Available online at www.sciencedirect.

com

Journal of Taibah University for Science 6 (2012) 1018

Critical factors affecting the adherence of Candida albicans

to the vaginal epithelium
Al-Zaharaa A. Karam El-Din 1,2 , Heba M. Al-Basri 2 , Moustafa Y. El-Naggar 2,3,
2

1 Microbiology Department, Faculty of Science, Ain Shams University, Cairo, Egypt

Department of Biology, Faculty of Science, University of Taibah, Al-Madinah Al-Munawarrah, P.O. Box 30002, Al-Madinah Al-Munawarrah,
Saudi Arabia
3 Botany and Microbiology Department, Faculty of Science, Alexandria University, Moharram Bay 21511, Alexandria, Egypt

Received 15 May 2012; received in revised form 15 July 2012; accepted 16 July 2012
Available online 9 October 2012

Abstract
A clinical isolate (Candida albicans) was collected from diagnosed cases as vaginal candidiasis. Identification of this isolate was
previously reported [11] using both API 20C kit and real-time PCR assay. Adherence of C. albicans to the vaginal epithelium was
evaluated. C. albicans recorded the highest rate (63.00%) of adherence among all collected isolates and recorded the highest record
for the number (131.00) of adhered yeast cells (data not shown). The evaluation of the critical factors affecting the adherence process
revealed that the maximum adherence values were recorded for a logarithmic phase-culture grown at 25 C, incubation temperature
of 37 C in phosphate buffer saline adjusted at pH 5. Moreover, the adherence pattern of C. albicans cells to the vaginal epithelium
was visualized by the scanning electron microscopy (SEM).
2012 Taibah University. Production and hosting by Elsevier B.V. All rights reserved.
Keywords: Adherence; Candida albicans; SEM; Vaginal candidiasis

1. Introduction
The inflammation of the vagina as a result of infectious diseases is very common [8]. Vaginal symptoms are
usually related to one of three conditions: bacterial vaginosis, trichomoniasis and yeast vaginitis [24,25,34,37].
Yeast vaginitis is a very common problem. Theories

Corresponding author. Tel.: +966 509904068; fax: +966 48454770.

E-mail address: moustafael naggar@hotmail.com
(M.Y. El-Naggar).
Peer review under responsibility of Taibah University.

1658-3655 2012 Taibah University. Production and hosting by

Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jtusci.2012.10.001

explain the repeated yeast infections have focused on

vaginal reinfection, either from a gastrointestinal source
or from sexual transmission, or on vaginal relapse, which
hypothesizes that recurrent infections are due to the
same infecting organism, which is only temporarily suppressed by antifungal therapy [24,33].
Adherence has been shown to play a central role
in the pathogenesis of many microbial infections
[2,3,9,10,12,29]. The adherence to various surfaces
represents the first step in the mechanisms of pathogenesis and suggests means of controlling infection at
an early stage [9,10]. The definition of the mechanisms
of attachment of Candida albicans may have important
therapeutic implications. New therapeutic strategies for
the treatment of candidiasis may involve inhibition of
the attachment of the organism to the host cell [16,36].
The present study was conducted to focus on the
characterization of the adherence of the C. albicans to
the epithelium cells and to determine the critical factors

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018

and their statistical significance that affect the adherence process and consequently have an impact on the
pathogenesis process.
2. Materials and methods
2.1. Microorganism and culture conditions
C. albicans was previously isolated and identified
[11]. C. albicans isolate was sub-cultured onto a set of
three tubes of Sabourauds dextrose broth (10 ml) that
sequentially had 1, 2 and 3 drops of 1 N HCl added to
them. These broth cultures were incubated for 4872 h
at 25 C. A loop of the inoculated Sabourauds dextrose
broth (supplemented with 2 drops 1 N HCl) was streaked
on Sabourauds dextrose agar plates, the plates were then
incubated at 25 C for 72 h. The developing colonies of
yeasts were maintained on culture slants for further use.
2.1.1. Morphological characteristics
A plate containing either corn meal agar with Tween
80 was inoculated and incubated at 25 C for 4872 h.
The growth was examined for the presence of pseudohyphae, true mycelium, blastospores and chlamydospores
[1] (Fig. 1).
2.1.2. Germ tube test
A tube containing 0.25 ml of yeast peptone dextrose
medium (YPD) was inoculated with the C. albicans for
the development of germ tubes [18]. The cultures were
incubated at 39 C and examined microscopically after
4 h of incubation for the development of germ tubes and
blastoconidia [1].

