A complex problem requiring examiners full attention and interest.

[Guest guest]

Ethically- I do not believe there is a quick fix.If you want the

right answer, you must consider all the variables.That takes time, a

genuine interest in what you are doing, pride in your work and

compassion for your fellow man. Not everything in life is an " easy

fix " . That is my opinion- Nina

Indoor Environment Resulting From Water Intrusion

By Jack D. Thrasher, Ph.D., Kaye Kilburn, M.D. and Nina Immers

The potential harmful effects of exposure to fungi (molds) in

inhabited buildings have been recognized and documented since early

Biblical times. In the Old Testament (King Version, Oxford)\,

1888 Edition, Chapter XIV: Verses 34 thru 47) Leviticus put forth a

detailed written protocol for the remediation of mold contaminated

structures,( including the destruction of dwellings and personal

belongings in failed remediations). Presently, it is scientifically

accepted that unwanted water intrusion into buildings results in

amplification of fungi and bacteria (1-11). The Centers for Disease

Control (CDC) and Environmental Protection Agency (EPA) recommend re-

mediation when water-damage and fungus growth are evident in a home

or office building. So, exactly what has changed since the

pronouncement of Leviticus?

Presently, we have much better comprehension of the types of

microorganisms, metabolic toxic by-products, the resulting risk from

a potentially toxic environment created by water-intrusion into an

inhabited structure or dwelling. A resulting pattern of adverse

health effects in occupants of these structures and the associated

long term risks based on exposure parameters is much better

understood.

Occupants of water-damaged buildings are found developing multiple

organ symptoms and experiencing adverse affects to the upper and

lower respiratory tract, central and peripheral nervous system, skin,

gastrointestinal tract, kidneys and urinary tract connective tissue,

and the musculoskeletal system. Copious peer reviewed literature

discusses adverse health effects with confidence intervals of 95 % or

higher. The human response or immune reaction usually falls into

one or more of the following four general types of immune reactions:

a Type I reaction otherwise commonly referred to as an IgE or

allergy mediated response;

a Type II reaction otherwise referred to as a cytotoxic reaction.

Target molecules on the cell surface and initiate processes leading

to the death of that specific cell. (eg. Hemolytic anemia)

a Type III reaction otherwise called " immune complex " reactions.

Protective antibodies attach to an antigen and initiate an

inflammatory reaction or response (eg. Glomerulonephritis)

or a Type IV reaction which involves the bio-mechanisms of cell

mediated immunity or the bodies immunological competency to respond

appropriately to foreign tissues, certain infectious agents,

chemicals and cancerous cells. (12)

Human illness caused by fungi and bacteria can result in a myriad of

ailments but most frequently include one or all of the following:

mycotic infections (mycoses) or infectious bio-mechanisms;

fungal rhino-sinusitis;

IgE mediated sensitivity and asthma;

hypersensitivity and related pulmonary inflammatory disease;

cytoxicity;

immune suppression/modulation;

autoimmune disorders or disease processes;

mitochondrial toxicity;

carcinogenicity;

renal toxicity;

neurotoxicity;

and adducts to nuclear and mitochondrial DNA causing mutations.

Finally, in the infectious state, fungi and bacteria secrete

extracellular digestive enzymes, hemolysins and toxins that cause

tissue destruction, angio-invasion, thrombosis, pulmonary bleeding,

infarction and other manifestations of the infectious state (for

review see references 13, 49, 52).

The purpose of this article is to succinctly review the state of art

with respect to indoor air contaminants resulting from water

intrusion (damage) and the associated health effects caused by human

exposure to this mixture. The most important Indoor environmental

biocontaminants currently discussed in the peer reviewed literature

can be grouped into the following categories:

(1) Microbes (fungi and bacteria);

(2) Particulates;

3) Mycotoxins;

(4) Volatile Organic Compounds;

(5); Extracellular digestive enzymes and Hemolysins;

(6) Extracellular polysaccharides; and

7) Endotoxins.

By categorizing the indoor environment contaminants based on their

general properties, we can simplify our discussion of the bio-

contaminants and the overview of their role in altering, if not

compromising the indoor environment.

