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Molds, Mycotoxins, and Human Health Michael R. Gray, M. D., M. P. H., C. I. M. E. There are two hundred
thousand different molds and fungi.
They have been present on this planet for 3 billion years, and certainly, many
of us love our bleu cheese. Most
molds are quite harmless, aside from their tendency to induce allergies in those
of us who are prone to develop allergies in the first place. HOWEVER:
There truly were good
reasons why we are warned in Leviticus: that if your house be contaminated with
plagues, mold and Leprosy, you should put the contents in the middle of it, and
set it aflame. The spores from
Stachybotrys chartarum (a.k.a. atra), a mold capable of producing
some of the most toxic substances known to human-kind, can survive temperatures
up to 500 degrees Fahrenheit, as well as acid, caustics, and bleach without
being destroyed. Spores from molds
have been removed from 2,000,000-year-old sedimentary rock and grown when placed
on appropriate media. And, every
nation that has developed biological warfare capability, has harvested
mycotoxins from molds, some of which are so toxic that microgram quantities are
capable of killing within twenty-four hours, while being so completely
metabolized that they are undetectable at autopsy. From 1987 through the
present Dr. Gray has developed a reasonably uniform database on 350 patients
with exposures to a variety of haptogenic (immunologically reactive), xenobiotic
(toxic) compounds, including 75 patients with confirmed exposure to toxigenic
structural molds. These patients
have been evaluated in the context of individual clinical encounters, with the
workup including standardized comprehensive Internal Medicine Database
questionnaires with an extensive Occupational History gathering component,
Environmental History gathering questionnaires, kindly provided by Grace Ziem,
M.D., Dr.P.H., direct interviews, physical examinations, extensive laboratory
testing including complete blood counts with differentials (CBCs), comprehensive
metabolic profiles (CMPs), arthritis and thyroid profiles, lymphocyte phenotype
studies including total white cell counts, total lymphocyte counts, T-cell and
B-cell counts, T-cell subsets, T-cell activation levels using both CD26 and
HLA-DR markers, evaluation of natural killer cell counts and functional status,
audits for auto antibody production, anti herpes viral titers, anti volatile
organic compound (VOC) antibody titers, evaluation of stimulated lymphocyte
mitogen response, and pulmonary
function testing when indicated, electrocardiograms and chest x-rays as
indicated, neuropsychological evaluations, quantitative electroencephalograms
(QEEGs), and in the cases in which excessive mold exposure was confirmed by
environmental hygiene evaluations with quantification and identification of the
specific molds present, appropriate audits were conducted for specific anti mold
antibody levels. Excel spreadsheets were prepared including the laboratory
data of the confirmed mold exposed patients evaluated between 1994 and February
2001. This exercise revealed
patterns of abnormalities consistent with what has been reported in the
literature in the last several centuries relating to the adverse health effects
of toxigenic molds and fungi in man and other species. These include, but are not limited to,
Alimentary toxic aleukia, Dendrodochiotoxicosis, Kashin Beck disease, 'Usov's
disease,' Stachybotryotoxicosis, Cardiac beriberi, Ergotism, Balkan nephropathy,
Reye's syndrome, hepatocellular carcinoma, Pink Rot, and Onyalai.
Specifically, Dr. Gray's
clinical evidence confirmed the presence of B-cell proliferation, excessive
T-cell activation, inhibition of suppressor cell complement receptor sites,
suppression of Natural Killer Cell populations which are centrally involved in
cancer cell surveillance and destruction, and excessive mitogen suppression,
confirmed by inhibition of stimulated lymphocyte mitosis in the presence of
extracts of pokeweed, concanavillin A (Con-A), and phytohemagglutinin (PHA)
implying the inhibition of immune cell reproduction, generally considered
necessary to mounting a competent immune response. In short, the immune system is showing signs of being
excessively stimulated by the inhalation of respirable spores, and
simultaneously is being partially inhibited by the effects of the mycotoxins
released by those spores. In addition, pulmonary
function testing (PFTs) confirmed excessive small airways obstruction, the
hallmark of mold induced hypersensitivity pneumonitis, and a review of the
neuropsychological evaluations, and QEEGs performed on the mold exposed
individuals confirmed the presence of central nervous system impairments
consistent with what is expected based on numerous animal and human
toxicological studies found in the many peer reviewed articles readily available
in the extensive world literature on the toxic effects of mycotoxins. Several types of
mycotoxins, including trichothecenes, ochratoxins, patulins, and aflatoxins
induce human illnesses, which resemble radiation sickness and result from the
random effects of being DNA "adduct formers."
