Control of Human Toxoplasmosis

International Journal for Parasitology 51 (2021) 95–121
Contents lists available at ScienceDirect
International Journal for Parasitology

journal homepage: www.elsevier.com/locate/ijpara
Review Article
Control of human toxoplasmosis

Nicholas C. Smith a,b,⇑, Cibelly Goulart 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
a r t i c l e i n f o a b s t r a c t
Article history: Toxoplasmosis is caused by Toxoplasma gondii, an apicomplexan parasite that is able to infect any nucle-
Received 16 September 2020 ated cell in any warm-blooded animal. Toxoplasma gondii infects around 2 billion people and, whilst only
Received in revised form 12 November 2020 a small percentage of infected people will suffer serious disease, the prevalence of the parasite makes it
Accepted 15 November 2020
one of the most damaging zoonotic diseases in the world. Toxoplasmosis is a disease with multiple man-
Available online 19 December 2020
ifestations: it can cause a fatal encephalitis in immunosuppressed people; if first contracted during preg-
nancy, it can cause miscarriage or congenital defects in the neonate; and it can cause serious ocular
Keywords:
disease, even in immunocompetent people. The disease has a complex epidemiology, being transmitted
Toxoplasmosis
Toxoplasma gondii
by ingestion of oocysts that are shed in the faeces of definitive feline hosts and contaminate water, soil
Chemotherapy and crops, or by consumption of intracellular cysts in undercooked meat from intermediate hosts. In this
Immunotherapy review we examine current and future approaches to control toxoplasmosis, which encompass a variety
Nanotechnology of measures that target different components of the life cycle of T. gondii. These include: education pro-
Vaccination grams about the parasite and avoidance of contact with infectious stages; biosecurity and sanitation to
ensure food and water safety; chemo- and immunotherapeutics to control active infections and disease;
prophylactic options to prevent acquisition of infection by livestock and cyst formation in meat; and vac-
cines to prevent shedding of oocysts by definitive feline hosts.
Ó 2020 The Author(s). Published by Elsevier Ltd on behalf of Australian Society for Parasitology. This is an
open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
1. Introduction warm-blooded animal. However, it is only in the intermediate

asexual phase of its life cycle that T. gondii is so promiscuous; in
Human toxoplasmosis is a global zoonotic disease with a com- the sexual phase, only felids can serve as definitive hosts due to
plex epidemiology and multiple manifestations. It is caused by Tox- a unique deficiency, amongst mammals, in intestinal delta-6-
oplasma gondii, a single-celled, eukaryotic parasitic organism saturase activity in cats (Martorelli Di Genova et al., 2019). Addi-
within the supergroup Alveolata, Phylum Apicomplexa, Class Con- tionally, there is a distinct difference in expression profiles of par-
oidasida, Subclass Coccidiasina, Order Eucoccidiorida, Suborder asite proteins involved in host cell invasion and modulation of
Eimeriorina and Family Sarcocystidae. Toxoplasma gondii is the intermediate versus definitive host cells (Behnke et al., 2014;
only species in the genus, Toxoplasma, but it is closely related to Hehl et al., 2015); thus, tachyzoites (the rapidly-dividing asexual
Neospora caninum and Hammondia hammondi, with which it shares stage in intermediate hosts) express a much wider array of pro-
morphological, molecular and life cycle traits. A key to understand- teins that facilitate host cell invasion and modulation of the host
ing the epidemiology and symptomology of toxoplasmosis lies in response to infection than do merozoites (the rapidly dividing
an appreciation of the complexity and elegance of its life cycle asexual stage that is found only in the definitive host intestine),
(see Ferguson, 2009, for a history and detailed illustrated descrip- potentially explaining the capacity of tachyzoites to infect a wide
tion); this is also key to control strategies. array of cells.
Unlike other coccidians, most of which are host-specific, In intermediate hosts, T. gondii is found within microscopic
T. gondii is seemingly able to infect any nucleated cell in any cysts in any part of the body but, most especially, in long-lived cells
of the musculature and CNS. Felids become infected when they
⇑ Corresponding author at: School of Life Sciences, University of Technology ingest these cysts after preying on an intermediate host. During
Sydney, Ultimo, NSW 2007, Australia. digestion, the haploid bradyzoite forms of T. gondii are released
E-mail address: [email protected] (N.C. Smith). from the cysts and invade enterocytes, progressing through
https://doi.org/10.1016/j.ijpara.2020.11.001
0020-7519/Ó 2020 The Author(s). Published by Elsevier Ltd on behalf of Australian Society for Parasitology.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
N.C. Smith, C. Goulart, J.A. Hayward et al. International Journal for Parasitology 51 (2021) 95–121
successive phases of asexual reproduction, which produces succes- livestock, due to the concentrated high levels of oocyst contamina-
sive generations of merozoites that reinvade the intestine before tion of farm land that accompanies our commensal relationship
ultimately differentiating into microgametocytes (each able to dif- with cats and mice (Shwab et al., 2018). It has, seemingly, even
ferentiate into 16–30 motile, flagellated microgametes) or resulted in the relatively recent introduction of the domestic life
macrogametocytes (each becoming a single sedentary macroga- cycle of T. gondii into North America with a concomitant domina-
mete). The microgametes fertilise the macrogametes, forming a tion of T. gondii clonal strains in that part of the world (Shwab
diploid zygote. Mobilisation of sub-cellular structures – veil- and et al., 2018).
wall-forming bodies – within the macrogamete leads to the forma- Today, around 2 billion people are chronically infected with T.
tion of a multi-layered wall around the zygote, which is now gondii across the world, though seroprevalence rates are particu-
referred to as an oocyst. The oocyst wall is extremely resistant to larly high in parts of tropical South America, Southeast Asia and
environmental and chemical insult, enabling the parasite to pass Africa (Pappas et al., 2009). In an immunocompetent host, T. gondii
safely out into the world in the felid host’s faeces. The resilience infection usually causes mild symptoms only and rarely requires
of the oocyst wall also provides a haven for meiosis to occur and intervention. This is because the disease-causing tachyzoites are
complete the sexual reproductive phase of the life cycle (Walker suppressed quickly by an immune response in which interferon-
et al., 2013). This results in the formation of eight haploid, infec- gamma (IFN-c) produced by CD4+ T cells plays a central role, sup-
tious sporozoites, contained within two sporocysts (i.e., four sporo- ported by a range of other immune cells, cytokines (including, in
zoites per sporocyst), inside an oocyst, which can survive for particular, ILs 12, 18, 1 and 2, and tumour necrosis factor), and
months, even years, in soil or water (Freppel et al., 2019). innate immune recognition and effector molecules and mecha-
Herbivorous intermediate hosts, including humans, can become nisms (Sher et al., 2017). However, the consequent differentiation
infected by drinking water, eating fruit or vegetables, or coming of tachyzoites into bradyzoites leads to the formation of long-
into contact with soil that is contaminated with oocysts of T. gondii. lived tissue cysts in the muscles and CNS (Montoya and
There is also evidence that the eating of raw or undercooked mar- Liesenfeld, 2004). These possibly persist for the life of the host
ine molluscs can result in infection because oocysts can accumu- (Rougier et al., 2017), also under the control of IFN-c-dependent
late in these animals after run-off of contaminated soil into processes (Sturge and Yarovinsky, 2014). Tissue cysts are capable
oceans (Freppel et al., 2019; Shapiro et al., 2019). Sporozoites exit of reactivating into the acute tachyzoite stage and this is of partic-
their sporocysts and oocysts during digestion, invade intestinal ular concern for immunocompromised individuals, particularly
cells, transform into tachyzoites (which are also haploid) and dis- AIDS patients, whose CD4+ T cell populations are drastically
seminate throughout the body. Carnivorous or omnivorous inter- reduced. Reactivation can lead to the formation of brain lesions
mediate hosts, again including humans, can also become infected and associated toxoplasmic encephalitis, which is fatal if left
by eating other infected intermediate hosts. In this case, it is brady- untreated (Luft and Remington, 1992). A first infection with T. gon-
zoites that are released into the intestine and invade intestinal dii during pregnancy is also of grave concern. It can lead to congen-
cells, differentiate into tachyzoites and disseminate throughout ital toxoplasmosis, which may cause miscarriage or stillbirth or
the body of the host. Tachyzoites reproduce asexually and rapidly, have serious effects for the new-born, which can be life-long and
rupturing and reinvading cells as they do so, until the immune may include impairment of mental development, hearing or sight
response of the host drives them into an evasion strategy that sees (Weiss and Dubey, 2009). Clinical disease can also occur in other-
them transform back into bradyzoites, which become encased and wise healthy, immunocompetent adults, in particular manifesting
protected by a cyst wall inside host cells. A single mature cyst may as ocular toxoplasmosis, one of the most frequently identified
contain large numbers of bradyzoites (Ferguson, 2009), and a sin- causes of uveitis (Weiss and Dubey, 2009). Infection is also associ-
gle bradyzoite can establish infection in either an intermediate or ated with inflammatory disease (Lidar et al., 2009; Severance et al.,
definitive host. Other means by which infection can occur is via 2012; Shapira et al., 2012), schizophrenia (Torrey et al., 2012), can-
transfer of tachyzoites congenitally (El Bissati et al., 2018) or via cer and, potentially, several other disorders of the brain (Thomas
organ transplants (Derouin et al., 2008). et al., 2012; Ngo et al., 2017), although it is often difficult to deter-
The life cycle of T. gondii underpins its successful dispersal to all mine whether the associations between these diseases and T. gon-
corners of the globe. However, humans have been unwitting con- dii infection are causal or correlative. Globally, it is likely that only
tributors to this success. There appear to have been two major a small percentage of people infected with T. gondii ever develop
events in the evolution of T. gondii. First, as hypothesised by any manifestations of toxoplasmosis; however, the simple fact that
Bertranpetit et al. (2017), based on compelling molecular phyloge- around 2 billion people are infected by this parasite means that
netic data, the most recent common ancestor of present-day large numbers of people inevitably suffer significantly. In tropical
strains of T. gondii appeared ~1.5 million years ago in South Amer- South America, severe forms of toxoplasmosis are more prevalent
ica, coincident with an expansion of both potential murine inter- than in other parts of the world, possibly reflecting the greater
mediate hosts and potential feline definitive hosts in South diversity of virulent strains of T. gondii (Bertranpetit et al., 2017;
America. This diversification of hosts favoured diversification of Shwab et al., 2018) combined with the high occurrence of infection
T. gondii too, leading to its spread into North America, via the Isth- via ingestion of oocysts (which have undergone recent sexual
mus of Panama, which formed 2–3 million years ago. From North recombination and are therefore more genetically diverse than clo-
America, further spread could occur, across the Bering Strait into nal infections derived from bradyzoites) in that part of the world
Asia. The second event was far more recent – between 11,000 (Galal et al., 2019). Hence, toxoplasmosis is one of the most dam-
and 4,000 years ago – that being the genesis of agriculture, in par- aging zoonotic diseases in the world, causing the loss of 2–8 mil-
ticular the cultivation of grains in Asia and the Middle East (Shwab lion Disability Adjusted Life Years (Torgerson and Macpherson,
et al., 2018), before further dissemination into Europe, Africa and 2011).
Southeast Asia. The adoption of agrarian practices also marked Despite the combined complexities of the ubiquity of the T. gon-
the start of commensal relationships between humans and house dii life cycle and the multiple manifestations of human toxoplas-
mice (Mus musculus musculus, Mus musculus domesticus and Mus mosis, control of this disease can potentially be narrowed in
musculus castaneus), and between humans and Felis catus, the focus to strategies that target and prevent: congenital disease;
house cat, setting in train the rise of the domestic cat and mouse reactivation of cysts (especially in immunocompromised people);
life cycle for T. gondii. This domestic cycle has since, arguably, formation of tissue cysts in food animals; and, release of oocysts
dominated the epidemiology of the parasite in humans and our into the environment. In this review, we present educational, food
96
and water safety, and therapeutic and prophylactic options to con- 2008; Opsteegh et al., 2014; Alizaddeh et al., 2018). These mea-
trol human toxoplasmosis, and comment on the prospects for sures can be classified as pre- or post-harvest. The former aims
developing new approaches. to ensure minimal contamination of farm land or fodder with
oocysts of T. gondii. The latter is aimed at removing or inactivat-
ing cysts or oocysts in or on meat, fruit and vegetables, but is
2. Public education, food and water safety to control
mainly focused on cysts in meat since oocysts are resistant to
toxoplasmosis
heat, cold and a variety of chemicals. Moreover, washing of fruit
and vegetables by individual consumers is already a widespread
The governments of many nations, through their health and/or
habit and probably reasonably effective at removing oocysts,
agricultural departments, issue clear advice and maintain educa-
assuming clean water is available (Shapiro et al., 2019), though
tional websites explaining how individuals can prevent toxoplas-
it should be noted that the increasing availability of pre-
mosis. Exemplifying this is the information provided by the
packaged, ‘‘ready to eat” salads is a potential source of infection
Centers for Disease Control and Prevention, U.S.A. (https://www.
(Caradonna et al., 2017). Pre-harvest efforts are, thus, focused
cdc.gov/parasites/toxoplasmosis/prevent.html), which details that,
on biosecurity to prevent or restrict the presence of cats and
to avoid toxoplasmosis, people need to:
rodents, and ensure that water for livestock and for irrigation of
crops is clean. This has significant capacity to be successful for
feed pet cats canned or dried commercial food only, never raw
animals raised indoors under controlled husbandry conditions,
or undercooked meat;
the reduction in prevalence of T. gondii cysts in pork with adop-
train pet cats to use cat litter;
tion of modern farming techniques being a prime example
change cat litter daily, wearing disposable gloves whilst doing
(Opsteegh et al., 2014). Such success is, however, less likely for
so;
animals raised on pasture or under free range organic practices.
keep pet cats indoors, especially at night, to minimise their
Programs to ensure neutering of pet cats, combined with effective
hunting activities and outside defecation;
programs to reduce the population of stray cats, would poten-
wear gloves during gardening or any other contact with soil;
tially help to reduce oocyst contamination of the environment
cover sandpits when not in use (as cats prefer sand or loose soil
but would be extremely difficult and costly to initiate and police
for defecation);
(Opsteegh et al., 2014). Vaccination of cats to prevent oocyst
wash fruit and vegetables thoroughly before eating;
excretion is conceivable, and a live, attenuated vaccine has been
not eat undercooked molluscs;
tested on pig farms (Mateus-Pinilla et al., 1999, 2002); the pro-
freeze meat for at least 2 days (at 12 °C or lower) before
spects for this approach will be discussed in more detail in Sec-
cooking;
tion 5. Vaccination of livestock to prevent infection with T.
cook meat to minimum temperatures (e.g., 74 °C for poultry,
gondii (discussed in Section 5) or chemoprophylactic prevention
71 °C for minced or ground meat, and 63 °C for other cuts of
of infection, a la the use of coccidiostats in the treatment of poul-
meat, followed by a minimum 3 min rest period) before eating;
try coccidiosis (see Chapman et al., 2013), may be conceivable
wash thoroughly any cutting boards, counters, cutlery, crockery
approaches but the necessarily long-term administration of effec-
and other kitchen utensils that have been in contact with any
tive drugs would be expensive and would also likely cause
uncooked food of any type;
unwanted side-effects or even toxicity (Sanchez-Sanchez et al.,
wash hands thoroughly after (i) contact with soil or sand, (ii)
2018). Post-harvest measures involve the inactivation of T. gondii
food preparation or contact with uncooked food, (iii) contact
tissue cysts in meat. This can be achieved through a number of
with pets or pet faeces (including cat litter), and reinforce with
treatments including freezing, irradiation and high-pressure pro-
children the importance of handwashing; and
cessing (Kijlstra and Jongert, 2008; Opsteegh et al., 2014;
avoid drinking untreated water.
