A water-damaged home and health of occupants: a case study.

A family of five and pet dog who rented a water-damaged home and developed multiple health problems. The home was analyzed for species of mold and bacteria. The diagnostics included MRI for chronic sinusitis with ENT and sinus surgery, and neurological testing for neurocognitive deficits. Bulk samples from the home, tissue from the sinuses, urine, nasal secretions, placenta, umbilical cord, and breast milk were tested for the presence of trichothecenes, aflatoxins, and Ochratoxin A. The family had the following diagnosed conditions: chronic sinusitis, neurological deficits, coughing with wheeze, nose bleeds, and fatigue among other symptoms. An infant was born with a total body flare, developed multiple Cafe-au-Lait pigmented skin spots and diagnoses with NF1 at age 2. The mycotoxins were detected in bulk samples, urine and nasal secretions, breast milk, placenta, and umbilical cord. Pseudomonas aueroginosa, Acinetobacter, Penicillium, and Aspergillus fumigatus were cultured from nasal secretions (father and daughter). RT-PCR revealed A. fumigatus DNA in sinus tissues of the daughter. The dog had 72 skin lesions (sebaceous glands and lipomas) from which trichothecenes and ochratoxin A. were detected. The health of the family is discussed in relation to the most recent published literature regarding microbial contamination and toxic by-products present in water-damaged buildings.

Use of patient-specific Leptospira isolates in the diagnosis of leptospirosis employing microscopic agglutination testing (MAT).

Given the protean manifestations of leptospirosis, adequate laboratory support for diagnosis is necessary. Traditionally, the gold standard is the microscopic agglutination test (MAT) using a panel of Leptospira isolates representing a broad range of serogroups and serovars. It has been proposed that screening with serovars circulating in a region would enhance test performance. We assessed the diagnostic usefulness of MAT using both regionally obtained clinical Leptospira isolates and the specific isolates recovered from the tested patients. Serum obtained from 41 acute febrile patients (obtained on average 7.2 days [SD±5.2] after onset of fever) was tested using a standard panel of 24 serovars along with regional isolates recovered from human and animal blood cultures from different regions in Egypt and a patient's own isolate, if available, to establish additional MAT panels. Serum samples tested by a standard 24 panel with a cut-off of >1:800 revealed five patients with positive serology. Only one patient had a positive result using a regional panel or patient's own culture developed MAT. However, the serovar with the highest titers did not match the cultured serovar. Region-specific MATs did not appear to be reliable in detection of infection or in identifying the infecting serovar.

Low-level hydrogen sulfide and central nervous system dysfunction.

Forty-nine adults living in Lovington, Tatum, and Artesia, the sour gas/oil sector of Southeastern New Mexico, were tested for neurobehavioral impairment. Contributing hydrogen sulfide were (1) an anaerobic sewage plant; (2) two oil refineries; (3) natural gas/oil wells and (4) a cheese-manufacturing plant and its waste lagoons. Comparisons were to unexposed Wickenburg, Arizona, adults. Neurobehavioral functions were measured in 26 Lovington adults including 23 people from Tatum and Artesia, New Mexico, and 42 unexposed Arizona people. Participants completed questionnaires including chemical exposures, symptom frequencies and the Profile of Mood States. Measurements included balance, reaction time, color discrimination, blink reflex, visual fields, grip strength, hearing, vibration, problem solving, verbal recall, long-term memory, peg placement, trail making and fingertip number writing errors (FTNWE). Average numbers of abnormalities and test scores were adjusted for age, gender, educational level, height and weight, expressed as percent predicted (% pred) and compared by analysis of variance (ANOVA). Ages and educational attainment of the three groups were not statistically significantly different (ssd). Mean values of Lovington residents were ssd from the unexposed Arizona people for simple and choice reaction times, balance with eyes open and closed, visual field score, hearing and grip strength. Culture Fair, digit symbol substitution, vocabulary, verbal recall, peg placement, trail making A and B, FTNWE, information, picture completion and similarities were also ssd. The Lovington adults who averaged 11.8 abnormalities were ssd from, Tatum-Artesia adults who had 3.6 and from unexposed subjects with 2.0. Multiple source community hydrogen sulfide exposures impaired neurobehavioral functions.

