Psk-1 virulence gene-induced pulmonary and systemic tuberculosis in a young female with normal immune function

Psk-1 virulence gene-induced pulmonary and systemic tuberculosis in a young female with normal immune function | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Psk-1 virulence gene-induced pulmonary and systemic tuberculosis in a young female with normal immune function fan wu, Bin Yang, Yan Xiao, Hongyi Chen, Xinlan Hu, Yanyu Pan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3103090/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Tuberculosis is a chronic infectious disease and an important public health threat. Despite China’s achievements in controlling tuberculosis, the prevalence of this disease is still very high, with 895,000 new cases annually. This case report aimed to ascertain why a Mycobacterium tuberculosis strain caused such a severe infection in a young adult with normal immune function. Case presentation: We present the case of a young female with normal immune function without the history of receiving bacillus Calmette–Guérin vaccine, who suffered from severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis. The M. tuberculosis was isolated from the bronchoalveolar lavage fluid of the patient. Further, we analysed the whole-genome sequence of the strain and designated it BLM-A21. Additional M. tuberculosis genomes were selected from the Virulence Factor Database ( http://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium ) , developed by the bioinformatics research team of the Institute of Pathogenic Biology, Chinese Academy of Medical Science. The evolutionary tree of disseminated tuberculosis was then built using the PhyML maximum likelihood software. Further gene analysis revealed that BLM-A21 has similar virulence genes to the strains CDC 1551 and H37Rv, which have lower dissemination, except for the pks-1 gene, which may be the key virulence gene responsible for the high dissemination ability of this M. tuberculosis strain. Conclusions We speculated that the pks-1 virulence gene of this strain induced severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis in this adult female with normal immune function. Mycobacterium tuberculosis disseminated tuberculosis spinal tuberculosis tuberculous meningitis Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis and is an important public health threat. In 1979, China carried out the first national tuberculosis epidemiologic survey, which showed that the prevalence of active tuberculosis was 717/100,000 [ 1 ]. Under the modern tuberculosis control and tuberculosis containment strategy implemented by China in 1992, the prevalence was reduced to 59/100,000 by 2020 [ 2 ]. This was mainly due to active prevention, including bacillus Calmette–Guérin (BCG) vaccination. Despite China’s achievements, it still has one of the highest burdens of tuberculosis worldwide, with 895,000 new cases annually [ 2 ]. We herein report a case of disseminated pulmonary tuberculosis with secondary systemic hematogenous dissemination in a young female with normal immune function and no underlying diseases and discuss the possible underlying causes. Case presentation A 28-year-old female presented with a 1-month history of recurrent fever and 1-week history of dyspnoea. She was admitted to Fujian Provincial Hospital on 25 August 2021. She had not been vaccinated with BCG, although her younger sister had received a BCG vaccination. She had no known underlying diseases or family history of hereditary diseases. Her parents and sister did not have similar symptoms. Physical examination on admission revealed the following vital signs: body temperature, 38.8℃; pulse rate, 117 beats/minute; respiratory rate, 40 breaths/minute; blood pressure, 127/64 mmHg; and peripheral oxygen saturation, 80% with an inhaled oxygen concentration of 29%. She had shallow, rapid breathing. Chest auscultation revealed bilateral diffuse moist rales. Her arterial blood gas results with 29% oxygen supplementation were as follows: pH, 7.483; PCO 2 , 34.6 mmHg; PO 2 , 44.2 mmHg; and the oxygenation index was 152 mmHg. Haematologic assessment revealed a white blood cell count of 5100 cells/µL, with 63.6% segmented neutrophils; a haemoglobin level of 131 g/L; and a platelet count of 273,000/µL. Blood biochemistry assessment revealed the following: serum albumin, 38 g/L; aspartate aminotransferase, 42 U/L; alkaline phosphatase, 110.6 U/L; lactate dehydrogenase, 548 U/L; procalcitonin, 2.4 ng/mL; C-reactive protein, 67.1 mg/L; and erythrocyte sedimentation rate, 13 mm/h. Immune function tests revealed the following: CD3 cell count, 106 cells/µL; CD4 cell count, 58 cells/µL; CD8 cell count, 43 cells/µL; NK cell count, 35 cells/µL; CD19 cell count, 86 cells/µL; CD45 cell count, 227 cells/µL; serum immunoglobulin G (IgG), 9.91 g/L; immunoglobulin A (IgA), 2.02 g/L; immunoglobulin M (IgM), 0.48 g/L; immunoglobulin E (IgE), 165 g/L; complement C3, 0.997 g/L; and complement C4, 0.125 g/L. The antinuclear antibody profile (full set of autoimmunity), antineutrophil cytoplasmic antibody, rheumatoid factor, and anticyclic citrulline polypeptide antibody tests were negative. Hepatitis B antibody, human immunodeficiency