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Mold and Mycotoxins: Effects on the Neurological and
Immune Systems in Humans
ANDREW W. CAMPBELL,* JACK D. THRASHER,
{
MICHAEL R. GRAY,
{
AND
ARISTO VOJDANI
}
*
Medical Center for Immune and Toxic Disorders, Spring, Texas
{
Sam-1 Trust, Alto, New Mexico
{
Progressive Health Care Group, Benson, Arizona
}
Immunosciences Laboratories, Beverly Hills, California
I. Introduction 375
II. Water Damage and Associated Molds 378
A. Mycobiota 378
B. Mycotoxins Produced by Toxigenic Molds 378
C. Human Exposure 380
III. Symptoms, Upper and Lower Respiratory Tract 380
A. Symptoms 380
B. Upper Respiratory Fungal Infections 382
C. Lower Respiratory Tract 383
D. Proinflammatory Cytokines and Biomarkers 385
IV. IgA, IgG, and IgE Antibodies to Molds and Mycotoxins 385
A. Salivary IgA Antibodies to Molds 385
B. Serum IgA, IgM, IgG, and IgE Antibodies to Molds 386
C. Cross-Reactivity of Antibodies to Molds 387
D. Antibodies to Extracellular Polysaccharides (EPS) 390
V. Alterations in T and B Cells, Natural Killer (NK) Cells, and Other
Immune Parameters in Humans Exposed to Toxigenic Molds 390
A. Alterations in Percentage of T and B cells 390
B. Mitogen Activity 391
C. Autoantibodies 392
D. Immune Complexes 392
E. Concluding Remarks on Immunological Observations 393
VI. Neurological Abnormalities 393
A. Neurocognitive Deficits and Central Nervous System Dysfunction 394
B. Peripheral Motor and Sensory Neuropathy 396
C. Neuronal Antibodies 396
D. Demyelination of Peripheral Nerves 397
VII. Conclusion 397
References 398
I. Introduction
The potential harmful effects of exposure to molds in inhabited
buildings were recognized in early Biblical times. In the Old Testa-
ment (King James Version, Oxford 1888 Edition, Chapter XIV: Verses
375
ADVANCES IN APPLIED MICROBIOLOGY, VOLUME 55
Copyright 2004, Elsevier Inc.
All rights reserved.
0065-2164/04 $35.00
34 thru 47) Leviticus put forth a detailed protocol for the remediation
of contaminated structures, including the destruction of dwellings and
personal belongings if remediation failed. Currently it is recognized
that water intrusion into buildings leads to amplification of molds
(Andersson et al., 1997; Gravesen et al., 1999; Hodgson et al., 1998;
Jaakkola et al., 2002; Johanning et al., 1996; Nielsen, 2003; Peltola et al.,
2001), which often requires remediation.
Fungal fragments occurin indoor air as biocontaminants(Burge, 1990;
Gorney et al., 2002). Potentially toxic and immunogenic byproducts of
fungi and molds include mycotoxins (Croft et al., 1986; Johanning et al.,
2002; Nielsen et al., 1999; Nieminen et al., 2002; Tuomi et al., 1998,
2000); 1,3-alpha-D-glucans (Andersson et al., 1997), extracellular poly-
sacharrides (EPS) (Duowes et al., 1999; Notermans et al., 1988; Wouters
et al., 2000); exodigestive enzymes (EDS) (Monod et al., 2002), and
solvents (Claeson et al., 2002). In addition, trichothecenes, ochratoxin
A, sterigmatocystin, and other mycotoxins have been identified in venti-
lation duct dust and in the air in buildings where occupants have experi-
enced adverse health effects related to mold exposure (Croft et al., 1986;
Engelhart et al., 2003; Jarvis, 2002; Johanning et al., 2002; Nieminen
et al., 2002; Skaug et al., 2000; Smoragiewicz et al., 1993; Tuomi et al.,
1998). The worst-case scenario appears to be repeated episodes of
water damage that promote fungal growth and mycotoxin production,
followed by drier conditions leading to release of spores and hyphal
fragments (Nielsen, 2003).
Occupants of affected structures develop multiple organ symptoms
and have adverse effects of the upper and lower respiratory system,
central and peripheral nervous system, skin, gastrointestinal tract,
kidneys and urinary tract, connective tissue, and the musculoskeletal
system (Anyanwu et al., 2003a; Croft et al., 1986; Gunnbjornsdottir
et al., 1998; Gray et al., 2003; Hodgson et al., 1998; Jaakkola et al.,
2002; Johanning et al., 1996; Kilburn, 2002; Sailvilahti et al., 2000).
Human illness caused by fungi can result via one or all of the following:
(1) mycotic infections (mycoses) (Anaissie et al., 2002; Eucker et al.,
2001; Fraser, 1993; Grossi et al., 2000), (2) fungal rhino-sinusitis (Braun
et al., 2003; Ponikau et al., 1999; Thrasher and Kingdom, 2003), (3) IgE-
mediated sensitivity and asthma (Barnes et al., 2002; Lander et al.,
2001; Zureik et al., 2002), (4) hypersensitivity pneumonitis and related
inflammatory pulmonary diseases (Erkinjuntti-Pekkanen et al., 1999;
Ojanen, 1992; Patel et al., 2001; Sumi et al., 1994), (5) cytotoxicity
(Desai et al., 2002; Gareis, 1995; Jones et al., 2002; Nagata et al., 2001;
Poapolathep et al., 2002), (6) immune suppression/modulation (Berek
et al., 2001; BondyandPetska,2000;Jakabetal.,1994),(7)mitochondrial
376 ANDREW W. CAMPBELL et al.
toxicity (Hoehler, et al., 1997; Niranjan et al., 1982; Pace, 1983, 1988;
Sajan et al., 1997; Wei et al., 1984), (8) carcinogenicity (Dominguez-
Malagon and Gaytan-Graham, 2001; Schwartz, 2002), (9) nephrotoxi-
city (Anyanwu et al., 2003c; Pfohl-Leszkowicz et al., 2002), (10) the
formation of nuclear and mitochondrial DNA adducts (Hsieh and
Hsieh, 1993; Petkova-Bochatrova et al., 1998; Pfhlohl-Leszkowicz
et al., 1993). Finally, in the infectious state, molds secrete extracellular
digestive enzymes (EDE) that cause tissue destruction, angioinvasion,
thrombosis, infarction and other manifestations of mycosis (Ebina et al.,
1985; Kordula et al., 2002; Kudo et al., 2002; Monod et al., 2002; Ribes
et al., 2000; Vesper et al., 2000).
