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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5219_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Foreword
- •Preface
- •Contents
- •Editors and Contributors
- •About the Editors
- •Contributors
- •1.1 Introduction
- •1.2 Conventional Methods
- •1.2.1 Microscopy
- •1.2.2 Culture
- •1.2.3 Germ Tube Test
- •1.2.5 Carbohydrate Assimilation Test
- •1.2.6 Nitrogen Assimilation Test
- •1.2.7 Carbohydrate Fermentation Test
- •1.2.8 Urease Test
- •1.2.9 Tween 80 Opacity Test
- •1.3 Nonculture-Based Conventional Methods
- •1.3.1 Serological Methods
- •1.3.1.2 ß-d-Glucan
- •1.3.1.3 C. albicans Germ Tube Antibody Assay (CAGTA)
- •1.4 Nucleic Acid-Based Detection
- •1.4.1 Polymerase Chain Reaction (PCR)
- •1.4.3 Peptide Nucleic Acid FISH (PNA-FISH)
- •1.4.4 PCR-Based Innovative Diagnosis
- •1.4.5 FilmArray System
- •1.4.6 Sepsis Flow Chip
- •1.4.7 ePlex System
- •1.4.8 The T2 Candida Assay
- •1.5 Rapid Identification Systems
- •1.5.1 Manual Rapid Identification System
- •1.5.1.1 The API System
- •1.5.1.2 The VITEK System
- •1.5.2 Automatic Rapid Identification System
- •1.5.2.1 MALDI-TOF MS
- •1.5.2.2 The MALDI Sepsityper IVD Kit
- •1.5.2.3 The BioFire FilmArray BCID2 Panel
- •1.5.2.4 The Accelerate Pheno BC Panel
- •1.6 Advanced Diagnostics
- •1.6.2 Biosensor-Based Tests
- •1.6.3 Next-Generation Sequencing (NGS)
- •1.7 Conclusion
- •References
- •2.1 Introduction
- •2.2.1.2 Echinocandins
- •First-Generation Echinocandin
- •Second-Generation Echinocandin
- •2.2.1.3 Other Cell Wall Inhibitors
- •2.2.2.1 Azoles
- •Imidazole
- •Triazole
- •Second-Generation Azole
- •Third-Generation Azole
- •2.2.2.2 Polyenes
- •Other Polyene Under Development
- •2.2.2.3 Allylamines
- •2.2.3 Flucytosine
- •2.3 Conclusion
- •References
- •3.1 Introduction
- •3.2.1 Control Diet
- •3.2.3 Toxification
- •3.2.4 Alternative Treatments
- •3.3.1 Prophylaxis
- •3.3.2 Preemptive Therapies
- •3.3.3 Empirical Therapies
- •3.4 Therapeutic Approach
- •3.4.1 Azoles
- •3.4.2 Echinocandins
- •3.4.3 Polyenes
- •References
- •4.1 Introduction
- •4.3 Eukarya Domain
- •4.4.1 Cryptococcus
- •4.4.2 Aspergillus
- •4.4.3 Mucorales
- •4.4.4 Candida
- •4.5.1 Candida albicans
- •4.5.2 Morphogenesis
- •4.5.3 Pathogenesis
- •4.5.4 Adherence
- •4.5.5 Morphological Switching
- •4.5.6 Invasion
- •4.6 Induced Endocytosis
- •4.7 Active Penetration
- •4.8.2 Biofilm Formation
- •4.8.4.1 Antifungals
- •4.8.4.2 Antifungal Resistance
- •References
- •5.1 Introduction
- •5.2.3.1 Serum
- •5.2.3.2 Low Nitrogen
- •5.2.3.5 Carbon Source
- •5.2.3.6 pH
- •5.2.3.7 N-acetylglucosamine (GlcNAc)
- •5.2.3.8 Quorum Sensing Molecule
- •5.5.5 Surface Colonization Factor1 (SCF1)
- •5.5.6 Other Putative Adhesins
- •5.6.1 Phospholipases
- •5.6.2 Proteinases
- •5.6.3 Hemolysins
- •5.6.4 Lipases
- •5.7 Secreted Cytolytic Peptide: Candidalysin
- •5.5.1 ALS Family
- •5.5.2 HWP Adhesin
- •5.5.3 HYR/IFF Family
- •5.5.4 EPA Family
- •5.9.2 Low Molecular Weight Hsp/Small Heat Shock Proteins
- •5.10.1 Amino Acid/Nitrogen Metabolism
- •5.10.1.1 Amino Acid Sensing Pathway
- •5.12.1.1 Glycolysis
- •5.12.1.2 Gluconeogenesis
- •5.12.1.3 Glyoxylate Cycle
- •5.12.1.4 Fatty Acid Oxidation