virus antibody, and syphilis-specific antibody tests were also negative. Sputum bacterial and fungal cultures were negative. Chest computed tomography scans showed diffuse lesions in both lungs, bone destruction from the eighth thoracic vertebra to the first lumbar vertebra, and a paravertebral soft tissue mass (Figs. 1 A and B). Enhanced magnetic resonance imaging (MRI) of the thoracolumbar spine showed abnormal signal shadows from the ninth thoracic vertebral body to the 1st lumbar vertebral body and the surrounding soft tissues (Figs. 1 C–E). Brain enhanced MRI showed abnormal signals in the right parietal lobe (Fig. 1 F). She underwent immediate endotracheal intubation and bronchoscopy. A bronchoalveolar lavage fluid (BALF) smear was positive for acid-fast bacilli, and a Gene X-pert MTB/RIF assay was also positive for M. tuberculosis nucleic acid. Next-generation sequencing of both blood and BALF also suggested M. tuberculosis . BALF culture also confirmed M. tuberculosis . Therefore, the patient was diagnosed with severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis, including spinal tuberculosis with a paravertebral abscess and tuberculous meningitis. After receiving isoniazid, rifampicin, ethambutol, and pyrazinamide, her temperature dropped, cough and shortness of breath improved, and the tracheal intubation was removed. On 3 March 2022, the imaging of the patient's brain, chest, and vertebral body suggested that her condition had greatly improved (Fig. 1 a–f). On 5 July 2022, she underwent debridement, bone graft, and internal fixation surgery for thoracolumbar tuberculosis, and left psoas abscess debridement for spinal tuberculosis. Since the surgery she has been able to walk unaided. In order to ascertain why this M. tuberculosis strain had caused such a severe infection in a young adult with normal immune function, we analysed the strain using whole-genome sequencing and designated it BLM-A21, which has a total of 4,155 genes. We selected other M. tuberculosis genomes from the Virulence Factor Database (VFDB) ( http://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium ) [ 3 ], developed by the bioinformatics research team of the institute of Pathogenic Biology, Chinese Academy of Medical Science. We then performed evolutionary analysis using the PhyML maximum likelihood software [ 4 ] to build an evolutionary tree (Fig. 2 ). We found that BLM-A21 had a close evolutionary relationship to CCDC5079, CCDC5180, and Beijing NTR203. Therefore, we analysed the whole genomes of several strains, including CCDC5079, CCDC5180, Beijing NTR203, CDC1551, and classic H37Rv and H37Ra, for subsequent genome comparison, as these strains have previously shown strong dissemination ability [ 5 , 6 ]. We used the BLASTP performance comparison algorithm [ 7 ], and the virulence factor protein reference sequence of the VFDB to annotate genes of these species (covering reference genes ≥ 85%, similarity ≥ 80%), and mapped the virulence gene classification and genome position information using CGView [ 8 ] (Fig. 3 ). We identified rich virulence genes in BLM-A21 and created a heat map to display them (Fig. 4 ). We found that compared with the high dissemination risk strains HN878 or W4 of the W/Beijing strain series, CDC 1551 has a lower dissemination ability owing to the absence of the pks1-15 gene. In our study, we found that BLM-A21 has similar virulence genes to CDC 1551 and H37Rv, except for the pks-1 gene, which may be the key virulence gene responsible for the high dissemination ability of this strain of M. tuberculosis. Discussion and Conclusions BCG is an attenuated form of Mycobacterium bovis that provides immune protection and has been the only vaccine available against tuberculosis in China since the 1930s. In 2000, the rate of BCG vaccination in newborns reached 90%, effectively preventing miliary tuberculosis and tuberculous meningitis in children, and also reducing the risk of M. tuberculosis infection in adults [ 9 ]. In this study, the patient suffered from severe M. tuberculosis infection without BCG vaccination, while her sister, who had received BCG vaccination, did not become ill. Previous studies showed most children with hematogenous disseminated pulmonary tuberculosis had not received BCG vaccination [ 10 ], suggesting that the risk of severe tuberculosis is higher in individuals without BCG vaccination. Severe pulmonary tuberculosis is very rare, accounting for approximately 3–7% of cases [ 11 ]. Most patients with severe tuberculosis have had previous contact with an individual with tuberculosis, have weakened cellular immune function, or have other conditions such as anaemia, malnutrition and delayed medical treatment [ 12 – 15 ]. However, this patient had none of these predisposing factors. Therefore, we hypothesised that the virulence gene of BLM-A21 may be the reason for the severity of the patient’s disease. A previous study showed that, compared with strains with a high risk of dissemination, strains that lack pks1-15 , a phenol glycolipid (PGL)-related synthesis gene, have weak ability to disseminate to the central nervous system [ 16 ]. We found that BLM-A21 carried the pks-1 but lacked the pks-15 gene, whereas the