New GMA Blog Coming Soon

It has been over a year now since Gordon Medical agreed to post the answers to patient questions on this blog, following a local presentation by Joseph J. Burrascano, MD and the GMA doctors. In that time, we have tried to work our way through the questions asked, and to bring you other information of interest.

The doctors at Gordon Medical, in addition to treating many patients with Lyme disease, also treat many other patients with acute and chronic illness, including Fibromyagia, mold illness, Chronic Fatigue and Immune Dysfunction, as well as many who have illness that doesn’t fit a specific category, other than chronic inflammatory illness. We have decided to expand our blog to one that addresses the full range of what we do. As we work to make the shift to the new blog, please forgive us if our attention is not fully on this one. It will be worth it in the end, as we hope to make it a resource for all patients in need of new thinking in treating their illness.

 

DHEA for Adrenal Fatigue

The following is a brief clip from the Biotoxin Illness weekend with Ritchie Shoemaker, MD, Neil Nathan, MD, and Eric Gordon MD, held in Santa Rosa, CA in October of 2011. Dr. Nathan responds to a question from the audience on the use of prednisone for adrenal fatigue.

The complete recording of the weekend is available as a 5 DVD set. To learn more, or to purchase the DVDs, click here: Biotoxin Illness: the science behind accurate diagnosis and effective treatment.

Dr. Nathan also goes into more detail about his use of DHEA in his book On Hope and Healing: For Those Who Have Fallen Through the Medical Cracks, and in his chapter of the book Insider Secrets for Treating Fibromyalgia. You can find more info on these books, links to exceprts, and how to purchase on our DVD and Book page.

Mold Remediation – Why Mold Professionals Should Avoid Using Bleach – Part Three

Why Restoration Professionals Should Avoid Using Bleach

There are many situations in which restoration professionals may think that use of bleach as a cleaner/sanitizer is effective. Indeed, there are certain restoration projects, such as sewage backflows, floods, and even mold remediation, where individuals have been taught to use bleach as part of their restoration protocol. This history is supported by continuing references in publications put out by numerous organizations including the EPA, American Red Cross, Salvation Army and others. The use of bleach as a “disinfectant” seemed to reach new heights over the past few months as semi-truckloads of the chemical were donated for disaster relief efforts in the Gulf states following hurricanes Katrina and Rita.

Despite this surge in bleach use for restoration of water-damaged and mold-impacted environments, I have one thing to say about the situation: Professional restoration contractors should not be using bleach for cleaning, sanitizing, or disinfecting surfaces! Of course this opinion comes with a few caveats: I do not have any financial or management interest in a chemical company that manufactures bleach or alternative chemical products. I have never been seriously injured by bleach in a personal or industrial accident. I use bleach for my laundry and a bleach derivative for sanitizing my swimming pool water.

So the question that is obvious is, Why is this environmental engineer so adamant about contractors not using bleach? The answer is related to both practical and legal implications for restoration professionals.

Practical Considerations
Let’s start with the practical considerations. Bleach is favored by many because of its long history of use by homeowners for cleaning and stain removal. Its relatively low cost has made it so widely available that its odor is now commonly associated with cleanliness by the general public. But in contrast to this widespread use are its dangers. Bleach is a corrosive that can irritate and eventually cause considerable damage to the skin. Bleach releases chlorine gas as it is sprayed or evaporates. The effect of bleach vapors on the eyes and respiratory system are immediately evident to anyone who is in an area where the product is being used liberally. Because of these potential effects on the body, appropriate personal protective equipment such as gloves, goggles, and respirators should be employed when bleach is utilized for situations beyond laundry. However, such essential precautions are often ignored because of the product’s acceptance in the mainstream of our society.

There are many practical impacts of bleach use beyond health concerns. Restoration professionals must appreciate the highly reactive nature of this chemical compound. The fact that bleach is used for stain removal and whitening means that it can also discolor and damage many fabrics. Less obvious is how bleach reacts with other materials. It is corrosive to many metals and stone products. It should never be used on stainless steel, aluminum, copper, brass, marble, or granite. In fact, bleach is so strong that it will etch glass if it is not neutralized after application to surfaces such as mirrors and windows. In New Orleans I observed how bleach solution had significantly corroded electrical components and anchoring bolts for load-bearing walls after less than 24 hours in a house where the drywall had been stripped due to flooding. In that particular case, the builder had been given bleach to use as a sanitizer and had sprayed it undiluted on all of the exposed studs and other building components.

A Bad Reaction
The reactive nature of bleach is even more troublesome when it is mixed. Bleach should never be mixed with acids, as dangerous fumes are usually the result. Even a mixture of two innocuous cleaning compounds such as bleach and ammonia can produce deadly gasses that can kill with just a few breaths. Depending on the ratio of bleach to ammonia, chlorine gas, nitrogen trichloride and/or hydrazine will be produced when these two are mixed. In addition to being toxic the last two listed by-products from this bleach mixture are also explosive. Other reactive by-products that can come from bleach mixtures are toxic chloramines and dioxins. With all of these potential “side effects” a restoration professional is taking a significant chance when bleach or a bleach solution is applied to varied materials in an uncontrolled environment – exactly the situation that occurs when bleach is sprayed following a sewage loss or fire.

