The possible linkage between exposure to airborne concentrations of Stachybotrys mold spores and bleeding of the lungs (i.e. pulmonary hemosiderosis) is controversial. In the United States, this association between contaminant and symptoms was first postulated by doctors Dorr Dearborn and Ruth Etziel in relation to a number of infant deaths and near deaths in 1994. Since this study of health problems involved both a clinical pediatrician (Dearborn) and an investigator from the Centers for Disease Control and Prevention (Etziel), the CDC accepted their findings of Stachybotrys as the probable cause of the infant symptoms. However, a later panel set up by the CDC to review the work of Dearborn and Etziel concluded the association of the mold to the babies' injuries could not be proven. Although the review did not conclude that Stachybotrys was ruled out as a cause and Dearborn/Etziel published a rebuttal to the review, the official position of most professionals in the mold control industry is that Stachybotrys has not been proven to cause bleeding from the lungs.
Despite these official pronouncements, doctors, consultants and contractors continue to receive reports from occupants of mold-contaminated buildings of significant symptoms, including coughing up blood from the lungs. This study presents information from one such case. Its credibility is enhanced by the fact that the impacted individual is herself a physician who compiled detailed charting of symptoms and diagnostic/treatment experiences. It is further strengthened by the history of the situation, where the doctor occupied a water-damaged environment and experienced progressively worse symptoms for several years prior to her exploring a possible connection between mold and her condition.
This paper is a summary of both the occupant's situation as well as the investigative and remediation efforts that took place. Observations of similarities with other cases investigated by Wonder Makers Environmental are also included. It concludes with a recommendation that all professionals involved with mold contamination situations look more conscientiously at anecdotal data as well as scientific when evaluating the possibility of Stachybotrys causing symptoms such as pulmonary hemosiderosis.
The Case Study
Dr. X is a female physician, obstetrician/gynecologist, in an upper Midwest state. At the time of the investigation, in late 2000, she was 44 years old. Dr. X had a private practice in rented office space where she employed a receptionist and a nurse/assistant. Her journey, which began as far back as 1995, is one that is fairly typical of what we hear from clients in our investigation processes. Often by the time they get to us in terms of mold or indoor air quality investigations, they report suffering a whole series of health effects.
Initially, Dr. X just felt that she was very susceptible to the winter colds that were going around. She had fatigue, muscle aches and flu-like symptoms. But by 1996, the respiratory distress was increasing coughing, burning airways and a heavy feeling in her chest. We have seen this supported in some of the medical data as being symptomatic of Stachybotrys exposure. By 1997, Dr. X began documenting her symptoms of violent coughing in order to get help.
She had graduated from the University of Michigan. This provided her with access to some of the best health care in the nation. She went back to her medical school and talked to many of her professors. When she started developing bleeding of the lungs, she consulted with one of her professors at Michigan who is the doctor who wrote the standard section on pulmonary hemosiderosis in the medical textbooks. None of the doctors she consulted could come up with a cause for her bleeding lungs. It was indeed bleeding from her lungs, not the upper respiratory system, such as dry nose (this was questioned later on).
By 1999, the episodes of bleeding from the lungs were recurring more frequently. Dr. X was "cycling" in terms of severe symptoms. She would get better for a short period of time. Then as soon as she got better and went back to work, the symptoms would begin to increase. By the year 2000, the symptoms had taken a toll on her and she was hospitalized many times. At one point the doctors did not think she was going to survive. Dr. X had called her lawyers to her bedside, as well as her two young children and husband. A priest was called in to administer last rites. Fortunately, she survived. She recovered at home for several months, then went back to work. The symptoms started to worsen again.
Mold Awareness
At about the time Dr. X was trying to get back to normal following the near death hospital episode, her father-in-law saw a news program that provided Web sites about fungus and lung disease. Her symptoms seemed to him to be very similar to those on the news program. She started searching to see if fungal contamination could be a cause. This is when our organization got involved to investigate her office.
Based on her symptoms and subsequent confirmation of Stachybotrys mold contamination in both the office air and dust, Dr. X talked to a number of doctors at the CDC. The CDC told her that "the bleeding could not be caused by mold." Because of her desperation, she did not stop there. At our suggestion, she contacted Dr. Dorr Dearborn at University Hospitals of Cleveland. Dearborn confirmed that fungus contamination could be a factor.
