What are the signs, symptoms, and treatment options for a patient with a suspected mold infection, particularly those with a history of respiratory issues, immunosuppression, or environmental mold exposure?

Signs and Symptoms of Mold Infection and Treatment

Clinical Manifestations

The most common presentation of mold exposure is sinopulmonary disease from inhaled fungal spores, with respiratory symptoms occurring in 64% of patients and neurologic manifestations in 70%. 1, 2

Respiratory Presentations

• Allergic manifestations include asthma (manifestation, progression, or exacerbation), allergic rhinitis, and exogenous allergic alveolitis, which have sufficient evidence for causation 1, 3
• Physical examination reveals pale nasal mucosa, pharyngeal "cobblestoning," and rhinorrhea in allergic patients 4
• Cough occurs in 52% of exposed patients, with respiratory symptoms broadly present in 34% 4
• Allergic bronchopulmonary aspergillosis (ABPA) should be suspected in asthma patients with recurrent exacerbations 5

Systemic and Neurologic Symptoms

• Headache (34%), central nervous system symptoms (25%), and fatigue (23%) are common constitutional complaints 4
• Objective neuropsychological testing in symptomatic patients demonstrates abnormalities in short-term memory, executive function/judgment, concentration, and hand-eye coordination 2
• Autonomic nervous system dysfunction occurs in nearly 100% of tested patients with chronic exposure 2

Invasive Disease in Immunocompromised Patients

• Primary cutaneous aspergillosis occurs in patients with breached skin barriers, including burn victims and neonates near vascular sites 1, 6
• Invasive aspergillosis presents with sinopulmonary disease as the most frequent manifestation, with potential dissemination to brain parenchyma and meninges 1, 7
• Candidemia and deep tissue Candida infections occur in non-neutropenic and immunocompromised patients 8

Treatment Approach

The primary and definitive treatment is immediate removal from the contaminated environment with prompt environmental remediation—there is no effective medical therapy without source elimination. 1, 5

Environmental Remediation (First-Line Treatment)

• Water damage must be cleaned within 24 hours to prevent mold amplification 5, 6
• For areas <10 ft², individuals can perform cleanup using soap and water or bleach solution on nonporous surfaces 5, 6
• For areas >10 ft² or HVAC system involvement, hire professional remediators following EPA's "Mold Remediation in Schools and Commercial Buildings" guidelines 5
• All porous materials (carpet, drywall, wood) must be discarded, not cleaned, as mold cannot be adequately removed from these surfaces 5, 6
• The patient must be completely removed from the contaminated environment during the entire remediation process and should not return until remediation is verified complete 5, 6

Medical Management for Invasive Fungal Infections

For immunocompromised patients with invasive aspergillosis, voriconazole is the treatment of choice, demonstrating superior survival (71% vs 58%) compared to amphotericin B. 8

Invasive Aspergillosis Treatment

• Voriconazole achieved 53% satisfactory global response versus 32% with amphotericin B (p<0.0001) in primary treatment 8
• Success rates by species: A. fumigatus (44%), A. flavus (50%), A. terreus (67%), A. niger (25%) 8
• For salvage therapy in refractory cases, voriconazole showed 44% success for A. fumigatus and 40% for non-fumigatus species 8

Candidemia and Deep Tissue Candida Infections

• Voriconazole demonstrated comparable efficacy to amphotericin B followed by fluconazole (41% vs 41% success at 12 weeks) for candidemia in non-neutropenic patients 8
• For deep tissue Candida infections, favorable responses were seen in intra-abdominal infections (4/7 patients), kidney/bladder infections (5/6), and deep tissue abscesses (3/3) 8

ABPA in Sensitized Asthma Patients

• Antifungal therapy with itraconazole or voriconazole may be beneficial in sensitized patients with recurrent asthma exacerbations 5

Supportive Management for Non-Invasive Exposure

• Approximately 85% of patients with documented mold exposure cleared completely with mold avoidance and desensitization therapy, 14% had partial improvement 2
• Treatment protocols included antigen injections, mycotoxin antigen desensitization, sauna therapy, oxygen therapy, and nutritional support in refractory cases 2
• Allergic responses (IgE-mediated) appeared to be the major cause of symptoms rather than toxic effects in most studied patients 4

Prevention Strategies

Moisture Control (Cornerstone of Prevention)

• Maintain indoor humidity <50% using dehumidifiers, as mold cannot grow without water 5, 6
• Vent moisture-producing appliances to outside and use bathroom fans or open windows during showering 5, 6
• Avoid carpeting in bathrooms and basements 5, 6

High-Risk Patient Precautions

• Immunocompromised inpatients require HEPA-filtered rooms with positive pressure and adequate air exchanges 1, 5
• Outpatient immunocompromised patients should avoid gardening, mulch spreading, and proximity to construction/renovation 1, 5
• No plants or cut flowers should be allowed in patient rooms 1, 5

Air Filtration

• HEPA filters can reduce airborne spore concentrations in single rooms, with medium-efficiency filters for central systems 5
• Avoid ozone generators marketed as "air purifiers", as they produce harmful ozone levels without proven benefit 5, 6

Critical Diagnostic Pitfalls to Avoid

There is no validated method to test humans for toxigenic mold exposure—do not order mycotoxin testing in blood or urine. 1, 5, 7

What NOT to Do

• Mycotoxin assays in blood or urine are not standardized for clinical use and unclear what levels correlate with health effects 1, 7, 3
• No uniformly accepted, valid quantitative environmental sampling methods or serologic tests exist to assess mold exposures 1
• Environmental mold testing should not be part of routine medical evaluation 7

Appropriate Testing for Specific Scenarios

• For immunocompromised patients with suspected invasive disease: obtain chest CT (superior to plain radiography), microbiological cultures, and serum galactomannan antigen testing for Aspergillus 7
• For suspected hypersensitivity pneumonitis: high-resolution CT showing centrilobular ground-glass nodules, mosaic attenuation, and air-trapping should be integrated with clinical findings, not used in isolation 7
• For atopic/allergic patients: skin prick testing and/or mold-specific IgE may identify sensitization (prevalence 3-10% in European population) 4, 3

Special Population Considerations

Infants with Acute Idiopathic Pulmonary Hemorrhage (AIPH)

• Inquire about home water damage and mold when treating infants with AIPH 1, 5
• Moisture sources should be eliminated before the infant returns home, though causal relationship not firmly established 1, 5
• Avoidance of secondhand cigarette smoke is especially critical 1

Food-Related Mycotoxin Exposure

• Mold-contaminated foods (especially grains) can contain harmful amounts of mycotoxins 1, 5
• Inquire about dietary history if mycotoxin-induced illness is suspected 1, 5
• USDA monitors allowable limits in food products 1, 5