Jurnal Internasional untuk Parasitologi

51 (2021) 95-121
Daftar isi tersedia di ScienceDirect
International Journal for Parasitology
: www.elsevier.com/locate/ijpara
Review Article
Control of human toxoplasmosis
Nicholas C. Smith a,b,CibellyGoulart a,b, Jenni A. Hayward b, Andreas Kupz c, Catherine M. Miller d, Giel G. van Dooren b

a School of Life Sciences, University of Technology Sydney, Ultimo, NSW 2007, Australia
b Research School of Biology, Australian National University, Canberra, ACT 0200, Australia
c Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University ,

Cairns, QLD 4878, Australia d College of Public Health, Medical and Veterinary Science, James Cook University,

Cairns, QLD 4878, Australia

info kali tertular saat hamil, dapat menyebabkan

artikel Riwayat artikel:
Diterima 16 September 2020 keguguran atau cacat bawaan pada neonatus;
Diterima dalam bentuk revisi 12 November 2020
dan dapat menyebabkan penyakit mata yang
Diterima 15 November 2020
serius, bahkan pada orang yang imunokompeten.
Tersedia online 19 Desember 2020
Kata kunci: Penyakit ini memiliki epidemiologi yang kompleks,
Toksoplasmosis
Toxoplasma gondii yang ditularkan melalui konsumsi ookista yang
Kemoterapi
Imunoterapi ditumpahkan dalam feses inang kucing definitif
Nanoteknologi
Vaksinasi dan mencemari air, tanah dan tanaman, atau
1. Pendahuluan
abstrak dengan konsumsi kista intraseluler dalam daging
Toksoplasmosis disebabkan oleh Toxoplasma
setengah matang dari inang perantara. Dalam
gondii, parasit apicomplexan yang mampu
tinjauan ini kami memeriksa pendekatan saat ini
menginfeksi sel berinti pada hewan berdarah
dan masa depan untuk mengendalikan
panas. Toxoplasma gondii menginfeksi sekitar 2
toksoplasmosis, yang mencakup berbagai
miliar orang dan, sementara hanya sebagian kecil
tindakan yang menargetkan komponen yang
dari orang yang terinfeksi akan menderita
berbeda dari siklus hidup T. gondii. Ini termasuk:
penyakit serius, prevalensi parasit menjadikannya
program pendidikan tentang parasit dan
salah satu penyakit zoonosis paling merusak di
menghindari kontak dengan tahap infeksi;
dunia. Toksoplasmosis adalah penyakit dengan
biosekuriti dan sanitasi untuk menjamin
banyak manifestasi manusia: penyakit ini dapat
keamanan pangan dan air; kemoterapi dan
menyebabkan ensefalitis fatal pada orang
imunoterapi untuk mengendalikan infeksi dan
dengan sistem imun yang tertekan; jika pertama
penyakit aktif; pilihan profilaksis untuk mencegah merupakan kunci untuk mengendalikan strategi.

penularan infeksi oleh ternak dan pembentukan Tidak seperti coccidian lain, yang sebagian besar

kista pada daging; dan vaksin untuk mencegah bersifat spesifik inang, T. gondii tampaknya dapat

pelepasan ookista oleh inang kucing definitif. menginfeksi sel berinti apa pun di

2020 Penulis. Diterbitkan oleh Elsevier Ltd atas Penulis yang sesuai di: School of Life Sciences, University of

nama Australian Society for Parasitology. Ini Technology Sydney, Ultimo, NSW 2007, Australia.

adalah artikel akses terbuka di bawah lisensi CC Alamat email: nicholas.smith@uts.edu.au (NC
Smith).
BY https://doi.org/10.1016/j.ijpara.2020.11.001
fase seksual, hanya kucing yang dapat berfungsi
(http://creativecommons.org/licenses/by/4.0/).
sebagai inang definitif karena defisiensi unik, di
hewan berdarah panas. Namun, hanya pada
fase aseksual menengah dari siklus hidupnya T. antara mamalia, dalam aktivitas delta-6- saturase
gondii begitu bebas; in
Human toksoplasmosis merupakan penyakitusus pada kucing (Martorelli Di Genova et al.,

zoonosis global dengan epidemiologi yang2019). Selain itu, ada perbedaan yang jelas dalam

kompleks dan manifestasi yang beragam.profil ekspresi protein parasit yang terlibat dalam

Penyakit ini disebabkan oleh Tox oplasma gondii,invasi sel inang dan modulasi sel inang perantara

organisme parasit eukariotik bersel tunggalversus definitif (Behnke et al., 2014; Hehl et al.,

dalam supergrup Alveolata, Filum Apicomplexa,2015); dengan demikian, takizoit (tahap aseksual

Kelas Con oidasida, Subkelas Coccidiasina, Ordoyang membelah dengan cepat pada inang

Eucoccidiorida, Subordo Eimeriorina dan Familiperantara) mengekspresikan susunan protein

Sarcocystidae. Toxoplasma gondii adalahyang jauh lebih luas yang memfasilitasi invasi sel

satu-satunya spesies dalam genus, Toxoplasma,inang dan modulasi respons inang terhadap

tetapi masih berkerabat dekat dengan Neosporainfeksi daripada merozoit (tahap aseksual yang

caninum dan Hammondia hammondi, yangmembelah dengan cepat yang hanya ditemukan

memiliki ciri-ciri morfologi, molekuler, dan siklusdi usus inang definitif), berpotensi menjelaskan

hidup yang sama. Kunci untuk memahamikapasitas takizoit untuk menginfeksi beragam sel.

epidemiologi dan gejala toksoplasmosis terletakPada hospes perantara, T. gondii ditemukan

pada apresiasi kompleksitas dan keanggunandalam kista mikroskopis di bagian tubuh mana

siklus hidupnya (lihat Ferguson, 2009, untukpun tetapi, terutama, di sel otot dan SSP yang

sejarah dan deskripsi ilustrasi rinci); ini jugaberumur panjang. Felids terinfeksi ketika mereka
menelan kista ini setelah memangsa inanghaploid dari T. gondii dilepaskan dari kista dan

perantara. Selama pencernaan, bentuk bradizoitmenginvasi enterosit, berlanjut hingga

0020-7519/ 2020 The Author(s). Diterbitkan oleh Elsevier Ltd atas nama Australian Society for Parasitology. Ini

adalah artikel akses terbuka di bawah lisensi CC BY (http://creativecommons.org/licenses/by/4.0/).

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95-121
fase berturut-turut dari reproduksi aseksual, yangdapat bertahan selama berbulan-bulan, bahkan

menghasilkan generasi merozoit berturut-turutbertahun-tahun, di tanah atau air (Freppel et al.,

yang menyerang kembali usus sebelum akhirnya2019).

berdiferensiasi menjadi mikrogametositInang perantara herbivora, termasuk manusia,

(masing-masing mampu berdiferensiasi menjadidapat terinfeksi melalui air minum, makan buah

16-30 mikrogamet berflagel) atauatau sayuran, atau kontak dengan tanah yang

makrogametosit (masing-masing menjadi satuterkontaminasi ookista T. gondii. Ada juga bukti

makroga mete yang tidak bergerak). Mikrogametbahwa memakan moluska laut mentah atau

membuahi makrogamet, membentuk zigot diploid.setengah matang dapat menyebabkan infeksi

Mobilisasi struktur sub-seluler – badankarena ookista dapat menumpuk di hewan ini

pembentuk selubung dan dinding – di dalamsetelah limpasan tanah yang terkontaminasi ke

makrogamet mengarah pada pembentukanlautan (Freppel et al., 2019; Shapiro et al., 2019) .

dinding berlapis-lapis di sekitar zigot, yangSporozoit keluar dari sporokista dan ookista

sekarang disebut sebagai ookista. Dindingselama pencernaan, menyerang sel usus, berubah

ookista sangat tahan terhadap lingkungan danmenjadi takizoit (yang juga haploid) dan

bahan kimia, memungkinkan parasit untuk keluarmenyebar ke seluruh tubuh. Inang perantara

dengan aman ke dunia melalui kotoran inangnya.karnivora atau omnivora, sekali lagi termasuk

Ketahanan dinding ookista juga menyediakanmanusia, juga dapat terinfeksi dengan memakan

tempat untuk meiosis terjadi dan menyelesaikaninang perantara lain yang terinfeksi. Dalam hal ini,

fase reproduksi seksual dari siklus hidup (Walkerbrady zoites yang dilepaskan ke usus dan

et al., 2013). Hal ini menghasilkan pembentukanmenyerang sel-sel usus, berdiferensiasi menjadi

delapan sporozoit infeksius haploid, yangtakizoit dan menyebar ke seluruh tubuh inang.

terkandung dalam dua sporokista (yaitu, empatTachyzoites bereproduksi secara aseksual dan

sporokista per sporokista), di dalam ookista, yang cepat, memecahkan dan menginvasi kembali sel
saat mereka melakukannya, sampai respon imunlalu. Dari Amerika Utara, penyebaran lebih lanjut

dari inang mendorong mereka ke dalam strategidapat terjadi, melintasi Selat Bering ke Asia.

penghindaran yang melihat mereka berubahPeristiwa kedua jauh lebih baru – antara 11.000

kembali menjadi bradizoit, yang menjadidan 4.000 tahun yang lalu – yang menjadi asal

terbungkus dan dilindungi oleh dinding kista dimula pertanian, khususnya budidaya biji-bijian di

dalam sel inang. Sebuah kista dewasa tunggalAsia dan Timur Tengah (Shwab et al., 2018),

dapat mengandung sejumlah besar bradizoitsebelum disebarluaskan lebih lanjut ke Eropa,

(Ferguson, 2009), dan satu bradizoit dapatAfrika dan Asia Tenggara. Penerapan praktik

menyebabkan infeksi baik pada hospes perantara agraria juga menandai dimulainya hubungan

atau definitif. Cara lain di mana infeksi dapatkomensal antara manusia dan tikus rumah (Mus

terjadi adalah melalui transfer takizoit secaramusculus musculus, Mus musculus domesticus

kongenital (El Bissati et al., 2018) atau melaluidan Mus musculus castaneus), dan antara

transplantasi organ (Derouin et al., 2008). manusia dan Felis catus, kucing rumah, yang

Siklus hidup T. gondii mendukung keberhasilanmengatur kebangkitan domestik. siklus hidup

penyebarannya ke seluruh penjuru dunia. Namun,kucing dan tikus untuk T. gondii. Siklus domestik

tanpa disadari manusia telah menjadi kontributorini, bisa dibilang, mendominasi epidemiologi

keberhasilan ini. Tampaknya ada dua peristiwaparasit pada manusia dan

besar dalam evolusi T. gondii. Pertama, sepertiShwab

ternak kami, karena tingginya tingkat kontaminasi
yang dihipotesiskan oleh Bertranpetit et al. (2017),
ookista yang terkonsentrasi di lahan pertanian
berdasarkan data filogenetik molekuler yang
yang menyertai hubungan komensal kami dengan
menarik, nenek moyang terbaru dari strain T.
kucing dan tikus (et al., 2018). Tampaknya,
gondii saat ini muncul ~1,5 juta tahun yang lalu di
bahkan menghasilkan pengenalan yang relatif
Amerika Selatan, bertepatan dengan perluasan
baru dari siklus hidup domestik T. gondii ke
inang perantara murine potensial dan potensial
Amerika Utara dengan dominasi strain klon T.
host definitif kucing di Amerika Selatan.
gondii di bagian dunia tersebut (Shwab et al.,
Diversifikasi inang ini juga mendukung
2018).
diversifikasi T. gondii, yang menyebabkan
Saat ini, sekitar 2 miliar orang terinfeksi kronis T.
penyebarannya ke Amerika Utara, melalui mus
gondii di seluruh dunia, meskipun tingkat
Isth Panama, yang terbentuk 2-3 juta tahun yang
seroprevalensi sangat tinggi di bagian tropisselama kehamilan juga menjadi perhatian serius.

Amerika Selatan, Asia Tenggara dan AfrikaHal ini dapat menyebabkan toksoplasmosis

(Pappas et al., 2009). Pada pejamu yangkongenital, yang dapat menyebabkan keguguran

imunokompeten, infeksi T. gondii biasanya hanyaatau lahir mati atau memiliki efek serius bagi bayi

menimbulkan gejala ringan dan jarangbaru lahir, yang dapat berlangsung seumur hidup

memerlukan intervensi. Hal ini karena takizoitdan mungkin termasuk gangguan perkembangan

penyebab penyakit ditekan dengan cepat olehmental, pendengaran atau penglihatan (Weiss

respon imun di mana interferon gamma (IFN-c)dan Dubey, 2009). Penyakit klinis juga dapat

yang diproduksi oleh sel T CD4+ memainkanterjadi pada orang dewasa sehat dan

peran sentral, didukung oleh berbagai sel imunimunokompeten lainnya, khususnya yang

lainnya, sitokin (termasuk, dalam khususnya, ILSbermanifestasi sebagai toksoplasmosis okular,

12, 18, 1 dan 2, dan faktor nekrosis tumor), dansalah satu penyebab uveitis yang paling sering

pengenalan imun bawaan serta molekul dandiidentifikasi (Weiss dan Dubey, 2009). Infeksi

mekanisme efektor (Sher et al., 2017). Namun,juga dikaitkan dengan penyakit inflamasi (Lidar et

diferensiasi konsekuen dari takizoit menjadial., 2009; Severance et al., 2012; Shapira et al.,

bradizoit mengarah pada pembentukan kista2012), skizofrenia (Torrey et al., 2012), dapat

jaringan yang berumur panjang di otot dan SSPmenyebabkan dan, berpotensi, beberapa

(Montoya dan Liesenfeld, 2004). Ini mungkingangguan lain. otak (Thomas et al., 2012; Ngo et

bertahan selama kehidupan inang (Rougier et al.,al., 2017), meskipun seringkali sulit untuk

2017), juga di bawah kendalipada IFNc(Sturgemenentukan apakah hubungan antara penyakit ini

dan Yarovinsky, 2014). Kista jaringan mampudan infeksi T. gon dii adalah kausal atau korelatif.

mengaktifkan kembali ke tahap takizoit akut danSecara global, kemungkinan hanya sebagian kecil

ini menjadi perhatian khusus bagi individu denganorang yang terinfeksi T. gondii yang pernah

gangguan kekebalan, terutama pasien AIDS, yangmengalami manifestasi toksoplasmosis; namun,

populasi sel T CD4+ secara drastis berkurang.fakta sederhana bahwa sekitar 2 miliar orang

Reaktivasi dapat menyebabkan pembentukan lesi terinfeksi parasit ini berarti banyak orang pasti

otak dan ensefalitis toksoplasma terkait, yangmenderita secara signifikan. Di daerah tropis

berakibat fatal jika tidak diobati (Luft danAmerika Selatan, bentuk toksoplasmosis parah

Remington, 1992). Infeksi pertama T. gon diilebih umum daripada di bagian lain dunia,
mungkin mencerminkan keragaman yang lebihdan Macpherson, 2011).

besar dari galur virulen T. gondii (Bertranpetit et al.Terlepas dari kompleksitas gabungan dari siklus

, 2017; Shwab et al., 2018) dikombinasikanhidup T. gon dii di mana-mana dan berbagai

dengan tingginya kejadian infeksi melaluimanifestasi toksoplasma manusia, pengendalian

konsumsi ookista (yang telah mengalamipenyakit ini berpotensi dipersempit dalam fokus

rekombinasi seksual baru-baru ini dan karena itupada strategi yang menargetkan dan mencegah:

lebih beragam secara genetik daripada infeksipenyakit bawaan; reaktivasi kista (terutama pada

klonal yang berasal dari bradizoit) di bagian dunia orang dengan gangguan kekebalan);

tersebut (Galal et al., 2019). Oleh karena itu,pembentukan kista jaringan pada hewan

toksoplasmosis adalah salah satu penyakitmakanan; dan, pelepasan ookista ke lingkungan.

zoonosis yang paling mematikan di dunia,Dalam ulasan ini, kami menyajikan pendidikan,

menyebabkan hilangnya 2-8 juta Tahun Hidupmakanan

yang Disesuaikan dengan Disabilitas (Torgerson

NC Smith, C. Goulart, JA Hayward et al. Jurnal Internasional untuk Parasitologi 51 (2021) 95-121
dan keamanan air, dan pilihan terapi danprevent.html), yang merinci bahwa, untuk

profilaksis untuk mengendalikan toksoplasmosismenghindari toksoplasmosis, orang perlu:

manusia, dan mengomentari prospek untuk memberi makan hewan peliharaan kucing hanya

mengembangkan pendekatan baru. makanan komersial kalengan atau kering, tidak

2. Pendidikan publik, keamanan pangan dan air pernah daging mentah atau setengah matang;

untuk mengendalikan toksoplasmosis melatih kucing peliharaan untuk menggunakan

kotoran kucing;
Pemerintah di banyak negara, melalui ganti kotoran kucing setiap hari, kenakan sarung

departemen kesehatan dan/atau pertaniantangan sekali pakai saat melakukannya;

mereka, mengeluarkan saran yang jelas dan memelihara kucing peliharaan di dalam ruangan,

memelihara situs web pendidikan yangterutama pada malam hari, untuk meminimalkan

menjelaskan bagaimana individu dapataktivitas berburu dan buang air besar di luar;

mencegah toksoplasmosis. Contohnya adalah kenakan sarung tangan selama berkebun atau

informasi yang diberikan oleh Pusatkontak lain dengan tanah; tutup lubang pasir saat

Pengendalian dan Pencegahan Penyakit, AStidak digunakan (karena kucing lebih suka pasir

(https://www.cdc.gov/parasites/toxoplasmosis/ atau tanah gembur untuk buang air besar);

 mencuci buah dan sayuran secara menyeluruh diberikan dan, kedua, seberapa dekat hal ini

sebelum makan; tidak makan moluska yang dipatuhi oleh pasien. Ada beberapa keraguan

kurang matang; tentang efektivitas upaya pendidikan tentang

bekukan daging setidaknya selama 2 hari (pada toksoplasmosis, dengan variabilitas yang

suhu 12 C atau lebih rendah) sebelum dimasak; dilaporkan dalam pemahaman masyarakat

memasak daging pada suhu minimum (misalnya,tentang keberadaan penyakit dan risiko yang

74 C untuk unggas, 71 C untuk daging cincangditimbulkannya (Gollub et al., 2008; Pereboom et

atau daging giling, dan 63 C untuk potonganal., 2013; Andiappan et al., 2014; Millar et al.,

daging lainnya, diikuti dengan waktu istirahat2014; Elsafi et al., 2015; Chandrasena et al., 2016;

minimal 3 menit) sebelum makan; Smereka et al., 2018; Velázquez-Hernán dez et al.,

cuci bersih semua talenan, meja, sendok garpu,2019) dan kurangnya evaluasi program yang

barang pecah belah dan peralatan dapur lainnyaketat (Di Mario dkk., 2015). Ini, bisa dibilang,

yang telah bersentuhan dengan makanan mentahterutama benar di negara-negara miskin tetapi

jenis apa pun; kesulitan dalam mengurangi beban, misalnya,

cuci tangan secara menyeluruh setelah (i)toksoplasmosis kongenital juga telah diamati di

kontak dengan tanah atau pasir, (ii) persiapanAmerika Serikat (Jones et al., 2003; Ogunmodede

makanan atau kontak dengan makanan mentah,et al., 2005; Montoya dan Remington, 2008; El

(iii) kontak dengan hewan peliharaan atauBissati dkk., 2018). Prancis telah disarankan

kotoran hewan peliharaan (termasuk kotoransebagai contoh keberhasilan (El Bissati et al.,

kucing), dan tekankan kepada anak-anak2018) karena integrasi pendidikan, skrining dan

pentingnya mencuci tangan; dan diagnosis rutin wajib selama kehamilan, dan

hindari minum air yang tidak diolah. pilihan pengobatan yang tepat waktu (dijelaskan
Edukasi tentang toksoplasmosis dan cara
secara mendalam oleh McLeod et al., 2014).
mencegahnya ditekankan oleh para profesional
Pada saat yang sama, bagaimanapun,
kesehatan, terutama sebagai bagian dari
biaya-manfaat dari skrining dan diagnosis dan
pendidikan pra dan neonatus dan dengan
efektivitas pengobatan telah dipertanyakan
orang-orang dengan gangguan kekebalan.
(Opsteegh et al., 2014).
Namun, keefektifannya tergantung pada, pertama,
Tanggapan sistematis untuk memastikan bahwa
kelengkapan dan keakuratan saran yang
makanan bebas dari kontaminasi T. gondii telah
diusulkan (Kijlstra dan Jongert, terkontrol, pengurangan prevalensi kista T. gondii

97 pada daging babi dengan adopsi teknik pertanian

2008; Opsteegh et al., 2014; Alizaddeh et al.,
modern menjadi contoh utama (Opsteegh et al.,
2018). Langkah-langkah ini dapat diklasifikasikan
2014). Keberhasilan seperti itu, bagaimanapun,
sebagai pra atau pasca panen. Yang pertama
lebih kecil kemungkinannya untuk hewan yang
bertujuan untuk memastikan minimal
dibesarkan di padang rumput atau di bawah
kontaminasi lahan pertanian atau pakan ternak
praktik organik bebas. Program untuk
dengan ookista T. gondii. Yang terakhir ini
memastikan sterilisasi kucing peliharaan,
ditujukan untuk menghilangkan atau
dikombinasikan dengan program yang efektif
menonaktifkan kista atau ookista dalam atau
untuk mengurangi populasi kucing liar, berpotensi
pada daging, buah dan sayuran, tetapi terutama
membantu mengurangi kontaminasi ookista
difokuskan pada kista dalam daging karena
terhadap lingkungan tetapi akan sangat sulit dan
ookista tahan terhadap panas, dingin dan
mahal untuk dimulai dan diawasi (Opsteegh et al.,
berbagai bahan kimia. Selain itu, mencuci buah
2014) . Vaksinasi kucing untuk mencegah
dan sayuran oleh konsumen individu sudah
ekskresi ookista dapat dilakukan, dan vaksin
menjadi kebiasaan yang tersebar luas dan
hidup yang dilemahkan telah diuji di peternakan
mungkin cukup efektif untuk menghilangkan
babi (Mateus-Pinilla et al., 1999, 2002); prospek
ookista, dengan asumsi air bersih tersedia
pendekatan ini akan dibahas lebih rinci di Bagian
(Saphiro et al., 2019), meskipun perlu dicatat
5. Vaksinasi ternak untuk mencegah infeksi T.
bahwa meningkatnya ketersediaan kemasan pra,
gondii (dibahas di Bagian 5) atau pencegahan
Salad "siap makan" adalah sumber infeksi yang
infeksi kemoprofilaksis, ala penggunaan
potensial (Caradonna et al., 2017). Oleh karena
coccidiostats dalam pengobatan koksidiosis
itu, upaya pra-panen difokuskan pada biosekuriti
unggas (lihat Chapman et al., 2013), mungkin
untuk mencegah atau membatasi keberadaan
merupakan pendekatan yang dapat dilakukan
kucing dan hewan pengerat, dan memastikan
tetapi pemberian obat yang efektif dalam jangka
bahwa air untuk ternak dan irigasi tanaman bersih.
panjang tentu akan mahal dan juga kemungkinan
Ini memiliki kapasitas yang signifikan untuk
akan menyebabkan efek samping yang tidak
berhasil bagi hewan yang dibesarkan di dalam
diinginkan atau bahkan toksisitas
ruangan di bawah kondisi peternakan yang
(Sanchez-Sanchez et al., 2018). Tindakan pasca
panen melibatkan inaktivasi kista jaringan T.air yang terkontaminasi dengan ookista selama

gondii dalam daging. Hal ini dapat dicapaihampir 50 tahun (Benson et al., 1982; Bowie et al.,

melalui beberapa perlakuan termasuk1997; Bahia-Oliveira et al., 2003; de Moura et al.,

pembekuan, iradiasi dan pengolahan tekanan2006; Ferreira et al. al., 2018; Shapiro et al., 2019).

tinggi (Kijlstra dan Jongert, 2008; Opsteegh et al.,Langkah-langkah yang sama yang tercantum di

2014; Alizaddeh et al., 2018), tetapi kurangnyaatas untuk melindungi individu dan peternakan

penerimaan oleh konsumen karena signifikandari paparan ookista T. gondii juga berlaku untuk

efek pada keempukan daging, tekstur danmengurangi kontaminasi lingkungan dan, oleh

kualitas yang dirasakan kemungkinan akankarena itu, saluran air. Deteksi ookista T. gondii

membuktikan hambatan utama untuk penerapandalam air bergantung pada kombinasi mikroskop,

yang tersebar luas. Opsteegh dkk. (2014) telahbioassay dan teknik molekuler tetapi, secara

mengusulkan bahwa perlakuan pascapanenumum, telah tertinggal dari pengembangan

selektif, yaitu, menargetkan hanya daging yangmetode untuk mendeteksi parasit terbawa air

ditujukan untuk dikonsumsi mentah ataulainnya seperti Giardia dan Cryptosporidium

setengah matang, atau dari hewan yang diketahui (Saphiro et al., 2019). Ookista tahan terhadap

terinfeksi atau peternakan berisiko tinggi (yaitu,prosedur desinfeksi kimia yang umumnya

non-biosecure) mungkin lebih dapat dicapai,digunakan untuk memastikan pasokan air bersih

sambil mengakui bahwa logistik tidak akan(misalnya, tahan terhadap asam kuat, deterjen,

sederhana dan skrining untuk infeksi yangklorin, ozon, radiasi ultraviolet) dan, oleh karena

dikonfirmasi akan mahal. itu, sistem filtrasi adalah suatu keharusan

Wabah besar toksoplasmosis telah ditelusuri ke(Freppel et al., 2019)).

NC Smith, C. Goulart, JA Hayward dkk. Jurnal Internasional untuk Parasitologi 51 (2021) 95-121
3. Kemoterapi untuk mengendalikan terhadap Toxoplasma gondii in vitro dan in vivo
toksoplasmosis
Pilihan kemoterapi saat ini untuk toksoplasmosispada tikus model infeksi akut dan kronis. Simbol

terbatas (Dunay et al., 2018), meskipun adaplus (+) menunjukkan aktif, simbol minus ( )

upaya bersama dalam dekade terakhir untukmenunjukkan tidak aktif dan (ND) tidak

memanfaatkan strategi penyaringan throughputditentukan terhadap T. gondii dalam sistem

yang tinggi eksperimental yang ditunjukkan (baik terhadap

Tabel 1 takizoit in vitro, infeksi takizoit akut in vivo atau

Beragam kelas senyawa memiliki aktivitas
infeksi kista otak bradizoit kronis in vivo ).

untuk menemukan kembali atau toksoplasmo sis adalah Bumped Kinase

Inhibitors
bahan kimia baru, meningkatkan obat kombinasi pirimetamin In Vivo (Akut)

termasuk produk alami, yang sudah ada dan dan sulfadiazin, obat In Vivo Kista (Kronik)

dengan aktivitas anti disetujui (Deng et al., yang

Toksoplasma atau 2019). Pengobatan lini Senyawa In Vitro

untuk menggunakan depan untuk (Tachyzoite)

bertindak secara sinergis dengan menargetkandengan frekuensi efek samping, membuat pilihan

dua langkah dalam metabolisme asam folat.kemoterapi saat ini kurang ideal dan menyoroti

Terapi lain menggabungkan pirimetamin dengankebutuhan akan kemoterapi anti-Toxoplasma

klindamisin, azi tromisin atau atovakuon, ataubaru. Agen anti-Toxoplasma yang ideal akan

trimetoprim dengan sulfametoksazol. Namun,memiliki sifat-sifat berikut:

semua perawatan umumnya dikaitkan dengan penurunan toksisitas dibandingkan dengan obat
yang ada;
efek samping dan toksisitas yang merugikan (Ben- aman untuk digunakan selama kehamilan;
peningkatan kemanjuran dibandingkan dengan
Harari et al., 2017); misalnya, dalam satuobat yang ada;
kemampuan untuk menargetkan takizoit untuk
penelitian, 60% pasien ensefalitis toksoplasma
mengobati infeksi akut; kemampuan untuk
yang diobati dengan pirimetamin dan sulfadiazin
menargetkan bradizoit untuk menghilangkan
mengalami efek samping termasuk toksisitas
kista jaringan; dan kemampuan untuk mencapai
hematologi, ruam dan demam, yang
konsentrasi yang cukup di SSP untuk
menyebabkan 45% penghentian terapi (Haverkos,
menghilangkan parasit di otak dan mata.
1987). Pada pasien imunokompeten dengan
Pada bagian berikut, kami meninjau tar get saat
gejala persisten atau berat, durasi pengobatan
ini dan yang baru muncul (lihat juga Tabel 1 dan
pirimetamin/sul fadiazin biasanya 4-6 minggu.
Gambar 1) dan tantangan kemoterapi anti-parasit
Immunocom berjanji pasien memerlukan terapi
untuk mengobati toksoplasmosis manusia.
pemeliharaan jangka panjang setelah pengobatan
3.1. Inhibitor metabolisme asam folat
6 minggu awal, karena kista jaringan tidakApicomplexans, seperti banyak protozoa,

dihilangkan dengan pengobatan saat ini. Durasimengkodekan fusi enzim dihydro folate

pengobatan yang lama dan ketidakmampuanreductase (DHFR)-thymidylate synthase yang

untuk menghilangkan infeksi, dikombinasikanpenting untuk metabolisme folat dan sintesis

nukleotida (Ivanetich dan Santi, 1990; Trujillo et al.WR99210, JPC-2067-B, sebagai inhibitor kuat

, 1996). Pengobatan lini depan

untuk98
BKI 1294a + + ND Senyawa 32b + ++ Senyawa 24c
toksoplasmosis, pirimetamin, menargetkan DHFR
+ ++ Senyawa 3ad + ++
dengan bertindak sebagai antagonis asam folat
Rantai Transpor Elektron
(Gbr. 1). Pirimetamin bekerja secara sinergisPenghambat
Atovaquonee + + + ELQ271f + ++ ELQ334
dengan sulfonamid, yang bekerja pada
(ELQ316)g + ++ ELQ400h + + ND
dihidropteroat sintase, enzim lain dalam jalur
Sintesis Asam Lemak
sintesis folat. Namun, pengobatan denganInhibitor
Triclosani + ++
pirimetamin dan sulfadiazin sering menyebabkanSintesis Asam Folat
Inhibitor
efek samping toksik pada pasien termasukJPC-2056 (JPC-2067-B)j + + ND TRC-19k + ND ND

hipersensitivitas terhadap pengobatan sulfadiazin,Compound 3l + + ND

mengakibatkan ruam kulit dan demam (McLeodHistone Modification

Inhibitors
et al., 2006), dan penekanan sumsum tulang danFR235222m + ND ND W363 dan W399n + ND ND

efek buruk pada janin yang sedang berkembangIsoprenoid Pathway

Inhibitors
yang disebabkan oleh folatpenipisan terkaitRisedronateo + + ND Compound 1p + + ND

dengan pengobatan pyri methamine (Serranti etAtorvastatinq ND + ND

al., 2011). Oleh karena itu, pirimetamin tidakProtein Synthesis

Inhibitors
selalu direkomendasikan untuk mengobati infeksi Clindamycintorsr +Azitromisins + + Guanabenzt +

kongenital selama trimester pertama kehamilan. ++

Senyawa penargetan DHFR dengan potensi yanga Doggett et al. (2014), Muller dkk. (2017).
b . Vidadala dkk. (2016).

