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''Candida albicans'' is an opportunistic pathogenic yeast that is a common member of the human
gut flora Gut microbiota, gut microbiome, or gut flora are the microorganisms, including bacteria, archaea, fungi, and viruses, that live in the digestive tracts of animals. The gastrointestinal metagenome is the aggregate of all the genomes of the g ...
. It can also survive outside the human body. It is detected in the gastrointestinal tract and mouth in 40–60% of healthy adults. It is usually a
commensal Commensalism is a long-term biological interaction (symbiosis) in which members of one species gain benefits while those of the other species neither benefit nor are harmed. This is in contrast with mutualism, in which both organisms benefit f ...
organism, but it can become
pathogen In biology, a pathogen (, "suffering", "passion" and , "producer of"), in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a Germ theory of d ...
ic in
immunocompromised Immunodeficiency, also known as immunocompromise, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that affe ...
individuals under a variety of conditions. It is one of the few species of the genus '' Candida'' that cause the human infection
candidiasis Candidiasis is a fungal infection due to any species of the genus '' Candida'' (a yeast). When it affects the mouth, in some countries it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the ...
, which results from an overgrowth of the fungus. Candidiasis is, for example, often observed in HIV-infected patients. ''C. albicans'' is the most common fungal species isolated from
biofilm A biofilm is a Syntrophy, syntrophic Microbial consortium, community of microorganisms in which cell (biology), cells cell adhesion, stick to each other and often also to a surface. These adherent cells become embedded within a slimy ext ...
s either formed on (permanent) implanted medical devices or on human tissue. ''C. albicans'', ''C. tropicalis'', ''C. parapsilosis'', and ''C. glabrata'' are together responsible for 50–90% of all cases of candidiasis in humans. A mortality rate of 40% has been reported for patients with systemic candidiasis due to ''C. albicans''. By one estimate, invasive candidiasis contracted in a hospital causes 2,800 to 11,200 deaths yearly in the US. Nevertheless, these numbers may not truly reflect the true extent of damage this organism causes, given studies indicating that ''C. albicans'' can cross the
blood–brain barrier The blood–brain barrier (BBB) is a highly selective semipermeable membrane, semipermeable border of endothelium, endothelial cells that regulates the transfer of solutes and chemicals between the circulatory system and the central nervous system ...
in mice. ''C. albicans'' is commonly used as a
model organism A model organism is a non-human species that is extensively studied to understand particular biological phenomena, with the expectation that discoveries made in the model organism will provide insight into the workings of other organisms. Mo ...
for fungal pathogens. It is generally referred to as a dimorphic fungus since it grows both as
yeast Yeasts are eukaryotic, single-celled microorganisms classified as members of the fungus kingdom (biology), kingdom. The first yeast originated hundreds of millions of years ago, and at least 1,500 species are currently recognized. They are est ...
and filamentous cells. However, it has several different morphological phenotypes including opaque, GUT, and pseudohyphal forms. ''C. albicans'' was for a long time considered an obligate diploid organism without a haploid stage. This is, however, not the case. Next to a haploid stage ''C. albicans'' can also exist in a tetraploid stage. The latter is formed when diploid ''C. albicans'' cells mate when they are in the opaque form. The diploid genome size is approximately 29 Mb, and up to 70% of the protein coding genes have not yet been characterized. ''C. albicans'' is easily cultured in the lab and can be studied both ''in vivo'' and ''in vitro''. Depending on the media different studies can be done as the media influences the morphological state of ''C. albicans''. A special type of medium is CHROMagar ''Candida'', which can be used to identify different ''Candida'' species.


Etymology

"''Candida albicans''" can be read as tautological. " Candida" comes from the Latin word " candidus", meaning "shining white". " Albicans itself is the present participle of the Latin word " albicō", meaning "becoming white". This leads to one possible interpretation as the redundant phrase "pure white becoming white". It is often shortly referred to as thrush, candidiasis, or candida. More than a hundred synonyms have been used to describe ''C. albicans''. Over 200 species have been described within the candida genus. The oldest reference to thrush, most likely caused by ''C. albicans'', dates back to 400 BC in
Hippocrates Hippocrates of Kos (; ; ), also known as Hippocrates II, was a Greek physician and philosopher of the Classical Greece, classical period who is considered one of the most outstanding figures in the history of medicine. He is traditionally referr ...
' work ''Of the Epidemics'' describing oral candidiasis.


