Overview of investigations into pulmonary hemorrhage among infants in Cleveland, Ohio.

Abstract

Idiopathic pulmonary hemorrhage was diagnosed in 37 infants in the Cleveland, Ohio, area between 1993 and 1998. This rare disorder has been related to 12 deaths, including 7 originally thought to be sudden infant death syndrome. Thirty of the infants were African American, all of whom lived in a limited geographic area of eastern metropolitan Cleveland, an area of older housing stock. An investigation led by the Centers for Disease Control and Prevention has found an association with household exposure to a toxigenic mold, Stachybotrys chartarum, and other fungi. The rapidly growing lungs of young infants appear to be especially vulnerable to the toxins made by toxigenic molds. Environmental tobacco smoke was frequently present in the infants' homes and may be a trigger precipitating the acute bleeding. Stachybotrys, although not thought to be a common mold, is known to have a wide geographic distribution. An additional 101 cases of acute, idiopathic pulmonary hemorrhage have been reported in infants in the United States over the past 5 years. In this overview, the investigations are summarized, the clinical profile is described, the toxicity of S. chartarum is discussed, and pathophysiologic concepts are presented.

Mycotoxins

“…Stachybotrys chartarum was implicated in the outbreak. The mold was found more frequently in the houses of affected babies than in control houses (58). A case-control study identified water damage (leaks and flooding) and smoking as risk factors for developing the infant pulmonary hemorrhage (183).…”

Idiopathic pulmonary haemosiderosis revisited

“…A series of articles linking environmental exposure to fungi (especially Stachybotrys atra) in water-damaged houses in Cleveland, OH, USA and infantile pulmonary haemosiderosis led to an extensive investigation of possible infectious or mycotoxigenic pathogenesis [46][47][48][49][50][51][52][53][54][55][56][57][58]. The postulated mechanism is that fungal toxins called trichotecens, which are potent protein synthesis inhibitors, impede the angiogenesis underneath the rapidly forming alveolar membranes, making the acinar region prone to bleeding.…”

Workshop to identify critical windows of exposure for children's health: immune and respiratory systems work group summary.

“…Remarkably, whereas infants under 1 year of age developed life-threatening pulmonary hemorrhage, adults and older children living in the same moldy home environments did not develop evidence of pulmonary bleeding. The authors suggested that this may be because young infants' lungs are growing very rapidly (52). In infant lungs, protein synthesis of type IV collagen and other endothelial basement membrane components would be particularly sensitive to inhibition by the trichothecene mycotoxins, which are contained in the inhaled mold spores (53) and are potent protein synthesis inhibitors.…”