- •5.12.3.2 Iron Metabolism
- •5.12.3.3 Candida Iron Transport
- •5.12.3.4 Reductive System
- •5.12.3.5 Siderophore Uptake System
- •5.12.3.6 Haemoglobin-Iron Uptake System
- •5.13.2 Zinc Metabolism
- •References
- •6.1 Introduction
- •6.2 Morphological Switching
- •6.3 Phenotypic Switching
- •6.4 Biofilm Formation
- •6.5 Metabolic Flexibility
- •6.8.1 Hemolysin
- •6.8.2 Phospholipases
- •6.8.3 Proteinase
- •6.8.4 Candidalysin
- •6.12 Conclusion
- •References
- •7.1 Introduction
- •7.2.4 Polymorphism
- •7.2.5.1 Secreted Aspartyl Proteinases
- •7.2.5.2 Phospholipase
- •7.2.6 Calcineurin-Signalling Pathway
- •7.2.7 Ion Homeostasis
- •7.2.7.1 Iron
- •7.2.7.2 Copper
- •7.2.8.1 Capsule
- •7.2.8.2 Melanin
- •7.2.8.3 Heat Shock Proteins
- •7.3 Conclusions
- •References
- •8.1 Introduction
- •8.4.1 ATP-Binding Cassette (ABC) Transporters
- •8.4.2 Major Facilitator Superfamily (MFS) Transporter
- •8.5.1 Biofilm Architecture Among Candida Species
- •References
- •9.1 Introduction
- •References
- •10.1 Introduction
- •10.3 Biofilm
- •10.5 Adherence
- •10.6 Maturation
- •10.8 Dispersion
- •10.11 Animal Models
- •10.18 Photodynamic Therapy
- •References
- •11.1 Introduction
- •11.9 Concluding Remarks
- •References
- •12.1 Introduction
- •12.2 Epidemiology
- •12.3.1 Humoral Response
- •12.3.2 Cellular Immunity
- •12.4 Virulence Factors
- •12.6.1 Fluconazole
- •12.6.2 Polyenes
- •12.6.3 Echinocandins
- •12.7 Drug Resistance
- •12.8 Future Prospects
- •12.9 Conclusions
- •References
- •13.1 Introduction
- •13.4 Translation Research
- •13.4.1 Disease-Oriented Translational Research
- •13.4.2 Lab-Oriented Translational Research
- •13.4.3 Patient-Oriented Translational Research
- •13.5 Conclusion
- •References
- •14.1 Introduction
- •14.2.3 Cutaneous Aspergillosis
- •14.2.4 Ocular Aspergillosis
- •14.2.5 Aspergillus Endocarditis
- •14.2.6 Aspergillus Osteomyelitis
- •14.2.7 Sinus Aspergillosis
- •14.3.2 Histopathology
- •14.3.3 Serological
- •14.3.4 Breath Testing
- •14.3.5 Monoclonal Antibody (mAbs)-Mediated Methods
- •14.4.1 Conventional Therapeutics
- •14.4.1.1 Azoles
- •14.4.1.2 Polyenes
- •14.4.1.3 Echinocandins
- •14.4.1.4 Fluoropyrimidines
- •14.5 Nonconventional Therapeutics
- •14.5.1 Vaccine
- •14.5.2 Monoclonal Antibodies (mAbs)
- •14.5.3 Nanotechnology-Based Therapeutics
- •14.5.4 Immune Therapy
- •14.5.5 Combination Therapy
- •14.8 Conclusion
- •References
- •15: Aspergillus Therapeutics: Future Agents
- •15.1 Introduction
- •15.2.1 Fosmanogepix
- •15.2.2 Ibrexafungerp
- •15.2.3 Olorofim
- •15.2.4 Opelconazole
- •15.2.5 Rezafungin
- •15.2.6 MGCD290
- •15.2.7 Tetrazoles (VT-1129/VT-1161/VT-1598)
- •15.2.8 Nikkomycin Z
- •15.2.9 VL-2397
- •15.2.10 T-2307/ATI-2307
- •15.2.11 Encochleated Amphotericin-B
- •15.2.12 SUBA-Itraconazole
- •15.2.13 Immunotherapy
- •15.2.14 Drug Repurposing
- •References
- •16.1 Introduction
- •16.2 Antifungal Agents
- •16.2.1 Azoles
- •16.2.2 Posaconazole
- •16.2.3 Isavuconazole
- •16.2.4 SUBA—Itraconazole
- •16.2.5 Nanovoriconazole
- •16.2.6 Adverse Effects
- •16.3 Liposomal Amphotericin B (LAMB)
- •16.3.1 Echinocandins
- •16.4 Combination Antifungal Therapy
- •16.5 Therapeutic Drug Monitoring (TDM)
- •16.5.1 Azole-Resistant Aspergillus Spp.