Perhaps the most misunderstood aspect of bleach when proposed as a cleaner or sanitizing agent is that its effectiveness is greatly reduced in the presence of organic material. To be a successful sanitizer, bleach must be used on clean materials and surfaces. This is why bleach products are used in the laundry after the wash cycle or in a commercial kitchen as a component in the third sink after the dishes have been washed and rinsed. The efficacy of bleach as a sanitizer is also compromised by heat and light. Despite the fact that the chlorine odor may linger for some time after use, bleach loses strength so quickly that it is not considered to have a residual effect that would prevent future bacterial or fungal growth.

The last, but by no means the least, issue related to the practicality of bleach for restoration projects is that many alternatives are readily available for contractors that need to incorporate a level of sanitization into their cleaning or restoration activities. These products are specifically developed for restoration projects such as sewage clean-up or mold remediation. They have been tested for the sorts of conditions and contaminants that the contractor faces rather than testing as a laundry additive. In areas where potable water is a concern, there are many formulations that are ready to use, avoiding the dilemma of having to use the product full strength or mixing it with contaminated water. In addition to their cost effectiveness and ease of use, many sanitizing products developed for the restoration industry have a true residual effect which prevents bacterial or fungal regrowth.

The Trap of Label Directions
If the practical reasons are not enough to change a contractor’s habits away from bleach, the legal ramifications should be. Most bleach products are not registered with the EPA as an antimicrobial. In addition, the label directions for bleach often only mention a sanitizing capability for hard non-porous surfaces. As such, using a bleach solution to minimize antimicrobial activity on carpets, drywall, wooden studs, or other common building components means that the restoration contractor is engaged in an “off label” utilization of the product. Under such conditions the manufacturer will not warrant or assist the contractor if a problem or dispute arises.

So there you have it. Bleach is cheap, convenient, and recommended to a lot of homeowners for various restoration activities, but it is not the best choice for a contractor. As a restoration professional you have an obligation to understand what the standard of care in your industry demands and provide a quality service to your client. This means using the right tools and products. So leave the bleach at home for the load of white laundry where it belongs.

About the Author
Michael A. Pinto currently serves as Chief Executive Officer of Wonder Makers Environmental, Inc. He has more than 30 years of safety and environmental experience from jobs in the private sector, the non-profit arena, and regulatory agencies. Michael is the author of five books, including Fungal Contamination: A Comprehensive Guide for Remediation, over 150 published articles, and 18 commercial training programs. He can be reached at map@wondermakers.com.

This article was published in the January 2006 issue of Cleaning and Restoration magazine.

Click here to download the article.

Look for more in this six part series on mold remediation from Michale Pinto at Wonder Maker’s Environmental. If you are looking for a remediation specialist who is local to the San Francisco Bay Area, Gordon Medical suggests you contact Indoor Air Science. The people at Indoor Air Science  do not do remediation themselves, they do excellent air quality testing, but they have contacts with reliable remediation companies in the area. The people at Indoor Air Science are very knowledgeable, and are constantly researching to stay up to date on the current state of the science for indoor air safety.If you have concerns about your home or business, they are a good place to start.

If you are interested in learning more about Dr. Shoemaker’s work on mold illness, we have copies available of the DVD recordings from the October Biotoxin Illness conference held in Santa Rosa in October 2011. This 5 DVD set includes over 9 hours of talks with Dr. Shoemaker and the Gordon Medical physicians, as well as Power Point presentations and supporting evidence for the treatments presented. For more information, links to clips,  or to order, look at Biotoxin Illness on the DVDs and Books page.

Mold Remediation Part Two – Mold Indoors

Mold Indoors

Killing It Is Not Enough

Indoor air quality is a broad field that continues to bedevil building service professionals. But the shift in focus over the last five years from general concerns such as adequate ventilation and sick building syndrome to mold contamination has caught many service contractors by surprise, particularly when they are asked for advice in dealing with mold growth or blamed for its appearance.

Unfortunately, many contractors are struggling to identify the current best practices in regards to mold – a reasonable way to evaluate potential contamination and implement control measures. With limited time, service managers try to make sense of media reports, liability concerns, and scientific research. As they dig deeper, many have found that media reports are often condensed sound bites, legal cases tend to emphasize the extremes of liability in an effort to win or fend off a claim, and scientific reports are filled with technical jargon or narrow limitations that restrict their application to the real world.

Without good information, positions related to mold situations are inclined to polarize. The extreme positions can be categorized as fungiphobics, those who are frightened by a single mold spore, and those who refuse to accept any possibility of health-related problems due to mold exposure, the mold minimizers.

The first step in developing a reasonable approach to mold is to understand that there is a reasonable approach. Many service professionals have the mistaken impression that liability concerns, based on high-profile lawsuits, are the driving force in the industry. In the absence of federal or uniform state regulations related to mold control, attorneys are clarifying the industry standard of care, not creating their own. By carefully examining generally available industry reference documents relating to mold, attorneys have been able to identify points of commonality which they correctly interpret as a de facto industry standard of care. Unfortunately, many service providers are asked to talk intelligently about the mold situation in general and/or make decisions about mold contamination conditions in their contract facilities without even understanding what the industry reference materials are, let alone the points of intersection between them.

While there is some variation in which references really form the core of the mold control industry, the following ten documents are cited frequently.

