Toxic Effects of Indoor Molds

[Guest guest]

Date: 12-30-2001 22:02

Pediatrics Volume 101, Number 4 April 1998, pp 712-714

Toxic Effects of Indoor Molds (RE9736)

AMERICAN ACADEMY OF PEDIATRICS

Committee on Environmental Health

ABSTRACT. This statement describes molds, their toxic properties,

and their potential for causing toxic respiratory problems in

infants. Guidelines for pediatricians are given to help reduce

exposures to mold in homes of infants. This is a rapidly evolving

area and more research is ongoing.

---------------------------------------------------------------------

-----------

ABBREVIATIONS. SIDS, sudden infant death syndrome; CDC, Centers for

Disease Control and Prevention.

---------------------------------------------------------------------

-----------

The growth of molds is pervasive throughout the outdoor environment.

Given the proper conditions, molds may also proliferate in the

indoor setting. Because Americans spend 75% to 90% of their time

indoors,1 they are exposed to molds that are growing indoors.

Molds readily enter indoor environments by circulating through

doorways, windows, heating, ventilation systems, and air

conditioning systems. Spores in the air also deposit on people and

animals, making clothing, shoes, bags, and pets common carriers of

mold into indoor environments. The most common indoor molds are

Cladosporium, Penicillium, Aspergillus, and Alternaria.2,3

Molds proliferate in environments that contain excessive moisture,

such as from leaks in roofs, walls, plant pots, or pet urine.4-6

Many building materials are suitable nutrient sources for fungal

growth. Cellulose substrates, including paper and paper products,

cardboard, ceiling tiles, wood, and wood products, are particularly

favorable for the growth of some molds. Other substrates such as

dust, paints, wallpaper, insulation materials, drywall, carpet,

fabric, and upholstery commonly support mold growth.3 Molds also may

colonize near standing water.7-9

Some indoor molds have the potential to produce extremely potent

toxins called mycotoxins.10-12 Mycotoxins are lipid-soluble and are

readily absorbed by the intestinal lining, airways, and skin.13

Species of mycotoxin-producing molds include Fusarium, Trichoderma,

and Stachybotrys. In general, the presence of these molds indicates

a long-standing water problem.

DIRECT TOXIC EFFECTS FROM MOLD EXPOSURE

The toxic effects from mold exposure are thought to be associated

with exposure to toxins on the surface of the mold spores, not with

the growth of the mold in the body. Until recently, there was only

one published report in the United States linking airborne exposure

to mycotoxins with health problems in humans.14 This report

described upper respiratory tract irritation and rash in a family

living in a Chicago home with a heavy growth of Stachybotrys atra

(also known as Stachybotrys chatarum). The investigators documented

that this mold was producing trichothecene mycotoxins. The symptoms

disappeared when the amount of mold was substantially reduced.

More recently, molds that produce potent toxins have been associated

with acute pulmonary hemorrhage among infants in Cleveland, Ohio.15

In November 1994, physicians and public health officials in

Cleveland reported a cluster of eight cases of acute pulmonary

hemorrhage and hemosiderosis that had occurred during January 1993

through November 1994 among infants in neighborhoods of eastern

metropolitan Cleveland.16 Two additional cases were identified in

December 1994. Pulmonary hemorrhage recurred in five of the

discharged infants after they returned to their homes; of these

infants, one died from pulmonary hemorrhage.

A case-control study comparing those 10 infants who had acute

pulmonary hemorrhage and hemosiderosis with 30 age-matched control

infants from the same area in Cleveland[17] revealed that the

infants with pulmonary hemorrhage were more likely to have resided

in homes with major water damage from chronic plumbing leaks or

flooding (95% confidence interval = 2.6 to infinity). The quantity

of molds, including the toxigenic fungus Stachybotrys atra, was

higher in the homes of infants with pulmonary hemorrhage than in

those of controls. Simultaneous exposure to environmental tobacco

smoke appeared to increase the risk of acute pulmonary hemorrhage

among these infants.

Stachybotrys atra requires water-saturated cellulose-based materials

for growth in buildings. In studies conducted in North America, it

has been found in 2% to 3% of home environments sampled.8-18

Although Stachybotrys atra has been associated with gastrointestinal

hemorrhaging in animals that had consumed moldy grain,19 the fungus

previously had not been associated with disease in infants. Infants

may be particularly susceptible to the effects of these inhaled

mycotoxins because their lungs are growing very rapidly. In an

animal model, intranasal administration of toxic spores of

Stachybotrys atra to mice resulted in severe interstitial

inflammation with hemorrhagic exudates in the alveoli.20

The county coroner re-examined all infant deaths in Cleveland during

January 1993 through December 1995 to determine whether pulmonary

hemosiderin-laden macrophages were present in the lung tissue.