lebih besar terhadap T. gondii dibandingkanc Rutaganira dkk. (2017).

d Janetka dkk. (2020).

dengan manusia telah diselidiki untuk mengatasie Araujo dkk. (1991a), Araujo dkk. (1991b), Araujo

masalah yang terkait dengan toksisitasdkk. (1992), Romand dkk. (1993), Ferguson dkk.

pirimetamin. Misalnya, WR99210 adalah(1994), Dunay dkk. (2004).

penghambat DHFR T. gondii yang aktif baikf Doggett dkk. (2012).

g Doggett dkk. (2012), Doggett dkk. (2020),

secara in vitro maupun dalam model infeksi tikus,

McConnell dkk. (2018). h Doggett dkk. (2012),
dan menunjukkan potensi ~10 kali lipat lebih
McConnell dkk. (2018).
besar daripada pirimetamin (Mui et al., 2005).
Saya McLeod dkk. (2001), El-Zawawy dkk. (2015a,

Studi lebih lanjut mengidentifikasi analogb).

j.Mui dkk.(2008). minimal terhadap sel manusia (Mui et al., 2008).
k Welsch dkk. (2016).
l Hopper dkk. (2019). JPC-2067-B dapat diberikan sebagai prodrug
m Bougdour dkk. (2009), Maubon dkk. (2010).
n Maubon dkk. (2010). berkemampuan bioavail oral yang disebut
o Martin dkk. (2001), Yardley dkk. (2002).
p Ling dkk. (2005). JPC-2056, yang aktif in vivo, dan menunjukkan
q Li dkk. (2013).
r Araujo dan Remington (1974). karakteristik farmakologis yang lebih baik
s Araujo dkk. (1991a), Araujo dkk. (1991b), Dumas

daripada WR99210.
dkk. (1994). t Benmerzouga dkk. (2015),
Pendekatan desain obat rasional berbasis
Martynowicz dkk. (2019), Martynowicz dkk.
struktur komputasi juga telah digunakan untuk
(2020).
mengidentifikasi senyawa dengan selektivitas
proliferasi takizoit in vitro (50% konsentrasi
yang lebih besar untuk DHFR T. gondii
penghambatan (IC50) 20 nM), dengan toksisitas
dibandingkan DHFR manusia. Menggunakan

NC Smith, C. Goulart, JA Hayward et al. Jurnal Internasional untuk Parasitologi 51 (2021) 95-121

Gambar 1. Ringkasan beberapa target intervensi kemoterapi terhadap Toxoplasma gondii. Target meliputi proses

yang terjadi di apicoplast, mitokondria, dan nukleus, serta regulasi translasi sitosolik dan sintesis folat dan

isoprenoid. Lihat Bagian 3 dan Tabel 1 untuk rincian lebih lanjut. Inset menggambarkan siklus Q dari rantai

transpor elektron mitokondria (ETC). Elektron (e ) yang berasal dari metabolisme mitokondria disumbangkan ke

koenzim Q (CoQ), kemudian kesitus Qo Kompleks III. Dari sini, elektron diangkut melalui sitokrom c (CytC) dan
Kompleks IV ke O2, atau kembali ke CoQ di situs Qi Kompleks III. Sebagian besar penghambat rantai transpor

elektron dalam parasit ini menargetkan situs Qi atau Qo Kompleks III. CDPK, protein kinase yang bergantung pada

kalsium; FPPS, farnesil difosfat/geranil geranil difosfat sintase; IPP, isopentenil pirofosfat; MEP, metileritritol

fosfat.

pirimetamin sebagai struktur timbal, satu studifarmakokinetik awal pada tikus menunjukkan

mengidentifikasi TRC-19, senyawa denganbahwa Senyawa 3 mampu menyeberang ke SSP

potensi ~25 kali lipat lebih besar terhadap enzim(Hopper et al., 2019). Studi-studi ini merupakan

TgDHFR daripada pirimetamin (9 nM versus 230awal yang menjanjikan dalam upaya untuk

nM IC50) dan selektivitas ~90 kali lipat lebih besar mengidentifikasi inhibitor T. gondii DHFR yang

untuk T. gondii DHFR atas enzim manusialebih selektif dan kuat dengan karakteristik

(Welsch et al., 2016). Sebuah studi hubunganfisikokimia yang diperlukan untuk menghindari

struktur-aktivitas baru-baru ini lebihtoksisitas yang terkait dengan pengobatan

mengoptimalkan TRC-19 untuk mengembangkanpirimetamin dan sulfadiazin saat ini.

2-metoksipirimidin, ''Senyawa 3", dengan IC503.2. Penghambat rantai transpor

elektron mitokondria Rantai transpor elektron
sebesar 1,6 nM terhadap aktivitas TgDHFR,
mitokondria terdiri dari serangkaian kompleks
selektivitas ~200 kali lipat untuk T. gon dii DHFR
protein yang tertanam dalam membran
melebihi enzim manusia, dan konsentrasi efektif
mitokondria bagian dalam dan memainkan peran
50% (EC50) 13 nM terhadap proliferasi T. gondii
kunci dalam biosintesis pirimidin dan fosforilasi
dalam model kultur in vitro (Hopper et al., 2013).
oksidatif
Pada tikus dengan infeksi T. gondii akut,
,
pengobatan dengan Senyawa 3 meningkatkansuatu proses di mana parasit T. gondii dapat

kelangsungan hidup dengan cara yangmenghasilkan adenosin trifosfat (ATP) (Hayward

bergantung pada dosis, dosis tertinggi yangdan van Dooren, 2019). Beberapa reaksi

menghasilkan kelangsungan hidup 100% selamaenzimatik yang berlangsung di mitokondria

30 hari, dibandingkan dengan tikus yang diobati(misalnya, reaksi dalam siklus asam

dengan kendaraan, yang menyerah pada infeksitrikarboksilat) menghasilkan transfer elektron ke

setelah 6 atau 7 hari (Hopper et al., 2019). Masihkoenzim Q (CoQ), pembawa elektron yang

harus dilihat apakah Senyawa 3 efektif melawantertanam dalam membran mitokondria bagian

infeksi kronis atau kista bradizoit tetapi studidalam (Gbr. 1, inset). Kompleks III (juga dikenal
sebagai kompleks sitokrom bc1 ) memfasilitasi(Gbr. 1, inset). Docking CoQ tereduksi pada apa

transfer bersih elektron dari CoQ ke sitokrom c,yang disebutRieske dari Kompleks III (dari mana ia

pembawa elektron bergerak di ruangdiangkut terus melalui sisa rantai transpor

intermembran mitokondria (Gbr. 1, inset).elektron), atau ke situs dok CoQ kedua pada

Elektron dari sitokrom c ditransfer ke Kompleks IVsitokrom b disebut situs Qi (Gbr. 1, inset). Di situs

dari rantai transpor elektron, di mana merekaQi , CoQ teroksidasi berkurang, menghilangkan

akhirnya mereduksi O2, (Gbr. 1inset). Transporproton dari matriks mitokondria dan dengan

elektron melalui Kompleks III dan IV digabungkandemikian berkontribusi pada gradien proton

dengan translokasi proton melintasi membranmelintasi membran dalam.

mitokondria bagian dalam, menghasilkan gradienSitusQo danGbr Qi dari sitokrom b adalah target

proton yang dapat digunakan oleh ATP sintasedari berbagai obat anti-parasit, termasuk senyawa

(Kompleks V) untuk sintesis ATP. Proteinyang menargetkan T. gondii (. 1, inset). Yang

sitokrom b Kompleks III berinteraksi dengan CoQterbaik dipelajari dari ini adalah atovaquone, yang

dalam proses yang dikenal sebagai "siklus Q"tar

NC Smith, C. Goulart, JA Hayward et al. Jurnal Internasional untuk Parasitologi 51 (2021) 95-121
situsmendapatkan dari sitokrom b (Fry dan Pudney,telah dilaporkan (Baatz et al., 2006; Megged et al.,

1992; Pfefferkorn et al., 1993; McFadden et al.,2008). Studi ini menunjukkan bahwa atovaquone

2000). Studi awal menunjukkan bahwa atotidak sepenuhnya menghilangkan kista jaringan

vaquone memiliki aktivitas melawan takizoit danpada manusia. Mengingat bahwa banyak uji klinis

kista jaringan baik secara in vitro maupun in vivobersifat retrospektif, non-acak dan

(Araujo et al., 1991a, 1991b, 1992; Romand et al.,non-komparatif, lebih banyak data klinis

1993; Ferguson et al., 1994; Dunay et al., 2004).diperlukan untuk mengevaluasi kemanjuran

Namun, uji klinis memiliki hasil yang beragamatovaquone yang sebenarnya, idealnya

mengenai kemampuan ato vaquone untukmembandingkan tingkat kekambuhan pada

mencegah kekambuhan infeksi, dengan antara 12 pasien yang diberi atovaquone atau pyri

dan 26% pasien mengalami kekambuhan setelahmethamine dan sulfadiazine, atau kombinasi dari

1 tahun, dan hingga 75% setelah 6 tahun terapikeduanya. perawatan.

(Katlama et al., 1996; Pearson et al., 1999).Ada banyak minat dalam mengembangkan

Contoh kegagalan pengobatan atovaquone jugapenghambat Kompleks III dengan potensi dan
bioavailabilitas yang lebih baik daripadamodel infeksi akut (Doggett et al., 2020).

atovakuon. Seri endochin-like-quinolone (ELQ)Perawatan oral dengan ELQ-334 juga mengurangi

dari 4(1H)-quinolone-3- diarylethers dapatbeban kista otak hingga 83% pada tikus yang

menargetkan situs Qi dan/atau situs Qosecara kronis terinfeksi parasit T. gondii (Doggett

tergantung pada kimianya.Qi ELQ-271 danet al., 2020). Meskipun lebih kecil dari kista yang

ELQ-316 adalah penghambat kuat proliferasi T.tidak diobati, kista jaringan yang bertahan dari

gondii in vitro (nilai IC50 masing-masing 0,1 danpengobatan ELQ-334 layak dan mampu

0,007 nM) dan dalam mengobati infeksi akutmenimbulkan infeksi pada tikus naif (Doggett et

pada tikus, dengan selektivitas tinggi dalamal., 2020), menunjukkan bahwa pengobatan

menargetkan T .gondii kompleks atas KompleksELQ-334 tidak sepenuhnya membersihkan kista

manusia III (>90.000 kali lipat dan >106kali lipat,otak.

masing-masing) (Doggett et al., 2012).Mutasi padaQo danQi sitokrom b adalah penyebab

Khususnya, pengobatan ELQ-271 dan ELQ-316umum resistensi terhadap senyawa yang

mengurangi kista otak T. gondii hingga 88% padamenargetkan situs tersebut (McFadden et al.,

tikus (Doggett et al., 2012), menunjukkan bahwa2000; Alday et al., 2017). Potensi penghambat

senyawa ini aktif melawan takizoit dan bradizoityang menargetkan situs Qodan Qi, seperti ELQ-400,

in vivo. ELQ-400 menargetkan baik Qo dan situs Qi atau terapi kombinasi denganQo daninhibitor Qi

sitokrom b, dan menunjukkan kemanjuran yangsebagai inhibitor Kompleks III ganda, dapat

lebih besar dalam mengobati infeksi T. gondiimemperlambat munculnya resistensi obat dan

akut pada tikus daripada atovaquone dandengan demikian memberikan pengobatan yang

ELQ-316 (Mcconnell et al., 2018; Song et al.,lebih efektif terhadap kista jaringan. Sementara

2018). belum diuji pada infeksi T. gondii, kombinasi

ELQ yang disebutkan di atas menunjukkanELQ-334 (penghambat situs Qi ) dan atovaquone

kelarutan air yang rendah dan kristalinitas yang(penghambat situs Qmicroti , parasit apicom plexan

tinggi, yang dapat membatasi bioavailabilitasterkait, tanpa rekrudescence setelah 122 hari

oralnya. Sebuah prodrug ester bonate mobil dari(Lawres et al., 2016).

ELQ-316, yang disebut ELQ-334, dibuat dan3.3. Calcium-dependent protein kinase-1

inhibitors
terbukti meningkatkan bioavailabilitas danCalcium-dependent protein kinases (CDPKs)

memperpanjang kelangsungan hidup tikus dalamadalah keluarga dari serin/treonin protein kinase
yang ditemukan pada tumbuhan dan banyakbahwa BKI bertindak sebagai penghambat

proto zoan, termasuk apicomplexans (Billker et al.,kompetitif dalam kantong pengikatan ATP (Ojo et

2009). Genom T. gondii mengkodekan 14 CDPK,al., 2010), yang telah memfasilitasi beberapa

dan ini diperkirakan berfungsi dalam berbagaiprogram pengembangan obat berbasis struktur

proses yang bergantung pada pensinyalan(Cardew et al., 2018) yang telah menyebabkan

kalsium di seluruh siklus hidup parasit (Long et al.,peningkatan farmakologi, efikasi dan keamanan

2016). TgCDPK1 penting untuk proliferasiBKI (Choi et al., 2020).

takizoit, di mana ia berfungsi dalam Senyawa PP, BKI 1294, memiliki IC50 sebesar 140

100 nM dan menunjukkan kemanjuran terhadap

mikronema yang bergantung pada kalsium, suatu
infeksi akut pada tikus ketika diberikan secara
proses yang sangat penting untuk parasit keluar
oral (Doggett et al., 2014). Pemberian oral BKI
dari sel inang, motilitas meluncur dan invasi
1294 juga meningkatkan kelangsungan hidup
parasit ke sel inang baru (Lourido et al., 2010).
anak anjing dari 31% menjadi 100% pada infeksi
TgCDPK1 dapat dihambat secara efektif oleh apa
kongenital tikus, dengan hanya 7% anak anjing
yang disebut penghambat bumped kinase (BKI;
yang positif infeksi otak (Müller et al., 2017).
Gbr. 1), yang dianggap sebagai terapi potensial
Namun, potensi kardiotoksisitas melalui
yang menjanjikan terhadap parasit apicomplexan
penghambatan saluran ion Human
(Choi et al., 2020). BKI menargetkan kantong
Ether-a-go-go-Related Gene (hERG) ditemukan
pengikat ATP dari TgCDPK1, dan selektivitas BKI
dan mencegah perkembangan senyawa ini ke
untuk TgCDPK1 di atas kinase inang (dan CDPK
dalam pengembangan klinis (Ojo et al., 2014).
lain yang dikodekan oleh T. gondii) terletak pada
Untuk mengatasinya, lini BKI berbasis PP yang
adanya "residu gatekeeper" kecil (sebuah glisin)
dioptimalkan dikembangkan untuk menghindari
di tempat pengikatan ATP dari TgCDPK1, sebagai
penghambatan hERG (Vidadala et al., 2016).
lawan dari residu yang lebih besar seperti
"Senyawa 32" dari penelitian ini memiliki IC50 60
metionin yang ditemukan dalam kinase manusia.
nM dan, yang penting, mampu menyeberang ke
Beberapa perancah BKI telah diidentifikasi,
SSP dan mengurangi jumlah kista otak hingga
dengan pyrazolopyrimidines (PPs) dan 5-
88% pada infeksi kronis tikus (Vidadala et al.,
aminopyrazole-4-carboxamides (ACs) dua kelas
2016). Studi hubungan struktur-aktivitas lainnya
utama. Struktur TgCDPK1 telah menunjukkan
ke dalam molekul PP mengidentifikasi senyawa
(''Compound 24") yang mengurangi penyebaranpenargetan TgCDPK1 dengan aktivitas melawan

situs para dari rongga peritoneum ke otak padatahap infeksi parasit akut dan kronis.

infeksi akut tikus (Rutaganira et al., 2017).3.4. Inhibitor sintesis asam lemak (FAS)
Asam lemak merupakan komponen utama dari
Senyawa 24 juga mengurangi beban kista otak
membran biologis, dan juga berfungsi sebagai
dan menyembuhkan 40% tikus atau menunda
molekul sinyal penting. Pekerjaan awal
kematian pada 60% tikus dalam model reaktivasi
menunjukkan bahwa parasit T. gondii mampu
infeksi parasit pada tikus yang mengalami
mengais lipid, termasuk asam lemak, dari sel
gangguan kekebalan (Rutaganira et al., 2017).
inang (Charron dan Sibley, 2002). Urutan genom
Studi hubungan struktur-aktivitas juga telah
parasit menemukan bahwa T. gondii
mengembangkan pengembangan BKI dengan
mengkodekan enzim yang disebut jalur FAS II
perancah AC (Zhang et al., 2014). Dalam satu
biosintesis asam lemak (Seeber dan Soldati-Favre,
studi, optimasi struktural senyawa dengan
2010). Enzim dari jalur FASII melokalisasi ke
perancah AC menyebabkan produksi ''Senyawa
organel apicoplast (Waller et al., 1998; Seeber
35", sebuah molekul yang mampu menyeberang
dan Soldati Favre, 2010), plastid non-fotosintetik
ke SSP dengan lebih rendah in vitro IC50 (89 nM)
yang tersebar luas di seluruh apikompleks.
dan meningkatkan sifat farmakokinetik
Khususnya, jalur apicoplast FAS II berbeda dari
dibandingkan dengan senyawa awal (Huang et al.,
jalur FAS yang ditemukan di mitokondria mamalia,
2015). Pengembangan BKI yang ditingkatkan
dan juga dari enzim sitosolik asam lemak
melalui penggabungan perancah AC dan PP
multifungsi sintase I (FAS I) untuk FAS.
menyoroti janji pengembangan senyawa

NC Smith, C. Goulart, JA Hayward dkk. Jurnal Internasional untuk Parasitologi 51 (2021) 95-121
Penipisan bersyarat protein pembawa asil, enzimobat-obatan seperti thiolacto mycin dan triclosan,

sentral dalam jalur FAS II, menyebabkanyang menargetkan jalur FASII pada bakteri,

penurunan proliferasi parasit in vitro danterbukti menghambat proliferasi parasit (McLeod

penurunan virulensi pada infeksi akut tikuset al., 2001; Mazumdar et al., 2006). Sebuah studi

(Mazumdar et al., 2006).). Ditambah denganyang lebih baru, bagaimanapun, menunjukkan

ketidakhadirannya dari inang mamalia, inibahwa parasit dapat berkembang biak secara in

menunjukkan bahwa jalur FASII dapat mewakilivitro, dan menyebabkan penyakit dalam model

target obat yang menjanjikan (Gbr. 1). Memang,infeksi akut, setelah KO gen yang mengkode
enzim kunci FASII (Liang et al., 2020a, 2020b).menargetkan protein TgHDAC3 di T. gondii (Gbr.

Proliferasi in vitro pada mutan FASII ini lebih1), dan merupakan inhibitor poten dari proliferasi

lambat daripada parasit tipe liar, dan cacattakizoit (Bougdour et al., 2009). Pengobatan

proliferasi ini dapat diselamatkan dengandengan FR235222 menginduksi upregulasi gen

suplementasi asam lemak berlebih dalam mediaspesifik bradizoit dan menghasilkan diferensiasi

pertumbuhan. Ini mencerminkan penelitiantakizoit menjadi bradizoit. Menariknya,

terbaru lainnya yang mengungkapkan bahwa jalur pretreatment dari kista yang mengandung

FASII diregulasi ketika parasit dikultur dalambradizoit ex vivo membuat mereka tidak mampu

media pertumbuhan yang miskin lipid (Amiar et al.berubah menjadi takizoit ketika diinokulasi ke

, 2020). Bersama-sama, temuan ini menunjukkantikus (Maubon et al., 2010). Ini menunjukkan

tingkat fleksibilitas metabolik yang cukup besarbahwa penghambat HDAC3 memegang janji

dalam perolehan lipid di T. gondii, menunjukkankhusus dalam mencegah reaktivasi kista otak.

bahwa jalur FASII mungkin sangat penting dalamKeterbatasan potensial adalah bahwa FR235222

relung intraseluler atau tahap infeksi di manahanya memiliki selektivitas 10 kali lipat untuk T.

asam lemak di lingkungan terbatas. Namungondii atas sel inang. Senyawa penargetan HDAC

demikian, keraguan tetap ada tentang apakahterkait W363 dan W399, bagaimanapun,

FASII mewakili target obat yang layak untukmenunjukkan potensi yang sama dengan

parasit ini. FR235222 dalam menghambat proliferasi parasit

3.5. Inhibitor modifikasi histon dan kurang beracun bagi sel manusia (Maubon et
Histon adalah protein pengikat DNA yang
al., 2010).
berfungsi dalam pengemasan DNA dalam inti sel
3.6. Inhibitor biosintesis
eukariotik. Modifikasi histon pasca-translasiisoprenoid Isoprenoid adalah lipid yang

memainkan banyak peran dalam mengaturberkontribusi pada berbagai aspek biologi seluler.

ekspresi gen, serta memfasilitasi replikasi danDalam parasit apicomplexan seperti T. gondii,

perbaikan DNA. Pada T. gondii, enzim histonemereka berfungsi sebagai prekursor untuk

deacetylase (HDAC) dan histone acetylasemolekul seperti pembawa elektron mitokondria,

penting untuk mengontrol ekspresi gen, termasukCoQ, dan kelas lipid yang disebut dolichols, serta

dalam interkonversi antara takizoit dan bradizoitdalam prenilasi protein yang berfungsi dalam

(Saksouk et al., 2005). Inhibitor HDAC, FR235222,sistem bran endomem (Imlay dan Odom, 2014).
Blok bangunan dasar isoprenoid adalah duakerjanya. Ekspresi berlebih pada protein bakteri T.

molekul berkarbon lima yang disebut isopentenilgondii yang mampu mengangkut fosmidomisin

pirofosfat (IPP) dan dimetilalil pirofosfatmembuat parasit ini sensitif terhadap

(DMAPP). Sintesis IPP dan DMAPP terjadi difosmidomisin baik in vitro maupun in vivo (Nair et

apicoplast api complexans melalui jalur tujuhal., 2011). Pengamatan serupa dari aksesibilitas

enzim yang disebut jalur methylery thritolfosmidomisin terbatas telah dilakukan pada

phosphate (MEP) (Imlay dan Odom, 2014). Jalurparasit Plasmodium stadium hati (Baumeister et

MEP, kadang-kadang disebut sebagai jalural., 2011; Nair et al., 2011). Untuk mengatasi

non-mevalonat, pada dasarnya berbeda dari apamasalah aksesibilitas obat ini, serangkaian yang

yang disebut jalur mevalonat yang mensintesisdisebut "MEPicides", yang merupakan prodrug

IPP dan DMAPP dalam sel mamalia dan,ester lipofilik yang secara struktural terkait

karenanya, telah diusulkan sebagai target terapidengan fosmidomycin dan dirancang untuk

yang menjanjikan meningkatkan masuknya ke dalam sel target,

101 telah disintesis baru-baru ini; mereka terbukti

dalam apikompleksans (Gambar 1). Memang,
menjadi penghambat kuat proliferasi
antibiotik fosmidomycin, yang menghambat
Plasmodium in vitro dan in vivo (Wang et al.,
1-D-xylulose-5-phosphate (DOXP) reductoi
2018a, 2018b) serta mampu menghambat
somerase, enzim kedua dalam jalur MEP, adalah
patogen intraseluler lainnya, seperti bakteri
penghambat kuat proliferasi parasit Plasmodium
Staphy lococcus, dengan cara yang tidak
stadium darah (Jomaa et al. ., 1999). Anehnya,
bergantung pada transporter (Edwards et al.,
bagaimanapun, fosmidomycin tidak berpengaruh
2020). Sekarang akan menarik untuk menguji
pada pertumbuhan T. gondii, meskipun
MEPisida untuk aktivitas anti-Toxoplasma.
reduktoisomerase DOXP menjadi penting untuk
Setelah sintesisnya di apicoplast, IPP diekspor ke
proliferasi T. gondii dan aktivitas
sitosol di mana ia dapat dimetabolisme lebih
reduktoisomerase DOXP rekombinan yang
lanjut untuk menghasilkan berbagai isoprenoid.
sensitif terhadap fosmidomisin (Ling et al., 2005;
Sebuah fungsi ganda farnesyl
Baumeister et al., 2011; Nair et al., 2011).
diphosphate/geranyl geranyl diphosphate
Pengamatan ini dapat dijelaskan dengan tidak
synthase (TgFPPS) enzim di T. gondii
dapat diaksesnya fosmidomycin ke tempat
menghasilkan 15- dan 20-karbon isoprenoid dari
IPP, dan penting untuk biosintesis isoprenoid hilirbersamaan dari jalur biosintesis isoprenoid

jalur DOXP (Ling et al., 2007). Senyawa bifosfonat,mevalonat inang menggunakan obat atorvastatin

risedronate, menghambat enzim ini (Gbr. 1) dan(Gbr. 1) meningkatkan kelangsungan hidup tikus

menunjukkan aktivitas melawan proliferasi T.yang terinfeksi dengan strain knockout TgFPPS

gondii in vitro (Martin et al., 2001). Risedronatedari 20% menjadi 90% (Li et al., 2013). Inhibitor

juga meningkatkan kelangsungan hidup tikusjalur mevalonat inang, termasuk statin seperti

yang terinfeksi kista jaringan sebesar 55% selama atorvastatin, digunakan secara luas untuk

30 hari infeksi pada dosis tertinggi yangpengobatan manusia yang berisiko penyakit

digunakan (Yardley et al., 2002). Bifosfonat lainjantung. Strategi penghambatan ganda

dengan indeks terapeutik dan potensi yang lebihmenggunakan obat untuk menargetkan jalur

besar daripada risedronate telah diidentifikasi,biosintesis isoprenoid parasit dan inang dapat

dengan satu senyawa meningkatkanmenghasilkan efek sinergis in vivo, dan studi

kelangsungan hidup tikus yang terinfeksi hinggamasa depan yang meneliti kelayakan terapeutik

80% selama periode 30 hari (Ling et al., 2005;dari pendekatan semacam itu untuk pengobatan

Shubar et al., 2008) . infeksi T. gondii menjadi perhatian khusus.

Gangguan genetik pada gen yang mengkode3.7. Inhibitor sintesis protein

Asal endosimbiotik dari apicoplast T. gondii
protein TgFPPS tidak mempengaruhi proliferasi
berarti bahwa kompartemen ini menampung
parasit dalam fibroblas in vitro tetapi
mesin translasi turunan bakteri (misalnya,
mempengaruhi proliferasi dalam kondisi stres
ribosom 70S). Banyak penghambat terjemahan
seperti pertumbuhan makrofag dan ketika parasit
bakteri telah terbukti menghambat proliferasi T.
ekstraseluler (Li et al., 2013). Dispensabilitas
gondii (Gbr. 1) dan apikompleks lainnya
TgFPPS dikaitkan dengan kemampuan T. gondii
(Goodman et al., 2016); misalnya, klindamisin,
untuk mengais isoprenoid dari sel inang. Untuk
penghambat bakteri 50S (besar) ribosom
mendukung hal ini, penghambatan secara

NC Smith, C. Goulart, JA Hayward et al. Jurnal Internasional untuk Parasitologi 51 (2021)

subunit 95-121, menghambat proliferasi T. gondiipirimetamin (Dannemann et al., 1992). Strain T.

