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Arafa FM, Mogahed NMFH, Eltarahony MM, Diab RG. Biogenic selenium nanoparticles: trace element with promising anti-toxoplasma effect. Pathog Glob Health 2023; 117:639-654. [PMID: 36871204 PMCID: PMC10498805 DOI: 10.1080/20477724.2023.2186079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Toxoplasmosis is an opportunistic infection caused by the coccidian Toxoplasma gondii which represents a food and water contaminant. The available chemotherapeutic agents for toxoplasmosis are limited and the choice is difficult when considering the side effects. Selenium is an essential trace element. It is naturally found in dietary sources, especially seafood, and cereals. Selenium and selenocompounds showed anti-parasitic effects through antioxidant, immunomodulatory, and anti-inflammatory mechanisms. The present study evaluated the potential efficacy of environmentally benign selenium nanoparticles (SeNPs) against acute toxoplasmosis in a mouse model. SeNPs were fabricated by nanobiofactory Streptomyces fulvissimus and characterized by different analytical techniques including, UV-spectrophotometry, transmission electron microscopy, EDX, and XRD. Swiss albino mice were infected with Toxoplasma RH strain in a dose of 3500 tachyzoites in 100 μl saline to induce acute toxoplasmosis. Mice were divided into five groups. Group I: non-infected, non-treated, group II: infected, non-treated, group III: non-infected, treated with SeNPs, group IV: infected, treated with co-trimoxazole (sulfamethoxazole/trimethoprim) and group V: infected, treated with SeNPs. There was a significant increase in survival time in the SeNPs-treated group and minimum parasite count was observed compared to untreated mice in hepatic and splenic impression smears. Scanning electron microscopy showed tachyzoites deformity with multiple depressions and protrusions, while transmission electron microscopy showed excessive vacuolization and lysis of the cytoplasm, especially in the area around the nucleus and the apical complex, together with irregular cell boundary and poorly demarcated cell organelles. The present study demonstrated that the biologically synthesized SeNPs can be a potential natural anti-Toxoplasma agent in vivo.
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Affiliation(s)
- Fadwa M. Arafa
- Department of Medical Parasitology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nermine M. F. H. Mogahed
- Department of Medical Parasitology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Marwa M. Eltarahony
- Environmental Biotechnology Department, Genetic Engineering and Biotechnology Research Institute (GEBRI), City of Scientific Research and Technological Applications (SRTA-City), Universities and Research centers District, Alexandria, Egypt
| | - Radwa G. Diab
- Department of Medical Parasitology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Anacleto-Santos J, Calzada F, López-Camacho PY, López-Pérez TDJ, Carrasco-Ramírez E, Casarrubias-Tabarez B, Fortoul TI, Rojas-Lemus M, López-Valdés N, Rivera-Fernández N. Evaluation of the Anti- Toxoplasma gondii Efficacy, Cytotoxicity, and GC/MS Profile of Pleopeltis crassinervata Active Subfractions. Antibiotics (Basel) 2023; 12:antibiotics12050889. [PMID: 37237792 DOI: 10.3390/antibiotics12050889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Pleopeltis crassinervata (Pc) is a fern that, according to ethnobotanical records, is used in Mexican traditional medicine to treat gastrointestinal ailments. Recent reports indicate that the hexane fraction (Hf) obtained from Pc methanolic frond extract affects Toxoplasma gondii tachyzoite viability in vitro; therefore, in the present study, the activity of different Pc hexane subfractions (Hsf) obtained by chromatographic methods was evaluated in the same biological model. Gas chromatography/mass spectrometry (GC/MS) analysis was carried out for hexane subfraction number one (Hsf1), as it showed the highest anti-Toxoplasma activity with a half-maximal inhibitory concentration (IC50) of 23.6 µg/mL, a 50% cytotoxic concentration (CC50) of 398.7 µg/mL in Vero cells, and a selective index (SI) of 16.89. Eighteen compounds were identified by Hsf1 GC/MS analysis, with the majority being fatty acids and terpenes. Hexadecanoic acid, methyl ester was the most commonly found compound (18.05%) followed by olean-13(18)-ene, 2,2,4a,8a,9,12b,14a-octamethyl-1,2,3,4,4a,5,6,6a,6b,7,8,8a,9,12,12a,12b,13,14,14a,14b-eicosahydropicene, and 8-octadecenoid acid, methyl ester, which were detected at 16.19%, 12.53%, and 12.99%, respectively. Based on the mechanisms of action reported for these molecules, Hsf1 could exert its anti-Toxoplasma activity mainly on T. gondii lipidomes and membranes.
