Genetic and phenotypic evaluation of Candida albicans strains isolated from subgingival biofilm of diabetic patients with chronic periodontitis

Candida spp. are commensal microorganisms that are part of the microflora of different sites within the oral cavity. In healthy subjects, who have an unaltered immunological status, these yeasts do not cause disease. However, in immunosuppressed individuals whose condition may have been caused by diabetes mellitus, Candida spp. can express different virulence factors and may consequently become pathogenic. Studies have detected the presence of Candida spp. in periodontal sites of patients with chronic periodontitis, especially those that are immunologically compromised. However, the role of these microorganisms in the pathogenesis of periodontal disease is still unknown. The objectives of this study were: (1) to isolate and identify Candida albicans strains from subgingival sites of diabetic patients with chronic periodontitis; (2) to evaluate the following virulence factors; colony morphology, proteinase, phospholipase and hemolysin activities and cell surface hydrophobicity (CSH) under different atmospheric conditions; and (3) to determine the genetic patterns of these C. albicans isolates. Microbial samples were collected from subgingival sites and seeded on CHROMagar for subsequent identification of C. albicans by polymerase chain reaction (PCR). For the phenotypic tests, all strains of C. albicans were grown under reduced oxygen (RO) and anaerobiosis (ANA) conditions. Genotypes were defined by the identification through PCR of the transposable introns in the 25S rDNA. The results obtained relative to virulence factors were analyzed according to the atmospheric condition or genetic group, using Chi-square and Wilcoxon non-parametric tests. In this study, 128 strains were identified as C. albicans and of these, 51.6% were genotype B, 48.4% were genotype A and Genotype C was not found. Most of the strains were alpha-hemolytic in both atmospheric conditions, without a statistical difference. However, when comparing the genotypes, 46.1% of the genotype A strains were beta-hemolytic. In relation to colony morphology, 100% of the strains under ANA showed rough colonies, which were especially prevalent in genotype A isolates. In contrast, most of the colonies were smooth under RO. C. albicans strains did not produce proteinase and phospholipase activity in the total absence of oxygen. In RO, most strains had high proteinase activity and were positive by phospholipase tests (P < 0.05). Hydrophobicity was higher in anaerobiosis and was noted mainly for genotype A isolates. In conclusion, environmental oxygen concentration influenced the virulence factors of C. albicans strains isolated from subgingival sites of diabetic and periodontal patients. In addition, genotype A seems to be more virulent based on the phenotypic tests evaluated in this study.     

In vitro investigation of antifungal activities of phenotypic variation Candida albicans strains against fluconazole, itraconazole and voriconazole.

The aim of this study was to investigate the susceptibility of the different phenotypes of Candida albicans strains isolated from clinical specimens to three antifungal agents, fluconazole, itraconazole and voriconazole. Totally 215 specimens were collected from oropharyngeal, gastrointestinal and urogenital tracts of non-neutropenic patients who had received no previous prophylactic treatment. Each of the 215 C. albicans strains recovered was found to express one of the six phenotypes: smooth 73%, fuzzy 10.7%, irregular 2.3%, star 2.8%, ring 6% or stipple 5.1%. The mean MICs for the six phenotypes of C. albicans strains ranged between 0.25 microg/ml and 64 microg/ml for fluconazole, 0.03 microg/ml and 1 microg/ml for itraconazole and 0.03 microg/ml and 0.5 microg/ml for voriconazole. The mean minimum inhibitory concentration (MIC) of fluconazole was consistently higher for C. albicans strains expressing the stipple phenotype. The antifungal susceptibility of the phenotypic switching requires attention, especially in patients who are clinically unresponsive to fluconazole chemotherapy or in cases of serious C. albicans infections of immunocompromised hosts.     

Genetic similarity and phenotypic diversity of commensal and pathogenic strains of Candida albicans isolated from the oral cavity.

Colony phenotype and genetic similarity were assessed within and between groups of commensal and pathogenic strains of Candida albicans collected from the oral cavities of individuals in a single geographical locale. Thirty-eight percent of pathogenic isolates contained predominant or minor variant colony morphologies (other than smooth) when samples from the sites of infection were cultured on plates, while 16% of commensal isolates contained minor variant colony morphologies when samples from the sites of carriage were cultured. The genetic similarities of isolates within and between groups were assessed by DNA fingerprinting by using Southern blot hybridization with the fingerprinting probe Ca3 and analysis with the computer-assisted, automated Dendron system. Both the commensal and the pathogenic groups contained a major cluster of genetically similar C. albicans isolates representing 31 and 33% of the strains in the respective groups. When a combined dendrogram of both commensal and pathogenic isolates was generated, the major clusters of genetically similar isolates in each group mixed into one large cluster. Minor clusters in the individual dendrograms also mixed. These results suggest common clonal origins for commensal and pathogenic strains in the same geographical locale.     