The pathological and inflammatory conditions associated with Sta-
chybotrys chartarum in infants with pulmonary hemosiderosis have
been characterized. S. chartarum isolated from the lungs of an affected
infant produced a hemolysin (stachylysin), a siderophore, and a prote-
ase (stachyrase) (Kordula et al., 2002; Vesper et al., 2000). Stachylysin
has also been demonstrated in the serum of adults ill from a building-
related exposure (Von Emon et al., 2003). In rodents, its presence has
been demonstrated by an immunocytochemical method following in-
stallation of S. chartarum spores into lungs. The hemolysin increases
in concentration from 24 to 72 hours following instillation of spores,
indicating that production/release is a relatively slow process (Gregory
et al., 2003). In addition, strains of S. chartarum produce different
quantities of toxic trichothecenes (Jarvis et al., 1998). In an earthworm
model, stachylysin increased the permeability of blood vessels, causing
leakage through the vessel endothelium and walls (Vesper and Vesper,
2002). Additionally, pathology may result from the interference of pul-
monary surfactant synthesis by S. chartarum spores and isosatratoxin-
F in juvenile mice. Ultrastructural changes in type II alveolar cells—
with condensed mitochondria, increased cytoplasmic rarefaction, and
distended lamellar bodies with irregularly shaped lamellae—have been
observed following exposure to S. chartarum (Mason et al., 1998, 2001;
McCrae et al., 2001; Rand et al., 2001). Thus, hemolysins, siderophores,
and proteases also appear to have an important role in the pathogenesis
of mold infections.
Recognizing the complexity of health problems associated with multi-
ple mold exposure, we have previously reported a multi-center investiga-
tion of patients with chronic health complaints from exposure to multiple
colonies of indoor fungi and molds. We utilized detailed health and
environmental history–gathering questionnaires, environmental moni-
toring data, physical examination, pulmonary function testing protocols,
routine clinical chemistries, measurements of lymphocyte phenotypic
MOLD AND MYCOTOXINS 377
markers (on T, B, and NK cells), antibodies to molds, mycotoxins,
neuronal antigen antibodies, leukocyte apoptosis, neurocognitive test-
ing, 16-channel quantitative EEGs (QEEG), nerve conduction studies
(NCS), brainstem auditory evoked potentials (BAER), visual evoked
responses (VER), and other neurological testing. The following is a sum-
mary of our findings on symptoms, pulmonary function, alterations in
peripheral lymphocyte phenotypes, autoantibodies, and neurological
abnormalities observed in patients by us and others. Currently we refer
to the illness of these individuals as a ‘‘mold mycotoxicosis’’ involving
the immune system, the lungs, the central and peripheral nervous sys-
tems, and generalized inflammatory and irritant responses to exposure to
spores, hyphal fragments, mycotoxins, solvents, and other byproducts
(e.g., EPS, EDS).
II. Water Damage and Associated Molds
A. MYCOBIOTA
Water intrusion into buildings can lead to an amplification of molds.
Molds growing on building materials (e.g., wall board, particle board,
plaster board, ceiling tiles, carpeting) are classifiable according to their
water activity, a
w
(Nielsen, 2003) as follows: (1) primary colonizers
have an a
w
of <0.8 with an optimal water requirement approaching 1
for growth. The group includes Penicillium chrysogenum and Aspergil-
lus versicolor, followed by other species of Aspergillus (niger, fumigatus,
sydowii, ustus), several Eurotium species, Penicillium species (brevi-
compactum, commune, corylophilum, pelicans), Paecilomyces variotti
and Wallemia sebi. (2) Secondary colonizers requiring a minimum of
between 0.8 and 0.9 a
w
include species of Alternaria, Cladosporium,
Phoma,andUlocladium. (3) Tertiary colonizers (water-damage molds)
that require 0.9 a
w
or greater include the most toxic molds: Chaetomium
globlosum, Stachybotrys chartarum, Memnoniella echinata,andTricho-
derma species (viride, citrinoviride, harzianum and longibrachiatum).
For a more detailed review, see Nielsen (2003).
B. MYCOTOXINS PRODUCED BY TOXIGENIC MOLDS
Fungi produce many metabolites, which are believed to play a cru-
cial role in their natural habitats. In addition, many of the metabolites
have been identified. Those that are toxic to animals and humans are
called mycotoxins. Paradoxically, antibiotics isolated from molds are
mycotoxins and are beneficial to humans. Table I lists the molds com-
monly found in water-damaged buildings and the toxic metabolites
378 ANDREW W. CAMPBELL et al.
TABLE I
TOXIGENIC MOLDS IN WATER-DAMAGED BUILDINGS
Mold Metabolites Health concern
Stachybotrys
chartarum
Spirocyclic drimanes;
satratoxins G, H and F;
hydroxyroridin E, verrucarin J;
trichodermin; dolabellanes;
atrones B and C;
stachyotryamide;
stachyotrylactams; stachylysin
Pulmonary hemosiderosis;
Induces proinflammatory
cytokines
Alternaria
tenuissima
Alternariols; tentoxin;
tenuazonic acids; altertoxin I
Unknown
Aspergillus
flavus
Aflatoxin B1; kojic acid;
aspergillic acid;
3-nitropropionic acid;
cyclopiazonic acid
Carcinogenesis;
aspergillosis
Aspergillus
fumigatus
Fumigaclavines; fumitoxins;
fumitremorgens; gliotoxins;
tryptoquivalines; verruculogen
Tremors and CNS injury;
Immune damage by
gliotoxin; aspergillosis;
Aspergillus niger Ochratoxin A Nephropathy
Aspergillus
ochraceous
Ochratoxin A, penicillic acid;
xanthomegnin; viomellein,
vioxanthin
Nephropathy
Aspergillus ustus Kotanins Unknown
Aspergillus
versicolor
Sterigmatocystin;
5-methoxy-sterigmatocystin
Carcinogenesis;
aspergillosis
Penicillium
chrysogenum
Secalonic acid D Unknown
Chaetomium
globosum
Chaetomins;
chaetoglobosins A and C
Cytoxicity; inhibition of
cell division
Memnoniella
echinata
Griseofulvin;
dechlorogriseofulvins;
trichodermin; trichodermol
Unknown
Penicillium
brevicompactum
Mycophenolic acid;
botryodiploidin.
Toxic (mutagenic)
Penicillium
expansum
Patulin; citrinin; chaetoglobosin;
Roquefortine C
Immune toxicity,
cytotoxic; tremorgenic
Penicillium
polonicum
Verrucosidins;
penicillic acid;
nephrotoxic glycopeptides
Tremors; cytotoxicity;
nephropathy
Trichoderma
species
Trichothecenes; trichodermol;
trichodermin; gliotoxin; viridin
Toxicity associated
with trichothecenes
This table summarizes the toxigenic molds found and/or identified in water-damaged buildings.
The mycotoxins isolated from the molds and their general toxic effects are also summarized. The
information in this table was obtained from the review Nielsen (2003).
MOLD AND MYCOTOXINS 379
(mycotoxins) that they produce with general statements on their toxic-
ity. Readers are referred to the literature cited in this chapter and in
Nielsen (2003) for more detailed information.
