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ElFeky DS, Awad AR, Shamseldeen AM, Mowafy HL, Hosny SA. Comparing the therapeutic potentials of Lactobacillus johnsonii vs. Lactobacillus acidophilus against vulvovaginal candidiasis in female rats: an in vivo study. Front Microbiol 2023; 14:1222503. [PMID: 37529322 PMCID: PMC10388188 DOI: 10.3389/fmicb.2023.1222503] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
Background Vulvovaginal candidiasis (VVC) is a highly prevalent illness affecting women globally. Lactobacilli, which make up the majority of healthy vaginal microbiota (VMB), serve as a powerful barrier against infections. Probiotic therapy has been recommended for the treatment or prevention of VVC. Aim of work To compare the in vivo therapeutic effects of Lactobacillus johnsonii (B-2178) vs. Lactobacillus acidophilus (LA-5®) on VVC in a rat model, particularly highlighting the immune response of the host vaginal epithelium. Methods In total, 30 female Sprague-Dawley rats were divided into 5 groups; Group 1: no intervention, Group 2: ovariectomy group, while animals in Groups 3-5 were subjected to ovariectomy and an intravaginal inoculation of Candida albicans (C. albicans) to establish VVC. The animals in Groups 4 and 5 received intravaginal lactobacilli treatment with L. acidophilus (LA-5®) and L. johnsonii (B-2178) strains, respectively, for 7 days. C. albicans load was measured in a vaginal lavage 1, 3, and 7 days after the stoppage of the treatment. Histological, morphometric, and immunohistochemical studies of the vaginal tissues were done. IFN-γ, IL-4, and IL-17 were measured in the vaginal tissue. Results Both L. johnsonii and L. acidophilus significantly reduced C. albicans vaginal load (250 ± 77.46 and 133.33 ± 40.82 CFU/mL) compared to the count before treatment in both groups (4,850 ± 1419.51 and 4966.67 ± 852.45 CFU/mL) even after 7 days of stoppage of lactobacilli treatment. A statistically significant reduction of the pro-inflammatory cytokines IL-17 and IFN-γ was reported in both treated groups compared to the infected untreated group. L. johnsonii has a significant effect on the reduction of hyphae formation of C. albicans as well as the nuclear factor kappa B (NF-κB) immunostaining density of vaginal tissue compared to L. acidophilus. Moreover, treatment with L. johnsonii significantly minimized the epithelium damage triggered by C. albicans infection and restored normal vaginal architecture as evidenced by the histologic and morphometric studies when compared to L. acidophilus. Conclusion Through maintaining an immune tolerant state in the vaginal epithelium and ameliorating the undesirable uncontrolled inflammatory response in the vaginal tissue, L. johnsonii (B-2178) has the potential to be utilized alone or in combination with other lactobacilli species in probiotic clinical trials to treat or prevent VVC.
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Affiliation(s)
- Dalia Saad ElFeky
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Alaa Reda Awad
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Asmaa Mohammed Shamseldeen
- Department of Physiology, Faculty of Medicine, Cairo University, Cairo, Egypt
- Department of Physiology, Faculty of Medicine, October 6 University, Giza, Egypt
| | - Hagar Lotfy Mowafy
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Sara Adel Hosny
- Histology Department, Faculty of Medicine, Cairo University, Giza, Egypt
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2
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Li X, Xu Y, Ouyang D, Ye K, Chen Y, Li Q, Xia Q, Wu X, Yang Y. Copper- and Iodine-Doped Nanozymes with Simulated Enzyme Activity and Efficient Antifungal Activity against Candida albicans. Biochem Eng J 2022. [DOI: 10.1016/j.bej.2022.108791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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3
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Yang X, Wang M, Kang X, Mo F, Si P, Ma J, Zhang P, Zheng S, Li J, Wang Y, Li Q, Zhang J. L-Se-methylselenocysteine loaded mucoadhesive thermogel for effective treatment of Vulvar candidiasis. Int J Pharm 2022; 622:121851. [PMID: 35618178 DOI: 10.1016/j.ijpharm.2022.121851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 01/17/2023]
Abstract
Vulvar candidiasis (VVC) is a vaginitis caused by vaginal mucosa infection of Candida, which greatly impairs women's health. Although there are more and more thiazoles on the market, new classes of antifungal drugs are still missing, it is still challenging to treat azole-resistant candidal vaginitis. We found that L-Se-methylselenocysteine (L-SeMC) could effectively inhibit the growth of Candida albicans, reduce the density and length of the mycelia. To extend the retention time of L-SeMC in the vaginal tract and enhance its therapeutic effect for VVC, a mucoadhesive thermogel (NAC-HA thermogel) was successfully synthesized and prepared. The gelation window was around 29-56℃ for L-SeMC loaded mucoadhesive thermogel (L-SeMC@NAC-HA thermogel), which exhibited a sustained release profile in the in vitro release study and an extended retention time in the vaginal tract. Besides, L-SeMC@NAC-HA thermogel exhibited a good safety profile in the in vivo safety study. The in vivo anti-VVC effect was examined in a rat VVC model and L-SeMC@NAC-HA thermogel significantly reduced the number of Candida albicans in the vaginal secreta, mitigated the vaginal damage and reduced the secretion of proinflammatory factors (TNF-α, IL-1α and IL-β). Therefore, it is a promising therapy for the clinical treatment of VVC in the near future.
