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Understanding Mold Related Illnesses

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Understanding Mold Related Illnesses

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    1. UNTHSC-FW TCOM 1 Understanding Mold Related Illnesses University of North Texas Health Science Center in Fort Worth Stevan Cordas DO MPH Occupational, Allergic and Environmental Medicine.

    2. UNTHSC-FW TCOM 2 Candida From a Skin Lesion

    3. UNTHSC-FW TCOM 3 A. Flavus Conidia

    4. UNTHSC-FW TCOM 4 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

    5. UNTHSC-FW TCOM 5 Different Types of Allergic Patterns to Aspergillus The conidia of Aspergillus can precipitate bronchial asthma. Allergic rhinitis. Allergic sinusitis.

    6. UNTHSC-FW TCOM 6 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.

    7. UNTHSC-FW TCOM 7 Invasive Aspergillosis in HIV

    8. UNTHSC-FW TCOM 8 Granulomatous Response and Mycelia of A. Fumigatus.

    9. UNTHSC-FW TCOM 9 Aspergillus of the Skin

    10. UNTHSC-FW TCOM 10 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.

    11. UNTHSC-FW TCOM 11 Potential Indoor Agents Fungal products Bacteria and their endotoxins Viruses Volatile Organic Compounds Other Materials outgassing Heavy metals (mercury)

    12. UNTHSC-FW TCOM 12 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)

    13. UNTHSC-FW TCOM 13 Products From Molds Allergens Endotoxins, 1-3 B-D- Glucans Mycotoxins Ergosterols Extracellular Polysaccharides VOC Enzymes

    14. UNTHSC-FW TCOM 14 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.

    15. UNTHSC-FW TCOM 15 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.

    16. UNTHSC-FW TCOM 16 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.

    17. UNTHSC-FW TCOM 17 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 don’t seem to improve on their own.

    18. UNTHSC-FW TCOM 18 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.

    19. UNTHSC-FW TCOM 19 T2

    20. UNTHSC-FW TCOM 20 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.

    21. UNTHSC-FW TCOM 21 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.

    22. UNTHSC-FW TCOM 22

    23. UNTHSC-FW TCOM 23 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.

    24. UNTHSC-FW TCOM 24 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.

    25. UNTHSC-FW TCOM 25 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.

    26. UNTHSC-FW TCOM 26 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.

    27. UNTHSC-FW TCOM 27 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. Don’t forget these.

    28. UNTHSC-FW TCOM 28 Fungal Sinusitis Allergic fungal sinusitis Chronic invasive fungal sinusitis Indolent granulomatous fungal sinusitis Fungal ball (mycetoma) Acute invasive fungal sinusitis

    29. UNTHSC-FW TCOM 29 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/concentration, set shifting. Also this group had a higher number of physical and behavioral symptoms.

    30. UNTHSC-FW TCOM 30 Encephalopathy Auger and his team report several cases of toxic encephalopathy apparently from neurotoxins from indoor molds.

    31. UNTHSC-FW TCOM 31 Cerebral Moniliasis

    32. UNTHSC-FW TCOM 32 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.

    33. UNTHSC-FW TCOM 33 Common Symptoms Found in Indoor Mold Exposures. Respiratory symptoms – rhinitis, sinusitis, asthma, SOB, chest discomfort, epistaxis. Neurologic – concentration, memory, fatigue, headaches, unsteadiness.

    34. UNTHSC-FW TCOM 34 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.

    35. UNTHSC-FW TCOM 35 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.

    36. UNTHSC-FW TCOM 36 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.

    37. UNTHSC-FW TCOM 37 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?

    38. UNTHSC-FW TCOM 38 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).

    39. UNTHSC-FW TCOM 39 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.

    40. UNTHSC-FW TCOM 40 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.

    41. UNTHSC-FW TCOM 41 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.

    42. UNTHSC-FW TCOM 42 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.

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