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Affiliation(s)
- Jhony Anacleto-Santos
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Fernando Calzada
- Unidad de Investigación Médica en Farmacología, Unidad Médica de Alta Especialidad, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Col. Doctores, Cuauhtémoc 06725, Mexico
| | - Perla Yolanda López-Camacho
- Unidad Cuajimalpa, Departamento de Ciencias Naturales, Universidad Autónoma Metropolitana (UAM), Cuajimalpa 05348, Mexico
| | - Teresa de Jesús López-Pérez
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Elba Carrasco-Ramírez
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Brenda Casarrubias-Tabarez
- Departamento de Biología Celular y Tisular, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Teresa I Fortoul
- Departamento de Biología Celular y Tisular, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Marcela Rojas-Lemus
- Departamento de Biología Celular y Tisular, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Nelly López-Valdés
- Departamento de Biología Celular y Tisular, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
| | - Norma Rivera-Fernández
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Mexico City 04510, Mexico
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Ghanadian M, Khamesipour F, Hejazi SH, Razavi SM, Sadraei H, Namdar F. In Vitro and In Vivo Anti-Toxoplasma Activities of Dracocephalum kotschyi Extract in Experimental Models of Acute Toxoplasmosis. Acta Parasitol 2022; 67:487-495. [PMID: 34800216 DOI: 10.1007/s11686-021-00491-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/26/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The problem of resistance to antiparasitic drugs, associated with their side effects, suggest exploring other alternatives, including medicinal plants. Dracocephalum kotschyi (D. kotschyi), for example, from Lamiaceae family, is a plant widely used in Iran and in many countries, and to which interesting pharmacological properties have been attributed. This study aimed to investigate in vitro and in vivo anti-Toxoplasma activities of D. kotschyi extract in experimental models of acute toxoplasmosis. METHODS Anti-Toxoplasma activity of the extracts in vitro was performed on Vero Cell, using the MTT test. Vero cell were infected with (3 × 105 tachyzoites/well) following treatment with Dichloromethane (F1), dichloromethane: methanol (F2), methanol (F3), methanol: water (F4), and deionized water (F5) extracts of D. kotschyi, and pyrimethamine and sulfadiazine (positive control). MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) was used to measure cell viability. Effects of extracts on tachyzoites viability were evaluated by trypan blue exclusion method, followed by light microscopy. For in vivo test, 18 groups of 8-10-week-old Inbred Balb/c mice weighing 18-20 g, were intraperitoneally infected with 2 × 103 tachyzoites and then treated with sterile PBS (negative control), pyrimethamine (25 mg/kg) and sulfadiazine (500 mg/kg) as positive controls, and F1 to F5 extracts (at doses 50, 100 and 200 mg/kg). RESULTS The 50% Inhibitory Concentration of F1 extract, F2 extract, Sulfadiazine (Positive control) and Pyrimethamine (Positive control) were 8.77 µg, 7.1 µg 391.18 µg, and 84.20 µg, respectively, while the selectivity indices were 15.667, 30.197, 1.552 and 4.064, respectively. In vivo anti-Toxoplasma activity test showed that Methanol: water (F-4) 50 extract was more active than the positive control. CONCLUSIONS Indeed, the extract allowed a survival rate of 10% of the mice, compared to 0% for all the other groups. D. kotschyi has the potential to be valorized in the management of toxoplasmosis.
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Affiliation(s)
- Mustafa Ghanadian
- Department of Pharmacognosy, Isfahan Pharmaceutical Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Faham Khamesipour
- Department of Pathobiology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran.