1. Microbes: The microbes consist of (a) fungi (molds) and

( bacteria.

a. Fungi ( molds): Once water intrusion occurs the

fungi begin to grow within 48 hours. They enlarge into more massive

growths called colonies. The colonies frequently have different

colors, depending upon the specific fungus, e.g. amber, orange, gray,

green and black (and / or the growth medium). Wherever water is

found in sufficient concentration they grow on surfaces. These

colonies also can be found hidden in the carpet, behind wall paper,

inside interior and exterior walls, attic, sub floors, etc in these

humid environments as discussed herein. The most common fungi

identified growing on various substrates (particle board, dry wall,

carpeting, etc.) consist of the following genera:

Cladosporium, Aspergillus, Penicillium, Chaetomium, Epicoccum,

Alternaria, Trichoderma and Stachybotrys.

Certain species of these genera amplify indoors vs outdoors:

Aspergillus species commonly identified include flavus, versicolor,

sydowii, niger, and fumigatus and the species of Penicillium include

chrysogenum, brevicompactum, citrinum, and decumbens. Stachybotrys

chartarum when present predominantly consists of two chemotypes. The

most dangerous chemotype identified is the one that produces

trichothecene mycotoxins, while the other chemotype releases

atranones. Both strains cause inflammation and have proved to be

cytotoxic in mouse lungs (14). The indoor fungal profile is constant

when compared to outdoor fungi with respect the presence of species

of Penicillium and Aspergillus being dominant (15, 16). In addition

Stachybotrys chartarum is readily cultured from indoor versus outdoor

environments.

Fungi grow on various building materials based upon water

content. Fungi gather nutrients from dead organic material (wood,

dry wall, paint, paper glues, etc.) by secreting digestive enzymes

into the matrix upon which they are growing. The digestive enzymes

break down the organic matter for absorption. The moisture content

of the material upon which fungi grow is critical and is called water

activity, aw. The aw is the ratio of the vapor pressure exerted by

water in the material to the vapor pressure of pure water at the same

temperature and pressure. Thus, the fungi are divided into primary,

secondary and tertiary colonizers depending upon the aw (5, 17). The

partial list of fungi that grow at various water activity ratios

given below is helpful for initial basic understanding.

-primary colonizers (aw <0.85): Alternaria citri,

Aspergillus (Eurotium) amstelodomi, Aspergillus candidus, glaucus,

niger, penicilloides, repens, restrictus, versicolor; Paedilomyces

varlotti; Penicillium aurantiogriseum, brevicompactum, chrysogenum,

commune, expansum, griseoflavum, commune, expansum, greiseofulvum;

Wallemia sebi;

-secondary colonizers (aw = 85-90): Cladosporium

cladosporoides, herbarum, sphaerosperumum; Mucor circinelloides;

Rhizopus oryzae;

-tertiary colonizers (aw = >90): Alternaria alternata;

Aspergillus fumigatus; Epicoccum species.; Exophiala species;

Fusarium moniforme; Mucor plumbeus; Phoma herbarum; Phiaosphora

species; Trichoderma species; Stachybotrys chartarum; Ulocladium

consortiale; Rhodotorula species; Sporobolomyces species;

Actinomycetes (Actinobacteria).

b. Bacteria: These consist of gram positive and

gram negative organisms. Gram is a stain that penetrates bacteria

and helps differentiate and classify the bacteria into positive and

negative organisms.

Examples of gram positive bacteria present in water damaged

buildings are the Actinomycetes (Actinobacteria). This includes

several species of Streptomyces, Mycobacterium as well as Nocardia.

These bacteria are filamentous bacteria and produce secondary by-

products. Streptomyces californicus produces spores that are

approximately 1 micron in size that penetrate deep into alveolar

spaces of the lungs. In vitro and in vivo studies have shown the

spores of Streptomyces species contain toxins that function as human

proinflammatory mediators that can affect the lungs. In addition,

the by-products of S. californicus act synergistically in vitro with

mycotoxins, increasing the toxicity of both by-products. (9, 18-20).

