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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

7 Factors Aecting Drug Resistance andVirulence inFungal Pathogen
179
library was used to complement the Pdr5p null mutant of Saccharomyces cerevisiae
and was considered the beginning of the recognition of the role of ABC proteins in
drug efux in pathogenic yeasts (Prasad etal. 1995). Similarly, CaCDR1 deletion
leads to sensitivity to several unrelated drugs, and the clinically resistant isolates of
C. albicans often show overexpression of CaCDR1 (Kumari etal. 2021). Later,
another transporter Cdr2p was found in C. albicans involved in resistance to many
drugs including azoles (Sanglard etal. 1997). Candida genome database analysis
has revealed a total of 26 putative ABC proteins, 19 of which are transporters that
exhibit both NBDs and TMDs (Prasad etal. 2015). Other clinically relevant Candida
species such as C. auris and C. glabrata have 28 and 25 ABC proteins, respectively
(Wasi etal. 2019; Kumari etal. 2018). Similarly, A. fumigatus AtrF is upregulated
during culture with itraconazole and is the rst ABC transporter associated with
resistance in molds (Slaven etal. 2002).
The MFS transporters also expel a range of substrates and are involved in resistance (Drew etal. 2021). MFS transporters are categorized into two drug-related
families: H+ antiporter families 1 (DHA1) and 2 (DHA2). The number of transmembrane spans (TMS) varies between these two families, with the rst family having
12 and the second having 14 (Costa etal. 2014). The C. albicans genome’s computational study revealed 95 putative MFS proteins, grouped into 17 families, including DHA1 and DHA2. Only a small number of them linked to resistance in
pathogenic fungi. DHA1 transporters in C. albicans (CaMdr1, CaNag3, CaNag4,
and CaNag6) and C. glabrata (CgQdr2, CgAqr1, CgTpo1_1, CgTpo1_2, and
CgTpo3) are involved in resistance to various drugs (Gaur etal. 2008). Interestingly,
in addition to resistance, the deletion of CgTpo1_1 and CgTpo1_2 also leads to a
reduction in virulence in the Galleria mellonella model and deletion of CgTpo1_2
prevents biolm formation (Santos etal. 2017). In C. glabrata, Qdr2p is found to be
necessary for adhesion, biolm formation, and biolm resistance to uconazole
(Widiasih Widiyanto et al. 2019). Similarly, deletion of the QDR genes (QDR1,
QDR2, and QDR3) in C. albicans results in biolm formation defects such as struc-
tural and thickness impairments (Shah etal. 2014). Thus, MFS antiporters, although
sometimes not acting as drug transporters, can signicantly inuence virulence.
7.2.2 Mutation intheGenes Coding forDrug Targets (ERG
andFKS)
The fungal sterol ergosterol is unique in the fungal kingdom. Its multistep biosynthesis (requiring nearly 20 enzymes) and its accumulated content in the membrane
are the targets of many antifungal drugs, including azoles and polyenes. Some proteins involved in its synthesis (Erg11p and Erg3p) are either inactivated, mutated, or
overexpressed and contribute to resistance (Ksiezopolska etal. 2021). Azoles bind
and inhibit 14α-lanosterol demethylase, a cytochrome P450 enzyme (CYP51)
encoded by the ERG11 gene, and cause lanosterol accumulation. Although it is not
an accumulation of lanosterol, rather its conversion to 14-methylated intermediates
via an alternative pathway that is lethal to the fungal cell (Warrilow etal. 2010).

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P. Sharma et al.