11

2.1.3. Adherence of C. albicans to the vaginal cells

C. albicans was incubated overnight in yeast extract
broth at 25 C under shaking conditions at 60 rpm. Yeast
cells were harvested by centrifugation after 18 h and
washed in PBS twice. The yeasts were enumerated
using haemocytometer, and then diluted to a density of
108 cells/ml in phosphate buffer saline (PBS) adjusted to
pH 7.0 [31]. The adherence of C. albicans to the vaginal
epithelium was determined according to King et al. [20]
and Segal et al. [30]. The freshly obtained vaginal epithelial cells (used within 4 h) were washed twice in 0.9%
saline and resuspended in PBS adjusted at pH of 7.0.
The concentration of the epithelial cells was adjusted to
105 cells/ml using haemocytometer.
2.1.4. Assay of C. albicans adherence
Equal volumes (0.25 ml) of epithelial cells (105 ) and
yeast cells (108 ) were mixed and incubated for 30 min
in a shaking incubator (50 rpm) at 37 C and pH 7.0.
After incubation, the suspensions were centrifuged and
washed twice with saline to separate the non-adhering
yeast cells. Several drops of the sediment were placed on
glass slide, fixed and stained with crystal violet, and then
the percentage of adherence was determined by counting
the number of epithelial cells with 20 or more adhered
yeasts out of a total of 100 cells. The number of yeast
cells attached to each of 100 epithelial cells was also
counted and the mean value was calculated [30]. The
adherence assay was performed in triplicates.
2.2. Factors affecting the adherence of C. albicans
to the vaginal epithelial cells
2.2.1. Effect of the pH of the assay medium
The phosphate buffer was prepared to the following
different pH values 59 to test the optimum pH value for
the adherence [26]. The cells were resuspended to the
desired concentration and used for the application of the
adherence assay.
2.2.2. Effect of the assay temperature
Equal volumes of epithelial cells and yeast cells
(0.25 ml) suspended in PBS adjusted at pH 7.0 were
mixed and incubated on a rotator individually at 25, 37
and 40 C for 30 min [19].

Fig. 1. Light micrograph of C. albicans (on corn meal agar with Tween
80) showing the terminal chlamydospores on pseudohyphae with blastospores. 400 magnification.

2.2.3. Effect of the yeast culture age

C. albicans was grown in yeast extract broth at 25 C.
The yeast cells were harvested by centrifugation after 8,
16, 24, 32, 44 and 56 h, washed twice and resuspended
in PBS adjusted at pH 7.0 to the desired concentration

12

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018

[28]. The cells were then ready for the application of the
adherence assay.
2.2.4. Effect of the incubation temperature
C. albicans was grown in yeast extract broth at 25,
30, 35 and 40 C. The yeast cells were harvested by
centrifugation after 18 h (Standard growth curve was
constructed to determine the timing of each of the growth
phases), washed twice and resuspended in PBS (pH 7) to
the desired concentration [28]. The cells were then ready
for the application of the adherence assay.
2.3. Scanning electron microscopy
The samples for electron microscopy were prepared
as described by El-Naggar et al. [10]. The processed samples were visualized using scanning electron microscope
(S 800 Hitachi Co., Ltd., Tokyo, Japan) with an accelerating voltage 1552 kV at magnification varied from
1000 to 12,000.
2.4. Statistical analyses
Statistical analyses of the adherence data were carried
out using SPSS program, version 12. One-way ANOVA
test was used to evaluate the differences in the adherence
values. A p-value of 0.05 was considered significant.
Pearsons correlation coefficient was also used.
3. Results and discussion
The incidence of the various fungal pathogens has
increased dramatically over the past few decades. Candida species are the most common of these pathogens
[5,27]. Vulvovaginitis is one of the commonest presentations of Candida infection. Despite therapeutic
advances, vulvovaginal candidiasis remains a common problem worldwide, affecting all strata of society
[2,29,32].
3.1. The adherence of the C. albicans to the vaginal
epithelial cells
The adherence of the C. albicans to the vaginal epithelial cells was observed under optimal temperature of
37 C and pH 7. The adherence ability is expressed as
the percentage of epithelial cells having more than 20 C.
albicans cells attached and the number of adhered yeast
cells attached to each of 100 epithelial cells. C. albicans
showed more remarkable and potent adherence percentage to the vaginal epithelial cells (63.00%). Regarding

