REVIEW

published: 01 November 2018

doi: 10.3389/fmicb.2018.02642

Mycobacterium abscessus:
Shapeshifter of the Mycobacterial
World
Keenan Ryan 1 and Thomas F. Byrd 2*
1
Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, United States, 2 Department of Medicine,
The University of New Mexico School of Medicine, Albuquerque, NM, United States

In this review we will focus on unique aspects of Mycobacterium abscessus (MABS)

which we feel earn it the designation of “shapeshifter of the mycobacterial world.” We
will review its emergence as a distinct species, the recognition and description of MABS
subspecies which are only now being clearly defined in terms of pathogenicity, its ability
to exist in different forms favoring a saprophytic lifestyle or one more suitable to invasion
of mammalian hosts, as well as current challenges in terms of antimicrobial therapy and
future directions for research. One can see in the various phases of MABS, a species
transitioning from a free living saprophyte to a host-adapted pathogen.
Keywords: glycopeptidolipid, toll-like receptor 2, cystic fibrosis, bronchiectasis, serpentine cording, fibroblasts

Edited by:
Thomas Dick, EVOLVING NOMENCLATURE
Rutgers, The State University
of New Jersey, United States
Mycobacterium abscessus (MABS), a rapidly growing non-tuberculous mycobacterium (NTM)
Reviewed by: (Howard and Byrd, 2000) is an emerging pathogen worldwide. Perhaps the earliest case of
Michael Henry Cynamon,
MABS was reported in 1951 and described infection which occurred in the setting of traumatic
Syracuse VA Medical Center,
knee injury. This infection was characterized by “subcutaneous, abscess-like lesions with a
United States
Joon Liang Tan, peripherally tuberculoid structure.” The unique characteristics of this mycobacterium prompted
Multimedia University, Malaysia the investigators to propose it as a new species, Mycobacterium abscessus (Moore and Frerichs,
Albertus Johannes Viljoen, 1953). In more recent times, MABS was considered a subspecies of Mycobacterium chelonae until
IRIM, France 1992 when genetic analysis demonstrated that it was a distinct species and it was elevated to species
*Correspondence: status as MABS (Kusunoki and Ezaki, 1992). This resulted in the realization that most prior reports
Thomas F. Byrd of M. chelonae lung infection were likely a mischaracterization of actual MABS lung infection as it
[email protected] is now recognized that pulmonary infection is a common clinical manifestation of MABS whereas
it is rarely caused by M. chelonae. In recent years, MABS has been further characterized into three
Specialty section: distinct subspecies; MABS subspecies abscessus, MABS subspecies bolletii and MABS subspecies
This article was submitted to
massiliense (Adekambi et al., 2017). They differ in terms of drug susceptibility, and may have
Antimicrobials, Resistance
and Chemotherapy,
differences related to transmissibility as well which will be discussed (Tan et al., 2017). Genomic
a section of the journal analysis of MABS reveals evidence of horizontal gene transfer (Howard et al., 2002). In addition
Frontiers in Microbiology to genes associated with mycobacterial virulence, genes with similar function to those found in
Received: 11 July 2018 Pseudomonas aeruginosa and Burkholderia cepacia, pathogens commonly found in the lungs of
Accepted: 16 October 2018 cystic fibrosis (CF) patients, have also been identified (Ripoll et al., 2009). Thus MABS can be
Published: 01 November 2018 thought of as a pathogen uniquely adapted to different niches within the host lung environment.
Citation:
Ryan K and Byrd TF (2018)
Mycobacterium abscessus: EPIDEMIOLOGY AND EMERGENCE AS A PATHOGEN
Shapeshifter of the Mycobacterial
World. Front. Microbiol. 9:2642. The incidence of NTM infection is increasing in the United States (Prevots et al., 2010)
doi: 10.3389/fmicb.2018.02642 and worldwide (Prevots and Marras, 2015). Pulmonary infection is the most common clinical

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Ryan and Byrd Mycobacterium abscessus: Shapeshifter

