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Pulmonary Hemorrhage And Hemosiderosis In Infants Introduction Over the past several years, there have been a number of young infants (most under 6 months old), in the eastern neighborhoods of Cleveland, who have been coughing up blood due to bleeding in their lungs. Some infants have died and more infants continue to to get ill. This bleeding, a disorder called Pulmonary Hemorrhage appears to be caused by something in their home environments, most likely toxins produced by an unusual fungus called Stachybotrys chartarum or similar fungi. What is Pulmonary Hemosiderosis? Bleeding in the lungs. What Are The Symptoms? Severe bleeding can cause coughing up blood or nose bleeds. This is particularly concerning in infants under 6 months old. Chronic, low grade bleeding can cause chronic cough and congestion with anemia. What Causes The Bleeding? Most likely, toxins made by an unusual fungus or mold Stachybotrys. When infants breathe in the toxins, the blood vessels in their lungs may become fragile. The weak vessels may be bothered by cigarette smoke or stresses from other illnesses and start to bleed. You cannot see the toxins in the air rather they are carried in the microscopic fungal spores. How Do I Know If The Fungus Or Mold Is In My House? This fungus or mold grows only on wood or paper that have gotten very wet for more than a few days or so. (It does NOT grow on plastic, vinyl, concrete products, or ceramic tiles). If the wood/paper gets wet and is not cleaned up and dried, the fungus may grow and spread. The fungus is black and slimy when wet. It is NOT found in the green mold on bread or the black mold on the shower tiles (but the shower tiles should be kept clean too). If you have had plumbing leaks, roof leaks, flooding in the basement (even if you don't use the basement), or sewer backup in the past year, look for mold or a musty odor. Common Areas for This Mold Growth Water soaked wood, ceiling tiles, wall paneling, unpainted plaster board surfaces, cotton items, cardboard boxes, and stacks of newspapers. If these areas have been very wet, usually for longer than one week, check for mold. After the area dries, the fungus will not continue to grow, but the black dust caused by the fungus can be sucked up by the furnace blower and spread throughout the house. Be sure and check your basement for the black mold. If you do not have access to the basement, ask your landlord for assistance. Note not all black mold is Stachybotrys, but moldy homes are not healthy homes. Heating Systems If you have mold in your basement, check to see if there is any way that your forced air furnace can send the mold dust up to the living spaces. Is there ductwork connecting the cold air returns to your furnace or does your furnace pull air from the basement? The latter is the case if you can seen the furnace filter face on (rather than just the edge). How To Clean-up Fungal Growth If you have more than two square feet of mold growth you should seek professional advice on how to perform the clean-up.
Call your city or county health department if you have questions or need assistance. THE CLEVELAND OUTBREAK Over the past seven years in the Cleveland, Ohio area there have been 45 cases of pulmonary hemorrhage (PH) in young infants. Sixteen of the infants have died. Thirty-two of the infants have been African American. Most of these cases have occurred within ten contiguous zip codes area in the eastern portion of the metropolitan area. In November/December, 1994, the Centers for Disease Control and Prevention (CDC) lead a case-control investigation on the first ten cases. This study found an epidemiological association of PH in these infants with water-damaged homes containing the toxic fungi, predominantly Stachybotrys. Several lines of evidence suggest that the most likely causal agents are fungal toxins from a fungus called Stachybotrys atra. This somewhat unusual fungus was found in high quantity in the home environments of the affected infants but also to a lesser degree in some of the comparison homes. Stachybotrys requires water soaked cellulose to grow, and was found in homes where there had been water damage from flooding, plumbing leaks or roof leaks involving wood or paper products (e.g. insulation, gypsum board, ceiling tile). The spores of this fungus contain very potent mycotoxins which appear to be particularly toxic to the rapidly growing lungs of young infants. The linkage of Stachybotrys to PH in infants is on the basis