the number of adhered yeast cells, this isolate recorded

the highest number of adhered yeast cells (131.00).
C. albicans strains produced different and high levels of adherence to vaginal epithelial cells among other
isolates (data not shown). Genomic variability may
account for varied adherence abilities among the tested
C. albicans strains. Kennedy [17] reported that the extent
of adherence to mucosal epithelium appears to be a
strain-dependent property. However, Vidotto et al. [35]
indicate that all C. albicans strains appear to adhere
equally well to exfoliate vaginal and buccal epithelial
cells. The high recorded adherence abilities of the tested
C. albicans strains should not surprising us if we consider
that adherence to cell surfaces is an important virulence
factor and that C. albicans is usually considered more
virulent than other Candida species.
3.2. Factors affecting the adherence of C. albicans
cells to vaginal epithelial cells
The adherence of C. albicans cells to vaginal epithelial cells under certain environmental conditions is most
likely a pivotal point in the pathophysiology of vaginal
candidiasis [26]. In the present study, we have sought
focus on how pH, the temperature of the adherence assay,
the growth phase and the growth temperature of the
yeasts affect its adherence to vaginal epithelial cells.
3.2.1. Effect of the pH of the assay medium
The results in Table 1 showed that although the pH
5 allowed a maximal adherence, attachment could still
be detected under both neutral and alkaline conditions.
Comparing the adherence ability at different pH values
(59), the highest value was recorded at pH 5 (84.50%,
157.50) and pH 6 (81.00%, 150.50), followed by pH 7
(62.00%, 133.50), while at pH 8 and pH 9 the adherence
ability was decreased (32.00%, 65.00 and 25.50%,
55.50, respectively). Dostal et al. [7] reported that the
pH values were the critical factors in proteolytic activity
Table 1
Effect of the initial pH values on the adherence of C. albicans to the
vaginal epithelial cells.
Initial pH

Adherence %
Mean SE

5
6
7
8
9

84.50
81.00
62.00
32.00
25.50

VEC: vaginal epithelial cell.

5.50
8.00
2.00
1.00
1.50

Number of adhered
yeast cells/VEC
Mean SE
157.50
150.50
133.50
65.00
55.50

3.50
1.50
4.50
3.00
4.50

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018
Table 2
Statistical analysis (one-way ANOVA test) for the data obtained in
Table 1.
p-Value

pH

.000**

p-value

pH (I)

pH (J)

Adherence %

Number of adhered
yeast cells/VEC

6
7
8
9

.606#
.017*
.000**
.000**

.225#
.005*
.000**
.000**

7
8
9

.031*
.001**
.000**

.020*
.000**
.000**

8
9

.005*
.002*

.000**
.000**

.354#

.119#

*
**
#

Table 3
Statistical analysis (bivariate correlations test) for the data obtained in
Table 1.
Initial pH

Adherence %

Number of adhered
yeast cells/VEC

Pearson correlation (r)

p-Value
Strength of the correlation (r2 )

.952
.000**
91

.940
.000**
88

.001**

Adherence %
Number of adhered yeast cells/VEC

The mean difference is significant (p .05).

The mean difference is highly significant (p .001).
The mean difference is insignificant (p > .05).

because relatively small shifts can cause changes in

extracellular proteolytic activity. Modification of the
host cell membrane could occur in an acidic environment, but under such conditions general proteolytic
activity and dissolution of host-cell membranes may
be more important than adherence considerations.
Modification of the cell surface of C. albicans, however,
may proceed if the surface pH is lowered because
of carbohydrate utilization and production of acidic
by-products. Proteolytic action on the Candida cell
surface alters hydrophobicity, which would also affect
adherence [6] (Table 2).
Variation of the pH of the adherence medium gave
highly significant differences (p .001) in the adherence
ability. The statistical analysis indicated that no significant difference (p > .05) in the adherence ability neither
between pH values (5 and 6), nor between (8 and 9), but
the differences in the adherence ability of the isolate at
pH (5 and 6) and that at pH (8 and 9) were highly significant (p .001). Significant difference (p .05) in the
adherence percentage between pH 7 and the other tested
pH values was observed, whereas the number of adhered
yeast cells at pH 7 differed significantly (p .05) from
that at pH (5 and 6) and highly significantly (p .001)
from that at pH (8 and 9). The results (Table 3) revealed a
negative correlation between the adherence ability of the
tested isolate to the vaginal epithelial cells and pH, as the
pH increased the adherence ability decreased, and this

13

* Correlation is significant (p .05).