C. HUMAN EXPOSURE
Humans can be exposed to mycotoxins and metabolites of molds in
the indoor environment via (1) ingestion (contaminated foods, dirt, and
dust) (2) the skin (contaminated clothing and surfaces), and (3) inhala-
tion. Inhalation is the primary mode of exposure in the inhalation of
spores (3 to 7 m), hyphal fragments, and particulate matter down to
0.05 m. It has been shown that particles smaller than spores can be
shed from colonies of molds (Gorney et al., 2002; Kildeso et al., 2000).
Large quantities of particles 0.03 m can be released from colonies,
creating a 300-fold higher concentration of fungal fragments as com-
pared with the number of spores released (Gorney et al., 2002). There is
no apparent correlation between the number of particles and the num-
ber of spores. Factors that influence the release of spores and particu-
lates include low humidity (stimulates release), ventilation, external
wind speeds, human activity, and pressure shocks (e.g., elevators,
doors). Finally, because it is difficult to quantify the particulate matter
shed by colonies, very few meaningful correlations have been found
between spore concentrations and adverse health effects on humans
from indoor exposure to toxigenic molds (Nielsen, 2003). Thus biomar-
kers for molds and mycotoxins have been and need to be further
developed for exposure assessment.
One successful approach has been to use DNA adducts to determine
exposure to aflatoxin B1 (Makarananda et al., 1998) and ochratoxin A
(Pfhohl-Leszkowicz, 1993a,b). However, another effective approach has
been the development of immune assays to detect the presence of anti-
bodies to mold-specific antigens and mycotoxins. Also, an appreciation
of the adverse health effects can be obtained by utilizing neurophysio-
logical, neuropsychological, and immunological diagnostic procedures
(see below).
III. Symptoms, Upper and Lower Respiratory Tract
A. SYMPTOMS
Occupants of water-damaged buildings express multiple organ symp-
toms. Table II summarizes observations made on 209 adults exposed at
home and/or at the workplace. Complaints significantly different from
controls occurred as follows: (1) central nervous system (headache,
380 ANDREW W. CAMPBELL et al.
TABLE II
FREQUENCY OF SYMPTOMS
Symptom
a
Mold Patients
(N ¼) 209 Controls N ¼28 P value
Excessive Fatigue 5.8 1.9 4.3 2.1 0.0001
Headache 5.2 1.9 4.1 2 0.005
Nasal Symptoms 5.1 2.2 4.1 2 0.02
Memory Problems 5.1 2.1 3.3 1.6 0.0002
Spaciness 4.8 2.3 3.2 1.8 0.0007
Sinus Discomfort 4.7 2.2 3.6 1.8 0.01
Coughing 4.6 2.2 3.2 1.6 0.001
Watery Eyes 4.6 2.1 3.4 1.7 0.004
Throat Discomfort 4.5 2.1 3.4 1.7 0.008
Slurred Speech 4.5 2.3 3.1 2 0.002
Lightheadedness 4.4 2.2 3.2 1.4 0.006
Joint Discomfort 4.4 2.3 3.7 2.1 NS
Dizziness 4.3 2.1 3.1 1.4 0.005
Weakness 4.2 2.3 3 1.7 0.008
Bloating 4.2 2.2 3.2 1.6 0.02
Insomnia 4.1 2.2 3.8 2NS
Weak Voice 4.1 2.2 2.8 1.4 0.003
Spasms 4 2.2 3.8 2.1 NS
Coordination Problems 4 2.2 2.9 1.4 0.01
Visual Changes 3.9 2.3 2.9 1.4 0.02
Rash 3.9 2.2 2.9 1.7 0.02
Numbness 3.9 2.2 3.4 1.7 NS
Cold Intolerance 3.9 2.4 3.1 1.8 NS
Heat Intolerance 3.8 2.4 3.6 2NS
Chest Tightness 3.8 2,2 2.6 1.3 0.006
Chest Discomfort 3.7 2.2 3 1.3 NS
Urine Frequency 3.7 2.3 3.8 2.1 NS
Excessive Thirst 3.6 2.3 3.4 2NS
Ringing Ears 3.6 2.2 4.4 2.4 NS
Wheezing 3.6 2 2.6 1.3 0.02
Swallowing Problems 3.2 231.7 NS
Flushing Skin 3.1 2.1 2.8 1.6 NS
Bladder Control 3.1 2 2.8 1.4 NS
Rapid Pulse 3 2 2.6 0.9 NS
(continued )
MOLD AND MYCOTOXINS 381
short-term memory loss, lightheadedness, dizziness, blurred vision,
tinnitus, and cognitive function loss),(2) the upper respiratory tract (nasal
congestion and chronic sinusitis), (3) the lower respiratory tract (cough,
wheezing, chest tightness, exertional dyspnea, and irritation of the
throat), and (4) general ill feeling (excessive fatigue, weakness, joint
aches and pains, and rashes) (Campbell et al., 2003; Gray et al., 2003).
In addition, others have shown similar increases in the incidence of
neurological and respiratory symptoms in individuals ill from mold
exposure in water-damaged buildings (Hodgson et al., 1998; Johanning
et al., 1996; Kilburn, 2002; Vojdani et al., 2003). Vojdani et al. (2003)
reported that patients exposed to molds had significant increases in
recurrent flu-like illnesses, anxiety, and symptoms of severe allergies.
It has become increasingly obvious that exposure to multiple toxigenic
molds in water-damaged buildings leads to an increased incidence of
multiple organ symptoms in the affected individuals.
B. UPPER RESPIRATORY FUNGAL INFECTIONS
Symptoms of upper respiratory involvement include nasal conges-
tion, sinusitis, sinus pain, and nasal bleeding (chronic rhinosinusitis).
Individuals with this condition do not respond to ordinary antibiotic
therapy.
Several reports have appeared in the literature demonstrating that a
large proportion of individuals with chronic rhinosinusitis (CRS) have
infections with molds and yeast. CRS is characterized by the presence
of eosinophilic mucin, fungal hyphae, Charcot-Leyden crystals, and
the presence or absence of polyposis (Ponikau et al., 1999; Taylor et al.,
Palpitations 2.8 1.9 2.4 0.8 NS
Bruising 2.8 1.7 2.4 0.9 NS
Swelling Ankles 2.7 1.8 2.6 1.5 NS
Hearing Changes 2.7 1.8 2.6 1.5 NS
This table summarizes the frequency of symptoms of the 38 most frequently reported symptoms in
the patients vs the controls. To obtain these data, a total of 209 patients filled out questionnaires.
Critical t-test analysis was performed and p values are given for each symptom of patients vs controls
(NS ¼Not Significant).
a
The symptoms compared were for females versus males. The females had significantly greater
frequency for 21 of the 38 reported symptoms (data not shown; see Results section).