(Pfefferkorn et al., 1992) dan telah digunakangondii yang resisten klindamisin memiliki mutasi

dalam pengobatan klinis pasien ensefalitispada rRNA besar yang dikodekan pada genom

toksoplasma dalam kombinasi denganapicoplast (Camps et al., 2002), menunjukkan

bahwa klindamisin menargetkan translasi proteinmemfasilitasi proliferasi parasit jangka panjang

dalam apicoplast parasit ini. setelah hilangnya apicoplast (Amberg- Johnson

Parasit yang diobati dengan klindamisin dandan Yeh, 2019).

senyawa lain yang mendapatkan terjemahanMakrolida, azitromisin, adalah penghambat lain

apicoplast menunjukkan fenotipe aneh yangtranslasi protein apicoplast, dan dapat digunakan

dikenal sebagai kematian tertunda (Fichera et al.,sendiri atau dalam kombinasi dengan

1995; Camps et al., 2002), di mana proliferasipirimetamin untuk mengobati episode akut

parasit tetap tidak terpengaruh oleh pengobatantoksoplasmosis okular (Rothova et al., 1998;

sampai mereka keluar dari inang yang ada selBosch-Driessen et al., 2002; Balaskas et al. al.,

dan menginvasi kembali sel inang baru.2012). Azitromisin memiliki banyak sifat yang

Fenomena ini terkait dengan hilangnya apicoplast menguntungkan termasuk bioavailabilitas oral

yang terjadi pada pengobatan dengan inhibitor iniyang baik, waktu paruh yang lama dan efek

– tampaknya parasit mampu mentolerirsamping yang lebih sedikit daripada pirimetamin

kehilangan apicoplast sampai merekadan sulfadiazin (Alday dan Doggett, 2017).

menginvasi kembali sel inang baru, yangSementara pasien mengalami lebih sedikit efek

mengarah pada usulan bahwa produksamping dengan pengobatan azitromisin

metabolisme apicoplast diperlukan untukdibandingkan dengan pirimetamin dan

membentuk yang baru. infeksi (Dia et al., 2001).sulfadiazin, satu penelitian mencatat bahwa 27%

Menariknya, pengobatan bersama denganpasien mengalami kekambuhan dalam satu

klindamisin dan penghambat jalur mevalonattahun monoterapi azi tromisin (Rothova et al.,

inang, atorvastatin, menghasilkan fenotipe1998). Hal ini menunjukkan bahwa azitromisin

kematian yang lebih cepat dibandingkan dengantidak sepenuhnya menghilangkan kista T. gondii

pengobatan dengan klindamisin sajapada pasien. Sesuai dengan ini, sementara

(Amberg-Johnson dan Yeh, 2019). Hal inipengobatan azitromisin memperpanjang

mengarah pada usulan bahwa pemulungankelangsungan hidup tikus pada model infeksi

isoprenoid inang mengkompensasi hilangnya apitikus akut dan kronis (Araujo et al., 1991a, 1991b;

koplast yang terjadi pada siklus litik pertamaDumas et al., 1994), pengobatan azitromisin pada

setelah pengobatan klindamisin tetapitikus yang terinfeksi parasit T. gondii secara

pemulungan isoprenoid inang tidak cukup untukkronis tidak tidak mengurangi beban kista otak
dibandingkan dengan kontrol (Dumas et al., 1994).penulis berspekulasi bahwa perbedaan ini dapat

Sintesis protein sitosolik juga merupakan targetmuncul dari perbedaan dalam reaktivasi kista

potensial intervensi terapeutik pada T. gondii (Gbr.jaringan, perbedaan

1). Studi telah mengungkapkan bahwa konversi102

kerentanan tikus terhadap infeksi T. gondii,
takizoit menjadi bradizoit bersamaan dengan
dan/atau perbedaan dalam respon imun yang
fosforilasi faktor inisiasi eukariotik T. gondii 2
ditimbulkan oleh kedua jenis tikus ini. Terlepas
(TgeIF2; Sullivan et al., 2004; Narasimham et al.,
dari alasannya, penelitian ini menyoroti
2008). TgeIF2 memiliki peran kunci dalam
pentingnya menyelidiki kontribusi biologi inang
memulai translasi pada ribosom sitosol dan,
terhadap hasil penyakit setelah perawatan obat.
seperti pada organisme lain, fosforilasinya
3.8. Tantangan dan prospek untuk pilihan
merusak translasi sitosol, yang menyebabkan
pengobatan kemoterapi yang lebih baik
penurunan global dalam sintesis protein parasit
Sementara banyak kemajuan telah dibuat untuk
(Sullivan et al., 2004; Narasimhan et al., 2008).
mengidentifikasi kemoterapi anti-Toxoplasma
Pengobatan parasit dengan obat antihipertensi
baru, masih banyak tantangan untuk
yang disetujui Food and Drug Administration
menerjemahkan temuan ini menjadi hasil klinis
(USA), guanabenz, menghambat defosforilasi
yang lebih baik untuk pasien. Kemoterapi yang
TgeIF2, yang pada gilirannya mendorong
ideal terhadap T. gondii akan menyembuhkan
pembentukan kista yang mengandung bradizoit
pasien infeksi, yang akan membutuhkan senyawa
dan mencegah reaktivasi menjadi takizoit in vitro
tersebut untuk memiliki aktivitas melawan bentuk
(Konrad et al., 2013). Pengobatan Guanabenz
takizoit penyebab penyakit dan bentuk bradizoit
memperpanjang kelangsungan hidup tikus dalam
yang tumbuh lebih lambat. Salah satu tantangan
model infeksi akut selama beberapa hari (Konrad
utama adalah untuk memperoleh pemahaman
et al., 2013; Benmerzouga et al., 2015).
yang lebih luas tentang biologi kista jaringan yang
Menariknya, efek guanabenz pada beban kista
mengandung bradizoit, dan mengapa obat gagal
otak tampaknya bervariasi antara strain tikus,
menghilangkan kista jaringan pada pasien.
dengan pengobatan guanabenz menyebabkan
Kemajuan terbaru dalam memfasilitasi
penurunan kista otak pada tikus BALB/c tetapi
diferensiasi in vitro takizoit menjadi bradizoit
mengarah ke peningkatan kista otak pada tikus
secara massal dapat membantu dalam upaya ini
C57BL/6J (Martynowicz et al ., 2019). Para
(Waldman et al., 2020), meskipun penting untukmanusia.

memverifikasi bahwa model in vitroDalam upaya untuk mengidentifikasi target obat

merekapitulasi biologi bradizoit dan kista jaringan baru dan kue kemoterapi baru, metode

di hidup. Khususnya, kapasitas replikasi danpenyaringan throughput tinggi semakin banyak

fisiologi bradizoit in vivo tampaknya lebihdigunakan untuk menilai perpustakaan senyawa

heterogen dan dinamis daripada yangbesar untuk aktivitas melawan proliferasi T.

diperkirakan sebelumnya (Watts et al., 2015; Sinai gondii in vitro (Boyom et al., 2014; Murata et al.,

et al., 2016), menyiratkan bahwa beberapa kista2017; Adeyemi dkk., 2018a). Salah satu

(berpotensi yang laten/tidak aktif ) mungkin lebihtantangan yang membatasi perkembangan

resisten terhadap obat daripada yang lain.senyawa hit adalah perbedaan dalam efektivitas

Memahami penyebab heterogenitas ini dapatin vitro versus in vivo, karena banyak senyawa

mengungkap jalan baru untuk intervensiyang menjanjikan dalam penyaringan awal

terapeutik, khususnya menentukan faktor apamenunjukkan sifat farmakokinetik yang tidak

yang mendorong bradizoit menjadimenguntungkan atau, pada akhirnya, proses tar

latensi/dormansi. get yang kurang penting untuk kelangsungan

Penghalang jalan lainnya adalah potensi efekhidup parasit in vivo daripada in vitro. Studi

strain spesifik obat pada T. gondii dan tikus.hubungan struktur-aktivitas dan pengembangan

Contoh mencolok dari hal ini adalah hasilprodrug dengan sifat in vivo yang lebih diinginkan

penyakit yang bergantung pada strain tikus yangsangat menjanjikan dalam pengembangan "hit"

diamati pada pengobatan guan abenz (lihatyang menjanjikan yang muncul dari layar

Bagian 3.7) (Konrad et al., 2013; Benmerzouga etthroughput tinggi.

al., 2015; Martynowicz et al., 2019). Studi-studi iniTantangan terakhir adalah memahami sejauh

menyoroti manfaat dan, mungkin, perlunyamana pengobatan anti-Tox oplasma dapat

menguji kemanjuran senyawa pada banyak tikus"membonceng" upaya pengobatan pada parasit

dan strain T. gondii untuk menginformasikanapicomplexan lainnya, terutama parasit

hasil yang mungkin lebih baik ketika senyawaPlasmodium, di mana upaya skrining obat

dikembangkan ke uji klinis. Ini jugaekstensif ada. Beberapa agen anti-Toksoplasma

mempertanyakan sejauh mana kinerja senyawasaat ini, termasuk pirimetamin dan atovakuon,

pada model tikus menyerupai hasil pada penyakitjuga merupakan penghambat kuat parasit
Plasmodium. Namun demikian, ada perbedaanobat-obatan yang sangat berkhasiat dalam satu

besar dalam jenis sel inang dan lingkunganparasit belum tentu menjadi penghambat kuat di

fisiologis yang didiami parasit ini, dan jugasitus para lain. Menekankan hal ini, layar obat

perbedaan besar dalam biologi tahap siklus hidup antimalaria di akhir

yang berbeda dari situs para ini. Ini berarti bahwa

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95-121
pengembangan praklinis mengungkapkan bahwaAktivasi atau penekanan elemen-elemen berbeda

sebagian besar obat antimalaria yang diuji hanyadari sistem kekebalan melalui imunoterapi

menunjukkan kemanjuran yang terbatas terhadapterarah yang ditargetkan telah mendapatkan

proliferasi T. gondii (Radke et al., 2018). Sebagaiperhatian yang signifikan di bidang penyakit

contoh yang lebih spesifik, cipargamin,menular, termasuk toksoplasmosis (Kaufmann et

penghambat kuat parasit P. falciparum yangal., 2018a, 2018b; Singh et al. al., 2019).

menargetkan pompa natrium PfATP4 (Spillman etImunoterapi kurang rentan terhadap munculnya

al., 2013), menunjukkan kemanjuran yangresistensi dan seringkali memiliki efek samping

terbatas terhadap T. gondii (Radke et al., 2018;yang lebih sedikit dibandingkan dengan obat

Lehane et al. , 2019). Hal ini dapat dijelaskan olehantimikroba. Sementara saat ini tidak ada pai

perbedaan konsentrasi natrium yang dialami olehimunoterapi yang digunakan untuk

tahap penyebab penyakit parasit ini di dalam seltoksoplasmosis manusia, model murine telah

inangnya, dengan homolog T. gondii dari PfATP4memberikan wawasan yang mungkin terbukti

dikeluarkan untuk proliferasi intraseluler (Lehanepenting untuk perkembangan masa depan (Gbr.

et al., 2019). Oleh karena itu, sementara gagasan2). Pada bagian berikut, kami meninjau kemajuan

untuk mengembangkan terapi pan-apicomplexanpenelitian terbaru dalam imunoterapi terhadap

yang bekerja pada jalur yang dilestarikan menarik, toksoplasmosis, termasuk peran imunisasi pasif,

kemungkinan bahwa memfokuskanterapi antibodi monoklonal, sel T reseptor antigen

pengembangan obat awal untuk mengoptimalkan chimeric (CAR), sitokin dan kemokin, obat

kemanjuran terhadap T. gondii akan mengarahimunomodulator dan kekebalan terlatih, yang

pada terapi yang lebih baik untuk pengobatanmana saja dapat dibayangkan. menjadi dasar

toksoplasmosis. untuk perawatan masa depan orang

4. Imunoterapi untuk mengendalikan imunosupresi.

toksoplasmosis
4.1. Imunisasi pasif, antibodi monoklonal dan sel trifosfat hidrolase-II ke tikus mempromosikan
T CAR
Imunisasi pasif, transfer antibodi poliklonal darikelangsungan hidup yang berkepanjangan (Cha

serum imun (Gbr. 2A), telah digunakan untuket al., 2001; Tan et al., 2010). Meskipun tidak satu

mengobati dan mencegah penyakit menularpun dari transfer ini memberikan kekebalan steril,

seperti tetanus, rabies, dan hepatitis B (Sparrowada kemungkinan bahwa identifikasi antigen

et al., 2017). Studi transfer adopsi awal dalamspesifik dinding bradizoit dan kista tambahan,

model hamster infeksi T. gondii menunjukkanseperti SRS9, CST1 dan MAG2 (Kim et al., 2007;

bahwa antibodi hanya berkontribusi sedikit untukTomita et al., 2013; Tu et al., 2020), dapat

perlindungan setelah transfer (Frenkel, 1967).membuka jalan bagi terapi kombinasi mAb masa

Temuan ini meletakkan dasar untuk konsepdepan yang menargetkan beberapa molekul

bahwa kekebalan terhadap T. gondii didominasispesifik tahap untuk perlekatan, invasi, proliferasi,

oleh IFNc memproduksi sel CD8+ T (Suzuki dandan persistensi secara bersamaan (Gbr. 2B).

Remington, 1990; Kang et al., 2000; Sayles et al.,Demikian pula, mAbs yang menargetkan

2000; Casciotti et al. , 2002). Namun, kemudianpenghambatan reseptor, seperti CTLA-4 dan PD-1,

ditunjukkan bahwa, pada murine toksoplasma103

pada sel T CD8+ dan sel pembunuh alami (NK)
mosis, antibodi berkontribusi untuk
telah terbukti meningkatkan kekebalan selama
mengendalikan kegigihan jangka panjang dan
infeksi T. gondii kronis (Hunter et al., 1997;
resistensi yang diinduksi vaksinasi (Kang et al.,
Bhadra et al., 2011, 2012; Xiao et al., 2018),
2000; Sayles et al., 2000). Dengan penggunaan
meskipun temuan ini memerlukan validasi lebih
terapi antibodi monoklonal (mAb) yang lebih baru
lanjut (Split et al., 2018).
dan meluas dalam pengobatan kanker (Byun et al.
Meskipun imunoterapi seluler, seperti transfer sel
, 2017), imunisasi pasif dengan mAbs pada
T CD8+ dan sel NK, dapat melindungi hewan dari
toksoplasmosis telah direvitalisasi. Ditunjukkan
tantangan T. gondii yang mematikan (Casciotti et
bahwa transfer fragmen mAb Fab manusia yang
al., 2002; Ivanova et al., 2019), strategi ini tidak
spesifik ke protein T. gondii surface antigen 1
cocok untuk skala besarskala aplikasi manusia.
(SAG1) ke dalam tikus secara signifikan
However, the advent of commercial-scale CAR T
meningkatkan tingkat kelangsungan hidup (Fu et
cell and NK cell therapy may provide a new
al., 2011). Demikian pula, transfer mAbs terhadap
avenue for cell-mediated immunother apy in
protein granul padat GRA2, GRA6 atau nukleosida
toxoplasmosis (Maldini et al., 2018; Liu et al.,mouse models of toxoplasmosis and in ex vivo

2020). CAR T cell therapy involves the transferinfection of human cells. Similarly, IL-18, formerly

into patients of genetically mod ified T cells thatknown as IFN-c enhancing factor, also plays a

not only recognise specific protein targets butcritical role in immunity to T. gondii, by

also co-express T cell activation functions in asynergising with IL-12 (Cai et al., 2000). The

single engineered recep tor. CAR T cell therapydevelopment, expansion and survival of

has revolutionised cancer treatment over the lastIFN-c-producing cell types depends on the c chain

decade and, despite non-cancer applications stillcytokines, IL-2, IL-7 and IL-15 and, thus,

being in their infancy, one could envisage that theimmunotherapies based on said cytokines have

re-engineering of patient-derived CD8+ T cell or NKalso shown improved outcomes of toxoplasmosis

cell receptors specific for stage specific T. gondiiin animal models (Fig. 2D). While the exact role of

antigens could significantly improve feasibilityIL-15 in immu nity to T. gondii remains somewhat

and success of cellular immunotherapy forunresolved (Khan et al., 2002; Lieberman et al.,

(latent) toxoplasmosis (Fig. 2C). Nevertheless, a2004), IL-2 deficient mice are highly susceptible

vigilant evaluation of these immunother apies into T. gondii infection (Villegas et al., 2002), and

the context of infection will be required, asadministration of recombinant IL-2 enhances

neurological complications and disseminatedsurvival of Toxoplasma-infected mice (Sharma et

toxoplasmosis have been reported in CAR Tal., 1985; Shirahata et al., 1993). Delivery of

cell-treated patients (Kersten et al., 2019; Kator etrecombi nant IL-15 also protects against lethal

al., 2020). infection by enhancing IFN-c production (Khan

4.2. Cytokines and Casciotti, 1999; Khan and Kasper, 1996) but
Immunity to toxoplasmosis is critically dependent
IL-15 deficient mice are able to develop protective
on ILs and IFN-c, in particular the IL-12/IFN-c axis
immunity (Lieberman et al., 2004). IL-7 and IL-15
(Yarovinsky, 2014); many studies have
appear to syner gise during acute infection
demonstrated beneficial outcomes after the
(Kasper et al., 1995; Bhadra et al., 2010), although
delivery of recombinant IL-12 (Hunter et al., 1995;
the recall response of memory CD8+ T cells to T.
Araujo et al., 1997) or IFN-c (Suzuki et al., 1988;
gondii is almost exclusively dependent on IL-15
Suzuki et al., 1990; Benedetto et al., 1991;
(Bhadra and Khan, 2012).
Delemarre et al., 1993; Delemarre et al., 1994) in
IL-2 and IL-15 are presented to the cytokine
receptor complex beta and the common c chain(IL15C) significantly enhances the biological

in the context of cell-bound high affinity alphaactivity of these cytokines in vivo (Boyman et al.,

chains of the cytokine receptor (Stoklasek et al.,2006; Votavova et al., 2014). The binding site of

2006; Stonier and Schluns, 2010). This processthe anti-IL2 mAb used in the IL2C determines

has been termed trans-presentation. Combiningwhether a preferen tial expansion of regulatory T

IL-2 with anti-IL-2 mAbs to form an IL-2 complexcells (TReg) or CD8+ T cell and NK cells occurs;

(IL2C) or combining IL-15 with a chimericanti-IL-2 mAb JES6-1A12 causes expansion of

receptor (IL-15RaFc) to form an IL-15 complexTReg cells;

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021)

95–121
 104

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
whereas anti-IL-2 mAb S4B6 causes expansion ofand reduced immunopathology and morbidity

CD8+ T cells and NK cells (Boyman et al., 2006;during acute type II T. gondii ME49 infection

Shevach, 2012). In animal studies,(Oldenhove et al., 2009), likely by preventing the

JES6-1A12-containing IL2C improved control ofcompetition for bioavailable IL-2 between

RH strain T. gondii infection (Akbar et al., 2015)regulatory and effector T cells. We have also
shown recently that S4B6-containingand their recep tors (Menzies et al., 2016). Similar

IL2C-mediated expan sion of non-CD4 immuneto most intracellular pathogens, T. gondii benefits

cells that produce IFN-c can be harnessed tofrom leukocyte recruitment, as it can use infected

rescue mice from acute lethal toxoplasmosiscells to spread through the host (Da Gama et al.,

(Kupz et al., 2020). Intriguingly, although this IL-12- 2004; Lambert et al., 2009). Hence, interfering with

and IL-18-dependent effect of treatment with SB46-the chemokine-chemokine receptor axis may

IL2C leads to reduced acute pathology, it does soprovide novel targets for host-directed therapies

without affecting TReg cells or parasite burden.(Fig. 2F). To illustrate, mouse studies have shown

Together, these IL2C studies suggest that cytokine that the absence of chemokine receptor type 5

complex immunotherapy may be a viable future(CCR5) leads to a reduction in tissue damage due

adjunct treatment in the context of chronic toxto reduced NK cell recruitment and IFN-c

oplasmosis, in particular for immunosuppressedproduction, but also to an increased parasite

people with impaired CD4+ T cells, eg, as causedburden (Khan et al., 2006). CCR5 signalling is also

by HIV co-infection in AIDS (Fig. 2E). However,involved in the T. gondii-induced interruption of

caution is needed because data on the clinical use pregnancy in mice (Nishimura et al., 2017), and

of IL2C and IL15C treatments in humans arehuman polymor phisms in CCR5 have been linked

lacking and it needs to be acknowledged thatto a greater risk of developing ocular

treatment with cytokine complexes could lead totoxoplasmosis (de Faria Junior et al., 2018). The T.

hyperinflammatory responses. Such angondii secreted effector molecule, cyclophilin 18

undesirable potential outcome should be taken(TgCyp18), binds to CCR5 and mimics CCR5

into careful consideration before embarking onligand binding (Aliberti et al., 2003), fur ther

translational studies in humans. supporting the idea that CCR5 activation favours T.

4.3. Chemokines gondii sur vival. However, no therapeutic or

Many parasitic infections, including toxoplasmosis,
prophylactic treatments with antibodies or
are charac terised by excessive or imbalanced
inhibitors targeting CCR5 or its ligands CCL3,
inflammation and pathology (Menzies et al., 2016).
CCL4 and CCL5 in the context of toxoplasmosis
These events are tightly linked to the recruitment,
have been reported to
influx and persistence of leukocytes to the site of
3
infection, events that are regulated by chemokinesdate. Given that CCR5 receptor antagonism
inhibits hepatitis C virus replication (Blackard et al.,benefit from further investigations.

2019) and limits the progression of gastric cancer 4.4. Immunomodulatory drugs
Immunomodulatory drugs comprise different
(Aldinucci and Casagrande, 2018), further studies
classes of com pounds with direct or indirect
into its effect on toxoplasmosis are warranted.
impact on the immune system (Gao et al., 2020).
CCL2, CCL3, CCL4 and CCL5 are produced by
The imide-containing class of immunomodula tory
intestinal cells after they become exposed to
drugs (IMiDs), such as thalidomide and several
tachyzoites (Gopal et al., 2011). In partic ular, the
analogues, are widely used in the treatment of
parasite-derived molecules GRA24 and SAG1 have
autoimmune diseases and can cer (Abe and Ishida,
been implicated in this process (Rachinel et al.,
2019; Fuchs, 2019). To date, none of these IMiDs
2004; Brenier-Pinchart et al., 2006; Braun et al.,
have been reported to have an impact on
2013), indicating that T. gondii actively
toxoplasmosis. However, there is growing interest
manipulates chemokine secretion pathways to its
in deciphering the role of vari ous
advantage. The double-edged sword of leukocyte
immunomodulatory compounds derived from
recruitment for the initiation of immunity against T.
chemical libraries as well as from natural products
gondii and the parasite's requirement to induce
on infectious diseases, including toxoplasmosis
inflammation, is also demonstrated by studies
(Sepulveda-Arias et al., 2014; Sharif et al., 2016)
using CCR1 and CCR2 knockout mice, both of
(Fig. 2G); for example, in one study, it was shown
which are highly susceptible to lethal
that treatment of mice with ursolic acid, a
toxoplasmosis (Khan et al., 2001; Dunay et al.,
compound commonly found in various fruits,
2008). Che mokine and anti-chemokine therapies
increased a number of critical anti-toxoplasmosis
are actively being pursued in the field of
cytokines in a mouse model of toxoplasmosis
inflammatory diseases (Castellani et al., 2007;
(Choi and Lee, 2019). Similarly, beneficial effects
Mohit and Rafati, 2012; Ambade et al., 2019) and
on murine toxoplasmosis have been reported after
cancer (Ruffini et al., 2007; Arakaki et al., 2016;
treatment with lectins (Ramos et al., 2016), Echi
Lim et al., 2016). However, similar to CCL3, CCL4
nacea purpurea extracts (Gasparotto Junior et al.,
and CCL5, no targeted therapies with CCL2, CCL7,
2016) and lacto ferrin (Anand et al., 2015).
CCL23, or synthetic CCR1 or CCR2 agonists and
4.5. Trained immunity
antagonists have been reported in the context ofIn recent years, the concept of ''trained immunity”

toxoplasmosis. This area of research wouldhas gained significant attention (Netea et al., 2016,
2020). It has been shown

Fig. 2. Summary of potential immunotherapies for the control of toxoplasmosis. (A) Isolation and transfer of

polyclonal antibodies from sera of Toxoplasma gondii immune individuals could be used for passive

immunisation. (B) Monoclonal antibody (mAb) therapy with mAbs could be used to target different antigens

expressed by tachyzoites, bradyzoites and the cyst wall. (C) Isolation of T and natural killer (NK) cells from T.

gondii-infected individuals followed by re-programming of these cells with chimeric antigen receptors (CAR)

specific for T. gondii epitopes. Expanded chimeric antigen receptors T and natural killer cells are re-infused into

infected individuals to target quiescent and actively replicating parasites. (D) The synergistic effects of IL-2, IL-7,

IL-12, IL-15 and IL-18 in mediating development, differentiation, expansion, survival and interferon-c production by

T cell subsets and natural killer cells could be used to boost immunity to T. gondii. (E) Cytokine complexes of

IL-2/anti-IL-2 and IL-15/anti-IL-15 could be used to expand interferon-c (IFN-c)-producing immune cells to boost

immunity against acute toxoplasmosis. Expansion of regulatory T cells could be used to reduce

immunopathology and morbidity. (F) Interference with the chemokine-chemokine receptor axis may be used to

target excessive and imbalanced inflammation and pathology during acute toxoplasmosis. The T. gondii secreted

effector molecules, TgCyp18, SAG1 and GRA24, either bind to CCR5 and mimic CCR5 ligand binding or induce

chemokine secretion by epithelial cells, respectively. Blocking these effector molecules in addition to CCL2, 3, 4, 5,

7 and 23, as well as their receptors, CCR1, 2 and 5, may prevent excessive recruitment, influx and persistence of

leukocytes to the site of infection. (G) Immunomodulatory compounds such as the imide-containing class of

immunomodulatory drugs (IMiDs) and natural products such as lectins, lactoferrin and ursolic acid, which

stimulate cytokines and immune cells, could be used as adjunct treatments of toxoplasmosis. (H) A further

understanding of trained immunity in the context of toxoplasmosis may reveal potential therapies to specifically

target epigenetic imprinting in immune cells and epithelial cells. Muramyl dipeptide and b-glucan in combination

with spiramycin have shown therapeutic potential in murine models of toxoplasmosis. See Section 4 for further

details.

105
NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
that some live attenuated vaccines, adjuvants,(Kaufmann et al., 2018a, 2018b). This trained

microbial ligands and b-glucan have a strongimmunity appears to be the rea son for adaptive

effect on ''training” hematopoietic stem cells andimmunity-independent protection against a vari

innate immune cells via epigenetic imprintingety of viral, bacterial and parasitic pathogens
(Arts et al., 2018; Dos Santos et al., 2019;Vaccination has been used extensively to control

Tarancon et al., 2020). To date, no study hasinfectious dis eases worldwide (Doherty et al.,

addressed the specific role of trained immunity in2016). Due to the complexity of the life cycle of T.

treating, pre venting or ameliorating T. gondiigondii and the parasite's ability to infect any

infection and disease, whether acute or latent.warm-blood animal, the challenge to develop a

However, given the explosion of research activityvaccine to control toxoplasmosis involves

in this field, it appears to be only a matter of timeconsideration of: (i) which stage of the par asite

before the impact of trained immunity onlife cycle and, hence, which host(s) to target; (ii)

toxoplasmosis will be investigated (Fig. 2H). Inwhich para site antigens to target; and (iii) the

that context, it is important to note thatmode of delivery.

Krahenbuhl et al. (1981) demonstrated thatA vaccine for direct use in humans should, ideally,

pre-treatment of mice with the synthetic adjuvantprotect against both the acute and chronic

muramyl dipeptide afforded resistance to subphases of infection, needing to prevent the severe

sequent T. gondii challenge. The authors of thatconsequences of ocular toxoplasmosis, con

study concluded that the protection wasgenital toxoplasmosis caused by a primary

independent of enhanced antibody produc tion orinfection in pregnant women, and the mortality

macrophage activation, and must have been duecaused by the reactivation of latent par asites in

to a yet to be identified mechanism. Interestingly,immunosuppressed individuals (Tenter et al.,

independently of assessing the impact on2000; Machala et al., 2015; El Bissati et al., 2018).

immunity, a synergistic effect of b-glucan with spiIt is debatable whether a single vaccine could

ramycin in the treatment of toxoplasmosis hasachieve all these requirements.

also been reported previously (Buyukbaba BoralA vaccine targeting T. gondii in livestock would

et al., 2012). It has also been proposed thatnot only need to prevent bradyzoite cyst

human T. gondii infection itself may haveformation in order to minimise transmis sion of

long-term effects on the phenotype andthe parasite to humans through consumption of

responsiveness of monocytes, implying a train ing under cooked meat (Tenter et al., 2000) but would

effect that may also impact immunity to unrelatedalso need to reduce the economic loss caused by

pathogens (Ehmen and Lüder, 2019). animal abortion, especially in sheep and goats

5. Vaccination for the control of toxoplasmosis (Stelzer et al., 2019), to encourage widespread
use. Again, these different requirements mightshould target young girls before they reach fertile

necessitate the identifi cation of different targetsage and induce a protective immune response

in T. gondii and require different modes ofable to prevent the vertical transmission of the

delivery. parasite from the mother to the unborn child.

A vaccine targeting felids, the only definitive hostSuch a vaccine would reduce the glo bal

of T. gondii, would be able to stop the shedding ofincidence of congenital toxoplasmosis, which is

highly infective oocysts into the environment and,estimated to be 1.5 cases per 1,000 live births

consequently, reduce the incidence of infec tion(~190,000 new cases every year) (Jones et al.,

via ingestion in both livestock and humans2001; Torgerson and Mastroiacovo, 2013). A

(Frenkel and Smith, 1982; Innes et al., 2009;vaccine to prevent acute and chronic

Torrey and Yolken, 2013). Mathe maticaltoxoplasmosis is desirable. Such a vaccine would

modelling highlights the attractiveness of the catprevent the severe illness caused by an acute

as a tar get for vaccination in order to preventinfec tion in immunocompromised individuals, as

toxoplasmosis in livestock and humanswell as protect against the life-threatening

(Mateus-Pinilla et al., 2002; Arenas et al., 2010;reactivation of latent bradyzoites present in tissue

Jiang et al., 2012; Turner et al., 2013; Sykes andcysts of individuals who acquired toxoplasmosis

Rychtárˇ, 2015; Bonacˇic´ Marinovic´ et al., 2020)when healthy but become immunocompromised

but the form and means of delivery to achieveafterwards (Pott and Castelo, 2013; Stajner et al.,

sufficient coverage of such a vaccine arguably2013; Wang et al., 2017).

presents a potential obstacle to success (BonacˇThere are no reports of T. gondii vaccine studies

ic´ Marinovic´ et al., 2020). in humans. There is, however, a long list of

106 experimental vaccines that have been tested

5.1. Anti-Toxoplasma vaccines for intermediate
hosts recently in murine models, examples of which are
5.1.1. Anti-Toxoplasma vaccines targeting
humans summarised in Table 2 and Fig. 3. As is the case
Virtually all individuals are at risk of acquiring
for any intermedi ate host, mice can be infected
toxoplasma infection at some point in their
by oral administration of oocysts or cysts
lifetime, therefore a vaccine to pre vent
containing bradyzoites, mimicking natural routes
toxoplasmosis in humans would benefit all
of infec tion, or by the artificial injection of
(Tenter et al., 2000). Ideally, a T. gondii vaccine
tachyzoites. Experimental mod els established in
mice include acute and lethal T. gondii infection,(Behnke et al., 2014; Hehl et al., 2015;

the formation of bradyzoite tissue cysts inRamakrishnan et al., 2019), combined with

muscles and brain, and congenital toxoplasmosisadvances in the use of CRISPR/Cas9 genome

(Subauste, 2012). Several vaccine candi datesediting strategies (Shen et al., 2017; Sidik et al.,

have been investigated including SAGs, rhoptry2018; Markus et al., 2019; Young et al., 2019) that

proteins (ROP), microneme proteins (MIC), GRAallow targeted and selectable marker-free

and other proteins secreted by tachyzoites (Fig.deletion of genes, may lead to the development of

3). Similarly, different formulations, adjuvants,optimised attenuated strains with reduced risks

immunisation routes and schedules have beenof reversion. Indeed, the prospects for

tested, spanning killed or live attenuateddevelopment of a live attenuated vaccine for

parasites, subunit vaccines, recombinant proteins,humans and other intermediate hosts have been

DNA vaccines and live vectors to deliver T. gondiienhanced by recent discoveries concerning how

antigens (Fig. 3). Despite showing some promisestage differ entiation is regulated at a molecular

– most candidates report ing some ability tolevel (Farhat et al., 2020; Waldman et al., 2020). In

reduce cyst formation and prolong survival of theparticular, the identification of a single

host – there is no report of progression of atranscription factor (the Myb-like transcription

vaccine tested in mice to human clinical trials. factor, BFD1) as a master-regulator for

To date, the only commercial vaccine against T.differentiation from tachyzoite to bradyzoite

gondii is based on an attenuated strain designed(Waldman et al., 2020) theoretically paves the

to prevent abortion in sheep which, due toway for develop ment of a live vaccine incapable

potential safety and regulatory issues associatedof forming cysts (Kochanowsky and Koshy, 2020).

with a possible reversion to fully virulent parasites, In addition, an advantage of CRISPR/Cas9 in the

is not consid ered suitable for administration tocontext of producing attenuated vaccine strains

humans (Innes et al., 2019). However, provision ofis that genes can be, effectively, knocked out

the genomes of the main T. gondii strainswithout introducing foreign DNA into the parasite.

(Lorenzi et al., 2015) and transcriptomic data sets This means that these strains would not neces

of different stages of the parasite life cycle

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
Table 2
Examples of recent experimental murine vaccines against Toxoplasma gondii.
Live Attenuated Vaccines
Gene deleted Immunising Toxoplasma Strain Vaccine Trial
Challenge Strain Immune Results
Toxoplasma Strain Murine Host Summary
Response

CDPK2a PruDcdpk2 RH, PRU Kunming IgG, Protection of host against lethal challenge;

Th1/Th2 cytokines partial reduction of brain cyst numbers.