Despite the fact that guidance for mold situations is coming from a variety of sources, there is a surprising consistency in the overall tone and approach. Some key consensus points that should frame any mold discussion include:

  • The understanding that mold is a biological agent. Since it has the ability to grow under the right conditions, isolation and deferred action to remove the source of the problem may not be possible as it is with asbestos materials. In such situations, the delay may allow mold contamination inside a building to grow to a point where it poses a hazard greater than when initially discovered.
  • Mold growth means that there is or has been moisture intrusion in the building. Removing surface mold contamination and not identifying and correcting the underlying moisture problem would be tantamount to a doctor treating symptoms rather than the disease itself.
  • Exposure to mold spores and other byproducts (microbial volatile organic compounds, mycotoxins, connecting filaments, etc) does cause real health symptoms. These symptoms can range from mildly annoying allergic reactions to serious, and even life-threatening, ailments.
  • Individuals respond to mold exposure in a variety of ways. There is a large variation in individual susceptibility to the same exposure levels and the possibility of a person becoming sensitized to specific specie of mold growing in a certain location. When added together this means that the range of potential responses to fungal exposure is greater than what is seen for many industrial chemicals.
  • Killing mold, but leaving the residue in place, is not acceptable. Since many health impacts can be triggered by exposure to both live and dead mold spores, the source and secondary contamination must be removed.
  • Mold removal is called remediation because special precautions, equipment and work procedures should be used to prevent the spread of material to other parts of the building.

Unfortunately, what this means is that there is no “quick fix” for mold contamination situations. The advertisements for various “magic potions” which “kills mold dead” are often not the best choice for contamination in commercial buildings since leaving mold residue behind puts the contractor outside the industry standard of care. A common sense assessment and remediation by trained individuals is the best way to protect the occupants, the building owner, and the service contractor.

As always, communication is the key. Even if a reasonable plan is developed and carried out, the proper communication of the remediation process may ultimately turn out to be just as important as competent performance of the work. To communicate clearly and convincingly, a service contractor should emphasize that the subject of mold exposure and control is complex, with many diverse opinions. Despite this diversity of opinion, an industry standard of care is in place which avoids the two extremes of mold minimizers and fungiphobics.

Staying within the standard of care, emphasizing the protection of occupants, workers, and building structures, and promoting the goal of a safe environment rather than pristine or spore- free indoor air, will help the smart building service provider navigate the tricky terrain of mold discussions.

About the Author
Michael A. Pinto currently serves as Chief Executive Officer of Wonder Makers Environmental, Inc. He has more than 30 years of safety and environmental experience from jobs in the private sector, the non-profit arena, and regulatory agencies. Michael is the author of five books, including Fungal Contamination: A Comprehensive Guide for Remediation, over 150 published articles, and 18 commercial training programs. He can be reached at map@wondermakers.com.

This article was published in the January 2005 issue of Services magazine.

Click here to download the article.

Look for more in this six part series on mold remediation from Michale Pinto at Wonder Maker’s Environmental. If you are looking for a remediation specialist who is local to the San Francisco Bay Area, Gordon Medical suggests you contact Indoor Air Science. The people at Indoor Air Science do not do remediation themselves, they do excellent air quality testing, but they have contacts with reliable remediation companies in the area. The people at Indoor Air Science are very knowledgeable, and are constantly researching to stay up to date on the current state of the science for indoor air safety. If you have concerns about your home or business, they are a good place to start.

If you are interested in learning more about Dr. Shoemaker’s work on mold illness, we have copies available of the DVD recordings from the October Biotoxin Illness conference held in Santa Rosa in October 2011. This 5 DVD set includes over 9 hours of talks with Dr. Shoemaker and the Gordon Medical physicians, as well as Power Point presentations and supporting evidence for the treatments presented. For more information, links to clips,  or to order, look at Biotoxin Illness on the DVDs and Books page.

Mold Remediation Part One

Michael Pinto, CSP, CMP, of Wonder Makers Environmental has compiled extensive information on mold remediation based on years of work and research. He wrote a series of articles that were published in Surviving Mold newsletters, and has given us permission to reproduce them here as a series. This is the first in that six part series.

Remediation Resources

REMEDIATION OF BUILDING MATERIALS
Excerpt from Fungal Contamination: A Comprehensive Guide for Remediation

This excerpt is taken from Chapter 10 of Fungal Contamination: A Comprehensive Guide for Remediation, Second Edition, a textbook used for mold remediation training that makes important and understandable connections between mold work and other restoration activities. This informative book of over 450 pages is available for purchase from Wonder Makers Environmental (www.wondermakers.com).


Remediating fungal contamination that is impacting building materials involves a number of steps that are widely accepted in the industry, and experience has determined that these steps should be performed in a particular order. This method offers the best possibility for removing visible mold growth and associated debris without cross contaminating surrounding areas. Remediation professionals should use the following steps as a starting point for developing a specific work plan for each project.

1. Set up initial engineering controls, including isolation barriers, negative pressure system, and drop cloths necessary to protect the structure during initial response activities.

2. Remove standing water.

3. Assess condition of contents, set up appropriate decontamination structure, and remove contents from the mold remediation work area.

4. Finalize engineering controls for removal of building materials harboring fungal growth. Make sure the setup can accommodate any unexpected hidden growth.

5. Work with the air flow. Generally this means that the project should be set up so that mold impacted materials closest to the decontamination unit are removed first. Work then progresses from the decon unit toward the negative air machine.