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Affiliation(s)
- Xianwei Yang
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Menghan Wang
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Ximeng Kang
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Fei Mo
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Peiru Si
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Jia Ma
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Peipei Zhang
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China
| | - Shaohua Zheng
- The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jiyu Li
- Henan Xibaikang Health Industry Co., Ltd., Jiyuan, China
| | - Yang Wang
- Henan Xibaikang Health Industry Co., Ltd., Jiyuan, China
| | - Qingqing Li
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China.
| | - Jiye Zhang
- School of Pharmacy, Health Science Center, Xi'an Jiaotong University, Xi'an, China.
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4
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Fabri RL, Freitas JCO, Lemos ASO, Campos LM, Diniz IOM, Pinto NCC, Silva TP, Palazzi C, Marchesini P, Monteiro C, Barbosa AF, Carvalho MG, Chedier LM, Araújo MGF, Apolônio ACM, Rocha VN, Melo RCN, Pinto PF. Spilanthol as a promising antifungal alkylamide for the treatment of vulvovaginal candidiasis. Med Mycol 2021; 59:1210-1224. [PMID: 34468763 DOI: 10.1093/mmy/myab054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/11/2021] [Accepted: 08/30/2021] [Indexed: 12/21/2022] Open
Abstract
Spilanthol is a bioactive alkylamide from the native Amazon plant species, Acmella oleracea. However, antifungal activities of spilanthol and its application to the therapeutic treatment of candidiasis remain to be explored. This study sought to evaluate the in vitro and in vivo antifungal activity of spilanthol previously isolated from A. oleracea (spilanthol(AcO)) against Candida albicans ATCC® 10231™, a multidrug-resistant fungal strain. Microdilution methods were used to determine inhibitory and fungicidal concentrations of spilanthol(AcO). In planktonic cultures, the fungal growth kinetics, yeast cell metabolic activity, cell membrane permeability and cell wall integrity were investigated. The effect of spilanthol(AcO) on the proliferation and adhesion of fungal biofilms was evaluated by whole slide imaging and scanning electron microscopy. The biochemical composition of the biofilm matrix was also analyzed. In parallel, spilanthol(AcO) was tested in vivo in an experimental vulvovaginal candidiasis model. Our in vitro analyses in C. albicans planktonic cultures detected a significant inhibitory effect of spilanthol(AcO), which affects both yeast cell membrane and cell wall integrity, interfering with the fungus growth. C. albicans biofilm proliferation and adhesion, as well as, carbohydrates and DNA in biofilm matrix were reduced after spilanthol(AcO) treatment. Moreover, infected rats treated with spilanthol(AcO) showed consistent reduction of both fungal burden and inflammatory processes compared to the untreated animals. Altogether, our findings demonstrated that spilanthol(AcO) is an bioactive compound against planktonic and biofilm forms of a multidrug resistant C. albicans strain. Furthermore, spilanthol(AcO) can be potentially considered for therapeutical treatment of vulvovaginal candidiasis caused by C. albicans. LAY SUMMARY This study sought to evaluate the antifungal activity of spilanthol against Candida albicans ATCC® 10 231™, a multidrug-resistant fungal strain. Our findings demonstrated that spilanthol(AcO) can be potentially considered for therapeutical treatment of vulvovaginal candidiasis caused by C. albicans.