Given the importance of the protein for fungal survival, its importance for resistance
development in fungi, including C. albicans, is easy to understand. Mutations in
ERG11 alter the spatial structure of Erg11p, which reduces the afnity of the protein
for azoles (Sardari et al. 2019). Several point mutations in Erg11p have been
reported to contribute to the formation of azole resistance (Lamb etal. 2000). Many
point mutations, including R467K and T315A, result in a conformational change
and a reduction in afnity for uconazole compared to wild-type Cyp51 (Lamb
etal. 1997; Akins 2005). A. fumigatus also develops azole resistance either by over-
expression or modication of Cyp51A.A single amino acid substitution (G138C,
Y431C, and G434C) and the tandem copies in the promoter of the Cyp51A gene
have been reported in previous studies (Albarrag etal. 2011). In C. albicans, the
ERG3 gene encodes a sterol C5,6-desaturase, which is required for ergosterol production. Variations in the ergosterol synthesis pathway caused by C5,6-desaturase
inactivation are recognized variables leading to azole resistance invitro (Sanglard
etal. 2003). Clinical isolates of C. albicans with a homozygous nonsense mutation
are highly resistant to uconazole and moderately resistant to Amp B, and the
mutants are shown to be less virulent in the murine infection model (Chau etal.
2005). Similarly, a missense mutation (R135I) in ERG3 of C. parapsilosis leads to
azole resistance (Branco etal. 2017).
For invasive candidiasis, echinocandins are the rst line of treatment until the
species is identied and veried by clinical diagnosis. The FKS genes encoding
glucan synthase, which embed β-(1,3)-D-glucan into the cell wall, are blocked by
echinocandins (Fig.7.2). However, echinocandin resistance due to single residue
substitutions in the hotspot regions (catalytic domains) of FKS1 and FKS2 has
already been reported (catalytic domains) (Lackner et al. 2014). There are two
genes, FKS1 and FKS2, in C. glabrata and three in C. albicans. In C. glabrata,
S629F and D632Y (in Fks1) lead to an increase in resistance to all three variants of
echinocandin drugs (Garcia-Effron etal. 2009). Similar reports of reduced sensitivity of the enzyme in C. auris have been reported following substitution in the FKS
gene (Kordalewska and Perlin 2019). In C. auris, the two hotspot regions of the
FKS1 gene extend from F635–P643 and D1350–L1357 (Asadzadeh etal. 2022).
Many point mutations have already been reported, including S639Y, S639P, D642Y,
and R1354S, which are relevant in both invitro and invivo studies and are resistant
to echinocandins (Hirayama et al. 2023). However, the role of mutations in the
FKS2 gene of C. auris in conferring echinocandin resistance has not yet been eluci-
dated. In addition, an F675S amino acid substitution in hot spot 1 (675–684) of
A. fumigatus has been reported to alter susceptibility to echinocandins (JiménezOrtigosa etal. 2017). However, C. neoformans has intrinsic resistance to echinocandins, while no FKS1 point mutations have been found in its genome (Cao etal.
2019), despite the sensitivity of β-(1,3)-D-glucan synthase activity to echinocandins
(Maligie and Selitrennikoff 2005).

7 Factors Aecting Drug Resistance andVirulence inFungal Pathogen
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7.2.3 Quorum Sensing andBiofilm Formation
Quorum sensing (QS) regulates the metabolic activity of planktonic cells, induces
microbial biolm formation and contributes to virulence. In this type of intercellular
communication, the microbes communicate via the synthesis and secretion of cell
signaling molecules. Once the Secreted signaling molecule reaches a threshold
level, the fungus can detect sufcient cell density (Padder etal. 2018). The importance of QS is illustrated by the fact that its inhibition has become a focus in the
development of new antifungal drugs. In addition to biolm formation, it also contributes to antibiotic resistance, virulence factors, bioluminescence and sporulation
(Hogan 2006)
QS begins with the formation of various small molecule signalling molecules,
called autoinducers (AIs), with a transcriptional activator protein that regulates their
own gene expression and controls pathogenicity in a variety of microorganisms
(Tian etal. 2021). Farnesol, a primary signalling substance in C. albicans, controls
the transition from yeast to hyphae. Farnesol binds to the Ras1 protein, which activates the adenylate cyclase Cyr1, which further increases the concentration of
cAMP necessary for lamentous growth in biolms (Ramage et al. 2002b).
Additionally, the plasma membrane of mammalian cells can internalize the quorum
sensing molecule (QSM) farnesol, which enhances the ability of C. albicans to
weaken host immunity. Here, farnesol considerably reduces the production of the
Th1 cytokines, interferon-γ (IFN-γ) and interleukin-12 (IL-12), which affects the
protective immunity development against systemic candidiasis (Tian etal. 2021).
Farnesol also obstructs the capability of immature dendritic cells to properly initiate
the T-cell response and differentiation of monocytes into mature dendritic cells
(Cottier et al. 2019). It also masks the pathogen-associated molecular patterns
(PAMP) β-glucan of C. albicans, which prevents their recognition and the initiation
of the immune response against the pathogen (Cottier etal. 2019). The QSM farnesol also provides C. albicans with resistance to oxidative stress by increasing the
reactive oxygen species (ROS) production in the mitochondria. Raised ROS levels
under hypoxic conditions are caused by the cAMP-PKA signalling pathway and
mitochondrial signalling, which increases β-glucan masking (Pradhan etal. 2018).
In 2007, Kwon-Chung identied Qsp1 as the rst known Cryptococcus QSM (Lee
etal. 2007). This QS peptide, Qsp1, is produced from a 24-amino acid pro-peptide
precursor, called proQSP1. The cell wall-associated serine protease Pqp1 cleaves
proQsp1 and helps to release the mature Qsp1. This Qsp1 activates intracellular
signalling cascades by entering fungal cells (Homer etal. 2016). Null mutants of
Δqsp1 show reduced infection, slower tissue accumulation, and an increase in mac-
rophage engulfment. At high cell densities, Qsp1 facilitates autoregulatory signals
that regulate secreted protease activity and improve cell wall integrity. Even melanin production, a crucial component of C. neoformans pathogenicity, can be attenuated by Qsp1 (Homer etal. 2016).
Some lamentous fungi use QS to control sexual differentiation. For example,
QS oxylipins, oxygenated fatty acid derivatives, are important for maintaining the

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P. Sharma et al.
ratio of ascospore to conidia in A. nidulans (Tsitsigiannis etal. 2005) and A. avus
(Horowitz Brown etal. 2008).
After the successful initiation of QS, biolm development begins and culminates
in the production of the extracellular matrix. Mature fungal biolms consist of
adherent cell communities surrounded by this extracellular matrix. Dimorphism, in
which fungal cells morphologically switch between yeast and hyphal forms, is critical for formation of biolm pathogenicity and broadly enables the fungus to transition to a pathogen (Cowen etal. 2015). During initiation, the spherical yeast cells
adhere to a solid surface. This phase, commonly referred to as ‘seeding’, is necessary for the proper growth of the biolm. In the following steps, the cells multiply
and early lament formation begins. This is followed by maturation of the biolm,
resulting in a complex network of polymorphic cells coated by an extracellular
matrix, including hyphal cells, pseudohyphae, and round yeast cells, which give the
biolm a thick and textured appearance and protect it from chemical and physical
injuries (Fig.7.3) (Gulati and Nobile 2016). Both yeast adhesion to epithelial cells
and hyphal development require hyphal wall protein 1 (Hwp1). The glucans and
mannans are important exopolysaccharides (EPS) associated with biolm formation. The agglutinin-like sequence 3 (ALS3) and the EAP1 gene, which encodes a
cell surface glycoprotein and a glycosylphosphatidylinositol-anchored glucancross- linked cell wall protein, respectively, are essential for biolm adhesion and
production (Li etal. 2007). The extracellular polysaccharides form the matrix and
the surface-associated microbial population organizes into a three-dimensional
Fig. 7.3 Yeast cells (blue) adhere to the surface (grey) to start biolm formation. In the initial
phase of the biolm, hyphal cells develop and the fungal cells multiply. The extracellular matrix is
then formed. The extracellular matrix builds up during the development phase. The yeast cells
nally disperse to a new location and form a completely new biolm

7 Factors Aecting Drug Resistance andVirulence inFungal Pathogen
183
community. The mechanical scaffold in the biolm defends the cells (Ghannoum
etal. 2015).