Adduct formers are compounds whose molecular size and configuration allow
them to insert themselves randomly into DNA, and RNA, thus resulting in the
inhibition of protein synthesis, bone marrow suppression, coagulation defects
and bleeding disorders resulting in nasal, pulmonary, and gastrointestinal
hemorrhaging, bleeding into the adrenal glands, uterus, vagina, and the brain.
In addition, many
mycotoxins are potently neurotoxic, producing central nervous system effects
including behavioral and cognitive changes, ataxia, and convulsions. This has
been extensively described in peer-reviewed literature in the early and mid
twentieth century-although this literature is not readily accessible on
computerized databases, such as the Medline, and Toxline search systems, because
these sources often do not include titles before the 1960's. Nonetheless, mycotoxicosis has clearly
been demonstrated to have been the cause of several major human epidemics,
usually involving ingestion of foods prepared with mold infested grains and
cereals, or from the consumption of livestock which had been fed mold infested
feed. Inhalation and
absorption of mycotoxins have also been clearly demonstrated to be causative of
human illnesses. Throughout the course of
almost thirty years of medical practice, Dr. Gray has treated hundreds of
patient with mold-induced diseases.
Until 1994, most of those patients were people with mold-related allergies and
asthma, and cases of symptomatic coccidiomycosis (valley fever). In 1994, he treated a group of employees
manifesting building related illnesses, which were ultimately confirmed to have
been caused by several molds, most prominently Stachybotrys atra,
Penicillium, Aspergillus, Chaetomium, and several others, usually referred
to as structural molds. He has since seen several dozen patients with
building-related mold exposures resulting in a wide variety of illnesses. The biological function
of mycotoxins is to enhance the probability of survival of the next generation
of mold. The mycotoxins are
typically "packaged" in the spores with the DNA of the organism. This process almost always takes place
under adverse environmental conditions: when nutrient substrates are becoming
less available, or when arid conditions prevail.
We see this with regularity in the Sonoran Desert climate experienced in
Tucson. With every rain the molds
grow. Within less than a day, when
the humidity returns to the teens (10 to 20% being the norm in the desert), the
ambient environmental spore counts reported by our local meteorologists
dramatically increases: it is a common species-specific survival mechanism. When spores are forming, mycotoxins are
being produced. The mycotoxins-many
of which are antibiotics or antifungal agents-provide an increased probability
that any given spore will be likely to survive in a very competitive environment
with many micro organisms competing for the same ecological "nitch." Because many of the molds also produce
solvent carriers they are not only a source of significant solvent exposure,
but, whether the mycotoxins do volatilize or not, the do aerosolize and become
air born via aerosol. In addition,
the spores in which the mycotoxins often reside do take flight as they are
released from the hyphae, hair like processes of the parent cell, and even the 7
by 4 micra Stachybotrys atra spore must be considered respirable (able to
penetrate to the respiratory surfaces of the lung-the alveoli) because these
particles tend to orient themselves parallel to the long dimension of the
progressively smaller bronchi as they travel down to the lungs tiny air sacs.
While the kinetics associated with spherical particles dictates that only
particles between 5 and 0.005 micron are capable of penetrating to the alveoli,
the size range of mold spores is from 7 to 0.003 micron, and they are uniquely
capable of penetrating to the alveoli.