Alizaddeh et al., 2018), but lack of acceptance by consumers
Education about toxoplasmosis and how to prevent it is rein- due to significant effects on meat tenderness, texture and per-
forced by health professionals, particularly as part of pre- and ceived quality would likely prove a major impediment to wide-
neo-natal education and with immunocompromised people. How- spread implementation. Opsteegh et al. (2014) have proposed
ever, its effectiveness depends on, first, the completeness and accu- that selective post-harvest treatment, i.e., targeting only meat
racy of the advice being given and, second, how closely this is destined to be consumed raw or undercooked, or from known
adhered to by patients. There is some doubt about the effectiveness infected animals or high-risk (i.e., non-biosecure) farms may be
of educational efforts on toxoplasmosis, with reported variability more achievable, whilst acknowledging that the logistics would
in people’s understanding of the existence of the disease and the not be simple and that screening for confirmed infection would
risks it poses (Gollub et al., 2008; Pereboom et al., 2013; be costly.
Andiappan et al., 2014; Millar et al., 2014; Elsafi et al., 2015; Major outbreaks of toxoplasmosis have been traced to water
Chandrasena et al., 2016; Smereka et al., 2018; Velázquez-Hernán contaminated with oocysts for nearly 50 years (Benenson et al.,
dez et al., 2019) and a lack of rigorous evaluation of programs (Di 1982; Bowie et al., 1997; Bahia-Oliveira et al., 2003; de Moura
Mario et al., 2015). This is, arguably, particularly true in poorer et al., 2006; Ferreira et al., 2018; Shapiro et al., 2019). The same
nations but difficulties in alleviating the burden of, e.g., congenital measures listed above to protect individuals and farms from
toxoplasmosis have also been observed in the U.S.A. (Jones et al., exposure to oocysts of T. gondii also apply to reducing contamina-
2003; Ogunmodede et al., 2005; Montoya and Remington, 2008; tion of the environment and, therefore, waterways. Detection of T.
El Bissati et al., 2018). France has been suggested as an exemplar gondii oocysts in water relies on a combination of microscopy,
of success (El Bissati et al., 2018) due to the integration of educa- bioassays and molecular techniques but, in general, has lagged
tion, mandatory regular screening and diagnosis throughout preg- behind development of methods for detecting other water-
nancy, and consequential timely treatment options (described in borne parasites such as Giardia and Cryptosporidium (Shapiro
depth by McLeod et al., 2014). At the same time, however, the et al., 2019). Oocysts are resistant to chemical disinfection proce-
cost-benefit of screening and diagnosis and the effectiveness of dures generally employed in ensuring sanitary water supplies
treatment have been questioned (Opsteegh et al., 2014). (e.g., they are resistant to strong acids, detergents, chlorine,
Systematic responses to ensure that food is free from contam- ozone, ultraviolet radiation) and, therefore, filtration systems
ination with T. gondii have been proposed (Kijlstra and Jongert, are a necessity (Freppel et al., 2019).
97
3. Chemotherapy for the control of toxoplasmosis Table 1

Diverse classes of compounds have activity against Toxoplasma gondii in vitro and
in vivo in mouse models of acute and chronic infection. Plus symbol (+) indicates
Current chemotherapeutic options for toxoplasmosis are lim- active, minus symbol ( ) indicates inactive and (ND) is not determined against T.
ited (Dunay et al., 2018), notwithstanding a concerted effort in gondii in the indicated experimental system (either against tachyzoites in vitro, acute
the last decade to harness high throughput screening strategies tachyzoite infection in vivo or chronic bradyzoite brain cyst infection in vivo).
to discover new chemicals, including natural products, with anti- Compound In Vitro In Vivo In Vivo Cyst
Toxoplasma activity or to repurpose or improve existing, approved (Tachyzoite) (Acute) (Chronic)
drugs (Deng et al., 2019). The frontline treatment for toxoplasmo- Bumped Kinase
sis is a combination of pyrimethamine and sulfadiazine, drugs that Inhibitors
act synergistically by targeting two steps in folic acid metabolism. BKI 1294a + + ND
Other therapies combine pyrimethamine with clindamycin, azi- Compound 32b + + +
Compound 24c + + +
thromycin or atovaquone, or trimethoprim with sulfamethoxazole.
Compound 3ad + + +
However, all treatments are commonly associated with adverse
Electron Transport Chain
side effects and toxicity (Ben-Harari et al., 2017); for example, in
Inhibitors
one study, 60% of toxoplasmic encephalitis patients treated with Atovaquonee + + +
pyrimethamine and sulfadiazine experienced adverse effects ELQ271f + + +
including hematologic toxicity, rash and fever, which led to 45% ELQ334 (ELQ316)g + + +
ELQ400h + + ND
discontinuing therapy (Haverkos, 1987). In immunocompetent
patients with persistent or severe symptoms, pyrimethamine/sul- Fatty Acid Synthesis
Inhibitors
fadiazine treatment duration is usually 4–6 weeks. Immunocom-
Triclosani + + +
promised patients require long-term maintenance therapy after
Folic Acid Synthesis
the initial 6 week treatment, since tissue cysts are not eliminated
Inhibitors
by any current treatments. The long duration of treatment and JPC-2056 (JPC-2067-B)j + + ND
inability to eliminate infection, combined with frequency of side TRC-19k + ND ND
effects, make current chemotherapeutic options less than ideal Compound 3l + + ND
and highlight the need for new anti-Toxoplasma chemotherapeu- Histone Modification
tics. The ideal anti-Toxoplasma agent would have the following Inhibitors
properties: FR235222m + ND ND
W363 and W399n + ND ND
decreased toxicity compared with existing drugs; Isoprenoid Pathway

Inhibitors
safe for use during pregnancy;
Risedronateo + + ND
enhanced efficacy compared with existing drugs; Compound 1p + + ND
the ability to target tachyzoites to treat acute infections; Atorvastatinq ND + ND
the ability to target bradyzoites to eliminate tissue cysts; and Protein Synthesis
the ability to reach sufficient concentrations in the CNS to elim- Inhibitors
inate parasites in the brain and eye. Clindamycinr + +
Azithromycins + +
In the following sections, we review current and emerging tar- Guanabenzt + + +
gets (see also Table 1 and Fig. 1) and challenges of anti-parasitic a
Doggett et al. (2014), Müller et al. (2017).
chemotherapy for treating human toxoplasmosis. b
Vidadala et al. (2016).
c
Rutaganira et al. (2017).
d
Janetka et al. (2020).
3.1. Folic acid metabolism inhibitors e
Araujo et al. (1991a), Araujo et al. (1991b), Araujo et al. (1992), Romand et al.
(1993), Ferguson et al. (1994), Dunay et al. (2004).
f
Apicomplexans, like many protozoans, encode a fused dihydro- Doggett et al. (2012).
g
folate reductase (DHFR)-thymidylate synthase enzyme that is Doggett et al. (2012), Doggett et al. (2020), McConnell et al. (2018).
h
Doggett et al. (2012), McConnell et al. (2018).
important for folate metabolism and nucleotide synthesis I
McLeod et al. (2001), El-Zawawy et al. (2015a, b).
(Ivanetich and Santi, 1990; Trujillo et al., 1996). The frontline treat- j
Mui et al. (2008).
k
ment for toxoplasmosis, pyrimethamine, targets DHFR by acting as Welsch et al. (2016).
l
a folic acid antagonist (Fig. 1). Pyrimethamine acts synergistically Hopper et al. (2019).
m
Bougdour et al. (2009), Maubon et al. (2010).
with sulfonamides, which act on dihydropteroate synthase, n
Maubon et al. (2010).
another enzyme in the folate synthesis pathway. However, treat- o
Martin et al. (2001), Yardley et al. (2002).
ment with pyrimethamine and sulfadiazine frequently causes toxic p
Ling et al. (2005).
q
side effects in patients including hypersensitivity to sulfadiazine Li et al. (2013).
r
treatment, resulting in skin rashes and fevers (McLeod et al., Araujo and Remington (1974).
s
Araujo et al. (1991a), Araujo et al. (1991b), Dumas et al. (1994).
2006), and bone marrow suppression and adverse effects on devel- t
Benmerzouga et al. (2015), Martynowicz et al. (2019), Martynowicz et al.
oping foetuses caused by folate depletion associated with pyri- (2020).
methamine treatment (Serranti et al., 2011). Pyrimethamine is,
therefore, not always recommended for treating congenital infec-
tions during the first trimester of pregnancy. of tachyzoite proliferation in vitro (50% inhibitory concentration
DHFR-targeting compounds with greater potency against T. (IC50) 20 nM), with minimal toxicity against human cells (Mui
gondii compared with humans have been investigated to overcome et al., 2008). JPC-2067-B can be administered as an orally bioavail-
issues associated with pyrimethamine toxicity. For instance, able prodrug called JPC-2056, which is active in vivo, and exhibits
WR99210 is a T. gondii DHFR inhibitor that is active both in vitro better pharmacological characteristics than WR99210.
and in a mouse infection model, and exhibits ~10-fold greater Computational structure-based, rational drug design
potency than pyrimethamine (Mui et al., 2005). Further studies approaches have also been utilised to identify compounds with
identified the WR99210 analogue, JPC-2067-B, as a potent inhibitor greater selectivity for T. gondii DHFR over human DHFR. Using
98
Fig. 1. Summary of some of the targets for chemotherepeutic interventions against Toxoplasma gondii. Targets include processes that occur in the apicoplast, mitochondrion,
and nucleus, as well as the regulation of cytosolic translation and the synthesis of folates and isoprenoids. See Section 3 and Table 1 for further details. Inset depicts the Q
cycle of the mitochondrial electron transport chain (ETC). Electrons (e ) derived from mitochondrial metabolism are donated to coenzyme Q (CoQ), then to the Qo site of
Complex III. From here, electrons are transported via cytochrome c (CytC) and Complex IV to O2, or back to CoQ at the Qi site of Complex III. Most inhibitors of the electron
transport chain in these parasites target either the Qi or Qo sites of Complex III. CDPK, calcium-dependent protein kinase; FPPS, farnesyl diphosphate/geranyl geranyl-
diphosphate synthase; IPP, isopentenyl pyrophosphate; MEP, methylerythritol phosphate.
pyrimethamine as a lead structure, one study identified TRC-19, a phosphorylation, a process by which T. gondii parasites can gener-
compound with ~25-fold greater potency against the TgDHFR ate adenosine triphosphate (ATP) (Hayward and van Dooren,
enzyme than pyrimethamine (9 nM versus 230 nM IC50) and a 2019). Several enzymatic reactions that take place in the mito-
~90-fold greater selectivity for T. gondii DHFR over the human chondrion (e.g., reactions in the tricarboxylic acid cycle) result in
enzyme (Welsch et al., 2016). A recent structure–activity relation- the transfer of electrons to coenzyme Q (CoQ), an electron carrier
ship study further optimised TRC-19 to develop the 2- embedded in the inner mitochondrial membrane (Fig. 1, inset).
methoxypyrimidine, ‘‘Compound 3”, with a resulting IC50 of Complex III (also known as the cytochrome bc1 complex) facilitates
1.6 nM against TgDHFR activity, an ~200-fold selectivity for T. gon- the net transfer of electrons from CoQ to cytochrome c, a mobile
dii DHFR over the human enzyme, and an 50% effective concentra- electron carrier in the mitochondrial intermembrane space
tion (EC50) of 13 nM against T. gondii proliferation in an in vitro (Fig. 1, inset). Electrons from cytochrome c are transferred to Com-
culture model (Hopper et al., 2013). In acute T. gondii infection of plex IV of the electron transport chain, where they ultimately
mice, treatment with Compound 3 improved survival in a dose- reduce O2 (Fig. 1, inset). Electron transport through Complexes III
dependent manner, the highest dose yielding 100% survival over and IV is coupled to the translocation of protons across the inner
30 days, as opposed to the vehicle-treated mice, which succumbed mitochondrial membrane, generating a proton gradient that can
to infection after 6 or 7 days (Hopper et al., 2019). It remains to be be utilised by ATP synthase (Complex V) for the synthesis of ATP.
