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5 Surviving the Storm: How Candida Species Master Adaptation…
Fig. 5.2 Regulation of white opaque switching in Candida albicans: the white phenotype in
Candida albicans is favored when cells are in a heterozygous state, and this state is transcription­ally regulated by EFG1. Meanwhile, the opaque state is governed by the master regulator WOR1, along with CZF1, and WOR2in the regulatory process
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another layer of versatility to its behaviour (Lachke etal. 2002). In 2018, pheno­typic switching in C. auris was rst documented. Bentz and colleagues observed three distinct colony types, white, pink, and dark purple, when the fungus was cul­tured on CHROMagar (Bentz etal. 2019). However, until 2021, there had been no reports on evidence of phenotypic switching in Candida haemulonii. This changed with a recent study, which unveiled that this closely related species to C. auris can indeed undergo such switching events. Candida haemulonii found to possess two distinct switching systems. The primary switching system involves the formation of either white and pink colonies on phloxine B plates or dark brown and light brown colonies on plates containing CuSO4. The second switching system exhibits a tran­sition from a yeast-like form to lamentous growth. Transcriptional data suggests the lament-specic regulator UME6 was upregulated in pink colonies. Certain GPI-anchored genes, such as ALS4 (adhesin), RBT4 (hyphal specic), and CSA1 (hyphal specic surface antigen), were found to be upregulated in pink colonies (Deng etal. 2021).
5.3 Biofilm inCandida Species
Biolms are intricate microbial communities that adhere to surfaces and are enclosed within a mesh-like matrix. The biolm formation as a critical weapon in fungal pathogens virulence arsenal. The biolm formation process begins with cell attachment to the substratum, followed by colonization and maturation, leading to the development of pseudohyphae or hyphae. These structures are enveloped within an ECM that serves as a protective shield, preventing the penetration of drugs and toxic substances and safeguarding the biolm from engulfment by phagocytes. The nal step in this intricate process involves dispersing cells from the matured biolm to new areas, fostering the growth of unique microbial communities. It is worth not­ing that the structure of biolms varies across Candida spp., with lamentous cells dominating in C. albicans and single-celled yeast forms in C. glabrata (Lagree and
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Mitchell 2017). The formation of biolms on medical implanted devices represents a signicant concern, as it is a leading cause of bloodstream and deep-seated infec­tions. These devices provide an ideal substrate for microorganisms to adhere and thrive, creating an environment conducive to biolm development.
Biolm development is a highly regulated process controlled by a complex net­work of transcription factors that govern various pathways and downstream target genes, each playing a specic role in the different stages of biolm development.
The transcriptional network identied by Nobile etal. consists of six key tran­scriptional factor networks, namely, EFG1, TEC1, NDT80, BCR1, ROB1, and BRG1. Disruption of any of these transcription factors results in defective biolm formation. Each transcription factor is involved at a specic stage of biolm formation (Nobile etal. 2012). BCR1 is mainly involved during the adherence of pathogens to a suitable substratum. Als1, Als3, and Hwp1 are under the control of BCR1. bcr1/bcr1 showed a decreased expression of Als3 and Hwp1 and also developed a thin biolm. TEC1 controls the expression of BCR1, which ne-tunes the downstream adhesion genes. TEC1 is regulated by EFG1, which is involved in lamentous growth. Biolm maturation is handled by NDT80, ROB1, and BRG1 (Araújo etal. 2017).
The formation of biolms is further complicated by variations observed on dif­ferent surfaces, such as mucosal or venous catheters. Transitioning from invitro biolm phenotypes to invivo results can be complicated. C. auris biolm shows heterogeneity on different substrates. The existing methods for biolm formation lack a standardized surface, leading to challenges in reproducibility in case of C. auris. Thermanox (polystyrene) coverslips for invitro growth of C. auris biolm, resulting in a single layer of yeast cells on the coverslip and multilayered biolm on porcine skin surfaces in synthetic sweat media (Zheng etal. 2021; Horton et al.
2020). A recent method developed by Biswas etal., involving gelatin surfaces,
mimics the host environment conditions to proliferate as a multilayer with extracel­lular polymeric substances (EPS). This approach proves feasible for drug screening and biolm analysis through three-dimensional (3D) reconstruction. Additionally, this invitro biolm formation technique extends its utility to studying biolm for­mation in other Candida species, such as C. glabrata and C. albicans, accurately mimicking their biolm formation environments. Consequently, this innovation in vitro method holds signicant potential for comprehending the mechanisms underlying biolm formation (Biswas etal. 2023a).
