S234

Immunopathogenesis of Cerebral Toxoplasmosis

Yasuhiro Suzuki
Center for Molecular Medicine and Infectious Diseases, Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, Virginia

Interferon (IFN)-g is an absolute requirement for resistance against acute acquired infection with Toxoplasma gondii and development of toxoplasmic encephalitis (TE) during the late stage of infection. Multiple populations of both T and nonT cells are important sources of IFN-g in resistance. In the absence of IFN-gproducing nonT cells, T cells cannot prevent TE. Interleukin-12, Bcl-3, NF-kB(2), and CD40-CD40L ligand interaction are important for up-regulation of IFN-g production. T. gondii infects a variety of host cells, and IFN-gmediated immune responses control the parasite in both phagocytic and nonphagocytic cells through at least ve different mechanisms, most likely depending on the types of cells responding to IFN-g. Such effector functions involve production of NO by iNOS, tryptophan degradation by the enzyme IDO (indolamine 2,3-dioxygenase), unidentied mechanism(s) mediated by 47- to 48-kDa proteins encoded by an IFN-g responsive gene family, limiting the availability of intracellular iron to the parasite, and production of reactive oxygen intermediates.

Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013

Toxoplasma gondii is a ubiquitous obligate intracellular protozoan parasite in humans and animals. Chronic (latent) infection with this parasite is likely one of the most common human infections. During the acute stage of the infection, tachyzoites quickly proliferate within a variety of nucleated cells and spread throughout host tissues. The acute infection/disease is caused by infection with this form of the parasite. Following the acute stage, the parasite forms cysts (latent stage) in various organs, especially the brain, heart, and skeletal muscle, establishing chronic infection. Infection in immunocompetent persons usually is unnoticed or is a benign self-limiting illness and results in chronic infection. Immunosuppression in the chronically infected person may result in reactivation of a latent infection that is initiated by disruption of cysts and followed by proliferation of tachyzoites. Such reactivation of T. gondii infection usually presents as toxoplasmic encephalitis (TE). TE has emerged as a major opportunistic infectious disease in the central nervous system in AIDS patients. Since immunocompetent persons usually have no apparent untoward effects, including development of encephalitis, it is clear that the immune response is critical for prevention of TE. Murine models are the primary means used to analyze the mechanisms of host resistance to acute infection and development of TE during the late stage of infection. Resistance of
Grant support: NIH (AI-47730). Reprints or correspondence: Dr. Yasuhiro Suzuki, Center for Molecular Medicine and Infectious Diseases, Department of Biomedical Sciences and Pathobiology, Virginia-Maryland Regional College of Veterinary Medicine, Virginia Polytechnic Institute and State University, 1410 Prices Fork Rd., Blacksburg, VA 24061 (ysuzuki@vt.edu).
The Journal of Infectious Diseases 2002; 186(Suppl 2):S23440 2002 by the Infectious Diseases Society of America. All rights reserved. 0022-1899/2002/18611S-0016$15.00

mice to chronic infection is under genetic control. Resistant mouse strains (e.g., BALB/c) establish a latent chronic infection, as do immunocompetent humans. In contrast, susceptible strains (e.g., C57BL/6) spontaneously develop necrotizing TE during late stage of infection. It is unclear whether the encephalitis in these mice is due to reactivation of infection. It may be caused by a continuous acute infection. Thus, resistant strains of mice are more suitable than susceptible strains for analyzing the mechanism for maintaining chronic (latent) infection and preventing TE. However, most available information on the resistance mechanism has been obtained with the use of susceptible mouse strains. Interferon (IFN)-gdependent cell-mediated immunity plays a major role in the resistance to T. gondii in both resistant and susceptible mouse strains, although humoral immunity is also involved. Many different types of cells are involved in the resistance as producers of IFNg and responders to IFN-g for controlling the parasite. Multiple cell types are also important as producers of interleukin (IL)12, which is required for induction of IFN-g production.

IL-12 Producers Dendritic cells. IL-12 is the most important inducer of IFN-g synthesis. Neutralization of IL-12 with antiIL-12 antibodies results in 100% mortality in mice infected with an avirulent strain of T. gondii in association with decreased IFN-g production [1], and dendritic cells were identied as the source of IL-12 in the spleen in response to T. gondii [2]. All IL12positive cells in spleens of T. gondiistimulated mice were found in T cell areas and were CD8a, CD11c, DEC205 dendritic cells. CCR5 expressed on the surface of dendritic cells is responsible for their migration into splenic T cell areas after

JID 2002;186 (Suppl 2)

