Patient Presentation
An 8-year-old male came to clinic with his parents because of uncontrolled asthma symptoms. They had moved into a rented home that was about 50 years old in August, when they moved to the area from another country. Since that time he had increased runny nose and coughing and used his albuterol only intermittently. He was coughing several times per day and his parents said he “coughed all night” but it didn’t wake up the patient. They denied that he was excessively sleepy, had problems with activity or keeping up with other children. The family had noticed some mold growing in the bathroom and had talked with the landlord. The landlord had changed out the bathroom ventilation filter and replaced the caulking. He had professionally cleaned the carpets in the unit before they had moved in. The parents said that the boy still was not getting better and they felt it was due to mold in the house and wanted the pediatrician to write a letter to the City to have the landlord take additional mitigation changes.
The past medical history showed that he had atopic dermatitis as an infant and was diagnosed with asthma at 2 years of age.
He used albuterol intermittently and used steroids for exacerbations about 2 times per year. The family denied any seasonal variation to his symptoms and had never used a steroid inhaler. He had not been hospitalized but had been in the emergency room for a couple of exacerbations within his lifetime but none recently. The family history was positive for several others who had asthma and allergies. No others had any increase in symptoms with moving into the new home.
The pertinent physical exam showed a patient with normal vital signs and growth parameters in the 90%. He had allergic shiners and boggy nasal mucosa with some clear rhinorrhea. His lungs were clear but had a slightly prolonged expiratory phase. His skin had general xerosis with patchy areas on extensor surfaces with some lichenification.
The diagnosis of atopy and asthma that was not controlled was made. The pediatrician recommended that they start using some long-acting antihistamine and nasal steroid daily to help with his rhinitis. He also recommended that they use his albuterol on a more regular basis for coughing and increased work of breathing, along with keeping a symptoms diary of how often they were using it. “He may also need to start a daily steroid medicine too, but I would like to see how he does with these medicines before starting that one,” he recommended. “I’m also going to go over some things you can do at home to help such as vacuuming his room and cleaning the bath more regularly and I think that should help as well.” The family was quite insistent upon having a letter that said that the boy’s symptoms were due to the mold they had found, and that the landlord was not responsive. “I don’t think I can write that letter now, but what I will do is have our social worker talk with you and give you some resources. I do want to see you back in about 2-3 weeks to see how he is doing though,” the pediatrician counseled. The social worker provided phone numbers to the local housing commission, and local contractors who could do evaluation and mitigation services. She also explained how the housing commission and landlord dispute system worked in the local area. The family asked for a list of lawyers they could contact if they continued to be not satisfied with their housing problem. At followup, the boy’s symptoms had improved but an inhaled steroid was prescribed. The family had contacted the local housing commission but had not heard back from them at that time.
Discussion
Fungi are ubiquitous and adaptive to all environments including buildings. They can be viewed as potential contaminants but mainly as environmental companions. Fungi are important for biodegrating and nutrient cycles and are commensal with other organisms such as bacteria and viruses. We use fungi to make food (e.g. beer, wine, bread) and assist with decomposition making compost. When there is a balance between the fungi and other systems, then there generally are not problems. It is when there is too much fungi for a particular time frame or location that fungi cause problems.
Fungi can also cause or exacerbate other problems such as increased respiratory problems, allergies or asthma. Examples of allergenic fungi include …Alternaria alternata, Aspergillus fumigatus and Clasosporium herbarum.” There is evidence to support health risks from fungi, but the exact mechanisms are not well understood.
“The endemic mycoses are a group of infections caused by fungi with distinct geographic distribution, determined by environment niche in which the causative pathogen can persist and sporulate.” These are divided into two groups. Those that are systemic and caused by inhalation or cutaneous caused by inoculation of the skin. Contaminated soil or vegetation are the most common reservoirs for these mycoses. For immunocompetent patients, many of the systemic mycoses produce asymptomatic infections or have relatively common self-limited symptoms such as cough, lethargy, fever, chest pain and mild acute weight loss. Therefore if patients have insidious, persistent or unexplained illness patterns, then systemic mycoses certainly should be considered. Cutaneous infections often will cause rashes and/or lymphadenopathy. The evaluation depends on the suspected fungal infection with culturing of body fluids, tissue or skin being common with treatment usually being systemic anti-fungal medications for prolonged periods of time.