The Nocardiopsis strains isolated from indoor water damaged

environments are also toxigenic (21). Finally, the CDC recognizes

that Mycobacterium avium, terrae and immunogenum have been implicated

in out breaks if hypersensitivity pneumonia (22). Asthma in adults

and children as well as a cluster of inflammatory rheumatic

conditions has been attributed to fungus and bacterial contamination

in water-damaged buildings and homes (23-27). Other Actinobacteria

in the indoor environment are Micrococcus species. Examples of other

Gram positive bacteria are species of Atrhrobacter, Bacillus ,

Cellumonas, Gordona, and Paeniibacillus (1).

Gram negative bacteria have also been identified in water-

damaged buildings. The potential danger of this group of bacteria is

the production endotoxins (lipopolysaccharides) and potential

infections, particularly species of Pseudomonas. Other gram negative

bacteria are species of Agrobacterium, Caulobacter, Stenophomonas and

Chryseomonas (1, 19-20).

2. Particulates: Colonies of fungi and bacteria shed

particulates into the indoor air, which range from <0.2 to 9

microns. The particulates can be subdivided into two fractions: (a)

Large particulates and ( fine particulates. The large particulate

fraction consists of fungus spores and fragments of fungal mycelia

(hyphae fragments) hyphae which range from 2 to approximately 9

microns. They are identified by collecting several liters of room

air on a membrane filter with a pore size of 2 microns. The large

particulates contain mycotoxins, antigenic material, enzymes,

hemolysins and other potentially toxic materials. These particulates

have been the subject of numerous studies demonstrating their affects

on the respiratory tract of mice and rats. Particular attention has

been paid to the spores and hyphae fragments of S. chartarum because

of its isolation from the lung of a child and its potential role in

pulmonary bleeding and hemosiderosis (28-31).

The fine particulate (less than 2 microns) matter consists of

material released by both fungus and bacterial growth (5-6). This

fraction is shed into the indoor air at activity levels that occur in

the frequency range of 1 -20 hertz. Moreover, these frequencies are

representative of normal human activity levels, e.g. talking,

walking, television, radio, etc. The amount of shed fine

particulates is 320 times greater than the large particulate fraction

released from fungus colonies. Furthermore, this fraction also

contains the by-products (mycotoxins, endotoxins, antigens,

hemolysin, etc.) produced by fungi and bacteria. The aerodynamics of

the fine particulates allows them to be inhaled deeply into the

microscopic alveolar spaces of the otherwise unreachable areas of the

lungs. Then simple diffusion takes place between the particulates

and the blood, which permits the entrance of mycotoxins and other

toxins into the systemic circulation (5, 6). This has been

demonstrated in a series of studies with respect to the fungus

Stachybotrys chartarum. First a laboratory bench study demonstrated

that the trichothecenes from S. chartarum are present in the fine

particulates (32). Three studies showed that the trichothecene

mycotoxins from this organism are present in the fine particulates

filtered from the indoor air of homes infested with S. chartarum (33-

37).

Additional research points towards the fine particulates as a

source of toxins. S. chartarum does not readily shed its spores

into the indoor air and arguments have been made that the

concentration of these spores cannot reach critical levels to be

toxic to humans. This fungus produces several different

trichothecene mycotoxins as well as a hemolytic protein,

Stachylysin. Trichothecene mycotoxins have been identified in the

blood and urine of symptomatic individuals occupying buildings where

this organism was detected (34-36). Stachylysin was shown to be

present in the blood of symptomatic individuals at an average

concentration of 371nanograms/milliliter (38). This occurred in

spite of the fact that these authors could not account for the

results of their study based upon indoor air spore counts. More

recently it has been demonstrated that exposure of humans and animals

to Satratoxin G (a trichothecene) leads to the production of

antibodies against Satratoxin G albumin adducts (39), confirming

earlier research demonstrating the presence of antibodies to the

mycotoxins in symptomatic exposed humans (40).

3. Mycotoxins: Mycotoxins are secondary metabolites

produced by some fungi (for further information see 13, 17, 41).

Most of these mycotoxins enhance the fitness of the fungi in nature.

However, they can also cause illness in humans and animals at low

concentrations. The illness is referred to as mycotoxicosis.

