THE PATH AHEAD
Is Mold Toxicity Really a Problem for Our
Patients? Part I—Respiratory Conditions
Joseph Pizzorno, ND, Editor in Chief
Abstract
The concept of mold toxicity being an unrecognized
cause of chronic disease has been around the integrative
medicine (IM) community for quite some time. Clearly
there is considerable interest in the public with a Google
search revealing more than half a million hits. In the first
part of this editorial, I address the research evaluating this
concept for respiratory conditions, the incidence in the
M
olds are fungi that grow best in warm, damp,
and humid conditions. There are tens of
thousands of species that spread and
reproduce by making spores that can survive harsh
environmental conditions. According to the Centers for
Disease Control (CDC), the most common indoor
molds are of the Cladosporium, Penicillium, Alternaria,
and Aspergillus genera.1 In general, any area with a
relative humidity of greater than 80% in the presence of
metabolizable organic materials supports their growth.
A relative humidity more than 90% is ideal for
proliferation. (Note, I am not considering in these 2
editorials the clinical significance of food-born
mycotoxins. This came up a quite a bit in my research
searches and looks like a good topic for a future
editorial.)
Many terms have been used to describe this
phenomenon, such as sick building syndrome (SBS). In
2009, the World Health Organization (WHO) published
a comprehensive guideline, “Indoor Air Quality:
Dampness and Mould.”2 In this 248-page report, the
WHO estimated that 10% to 50% of indoor environments
in Europe, North America, Australia, India, and Japan
have clinically significant mold problems. The percentage
is higher in river valleys and coastal areas. Table 1 lists
the WHO primary indicators of dampness and microbial
growth.
6 Integrative Medicine • Vol. 15, No. 2 • April 2016
population, diagnosis, and intervention. In the second
part of my editorial, I will address the far more complicated
and controversial nonrespiratory mold-related conditions
(tentatively next issue, as I will be attending the SpiritMed
Environmental Medicine conference, which is providing
a full day on this issue). As usual, I am taking my own
fresh look at the concepts and research.
Table 1. The Primary Indicators of Dampness and
Microbial Growth
• Condensation on surfaces or in structures such
as windows
• Visible mold, especially black mold
• Perceived moldy odor
• Poorly maintained air conditioning systems
• A history of water damage (exterior leaks, wet
basement, leaking plumbing)
The primary clinical indications in the WHO and
CDC (discussed later) reports are listed in Table 2 and
have been shown to improve with remediation of dampness
and eradication of microbial overgrowth in building.
Note that the WHO does not provide any support for
the nonrespiratory conditions considered important
indicators of mold problems in the integrative medicine
(IM) community. Finally, a quote from this report:
Microbial growth may result in greater numbers of spores,
cell fragments, allergens, mycotoxins, endotoxins, β-glucans
and volatile organic compounds in indoor air. The causative
agents of adverse health effects have not been identified
conclusively, but an excess level of any of these agents in the
indoor environment is a potential health hazard.
Pizzorno—The Path Ahead
 Table 2. Clinical Conditions Indicative of Dampness
and Mold
• Common conditions
• Allergic rhinitis
• Exacerbation of asthma
• Respiratory infections
• Common symptoms
• Cough
• Upper respiratory tract (nasal and throat)
symptoms
• Wheeze
• Rare conditions
• Allergic alveolitis
• Allergic fungal sinusitis
• Chronic rhinosinusitis
• Hypersensitivity pneumonitis
I have italicized the key phrase that highlights why
this has been such a challenging issue to address
quantitatively as the causative agents can be so diverse and
clinical effects appear to be highly dependent on individual
susceptibility and sensitivity.
How Dampness Causes Problems
Indoor environments contain a complex mixture of
live and dead microorganisms, fragments of dead
organisms, toxins, allergens, volatile microbial organic
compounds, and other chemicals. Table 3 lists some of the
many ways damp building materials can cause the
production of toxins. Table 4 lists the kinds of biological
and chemical toxins that have been found. This is by no
means complete; rather, those included are worst or most
prevalent. Finally, Table 5 lists the scientifically accepted
physiological effects. It’s strange that only the respiratory
effects are considered clinically important.
Table 3. Damp Building Materials Can Cause the
Production of Undesirable Organisms and Toxins
• Growth of molds that release biological agents,
toxic chemicals, and spores
• Growth of bacteria that release biological agents,
toxic chemicals, and spores
• Protozoal growth
• Virus survival
• Dust mites (arachnids of many different species)
proliferation
• Proliferation of rodents and cockroaches that
can carry infectious organisms
• Release of chemicals and particles from building
materials
Pizzorno—The Path Ahead
Table 4. Partial List the Toxic Agents Found in Dust
and Air of Damp Buildings
• Allergens
• Dust mite allergens. Dust mites produce the
predominant inhalation allergens in most of
the world. Most common are proteases from
Dermatophagoides pteronyssinus and
Dermatophagoides farinae.
