THE FUNGUS AMONG USOrHow to break the medicolegalMold dilemma

Warren Silverman MDMedical DirectorAccess Health SystemsLatham, NY

How are we affected by Fungi?

•ACTUAL INFECTIONS•ALLERGIC REACTIONS•FUNGAL TOXINS

Skin Infections

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Enough Gross Pictures

Fungal infections can be bad, particularly in the immunosuppressed, but what about allergies?

Symptoms of Allergic Reaction

• Wheezing• Coughing• Runny Nose• Itchy Nose• Sinus congestion• Eye tearing • Eye itching

• 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.

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

Allergic Reactions – Cont.

• 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)

• Symptoms will go away when away from the environment and return upon re-exposure. There are no persistent manifestations.

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

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

Nasal Cultures :Normals

• Acremonium 7%• Alternaria 50%• Aspergillus 42.9%• Candida 7.1%• Cladosporium 57.1%• Geotrichum 28.6%• Penicillium 21.4%• Pithomyces 7.1%

FUNGAL TOXINS

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

ERGOTISM

• Known for hundreds of years• Causes limb gangrene• Hallucinations• Death• Classical Case: Ingestion of Rye

contaminated by Claviceps Purpurae producing ergot alkaloids

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

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

• 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. 1954. Mikotoksikozi (Gribkovye otravleniia). Moscow. 216 pp. (click image for larger view).

Straw contaminated with S. chartarum (top) compared to clean straw. Persons handling this heavily contaminated straw could develop stachybotryotoxicosis

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.

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,

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

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.

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

Some Mycotoxins we love• Antibiotics• Griseofulvin• Cyclosporins

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 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 

A. aculeatu Secalonic acid D A. albertensis Ochratoxin A, Ochratoxin BA. alliaceus Ochratoxin A, Ochratoxin BA. auricomus Ochratoxin A, Ochratoxin BA. brevipes ViriditoxinA. bombycis Aflatoxin B, Aflatoxin G A. caespitosus Fumitremorgin AA. candidus Citrinin, AcT1A. carneus CitrininA. 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, AspertoxinA. flavipes CitrininA. fresenii Xanthomegnin

A. fumigatus Fumitremorgin A, Verruculogen, Gliotoxin, Fumagillin, Fumigaclavine, Helvolic acid, Sphingofungins, Brevianamide A, phthioic acidA. giganteus PatulinA. melleus Ochratoxin A, Viomellein, Xanthomegnin A. microcysticus AspochalasinA. nidulans Sterigmatocystin, DechloronidulinA. niger MalforminsA. nomius Aflatoxin B1, Aflatoxin B2, Aflatoxin G1, Aflatoxin G2 A. ochraceoroseus Aflatoxin B1, SterigmatocystinA. ochraceus

Ochratoxin A, Ochratoxin B, Ochratoxin C, Viomellein, Penicillic acidA. oryzae Cyclopiazonic acid, Maltoryzine, 3-Nitropropionic acidA. ostianus Ochratoxin A A. parasiticus Aflatoxins B1, Aflatoxin B2, Aflatoxin G1, Aflatoxin G2, Aflatoxin M1, Versicolorin AA. petrakii Ochratoxin A A. restrictus RestrictocinA. sclerotiorum Ochratoxin A, Ochratoxin BA. sulphurous Ochratoxin A, Ochratoxin BA. pseudotamarii Cyclopiazonic acid, Aflatoxin B1A. terreus Territrem A , Citreoviridin, Citrinin, Gliotoxin, Patulin, Terrein, Terreic acid, TerretoninA. ustus Austdiol, Austin, Austocystin A, Sterigmatocystin,A. variecolor SterigmatocystinA. versicolor Sterigmatocystin, Cyclopiazonic acid, Versicolorin AA. viridinutans Viriditoxin A. wentii Emodin, 3-Nitropropionic acid, Ochratoxin A, Ochratoxin BEmericella nidulans Sterigmatocystin, Emestrin Emericella venezuelensis AflatoxinEurotium chevalieri Echinulin, neoechinulin, Gliotoxin, Xanthocillin

Neosartorya fischeri Fumitremorgin A, Fumitremorgin C, Verruculogen, Tryptoquivalin A (C)

Sick Building Building Factors

Mechanical ventilationRelative 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 &amp; 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 tensionsJob dissatisfaction

Dampness and Odors

• Dampness Index1. Odor2. Condensatio

n on windows

3. Humidity in Bathrooms

4. Water leakage

Eye Sx Throat Headache

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Eye /Nasal/Throat/Facial-Skin

Headache/Tiredness

What are safe levels of Fungi?

?

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