Adverse Health Effects of Indoor Molds

Abstract

Purpose: It has long been known that eating moldy food is hazardous, and airborne Aspergillus and other fungi can cause life‐threatening illnesses in immunocompromised patients. However, the possible health risks of indoor mold exposure in immunocompetent humans are controversial. This literature review examines the health effects of indoor airborne exposure to mold.
Design: Literature review.
Materials and Methods: This review was conducted by searching PubMed and other medical databases, as well as reading recent conference reports.
Results: Many studies link exposure to damp or moldy indoor conditions to increased incidence and/or severity of respiratory problems such as asthma, wheezing and rhinosinusitis. Stachybotrys produces trichothecenes and other mycotoxins, which can inhibit protein synthesis and induce hemorrhaging disorders. Indoor mold exposure can alter immunological factors and produce allergic reactions. Several studies have indicated that indoor mold exposure can alter brain blood flow, autonomic nerve function, and brain waves, and worsen concentration, attention, balance and memory. Failure to perform the appropriate objective evaluations on patients may account for the commonly held belief that indoor mold exposure poses no significant health risks to immunocompetent humans.
Conclusions: Exposure to high levels of indoor mold can cause injury to and dysfunction of multiple organs and systems, including respiratory, hematological, immunological, and neurological systems, in immunocompetent humans.

Full text

REVIEW
Adverse Health Effects of Indoor Molds
LUKE CURTIS MS, CIH,
1
ALLAN LIEBERMAN MD,
2
MARTHA STARK
MD,
3
WILLIAM REA MD
4
AND MARSHA VETTER MD, PHD
5
1
School of Public Health, University of Illinois at Chicago, Illinois,
2
Center for
Occupational and Environmental Health, North Charleston, South Carolina,
3
Harvard
University, Newton Center, Massachusetts,
4
Environmental Health Center, Dallas,
Texas,
5
Environmental Health Center, Hoffman Estates, Illinois, USA
Abstract
Purpose: It has long been known that eating moldy food is hazardous, and airborne
Aspergillus and other fungi can cause life-threatening illnesses in immunocompromised
patients. However, the possible health risks of indoor mold exposure in immunocompetent
humans are controversial. This literature review examines the health effects of indoor airborne
exposure to mold.
Design: Literature review.
Materials and Methods: This review was conducted by searching PubMed and other medical
databases, as well as reading recent conference reports.
Results: Many studies link exposure to damp or moldy indoor conditions to increased
incidence and/or severity of respiratory problems such as asthma, wheezing and rhinosinusitis.
Stachybotrys produces trichothecenes and other mycotoxins, which can inhibit protein
synthesis and induce hemorrhaging disorders. Indoor mold exposure can alter immunological
factors and produce allergic reactions. Several studies have indicated that indoor mold
exposure can alter brain blood flow, autonomic nerve function, and brain waves, and worsen
concentration, attention, balance and memory. Failure to perform the appropriate objective
evaluations on patients may account for the commonly held belief that indoor mold exposure
poses no significant health risks to immunocompetent humans.
Conclusions: Exposure to high levels of indoor mold can cause injury to and dysfunction of
multiple organs and systems, including respiratory, hematological, immunological, and
neurological systems, in immunocompetent humans.
Keywords: mold, fungi, mycotoxin, allergy, indoor air quality, asthma, neurotoxicity, lung hemorrhage,
Aspergillus, Penicillium, Cladosporium, Alternaria, Stachybotrys.
INTRODUCTION
In recent years, public attention has become increasingly focused on human health
concerns linked with mold (fungi) inside homes and workplaces. Indoor airborne mold
exposure has been associated with adverse human health effects in multiple organs and
body systems, including respiratory, nervous, immune, hematological and dermatological
systems. Indoor mold exposure can also lead to life-threatening systemic infections in
immunocompromised patients.
