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Mold and Their Health Effects

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Human Disease Caused by the Inhalation of 'Killer Mold' ... 'Killer Mold' is only rarely found in the air and its mycotoxins are not breathable. ... – PowerPoint PPT presentation

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Title: Mold and Their Health Effects


1
Mold and Their Health Effects
  • Edward J Peters, MD
  • Austin Texas
  • epeters_at_austinallergy.com

2
Fungi Toxic Killers or Unavoidable Nuisances?
  • Court finds insurer at fault in mold case 32
    million awarded…

The Austin American-Statesman, 6-2-2001
3
Austin American-Statesman 1-14-02
4
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.

5
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).

6
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.

7
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.

8
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.

9
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.
10
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.

11
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.

12
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)

13
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.

14
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.

15
Hypersensitivity Pneumonitis
16
CT Scan Changes in HP
17
Hypersensitivity Pneumonitis
Jacobs et al Ann Allergy Asthma Immunol 2002
8830
18
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.

19
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20
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.

21
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.

22
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.
23
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.

24
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.
25
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.

26
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.

27
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.

28
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.

29
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
30
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.
31
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.
32
Perennial Allergens Dust Mite
33
Perennial Allergens German Cockroaches
34
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
35
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.

36
Would you live in these homes?
37
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
38
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.
39
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.

40
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.

41
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.

42
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.

43
Any Questions?
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