** Correlation is highly significant (p .001).
# Correlation is insignificant (p > .05).

correlation was highly significant (r = .952, p .001

and r = .940, p .001).
The results of the adherence assays of C. albicans
to vaginal epithelial cells at different pH values showed
that there was strong, statistically significant association
between the adherence ability of the tested isolate and
pH. The adherence at the neutral pH was slightly less than
that at the acidic conditions. Under alkaline conditions
the adherence was much less that under both neutral and
acidic conditions. Our data thus differ from that of Lehrer
et al. [23] who found that adherence was not influenced
by pH or pre-treatment of yeast cells with salts, divalent
cations, detergents, urea, lipase or -mannosidase.
3.2.2. Effect of the assay temperature
Table 4 showed that the assay mixture incubated at
37 C gave the maximal adherence (62.50%, 132.00),
followed by those incubated at 25 C (36.00%, 89.50)
and the least at 40 C (32.50%, 70.50). Statistically, there
were significant differences (p .05) in the adherence
ability of the tested isolate to the vaginal epithelial cells
obtained at the different temperatures tested (Table 5).
The adherence ability of C. albicans at 37 C was significantly (p .05) greater than that at 25 and 40 C
(Table 6). Interestingly, the adherence percentage was
almost twofold greater when the assay was performed at
37 C compared to 25 and 40 C. The adherence percentage was affected equally by the two temperatures 40 and
25 C. There was no significant difference (p > .05) in the
Table 4
Effect of the assay temperature on the adherence of C. albicans to the
vaginal epithelial cells.
Temperature ( C)
of the adherence
assay

Adherence %
Mean SE

Number of adhered
yeast cells/VEC
Mean SE

25
37
40

36.00 3.00
62.50 0.50
32.50 2.50

89.50 2.50
132.00 3.00
70.50 9.50

VEC: vaginal epithelial cell.

14

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018

Table 5
Statistical analysis (one-way ANOVA test) for the data obtained in
Table 4.
p-Value

Table 7
Effect of the age of C. albicans on its adherence to the vaginal epithelial
cells.
Yeast age (h)

Adherence %
Mean SE

8
16
24
32
44
56

51.50
62.50
54.00
43.00
39.00
31.50

.005*

Adherence %
Number of adhered yeast cells/VEC

.011*

Temperature ( C) of the adherence assay p-value

Temperature (I)

Temperature (J)

Adherence Number of
%
adhered yeast
cells/VEC

25

37
40

.004*
.356#

.015*
.108#

37

40

.003*

.005*

The mean difference is significant (p .05).

** The mean difference is highly significant (p .001).
# The mean difference is insignificant (p > .05).
*

adherence ability at 25 and 40 C. Data in Table 6 indicated a weak and not significant correlation between the
adherence ability of the tested isolate and the temperature of the adherence assay (r = .221, p > .05 and r = .026,
p > .05).
3.2.3. Effect of the yeast culture age
Yeast cell adherence is also influenced by the growth
phase of the culture. In the present study, it was found that
logarithmic-phase-yeasts had greater adherence ability
than stationary-phase-yeasts. Maximal adherence ability
was obtained with culture which has been incubated for
16 h while the minimal obtained with culture incubated
for 56 h. This finding may be due to that the factor(s)
present on the surface of logarithmic-phase-cells than
on cells in the stationary phase of growth. In addition,
enzymes such as phospholipase and proteinase which
play a critical role in the adherence process are more
active in cultures in the exponential growth phase than
in the stationary phase.
Table 6
Statistical analysis (bivariate correlations test) for the data obtained in
Table 4.
Temperature ( C) of
the adherence assay

Adherence %

Number of adhered
yeast cells/VEC

Pearson correlation (r)

p-Value
Strength of the
correlation (r2 )

.221
.673#
49

.026
.961#
4

* Correlation is significant (p .05).

** Correlation is highly significant (p .001).
# Correlation is insignificant (p > .05).

1.50
0.50
1.00
1.00
3.00
2.50

Number of adhered yeast

cells/VEC
Mean SE
108.00
130.00
115.50
93.50
86.00
60.50

3.00
5.00
0.50
4.50
5.00
3.50

VEC: vaginal epithelial cell.

