A Water-Damaged Home and Health of Occupants: A Case Study
Jack Dwayne Thrasher,1 Michael R. Gray,2 Kaye H. Kilburn,3, 4
Donald P. Dennis,5 and Archie Yu6
1Citrus Heights, CA, USA
2Progressive Healthcare Group, Benson, AZ 85602, USA
3Neurotest, Inc., Pasadena, CA 91107, USA
4USC Keck School of Medicine, Los Angeles, CA 90089, USA
5Center for ENT and Facial Plastic Surgery, Atlanta, GA 30327, USA
6Compliance Solution, Honolulu, HI 96823, USA
Correspondence should be addressed to Jack Dwayne Thrasher, firstname.lastname@example.org
Received 16 July 2011; Accepted 4 September 2011
Academic Editor: Janette Hope
Copyright © 2012 Jack Dwayne Thrasher et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
A family of five and pet dog who rented a water-damaged home and developed multiple health problems. The home was
analyzed for species of mold and bacteria. The diagnostics included MRI for chronic sinusitis with ENT and sinus surgery, and
neurological testing for neurocognitive deficits. Bulk samples from the home, tissue from the sinuses, urine, nasal secretions,
placenta, umbilical cord, and breast milk were tested for the presence of trichothecenes, aflatoxins, and Ochratoxin A. The family
had the following diagnosed conditions: chronic sinusitis, neurological deficits, coughing with wheeze, nose bleeds, and fatigue
among other symptoms. An infant was born with a total body flare, developed multiple Cafe-au-Lait pigmented skin spots and
diagnoses with NF1 at age 2. The mycotoxins were detected in bulk samples, urine and nasal secretions, breast milk, placenta, and
umbilical cord. Pseudomonas aueroginosa, Acinetobacter, Penicillium, and Aspergillus fumigatus were cultured from nasal secretions
(father and daughter). RT-PCR revealed A. fumigatus DNA in sinus tissues of the daughter. The dog had 72 skin lesions (sebaceous
glands and lipomas) fromwhich trichothecenes and ochratoxin A. were detected. The health of the family is discussed in relation to
themost recent published literature regarding microbial contamination and toxic by-products present in water-damaged buildings.
Indoor dampness and fungal contamination have been
shown in qualitative reviews to be associated with a variety
of respiratory health effects, including infections, sinusitis,
and otitis media [1–4]. In addition, case studies with and
without controls have demonstrated the existence of severe
sinusitis as well as neurological deficits in occupants in waterdamaged
homes and buildings [5–12]. Currently, it is recognized
that the indoor water-damaged environment resulting
from microbial growth is a complex mixture of mold and
bacteria along with their by-products [13–15]. Thus, the
illnesses resulting from exposure cannot be defined by any
specific component of the affected environment [2, 13–17].
In this paper we present a family of five exposed to fungi and
bacteria in a water-damaged home located in Maui, Hawaii.
Members of the family developed multiple health problems,
including sinusitis and neurological deficits. In addition, the
mother was pregnant during occupation of the contaminated
home giving birth to a girl who had a total body flare with
development of Cafe-au-Lait spots. Her condition has been
diagnosed with Neurofibromastosis type (NF1).
2. The Family
The family of five moved from Canada to Maui, Hawaii, in
February 2008, where they rented a home. All were healthy
prior to the move and began experiencing symptoms shortly
after the move in. Chief health complaints were as follows.
Father (age 40) had persistent cough with phlegm, throat
irritation, headaches, sinusitis, severe fatigue, somnolence,
decreased concentration, long-term and recent memory loss,
nose bleeds, decreased libido, hair loss, and shortness of
2 Journal of Environmental and Public Health
(a) Newborn—Total Body Flare (b) 2 weeks—Father’s Hand Print
(c) 23Weeks—Caf´e-au-Lait Pigment Spots (d) 28Weeks—Pigment Spots on the Back
Figure 1: The upper two photos are of the newborn girl demonstrating the total body flare and the impression of the Father’s hand on her
back. The bottom two photos show the pigmented sports that appear to be Cafe-au-Lait skin pigmentation that were apparent at birth and
are still present. The flare reaction was present at birth, began to subside at 10–12 weeks, and occurred periodically through 55 weeks of age.
