PPARγ mediated enhanced lipid biogenesis fuels Mycobacterium tuberculosis growth in a drug-tolerant hepatocyte environment

Reviewer #1 (Public review):

Summary:

The authors showed the presence of Mtb in human liver biopsy samples of TB patients and reported that chronic infection of Mtb causes immune-metabolic dysregulation. Authors showed that Mtb replicates in hepatocytes in a lipid rich environment created by up regulating transcription factor PPARγ. Authors also reported that Mtb protects itself from anti-TB drugs by inducing drug metabolising enzymes.

Strengths:

It has been shown that Mtb induces storage of triacylglycerol in macrophages by induction of WNT6/ACC2 which helps in its replication and intracellular survival, however, creation of favorable replicative niche in hepatocytes by Mtb is not reported. It is known that Mtb infects macrophages and induces formation of lipid-laden foamy macrophages which eventually causes tissue destruction in TB patients. In a recent article it has been reported that "A terpene nucleoside from M. tuberculosis induces lysosomal lipid storage in foamy macrophages" that shows how Mtb manipulates host defense mechanisms for its survival. In this manuscript, authors reported the enhancement of lipid droplets in Mtb infected hepatocytes and convincingly showed that fatty acid synthesis and triacylglycerol formation is important for growth of Mtb in hepatocytes. The authors also showed the molecular mechanism for accumulation of lipid and showed that the transcription factor associated with lipid biogenesis, PPARγ and adipogenic genes were upregulated in Mtb infected cells.

The comparison of gene expression data between macrophages and hepatocytes by authors is important which indicates that Mtb modulates different pathways in different cell type as in macrophages it is related to immune response whereas, in hepatocytes it is related to metabolic pathways.

Authors also reported that Mtb residing in hepatocytes showed drug tolerance phenotype due to up regulation of enzymes involved in drug metabolism and showed that cytochrome P450 monooxygenase that metabolize rifampicin and NAT2 gene responsible for N-acetylation of isoniazid were up regulated in Mtb infected cells.

Weaknesses:

There are reports of hepatic tuberculosis in pulmonary TB patients especially in immune-compromised patients, therefore finding granuloma in human liver biopsy samples is not surprising.
Mtb infected hepatic cells showed induced DME and NAT and this could lead to enhanced metabolism of drug by hepatic cells as a result Mtb in side HepG2 cells get exposed to reduced drug concentration and show higher tolerance to drug. The authors mentioned that " hepatocyte resident Mtb may display higher tolerance to rifampicin". In my opinion higher tolerance to drugs is possible only when DME of Mtb inside is up regulated or the target is modified. Although, in the end authors mentioned that drug tolerance phenotype can be better attributed to host intrinsic factors rather than Mtb efflux pumps. It may be better if the Drug tolerant phenotype section can be rewritten to clarify the facts.

Reviewer #2 (Public review):

The manuscript by Sarkar et al has demonstrated the infection of liver cells/hepatocytes with Mtb and the significance of liver cells in the replication of Mtb by reprogramming lipid metabolism during tuberculosis. Besides, the present study shows that similar to Mtb infection of macrophages (reviewed in Chen et al., 2024; Toobian et al., 2021), Mtb infects liver cells but with a greater multiplication owing to consumption of enhanced lipid resources mediated by PPARg that could be cleared by its inhibitors. The strength of the study lies in the clinical evaluation of the presence of Mtb in human autopsied liver samples from individuals with miliary tuberculosis and the presence of a clear granuloma-like structure. The interesting observation is of granuloma-like structure in liver which prompts further investigations in the field.

The modulation of lipid synthesis during Mtb infection, such as PPARg upregulation, appears generic to different cell types including both liver cells and macrophage cells. It is also known that infection affect PPARγ expression and activity in hepatocytes. It is also known that this can lead to lipid droplet accumulation in the liver and the development of fatty liver disease (as shown for HCV). This study is in a similar line for M.tb infection. As the liver is the main site for lipid regulation, the availability of lipid resources is greater and higher is the replication rate. In short, the observations from the study confirm the earlier studies with these additional cell types. It is known that higher the lipid content, the greater are Lipid Droplet-positive Mtb and higher is the drug resistance (Mekonnen et al., 2021). The DMEs of liver cells add further to the phenotype.

Reviewer #3 (Public review):

This manuscript by Sarkar et al. examines the infection of the liver and hepatocytes during M. tuberculosis infection. They demonstrate that aerosol infection of mice and guinea pigs leads to appreciable infection of the liver as well as the lung. Transcriptomic analysis of HepG2 cells showed differential regulation of metabolic pathways including fatty acid metabolic processing. Hepatocyte infection is assisted by fatty acid synthesis in the liver and inhibiting this caused reduced Mtb growth. The nuclear receptor PPARg was upregulated by Mtb infection and inhibition or agonism of its activity caused a reduction or increase in Mtb growth, respectively, supporting data published elsewhere about the role of PPARg in lung macrophage Mtb infection. Finally, the authors show that Mtb infection of hepatocytes can cause upregulation of enzymes that metabolize antibiotics, resulting in increased tolerance of these drugs by Mtb in the liver.