C. albicans cultures grown at logarithmic phase for

periods 8, 16 and 24 h had greater adherence ability than
those grown at stationary phase for periods 32, 44 and
56 h. Maximal adherence ability was obtained with culture grown for 16 h (62.50%) with number of adhered
cells reached (130.00), while the minimal obtained with
culture grown for 56 h (31.50%) with number of adhered
cells reached (60.50) (Table 7). Highly significant differences (p .001) in the adherence ability of the isolate
were obtained at the different growth phases tested. It
was obvious that adherence ability of C. albicans grown
for 16 h of the logarithmic phase differed significantly
(p .05) from those grown for 8 and 24 h. Although
the adherence ability of the 24-h-culture was higher
than that of the 8-h-culture, statistically, this difference
was not significant (p > .05). Regarding the adherence
ability of the stationary-phase-yeasts, no marked differences (p > .05) in the adherence ability were observed
when the 32-h- and 44-h-cultures were compared. The
adherence percentage of the 32-h- and 44-h-cultures differed significantly (p .05) from that of the 56-h-culture.
The number of adhered yeast cells of the 56-h-culture
recorded a high significant difference (p .001) from
that of 32-h-culture, while the difference was significant
(p .05) with that of 44-h-culture (Table 8).
The results of the two phases of growth (logarithmic and stationary) showed that high significant
differences (p .001) in the adherence ability were
recorded between the 16-h-culture and all cultures of
the stationary phase. The difference in adherence ability of the 8-h-culture was highly significant (p .001)
with that of the 56-h-culture and significant differences
(p .05) with those of the 32-h- and 44-h-cultures were
recorded. There was a significant difference (p .05) in
the adherence ability of the 24-h-culture and that of the
32-h-culture, but high significant differences (p .001)
were obtained with those at 44-h- and 56-h-cultures. The
results in Table 9 revealed that there was a negative

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018
Table 8
Statistical analysis (one way ANOVA test) for the data obtained in
Table 7.
p-Value
.000**

Adherence %
Number of adhered yeast cells/VEC
Yeast age (h)
Yeast age (I)

Yeast age (J)

Adherence %

Number of adhered
yeast cells/VEC

16
24
32
44
56

.005*
.368#
.016*
.003*
.000**

.007*
.224#
.039*
.007*
.000**

16

24
32
44
56

.016*
.000**
.000**
.000**

.039*
.001**
.000**
.000**

24

32
44
56

.005*
.001**
.000**

.007*
.002*
.000**

32

44
56

.170#
.004*

.224#
.001**

44

56

.027*

.004*

*
**
#

The mean difference is significant (p .05).

The mean difference is highly significant (p .001).
The mean difference is insignificant (p > .05).

and highly significant correlation between the growth

phase of the selected isolate and its adherence ability
to the vaginal epithelial cells (r = .866, p .001 and
r = .868, p .001).
3.2.4. Effect of the incubation temperature
Our data also indicated that strong correlation exists
between the growth temperature of the tested isolate
and its adherence to vaginal epithelial cells. Yeast cells
grown at 25 C gave the highest adherence ability and as
the growth temperature increased the adherence ability
Table 9
Statistical analysis (bivariate correlations test) for the data obtained in
Table 7.
Yeast age (h)

Adherence %

Number of adhered
yeast cells/VEC

Pearson correlation (r)

p-Value
Strength of the correlation (r2 )

.866
.000**
75

.868
.000**
75

* Correlation is significant (p .05).

** Correlation is highly significant (p .001).
# Correlation is insignificant (p > .05).

Table 10
Effect of the incubation temperature on the adherence of C. albicans
to the vaginal epithelial cells.
Incubation
temperature ( C)

Adherence %
Mean SE

25
30
35
40

63.50
51.50
44.00
25.00

.000**

p-value

15

5.50
4.50
5.00
2.00

Number of adhered
yeast cells/VEC
Mean SE
130.50
99.50
89.00
59.00

9.50
1.50
1.00
7.00

VEC: vaginal epithelial cell.