Genome

The genome of ''C. albicans'' is almost 16Mb for the haploid size (28Mb for the diploid stage) and consists of 8 sets of chromosome pairs called chr1A, chr2A, chr3A, chr4A, chr5A, chr6A, chr7A and . The second set (''C. albicans'' is diploid) has similar names but with a B at the end. Chr1B, chr2B, ... and chrRB. The whole genome contains 6,198
open reading frame In molecular biology, reading frames are defined as spans of DNA sequence between the start and stop codons. Usually, this is considered within a studied region of a prokaryotic DNA sequence, where only one of the six possible reading frames ...
s (ORFs). Seventy percent of these ORFs have not yet been characterized. The whole genome has been sequenced making it one of the first fungi to be completely sequenced (next to ''Saccharomyces cerevisiae'' and ''Schizosaccharomyces pombe''). All open reading frames (ORFs) are also available in Gateway-adapted vectors. Next to this ORFeome there is also the availability of a GRACE (gene replacement and conditional expression) library to study essential genes in the genome of ''C. albicans''. The most commonly used strains to study ''C. albicans'' are the WO-1 and SC5314 strains. The WO-1 strain is known to switch between white-opaque form with higher frequency while the SC5314 strain is the strain used for gene sequence reference. One of the most important features of the ''C. albicans'' genome is the high heterozygosity. At the base of this heterozygosity lies the occurrence of numeric and structural
chromosomal A chromosome is a package of DNA containing part or all of the genetic material of an organism. In most chromosomes, the very long thin DNA fibers are coated with nucleosome-forming packaging proteins; in eukaryotic cells, the most importa ...
rearrangements and changes as means of generating genetic diversity by chromosome length polymorphisms (contraction/expansion of repeats), reciprocal translocations, chromosome deletions, Nonsynonymous
single-nucleotide polymorphism In genetics and bioinformatics, a single-nucleotide polymorphism (SNP ; plural SNPs ) is a germline substitution of a single nucleotide at a specific position in the genome. Although certain definitions require the substitution to be present in a ...
s and
trisomy A trisomy is a type of polysomy in which there are three instances of a particular chromosome, instead of the normal two. A trisomy is a type of aneuploidy (an abnormal number of chromosomes). Description and causes Most organisms that reprod ...
of individual chromosomes. These karyotypic alterations lead to changes in the phenotype, which is an
adaptation In biology, adaptation has three related meanings. Firstly, it is the dynamic evolutionary process of natural selection that fits organisms to their environment, enhancing their evolutionary fitness. Secondly, it is a state reached by the p ...
strategy of this fungus. These mechanisms are further being explored with the availability of the complete analysis of the ''C. albicans'' genome. An unusual feature of the genus ''Candida'' is that in many of its species (including ''C. albicans'' and ''C. tropicalis'', but not, for instance, ''C. glabrata'') the CUG
codon Genetic code is a set of rules used by living cells to translate information encoded within genetic material (DNA or RNA sequences of nucleotide triplets or codons) into proteins. Translation is accomplished by the ribosome, which links prote ...
, which normally specifies leucine, specifies serine in these species. This is an unusual example of a departure from the standard
genetic code Genetic code is a set of rules used by living cell (biology), cells to Translation (biology), translate information encoded within genetic material (DNA or RNA sequences of nucleotide triplets or codons) into proteins. Translation is accomplished ...
, and most such departures are in
start codon The start codon is the first codon of a messenger RNA (mRNA) transcript translated by a ribosome. The start codon always codes for methionine in eukaryotes and archaea and a ''N''-formylmethionine (fMet) in bacteria, mitochondria and plastids. ...
s or, for
eukaryote The eukaryotes ( ) constitute the Domain (biology), domain of Eukaryota or Eukarya, organisms whose Cell (biology), cells have a membrane-bound cell nucleus, nucleus. All animals, plants, Fungus, fungi, seaweeds, and many unicellular organisms ...
s, mitochondrial genetic codes. This alteration may, in some environments, help these ''Candida'' species by inducing a permanent stress response, a more generalized form of the
heat shock response The heat shock response (HSR) is a cell stress response that increases the number of molecular chaperones to combat the negative effects on proteins caused by stressors such as increased temperatures, oxidative stress, and heavy metals. In a norm ...
. However, this different codon usage makes it more difficult to study ''C. albicans'' protein-protein interactions in the model organism ''S. cerevisiae''. To overcome this problem a ''C. albicans'' specific two-hybrid system was developed. The genome of ''C. albicans'' is highly dynamic, contributed by the different CUG translation, and this variability has been used advantageously for molecular epidemiological studies and population studies in this species. The genome sequence has allowed for identifying the presence of a parasexual cycle (no detected meiotic division) in ''C. albicans''. This study of the evolution of sexual reproduction in six ''Candida'' species found recent losses in components of the major meiotic crossover-formation pathway, but retention of a minor pathway. The authors suggested that if ''Candida'' species undergo meiosis it is with reduced machinery, or different machinery, and indicated that unrecognized meiotic cycles may exist in many species. In another evolutionary study, introduction of partial CUG identity redefinition (from ''Candida'' species) into ''Saccharomyces cerevisiae'' clones caused a stress response that negatively affected sexual reproduction. This CUG identity redefinition, occurring in ancestors of ''Candida'' species, was thought to lock these species into a diploid or polyploid state with possible blockage of sexual reproduction.


