Pathogenicity ofCandida albicanswith particular reference to the vagina

Strain persistence of invasive Candida albicans in chronic hyperplastic candidosis that underwent malignant change

OBJECTIVES

The aim of this study was to assess persistence and tissue invasion of Candida albicans strains isolated from a 65 year-old patient with chronic hyperplastic candidosis (CHC), that subsequently developed into squamous cell carcinoma (SCC).

MATERIALS AND METHODS

C. albicans (n=7) were recovered from the oral cavity of the patient over seven years. Confirmation of CHC and SCC in this patient was achieved by histopathological examination of incisional biopsy tissue. DNA fingerprinting was performed on the seven isolates from the CHC patient together with a further eight isolates from patients with normal oral mucosa (n=2), chronic atrophic candidosis (n=1), SCC (n=1) and CHC (n=4). Genotyping involved the use of inter-repeat PCR using the eukaryotic repeat primer 1251. Characterisation of the tissue invasive abilities of the isolates was achieved by infecting a commercially available reconstituted human oral epithelium (RHE; SkinEthic, Nice, France). After 24 h, C. albicans tissue invasion was assessed by histopathological examination.

RESULTS

DNA fingerprinting demonstrated strain persistence of C. albicans in the CHC patient over a seven year period despite provision of systemic antifungal therapy. The strain of C. albicans isolated from this patient was categorised as a high invader within the RHE compared to other isolates.

CONCLUSIONS

Candidal strain persistence was evident in a patient with CHC over seven years. This persistence may be due to incomplete eradication from the oral cavity following antifungal therapy or subsequent recolonisation from other body sites or separate exogenous sources. The demonstration of enhanced in vitro tissue invasion by this particular strain may, in part, explain the progression to carcinoma.

Prevalence and susceptibility of vaginal yeast isolates in Jordan

The prevalence of vaginal yeast species has been studied in 140 women (41 pregnant, 66 infertile and 33 healthy controls) attending a gynaecological private clinic in Amman, Jordan. Yeast species were isolated from pregnant (68.2%), infertile (51.5%) and healthy control (48.4%) women. Patients manifesting one, two or three symptoms of vulvovaginitis were 22.1%, 26.8% or 24.2% respectively. Asymptomatic cases and cases with more than three symptoms were 22.4% and 4.5% respectively. Candida albicans was the dominant species (in 51.3% of the patients) followed by C. glabrata (17.9%). The percentage occurrence as well as the pattern of Candida species differed among the different groups of patients. Candida kefyr was found to be significantly higher in the infertile women. In vitro sensitivity tests using amphotericin B, nystatin, miconazole nitrate and chlorhexidine were carried out; amphotericin B was the most effective and miconazole nitrate the least.

Characterisation of the inflammatory cell infiltrate in chronic hyperplastic candidosis of the oral mucosa

The inflammatory cell infiltrate in biopsy material of chronic hyperplastic candidosis (CHC) from the oral mucosa was characterised using immunocytochemical techniques. Nine specimens were stained for human kappa and lambda immunoglobulin light chains, CD68 antigen (macrophages), lysozyme (macrophages, granulocytes), CD3 antigen (T-lymphocytes), CD20 antigen (B-lymphocytes) and leucocyte common antigen (LCA). In addition, these and a further 13 specimens were also examined for immunoglobulin (Ig)-containing cells (IgA, IgG and IgM). The density of the infiltrate varied considerably between cases; T-lymphocytes were the dominant cell type (53.9%), with fewer B-lymphocytes (8.2%) and macrophages (14.2%). Many Ig-containing cells were seen, and although IgG-containing cells predominated, (60.8%, SD +/- 9.0) there was a high proportion of IgA-containing cells (36.7%, SD +/- 9.1) with few IgM-containing cells (2.5%, SD +/- 3.0). Many neutrophils, together with smaller numbers of T-lymphocytes and macrophages, were seen in the epithelium. It is suggested that mucosal defence to Candida infection involves a cell-mediated reaction in which there is recruitment of macrophages and local production of immunoglobulin with a prominent IgA component.

Induction of candidal vaginitis in diabetic mice and attempts to prevent the infection

In the present study on the induction and prevention of candidal vaginal infection in diabetic mice, ICR female mice were rendered diabetic by intraperitoneal injections of 160 mg kg-1 streptozotocin (SZ) which induced a stable non-lethal diabetic state apparent 2-7 days post-SZ injection. Diabetic mice and non-diabetic controls were inoculated intravaginally with 10(7)-10(10) Candida albicans yeasts. Infection was evaluated by the number of infected mice 3 days post-inoculation and the rate of clearance of infection during a 35-day follow-up. All C. albicans doses investigated induced vaginal infection in the diabetic mice, while in the non-diabetic controls only 40% of those inoculated with the lower (10(7) CFU) dose developed infection. The yeast load in the diabetic mice was 10-fold higher than in the controls and the duration of infection was longer. In an attempt to prevent infection intravaginal treatment with 5-40 mg of a chitin derivative (CSE) mouse-1 was given prior and pre- and post-inoculation with C. albicans. The optimal CSE treatment regimen was both pre- and post-administration of 10 or 20 mg CSE mouse-1 which significantly reduced the number of infected animals and also the duration of infection.