seen whether Compound 3 is effective against chronic infection or The cytochrome b protein of Complex III interacts with CoQ in a
bradyzoite cysts but preliminary pharmacokinetic studies in mice process known as the ‘‘Q-cycle” (Fig. 1, inset). Reduced CoQ docks
suggest Compound 3 is able to cross into the CNS (Hopper et al., at the so-called Qo site of cytochrome b, donating electrons to
2019). These studies are a promising start in the bid to identify either the iron-sulfur cluster of the Rieske protein of Complex III
more selective and potent inhibitors of T. gondii DHFR with the (from where it is transported onward through the remainder of
physicochemical characteristics needed to avoid the toxicity asso- the electron transport chain), or to a second CoQ docking site on
ciated with current pyrimethamine and sulfadiazine treatment. cytochrome b called the Qi site (Fig. 1, inset). At the Qi site, oxidised
CoQ is reduced, removing protons from the mitochondrial matrix
and thereby contributing to the proton gradient across the inner
3.2. Mitochondrial electron transport chain inhibitors membrane.
The Qo and Qi sites of cytochrome b are targets of a broad range
The mitochondrial electron transport chain consists of a series of anti-parasitic drugs, including compounds that target T. gondii
of protein complexes embedded in the inner mitochondrial mem- (Fig. 1, inset). The best studied of these is atovaquone, which tar-
brane and plays a key role in pyrimidine biosynthesis and oxidative
99
gets the Qo site of cytochrome b (Fry and Pudney, 1992; Pfefferkorn microneme secretion, a process that is critical for parasite egress
et al., 1993; McFadden et al., 2000). Early studies showed that ato- from host cells, gliding motility and invasion of parasites into
vaquone has activity against tachyzoites and tissue cysts both new host cells (Lourido et al., 2010). TgCDPK1 can be effectively
in vitro and in vivo (Araujo et al., 1991a, 1991b, 1992; Romand inhibited by so-called bumped kinase inhibitors (BKIs; Fig. 1),
et al., 1993; Ferguson et al., 1994; Dunay et al., 2004). However, which are considered to be promising potential therapies against
clinical trials have had mixed results regarding the ability of ato- apicomplexan parasites (Choi et al., 2020). BKIs target the ATP
vaquone to prevent relapse of infection, with between 12 and binding pocket of TgCDPK1, and the selectivity of BKIs for TgCDPK1
26% of patients experiencing relapse after 1 year, and up to 75% over host kinases (and other CDPKs encoded by T. gondii) lies in the
after 6 years of therapy (Katlama et al., 1996; Pearson et al., presence of a small ‘‘gatekeeper residue” (a glycine) in the ATP
1999). Instances of failure of atovaquone treatment have also been binding site of TgCDPK1, as opposed to bulkier residues such as
reported (Baatz et al., 2006; Megged et al., 2008). These studies methionine found in human kinases. Several BKI scaffolds have
suggest that atovaquone does not completely eliminate tissue been identified, with pyrazolopyrimidines (PPs) and 5-
cysts in humans. Given that many clinical trials were retrospective, aminopyrazole-4-carboxamides (ACs) the two main classes. The
non-randomized and non-comparative, more clinical data is structure of TgCDPK1 has shown that BKIs act as competitive inhi-
required to evaluate the true efficacy of atovaquone, ideally com- bitors in the ATP binding pocket (Ojo et al., 2010), which has facil-
paring the rates of relapse in patients given atovaquone or pyri- itated several structure-based drug development programs
methamine and sulfadiazine, or combinations of these treatments. (Cardew et al., 2018) that have led to improved pharmacology, effi-
There has been much interest in developing Complex III inhibi- cacy and safety of BKIs (Choi et al., 2020).
tors with better potency and bioavailability than atovaquone. The The PP compound, BKI 1294, had an in vitro IC50 of 140 nM and
endochin-like-quinolone (ELQ) series of 4(1H)-quinolone-3- showed efficacy against acute infection in mice when administered
diarylethers can target the Qi site and/or the Qo site depending orally (Doggett et al., 2014). Oral administration of BKI 1294 also
on their chemistry. The Qi site inhibitors ELQ-271 and ELQ-316 increased the survival of pups from 31% to 100% in a congenital
are potent inhibitors of T. gondii proliferation in vitro (IC50 values infection of mice, with only 7% of pups positive for brain infection
of 0.1 and 0.007 nM, respectively) and in treating acute infection (Müller et al., 2017). However, a potential for cardiotoxicity via
in mice, with a high selectivity in targeting the T. gondii complex inhibition of the ion channel human Ether-a-go-go-Related Gene
over the human Complex III (>90,000-fold and >106-fold, respec- (hERG) was discovered and prevented progression of this com-
tively) (Doggett et al., 2012). Notably, ELQ-271 and ELQ-316 treat- pound into clinical development (Ojo et al., 2014). To overcome
ment reduced T. gondii brain cysts by up to 88% in mice (Doggett this, a line of optimized PP-based BKIs were developed to avoid
et al., 2012), suggesting these compounds are active against both hERG inhibition (Vidadala et al., 2016). ‘‘Compound 32” from this
tachyzoites and bradyzoites in vivo. ELQ-400 targets both the Qo study had an in vitro IC50 of 60 nM and, importantly, was able to
and Qi sites of cytochrome b, and exhibits greater efficacy in treat- cross into the CNS and reduce the number of brain cysts by 88%
ing acute T. gondii infections in mice than both atovaquone and in a chronic infection of mice (Vidadala et al., 2016). Another struc-
ELQ-316 (McConnell et al., 2018; Song et al., 2018). ture–activity relationship study into PP molecules identified a
The aforementioned ELQs exhibit low aqueous solubility and compound (‘‘Compound 24”) that reduced dissemination of para-
high crystallinity, which may limit their oral bioavailability. A car- sites from the peritoneal cavity to the brain in acute infection of
bonate ester prodrug of ELQ-316, called ELQ-334, was created and mice (Rutaganira et al., 2017). Compound 24 also reduced brain
shown to both improve bioavailability and prolong the survival of cyst burden and cured 40% of mice or delayed death in 60% of mice
mice in an acute infection model (Doggett et al., 2020). Oral treat- in a reactivation model of parasite infection in immunocompro-
ment with ELQ-334 also reduced the brain cyst burden by up to mised mice (Rutaganira et al., 2017).
83% in mice chronically infected with T. gondii parasites (Doggett Structure-activity relationship studies have also progressed the
et al., 2020). While smaller than non-treated cysts, the tissue cysts development of BKIs with an AC scaffold (Zhang et al., 2014). In one
that survived ELQ-334 treatment were viable and capable of estab- study, structural optimisation of compounds with an AC scaffold
lishing an infection in naïve mice (Doggett et al., 2020), suggesting led to the production of ‘‘Compound 35”, a molecule that is able
that ELQ-334 treatment does not entirely clear brain cysts. to cross into the CNS with a lower in vitro IC50 (89 nM) and
Mutations in the Qo and Qi sites of cytochrome b are common improved pharmacokinetic properties compared with the starting
causes of resistance against compounds that target these sites compound (Huang et al., 2015). The development of improved BKIs
(McFadden et al., 2000; Alday et al., 2017). The potential of inhibi- via the incorporation of AC and PP scaffolds highlights the promise
tors that target both the Qo and Qi site, such as ELQ-400, or combi- of developing TgCDPK1-targeting compounds with activity against
nation therapy with Qo and Qi site inhibitors as dual Complex III both acute and chronic stages of parasite infection.
inhibitors, could slow the emergence of drug resistance and
thereby provide more effective treatments against tissue cysts.
While yet to be tested in T. gondii infection, a combination of 3.4. Fatty acid synthesis (FAS) inhibitors
ELQ-334 (Qi site inhibitor) and atovaquone (Qo site inhibitor)
cleared mice of infection with Babesia microti, a related apicom- Fatty acids are major components of biological membranes, and
plexan parasite, with no recrudescence after 122 days (Lawres also serve as important signaling molecules. Early work indicated
et al., 2016). that T. gondii parasites are able to scavenge lipids, including fatty
acids, from host cells (Charron and Sibley, 2002). Sequencing of
3.3. Calcium-dependent protein kinase-1 inhibitors the parasite genome found that T. gondii encodes enzymes of the
so-called FAS II pathway of fatty acid biosynthesis (Seeber and
Calcium-dependent protein kinases (CDPKs) are a family of ser- Soldati-Favre, 2010). Enzymes of the FASII pathway localise to
ine/threonine protein kinases found in plants and numerous proto- the apicoplast organelle (Waller et al., 1998; Seeber and Soldati-
zoans, including apicomplexans (Billker et al., 2009). The T. gondii Favre, 2010), a non-photosynthetic plastid that is widespread
genome encodes 14 CDPKs, and these are predicted to function throughout apicomplexans. Notably, the apicoplast FAS II pathway
in a range of calcium signaling-dependent processes across the life differs from the FAS pathway found in the mitochondria of mam-
cycle of the parasite (Long et al., 2016). TgCDPK1 is important for mals, and also from the cytosolic single multifunctional fatty acid
tachyzoite proliferation, where it functions in calcium-dependent synthase I (FAS I) enzyme for FAS.
100
Conditional depletion of acyl carrier protein, a central enzyme in apicomplexans (Fig. 1). Indeed, the antibiotic fosmidomycin,
in the FAS II pathway, led to reduced parasite proliferation which inhibits 1-deoxy-D-xylulose-5-phosphate (DOXP) reductoi-
in vitro and reduced virulence in an acute infection of mice somerase, the second enzyme in the MEP pathway, is a potent inhi-
(Mazumdar et al., 2006). Coupled with its absence from the mam- bitor of proliferation of blood-stage Plasmodium parasites (Jomaa
malian host, this suggested that the FASII pathway may represent a et al., 1999). Curiously, however, fosmidomycin has no effect on
promising drug target (Fig. 1). Indeed, drugs such as thiolacto- the growth of T. gondii, despite DOXP reductoisomerase being crit-
mycin and triclosan, which target the FASII pathway in bacteria, ical for T. gondii proliferation and activity of recombinant DOXP
were shown to inhibit parasite proliferation (McLeod et al., 2001; reductoisomerase being sensitive to fosmidomycin (Ling et al.,
Mazumdar et al., 2006). A more recent study, however, demon- 2005; Baumeister et al., 2011; Nair et al., 2011). This observation
strated that parasites are able to proliferate in vitro, and cause dis- can be explained by the inaccessibility of fosmidomycin to its site
ease in an acute infection model, upon the knockout of genes of action. Overexpression in T. gondii of a bacterial protein capable
encoding key FASII enzymes (Liang et al., 2020a, 2020b). In vitro of fosmidomycin transport rendered these parasites sensitive to
proliferation in these FASII mutants was slower than in wild type fosmidomycin both in vitro and in vivo (Nair et al., 2011). Similar
parasites, and this proliferation defect could be rescued by supple- observations of limited fosmidomycin accessibility have been
mentation with excess fatty acids in the growth medium. This mir- made in liver-stage Plasmodium parasites (Baumeister et al.,
rors another recent study that revealed that the FASII pathway is 2011; Nair et al., 2011). To overcome these drug accessibility
upregulated when parasites are cultured in a lipid-poor growth issues, a series of so called ‘‘MEPicides”, which are lipophilic ester
medium (Amiar et al., 2020). Together, these findings point to a prodrugs structurally related to fosmidomycin and designed to
considerable degree of metabolic flexibility in lipid acquisition in improve entry into target cells, have been synthesised recently;
T. gondii, suggesting that the FASII pathway may be particularly they were shown to be potent inhibitors of Plasmodium prolifera-
important in intracellular niches or stages of infection where fatty tion in vitro and in vivo (Wang et al., 2018a, 2018b) as well as
acids in the environment are limiting. Nevertheless, doubts remain being able to inhibit other intracellular pathogens, such as Staphy-
about whether FASII represents a feasible drug target in these lococcus bacteria, in a transporter-independent manner (Edwards
parasites. et al., 2020). It will now be of particular interest to test MEPicides
for anti-Toxoplasma activity.
3.5. Histone modification inhibitors Following its synthesis in the apicoplast, IPP is exported into the
cytosol where it can be metabolised further to generate a range of
Histones are DNA binding proteins that function in packaging isoprenoids. A dual-function farnesyl diphosphate/geranyl geranyl-
DNA in the nucleus of eukaryotic cells. Post-translational histone diphosphate synthase (TgFPPS) enzyme in T. gondii generates 15-
modifications play many and various roles in regulating gene and 20-carbon isoprenoids from IPP, and is important for the
expression, as well as facilitating DNA replication and repair. In biosynthesis of isoprenoids downstream of the DOXP pathway
T. gondii, histone deacetylase (HDAC) and histone acetylase (Ling et al., 2007). The bisphosphonate compound, risedronate,
enzymes are important for controlling gene expression, including inhibits this enzyme (Fig. 1) and shows activity against T. gondii
in the interconversion between tachyzoites and bradyzoites proliferation in vitro (Martin et al., 2001). Risedronate also
(Saksouk et al., 2005). A HDAC inhibitor, FR235222, targets the improved the survival of mice infected with tissue cysts by 55%
TgHDAC3 protein in T. gondii (Fig. 1), and is a potent inhibitor of over 30 days of infection at the highest dose used (Yardley et al.,
tachyzoite proliferation (Bougdour et al., 2009). Treatment with 2002). Other bisphosphonates with a greater therapeutic index
FR235222 induces the upregulation of bradyzoite-specific genes and potency than risedronate have been identified, with one com-
and results in the differentiation of tachyzoites into bradyzoites. pound improving the survival of infected mice by up to 80% over a
Interestingly, pretreatment of ex vivo bradyzoite-containing cysts 30 day period (Ling et al., 2005; Shubar et al., 2008).
rendered them incapable of converting to tachyzoites when inocu- Genetic disruption of the gene encoding the TgFPPS protein did
lated into mice (Maubon et al., 2010). This suggests that HDAC3 not affect proliferation of parasites in fibroblasts in vitro but did
inhibitors hold particular promise in preventing reactivation of affect proliferation under stress conditions such as growth in
brain cysts. A potential limitation is that FR235222 has only 10- macrophages and when parasites were extracellular (Li et al.,
fold selectivity for T. gondii over host cells. The related HDAC- 2013). The dispensability of TgFPPS was attributed to the ability
targeting compounds W363 and W399, however, exhibit similar of T. gondii to scavenge isoprenoids from the host cell. In support
potency to FR235222 in inhibiting parasite proliferation and are of this, concomitant inhibition of the host mevalonate isoprenoid
less toxic to human cells (Maubon et al., 2010). biosynthesis pathway using the drug atorvastatin (Fig. 1) increased
survival of mice infected with a TgFPPS knockout strain from 20%
3.6. Isoprenoid biosynthesis inhibitors to 90% (Li et al., 2013). Inhibitors of the host mevalonate pathway,
including statins such as atorvastatin, are in widespread use for the
Isoprenoids are lipids that contribute to various aspects of cel- treatment of humans at risk of heart disease. A dual inhibition
lular biology. In apicomplexan parasites such as T. gondii, they strategy using drugs to target both the parasite and host isoprenoid
function as precursors for molecules such as the mitochondrial biosynthesis pathways could yield synergistic effects in vivo, and
electron carrier, CoQ, and a class of lipids termed dolichols, as well future studies examining the therapeutic feasibility of such an
as in the prenylation of proteins that function in the endomem- approach for the treatment of T. gondii infections are of particular
brane system (Imlay and Odom, 2014). The basic building blocks interest.
