Understanding Mold Related Illnesses

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Understanding Mold Related Illnesses

• University of North Texas Health Science Center
  in Fort Worth
• Stevan Cordas DO MPH
• Occupational, Allergic and Environmental Medicine.

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Candida From a Skin Lesion
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A. Flavus Conidia
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Aspergillosis

• 900 species of aspergilla. 75 of human infection
  caused by A. fumigatus. A flavus next and more
  likely to disseminate. Usually in neutropenic or
  immunocompromised hosts (esp. HIV)
• May cause 3 types of problems. Allergic
  Localized - Invasive

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Different Types of Allergic Patterns to
Aspergillus

• The conidia of Aspergillus can precipitate
  bronchial asthma.
• Allergic rhinitis.
• Allergic sinusitis.

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Different Types of Allergic Patterns to
Aspergillus

• Allergic bronchopulmonary aspergillosis (ABA)
  Transient atelectatic lines on x ray, fever,
  eosinophilia sputum, blood. More persistent
  bronchial obstruction.
• Extrinisic allergic bronchiolitis (EAB) - A.
  clavatus 4 hours after breathing malt or grain.
  Repeated bouts can lead to pulmonary fibrosis.

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Invasive Aspergillosis in HIV
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Granulomatous Response and Mycelia of A.
Fumigatus.
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Aspergillus of the Skin
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Treatment of Various Aspergillus Infections.

• ABA Corticosteroids.
• EAE Same avoid moldy grains.
• Invasive liposomal Amphotericin B, regular
  Amphotericin B or itraconazole.
• Aspergilloma Removal if massive hemoptysis
  occurs only.
• Resection with Sino naso orbital type may be
  required. Usually A. flavus.

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Potential Indoor Agents

• Fungal products
• Bacteria and their endotoxins
• Viruses
• Volatile Organic Compounds
• Other Materials outgassing
• Heavy metals (mercury)

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Molds

• Over a 100,000 types
• Separate kingdom
• Indoor molds include Cladosporium,Penicillium,
  Aspergillus, Alternaria, Wallenia,and less
  commonly Stachybotrys chartarum (the famous black
  mold)

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Products From Molds

• Allergens
• Endotoxins,
• 1-3 B-D- Glucans
• Mycotoxins
• Ergosterols
• Extracellular Polysaccharides
• VOC
• Enzymes

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Exposures From Work or Schools

• Of 131.2 Million workers in the US, 70 Million
  work indoors. OSHA reported that 30 of those
  indoors are subjected to poor air quality.
• NIOSH reported that of 104 buildings
  investigated, 42 had water damage.
• 1/3 of our 80,000 schools in the US are in need
  of substantial repair.

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Exposure From Homes

• US Census 1998 indicates that 13 or 10.9 million
  US homes had water damage from inside.
• 16.9 million or 21 of US homes had leakage from
  outside.

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Allergic Statistics

• 50 Million allergic rhinitis cases in US.
• 17.3 Million asthmatics in the US (CDC).
• Expected to double by 2020.
• 15 of asthmatics are reported to be from
  occupational causes.
• 450 Substances in the workplace that can cause
  occupational asthma.
• Molds are the second most common allergy in the
  US after dust mites.

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Clinical Observations

• A number of investigators are observing patients
  that are not allergic but have similar symptoms.
• In most cases, the symptoms persist as long as
  they are in the moldy environment and get better
  eventually if they leave it.
• We are interested in investigating and helping
  those cases that dont seem to improve on their
  own.

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Mycotoxins

• Over 400 now identified.
• 5 types Ochratoxins (nephrotoxic), Rubratoxins,
  Fumonisins (produce many harmful types),
  Aflatoxins (the most carcinogenic natural
  substance known), and trichothecenes.
• One fumonisin was weaponized T2.

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T2
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Mycotoxins

• Stachybotrys produces a number of trichothecene
  mycotoxins that inhibit DNA and other protein
  metabolism, Reduce immune responses and cause
  cell apoptosis. There are 15 species of this
  mold.
• The mycotoxins are Satratoxins, Roridin,
  lactams, Isosatratoxin, Verrucarin, Epiisororidin
  and Trichoverrol B.

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Stachybotrys Chartarum

• Uses cellulose as its carbon source (wall board,
  sheet rock, paper, ceiling tile).
• Not very allergenic.
• Implicated in infant Hemosiderosis and hemorrhage
  (CDC).
• 15 strains not all produce mycotoxins.
• Depends on the strain and moisture.

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Clinical Observations

• The role of mycotoxins creating illness is
  controversial.
• Evidence leans toward it being valid in some
  cases with high exposure clinically.
• Many fungi can make mycotoxins including
  Tricoderma, Menmoniella, Aspergillus, Fusarium,
  and Penicillium in addition to S. chartarum.

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Clinical Observations

• The presence of mold as observed or bulk sampling
  does not correlate with clinical symptoms well.
  There must be the presence of spores, fragments
  or metabolites in the air or direct contact or
  ingestion of the material to make problems.
• Problems develop and vary with atopic status,
  age, state of health and concurrent exposures.