Histopathology of experimental vaginal candidosis in immunosuppressed mice

The histopathology of vaginal candidosis was studied in cyclophosphamide (CY)-immunosuppressed mice. In severely leucopenic animals acutely treated with high doses of CY the fungal inoculation resulted in a massive invasion of the pathogen, which penetrated the whole thickness of vaginal wall and was able to spread further into the surrounding tissues. In some animals, a haematogenous dissemination of the infection was detected. In mice chronically treated with lower doses of CY, moderate leucopenia combined with impaired antifungal granulocyte activity and suppressed cellular immunity resulted in the development of only superficial mycotic lesions. Pathogenetic mechanisms of vaginal candidosis in immunocompetent and immunosuppressed hosts are discussed.

The possible influence of the menstrual cycle on the adherence of Candida albicans to human buccal epithelial cells in vitro

Although the influence of the menstrual cycle on both vaginal candidosis and Candida albicans adherence to vaginal epithelial cells in vitro has been shown to be significant, similar studies have not been made on oral candidosis and adherence to buccal epithelial cells. The aim of this study was therefore to use an in vitro adherence assay to investigate the possible influence of the menstrual cycle on the adherence of C. albicans to buccal epithelial cells. Epithelial cells were collected from a single, healthy, female volunteer on days 5, 15, 22 and 28 of six menstrual cycles. Adherence of C. albicans was significantly higher to buccal epithelial cells collected on day 5 of the menstrual cycle when compared with days 15, 22 and 28, both in terms of the percentage of buccal epithelial cells with adherent C. albicans and the number of C. albicans adhering per 200 buccal epithelial cells in four out of six menstrual cycles (p < 0.001). This result indicates that hormonal influences should be considered when buccal epithelial cells are used in vitro to assess candidal adherence and may implicate hormonal factors in the aetiology of oral candidosis.

Infantile diarrhoea and malnutrition associated with Candida in a developing community

The association of infantile diarrhoea with the occurrence of Candida species and their different morphological cell forms (pseudohyphae and/or blastospores) in faeces was studied in children of 0-15 months in a developing community (Lahore, Pakistan) where malnutrition is prevalent. Stool samples from 119 patients admitted to the Diarrhoea Treatment Unit, Department of Pediatrics, King Edward Medical College, and 46 healthy children were investigated for yeasts, bacteria, viruses and parasites. Salmonella and enteropathogenic Escherichia coli were seen in 13 (11%) each of the cases while Candida was the most frequent micro-organism, grown in cultures from 38 (32%) of the diarrhoea cases. C. tropicalis dominated (19%) over C. albicans (6%) and C. parapsilosis (3%). However, in a great number of cases (23, equals 19%), Candida did not grow in cultures but blastospores and/or pseudohyphae were seen on microscopical examination. Other Candida species and yeasts were relatively more common in the control group. Candida albicans, C. tropicalis and C. parapsilosis were the only identified agents in 23 of the cases (19%). The characteristic clinical findings in children with Candida as the only identified pathogen were malnutrition (69%), age less than 8 months (90%), and microscopically identified pseudohyphae in faecal smears (71%).

Factors influencing oral carriage of yeasts among individuals with diabetes mellitus

A total of 439 individuals with diabetes mellitus were examined for carriage of yeasts by the oral rinse and palatal swab techniques. Eighteen genetic or environment variables were assessed for their contribution to carriage of yeasts. The factor contributing to palatal and oral carriage of yeasts among individuals with insulin dependent diabetes mellitus (IDDM) was age (P < 0.01). The factor contributing to palatal carriage of yeasts among individuals with non-insulin dependent diabetes mellitus (NIDDM) was poor glycaemic control (glycosuria P < 0.01); carriage in the oral cavity as a whole was influenced additionally by non-secretion of ABH blood group antigens (P < 0.05). Introduction of a denture altered the above risk factors. For individuals with IDDM, oral carriage was associated with the presence of retinopathy (P < 0.05); palatal carriage was influenced by poor glycaemic control (HbA1P < 0.01, plasma glucose levels P < 0.05) and age (P < 0.05). For those with NIDDM, palatal carriage was associated with continuous presence of the denture in the mouth (P < 0.01); oral carriage was associated with plasma glucose levels (P < 0.05).

