of
mycobacteria species in formalin-fixed tissue sections.
Histopathology 2011. 59: 993-1005.
67. Guerardel, Y., E. Maes, V. Briken, F. Chirat, Y. Leroy, C.
Locht, G. Strecker, and L. Kremer. Lipomannan and lipoarabi-
nomannan from a clinical isolate of Mycobacterium kansasii:
386 Annals of Clinical & Laboratory Science, vol. 44, no. 4, 2014
novel structural features and apoptosis-inducing properties. J
Biol Chem 2003. 278: 36637-36651.
68. Chan, J., X. D. Fan, S. W. Hunter, P. J. Brennan, and B. R.
Bloom. Lipoarabinomannan, a possible virulence factor in-
volved in persistence of Mycobacterium tuberculosis within
macrophages. Infect Immun 1991. 59: 1755-1761.
69. Talaat, A. M., S. K. Ward, C. W. Wu, E. Rondon, C. Tavano,
J. P. Bannantine, R. Lyons, and S. A. Johnston. Mycobacterial
bacilli are metabolically active during chronic tuberculosis in
murine lungs: insights from genome-wide transcriptional pro-
filing. J Bacteriol 2007. 189: 4265-4274.
70. Rogerson, B. J., Y. J. Jung, R. LaCourse, L. Ryan, N. Enright,
and R. J. North. Expression levels of Mycobacterium tubercu-
losis antigen-encoding genes versus production levels of anti-
gen-specific T cells during stationary level lung infection in
mice. Immunology 2006. 118: 195-201.
71. Bhalla, A., M. Mahapatra, R. Singh, and S. D’Cruz. Acute
lung injury in miliary tuberculosis. Indian Journal of
Tuberculosis 2002. 49: 125-128.
72. Lincoln, E. M., and W. Grethmann. The potetial dangers of
tuberculin tests. J Pediatrics 1939. 15: 682-696.
73. Massaro, D., and S. Katz. Rapid Clearing in Hematogenous
Pulmonary Tuberculosis. Archives of internal medicine 1964.
113: 573-577.
74. Trapnell, B. C., B. C. Carey, K. Uchida, and T. Suzuki.
Pulmonary alveolar proteinosis, a primary immunodeficiency
of impaired GM-CSF stimulation of macrophages. Current
opinion in immunology 2009. 21: 514-521.
75. Carey, B., and B. C. Trapnell. The molecular basis of pulmo-
nary alveolar proteinosis. Clin Immunol 2010. 135: 223-235.
76. Ramirez, J. Pulmonary alveolar proteinosis. Treatment in a
case complicated by tuberculosis. Am Rev Respir Dis 1967. 95:
491-495.
77. Huang, X. Y., C. Yu, X. M. Xu, W. T. Yang, X. Zhang, P. P.
Liu, and L. X. Wang. Pulmonary alveolar proteinosis associat-
ed with tuberculosis and aspergilloma formation. Chinese
medical journal 2012. 125: 3191-3192.
78. Betancourt, S. L., S. Martinez-Jimenez, S. E. Rossi, M. T.
Truong, J. Carrillo, and J. J. Erasmus. Lipoid pneumonia: spec-
trum of clinical and radiologic manifestations. AJR Am J
Roentgenol 2010. 194: 103-109.
79. Sulkowska, M., and S. Sulkowski. Endogenous lipid pneumo-
nia- and alveolar proteinosis-type changes in the vicinity of
non-small cell lung cancer: histiopathologic, immunohisto-
chemical, and ultrastructural evaluation. Ultrastructural pa-
thology 1998. 22: 109-119.
80. Mustafa, T., S. Phyu, R. Nilsen, R. Jonsson, and G. Bjune. A
mouse model for slowly progressive primary tuberculosis.
Scand J Immunol 1999. 50: 127-136.
81. Chapman, R. C., and S. M. Claydon. Mycobacterium tubercu-
losis: a continuing cause of sudden and unexpected death in
west London. Journal of clinical pathology 1992. 45:
713-715.
82. Alzeer, A., A. Mashlah, N. Fakim, N. Al-Sugair, M. Al-
Hedaithy, S. Al-Majed, and G. Jamjoom. Tuberculosis is the
commonest cause of pneumonia requiring hospitalization dur-
ing Hajj (pilgrimage to Makkah). J Infect 1998. 36: 303-306.
83. Gonzalez Saldana, N., M. Macias Parra, M. Hernandez Porras,
P. Gutierrez Castrellon, V. Gomez Toscano, and H. Juarez
Olguin. Pulmonary Tuberculous: Symptoms, diagnosis and
treatment. 19-year experience in a third level pediatric hospital.
