Floods Carry Potential for Toxic Mold Disease - JAMA - Medical News & Perspectives - May 7, 1997

[Guest guest]

http://www.ama-assn.org/sci-pubs/journals/archive/jama/vol_277/no_17/mn7066.

htm

Medical News & Perspectives - May 7, 1997

Floods Carry Potential for Toxic Mold Disease

MOLD GROWTH in water-damaged homes is a potential hazard from spring

flooding. Health officials in Ohio are already familiar with a toxic mold

that has been linked to life-threatening pulmonary hemorrhage in infants

younger than 1 year in Cleveland. The mold, Stachybotrys atra, may be found

in houses affected by major water damage.

" Unless the water damage is properly cleaned up, the recent floods in the

midwest may provide an ideal opportunity for the growth of fungi. The

Stachybotrys fungus seems to need a lot of water to grow, " noted Ruth A.

Etzel, MD, an epidemiologist in the Division of Environmental Hazards and

Health Effects at the Centers for Disease Control and Prevention (CDC),

Atlanta, Ga.

" But, " she said, " it's not just a matter of drainage. If carpeting has been

soaked there's almost no way to get the water out of it. It has to be pulled

up and thrown away. " Soaked paper, cardboard, and cellulose products should

also be discarded. Etzel also recommended using a diluted chlorine bleach

solution--1 cup of bleach in 1 gallon of water--to wash down areas that have

been soaked by flood waters.

Toxigenic fungi have been associated with pulmunary hemorrhage in 10 infants

living on the east side of metropolitan Cleveland. The original cluster of

cases was reported by physicians and public health officials in Cleveland in

November 1994 (MMWR Morb Mortal Wkly Rep. 1994;43:881-883). All 10 infants

were hospitalized, and in 5 infants, pulmonary hemorrhages recurred shortly

after they had been discharged from the hospital; 1 infant died.

The role of S atra in fatal gastrointestinal hemorrhage in livestock has

long been recognized in Europe. The fungus proliferates in moldy feed, but

it has not been associated previously with illness in human infants. Whether

the fungal problem is more widespread in the United States than the

Cleveland cases suggest is not known.

Informal surveillance for pulmonary hemorrhage by the CDC following the

original report from Cleveland uncovered an additional 32 cases in Ohio and

47 cases among infants in the rest of the country, including 8 in Chicago,

Ill (MMWR Morb Mortal Wkly Rep. 1995;44:67-74), Etzel reported at a research

conference on children's environmental health held recently in Washington,

DC. However, she noted, " we were not able to do studies of these infants. So

we are not able to say that the fungus was involved. All we know is that

they were reported cases of idiopathic pulmonary hemorrhage. "

So far all of the reported human cases have occurred in infants; there have

been no reported cases in older persons. Etzel speculated that infants are

affected because their lungs are developing rapidly but cautioned that

" that's only a guess. "

To investigate the risk factors for acute pulmonary hemorrhage, the Rainbow

Babies and Childrens Hospital in Cleveland, Cuyahoga County Board of Health,

Cleveland Department of Public Health, and CDC conducted a case control

study. The 10 case patients were matched for age and geographic location

with 30 healthy control patients. Etzel reported the results of this study

at the Washington meeting.

She noted that the presence of tobacco smoke was an added risk factor:

" There may be a synergistic effect between exposure to mold and the presence

of tobacco smoke. "

The fact that all 10 of the case infants and 7 of the controls lived in

homes where there had been water damage during the previous 6 months, as a

result of faulty plumbing or from flooding, prompted the investigators to

take air samples to look for fungi. They found a clear correlation between

the presence of fungi, including S atra, in the homes of the affected

infants compared with the control infants (MMWR Morb Mortal Wkly Rep.

1997;46:33-35).

Additional active surveillance by the Rainbow Babies and Childrens Hospital

from January 1995 to December 1996 uncovered 11 more patients with acute

pulmonary hemorrhage, 2 of whom died.

Following the report of these 3 deaths, the Cuyahoga County coroner reviewed

the postmortem examinations of all infant deaths in the county from January

1993 to December 1995. There were 172, of which 117 had been attributed to

sudden infant death syndrome (SIDS), a diagnosis made only after exclusion

of other known causes, Etzel said. Extensive hemosiderin-laden macrophages

were present in the lung tissue in 9 of the 172 cases, indicating that

alveolar bleeding had occurred for at least several days before death.

" This indicates, " she said, " that these were not SIDS cases, since it takes

at least 48 hours for macrophages to convert the iron of the ingested

erythrocytes into hemosiderin. " The 1997 MMWR report states: " Causes of such

bleeding and pulmonary hemosiderosis may include cardiac lesions associated

with left atrial pressure, trauma, pneumonia, and perhaps suffocation. "

The report continues: " The findings of this investigation--including the

association of environmental factors with pulmonary hemorrhage/hemosiderosis

and the presence of extensive hemosiderin-laden macrophages in some infants

with SIDS--underscore the need for further investigation of these relations.

In particular, further efforts are needed to clarify the association between

pulmonary hemorrhage in infants and exposoure to water-damaged building

materials and to evaluate pathologic methods to identify and quantify

pulmonary hemorrhage and hemosiderosis. "

--by Marwick

(JAMA. 1997;277:1342)