Some New Facts About Black Mould Sinusitus
Good afternoon. My name's Dr. Cameron Jones and I'm an environmental microbiologist. This week I'm going to bring you a very exciting show on the topic of black mould, the infamous Stachybotrys. If you have ever considered that your home or property could be contaminated with mould, you've probably looked up online and you've probably found page after page referring to something called black mould or Stachybotrys chartarum. This is the most infamous black mould. It's not as common as people think, but there has been an increasing amount of research done. I'm going to be taking you through this week some of the key publications as well as one which is just come out in the research literature, which is talking about a patient who presented to the medical clinic with a sinusitis infection. It was typed out to be Stachybotrys.
In any case, we're going to get into this publication and what this means to you, but I want to firstly overview you on what we're going to be talking about today. The topic that we're focusing on is facts about black mould and fungal sinusitis. If you look at this particular photograph, which I've used as the cover of this week's live stream, you'll see that it is the underside of a ceiling in someone's home. This is an onsite photograph from an inspection I did myself a couple of weeks ago, and the occupants have actually moved out because the mould, in their opinion, was making the entire property uninhabitable. Now, what does it actually mean when a property is uninhabitable? Well, it means that no one wants to live there, but the owner of this property wanted to investigate further because it was his opinion that there were some intrinsic building defects that had allowed water to penetrate into this property and produce the correct conditions for mould to grow.
As we know, mould loves water. It loves carbon-rich foods like timber and the underside of the plasterboard. You can see there's evidence of visual mould here when the underside of the ceiling in this particular hallway underneath the balcony was removed. But what I want to talk to you about and put this in perspective is this is what I actually was able to see inside this property. Just to orient you this, and you can see the front door of this particular individual's property. You can see that some of the wall's sheeting plasterboard has been removed to expose the frame. Up top, this is immediately above the front doorway, you can see that the investigations by the building inspector and the builder have lifted the tiles to look for the problem. You can see that some of the framing timbers and the structural components to the ceiling affecting the ground floor are covered with visual mould.
But to put this in perspective for you is that something called Stachybotrys has been infamously and controversially linked to something called idiopathic pulmonary hemorrhage and sick building syndrome. Now, what do I mean by idiopathic? Well, idiopathic means really no known cause, but quite severe symptoms. Historically there are a number of papers that have linked Stachybotrys chartarum with sick building syndrome, and the reason I wanted to show you those photographs at the beginning of this talk is essentially to orient you with the fact that Stachybotrys, we actually found that when we did Petri plate press cultures up against those framing timbers, as well as tape lifts that were assessing physical structure, the underside of the plasterboard. Not only that, but when we use spore traps to capture air samples, we were able to find Stachybotrys in the air space. So I'm not surprised by the people who lived in that particular home chose to move out.
But what are the historically relevant paper for linking Stachybotrys with adverse health? Well, we have to go back to 1999 and a famous publication appeared in research literature talking about an infant or a young child who had a hemorrhage reaction to the Stachybotrys in the home. The micrograph that I've put underneath this publication, this is what I found inside the home a couple of weeks ago. This is from a tape lift that I took off the underside of the plasterboard. I just want to make the very clear connection with the effect that complaints of mould, you have to find the source. Once you find the source, it's also very important to determine what type of mould is present and we're going to get to that, and that's the topic of today's talk. Because a certain percentage of the population is particularly susceptible to these toxic moulds, like Stachybotrys chartarum.
Okay. Let's look at some of the other historically relevant pieces of literature. We have another one from 2000. Yes, 20 years ago. This was also making a connection with Stachybotrys and sick building syndrome. I would encourage you to go to the references at the end of this in the show notes to this podcast and also to the live stream where you can look up this literature itself and verify that what I'm saying to you about the connection with Stachybotrys and sick building syndrome and hemorrhage reactions in people is very real and a potential adverse consequence of living in a water-damaged or mould affected building.