presentation, however, extrapulmonary infection either due to CLINICAL INFECTION

direct inoculation into the skin or due to disseminated disease,
often in association with disease modifying anti-TNFα therapy, The clinical spectrum of MABS and other rapidly growing
is also being recognized with increased frequency (Winthrop mycobacteria has been well-described and broadly categorized
et al., 2009). In the United States, Mycobacterium avium complex as pulmonary and extrapulmonary disease (Howard and Byrd,
(MAC) is the most common NTM clinical pulmonary isolate 2000). MABS extrapulmonary infection can involve a variety of
followed by MABS (Prevots and Marras, 2015). It has also been sites, most commonly the skin. It can occur via dissemination
reported that there are geographic differences in the types of in immunosuppressed patients (Scholze et al., 2005), often
NTM isolates in the United States. MAC is the most frequent from an occult source, or from direct inoculation, either
and predominant isolate in the South and Northeast with iatrogenically [for example, contaminated acupuncture needles,
proportionally higher rates of isolation of MABS, M. chelonae, injection solutions, and surgical procedures (Ryu et al., 2005;
M. fortuitum, and M. kansasii in the Western United States Yuan et al., 2009; Schnabel et al., 2016)], or as a result of wound
(Spaulding et al., 2017). It is noteworthy that in parts of contamination in the setting of trauma (Petrini et al., 2006).
Asia MABS is the predominant pulmonary NTM pathogen Infection of many anatomic sites has been reported including
(Umrao et al., 2016; Nagano et al., 2017; Lim et al., 2018). the eye, bone, joint, and central nervous system (Chu et al.,
Furthermore, limited epidemiologic data suggests that there may 2015; Fukui et al., 2015; Baidya et al., 2016; Jeong et al., 2017).
be a relative genetic susceptibility to MABS infection in certain Extrapulmonary infection is generally responsive to treatment
Asian populations (Adjemian et al., 2017). with antibiotics to which the isolate is susceptible with adjunctive
Perhaps what is most disconcerting about MABS from an surgical debridement where indicated.
epidemiologic standpoint is its unique ability among NTM MABS was first recognized as a cause of chronic pulmonary
to cause outbreaks of infection over wide geographic regions infection in 1993. The majority of pulmonary infections occur
without linkage to a single or specific point source. The in older adults often with no history of cigarette smoking who
best described instance of this relates to a study of post- are otherwise healthy, but who have underlying lung airway
surgical wound infections with MABS subspecies massiliense abnormalities (Griffith et al., 1993). The clinical presentation is
in Brazil. Using genomic analysis it was found that a recently indistinguishable from lung infection caused by MAC. Unlike
emergent single clone caused multiple outbreaks of post-surgical MAC, however, effective antibiotic treatment options are limited
wound infections. The organism spread throughout Brazil and with many patients requiring a combination of medical and
persisted in hospital environments. Evidence was also provided surgical intervention for cure (Jarand et al., 2011). In patients
that there is a loss of genetic material from this lineage with CF, MABS pulmonary infection is an important cause of
raising the possibility that it is undergoing reductive evolution morbidity and mortality, and is a relative contraindication to lung
as it adapts to its new niche in the hospital environment transplantation (Dorgan and Hadjiliadis, 2014). It is important to
(Everall et al., 2017). It is noteworthy that this isolate is note that immune dysregulation as a result of mutations in the CF
genetically related to another MABS subspecies massillense Transmembrane Conductance Regulator gene (CFTR) contributes
clone that has been reported to be circulating among CF to the inflammatory phenotype in CF lung disease, and may result
treatment centers throughout the world. There is evidence that in a pathogenic process that differs from that seen in otherwise
acquisition of this strain by CF patients may be associated healthy individuals who have MABS infection and abnormal lung
with worse clinical outcomes. Data from cell culture and airways (Rieber et al., 2014). One clinically apparent difference is
animal infection experiments provide evidence that this clone that MABS chronic colonization of the lung by smooth variants
may be more virulent in comparison to unclustered MABS as well as by rough invasive variants is a cause of morbidity in CF
subspecies abscessus isolates. Review of this data shows that patients (Bryant et al., 2016). In otherwise healthy patients with
although the observed differences are statistically significant, abnormal lung airways MABS colonization is more likely to be
they are small (Bryant et al., 2016), and whether they have transient.
clinical relevance in terms of virulence remains unclear. A common characteristic of patients with MABS pulmonary
Nonetheless these studies raise the disconcerting possibility that infection is bronchiectasis. An obvious question is whether
evolutionary changes affecting transmissibility and adaptation to bronchiectasis is the end result of infection with MABS or
mammalian hosts could lead to further spread of MABS into a predisposing factor for MABS infection? An experiment of
the susceptible general population of patients with abnormal nature provides evidence that bronchiectasis per se predisposes
lung airways and/or states of immunosuppression (Winthrop to NTM infection in the absence of preceding inflammation.
et al., 2009). The possible mechanisms responsible for spread Patients with the genetic disorder known as primary ciliary
of MABS include fomites, aerosolized airway secretions and dyskinesia have a loss of normal ciliary structure and function
contaminated hospital and municipal tap water (Baker et al., leading to development of bronchiectasis which may occur in
2017; Donohue, 2018). One study has reported an association the absence of antecedent inflammation. These individuals are
between warm humid climates and high atmospheric vapor prone to recurrent oto-sino-pulmonary infections. In addition
pressure with the prevalence of NTM infection (Prevots and to lung infection with pyogenic bacteria such as P. aeruginosa
Marras, 2015). This raises the question of whether climate and Staphylococcus aureus, these patients are also susceptible
change is contributing to the rising incidence of NTM to colonization and invasive infection with MABS and MAC
infection. (Noone et al., 2004). The other lung airway disease which

