March 1997
---
Toxins from Stachybotrys atra have already been linked
to gastrointestinal bleeding in animals.
CLEVELAND — Three children have died here, and many more were sickened, possibly from inhaling spores containing toxins produced by a black fungus growing in their basements, according to the Centers for Disease Control and Prevention (CDC).
Toxins from the black, slimy fungus known as Stachybotrys atra apparently killed the infants and sickened the others by causing pulmonary hemorrhage. The fungus has been associated with gastrointestinal bleeding in animals that ate moldy grain, but this is the first link to bleeding in U. S. infants, according to Terry Allan, investigator in the United States with the Cuyahoga County Board of Health (CCBOH). There have been reports of cases in Greece. These occurred in rural areas, where children slept near grain storage areas. The grain was contaminated by S. atra.
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Stachybotrys requires water-soaked cellulose to grow and is most often found outdoors on rotten leaves. In very wet conditions, it can grow inside on rotting drywall, ceiling tiles, etc.
Health authorities first became familiar with this type of mold after a cluster of 10 cases of pulmonary hemorrhage/hemosiderosis occurred between January 1993 and December 1994 among infants in one particular area of the city. Hemorrhaging recurred in five infants after returning home from the hospital; one infant died.
Surveillance by Rainbow Babies and Children's Hospital here identified 11 additional cases of acute pulmonary hemorrhage/hemosiderosis among infants in Cleveland between December 1994 and December 1996 in which two infants died. The demographic characteristics and clinical presentation of these 11 cases were consistent with the initial cluster of cases, according to the CDC.
After realizing this illness could easily be misdiagnosed, the Cuyahoga County coroner re-examined all infant deaths in Cuyahoga County between January 1993 and December 1995. Postmortem examinations were reviewed for all 172 infants who died in the county during that period, including 117 deaths attributed to sudden infant death syndrome (SIDS). This investigation revealed six additional cases of lung bleeding.
This pulmonary hemosiderosis disorder linked to S. atra has so far been limited to infants. Of the original 10 cases studied, the mean age of the infants was 10.2 weeks. Those primarily affected were black boys; 90% were boys and 100% were black. The reason is yet to be determined.
Case infants were also eight times more likely than control infants to have been exposed to environmental tobacco smoke, but authorities do not know the significance, if any, of these findings.
Many of the infants lived in old, rundown homes with water damage from flooding, roof leaks or plumbing that occurred within six months prior to the illness. The fungus had a black, slimy appearance when wet and looked like "chimney soot" when dry, according to Ruth Etzel, MD, PhD, chief of air pollution and respiratory health, CDC.
The fungus apparently will not grow under dry conditions.
This illness may begin with subtle initial symptoms and doesn't always develop into frank hemorrhage, according to Dorr Dearborn, MD, PhD, who helped with the investigation.
"One-tenth of the patients don't have noticeable symptoms and pulmonary hemosiderosis can occur without overt clinical bleeding," he said.
Agricultural problems with this fungus have mainly been concentrated in eastern Europe where horses, sheep and cattle have been affected by fatal hemorrhages upon acute exposure. Occupational human exposures to contaminated straw or hay result in numerous symptoms which include nasal and tracheal bleeding, skin irritation and alterations in white blood cell counts.
The study was conducted by the Rainbow Babies and Children's Hospital, Cuyahoga County Board of Health, the Cleveland Department of Public Health and the CDC.
The results of the investigation underscores the need for further research into these relationships, according to the board of health and the CDC. There is concern that more infants could contract this life-threatening disease. "We don't want to alarm anyone, just alert them," Etzel said.
An informal national survey conducted last year of pediatric pulmonary centers identified more than 30 similar cases of pulmonary hemorrhage in infants across the country. The challenge, Etzel said, is reaching pediatricians to make them aware of this illness.
"We think it may have been occurring, but doctors may never have thought about notifying the CDC about individual cases," Etzel said. "This association is completely new."
Numerous sporadic cases have occurred throughout the United States including cases in Chicago, Detroit and Ann Arbor, Mich.
As for more formal studies across the United States, there is ongoing surveillance for infants with these symptoms.
"We recommend coroners do iron staining on all infants diagnosed with SIDS," Dearborn said, which can reveal previous pulmonary hemorrhaging.
The 30% mortality rate and the concern regarding undetected cases has led the CDC to urge the Cleveland area health and housing authorities to institute public health measures focused on the home environment of newborn infants in the geographic cluster area.
For more information:
- CDC. Update: Pulmonary hemorrhage/hemosiderosis among infants — Cleveland, Ohio, 1993-1996. MMWR 1997;46: 33-35.
- Toxigenic Fungi Abatement Workshop. March , 1996. Case Western Reserve University.
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