Open access peer-reviewed chapter

Genetic Variation in Pattern-Recognition Receptors and Association with Leprosy

Written By

Karina Talita de Oliveira Santana Jorge and Frederico Marianetti Soriani

Submitted: October 23rd, 2017 Reviewed: January 12th, 2018 Published: February 22nd, 2018

DOI: 10.5772/intechopen.73871

Chapter metrics overview

945 Chapter Downloads

View Full Metrics


Mycobacterium leprae is a highly infectious and low pathogenic microorganism that is the causal agent of leprosy. The differences in vulnerability to leprosy, the spectral immune response, and the clinical manifestations of this disease are related to different genetic backgrounds among individuals. In this sense, genetic variants, especially in genes related to mycobacteria recognition and host immune response, may be key factors to explain individual susceptibility and resistance to leprosy and their conditions. In this chapter, studies regarding association of genetic variants in pattern-recognition receptors (PRRs) and leprosy will be reviewed revealing the importance of molecules such as Toll-like receptors (TLRs) and nucleotide-binding oligomerization domain-containing protein 2 (NOD2) in leprosy initiation and maintenance.


  • polymorphisms
  • pattern-recognition receptors
  • mycobacterium leprae
  • leprosy

1. Introduction

Leprosy is caused by Mycobacterium leprae, which is an intracellular bacterium with high infectivity and low pathogenicity. It means that there are a large number of people exposed to this pathogen; however, the majority of them are naturally resistant. On the other hand, some people develop leprosy once challenged with M. leprae. The people who develop disease may present different clinical forms of leprosy. Some of them develop a localized disease, named tuberculoid leprosy, with a strong host response, which does not avoid development of nerve injury and physical disabilities. Some patients develop a more severe form of leprosy, named lepromatous leprosy, whereas other patients present intermediate and instable clinical forms (borderline tuberculoid, borderline borderline, and borderline lepromatous). Besides, there are different levels of susceptibility to leprosy reactions. The differences among M. lepraestrains are not sufficient to explain this variable outcome of leprosy. There is a variable spectrum of host immune response that depends on the genetic characteristics of the infected individual. The immunological and genetic basis underlying M. lepraeinfection remains largely unknown.

In this sense, several studies have been conducted aiming to explore the molecular basis of leprosy, and they are mainly focused on aspects of host-pathogen interaction and modulation of host immune response against M. leprae.

Recognition of M. lepraeby the host innate immune system is the first step in dealing with the invading bacteria and is crucial to initialize the adaptive immune response to infection. Microorganisms are recognized by host through germline-encoded pattern-recognition receptors (PRRs). The PRRs are able to sense highly conserved motifs from the invading microorganisms. These motifs are called pathogen-associated molecular patterns (PAMPs) [1].

One family of PRRs is the Toll-like receptors (TLRs) that are expressed on cell surface of different cells from innate immune system or endocytic vesicle membrane [2]. These receptors have an extracellular domain that recognizes different bacterial agonists. The activation of TLRs mediate host immune response regulating phagocytosis and antimicrobial activity or initiating signaling cascades (through activation of transcription factors NF-κB and IRF) culminating in modulation of cytokines and chemokines release [3].

There is another family of PRR, called nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) that are cytoplasmic receptors, and they are able to recognize bacterial agonists inside the host cells. Some members of this family activates NF-κB, interferon regulatory factors (IRFs), and mitogen-activated protein kinases (MAPKs), which control the expression of mediators of immune response, such as cytokines, chemokines, and type I interferons. On the other hand, other members lead to activation of caspase-1 acting through inflammasomes [4].

Genetic variants leading to functional changes in PRRs, such as TLRs and NLRs, may be involved with differences in host immune response modulation and consecutive susceptibility or resistance to leprosy and their clinical forms as well leprosy reactions.

In this chapter, studies about genetic association of PRRs, specifically TLRs and NOD2, with leprosy will be reviewed.


2. Genetic variations in toll-like receptors (TLRs)

TLRs were first described in the mid-1990s after genome sequencing of Drosophila melanogaster. Toll protein from D. melanogasterwas identified as an important molecule in initiating innate immune response in this organism in response to fungal infection and Gram-positive bacteria. This molecule was also described as important in embryonic dorsoventral patterning [5]. After this first description, proteins similar to Toll protein from D. melanogasterwere identified in mammalian cells, including humans, and they are referred as Toll-like receptors. TLRs are members of superfamily of interleukin receptors, and they act as PRRs recognizing PAMPs [6, 7].

The TLRs are also type 1 transmembrane receptors and may be expressed at cell surface or endocytic vesicle membrane. The receptors TLR1, TLR2, TLR4, TLR5, and TLR6 are expressed at cell surface, whereas TLR7, TLR8, and TLR9 are expressed at endosomes and lysosomes. TLR3 may be expressed either at cell surface and endosomes or lysosomes [2]. The intracellular TLRs recognize viral and bacterial nucleic acids [8].

There are ten human TLRs already described (TLR1–TLR10), and they recognize different kinds of ligands [2, 9]. TLR1, TLR2, and TLR6 are mainly stimulated by lipoproteins from Gram-positive bacteria; TLR2 also recognizes lipoteichoic acid (Gram-positive bacteria), zymosan, β-glucan from fungi, and GPI anchors; TLR3 recognizes dsRNA from viruses; TLR4 is activated by lipopolysaccharides (Gram-negative bacteria) and GPI anchors; TLR5 recognizes bacterial flagellin; TLR7 and TLR8 recognize ssRNA from viruses; TLR9 is activated by DNA; and ligands for TLR10 are still not known [10]. TLRs are also able to sense and signal tissue damage through recognition of damage-associated molecular pattern molecules (DAMPs) [11].

After recognition of ligands by the specific TLR, a dimerization of TLRs as homodimers or heterodimers may occur. Ligation of TLR and a ligand may also lead to conformational changes in dimers. The differential association in heterodimers causes a diversification in ligand recognition. For example, the heterodimer TLR1-TLR2 recognizes triacylated bacterial lipopeptides, whereas TLR2-TLR6 heterodimer recognizes diacylated lipopeptides [12, 13].

