Methods for treating severe tuberculosis

Abstract

Methods for treating tuberculosis are provided.

Description

[0001] 00819.006WO1 / SCRI.563WO METHODS FOR TREATING SEVERE TUBERCULOSIS CROSS REFERENCE TO RELATED APPLICATION This application claims priority to United States Provisional Application Number 63 / 566,580, filed on 18 March 2024. The entire content of this United States Provisional Application is hereby incorporated by reference herein. STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH This invention was made with government support under 75N93019C00070 awarded by National Institutes of Health. The government has certain rights in the invention. BACKGROUND Tuberculosis (TB) remains the deadliest bacterial disease world-wide, with an estimated 10 million cases of active disease and 1.5 million deaths in 2020 (World Health Organization. Global tuberculosis report 2021. (World Health Organization, 2021)). The current vaccine, BCG, provides incomplete protection and treatment regimens extend for months and require multiple drugs with significant toxic side effects. Because of these limitations new host-directed therapies are urgently needed. Neutrophils trap and kill bacteria, in part, by forming neutrophil extracellular traps (NETs), through a process known as NETosis. During NETosis peptidyl-arginine deaminase 4 (PAD4) is transferred from the cytoplasm to the nucleus and catalyzes citrullination of histones, which leads to chromatin decondensation. Inhibiting the action of PAD4 has also been shown prevent NET formation (PMID 20733033). In humans, neutrophils are the predominant cell type infected with Mtb in the airway (PMID 19749004) and neutrophils are detected in inflammatory TB lesions (PMID 24047412). NETs have been identified in necrotic lesions of patients with non-resolving pulmonary TB (PMID 33149141). Currently there is a need for methods that are useful for trerating tuberculosis and, in particular, severe tuberculosis. SUMMARY In one embodiment, a method for treating tuberculosis in an animal, comprising inhibiting the formation of a neutrophil extracellular trap in the animal is provided. In one embodiment, a method for treating severe tuberculosis in an animal, comprising inhibiting the formation of a neutrophil extracellular trap in the animal is provided. 00819.006WO1 / SCRI.563WO In one embodiment, a compound that inhibits the formation of a neutrophil extracellular trap for the treatment of severe tuberculosis is provided. In one embodiment, the use of a compound that inhibits the formation of a neutrophil extracellular trap to prepare a medicament for the treatment of severe tuberculosis in an animal is provided. In one embodiment, a method comprising, inhibiting the formation of a neutrophil extracellular trap to treat severe tuberculosis is provided. In one embodiment, inhibiting the formation of a neutrophil extracellular trap for the treatment of severe tuberculosis is provided. BRIEF DESCRIPTION OF DRAWINGS Figure 1 shows a plot of bacterial burden measured by colony forming units (CFU) in wild-type (B6) or Apoe- / -mice on a high-cholesterol diet infected with the H37Rv strain of Mycobacterium tuberculosis (Mtb) for 28 days. Mice were either left untreated or treated daily with GSK484 starting at day 7 post-infection (PI). (Example 1) Figure 2 shows bacterial burden measured by CFU in B6 mice on standard chow diet infected with the H37Rv strain of Mycobacterium tuberculosis (Mtb) for 28 days. Mice were either left untreated or treated daily with GSK484 starting at day 7 post-infection (PI). (Example 1) Figure 3 shows data from Example 2. Apoe- / -HC mice were infected with about 50 CFU of H37Rv and treated with GSK484 or vehicle daily starting at either day 7 or day 14 PI. The fraction of mice surviving to day 40 is plotted. (n=5-6 mice / group). Figure 4 shows data from Example 3. C3H mice were infected with about 50 CFU Mtb SA161 and treated with GSK484 or vehicle daily starting at day 7 PI. Bacterial burden in the lung was measured by CFU at day 28 PI (n=6-7 mice / group). DETAILED DESCRIPTION The following definitions are used, unless otherwise described. As used herein, the term “severe tuberculosis” includes: pulmonary tuberculosis with cavitary lesions, necrotic granulomas, and / or alveolar hemorrhage; disseminated tuberculosis including TB meningitis and pericarditis; infection with any drug a resistant strain; tuberculosis in patients with a high bacterial burden at the time of diagnosis; and tuberculosis in patients with underlying pulmonary co-morbidities. 