Environmental and Regulatory Control of RTX Toxins in Gram-Negative Pathogens.

Repeat-in-toxin (RTX) toxins are calcium-dependent exoproteins secreted by diverse Gram-negative bacteria and play central roles in cytotoxicity, immune modulation, and tissue colonization. While their structure and secretion mechanisms are well-characterized, the regulation of RTX toxin expression remains complex and species-specific. This review provides a comprehensive overview of the regulatory networks governing RTX gene expression, highlighting both conserved mechanisms and niche-specific adaptations. RTX genes are controlled by multilayered regulatory systems that integrate global transcriptional control, metabolic regulation, and environmental sensing. Expression is further shaped by host-derived signals, physical contact with host cells, and population-dependent cues. Quorum sensing, post-transcriptional regulation by small RNAs, and post-translational activation mechanisms contribute additional layers of control to ensure precise regulation of toxin production. We also explore how RTX regulation varies across anatomical niches, including the gut, lung, bloodstream, and biofilms, and how it is co-regulated with broader bacterial virulence. Finally, we discuss emerging insights from omics-based approaches and the potential of anti-virulence strategies targeting RTX regulatory pathways. Together, these topics underscore RTX regulation as a model for adaptive virulence control in bacterial pathogens.