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Affiliation(s)
- Rodrigo L Fabri
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Jhamine C O Freitas
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Ari S O Lemos
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Lara M Campos
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Irley O M Diniz
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Nícolas C C Pinto
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Thiago P Silva
- Laboratory of Cellular Biology, Department of Biology, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Cinthia Palazzi
- Laboratory of Cellular Biology, Department of Biology, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Paula Marchesini
- Post-graduate Program in Veterinary Science, Federal Rural University of Rio de Janeiro, CEP 323897-970, Seropédica, RJ, Brazil
| | - Caio Monteiro
- Institute of Tropical Pathology and Public Health, Federal University of Goiás, CEP 374690-000, Goiânia, Go, Brazil
| | - Alan F Barbosa
- Federal Institute of Education, Science and Technology of Mato Grosso, CEP 378890-000, Sorriso, MG, Brazil
| | - Mário G Carvalho
- Department of Chemistry, Institute of Exact Sciences, Federal Rural University of Rio de Janeiro, CEP 323897-970, Seropédica, RJ, Brazil
| | - Luciana M Chedier
- Department of Botany, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Marcelo G F Araújo
- Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, CEP 35501-296, Divinópolis, MG, Brazil
| | - Ana Carolina M Apolônio
- Department of Parasitology, Microbiology and Imunology, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Vinícius N Rocha
- Department of Veterinary Medicine, Faculty of Medicine, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Rossana C N Melo
- Laboratory of Cellular Biology, Department of Biology, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
| | - Priscila F Pinto
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, CEP 36036-900, Juiz de Fora, MG, Brazil
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5
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Ferreira PS, Victorelli FD, Rodero CF, Fortunato GC, Araújo VHS, Fonseca-Santos B, Bauab TM, Van Dijck P, Chorilli M. p-Coumaric acid loaded into liquid crystalline systems as a novel strategy to the treatment of vulvovaginal candidiasis. Int J Pharm 2021; 603:120658. [PMID: 33964336 DOI: 10.1016/j.ijpharm.2021.120658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/08/2021] [Accepted: 04/25/2021] [Indexed: 12/30/2022]
Abstract
Vulvovaginal candidiasis (VVC) is an extremely common type of vaginal infection, which is mainly caused by Candida albicans. However, non-albicans Candida species are frequently more resistant to conventional antifungal agents and can represent up to 30% of cases. Due to side effects and increasing antifungal resistance presented by standard therapies, phenolic compounds, such as p-coumaric acid (p-CA), have been studied as molecules from natural sources with potential antifungal activity. p-CA is a poorly water-soluble compound, thus loading it into liquid crystals (LCs) may increase its solubility and effectiveness on the vaginal mucosa. Thereby, here we propose the development of mucoadhesive liquid crystalline systems with controlled release of p-CA, for the local treatment of VVC. Developed LCs consisted of fixed oily and aqueous phases (oleic acid and cholesterol (5:1) and poloxamer dispersion 16%, respectively), changing only the surfactant phase components (triethanolamine oleate (TEA-Oleate) or triethanolamine (TEA), the latter producing TEA-Oleate molecules when mixed with oleic acid). Systems were also diluted in artificial vaginal mucus (1:1 ratio) to mimic the vaginal environment and verify possible structural changes on formulations upon exposure to the mucosa. From the characterization assays, p-CA loaded TEA-Oleate systems presented mucoadhesive profile, liquid crystalline mesophases, well-organized structures and pseudoplastic behaviour, which are desirable parameters for topical formulations. Moreover, they were able to control the release of p-CA throughout the 12 h assay, as well as decrease its permeation into the vaginal mucosa. p-CA showed antifungal activity in vitro against reference strains of C. albicans (SC5314), C. glabrata (ATCC 2001) and C. krusei (ATCC 6258), and exhibited higher eradication of mature biofilms than amphotericin B and fluconazole. In vivo experiments demonstrated that the formulations reduced the presence of filamentous forms in the vaginal lavages and provided an improvement in swelling and redness present in the mice vaginal regions. Altogether, here we demonstrated the potential and feasibility of using p-CA loaded liquid crystalline systems as a mucoadhesive drug delivery system for topical treatment of VVC.
