The Mycobacterium tuberculosis genome contains four phospholipase C (PLC)-encoding genes, designated plcA, plcB, plcC, and plcD, respectively. Each of the four genes contributes to the overall PLC activity of M. tuberculosis. PLC is hypothesized to contribute to M. tuberculosis virulence. Infection of M. tuberculosis strains carrying a truncated plcD gene is associated with the occurrence of extrathoracic tuberculosis. However, whether the other three plc genes are also associated with extrathoracic tuberculosis remains to be assessed. We investigated the insertion-and deletion-associated genetic diversity in all four plc genes among 682 epidemiologically and clinically well-characterized M. tuberculosis clinical isolates using PCR, DNA sequencing, and Southern hybridization. Two hundred sixty-six (39%) of the 682 isolates had an interruption in at least one of the four plc genes, most often associated with an IS6110 insertion. The plcD gene interruption was the most common: it was observed in 233 (34%) of the isolates, compared to 4.7%, 4.1%, and 5.9% for plcA, plcB, and plcC gene interruption, respectively. The association between the plc gene genotypes and disease presentation was adjusted for clustering using generalized estimating equations for both bivariate and multivariate analyses. After controlling for the genotypes of the plcABC genes and the host-related risk factors, interruption in the plcD gene remained significantly associated with extrathoracic tuberculosis (odds ratio, 3.27; 95% confidence interval, 1.32 to 8.14). The data suggest that the plcD gene might play a more important role in the pathogenesis of thoracic TB than it does in the pathogenesis of extrathoracic TB.Phospholipase C (PLC) is involved in the pathogenesis of several bacterial infections (11,16,19,20). For Mycobacterium leprae, Mycobacterium microti, and Mycobacterium avium, high phospholipase activity was observed among bacilli harvested from host tissues (28,29), suggesting that phospholipase might be involved in the virulence of mycobacteria. However, the precise role of PLC in tuberculosis (TB) pathogenesis is unknown. Genome sequencing of Mycobacterium tuberculosis laboratory strain H37Rv (5) and clinical strain CDC1551 (http: //www.tigr.org) revealed four genes encoding PLC enzymes. Three of these genes, plcA, plcB, and plcC, are organized in tandem (locus plcABC). The fourth gene, plcD, is located in a separate region. A recent functional study of M. tuberculosis demonstrated that all four genes encode functional PLC in M. tuberculosis, and each gene contributes to overall PLC activity (13). Furthermore, in mice, when the virulence of a plcABCD quadruple mutant was compared to a plcABC triple mutant, both showed the same level of attenuation, suggesting that either plcD does not contribute to virulence or it acts in association with other phospholipase-encoding genes.Several previous studies using small, selected samples of M. tuberculosis clinical isolates have found insertions or deletions in the plcA, plcB, plcC, and pl...