The cell fate regulator NUPR1 is induced by Mycobacterium leprae via type I interferon in human leprosy

The initial interaction between a microbial pathogen and the host immune response influences the outcome of the battle between the host and the foreign invader. Leprosy, caused by the obligate intracellular pathogen Mycobacterium leprae, provides a model to study relevant human immune responses. Previous studies have adopted a targeted approach to investigate host response to M. leprae infection, focusing on the induction of specific molecules and pathways. By measuring the host transcriptome triggered by M. leprae infection of human macrophages, we were able to detect a host gene signature 24–48 hours after infection characterized by specific innate immune pathways involving the cell fate mechanisms autophagy and apoptosis. The top upstream regulator in the M. leprae-induced gene signature was NUPR1, which is found in the M. leprae-induced cell fate pathways. The induction of NUPR1 by M. leprae was dependent on the production of the type I interferon (IFN), IFN-β. Furthermore, NUPR1 mRNA and protein were upregulated in the skin lesions from patients with the multibacillary form of leprosy. Together, these data indicate that M. leprae induces a cell fate program which includes NUPR1 as part of the host response in the progressive form of leprosy.


Introduction
The causative agent of leprosy, Mycobacterium leprae was discovered by Armauer Hansen in 1873 and became the first bacterial pathogen to be associated with a human disease [1]. M. leprae is an intracellular pathogen that primarily infects macrophages and Schwann cells [2]. Although identified more than a century ago, it has not been possible to culture M. leprae in vitro, so bacilli are grown in the mouse foot pad and nine banded armadillos and then harvested for in vitro studies and animal experiments. Currently, there is no animal model that mimics the human disease spectrum, presenting a challenge to understand how distinct responses to the bacteria contribute to the pathogenesis of leprosy [3,4].
Leprosy provides an excellent model to study human pathways of host defense as well as mechanisms by which an intracellular bacterium evades antimicrobial responses and establishes chronic infection. The disease presents as a clinical spectrum, with the two poles mirroring opposite immune responses to the pathogen M. leprae [5]. At one end of the spectrum, tuberculoid leprosy (T-lep) represents a self-contained form of disease, with few lesions in which bacilli are rarely found. T-lep lesions are characterized by production of Th1-cytokine expression including type II interferon (IFN-γ), known to activate macrophages to kill intracellular mycobacteria [6][7][8]. At the other end of the spectrum, lepromatous leprosy (L-lep) represents the disseminated form of the disease, characterized by production of Th2-cytokines that promote antibody responses but inhibit cell-mediated immunity [6][7][8].
In addition to the presence of distinct T cell cytokine patterns in the different forms of leprosy, there is divergence of macrophage functional programs across the spectrum of disease that can play a role in determining the host's immune responses to the bacteria and the extent of leprosy neuropathy [7,9,10]. The ability of activated human macrophages to eliminate intracellular mycobacteria involves the induction of both vitamin D dependent and independent antimicrobial responses [11][12][13][14][15]. Activation of the vitamin D pathway leads to the induction of autophagy and antimicrobial peptides such as cathelicidin and β-defensin 2, culminating in the elimination of bacteria [6,7,[11][12][13]16]. The expression of these antimicrobial genes and the presence of cells undergoing autophagy is more prominent in T-lep than L-Lep lesions. By contrast, L-lep lesions are characterized by the accumulation of macrophages programmed to express scavenger receptors involved in phagocytosis, but lack expression of antimicrobial molecules [7]. M. leprae induces type I interferons and subsequently IL-10, all prominent in L-lep lesions. The result is inhibition of IFN-γ-and vitamin D-dependent antimicrobial responses in macrophages thereby contributing to bacterial persistence [8,17].
The incubation time after exposure to M. leprae infection is long, months to years, such that patients with leprosy are often diagnosed after they have been chronically infected. Therefore, it is difficult to investigate the initial events in which the bacterium interacts with the host's immune response, as is the case for M. tuberculosis [18]. Furthermore, the studies that have investigated the host macrophage response to M. leprae infection so far adopted a targeted approach, focusing on a group of molecules or pathways involved in response to infection [19][20][21]. Here we performed a host transcriptome analysis of M. leprae infected human monocyte-derived macrophages (MDMs) which we integrated with the transcriptomes of leprosy lesions in order to characterize the initial host-pathogen interactions that are relevant at the site of disease.

