In the outdoor environment molds are ubiquitous. Moist conditions involving drywall, wood, carpeting, or paper material are the proliferation medium in the indoor environment for toxic molds. Since Americans spend 75 to 90% of their time indoors, the risk of exposure to toxic molds that may grow indoors is increased (R- 1). Toxic molds enter the indoor environment through doorways, windows, heating and ventilation systems, and air conditioning systems, given the appropriate circumstances. Spores from toxic molds in the air deposit on people, animals, clothing, shoes, and bags, turning them into common and potential carriers of toxic molds into the indoor environments (home and office) (R-2).
Indoor environments that contain excessive moisture such as leakage from roofs, walls, plant pots, or pet urine cause proliferation and development of molds. The most common molds which are found indoor are Cladosporium, Penicillium, and Aspergillus. In order to proliferate, molds need nutrients which are commonly present in building environments such as cellular substrates in paper, paper products, cardboard, ceiling tiles, wood, wood products, drywall, carpet, fabric, insulation materials, wallpaper, paints, and dusts. Some of the indoor molds have the potential to produce extremely toxic materials called toxic mycotoxins (R-3, 4). Those toxic molds which have the potential of producing toxic materials include Fusarium and Stachybotrys, among others.
Depending on the quantities produced and consumed, mycotoxins can cause acute or chronic toxicity in animals and humans. Home dampness with resulting mold growth may be associated with several medical conditions (one or sometimes all) including immediate hypersensitivity reaction, hypersensitivity pneumonia, or what has been described as "humidifier fever". Clinically, I see these patients with recent onset asthma, recent onset sinusitis, and/or recent onset skin rashes (R-5, 6). Several studies have shown a clear correlation and association between the occurrence of molds in the inside air environment, dampness in the indoor environment, and the symptomatology of the skin, and respiratory tract, especially in children. This has been summarized in an interesting study published in the American Journal of Epidemiology by Robert E. Dales (R-7).
Since the symptoms in this study were comparable to the symptoms described with humidifier fever and mycotoxicosis, the authors suggested a common pathogenic and etiological mechanism (R-7, 8), toxic molds being one.
The role of indoor molds, especially the most toxic one - Stachybotrys, has been shown recently in a scientific paper published in the journal Pediatrics R-9). The authors described a child with pulmonary hemorrhaging where Stachybotrys was isolated from the lung. Indeed, epidemiological data to support the connection between toxic mold exposure and lung hemorrhage was published in the scientific literature from Cleveland, Ohio, which was later examined by the Center for Disease Control (R-10, 11).
The scientific data clearly demonstrates a high spore count of the toxic mold Stachybotrys in 9 out of 10 of the houses where these infants lived, and 5 infants had recurrence of the bleeding of the lungs on reentry to their homes, implicating that the fungus is a potential agent in the pathogenesis of infantile pulmonary hemorrhage. The study by Okan Alidemir, et al, (R-9) shows the isolation of the toxic mold Stachybotrys atra from the BAL fluid of a child with pulmonary hemorrhage, thus connecting the epidemiological data and the historical data in this case report with objective findings of Stachybotrys from lung fluids. In the scientific paper entitled "Stachybotrys: Mycotoxin Producing Fungus of Increasing Toxicological Importance" (R-12), the investigators concluded "Current data on the toxicology of mycotoxins produced by Stachybotrys demonstrates that this group of mycotoxins is capable of producing immunosuppression and inflammatory insults to the gastrointestinal and pulmonary system".
While it is an ideal situation to have "statistical firmness", in medicine the clinician establishes a diagnosis and causation based an known and accepted factors where statistical firmness is not a prerequisite. (R-13, 14). The causal clinical association between allergic reaction to the sinuses in the form of rhinitis, sinusitis, or asthma and indoor air mold exposure has been very well documented in the scientific literature in an early review by Susan Gravesen (R 15).
That indoor moisture and toxic molds represents a public health issue is described in the scientific paper by Hodgson (R- 16). These authors report an outbreak of disease associated with exposure to these toxic molds in 2 buildings in Florida.
The specific buildings were a new court house and office building which were constructed between 1986 and 1989. Within weeks after moving in patients described mucous: membrane irritation fatigue. headaches. and chest tightness. Moisture problems such as window and roof leaks have been described as starting in 1987 and persisting through 1992. Utilizing epidemiological methodology the investigators concluded that this outbreak represents a likely human response to inhaled fungal toxins in indoor air environments.
What to do when you suspect toxic molds as a cause for symptomatology.