LDH1 and LDH2b,c RH, ME49, VEG micec challengeb reduction of brain
IgG, IFN-c, IL 12
PruDldhb and a field isolate Protection of host cyst numbersc
Protection of host
ME49Dldh c of Chinese 1c against lethal
against lethal
RHb BALB/cb ICR challenge; partial

Gra17 and NPT1d RHDgra17Dnpt1 RH, PRU partial reduction of brain cyst numbers; partial

Kunming IgG, IFN-c, IL 2, IL-10 and protection against congenital toxoplasmosis

IL-12 Protection of host against lethal challenge;

Tyrosine kinase-like 1e RHDtkl1 RH, PRU
partial reduction of brain cyst numbers; partial
Kunming IgG1, IgG2a, IFN-c, IL-2
protection against congenital toxoplasmosis
Protection of host against lethal challenge;

Adenylosuccinate lyasef ME49D ADSL RH, ME49, VEG ICR IgG and IgA Protection of host against lethal challenge

Subunit/Recombinant Vaccines

Antigen nt Toxoplasma Murine Host Vaccine Trial

Results Summary
Formulation/Adjuva Challenge Strain Strain
Immune Response

Recombinant GRA2g Monophosphorryl lipid Tehran C57BL/6 IgG, IFN-c Partial

reduction of brain cyst numbers
A (MPL)

Recombinant inhibitor-1 and/or GRA4h hydroxide or IgG, Th1/Th2

serine protease (TgPI-1), ROP2 Aluminium CpG-ODN cytokines

ME49 C3H/ HeN
Partial reduction
of brain cyst
numbers
Recombinant calcium kinases family, TgCDPK1i IFN-c, IL 12, IL-10
BALB/c RH BALB/c IgG,
dependent protein Prolonged survival of host

Epitopes of GRA10j peptide (MAP) in C57BL/6 against lethal

IgG1, IgG2a, IFN-c, IL-2
Multiple antigenic chitosan microspheres challenge; partial
RH, PRU BALB/c and Protection of host
reduction of brain cyst numbers

Epitopes of SAG1, Poly nanoparticle + Prolonged survival

Alum of host
AMA1, ROP2, and lactic-co-glycolic RH BALB/c IgG1,

GRA4k acid (PLGA) IgG2a, IFN-c, IL-2

Apical membrane antigen 1 VLP containing partial reduction of brain cyst

influenza M1 protein
(AMA1)l ME49 BALB/c IgG, IgA numbers

DNA Vaccines Prolonged survival of host;

Gene nt Toxoplasma Murine Host Vaccine Trial

Results Summary
Formulation/Adjuva Challenge Strain Strain
Immune Response

GRA7 and ROP2m RH BALB/c IgG2a, IFN-y Prolonged survival of host

T. gondii profilin (TgPF)n IL-15 PRU IL-4, IL-10
Partial reduction of brain cyst numbers
Kunming IgG, IgG2a, IFN-c, IL-2,

Perforin-like protein (PLP1) and IL-12, IFN-c numbers

ROP18o Prolonged survival of host;

IL-18 PRU Kunming IgG2a, IL-2, partial reduction of brain cyst

ROP22p RH BALB/c IgG1, IgG2a, IL-2, IFN-c Prolonged survival of host; partial reduction of

ROP21q RH, PRU BALB/c IgG1, IgG2a, IFN-c brain cyst numbers

ROP5 and ROP18r IL-33 RH Kunming IgG2, Prolonged survival of host; partial reduction of

IFN-c, IL-2, IL-12 brain cyst numbers

ROP 8 epitopess RH BALB/c IgG1, IgG2a, IFN-c Prolonged survival 0f host; partial reduction of

Heterologous Vector Expressing Toxoplasma brain cyst numbers

proteins
Prolonged survival of host
Gene Vector Challenge Strain Strain Results Summary
Immune Response
Toxoplasma Murine Host
Vaccine Trial
Apical membrane antigen 1 (AMA1)t (2017). c Xia et al. (2018).

a Wang et al. (2018a). b Abdelbaset et al.Adenovirus vaccine RH BALB/c IFN-c, IL-

4 Increased survival of host
d Liang et al. (2020a), Liang et al. (2020b).
e Wang et al. (2020a).
f Wang et al. (2020b).
g Babaie et al. (2018).
h Picchio et al. (2018).
i Huang et al. (2019).
j Guo et al. (2018).
107
NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
k Roozbehani et al. (2018).
l Kim et al. (2020).
m Vazini et al. (2018).
n Gao et al. (2018).
o Chen et al. (2018).
p Zhang et al. (2019).
q Zhang et al. (2018).
r Zhu et al. (2020).
s Foroutan et al. (2020).
t Jia et al. (2018).

Fig. 3. Summary of some recent experimental murine vaccines against Toxoplasma gondii infection. Targets

include proteins that function in the micronemes, rhoptries, dense granules, cytosol, nucleus, plasma membrane,

or parasitophorous vacuole membrane. Vaccine strategies include the production of protein subunit vaccines,

DNA vaccines, adenovirus vaccines, and attenuated parasite strains (refer to key for symbols). See Section 5 and

Table 2 for further details.

sarily be classified as Genetically Modified al., 2020).

Organisms (GMOs) in many countries (Zhang et Another approach to vaccine development has
been to combine bioinformatic tools withclass I pathway. These peptides can eli cit the

immunological approaches. Such studies haveproduction of IFN-c from CD8+ T cells in

focussed on identifying peptide epitopes fromperipheral blood mononuclear leukocytes of

proteins humans who are T. gondii seropositive (Cong et

108 al., 2010, 2011). Immunisation of human

secreted during infection with T. gondii that can
leukocyte anti
access the major histocompatibility complex

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
gen (HLA) transgenic mice with multi-epitopevaccine is recom mended for immunisation of

DNA or protein vac cines in combination with aewes as a single intramuscular injec tion at least

universal CD4+ epitope peptide and adjuvant4 weeks before mating. Following immunisation,

induced high levels of IFN-c and protected micethe attenuated parasites undergo limited

against challenge with type II parasites (Cong etreplication cycles, mimicking a natural infection,

al., 2010, 2011; El Bissati et al., 2016). Althoughand this is able to induce long-lasting protec tion,

the high polymorphism of HLA mole cules in thelikely involving CD4+ and CD8+ cell responses

human population may be an obstacle for epitope along with IFN-c production (Buxton et al., 1994).

based vaccines, studies have demonstrated thatToxovax is commer cialised through MSD Animal

the specificity of peptide-binding shared by theHealth and is available in the UK, Ire land, France

HLA supertypes A02, A03, and B07 correspondsand New Zealand.

to ~90% of the world's population (Barber et al.,Vaccination with the S48 strain of T. gondii

1995; Sidney et al., 1995). impairs the forma tion of bradyzoite tissue cysts

5.1.2. Anti-Toxoplasma vaccines targeting in animals subsequently treated with wild type
livestock
The only commercial T. gondii vaccine (Toxovax )parasites; immunisation of lambs with the S48

was devel oped over three decades ago in Newstrain reduced the presence of parasites detected

Zealand for control of abortion in sheepby PCR in the heart (by 75%) and skeletal muscles

(O'Connell et al., 1988; Buxton and Innes, 1995).(by 82%) of lambs challenged with wild type

Toxovax consists of attenuated tachyzoites ofoocysts (Katzer et al., 2014). Similar results were

the S48 strain of T. gondii, which after over 3000observed in pigs immunised with the S48 strain

passages in mice lost its ability to developbefore challenge with wild type oocysts (Burrells

bradyzoite tissue cysts (Buxton, 1993). Thiset al., 2015). A bioassay showed increased
survival (48.5%) of mice that received tissueeval uated for its ability to prevent tissue cysts in

samples from vaccinated pigs compared withpigs (Lindsay et al., 1993). A bioassay showed

mice that received porcine tissue samples fromthat immunisation of pigs with TS-4 tachyzoites

the control group (Burrells et al., 2015). Althoughby subcutaneous or intravenous routes did not

S48 vaccination did not completely prevent tissue protect against bradyzoite cyst formation in the

cyst formation following challenge in lambs andtissues of pigs challenged with wild type oocysts

pigs, these studies indicate that a vaccine able to(Lindsay et al., 1993; Dubey et al., 1994). Similarly,

reduce the cyst burden in livestock may reduceoral administration of oocysts inactivated by

the risk of infection of humans through137Cs gamma irradiation (0.3 or 0.4 kGy) did not

consumption of undercooked meat (Katzer et al.,prevent bradyzoite tis sue cyst formation in pigs

2014; Burrells et al., 2015). challenged with live oocysts (Dubey et al., 1998).

Since the approval of Toxovax , other liveExtracts or purified fractions of T. gondii

attenuated and inac tivated parasites have beenparasites in combina tion with adjuvants have

investigated in order to develop an improvedbeen investigated as subunit vaccines.

vaccine to prevent sheep abortion and protect109

Microspheres containing proteins from a crude
against tissue cyst development. Immunisation of
extract of RH strain tachyzoites encapsulated into
ewes with tachyzoites of a strain of T. gondii,
poly(D,L-lactide-co-glycolide) were investigated as
wherein MIC1 and MIC3 were knocked out
an intranasal vaccine for sheep with and without
(MIC1-3KO) 2 months before mating, induced
cholera holotoxin (Stanley et al., 2004). Although
humoral responses and reduced the abortion of
both systemic and mucosal humoral responses,
lambs in ~72% of ewes after a chal lenge with
together with cell-mediated immunity, were
wild type oocysts mid-gestation (Mevelec et al.,
observed, immunisation with microspheres con
2010). However, MIC1-3KO tachyzoites were
taining T. gondii proteins failed to protect sheep
reported to persist as tissue cysts in immunised
against clinical signs of infection upon challenge
animals (Mevelec et al., 2010). A
with oocysts of the M3 strain of T. gondii.
temperature-sensitive mutant (TS-4) of the RH
Western blot analysis demonstrated that the main
isolate of T. gondii (Pfefferkorn and Pfefferkorn,
anti body elicited after immunisation was reactive
1976), which does not persist as tis sue cysts in
against a protein of approximately 30 kDa, likely
the tissues of mice (Waldeland et al., 1983), was
to be the major surface antigen of the parasite,animals tested and the unnatural route of

SAG1 (Stanley et al., 2004). This suggests thatchallenge infection combined with the use FCA, a

SAG1 antibodies are not sufficient to protectpowerful inducer of cell-mediated immune

against infection. In pigs, subcutaneousresponses that is not used commercially due to

immunisation with two doses of crude rhoptrysafety issues, restricts evaluation of this study's

proteins formulated as immunostimulatingpractical implications.

complexes (ISCOMs), induced a systemic IgGDNA vaccines encoding several T. gondii antigens

response. Following challenge with oocysts, thehave been investigated for their ability to induce

animals immunised with rhoptry proteins showedan immunological response in sheep and pigs.

the same clinical signs of infection as controlImmunisation of sheep with a DNA vaccine

pigs (including fever, secretions from the eye,encoding the bradyzoite-specific antigen, MAG1,

coughing and loss of appetite) and only 20% ofalone or co expressed with the cytokine, IL-6,

vacci nated pigs did not develop tissue cysts asinduced a specific humoral response

indicated by a bioassay in mice (Garcia et al.,(Hiszczynska-Sawicka et al., 2010). Comparison

2005). Similarly, a further investigation showedof the immune response in sheep immunised with

that crude ROPs administered by the intranasala DNA vaccine encod ing SAG1 or ROP1

route in combina tion with the adjuvant, Quil A, did combined with unmethylated cytosine

not induce strong humoral or cellular immunephosphate-guanosine oligodeoxynucleotide

responses prior to challenge infection, and onlymotifs showed that ROP1-encoding DNA, but not

one of four pigs tested negative for T. gondii bySAG1-encoding DNA, was able to induce humoral

bioassays post challenge (da Cunha et al., 2012).and IFN-c responses (Li et al., 2010). Similarly,

In contrast, another study showed thatplasmids encoding for ROP1 in fusion with CD154,

immunisation of pigs with a mixture of tachyzoite a co stimulatory molecule expressed by activated

excretory/secretory antigens induced humoralT-cells, induced a mixed Th1/Th2 response in

and cellular immune responses, including IFN-csheep, with higher IFN-c levels than was induced

and IL-4, and prevented the development of tissue by plasmids encoding ROP1 protein only

cysts in four out of five pigs following chal lenge(Hiszczynska-Sawicka et al., 2011a). DNA

with tachyzoites injected intraperitoneally (Wangvaccines encoding GRA1, GRA4, GRA6 or GRA7

et al., 2013). However, the small number ofshowed that GRA7 can stimulate the ovine
immune system and was able to induce IFN-c and ever been tested for efficacy against T. gondii

IgG2 responses (Hiszczynska-Sawicka et al.,challenge.

2011b). In pigs, immunisa tion with a DNA5.2. Anti-Toxoplasma vaccines for the definitive
host
vaccine encoding for GRA1 and GRA7 inducedFelids are the only definitive host of T. gondii.

antibodies and cellular immune responses toAfter a primary infection with T. gondii, cats may

both proteins (Jongert et al., 2008). Unfortunately, shed millions of oocysts that can persist in soil

none of the DNA vaccines described above haveand water as sources of infection for many

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
months/years (Ferguson, 2009). Upon reinfection, reduced the bradyzoite cyst burden in the brains

few or, more usually, no oocysts are observed inof cats but failed to prevent oocyst shedding after

the faeces of challenged cats indicating that,challenge with bradyzoite-containing cysts of the

even after a single infection, cats develop anBeverley strain (Mishima et al., 2002). Crude

immune response that is able to prevent repeated rhoptry pro teins purified from tachyzoites were

oocyst shedding (Dubey, 1995). Moreover, there isinvestigated as a vaccine can didate in

evidence that this immunity cross-protectscombination with the adjuvant Quil A;

against heterologous strains (Freyre et al., 2007).administration via the intranasal or rectal routes

Thus, although the nature of this immunefollowed by oral challenge with bradyzoite cysts

response is not known, there are grounds toof ME49 strain showed some ability to prevent

believe that a vaccine that is able to block oocystoocyst shedding by cats compared with a control

shedding by cats would reduce the number ofgroup receiving BSA and Quil A (Zulpo et al.,

oocysts in the environment and, consequently,2012). Similarly, immunisation of cats with

reduce the prevalence of tox oplasmosis,recombinant ROP2 plus Quil A via the nasal route

providing that issues related to vaccine coveragereduced the total number of oocysts in only 23.9%

of pets and stray or feral cats could be resolved. of cats compared with the control group receiving

Attempts to develop recombinant and subunitBSA and the adjuvant (Zulpo et al., 2017).

vaccines to pre vent the shedding of oocysts byIn contrast, immunisation of cats by infection with

cats have been few and have shown only limitedlive attenu ated strains of T. gondii has proven

promise. A recombinant feline herpesvirus type 1highly effective at preventing oocyst shedding.

(FHV1) expressing the T. gondii ROP2 proteinThe T-263 strain of T. gondii, which is a
chemically-induced mutant that develops throughdocumentation ~40 years ago of enzymatic

to micro- and macrogametes but lacks the abilityperturbations (Pfefferkorn, 1978; Pfefferkorn and

to produce oocysts (Dubey, 2017), was the firstKasper, 1983), these mutations have not been

reported live attenuated vaccine investigated.defined. The advent of next-generation

Oral administration of two doses of T-263 tissuesequencing approaches may facilitate a better

cysts or brady zoites released by pepsin digestion understanding of this strain in future. Other

induced antibody responses and preventedstudies on live vaccines indicate that

oocyst shedding in 84% (Frenkel et al., 1991) orstage-specific antigens and administration routes

100% (Freyre et al., 1993) of kittens aftermay play an important role in the protective

challenge with an oocyst producing strain. Theimmune response against the enteric stages of T.

efficacy of the live attenuated T-263 strain as agondii. For example, immunisation by oral or

transmission-blocking vaccine was alsoduodenal adminis tration of T-263 tachyzoites

investigated in a long term field trial in swinefailed to prevent oocyst shedding upon

farms in the USA (Mateus-Pinilla et al., 1999).subsequent challenge of cats (Freyre et al., 1993).

Cats present on these swine farms were caughtSimilarly, immu nisation of cats by the

and immu nised by infection with bradyzoites ofintramuscular injection of 60Co-irradiated

the T-263 strain. Immunisa tion of catstachyzoites of the Beverley strain prevented

significantly reduced T. gondii infection inoocyst shedding in only 43% of the immunised

finishing pigs on these farms across timecats following challenge with homolo gous

(Mateus-Pinilla et al., 1999). Despite thebradyzoites, and immunisation with

promising results achieved with the T-263 strain60Co-irradiated tachy

of T. gondii, diffi culties associated with110

zoites of the RH strain failed to prevent oocyst
large-scale production of bradyzoites, cold chain
shedding upon challenge with bradyzoites of the
transportation, and perceived risks to people
heterologous Beverley strain (Omata et al., 1996).
handling and administering the vaccine inhibited
Recently, the aforementioned MIC1-3KO strain
its commercialisation (Choromanski et al., 1995).
was investigated as a live attenuated vaccine for
Given the manner of its derivation, the T-263
cats. Although promising results were reported in
strain of T. gondii is likely to possess multiple
mice and sheep, immunisation of cats with
mutations. However, apart from some
tachyzoites of the MIC1-3KO strain by either theoocysts. Moreover, all cats previously immunised

subcutaneous or oral route did not protectby infection with the HAP2-deficient T. gondii

against oocyst shedding (Le Roux et al., 2020). parasites shed no oocysts upon challenge with

There is reason to hope that targeted attenuatedbradyzoite-containing cysts from the wild-type

vaccines are a realistic proposition.parental strain (Ramakrishnan et al., 2019). An

RNA-sequencing data and analyses of cat entericimpediment to application of a targeted

stages of T. gondii (Behnke et al., 2014; Hehl et al.,attenuated vaccine to block transmission of T.

2015; Ramakrishnan et al., 2019) have providedgondii oocysts is, as it was for the T 263 mutant

valuable insights into genes expressedstrain, the provision of bradyzoites for

specifically in merozoites, microgametes andimmunising infection of kittens. However, the

macrogametes with presumptive roles in sexualrecent identification of a master switch for the

reproduction and oocyst formation. These studiesconversion of tachyzoites to bradyzoites

bring with them the opportu nity to design(Waldman et al., 2020) significantly improves the

vaccines that specifically target the feline entericprospects for development of an in vitro ''cell

stages of T. gondii. Indeed, to establishfactory” system for the mass production of

proof-of-principle, a CRISPR/Cas9 gene-editingbradyzoites.

strategy was used to engineer a T. gon dii strain6. Nanotechnology for the control of
toxoplasmosis
lacking the expression of a putative microgameteThe use of nanomaterials in medicine has been

specific fertilisation factor, HAP2 (Ramakrishnantermed nano medicine (Soares et al., 2018) and,

et al., 2019). Infection of rats with HAP2-deficientincreasingly, nanoparticles are being assessed for

tachyzoites led to the estab lishment of chronicinclusion in a range of diagnostic, thera peutic

infection and tissue cyst development. Pri maryand preventative applications. Nanomaterials can

infection of cats with bradyzoite-containing cystsbe defined as organic or inorganic, crystalline or

from these rats demonstrated thatamorphous particles in the range of tens to

HAP2-deficient T. gondii parasites were unable tohundreds of nanometres in size (Assolini et al.,

complete fertilisation and, as a result, very few2017; Soares et al., 2018). They can be organised

oocysts were produced and those that were hadas single particles, aggregates, powders, or

an aberrant mor phology and could not undergodispersed in a matrix to form suspensions,

meiosis to form infectious sporo zoites withinemulsions or nanolayer films (Soares et al., 2018).
 A consequence of their size is a very largeinteractions are also influenced by shape, chemi

surface area to volume ratio, making them muchcal composition, surface charge and roughness,

more reactive than larger particles. This givesallowing them to be tailor-made for specific

them a tendency to adsorb biomolecules when intargets (Soares et al., 2018). Their diversity

contact with biological fluids so that a layermakes them very versatile and nanoparticles have

known as the corona forms on the surface ofbeen used to improve diagnostic assays, as a

colloidal nanoparticles. Their size also allowsnew way of delivering chemotherapy or vaccine

them to penetrate cells and interact withformulations, or as therapeutic agents and

intracellular molecules. Their biologicaladjuvants themselves.

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95–121
6.1. Nanotechnology in the diagnosis of T. gondii inclusion of nanoparticles due to increased
infection
Diagnosis of acute infections with T. gondii issurface area available for adsorption of reagents

usually through the detection of anti-T. gondii IgM,(Medawar-Aguilar et al., 2019). Assays that have

IgA, IgE or IgG antibodies in the serum of patientsbeen developed include a microfluidic assay

by ELISA, indirect haemagglutination tests orusing zinc oxide nanoparticles coated with

immunosorbent agglutination tests (Ybañez et al., chitosan (Medawar-Aguilar et al., 2019) and an

2020). An increase in IgM, IgA and IgE iselectrochemical immunosensor consisting of gra

considered to be characteristic of an acutephene sheets, goldmag (Au-Fe3O4) nanoparticles

infection, whereas detection of only IgG isand thionine (Jiang et al., 2013). Both of these

characteristic of a chronic or previous infectionassays used T. gondii lysate con jugated to the

(Ybañez et al., 2020). A major drawback to thesenanoparticles to capture anti-T. gondii antibodies

methods is low sensitivity, which results in falsein serum samples and demonstrated increased

negatives. Accurate diagnosis can also besensitivity compared with conventional sandwich

complicated by the presence ofELISAs. Li et al. (2015) used goldmag

immunosuppressed patients who produce verynanoparticles modified with polymethacrylic acid

low levels of IgM or patients who can produceconjugated with anti-human IgM antibodies in a

IgM for up to a year after initial infection (Ybañezlateral flow immunochro matographic assay

et al., 2020). A number of stud ies have aimed to(LFIA) to test for the TORCH pathogens (Toxo

increase the sensitivity of the assays by theplasma, rubella virus, cytomegalovirus and herpes
simplex virus) in pregnant women (Li et al., 2015). to SAG1 to detect parasite antigens in serological

This assay also displayed increased sensitivitysam ples, increasing sensitivity from 92% to 98%.

and specificity compared with commerciallyXu et al. (2013) devel oped a probe using

available LFIA assays. TORCH pathogens werenickel-magnetic nanoparticles and fluorescence

also targeted in the development of a microarrayresonance energy transfer to detect T. gondii DNA,

using quantum dots (photolumines cent although it should be noted that the probe was

nanomaterials) coated with antigens to detectnot validated using patient samples. It is unlikely

infections in serological samples (Yang et al.,that sensitivity of this probe would exceed that of

2009). This assay had comparable sensitivity andthe real-time PCR assay developed by Lin et al.

specificity to conventional ELISA but had the(2000), lim iting its usefulness.

advantage of a shorter run time and a more stableIn addition to increased sensitivity and specificity

signal (Yang et al., 2009). of diagnostic tests incorporating nanoparticles,

Toxoplasmosis can also be diagnosed throughthe speed, cost and convenience were also often

direct detection of T. gondii. This is particularlyimproved compared with existing tests. These

useful in immunocompromised patients where aimprovements have led to a more accurate

serological response is reduced and there is thediagnosis and faster implementation of

risk of false negative results. These tests can beappropriate treatments for patients identified as

developed to detect either DNA or antigens of thesuffering from toxoplasmosis.

parasite. As with assays to detect antibodies,111

6.2. Nanotechnology in the treatment of T. gondii
nanoparticles were used to increase theinfection
As discussed above, the most commonly used
sensitivity of diagnostic assays that detect
drugs for human toxoplasmosis are sulfadiazine
parasite antigen. Aly et al. (2018) used silica
and pyrimethamine, both of which can cause
particles coated with polyclonal antibodies to T.
serious side effects such as bone marrow
gondii lysate to detect circulating parasite antigen
suppression, allergy and renal and hepatic
in serological and urine samples. Sensitivity was
complications (Gaafar et al., 2014). Other drugs,
increased from 85.7% to 90% for serum samples
including a range of antibiotics and anti-malarials,
and 78.6% to 82.6% in urine samples (Aly et al.,
have also been used but they can also have
2018). Hegazy et al. (2015) used
serious side effects (Abou-El-Naga et al., 2017).
immunomagnetic beads coated with antibodies
The unique physicochemical proper ties ofburden compared with infected, untreated mice;

nanoparticles can be harnessed to improvehowever, they were not as effective as treatment

delivery of drugs by altering theirwith sulfadiazine (Teimouri et al., 2018). Addition

pharmacokinetics. This can lead to a slower drugof anti-T. gondii drugs to chitosan nanoparti cles

delivery, better target specificity, increaseddid, however, increase effectiveness of parasite

efficacy and a reduc tion in side effects (Anand et killing com pared with chitosan or the drug alone.

al., 2015). Drugs that are toxic, or have poorSpiramycin is an antibiotic that is used to treat

solubility, or are easily degraded in thetoxoplasmosis in pregnant women but is limited

gastrointestinal tract, can be delivered into thein its effectiveness by low bioavailability and an

body for more effective treatment at lower dosesinability to cross the blood–brain barrier. Loading

using nanotechnology-based approaches.of spiramycin into chitosan nanoparticles

Nanoparti cles have been evaluated both as aincreased its absorption and perme ation,

way of delivering current anti-toxoplasmosisincreasing survival time and reducing parasite

treatments more effectively and as anti microbialburden in mice compared with spiramycin or

agents themselves (Pissuwan et al., 2009). chitosan nanoparticles alone. The inflammatory

Chitosan is a natural polysaccharide that hasresponse to infection was lessened in the treated

been shown to have anti-bacterial andanimals and the parasites that were isolated

anti-malarial effects, and has been investi gatedshowed morphologi cal deformities, indicating a

for anti-Toxoplasma effects (Teimouri et al.,direct effect of the spiramycin chitosan

2018). Low molecular weight (86 kDa), mediumnanoparticles on the parasites themselves (Etewa

molecular weight (234 kDa) and high molecularet al., 2018; Hagras et al., 2019). Similarly, Abou-El-

weight (353 kDa) nanoparticles were synthe sised Naga et al. (2017) found that administration of

and tested against RH strain T. gondii in vitro andthe anti-retroviral lopinvar/ritonavir combination

in vivo. Anti-T. gondii activity was demonstratedencapsulated in polylactic-co-glycolic acid

in vitro with all nanopar ticle sizes but killing of(PLGA) nanoparticles to mice infected with T.

exposed tachyzoites was fastest with lowgondii reduced parasite bur den significantly

molecular weight nanoparticles. Smallercompared with administration as free drug. Infec

nanoparticles also per formed best in an in vivotivity of tachyzoites exposed to lopinvar/ritonavir

model, resulting in a significant drop in parasitein PLGA nanoparticles was also reduced
significantly compared with tachy zoites frompromising activ ity against protozoan parasites in

mice treated with free drug, although mortalityvitro, but its poor solubility has limited its use in

rates in the two groups were not significantlyvivo. Loading triclosan into nanoparticles

different (Abou-El-Naga et al., 2017). comprised of lipids (liposomes) significantly

Mixed results have been seen with other potentialreduced parasite burden in mice infected with a

anti-Toxo plasma drugs loaded into nanoparticles,virulent strain of T. gondii compared with

with effects seemingly dependent on thetriclosan alone (El-Zawawy et al., 2015a).

pharmacokinetics of individual drugs. Triclosan,Surprisingly, similar experiments using an

an inhibitor of fatty acid synthesis, is a drug withavirulent strain of T. gondii found no

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
difference in parasite burden after treatment with 2015).

triclosan in lipo somes compared with triclosanChitosan nanoparticles have also been combined

alone, although both groups had significantwith silver nanoparticles to increase their efficacy

reductions in parasite burden compared with(Gaafar et al., 2014). Mice infected with T. gondii

infected, untreated mice (El-Zawawy et al., 2015b).were treated with pyrimethamine, chitosan

This may indicate a T. gondii strain effect on thenanoparticles, silver nanoparticles, or a

mode of action of the drug, although dif ferentcombination of chitosan and silver nanoparticles.

doses of triclosan and triclosan/liposomes wereParasite burden was significantly reduced after

used in the studies, complicating comparisons.treatment with silver nanoparticles or the

Bottari et al., (2015) compared brain cyst burdenscombination of sil ver and chitosan nanoparticles,

in mice infected with T. gondii then treated withpyrimethamine or chitosan parti cles. However,

sulfamethoxazole/trimethoprim and reseveratrolthere was no significant difference between silver

packaged into nanoparticles or as free drug. Theynanoparticles and the combination of silver and

found a significant reduction in cyst burden inchitosan nanopar ticles, suggesting it is the silver

mice treated with sulfamethoxazole/trimethonanoparticles that had the anti-T. gondii effect

prim and resveratrol compared with mice treated(Gaafar et al., 2014). This finding is supported by

with sul famethoxazole/trimethoprim only, butin vitro studies with gold, silver and platinum

there was no significant difference between thenanoparticles by Adeyemi et al. (2017) who found

two delivery methods of reseveratrol (Bottari et al.,tachyzoite viability was reduced by 90% in the
presence of the metallic nanoparticles. Theduce biogenic silver nanoparticles and examined

selectivity index was 20, indicating markedtheir effect on survival rate and hepatic damage

toxicity towards the parasite without affecting the in mice infected with T. gondii. Mice treated with

host cells. Silver and gold nanoparticles werethe biogenic nanoparticles or sulfadiazine sur

more effective than platinum at killing thevived for longer than infected, untreated mice.

parasites (Adeyemi et al., 2017). In a subsequentMice given the bio genic silver particles showed

study, T. gondii parasites exposed to metallicless signs of hepatic damage due to the infection

nanoparticles were impaired in converting frombut the mortality rate was higher than in mice

tachy zoite to bradyzoite in vitro (Adeyemi et al.,given sulfadiazine (Alajmi et al., 2019). This

2019), suggesting that metallic nanoparticlestreatment may have been more effective if a less

target both tachyzoites and bradyzoites. Killing ofvirulent strain of T. gondii had been used for the

parasites was linked to the production of reactiveexperiments. Machado et al. (2020) created

oxygen species stimulated by the metalbiogenic silver nanoparticles with the fungus,

nanoparticles (Adeyemi et al., 2017, 2019). AFusarium oxysporum, and assessed their effect

further study using combinations of the metalson T. gondii in vitro. Treatment with the

con firmed their anti-T. gondii activity but notednanoparticles significantly reduced the ability of

some potential safety concerns since theparasites to invade and prolifer ate inside HeLa

selectivity index of effect on parasite versus hostcells (Machado et al., 2020). These results were

cells was 2-fold (Adeyemi et al., 2018b). consistent with those obtained by Gaafar et al.