A qualitative systematic literature review was undertaken in order to examine and
Journal of Nutritional & Environmental Medicine (September 2004) 14(3), 261–274
ISSN 1359-0847 print/ISSN 1364-6907 online/04/030261-14
#
2004 Taylor & Francis Ltd
DOI: 10.1080/13590840400010318

appraise the current state of knowledge about indoor mold-linked health effects, and to
summarize the available evidence for use by health professionals. Physicians, in particular,
may encounter patients with common symptoms occurring in particular environments, and
understanding the potential for mold-related health effects is key to the complete
investigation of those environments. Physicians and industrial hygienists may be asked to
contribute reports to assist the courts in settling suits. In 2002, an estimated 10,000 mold-
related cases were pending in US courts [1]. Also in 2002, the insurance industry paid out
$2 billion in mold-related claims in Texas alone [2].
Literature was reviewed using the peer-reviewed database, and from recent conferences
on indoor molds. The levels of evidence available for each topic varied from level I (from at
least one properly randomized controlled trial) through level II (from trials without
randomization, exceptionally convincing uncontrolled experiments, cohort or case–control
studies), to level III (opinion of respected authorities based on clinical experience,
descriptive studies, or reports of expert committees) [3].
MOLDS IN THE INDOOR ENVIRONMENT
Fungi (or molds) are ubiquitous in both indoor and outdoor environments and are
frequently dispersed by airborne spores. Mold and mold spores require moisture and a
food source, such as cellulose or decaying food, to grow [4]. As mold spores swell with
water and grow, they elongate, forming balloon-like protuberances (hyphae), which secrete
digestive enzymes and mycotoxins. The fungi then digest the food source to support their
growth.
About 100,000 fungal species have already been identified; in fact, fungi are estimated to
comprise an astounding 25% of the world’s biomass [5]. Various surveys of homes in North
America and Europe have reported that visible mold and/or water damage are common,
found in 23–98% of all homes examined [6–9]. There are no official standards at this time
for indoor airborne fungi concentrations. However, indoor fungal levels above a range of
150–1000 colony-forming units per cubic meter of air (cfu m
23
) are considered to be
sufficient to cause human health problems [7, 10–12]. Numerous reports have documented
that indoor air can be contaminated with fungal spore levels well in excess of 1000 cfu m
23
[13–20]. The most common indoor fungal genera collected are Cladosporium, Aspergillus
and Penicillium [13–20]. Alternaria, Stachybotrys, Rhizopus, Mucor, Wallemia, Trichoderma,
Chaetonium, yeasts, Botrytis, Epicoccum and Fusarium species are often found indoors as
well [13–20].
MOLD-RELATED HEALTH SYMPTOMS
Patients have been reporting multiple ill health effects linked to exposures to mold. Studies
of more than 1600 patients suffering ill effects associated with fungal exposure were
presented at one meeting in Dallas in 2003 (21st Annual Symposium of Man and His
Environment, Dallas, Texas, 19–22 June 2003) [21–25].
To cite a few studies: Lieberman [21] examined 48 heavily mold-exposed patients who
had the following health problems: muscle and/or joint pain (71%), fatigue/weakness (70%),
neurocognitive dysfunction (67%), sinusitis (65%), headache (65%), gastrointestinal
problems (58%), shortness of breath (54%), anxiety/depression/irritability (54%), vision
problems (42%), chest tightness (42%), insomnia (40%), dizziness (38%), numbness/tingling
(35%), laryngitis (35%), nausea (33%), skin rashes (27%), tremors (25%) and heart
palpitations (21%). Rea et al.’s study [23] of 150 heavily indoor mold-exposed patients
found the following health problems: fatigue (100%), rhinitis (65%), memory loss and other
neuropsychiatric problems (46%), respiratory problems (40%), fibromyalgia (29%), irritable
L. CURTIS ET AL.262

bowel syndrome (25%), vasculitis (4.7%) and angioedema (4.0%). These clinical reports
suggest that there can be multisystem adverse effects of airborne mold. All reported cases
had environmental mold exposure consistent with toxic mold exposure.