6. Remove porous materials with visible growth. Use work practices that minimize the generation of dust. This may include the use of hand tools or power tools to which a HEPA vacuum can be attached.

7. Enforce work procedures that emphasize a clean-as-you-go approach. Whenever possible, as they are removed from walls and ceilings, cut building materials in sections small enough to fit directly into waste bags. Bag all waste immediately rather than allowing it to pile up on the floor. Change negative air machine and vacuum filters often enough to keep them operating at optimum levels.

8. Seal waste bags using the gooseneck technique. Move waste bags into the decontamination unit where the exteriors of the bags are cleaned or they are double bagged prior to movement through unprotected areas of the building.

9. Determine the remediation approach for semi-porous materials that have visible fungal growth. Depending on the condition of the material some items, such as rotted wood studs, may have to be removed for later replacement. Other semi-porous materials that have not suffered structural damage can be cleaned by scraping, sanding, scrubbing, or blasting. Whenever possible, use tools in conjunction with a HEPA vacuum. Specialty tools, such as the Scravac, are specifically designed for scraping contamination directly into a vacuum nozzle. Make sure that the cleaning technique does not exceed the capacity of the engineering controls. Blasting, for example, may require a substantial increase in the amount of negative pressure and airflow as compared to a standard mold remediation work area.

10. Clean all non-porous materials that have visible fungal growth. This usually involves damp wiping or HEPA vacuuming.

11. Using the HEPA sandwich technique, clean the entire isolated work area, including ceilings and non-impacted walls. If there are any bacterial concerns because of gray or black water, incorporate appropriate antimicrobial chemicals into the damp wiping step.

12. If necessary, dry the remaining material in the work area through dehumidification. Be careful that airflow from fans and dehumidifiers does not impact the integrity of the isolation barriers.

13. Conduct a thorough visual inspection of the isolated work area. Use the white glove test to ensure that the area is free of dust. Re-clean as necessary.

14. Conduct post-remediation evaluation sampling. Compare the results to the company’s standards for mold remediation (see box for suggested post-remediation sample criteria). Re-clean and re-sample if necessary.

15. Coordinate post-remediation verification sampling by a pre-selected third party. Evaluate the results in comparison to the criteria that were agreed upon at the beginning of the project (see box for suggested post-remediation sample criteria). Re-clean and re-sample if necessary. If the building owner chooses to forgo verification sampling, move to the next step.

16. If included as part of the remediation project, apply antimicrobial coating to exposed structural members to prevent future mold contamination. Follow the manufacturer’s instructions for application. Allow all surfaces to dry thoroughly.

17. Have the HVAC system cleaned following NADCA guidelines.

18. If included as part of the project, replace and refinish building materials that were removed during remediation.

19. Remove isolation barriers and remediation equipment. Unless specifically exempted in the remediation contract, repair any damage to finish materials caused by the isolation barriers.


Look for more in this six part series on mold remediation from Michale Pinto at Wonder Maker’s Environmental. If you are looking for a remediation specialist who is local to the San Francisco Bay Area, Gordon Medical suggests you contact Indoor Air Science. The people at Indoor Air Science  do not do remediation themselves, they do excellent air quality testing, but they have contacts with reliable remediation companies in the area. The people at Indoor Air Science are very knowledgeable, and are constantly researching to stay up to date on the current state of the science for indoor air safety.If you have concerns about your home or business, they are a good place to start.

If you are interested in learning more about Dr. Shoemaker’s work on mold illness, we have copies available of the DVD recordings from the October Biotoxin Illness conference held in Santa Rosa in October 2011. This 5 DVD set includes over 9 hours of talks with Dr. Shoemaker and the Gordon Medical physicians, as well as Power Point presentations and supporting evidence for the treatments presented. For more information, links to clips,  or to order, look at Biotoxin Illness on the DVDs and Books page.


Reading an HLA DR by PCR Test Using the HLA Rosetta Stone

During the Biotoxin Illness Conference in October 2011, Dr. Gordon promised to provide  help to people trying to read HLA test results. In the video here, he talks with Annemieke Austin, MD about how you decode the results based on the Rosetta Stone that can be found in the books Surviving Mold and Mold Warriors.

The video from the weekend Biotoxin Illness conference is available for purchase. The cost for the full 5 disc set is $125, plus tax and shipping. Call (707) 575-5180 or email Justin to order.

The 5 DVD set Of Biotoxin Illness: the science behind accurate diagnosis and effective treatment includes the entire weekend, with both the public and the medical professional day’s information. The Power Point Slides are included in the DVD, overlaid during the talks, and as separate PDF documents for you to read through at your leisure. The talks and resources on this DVD set will provide necessary information to diagnose the problem, treat the layers of dysregulation of the immune system, and to manage the environment to protect against further exposure.

There is  a CD with the full set of Power Points as PDF, including slides that were not seen during the conference, a full Syllabus from the conference, and a list of PDF documents that Dr. Shoemaker has collected as supportive documentation of his work. Of special interest were the question and answer panels with Dr. Shoemaker and the Gordon Medical physicians, providing a range of physician experience.

Dr. Eric Gordon is the founder of  Gordon Medical Associates. What Dr. Gordon emphasizes is listening to his patients. “I believe my patients. Their description of what is going on in their body is the most accurate way we have to assess what is going on with them. I interpret the information they present, and blend it with laboratory results and imaging and other tests to determine a protocol that is customized to their condition.”