- •16.6 Guideline Recommendations
- •16.10 Conclusion
- •References
- •17.1 Introduction
- •17.3 Potent Antifungal Molecules Under Investigations
- •References
- •19.2 Host–A. fumigatus Interactions
- •19.3.1 Hydrophobicity or Rodlet Layer
- •19.3.2 Conidiation
- •19.3.3 DHN Melanin
- •19.3.5 Siderophores
- •19.3.6 Biofilm Formation
- •19.4 Conclusion
- •References

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 WOR2in the regulatory process
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another layer of versatility to its behaviour (Lachke etal. 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 etal. 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-specic regulator UME6 was upregulated in pink colonies. Certain
GPI-anchored genes, such as ALS4 (adhesin), RBT4 (hyphal specic), and CSA1
(hyphal specic surface antigen), were found to be upregulated in pink colonies
(Deng etal. 2021).
5.3 Biofilm inCandida Species
Biolms are intricate microbial communities that adhere to surfaces and are
enclosed within a mesh-like matrix. The biolm formation as a critical weapon in
fungal pathogens virulence arsenal. The biolm 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 biolm from engulfment by phagocytes. The
nal step in this intricate process involves dispersing cells from the matured biolm
to new areas, fostering the growth of unique microbial communities. It is worth noting that the structure of biolms varies across Candida spp., with lamentous cells
dominating in C. albicans and single-celled yeast forms in C. glabrata (Lagree and

118
A. Rana et al.
Mitchell 2017). The formation of biolms on medical implanted devices represents
a signicant 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 biolm development.
Biolm 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 specic role in the different stages of biolm development.
The transcriptional network identied by Nobile etal. 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 biolm formation.
Each transcription factor is involved at a specic stage of biolm formation (Nobile
etal. 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 biolm.
TEC1 controls the expression of BCR1, which ne-tunes the downstream adhesion
genes. TEC1 is regulated by EFG1, which is involved in lamentous growth. Biolm
maturation is handled by NDT80, ROB1, and BRG1 (Araújo etal. 2017).
The formation of biolms is further complicated by variations observed on different surfaces, such as mucosal or venous catheters. Transitioning from invitro
biolm phenotypes to invivo results can be complicated. C. auris biolm shows
heterogeneity on different substrates. The existing methods for biolm formation
lack a standardized surface, leading to challenges in reproducibility in case of
C. auris. Thermanox (polystyrene) coverslips for invitro growth of C. auris biolm,
resulting in a single layer of yeast cells on the coverslip and multilayered biolm on
porcine skin surfaces in synthetic sweat media (Zheng etal. 2021; Horton et al.
2020). A recent method developed by Biswas etal., 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 biolm analysis through three-dimensional (3D) reconstruction. Additionally,
this invitro biolm formation technique extends its utility to studying biolm formation in other Candida species, such as C. glabrata and C. albicans, accurately
mimicking their biolm formation environments. Consequently, this innovation
in vitro method holds signicant potential for comprehending the mechanisms
underlying biolm formation (Biswas etal. 2023a).