TABLE II (Continued)
Symptom
a
Mold Patients
(N ¼) 209 Controls N ¼28 P value
382 ANDREW W. CAMPBELL et al.
2002). The incidence of fungal involvement in different case studies was
82% to 100% (Braun et al., 2003; Dosa et al., 2001; Ponikau et al., 1999)
and 100% (Taylor et al., 2002). The fungal genera isolated and cultured
from nasal secretions include such indoor contaminants as Aspergillus
sp., Alternaria, Chaetomium, Cladosporium, Epicoccum, Penicillium,
Phoma, Trichoderma, and others (Dosa et al., 2002; Ponikau et al., 1999;
Taylor et al., 2002). The isolation of fungi and the presence of eosino-
phils and eosinophilic mucin rule out type I (IgE) hypersensitivity
(allergy) and strongly point to the role of invasive fungi as the cause of
CRS (Braun et al., 2003; Ponikau et al., 1999).
C. LOWER RESPIRATORY TRACT
Molds can cause lung disease by different mechanisms: allergic asthma
(Jaakkola et al., 2002; Zureik et al., 2002), infections (e.g., aspergillosis)
(Fraser, 1993; Sumi et al., 1994), and inflammation (e.g., hypersensitivity
pneumonitis, and farmer’s lung disease) (Fan, 2002; Ojanene, 1990,
1992; Patel et al., 2001). Chest x-rays can be used to detect pathological
changes associated with infections (e.g., aspergillosis and granuloma-
tous lesions). Pulmonary function testing (PFT) is used to diagnose
airway restriction caused by allergies to molds as well as inflammatory
conditions (hypersensitivity pneumonitis and farmer’s lung disease).
PFT measures flow rates in the airways of the lungs. The forced vital
capacity (FVC) is the maximum amount of air expelled during forced
expiration. The fraction of the vital capacity expired in one second is the
FEV
1
. The importance of these measurements arises from the fact that
during disease states, (e.g., asthma), the FVC may be normal while the
FEV
1
is reduced because of increased airway resistance. However, these
two measurements do not discriminate between the airways of different
caliber and therefore are not able to distinguish between the status of the
large, medium, and small airways. Airborne particulate matter and
spores (bioaerosols) from fungi range from 0.03 to 10 microns. ‘‘Respira-
ble particles’’ range from 5 microns to 0.005 microns and are capable
of reaching the small airways and alveoli of lungs. Therefore, PFT
measurements used must also detect inflammatory or obstructive
changes within the small airways. The PFT measurements most suited
for small airway obstruction are FEF 75% and FEF 25–75%. These
measure the flow rates at 75% and 25–75% of the exhalation and are
indicative of air flow through the small airways. A reduction in these
PFT values is evidence of small airway obstruction. The results pre-
sented in Fig. 1 show the mean and standard deviation of PFT values in
MOLD AND MYCOTOXINS 383
individuals with symptoms of airway obstruction following exposure to
multiple colonies of molds in water-damaged buildings. The FEF 75% is
the most significantly affected parameter, demonstrating that the airway
symptoms are probably the result of obstruction of the small airways in
these individuals.
Small airway obstruction separates these patients from the typi-
cal occurrence in asthmatic patients, which is generally more global,
involving all levels of the bronchial tree. The observed small airway
obstruction indicates that particulates from <0.3 to 5 microns are being
delivered to the alveoli in the deepest regions of the lung. This model is
supported by the lack of a rise in mycotoxin-specific IgA (see Table VI)
and the findings of Rand et al.(2002, 2003) and, thus, represents the most
likely exposure route of relevance in patients exposed to indoor bioaer-
osols when multiple mold colonies are present. Therefore, the FEF 75%
appears to be a biomarker that can be used to identify injury to the small
airways as result of particulates containing mycotoxins, EPS, and EDEs
(Rand et al., 2002, 2003).
Figure 1. The results of PFT testing on individuals exposed to molds in water-damage
structures.
384 ANDREW W. CAMPBELL et al.
D. PROINFLAMMATORY CYTOKINES AND BIOMARKERS
Proinflammatory cytokines and other biomarkers have been demon-
strated to be elevated in the nasal lavage fluid of individuals with upper
respiratory symptoms in moldy buildings versus control subjects. Thirty-
two full-time employees in a school building contaminated with A.
fumigatus and A. versicolor, Eurotium, Exophiala, Phialophora, Rhodo-
torula, Stachybotrys, Trichoderma, Ulocladium, Willenia, and actinomy-
cetes had increased concentrations of alpha-tumor necrosis factor (TNF),
interleukin 6 (IL-6), and nitric oxide (Hirvonen et al., 1999). Furthermore,
Walinder et al.(2001)demonstrated increased concentrations of eosino-
philic cationic protein, myeloperoxidase, and albumin in the nasal
lavages of occupants in buildings with mold infestation of the gypsum
board, insulation, wallpaper, and wood. Multiple genera, including
Stachybotrys,wereidentified. Finally, Nielsen et al.(2001)have shown
that an extract of metabolites from Stachybotrys independent of macrocy-
clic trichothecenes and atranones is capable of inducing in vitro macro-
phage production of alpha-TNF and IL-4. This suggests that in addition
to mycotoxins, other metabolites (e.g., spirocyclic drimanes) have a role
in the nasal inflammatory process seen in mold exposure individuals
(Nielsen, 2003; Nielsen et al., 2001). Further support comes from Leino
et al. (2003), who have shown that exposure of mice to spores from
S. chartarum increases monocytes, neutrophils, and lymphocytes in
bronchial alveolar lavage fluid (BAL). The infiltration of inflammatory
cells was associated with the induction of proinflammatory cytokines (IL-
1, IL-6, TNF-alpha), chemokines (CCL3/MIP-1, CCL4/MIP-1, and CCL2/
MCP-1), and mRNA levels in the lungs. This effect was independent
of the mycotoxin satratoxin produced by this mold. Furthermore, the
effects were observed with no significant increase in IgE, IgG2a, and
IgG1 antibody levels after exposure to S. chartarum.
IV. IgA, IgG, and IgE Antibodies to Molds and Mycotoxins
Molds release antigenic determinants (e.g., EPS, EDS, and proteins)
that elicit an antigen-antibody response. In addition, mycotoxins can
act as haptens, binding to proteins, forming a new antigenic determi-
nant (NAD). The immune system then recognizes the NAD as foreign
and makes antibodies directed against the NAD.
