Quantitative polymerase chain reaction analysis of fungi in dust from homes of infants who developed idiopathic pulmonary hemorrhaging

Does evidence support measuring spore counts to identify dampness or mold in buildings? A literature review

BACKGROUND

To identify dampness or mold (D/M) in buildings, investigators generally inspect for observable D/M indicators, the presence of which justifies remediation. Investigators may also use microbiological measurement and interpretation strategies with uncertain scientific support.

OBJECTIVE

We assessed available evidence supporting uses of spore counts, the microbiological measurement most commonly used to assess D/M.

METHODS

We reviewed published studies assessing relationships between spore counts and observable D/M, across buildings with different observable D/M levels.

RESULTS

Penicillium/Aspergillus counts were consistently elevated in damp vs. reference (dry or outdoor) locations. Total spore counts provided a weaker, less consistent signal. The most detailed published analysis could distinguish groups of damp homes but not individual damp homes.

SIGNIFICANCE

Evidence did not validate current interpretations of spore count data for identifying single damp homes. Thus, such interpretations rest primarily on professional judgment. An additional series of informative but ineligible articles demonstrated an unconventional, more powerful "statistically based" comparison of multiple indoor vs. outdoor spore counts for identifying elevated indoor spores (and assumed D/M). Findings suggest that validation of enhanced spore trap approaches, including more samples indoors and outdoors plus statistically based comparisons of specific fungal groups, may allow evidence-based microbial identification of probable dampness in individual buildings.

Household dampness and microbial exposure related to allergy and respiratory health in Danish adults

Background: Indoor dampness has consistently been associated with respiratory symptoms and exacerbations. The causal mechanisms may involve increased microbial exposures. However, the evidence regarding the influence of indoor microbial exposures under damp- and non-damp conditions on the risk of asthma and allergy has been inconclusive. Objective: The aim of this study was to investigate the association between dampness and microbial exposure with allergy and respiratory health in Danish adults using a cross-sectional design. Methods: From 1,866 participants of the Health2006 cohort, we selected three non-overlapping groups: 196 at random, 107 with confirmed atopy, and 99 without atopy. Bedroom dust was sampled using electrostatic dust fall collectors and analysed for endotoxin, β-(1,3)-D-glucan, 19 microbial species or groups, and total fungal load. Household moisture-related problems and asthma were self-reported by questionnaire. Atopy was determined by skin-prick-testing and lung function was measured by spirometry. Results: Household moisture damage was positively associated with asthma outcomes, although this was statistically significant only in atopics for self-reported asthma (odds ratio (OR) 3.52; 95%CI 1.01-12.7). Mould odor was positively associated with wheezing (OR 6.05; 95%CI 1.19-30.7) in atopics. Inconsistent associations were found for individual microbial exposures and health outcomes. Inverse associations were observed between microbial diversity and rhinitis in the random sample and both doctor-diagnosed and self-reported asthma in non-atopics. Conclusions: In conclusion, our findings suggest that household moisture damage may increase the risk of asthma and wheeze with mould odor in atopics. In addition, asthma and allergy may be affected by the indoor microbial composition in urban domestic environments. Further studies are needed to identify and understand the causal agents and underlying mechanisms behind the potential effects of environmental microbial exposure on human health.

Mold and Human Health: a Reality Check

There are possibly millions of mold species on earth. The vast majority of these mold spores live in harmony with humans, rarely causing disease. The rare species that does cause disease does so by triggering allergies or asthma, or may be involved in hypersensitivity diseases such as allergic bronchopulmonary aspergillosis or allergic fungal sinusitis. Other hypersensitivity diseases include those related to occupational or domiciliary exposures to certain mold species, as in the case of Pigeon Breeder's disease, Farmer's lung, or humidifier fever. The final proven category of fungal diseases is through infection, as in the case of onchomycosis or coccidiomycosis. These diseases can be treated using anti-fungal agents. Molds and fungi can also be particularly important in infections that occur in immunocompromised patients. Systemic candidiasis does not occur unless the individual is immunodeficient. Previous reports of "toxic mold syndrome" or "toxic black mold" have been shown to be no more than media hype and mass hysteria, partly stemming from the misinterpreted concept of the "sick building syndrome." There is no scientific evidence that exposure to visible black mold in apartments and buildings can lead to the vague and subjective symptoms of memory loss, inability to focus, fatigue, and headaches that were reported by people who erroneously believed that they were suffering from "mycotoxicosis." Similarly, a causal relationship between cases of infant pulmonary hemorrhage and exposure to "black mold" has never been proven. Finally, there is no evidence of a link between autoimmune disease and mold exposure.

Butyrate influences intracellular levels of adenine and adenine derivatives in the fungus Penicillium restrictum

Butyrate, a small fatty acid, has an important role in the colon of ruminants and mammalians including the inhibition of inflammation and the regulation of cell proliferation. There is also growing evidence that butyrate is influencing the histone structure in mammalian cells by inhibition of histone deacetylation. Butyrate shows furthermore an antimicrobial activity against fungi, yeast and bacteria, which is linked to its toxicity at a high concentration. In fungi there are indications that butyrate induces the production of secondary metabolites potentially via inhibition of histone deacetylases. However, information about the influence of butyrate on growth, primary metabolite production and metabolism, besides lipid catabolism, in fungi is scarce. We have identified the filamentous fungus Penicillium (P.) restrictum as a susceptible target for butyrate treatment in an antimicrobial activity screen. The antimicrobial activity was detected only in the mycelium of the butyrate treated culture. We investigated the effect of butyrate ranging from low (0.001mM) to high (30mM), potentially toxic, concentrations on biomass and antimicrobial activity. Butyrate at high concentrations (3 and 30mM) significantly reduced the fungal biomass. In contrast P. restrictum treated with 0.03mM of butyrate showed the highest antimicrobial activity. We isolated three antimicrobial active compounds, active against Staphylococcus aureus, from P. restrictum cellular extracts treated with butyrate: adenine, its derivate hypoxanthine and the nucleoside derivate adenosine. Production of all three compounds was increased at low butyrate concentrations. Furthermore we found that butyrate influences the intracellular level of the adenine nucleoside derivate cAMP, an important signalling molecule in fungi and various organisms. In conclusion butyrate treatment increases the intracellular levels of adenine and its respective derivatives.

Microbiome of the paranasal sinuses: Update and literature review

BACKGROUND

Our understanding of the resident microbiome of the paranasal sinuses has changed considerably in recent years. Once presumed to be sterile, healthy sinus cavities are now known to harbor a diverse assemblage of microorganisms, and, it is hypothesized that alterations in the kinds and quantities of these microbes may play a role in the pathogenesis of chronic rhinosinusitis (CRS).

OBJECTIVES

To review the current literature regarding the sinus microbiome and collate research findings from relevant studies published to date.

METHODS

A systematic literature review was performed on all molecular studies that investigated the microbial communities of the paranasal sinuses. Methods of detection, microbiome composition, and comparative profiling between patients with and without CRS were explored.

RESULTS

A complex consortium of microorganisms has been demonstrated in the sinuses of both patients with and without CRS. However, the latter generally have been characterized by reduced biodiversity compared with controls, with selective enrichment of particular microbes (e.g., Staphylococcus aureus). Such disruptions in the resident microbiome may contribute to disease pathogenesis by enhancing the virulence of potential pathogens and adversely modulating immune responses.

