key: cord-0692924-ohq2wwmy
authors: Mahalingam, Shanmuga S.; Jayaraman, Sangeetha; Pandiyan, Pushpa
title: Fungal Colonization and Infections—Interactions with Other Human Diseases
date: 2022-02-06
journal: Pathogens
DOI: 10.3390/pathogens11020212
sha: c549e066cca44fb18940ee8203704da06239b61f
doc_id: 692924
cord_uid: ohq2wwmy

Candida albicans is a commensal fungus that asymptomatically colonizes the skin and mucosa of 60% of healthy individuals. Breaches in the cutaneous and mucosal barriers trigger candidiasis that ranges from asymptomatic candidemia and mucosal infections to fulminant sepsis with 70% mortality rates. Fungi influence at least several diseases, in part by mechanisms such as the production of pro-carcinogenic agents, molecular mimicking, and triggering of the inflammation cascade. These processes impact the interactions among human pathogenic and resident fungi, the bacteriome in various organs/tissues, and the host immune system, dictating the outcomes of invasive infections, metabolic diseases, and cancer. Although mechanistic investigations are at stages of infancy, recent studies have advanced our understanding of host–fungal interactions, their role in immune homeostasis, and their associated pathologies. This review summarizes the role of C. albicans and other opportunistic fungi, specifically their association with various diseases, providing a glimpse at the recent developments and our current knowledge in the context of inflammatory-bowel disease (IBD), cancers, and COVID-19. Two of the most common human diseases where fungal interactions have been previously well-studied are cancer and IBD. Here we also discuss the emerging role of fungi in the ongoing and evolving pandemic of COVID-19, as it is relevant to current health affairs.

The past century has witnessed a significant increase in the wealth of knowledge on infectious diseases caused by viruses, bacteria, fungi, protozoa, and prions. Among the public health issues caused by microbes, fungal diseases are relatively neglected, owing to the low mortality rate of 1.5% globally [1] . Fungal diseases, also known as mycoses, although acknowledged in the late 1980s, have now captured greater attention than ever before because of the escalating population of high-risk elderly individuals, immunosuppressed individuals, transplant recipients, and premature neonates [2] [3] [4] [5] [6] [7] . The average life expectancy has increased tremendously with our current scientific knowledge and advancements in medical treatments increasing the population size of individuals over 65 years of age. The United States census reports 39.6 million people aged 65 and over, which is expected to double by 2050, contributing to 21% of the population [8, 9] . This population and other immunosuppressed individuals show a significant increase in the prevalence of fungal infections because of environmental factors as well as intrinsic degenerative immune and metabolic changes [10] [11] [12] .

Among fungi, the Candida species have co-existed as the most common and innocuous commensals associated with human beings for quite a long time. They are frequently encountered on human skin, the mucosal surfaces of gastrointestinal and genitourinary tracts. Nonetheless, in immunologically weak, premature neonates, elderly people, and ( Figure 1 ) [38, 39] . The mechanisms of barrier breach and the innate factors produced by the host are reviewed elsewhere [17, 21, [40] [41] [42] . This review sheds light on recent studies on how fungal components including those from Candida are mechanistically involved in human health and the diseases discussed here. During infection or dysbiosis in the context of diseases, yeast transform into hyphal form, gaining access to underlying host tissues (albeit hyphal transition does not occur in certain species including C. glabrata). Fungal components such as mannans, mannoproteins, β-glucans, and chitin are sensed by innate antigen-presenting cells through pattern-recognition receptors (PRRs) on their surface. Dectin-1 activation and the phosphorylation of the receptor at the cytoplasmic domain leads to the activation of spleen tyrosine kinase (Syk). Upon activation, a series of events leads to the assembly of a complex that activates the NF-kB pathway. NF-kB activation results in the release of pro-inflammatory cytokines and reactive oxygen species (ROS) triggering phagocytosis. These events also lead to inflammasome activation, triggering IL-1β and IL-18 production that further prime the innate immune activation. Some of the cytokines modulate PI3K/AKT and glycolytic pathways, instructing T-helper (Th)1, Th17, and regulatory T-cell (Treg) polarization and their functions. Th17 cells additionally promote the production of innate anti-microbial proteins. For example, pro-inflammatory cytokines secreted by macrophages induce a Th17 response releasing IL-22, which stimulates defensin secretion by epithelial cells. Besides the activation of the immune system, direct production of acetaldehyde resulting from Candida metabolism inhibits the expression of glucose trans-porter1 (GLUT1) and hypoxia-inducible factor-1α (HIF-1α), which subsequently may also control Th and Treg homeostasis. Thus, fungal dysbiosis modulates local immune milieu and alters Th functions, which significantly switches the balance between health and disease states.

