Sick building syndrome--a wolf in sheep's clothing

Building-related illness (BRI) in all family members caused by mold infestation after dampness damage of the building

Introduction: In 2010, dampness damage in a single-family house caused a massive mold infestation. In the further course, the 5 family members developed severe health problems. This report investigates the extent and cause of the water damage. In addition, the various visible fungal infestations were analyzed in a specialized laboratory. Results: Due to building construction errors, starting from the basement, an increased moisture penetration of the residential building was detected. Within 2 years, massive mold infestation occurred. In 2016, the following species were detected: Cladosporium sphaerospermum, Chaetomium globosum, Penicillium chrysogenum, Scopularis brevicaulis, Acremonium furculum, A. charticola and A. sclerotigenum, Trichomonascus apis Aspergillus versicolor and Debaryomyces hansenii. Additionally, different black molds were macroscopically detected. The severity of the disease process varied, probably due to the different daily exposure of the family members, and possibly influenced by age. The children presented acute episodes with nocturnal cough, associated with sleep disturbances and respiratory infections with severe rhinitis. In addition, general fatigue was noticeable. The course of the disease was complicated by recurrent nightly nosebleeds. The mother developed a much more severe course as chronic fatigue syndrome. Additionally, the following continuous complaints occurred: sore throat and headache, nocturnal irritable cough, chronic rhinitis, difficulty concentrating, increasing forgetfulness and word-finding disorders, cognitive impairment with reduced short-term memory, extremely dry eyes with red sclerae, morning stiffness, dyspnea, disturbed temperature regulation (chills), increased feeling of thirst, and menstrual disorders. The father's building-related illness (BRI) was comparatively mild due to much lower exposure, with nocturnal irritable cough, rhinitis, and marked fatigue. In 2018, after moving out of the house, the father was symptom-free after 2 weeks, the three children after 6 months, but the mother only after 18 months. Discussion: The symptoms are consistent with reports from the literature, according to which fatigue, sleep disturbances, lack of concentration and headache as well as recurrent infections of the upper respiratory tract are caused by microbial volatile organic compounds (MVOCs) released by molds. The association with recurrent nosebleeds in childhood has not been described in this form before. Conclusion: Since in all family members complete remission of symptoms occurred after cessation of the 6-year exposure, there is no doubt that the BRI was caused by the massive mold infestation.

The Roles of Autoimmunity and Biotoxicosis in Sick Building Syndrome as a "Starting Point" for Irreversible Dampness and Mold Hypersensitivity Syndrome

BACKGROUND

The terminology of "sick building syndrome" (SBS), meaning that a person may feel sick in a certain building, but when leaving the building, the symptoms will reverse, is imprecise. Many different environmental hazards may cause the feeling of sickness, such as high indoor air velocity, elevated noise, low or high humidity, vapors or dust. The Aim: To describe SBS in connection with exposure to indoor air dampness microbiota (DM). Methods: A search through Medline/Pubmed. Results and Conclusions: Chronic course of SBS may be avoided. By contrast, persistent or cumulative exposure to DM may make SBS potentially life-threatening and lead to irreversible dampness and mold hypersensitivity syndrome (DMHS). The corner feature of DMHS is acquired by dysregulation of the immune system in the direction of hypersensitivities (types I-IV) and simultaneous deprivation of immunity that manifests as increased susceptibility to infections. DMHS is a systemic low-grade inflammation and a biotoxicosis. There is already some evidence that DMHS may be linked to autoimmunity. Autoantibodies towards, e.g., myelin basic protein, myelin-associated glycoprotein, ganglioside GM1, smooth muscle cells and antinuclear autoantibodies were reported in mold-related illness. DMHS is also a mitochondropathy and endocrinopathy. The association of autoimmunity with DMHS should be confirmed through cohort studies preferably using chip-based technology.

Symptoms after mould exposure including Stachybotrys chartarum, and comparison with darkroom disease

BACKGROUND

Mould-attributed symptoms have included features which overlap with unexplained syndromes such as sick building syndrome.