CONCLUSION

The advent of culture-independent molecular approaches has led to a greater appreciation of the intricate microbial ecology of the paranasal sinuses. Microbiota composition, distribution, and abundance impact mucosal health and influence pathogen growth and function. A deeper understanding of the host-microbiome relationship and its constituents may encourage development of new treatment paradigms for CRS, which target restoration of microbiome homeostasis and cultivation of optimal microbial communities.

Microbial communities associated with house dust

House dust is a complex mixture of inorganic and organic material with microbes in abundance. Few microbial species are actually able to grow and proliferate in dust and only if enough moisture is provided. Hence, most of the microbial content originates from sources other than the dust itself. The most important sources of microbes in house dust are outdoor air and other outdoor material tracked into the buildings, occupants of the buildings including pets and microbial growth on moist construction materials. Based on numerous cultivation studies, Penicillium, Aspergillus, Cladosporium, and about 20 other fungal genera are the most commonly isolated genera from house dust. The cultivable bacterial flora is dominated by Gram-positive genera, such as Staplylococcus, Corynebacterium, and Lactococcus. Culture-independent studies have shown that both the fungal and the bacterial flora are far more diverse, with estimates of up to 500-1000 different species being present in house dust. Concentrations of microbes in house dust vary from nondetectable to 10(9) cells g(-1) dust, depending on the dust type, detection method, type of the indoor environment and season, among other factors. Microbial assemblages in different house dust types usually share the same core species; however, alterations in the composition are caused by differing sources of microbes for different dust types. For example, mattress dust is dominated by species originating from the user of the mattress, whereas floor dust reflects rather outdoor sources. Farming homes contain higher microbial load than urban homes and according to a recent study, temperate climate zones show higher dust microbial diversity than tropical zones.

Application of the Environmental Relative Moldiness Index in Finland

The environmental relative moldiness index (ERMI) metric was previously developed to quantify mold contamination in U.S. homes. This study determined the applicability of the ERMI for quantifying mold and moisture damage in Finnish residences. Homes of the LUKAS2 birth cohort in Finland were visually inspected for moisture damage and mold, and vacuumed floor dust samples were collected. An ERMI analysis including 36 mold-specific quantitative PCR assays was performed on the dust samples (n = 144), and the ERMI metric was analyzed against inspection-based observations of moisture damage and mold. Our results show that the ERMI was significantly associated with certain observations of visible mold in Finnish homes but not with moisture damage. Several mold species occurred more frequently and at higher levels in Finnish than in U.S. homes. Modification of the ERMI toward Finnish conditions, using a subsample of LUKAS2 homes with and without moisture damage, resulted in a simplified metric based on 10 mold species. The Finnish ERMI (FERMI) performed substantially better in quantifying moisture and mold damage in Finnish homes, showing significant associations with various observations of visible mold, strongest when the damage was located in the child's main living area, as well as with mold odor and moisture damage. As shown in Finland, the ERMI as such is not equally well usable in different climates and geographic regions but may be remodeled to account for local outdoor and indoor fungal conditions as well as for moisture damage characteristics in a given country.

Indoor fungi: companions and contaminants

This review discusses the role of fungi and fungal products in indoor environments, especially as agents of human exposure. Fungi are present everywhere, and knowledge for indoor environments is extensive on their occurrence and ecology, concentrations, and determinants. Problems of dampness and mold have dominated the discussion on indoor fungi. However, the role of fungi in human health is still not well understood. In this review, we take a look back to integrate what cultivation-based research has taught us alongside more recent work with cultivation-independent techniques. We attempt to summarize what is known today and to point out where more data is needed for risk assessment associated with indoor fungal exposures. New data have demonstrated qualitative and quantitative richness of fungal material inside and outside buildings. Research on mycotoxins shows that just as microbes are everywhere in our indoor environments, so too are their metabolic products. Assessment of fungal exposures is notoriously challenging due to the numerous factors that contribute to the variation of fungal concentrations in indoor environments. We also may have to acknowledge and incorporate into our understanding the complexity of interactions between multiple biological agents in assessing their effects on human health and well-being.

Assessing the allergenic potential of molds found in water-damaged homes in a mouse model

Damp/moldy indoor environments, which have resulted from flooding events and may increase as a result of climate change, have been associated with asthma exacerbation. Certain molds found in significantly higher or lower concentrations in asthmatics' homes compared to control homes have been categorized as Group 1 (G1) and Group 2 (G2) molds, respectively. We have compared the allergic potential of selected G1/G2 molds to house dust mite (HDM) in a mouse model. BALB/c mice were exposed to mold (0-80 µg) or HDM (20 µg) extract by intratracheal aspiration either 4X over 4 weeks (allergenicity) or 1X (non-specific responses). Airflow limitation (methacholine challenge) was measured (Day 1) and serum and bronchoalveolar lavage fluid were collected (Day 2) after the final exposure. The G1 molds induced low-to-moderate responses and required higher doses to achieve antigen-specific IgE results similar to those induced by HDM. Compared to HDM responses, the G2 mold in this study required lower doses to induce a similar response. Acute exposure responses suggest some molds may exacerbate asthmatic responses. These studies demonstrate the differing capacities of molds to induce responses associated with allergic asthma, including differences in the threshold dose for allergy induction. Therefore, molds must be evaluated individually for allergic/asthmatic potential. These studies along with our previous studies with G1 (Stachybotrys chartarum)/G2 (Penicillium chrysogenum) molds suggest that the G1/G2 categorization is not indicative of allergic potential but they do not preclude this categorization's utility in determining unhealthy building dampness.

Determining fungi rRNA copy number by PCR

The goal of this project is to improve the quantification of indoor fungal pollutants via the specific application of quantitative PCR (qPCR). Improvement will be made in the controls used in current qPCR applications. This work focuses on the use of two separate controls within a standard qPCR reaction. The first control developed was the internal standard control gene, benA. This gene encodes for β-tubulin and was selected based on its single-copy nature. The second control developed was the standard control plasmid, which contained a fragment of the ribosomal RNA (rRNA) gene and produced a specific PCR product. The results confirm the multicopy nature of the rRNA region in several filamentous fungi and show that we can quantify fungi of unknown genome size over a range of spore extractions by inclusion of these two standard controls. Advances in qPCR have led to extremely sensitive and quantitative methods for single-copy genes; however, it has not been well established that the rRNA can be used to quantitate fungal contamination. We report on the use of qPCR, combined with two controls, to identify and quantify indoor fungal contaminants with a greater degree of confidence than has been achieved previously. Advances in indoor environmental health have demonstrated that contamination of the built environment by the filamentous fungi has adverse impacts on the health of building occupants. This study meets the need for more accurate and reliable methods for fungal identification and quantitation in the indoor environment.

The Head-off Environmental Asthma in Louisiana (HEAL) study--methods and study population

BACKGROUND

In the city of New Orleans, Louisiana, and surrounding parishes (NOLA), children with asthma were perilously impacted by Hurricane Katrina as a result of disrupted health care, high home mold and allergen levels, and high stress.

