Research Article

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, toxicologist1@msn.com

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

cited.

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.

1. Introduction

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

(Figure 2).

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

28/01/2010

Lesion on the ear

28/01/2010

Lesions on the back

28/01/2010

Lesions on the abdomen

28/01/2010

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).

4. MRI

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 [26] and Engineering Dynamics Corp [27]. 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

grading.

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

moderate contamination.

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

Carpet, master

Bdrm

Insulation master

Bdrm1

Insulation return air

duct

Moist fiberglass

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 [28].

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

environments [15].

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

reported [40].

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.

(a)

Sample Sample # Media Temp (C)

Analytical

sensitivity CFU/g

Bacteria Colony count CFU/g

Plastic sheeting,

crawl space

#34 SBA 35 98.000

Bacillus sp

Streptomyces sp.

Actinomycetes

25 2.450.000

Moist gravel,

crawl space

#27 SBA1 35 885

B. megaterium

Bacillus sp.

Total

10

7

17

8.850

6.190

15.000

Moist dirt, crawl space #28 SBA1 35 8130

B. megaterium

Bacillus sp.

Total

4

6

10

32.500

48.800

81.300

Swab of wood,

crawl space

#25 SBA2 35 10.000

Microbacterium hominis 972 9.720.000

Staphylococcus sp (not

aureus)

2 20.000

Total 974 9.740.000

Dirt crawl space #28 Blood Agar 353

Bacillus sp.

Proteus sp

Pseudomonas sp.

TNC4 TNC4

Gravel, crawl space #27 Blood Agar 353

Bacillus sp.

Proteus sp.

Pseudomonas sp.

TNC4 TNC4

Sandal, under

master bed

#36 Blood Agar 353

Bacillus sp.

Proteus sp.

Pseudomonas sp.

TNC4 TNC4

(b)

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.

12. Discussion

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 [10].

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

buildings.

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

Wood truss—crawl

space

1.68 3.5 5.8

Gravel—crawl space 7.7 NP 7.7

Dirt—crawl space 2.1 NP 2.1

Plastic sheet—crawl

space

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.

Patient specimen

Trichothecenes

(ppb)

Aflatoxins

(ppb)

Ochratoxin

(ppb)

Father-Urine NP NP 18.2

Father-Nasal1 Secretion NP

0.5

11.2

13

7.7

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.