Leptospirosis in Kamphaeng Phet, Thailand.

Leptospirosis, which is caused by pathogenic spirochetes of the genus Leptospira, is a zoonotic disease of global importance and an emerging health problem. We studied patients suspected of having leptospirosis in Kamphaeng Phet Province, Thailand. Of 106 patients with suspected leptospirosis evaluated at the provincial hospital, 69 (65%) were confirmed positive (titer > or = 1:800 or > or = 4-fold increase in titer) by microscopic agglutination testing. Seventy-seven percent (53) of the cases occurred during the rainy season (June through November). Sera reacted predominantly with Bratislava, Autumnalis, and Icterohaemorrhagiae serovars. The screening Leptospira Dip-S-Ticks test had poor sensitivity (32%) but a specificity of 100% compared with a Leptospira IgM enzyme-linked immunosorbent assay. Leptospirosis was found to be a frequently confirmed cause of morbidity in Kamphaeng Phet Province in those suspected of having the illness.

Causes of fever in adults on the Thai-Myanmar border.

A hospital-based study was conducted along the Thai-Myanmar border to provide greater knowledge of the causes of febrile illness and to determine what zoonotic and vector-borne emerging infectious diseases might be present. A total of 613 adults were enrolled from June 1999 to March 2002. Cases were classified based on clinical findings and laboratory results. An etiologic diagnosis was made for 48% of subjects. Malaria was the most common diagnosis, accounting for 25% of subjects, with two-thirds Plasmodium falciparum. Serologic evidence for leptospirosis was found in 17% of subjects. Other etiologic diagnoses included rickettsial infections, dengue fever, and typhoid. The most frequent clinical diagnoses were nonspecific febrile illness, respiratory infections, and gastroenteritis. Clinical associations were generally not predictive of etiologic diagnosis. Apparent dual diagnoses were common, particularly for malaria and leptospirosis. Findings have been used to modify treatment of unspecified febrile illness in the area.

Funnel-web spider bite: a systematic review of recorded clinical cases.

OBJECTIVE: To investigate species-specific envenoming rates and spectrum of severity of funnel-web spider bites, and the efficacy and adverse effects of funnel-web spider antivenom. DATA SOURCES: Cases were identified from a prospective study of spider bite presenting to four major hospitals and three state poisons information centres (1999-2003); museum records of spider specimens since 1926; NSW Poisons Information Centre database; MEDLINE and EMBASE search; clinical toxinology textbooks; the media; and the manufacturer's reports of antivenom use. DATA EXTRACTION: Patient age and sex, geographical location, month, expert identification of the spider, clinical effects and management; envenoming was classified as severe, mild-moderate or minor/local effects. DATA SYNTHESIS: 198 potential funnel-web spider bites were identified: 138 were definite (spider expertly identified to species or genus), and 77 produced severe envenoming. All species-identified severe cases were attributed to one of six species restricted to NSW and southern Queensland. Rates of severe envenoming were: Hadronyche cerberea (75%), H. formidabilis (63%), Atrax robustus (17%), Hadronyche sp. 14 (17%), H. infensa (14%) and H. versuta (11%). Antivenom was used in 75 patients, including 22 children (median dose, 3 ampoules; range, 1-17), with a complete response in 97% of expertly identified cases. Three adverse reactions were reported, all in adults: two early allergic reactions (one mild and one with severe systemic effects requiring adrenaline), and one case of serum sickness. CONCLUSIONS: Severe funnel-web spider envenoming is confined to NSW and southern Queensland; tree-dwelling funnel webs (H. cerberea and H. formidabilis) have the highest envenoming rates. Funnel-web spider antivenom appears effective and safe; severe allergic reactions are uncommon.