MECHANISMS OF MOLD-RELATED HEALTH EFFECTS
Fungi can exert ill health effects by three major mechanisms: allergy, toxicity, and
infection.
Allergy and Irritation
At least 70 allergens have been well characterized from spores, vegetative parts and small
particles from fungi (0.3 mm and smaller) [26, 27]. A review of 17 studies revealed that
6–10% of the general population and 15–50% of atopics had immediate skin sensitivity to
fungi [28]. Fungi produce beta glucans, which have irritant properties [29].
Toxicity
Fungi produce a wide variety of toxic chemicals called mycotoxins [4, 30, 31]. Some
common mycotoxins include: aflatoxins—very potent carcinogens and hepatotoxins,
produced by some Aspergillus species; ochratoxins—nephrotoxic and carcinogenic,
produced by some Aspergillus and Penicillium; sterigmatocystin—immunosuppressive
and a liver carcinogen, produced by Aspergillus species, especially A. versicolor;
trichothecenes—produced primarily by Stachybotrys and Fusarium species and have
been reported to inhibit protein synthesis and cause hemorrhage and vomiting. Fungi also
produce beta glucans, which have immunological effects [32]. The smell of molds comes
primarily from volatile organic compounds [33].
Adverse human and animal effects from mycotoxin-contaminated foodstuffs have been
well recognized since the early twentieth century [30, 34], but the pathway of mycotoxin
injury through inhalation is questioned [35]. Because it is unethical to conduct controlled
studies on humans with inhaled mycotoxin exposure, only controlled animal exposures and
human cohort and case–control studies can be carried out. The literature reveals that
significant amounts of mycotoxins (including ochratoxin, sterigmatocystin and trichothe-
cenes) are present in indoor dust [36–39] and dust or fungal particles less than 10 mm
in diameter are respirable, thus allowing absorption of mycotoxins through the lungs
[31, 34, 40, 41].
Patients exposed to indoor Stachybotrys have been found to have measurable blood
levels of the Stachybotrys hemorrhagic toxin stachylysin [42]. Levels of trichothecene
mycotoxins in urine have also been found in significantly higher levels in patients exposed
to high indoor fungal levels as opposed to an unexposed control group [43].
Blood ochratoxin levels have been found to be significantly higher in food industry
workers exposed to airborne ochratoxin vs. unexposed controls [39]. These findings support
an inhalation pathway for entry of mycotoxins into the body.
Infection
Fungi such as Candida, Histoplasmosis, Cryptococcus, Blastomyces and Coccidioides can
infect immunocompetent people [44]. Fungi such as Trichophyton, Candida and Malasezia
commonly cause minor skin infections in immunocompetent humans [45].
Serious infections by such fungi as Candida, Aspergillus and Pneumocystis mostly involve
severely immunocompromised patients [45–47]. In recent years, the incidence of life-
threatening infections in immunocompromised patients from Aspergillus and other common
ADVERSE HEALTH EFFECTS OF INDOOR MOLDS 263

fungi has been growing rapidly [48, 49]. Invasive aspergillosis is very common among
immunocompromised patients, with the following reported incidence rates: lung
transplants: 17–26%; allogenic bone marrow transplants: 5–15%; acute leukemia: 5–24%;
heart transplants: 2–13% [50–51]. Even with strong anti-fungal drugs and intense hospital
treatment, mortality rates from invasive aspergillosis range from 50 to 99% in the
immunocompromised [52, 53].
SAMPLING FOR MOLD EXPOSURE
Indoor fungal sampling is most commonly performed by measuring airborne levels of
viable (culturable) or total (viable and non-viable) spores [54, 55]. Some of the airborne
viable sampling methods, such as Andersen samplers, collect air for only a few minutes.
