Mold and Their Health Effects

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Mold and Their Health Effects

• Edward J Peters, MD
• Austin Texas
• epeters_at_austinallergy.com

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Fungi Toxic Killers or Unavoidable Nuisances?

• Court finds insurer at fault in mold case 32
  million awarded

The Austin American-Statesman, 6-2-2001
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Austin American-Statesman 1-14-02
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Fungi

• Filamentous organisms that absorb food from the
  environment after external digestion.
• Cell walls are made of a variety of materials
  that carry some antigenicity.
• Most have a melanin pigment in the cell wall to
  protect from UV light.
• Glucans in the cell wall are endotoxin-like and
  irritating and stimulate the immune system.

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Definition Molds

• Common term for the multicellular fungi that grow
  as a mat of filaments.
• Familiar fungi yeasts, rusts, smuts, mushrooms,
  puffballs, and bracket fungi.
• Exposure to fungi and their spores is unavoidable
  except in stringent air filtration and isolation
  situations (laminar flow units for bone marrow
  transplantation).

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Are Fungi Pathogenic?

• In healthy individuals, most fungi are not
  pathogenic.
• Superficial infections of the feet, groin, nails
  and skin are the most common infection.
• Limited number of fungi Blastomyces,
  Coccidiodes, Cryptococcus, and Histoplasma can
  cause a severe illness in healthy individuals.

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Allergenic Substances

• All fungi produce some allergenic substances
  (enzymes) in the process of food digestion.
• Mycotoxins and antibiotics can be released into
  the environment during growth.
• 10 of the entire population and 40 of asthmatic
  patients are fungal-sensitive.

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What do we know so far?

• Lots of molds are black.
• Exposure is unavoidable.
• Most fungi have never caused disease in humans.
• Lots of people but not all are allergic to fungi.

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Indoor Levels of Fungi

• In a home without water intrusion, the levels of
  airborne fungi will be 40-80 of the outdoor
  levels.
• Outdoor concentrations vary widely by geographic
  area, season, atmospheric conditions (humidity,
  wind), and even time of the day.

Verhoeff AP et al Allergy 1992 4783-91.
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Sampling of Indoor Air Problems

• No uniform numeric standards for indoor sampling
  data.
• No known dose-response relationship between a
  specific mold and any human health effects.
• Exposure to fungi occurs indoors as well as
  outdoors, thus there is no way to ascribe a
  health effect or sensitivity to any specific
  exposure or time period.

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Indoor Ambient Air Fungal Concentrations

• In 820 residences without health complaints,
  indoor fungal counts averaged 1252 CFU/m3 and
  outdoor were 1524 CFU/m3.
• In sawmills the airborne concentrations have been
  reported as high as 1.5 million CFU/m3 without
  health effects reported.

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Respiratory Disease Caused by Fungi

• Allergic asthma and allergic rhinitis are the
  commonest problems.
• Allergic Fungal Diseases
• ABPA allergic bronchopulmonary aspergillosis
• AFS allergic fungal sinusitis
• Invasive Fungal Diseases
• Immunocompromised hosts (bone marrow transplant
  recipients/diabetes)

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Hypersensitivity Pneumonitis

• Results form the inhalation of significant
  quantities of fungal (or other) proteins.
• Occupational exposures are the most common cause.
  Malt Workers Lung (Aspergillus) and Cheese
  Washers Lung (Penicillium) are due to fungal
  proteins.
• Characterized by acute febrile illness and
  pneumonitis.

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HP Case Report

• 82-year-old female, hospitalized with acute RLL
  pneumonia, and symptoms cleared only to quickly
  return when she went home.
• Repeat chest X-ray 2 weeks later R and L lung
  infiltrates.
• Pulmonary function studies showed a FVC of 56
  and FEV1 of 58.

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Hypersensitivity Pneumonitis
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CT Scan Changes in HP
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Hypersensitivity Pneumonitis
Jacobs et al Ann Allergy Asthma Immunol 2002
8830
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Did I lose you yet?