Besides direct infections and morbidities, there is an accumulative concern about Candida colonization and invasion associated with several pathophysiological disorders Figure 1 . Molecular events characteristic of interactions of fungi with mucosal surfaces. Fungi including C. albicans colonize healthy human skin and other mucosal surfaces in yeast form. In healthy individuals, yeast colonization does not induce epithelial damage or an intense cytokine response. During infection or dysbiosis in the context of diseases, yeast transform into hyphal form, gaining access to underlying host tissues (albeit hyphal transition does not occur in certain species including C. glabrata). Fungal components such as mannans, mannoproteins, β-glucans, and chitin are sensed by innate antigen-presenting cells through pattern-recognition receptors (PRRs) on their surface. Dectin-1 activation and the phosphorylation of the receptor at the cytoplasmic domain leads to the activation of spleen tyrosine kinase (Syk). Upon activation, a series of events leads to the assembly of a complex that activates the NF-kB pathway. NF-kB activation results in the release of pro-inflammatory cytokines and reactive oxygen species (ROS) triggering phagocytosis. These events also lead to inflammasome activation, triggering IL-1β and IL-18 production that further prime the innate immune activation. Some of the cytokines modulate PI3K/AKT and glycolytic pathways, instructing T-helper (Th)1, Th17, and regulatory T-cell (T reg ) polarization and their functions. Th17 cells additionally promote the production of innate anti-microbial proteins. For example, pro-inflammatory cytokines secreted by macrophages induce a Th17 response releasing IL-22, which stimulates defensin secretion by epithelial cells. Besides the activation of the immune system, direct production of acetaldehyde resulting from Candida metabolism inhibits the expression of glucose transporter1 (GLUT1) and hypoxia-inducible factor-1α (HIF-1α), which subsequently may also control Th and T reg homeostasis. Thus, fungal dysbiosis modulates local immune milieu and alters Th functions, which significantly switches the balance between health and disease states.

Cancer is among the most prominent causes of death worldwide, posing an important threat to life expectancy in every country regardless of the level of economic development [43] . Based on the recent study by GLOBOCAN 2020, an estimate of 20 million new cancer cases have been reported and~10 million deaths have occurred in 2020 alone [44] . Lately, the relationship between cancer and microbial infections has attracted enormous attention [45] . Transient immunosuppression is commonly seen in cancer patients undergoing chemotherapy, which consequently has been linked to bacterial and fungal infections. Recent studies provide insights on the association between the presence of microorganisms and the augmented risk of cancer development. The role of microbes and their involvement in diverse mechanisms including the initiation, establishment, and spread of cancer is reviewed elsewhere [46, 47] . Here we will review in particular the contribution of colonization and infections by Candida species and their role in cancer.

Although Candida species are capable of fueling the initiation and propagation of cancerous processes, they are not by themselves oncogenic [48] [49] [50] [51] [52] [53] . Candidiasis, although a predictor of cancer risk, may also result from cancer and their establishment could be favored by the immunosuppression resulting from cancer chemotherapy. Fungal infections modulate cancer development by impacting the host through diverse mechanisms: (1) perturbations in the DNA-damage response cause genetic mutations that accumulate inside the cell, modifying the oncogene expression involved in cell survival and proliferation; (2) oncogenic inflammation induced by DNA-damaging fungal toxins and their carcinogenic-inducing metabolites; and (3) fungal colonization or infection resulting in intense inflammation favoring the growth of primary tumors and metastases, making tumors resistant to chemotherapy drugs and suppressing the host's anti-cancer immune responses [45] .

In normal healthy individuals, Candida species are commonly found as a commensal colonizer in the skin and mucous membranes including the nose, mouth, gastrointestinal tract, reproductive organs, etc. [41, 54] . Understandably, Candida burden has been shown to positively correlate with the progression of oral, esophageal, and colorectal cancer, which is consistent with their presence in these mucosa [55] [56] [57] . In a recent study of 100 patients inflicted with oral squamous-cell carcinoma (OSCC), 75% of the patients had Candida species [58] : 84% of those identified were C. albicans, and other non-albicans species varied between 1% and 8%. Patients with hematopoietic neoplasms, head and neck malignancies as well patients undergoing chemo/radiotherapy have also presented with oral candidiasis ranging from 7% to 52% [59, 60] . Studies on animal models have also indicated that infections caused by C. albicans can contribute to carcinogenesis similar to known carcinogenic substances [45, 48, 55] . Several studies have shown substantial associations between candidiasis and dysplasia in the oral cavity, precancerous disorders, and OSCC [56, 61, 62] .

A widely regarded hypothesis for the pro-carcinogenic effect of Candida species is the direct production of carcinogens and/or the metabolism of pro-carcinogens among other molecular mechanisms. Studies using Sprague-Dawley rats showed that nitrosamine production and release occurring through the hyphal invasion caused by oral microbiota dysbiosis leads to oral tumor growth and progression [63, 64] . These findings are in line with the initial studies establishing that C. albicans can act as a promoter of carcinogenesis in the rat/mouse tongue following recurrent applications of nitroquinoline (4-nitroquinoline 1-oxide; 4-NQO), thereby mimicking the human neck and head cancer [65, 66] . Furthermore, overexpression of Ki-67, P53, and COX-2 by the host cells following Candida infection appears to suggest the involvement of this fungus in the malignant transformation of the host cells [67] . Cell-proliferation markers (Ki-67 and P53) and their overexpression are welldescribed in several malignancies. Inflammatory marker COX-2, an enzyme that converts arachidonic acid to prostanoids (prostaglandins, thromboxanes and prostacyclins) are expressed in several cancers and precancerous lesions, thereby prompting cell proliferation, tumor invasion, and cell death [55] .

Oral carcinogenesis begins as an epithelial dysplasia where the normal structure of epithelial cells is altered to an unusual proliferative state. Dysplasia usually results from a cell injury followed by chronic inflammation [68, 69] . The characteristic feature of epithelial dysplasia is the altered proliferation of the damaged squamous cells on the epithelial surface leading to degradation of the basal membrane. These damaged cells undergo apoptosis or may transform into a malignant state, thereby resulting in local destruction and distant invasion [70] .