Morphology

''C. albicans'' exhibits a wide range of morphological
phenotype In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology (physical form and structure), its developmental processes, its biochemical and physiological propert ...
s due to phenotypic switching and bud to hypha transition. The yeast-to-hyphae transition (filamentation) is a rapid process and induced by environmental factors. Phenotypic switching is spontaneous, happens at lower rates and in certain strains up to seven different phenotypes are known. The best studied switching mechanism is the white to opaque switching (an epigenetic process). Other systems have been described as well. Two systems (the high-frequency switching system and white to opaque switching) were discover by David R. Soll and colleagues. Switching in ''C. albicans'' is often, but not always, influenced by environmental conditions such as the level of CO2, anaerobic conditions, medium used and temperature. In its yeast form ''C. albicans'' ranges from 10 to 12
microns The micrometre (English in the Commonwealth of Nations, Commonwealth English as used by the International Bureau of Weights and Measures; SI symbol: μm) or micrometer (American English), also commonly known by the non-SI term micron, is a uni ...
. Spores can form on the pseudohyphae called chlamydospores which survive when put in unfavorable conditions such as dry or hot seasons.


Yeast-to-hypha switching

Although often referred to as dimorphic, ''C. albicans'' is, in fact, polyphenic (often also referred to as pleomorphic). When cultured in standard yeast laboratory medium, ''C. albicans'' grows as ovoid "yeast" cells. However, mild environmental changes in temperature, CO2, nutrients and pH can result in a morphological shift to filamentous growth. Filamentous cells share many similarities with yeast cells. Both cell types seem to play a specific, distinctive role in the survival and pathogenicity of ''C. albicans''. Yeast cells seem to be better suited for the dissemination in the bloodstream while hyphal cells have been proposed as a virulence factor. Hyphal cells are invasive and speculated to be important for tissue penetration, colonization of organs and surviving plus escaping macrophages. The transition from yeast to hyphal cells is termed to be one of the key factors in the virulence of ''C. albicans''; however, it is not deemed necessary. When ''C. albicans'' cells are grown in a medium that mimics the physiological environment of a human host, they grow as filamentous cells (both true hyphae and pseudohyphae). ''C. albicans'' can also form chlamydospores, the function of which remains unknown, but it is speculated they play a role in surviving harsh environments as they are most often formed under unfavorable conditions. The cAMP-PKA signaling cascade is crucial for the morphogenesis and an important transcriptional regulator for the switch from yeast like cells to filamentous cells is EFG1.


High-frequency switching

Besides the well-studied yeast-to-hyphae transition other switching systems have been described. One such system is the "high-frequency switching" system. During this switching different cellular morphologies (
phenotype In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology (physical form and structure), its developmental processes, its biochemical and physiological propert ...
s) are generated spontaneously. This type of switching does not occur en masse, represents a variability system and it happens independently from environmental conditions. The strain 3153A produces at least seven different colony morphologies. In many strains the different phases convert spontaneously to the other(s) at a low frequency. The switching is reversible, and colony type can be inherited from one generation to another. Being able to switch through so many different (morphological) phenotypes makes ''C. albicans'' able to grow in different environments, both as a commensal and as a pathogen. In the 3153A strain, a gene called ''SIR2'' (for silent information regulator), which seems to be important for phenotypic switching, has been found. ''SIR2'' was originally found in ''
Saccharomyces cerevisiae ''Saccharomyces cerevisiae'' () (brewer's yeast or baker's yeast) is a species of yeast (single-celled fungal microorganisms). The species has been instrumental in winemaking, baking, and brewing since ancient times. It is believed to have be ...
'' (brewer's yeast), where it is involved in chromosomal silencing—a form of
transcriptional regulation In molecular biology and genetics, transcriptional regulation is the means by which a cell regulates the conversion of DNA to RNA ( transcription), thereby orchestrating gene activity. A single gene can be regulated in a range of ways, from al ...
, in which regions of the
genome A genome is all the genetic information of an organism. It consists of nucleotide sequences of DNA (or RNA in RNA viruses). The nuclear genome includes protein-coding genes and non-coding genes, other functional regions of the genome such as ...
are reversibly inactivated by changes in
chromatin Chromatin is a complex of DNA and protein found in eukaryote, eukaryotic cells. The primary function is to package long DNA molecules into more compact, denser structures. This prevents the strands from becoming tangled and also plays important r ...
structure (chromatin is the complex of
DNA Deoxyribonucleic acid (; DNA) is a polymer composed of two polynucleotide chains that coil around each other to form a double helix. The polymer carries genetic instructions for the development, functioning, growth and reproduction of al ...
and proteins that make
chromosome A chromosome is a package of DNA containing part or all of the genetic material of an organism. In most chromosomes, the very long thin DNA fibers are coated with nucleosome-forming packaging proteins; in eukaryotic cells, the most import ...
s). In yeast, genes involved in the control of mating type are found in these silent regions, and ''SIR2'' represses their expression by maintaining a silent-competent chromatin structure in this region. The discovery of a ''C. albicans SIR2'' implicated in phenotypic switching suggests it, too, has silent regions controlled by ''SIR2'', in which the phenotype-specific genes may reside. How ''SIR2'' itself is regulated in ''S. cerevisiae'' may yet provide more clues as to the switching mechanisms of ''C. albicans''.