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Ryan and Byrd Mycobacterium abscessus: Shapeshifter

predisposes to colonization and infection with NTM such as majority of clinical isolates from individuals with chronic lung
MABS and MAC is chronic obstructive pulmonary disease disease exhibit the rough phenotype whereas environmental
(COPD) (Billinger, 2009). Large upper lobe bullous cavities in contaminants and isolates from wounds exhibit the smooth
the lung are a predisposing factor to NTM infection in these phenotype (Jonsson et al., 2007). A study which longitudinally
patients. It is also noteworthy that bronchiectasis is also present in characterized MABS isolates from ten CF and three non-CF
a high percentage of patients diagnosed with COPD (Patel et al., patients over a 10 year period found that a switch from
2004; Martinez-Garcia et al., 2013) suggesting that the presence smooth to rough colony morphology was observed in 6 of
of bronchiectasis may be an important factor in MABS and MAC the patients during the course of long-term infection and
disease pathogenesis in these patients as well. was associated with increased severity of clinical symptoms
(Kreutzfeldt et al., 2013). In addition, it has been documented
that deterioration of lung function in a MABS-infected CF
PATHOGENESIS: THE IMPORTANCE OF patient was associated with conversion of a sputum isolates
ROUGH AND SMOOTH COLONY from the smooth phenotype to an isogenic rough phenotype
PHENOTYPES (Catherinot et al., 2009). These observations are consistent with
our hypothesis that MABS initially gains entry to the lung as a
Microdroplet nuclei aerosolized after an individual with GPL-expressing smooth variant which colonizes abnormal lung
pulmonary tuberculosis coughs, with subsequent inhalation airways, and that spontaneous loss of GPL expression leads
by an uninfected host, is the mode of person to person spread to a virulent phenotype capable of causing inflammation and
of M. tuberculosis. In contrast, epidemiologic studies have not invasive lung disease (Howard et al., 2006; Rhoades et al., 2009).
demonstrated this to be an efficient mechanism for acquisition In support of this pathogenic mechanism, we have provided
of pulmonary MABS infection although there is experimental evidence that MABS GPL is immunologically inert and that
evidence that long lived infected aerosols generated by a loss of GPL unmasks underlying MABS cell wall molecules
coughing patient may contain respiratable bacteria (Bryant et al., such phosphatidyl-myo-inositol mannosides (PIMs) which are
2016). Respiratable bacteria could also result from other sources recognized by toll like receptor 2 (TLR2) on macrophages
of aerosols contaminated with MABS, for example colonized and epithelial cells thereby initiating an inflammatory response.
showerheads. Fomites have also been implicated in transmission Establishment of a smooth strain in the lungs of individuals
of an outbreak strain (Bryant et al., 2016). It would seem unlikely with normal lung airways is likely prevented by the normal lung
that bacteria adherent to a fomite could be easily re-aerosolized. mucociliary clearance mechanism. This prevents establishment
This mechanism of transmission could involve contact transfer of lung airway biofilm from which invasive rough variants which
from the fomite to the mouth with subsequent colonization of have lost GPL can emerge. In patients with abnormal lung airways
the oropharynx. Microaspiration of bacteria into the lung would and diminished mucociliary clearance, MABS smooth variants
lead to colonization of the lung airways and/or invasive lung have been demonstrated to establish biofilm in lung airways
infection (Thomson et al., 2007). (Qvist et al., 2015). In CF patients, heavy colonization of lung
We first described rough and smooth colony phenotypes airways with smooth variants in the absence of lung invasion
of MABS which arose from a single parental strain, and is also likely to contribute to morbidity. Evidence indicates
demonstrated that the rough variant persists in the lungs that genetic mutation involving a gene coding for one of the
of SCID mice, replicates in macrophages, and forms corded, MmpL proteins involved in the biosynthesis of the MABS cell
invasive microcolonies in fibroblast monolayers. The smooth envelope is responsible for the smooth to rough transition in
variant demonstrated none of these characteristics (Byrd and one MABS strain (Bernut et al., 2016b). However, we have
Lyons, 1999). We then identified glycopeptidolipid (GPL) in presented evidence that in some strains of MABS, expression of
the cell wall of the smooth variant as being responsible for GPL is temperature dependent and reversible, with expression at
the smooth colony phenotype and for the ability of the lower temperatures and loss of expression at higher temperatures
smooth strain to exhibit sliding motility and biofilm formation (Rhoades et al., 2009). This suggests that alternative mechanisms
(Howard et al., 2006; Nessar et al., 2011). Importantly, we regulating GPL production in the smooth to rough transition are
demonstrated that a mutant which lacks GPL and exhibits the operating. In addition, temperature-dependent transitioning of
rough phenotype can spontaneously arise from the smooth the smooth to rough phenotype could be a mechanism whereby a
phenotype and regain virulence characteristics (Howard et al., GPL expressing environmental strain gains access to abnormal
2006). We showed by light and electron microscopy (Byrd and lung airways where higher internal core temperature of the
Lyons, 1999; Howard et al., 2006), and in a later publication lungs would result in loss of GPL and emergence of the rough
using scanning electron microscopy (Sanchez-Chardi et al., virulent phenotype. Our current model of MABS pathogenesis is
2011), that the rough phenotype exhibits cording, a property summarized in Figure 1.
associated with virulence in M. tuberculosis. These observations With the exception of MABS rough strains from chronically
were replicated by others, and the ability of spontaneous rough infected CF patients contaminating the hospital/surgical or CF
mutants to arise in infected mice from initial infecting MABS clinic environment, the majority of environmental strains have
smooth variants was subsequently demonstrated (Catherinot the smooth colony phenotype (Jonsson et al., 2007; Baker
et al., 2007; De Groote et al., 2014). The clinical relevance of et al., 2017). Direct acquisition of a MABS rough variant into
these observations is supported by studies indicating that the abnormal lung airways as might occur in a contaminated clinical