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Some Known Clinical Responses to Fungi.

• Organic toxic dust syndrome Can come from a
  single exposure. Flu-like, not immune mediated.
• Hypersensitivity pneumonitis- Repeated exposures,
  immune mediated. Can lead to interstitial
  fibrosis in rare cases.
• Fungal sinusitis.
• Activation or aggravation of bronchial asthma or
  other allergic manifestations.

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Other Molds of Concern and Their Mycotoxins.

• Aspergillus flavus Kojic acid, 3-nitoproprionic
  acid, aflatoxin B-1, aspergillic acid.
• Alternaria tenuazonic acid, alternariol,
  altertoxins.
• Aspergillus niger naphtha-pyrones, malformins.

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Other Molds of Concern and Their Mycotoxins.

• Cladosporium herbarum cladosporic acid.
• There are over 400 more mycotoxins.
• Cryptosporidia transient flu in normal patients.
  Can kill a immunocompromised patient. May respond
  to Diflucan.
• Histoplasmosis Capsulatum. Coccidiomycosis,
  Blastomycosis. Dont forget these.

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Fungal Sinusitis

• Allergic fungal sinusitis
• Chronic invasive fungal sinusitis
• Indolent granulomatous fungal sinusitis
• Fungal ball (mycetoma)
• Acute invasive fungal sinusitis

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Cognitive Impairment Associated With Exposure to
Toxigenic Fungi

• Gordan et al at Mt Sinai School of Medicine have
  shown that 13 out of 20 subjects tested with
  neuropsychological batteries, who were exposed to
  Stachybotrus, have cognitive impairment. This was
  especially in verbal learning, attention/concentra
  tion, set shifting. Also this group had a higher
  number of physical and behavioral symptoms.

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Encephalopathy

• Auger and his team report several cases of toxic
  encephalopathy apparently from neurotoxins from
  indoor molds.

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Cerebral Moniliasis
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Common Symptoms Found in Indoor Mold Exposures.

• Generally non-specific.
• Skin itching, rashes, periorbital swelling.
• GI - Anorexia, diarrhea.
• Muscular pains. Flu-like.
• Low grade fever.

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Common Symptoms Found in Indoor Mold Exposures.

• Respiratory symptoms rhinitis, sinusitis,
  asthma, SOB, chest discomfort, epistaxis.
• Neurologic concentration, memory, fatigue,
  headaches, unsteadiness.

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Diagnosis

• Reasonable suspicion on the part of the health
  care provider or the patient.
• Screening or IAQ testing showing presence of
  toxigenic mold.
• Rule out confounding variables.
• Consider toxigenic and allergic testing to
  confirm correlation.

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Testing

• Blood mycotoxins. PCR, IgE, IgA and IgG fungal
  tests. Precipitins.
• Blood allergy or skin allergy testing.
• General tests to rule out other causes of these
  symptoms. HIV, ANA.
• Pulmonary function testing.
• Imaging studies of sinuses, chest etc. as
  appropriate. Immune studies.
• May test for autoantibodies to glial and neuronal
  tissue.

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Treatment for Indoor Mold Related Symptoms

• Remove source of water or humidity. Keep it below
  55.
• Remove the subject from the environment. In most
  cases it is reversible.
• Remediate using professional assistance.

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Treatment (ctd)

• Recheck IAQ afterwards.
• Palliative therapy, antihistamines, dietary,
  nutritional, emotional, immunotherapy.
• Trial of itraconazole or fluconazole?
• Trial of mold yeast free diet?
• Natural anti fungals - caprylic acid, Pau d
  Arco?

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Experimental Therapies.

• Xolair and Anti IgE RhumAb.
• Valinomycin is produced by a bacterium
  (Streptomyces griseus) living closely associated
  with the fungus Stachybotrys is a poison in sick
  buildings that is being investigated.
• Anidulafungin (Versicor).
• Voriconazole (Pfizer).

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Preventing Mold Buildup.

• Use air conditioner or dehumidifier during humid
  months.
• Be sure home has adequate ventilation, including
  exhaust fans in kitchen and bathroom.
• Use mold inhibitors in paints.

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Preventing Mold Buildup.

• Clean bathroom with mold killing products.
• Do not carpet bathroom.
• Remove and replace flooded carpets.
• Clean small areas with bleach while wearing
  protective mask.
• Seek services of a certified industrial hygienist
  if larger areas are involved.

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Recent Conference on Mycotoxins

• Bioaerosols, Fungi and Mycotoxins Health
  Effects, Assessment, Prevention and Control.
  Edited by Eckhardt Johanning MD 2001, Mount Sinai
  School of Medicine, Department of Community
  Medicine, Fungal Research Group.
• This publication is from the Third International
  Conference on Fungi, Mycotoxins and Bioaerosols
  held Sept 23-25 1998.

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Summary

• Most cases of mold related illness get better
  once the problem is remediated.
• For those remaining, it is useful to determine
  extent of problems objectively and treat in a
  holistic manner (mind and body).
• Education is very important.