Re: 4 April 1998 AMERICAN ACADEMY OF PEDIATRICS: Toxic Effects of Indoor Mold

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>

> PEDIATRICS Vol. 101 No. 4 April 1998, pp. 712-714

>

> AMERICAN ACADEMY OF PEDIATRICS:

> Toxic Effects of Indoor Molds

> 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.

>

> INTRODUCTION

>

> 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 Cleveland17 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

> Top

> Abstract

> Introduction

> Conclusion

> Recommendation

> References

> 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

> Top

> Abstract

> Introduction

> Conclusion

> Recommendation

> References

>

> 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

>

> FOOTNOTES

>

> The recommendations in this statement do not indicate an exclusive

> course of treatment or serve as a standard of medical care.

> Variations, taking into account individual circumstances, may be

> appropriate.

>

>

>

>

>

> ABBREVIATIONS

>

> SIDS, sudden infant death syndrome. CDC, Centers for Disease

Control

> and Prevention.

>

> REFERENCES

> Top

> Abstract

> Introduction

> Conclusion

> Recommendation

> References

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

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> JD Fungi as contaminants in indoor air. Atmospheric

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> [Abstract]

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Fund

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>

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> Pediatrics (ISSN 0031 4005). Copyright ©1998 by the American

Academy

> of Pediatrics

>

> This article has been cited by other articles:

>

>

>

>

> J. W. and M. Klich

> Mycotoxins

> Clin. Microbiol. Rev., July 1, 2003; 16(3): 497 - 516.

> [Abstract] [Full Text] [PDF]

>

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> Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants--

Cleveland,

> Ohio, 1993-1996

> JAMA, April 19, 2000; 283(15): 1951 - 1953.

> [Full Text] [PDF]

>

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>

> W. E. Novotny and A. Dixit

> Pulmonary Hemorrhage in an Infant Following 2 Weeks of Fungal

> Exposure

> Arch Pediatr Adolesc Med, March 1, 2000; 154(3): 271 - 275.

> [Abstract] [Full Text] [PDF]

>

>

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>

> D. M. Kuhn and M. A. Ghannoum

> Indoor Mold, Toxigenic Fungi, and Stachybotrys chartarum:

Infectious

> Disease Perspective

> Clin. Microbiol. Rev., January 1, 2003; 16(1): 144 - 172.

> [Abstract] [Full Text] [PDF]

>

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> D. G. Dearborn, P. G. , B. B. Dahms, T. M. Allan, W.G.

> Sorenson, E. Montana, and R. A. Etzel

> Clinical Profile of 30 Infants With Acute Pulmonary Hemorrhage in

> Cleveland

> Pediatrics, September 1, 2002; 110(3): 627 - 637.

> [Abstract] [Full Text] [PDF]

>

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>

> S. J. Vesper, D. G. Dearborn, O. Elidemir, and R. A. Haugland

> Quantification of Siderophore and Hemolysin from Stachybotrys

> chartarum Strains, Including a Strain Isolated from the Lung of a

> Child with Pulmonary Hemorrhage and Hemosiderosis

> Appl. Envir. Microbiol., June 1, 2000; 66(6): 2678 - 2681.

> [Abstract] [Full Text]

>

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> O. Elidemir, G. N. Colasurdo, S. N. Rossmann, and L. L. Fan

> Isolation of Stachybotrys From the Lung of a Child With Pulmonary

> Hemosiderosis

> Pediatrics, October 1, 1999; 104(4): 964 - 966.

> [Abstract] [Full Text]

>

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