While the regulation of biolm formation appears tightly controlled, there is still
much to understand about how these phenotypic changes contribute to differences
in biolm development.
5.4 Aggregation inCandida 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 specic protein that plays a pivotal role in this clumping process
(Kumar etal. 2015). Additionally, coaggregation with other Candida spp. or even

5 Surviving the Storm: How Candida Species Master Adaptation…
119
various microbial entities is controlled by Als1p, another key player in the formation of aggregates (Klotz etal. 2007). In C. auris, cells have been found to form
large cellular clumps, often referred to as aggregates (Borman etal. 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 etal. 2017).
In contrast, other studies have highlighted the proinammatory 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 identied as inuencers 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 etal. 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 etal. 2023; Bing etal. 2023). Pelletier etal. 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 etal. 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
proinammatory nature and potential benets. Understanding the factors inuencing 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 ofAdhesion inCandida 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

120
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 etal. 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 etal. 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 biolm. These
biolms, with their EPS layers, serve as barriers that hinder the penetration of drugs,
contributing to the development of resistance (Ramage etal. 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.
A. Rana et al.
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 signicantly affect adhesion to buccal epithelial cells (Zhao etal.
2005). Moreover, ALS4 duplication in C. auris leads to the formation of aggregative
phenotype and contributes to enhanced adherence and biolm formation, which are the
virulent characteristics of Candida spp. (Bing etal. 2023). Notably, adhesins within this
family, such as Als1, Als3, and Als5, are capable of forming amyloids, leading to yeast
aggregation (Otoo etal. 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 etal. 2007; Nobbs etal. 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 etal. 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 etal. 2023). Hyr1 is involved in biolm formation, which will be
discussed in the next section.
121
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 signicantly enhanced
adherence to both abiotic surfaces and epithelial cells (Castaño etal. 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 etal. 2019).
5.5.5 Surface Colonization Factor1 (SCF1)
Recently discovered, SCF1 is specic 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 etal. 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 etal. 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 etal. 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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A. Rana et al.
5.6 Extracellular Hydrolytic Enzymes Aids toVirulence
ofCandida 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 esteried
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 etal. 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
etal. 2011). The murine model of disseminated candidiasis showed positive correla-
tion between higher virulence and phospholipase activity (Ibrahim etal. 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 classied 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 etal. 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 biolm formation, and
they are also crucial for hyphal formation and involved in defence from the host
immune system (Kadry etal. 2018; Veni etal. 2022; Wu etal. 2016; Zaugg etal.

5 Surviving the Storm: How Candida Species Master Adaptation…
123
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 etal. 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 etal. 1999; Ollert etal. 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 etal. 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 etal. 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 48h. 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 etal. 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 etal. 2009; Wan etal. 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 etal. 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 etal. 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
etal. 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 inammation (Inci etal. 2012; Khedidja and Abderrahman
2011). They are encoded by a gene family of ten members (LIP1-10), with varying
expression proles in different invivo conditions. In mouse model of systemic candidiasis, an expression prole 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
etal. 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 etal. 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 identied with such specic characteristics
(Moyes etal. 2016). Ece1p protein has 271 amino acids (Birse etal. 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,

5 Surviving the Storm: How Candida Species Master Adaptation…
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amphipathic, and had two amyloidogenic regions (Richardson etal. 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 inux, 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 proinammatory 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 etal. 2012) (Fig.5.3). Candidalysin is also known
to trigger NLRP3 inammasome. It induces primary macrophages, primary
monocyte- derived macrophages, and dendric cells to create NLRP3 inammasome
by recruiting other inammatory cell subtypes in human and mouse (Kasper etal.
2018; Rogiers etal. 2019). Candidalysin also have potential to be used as a bio-
marker since this toxin peptide is specic 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 inux,
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 biolm formation (Haque
etal. 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 etal. 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 etal. 2020).
etal. 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.
A. Rana et al.
5.8 pH Sensing andAdaptation Mechanism
inCandida 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 etal. 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 etal. 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, biolm formation, cell wall remodelling, adhesion, iron metabolism, and more.
Disruption of Rim101 in C. albicans increase susceptibility to antifungals like
azoles and echinocandins (Cornet etal. 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 etal. 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.
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