• Fungal allergens. Typically glycopeptides with
enzymatic properties and are typically found
in spores, hyphae and fungal fragments. Have
the strongest correlation with asthma.
• Biologicals
• β-glucans. These are proinflammatory,
nonallergenic, water-insoluble, structural
cell-wall components found in most fungi,
some bacteria, most higher plants, and many
lower plants.
• Multiple organic molecules. Examples include
endotoxins and ergosterol (yes, vitamin D2)
and penicillin G (which would seem likely a
problem for patients allergic this class of
antibiotics).
• Mycotoxins. These are metabolites produced
by fungi, which can cause a toxic response
in animals and human beings, often at very
low concentrations. See below for a more
complete discussion.
• MVOC (methane VOC). Several fungi
produce volatile metabolites depending on
species and substrate.
• Toxic chemicals
• Phthalates
• Formaldehyde
• VOC such as alcohols, aldehydes, ketones,
terpenes, esters, aromatic compounds,
amines, and sulfur-containing compounds.
Abbreviation: VOC, volatile organic compounds.
Table 5. Primary Mechanisms for Damp Building
Toxicity
• Immunology
• Stimulation
• Suppression
• Autoimmunity
• Toxicity
• Neurotoxicity
• Genotoxicity
• Reproductive damage
• Inflammation
Integrative Medicine • Vol. 15, No. 2 • April 2016 7
 Health Effects
Since approximately 2005, a broad international
consensus has been reached that mold and dampness in
buildings significantly increases disease risk and is a public
health hazard. However, the various governmental agencies,
such as the Institute of Medicine report commissioned by the
CDC and released in 2004, concluded that only conditions
considered to have sufficient evidence of causation by mold
or damp buildings are respiratory.3 The vast majority of the
peer-reviewed published research is on respiratory conditions.
The increased risk has been found throughout the population
and not limited to those with atopy as was originally thought.
Interestingly, the research is supporting that exposure to
mold and dampness increases the risk of allergy to other
allergens such as house dust mites and pollen, not only fungi,
and causes epigenetic modulation that upregulates many
inflammatory genes.4 This may help explain the nonrespiratory
conditions considered mold-related by the IM community,
which will be discussed in my next editorial.
Asthma, Asthma-related and Respiratory Conditions
The research is clear that mold and damp building
exposure is a major factor in the asthma epidemic. One
study estimated that dampness or mold in houses causes
21% of asthma in the United States, whereas a meta-analysis
found a 30% to 50% increase in asthma and asthma-related
health problems.5,6 However, the incidence may be much
higher. One study of 1300 office workers found that a
remarkable 67% of adult-onset asthma started after working
in a water-damaged office building.7 The rare condition
allergic alveolitis, also known as extrinsic allergic alveolitis
and hypersensitivity pneumonitis, is likely primarily due to
mold reactivity and has a strong correlation with the use of
contaminated air humidifiers. Inhalation fever, also known
as toxic pneumonitis, humidifier fever, and organic dust
toxic syndrome, also occurs with contaminated humidifiers.
Looking at quite a number of studies, the research is clear:
Every patient suffering any kind of chronic respiratory
condition—especially those of adult onset—must be fully
evaluated for mold/damp building exposure. Included in this
list should be also be symptoms such as dyspnea, wheeze,
cough, respiratory infections, bronchitis, allergic rhinitis,
eczema, vocal cord dysfunction, and upper respiratory tract
symptoms. Once a person has become sensitized, they become
much more reactive to even low to modest exposure. The
symptom and disease associations are far stronger when dust
levels rather than air levels of mold products are measured.
This seems logical as air levels are much more likely to vary
dramatically while dust averages exposure over time.
Diagnosis/Assessment
Basically, the clinician needs to determine if the
patient has a high likelihood of a condition caused by
building dampness, they spend time in a home or office
building with dampness problems, or if mold is obviously
present in their environment according to visuals or odor.
8 Integrative Medicine • Vol. 15, No. 2 • April 2016
The level of humidity in the various parts of the
building can be easily measured by a variety of readily
available and inexpensive monitors. I have measured
various areas in my own home and can affirm that on
rainy days in Seattle, even my modern well-kept house has
many areas conducive to mold growth. I found one area of
my home with 88% humidity, which had black mold that
we had to remove. In fact, to fix the problem we had to
reroute the plumbing and totally replace all the plaster
board in the area.