number of other virulence genes was consistent with that of other low dissemination strains such as CDC 1551 and H37Rv. Based on an in vitro live bacterial transcriptome experiment, pks-1 has been reported to have a greater effect than pks-15 on regulating fadD22 , Rv2949c , lppX , fadD29 , and other genes, thus promoting PGL synthesis. PGL is known to be related to several cell functions, particularly the impermeability of the cell wall, phagocytosis, the defence mechanism against nitroso compounds, oxidative stress, and the ability of mycobacteria to form biofilms, allowing strains to grow rapidly and invade the host [ 17 ]. According to the above findings, we speculate that the pks-1 virulence gene of the BLM-A21 M. tuberculosis strain, induced severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis in this patient with normal immune function and no vaccination protection. The mechanism of the pks-1 gene’s role in causing highly invasive tuberculosis needs further study. Abbreviations BALF, bronchoalveolar lavage fluid BCG, bacillus Calmette–Guérin IgA, immunoglobulin A IgE, Immunoglobulin E IgG, immunoglobulin G IgM, immunoglobulin M Declarations Ethics approval and consent to participate When conducting the case report, we followed the indications of the Declaration of Helsinki. The patient was treated using clinical standard treatment. Consent to publish The participant gave her written informed consent to use clinical information and images relating to her case to be reported in a medical publication. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests We declare no conflicts of interest . Funding No fundings. Acknowledgments We thank the patient for her permission and cooperation in drafting the final manuscript and permission to use images. Author’s Contributions Conceptualisation, Supervision, Evaluation, and Writing–Review & Editing: F.W., B.Y., Y.X., and H.C.; Methodology: B.Y, X.H., and Y.P.; Writing–Review & Editing: L.R., Y.C., and H.L. All authors have read and agreed to the published version of the manuscript. References Tu DH. Tuberculosis control in China for 60 years. Chin J Tuberc Respir. 2013;36:886–7. https://doi.org/10.3760/cma.j.issn.1001-0939.2013.12.003 . World Health Organization. Global tuberculosis report 2017. Geneva: World Health Organization; 2017. Liu B, Zheng D, Jin Q, Chen L, Yang J. VFDB 2019: a comparative pathogenomic platform with an interactive web interface. Nucleic Acids Res. 2019;47:D687–92. https://doi.org/10.1093/nar/gky1080 . Guindon S, Delsuc F, Dufayard JF, Gascuel O. Estimating maximum likelihood phylogenies with PhyML. Methods Mol Biol. 2009;537:113–37. https://doi.org/10.1007/978-1-59745-251-9_6 . Kohli S, Singh Y, Sharma K, Mittal A, Ehtesham NZ, Hasnain SE. Comparative genomic and proteomic analyses of PE/PPE multigene family of Mycobacterium tuberculosis H ₃ ₇Rv and H ₃ ₇Ra reveal novel and interesting differences with implications in virulence. Nucleic Acids Res. 2012;40:7113–22. https://doi.org/10.1093/nar/gks465 . Bucsan AN, Rout N, Foreman TW, Khader SA, Rengarajan J, Kaushal D. Mucosal-activated invariant T cells do not exhibit significant lung recruitment and proliferation profiles in macaques in response to infection with Mycobacterium tuberculosis CDC1551. Tuberc (Edinb). 2019;116:11–8. https://doi.org/10.1016/j.tube.2019.04.006 . Camacho C, Coulouris G, Avagyan V, Ma N, Papadopoulos J, Bealer K, et al. Blast+: architecture and applications. BMC Bioinf ID: Pan-Massachusetts Chall. 2009;10:421. https://doi.org/10.1186/1471-2105-10-421 . Stothard P, Grant JR, Van Domselaar G. Visualizing and comparing circular genomes using the CGView family of tools. Brief Bioinform. 2019;20:1576–82. https://doi.org/10.1093/bib/bbx081 . Zhu BD, Wang HH. History and current status of tuberculosis vaccine research. Chin J Tuberc Respir. 2007;30:378–82. Yang M, Yuan P, Wang Y, et al. Analysis of clinical prevalence of 502 cases of hematogenous disseminated pulmonary tuberculosis in Sichuan. Sichuan Med. 2018;39:977–82. https://doi.org/10.16252/j.cnki.issn1004-0501-2018.09.002 . Liu TL. Practical tuberculosis. Shenyang: Liaoning Science and Technology Press; 1987. pp. 284–9. Yun J, Wang AM. Clinical characteristics of 146 patients with hematogenous disseminated pulmonary tuberculosis and analysis of influencing factors of curative effect. Chin Med Rec. 2016;17:70–3. Liu XN, Li Y. Analysis of clinical characteristics and risk factors of young patients with severe pulmonary tuberculosis. J Clin Pulm Med. 2020;25:1419–23. Ashenafi S, Bekele A, Aseffa G, Amogne W, Kassa E, Aderaye G, et al. Anemia is a strong predictor of wasting, disease severity, and progression, in clinical tuberculosis (TB). Nutrients. 