A. SALIVARY IGAANTIBODIES TO MOLDS
IgA antibodies are the first line of defense against foreign invasion by
preventing the attachment of microorganisms and toxins to epithelial
MOLD AND MYCOTOXINS 385
cells by complexing antigens (Challancombe, 1987). Recently Vojdani
et al. (2003) tested for the presence of saliva secretory IgA antibodies
against molds and mycotoxins in occupants with upper respiratory
symptoms of a water-damaged building. The patients had significantly
increased salivary IgA antibodies to Alternaria, Aspergillus, Chaeto-
mium, Cladosporium, Epicoccum, Penicillium, Stachybotrys, satratoxin
H, and other trichothecenes. It is probable that these IgA antibodies play
a role in late-phase type-1 and type-2 hypersensitivity as well as type-3
delayed sensitivities to molds and their byproducts. For example, in
farmer’s lung disease, serum IgA antibodies against A. fumigatus and
other molds are elevated and are correlated with the state of the disease
(Knutsen et al., 1994; Ojanen, 1992; Ojanen et al., 1990). In addition,
serum IgA antibodies to this organism are associated with exacerbations
of bronchopulmonary aspergillosis along with elevated IgE, peripheral
eosinophilia, and roentgenographic infiltrations (Apter et al., 1989).
B. SERUM IGA, IGM, IGG, AND IGEANTIBODIES TO MOLDS
IgA, IgM, IgG, and IgE antibodies to 7 different molds (Alternaria,
Aspergillus, Stachybotrys, Chaetomium, Cladosporium, Epicoccum,
and Penicillium), satratoxin H, and other trichothecenes in 40 patients
with multiple organ symptoms were compared with 40 age- and sex-
matched controls (Vojdani et al., 2003). The exposed individuals occu-
pied a water-damaged building and were tested within days following
evacuation of the premises. Quantitative enzyme-linked immunosor-
bent assay (ELISA) produced the following results: (1) IgG antibodies to
the molds and the two mycotoxins were significantly elevated in the
patients versus the controls. (2) Levels of serum IgA antibodies for each
mold and the mycotoxins were significantly elevated in the patients,
with the exception of Epicoccum. The highest titers in descending
order were found for Stachybotrys, Penicillium, and Chaetomium.
(3) IgM titers were significantly elevated in these patients versus the
controls for Stachybotrys, Cladosporium, Alternaria, Aspergillus, sa-
tratoxin H, and other trichothecenes. No difference in IgM titers were
observed between patients and controls for Chaetomium, Epicoccum,
and Penicillium. (4) With respect to IgE antibodies, a significant in-
crease in titers in these patients was found only for Aspergillus and
satratoxin H. It appears from these observations that randomly selected
controls without symptoms and apparent mold exposure have low titers
of antibodies to a variety of mold and mycotoxins. However, mold-
exposed symptomatic individuals have titers that are significantly
elevated over the control values.
386 ANDREW W. CAMPBELL et al.
In another study, Vojdani et al. (2003), utilizing ELISA assay proce-
dures, tested for IgA, IgM, and IgG antibodies against S. chartarum,
A. niger, P. notatum, satratoxin H, and other trichothecenes in the
following three groups: healthy donors (N ¼500); 500 patients referred
to the laboratory for various diagnostic tests for illnesses without ap-
parent exposure to molds (N ¼500); and randomly selected patients
referred for illness associated with exposure to molds (N ¼500). The
results of this study are summarized in Tables III through VI. Briefly,
the concentration of IgA, IgM, and IgG antibody titers were lowest in
the blood donors, intermediate in the randomly selected patients, and
highest in the mold-exposed patients for each of the molds. With
respect to satratoxin H and trichothecene antibodies, the antibody
titers had a different distribution. When the mold-exposed patients
were compared with the healthy controls, IgG and IgM titers were
significantly elevated, while IgA titers were not. When the mold-
exposed patients were compared with the random patients, only the
IgG titers were significantly different. Moreover, on inspection of the
data on the random patients, it was noted that the standard deviation
(SD) was large and overlapped with the mean value and SD of the mold
patients. It appears from these observations that the randomly selected
patients may have been exposed to molds without recognition by the
attending physician that such exposure might have occurred. Barnes
et al. (2002) reached similar conclusions. They demonstrated IgE and
IgG antibodies to Stachybotrys chartarum in 9.4% and 42.2% of the sera
of 139 blood donors. They concluded that sensitivity to S. chartarum is
potentially much more widespread than previously appreciated. This
fungus may affect the asthmatic and allergic population through both
immunologic and toxic mechanisms. The significance of the fungus in
the milieu of allergenic fungi may need to be re-evaluated.
C. CROSS-REACTIVITY OF ANTIBODIES TO MOLDS
The use of antibodies to molds as a biomarker of exposure has been
criticized (Musmand, 2003). The critique is based on two publications.
One is an abstract the full results of which have never been published
(Halsey et al., 2001); therefore, it is impossible to determine anything
about the methods used in this paper. The second is a position paper
published on the Internet by the California Department of Public Services
in which not a single experiment was conducted. Recently the question of
cross-reactivity between mold antigens (S. chartarum, A. niger, and P.
notatum) was investigated by using affinity-purified rabbit sera (Vojdani
et al., 2004). The results of this study showed that non-immunized rabbits
MOLD AND MYCOTOXINS 387
TABLE III
ANTIBODY LEVELS TO PENICILLIUM NOTATUM
Antibody
Healthy
Controls
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
Random
Patients
N¼500
Mold
Patients
N¼500
Z
Score
P
Value
IgG 620 535 2159 2458 13.7 <0.001 1383 1839 2159 2458 5.6 <0.001
IgM 692 551 1692 2442 8.9 <0.001 1241 1530 1692 2442 3.5 <0.001
IgA 640 572 1256 2163 6.1 <0.001 853 1070 1256 2163 3.7 <0.001
Mean S.D. IgG, IgM, and IgA antibody levels in ELISA units to Penicillium notatum in controls, randomly selected patients and mold-exposed patients
with Z test and P values.
TABLE IV
ANTIBODY LEVELS TO ASPERGILLUS NIGER
Antibody
Healthy
Controls
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
Random
Patients
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
IgG 618 426 1795 2316 11.1 <0.001 1349 1417 1795 2316 3.7 <0.001
IgM 782 420 1725 2449 8.5 <0.001 1177 1302 1725 2449 4.4 <0.001
IgA 732 595 1346 2456 5.4 <0.001 849 938 1346 2456 4.2 <0.001
Mean S.D. IgG, IgM, and IgA antibody levels in ELISA units to Aspergillus niger in controls, randomly selected patients and mold-exposed patients with
Z test and P values.
TABLE V
ANTIBODY LEVELS TO STACHYBOTRYS CHARTARUM
Antibody
Healthy
Controls
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
Random
Patients
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
IgG 803 530 2304 2432 13.5 <0.001 973 1234 2304 2432 10.9 <0.001
IgM 629 602 1940 2478 11.5 <0.001 1115 1212 1940 2478 6.7 <0.001
IgA 665 665 1511 2660 6.9 <0.001 760 1086 1511 2660 5.8 <0.001
Mean S.D. IgG, IgM, and IgA antibody levels in ELISA units to Stachybotrys chartarum in controls, randomly selected patients and mold-exposed
patients with Z test and P values.
