Water Damaged Buildings and Mold: Controversies and Overlooked issues

1. Water Damaged Buildings and Mold: Controversies and Overlooked issues Dave W. Ou, M.D. Healing the Brain May 2015

2. Why mold? • My Practice -Most of my patients present with some combination of fatigue, brain fog, poor concentration, insomnia, anxiety/depression, hormone imbalances, digestive problems, musculoskeletal and neurologic sx. Many with autoimmune disease esp. thyroid. Some have been to university med centers with unsatisfactory dx and tx. -Most not helped by allopathic medicine Some diagnosed as CFS, FMS, depression Many diagnosed as nothing wrong with them, hypochondriacs

3. Why mold? • Many not helped by alternative and integrative practitioners who worked on: • Diet: Food allergies and sensitivities • Dysbiosis • Hormones: adrenals, thyroid, sex hormones • Detoxification: metals • Nutrient replacement • Treated for vector born illnesses egBorrelia

4. Why mold? • As I tried to understand the cause, I learned about the work of Ritchie Shoemaker, MD. Author of Desperation Medicine, Mold Warriors, and Surviving Mold. He describes a syndrome in which a person with a genetic disposition is exposed to biotoxins from a water damaged building, develops an uncontrolled cycle of inflammation (Chronic Inflammatory Response Syndrome [CIRS]).

5. Definitions • Biotoxins • Substance released by organisms which are harmful to others • Eg. Staph, Shiga, E. coli, snake venom • In CIRS, we are looking at ionophores: much smaller than above biotoxins. • Mold, borrelia, pfisteria, ciguatera

6. Definitions • Inflammation -simplified, it’s the body’s way of removing what does not belong in the body.

7. Chronic Inflammatory Response Syndrome (CIRS) from WDB (water damaged building) • Not mold allergy: runny nose, sinus, eye • Shoemaker: an acute and chronic, systemic inflammatory response syndrome acquired following exposure to the interior environment of a water-damaged building with resident toxigenic organisms, including, but not limited to fungi, bacteria, actinomycetes and mycobacteria as well as inflammagens such as endotoxins, beta glucans, hemolysins, proteinases, mannans, c-type lectins and possibly spirocyclicdrimanes, plus volatile organic compounds.

8. CIRS • Note that CIRS is also a consequence of Chronic Lyme. • This talk will focus on CIRS from water damaged buildings but they is much overlap with CIRS from Chronic Lyme

9. Water Damaged Building

10. What mold needs to thrive? • Food: Cellulose from wood and paper • Drywall, OSB, plywood are perfect!

11. What mold needs to thrive: Water

12. Water from leaks

13. Water from leaks mixing with wood and paper

14. Dampness from high humidity in a basement

15. Dampness from high humidity in a crawlspace

16. Dampness in HVAC

17. “Mold Illnesses” are not just caused by mold • Complex ecosystem when cellulose and water mix • Mold • Bacteria • Amoeba / protozoa • Mycobacteria • Actinomycetes • Offgassing of building materials eg formaldehyde

18. Impossible to identify a single compound from a water damaged building that is “the cause” of someone’s illness.

19. Inflammagens in a water damaged building: a toxic stew well beyond mold • Mycotoxins – from mold. Levels influenced by other microbes • 1-3-beta-D-glucans – from mold • mVOCs – from bacteria • Endotoxins – from the cell wall of bacteria • Hemolysins – from bacteria • Proteinases • Mannans

20. Genetic predisposition: Only 25% of people can be seriously affected • HLA DR/DQ from Labcorp • Encodes MHC Class II protein on chromosome 6 • Over 55 haplotypes. Of those, 9 are predisposed to biotoxin illness • Unable to form antibodies against small biotoxins • Biotoxins accumulate and cause a inflammatory response • These 9 types make up 25% of the population.

21. Explains why most people in a “sick building” feels fine and do not take the minority who are ill seriously. • Common example: husband does not believe the wife’s symptoms

22. Genetic predisposition • 99% of all patients with mold illnesses or Lyme have one of these 9 haplotypes. • 98% of my patients no matter the reason for seeing me. • The “see an alternative healthcare practitioner” gene. • Dr. Klinghardt says that these haplotypes increase the potential for greater intelligence, creativity, and spirituality. Sometimes the potential is never accessed. • http://www.drdaveou.com/blog/?p=406 for more information

23. HLA DR/DQ • Mold and Lyme susceptible • 4-3-53 • 11/12-3-52B • 14-5-52B: • Mold susceptible • 7-2-53 • 13-6-52A, B, or C • 17-2-52A • 18-4-52A • Lyme Susceptible • 15-6-51 • 16-5-51

25. Pathophysiology • Inhalation of “chemical soup” in water damaged building • Neurotoxic: likes nerve and brain cells • Dendritic cells engulfs toxins and presents it to T-cells attached to MHC II protein. • MHC II encoded by HLA DR/DQ. • In non-susceptible, T cells learn to make antibodies and neurotoxins neutralized • In susceptible, defect in antibody formation so neurotoxins accumulate

26. Pathophysiology • Neurotoxins activate TLR receptors which activate NFKB which then tells DNA to make cytokines • Cytokines recruit immune system cells which in turn makes more cytokines • Cytokines create sx of flu; (sx of flu caused by immune system, not virus) • Direct cytokine effects: Headaches, muscleache, fatigue, unstable temp, poor conc, decreased blood flow to brain and organs • Cytokines increase TGF beta which ultimately if chronic causes a decrease in T regulatory cells. • T reg cells control inflammation • Cytokines confuse immune system: food sensitivity esp gluten, autoimmunity • Cytokines cause WBCs to stick to capillaries causes hypoperfusion: metabolism becomes anaerobic instead of aerobic. • Mitochondria can’t make enough ATP: fatigue, poor recovery from exercise, dyspnea (post exertional malaise) • Exhaust glycogen stores • Uses protein stores: sarcopenia