Annemieke Austin, MD views her role as both a medical detective and a physician with excitement. The challenge to discover the underlying cause of illness and the search for answers is a privilege she approaches with great vigor.

Fungus Allergy and Hypersensitivity

Fungus Allergy and Hypersensitivity
Notes from the Biotoxin Conference

by Alan B. McDaniel, MD

 Introduction:

Some molds release toxins, as certain snakes are poisonous.  These mold toxins activate our innate immune system and provoke disabling chronic inflammation and many hormonal disturbances.  This is quite distinct from the hay fever-allergic reaction molds can provoke.  There is a third way fungi (mold, yeast, etc) can make us sick.  This is generally neglected because of scientific orthodoxy and institutional dogma.

Fungus hypersensitivity can create inflammation that mimics infection

Case 1: Doc’s oldest son AP got fungal ringworm.  Doc prescribed Lotrimin cream, applied four-times daily by AP’s Mom, a nurse.  It was no better after ten days and the boy was taken to a Dermatologist, Dr. Bob Weiss.  When Weiss prescribed Lotrizone cream, Doc protested: This was the same antifungal that already had failed and it had steroids, which promote fungus growth.  Weiss winked and said: “Try it!” 

 In three days, the ringworm was gone.  Allergy tests confirmed AP reacted to Trichophyton not immediately but quite strongly 24 and 48 hours after the test was placed.  The Trichophyton causing AP’s ringworm had been killed by the antifungal in Lotrimin but the dead fungal remains in his skin provoked immune inflammation – until that was quenched by the steroid in Lotrizone. 

Inflammation from fungal hypersensitivity responds to immunotherapy

Case 2: Both of MB’s ear canals had been itching, then painful and swollen for years.   A sensible ENT surgeon had performed a right mastoidectomy but found no disease.  On Doc’s examination, both ears were red and chronically thickened with “peau d’orange” and neither canal could admit even a newborn speculum. She had skin tests for allergy and days later had big reactions to Aspergillus, Candida and Staph phage lysate. 

 Desensitization shots were started and she was put on a “Candida program.”  Doc operated on her worst ear, removed a solid mass of scar tissue from the ear canal and placed skin grafts.  After six months, the operation planned for her other ear was unnecessary – both ears were perfectly normal.

To understand what happened to these people, we must examine the immune system.

The immune system has one great task: It protects us from dangerous invaders.  These micro-terrorists include parasites; bacteria; viruses; toxins (such as tetanus and Stachybotrys) and cancer cells.

To master this task, the immune system must first discriminate between the many, many things that make up our own body (properly called “self”) and the vast amount of everything else that is not our body (right, called “non-self”).   Certainly, the immune system should not attack “self!”

Secondly, it must sort through that vast array of “non-self” and differentiate between the harmless and the dangerous.  It must leave “harmless” things alone and save its killing energy to attack and destroy the “dangerous” foreign matter.  When you think about it, that is an awesome task.  To achieve this, the immune system has two main divisions.

Immunity 101: The innate immune system

First, some immune protection is programmed right into our DNA.  Virtually all living things, even plants and quite primitive creatures are genetically – innately – directed to defend themselves by attacking a variety of biochemical molecules.

In humans, this Innate Immune System has developed several “operational arms.”  First, white blood cells (WBCs) called macrophages – translated “big eaters” – using primitive amoebic action engulf annoying foreign material and “process” it chemically.  What they do with this is important, as we’ll soon see.

Secondly, these white cells also release a variety of chemicals, by which the innate immune system recruits more WBCs (think “pus”) and promotes inflammation, which should be a protective defense.

Finally, a sequence of proteins collectively called the Complement Cascade is considered part of the innate immune system.  When triggered by various immune responses – and by toxins, these proteins activate each other in a chain-reaction that amplifies the power of the immune response (http://en.wikipedia.org/wiki/Innate_immune_system).

Immunity 102: The acquired immune system

We higher vertebrates are also equipped with more versatile defenses, the Acquired Immune System.  It fields a fields a team of “programmable” WBCs, including T and B-lymphocytes.  These cells are at first called “naïve” and indeed they are harmless as puppies – but they won’t stay that way.  Here’s how immune cells learn What to Attack:

These naïve cells become educated by hooking-up with “big eaters” of the innate system.  From them, they receive their load of ingested foreign material.  Macrophages’ processing has unmistakably labeled this as “bad.”  The T- and B-cells are galvanized to attack the foreign material – and thus the immune response is acquired.  It is also enduring: These educated immune cells alter their DNA, passing sensitization to all their descendants – creating clones of protective cells.

On receiving this molecular mug-shot, T-lymphocytes are programmed to fasten onto and destroy anything carrying that particular foreign “label.”  They become killer cells – certainly no longer naïve.

B-lymphocytes, having received the same information and thusly primed, begin to make protein antibodies called immunoglobulins (especially IgE and IgG).  These molecular equivalents of Predator drones are released into the blood and very specifically target the foreign material processed by the Big Eaters.  Some reactions provoke little incident but others produce very much inflammation, indeed.