Dimerization and conformational changes will activate intracellular signaling cascade and innate immune response against the pathogen, produce acute inflammation, lead to modulation of adaptive immune response, and induce antimicrobial pathways [3, 12, 14].

The important roles played by TLR in recognizing PAMPs, especially PAMPs from M. lepraeand initiation of immune response, highlight its potential involvement with leprosy susceptibility and development. In the following sections, studies about association between polymorphisms in TLR1, TLR2, and TLR4 leprosy will be presented. The genetic association studies between TLRs and leprosy are summarized in Table 1. The other TLRs do not interact with M. lepraeor do not have genetic association with leprosy.

Table 1.

Association studies of genetic polymorphisms in TLRs and leprosy.

2.1. Genetic variations in TLR1

The heterodimer formed by TLR1 and TLR2 recognizes killed M. lepraethrough triacylated lipoproteins leading to cell activation. These two receptors are expressed in a higher level in localized tuberculoid form than in disseminated lepromatous form, evidencing the role of TLRs in host defense. Type-1 cytokines IFN-γ, GM-CSF, IL-12, and IL-18 stimulate TLR1 and TLR2 activation, while type-2 cytokines IL-4 and IL-10 impair its activation. Although TLR1 response is important to fight infection, exacerbated activation of TLR can lead to immunopathology, tissue damage, and, in the case of leprosy, nerve damage [15].

The involvement of TLR1 in leprosy has been highlighted by several association studies.

Some polymorphisms in TLR1 were studied in different populations revealing their association with conditions related to leprosy. One of them is the SNP rs5743618 (T/G I602S) which presents a variable frequency depending on the population. Hawn et al. (2007) showed that rs5743618 in TLR1is involved with the regulation of innate immune response to triacylated lipopeptides (ligands of TLR1/TLR2 heterodimer), and it is also related to the differential response to M. tuberculosisextract. The 602I variant was shown as able to induce an increased level of NF-κB signaling after induction by lipopeptides in a Vietnamese population. As expected, there is also an association with the cytokine profile as the 602I genotype presents a higher production of IL-6 in whole blood stimulated with lipopeptides supporting the role of TLR receptors in activating innate immune response against M. leprae[16]. In the same year, Johnson and coll. (2007) noted an association of this same SNP rs5743618 with surface trafficking of TLR1 and response of blood monocytes to bacterial ligands. More specifically, the variant 602S is associated with an impairment of TLR1 expression in cell surface leading to a loss of cellular responses. Corroborating these evidences, the variant 602S was shown to be a protective factor for leprosy [17]. Wong and coll. (2010) have analyzed the data from more than 1500 individuals from different studies and regions and identified TLR1and HLA-DRB1DQA1as the main genes related to leprosy susceptibility. Besides that, the protective variant 602S is rare in Africa but is the most frequent among European descendants, which suggests the selection pressure over this locus from mycobacteria [18].

Investigating the possible involvement of TLR1 with adaptive immune response affecting the clinical manifestations of leprosy, Misch and coll. (2008) evaluated rs5743618 polymorphism demonstrating a decrease of NF-κB activity related to the 1805G allele. In a Nepalese sample, the 1805G allele was protective against reversal reaction, which is characterized by an exacerbated Th1 cytokine response [19]. Another polymorphism able to interfere with TLR1 activity is rs4833095 (C/T N248S) as the 248 N variant impairs TLR1 functioning and sensing of microbial cell wall components [20]. In a Bangladeshi study, the homozygous 248SS genotype was associated with leprosy, but 248 N is homogeneously distributed among subjects. The 248 N allele is associated with erythema nodosum leprosum, while patients with reversal reaction are more likely to have the 248S allele [21]. These results were corroborated in a Brazilian sample, in which an association effect of 248S allele with leprosy susceptibility was found. In this same study, no association was identified between rs5743618 and leprosy diverging from previous results. However, rs4833095 was shown to be in a moderate linkage disequilibrium with rs5743618, suggesting a higher effect of the last one among Brazilians. The susceptibility allele 248S leads to a lower tumor necrosis factor (TNF)/IL-10 ratio after stimulation with M. leprae, and this same allele influences on TLR1 structure which may explain the functional alterations [22]. The association of 248S allele was not confirmed by Santana and coll. (2017) in another study with a Brazilian sample. However, they found association of rs4833095 with differential production of IL-17 and IL-12p40 [23]. These variations in TLR1 highlight the functional role of these genetic determinants in modulating the immune response during M. lepraeinfection.

2.2. Genetic variations in TLR2

TLR2 can form heterodimer with TLR1, as mentioned before, and with TLR6. These different forms of presentation allow TLR2 to recognize different cell wall components, such as lipopeptides, peptidoglycan, glycosylphosphatidylinositol-linked proteins, and zymosan [24].

TLR2 is responsible by recognition of cell wall fractions from M. lepraeand mediate proinflammatory signaling by stimulating TNF-α production in macrophages in a Toll-like receptor-dependent manner [25]. Moreover, TLR2 is able to stimulate NF-κB signaling and subsequent induction of inflammatory cytokines [26]. As described to TLR1, type-1 cytokines IFN-γ, GM-CSF, IL-12, and IL-18 lead to enhancement of TLR2 activation, and type-2 cytokines IL-4 and IL-10 inhibit activation of TLR2 [15]. TLR2 is also expressed at surface of Schwann cells. Recognition of lipoproteins from M. lepraeby TLR2 is required to stimulate apoptosis of these cells and may be related to nerve injury in leprosy [27].