Postmortem examinations were reviewed for all 172 infants who died

during that period, including 117 deaths attributed to sudden infant

death syndrome (SIDS). Pathologic lung specimens were sectioned,

stained with Prussian blue, and screened for the presence of

hemosiderin. The presence of hemosiderin-laden macrophages in

alveoli indicates alveolar bleeding at least 2 days before death.21

Hemosiderin-laden macrophages were abundantly present in the lung

tissue of nine (5%) infants. Of these nine deaths, two resulted from

homicide, and one had a recent history of child abuse. The other six

deaths that were accompanied by hemosiderin-laden macrophages in the

lung thus may have been misclassified as deaths from SIDS. All six

infants had lived in the same limited geographic area as the

previously described cases of pulmonary hemosiderosis.

The extent of this problem in other areas of the United States is

still unknown. Further investigation is needed to establish

causation and prevent further health effects if the findings in

Cleveland are confirmed in other areas.

CONCLUSION

Very little is currently known about acute idiopathic pulmonary

hemorrhage among infants. This is a newly recognized problem and

knowledge is expected to be evolving rapidly. In view of the

severity of the problem, environmental controls to eliminate water

problems and to reduce the growth of indoor molds are wise. Until

more is known about the etiology of idiopathic pulmonary hemorrhage,

prudence dictates that pediatricians try to ensure that infants

under 1 year of age are not exposed to chronically moldy, water-

damaged environments.

Coroners and medical examiners should consider using the recently

published Guidelines for Death Scene Investigation of Sudden,

Unexplained Infant Deaths, which includes a question about dampness,

visible standing water, or mold growth.

Little is known about the prevalence of toxigenic molds in homes,

nor is it clear how extensive measures must be to achieve

environments sufficiently free of molds to avoid disease. Bulk mold

must be removed, followed by a thorough cleaning with soap and

water. Caution must be used, because it is possible that homeowners

could actually increase the levels of mold spores in the air by

attempting extensive clean-up efforts without guidance from a

professional (a certified industrial hygienist or ventilation

engineer). These specialists can be found in the yellow pages in the

telephone directory under the listing for Industrial Hygiene

Consultants. Additional research is needed before the most

appropriate recommendations for home clean-up can be determined.

Until then, interim guidelines have been formulated.

RECOMMENDATIONS

In areas where flooding has occurred, prompt cleaning of walls and

other flood-damaged items with water mixed with chlorine bleach,

diluted four parts water to one part bleach, is necessary to prevent

mold growth. Never mix bleach with ammonia. Moldy items should be

discarded.

Pediatricians should ask about mold and water damage in the home

when they treat infants with idiopathic pulmonary hemorrhage. If

mold is in the home, pediatricians should encourage parents to try

to find and eliminate sources of moisture. Testing the environment

for specific molds is usually not necessary. It appears to be

important to clean up moldy conditions before the infant is

discharged from the hospital to prevent recurrent pulmonary

hemorrhage, although this needs further study. Interim clean-up

guidelines are available through the Centers for Disease Control and

Prevention (CDC), 1600 Clifton Rd, Atlanta, GA 30333.

Infants with idiopathic pulmonary hemorrhage must not be exposed to

environments in which smoking occurs.

Pediatricians should report cases of idiopathic pulmonary hemorrhage

and hemosiderosis to state health departments. A reporting form is

available through the CDC.

Pediatricians should be aware that there is currently no method to

test humans for toxigenic molds such as Stachybotrys or mycotoxins.

Infants who die suddenly without known cause should have an autopsy

done including a Prussian blue stain of lung tissue to look for the

presence of hemosiderin.

COMMITTEE ON ENVIRONMENTAL HEALTH, 1997 to 1998

Ruth A. Etzel, MD, PhD, Chairperson

Sophie J. Balk, MD

F. Bearer, MD, PhD

Mark D. , MD

W. , MD, MPH

M. Shea, MD, MPH

LIAISON REPRESENTATIVES

Henry Falk, MD

Centers for Disease Control and Prevention

Lynn R. Goldman, MD

Environmental Protection Agency

W. , MD

National Cancer Institute

Walter Rogan, MD

National Institute of Environmental Health Sciences

SECTION LIAISON

Barbara Coven, MD

Section on Community Pediatrics

CONSULTANT

Holly J. Fedeyko, MPH

REFERENCES

Lebowitz MD. Health effects of indoor pollutants. Annu Rev Public

Health. 1983;4:203-221

JD. Fungi as contaminants in indoor air. Atmospheric Environ.