OBJECTIVES

The Head-off Environmental Asthma in Louisiana (HEAL) study was conducted to examine relationships between the post-Katrina environment and childhood asthma in NOLA and assess a novel asthma counselor intervention that provided case management and guidance for reducing home mold and allergen levels.

METHODS

Children (4-12 years old) with moderate-to-severe asthma were recruited from NOLA schools. Over 1 year, they received two clinical evaluations, three home environmental evaluations, and the asthma intervention. Quarterly end points included symptom days, medication use, and unscheduled emergency department or clinic visits. A community advisory group was assembled and informed HEAL at all phases.

RESULTS

Of the children (n = 182) enrolled in HEAL, 67% were African American, and 25% came from households with annual incomes < $15,000. HEAL children were symptomatic, averaging 6.6 symptom days in the 2 weeks before baseline, and had frequent unscheduled visits to clinics or emergency departments (76% had at least one unscheduled visit in the preceding 3 months). In this report, we describe study design and baseline characteristics of HEAL children.

CONCLUSIONS

Despite numerous challenges faced by investigators, study staff, and participants, including destroyed infrastructure, disrupted lives, and lost jobs, HEAL was successful in terms of recruitment and retention, the high quality of data collected that will provide insight into asthma-allergen relationships, and the asthma intervention. This success was attributable to using an adaptive approach and refining processes as needed.

Efficacy of occupant-collected dust samples in the evaluation of residential allergen and fungal levels

This study evaluated the ability of a resident to evaluate their home for allergens and mold using a settled dust test kit compared with evaluation and collection of settled dust by an industrial hygienist. Forty-three home residents were provided with a kit containing written instructions and a vacuum cleaner attachment for collecting a settled dust sample. Within 2 weeks of receiving the occupant-collected sample, an industrial hygienist evaluated these homes, including a visual inspection, collection of settled dust, and collection of spore trap samples. Settled dust samples were analyzed for major dog, cat, dust mite, and cockroach allergens using immunoassay methods, and for mold spore equivalents using quantitative polymerase chain reaction methods for the 13 mold species or species groups comprising the American Relative Moldiness Index (ARMI). Allergen concentrations and ARMIs were compared between the resident- and industrial hygienist-collected samples. Linear regression between the two sets of samples showed strong correlations for dog allergen (r(2) = 0.92) and cat allergen (r(2) = 0.90). Correlations for dust mite (r(2) = 0.57) and cockroach allergens (r(2) = 0.22) were lower, likely due to most samples being near the limit of detection. ARMIs were highly correlated (r(2) = 0.68) and were in categorical (high, medium, or low) agreement for 76% of residences. These results show that residents can reliably follow directions and collect settled dust samples, providing an efficient method to remotely screen homes for elevated allergen levels and to identify homes with a potential mold or moisture problem that may need further evaluation.

Assessing allergenic fungi in house dust by floor wipe sampling and quantitative PCR

In the present study, we modified an existing surface wipe sampling method for lead and other heavy metals to create a protocol to collect fungi in floor dust followed by real-time quantitative PCR (qPCR)-based detection. We desired minimal inconvenience for participants in residential indoor environmental quality and health studies. Accuracy, precision, and method detection limits (MDLs) were investigated. Overall, MDLs ranged from 0.6 to 25 cell/cm² on sampled floors. Overall measurement precisions expressed as the coefficient of variation because of sample processing and qPCR ranged 6-63%. Median and maximum fungal concentrations in house dust in study homes in Visalia, Tulare County, California, were 110 and 2500 cell/cm², respectively, with universal fungal primers (allergenic and nonallergenic species). The field study indicated samplings in multiple seasons were necessary to characterize representative whole-year fungal concentrations in residential microenvironments. This was because significant temporal variations were observed within study homes. Combined field and laboratory results suggested this modified new wipe sampling method, in conjunction with growth-independent qPCR, shows potential to improve human exposure and health studies for fungal pathogens and allergens in dust in homes of susceptible, vulnerable population subgroups.

PRACTICAL IMPLICATIONS

Fungi are ubiquitous in indoor and outdoor environments, and many fungi are known to cause allergic reactions and exacerbate asthma attacks. This study established--by modifying an existing--a wipe sampling method to collect fungi in floor dust followed by real-time quantitative PCR (qPCR)-based detection methodologies. Results from this combined laboratory and field assessment suggested the methodology's potential to inform larger human exposure studies for fungal pathogens and allergens in house dust as well as epidemiologic studies of children with asthma and older adults with chronic respiratory diseases.

Streptomycetes in house dust: associations with housing characteristics and endotoxin

In addition to mold, indoor bioaerosols also contain bacterial components that may have implications for human health. Endotoxin is a cell wall component in Gram-negative bacteria present at varying levels indoors that has been found to have respiratory health implications. Streptomyces is a large genus of Gram-positive bacteria, and some species have been shown to produce inflammatory reactions in vitro and in vivo. The aim of this study was to determine predictors of streptomycetes levels in house dust and to compare the variation in streptomycetes levels with that in endotoxin levels. Dust was collected by floor vacuuming from 178 homes in the Cincinnati metropolitan area. Streptomycetes levels were measured by quantitative PCR, and endotoxin was assayed by the Limulus amebocyte lysate method. Associations between home characteristics and bacterial contaminants, expressed as concentration and load, were investigated through multiple regression analyses. The presence of two or more dogs was a strong predictor of both streptomycetes and endotoxin levels. Season of dust collection and levels of outdoor molds were predictors of streptomycetes but not endotoxin levels. In contrast, number of inhabitants was a significant predictor of endotoxin load only. Neither streptomycetes nor endotoxin levels were associated with metrics of moisture damage.

Traditional mould analysis compared to a DNA-based method of mould analysis

Traditional environmental mould analysis is based on microscopic observations and counting of mould structures collected from the air on a sticky surface or culturing of moulds on growth media for identification and quantification. These approaches have significant limitations. A DNA-based method of mould analysis called mould specific quantitative PCR (MSQPCR) was created for more than 100 moulds. Based on a national sampling and analysis by MSQPCR of dust in US homes, a scale for comparing the mould burden in homes was created called the Environmental Relative Mouldiness Index (ERMI).

[Moulds in dwellings: health risks and involved species]

INTRODUCTION

In industrialized countries the population spends 90% of its time in enclosed spaces. Since 1973, energy consumption for heating decreased on average by 36% per dwelling. Low-quality insulation, a fall in temperature and inadequate ventilation translated into high humidity in dwellings, which led to proliferation of moulds.

BACKGROUND

The allergenic, toxic and infectious effects of moulds on human health are documented. However, the potential dose/effect relationship between measured concentrations of indoor moulds and respiratory disorders often remains difficult to assess accurately. In several cases, fungi were demonstrated only as a promoter of health disorders. In a few cases (hypersensitivity pneumonitis, invasive fungal infections), the pathogenesis is without doubt due to environmental fungal exposure in a limited number of patients. On the other hand, the role of fungi was suspected but not proven for some well-defined pathologies, and some ill-defined health disorders, affecting large numbers of patients, such as the Sick Building Syndrome, rhinitis, sinusitis and conjunctivitis, as well as asthma and exacerbations of bronchitis. Eighteen fungal species, suspected of playing a role in public health, have been listed by the French Superior Council of Public Health. For each species, the proliferation conditions, type of substrates contaminated and heath effects reported in the literature are described.