A more sophisticated and clinically validated method is
to directly measure the contaminants in the air, on surfaces,
or in dust. There are basically 4 methods: culture, nonculture,
chemical assays for key toxic molecules, and immunoassays.
The obvious advantage of culturing is being able to
definitively determine the organisms involved. The
disadvantages are delay and cost, but probably most
problematic is that many are difficult to culture and there is
poor reproducibility between the several different collection
and culturing protocols. The nonculture protocols basically
count the number of particles, organisms, and others caught
by the collection tools, such as air filtration or liquid
capturing. Their big advantage is quantification but suffer
from poor differentiation. The latter can be helped with
various staining methods. A typical stain is lactophenol blue
for fungal spores. The chemical assay depends on the toxins
chosen to evaluate. Typical assessment methodologies
include polymerase chain reaction (PCR), immunoassays,
gas chromatography, high-pressure liquid chromatography,
and mass spectrometry. In general, immunoassays are used
to determine allergen types. Regardless of the methodology
used, in general dust samples are more sensitive and
accurate measures than air samples with better clinical
correlation.
According to a local mold testing service, an onsite
inspection typically costs $289. They visually check typical
locations for water damage, mold growth, and others, and
they take samples as appropriate. Nonculture, microscopic
evaluation mold analysis costs $100 per sample and
evaluations of biologicals (pollens, insect fragments, etc)
adds another $175. Obviously, it’s not inexpensive, but if the
core cause of an unresolved clinical problem can be
identified and treated, it’s well worth the investment.
Table 6 shows the several national associations that
credential individuals and companies and the certifications.
Table 6. Certifications and Certification Organizations
• ACAC – American Council of Accredited
Certifications
• AIHA – American Industrial Hygiene Association
• CMC – certified mold consultant
• CIEC – certified indoor environmental consultant
• CIH – certified industrial hygienist w/mold
experience
Pizzorno—The Path Ahead
 Table 7. Diseases and Symptoms Caused or Aggravated by Mold/Damp Buildings
Diseases
Allergic rhinitis
Allergic alveolitis (hypersensitivity pneumonitis)
Asthma
Chronic respiratory infections
Eczema
Inhalation fever (toxic pneumonitis, humidifier fever
and organic dust toxic syndrome)
Clinical Evaluation
Table 7 lists alphabetically the conditions and
symptoms that should alert a clinician of a mold/damp
building problem. I think these can be simply summed up
as any chronic, unexplained respiratory tract problem.
A number of laboratories run a wide range of tests
that can help with diagnosis. For example, LabCore
responds with 58 tests for the search term mold. These
include mold identification through DNA and culturing,
antibodies to specific molds, various inflammatory
markers, and others.
Intervention
Decrease Exposure
Of course, we have to start by dealing with the causes,
which starts with decreasing exposure. There is no substitute
for fixing with the foundational causes: typically excessive
building humidity from poor design or water damage,
inadequate ventilation, and contaminated air conditioning
vents. Addressing these is obviously beyond the scope of
this journal and will require professional assistance.
Nonetheless, there is not much point in trying to only treat
the patient when the problem is almost entirely due to the
environment. In many ways, this is a problem of civilization.
Several studies in both children and adults have
objectively assessed the clinical effects of addressing
building moisture. An excellent review paper evaluated
8 studies (6538 participants); 2 randomized controlled
trials (RCTs) (294 participants), 1 cluster randomized
controlled trial (cRCT) (4407 participants), and
5 controlled before-after (CBA) studies (1837 participants)
for the effects of building remediation. They found
moderate-quality evidence in adults that repairing houses
decreased asthma-related symptoms (odds ratio [OR],
0.64) and respiratory infections (OR, 0.57). For children,
they reported moderate-quality evidence for reduction of
the number of acute care visits (mean difference, -0.45).8
Obviously, complete care is more than building
remediation, but it needs to start there. I believe reasonable
to expect that dealing with building moisture will facilitate
the efficacy of our normal dietary, allergen control,
nutritional, and herbal medicine treatments for asthma
and other chronic respiratory conditions.
Pizzorno—The Path Ahead
Symptoms
Bronchitis
Cough
Dyspnea
Hoarseness
Vocal cord dysfunction
Wheeze
Conclusion
Considering the remarkable diversity of allergenic,
biological, and organic and inorganic molecules released
into the air and concentrated in the dust of damp buildings
and that as many as 50% of buildings have moisture
problems, harmful physiological effects are certain. What is
uncertain is which patients are susceptible, which conditions
are most predictive, and the optimal interventions.