2022;14:3318. https://doi.org/10.3390/nu14163318 . Tedla K, Medhin G, Berhe G, Mulugeta A, Berhe N. Delay in treatment initiation and its association with clinical severity and infectiousness among new adult pulmonary tuberculosis patients in Tigray, northern Ethiopia. BMC Infect Dis. 2020;20:456. https://doi.org/10.1186/s12879-020-05191-4 . Tsenova L, Ellison E, Harbacheuski R, Moreira AL, Kurepina N, Reed MB, et al. Virulence of selected Mycobacterium tuberculosis clinical isolates in the rabbit model of meningitis is dependent on phenolic glycolipid produced by the bacilli. J Infect Dis. 2005;192:98–106. https://doi.org/10.1086/430614 . Ramos B, Gordon SV, Cunha MV. Revisiting the expression signature of pks15/1 unveils regulatory patterns controlling phenolphtiocerol and phenolglycolipid production in pathogenic mycobacteria. PLoS ONE. 2020;15:e0229700. https://doi.org/10.1371/journal.pone.0229700 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3103090","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":218339631,"identity":"06bd121b-ae06-4939-ad08-152c963cc2ce","order_by":0,"name":"fan wu","email":"","orcid":"","institution":"Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"fan","middleName":"","lastName":"wu","suffix":""},{"id":218339632,"identity":"d2f33c13-4cf9-4cd3-9996-bad2b8e854af","order_by":1,"name":"Bin Yang","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Yang","suffix":""},{"id":218339633,"identity":"ed6187f8-b304-42a1-b52e-558c1759ebbc","order_by":2,"name":"Yan Xiao","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Xiao","suffix":""},{"id":218339634,"identity":"a1d8f6a9-05e1-4315-af2b-37bbf8259ed2","order_by":3,"name":"Hongyi Chen","email":"","orcid":"","institution":"Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongyi","middleName":"","lastName":"Chen","suffix":""},{"id":218339635,"identity":"1d9b9d88-3253-4d21-9591-b965d5d359e3","order_by":4,"name":"Xinlan Hu","email":"","orcid":"","institution":"Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xinlan","middleName":"","lastName":"Hu","suffix":""},{"id":218339637,"identity":"f8571272-14d5-48b3-a7b4-cdc42b1e0aaf","order_by":5,"name":"Yanyu Pan","email":"","orcid":"","institution":"the 900th Hospital of the PLA Joint Support Force","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yanyu","middleName":"","lastName":"Pan","suffix":""},{"id":218339639,"identity":"fd8963f2-16b5-4fd2-ac8d-7d3855e46900","order_by":6,"name":"Lili Ren","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lili","middleName":"","lastName":"Ren","suffix":""},{"id":218339640,"identity":"b2bce2a2-7671-4a7d-b98b-13ad57c2f014","order_by":7,"name":"Yusheng Chen","email":"","orcid":"","institution":"Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yusheng","middleName":"","lastName":"Chen","suffix":""},{"id":218339642,"identity":"171453cf-fa04-41ac-84cb-c464812df853","order_by":8,"name":"Hongru Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIie3QsQrCMBCA4SuF6HDQTSIKPoFQEaRDoa+S4tDFwdFJCq5xr/gSPsJJQBfdBQctBee4ZVQcRWzcHPLN95PcATjOnyJhOAaNBZE2tkkpo25b7tLtSlom3pXN4vA0GaomsxjvF1lJAjkCTbQChF7Qou/J6CQEiYijlx83ahrBYLUWtQm9XvG95UYVCCI81yZpToJxZD5eFTKrZAyvBBmCZXK4AaWSP7/GwueRucUu+6y6GzNPkktVaW3iXtCpSd7x38Ydx3Gczx7OXUj0EbuPPQAAAABJRU5ErkJggg==","orcid":"","institution":"Fujian Provincial Hospital, Shengli Clinical College of Fujian Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hongru","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2023-06-24 08:29:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3103090/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3103090/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":40197492,"identity":"4f4ad15c-16a4-4319-9855-f433166f63eb","added_by":"auto","created_at":"2023-07-18 13:46:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":378032,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChest computed tomography and enhanced magnetic resonance imaging (MRI) of the thoracolumbar spine and brain\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A and B) Chest computed tomography scans showing diffuse lesions in both lungs on 25 August 2021. (C, D, and E) The enhanced MRI of the thoracolumbar spine performed on 7 September 2021, showing abnormal signal shadows from the ninth thoracic vertebral body to the first lumbar vertebral body and the surrounding soft tissues. (F) The enhanced MRI of the brain performed on 6 September 2021, shows an abnormal right parietal lobe signal. (a and b) The chest computed tomography scan from 16 March 2022, showing an improvement in the diffuse lesions in both lungs. (c, d, and e) Enhanced MRI of the thoracic spine from 17 March 2022, showing improved signal shadows from the ninth thoracic vertebral body to the first lumbar vertebral body and the surrounding soft tissues. (f) Enhanced MRI of the brain from 16 March 2022, showing that the signal intensity of the right parietal lobe was similar to that of the front.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/75a0cc106aef353539d1c0ac.png"},{"id":40196201,"identity":"3f0f0f91-d13e-40f7-9798-aaddf946ec31","added_by":"auto","created_at":"2023-07-18 13:38:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47833,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWhole-genome evolutionary tree of \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eMycobacterium tuberculosis\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditional \u003cem\u003eM. tuberculosis\u003c/em\u003e genomes were selected from the Virulence Factor Database (VFDB) (\u003cu\u003ehttp://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium\u003c/u\u003e), developed by the bioinformatics research team of the institute of Pathogenic Biology, Chinese Academy of Medical Science, and an evolutionary tree was built using the PhyML (maximum likelihood) software. The whole genomes of several strains, including CCDC5079, CCDC5180, Beijing NTR203, CDC1551, and classic H37Rv and H37Ra, were analysed for subsequent genome comparison, as these strains have previously shown strong dissemination ability. BLM-A21 was closer to CCDC5079, CCDC5180, and Beijing NTR203 as shown on the evolutionary tree.