First and most importantly is to see a doctor who specializes in the fields of internal medicine, occupational medicine and toxicology with the understanding of building-related illnesses and, toxic molds. The doctor will have to rule out other diseases, perform laboratory studies, and provide an opinion as to whether these symptoms can be and have been described with toxic molds. Upon determination that these symptoms may be related to mold exposure, you should have an industrial hygienists inspect your residence or alternatively office/work place (depending on where the suspected mold resides) to do a careful investigation of any water damages, and air counts both inside and outside at several locations for toxic molds and spores.
A well-trained industrial hygienist will not only take air counts but also will go under and behind the walls and/or carpeting where the water damage is anticipated to be in order to further evaluate for mold spores and mold growth. Once toxic molds are discovered, depending on the damage that occurred, either expert remediation (with appropriate protective devices and removal of the inhabitants from the area) or at times destruction and rebuilding of the damaged house or building area is necessary.
During the last 5 years I have treated patients with various mold related illnesses contracted at either industrial buildings such as old buildings, schools, and governmental offices, as well as residences, all of which have suffered either faulty ventilation, water damages, or both. The most common presenting symptoms are those of 1) cough, 2) asthma, atypical asthma, 3) nasal congestion, 4) sinusitis/rhinitis, 5) skin rashes, and 6) generalized fatigue. On many occasions the patients presented with neurological symptoms such as headaches, reduced concentration ability, and memory loss. The patients may present with only one symptom (such as sinusitis) or a combination of symptoms. For causation determination the doctor should use the methodology commonly used in diagnosing and treating this condition and utilize, among others, careful review of other causes, temporal relationship, and a biological plausibility that mold can cause these types of diseases.
ReferencesLeibowitz MD, Health Effects of Indoor Pollutants, Annual Review of Public Health, I 983, Volume 4, 203-221
Miller JD, Fungi as Contaminants in Indoor Air, Atmospheric Environment 1992, Volume 26, 2163-2172
Burge HA, Toxicogenic Potential of Indoor Microbial Indoor Aerosols, In: Short-Term BioAssays in the Analysis of Complex Environmental Mixtures, NY, NY, Plano Press, 1987
Henry KM, et al, A Review of Mycotoxins in Indoor Air, Journal of Toxicology and Environmental Health, 1993, Volume 38, pages 183-198
Edward JH, et al, Humidifier Fever, Thorax, 1977, Volume 32, 653-663
Arundel AV, et al, Indirect Health Effects of Relative Humidity in Indoor Environment, Environmental Health Perspective, 1986, Volume 65, pages 351-361
Dales RE, Respiratory Health Effects of Home Dampness and Molds Among Canadian Children, American Journal of Epidemiology, Volume 134, Number 2, pages 196-203
May JJ, et al, Organic Dust Toxicity, Pulmonary Mycotoxicosis Associated with Silo Unloading, Thorax, 1986, Volume 41, pages 919-923
Okan Alidemir, et al, Pediatrics, 1999, Volume 104, pages 964-966
Montana E, et al, Pediatrics, 1997, Volume 99(1)
Atzel RA, et al, Acute Pulmonary Hemorrhage in Infants Associated with Exposure to Stachvbotrys, Stachybotrys Atra and Other Fungi. Archives of Pediatrics and Adolescent Medicine, 1998, Volume 152, pages 757-762
Stachybotrys: Mycotoxin Producing Fungus of Increasing Toxicological Importance, Clinical Toxicology, Volume 36, pages 79-86, 1998
Brautbar N, Science and the Law: Scientific Evidence, Causation, Admissibility, Reliability - "Daubert" Decision Revisited, Toxicology and Industrial Health, 1999, Volume 15, pages 532-551
Brautbar N, Scientific Evidence, Chapter 15, pages 92- 121, In: Ethics in Forensic Science and Medicine, MA Schiffman (ed), Charles C. Thomas Publisher, Ltd, 2000
Gravesen S, Fungi as a Cause for Allergic Disease, Review Article, Allergy, 1979, Volume 34, pages 135-154 Hodgson, Building-Associated Pulmonary Disease from Exposure to Stachybotrys Chartarum and Aspergillus Versicolor, Journal of Occupational and Environmental Medicine, Volume 14, Number 3, March 1998, pages 241-249
Nachman Brautbar, M.D. is a board-certified internist and nephrologist, with a specialization in toxicology. His list of academic appointments include Associate Professor of Pharmacology and Clinical Professor of Medicine at the University of Southern California, School of Medicine. He specializes in the toxicological and internal medicine aspects of injury in the workplace, product liability, personal injury, standard of care.
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