VIEWPOINT

The lack of standardization of measurements of concentrations of fungal species, the interactions with chemical compounds (formaldehydes), organic compounds (mycotoxins, endotoxins) and between species, makes the analysis of indoor fungal contamination complicated. The time has come to establish clearly a relationship between exposure to fungi and health disorders, rather than continuing to investigate factors related to the level of indoor fungal contamination.

Indoor mold concentration in Eastern France

Our prospective case-control study of 118 dwellings in Eastern France examined fungal contamination in unhealthy dwellings (n = 32) (homes with visible mold contamination and adverse health outcomes reported by the occupants), dwellings occupied by allergic patients (with medical diagnostic and positive prick-tests for molds) (n = 27) and matched control dwellings (n = 59). Unhealthy dwellings present higher airborne concentrations of Aspergillus, Penicillium, and Cladosporium than control dwellings, irrespective of the room sampled. Bedroom walls were more highly contaminated by molds than others. Dwellings occupied by allergic patients differed significantly for airborne concentrations of Penicillium only, but not for wall surface contamination, whereas bathroom walls were more highly contaminated than other rooms. Molecular identification of 12 Penicillium species showed Penicillium chrysogenum and Penicillium olsonii to be the two main species. From the total average of molds, by impaction method, useful thresholds can be given: below 170 CFU/m(3), between 170 and 560 CFU/m(3), 560 and 1000 CFU/m(3) and above 1000 CFU/m(3), respectively for dwellings with low, moderate, high, and very high concentrations. The latter would be considered a potential health hazard.

PRACTICAL IMPLICATIONS

A single measure of airborne concentrations of molds by impaction allows to establish useful thresholds by social services to estimate in a objective way the housing moldiness. Excluding the summer period, reproducibility of this kind of measure on 3 months, in the fixed limits, is 94.3%. The differences in terms of biodiversity of the unhealthy housing and those accommodating allergic patients imply a specific approach to decrease fungi airborne concentrations. The biodiversity of Penicillium raises the problem of the use of the single extract of Penicillium chrysogenum for skin-tests. The extent of the contaminated surfaces must be measured to assess the potential risk linked to spore contamination. Indeed, surface sampling mostly allows qualitative assessment of the environment.

Correlation between ERMI values and other moisture and mold assessments of homes in the American Healthy Homes Survey

The main objective of this study was to evaluate the correlation between the Environmental Relative Moldiness Index (ERMI) values in the Department of Housing and Urban Development American Healthy Homes Survey (AHHS) homes and an alternative analysis frequently used in mold investigations, i.e., the inspector's "walk-through" assessment of visual or olfactory evidence of mold combined with occupant's answers to a questionnaire about mold odors and moisture. Homes in the highest ERMI quartile were in agreement with visual inspection and/or occupant assessment 48% of the time but failed to detect the mold in 52% of the fourth quartile homes. In about 7% of lowest ERMI quartile homes, the inspection and occupant assessments overestimated the mold problem. The ERMI analysis of dust from homes may be useful in finding hidden mold problems. An additional objective was to compare the ERMI values in inner city east-Baltimore homes, where childhood asthma is common, to the AHHS randomly selected homes.

The biocontaminants and complexity of damp indoor spaces: more than what meets the eyes

Nine types of biocontaminants in damp indoor environments from microbial growth are discussed: (1) indicator molds; (2) Gram negative and positive bacteria; (3) microbial particulates; (4) mycotoxins; (5) volatile organic compounds, both microbial (MVOCs) and non-microbial (VOCs); (6) proteins; (7) galactomannans; (8) 1-3-β-D-glucans (glucans) and (9) lipopolysaccharides (LPS — endotoxins). When mold species exceed those outdoors contamination is deduced. Gram negative bacterial endotoxins, LPS in indoor environments, synergize with mycotoxins. The gram positive Bacillus species, Actinomycetes (Streptomyces, Nocardia and Mycobacterium), produce exotoxins. The Actinomycetes are associated with hypersensitivity pneumonitis, lung and invasive infections. Mycobacterial mycobacterium infections not from M. tuberculosis are increasing in immunocompetent individuals. In animal models, LPS enhance the toxicity of roridin A, satratoxins G and aflatoxin B1 to damage the olfactory epithelium, tract and bulbs (roridin A, satratoxin G) and liver (aflatoxin B1). Aflatoxin B1 and probably trichothecenes are transported along the olfactory tract to the temporal lobe. Co-cultured Streptomyces californicus and Stachybotrys chartarum produce a cytotoxin similar to doxorubicin and actinomycin D (chemotherapeutic agents). Trichothecenes, aflatoxins, gliotoxin and other mycotoxins are found in dust, bulk samples, air and ventilation systems of infested buildings. Macrocyclic trichothecenes are present in airborne particles <2 μm. Trichothecenes and stachylysin are present in the sera of individuals exposed to S. chartarum in contaminated indoor environments. Haemolysins are produced by S. chartarum, Memnoniella echinata and several species of Aspergillus and Penicillium. Galactomannans, glucans and LPS are upper and lower respiratory tract irritants. Gliotoxin, an immunosuppressive mycotoxin, was identified in the lung secretions and sera of cancer patients with aspergillosis produced by A. fumigatus, A. terreus, A. niger and A. flavus.

Concentration of the genera Aspergillus, Eurotium and Penicillium in 63-microm house dust fraction as a method to predict hidden moisture damage in homes

BACKGROUND

Quantitative measurements of mould enrichment of indoor air or house dust might be suitable surrogates to evaluate present but hidden moisture damage. Our intent was to develop a house-dust monitoring method to detect hidden moisture damage excluding the influence of outdoor air, accumulated old dust, and dust swirled up from room surfaces.

METHODS

Based on standardized measurement of mould spores in the 63-microm fraction of house dust yielded by carpets, the background concentrations were determined and compared to simultaneously obtained colony numbers and total spore numbers of the indoor air in 80 non-mouldy living areas during summer and winter periods. Additionally, sampling with a vacuum-cleaner or manual sieve was compared to sampling with a filter holder or sieving machine, and the evaluative power of an established two-step assessment model (lower and upper limits) was compared to that of a one-step model (one limit) in order to derive concentration limits for mould load in house dust.

RESULTS

Comparison with existing evaluation procedures proved the developed method to be the most reliable means of evaluating hidden moisture damage, yielding the lowest false-positive results (specificity 98.7%). Background measurements and measurements in 14 mouldy rooms show that even by evaluating just the indicator genera in summer and winter, a relatively certain assessment of mould infestation is possible.

CONCLUSION

A one-step evaluation is finally possible for house dust. The house-dust evaluation method is based on analysis of the indicator genera Aspergillus, Eurotium and Penicillium spp., which depend on the total fungal count. Inclusion of further moisture indicators currently appears questionable, because of outdoor air influence and the paucity of measurements.

Indoor fungal contamination of moisture-damaged and allergic patient housing analysed using real-time PCR

AIMS

The aim of our study was to compare, using real-time (Rt) PCR, quantitative levels of five fungal species in three kinds of dwellings.