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Affiliation(s)
- P S Ferreira
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil.
| | - F D Victorelli
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - C F Rodero
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - G C Fortunato
- Department of Biological Sciences, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - V H S Araújo
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - B Fonseca-Santos
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - T M Bauab
- Department of Biological Sciences, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
| | - P Van Dijck
- Laboratory of Molecular Cell Biology, Institute of Botany and Microbiology, KU Leuven, Leuven-Heverlee, Belgium; VIB-KU Leuven Center for Microbiology, Flanders, Belgium
| | - M Chorilli
- Department of Drugs and Medicines, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara, São Paulo, Brazil
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6
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Mosca V, S Arita G, Vilegas LV, Faria DR, Sakita KM, Vendramini FA, Capoci IR, Becker TC, de Oliveira AG, Kioshima ÉS, S Bonfim-Mendonça PD, Svidzinski TI. Vulvovaginal candidiasis in a murine model of diabetes emphasizing the invasive ability of etiological agents. Future Microbiol 2020; 15:1001-1013. [PMID: 32811174 DOI: 10.2217/fmb-2019-0223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare the pathogenesis of vulvovaginal candidiasis by three Candida species in diabetic mice. Materials & methods: Estrogenized and diabetic mice were challenged with C. albicans, C. tropicalis and C. glabrata. Results: Diabetic animals infected with C. albicans and C. tropicalis maintained the highest fungal burden, despite of high levels of proinflammatory cytokines (IL-6 and TNF-α), respectively. For C. glabrata, the results were similar in diabetic and nondiabetic groups. Conclusion: C. tropicalis was as invasive as C. albicans, and both were more effective than C. glabrata. This ability was attributed to filamentation, which may be stimulated by glucose levels from vaginal fluid. In addition, the high burden may be attributed to the apparent immunological inefficiency of the diabetic host.
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Affiliation(s)
- Valéria Mosca
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Glaucia S Arita
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Lenisa V Vilegas
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Daniella R Faria
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Karina M Sakita
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Franciele Avr Vendramini
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Isis Rg Capoci
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Tania Ca Becker
- Laboratory of Pathology, Department of Basic Health Sciences, Maringá, PR 87020-900, Brazil
| | - Admilton G de Oliveira
- Laboratory of Electron Microscopy & Microanalysis - LMEM, Londrina, PR 86057-970, Brazil
| | - Érika S Kioshima
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Patrícia de S Bonfim-Mendonça
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
| | - Terezinha Ie Svidzinski
- State University of Maringá, Maringá, PR 87020-900, Brazil.,Laboratory of Medical Mycology, Department of Clinical Analysis & Biomedicine Maringá, PR 87020-900, Brazil
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Campos LM, de Oliveira Lemos AS, da Cruz LF, de Freitas Araújo MG, de Mello Botti GCR, Júnior JLR, Rocha VN, Denadai ÂML, da Silva TP, Tavares GD, Scio E, Fabri RL, Pinto PF. Development and in vivo evaluation of chitosan-gel containing Mitracarpus frigidus methanolic extract for vulvovaginal candidiasis treatment. Biomed Pharmacother 2020; 130:110609. [PMID: 34321177 DOI: 10.1016/j.biopha.2020.110609] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/22/2020] [Accepted: 08/02/2020] [Indexed: 02/08/2023] Open
Abstract
Vulvovaginal candidiasis (VVC) is characterized by inflammatory changes in the vaginal mucosa caused by abnormal colonization of Candida species. Traditional topical therapies using reference antifungal drugs usually present several issues and limitations for VVC treatment. Thus, the interest in new vaginal formulations, mainly those based on compounds from natural origin, has been growing over the last years. Methanolic extract from the plant species Mitracarpus frigidus (Willd. Ex Reem Schult.) K. Schum (MFM) has presented potential antifungal activity against C. albicans vaginal infection. Here, we aimed to develop and characterize a gynecological gel formulation based on chitosan containing MFM and to evaluate its anti-C. albicans effectiveness in the treatment of VVC. First, MFM was incorporated into a gel formulation based on chitosan in three final concentrations: 2.5 %, 5.0 %, and 10.0 %. Next, these gel formulations were subjected to stationary and oscillatory rheological tests. Finally, the gel was tested in an experimental VVC model. The rheological tests indicated pseudoplastic fluids, becoming more viscous and elastic with the increase of the extract concentration, indicating intermolecular interactions. Our in vivo analyses demonstrated a great reduction of vulvovaginal fungal burden and infection accompanied with the reduction of mucosal inflammation after MFM chitosan-gel treatment. The present findings open perspectives for the further use of the MFM-chitosan-gel formulation as a therapeutic alternative for VVC treatment.