Once having arrived in the alveoli, they stimulate a dramatic immune
response. This is also a site in
which they are able to release their mycotoxins, allowing them to be absorbed
into the blood flowing through the prolific capillary beds found adjacent to the
air sacs. The mycotoxins then circulate throughout the body. Just as psilicybin
containing mushrooms and lysergic acid (LSD) are capable of inducing
hallucinations, and cognitive distortions, a number of mycotoxins are capable of
causing both transient, and permanent neurotoxicity. Approximately 70% of the patients with
confirmed exposure to toxigenic structural mold have been demonstrated to have
significant neurotoxicity.
Neurological problems encountered among these patients have included optic
neuritis, multiple sclerosis, basal ganglion and midbrain based movement
disorders--developing in some cases within months of occupancy of contaminated
residences. In two female patients
from Phoenix, blindness was demonstrated in one or both eyes, and then within
several months of the onset of the optic neuritis, both were diagnosed with MRI
confirmed multiple sclerosis, first manifesting in the spinal cord of one of
them. Four of the patients in the
same group were confirmed to have serious movement disorders thought to be
arising from midbrain structures. Another patient was confirmed to have
developed occulomotor nerve palsy on three separate occasions, each time in
conjunction with documented exposure to Stachybotrus, and other structural molds
and their associated mycotoxins.
Others were diagnosed with variable toxic encephalopathies by QEEG brain
mapping, neuropsychological testing, and specialized techniques measuring
specific quantifiable neurological parameters. Toxic encephalopathy is a fluctuant neurological condition
manifested by cognitive impairments, which are the direct result of the
recurrent and paroxysmal activity of the immune system and the central nervous
system interacting with each other to cause episodic cognitive and neurological
dysfunction in the form of abnormal brainwave activity and associated variable
signs and symptoms of cognitive dysfunction such as memory loss, dyslexia, word
finding difficulties and attention deficit disorders. These neurological
abnormalities, which are triggered by exposure to concentrations of haptogenic,
xenobiotic, volatile, organic compounds at sub-osmic threshold levels, have been
demonstrated, by the work of Iris Bell M.D., Ph. D., at the University of
Arizona, as well as other researchers, to trigger abnormal brainwave activity
that is regionally specific, affecting the temporal lobes bilaterally, the right
parietal lobe and the frontal lobes of the brain. These three central nervous system
structures are involved in memory function, spatial relations, and cognitive
integrative functions respectively.
These effects are recurrent and can be demonstrated through the use of multiple
diagnostic modalities, including electroencephalograms (EEGs), quantitative
electroencephalograms (QEEGs), PET scans, SPECT scans, and other objective
neurophysiologic modalities.
When a patient is exposed to a haptogenic (immunologically active), xenobiotic
(toxic) trigger to which they are historically reactive, abnormalities are
observed on electroencephalographic tracings within fifteen seconds of said
exposure, even when administered in a double blind fashion. It is now becoming clear that this
paroxysmal activity can, in fact, take the form of complex partial seizures, and
often leads to immediate, transient cognitive impairment, followed by a
"post-ictal" condition, characterized by excessive fatigue. Because the victim of
these episodes does not lose consciousness, as occurs in grand mal seizures,
they are often unaware that these episodes are occurring, but an astute observer
watching the individual would see what in essence is described in the literature
as an "absence seizure." In many of
the patients who suffer from toxic encephalopathy that have been tested with
24-hour, ambulatory electroencephalograms, multiple seizures per hour in some
cases, and certainly multiple seizures in a 24-hour period have been
demonstrated.
Brain mapping, done by
quantitative electroencephalographic techniques (QEEG), also has demonstrated
consistent abnormalities in several types of brainwaves. This mode of analysis has become the
clinically relevant standard in the assessment of patients suffering from toxic
encephalopathy, and actually offers the potential for therapeutic intervention
using neurotherapy with QEEG-gated biofeedback techniques. Neurotherapeutic intervention has been
shown to reduce the frequency and severity of these episodes, and may improve
cognitive function and memory. A wealth of literature in
the field of Occupational Medicine has appeared over a more than a century
confirming the significance of molds in both residential and workplace
environments. Molds have long been known to lead to the development of a severe
debilitating lung disease known as hypersensitivity pneumonitis.