The multiple pigmented spots has been diagnosed as NF1 at U.S. San Francisco, Department of Dermatology.
breath with wheezing. The mother (age 39) complained of
cough with phlegm, throat irritation, headaches, sinusitis,
extreme fatigue, somnolence, recent and long-term memory
loss, decreased libido, and shortness of breath with wheezing.
She became pregnant while living in the home and gave
birth to a girl 3 months after moving out of the home.
The eldest daughter (age 8) had the same symptoms as the
parents, except she had decreased concentration, nausea, and
loss of appetite. The son (age 5) had frequent headaches,
fatigue and tiredness, nasal congestion, nose bleeds, throat
irritation, shortness of breath with mild wheezing, and
decreased attention in classroom activities. The newborn had
a total body flare (pinkish red) that continued to age 10–12
weeks, after which the flare would appear periodically. She
had multiple pigmented skin spots on her back, chest, and
abdomen at birth that appeared to be Cafe-au-Lait spots.
The pigmented areas are still present at 2 years of that are
scheduled for additional diagnostics for neurofibromatosis
(Figure 1). Finally, the pet dog developed approximately
72 skin lesions diagnosed as sebaceous and lipoma tumors
3. Neurological Evaluation
The family sought neurological consultation from one of the
authors as previously published [8, 9]. The results of the
evaluations are briefly summarized as follows.
The father had 17 neurological deficits as follows: simple
and choice reaction time, sway-balance with eyes open and
closed, decreased right and left grip strength, abnormal right
and left color vision, abnormal visual field performance
(right and left), abnormal digit symbol, abnormal perceptual
motor speed (dominant pegboard, Trails A and B, right and
left finger writing errors), abnormal smell score, abnormal
picture completion and elevated Profile of Mood States
(POMS), Beck’s depression inventory, and Limbic System
Check List score. The increased POMS score was consistent
Journal of Environmental and Public Health 3
Lesion on the ear
Lesions on the back
Lesions on the abdomen
Lesions on rear legs
Figure 2: This figure demonstrates the sites of the subcutaneous and lipoma tumors that were removed from the pet dog. The Veterinarian
stated that the presence of 72 such lesions on an animal is a very rare observation.
with elevated confusion, fatigue, and tension. The mother
also had 17 abnormalities, identical to those of the husband
(data not repeated). The neurological scores for the daughter
were within normal ranges. However, the physical exam
revealed abnormal past pointing without dysmetria (finger
to nose) and fine resting tremors at 3-4 per second increasing
to 10 by intention with amplitude increased. The son (age 5)
did not have any detectable neurological deficits. However,
the neurological testing is not designed for 5 year olds.
In conclusion, the neurological evaluation revealed multiple
deficits in both parents as previously published [8,
9]. The daughter had noticeable tremors which may have
resulted from exposure to tremorgenic mycotoxins [18–22]
as well as others described here in after (see Section 9 and
Tables 4 and 5).
MRIs were performed at Oak Tree Medical Imaging,
Pasadena, California, for each family member with special
reference to the sinuses.
Father. The father had mild diffuse thickening- bi-ethmoid,
bi-maxillary, right sphenoid and frontal sinuses.
Mother. The cavernous and paranasal sinuses were normal.
Prior to the MRI, she had been prescribed corticosteroids,
antibiotics, and antifungals.
Daughter. The daughter had mild fluid within the bilateral
mastoid air cells. There is moderate to severe mucosal
thickening in the maxillary and ethmoid sinuses without
evidence of air fluid level.
Son. The bifrontal and sphenoid sinuses have not developed.
Maxillary sinuses are unremarkable. There is slight mucosal
thickening within the bilateral sphenoid sinuses, right greater
than left without air fluid level.
In conclusion, the results of the MRI studies demonstrated
mucosal thickening of the sinuses of the father
and two children. The absence of findings in the mother
most likely resulted from the use of corticosteroids and
medications to treat her sinusitis.
4 Journal of Environmental and Public Health
5. ENT Evaluation
The father and daughter were evaluated at the Atlanta Center
for ENT & Facial Plastic surgery according to procedures
previously published [5, 6]. The results of the evaluation are
briefly summarized as follows.