OBJECTIVES

We describe questionnaire and chart review findings in patients following exposure to moulds which include Stachybotrys and compare responses with two control groups.

METHODS

Thirty-two patients presented with symptoms attributed to mould exposures. Exposure identification for 25 patients had reported S tachybotrys chartarum as well as other mould (Aspergillus, Penicillium), 88% at work. The remaining seven had professionally visualized or self-reported/photographic exposure evidence only. A chart review was performed and a follow-up with a questionnaire, including questions on current health status, and nonspecific symptoms.

RESULTS

Cough, shortness of breath and chest tightness (at presentation) were reported in 79%, 70% and 64%, respectively, and persisted >6 weeks in 91%. Skin test(s) were positive to fungal extract(s) in 30%. Seventeen returned questionnaires were obtained 3.1 (SD 0.5) years after the initial clinic assessment. Among this subgroup, persisting asthma-like symptoms and symptoms suggestive of sick building syndrome were frequent, and similar to a group previously assessed for darkroom disease among medical radiation technologists. The mould-exposed group more commonly reported they were bothered when walking in a room with carpets, complained of a chemical or metallic taste in their mouth, and had problems in concentration when compared with a control physiotherapist group (P < 0.005).

CONCLUSIONS

Although only a minority with health concerns from indoor mould exposure had demonstrable mould-allergy, a significant proportion had asthma-like symptoms. Other symptoms were also common and persistent after the initial implicated exposure.

Sick building syndrome and perceived indoor environmental quality: A survey of apartment buildings in Hong Kong

The outbreak of a highly communicable disease, SARS, in Asia in 2003 has revealed the health risk of living in a high-density environment. To show the important connection between human health and environmental quality, this study surveys the prevalence of sick building syndrome (SBS) among apartment residents and their evaluation of indoor environmental quality (IEQ). Based on a sample of 748 households living in Hong Kong, two interesting findings are revealed: (1) nasal discomfort was the commonest home-related SBS symptom despite the absence of any central ventilation system in apartment buildings; (2) noise, rather than ventilation, was the major IEQ problem perceived by residents. Our statistical analysis further showed that residents with SBS symptoms were less satisfied with their IEQ than those without. That is, despite a positive evaluation of specific IEQ criteria with respect to the building residents lived in, if they reported feeling SBS related symptoms, the overall IEQ evaluation of their building could still be negative. This perception bias gives rise to a sample selection problem in measuring perceived IEQ, which has implications on housing management practices and the formulation of a healthy housing policy.

Formaldehyde exposure induces airway inflammation by increasing eosinophil infiltrations through the regulation of reactive oxygen species production

Formaldehyde (FA) is a well-known cytotoxic irritant to the airways, but the mechanism of airway inflammation due to FA has not been clarified. In the present study, C57BL/6 mice were exposed to two concentrations (5 and 10ppm) of FA for 6h/day, 5days/week, for 2 weeks. The FA-exposed mice had much higher number of CCR3(+) eosinophils than control mice, and showed upregulated gene expression of CC-chemokine receptor-3 (CCR3), eotaxin and intercellular adhesion molecules-1 (ICAM-1) as well as an increased expression of proinflammatory and Th2 cytokines, such as interleukin (IL)-1β, IL-4 and IL-5. In addition, FA exposure revealed a considerable increase in the serum levels of IgG1, IgG3, IgA and IgE compared to controls. Histopathological analysis of the lung tissues demonstrated eosinophils and mononuclear cell infiltration of the alveolar cell walls and alveolar spaces. Gene expression of thioredoxin (TRX), redox-regulating antioxidant proteins, was markedly suppressed in FA-exposed mice, and thereby intracellular ROS levels were increased along with increased FA concentration. These results were consistent with an increase in the number of CCR3-expressing eosinophils, and indicate that FA-induced ROS was generated from eosinophils recruited to the inflammatory sites of the airways.