Environmental alteration and phenotypic regulation of Candida albicans adhesion to plastic.

The adhesion of Candida albicans to plastic was examined after growth in two chemically defined media, Lee-Buckley-Campbell (LBC) and yeast nitrogen base (YNB), by binding isotherms, Langmuir isotherms, and Scatchard plots, and the number of binding sites (N) and the affinity constants (K) were calculated. K and N were twofold and fourfold higher, respectively, after growth in LBC compared with that in YNB. A comparison of adhesion in different assay solutions gave similar results, with the solution given to dehydrated patients (5% glucose in 0.45% NaCl [D5.45]) allowing for the highest K and the largest N. Scatchard curves for both LBC- and YNB-grown cells had negative slopes, which is supportive evidence for the view that negative cooperativity is involved in the binding process. Additional experiments to examine the role of cell surface hydrophobicity in adhesion to plastic were conducted with the white and opaque phenotypes of C. albicans. There was no significant difference in the adhesion of these phenotypes to plastic, although the opaque phenotype was significantly more hydrophobic. Adhesion, but not cell surface hydrophobicity, of both phenotypes was significantly greater in D5.45. Moreover, relatively hydrophilic mycelial forms of C. albicans were found to attach only when D5.45 was used as the assay medium and, in contrast to yeast-phase cells, were insensitive to reduced adhesion by nonionic detergents. These results suggest that the adhesion of C. albicans to plastic is regulated by environmental circumstances and the phenotypic state of the organism.     

Increased phenotypic switching in strains of Candida albicans associated with invasive infections.

This study reports the rates of phenotypic switching in strains of Candida albicans isolated from superficial and invasive infections. Of 19 invasive strains, 68% showed switching activity, often at very high rates, compared with only 28% of 40 strains isolated from superficial sites (P = 0.004).     

Genetic relationship between human and animal isolates of Candida albicans

Analyzing Candida albicans isolates from different human and animal individuals by Ca3 fingerprinting, we obtained no evidence for host-specific genotypes and for the existence of species-specific lineages, even though a certain degree of separation between human and animal isolates was found. Therefore, animals could potentially serve as reservoirs for human Candida infection.     

Genetic analysis of innate immunity in resistance to Candida albicans

Systemic candidiasis is a significant cause of nosocomial infections and the mechanisms of defense against Candida albicans in humans remain poorly understood. Studies in animal models have demonstrated the importance of innate immunity in controlling the response to infection. Although Th1 cytokines have been shown to direct the overall outcome of infection, the precise role of the Th1/Th2 response and, more generally, the adaptive immune response as a whole, in systemic candidiasis, appears to apply mainly to the development of resistance to reinfection. A genetic approach to the identification of host factors regulating pathogenesis and susceptibility to C. albicans infection has been used in humans and in mouse models of infection. Mouse mutants bearing experimentally induced mutations in specific genes have provided a systematic tool for directly assessing the role of individual proteins in C. albicans susceptibility. Inbred mouse strains have been valuable in showcasing the spectrum of naturally occurring variations in initial susceptibility to infection, and type of disease developed. Crosses between resistant and susceptible strains have led to the detection of additional gene effects affecting innate immunity. Of particular interest is the major effect of a naturally occurring loss-of-function mutation in the C5 complement component that has become fixed in many inbred strains. These and other studies have shown that both a functional complement pathway and robust inflammatory response are critical for resistance to C. albicans.     

Candida albicans and selenium

Although low selenium levels have been recorded in infants, no specific human disorder has been linked to low selenium status. The incidence of thrush, the common enteric fungal infection caused by Candida albicans, has increased markedly with antibiotic therapy and research has provided evidence that its colonization leads to competition for Coenzyme Q10 (CoQ10) in the host. Furthermore it is now known that ubiquinones are essential in heart muscle for oxidative phosphorylation in the mitochondrial respiratory chain and considered that glutathione peroxidase (GSHPx) in the mitochondria protects ubiquinone from oxidation.     

Morphogenesis in Candida albicans

This review will survey environmental controls on the morphology of Candida albicans, describe the cellular and ultrastructural events associated with morphological transitions in this fungus, and attempt to relate biochemical phenomena that have been reported to be associated with dimorphic change to C. albicans cell biology. The synthesis of the cell wall of C. albicans and its control remain largely undiscovered, but it is clear that the cell wall is the principal component involved in shape determination. Possible models for C. albicans dimorphism will be critically reviewed.     