METHODS AND RESULTS

Three groups of homes were recruited: moisture-damaged homes (MDH, n = 30), allergic patient homes (APH, n = 25) and paired control homes (CH, n = 55). Five moulds with allergenic compounds or mycotoxin production characteristics (Cladosporium sphaerospermum, Penicillium chrysogenum, Aspergillus versicolor, Alternaria alternata and Stachybotrys chartarum) were quantified using Rt-PCR. Cycle threshold results were expressed in spore equivalent per volume or surface unit using a direct calculation based on a spore standard curve. MDH presented significantly higher amounts of DNA from C. sphaerospermum in both air and surface samples than CH (P < 0.001). APH presented slightly elevated amounts of DNA from A. versicolor in both air and surface samples, compared to CH (P < 0.05).

CONCLUSION

Rt-PCR quantification of targeted fungal species is a rapid, reliable tool that could be included in a global indoor mould evaluation.

SIGNIFICANCE AND IMPACT OF THE STUDY

Quantification of C. sphaerospermum using Rt-PCR can help to better target social service intervention in MDH. Quantification of A. versicolor DNA could be informative for characterization of APH.

Molds and mycotoxins in dust from water-damaged homes in New Orleans after hurricane Katrina

Dust collected in New Orleans homes mold-contaminated because of the flooding after hurricane Katrina was analyzed for molds and mycotoxins. The mycoflora was studied by cultivation and quantitative PCR for selected molds. The most commonly found mold taxa were Aspergillus, Cladosporium, and Penicillium. Verrucarol, a hydrolysis product of macrocyclic trichothecenes predominately produced by Stachybotrys spp. was identified in three dust samples by gas chromatography-tandem mass spectrometry, and sterigmatocystin (produced by various Aspergillus spp.) was found in two samples by high pressure liquid chromatography-tandem mass spectrometry. This is the first demonstration of mycotoxins in Katrina-associated dust samples. The analytical methods used represent valuable tools in further studies on bioaerosol exposure and health risks.

PRACTICAL IMPLICATIONS

In the aftermath of natural disasters like hurricane Katrina water-damages on infrastructure and public and private property are often associated with health risks for remediation workers and returning residents. In the case of New Orleans evaluations of health hazards, health studies, and assessments of bioaerosol have been conducted previously. However, until now mycotoxins have not been addressed. Our study shows, for the first time, the presence of mycotoxins in dust collected in houses in New Orleans mold-contaminated because of the hurricane Katrina. The results may highlight the potential health threats posed by mold aerosols in post-disaster inhabited areas.

Evaluation of quantitative PCR and culture methods for detection of house dust fungi and streptomycetes in relation to moisture damage of the house

AIMS

Microbial concentrations in vacuumed house dust samples (n = 71) were analysed by culture and quantitative polymerase chain reaction (qPCR) methods and their association with extent of moisture damage in the house was studied.

METHODS AND RESULTS

Microbial concentrations measured by qPCR correlated with concentrations obtained by culture method, but were orders of magnitude higher. qPCR also had better sensitivity. Concentrations of several microbes in house dust, determined with qPCR, were associated with the extent of moisture damage in the house. This association was strongest for Penicillium brevicompactum, one of the fungi detected in highest concentrations by qPCR. Furthermore, house dust concentrations of Wallemia sebi, Trichoderma viride, Cladosporium sphaerospermum, Eurotium amstelodami and the combined assay group for Penicillium spp., Aspergillus spp. and Paecilomyces variotii were significantly associated with the extent of the moisture damage.

CONCLUSION

These species or assay groups could probably be used as indicators of moisture damage in the house.

SIGNIFICANCE AND IMPACT OF THE STUDY

This finding indicates the benefits of the qPCR method, which is sensitive enough to reveal the differences in microbial concentrations of house dust between moisture-damaged and undamaged houses.

Sudden oronasal bleeding in a young child

Sudden severe upper-airway obstruction occurring in a hospital setting can sometimes precipitate an episode of acute haemorrhagic pulmonary oedema. A review of 197 published case reports shows that the presenting feature is almost always the sudden appearance of blood stained fluid coming up through the larynx or out through the mouth and nose of an adult or child in obvious respiratory distress. Such overt features are seen in 10-15% of cases of sudden severe, but sub-lethal, upper-airway obstruction. Signs normally appear within minutes once the obstruction is relieved but are occasionally only recognized after 1-4 h. All signs and symptoms usually resolve within 12-24 h. Other causes of acute pulmonary haemorrhage are rare in young children.

CONCLUSION

If what looks like blood is seen in, or coming from, the mouth or nose of a previously healthy young child who has suddenly become distressed and started to struggle for breath, that child has most probably suffered an episode of acute pulmonary oedema, and the commonest precipitating cause is sudden upper-airway obstruction.

Indoor air particles and bioaerosols before and after renovation of moisture-damaged buildings: the effect on biological activity and microbial flora

Many building-related health problems coincide with moisture damage and mold growth within a building. Their elimination is assumed to improve indoor air quality. The aim of this study was to follow the success of remediation in two individual buildings by analyzing the microbial flora and immunotoxicological activity of filter samples. We compare results from samples collected from indoor air in the moisture-damaged buildings before and after renovation and results from matched reference buildings and outdoor air. The microbial characteristics of the samples were studied by analyzing ergosterol content and determining the composition of fungal flora with quantitative polymerase chain reaction (QPCR). In addition, the concentrations of particles were monitored with optical particle counter (OPC). The immunotoxicological activity of collected particle samples was tested by exposing mouse macrophages (RAW264.7) for 24 h to particle suspension extracted from the filters, and measuring the viability of the exposed cells (MTT-test) and production of inflammatory mediators (nitric oxide, IL-6 and TNF*) in cell culture medium by enzyme-linked immunoassay (ELISA). The results show that for Location 1 the renovation decreased the immunotoxicological activity of the particles collected from damaged building, whereas no difference was detected in the corresponding samples collected from the reference building. Interestingly, only slight differences were seen in the concentration of fungi. In the Location 2, a decrease was seen in the concentration of fungi after the renovation, whereas no effect on the immunotoxicological responses was detected. In this case, the immunotoxicological responses to the indoor air samples were almost identical to those caused by the samples from outdoor air. This indicates that the effects of remediation on the indoor air quality may not necessarily be readily measurable either with microbial or toxicological parameters. This may be associated with different spectrum of harmful agents in different mold and moisture-damaged buildings.

Use of (1-3)-beta-d-glucan concentrations in dust as a surrogate method for estimating specific fungal exposures

Indoor exposure to fungi has been associated with respiratory symptoms,often attributed to their cell wall component, (1-3)-beta-D-glucan. Performing(1-3)-beta-D-glucan analysis is less time consuming and labor intensive than cultivation or microscopic counting of fungal spores. This has prompted many to use(1-3)-beta-D-glucan as a surrogate for fungal exposure. The aim of this study was to examine which indoor fungal species are major contributors to the (1-3)-beta-D-glucan concentration in field dust samples. We used the quantitative polymerase chain reaction (QPCR) method to analyze 36 indoor fungal species in 297 indoor dust samples. These samples were also simultaneously analyzed for (1-3)-beta-D-glucan concentration using the endpoint chromogenic Limulus Amebocyte lysate assay. Linear regression analysis, followed by factor analysis and structural equation modeling, were utilized in order to identify fungal species that mostly contribute to the (1-3)-beta-D-glucan concentration in field dust samples. The study revealed that Cladosporium and Aspergillus genera, as well as Epicoccum nigrum, Penicillium brevicompactum and Wallemia sebi were the most important contributors to the (1-3)-beta-D-glucan content of these home dust samples. The species that contributed most to the (1-3)-beta-D-glucan concentration were also the most prevalent in indoor environments. However, Alternaria alternata, a common fungal species in indoor dust, did not seem to be a significant source of (1-3)-beta-D-glucan.

