5 valtonen mould building syndrome nsmm 1

” Mold building syndrome ”:
Symptoms caused by enviromental
moulds; any treatment for patients ?
Ville Valtonen M.D.
Professor, Chief ( retired )
Division of Infectious Diseases, Department of
Medicine
Helsinki University Central Hospital
Symtoms caused by enviromental
moulds; any treatment for patients ?
• Definitions of ”mould building syndrome”
• Some patient cases
• Clinical symptoms
• Treatment
• Prevention
• Summary
Definitions of ”mold building syndrome”
• Terms used in medical literature from similar problems
– Mold allergy ; Organic dust toxic syndrome ; Toxic
volatile organic compounds ; ”Sick building syndrome” ;
Indoor air pollution ; Allergic bronchopulmonary
aspergillosis
• Definition used in this lecture
– ”Mold building syndrome” covers any clinical symptoms
in patients exposed to persistent dampness and
microbial growth on interior surfaces and in building
structures and which symptoms are aggravated in
buildings with moisture damages and which symptoms
are propably caused by molds and other microbes in
moisture buildings by immunological, toxic and other
mechanisms
• SOME ”MOLD BUILDING SYNDROME”
PATIENT CASES TO ILLUSTRATE THE WIDE
CLINICAL SPECTRUM OF THIS SYNDROME
• 1) A TYPICAL CASE
• 2) AN ALLERGIC ALVEOLITIS CASE
• 3) AN OPTICUS NEURITIS CASE
A female teacher with ”mold building
syndrome” ( 1 )
• A female teacher, born 1966, who has been earlier
very healthy
• She has been working in a school in Helsinki from
1999, in which school there has been severe moisture
damages, visible molds in building structures and
heavy growth of various fungi and bacteria from
moisture damages and where many teachers and
pupils have experienced irritating respiratory tract
symptoms
• In addition from 2005 she has been living in an
apartment where there has been moisture damages,
too
A female teacher with mold building
syndrome ( 2 )
• From 2006 onwards she has had several
respiratory tract infections like sinusitis and
bronchitis
• During 2010 she had severe arthralgia and back
pain and she was out of work several months
without relief
• In summer 2010 she could not live any more in
her apartment because her symptoms became
worse when she was in the apartment but the
symptoms were relieved when she was out of
the apartment
A female teacher with mold building
syndrome ( summary ) ( 3 )
• She has respiratory symptoms and arthralgia in many public
buildings but almost symptomless in nature
• Her laboratory tests are normal except mild eosinophilia but
corticosteroid therapy is not helping much
• She is now looking for a ”healthy” apartment and a shool
where she could work
• She is depressed because many physicians do not believe
her symptoms and her economical situation is poor
• She is fullfilling the clinical criteria for ”mold building
syndrome” diagnosis which is , however, not an ”official”
diagnosis and she is receiving no economical support from
the society
Mold building syndrome case ( TLJ 1 )
( allergic alveolitis )
• A female, born in 1951
• She worked from 1970s in an office building in Helsinki, in
which building severe moisture damages were found in
1990s and where several workers reported respiratory tract
symptoms from 1990 onwards
• The building was renovated in 2000 but symptoms among
many workers continued
• The female patient started to have dyspnoe and mild fever
around 2000 and the symptoms were clearly linked to her
presence in the office building but were absent when the
patient was away from the building more than two days
• From 2000 the patients had many sinusitis and
bronchitis; 2001 the asthma diagnosis was done
• In 2002 she was studied in Finnish Institute of
Occupational Health and the diagnosis was allergic
alveolitis based on the pulmonary infiltrates in
HRCT, strong lymphocytosis in BAL, decreased
diffusion capacity ad 76 %, and reversible bronchial
obstruction
• She started corticosteroid treatment and was out of
work on pension
• Her condition was followed in Helsinki University
Central Hospital in 2003-2011
• She had severe shortness of breath, cough and
fever when visiting many ”moisture buildings” and
gardens during summertime but almost
symptomless at home
• She could walk only a couple of hundred meters
during summer time outside home
• Corticosteroids and antibiotics helped a little but
she developed secondary diabetes due to
corticosteroids
• In 2007 her diffusion capacity was dropped to 49 %
from normal and CRP value was 23 and blood sugar
was 22 and she started metformin treatment and
continuous doxycycline plus low dose corticosteroid
treatment and she avoided ”mold places”
• Her condition was rather stabile but poor during
2007-2008 and 2009 there were new pulmonary
infiltrates and lung biopsy was done, where clear
allergic alveolitis was observed, no bacteria or fungi
were isolated from the lung tissue
• Some immunogenetic studies were done; she was HLA B35+,
HLA DR1*1+, HLADR1*15+, Complement 4B one allele was
lacking, immunoglobulin levels were normal
• 2009 she was started experimental treatment with IV-
immunoglobulins and the response was very good
• She could walk outside the home many kilometers but still
experienced shortness of breath in severe moisture
buildings
• Her diffusion capacity increased to almost normal, her
pulmonary infiltrates disappeared, serum inflammation
parameters turned to normal
An allergic alveolitis case- summary
• PAD verification for allergic alveolitis and her
symptoms were worsening in moisture buildings
and also in gardens during summer time
• The experimental treatment with IV -
immunoglobulins gave a good clinical , laboratory
and radiologic response and the remission has
lasted now almost two years
• Allergic alveolitis cases due to molds have been
published, but no controlled trial with IV - Ig
treatment has so far been published in this disease
Patient case JPK ( 1 )
( Opticus neuritis )
• A man, born 1953
• He has had hypertension and asthma for over
ten years beginning from 1990s
• 1990s he had many sinusitis, which were
suspected to be caused by molds in his
working place
• 1996 he changed his working place and his
sinusitis problems and respiratory infections
were stopped altogether and also asthma
and hypertension were milder
• In May 2004 he was helping his wife by
gathering various things for a couple of hours
at school ( his wife´s working place ), where
there has lately been a severe dampness
damage and visible mold
• A couple of weeks afterwards his vision
became worse
• In June 2004 he was studied in Helsinki
University Central Hospital, in Eye and
Neurological clinics
• The diagnosis was bilateral opticus neuritis
• His vision was only 0,2 l.a.