BMC infectious diseases 2014. 14: 401.
84. Eldour, A. A. A., M. Elfatih, R. A. A. Salih, and H. G. Ahmed.
Blood Coagulation Changes among Sudanese Patients with
Pulmonary Tuberculosis. International Journal of Science and
Research 2014. 3: 176-719.
85. Birnbaum, M. Prof. Koch’s Method to Cure Tuberculosis
Popularly Treated. In PROJECT GUTENBERG EBOOK
METHOD TO CURE TUBERCULOSIS. http://www.
gutenberg.net EBook #27181. 2008.
86. Moreira, A. L., L. Tsenova, M. H. Aman, L. G. Bekker, S.
Freeman, B. Mangaliso, U. Schroder, J. Jagirdar, W. N. Rom,
M. G. Tovey, V. H. Freedman, and G. Kaplan. Mycobacterial
antigens exacerbate disease manifestations in Mycobacterium
tuberculosis-infected mice. Infect Immun 2002. 70:
2100-2107.
87. Medlar, E. M. The pathogenesis of minimal pulmonary tuber-
culosis; a study of 1,225 necropsies in cases of sudden and un-
expected death. Am Rev Tuberc 1948. 58: 583-611.
88. Wayne, L. G., and C. D. Sohaskey. Nonreplicating persistence
of mycobacterium tuberculosis. Annu Rev Microbiol 2001. 55:
139-163.
89. Hurford, J. V., and W. H. Valentine. Viable tubercle bacilli in
closed lesions. Tubercle 1957. 38: 194-198.
90. Hunter, R. L., M. R. Olsen, C. Jagannath, and J. K. Actor.
Multiple roles of cord factor in the pathogenesis of primary,
secondary, and cavitary tuberculosis, including a revised de-
scription of the pathology of secondary disease. Ann Clin Lab
Sci 2006. 36: 371-386.
91. Rook, G. A., K. Dheda, and A. Zumla. Immune responses to
tuberculosis in developing countries: implications for new vac-
cines. Nat Rev Immunol 2005. 5: 661-667.
92. Dheda, K., H. Booth, J. F. Huggett, M. A. Johnson, A. Zumla,
and G. A. Rook. Lung remodeling in pulmonary tuberculosis.
J Infect Dis 2005. 192: 1201-1209.
93. Chapel, H. M., and P. J. August. Report of nine cases of acci-
dental injury to man with Freund’s complete adjuvant. Clin
Exp Immunol 1976. 24: 538-541.
94. Freedman, D. H. Why Scientific Studies Are So Often Wrong:
The Streetlight Effect. Discover 2010. July-August.
95. Hatipoglu, O. N., E. Osma, M. Manisali, E. S. Ucan, P. Balci,
A. Akkoclu, O. Akpinar, C. Karlikaya, and C. Yuksel. High
resolution computed tomographic findings in pulmonary tu-
berculosis. Thorax 1996. 51: 397-402.
96. Collins, J., D. Blankenbaker, and E. J. Stern. CT patterns of
bronchiolar disease: what is “tree-in-bud”? AJR Am J
Roentgenol 1998. 171: 365-370.
97. Karimi, S., M. Shamaei, M. Pourabdollah, M. Sadr, M.
Karbasi, A. Kiani, and M. Bahadori. Histopathological find-
ings in immunohistological staining of the granulomatous tis-
sue reaction associated with tuberculosis. Tuberculosis research
and treatment 2014. 2014: 858396.
98. Corbett, E. L., A. Zezai, Y. B. Cheung, T. Bandason, E. Dauya,
S. S. Munyati, A. E. Butterworth, S. Rusikaniko, G. J.
Churchyard, S. Mungofa, R. J. Hayes, and P. R. Mason.
Provider-initiated symptom screening for tuberculosis in
Zimbabwe: diagnostic value and the effect of HIV status. Bull
World Health Organ 2010. 88: 13-21.
99. van Rie, A., R. Warren, M. Richardson, T. C. Victor, R. P. Gie,
D. A. Enarson, N. Beyers, and P. D. van Helden. Exogenous
reinfection as a cause of recurrent tuberculosis after curative
treatment. N Engl J Med 1999. 341: 1174-1179.
100. Huaman, M. A., C. T. Fiske, T. F. Jones, J. Warkentin, B. E.
Shepherd, L. A. Ingram, F. Maruri, and T. R. Sterling.
Tuberculosis and the risk of infection with other intracellular
bacteria: a population-based study. Epidemiology and infec-
tion 2014. 1-9.