The excessive production of pro-inflammatory cytokines during oral Candida infection such as IL-1α, IL-1β, IL-6, IL-8, TNF-α, IFN-γ, etc. suggests that alterations in metabolic pathways and dysfunction of the endothelium may negatively affect immune-related mechanisms leading to cancer development [8, 71, 72] . For instance, the production of acetaldehyde by Candida species, especially C. albicans, is mainly found in the oral cavity. Acetaldehyde is produced catabolically from its substrate ethanol/glucose by the action of alcohol dehydrogenases (ALDHs) and is found to be elevated in oral carcinomas compared to healthy individuals [55] . The fundamental characteristic features of acetaldehyde are genotoxicity, electrophilicity, effects on DNA repair, and induction of oxidative stress, thereby leading to the formation of protein and DNA adducts and gene mutations. The acetaldehyde-induced formation of DNA adducts interferes with DNA replication, thereby causing point mutations and chromosomal aberrations [73] . Synergistically, they also affect DNA repair and cytosine methylation, stimulating the activation of proto-oncogene and disturbances in the cell cycle, thereby resulting in tumor development. Glutathione, a tripeptide containing glutamate, cysteine, and glycine, functions as a potent anti-oxidant in the antioxidative system [74] . ROS produced during the aerobic metabolism via mitochondrial respiratory chain are well known to be elevated in cancer cells to back their rapid progression [75] . In human neuroblastoma, SH-SY5Y-cell acetaldehyde binds to the glutathione and thereby raises the intracellular ROS and calcium to arbitrate mitochondrial dysfunction [76] . Interestingly, apart from C. albicans, non-albicans such as C. tropicalis and C. parapsilosis are also able to produce significant amounts of acetaldehyde comparable to the carcinogenic levels (>100 µM), which is indicative of the carcinogenic nature of these organisms [77] .

Glucose metabolism plays a crucial role in the regulation of T-cell activation and cytokine production. Conversion of excessive glucose to acetaldehyde is known to inhibit T cells by downregulating glucose-transporter-1 (Glut1) mRNA expression [78] [79] [80] . For example, exposure of cultured T cells to acetaldehyde (200 µM) reduces glucose uptake with a concomitant reduction in the expression of the Glut1 transcript. This process also involves the downregulation of hypoxia-inducible factor-1α (Hif-1α) mRNA and subsequent suppression of downstream pathways including mammalian target of rapamycin (mTOR), Protein kinase B (PKB or AKT), and translation-initiation factor 4E-binding protein 1 (4E-BP1), all of which are involved in T-cell aerobic glycolysis [80] . Moreover, HIF-1α is known to regulate FOXP3 + -regulatory-T-cell (T reg ) differentiation and accumulation [81, 82] . Thus, it is clear that alterations in glucose metabolism by Candida can impact T-cell function including the suppressive activity by T regs . In aging oral mucosa, immune dysfunction is associated with an augmented accumulation of dysfunctional T regs during Candida infection ( Figure 1 ) [83] . Similarly, the increased accrual of T regs was also observed in human oral cancers as well in a mouse model of oral cancer [48] . Interestingly, the accumulation of dysfunctional T regs observed in the oral tumor microenvironment somehow positively correlates with the Candida burden [48] . However, the role of acetaldehyde expression by Candida, metabolic changes in T cells, and their impact on T reg accumulation remains to be seen. Interestingly, Dectin-1, an intermediate in anti-fungal signaling, promotes carcinogenesis. Dectin-1-deficient mice exhibit lowered IL-1β, decreased infiltration of myeloid-derived suppressor cells (MDSC) in the mouse tongues as well as slower progression and a significantly reduced tumor burden. These outcomes significantly correlate with the lower percentage of T regs in the oral tumor environment in these mice [48] . Nevertheless, in the context of tumors, how advanced aging influences Candida colonization and infection and alters Dectin-1 signaling remains an intriguing question to be addressed by future studies.

Gastrointestinal diseases, predominantly IBD, have emerged as an important public health challenge by globally affecting over 1.5 million annually in North America [84, 85] . The causes of IBD remain obscure, though studies on mice and clinical data demonstrate several factors including gut micro/mycobiota, environmental factors, the host's genetic makeup, etc. that are known to promote disease susceptibility. Microbiota including bacteria, viruses, protozoa, and fungi colonize the mammalian intestine. An intact equilibrium between the resident microbial communities and homeostatic immune responses is indispensable for mammalian health. Recent discoveries have revealed the roles of the fungal community, i.e., mycobiota, in regulating gut immunity as well as the inflammatory origin of human gastrointestinal diseases in their development and progression [86, 87] .

Several gastrointestinal diseases are interconnected with fungal dysbiosis, which has been shown to contribute to disease sensitivity and severity [88, 89] . Antibiotic exposure, genetic diversity, and diet are the underlying factors that promote fungal dysbiosis [87, 90, 91] . Fungal genera, mostly belonging to the Candida and Saccharomyces species have been shown to correlate with chronic idiopathic disorders such as ulcerative colitis (UC) and Crohn's disease (CD), which together are known as IBD [87] . Candida species overgrowth in the gut due to antibacterial exposure has been known for a long time [86, 87, 91] . Antibiotic treatment in the context of oral fungal infection induces not only oral but also gut inflammation [88, 89] .