Effects of envenoming by comb-footed spiders of the genera Steatoda and Achaearanea (family Theridiidae: Araneae) in Australia.

BACKGROUND: The family Theridiidae (comb-footed spiders) contains the well-known and medically important widow spider group (Latrodectus spp.). Little is known about the effects of envenoming by other common members of this family. OBJECTIVE: The objective of this study was to determine the clinical effects of bites by common theridiid spiders of the genera Steatoda and Achaearanea. METHODS: This was a prospective cohort study of calls to Australian poison information centers and presentations to emergency departments. Twenty-eight persons with a definite bite by a spider of the family Theridiidae, excluding Latrodectus spp., were included where the spider was immediately collected and expertly identified from February 1999 to April 2002. RESULTS: There were 23 bites by Steatoda spp. and five bites by Achaearanea spp. Steatoda bites occurred across Australia, throughout the year, and the majority during waking hours. Seventy-eight percent of bites occurred indoors and 48% while dressing indoors. Pain was universal and was severe in six (26%). Increasing pain in the first hour occurred in 30%, and the median duration of pain was 6 hr (interquartile range: 1-12 hr). Local or regional diaphoresis did not occur. Systemic effects occurred in 30% and included nausea, headache, lethargy, and malaise. The majority received no treatment: seven patients presented to a hospital (two patients received opiates for analgesia) and 1 patient inadvertently received intravenous redback spider (RBS) antivenom because the spider was initially misidentified as a RBS (Latrodectus). The pain and symptoms responded over 1 hr following antivenom administration. Bites by Achaeranea spp. caused moderate to severe persistent pain, but no systemic effects. CONCLUSIONS: Steatoda spp. bites or "steatodism" may cause prolonged pain and systemic effects similar to Latrodectus bites, but less severe. In severe cases, the clinical effects were almost indistinguishable from Latrodectus, except diaphoresis was absent, and the spiders were often mistaken for Latrodectus. Intravenous RBS antivenom appears to be an effective treatment in isolated severe cases, consistent with in vitro work. Achaearanea bites caused pain similar to Latrodectus bites.

White-tail spider bite: a prospective study of 130 definite bites by Lampona species.

OBJECTIVE: To investigate the circumstances and clinical effects of bites by white-tail spiders, including the two species Lampona cylindrata and L. murina commonly encountered by humans, and the incidence of necrotic lesions. DESIGN: Prospective cohort study of definite white-tail spider bites. Cases were only included if there was a clear history of bite, the spider was caught and was identified by an expert. SETTING: Calls to Australian poisons information centres and emergency departments. PATIENTS: 130 patients with a definite bite by a white-tail spider from February 1999 to April 2002. RESULTS: There were 79 bites by L. cylindrata and 51 by L. murina. Bites occurred in warmer months, 95% indoors and 75% between 16: 00 and 08: 00. The activity at the time of the bite was characteristic and the spider was encountered between bedclothes, towels or clothing. 25% of bites occurred on distal limbs. Pain/discomfort occurred in all cases, and was severe in 27%. Other effects included puncture marks (17%), redness/red mark (83%) and itchiness (44%). Systemic effects occurred in 9%. There were no cases of necrotic ulcers (97.5% CI, 0-2.8%) or confirmed infections. Median duration of effects was 24 hours (interquartile range, 1-168 hours). There were three distinct clinical patterns: pain only (21%), pain and red mark for < 24 hours (35%), and a persistent painful or irritating red lesion (44%). CONCLUSIONS: Bites by Lampona spp. cause minor effects in most cases, or a persistent painful red lesion in almost half the cases. White-tail spider bites are very unlikely to cause necrotic ulcers, and other diagnoses must be sought.

Latrodectism: a prospective cohort study of bites by formally identified redback spiders.

