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Did you know? Standard medical diagnostic tests are usually normal in patients who have these illnesses.



A PRIMER IN SICK BUILDING SYNDROME
LESSONS FROM THE SOMERSET COUNTY DISTRICT COURT

There are tremendous variations in the kinds of buildings that can become home to toxin-forming species of fungi. Any building that provides the proper mix of food and water can potentially be at-risk. When the building has air circulation that is closed, with little outside air input and windows that don't open, any intrusion of water can become the source of fungal blooms. The variations on how the building became sick (water intrusion through leaky roofs, windows or doors; wicking of water along a concrete slab or saturation of carpets; and pooling of surface water in basements come to mind) are relatively few. The Somerset County District Court Building in Princess Anne, Md., provides a great example of the most common problems seen in typical sick building syndrome (SBS) site investigations. This is a true story; it has been presented on TV, discussed in the newspaper and on radio.

It was the judge who called me, "Ritchie, I think I have a sick building here. The entrance foyer smells like a four day old wet sock, you can see the black mold on the ceiling tiles and all of us are sick." It seemed ironic; the debate about whether or not a building makes people sick usually ends up in court (or is settled before trial). This one already was in court! I agreed to do a site visit and test everyone who worked there using visual contrast sensitivity (VCS). Contrast testing is such an elegant diagnostic device--portable, non-invasive, reproducibly reliable, fast and low cost. A neurotoxin history, an essential part of the case definition of a SBS patient, is so easy to do once you learn how (it takes less time than asking a good cardiac history!), so I was ready to go.

The case definition of SBS isn't too complicated. You need to show exposure, a distinctive grouping of symptoms, presence of biomarkers, especially VCS, have no confounding exposures, respond to cholestyramine (CSM), proven to be effective when prescribed properly, as in our time-tested protocol, show relapse with re-exposure off medication, and again respond to CSM treatment. Seeing the biomarkers, blood tests, neurotoxicologic tests and physiologic measures of blood flow in the neural rim of the optic nerve, change in step with improvement or worsening of symptoms are important features that add to confirmation of the neurotoxic basis of SBS.

"Don't forget your CSM, Ritch," I could almost hear my wife say. No problem there. Over the past 4 years, I have sampled molds and tested patients in so many buildings that have subsequently made me sick that I don't forget to take my mycotoxin (fungal toxin) binding medication before exposure. I can just about tell within 20 minutes after entry into a building when mycotoxins are present. There is nothing else that gives me that distinctive hot taste on the sides of my tongue, queasy stomach, headache and sensitivity to the fluorescent lights found in nearly all office buildings. After being in the buildings with the worst mold contamination, I end up being extra-sensitive to smells, too. Visitors to my office after I have been testing in such a building often ask why a fan by my desk blows upward next to the computer. Get those fumes away from me! Fortunately, CSM, taken as a preventive measure, blocks the group of symptoms that define the acquisition phase of illness caused by toxin-forming fungal species. Maybe this time I won't again be forced to have the papers on my desk weighted down while my sensitivity to many chemicals is again being treated successfully.

So armed with my standardized light source, symptoms lists, VCS equipment and score sheets, I'm off to the architectural jewel of the judicial system in rural Somerset County, Md., about 15 miles from home. The single-level, colonial style building is only about 5 years old. Built on a concrete slab and surrounded by a paved parking lot, with marginal drainage at best, it has several suspect angles in the roof, and moisture-retaining carpet covering all the concrete. If the roof doesn't leak, just the run-off from the pavement could provide the moisture necessary to provide favorable habitat for growth of any number of genera of fungi. The drywall and composition ceiling tiles provide a welcome source of nutrients for fungi too. With the water (possibly) entering through the roof or from the outside, the mold could grow freely, hidden from view on the out-of-sight side of the cellulose construction materials. To be a fungus finder, one has to look where the sun doesn't shine!

The building was built to satisfy all codes (we might use a derivation of the "Nuremberg Trial" argument here that the real culprit in the explosion of the number of sick buildings, like this one, is a lack of understanding of fungal adaptation by those who write the building codes - does that mean those who knew the codes were inadequate have an ethical obligation to surpass them, thereby increasing building costs? Quality construction at the start, including putting the "V" in the HVAC, can save suffering and lots of money spent on remediation in the long run). It really isn't anyone's fault that the sewer pipes backed up shortly after the building opened. The indoor "flood" from the malfunctioning exhaust side of the plumbing might have started the fungus ball rolling. We will never know if that first water intrusion created the sanctuary that later nourished impressive numbers of Stachybotrys, Aspergillus and Penicillium. We can't dump all the blame on the plumbers because the front entry way lets in water whenever the wind comes from the West, as it usually does, except for the occasional Nor'easter that buffets this small Chesapeake Bay town. And the framing carpenters who are responsible for moisture seals around the doorway are off the hook too, because the concrete slab, poured as a foundation to save money, was like a fungal roller rink due to water draining off the impervious surface of the parking lot. Why didn't someone recognize that concrete slabs are portals of entry, especially in low-lying, high water-table areas? Sure, when the roof leaked, everyone noticed it. Just imagine the scene when an indoor trial was postponed because of rain!

Most sick buildings don't have this many sources of water intrusion. It usually is easy to isolate one source of water entry, like a roof with inadequate flashing or a basement with inadequate ventilation. Being able to pinpoint a single source of negligence gives attorneys an open invitation to get to work. Lawyers often pick out a responsible party, usually one with deep insurance pockets, as a target of negligence suits. Yet all the litigation, settled claims, abandoned buildings (how about the burned buildings!), and expensive retrofits won't do what our treatment protocols do: restore health of affected patients. We hope that we can identify and treat the patients before irreversible adverse downstream health effects caused by the pro-inflammatory cytokines, released in response to mycotoxin exposure in susceptible patients, either damage critical immunomodulatory hormone pathways in the hypothalamus or alter the normal defense mechanisms in mucus membranes, or (even worse) both. Once the exposure has gone on too long or with too much intensity, we have to do much more clinically to help SBS victims regain energy, cognitive function and quality of life. Don't think for a minute that ongoing mycotoxin exposure is benign. When I hear someone (especially someone with political power) say that a little mold isn't harmful, I wonder if they realize how dangerous their misinformation can become.

Letting adults work in a poisoned environment is bad enough, but just imagine if the sick building is a school. How will we know if our recognition of the effects of chronic exposure to mycotoxins is too late? Low scores on standardized tests? An increase in learning disorders? A rise in Ritalin prescriptions? An increase in absenteeism? Low SAT scores years later? The answers to these questions will only arrive when VCS testing becomes a mandatory part of the yearly school health evaluation, just like a hearing test and a visual acuity. And that will happen only when groups like the PTA demand action and no longer put up with empty statements, like "mold isn't harmful."
Remediation is costly, but so is impaired ability to learn.

So who was negligent in the construction of the courthouse? Who do the victims sue? Which water intrusion allowed the mold to grow? Who should pay for clean up and remediation? If everyone can blame someone else, who lets the bill stop on his or her desk? Why were so many fungi found? Which fungus made the judge sick?

When patients ask me why we rarely see "monocultures" of fungi in sick buildings, the answer is simple. A sick building simply lets fungi survive, reproduce and release mycotoxins and other compounds into the air the inhabitants breathe. With many organisms able to grow, and given food, water, cover and a chance to reproduce (the building amply provided for all of those), it is a fact of biology that multiple species will compete for small econiches well enough to survive. Every time the front door opened, for example, or when the judge came in on Saturdays to do some paper work, wearing his gardening shoes, a new opportunistic invader could have been introduced.