Histopathology of human vaginal candidosis

Histological changes of vaginal and ectocervical mucosa in women of reproductive age suffering from vaginal candidosis are described. The epithelial surface is covered with adherent masses composed of desquamated and destroyed epithelial cells and leucocytes impregnated with proteinaceous fluid and penetrated by pseudomycelium. The outer epithelial layers are characterized by dystrophic and necrobiotic changes, desquamation, formation of fissures and small cavities. Pseudomycelium penetrates 4 to 6 superficial epithelial layers. The barrier between the invading pseudomycelium and the blood vessels of the lamina propria papillae in some sites is only 5 to 6 flattened epithelial cells thick. In the basal epithelial layer, increased mitotic activity is noted. Lamina propria contains lympho-plasmocytic infiltrates. The problems of pathogenesis and diagnosis of vaginal candidosis are discussed in connection with the present findings.

Neisseria gonorrhoeae colonises the genital tract of oestradiol-treated germ-free female mice

Germ-free BALB/c mice treated with oestradiol and inoculated intravaginally with a serum-resistant strain or a freshly isolated, piliated strain of Neisseria gonorrhoeae were colonised vaginally. The organisms were recovered intermittently for a month or longer and there was evidence that they could reach the upper genital tract. Mice given progesterone and those not treated with either hormone did not become colonised. This is the first evidence of sustained mucosal colonisation in animals other than chimpanzees.

Changes in internal and external pH accompanying growth of Candida albicans: studies of non-dimorphic variants

Non-dimorphic variants of Candida albicans, which were unable to form germ tubes or mature hyphae in media containing amino acids, glucose and salts or N-acetylglucosamine or serum, were prepared from two hyphal positive laboratory strains using a physical separation method. The hyphal-minus phenotype was stable and may be due to mutations or phenotypic variation. The variant strains maintained their internal pH within narrower bounds as compared to their parental wild-types. When exposed to conditions that normally supported the induction of germ tubes the cytoplasmic pH of the wild type strains increased from 6.8 to over pH 8.0 within 5 min while in the variants the rise in internal pH was only about 0.3 pH units. The wild type strains acidified the growth medium more rapidly than the variants. The results suggest that the control of internal pH is directly or indirectly associated with the regulation of dimorphism. The variants had unaltered cell volumes and specific growth rates. The hyphal-minus phenotype was however fully reversible since revertants occurred spontaneously on serum containing agar.

Activity of ICI 195,739--a novel, orally active bistriazole--in rodent models of fungal and protozoal infections

ICI 195,739 shows superior potency to other azoles in eliminating vaginal candidosis or dermatophyte infections in animal models of infection by both oral dosing and topical application; effective doses are in the range of 0.5-5.0 mg/kg/day or 0.01-0.30% in a topical formulation. ICI 195,739 is likewise effective in models of systemic fungal infection; 1, 10, 25 mg/kg/day will protect animals given a lethal inoculum of C. albicans, C. neoformans, or A. fumigatus, respectively, as long as dosing is continued, showing activity in this respect superior to that of other azoles tested. ICI 195,739 will suppress infections in mice with T. cruzi and prevent mortality with five daily doses of 1 mg/kg; cure rather than suppression of patent infections has been achieved with 35 daily doses of 10 mg/kg.

Association of electrophoretic karyotype of Candida stellatoidea with virulence for mice

Seven isolates of Candida stellatoidea were studied for their electrophoretic karyotype, virulence for mice, sensitivity to UV radiation, growth rate in vitro, reaction on cycloheximide-indicator medium, and proteinase activity. The isolates exhibited one of two distinct electrophoretic karyotypes as determined by orthogonal field alternating gel electrophoresis (OFAGE). Four isolates, including the type culture of C. stellatoidea, belonged to electrophoretic karyotype type I by OFAGE, showing eight to nine bands of which at least two bands were less than 1,000 kilobases in size as estimated by comparison with the DNA bands of Saccharomyces cerevisiae. These isolates failed to produce fatal infection in mice within 20 days when 5 X 10(5) cells were injected intravenously. The yeasts were cleared from the kidneys of two of three mice tested by day 30. Type I showed proteinase activity on bovine serum albumin agar at pH 3.8 and produced a negative reaction on cycloheximide-bromcresol green medium within 48 h. The three grouped in type II by OFAGE showed banding patterns similar to those of a well-characterized isolate of Candida albicans. The isolates of type II had an electrophoretic karyotype of six to seven bands approximately 1,200 kilobases or greater in size. All three type II isolates were highly virulent for mice, producing fatality curves similar to those of a previously studied C. albicans isolate. From 80 to 90% of the mice injected with 5 X 10(5) cells intravenously died within 20 days. The type II isolates produced a positive reaction on cycloheximide-bromcresol green agar and showed no proteinase activity on bovine serum albumin agar at the low pH. In addition, the type II isolates grew faster and were significantly more resistant to UV irradiation than the type I isolates. These results indicated that type II, but not type I, isolates can be considered simply as sucrose-negative C. albicans.

