1. Or How to break the medicolegal Mold dilemma
THE FUNGUS AMONG US Or
How to break the medicolegal
Mold dilemma
Warren Silverman MD
Medical Director
Access Health Systems
Latham, NY

2. How are we affected by Fungi?
ACTUAL INFECTIONS
ALLERGIC REACTIONS
FUNGAL TOXINS

3. Skin Infections

13. Enough Gross Pictures
Fungal infections can be bad, particularly in the immunosuppressed, but what about allergies?

14. Symptoms of Allergic Reaction
Symptoms can be caused by dead fungi as well as live organisms. The reaction is to the antigens which make up parts of the organism.
Wheezing
Coughing
Runny Nose
Itchy Nose
Sinus congestion
Eye tearing
Eye itching

15. Allergic Reactions Usually require
Prior exposure
Reaction upon re-exposure
Allergic Bronchopulmonary Aspergillosis
Rarely: Organic Dust Toxic Exposure
Single exposure to a large amount of fungal containing dust
Flu-like Symptoms
Usually in an occupational setting (i.e.: fungal contamination of grain dust, saw dust, or fungal remediation work

16. Allergic Reactions – Cont.
Symptoms will go away when away from the environment and return upon re-exposure. There are no persistent manifestations.
Fungi can produce VOC’s causing the musty odor (2-octen-1-ol), but the health risk is not demonstrated
Other environmental agents can cause identical symptoms (bacteria, avian proteins)

17. ASPERGILLOSIS Over 100 species of Aspergillus
Most infection by A. fumigatus and A.niger, less by flavus and clavatus
4 syndromes:
Allergic bronchopulmonary aspergillosis
Chronic necrotizing pneumonia
Aspergilloma
Invasive aspergillosis

18. Hypersensitivity Pneumonitis
Farmer’s lung
Maple Bark stripper’s lung
Chicken Plucker’s Lung
Humidifier Lung
Malt Worker’s Lung
Grain Handler’s Lung
Woodworker’s lung
Bagassosis
Bird Breeders Lung
Cheese worker’s Lung
Wheat Weevil Lung
Paprika Splitter’s Lung

19. Nasal Cultures :Normals
Acremonium 7%
Alternaria 50%
Aspergillus %
Candida %
Cladosporium %
Geotrichum %
Penicillium %
Pithomyces %

20. FUNGAL TOXINS
ALMOST ALL REAL EPISODES OF HUMAN ILLNESS DUE TO FUNGAL TOXINS OCCUR FOLLOWING INGESTION

22. ERGOTISM Known for hundreds of years Causes limb gangrene
Hallucinations
Death
Classical Case: Ingestion of Rye contaminated by Claviceps Purpurae producing ergot alkaloids

23. Why not by inhalation?
The toxins are produced in very low levels (in many cases, while they can be found on a culture plate, they may not be produced at all in an environmental setting)
Mycotoxins are large non-volatile molecules
Direct contact is required
Multiple fungi are usually present

24. Stachybotrys: Perils and Pitfalls
Stachybotrys chartarum (aka S. atra or S. alternans) known to produce mycotoxins called trichothecenes as well as a variety of other toxins.
Contaminated straw and grain caused epidemics in Ukraine in horses and other animals called stachybotryocosis

25. Straw contaminated with S. chartarum (top) compared to clean straw
Straw contaminated with S. chartarum (top) compared to clean straw. Persons handling this heavily contaminated straw could develop stachybotryotoxicosis
Hyperplastic dermatitis on a horse four days after feeding on straw infested with S. chartarum. Notice the scaly appearance of the upper lip area. Photograph reprinted from Sarkisov, A. Kh Mikotoksikozi (Gribkovye otravleniia). Moscow. 216 pp. (click image for larger view).

27. The Human connection?
From 1/93 – 11/94 a number of infants in Cleveland died with a hemorrhagic lung disease first labeled acute idiopathic pulmonary hemosiderosis
A study reported that the majority lived in water damaged homes and these homes were more likely to contain S. chartarum than controls.

28. Beware the mold stachybotrys
                                          
'The average person will spread the mold'
November 5, 1997 Web posted at: 11:34 p.m. EST (0434 GMT)
From Correspondent Joan MacFarlane
WEST BLOOMFIELD, Michigan (CNN)-- Deloris Griffin's 14-month-old granddaughter, Mikala,

29. Inconsistencies
The symptoms were different than that seen in veterinary disease
Other infants heavily exposed to this fungus did not develop disease
Another cluster of these cases in Chicago did not have the fungal link

30. Conclusions
The original study and data were reviewed and a statistical connection could not be established
The CDC retracted the conclusions reached based upon the original study
No clear evidence of human disease based upon environmental inhalation exposure is established.
The amount of S. Chartarum required to produce human illness is estimated at 1000 times that measured in most environmental surveys.