of epidemiological data and has not been conclusively demonstrated. Other factors such as environmental tobacco smoke appear to be important triggers in precipitating overt pulmonary hemorrhage. More cases continue to occur, a few infants having had only very subtle initial symptoms such as nose bleeds and chest congestion. Concern that there may be a larger number of undetected young infants with this disorder, led to the examination of all infant coroner cases over a three year period, 1993-1995. This revealed seven "SIDS" (sudden infant death syndrome) cases with evidence of preexisting major pulmonary bleeding. All but one of these infants had lived in the ten zip code cluster area. This disorder is likely to extend beyond Cleveland since an informal national survey of all pediatric pulmonary centers and continued reporting has identified over 100 similar cases of pulmonary hemorrhage in infants across the country over the last seven years. IS MY MOLD STACHYBOTRYS? While Stachybotrys chartarum (atra) occurs widely in North America, it is probably rather uncommon to find it in homes. It requires water soaked cellulose (wood, paper, and cotton products) to grow. While wet it looks black and slimy perhaps with the edges white, and when dry it looks less shiny. It is not the only or the most common black mold to be found in these conditions. If your clean-up is not simple, i.e. your water damage and mold growth is extensive and/or involves structural materials, contact your city or county health department for assistance in assessing the problem. They can put you in contact with environmental laboratories capable of identifying Stachybotrys and with abatement contractors familiar with the precautions and other specifics important for extensive clean-up. If you have a large area of mold growth (greater than two square feet or so), seek professional assistance in the clean-up. You can get quite ill yourself if you inhale a large quantity of the fungal dust or get it on your skin. Testing for Mold For a more detailed discussion on the assessment and remediation of Stachybotrys in indoor environments, please refer to The Proceedings of the International Conference held on October 6-7, 1994 in Sarasota Springs, NY entitled "Fungi and Bacteria in Indoor Environments", pages 201-207, published by the Eastern New York Occupational Health Program [(518)436-5511]. In cases of minor mold contamination, small isolated areas (2 to 10 sq.ft.), testing is usually not necessary. In most of these cases, the area can be addressed by using the clean-up recommendations given elsewhere on this home page. In cases of more extensive contamination, testing may be necessary. Some private environmental consulting firms may have the ability to conduct home assessments and sample for mold identification. Please refer to the section of your yellow pages entitled "Environmental Consultants" to find a company in your area that might be capable of performing these tasks effectively. Ask if the company has experience with mold testing; it is recommended that several price quotes be obtained for field work and analysis. Consulting firms should be familiar with the American Industrial Hygiene Association (AIHA) document entitled "Field Guide for the Determination of Biological Contaminants in Environmental Samples". This document provides guidelines for the sampling of mold in indoor environments. For a list of accredited labs, please see the AIHA web site. DOES MY INFANT OR CHILD HAVE PULMONARY HEMOSIDEROSIS? Pulmonary hemosiderosis is a rare lung disorder which can also occur as part of other medical conditions. If your infant or child is coughing blood, you need to seek medical attention immediately. If your young infant (<6 months old) is having nose bleeds without any injury, you should seek medical attention right away. If your infant or child has chronic cough and chest congestion and is anemic, ask your physician to consider the possibility of pulmonary hemosiderosis among all the other more common diagnostic possibilities. If your physician would like more information about looking for pulmonary hemosiderosis, have them contact Dorr G. Dearborn, Ph.D., M.D. If your physician would like consultation regarding pulmonary hemosiderosis have them contact the nearest Pediatric PulmonaryCenter. The local chapter of the American Lung Association can be of assistance if necessary. REPORTING A CASE If you are a physician and have had an infant with idiopathic pulmonary hemorrhage or hemosiderosis in the past