Adverse Health Effects of Indoor Molds
LUKE CURTIS MS, CIH, 1
ALLAN LIEBERMAN MD, 2
MARTHA STARK MD, 3
WILLIAM REA MD 4
AND MARSHA VETTER MD, P H D
of Public Health, University of Illinois at Chicago, Illinois,
for Occupational and Environmental Health, North Charleston, South
Harvard University, Newton Center,
Health Center, Dallas, Texas, 5Environmental
Health Center, Hoffman Estates, Illinois, USA
Purpose: It has long been known that eating moldy food is hazardous, and
airborne Aspergillus and other fungi can cause life-threatening
illnesses in immuno-compromised patients. However, the possible health
risks of indoor mold exposure in immunocompetent humans are
controversial. This literature review examines the health effects of
indoor airborne exposure to mold.
Design: Literature review.
Materials and Methods: This
review was conducted by searching PubMed and other medical databases, as
well as reading recent conference reports.
Results: Many studies link exposure to damp or moldy indoor conditions
to increased incidence and/or severity of respiratory problems such as
asthma, wheezing and rhinosinusitis. Stachybotrys produces
trichothecenes and other mycotoxins, which can inhibit protein synthesis
and induce hemorrhaging disorders. Indoor mold exposure can alter
immunological factors and produce allergic reactions. Several studies
have indicated that indoor mold exposure can alter brain blood flow,
autonomic nerve function, brain waves and worsen concentration,
attention, balance and memory. Failure to perform the appropriate
objective evaluations on patients may account for the commonly held
belief that indoor mold exposure poses no significant health risks to immunocompetent humans.
Conclusions: Exposure to high levels of indoor mold can cause
injury to and dysfunction of multiple organs and systems, including
respiratory, hematological, immunological, and neurological systems, in
Keywords: mold, fungi,
mycotoxin, allergy, indoor air quality, asthma, neurotoxicity, lung
hemorrhage, Aspergillus, Penicillium, Cladosporium, Alternaria,
In recent years, public attention has become increasingly focused on
human health concerns linked with mold (fungi) inside homes and
workplaces. Indoor airborne mold exposure has been associated with
adverse human health effects in multiple organs and body systems,
including respiratory, nervous, immune, hematological and dermatological
systems. Indoor mold exposure can also lead to life-threatening systemic
infections in immunocompromised patients. A qualitative systematic
literature review was undertaken in order to examine and JNE (gamma)
JNE51751.3d 23/11/04 18:04:51 Rev 7.51n/W (Jan 20 2003) The Charlesworth
Group, Wakefield +44(0)1924 369598 101014 Journal of Nutritional &
Environmental Medicine (September 2004) 14(3), 114 ISSN 1359-0847
print/ISSN 1364-6907 online/02/010071-02
# 2004 Taylor & Francis Ltd DOI: 10.1080/13590840400010318 appraise the
current state of knowledge about indoor mold-linked health effects, and
summarize the available evidence for the use by health professionals.
Physicians, in particular, may encounter patients with common symptoms
occurring in particular
environments, and understanding the potential for mold-related health
effects is key to the complete investigation of those environments.
Physicians and industrial hygienists may be asked to contribute reports
to assist the courts in settling suits. In 2002, an estimated 10,000
mold-related cases were pending in US courts . Also in 2002, the
insurance industry paid out $2 billion in mold-related claims in Texas
alone . Literature was reviewed using the peer-reviewed database, and
from recent conferences on indoor molds. The levels of evidence
available for each topic varied from level I (from at least one properly
randomized controlled trial) through level II (from trials without
randomization, exceptionally convincing uncontrolled experiments, cohort
or casecontrol studies), to level III (opinion of respected authorities
based on clinical experience, descriptive studies, or reports of expert
committees) . [Return to MH]
MOLDS IN THE INDOOR ENVIRONMENT
Fungi (or molds) are ubiquitous in both indoor and outdoor environments
and are frequently dispersed by airborne spores. Mold and mold spores
require moisture and a
food source, such as cellulose or decaying food, to grow . As mold
spores swell with water and grow, they elongate, forming balloon-like
protuberances (hyphae), which secrete digestive enzymes and mycotoxins.