Ethics statement
Human peripheral blood was obtained from healthy donors with informed consent (UCLA Institutional Review Board #125. 15.0-f). Written informed consent was provided by all study participants.

Monocyte-derived macrophage experiments
Peripheral blood mononuclear cells (PBMCs) were isolated from peripheral blood using a Ficoll-hypaque (GE Healthcare) density gradient. MDMs were generated as previously described [15]. In brief, blood monocytes were isolated by CD14 + positive selection using CD14 Microbeads (Mylteni Biotec) according to the manufacturer's instructions. For monocyte differentiation into macrophages, CD14 + cells were cultured for 5 days in RPMI 1640 supplemented with 10% fetal calf serum (FCS) (Omega Scientific) and M-CSF (50 ng/ml) and maintained at 37˚C with 4% CO 2 . For RNA sequencing, MDMs were either uninfected and collected at 0h, or infected with M. leprae at a multiplicity of infection (MOI) of 10 for 1h, 2h, 24h and 48h. For uptake efficiency, 3 x 10 5 MDMs were uninfected or infected with PKH26-labeled M. leprae at MOI 10 for 24 hours. Cells were then either stained with DAPI and assessed via confocal microscopy or analyzed using Flow Cytometry. For neutralization experiments, MDMs were pre-treated with anti-IFNAR blocking antibody or Isotype control (10ug/ml) one hour prior to infection with M. leprae. In a separate experiment, MDMs were stimulated with different concentrations of human recombinant IFN-β (285u/ml) vs. IFN-γ (1.5ng/ml) for 2h, 6h and 24h. The IFN-γ data was previously published [15]. All experiments with live M. leprae were conducted at 33˚C with 4% CO 2 .

RNA sequencing
One and a half million MDMs from one healthy donor were infected with M. leprae at multiplicity of infection (MOI) of 10 in RPMI 1640 with 10% FCS. Cells were lysed at varying time points post-infection using RLT Buffer (Qiagen) supplemented with 1% β-mercaptoethanol. Samples were added to Lysing Matrix B tubes containing 0.1mm silica beads (MP Biomedicals) and sonicated in FastPrep-24 instrument (MP Biomedicals) for 2 cycles of 45 seconds at 6.5m/ s with one minute interval on ice. Total RNA was then isolated using RNeasy Micro kit (Qiagen) according to manufacturer's protocol and quantified by RiboQuantitation and Qubit. All samples had RNA integrity above 8.0 as determined by Bioanalyzer (Agilent Technologies). Depletion of ribosomal RNA and library preparation was performed using Ribozero Gold Epidemiology (Illumina) and TruSeq Sample Preparation Kit (Illumina) as per manufacturer's protocols. Final libraries were reassessed for quality (Qubit and Bioanalyzer), multiplexed at two samples per lane (10μM each library), and sequenced on a HiSeq 2000 sequencer (Illumina) generating 50bp single-end reads.

Bioinformatics analysis
Sequenced reads were demultiplexed and aligned to the human reference genome hg19 (UCSC) using TopHat (version 2.0.6) and Bowtie2 (version 2.0.2). Once raw counts were generated using HTSeq, data normalization was performed using the DESeq (version 1.5) Bioconductor package. Clustering was performed on genes after filtering according to DESeq normalized counts (> 2) in any one sample and variation between maximum and minimum expression values across samples (> 2). Genes were clustered with Cluster 3.0 using single linkage and Pearson correlation as similarity measure and heatmap was generated by TreeView.

Weighted gene network correlation analysis (WGCNA)
WGCNA was performed using the "WGCNA" R package as previously described [22]. In brief, genes were filtered first by excluding genes with 0 counts across all samples, then by calculating the overall sum of counts across all samples and removing genes in the lowest 40% quantile range. All samples were analyzed simultaneously. The function "blockwiseModules()" was used to construct signed hybrid, weighted correlation networks with a soft thresholding power of 10. Each time point was encoded as a binary vector that was one for a specific time point and zero for the other timepoints. A vector was also created for timepoint combinations including 1 + 2 hours as well as 24 + 48 hours. Module correlations were generated by coding traits (0h, 1h, 2h, 24h, 48h, 1+2h and 24+48h) as a binary matrix of zeros and ones: each sample had a value of '1' for its corresponding subtype and '0' for all other subtypes. The WGCNA built-in 'Heatmap' function was used to display the correlation and significance (p-value) of traits versus modules.

Functional gene annotation analysis
Two lists of curated genes of IFN-β -and IFN-γ specific downstream genes derived from RNA-seq data from stimulated MDMs were generated (GSE125352 and GSE82227). We identified IFN-β and IFN-γ specific downstream genes by first using a 3-fold change cutoff difference between the IFNs vs media and including the genes that were exclusively upregulated by each cytokine. Because IFN-β and IFN-γ can induce a common set of genes, we addressed gene specificity by applying a difference of 5-fold change expression between the two stimuli. We identified 438 IFN-β specific genes and 166 IFN-γ specific genes. Tuberculoid (T-lep) and Lepromatous (L-lep) leprosy genes were derived from microarray data using molecules with p<0.05, fold change>2 and probe intensity average>100 as previously described [8] (GSE17763). Canonical pathway, Disease & Functions and Upstream Regulator analyses were performed using Ingenuity Pathway Analysis (IPA-Qiagen). Gene ontology (GO) enrichment analysis was performed using Cytoscape (version 3.6.0) software with ClueGO (version 2.5.0) plugin [23]. The GO term database file (updated on January 6th, 2018) was used and the significance of each term was calculated with a right-sided hypergeometric test with the Benjamini-Hochberg correction of p-values. Significantly overrepresented terms were defined as having Benjamini-Hochberg corrected p-values less than 0.05.

Leprosy biopsy specimens and immunoperoxidase labeling
Skin biopsy specimens were collected from untreated patients at the Leprosy Clinic at the Oswaldo Cruz Foundation in Brazil as well as at the Hansen's Disease Clinic at Los Angeles Country and University of Southern California Medical Center. The diagnosis and classification of patients were determined based on clinical and histopathological criteria of Ridley and Jopling [5]. Cryosections (4μm) from skin lesions of T-lep and L-lep patients were incubated with normal horse serum followed by staining with anti-NUPR1, anti-CD3, or isotype control. Sections were subsequently incubated with biotinylated horse anti-mouse IgG, ABC Elite system, and AEC Peroxidase Substrate Kit (Vector Laboratories) and counterstained with hematoxylin prior to mounting in crystal mounting medium (Biomeda). NUPR1 and CD3 staining was visualized using a Leica microscope (Leica 250). NUPR1 staining was quantified using ImmunoRatio [24].

Live Mycobacterium leprae
Live M. leprae (unlabeled or labeled with PKH26) was graciously provided by Dr. Ramanuj Lahiri of the National Hansen's Disease Program, Health Resources Service Administration, Baton Rouge, Louisiana. M. leprae was grown in athymic (nu/nu) mouse foot pad as previously described [25].

Statistical analysis
Descriptive statistics were calculated for all continuous variables. Specifically, the mean ± the standard error of the mean (SEM) were reported for normally distributed data. Data distribution was graphically assessed by using quantile-quantile (Q-Q) plots. The repeated measures one way-ANOVA with Bonferroni's multiple comparisons test was used to evaluate differences among three or more groups that satisfied the normality assumption. The Geisser-Greenhouse correction was applied when the sphericity assumption was not met.
Repeated measures two-way ANOVA with Bonferroni's multiple comparisons test was performed to evaluate differences involving two variables among groups that satisfied the normality assumption. Comparisons between two independent groups with normal distribution were performed using the two-sample T-test when equal variance was assumed or the Welch's Ttest when unequal variances were observed. Enrichment analyses of the overlap between IFNs or leprosy lesion gene signatures and the M. leprae transcriptome were performed using the hypergeometric distribution to control for differences in the overall number of differentially expressed genes. The hypergeometric distribution (hypergeometric test) is equivalent to the one-tailed version of Fisher's exact test and determines the degree the observed amount of enrichment is greater than expected [26,27]. The fold change was calculated to display both over and under enrichment of the gene sets in the M. leprae gene induced signature as previously described [8]. The over enrichment fold change was calculated as number of Observed genes/number of Expected genes. However, in order to avoid plotting fold changes < 1, we calculated the under-enrichment fold changes as -1(number of Expected genes/number of Observed genes). All statistical analyses were performed using GraphPad Prism 7 software. All tests except the hypergeometric test were two-sided, and the level of statistical significance was set at 0.05.

Pathway Analysis of M. leprae-induced gene signatures in human MDMs
To investigate the effect of M. leprae on the innate immune response in human macrophages, we performed RNA sequencing (RNA-seq) on infected cells in vitro. Briefly, CD14 + monocytes were isolated from a single healthy donor and cultured with recombinant human M-CSF for five days to allow differentiation into macrophages (S1 Fig). The monocyte-derived macrophages (MDMs) were infected with M. leprae at a multiplicity of infection (MOI) of 10 for 1, 2, 24 and 48 hours, as we found consistent with previous studies [8,17]. This resulted in infection of over 85% of the cultured macrophages (S2 Fig). RNA was harvested at each time point, yielding five samples that were subsequently sequenced (S3 Fig). Gene clustering analysis identified a cluster of 4,214 genes detected at either 0h (uninfected), or 1 and 2 hours after infection. We also observed a cluster of 2,784 late response genes differentially expressed at 24 and 48h post-infection (Fig 1A), of which 2,107 were upregulated by >1.5-fold change (FC) (S1 Table). In order to determine the biological functions of this M. leprae induced gene signature, we performed Ingenuity Pathway Analysis using their curated database of canonical pathways. The most significantly enriched canonical pathways in the M. leprae induced gene signature were "Interferon Signaling" (-log 10 p-value = 8.78), "Antigen Presentation Pathway" (-log 10 p-value = 8.36), and "Th1 and Th2 activation pathway" (-log 10 p-value = 6.01 (Fig 1B; S2 Table). We noted that there was significant enrichment for cell fate pathways including "Death Receptor Signaling" (-log 10 p-value = 5.46) and "Autophagy" (-log 10 p-value = 4.57) in the M. leprae induced gene set. The "Death Receptor Signaling" pathway included CASP3, CASP7 and TRADD, which are involved in apoptosis, and the "Autophagy" pathway included the genes ATG13, ATG4D and ULK1, which play a role in autophagosome formation.
We also found enrichment of cell fate pathways in the M. leprae induced transcriptome using a second method, weighted gene correlation network analysis (WGCNA), which is an unbiased approach that defines modules of highly interconnected genes based on pairwise correlations using only the gene expression data without any identifiers [22]. The individual modules were next correlated with the expression data at specific time points after M. leprae infection, identifying six modules significantly associated with defined time points (p<0.05, correlation>0.8) (S4 Fig; S1 Table). 'GreenYellow' (1,627 genes) was the only module that correlated with the combined 24+48h vector (r = 0.99, p = 6x10 -4 ). We observed that 883 of the 1,627 genes in the 'GreenYellow' module were also upregulated in the M. leprae induced signature (enrichment p-value = 6.15E −611 ; Fold-change enrichment = 7.2) (S4 Fig). Ingenuity analysis of the 1,627 genes in this module identified similar canonical pathways as the M. leprae induced signature, despite the relatively small number of datasets used to generate the WGCNA [22] (S5 Fig, S2 Table). The canonical pathways identified in 'GreenYellow' included "Interferon Signaling" (-log 10 p-value = 7.8), "Antigen Presentation Pathway" (-log 10 p-value = 6.7), and "Autophagy" (-log 10 p-value = 2.98).

NUPR1 is a top upstream regulator of the M. leprae induced gene signature
We performed further investigation by Ingenuity Pathway Analysis to identify upstream regulators that could be driving the M. leprae-induced gene signature. We filtered this analysis based on FC>1.5 for expression of the upstream regulator gene in the M. leprae induced gene signature and included only the transcription and translational regulators, cytokines and enzymes categories of the IPA database. Nuclear protein 1 (NUPR1) was the most induced upstream regulator in the signature (Fold change = 45.9) (Fig 1C, S2 Table). Type I interferons The p-value is calculated by Fisher's Exact Test and measures the significant overlap between the dataset genes and the genes that belong to a canonical pathway, upstream regulator or the 'Disease and Function' categories in the IPA knowledge database. Adjusted p-values (padj) were calculated using Bonferroni correction. Ratios represent the number of genes in the dataset that appear in an IPA term divided by the total number of genes of the same term. Genes of the canonical pathway, upstream regulator or 'Disease and Functions' analyses were selected based on their functional relevance and displayed in boxes. # genes represent the exact number of molecules in our dataset regulated by an upstream regulator or found in the Disease and Functions categories.  Table). We noted that NUPR1 was present in all of these biological functional pathways, consistent with its known role in regulating cell fate.

M. leprae induction of NUPR1 is dependent on type I IFN signaling
Given that M. leprae infection of MDMs induced NUPR1 mRNA at 24h and 48h in the RNAseq data (Fig 2A), we further validated this finding by qPCR in eight additional donors. NUPR1 mRNA was upregulated by a mean log 10 fold change of 1.3 at 48h in MDMs postinfection compared to uninfected cells (Fig 2B).
Given that "Interferon Signaling" was identified in the M. leprae induced gene signature, we sought to determine whether this reflected a type I-and/or type II IFN response. Considering that expression of the genes encoding the type I and type II IFNs was not detected in the M. leprae induced gene signature, we utilized an integrative bioinformatics approach to attribute the relative contribution of the type I and type II IFNs to the M. leprae induced immune response. The genes with fold change >2 in the M. leprae induced gene signature were overlapped with curated lists of IFN-β-and IFN-γ specific downstream genes derived from RNA- seq data from interferon-stimulated MDMs (GSE125352 and GSE82227). We found an enrichment of IFN-β specific genes 3.53-fold higher than expected in the M. leprae induced gene signature (-log 10 p-value = 19.9), with 71 genes found in this overlap, including NUPR1 (Fig 3A-3D; S3 Table). By contrast, there were only four genes in common with the IFN-γspecific dataset, suggesting a predominance of type I IFN downstream genes, which is characteristic of chronic mycobacterial infections including tuberculosis and leprosy [8,28].
Although NUPR1 was identified as an IFN-β-specific gene in the M. leprae gene signature, it had not been previously shown that this gene is induced by type I IFNs. We assessed the ability of type I and type II IFNs to induce NUPR1 gene expression by mining the IFN-β-and IFN-γ-stimulated MDM RNA-seq data derived from five donors. NUPR1 mRNA was highly induced by IFN-β, increasing by a mean log 10 fold change of 2.73, but only modestly induced by IFN-γ (mean log 10 fold change = 0.42) (GSE125352 and GSE82227) (Fig 3E). These results were validated by qPCR in the same five donors, which confirmed that IFN-β strongly induced NUPR1 at 24h (Fig 3F).
To establish whether the induction of NUPR1 in MDMs by M. leprae infection involved type I IFN signaling, we first performed a dose titration in four additional donors. This analysis found that the ability of IFN-β to induce NUPR1 gene expression was dose dependent ( Fig  4A). As expected, IFN-β induction of NUPR1 in MDMs was effectively blocked by αIFNAR antibody (Fig 4B). Next, to evaluate if M. leprae induction of NUPR1 gene expression was dependent on IFN-β signaling, we incubated MDMs with αIFNAR antibody prior to infection and, in six donors, observed a drastic decrease in NUPR1 expression at 24 and 48h (Fig 4C and  4D). These data indicate that M. leprae induction of NUPR1 is dependent on the activity of type I IFN.  p-value = 12.1) and NUPR1 was identified in the overlap (Fig 5A, S3 Table, S6 Fig). NUPR1 gene expression was 2.7-fold greater in L-lep versus T-lep lesions in the microarray data ( Fig  5B) (GSE17763) [8]. We confirmed NUPR1 expression in leprosy lesions by qPCR of additional five T-lep and five L-lep samples and detected a 5.5-fold greater expression in L-lep vs. T-lep specimens (Fig 5C). Next, NUPR1 protein expression in leprosy skin lesions was evaluated by immunoperoxidase staining and concordantly, NUPR1 was more abundant in L-lep versus T-lep lesions (Fig 5D). In L-lep granulomas, NUPR1 was expressed in the nuclear, perinuclear and cytoplasmic compartments of large cells with an ovoid nucleus resembling The cell fate regulator NUPR1 is induced by Mycobacterium leprae infection macrophages. In contrast, CD3 was detected on the membrane of small round cells resembling lymphocytes in both L-lep and T-lep lesions. Using the online software ImmunoRatio [24], we quantified the overlap of NUPR1 immunoperoxidase staining with hematoxylin-stained nuclei and observed that~75% of cells in L-lep lesions were positive for NUPR1 versus~45% of cells in T-lep lesions (Fig 5E). These data suggest that NUPR1 is induced in the early stages of M. leprae infection as well as differentially expressed at the site of disease in lepromatous leprosy.

