1. Goals and Objectives
• To discuss illnesses caused or
exacerbated by mold exposure
• To discuss the impact of hurricane Katrina
related flood damage and resulting mold
exposure on human health
• To briefly describe mold remedial
measures and mold associated medico-
legal issues
2. Case #1
• PC is a 65 y/o male with a hx of allergic
rhinitis chronic cough( post nasal drip)
who has a 10 year history of allergen IT
with his symptoms being totally controlled
with Dust mite immunotherapy on
maintenance. He denied wheezing SOB,
3. Skin Prick test result comparison
Pre Katrina 1998 Post Katrina 2006
Grasses Neg. Pos. (Italian rye)
Trees Neg. Pos.
Dust mite Pos. Pos.
Weeds Neg. Neg.
Molds Neg. Pos.
Penicillium
Aspergillus Neg. Pos.
Cladosporium Neg. Pos.
4. HPI
• Post Katrina with a 8 month hiatus in
immunotherapy he had a total of 5 ER visits ,
wheezing , SOB, exacerbation of rhinitis
symptoms , several antibiotic courses for
sinusitis and systemic oral steroids for asthma
exacerbations
• He was also found to have AERD (Aspirin
exacerbated respiratory disease) demonstrated
by history latter confirmed by challenge.
5. CONT of HPI
• Skin prick tests prior to Katrina were only
positive to dust mite.
• Pmhx: Allergic rhinitis, chronic cough, chronic
sinusitis and allergen immunotherapy
• PShx: Sinus Surgery 2000 for nasal polyps
• Meds: Amoxicillin, Guafinessin, desloratidine,
fluticosone, albuterol and budesonide nasal
spray
• Drug Allergies: Aspirin hypersensitivity
6. Physical Exam
• Vital signs: 180lbs, temp 98.3, Bp 138/74
• Nares congested
• Lungs clear
• Rest of exam within normal limits
7. Assesment/ Plan
• Exacerbation of Allergic rhinitis, sinusitis, chronic
cough with possible GERD association
• Chest x ray wnl
• Amoxicillin/Clavulinic acid 875 mg po bid for
suspected sinusitis
• desloratidine Qam
• Azelastine spray each nostril qd
• Fluticasone inhaler Bid
• PEFR twice daily
• Albuterol prn
13. The Relationship of Molds to
Allergy
• Alternaria sp, a common outdoor mold has been linked
to asthma severity, increased likelihood of emergency
room visits in sensitized individuals and even life
threatening episodes of asthma
• Alternaria spores are abundant in grain growing areas
the peak seasons are late summer and early fall.
Approximately 80% of asthmatics may have positive skin
tests to one or more fungi, up to 70% of patients with
fungal allergy have positive skin tests to alternaria
• Cladosporium the commonest allergenic mold has also
been implicated in asthma exacerbations.
14. Hypersensitivity Pneumonitis(HP)
• Immunologic lung disease caused by high dose
exposure, prolonged exposure or both to the
causative inhalational allergens.
• The causative agents include both Thermophillic
actinomycetes from moldy hay( Farmers Lung),
Pigeon droppings as well as many fungi
particularly aspergillus , penicillium species.