27. Pathophysiology • Cytokines bind hypothalamus blocking release of MSH (melanocyte stimulation hormones) • MSH, a peptide which help counteract inflammation • Assoc low endorphins, low ACTH, low melatonin • Low MSH assoc leaky gut • Assoc decreased sex hormones • Low ADH (Antidiuretic Hormone) : thirst, freq urination, inflammation • People worry they have diabetes or spastic bladder • Low VIP (Vasoactive Intestinal Polypeptide): inflammation, air hunger • Cytokines also cause leptin resistance • Leptin needed to control appetite and metabolism. With leptin resistance, can’t break down fat cells

28. Biotoxins from Lyme follow the same path • Symptoms of Lyme and mold are identical according to Dr. Shoemaker

29. Symptoms according to Dr. Shoemaker • Fatigue • Weakness

30. Symptoms according to Dr. Shoemaker • Memory Impairment • Difficulty concentrating • Poor memory • Decreased word finding • Decreased assimilation of information • Confusion • Disorientation • Mood Swings

31. Symptoms according to Dr. Shoemaker • Headache • Vertigo • Light sensitivity • Red Eyes • Blurry Vision • Tearing • Metallic Taste

32. Symptoms according to Dr. Shoemaker • Sinus Congestion • Shortness of Breath • Cough • Abdominal Pain • Diarrhea • Appetite Swings

33. Symptoms according to Dr. Shoemaker • Night sweats • Difficulty regulating body temperature • Excessive thirst • Frequent urination • Increased susceptibility to static shocks

34. Symptoms according to Dr. Shoemaker • Aches • Cramps • Morning joint stiffness • Joint Pain • Unusual pain • Ice pick pain

35. Symptoms according to Dr. Shoemaker • Numbness • Tingling

36. Other associated symptoms • Adrenal dysfunction • Non restorative sleep • Food sensitivity • Autoimmunity

37. I suspect CIRS when: • CFS • FMS • All hormone • Adrenal • Thyroid • Hypogonad/ ED • Any unresponsive to HRT • Dysmenorrhea, IC • All autoimmune • ANA+ Family Hx • Tx for vector borne/ thinks they have • All fatigue • All brain fog • Neurologic illness: numbness / tingling • Mood do: bipolar, depression, anxiety • Multiple food all • Celiac • Leaky gut • Dysbiosis • Candida • Chemical sensitivity • Insulin resistance • Difficulty losing wt • Endometriosis • Thirst / freq urination • Chronic pain • ADD • Anything mysterious

38. Diagnosis of CIRS-WDB • Exposure to a water damaged buildings • Symptoms consistent with CIRS • Tests and labs consistent with CIRS

39. Visual Contrast Sensitivity • Measures the ability to distinguish shades of grey • Reflects blood flow to the retina • Developed by the military to screen pilots • Abnormal in 93% of CIRS patients per Dr. Shoemaker • http://www.survivingmold.com/store1/online-screening-test

40. VCS • Normalizes as patient recovers

41. Labs • Labs: (see http://www.survivingmold.com/diagnosis/lab-tests • TGF beta (Cambridge Biomedical)– most sensitive, not as specific • Complement C4a (NJH) – not Labcorp • HLA DR/DQ (Labcorp) • MSH (Melanocyte Stimulating Hormone) (Labcorp) • MMP 9 (Matrix Metalloproteinase) • VIP (Vasoactive Intestinal Polypeptide) • VEGF (Vascular endothelial growth factor) • ADH / Osmolality • Radiology: NeuroQuant MRI

42. Proving exposure

43. Urinary mycotoxins • Tests for ochratoxins, trichothecenes, and aflatoxins • Limitations • Hundreds of other mycotoxins • Severely ill patients do not excrete mycotoxins into their urine so the test looks normal • Can not distinguish between inhalation, ingestion, or colonization

44. Air testing • The standard test by industrial hygienists and mold inspectors • Never recommended by the vast majority of mold specialists

45. Air testing limitations • Measures mold spores ( > 2.25 µm) Studies show that for every spore, there are 300-500 fragments (1 µm) • The vast majority of the inflammagens are in the fragments. • Air testing can not detect fragments • Mold plates can not detect fragments • Small fragments travel deeper into the lungs

46. Limitations of air testing • A 5 minute sample measures at best, 0.013% of the volume of a 2500 square foot home • Assumes the mold produces spores constantly • Wrong! Can be intermittently produced. • Assumed equal distribution of spores • Wrong! Uneven distribution

47. Limitations of air testing • Example: Lousy at detecting stachybotrys • Spore is very heavy and does not travel far. Often can’t travel to the spore trap • Studies have shown high levels of mycotoxins with zero spores with air testing.

48. Limitations of air testing • No agreed upon standards for what is safe for a genetically susceptible individual

49. Limitations of air testing • To do correctly, must take multiple samples per room multiple times over a 24 hours period. • $$$ • Dr. Shoemaker jokingly says the main reason to do air testing is to defend the landlord with “normal” results.

50. But I don’t see any mold • In a German study looking at homes in which mold was visually confirmed after tearing down walls, only 25% had positive air tests.