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Also please read:
The Impact of Environmental Molds in the Home
Anthony Montanaro, MD, on medscape.com, 2002
A fascinating review of the potential human health impact of
environmental molds was presented during the recent 60th Annual Meeting of
the American College of Allergy, Asthma and Immunology. In the initial
presentation, undertaken by Elliott Horner, PhD, Microbial
Laboratory Director at Air Quality Sciences, Inc. in Marietta, Georgia, it
was pointed out that environmental molds potentially can result in human
illness by the production of allergens, proteases, beta-glucans, and
volatile organic compounds. Dr. Horner further emphasized that in order for
molds to grow, they require moisture. The temperature tolerance of molds is
extremely variable. The ecologic types of molds are those included in the
classes of phylloplane, which are molds that can grow on leaf surfaces.
These molds include Cladosporium and Alternaria. Soil-based
molds are typified by Penicillium and Aspergillus. Typical
molds found in wood decay include the Basidiomycetes. Indoor molds
typically include Alternaria, Cladosporium, and Epicoccum,
but Dr. Horner pointed out that these are typically from outdoor sources.
Dr. Horner pointed out that in interpreting industrial hygiene reports on
mold measurements, colonization vs contamination must be determined. When
mold contaminates, the mycelia elements will actually penetrate the
substrate. The mycelium is connected to the conidiophore, which is the
reproductive structure of the mold. The food source for fungal growth in
buildings may include cellulose, which can be found in ceiling tile,
insulation, sheetrock, as well as wood and dirt.
Biology of Mold in the Home
Dr. Horner reviewed potential detection methodology for molds. These
include the use of direct microscopy or culture-based methods. Dr. Horner
stated that use of "settle plates" are no longer considered a reliable
methodology. Dr. Horner further noted the importance of taxa identification,
which is much more important than the absolute number of colony-forming
units. Taxa identification may allow comparisons of indoor vs outdoor taxa.
Doing an Effective Home Assessment
M. Joseph Fedoruk, MD, of Exponent and Associate Clinical
Professor at the University of California, Irvine, California, further
elaborated on the importance of home inspections when evaluating potential
mold contamination. Dr. Fedoruk pointed out that the home inspection
industry is essentially unregulated. He noted that many home inspectors for
mold contamination, in fact, are qualified only by attending a meeting
without any subsequent testing. Dr. Fedoruk noted the importance of visual
inspection of potential moisture intrusions, including inspection for the
presence of staining or discoloration. He also pointed out that odor
detection can be quite important and noted that "if you can smell mold, you
have a problem." Dr. Fedoruk also reviewed air testing methodology surface
dust analysis and noted that, in many cases, "destructive testing" is
necessary. He pointed out that this destructive testing requires actual
destruction of walls or floors.
Dr. Fedoruk also highlighted the importance of measuring both indoor and
outdoor levels of molds as has previously been noted. He further pointed out
that both complaint and noncomplaint areas of homes must be evaluated. He
re-emphasized that both direct microscopy as well as culture identification
must be undertaken. Dr. Fedoruk also mentioned that a specific number of
colony-forming units are rarely of any benefit.
Evaluating Patients for Mold Exposure
Emil J. Bardana, Jr., MD, presented the Jean S. Chapman
Keynote Lecture on the potential human health effects of mold contamination.
Dr. Bardana presented the historical background of mold sensitivity by
pointing out that indoor air quality problems had actually begun in
approximately 1973, following the oil embargo and subsequent efforts to
conserve energy. Subsequently, in 1994, a paradigm shift had occurred in
which individuals who had previously been diagnosed with "sick building
syndrome" were subsequently informed that they were potentially suffering
from "toxic mold syndrome."
Dr. Bardana highlighted the fact that in any well constructed home
without evidence of water contamination, significant levels of airborne
fungi can be measured. Dr. Bardana noted that these airborne fungi typically
reflect outdoor levels of fungi. Furthermore, it was noted that fungi are
ubiquitous and, in fact, account for at least 25% of the earth's biomass.
Dr. Bardana again emphasized that while there were guidelines for the
assessment of mold contamination in homes, there had been no uniformity or
agreement of any specific level that could potentially result in human
disease. In addition, there has been no established dose-response
relationship between mold levels and human disease. Dr. Bardana gave
examples of sawmills that had been evaluated that revealed workers without
symptoms exposed to 1.5 M cfu/m3. In addition, there have been
studies of farmers without symptoms who were exposed to 120 M cfu/m3.
Dr. Bardana reviewed the 6 types of human responses associated with mold
exposure. These responses include:
- Potential irritant effect, which at best is mild and transient and may
be associated with exposure to beta-1,3 glucans or volatile organic
- Nonspecific respiratory symptoms, which are poorly correlated to
airborne fungal levels;
- Allergic sensitization, which is usually not considered to be severe
and is usually not considered to be a major problem and is more
problematic with outdoor exposures;
- Fungal infections, which mostly arise from outdoor sources and may
occur from exposure to soil-based saprophytic fungi;
- Exposure to mycotoxins, which have recently been described. There are
currently more than 300 mycotoxins that have been described that are low
in molecular weight and nonvolatile in nature. Dr. Bardana highlighted the
fact that all species of fungi are capable of producing mycotoxins; and
- Psychogenic effects, which can occur when an individual perceives that
he or she is being harmed by the effects of fungal exposure.