Recently, plant extracts have been used as(2014) and Adeyemi et al. (2017), although how

stabilising or reduc ing agents in the preparationthe silver nanoparticles are damaging the

of so-called ''biogenic” nanoparticles. Thisparasite remains to be determined. Biogenic sele

manufacturing method has the advantages ofnium nanoparticles created with Bacillus were

being more cost effective, producing less toxicalso found to be

waste, and generating morereactive112

effective against T. gondii in chronically infected
nanoparticles. Coating the particles with plant
mice (Keyhani et al., 2020). A significant
molecules also increases their biocompatibility
reduction in brain cysts was seen in chronically
(Sharma et al., 2019). Alajmi et al. (2019) used
infected mice treated for 14 days with the
extracts of date seeds and nabka leaves to pro
selenium nanoparticles compared with untreatedElsharawy et al., 2020) and this will potentially

mice, although complete elimination was notlimit their utility in control of congenital

achieved. No toxicity was observed in the micetoxoplasmosis.

although mRNA levels of inflammatory cytokines6.3. Nanotechnology in vaccines against T. gondii

infection
were raised, and the authors speculated that theImmunogenicity is an issue with subunit and DNA

reason for the decrease in brain cysts was due tovaccines. The plasmids and antigens that make

induction of an inflammatory response by seleup these vaccines are prone to enzymatic

nium (Keyhani et al., 2020). Another study by thedegradation and can be poorly taken up by the

same group showed that biogenic seleniumrelevant cells so that only a weak immune

nanoparticles administered prior to infectionresponse is stimulated (Maeta et al., 2020).

could significantly reduce parasite burden in aNanoparticles can act as adjuvants and have

model of acute toxoplasmosis (Shakibaie et al.,been shown to increase immunogenicity of a

2020). number of T. gondii anti gens that have potential

Toxicity can be an issue with metal nanoparticlesas vaccine candidates including ROP18 (Nabi et

as they are not biodegradable like other types,al., 2017) and SAG1 (Naeem et al., 2018).

such as chitosan or liposomes, and canPeptides corre sponding to epitopes of key

accumulate in organs. However, the nanoparticlesantigens (SAG1, AMA1, ROP2 and GRA4) have

tested to date display toxicity towards thebeen encapsulated in nanoparticles and tested

parasite and, apart from one study (Adeyemi et al.,for immunogenicity (Roozbehani et al., 2018).

2018b), show little toxicity towards host cells inUnlike commonly used adjuvants, such as alum,

vitro or in vivo. The alterations that packagingnanoparticles appear able to induce cellu lar and

drugs in nanoparticles makes to thehumoral responses that are more likely to

pharmacokinetics of those drugs may lead toproduce a pro tective response. Another benefit

lower doses being effective. This, in turn, givesof encapsulating subunit vaccines in

hope that this approach will lead to morenanoparticles is that encapsulation can guard

effective treatments with fewer side effects foragainst degradation. In addition to this,

patients. However, it does need to benanoparticles can be targeted for delivery to

acknowledged that nanoparticles cancertain cells by the adsorption of antibodies on

compromise pregnancy (Park et al., 2013;their surfaces, and lower amounts of DNA and
protein can be used in the formulation, reducingalone. Ducournau et al. (2017) found the same

the risk of toxicity and side effects (Wang et al.,formulation could also reduce vertical

2019). transmission in immunised mice infected during

The properties of nanoparticles allow efficientpregnancy.

delivery of vac cine candidates via routes otherDNA vaccines can stimulate a cellular response

than subcutaneous or intramuscu lar.that is most effective for intracellular pathogens

Dimier-Poisson et al. (2015) used nasal delivery(Maeta et al., 2020) and nanoparticles have been

to immunise mice with a total extract T. gondiishown to increase their effectiveness. Issues

antigens loaded onto nanoparti cles made ofaffecting the success of DNA vaccines include

maltodextrin and challenged mice with lethal anddegradation of the DNA by extracellular nucleases,

chronic doses of T. gondii. All mice immunised poor uptake by cells, and inability to escape the

with the antigen/- nanoparticle combinationendosome once inside the cell (Maeta et al.,

survived a lethal challenge infection and had2020). Nanoparticles protect DNA from

reduced cyst burdens in the chronic modeldegradation during

compared with mice immunised with antigen

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
delivery and are more easily taken up byintegration into the host genome. To overcome

macrophages. Addition of calcium phosphatethis possibility, a modified dendrimer nanoparticle

nanoparticles to DNA vaccine formulations based that encapsulated RNA encoding for six T. gondii

on GRA14 and ROM4 have been shown toanti gens (GRA6, ROP2A, ROP18, SAG1, SAG2A

increase their immunogenicity in mice andand AMA1) was devel oped. This vaccine was

prolong survival against a challenge with T. gondiiable to stimulate a cellular adaptive immune

RH (Ahmadpour et al., 2017; Rahimi et al., 2017;response and protect mice against a lethal

Pagheh et al., 2019). Maeta et al. (2020) werechallenge with T. gondii (Chahal et al., 2016). Luo

also able to demon strate significant protectiondkk. (2017) also encased RNA coding for T.

against T. gondii in mice immunised with DNAgondii NTPase II in synthetic lipid nanoparticles

encoding T. gondii profilin encapsulated inand found a significantly increased cellular and

liposomal nanocarriers. humoral response in mice immunised with the

A risk with DNA vaccines is their potentialRNA in lipid nanoparticles compared with the
RNA alone. Mice immunised with thesignificant zoonotic dis eases. On health,

nanoparticles had prolonged survival rates wheneconomic and ecological grounds, the control of

challenged with T. gondii RH although there wastoxoplasmosis is therefore a necessity, not a

no significant advantage conferred by theluxury.

nanoparticles when mice were challenged with T.The success of T. gondii is underpinned by an

gondii Pru. Cyst burden was reduced comparedexquisitely com plex life cycle, which means that

with untreated, infected mice but was notthe manifestations of toxoplas mosis are also

significantly different from mice immunised withcomplex. Public education is, therefore, critically

only the RNA (Luo et al., 2017). important, notwithstanding doubts about its

As was noted for diagnostic tests andeffectiveness. It is particularly important for

administration of thera peutic drugs,pregnant women and immunocompro mised

nanoparticles have the potential to increase thepeople but it must be clever, informative, detailed

effec tiveness of vaccine formulations and,and prac tical enough to enable clear

therefore, should be considered for inclusion incommunication between medical professionals

any development of vaccines to targetand their patients, and to encourage adherence to

toxoplasmosis. measures and habits that will reduce exposure to

7. Concluding remarks oocysts and cysts of T. gondii for those most at

Toxoplasma gondii has been described, with
risk. Additionally, freely available accurate and
justification, as ''the world's most successful
practical information about toxoplasmosis is
parasite” and ''the model apicomplexan” (Weiss
useful for both medical professionals and the
and Kim, 2020). It is a parasite that can seemingly
general public. There is some evidence that this
infect any nucleated cell in any warm-blooded
can have an effect since education is con sidered
animal, has spread across the Earth from origins
at least partly responsible for an apparent
in South America, adapting to human agri cultural
reduction, over recent decades, in prevalence of
development in the process, and causes only
infection with T. gondii in, eg, the USA (Jones et al.
minor, if any, symptoms in the majority of its
, 2007, 2014), the Netherlands (Hofhuis et al.,
hosts. However, the sheer enormity of the
2011), France (Nogareda et al., 2014) and
numbers of people and animals infected with this
Germany (Wilking et al., 2016), particularly
parasite make it one of the most globally
through improved understand ing of food and
water hygiene. targeted drugs are real, fueled by insights into the

113 parasite's genome, transcriptome and

Protection of food and water from contamination
biochemistry. Addi tionally, nanotechnological
with T. gondii is a requisite for control of human
advances have the potential to improve delivery
toxoplasmosis. Biosecurity mea sures to
of existing and future chemotherapeutic agents.
minimise the presence of cats and rodents on
Similarly, new insights into the immunobiology of
farms is important, particularly since post-harvest
toxoplasmosis are paving the way for the
detection and removal of the parasite in or on
development of immunotherapeutics, particularly
food is not straightforward. Availability of water
to prevent toxoplasmic encephalitis resulting
that is oocyst-free is absolutely essential, not just
from immunosuppression.
for human consumption but also for raising
Live attenuated vaccines have proven to be
livestock and producing crops. By 2020, access
effective in both intermediate and definitive hosts
to clean water should be a right, not a privilege
of T. gondii but subunit vaccines have not. This
but, sadly, this is not the case and it is no
probably tells us something about the importance
coincidence that the signifi cant incidence of
of cell-mediated immunity in both intermediate
toxoplasmosis traceable to oocyst-derived infec
and definitive hosts (Innes et al., 2019), and
tion is often linked to socio-economic status
perhaps also exposes our current lack of
(Bahia-Oliveira et al., 2003; Carellos et al., 2014;
understanding and options for antigen
Singh et al., 2014; Mareze et al., 2019; Shapiro et
presentation in the delivery of subunit vaccines;
al., 2019). Thus, a genuine global effort to
nanotechnology may help address this. In the
address pov erty and ensure provision of clean
meantime, recent research has utilised the
water for all people would go a long way to
availability of robust data sets for the genome
reducing the incidence of toxoplasmosis.
and transcriptomes of T. gondii, combined with
Timely treatment following diagnosis of infection
the gene editing power of CRISPR/Cas9 protocols
with T. gondii is important, particularly for
to demon strate that: (i) single transcription
pregnant women and immunosup pressed people
factors largely control the switch to sexual stage
– it saves lives even if current drugs do not
development (Farhat et al., 2020) and brady zoite
possess all the characteristics and efficacy of the
development (Waldman et al., 2020) in T. gondii;
ideal therapy. The pro spects for new, better
and (ii) kit tens can be rendered totally incapable
of transmitting viable oocysts followinginfection with T. gondii, treatments for which we

immunisation with a parasite strain gene editedlack currently; and second, an in vitro mass

to prevent expression of a parasite fertilisationproduction system for bradyzoites, which could

factor (Ramakrishnan et al., 2019). The discoveryovercome one of the main obstacles to the

of a master-regulator of conversion of tachyzoitesimplementation of a transmission-blocking

to bradyzoites opens the door to development ofvaccine program for cats using attenuated

an attenuated vaccine for intermediate hosts thatparasites. A vaccine to stop transmission of

will have an inbuilt safeguard of not being able tooocysts of T. gondii is attractive because it

progress into a long-lived tissue cyst. This istargets the core of the life cycle of T. gondii –

particularly attractive since cultiva tion ofwithout sexual reproduction and oocysts, all

tachyzoites in vitro is not difficult and may well be routes of infection with this parasite ultimately

amen able to commercial scale-up. This samecease to exist. Completely preventing

discovery also paves the way for potentialtransmission of oocysts worldwide is, seemingly,

scale-up of in vitro production of bradyzoites,impossible as vaccine coverage of all pet,

which would enable two things: first, thecommunity, stray and wild cats is a challenge that

development of high throughput approaches forwould necessitate delivery technologies and

the discovery and testing of drugs to treat chronic regimens we have not yet imagined. But, similar

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
to the provision of clean water for all, it is surely from the NHMRC (GNT1182369) and the

an ambition worth our effort. Australian Research Council (DP200100483).

Acknowledgements These funders played no role in interpretation of

We apologise to colleagues whose work we may
data and information researched for this review,
have over looked and not cited in this review. NCS
the writing of the manuscript, or the decision to
is very grateful for research support from the
submit this article for publication.
National Health and Medical Research Council
References
(NHMRC) of the Australian Government (ProjectAbdelbaset, AE, Fox, BA, Karram, MH, Abd Ellah,

Grant GNT1128911) and AK is thankful for aMR, Bzik, DJ, Igarashi, M., 2017. Lactate

Career Development Level 1 Fellowship from thedehydrogenase in Toxoplasma gondii controls

NHMRC (GNT1140709). GGvD is also grate ful tovirulence, bradyzoite differentiation, and chronic

the Australian Government for research grantsinfection. PLoS ONE 12, e0173745.
Abe, Y., Ishida, T., 2019. Immunomodulatory Montazeri, M., Fasihi-Ramandi, M., Daryani, A.,

drugs in the treatment of multiple myeloma. 2017. Enhancing immune responses to a DNA

Japanese J. Clin. Onkol. 49, 695–702. vaccine encoding Toxoplasma gondii GRA14 by

Abou-El-Naga, IF, El Kerdany, ED, Mady, RF,calcium phosphate nanoparticles as an adjuvant.

Shalaby, TI, Zaytoun, EM, 2017. The effect ofImmunol. Lett. 185, 40–47.

lopinavir/ritonavir and lopinavir/ritonavir loadedAkbar, H., Dimier-Poisson, I., Moire, N., 2015. Role

PLGA nanoparticles on experimentalof CD4+ Foxp3+ Regulatory T cells in protection

toxoplasmosis. Parasitol. Int. 66, 735–747. induced by a live attenuated, replicating type I

Adeyemi, OS, Sugi, T., Han, Y., Kato, K., 2018a.vaccine strain of Toxoplasma gondii. Menulari.

Screening of chemical compound librariesImmun. 83, 3601–3611.

identified new anti-Toxoplasma gondii agents.Alajmi, RA, Al-Megrin, WA, Metwally, D., Al-Subaie,

Parasitol. Res. 117, 355– 363. H., Altamrah, N., Barakat, AM, Abdel Moneim, AE,

Adeyemi, SO, Molefe, NI, Awakan, OJ, Nwonuma,Al-Otaibi, TT, El-Khadragy, M., 2019.

CO, Alejolowo, OO, Olaolu, T., Maimako, RF,Anti-Toxoplasma activity of silver nanoparticles

Suganama, K., Han, Y., Kato, K., 2018b. Metalgreen synthesizes with Phoenix dactylifera and

nanoparticles restrict the growth of protozoanZiziphus spina-christi extracts which inhibits

parasites. Artificial Cells Nanomed. Bioteknologi.inflammation through liver regulation of cytokines

46, S86–S94. in Balb/c mice. Biosci. Rep. 39. BSR20190379.

Adeyemi, SO, Murata, Y., Sugi, T., Han, Y., Kate, K.,Alday, PH, Bruzual, I., Nilsen, A., Pou, S., Winter, R.,

2019. Nanoparticles show potential to retardMamoun, CB, Riscoe, MK, Doggett, JS, 2017.

bradyzoites in vitro formation of ToxoplasmaGenetic evidence for cytochrome b Qi site

gondii. Folia Parasitol. 66, 001. inhibition by 4 (1H)-quinolone-3-diarylethers and

Adeyemi, SO, Murata, Y., Sugi, T., Kato, K., 2017.antimycin in Toxoplasma gondii. Antimikroba.

Inorganic nanoparticles kill Toxoplasma gondiiAgen Kemo. 61, e01866–e1916.

via changes in redox status and mitochondrialAlday, PH, Doggett, JS, 2017. Drugs in

membrane potential. Int. J. Nanomed. 12, 1647–development for toxoplasmosis: advances,

1661. challenges, and current status. Obat. Des. Devel.

Ahmadpour, E., Sarvi, S., Soteh, MBH, Sharif, M.,Ada. 11, 273–293. Aldinucci, D., Casagrande, N.,

Rahimi, MT, Valadan, R., Tehrani, M., Khalilian, A.,2018. Inhibition of the CCL5/CCR5 axis against
the progression of gastric cancer. Int. J. Mol. Sci. of apicoplast inhibitors in Toxoplasma gondii.

19, 1477. Antimikroba. Agen Kemo. 63. e01646-e1718.

Aliberti, J., Valenzuela, JG, Carruthers, VB, Hieny, S.Amiar, S., Katris, NJ, Berry, L., Dass, S., Duley, S.,

, Andersen, J., Charest, H., Reis e Sousa, C.,Arnold, C.-S., Shears, MJ, Brunet, C., Touquet, B.,

Fairlamb, A., Ribeiro, JM, Sher, A., 2003. Molecular McFadden, GI, Yamaryo-Botté, Y., Botté, CY, 2020.

mimicry of a CCR5 binding-domain in theDivision and adaptation to host environment of

microbial activation of dendritic cells. Nat.apicomplexan parasites depend on apicoplast

Immunol. 4, 485–490. lipid metabolic plasticity and host organelle

Alizaddeh, AM, Jazaeri, S., Shemshadi, B.,remodeling. Cell Rep. 30. 3778-3792.e9.

Hashempour-Baltork, F., Sarlak, Z., Pilever, Z.,Anand, N., Sehgal, R., Kanwar, RK, Dubey, ML,

Hosseini, H., 2018. A review on inactivation ofVasishta, RK, Kanwar, JR, 2015. Oral

Toxoplasma gondii in foods. Path. Glob. Healthadministration of encapsulated bovine lactoferrin

112, 306–319. nanocapsules against intracellular parasite

Aly, I., Taher, EE, El Nain, G., El Sayed, H.,Toxoplasma gondii. Int. J. Nanomed. 10, 6355–

Mohammed, FA, Hamad, RS, Bayoumy, EM, 2018.6369.

Advantages of bioconjugated silica-coatedAndiappan, H., Nissapatorn, V., Sawangjaroen, N.,

nanoparticles as an innovative diagnosis forKhaing, SL, Salibay, CC, Cheung, MM, Dungca, JZ,

human toxoplasmosis. Acta Tropica 177, 19–24. Chemoh, W., Xiao Teng, C., Lau, YL, Mat Adenan,

Ambade, A., Lowe, P., Kodys, K., Catalano, D.,NA, 2014. Knowledge and practice on

Gyongyosi, B., Cho, Y., Iracheta-Vellve, A.,Toxoplasma infection in pregnant women from

Adejumo, A., Saha, B., Calenda, C., Mehta, J.,Malaysia, Philippines, and Thailand. Front.

Lefebvre, E., Vig, P., Szabo, G., 2019.Mikrobiol. 5, 291.

Pharmacological inhibition of CCR2/5 signalingArakaki, R., Yamasaki, T., Kanno, T., Shibasaki, N.,

prevents and reverses alcohol-induced liverSakamoto, H., Utsunomiya, N., Sumiyoshi, T.,

damage, steatosis, and inflammation in mice.Shibuya, S., Tsuruyama, T., Nakamura, E., Ogawa,

Hepatology 69, 1105–1121. O., Kamba, T., 2016. CCL2 as a potential

114 therapeutic target for clear cell renal cell

Amberg-Johnson, K., Yeh, E., 2019. Host cell
carcinoma. Cancer Med. 5, 2920–2933.
metabolism contributes to delayed death kinetics
Araujo, FG, Hunter, CA, Remington, JS, 1997.
Treatment with interleukin 12 in combination withvan Crevel, R., Netea, MG, 2018. BCG vaccination

atovaquone or clindamycin significantly increasesprotects against experimental viral infection in

survival of mice with acute toxoplasmosis.humans through the induction of cytokines

Antimikroba. Agen Kemo. 41, 188–190. associated with trained immunity. Cell Host

Araujo, FG, Huskinson-Mark, J., Gutteridge, WE,Microbe 23, 89–100. Assolini, JP, Concate, VM,

Remington, JS, 1992. In vitro and in vivo activitiesConcalves, MD, Carloto, ACM, Conchon-Costa, I.,

of the hydroxynaphthoquinone 566C80 againstPavanelli, WR, Melanda, FN, Costa, IN, 2017.

the cyst form of Toxoplasma gondii. Antimikroba.Nanomedicine advances in toxoplasmosis:

Agen Kemo. 36, 326–330. diagnostic, treatment and vaccine applications.

Araujo, FG, Huskinson, J., Remington, JS, 1991a.Parasitol. Res. 116, 1603–1615.

Remarkable in vitro and in vivo activities of theBaatz, H., Mirshahi, A., Puchta, J., Gümbel, H.,

hydroxynaphthoquinone 566C80 againstHattenbach, LO, 2006. Reactivation of

tachyzoites and tissue cysts of ToxoplasmaToxoplasma retinochoroiditis under atovaquone

gondii. Antimikroba. Agen Kemo. 35, 293–299. therapy in an immunocompetent patient. Ocular

Araujo, FG, Remington, JS, 1974. Effect of Immunol. Inflamm. 14, 185–187.

clindamycin on acute and chronic toxoplasmosis Babaie, J., Amiri, S., Homayoun, R., Azimi, E.,

in mice. Antimikroba. Agen Kemo. 5, 647–651. Mohabati, R., Berizi, M., Sadaie, MR, Golkar, M.,

Araujo, FG, Shepard, RM, Remington, JS, 1991b. In 2018. Immunization of C57BL/6 Mice with GRA2

vivo activity of the macrolide antibiotics combined with MPL conferred partial immune

azithromycin, roxithromycin and spiramycin protection against Toxoplasma gondii. Iran.

against Toxoplasma gondii. Eur. J.klin. Mikrobiol. Bioma. J. 22, 22–32.

Menulari. Dis. 10, 519–524. Bahia-Oliveira, LM, Jones, JL, Azevedo-Silva, J.,

Arenas, AJ, Gonzalez-Parra, G., Villanueva Mico, Alves, CC, Orefice, F., Addiss, DG, 2003. Highly

RJ, 2010. Modeling toxoplasmosis spread in cat endemic, waterborne toxoplasmosis in north Rio

populations under vaccination. Theoret. Pop. Biol. de Janeiro state, Brazil. Emerg. Menulari. Dis. 9,

77, 227–237. Arts, RJW, Moorlag, S., Novakovic, B.55–62.

, Li, Y.,Wang, SY, Oosting, M., Kumar, V., Xavier, Balaskas, K., Vaudaux, J., Boillat-Blanco, N.,

RJ,Wijmenga, C., Joosten, LAB, Reusken, C., Benn, Guex-Crosier, Y., 2012. Azithromycin versus

CS, Aaby, P., Koopmans, MP, Stunnenberg, HG, sulfadiazine and pyrimethamine for
non-vision-threatening toxoplasmicWatier, H., Capron, A., 1991. Effect of rIFN-gamma

retinochoroiditis: a pilot study. Med. Sci. Monitorand IL-2 treatments in mouse and nude rat

18, CR296–CR302. infections with Toxoplasma gondii. Eur. Cytokine

Barber, LD, Gillece-Castro, B., Percival, L., Li, X.,Netw. 2, 107–114.

Clayberger, C., Parham, P., 1995. Overlap in the Benenson, MW, Takafuji, ET, Lemon, SM,

repertoires of peptides bound in vivo by a group Greenup, RL, Sulzer, AJ, 1982. Oocyst

of related class I HLA-B allotypes. Curr. Biol. 5, transmitted toxoplasmosis associated with

179–190. ingestion of contaminated water. N. Engl. J.

Baumeister, S., Wiesner, J., Reichenberg, A., Hintz, Med. 307, 666–669.

M., Bietz, S., Harb, OS, Roos, DS, Kordes, M.,Benmerzouga, I., Checkley, LA, Ferdig, MT,

Friesen, J., Matuschewski, K., Lingelbach, K.,Arrizabalaga, G., Wek, RC, Sullivan Jr., WJ, 2015.

Jomaa, H., Seeber, F., 2011. FosmidomycinGuanabenz repurposed as an antiparasitic with

uptake into Plasmodium and Babesia-infectedactivity against acute and latent toxoplasmosis.

erythrocytes is facilitated by parasite-inducedAntimikroba. Agen Kemo. 59, 6939–6945.

new permeability pathways. PLoS One 6, e19334. Bertranpetit, E., Jombart, T., Paradis, E., Pena,

Behnke, MS, Zhang, TP, Dubey, JP, Sibley, LD, H., Dubey, JP, Su, C., Mercier, A., Devillard, S.,

2014. Toxoplasma gondii merozoite gene Ajzendberg, D., 2017. Phylogeography of

expression analysis with comparison to the life Toxoplasma gondii points to a South

cycle discloses a unique expression state during American origin. Menulari. gen. Evol. 48, 150–

enteric development. BMC Genomics 15, 350. 155.

Ben-Harari, RR, Goodwin, E., Casoy, J., 2017.Bhadra, R., Gigley, JP, Khan, IA, 2012.

Adverse event profile of pyrimethamine-basedPD-1-mediated attrition of polyfunctional memory

therapy in toxoplasmosis: a systematic review.CD8+ T cells in chronic Toxoplasma infection. J.

Drugs R&D 17, 523–544. Infect. Dis. 206, 125– 134.

Benedetto, N., Auriault, C., Darcy, F., Lando, D.,

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95–121
Bhadra, R., Gigley, JP, Weiss, LM, Khan, IA, 2011.PD-1-PDL-1 blockade. Prok. Natl. akad. Sci. USA

Control of Toxoplasma reactivation by rescue of108, 9196–9201.

dysfunctional CD8+ T-cell response viaBhadra, R., Guan, H., Khan, IA, 2010. Absence of
both IL-7 and IL-15 severely impairs theMorsch, VM, Camillo, G., Vogel, FF, Tochette, C.,

development of CD8 T cell response againstFighera, R., Machado, G., Stefani, LM, Da Silva, AS,

Toxoplasma gondii. PLoS One 5, e10842. 2015. Sulfamethoxazole trimethoprim associated

Bhadra, R., Khan, IA, 2012. IL-7 and IL-15 do notwith resveratrol for the treatment of

synergize during CD8 T cell recall responsetoxoplasmosis in mice: Influence on the activity

against an obligate intracellular parasite.of enzymes involved in brain neurotransmission.

Microbes Infect. 14, 1160– 1168. Microb. Pathog. 79, 17–23.

Billker, O., Lourido, S., Sibley, LD, 2009. Bougdour, A., Maubon, D., Baldacci, P., Ortet, P.,

Calcium-dependent signaling and kinases in Bastien, O., Bouillon, A., Barale, JC, Pelloux, H.,

apicomplexan parasites. Cell Host Microbe 5, Ménard, R., Hakimi, MA, 2009. Drug inhibition of

612–622. HDAC3 and epigenetic control of differentiation in

Blackard, JT, Kong, L., Rouster, SD, Karns, R., Horn, Apicomplexa parasites. J. Eks. Med. 206, 953–

PS, Kottilil, S., Shata, MT, Sherman, KE, 2019.966.

CCR5 receptor antagonism inhibits hepatitis CBowie, WR, King, AS, Werker, DH, Isaac-Renton, JL,

virus (HCV) replication in vitro. PLoS One 14,Bell, A., Eng, SB, Marion, SA, 1997. Outbreak of

e0224523. toxoplasmosis associated with municipal

Bonacˇic´ Marinovic´, AA, Opsteegh, M., Deng, H.,drinking water. The BC Toxoplasma Investigation

Suijkerbuijk, AWM, van Gils, PF, van der Giessen, J.Team. Lancet 350, 173–177.

, 2020. Prospects of toxoplasmosis control by catBoyman, O., Kovar, M., Rubinstein, M., Surh, C.,

vaccination. Epidemics 30, 100380. Sprent, J., 2006. Selective stimulation of T cell

Bosch-Driessen, LH, Verbraak, FD,subsets with antibody-cytokine immune

Suttorp-Schulten, MS, van Ruyven, RL, Klok, AM,complexes. Science 311, 1924–1927.

Hoyng, CB, Rothova, A., 2002. A prospective,Boyom, FF, Fokou, PV, Tchokouaha, LR,

randomized trial of pyrimethamine andSpangenberg, T., Mfopa, AN, Kouipou, RM,

azithromycin vs pyrimethamine and sulfadiazineMbouna, CJ, Donfack, VF, Zollo, PH, 2014.

for the treatment of ocular toxoplasmosis.Repurposing the open access malaria box to

American J. Ophthalmol. 134, 34–40. discover potent inhibitors of Toxoplasma gondii

Bottari, NB, Baldissera, MD, Tonin, AA, Rech, VC,and Entamoeba histolytica. Antimikroba. Agen

Nishihira, VSK, Thomé, GR, Schetinger, M.-RC,Kemo. 58, 5848–5854.

Braun, L., Brenier-Pinchart, MP, Yogavel, M.,node to Toxoplasma gondii: cell output in efferent

Curt-Varesano, A., Curt-Bertini, RL, Hussain, T.,lymph and parasite detection. J. Comp. Patol.

Kieffer-Jaquinod, S., Coute, Y., Pelloux, H.,111, 231–241.

Tardieux, I., Sharma, A., Belrhali, H., Bougdour, A.,Buyukbaba Boral, O., Sonmez Tamer, G., Keceli

Hakimi, MA, 2013. A Toxoplasma dense granuleOzcan, S., Sonmez, N., Issever, H., Tekeli, F., 2012.

protein, GRA24, modulates the early immuneInvestigation of combined effectiveness of

response to infection by promoting a direct andspiramycin and beta glucan in mice models of

sustained host p38 MAPK activation. J. Eks. Med. acute toxoplasmosis and determination of IL-10,

210, 2071–2086. IL-12 and TNF-alpha levels. Mikrobiyoloji bulteni

Brenier-Pinchart, MP, Villena, I., Mercier, C.,46, 446–455.

Durand, F., Simon, J., Cesbron-Delauw, MF,Byun, DJ, Wolchok, JD, Rosenberg, LM, Girotra, M.,

Pelloux, H., 2006. The Toxoplasma surface2017. Cancer immunotherapy - immune

protein SAG1 triggers efficient in vitro secretioncheckpoint blockade and associated

of chemokine ligand 2 (CCL2) from humanendocrinopathies. Nat. Rev. Endocrinol. 13, 195–

fibroblasts. Microbes Infect. 8, 254–261. 207.

Burrells, A., Benavides, J., Canton, G., Garcia, JL,Cai, G., Kastelein, R., Hunter, CA, 2000.

Bartley, PM, Nath, M., Thomson, J., Chianini, F.,Interleukin-18 (IL-18) enhances innate IL

Innes, EA, Katzer, F., 2015. Vaccination of pigs12-mediated resistance to Toxoplasma gondii.

with the S48 strain of Toxoplasma gondii – saferMenulari. Immun. 68, 6932–6938. Camps, M.,

meat for human consumption. Dokter hewan. Res.Arrizabalaga, G., Boothroyd, J., 2002. An rRNA

46, 47. mutation identifies the apicoplast as the target

Buxton, D., 1993. Toxoplasmosis: the first for clindamycin in Toxoplasma gondii. mol.

commercial vaccine. Parasitol. Today 9, 335–337.Mikrobiol. 43, 1309–1318.

Buxton, D., Innes, EA, 1995. A commercial vaccine Caradonna, T., Marangi, M., Del Chierico, F., Ferrari,

for ovine toxoplasmosis. Parasitology (110 N., Reddel, S., Bracaglia, G., Normanno, G.,

Suppl.), S11–S16. Putignani, L., Giangaspero, A., 2017. Detection

Buxton, D., Thomson, KM, Maley, S., Wastling, JM,and prevalence of protozoan parasites in ready-to-

Innes, EA, Panton, WR, Nicoll, S., 1994. Primaryeat packaged salads on sale in Italy. Food

and secondary responses of the ovine lymphMicrobiol. 67, 67–75.

Cardew, EM, Verlinde, C., Pohl, E., 2018. The Tsosieb, JK, Tilleya, LD, Sidika, SM, Louridoa, S.,

calcium-dependent protein kinase 1 fromLanger, R., Bavaric, S., Ploegha, HL, Anderson, DG,

Toxoplasma gondii as target for structure-based2016. Dendrimer-RNA nanoparticles generate

drug design. Parasitology 145, 210–218. protective immunity against lethal Ebola, H1N1

Carellos, EV, de Andrade, GM,influenza, and Toxoplasma gondii challenges with

Vasconcelos-Santos, DV, Januario, JN, Romanelli,a single dose. Prok. Natl. akad. Sci. USA 113,

RM, Abreu, MN, et al., 2014. AdverseE4133–E4142.

socioeconomic conditions and oocyst relatedChandrasena, N., Herath, R., Rupasinghe, N.,

factors are associated with congenitalSamarasinghe, B., Samaranayake, H.,

toxoplasmosis in a population based study inKastuririratne, A., de Silva, NR, 2016.