In patients, fungal biolms develop on many different medical devices, such as
dentures, prostheses, ventricular assist devices, central venous catheters, urinary
catheters, and prostheses. In addition, mucosal surfaces in the mouth and vaginal
area can also promote the growth of biolms (Ramage etal. 2009). Biolms are
resistant to antifungals and host defences and are a protective feature of many fungi.
For this reason, they are extensively studied. The cells in biolms are resistant to
antifungal drugs and host defences, making biolm infections difcult to treat.
Biolms protect the fungi from the various innate immune system components,
such as neutrophil and monocyte-mediated death (Kernien etal. 2018). The predominant species, C. albicans, has been used in both invitro and invivo biolm
researches. However, non-albicans species, including C. tropicalis, C. parapsilosis,
and C. glabrata, also form clinically signicant biolms, although the extent may
vary depending on strain and environment (Kojic and Darouiche 2004). In particular, in mature biolms, the genes that produce efux pumps such as ABC and MFS
transporters are the reasons for antifungal drugs resistance, including azoles (Kean
etal. 2018). Ramage etal. investigated the role of efux transporters Cdr1 and
Mdr1in planktonic cells and biolm after 24h. The genes CDR1 and MDR1 are
upregulated during biolm development. The mutants lacking CDR1 and MDR1 are
hypersensitive to azoles, but the biolms of the mutants maintained the resistant
phenotype during biolm development. This directly indicates that resistance in
biolms is a complex phenomenon (Ramage etal. 2002a). Since non-albicans species cannot form true hyphae, their biolms generally consist of yeast cells layers
immersed in an extracellular matrix (Silva etal. 2009). The newly discovered pathogen C. auris also exhibits this pathogenicity characteristic. Differential expression
in C. auris shows that 464 and 791 genes are upregulated after 24h in planktonic
cells and in biolm development, respectively, compared to 0h (Kean etal. 2018).
A. fumigatus also develops a conventional microbial biolm that is resistant to several azoles, including voriconazole. Within 8–12h of biolm growth, the minimum
inhibitory concentration (MIC)90 increases vefold (Morelli etal. 2021). The biolms of C. neoformans contained glucuronoxylomannan (GXM), a constituent of
its polysaccharide capsule, which plays signicant role in disrupting the host’s
immunological defences (Aslanyan etal. 2017). During the development of the
cryptococcal biolm, a large amount of capsular polysaccharide is released, forming an intricate exopolysaccharide matrix or three-dimensional scaffold that envelops the cell population for protection and mechanical stability. The non-pathogenic
acapsular mutant strain C. neoformans C536 with a disruption of the CAP59 gene is
unable to form biolms, highlighting its role in biolms (Martinez and Casadevall
2015). Biolms formed by Cryptococcus spp. are less susceptible to thermal stress
and UV exposure than planktonic cells (Martinez and Casadevall 2007).

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P. Sharma et al.