Settle plates are an inexpensive method to obtain a semi-quantitative measure of indoor
airborne fungi levels. Viable and non-viable airborne spore counts can vary considerably
over a period of minutes, so air sampling over several periods of time may be necessary to
accurately characterize airborne fungal spore levels [54, 55]. However, airborne fungi
measurements fail to take into consideration mold contamination in dust or surfaces (often
visible to the naked eye) and mycotoxins in air, dust and on surfaces [54, 56]. Therefore,
testing settled dust for fungi and mycotoxins has been recommended [54, 55]. Other
techniques, such as polymerase chain reaction (PCR), enzyme-linked immunosorbent assay
(ELISA), and measurement of fungal volatile organic compounds, polysaccharides,
ergosterol and beta glucans, have also been found to be useful in assaying indoor
environments for molds, their allergens and mycotoxins [54].
INDOOR MOLD EXPOSURE AND HEALTH EFFECTS IN BODY SYSTEMS
Respiratory System
Many epidemiological studies have noted that residential exposure to molds and/or chronic
dampness can increase asthma/wheezing incidence or morbidity in both children and adults
[7–9, 57–70]. Asthma and related conditions are very common in the USA, with an overall
prevalence of about 5.4% among all age groups and incidences as high as 27% in inner city
children [71]. Studies with infants have reported that higher fungal exposures are associated
with more wheezing, coughing and respiratory illness [72, 73]. Higher indoor beta glucan
levels have been associated with significantly higher levels of chest tightness and joint pain
[74]. Non-industrial occupational mold exposure has been reported to be associated with
significantly higher levels of asthma, sinusitis, irritated skin and eyes, and chronic fatigue
[75–79]. One study found that patients exposed to high indoor fungal levels had
significantly lower lung function than unexposed controls [24]. Higher outdoor fungal
concentrations have been linked to higher asthma death rates [80] and higher asthma
incidence [81–83] in children or young adults. Challenge exposures with Penicillium and
Alternaria extracts equivalent to high outdoor levels of fungi were noted to severely lower
lung function in asthmatics [84]. Skin sensitivity to Alternaria has been linked to much
higher risk (odds ratio 190, 95% confidence interval 6.5–6.536, pv0.0001) of respiratory
arrest [85]. Various epidemiological studies have associated skin sensitivity to common
indoor fungi and higher asthma incidence or severity [86–90] and higher rates of sinusitis
[91].
Airborne fungal exposure is known to cause bronchopulmonary aspergillosis and
hypersensitivity pneumonitis, and can cause sinusitis [92, 93]. An estimated 14% of the US
population suffers from rhinosinusitis and related conditions [94]. Allergic fungal sinusitis
was diagnosed on the basis of fungal growth in nasal secretions and the presence of allergic
mucin in 93% of 101 consecutive patients undergoing sinus surgery [94]. Another study was
L. CURTIS ET AL.264

able to recover and culture fungi from the sinuses of 56% of 45 patients undergoing
endoscopic sinus surgery for chronic rhinosinusitis [95]. A long-term cohort study of 639
patients with allergic fungal sinusitis demonstrated that remedial steps taken to reduce
fungal exposure (by utilizing, for example, air filters, ionizers, moisture control and anti-
microbial nasal sprays) significantly reduced rhinosinusitis and improved nasal mucosa
morphology [22]. This study concluded that failure to reduce airborne fungi levels to less
than four per hour on a settle plate failed to resolve the sinusitis [22]. Although,
historically, anti-fungal drugs have generally not been recommended for the treatment of
fungal sinusitis [92, 93], recent observational studies have found beneficial effects of oral
and nasal medication for sinusitis patients [22, 96]. Several studies have linked residential
exposure to various fungi with hypersensitivity pneumonitis [97–99].