1992;26:2163-2172

Gravesen S, Frisvad JC, Samson RA. Microfungi. Copenhagen, Denmark:

Munksgaard Publishing; 1994

WR. Fungus aerosols arising from cold-mist vaporizers. J

Allergy. 1974;54:222-228

Kozak PP, Gallup J, Cummins LH, et al. Currently available methods

for home mould surveys: II. examples of problem homes studied. Ann

Allergy. 1980;45:167-176

Fergusson RJ, Milne LJ, Crompton GK. Penicillium allergic

alveolitis: faulty installation of central heating. Thorax.

1984;39:294-298

Kapyla M. Frame fungi on insulated windows. J Allergy. 1985;40:558-

564

JD, Laflamme AM, Sobol Y, et al. Fungi and fungal products in

some Canadian houses. Int Biodeterioration. 1988;24:103-120

Pasanen P, Pasanen AL, Janunen M, et al. Water condensation promotes

fungal growth in ventilation ducts. Indoor Air. 1993;3:106-112

Burge HA. Toxigenic potential of indoor microbial aerosols. In:

Sandu SS, DeMarini DM, et al, eds. Short-term Bioassays in the

Analysis of Complex Environmental Mixtures. New York, NY: Plenum

Press; 1987

Jarvis BB. Mycotoxins and indoor air quality. In: Morey PM, Feeley

JC, Otten JA, eds. Biological Contaminants in Indoor Environments.

Philadelphia, PA: American Society for Testing and Materials; 1990

Hendry KM, Cole EC. A review of mycotoxins in indoor air. J Toxicol

Environ Health. 1993;38:183-198

Kemppainen BW, Riley RT, Pace JG. Skin absorption as a route of

exposure for aflatoxin and trichothecenes. J Toxicol/Toxin Rev.

1988;7:95-120

Croft WA, Jarvis BB, Yatawara CS. Airborne outbreak of trichothecene

toxicosis. Atmos Environ. 1986;20:549-552

Centers for Disease Control and Prevention. Update: pulmonary

hemorrhage/hemosiderosis among infants--Cleveland, Ohio, 1993-1996.

MMWR Morb Mortal Wkly Rep. 1997;46:33-35

Centers for Disease Control and Prevention. Acute pulmonary

hemorrhage/hemosiderosis among infants-Cleveland, January 1993-

November 1994. MMWR Morb Mortal Wkly Rep. 1994;43:881-883

Montaña E, Etzel RA, Allan T, Horgan TE, Dearborn DG. Environmental

risk factors associated with pediatric idiopathic pulmonary

hemorrhage and hemosiderosis in a Cleveland community. Pediatrics.

1997;99(1). URL: http://www.pediatrics.org/cgi/content/full/99/1/e5

Kozak PP Jr, Gallup J. Endogenous mold exposure: environmental risk

to atopic and non-atopic patients. In: Gammage RV, Kay SV, eds.

Indoor Air and Human Health. Chelsea, MI: Publishers; 1985:149-

167

Hintikka E-L. Stachybotryotoxicosis as a veterinary problem. In:

Rodricks JV, Hesseltine CW, Mehlman MA, eds. Mycotoxins in Human and

Animal Health. Park Forest, IL: Pathotox Publishers; 1977:277-284

Nikulin M, Reijula K, Jarvis BB, Veijalainen P, Hintikka E-L.

Effects of intranasal exposure to spores of Stachybotrys atra in

mice. Fund Appl Toxicol. 1997;35:182-188

S, Fawcett J, son W. Interstitial haemosiderin in the

lungs of sudden infant death syndrome: a histological hallmark

of 'near-miss' episodes? J Pathol. 1985;145:53-58

[Guest guest]

--- In , " tigerpaw2c " <tigerpaw2c@...>

wrote:

>

> Date: 12-30-2001 22:02

>

> Pediatrics Volume 101, Number 4 April 1998, pp 712-714

>

> Toxic Effects of Indoor Molds (RE9736)

>

> AMERICAN ACADEMY OF PEDIATRICS

> Committee on Environmental Health

>

> ABSTRACT. This statement describes molds, their toxic properties,

> and their potential for causing toxic respiratory problems in

> infants. Guidelines for pediatricians are given to help reduce

> exposures to mold in homes of infants. This is a rapidly evolving

> area and more research is ongoing.

