Pulmonary Hemorrhage And
Hemosiderosis In Infants
the past several years, there have been a number of young infants (most under 6 months
old), in the eastern neighborhoods of Cleveland, who have been coughing up blood due to
bleeding in their lungs. Some infants have died and more infants continue to to get ill.
This bleeding, a disorder called Pulmonary Hemorrhage appears to be caused by something in
their home environments, most likely toxins produced by an unusual fungus called Stachybotrys
chartarum or similar fungi.
What is Pulmonary Hemosiderosis?
in the lungs.
What Are The Symptoms?
Severe bleeding can cause coughing up blood or nose bleeds. This is
particularly concerning in infants under 6 months old. Chronic, low grade bleeding can
cause chronic cough and congestion with anemia.
What Causes The Bleeding?
likely, toxins made by an unusual fungus or mold Stachybotrys. When infants breathe
in the toxins, the blood vessels in their lungs may become fragile. The weak vessels may
be bothered by cigarette smoke or stresses from other illnesses and start to bleed. You
cannot see the toxins in the air rather they are carried in the microscopic fungal spores.
How Do I Know If The Fungus Or Mold Is In My House?
fungus or mold grows only on wood or paper that have gotten very wet for more than a few
days or so. (It does NOT grow on plastic, vinyl, concrete products, or ceramic
tiles). If the wood/paper gets wet and is not cleaned up and dried, the fungus may grow
and spread. The fungus is black and slimy when wet. It is NOT found in the green
mold on bread or the black mold on the shower tiles (but the shower tiles should be kept
clean too). If you have had plumbing leaks, roof leaks, flooding in the basement (even if
you don't use the basement), or sewer backup in the past year, look for mold or a musty
Common Areas for This Mold Growth
soaked wood, ceiling tiles, wall paneling, unpainted plaster board surfaces, cotton items,
cardboard boxes, and stacks of newspapers. If these areas have been very wet, usually for
longer than one week, check for mold. After the area dries, the fungus will not continue
to grow, but the black dust caused by the fungus can be sucked up by the furnace blower
and spread throughout the house. Be sure and check your basement for the black mold. If
you do not have access to the basement, ask your landlord for assistance. Note not all
black mold is Stachybotrys, but moldy homes are not healthy homes.
you have mold in your basement, check to see if there is any way that your forced air
furnace can send the mold dust up to the living spaces. Is there ductwork connecting the
cold air returns to your furnace or does your furnace pull air from the basement? The
latter is the case if you can seen the furnace filter face on (rather than just the edge).
How To Clean-up Fungal Growth
you have more than two square feet of mold growth you should seek professional advice on
how to perform the clean-up.
source of the water problem must first be corrected. All roof or plumbing leaks/flooding
must be fixed.
moldy surfaces should be cleaned with a household bleach (like Clorox) and water mix =
1 cup of bleach mixed in 1 gallon of water. You can add a little dish soap to the
bleach water to cut dirt and oil on the wall that can hold mold. With good ventilation,
apply the bleach water mix to the surface with a sponge, let it sit for 15 minutes, then
thoroughly dry the surface. Be sure to wear a dust mask, rubber gloves and open
lots of windows when cleaning with bleach water.
the area cannot be cleaned (like some wet broken ceiling tiles), is too damaged, or is
disposable (like cardboard boxes) discard them and replace with new ones.
may be necessary to do more clean up in the home (carpets, crawl spaces, heating ducts) if
you have a bad mold problem.
your city or county health department if you have questions or need assistance.
the past seven years in the Cleveland, Ohio area there have been 45 cases of pulmonary
hemorrhage (PH) in young infants. Sixteen of the infants have died. Thirty-two of the
infants have been African American. Most of these cases have occurred within ten
contiguous zip codes area in the eastern portion of the metropolitan area. In
November/December, 1994, the Centers for Disease Control and Prevention (CDC) lead a
case-control investigation on the first ten cases. This study found an epidemiological
association of PH in these infants with water-damaged homes containing the toxic fungi,
predominantly Stachybotrys. Several lines of evidence suggest that the most likely
causal agents are fungal toxins from a fungus called Stachybotrys atra. This
somewhat unusual fungus was found in high quantity in the home environments of the
affected infants but also to a lesser degree in some of the comparison homes. Stachybotrys
requires water soaked cellulose to grow, and was found in homes where there had been water
damage from flooding, plumbing leaks or roof leaks involving wood or paper products (e.g.