In this way, variations in TLR2could be associated with a differential response against mycobacteria and be involved with individual susceptibility to leprosy. Looking for genetic variants in TLR2 in an association study about leprosy, Kang and coll. (2001) performed a screening in intracellular domain in leprosy patients. They detected the polymorphism rs121917864 (C/T R677W) in a conserved region of TLR2 present only in lepromatous patients, which suggests a role in susceptibility to this form of the disease [28]. After this, the same research group published a study demonstrating a role of rs121917864 in innate immune response activation, specifically the response by monocytes. Patients with the variant 677 W present a decrease in serum levels of IL-12 after stimulation with cell lysate of M. lepraecompared to the patients with no amino acid substitution confirming that TLR2 is involved with immune response against M. leprae[26]. Another study also showed the relation of TLR2 with innate immune response studying the polymorphism rs121917864. In this study, the M. leprae-dependent activation of NK-κB signaling was impaired with 677 W variant in response to cell wall fractions of M. lepraeand M. tuberculosis. These results allow to hypothesize that this variation in TLR2may be involved with the poor cellular immune response in leprosy patients [29]. The profiles of different cytokines are also affected by rs121917864 substitution. Peripheral blood mononuclear cells (PBMC) from lepromatous leprosy patients carrying this transition showed a lower level of expression of IL-2, IL-12, IFN-γ, and TNF-α after stimulation with M. leprae. On the other hand, levels of IL-10 increased, while there is no change in IL-4 production. This alteration in cytokines profiles in lepromatous patients can also be involved with a low level of cellular immune response in these patients during M. lepraeinfection [30]. Despite of what was shown in Korean population by Kang and coll. (2001), Malhotra and coll. (2005) did not identified the rs121917864 substitution in an Indian population. According to authors, rs121917864 is in fact a variation in a duplicated region 93% homologous located in exon 3 of TLR2. This duplicated region is a pseudogene [28, 31]. The rs121917864 polymorphism was also not identified in Japanese leprosy patients [32]. However, although such conflicting results may be related to the fact occurring in a duplicated region, these different results may also be explained by different genetic backgrounds among different populations.

Another important SNP in TLR2in the context of leprosy is the silent mutation rs3804099 (C/T N199 N). Santana and coll. (2017) found that the T allele is associated with an increased risk to leprosy and patients carrying this allele produce a high level of IL-17 and IL-6. In this same study, an intronic transition of SNP in TLR2rs7656411 (G3724 T) presented no association with leprosy in Brazilian population. However, individuals carrying G allele presented high levels of CXCL10 production [23]. Although no association of rs3804099 (C/T N199 N) with leprosy was found, Bochud and coll. (2008) have already demonstrated that T allele has a protective effect against reversal reaction [33].

In addition to SNPs, microsatellites are important polymorphisms that can be markers of disease susceptibility, and there are studies trying to identify microsatellites in TLR2and investigating their association with leprosy conditions. In an case-control study with leprosy patients from Ethiopia, a microsatellite upstream to TLR2start codon containing two variable nucleotide tandem repeats (VNTR) (CT and TG) is associated with leprosy reversal reaction which is mainly characterized by a Th1 immune profile [33]. TLRs are able to modulate the immune response inducing a Th1 or Th2 profile; in this way, changes in these receptors may lead to a differentiation in immune profile from patients and involve with development of leprosy reactions. The microsatellite characterized by GT repeats on intron II of TLR2 is associated with protection against leprosy with 13 repeats being related to resistance. On the other hand, longer GT repeats are associated with a decrease in TLR2expression and increase in IL-10 production being associated with leprosy susceptibility [34].

2.3. Genetic variations in TLR4

TLR4 has as main ligand LPS from Gram-negative bacteria. However, studies have already demonstrated that TLR4 also recognizes ligands from M. leprae[35, 36]. TLR4 acts through MyD88-dependent and MyD88-independent (TRIF) signaling [37, 38].

The association of polymorphisms in TLR4with leprosy susceptibility was investigated in some studies reinforcing the involvement of this gene in response against leprosy. Bochud and coll. (2009) identified two polymorphisms rs4986790 (G/A D299G) and rs4986791 (C/T T399I) with the minor alleles presenting a protective effect against leprosy in an Ethiopian population. Eventually, these variations may have a role in TLR4-induced effects in immune response against leprosy [39]. Polymorphism rs4986790 was also investigated in a population from Malawi revealing borderline association with leprosy. There is a increased frequence of heterozygosity in control group which is contradictory with another study that demonstrated that heterozygosity of rs4986790 was associated with hyporesponsiveness after LPS inhalation [40, 41]. However, the Malawi study was corroborated by a family-based and case-control study, in which the AA genotype was associated with leprosy susceptibility and GA genotype associated with leprosy protection in an Indian population [42]. Aiming to understand the effect of polymorphisms in TLR4 signaling, Figueroa and coll. (2012) compared cells of human embryonic kidney 293/CD14/MD2 complemented with wild-type TLR4and mutant variants. No differences in TLR4expression were identified after induction by LPS. However, the TLR4signaling was altered since MyD88 and TRIF recruitment were impaired with TLR4carrying the rs4986790 polymorphism. These results were also observed with polymorphism rs4986791, however, in a lesser extent [43].

Changes in non-translated regions of TLR4gene may also be able to induce changes in immune profile. The A > G substitution in an intergenic upstream region (rs1927914) and A > G substitution in an intronic region (rs1927911) were associated with both leprosy per se and leprosy reactions. Although rs1927911 induces no differences in cytokines and chemokines level of production, the allele A of rs1927914 is associated with a higher expression of IL-17 and IL-1β, which is highly produced in multibacillary leprosy patients [23].

2.4. Genetic variations in toll-interacting protein (TOLLIP)

The activity of TLRs must be under tight regulation to avoid an exacerbated response that would be harmful to the host. Toll-interacting protein (TOLLIP) is an adaptor protein which impairs the NF-κB and JNK signaling induced by TLR2 and TLR4, among other signaling pathways, playing a role in immune response regulation. TOLLIP is able to suppress IRAK-1 activity facilitating IL-1R/TLR-induced cell signaling during inflammation [44, 45]. After TLR2 stimulation, TOLLIP regulates the pro-inflammatory and anti-inflammatory balance by inhibiting IL-6 and TNF and stimulating IL-10 [46].