Father. Nasal endoscopy revealed (a) nasal polyps and (b)
the ethmoid, sphenoid, and frontal sinuses were edematous
with visible thick mucoid material (mucin) bilaterally,
confirming the results of earlier MRI and CT scans (data
not described). Total IgE was 76.9 IU/mL with a positive
IgE score at level IV for Alternaria. He was tested for
IgG antibodies for ten fungi and was positive for Epiccocum
and Cladosporium at level I, Penicillium, Aspergillus,
Alternaria, Fusarium, and Acremonium at level III, and
Candida at level III. Recommended treatment was saline
nasal wash, intranasal amphotericin B, oral fluconazole,
Nystatin, intranasal glutathione, and oxygen via a face
mask. Surgery was performed to remove nasal polyps and
inflamed sinus tissues. Tissue samples were sent to RealTime
Laboratories, Carrollton, Texas, for RT-PCR DNA probes (10
species of fungi), and mycotoxin testing.
The RT-PCR-DNAprobes were negative for the following
fungi: Aspergillus flavus, fumigatus, niger, and versicolor;
Eurotium amstelodami; Fusarium solani; Penicillium chrysogenum
and verrucosum; and Stachybotrys chartarum and
echinata. Cultures for bacteria (SBA) and fungi (MEA) in
nasal secretions were positive for Pseudomonas aeuroginosa
and Penicillium spp.
Daughter. Endoscopic examination revealed that left maxillary,
ethmoid, sphenoid, and frontal recesses were edematous.
The turbinates were 4+ enlarged. The nasal septum
was deviated to the left. On the right side there was some
white material on the middle turbinate. The adenoids were
hypertrophied. In addition, small white flecks were present
in the soft tissue of the left maxillary, ethmoid, and left
sphenoid sinuses. Medications include fluconazole, liposomal
glutathione, amphotericin B, inhaled corticosteroid,
Nystatin, and oxygen via face mask. The patient required
left sphenoidotomy. Also, the previous MRI and CT scans
showed opacification of the left infundibulum and left
maxillary sinus os. Surgical specimens were sent to RealTime
Laboratories tor RT-PCR DNA probe (10 species of fungi)
and mycotoxin detection.
The RT-PCR tests were negative for the same species as
done on the father (see above).However, cultures for bacteria
(SBA) and molds (MEA) on nasal secretions revealed
Acinetobacter spp. and Aspergillus fumigatus.
In conclusion, the nasal endoscopic examinations of the
father and daughter revealed edematous inflammation of the
paranasal sinuses that required surgery. The RT-PCR tests
were negative for 10 species of fungi, which did not eliminate
the presence of fungi other than those tested. Finally, bacterial
and fungal cultures of nasal mucous secretions did reveal
the presence of bacteria (Pseudomonas and Acinetobacter)
as well as fungi (Penicillium and Aspergillus). Thus both
patients had severe chronic rhinosinusitis most likely related
to microbes (bacteria and fungi) detected in their waterdamaged
home [1–3, 5, 6, 23–25].
6. The Home
The home was inspected for construction defects and
dampness by two independent services: Barkman Inspection
Services  and Engineering Dynamics Corp . The
results of the two inspections are briefly summarized.
6.1. Barkman Report. A serious moisture/mold problem is
observed in the crawlspace directly below the bedrooms.
Moisture is penetrating the walls of the foundation. The
HVAC system is designed to force air into the crawl space,
forcing crawl space air into the bedrooms and other areas
above. Moisture intrusion also results from the master
shower into the crawl space as well as from sprinklers, damp
soil against the foundation, lack of roof gutters, and poor
6.2. Engineering Dynamics Report. This is a two-story house
with a crawl space. Lower level has a family room, guest
bedroom, bathroom, powder room, arts and crafts room,
storage closet, garage, and crawl space, which are under
upper level bedrooms and bathrooms. Upper level has 3
bedrooms, 3 bathrooms, entertainment room, living room,
kitchen, office, and powder room.
The crawl space had water intrusion, musty mold odor,
and visible mold on floor joists. The yard sprinklers were
directed towards the house and the eaves did not have
rain gutters, permitting the pooling of water. Water entered
the crawl space through cement walls and followed piping
present in the crawl space. Smoke testing revealed communication
between the crawl space and upper level bedrooms
via electrical outlets and electrical ducts and plumbing. The
conduit holes were not sealed, permitting observance of light
coming through spaces in the floor joists. A musty odor was
present in the master bathroom and noted to get stronger
when the fan coil was turned on.
