Resources for Providers and Their Patients Who Are Exposed to Damp, Moldy Environments

Case Introduction

A woman with newly exacerbated asthma symptoms living in a condominium

A 43 year old female patient with a three year history of asthma, is referred by an allergist to an occupational medicine physician because of exacerbated asthma symptoms (onset over the winter). Her symptoms include dyspnea, needing her rescue inhaler more frequently, and increasing occurrences of night time cough. At the time of the visit her spirometry is within normal range (in compliance with maintenance medication). She had a previous history of allergic rhinitis –sensitive to mold, pollen, grass and cedar-, epilepsy-diagnosed 30 years ago-, and Stage 4 breast cancer diagnosed two years ago. As part of her treatment she completed chemotherapy the previous fall. She recently moved to her grandmother’s home because she reports that her condominium (condo) is water damaged from winter storms and smells of mold. She says there is mold and wetness along the wall shared with the next condo and mold on wallboard in the basement level. Her family is concerned over her immune status so insisted she move out of the condo and seek treatment. She returns to her condo to empty a dehumidifier, but stays only briefly because when she is there she especially feels that her breathing becomes difficult. She misses living on her own in the condo. She is a paralegal for an insurance company and denies any adverse breathing concerns or exposures while at work.

The patient believes that exposures in the condo environment are causing her symptoms and asks for support to convince the condo association to fix the damage in her condo. You are aware of record-setting ice storms that winter - 54.9 inches of snowfall was recorded at the nearby airport for January 2011. You consider that her respiratory symptom onset coincides with snow and ice in winter 2011 possibly indicating a building relationship. You advise the patient not to return to condo until after the condo problems are fixed.

The clinic environmental specialist provides educational materials from the US Environmental Protection Agency and the Centers for Disease Control and Prevention and facilitates her locating an appropriate building engineering expert to assess the condo damage. The patient retains the expert and his thorough building review concludes that extreme accumulation of snow on the patient’s roof over several weeks led to ice dams and water leaking into the building. The remediation plan calls for fixing the roof and flashing to avoid future ice dams and removing and replacing all damaged materials including severely wetted wall board. You medically follow her over the next few months documenting that she feels well and is asymptomatic while living at her grandmother’s home. Seventeen months after the ice storms, she moves back to a rebuilt condominium. Three months later she denies any dyspnea, other symptoms of asthma exacerbation and reports that she hasn’t used her rescue inhaler at all since moving back into her condo, and you discharge her from care.

Teaching Points

Providers should consider multiple factors in determining the strength of an environmental—or as in this case, a building—relationship with illness. To establish that indoor exposures are agents of illness the provider should explore; biological reasonableness, time relationships, patterns and consistency of symptoms, exposures in the environment, the status of others in the same environment, and alternate explanations. In this teaching case, the advent of ice storms coincident with the onset of new (or renewed) respiratory symptoms, the patient’s temporal symptom pattern in the damaged condo, her recovery out of the environment, and the expert confirmation of water damage established a strong likelihood of a relationship.

Where information is limited, the provider may judge that individual factors alone provide a reason to suggest changes in the environment, to reduce exposures to contributing agents of illness. Symptom onset coincident with severe wet weather and indoor water incursion is sufficient to suspect an environmental relationship with respiratory illness.

This case illustrates the importance of exploring symptom occurrence, environmental conditions, and temporality of events in the patient’s history and underscores the value of an environmental change in medical management. Even though other factors in the patient’s medical history may be contributing causes, intervening to eliminate or reduce probable environmental exposures can be part of efficacious treatment.

In Brief

A 43-year-old woman diagnosed with building-related asthma exacerbation has full remission of asthma symptoms after environmental remediation of a condominium apartment. Symptom onset coincided with a series of winter snow and ice storms. Ice dams on the condo roof resulted in massive water incursion. Avoiding the environment until the building was completely fixed and all damaged materials replaced was a key element of medical care. Severe weather events bring attention to threats of respiratory illness associated with moisture incursion and indoor exposures.