Minas Gerais, Brazil. PLoS One 9, e88588. Toxoplasmosis awareness, seroprevalence and

115 risk behavior among pregnant women in the

Casciotti, L., Ely, KH, Williams, ME, Khan, IA, 2002.
Gampaha district, Sri Lanka. Pathog. Glob. Health
CD8(+)-T-cell immunity against Toxoplasma
110, 62–67.
gondii can be induced but not maintained in mice
Chapman, HD, Barta, JR, Blake, D., Gruber, A.,
lacking conventional CD4(+) T cells. Menulari.
Jenkins, M., Smith, NC, Suo, X., Tomley, FM, 2013.
Immun. 70, 434–443.
A selective review of advances in coccidiosis
Castellani, ML, Bhattacharya, K., Tagen, M.,
research. Adv. Parasitol. 83, 93–172.
Kempuraj, D., Perrella, A., De Lutiis, M., Boucher, W.
Charron, AJ, Sibley, LD, 2002. Host cells:
, Conti, P., Theoharides, TC, Cerulli, G., Salini, V.,
mobilizable lipid resources for the intracellular
Neri, G., 2007. Anti-chemokine therapy for
parasite Toxoplasma gondii. J. Cell. Sci. 115,
inflammatory diseases. Int. J. Immunopathol.
3049–3059. Chen, Y., Yu, M., Hemandez, JA, Li, J.,
Pharmacol. 20, 447–453.
Yuan, ZG, Yan, H., 2018. Immuno-efficacy of DNA
Cha, DY, Song, IK, Lee, GS, Hwang, OS, Noh, HJ,
vaccines encoding PLP1 and ROP18 against
Yeo, SD, Shin, DW, Lee, YH, 2001. Effects of
experimental Toxoplasma gondii infection in mice.
specific monoclonal antibodies to dense granular
Eks. Parasitol. 188, 73–78.
proteins on the invasion of Toxoplasma gondii in
Choi, R., Hulverson, MA, Huang, W., Vidadala, RSR,
vitro and in vivo. Korean J. Parasitol. 39, 233–240.
Whitman, GR, Barrett, LK, Schaefer, DA, Betzer, DP,
Chahal, JS, Khanb, OF, Cooper, CL, McPartlana, JS,
Riggs, MW, Doggett, JS, Hemphill, A., Ortega-Mora,
LM, McCloskey, MC, Arnold, SLM, Hackman, RC,prevent toxoplasmosis: protective Toxoplasma

Marsh, KC, Lynch, JJ, Freiberg, GM, Leroy, BE,gondii epitopes restricted by HLA-A*0201.

Kempf, DJ, Choy, RKM, de Hostos, EL, Maly, DJ,Vaccine 29, 754–762.

Fan, E., Ojo, KK, Van Voorhis, WC, 2020. Bumpedda Cunha, IA, Zulpo, DL, Bogado, AL, de Barros, LD,

kinase inhibitors as therapy for apicomplexanTaroda, A., Igarashi, M., Navarro, IT, Garcia, JL,

parasitic diseases: lessons learned. Int. J.2012. Humoral and cellular immune responses in

Parasitol. 50, 413–422. pigs immunized intranasally with crude rhoptry

Choi, WH, Lee, IA, 2019. The mechanism of action proteins of Toxoplasma gondii plus Quil-A. Dokter

of ursolic acid as a potential anti-toxoplasmosis hewan. Parasitol. 186, 216–221.

agent, and Its immunomodulatory effects. Da Gama, LM, Ribeiro-Gomes, FL, Guimarães Jr., U.

Pathogens 8, 61. Choromanski, L., Freyre, A., , Arnholdt, AC, 2004. Reduction in adhesiveness to

Popiel, R., Brown, K., Grieve, R., Shibley, G., 1995. extracellular matrix components, modulation of

Safety and efficacy of modified live feline adhesion molecules and in vivo migration of

Toxoplasma gondii vaccine. Dev. Biol. Berdiri. 84, murine macrophages infected with Toxoplasma

269–281. gondii. Microbes Infect. 6, 1287–1296.

Cong, H., Mui, EJ, Witola, WH, Sidney, J.,Dannemann, B., McCutchan, JA, Israelski, D.,

Alexander, J., Sette, A., Maewal, A., McLeod, R.,Antoniskis, D., Leport, C., Luft, B., Nussbaum, J.,

2010. Human immunome, bioinformatic analysesClumeck, N., Morlat, P., Chiu, J., The California

using HLA supermotifs and the parasite genome,Collaborative Treatment Group, 1992. Treatment

binding assays, studies of human T cellof toxoplasmic encephalitis in patients with AIDS.

responses, and immunization of HLA-A*1101A randomized trial comparing pyrimethamine plus

transgenic mice including novel adjuvants provideclindamycin to pyrimethamine plus sulfadiazine.

a foundation for HLA-A03 restricted CD8+T cellAnnals Internal Med. 116, 33–43.

epitope based, adjuvanted vaccine protectivede Faria Junior, GM, Ayo, CM, de Oliveira, AP,

against Toxoplasma gondii. Immunome Res. 6,Lopes, AG, Frederico, FB, Silveira Carvalho, AP,

12. Previato, M., Barbosa, AP, Murata, FHA, de

Cong, H., Mui, EJ, Witola, WH, Sidney, J.,Almeida Junior, GC, Siqueira, RC, de Mattos, LC,

Alexander, J., Sette, A., Maewal, A., McLeod, R.,Brandão de Mattos, CC, 2018. CCR5 chemokine

2011. Towards an immunosense vaccine toreceptor gene polymorphisms in ocular

toxoplasmosis. Acta Tropica 178, 276– 280. JL, Tuboi, SH, Carmo, EH, Ramalho, WM, Camargo,

Delemarre, FG, Stevenhagen, A., Kroon, FP, van Eer, NJ, Trevisan, R., Graça, RMT, da Silva, AJ, Moura, I.

MY, Meenhorst, PL, van Furth, R., 1994. Effect of, Dubey, JP, Garrett, DO, 2006. Waterborne

IFN-gamma on the proliferation of Toxoplasmatoxoplasmosis, Brazil, from field to gene. Emerg.

gondii in monocytes and monocyte-derivedMenulari. Dis. 12, 326–329.

macrophages from AIDS patients. ImmunologyDeng, Y., Wu, T., Zhai, S.-Q., Li, C.-H., 2019. Recent

83, 646–650. progress on anti-Toxoplasma drugs discovery:

Delemarre, FG, Stevenhagen, A., Snijders, F., Kroon,design, synthesis and screening. Eur. J. Med.

FP, van Eer, MY, Reiss, P., van Furth, R., 1993.Kimia 183, 111711.

Restoration of the toxoplasmastatic activity ofDerouin, F., Pelloux, H., on behalf of the ESCMID

monocytes from AIDS patients during in vivoStudy Group on Clinical Parasitology, 2008.

treatment with interferon-gamma. J. Infect. Dis.Prevention of toxoplasmosis in transplant

168, 516–518. patients. klinik Mikrobiol. Menulari. 14, 1089–

de Moura, L., Bahia-Oliveira, LM, Wada, MY, Jones, 1101.

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95–121
Di Mario, S., Basevi, V., Gagliotti, C., Spettoli, D.,Endochin-like quinolones are highly efficacious

Gori, G., D'Amico, R., Magrini, N., 2015. Prenatalagainst acute and latent experimental

education for congenital toxoplasmosis.toxoplasmosis. Prok. Natl. akad. Sci. USA 109,

Cochrane Database Syst. Rev. 2015, CD006171. 15936–15941.

Dimier-Poisson, I., Carpentier, R., N'Guyen, TTL,Doggett, JS, Ojo, KK, Fan, E., Maly, DJ, Van Voorhis,

Dahmani, F., Ducournau, C., Betbeder, D., 2015. WC, 2014. Bumped kinase inhibitor 1294 treats

Porous nanoparticles as delivery system ofestablished Toxoplasma gondii infection.

complex antigens for an effective vaccine against Antimikroba. Agen Kemo. 58, 3547–3549.

acute and chronic Toxoplasma gondii infection.Doggett, JS, Schultz, T., Miller, AJ, Bruzual, I., Pou,

Biomaterials 50, 164–175. S., Winter, R., Dodean, R., Zakharov, LN, Nilsen, A.,

Doggett, JS, Nilsen, A., Forquer, I., Wegmann, KW,Riscoe, MK, Carruthers, VB, 2020. Orally

Jones-Brando, L., Yolken, RH, Bordon, C., Charman,bioavailable endochin-like quinolone carbonate

SA, Katneni, K., Schultz, T., Burrows, JN, Hinrichs,ester prodrug reduces Toxoplasma gondii brain

DJ, Meunier, B., Carruthers, VB, Riscoe, MK, 2012.cysts. Antimikroba. Agen Kemo. 64, e00535–
e620. , Dimier-Poisson, I., 2017. Synthetic parasites: a

Doherty, M., Buchy, P., Standaert, B., Giaquinto, C., successful mucosal nanoparticle vaccine against

Prado-Cohrs, D., 2016. Vaccine impact: Benefits Toxoplasma congenital infection in mice. Future

for human health. Vaccine 34, 6707–6714. Microbiol. 12, 393–405. Dumas, JL, Chang, R.,

Dos Santos, JC, Barroso de Figueiredo, AM,Mermillod, B., Piguet, PF, Comte, R., Pechère, JC,

Teodoro Silva, MV, Cirovic, B., de Bree, LCJ,1994. Evaluation of the efficacy of prolonged

Damen, M., Moorlag, S., Gomes, RS, Helsen, MM,administration of azithromycin in a murine model

Oosting, M., Keating, ST, Schlitzer, A., Netea, MG,of chronic toxoplasmosis. J. Antimicrob.

Ribeiro-Dias, F., Joosten, LAB, 2019. Beta-GlucanChemother. 34, 111– 118.

induced trained immunity protects againstDunay, IR, Damatta, RA, Fux, B., Presti, R., Greco, S.,

Leishmania braziliensis infection: a crucial role Colonna, M., Sibley, LD, 2008. Gr1(+)

for IL-32. Cell Rep. 28, 2659–2672. inflammatory monocytes are required for

Dubey, JP, 1995. Duration of immunity to mucosal resistance to the pathogen Toxoplasma

shedding of Toxoplasma gondii oocysts by cats. gondii. Immunity 29, 306–317.

J. Parasitol. 81, 410–415. Dunay, IR, Gajurel, K., Dhakal, R., Liesenfeld, O.,

Dubey, JP, 2017. Schizogony and gametogony of Montoya, JG, 2018. Treatment of toxoplasmosis:

oocyst-deficient T-263 strain of Toxoplasma historical perspective, animal models, and current

gondii. Dokter hewan. Parasitol. 245, 160–162. clinical practice. klinik Mikrobiol. Rev. 31,

Dubey, JP, Baker, DG, Davis, SW, Urban Jr., JF,e00057–e117.

Shen, SK, 1994. Persistence of immunity toDunay, IR, Heimesaat, MM, Bushrab, FN, Müller,

toxoplasmosis in pigs vaccinated with aRH, Stocker, H., Arasteh, K., Kurowski, M., Fitzner,

nonpersistent strain of Toxoplasma gondii. Saya.R., Borner, K., Liesenfeld, O., 2004. Atovaquone

J. Dokter hewan. Res. 55, 982–987. maintenance therapy prevents reactivation of

Dubey, JP, Lunney, JK, Shen, SK, Kwok, OC, 1998. toxoplasmic encephalitis in a murine model of

Immunity to toxoplasmosis in pigs fed irradiated reactivated toxoplasmosis. Antimikroba. Agen

Toxoplasma gondii oocysts. J. Parasitol. 84, Kemo. 48, 4848–4854.

749–752. Ducournau, C., N'Guyen, TTL, Carpentier,Edwards, RL, Heueck, I., Lee, SG, Shah, IT, Miller,

R., Lantier, I., Germon, S., Précausta, F., Pisella, JJ, Jezewski, AJ, Mikati, MO, Wang, X., Brothers,

P.-J., Leroux, H., Van Langendonck, N., Betbeder, D.RC, Heidel, KM, Osbourn, DM, Burnham, CD,
Alvarez, S., Fritz, SA, Dowd, CS, Jez, JM, Odom109, 377–382.

John, AR, 2020. Potent, specific MEPicides forElsharawy, K., Abou-Dobara, M., El-Gammal, H.,

treatment of zoonotic staphylococci. PLoSHyder, A., 2020. Chitosan coating does not

Pathogens 16, e1007806. prevent the effect of the transfer of green silver

Ehmen, HG, Lüder, CGK, 2019. Long-term impact nanoparticles biosynthesized by Streptomyces

of Toxoplasma gondii infection on human malachitus into fetuses via the placenta. Reprod.

monocytes. Front. Sel. Menulari. Mikrobiol. 9, 235.Biol. 20, 97–105.

El Bissati, K., Chentoufi, AA, Krishack, PA, Zhou, Y., El-Zawawy, LA, El-Said, D., Mossallam, SF,

Woods, S., Dubey, JP, Vang, L., Lykins, J.,Ramadan, HS, Younis, SS, 2015a. Triclosan and

Broderick, KE, Mui, E., Suzuki, Y., Sa, Q., Bi, S.,triclosan-loaded liposomal nanoparticles in the

Cardona, N., Verma, SK, Frazeck, L., Reardon, CA,treatment of acute experimental toxoplasmosis.

Sidney, J., Alexander, J., Sette, A., Vedvick, T., Fox,Eks. Parasitol. 149, 54–64.

C., Guderian, JA, Reed, S., Roberts, CW, McLeod, R.,El-Zawawy, LA, El-Said, D., Mossallam, SF,

2016. Adjuvanted multi epitope vaccines protectRamadan, HS, Younis, SS, 2015b. preventative

HLA-A*11:01 transgenic mice againstprospective of triclosan and triclosan-liposomal

Toxoplasma gondii. JCI Insight 1, e85955. nanoparticles against experimental infection with

El Bissati, K., Levigne, P., Lykins, J., Adlaoui, EB,a cystogenic ME49 strain of Toxoplasma gondii.

Barkat, A., Berraho, A., Laboudi, M., El Mansouri, B.,Acta Trop. 141, 103–111.

Ibrahimi, A., Rhajaoui, M., Quinn, F., Murugesan, M.116

Etewa, SE, El-Maaty, DAA, Hamza, RS, Metwaly, AS,
, Seghrouchni, F., Gomez-Marin, JE, Peyron, F.,
Sarham, MH, Abdel Rahman, SA, Fathy, GM,
McLeod, R., 2018. Global initiative for congenital
El-Shafey, MA, 2018. Assessment of spiramycin
toxoplasmosis: an observational and international
loaded chitosan nanoparticles treatment on acute
comparative clinical analysis. Emerg. Microbes
and chronic toxoplasmosis in mice. J. Parasit. Dis.
Infect. 7, 165.
42, 102–113.
Elsafi, SH, Al-Mutairi, WF, Al-Jubran, KM, Abu
Farhat, SC, Swale, C., Dard, C., Cannella, D., Ortet,
Hassan, MM, Al Zahrani, EM, 2015.
P., Barakat, M., Sindikubwabo, F., Belmudes, L., De
Toxoplasmosis seroprevalence in relation to
Bock, P.-J., Coute, Y., Bourgdour, A., Hakimi, M.-A.,
knowledge and practice among pregnant women
2020. A MORC-driven transcriptional switch
in Dhahran, Saudi Arabia. Pathog. Glob. Health
controls Toxoplasma developmental trajectoriesFrenkel, JK, 1967. Adoptive immunity to

and sexual commitment. Nat. Mikrobiol. 5, 570–intracellular infection. J. Immunol. 98, 1309–1319.

583. Frenkel, JK, Pfefferkorn, ER, Smith, DD, Fishback,

Ferguson, DJP, 2009. Toxoplasma gondii: 1908– JL, 1991. Prospective vaccine prepared from a

2008, homage to Nicolle, Manceaux and new mutant of Toxoplasma gondii for use in cats.

Splendore. m. Inst. Oswaldo Cruz 104, 133–148. Saya. J. Dokter hewan. Res. 52, 759–763.

Ferguson, DJP, Huskinson-Mark, J., Araujo, FG,Frenkel, JK, Smith, DD, 1982. Immunization of

Remington, JS, 1994. An ultrastructural study ofcats against shedding of Toxoplasma oocysts. J.

the effect of treatment with atovaquone in brainsParasitol. 68, 744–748.

of mice chronically infected with the ME49 strainFreppel, W., Ferguson, DJP, Shapiro, K., Dubey, JP,

of Toxoplasma gondii. Int. J. Eks. Patol. 75, 111–Puech, P.-H., Dumètre, A., 2019. Structure,

116. composition, and roles of the Toxoplasma gondii

Ferreira, FP, Caldart, ET, Freire, RL,oocyst and sporocyst walls. Cell Surf. 5, 10016.

Mitsuka-Bregano, R., de Freitas, FM, Miura, AC,Freyre, A., Choromanski, L., Fishback, JL, Popiel, I.,

Mareze, M., Martins, FDC, Urbano, MR, Selfert, AL,1993. Immunization of cats with tissue cysts,

Navarro, IT, 2018. The effect of water source andbradyzoites, and tachyzoites of the T-263 strain of

soil supplementation on parasite contaminationToxoplasma gondii. J. Parasitol. 79, 716–719.

in organic vegetable gardens. Pdt. Bras. Parasitol.Freyre, A., Falcon, J., Mendez, J., Gastell, T.,

Dokter hewan. 27, 327–337. Venzal, JM, 2007. Toxoplasma gondii:

Fichera, ME, Bhopale, MK, Roos, DS, 1995. In vitrocross-immunity against the enteric cycle. Eks.

assays elucidate peculiar kinetics of clindamycinParasitol. 115, 48–52. Fry, M., Pudney, M., 1992.

action against Toxoplasma gondii. Antimikroba.Site of action of the antimalarial

Agen Kemo. 39, 1530–1537. hydroxynaphthoquinone,

Foroutan, M., Ghaffarifar, F., Sharifi, Z., Dalimi, A.,2-[trans-4-(4'-chlorophenyl) cyclohexyl]-3-hydroxy

2020. Vaccination with a novel multi-epitope1,4-naphthoquinone (566C80). Biochem.

ROP8 DNA vaccine against acute ToxoplasmaPharmacol. 43, 1545–1553. Fu, YF, Feng, M.,

gondii infection induces strong B and T cellOhnishi, K., Kimura, T., Itoh, J., Cheng, XJ,

responses in mice. Komp. Immunol. Mikrobiol.Tachibana, H., 2011. Generation of a neutralizing

Menulari. Dis. 69, 101413. human monoclonal antibody Fab fragment to

surface antigen 1 of Toxoplasma gondii Dos Santos, PS, Goncalves, DD, Gasparotto, FM,

tachyzoites. Menulari. Immun. 79, 512–517. Navarro, IT, Lourenco, EL, 2016. Effects of

Fuchs, O., 2019. Treatment of lymphoid and extracts from Echinacea purpurea (L) MOENCH

myeloid malignancies by immunomodulatory on mice infected with different strains of

drugs. Cardiovasc. Hematol. gangguan. Drug Toxoplasma gondii. Parasitol. Res. 115, 3999–

Targets 19, 51– 78. 4005.

Gaafar, MR, Mady, RF, Diab, RG, Shalaby, Th.I., Gollub, EL, Leroy, V., Gilbert, R., Chêne, G., Wallon,

2014. Chitosan and silver nanoparticles: M., European Toxoprevention Study Group

promising anti-Toxoplasma agents. Eks. Parasitol.(EUROTOXO), 2008. Effectiveness of health

143, 30–38. Galal, L., Hamidovic´, A., Dardé, ML, education on Toxoplasma-related knowledge,

Mercier, M., 2019. Diversity of Toxoplasma gondii behaviour, and risk of seroconversion in

strains at the global level and its determinants. pregnancy. Eur. J. Obstesi. Ginekol. Reprod. Biol.

Food Waterborne Parasitol. 12, e00052. 136, 137–145.

Gao, Q., Zhang, NZ, Zhang, FK, Wang, M., Hu, LY,Goodman, CD, Pasaje, CFA, Kennedy, K.,

Zhu, XQ, 2018. Immune response and protectiveMcFadden, GI, Ralph, SA, 2016. Targeting protein

effect against chronic Toxoplasma gondiitranslation in organelles of the Apicomplexa.

infection induced by vaccination with a DNATrends Parasitol. 32, 953–965.

vaccine encoding profilin. BMC Infect. Dis. 18,Gopal, R., Birdsell, D., Monroy, FP, 2011.

117. Regulation of chemokine responses in intestinal

Gao, S., Wang, S., Song, Y., 2020. Novel epithelial cells by stress and Toxoplasma gondii

immunomodulatory drugs and neo substrates. infection. Parasite Immunol. 33, 12–24.

Biomarker Res. 8, 2. Guo, J., Sun, X., Yin, H., Wang, T., Li, Y., Zhou, C.,

Garcia, JL, Gennari, SM, Navarro, IT, Machado, RZ,Zhou, H., He, S., Cong, H., 2018. Chitosan

Sinhorini, IL, Freire, RL, Marana, ER, Tsutsui, V.,microsphere used as an effective system to

Contente, AP, Begale, LP, 2005. Partial protectiondeliver a linked antigenic peptides vaccine protect

against tissue cysts formation in pigs vaccinatedmice against acute and chronic toxoplasmosis.

with crude rhoptry proteins of Toxoplasma gondii. Front. Sel. Menulari. Mikrobiol. 8, 163.

Dokter hewan. Parasitol. 129, 209–217. Hagras, NA, Allam, AF, Farag, HF, Osman, MM,

Gasparotto Junior, A., Cosmo, ML, Reis Mde, P.,Shalaby, Th.I., Mogahed, NMFH, Tolba, MM,
Shehab, AY, 2019. Successful treatment of acutespiramycin-loaded chitosan nanoparticles. Eks.

experimental toxoplasmosis byParasitol. 204, 107717.

NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
Haverkos, HW, 1987. Assessment of therapy for sheep after DNA immunization with, Toxoplasma

toxoplasma encephalitis. The TE Study Group. gondii MAG1 antigen-with and without co

Am J. Med. 82, 907–914. expression of ovine interleukin 6. Vet. Immunol.

Hayward, JA, van Dooren, GG, 2019. Same, sameImmunopathol. 136, 324–329.

but different: uncovering unique features of theHiszczynska-Sawicka, E., Li, H., Xu, JB,

mitochondrial respiratory chain of apicomplexans.Holec-Gasior, L., Kur, J., Sedcole, R., Bickerstaffe,

mol. Biochem. Parasitol. 232, 111204. R., Stankiewicz, M., 2011a. Modulation of immune

He, CY, Shaw, MK, Pletcher, CH, Striepen, B., Tilney,response to Toxoplasma gondii in sheep by

LG, Roos, DS, 2001. A plastid segregation defectimmunization with a DNA vaccine encoding ROP1

in the protozoan parasite Toxoplasma gondii.antigen as a fusion protein with ovine CD154.

EMBO J. 20, 330–339. Dokter hewan. Parasitol. 183, 72–78.

Hegazy, S., Farid, A., Rabae, I., El-Amir, A., 2015.Hiszczynska-Sawicka, E., Oledzka, G.,

Novel IMB-ELISA assay for rapid diagnosis ofHolec-Gasior, L., Li, H., Xu, JB, Sedcole, R., Kur, J.,

human toxoplasmosis using SAG-1 antigen. Jpn.Bickerstaffe, R., Stankiewicz, M., 2011b.

J. Infect. Dis. 68, 474–480. Evaluation of immune responses in sheep

Hehl, AB, Basso, WU, Lippuner, C., Ramakrishnan,induced by DNA immunization with genes

C., Okoniewski, M., Walker, RA, Grigg, ME, Smith,encoding GRA1, GRA4, GRA6 and GRA7 antigens

NC, Deplazes, P., 2015. Asexual expansion ofof Toxoplasma gondii. Dokter hewan. Parasitol.

Toxoplasma gondii merozoites is distinct from177, 281–289.

tachyzoites and entails expression of nonHofhuis, A., van Pelt, W., van Duynhoven, YTHP,

overlapping gene families to attach, invade, andNijhuis, CDM, Mollema, L., van der Klis, FRM,

replicate within feline enterocytes. BMCHavelaar, AH, Kortbeek, LM, 2011. Decreased

Genomics 16, 66. prevalence and age-specific risk factors for

Hiszczynska-Sawicka, E., Akhtar, M., Kay, GW,Toxoplasma gondii IgG antibodies in The

Holec-Gasior, L., Bickerstaffe, R., Kur, J.,Netherlands between 1995/1996 and 2006/2007.

Stankiewicz, M., 2010. The immune responses ofEpidemiol. Menulari. 139, 530–538.
Hopper, AT, Brockman, A., Wise, A., Gould, J.,1997. The role of the CD28/B7 interaction in the

Barks, J., Radke, JB, Sibley, LD, Zou, Y., Thomas, S.,regulation of NK cell responses during infection

2019. Discovery of selective Toxoplasma gondiiwith Toxoplasma gondii. J. Immunol. 158, 2285–

dihydrofolate reductase inhibitors for the2293.

treatment of toxoplasmosis. J. Med. Kimia 62,Imlay, L., Odom, AR, 2014. Isoprenoid metabolism

1562–1576. in apicomplexan parasites. Curr. klinik Mikrobiol.

Huang, SY, Chen, K., Wang, JL, Yang, B., Zhu, XQ,Rep. 1, 37–50.

2019. Evaluation of protective immunity inducedInnes, EA, Bartley, PM, Maley, S., Katzer, F., Buxton,

by recombinant calcium-dependent proteinD., 2009. Veterinary vaccines against Toxoplasma

kinase 1 (TgCDPK1) protein against acutegondii. m. Inst. Oswaldo Cruz 104, 246–251.

toxoplasmosis in mice. Microb. Pathog. 133,Innes, EA, Hamiliton, C., Garcia, JL, Chryssafidis, A.

103560. , Smith, D., 2019. A one health approach to

Huang, W., Ojo, KK, Zhang, Z., Rivas, K., Vidadala,vaccines against Toxoplasma gondii. Food

RS, Scheele, S., DeRocher, AE, Choi, R., Hulverson,Waterborne Parasitol. 15, e00053.

MA, Barrett, LK, Bruzual, I., Siddaramaiah, LK,Ivanetich, KM, Santi, DV, 1990. Thymidylate

Kerchner, KM, Kurnick, MD, Freiberg, GM, Kempf,synthase-dihydrofolate reductase in protozoa. Eks.

D., Hol, WG, Merritt, EA, Neckermann, G., de Parasitol. 70, 367–371.

Hostos, EL, Isoherranen, N., Maly, DJ, Parsons, M.,Ivanova, DL, Mundhenke, TM, Gigley, JP, 2019.

Doggett, JS, Van Voorhis, WC, Fan, E., 2015. SARThe IL-12- and IL-23-dependent NK cell response

Studies of 5- Aminopyrazole-4-carboxamideis essential for protective immunity against

Analogues as Potent and Selective Inhibitors ofsecondary Toxoplasma gondii Infection. J.

Toxoplasma gondii CDPK1. ACS Med. Kimia Lett.Immunol. 203, 2944–2958.

6, 1184–1189. Janetka, JW, Hopper, AT, Yang, Z., Barks, J.,

Hunter, CA, Candolfi, E., Subauste, C., Van Cleave,Dhason, MS, Wang, Q., Sibley, LD, 2020.

V., Remington, JS, 1995. Studies on the role ofOptimizing pyrazolopyrimidine inhibitors of

interleukin-12 in acute murine toxoplasmosis.calcium dependent protein kinase 1 for treatment

Immunology 84, 16–20. of acute and chronic toxoplasmosis. J. Med.

Hunter, CA, Ellis-Neyer, L., Gabriel, KE, Kennedy,Kimia 63, 6144–6163.

MK, Grabstein, KH, Linsley, PS, Remington, JS,Jia, L., Guo, H., Liu, M., Gao, Y., Zhang, L., Li, H., Xie,
 S., Zhang, N., 2018. Construction of anprior decade. Saya. J. Trop. Med. Hyg. 77, 405–

adenovirus vaccine expressing the cross-reactive410.

antigen AMA1 for Neospora caninum andJones, JL, Lopez, A., Wilson, M., Schulkin, J., Gibbs,

Toxoplasma gondii and its immune response in R., 2001. Congenital toxoplasmosis: a review.

an animal model. Iran. J. Parasitol. 13, 235–243. Obstet. Ginekol. bertahan 56, 296–305.

Jiang, S., Hua, E., Liang, M., Liu, B., Xie, G., 2013. AJones, JL, Ogunmodede, F., Scheftel, J., Kirkland,

novel immunosensor for detecting ToxoplasmaE., Lopez, A., Schulkin, J., Lynfield, R., 2003.

gondii-specific IgM based on goldmagToxoplasmosis-related knowledge and practices

nanoparticles and graphene sheets. Colloids Surf.,among pregnant women in the United States.

B Biointerfaces 101, 481–486. Menulari. Dis. Obstet. Ginekol. 11, 139–145.

Jiang, W., Sullivan, AM, Su, C., Zhao, X., 2012. An Jongert, E., Melkebeek, V., De Craeye, S., Dewit, J.,

agent-based model for the transmission Verhelst, D., Cox, E., 2008. An enhanced

dynamics of Toxoplasma gondii. J. Theoret. Biol. GRA1-GRA7 cocktail DNA vaccine primes

293, 15–26. Jomaa, H., Wiesner, J., Sanderbrand, anti-Toxoplasma immune responses in pigs.

S., Altincicek, B., Weidemeyer, C., Hintz, M., Vaccine 26, 1025–1031.

Türbachova, I., Eberl, M., Zeidler, J., Lichtenthaler, Kang, H., Remington, JS, Suzuki, Y., 2000.

HK, Soldati, D., Beck, E., 1999. Inhibitors of the Decreased resistance of B cell-deficient mice to

nonmevalonate pathway of isoprenoid infection with Toxoplasma gondii despite

biosynthesis as antimalarial drugs. Science 285, unimpaired expression of IFN gamma, TNF-alpha,

1573–1576. and inducible nitric oxide synthase. J. Immunol.

Jones, JL, Kruszon-Moran, D., Rivera, HN, Price, C., 164, 2629– 2634.

Wilkins, PP, 2014. Toxoplasma gondiiKasper, LH, Matsuura, T., Khan, IA, 1995. IL-7

seroprevalence in the United States 2009–1010stimulates protective immunity in mice against

and comparison with the past two decades. Saya. the intracellular pathogen, Toxoplasma gondii. J.