PRACTICAL IMPLICATIONS

This study revealed that the (1-3)-beta-D-glucan content of different fungal species varies widely. (1-3)-beta-D-glucan inhouse dust from the Greater Cincinnati area may be a good marker for some fungal species of the Cladosporium and Aspergillus genera. In contrast, Alternaria alternata did not contribute much to the (1-3)-beta-D-glucan load. Therefore, (1-3)-beta-D-glucan concentration in field samples as a surrogate for total fungal exposure should be used with caution.

Higher Environmental Relative Moldiness Index (ERMIsm) values measured in Detroit homes of severely asthmatic children

Sieved vacuum bag dust from the homes of 143 children in Detroit was analyzed by mold specific quantitative PCR (MSQPCR) and the Environmental Relative Moldiness Index (ERMIsm) was calculated for each home. Children living in these homes were grouped as non-asthmatic (n=83), moderately asthmatic (n=28) and severely asthmatic (n=32) based on prescription medication usage for their asthma management (none, occasional and daily, respectively). The mean ERMI for each group of homes was 6.2 for non-asthmatic, 6.3 for moderately asthmatic and 8.2 for severely asthmatic children. The ERMI values in the homes of severely asthmatic children were significantly greater compared to the non-asthmatics (p=0.04 in Wilcoxon Rank-sum test). Aspergillus niger and Aspergillus unguis were the primary mold species that distinguished severely asthmatic children's homes and non-asthmatic children's homes (p<0.05; Wilcoxon Rank-sum test). The determination of the home's ERMI values may aid in prioritizing home remediation efforts, particularly in those children who are at increased risk for asthma exacerbation.

Development of an Environmental Relative Moldiness index for US homes

OBJECTIVE

The objective of this study was to establish a national relative moldiness index for homes in the United States.

METHODS

As part of the Housing and Urban Development's American Healthy Homes Survey, dust samples were collected by vacuuming 2 m in the bedrooms plus 2 m in the living rooms from a nationally representative 1096 homes in the United States using the Mitest sampler. Five milligrams of sieved (300 mum pore, nylon mesh) dust was analyzed by mold-specific quantitative polymerase chain reaction for the 36 indicator species in 1096 samples.

RESULTS

On the basis of this standardized national sampling and analysis, an "Environmental Relative Moldiness Index" was created with values ranging from about -10 to 20 or above (lowest to highest).

CONCLUSIONS

The Environmental Relative Moldiness Index scale may be useful for home mold-burden estimates in epidemiological studies.

Detection of Stachybotrys chartarum using rRNA, tri5, and beta-tubulin primers and determining their relative copy number by real-time PCR

Highly conserved regions are attractive targets for detection and quantitation by PCR, but designing species-specific primer sets can be difficult. Ultimately, almost all primer sets are designed based upon literature searches in public domain databases, such as the National Center for Biotechnology Information (NCBI). Prudence suggests that the researcher needs to evaluate as many sequences as available for designing species-specific PCR primers. In this report, we aligned 11, 9, and 16 DNA sequences entered for Stachybotrys spp. rRNA, tri5, and beta-tubulin regions, respectively. Although we were able to align and determine consensus primer sets for the 9 tri5 and the 16 beta-tubulin sequences, there was no consensus sequence that could be derived from alignment of the 11 rRNA sequences. However, by judicious clustering of the sequences that aligned well, we were able to design three sets of primers for the rRNA region of S. chartarum. The two primer sets for tri5 and beta-tubulin produced satisfactory PCR results for all four strains of S. chartarum used in this study whereas only one rRNA primer set of three produced similar satisfactory results. Ultimately, we were able to show that rRNA copy number is approximately 2-log greater than for tri5 and beta-tubulin in the four strains of S. chartarum tested.

Stachybotrys chartarum, trichothecene mycotoxins, and damp building-related illness: new insights into a public health enigma

Damp building-related illnesses (DBRI) include a myriad of respiratory, immunologic, and neurologic symptoms that are sometimes etiologically linked to aberrant indoor growth of the toxic black mold, Stachybotrys chartarum. Although supportive evidence for such linkages is limited, there are exciting new findings about this enigmatic organism relative to its environmental dissemination, novel bioactive components, unique cellular targets, and molecular mechanisms of action which provide insight into the S. chartarum's potential to evoke allergic sensitization, inflammation, and cytotoxicity in the upper and lower respiratory tracts. Macrocyclic trichothecene mycotoxins, produced by one chemotype of this fungus, are potent translational inhibitors and stress kinase activators that appear to be a critical underlying cause for a number of adverse effects. Notably, these toxins form covalent protein adducts in vitro and in vivo and, furthermore, cause neurotoxicity and inflammation in the nose and brain of the mouse. A second S. chartarum chemotype has recently been shown to produce atranones-mycotoxins that can induce pulmonary inflammation. Other biologically active products of this fungus that might contribute to pathophysiologic effects include proteinases, hemolysins, beta-glucan, and spirocyclic drimanes. Solving the enigma of whether Stachybotrys inhalation indeed contributes to DBRI will require studies of the pathophysiologic effects of low dose chronic exposure to well-characterized, standardized preparations of S. chartarum spores and mycelial fragments, and, coexposures with other environmental cofactors. Such studies must be linked to improved assessments of human exposure to this fungus and its bioactive constituents in indoor air using both state-of-the-art sampling/analytical methods and relevant biomarkers.

Quantitative PCR analysis of molds in the dust from homes of asthmatic children in North Carolina

The vacuum bag (VB) dust from the homes of 19 asthmatic children in North Carolina (NC) was analyzed by mold specific quantitative PCR. These results were compared to the analysis of the VB dust from 176 homes in the HUD, American Healthy Home Survey of homes in the US. The Environmental Relative Moldiness Index (ERMI) was calculated for each of the homes. The mean and standard deviation (SD) of the ERMI values in the homes of the NC asthmatic children was 16.4 (6.77), compared to the HUD survey VB ERMI value mean and SD of 11.2 (6.72), and was significantly greater (t-test, p = 0.003) in the NC asthmatic children's homes. The molds Chaetomium globosum, Aspergillus fumigatus, and the Eurotium Group were the primary species in the NC homes of asthmatics, making the ERMI values significantly higher (p < 0.02 for each). Vacuum bag dust analysis may be a useful method for estimating the mold burden in a home.

Current state of the science: health effects and indoor environmental quality

Our understanding of the relationship between human health and the indoor environment continues to evolve. Previous research on health and indoor environments has tended to concentrate on discrete pollutant sources and exposures and on specific disease processes. Recently, efforts have been made to characterize more fully the complex interactions between the health of occupants and the interior spaces they inhabit. In this article we review recent advances in source characterization, exposure assessment, health effects associated with indoor exposures, and intervention research related to indoor environments. Advances in source characterization include a better understanding of how chemicals are transported and processed within spaces and the role that other factors such as lighting and building design may play in determining health. Efforts are under way to improve our ability to measure exposures, but this remains a challenge, particularly for biological agents. Researchers are also examining the effects of multiple exposures as well as the effects of exposures on vulnerable populations such as children and the elderly. In addition, a number of investigators are also studying the effects of modifying building design, materials, and operations on occupant health. Identification of research priorities should include input from building designers, operators, and the public health community.