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Affiliation(s)
- Lara Melo Campos
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Ari Sérgio de Oliveira Lemos
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Luisa Ferreira da Cruz
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, MG, Brazil
| | | | | | - Janildo Ludolf Reis Júnior
- Department of Veterinary Medicine, Faculty of Medicine, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Vinícius Novaes Rocha
- Department of Veterinary Medicine, Faculty of Medicine, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Ângelo Márcio Leite Denadai
- Department of Pharmacy, Institute of Life Sciences, Federal University of Juiz de Fora, Campus Governador Valadares, Governor Valadares, MG, Brazil
| | - Thiago Pereira da Silva
- Laboratory of Cellular Biology, Department of Biology, Institute of Biological Sciences, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Guilherme Diniz Tavares
- Laboratory of Nanostructured Systems Development, Department of Pharmaceutical Science, Faculty of Pharmacy, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Elita Scio
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
| | - Rodrigo Luiz Fabri
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil.
| | - Priscila Faria Pinto
- Bioactive Natural Products Laboratory and Protein Structure and Function Laboratory, Department of Biochemistry, Institute of Biological Sciences, Federal University of Juiz de Fora, Campus, Juiz de Fora, MG, Brazil
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8
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Andrade JT, Fantini de Figueiredo G, Cruz LF, Eliza de Morais S, Souza CDF, Pinto FCH, Ferreira JMS, Araújo MGDF. Efficacy of curcumin in the treatment of experimental vulvovaginal candidiasis. Rev Iberoam Micol 2019; 36:192-199. [DOI: 10.1016/j.riam.2019.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/02/2018] [Accepted: 01/22/2019] [Indexed: 12/22/2022] Open
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9
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Zhang X, Li T, Chen X, Wang S, Liu Z. Nystatin enhances the immune response against Candida albicans and protects the ultrastructure of the vaginal epithelium in a rat model of vulvovaginal candidiasis. BMC Microbiol 2018; 18:166. [PMID: 30359236 PMCID: PMC6202846 DOI: 10.1186/s12866-018-1316-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023] Open
Abstract
Background Vulvovaginal candidiasis (VVC) is a common infectious disease of the lower genital tract. Nystatin, a polyene fungicidal antibiotic, is used as a topical antifungal agent for VVC treatment. The aim of the current study was to investigate the possible immunomodulatory effects of nystatin on the vaginal mucosal immune response during Candida albicans infection and examine its role in protection of vaginal epithelial cell (VEC) ultrastructure. Results Following infection with C. albicans, IFN-γ and IL-17 levels in VECs were significantly elevated, while the presence of IgG was markedly decreased as compared to uninfected controls (P < 0.05). No significant differences in IL4 expression were observed. After treatment with nystatin, the level of IFN-γ, IL-17 and IgG was dramatically increased in comparison to the untreated group (P < 0.05). Transmission electron microscopy revealed that C. albicans invades the vaginal epithelium by both induced endocytosis and active penetration. Nystatin treatment protects the ultrastructure of the vaginal epithelium. Compared with the untreated C. albicans-infected group, Flameng scores which measure mitochondrial damage of VECs were markedly decreased (P < 0.001) and the number of adhesive and invasive C. albicans was significantly reduced (P < 0.01) after treatment with nystatin. Conclusions Nystatin plays a protective role in the host defense against C. albicans by up-regulating the IFN-γ-related cellular response, the IL-17 signaling pathway and possibly through enhancing VEC-derived IgG-mediated immunity. Furthermore, nystatin notably improves the ultramorphology of the vaginal mucosa, partially through the protection of mitochondria ultrastructure in VECs and inhibition of adhesion and invasion by C. albicans. Together, these effects enhance the immune response of the vaginal mucosa against C. albicans and protect the ultrastructure of vaginal epithelium in VVC rats.