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran.
| | - Seyed Hossein Hejazi
- Department of Parasitology and Mycology, Skin Diseases and Leishmaniasis Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Mostafa Razavi
- Department of Pathobiology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Hassan Sadraei
- Isfahan Pharmaceutical Sciences Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Namdar
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
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Anacleto-Santos J, López-Camacho P, Mondragón-Flores R, Vega-Ávila E, Islas GB, Mondragón-Castelán M, Carrasco-Ramírez E, Rivera-Fernández N. Anti-toxoplasma, antioxidant and cytotoxic activities of Pleopeltis crassinervata (Fée) T. Moore hexane fraction. Saudi J Biol Sci 2019; 27:812-819. [PMID: 32127756 PMCID: PMC7042671 DOI: 10.1016/j.sjbs.2019.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 12/12/2019] [Accepted: 12/22/2019] [Indexed: 12/31/2022] Open
Abstract
The apicomplexan parasite Toxoplasma gondii (T. gondii) causes toxoplasmosis in humans. Pyrimethamine and sulfadiazine that are the drugs of choice to treat the disease, produce severe side effects as well as failure treatments because of drug resistance; thus, novel anti-Toxoplasma compounds are needed and natural compounds can be a good source to obtain them, as medicinal plants have been used to control other apicomplexan parasites. Pleopeltis crassinervata (P. crassinervata) is a fern used in some rural areas of Mexico to treat among other malaises, mouth ulcers, gastrointestinal problems and parasites. Therefore, the efficacy of extracts and fractions obtained from P. crassinervata fronds was evaluated on the viability of T. gondii RH strain tachyzoites by the Stytox green method. RH is the prototypical type 1 Toxoplasma strain, isolated for the first time from the brain of a patient boy named R. H. Its phytochemical profile, MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay, Hep-2 cytotoxicity and antioxidant activity by ABTS (2,2′-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) and DPPH (2,2-diphenyl-1-picrylhydrazyl) methods, were also assessed. Hexane fraction exhibited the highest anti-Toxoplasma activity with an IC50 of 16.90 µg/mL. This fraction did not show antioxidant activity and contained at least 2 terpenoid type compounds with retention factor (Rf) of 0.75 and 0.86. The fraction was not toxic to the host cells in doses up to 50 µg/mL. P. crassinervata frond hexane fraction seems to be a good candidate to obtain possible anti-Toxoplasma compounds. This study is the first to report the biological, antioxidant and cytotoxic activity of P. crassinervata fern.
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Affiliation(s)
- Jhony Anacleto-Santos
- Doctorado en Ciencias Biológicas y de la Salud, Departamento de Ciencias Naturales e Ingeniería, Universidad Autónoma Metropolitana, Cuajimalpa 05370, CDMX, México
| | - Perla López-Camacho
- Departamento de Ciencias Naturales e Ingeniería, Universidad Autónoma Metropolitana, Cuajimalpa 05370, CDMX, México
| | - Ricardo Mondragón-Flores
- Departamento de Bioquímica, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN), Col Zacatenco 07360, CDMX, México
| | - Elisa Vega-Ávila
- Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana, Iztapalapa 09340, CDMX, México
| | - Gustavo Basurto Islas
- Departamento de Ingenierías, Química, Electrónica y Biomédica, Universidad de Guanajuato Mex, Campus León, México
| | - Mónica Mondragón-Castelán
- Departamento de Bioquímica, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN), Col Zacatenco 07360, CDMX, México
| | - Elba Carrasco-Ramírez
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, 04510 CDMX, México
| | - Norma Rivera-Fernández
- Departamento de Microbiología y Parasitología, Facultad de Medicina, Universidad Nacional Autónoma de México, 04510 CDMX, México
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Deng Y, Wu T, Zhai SQ, Li CH. Recent progress on anti-Toxoplasma drugs discovery: Design, synthesis and screening. Eur J Med Chem 2019; 183:111711. [PMID: 31585276 DOI: 10.1016/j.ejmech.2019.111711] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/27/2019] [Accepted: 09/16/2019] [Indexed: 01/30/2023]
Abstract
Toxoplasma gondii severely threaten the health of immunocompromised patients and pregnant women as this parasite can cause several disease, including brain and eye disease. Current treatment for toxoplasmosis commonly have high cytotoxic side effects on host and require long durations ranging from one week to more than one year. The regiments lack efficacy to eradicate T. gondii tissue cysts to cure chromic infection results in the needs for long treatment and relapsing disease. In addition, there has not been approved drugs for treating the pregnant women infected by T. gondii. Moreover, Toxoplasma vaccine researches face a wide variety of challenges. Developing high efficient and low toxic agents against T. gondii is urgent and important. Over the last decade, tremendous progress have been made in identifying and developing novel compounds for the treatment of toxoplasmosis. This review summarized and discussed recent advances between 2009 and 2019 in exploring effective agents against T. gondii from five aspects of drug discovery.