Mycotoxicoses include aflatoxicosis, ochratoxicosis, trichothecene

toxicosis, citreviridin toxicosis, fumonisin toxicosis, and gliotoxin

toxicosis. In addition, mycotoxins can modulate the immune system as

well as inhibit protein, RNA and DNA synthesis. Moreover, they can

adduct (bind) to cellular constituents, e.g. DNA, proteins,

mitochondria, and cell receptors altering their function. Mycotoxin

producing fungi of animal and human health concerns are listed in

Table 1.

The neurotoxic mycotoxins include ergot alkaloids, trichothecenes,

citreviridin, patulin, fumonisins and tremorgens. They neurotoxicity

of the tremorgens has been investigated in laboratory animals. The

have been shown to affect the brainstem, stellate ganglion, and

Purkinjee cells of the cerebellum. Mycotoxins can affect

neuroreceptor sites (e.g. gamma-aminobutyric acids (GABA and inositol

1, 4, 5 trisphosphate receptor, inhibit acetylcoholinesterase,

release excitatory neurotransmitters (e.g., glutamate aspartate,

GABA, serotonin) and block biosynthesis of complex sphingolipids

through the inhibition of ceramide synthetase (for review see 13,

71). Finally, Zearalenone and zearalenol are potent estrogenic

compounds already associated or correlated with increased incidence

rates of infertility, abortion and uterine prolapse in livestock.

Table 1. This table summarizes the toxigenic molds found and/or

identified in water-damaged buildings. The mycotoxins isolated from

the molds and their general toxic effects are also summarized. The

information in this table is obtained from the review Nielsen, 2003

and published work from EMLab P & K.

Mold Metabolites Health Concern

Stachybotrys chartarum – depending upon chemotype

Commonly found indoors on wet materials containing cellulose, such as

wallboard, jute, wicker, straw baskets, and other paper materials.

(See " Characteristics: Growth/Culture " ).

Aw=0.94

Grows well on general fungal media. Stachybotrys is slow growing as

compared to Penicillium and other common mold genera, and may not

compete well in the presence of other fungi. However, when water

availability is high for prolonged periods on environmental material,

Stachybotrys may gradually become the predominating mold, especially

on cellulose containing materials Spirocyclic drimanes;

satratoxins G,H and F; hydroxyroridin E, verrucarin J; trichodermin;

dolabellanes; atrones B and C; stachyotryamide; stachyotrylactams;

stachylysin Macrocyclic trichothecenes: verrucarin J, roridin E,

satratoxin F, G & H, sporidesmin G, trichoverrol; cyclosporins,

stachybotryolactone.

Stachybotrys mycotoxicosis:

Pulmonary hemosiderosis;

Induces proinflammatory cytokines

human toxicosis has been described;

human toxicosis may be characterized by dermatitis, cough, rhinitis,

itching or burning sensation in mouth, throat, nasal passages and

eyes. The best described toxicoses are from domestic animals that

have eaten contaminated hay and straw or inhaled infected material

from contaminated bedding.

Alternaria tenuissima

Alternara is a commonly recognized fungi with associated:.

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Woodworker's lung, Apple store

hypersensitivity.

May cross react with Ulocladium, Stemphylium, Phoma, others.

Alternariols; tentoxin; tenuazonic acids; alterion I

Alternaria alternata produces the antifungal alternariol. Other

metabolites include AME (alternariol monomethylether), tenuazonic

acid, and altertoxins (mutagenic). Mutagen associated with both

Type I & Type III responses

Respiratory, invasive, cutaneous, ear, and corneal disease. Severe,

invasive disease is usually associated with immunosuppressed hosts.

Many species grow at 37°C (body temperature).

Aspergillus flavus Alfatoxin B1 & B2 kojic acid; aspergillic

acid; 3-nitropropionic acid; cylopiazonic acid Carcinogenesis;

aspergillosis; nasal sinus lesions, invasive disease.

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Humidifier lung, Malt worker's

lung, Compost lung, Wood trimmer's disease, Straw hypersensitivity,

Farmer's lung, Oat grain hypersensitivity, others.

Aspergillus fumigatus Fumigaclavines; fumitoxins; fumitremorgens;

gliotoxins; typtoquivalins;

ergot alkaloids; fumigillin, helvolic acid, tryptoquivaline

tremorgens, verruculogen; Tremors and CNS injury; Immune damage

by gliotoxin; aspergillosis; allergic bronchopulmonary aspergillosis

(ABPA), allergic fungal sinusitis

: fungus ball and invasive disease

Aspergillus niger

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Humidifier lung, Malt worker's

lung, Compost lung, Wood trimmer's disease, Straw hypersensitivity,

Farmer's lung, Oat grain hypersensitivity, others. Ochtratoxin

A, malformin C, oxalic acid;.