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Affiliation(s)
- Xu Zhang
- Laboratory of Electron Microscopy, Ultrastructural Pathology Center, Peking University First Hospital, Beijing, 100034, China
| | - Ting Li
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Xi Chen
- Department of Gynecology Minimally Invasive Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Suxia Wang
- Laboratory of Electron Microscopy, Ultrastructural Pathology Center, Peking University First Hospital, Beijing, 100034, China
| | - Zhaohui Liu
- Department of Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
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10
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Fernandes LDS, Amorim YM, da Silva EL, Silva SC, Santos AJA, Peixoto FN, Neves Pires LM, Sakamoto RY, Horta Pinto FDC, Scarpa MVC, Araújo MGDF. Formulation, stability study and preclinical evaluation of a vaginal cream containing curcumin in a rat model of vulvovaginal candidiasis. Mycoses 2018. [PMID: 29517833 DOI: 10.1111/myc.12762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Owing to the growing resistance among isolates of Candida species to usual antifungal agents and the well-known therapeutic potential of curcumin, the purpose of this study was to develop and validate a vaginal formulation containing this substance and to evaluating its effectiveness in the treatment of experimental vulvovaginal candidiasis. Curcumin was incorporated in a vaginal cream in three concentrations (0.01%, 0.1% and 1.0%). The different concentrations of the cream and its controls were intravaginally administered in an immunosuppressed rat model to evaluate the efficacy in the treatment of experimental vulvovaginal candidiasis. Samples of the cream were also subjected to centrifugation and physical stability tests and an analytical method for quantification of curcumin was validated based on HPLC. The formulation was stable and the HPLC method could be considered suitable for the quantitative determination of curcumin in the cream. After 6 days of preclinical study, the number of infected animals was 1/6 in all groups treated with curcumin vaginal cream and the fungal burden showed a progressive reduction. Reduction in the inflammatory infiltrate was observed in the group treated with 1.0% cream. Vaginal cream containing curcumin could be considered a promising effective antifungal medicine in the treatment of vulvovaginal candidiasis.
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Affiliation(s)
- Lígia de Souza Fernandes
- Department of Drugs and Pharmaceutics, Faculty of Pharmaceutical Sciences, São Paulo State University - UNESP, Araraquara, SP, Brazil
| | - Yuri Martins Amorim
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Elton Libério da Silva
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Samuel Calixto Silva
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Alécia Junia Aparecida Santos
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Franciele Natália Peixoto
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Luara Moniele Neves Pires
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Raquel Yumi Sakamoto
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
| | - Flávia do Carmo Horta Pinto
- Natural Sciences Department, Federal University of São João Del-Rei, Campus Dom Bosco, São João Del-Rei, Minas Gerais, Brazil
| | - Maria Virgínia Costa Scarpa
- Department of Drugs and Pharmaceutics, Faculty of Pharmaceutical Sciences, São Paulo State University - UNESP, Araraquara, SP, Brazil
| | - Marcelo Gonzaga de Freitas Araújo
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, Minas Gerais, Brazil
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11
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Experimental Models of Vaginal Candidiasis and Their Relevance to Human Candidiasis. Infect Immun 2016; 84:1255-1261. [PMID: 26883592 DOI: 10.1128/iai.01544-15] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Vulvovaginal candidiasis (VVC) is a high-incidence disease seriously affecting the quality of life of women worldwide, particularly in its chronic, recurrent forms (RVVC), and with no definitive cure or preventive measure. Experimental studies in currently used rat and mouse models of vaginal candidiasis have generated a large mass of data on pathogenicity determinants and inflammation and immune responses of potential importance for the control of human pathology. However, reflection is necessary about the relevance of these rodent models to RVVC. Here we examine the chemical, biochemical, and biological factors that determine or contrast the forms of the disease in rodent models and in women and highlight the differences between them. We also appeal for approaches to improve or replace the current models in order to enhance their relevance to human infection.