Both T- and B-cell activity leads to the release of chemicals that promote inflammation and recruit many other cells to the sites of conflict.  Both these effects amplify the innate system and trigger the complement cascade.  Please note that ultimately, the innate and acquired immune systems stimulate the same final consequences.  This is a “key” point for today.

Immunity 201: Immune protection

Many of a pregnant woman’s immune globulins cross the placenta to her child.  Thus, babies at birth have a good measure of immune protection received “passively” from our mother.  This is temporary, lasting some 3 months.  So, the baby’s acquired immune system gets busy learning its “craft,” a lifelong process.

History, 1796: Smallpox killed one of five people who contracted it but survivors never got it again; their acquired immune system had become educated to kill the virus on sight and prevent a recurrence.  When Dr. Edward Jenner noted the mild infection called Cowpox made milkmaids immune to Smallpox, he inoculated his patients with Cowpox.  By this, they were protected from Smallpox.  Many have credited Jenner with saving more lives than anyone else in the history of the world (http://en.wikipedia.org/wiki/Edward_Jenner).

Vaccinations educate our immune system.  They present harmless proteins that will stimulate an immune response protecting us from dangerous ones.  When the immune system attacks dangerous “invaders,” it keeps us well. This is healthy immunity.

Immunity 202: Unwanted immunity

History, 1819: Tom was an agricultural worker.  Every year, he’d get sick when bringing in the harvest: Watery eyes, running nose, sneezing and fullness and itching in his throat.  He thought it was a cold, caught from other workers who had it too – but it happened every year.  He saw Dr. John Bostock, who diagnosed “hay fever” (http://www.allergyclinic.co.nz/guides/39.html).

When the immune system is confused between harmless and dangerous, it attacks harmless substances.  This unnecessary immunological “warfare” makes us sick.  We call this illness “allergy.”

Case 3: Big Al was a surgeon with five kids and a stressed wife.  He was really tired and needed to drink two pots of coffee daily to keep going.  He repeatedly asked his GP test his thyroid gland.  Every time it was checked, thyroid-stimulating hormone was normal but the level got worse and worse.  The gland was failing.  Fine-needle aspiration biopsy showed Big Al had Autoimmune Thyroiditis (AIT), which was slowly destroying his thyroid gland. 

When the immune system cannot recognize “self” is harmless, trouble follows.  It may attack some part of its own body and destroys it, as though it were rejecting a mismatched transplanted organ. Our thyroid gland is the most common target: 15% of Americans have AIT, including 24% of allergic women.  We call this auto-immune disease.

Graduate Immunology: Application to patient care

Medical science has several occupations.  In outline form, we endeavor to:

  • observe what is happening
  • understand what we have observed
  • apply this knowledge to cure people or relieve their suffering
  • improve our results by observing what is happening, etc

There are many types of immune reactions – as you might expect from having learned there are two types of immune system, many types of white blood cells and very many chemicals produced by their activities.  Doctors have observed these reactions for generations.  Unfortunately, they still argue about what they mean.

Case 4: When Percival’s cat scratched him, his skin swelled all along the scratch.  The first deliberate skin test for allergy was done in 1869 by Charles Blakely, who had hay fever.  He nicked his skin, put some pollen onto the cut and within 20 minutes saw his skin swell up all around the cut.  (http://www.allergyclinic.co.nz/guides/39.html)

Do skin tests actually identify trouble-making pollens?  Yes; when pollens identified by positive skin tests are spritzed into the person’s eyes, nose and airways, they provoke the person’s “hay fever” symptoms.

Nineteenth Century Immunology

Case 5: Dr. Wright made a night-call on a household with diphtheria.  Arriving home, he stabled his horse and to prevent contagion, changed his clothes in the barn.  Before going to bed, he paused look through the doorway at his only son, baby George.  The baby sickened and died of diphtheria the following week. 

Tetanus and diphtheria were dreaded killers in pre-antibiotic times.  By the 1890s, Physicians had learned how to protect people after they’d been exposed – by giving passive immunity, the kind a baby gets from its mother.  Horses were injected with the deadly toxins and those that survived became immune – with lots of protective immune globulins circulating in their blood.  This immune horse serum was injected and it protected the recipient (http://en.wikipedia.org/wiki/Passive_immunity).  A century later, we have better methods but we must honor the innovative scientists of the Gaslight Era!

They also knew injections should not be contaminated with bacteria.  To prove the horse serum sterile, they injected rabbits with some of each batch – and watched to see if an abscess would develop.  These frugal scientists found they couldn’t use the same rabbits repeatedly: Previously-injected rabbits often died immediately after the shot.  Dr. Arthus noted the surviving rabbits developed slow-healing lumps or nasty ulcers at the test site over a few days (http://en.wikipedia.org/wiki/Arthus_reaction).  Humans had similar problems after repeated injections of horse serum – not with the first but on repeated injections.

Twentieth Century Immunology

The fledgling science of Immunology couldn’t explain all this but they tried.  In 1921, Otto Prausnitz and Heinz Küstner demonstrated quite clearly that the immediate hypersensitivity of hay-fever and fatal horse serum injections was caused by a reactive substance in the serum; they called it “reagin” but we now know it as immunoglobulin E (IgE) (http://en.wikipedia.org/wiki/Prausnitz-K%C3%BCstner_test and http://en.wikipedia.org/wiki/Reaginic_antibody).  Oh, how the Allergists of the world rejoiced at the demonstration of the “P-K reaction!”  No longer were hay fever treatment and allergy shots a disreputable pseudo-science belittled by their more august colleagues.