TABLE VI
ANTIBODY LEVELS TO SATRATOXIN H
Antibody
Healthy
Controls
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
Random
Patients
N¼500
Mold
Patients
N¼500
Z
Score
P
Values
IgG 767 641 1523 1352 11.3 <0.001 1054 1147 1523 1352 5.9 <0.001
IgM 611 648 1320 1590 9.2 <0.001 1160 1170 1320 1590 1.8 <0.060
IgA 715 588 705 868 2.1 <0.440 747 819 705 868 0.78 <0.430
Mean S.D. IgG, IgM, and IgA antibody levels in ELISA units to satratoxin H in controls, randomly selected patients and mold-exposed patients with Z test
and P values.
develop IgG antibody titers to these molds that increase in concentration
with age. The sera from these rabbits gave an impression of up to 52%
cross-reaction with Aspergillus, Penicillium,andStachybotrys.When
using affinity-purified antibodies in cross-inhibition studies, the antigen-
ic cross-reaction between Stachybotrys and Aspergillus was between
8.6% and 12.3%, and between Stachybotrys and Penicillium extracts it
showed 9.3–9.6% antigenic similarities. Thus, for cross-reaction studies
between different molds, affinity-purified antibodies and a sensitive and
quantitative assay with natural antigens should be used. When using
such an assay, it was concluded that cross-reactions between Stachybo-
trys, Aspergillus,andPenicillium exist but are much less widespread
than previously believed. Based on these observations, antibodies to
molds and mycotoxins as developed by this laboratory methodology are
reliable biomarkers of mold and mycotoxin exposure.
D. ANTIBODIES TO EXTRACELLULAR POLYSACCHARIDES (EPS)
EPS can cause type I and type III inflammatory processes. They have
been shown to be present in mold-contaminated buildings and can be
used as a marker of mold contamination and exposure (Duowes et al.,
1999; Wouters et al., 2000). Exposure to 1–3 beta-D-glucan caused air-
way inflammation with symptoms of dry cough, phlegm, and hoarseness
(Rylander, 1997; Rylander et al., 1998). IgG antibodies in immunized
rabbits against EPS from several mold genera have been reported
(Notermans et al., 1987, 1988). The EPS antigens caused the production
of fairly specific antibodies, with some cross-reactivity as determined by
an ELISA. The EPS antigens produced by species of Penicillium, Asper-
gillus,andGeotrichum lost their immunological activity with heating at
100 CatpH1.8.TheEPSantigensfromMucor recemosus, Rhizopus
olgosporus,andC. cladosporoides were stable under the same conditions.
It appears from these data that an ELISA for antibodies to EPS released by
various molds could be developed as an additional biomarker for mold
exposure.
V. Alterations in T and B Cells, Natural Killer (NK) Cells, and Other
Immune Parameters in Humans Exposed to Toxigenic Molds
A. ALTERATIONS IN PERCENTAGE OF TAND BCELLS
Peripheral blood lymphocytes can be identified and quantified by
using fluorescent antibodies to cell surface antigens. Typical markers
for T cells are designated as CD2, CD3, CD4, and CD8. B cells are
identified by CD19 or CD20. In addition, other markers can be used to
390 ANDREW W. CAMPBELL et al.
identify activation of T and B cells, (e.g., CD25, CD26, HLR-DRþ,
CD8CD11bþ). Patients chronically ill from exposure to toxigenic molds
in water-damaged office buildings, schools, and homes have altered
percentages of lymphocyte markers in their peripheral blood when
compared with expected ranges (Gray et al., 2003). The patients had
increased B cells (CD20) (75.6%). T cell activation markers increased
for the following cell types: CD5CD25 (68.9%), CD3CD26 (91.2%),
CD8HLR-DRþ(62%), and CD8CD38 (56.6%). Decreases were observed
for CD8CD11bþ(15.6%) and natural killer (NK) cells (CD3CD16CD56,
38.5%). Moreover, Thrasher et al. (2004) found that individuals with
an ongoing exposure to molds in a water-damaged building had re-
lative increases over controls of the following: total lymphocyte count,
T cells (CD2, CD3, CD4, CD8, and CD3CD16), B (CD19) cells, and
NK cells (CD3CD16CD56).
B. MITOGEN ACTIVITY
T and B cells respond to specific and nonspecific antigens by under-
going cell division (mitogenesis). Mitogenesis responses to nonspecific
mitogens were as follows: phytohematogglutinin (PHA) was decreased
by 26.2% in mold-exposed subjects, while only 5.9% had decreased
response to Concanavalin A (ConA) (Gray et al., 2003). PHA stimulates
T cells, while Con A causes T and B cells to divide.
Mitotic responses to ConA, PHA, PWM (pokeweed mitogen), and
LPS (lipopolysaccharides) were examined in patients with an ongoing
exposure to toxigenic molds. In general, mitogenesis to PHA and Con
A was significantly elevated over controls, indicating increased
response of T cells to nonspecific antigens. In addition, mitogenic
response to B cell stimulators (ConA, PWM, and LPS) was also signifi-
cantly elevated. Although mitogenesis was increased, the patients
could be subdivided into three distinct responses to each mitogen as
follows: suppression, elevation, and extremely elevated (Thrasher
et al., 2004). Analysis of the NK cell (CD3CD16CD56) activity revealed
that 42.4% of these patients had decreased killing of target cells.
Furthermore, the CD4/CD8 (helper/suppressor) ratio was significantly
elevated.
These two studies (Gray et al., 2003; Thrasher et al., 2004) indicated
that alterations in the percentages of T and B cells, mitogenesis, and
NK cell activity ccurred in mold-exposed humans. The alterations
included an increase in activation markers, which may be a result
of antigenic stimulation. Furthermore, the changes in mitogenic re-
sponse to both nonspecific and specific mitogens indicate immune
MOLD AND MYCOTOXINS 391
suppression occurred in some individuals, while others experienced
immune stimulation. The decrease in NK cells and their activity may
indicate that there was a decrease in immune surveillance, which
may have importance with respect to cancer and/or infectious diseases.
C. AUTOANTIBODIES
Autoantibodies directed against self-antigens are known to occur in
a variety of autoimmune diseases and degenerative neurologic
disorders. Antinuclear autoantibodies (ANA) are the ones most com-
monly recognized and are usually associated with connective tissue
disease (e.g., lupus). However, other autoantibodies can be directed
against a variety of self-antigens and can also be used as biomarkers of
toxic exposure (Thrasher et al., 2002; Vojdani et al., 1992, 1993). Hu-
mans exposed to toxigenic molds have abnormally elevated autoanti-
bodies to the following: ANA, anti-smooth muscle, peripheral, and
central nervous system myelin and eight different neural antigens
including myelin basic protein, ganglioside G1, sulfatide, tubulin,
crystallin, filament, MOG, and MAG (Campbell et al., 2003; Gray
et al., 2003). Odds ratios for each autoantibody at 95% C.I. was signifi-
cant, showing an increased risk for autoimmunity. Autoantibodies and
autoimmune diseases are recognized as occurring from toxic exposures
(Cooper et al., 2002; Griem et al., 1998). For the significance regarding
the neural antigen autoantibodies, see Neurological Abnormalities,
Section VI.