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/63def632fd6cb14b8bba5675.png"},{"id":40197493,"identity":"e558fe39-4bdf-4168-8723-98140c9a7a1c","added_by":"auto","created_at":"2023-07-18 13:46:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":124315,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChromosome genome circle map and virulence factor annotation of \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eMycobacterium tuberculosis \u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003estrain BLM-A21\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe BLASTP performance comparison algorithm and the virulence factor protein reference sequence of the Virulence Factor Database (VFDB) was used to annotate genes of these species, and the virulence gene classification and genome position information was mapped using CGView.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/949fefe7d23502cc9df50dd7.png"},{"id":40196204,"identity":"47845f56-6842-4b4b-aae9-730ee159505b","added_by":"auto","created_at":"2023-07-18 13:38:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":149318,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVirulence genes of \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eMycobacterium tuberculosis\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e strains and their related genomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe red colour indicates that the virulence gene exists in the genome, whereas the pink colour indicates that the virulence gene does not exist in the genome. As the figure shows, CDC1551 lacks \u003cem\u003epks1-15\u003c/em\u003e.\u003csup\u003e \u003c/sup\u003eBLM-A21 carries the \u003cem\u003epks-1\u003c/em\u003e gene but lacks \u003cem\u003epks-15\u003c/em\u003e; nevertheless, the number of other virulence genes is essentially consistent with that of CDC1551 and H37Rv.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/c1e8e197dcfc7d54f10dc239.png"},{"id":43869980,"identity":"946745cc-ecd6-4f12-a697-1198b1f0f905","added_by":"auto","created_at":"2023-09-29 08:52:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":975173,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/59b7392c-0eb9-4f78-a0cd-9bfbbcd38a84.pdf"},{"id":40196206,"identity":"42c9573a-c614-493b-8448-4f6e0fc103a9","added_by":"auto","created_at":"2023-07-18 13:38:55","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2351802,"visible":true,"origin":"","legend":"","description":"","filename":"SFig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/4fa4e75fde17c7c7bf49df22.png"},{"id":40196203,"identity":"40be68d7-5c83-4161-820d-289750059775","added_by":"auto","created_at":"2023-07-18 13:38:55","extension":"png","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":2392619,"visible":true,"origin":"","legend":"","description":"","filename":"SFig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/cd953f4bbe2248b3d3f83718.png"},{"id":40196208,"identity":"e6549af7-a101-4a7a-9c32-5009d972090c","added_by":"auto","created_at":"2023-07-18 13:38:55","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":2414945,"visible":true,"origin":"","legend":"","description":"","filename":"SFig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/7e39187610c6d73b06ad78b7.png"},{"id":40196210,"identity":"a99bd13a-644d-450d-b7a8-c4ef9964e340","added_by":"auto","created_at":"2023-07-18 13:38:56","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":6184653,"visible":true,"origin":"","legend":"","description":"","filename":"SFig.4.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/1e39bbdedb84fb52183b82b8.png"},{"id":40196207,"identity":"fcc6955a-5719-454a-ab30-5999d7474e5e","added_by":"auto","created_at":"2023-07-18 13:38:55","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":2402920,"visible":true,"origin":"","legend":"","description":"","filename":"SFig.5.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/de7c161a7148061dd770b983.png"},{"id":40196209,"identity":"db7e95dd-161b-49da-99f1-ae7c6b1c2560","added_by":"auto","created_at":"2023-07-18 13:38:56","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":2388746,"visible":true,"origin":"","legend":"","description":"","filename":"SFig.6.png","url":"https://assets-eu.researchsquare.com/files/rs-3103090/v1/29d22144d30c3c4373921af0.