00819.006WO1 / SCRI.563WO As used herein, the term “high bacterial burden” includes patients whose sputum counts of acid-fast bacilli score 3+ on the International Union Against Tuberculosis and Long Disease (IUATLD) or WHO scales. Compounds that Inhibit Neutrophil Extracellular Trap Formation As used herein, a “compound that inhibits neutrophil extracellular trap formation” includes any agent that inhibits neutrophil extracellular trap formation in an animal. For example, compounds that inhibits neutrophil extracellular trap formation include: DNase I, sivelestat, PAD4 inhibitors, Cl-amidine, BB-Cl-amidine, GSK484, dipyridamole, hydroxychloroquine, statins, and metformin. Compounds that inhibit neutrophil extracellular trap formation also include the anti-NET compounds discussed in International Patent Application Publication Number WO2016 / 118476. In certain embodiments, the anti-NET compound is selected from the group consisting of: DNase; a histone-degrading enzyme; an inhibitor of chromatin decondensation; an antibody against a component of a NET; a protease inhibitor, an elastase inhibitor; and a PAD4 inhibitor. In certain embodiments, the PAD4 inhibitor is selected from the group consisting of: Cl-amidine and F-amidine. In certain embodiments, the inhibitors are selective PAD4 inhibitors that are reversible, e.g. including but not limited to GSK484 and GSK199 (Nat. Chem. Biology, in Press). In certain embodiments, the PAD4 inhibitor is a tetrazole analog, e.g., as described in Subramanian et al., Design, synthesis and biological evaluation of tetrazole analogs of Cl-amidine as protein arginine deiminase inhibitors J. Med. Chem., DOI: 10.1021 / jm501636x Publication Date (Web): January 5, 2015. In one embodiment the tetrazole analog is biphenyl tetrazole tert-butyl clamidine (BTT-Cl-amidine) that exhibits enhanced cell killing in a PAD4 expressing cells also blocks the formation of neutrophil extracellular trap. In certain embodiments, the PAD4 inhibitor is a peptidomimetic compound, e.g. including but not limited to 1,2,3-triazole peptidomimetic based derivatives incorporating beta-phenylalanine and guanidine scaffolds, e.g., as described in Trabocchi et al. Peptidomimetics as protein arginine deiminase 4 (PAD4) inhibitors, J. Enzyme Inhib. Med. Chem., early online 1-6 (2014): DOI: 10.3109 / 147563662014947976. See also Figure 13 therein that illustrates chemistry for 16 peptidomimetic PAD4 inhibitors as described in 00819.006WO1 / SCRI.563WO Trabocchi et al. Supra, e.g. 1,2,3-triazole peptidomimetic based derivatives. In certain embodiments, the anti-NET compound is an inhibitor of NET release from cells, e.g. Cl-amidine blocks NET release from NZM neutrophils in vitro, other inhibitors of NET release are known to those of skill in the art. In certain embodiments, the PAD4 inhibitor is BB-Cl-amidine (Knight et al. Peptidylarginine deiminase inhibition disrupts NET formation and protects against kidney, skin and vascular disease in lupus-prone MRL / lpr nn Rheum Dis doi:10.1136 / annrheumdis- 2014-205365, online August 2014). In certain embodiments, the PAD4 inhibitor is YW3-56, as described in Wang et al., (2012) J. Biol. Chem 287(31):25941-53. Compounds that inhibit neutrophil extracellular trap formation also include the PAD4 inhibitors discussed in United States Application Publication Number WO2021 / 0188810. For example, compounds that inhibit neutrophil extracellular trap formation include the compounds of formula (I): and salts described therein, wherein: Ring A is:

[0002] 00819.006WO1 / SCRI.563WO wherein: Ring A is optionally substituted with 1-4 groups selected from fluorine, -CN, -OR, and C1-6 aliphatic optionally substituted with 1-3 fluorine atoms; Ring B is a 5-6 membered heteroaryl ring having 1-3 heteroatoms independently selected from nitrogen, oxygen, and sulfur; R1is hydrogen, -Cy, or C1-6aliphatic optionally substituted with -Cy and optionally further substituted with 1-4 groups selected from fluorine, -CN, and -OR; each -Cy is independently a 6-membered aryl ring containing 0-2 nitrogen atoms, or a 4- 7 membered saturated monocyclic ring having 0-2 heteroatoms independently selected from nitrogen, oxygen and sulfur, wherein -Cy is optionally substituted with 1-4 groups selected from fluorine, -CN, and -OR; R² is hydrogen, -CN, -OR, -Cy, or C1-10aliphatic optionally substituted with -Cy and optionally further substituted with 1-5 groups selected from fluorine, CN, and -OR; or two R2groups on the same carbon atom are optionally taken together to form =O; n is 1, 2, or 3; X1is N or C(R3); R3is -R, halogen or -OR; each R is independently hydrogen or C1-6aliphatic optionally substituted with 1-3 fluorine atoms; 00819.006WO1 / SCRI.563WO L is selected from a covalent bond and a C1-6 membered straight or branched, saturated or unsaturated hydrocarbon chain wherein one methylene unit of L is optionally replaced by -S(O)2- or —C(O)N(Ry)—, wherein Ryis R or -CH2-phenyl; and R4is halogen, R, phenyl, or a 5-6 - membered heteroaryl ring having 1-3 heteroatoms independently selected from nitrogen, oxygen, and sulfur, wherein R4is optionally substituted with 1-4 groups independently selected from halogen, =CN, =OR, and C1-6aliphatic optionally substituted with 1-3 fluorine atoms. Compounds that inhibit neutrophil extracellular trap formation also include the PAD4 inhibitors discussed in International Patent Application Publication Number WO 2016 / 185279. For example, compounds that inhibit neutrophil extracellular trap formation include the compounds of formula (II): or a salt thereof, wherein: X is O or S; Y is N or CR2 R1is-H or -C1-6alkyl; R2 is -H, -OH, -C1-6alkyl, -O-C1-6alkyl, -CN, -halo, -C(=O)NH2, -C1-6haloalkyl, -O-C1- 6alkylO-C1-6alkyl, -O-C1-6alkyl-OH, -O-C1-6alkyl-C(=O)NH2, -O-C1-6alkyl-CN, -O-C1-6haloalkyl, -NH-C1-6alkyl, -N(C1-6alkyl)2or heteroaryl; R3 is -C1-6alkyl, -C1-6alkyl-NH2, or -C1-6alkyl-O-C1-6alkyl; R4is H, -C1-6alkyl, -C1-6haloalkyl, -C1-6alkyl-heteroaryl (wherein the heteroaryl group is optionally substituted by one, two or three C1-6alkyl groups), -C1-6alkyl-phenyl (wherein the phenyl group is optionally substituted by one, two or three substituents selected from the list consisting of halo, C1-6alkyl and-O-C1-6alkyl), -C1-6alkyl-heterocyclyl, -C1-6alkyl-C3.-6cycloalkyl, -C1-6alkyl-OH, -C1-6alkyl-CN or -C1-6alkyl-O-C1-6alkyl; R5is -H, -C1-6alkyl, -O-C1-6alkyl, -OH, -halo, or -CN; or R4 together with R5 are -(R4)-CH2CH2O-( R5)-, -(R4)-CH2CH2CH2O-( R5)- or -(R4)CH( Me)CH2O-( R5)-, wherein -(R4)- and-( R5)- denote the positions of attachment of the 00819.006WO1 / SCRI.563WO alkenyloxy chain to the respective ring atoms; R6is -H, -halo, -CN, -C1-6alkyl, -O-C1-6alkyl, or -OH; R7is -H, -halo, -CN, -C1-6alkyl, -O-C1-6alkyl, or -OH; R8 is -H, -F, or -C1-6alkyl; R9is-H or -C1-6alkyl; and R10is -H and R11is a 5-7 membered monocyclic saturated heterocycle (containing one nitrogen atom and optionally one oxygen atom) or a 7 membered bicyclic heterocycle (containing one nitrogen atom) or -CH2CH2NH2; or NR10R11 taken together form a 5-7 membered mono- or bi-cyclic saturated or unsaturated heterocycle containing one nitrogen atom, wherein the heterocycle is substituted by one, two or three substituents independently selected from the list consisting of -NH2, -C1-6alkyl-NH2, -NH-C1-6alkyl, -NHC(=NH)CH2Cl, -C1-6alkyl, -halo, -O-C1-6alkyl, -OH and -C(O)NH2. In one embodiment, the PAD4 inhibitor is GSK484: or a salt (e.g., the hydrochloride salt) thereof. In cases where compounds are sufficiently basic or acidic, a salt of a compound of formula (I) can be useful as an intermediate for isolating or purifying a compound of formula (I). Additionally, administration of a compound of formula (I) as a pharmaceutically acceptable acid or base salt may be appropriate. Examples of pharmaceutically acceptable salts are organic acid addition salts formed with acids which form a physiological acceptable anion, for example, tosylate, methanesulfonate, acetate, citrate, malonate, tartarate, succinate, benzoate, ascorbate, - ketoglutarate, and -glycerophosphate. Suitable inorganic salts may also be formed, including hydrochloride, sulfate, nitrate, bicarbonate, and carbonate salts. Salts may be obtained using standard procedures well known in the art, for example by reacting a sufficiently basic compound such as an amine with a suitable acid affording a physiologically acceptable anion. Alkali metal (for example, sodium, potassium or lithium) or alkaline earth metal (for example calcium) salts of carboxylic acids can also be made. 00819.006WO1 / SCRI.563WO The compounds can be formulated as pharmaceutical compositions and administered to a mammalian host, such as a human patient in a variety of forms adapted to the chosen route of administration, i.e., orally or parenterally, by intravenous, intramuscular, topical or subcutaneous routes. Thus, the present compounds may be systemically administered, e.g., orally, in combination with a pharmaceutically acceptable vehicle such as an inert diluent or an assimilable edible carrier. They may be enclosed in hard or soft shell gelatin capsules, may be compressed into tablets, or may be incorporated directly with the food of the patient's diet. For oral therapeutic administration, the active compound may be combined with one or more excipients and used in the