decreased. These data are supported by other investigators who reported that blastospores harvested from
cultures grown at 25 C adhered to vaginal epithelial
cells in significantly greater numbers than did blastospores isolated from cultures grown at 37 C [22,30].
Variation in growth temperature is one of the factors
that are known to affect yeast cell surface hydrophobicity
(CSH) [4,14] which has been shown to be involved in the
adherence process of the yeast. Cell surface hydrophobicity is characterized by the presence of hydrophobic
proteins embedded in the yeast cell wall matrix beneath
an outer fibrillar layer [13]. Exposure of these hydrophobic proteins results in CSH; therefore, CSH is subject
to cell surface variations such as a shortened or rearranged fibrillar layer [1315]. In fact, C. albicans cells
are hydrophobic when grown at 25 C and hydrophilic at
37 C [13,14] this may explain why cells grown at 25 C
gave the highest adherence capacity.
Table 11
Statistical analysis (one way ANOVA test) for the data obtained in
Table 10.
p-Value
.015*
.005*

Adherence %
Number of adhered yeast cells/VEC
Incubation temperature ( C)

p-Value

Temperature (I)

Temperature
(J)

Adherence
%

Number of adhered
yeast cells/VEC

25

30
35
40

.130#
.036*
.004*

.021*
.008*
.001**

30

35
40

.300#
.014*

.281#
.009*

35

40

.039*

.024*

*
**
#

The mean difference is significant (p .05).

The mean difference is highly significant (p .001).
The mean difference is insignificant (p > .05).

16

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018

Fig. 2. Scanning electron micrograph showing (a) the adherence of C. albicans to the surface of the vaginal epithelial cells. (b) A direct attachment
of the yeast cells of C. albicans to the vaginal epithelial cell and yeast cells co-adherence. Scale bar: 10 m. (c) The formation of germ tubes by C.
albicans. Scale bar: 5 m. (d) the formation of pseudomycelium by C. albicans. Scale bar: 1 m.

Comparing the adherence ability at different growth

temperatures (25, 30, 35 and 40 C), the culture that incubated at 25 C had a greater adherence ability (63.50%,
130.50) than the others, whereas that incubated at 40 C
had the lowest adherence ability (25.00%, 59.00). It
is worth mentioning that the percentage of adherence
at 30 C was twice that recorded at 40 C (Table 10).
The results in Table 11 suggested that among the tested
growth temperatures, there was a statistically significant
difference (p .05) in the yeast adherence ability to the
vaginal epithelial cells. The percentage of adherence at
25 C differed significantly (p .05) from that at 35 and
40, but not at 30 C. The number of adhered yeast cells
at 25 C differed significantly (p .05) from that at 30
and 35 C, while the difference was highly significant
(p .001) from that at 40 C. Although there was a significant difference (p .05) in the adherence ability of
the isolate at 35 and 40, also at 30 and 40 C, but there
was not (p > .05) at 30 and 35 C (Table 11). The results in

Table 12 revealed that the adherence ability of the isolate

to the vaginal epithelial cells and its growth temperature were negatively correlated and this correlation was
highly significant (r = .937, p .001 and r = .959,
p .001).

Table 12
Statistical analysis (bivariate correlations test) for the data obtained in
Table 10.
Incubation temperature ( C)

Adherence %

Number of adhered
yeast cells/VEC

Pearson correlation (r)

p-Value
Strength of the correlation (r2 )

.937
.001**
88

.959
.000**
92

* Correlation is significant (p .05).

** Correlation is highly significant (p .001).
# Correlation is insignificant (p > .05).

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018

3.3. Scanning electron microscopy

The morphological characteristics related to adherence of C. albicans to vaginal epithelial cells were
observed using scanning electron microscope. The large
numbers of adhered yeast cells noted were a reflection
not only of yeast cell-to-epithelial cell adherence, but
also of yeast cells co-adherence. The latter type of interaction resulted in the formation of aggregates of yeasts
on the epithelial cell surface which could be observed
both by light microscopy and by scanning microscopy.
Klotz and Penn [21] showed that the addition of a highly
concentrated blastospore inoculum led to blastospore
aggregation (self-adherence) and to a greater destruction
of the intestinal cells used in the adherence study than to a
normal random distribution of yeast cells. We suggested
that formation of yeast aggregates through co-adherence
may allow C. albicans to effectively amplify its cell numbers in vivo. Such amplification may localize aggregates
of organisms in sufficient numbers to overcome host
defences resulting in numerous foci of infection.
The features of the adherence of C. albicans to vaginal epithelial cells are shown in Fig. 2ad. Blastospores
with germ tubes and pseudomycelium were also seen
on the surface of the vaginal epithelial cells after C.
albicans was allowed to interact with them (Fig. 2c
and d). Although many of the yeasts adhered directly to
the mucosal cells, some yeast cell-to-yeast cell attachment was also noted. This latter type of interaction,
co-adherence, appeared to result from yeasts attaching
to those yeasts which had already established contact
with the epithelial cells. Co-adherence was not noted
except at the epithelial cell surface. Thus, preaggregation
of the yeasts before their attachment to the epithelial cell
apparently does not occur.
4. Conclusion
Since the adherence of C. albicans to the mucosal
epithelial cells is considered as the initial step in
the mucocutaneous candidiasis. So understanding of
Candidahost cell interaction will have important therapeutic implications to figure out therapeutic strategies
for the treatment of candidiasis, especially with the availability of some effective and safe antifungal agents.

