Isoxyl (ISO), a thiourea derivative that was successfully used for the clinical treatment of tuberculosis during the 1960s, is an inhibitor of the synthesis of oleic and mycolic acids in Mycobacterium tuberculosis. Its effect on oleic acid synthesis has been shown to be attributable to its inhibitory activity on the stearoylcoenzyme A desaturase DesA3, but its enzymatic target(s) in the mycolic acid pathway remains to be identified. With the goal of elucidating the mode of action of ISO, we have isolated a number of spontaneous ISO-resistant mutants of M. tuberculosis and undertaken their genotypic characterization. We report here the characterization of a subset of these strains carrying mutations in the monooxygenase gene ethA. Through complementation studies, we demonstrate for the first time that the EthA-mediated oxidation of ISO is absolutely required for this prodrug to inhibit its lethal enzymatic target(s) in M. tuberculosis. An analysis of the metabolites resulting from the in vitro transformation of ISO by purified EthA revealed the occurrence of a formimidamide allowing the formulation of an activation pathway in which the oxidation of ISO catalyzed by EthA is followed by chemical transformations involving extrusion or elimination and, finally, hydrolysis.Mycobacterium tuberculosis, the etiologic agent of tuberculosis (TB), claims about 1.7 million lives annually, and the global number of TB cases is still rising at a rate of 0.6% per year (28). Approximately 2% of new TB cases in the world are attributed to multidrug-resistant strains, defined as M. tuberculosis isolates resistant to at least isoniazid and rifampin, the two most powerful anti-TB drugs. However, multidrug resistance rates in some countries, particularly in the former Soviet Union, Asia, the Dominican Republic, and Argentina, are much higher and may reach more than 22% of all isolates (16). Moreover, extensively drug-resistant strains that are resistant to three or more of the six classes of second-line drugs in addition to rifampin and isoniazid have been reported in all regions of the world (5), raising the possibility of future epidemics of virtually untreatable forms of TB. The continuing rise in disease incidence, the problem of drug resistance, and the need to reduce treatment duration has prompted research on new drug developments (11). In this light, the reexamination of isoxyl (ISO) (4,4Ј-diisoamyloxydiphenylthiourea; 4,4Ј-diisoamyloxythiocarbanilide; thiocarlide), a thiourea derivative that was successfully used for the clinical treatment of TB during the 1960s, may prove useful in identifying new therapeutic targets and in developing new therapeutic agents with greater potency and more desirable features than earlier thioureas (1,14,21,(23)(24)).An early article reported that ISO inhibits the synthesis of mycolic acids and free fatty acids in Mycobacterium bovis BCG (27). We later demonstrated that ISO displays potent activity against other slow-and fast-growing species of Mycobacterium, including multidrug-resistant clinic...