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PULMONARY
HEMORRHAGE
AND HEMOSIDEROSIS IN INFANTS
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Pediatric
Pulmonary
Dorr G. Dearborn,
Ph.D., M.D.
Michael D. Infeld, M.D.
Pediatric Critical Care
Paul G. Smith, D.O.
Environmental Hygiene
Terrence M. Allan,
M.P.H.
Cuyahoga County Board of Health |
Introduction
Over 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?
Bleeding 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?
Most 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.
THE CLEVELAND OUTBREAK
Over 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 pulmonary
hemorrhage.
More 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.
This 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.
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