A. niger is used in the bread and beer making industries (enzyme

production) and also is able to decompose plastic. A. niger is used

in cortisone production. Nephropathy; : " Swimmer's ear, " and

invasive disease ; Respiratory, invasive, cutaneous, ear, and corneal

disease. Severe, invasive disease is usually associated with

immunosuppressed hosts. Many species grow at 37°C (body temperature).

Aspergillus ochraceus

A. terreus produces mevinolin which is able to reduce blood

cholesterol Ochratoxin A, penicillic acid; xanthomegnin;

viomelllein, vioxanthin

A. ochraceus is used in cortisone production.

Nephropathy

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Humidifier lung, Malt worker's

lung, Compost lung, Wood trimmer's disease, Straw hypersensitivity,

Farmer's lung, Oat grain hypersensitivity, others.

Aspergillus ustus

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Humidifier lung, Malt worker's

lung, Compost lung, Wood trimmer's disease, Straw hypersensitivity,

Farmer's lung, Oat grain hypersensitivity, others.

Kotanins, : austocystins

allergic bronchopulmonary aspergillosis (ABPA), allergic

fungal sinusitis

Aspergillus versicolor Sterigmatocystin; 5-methoxy-

sterigmatocystin; : aspercolorin, averufin, cyclopiazonic acid,

versicolorin. Carcinogenesis; aspergillosis

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Humidifier lung, Malt worker's

lung, Compost lung, Wood trimmer's disease, Straw hypersensitivity,

Farmer's lung, Oat grain hypersensitivity, others.

Penicillium chrysogenumate

(one of approximately 200 separate known species of penicillium)

Commonly found in house dust

Penicillium is one of the most common fungal genera, worldwide.

Microbial volatile organic compounds (MVOCs) produced: Penicillium

commune produces 2-methyl-isoborneol, a heavy musty odor.

Sterigmatocystin; 5-methoxy-sterigmatocystin

Various toxins by different species: penicillic acid, peptide

nephrotoxin, viomellein, xanthomegin, xanthocillin X, decumbin

mycophenolic acid, roquefortine C & D, citrinin, penicillin,

cyclopiazonic acid, isofumigaclavine A, penitrem A, , patulin

citreoviridin, griseofulvin, verruculogen, ochratoxin, chrysogine,

and meleagrin. Carcinogenesis; secondary infections

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis: Cheese washer's lung,

Woodman's lung, Moldy wall hypersensitivity.

Chaetomium globosum

One of approximately 81 separate known species of chaetomium)

Chaetomins; chaetoglobosins A and C

Sterigmatocystin is produced by rare species. Other compounds

produced (which may not be mycotoxins in the strict sense) include a

variety of mutagens Cytoxicity; inhibition of cell division

Type I responses

Memnoniella echinata

One of 5 species identified so far, closely resembles stachybotrys

Griseofulvin; dechlorogriseofulvins; Trichothecenes:

(trichodermol and trichodermin) and griseofulvins. Trichothecene

toxicity is due to the ability to bind ribosomal protein.

Griseofulvin has been made commercially available as an anti-

dermatophyte drug : trichodermin; trichodermol Trichothecenes

(trichodermol and trichodermin) and griseofulvins. Trichothecene

toxicity is due to the ability to bind ribosomal protein.

Griseofulvin has been made commercially available as an anti-

dermatophyte drug (trichodermol and trichodermin) and griseofulvins.

Trichothecene toxicity is due to the ability to bind ribosomal

protein. Griseofulvin has been made commercially available as an anti-

dermatophyte drug

Penicicillium brevicompactum Mycophenolic acid; botryodiploidin.

Toxic

Penicillium expansum Patulin; citrinin; chaetoglobosin;

Roquerfortine C. Immune toxicity, cytotoxic; tremorgenic

Penicillium polonicum Verrucosidins; penicillic acid; nephrotoxic

glyopeptides Tremors; cytotoxicity; nephropathy

Trichoderma species

Type I allergies (hay fever, asthma).