OBJECTIVE: To determine the spectrum of severity and early diagnostic predictors of redback spider bites (Latrodectus hasselti), and to examine the effect of intramuscular redback antivenom. DESIGN AND SETTING: Prospective cohort study of calls to New South Wales, Queensland and Western Australian poisons information centres and presentations to Royal Prince Alfred Hospital and Royal Darwin Hospital emergency departments. PATIENTS: 68 people with definite redback spider bites in which the spider was immediately collected and expertly identified (1 February 1999 to 30 April 2002). INTERVENTIONS: Intramuscular redback spider antivenom in a smaller cohort of hospitalised patients. MAIN OUTCOME MEASURES: Pain severity and duration, local effects and systemic envenomation (effects, prevalence, and persistence > 24 hours). RESULTS: The median duration of effects was 48 hours (interquartile range, 24-96 hours). Pain occurred after all bites and was severe in 42 (62%). Forty-five patients (66%) had pain lasting longer than 24 hours, and 22 (32%) were unable to sleep because of pain. Systemic effects occurred in 24 (35%). Increasing pain over one hour occurred in 37 cases (54%), and local/regional diaphoresis in 23 (34%); both these features were highly predictive of L. hasselti bites compared with bites of other spiders. One of six patients treated with intramuscular antivenom (17%) had no pain at 24 hours, compared with two of 17 untreated patients (12%) (difference, 5%; 95% CI, -36% to +64%; P = 0.95). There was no difference in duration of systemic effects with antivenom administration. CONCLUSIONS: Most redback spider bites cause severe and persistent effects. Intramuscular antivenom appears to be less effective than previously thought and its use by this route needs review.

Bites by spiders of the family Theraphosidae in humans and canines.

Spiders of the family Theraphosidae occur throughout most tropical regions of the world. There have only been three case reports of bites by these spiders in Australia. The aim of this study was to describe the clinical effects of bites by Australian theraphosid spiders in both humans and canines. Cases of spider bite were collected by the authors over the period January 1978-April 2002, either prospectively in a large study of Australian spider bites, or retrospectively from cases reported to the authors. Subjects were included if they had a definite bite and had collected the spider. The spiders were identified by an expert arachnologist to genus and species level where possible. There were nine confirmed bites by spiders of the family Theraphosidae in humans and seven in canines. These included bites by two Selenocosmia spp. and by two Phlogiellus spp. The nine spider bites in humans did not cause major effects. Local pain was the commonest effect, with severe pain in four of seven cases where severity of pain was recorded. Puncture marks or bleeding were the next most common effect. In one case the spider had bitten through the patient's fingernail. Mild systemic effects occurred in one of nine cases. There were seven bites in dogs (Phlogellius spp. and Selenocosmia spp.), and in two of these the owner was bitten after the dog. In all seven cases the dog died, and as rapidly as 0.5-2h after the bite. This small series of bites by Australian theraphosid spiders gives an indication of the spectrum of toxicity of these spiders in humans. Bites by these spiders are unlikely to cause major problems in humans. The study also demonstrates that the venom is far more toxic to canines.

Mixed mold mycotoxicosis: immunological changes in humans following exposure in water-damaged buildings.

The study described was part of a larger multicenter investigation of patients with multiple health complaints attributable to confirmed exposure to mixed-molds infestation in water-damaged buildings. The authors present data on symptoms; clinical chemistries; abnormalities in pulmonary function; alterations in T, B, and natural killer (NK) cells; the presence of autoantibodies (i.e., antinuclear autoantibodies [ANA], autoantibodies against smooth muscle [ASM], and autoantibodies against central nervous system [CNS] and peripheral nervous system [PNS] myelins). A total of 209 adults, 42.7 +/- 16 yr of age (mean +/- standard deviation), were examined and tested with (a) self-administered weighted health history and symptom questionnaires; (b) standardized physical examinations; (c) complete blood counts and blood and urine chemistries; (d) urine and fecal cultures; (e) thyroid function tests (T4, free T3); (f) pulmonary function tests (forced vital capacity [FVC], forced expiratory volume in 1 sec [FEV1.0], and forced expiratory flow at 25%, 50%, 75%, and 25-75% of FVC [FEF25, FEF50, FEF75, and FEF2(25-75)]); (g) peripheral lymphocyte phenotypes (T, B, and NK cells) and mitogenesis determinations; and (h) a 13-item autoimmune panel. The molds-exposed patients reported a greater frequency and intensity of symptoms, particularly neurological and inflammatory symptoms, when compared with controls. The percentages of exposed individuals with increased lymphocyte phenotypes were: B cells (CD20+), 75.6%; CD5+CD25+, 68.9%; CD3+CD26+, 91.2%; CD8+HLR-DR+, 62%; and CD8+CD38+, 56.6%; whereas other phenotypes were decreased: CD8+CD11b+, 15.6% and CD3-CD16+CD56+, 38.5%. Mitogenesis to phytohemagglutinin was decreased in 26.2% of the exposed patients, but only 5.9% had decreased response to concanavalin A. Abnormally high levels of ANA, ASM, and CNS myelin (immunoglobulins [Ig]G, IgM, IgA) and PNS myelin (IgG, IgM, IgA) were found; odds ratios for each were significant at 95% confidence intervals, showing an increased risk for autoimmunity. The authors conclude that exposure to mixed molds and their associated mycotoxins in water-damaged buildings leads to multiple health problems involving the CNS and the immune system, in addition to pulmonary effects and allergies. Mold exposure also initiates inflammatory processes. The authors propose the term "mixed mold mycotoxicosis" for the multisystem illness observed in these patients.

Antibodies to molds and satratoxin in individuals exposed in water-damaged buildings.

Immunoglobulin (Ig)A, IgM, and IgG antibodies against Penicillium notatum, Aspergillus niger, Stachybotrys chartarum, and satratoxin H were determined in the blood of 500 healthy blood donor controls, 500 random patients, and 500 patients with known exposure to molds. The patients were referred to the immunological testing laboratory for health reasons other than mold exposure, or for measurement of mold antibody levels. Levels of IgA, IgM, and IgG antibodies against molds were significantly greater in the patients (p < 0.001 for all measurements) than in the controls. However, in mold-exposed patients, levels of these antibodies against satratoxin differed significantly for IgG only (p < 0.001), but not for IgM or IgA. These differences in the levels of mold antibodies among the 3 groups were confirmed by calculation of z score and by Scheffé's significant difference tests. A general linear model was applied in the majority of cases, and 3 different subsets were formed, meaning that the healthy control groups were different from the random patients and from the mold-exposed patients. These findings indicated that mold exposure was more common in patients who were referred for immunological evaluation than it was in healthy blood donors. The detection of antibodies to molds and satratoxin H likely resulted from antigenic stimulation of the immune system and the reaction of serum with specially prepared mold antigens. These antigens, which had high protein content, were developed in this laboratory and used in the enzyme-linked immunosorbent assay (ELISA) procedure. The authors concluded that the antibodies studied are specific to mold antigens and mycotoxins, and therefore could be useful in epidemiological and other studies of humans exposed to molds and mycotoxins.

Neural autoantibodies and neurophysiologic abnormalities in patients exposed to molds in water-damaged buildings.