of isoprenoids are two five-carbon molecules termed isopentenyl
pyrophosphate (IPP) and dimethylallyl pyrophosphate (DMAPP). 3.7. Protein synthesis inhibitors
The synthesis of IPP and DMAPP occurs in the apicoplast of api-
complexans via a seven-enzyme pathway termed the methylery- The endosymbiotic origin of the apicoplast of T. gondii means
thritol phosphate (MEP) pathway (Imlay and Odom, 2014). The that this compartment houses a bacterially-derived translational
MEP pathway, sometimes referred to as the non-mevalonate path- machinery (e.g., 70S ribosomes). Numerous inhibitors of bacterial
way, is fundamentally different from the so-called mevalonate translation have been shown to inhibit the proliferation of T. gondii
pathway that synthesises IPP and DMAPP in mammalian cells (Fig. 1) and other apicomplexans (Goodman et al., 2016); for exam-
and, hence, it has been proposed as a promising therapeutic target ple, clindamycin, an inhibitor of the bacterial 50S (large) ribosomal
101
subunit, inhibits T. gondii proliferation (Pfefferkorn et al., 1992) and susceptibility of mice to T. gondii infection, and/or differences in
has been used in clinical treatment of toxoplasmic encephalitis the immune response elicited by these two mouse strains. Regard-
patients in combination with pyrimethamine (Dannemann et al., less of the reasons, this study highlights the importance of investi-
1992). Clindamycin-resistant T. gondii strains have mutations in gating the contributions of host biology to disease outcomes
the large rRNA that is encoded on the apicoplast genome (Camps following drug treatments.
et al., 2002), suggesting that clindamycin targets protein transla-
tion in the apicoplast of these parasites. 3.8. Challenges and prospects for better chemotherapeutic treatment
Parasites treated with clindamycin and other compounds tar- options
geting apicoplast translation exhibit a peculiar phenotype known
as delayed death (Fichera et al., 1995; Camps et al., 2002), where While much progress has been made towards identifying new
parasite proliferation remains unaffected by drug treatment until anti-Toxoplasma chemotherapeutics, there are still many chal-
they have egressed from existing host cells and reinvaded new host lenges to translate these findings into better clinical outcomes
cells. This phenomenon is tied to apicoplast loss that occurs upon for patients. The ideal chemotherapeutic against T. gondii would
treatment with these inhibitors – it appears that the parasites cure patients of infection, which would require the compound to
are able to tolerate apicoplast loss until they reinvade new host have activity against both the disease-causing tachyzoite form
cells, leading to the proposal that a product of apicoplast metabo- and the slower-growing bradyzoite form. One of the key challenges
lism is required to establish a new infection (He et al., 2001). Inter- is to obtain a broader understanding of the biology of bradyzoite-
estingly, co-treatment with clindamycin and the host mevalonate containing tissue cysts, and why drugs fail to eliminate tissue cysts
pathway inhibitor, atorvastatin, results in a more immediate death in patients. Recent advances in facilitating the in vitro differentia-
phenotype compared with treatment with clindamycin alone tion of tachyzoites into bradyzoites en masse may aid in these
(Amberg-Johnson and Yeh, 2019). This leads to the proposal that efforts (Waldman et al., 2020), although it will be important to ver-
scavenging of host isoprenoids compensates for the loss of the api- ify that in vitro models recapitulate the biology of bradyzoites and
coplast that occurs in the first lytic cycle after clindamycin treat- tissue cysts in vivo. Notably, the replicative capacity and physiol-
ment but that host isoprenoid scavenging is not sufficient to ogy of bradyzoites in vivo seems to be more heterogeneous and
facilitate longer-term parasite proliferation following apicoplast dynamic than appreciated previously (Watts et al., 2015; Sinai
loss (Amberg-Johnson and Yeh, 2019). et al., 2016), implying that some cysts (potentially those that are
The macrolide, azithromycin, is another inhibitor of apicoplast latent/dormant) may be more resistant to drugs than others.
protein translation, and it can be used alone or in combination with Understanding the causes of this heterogeneity may uncover new
pyrimethamine to treat acute episodes of ocular toxoplasmosis avenues for therapeutic intervention, in particular determining
(Rothova et al., 1998; Bosch-Driessen et al., 2002; Balaskas et al., what factors drive bradyzoites to latency/dormancy.
2012). Azithromycin has many favourable properties including Another roadblock is the potential for strain-specific effects of
good oral bioavailability, long half-life and fewer side-effects than drugs in both T. gondii and mice. A striking example of this is the
pyrimethamine and sulfadiazine (Alday and Doggett, 2017). While mouse strain-dependent disease outcomes observed upon guan-
patients experienced fewer side effects with azithromycin treat- abenz treatment (see Section 3.7) (Konrad et al., 2013;
ment than with pyrimethamine and sulfadiazine, one study noted Benmerzouga et al., 2015; Martynowicz et al., 2019). These studies
that 27% of patients experienced recurrence within a year of azi- highlight the benefit and, perhaps, necessity of testing compound
thromycin monotherapy (Rothova et al., 1998). This suggests that efficacy in multiple mouse and T. gondii strains to better inform
azithromycin does not fully eliminate T. gondii cysts in patients. the possible outcomes when compounds are progressed to clinical
In agreement with this, while azithromycin treatment prolonged trials. This also questions the extent to which the performance of a
survival of mice in both acute and chronic mouse infection models compound in mouse models resembles the outcome in human
(Araujo et al., 1991a, 1991b; Dumas et al., 1994), azithromycin disease.
treatment of mice chronically infected with T. gondii parasites In the bid to identify new drug targets and novel chemothera-
did not lessen brain cyst burden compared with controls (Dumas pies, high throughput screening methods are increasingly utilised
et al., 1994). to assess large compound libraries for activity against T. gondii pro-
Cytosolic protein synthesis is also a potential target of thera- liferation in vitro (Boyom et al., 2014; Murata et al., 2017; Adeyemi
peutic intervention in T. gondii (Fig. 1). Studies have revealed that et al., 2018a). One challenge that limits the progression of hit com-
the conversion of tachyzoites to bradyzoites is concomitant with pounds is differences in their in vitro versus in vivo effectiveness,
the phosphorylation of the a subunit of the T. gondii eukaryotic ini- as many compounds that show promise in preliminary screens
tiation factor 2 (TgeIF2; Sullivan et al., 2004; Narasimham et al., exhibit unfavorable pharmacokinetic properties or, ultimately, tar-
2008). TgeIF2 has a key role in initiating translation at cytosolic get processes that are less important for parasite survival in vivo
ribosomes and, as in other organisms, its phosphorylation impairs than in vitro. Structure-activity relationship studies and the devel-
cytosolic translation, leading to a global reduction in parasite pro- opment of prodrugs with more desirable in vivo properties hold
tein synthesis (Sullivan et al., 2004; Narasimhan et al., 2008). particular promise in the development of promising ‘‘hits” that
Treatment of parasites with the Food and Drug Administration emerge from high throughput screens.
(U.S.A.)-approved anti-hypertension drug, guanabenz, inhibits A final challenge is understanding the extent to which anti-Tox-
TgeIF2 dephosphorylation, which in turn promotes the formation oplasma treatments can ‘‘piggy-back” on treatment efforts in other
of bradyzoite-containing cysts and prevents reactivation into apicomplexan parasites, most notably Plasmodium parasites, for
tachyzoites in vitro (Konrad et al., 2013). Guanabenz treatment which extensive drug screening efforts exist. Several current
prolonged the survival of mice in an acute infection model by sev- anti-Toxoplasma agents, including pyrimethamine and atovaquone,
eral days (Konrad et al., 2013; Benmerzouga et al., 2015). Interest- are also potent inhibitors of Plasmodium parasites. Nevertheless,
ingly, the effects of guanabenz on brain cyst burden seems to vary there are major differences in the host cell types and physiological
between mouse strains, with guanabenz treatment leading to a environments that these parasites inhabit, and also major differ-
decrease in brain cysts in BALB/c mice but leading to an increase ences in the biology of the different life cycle stages of these para-
in brain cysts in C57BL/6J mice (Martynowicz et al., 2019). The sites. This means that drugs that are highly efficacious in one
authors speculated that these differences could arise from parasite will not necessarily be potent inhibitors in another para-
differences in the reactivation of tissue cysts, differences in site. Emphasising this point, a screen of antimalarial drugs in late
102
preclinical development revealed that most anti-malarials tested on CD8+ T cells and natural killer (NK) cells have been shown to
exhibited only a limited efficacy against T. gondii proliferation enhance immunity during chronic T. gondii infection (Hunter
(Radke et al., 2018). As a more specific example, cipargamin, a et al., 1997; Bhadra et al., 2011, 2012; Xiao et al., 2018), though
potent inhibitor of P. falciparum parasites that targets the PfATP4 these findings require further validation (Splitt et al., 2018).
sodium pump (Spillman et al., 2013), shows limited efficacy Although cellular immunotherapies, such as the transfer of
against T. gondii (Radke et al., 2018; Lehane et al., 2019). This can immune CD8+ T cells and NK cells, can protect animals from lethal
be explained by the differences in sodium concentrations experi- T. gondii challenge (Casciotti et al., 2002; Ivanova et al., 2019),
enced by the disease-causing stages of these parasites within their these strategies are not suitable for large scale human application.
host cells, with the T. gondii homologue of PfATP4 being dispens- However, the advent of commercial-scale CAR T cell and NK cell
able for intracellular proliferation (Lehane et al., 2019). Therefore, therapy may provide a new avenue for cell-mediated immunother-
while the idea of developing pan-apicomplexan therapeutics that apy in toxoplasmosis (Maldini et al., 2018; Liu et al., 2020). CAR T
act on conserved pathways is appealing, it is likely that focusing cell therapy involves the transfer into patients of genetically mod-
early drug development to optimise efficacy against T. gondii will ified T cells that not only recognise specific protein targets but also
lead to better therapeutics for treatment of toxoplasmosis. co-express T cell activation functions in a single engineered recep-
tor. CAR T cell therapy has revolutionised cancer treatment over
the last decade and, despite non-cancer applications still being in
4. Immunotherapies for the control of toxoplasmosis
their infancy, one could envisage that the re-engineering of
patient-derived CD8+ T cell or NK cell receptors specific for stage-
The activation or suppression of distinct elements of the
specific T. gondii antigens could significantly improve feasibility
immune system via targeted host-directed immunotherapy has
and success of cellular immunotherapy for (latent) toxoplasmosis
gained significant attention in the field of infectious diseases,
(Fig. 2C). Nevertheless, a vigilant evaluation of these immunother-
including toxoplasmosis (Kaufmann et al., 2018a, 2018b; Singh
apies in the context of infection will be required, as neurological
et al., 2019). Immunotherapies are less prone to the emergence
complications and disseminated toxoplasmosis have been reported
of resistance and often have fewer side effects compared with
in CAR T cell-treated patients (Kersten et al., 2019; Kator et al.,
antimicrobial drugs. Whilst there are currently no immunothera-
2020).
pies in use for human toxoplasmosis, murine models have pro-
vided insight that may prove crucial for future developments
4.2. Cytokines
(Fig. 2). In the following section, we review recent research
advances in immunotherapies against toxoplasmosis, including
Immunity to toxoplasmosis is critically dependent on ILs and
the role of passive immunisation, monoclonal antibody therapy,
IFN-c, in particular the IL-12/IFN-c axis (Yarovinsky, 2014); many
chimeric antigen receptor (CAR) T cells, cytokines and chemokines,
studies have demonstrated beneficial outcomes after the delivery
immunomodulatory drugs and trained immunity, any of which
of recombinant IL-12 (Hunter et al., 1995; Araujo et al., 1997) or
could conceivably become the basis for future treatments of
IFN-c (Suzuki et al., 1988; Suzuki et al., 1990; Benedetto et al.,
immunosuppressed people.
1991; Delemarre et al., 1993; Delemarre et al., 1994) in mouse
models of toxoplasmosis and in ex vivo infection of human cells.
4.1. Passive immunisation, monoclonal antibodies and CAR T cells Similarly, IL-18, formerly known as IFN-c enhancing factor, also
plays a critical role in immunity to T. gondii, by synergising with
Passive immunisation, the transfer of polyclonal antibodies IL-12 (Cai et al., 2000). The development, expansion and survival
from immune sera (Fig. 2A), has been used to treat and prevent of IFN-c-producing cell types depends on the c chain cytokines,
infectious diseases such as tetanus, rabies and hepatitis B IL-2, IL-7 and IL-15 and, thus, immunotherapies based on said
(Sparrow et al., 2017). Early adoptive transfer studies in a hamster cytokines have also shown improved outcomes of toxoplasmosis
model of T. gondii infection suggested that antibodies contribute in animal models (Fig. 2D). While the exact role of IL-15 in immu-
only marginally to protection after transfer (Frenkel, 1967). These nity to T. gondii remains somewhat unresolved (Khan et al., 2002;
findings laid the foundation for the concept that immunity to T. Lieberman et al., 2004), IL-2 deficient mice are highly susceptible
gondii is dominated by IFN-c producing CD8+ T cells (Suzuki and to T. gondii infection (Villegas et al., 2002), and administration of
Remington, 1990; Kang et al., 2000; Sayles et al., 2000; Casciotti recombinant IL-2 enhances survival of Toxoplasma-infected mice
et al., 2002). However, it was later shown that, in murine toxoplas- (Sharma et al., 1985; Shirahata et al., 1993). Delivery of recombi-
mosis, antibodies contribute to controlling long-term persistence nant IL-15 also protects against lethal infection by enhancing
and vaccination-induced resistance (Kang et al., 2000; Sayles IFN-c production (Khan and Casciotti, 1999; Khan and Kasper,
et al., 2000). With the more recent and widespread use of mono- 1996) but IL-15 deficient mice are able to develop protective
clonal antibody (mAb) therapy in the treatment of cancer (Byun immunity (Lieberman et al., 2004). IL-7 and IL-15 appear to syner-
et al., 2017), passive immunisation with mAbs in toxoplasmosis gise during acute infection (Kasper et al., 1995; Bhadra et al., 2010),
has been revitalised. It was shown that the transfer of human although the recall response of memory CD8+ T cells to T. gondii is
mAb Fab fragments specific to the T. gondii surface antigen 1 almost exclusively dependent on IL-15 (Bhadra and Khan, 2012).
