Macrophage Cholesterol Homeostasis Underpins the role of Sertraline as an Adjunctive Agent in Tuberculosis Therapy

An intricate relationship exists between metabolism and the macrophage response in controlling intracellular pathogens such as Mycobacterium tuberculosis (Mtb). Here, we identify a deterministic role for macrophage cholesterol metabolism in the efficacy of anti-tubercular therapy (ATT). We that sertraline (SRT), an FDA-approved antidepressant, capable of enhancing tuberculosis treatment, rewires the macrophage lipid metabolism to potentiate Mtb clearance. Treatment with SRT leads to lysosomal cholesterol accumulation thereby activating the cholesterol-sensing transcription factor SREBP2 and increasing biosynthetic cholesterol flux in macrophages. In addition, this buildup of cholesterol induces lysosomal membrane permeabilization (LMP), mitochondrial ROS production, and downstream NLRP3 inflammasome activation, contributing to enhanced macrophage-mediated bacterial killing. Our results thus highlight a previously underappreciated link between cholesterol homeostasis and inflammasome activation, which contributes to improved Mtb clearance in the presence of adjunctive sertraline therapy.