J. Trop. Med. Hyg. 90, 1135–1139. Immunol. 155, 4798–4804.

117 Katlama, C., Mouthon, B., Gourdon, D., Lapierre, D.,

Jones, JL, Kruszon-Moran, D., Sanders-Lewis, K.,
Rousseau, F., 1996. Atovaquone as long-term
Wilson, M., 2007. Toxoplasma gondii infection in
suppressive therapy for toxoplasmic encephalitis
the United States, 1999–2004, decline from the
in patients with AIDS and multiple drug
intolerance. Atovaquone Expanded Access Group.Unexpected neurologic complications following a

AIDS 10, 1107–1112. novel lymphoma treatment 'expected' to give rise

Kator, S., Zurko, J., Webb, BJ, Balatico, MA,to neurologic toxicity. BMJ Case Rep. 12,

Clayton, F., Palmer, CA, Konopa, K., Motyckova, G., e229946.

Ford, CD, Ostronoff, F., 2020. DisseminatedKeyhani, A., Ziaali, N., Shakibaie, M., Kareshk, AT,

toxoplasmosis and haemophagocyticShojaee, S., Asadi-Shekaarii, M., Sephvand, M.,

lymphohistiocytosis following chimeric antigenMahmoudvand, H., 2020. Biogenic selenium

receptor T cell therapy. sdr. J. Haematol. 189, e4–nanoparticles target chronic toxoplasmosis with

e6. minimal cytotoxicity in a mouse model. J. Med.

Katzer, F., Canton, G., Burrells, A.,Mikrobiol. 69, 104–110.

Palarea-Albaladejo, J., Horton, B., Bartley, PM,Khan, IA, Casciotti, L., 1999. IL-15 prolongs the

Pang, Y., Chianini, F., Innes, EA, Benavides, J.,duration of CD8+ T cell-mediated immunity in

2014. Immunization of lambs with the S48 strainmice infected with a vaccine strain of

of Toxoplasma gondii reduces tissue cyst burdenToxoplasma gondii. J. Immunol. 163, 4503–4509.

following oral challenge with a complete strain ofKhan, IA, Kasper, LH, 1996. IL-15 augments CD8+

the parasite. Dokter hewan. Parasitol. 205, 46– 56.T cell-mediated immunity against Toxoplasma

Kaufmann, E., Sanz, J., Dunn, JL, Khan, N.,gondii infection in mice. J. Immunol. 157, 2103–

Mendonca, LE, Pacis, A., Tzelepis, F., Pernet, E.,2108. Khan, IA, Moretto, M., Wei, XQ, Williams, M.,

Dumaine, A., Grenier, JC, Mailhot-Leonard, F.,Schwartzman, JD, Liew, FY, 2002. Treatment with

Ahmed, E., Belle, J., Besla, R., Mazer, B., King, IL,soluble interleukin-15Ralpha exacerbates

Nijnik, A., Robbins, CS, Barreiro, LB, Divangahi, M.,intracellular parasitic infection by blocking the

2018a. BCG educates hematopoietic stem cellsdevelopment of memory CD8+ T cell response. J.

to generate protective innate immunity againstEks. Med. 195, 1463–1470.

tuberculosis. Cell 172, 176–190. Khan, IA, Murphy, PM, Casciotti, L., Schwartzman,

Kaufmann, SHE, Dorhoi, A., Hotchkiss, RS,JD, Collins, J., Gao, JL, Yeaman, GR, 2001. Mice

Bartenschlager, R., 2018b. Host directedlacking the chemokine receptor CCR1 show

therapies for bacterial and viral infections. Natureincreased susceptibility to Toxoplasma gondii

Rev. Drug Discovery 17, 35–56. infection. J. Immunol. 166, 1930–1937.

Kersten, MJ, van Ettekoven, CN, Heijink, DM, 2019. Khan, IA, Thomas, SY, Moretto, MM, Lee, FS, Islam,
SA, Combe, C., Schwartzman, JD, Luster, AD, 2006.Konrad, C., Queener, SF, Wek, RC, Sullivan Jr., WJ,

CCR5 is essential for NK cell trafficking and host2013. Inhibitors of eIF2a dephosphorylation slow

survival following Toxoplasma gondii infection.replication and stabilize latency in Toxoplasma

PLoS Pathogens 2, e49. gondii. Antimikroba. Agents Chemoth. 57, 1815–

Kijlstra, A., Jongert, E., 2008. Control of the risk of 1822.

human toxoplasmosis transmitted by meat. Int. J. Krahenbuhl, JL, Sharma, SD, Ferraresi, RW,

Parasitol. 38, 1359–1370. Remington, JS, 1981. Effects of muramyl

Kim, MJ, Lee, SH, Kang, HJ, Chu, KB, Park, H., Jin,dipeptide treatment on resistance to infection

H., Moon, EK, Kim, SS, Quan, FS, 2020. Virus-likewith Toxoplasma gondii in mice. Menulari. Immun.

particle vaccine displaying Toxoplasma gondii 31, 716–722.

apical membrane antigen 1 induces protectionKupz, A., Pai, S., Giacomin, PR, Whan, JA, Walker,

against T. gondii ME49 infection in mice. Microb.RA, Hammoudi, P.-M., Smith, NC, Miller, CM, 2020.

Pathog. 142, 104090. Treatment of mice with S4B6 IL2-complex

Kim, SK, Karasov, A., Boothroyd, JC, 2007.prevents lethal toxoplasmosis via IL-12- and IL-18-

Bradyzoite-specific surface antigen SRS9 plays adependent IFN-gamma production by non CD4

role in maintaining Toxoplasma gondiiimmune cells. Sci. Rep. 10, 13115.

persistence in the brain and in host control ofLambert, H., Vutova, PP, Adams, WC, Loré, K.,

parasite replication in the intestine. Menulari.Barragan, A., 2009. The Toxoplasma

Immun. 75, 1626– 1634. gondii-shuttling function of dendritic cells is

Kochanowsky, JA, Koshy, AA, 2020. A single linked to the parasite genotype. Menulari. Immun.

transcription factor drives Toxoplasma gondii 77, 1679–1688.

differentiation. Cell 180, 216–218.

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95–121
Lawres, LA, Garg, A., Kumar, V., Bruzual, I., Forquer,of experimental babesiosis in immunodeficient

IP, Renard, I., Virji, AZ, Boulard, P., Rodriguez, EX,mice using a combination of an endochin-like

Allen, AJ, Pou, S., Wegmann, KW, Winter, RW,quinolone and atovaquone. J. Eks. Med. 213,

Nilsen, A., Mao, J., Preston, DA, Belperron, AA,1307–1318.

Bockenstedt, LK, Hinrichs, DJ, Riscoe, MK,Le Roux, D., Djokic, V., Morisse, S., Chauvin, C.,

Doggett, JS, Ben Mamoun, C., 2016. Radical cureDore, V., Lagree, AC, Voisin, D., Villain, Y.,
Grasset-Chevillot, A., Boursin, F., Su, C., Perrot, S.,Li, TT, Li, TS, Zhu, XQ, Wang, JL, 2020a.

Vallee, I., Seche, E., Blaga, R., 2020. Evaluation ofRHD17Dnpt1 strain of Toxoplasma gondii elicits

immunogenicity and protection of the Mic1-3protective immunity against acute, chronic and

knockout Toxoplasma gondii live attenuatedcongenital toxoplasmosis in mice.

strain in the feline host. Vaccine 38, 1457–1466. Microorganisms 8, 352.

Lehane, AM, Dennis, ASM, Bray, KO, Li, D.,Liang, X., Cui, J., Yang, X., Xia, N., Li, Y., Zhao, J.,

Rajendren, E., McCoy, JM, McArthur, HM,Gupta, N., Shen, B., 2020b. Acquisition of

Winterberg, M., Rahimi, F., Tonkin, CJ, Kirk, K., vanexogenous fatty acids renders apicoplast-based

Dooren, GG, 2019. Characterization of the ATP4biosynthesis dispensable in tachyzoites of

ion pump in Toxoplasma gondii. J.Biol. Kimia 294,Toxoplasma. J.Biol. Kimia 295, 7743–7752.

5720–5734. Lidar, M., Langevitz, P., Barzilai, O., Ram, M.,

Li, B., Oledzka, G., McFarlane, RG, Spellerberg, MB,Porat-Katz, B.-S., Bizzaro, N., Tonutti, E., Maieron,

Smith, SM, Gelder, FB, Kur, J., Stankiewicz, M.,R., Chowers, Y., Bar-Meier, S., Shoenfeld, Y., 2009.

2010. Immunological response of sheep toInfectious serologies and autoantibodies in

injections of plasmids encoding Toxoplasmainflammatory bowel disease: insinuations at a

gondii SAG1 and ROP1 genes. Parasite Immunol.true pathogenic role. Ann. NY Acad. Sci. 1173,

32, 671–683. 640–648.

Li, X., Zhang, Q., Hou, P., Chen, M., Hui, W.,Lieberman, LA, Villegas, EN, Hunter, CA, 2004.

Vermorken, A., Luo, Z., Li, H., Li, Q., Cui, Y., 2015.Interleukin-15-deficient mice develop protective

Gold magnetic nanoparticle conjugate-basedimmunity to Toxoplasma gondii. Menulari. Immun.

lateral flow assay for the detection of IgM class 72, 6729– 6732.

antibodies related to TORCH infections. Int. J.Lim, SY, Yuzhalin, AE, Gordon-Weeks, AN, Muschel,

Mol. Med. 36, 1319–1326. RJ, 2016. Targeting the CCL2-CCR2 signaling

Li, ZH, Ramakrishnan, S., Striepen, B., Moreno, SN,axis in cancer metastasis. Oncotarget 7, 28697–

2013. Toxoplasma gondii relies on both host and28710.

parasite isoprenoids and can be renderedLin, M.-H., Chen, T.-C., Kuo, T.-T., Tseng, C.-C.,

sensitive to atorvastatin. PLoS Pathogens 9,Tseng, C.-P., 2000. Real-time PCR for quantitative

e1003665. detection of Toxoplasma gondii. J.klin. Mikrobiol.

Liang, QL, Sun, LX, Elsheikha, HM, Cao, XZ, Nie, LB, 38, 41221–44125. Lindsay, DS, Blagburn, BL,
Dubey, JP, 1993. Safety and results of challenge using CRISPR/ Cas9. Menulari. Immun. 84, 1262–

of weaned pigs given a temperature-sensitive 1273.

mutant of Toxoplasma gondii. J. Parasitol. 79, Lorenzi, H., Khan, A., Behnke, MS, Namasivayam, S.

71–76. , Swapna, LS, Hadjithomas, M., Karamycheva, S.,

Ling, Y., Li, ZH, Miranda, K., Oldfield, E., Moreno,Pinney, D., Brunk, BP, Ajioka, JW, Ajzenberg, D.,

SN, 2007. The farnesylBoothroyd, JC, Boyle, JP, Dardé, ML, Diaz-Miranda,

diphosphate/geranylgeranyl-diphosphate MA, Dubey, JP, Fritz, HM, Gennari, SM, Gregory, BD,

synthase of Toxoplasma gondii is a bifunctional Kim, K., Saeij, JP, Su, C., White, MW, Zhu, XQ,

enzyme and a molecular target ofHowe, DK, Rosenthal, BM, Grigg, ME, Parkinson, J.,

bisphosphonates. J.Biol. Kimia 282, 30804–Liu, L., Kissinger, JC, Roos, DS, Sibley, LD, 2015.

30816. Local admixture of amplified and diversified

Ling, Y., Sahota, G., Odeh, S., Chan, JM, Araujo, FG,secreted pathogenesis determinants shapes

Moreno, SN, Oldfield, E., 2005. Bisphosphonatemosaic Toxoplasma gondii genomes. Nat.

inhibitors of Toxoplasma gondii growth: in vitro,komuni. 7, 10147.

QSAR, and in vivo investigations. J. Med. KimiaLourido, S., Shuman, J., Zhang, C., Shokat, KM, Hui,

48, 3130–3140. R., Sibley, LD, 2010. Calcium dependent protein

Liu, E., Marin, D., Banerjee, P., Macapinlac, HA,kinase 1 is an essential regulator of exocytosis in

Thompson, P., Basar, R., Nassif Kerbauy, L.,Toxoplasma. Nature 465, 359–362.

Overman, B., Thall, P., Kaplan, M., Nandivada, V.,Luft, BJ, Remington, JS, 1992. Toxoplasmic

Kaur, I., Nunez Cortes, A., Cao, K., Daher, M.,encephalitis in AIDS. klinik Menulari. Dis. 15, 211–

Hosing, C., Cohen, EN, Kebriaei, P., Mehta, R.,222.

Neelapu, S., Nieto, Y., Wang, M., Wierda, W.,Luo, F., Zheng, L., Hu, Y., Liu, S., Wang, Y., Xiong, Z.,

Keating, M., Champlin, R., Shpall, EJ, Rezvani, K.,Hu, X., Tan, F., 2017. Induction of protective

2020. Use of CAR-transduced Natural Killer cellsimmunity against Toxoplasma gondii in mice by

in CD19-positive lymphoid tumors. N. Engl. J.nucleoside triphosphate hydrolase-II (NTPase-II)

Med. 382, 545–553. self-amplifying RNA vaccine encapsulated in lipid

Long, S., Wang, Q., Sibley, LD, 2016. Analysis ofnanoparticle (LNP). Front. Mikrobiol. 8, 605.

noncanonical calcium-dependent protein kinasesMachado, LF, Sanfelice, RA, Bosqui, LR, Assolini,

in Toxoplasma gondii by targeted gene deletionJP, Scandorieiro, S., Navarro, IT, Cataneo, AHD,
Wowk, PF, Nakazato, G., Bordignon, J., Pavanelli,Markus, BM, Bell, GW, Lorenzi, HA, Lourido, S.,

WR, Conchon-Costa, I., Costa, IN, 2020. Biogenic2019. Optimizing systems for Cas9 expression in

silver nanoparticles reduce adherence, infectionToxoplasma gondii. mSphere 4, 00386–419.

and proliferation of Toxoplasma gondii RH strainMartin, MB, Grimley, JS, Lewis, JC, Heath 3rd, HT,

in HeLa cells without inflammatory mediatorsBailey, BN, Kendrick, H., Yardley, V., Caldera, A.,

induction. Eks. Parasit. 211, 107853. Lira, R., Urbina, JA, Moreno, SN, Docampo, R.,

118 Croft, SL, Oldfield, E., 2001. Bisphosphonates

Machala, L., Kodym, P., Maly, M., Geleneky, M.,
inhibit the growth of Trypanosoma brucei,
Beran, O., Jilich, D., 2015. Toxoplasmosis in
Trypanosoma cruzi, Leishmania donovani,
immunocompromised patients. Epidemiol.
Toxoplasma gondii, and Plasmodium falciparum:
Mikrobiol. Imunol. 64, 59–65.
a potential route to chemotherapy. J. Med. Kimia
Maeta, M., Miura, N., Tanaka, H., Nakamura, T.,
44, 909–916.
Kawanishi, R., Nishikawa, Y., Asano, K., Tanaka, M.,
Martorelli Di Genova, B., Wilson, SK, Dubey, JP,
Tamagawa, S., Nakai, Y., Tange, K., Yoshioka, H.,
Knoll, LJ, 2019. Intestinal-delta-6- desaturase
Harashima, H., Akita, H., 2020. Vitamin E
activity determines hots range for Toxoplasma
scaffolds of pH-responsive lipid nanoparticles as
sexual reproduction. PLoS Biol. 17, e3000364.
DNA vaccines in cancer and protozoan infection
Martynowicz, J., Augusto, L., Wek, RC, Boehm 2nd,
Mol. Pharmaceutics 17, 1237–1247.
SL, Sullivan Jr., WJ, 2019. Guanabenz reverses a
Maldini, CR, Ellis, GI, Riley, JL, 2018. CAR T cells
key behavioral change caused by latent
for infection, autoimmunity and
toxoplasmosis in mice by reducing
allotransplantation. Nat. Rev. Immunol. 18, 605–
neuroinflammation. mBio 10, 00381–419.
616.
Martynowicz, J., Doggett, JS, Sullivan Jr., WJ,
Mareze, M., do Nascimento, Benitez, A., Brandao,
2020. Efficacy of guanabenz combination therapy
APD, Pinto-Ferreira, F., Miura, AC, Martins, FDC,
against chronic toxoplasmosis across multiple
Caldart, ET, Biondo, AW, Freire, RL,
mouse strains. Antimikroba. Agen Kemo.
Misuka-Bregano, R., Navarro, IT, 2019.
https://doi.org/10.1128/AAC00539-20.
Socioeconomic vulnerability associated to
Mateus-Pinilla, NE, Dubey, JP, Choromanski, L.,
Toxoplasma gondii exposure in southern Brazil.
Weigel, RM, 1999. A field trial of the effectiveness
PLoS One 14, e0212375.
of a feline Toxoplasma gondii vaccine in reducing
T. gondii exposure for swine. J. Parasitol. 85,McFadden, DC, Tomavo, S., Berry, EA, Boothroyd,

855–860. JC, 2000. Characterization of cytochrome b from

Mateus-Pinilla, NE, Hannon, B., Weigel, RM, 2002.Toxoplasma gondii and Q(o) domain mutations

A computer simulation of the prevention of theas a mechanism of atovaquone-resistance. mol.

transmission of Toxoplasma gondii on swineBiochem. Parasitol. 108, 1–12.

farms using a feline T. gondii vaccine.McLeod, R., Khan, AR, Noble, GA, Latkany, P.,

sebelumnya Dokter hewan. Med. 55, 17–36. Jalbrzikowski, L., Boyer, K., Toxoplasmois Study

Maubon, D., Bougdour, A., Wong, YS,Group, 2006. Severe sulfadiazine hypersensitivity

Brenier-Pinchart, MP, Curt, A., Hakimi, MA, Pelloux, in a child with reactivated congenital toxoplasmic

H., 2010. Activity of the histone deacetylasechorioretinitis. Pediatr. Menulari. Dis. J. 25, 270–

inhibitor FR235222 on Toxoplasma gondii:272.

inhibition of stage conversion of the parasite cystMcLeod, R., Lykins, J., Noble, AG, Rabiah, P.,

form and study of new derivative compounds.Swisher, CN, Heydemann, PT, McLone, D., From, D.

Antimikroba. Agen Kemo. 54, 4843– 4850. , Withers, S., Clouser, F., Boyer, K., 2014.

Mazumdar, J., Emma, HW, Masek, K., Christopher,Management of congenital toxoplasmosis. Curr.

AH, Striepen, B., 2006. Apicoplast fatty acidPediatr. Rep. 2, 166–194.

synthesis is essential for organelle biogenesisMcLeod, R., Muench, SP, Rafferty, JB, Kyle, DE,

and parasite survival in Toxoplasma gondii. Prok.Mui, EJ, Kirisits, MJ, Mack, DG, Roberts, CW,

Natl. akad. Sci. USA 103, 13192–13197. Samuel, BU, Lyons, RE, Dorris, M., Milhous, WK,

McConnell, EV, Bruzual, I., Pou, S., Winter, R.,Rice, DW, 2001. Triclosan inhibits the growth of

Dodean, RA, Smilkstein, MJ, Krollenbrock, A.,Plasmodium falciparum and Toxoplasma gondii

Nilsen, A., Zakharov, LN, Riscoe, MK, Doggett, JS,by inhibition of apicomplexan Fab I. Int. J.

2018. Targeted structure-activity analysis ofParasitol. 31, 109–113.

endochin-like quinolones reveals potent Qi andMedawar-Aguilar, V., Jofre, CF, Fernández-Baldo,

Qo site inhibitors of Toxoplasma gondii andMA, Alonso, A., Angel, S., Raba, J., Pereira, SV,

Plasmodium falciparum cytochrome bc1 andMessina, GA, 2019. Serological diagnosis of

identifies ELQ-400 as a remarkably effectivetoxoplasmosis disease using a fluorescent

compound against acute experimentalimmunosensor with chitosan-ZnO-nanoparticles.

toxoplasmosis. ACS Infect. Dis. 4, 1574–1584. dubur. Biochem. 564–565, 116–122.

Megged, O., Shalit, I., Yaniv, I., Stein, J., Fisher, S.,Fonseca, AB, Sudré, AP, Leles, D., Amendoeira, MR,

Levy, I., 2008. Breakthrough cerebral 2014. Toxoplasmosis-related knowledge among

toxoplasmosis in a patient receiving atovaquonepregnant and postpartum women attended in

prophylaxis after a hematopoietic stem cellpublic health units in Niterói, Rio de Janeiro, Brazil.

transplantation. Pediatr. Transplant. 12, 902–905. Rev. Inst. Med. Trop. Sao Paulo 56, 433–438.

Menzies, FM, Macphail, D., Henriquez, FL, 2016. Mishima, M., Xuan, X., Yokoyama, N., Igarashi, I.,

The role of chemokines and their receptors during Fujisaki, K., Nagasawa, H., Mikami, T., 2002.

protist parasite infections. Parasitology 143, Recombinant feline herpesvirus type 1 expressing

1890–1901. Mevelec, MN, Ducournau, C., Toxoplasma gondi ROP2 antigen inducible

Bassuny Ismael, A., Olivier, M., Seche, E., Lebrun, protective immunity in cats. Parasitol. Res. 88,

M., Bout, D., Dimier-Poisson, I., 2010. Mic1-3 144–149.

Knockout Toxoplasma gondii is a good candidate Mohit, E., Rafati, S., 2012. Chemokine-based

for a vaccine against T. gondii-induced abortion inimmunotherapy: delivery systems and

sheep. Dokter hewan. Res. 41, 49. combination therapies. Immunotherapy 4, 807–

Millar, PR, Moura, FL, Bastos, OM, Mattos, DP,840.

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95–121
Montoya, JG, Liesenfeld, O., 2004. Toxoplasmosis.Liu, SR, Jacobus, DP, McLeod, R., 2008. Novel

Lancet 363, 1965–1976. Montoya, JG, triazine JPC-2067-B inhibits Toxoplasma gondii in

Remington, JS, 2008. Management of vitro and in vivo. PLoS Neglect. Trop. Dis. 2, e190.

Toxoplasma gondii infection during pregnancy. Müller, J., Aguado-Martínez, A., Ortega-Mora, LM,

klinik Menulari. Dis. 47, 554–566. Moreno-Gonzalo, J., Ferre, I., Hulverson, MA, Choi,

Mui, EJ, Jacobus, D., Milhous, WK, Schiehser, G.,R., McCloskey, MC, Barrett, LK, Maly, DJ, Ojo, KK,

Hsu, H., Roberts, CW, Kirisits, MJ, McLeod, R.,Van Voorhis, W., Hemphill, A., 2017. Development

2005. Triazine Inhibits Toxoplasma gondiiof a murine vertical transmission model for

tachyzoites in vitro and in vivo. Antimikroba. Agen Toxoplasma gondii oocyst infection and studies

Kemo. 49, 3463–3467. on the efficacy of bumped kinase inhibitor

Mui, EJ, Schiehser, GA, Milhous, WK, Hsu, H.,(BKI)-1294 and the naphthoquinone

Roberts, CW, Kirisits, M., Muench, S., Rice, D.,buparvaquone against congenital toxoplasmosis.

Dubey, JP, Fowble, JW, Rathod, PK, Queener, SF,J. Antimicrob. Chemother. 72, 2334–2341.
Murata, Y., Sugi, T., Weiss, LM, Kato, K., 2017.Netea, MG, Dominguez-Andres, J., Barreiro, LB,

Identification of compounds that suppressChavakis, T., Divangahi, M., Fuchs, E., Joosten,

Toxoplasma gondii tachyzoites and bradyzoites.LAB, van der Meer, JWM, Mhlanga, MM, Mulder,

PloS One 12, e0178203. WJM, Riksen, NP, Schlitzer, A., Schultze, JL,

Nabi, H., Rashid, I., Ahmad, N., Durrani, A., Akbar, H.Stabell Benn, C., Sun, JC, Xavier, RJ, Latz, E., 2020.

, Islam, S., Bajwa, AA, Shehzad, W., Ashraf, K.,Defining trained immunity and its role in health

Imran, N., 2017. Induction of specific humoraland disease. Nat. Rev. Immunol. 20, 375–388.

immune response in mice immunized with ROP18 Netea, MG, Joosten, LA, Latz, E., Mills, KH, Natoli,

nanospheres from Toxoplasma gondii. Parasitol.G., Stunnenberg, HG, O'Neill, LA, Xavier, RJ, 2016.

Res. 116, 359–370. Trained immunity: a program of innate immune

Naeem, H., Sana, M., Islam, S., Khan, M., Riaz, F.,memory in health and disease. Science 352,

Zafar, Z., Akbar, H., Shehzad, W., Rashid, I., 2018.aaf1098.

Induction of Th1 type oriented humoral responseNgo, HM, Zhou, Y., Lorenzi, H., Wang, K., Kim, T.-K.,

through intranasal immunization of mice withZhou, Y., El Bissati, K., Mui, E., Fraczek, L.,

SAG1-Toxoplasma gondii polymeric nanospheres.Rajagopala, SV, Roberts, CW, Henriquez, FL,

Arti. Cells Nanomed. Bioteknologi. 46, 1025–Montpetit, A., Blackwell, JM, Jamieson, SE,

1034. Wheeler, K., Begeman, IJ, Naranjo-Galvis, C., Alliey-

Nair, SC, Brooks, CF, Goodman, CD, Sturm, A.,Rodrigues, N., Davis, RG, Soroceanu, L., Cobbs, C.,

McFadden, GI, Sundriyal, S., Anglin, JL, Song, Y.,Steindler, DA, Boyer, K., Noble, AG, Swisher, CN,

Moreno, SN, Striepen, B., 2011. ApicoplastHeydemann, PT, Rabiah, P., Withers, S.,

isoprenoid precursor synthesis and the molecularSoteropoulos, P., Hood, L., McLeod, R., 2017.

basis of fosmidomycin resistance in ToxoplasmaToxoplasma modulates signature pathways of

gondii. J. Eks. Med. 208, 1547–1559. human epilepsy, neurodegeneration and cancer.

Narasimhan, J., Joyce, BR, Naguleswaran, A.,Sci. Rep. 7, 11496.

Smith, AT, Livingston, MR, Dixon, SE, Coppens, I.,Nishimura, M., Umeda, K., Suwa, M., Furuoka, H.,

Wek, RC, Sullivan Jr., WJ, 2008. TranslationNishikawa, Y., 2017. CCR5 Is involved in

regulation by eukaryotic initiation factor-2 kinases interruption of pregnancy in mice infected with

in the development of latent cysts in ToxoplasmaToxoplasma gondii during early pregnancy.

gondii. J.Biol. Kimia 283, 16591–16601. Menulari. Immun. 85, e00257–e317.

Nogareda, F., Le Strat, Y., Villena, I., De Valk, H., mol. Biol. 17, 602–607.

Goulet, V., 2014. Incidence and prevalence ofOldenhove, G., Bouladoux, N., Wohlfert, EA, Hall,

Toxoplasma gondii infection in France, 1980–JA, Chou, D., Dos Santos, L., O'Brien, S., Blank, R.,

2020: model-based estimation. Epidemiol.Lamb, E., Natarajan, S., Kastenmayer, R., Hunter, C.

Menulari. 142, 1661–1670. , Grigg, ME, Belkaid, Y., 2009. Decrease of Foxp3+

O'Connell, E., Wilkins, MF, Te Punga, WA, 1988.Treg cell number and acquisition of effector cell

Toxoplasmosis in sheep. II. The ability of a livephenotype during lethal infection. Immunity 31,

vaccine to prevent lamb losses after an772–786.

intravenous challenge with Toxoplasma gondii.Omata, Y., Aihara, Y., Kanda, M., Saito, A., Igarashi,

NZ Vet. J. 36, 1–4. I., Suzuki, N., 1996. Toxoplasma gondii:

Ogunmodede, F., Scheftel, J., Jones, JL, Lynfield, experimental infection in cats vaccinated with

R., 2005. Toxoplasmosis prevention knowledge 60Co-irradiated tachyzoites. Dokter hewan.

among pregnant women in Minnesota. Minn. Med.Parasitol. 65, 173–183.

88, 32–34. Ojo, KK, Eastman, RT, Vidadala, R., Opsteegh, M., Kortbeek, TM, Havelaar, AH, van der

Zhang, Z., Rivas, KL, Choi, R., Lutz, JD, Reid, M. Giessen, JWB, 2014. Intervention strategies to

C., Fox, AM, Hulverson, MA, Kennedy, M.,reduce human Toxoplasma gondii disease burden.

Isoherranen, N., Kim, LM, Comess, KM, Kempf, DJ, klinik Menulari. Dis. 60, 101–107.

Verlinde, CL, Su, XZ, Kappe, SH, Maly, DJ, Fan, E.,Pagheh, AS, Sarvi, S., Gholami, S., Asgarian-Omran,

Van Voorhis, WC, 2014. A specific inhibitor of H., Valadan, R., Hassannia, H., Ahmadpour, E.,

PfCDPK4 blocks malaria transmission:Fasihi-Ramandie, M., Dodangeh, S., Hosseni-Khah,

chemical-genetic validation. J. Infect. Dis. 209,Z., Daryani, A., 2019. Protective efficacy induced

275–284. by DNA prime and recombinant protein boost

Ojo, KK, Larson, ET, Keyloun, KR, Castaneda, LJ,vaccination with Toxoplasma gondii GRA14 in

Derocher, AE, Inampudi, KK, Kim, JE, Arakaki, TL,mice. Microb. Patol. 134, 103601.

Murphy, RC, Zhang, L., Napuli, AJ, Maly, DJ,119

Pappas, G., Roussos, N., Falaga, ME, 2009.
Verlinde, CL, Buckner, FS, Parsons, M., Hol, WG,
Toxoplasmosis snapshots: global status of
Merritt, EA, Van Voorhis, WC, 2010. Toxoplasma
Toxoplasma gondii seroprevalence and
gondii calcium-dependent protein kinase 1 is a
implications for pregnancy and congenital
target for selective kinase inhibitors. Nat. Struktur.
toxoplasmosis. Int. J. Parasitol. 39, 1385–1394. Toxoplasma gondii grown in cultured cells and

Park, M.-R., Gurunathan, S., Choi, Y.-J., Kwon, D.-N.,selection of a drug-resistant mutant. Antimikroba.

Han, J.-W., Cho, S.-G., Park, C., Seo, HG, Kim, J.-H., Agen Kemo. 36, 1091–1096.

2013. Chitosan particles cause pre- andPfefferkorn, ER, Pfefferkorn, LC, 1976.

postimplantation embryo complications in mice.Toxoplasma gondii: isolation and preliminary

Biol. Reprod. 88, 1–13. characterization of temperature-sensitive

Pearson, PA, Piracha, AR, Sen, HA, Jaffe, GJ, 1999.mutants. Eks. Parasitol. 39, 365–376.