(SAG1) protein into mice significantly improved survival rates IL-2 and IL-15 are presented to the cytokine receptor complex
(Fu et al., 2011). Similarly, the transfer of mAbs against dense gran- beta and the common c chain in the context of cell-bound high-
ule proteins GRA2, GRA6 or nucleoside triphosphate hydrolase-II affinity alpha chains of the cytokine receptor (Stoklasek et al.,
into mice promoted prolonged survival (Cha et al., 2001; Tan 2006; Stonier and Schluns, 2010). This process has been termed
et al., 2010). Even though none of these transfers provided sterile trans-presentation. Combining IL-2 with anti-IL-2 mAbs to form
immunity, it is possible that the identification of additional an IL-2 complex (IL2C) or combining IL-15 with a chimeric receptor
bradyzoite- and cyst wall-specific antigens, such as SRS9, CST1 (IL-15RaFc) to form an IL-15 complex (IL15C) significantly
and MAG2 (Kim et al., 2007; Tomita et al., 2013; Tu et al., 2020), enhances the biological activity of these cytokines in vivo
may pave the way for future combination mAb therapies targeting (Boyman et al., 2006; Votavova et al., 2014). The binding site of
several stage-specific molecules for attachment, invasion, prolifer- the anti-IL2 mAb used in the IL2C determines whether a preferen-
ation and persistence simultaneously (Fig. 2B). Similarly, mAbs tial expansion of regulatory T cells (TReg) or CD8+ T cell and NK cells
that target the inhibition of receptors, such as CTLA-4 and PD-1, occurs; anti-IL-2 mAb JES6-1A12 causes expansion of TReg cells;
103
104
whereas anti-IL-2 mAb S4B6 causes expansion of CD8+ T cells and date. Given that CCR5 receptor antagonism inhibits hepatitis C
NK cells (Boyman et al., 2006; Shevach, 2012). In animal studies, virus replication (Blackard et al., 2019) and limits the progression
JES6-1A12-containing IL2C improved control of RH strain T. gondii of gastric cancer (Aldinucci and Casagrande, 2018), further studies
infection (Akbar et al., 2015) and reduced immunopathology and into its effect on toxoplasmosis are warranted.
morbidity during acute type II T. gondii ME49 infection CCL2, CCL3, CCL4 and CCL5 are produced by intestinal cells after
(Oldenhove et al., 2009), likely by preventing the competition for they become exposed to tachyzoites (Gopal et al., 2011). In partic-
bioavailable IL-2 between regulatory and effector T cells. We have ular, the parasite-derived molecules GRA24 and SAG1 have been
also shown recently that S4B6-containing IL2C-mediated expan- implicated in this process (Rachinel et al., 2004; Brenier-Pinchart
sion of non-CD4 immune cells that produce IFN-c can be harnessed et al., 2006; Braun et al., 2013), indicating that T. gondii actively
to rescue mice from acute lethal toxoplasmosis (Kupz et al., 2020). manipulates chemokine secretion pathways to its advantage. The
Intriguingly, although this IL-12- and IL-18-dependent effect of double-edged sword of leukocyte recruitment for the initiation of
treatment with SB46-IL2C leads to reduced acute pathology, it does immunity against T. gondii and the parasite’s requirement to
so without affecting TReg cells or parasite burden. Together, these induce inflammation, is also demonstrated by studies using CCR1
IL2C studies suggest that cytokine complex immunotherapy may and CCR2 knockout mice, both of which are highly susceptible to
be a viable future adjunct treatment in the context of chronic tox- lethal toxoplasmosis (Khan et al., 2001; Dunay et al., 2008). Che-
oplasmosis, in particular for immunosuppressed people with mokine and anti-chemokine therapies are actively being pursued
impaired CD4+ T cells, e.g., as caused by HIV co-infection in AIDS in the field of inflammatory diseases (Castellani et al., 2007;
(Fig. 2E). However, caution is needed because data on the clinical Mohit and Rafati, 2012; Ambade et al., 2019) and cancer (Ruffini
use of IL2C and IL15C treatments in humans are lacking and it et al., 2007; Arakaki et al., 2016; Lim et al., 2016). However, similar
needs to be acknowledged that treatment with cytokine complexes to CCL3, CCL4 and CCL5, no targeted therapies with CCL2, CCL7,
could lead to hyperinflammatory responses. Such an undesirable CCL23, or synthetic CCR1 or CCR2 agonists and antagonists have
potential outcome should be taken into careful consideration been reported in the context of toxoplasmosis. This area of
before embarking on translational studies in humans. research would benefit from further investigations.
4.4. Immunomodulatory drugs

4.3. Chemokines
Immunomodulatory drugs comprise different classes of com-

Many parasitic infections, including toxoplasmosis, are charac-
pounds with direct or indirect impact on the immune system
terised by excessive or imbalanced inflammation and pathology
(Gao et al., 2020). The imide-containing class of immunomodula-
(Menzies et al., 2016). These events are tightly linked to the
tory drugs (IMiDs), such as thalidomide and several analogues,
recruitment, influx and persistence of leukocytes to the site of
are widely used in the treatment of autoimmune diseases and can-
infection, events that are regulated by chemokines and their recep-
cer (Abe and Ishida, 2019; Fuchs, 2019). To date, none of these
tors (Menzies et al., 2016). Similar to most intracellular pathogens,
IMiDs have been reported to have an impact on toxoplasmosis.
T. gondii benefits from leukocyte recruitment, as it can use infected
However, there is growing interest in deciphering the role of vari-
cells to spread through the host (Da Gama et al., 2004; Lambert
ous immunomodulatory compounds derived from chemical
et al., 2009). Hence, interfering with the chemokine-chemokine
libraries as well as from natural products on infectious diseases,
receptor axis may provide novel targets for host-directed therapies
including toxoplasmosis (Sepulveda-Arias et al., 2014; Sharif
(Fig. 2F). To illustrate, mouse studies have shown that the absence
et al., 2016) (Fig. 2G); for example, in one study, it was shown that
of chemokine receptor type 5 (CCR5) leads to a reduction in tissue
treatment of mice with ursolic acid, a compound commonly found
damage due to reduced NK cell recruitment and IFN-c production,
in various fruits, increased a number of critical anti-toxoplasmosis
but also to an increased parasite burden (Khan et al., 2006). CCR5
cytokines in a mouse model of toxoplasmosis (Choi and Lee, 2019).
signalling is also involved in the T. gondii-induced interruption of
Similarly, beneficial effects on murine toxoplasmosis have been
pregnancy in mice (Nishimura et al., 2017), and human polymor-
reported after treatment with lectins (Ramos et al., 2016), Echi-
phisms in CCR5 have been linked to a greater risk of developing
nacea purpurea extracts (Gasparotto Junior et al., 2016) and lacto-
ocular toxoplasmosis (de Faria Junior et al., 2018). The T. gondii
ferrin (Anand et al., 2015).
secreted effector molecule, cyclophilin 18 (TgCyp18), binds to
CCR5 and mimics CCR5 ligand binding (Aliberti et al., 2003), fur-
ther supporting the idea that CCR5 activation favours T. gondii sur- 4.5. Trained immunity
vival. However, no therapeutic or prophylactic treatments with
antibodies or inhibitors targeting CCR5 or its ligands CCL3, CCL4 In recent years, the concept of ‘‘trained immunity” has gained
and CCL5 in the context of toxoplasmosis have been reported to significant attention (Netea et al., 2016, 2020). It has been shown
3
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
that some live attenuated vaccines, adjuvants, microbial ligands 5.1. Anti-Toxoplasma vaccines for intermediate hosts
and b-glucan have a strong effect on ‘‘training” hematopoietic stem
cells and innate immune cells via epigenetic imprinting (Kaufmann 5.1.1. Anti-Toxoplasma vaccines targeting humans
et al., 2018a, 2018b). This trained immunity appears to be the rea- Virtually all individuals are at risk of acquiring toxoplasma
son for adaptive immunity-independent protection against a vari- infection at some point in their lifetime, therefore a vaccine to pre-
ety of viral, bacterial and parasitic pathogens (Arts et al., 2018; Dos vent toxoplasmosis in humans would benefit all (Tenter et al.,
Santos et al., 2019; Tarancon et al., 2020). To date, no study has 2000). Ideally, a T. gondii vaccine should target young girls before
addressed the specific role of trained immunity in treating, pre- they reach fertile age and induce a protective immune response
venting or ameliorating T. gondii infection and disease, whether able to prevent the vertical transmission of the parasite from the
acute or latent. However, given the explosion of research activity mother to the unborn child. Such a vaccine would reduce the glo-
in this field, it appears to be only a matter of time before the impact bal incidence of congenital toxoplasmosis, which is estimated to be
of trained immunity on toxoplasmosis will be investigated 1.5 cases per 1,000 live births (~190,000 new cases every year)
(Fig. 2H). In that context, it is important to note that Krahenbuhl (Jones et al., 2001; Torgerson and Mastroiacovo, 2013). A vaccine
et al. (1981) demonstrated that pre-treatment of mice with the to prevent acute and chronic toxoplasmosis is desirable. Such a
synthetic adjuvant muramyl dipeptide afforded resistance to sub- vaccine would prevent the severe illness caused by an acute infec-
sequent T. gondii challenge. The authors of that study concluded tion in immunocompromised individuals, as well as protect against
that the protection was independent of enhanced antibody produc- the life-threatening reactivation of latent bradyzoites present in
tion or macrophage activation, and must have been due to a yet to tissue cysts of individuals who acquired toxoplasmosis when
be identified mechanism. Interestingly, independently of assessing healthy but become immunocompromised afterwards (Pott and
the impact on immunity, a synergistic effect of b-glucan with spi- Castelo, 2013; Stajner et al., 2013; Wang et al., 2017).
ramycin in the treatment of toxoplasmosis has also been reported There are no reports of T. gondii vaccine studies in humans.
previously (Buyukbaba Boral et al., 2012). It has also been proposed There is, however, a long list of experimental vaccines that have
that human T. gondii infection itself may have long-term effects on been tested recently in murine models, examples of which are
the phenotype and responsiveness of monocytes, implying a train- summarised in Table 2 and Fig. 3. As is the case for any intermedi-
ing effect that may also impact immunity to unrelated pathogens ate host, mice can be infected by oral administration of oocysts or
(Ehmen and Lüder, 2019). cysts containing bradyzoites, mimicking natural routes of infec-
tion, or by the artificial injection of tachyzoites. Experimental mod-
els established in mice include acute and lethal T. gondii infection,
5. Vaccination for the control of toxoplasmosis the formation of bradyzoite tissue cysts in muscles and brain, and
congenital toxoplasmosis (Subauste, 2012). Several vaccine candi-
Vaccination has been used extensively to control infectious dis- dates have been investigated including SAGs, rhoptry proteins
eases worldwide (Doherty et al., 2016). Due to the complexity of (ROP), microneme proteins (MIC), GRA and other proteins secreted
the life cycle of T. gondii and the parasite’s ability to infect any by tachyzoites (Fig. 3). Similarly, different formulations, adjuvants,
warm-blood animal, the challenge to develop a vaccine to control immunisation routes and schedules have been tested, spanning
toxoplasmosis involves consideration of: (i) which stage of the par- killed or live attenuated parasites, subunit vaccines, recombinant
asite life cycle and, hence, which host(s) to target; (ii) which para- proteins, DNA vaccines and live vectors to deliver T. gondii antigens
site antigens to target; and (iii) the mode of delivery. (Fig. 3). Despite showing some promise – most candidates report-
A vaccine for direct use in humans should, ideally, protect ing some ability to reduce cyst formation and prolong survival of
against both the acute and chronic phases of infection, needing the host – there is no report of progression of a vaccine tested in
to prevent the severe consequences of ocular toxoplasmosis, con- mice to human clinical trials.
genital toxoplasmosis caused by a primary infection in pregnant To date, the only commercial vaccine against T. gondii is based
women, and the mortality caused by the reactivation of latent par- on an attenuated strain designed to prevent abortion in sheep
asites in immunosuppressed individuals (Tenter et al., 2000; which, due to potential safety and regulatory issues associated
Machala et al., 2015; El Bissati et al., 2018). It is debatable whether with a possible reversion to fully virulent parasites, is not consid-
a single vaccine could achieve all these requirements. ered suitable for administration to humans (Innes et al., 2019).
A vaccine targeting T. gondii in livestock would not only need to However, provision of the genomes of the main T. gondii strains
prevent bradyzoite cyst formation in order to minimise transmis- (Lorenzi et al., 2015) and transcriptomic data sets of different
sion of the parasite to humans through consumption of under- stages of the parasite life cycle (Behnke et al., 2014; Hehl et al.,
cooked meat (Tenter et al., 2000) but would also need to reduce 2015; Ramakrishnan et al., 2019), combined with advances in the
the economic loss caused by animal abortion, especially in sheep use of CRISPR/Cas9 genome editing strategies (Shen et al., 2017;
and goats (Stelzer et al., 2019), to encourage widespread use. Sidik et al., 2018; Markus et al., 2019; Young et al., 2019) that allow
Again, these different requirements might necessitate the identifi- targeted and selectable marker-free deletion of genes, may lead to
cation of different targets in T. gondii and require different modes the development of optimised attenuated strains with reduced
of delivery. risks of reversion. Indeed, the prospects for development of a live
A vaccine targeting felids, the only definitive host of T. gondii, attenuated vaccine for humans and other intermediate hosts have
would be able to stop the shedding of highly infective oocysts into been enhanced by recent discoveries concerning how stage differ-
the environment and, consequently, reduce the incidence of infec- entiation is regulated at a molecular level (Farhat et al., 2020;
tion via ingestion in both livestock and humans (Frenkel and Waldman et al., 2020). In particular, the identification of a single
Smith, 1982; Innes et al., 2009; Torrey and Yolken, 2013). Mathe- transcription factor (the Myb-like transcription factor, BFD1) as a
matical modelling highlights the attractiveness of the cat as a tar- master-regulator for differentiation from tachyzoite to bradyzoite
get for vaccination in order to prevent toxoplasmosis in livestock (Waldman et al., 2020) theoretically paves the way for develop-
and humans (Mateus-Pinilla et al., 2002; Arenas et al., 2010; ment of a live vaccine incapable of forming cysts (Kochanowsky
Jiang et al., 2012; Turner et al., 2013; Sykes and Rychtář, 2015; and Koshy, 2020). In addition, an advantage of CRISPR/Cas9 in
Bonačić Marinović et al., 2020) but the form and means of delivery the context of producing attenuated vaccine strains is that genes
to achieve sufficient coverage of such a vaccine arguably presents a can be, effectively, knocked out without introducing foreign DNA
potential obstacle to success (Bonačić Marinović et al., 2020). into the parasite. This means that these strains would not neces-
106
Table 2
Examples of recent experimental murine vaccines against Toxoplasma gondii.