While the regulation of biolm formation appears tightly controlled, there is still much to understand about how these phenotypic changes contribute to differences in biolm development.
5.4 Aggregation inCandida spp.
The aggregative phenotype is a unique characteristic found in certain Candida spp. In Candida albicans, for instance, aggregation is primarily facilitated by the expres- sion of Sap6, a specic protein that plays a pivotal role in this clumping process (Kumar etal. 2015). Additionally, coaggregation with other Candida spp. or even
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various microbial entities is controlled by Als1p, another key player in the forma­tion of aggregates (Klotz etal. 2007). In C. auris, cells have been found to form large cellular clumps, often referred to as aggregates (Borman etal. 2016). Different studies have reported contrasting ndings, making it a complex aspect of Candida biology to unravel. For example, Sherry and colleagues reported that the nonaggre­gating phenotype exhibits higher virulence potential than the aggregative pheno­type. This nding suggests that the ability of Candida cells to form aggregates may not necessarily correlate with increased virulence (Sherry etal. 2017).
In contrast, other studies have highlighted the proinammatory nature of the aggregating phenotype. This phenotype is associated with the upregulation of genes such as ALS and SAP, which play crucial roles in colonization and invasion within the host. This nding implies that the aggregative phenotype may contribute to a more aggressive interaction with the host’s immune system (Brown et al. 2020). Several factors have been identied as inuencers of the aggregative phenotype in Candida spp. One key factor is temperature, as described by Malavia-Jones. This researcher noted that the aggregative phenotype in all four clades of C. auris is temperature dependent (Malavia-Jones etal. 2023).
Furthermore, the aggregative phenotype is inhibited by amyloid inhibitors and exhibits differences in the expression of GPI adhesins, highlighting the intricate regulatory mechanisms at play. Moreover, research by Bing and associates revealed that the duplication of Als4 can lead to the formation of the aggregative phenotype in C. auris. This duplication enhances adherence, further complicating the relation­ship between this phenotype and virulence. Notably, aggregation can be induced by various factors, including antifungal treatments and the expression of adhesins (Malavia-Jones etal. 2023; Bing etal. 2023). Pelletier etal. recently described how aggregation can be induced in echinocandins, an essential class of antifungal drugs. Interestingly, this induction of aggregation is independent of adhesin proteins, dem­onstrating the multifaceted nature of this phenomenon (Pelletier etal. 2024). The aggregative phenotype in Candida spp. is a captivating aspect of their biology. It involves the formation of cellular clumps and has raised questions about its role in virulence. As mentioned above, while some studies suggest that nonaggregating phenotypes may exhibit higher virulence potential, others emphasize aggregation’s proinammatory nature and potential benets. Understanding the factors inuenc­ing this phenotype is crucial for unravelling the complex interactions between Candida spp. and their hosts, ultimately contributing to our knowledge of fungal pathogenesis and potential therapeutic strategies.
5.5 The Vital Role ofAdhesion inCandida Infection
Adhesion is the rst stage of the infection process for members of the Candida spp. in establishing colonization within the host environment and initiating infection (Sundstrom 2002). Adhesion is mainly established by proteins known as adhesins; these are vital components of cell walls. These adhesins play multifaceted roles, including mediating attachment to host surfaces and facilitating cell-to-cell
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connections. The fungal cell wall proteins (adhesins) are critical in adhering to the host tissue and abiotic surfaces such as medical devices like catheters, feeding tubes, and syringes (de Groot etal. 2013). Recent outbreaks in European and the UK hos­pitals have underscored the resilience of Candida auris, which can remain viable for several weeks in hospital settings and on medical instruments (Borman etal. 2016).
Adhesins are GPI-anchored proteins with their N terminal protruding at the outer surface of the cell and their C terminal attached to GPI.This initial attachment to the host surface provides a foundation for the pathogen to colonize and subsequently form a dense mesh of extracellular polysaccharides (EPS) within the biolm. These biolms, with their EPS layers, serve as barriers that hinder the penetration of drugs, contributing to the development of resistance (Ramage etal. 2010). Across Candida spp., a diverse array of adhesins can be categorized into different classes. These adhesins collectively enable the pathogen to establish a foothold within the host and navigate the complex landscape of infection.