Cerebral Toxoplasmosis

S235

stimulation [2]. CCR5 signaling also plays an important role in activation of dendritic cells to produce IL-12 [3]. CCR5decient mice are impaired in IL-12 production by dendritic cells and are highly susceptible to T. gondii infection. During the chronic stage of infection, cells bearing dendritic cell markers (e.g., CD11c and 33D1) are located at the inammatory site in the mouse brain [4]. These brain dendritic cells are mature as indicated by high-level expression of major histocompatibility complex (MHC) class II, CD40, CD54, CD80, and CD86 and can trigger antigen-specic T cell responses in vitro. The dendritic cells were the major producers of IL-12 among mononuclear cells isolated from brains of infected animals [4]. Granulocyte-macrophage colony-stimulating factor is suggested to be important for induction of the dendritic cells in primary brain cell cultures with T. gondii [4]. Because IL-12 is important for the maintenance of IFN-g production in T cells mediating resistance to chronic infection [5], dendritic cells in the brains of infected mice might play a role in maintaining IFN-g production by T cells in the brain. Neutrophils. Neutrophils rapidly inltrate into the peritoneal cavity of mice following intraperitoneal infection with T. gondii. About 85% of the neutrophils displayed intracellular storage of IL-12 [6]. Depletion of neutrophils during the rst 6 days of infection results in increased mortality in mice in association with decreased production of IL-12 and IFN-g by splenocytes [7]. Rapid inltration of neutrophils into the site of infection appears to play an important role in induction of the protective Th1-type immune responses against T. gondii during the early stage of infection. IFN-g Producers
Involvement of Innate Immunity

gd T cells. During the acute stage of infection with T. gondii, increased numbers of T cells expressing the gd T cell receptor (TCR) have been observed in the spleen and peritoneal cavity of mice and in peripheral blood of humans. gd T cells are cytotoxic to infected target cells and produce IFN-g and tumor necrosis factor (TNF)-a in vitro in response to the parasite. Involvement of gd T cells in resistance against acute infection with T. gondii has been shown in mice. Mice decient in gd T cells due to treatment with anti-TCR d monoclonal antibody (MAb) [8] or lack of the functional TCR d gene [9] die earlier than control mice during the acute stage of infection. gd T cells, which are detectable in brains of chronically infected mice and rats, may also be involved in prevention of TE during the late stage of infection. Of interest, the relative percentages of gd T cells in lymphocyte preparations isolated from brains of infected mice are signicantly higher than in the spleen [10]. This suggests that gd T cells preferentially inltrate the brain of T. gondiiinfected mice. A human with a CD40L defect (hyper-IgM syndrome) who developed TE had a marked increase in gd T cells in his peripheral blood [11]. He responded

well to antitoxoplasmic chemotherapy and to high-dose immunoglobulin replacement therapy. gd T cells may play a partial but important role against T. gondii in the brain although their protective activity is not sufcient by itself to prevent TE. Lepage et al. [12] suggested a possible role for gd T cells to enhance the protective activity of CD8 ab T cells in their studies that used adoptive transfer of the lymphocyte populations. NK cells. NK cells are an important source of IFN-g in resistance against T. gondii during early infection. Depletion of NK cells results in early or increased mortality in SCID and wild type mice. In contrast to the early stage of infection, NK cells do not appear to be crucial for prevention of TE during the late stage of infection. Our recent studies revealed that depletion of NK cells did not abolish resistance of SCID mice that had received adoptive transfer of immune T cells against development of TE [13]. In the depleted mice, NK cells were undetectable in brain and spleen by ow cytometry. Unidentied IFN-gproducing nonT cells. We recently found that IFN-gproducing nonT cells are required to prevent reactivation of T. gondii infection in mouse brains [13]. Athymic nude, SCID, and IFN-gdecient mice were infected with T. gondii and treated with sulfadiazine to establish chronic infection. After discontinuation of sulfadiazine, each animal developed severe TE due to reactivation of the chronic infection and died. When animals received adoptive transfer of immune spleen or T cells before discontinuation of sulfadiazine, infected athymic nude and SCID mice did not develop TE and survived. However, the infected IFN-gdecient mice still developed TE and died even after the cell transfer [13]. Before cell transfer, IFN-g mRNA was detected in brains of nude and SCID mice but not in brains of the IFN-gdecient mice. IFN-g mRNA was also detected in brains of infected SCID mice depleted of NK cells and these animals did not develop TE after receiving immune T cells [13]. Thus, IFN-g production by nonT cells, in addition to T cells, is required for prevention of reactivation of T. gondii infection in the brain. The IFN-gproducing nonT cells do not appear to be NK cells.

Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013

Importance of Acquired Immunity

CD4 and CD8 ab T cells. It is clear that ab T cells are essential for resistance against T. gondii since athymic nude and SCID mice that lack T cells succumb to the acute infection and their mortality is associated with proliferation of large numbers of tachyzoites in various organs including the brain. CD8 T cells are the major efferent limb of the protective cellular immunity against acute infection although CD4 T cells are also involved. The protective activity of CD8 T cells is predominantly mediated by IFN-g and these cells appear to be a major source of IFN-g during the acute stage of the infection [14]. However, both CD8 and CD4 T cells from spleens of infected mice can produce this cytokine in vitro after stimulation with tachyzoite antigens.