Live Attenuated Vaccines

Gene deleted Toxoplasma Immunising Toxoplasma Murine Immune Vaccine Trial Results Summary
Strain Challenge Strain Host Response
Strain
CDPK2a PruDcdpk2 RH, PRU Kunming IgG, Th1/Th2 Protection of host against lethal challenge; partial
cytokines reduction of brain cyst numbers.
LDH1 and LDH2b,c PruDldhb RHb BALB/cb Protection of host against lethal challengeb
ME49Dldh c
RH, ME49, VEG and ICR IgG, IFN-c, IL- Protection of host against lethal challenge; partial
a field isolate of micec 12 reduction of brain cyst numbersc
Chinese 1c
Gra17 and NPT1d RHDgra17Dnpt1 RH, PRU Kunming IgG, IFN-c, IL- Protection of host against lethal challenge; partial
2, IL-10 and reduction of brain cyst numbers; partial protection
IL-12 against congenital toxoplasmosis
Tyrosine kinase-like 1e RHDtkl1 RH, PRU Kunming IgG1, IgG2a, Protection of host against lethal challenge; partial
IFN-c, IL-2 reduction of brain cyst numbers; partial protection
against congenital toxoplasmosis
Adenylosuccinate lyasef ME49D ADSL RH, ME49, VEG ICR IgG and IgA Protection of host against lethal challenge
Subunit/Recombinant Vaccines
Antigen Formulation/Adjuvant Toxoplasma Murine Immune Vaccine Trial Results Summary
Challenge Strain Host Response
Strain
Recombinant GRA2g Monophosphorryl lipid Tehran C57BL/6 IgG, IFN-c Partial reduction of brain cyst numbers
A (MPL)
Recombinant serine protease Aluminium hydroxide ME49 C3H/ IgG, Th1/Th2 Partial reduction of brain cyst numbers
inhibitor-1 (TgPI-1), ROP2 or HeN cytokines
and/or GRA4h CpG-ODN
Recombinant calcium- BALB/c RH BALB/c IgG, IFN-c, IL- Prolonged survival of host
dependent protein 12, IL-10
kinases family, TgCDPK1i
Epitopes of GRA10j Multiple antigenic RH, PRU BALB/c IgG1, IgG2a, Protection of host against lethal challenge; partial
peptide (MAP) in and IFN-c, IL-2 reduction of brain cyst numbers
chitosan microspheres C57BL/6
Epitopes of SAG1, AMA1, Poly lactic-co-glycolic RH BALB/c IgG1, IgG2a, Prolonged survival of host
ROP2, and GRA4k acid (PLGA) IFN-c, IL-2
nanoparticle + Alum
Apical membrane antigen 1 VLP containing ME49 BALB/c IgG, IgA Prolonged survival of host; partial reduction of brain
(AMA1)l influenza M1 protein cyst numbers
DNA Vaccines
Gene Formulation/Adjuvant Toxoplasma Murine Immune Vaccine Trial Results Summary
Strain
GRA7 and ROP2m RH BALB/c IgG2a, IFN-y Prolonged survival of host
T. gondii profilin (TgPF)n IL-15 PRU Kunming IgG, IgG2a, Partial reduction of brain cyst numbers
IFN-c, IL-2,
IL-4, IL-10
Perforin-like protein (PLP1) IL-18 PRU Kunming IgG2a, IL-2, Prolonged survival of host; partial reduction of brain
and ROP18o IL-12, IFN-c cyst numbers
ROP22p RH BALB/c IgG1, IgG2a, Prolonged survival of host; partial reduction of brain
IL-2, IFN-c cyst numbers
ROP21q RH, PRU BALB/c IgG1, IgG2a, Prolonged survival of host; partial reduction of brain
IFN-c cyst numbers
ROP5 and ROP18r IL-33 RH Kunming IgG2, IFN-c, Prolonged survival 0f host; partial reduction of brain
IL-2, IL-12 cyst numbers
s
ROP 8 epitopes RH BALB/c IgG1, IgG2a, Prolonged survival of host
IFN-c
Heterologous Vector Expressing Toxoplasma proteins
Gene Vector Toxoplasma Murine Immune Vaccine Trial Results Summary
Strain
Apical membrane antigen 1 Adenovirus vaccine RH BALB/c IFN-c, IL-4 Increased survival of host
(AMA1)t
a
Wang et al. (2018a).
b
Abdelbaset et al. (2017).
c
Xia et al. (2018).
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
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 Organisms (GMOs) in secreted during infection with T. gondii that can access the major
many countries (Zhang et al., 2020). histocompatibility complex class I pathway. These peptides can eli-
Another approach to vaccine development has been to combine cit the production of IFN-c from CD8+ T cells in peripheral blood
bioinformatic tools with immunological approaches. Such studies mononuclear leukocytes of humans who are T. gondii seropositive
have focussed on identifying peptide epitopes from proteins (Cong et al., 2010, 2011). Immunisation of human leukocyte anti-
108
gen (HLA) transgenic mice with multi-epitope DNA or protein vac- Microspheres containing proteins from a crude extract of RH strain
cines in combination with a universal CD4+ epitope peptide and tachyzoites encapsulated into poly(D,L-lactide-co-glycolide) were
adjuvant induced high levels of IFN-c and protected mice against investigated as an intranasal vaccine for sheep with and without
challenge with type II parasites (Cong et al., 2010, 2011; El cholera holotoxin (Stanley et al., 2004). Although both systemic
Bissati et al., 2016). Although the high polymorphism of HLA mole- and mucosal humoral responses, together with cell-mediated
cules in the human population may be an obstacle for epitope- immunity, were observed, immunisation with microspheres con-
based vaccines, studies have demonstrated that the specificity of taining T. gondii proteins failed to protect sheep against clinical
peptide-binding shared by the HLA supertypes A02, A03, and B07 signs of infection upon challenge with oocysts of the M3 strain of
corresponds to ~90% of the world’s population (Barber et al., T. gondii. Western blot analysis demonstrated that the main anti-
1995; Sidney et al., 1995). body elicited after immunisation was reactive against a protein
of approximately 30 kDa, likely to be the major surface antigen
5.1.2. Anti-Toxoplasma vaccines targeting livestock of the parasite, SAG1 (Stanley et al., 2004). This suggests that
The only commercial T. gondii vaccine (ToxovaxÒ) was devel- SAG1 antibodies are not sufficient to protect against infection. In
oped over three decades ago in New Zealand for control of abortion pigs, subcutaneous immunisation with two doses of crude rhoptry
in sheep (O’Connell et al., 1988; Buxton and Innes, 1995). ToxovaxÒ proteins formulated as immunostimulating complexes (ISCOMs),
consists of attenuated tachyzoites of the S48 strain of T. gondii, induced a systemic IgG response. Following challenge with oocysts,
which after over 3000 passages in mice lost its ability to develop the animals immunised with rhoptry proteins showed the same
bradyzoite tissue cysts (Buxton, 1993). This vaccine is recom- clinical signs of infection as control pigs (including fever, secretions
mended for immunisation of ewes as a single intramuscular injec- from the eye, coughing and loss of appetite) and only 20% of vacci-
tion at least 4 weeks before mating. Following immunisation, the nated pigs did not develop tissue cysts as indicated by a bioassay in
attenuated parasites undergo limited replication cycles, mimicking mice (Garcia et al., 2005). Similarly, a further investigation showed
a natural infection, and this is able to induce long-lasting protec- that crude ROPs administered by the intranasal route in combina-
tion, likely involving CD4+ and CD8+ cell responses along with tion with the adjuvant, Quil A, did not induce strong humoral or
IFN-c production (Buxton et al., 1994). ToxovaxÒ is commer- cellular immune responses prior to challenge infection, and only
cialised through MSD Animal Health and is available in the UK, Ire- one of four pigs tested negative for T. gondii by bioassays post-
land, France and New Zealand. challenge (da Cunha et al., 2012). In contrast, another study
Vaccination with the S48 strain of T. gondii impairs the forma- showed that immunisation of pigs with a mixture of tachyzoite
tion of bradyzoite tissue cysts in animals subsequently treated excretory/secretory antigens induced humoral and cellular
with wild type parasites; immunisation of lambs with the S48 immune responses, including IFN-c and IL-4, and prevented the
strain reduced the presence of parasites detected by PCR in the development of tissue cysts in four out of five pigs following chal-
heart (by 75%) and skeletal muscles (by 82%) of lambs challenged lenge with tachyzoites injected intraperitoneally (Wang et al.,
with wild type oocysts (Katzer et al., 2014). Similar results were 2013). However, the small number of animals tested and the
observed in pigs immunised with the S48 strain before challenge unnatural route of challenge infection combined with the use
with wild type oocysts (Burrells et al., 2015). A bioassay showed FCA, a powerful inducer of cell-mediated immune responses that
increased survival (48.5%) of mice that received tissue samples is not used commercially due to safety issues, restricts evaluation
from vaccinated pigs compared with mice that received porcine of this study’s practical implications.
tissue samples from the control group (Burrells et al., 2015). DNA vaccines encoding several T. gondii antigens have been
Although S48 vaccination did not completely prevent tissue cyst investigated for their ability to induce an immunological response
formation following challenge in lambs and pigs, these studies in sheep and pigs. Immunisation of sheep with a DNA vaccine
indicate that a vaccine able to reduce the cyst burden in livestock encoding the bradyzoite-specific antigen, MAG1, alone or co-
may reduce the risk of infection of humans through consumption expressed with the cytokine, IL-6, induced a specific humoral
of undercooked meat (Katzer et al., 2014; Burrells et al., 2015). response (Hiszczynska-Sawicka et al., 2010). Comparison of the
Since the approval of ToxovaxÒ, other live attenuated and inac- immune response in sheep immunised with a DNA vaccine encod-
tivated parasites have been investigated in order to develop an ing SAG1 or ROP1 combined with unmethylated cytosine-
improved vaccine to prevent sheep abortion and protect against phosphate-guanosine oligodeoxynucleotide motifs showed that
tissue cyst development. Immunisation of ewes with tachyzoites ROP1-encoding DNA, but not SAG1-encoding DNA, was able to
of a strain of T. gondii, wherein MIC1 and MIC3 were knocked out induce humoral and IFN-c responses (Li et al., 2010). Similarly,
(MIC1-3KO) 2 months before mating, induced humoral responses plasmids encoding for ROP1 in fusion with CD154, a co-
and reduced the abortion of lambs in ~72% of ewes after a chal- stimulatory molecule expressed by activated T-cells, induced a
lenge with wild type oocysts mid-gestation (Mevelec et al., mixed Th1/Th2 response in sheep, with higher IFN-c levels than
2010). However, MIC1-3KO tachyzoites were reported to persist was induced by plasmids encoding ROP1 protein only
as tissue cysts in immunised animals (Mevelec et al., 2010). A (Hiszczynska-Sawicka et al., 2011a). DNA vaccines encoding
temperature-sensitive mutant (TS-4) of the RH isolate of T. gondii GRA1, GRA4, GRA6 or GRA7 showed that GRA7 can stimulate the
(Pfefferkorn and Pfefferkorn, 1976), which does not persist as tis- ovine immune system and was able to induce IFN-c and IgG2
sue cysts in the tissues of mice (Waldeland et al., 1983), was eval- responses (Hiszczynska-Sawicka et al., 2011b). In pigs, immunisa-
uated for its ability to prevent tissue cysts in pigs (Lindsay et al., tion with a DNA vaccine encoding for GRA1 and GRA7 induced
1993). A bioassay showed that immunisation of pigs with TS-4 antibodies and cellular immune responses to both proteins
tachyzoites by subcutaneous or intravenous routes did not protect (Jongert et al., 2008). Unfortunately, none of the DNA vaccines
against bradyzoite cyst formation in the tissues of pigs challenged described above have ever been tested for efficacy against T. gondii
with wild type oocysts (Lindsay et al., 1993; Dubey et al., 1994). challenge.
Similarly, oral administration of oocysts inactivated by 137Cs
gamma irradiation (0.3 or 0.4 kGy) did not prevent bradyzoite tis- 5.2. Anti-Toxoplasma vaccines for the definitive host
sue cyst formation in pigs challenged with live oocysts (Dubey
et al., 1998). Felids are the only definitive host of T. gondii. After a primary
Extracts or purified fractions of T. gondii parasites in combina- infection with T. gondii, cats may shed millions of oocysts that
tion with adjuvants have been investigated as subunit vaccines. can persist in soil and water as sources of infection for many
109
months/years (Ferguson, 2009). Upon reinfection, few or, more zoites of the RH strain failed to prevent oocyst shedding upon
usually, no oocysts are observed in the faeces of challenged cats challenge with bradyzoites of the heterologous Beverley strain
indicating that, even after a single infection, cats develop an (Omata et al., 1996). Recently, the aforementioned MIC1-3KO
immune response that is able to prevent repeated oocyst shedding strain was investigated as a live attenuated vaccine for cats.