101. Ledru, E., S. Ledru, and A. Zoubga. Granuloma formation and
tuberculosis transmission in HIV-infected patients. Immunol
Today 1999. 20: 336-337.
102. Kenyon, T. A., T. Creek, K. Laserson, M. Makhoa, N.
Chimidza, M. Mwasekaga, J. Tappero, S. Lockman, T. Moeti,

and N. Binkin. Risk factors for transmission of Mycobacterium
tuberculosis from HIV-infected tuberculosis patients,
Botswana. Int J Tuberc Lung Dis 2002. 6: 843-850.
103. Wang, C. S., H. C. Chen, C. J. Yang, W. Y. Wang, I. W.
Chong, J. J. Hwang, and M. S. Huang. The impact of age on
the demographic, clinical, radiographic characteristics and
treatment outcomes of pulmonary tuberculosis patients in
Taiwan. Infection 2008. 36: 335-340.
104. Dannenberg, A. M., Jr., and F. M. Collins. Progressive pulmo-
nary tuberculosis is not due to increasing numbers of viable
bacilli in rabbits, mice and guinea pigs, but is due to a continu-
ous host response to mycobacterial products. Tuberculosis
(Edinb) 2001. 81: 229-242.
105. McGrath, J. W. Social networks of disease spread in the lower
Illinois valley: a simulation approach. Am J Phys Anthropol
1988. 77: 483-496.
106. Musser, J. M., A. Amin, and S. Ramaswamy. Negligible genetic
diversity of mycobacterium tuberculosis host immune system
protein targets: evidence of limited selective pressure. Genetics
2000. 155: 7-16.
107. Rook, G. A., and R. Hernandez-Pando. The pathogenesis of
tuberculosis. Annu Rev Microbiol 1996. 50: 259-284.
108. Fujita, Y., Y. Okamoto, Y. Uenishi, M. Sunagawa, T. Uchiyama,
and I. Yano. Molecular and supra-molecular structure related
differences in toxicity and granulomatogenic activity of myco-
bacterial cord factor in mice. Microb Pathog 2007. 43: 10-21.
109. McMullen, A. M., S. A. Hwang, K. O’Shea, M. L. Aliru, and
J. K. Actor. Evidence for a unique species-specific hypersensi-
tive epitope in Mycobacterium tuberculosis derived cord factor.
Tuberculosis (Edinb) 2013. 93 Suppl: S88-93.
110. Okamoto, Y., Y. Fujita, T. Naka, M. Hirai, I. Tomiyasu, and I.
Yano. Mycobacterial sulfolipid shows a virulence by inhibiting
cord factor induced granuloma formation and TNF-alpha re-
lease. Microb Pathog 2006. 40: 245-253.
111. Middlebrook, G., R. G. Dubos, and C. Pierce. Virulence and
morphological characteristics of mammalian tubercle bacilli. J.
Exp. Med. 1947. 86: 175-184.
112. Bloch, H. Studies on the virulence of tubercle bacilli: Isolation
and biological properties of a constituent of virulent organisms.
J. Exp. Med. 1950. 91: 197-219.
113. Hunter, R. L., N. Venkataprasad, and M. R. Olsen. The role of
trehalose dimycolate (cord factor) on morphology of virulent
M. tuberculosis in vitro. Tuberculosis (Edinb) 2006. 86:
349-356.
114. Goren, M., O. Brokl, B. Das, and E. Lederer. Sulfolipid I of
Mycobacterium tuberculosis, strain H37Rv. Nature of the acyl
substituents. Biochemistry 1971. 10: 72-81.
115. Andreu, N., I. Gibert, M. Luquin, P. E. Kolattukudy, and T.
Sirakova. Neutral red staining of cells of a sulfolipid-deficient
Mycobacterium tuberculosis pks2 mutant proves that sulfolip-
ids are not responsible for this cytochemical reaction. J Clin
Microbiol 2004. 42: 1379-1380.
116. Goren, M. Cord Factor Revisited: A tribute to the late Hubert
Bloch. Tubercle 1975. 56: 65-71.
117. Goren, M. B., and P. J. Brennan. Chapter 4. Mycobacterial
lipids: chemistry and biologic activities. In Tuberculosis. G. P.
Youmans, ed. W.B. Saunders, Philadelphia, PA. 1979. 63-193.
118. Indrigo, J., R. L. Hunter, Jr., and J. K. Actor. Influence of tre-
halose 6,6’-dimycolate (TDM) during mycobacterial infection
of bone marrow macrophages. Microbiology 2002. 148:
1991-1998.
119. Spitznagel, J. K., and R. J. Dubos. A fraction of tubercle bacilli
possessing primary toxicity. J Exp Med 1955. 101: 291-311.