Recently, the fungal mycobiome has gained an expanded role in promoting human health and disease. Numerous studies have shed light on understanding the role of fungal dysbiosis and altered fungal immune responses in IBD [92] [93] [94] . In fact, early diagnosis of IBD relies on the prevalence of the anti-Saccharomyces cerevisiae antibody (ASCA) among the patients with confirmed IBD, indicating the clinical relevance of yeast in IBD. Explicitly, C. albicans and C. parapsilosis were consistently found in several IBD cohort studies. Conversely, Saccharomyces including S. cerevisiae have been found to be reduced in the feces of IBD patients with active inflammation [95] [96] [97] .

The gut fungal composition in patients with CD, UC, and healthy subjects has been evaluated by Liguori et al., who showed that C. glabrata predominates during the disease state [97] . Additionally, non-candida fungi such as Filobasicium uniguttulatum and S. cerevisiae are found to be significantly elevated in the non-inflamed mucosa of CD. On the contrary, UC patients exhibit comparatively lowered fungal diversity [97] [98] [99] . This could be attributed to the inhibition of antimicrobial peptides against the bacteria in the small bowel modifying the bile-acid reabsorption, thereby benefiting the growth of fungi in patients with CD but not UC. These data also suggest that an increased fungal load of Candida species along with altered bacterial diversity could be associated with the pathogenic features of CD. In line with these findings, the 18S rRNA sequence analysis of a colonic biopsy of mucosa tissues and stool samples from patients with UC and healthy individuals revealed marked differences in the fungal communities. UC patients that were profoundly colonized with C. albicans displayed heightened mucosal injury and generation of ASCA [100] [101] [102] . Studies on dextran sodium sulfate (DSS)-induced colitis in C57BL/6J mice usually exhibited fungal invasion to colonic mucosa along with the expansion of Candida and Trichosporon and a decrease in non-pathogenic Saccharomyces spp., [94, 102, 103] . Numerous studies have shown a high abundance of colonization of Candida in ulcer and IBD patients, signifying the association of fungal dysbiosis with IBD [92, 96, 97, 103] . A recent study by Sokol et al. involving the internal transcribed spacer2 (ITS2)-sequencing of rDNA also showed an increase in C. albicans and a decrease in S. cerevisiae abundance in IBD patients [92] .

The relationship between intestinal inflammation and mycobiome dysbiosis appears to be a vicious cycle. Animal studies have also been employed to elucidate the relationship between IBD and the mycobiome. Studies involving the subcutaneous administration of cysteamine, an amino thiol to induce duodenal ulcers have revealed that rats receiving cysteamine and C. albicans inoculum progressed with perforated duodenal ulcers in contrast to the rats receiving cysteamine alone [104] . Seminal studies by Iliev et al. showed the protective role of Dectin-1 in colitis in a DSS-induced-colitis mouse model [94] . The study described the association of Dectin-1, which is encoded by the gene C-type lectin domain family 7 member A (CLEC7A), with the severity of UC. Mice with Dectin-1-deficiency (Clec7a -/-) displayed augmented severity of IBD symptoms, namely worse mucosal erosion, destruction of crypts, and inflammatory cell infiltration than wild-type mice. Clec7a -/mice also showed an increased production of inflammatory cytokine TNF-α in the colon and an amplified production of IFN-γ and IL-17 in the intestines compared to wild-type littermate controls. The histological examination of colons from DSS-induced Clec7a -/mice revealed the invasion of fungi in the inflamed tissues while they were localized to the lumens of the wild-type mice. This is in agreement with in vitro studies that showed intestinally conditioned Clec7a -/-DC were less effective in clearing C. tropicalis. The study also probed the role of C. tropicalis in colitis by comparing it with the non-pathogenic fungi S. fibuligeria, where both the yeasts grew in filamentous form and were sensed by Dectin-1. Clec7a -/mice treated with C. tropicalis exhibited augmented colitis symptoms, IFN-γ, and IL-17 produced by T cells from mesenteric lymph nodes and colons compared with nontreated Clec7a -/controls [86, 94, 102] . A recent study using Dectin-3-deficient (Clec4d -/-) mice showed their susceptibility to DSS-induced colitis. Clec4d -/bone-marrow-derived macrophages were defective in NF-κB activation induced by C. tropicalis, thereby hindering their involvement in tissue repair during fungal invasion [26, 105] . Taken together, fungal dysbiosis, impaired anti-fungal immunity and excessive overgrowth of C. albicans in the intestine escalate the IBD severity and hinder the gut's wound-healing processes.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic virus that emerged in late 2019. It has caused a global pandemic of coronavirus disease 2019 (COVID-19), which is an acute respiratory disease threatening human health and public safety [106, 107] . As of 24 January 2022,~349 million confirmed cases and~5.59 million deaths have been reported globally [108]. SARS-CoV-2 spreads predominantly via respiratory droplets through close person-to-person contact, pre-symptomatic, asymptomatic, and symptomatic carriers. Infections vary from asymptomatic to a fullblown disease with a range of symptoms including upper-respiratory-tract infection or life-threatening sepsis with prolonged hospital stays [106, 107, 109] . COVID-19 patients show changes in their microbiota composition [110] , due to secondary infections including those caused by bacteria and fungi [111] . Among the opportunistic infections in COVID-19 patients, a higher incidence of fungal co-infections was observed [112] [113] [114] [115] . Most fungalrelated co-infections in COVID-19 patients involved Aspergillus spp., C. albicans, C. auris, C. dubliniensis, C. glabrata, C. tropicalis, C. krusei, and C. parapsilosis sensu stricto [116, 117] .