• Aspergillus species commonly present in house
dust , soil particles , rotting leaves , lawn cutting
leaf raking and in many occupational settings as
well
• Spoiled food and moldy cheese ( Pencillium sp)
18. HP: Clinical Features
Acute, Fever cough shortness of breath,
myalgias crackles in lung fields
Chronic, Progressive shortness of breath
weakness, weight loss on P/E bibasilar
fine crackles
CXR patchy ill defined densities, PFT’s
restrictive defect
22. IGG Precipitins
• HP: the characteristic
finding is the
demonstration of
serum precipitins( IgG
class antibodies )
directed against
offending antigens
23. Allergic Broncho pulmonary
aspergillosis (ABPA)
• Exposure can occur from both indoor and outdoor
sources
• Occurs in patients with asthma cystic fibrosis etc
• Diagnostic features include cxr infiltrates , immediate
cutaneous reactivity, peripheral blood eosinophillia,
elevated total serum IgE as well as aspergillus specific
IgE and IgG
• Immunologic pathogenesis related to both type I and
type III hypersensitivity reactions
• Aspergillus species prevalent in house dust collected
from beds
• Tx, High dose and long term steroids, role of avoidance
measures uncertain
26. Allergic Fungal Sinusitis (AFS)
Similar to ABPA. Nasal polyps predispose,
localized hypersensitivity reaction to aspergillus
fumigatus in sinus cavity. Other fungi could also
contribute to AFS i.e. bipolaris, curvalaria
Features include eosinophillic mucous
demonstrating non invasive fungi, positive skin
tests or invitro test to aspergillus
Difficult to treat and often times frequent
endoscopic sinus surgery procedures is
necessary
28. Toxic effects of Mold Exposure
• Mycotoxins are low molecular weight
chemicals produced by certain molds
• Mycotoxin producing molds infect plants,
agricultural crops (cereal grains, human
foods)
• Ingestion of mycotoxin can cause serious
human disease. Fusarium and aspergillus
species are important examples.
29. (Contd)Toxic effects of Mold
exposure
• There has been an illness described in the
literature as Alimentary toxic aleukia
characterized by GI symptoms, weakness
and aplastic cytopenia
• The occurrence of Mycotoxicosis from
exposure to inhaled mycotoxins in non
occupational setting in not supported by
current data and its occurrence is
improbable (Bush et al 06)
30. Irritant effects of mold exposure
• Irritating substances produced by molds include
volatile organic compounds (MVOCs) and
particulates (e.g. spores, hyphae, and their
components)
• MVOCs are responsible for musty odor
• Mold related irritant reactions involving eyes,
upper and lower airways may be transient
symptoms and signs persisting for weeks after
exposure, and neurologic, cognitive or systemic
complaints
• (e.g. chronic fatigue) should not be ascribed to
irritant exposure (Bush et al JACI 06)
31. Immune Dysfunction
• Exposure to Molds and their products
does not induce a state of immune
dysregulation (immune deficiency or
autoimmunity)
33. Patient workup, Lab assessment
• Measurement of antibodies to specific molds
has scientific merit in the assessment of IgE
mediated allergic disease, HP and ABPA
• Presence of antibodies to molds can not be
used as a marker to define dose timing or
location of exposure.
• Testing of antibodies to mycotoxins is not
scientifically validated and should not be relied
on
34. Measurement of molds and mold
product exposure in the patients
environment
• Air testing is the most relevant measure of
exposure and is reported as CFU or spore/m3
• Simultaneous indoor vs. outdoor fungal spore is
necessary to interpret mold exposure
• Total fungal spore greater in concentration
indoors than outdoor air might be evidence of
increased fungal spores indoors
• Bulk surface and within wall cavity
measurements don't necessarily provide a
measure of exposure
36. Controversies in fungal disease
• The overwhelming majority of claims for
illness that generate litigation are based
on the presence of any indoor molds and
non specific symptoms
• Often times without objective physical
findings and lack of specific relevant
laboratory supporting data
37. Published mold exposure studies
Reference History attributed to mold Affected building and specific
exposure mold implicated
Brunkreef 1989 6273 children respiratory Homes total mold spores count
questionnaires no controls
*Strachan 1990 Children with asthma wheezing Homes total mold spores count
more in home units higher mold
counts. Spirometry performed
Johanning 1993 43 workers questionnaires no Office building stachyboytrus
control subjects species
Hodgosn 1998 197 workers questionnaires case Office building aspergillus
control study control building was penicillium stachyboytrus
not tested for mold quantitation
*Santilli and rockwell 2003 Rhinitis questionnaire 85 students Two schools total mold spores
and teachers
Cooley 1998 622 adult workers at 48 schools Schools penicillium
with indoor air quality complaints stachyboytrus
no control subjects
38. Sick Building Syndrome
• The term "sick building
syndrome" (SBS) is used
to describe situations in
which building occupants
experience acute health
and comfort effects that
appear to be linked to
time spent in a building,
but no specific illness or
cause can be identified.