The fungi then digest the food source to support their growth. About
100,000 fungal species have already been identified; in fact, fungi are
estimated to comprise an astounding 25% of the world's biomass .
Various surveys of homes in North America and Europe have reported that
visible mold and/or water damage are common, found in 2398% of all
homes examined . There are no official standards at this time for
indoor airborne fungi concentrations. However, indoor fungal levels
above a range of 1501000 colony-forming units per cubic meter of air (cfu
m 2 3 ) are considered to be
sufficient to cause human health problems [7, 1012]. Numerous reports
have documented that indoor air can be contaminated with fungal spore
levels well in excess of 1000 cfu m 2 3 . The most common indoor
fungal genera collected are Cladosporium, Aspergillus and Penicillium
. Alternaria, Stachybotrys, Rhizopus, Mucor, Wallemia,
Trichoderma, Chaetomium, yeasts, Botrytis, Epicoccum and Fusarium
species are often found indoors as well .
[Return to MH]
MOLD-RELATED HEALTH SYMPTOMS
Patients have been reporting multiple ill health effects linked to
exposures to mold. Studies of more than 1600 patients suffering ill
effects associated with fungal exposure were presented at one meeting in
Dallas in 2003 (21st Annual Symposium of Man and His Environment,
Dallas, Texas, 1922 June 2003) .
To cite a few studies: Lieberman  examined 48 heavily mold-exposed
patients who had the following health problems: muscle and/or joint pain
(71%), fatigue/weakness (70%), neurocognitive dysfunction (67%),
sinusitis (65%), headache (65%), gastrointestinal problems (58%),
shortness of breath (54%), anxiety/depression/irritability (54%), vision
problems (42%), chest tightness (42%), insomnia (40%), dizziness (38%),
numbness/tingling (35%), laryngitis (35%), nausea (33%), skin rashes
(27%), tremors (25%) and heart palpitations (21%). Rea et al.'s study
 of 150 heavily indoor mold-exposed patients
found the following health problems: fatigue (100%), rhinitis (65%),
memory loss and other neuropsychiatric problems (46%), respiratory
problems (40%), fibromyalgia (29%), irritable
bowel syndrome (25%), vasculitis (4.7%) and angioedema (4.0%). These
clinical reports suggest that there can be multisystem adverse effects
of airborne mold. All reported cases had environmental mold exposure
consistent with toxic mold exposure.
[Return to MH]
MECHANISMS OF MOLD-RELATED HEALTH EFFECTS
Fungi can exert ill health effects
by three major mechanisms: allergy, toxicity, and infection.
Allergy and Irritation
At least 70 allergens have been well
characterized from spores, vegetative parts and small particles from
fungi (0.3 mm and smaller) [26, 27]. A review of 17 studies revealed
that 610% of the general population and 1550% of atopics had immediate
skin sensitivity to fungi . Fungi produce beta glucans, which have
irritant properties .
Fungi produce a wide variety of toxic
chemicals called mycotoxins [4, 30, 31]. Some common mycotoxins include:
aflatoxinsvery potent carcinogens and hepatotoxins, produced by some
Aspergillus species; ochratoxinsnephrotoxic and carcinogenic, produced
by some Aspergillus and Penicillium; sterigmatocystinimmunosuppressive
and a liver carcinogen, produced by Aspergillus species, especially A.
versicolor; trichothecenesproduced primarily by Stachybotrys and
Fusarium species and have been reported to inhibit protein synthesis and
cause hemorrhage and vomiting. Fungi also produce beta glucans, which
have immunological effects . The smell of molds comes primarily from
volatile organic compounds . Adverse human and animal effects from
mycotoxin-contaminated foodstuffs have been well recognized since the
early twentieth century [30, 34], but the pathway of mycotoxin injury
through inhalation is questioned . Because it is unethical to
conduct controlled studies on humans with inhaled mycotoxin exposure,
only controlled animal exposures and human cohort and casecontrol
studies can be carried out. The literature reveals that significant
amounts of mycotoxins (including ochratoxin, sterigmatocystin and
trichothecenes) are present in indoor dust  and dust or fungal
particles less than 10 mm in diameter are respirable, thus allowing
absorption of mycotoxins through the lungs [31, 34, 40, 41].