>

>

>

> -------------------------------------------------------------------

--

> -----------

> ABBREVIATIONS. SIDS, sudden infant death syndrome; CDC, Centers

for

> Disease Control and Prevention.

> -------------------------------------------------------------------

--

> -----------

>

>

> The growth of molds is pervasive throughout the outdoor

environment.

> Given the proper conditions, molds may also proliferate in the

> indoor setting. Because Americans spend 75% to 90% of their time

> indoors,1 they are exposed to molds that are growing indoors.

>

> Molds readily enter indoor environments by circulating through

> doorways, windows, heating, ventilation systems, and air

> conditioning systems. Spores in the air also deposit on people and

> animals, making clothing, shoes, bags, and pets common carriers of

> mold into indoor environments. The most common indoor molds are

> Cladosporium, Penicillium, Aspergillus, and Alternaria.2,3

>

> Molds proliferate in environments that contain excessive moisture,

> such as from leaks in roofs, walls, plant pots, or pet urine.4-6

> Many building materials are suitable nutrient sources for fungal

> growth. Cellulose substrates, including paper and paper products,

> cardboard, ceiling tiles, wood, and wood products, are

particularly

> favorable for the growth of some molds. Other substrates such as

> dust, paints, wallpaper, insulation materials, drywall, carpet,

> fabric, and upholstery commonly support mold growth.3 Molds also

may

> colonize near standing water.7-9

>

> Some indoor molds have the potential to produce extremely potent

> toxins called mycotoxins.10-12 Mycotoxins are lipid-soluble and

are

> readily absorbed by the intestinal lining, airways, and skin.13

> Species of mycotoxin-producing molds include Fusarium,

Trichoderma,

> and Stachybotrys. In general, the presence of these molds

indicates

> a long-standing water problem.

>

> DIRECT TOXIC EFFECTS FROM MOLD EXPOSURE

>

> The toxic effects from mold exposure are thought to be associated

> with exposure to toxins on the surface of the mold spores, not

with

> the growth of the mold in the body. Until recently, there was only

> one published report in the United States linking airborne

exposure

> to mycotoxins with health problems in humans.14 This report

> described upper respiratory tract irritation and rash in a family

> living in a Chicago home with a heavy growth of Stachybotrys atra

> (also known as Stachybotrys chatarum). The investigators

documented

> that this mold was producing trichothecene mycotoxins. The

symptoms

> disappeared when the amount of mold was substantially reduced.

>

> More recently, molds that produce potent toxins have been

associated

> with acute pulmonary hemorrhage among infants in Cleveland,

Ohio.15

> In November 1994, physicians and public health officials in

> Cleveland reported a cluster of eight cases of acute pulmonary

> hemorrhage and hemosiderosis that had occurred during January 1993

> through November 1994 among infants in neighborhoods of eastern

> metropolitan Cleveland.16 Two additional cases were identified in

> December 1994. Pulmonary hemorrhage recurred in five of the

> discharged infants after they returned to their homes; of these

> infants, one died from pulmonary hemorrhage.

>

> A case-control study comparing those 10 infants who had acute

> pulmonary hemorrhage and hemosiderosis with 30 age-matched control

> infants from the same area in Cleveland[17] revealed that the

> infants with pulmonary hemorrhage were more likely to have resided

> in homes with major water damage from chronic plumbing leaks or

> flooding (95% confidence interval = 2.6 to infinity). The quantity

> of molds, including the toxigenic fungus Stachybotrys atra, was

> higher in the homes of infants with pulmonary hemorrhage than in

> those of controls. Simultaneous exposure to environmental tobacco

> smoke appeared to increase the risk of acute pulmonary hemorrhage

> among these infants.

>

> Stachybotrys atra requires water-saturated cellulose-based

materials

> for growth in buildings. In studies conducted in North America, it

> has been found in 2% to 3% of home environments sampled.8-18

> Although Stachybotrys atra has been associated with

gastrointestinal

> hemorrhaging in animals that had consumed moldy grain,19 the

fungus

> previously had not been associated with disease in infants.

Infants

> may be particularly susceptible to the effects of these inhaled

> mycotoxins because their lungs are growing very rapidly. In an

> animal model, intranasal administration of toxic spores of

> Stachybotrys atra to mice resulted in severe interstitial

> inflammation with hemorrhagic exudates in the alveoli.20

>

> The county coroner re-examined all infant deaths in Cleveland

during

> January 1993 through December 1995 to determine whether pulmonary

> hemosiderin-laden macrophages were present in the lung tissue.