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5.5.1 ALS Family
The ALS family of adhesins consists of eight proteins (Als1-7 and Als 9), with Als2 and Als4 showing reduced adhesion to vascular endothelial cells. Deletion of Als2p and Als4p results in decreased adhesion to a reconstituted human epithelium (RHE) model; however, it does not signicantly affect adhesion to buccal epithelial cells (Zhao etal.
2005). Moreover, ALS4 duplication in C. auris leads to the formation of aggregative
phenotype and contributes to enhanced adherence and biolm formation, which are the virulent characteristics of Candida spp. (Bing etal. 2023). Notably, adhesins within this family, such as Als1, Als3, and Als5, are capable of forming amyloids, leading to yeast aggregation (Otoo etal. 2008). The heterologous expression of C. albicans Als3 showed adherence to endothelial cells, oral epithelial cells, gelatin, etc., in nonadherent Saccharomyces cerevisiae. Als3 exhibits an invasive characteristic by mimicking cad­herin properties and binding to oral epithelial cells. This interaction leads to phagocyto­sis and subsequent invasion into the host cell (Phan etal. 2007; Nobbs etal. 2010).
5.5.2 HWP Adhesin
HWPs form tight attachments to buccal epithelial cells. The N-terminal of the adhesin has an amino acid sequence that resembles the substrate of transglutaminases, enabling strong adherence to the host cell surface. Deletion of HWP genes results in unstable adhesion and diminished ability to cause systemic candidiasis (Staab etal. 1999).
5.5.3 HYR/IFF Family
This family consists of 12 adhesins (Iff1 to Iff11 and Hyr1). Eleven of them are GPI-anchored proteins except Iff11, which is secretory in nature. Overexpression of Iff4 increases adherence to epithelial cells but not to endothelial cells. Iff4109
5 Surviving the Storm: How Candida Species Master Adaptation…
mutants in C. auris exhibit reduced adherence to substrates but did not confer com­plete loss (Santana etal. 2023). Hyr1 is involved in biolm formation, which will be discussed in the next section.
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5.5.4 EPA Family
The epithelial adhesins (EPA) family consists of 20–25 EPA genes with Epa1, Epa6, and Epa7 are majorly involved in the process of adhesion. EPA adhesins have N-terminal lectin domains that bind to host glycans for mediating attachment. Many EPA genes are under telomeric silencing regulation by the SIR2 complex. In the absence of the SIR gene, Epa1, Epa6, and Epa7 exhibited signicantly enhanced adherence to both abiotic surfaces and epithelial cells (Castaño etal. 2005). These three adhesin mutants (Epa1, Epa6, and Epa7) excel in mediating adherence across hydrophilic and hydrophobic substrates. Interestingly, while each mutant is a force to be reckoned with in its own right, no single mutant has managed to outperform the wild type (Valotteau etal. 2019).
5.5.5 Surface Colonization Factor1 (SCF1)
Recently discovered, SCF1 is specic to Candida auris and is involved in mediating attachment and colonization to host surfaces. SCF1 has the ability to bind to both hydrophilic and hydrophobic surfaces, and its expression of SCF1 across isolates of C. auris is positively correlated with the adherence variation. The N-terminal domain consists of a cationic stretch of arginine and lysine residues contributing adhesion to the substratum (Santana etal. 2023).
5.5.6 Other Putative Adhesins
Predicted GPI anchored protein, Pga59 initiates attachment through the forma­tion of amyloid brils. It contains 42 amino acids long stretch, which shows beta aggregation potential. This amyloid-mediated adhesion is essential for C. albicans to promote attachment to substrates (Mourer etal. 2023).
Pwp14 and Aed1, PA14 domains containing wall protein (PWP14) and Aed1p, adherence to endothelial cells, respectively, are involved in adherence to endothelial cells. Deleting these mutant strains results in loose adherence in the stationary phase (Desai etal. 2011).
This initial step subsequently leads to colonization and invasion in the host. Studies on adhesion factors are less explored in non-albicans Candida spp., which can provide us with targets for further studies. Targeting the initial infection step can reduce the risk of persistent colonization within the host.
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5.6 Extracellular Hydrolytic Enzymes Aids toVirulence
ofCandida spp.