Type III hypersensitivity pneumonitis. Trichothecenes; trichodermol;

trichodermin; gliotoxin; viridian

One of 20 species : Trichothecene and cyclic peptides; gliotoxin,

isocyanides, T-2 toxin, trichodermin. Trichoderma may cause a

mycotoxicosis similar to that caused by Stachybotrys chartarum; some

of the metabolic substances produced are closely related to

trichothecenes. Toxicity associated with trichothecenes

Human infections include a pulmonary cavity, peritonitis in a

dialysis patient, and a perihepatic infection in a liver transplant

patient. Considered an emerging opportunist in immunocompromised

persons.

Fusarium verticillioides Fumonisins

Trichothecenes (type ; T-2 toxin; zearalenone (F-2 toxin),

vomitoxin, deoxynivalenol, and fumonisin. Zearalenone is not acutely

toxic, and actually may have positive effects with controlled

ingestion. (Neurotoxin, neural tube defects)

Somewhere between 59 -70 secies identified

Causes keratitis, endophthalmitis, onychomycosis, mycetoma, and

disseminated infection in immunocompromised patients; infections in

burn victims, and systemic opportunistic infections in severely

disabled hosts.

4. Volatile Organic Compounds. Fungi and bacteria

release volatile organic compounds (VOCS) into the indoor air. It is

well accepted that VOCS are irritating to the mucous membranes of the

eyes, nose, throat and lungs in settings of sick building syndrome.

Thus, the VOCS emitted by microbial growth and water intrusion are an

additional factor for consideration in the evaluation process of the

indoor environment as contamination is investigated bearing in mind

emissions also occur from newly furnished environments. The VOCS

emitted by fungi and bacteria include 2-ethyl-1-1hexanol, 1-butanol,

3-methyl-1-butanol, 2-methyl-1-propanol, terpineol, 2-heptanone, 1-

octen-3-ol, dimethyl disulfide, 2-hexanone, 3-octanone, 2

pentylfuran, Aldehydes, ammonia, and various amine compounds (42-46,

71).

5. Extracellular Enzymes, Siderophores and Hemolysins and

Pulmonary Hemorrhage. Fungi secrete a variety of enzymes that allow

them to digest the substrate upon which they grow into their

surroundings. This occurs on building materials and also occurs on

human tissue in infectious states. The enzymes include lipases,

proteinases, metalloproteinases, fibrinolytic enzymes,

galactosidases, siderophores, and hemolysins among others. In the

human body these secreted enzymes can also become allergens,

resulting in an IgE allergic response as well as non IgE mediated

lung disease. In addition, they are inflammatory leading to lung

disease and the release of proinflammatory cytokines (47-55).

An outbreak of infant pulmonary hemosiderosis was reported in

Cleveland and was initially associated with the presence of

Stachybotrys chartarum (53, 54). Eventually a hemolysin

(Stachylysin) and a siderophore were quantified from strains of

Stachybotrys isolated from the infants' homes and from a lung of a

child with pulmonary hemorrhage (53, 54). In addition, this same

investigative team (54) analyzed the dust these homes for fungi and

the production of hemolysins. Eleven species of Aspergillus, ten

species of Penicillium, two species of Ulocladium, Paecilomyces

variotil, Memnoniella echinata, Scopulariopsis bervicaulis,

Trichoderma longibrachiatum and viride and Stachybotrys chartarum

were demonstrated to cause hemolysis of sheep's blood agar.

Hemolysins were more commonly produced by the fungi from homes with

pulmonary hemorrhage (42%) than from reference homes (10%). These

observations are significant in that they demonstrate the complexity

of the indoor environment resulting from fungal contamination.