[3]

[4]
[5]

[6]

[7]

[8]
[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

References
[1] D.G. Ahearn, Medically important yeasts, Annual Review of
Microbiology 32 (1978) 5968.
[2] R. Alonso-Vargas, L. Elorduy, E. Evaso, J.F. Cano, J. Guarro, J.
Ponton, G. Quinds, Isolation of Candida africana, probable a

[19]

17

typical strains of Candida albicans, from a patient with vaginitis,

Journal of Medical Mycology 46 (2008) 167170.
C.M. Bendel, Colonization and epithelial adhesion in the pathogenesis of neonatal candidiasis, Seminars in Perinatology 27
(2003) 357364.
R.A. Calderone, P.C. Braun, Adherence and receptor relationships
of Candida albicans, Microbiological Reviews 55 (1991) 120.
M.R. Capoor, D. Nair, M. Deb, P.K. Verm, L. Srivastava, P. Aggarwal, Emergence of non-albicans Candida species and antifungal
resistance in a tertiary care hospital, Japanese Journal of Infectious
Diseases 58 (2005) 344348.
J.E. Cutler, Differential adherence of hydrophobic and
hydrophilic Candida albicans yeast cells to mouse tissues, Infection and Immunity 59 (1991) 907912.
J. Dostal, P. Hamal, L. Pavlicova, M. Soucek, M.T. Ruml,
I. Pichova, O. Hruskov-Heidingsfeldov, Simple method
for screening Candida species isolates for the presence of
secreted proteinases: a tool for the prediction of successful
inhibitory treatment, Journal of Clinical Microbiology 41 (2003)
712716.
L. Edwards, The diagnosis and treatment of infectious vaginitis,
Dermatologic Therapy 17 (2004) 102110.
M.Y. El-Naggar, M.A. Akeila, A.M. El-Kenany, Immunomodulatory role of two commercial probiotics in poultry industry,
Advances in Food Sciences (CMTL) 27 (2005) 2226.
M.Y. El-Naggar, M.A. Akeila, A.M. El-Kenany, Influence of
two probiotic consortia on the colonization of enteroinvasive
pathogens in the intestinal tract of chicken in poultry farms,
Advances in Food Sciences (CMTL) 27 (2005) 8593.
M.Y. El-Naggar, H.M. Al-Basri, A.A. Karam El-Din, Molecular diagnosis of Candida albicans using real-time polymerase
chain reaction of a CaYST1 gene, Journal of Taibah University
for Science 3 (2010) 813.
N.A.R. Gow, F.L. van de Veerdonk, A.J.P. Brown, M.G. Netea,
Candida albicans morphogenesis and host defence: discriminating invasion from colonization, Nature Reviews 10 (2012)
112122.
K.C. Hazen, Participation of yeast cell surface hydrophobicity in
adherence of Candida albicans to human epithelial cells, Infection and Immunity 57 (1989) 18941900.
K.C. Hazen, D.L. Brawner, M.H. Riesselman, M.A. Jutila, J.E.
Cutler, Differential adherence of hydrophobic and hydrophilic
Candida albicans yeast cells to mouse tissues, Infection and
Immunity 59 (1991) 907912.
F. Jabra-Rizk Jr., W.G. Merz, J.I. Kelley, A.A. Baqui, T.F. Meiller,
Candida dubliniensis and Candida albicans display surface
variations consistent with observed intergeneric coaggregation,
Revista Iberoamericana de Micologa 16 (1999) 814.
I.D. Jacobsen, D. Wilson, B. Wchtler, S. Brunke, J.R. Naglik,
B. Hube, Candida albicans dimorphism as a therapeutic target,
Expert Review of Anti-infective Therapy 10 (2012) 8593.
M.J. Kennedy, Adhesion and association mechanisms of
C. albicans, in: M.R. Mcginnis (Ed.), Current Topics
in Medical Mycology, Springer-Verlag, New York, 1988,
pp. 73169.
D. Kim, W.S. Shin, K.H. Lee, K. Kim, J.Y. Park, Rapid differentiation of Candida albicans from other Candida species
using its unique germ tube formation at 39 C, Yeast 19 (2002)
957962.
L.H. Kimura, N.N. Pearsall, Adherence of Candida albicans to
human buccal epithelial cells, Infection and Immunity 21 (1978)
6468.