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12
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Payne MS, Kemp MW, Kallapur SG, Kannan PS, Saito M, Miura Y, Newnham JP, Stock S, Ireland DJ, Kramer BW, Jobe AH. Intrauterine Candida albicans infection elicits severe inflammation in fetal sheep. Pediatr Res 2014; 75:716-22. [PMID: 24632681 PMCID: PMC4530618 DOI: 10.1038/pr.2014.35] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 12/07/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Preventing preterm birth and subsequent adverse neonatal sequelae is among the greatest clinical challenges of our time. Recent studies suggest a role for Candida spp. in preterm birth and fetal injury, as a result of their colonization of either the vagina and/or the amniotic cavity. We hypothesized that intraamniotic Candida albicans would cause a vigorous, acute fetal inflammatory response. METHODS Sheep carrying singleton pregnancies received single intraamniotic injections of either saline (control) or 10(7) colony-forming units C. albicans 1 or 2 d prior to surgical delivery and euthanasia at 124 ± 2 d gestation. RESULTS Colonization of the amniotic cavity by C. albicans resulted in a modest inflammatory response at 1 d and florid inflammation at 2 d, characterized by fetal thrombocytopenia, lymphopenia, and significant increases of inflammatory cytokines/chemokines in the fetal membranes skin, lung, and the amniotic fluid. CONCLUSION Acute colonization of the amniotic cavity by C. albicans causes severe intrauterine inflammation and fetal injury. C. albicans is a potent fetal pathogen that can contribute to adverse pregnancy outcomes.
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Affiliation(s)
- Matthew S. Payne
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia
| | - Matthew W. Kemp
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,CORRESPONDING AUTHOR: Matthew W. Kemp Ph.D., School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia 6009., Phone: 61-8-6488-7970, Fax: 61-8-6488-7971,
| | - Suhas G. Kallapur
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Centre, University of Cincinnati School of Medicine Cincinnati, Ohio USA
| | - Paranthaman Senthamarai Kannan
- Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Centre, University of Cincinnati School of Medicine Cincinnati, Ohio USA
| | - Masatoshi Saito
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,Division of Perinatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yuichiro Miura
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,Division of Perinatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - John P. Newnham
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia
| | - Sarah Stock
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,MRC Centre for Reproductive Health Queen’s Medical Research Institute University of Edinburgh Edinburgh, UK
| | - Demelza J. Ireland
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia
| | - Boris W. Kramer
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,Department of Paediatrics, School of Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Alan H. Jobe
- School of Women’s and Infants’ Health, The University of Western Australia, Perth, Western Australia,Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical Centre, University of Cincinnati School of Medicine Cincinnati, Ohio USA
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13
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Zhang JE, Luo D, Chen RY, Yang YP, Zhou Y, Fan YM. Feasibility of histological scoring and colony count for evaluating infective severity in mouse vaginal candidiasis. Exp Anim 2014; 62:205-10. [PMID: 23903055 PMCID: PMC4160942 DOI: 10.1538/expanim.62.205] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Qualitative measurement of the infective level is relatively difficult in experimental
vaginal candidiasis. Female BALB/c mice aged 8 to 10 weeks were randomly divided into E1,
E2 and E0 groups, which received subcutaneous injection of 0.05 mg, 0.1 mg of estradiol
benzoate or 0.1 ml soybean oil 3 days before vaginal inoculation, respectively, and
hormone treatment continued every other day thereafter. Each group was further divided
into infected and noninfected subgroups. The infected mice were inoculated intravaginally
with 10 µl (5 × 104 conidia) of Candida
albicans suspension, while the noninfected mice were inoculated with 10
µl phosphate-buffered saline. Direct microscopic examination, colony
count and vaginal histopathology including infection degree and inflammation extent were
performed at 3, 7 and 14 days post inoculation. Estrogen treatment increased the vaginal
fungal burden and extent of infection and inflammation compared with the control group,
and 0.3 mg/week estrogen generally induced more severe infection and inflammation than
0.15 mg/week estrogen did. Colony count peaked on day 3 and decreased remarkably after 7
days. Infection score increased gradually during the first 7 days and decreased on day 14,
while inflammation extent exacerbated progressively over the course of 14 days. This study
demonstrates that the modified histological scoring system might be more feasible than
colony count for evaluation of infectivity and dynamic change in experimental vaginal
candidiasis.