White-opaque switching

Next to the dimorphism and the first described high-frequency switching system ''C. albicans'' undergoes another high-frequency switching process called white-opaque switching, which is another
phenotypic switching In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology (physical form and structure), its developmental processes, its biochemical and physiological propertie ...
process in ''C. albicans''. It was the second high-frequency switching system discovered in ''C. albicans''. The white-opaque switch is an
epigenetic In biology, epigenetics is the study of changes in gene expression that happen without changes to the DNA sequence. The Greek prefix ''epi-'' (ἐπι- "over, outside of, around") in ''epigenetics'' implies features that are "on top of" or "in ...
switching system. Phenotypic switching is often used to refer to white-opaque switching, which consists of two phases: one that grows as round cells in smooth, white colonies (referred to as white form) and one that is rod-like and grows as flat, gray colonies (called opaque form). This switch between white cells and opaque cells is important for the virulence and the
mating In biology, mating is the pairing of either opposite-sex or hermaphroditic organisms for the purposes of sexual reproduction. ''Fertilization'' is the fusion of two gametes. '' Copulation'' is the union of the sex organs of two sexually repr ...
process of ''C. albicans'' as the opaque form is the
mating In biology, mating is the pairing of either opposite-sex or hermaphroditic organisms for the purposes of sexual reproduction. ''Fertilization'' is the fusion of two gametes. '' Copulation'' is the union of the sex organs of two sexually repr ...
competent form, being a million times more efficient in mating compared to the white type. This switching between white and opaque form is regulated by the WOR1 regulator (White to Opaque Regulator 1) which is controlled by the mating type locus (MTL) repressor (a1-α2) that inhibits the expression of WOR1. Besides the white and opaque phase there is also a third one: the gray phenotype. This phenotype shows the highest ability to cause cutaneous infections. The white, opaque, and gray phenotypes form a phenotypic switching system where white cells switch to and from the opaque phase, white cells can irreversibly switch to the gray phase, and both white and gray cells can switch to and from the opaque/an opaque-like phase, respectively. Since it is often difficult to differentiate between white, opaque and gray cells phloxine B, a dye, can be added to the medium. A potential regulatory molecule in the white to opaque switching is ''Efg1p'', a
transcription factor In molecular biology, a transcription factor (TF) (or sequence-specific DNA-binding factor) is a protein that controls the rate of transcription (genetics), transcription of genetics, genetic information from DNA to messenger RNA, by binding t ...
found in the WO-1 strain that regulates dimorphism, and more recently has been suggested to help regulate phenotypic switching. ''Efg1p'' is expressed only in the white and not in the gray cell-type, and overexpression of ''Efg1p'' in the gray form causes a rapid conversion to the white form.


Environmental stress

Glucose starvation is a likely common environmental stress encountered by ''C. albicans'' in its natural habitat. Glucose starvation causes an increase in intracellular reactive oxygen. This stress can lead to mating between two individuals of the same mating type, an interaction that may be frequent in nature under stressful conditions.


White-GUT switch

A very special type of phenotypic switch is the white-GUT switch (Gastrointestinally-IndUced Transition). GUT cells are extremely adapted to survival in the digestive tract by metabolic adaptations to available nutrients in the digestive tract. The GUT cells live as commensal organisms and outcompete other phenotypes. The transition from white to GUT cells is driven by passage through the gut where environmental parameters trigger this transition by increasing the WOR1 expression.


Role in disease

''Candida'' is found worldwide but most commonly compromises immunocompromised individuals diagnosed with serious diseases such as HIV and cancer. ''Candida'' are ranked as one of the most common groups of organisms that cause
hospital-acquired infection A hospital-acquired infection, also known as a nosocomial infection (from the Greek , meaning "hospital"), is an infection that is acquired in a hospital or other health care, healthcare facility. To emphasize both hospital and nonhospital sett ...
s. Especially high-risk individuals are patients that have recently undergone surgery, a transplant or are in the Intensive Care Units (ICU), ''C. albicans'' infections is the top source of fungal infections in critically ill or otherwise immunocompromised patients. These patients predominantly develop oropharyngeal or thrush candidiasis, which can lead to malnutrition and interfere with the absorption of medication. Methods of transmission include mother to infant through childbirth, people-to-people acquired infections that most commonly occur in hospital settings where immunocompromised patients acquire the yeast from healthcare workers and has a 40% incident rate. People can become infected after having sex with a woman that has an existing vaginal yeast infection. Parts of the body that are commonly infected include the skin, genitals, throat, mouth, and blood. Distinguishing features of vaginal infection include discharge, and dry and red appearance of vaginal mucosa or skin. ''Candida'' continues to be the fourth most commonly isolated organism in bloodstream infections. Healthy people usually do not suffer (severely) from superficial infections caused by a local alteration in cellular immunity as seen by asthma patients that use oral corticosteroids.