5.6.1 Phospholipases
Candida species employ extracellular hydrolytic enzymes to enhance their viru­lence. Phospholipases are key players in this strategy, as they hydrolyze phospholip­ids into fatty acids and other lipophilic products. They are ubiquitously present and aid in penetrating and breaking down of the host cell by cleaving ester bonds of phospholipids. Phospholipase can be categorized into four kinds A, B, C, and D, those are encoded by following genes PLA, PLB1, PLB2, PLC1, PLC2, PLC3, and PLD1. In C. albicans, these genes are extensively studied but in non-albicans spe- cies, more experimental studies are required especially with reference to virulence and pathogenesis. Phospholipase A helps in the removal of one of the two esteried fatty acids of glycerol. However, phospholipase B removes both the fatty acid chains at once. B1 and B2 play an important role in host cell destruction. Phospholipase C cleaves the carbon-phosphate bond of phosphatidylcholine releasing phosphoryl­choline and diacylglyceride. It also plays a role in signal transduction. Phospholipase D helps in the release of choline from phosphatidylcholine to release phosphatidic acid (Tanju etal. 2001). Phospholipase activity has also correlated to virulence; in 97% of C. albicans strains isolated from denture stomatitis, patients showed higher phospholipase activity and C. dubliniensis showed moderate activity (Marcos-Arias etal. 2011). The murine model of disseminated candidiasis showed positive correla- tion between higher virulence and phospholipase activity (Ibrahim etal. 1995). Fluconazole resistant strains showed higher phospholipase activity (Ying and Chunyang 2012). In C. albicans, 30–100% strains are reported to produce phospho­lipase (Tsang et al. 2007). Non-albicans species like C. glabrata, C. tropicalis, C. krusei, and C. parapsilosis are known to produce phospholipase. Aforementioned studies substantiate that phospholipase can be a potential biomarker for systemic infection.
5.6.2 Proteinases
Proteinase hydrolyzes peptide bonds in proteins, and they differ in their mechanism of action; hence, they are classied according to their mechanism of catalysis. Proteinase can be distinguished into four classes: (a) serine proteinase, e.g., trypsin, chymotrypsin, and subtilisin, (b) aspartyl proteinase, e.g., HIV aspartyl proteinase, and pepsin and renin in humans, (c) cysteine proteinase, e.g., streptococcal protein­ase and papain, and (d) metalloproteinase, e.g., collagenases and microvillus pro­teinases (Naglik etal. 2003). SAP proteinase contributes to the virulence of the fungus and increases penetration and colonization of host tissue. These proteinases are also involved in adherence, phenotypic switching, and biolm formation, and they are also crucial for hyphal formation and involved in defence from the host immune system (Kadry etal. 2018; Veni etal. 2022; Wu etal. 2016; Zaugg etal.
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2001). Family of 10 SAP genes contributes to the production of SAP proteinase in
C. albicans, and different SAP genes help in determining the type of candidiasis. SAP 1–8 are extracellular secretory proteinase while SAP 9 and 10 are membrane-
bound GPI anchors (Naglik etal. 2003). Non-albicans species also possess SAP genes. C. tropicalis is known to produce four SAP genes, C. parapsilosis have two SAP genes; however, C. dubliniensis might have at least nine SAP genes. There are many studies which correlates SAPs with Candida virulence. C. albicans strains isolated from HIV-positive patients with vaginal candidiasis and oropharyngeal showed higher levels of SAP activity as compared to HIV-negative patients (De Bernardis etal. 1999; Ollert etal. 1995). Recent study has revealed that SAP3 shares structural similarities with HIV-1 protease. Using molecular ngerprinting of GRL-09510, an inhibitor of HIV-1 protease, virtual screening of peptidomimetic library, molecular docking, and simulations were performed. Two molecules were shortlisted which showed 50% reduction in uconazole MIC in C. albicans (Chakraborty etal. 2023). In silico studies revealed that structurally diverse drugs gentamicin, clindamycin, meropenem, metronidazole, and aztreonam showed high binding energy with core catalytic residues of SAP and can be used for drug repur­posing (Dhanasekaran et al. 2023). Melianone, a triterpenoid, from Swietenia mahagoni, showed IC50 0.1 μM via interacting with a catalytic site of SAP6 which hampers hyphal formation (Veni etal. 2022).