> Postmortem examinations were reviewed for all 172 infants who died

> during that period, including 117 deaths attributed to sudden

infant

> death syndrome (SIDS). Pathologic lung specimens were sectioned,

> stained with Prussian blue, and screened for the presence of

> hemosiderin. The presence of hemosiderin-laden macrophages in

> alveoli indicates alveolar bleeding at least 2 days before

death.21

>

> Hemosiderin-laden macrophages were abundantly present in the lung

> tissue of nine (5%) infants. Of these nine deaths, two resulted

from

> homicide, and one had a recent history of child abuse. The other

six

> deaths that were accompanied by hemosiderin-laden macrophages in

the

> lung thus may have been misclassified as deaths from SIDS. All six

> infants had lived in the same limited geographic area as the

> previously described cases of pulmonary hemosiderosis.

>

> The extent of this problem in other areas of the United States is

> still unknown. Further investigation is needed to establish

> causation and prevent further health effects if the findings in

> Cleveland are confirmed in other areas.

>

> CONCLUSION

>

> Very little is currently known about acute idiopathic pulmonary

> hemorrhage among infants. This is a newly recognized problem and

> knowledge is expected to be evolving rapidly. In view of the

> severity of the problem, environmental controls to eliminate water

> problems and to reduce the growth of indoor molds are wise. Until

> more is known about the etiology of idiopathic pulmonary

hemorrhage,

> prudence dictates that pediatricians try to ensure that infants

> under 1 year of age are not exposed to chronically moldy, water-

> damaged environments.

>

> Coroners and medical examiners should consider using the recently

> published Guidelines for Death Scene Investigation of Sudden,

> Unexplained Infant Deaths, which includes a question about

dampness,

> visible standing water, or mold growth.

>

> Little is known about the prevalence of toxigenic molds in homes,

> nor is it clear how extensive measures must be to achieve

> environments sufficiently free of molds to avoid disease. Bulk

mold

> must be removed, followed by a thorough cleaning with soap and

> water. Caution must be used, because it is possible that

homeowners

> could actually increase the levels of mold spores in the air by

> attempting extensive clean-up efforts without guidance from a

> professional (a certified industrial hygienist or ventilation

> engineer). These specialists can be found in the yellow pages in

the

> telephone directory under the listing for Industrial Hygiene

> Consultants. Additional research is needed before the most

> appropriate recommendations for home clean-up can be determined.

> Until then, interim guidelines have been formulated.

>

> RECOMMENDATIONS

>

> In areas where flooding has occurred, prompt cleaning of walls and

> other flood-damaged items with water mixed with chlorine bleach,

> diluted four parts water to one part bleach, is necessary to

prevent

> mold growth. Never mix bleach with ammonia. Moldy items should be

> discarded.

> Pediatricians should ask about mold and water damage in the home

> when they treat infants with idiopathic pulmonary hemorrhage. If

> mold is in the home, pediatricians should encourage parents to try

> to find and eliminate sources of moisture. Testing the environment

> for specific molds is usually not necessary. It appears to be

> important to clean up moldy conditions before the infant is

> discharged from the hospital to prevent recurrent pulmonary

> hemorrhage, although this needs further study. Interim clean-up

> guidelines are available through the Centers for Disease Control

and

> Prevention (CDC), 1600 Clifton Rd, Atlanta, GA 30333.

> Infants with idiopathic pulmonary hemorrhage must not be exposed

to

> environments in which smoking occurs.

> Pediatricians should report cases of idiopathic pulmonary

hemorrhage

> and hemosiderosis to state health departments. A reporting form is

> available through the CDC.

> Pediatricians should be aware that there is currently no method to

> test humans for toxigenic molds such as Stachybotrys or

mycotoxins.

> Infants who die suddenly without known cause should have an

autopsy

> done including a Prussian blue stain of lung tissue to look for

the

> presence of hemosiderin.