Superficial and local infections

It commonly occurs as a superficial infection on mucous membranes in the
mouth A mouth also referred to as the oral is the body orifice through which many animals ingest food and animal communication#Auditory, vocalize. The body cavity immediately behind the mouth opening, known as the oral cavity (or in Latin), is also t ...
or vagina. Once in their lives around 75% of women will suffer from vulvovaginal candidiasis (VVC) and about 90% of these infections are caused by ''C. albicans''. It may also affect a number of other regions. For example, higher
prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of
colonization 475px, Map of the year each country achieved List of sovereign states by date of formation, independence. Colonization (British English: colonisation) is a process of establishing occupation of or control over foreign territories or peoples f ...
of ''C. albicans'' was reported in young individuals with tongue piercing, in comparison to unpierced matched individuals, but not in healthy young individuals who use intraoral orthodontic acrylic appliances. To infect host tissue, the usual
unicellular A unicellular organism, also known as a single-celled organism, is an organism that consists of a single cell, unlike a multicellular organism that consists of multiple cells. Organisms fall into two general categories: prokaryotic organisms and ...
yeast-like form of ''C. albicans'' reacts to environmental cues and switches into an invasive, multicellular filamentous form, a phenomenon called dimorphism. In addition, an overgrowth infection is considered a superinfection, the term usually applied when an infection becomes opportunistic and very resistant to
antifungal An antifungal medication, also known as an antimycotic medication, is a pharmaceutical fungicide or fungistatic used to treat and prevent mycosis such as athlete's foot, ringworm, candidiasis (thrush), serious systemic infections such as ...
s. It then becomes suppressible by antibiotics. The infection is prolonged when the original sensitive strain is replaced by the antifungal-resistant strain. Candidiasis is known to cause gastrointestinal (GI) symptoms particularly in immunocompromised patients or those receiving steroids (e.g. to treat
asthma Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wh ...
) or antibiotics. Recently, there is an emerging literature that an overgrowth of fungus in the small intestine of non-immunocompromised subjects may cause unexplained GI symptoms. Small intestinal fungal overgrowth (SIFO) is characterized by the presence of an excessive number of fungal organisms in the small intestine associated with gastrointestinal symptoms. The most common symptoms observed in these patients were belching, bloating, indigestion, nausea, diarrhea, and gas. The underlying mechanism(s) that predisposes to SIFO is unclear. Further studies are needed; both to confirm these observations and to examine the clinical relevance of fungal overgrowth.


Systemic infections

Systemic fungal infections ( fungemias) including those by ''C. albicans'' have emerged as important causes of
morbidity A disease is a particular abnormal condition that adversely affects the structure or function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical conditions that are asso ...
and mortality in
immunocompromised Immunodeficiency, also known as immunocompromise, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that affe ...
patients (e.g.,
AIDS The HIV, human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system. Without treatment, it can lead to a spectrum of conditions including acquired immunodeficiency syndrome (AIDS). It is a Preventive healthcare, pr ...
, cancer
chemotherapy Chemotherapy (often abbreviated chemo, sometimes CTX and CTx) is the type of cancer treatment that uses one or more anti-cancer drugs (list of chemotherapeutic agents, chemotherapeutic agents or alkylating agents) in a standard chemotherapy re ...
, organ or
bone marrow Bone marrow is a semi-solid biological tissue, tissue found within the Spongy bone, spongy (also known as cancellous) portions of bones. In birds and mammals, bone marrow is the primary site of new blood cell production (or haematopoiesis). It i ...
transplantation). ''C. albicans'' often forms biofilms inside the body. Such ''C. albicans''
biofilm A biofilm is a Syntrophy, syntrophic Microbial consortium, community of microorganisms in which cell (biology), cells cell adhesion, stick to each other and often also to a surface. These adherent cells become embedded within a slimy ext ...
s may form on the surface of implantable medical devices or organs. In these biofilms it is often found together with ''
Staphylococcus aureus ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often posi ...
''. Such multispecies infections lead to higher mortalities. In addition hospital-acquired infections by ''C. albicans'' have become a cause of major health concerns. Especially once candida cells are introduced in the bloodstream a high mortality, up to 40–60% can occur. Although ''Candida albicans'' is the most common cause of
candidemia Fungemia is the presence of fungi or yeast in the blood. The most common type, also known as candidemia, candedemia, or systemic candidiasis, is caused by '' Candida'' species. Candidemia is also among the most common bloodstream infections ...
, there has been a decrease in the incidence and an increased isolation of non-albicans species of ''Candida'' in recent years. Preventive measures include maintaining a good oral hygiene, keeping a healthy lifestyle including good nutrition, the careful use of antibiotics, treatment of infected areas and keeping skin dry and clean, free from open wounds.


Role of ''C. albicans'' in Crohn's disease

The link between ''C. albicans'' and
Crohn's disease Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea, fever, abdominal distension, and weight loss. Complications outside of the ...
has been investigated in a large cohort. This study demonstrated that members of families with multiple cases of Crohn's disease were more likely to be colonized by ''C. albicans'' than members of control families. Experimental studies show that chemically induced colitis promotes ''C. albicans'' colonization. In turn, ''C. albicans'' colonization generates anti-''Saccharomyces cerevisiae'' antibodies (ASCA), increases inflammation, histological scores and pro-inflammatory cytokine expression.