Hematological Effects
Exposure to high indoor levels of Stachybotrys, Aspergillus and other fungi has been
epidemiologically associated with infant lung hemorrhage [100–104]. Although questions
were raised after this association was discovered [105], it meets many epidemiological
criteria for causality [106]. Acute infant pulmonary hemorrhage can be rapidly fatal; when
the infant survives, lung blood vessel damage is present and deposits of hemosiderin will
remain in the lung macrophages and can be seen in tissue obtained during bronchoscopy
[101]. Stachybotrys fungi produce a wide range of trichothecene mycotoxins (including
satratoxins and T2), several roridin epimers, verrucarin J and B and hemolysin [31, 103]. A
hemorrhagic protein called stachylysin has been isolated from Stachybotrys collected from
homes of infants with lung hemorrhage [107, 108] and from serum of patients with
residential Stachybotrys exposure [42]. It is hypothesized that infants with their rapidly
growing lungs are more susceptible to the toxic effects of Stachybotrys mycotoxins [109].
Studies with Stachybotrys-exposed adults have noted a significantly higher incidence of
health conditions such as wheezing, skin and eye irritation, ’flu-like symptoms and chronic
fatigue [110]. Stachybotrys has been isolated from the lungs of a child with pulmonary
hemosiderosis [111].
A case study was presented of 16-month-old twins in a mold-infested home, one of whom
died of pulmonary hemosiderosis [112]. High levels of trichothecene mycotoxins were found
in the lungs and liver of the dead infant, while high IgG levels to Stachybotrys and IgM
levels to satratoxin and trichothecenes were found in the serum of the surviving infant.
Environmental sampling in the twins’ home found high levels of satratoxin as well as high
levels of spores from Stachybotrys, Aspergillus versicolor and Penicillium [112].
Immune System
Some studies have reported that indoor fungi-exposed patients have higher serum levels of
IgG, IgA and IgM antibodies to common fungi, trichothecenes and satratoxins [113–115].
IgG antibodies to nine common indoor fungi were significantly higher in subjects with
sinusitis vs. non-sinusitis subjects in a moldy school [116]. Other studies have noted no
significant increases in fungal IgG [117, 118] or fungal IgE [113] in fungi-exposed patients.
indoor fungal exposure has been associated with altered levels of T4, T8 and natural killer
cells and higher levels of autoantibodies [23, 25, 119, 120]. Occupants of homes with high
indoor glucan exposure had a lower proportion of cytotoxic t-cells (CD8zSF61z) and
higher secretion of tumor necrosis factor than occupants of homes with lower levels of beta
glucans [121]. Studies of animals given such common mycotoxins as aflatoxins, ochratoxins
and trichothecenes orally showed considerable immune impairment, including depression
of T cells, B cells and macrophages [122]. Human cell line studies have also found that
ADVERSE HEALTH EFFECTS OF INDOOR MOLDS 265

many mycotoxins can suppress T-cell, B-cell and natural killer cell activity at serum
concentrations similar to those found in indoor mold-exposed patients [123].
Central Nervous System
Two case series of 48 and 150 mold-exposed patients found significant fatigue and
weakness in 70–100% of cases, and neurocognitive dysfunction including memory loss,
irritability, anxiety and depression in over 40% of the patients [21, 23]. Numbness, tingling
and tremor were also found in a significant number of patients [21, 23]. These signs and
symptoms have been described as classic manifestations of neurotoxicity [124].
A study of 43 mold-exposed patients found that they performed significantly worse than
202 controls on many neuropsychiatric tests, including balance sway speed, blinking reflex,
color perception, reaction times and left grip strength (pv0.0001) [125]. Quantitative
electroencephalogram (qEEG) studies in 182 patients with documented mold exposure also
noted significant alterations in brain waves, including hypoactivation of the frontal cortex
and narrowed frequency bands [126]. Higher levels of mold exposure (longer time in mold-
infested area, presence of Stachybotrys or higher cfu m
23
air) were associated with
significantly more abnormal qEEGs as well as significantly worse scores of concentration
and motor and verbal skills in these 182 patients [126]. A triple-headed SPECT brain scan
revealed neurotoxic patterns in 26 of 30 (87%) mold-exposed patients [127]. An iriscorder
study of autonomic nervous function in 60 mold-exposed patients found that 95% had
abnormal autonomic responses of the pupil compared with the population reference range
[23]. Visual contrast sensitivity studies were often abnormal in indoor mold-exposed
patients [23]. Additional studies have reported that mold-exposed patients do significantly
worse on tests of attention, balance, reaction time, verbal recall, concentration, memory,
and finger tapping compared with the general population reference range [24, 128, 129].