In this way, changes in TOLLIP activity may be related to leprosy susceptibility. In a Mexican population, the possible association of TOLLIP polymorphisms with leprosy susceptibility was analyzed. The following four polymorphisms were investigated in lepromatous leprosy patients and control individuals: promoter −526 C > G (rs5743854), silent mutation rs3750920 (C/T P139P), rs5744015 (C/A A222S), and 3’UTR rs3750919 (G/A). However, no association was identified between the cited polymorphisms and lepromatous leprosy, but a trend of protective association to lepromatous leprosy was identified in homozygous CC genotype of rs3750920 [44].

Six haplotype-tagging SNPs were also analyzed regarding association with leprosy in a population from Nepal. Among the tested SNPs, the intronic rs3793964 (C/T) exhibited association with leprosy being the TT genotype associated with leprosy susceptibility. Moreover, TT genotype and T allele were associated with increased expression of TOLLIP and IL-1Ra in the skin tissue. The study also demonstrates that TOLLIP induces IL-1Ra in monocytes that inhibit IL-1R activating helping M. lepraeto evade from host immune response in early stages of leprosy development [47].


3. Genetic variations in nucleotide-binding oligomerization domain-containing protein 2 (NOD2)

Nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) is a family of intracellular PRR that is able to recognize bacterial molecules. Humans have 23 different NLRs that present two characteristic domains: NOD and leucine-rich repeats (LRRs). The first one is required for oligomerization, while the second one is required for ligand binding. There are different subfamilies of NLRs [48]. Some NLRs activate the protease caspase-1, so they act through inflammasomes leading to pyroptosis. The inflammasome-related NLRs are NLRP1, NLRP3, NLRP6, NLRP7, NLRP12, NLRC4, and NAIP. However, other components of NLR family (NOD1, NOD2, NLRP10, NLRX1, NLRC5, and CIITA) act through activation of NF-κB, mitogen-activated protein kinases (MAPKs), and interferon regulatory factors (IRFs) leading to innate immune response stimulation [4].

There are some PAMPs exclusively recognized by NLRs, such as muramyl dipeptide (MDP) that is a constituent of peptidoglycan cell wall present in Gram-positive and Gram-negative bacteria [49]. M. leprae, in turn, presents a distinct MDP structure, and some studies have evidenced the role of NOD2 in recognizing M. lepraethrough MDP [50]. NOD2-mediated recognition of MDP from M. lepraeinduces bacterial killing activating NF-κB signaling cascade, production of IL-32, differentiation of dendritic cells, and autophagy [51, 52, 53].

Due to its role in immune response modulation, variations in NOD2gene is involved with different inflammatory diseases, such as Crohn’s disease [54], Blau’s syndrome [55], arthritis [56], and others. In this sense, several studies have investigated the association of NOD2genetic variants with leprosy susceptibility and leprosy reaction.

In a genome-wide association study from Zhang and coll. (2009) about susceptibility to leprosy in a Chinese population, variants in six genes of innate immune response were identified as associated with the disease (CCDC122, C13orf31, NOD2, TNFSF15, HLA-DR, and RIPK2). Specifically, in NOD2gene, two variants were identified in association with susceptibility to the disease: rs9302752 (A/G) and rs7194886 (G/A), being the first one with a stronger association with multibacillary leprosy. The two other evaluated SNPs in NOD2, rs8057341 (A/G) and rs3135499 (A/C), exhibited no association with leprosy in this study [57]. After this genome-wide association study, Grant and coll. (2012), in a family-based study, tried to validate in a Vietnamese population the genetic variants previously associated with leprosy in the Chinese study. They analyzed SNPs in HLA-DR-DQ, RIPK2, CCDC122-LACC1, and NOD2in leprosy patients and control individuals. Four polymorphisms were evaluated in NOD2: rs9302752, rs7194886, rs8057341, and rs3135499. The G risk allele for the variant rs9302752 was associated with leprosy, as identified in Chinese population. According to this Vietnamese study, some variants identified by Zhang and coll. may not directly associated with leprosy risk, but they are in linkage disequilibrium with another variants, which are the causal ones. This possibility could explain the divergent results found in different studies [57, 58].

In a subsequent study, Marcinek and coll. (2013) genotyped the variant rs9302752 but now in an Indian population. However, this variant was not in Hardy-Weinberg equilibrium in this population. Some other variants in genes involved in signaling pathways mediated by NOD2 were shown to be associated with leprosy in this study. One of them is the haplotype formed by rs40457 G and rs42490 A in RIPK2gene that together with NOD2is responsible for activate NF-κB signaling. This haplotype gives an increased risk to leprosy in individuals, whereas the haplotype AA has a protective role. In addition, the minor A allele of rs1873613 polymorphism in LRRK2is associated with paucibacillary leprosy progression [59].

Other conflicting results about genetic variants in NOD2and their relation with leprosy emerged in a Brazilian study from Marques and coll. (2014) [60]. In this study, authors aimed to validate the results found in the previous Chinese study regarding SNPs in four genes: CCDC122-LACC1, NOD2, TNFSF15, and RIPK2[57]. The A allele of variant rs8057341 in NOD2was associated with leprosy resistance in Brazilian population. This result is also different from that identified in Vietnamese study, in which rs8057341 has no association with leprosy. Other variants from NOD2, besides rs8057341 A, were related to leprosy protection being under-transmitted to the affected offspring in Brazilian population: rs2111234 G and rs3135499 C [58, 60]. These conflicting results may be, at least partially, related to different genetic backgrounds among different populations.