Hypersensitivity pneumonitis is an inflammatory condition which involves
inflammation in the smallest of the airways in the lungs, triggered by exposure
to commonly encountered volatile organic compounds of a chemical nature, as well
as several types of biological dusts, pollens, mold spores and mycotoxins
"packaged" within the spores. The ensuing inflammation results in small airways
spasms, and obstruction occurring in regular and repetitive episodes. This condition which causes shortness of
breath, and often severe debilitating chest pain, is generally treatable with
medications commonly used for asthma, and is only preventable by avoidance of
exposure to the triggering agents such as mold spores. Although the condition of
hypersensitivity pneumonitis was first described in association with mold spore
exposure in conditions varyingly described as reactive airways disease, silo
filler's disease, farmer's lung, bird fancier's disease--which rarely occurs
among individuals keeping a single bird as a pet, but frequently is seen among
those maintaining pigeon coups with hundreds of birds present at a time--and
byssinosis or "Brown Lung Disease" in cotton mill workers. If not treated aggressively,
hypersensitivity pneumonitis will lead to the progressive development of
emphysema. In the case of
structural mold-exposed individuals, treatment with antifungal medication, such
as ketaconazole, itraconazole, and/or fluconazole-each produced or derived from
mold mycotoxins themselves-may be appropriate and necessary.
There is allegedly
"disagreement within the scientific community as to whether the relatively large
size of Stachybotrys spores prevents it from penetrating to the deepest areas of
the lung." However, this controversy was resolved by the documented presence of
Stachybotrys spores in the alveoli and small airways of the lung of an infant
suffering and dying from mold-induced hemorrhagic pneumonitis a rare lung
disease, found to have occurred in a series of nine infants in Cleveland, Ohio
by Dr. Dorr Dearborn, who confirmed the presence of Stachybotrys mold in each of
the infants' homes. These cases were reported by the Centers for Disease Control
(CDC), in their 1998 Morbidity and Mortality Weekly Reports (MMWR). There has been some controversy raised
by some researchers claiming that they cultured the organism from these homes,
and were unable to detect mycotoxins in the resultant cultures. The problem is that they are not
acknowledging that molds in general do not produce mycotoxins when they are
growing under "ideal" conditions, such as those that usually obtain in
laboratory settings. They generally
produce their toxins when austere living conditions bring about sporulation, for
example when nutrients are depleted, or when arid conditions prevail. The clinical observations
from the patients in Dr. Gray's practice who presented between 1994 and the
present with environmental hygiene documentation of exposure to
structurally-related molds in their homes or workplaces provides clear evidence
of the presence of consistent abnormalities in the clinically relevant workup.
These abnormalities include, but are not limited to, the immunologic, pulmonary,
and neurological workup, that is clearly parallel to the findings in both human
and animal studies recorded in the local, national, and international medical
literature. Similar findings were reported in the case of Ron Allison-Melinda
Ballard's husband-who suffered debilitating memory loss, which, to a reasonable
medical certainty, was causally related to the confirmed and relevant mold
exposure in their home. The congruency of the findings in these cases,
collectively have confirmed the presence of a "clinical fingerprint" that allows
for the clinical diagnosis of mycotoxicosis-within reasonable medical
certainty. It is quite clear, when
the clinical fingerprint is evident, that "but for the exposure to mixed
toxigenic structural molds" these constellations of illness would not be
occurring. One Tucson based
neurotherapist, who has career long experience treating patients with blunt head
trauma, strokes, and toxin induced trauma, stated that never in his experience
has he seen entire families present demonstrating cognitive deficits of
such severity. The variety of
abnormalities reported is consistent with the random nature of the damage
induced by "adduct formers" discussed below.