18

A.-Z.A. Karam El-Din et al. / Journal of Taibah University for Science 6 (2012) 1018

[20] R.D. King, J.C. Lee, A. Morris, Adherence of Candida albicans

and other Candida species to mucosal epithelial cells, Infection
and Immunity 27 (1980) 667674.
[21] S.A. Klotz, R.L. Penn, Multiple mechanisms may contribute to the
adherence of Candida yeasts to living cells, Current Microbiology
16 (1987) 119122.
[22] J.C. Lee, R.D. King, Characterization of Candida albicans adherence to human vaginal epithelial cells in vitro, Infection and
Immunity 41 (1983) 10241030.
[23] N. Lehrer, E. Segal, L. Cihlar, R. Calderone, Pathogenesis of vaginal candidiasis: studies with a mutant which has reduced ability
to adhere in vitro, Journal of Medical and Veterinary Mycology
24 (1985) 127131.
[24] R. McCathie, Vaginal discharge: common causes and management, Current Obstetrics & Gynaecology 16 (2006) 211217.
[25] M.K. Owen, T.L. Clenney, Management of vaginitis, American
Family Physician 70 (2004) 21252132.
[26] A.M. Persi, C.J. Burnham, L.J. Duhring, Effect of carbon dioxide
and pH on adhesion of Candida albicans to vaginal epithelial
cells, Infection and Immunity 50 (1985) 8290.
[27] M.A. Pfaller, R.N. Jones, G.V. Doern, H.S. Sader, S.A. Messer,
S. Coffman, R.J. Hollis, Blood stream infection due to Candida
species. SENTRY antimicrobial surveillance program in North
America and Latin America, 19971998, Antimicrobial Agents
and Chemotherapy 44 (2000) 747751.
[28] C.M. Pires, B. Correa, W. Gambale, C.R. Paula, Experimental model of Candida albicans (serotypes A and B) adherence
in vitro, Brazilian Journal of Microbiology 32 (2001) 110.
[29] M.V. Pirotta, S.M. Garland, Genital Candida species detected in
samples from women in Melbourne, Australia, before and after

[30]

[31]

[32]
[33]

[34]

[35]

[36]

[37]

treatment with antibiotica, Journal of Clinical Microbiology 44

(2006) 32133217.
E. Segal, N. Lehrer, I. Ofek, Adherence of Candida albicans
to human vaginal epithelial cells: inhibition by amino sugars,
Experimental Cell Biology 50 (1982) 1317.
E. Segal, O. Trygerman, Y. Gov, H. Sandovsky-Losica, I.
Berdicevsky, Adhesion of Candida albicans to epithelial cells:
effect of antimycotics, Journal of Medical Mycology 7 (1997)
7176.
J.D. Sobel, Vulvovaginal candidiasis, Lancet 369 (2007)
19611971.
J.D. Sobel, H.C. Wiesenfeld, N. Martens, Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis, New England
Journal of Medicine 351 (2004) 876883.
D.E. Soper, Taking the guesswork out of diagnosing and managing vaginitis, Contemporary Obstetrics & Gynecology 50 (2005)
3239.
V. Vidotto, B. Mantoan, A. Pugliese, J. Pontn, G. Quinds, S.
Aoki, et al., Adherence of Candida albicans and Candida dubliniensis to buccal and vaginal cells, Revista Iberoamericana de
Micologa 20 (2003) 5254.
B. Wchtler, D. Wilson, B. Hube, Stage-specific inhibition by
clotrimazole and damage of vaginal epithelial cells: Candida
albicans adhesion to and invasion, Antimicrobial Agents and
Chemotherapy 55 (2011) 44364439.
H. Xiang, L. Xiong, X. Liu, Z. Tu, Rapid simultaneous detection and identification of six species Candida using polymerase
chain reaction and reverse line hybridization assay, Journal of
Microbiological Methods 69 (2007) 282287.