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psk-1 virulence gene-induced pulmonary and systemic tuberculosis in a young female with normal immune function","fulltext":[{"header":"Background","content":"\u003cp\u003eTuberculosis is a chronic infectious disease caused by \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e and is an important public health threat. In 1979, China carried out the first national tuberculosis epidemiologic survey, which showed that the prevalence of active tuberculosis was 717/100,000 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Under the modern tuberculosis control and tuberculosis containment strategy implemented by China in 1992, the prevalence was reduced to 59/100,000 by 2020 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This was mainly due to active prevention, including bacillus Calmette\u0026ndash;Gu\u0026eacute;rin (BCG) vaccination. Despite China\u0026rsquo;s achievements, it still has one of the highest burdens of tuberculosis worldwide, with 895,000 new cases annually [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe herein report a case of disseminated pulmonary tuberculosis with secondary systemic hematogenous dissemination in a young female with normal immune function and no underlying diseases and discuss the possible underlying causes.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 28-year-old female presented with a 1-month history of recurrent fever and 1-week history of dyspnoea. She was admitted to Fujian Provincial Hospital on 25 August 2021. She had not been vaccinated with BCG, although her younger sister had received a BCG vaccination. She had no known underlying diseases or family history of hereditary diseases. Her parents and sister did not have similar symptoms. Physical examination on admission revealed the following vital signs: body temperature, 38.8℃; pulse rate, 117 beats/minute; respiratory rate, 40 breaths/minute; blood pressure, 127/64 mmHg; and peripheral oxygen saturation, 80% with an inhaled oxygen concentration of 29%. She had shallow, rapid breathing. Chest auscultation revealed bilateral diffuse moist rales. Her arterial blood gas results with 29% oxygen supplementation were as follows: pH, 7.483; PCO\u003csub\u003e2\u003c/sub\u003e, 34.6 mmHg; PO\u003csub\u003e2\u003c/sub\u003e, 44.2 mmHg; and the oxygenation index was 152 mmHg. Haematologic assessment revealed a white blood cell count of 5100 cells/\u0026micro;L, with 63.6% segmented neutrophils; a haemoglobin level of 131 g/L; and a platelet count of 273,000/\u0026micro;L. Blood biochemistry assessment revealed the following: serum albumin, 38 g/L; aspartate aminotransferase, 42 U/L; alkaline phosphatase, 110.6 U/L; lactate dehydrogenase, 548 U/L; procalcitonin, 2.4 ng/mL; C-reactive protein, 67.1 mg/L; and erythrocyte sedimentation rate, 13 mm/h. Immune function tests revealed the following: CD3 cell count, 106 cells/\u0026micro;L; CD4 cell count, 58 cells/\u0026micro;L; CD8 cell count, 43 cells/\u0026micro;L; NK cell count, 35 cells/\u0026micro;L; CD19 cell count, 86 cells/\u0026micro;L; CD45 cell count, 227 cells/\u0026micro;L; serum immunoglobulin G (IgG), 9.91 g/L; immunoglobulin A (IgA), 2.02 g/L; immunoglobulin M (IgM), 0.48 g/L; immunoglobulin E (IgE), 165 g/L; complement C3, 0.997 g/L; and complement C4, 0.125 g/L. The antinuclear antibody profile (full set of autoimmunity), antineutrophil cytoplasmic antibody, rheumatoid factor, and anticyclic citrulline polypeptide antibody tests were negative. Hepatitis B antibody, human immunodeficiency virus antibody, and syphilis-specific antibody tests were also negative. Sputum bacterial and fungal cultures were negative. Chest computed tomography scans showed diffuse lesions in both lungs, bone destruction from the eighth thoracic vertebra to the first lumbar vertebra, and a paravertebral soft tissue mass (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA and B). Enhanced magnetic resonance imaging (MRI) of the thoracolumbar spine showed abnormal signal shadows from the ninth thoracic vertebral body to the 1st lumbar vertebral body and the surrounding soft tissues (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC\u0026ndash;E). Brain enhanced MRI showed abnormal signals in the right parietal lobe (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF).\u003c/p\u003e \u003cp\u003eShe underwent immediate endotracheal intubation and bronchoscopy. A bronchoalveolar lavage fluid (BALF) smear was positive for acid-fast bacilli, and a Gene X-pert MTB/RIF assay was also positive for \u003cem\u003eM. tuberculosis\u003c/em\u003e nucleic acid. Next-generation sequencing of both blood and BALF also suggested \u003cem\u003eM. tuberculosis\u003c/em\u003e. BALF culture also confirmed \u003cem\u003eM. tuberculosis\u003c/em\u003e. Therefore, the patient was diagnosed with severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis, including spinal tuberculosis with a paravertebral abscess and tuberculous meningitis. After receiving isoniazid, rifampicin, ethambutol, and pyrazinamide, her temperature dropped, cough and shortness of breath improved, and the tracheal intubation was removed. On 3 March 2022, the imaging of the patient's brain, chest, and vertebral body suggested that her condition had greatly improved (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea\u0026ndash;f). On 5 July 2022, she underwent debridement, bone graft, and internal fixation surgery for thoracolumbar tuberculosis, and left psoas abscess debridement for spinal tuberculosis. Since the surgery she has been able to walk unaided.