The previous study conducted by Zhang and coll. was realized in a Han Chinese population, which is the main ethnic group from China [57, 61]. A second study was realized in a Chinese population evaluating the genetic association of NOD2(C13orf31and CCDC122) with leprosy but now in a population from Yi ethnic group that represents a minority group. The following polymorphisms in NOD2were investigated: rs9302752, rs7194886, rs8057341, and rs3135499. Only the SNP rs3135499 was differentially distributed between leprosy patients and healthy control individuals [62]. This result is different from that found for rs9302752 by Zhang and coll., Marcinek and coll., and Grant and coll. and rs7194886 and rs8057431 by Zhang and coll. [57, 58, 59].

Even with some discrepant results, the cited studies agree in associate NOD2with leprosy, however, with different specific variants. These differences may be due to the influence of different ethnicities or linkage disequilibrium between different SNPs.

In addition to association with susceptibility to leprosy, variation in NOD2may be related to susceptibility to development of leprosy reactions. Leprosy reactions are acute inflammatory reactions that may occur before leprosy diagnosis, during the treatment or after the treatment. Some factors are able to initiate these reactions, like intercurrent infections, pregnancy, and physical and emotional stress, among others [63]. Leprosy reactions are classified into two main types: type 1—reversal reaction (RR) and type 2—erythema nodosum leprosum (ENL). RR occurs mainly in earlier stages of treatment but can also occur after the treatment, in borderline clinical forms. It is characterized by an exacerbated Th1 response. The patient with RR presents an exacerbation of preexisting lesions, which became edematous and erythematous and may develop ulceration. RR is the leading cause of nerve damage in leprosy and consequent physical disability [63, 64, 65]. ENL, in turn, mainly occurs in lepromatous and borderline lepromatous leprosy and may happen during treatment but is more frequent after the treatment. Patients present subcutaneous nodules that are painful and erythematous and also may be ulcerative. In this kind of reaction, immune complexes are related to their initiation, but cell-mediated immunity also plays a role in ENL. There is an increase in CD4+ T cells, TNF-α, and IFN-γ [63, 66, 67]. Several studies have already evidenced the possible functional mechanisms by which NOD2 plays a role during development of leprosy reactions by pro-inflammatory activities. The stimulation of Th1 and Th2 is one of these mechanisms [68, 69], as well as negative regulation of TLR2-mediated Th1 response [33, 70, 71].

Some of the previously mentioned polymorphisms in NOD2(rs7194886, rs9302752, and rs8057341), besides the additional rs751271 (G/T) and rs2066843 (C/T), were investigated for their association with leprosy inflammatory reactions in a Brazilian population. The variant rs751271 is associated with leprosy, being the genotype TT related to faster reaction development, whereas the genotype GT and G allele carriers are protection factors against leprosy reactions. The authors also suggest that rs751271-GT genotype produces lower levels of IL-6 in patients without reaction, so the hypothesis is that individuals with this genotype present a better balance in cytokine production which could be related to protection against leprosy reactions [72].

Polymorphism rs751271 were already investigated in a Nepal population regarding its association with reactive states of leprosy showing no association with type 1 reversal reaction (RR) neither with erythema nodosum leprosum (ENL). In this study, 32 polymorphisms in NOD2gene were evaluated. Four out of 32 polymorphisms were associated to leprosy susceptibility when the allele frequencies were compared between leprosy patients and healthy control: rs12448797, rs2287195, rs8044354, and rs1477176. When the genotype frequencies were compared, eight SNPs were associated with leprosy: rs2287185, rs8044354, rs8043770, rs13339578, rs4785225, rs751271, rs12448797, and rs1477176. The variants rs12448797 and rs1477176 are located in genes adjacent to NOD2, SL1C1, and CYLD, which are regions in linkage disequilibrium with NOD2that may influence the expression of SL1C1or CYLDand NOD2. Regarding to RR, five SNPs showed association of their allele frequencies (rs2287195, rs8044354, rs8043770, rs7194886, and rs1861759), and seven SNPs exhibited association of their genetic frequencies in a dominant model (rs2287195, rs8044354, rs8043770, rs7194886, rs1861759, rs4785225, and rs751271). Four SNPs were associated with ENL in an allelic level (rs8044354, rs17312836, rs1861758 and rs1861759), while seven SNPs at the genotypic level (rs2287195, rs8044354, rs7194886, rs6500328, rs17312836, rs1861759, and rs18611758) [73].

The association of polymorphisms in NOD2gene with leprosy reactions highlights the potential role of this gene in susceptibility and development of RR and ENL. The genetic association studies between NOD2 and leprosy are summarized in Table 2.

Table 2.

Association studies of genetic polymorphisms in NOD2 and leprosy.



This work received financial support by Fundação de Amparo à Pesquisa de Minas Gerais (FAPEMIG), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes).