Discussion
Uncovering the initial events by which an intracellular bacterium interacts with the host immune response is essential for delineating pathways of host defense as well as strategies by which the pathogen evades or alters them to establish a chronic infection. Given that M. leprae is an obligate intracellular pathogen, we investigated the initial interaction between M. leprae and macrophages, using MDMs as an in vitro model and measuring the host transcriptome induced by M. leprae. Our data revealed that M. leprae induces a host gene signature at 24-48 hours after infection characterized by specific innate immune pathways involving cell fate mechanisms including autophagy and apoptosis. We observed that the most expressed upstream regulator in the M. leprae induced gene signature was NUPR1, which is part of the cell fate pathways, and demonstrated that its induction by M. leprae was dependent on the activity of type I IFN. The differential expression of NUPR1 in skin lesions from patients with multibacillary infection suggests an association between the induction of NUPR1 by M. leprae and a cell fate program that contributes to progressive mycobacterial infection in humans.
Functional pathway analyses of the M. leprae induced gene signature in MDMs revealed that NUPR1 was the highest induced upstream regulator of this gene set. Our bioinformatics analysis indicated that NUPR1 was part of an IFN-β-induced gene signature that overlapped with the M. leprae induced gene signature. Although we initially found that M. leprae infection of macrophages induced NUPR1 mRNA by transcriptome analysis, we validated this finding by RT-qPCR in additional donors. We provide novel evidence that IFN-β induced NUPR1 mRNA and determined that the ability of M. leprae to induce NUPR1 was dependent on the activation of the type I IFN receptor. Finally, the overexpression of NUPR1 in lesions from the progressive forms of leprosy was validated by RT-qPCR and immunohistochemistry in skin biopsy samples, consistent with the finding that IFN-β induced genes are significantly enriched in L-lep lesions [8]. The overexpression of type I IFN downstream genes has also been linked to the pathogenesis of active disease in tuberculosis [28]. In vitro studies have shown that mycobacterial infection can lead to release of mitochondrial and bacterial DNA, as well as generation of cyclic di-nucleotides that lead to activation of cyclic GMP-AMP Synthase (cGAS) and Stimulator of Interferon Genes (STING), culminating in the induction of type I IFN gene expression [29][30][31][32][33][34].
Analysis of the M. leprae induced macrophage transcriptome identified cell fate pathways involved in both autophagy and apoptosis. Both pathways represent host mechanisms to deal with cellular damage. Autophagy results in sequestration and degradation of damaged organelles and proteins towards cell preservation, whereas, apoptosis is a response to cell damage that results in programmed cell death. These pathways are generally cross-inhibitory, such that a given cell undergoes either autophagy or apoptosis, but in some instances, autophagy can induce apoptosis [35,36]. The two pathways can also collaborate to maintain tissue homeostasis, such that autophagy provides a mechanism for clearing apoptotic cellular debris [37]. In leprosy