Multivariate evaluation of VOCs in buildings where people with non-specific building-related symptoms perceive health problems and in buildings where they do not

Volatile organic compounds (VOCs) were sampled in buildings where people with non-specific building-related symptoms perceive health problems and in buildings where they do not. In total, nine persons and 34 buildings were included in the study. The obtained VOC data was evaluated using multivariate methods, to investigate possible systematic differences in air quality of 'problem' and 'non-problem' buildings. All individual compounds were included as variables in a multivariate partial least squares (PLS) data analysis. 'Problem' and 'non-problem' buildings separated into two distinct groups, showing that air samples of the two groups of building were chemically different.

PRACTICAL IMPLICATIONS

The study showed that there was an identifiable systematic difference in the collected VOC data between buildings causing and not causing problems for people with non-specific building-related symptoms (also called sick building syndrome, SBS). This is an important indication that even such volatile organic compounds that can be sampled by commonly used adsorbents are of importance for the presence of such symptoms. By coordination of procedures for sampling and analysis of VOCs in buildings between laboratories, to get large datasets and more general models, the method can become a useful diagnostic measure in evaluating indoor air and to identify chemical compounds and sources that contribute to SBS problems.

Persistent allergic rhinitis and indoor air quality perception--an experimental approach

In order to compare patterns of indoor air perception, including perceptions of temperature, air movement, indoor air quality (IAQ), mental concentration, and comfort, 33 subjects either with persistent allergic rhinitis or controls were exposed to different temperatures and constant relative humidity in an experimental office environment. Results were obtained by means of a self-administered visual analogue scale, analyzed using mean score comparisons and principal component analysis. At 14 degrees C, the rhinitis group reported higher scores for sensations of air dryness than controls. At 18 degrees C, in the rhinitis group, there was a correlation between dry, stagnant air, and difficult mental concentration. This group also correlated heat, dry air, and poor IAQ, in contrast to the control group, which correlated comfort, easy mental concentration, and freshness. At 22 degrees C, the rhinitis group correlated heat, dryness, stagnant air, and overall discomfort. This group also correlated non-dry air, freshness, and comfort, whereas the control group correlated heat, humidity, good indoor air, freshness, and comfort. This study suggests that the rhinitis group perceives indoor temperatures of 14 degrees C as dryer than controls do, and that at 18 and 22 degrees C this group positively correlates different adverse perceptions of IAQ. By means of a self-administered questionnaire in an experimental condition, the present study compares subjective patterns of indoor air perception from individuals with respiratory allergy (allergic rhinitis) to control individuals. It reports different patterns of perception of indoor air quality (IAQ) between the two groups, suggesting that allergic individuals could have different IAQ perception.

Inhalational mold toxicity: fact or fiction? A clinical review of 50 cases

BACKGROUND

Three well-accepted mechanisms of mold-induced disease exist: allergy, infection, and oral toxicosis. Epidemiologic studies suggest a fourth category described as a transient aeroirritation effect. Toxic mold syndrome or inhalational toxicity continues to cause public concern despite a lack of scientific evidence that supports its existence.

OBJECTIVES

To conduct a retrospective review of 50 cases of purported mold-induced toxic effects and identify unrecognized conditions that could explain presenting symptoms; to characterize a subgroup with a symptom complex suggestive of an aeroirritation-mediated mechanism and compare this group to other diagnostic categories, such as sick building syndrome and idiopathic chemical intolerance; and to discuss the evolution of toxic mold syndrome from a clinical perspective.

METHODS

Eighty-two consecutive medical evaluations were analyzed of which 50 met inclusion criteria. These cases were critically reviewed and underwent data extraction of 23 variables, including demographic data, patient symptoms, laboratory, imaging, and pulmonary function test results, and an evaluation of medical diagnoses supported by medical record review, examination, and/or test results.