7.2.4 Polymorphism
Polymorphism, another factor responsible for fungal virulence, can be observed in
several fungal species, including C. albicans. Fungus can take the form of parallelwalled true hyphae, long elliptical cells with constricted septa, or ovoid budding
yeast. Other morphologies include Aspergillus spp. spores and white-opaque cells
that form during switching (Ni etal. 2010). Yeasts and hyphae have different functions and are commonly seen during an infection (Mayer etal. 2013). The ‘dimorphism’ is the transition between the growth forms hyphae and yeast, which is crucial
for pathogenicity. Attenuated pathogenicity is typically associated with mutants that
cannot form hyphae invitro. Nevertheless, both forms have their advantages, as the
hyphae form is more invasive and the smaller yeast form is most responsible for
spread. Numerous elements, including nutrient deprivation, serum or
N-acetylglucosamine, physiological temperature, and CO2, encourage the growth
of hyphae during infection. Quorum sensing, which is required for microbial communication, also controls morphogenesis (Sudbery 2011). Factors such as the gene
products, TUP1, CPH1 and EFG1, are important transcriptional regulators that
regulate lamentous growth. EFG1 and CPH1 are the activators of lamentous
growth in C. albicans, as the null mutants of CPH1 show a defect in normal hyphal
growth at 37°C (Csank etal. 1997). Similarly, the null mutants of CPH1 and EFG1
show large and smooth colonies. Moreover, the deletion of both copies of the TUP1
gene shows the lamentous form in C. albicans, indicating the role of TUP1 as a
negative regulator of lamentous growth (Braun and Johnson 1997). The switch
from a budding yeast form to a lamentous form in Candida can be initiated by a
MAP kinase cascade (Csank etal. 1997). Hyphal development is associated with
the expression of several genes encoding virulence factors. The aspartic proteases
Sap4, Sap5, and Sap6, the hyphal wall protein Hwp1, the agglutinin-like sequence
protein Als3, and the hyphal-associated proteins Ece1 and Hyr1 are examples of
these types of proteins (Mayer etal. 2013). The growth of Aspergillus spp. begins
with the germination of the conidium, which leads to the formation of an undifferentiated mass of hyphal cells. The hyphal cells form a mycelium during sexual
reproduction. On the other hand, these hyphal cells stop growing, which also leads
to the formation of spores and conidiophores (Ni et al. 2010). The conidia of
A. fumigatus are released into the atmosphere and are so small that they can be
ingested by humans as soon as they reach the alveoli. In immunocompromised
hosts, the conidia can germinate into invasive hyphae that can invade the blood vessels and migrate to distant sites. The hyphal cell wall’s rigidity, the synthesis of
different fungal proteins including hydrophobins, melanin, and toxins, as well as the
spores’ structural characteristics, all aid in the fungus’s ability to escape the host’s
defences and increase A. fumigatus’ virulence (Yu 2010).

7 Factors Aecting Drug Resistance andVirulence inFungal Pathogen
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7.2.5 Production ofEnzymes
Both saprophytic and pathogenic fungal species require the digestion of lipids or
proteins by lipases and proteases in order to survive and grow. In pathogenic fungi,
hydrolytic enzymes are crucial for their virulence. Among these enzymes, proteases
and lipases are the best known extracellular enzymes that can damage host tissues
and promote the spread of infection (Park etal. 2013).
7.2.5.1 Secreted Aspartyl Proteinases
Candida produces several secreted aspartyl proteinases (SAPs) that can degrade
host proteins by breaking the peptide bond between two hydrophobic amino acids
and damaging the host cells (Mayer etal. 2013). A family of 10 genes encodes SAP
proteins. In addition to tissue adhesion, proteases increase the ability of the fungus
to colonize and penetrate deeper into the tissue by degrading host proteins (Cowen
etal. 2015). In addition to C. albicans, C. tropicalis, Candida dubliniensis, and
C. parapsilosis also produce active SAP enzymes invitro (Naglik etal. 2003). The
virulence of C. albicans was investigated by targeted disruption of the SAP gene
(SAP1 to SAP6). Null mutants of SAP1 to SAP3 (Δsap1, Δsap2, and Δsap3) become
less pathogenic and more sensitive to pepstatin, a protease inhibitor, compared to
SAP4 to SAP6 null mutants (De Bernardis et al. 1999). Three genes coding for
aspartyl acid protease (SAPP1, SAPP2, and SAPP3) were identied in C. parapsilosis. C. parapsilosis, ΔΔsapp1a- ΔΔsapp1b mutants show less host tissue damage, become hypersensitive to human serum, and are more efciently taken up by
peripheral blood mononuclear cells (Horváth etal. 2012). SAPP1 and SAPP2 are
responsible for host tissue adhesion, phagosome and lysosome maturation, and
phagocytosis. SAPP2 can also cleave host complement component 4b (C4b) and
C3b and inuences the host’s immune system (Singh etal. 2019). C. tropicalis con-
tains four 4-membered SAPT genes, of which SAPT1 plays the main role in the virulence of the fungus (Zaugg etal. 2001). It can efciently cleave the lectin pathway
components of the complement system, such as mannose-binding lectin (MBL) and
collectin-11, and also interfere with the activation of the complement pathway
(Valand etal. 2022). Like other Candida spp. C. auris also possesses SAP activity
of 25–42°C (Kim etal. 2023). Out of seven identied SAPs (Sapa1 to Sapa7) in
C. auris., SAPA3 is mainly involved in virulence. Disruption of SAPA3 (Sapa3Δ)
leads to attenuated virulence and a considerable decrease in SAP activity and biolm formation (Kim etal. 2023).
