Neuropsychological Evaluation of a Practicing Physician with Mold Exposure

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Tuesday, November 20, 2007

Neuropsychological Evaluation of a Practicing Physician with Mold

Exposure

http://neurotox.blogspot.com/2007/11/neuropsychological-evaluation-

of.html

Neuropsychological Evaluation of a Practicing Physician with Mold

Exposure

Singer, Ph.D.

Independent Practice

Santa Fe, New Mexico

and

New York, New York

www.neurotox.com

ray.singer@...

and

Gray, M.D.

Independent practice

Benson, Arizona

Published until Dec. 15 at: http://neurotox.blogspot.com/

Presented at the National Academy of Neuropsychology, 27th Annual

Meeting, sdale, Arizona, November 17, 2007.

Singer, R. and Gray, M. (2007). Neuropsychological evaluation of a

practicing physician with mold exposure. Archives of Clinical

Neuropsychology, Volume 22, Issue 7, September, p 892.

Objective: Differential diagnosis of mold-exposed patient

demonstrates an application of neuropsychology to salient issues of

medicine and toxicology.

Introduction: Scientific support for the identification of mold

neurotoxicity can be found in numerous reports, including in vitro

studies, animal studies and human studies (see references at end).

Case: The subject was a formerly financially successful chiropractic

physician and former chemical engineer, still practicing medicine at

the time of the exam. Symptoms included rapid weight loss, chronic

fatigue, respiratory problems, erectile dysfunction, night sweats,

hot flashes, and irritability, which began three years after working

at the high school, in the spring of 2002, initially diagnosed as

mild hyperthyroidism, but the diagnosis was not supported by tests

of thyroid hormone levels - although his eyes remain mildly

protruding. Sex hormone testing for erectile dysfunction was also

negative.

Exposure duration: After treating patients at his private

chiropractic practice in the early parts of the day, since the fall

of 1999, he worked from 3 pm, five days a week, for a minimum of 3

and up to 10 hours a day, as the sports physician for 15 different

sports at a local high school. He served the football team needs at

all of the home and away games. On days when there were games at the

high school, he worked up to 10 hours at the school. Roughly

speaking, he worked roughly 30 hours a week, 30 weeks a year, in a

potentially contaminated environment, for 7 years, from 1999 until

the time of the examination in until Fall, 2006.

While at the high school, he spent most of his time in his office

next to the laundry room. The laundry room was found to have mold in

the fall of 2002; the washing machine in the laundry room was

leaking water; the clothing dryer exhaust was not vented to outside

the building, but vented into the laundry room.

The door between the laundry room and the subject's office door,

which connected the laundry room and the subject's office, was often

propped open by various coaches, because the laundry room was

frequently overheated.

Although renovations took place to ameliorate the mold problems,

completed in January, 2003, it was since discovered during a

subsequent remodeling of the entire gym in the summer of 2007 that

mold was still growing on the ceiling tile and in the cabinets.

Medical question: Was there any neuropsychological decline; what was

the nature of the decline; if so, what is/was the cause; and could

the exposure be impacting other medical conditions that have

neuropsychological components? Knowing the cause helps to determine

the treatment.

Method: Interview, neuropsychological testing, medical and exposure

records review.

Exposure assessment:

Visual inspection showed mold on the drywall, metal studs in the

wall, ceiling tile, and in cabinets. The studs in the laundry were

deteriorated from rust and corrosion.

Air testing in the subject's high school office on Dec 4, 2002 for

spores showed the following counts/M3, " background corrected " (minus

the amounts of the spores found in the outdoor environment):

Aspergillus/Penicillium, 457; Stachybotrys, 549.

In the American Industrial Hygiene Association

periodical " Synergist " (Geoffrey A. , November 2001), spore

counts above 2,5000 indicates possible contamination. However, molds

vary extremely widely in their potential toxicity, so this number is

not meaningful.

Stachybotrys represents a special mold problem because it produces

mixed trichothecenes mycotoxins which interfere with protein

synthesis at a cellular level, and have been weaponized because of

it's damage potential.

Mycotoxins, by-products of fungal metabolism: The trichothecenes are

a very large family of chemically related toxins produced by various

species including Stachybotrys.They are markedly stable under

different environmental conditions. All trichothecenes are

mycotoxins, but not all mycotoxins are trichothecenes. This family

of mycotoxins causes multiorgan effects including emesis and

diarrhea, weight loss, nervous disorders, cardiovascular

alterations, immunodepression, hemostatic derangements, skin

toxicity, decreased reproductive capacity, and bone marrow damage

(Chapter 34, TRICHOTHECENE MYCOTOXINS. ROBERT W. WANNEMACHER, JR.,

PH.D. AND STANLEY L. WIENER, M.D., Medical Aspects of Chemical and

Biological Warfare, 1997)

Medical record review:

12/15/03 Spirometry shows mild obstructive airways disease; flow

volume loop demonstrates large airway obstruction; static lung

volumes show hyperinflation is present; diffusion capacity shows

normal diffusion capacity. DIAGNOSIS: Hypoxia Occupational exposure.

Dr. Gray, second author of this paper found:

06/01/06: Positive fungus culture for Cladosporium species and

Beauveria species

06/05/06: Mycotoxin report taken from urine: positive for

Tricothecenes.