  1. 1. Beutler B. Innate immunity: An overview. Molecular Immunology. 2004;40:845-859. DOI:
  2. 2. Noreen M, Arshad M. Association of TLR1, TLR2, TLR4, TLR6, and TIRAP polymorphisms with disease susceptibility. Immunologic Research. 2015;62:234-252. DOI: 10.1007/s12026-015-8640-6
  3. 3. Iwasaki A, Medzhitov R. Regulation of adaptive immunity by the innate immune system. Science. 2010;327:291-295. DOI: 10.1126/science.1183021
  4. 4. Zhong Y, Kinio A, Saleh M. Functions of NOD-like receptors in human diseases. Frontiers in Immunology. 2013;4:333. DOI: 10.3389/fimmu.2013.00333
  5. 5. Lemaitre B, Nicolas E, Michaut L, et al. The Dorsoventral regulatory gene cassette spä tzle/toll/cactus controls the potent antifungal response in drosophila adults. Cell. 1996;86:973-983. DOI: 10.1016/S0092-8674(00)80172-5
  6. 6. Lemaitre B. Landmark: The road to toll. Nature Reviews. Immunology. 2004;4:521-527. DOI: 10.1038/nri1390
  7. 7. Medzhitov R, Preston-Hurlburt P, Janeway CA. A human homologue of the drosophila toll protein signals activation of adaptive immunity. Nature. 1997;388:394-397. DOI: 10.1038/41131
  8. 8. Miggin SM, O’Neill LAJ. New insights into the regulation of TLR signaling. Journal of Leukocyte Biology. 2006;80:220-226. DOI: 10.1189/jlb.1105672
  9. 9. Lee CC, Avalos AM, Ploegh HL. Accessory molecules for toll-like receptors and their function. Nature Reviews. Immunology. 2012;12:168-179. DOI: 10.1038/nri3151
  10. 10. Bryant CE, Gay NJ, Heymans S, et al. Advances in toll-like receptor biology: Modes of activation by diverse stimuli. Critical Reviews in Biochemistry and Molecular Biology. 2015;50:359-379. DOI: 10.3109/10409238.2015.1033511
  11. 11. Piccinini AM, Midwood KS. DAMPening inflammation by modulating TLR signalling. Mediators of Inflammation. 2010;2010. DOI: 10.1155/2010/672395
  12. 12. Fleer A, Krediet TG. Innate immunity: Toll-like receptors and some more. Neonatology. 2007;92:145-157. DOI: 10.1159/000102054
  13. 13. Okusawa T, Fujita M, Nakamura J-I, et al. Relationship between structures and biological activities of mycoplasmal diacylated lipopeptides and their recognition by toll-like receptors 2 and 6. Infection and Immunity. 2004;72:1657-1665. DOI: 10.1128/IAI.72.3.1657-1665.2004
  14. 14. Thoma-Uszynski S, Stenger S, Takeuchi O, et al. Induction of direct antimicrobial activity through mammalian toll-like receptors. Science. 2001;291:1544-1547. DOI: 10.1126/science.291.5508.1544
  15. 15. Krutzik SR, Ochoa MT, Sieling PA, et al. Activation and regulation of toll-like receptors 2 and 1 in human leprosy. Nature Medicine. 2003;9:525-532. DOI: 10.1038/nm864
  16. 16. Hawn TR, Misch EA, Dunstan SJ, et al. A common human TLR1 polymorphism regulates the innate immune response to lipopeptides. European Journal of Immunology. 2007;37:2280-2289. DOI: 10.1002/eji.200737034
  17. 17. Johnson CM, Lyle EA, Omueti KO, et al. Cutting edge: A common polymorphism impairs cell surface trafficking and functional responses of TLR1 but protects against leprosy. Journal of Immunology. 2007;178:7520-7524. DOI:
  18. 18. Wong SH, Gochhait S, Malhotra D, et al. Leprosy and the adaptation of human toll-like receptor 1. PLoS Pathogens. 2010;6:e1000979. DOI: 10.1371/journal.ppat.1000979
  19. 19. Misch EA, Macdonald M, Ranjit C, et al. Human TLR1 deficiency is associated with impaired mycobacterial signaling and protection from leprosy reversal reaction. PLoS Neglected Tropical Diseases. 2008;2:e231. DOI: 10.1371/journal.pntd.0000231
  20. 20. Omueti KO, Mazur DJ, Thompson KS, et al. The polymorphism P315L of human toll-like receptor 1 impairs innate immune sensing of microbial cell wall components. Journal of Immunology. 2007;178:6387-6394. DOI: 10.4049/JIMMUNOL.178.10.6387
  21. 21. Schuring RP, Hamann L, Faber WR, et al. Polymorphism N248S in the human toll-like receptor 1 gene is related to leprosy and leprosy reactions. The Journal of Infectious Diseases. 2009;199:1816-1819. DOI: 10.1086/599121
  22. 22. De Sales Marques C, Brito-De-Souza VN, Guerreiro LTA, et al. Toll-like receptor 1 N248s single-nucleotide polymorphism is associated with leprosy risk and regulates immune activation during mycobacterial infection. The Journal of Infectious Diseases. 2013;208:120-129. DOI: 10.1093/infdis/jit133
  23. 23. Santana N de L, Rêgo JL, Oliveira JM, et al. Polymorphisms in genes TLR1, 2 and 4 are associated with differential cytokine and chemokine serum production in patients with leprosy. Memórias do Instituto Oswaldo Cruz. 2017;112:260-268. DOI: 10.1590/0074-02760160366
  24. 24. Skevaki C, Pararas M, Kostelidou K, et al. Single nucleotide polymorphisms of toll-like receptors and susceptibility to infectious diseases. Clinical and Experimental Immunology. 2015;180:165-177. DOI: 10.1111/cei.12578
  25. 25. Underhill DM, Ozinsky A, Smith KD, et al. Toll-like receptor-2 mediates mycobacteria-induced proinflammatory signaling in macrophages. Proceedings of the National Academy of Sciences of the United States of America. 1999;96:14459-14463
  26. 26. Kang TJ, Lee S-B, Chae G-T. A polymorphism in the toll-like receptor 2 is associated with Il-12 production from monocyte in Lepromatous leprosy. Cytokine. 2002;20:56-62. DOI: 10.1006/cyto.2002.1982