7. Identification ofMold
All air and bulk samples were sent under chain of custody
to EMSL Analytical, Inc., Westmont, NJ. The ERMI QPCR
36 for mold species was performed on 5 different bulk
samples. The data are summarized in Table 1. The identified
species of mold varied according to source but included
species of Aspergillus, Penicillium, Eurotium amstelodami, A
pullulans, C. globosum, and T. viride, among others. The
ERMI interpretation level ranged from 2 to 3, indicating
Airborne viable spores were determined by Air-O-Cell
cassettes and cultured and identified by EMSLMethodM050
and the data are summarized in Table 2. The viable airborne
spores (Table 2) showed the presence of toxic fungi inside
of the home and none outdoors. The viable spores included
species of Aspergillus and Penicillium, which varied according
Journal of Environmental and Public Health 5
Table 1: This table summarizes the results of the E.P.A. ERMI PCR-DNA tests performed on 5 mg dust samples from basement and master
bedroom carpeting and master bedroom wall insulation. Only the species detected are listed.
Sample 36 ERMI Q-PCR test Carpet basement
Insulation return air
Group 1 Molds
Asp. penicillioides 77 26 ND ND
A. restrictus ND ND ND 40 40
A. versicolor ND ND ND ND 50
E. amstelodami ND ND ND 4 4
Aur. pullulans 189 20 ND ND ND
Ch. globosum ND 14 ND ND 2
Cl. Sphaerospermum 9 3 ND ND ND
Pae. variotii ND 2 87 ND 734
P. brevicompactum ND 19 ND ND ND
P. corylophilum ND ND ND ND 85
P. crustosum ND ND 3 ND ND
P. purpurogenum ND 2 ND ND ND
P. spinulosum 15 ND 3 ND ND
P. variabile ND ND ND 136 3
T. viride ND ND NS ND 15
Sum of the Logs 6.6 6.2 2.8 2.8 10.6
Group 2 Molds
A. ustus 2 4 187 ND 226
Cl. cladosporioides II 1 ND ND 65 2
Ep. nigrum 15 17 ND 65 8
Ep. nigrum 15 17 ND 14 5
Mucor/Rhizopus 9 21 ND ND ND
P. chrysogenum 5 4 8.738 ND 14.013
Sum of the logs 3.3 3.7 6.2 3.0 8.1
ERMI Value 3 2 −3 0 3
ERMI Interpretation Level 3 Level 3 Level 2 Level 2 Level 3
ND: Not detected.
1RT-PCR detected Aspergillus fumigatus in a towel taken from the master bathroom.
All values are in Spores E.−/mg dust.
to the sample area, for example, crawl space versus bedroom
air and wall space cavity.
In conclusion, these data demonstrated that testing for
fungal contamination must include several different sample
locations involving dust and bulk materials as well as
airborne viable spores .
8. Identification of Bacteria and Endotoxins
Bulk samples of crawl space dirt, gravel, plastic sheeting,
wood, and a sandal from under the master bed were sent
to EMSL Analytical, Inc., Westmont, NJ and RealTime
Laboratories, Carrolton, TX, to culture and identify bacteria
using sheep blood agar (SBA) plates. In addition, two swab
samples from the kitchen were analyzed for endotoxins by
EMSL. The results are summarized in Table 3.
Bacteria detected by both laboratories included Gram
negative and positive organisms. The primary Gram positive
bacteria included Bacillus spp, Actinomycetes (e.g., Streptomyces
sp., Mycobacterium hominis), and Staphylococcus
(non aureus). The Gram negative bacteria were species of
Pseudomonas and Proteus spp. Both groups of bacteria are
potential human pathogens. For example, Mycobacterium
and Streptomyces spp. are capable of causing lung abscesses
and granulomatous mycetomas, while Pseudomonas species
can cause respiratory and other infections [29–31].
Endotoxins were tested in only two areas of the home.
The J-tube under the kitchen sink, a relatively protected
area, had a concentration of 4.930 EU per swab. In contrast,
the top of the kitchen cabinet had a concentration of
24.800 EU/swab. The two control swabs were negative. These
observations indicate that additional testing was probably
warranted, since endotoxins cause respiratory inflammation,
sensitizers, and exacerbation of asthma [32–35]. In conclusion,
bacterial cultures identified potentially pathogenic
Gram negative and positive bacteria. In addition, these
bacteria are known to produce toxic secondary metabolites
6 Journal of Environmental and Public Health
Table 2: This table summarizes the identification and enumeration of culturable air-borne fungi collected by Aerotech cassettes (including
speciation of Penicillium, Aspergillus, Cladosporium, and Stachybotrys) by EMSL Method M050.