While COVID vaccination has tremendously improved the morbidity and mortality of the disease, secondary fungal infections were common and had worsened the morbidity during the full-blown pandemic until 2021 [114, 118] . SARS-CoV-2 triggers host immune dysregulation, which has been postulated to contribute to fungal co-infections increasing the morbidity and mortality associated with COVID-19 [119] . Candidiasis is one of the major complications of severe COVID-19, concomitant with a longer stay in the intensive care unit, a greater usage of broad-spectrum of antibiotics, and a higher mortality rate [115, 120, 121] . A study by Nucci et al. showed that COVID-19 patients with candidemia were more likely to be under mechanical ventilation compared to non-COVID-19 patients [122, 123] . Moreover, Aspergillus spp., causes a life-threatening disease-invasive pulmonary aspergillosis (IPA) that is characteristically associated with immune-system dysregulation and affects the respiratory system. IPA chiefly arises due to the prolonged usage of glucocorticoids, immunosuppressive agents, chronic neutropenia, and in transplant recipients [124, 125] . Case reports and observational studies have shown that COVID-19-associated pulmonary aspergillosis (CAPA) is of significant concern in hospitalized COVID-19 patients with complications [125, 126] .

Case reports show that patients treated with steroids during COVID-19 treatment often developed histoplasmosis caused by a dimorphic fungus Histoplasma capsulatum [127] . Fungus histoplasmosis is highly endemic and has been found in regions of the United States (California), Rio Grande, Southern Brazil, Buenos Aires, and Argentina [124] . This fungus is found in soil containing the excreta of birds or bats [127] and is associated with immunosuppressive conditions [127, 128] . Histoplasmosis was previously shown to be associated with acquired immunodeficiency syndrome (AIDS) [129, 130] , another immunedysfunction disease. It is noteworthy that this re-emerged as a co-infection in COVID-19 patients [131] [132] [133] . Another severe opportunistic infection in immune-compromised patients is Cryptococcus neoformans, which has a high risk of mortality. Studies have also shown that most COVID-19 patients with C. neoformans co-infection did not survive despite treatment with anti-fungal agents such as fluconazole and amphotericin B [114, 134] .

During or after weeks or months of recovery from COVID-19, patients who suffered lung complications have reported experiencing Mucormycosis, commonly known as COVID19-associated Mucormycosis (CAM). CAM was reported in many countries during the COVID-19 second wave including Brazil, Egypt, Austria, Iran, Italy, the United States, France, and India, constituting about 0.3% of COVID-19 infections [135, 136] . Mucormycosis is characterized by the presence of hyphal infiltration of the sinus tissue and has a temporal course of roughly four weeks. The common species responsible for Mucormycosis belong to Rhizopus spp., Mucor spp., and Cunninghamella spp. Typical symptoms include complicated sinusitis, crusting nasal blockage, proptosis, facial pain, edema, ptosis, ophthalmoplegia with intracranial extension, and characteristically, a black eschar on the hard palate or in the nasal cavity [114] . For a short period during pandemic, an intensive increase in cases of CAM was observed in several patients requiring extreme surgical operations to treat the disease [114, 137, 138] . Other fungal co-infections were also described including those by Pneumocystis jirovecii and Coccidioides immitis [139] [140] [141] . Some of these co-infections, especially with P. jirovecii, are thought to be life threatening or have an adverse impact on COVID-19 [139, 141] .

The concurrent usage of steroids to control COVID-19 symptoms might contribute to the suppression of immunity, and consequently lead to these infections during different stages of the disease, but this possibility remains to be validated. Because steroids may promote these conditions [70, 142] , a sensible use of these drugs is critical while evaluating the treatment options for COVID-19 and its related co-infections. Additionally, a better understanding of the underlying COVID-19 immune dysfunction is imperative for the appropriate diagnosis and effective treatment of fungal co-infections.

C. albicans, the most common member of the intestinal mycobiota, is known to be associated with numerous inflammatory conditions in humans [143, 144] . Candida is known to poorly interact with epithelial cells. Conversely, its hyphae can enter the epithelial cells and induce numerous pro-inflammatory cytokines and host-defense peptides. The hyphal transition also reduces the colonization potential of Candida, typically via the anti-fungal immunity exerted by the augmented expression of hyphal-specific genes [86, 145] . Notably, the formation of hyphae in C. albicans occurs by its adhesion to the epithelial cells, which is a strong inducer and complemented by hyphal-associated protein expression. Hwp1 (hyphal wall protein 1) and Als3 (agglutinin-like sequence 3) are the two essential proteins that stimulate epithelial adhesion [146] [147] [148] . These proteins are well-known to possess critical roles in adhesion, invasion, induction of damage, and immune activation/evasion. Candidalysin, which is encoded solely by C. albicans, is a pore-forming peptide and an essential virulent factor associated with epithelial damage and host immune-cell activation [149] . This peptide stimulates the MPK1/MAPK/cFos-activation pathway, thereby leading to pro-inflammatory cytokine production such as IL-1α, IL-1β, IL-6, IL-8, GM-CSF, and G-CSF. Candidalysin by itself also induces in vitro cell damage in Caco-2 cells; however, ascertaining its effects on the gut epithelium needs additional studies [149] [150] [151] . Remarkably, candidalysin-mediated epithelial activation does not involve Toll-like receptors (TLRs) or CLRs, demonstrating that these cells utilize sensing mechanisms that are distinct from myeloid cells. This notion is consistent with previous studies that have shown that myeloid cells specifically sense Candida cell-wall moieties by β-glucans and mannans while epithelial-cell damage is mediated by the MPK1/MAPK/cFos pathway [147, 152, 153] .