5.6.3 Hemolysins
Iron acquisition is important for any pathogen to survive and cause infection. However, free iron is absent in host microenvironment, and it is only available in a haemoglobin bound state. So, in order to acquire the iron molecules, bound to hae­moglobin, many human pathogens secrete a hydrolytic enzyme called hemolysins. It facilitates pathogen in degrading cellular component of blood and haemoglobin breakdown causing iron release which helps in persistence and hyphal invasion dur­ing systemic or disseminated candidiasis, making it a crucial virulence factor. Hemolysis activity can be demonstrated using Sabouraud dextrose agar media with 7% fresh blood at 37°C in 5% CO2 for 48h. Formation of translucent greenish or black precipitation zone around the inoculum indicates positive hemolysins activity (Yigit and Aktas 2009). Hemolysins can be categorized into three types: alpha, hav­ing incomplete hemolytic activity; beta hemolysins can completely hydrolyze hemoglobin and it is present in both C. albicans and non-albicans species; gamma hemolysins are completely inactive (Luo etal. 2001). Hemolysins production can be controlled by blood glucose levels and certain electrolytes. High blood glucose levels can enhance hemolysins production and electrolytes like NaCl, CaCl2 and KCl can supress its production (Malcok etal. 2009; Wan etal. 2015). A recent study with 100 clinical isolates of Candida species revealed that C. albicans showed max­imum hemolytic activity in 96% strains, which was followed by C. tropicalis (87%) and C. krusei (55.5%) (Aparna etal. 2023). However, study by (Pandey et al. (2018)), in 79 strains isolated from patients admitted in ICU revealed 95.8% of
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C. tropicalis, 90.9% strains of the C. krusei, and 87.5% strain of C. albicans showed hemolytic activity (Pandey etal. 2018). Another study in which hemolytic activity of Candida strain isolated from HIV-positive and HIV-negative patients revealed that 15.2% strains exhibit less hemolytic activity in HIV-negative patients (Fathi etal. 2022).
5.6.4 Lipases
Lipases, carboxylic ester hydrolases aid in nutrient acquisition through lipid diges­tion. They are carboxylic ester hydrolases and can also be termed as triacylglycerol hydrolases. They hydrolyze triglycerides into diglycerides releasing monoglycer­ides, fatty acids, and glycerol. Lipases are reported to have role in adhesion to host tissue and also initiating inammation (Inci etal. 2012; Khedidja and Abderrahman
2011). They are encoded by a gene family of ten members (LIP1-10), with varying
expression proles in different invivo conditions. In mouse model of systemic can­didiasis, an expression prole of LIP genes was observed using RT-PCR and showed that levels of LIP genes were varied during different infection stages. Samples from oral candidiasis patients revealed highest expression of LIP5 and LIP8 genes (Stehr etal. 2004). Another study showed that extracellular secreted lipases from C. albi- cans causes lipid droplet accumulation in macrophages and hepatocytes causing cytotoxicity probably due to ROS production (Paraje et al. 2008). Non-albicans Candida species (NCAS) like C. parapsilosis, C. tropicalis, and C. krusei also pos- sess the orthologs of C. albicans LIP1 (Park etal. 2016). Extracellular hydrolytic enzymes are critical for the virulence of Candida species and provide potential tar­gets for therapeutic interventions. Understanding their roles and regulatory mecha­nisms is essential for combating Candida infections.

5.7 Secreted Cytolytic Peptide: Candidalysin

Candida albicans, a leading human fungal pathogen, deploys various virulence fac­tors to transition from a commensal to a pathogenic state. Among these factors, Candidalysin stands out as the rst amino acid peptide toxin discovered in any human fungal pathogen. This remarkable toxin plays a crucial role in the host­pathogen interaction and pathogenesis. Library screening of C. albicans for those mutants which can form hypha but unable to induce damage, cytokines or cFOS/ MAPK signalling led to the discovery of Candidalysin. Interestingly, single mutant, ECE1 (extent of elongation), was identied with such specic characteristics (Moyes etal. 2016). Ece1p protein has 271 amino acids (Birse etal. 1993). It pos­sesses seven arginine-lysine (KR) motif which is dispersed throughout the total pro­tein. These KR motifs are cleaved by Kexin (Kex2p) which can cleave the whole peptide into eight sites. Later on, site-directed mutagenesis studies showed that Kex2p cleaves the peptide from Arg61 and Arg93 producing 32 amino acid long peptide which was indispensable for damage induction. The peptide was α-helical,
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amphipathic, and had two amyloidogenic regions (Richardson etal. 2018). The transition of C. albicans from a commensal to a pathogenic state initiates with hyphal formation. Increased hyphal burden led to the production of Candidalysin. When Candidalysin concentration accumulates to a threshold, it interacts with cell wall leading to membrane damage by creating pores. This membrane damage causes the release of lactate dehydrogenase (LDH) and calcium inux, which in turn activates matrix metalloproteinases and leads to the release of EGFR ligands. These ligands bind to the EGFR receptor, initiating the MAPK signalling pathway through p38 and ERK1-2 and inducing c-Fos transcription factor. ERK1-2 activates MKP-1 which dephosphorylates p38, thereby regulating the epithelial immune response. The activation of c-Fos leads to the production of proinammatory media­tors like chemokine and cytokine which recruit innate immune cells such as neutro­phils and natural killer cells and Th-17 cells. These immune cells work together to clear the fungal burden (Moyes etal. 2012) (Fig.5.3). Candidalysin is also known to trigger NLRP3 inammasome. It induces primary macrophages, primary monocyte- derived macrophages, and dendric cells to create NLRP3 inammasome by recruiting other inammatory cell subtypes in human and mouse (Kasper etal.