The Cleveland cases were criticized because it was felt by

the CDC that sufficient care was not taken in the initial evaluation

to implicate Stachybotrys chartarum. In retrospect, it would have

been more judicious to include all that is currently known about

these indoor environments. This would include the following: 1)

Fine particulates that contain mycotoxins and other fungal by-

products (5, 6, 32-37). These occur up to 320 greater concentration

than mold spores; 2) The fact that stachylysin and trichothecenes are

present in body fluids when such findings cannot be attributed to the

ambient spore count; 3) Several species of several different fungi do

produce hemolysins and siderophores that could also account for the

pulmonary bleeding; and 4) Both gram negative and gram positive

bacteria co-exist with the fungi and add their toxic by-products to

the mixture. It must be remembered that the mold spores and hyphae

fragment are primarily removed from inhaled air in the nasal cavity,

The much smaller fine particulates enter the alveoli where simple

diffusion occurs and their contents are able to directly affect

surrounding tissue elements and also get into the systemic

circulation.

6. Extracellular polysaccharides (EPS). The cell wall of

fungi is a complex structure mainly composed of polysaccharides and

from where the majority of antigens, proteins, polypeptide-

polysaccharide (EPS) of the fungus are secreted into the surrounding

environment. Some of the components of the wall are directly

associated with the colonization of the host tissue and others with

damage to the same tissues. For example, the genes and their

products with respect to Aspergillus fumigatus and other fungi have

been reviewed above (45-55).

Two EPS compounds of medical importance are 1, 3 beta-D-

glucans (glucans) and galactomannans. Both are diagnostic markers

for fungal infections, particularly, Aspergillus species, systemic

Candidiasis, and exposure to several other genera of fungi (49, 52,

55-58). The glucans have been demonstrated in the indoor air and

dust and their presence is related to fungal growth as well as

intrusion of outdoor sources into homes or buildings (60, 61). The

glucans cause airway inflammation and they have been identified in

brochoalveolar lavage fluid from individuals with acute eosinophilic

pneumonia (62, 63). In addition, they have been reported to

potentiate airway allergic conditions by down regulating IgE and

promoting airway eosinophil infiltration against inhaled antigens

(64, 65). In children this effect is seen as an increased

variability in peak expiratory flow probably through nonallergic

mechanisms in atopic asthmatic children (65).

7. Endotoxins. Endotoxins are lipopolysaccharide complexes

that are part of the outer cell wall of bacteria. They are

associated with gram-negative bacteria, usually pathogens such as E.

coli, Salmonella, Shigella, and Pseudomonas, etc. The endotoxins are

maintained within the outer cell wall until autolysis of the bacteria

occurs, releasing them into the surrounding environment. They are

not only pyrogenic (fever production) but also are antigenic as well

as causing inflammation through the activation of the complement

system and the TLR4-signaling pathway. They are present in the

indoor environment of normal water-damaged homes and buildings (5,

60, 68, 69). In animal models and in humans endotoxins have a

synergistic role with the TLR4- signaling pathway leading to increase

airway inflammation (5, 26, 65-69).

Summary, Conclusions and Human Health

We have attempted to simplify and summarize the complexity of

the indoor environment resulting from the presence of fungi and

bacteria in water-damaged homes and buildings. This environment is

complex containing spores of fungi and some bacteria (Streptomyces

californicus), growing and dead fungi and bacteria, fungal and

bacterial VOCS, other chemicals and chemical compounds, both large

and fine particulates, mycotoxins, extracellular digestive proteins,

hemolysins, and extracellular polysaccharides (EPS) and endotoxins.

The physical components such as humidity, barometric pressure,

ambient temperature, drafts, room size, air flow, air currents,

chemicals used on a regular basis, such as deoderizers, sanitizers,

pesticides, paints… the properties of the building materials used

including lead paints, asbestos and other known health hazards,

architectural design and site are all important components for

consideration. The overall health or health problems (including

allergies, asthma, immune status, age, previous medical problems

experienced by inhabitants), time spent in the structure, any

patterns of illness, -should also be considered if possible when

attempting to rule in or out safety for particular inhabitants. To

isolate a single fraction of this environment, e.g. spore counts, and

attempt to indicate from this fraction that adverse health effects

upon occupants could not occur is unscientific and irresponsible.

