LNSLNS We thank all our readers (including those who communicated their feedback to the authors directly) for contributing to the discussion of our article (1), which was controversial and thus underlines the continuing interest in the topic.

Hans Rieth (19141994) vitally contributed to developments in medical mycology in the German speaking area, together with a small number of clinical mycologists in both parts of Germany, in the 1960s to 1980s, by conducting elegant microbiological and experimental clinical studies (including courageous self experiments). However, at this time, the so called “Omics” technologies of molecular biology were in their infancy, at best. Sometimes, the deducted practical conclusions were exaggerated—one reason why colleagues from other specialties, especially gastronenterologists, opposed the “mycophobic” tendencies that started to develop among patients. Rudolf Ottenjann (19252005), a gifted endoscopist, opposed these trends vehemently and declared that only the treatment of Candida induced thrush on the squamous epithelium, which could be (macro)endoscopically confirmed, was necessary (2). New, high resolution techniques, such as confocal endoscopy (3), may open up opportunities to detect micoorganisms during endoscopy on the cylinder epithelium without requiring a biopsy (see image in our article).

Candida yeasts—which multiply only by means of budding and, in contrast to molds, do not form spores—are able to overcome the host’s defenses by a reversible change between yeast and hyphal stages. These changes of cell morphology are accompanied by a -reduction in the immunogenic ß-glucan content of the yeast cell wall (4). The phenotypic switching that is associated with biofilm formation heads in the same direction (immunoevasion) (5). The ability to form biofilms in itself is not a marker of pathogenicity, but it protects the yeasts from being attacked by the immune system.

The pathogenesis of irritable bowel syndrome remains unclear to this day. Current discussions are focused on changed reactions of the enteric nervous system, visceral sensitivity and mobility, and persistent underlying inflammatory conditions. Preclinical studies have shown the influence of intestinal microbes on the functions and reactions of the intestinal tract. This is especially true for the irritable bowel syndrome that develops subsequent to an infection (“postinfectious irritable bowel syndrome”) (6). The association between Candida and irritable bowel syndrome—not proved so far—has assumed relevance for Candida problems by way of the current discussion of the pathogenetic background of the irritable bowel syndrome.

Review articles relate facts; their purpose is not to relate pre-formed opinions, nor semantically unclear phrases. We therefore follow in this context the request to substitute “Candida load”—used once in the German manuscript—with the term “Candida colonization”—used more than 10 times in the German manuscript.

The situation is different for formulating conclusions and key messages—these require distilling the topic at hand into central key statements without any accompanying explanations. The authors may assume that the entire article has been read in order to understand these.

It was not planned in a review article (1) to comment on individual case reports and studies that were conducted in a manner not consistent with GCP (Good Clinical Practice); as a result, many reported results, especially from the naturopathic field, were not included. It is therefore not possible to assess the entire multitude of therapeutic strategies, which would exceed the size of this authors’ reply.
DOI: 10.3238/arztebl.2010.0369b

PD Dr. rer. nat. habil. Jürgen Schulze
Alice-Bloch-Str. 7
14558 Nuthetal, Germany
JuR.Schulze@t-online.de

Conflict of interest statement
Until 2005, Dr. Schulze was an employee of the company Ardeypharm GmbH.
Since January 2006, he has not maintained any financial or non-material relations with the company.
1.
Schulze J, Sonnenborn U: Yeasts in the gut: from commensals to infectious agents [Pilze im Darm – von kommensalen Untermietern zu Infektionserregern]. Dtsch Arztebl Int 2009; 106: 837–42. VOLLTEXT
2.
Anonymus: Streitthema Darmsanierung – Kontra: Prof. Dr. med. Rudolf Ottenjann. Naturamed 1994; (12): 13–4.
3.
Hoffmannn A, Kiesslich R: Gastrointestinale Endoskopie – erweiterte Bildgebung. Gastroenterologie up2date 2009; 5: 145–63.
4.
Netea MG, Brown GD, Kullberg BJ, Gow NAR: An integrated model of the recognition of Candida albicans by the innate immune system. Nat Rev Immunol 2008; 6: 67–78. MEDLINE
5.
Ramirez-Zavala B, Reuß O, Park YN, Ohlsen K, Morschhäuser J: Environmental induction of white-opaque switching in Candida albicans. PloS Pathog 2008; 4: e1000089. MEDLINE
6.
McKeown ES, Parry SD, Stansfield R, Barton JR, Welfare MR: Postinfectious irritable bowel syndrome may occur after non-gastrointestinal and intestinal infection. Neurogastroenterol Motil 2006; 18: 839–43. MEDLINE
1. Schulze J, Sonnenborn U: Yeasts in the gut: from commensals to infectious agents [Pilze im Darm – von kommensalen Untermietern zu Infektionserregern]. Dtsch Arztebl Int 2009; 106: 837–42. VOLLTEXT
2. Anonymus: Streitthema Darmsanierung – Kontra: Prof. Dr. med. Rudolf Ottenjann. Naturamed 1994; (12): 13–4.
3. Hoffmannn A, Kiesslich R: Gastrointestinale Endoskopie – erweiterte Bildgebung. Gastroenterologie up2date 2009; 5: 145–63.
4. Netea MG, Brown GD, Kullberg BJ, Gow NAR: An integrated model of the recognition of Candida albicans by the innate immune system. Nat Rev Immunol 2008; 6: 67–78. MEDLINE
5. Ramirez-Zavala B, Reuß O, Park YN, Ohlsen K, Morschhäuser J: Environmental induction of white-opaque switching in Candida albicans. PloS Pathog 2008; 4: e1000089. MEDLINE
6. McKeown ES, Parry SD, Stansfield R, Barton JR, Welfare MR: Postinfectious irritable bowel syndrome may occur after non-gastrointestinal and intestinal infection. Neurogastroenterol Motil 2006; 18: 839–43. MEDLINE