Atovaquone for the treatment of ToxoplasmaPicchio, MS, Sanchez, VR, Arcon, N., Soto, AS,

retinochoroiditis in immunocompetent patients.Perrone Sibilia, M., Aldirico, MLA, Urrutia, M.,

Ophthalmology 106, 148–153. Moretta, R., Fenoy, IM, Goldman, A., Martin, V.,

Pereboom, MT, Manniën, J., Spelten, ER,2018. Vaccine potential of antigen cocktails

Schellevis, FG, Hutton, EK, 2013. Observationalcomposed of recombinant Toxoplasma gondii

study to assess pregnant women's knowledgeTgPI 1, ROP2 and GRA4 proteins against chronic

and behaviour to prevent toxoplasmosis,toxoplasmosis in C3H mice. Eks. Parasitol. 185,

listeriosis and cytomegalovirus. BMC Pregnancy62–70.

Childbirth 13, 98. Pissuwan, D., Valenzuela, SM, Miller, CM,

Pfefferkorn, ER, 1978. Toxoplasma gondii: the Killingsworth, MC, Cortie, MB, 2009. Destruction

enzymic defect of a mutant resistant to and control of Toxoplasma gondii tachyzoites

5-fluorodeoxyuridine. Eks. Parasitol. 44, 26–35. using gold nanosphere/antibody conjugates.

Pfefferkorn, ER, Borotz, SE, Nothnagel, RF, 1993. Small 5, 10301034.

Mutants of Toxoplasma gondii resistant to Pott Jr., H., Castelo, A., 2013. Isolated cerebellar

atovaquone (566C80) or decoquinate. J. Parasitol.toxoplasmosis as a complication of HIV infection.

79, 559–564. Pfefferkorn, ER, Kasper, LH, 1983. Int. J. STD AIDS 24, 70–72.

Toxoplasma gondii: genetic crosses reveal Rachinel, N., Buzoni-Gatel, D., Dutta, C.,

phenotypic suppression of hydroxyurea Mennechet, FJ, Luangsay, S., Minns, LA, Grigg, ME,

resistance by fluorodeoxyuridine resistance. Eks. Tomavo, S., Boothroyd, JC, Kasper, LH, 2004. The

Parasitol. 55, 207–218. induction of acute ileitis by a single microbial

Pfefferkorn, ER, Nothnagel, RF, Borotz, SE, 1992.antigen of Toxoplasma gondii. J. Immunol. 173,

Parasiticidal effect of clindamycin on2725–2735.

Radke, JB, Burrows, JN, Goldberg, DE, Sibley, LD,clarithromycin, or minocycline against

2018. Evaluation of current and emergingToxoplasma gondii. Antimikroba. Agen Kemo. 37,

antimalarial medicines for inhibition of2371–2378.

Toxoplasma gondii growth in vitro. ACS Infect.Roozbehani, M., Falak, R., Mohammadi, M.,

Dis. 4, 1264–1274. Hemphill, A., Razmjou, E., Meamar, AR, Masoori, L.,

Rahimi, MT, Sarvi, S., Sharif, M., Abediankenari, S., Khoshmirsafa, M., Moradi, M., Gharavi, MJ, 2018.

Ahmadpour, E., Valadan, R., Fasihi- Ramandie, M.,Characterization of a multi-epitope peptide with

Hosseini, S.-A., Daryani, A., 2017. Immunologicalselective MHC-binding capabilities encapsulated

evaluation of a DNA cocktail vaccine within PLGA nanoparticles as a novel vaccine

co-delivery of calcium phosphate nanoparticlescandidate against Toxoplasma gondii infection.

(CaPNs) against the Toxoplasma gondii RH strain Vaccine 36, 6124–6132.

in BALB/c mice. Parasitol. Res. 116, 609–616. Rothova, A., Bosch-Driessen, LEH, van Loon, NH,

Ramakrishnan, C., Maier, S., Walker, RA, Rehrauer,Treffers, WF, 1998. Azithromycin for ocular

H., Joekel, DE, Winiger, RR, Basso, WU, Grigg, ME,toxoplasmosis. sdr. J. Ophthalmol. 82, 1306–

Hehl, AB, Deplazes, P., Smith, NC, 2019. An1308. Rougier, S., Montoya, JG, Peyron, F., 2017.

experimental genetically attenuated live vaccineLifelong persistence of Toxoplasma cysts: a

to prevent transmission of Toxoplasma gondii byquestionable dogma?. Trends Parasitol. 33, 93–

cats. Sci. Rep. 9, 1474. 101.

Ramos, EL, Santana, SS, Silva, MV, Santiago, FM,Ruffini, PA, Morandi, P., Cabioglu, N., Altundag, K.,

Mineo, TW, Mineo, JR, 2016. Lectins fromCristofanilli, M., 2007. Manipulating the

Synadenium carinatum (ScLL) and Artocarpuschemokine-chemokine receptor network to treat

heterophyllus (ArtinM) are able to inducecancer. Cancer 109, 2392–2404.

beneficial immunomodulatory effects in a murineRutaganira, FU, Barks, J., Dhason, MS, Wang, Q.,

model for treatment of Toxoplasma gondiiLopez, MS, Long, S., Radke, JB, Jones, NG,

Infection. Front. Sel. Menulari. Mikrobiol. 6, 164. Maddirala, AR, Janetka, JW, El Bakkouri, M., Hui, R.

Romand, S., Pudney, M., Derouin, F., 1993. In vitro, Shokat, KM, Sibley, LD, 2017. Inhibition of

and in vivo activities of thecalcium dependent protein kinase 1 (CDPK1) by

hydroxynaphthoquinone atovaquone alone orpyrazolopyrimidine analogs decreases

combined with pyrimethamine, sulfadiazine,establishment and reoccurrence of central

nervous system disease by Toxoplasma gondii. J. protozoan parasite Toxoplasma gondii. mol. Sel.

Med. Kimia 60, 9976– 9989. Biol. 25, 10301–10314.

Saksouk, N., Bhatti, MM, Kieffer, S., Smith, AT,Sanchez-Sanchez, R., Vazquez, P., Ferre, I.,

Musset, K., Garin, J., Sullivan Jr., WJ,Ortega-Mora, LM, 2018. Treatment of

Cesbron-Delauw, MF, Hakimi, MA, 2005.toxoplasmosis and neosporosis in farm

Histone-modifying complexes regulate generuminants: state of knowledge and futue trends.

expression pertinent to the differentiation of theCurr. Top. Med. Kimia 18, 1304–1323.

NC Smith, C. Goulart, JA Hayward dkk. International Journal for Parasitology 51 (2021) 95–121
Sayles, PC, Gibson, GW, Johnson, LL, 2000. B E., Jahanbakhsh, S., Mahmoudvand, H., 2020.

cells are essential for vaccination induced Prophylactic effects of biogenic selenium

resistance to virulent Toxoplasma gondii. nanoparticles on acute toxoplasmosis: an in vivo

Menulari. Immun. 68, 1026–1033. Seeber, F., study. Ann. Med. Surg. 54, 85–88.

Soldati-Favre, D., 2010. Metabolic pathways in the Shapira, Y., Agmon-Levin, N., Selmi, C., Petríková,

apicoplast of apicomplexa. Int. Rev. Cell. mol. J., Barzilai, O., Ram, M., Bizzaro, N., Valentini, G.,

Biol. 281, 161–228. Matucci-Cerinic, M., Anaya, J.-M., Porat-Katz, B.-S.,

Sepulveda-Arias, JC, Veloza, LA, Mantilla-Muriel, Shoenfeld, Y., 2012. Prevalence of

LE, 2014. Anti-Toxoplasma activity of naturalanti-toxoplasma antibodies in patients with

products: a review. Recent Pat. Anti-Infect. Drugautoimmune diseases. J. Autoimmun. 39, 112–

Disc. 9, 186– 194. 116.

Serranti, D., Buonsenso, D., Valentini, P., 2011. Shapiro, K., Bahia-Oliveira, L., Dixon, B., Dumètre, A.

Congenital toxoplasmosis treatment. Eur. Rev. , de Wit, LA, VanWormer, E., Villena, I., 2019.

Med. Pharmacol. Sci. 15, 193–198. Environmental transmission of Toxoplasma

Severance, EG, Alaedini, A., Yang, S., Halling, M.,gondii: oocysts in water, soil and food. Food

Gressitt, KL, Stallings, CR, Origoni, AE, Vaughan, C.,Waterborne Parasitol. 12, e00049.

Khushalani, S., Leweke, FM, Dickerson, FB, Yolken,Sharif, M., Sarvi, S., Pagheh, AS, Asfaram, S.,

RH, 2012. Gastrointestinal inflammation andRahimi, MT, Mehrzadi, S., Ahmadpour, E., Gholami,

associated immune activation in schizophrenia.S., Daryani, A., 2016. The efficacy of herbal

Schizophrenia Res. 138, 48–53. medicines against Toxoplasma gondii during the

Shakibaie, M., Ezzatkhah, F., Gabal, E., Badparva,last 3 decades: a systematic review. Bisa. J.
Fisiol. Pharmacol. 94, 1237–1248. vivo. J. Antimicrob. Chemother. 61, 1110–1119.

Sharma, D., Kanchi, S., Bisetty, K., 2019. Biogenic Shwab, EK, Saraf, P., Zhu, X.-Q., McFerrin, BM,

synthesis of nanoparticles: a review. Arab. J. Ajzenberg, D., Schares, G., Hammond-Ayree, K.,

Kimia. 12, 3576–3600. van Helden, P., Higgins, SA, Gerhold, RW,

Sharma, SD, Hofflin, JM, Remington, JS, 1985. InRosenthal, BM, Zhao, X., Dubey, JP, Su, C., 2018.

vivo recombinant interleukin 2 administrationHuman impact on the diversity and virulence of

enhances survival against a lethal challenge withthe ubiquitous zoonotic parasite Toxoplasma

Toxoplasma gondii. J. Immunol. 135, 4160–4163.gondii. Prok. Natl. akad. Sci. USA 115, e6956–

Shen, B., Brown, K., Long, S., Sibley, LD, 2017. e6963.

Development of CRISPR/Cas9 for efficient Sidik, SM, Huet, D., Lourido, S., 2018.

genome editing in Toxoplasma gondii. Methods CRISPR-Cas9-based genome-wide screening of

Mol. Biol. 1498, 79–103. Sher, A., Tosh, K., Toxoplasma gondii. Nat. Protoc. 13, 307–323.

Jankovic, D., 2017. Innate recognition of Sidney, J., del Guercio, MF, Southwood, S.,

Toxoplasma gondii in humans involves a Engelhard, VH, Appella, E., Rammensee, HG, Falk,

mechanism distinct from that utilized by rdents. K., Rotzschke, O., Takiguchi, M., Kubo, RT, et al.,

Sel. mol. Immunol. 14, 36–42. 1995. Several HLA alleles share overlapping

Shevach, EM, 2012. Application of IL-2 therapy to peptide specificities. J. Immunol. 154, 247–259.

target T regulatory cell function. Trends Immunol. Sinai, AP, Watts, EA, Dhara, A., Murphy, RD, Gentry,

33, 626–632. MS, Patwardhan, A., 2016. Reexamining chronic

Shirahata, T., Muroya, N., Ohta, C., Goto, H.,Toxoplasma gondii infection: surprising activity

Nakane, A., 1993. Enhancement by recombinantfor a ''dormant” parasite. Current Clin. Mikrobiol.

human interleukin 2 of host resistance toRep. 3, 175–185.

Toxoplasma gondii infection in pregnant mice.Singh, B., Varikuti, S., Halsey, G., Volpedo, G.,

Mikrobiol. Immunol. 37, 583–590. Hamza, OM, Satoskar, AR, 2019. Host-directed

Shubar, HM, Mayer, JP, Hopfenmüller, W.,therapies for parasitic diseases. Future Med.

Liesenfeld, O., 2008. A new combinedKimia 11, 1999– 2018.

flow-cytometry-based assay reveals excellentSingh, S., Munawwar, A., Rao, S., Mehta, S.,

activity against Toxoplasma gondii and lowHazarika, NK, 2014. Serologic prevalence of

toxicity of new bisphosphonates in vitro and inToxoplasma gondii in Indian women of child
bearing age and effects of social andBE, Curd, AB, Hoyer, KK, Jensen, KDC, 2018. PD-L1,

environmental factors. PLoS Negl. Trop. Dis. 8, TIM-3, and CTLA-4 blockade fails to promote

e2737. resistance to secondary infection with virulent

Smereka, J., Szarpak, L., Ruetzler, K., Schacham, Y.strains of Toxoplasma gondii. Menulari. Immun.

, Smereka, A., Dabrowski, M., Terpilowska, M.,86, e00459–e518.

Terpilowski, L., Adam, I., 2018. A multicenterStajner, T., Vasiljevic, Z., Vujic, D., Markovic, M.,

survey on toxoplasmosis knowledge amongRistic, G., Micic, D., Pasic, S., Ivovic, V., Ajzenberg,

women in Poland (the TOWER study). BMCD., Djurkovic-Djakovic, O., 2013. Atypical strain of

Pregnancy Childbirth 18, 389. Toxoplasma

Soares, S., Sousa, J., Pais, A., Vitorino, C., 2018. 120
gondii causing fatal reactivation after
Nanomedicine: Principles, properties and
hematopoietic stem cell transplantion in a patient
regulatory issues. Front. Kimia 6, 360.
with an underlying immunological deficiency.
Song, Z., Iorga, BI, Mounkoro, P., Fisher, N.,
J.klin. Mikrobiol. 51, 2686–2690.
Meunier, B., 2018. The antimalarial compound
Stanley, AC, Buxton, D., Innes, EA, Huntley, JF,
ELQ-400 is an unusual inhibitor of the bc(1)
2004. Intranasal immunisation with Toxoplasma
complex, targeting both Q(o) and Q(i) sites. FEBS
gondii tachyzoite antigen encapsulated into PLG
Lett. 592, 1346–1356.
microspheres induces humoral and cell-mediated
Sparrow, E., Friede, M., Sheikh, M., Torvaldsen, S.,
immunity in sheep. Vaccine 22, 3929–3941.
2017. Therapeutic antibodies for infectious
Stelzer, S., Basso, W., Benavides Silvan, J.,
diseases. Banteng. World Health Org. 95, 235–
Ortega-Mora, LM, Maksimov, P., Gethmann, J.,
237.
Conraths, FJ, Schares, G., 2019. Toxoplasma
Spillman, NJ, Allen, RJ, McNamara, CW, Yeung,
gondii infection and toxoplasmosis in farm
BKS, Winzeler, EA, Diagana, TT, Kirk, K., 2013.
animals: risk factors and economic impact. Food
Na(+) regulation in the malaria parasite
Waterborne Parasitol. 15, e00037.
Plasmodium falciparum involves the cation
Stoklasek, TA, Schluns, KS, Lefrançois, L., 2006.
ATPase PfATP4 and is a target of the
Combined IL-15/IL-15Ra immunotherapy
spiroindolone antimalarials. Cell Host Microbe 13,
maximizes IL-15 activity in vivo. J. Immunol. 177,
227–237.
6072–6080. Stonier, S., Schluns, K., 2010.
Splitt, SD, Souza, SP, Valentine, KM, Castellanos,
Trans-presentation: a novel mechanism strategies. Theoret. Pop. Biol. 105, 33–38.

regulating IL 15 delivery and responses. Immunol. Tan, F., Hu, X., Pan, CW, Ding, JQ, Chen, XG, 2010.

Lett. 127, 85–92. Monoclonal antibodies against nucleoside

Sturge, CR, Yarovinsky, F., 2014. Complextriphosphate hydrolase-II can reduce the

immune cell interplay in the gamma interferonreplication of Toxoplasma gondii. Parasitol. Int.

response during Toxoplasma gondii infection.59, 141–146.

Menulari. Immun. 82, 3090–3097. Tarancon, R., Dominguez-Andres, J., Uranga, S.,

Subauste, C., 2012. Animal models for Ferreira, AV, Groh, LA, Domenech, M.,

Toxoplasma gondii infection. Curr. Protoc. Gonzalez-Camacho, F., Riksen, NP, Aguilo, N.,

Immunol. 96. 19.3.1-19.3.23. Yuste, J., Martin, C., Netea, MG, 2020. New live

Sullivan Jr., WJ, Narasimhan, J., Bhatti, MM, Wek,attenuated tuberculosis vaccine MTBVAC

RC, 2004. Parasite-specific eIF2 (eukaryoticinduces trained immunity and confers protection

initiation factor-2) kinase required foragainst experimental lethal pneumonia. PLoS

stress-induced translation control. Biochem. J.Pathog. 16, e1008404.

380, 523–531. Teimouri, A., Azami, SJ, Keshavarz, H., Esmaeili, F.,

Suzuki, Y., Conley, FK, Remington, JS, 1990. Alimi, R., Mavi, SA, Shojaee, S., 2018.

Treatment of toxoplasmic encephalitis in mice Anti-Toxoplasma activity of various molecular

with recombinant gamma interferon. Menulari. weight and concentrations of chitosan

Immun. 58, 3050–3055. Suzuki, Y., Orellana, MA, nanoparticles on tachyzoites of RH strain. Int. J.

Schreiber, RD, Remington, JS, 1988. Nanomed. 13, 1341– 1351.

Interferon-gamma: the major mediator of Tenter, AM, Heckeroth, AR, Weiss, LM, 2000.

resistance against Toxoplasma gondii. Science Toxoplasma gondii: from animals to humans. Int.

240, 516– 518. J. Parasitol. 30, 1217–1258.

Suzuki, Y., Remington, JS, 1990. The effect of anti-Thomas, F., Lafferty, KD, Brodeur, J., Elguero, E.,

IFN-gamma antibody on the protective effect ofGauthier-Clerc, M., Missé, D., 2012. Incidence of

Lyt-2+ immune T cells against toxoplasmosis inadult brain cancers is higher in countries where

mice. J. Immunol. 144, 1954–1956. the protozoan parasite Toxoplasma gondii is

Sykes, D., Rychtárˇ, J., 2015. A game-thery common. Biol. Lett. 8, 101–103.

approach to valuating toxoplasmosis vaccination Tomita, T., Bzik, DJ, Ma, YF, Fox, BA, Markillie, LM,
Taylor, RC, Kim, K., Weiss, LM, 2013. TheTurner, M., Lenhart, S., Rosenthal, B., Zhao, X.,

Toxoplasma gondii cyst wall protein CST1 is2013. Modeling effective transmission pathways

critical for cyst wall integrity and promotesand control of the worlds' most successful

bradyzoite persistence. PLoS Pathog. 9,parasite. Theor. Pop. Biol. 86, 50–61.

e1003823. Vazini, H., Ghafarifar, F., Sharifi, Z., Dalimi, A.,

Torgerson, PR, Macpherson, CNL, 2011. The 2018. Evaluation of immune responses induced

socioeconomic burden of parasitic zoonoses: by GRA7 and ROP2 genes by DNA vaccine

global trends. Dokter hewan. Parasitol. 182, 79– cocktails against acute toxoplasmosis in BALB/c

85. mice. Avicenna J. Med. Bioteknologi. 10, 2–8.

Torgerson, PR, Mastroiacovo, P., 2013. The global Velázquez-Hernández, N., Ávila, AYA,

burden of congenital toxoplasmosis: a Rivas-González, MA, Delgado-González, SP,

systematic review. Banteng. World Health Org. 91,Alvarado-Félix, GA, Alvarado-Félix, AO,

501–508. Torrey, EF, Bartko, JJ, Yolken, RH, 2012.Beristain-Garcia, I., Alvarado Esquivel, C., 2019.

Toxoplasma gondii and other risk factors Knolwedge and practices regarding

for schizophrenia: an update. Schizophrenia Bull. toxoplasmosis in housewives: a cross sectional

38, 642–647. Torrey, EF, Yolken, RH, 2013. study in a northern Mexican city. PLoS One 14,

Toxoplasma oocysts as a public health problem. e0222084.

Trends Parasitol. 29, 380–384. Vidadala, RS, Rivas, KL, Ojo, KK, Hulverson, MA,

Trujillo, M., Donald, RG, Roos, DS, Greene, PJ,Zambriski, JA, Bruzual, I., Schultz, TL, Huang, W.,

Santi, DV, 1996. Heterologous expression andZhang, Z., Scheele, S., DeRocher, AE, Choi, R.,

characterization of the bifunctional dihydrofolateBarrett, LK, Siddaramaiah, LK, Hol, WG, Fan, E.,

reductase thymidylate synthase enzyme ofMerritt, EA, Parsons, M., Freiberg, G., Marsh, K.,

Toxoplasma gondii. Biochemistry 35, 6366–Kempf, DJ, Carruthers, VB, Isoherranen, N.,

6374. Doggett, JS, Van Voorhis, WC, Maly, DJ, 2016.

Tu, V., Mayoral, J., Yakubu, RR, Tomita, T., Sugi, T.,Development of an orally available and central

Han, B., Williams, T., Ma, Y., Weiss, LM, 2020.nervous system (CNS) penetrant Toxoplasma

MAG2, a Toxoplasma gondii bradyzoitegondii calcium-dependent protein kinase 1

stage-specific cyst matrix protein. mSphere 5,(TgCDPK1) inhibitor with minimal human

e00100–e00120. ether-a-go-go-related gene

 NC Smith, C. Goulart, JA Hayward et al. International Journal for Parasitology 51 (2021) 95–121
(hERG) activity for the treatment of Wang, J.-L., Zhang, N.-Z., Li, T.-T., He, J.-J.,

toxoplasmosis. J. Med. Kimia 59, 6531– 6546. Elsheikha, HM, Zhu, X.-Q., 2019. Advances in the

Villegas, EN, Lieberman, LA, Carding, SR, Hunter,development of anti-Toxoplasma gondii vaccines:

CA, 2002. Susceptibility of interleukin-2-deficientchallenges, opportunities, and perspectives.

mice to Toxoplasma gondii is associated with aTrends Parasitol. 35, 239–253.

defect in the production of gamma interferon.Wang, JL, Li, TT, Elsheikha, HM, Chen, K., Cong, W.,

Menulari. Immun. 70, 4757–4761. Yang, WB, Bai, MJ, Huang, SY, Zhu, XQ, 2018a.

Votavova, P., Tomala, J., Kovar, M., 2014.Live attenuated Pru:Dcdpk2 Strain of Toxoplasma

Increasing the biological activity of IL-2 and IL-15gondii protects against acute, chronic, and

through complexing with anti-IL-2 mAbs andcongenital toxoplasmosis. J. Infect. Dis. 218,

IL-15Ra-Fc chimera. Immunol. Lett. 159, 1–10. 768–777.

Waldeland, H., Pfefferkorn, ER, Frenkel, JK, 1983.Wang, JL, Liang, QL, Li, TT, He, JJ, Bai, MJ, Cao,

Temperature-sensitive mutants of ToxoplasmaXZ, Elsheikha, HM, Zhu, XQ, 2020a. Toxoplasma

gondii: pathogenicity and persistence in mice. J.gondii tkl1 deletion mutant is a promising vaccine

Parasitol. 69, 171–175. against acute, chronic, and congenital

Waldman, BS, Schwarz, D., Wadsworth 2nd, MH,toxoplasmosis in mice. J. Immunol. 204, 1562–

Saeij, JP, Shalek, AK, Lourido, S., 2020.1570.

Identification of a master regulator ofWang, L., Tang, D., Yang, C., Yang, J., Fang, R.,

differentiation in Toxoplasma. Cell 180, 359–372. 2020b. Toxoplasma gondii ADSL knockout

Walker, RA, Ferguson, DJP, Miller, CMD, Smith, NC, provides excellent immune protection against a

2013. Sex and Eimeria: a molecular perspective. variety of strains. Vaccines 8, 16.

Parasitology 140, 1701–1717. Wang, X., Edwards, RL, Ball, H., Johnson, C.,

Waller, RF, Keeling, PJ, Donald, RG, Striepen, B.,Haymond, A., Girma, M., Manikkam, M., Brothers,

Handman, E., Lang-Unnasch, N., Cowman, AF,RC, McKay, KT, Arnett, SD, Osbourn, DM, Alvarez, S.

Besra, GS, Roos, DS, McFadden, GI, 1998., Boshoff, HA, Meyers, MJ, Couch, RD, Odom John,

Nuclear-encoded proteins target to the plastid inAR, Dowd, CS, 2018b. MEPicides: a, b unsaturated

Toxoplasma gondii and Plasmodium falciparum.fosmidomycin analogues as DXR inhibitors

Prok. Natl. akad. Sci. USA 95, 12352–12357. against malaria. J. Med. Kimia 61, 8847–8858.
Wang, Y., Zhang, D., Wang, G., Yin, H., Wang, M.,Wilking, H., Thamm, M., Stark, K., Aebisher, T.,

2013. Immunization with excreted secretedSeeber, F., 2016. Prevalence, incidence

antigens reduces tissue cyst formation in pigs.estimations, and risk factors of Toxoplasma

Parasitol. Res. 112, 3835–3842. gondii infection in Germany: a representative,

Wang, ZD, Liu, HH, Ma, ZX, Ma, HY, Li, ZY, Yang, ZB,cross-sectional, serological study. Sci. Rep. 6,

Zhu, XQ, Xu, B., Wei, F., Liu, Q., 2017. Toxoplasma22551.

gondii Infection in immunocompromised patients:Xia, N., Zhou, T., Liang, X., Ye, S., Zhao, P., Yang, J.,

a systematic review and meta-analysis. Front.Zhou, Y., Zhao, J., Shen, B., 2018. A lactate

Mikrobiol. 8, 389. fermentation mutant of Toxoplasma stimulates

Watts, E., Zhao, Y., Dhara, A., Eller, B., Patwardhan,protective immunity against acute and chronic

A., Sinai, AP, 2015. Novel approaches reveal thattoxoplasmosis. Front. Immunol. 9, 1814.

Toxoplasma gondii bradyzoites within tissueXiao, J., Li, Y., Yolken, RH, Viscidi, RP, 2018. PD-1

cysts are dynamic and replicating entities in vivo.immune checkpoint blockade promotes brain

mBio 6. e01155-01115. leukocyte infiltration and diminishes cyst burden

Weiss, LM, Dubey, JP, 2009. Toxoplasmosis: a in a mouse model of Toxoplasma infection. J.

history of clinical observations. Int. J. Parasitol. Neuroimmunol. 319, 55–62.

39, 895–901. Xu, S., Zhang, C., Lei, H., Wang, T., Ni, L., Sun, M.,

Weiss, L., Kim, K., 2020. Toxoplasma gondii: TheMiao, H., Zhang, J., Dai, Z., Wang, B., Zheng, G.,

Model Apicomplexan – Perspectives and2013. DNA detection of Toxoplasma gondii with a

Methods. Academic Press, London (UK), Sanmagnetic molecular beacon probe via CdTe@Ni

Diego (USA), Cambridge (USA) and Oxford (UK).quantum dots as energy donor. J. Nanomater.

ISBN 9780128150412. 2013, 62.

Welsch, ME, Zhou, J., Gao, Y., Yan, Y., Porter, G.,Yang, H., Guo, Q., He, R., Li, D., Zhang, X., Bao, C.,

Agnihotri, G., Li, Y., Lu, H., Chen, Z., Thomas, SB,Hu, H., Cui, D., 2009. A quick and parallel

2016. Discovery of potent and selective lLeadsanalytical method based on quantum dots

against Toxoplasma gondii dihydrofolatelabeling for TORCH-related antibodies. Nanoscale

reductase via structure-based design. ACS Med.Res. Lett. 4, 1469–1474.

Kimia Lett. 7, 1124–1129. Yardley, V., Khan, AA, Martin, MB, Slifer, TR, Araujo,

121 FG, Moreno, SN, Docampo, R., Croft, SL, Oldfield, E.

, 2002. In vivo activities of farnesyl pyrophosphaterhoptry protein 22 of Toxoplasma gondii as a

synthase inhibitors against Leishmania donovaniDNA vaccine candidate against toxoplasmosis. J.

and Toxoplasma gondii. Antimikroba. Agen Kemo.Eukaryot. Mikrobiol. 66, 147–157.

46, 929–931. Zhang, Z., Ojo, KK, Vidadala, R., Huang, W., Geiger,

Yarovinsky, F., 2014. Innate immunity to JA, Scheele, S., Choi, R., Reid, MC, Keyloun, KR,

Toxoplasma gondii infection. Nat. Rev. Immunol. Rivas, K., Siddaramaiah, LK, Comess, KM,

14, 109–121. Robinson, KP, Merta, PJ, Kifle, L., Hol, WG,

Ybañez, RHD, Ybañez, AP, Nishikawa, Y., 2020. Parsons, M., Merritt, EA, Maly, DJ, Verlinde, CL,

Review on the current trends of toxoplasmosis Van Voorhis, WC, Fan, E., 2014. Potent and

serodiagnosis in humans. Front. Sel. Menulari. selective inhibitors of CDPK1 from T. gondii and C.

Mikrobiol. 10, 204. Young, J., Dominicus, C., parvum based on a

Wagener, J., Butterworth, S., Ye, X., Kelly, G., Ordan,5-aminopyrazole-4-carboxamide scaffold. ACS

M., Saunders, B., Instrell, R., Howell, M., Stewart, A.Med. Kimia Lett. 5, 40–44.

, Treeck, M., 2019. A CRISPR platform for targeted Zhu, YC, He, Y., Liu, JF, Chen, J., 2020. Adjuvantic

in vivo screens identifies Toxoplasma gondii cytokine IL-33 improves the protective immunity

virulence factors in mice. Nat. komuni. 10, 3963. of cocktailed DNA vaccine of ROP5 and ROP18

Zhang, D., Hussain, A., Manghwar, H., Xie, K., Xie, S.against Toxoplasma gondii infection in mice.

, Zhao, S., Larkin, RM, Qing, P., Jin, S., Ding, F.,Parasite 27, 26.

2020. Genome editing with the CRISPR-CasZulpo, DL, Headley, SA, Biazzono, L., da Cunha, IA,

system: an art, ethics and global regulatoryIgarashi, M., de Barros, LD, Taroda, A., Cardim, ST,

perspective. Plant Biotechnol. J. 18, 1651–1669. Bogado, AL, Navarro, IT, Garcia, JL, 2012. Oocyst

Zhang, Z., Li, Y., Wang, M., Xie, Q., Li, P., Zuo, S.,shedding in cats vaccinated by the nasal and

Kong, L., Wang, C., Wang, S., 2018. Immunerectal routes with crude rhoptry proteins of

protection of rhoptry protein 21 (ROP21) ofToxoplasma gondii. Eks. Parasitol. 131, 223–230.

Toxoplasma gondii as a DNA vaccine againstZulpo, DL, Igarashi, M., Sammi, AS, Santos, JR,

toxoplasmosis. Front. Mikrobiol. 9, 909. Sasse, JP, Cunha, IA, Taroda, A., Barros, LD,

Zhang, Z., Li, Y., Xie, Q., Li, P., Nan, X., Kong, L.,Almeida, JC, Jenkins, MC, Navarro, IT, Garcia, JL,

Zeng, D., Ding, Z., Wang, S., 2019. The molecular2017. rROP2 from Toxoplasma gondii as a

characterization and immunity identification ofpotential vaccine against oocyst shedding in

domestic cats. Pdt. Bras. Parasitol. Dokter hewan.

26, 67–73.