\u003c/p\u003e \u003cp\u003eIn order to ascertain why this \u003cem\u003eM. tuberculosis\u003c/em\u003e strain had caused such a severe infection in a young adult with normal immune function, we analysed the strain using whole-genome sequencing and designated it BLM-A21, which has a total of 4,155 genes. We selected other \u003cem\u003eM. tuberculosis\u003c/em\u003e genomes from the Virulence Factor Database (VFDB) (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium\u003c/span\u003e\u003cspan address=\"http://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], developed by the bioinformatics research team of the institute of Pathogenic Biology, Chinese Academy of Medical Science. We then performed evolutionary analysis using the PhyML maximum likelihood software [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] to build an evolutionary tree (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). We found that BLM-A21 had a close evolutionary relationship to CCDC5079, CCDC5180, and Beijing NTR203. Therefore, we analysed the whole genomes of several strains, including CCDC5079, CCDC5180, Beijing NTR203, CDC1551, and classic H37Rv and H37Ra, for subsequent genome comparison, as these strains have previously shown strong dissemination ability [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. We used the BLASTP performance comparison algorithm [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the virulence factor protein reference sequence of the VFDB to annotate genes of these species (covering reference genes\u0026thinsp;\u0026ge;\u0026thinsp;85%, similarity\u0026thinsp;\u0026ge;\u0026thinsp;80%), and mapped the virulence gene classification and genome position information using CGView [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). We identified rich virulence genes in BLM-A21 and created a heat map to display them (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). We found that compared with the high dissemination risk strains HN878 or W4 of the W/Beijing strain series, CDC 1551 has a lower dissemination ability owing to the absence of the \u003cem\u003epks1-15\u003c/em\u003e gene. In our study, we found that BLM-A21 has similar virulence genes to CDC 1551 and H37Rv, except for the \u003cem\u003epks-1\u003c/em\u003e gene, which may be the key virulence gene responsible for the high dissemination ability of this strain of \u003cem\u003eM. tuberculosis.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eBCG is an attenuated form of \u003cem\u003eMycobacterium bovis\u003c/em\u003e that provides immune protection and has been the only vaccine available against tuberculosis in China since the 1930s. In 2000, the rate of BCG vaccination in newborns reached 90%, effectively preventing miliary tuberculosis and tuberculous meningitis in children, and also reducing the risk of \u003cem\u003eM. tuberculosis\u003c/em\u003e infection in adults [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In this study, the patient suffered from severe \u003cem\u003eM. tuberculosis\u003c/em\u003e infection without BCG vaccination, while her sister, who had received BCG vaccination, did not become ill. Previous studies showed most children with hematogenous disseminated pulmonary tuberculosis had not received BCG vaccination [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], suggesting that the risk of severe tuberculosis is higher in individuals without BCG vaccination. Severe pulmonary tuberculosis is very rare, accounting for approximately 3\u0026ndash;7% of cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Most patients with severe tuberculosis have had previous contact with an individual with tuberculosis, have weakened cellular immune function, or have other conditions such as anaemia, malnutrition and delayed medical treatment [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, this patient had none of these predisposing factors. Therefore, we hypothesised that the virulence gene of BLM-A21 may be the reason for the severity of the patient\u0026rsquo;s disease. A previous study showed that, compared with strains with a high risk of dissemination, strains that lack \u003cem\u003epks1-15\u003c/em\u003e, a phenol glycolipid (PGL)-related synthesis gene, have weak ability to disseminate to the central nervous system [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We found that BLM-A21 carried the \u003cem\u003epks-1\u003c/em\u003e but lacked the \u003cem\u003epks-15\u003c/em\u003e gene, whereas the number of other virulence genes was consistent with that of other low dissemination strains such as CDC 1551 and H37Rv. Based on an in vitro live bacterial transcriptome experiment, \u003cem\u003epks-1\u003c/em\u003e has been reported to have a greater effect than \u003cem\u003epks-15\u003c/em\u003e on regulating \u003cem\u003efadD22\u003c/em\u003e, \u003cem\u003eRv2949c\u003c/em\u003e, \u003cem\u003elppX\u003c/em\u003e, \u003cem\u003efadD29\u003c/em\u003e, and other genes, thus promoting PGL synthesis. PGL is known to be related to several cell functions, particularly the impermeability of the cell wall, phagocytosis, the defence mechanism against nitroso compounds, oxidative stress, and the ability of mycobacteria to form biofilms, allowing strains to grow rapidly and invade the host [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the above findings, we speculate that the \u003cem\u003epks-1\u003c/em\u003e virulence gene of the BLM-A21 \u003cem\u003eM. tuberculosis\u003c/em\u003e strain, induced severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis in this patient with normal immune function and no vaccination protection. The mechanism of the \u003cem\u003epks-1\u003c/em\u003e gene\u0026rsquo;s role in causing highly invasive tuberculosis needs further study.