These potential health effects of indoor fungal bioaerosol exposures are
highlighted in a recent publication.
Finally, Dr. Bardana outlined the recent health concerns of individuals
exposed to species of Stachybotyrs. Dr. Bardana reviewed the fact
that Stachybotyrs has been referred to as toxic or "black mold." Dr.
Bardana highlighted the fact that there were, in fact, no bona fide reports
of human infection in the medical literature. Reports of potential allergic
disease have been characterized as being inconclusive. In fact, Dr. Bardana
highlighted a recent observation that pointed out that half of blood donors
have immunoglobulin (Ig) G antibody to Stachybotyrs, with 9% of these
individuals having evidence of IgE to Stachybotyrs. Given the
ubiquitous nature of Stachybotyrs, it is not considered to be unusual
that one would observe these findings. Dr. Bardana further noted that there
have been no reports of allergic alveolitis or sinusitis due to
Stachybotyrs. Although there have been recent concerns regarding the
potential of "toxic encephalopathy and Stachybotyrs," Dr. Bardana
pointed out there has been "no scientific link." Dr. Bardana suggested
further reading on the potential role of Stachybotyrs in a recent
publication by the American Industrial Hygiene Association.
The potential human effects of mold exposure have led to a new legal
industry with devastating impact on the immune insurance industry. A recent
example of mold litigation occurred in Texas, where a jury determined that
an insurance company acted fraudulently and in bad faith when fixing water
damage in a 22-room mansion. This particular case resulted in
a delay in the repair of what many considered a relatively small innocuous
water leak but awarded the homeowner with a multimillion dollar verdict. It
is pointed out that the number of mold-related claims in the State of Texas
alone rose from 7000 in the year 2000 to 37,000 in the year 2001! These
claims were further fueled by the presence of tropical storm Alison, which
occurred in June of 2001 and affected the Houston metropolitan area for
approximately 2 days, resulting in massive flooding along the Gulf Coast. In
Houston alone, there was a 58% increase in claims, representing 2.96 claims
for every 1000 households. There have been many high profile lawsuits
reported in the press, including that of Johnny Carson's ex-sidekick, Ed
McMahon, who brought suit against his insurance company for 20 million
dollars in April of 2002 for the death of his dog, which was alleged to have
been due to exposures to mycotoxins from Stachybotyrs chartarum.
Sports stars have not been immune from this weight of litigation. Michael
Jordan has required that his home in the Washington, DC area at the
Ritz-Carlton Hotel have extensive renovation due to the perception of
mold-related problems. The celebrity status of some of these claims has
resulted in increased hysteria in the general population. The ultimate
effect of this hysterical response to suspected phoma-related problems has
had a tremendous impact on the insurance industry, with more than 1.3
billion dollars spent in 2002 to settle lawsuits and mold-related damages.
Unfortunately, the response from the insurance industry has clearly been to
settle cases and to attempt to no longer put themselves at risk of covering
potential mold-related damages. Recently, the State Farm Mutual Automobile
Insurance Company has attempted to eliminate coverage from mold-related
damages in 33 states.
There is little doubt that mold can indeed result in human disease. Mold
exposure can result in allergic rhinitis, allergic asthma, allergic sinus
disease, and pulmonary hypersensitivity pneumonitis. Despite the fact that
there is no doubt that mold can result in human disease, aside from these
specific incidences, there was very little data to support human disease
caused by "mycotoxins." All of the presenters emphasized the need for
further research in this area.
- Horner E. General sessions. Environmental molds: biology of molds.
Program and abstracts of the 60th Annual Meeting of the American College
of Allergy, Asthma and Immunology; November 15-20, 2002; San Antonio,
- Fedoruk J. General sessions. Environmental molds: home assessments:
how they are done. Program and abstracts of the 60th Annual Meeting of the
American College of Allergy, Asthma and Immunology; November 15-20, 2002;
San Antonio, Texas.
- Bardana EJ. General sessions. Environmental molds: Jean A. Chapman
Lecture. Health effects of mold exposure and how to evaluate patients who
think they have it. Program and abstracts of the 60th Annual Meeting of
the American College of Allergy, Asthma and Immunology; November 15-20,
2002; San Antonio, Texas.
- Fung F, Hughson WG. Health effects of indoor and fungal bioaerosol
exposure. Proc Indoor Air. 2002;1:46-51.
- Page EH, Trout DB. The role of Stachybotyrs mycotoxins in
building-related illness. Amer Indus Hyg Assoc J. 2001;62:644-648.
- Sharp R. Mold getting a costly hold on homes. USA Today. June 19,
- Cahill SF. For some lawyers mold is gold. Amer Bar Assoc J. December
Copyright © 2002 Medscape.
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