Innate activation through Dectin-1/CARD9 facilitating IL-1β, IL-6, and IL-23 secretion by dendritic cells is critical for disseminating adaptive antifungal Th17-cell responses [31] . A deficiency of Dectin-1 increases the risk of infectious diseases and thus reflects its pivotal role in immune defense [154] . In mice, Dectin-1 deficiency results in a significantly increased fungal burden and a low survival rate [155] . This is associated with a decrease in phagocytic cell recruitment and reduced pro-inflammatory-cytokine release at the site of infection in Dectin-1-knockout mice [155] . Oral candidiasis also showed augmented dissemination in Dectin-1-knockout mice [156] . A deficiency of CARD9, an important intermediate in the Dectin-1/Syk pathway, also results in augmented sensitivity to systemic candidiasis, further reiterating the significance of Dectin-1-mediated signaling in controlling inflammatory diseases involving fungi [28] . mTOR, a conserved Ser/Thr kinase, plays an essential role in the regulation of cell growth and metabolism. mTOR senses and combines several environmental cues, ultimately delivering them to the PI3K-AKT pathway, thereby activating two multiprotein complexes, namely complex1 (mTORC1) and complex2 (mTORC2) [157] . These complexes play divergent roles in T cells, especially in instructing the differentiation of Th cells. By modulating the autophagy/apoptosis pathway, the survival of CD4 + T cells during fungal sepsis, as well as CD8 + -T-cell differentiation, the mTOR pathway regulates the aspergillosis prognosis in mice [158] . Compared with wild-type mice, T-cell-specific mTOR-knockout mice showed a higher survival rate after fungal sepsis, whereas after the T-cell-specific knockout of tuberous sclerosis complex 1(TSC1), which is a negative regulator of mTORC1, mice displayed lower survival rates after fungal sepsis [158, 159] . These results show that mTOR activation in CD4 + T cells may have a detrimental role in exacerbating inflammation during fungal sepsis. Additionally, mTOR activation impairs CD8 + -T-cell immunity via the augmentation of Eomesodermin in the context of invasive candidiasis [160] . Moreover, mTOR complexes possess dual and opposing roles in T regs , either promoting or inhibiting inflammation depending on the context [161] [162] [163] . mTOR activation downstream of IL-1β and the myeloid-differentiation-primary-response-88 (MyD88) signaling are critical for T reg homeostasis in oral mucosa. Consequently, the mTOR/IL-1β/MyD88-signaling axis promotes the induction and expansion of an exclusive population of FOXP3 + cells expressing IL-17A, known as T reg 17 [83] . However, the dysregulation of any node in this axis appears to diminish these cells and cause increased accumulation of dysfunctional T regs . Additionally, it appears that aging and tumorigenesis may disrupt this signaling and potentially cause Candida dysbiosis and infection. Thus, mTOR appears to regulate immune dysfunction, dysbiosis, and Candida-associated oral inflammation [83] . The role of this signaling in gut dysbiosis or in relevance to other diseases remains unclear and warrants further investigation. Taken together, emerging roles of fungi in altering various mechanistic components including mTOR highlight their critical functions in skewing the regulation of T-cell metabolism/differentiation and mucosal homeostasis.

Fungal dysbiosis and altered immune responses to fungi are linked to several human pathologies. Most fungal infections represent polymicrobial diseases in susceptible hosts and are more prevalent in immune-compromised and elderly individuals. Candida infections have steadily increased because of a higher incidence of systemic diseases including tumors, IBD, AIDS, disorders of the kidney and liver, the extensive development of interventional therapy, transplantations, and the over-exploitation of various antibiotics. Lymphocytopenia is commonly observed in immunocompromised/elderly population/COVID-19 patients, making them prone to persistent fungal infections or nonresolving inflammation associated with such infections. Over the last decade, a tremendous advancement has been made in understanding anti-fungal immunity. However, further understanding of the precise mechanistic interplay between fungal dysbiosis and mucosal immune system and its impact on the host in the context of diseases needs additional detailed investigations. Those studies will lead to potential new targets for reversing immune dysfunction in the context of fungal dysbiosis.

Author Contributions: P.P. drafted the framework for the review. S.S.M. wrote the preliminary drafts. S.S.M. and P.P. wrote and edited the final manuscript, and S.J. contributed to editing. All authors have read and agreed to the published version of the manuscript.

Funding: This work was funded by NIH, NIDCR R01 DE026923.

Institutional Review Board Statement: Not applicable.

Data Availability Statement: Not applicable.

The authors declare no conflict of interest.

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Creating and maintaining the gastrointestinal ecosystem: What we know and need to know from gnotobiology. Microbiol

Getting a grip on things: How do communities of bacterial symbionts become established in our intestine?

