RESEARCH ADVANCE Expandable and reversible copy number amplification drives rapid adaptation to antifungal drugs Robert T Todd, Anna Selmecki* Department of Microbiology and Immunology, University of Minnesota Medical School, Minneapolis, Minnesota, United States Abstract Previously, we identified long repeat sequences that are frequently associated with genome rearrangements, including copy number variation (CNV), in many diverse isolates of the human fungal pathogen Candida albicans (Todd et al., 2019). Here, we describe the rapid acquisition of novel, high copy number CNVs during adaptation to azole antifungal drugs. Single- cell karyotype analysis indicates that these CNVs appear to arise via a dicentric chromosome intermediate and breakage-fusion-bridge cycles that are repaired using multiple distinct long inverted repeat sequences. Subsequent removal of the antifungal drug can lead to a dramatic loss of the CNV and reversion to the progenitor genotype and drug susceptibility phenotype. These findings support a novel mechanism for the rapid acquisition of antifungal drug resistance and provide genomic evidence for the heterogeneity frequently observed in clinical settings. Introduction The evolution of antifungal drug resistance is an urgent threat to human health worldwide, particu- larly for hospitalized and immune-compromised individuals (Perea and Patterson, 2002; Pfal- ler, 2012; Vandeputte et al., 2012). Only three classes of antifungal drugs are currently available *For correspondence:
[email protected] and resistance to all three classes occurred for the first time in the emerging fungal pathogen Can- dida auris (Chen and Sorrell, 2007; Ghannoum and Rice, 1999; Lockhart et al., 2017). Importantly, Competing interests: The the mechanisms and dynamics of acquired antifungal drug resistance, in vitro or in a patient under- authors declare that no going antifungal drug therapy, are not fully understood.