Most of these patients also experienced many health problems, including chronic fatigue,
headaches, insomnia and decreased balance, concentration and attention. Studies of indoor
mold-exposed children and adults found significantly more neurophysiological abnorm-
alities vs. controls, including abnormal EEGs and abnormal brainstem, visual and
somatosensory evoked potentials [25, 130, 131].
Lieberman [21] presented a case series of 12 patients who developed tremors following
documented heavy indoor mold exposure. Numerous articles have reported domestic dogs
developing tremors following ingestion of moldy food [132–134]. Territrem b, a mycotoxin
produced by the common fungus Aspergillus terreus, has been shown to be an irreversible
binder and inhibitor of acetylcholinesterase [135].
Renal System
It is known that ochratoxin-contaminated food is nephrotoxic [136, 137]. Indoor airborne
exposure to ochratoxin may also be nephrotoxic. In a case report of a family presenting
with increasing thirst/urination, lethargy, and skin rash, a considerable amount of
ochratoxin was found in their house dust. The family recovered after moving to another
home [36].
Reproductive System
The literature suggests a relationship between heavy airborne fungal exposure and
reproductive dysfunction. Kristensen et al. [138, 139] reported that airborne mycotoxin
exposures in Norwegian grain farmers were significantly related to higher rates of pre-
term deliveries, late-term miscarriages and higher rates of endometrial and ovarian
L. CURTIS ET AL.266

endocarcinoma. The veterinary literature finds a strong association between mycotoxtins in
feedstuffs and reproductive problems [140].
Diabetes
There is a great deal of evidence that links environmental factors to the triggering of type 1
diabetes. Exposure to viruses, bacteria and mycotoxins such as alloxan, streptozatocin and
L-asparginase has been linked to the development of type 1 diabetes in animals and
humans [141–143]. Lieberman [21] reported that in a single year, five of his patients
developed type 1 diabetes following documented heavy indoor mold exposure.
DIAGNOSIS AND MANAGEMENT OF POTENTIALLY MOLD-RELATED
HEALTH PROBLEMS
A careful medical and environmental history is an essential first step in evaluating a patient
for mold-related health problems [144–147]. Particular attention should be paid to any
history of exposure to visible mold and/or water damage at the home or workplace.
Environmental sampling for viable spores, total spores, and mycotoxins in the air and dust
can provide important exposure information. For a helpful overview of sampling methods,
see references [54, 148, 149]. For an informative guide to the classification, identification
and biology of common indoor fungi, see reference [4]. Several good guides exist for the
prevention and remediation of indoor fungi problems [144, 148–151].
For patients suspected of having substantial fungal exposure, a battery of sophisticated
laboratory tests has been developed:
(1) a basic metabolic panel to test for several important parameters (including
electrolytes, blood sugar, liver and kidney status)
(2) measurement of antibodies to molds and mycotoxins in serum [113, 114]
(3) immune tests for autoantibodies, complement, gamma globulins and lymphocyte
panels [120]
(4) urine and blood testing for mycotoxins [43]
(5) visual contrast sensitivity tests
(6) pupillometry and heart rate variation to assist in the evaluation of autonomic nervous
system function
(7) standard neuropsychological test batteries [23, 128–130]
(8) EEG and brain imaging techniques
(9) SPECT and magnetic resonance imaging (MRI) can be very helpful tools in
documenting neurological damage [25,125, 127, 131, 145]
(10) pulmonary function tests are also useful for patients with respiratory symptoms
[24, 124].