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Ryan and Byrd Mycobacterium abscessus: Shapeshifter

FIGURE 1 | Environmental Mycobacterium abscessus (MABS) isolates have the smooth colony morphotype and express glycopeptidolipid (GPL). GPL in the
outermost aspect of the cell wall “masks” underlying glycosylated lipoproteins such as phosphatidyl-myo-inositol mannosides (PIMs) involved in immune recognition
and blocks the bacterial cell–cell interaction of lipids such trehalose polyphleates which may play a role in clumping and cord formation. By preventing MABS from
being recognized by innate immune surveillance mechanisms and promoting biofilm formation, GPL facilitates colonization of bronchiectatic lung airways. After
colonization, spontaneous or temperature sensitive loss of GPL is associated with “unmasking” of these molecules. This leads to recognition by TLR2 on
macrophages and respiratory epithelial cells resulting in release of the proinflammatory cytokines TNFα (from macrophages) and IL-8 (from respiratory epithelial cells).
Rough variants acquire a virulent phenotype characterized by the ability to grow in serpentine cords and cause macrophage apoptosis leading to rapid cell–cell
spread and propagation of infection. Isolation of MABS rough variants from the sputum is associated with progressive lung infection.

environment would likely result in a less indolent infection due to MABS that is associated with mycobacterial virulence (Tu et al.,
the greater virulence of rough variants and stimulation of a robust 2003). In contrast, M. marinum does not express GPLs, but
innate immune response. does exhibit serpentine cording (Hall-Stoodley et al., 2006).
Thus, MABS may be viewed as a pathogen which has a unique
ability to shift from a ubiquitous environmental saprophyte to
COMPARISON TO OTHER CLINICALLY an invasive human pathogen – this transformation is apparent
SIGNIFICANT NTM upon inspection of the shape of its bacterial colonies growing on
nutrient agar.
Other clinically significant NTM may express some form of GPL
or exhibit cording, but there are few examples of other NTM
which can transition between both phenotypes with such a clear THE PARADOX OF LOW VIRULENCE
correlation between colonization and invasion. For example, AND INEFFECTIVE HOST RESPONSE
MAC expresses serovar-specific GPLs that differ from the non-
specific core GPL found in MABS through modification by Perhaps the most puzzling aspect of MABS pulmonary infection
addition of oligosaccharides (Brennan et al., 1981). In contrast to is that it rarely occurs in immunocompetent individuals with
MABS GPL, these molecules are immunogenic and are associated normal lung airways in spite of the ability of this pathogen
with MAC virulence (Barrow et al., 1995; Sweet and Schorey, to invade and replicate in mononuclear phagocytes and non-
2006). M. kansasii variants may have a smooth colony phenotype professional phagocytes (Byrd and Lyons, 1999). Determining the
associated with expression of characteristic lipids distinct from reason(s) why has been impeded by the lack of a suitable mouse
GPLs (Nataraj et al., 2015). Both MAC and M. kansasii form model that mimics human lung bronchiectasis. For example,
microscopic bacterial aggregates in broth culture, but do not mice with in which the CFTR gene has been disrupted have organ
exhibit the serpentine cording found in M. tuberculosis and specific pathology which is mild in the lung (Clarke et al., 1994).