S236

Suzuki

JID 2002;186 (Suppl 2)

IFN-g also plays a critical role in prevention of TE during the late stage of infection in mice [15, 16]. Neutralization of the activity of IFN-g in chronically infected mice by treatment with antiIFN-g MAb resulted in severe acute inammation and development of large areas of necrosis in the brain [15]. In areas of acute inammation and necrosis, tachyzoites and T. gondii antigens were detected, indicating that such inammatory responses were caused by proliferation of tachyzoites. Reverse transcriptase polymerase chain reaction also detected increased amounts of tachyzoite-specic SAG1 and SAG2 mRNA, indicating a marked increase in numbers of tachyzoites in mouse brains after treatment with antiIFN-g MAb [17]. Thus, IFN-g clearly is critical for preventing proliferation of tachyzoites in mouse brains. The same appears to be true in humans, since AIDS patients have an impaired activity to produce IFN-g and frequently develop TE. Both CD4 and CD8 T cells inltrate the brain of mice following infection. Gazzinelli et al. [16] reported that CD4 and CD8 T cells act additively or synergistically to prevent development of TE, probably through production of IFN-g. Brown and McLeod [18] reported that CD8 T cells are involved in the resistance by regulating the numbers of T. gondii cysts in the brains of mice. Bcl-3 oncoprotein, a distinct member of the I-kB family, which functions as a positive regulator of nuclear factor (NF) kB activity, plays a critical role in mounting a protective Th1 immune response to T. gondii [19]. Bcl-3decient mice survive the early acute stage of the infection, but most die 35 weeks after infection. The ability of spleen cells to produce IFN-g in response to T. gondii antigens is normal in the early stage (7 days after infection) but impaired in the later stage (1231 days after infection). Cytotoxic activity of T cells but not of NK cells is also defective in these mice. These results suggest a critical role for Bcl-3 in antigen-specic priming of the longterm protective Th1-type T cells following T. gondii infection. In regard to NF-kB, Caamano et al. [20] recently showed the importance of NF-kB(2) for T cell responses in resistance to TE. NF-kB(2)decient mice have no defect in their ability to produce IL-12 and IFN-g during the acute stage of infection, but during the chronic stage of infection, succumb to TE in association with a reduced capacity of production of IFN-g by splenocytes. T cell apoptosis appears to be involved in the reduced production of this cytokine. Subauste et al. [21] recently reported that CD40-CD40L signaling is required for optimal T cell production of IFN-g in response to T. gondii in humans. However, the role of the CD40CD40L interaction in the T cell response appears to differ in mice. CD40L-decient mice produce comparable levels of IFNg to control animals following infection, although CD40L is important for resistance to TE [22]. In addition to production of IFN-g, both human and mouse CD4 and CD8 T cells are capable of killing T. gondiiinfected target cells in vitro in a major histocompatibility complex

(MHC)-restricted manner. Denkers et al. [23] reported an accelerated mortality beginning 75 days after infection in perforin-decient mice. In their studies, about half of the perforindecient animals survived until day 150 after infection whereas all CD8 T celldecient mice died by day 50 after infection [23]. Thus, perforin-mediated cytolysis by T cells appears to play a limited role in resistance against T. gondii. Since perforindecient mice die during the late stage of the infection, the cytotoxic activity of T cells might play a role in prevention of TE. This point needs clarication.

Effector Mechanisms in IFN-gMediated Resistance NO produced by inducible NO synthase (iNOS). As mentioned, IFN-g is the central cytokine in resistance against acute acquired infection with T. gondii and recrudescence of chronic infection (TE). Macrophages become quickly activated to kill intracellular tachyzoites following infection. This activation is mediated by IFN-g since neutralization of the activity of this cytokine by treatment with antiIFN-g MAb blocks the activation [24]. In the absence of activity of endogenous IFN-g, mice die within 1 week after intraperitoneal infection and their mortality is associated with numerous tachyzoites in the peritoneal cavities [24]. Thus, IFN-gmediated activation of macrophages is critical for resistance against acute infection with this parasite. Murine peritoneal macrophages become activated after treatment with a combination of IFN-g and TNF-a in vitro and the activated cells inhibit intracellular replication of tachyzoites through generation of NO by iNOS. However, the situation appears to differ in vivo. Mice lacking TNF receptor types 1 (R1) and 2 (R2) [25] and those lacking iNOS [26] can control parasite growth in the peritoneal cavity following intraperitoneal infection, indicating that TNF-a and iNOS are not essential for control of acute infection in mice. Consistent with these ndings are ndings in experiments in mice that lack IFN-g regulatory factor 1 (IRF-1), which is essential for iNOS induction by IFN-g [27]. Although IRF-1decient animals are more susceptible to infection with T. gondii than control animals, they survive the acute stage of the infection through iNOS-independent mechanism(s). These results indicate that the protective mechanism(s), which requires IFN-g but not TNF-a or iNOS, is sufcient for mice to control parasite growth during the acute stage of the infection. These results do not exclude the possibility that TNF-a and iNOS play a partial role in resistance to T. gondii in this stage of infection. The iNOS-independent mechanisms described in the sections below (e.g., tryptophan degradation by IDO [indolamine 2,3-dioxygenase], IGTP) may be involved in this resistance. In contrast to the acute stage of infection, mice decient in TNF R1/R2 [25] or iNOS [26] succumb to necrotizing TE during the late stage of infection. These results are consistent with those of earlier studies; treatments of chronically infected wild
Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013