(Dubey, 1995). Moreover, there is evidence that this immunity Although promising results were reported in mice and sheep,
cross-protects against heterologous strains (Freyre et al., 2007). immunisation of cats with tachyzoites of the MIC1-3KO strain by
Thus, although the nature of this immune response is not known, either the subcutaneous or oral route did not protect against oocyst
there are grounds to believe that a vaccine that is able to block shedding (Le Roux et al., 2020).
oocyst shedding by cats would reduce the number of oocysts in There is reason to hope that targeted attenuated vaccines are a
the environment and, consequently, reduce the prevalence of tox- realistic proposition. RNA-sequencing data and analyses of cat
oplasmosis, providing that issues related to vaccine coverage of enteric stages of T. gondii (Behnke et al., 2014; Hehl et al.,
pets and stray or feral cats could be resolved. 2015; Ramakrishnan et al., 2019) have provided valuable insights
Attempts to develop recombinant and subunit vaccines to pre- into genes expressed specifically in merozoites, microgametes
vent the shedding of oocysts by cats have been few and have and macrogametes with presumptive roles in sexual reproduction
shown only limited promise. A recombinant feline herpesvirus and oocyst formation. These studies bring with them the opportu-
type 1 (FHV1) expressing the T. gondii ROP2 protein reduced the nity to design vaccines that specifically target the feline enteric
bradyzoite cyst burden in the brains of cats but failed to prevent stages of T. gondii. Indeed, to establish proof-of-principle, a
oocyst shedding after challenge with bradyzoite-containing cysts CRISPR/Cas9 gene-editing strategy was used to engineer a T. gon-
of the Beverley strain (Mishima et al., 2002). Crude rhoptry pro- dii strain lacking the expression of a putative microgamete-
teins purified from tachyzoites were investigated as a vaccine can- specific fertilisation factor, HAP2 (Ramakrishnan et al., 2019).
didate in combination with the adjuvant Quil A; administration via Infection of rats with HAP2-deficient tachyzoites led to the estab-
the intranasal or rectal routes followed by oral challenge with lishment of chronic infection and tissue cyst development. Pri-
bradyzoite cysts of ME49 strain showed some ability to prevent mary infection of cats with bradyzoite-containing cysts from
oocyst shedding by cats compared with a control group receiving these rats demonstrated that HAP2-deficient T. gondii parasites
BSA and Quil A (Zulpo et al., 2012). Similarly, immunisation of cats were unable to complete fertilisation and, as a result, very few
with recombinant ROP2 plus Quil A via the nasal route reduced the oocysts were produced and those that were had an aberrant mor-
total number of oocysts in only 23.9% of cats compared with the phology and could not undergo meiosis to form infectious sporo-
control group receiving BSA and the adjuvant (Zulpo et al., 2017). zoites within oocysts. Moreover, all cats previously immunised by
In contrast, immunisation of cats by infection with live attenu- infection with the HAP2-deficient T. gondii parasites shed no
ated strains of T. gondii has proven highly effective at preventing oocysts upon challenge with bradyzoite-containing cysts from
oocyst shedding. The T-263 strain of T. gondii, which is a the wild-type parental strain (Ramakrishnan et al., 2019). An
chemically-induced mutant that develops through to micro- and impediment to application of a targeted attenuated vaccine to
macrogametes but lacks the ability to produce oocysts (Dubey, block transmission of T. gondii oocysts is, as it was for the T-
2017), was the first reported live attenuated vaccine investigated. 263 mutant strain, the provision of bradyzoites for immunising
Oral administration of two doses of T-263 tissue cysts or brady- infection of kittens. However, the recent identification of a master
zoites released by pepsin digestion induced antibody responses switch for the conversion of tachyzoites to bradyzoites (Waldman
and prevented oocyst shedding in 84% (Frenkel et al., 1991) or et al., 2020) significantly improves the prospects for development
100% (Freyre et al., 1993) of kittens after challenge with an oocyst of an in vitro ‘‘cell factory” system for the mass production of
producing strain. The efficacy of the live attenuated T-263 strain as bradyzoites.
a transmission-blocking vaccine was also investigated in a long-
term field trial in swine farms in the U.S.A. (Mateus-Pinilla et al.,
1999). Cats present on these swine farms were caught and immu-
nised by infection with bradyzoites of the T-263 strain. Immunisa- 6. Nanotechnology for the control of toxoplasmosis
tion of cats significantly reduced T. gondii infection in finishing pigs
on these farms across time (Mateus-Pinilla et al., 1999). Despite the The use of nanomaterials in medicine has been termed nano-
promising results achieved with the T-263 strain of T. gondii, diffi- medicine (Soares et al., 2018) and, increasingly, nanoparticles
culties associated with large-scale production of bradyzoites, cold are being assessed for inclusion in a range of diagnostic, thera-
chain transportation, and perceived risks to people handling and peutic and preventative applications. Nanomaterials can be
administering the vaccine inhibited its commercialisation defined as organic or inorganic, crystalline or amorphous particles
(Choromanski et al., 1995). in the range of tens to hundreds of nanometres in size (Assolini
Given the manner of its derivation, the T-263 strain of T. gondii et al., 2017; Soares et al., 2018). They can be organised as single
is likely to possess multiple mutations. However, apart from some particles, aggregates, powders, or dispersed in a matrix to form
documentation ~40 years ago of enzymatic perturbations suspensions, emulsions or nanolayer films (Soares et al., 2018).
(Pfefferkorn, 1978; Pfefferkorn and Kasper, 1983), these mutations A consequence of their size is a very large surface area to volume
have not been defined. The advent of next-generation sequencing ratio, making them much more reactive than larger particles. This
approaches may facilitate a better understanding of this strain in gives them a tendency to adsorb biomolecules when in contact
future. Other studies on live vaccines indicate that stage-specific with biological fluids so that a layer known as the corona forms
antigens and administration routes may play an important role on the surface of colloidal nanoparticles. Their size also allows
in the protective immune response against the enteric stages of them to penetrate cells and interact with intracellular molecules.
T. gondii. For example, immunisation by oral or duodenal adminis- Their biological interactions are also influenced by shape, chemi-
tration of T-263 tachyzoites failed to prevent oocyst shedding upon cal composition, surface charge and roughness, allowing them to
subsequent challenge of cats (Freyre et al., 1993). Similarly, immu- be tailor-made for specific targets (Soares et al., 2018). Their
nisation of cats by the intramuscular injection of 60Co-irradiated diversity makes them very versatile and nanoparticles have been
tachyzoites of the Beverley strain prevented oocyst shedding in used to improve diagnostic assays, as a new way of delivering
only 43% of the immunised cats following challenge with homolo- chemotherapy or vaccine formulations, or as therapeutic agents
gous bradyzoites, and immunisation with 60Co-irradiated tachy- and adjuvants themselves.
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6.1. Nanotechnology in the diagnosis of T. gondii infection 6.2. Nanotechnology in the treatment of T. gondii infection
Diagnosis of acute infections with T. gondii is usually through As discussed above, the most commonly used drugs for human
the detection of anti-T. gondii IgM, IgA, IgE or IgG antibodies in toxoplasmosis are sulfadiazine and pyrimethamine, both of which
the serum of patients by ELISA, indirect haemagglutination tests can cause serious side effects such as bone marrow suppression,
or immunosorbent agglutination tests (Ybañez et al., 2020). An allergy and renal and hepatic complications (Gaafar et al., 2014).
increase in IgM, IgA and IgE is considered to be characteristic of Other drugs, including a range of antibiotics and anti-malarials,
an acute infection, whereas detection of only IgG is characteristic have also been used but they can also have serious side effects
of a chronic or previous infection (Ybañez et al., 2020). A major (Abou-El-Naga et al., 2017). The unique physicochemical proper-
drawback to these methods is low sensitivity, which results in ties of nanoparticles can be harnessed to improve delivery of drugs
false negatives. Accurate diagnosis can also be complicated by by altering their pharmacokinetics. This can lead to a slower drug
the presence of immunosuppressed patients who produce very delivery, better target specificity, increased efficacy and a reduc-
low levels of IgM or patients who can produce IgM for up to a tion in side effects (Anand et al., 2015). Drugs that are toxic, or
year after initial infection (Ybañez et al., 2020). A number of stud- have poor solubility, or are easily degraded in the gastrointestinal
ies have aimed to increase the sensitivity of the assays by the tract, can be delivered into the body for more effective treatment at
inclusion of nanoparticles due to increased surface area available lower doses using nanotechnology-based approaches. Nanoparti-
for adsorption of reagents (Medawar-Aguilar et al., 2019). Assays cles have been evaluated both as a way of delivering current
that have been developed include a microfluidic assay using zinc anti-toxoplasmosis treatments more effectively and as anti-
oxide nanoparticles coated with chitosan (Medawar-Aguilar et al., microbial agents themselves (Pissuwan et al., 2009).
2019) and an electrochemical immunosensor consisting of gra- Chitosan is a natural polysaccharide that has been shown to
phene sheets, goldmag (Au-Fe3O4) nanoparticles and thionine have anti-bacterial and anti-malarial effects, and has been investi-
(Jiang et al., 2013). Both of these assays used T. gondii lysate con- gated for anti-Toxoplasma effects (Teimouri et al., 2018). Low
jugated to the nanoparticles to capture anti-T. gondii antibodies in molecular weight (86 kDa), medium molecular weight (234 kDa)
serum samples and demonstrated increased sensitivity compared and high molecular weight (353 kDa) nanoparticles were synthe-
with conventional sandwich ELISAs. Li et al. (2015) used goldmag sised and tested against RH strain T. gondii in vitro and in vivo.
nanoparticles modified with polymethacrylic acid conjugated Anti-T. gondii activity was demonstrated in vitro with all nanopar-
with anti-human IgM antibodies in a lateral flow immunochro- ticle sizes but killing of exposed tachyzoites was fastest with low
matographic assay (LFIA) to test for the TORCH pathogens (Toxo- molecular weight nanoparticles. Smaller nanoparticles also per-
plasma, rubella virus, cytomegalovirus and herpes simplex virus) formed best in an in vivo model, resulting in a significant drop in
in pregnant women (Li et al., 2015). This assay also displayed parasite burden compared with infected, untreated mice; however,
increased sensitivity and specificity compared with commercially they were not as effective as treatment with sulfadiazine (Teimouri
available LFIA assays. TORCH pathogens were also targeted in the et al., 2018). Addition of anti-T. gondii drugs to chitosan nanoparti-
development of a microarray using quantum dots (photolumines- cles did, however, increase effectiveness of parasite killing com-
cent nanomaterials) coated with antigens to detect infections in pared with chitosan or the drug alone. Spiramycin is an
serological samples (Yang et al., 2009). This assay had comparable antibiotic that is used to treat toxoplasmosis in pregnant women
sensitivity and specificity to conventional ELISA but had the but is limited in its effectiveness by low bioavailability and an
advantage of a shorter run time and a more stable signal (Yang inability to cross the blood–brain barrier. Loading of spiramycin
et al., 2009). into chitosan nanoparticles increased its absorption and perme-
Toxoplasmosis can also be diagnosed through direct detection ation, increasing survival time and reducing parasite burden in
of T. gondii. This is particularly useful in immunocompromised mice compared with spiramycin or chitosan nanoparticles alone.
patients where a serological response is reduced and there is the The inflammatory response to infection was lessened in the treated
risk of false negative results. These tests can be developed to detect animals and the parasites that were isolated showed morphologi-
either DNA or antigens of the parasite. As with assays to detect cal deformities, indicating a direct effect of the spiramycin-
antibodies, nanoparticles were used to increase the sensitivity of chitosan nanoparticles on the parasites themselves (Etewa et al.,
diagnostic assays that detect parasite antigen. Aly et al. (2018) 2018; Hagras et al., 2019). Similarly, Abou-El-Naga et al. (2017)
used silica particles coated with polyclonal antibodies to T. gondii found that administration of the anti-retroviral lopinvar/ritonavir
lysate to detect circulating parasite antigen in serological and urine combination encapsulated in polylactic-co-glycolic acid (PLGA)
samples. Sensitivity was increased from 85.7% to 90% for serum nanoparticles to mice infected with T. gondii reduced parasite bur-
samples and 78.6% to 82.6% in urine samples (Aly et al., 2018). den significantly compared with administration as free drug. Infec-
Hegazy et al. (2015) used immunomagnetic beads coated with tivity of tachyzoites exposed to lopinvar/ritonavir in PLGA
antibodies to SAG1 to detect parasite antigens in serological sam- nanoparticles was also reduced significantly compared with tachy-
ples, increasing sensitivity from 92% to 98%. Xu et al. (2013) devel- zoites from mice treated with free drug, although mortality rates in
oped a probe using nickel-magnetic nanoparticles and fluorescence the two groups were not significantly different (Abou-El-Naga
resonance energy transfer to detect T. gondii DNA, although it et al., 2017).
should be noted that the probe was not validated using patient Mixed results have been seen with other potential anti-Toxo-
samples. It is unlikely that sensitivity of this probe would exceed plasma drugs loaded into nanoparticles, with effects seemingly
that of the real-time PCR assay developed by Lin et al. (2000), lim- dependent on the pharmacokinetics of individual drugs. Triclosan,
iting its usefulness. an inhibitor of fatty acid synthesis, is a drug with promising activ-
In addition to increased sensitivity and specificity of diagnostic ity against protozoan parasites in vitro, but its poor solubility has
tests incorporating nanoparticles, the speed, cost and convenience limited its use in vivo. Loading triclosan into nanoparticles
were also often improved compared with existing tests. These comprised of lipids (liposomes) significantly reduced parasite
improvements have led to a more accurate diagnosis and faster burden in mice infected with a virulent strain of T. gondii compared
implementation of appropriate treatments for patients identified with triclosan alone (El-Zawawy et al., 2015a). Surprisingly, similar
as suffering from toxoplasmosis. experiments using an avirulent strain of T. gondii found no
111
difference in parasite burden after treatment with triclosan in lipo- effective against T. gondii in chronically infected mice (Keyhani
somes compared with triclosan alone, although both groups had et al., 2020). A significant reduction in brain cysts was seen in
significant reductions in parasite burden compared with infected, chronically infected mice treated for 14 days with the selenium
untreated mice (El-Zawawy et al., 2015b). This may indicate a T. nanoparticles compared with untreated mice, although complete
gondii strain effect on the mode of action of the drug, although dif- elimination was not achieved. No toxicity was observed in the mice
ferent doses of triclosan and triclosan/liposomes were used in the although mRNA levels of inflammatory cytokines were raised, and
studies, complicating comparisons. Bottari et al., (2015) compared the authors speculated that the reason for the decrease in brain
brain cyst burdens in mice infected with T. gondii then treated with cysts was due to induction of an inflammatory response by sele-
sulfamethoxazole/trimethoprim and reseveratrol packaged into nium (Keyhani et al., 2020). Another study by the same group
nanoparticles or as free drug. They found a significant reduction showed that biogenic selenium nanoparticles administered prior
in cyst burden in mice treated with sulfamethoxazole/trimetho- to infection could significantly reduce parasite burden in a model
prim and resveratrol compared with mice treated with sul- of acute toxoplasmosis (Shakibaie et al., 2020).