In addition, May1 is the primary secreted protease in C. neoformans. This protease is responsible for a variety of tasks, such as altering virulence, invading host
tissue, spreading into the central nervous system, and assimilating nitrogen
(Kryštůfek etal. 2021). Disruption of MAY1 (may1Δ) in C. neoformans leads to a
signicant reduction in virulence (Clarke etal. 2016). A. fumigatus secretes an alka-
line protease Alp1 that cleaves brinogen, collagen, and elastin (Davies etal. 2005).
Alp1 also inuences the response of the complementary system by cleaving the
complement proteins C3b, C4, and C5 and increasing the infection rate. The ALP1

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(Δalp1) mutants do not exhibit the cleavage properties and the activity of ALP1 is
also inhibited by chymostatin, a serine protease inhibitor (Behnsen etal. 2010).
7.2.5.2 Phospholipase
Phospholipases are a large group that break and cleave ester bonds in glycerophospholipids, which are vital components of pulmonary surfactants and cell membranes. Five kinds of phospholipases can be distinguished based on the ester bond
that is hydrolysed: A1–A2 and B–C–D.Phospholipase B (Plb) and phospholipase C
(Plc) are two important phospholipases related to fungal pathogenicity. The Plb
enzymes eliminate both fatty acyl chains of glycerophospholipids (Djordjevic
2010). Five potential members of the Plb multigene family are encoded in the
genome of C. albicans. The CaPLB1 gene, the CaPLB2 gene, and the CaPLB5
gene, which encode potential secreted proteins, have attracted the most attention.
The only CaPLBs with a known function in virulence are CaPLB1 and CaPLB5.
The null mutant of Δcaplb5 shows reduced phospholipase A2 activity and becomes
avirulent in the mouse model (Theiss etal. 2006). Moreover, there are extracellular
glycosylphosphatidylinositol-linked aspartyl proteases encoded by the YPS gene
family in C. glabrata. The YPS gene family consists of 11 putative GPI-linked cell
surface proteases (Rasheed etal. 2018). These genes have been found to be involved
in cell wall integrity, survival in macrophages, attachment to host cells, and virulence (Kaur etal. 2007). The ypsΔ strains of C. glabrata show a signicant increase
in the nitric oxide (NO) production, which is involved in macrophage activation
(Kaur etal. 2007). YPS genes also inuence the proteolytic processing of the cell
wall adhesin protein Epa1. The ypsΔ strains of C. glabarta adhere more strongly to
epithelial cells. In addition, these strains are also sensitive to cell wall stressors,
highlighting the role of YPS genes in maintaining cell wall integrity (Kaur
etal. 2007).
Three recognized PLB gene products, Afplb1, Afplb2, and Afpl3, are present in
the genome of A. fumigatus. These three AfPLBs also have a conserved catalytic
triad of Ser, Arg, and Asp residues. AfPLB1 and AfPLB3 play an important role in
lung infections and enhance the pathogenicity of A. fumigatus. In the presence of
lecithin, which is the main component of pulmonary surfactant, Afplb1 and Afplb3
are upregulated (Barman etal. 2018). In C. neoformans, the phospholipase enzyme
Plb also exhibits lysophospholipase hydrolase and lysophospholipase transacylase
activity. Disruption of PLB1 (Δplb1) in C. neoformans leads to a marked decrease
in all three activities. Δplb1 strains show signicant reduction in virulence and substantial developmental defects in a macrophage cell line in inhalation models in
mice and meningitis in rabbits. This suggests that the Plb1 enzyme of C. neofor-
mans is a virulence factor (Cox etal. 2001). Plb mediates capsule enlargement and
intracellular replication and affects the host immune system. PLB1 increases the
survival and growth of the fungus in the CNS and enhances its pathogenicity. PLB1
expression impairs glial cell activities and damages brain tissue (Hamed etal. 2023).