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Affiliation(s)
- Yu Deng
- Institute of Veterinary Sciences & Pharmaceuticals, Chongqing Academy of Animal Sciences, Rongchang, 402460, China
| | - Tao Wu
- Institute of Veterinary Sciences & Pharmaceuticals, Chongqing Academy of Animal Sciences, Rongchang, 402460, China
| | - Shao-Qin Zhai
- Institute of Veterinary Sciences & Pharmaceuticals, Chongqing Academy of Animal Sciences, Rongchang, 402460, China
| | - Cheng-Hong Li
- Institute of Veterinary Sciences & Pharmaceuticals, Chongqing Academy of Animal Sciences, Rongchang, 402460, China.
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Anti-parasitic effect on Toxoplasma gondii induced by a spider peptide lycosin-I. Exp Parasitol 2019; 198:17-25. [DOI: 10.1016/j.exppara.2019.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 11/30/2018] [Accepted: 01/20/2019] [Indexed: 12/21/2022]
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Mycophenolic acid induces differentiation of Toxoplasma gondii RH strain tachyzoites into bradyzoites and formation of cyst-like structure in vitro. Parasitol Res 2018; 117:547-563. [DOI: 10.1007/s00436-017-5738-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
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Isopropyl quinoxaline-7-carboxylate 1,4-di-N-oxide derivatives induce regulated necrosis-like cell death on Leishmania (Leishmania) mexicana. Parasitol Res 2017; 117:45-58. [PMID: 29159705 DOI: 10.1007/s00436-017-5635-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/25/2017] [Indexed: 02/03/2023]
Abstract
Leishmaniasis is a neglected tropical disease caused by the parasite of the genus Leishmania. About 13 million people are infected worldwide, and it is estimated that 350 million are at risk of infection. Clinical manifestations depend on the parasite species and factors related to the host such as the immune system, nutrition, housing, and financial resources. Available treatments have severe side effects; therefore, research currently focuses on finding more active and less toxic compounds. Quinoxalines have been described as promising alternatives. In this context, 17 isopropyl quinoxaline-7-carboxylate 1,4-di-N-oxide derivatives were evaluated as potential leishmanicidal agents. Their effect on the cell metabolism of Leishmania mexicana promastigotes and their cytotoxic effects on the J774.A1 cell line and on erythrocytes were evaluated, and their selectivity index was calculated. Compounds T-069 (IC50 = 1.49 μg/mL), T-070 (IC50 = 1.71 μg/mL), T-072 (IC50 = 6.62 μg/mL), T-073 (IC50 = 1.25 μg/mL), T-085 (IC50 = 0.74 μg/mL), and T-116 (IC50 = 0.88 μg/mL) were the most active against L. mexicana promastigotes and their mechanism of action was characterized by flow cytometry and microscopy. Compound T-073, the most selective quinoxaline derivative, induced cell membrane damage, phosphatidylserine exposition, reactive oxygen species production, disruption of the mitochondrion membrane potential, and DNA fragmentation, all in a dose-dependent manner, indicating the induction of regulated necrosis. Light and transmission electron microscopy showed the drastic morphological changes induced and the mitochondrion as the most sensitive organelle in response to T-073. This study describes the mechanism by which active isopropyl quinoxaline-7-carboxylate 1,4-di-N-oxide quinoxalines affect the parasite.