JID 2002;186 (Suppl 2)

Cerebral Toxoplasmosis

S237

type mice with antiTNF-a MAb or aminoguanidine (an iNOS inhibitor) resulted in development of TE [17, 28]. Thus, TNFa and iNOS are critical for prevention of proliferation of tachyzoites in the brain, although there is a possibility that in decient mice the absence of TNF-a and iNOS-mediated resistance during the acute stage of infection may have resulted in increased cyst burden in organs and may have partially contributed to increased mortality during the late stage of infection. As mentioned, IFN-g plays a central role in resistance of the brain against this parasite [15, 16]. Since neutralization of IFNg or TNF-a results in decreased iNOS expression and development of severe TE [17], activation of iNOS mediated by IFNg and TNF-a appears to play a key role in prevention of TE. Microglia are likely important effector cells involved in iNOS-mediated protective mechanisms in mouse brains. Murine microglia become activated in vitro to inhibit intracellular proliferation of tachyzoites following treatment with IFN-g plus lipopolysaccharide (LPS) [29]. NO mediates the inhibitory effect of activated murine microglia on intracellular replication of tachyzoites; treatment of these cells with NG-monomethylL-arginine (which blocks the generation of NO) ablates their inhibitory activity [29]. Recently, Freund et al. [30] reported an involvement of both NO-dependent and -independent mechanisms in the resistance of murine microglia activated by a combination of IFN-g and TNF-a. Human microglia also become activated in vitro to inhibit intracellular proliferation of tachyzoites following treatment with IFN-g plus LPS [31]. TNF-a and IL-6 are involved in activation of human microglia. However, unlike murine microglia, NO is not involved in the inhibitory effect of human microglia against tachyzoites [31]. In vivo, following T. gondii infection, microglia become activated to produce TNF-a, and IFN-g mediates the activation [32]. IFNgmediated activation of microglia in collaboration with autocrine TNF-a is likely one of the resistance mechanisms of the brain against T. gondii, although the role of NO in resistance differs between humans and mice. Astrocytes appear to be another type of IFN-gresponding effector cells involved in prevention of T. gondii growth in the brain. Peterson et al. [33] reported that human astrocytes become activated following treatment with IFN-g plus IL-1b to inhibit intracellular proliferation of tachyzoites and that the inhibitory effect is mediated by NO. Pelloux et al. [34] found that TNF-a induces a signicant reduction in intracellular multiplication of the parasite in human astrocytoma-derived cells, whereas IL-1a induces an increase in the parasite multiplication. The importance of IDO, but not of NO, was shown in human astrocytes and glioblastoma cells activated by a combination of IFN-g and TNF-a [35] (discussed later). In addition to the iNOS-mediated mechanism, an iNOS-independent mechanism(s) also plays an important role in resistance against TE. Yap et al. [36] demonstrated an involvement of iNOS-independent mechanisms in prevention of mortality in T. gondiiinfected mice in an elegant study that used bone