Adverse health effects of fungal bioaerosols on occupants of water-damaged homes and other buildings have been reported. Recently, it has been suggested that mold exposure causes neurological injury. The authors investigated neurological antibodies and neurophysiological abnormalities in patients exposed to molds at home who developed symptoms of peripheral neuropathy (i.e., numbness, tingling, tremors, and muscle weakness in the extremities). Serum samples were collected and analyzed with the enzyme-linked immunosorbent assay (ELISA) technique for antibodies to myelin basic protein, myelin-associated glycoprotein, ganglioside GM1, sulfatide, myelin oligodendrocyte glycoprotein, alpha-B-crystallin, chondroitin sulfate, tubulin, and neurofilament. Antibodies to molds and mycotoxins were also determined with ELISA, as reported previously. Neurophysiologic evaluations for latency, amplitude, and velocity were performed on 4 motor nerves (median, ulnar, peroneal, and tibial), and for latency and amplitude on 3 sensory nerves (median, ulnar, and sural). Patients with documented, measured exposure to molds had elevated titers of antibodies (immunoglobulin [Ig]A, IgM, and IgG) to neural-specific antigens. Nerve conduction studies revealed 4 patient groupings: (1) mixed sensory-motor polyneuropathy (n = 55, abnormal), (2) motor neuropathy (n = 17, abnormal), (3) sensory neuropathy (n = 27, abnormal), and (4) those with symptoms but no neurophysiological abnormalities (n = 20, normal controls). All groups showed significantly increased autoantibody titers for all isotypes (IgA, IgM, and IgG) of antibodies to neural antigens when compared with 500 healthy controls. Groups 1 through 3 also exhibited abnormal neurophysiologic findings. The authors concluded that exposure to molds in water-damaged buildings increased the risk for development of neural autoantibodies, peripheral neuropathy, and neurophysiologic abnormalities in exposed individuals.

Psychological, neuropsychological, and electrocortical effects of mixed mold exposure.

The authors assessed the psychological, neuropsychological, and electrocortical effects of human exposure to mixed colonies of toxigenic molds. Patients (N = 182) with confirmed mold-exposure history completed clinical interviews, a symptom checklist (SCL-90-R), limited neuropsychological testing, quantitative electroencephalogram (QEEG) with neurometric analysis, and measures of mold exposure. Patients reported high levels of physical, cognitive, and emotional symptoms. Ratings on the SCL-90-R were "moderate" to "severe," with a factor reflecting situational depression accounting for most of the variance. Most of the patients were found to suffer from acute stress, adjustment disorder, or post-traumatic stress. Differential diagnosis confirmed an etiology of a combination of external stressors, along with organic metabolically based dysregulation of emotions and decreased cognitive functioning as a result of toxic or metabolic encephalopathy. Measures of toxic mold exposure predicted QEEG measures and neuropsychological test performance. QEEG results included narrowed frequency bands and increased power in the alpha and theta bands in the frontal areas of the cortex. These findings indicated a hypoactivation of the frontal cortex, possibly due to brainstem involvement and insufficient excitatory input from the reticular activating system. Neuropsychological testing revealed impairments similar to mild traumatic brain injury. In comparison with premorbid estimates of intelligence, findings of impaired functioning on multiple cognitive tasks predominated. A dose-response relationship between measures of mold exposure and abnormal neuropsychological test results and QEEG measures suggested that toxic mold causes significant problems in exposed individuals. Study limitations included lack of a comparison group, patient selection bias, and incomplete data sets that did not allow for comparisons among variables.

Arthropod Cladistics: Combined Analysis of Histone H3 and U2 snRNA Sequences and Morphology.

Morphological, developmental, ultrastructural, and gene order characters are catalogued for the same set of arthropod terminals as we have scored in a recent study of histone H3 and U2 snRNA sequences (D. J. Colgan et al., 1998, Aust. J. Zool. 46, 419-437). We examine the implications of separate and simultaneous analyses of sequence and non-sequence data for arthropod relationships. The most parsimonious trees based on 211 non-sequence characters (273 apomorphic states) support traditional higher taxa as clades, including Mandibulata, Crustacea, Atelocerata, Myriapoda, and Hexapoda. Combined analysis of morphology with histone H3 and U2 sequences with equal character weights differs from the morphological results alone in supporting Progoneata + Hexapoda (= Labiophora) in favor of a monophyletic Myriapoda, resolves the entognathous hexapods as a grade, and supports pycnogonids as sister group to Euchelicerata (rather than as basal euarthropods). Monophyly of Chelicerata (including pycnogonids), Mandibulata, Crustacea, Progoneata, Chilopoda, and Hexapoda is maintained under a range of transition/transversion and third codon weights, whereas Atelocerata and Myriapoda/Labiophora do not withstand all sensitivity analyses.