Now, the paper that just came out, it's published ahead of print, 2020 first case of invasive Stachybotrys. You can see the characteristic black spores that this fungus produces. Now, just so you don't think it's just Stachybotrys that causes severe reactions like sinusitis. Even a publication from 2015 was focusing on the fact that other fungi caused severe problems. I know that we're often talking about asthma and allergy and the link with these airborne spores causing an irritation reaction to the individual, but they call serious reactions, not just singular case studies linking Stachybotrys with hemorrhage in infants, but aspergillosis and sinus reactions and even cerebral aneurysms that are found to be completely overgrown with fungal hyphae.
Now, I know this sounds like science fiction, but it's science fact, and that's why I'm using the references to support my statements and claims and I encourage you to download these and read these yourself. But let's put this on a practical footing. Let's move away, step away from the research literature. In Australia, landlords have an obligation to ensure that their homes that they offer up for leasing accommodation are in a reasonable state of cleanliness and fit for habitation. This concept of fit for habitation is a little bit gray and it's difficult, certainly for microbiologists and public health individuals like myself and occupational hygienists to often collect the correct information to make a connection between the water-damaged building and whether or not it is, in fact, fit for purpose.
I strongly advise all of you, if that is an outcome that you wish to achieve, you need to take appropriate samples. You can't rely on visual estimation alone. But look, we'll get to that a little bit later, but I just want to make the point that if mould in any property is caused by, for example, a roofing leak or some type of structural defect, like a guttering problem, then the landlord is responsible for fixing the problem and remediating the damage caused by the water ingress, and same goes for the insurance on those types of properties. So although the fit for habitation maybe sometimes a gray area and requiring evidence to support claims made by individuals, it's still an important question that needs an answer.
Let's get back to Stachybotrys, and let's go all the way back to 1945 when one of the first publications appeared linking Stachybotrys, this particular black mould, and adverse health in horses. I put the paper up here. Again, you can read about this at your own time and leisure, but I've highlighted some key facts here and a toxic reaction to Stachybotrys. It was first started back in 1945 and this toxic name was given to a newly discovered disease in horses that was observed in Ukraine. It was characterized by mucus in the airway, hemorrhage, ulceration of the mucosal membranes in the mouth, nose, and throat. And if that disease progresses, then the observation would be a reduced or lower white blood cell count, which means that there is a significant impact on the immune system of, in this case, the horse.
But what does that mean? Well, the scientists then went on to state that the disease caused by Stachybotrys was associated with the horse feeding on mould contaminated hay dominated by growth of Stachybotrys. And when horses were deliberately and experimentally fed pure cultures of the contaminated hay or pure cultures of the fungus that had been cultured in Petri plates in the lab, this led to severe symptoms in the horses and there was a dose-dependent relationship between disease severity and the consumption and concentration of these Stachybotrys.
Now, this is a very important publication because it also made another key observation. We hear the term mycotoxins all the time. Many people ask me, "What's the relationship between the fungus and the mycotoxins?" Well, think of mycotoxins as something that the fungus produces to enable it to survive in the environment. Often it's a toxic substance which the fungus produces as part of its natural metabolism, which gives it a competitive edge against other pathogens in the wild. But these mycotoxins are often volatile or they are exuded in droplets called guttation droplets for some funny, and these can be toxic as well. So this is something extracellular to the fungus, which is nevertheless toxic.
So back in 1945, the scientists were able to establish that a toxic substance, independent to the vegetative cell, was able to elicit this severe adverse immune reaction in these horses, and not only living or dead cultures were able to cause the severe reaction. When exudates from the fungus were streaked onto the skin of even humans or rabbits, it provoked allergic dermatitis, sometimes with necrosis. Now, what else do I want to tell you about this? Well, what Stachybotrys does is that when healthy volunteers were exposed to the mouldy hay, they also developed the disease, and back in 1945, they were able to establish that this is caused by inhalation of the toxins or the fungus.