marrow chimera. In order to address the mechanisms for restricting the growth of T. gondii within cells of nonhematopoietic origin, they developed chimeric mice that expressed IFN-g receptors, TNF R1/R2, or iNOS on hematopoietic or nonhematopoietic cells. Resistance to acute and persistent infection was displayed only by mice in which IFN-g receptors and TNF R1/R2 were expressed in both hematopoietic and nonhematopoietic cells. In contrast, expression of iNOS by only hematopoietic cells was sufcient for host resistance. These results suggest that in concert with bone marrowderived effector cells, nonhematopoietic cells can directly mediate IFN-g and TNF-adependent resistance to the parasite. This resistance does not require expression of iNOS in nonhematopoietic cells. Requirement of these multiple mechanisms for resistance to T. gondii appears to be due to its infection of not only mononuclear phagocyte lineage but also of a wide variety of host cells. Resistance to development of TE is under genetic control in both humans and mice. Our recent studies suggest a crucial role for IFN-gdependent, but iNOS-independent, mechanism in the genetic resistance of BALB/c mice to this disease. BALB/ c-background IFN-gdecient mice infected and treated with sulfadiazine developed severe TE after discontinuation of sulfadiazine treatment even though these animals expressed large amounts of mRNA for TNF-a and iNOS and in their brains. The amounts of the mRNA expressed were equivalent to those expressed in the brains of infected control mice, which prevented development of TE [37]. Thus, expression of TNF-a and iNOS is insufcient for prevention of TE in the absence of IFN-g. Tryptophan degradation by IDO. IDO is an enzyme that catalyzes the initial rate-limiting step of tryptophan catabolism to N-formylkynurenine and kynurenine. The depletion of intracellular tryptophan pools by IDO is an important mechanism by which IFN-g controls the intracellular replication of T. gondii tachyzoites in various types of human cells. IFNgmediated induction of IDO appears to be critical for resistance of the brain against T. gondii in humans. TNF-a and IFN-g are synergistic in activation of IDO in human glioblastoma cell lines and native astrocytes [35]. This IDO activity results in a strong toxoplasmostatic effect of the activated glioblastoma cells [35]. Daubener et al. [38] found that stimulation of human brain microvascular endothelial cells (HBMEC) with IFN-g resulted in the induction of toxoplasmostasis. The capacity of HBMEC to restrict Toxoplasma growth after IFN-g stimulation was enhanced in the presence of TNF-a, and such capability correlated with their IDO activities. Furthermore, the addition of excess amounts of tryptophan to the HBMEC cultures resulted in a complete abrogation of IFN-gTNFamediated toxoplasmostasis, indicating that the protective activity is mediated by IDO. In contrast to human models, the role of IDO in resistance to T. gondii is unclear in mice. IFN-g does not induce IDO

Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013

S238

Suzuki

JID 2002;186 (Suppl 2)

Table 1.
Molecule IL-12 Bcl-3 NF-kB(2) CD40L IFN-g

Interferon (IFN)-gmediated resistance against Toxoplasma gondii in the brain.

Function Maintaining IFN-g production by T cells Maintaining IFN-g production by T cells Maintaining IFN-g production by T cells Up-regulating IFN-g production by T cells (human) Activation of effector cells to control T. gondii Cells Dendritic T T T gd T (?) Non-T (non-NK) ab T Microglia (mouse) Astrocytes (human) Astrocytes (human) Brain vascular endothelial (human) Astrocytes (mouse) References [4, 5] [19] [20] [11, 21] [10, 11] [13] [13, 16, 18] [29, 30] [34] [35] [38] [40]

iNOS IDO IGTP NOTE.

Production of NO to control T. gondii in effector cells Tryptophan degradation to control T. gondii in effector cells Unidentied mechanism to control T. gondii in effector cells

IDO, indolamine 2,3-dioxygenase; IL, interleukin; iNOS, inducible nitric oxide synthase; NF, nuclear factor.

Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013

and toxoplasmastatic activity in mouse broblasts [39] and is not important for controlling T. gondii in murine astrocytes [40]. However, two groups recently reported IFN-gdependent expression of IDO in the brains and lungs of mice during the acute stage of infection [41, 42]. More studies are needed to assess a possible involvement of IDO in resistance to T. gondii in mice. IGTP. IGTP, a recently identied IFN-g responsive gene, is representative of a family of at least 6 genes encoding 47- to 48-kDa proteins that contain a GTP-binding sequence and that are expressed at high levels in immune and nonimmune cells after exposure to IFN-g. Several of these proteins, including IGTP, localize to the endoplasmic reticulum of cells, suggesting they may be involved in the processing or trafcking of immunologically relevant proteins, such as antigens or cytokines. Taylor et al. [43] recently generated IGTP-decient mice and found that despite normal immune cell development and normal clearance of Listeria monocytogenes and cytomegalovirus, the mice displayed a profound loss of host resistance to acute infection with T. gondii. Thus, IGTP is an essential mediator of specialized antimicrobial activities of IFN-g. In vitro studies demonstrated an importance of IGTP for prevention of T. gondii replication in murine astrocytes. After pretreatment with IFN-g or a combination of this cytokine with either TNF-a, IL-1, or IL-6, murine astrocytes can inhibit proliferation of tachyzoites in vitro. The inhibitory effect of activated astrocytes is not mediated by IDO, NO, reactive oxygen intermediates, or iron deprivation. Halonen et al. [40] recently reported that astrocytes from IGTP-decient mice did not cause a signicant inhibition of T. gondii growth following treatment with IFN-g, whereas wild type astrocytes inhibited the growth. Therefore, IGTP plays a central role in the IFN-ginduced inhibition of the parasite in murine astrocytes. In relation to IGTP, the roles of other members of the gene family in resistance against T. gondii were studied in knockout mice that lacked expression of the genes LRG-47 and IRG-47 [44]. LRG-47decient mice succumbed uniformly and rapidly during the acute stage of the infection; in contrast, IRG-47decient mice displayed only partially decreased resistance that

