Purpose: The authors investigate the outbreak of discomfort related to Stachybotrys chartarum and Aspergillus species among employees of the same building.

Design: Case series. A courthouse and two office buildings underwent wall and air sampling throughout its heating, ventilation, and air conditioning ("HVAC") systems. Over 90% of employees answered a simple questionnaire. Employees complaining of health problems underwent full pulmonary function testing. Additional subsets of employees received antibody workups and psychological testing. Two buildings of similar size and age were used as controls, although they were not evaluated in the same fashion as the case buildings (i.e., the ventilation systems were not evaluated in one control building and air quality was not systematically evaluated in either control building). Data for subjects in the control buildings were collected when convenient.

Outcome: The authors described a series of building problems, which they perceived as leading to water intrusion through the walls and condensation in the HVAC system over a five year period. Mold was detected visually and by odor throughout the buildings. They also reported reservoirs and growth sites of A. versicolor and S. chartarum occurring in many areas of the ceiling, perimeter walls, and flooring of the courthouse complex. The authors also stated that Satratoxins G and H were identified on moldy ceiling tiles. The patients reported symptoms including lethargy, headache, dry throat, stuffy nose, eye dryness and irritation, and difficulty breathing. The authors stated that the employees from the courthouse were much more likely to pick several of these symptoms than those who were taken from the control buildings. The authors were unable to document objective findings in the individuals with complaints. Three subjects reported asthma-like symptoms, although only one had a decreased FEF25-75. Seven of the sixteen workers reporting symptoms of interstitial lung disease ("ILD") were smokers. There was no correlation between any of the immunology tests and any of the agents detected in air or wall samples. There was no radiologic evidence of fibrosis. There was no measurable evidence of cognitive disfunction in individuals from the contaminated buildings, although patients with ILD symptoms reported more stress, anxiety and depression.

Significant Quotes: "Chemical analyses demonstrated the presence of satratoxins G and H. Cytotoxic laboratory analyses demonstrated the presence of agents with biological effectiveness in bulk materials. This outbreak represents a likely human response to inhaled fungal toxins in indoor environments. Moisture indoors represents a public health issue currently inadequately addressed by building, health, or housing codes." (p. 241).

"Overall, the results do not support the hypothesis of lower cognitive function among cases." (p. 246).

Defendants' Perspective: There were numerous methodologic limitations that render this study unreliable. The data were based on self-diagnosis of symptoms rather than doctor diagnosis. The cases were handled preferentially and differently from the controls. Furthermore, no association between exposure and objective measures of illness was reported.

Plaintiffs' Perspective: The authors suggest that there was a clear connection between the presence of the mold and the sudden onset of the health outbreak. The authors make numerous statements that could be taken out of context as being supportive of an association between mold exposure and illness.

Peer Review: Yes.

Relevance to Ongoing Cases: Plaintiffs' experts will likely cite this study in order to establish a connection between pulmonary disease and indoor mold-associated exposure.

How to Obtain the Article: http://www.joem.org/