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eBALF, bronchoalveolar lavage fluid\u003c/p\u003e \u003cp\u003eBCG, bacillus Calmette\u0026ndash;Gu\u0026eacute;rin\u003c/p\u003e \u003cp\u003eIgA, immunoglobulin A\u003c/p\u003e \u003cp\u003eIgE, Immunoglobulin E\u003c/p\u003e \u003cp\u003eIgG, immunoglobulin G\u003c/p\u003e \u003cp\u003eIgM, immunoglobulin M\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen conducting the case report, we followed the indications of the Declaration of Helsinki. The patient was treated using clinical standard treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participant gave her written informed consent to use clinical information and images relating to her case to be reported in a medical publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare no conflicts of interest\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo fundings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the patient for her permission and cooperation in drafting the final manuscript and permission to use images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualisation, Supervision, Evaluation, and Writing\u0026ndash;Review \u0026amp; Editing: F.W., B.Y., Y.X., and H.C.; Methodology: B.Y, X.H., and Y.P.; Writing\u0026ndash;Review \u0026amp; Editing: L.R., Y.C., and H.L. 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Revisiting the expression signature of pks15/1 unveils regulatory patterns controlling phenolphtiocerol and phenolglycolipid production in pathogenic mycobacteria. PLoS ONE. 2020;15:e0229700. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0229700\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0229700\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mycobacterium tuberculosis, disseminated tuberculosis, spinal tuberculosis, tuberculous meningitis","lastPublishedDoi":"10.21203/rs.3.rs-3103090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3103090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTuberculosis is a chronic infectious disease and an important public health threat. Despite China\u0026rsquo;s achievements in controlling tuberculosis, the prevalence of this disease is still very high, with 895,000 new cases annually. This case report aimed to ascertain why a \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e strain caused such a severe infection in a young adult with normal immune function.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe present the case of a young female with normal immune function without the history of receiving bacillus Calmette\u0026ndash;Gu\u0026eacute;rin vaccine, who suffered from severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis. The \u003cem\u003eM. tuberculosis\u003c/em\u003e was isolated from the bronchoalveolar lavage fluid of the patient. Further, we analysed the whole-genome sequence of the strain and designated it BLM-A21. Additional \u003cem\u003eM. tuberculosis\u003c/em\u003e genomes were selected from the Virulence Factor Database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium\u003c/span\u003e\u003cspan address=\"http://www.mgc.ac.cn/cgi-bin/VFs/genus.cgi?Genus=Mycobacterium\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e, developed by the bioinformatics research team of the Institute of Pathogenic Biology, Chinese Academy of Medical Science. The evolutionary tree of disseminated tuberculosis was then built using the PhyML maximum likelihood software. Further gene analysis revealed that BLM-A21 has similar virulence genes to the strains CDC 1551 and H37Rv, which have lower dissemination, except for the \u003cem\u003epks-1\u003c/em\u003e gene, which may be the key virulence gene responsible for the high dissemination ability of this \u003cem\u003eM. tuberculosis\u003c/em\u003e strain.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe speculated that the \u003cem\u003epks-1\u003c/em\u003e virulence gene of this strain induced severe pulmonary tuberculosis and secondary systemic disseminated tuberculosis in this adult female with normal immune function.\u003c/p\u003e","manuscriptTitle":"Psk-1 virulence gene-induced pulmonary and systemic tuberculosis in a young female with normal immune function","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-18 13:38:50","doi":"10.21203/rs.3.rs-3103090/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f0e9ed6c-c11e-4143-bb6e-7edd8dc63b90","owner":[],"postedDate":"July 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-09-29T08:44:24+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-18 13:38:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3103090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3103090","identity":"rs-3103090","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}