was not manifested until the chronic phase of infection. Thus, LRG-47 and IRG-47 have vital but distinct roles in immune defense against T. gondii. Limiting the availability of intracellular iron to the parasite. Dimier and Bout [45] reported that activation of rat enterocytes with rat recombinant IFN-g resulted in an inhibition of intracellular replication of T. gondii. Neither nitrogen and oxygen derivatives nor tryptophan starvation are involved in the inhibitory effect. Experiments that used Fe2 salt as well as carrier and chelator suggested that IFN-gtreated enterocytes inhibit T. gondii replication by limiting the availability of intracellular iron to the parasite [45]. It is not known whether this irondependent mechanism is also involved in resistance of other types of cells activated by IFN-g. Reactive oxygen intermediates (ROI). ROI have been implicated in the toxoplasmacidal activity of normal human monocytes and IFN-gactivated human macrophages in vitro [46, 47]. Involvement of ROI in their antimicrobial activity was suggested since impairing the ability of the cells to generate oxygen intermediates (by glucose deprivation or treatment with superoxide dismutase, catalase, or mannitol) inhibited toxoplasmacidal activity by greater than 80% [47] and because killing of T. gondii by monocytes obtained from chronic granulomatous disease patients was impaired [47]. However, the physiologic signicance of the ROI pathway remains unclear, especially in mice. The parasites are resistant to the oxygen metabolites produced in murine macrophages [48]. Recently, p47 phox-decient mice, which lack an inducible oxidative burst, were reported to control both the acute and chronic stages of T. gondii infection [26]. Conclusions Resistance against T. gondii requires a network that involves 4 different types of IFN-gproducing cells and many types of IFN-gresponding effector cells that prevent proliferation of the parasite through at least 5 different mechanisms. For controlling T. gondii in the brain during the late stage of infection, at least 3 types of IFN-gproducing cells and 3 effector mech-

JID 2002;186 (Suppl 2)

Cerebral Toxoplasmosis

S239

anisms in IFN-gresponding effector cells appear to be involved (table 1). IL-12, Bcl-3, NF-kB(2), and CD40-CD40L ligand interaction are important for up-regulating and maintaining the IFN-gmediated resistance for prevention of TE (table 1). However, IL-10 plays a crucial role in down-regulating the responses for preventing development of immune responsemediated pathology during the acute stages of infection. Lipoxin A4 may play an important down-regulatory role during the late stage of infection [49]. Further studies will elucidate more details of the resistance mechanisms and provide better understanding of how this resistance network functions and how the system is regulated.

16.

17.

18.

19.

20. References 1. Gazzinelli RT, Wysocka M, Hayashi S, et al. Parasite-induced IL-12 stimulates early IFN-g synthesis and resistance during acute infection with Toxoplasma gondii. J Immunol 1994; 153:253343. 2. Sousa CR, Hieny S, Scharton-Kersten T, et al. In vivo microbial stimulation induces rapid CD40 ligand-independent production of interleukin-12 by dendritic cells and their redistribution to T cell areas. J Exp Med 1997; 186:181929. 3. Aliberti J, Reis e Sousa C, Schito M, et al. CCR5 provides a signal for microbial-induced production of IL-12 by CD8 alpha dendritic cells. Nat Immunol 2000; 1:837. 4. Fischer HG, Bonifas U, Reichmann G. Phenotype and functions of brain dendritic cells emerging during chronic infection of mice with Toxoplasma gondii. J Immunol 2000; 164:482634. 5. Yap G, Pesin M, Sher A. Cutting edge: IL-12 is required for the maintenance of IFN-gamma production in T cells mediating chronic resistance to the intracellular pathogen, Toxoplasma gondii. J Immunol 2000; 165:62831. 6. Bliss SK, Butcher BA, Denkers EY. Rapid recruitment of neutrophils containing prestored IL-12 during microbial infection. J Immunol 2000; 165: 451521. 7. Bliss SK, Gavrilescu LC, Alcaraz A, Denkers EY. Neutrophil depletion during Toxoplasma gondii infection leads to impaired immunity and lethal systemic pathology. Infect Immun 2001; 69:4898905. 8. Hisaeda H, Nagasawa H, Maeda K, et al. gd T cells play an important role in hsp65 expression and in acquiring protective immune responses against infection with Toxoplasma gondii. J Immunol 1995; 155:24451. 9. Kasper LH, Matsuura T, Fonseka S, Arruda J, Channon JY, Khan IA. Induction of gd T cells during acute murine infection with Toxoplasma gondii. J Immunol 1996; 157:55217. 10. Suzuki Y, Rani S, Liesenfeld O, et al. Impaired resistance to the development of toxoplasmic encephalitis in interleukin-6decient mice. Infect Immun 1997; 65:233945. 11. Leiva LE, Junprasert J, Hollenbaugh D, Sorensen RU. Central nervous system toxoplasmosis with an increased proportion of circulating gamma delta T cells in patient with hyper-IgM syndrome. J Clin Immunol 1998;18: 28390. 12. Lepage AC, Buzoni-Gatel D, Bout DT, Kasper LH. Gut-derived intraepithelial lymphocytes induce long term immunity against Toxoplasma gondii. J Immunol 1998; 161:49028. 13. Kang H, Suzuki Y. Requirement of nonT cells that produce gamma interferon for prevention of reactivation of Toxoplasma gondii infection in the brain. Infect Immun 2001; 69:29207. 14. Suzuki Y, Remington JS. Dual regulation of resistance against Toxoplasma gondii infection by Lyt-2 and Lyt-1, L3T4 T cells in mice. J Immunol 1988; 140:39439. 15. Suzuki Y, Conley FK, Remington JS. Importance of endogenous IFN-g for