Sample location Media Temp (◦C) Sensitivity & dilution Fungal identification Colon count CFU per cassette
Swimming pool deck MEA 25 100 & 100 None detected 0 0
Master bedroom MEA 25
100 & 100 Asp. sydowii 1 100
100 & 100 Cl. sphaerospermum 1 100
P. chrysogenum 1 100
Total 3 300
Crawl space MEA 25
100 & 100 Asp. ochraceus 5 500
100 & 100 Asp. sydowii 2 200
100 & 100 P. chrysogenum 1 100
1000 & 1000 P. citreonigrum 1 1000
1000 & 1000 Phialophora sp. 1 1000
1000 & 1000 Sterile (dark) sp. 1 1000
Total 11 3.800
Wall space master bedroom MEA 25
100 & 100 Asp. fumigatus 1 100
100 & 100 Asp. ustus 3 300
100 & 100 Paecilomyces sp. 2 200
1000 & 1000 P. chrysogenum 1 1000
Total 7 1.600
of which Valinomycin is a mitochondrial toxin and is synergistic
with macrocyclic trichothecenes [36–39]. Recently,
several toxic bacterial metabolites have been demonstrated
to cooccur with mycotoxins in moisture-damaged indoor
9. Identification ofMycotoxins in
Environmental Samples and Body Fluids
Bulk samples were sent to RealTime Laboratories, Carrollton,
TX, to test for the presence of mycotoxins. In addition,
urine and nasal mucous were collected in sterile cups, sealed
and sent to RealTime Laboratories to test for the presence
of mycotoxins. The tests for macrocyclic trichothecenes,
aflatoxins, and ochratoxin A were performed as previously
9.1. Environmental Samples. The data for mycotoxins
detected in bulk samples are summarized in Table 4. Trichothecenes
and ochratoxin A were detected in the bathroom
towel (11.71 and 4.9 ppb), respectively, and the sandal (0.47
and 3.4 ppb), respectively. Mycotoxins were identified in
the samples from the crawl space as follows: Wood truss:
trichothecenes (1.69 ppb), aflatoxins (3.5 ppb), ochratoxin
A (5.8 ppb); Gravel: trichothecenes (7.7 ppb), ochratoxin
A (7.7 ppb); Dirt: trichothecenes (2.1 ppb), ochratoxin A
(2.1 ppb); and Plastic sheeting: ochratoxin A (2.8 ppb).
9.2. Body Fluids. Mycotoxins detected in body fluids of
family members and the pet dog are summarized in Table 5.
The father was positive for ochratoxin A in his urine
(18.2 ppb), while two separate nasal mucous samples were
positive for both aflatoxins (0.5 and 11.2 ppb) and ochratoxin
A (18.2 ppb). The mother’s urine contained ochratoxin
A (18.2 ppb), while nasal mucous contained the three
mycotoxins aflatoxin, ochratoxin A, and trichothecenes at
1.02, 1.2, and 1.5 ppb, respectively. The daughter’s urine had
trichothecenes (0.23 ppb) and ochratoxin (28 ppb), while
nasal mucosa had trichothcenes (4.68 ppb) and ochratoxin
A (3.8 ppb). The urine sample from the son was positive for
ochratoxin A (18.9 ppb), while tests on nasal mucous were
not performed. The urine from the pet dog was positive for
trichothecenes (1.49 ppb) and ochratoxin A (25.9 ppb).
10. Newborn Baby
The mother gave birth to a girl who was born with a total
body flare 3 months after vacating the home (Figure 1).
The infant was born with pigmented skin identified as Cafeau-
lait. They are currently distributed as follows: Face (2),
neck (6), right axilla (9), left axilla (10), left and right arms
(4), abdomen (16), back (28), buttocks (9), right leg (8),
and left leg (2) for a total of 84. As a result, breast milk,
placenta, umbilical cord, and the baby’s urine were tested
for the presence of mycotoxins. Ochratoxin A was detected
in the breast milk (2.7 ppb), placenta (4.2 ppb), and the
umbilical cord (7 ppb). The newborn’s urine was negative
for mycotoxins. In retrospect, the amniotic fluid (lost during
birth) should have been tested.
