Indian Pediatrics 2001; 38: 949-951  

Environment and Child Health: What is Stachybotrys?

It finally hit me the fourth time the infant presented to the busy inner-city emergency department with hemoptysis. Although not yet 6 months old, the baby had already been admitted to the Pediatric Intensive Care Unit three times in respiratory failure with previous pulmonary bleeds. Each time, after a couple of days of ventilatory support, the infant had recovered rapidly and was discharged from the hospital in good condition. Each time he developed recurrent hemoptysis after discharge from the hospital (once within just 12 hours of returning home). Was it possible that there was a link between the infant’s acute pulmonary bleeds and exposure to some toxin in the home? Ultimately, the Centers for Disease Control and Prevention (CDC) initiated a study and found that infants with acute pulmonary bleeding were more likely than a group of comparison infants to live in homes with Stachybotrys and other molds (1). When removed from the moldy home environment, the recurrent pulmonary bleeding ceased.

Stachybotrys atra (also known as Stachybotrys chartarum) is a toxigenic mold. Toxigenic molds produce potent toxins called mycotoxins. These molds grow on any cellulose product, such as wood and paper, but usually only in chronically water-damaged environments.

In 1998 the American Academy of Pediatrics (AAP) released a statement "Toxic Effects of Indoor Molds" to inform pediatricians of the newly-discovered association between 

acute pulmonary hemorrhage among infants and exposure to toxigenic molds in the home (2). One current hypothesis is that pulmonary hemorrhage occurs when Stachybotrys fungal spores or other spore fragments reach the infant’s breathing zones and are inhaled. The surface of these spores contains trichothecene mycotoxins, lipid-soluble toxins readily absorbed by the airways. In horses and cows, oral exposure to trichothecene mycotoxins in moldy grain has been associated with gastro-intestinal hemorrhage and death.

Stachybotrys atra has subsequently been associated with acute pulmonary hemorrhage in an infant in Kansas City, Missouri (3) and with pulmonary hemosiderosis in a 7-year old child in Houston,Texas (4). Additional research is needed to determine whether exposure to toxigenic S. atra is a risk factor for acute pulmonary hemorrhage and hemo-siderosis in other areas of the world.

The American Academy of Pediatrics recommends that pediatricians ask about mold and water damage in the home when they treat infants with idiopathic pulmonary hemorrhage. If mold is in the home, pediatricians should encourage parents to try to find and eliminate sources of moisture. It appears to be important to clean up moldy conditions before the infant is discharged from the hospital to prevent recurrent pulmonary hemorrhage. Infants who die suddenly without known cause should have an autopsy done including a Prussian blue stain of lung tissue to look for the presence of hemosiderin.

Molds are among the newly-emerging enviromental health concerns that fall into the burgeoning specialty of pediatric environmental health. This specialty has been established because a tremendous amount has been learned in the past twenty years about the effects of the environment on child health. We now have a far better understanding that exposures once thought to be innocuous, such as to air pollution, ionizing radiation, lead, mercury, and molds, may actually pose threats to children’s health. But we have a long way to go towards integrating this knowledge into clinical practice. One major reason that we have not managed to integrate environmental health into practice is that we know very little about the specific environments our patients call home.

Before World War II more than half of patients who saw a doctor in the United States saw him in their home. House calls provided an opportunity to observe the conditions in which the patient and family lived. This allowed the physician to identify possible environmental risks and to provide appropriate advice to the patient about preventing disease. The drive to the patient’s home offered the opportunity to note whether the neighborhood was rural, urban, or suburban. Noting this enabled the physician to provide the most relevant anticipatory guidance to the family and patient. For example, in rural areas, where well water may have high nitrate levels, families would be instructed to have the water tested and to stop using it for infants if the concentration was above 10 ppm in order to prevent methemoglobinemia. When the physician entered the patient’s home, he would note the condition of the interior. Characteristics such as the presence of peeling paint on window sills, the growth of mold on ceilings and walls, and the presence of insects and rodents were easily discernible. If the physician’s nose detected tobacco’s familiar odor, he would counsel the family about the importance of quitting.

The practice of medicine has undergone significant change since the days when house calls were commonplace. Because we do not visit the patient’s home, we usually have little understanding of the environment in which the family lives, and this makes it less likely that we have the information needed to offer appropriate anticipatory guidance to the family about environmental hazards. There is a sort of paradox here: we now know far more about the effects of environmental factors on human health, but we know far less about the specific environments in which our patients live. One time-saving way to integrate environmental health into practice is to provide families with a short "home inventory" checklist to complete at the first office visit. Although not a perfect substitute for the house call, the home inventory includes questions about the home 

environment, such as the presence of peeling lead paint, smoking, household water sources, and molds. The home inventory can help the clinician to identify areas for anticipatory guidance. The Handbook of Pediatric Environmental Health from the American Academy of Pediatrics describes the home inventory and other ways that clinicians can begin making environmental health an integral part of good pediatric practice (5). Interested pediatricians may order a copy of the Handbook of Pediatric Environmental Health from the American Academy of Pediatrics at http://www.aap.org

Funding: None.
Competing interests: None stated.

Ruth A. Etzel,
Professor,
The George Washington University
School of Public Health and
Health Sciences,
Washington, D.C.,
USA.

1. Etzel RA, Montana E, Sorenson WG, Kullman GJ, Allan TM, Dearborn DG. Acute pulmonary hemorrhage in infants associated with exposure to Stachybotrys atra and other fungi. Arch Pediatric Adolescent Medicine 1998,152:757-762.

2. American Academy of Pediatrics. Toxic Effects of Indoor Molds. Pediatrics 1998;101:712-724.

3. Flappan SM, Portnoy J, Jones P, Barnes C. Infant pulmonary hemorrhage in a suburban home with water damage and mold (Stachybotrys atra). Environ Health Perspect 1999;107:927-930

4. Elidemir O, Colasurdo GN, Rossmann SN, Fan LL. Isolation of Stachybotrys from the lung of a child with pulmonary hemosiderosis. Pediatrics 1999;104:964-966.

5. American Academy of Pediatrics Committee on Environmental Health. Handbook of Pediatric Environmental Health. American Academy of Pediatrics: Elk Grove Village, 1999.