[Return to MH]
Patients exposed to indoor Stachybotrys
have been found to have measurable blood levels of the Stachybotrys
hemorrhagic toxin stachylysin . Levels of trichothecene mycotoxins
in urine have also been found in significantly higher levels in patients
exposed to high indoor fungal levels as opposed to an unexposed control
group . Blood ochratoxin levels have been found to be significantly
higher in food industry workers exposed to airborne ochratoxin vs.
unexposed controls . These findings support an inhalation pathway
for entry of mycotoxins into the body.
[Return to MH]
Fungi such as Candida, Histoplasmosis,
Cryptococcus, Blastomyces and Coccidioides can infect immunocompetent
people . Fungi such as Trichophyton, Candida and Malasezia commonly
cause minor skin infections in immunocompetent humans .
Serious infections by such fungi as Candida, Aspergillus and
Pneumocystis mostly involve severely immunocompromised patients .
In recent years, the incidence of life-threatening infections in
immunocompromised patients from Aspergillus and other common serious infections by such fungi as Candida, Aspergillus and Pneumocystis mostly involve severely immunocompromised patients .
In recent years, the incidence of life-threatening infections in
immunocompromised patients from Aspergillus and other common3 fungi has
been growing rapidly [48, 49]. Invasive aspergillosis is very common
among immunocompromised patients, with the following reported incidence
rates: lung transplants: 1726%; allogenic bone marrow transplants:
515%; acute leukemia: 524%; heart transplants: 213% . Even
with strong anti-fungal drugs and intense hospital
treatment, mortality rates from invasive aspergillosis range from 50 to
99% in the immunocompromised [52, 53].
[Return to MH]
SAMPLING FOR MOLD EXPOSURE
Indoor fungal sampling is most commonly performed by measuring airborne
levels of viable (culturable) or total (viable and non-viable) spores
[54, 55]. Some of the airborne viable sampling methods, such as Andersen
samplers, collect air for only a few minutes. Settle plates are an
inexpensive method to obtain a semi-quantitative measure of indoor
airborne fungi levels. Viable and non-viable airborne spore counts can
vary considerably over a period of minutes, so air sampling over several
periods of time may be necessary to accurately characterize airborne
fungal spore levels [54, 55]. However, airborne fungi measurements fail
to take into consideration mold contamination in dust or surfaces (often
visible to the naked eye) and mycotoxins in air, dust and on surfaces
[54, 56]. Therefore,
testing settled dust for fungi and mycotoxins has been recommended [54,
55]. Other techniques, such as polymerase chain reaction (PCR),
enzyme-linked immunosorbent assay (ELISA), and measurement of fungal
volatile organic compounds, polysaccharides, ergosterol and beta glucans,
have also been found to be useful in assaying indoor environments for
molds, their allergens and mycotoxins .
[Return to MH]
INDOOR MOLD EXPOSURE AND HEALTH EFFECTS IN BODY SYSTEMS
Many epidemiological studies have noted that residential exposure to
molds and/or chronic dampness can increase asthma/wheezing incidence or
morbidity in both children and adults [79, 5770]. Asthma and related
conditions are very common in the USA, with an overall prevalence of
about 5.4% among all age groups and incidences as high as 27% in inner
city children . Studies with infants have reported that higher
fungal exposures are associated with more wheezing, coughing and
respiratory illness [72, 73]. Higher indoor beta glucan levels have been
associated with significantly higher levels of chest tightness and joint
. Non-industrial occupational mold exposure has been reported to be
associated with significantly higher levels of asthma, sinusitis,
irritated skin and eyes, and chronic fatigue . One study found
that patients exposed to high indoor fungal levels had significantly
lower lung function than unexposed controls . Higher outdoor fungal
concentrations have been linked to higher asthma death rates  and
higher asthma incidence  in children or young adults. Challenge
exposures with Penicillium and Alternaria extracts equivalent to high
outdoor levels of fungi were noted to severely lower lung function in
asthmatics . Skin sensitivity to Alternaria has been linked to much
higher risk (odds ratio 190, 95% confidence interval 6.56.536,
pv0.0001) of respiratory arrest . Various epidemiological studies
have associated skin sensitivity to common indoor fungi and higher
asthma incidence or severity  and higher rates of sinusitis
. Airborne fungal exposure is known to cause bronchopulmonary
aspergillosis and hypersensitivity pneumonitis, and can cause sinusitis
[92, 93]. An estimated 14% of the US population suffers from
rhinosinusitis and related conditions . Allergic fungal sinusitis
was diagnosed on the basis of fungal growth in nasal secretions and the