five years, Dr. Dearborn would appreciate your reporting it to us. Reporting forms can be obtained by calling (216) 368-4369. IDIOPATHIC PULMONARY HEMOSIDEROSIS NATIONAL ORGANIZATION Some parents of children with the rare disorder Idiopathic Pulmonary Hemosiderosis have expressed an interest in establishing a national organization. The problem described here with young infants is a form of this disorder but older children can also have IPH from other unknown causes or even an allergy to cow's milk (Heiner's Syndrome). The national organization would primarily be a parental group interested in communication and optimizing the medical care for their children. If you would be interested in participating in this new organization, contact Dorr
G. Dearborn, Ph.D., M.D. ADULT HEALTH CONCERNS If you have concerns about the health of adults who have been been exposed to Stachybotrys, contact the Occupational Medicine physician listed below Eckardt
Johanning, MD, MSc ADDITIONAL INFORMATION Dearborn, D.G., Pulmonary hemorrhage in infants and children. Current Opinions in Pediatrics, June, 1997, Vol 9., pp 219-224 (Clinical management suggestions). Centers for Disease Control and Prevention. Update on Pulmonary Hemorrhage/Hemosiderosis among Infants-Cleveland, Ohio, 1993-1996. Morbidity and Mortality Weekly Report, Vol. 46, No. 2., January 17, 1997. (Internet http//www.cdc.gov/cd) Centers for Disease Control and Prevention. Acute Pulmonary Hemorrhage/Hemosiderosis among Infants- Cleveland, January 1993-November 1994. Morbidity and Mortality Report, Vol. 43, No. 48, December 9, 1994. (Internet http//www.cdc.gov/cdc.htm) Montana, E., Etzel, R., Allan, T., Horgan, T., and Dearborn, D., Environmental Risk Factors Associated with Pediatric Idiopathic Pulmonary Hemorrhage and Hemosiderosis in a Cleveland Community. Pediatrics, Vol 99, No. 1, January, 1997. (Internet http//www.pediatrics.org/cgi/content/full/99/1/e5) Etzel, R., Montana, E., Sorenson, W., Kullman, G., Allan, T., and Dearborn, D., Acute pulmonary hemorrhage is infants associated with exposure to Stachybotrys atra and other fungi, Arch. Pediatr. Adolesc. Med. 152757-762, 1998. Yike, I, Allan, T, Sorenson, WG, and Dearborn, DG. Highly sensitive protein translation assay for trichothecene toxicity in airborne particulates. Comparison with cytotoxicity assays. Appl. Environ. Microbiol. 6588-94, 1999. Dearborn, DG, Yike, I, Sorenson, WG, Miller, MJ, and Etzel, RA, Overview of investigations into pulmonary hemorrhage among infants in Cleveland, Ohio, Environmental Health Perspectives, Vol.107, Suppl.3, 495-499, 1999. Vesper, SJ, Dearborn, DG, Yike, I, Sorenson, WG, and Haugland, RA, Hemolysis, toxicity, and randomly amplified polymorphic DNA analysis of Stachybotrys chartarum strains, Applied Environ Microbiol, 653175-3181, 1999. Tripi, PA, Modlin, S, Sorenson, WG, and Dearborn, DG, Acute pulmonary hemorrhage in an infant during induction of general anesthesia, Paediatric Anesthesia, 1092-94, 2000. Vesper, SJ, Dearborn, DG, Yike, I, Allan, T, Sobolewski, J., and Haugland, RA, Evaluation of Stachybotry chartarum in idiopathic pulmonary hemorrhage case house before, during, and after remediation. J. Urban Health (in press). Etzel, R.A., and Dearborn, D.G. Pulmonary hemorrhage among infants with exposure to toxigenic molds An update. In Bioaerosols, Fungi, and MycotoxinsHealth effect, Assessment, Prevention and Control, Ed. E. Johanning, Boyd Printing Co., Inc., Albany, NY, 1999, pp 70-83. Dearborn DG. Pulmonary Hemosiderosis (pulmonary hemorrhage), in Nelson s Textbook of Pediatrics, 16th edition. Editors R Behrman, R Kleigman, H Jenson, p 1295-1297, 2000. Elidemir, O., Colasurdo, G.N., Rossmann, S.N., and Fan, L.L., Isolation of Stachybotrys from the lung of a child with pulmonary hemosiderosis, Pediatrics, 104964-966, 1999. Flappan, S.M., Portnoy, J., Jones, P., and Barnes, C., Infant pulmonary hemorrhage in a suburban home with water damage and mold (Stachybotrys atra), Environ Health Perspect, 107927-930, 1999 Fact sheets and other indoor air quality related publications including "Biological Pollutants in Your Home" and "Flood Cleanup Avoiding Indoor Air Quality Problems" are available from Indoor
Air Quality Information Clearinghouse Should You Have the Air Ducts in Your Home Cleaned? Also visit the web site of U.S. Environmental Protection Agency, Indoor Environments Division: http//www.epa.gov/iaq/ US Dept of Energy's "Hazard Identification and Mitigation Workshop Manual" |
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