Diagnosis

A United States study in 2022 showed that most cases of candidiasis are treated
empirically In philosophy, empiricism is an Epistemology, epistemological view which holds that true knowledge or justification comes only or primarily from Sense, sensory experience and empirical evidence. It is one of several competing views within ...
(without culture, pending culture or by symptoms in cases where culture did not show candida), thus not knowing whether the subtype is ''Candida albicans'' or any other candida species. For subtyping of candidiasis, a fungal culture can be performed, followed by a
germ tube A germ tube is an outgrowth produced by spores of spore-releasing fungi during germination. The germ tube differentiates, grows, and develops by mitosis to create somatic hyphae.C.J. Alexopolous, Charles W. Mims, M. Blackwell, ''Introductory My ...
test in which a sample of fungal spores are suspended in animal serum and examined by
microscopy Microscopy is the technical field of using microscopes to view subjects too small to be seen with the naked eye (objects that are not within the resolution range of the normal eye). There are three well-known branches of microscopy: optical mic ...
for the detection of any germ tubes.Chapter IV. Germ Tube Test i
YEAST IDENTIFICATION
document at doctorfungus.org. Retrieved July 2011
Colonies of white or cream color on fungal culture having a positive germ tube test is strongly indicative of ''Candida albicans''. File:Candida albicans PHIL 3192 lores.jpg,
Agar plate An agar plate is a Petri dish that contains a growth medium solidified with agar, used to Microbiological culture, culture microorganisms. Sometimes selective compounds are added to influence growth, such as antibiotics. Individual microorganism ...
culture of ''C. albicans'' File:C albicans germ tubes.jpg, Germ tubes of ''Candida albicans'' File:Candida Gram stain.jpg,
Gram stain Gram stain (Gram staining or Gram's method), is a method of staining used to classify bacterial species into two large groups: gram-positive bacteria and gram-negative bacteria. It may also be used to diagnose a fungal infection. The name comes ...
of ''Candida albicans'' from a vaginal swab; the small oval chlamydospores are 2–4  μm in diameter File:CHROMAgar with N glabratus, P kudriavzevii, Candida albicans and Candida tropicalis, annotated.jpg, Chromogenic agar can help in indicating main species of ''Candida'' versus similar fungi. (CHROMAgar shown) File:Mycology algorithm.png, Algorithm for the diagnosis of ''Candida albicans'' versus differential diagnoses


Treatment

There are relatively few drugs that can successfully treat Candidiasis. Treatment commonly includes: *
amphotericin B Amphotericin B is an antifungal medication used for serious fungal infections and leishmaniasis. The fungal infections it is used to treat include mucormycosis, aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, and cryptococ ...
,
echinocandin Echinocandins are a class of antifungal drugs that inhibit the synthesis of β-glucan in the fungal cell wall via noncompetitive inhibition of the enzyme 1,3-β glucan synthase. The class has been dubbed the "penicillin of antifungals," along w ...
, or
fluconazole Fluconazole is an antifungal medication used for a number of fungal infections. These include candidiasis, blastomycosis, coccidioidomycosis, cryptococcosis, histoplasmosis, dermatophytosis, and tinea versicolor. It is also used to pr ...
for systemic infections *
nystatin Nystatin, sold under the brand name Mycostatin among others, is an antifungal medication. It is used to treat ''Candida (fungus), Candida'' infections of the skin including diaper rash, Candidiasis, thrush, esophageal candidiasis, and vaginal ...
for oral and esophageal infections *
clotrimazole Clotrimazole, sold under the brand name Lotrimin, among others, is an antifungal medication. It is used to treat vaginal yeast infections, oral thrush, diaper rash, tinea versicolor, and types of ringworm including athlete's foot and jock itc ...
for skin and genital yeast infections Similarly to antibiotic resistance, resistance to many anti-fungals is becoming a problem. New anti-fungals have to be developed to cope with this problem since only a limited number of anti-fungals are available. A general problem is that in contrast to bacteria, fungi are often overlooked as a potential health problem.


Economic implications

Given the fact that candidiasis is the fourth- (to third-) most frequent hospital acquired infection worldwide it leads to immense financial implications. Approximately 60,000 cases of systemic candidiasis each year in the USA alone lead up to a cost to be between $2–4 billion. The total costs for candidiasis are among the highest compared to other fungal infections due to the high prevalence. The immense costs are partly explained by a longer stay in the intensive care unit or hospital in general. An extended stay for up to 21 more days compared to non-infected patients is not uncommon.