31. S. chartarum growing on the back side of water damaged gypsum wall board (i.e. sheetrock) behind a basement shower stall. A high water table caused flooding in the basement
Heavy growth of S. chartarum and some other fungi on gypsum wall board in a flooded school basement. This growth occurred about one week after the flood. It was removed before remodeling

32. Some Mycotoxins we love
Many fungi are very useful to humans:
yeasts-- baking and brewing wine, beer
many organic acids are commercially produced with fungi- - e.g. citric acid in Coke is produced by an Aspergillus
steroids and hormones--- e.g. the pill
certain “stinky” cheeses-- e.g. blue cheese, Roquefort and Camembert
Some Mycotoxins we love
Antibiotics
Griseofulvin
Cyclosporins

33. Some of the rest
MycotoxinOrganismAcetoxyscirpenediolFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleAcetyldeoxynivalenolFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleAcetylneosolaniolFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleAcetyl T-2 toxin Fusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleAflatoxinAspergillus flavus, A. parasiticusAflatrem Aspergillus flavusAltenuic acid Alternaria alternataAlternariolAlternaria alternataAustdiol  Aspergillus ustusAustamide Aspergillus ustusAustocystin Aspergillus ustusAvenacein +1Fusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleBeauvericin +2 Fusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleBentenolide Monographella nivalisBrevianamide Aspergillus ustusButenolideFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleCalonectrinFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleChaetoglobosinChaetomium globosumCitrinin  Aspergillus carneus, A. terreus, Penicillium citrinum, P. hirsutum, P. verrucosumCitreoviridin Aspergillus terreus, Penicillium citreovirideCochliodinol Chaetomium cochliodesCrotocin Acremonium crotocinigenumCytochalasin E Aspergillus clavatusCyclopiazonic acidAspergillus versicolorDeacetylcalonectrinFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleDeoxynivalenol diacetateFusarium moniliforme, and F. nivaleDeoxynivalenol monoacetateFusarium moniliforme, F. culmorum, F. avenaceum, F. roseum, and F. nivaleDiacetoxyscirpenolFusarium moniliforme, F. equisetiDestruxin B  Aspergillus ochraceusEnniatinsFusarium moniliforme,  F. avenaceum, F. roseum, F. solani, and F. nivaleFructigenin +1Fusarium moniliforme, F. culmorum, F. avenaceum, and F. roseumFumagilin Aspergillus fumigatusFumonisin B1Fusarium moniliforme, F. culmorum, F. avenaceum, and F. nivaleFusaric acidFusarium moniliformeFusarin  Fusarium moniliformeGliotoxinAlternaria, Aspergillus fumigatus, PenicilliumHT-2 toxinFusarium moniliforme, F. culmorum, F. avenaceum, and F. nivaleIpomeanineFusarium moniliforme, F. culmorum, F. avenaceum, and F. nivaleIslanditoxinPenicillium islandicumLateritin +1 Fusarium moniliforme, F. culmorum, F. avenaceum, and F. nivaleLycomarasmin +1 Fusarium moniliformeMalformin Aspergillus nigerMaltoryzine Aspergillus spp.Moniliformin Fusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleMonoacetoxyscirpenolFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleNeosolaniol Fusarium moniliforme, F. solani, F. culmorum, F. avenaceum, and F. roseumNivalenolFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleNT-1 toxinFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. avenaceum, F. roseum, and F. nivaleNT-2 toxinFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F., F. solani, avenaceum, F. roseum, and F. nivaleOchratoxinAspergillus ochraceus, Penicillium viridictumOxalic acidAspergillus nigerPatulinAspergillus clavatus, Penicillium expansum, Botrytis, P. roquefortii, P. claviforme, P. griseofulvumPenicillic acidAspergillus ochraceusPenitremPenicillium crustosumRoridin EMyrothecium roridum, M. verrucaria, Dendrodochium spp., Cylindrocarpon spp., Stachybotrys spp.RubratoxinPenicillium rubrumRubroskyrinPenicillium spp.RubrosulphinPenicillium viridicatumRugulosinPenicillium brunneum, P. kloeckeri, P. rugulosumSambucynin +1 Fusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. solani, F. avenaceum, F. roseum, and F. nivaleSatratoxins, F,G,HStachybotrys chartarum, Trichoderma viridiScirpentriolFusarium moniliforme, F. equiseti, F. oxysporum, F. culmorum, F. solani, F. avenaceum, F. roseum, and F. nivaleSlaframineRhizoctonia leguminicolaSterigmatocystinAspergillus flavus, A. nidulans, A. versicolor, Penicillium rugulosumT-1 toxin Fusarium moniliforme, F. equiseti,  F. culmorum, F. solani, F. avenaceum, F. roseum, and F. nivaleT-2 toxin Fusarium moniliforme, F. equiseti,  F. culmorum, F. solani, F. avenaceum, F. roseum, and F. nivaleTriacetoxyscirpendiolFusarium moniliforme, F. equiseti,  F. avenaceum, F. roseum, and F. nivaleTrichoderminTrichoderma virideTrichothecinTrichothecium roseumTrichoverrinsStachybotrys chartarumTrichoverrolsStachybotrys chartarumTryptoquivaleneAspergillus clavatusVerrucarinMyrothecium verrucaria, Dendrodochium spp., Stachybotrys chartarumVerruculogenAspergillus fumigatus, Stachybotrys chartarumViopurpurinTrichophyton spp., Penicillium viridicatumViomelleinAspergillus spp., Penicillium aurantiogriseum, P. crustosum, P. viridicatumViriditoxinAspergillus fumigatusXanthocillinEurotium chevalieriYavanicin  +1 Fusarium culmorum, F. graminearum, F. oxysporum, F. roseum,  F. moniliforme, F. avenaceum, F. equiseti, and F. nivaleZearalenoneFusarium culmorum, F. graminearum, F. oxysporum, F. roseum,  F. moniliforme, F. avenaceum, F. equiseti, and F. nivale 