Now, we know this is a fact and there is increasing literature appearing literally month by month in the peer-reviewed literature. Here's a paper that came out on the 26th of June, 2020, and the conclusion was that living or working in damp or mouldy buildings increases the risks of many adverse health effects, including asthma and other respiratory diseases. Now, this came out in Applied and Environmental Microbiology and all too often, I get calls from people questioning whether or not could it be true that people being exposed to water-damaged buildings are in fact made ill? Often their rationale for making those statements is often very self-serving in that they don't want to admit liability or often responsibility that individuals in their buildings have potentially been exposed to quite severe toxins. Often people often say that they just don't believe that this be true because they feel fine.
Well, I want you to think about this research that has been coming out since 1945 about one particular microorganism, specifically Stachybotrys. We're going to focus a little bit more on this microorganism now. But to put this in the context of people's buildings, Suncor, one of the largest insurers in Australia, they publicly state that 17% of their claims are water damage related. Think about that. 17% of insurable events have a water component to it. That is a significant amount of potential mould affecting Australian homes, buildings, and businesses.
But let's get back to what happened to that young man, the focus of the publication. That's just come out about Stachybotrys sinusitis. You're probably somewhat in suspense. What happened to him? Well, the outcome isn't great, but I'm going to lead you through the case study because this establishes a couple of things that I want you to take home from this stream. A 23-year-old man with a history of leukemia, yes, he was already immunocompromised, was admitted to hospital with bone pain. He'd been diagnosed with leukemia 18 months prior to fronting up to the hospital and had undergone chemotherapy in that prior 18 months.
He had evidence of tissue invasion by Stachybotrys, which showed up in his sinuses. He had periorbital pain in his face and headaches and a CAT scan showed that he had definitely a sinusitis reaction. He underwent surgery. The doctors were able to isolate from the surgery, and also a biopsy, that Stachybotrys was present in his sinus cavities. Unfortunately, he didn't get better from the sinus. He did recover from the Stachybotrys infection, but he ended up with two further surgical procedures, and each next surgical procedure led to observations of extensive inflammation and congestion and further colonization by another fungus, extremely common everywhere, worldwide, global incidents called Aspergillus. Unfortunately, the patient continued to deteriorate and he passed away 139 days after having entered the hospital with headaches and sinus pain.
What I want to make clear is that Stachybotrys and Aspergillus fungus were isolated and were characterized and were able to be regrown from the sinus cavity. We're not talking about sampling in people's homes. We're talking about sampling side someone's nose, and then gene sequencing speciated and ensured that the identification of the Stachybotrys was, in fact, correct.
This paper essentially is the first case of invasive Stachybotrys sinusitis. Based on the results and outcome of the first surgery, it was medically cured. However, the patient did succumb to an Aspergillus mediated sinusitis, and eventually, he did pass away. He was immunocompromised. So where to from here? Well, you might be thinking I'm being sensationalist by focusing on a case study from a patient with leukemia, who ended up with a Stachybotrys infection. It's like, "That's not going to happen to me." I now want to talk about immunocompromise and about how common it is. Immuno-deficiency disorders in general prevent your body from fighting off diseases and infections. They fall into two types, congenital and acquired.
So congenital immune disorders mean that you're born with it. But the second, the acquired, is very much like when we talk about hypersensitivity reactions to mould or outdoor pollution, for example. This is often an acquired response to something toxic, which is causing an adverse reaction in your body. These secondary or acquired conditions often occur later in life, and they are very, very common and they outnumber the congenital disorders. Now, when an immune system is not functioning properly, you end up with problems and there are over 100 conditions that are known that cause immune compromise.