Consequently, a California Court recognized these facts under the

-Frye ruling and disallowed defense testimony regarding this

issue. The Honorable P. Kenny, Superior Court of California,

County of Sacramento, Case # 02AS04291, found that mathematical

extrapolations from a rodent study to determine human illness from

exposure to molds and mycotoxins is not acceptable science. Judge

Kenny ruled … " with regard to Dr. Robbins relying upon her literature

review and then jumping to animal studies and then jumping to

modeling conclusions, my ruling is she will not be allowed to present

that. There is not a generally accepted view of that particular

approach in the scientific community and so therefore it's

inappropriate to present that to the jury. " Thus, the modeling

studies done by GlobalTox were not allowed in the Honorable Kenny's

Court.

The court recognized the IOM position in matters regarding

modeling from animal data and the Robbins data did not fit this

position. The position clearly states " Risk can be extrapolated from

animal studies to human health effects only if chronic animal

exposures have produced sufficient information to establish no-

observed-adverse-effect levels (NOAELs) and lowest –observed-adverse-

effect-levels (LOAELs). Extrapolation of risk exposure from animal

experiments must always take into account species differences between

animals and humans, sensitivities of vulnerable human populations and

gaps in animal data. " " Except for a few studies on cancer,

toxicologic studies of mycotoxins are acute or short-term studies

that use high exposure concentrations to reveal immediate effects in

small populations of animals. Chronic studies that use lower

exposure concentrations and approximate human exposure more closely

have not been done except for a small number of cancer

studies. " " The results of animal studies cannot be used by

themselves to draw conclusions about human health effects. " More

will be written on this matter as a follow up article in The Column.

In another case, an Appellate Court decision allowed the

testimony of Ritchie Shoemaker, M.D., on behalf of the plaintiff in

Montgomery Mutual Insurance Company v. phine Chesson, et al, No.

1270, September, 2005. The ruling states " Trial court did not err or

abuse its discretion in concluding that the methodologies employed by

Appellees' expert witness, Dr. Shoemaker, in his determination

regarding causation due to exposure to mold were not new or novel

scientific techniques requiring application of the Frye- test. "

What are the health effects in humans resulting from exposure

to indoor environments resulting from water intrusion and microbial

growth? There are three monographs and a reviewed research papers.

The first monograph was published by the Institute of

Medicine, " Damp Indoor Spaces and Health. " (69). The committee met on

March 26, June 17 and October 8, 2002. The literature review was

predominantly from 2002 and earlier with a few papers published in

early 2003. Essentially, the IOM Committee missed the scientific and

medical literature published after early 2003. Nonetheless, the

committee did conclude on page 212, Tables 5-12 and 5-13, that

sufficient evidence did exist to demonstrate upper respiratory tract

symptoms, cough wheeze, asthma and hypersensitivity pneumonitis are

associated with damp indoor spaces. What the tables also show is

that there is " inadequate or insufficient evidence to determine

whether an association exists " for several other symptoms and/or

health problems. Thus, the Committee did not exclude such health

problems as asthma, COPD, lower respiratory illness, idiopathic

pulmonary hemosiderosis, skin, G.I. tract, fatigue, neuropsychiatric

symptoms, cancer, reproductive effects, and rheumatologic and other

immune diseases.

Subsequent monographs of peer reviewed publications have been

published (71, 72). These two monographs feature independent

research on subject of indoor mold, water damage and human health.

The various authors have clearly used scientifically and medically

accepted methodologies to come their conclusions. The health

problems attributed to verified exposure to these indoor environments

include, but not limited to, multiple organ symptoms, asthma (adults

and children), pulmonary impairment, building related illnesses,

neurocognitive deficits, central and peripheral neurological injury,

autoantibodies (neural antigens and ANA), immune alterations

(activation and suppression), changes in quantitative

electroencephalogram, antibodies to molds and mycotoxins, and chronic

fungal sinusitis. The statistical analyses presented in several of

these papers demonstrated significant health problems with

confidence intervals ranging from 95 % and greater (p values from 0.5

to 0.001). Finally, several other peer reviewed research papers

published after the cutt off date of the IOM Committee confirm and

extend the observations published in these two monographs (73, 74) as

well the observations in research papers previously cited (5, 21, 26,

32-35, 39, 54).

Currently, technology does exist to determine total indoor

particulate mycotoxins, mycotoxins in urine and body fluids as well

as real time PCR DNA tests for fungi in human tissues (biopsy and

pathology specimens) from exposed ill patients. For further

information regarding these technologies contact the senior author of

this publication.

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