D. IMMUNE COMPLEXES
Immune complexes occur when antigen and antibodies combine and
have been implicated in numerous immunopathologic conditions, in-
cluding systemic lupus erythematosus, rheumatoid arthritis, glomerulo-
nephritis, and infectious induced inflammation (Abbas et al., 1994).
Deposition of immune complexes can occur from cell or tissue specific
antibody-antigen reactions resulting in organ injury and/or immune com-
plex diseases (Bigazzi et al., 1986). Thus it would appear from these
observations on increased immune complexes that inflammation and
autoimmune reactions may exist in mold-exposed patients. Circulating
immune complexes containing IgG, IgM, and IgA antibodiescan generate
a variety of substances associated with muscle damage and the acute
phase response that can activate the classic pathway of complement
(Sorensen et al., 2003). Autoantibodies are also known to activate the
complement system.
392 ANDREW W. CAMPBELL et al.
E. CONCLUDING REMARKS ON IMMUNOLOGICAL OBSERVATIONS
The increase in B cells, activation markers, and helper/suppressor
ratio all indicate immune activation has occurred as demonstrated by
Gray et al. (2003) and Thrasher et al. (2004). Increased activation marker
(CD45RO) has been reported for symptomatic children with exposure to
molds in contaminated homes (Dales et al., 1998). These observations
are consistent with production of proinflammatory cytokines as dis-
cussed above with antigenic stimulation. In addition, elevated immune
complexes are further support for immune activation and antigenic
stimulation. The presence of elevated immune complexes is compatible
with increased production of antibodies to mold antigens as well as the
presence of ANA, anti-smooth muscle, and anti-neural antigen antibo-
dies. The observations on immune alterations discussed above are also
consistent with the suggestion that mold exposure causes immune dys-
regulation (Hirvonen et al., 1999; Wichman, et al., 2002). Recently a
review by Anyanwu et al. (2003b) showed that natural killer cell activity
was adversely affected in patients with chronic exposure to indoor
molds and may be implicated in causing neurological abnormalities.
VI. Neurological Abnormalities
Neurological abnormalities caused by mycotoxins from molds
have been described in the literature. The neurotoxic mycotoxins
include trichothecenes, citreoviridin, patulin, fumonisin, penitrem,
verruculogen, rubratoxin, ergot alkaloids, and tremorgens.
Wilson et al. were the first to isolate a tremorgenic mycotoxin in 1964.
The mycotoxin penitrem has been shown to induce tremors and con-
vulsions in experimental animals (Hayes, 1980). Jorntner et al. (1986)
and Norris et al. (1980) studied the neurological effects of the mycotox-
ins penitrem A and verruculogen, which are known to cause a neuro-
toxicity characterized by sustained tremors. Their findings support a
primary site of action of both of these mycotoxins as being presynaptic.
Mycotoxins, being relatively nonpolar, pass through the blood-brain
barrier and thereby have access to synapses. The neurotoxic effects of
ergot alkaloids are known to affect the postganglionic parasympathetic
synapses (Berde et al., 1978).
Wang et al. (1998) in their study suggested that the primary site of
trichothecene action is the brain. Chapman (2003) reported how tricho-
thecene mycotoxins from Stachybotrys cause neurological disorders by
being neurotoxic. The clinical signs of trichothecene mycotoxicosis
include eye pain, dyspnea, tachycardia, vomiting, muscle tremors and
MOLD AND MYCOTOXINS 393
weakness, lack of coordination, and confusion. Patients affected devel-
op seizures, central nervous system dysfunction, hypotension, and
myelosuppression (Stahl et al., 1985). Studies have shown that expo-
sure to molds can cause optic demyelinating neuritis and multifocal
choroiditis (Campbell et al., 2003; Rudich et al., 2003).
The nephrotoxic and hepatotoxic effects of mycotoxins have been
well documented in several studies (Anyanwu et al., 2003c; Bhat et al.,
1989; Etzel et al., 1998). The mycotoxin rubratoxin was studied by
Moss (1971) and was shown to cause liver and kidney damage
and lesions of the central nervous system. Ciegler and Bennett (1980)
stated that trichothecene mycotoxins cause clinical conditions that
include skin irritations, vomiting, anorexia, diarrhea, hemorrhage,
and convulsions.
Walsh et al. (1985) reviewed a large number of patients with necropsy-
proven central nervous system aspergillosis and identified important
epidemiological, pathological, and clinical features. In their study, the
most common central nervous system lesions were subcortical hemor-
rhagic infarcts in the cerebral hemispheres or cerebellum, and they found
that the most common entry of Aspergillus into the central nervous system
was the lower respiratory tract. Aspergillosis of the central nervous sys-
tem, lungs, and at least one other organ was found in almost 66% of the
patients. Beal et al.(1982), in their neuropathological review, discovered
that the pathologic hallmark of neurologic aspergillosis cases was the
invasion of fungal hyphae into the blood vessel walls with subsequent
necrosis and thrombosis and spread into the surrounding tissues.
A. NEUROCOGNITIVE DEFICITS AND CENTRAL NERVOUS SYSTEM DYSFUNCTION
Pena (1970) noted subtle personality changes were observed as an
initial sign in cases of disseminated aspergillosis. Young et al. (1970)
noted in their study of 13 patients with disseminated aspergillosis that
all had some degree of lethargy or fatigue. Malkin et al. (1998) in their
study at National Institute of Occupational Safety and Health reported
multiple neurological symptoms in occupants of an office building
contaminated by several species of fungi, including Penicillium, As-
pergillus, Alternaria, Candida, Cladosporium, Epicoccum, Fusarium,
and Pullularia.Gordon et al. (1993) described a patient who after being
exposed to Aspergillus, Penicillium, and Rhizopus developed fatigue,
headache, progressive somnolence, slowness of thinking, and severe
tremors. The patient had coarse fasciculations of the muscles of the
face and tongue and was unable to stand unassisted. His EEG showed a
general dysrythmia consistent with a toxic encephalopathy.
394 ANDREW W. CAMPBELL et al.
Baldo et al. (2002) studied the neuropsychological performance of
10 patients exposed to molds (Stachybotrys atra, Penicillium, and
Aspergillus). The patients had a variety of symptoms: fatigue, respira-
tory problems, recurring bloody noses, nausea, frequent sore throats,
and headaches, among others. The mold-exposed patients were im-
paired on a number of cognitive measures, with the most consistent
deficits in visuospatial learning, visuospatial memory, verb, learning,
and psychomotor speed. In addition, the mold-exposed patients had
evidence of Axis I and Axis II pathology. There was a significant
correlation among patient’s scores on the Beck Depression Inventory,
with a number of neuropsychological tests falling within the impaired
range. The authors put forth a model by which to investigate the effects
of mold exposure on the central nervous system.