11. Pet Dog
The pet dog had approximately 72 skin lesions on its legs,
trunk, and ears (Figure 2). The lesions were surgically
removed. Pathology of the ear mass described it as a
sebaceous gland, while the other lesions were lipomas. Tests
Journal of Environmental and Public Health 7
Table 3: This table summarizes the bacteria and endotoxins identified in various bulk samples taken from the home (EMSL Method M009)
and by RealTime Laboratories (RTL), Dallas, TX.
Sample Sample # Media Temp (◦C)
Bacteria Colony count CFU/g
#34 SBA 35 98.000
#27 SBA1 35 885
Moist dirt, crawl space #28 SBA1 35 8130
Swab of wood,
#25 SBA2 35 10.000
Microbacterium hominis 972 9.720.000
Staphylococcus sp (not
Total 974 9.740.000
Dirt crawl space #28 Blood Agar 353 —
Gravel, crawl space #27 Blood Agar 353 —
#36 Blood Agar 353 —
Endotoxins Sample # Sample type Location Concentration (EU/Swab)5
#3 Swab J-Tube, Under Sink 4930
#4 Swab Top, Kitchen Cabinet 24.800
Blank Swab Field Blank None Detected
Blank Swab Lab Blank None Detected
1 These samples were tested to determine the major species of Bacillus.
2This sample was tested for Actinomycetes because of white mycelia type growth on wood truss.
3These samples were tested by RealTime Laboratories for the presence of bacteria species on samples tested for mycotoxins.
4CFU was not determined. TNTC: too numerous to count.
5Endotoxins were analyzed by ESML using LAL Kinetic Chromogenic Assay.
formycotoxins in the surgical specimens revealed the following:
Ear mass—trichothecenes (23.07 ppb) and ochratoxin
A (2.2 ppb); and Lipoma—trichothecenes (20.9 ppb) and
ochratoxin A (1.4 ppb). The veterinarian stated that lipomas
in dogs are normal; however, the presence of multiple
lipomas is a rare occurrence.
We have presented a family of five who had no history of
health problems until they moved into a water-damaged
home in Hawaii. Shortly after the move in they began to
develop multiple symptoms, sought medical consultation
for the health problems involving the upper and lower
respiratory tract, headaches, neurocognitive deficits, and
severe sinusitis. Neurological evaluation revealed 17 areas
of neurological abnormalities in the two adults, consistent
with previous reports [8, 9]. The daughter developed tremors
that could be related to exposure to tremorgenic and other
mycotoxins [18–22]. The son, age 5 at the time of examination,
did not have neurological deficits. However, he did
have a variety of symptoms (e.g., nose bleeds, cough, wheeze,
and headaches) consistent with exposure to water-damaged
indoor environments. In addition, when he began school, the
teacher reported lack of concentration while in class. Perhaps
he was showing signs of autistic spectrum disorder and/or
ADD/ADHD as previously reported in children exposed to
water-damaged home environments .
The parents and the two children have chronic sinusitis
and nasal inflammation. The isolation of bacteria (Pseudomonas
and Acinetobacter) and molds (Penicillium and
Aspergillus) from nasal secretions from the father and
daughter is consistent with the literature. Bacterial and
fungal sinusitis has been reported [1, 5, 6, 23–25]. In
8 Journal of Environmental and Public Health
addition, the detection of mycotoxins in the nasal secretions
from the family points towards fungal rhinosinusitis. Finally,
the culture of surgical specimens taken from the daughter’s
sphenoid/ethmoid mucosa identified Aspergillus fumigatus.
Macrocyclic trichothecenes and tremorgens have been
detected in airborne fungal fragments less than the size of
conidia [22, 41–43]. Furthermore, trichothecenes, aflatoxins,
sterigmatocystin, ochratoxin A, and other mycotoxins are
present in the dust of water-damaged buildings [13, 16].
In addition, indoor microbial growth fragments, releasing
particulates less than one micron that penetrate deep into the
alveolar spaces [44–46]. Thus, the presence of trichothecenes,
ochratoxin A, and aflatoxins in bulk samples (Table 4)
and body fluids of the family (Table 5) is interpreted as
an inhalation exposure resulting in uptake of mycotoxins
attached to dust and fine microbial particulates.Moreover, it
is reported in this issue and elsewhere that these mycotoxins
are present in the urine and tissue biopsy/necropsy materials
taken from individuals residing in water-damaged homes
and buildings [42, 47–50].
The newborn girl had a total body flare at birth that
began to clear at 10–12weeks after birth, which may have
been associated with mast cell/eosinophil activity. However,
medical workup was not done in this area. The body flaring
periodically appeared until approximately 55 months of age.