form of ingestible tablets, buccal tablets, troches, capsules, elixirs, suspensions, syrups, wafers, and the like. Such compositions and preparations should contain at least 0.1% of active compound. The percentage of the compositions and preparations may, of course, be varied and may conveniently be between about 2 to about 60% of the weight of a given unit dosage form. The amount of active compound in such therapeutically useful compositions is such that an effective dosage level will be obtained. The tablets, troches, pills, capsules, and the like may also contain the following: binders such as gum tragacanth, acacia, corn starch or gelatin; excipients such as dicalcium phosphate; a disintegrating agent such as corn starch, potato starch, alginic acid and the like; a lubricant such as magnesium stearate; and a sweetening agent such as sucrose, fructose, lactose or aspartame or a flavoring agent such as peppermint, oil of wintergreen, or cherry flavoring may be added. When the unit dosage form is a capsule, it may contain, in addition to materials of the above type, a liquid carrier, such as a vegetable oil or a polyethylene glycol. Various other materials may be present as coatings or to otherwise modify the physical form of the solid unit dosage form. For instance, tablets, pills, or capsules may be coated with gelatin, wax, shellac or sugar and the like. A syrup or elixir may contain the active compound, sucrose or fructose as a sweetening agent, methyl and propylparabens as preservatives, a dye and flavoring such as cherry or orange flavor. Of course, any material used in preparing any unit dosage form should be pharmaceutically acceptable and substantially non-toxic in the amounts employed. In addition, the active compound may be incorporated into sustained-release preparations and devices. The active compound may also be administered intravenously or intraperitoneally by infusion or injection. Solutions of the active compound or its salts can be prepared in water, 00819.006WO1 / SCRI.563WO optionally mixed with a nontoxic surfactant. Dispersions can also be prepared in glycerol, liquid polyethylene glycols, triacetin, and mixtures thereof and in oils. Under ordinary conditions of storage and use, these preparations contain a preservative to prevent the growth of microorganisms. The pharmaceutical dosage forms suitable for injection or infusion can include sterile aqueous solutions or dispersions or sterile powders comprising the active ingredient which are adapted for the extemporaneous preparation of sterile injectable or infusible solutions or dispersions, optionally encapsulated in liposomes. In all cases, the ultimate dosage form should be sterile, fluid and stable under the conditions of manufacture and storage. The liquid carrier or vehicle can be a solvent or liquid dispersion medium comprising, for example, water, ethanol, a polyol (for example, glycerol, propylene glycol, liquid polyethylene glycols, and the like), vegetable oils, nontoxic glyceryl esters, and suitable mixtures thereof. The proper fluidity can be maintained, for example, by the formation of liposomes, by the maintenance of the required particle size in the case of dispersions or by the use of surfactants. The prevention of the action of microorganisms can be brought about by various antibacterial and antifungal agents, for example, parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and the like. In many cases, it will be preferable to include isotonic agents, for example, sugars, buffers or sodium chloride. Prolonged absorption of the injectable compositions can be brought about by the use in the compositions of agents delaying absorption, for example, aluminum monostearate and gelatin. Sterile injectable solutions are prepared by incorporating the active compound in the required amount in the appropriate solvent with various of the other ingredients enumerated above, as required, followed by filter sterilization. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and the freeze drying techniques, which yield a powder of the active ingredient plus any additional desired ingredient present in the previously sterile-filtered solutions. Useful dosages of the compounds of formula (I) can be determined by comparing their in vitro activity, and in vivo activity in animal models. Methods for the extrapolation of effective dosages in mice, and other animals, to humans are known to the art; for example, see U.S. Pat. No. 4,938,949. The amount of the compound, or an active salt or derivative thereof, required for use in treatment will vary not only with the particular salt selected but also with the route of 00819.006WO1 / SCRI.563WO administration, the nature of the condition being treated and the age and condition of the patient and will be ultimately at the discretion of the attendant physician or clinician. The desired dose may conveniently be presented in a single dose or as divided doses administered at appropriate intervals, for example, as two, three, four or more sub-doses per day. The sub-dose itself may be further divided, e.g., into a number of discrete loosely spaced administrations; such as multiple inhalations from an insufflator or by application of a plurality of drops into the eye. Moreira-Teixeira, L., et al., Nat. Commun., 2020, 11(1), 5566 (PMID 33149141) discusses NETosis in the pathology of Mtb infection. However, the data in Figure 8 therein decouples NET formation from the severity of disease. The outcome of disease was improved in the mice by altering the sensitivity of neutrophils to type I interferon signaling, but despite a lower CFU in these mice there was no change in the number of NETs. This suggests that blocking NETosis would not improve outcomes. The invention will now be illustrated by the following non-limiting Examples.