• All homes (buildings) have some fungi especially
  if there is some water intrusion.
• No standard way to sample airborne fungi.
• Fungal diseases are either due to allergy or
  hypersensitivity in healthy people.

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Sick Building Syndrome

• Poorly defined set of symptoms (often sensory)
  attributed to occupancy of a building.
• Investigations generally find no specific cause
  for the complaints.
• Toxic Mold (Stachybotrys) and its mycotoxins
  have been blamed but no causal relationship has
  been found.

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Mycotoxins

• Metabolites from food digestion.
• Aid the fungi compete for food by inhibiting
  growth of other organisms.
• Low molecular weight and nonvolatile (not in
  air).
• Health effects of mycotoxins comes from the
  animal or (rarely) human ingestion data, but not
  inhalation.
• Penicillin and cyclosporine are examples of
  important mycotoxins.

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Airborne Fungi in Buildings

• Highest fungal levels (indoors and outdoors) from
  1,717 buildings were found in the Southwest
  region.
• Most common culturable airborne fungi were
  Cladosporium, Penicillium, and Aspergillus.
• Stachybotrys chartarum was identified in the air
  of 6 of the buildings.

Shelton et al Appl Environ Microbiol
2002681743-53.
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Deuteromycete Stachybotrys Fatal Fungus

• Spores are found worldwide on cellulose materials
  such as foam insulation, fiberboard, carpets, and
  even tobacco in cigarettes.
• Mean concentration of 0.3 spores/m3 in 2.9 of
  homes in southern California.
• In all cases, Stachybotrys is only a minor
  component of the mycoflora.

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Deuteromycete Stachybotrys Fatal Fungus

• Slow-growing fungi that competes poorly with
  other rapidly growing fungi.
• Recovered from air samples in 3-6 of surveys.
• Saprophytic mold that grows on nonliving organic
  material (cellulose) in high humidity, and low
  nitrogen content.
• Stachybotrys is recovered from water damaged
  building surfaces, but in low concentrations
  compared to Pencillium and Aspergillus species.

Terr AI. Ann Allergy Asthma Immunol
200187S57-63.
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Human Diseases Caused by Stachybotrys

• No case of a human systemic or local infection
  caused by any species of Stachybotrys.
• One case of asthma improving in a 4 year old who
  was lived in a home that had Stachybotrys in
  water-damaged carpet, but not in air samples.
• Possible toxicity to humans from ingestion of
  Stachybotrys exists as there are reports of
  horses dieing as the result of ingesting
  contaminated fodder in the 1930-1940s in Russia.

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Human Disease Caused by the Inhalation of Killer
Mold

• In 1986, five family members and their maid
  suffered from a variety of maladies. These
  authors claimed that there was a trichothecene
  mycotoxin in the air which caused the illnesses.
• Two additional reports of work exposure to a
  variety of molds, including S. atra, in 1996 and
  1998 resulted in various non-specific complaints
  and a single case of interstitial lung disease
  based on history.
• Serum IgE and IgG to various fungi in all these
  cases were either negative or did not correlate
  with the exposures.

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Acute Pulmonary Hemorrhage in Infants

• Geographic cluster of 10 cases between the ages
  of 1 and 8 months in Cleveland, OH in 1993-1994.
• Successfully treated in the hospital, but
  recurred in five of the infants shortly after
  returning home.
• No other household members were effected.
• Most lived in older, water damaged housing and
  had household exposure to Stachybotrys and other
  molds.

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Killer Mold is not a killer?

• Blamed for many problems (neurologic, memory,
  headaches) which have not been substantiated.
• Killer Mold is only rarely found in the air and
  its mycotoxins are not breathable.
• The term Toxic Mold is misleading as many molds
  are toxic if you ingest them.

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Does Mold Cause Asthma?

• 50 or more of homes of 4625 children reported
  dampness (molds, water damage, or water in
  basement).
• Reported home dampness and mold is associated
  with cough and wheezing, but not clearly
  associated with asthma.
• Pulmonary Function Tests (FVC or FEV1) were not
  effected by home dampness.