> COMMITTEE ON ENVIRONMENTAL HEALTH, 1997 to 1998

> Ruth A. Etzel, MD, PhD, Chairperson

> Sophie J. Balk, MD

> F. Bearer, MD, PhD

> Mark D. , MD

> W. , MD, MPH

> M. Shea, MD, MPH

>

> LIAISON REPRESENTATIVES

> Henry Falk, MD

> Centers for Disease Control and Prevention

> Lynn R. Goldman, MD

> Environmental Protection Agency

> W. , MD

> National Cancer Institute

> Walter Rogan, MD

> National Institute of Environmental Health Sciences

>

> SECTION LIAISON

> Barbara Coven, MD

> Section on Community Pediatrics

>

> CONSULTANT

> Holly J. Fedeyko, MPH

>

> REFERENCES

>

> Lebowitz MD. Health effects of indoor pollutants. Annu Rev Public

> Health. 1983;4:203-221

> JD. Fungi as contaminants in indoor air. Atmospheric

Environ.

> 1992;26:2163-2172

> Gravesen S, Frisvad JC, Samson RA. Microfungi. Copenhagen,

Denmark:

> Munksgaard Publishing; 1994

> WR. Fungus aerosols arising from cold-mist vaporizers. J

> Allergy. 1974;54:222-228

> Kozak PP, Gallup J, Cummins LH, et al. Currently available methods

> for home mould surveys: II. examples of problem homes studied. Ann

> Allergy. 1980;45:167-176

> Fergusson RJ, Milne LJ, Crompton GK. Penicillium allergic

> alveolitis: faulty installation of central heating. Thorax.

> 1984;39:294-298

> Kapyla M. Frame fungi on insulated windows. J Allergy. 1985;40:558-

> 564

> JD, Laflamme AM, Sobol Y, et al. Fungi and fungal products

in

> some Canadian houses. Int Biodeterioration. 1988;24:103-120

> Pasanen P, Pasanen AL, Janunen M, et al. Water condensation

promotes

> fungal growth in ventilation ducts. Indoor Air. 1993;3:106-112

> Burge HA. Toxigenic potential of indoor microbial aerosols. In:

> Sandu SS, DeMarini DM, et al, eds. Short-term Bioassays in the

> Analysis of Complex Environmental Mixtures. New York, NY: Plenum

> Press; 1987

> Jarvis BB. Mycotoxins and indoor air quality. In: Morey PM, Feeley

> JC, Otten JA, eds. Biological Contaminants in Indoor Environments.

> Philadelphia, PA: American Society for Testing and Materials; 1990

> Hendry KM, Cole EC. A review of mycotoxins in indoor air. J

Toxicol

> Environ Health. 1993;38:183-198

> Kemppainen BW, Riley RT, Pace JG. Skin absorption as a route of

> exposure for aflatoxin and trichothecenes. J Toxicol/Toxin Rev.

> 1988;7:95-120

> Croft WA, Jarvis BB, Yatawara CS. Airborne outbreak of

trichothecene

> toxicosis. Atmos Environ. 1986;20:549-552

> Centers for Disease Control and Prevention. Update: pulmonary

> hemorrhage/hemosiderosis among infants--Cleveland, Ohio, 1993-

1996.

> MMWR Morb Mortal Wkly Rep. 1997;46:33-35

> Centers for Disease Control and Prevention. Acute pulmonary

> hemorrhage/hemosiderosis among infants-Cleveland, January 1993-

> November 1994. MMWR Morb Mortal Wkly Rep. 1994;43:881-883

> Montaña E, Etzel RA, Allan T, Horgan TE, Dearborn DG.

Environmental

> risk factors associated with pediatric idiopathic pulmonary

> hemorrhage and hemosiderosis in a Cleveland community. Pediatrics.

> 1997;99(1). URL:

http://www.pediatrics.org/cgi/content/full/99/1/e5

> Kozak PP Jr, Gallup J. Endogenous mold exposure: environmental

risk

> to atopic and non-atopic patients. In: Gammage RV, Kay SV, eds.

> Indoor Air and Human Health. Chelsea, MI: Publishers;

1985:149-

> 167

> Hintikka E-L. Stachybotryotoxicosis as a veterinary problem. In:

> Rodricks JV, Hesseltine CW, Mehlman MA, eds. Mycotoxins in Human

and

> Animal Health. Park Forest, IL: Pathotox Publishers; 1977:277-284

> Nikulin M, Reijula K, Jarvis BB, Veijalainen P, Hintikka E-L.

> Effects of intranasal exposure to spores of Stachybotrys atra in

> mice. Fund Appl Toxicol. 1997;35:182-188

> S, Fawcett J, son W. Interstitial haemosiderin in the

> lungs of sudden infant death syndrome: a histological hallmark

> of 'near-miss' episodes? J Pathol. 1985;145:53-58

>