• Inflammation parameters like CRP and ESR
were normal, but there were 4 leucocytes in
cerebrospinal fluid and his antinuclear
antibodies in serum were high, 1280
• NMR from head was normal
• He was given high doses of corticosteroids,
which helped a little
• In winter 2005 he was almost blind, vision
only 0,1 or under
• Infectious disease physician was consulted
whether opticus neuritis could be due to
mold allergy
• The consultation answer: possibly there was
a connection between the heavy exposure to
molds and the onset of opticus neuritis in a
patient who had had earlier sinusitis problem
probably due to molds
• An experimental IV-immunoglobulin therapy was
started in July 2005, when his vision was 0,1
• There was a remarkable treatment response; his
vision was 0,7 ( dx ) and 0,3 ( sin ) in August, 2005
• His vision was 0,8 in both eyes in November, 2005
and he returned to work
• IV-immunoglobulin therapy was stopped in
December, 2005, but his vision has been 0,8 ( l.a )
since then and he has avoided molds as well as
possible
JPK ( 6 ) Opticus neuritis
( summary )
• Many infections and vaccines may trigger opticus
neuritis, but no opticus neuritis case has been
published so far to be due to mold allergy
• IV-immunoglobulin therapy has been used in
various autoimmune and neurological diseases
including opticus neuritis with variable success
• No reports have been published so far from the use
of IV-immunoglobulin therapy in mold allergy
patients
The clinical symptoms of ”mold
building syndrome” ( 1 )
• The clinical symptoms are very variable
• As a rule the clinical picture starts with
irritation symptoms in eyes and respiratory
tract like redness and itching in eyes and
sneezing and cough which are bad when the
person is in the building where there is
indoor air problems or dampness damages,
but the symptoms disappear when the
person is out of the ”mold building”
The clinical symptoms of ”mold
building syndrome” ( 2 )
• Later on the amount of respiratory tract infections
( like sinusitis and bronchitis ) is increasing and skin
manifestations, fatigue, arthralgia, gastrointestinal
symptoms, head ache and various neurologic
symptoms are also rather common
• Some patients may develop asthma and very rare
patients may have allergic alveolitis
• Also rheumatic diseases and vasculitis cases have
been published
The clinical symptoms of ”mold
building syndrome” ( 3 )
• Clinical hints which favor the diagnosis of mold
building syndrome
• 1 ) The symptoms are clearly associated with the
presence of the person in ” sick buildings ”, where
there are or has been clear dampness damages,
visible mold in structures or heavy growth of
various molds in the structures, but his or her
symptoms diminish clearly when the person is away
from ” the mold buildings”
The clinical symptoms of ”mold
building syndrome” ( 4 )
• 2) Typical symptoms or findings ( but not always
present in every patient )
– High blood pressure and tachycardia attacks
when exposed to molds
– Disseminated herpes infections in head region
without heavy immunosupression
– Dizziness and various unspecific neurological
symptoms like head ache, pain or diminished
sensoral findings all over the body
– A very sensitive ability to smell molds
The diagnosis of ”mold building
syndrome”
• Always a clinical diagnosis
• No specific diagnostic laboratory tests available
• The key elements in diagnosis:
– The clear association of symptoms with ”mold buildings”
– The clinical picture may vary but as a rule irritative
symptoms in eyes and respiratory tract predominate in
the beginning
– Later on increased amounts of respiratory tract infections
and arthralgia, skin manifestations are common, but
asthma, various autoimmune manifestations and
neurological symptoms vary from patient to patient
The treatment of ”mold building
syndrome”
• The avoidance of molds is the most important form of
• Antihistamines may offer little help
• Corticosteroids help in some cases but not as well as e.g. in
classic asthma
• Antibiotics help in secondary infections
• Antifungal agents especially sporaconazole has been used
especially in allergic bronchopulmonary aspergillosis with
some success
• IV-immunoglobulin therapy may help in some severe cases
but no controlled studies are available
The prevention of ”mold building
syndrome”
• The quality of construction work should be
improved
• The renovation of the building with moisture
damages does not help necessarily those patients
who are very allergic to molds ( spores left ? ), but
may help to prevent new victims of this syndrome
• There are propably genetic susceptibilities in
persons who develop this syndrome more easily
than others but we do not know these genes
”Mold building syndrome”
( Summary )
• ”Mold building syndrome” is a clinical
diagnosis but we urgently need better
laboratory tests to confirm this diagnosis
• The avoidance of molds is the best treatment
for this syndrome
• Better quality in building may diminish this
syndrome in the future
Further readings from ”mold
building syndrome”
• 1) WHO guidelines for indoor air quality:
dampness and mold; WHO 2009
• 2) Putus T: Home ja terveys,
kosteusvauriohomeiden ja hiivojen
terveyshaitat ( in Finnish ); Suomen
ympäristö- ja terveysalan kustannus oy, 2010
• 3) Strauss: molds, mycotoxins and sick
building syndrome. Toxicology and industrial
health 2009; 25: 617

Source: http://www.nsmm.nu/nsmm2011Valtonen.pdf