Dr. X got more aggressive in trying to help herself. She became one of only three adult patients that Dearborn looked at in the last few years for continuing episodes of pulmonary hemosiderosis. Dearborn suggested that Dr. X have a bronchial lavage: a procedure where a tube is inserted in each lobe of the lungs and flushed with water and the lobes are suctioned out at the same time. In the water that was flushed out, Dearborn cultured a fair amount of Stachybotrys, which was identified visually and by cultured analysis of water from her lungs.
Despite the pain of the bronchial lavage, Dr. X reported feeling significantly better within hours of the completion of the procedure. The heaviness in her chest was gone and some of the respiratory symptoms were significantly better than before. Immediately after that, she stopped taking steroids and antibiotics. She was convinced that she had been suffering from some ill health effects from the Stachybotrys spores.
Building History
There was water intrusion in Dr. X's building dating back to the early 1990s. Based on historical data that we gathered later, the gutters and downspouts on the back side of the building were ineffective at routing water away from the foundation, resulting in extensive mold growth on the interior drywall. Dr. X had requested that her landlord clean and repair the affected treatment room for a number of years. Later on, we found out that there was a secondary moisture source as well.
By the spring of 2000, after Dr. X had complained repeatedly and started to get some information that her symptoms might be related to mold exposure, the landlord hurriedly reacted. A contractor was brought in who ripped out a number of pieces of mold-contaminated drywall without any engineering controls. This, in our opinion, made the situation much worse by contaminating the rest of her office. Fortunately, when the landlord conducted the uncontrolled tear-out of the water-impacted materials, Dr. X held back several samples of some of the drywall material that had fungus contamination. The samples were sent to Dr. Chin Yang's lab at P&K Microbiology, Cherry Hill, N.J. (see attached results). The counts were into the millions of Stachybotrys spores per gram of the materials. Obviously there was contamination on the drywall pieces.
As noted earlier, it was about that time that Wonder Makers became involved in the investigation. We conducted some sampling and confirmed Stachybotrys spore contamination of the air and dust in her office. We then proceeded with developing the work plan, and oversight of the cleaning. Based on the initial airborne and dust sampling, we recommended that she not enter her building (which was her primary office) until the problem was resolved. We put an additional burden on her by telling her that we did not think she should take any records or materials from her building unless they were cleaned. We identified a qualified contractor who did the cleaning. We were called back in early 2001 and found the secondary water source.
Dr. X's Office Environment
Dr. X's office was in a modest midwestern office building. It is approximately 2,000 square feet with 15 small areas. There was known long-term water intrusion in the back treatment room because of poor gutters and downspouts. As stated earlier, the landlord had removed about 35 square feet of black moldy drywall. Dr. X would retreat to her office when she was feeling poorly. As it turned out, there was moisture damage in her office wall as well, due to an automatic sprinkler head that had most likely been knocked ajar by a lawnmower.
Because the wall in the treatment room had been torn out incorrectly, we felt that it was important to remediate the area again. So the mold remediation contractor pulled out the new drywall and cleaned all the interstitial space. This was the simplest part of the project. Dr. X had thousands of open medical files and dust sampling indicated a significant amount of mold spore deposition on the files and office furnishings. As a result, we felt it was better to have the contractor clean all the files and furnishings rather than try to identify which individual items needed cleaning.
Remediation Procedures
Using the New York City and EPA standard guidelines, as well as the information in the American Conference of Governmental Industrial Hygienists (ACGIH) manual, we set up standard procedures as follows:
1. Seal off the HVAC system
2. Install barriers at the entry to each room or area
3. Begin work from one end and move progressively toward the decontamination unit at the exterior door
4. Clean each room in a specific pattern:
- Dispose of all unnecessary items as decided by Dr. X
- Clean all items in drawers or files using a "HEPA Sandwich" process: HEPA vacuum; wet wipe with a disinfectant; HEPA vacuum again
- HEPA vacuum all ceiling tiles
- Wet wipe all walls and fixtures moving from back to front, including furniture
- Thoroughly clean floor or carpet, cleaning from back to front
5. Thoroughly "air wash" all medical records
- Set up large and small negative air machine so that the filtered exhaust from the small machine is directed into the face of the large machine
- Individually HEPA vacuum each file on the exposed surfaces and edges
- Hold the file in the exhaust air stream just in front of the large negative air machine and slowly flip as if thumbing through a book
- Store the records in small crates until released by testing. Any random sample that shows spore residue as part of the invisible dust left on the file means that the whole crate of files has to be re-cleaned.