insulation, gypsum board, ceiling tile). The spores of this fungus contain very potent
mycotoxins which appear to be particularly toxic to the rapidly growing lungs of young
infants. The linkage of Stachybotrys to PH in infants is on the basis of
epidemiological data and has not been conclusively demonstrated. Other factors such as
environmental tobacco smoke appear to be important triggers in precipitating overt
cases continue to occur, a few infants having had only very subtle initial symptoms such
as nose bleeds and chest congestion. Concern that there may be a larger number of
undetected young infants with this disorder, led to the examination of all infant coroner
cases over a three year period, 1993-1995. This revealed seven "SIDS" (sudden
infant death syndrome) cases with evidence of preexisting major pulmonary bleeding. All
but one of these infants had lived in the ten zip code cluster area.
disorder is likely to extend beyond Cleveland since an informal national survey of all
pediatric pulmonary centers and continued reporting has identified over 100 similar cases
of pulmonary hemorrhage in infants across the country over the last seven years.
MY MOLD STACHYBOTRYS?
Stachybotrys chartarum (atra) occurs widely in North America, it is probably rather
uncommon to find it in homes. It requires water soaked cellulose (wood, paper, and cotton
products) to grow. While wet it looks black and slimy perhaps with the edges white, and
when dry it looks less shiny. It is not the only or the most common black mold to be
found in these conditions. If your clean-up is not simple, i.e. your water damage and
mold growth is extensive and/or involves structural materials, contact your city or county
health department for assistance in assessing the problem. They can put you in contact
with environmental laboratories capable of identifying Stachybotrys and with
abatement contractors familiar with the precautions and other specifics important for
extensive clean-up. If you have a large area of mold growth (greater than two square feet
or so), seek professional assistance in the clean-up. You can get quite ill yourself if
you inhale a large quantity of the fungal dust or get it on your skin.
Testing for Mold
a more detailed discussion on the assessment and remediation of Stachybotrys in
indoor environments, please refer to The Proceedings of the International Conference held
on October 6-7, 1994 in Sarasota Springs, NY entitled "Fungi and Bacteria in
Indoor Environments", pages 201-207, published by the Eastern New York
Occupational Health Program [(518)436-5511].
cases of minor mold contamination, small isolated areas (2 to 10 sq.ft.), testing is
usually not necessary. In most of these cases, the area can be addressed by using the
clean-up recommendations given elsewhere on this home page.
cases of more extensive contamination, testing may be necessary. Some private
environmental consulting firms may have the ability to conduct home assessments and sample
for mold identification. Please refer to the section of your yellow pages entitled
"Environmental Consultants" to find a company in your area that might be capable
of performing these tasks effectively. Ask if the company has experience with mold
testing; it is recommended that several price quotes be obtained for field work and
analysis. Consulting firms should be familiar with the American Industrial Hygiene
Association (AIHA) document entitled "Field Guide for the Determination of
Biological Contaminants in Environmental Samples". This document provides
guidelines for the sampling of mold in indoor environments. For a list of accredited labs,
please see the AIHA web site.
DOES MY INFANT OR CHILD HAVE PULMONARY HEMOSIDEROSIS?
hemosiderosis is a rare lung disorder which can also occur as part of other medical
conditions. If your infant or child is coughing blood, you need to seek medical attention
immediately. If your young infant (<6 months old) is having nose bleeds without any
injury, you should seek medical attention right away. If your infant or child has chronic
cough and chest congestion and is anemic, ask your physician to consider the possibility
of pulmonary hemosiderosis among all the other more common diagnostic possibilities.
your physician would like more information about looking for pulmonary hemosiderosis, have
Dorr G. Dearborn, Ph.D., M.D.
Pediatric Pulmonary Division
Rainbow Babies & Childrens Hospital
11100 Euclid Avenue
Cleveland, Ohio 44106
FAX (216) 844-5916
your physician would like consultation regarding pulmonary hemosiderosis have them contact
the nearest Pediatric PulmonaryCenter. The local chapter of the American Lung Association
can be of assistance if necessary.