Characterization of the oral fungal microbiome (mycobiome) in healthy individuals

Mycobiota in gastrointestinal diseases

Bacteriome and mycobiome associations in oral tongue cancer

Innate antifungal immunity: The key role of phagocytes

Albicans: A molecular revolution built on lessons from budding yeast

Innate immune cell response upon Candida albicans infection

Adaptive immune responses to Candida albicans infection

The Interactions between Candida albicans and mucosal immunity

Fungal diseases: Oral dysbiosis in susceptible hosts

Soerjomataram, I. The ever-increasing importance of cancer as a leading cause of premature death worldwide

Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries

Candida albicans and cancer: Can this yeast induce cancer development or progression?

Fighting cancer with microbes

The Role of the Microbiome in Cancer Initiation and Progression: How Microbes and Cancer Cells Utilize Excess Energy and Promote One Another's Growth

The Role of Dectin-1 Signaling in Altering Tumor Immune Microenvironment in the Context of Aging

Deciphering the Role of Regulatory CD4 T Cells in Oral and Oropharyngeal Cancer: A Systematic Review

IL-1β promotes malignant transformation and tumor aggressiveness in oral cancer

A dysbiotic mycobiome dominated by

Cancer risk in patients with candidiasis: A nationwide population-based cohort study

T-cells of invasive candidiasis patients show patterns of T-cell-exhaustion suggesting checkpoint blockade as treatment option

New Insights in Candida albicans Innate Immunity at the Mucosa: Toxins, Epithelium, Metabolism, and Beyond. Front

Candida albicans and Oral Carcinogenesis. A Brief Review

Oral Candida colonization in oral cancer patients and its relationship with traditional risk factors of oral cancer: A matched case-control study

Fungal Gut Microbiota Dysbiosis and Its Role in Colorectal, Oral, and Pancreatic Carcinogenesis

Role of Non-Albicans Candida and Candida Albicans in Oral Squamous Cell Cancer Patients

Oral Candidiasis among Cancer Patients Attending a Tertiary Care Hospital in Chennai, South India: An Evaluation of Clinicomycological Association and Antifungal Susceptibility Pattern. Can

Candida prevalence in saliva before and after oral cancer treatment

Prevalence of fungal hyphae in potentially malignant lesions and conditions-does its occurrence play a role in epithelial dysplasia?

Evaluation of candidal species among individuals with oral potentially malignant disorders and oral squamous cell carcinoma

Rebalancing the Oral Microbiota as an Efficient Tool in Endocrine, Metabolic and Immune Disorders

Does it make sense that diabetes is reciprocally associated with periodontal disease?

4NQO carcinogenesis: A mouse model of oral cavity squamous cell carcinoma

Candida albicans as a promoter of oral mucosal neoplasia

The Cytological Findings of Oral Inflammatory Lesions, Lichen Planus and Leukoplakia Coexisted with and without Candida: With Special Reference to Clinical, Histopathological, Immunohistochemical and Flow Cytometrical Analyses

Essentials of oral cancer

Histological and molecular aspects of oral squamous cell carcinoma (Review)

The role of Candida albicans candidalysin ECE1 gene in oral carcinogenesis

Candida albicans strain-dependent modulation of pro-inflammatory cytokine release by in vitro oral and vaginal mucosal models

The association of Candida and antifungal therapy with pro-inflammatory cytokines in oral leukoplakia

Molecular mechanisms of alcohol-mediated carcinogenesis

Application of glutathione depletion in cancer therapy: Enhanced ROS-based therapy, ferroptosis, and chemotherapy

ROS in cancer therapy: The bright side of the moon

Acetaldehyde induces phosphorylation of dynamin-related protein 1 and mitochondrial dysfunction via elevating intracellular ROS and Ca 2+ levels

Alcohol-Derived Acetaldehyde Exposure in the Oral Cavity. Cancers

Nutritional effects on T-cell immunometabolism

Metabolic regulation of T lymphocytes

Alcohol inhibits T-cell glucose metabolism and hepatitis in ALDH2-deficient mice and humans: Roles of acetaldehyde and glucocorticoids

Control of T(H)17/T(reg) balance by hypoxia-inducible factor 1

Hypoxia-inducible factor-1 alpha-dependent induction of FoxP3 drives regulatory T-cell abundance and function during inflammatory hypoxia of the mucosa

IL-1β-MyD88-mTOR Axis Promotes Immune-Protective IL-17A. Front

Immunopathogenesis of IBD: Current state of the art

Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: A systematic review of population-based studies

Gut Mycobiota in Immunity and Inflammatory Disease

Host-microbe interactions: Commensal fungi in the gut

Role of Short Chain Fatty Acids in Controlling T regs and Immunopathology During Mucosal Infection

Microbiome Dependent Regulation of T regs and Th17 Cells in Mucosa

Candida albicans and bacterial microbiota interactions in the cecum during recolonization following broad-spectrum antibiotic therapy

Antibiotic exposure as a risk factor for fluconazole-resistant Candida bloodstream infection

Nion-Larmurier, I.; et al. Fungal microbiota dysbiosis in IBD

Immunological Consequences of Intestinal Fungal Dysbiosis

Interactions between commensal fungi and the C-type lectin receptor Dectin-1 influence colitis

Fungal Signature in the Gut Microbiota of Pediatric Patients With Inflammatory Bowel Disease

Dysbiosis of gut fungal microbiota is associated with mucosal inflammation in Crohn's disease

Fungal Dysbiosis in Mucosa-associated Microbiota of Crohn's Disease Patients

The fungal microbiota of de-novo paediatric inflammatory bowel disease. Microbes Infect