lesions, there is a greater frequency of cells undergoing autophagy as well as apoptosis in T-lep compared to L-lep patients [21,38,39]. Autophagy has an important role in controlling mycobacterial infection, required for the vitamin D induction of antimicrobial activity against mycobacteria [11,12,16,40,41], although one component of the autophagy machinery, autophagy protein 5 (ATG5), may contribute to host defense via an autophagy-independent pathway suggesting that other mechanisms may be involved [42]. Therefore, the induction of genes involved in both autophagy and apoptosis by M. leprae may represent a host response to kill the bacteria and clear damaged cells.
NUPR1 is a multifunctional protein capable of interacting with a great variety of molecules, and thus regulating several intracellular pathways involved in cell fate and stress responses [43]. IPA 'Disease & Function' annotation of the M. leprae induced signature showed that NUPR1 was involved in autophagy and cell death pathways. There is experimental evidence to suggest that NUPR1 contributes to the inhibition of autophagy and apoptosis [44][45][46][47][48], with recent studies showing that NUPR1 knockdown leads to induction of apoptosis [49][50][51][52]. However, information on the role of NUPR1 in these processes is conflicting and seem to be determined by the cell metabolic and environmental context [44][45][46][47][53][54][55][56][57]. Nevertheless, the expression of NUPR1 was greater in L-lep vs. T-lep lesions, inversely correlating with the reported frequency of autophagy and apoptosis [21,38,39]. Impairment of autophagic flux was observed in macrophages in multibacillary L-lep skin lesions [21] and M. leprae was shown to inhibit autophagy by the induction of OASL gene expression [58]. OASL is induced by type I IFN and contributes to the downregulation of the antimicrobial peptide cathelicidin [58]. Furthermore, some alleles of PARK2 gene, a ubiquitin ligase involved in ubiquitin-mediated autophagy of mycobacteria, are associated with leprosy susceptibility [59,60]. Apoptosis has also been detected more frequently in the T-lep skin lesions when compared to L-lep specimens [38,39,61], which can be associated with higher expression of the anti-apoptotic molecule BCL-2 in lepromatous skin lesions [39,61].
NUPR1 was found to be upregulated in the host response to infection by Histoplasma capsulatum [62] and detected as an upstream regulator in the host transcriptome associated with other fungal and bacterial infections [63][64][65]. Although our study was exploratory, it did result in novel findings: 1) We report for the first time that NUPR1 is expressed at the site of infectious disease; and, 2) We provide novel information about the mechanism of NUPR1 induction, demonstrating that it is induced by a human pathogen via the production of type I IFN and giving new insight into the link between NUPR1 and microbial infection. It remains to be determined how upregulation of NUPR1 affects the fate of M. leprae infected macrophages. The identification of such pathways that favors the survival and persistence of M. leprae within host cells [6,8,17,38,39,61] is needed to identify potential host-directed therapy targets to regulate cellular homeostasis as part of the host immune response against infection by M. leprae.