What of the rabbits’ ulcers, the astute critic might ask?  Because they weren’t fatal, they were largely ignored.  Scientists later showed these lesions were caused by rabbit immunoglobulin binding to horse proteins, causing inflammation of blood vessels – “vasculitis.”

Immunology becomes politicized

Leading immunologists met first in Europe and then in the US, agreeing from thence forward they would define “Allergy” solely as the P-K reaction.  Dr. Coca, who developed the solution still used to make allergy extracts, protested against this decision.  He stated many types of immune reactions did not fit the P-K model but he and his supporters were voted down.

The argument was not solved though; it got worse.  As the allergy academy embraced the creed and catechism of IgE, groups of members rebelled and left to form their own, less-dogmatic societies.  First to go were the Ear, Nose and Throat docs in 1941, then General Practitioners in 1956 and finally dissenting Internists and Pediatricians in 1965.

The dispute over defining “allergy” became so acrimonious that there could be no reconciliation even after 1963, when Gell and Coombs showed there are at least 4 major types of acquired immune responses (http://en.wikipedia.org/wiki/Hypersensitivity).  Their four “classical” pathways are:

  • Type 1 reactions, caused by IgE (hay fever); they occur within minutes and give us protection against parasites
  • Type 2 reactions, caused when immunoglobulin types G (IgG) or M (IgM) attach themselves to a foreign protein and provoke the complement cascade; these develop over hours to a day and protect against bacteria and viruses
  • Type 3 reactions (Arthus reactions), occurring when IgG binds to a dissolved foreign substance and precipitates as an irritating, inflammatory complex; they occur in hours to a day and offer protection against toxins
  • Type 4 reactions, caused by sensitized T-cells; these reactions peak at 48-72 hours (think Tb skin tests) and protect against bacteria

Please note this important fact: Hay fever allergy, the type 1 pathway does not activate the complement cascade.  Are Allergists correct, who believe mold can stimulate the immune system only through type 1, IgE-mediated reactions?  If so, Dr. Shoemaker’s observations that mold activates complement must be explained only as a direct effect of mold toxins, without acquired immunity.

But reaction types 2-4 trigger the complement cascade (http://en.wikipedia.org/wiki/Hypersensitivity).  What if the dissenting Allergists are right; what if molds do indeed stimulate these late and delayed immune reactions?  That would mean non-toxic molds can trigger complement – and that we are dealing with a broader problem than mold toxins alone.  Treatments for these two conditions are very different.

Seeking the Truth: “Think for yourself and question authority.” – Timothy Leary, PhD

Allergists in the US agree that type 2-4 immune reactions – call them “late and delayed” reactions (L/D) – can be clinically important, causing asthma and other stubborn problems.  However, their orthodoxy requires them to believe type 1 reactions must trigger significant L/D hypersensitivity.  So, when skin tests show no immediate reaction but only later develop large red bumps lasting days to weeks, these lesions are dismissed as “meaningless Arthus reactions” and patient’s symptoms are called “non-allergic.”

How would Allergists learn any differently?  Americans studying late and delayed reactions after provocation-challenges choose only allergens positive on skin testing.  Fortunately, European and Asian researchers use a different approach; they challenge common pollens regardless of the skin test responses.  This is far from being futile: They’ve found that up to 30% of allergens provoking airway reactions do not produce an immediate skin response.  This is “key” information: Antigens that do not provoke immediate hypersensitivity can cause clinically significant immunological reactions.

Fungi provoke the immune system differently than do pollens

Before Science described the Fungus Kingdom (http://en.wikipedia.org/wiki/Fungi), Mankind had given its members common names: Mold, mildew, yeast, rusts, smuts and blights – they are all fungi and are rather similar.  Fungi are always present in the human environment.  They live in our homes and in our food.  With fungus, bread is raised and wine fermented.  Bleu cheese is made with Penicillium and soy sauce uses Aspergillus (black mold!).

Fungus also lives on and inside of humans: Aspergillus and Candida normally live in the external ear canal.  Fungus lives in everybody’s gut: The average healthy Englishman has >1,000 fungi per gram of stool; Candida, Geotrichum and Rhodotorula are most common.

Why do molds and yeast occupy center-stage today?  Exposure leads to sensitization.  To be sure, some make toxins but they also provoke late and delayed-type hypersensitivity much more often – and more severely – than do pollens.  It appears this difference is due to the types and locations of exposures and even the kinds of proteins involved.

Type 1 reactions to pollens seem related to the relatively brief seasonal exposure of large quantities of allergens that remain on the surface of our mucous membranes, where macrophages and IgE-laden Mast cells “hang out.”  In contrast, molds and yeast are ubiquitous and perennial.  Living in and on the human body, they cross our mucosa and enter our fluid compartments, where IgG and IgM rule.

Fungal antigens are also biochemically different from those of pollen.  All these characteristics lead molds to produce type 2-4 immune reactions.  Fungi so commonly cause late and delayed reactions that Candida is among the antigens doctors used to test a patient’s immune competency.

Case 6: Doc’s left hand developed dyshidrotic eczema when he was an undergraduate.  The Dermatology resident at Student Health said it was caused by a fungus but couldn’t say where the fungus was located.  Other Dermatologists scoffed at the fungus theory and recommended many peculiar treatments.  The problem gradually disappeared after about ten years.