Learning Point
Indoors, the most common source of fungi are airborne outdoor fungi. Thus the content of indoor fungi varies based on location and seasonality. Farming areas have a large number of species and counts overall, but interestingly have fewer allergies and asthma problems. Other sources of indoor fungi are handling of biological materials (e.g. fruits, root vegetables, blue cheese) including spoiled material (e.g. moldy vegetables or bread), houseplants and potting soil, and firewood. Clothing and shoes brought inside are also sources. Humans can also bring it into the home though contamination of skin, hair and nails, and similarly animals can bring it in on their fur and nails.
Flooring is an important source of fungi location. Fungal levels are driven by house dust levels. Smooth flooring has less dust, yet can more easily have this dust and fungi re-aerosolized. Carpeting acts more like a filter in that house dust and fungi can be trapped in it. However there is more of it within the carpet and significant build up of the house dust and fungi can then cause re-aerosolization of the dust and fungi as well.
Dampness and moisture are wonderful environments for fungi to grow and therefore can cause enough mold to form that is visible to the naked eye. This occurs often in humid environments such as bathrooms, kitchens and laundry. It can occur in other areas as well such as when condensation forms on cold machinery in a humid environment or systems that are designed for it such as drip pans. Mold growth is not considered a normal source indoors and can be more of ahealth issue.
How to help mitigate over accumulation of fungi is always a question. Any of these methods may increase exposure and therefore individuals who are more affected should be out of the immediate environment if possible, or if doing the cleaning themselves should wear protective equipment to help reduce exposure.
Ventilation helps. Although ventilation can bring in outdoor air, it also serves to remove contaminants (including particles and gaseous chemicals) and moisture. It also can speed up the drying of areas that are intermittently moist. Ventilation systems filters can help to trap indoor air contaminants but need to be cleaned often. Air ducting requires deep cleaning and is often not cleaned regularly. These ducts can accumulate years of dust and debris. If moisture is added into this environment it is a wonderful medium for growing organisms including fungi. Similarly any air filters for ventilation systems, or even the vents themselves should be cleaned frequently. Frequent vacuuming of surfaces can stir up the dust, but eliminates the dust and decreases fungal counts.
For mold, increasing ventilation, and eliminating infected items that can be changed (e.g. kitchen sponges, shower curtains, bathroom filters) regularly can help prevent problems. Regular wet cleaning with household bleach of bathroom tile and similar surfaces usually can help mitigate the problem.
Extensive damp and wetness problems within the building structure due to ongoing moisture issues needs to be mitigated professionally. Cleanup from weather related events such as severe storms, tornados, hurricanes or flooding require more extensive mitigation but the principles are similar in eliminating infected materials, cleaning remaining materials and increasing ventilation.
Questions for Further Discussion
1. What do you recommend for environmental changes for asthma?
2. What systemic and cutaneous mycoses are endemic to your area?
3. What community resource assistance do you have in your local area for housing and legal resources?
4. What causes indoor air pollution?
Related Cases
- Disease: Asthma | Molds | Fungal Infections
- Specialty: Allergy / Pulmonary Diseases | Preventive Medicine and Health Maintenance | Social Services
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Molds, Indoor Air Pollution, and Fungal Infections.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Nevalainen A, Taubel M, Hyvarinen A. Indoor fungi: companions and contaminants. Indoor Air. 2015;25(2):125-156. doi:10.1111/ina.12182
Adams RI, Lymperopoulou DS, Misztal PK, et al. Microbes and associated soluble and volatile chemicals on periodically wet household surfaces. Microbiome. 2017;5(1):128. doi:10.1186/s40168-017-0347-6
Yeah DK, Butters C, Curtis N. Endemic Mycoses in Children. Ped Inf Dis J. 2019:38(6S); S52-59.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa