Purpose: The authors updated their 1994 report on the Cleveland case series of infant pulmonary hemorrhaging and found an association between the health claims and indoor mold contamination for the first time.

Design: Case control.

Outcome: In a follow-up investigation, Dearborn and colleagues conducted a case control study to identify the risk factors for pulmonary hemorrhage in a cluster of infants in Cleveland. Two new cases brought the total number of infants with pulmonary hemorrhage to ten. Thirty controls were added to the study. The major finding of the study was that all of the cases resided in homes with major water damage whereas only 23% of controls lived in water-damaged homes. The amount of Stachybotrys atra was purportedly higher in the case homes as compared to the controls, although no information was provided as to how the fungus was measured. There were some differences between the two groups that may have resulted in confounding of the interpretation of the data. Only fifty percent of the controls were male, while ninety percent of the cases were male. Ninety percent of case-infants resided in households with smokers, as opposed to 53% of controls. None of the cases were breast fed as compared to 37% of controls. The authors also reported an assessment made by the county coroner. Upon reexamination of the 172 infants who died in the county from 1993-1995, the coroner discovered hemosiderin-laden macrophages in the lung tissue of nine infants. The authors concluded that major pulmonary hemorrhaging was associated with indoor mold exposure in the ten cases identified in their cluster and possibly in some of the cases identified by the coroner.

Significant Quotes: "These findings documented an association between acute pulmonary hemorrhage/hemosiderosis in this cluster of cases and mold growth in their water-damaged homes." (p. 33).

"The quantity of fungi, including the toxigenic fungus Stachybotrys atra (whose toxins have been implicated in hemorrhagic disorders in animals), was higher in the homes of case-infants than in those of controls (OR=1.6; 95% Cl=1.0-30.8)." (p. 33).

"Although S. atra has been associated with gastrointestinal hemorrhaging in animals that had consumed moldy grain, the fungus previously has not been associated with disease in infants." (p. 34).

Defendants' Perspective: The inconsistencies between the case and control infants mentioned by the authors weakens any connection established between mold exposure and pulmonary illness.

Plaintiffs' Perspective: This article may be relied upon by plaintiffs' experts trying to draw a causal relationship between Stachybotrys and illness, especially respiratory problems. This article would generate sympathy from a jury, since it describes the loss of indigent children's lives.

Peer Review: No.

Relevance to Ongoing Cases: The Cleveland cases are among the most frequently cited examples of illness associated with indoor mold.

How to Obtain the Article: http://www.cdc.gov/mmwr/