39. Sick Building Syndrome
• A 1984 World Health Organization Committee
report suggested that up to 30 percent of new
and remodeled buildings worldwide may be the
subject of excessive complaints related to indoor
air quality (IAQ)
• The causes usually inadequate ventilation,
biological contaminants, chemical agents and
the symptoms improve on leaving the
environment
40. Stachybotrys
• 45 young infants (most under
6 months old), in the eastern
neighborhoods of Cleveland,
who had Pulmonary
Hemorrhage (16 kids died)
appears to be caused by
something in their home
environments, most likely
toxins produced by an unusual
fungus called Stachybotrys
chartarum or similar fungi
Centers for Disease Control and
Prevention. Acute Pulmonary
Hemorrhage/Hemosiderosis among Infants-
Cleveland, January 1993-November 1994.
Morbidity and Mortality Report, Vol. 43, No.
48, December 9, 1994
41. The Case of Stachybotrys
• Requires substantial humidity for growth
• Grows on cellulose rich media-examples
wall paper, fiber board , gypsum,
insulation materials, wood pulp, Lint,
carpet, cereal grains, plant, debris flood
damaged buildings with high humidity
• Produces mycotoxins( trichotecenes)
• Similar mycotoxins produced by other
fungi i.e. fusarium, acretonium
42. • In 1931(Ukraine) there was an epidemic
amongst horses who developed stomatitis,
rhinitis, conjunctivitis, pancytopenia, neurologic
disorders, deaths( Massovie Zabouluanie)
• Trichothecenes mycotoxins inhibit protein
synthesis , impair immune function , prolong skin
graft survival, hemorrhagic inflammatory lung
injury.
• (Mahmoudi M, Gershwine. Jr of Asthma
37(2)191,2000)
43. • The contaminated buildings had
considerably higher indoor mold counts
than outdoor counts( IOM report 2004)
• Several clinical studies report significant
respiratory disease in schools, office
buildings, court houses and homes in
many instances Stachyboytrys was
isolated (Goldstein GB, Jaci Sep 2006)
44. Air conditioner Mold Contamination
• Automobile air
conditioner contamination
with molds and
exacerbation of
respiratory allergies;
Kumar et al NEJM 1984
• Hypersensitivity
pneumonitis due to air
conditioner
contamination; Kumar et
al NEJM 1983
45. Mold remediation
• DRY QUICKLY
– Dry items before mold grows, if possible. In most cases, mold will not grow if wet
or damp items are dried within 24-48 hours
• ASSESS MOLD PROBLEM
– Are there existing moisture problems in the building?
– Have building materials been wet more than 48 hours?
– Are there hidden sources of water, or is the humidity high enough to cause
condensation?
• REMEDIATION PLAN
– How the water or moisture problem will be fixed so the mold problem does not
recur.
– How the moldy building materials will be removed to avoid spreading mold
• MOLD REMEDIATION PROCEDURES
– Damp wipe with bleach and detergent mixed one cup to a gallon of water avoid
mixing with ammonia ( i.e. cleaning detergents)
46. Rebuttal of position paper on Mold
Allergy
• (JACI-correspondence, vol 118, No3, sep 2006)
• The authors of the position paper had conflict of interest
• Respirable trichotehecene mycotoxins can be
demonstrated in the air of stachybotrys chartarum
contaminated buildings
• Trichothecene mycotoxin has been shown to cause
nausea vomiting, low blood pressure, drowsiness,
ataxia, mental confusion
• Similar symptoms reported by individuals from sc-
contaminated buildings (Straus, Wilson, JACI 2006)
• 93 residents of apt. complex with chronic visible mold
contamination reported multiple symptoms (cough 49%,
rhinitis 44%, wheeze 31%, headache 41%.
47. Adverse Health effects of Indoor
Mold exposure
• “ We agree the mold exposure has become a
litigious issue. But are we as physicians to
choose sides ? Or are we to evaluate objectively
the alleged effects of toxic mold exposure? We
suspect your interpretations of where and what
is not supported by scientific evidence might at
least in part represent an agenda for the
defense”
(Lieberman A, JACI Sep 2006)