That is, until six years later, when he heard Billy Crook lecture on the Yeast Connection and decided to find out what the non-absorbed antifungal nystatin would do …he did!  After taking one-eighth teaspoon at dinner and another at bedtime, Doc woke with his biggest-ever jock rash.  Then two days later, he had his worst-ever outbreak of dyshidrotic eczema – on both hands!  The Derm resident had been right – and the fungus was in Doc’s gut.  Nystatin killed it and dead yeast proteins flooded Doc’s bloodstream.  Every part of his skin that had ever been sensitized to fungus reacted (it was bad, y’all!). 

With near-preternatural timing, Doc’s allergy nurse then came to him with an issue: Marlene wanted to take Candida (“yeast”) off the testing menu.  Every time a patient tested positive for Candida, they had treatment problems.  They did not react to the shot right away but got big, red lumps after a day or two – which lasted a week or more.  Obviously, Candida provoked type 2-4 reactions more strongly than it did the type 1.  Doc had not known to check for L/D hypersensitivity before treating with fungus.   

Diagnosing late and delayed-type hypersensitivity 

When humans are tested, most doctors record only the type 1 IgE responses at ten minutes.  They truly ignore reactions that develop over the next few days, calling them “meaningless Arthus reactions.”  Yet foreign research shows many provocative allergens have no immediate hypersensitivity responses.

Veterinary Case: Sue loved her friend’s horse Cappy.  He was a big, gentle 12 year-old with impressive dressage skills and bad lungs.  In fact, his asthma got so severe that his destruction was planned but Cappy’s owner told Sue she could have him if she could help him.  Sue got a trailer and drove Cappy 100 miles to the University of Pennsylvania Vet School.  They promptly tested Cappy for allergies with skin tests – and measured his reactions every six hours for two days.  He had terrible late and delayed reactions to molds: He had “sick-stall syndrome.”  His stable was thoroughly cleaned, giving him complete relief. 

Case 7: Dr. Gordon’s patient had chronic sinus infections, asthma and occasional eczema.  Her symptoms worsened in cool, wet weather; in musty places and just before a rainfall.  He tested her for allergy to mold using blood tests measuring both IgE and IgG.  All 14 of her IgE tests were negative; 12 of 14 IgG tests were positive – several exceeding the upper limit of reporting. 

Integrated Approach to treatment

 Avoidance is the most obvious first step in dealing with immunological hypersensitivity to harmless substances.  Put the cat out; don’t drink milk and put allergen-proof covers on your mattress and pillows are well-known recommendations.  But what about the ubiquitous fungi – they cannot long be avoided.

Case 8: An ENT-Allergist from New Mexico spoke with Doc at an allergy course.  After moving there, his wife was still sick with headaches, “sinus,” respiratory and skin problems.  Skin tests had shown no allergies at all and he was baffled.  Doc told him to repeat the tests and measure her reactions at 24 and 48-hours.  There were lots of these reactions and he used them to formulate allergy shots for her.  At the next annual meeting, he was delighted to report his wife had improved dramatically. 

Immunotherapy (IT) develops tolerance by inducing T-suppressor cells that “quench” reactions to the foreign substances to which they are directed.  If the allergic response calls out the Marines, treatment with IT means that instead, Social Workers will answer the summons.  Skin tests measuring immediate, late and delayed-type reactions give us the best data to successfully formulate immunotherapy.

IT works both for immediate and late/ delayed hypersensitivity.  Environmental control works only as long as the environment is controlled – remember: Sensitization is long-enduring.  Desensitization, either by shots or sublingually, offers us lasting tolerance.

Summary:

Fungi (molds, yeasts, etc) cause immunological inflammation.  They mildly stimulate IgE-mediated immediate hypersensitivity.  They also provoke non-IgE late and delayed-type hypersensitivity.  Some of them, like Stachybotrys, can release toxins that directly activate the complement cascade.

Nearly every physician knows about the first of these, though it is rather insignificant.  The latter is becoming recognized and today we’ve heard about ingenious treatment options.  The second is the most commonly encountered but the least often recognized.  Our challenge is learning how to distinguish between these problems.

Of course, patients can have several, overlapping problems.  Some fungi provoke immediate as well as late/ delayed reactions.  Surely some people poisoned with mold toxin will already be allergic to molds.  It would be wonderful to study “mold-patients” for these and other related problems including insulin resistance; adrenal fatigue and autoimmune thyroiditis and “non-thyroidal illness”– to name a few.

Some day, a group of patients may be randomly divided into two groups:

  • One group could be treated by Dr. Shoemaker’s protocol
  • The other group by desensitization and Environmental Medicine principles

After sufficient time, perhaps two years, symptomatic patients would “cross-over” and try the other treatment.  Their outcome data could help determine which patient is best suited for what treatment.  Applying that knowledge is the ultimate goal for all serious physicians.

Alan McDaniel, MD is a Board-certified Ear, Nose & Throat specialist with two sub-specialties.  His work with dizziness and allergy in the 1980s led him to seek solutions for Chronic Fatigue Syndrome.  Since 2003, Dr. McDaniel has taught physicians practicing on five continents to effectively employ nutrition and hormones for this and other issues in his two-day course titled “The New Endocrinology.”