[0003] 00819.006WO1 / SCRI.563WO EXAMPLES Example 1. To establish severe TB disease in mice, Apoe- / -mice (JAX002052) were put on a high cholesterol diet (D12109C, Research Diets) for 2 weeks and then infected via aerosol with the H37Rv strain of Mycobacterium tuberculosis. Mice were treated daily with 4 mg / kg of GSK484 intraperitoneally in 400 uL of PBS starting at day 7 post-infection. At day 28 post-infection the whole lung was homogenized in 0.05% Tween-80 in PBS with a gentleMACS Tissue Dissociator (Miltenyi Biotec) and serial dilutions were plated onto 7H10 plates for enumeration of bacterial colonies, as described previously (PMID: 31350281). Apoe- / -mice on high cholesterol diet are highly susceptible to Mtb infection and develop severe disease with multiple necrotic granulomas and large cavitary lesions. Treatment with the anti-NETosis drug GSK484 dramatically reduced bacterial burden (Figure 1.). Wild-type B6 mice are relatively resistant to Mtb infection and do not develop necrotic granulomas or cavitary lesions. Treatment with the anti-NETosis drug GSK484 had no effect on bacterial burden in these mice (Figure 2.). Example 2. To explore the potential clinical efficacy of blocking NET formation, Apoe- / -HC mice were infected with about 50 CFU of H37Rv and treated with GSK484 daily starting at day 7 or day 14 PI until a pre-specified endpoint of 40 days PI. Treatment with GSK484 significantly decreased mortality compared to controls (Figure 3). Example 3. To determine the generalizability of the findings from Example 2, the effect of blocking NET formation in a different mouse strain / bacterial strain combination was evaluated. C3HeB / FeJ (C3H) mice are highly susceptible to Mtb and the pathology in these mice has been shown to be driven, at least in part, by excess neutrophil recruitment, particularly when infected with the hypervirulent SA161 strain of Mtb (Mishra BB, et al., J Exp Med. 2018 Apr 2;215(4):1035–45; and Gern BH, et al., BioRxiv Prepr Serv Biol. 2024 Apr 15;2024.04.12.589315). Treatment of SA161-infected C3H mice with GSK484 decreased the bacterial burden by approximately 8-fold (Figure 4). In contrast, blocking PAD4-induced NET 00819.006WO1 / SCRI.563WO formation with GSK484 in B6 mice did not affect the pulmonary bacterial burden or decrease the numbers of neutrophils or monocyte-derived macrophages. These results are concordant with a minimal role for neutrophils in the pathology of Mtb infection in B6 mice ( Lovewell RR, et al., Mucosal Immunol. 2021 Jan;14(1):229–41) and suggest that GSK484 does not have any significant direct anti-mycobacterial activity under the in vivo conditions tested. All publications, patents, and patent documents are incorporated by reference herein, as though individually incorporated by reference. The invention has been described with reference to various specific and preferred embodiments and techniques. However, it should be understood that many variations and modifications may be made while remaining within the spirit and scope of the invention.