The Gut Microbiota in the Pathogenesis and Therapeutics of Inflammatory Bowel Disease

Fungi and inflammatory bowel diseases: Alterations of composition and diversity

Secukinumab failure in Crohn's disease: The yeast connection? Gut

Fungi in Gastrointestinal Tracts of Human and Mice: From Community to Functions

Changes in the composition of intestinal fungi and their role in mice with dextran sulfate sodium-induced colitis

Candida albicans aggravates duodenal ulcer perforation induced by administration of cysteamine in rats

Lectin-Like Receptors As Emerging Orchestrators of Sterile Inflammation Represent Potential Therapeutic Targets

Characteristics of SARS-CoV-2 and COVID-19

Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review

COVID-19: A Review on the Novel Coronavirus Disease Evolution, Transmission, Detection, Control and Prevention

The Role of Bacterial and Fungal Human Respiratory Microbiota in COVID-19 Patients

The lurking scourge of multidrug resistant Candida auris in times of COVID-19 pandemic

Fungal Infections Complicating COVID-19: With the Rain Comes the Spores

Impact of the SARS-CoV-2 Pandemic in Candidaemia, Invasive Aspergillosis and Antifungal Consumption in a Tertiary Hospital

Overview on the Prevalence of Fungal Infections, Immune Response, and Microbiome Role in COVID-19 Patients

COVID-19 Impairs Immune Response to Candida albicans

The microbial coinfection in COVID-19

Invasive Infections during a COVID-19 Case Surge

Invasive Fungal Infections Complicating COVID-19: A Narrative Review

Immune dysregulation and immunopathology induced by SARS-CoV-2 and related coronaviruses-are we our own worst enemy?

COVID-19-Associated Candidiasis (CAC): An Underestimated Complication in the Absence of Immunological Predispositions?

Oral candidiasis of COVID-19 patients: Case report and review of evidence

Increased incidence of candidemia in a tertiary care hospital with the COVID-19 pandemic

Prevalence of candidiasis and oral candidiasis in COVID-19 patients: A cross-sectional pilot study from the patients' registry in a large health center

Epidemiology of Systemic Mycoses in the COVID-19 Pandemic

Prevalence of putative invasive pulmonary aspergillosis in critically ill patients with COVID-19

Is the COVID-19 Pandemic a Good Time to Include Aspergillus Molecular Detection to Categorize Aspergillosis in ICU Patients? A Monocentric Experience

Clinical Perspectives in the Diagnosis and Management of Histoplasmosis. Clin

COVID-19) in a Patient with Disseminated Histoplasmosis and HIV-A Case Report from Argentina and Literature Review

COVID-19-Associated Histoplasmosis in an AIDS Patient

Report: Incidental Finding of COVID-19 Infection after Positron Emission Tomography/CT Imaging in a Patient with a Diagnosis of Histoplasmosis and Recurring Fever

Acute Pulmonary Histoplasmosis Following COVID-19: Novel Laboratorial Methods Aiding Diagnosis

COVID-19 associated with AIDS-related disseminated histoplasmosis: A case report

Cryptococcemia in a patient with COVID-19: A case report

COVID-19-associated mucormycosis: Evidence-based critical review of an emerging infection burden during the pandemic's second wave in India

COVID-19 associated mucormycosis-An emerging threat

Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study

Pneumocystis jirovecii Pneumonia and Severe Acute Respiratory Syndrome Coronavirus 2 Coinfection in a Patient With Newly Diagnosed HIV-1 Infection

No Change of Pneumocystis jirovecii Pneumonia after the COVID-19 Pandemic: Multicenter Time-Series Analyses

Pneumocystis jirovecii pneumonia in an immunocompetent patient recovered from COVID-19

Coronavirus Disease-Associated Pulmonary Aspergillosis: A Devastating Complication of COVID-19

Human Anti-fungal Th17 Immunity and Pathology Rely on Cross-Reactivity against Candida albicans

Candida albicans Morphogenesis Programs Control the Balance between Gut Commensalism and Invasive Infection

Adhesive and mammalian transglutaminase substrate properties of Candida albicans Hwp1

Candida albicans-epithelial interactions and induction of mucosal innate immunity

Candida albicans Als3, a multifunctional adhesin and invasin

Candidalysin is a fungal peptide toxin critical for mucosal infection

Oral epithelial cells orchestrate innate type 17 responses to Candida albicans through the virulence factor candidalysin

Candida albicans pathogenicity and epithelial immunity

Epithelial discrimination of commensal and pathogenic Candida albicans

The role of dectin-1 in health and disease

Dectin-1 is required for beta-glucan recognition and control of fungal infection

An essential role for the NLRP3 inflammasome in host defense against the human fungal pathogen Candida albicans

Regulation and function of mTOR signalling in T cell fate decisions

mTOR Modulates CD8+ T Cell Differentiation in Mice with Invasive Pulmonary Aspergillosis

T-cell-specific mTOR deletion in mice ameliorated CD4 + T-cell survival in lethal sepsis induced by severe invasive candidiasis

Impact of mTOR signaling pathway on CD8+ T cell immunity through Eomesodermin in response to invasive candidiasis

D. mTORC1 and mTORC2 selectively regulate CD8 + T cell differentiation

Mammalian Target of Rapamycin Complex 2 Controls CD8 T Cell Memory Differentiation in a Foxo1-Dependent Manner