Overall, this is an interesting paper on an area of TB research where we lack understanding. However, some additions to the experiments and figures are needed to improve the rigor of the paper and further support the findings. Most importantly, although the authors show that Mtb can infect hepatocytes in vitro, they fail to describe how bacteria get from the lungs to the liver in an aerosolized infection. They also claim that "PPARg activation resulting in lipid droplets formation by Mtb might be a mechanism of prolonging survival within hepatocytes" but do not show a direct interaction between PPARg activation and lipid droplet formation and lipid metabolism, only that PPARg promotes Mtb growth. Thus, the correlations with PPARg appear to be there but causation, implied in the abstract and discussion, is not proven.

The human photomicrographs are important and overall well done (lung and liver from the same individuals is excellent). However, in lines 120-121, the authors comment on the absence of studies on the precise involvement of different cells in the liver. In this study there is no attempt to immunophenotype the nature of the cells harboring Mtb in these samples (esp. hepatocytes). Proving that hepatocytes specifically harbor the bacteria in these human samples would add significant rigor to the conclusions made.

Author response:

Reviewer #1 (Public review):

Summary:

The authors showed the presence of Mtb in human liver biopsy samples of TB patients and reported that chronic infection of Mtb causes immune-metabolic dysregulation. Authors showed that Mtb replicates in hepatocytes in a lipid rich environment created by up regulating transcription factor PPARγ. Authors also reported that Mtb protects itself from anti-TB drugs by inducing drug metabolising enzymes.

Strengths:

It has been shown that Mtb induces storage of triacylglycerol in macrophages by induction of WNT6/ACC2 which helps in its replication and intracellular survival, however, creation of favorable replicative niche in hepatocytes by Mtb is not reported. It is known that Mtb infects macrophages and induces formation of lipid-laden foamy macrophages which eventually causes tissue destruction in TB patients. In a recent article it has been reported that "A terpene nucleoside from M. tuberculosis induces lysosomal lipid storage in foamy macrophages" that shows how Mtb manipulates host defense mechanisms for its survival. In this manuscript, authors reported the enhancement of lipid droplets in Mtb infected hepatocytes and convincingly showed that fatty acid synthesis and triacylglycerol formation is important for growth of Mtb in hepatocytes. The authors also showed the molecular mechanism for accumulation of lipid and showed that the transcription factor associated with lipid biogenesis, PPARγ and adipogenic genes were upregulated in Mtb infected cells.

The comparison of gene expression data between macrophages and hepatocytes by authors is important which indicates that Mtb modulates different pathways in different cell type as in macrophages it is related to immune response whereas, in hepatocytes it is related to metabolic pathways.

Authors also reported that Mtb residing in hepatocytes showed drug tolerance phenotype due to up regulation of enzymes involved in drug metabolism and showed that cytochrome P450 monooxygenase that metabolize rifampicin and NAT2 gene responsible for N-acetylation of isoniazid were up regulated in Mtb infected cells.

We thank the reviewer for the positive feedback and for highlighting the strengths of our study.

Weaknesses:

There are reports of hepatic tuberculosis in pulmonary TB patients especially in immune-compromised patients, therefore finding granuloma in human liver biopsy samples is not surprising.

Mtb infected hepatic cells showed induced DME and NAT and this could lead to enhanced metabolism of drug by hepatic cells as a result Mtb in side HepG2 cells get exposed to reduced drug concentration and show higher tolerance to drug. The authors mentioned that " hepatocyte resident Mtb may display higher tolerance to rifampicin". In my opinion higher tolerance to drugs is possible only when DME of Mtb inside is up regulated or the target is modified. Although, in the end authors mentioned that drug tolerance phenotype can be better attributed to host intrinsic factors rather than Mtb efflux pumps. It may be better if the Drug tolerant phenotype section can be rewritten to clarify the facts.

We agree that several case studies regarding liver infection in pulmonary TB patients have been reported in the literature, however this report is the first comprehensive study that establishes hepatocytes to be a favourable niche for Mtb survival and growth.

Drug tolerance is a phenomenon that is exhibited by the bacteria and in the course of host-pathogen interactions, can be influenced by both intrinsic (bacterial) and extrinsic (host-mediated) factors. Multiple examples of tolerance being attributed to host driven factors can be found in literature (PMID 32546788, PMID: 28659799, PMID: 32846197). Our studies demonstrate that Mtb infected hepatocytes create a drug tolerant environment by modulating the expression of Drug modifying enzymes (DMEs) in the hepatocytes.