Specific molds associated with asthma in water-damaged homes

OBJECTIVE

We sought to determine if specific molds were found in significantly higher concentrations in the water-damaged homes of asthmatic children compared with homes with no visible water damage.

METHODS

The mold concentrations in the dust in asthmatic children's bedrooms in water-damaged homes (N = 60) and control homes (N = 22) were measured by mold-specific quantitative polymerase chain reaction.

RESULTS

Two molds, Scopulariopsis brevicaulis and Trichoderma viride, had significantly (P < 0.05) higher concentrations in asthmatics' homes compared with control homes and three other molds (Penicillium crustosum group, Stachybotrys chartarum, and Wallemia sebi) had P values <0.1.

CONCLUSIONS

A relative moldiness index was developed to predict the likely development of asthma in water-damaged homes in Cleveland.

Relative moldiness index as predictor of childhood respiratory illness

The results of a traditional visual mold inspection were compared to a mold evaluation based on the Relative Moldiness Index (RMI). The RMI is calculated from mold-specific quantitative PCR (MSQPCR) measurements of the concentration of 36 species of molds in floor dust samples. These two prospective mold evaluations were used to classify the mold condition in 271 homes of infants. Later, the development of respiratory illness was measured in the infants living in these homes and the predictive value of each classification system was evaluated. The binary classification of homes as either moldy or non-moldy by on-site visual home inspection was not predictive of the development of respiratory illness (wheeze and/or rhinitis) (P=0.27). Conversely, a method developed and validated in this paper, using the RMI index fit to a logistic function, can be used to predict the occurrence of illness in homes and allows stake-holders the choice among various levels of risk.

Mold and endotoxin levels in the aftermath of Hurricane Katrina: a pilot project of homes in New Orleans undergoing renovation

BACKGROUND

After Hurricane Katrina, many New Orleans homes remained flooded for weeks, promoting heavy microbial growth.

OBJECTIVES

A small demonstration project was conducted November 2005-January 2006 aiming to recommend safe remediation techniques and safe levels of worker protection, and to characterize airborne mold and endotoxin throughout cleanup.

METHODS

Three houses with floodwater lines between 0.3 and 2 m underwent intervention, including disposal of damaged furnishings and drywall, cleaning surfaces, drying remaining structure, and treatment with a biostatic agent. We measured indoor and outdoor bioaerosols before, during, and after intervention. Samples were analyzed for fungi [culture, spore analysis, polymerase chain reaction (PCR)] and endotoxin. In one house, realtime particle counts were also assessed, and respirator-efficiency testing was performed to establish workplace protection factors (WPF).

RESULTS

At baseline, culturable mold ranged from 22,000 to 515,000 colony-forming units/m3, spore counts ranged from 82,000 to 630,000 spores/m3, and endotoxin ranged from 17 to 139 endotoxin units/m3. Culture, spore analysis, and PCR indicated that Penicillium, Aspergillus, and Paecilomyces predominated. After intervention, levels of mold and endotoxin were generally lower (sometimes, orders of magnitude). The average WPF against fungal spores for elastomeric respirators was higher than for the N95 respirators.

CONCLUSIONS

During baseline and intervention, mold and endotoxin levels were similar to those found in agricultural environments. We strongly recommend that those entering, cleaning, and repairing flood-damaged homes wear respirators at least as protective as elastomeric respirators. Recommendations based on this demonstration will benefit those involved in the current cleanup activities and will inform efforts to respond to future disasters.

A simple polymerase chain reaction-sequencing analysis capable of identifying multiple medically relevant filamentous fungal species

Due to the accumulating evidence that suggests that numerous unhealthy conditions in the indoor environment are the result of abnormal growth of the filamentous fungi (mold) in and on building surfaces it is necessary to accurately determine the organisms responsible for these maladies and to identify them in an accurate and timely manner. Historically, identification of filamentous fungal (mold) species has been based on morphological characteristics, both macroscopic and microscopic. These methods may often be time consuming and inaccurate, necessitating the development of identification protocols that are rapid, sensitive, and precise. To this end, we have devised a simple PAN-PCR approach which when coupled to cloning and sequencing of the clones allows for the unambiguous identification of multiple fungal organisms. Universal primers are used to amplify ribosomal DNA sequences which are then cloned and transformed into Escherichia coli. Individual clones are then sequenced and individual sequences analyzed and organisms identified. Using this method we were capable of identifying Stachybotrys chartarum, Penicillium purpurogenum, Aspergillus sydowii, and Cladosporium cladosporioides from a mixed culture. This method was found to be rapid, highly specific, easy to perform, and cost effective.

Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources

OBJECTIVE

Home dampness and the presence of mold and allergens have been associated with asthma morbidity. We examined changes in asthma morbidity in children as a result of home remediation aimed at moisture sources.

DESIGN

In this prospective, randomized controlled trial, symptomatic, asthmatic children (n = 62), 2-17 years of age, living in a home with indoor mold, received an asthma intervention including an action plan, education, and individualized problem solving. The remediation group also received household repairs, including reduction of water infiltration, removal of water-damaged building materials, and heating/ventilation/air-conditioning alterations. The control group received only home cleaning information. We measured children's total and allergen-specific serum immuno-globulin E, peripheral blood eosinophil counts, and urinary cotinine. Environmental dust samples were analyzed for dust mite, cockroach, rodent urinary protein, endotoxin, and fungi. The follow-up period was 1 year.

RESULTS

Children in both groups showed improvement in asthma symptomatic days during the preremediation portion of the study. The remediation group had a significant decrease in symptom days (p = 0.003, as randomized; p = 0.004, intent to treat) after remodeling, whereas these parameters in the control group did not significantly change. In the postremediation period, the remediation group had a lower rate of exacerbations compared with control asthmatics (as treated: 1 of 29 vs. 11 of 33, respectively, p = 0. 003; intent to treat: 28.1% and 10.0%, respectively, p = 0.11).

CONCLUSION

Construction remediation aimed at the root cause of moisture sources and combined with a medical/behavioral intervention significantly reduces symptom days and health care use for asthmatic children who live in homes with a documented mold problem.

Fungal speciation using quantitative polymerase chain reaction (QPCR) in patients with and without chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objectives of this study were to determine the mycology of the middle meatus using an endoscopically guided brush sampling technique and polymerase chain reaction laboratory processing of nasal mucous; to compare the mycology of the middle meatus in patients with sinus disease with subjects without sinus disease; to compare the responses on two standardized quality-of-life survey forms between patients with and without sinusitis; and to determine whether the presence of fungi in the middle meatus correlates with responses on these data sets.

STUDY DESIGN

The authors conducted a single-blind, prospective, cross-sectional study.