120. Indrigo, J., R. L. Hunter, Jr., and J. K. Actor. Cord factor tre-
halose 6,6’-dimycolate (TDM) mediates trafficking events
View publication stats
Pathogenesis of Post Primary Tuberculosis 387
during mycobacterial infection of murine macrophages.
Microbiology 2003. 149: 2049-2059.
121. Kan-Sutton, C., C. Jagannath, and R. L. Hunter, Jr. Trehalose
6,6’-dimycolate on the surface of Mycobacterium tuberculosis
modulates surface marker expression for antigen presentation
and costimulation in murine macrophages. Microbes Infect
2009. 11: 40-48.
122. Behling, C. A., B. Bennett, K. Takayama, and R. L. Hunter.
Development of a trehalose 6,6’-dimycolate model which ex-
plains cord formation by Mycobacterium tuberculosis. Infect
Immun 1993. 61: 2296-2303.
123. Retzinger, G. S., S. C. Meredith, R. L. Hunter, K. Takayama,
and F. J. Kezdy. Identification of the physiologically active state
of the mycobacterial glycolipid trehalose 6,6’-dimycolate and
the role of fibrinogen in the biologic activities of trehalose
6,6’-dimycolate monolayers. J Immunol 1982. 129: 735-744.
124. Retzinger, G. S., S. C. Meredith, K. Takayama, R. L. Hunter,
and F. J. Kezdy. The role of surface in the biological activities of
trehalose 6,6’- dimycolate. Surface properties and development
of a model system. J Biol Chem 1981. 256: 8208-8216.
125. Schabbing, R. W., A. Garcia, and R. L. Hunter. Characterization
of the trehalose 6,6’-dimycolate surface monolayer by scanning
tunneling microscopy. Infect Immun 1994. 62: 754-756.
126. Bekierkunst, A. Acute granulomatous response produced in
mice by trehalose-6,6-dimycolate. J Bacteriol 1968. 96:
958-961.
127. Bekierkunst, A., and E. Yarkoni. Granulomatous hypersensi-
tivity to trehalose 6,6’-dimycolate (cord factor) in mice infect-
ed with BCG. Infect Immun 1973. 7: 631-638.
128. Geisel, R. E., K. Sakamoto, D. G. Russell, and E. R. Rhoades.
In Vivo Activity of Released Cell Wall Lipids of Mycobacterium
bovis Bacillus Calmette-Guerin Is Due Principally to Trehalose
Mycolates. J Immunol 2005. 174: 5007-5015.
129. Yarkoni, E., and H. J. Rapp. Toxicity of emulsified trehalose
6,6’ dimycolate (cord factor) in mice depends on size distribu-
tion of mineral oil droplets. Infect. Immun. 1978. 20:
856-860.
130. Syed, S. S., and R. L. Hunter, Jr. Studies on the toxic effects of
quartz and a mycobacterial glycolipid, trehalose 6,6’-dimyco-
late. Ann Clin Lab Sci 1997. 27: 375-383.
131. Ashenafi, S., G. Aderaye, A. Bekele, M. Zewdie, G. Aseffa, A.
T. Hoang, B. Carow, M. Habtamu, M. Wijkander, M.
Rottenberg, A. Aseffa, J. Andersson, M. Svensson, and S.
Brighenti. Progression of clinical tuberculosis is associated with
a Th2 immune response signature in combination with elevat-
ed levels of SOCS3. Clin Immunol 2014. 151: 84-99.
132. Young, D. Animal models of tuberculosis. Eur J Immunol
2009. 39: 2011-2014.
133. Kubler, A., B. Luna, C. Larsson, N. C. Ammerman, B. B.
Andrade, M. Orandle, K. W. Bock, Z. Xu, U. Bagci, D. J.
Molura, J. Marshall, J. Burns, K. Winglee, B. A. Ahidjo, L. S.
Cheung, M. Klunk, S. K. Jain, N. P. Kumar, S. Babu, A. Sher,
J. S. Friedland, P. T. Elkington, and W. R. Bishai.
Mycobacterium tuberculosis dysregulates MMP/TIMP bal-
ance to drive rapid cavitation and unrestrained bacterial prolif-
eration. J Pathol 2014 Sept epub ahead of print.
134. Frick, M. The TB Vaccines Pipeline. In HIV.HCV.TB Pipeline
Report. Treatment Action Group http://www.pipelinereport.
org, New York. 2013. 263-283.
135. Kondratieva, T., T. Azhikina, B. Nikonenko, A. Kaprelyants,
and A. Apt. Latent tuberculosis infection: What we know
about its genetic control? Tuberculosis (Edinb) 2014.