As suggested by the reviewer we will rewrite the drug tolerant phenotype section.

Reviewer #2 (Public review):

The manuscript by Sarkar et al has demonstrated the infection of liver cells/hepatocytes with Mtb and the significance of liver cells in the replication of Mtb by reprogramming lipid metabolism during tuberculosis. Besides, the present study shows that similar to Mtb infection of macrophages (reviewed in Chen et al., 2024; Toobian et al., 2021), Mtb infects liver cells but with a greater multiplication owing to consumption of enhanced lipid resources mediated by PPARg that could be cleared by its inhibitors. The strength of the study lies in the clinical evaluation of the presence of Mtb in human autopsied liver samples from individuals with miliary tuberculosis and the presence of a clear granuloma-like structure. The interesting observation is of granuloma-like structure in liver which prompts further investigations in the field.

The modulation of lipid synthesis during Mtb infection, such as PPARg upregulation, appears generic to different cell types including both liver cells and macrophage cells. It is also known that infection affect PPARγ expression and activity in hepatocytes. It is also known that this can lead to lipid droplet accumulation in the liver and the development of fatty liver disease (as shown for HCV). This study is in a similar line for M.tb infection. As the liver is the main site for lipid regulation, the availability of lipid resources is greater and higher is the replication rate. In short, the observations from the study confirm the earlier studies with these additional cell types. It is known that higher the lipid content, the greater are Lipid Droplet-positive Mtb and higher is the drug resistance (Mekonnen et al., 2021). The DMEs of liver cells add further to the phenotype.

We thank the reviewer for emphasizing on the strengths of our study and how it can lead to further investigations in the field.

Reviewer #3 (Public review):

This manuscript by Sarkar et al. examines the infection of the liver and hepatocytes during M. tuberculosis infection. They demonstrate that aerosol infection of mice and guinea pigs leads to appreciable infection of the liver as well as the lung. Transcriptomic analysis of HepG2 cells showed differential regulation of metabolic pathways including fatty acid metabolic processing. Hepatocyte infection is assisted by fatty acid synthesis in the liver and inhibiting this caused reduced Mtb growth. The nuclear receptor PPARg was upregulated by Mtb infection and inhibition or agonism of its activity caused a reduction or increase in Mtb growth, respectively, supporting data published elsewhere about the role of PPARg in lung macrophage Mtb infection. Finally, the authors show that Mtb infection of hepatocytes can cause upregulation of enzymes that metabolize antibiotics, resulting in increased tolerance of these drugs by Mtb in the liver.

Overall, this is an interesting paper on an area of TB research where we lack understanding. However, some additions to the experiments and figures are needed to improve the rigor of the paper and further support the findings. Most importantly, although the authors show that Mtb can infect hepatocytes in vitro, they fail to describe how bacteria get from the lungs to the liver in an aerosolized infection. They also claim that "PPARg activation resulting in lipid droplets formation by Mtb might be a mechanism of prolonging survival within hepatocytes" but do not show a direct interaction between PPARg activation and lipid droplet formation and lipid metabolism, only that PPARg promotes Mtb growth. Thus, the correlations with PPARg appear to be there but causation, implied in the abstract and discussion, is not proven.

The human photomicrographs are important and overall, well done (lung and liver from the same individuals is excellent). However, in lines 120-121, the authors comment on the absence of studies on the precise involvement of different cells in the liver. In this study there is no attempt to immunophenotype the nature of the cells harboring Mtb in these samples (esp. hepatocytes). Proving that hepatocytes specifically harbor the bacteria in these human samples would add significant rigor to the conclusions made.

We thank the reviewer for nicely summarizing our manuscript.

Our study establishes the involvement of liver and hepatocytes in pulmonary TB infection in mice. Understanding the mechanism of bacterial dissemination from the lung to the liver in aerosol infections demands a detailed separate study.

Figure 6E and 6F shows how PPARγ agonist and antagonist modulate (increase and decrease respectively) bacterial growth in hepatocytes (further supported by the CFU data in Supplementary Figure 9B). Again, the number of lipid droplets in hepatocytes increase and decrease with the application of PPARγ agonist and antagonist respectively as shown in Figure 6G and 6H. Collectively, these studies provide strong evidence that PPARγ activation leads to more lipid droplets that support better Mtb growth.

We thank the reviewer for finding our human photomicrographs convincing. In the manuscript, we provide evidence for the direct involvement of the hepatocytes (and liver) in Mtb infection. We perform detailed immunophenotyping of hepatocyte cells in the mice model with ASPGR1 (asialoglycoprotein receptor 1) and in the revised version of record, we will further stain the infected hepatocytes with anti-albumin antibody.