7 Factors Aecting Drug Resistance andVirulence inFungal Pathogen
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7.2.6 Calcineurin-Signalling Pathway
Various stress signals activate phospholipase C, which increases the cytosolic Ca2+
level, which binds to calmodulin (CaM) and activates the downstream protein calcineurin. Calcineurin is a heterodimeric complex cytoplasmic protein comprised of a
catalytic subunit, calcineurin A (cnA), and a regulatory subunit, calcineurin B (cnB)
(Juvvadi etal. 2017). Activated calcineurin, a conserved Ca2+/CaM-dependent serine/threonine phosphatase, dephosphorylates the downstream protein Crz1 (NFAT
homolog), a transcription factor that translocates in nucleus and causes expression
of the target genes FKS2, PMR1, PMC2, and CHS6, which are crucial for fungal
cell sensitivity to drugs and virulence (Lev etal. 2012; Tisi etal. 2016).
The calcineurin pathway (Fig.7.4) inuences cell wall integrity, ion homeostasis, virulence, and plasma membrane homeostasis by regulating ergosterol, chitin
and glucan synthesis, and drug resistance (Ueno etal. 2011). The essential role of
calcineurin in the virulence of fungal pathogens became clear in studies with C. neo-
formans when it was found that the immunosuppressive drugs cyclosporin A (CsA)
and FK506 inhibit calcineurin signalling and suppress fungal growth (Odom etal.
1997). The deletion mutants of the calcineurin protein are sensitive to various anti-
fungal agents. The Δcna1 mutant of C. neoformans leads to a loss of pathogenicity
in animal models (Odom etal. 1997). The Δcna1 strain is degraded faster than the
wild-type in an immunosuppressive rabbit model and becomes more temperaturesensitive (Odom etal. 1997). The crz1 mutant of C. neoformans is susceptible to
cell wall inhibitors due to the downregulation of the chitin synthase gene CHS6
(Lev etal. 2012). The importance of this gene has also been conrmed in other species, including Candida and A. fumigatus (Bader etal. 2003; Steinbach etal. 2006).
The pathogenicity and virulence of fungal pathogens, including C. albicans, are
strongly dependent on calcium (Ca2+) signalling. CsA and FK506 show synergistic
effects with uconazole and the fungistatic effect of azoles becomes fungicidal
through calcineurin inhibitors (Uppuluri et al. 2008). In A. niger, the deletion
mutants ΔcrzA and ΔcnaA reduce the Ca2+ concentration in the mycelium, reduce
biolm formation, lower hydrophobicity, and impair the integrity of the cell wall
(Liu etal. 2020). In C. glabrata, calcineurin is responsible for the regulation of the
transcription factor Pdr1 and controls the expression of Cdr1p. Disruption of CNA1
in C. glabrata Δcna1 shows a remarkable reduction in PDR1 and CDR1 expression,
which is responsible for azole resistance in C. glabrata. The Δcna1 and Δcnb1
mutants become sensitive to caspofungin and uconazole (Vu etal. 2023).
7.2.7 Ion Homeostasis
Ion signalling and transduction networks control gene expression, lamentation,
attachment to the host, invasion, pathogen stress response, and survival and are thus
essential for fungal growth and virulence (Zhang etal. 2012).

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inux is sensed by
2+
ions. The Ca
2+
Fig. 7.4 The role of the calcineurin signalling pathway in fungi: The transporters Cch1 and mid1 regulate the uptake of Ca
the CaM protein, which forms a complex with the calcineurin protein subunits cnA and cnB.The CaM-calcineurin complex dephosphorylates the Crz1 protein,
which migrates into the nucleus and activates the genes involved in the virulence of the fungus
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