famethoxazole/trimethoprim only, but there was no significant Toxicity can be an issue with metal nanoparticles as they are
difference between the two delivery methods of reseveratrol not biodegradable like other types, such as chitosan or liposomes,
(Bottari et al., 2015). and can accumulate in organs. However, the nanoparticles tested
Chitosan nanoparticles have also been combined with silver to date display toxicity towards the parasite and, apart from one
nanoparticles to increase their efficacy (Gaafar et al., 2014). Mice study (Adeyemi et al., 2018b), show little toxicity towards host
infected with T. gondii were treated with pyrimethamine, chitosan cells in vitro or in vivo. The alterations that packaging drugs in
nanoparticles, silver nanoparticles, or a combination of chitosan nanoparticles makes to the pharmacokinetics of those drugs may
and silver nanoparticles. Parasite burden was significantly reduced lead to lower doses being effective. This, in turn, gives hope that
after treatment with silver nanoparticles or the combination of sil- this approach will lead to more effective treatments with fewer
ver and chitosan nanoparticles, pyrimethamine or chitosan parti- side effects for patients. However, it does need to be acknowledged
cles. However, there was no significant difference between silver that nanoparticles can compromise pregnancy (Park et al., 2013;
nanoparticles and the combination of silver and chitosan nanopar- Elsharawy et al., 2020) and this will potentially limit their utility
ticles, suggesting it is the silver nanoparticles that had the anti-T. in control of congenital toxoplasmosis.
gondii effect (Gaafar et al., 2014). This finding is supported by
in vitro studies with gold, silver and platinum nanoparticles by 6.3. Nanotechnology in vaccines against T. gondii infection
Adeyemi et al. (2017) who found tachyzoite viability was reduced
by 90% in the presence of the metallic nanoparticles. The selectivity Immunogenicity is an issue with subunit and DNA vaccines. The
index was 20, indicating marked toxicity towards the parasite plasmids and antigens that make up these vaccines are prone to
without affecting the host cells. Silver and gold nanoparticles were enzymatic degradation and can be poorly taken up by the relevant
more effective than platinum at killing the parasites (Adeyemi cells so that only a weak immune response is stimulated (Maeta
et al., 2017). In a subsequent study, T. gondii parasites exposed to et al., 2020). Nanoparticles can act as adjuvants and have been
metallic nanoparticles were impaired in converting from tachy- shown to increase immunogenicity of a number of T. gondii anti-
zoite to bradyzoite in vitro (Adeyemi et al., 2019), suggesting that gens that have potential as vaccine candidates including ROP18
metallic nanoparticles target both tachyzoites and bradyzoites. (Nabi et al., 2017) and SAG1 (Naeem et al., 2018). Peptides corre-
Killing of parasites was linked to the production of reactive oxygen sponding to epitopes of key antigens (SAG1, AMA1, ROP2 and
species stimulated by the metal nanoparticles (Adeyemi et al., GRA4) have been encapsulated in nanoparticles and tested for
2017, 2019). A further study using combinations of the metals con- immunogenicity (Roozbehani et al., 2018). Unlike commonly used
firmed their anti-T. gondii activity but noted some potential safety adjuvants, such as alum, nanoparticles appear able to induce cellu-
concerns since the selectivity index of effect on parasite versus lar and humoral responses that are more likely to produce a pro-
host cells was 2-fold (Adeyemi et al., 2018b). tective response. Another benefit of encapsulating subunit
Recently, plant extracts have been used as stabilising or reduc- vaccines in nanoparticles is that encapsulation can guard against
ing agents in the preparation of so-called ‘‘biogenic” nanoparticles. degradation. In addition to this, nanoparticles can be targeted for
This manufacturing method has the advantages of being more cost delivery to certain cells by the adsorption of antibodies on their
effective, producing less toxic waste, and generating more reactive surfaces, and lower amounts of DNA and protein can be used in
nanoparticles. Coating the particles with plant molecules also the formulation, reducing the risk of toxicity and side effects
increases their biocompatibility (Sharma et al., 2019). Alajmi (Wang et al., 2019).
et al. (2019) used extracts of date seeds and nabka leaves to pro- The properties of nanoparticles allow efficient delivery of vac-
duce biogenic silver nanoparticles and examined their effect on cine candidates via routes other than subcutaneous or intramuscu-
survival rate and hepatic damage in mice infected with T. gondii. lar. Dimier-Poisson et al. (2015) used nasal delivery to immunise
Mice treated with the biogenic nanoparticles or sulfadiazine sur- mice with a total extract T. gondii antigens loaded onto nanoparti-
vived for longer than infected, untreated mice. Mice given the bio- cles made of maltodextrin and challenged mice with lethal and
genic silver particles showed less signs of hepatic damage due to chronic doses of T. gondii. All mice immunised with the antigen/-
the infection but the mortality rate was higher than in mice given nanoparticle combination survived a lethal challenge infection
sulfadiazine (Alajmi et al., 2019). This treatment may have been and had reduced cyst burdens in the chronic model compared with
more effective if a less virulent strain of T. gondii had been used mice immunised with antigen alone. Ducournau et al. (2017) found
for the experiments. Machado et al. (2020) created biogenic silver the same formulation could also reduce vertical transmission in
nanoparticles with the fungus, Fusarium oxysporum, and assessed immunised mice infected during pregnancy.
their effect on T. gondii in vitro. Treatment with the nanoparticles DNA vaccines can stimulate a cellular response that is most
significantly reduced the ability of parasites to invade and prolifer- effective for intracellular pathogens (Maeta et al., 2020) and
ate inside HeLa cells (Machado et al., 2020). These results were nanoparticles have been shown to increase their effectiveness.
consistent with those obtained by Gaafar et al. (2014) and Issues affecting the success of DNA vaccines include degradation
Adeyemi et al. (2017), although how the silver nanoparticles are of the DNA by extracellular nucleases, poor uptake by cells, and
damaging the parasite remains to be determined. Biogenic sele- inability to escape the endosome once inside the cell (Maeta
nium nanoparticles created with Bacillus were also found to be et al., 2020). Nanoparticles protect DNA from degradation during
112
delivery and are more easily taken up by macrophages. Addition of Protection of food and water from contamination with T. gondii
calcium phosphate nanoparticles to DNA vaccine formulations is a requisite for control of human toxoplasmosis. Biosecurity mea-
based on GRA14 and ROM4 have been shown to increase their sures to minimise the presence of cats and rodents on farms is
immunogenicity in mice and prolong survival against a challenge important, particularly since post-harvest detection and removal
with T. gondii RH (Ahmadpour et al., 2017; Rahimi et al., 2017; of the parasite in or on food is not straightforward. Availability of
Pagheh et al., 2019). Maeta et al. (2020) were also able to demon- water that is oocyst-free is absolutely essential, not just for human
strate significant protection against T. gondii in mice immunised consumption but also for raising livestock and producing crops. By
with DNA encoding T. gondii profilin encapsulated in liposomal 2020, access to clean water should be a right, not a privilege but,
nanocarriers. sadly, this is not the case and it is no coincidence that the signifi-
A risk with DNA vaccines is their potential integration into the cant incidence of toxoplasmosis traceable to oocyst-derived infec-
host genome. To overcome this possibility, a modified dendrimer tion is often linked to socio-economic status (Bahia-Oliveira et al.,
nanoparticle that encapsulated RNA encoding for six T. gondii anti- 2003; Carellos et al., 2014; Singh et al., 2014; Mareze et al., 2019;
gens (GRA6, ROP2A, ROP18, SAG1, SAG2A and AMA1) was devel- Shapiro et al., 2019). Thus, a genuine global effort to address pov-
oped. This vaccine was able to stimulate a cellular adaptive erty and ensure provision of clean water for all people would go a
immune response and protect mice against a lethal challenge with long way to reducing the incidence of toxoplasmosis.
T. gondii (Chahal et al., 2016). Luo et al. (2017) also encased RNA Timely treatment following diagnosis of infection with T. gondii
coding for T. gondii NTPase II in synthetic lipid nanoparticles and is important, particularly for pregnant women and immunosup-
found a significantly increased cellular and humoral response in pressed people – it saves lives even if current drugs do not possess
mice immunised with the RNA in lipid nanoparticles compared all the characteristics and efficacy of the ideal therapy. The pro-
with the RNA alone. Mice immunised with the nanoparticles had spects for new, better targeted drugs are real, fueled by insights
prolonged survival rates when challenged with T. gondii RH into the parasite’s genome, transcriptome and biochemistry. Addi-
although there was no significant advantage conferred by the tionally, nanotechnological advances have the potential to improve
nanoparticles when mice were challenged with T. gondii Pru. Cyst delivery of existing and future chemotherapeutic agents. Similarly,
burden was reduced compared with untreated, infected mice but new insights into the immunobiology of toxoplasmosis are paving
was not significantly different from mice immunised with only the way for the development of immunotherapeutics, particularly
the RNA (Luo et al., 2017). to prevent toxoplasmic encephalitis resulting from
As was noted for diagnostic tests and administration of thera- immunosuppression.
peutic drugs, nanoparticles have the potential to increase the effec- Live attenuated vaccines have proven to be effective in both
tiveness of vaccine formulations and, therefore, should be intermediate and definitive hosts of T. gondii but subunit vaccines
considered for inclusion in any development of vaccines to target have not. This probably tells us something about the importance of
toxoplasmosis. cell-mediated immunity in both intermediate and definitive hosts
(Innes et al., 2019), and perhaps also exposes our current lack of
understanding and options for antigen presentation in the delivery
7. Concluding remarks of subunit vaccines; nanotechnology may help address this. In the
meantime, recent research has utilised the availability of robust
Toxoplasma gondii has been described, with justification, as ‘‘the data sets for the genome and transcriptomes of T. gondii, combined
world’s most successful parasite” and ‘‘the model apicomplexan” with the gene editing power of CRISPR/Cas9 protocols to demon-
(Weiss and Kim, 2020). It is a parasite that can seemingly infect strate that: (i) single transcription factors largely control the
any nucleated cell in any warm-blooded animal, has spread across switch to sexual stage development (Farhat et al., 2020) and brady-
the Earth from origins in South America, adapting to human agri- zoite development (Waldman et al., 2020) in T. gondii; and (ii) kit-
cultural development in the process, and causes only minor, if tens can be rendered totally incapable of transmitting viable
any, symptoms in the majority of its hosts. However, the sheer oocysts following immunisation with a parasite strain gene-
enormity of the numbers of people and animals infected with this edited to prevent expression of a parasite fertilisation factor
parasite make it one of the most globally significant zoonotic dis- (Ramakrishnan et al., 2019). The discovery of a master-regulator
eases. On health, economic and ecological grounds, the control of of conversion of tachyzoites to bradyzoites opens the door to
toxoplasmosis is therefore a necessity, not a luxury. development of an attenuated vaccine for intermediate hosts that
The success of T. gondii is underpinned by an exquisitely com- will have an inbuilt safeguard of not being able to progress into a
plex life cycle, which means that the manifestations of toxoplas- long-lived tissue cyst. This is particularly attractive since cultiva-
mosis are also complex. Public education is, therefore, critically tion of tachyzoites in vitro is not difficult and may well be amen-
important, notwithstanding doubts about its effectiveness. It is able to commercial scale-up. This same discovery also paves the
particularly important for pregnant women and immunocompro- way for potential scale-up of in vitro production of bradyzoites,
mised people but it must be clever, informative, detailed and prac- which would enable two things: first, the development of high-
tical enough to enable clear communication between medical throughput approaches for the discovery and testing of drugs to
professionals and their patients, and to encourage adherence to treat chronic infection with T. gondii, treatments for which we lack
measures and habits that will reduce exposure to oocysts and cysts currently; and second, an in vitro mass production system for
of T. gondii for those most at risk. Additionally, freely available bradyzoites, which could overcome one of the main obstacles to
accurate and practical information about toxoplasmosis is useful the implementation of a transmission-blocking vaccine program
for both medical professionals and the general public. There is for cats using attenuated parasites. A vaccine to stop transmission
some evidence that this can have an effect since education is con- of oocysts of T. gondii is attractive because it targets the core of the
sidered at least partly responsible for an apparent reduction, over life cycle of T. gondii – without sexual reproduction and oocysts, all
recent decades, in prevalence of infection with T. gondii in, e.g., routes of infection with this parasite ultimately cease to exist.
the U.S.A. (Jones et al., 2007, 2014), the Netherlands (Hofhuis Completely preventing transmission of oocysts worldwide is,
et al., 2011), France (Nogareda et al., 2014) and Germany seemingly, impossible as vaccine coverage of all pet, community,
(Wilking et al., 2016), particularly through improved understand- stray and wild cats is a challenge that would necessitate delivery
ing of food and water hygiene. technologies and regimens we have not yet imagined. But, similar
113
to the provision of clean water for all, it is surely an ambition Amberg-Johnson, K., Yeh, E., 2019. Host cell metabolism contributes to delayed-
death kinetics of apicoplast inhibitors in Toxoplasma gondii. Antimicrob. Agents
worth our effort.
Chemother. 63. e01646-e1718.
Amiar, S., Katris, N.J., Berry, L., Dass, S., Duley, S., Arnold, C.-S., Shears, M.J., Brunet, C.,
Acknowledgements Touquet, B., McFadden, G.I., Yamaryo-Botté, Y., Botté, C.Y., 2020. Division and
adaptation to host environment of apicomplexan parasites depend on
apicoplast lipid metabolic plasticity and host organelle remodeling. Cell Rep.
We apologise to colleagues whose work we may have over- 30. 3778-3792.e9.
looked and not cited in this review. NCS is very grateful for Anand, N., Sehgal, R., Kanwar, R.K., Dubey, M.L., Vasishta, R.K., Kanwar, J.R., 2015.
research support from the National Health and Medical Research Oral administration of encapsulated bovine lactoferrin nanocapsules against
intracellular parasite Toxoplasma gondii. Int. J. Nanomed. 10, 6355–6369.
Council (NHMRC) of the Australian Government (Project Grant Andiappan, H., Nissapatorn, V., Sawangjaroen, N., Khaing, S.L., Salibay, C.C., Cheung,
GNT1128911) and AK is thankful for a Career Development Level M.M., Dungca, J.Z., Chemoh, W., Xiao Teng, C., Lau, Y.L., Mat Adenan, N.A., 2014.
1 Fellowship from the NHMRC (GNT1140709). GGvD is also grate- Knowledge and practice on Toxoplasma infection in pregnant women from
Malaysia, Philippines, and Thailand. Front. Microbiol. 5, 291.
ful to the Australian Government for research grants from the Arakaki, R., Yamasaki, T., Kanno, T., Shibasaki, N., Sakamoto, H., Utsunomiya, N.,
NHMRC (GNT1182369) and the Australian Research Council Sumiyoshi, T., Shibuya, S., Tsuruyama, T., Nakamura, E., Ogawa, O., Kamba, T.,
(DP200100483). These funders played no role in interpretation of 2016. CCL2 as a potential therapeutic target for clear cell renal cell carcinoma.
Cancer Med. 5, 2920–2933.
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