So think about it. Over 100 different reasons to potentially front up to the hospital with a sinus infection potentially caused by black mould contaminants picked up in a water-damaged building. Let's look at some of these problems that contribute to immunocompromised status. You could be sleep deprived. You might have arthritis. Even type one diabetes makes individuals immunocompromised. Birthday on, birthday off. Successive birthdays, just getting older is going to over time lead to immunocompromise. Behaviors, risky behaviors like smoking cigarettes. Obviously accidents like severe burns make individuals immunocompromised. Chemotherapy, exposure to radiation, individuals undergoing transplants. Malnutrition. If you don't eat well, you can be immunocompromised. Obviously viral infections like HIV (AIDS). Cancers of the immune system, which we've already covered like leukemia. Viral hepatitis and serious diseases like multiple myeloma all ensure that the individual is immunocompromised.
Now, what are the percentages of immunocompromised status in the community? Well, immunocompromised individuals are everywhere. Studies in the United States have confirmed that 3.6% of the entire population has an immunocompromised status. That is a huge number of potential people who could behave in the same way after repeated exposure to toxic mould in the home or workplace, and imagine if 3.6% of the population were exposed to Stachybotrys. That's why this publication is so important because it establishes that exposure to toxic moulds like Stachybotrys can lead to very serious sinusitis reactions, and there's a huge pool of immunocompromised individuals.
So next time you unenviably find yourself in a dispute with a landlord, a builder, or an insurer concerning whether or not you should just let the building dry out, that is leave the mould there, think about it. Imagine you might be in perfect health. All of your family might be in perfect health, but what happens if, and when you become part of that 3.6% pool of immunocompromised status people? That cohort exposed to water damage like I'm showing up on screen is particularly severe. You can see I'm holding a RODAC and look again at what we have been able to culture and then visualize with tape lifts from a simple hallway, something that this family would have gone in and out through their front door, out their front door, and into life. Well, it puts it in perspective what sick building syndrome is, doesn't it?
Anyway, I hope you've learned something about the importance of black bold. The fact that many different types of moulds can cause hypersensitivity and allergic reactions. Not everyone's going to end up with invasive fungal sinusitis, but similarly, it could happen. The fact that it could happen means that water damage needs to be taken very seriously and remediated properly. Not covered up or hoping for the best or suggesting that it's unlikely to happen to you. Just think about it. 3.6% of the population is immunocompromised. When will it be your turn?
Anyway, my name's Dr. Cameron Jones have a great week, stay safe, and I'll see you next week. Bye now.
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REFERENCES:
Semis M, Dadwal SS, Tegtmeier BR, Wilczynski SP, Ito JI, Kalkum M. First Case of Invasive Stachybotrys Sinusitis [published online ahead of print, 2020 Mar 10]. Clin Infect Dis. 2020;ciaa231. doi:10.1093/cid/ciaa231
Flappan SM, Portnoy J, Jones P, Barnes C. Infant pulmonary hemorrhage in a suburban home with water damage and mold (Stachybotrys atra). Environ Health Perspect. 1999;107(11):927-930. doi:10.1289/ehp.99107927
Massoud Mahmoudi & M. Eric Gershwin (2000) Sick Building Syndrome. III. Stachybotrys chartarum, Journal of Asthma, 37:2, 191-198, DOI: 10.3109/02770900009055442
Shinya Y, Miyawaki S, Nakatomi H, et al. Recurrent cerebral aneurysm formation and rupture within a short period due to invasive aspergillosis of the nasal sinus; pathological analysis of the catastrophic clinical course. Int J Clin Exp Pathol. 2015;8(10):13510-13522. Published 2015 Oct https://europepmc.org/article/pmc/4680511
Identifying a fungal signature of moisture damage in buildings: targeted and untargeted approaches with mycobiome data. Rachel I. Adams, Iman Sylvain, Michal P. Spilak, John W. Taylor, Michael S. Waring, Mark J. Mendell. Applied and Environmental Microbiology Jun 2020, AEM.01047-20; DOI: 10.1128/AEM.01047-20
Khan L. The growing number of immunocompromised - Bulletin of the Atomic Scientists. Bulletin of the Atomic Scientists. https://thebulletin.org/2008/01/the-growing-number-of-immunocompromised/. Published 2008. Accessed August 9, 2020.