The majority of the Cafe-au-Lait spots were apparent soon
after delivery and continued to develop after birth and
continue to be present (Figure 1). She was diagnosed with
NF1 by Dr. Frieden at U.C.S.F. at age 2, and additional
diagnostics are anticipated. The placenta, umbilical, breast
milk, urine, and nasal secretion of the mother were positive
for Ochratoxin A (Table 5), while a urine sample from the
infant was negative. It is reasoned that amniotic fluid (lost at
birth) would have been a better choice for mycotoxin testing.
However, the presence of ochratoxin A in the placenta
and umbilical cord suggests that the infant most likely was
exposed in utero. There is no family history of NF1 leading
Dr. Frieden with conclusion that the mutation to NF1 gene
most likely occurred sometime during in utero development.
It is possible that her condition could be related to ochratoxin
A or other toxins known to be present in water-damaged
A few comments are in order regarding the pet dog. The
dog developed 72 cutaneous lesions that were distributed
over its body, including the ears (Figure 2). The dog’s
urine was positive for ochratoxin A and trichothecenes. In
addition, surgical specimens of the ear (sebaceous gland) and
body tumors (lipomas) were also positive for trichothecenes
and ochratoxin A. The question that arises is were the
growths caused by the mycotoxins or were they storage sites
for the toxins.
In conclusion, a family of five (one in utero) was exposed
to several species of mold and bacteria while occupying a
water-damaged home. They presented with multiple symptoms,
including chronic sinusitis, fatigue, and neurological
complaints. Testing of the home revealed the presence of
both mold and bacteria. Differential diagnostic procedures
demonstrated in up to seventeen areas of central nervous
system deficits as well as chronic fungal/bacterial sinusitis.
Table 4: This table summarizes the detection of trichothecenes,
aflatoxins and ochratoxin A present in bulk samples taken from
the master bath, master bedroom (sandal), and crawl space. The
reported data are in ppb per mycotoxin.
Sample Trichothecenes Aflatoxins Ochratoxin A
Towel—master bath 11.71 NP 4.9
Sandal—master bdrm 0.47 NP 3.4
1.68 3.5 5.8
Gravel—crawl space 7.7 NP 7.7
Dirt—crawl space 2.1 NP 2.1
NP NP 2.8
Reported data are ppb.
NP: Not present.
Limit of Detection: Trichothecenes (0.2 ppb); Aflatoxins (1.0 ppb); Ochratoxin
A (2.0 ppb).
Table 5: Mycotoxins present in body fluid of the five members of
the family and the pet dog.
Father-Urine NP NP 18.2
Father-Nasal1 Secretion NP
Mother-Urine NP NP 18.2
Mother-Nasal Secretion 1.02 1.2 1.6
Daughter-Urine 0.23 NP 28.0
Daughter-Nasal2 Secretion 4.68 NP 3.8
Son-Urine 0.2 NP 18.9
Son-Nasal Secretion ND ND ND
Breast Milk 0.18 0.9 2.7
Placenta NP NP 4.2
Umbilical Cord NP NP 7
New Born-Urine NP NP NP
Dog-Urine 1.49 NP 25.9
Dog-Ear Mass 23.07 0 2.2
Dog-Lipoma 20.9 0 1.4
Limits of Detection: Trichothecenes (0.2 ppb); Aflatoxins (1.0 ppb); Ochratoxin
A (2.0 ppb).
ND: Not done.
NP: Not present.
1Pseudomonas aueroginosa and Penicillium were cultured from the nasal
secretions. These data represent two different tests.
2Acinetobacter sp. was cultured from nasal secretion at too numerous to
count. In addition, Aspergillus fumigatus was cultured from left ethmoid and
sphenoid mucosal surgical specimen.
Mycotoxins testing demonstrated that ochratoxin A was
the predominant mycotoxin in samples of urine, nasal
secretions, breast milk, placenta, and umbilical cord. Lesser
concentrations of macrocyclic trichothecenes were also
detected. A newborn girl had a total body flare and had
Cafe-au-Lait pigmentation spots. The infant is scheduled for
further evaluation for her NF1 condition. This case study
Journal of Environmental and Public Health 9
indicates that mold and bacteria and by-products in waterdamaged
homes are most likely the cause of the adverse
health conditions of these occupants.