34. A. aculeatu
Secalonic acid D
A. albertensis
Ochratoxin A, Ochratoxin B
A. alliaceus
A. auricomus
A. brevipes
Viriditoxin
A. bombycis
Aflatoxin B, Aflatoxin G
A. caespitosus
Fumitremorgin A
A. candidus
Citrinin, AcT1
A. carneus
Citrinin
A. clavatus
Patulin, Tryptoquivalone A (C), Cytochalasin E
A. flavus
Aflatoxin B1, Aflatoxin B2, Aflatoxin M1, Cyclopiazonic acid, Aflatrem (alkaloid), Aflatrem (indole alkaloid), 3-Nitropropionic acid, Sterigmatocystin, Versicolorin A, Aspertoxin
A. flavipes
A. fresenii
Xanthomegnin
A. fumigatus
Fumitremorgin A, Verruculogen, Gliotoxin, Fumagillin, Fumigaclavine, Helvolic acid, Sphingofungins, Brevianamide A, phthioic acid
A. giganteus
Patulin
A. melleus
Ochratoxin A, Viomellein, Xanthomegnin
A. microcysticus
Aspochalasin
A. nidulans
Sterigmatocystin, Dechloronidulin
A. niger
Malformins
A. nomius
Aflatoxin B1, Aflatoxin B2, Aflatoxin G1, Aflatoxin G2
A. ochraceoroseus
Aflatoxin B1, Sterigmatocystin
A. ochraceus
Ochratoxin A, Ochratoxin B, Ochratoxin C, Viomellein, Penicillic acid
A. oryzae
Cyclopiazonic acid, Maltoryzine, 3-Nitropropionic acid
A. ostianus
Ochratoxin A
A. parasiticus
Aflatoxins B1, Aflatoxin B2, Aflatoxin G1, Aflatoxin G2, Aflatoxin M1, Versicolorin A
A. petrakii
A. restrictus
Restrictocin
A. sclerotiorum
A. sulphurous
A. pseudotamarii
Cyclopiazonic acid, Aflatoxin B1
A. terreus
Territrem A , Citreoviridin, Citrinin, Gliotoxin, Patulin, Terrein, Terreic acid, Terretonin
A. ustus
Austdiol, Austin, Austocystin A, Sterigmatocystin,
A. variecolor
Sterigmatocystin
A. versicolor
Sterigmatocystin, Cyclopiazonic acid, Versicolorin A
A. viridinutans
A. wentii
Emodin, 3-Nitropropionic acid, Ochratoxin A, Ochratoxin B
Emericella nidulans
Sterigmatocystin, Emestrin
Emericella venezuelensis
Aflatoxin
Eurotium chevalieri
Echinulin, neoechinulin, Gliotoxin, Xanthocillin
Neosartorya fischeri
Fumitremorgin A, Fumitremorgin C, Verruculogen, Tryptoquivalin A (C)

35. Sick Building Building Factors
Mechanical ventilation
Relative humidity < 30%
Fresh air ventilation rates < 10 liters/second/person
Specific Environmental Factors & Pollutants
Volatile organic compounds (VOCs): formaldehyde, solvents, etc.
Carbon monoxide: Stoves, heaters, and furnaces
Dust & fibres: asbestosis, fibreglass, dirt
Bioaerosols: Bacteria, moulds, viruses, pollen, dust mites, animal danders, animal excreta
Trapped outdoor pollutants: vehicle or industrial exhausts
Physical factors: Lighting, vibration, noise, temperature, crowding, photoduplication
Personal Factors
Female sex
History of being allergic (atopic)
Job-related tensions
Job dissatisfaction

36. Dampness and Odors Dampness Index Odor Condensation on windows
Humidity in Bathrooms
Water leakage
Eye /Nasal/Throat/Facial-Skin
Headache/Tiredness

37. What are safe levels of Fungi?

39. How to clean the site? You are done when: There is no visible mold
There are no mold odors
You have fixed all of the moisture/water problems