The medical effects of mold exposure

doi:10.1016/j.jaci.2005.12.001

Journal of Allergy and Clinical Immunology

Volume 117, Issue 2, February 2006, Pages 326-333

https://doi.org/10.1016/j.jaci.2005.12.001 Get rights and content

Exposure to molds can cause human disease through several well-defined mechanisms. In addition, many new mold-related illnesses have been hypothesized in recent years that remain largely or completely unproved. Concerns about mold exposure and its effects are so common that all health care providers, particularly allergists and immunologists, are frequently faced with issues regarding these real and asserted mold-related illnesses. The purpose of this position paper is to provide a state-of-the-art review of the role that molds are known to play in human disease, including asthma, allergic rhinitis, allergic bronchopulmonary aspergillosis, sinusitis, and hypersensitivity pneumonitis. In addition, other purported mold-related illnesses and the data that currently exist to support them are carefully reviewed, as are the currently available approaches for the evaluation of both patients and the environment.

Section snippets

The relationship of molds to allergy and asthma

It is estimated that approximately 10% of the population have IgE antibodies to common inhalant molds.³ About half of these individuals (5% of the population) are predicted to have, at some time, allergic symptoms as a consequence of exposure to fungal allergens.⁴ Although indoor fungal allergen exposure occurs, outdoor exposure is generally more relevant in terms of sensitization and disease expression. The role of indoor fungi in the pathogenesis of allergic disease has been extensively

Allergic bronchopulmonary aspergillosis and sinusitis

Allergic bronchopulmonary aspergillosis (ABPA) is a well-recognized clinical entity affecting individuals with asthma or cystic fibrosis.²¹ A variety of fungi in addition to Aspergillus fumigatus can produce a similar clinical picture. The critical element in ABPA is an underlying anatomic change in the lung and not a specific mold exposure because at-risk individuals will have ongoing exposures caused by the ubiquitous nature of the fungi involved. Exposure to A fumigatus can occur both from

Hypersensitivity pneumonitis

HP, also referred to as extrinsic allergic alveolitis, is a disease that exists in acute, subacute, and chronic forms but with considerable overlap. It is an allergic disease in which the allergen is inhaled in the form of an organic dust of bacterial, fungal, vegetable, or avian origin. Both sensitization and the elicitation of the disease state generally require high-dose exposure, prolonged exposure, or both to the causative allergen. Many cases are, in fact, occupational because of this.

Infection

Superficial mold infections (eg, tinea cruris, onychomycosis, and thrush) are common in healthy individuals and result primarily from local changes in the cutaneous or mucosal barrier, resident microflora, or both.24, 25 These infections are not the result of environmental exposure, except occasionally as related to certain animal vectors. Indeed, molds of the Malassezia genus are resident on the vast majority of human subjects and only become evident as “tinea versicolor” during periods of

Ingestion

Ingestion of mycotoxins in large doses (generally on the order of a milligram or more per kilogram of body weight) from spoiled or contaminated foods can cause severe human illness.²⁶ Toxicity from ingested mycotoxins is primarily a concern in animal husbandry, although human outbreaks do occur occasionally when starvation forces subjects to eat severely contaminated food. Specific adverse effects from a given toxin generally occur in a narrower and better-defined dose range than for

Irritant effects of mold exposure

The Occupational Health and Safety Administration defines an irritant as a material causing “a reversible inflammatory effect on living tissue by chemical action at the site of contact.” Irritant effects are dose related, and the effects are transient, disappearing when the exposure has decreased or ceased.

Molds produce a number of potentially irritating substances that can be divided into volatile organic compounds (VOCs) and particulates (eg, spores, hyphae fragments, and their components).

Immune dysfunction

The question has been raised as to whether mold or mycotoxin exposure can induce disorders of immune regulation. At this time, there is no credible evidence to suggest that environmental exposure to molds or their products leads to a state of clinically significant altered immunity expressed as either immunodeficiency or autoimmunity. The published literature in this regard is of particularly poor quality and should not be relied on as scientifically valid.33, 34 Individuals who have had

Measurement of IgE antibodies to mold proteins

Assessment for IgE antibodies to mold antigens has clearly been validated as a measure of potential allergic reactivity to mold. This assessment can be done through either in vivo or in vitro testing. The relative strengths of these different forms of testing have been reviewed recently.36, 37 In general, there is a weaker correlation between in vivo and in vitro testing for IgE antibodies to mold antigens than for other antigens, partly as a result of the heterogeneity of extractable mold

Remediation

Issues regarding remediation of mold are beyond the scope of this article. Indoor mold growth should be addressed. These matters are reviewed at length in the Institute of Medicine 2004 report “Damp indoor spaces and health.” For an overview, the reader can refer to the Occupational Health and Safety Administration document “A brief guide to mold in the workplace.”⁴² The true challenges of mold remediation are currently being addressed in the flood-ravaged areas struck by hurricane Katrina,

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Environmental and occupational respiratory disordersThe medical effects of mold exposure

Section snippets

The relationship of molds to allergy and asthma

Allergic bronchopulmonary aspergillosis and sinusitis

Hypersensitivity pneumonitis

Infection

Ingestion

Irritant effects of mold exposure

Immune dysfunction

Measurement of IgE antibodies to mold proteins

Remediation

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Environ Int

Adv Appl Microbiol

J Allergy Clin Immunol

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Board of Health Promotion and Disease Prevention. Institute of Medicine of the National Academies. Damp indoor spaces and health

Division of Health Promotion and Disease Prevention. Institute of Medicine. Clearing the air: asthma and indoor air exposure

Fungal allergens

Clin Microbiol Rev

American College of Environmental and Occupational Medicine position statement. Adverse health effects associated with molds in the indoor environment

Daily asthma severity in relation to personal ozone exposure and outdoor fungal spores

Am J Respir Crit Care Med

Health risk assessment of fungi in home environments

Ann Allergy Asthma Immunol

Effects of damp and mould in the home on respiratory health: a review of the literature

Allergy

Levels of household mold associated with respiratory symptoms in the first year of life in a cohort at risk for asthma

Environ Health Perspect

Symptoms of wheeze and persistent cough in the first year of life: association with indoor allergens air contaminants, and maternal history of asthma

Am J Epidemiol

Environmental and occupational respiratory disorders
The medical effects of mold exposure