Failure to perform objective evaluations to access system or organ dysfunction account
for the presently accepted position that airborne mold exposures have no significant
adverse effects [35]. If end-stage organ damage is suspected, consultation with a specialist
may be useful.
Other common indoor environmental exposures should also be considered as a potential
source of health problems. Common non-fungal indoor environmental factors include poor
ventilation, carbon monoxide from faulty heat sources, leaking natural gas, pesticides,
wood smoke, second-hand tobacco smoke, petrochemicals, such as cleaners/building
materials/solvents, formaldehyde from outgassing carpets, building materials, bacteria, and
allergens from the fur, feathers, saliva and excrement of common household animals such
as cockroaches, dust mites, cats, dogs, mice, rats, caged birds, and pigeons. Exposure to
ozone, second-hand tobacco smoke, cockroach allergens, formaldehyde, and viral
ADVERSE HEALTH EFFECTS OF INDOOR MOLDS 267

infections have been noted to have a synergistic effect with fungal exposure to worsen
asthma and rhinitis [152–156].
The most important part of treatment for mold-exposed patients, symptomatic or not, is
avoidance of fungal exposure and remediation of mold contamination in the home and
workplace. Any water leaks and damage from flooded or damp areas should be rectified
immediately. Non-porous surfaces such as floors and walls that have visible mold growth
should be cleaned. Porous waterlogged materials like carpet and furniture should be
discarded. Control of humidity is important to control mold growth. The use of air
conditioners and dehumidifiers can significantly reduce summertime indoor airborne mold
concentrations [13, 157]. HEPA air filters can also significantly reduce indoor airborne
fungi concentrations [158]. For cleaning severe indoor water or mold problems, the use of
protective equipment like face masks and/or the use of a professional remediation firm may
be essential [148–151].
Environmental control plays a key role in preventing Aspergillus infections. Several
studies have linked hospital construction work to increased rates of invasive aspergillosis
[159–162]. Environmental controls such as using HEPA filters, sealing rooms, regular
cleaning of rooms, and using anti-fungal copper-8-quionolate paint have been shown to
both significantly reduce airborne levels of Aspergillus and significantly reduce rates of
invasive aspergillosis in immunocompromised hospital patients [158, 160–165]. Other recent
research has indicated that a large number of Aspergillus spores can spread through water
supplies [166] and that cleaning shower facilities can significantly lower airborne levels of
Aspergillus [167].
Use of sublingual or fungal immunotherapy by injection has been shown to be beneficial
to some patients sensitized to common indoor molds such as Alternaria and Cladosporium
herbarium [168, 169]. Some studies with laboratory animals suggest that a high-quality diet
with adequate antioxidant vitamins, selenium, phytochemicals, methionine and total
protein can reduce the harmful effects of food mycotoxins [170, 171].
SUMMARY
There is an accumulated weight of evidence linking indoor airborne mold and/or
mycotoxin exposures to multisystem adverse human health effects. A history of new
neurocognitive symptoms occurring in patients soon after heavy mold exposure,
accompanied by objective neuropsychological findings in such patients, adds considerably
to the weight of evidence from animal studies, epidemiological research, and case series.
Health care professionals, building managers, homeowners and the general public need
to be much more aware of the potential adverse health effects of high indoor fungal
exposures and the need for proper building construction, maintenance, and remediation of
dampness to prevent such effects. Potentially mold-related illnesses need to be considered in
differential diagnoses, and careful exposure histories taken. Prompt removal from exposure
to fungal contamination remains the treatment of choice, with some evidence that
immunotherapy and nutritional support are also useful. Indoor airborne mold particles can
be irritative to the respiratory tract, and fungal spores, antigens, volatile organic
compounds, and mycotoxins can be absorbed through the respiratory route to provoke
injury by the mechanisms of allergy, toxicity, and infection.
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