Co-regulation of pathogenesis with dimorphism and phenotypic switching in Candida albicans,a commensal and a pathogen

Candida albicans, a common fungal pathogen of humans, can colonize in many diverse environments of the host and convert between a harmless commensal and a pathogen. Recent advances indicate that C. albicans uses a common set of conserved pathways to regulate dimorphism, mating and phenotypic switching. Major pathways known to regulate dimorphism include a mitogen-activated protein (MAP) kinase pathway through Cph1, the cAMP-dependent protein kinase pathway via Efg1, and Tup1-mediated repression through Rfg1 and Nrg1. The Cph1-mediated MAP kinase pathway is critical for the mating process, while all three pathways are implicated in the regulation of white-opaque switching. All these developmental pathways regulate the expression of hypha-specific and/or phase-specific genes. A high proportion of hypha-specific genes and phase-specific genes encode proteins that contribute directly or indirectly to pathogenesis and virulence of C. albicans. Therefore, virulence genes are co-regulated with cell morphogenesis. This supports a previous notion that the unique aspects of C. albicans commensalism and pathogenesis may lie in the developmental programs of dimorphism and phenotypic switching.     

Fingerprinting Candida albicans

A new method of typing Candida albicans based on immunoblotting is described. Isolates were disrupted by a mixture of enzymic pretreatment with alpha-mannosidase followed by sonication. They were then stained using a modified ELISA system by a rabbit hyperimmune serum raised against a single isolate, C. albicans NCTC 3153. The 190 isolates examined from the London Hospital produced 16 different types. Type 1 accounted for 43% of the isolates and was the commonest type outside the intensive care unit. Type 2 caused an outbreak of systemic candidosis on the intensive care unit. The technique was much more sensitive than the serotyping and morphotyping methods and lacked the phenotypic variability of the biotyping procedure previously used to define the outbreak. The gel-to-gel variation precludes its use in large scale epidemiological work. Its value lies in identification of outbreaks so that they can be controlled by the introduction of measures to prevent cross-infection.     

Effects of neutrophils and in vitro oxidants on survival and phenotypic switching of Candida albicans WO-1.

The relationship to pathogenesis of the spontaneous phenotypic switching of Candida albicans is uncertain. Since neutrophils are critical in containment of disseminated candidiasis, we used these cells and some of their potentially microbicidal oxidative products to define effects on a C. albicans strain (WO-1) that exhibits characteristic, easily recognized switching between the white and opaque phenotypes. Blastoconidia of the opaque phenotypes were more susceptible than those of the white to killing by either intact neutrophils or cell-free oxidants, including reagent hydrogen peroxide or the myeloperoxidase-H2O2-Cl- system. Paralleling these findings, opaque blastoconidia were 2.8- to 3.6-fold more potent stimuli of neutrophil superoxide generation than were the white cells. In addition, both neutrophils and oxidants (reagent H2O2 or hypochlorous acid as well as the myeloperoxidase-H2O2-Cl- system) induced unidirectional increases in spontaneous rates of switching from white to opaque phenotypes. Differences in expression of C. albicans phenotypes therefore may determine relative susceptibility to neutrophil fungicidal mechanisms, and neutrophils themselves appear to be capable of selectively augmenting the switching process.     

Candida albicans and atopic dermatitis

The role of sensitization and exposure to Candida albicans in atopic dermatitis (AD) was studied with skin-prick tests, yeast cultures and immunoblotting in 156 young adults with AD attending the Department of Dermatology, University of Turku, during 1983–89. Eighteen patients with allergic rhinitis without eczema and 39 non-atopics were included as controls. Parameters associated with severe AD were simultaneous anti-C. albicans IgE and saprophytic C. albicans growth. A statistically significant correlation between C. albicans sensitization (specific IgE antibodies) and AD symptoms was observed only in patients with saprophytic C. albicans exposure. No correlation between C. albicans-specific IgE and AD severity was shown in patients without gastrointestinal growth. Furthermore, severe eczema was seldom seen in patients without saprophytic C. albicans growth. The most important IgE-binding components of C. albicans in immunoblotting were 27 and 46 kD proteins and mannan, a polysaccharide. IgG and IgA antibodies to C. albicans, mainly towards C. albicans mannan, were found in practically all 70 sera studied. These results suggest a continuous exposure and induction of IgE antibodies by C. albicans in AD patients. Severe phases of AD in colonized patients are associated with IgE synthesis against C. albicans. These findings suggest a role for C. albicans in the exacerbations of AD but the clarification of this subject needs double-blind placebo-controlled treatment trials.     