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Montazeri M, Sharif M, Sarvi S, Mehrzadi S, Ahmadpour E, Daryani A. A Systematic Review of In vitro and In vivo Activities of Anti -Toxoplasma Drugs and Compounds (2006-2016). Front Microbiol 2017; 8:25. [PMID: 28163699 PMCID: PMC5247447 DOI: 10.3389/fmicb.2017.00025] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/05/2017] [Indexed: 11/23/2022] Open
Abstract
The currently available anti-Toxoplasma agents have serious limitations. This systematic review was performed to evaluate drugs and new compounds used for the treatment of toxoplasmosis. Data was systematically collected from published papers on the efficacy of drugs/compounds used against Toxoplasma gondii (T. gondii) globally during 2006-2016. The searched databases were PubMed, Google Scholar, Science Direct, ISI Web of Science, EBSCO, and Scopus. One hundred and eighteen papers were eligible for inclusion in this systematic review, which were both in vitro and in vivo studies. Within this review, 80 clinically available drugs and a large number of new compounds with more than 39 mechanisms of action were evaluated. Interestingly, many of the drugs/compounds evaluated against T. gondii act on the apicoplast. Therefore, the apicoplast represents as a potential drug target for new chemotherapy. Based on the current findings, 49 drugs/compounds demonstrated in vitro half-maximal inhibitory concentration (IC50) values of below 1 μM, but most of them were not evaluated further for in vivo effectiveness. However, the derivatives of the ciprofloxacin, endochin-like quinolones and 1-[4-(4-nitrophenoxy) phenyl] propane-1-one (NPPP) were significantly active against T. gondii tachyzoites both in vitro and in vivo. Thus, these compounds are promising candidates for future studies. Also, compound 32 (T. gondii calcium-dependent protein kinase 1 inhibitor), endochin-like quinolones, miltefosine, rolipram abolish, and guanabenz can be repurposed into an effective anti-parasitic with a unique ability to reduce brain tissue cysts (88.7, 88, 78, 74, and 69%, respectively). Additionally, no promising drugs are available for congenital toxoplasmosis. In conclusion, as current chemotherapy against toxoplasmosis is still not satisfactory, development of well-tolerated and safe specific immunoprophylaxis in relaxing the need of dependence on chemotherapeutics is a highly valuable goal for global disease control. However, with the increasing number of high-risk individuals, and absence of a proper vaccine, continued efforts are necessary for the development of novel treatment options against T. gondii. Some of the novel compounds reviewed here may represent good starting points for the discovery of effective new drugs. In further, bioinformatic and in silico studies are needed in order to identify new potential toxoplasmicidal drugs.
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Affiliation(s)
- Mahbobeh Montazeri
- Toxoplasmosis Research Center, Mazandaran University of Medical SciencesSari, Iran
- Student Research Committee, Mazandaran University of Medical SciencesSari, Iran
| | - Mehdi Sharif
- Toxoplasmosis Research Center, Mazandaran University of Medical SciencesSari, Iran
- Department of Parasitology and Mycology, Sari Medical School, Mazandaran University of Medical SciencesSari, Iran
| | - Shahabeddin Sarvi
- Toxoplasmosis Research Center, Mazandaran University of Medical SciencesSari, Iran
- Department of Parasitology and Mycology, Sari Medical School, Mazandaran University of Medical SciencesSari, Iran
| | - Saeed Mehrzadi
- Department of Pharmacology, School of Medicine, Iran University of Medical Sciences TehranIran
| | - Ehsan Ahmadpour
- Drug Applied Research Center, Tabriz University of Medical SciencesTabriz, Iran
| | - Ahmad Daryani
- Toxoplasmosis Research Center, Mazandaran University of Medical SciencesSari, Iran
- Department of Parasitology and Mycology, Sari Medical School, Mazandaran University of Medical SciencesSari, Iran
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