  27. 27. Oliveira R, Ochoa M, Sieling P. Expression of toll-like receptor 2 on human Schwann cells: A mechanism of nerve damage in leprosy. Infection and Immunity. 2003;71:1427-1433. DOI: 10.1128/IAI.71.3.1427
  28. 28. Kang TJ, Chae GT. Detection of toll-like receptor 2 (TLR2) mutation in the lepromatous leprosy patients. FEMS Immunology and Medical Microbiology. 2001;31:53-58. DOI: 10.1016/S0928-8244(01)00239-5
  29. 29. Bochud P-Y, Hawn TR, Aderem A. Cutting edge: A toll-like receptor 2 polymorphism that is associated with lepromatous leprosy is unable to mediate mycobacterial signaling. Journal of Immunology. 2003;170:3451-3454. DOI: 10.4049/jimmunol.170.7.3451
  30. 30. Tae JK, Chung EY, Byoung CK, et al. Differential production of interleukin-10 and interleukin-12 in mononuclear cells from leprosy patients with a toll-like receptor 2 mutation. Immunology. 2004;112:674-680. DOI: 10.1111/j.1365-2567.2004.01926.x
  31. 31. Malhotra D, Relhan V, Reddy BSN, et al. TLR2 Arg677Trp polymorphism in leprosy: Revisited. Human Genetics. 2005;116:413-415. DOI: 10.1007/s00439-004-1249-9
  32. 32. Mikita N, Kanazawa N, Ozaki M, et al. No involvement of non-synonymous TLR2 polymorphisms in Japanese leprosy patients. Journal of Dermatological Science. 2009;54:48-49. DOI: 10.1016/j.jdermsci.2008.11.001
  33. 33. Bochud P, Hawn TR, Siddiqui MR, et al. Toll-like receptor 2 (TLR2) polymorphisms are associated with reversal reaction in leprosy. The Journal of Infectious Diseases. 2008;197:253-261. DOI: 10.1086/524688
  34. 34. Suryadevara NC, Neela VSK, Devalraju KP, et al. Influence of intron II microsatellite polymorphism in human toll-like receptor 2 gene in leprosy. Human Immunology. 2013;74:1034-1040. DOI: 10.1016/j.humimm.2013.04.009
  35. 35. Poltorak A, He X, Smirnova I, et al. Defective LPS signaling in C3H/HeJ and C57BL/10ScCr mice: Mutations in Tlr4 gene. Science. 1998;282:2085-2088. DOI: 10.1126/science.282.5396.2085
  36. 36. Polycarpou A, Holland MJ, Karageorgiou I, et al. Mycobacterium leprae activates toll-like Receptor-4 Signaling and expression on macrophages depending on previous bacillus Calmette-Guerin vaccination. Frontiers in Cellular and Infection Microbiology. 2016;6:72. DOI: 10.3389/fcimb.2016.00072
  37. 37. Hoebe K, Du X, Georgel P, et al. Identification of Lps2 as a key transducer of MyD88-independent TIR signalling. Nature. 2003;424:743-748. DOI: 10.1038/nature01889
  38. 38. Yamamoto M, Sato S, Hemmi H, et al. Role of adaptor TRIF in the MyD88-independent toll-like receptor Signaling pathway. Science. 2003;301:640-643. DOI: 10.1126/science.1087262
  39. 39. Bochud P-Y, Sinsimer D, Aderem A, Siddiqui MR, Saunderson P, Britton S, Abraham I, Tadesse Argaw A, Janer M, Hawn TR, Kaplan G. Polymorphisms in toll-like receptor 4 (TLR4) are associated with protection against leprosy. Journal of Clinical Microbiology & Infectious Diseases. 2009;28:1055-1065. DOI: 10.1007/s10096-009-0746-0
  40. 40. Fitness J, Floyd S, Warndorff DK, et al. Large-scale candidate gene study of leprosy susceptibility in the Karonga District of northern Malawi. The American Journal of Tropical Medicine and Hygiene. 2004;71:330-340. DOI:
  41. 41. Lorenz E, Mira JP, Frees KL, et al. Relevance of mutations in the TLR4 receptor in patients with gram-negative septic shock. Archives of Internal Medicine. 2002;162:1028-1032. DOI: 10.1001/archinte.162.9.1028
  42. 42. Suryadevara NC, Neela VSK, Kovvali S, et al. Genetic association of G896A polymorphism of TLR4 gene in leprosy through family-based and case-control study designs. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2013;107:777-782. DOI: 10.1093/trstmh/trt084
  43. 43. Figueroa L, Xiong Y, Song C, et al. The Asp299Gly polymorphism alters TLR4 Signaling by interfering with recruitment of MyD88 and TIR domain- containing adapter inducing IFN-β1. Journal of Immunology. 2012;188:4506-4515. DOI: 10.1002/ana.22528
  44. 44. Montoya-Buelna M, Fafutis-Morris M, Tovar-Cuevas AJ, et al. Role of toll-interacting protein gene polymorphisms in leprosy Mexican patients. BioMed Research International. 2013;2013:459169. DOI: 10.1155/2013/459169
  45. 45. Bulut Y, Faure E, Thomas L, et al. Cooperation of toll-like receptor 2 and 6 for cellular activation by soluble tuberculosis factor andBorrelia burgdorferiouter surface protein a lipoprotein: Role of toll-interacting protein and IL-1 receptor signaling molecules in toll-like receptor 2 signaling. Journal of Immunology. 2001;167:987-994. DOI:
  46. 46. Shah JA, Vary JC, Chau TTH, et al. Human TOLLIP regulates TLR2 and TLR4 Signaling and its polymorphisms are associated with susceptibility to tuberculosis. Journal of Immunology. 2012;189:1737-1746. DOI: 10.4049/jimmunol.1103541
  47. 47. Shah JA, Berrington WR, Vary JC, et al. Genetic variation in toll-interacting protein is associated with leprosy susceptibility and cutaneous expression of interleukin 1 receptor antagonist. The Journal of Infectious Diseases. 2016;213:1189-1197. DOI: 10.1093/infdis/jiv570
  48. 48. Inohara N, Chamaillard M, McDonald C, et al. NOD-LRR PROTEINS: Role in host-microbial interactions and inflammatory disease. Annual Review of Biochemistry. 2005;74:355-383. DOI: 10.1146/annurev.biochem.74.082803.133347
  49. 49. McDonald C, Inohara N, Nuñez G. Peptidoglycan Signaling in innate immunity and inflammatory disease. The Journal of Biological Chemistry. 2005;280:20177-20180. DOI: 10.1074/jbc.R500001200
