Mold and Moisture Course

Health Effects Related to Mold and Moisture in Indoor Environments

Case Introduction

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.

Multiple Choice Questions

Choose the single best answer.

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.

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.