Without doubt, every patient with any kind of chronic
respiratory condition, especially asthma, must be evaluated
for damp building exposure. Frankly, this is a much bigger
clinical problem than I had realized before looking at the
voluminous research in this area.
In This Issue
There is simply no better clinical care than treating
the whole person, not only their biochemistry. This is well
illustrated by the original research of Hannah Chatwin,
MClinPsych; Peta Stapleton, PhD; Brett Porter, EFT; Sharon
Devine, MClinPsych; and Terri Sheldon, BA(Hons). They show
in this pilot study that cognitive behavioral therapy and
emotional freedom techniques are effective in reducing
depression and anxiety without drugs—no matter how
natural. Also, as editor in chief, I must admit to being
delighted by the growing interest in IMCJ by the
international research community.
The need to address the whole person is well
demonstrated by the remarkable work of my friend James
Gordon, MD. As documented in the interview by managing
editor, Craig Gustafson, he has worked tirelessly worldwide
to address the health effects of serous stress. His work has
shown in groups and individuals that addressing the
emotional side of posttraumatic stress disorder (PTSD) is
critical for health and recovery. His work and training
programs are quite remarkable.
I suspect few readers realize that taking care of
patients with neurodegenerative disease now costs more
than patients with cancer or heart disease. Associate
editor, Jeffrey Bland, PhD, provides us a fascinating article
on dietary and environmental causes. These range from
nutrient deficiencies, to environmental toxins to genetic
polymorphisms affecting susceptibility. The neuro-
degenerative disease epidemic is quite worrisome.
Integrative Medicine • Vol. 15, No. 2 • April 2016 9
 Addressing MTHFT polymorphisms in our patients
is turning out to be much more complicated than expected.
The interesting case report by Shanna Anderson, BA; Jacob
Panka, BA; Robin Rakobitsch, BA; Kaitlin Tyre, BS; and
Kerry Pulliam, MD, illustrates this quite effectively. To their
discussion, I suggest considering the impact of catechol-
O-methyltransferase (COMT) polymorphisms. I suspect
this may explain the substantial benefit they found with
S-adenosyl methionine (SAMe) supplementation.
I am so happy that John Weeks has returned to Seattle
as I sorely missed our provocative and wide-ranging
quarterly breakfast conversations. I very much appreciate
his documentation of the disproportionate impact of the
very small profession of naturopathic medicine in the
advancement of this medicine. His documentation of the
growing acceptance of how IM (by all its name) is
changing health care is very important.
I love when I crack up before the end of the first
paragraph of Bill Benda, MD’s BackTalk. Seems such a
great way to balance out the seriousness of our typical
articles on suffering and disease. Bill, someday I hope you
compile your BackTalks into a book about life.
Joseph Pizzorno, ND, Editor in Chief
drpizzorno@innovisionhm.com
http://twitter.com/drpizzorno
10 Integrative Medicine • Vol. 15, No. 2 • April 2016
References
1. Centers for Disease Control. Mold. http://www.cdc.gov/mold/faqs.htm.
Updated May 22, 2014. Accessed February 1, 2016.
2. World Health Organization. WHO guidelines for indoor air quality: dampness
and mould. http://www.who.int/indoorair/publications/7989289041683/en/.
Published 2009. Accessed March 25, 2016.
3. The National Academies of Sciences, Engineering, Mathematics. Damp
indoor spaces and health. https://iom.nationalacademies.org/Reports/2004/
Damp-Indoor-Spaces-and-Health.aspx. Published May 25, 2004. Accessed
February 5, 2016.
4. Miller JD, McMullin DR. Fungal secondary metabolites as harmful indoor air
contaminants: 10 years on. Appl Microbiol Biotechnol. 2014;98(24):9953-9966.
5. Mudarri D, Fisk WJ. Public health and economic impact of dampness and
mold. Indoor Air. 2007;17(3):226-235.
6. Fisk WJ, Lei-Gomez Q, Mendell MJ. Meta-analyses of the associations of
respiratory health effects with dampness and mold in homes. Indoor
Air. 2007;17(4):284-296.
7. Cox-Ganser JM, White SK, Jones R, et al. Respiratory morbidity in office workers
in a water-damaged building. Environ Health Perspect. 2005;113:485–490.
8. Sauni R, Uitti J, Jauhiainen M, et al. Remediating buildings damaged by
dampness and mould for preventing or reducing respiratory tract symptoms,
infections and asthma (Review). Evid Based Child Health. 2013;8(3):944-1000.
Pizzorno—The Path Ahead
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