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Ryan and Byrd Mycobacterium abscessus: Shapeshifter

A non-CF mouse model utilizes GM-CSF knock out mice in for causing phagosome rupture (Laencina et al., 2018). Other
which a chronic lung infection can be established. In this model, studies have found that under stringent conditions to prevent
colony forming units in mouse lung persist and gradually decline extracellular replication in tissue culture media, colony forming
over a month but then begin to increase at 2 months – at that time units of MABS smooth variants in human monocyte-derived
the mice have begun to develop bronchiectasis. The limitations macrophage monolayers have limited replicative capacity over
of this model are that the mice are immunocompromised, and a 5 day period and do not persist in the lungs of infected
that bronchiectasis develops late in the course of infection (De SCID mice (Byrd and Lyons, 1999; Howard et al., 2006).
Groote et al., 2014). In spite of the current lack of an ideal model, These latter findings raise the question of the significance
a pattern of bacterial – host interaction is beginning to emerge of the slight loss of replicative ability in the eccB4 deletion
based on clinical and experimental evidence to date. mutant. The question of the effect of expression of the genes
At the cellular level, important differences have been reported of the ESX-4 type VII type secretion system by the more
regarding the intracellular life cycle of MABS smooth and rough virulent rough MABS phenotype is unexplored although as
variants. Since both variants replicate in tissue culture medium noted, another study did not report phagosome disruption but
assessing growth in macrophages requires extensive washing rather trafficking of rough variants through the autophagic
after infection, incubation with amikacin to kill extracellular pathway ending up in phagolysosomes where they replicate
bacteria and then removal of amikacin followed by lysis of and rapidly induce apoptosis (Roux et al., 2016). It remains
macrophages and plating lysates for bacterial CFU. Using this unclear why rough variants, which are able to arise from the
model, rough variants replicate intracellularly resulting in lysis of smooth variant used in this study (Ripoll et al., 2009), would
cell monolayers whereas smooth variants persist and/or decline not also rupture the phagosome. Finally, as would be expected
within cells, but do not destroy cell monolayers in the time frames for an intracellular pathogen establishing cytosolic contact and
studied in these experiments (Byrd and Lyons, 1999; Howard activating the inflammasome, this study found that IL1β release
et al., 2006; Greendyke and Byrd, 2008; Nessar et al., 2011). was increased by cells infected with wild type bacteria. There was
Recent studies have demonstrated differences in intracellular a significant decrease in IL1β release from cells infected with the
behavior comparing smooth and rough variants which may eccB4 deletion mutant. Since inflammasome activation results in
account for these findings. Smooth variants have been found to cell death via pyroptosis (Sharma and Kanneganti, 2016), and
reside in phagosomes in which they are surrounded by electron human macrophage monolayers infected with MABS smooth
translucent zone representing cell wall GPL. They are typically variants typically remain intact and viable throughout the course
present as a single organism which is likely due to the fact that of infection, this discrepancy remains unexplained. It may be that