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31. 32.

33.

34.

prevention of toxoplasmic encephalitis in mice. J Immunol 1989; 143: 204550. Gazzinelli RT, Xu Y, Hieny S, Cheever A, Sher A. Simultaneous depletion of CD4 and CD8 T lymphocytes is required to reactivate chronic infection with Toxoplasma gondii. J Immunol 1992; 149:17580. Gazzinelli RT, Eltoum I, Wynn TA, Sher A. Acute cerebral toxoplasmosis is induced by in vivo neutralization of TNF-a and correlates with the down-regulated expression of inducible nitric oxide synthase and other markers of macrophage activation. J Immunol 1993; 151:367281. Brown CW, McLeod R. Class I MHC genes and CD8 T cells determine cyst number in Toxoplasma gondii infection. J Immunol 1990; 145: 343841. Franzogo G, Carlson L, Scharton-Kerston T, et al. Critical role for the Bcl3 oncoprotein in T cellmediated immunity, splenic microarchitecture, and germinal center reactions. Immunity 1997; 6:47990. Caamano J, Tato C, Cai G, et al. Identication of a role for NF-kappa B2 in the regulation of apoptosis and in maintenance of T cellmediated immunity to Toxoplasma gondii. J Immunol 2000; 165:57208. Subauste CS, Wessendarp M. Sorensen RU, Leiva LE. CD40-CD40 ligand interaction is central to cell-mediated immunity against Toxoplasma gondii: patients with hyper IgM syndrome have a defective type 1 immune response that can be restored by soluble CD40 ligand trimer. J Immunol 1999; 162:6690700. Reichmann G, Walker W, Villegas EN, et al. The CD40/40 ligand interaction is required for resistance to toxoplasmic encephalitis. Infect Immun 2000; 68:13128. Denkers EY, Yap G, Scharton-Kersten T, et al. Perforin-mediated cytolysis plays a limited role in host resistance to Toxoplasma gondii. J Immunol 1997; 159:19038. Suzuki Y, Orellana MA, Schreiber RD, Remington JS. Interferon-g: the major mediator of resistance against Toxoplasma gondii. Science 1988; 240: 5168. Yap GS, Scharton-Kersten T, Charest H, Sher A. Decreased resistance of TNF receptor p55- and p75-decient mice to chronic toxoplasmosis despite normal activation of inducible nitric oxide synthase in vivo. J Immunol 1998; 160:13405. Scharton-Kersten TM, Yap G, Magram J, Sher A. Inducible nitric oxide is essential for host control of persistent but not acute infection with the intracellular pathogen Toxoplasma gondii. J Exp Med 1997; 185:126173. Khan IA Matsuura T, Fonseka S, Kasper LH. Production of nitric oxide (NO) is not essential for protection against acute Toxoplasma gondii infection in IRF-1-/- mice. J Immunol 1996; 156:63643. Hayashi S, Chan CC, Gazzinelli R, Roberge FG. Contribution of nitric oxide to the host parasite equilibrium in toxoplasmosis. J Immunol 1996; 156: 147681. Chao CC, Anderson WR, Hu S, Martella A, Gekker G, Peterson PK. Activated microglia inhibit Toxoplasma gondii via a nitric oxide-mediated mechanism. Clin Immunol Immunopathol 1993; 67:17883. Freund YR, Zaveri NT, Javitz HS. In vitro investigation of host resistance to Toxoplasma gondii infection in microglia of BALB/c and CBA/Ca mice. Infect Immun 2001; 69:76572. Chao CC, Gekker G, Hu S, Peterson PH. Human microglia cell defense against Toxoplasma gondii. J Immunol 1994; 152:124652. Deckert-Schlu ter M, Bluethman H, Kaefer N, Rang A, Schlu ter D. Interferon-g receptor-mediated but not tumor necrosis factor receptor type-1 or type 2mediated signaling is crucial for the activation of cerebral blood vessel endothelial cells and microglia in murine toxoplasma encephalitis. Am J Pathol 1999; 154:154961. Peterson PK, Gekker G, Hu S, Chao CC. Human astrocytes inhibit intracellular multiplication of Toxoplasma by a nitric oxidemediated mechanism. J Infect Dis 1995; 171:5168. Pelloux H, Pernod G, Polack B, et al. Inuence of cytokines on Toxoplasma gondii growth in human astrocytoma-derived cells. Parasitol Res 1996; 82:598603.

Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013

S240

Suzuki

JID 2002;186 (Suppl 2)

35. DaubenerW, Remscheid C, Nockemann S, et al. Anti-parasitic effector mechanisms in human brain tumor cells: role of interferon-g and tumor necrosis factor-a. Eur J Immunol 1996; 26:48792. 36. Yap GS, Sher A. Effector cells of both nonhematopoietic and hematopoietic origin are required for interferon (IFN)-g and tumor necrosis factor (TNF)-adependent host resistance to the intracellular pathogen, Toxoplasma gondii. J Exp Med 1999; 189:108391. 37. Suzuki Y, Kang H, Parmley S, Lim S, Park D. Induction of tumor necrosis factor-a and inducible nitric oxide synthase fails to prevent toxoplasmic encephalitis in the absence of interferon-g in genetically resistant BALB/ c mice. Microbes Infect 2000; 2:45562. 38. Daubener W, Spors B, Hucke C, et al. Restriction of Toxoplasma gondii growth in human brain microvascular endothelial cells by activation of indolamine 2,3-dioxygenase. Infect Immun 2001; 69:652731. 39. Turco J, Winkler HH. Gamma-interferon-induced inhibition of the growth of Rickettsia prowazekii in broblasts cannot be explained by the degradation of tryptophan or other amino acids. Infect Immun 1986; 53: 3846. 40. Halonen SK, Taylor GA, Weiss LM. Gamma interferon-induced inhibition of Toxoplasma gondii in astrocytes is mediated by IGTP. Infect Immun 2001; 69:55736. 41. Fijigaki S, Saito K, Takemura M, et al. l-tryptophan-l-kynurenine pathway metabolism accelerated by Toxoplasma gondii infection is abolished in gamma interferon-genedecient mice: cross-regulation between inducible nitric oxide synthase and indoleamine-2,3-dioxygenase. Infect Immun 2002; 70:77986.

42. Silva NM, Rodrigues CV, Santoro MM, Reis LF, Alvarez-Leite JI, Gazzinelli RT. Expression of indolamine 2,3-dioxygenasee tryptophan degradation, kynurenine formation during in vivo infection with Toxoplasma gondii: induction by endogenous gamma interferon and requirement of interferon regulatory factor 1. Infect Immun 2002; 70:85968. 43. Taylor GA, Collazo CM, Yap GS, et al. Pathogen-specic loss of host resistance in mice lacking the IFN-ginducible gene IGTP. Proc Natl Acad Sci USA 2000; 97:7515. 44. Callazo CM, Yap GS, Sempowski GD, et al. Inactivation of LRG-47 and IRG-47 reveals a family of interferon gammainducible genes with essential, pathogen-specic roles in resistance to infection. J Exp Med 2001; 194:1818. 45. Dimier IH, Bout DT. Interferon-gammaactivated primary enterocytes inhibit Toxoplasma gondii replication: a role for intracellular iron. Immunology 1998; 94:48895. 46. Wilson CB, Remington JS. Activity of human blood leukocytes against Toxoplasma gondii. J Infect Dis 1979; 140:8905. 47. Murray HW, Rubin BY, Carriero SM, Harris AH, Jaffee EA. Human mononuclear phagocyte antiprotozoal mechanisms: oxygen-dependent vs. oxygen-independent activity against intracellular Toxoplasma gondii. J Immunol 1985; 134:19828. 48. Cahng HR, Pechere JC. Macrophage oxidative metabolism and intracellular Toxoplasma gondii. Microb Pathog 1989; 7:3744. 49. Aliberti J, Hieny S, Reis e Sousa C, Serhan C, Sher A. Lipoxin-mediated inhibition of IL-12 production by dendritic cells: a mechanism for the regulation of microbial immunity. Nat Immunol 2002; 3:7682.

Downloaded from http://jid.oxfordjournals.org/ by guest on December 22, 2013