The random mutagenic events encountered with mycotoxins is reminiscent of
radiation induced damage, and the same constellation of bone marrow suppression,
interference with protein synthesis resulting in failure to thrive, weight loss
and weakness, easy bruising, frequent nosebleeds, and increased susceptibility
to infections, skin lesions, and rashes is clinically similar.
In reply to the
assertions that the symptoms reported by the victims of toxigenic structural
mold exposure, sick building syndromes, or chemical hyper-reactivity are
psychosomatic, or somatoform disorders, Ann Davidoff (l994) clearly demonstrated
the absence of any data supporting such hypotheses. In addition, rebutting assertions of
malingering by "litigenous" victims of exposure to environmental toxins,
powerful data has been filed with the Federal Agency for Toxic Substances
Disease Registry (ATSDR) in relation to the sub-registry on the benzene exposed
residents of the Three Lakes Subdivision north of Houston, which clearly
demonstrated that there was no shift in the symptoms reported by this
cohort of 1100 residents when they were surveyed both before and after
litigation was filed in that matter.
Thus claims of somatoform origins of patients complaints are seriously
flawed, misleading, and biased, and represent an unsubstantiated hypothesis
which is at best without merit, and at worst cruel, as it demeans patients who
are suffering from serious, organic, physiologic problems usually affecting
multiple organ systems. Mycotoxins produced by
structural molds-meaning molds imported into the residences, workplaces, and
public buildings on the paper covering the drywall, and other wood based
composite materials-- often represent some of the most toxic substances known to
humankind. The molds imported on
building materials are not the same as molds commonly encountered in outdoor
environments. The wood chips, and
wood pulp imported from the Amazon rain forests bring with them their own
varieties of mold spores. The
climate of "deregulation" that has prevailed since the early eighties has
favored the proliferation of new construction in which building codes requiring
pretreatment of building materials with anti-fungal agents have simply not been
adequately enforced. This in turn
has led to circumstances, which when coupled with "corner-cutting" structural
defects, have led to the conditions which favor water intrusion that has all to
often allowed the appearance of truly toxic levels of mold spores and
mycotoxins, which are, in turn, capable of inducing serious diseases resulting
from the presence of agents with the potential for damaging the human immune
system, inducing allergies, gastrointestinal disorders, skin disease,
neurological disease, endocrine disruption, birth defects, cancer, pulmonary,
renal, hepatic, and general metabolic disorders. Treatment protocols for
the problems seen must be individualized, and carefully constructed, taken great
care to avoid overuse of antibiotics with infection mimicking inflammatory
conditions. This is particularly
relevant, because inappropriate antibiotic use may foster further mold and
fungal growth in an already compromised host. One of the most
frustrating problems relating to dealing with patients experiencing illness from
exposure to structural molds, and bioaerosols from gray water contamination is
the inability to mobilize a proactive response from public agencies. The issue is like the "hot potato." In the apartment complex alluded to
above in the Phoenix area, when tenants complained to the County Health
officials, they came to inspect without the instrumentation required for the
detection of moisture or mold. And when attempts were made to report cases of
illness to the State Health Department, after being told by a Deputy Assistant
Director that the problem would be referred to the Director of the Division of
Epidemiology and Chronic Disease, no return call was forthcoming. Similarly, when Dr. Gray raised the
issue of structural mold, which resulted in the closure of the Bella Vista
Elementary School in Sierra Vista with the Cochise County Board of Health--on
which he served for six years-- the only physician member of the Board
opined that "mold was not a public health issue!" Clearly, education is the order of the
day. Michael R. Gray, M.D.,
M.P.H., C.I.M.E. Preventive Medicine and
Occupational Medicine, Board Certified Internal Medicine,
Emergency Medicine, and Toxicology, Board Prepared Certified Independent
Medical Examiner, and Commissioner, Medical
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