presence of allergic mucin in 93% of 101 consecutive patients undergoing
sinus surgery . Another study was able to recover and culture fungi
from the sinuses of 56% of 45 patients undergoing endoscopic sinus
surgery for chronic rhinosinusitis . A long-term cohort study
of 639 patients with allergic fungal sinusitis demonstrated that
remedial steps taken to reduce fungal exposure (by utilizing, for
example, air filters, ionizers, moisture control and anti-microbial
nasal sprays) significantly reduced rhinosinusitis and improved nasal
mucosa morphology . This study concluded that failure to reduce
airborne fungi levels to less than four per hour on a settle plate
failed to resolve the sinusitis . Although, historically,
anti-fungal drugs have generally not been recommended for the treatment
of fungal sinusitis [92, 93], recent observational studies have found
beneficial effects of oral and nasal medication for sinusitis patients
[22, 96]. Several studies have linked residential exposure to various
fungi with hypersensitivity pneumonitis .[Return
Exposure to high indoor levels of Stachybotrys, Aspergillus and other
fungi has been epidemiologically associated with infant lung hemorrhage
. Although questions were raised after this association was
discovered , it meets many epidemiological criteria for causality
. Acute infant pulmonary hemorrhage can be rapidly fatal; when the
infant survives, lung blood vessel damage is present and deposits of
hemosiderin will remain in the lung macrophages and can be seen in
tissue obtained during bronchoscopy . Stachybotrys fungi produce a
wide range of trichothecene mycotoxins (including satratoxins and T2),
several roridin epimers, verrucarin J and B and hemolysin [31, 103]. A
hemorrhagic protein called stachylysin has been isolated from
Stachybotrys collected from
homes of infants with lung hemorrhage [107, 108] and from serum of
patients with residential Stachybotrys exposure . It is hypothesized
that infants with their rapidly growing lungs are more susceptible to
the toxic effects of Stachybotrys mycotoxins . Studies with
Stachybotrys-exposed adults have noted a significantly higher incidence
of health conditions such as wheezing, skin and eye irritation,
'flu-like symptoms and chronic fatigue . Stachybotrys has been
isolated from the lungs of a child with pulmonary hemosiderosis . A
case study was presented of 16-month-old twins in a mold-infested home,
one of whom died of pulmonary hemosiderosis . High levels of
trichothecene mycotoxins were found in the lungs and liver of the dead
infant, while high IgG levels to Stachybotrys and IgM
levels to satratoxin and trichothecenes were found in the serum of the
surviving infant. Environmental sampling in the twins' home found high
levels of satratoxin as well as high levels of spores from Stachybotrys,
Aspergillus versicolor and Penicillium .
[Return to MH]
Some studies have reported that indoor fungi-exposed patients have
higher serum levels of IgG, IgA and IgM antibodies to common fungi,
trichothecenes and satratoxins . IgG antibodies to nine common
indoor fungi were significantly higher in subjects with sinusitis vs.
non-sinusitis subjects in a moldy school . Other studies have noted
no significant increases in fungal IgG [117, 118] or fungal IgE  in
fungi-exposed patients. Indoor fungal exposure has been associated with
altered levels of T4, T8 and natural killer cells and higher levels of
autoantibodies [23, 25, 119, 120]. Occupants of homes with high Indoor
glucan exposure had a lower proportion of cytotoxic t-cells (CD8zSF61z)
and higher secretion of tumor necrosis factor than occupants of homes
with lower levels of beta glucans . Studies of animals given such
common mycotoxins as aflatoxins, ochratoxins and trichothecenes orally
showed considerable immune impairment, including depression
of T cells, B cells and macrophages . Human cell line studies have
also found that many mycotoxins can suppress T-cell, B-cell and natural
killer cell activity at serum concentrations similar to those found in
indoor mold-exposed patients . Central Nervous System Two case
series of 48 and 150 mold-exposed patients found significant fatigue and
weakness in 70100% of cases, and neurocognitive dysfunction including
memory loss, irritability, anxiety and depression in over 40% of the
patients [21, 23]. Numbness, tingling and tremor were also found in a
significant number of patients [21, 23]. These signs and symptoms have
been described as classic manifestations of neurotoxicity . A study
of 43 mold-exposed patients found that they performed significantly
worse than 202 controls on many neuropsychiatric tests, including
balance sway speed, blinking reflex, color perception, reaction times
and left grip strength (pv0.0001) . Quantitative
electroencephalogram (qEEG) studies in 182 patients with documented mold
exposure also noted significant alterations in brain waves, including
hypoactivation of the frontal cortex and narrowed frequency bands .