6. Re-isolate each room after cleaning
7. Utilize negative pressure throughout the cleaning process both as an overall engineering control and for local exhaust at the cleaning location
8. Use air scrubbing throughout the process to lower airborne spore concentrations
9. Have the air ducts professionally cleaned
10. Collect cultured and non-cultured samples for post-remediation testing
The testing showed that this was a very effective procedure for removing the airborne deposition. Anything that had visual growth on it was treated differently: controlled removal and disposal. We disposed of whatever we could to save cleaning time. Primarily we used non-cultured Air-O-Cell cassettes, although we did collect cultured samples for confirmation purposes. We set up criteria for post-remediation evaluation based on non-cultured samples so we could get a quicker turnaround and feedback to the contractors.
One of the primary keys was that we were going to have no Stachybotrys spores allowed either in the air or in any of the wipe samples. Initially, three of 15 areas didn't meet the work plan criteria and had to be re-cleaned; negative air machines were run. We then re-sampled, and the areas passed. We now felt that we were ready to have Dr. X check the facility.
Re-occupancy of Dr. X's Office
We brought Dr. X back in with some concern since prior to the remediation she had exhibited symptoms that indicated she was sensitized to the building. She walked in and said that everything was great except for her office. When she walked into her office, she said, "Your group hasn't cleaned this or something is wrong in here." Based on the cleaning procedure, we didn't feel that we had missed anything significant. So we started talking to people about other water intrusion incidents. Even though they didn't remember previously, when we started pressing them, they recalled that the sprinkler bounced up against one outside wall. That led us to start investigating there, even though it was dry (we had done moisture measurements earlier). At that point, we started doing some invasive sampling and found that there was an additional source of Stachybotrys on the drywall. Then we had to seal that area up again and follow the same work plan as before. We kept working until we got it cleaned and met the criteria we had established earlier.
Once we got Dr. X back into her office, she was able to talk to Dearborn and then followed up with a letter to him. Here is an excerpt from that letter:
I've had no further pulmonary hemorrhages, and am feeling the best I've felt in about three years. The daily headaches and sinusitis/scratchy throat feeling have been gone for a while. My head feels clear! I'd been feeling so congested and headachy for so long, I'd just put up with it and the difference now is striking.
This dramatic sort of recovery is not unusual from our experience; people just learn to put up with a certain level of discomfort and feel it's normal until they get it corrected and realize that it was not normal. Perhaps most important, Dr. X is not the only adult whom we found in this situation. But Dr. X is very credible because she is in the medical community, she took good notes and she went to great lengths to prove or disprove the source of her pulmonary hemosiderosis.
Anecdotal Data as Evidence
Is she just a single individual, an anomaly? Our belief is, she is not. We have to be careful as professionals to give appropriate weight to anecdotal data in these situations, as well as scientific data, and share this information so that proper statistical analysis can be done. The CDC says the association between Stachybotrys exposure and pulmonary hemosiderosis should not be considered proven. But I've seen enough evidence, and I'm convinced.
Dr. Michael A. Pinto currently serves as chief executive officer of Wonder Makers Environmental Inc. His Ph.D. is in environmental engineering, and he holds credentials such as Certified Safety Professional, Asbestos Instructor, and others. Dr. Pinto has authored three books, including Fungal Contamination: A Comprehensive Guide for Remediation, over 90 technical articles, and 18 commercial training programs. Pinto can be reached at (888) 382-4154 or [email protected].
Cherie Fennema serves as the director of administration at Wonder Makers Environmental Inc. She has been involved in various aspects of the environmental field with Wonder Makers Environmental for eight years. Fennema is experienced in microscopic analysis of non-cultured bioaerosol samples as well as the interpretation and communication of sample results. She can be reached at (888) 382-4154 or [email protected]