  50. 50. Schenk M, Mahapatra S, Le P, et al. Human NOD2 recognizes structurally unique Muramyl dipeptides from mycobacterium leprae. Infection and Immunity. 2016;84:2429-2438. DOI: 10.1128/IAI.00334-16
  51. 51. Cooney R, Baker J, Brain O, et al. NOD2 stimulation induces autophagy in dendritic cells influencing bacterial handling and antigen presentation. Nature Medicine. 2010;16:90-97. DOI: 10.1038/nm.2069
  52. 52. Schenk M, Krutzik SR, Sieling PA, et al. NOD2 triggers an interleukin-32-dependent human dendritic cell program in leprosy. Nature Medicine. 2012;18:555-563. DOI: 10.1038/nm.2650
  53. 53. Chauhan S, Mandell MA, Deretic V. Mechanism of action of the tuberculosis and Crohn’s disease risk factor IRGM in autophagy. Autophagy. 2016;12:429-431. DOI: 10.1080/15548627.2015.1084457
  54. 54. Hugot J-P, Chamaillard M, Zouali H, et al. Association of NOD2 leucine-rich repeat variants with susceptibility to Crohn’s disease. Nature. 2001;411:599-603. DOI: 10.1038/35079107
  55. 55. Miceli-Richard C, Lesage S, Rybojad M, et al. CARD15 mutations in Blau syndrome. Nature Genetics. 2001;29:19-20. DOI: 10.1038/ng720
  56. 56. Vieira SM, Cunha TM, Franca RFO, et al. Joint NOD2/RIPK2 Signaling regulates IL-17 Axis and contributes to the development of experimental arthritis. Journal of Immunology. 2012;188:5116-5122. DOI: 10.4049/jimmunol.1004190
  57. 57. Zhang F-R, Huang W, Chen S-M, et al. Genome wide association study of leprosy. The New England Journal of Medicine. 2009;361:2609-2618. DOI: 10.1056/NEJMoa0903753
  58. 58. Grant AV, Alter A, Huong NT, et al. Crohn’s disease susceptibility genes are associated with leprosy in the Vietnamese population. The Journal of Infectious Diseases. 2012;206:1763-1767. DOI: 10.1093/infdis/jis588
  59. 59. Marcinek P, Jha AN, Shinde V, et al. LRRK2 and RIPK2 variants in the NOD 2-mediated Signaling pathway are associated with susceptibility to mycobacterium leprae in Indian populations. PLoS One. 2013;28:e73103. DOI: 10.1371/journal.pone.0073103
  60. 60. Sales-Marques C, Salomão H, Fava VM, et al. NOD2 and CCDC122-LACC1 genes are associated with leprosy susceptibility in Brazilians. Human Genetics. 2014;133:1525-1532. DOI: 10.1007/s00439-014-1502-9
  61. 61. Chen J, Zheng H, Bei J-X, et al. Genetic structure of the Han Chinese population revealed by genome-wide SNP variation. American Journal of Human Genetics. 2009;85:775-785. DOI: 10.1016/J.AJHG.2009.10.016
  62. 62. Xiong J-H, Mao C, Sha X-W, et al. Association between genetic variants inNOD2, C13orf31, andCCDC122genes and leprosy among the Chinese Yi population. International Journal of Dermatology. 2016;55:65-69. DOI: 10.1111/ijd.12981
  63. 63. Araújo MG. Hanseníase no Brasil. Revista da Sociedade Brasileira de Medicina Tropical. 2003;36:373-382. DOI: 10.1590/S0037-86822003000300010
  64. 64. Narayanan RB, Laal S, Sharmat AK, et al. Differences in predominant T cell phenotypes and distribution pattern in reactional lesions of tuberculoid and lepromatous leprosy. Clinical and Experimental Immunology. 1984;55:623-628
  65. 65. Goodless DR, Ramos-Caro FA, Flowers FP. Reactional states in Hansen’s disease: Practical aspects of emergency management. Southern Medical Journal. 1991;84:237-241
  66. 66. Kamath S, Vaccaro SA, Rea TH, et al. Recognizing and managing the immunologic reactions in leprosy. Journal of the American Academy of Dermatology. 2014;71:795-803. DOI: 10.1016/j.jaad.2014.03.034
  67. 67. Modlin RL, Gebhard JF, Taylor CR, et al. In situ characterization of T lymphocyte subsets in the reactional states of leprosy. Clinical and Experimental Immunology. 1983;53:17-24
  68. 68. Tada H, Aiba S, Shibata K-I, et al. Synergistic effect of Nod1 and Nod2 agonists with toll-like receptor agonists on human dendritic cells to generate interleukin-12 and T helper type 1 cells. Infection and Immunity. 2005;73:7967-7976. DOI: 10.1128/IAI.73.12.7967-7976.2005
  69. 69. Magalhaes JG, Fritz JH, Le Bourhis L, et al. Nod2-dependent Th2 polarization of antigen-specific immunity. Journal of Immunology. 2008;181:7925-7935. DOI: 10.4049/JIMMUNOL.181.11.7925
  70. 70. Yang Z, Fuss IJ, Watanabe T, et al. NOD2 transgenic mice exhibit enhanced MDP-mediated down-regulation of TLR2 responses and resistance to colitis induction. Gastroenterology. 2007;133:1510-1521. DOI: 10.1053/j.gastro.2007.07.025
  71. 71. Watanabe T, Kitani A, Murray PJ, et al. NOD2 is a negative regulator of toll-like receptor 2–mediated T helper type 1 responses. Nature Immunology. 2004;5:800-808. DOI: 10.1038/ni1092
  72. 72. Sales-Marques C, Cardoso CC, Alvarado-Arnez LE, et al. Genetic polymorphisms of the IL6 and NOD2 genes are risk factors for inflammatory reactions in leprosy. PLoS Neglected Tropical Diseases. 2017;11:e0005754. DOI: 10.1371/journal.pntd.0005754
  73. 73. Berrington WR, Macdonald M, Khadge S, et al. Common polymorphisms in the NOD2 gene region are associated with leprosy and its reactive states. The Journal of Infectious Diseases. 2010;201:1422-1435. DOI: 10.1086/651559

Written By

Karina Talita de Oliveira Santana Jorge and Frederico Marianetti Soriani

Submitted: October 23rd, 2017 Reviewed: January 12th, 2018 Published: February 22nd, 2018