Higher levels of mold exposure (longer time in mold-infested area,
presence of Stachybotrys or higher cfu m
air) were associated with significantly more abnormal qEEGs as well as
significantly worse scores of concentration and motor and verbal skills
in these 182 patients . A triple-headed SPECT brain scan revealed
neurotoxic patterns in 26 of 30 (87%) mold-exposed patients . An
iriscorder study of autonomic nervous function in 60 mold-exposed
patients found that 95% had abnormal autonomic responses of the pupil
compared with the population reference range
. Visual contrast sensitivity studies were often abnormal in indoor
mold-exposed patients . Additional studies have reported that
mold-exposed patients do significantly worse on tests of attention,
balance, reaction time, verbal recall, concentration, memory, and finger
tapping compared with the general population reference range [24, 128,
129]. [Return to MH]
Most of these patients also experienced
many health problems, including chronic fatigue, headaches, insomnia and
decreased balance, concentration and attention. Studies of indoor
mold-exposed children and adults found significantly more
neurophysiological abnormalities vs. controls, including abnormal EEGs
and abnormal brainstem, visual and somatosensory evoked potentials [25,
130, 131]. Lieberman  presented a case series of 12 patients who
developed tremors following
documented heavy indoor mold exposure. Numerous articles have reported
domestic dogs developing tremors following ingestion of moldy food
. Territrem b, a mycotoxin produced by the common fungus
Aspergillus terreus, has been shown to be an irreversible binder and
inhibitor of acetylcholinesterase .
It is known that ochratoxin-contaminated food is nephrotoxic [136, 137].
Indoor airborne exposure to ochratoxin may also be nephrotoxic. In a
case report of a family presenting with increasing thirst/urination,
lethargy, and skin rash, a considerable amount of ochratoxin was found
in their house dust. The family recovered after moving to another home
. [Return to MH]
The literature suggests a relationship between heavy airborne fungal
exposure and reproductive dysfunction. Kristensen et al. [138, 139]
reported that airborne mycotoxin exposures in Norwegian grain farmers
was significantly related to higher rates of pre-term deliveries,
late-term miscarriages and higher rates of endometrial and ovarian
endocarcinoma. The veterinary literature finds a strong association
between mycotoxtins in feedstuffs and reproductive problems .
There is a great deal of evidence that links environmental factors to
the triggering of type 1 diabetes. Exposure to viruses, bacteria and
mycotoxins such as alloxan, streptozatocin and L-asparginase has been
linked to the development of type 1 diabetes in animals and humans
. Lieberman  reported that in a single year, five of his
patients developed type 1 diabetes following documented heavy indoor
DIAGNOSIS AND MANAGEMENT OF
POTENTIALLY MOLD-RELATED HEALTH PROBLEMS
A careful medical and environmental
history is an essential first step in evaluating a patient for
mold-related health problems . Particular attention should be
paid to any history of exposure to visible mold and/or water damage at
the home or workplace. Environmental sampling for viable spores, total
spores, and mycotoxins in the air and dust can provide important
exposure information. For a helpful overview of sampling methods, see
references [54, 148, 149]. For an informative guide to the
classification, identification and biology of common indoor fungi, see
reference . Several good guides exist for the prevention and
remediation of indoor fungi problems [144, 148151]. For patients
suspected of having substantial fungal exposure, a battery of
sophisticated laboratory tests has been developed: a basic metabolic
panel to test for several important parameters (including electrolytes,
blood sugar, liver and kidney status); measurement of antibodies to
molds and mycotoxins in serum [113, 114]; immune tests for
autoantibodies, complement, gamma globulins and lymphocyte panels ;
urine and blood testing for
mycotoxins ; visual contrast sensitivity tests; and pupillometry and
heart rate variation to assist in the evaluation of autonomic nervous
system function. The use of standard neuropsychological test batteries
[23, 128130], EEG and brain imaging techniques such as SPECT and
magnetic resonance imaging (MRI) can be very helpful tools in
documenting neurological damage [25,125, 127, 131, 145].