they are easily dispersed into single cell suspensions prior to GPL-mediated inhibition of macrophage apoptosis counteracts
infecting cells. In contrast, rough variants clump in a manner the effect of inflammasome activation (Whang et al., 2017).
similar to M. tuberculosis and are difficult to get into single One important function of GPL is that it prevents bacteria
cells suspension, thus they are usually present as two or more to bacteria interaction of underlying surface molecules such
bacteria per phagosome (Byrd and Lyons, 1999; Roux et al., as trehalose polyphleates which may play a role in the
2016). Consistent with the lack of destruction of macrophage cording exhibited by rough variants (Llorens-Fons et al., 2017).
monolayers infected with smooth variants (Nessar et al., 2011) is With loss of GPL, rough variants taken up by macrophages
the finding that smooth variants are poor inducers of apoptosis rapidly induce apoptosis (Roux et al., 2016) and demonstrate
and autophagy in contrast to rough variants which end up rapid cell–cell spread via serpentine cord formation (Byrd
in phagolysosomes but nonetheless replicate intracellularly and and Lyons, 1999). The fact that serpentine cording is an
induce apoptosis (Roux et al., 2016). In fact, uptake of large important virulence determinant of rough MABS strains was
clumps of MABS rough variants leads to rapid dissolution of demonstrated using a rough deletion mutant lacking a gene
macrophages and emergence of MABS cords (Brambilla et al., coding for a dehydratase necessary for cord formation. This
2016). There is evidence that smooth variants cause disruption of mutant was found to be markedly attenuated for virulence in
the phagosomal membrane allowing for direct cytosolic contact the zebrafish model (Halloum et al., 2016). A comparison of the
(Roux et al., 2016). Thus, as a mechanism of apoptosis inhibition, behavior of MABS rough and smooth variants to the virulent
polar GPLs found on the surface of MABS smooth variants M. tuberculosis strains H37Rv/Erdman, and the avirulent strain
(Lopez-Marin et al., 1994; Howard et al., 2006) have access to H37Ra shows similar behavior in a fibroblast microcolony assay
cytosolic contents and have been demonstrated to interact with which we described (Byrd et al., 1998; Byrd and Lyons, 1999).
mitochondrial cyclophilin D, a component of the mitochondrial The differences relate to the addition of extracellular acting
permeability transition pore (MPTP) to stabilize the pore and aminoglycoside antibiotics. Both the MABS rough variant and
inhibit apoptosis (Whang et al., 2017). H37Rv/Erdman demonstrate elongated, corded microcolonies
MABS has an ESX-4 type VII secretion system encoded within the plane of the agar-overlaid monolayers, while the MABS
for by five genes. A gene in this locus, eccB4 was found to smooth variant and H37Ra demonstrate significantly smaller,
be necessary for low level replication (approximately 0.5 log rounded microcolony morphology. Importantly, the addition
over 5 days), but not persistence, of the smooth MABS of streptomycin does not prevent formation of H37Rv/Erdman
subspecies massiliense 43S strain in Acanthamoeba castellani microcolonies, presumably due to a mechanism of direct cell–
and J774.2 mouse macrophages. This gene was also found to cell spread wherein M. tuberculosis avoids exposure to the
be necessary for prevention of phagosome acidification and extracellular environment. In contrast, addition of amikacin to

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Ryan and Byrd Mycobacterium abscessus: Shapeshifter

fibroblast monolayers infected with the MABS rough variant importance of IFNγ in control of MABS infection is highlighted
prevents the formation of corded microcolonies. This suggests in a recent case-control study from Thailand in which MABS
that M. tuberculosis is host adapted to favor replication within was found to be the most common NTM clinical isolate, and
the intracellular environment while MABS may be viewed as an the presence of anti-IFNγ autoantibody was strongly associated
environmental saprophyte that has not quite made the transition with disseminated infection (Phoompoung et al., 2017). Since
to an intracellular lifestyle. defects in cell-mediated immunity have not been identified in the
In spite of the ability to replicate extracellularly and form majority of non-CF patients with chronic MABS lung infection,
microabscesses in the zebrafish model of infection, MABS it remains unclear why patients with underlying lung airway
pulmonary infection does not occur in immunocompetent abnormalities such as bronchiectasis are uniquely susceptible to
humans (or mice) with normal lung airways. Why this is so infection, and why an effective cell-mediated immune response
is a central question in terms of MABS pathogenesis. TLR2 does not develop in response to pulmonary infection.
has been found to be important in innate immune recognition
and signaling in response to MABS. PIMs exposed on the
surface of rough variants interact directly with TLR2 on human A LIMITED ANTIMICROBIAL
macrophages and epithelial cells to promote release of TNFα ARMAMENTARIUM
and IL-8, respectively, whereas PIMs are “masked” by GPL
on the surface of smooth variants which are not recognized In spite of its low virulence compared to pathogens such as
by TLR2 (Rhoades et al., 2009; Davidson et al., 2011). Both M. tuberculosis, MABS infection of the lung is the most difficult
TNFα and IL-8 have both been found to be important for NTM to treat, resembling multi-drug resistant tuberculosis.
control of infection by MABS rough variants in the zebrafish Numerous resistance mechanisms in MABS have been identified
model of infection (Bernut et al., 2016a). On the other hand, that limit the number of available antibiotics in comparison
human neutrophils have been found to be less effective at killing to infections caused by other NTM (Brown-Elliott et al.,
MABS than killing S. aureus, and dead and dying neutrophils 2012; Nessar et al., 2012; Luthra et al., 2018). Of the limited
have been found to enhance biofilm formation by smooth antibiotics used to treat MABS infection most are bacteriostatic
variants (Malcolm et al., 2013). Thus in abnormal lung airways and not bactericidal for both intra- and extracellular bacteria
with impaired mucociliary clearance and MABS smooth variant in vitro (Greendyke and Byrd, 2008; Maurer et al., 2014). MABS
biofilm formation, ongoing inflammation with IL-8 mediated biofilm formation has been described for GPL-expressing smooth
neutrophil recruitment may promote biofilm persistence. This variants, and biofilm consisting primarily of smooth variants
may have particular relevance in patients with CF who are has been found in the lung airways of explanted lungs from
often co-infected with multiple pulmonary pathogens and in CF patients prior to lung transplantation (Qvist et al., 2015).
whom chronic lung airway inflammation dominated by the Under certain in vitro culture conditions MABS rough variants
presence of neutrophils is felt to be central to disease pathogenesis grow as biofilms as well (Clary et al., 2018). Biofilms formed by
(Cantin et al., 2015). Another aspect of the innate immune both smooth and rough MABS variants are relatively resistant
response relates to single nucleotide polymorphisms (SNPs) that to antibiotics when compared to planktonic bacteria (Greendyke
alter host responses to infectious agents. TLR2 signaling in and Byrd, 2008; Clary et al., 2018). The bacteriostatic activity
response to mycobacterial lipopeptides depends upon formation of currently used antibiotics against intracellular MABS, and the
of TLR2/TLR1 heterodimers at the cell surface. SNPs that alter relative antibiotic resistance of MABS biofilms in abnormal lung
the function of either TLR2 and/or TLR1 may thus affect airways make eradication of MABS from the lung extremely
innate immune responses to mycobacteria. We have reported difficult.
that a well described SNP, TLR1 SNP I602S, is present in the Of the antibiotics used to treat MABS infection, macrolides
respiratory epithelial cell line CFBE41o-, which was derived are felt to be the cornerstone of therapy. Importantly, there are
from the bronchus of a patient with CF and immortalized with differences in macrolide susceptibility among the different MABS
SV40. This cell line is hyporesponsive to TLR2/TLR1 receptor subspecies based on the presence and functional status of the
agonist and the rough MABS 390R strain. This SNP is likely erythromycin ribosomal methylation gene 41 (erm41). The erm41
to be present in the CF patient population (Kempaiah et al., gene encodes for an enzyme that confers intrinsic, inducible
2013). Paradoxically the presence of this SNP is protective against resistance in MABS (Nash et al., 2009). In MABS strains with
infection with Mycobacterium leprae (Johnson et al., 2007). An a functional erm41 gene, clarithromycin may initially appear to
unanswered question is how the presence of this SNP affects be active; however, resistance may develop in the time frame of
susceptibility to NTM infection in both CF and non-CF patients. 3–14 days, the Clinical and Laboratory Standard Institute (CLSI)
In terms of the cell-mediated immune response, as would recommendation for length of incubation (Nash et al., 2009; Koh
be predicted, anti-TNFα inhibitor therapy has been associated et al., 2011; CLSI, 2011). PCR is now being used to identify MABS
with disseminated NTM infection, including MABS (Winthrop subspecies and erm41 gene status (Shallom et al., 2015).
et al., 2009). Th1 CD4+ T cell responses are also important for Broth microdilution with determination of minimum
control of infection with NTM. It is established that patients with inhibitory concentration (MIC) is recommended as the gold
advanced HIV and low CD4+ T cell counts are susceptible to standard for NTM antibiotic susceptibility testing. Due to
infection with MAC, and cases of disseminated MABS infection the relative rarity of MABS infections in the past, correlating
have been reported in these patients as well (Tan et al., 2010). The in vitro modeling and susceptibility testing with effective clinical

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Ryan and Byrd Mycobacterium abscessus: Shapeshifter

response has been limited. In fact, tigecycline, a glycine antibiotic and Wallace, 2017). Importantly, tedizolid has a lower incidence
commonly used in treatment of MABS infection, currently lacks of side-effects and drug interactions as compared to linezolid
MIC interpretation from CLSI (Brown-Elliott et al., 2012). When (Burdette and Trotman, 2015). There is little data on long-
MABS infection involves sites such as the CNS and bone, it is term use of tedizolid that has been reported, but overall it
important to consider pharmacokinetic properties to maximize appears to be well tolerated (Nigo et al., 2018). The second
antibiotics exposure at the target site (Landersdorfer et al., 2009; antibiotic is avibactam, a non-β-lactam β-lactamase inhibitor
Nau et al., 2010). Dosing regimens should be individualized to commercially available as a coformulation with ceftazidime,
maximize drug exposure at the target site while limiting potential which can inactivate the MABS β-lactmase Blamab . When
side-effects. The use of inhaled aminoglycosides for pulmonary avibactam is combined with β-lactams, this combination may
MABS infection is one strategy to maximize the concentration have enhanced activity for the treatment of MABS infection
at the active site while decreasing the likelihood of side-effects. (Kaushik et al., 2017; Le Run et al., 2018).
Several small trials of inhaled amikacin for the treatment of
NTM, specifically MABS and MAC, have had positive results
including negative culture conversion and improvement seen on FUTURE DIRECTIONS
lung imaging (Olivier et al., 2014; Yagi et al., 2017). Even though
serum concentrations are lower with inhaled amikacin it is not Mycobacterium abscessus (MABS) has emerged as a significant
completely without risk. In one study, ototoxicity occurred at infectious disease threat and warrants the designation of
a relatively high rate (Olivier et al., 2014). Inhaled liposomal “shapeshifter of the mycobacterial world.” Its ability to exist as
amikacin may be a further advancement in localized therapy for a GPL-expressing environmental saprophyte forming biofilms
MABS. The liposome capsule penetrates biofilms and is also taken along with the ability to “unmask” itself within the human host
up by macrophages within the lung, thus delivering amikacin and display virulence properties such as serpentine cording is
directly to the site of infection (Zhang et al., 2018). It should unprecedented for a bacterial pathogen. The ability of evolving
be noted that a Phase 2 trial of inhaled liposomal amikacin clones to spread among clinical environments foreshadows an
in addition to standard therapy failed to meet its primary increasing incidence of nosocomial infections. The fact that many
endpoint for both MABS and MAC but did show improvement strains are multidrug resistant and that the MABS subspecies
in culture clearance and 6-minute walk test (Olivier et al., differ in terms of their inherent antimicrobial susceptibility
2017). Inhaled liposomal amikacin has recently been approved creates an enormous challenge, particularly since patients often
in the United States for the treatment of refractory MAC require months of therapy to achieve cure. There is an urgent
following a Phase 3 trial that demonstrated an increase in sputum need for better models that mimic human pulmonary infection to
clearance at 6 months (Griffith et al., 2018). More data about better understand disease pathogenesis and test new compounds
the use specifically in MABS is still needed. It is apparent that for antimicrobial activity.
development of new drugs specifically targeting MABS infection
should be a high priority and drug discovery efforts are underway
utilizing novel high throughput screening platforms (Gupta AUTHOR CONTRIBUTIONS
et al., 2017). There are currently two new antibiotics designed
and approved for alternative infectious indications which may KR contributed ideas and expertise, and drafted the section
add to the MABS antimicrobial armamentarium and are worth related to antimicrobial therapy. TFB conceived and wrote the
mentioning. The first antibiotic is an FDA-approved agent final manuscript.
named tedizolid. Compared to the related antibiotic linezolid
which is generally active against MABS, tedizolid has a higher
ribosomal binding affinity that allows for lower effective serum FUNDING
concentration and once daily dosing (Burdette and Trotman,
2015). In vitro testing of NTM isolates shows promise as MIC Ongoing work in the TFB laboratory is supported by the National
values are 1–8 times lower than that of linezolid (Brown-Elliott Institutes of Health (NIH) grant AI137633.

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Tan, C. K., Lai, C. C., Liao, C. H., Chou, C. H., Hsu, H. L., Huang, Y. T., et al. Conflict of Interest Statement: The authors declare that the research was
(2010). Mycobacterial bacteraemia in patients infected and not infected with conducted in the absence of any commercial or financial relationships that could
human immunodeficiency virus, Taiwan. Clin. Microbiol. Infect. 16, 627–630. be construed as a potential conflict of interest.
doi: 10.1111/j.1469-0691.2009.02939.x
Tan, J. L., Ng, K. P., Ong, C. S., and Ngeow, Y. F. (2017). Genomic comparisons Copyright © 2018 Ryan and Byrd. This is an open-access article distributed under the
reveal microevolutionary differences in Mycobacterium abscessus subspecies. terms of the Creative Commons Attribution License (CC BY). The use, distribution
Front. Microbiol. 8:2042. doi: 10.3389/fmicb.2017.02042 or reproduction in other forums is permitted, provided the original author(s) and
Thomson, R. M., Armstrong, J. G., and Looke, D. F. (2007). Gastroesophageal the copyright owner(s) are credited and that the original publication in this journal
reflux disease, acid suppression, and Mycobacterium avium complex pulmonary is cited, in accordance with accepted academic practice. No use, distribution or
disease. Chest 131, 1166–1172. doi: 10.1378/chest.06-1906 reproduction is permitted which does not comply with these terms.

Frontiers in Microbiology | www.frontiersin.org 10 November 2018 | Volume 9 | Article 2642