REPORTING A CASE
If you are a physician and have had an infant with idiopathic
pulmonary hemorrhage or hemosiderosis in the past five years, Dr. Dearborn would
appreciate your reporting it to us. Reporting forms can be obtained by calling (216)
IDIOPATHIC PULMONARY HEMOSIDEROSIS NATIONAL ORGANIZATION
parents of children with the rare disorder Idiopathic Pulmonary Hemosiderosis have
expressed an interest in establishing a national organization. The problem described here
with young infants is a form of this disorder but older children can also have IPH from
other unknown causes or even an allergy to cow's milk (Heiner's Syndrome). The national
organization would primarily be a parental group interested in communication and
optimizing the medical care for their children.
you would be interested in participating in this new organization, contact
G. Dearborn, Ph.D., M.D.
Pediatric Pulmonary Division
Case Western Reserve University, School of Medicine
10900 Euclid Avenue, BRB 824
Cleveland, Ohio 44106-4948
If you have concerns about the health of adults who have been been exposed to
Stachybotrys, contact the Occupational Medicine physician listed below
Johanning, MD, MSc
Eastern New York Occupational Health Program
D.G., Pulmonary hemorrhage in infants and children. Current Opinions in Pediatrics, June,
1997, Vol 9., pp 219-224 (Clinical management suggestions).
for Disease Control and Prevention. Update on Pulmonary Hemorrhage/Hemosiderosis among
Infants-Cleveland, Ohio, 1993-1996. Morbidity and Mortality Weekly Report, Vol. 46, No.
2., January 17, 1997. (Internet http//www.cdc.gov/cd)
for Disease Control and Prevention. Acute Pulmonary Hemorrhage/Hemosiderosis among
Infants- Cleveland, January 1993-November 1994. Morbidity and Mortality Report, Vol. 43,
No. 48, December 9, 1994. (Internet http//www.cdc.gov/cdc.htm)
E., Etzel, R., Allan, T., Horgan, T., and Dearborn, D., Environmental Risk Factors
Associated with Pediatric Idiopathic Pulmonary Hemorrhage and Hemosiderosis in a Cleveland
Community. Pediatrics, Vol 99, No. 1, January, 1997. (Internet
R., Montana, E., Sorenson, W., Kullman, G., Allan, T., and Dearborn, D., Acute pulmonary
hemorrhage is infants associated with exposure to Stachybotrys atra and other
fungi, Arch. Pediatr. Adolesc. Med. 152757-762, 1998.
I, Allan, T, Sorenson, WG, and Dearborn, DG. Highly sensitive protein translation assay
for trichothecene toxicity in airborne particulates. Comparison with cytotoxicity assays.
Appl. Environ. Microbiol. 6588-94, 1999.
DG, Yike, I, Sorenson, WG, Miller, MJ, and Etzel, RA, Overview of investigations into
pulmonary hemorrhage among infants in Cleveland, Ohio, Environmental Health Perspectives,
Vol.107, Suppl.3, 495-499, 1999.
SJ, Dearborn, DG, Yike, I, Sorenson, WG, and Haugland, RA, Hemolysis, toxicity, and
randomly amplified polymorphic DNA analysis of Stachybotrys chartarum strains,
Applied Environ Microbiol, 653175-3181, 1999.
PA, Modlin, S, Sorenson, WG, and Dearborn, DG, Acute pulmonary hemorrhage in an infant
during induction of general anesthesia, Paediatric Anesthesia, 1092-94, 2000.
SJ, Dearborn, DG, Yike, I, Allan, T, Sobolewski, J., and Haugland, RA, Evaluation of Stachybotry
chartarum in idiopathic pulmonary hemorrhage case house before, during, and
after remediation. J. Urban Health (in press).
R.A., and Dearborn, D.G. Pulmonary hemorrhage among infants with exposure to toxigenic
molds An update. In Bioaerosols, Fungi, and MycotoxinsHealth effect, Assessment,
Prevention and Control, Ed. E. Johanning, Boyd Printing Co., Inc., Albany, NY, 1999, pp
DG. Pulmonary Hemosiderosis (pulmonary hemorrhage), in Nelson s Textbook of Pediatrics,
16th edition. Editors R Behrman, R Kleigman, H Jenson, p 1295-1297, 2000.
O., Colasurdo, G.N., Rossmann, S.N., and Fan, L.L., Isolation of Stachybotrys from
the lung of a child with pulmonary hemosiderosis, Pediatrics, 104964-966, 1999.
S.M., Portnoy, J., Jones, P., and Barnes, C., Infant pulmonary hemorrhage in a suburban
home with water damage and mold (Stachybotrys atra), Environ Health Perspect,
sheets and other indoor air quality related publications including "Biological
Pollutants in Your Home" and "Flood Cleanup Avoiding Indoor Air Quality
Problems" are available from
Air Quality Information Clearinghouse
P.O. Box 37133
Washington, D.C. 20013-7133
(800) 438-4318 or (202) 484-1307
You Have the Air Ducts in Your Home Cleaned?
visit the web site of U.S. Environmental Protection Agency, Indoor Environments Division:
US Dept of Energy's "Hazard Identification and Mitigation Workshop