RESULTS

Upper respiratory tract, lower respiratory tract, systemic, and neurocognitive symptoms were reported in 80%, 94%, 74%, and 84% of patients, respectively. Thirty patients had evidence of non-mold-related conditions that explained their presenting complaints. Two patients had evidence of allergy to mold allergens, whereas 1 patient exhibited mold-induced psychosis best described as toxic agoraphobia. Seventeen patients displayed a symptom complex that could be postulated to be caused by a transient mold-induced aeroirritation.

CONCLUSION

The clinical presentation of patients with perceived mold-induced toxic effects is characterized by a disparate constellation of symptoms. Close scrutiny revealed a number of preexisting diagnoses that could plausibly explain presenting symptoms. The pathogenesis of aeroirritation implies completely transient symptoms linked to exposures at the incriminated site. Toxic mold syndrome represents the furtive evolution of aeroirritation from a transient to permanent symptom complex in patients with a psychogenic predisposition. In this respect, the core symptoms of toxic mold syndrome and their gradual transition to chronic symptoms related to nonspecific environmental fragrances and irritants appear to mimic what has been observed with other pseudodiagnostic categories, such as sick building syndrome and idiopathic chemical intolerance.

Unloading the trunk: neurasthenia, CFS and race

The aetiologies of both chronic fatigue syndrome (CFS) and its predecessor neurasthenia, have been linked to technological advances in 'developed' countries. This paper discusses how this has led to a form of race thinking within discussions about fatigue which has persisted for more than a century. We review the historical development of this race thinking from neurasthenia to CFS and describe how it is manifested in both the lay- and medical literature. We also review the epidemiological literature on CFS and ethnicity to better understand the relatively low percentage of non-white patients seen in tertiary referral clinics for CFS. The aim of this paper is to act as a starting point for a debate on race and CFS.

Decreased Respiratory Symptoms After Intervention in Artificially Ventilated Offices in São Paulo, Brazil

BACKGROUND

The increase in work-related respiratory complaints in artificially ventilated buildings have multiple causes, and intervention studies are a valuable approach to understanding possible mechanisms.

STUDY OBJECTIVES

To analyze the effects of an intervention in a ventilation system with > 20 years of continuous use, and with a high rate of building-related respiratory complains.

DESIGN

An epidemiologic study was done among individuals working in places with ventilation machinery and ducts with > 20 years of use, before and after intervention. Analysis of symptoms and logistic regression were performed to check the associations between air-conditioning intervention and reported symptoms.

RESULTS

The air-conditioning intervention showed a protective effect on building-related worsening of respiratory symptoms (odds ratio, 0.132; 95% confidence interval, 0.030 to 0.575), naso-ocular symptoms (odds ratio, 0.231; 95% confidence interval, 0.058 to 0.915), and persistent cough (odds ratio, 0.071; 95% confidence interval, 0.014 to 0.356).

CONCLUSION

Intervention in high-risk occupational locations can be effective in improving perceived indoor air quality.

Indoor air quality and health does fungal contamination play a significant role?

Fungal contamination in buildings can vary greatly, and their presence in a dwelling does not necessarily constitute exposure. Measurement of mold spores and fragments varies depending on the methodology and instruments used. Meaningful comparison of data is rarely possible. The presence of a specific immune response to a fungal antigen only connotes that exposure to one or more related species has occurred, but not that there is a symptomatic clinical state. The response of individuals to indoor bioaerosols is complex and depends on age, gender, state of health, genetic makeup, and degree and time of bioaerosol exposure. In general, mold contamination in buildings is associated with incursion of water or moisture, which should be remedied as efficiently as possible. When disease occurs, it more likely is related to transient annoyance or irritational reactions. Allergic symptoms may be related to mold proliferation in the home environment. Because molds are encountered both indoors and outdoors, it is difficult to determine where the sensitivity initially arose and if the response is solely provoked by either an indoor or outdoor source. As an indoor allergen, mold is considered to be an infrequent participant in the induction of allergic disease when compared with housedust mites, animal dander, and cockroach allergens. Infection in healthy individuals is rare and usually is caused by an outdoor source. Building-related disease caused by mycotoxicosis has not been proved in the medical literature.