Genetic similarity of Candida albicans strains from vaginitis patients and their partners.

The moderately repetitive sequence Ca3 was used to fingerprint strains of Candida albicans isolated from vulvovaginal infections of 10 women and strains isolated from their male partners. The Dendron software package was then used to compare the DNA fingerprints of these strains with those of vaginal commensals from women from the same geographical locale, vaginal commensals from women from a different geographical locale, and commensals from male partners of asymptomatic women from the same geographical locale. The results demonstrate that, in the majority of cases (8 of 10), strains from symptomatic patients and their partners are either identical or more similar to each other than to other strains, infecting strains do not represent a group genetically distinguishable from vaginal commensal isolates from women from the same geographical locale, and both infecting strains and commensals from individuals in the test locale can be distinguished from commensals obtained in another geographical locale. The results also suggest that women with vaginal infections are responsible for strain replacement in their male partners.     

Genetic evidence for role of extracellular proteinase in virulence of Candida albicans.

The relationship between extracellular proteinase and the virulence for mice in Candida albicans was studied by using a set of three isolates. The set included a proteinase-producing parent (C9), a proteinase-deficient mutant derived from C9 by nitrous acid treatment (C9M1), and a spontaneous revertant (C9M1M) obtained by mouse passage of C9M1. The morphological markers and the carbon assimilation pattern were identical in these isolates. Isolate C9 produced a high level of proteinase in vitro and caused fatal infection (100%) within 21 days. The mutant produced no detectable enzymes in vitro, and all mice survived until day 22. Only 30% of the mice infected with C9M1 died between day 23 and 30. The isolates recovered from the dead mice were found to be proteinase sufficient, indicating that the mice died after the organism in tissue had reverted. The C9M1M isolate produced proteinase in vitro at 44% the level of C9 and induced fatal infection in 90% of the mice within 30 days. The number of CFU recovered from the kidneys correlated with the level of proteinase produced in vitro and, in turn, the rate of fatal infection produced by the isolates. These results support a previous observation indicating that proteinase activity is one of the virulence factors associated with C. albicans.     

Genomic analysis in Candida albicans]

With the recent advances in DNA sequencing technology, a succession of entire genome sequences have been published. A number of genome projects are underway in pathogenic fungi. From these, we present the history and current status of the genomic analysis of Candida albicans. The sequencing project for this organism has been undertaken at Stanford University, and is now nearing the end.     

Detecting Candida albicans in human milk

Procedures for diagnosis of mammary candidosis, including laboratory confirmation, are not well defined. Lactoferrin present in human milk can inhibit growth of Candida albicans, thereby limiting the ability to detect yeast infections. The inhibitory effect of various lactoferrin concentrations on the growth of C. albicans in whole human milk was studied. The addition of iron to the milk led to a two- to threefold increase in cell counts when milk contained 3.0 mg of lactoferrin/ml and markedly reduced the likelihood of false-negative culture results. This method may provide the necessary objective support needed for diagnosis of mammary candidosis.     

High-frequency switching in Candida albicans.

Most strains of Candida albicans are capable of switching frequently and reversibly between a number of phenotypes distinguishable by colony morphology. A number of different switching systems have been defined according to the limited set of phenotypes in each switching repertoire, and each strain appears to possess a single system. Switching can affect many aspects of cellular physiology and morphology and appears to be a second level of phenotypic variability superimposed upon the bud-hypha transition. The most dramatic switching system so far identified is the "white-opaque transition." This system dramatizes the extraordinary effects switching can have on the budding cell phenotype, including the synthesis of opaque-specific antigens, the expression of white-specific and opaque-specific genes, and the genesis of unique cell wall structures. Switching has been demonstrated to occur at sites of infection and between episodes of recurrent vaginitis, and it may function to generate variability in commensal and infecting populations for adaptive reasons. Although the molecular mechanisms involved in the switch event are not understood, recent approaches to its elucidation are discussed and an epigenetic mechanism is proposed.     

UV-induced instability in Candida albicans hybrids

Summary Auxotrophic variants were obtained following UV-irradiation of Candida albicans hybrids which were heterozygous (+/+/-/-/) for various genetic markers (met, ade, his, lys). Some variants contained less DNA (per cell) than did the hybrids from which they originated; such variants were considered to arise in a process which resulted in generalized reduction in ploidy. These results provide the basis for a cyclic parasexual system (2n × 2n 4n 2n) for genetic analysis in this amictic diploid species.