Cragoetal.(2003)furtherdemonstratedthatmeasuresofexposurewere
highly predictive of neuropsychological test performance using two sub-
tests from the Delis–Kaplan Executive Function System (D–KEFS) to mea-
sure executive or higher-level cognitive functions. Significant predictive
power was observed for the D–KEFS Trail Making subtests of visual
scanning, letter sequencing, number–letter sequencing, and motor speed;
the D–KEFS Color–Word Inhibition/Switching subtest; the WAIS-III
Digit Symbol Coding and Symbol Search subtests; and the IVA-CPT
full-scale attention quotient and the visual and auditory attention quoti-
ents. Crago et al. (2003) also reported that significant predictive power
was found for estimates of degree of exposure and for the QEEG variables
of mean frequency delta, relative power theta, relative power alpha,
absolute power delta, absolute power theta, and absolute power alpha.
In addition, the QEEG findings in confirmed mold-exposed patients in-
dicated a restriction in the range of functioning (narrowed frequency
bands) of the frontal lobes, that is, increased (accelerated) meanfrequency
of the slower frequencies (delta range) and decreased (slowed) higher
frequencies (beta range), indicating a collapse toward the middle of the
frequency spectrum. These findings, coupled with observed increased
levels of absolute and relative power theta and alpha waves in frontal
sites, indicated hypoactivation of the frontal cortex consistent with insuf-
ficient excitatory input from the reticular activating system anatomically
seated in the midbrain.
Finally, Kilburn (2002) reported on both objective neurological tests
and neuropsychological evaluation of 20 mold-exposed patients. Ob-
jective tests showed impaired balance, reaction time, color discrimina-
tion, and visual fields in the mold-exposed patients. Neuropsychological
tests showed impaired cognition, verbal recall, and trail making. Pulmo-
nary function testing showed small airway obstruction was observed in 4
MOLD AND MYCOTOXINS 395
patients. Longer durations of exposure and aging appeared to increase the
total abnormalities. He concluded ‘‘Moulds appear to cause chemical
encephalopathy and these abnormalities.’’
Neurophysiological effects of mold exposure have been reported in
children as compared with controls (Anyanwu et al., 2003a). Brainstem
auditory evoked response (BAER), electroencephalogram (EEG), visual
evoked potential (VEP), and somatosensory evoked potential (SSEP) were
used to test neurological abnormalities. Three of 10 children had an
abnormal EEG following moldexposure. The frontal-temporal theta wave
activity in the 10 patients seemed to indicate diffuse changes consistent
with metabolic encephalopathies. Also, 1 to 3 hertz delta activity was
asymmetric in the right hemisphere of 3 patients. BAER showed abnorm-
alities in 9 patients with both 150and 3500 check sizes. A significant delay
in waveform V occurred in the majority of patients, representing dysfunc-
tional cognitive process and conductive hearing loss in both ears. VEP
showed clear abnormalities in 4 of the children with P100 amplitudes and
latencies decreased bilaterally. SSEP showed diffuse polyneuropathy in
three patients. The authors concluded that exposure to toxic molds can
affect neurological and behavioral status of children.
B. PERIPHERAL MOTOR AND SENSORY NEUROPATHY
Campbell et al. (2003) studied 119 patients with symptoms of neuro-
toxicity with documented measured exposure to molds. These patients
complained of fatigue, memory loss, cognitive function loss, headaches,
tremors, numbness and tingling, blurred vision, tinnitus, and muscle
weakness. Ninety-nine of these patients had abnormal clinical neuro-
logical examinations, abnormal findings on neurophysiological testing,
and elevated antibodies to neuronal antigens. Nerve conduction studies
(NCVs) revealed three groups of abnormal patients (ABM) and one
group of normal (NM): mixed sensory motor polyneuropathy (55
ABN); motor neuropathy (17 ABN); sensory neuropathy (27 ABN); and
symptoms without neurophysiological abnormalities (20 NM, controls).
C. NEURONAL ANTIBODIES
Elevated autoantibodies by ELISA to several neuronal antigens were
found in patients with documented measured exposure to molds. The
titers of the autoantibodies were significantly elevated over controls.
These included IgA, IgG, and IgM antibodies to myelin basic protein,
myelin associated glycoprotein, oligodendrocyte glycoprotein, ganglio-
side GM-1, chondroitin sulfate, crystalline, tubulin, and neurofilament.
396 ANDREW W. CAMPBELL et al.
D. DEMYELINATION OF PERIPHERAL NERVES
Campbell et al.(2003)concluded their observations on changes in
nerve conduction velocities and the presence of neural antigen autoanti-
bodies as follows: ‘‘The increased latency for motor and sensory nerves
observed in the 55 patients with mixed neuropathy is suggestive of a
demyelinating process (Busby et al., 2003).’’ This was accompanied by
a decrease in velocities for the median, ulnar, and peroneal nerves while
the tibial nerve had a decrease in the amplitude. All three sensory nerves
(median, ulnar, and superficial peroneal) exhibited increased latencies
and decreased amplitudes. Thus the polyneuropathy observed in these
patients appeared to be a demyelinating process with decreased number
and size of fibers (decreased amplitude) and chronic involvement of the
nerve (decreased velocities) (Busby et al., 2003; Steck et al., 1987).
The motor neuropathies (17 patients) had decreases in latencies (peroneal
and tibial nerves), decreased amplitudes (median and peroneal nerves),
and decreased velocities(median, ulnar, peroneal, and tibial nerves). This
appeared to be a diffuse neuropathy and may involve some demyelination
(Berger et al., 2003). Finally, the sensory neuropathies (27 patients) had
increased latencies for all three nerves, with that of the superficial pero-
neal being not significant. The increased latencies and the decreased
amplitude of the superficial peroneal suggested demyelination was
occurring (Reindl et al., 1999; Willison and Yuki, 2002).
VII. Conclusion
Forgacs noted in 1962 that mold mycotoxicosis was called ‘‘the
neglected disease.’’ The manifestations and disorders in humans
caused by molds and mycotoxins continues to be overlooked or unno-
ticed by many physicians. Each year studies continue to be published
throughout the world medical and scientific literature elucidating and
explaining the pathological processes and biomechanisms by which
exposure to molds and mycotoxins cause sickness in humans. We have
described in this chapter the most recent neuroimmune mechanisms of
disease process in humans of molds and mycotoxins. The exact
biological and chemical actions through which these mechanisms un-
fold is not completely understood. However, molds do produce meta-
bolites (mycotoxins, solvents) and shed antigenic materials (spores,
hyphae, extracellular polysaccharides, and enzymes), which are toxic
(mycotoxins) and or cause immunologic responses (antigens). Science
and medicine should continue its work in these areas and bring about
the much-needed change from ‘‘the neglected disease’’ to ‘‘the accepted
disease.’’
MOLD AND MYCOTOXINS 397
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