Idiopathic Environmental Intolerance

Toxicogenic and psychogenic theories have been proposed to explain idiopathic environmental intolerance (IEI). Part 2 of this article is an evidence-based causality analysis of the psychogenic theory using an extended version of Bradford Hill's criteria. The psychogenic theory meets all of the criteria directly or indirectly and is characterised by a progressive research programme including double-blind, placebo-controlled provocation challenge studies. We conclude that IEI is a belief characterised by an overvalued idea of toxic attribution of symptoms and disability, fulfilling criteria for a somatoform disorder and a functional somatic syndrome. A neurobiological diathesis similar to anxiety, specifically panic disorder, is a neurobiologically plausible mechanism to explain triggered reactions to ambient doses of environmental agents, real or perceived. In addition, there is a cognitively mediated fear response mechanism characterised by vigilance for perceived exposures and bodily sensations that are subsequently amplified in the process of learned sensitivity. Implications for the assessment and treatment of patients are presented.

Idiopathic environmental intolerances (IEI): myth and reality

The psychogenic theory presupposes that idiopathic environmental intolerance (IEI) is an overvalued idea explained by psychological and psychosocial processes. The polysomatic symptoms are amplifications of complaints common to the general population, psychophysiological manifestations of stress and the stress-response, or symptoms of psychiatric clinical syndromes. The psychogenic theory is supported by provocation challenge studies which demonstrate that appraisals of 'reactions' are unreliable and cognitively mediated. Clinical studies of IEI cases consistently identify greater incidence of current and premorbid lifetime psychiatric disorders and co-morbidity with functional somatic syndromes that are fashionable 'diagnoses'. The toxicogenic theory presupposes low-level chemical sensitivity or intolerance without objective signs to a plethora of diverse chemical agents. Symptoms are synonymous with disease and attributions are synonymous with cause. Hypotheses about physiological processes and mechanisms are implausible and unsupported by evidence. Advocates claim this phenomenon is so ephemeral that the principles and methods of toxicology do not apply and that a scientific paradigm shift is in order.

The role and abatement of fungal allergens in allergic diseases

Sensitivity to a variety of fungi is known to be a factor in allergic rhinitis and asthma. In this review methods for measuring exposure to fungi in the indoor environment are evaluated. A variety of markers for the presence of fungi are also described in addition to their known relationship to either toxic or adverse immunologic effects. Key studies documenting the clinical effects of different types of fungi are also reviewed, as well as a description of abatement methods that either have been successful or need further investigation. Although many studies have shown an association between exposure to fungi and allergic disease, in many cases a direct cause-and-effect relationship has not been established. Improved knowledge of the epidemiology and mechanisms behind fungal-induced human disease will hopefully establish this causal link and suggest methods for reducing morbidity.

Sick building syndrome in an office building formerly used by a pharmaceutical company: a case study

In the past two decades, a group of health problems related to the indoor environment--generally termed sick building syndrome (SBS)--has emerged. We present an investigation of SBS in employees of a ministry working in a naturally ventilated office building that formerly had been used by a pharmaceutical company. A preceding environmental monitoring had failed to identify the cause(s) for the complaints. We conducted a questionnaire-based investigation and categorized the building sections and rooms according to their renovation status and their former use, respectively. The highest level of complaints was found among the employees working in rooms that in the past had been used for the production or storage of various pharmaceutical products suggesting that pharmaceutical odors may be a risk factor for SBS. Clinical laboratory tests did not show any unusual results. We conclude that the former use of a building for production and storage of pharmaceutical products should be considered as a possible risk factor for complaints about indoor air quality, e.g., when advising about or planning for renovations of buildings formerly used for production, handling, or storing of chemicals.