Candidal vaginitis in hormone-treated mice: prevention by a chitin extract

In view of findings from previous studies that a chitin soluble extract (CSE) blocked adhesion of Candida albicans in vitro and in vivo and prevented thereby a short lived candidal infection in naive mice, we attempted in the present study to block by CSE the development of a persistent infection, induced in hormone-treated animals. Continuous oestrus phase was obtained in mice by repeated weekly subcutaneous injections with estradiol benzoate. Intravaginal inoculation of the hormone-treated mice with 10(7)-10(10) C. albicans cells induced a persistent candidal infection. Fifty three mice were pretreated intravaginally prior to inoculation of C. albicans with 2.5, 5.0 or 10 mg/mouse of a CSE cream and followed up for development of infection in comparison to 30 untreated animals. Twenty four hrs post fungus inoculation the infection rate among the CSE treated mice was 11-23% VS 84% among the controls; the rate increased a week later to 97% among the controls VS 41-50% among the CSE treated. Administering the CSE to the mice prior--and post-yeast inoculation (37 mice), led to increased efficacy of the treatment. The data, indicating that CSE is an effective measure for preventing persistent candidal vaginitis, may open the way to consider a similar approach for prophylaxis of vaginitis in human susceptible populations.

Recurrent vaginal candidosis: prospective study of effectiveness of maintenance miconazole treatment

In a prospective study, 100 women with recurrent vaginal candidosis were treated with miconazole, using two 100 mg vaginal pessaries a day for one week, then one pessary twice a week for three months followed by one pessary a week for a further three months. Fifty four women elected to continue using one pessary a week for longer than six months. Symptomatic vaginal candidosis did not occur in any patient during regular maintenance treatment. Of the 46 women who discontinued treatment before six months, however, 22 had a recurrence. Maintenance prophylactic treatment with miconazole pessaries appears to be an acceptable and effective method of preventing recurrent episodes of vaginal candidosis.

Candida proteinases and candidosis

Infections caused by the opportunistic yeast pathogen, Candida albicans, are becoming increasingly important. Superficial Candida infections, particularly those of the mouth and vagina, are very common; for example, candidal vaginitis plaques millions of women worldwide, often proving refractory to treatment. Systemic candidosis is much rarer, but it is an important hazard of modern medical procedures such as transplant surgery, i.v. hyperalimentation, and immunosuppressive therapy. One significant virulence factor of C. albicans is its ability to secrete extracellular acid proteinase. This attribute is shared by C. tropicalis and C. parapsilosis, but not by other less pathogenic Candida species. The enzymes produced by these yeasts are all carboxyl proteinases capable of degrading secretory IgA, the major immunoglobulin of mucous membranes. Some have keratino- or collagenolytic activity. Two secretory proteinases of C. albicans have been purified and characterized; their properties are reviewed. Possible applications of this work to the treatment and diagnosis of candidosis are discussed.

Interaction between Candida agglutinins and antifungal agents

Antifungal agents alter the function and morphology of Candida cell membranes and cell walls. We observed that brief (30 minute) exposure to either amphotericin B or clotrimazole inhibited the agglutination of Candida blastoconidia by murine bronchoalveolar lavage fluid. This inhibition required continuous drug presence. Neither amphotericin nor clotrimazole inhibited Candida agglutination by concanavalin A or pooled human serum. These results demonstrate that antifungal drugs can produce rapid changes in the surface characteristics of some fungi.

Effect of growth of Candida spp. in the presence of various glucocorticoids on the adherence to human buccal epithelial cells

In vitro culturing of three different yeast species with a number of glucocorticoids altered their adherence ability in two ways: Incubation with dexamethasone and triamcinolone acetonide promoted the adherence in general (the increase in adherence ranged between 17% and 44%), whilst growth in the presence of cortisone acetate or hydrocortisone blocked the adherence (inhibition ranged from 16% to 32%). No statistical difference in the adherence capabilities of different growth phases of C. albicans noted, and the effects of glucocorticoids persisted irrespective of the phase of growth used. An attempt to explain the differences in adherence of the Candida spp. investigated, in the presence of various steroids, on the basis of variation in their structural configurations and/or steroid-receptor interaction is given.