METHODS

Patients with sinus disease and a control group without sinus disease were enrolled in the study. A disease-specific, validated Sinonasal Outcomes Test survey (SNOT-20) was completed by the subjects and a generalized validated Medical Outcomes Short Form 36 Survey (SF-36) was also completed. An endoscopically guided brush sampling of nasal mucous was obtained from the middle meatus. Fungal specific quantitative polymerase chain reaction (QPCR) was performed on the obtained sample to identify one of 82 different species of fungus in the laboratory. Statistical analysis was used to categorize the recovered fungal DNA and to crossreference this information with the outcomes surveys.

RESULTS

The fungal recovery rate in the study was 45.9% in patients with sinus disease and 45.9% in control subjects. Patients with chronic rhinosinusitis had a mean SNOT-20 score of 1.80 versus the control group mean score of 0.77 (P < .0001). SF-36 data similarly showed a statistically significant difference between diseased and control populations with controls scoring a mean of 80.37 and patients with chronic rhinosinusitis scoring a mean of 69.35 for a P value of .02. However, no statistical significance could be ascribed to the presence or absence of fungi recovered, the type of fungi recovered, or the possible impact of fungi on the quality-of-life survey results.

CONCLUSION

The recovery rate of fungi from the middle meatus of patients with chronic rhinosinusitis and a control population without chronic rhinosinusitis is 45.9% using QPCR techniques. No direct causation with regard to fungal species or presence was proven; however, a species grouping for future studies is proposed based on trends in this data and other reports. Disease-specific outcomes surveys revealed a statistically significant difference between the two groups.

The development of species-specific immunodiagnostics for Stachybotrys chartarum: the role of cross-reactivity

Mold contamination and exposure to fungi in indoor environments has been associated with various adverse health effects but little is known about the significance of individual fungal species in the initiation or exacerbation of such effects. Using Stachybotrys chartarum as a model fungus we sought to demonstrate that monoclonal antibodies (mAbs) can provide species-specific diagnostic reagents and also be used to investigate immunological cross-reactivity patterns among fungi. Mice were immunized with S. chartarum spore walls and monoclonal antibodies were screened against 60 fungal species and 24 different isolates of S. chartarum using an indirect ELISA. One species-specific mAb (IgG(1)) reacted only with spore preparations but not mycelium of S. chartarum or propagules of any other fungus. Five cross-reactive mAbs (IgM) documented extensive cross-reactivity among nine related Stachybotrys species and several non-related genera including several species of Cladosporium, Memnoniella, Myrothecium and Trichoderma. We also found that the ELISA reactivity for cross-reactive antigens and different isolates of S. chartarum differed considerably for normalized total amounts of mycelial antigen. We demonstrate that mAbs and immunoassays have the potential to detect S. chartarum species-specifically. The observed reactivity patterns with cross-reactive mAbs suggest that several fungi may share common antigens and that the majority of antigens are expressed by spores and mycelia. The observed cross-reactivity patterns need to be considered for accurate interpretations of environmental and serological analyses.

A simple polymerase chain reaction/restriction fragment length polymorphism assay capable of identifying medically relevant filamentous fungi

Because of the accumulating evidence that suggests that numerous unhealthy conditions in the indoor environment are the result of abnormal growth of the filamentous fungi (mold) in and on building surfaces, it is necessary to accurately reflect the organisms responsible for these maladies and to identify them in precise and timely manner. To this end, we have developed a method that is cost effective, easy to perform, and accurate. We performed a simple polymerase chain reaction/restriction fragment length polymorphism (PCR/RFLP) analysis on multiple members of species known to negatively influence the indoor environment. The genera analyzed were Stachybotrys, Penicillium, Aspergillus, and Cladosporium. Each organism underwent PCR with universal primers that amplified ribosomal sequences generating products from 550 to 600 bp followed by enzymatic digestion with EcoRI, HaeIII, MspI, and HinfI. Our results show that using this combination of restriction enzymes enables the identification of these fungal organisms at the species level.

Comparison of populations of mould species in homes in the UK and USA using mould-specific quantitative PCR

AIMS

To compare the populations of 81 mould species in homes in the USA and UK using mould-specific quantitative polymerase chain reaction (MSQPCR) technology.

METHODS AND RESULTS

Dust samples were obtained from randomly selected homes in the UK (n=11). The mould populations in British homes were compared with those found in typical homes (no visible mould) in the USA (in the state of Ohio, n=45). Only 13 of 81 species screened showed significantly different concentrations in these two sets of home.

CONCLUSIONS

Although only a small survey, the results suggest that typical mould profiles in the USA (Ohio) and British homes are very similar. Analysis of 26 mould indicator species revealed that the British homes fell into two clusters, tentatively identified as 'atypical' and 'typical' mould conditions.

SIGNIFICANCE AND IMPACT OF THE STUDY

MSQPCR analysis of dust samples can provide an objective measure of indoor moulds which could lead to better management of their health effects.

Enumeration and detection of aerosolized Aspergillus fumigatus and Penicillium chrysogenum conidia and hyphae using a novel double immunostaining technique

The identification of collected airborne unicellular fungal conidia and hyphae using nonviable techniques is subjective and an imprecise process. Similarly, to determine whether an individual is allergic to a particular genus requires a separate immunodiagnostic analysis. This study demonstrates the development of a novel double immunostaining halogen assay, which enables (1) the simultaneous identification of collected airborne fungal conidia and hyphae of Aspergillus fumigatus and Penicillium chrysogenum using monoclonal antibodies and (2) the demonstration of patient-specific allergy to the same particles using human serum IgE. The results demonstrate that when conidia were ungerminated the binding of antibodies was homogeneous and localized in close proximity around the entire conidia for both species. However, when conidia were germinated, the proportion expressing antigen increased (P < 0.0001) for both species and the sites of binding of the two antibodies changed with double immunostaining restricted to the hyphal tips for A. fumigatus, in addition to the sites of germination for P. chrysogenum. The described immunoassay has the potential to identify fungal particles in personal environmental air samples, provided species-specific monoclonal antibodies are available, while simultaneously demonstrating allergic sensitization to the same particles by co-staining the samples with the patient's own serum. Such an immunoassay can use those fungi that the patient is actually exposed to and potentially avoids many problems associated with extract variability based on the performance of current diagnostic techniques for fungal allergy.

A simple multiplex polymerase chain reaction assay for the identification of four environmentally relevant fungal contaminants

Historically, identification of filamentous fungal (mold) species has been based on morphological characteristics, both macroscopic and microscopic. These methods may often be time-consuming and inaccurate, necessitating the development of identification protocols that are rapid, sensitive, and precise. The polymerase chain reaction (PCR) has shown great promise in its ability to identify and quantify individual organisms from a mixed culture environment; however, the cost effectiveness of single organism PCR reactions is quickly becoming an issue. Our laboratory has developed a simple method to identify multiple fungal species, Stachybotrys chartarum, Aspergillus versicolor, Penicillium purpurogenum, and Cladosporium spp. by performing multiplex PCR and distinguishing the different reaction products by their mobility during agarose gel electrophoresis. The amplified genes include the beta-Tubulin gene from A. versicolor, the Tri5 gene from S. chartarum, and ribosomal sequences from both P. purpurogenum and Cladosporium spp. This method was found to be both rapid and easy to perform, while maintaining high sensitivity and specificity for characterizing isolates, even from a mixed culture.