Step 1 of 4 25% Health Effects Related to Mold and Moisture in Indoor EnvironmentsName* First Last DegreeAPRNDrPHM.D.M.P.H.P.A.Ph.D.R.N.Multiple/Other/Prefer not to saySelect from the menu.Specify Degree List degrees or leave blank.Medical Specialty Allergy Family Medicine Internal Medicine Occupational and Environmental Medicine Pediatrics Pulmonary Medicine Other Select all that apply.Specify Other Specialty Email* PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Case Introduction A Middle School Teacher with Successive Respiratory Diseases A 57-year-old woman middle school teacher presents with a 6-year history of cough that typically is worse during the school year and frequently clears completely during long vacations. She has been treated for asthma over the preceding 18 months with oral and inhaled steroids as well as bronchodilators. She at times notes musty smells in her classroom, and at times obtains relief by going outdoors. The building has a history of roof leaks and water incursion in around the windows, and her classroom has stained ceiling tiles. She also notes that at least one other teacher is having similar symptoms, and there are a number of asthmatic children in her classroom.What do you think are the patient’s main concerns?What approach do you think the treating physician should take?Aside from the immediate needs of the patient what are other considerations? Video Lecture: Health Effects of Mold & MoistureSpeaker: Marc Croteau, M.D., M.P.H. Multiple Choice Questions Choose the single best answer. 1. Asthma is characterized by the following:* A. Reversible airways obstruction B. Hyper-responsiveness C. Airway inflammation D. Only A and B are correct E. A, B, and C are all correct 2. Inspiratory stridor is most consistent with the following condition:* Asthma Hypersensitivity Pneumonitis Paradoxical Vocal Cord Motion None of the above All of the above 3. Limiting exposure to environmental triggers is an appropriate treatment approach to:* Allergic rhinitis Hypersensitivity Pneumonitis Occupational Asthma Paradoxical Vocal Cord Motion All of the above 4. Variable patterns of centrilobular ground-glass or micronodular opacities and mediastinal lymphadenopathy found on high resolution CAT scans of the chest is most consistent with the following: Asthma Paradoxical Vocal Cord Motion Acute Hypersensitivity Pneumonitis Inhalational Fevers All of the above 5. Rhinosinusitis may co-exist with* A. Asthma B. Paradoxical Vocal Cord Motion C. Both A and B are correct D. Neither A nor B are correct 6. The pathophysiology of Organic Dust Toxic Syndrome involves sensitization.* True False 7. Mold does not have to be living to have an immunologic effect on building occupants* True False 8. Bronchoprovocative testing with methacholine is a useful tool when the diagnosis of asthma is uncertain. True False 9. Fit testing is typically not necessary for effective use of N95 respirators.* True False 10. Qualitative assessments of visible dampness, water damage, visible mold, or mold odor have more consistent associations with health effects than quantitative measurements such as culture counts of airborne molds.* True False Case Conclusion: A Middle School Teacher with Successive Respiratory Diseases To determine if the building is contributing to her symptoms, you suggest that she take an additional two weeks off after the December holiday recess. During this time her symptoms disappear and she is able to stop her asthma medications. During her absence, the carpeting is removed from her classroom, the crawl space under the building is cleaned and the stained ceiling tiles are replaced. Before she returns to work, you obtain lung function testing with spirometry. You repeat the test after she returns to work for one week. The initial FEV1 (forced expiratory volume exhaled during the first second) is normal, but the repeat study after being back at school shows a 20% decrease.What can one conclude from these results?What should you recommend now?What concerns do you have about the other teachers and students exposed to this environment?Teaching Points Mold and other environmental allergens can sensitize in two ways. The most common is via an allergic mechanism involving IgE antibody possibly resulting in asthma, and the other is a delayed response involving IgG possibly resulting in hypersensitivity pneumonitis. Once sensitized, symptoms result from further exposure, and the more an individual is exposed, the more reactive they may become. This means that over time, a lesser degree of exposure can trigger symptoms. Because of this risk, sensitized individuals should be removed from the exposure to prevent worsening of symptoms. When symptoms first develop, they tend to be self-remitting shortly after removal from exposure. However, as individuals become more sensitized, the symptoms do not revert as quickly, and it may take weeks or months of removal from exposure before symptoms remit. Because temporal associations are stronger early in the course, it may be harder to identify environmental causation when individuals present late. This makes the association harder to establish. When the environment is involved in illness, the scope of the problem for the physician may become larger than treating the individual patient. The physician may be called upon to respond to concerns about others potentially exposed to that environment, and address the building environmental problems. This undertaking could involve interaction with building administrators, and the public. Tools such as building occupant health surveys, building inspections and intervention planning may be helpful. Although often handled by occupational/environmental health specialists, the provider may need assistance and public health resources from state, and local and community health departments. In Brief A career elementary school teacher with adult-onset asthma was evaluated and diagnosed with building-related respiratory disease. Leaving the environment for a few months (under doctor’s orders) led to nearly complete resolution of symptoms. After returning to work and moving to a second school building contaminated with mold, the teacher became quite ill with respiratory disease, the pattern being more consistent with hypersensitivity pneumonitis. The case description demonstrates (1) some of the essential factors in recognizing and treating environmentally related respiratory disease including consideration of temporal relationships in clinical evaluations, (2) the importance of managing the illness by changing the environment, and (3) the difficulties inherent in “fixing” environmental exposures. NameThis field is for validation purposes and should be left unchanged.