Pulmonary function tests are also
useful for patients with respiratory symptoms [24, 124]. Failure to
perform objective evaluations to access system or organ dysfunction
account for the presently accepted position that airborne mold exposures
have no significant adverse effects . If end-stage organ damage
is suspected, consultation with a specialist may be useful. Other common
indoor environmental exposures should also be considered as a potential
source of health problems. Common non-fungal indoor environmental
factors include poor ventilation, carbon monoxide from faulty heat
sources, leaking natural gas, pesticides, wood smoke, second-hand
tobacco smoke, petrochemicals, such as cleaners/building
materials/solvents, formaldehyde from outgassing carpets, building
materials, bacteria, and allergens from the fur, feathers, saliva and
excrement of common household animals such as cockroaches, dust mites,
cats, dogs, mice, rats, caged birds, and pigeons. Exposure to ozone,
second-hand tobacco smoke, cockroach allergens, formaldehyde, and viral
infections have been noted to have a synergistic effect with fungal
exposure to worsen asthma and rhinitis . The most important
part of treatment for mold-exposed patients, symptomatic or not, is
avoidance of fungal exposure and remediation of mold contamination in
the home and workplace. Any water leaks and damage from flooded or damp
areas should be rectified immediately. Non-porous surfaces such as
floors and walls that have visible mold growth should be cleaned. Porous
waterlogged materials like carpet and furniture should be discarded.
Control of humidity is important to control mold growth. The use of air
conditioners and dehumidifiers can significantly reduce summertime
indoor airborne mold concentrations [13, 157]. HEPA air filters can also
significantly reduce indoor airborne fungi concentrations . For
cleaning severe indoor water or mold problems, the use of protective
equipment like face masks and/or the use of a professional remediation
firm may be essential .
[Return to MH]
Environmental control plays a key role
in preventing Aspergillus infections. Several studies have linked
hospital construction work to increased rates of invasive aspergillosis
. Environmental controls such as using HEPA filters, sealing
rooms, regular cleaning of rooms, and using anti-fungal
copper-8-quionolate paint have been shown to both significantly reduce
airborne levels of Aspergillus and significantly reduce rates of
invasive aspergillosis in immunocompromised hospital patients [158,
160165]. Other recent research has indicated that a large number of
Aspergillus spores can spread through water supplies  and that
cleaning shower facilities can significantly lower airborne levels of
Aspergillus . [Return to MH]
Use of sublingual or fungal
immunotherapy by injection has been shown to be beneficial to some
patients sensitized to common indoor molds such as Alternaria and
Cladosporium herbarium [168, 169]. Some studies with laboratory
animals suggest that a high-quality diet with adequate antioxidant
vitamins, selenium, phytochemicals, methionine and total protein can
reduce the harmful effects of food mycotoxins [170, 171].
There is an accumulated weight of evidence linking indoor airborne mold
and/or mycotoxin exposures to multisystem adverse human health effects.
A history of new
neurocognitive symptoms occurring in patients soon after heavy mold
exposure, accompanied by objective neuropsychological findings in such
patients, adds considerably to the weight of evidence from animal
studies, epidemiological research, and case series. Health care
professionals, building managers, homeowners and the general public need
to be much more aware of the potential adverse health effects of high
indoor fungal exposures and the need for proper building construction,
maintenance, and remediation of dampness to prevent such effects.
Potentially mold-related illnesses need to be considered in differential
diagnoses, and careful exposure histories taken. Prompt removal from
exposure to fungal contamination remains the treatment of choice, with
some evidence that immunotherapy and nutritional support are also
useful. Indoor airborne mold particles can be irritative to the
respiratory tract, and fungal spores, antigens, volatile organic
compounds, and mycotoxins can be absorbed through the respiratory route
to provoke injury by the mechanisms of allergy, toxicity, and infection.
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