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Affiliation(s)
- Jin-E Zhang
- Department of Dermatology, Affiliated Hospital of Guangdong Medical College, No.57, Renmin Avenue, Xiashan District, Zhanjiang, Guangdong, 524001, PR, China
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14
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Ji HX, Zou YL, Duan JJ, Jia ZR, Li XJ, Wang Z, Li L, Li YW, Liu GY, Tong MQ, Li XY, Zhang GH, Dai XR, He L, Li ZY, Cao C, Yang Y. The synthetic melanocortin (CKPV)2 exerts anti-fungal and anti-inflammatory effects against Candida albicans vaginitis via inducing macrophage M2 polarization. PLoS One 2013; 8:e56004. [PMID: 23457491 PMCID: PMC3573073 DOI: 10.1371/journal.pone.0056004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 01/04/2013] [Indexed: 12/30/2022] Open
Abstract
In this study, we examined anti-fungal and anti-inflammatory effects of the synthetic melanocortin peptide (Ac-Cys-Lys-Pro-Val-NH2)2 or (CKPV)2 against Candida albicans vaginitis. Our in vitro results showed that (CKPV)2 dose-dependently inhibited Candida albicans colonies formation. In a rat Candida albicans vaginitis model, (CKPV)2 significantly inhibited vaginal Candida albicans survival and macrophages sub-epithelial mucosa infiltration. For mechanisms study, we observed that (CKPV)2 inhibited macrophages phagocytosis of Candida albicans. Meanwhile, (CKPV)2 administration inhibited macrophage pro-inflammatory cytokines (TNF-α, IL-1β and IL-6) release, while increasing the arginase activity and anti-inflammatory cytokine IL-10 production, suggesting macrophages M1 to M2 polarization. Cyclic AMP (cAMP) production was also induced by (CKPV)2 administration in macrophages. These above effects on macrophages by (CKPV)2 were almost reversed by melanocortin receptor-1(MC1R) siRNA knockdown, indicating the requirement of MC1R in the process. Altogether, our results suggest that (CKPV)2 exerted anti-fungal and anti-inflammatory activities against Candida albicans vaginitis probably through inducing macrophages M1 to M2 polarization and MC1R activation.
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Affiliation(s)
- Hai-xia Ji
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Yu-lian Zou
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Jing-jing Duan
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Zhi-rong Jia
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Xian-jing Li
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Zhuo Wang
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Li Li
- Department of Pharmacology, Department of Physiology, Guilin Medical University, Guilin, Guangxi, People’s Republic of China
| | - Yong-wen Li
- Department of Pharmacology, Department of Physiology, Guilin Medical University, Guilin, Guangxi, People’s Republic of China
| | - Gen-yan Liu
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Ming-Qing Tong
- Department of Laboratory Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Xiao-yi Li
- Hefei Zhaoke Pharmaceutical, Hefei, People’s Republic of China
| | - Guo-hui Zhang
- Hefei Zhaoke Pharmaceutical, Hefei, People’s Republic of China
| | - Xiang-rong Dai
- Hefei Zhaoke Pharmaceutical, Hefei, People’s Republic of China
| | - Ling He
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
| | - Zhi-yu Li
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
- * E-mail: (YY); (CC); (ZL)
| | - Cong Cao
- Neuroscience Institute, Soochow University, Soochow, Jiangsu, People’s Republic of China
- * E-mail: (YY); (CC); (ZL)
| | - Yong Yang
- State Key Laboratory of Natural Medicines, Academic Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, Jiangsu, People’s Republic of China
- * E-mail: (YY); (CC); (ZL)
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15
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MacCallum DM. Hosting infection: experimental models to assay Candida virulence. Int J Microbiol 2011; 2012:363764. [PMID: 22235206 PMCID: PMC3253448 DOI: 10.1155/2012/363764] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 10/13/2011] [Indexed: 02/01/2023] Open
Abstract
Although normally commensals in humans, Candida albicans, Candida tropicalis, Candida parapsilosis, Candida glabrata, and Candida krusei are capable of causing opportunistic infections in individuals with altered physiological and/or immunological responses. These fungal species are linked with a variety of infections, including oral, vaginal, gastrointestinal, and systemic infections, with C. albicans the major cause of infection. To assess the ability of different Candida species and strains to cause infection and disease requires the use of experimental infection models. This paper discusses the mucosal and systemic models of infection available to assay Candida virulence and gives examples of some of the knowledge that has been gained to date from these models.
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Affiliation(s)
- Donna M. MacCallum
- Aberdeen Fungal Group, School of Medical Sciences, Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
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16
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Coenye T, Nelis HJ. In vitro and in vivo model systems to study microbial biofilm formation. J Microbiol Methods 2010; 83:89-105. [DOI: 10.1016/j.mimet.2010.08.018] [Citation(s) in RCA: 251] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 08/19/2010] [Accepted: 08/23/2010] [Indexed: 12/23/2022]
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