06/12/06: Decreased Natural Killer cells, slightly elevated

Activator Suppressor cells and elevated Activated T cells.

06/22/06: Patient's Immunosciences Laboratory fungal, mold and

mycotoxin panels had multiple positives with multiple IgMs positive

and several IgEs positive.

Weight loss, suspect trichothecene mycotoxicosis.

Gray's panel at AAL was positive for 6/8 mold congruity factors in

the autoimmune series...no herpes, no candida. ANA was

negative...his hypersensitivity pneumonitis panel was positive for

5/8 of the fungal specific antigens for which IgG was evaluated.

The Immunosciences fungal, mold and mycotoxin panels revealed

multiple positives for the various funguses associated with damp

indoor environments. Several of the neural antigen antibody screens

were positive, consistent with injury to CNS neurons, and the

mycotoxin assays were also positive for multiple mycotoxins at a

significant abnormal level.

In his original set of neurologic tests, he was showing

abnormalities on six of the areas tested including abnormal sway

balance with eyes closed, visual performance on the visual field

testing was abnormal bilaterally, and his long-term crystalized

memory for information and recognition of similarities was abnormal.

08/31/06: Abnormalities on physical exam and neuropsychological

testing: Neurological: 6 abnormal items. Visual Quadrant: 1 abnormal

item. Smell Recognition: 1 item. Pulmonary function: 2 items.

09/07/06: DNA tissue/fluid panel report - sputum samples: positive

for mold Aspergillus niger.

08/29/06 Quantitative EEG with neurometric analysis produces results

that are statistically significant and of clinical significance,

reported as consistent with results found in over 250 individuals

who had toxic mold exposure.

Results:

Dates of exam: 11/15/06

Gender: Male

Age at exam: 43

Educational level: 16+

Height: 6'0 "

Weight: 188 lb

Ethnicity: White

Marital Status: Single

Number of Children: 0

Neurotoxicity Screening Survey

Elevated: Consistent with neurotoxicity

Function Percentile rank Score

Pre-morbid IQ 97 128

WAIS-III Processing Speed 58

WMS III: Auditory Process Learning Slope 25

WMS III: Verbal Paired Associates 1st Recall Total 37

WMS-III Immediate Memory 70

WMS-III Auditory Retrieval 21

Ruff Figural Fluency 40

Stroop Color-Word 10

Visual Search and Attention Test 40

WRAT-II Reading 50

Beck: Mild anxiety and depression

Quick Environmental Exposure and Sensitivity Inventory :Elevated

TOMM 47, 50, 50

Boone et al. Dot Counting

E-Score: 7

E-Score Cutoff: 22

Portland Digit Recognition Test

15/15 correct

FRSBE: Symptomatic of executive dysfunction

Ruff Neurobehavioral Inventory: No distortion

Elevated on the scales E (emotional), At (attention and

concentration), An (anger and aggression), So (Psychosocial

integration and recreation) and Nr (neurological status).

Neo Personality Inventory

Emergence of possible personality disorder

Paranoid, obsessive-compulsive, but not anti-social.

Conclusions: Symptoms were found consistent with mold toxicity,

affecting multi-systems, including respiratory, immune and nervous.

Neuropsychological testing showed mild declines in function,

consistent with self-report, affecting memory, concentration and

personality. Clinical diagnosis was mold neurotoxicity. Differential

diagnosis found no competing diagnoses.

References

Toxicol Sci. 2007 May 4; Neurotoxicity and Inflammation in the Nasal

Airways of Mice Exposed to the Macrocyclic Trichothecene Mycotoxin

Roridin A: Kinetics and Potentiation by Bacterial Lipopolysaccharide

Co-Exposure. Islam Z, Amuzie CJ, Harkema JR, Pestka JJ.

Satratoxin G from the Black Mold Stachybotrys chartarum Evokes

Olfactory Sensory Neuron Loss and Inflammation in the Murine Nose

and Brain Zahidul Islam, Jack R. Harkema, and J. Pestka

doi:10.1289/ehp.8854 (available at http://dx.doi.org/ Online 27

February 2006)

Pharmacol Toxicol. 1992 Feb;70(2):111-4. Acute neurobehavioural

toxicity of trichothecene T-2 toxin in the rat. Sirkka U, Nieminen

SA, Ylitalo P.

J Environ Pathol Toxicol Oncol. 1990 Jan-Apr;10(1-2):17-30. Changes

in transmitter release patterns in vitro induced by tremorgenic

mycotoxins. Bradford HF, Norris PJ, CC.

Singer, R. (2005). Clinical evaluation of suspected mold

neurotoxicity. Proceedings of the Fifth International Conference on

Bioaerosols, Fungi, Bacteria, Mycotoxins and Human Health, Albany,

New York: Boyd Printing.

Singer, R. (2005). Forensic evaluation of a mold (repeated water

intrusions) neurotoxicity case. Archives of Clinical

Neuropsychology, Volume 20, Issue 7, p. 808.

Appl Neuropsychol. 2002;9(4):193-202. Neuropsychological performance

of patients following mold exposure. Baldo JV, Ahmad L, Ruff R.

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