2018; Rogiers etal. 2019). Candidalysin also have potential to be used as a bio-
marker since this toxin peptide is specic to pathogen and candidalysin can also be utilized as a therapeutic target. Sophorolipid (SL) was observed to downregulate the transcript level of ECE1, ALS1, ALS3, HWP1, and SAP4 genes and SL treatment also reduced hyphal formation. In combination with antifungals like uconazole
Fig. 5.3 Molecular pathway: candidalysin-induced immune response: increased hyphal bur­den leads to the accumulation of candidalysin, which triggers LDH release and calcium inux, leading to the activation of matrix metalloproteinases, which in turn activates EGFR via EGFR ligands. The activation of EGFR induces MAPK signalling via p38 and ERK1/2. These events nally lead to the activation of the c-Fos transcription factor, causing the release of cytokine and chemokine and, ultimately, the recruitment of immune cells
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and amphotericin B, SL acts synergistically to reduce biolm formation (Haque etal. 2016). Another compound, minocycline, a tetracycline derivative, was also shown to downregulate level of ECE1, ALS3, and HWP1 and blocks yeast to hyphal transition (Kurakado etal. 2017). Allicin, active compound isolated from garlic, showed the downregulation of ECE1 and SIR2 genes in C. albicans strains isolated from vulvovaginal candidiasis patients (Said etal. 2020).
etal. 2016). Interestingly, other pathogenic species such as C. glabrata, C. parapsi- losis, and C. auris do not harbor candidalysin or Ece1p or orthologs. C. tropicalis and C. dubliniensis candidalysin are reported to have enhanced cytolytic and immu- nostimulatory effect as compared to C. albicans; however, both the aforementioned species are less pathogenic than C. albicans (Richardson et al. 2022). While Candidalysin plays a central role in C. albicans pathogenicity, its orthologs diverse effects in other Candida species highlight the complexity of host-fungal interac­tions and the need for further research in this area.
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5.8 pH Sensing andAdaptation Mechanism
inCandida Species
The pH adaptation in Candida species involves the Rim pathway. The Rim pathway is conserved throughout the fungal kingdom. The processes begin when two trans­membrane receptors called Rim9 and Rim21/Dfg16 sense the external pH.When pH is neutral or alkaline, it activate the Rim9 and Rim21, leading to hyperphos­phorylation of Rim8, which is an arrestin (Davis etal. 2000). Rim8 triggers the endocytosis of transmembrane complex and assembly of endosomal sorting com­plexes required for transport (ESCRT) I, II, and III on Rim 101 (Xu etal. 2004). Along with ESCRT complex, Rim13 is involved in the proteolysis of Rim101 and recruits Rim 20, a scaffolding protein. Overall, this complex cleaves C-terminal domain of Rim101 and produces active transcription factor which migrates to the nucleus where it helps in regulating various processes such as yeast to hyphal transi­tion, biolm formation, cell wall remodelling, adhesion, iron metabolism, and more. Disruption of Rim101 in C. albicans increase susceptibility to antifungals like azoles and echinocandins (Cornet etal. 2006). The Rim101 pathway modulates cell wall structure through PHR1 and PHR2, which codes for cell wall transglycosi­dases. Under alkaline pH, Rim101 positively regulates PHR1 and negatively regu­lates PHR2 causing hypha formation (Davis etal. 2000; Mühlschlegel and Fonzi
1997) (Fig.5.4).
Candida adapts to different acidic niches inside the host, such as the oral tracts, stomach lining (pH 2–7.7), and vaginal tracts (pH 3.8–5). The Rim101 pathway also have a crucial role in acidic pH induced cell wall remodelling.