Claims

00819.006WO1 / SCRI.563WO CLAIMS What is claimed is:

1. A method for treating severe tuberculosis in an animal, comprising inhibiting the formation of a neutrophil extracellular trap in the animal.

2. The method of claim 1, wherein the severe tuberculosis comprises pulmonary tuberculosis with cavitary lesions.

3. The method of claim 1, wherein the severe tuberculosis comprises necrotic granulomas, and / or alveolar hemorrhage.

4. The method of claim 1, wherein the severe tuberculosis comprises disseminated tuberculosis.

5. The method of claim 1, wherein the severe tuberculosis comprises infection with a drug resistant strain.

6. The method of claim 1, wherein the severe tuberculosis comprises a sputum count of acid-fast bacilli scoring 3+ on the International Union Against Tuberculosis and Long Disease (IUATLD) or WHO scales.

7. The method of claim 1, wherein the animal has underlying pulmonary co-morbidities.

8. The method of any one of claims 1-7, wherein inhibiting the formation of the neutrophil extracellular trap comprises administering a compound to the animal that inhibits the formation of a neutrophil extracellular trap.

9. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a DNase.00819.006WO1 / SCRI.563WO 10. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a histone-degrading enzyme.

11. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is an inhibitor of chromatin decondensation.

12. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is an antibody against a component of a NET.

13. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a protease inhibitor.

14. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is an elastase inhibitor.

15. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a PAD4 inhibitor.

16. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is Cl-amidine or F-amidine.

17. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a reversible inhibitor.

18. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a tetrazole analog.

19. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a biphenyl tetrazole.

20. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a peptidomimetic compound.00819.006WO1 / SCRI.563WO 21. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is an inhibitor of NET release from cells.

22. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is BB-Cl-amidine.

23. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is YW3-56.

24. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a compound of formula (I):and salts described therein, wherein: Ring A is:00819.006WO1 / SCRI.563WOwherein: Ring A is optionally substituted with 1-4 groups selected from fluorine, -CN, -OR, and C1-6 aliphatic optionally substituted with 1-3 fluorine atoms; Ring B is a 5-6 membered heteroaryl ring having 1-3 heteroatoms independently selected from nitrogen, oxygen, and sulfur; R1is hydrogen, -Cy, or C1-6aliphatic optionally substituted with -Cy and optionally further substituted with 1-4 groups selected from fluorine, -CN, and -OR; each -Cy is independently a 6-membered aryl ring containing 0-2 nitrogen atoms, or a 4- 7 membered saturated monocyclic ring having 0-2 heteroatoms independently selected from nitrogen, oxygen and sulfur, wherein -Cy is optionally substituted with 1-4 groups selected from fluorine, -CN, and -OR; R² is hydrogen, -CN, -OR, -Cy, or C1-10aliphatic optionally substituted with -Cy and optionally further substituted with 1-5 groups selected from fluorine, CN, and -OR; or two R2groups on the same carbon atom are optionally taken together to form =O; n is 1, 2, or 3; X1is N or C(R3); R3is -R, halogen or -OR; each R is independently hydrogen or C1-6aliphatic optionally substituted with 1-3 fluorine atoms;00819.006WO1 / SCRI.563WO L is selected from a covalent bond and a C1-6 membered straight or branched, saturated or unsaturated hydrocarbon chain wherein one methylene unit of L is optionally replaced by -S(O)2- or —C(O)N(Ry)—, wherein Ryis R or -CH2-phenyl; and R4is halogen, R, phenyl, or a 5-6 - membered heteroaryl ring having 1-3 heteroatoms independently selected from nitrogen, oxygen, and sulfur, wherein R4is optionally substituted with 1-4 groups independently selected from halogen, =CN, =OR, and C1-6aliphatic optionally substituted with 1-3 fluorine atoms.

25. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is a compound of formula (II):or a salt thereof, wherein: X is O or S; Y is N or CR2 R1 is-H or -C1-6alkyl; R2is -H, -OH, -C1-6alkyl, -O-C1-6alkyl, -CN, -halo, -C(=O)NH2, -C1-6haloalkyl, -O-C1-6alkylO-C1-6alkyl, -O-C1-6alkyl-OH, -O-C1-6alkyl-C(=O)NH2, -O-C1-6alkyl-CN, -O-C1- 6haloalkyl, -NH-C1-6alkyl, -N(C1-6alkyl)2 or heteroaryl; R3is -C1-6alkyl, -C1-6alkyl-NH2, or -C1-6alkyl-O-C1-6alkyl; R4is H, -C1-6alkyl, -C1-6haloalkyl, -C1-6alkyl-heteroaryl (wherein the heteroaryl group is optionally substituted by one, two or three C1-6alkyl groups), -C1-6alkyl-phenyl (wherein the phenyl group is optionally substituted by one, two or three substituents selected from the list consisting of halo, C1-6alkyl and-O-C1-6alkyl), -C1-6alkyl-heterocyclyl, -C1-6alkyl-C3.-6cycloalkyl, -C1-6alkyl-OH, -C1-6alkyl-CN or -C1-6alkyl-O-C1-6alkyl; R5is -H, -C1-6alkyl, -O-C1-6alkyl, -OH, -halo, or -CN; or R4together with R5are -(R4)-CH2CH2O-( R5)-, -(R4)-CH2CH2CH2O-( R5)- or -(R4)CH( Me)CH2O-( R5)-, wherein -(R4)- and-( R5)- denote the positions of attachment of the alkenyloxy chain to the respective ring atoms;00819.006WO1 / SCRI.563WO R6 is -H, -halo, -CN, -C1-6alkyl, -O-C1-6alkyl, or -OH; R7is -H, -halo, -CN, -C1-6alkyl, -O-C1-6alkyl, or -OH; R8is -H, -F, or -C1-6alkyl; R9 is-H or -C1-6alkyl; and R10is -H and R11is a 5-7 membered monocyclic saturated heterocycle (containing one nitrogen atom and optionally one oxygen atom) or a 7 membered bicyclic heterocycle (containing one nitrogen atom) or -CH2CH2NH2; or NR10R11 taken together form a 5-7 membered mono- or bi-cyclic saturated or unsaturated heterocycle containing one nitrogen atom, wherein the heterocycle is substituted by one, two or three substituents independently selected from the list consisting of -NH2, -C1-6alkyl-NH2, -NH-C1-6alkyl, -NHC(=NH)CH2Cl, -C1-6alkyl, -halo, -O-C1-6alkyl, -OH and -C(O)NH2.

26. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is GSK484 or GSK199.

27. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is GSK484:or a pharmaceutically acceptable salt thereof.

28. The method of claim 8, wherein the compound that inhibits neutrophil extracellular trap formation is GSK484 hydrochloride.

29. A compound that inhibits the formation of a neutrophil extracellular trap for the prophylactic or therapeutic treatment of severe tuberculosis.

30. A compound that inhibits neutrophil extracellular trap formation as described in any one of claims 9-28 for the prophylactic or therapeutic treatment of severe tuberculosis.00819.006WO1 / SCRI.563WO 31. Use of a compound that inhibits the formation of a neutrophil extracellular trap to prepare a medicament for treating severe tuberculosis in an animal.

32. Use of a compound that inhibits the formation of a neutrophil extracellular trap as described in any one of claims 9-28 to prepare a medicament for treating severe tuberculosis in an animal.

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