Role of GSDMD in C.albicans infection

Gasdermin D (GSDMD) is a protein that in humans is encoded by the GSDMD gene and is a known target of the inflammasome and acts as an effector molecule of programmed cell death known as pyroptosis. This protein determines cell lysis to prevent pathogen replication and results in the release of the inflammatory cytokine interleukin-1β (IL-1β) into the extracellular space to recruit and activate immune cells at the site of infection. Inflammasome activation due to C.albicans infection triggers the release of a
cytokine storm A cytokine storm, also called hypercytokinemia, is a pathological reaction in humans and other animals in which the innate immune system causes an uncontrolled and excessive release of pro-inflammatory signaling molecules called cytokines. Cytok ...
necessary to fight the pathogen. Excessive release of these pro-inflammatory mediators has been shown to exaggerate systemic inflammation leading to vascular injury and damage to vital organs. Unfortunately, Candida albicans therapy is often ineffective despite the availability of many antifungal drugs, mainly because of resistance phenomena. During conventional pyroptosis controlled by the inflammasome-GSDMD axis is hijacked by C. albicans to facilitate escape from macrophages through unfolding of hyphae and candidalysin, a fungal toxin released from hyphae. It has been shown that disruption of GSDMD in macrophages infected with Candida albicans reduces the fungal load. In addition, the presence of hyphae and candidalysin are key factors in the activation of GSDMD and the release of Candida from macrophages. Also using Candida-infected mice, inhibition of GSDMD has been shown to paradoxically improve prognosis and survival, indicating that this protein may be a potential therapeutic target in C. albicans-induced sepsis.


Biofilm development


Biofilm formation steps

The biofilm of ''C. albicans'' is formed in four steps. First, there is the initial adherence step, where the yeast-form cells adhere to the substrate. The second step is called Intermediate step, where the cells propagate to form micro colonies, and germ tubes form to yield hyphae. In the maturation step, the biofilm biomass expands, the extracellular matrix accumulates and drug resistance increases. In the last step of biofilm formation, the yeast-form cells are released to colonize the surrounding environment (dispersion). Yeast cells released from a biofilm have novel properties, including increased virulence and drug tolerance.


Zap1

Zap1, also known as Csr1 and Sur1 (zinc-responsive activator protein), is a transcription factor required for the ''C. albicans'' hypha formation in biofilms. Zap1 controls the equilibrium of yeast and hyphal cells, the zinc transporters and zinc regulated genes in biofilms of ''C. albicans''.


Zinc

Zinc (Zn2+) is important for cell function of ''C. albicans'' and Zap1 controls the Zinc levels in the cells through the zinc transporters Zrt1 and Zrt2. The regulation of zinc concentration in the cells is important for the cell viability and if the zinc levels get too high, it is toxic for the cells. The Zrt1 is transporting the zinc ions with high affinity and the Zrt2 is transporting the zinc ions with low affinity.


Mechanisms and proteins important for pathogenesis


Filamentation

The ability to switch between yeast cells and hyphal cells is an important virulence factor. Many proteins play a role in this very complex process. The formation of hyphae can for example help ''Candida albicans'' to escape from macrophages in the human body. Moreover, ''C. albicans'' undergo yeast-to-hyphal transition within the acidic macrophage phagosome. This initially causes phagosome membrane distension which eventually leads to phagosomal alkalinization by physical rupture, followed by escape.


Hwp1

Hwp1 stands for Hyphal wall protein 1. Hwp1 is a mannoprotein located on the surface of the hyphae in the hyphal form of ''C. albicans''. Hwp1 is a mammalian transglutaminase substrate. This host enzyme allows ''Candida albicans'' to attach stably to host epithelial cells. Adhesion of ''C. albicans'' to host cells is an essential first step in the infection process for colonization and subsequent induction of mucosal infection.


Slr1

The
RNA-binding protein RNA-binding proteins (often abbreviated as RBPs) are proteins that bind to the double or single stranded RNA in cell (biology), cells and participate in forming ribonucleoprotein complexes. RBPs contain various structural motifs, such as RNA reco ...
Slr1 plays a role in instigating hyphal formation and virulence in ''C. albicans''.


Candidalysin

Candidalysin is a cytolytic 31-amino acid α-helical peptide toxin that is released by ''C. albicans'' during hyphal formation. It contributes to virulence during mucosal infections.


PRA1

During vaginal infections PRA1 (pH-regulated antigen) gene is up-regulated. Its expression correlates with the concentration of proinflammatory cytokines.


Genetic and genomic tools

Due to its nature as a model organism, being an important human pathogen and the alternative codon usage (CUG translated into serine rather than leucine), several specific projects and tools have been created to study ''C. albicans''. The diploid nature and the absence of a sexual cycle make the organism difficult to study, but in the last 20 years, many systems have been developed to observe its genetics.


Selection markers

The selection markers most used in ''C. albicans'' are the CaNAT1 resistance marker (confers resistance against nourseothricin) and MPAr or IMH3r (confers resistance to
mycophenolic acid Mycophenolic acid is an immunosuppressant medication used to prevent rejection following organ transplantation and to treat autoimmune conditions such as Crohn's disease and lupus. Specifically it is used following kidney, heart, and live ...
). Next to the above-mentioned selection makers a few auxotrophic strains were generated to work with auxotrophic makers. The URA3 marker (URA3 blaster method) is an often-used strategy in uridine auxotrophic strains; however, studies have shown that differences in URA3 position in the genome can be involved in the pathogeny of ''C. albicans''. Besides the URA3 selection one can also use the histidine, leucine and arginine autotrophy. The advantage of using those autotrophies lies in the fact that they exhibit wild-type or nearly wild-type virulence in a mouse model compared to the URA3 system. One application of the leucine, arginine and histidine autotrophy is for example the candida two-hybrid system.