Brunekreef et al Am Rev Respir Dis 1989 1401363
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Household Mold Exposure in the First Year of Life

• 880 infants at high risk for asthma (sibling with
  asthma) were followed for the first 12 months of
  life.
• Cladosporium (62) and Penicillium (41) were the
  most commonest fungi found in these homes.
• Highest Penicillium levels (gt1,000 CFU/m3) were
  associated with wheeze and cough.

Gent et al Environ Health Perspect
2002110A781-A786.
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Effects of Indoor Fungi and Dust Mite Allergen
Levels on Adults

• Bronchial hyperreactivity (BHR) and history of
  wheezing were evaluated in 485 adults who
  participated in the ECRHS.
• 77 of homes had levels of gt10 µg/g dust mite
  allergen and 55 had airborne fungal counts gt500
  CFU/m3.
• High levels of mold associated with BHR, but
  subsequent studies showed no relationship of
  levels of fungi (only visible mold) to Peak
  Flow.

Dharmage et al Am J Repir Crit Care Med
200116465-71. Dharmage et al Clin Exp Allergy
200232714-20.
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Perennial AllergensDust Mite
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Perennial AllergensGerman Cockroaches
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Dust Mite Exposure in US Beds

• Dust mite allergen is a major risk factor for
  allergic sensitization and asthma.
• Measurable dust mite allergen was found in bed
  dust of 84 of 831 homes with children.
• 46 had levels associated with allergies, and 24
  had levels seen in asthma (gt10 µg/g).
• Older single family homes, musty odor, and high
  bedroom humidity predicted higher levels.

Arbes et al J Allery Clin Immunol 2003111408-14
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Conclusion

• Fungi are a major component of the biosphere and
  adapt well to varying conditions, such as
  water-damaged building materials.
• Mycotoxins are produced by most fungi and
  Stachybotrys is not unique in this regard.
• Stachybotrys remains a potential health risk, but
  human disease related to inhalation has not been
  established.
• Furthermore, reports of subjective illnesses
  attributed to Stachybotrys are not compelling.

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Would you live in these homes?
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American Academy of Pediatrics Recommendations

• Prompt cleaning of water damaged areas with
  dilute bleach.
• Parents of infants with Idiopathic Pulmonary
  Hemorrhage should be questioned about mold, but
  testing of the environment for specific molds is
  usually not necessary.
• Pediatricians should be aware that there is no
  method to test humans for toxigenic molds.

Pediatrics 1998101712-4
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Do we have to destroy everything because of mold?

• No scientific studies support the need to destroy
  personal belongings or contents of rooms and
  buildings because they were in the environment.
• Cleaning of the HVAC units with 0.25
  Glutaraldehyde solution reduced fungi growth
  (CFU) for a least 8 weeks.

Garrison et al Ann Allergy 199371548-56.
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Evaluation of Patient with Toxic Mold Symptoms

• Many patients are CERTAIN that mold exposure has
  caused the problem.
• Mold exposure advocates (physicians) have
  inappropriately promoted this idea.
• A thorough evaluation often uncovers a
  pre-existing problem or underlying condition as
  the cause.

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Evaluation and Work-up of Mold Exposure

• Comprehensive medical history and complete
  physical examination.
• Obtain and review all prior pertinent medical
  records which can sometimes be voluminous.
• Laboratory evaluation may include a variety of
  tests depending on the type of complaint and
  exposure.

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Laboratory Testing in Mold Exposure

• CBC, chest x-ray, pulmonary function studies, and
  some testing for common allergens (skin testing
  or serologic testing) are usually necessary and
  indicated.
• Nasal smears, CT scan of the sinuses, and general
  chemistry screens are often obtained.
• Methacholine challenge for hyperreactivity can be
  very helpful when spirometry is normal.

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Role of Consultants in the Evaluation of Mold
Exposure

• Indoor air quality assessment by a Certified
  Industrial Hygienist may be necessary especially
  in medical-legal evaluations.
• Rely on cultures of airborne fungi (CFU/m3) and
  do not rely on spore counts or bulk specimens if
  you are trying to evaluate the health risk.

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Any Questions?