Full sequence genome

The full genome of ''C. albicans'' has been sequenced and made publicly available in
Candida database
The heterozygous diploid strain used for this full genome sequence project is the laboratory strain SC5314. The sequencing was done using a whole-genome shotgun approach.


ORFeome project

Every predicted ORF has been created in a gateway adapted vector (pDONR207) and made publicly available. The vectors (
plasmid A plasmid is a small, extrachromosomal DNA molecule within a cell that is physically separated from chromosomal DNA and can replicate independently. They are most commonly found as small circular, double-stranded DNA molecules in bacteria and ...
s) can be propagated in ''E.coli'' and grown on LB+
gentamicin Gentamicin is an aminoglycoside antibiotic used to treat several types of bacterial infections. This may include bone infections, endocarditis, pelvic inflammatory disease, meningitis, pneumonia, urinary tract infections, and sepsis amo ...
medium. This way every ORF is readily available in an easy to use vector. Using the gateway system it is possible to transfer the ORF of interest to any other gateway adapted vector for further studies of the specific ORF.


CIp10 integrative plasmid

Contrary to the yeast ''S. cerevisiae'' episomal plasmids do not stay stable in ''C. albicans''. In order to work with plasmids in ''C. albicans'' an integrative approach (plasmid integration into the genome) thus has to be used. A second problem is that most plasmid transformations are rather inefficient in ''C. albicans''; however, the CIp10 plasmid overcomes these problems and can be used with ease to transform ''C. albicans'' in a very efficient way. The plasmid integrates inside the RP10 locus as disruption of one RP10 allele does not seem to affect the viability and growth of ''C. albicans''. Several adaptations of this plasmid have been made after the original became available.


Candida two-hybrid (C2H) system

Due to the aberrant codon usage of ''C. albicans'' it is less feasible to use the common host organism (''
Saccharomyces cerevisiae ''Saccharomyces cerevisiae'' () (brewer's yeast or baker's yeast) is a species of yeast (single-celled fungal microorganisms). The species has been instrumental in winemaking, baking, and brewing since ancient times. It is believed to have be ...
'') for two-hybrid studies. To overcome this problem a ''C. albicans'' two-hybrid (C2H) system was created. The strain SN152 that is auxotrophic for leucine, arginine and histidine was used to create this C2H system. It was adapted by integrating a HIS1 reporter gene preceded by five LexAOp sequences. In the C2H system the bait plasmid (pC2HB) contains the ''
Staphylococcus aureus ''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often posi ...
'' LexA BD, while the prey plasmid (pC2HP) harbors the viral AD VP16. Both plasmids are integrative plasmids since episomal plasmids do not stay stable in ''C. albicans''. The reporter gene used in the system is the ''HIS1'' gene. When proteins interact, the cells will be able to grow on medium lacking histidine due to the activation of the ''HIS1'' reporter gene. Several interactions have thus far been detected using this system in a low scale set up. A first high-throughput screening has also been performed. Interacting proteins can be found at the BioGRID.


Bimolecular fluorescence complementation (BiFC)

Besides the C2H system, a BiFC system has been developed to study protein-protein interactions in ''C. albicans''. With this systems protein interactions can be studied in their native sub cellular location contrary to a C2H system in which the proteins are forced into the nucleus. With BiFC one can study for example protein interactions that take place at the cell membrane or vacuolar membrane.


Microarrays

Both DNA and protein microarrays were designed to study DNA expression profiles and antibody production in patients against ''C. albicans'' cell wall proteins.


GRACE library

Using a tetracycline-regulatable promoter system a gene replacement and conditional expression (GRACE) library was created for 1,152 genes. By using the regulatable promoter and having deleted 1 of the alleles of the specific gene it was possible to discriminate between non-essential and essential genes. Of the tested 1,152 genes 567 showed to be essential. The knowledge on essential genes can be used to discover novel antifungals.


CRISPR/Cas9

CRISPR/Cas9 has been adapted to be used in ''C. albicans''. Several studies have been performed using this system.


Application in engineering

''C. albicans'' has been used in combination with carbon nanotubes (CNT) to produce stable electrically conductive bio-nano-composite tissue materials that have been used as temperature-sensing elements.


Notable ''C. albicans'' researchers

* Neil A. R. Gow * Alexander D. Johnson * Frank C. Odds * Charles Philippe Robin * Fred Sherman * David R. Soll


See also

* Intestinal permeability * Torula yeast (''Candida utilis'') * Neonatal infection * Codon usage


References


Further reading

* * * * *


External links


''Candida'' Genome Database

U.S. National Institutes of Health on the ''Candida albicans'' genome

Mycobank data on ''Candida albicans''



Protein-protein interactions for Candida albicans
{{Authority control albicans Gut flora Organisms with an alternative genetic code Pathogenic microbes Fungal pathogens of humans Yeasts Fungi described in 1923 Fungus species