Pulmonary Hemorrhage In Infants Research Articles

Update on Stachybotrys chartarum-Black Mold Perceived as Toxigenic and Potentially Pathogenic to Humans.

Simple SummaryAmong the 123 currently accepted species of the genus Stachybotrys, S. chartarum consistently deserves special attention. This one is the most frequently isolated species of the aforementioned genus and one of the world’s 10 most hazardous fungi. S. chartarum owes its notoriety to the secondary metabolites that are released in the host environment. Interaction of these metabolites with mucous membranes of the respiratory or digestive tract and with the skin can induce necrotic changes and even life-threatening pulmonary or gastrointestinal hemorrhage. Pulmonary hemorrhage was of major concern to the public when, in the period of 1993–1998, this ailment was identified in 138 infants in Cleveland, Ohio, USA, among which 12 cases were fatal. Since this first documented outbreak, the number of publications dealing with the toxigenic properties of this fungus, and even its potential pathogenicity, has rapidly grown. In this comprehensive review we present the most updated information about taxonomy, macro- and micromorphology, biology and ecology of this fungus. Within this work, we focus on the factors that prompted this fungus to be extremely dangerous for people and animals living in moldy conditions, as well as antifungals efficient in its eradication from indoor environments.In nature, there are many species of fungi known to produce various mycotoxins, allergens and volatile organic compounds (VOCs), as well as the commonly known etiological agents of various types of mycoses. So far, none of them have provoked so much emotion among homeowners, builders, conservators, mycologists and clinicians as Stachybotrys chartarum. This species compared to fungi of the genera Fusarium and Aspergillus is not as frequently described to be a micromycete that is toxigenic and hazardous to human and animal health, but interest in it has been growing consistently for three decades. Depending on the authors of any given review article, attention is focused either on the clinical aspects alongside the role of this fungus in deterioration of biomaterials, or aspects related to its biology, ecology and taxonomic position. On the one hand, it is well established that inhalation of conidia, containing the highest concentrations of toxic metabolites, may cause serious damage to the mammalian lung, particularly with repeated exposure. On the other hand, we can find articles in which authors demonstrate that S. chartarum conidia can germinate and form hyphae in lungs but are not able to establish an effective infection. Finally, we can find case reports that suggest that S. chartarum infection is linked with acute pulmonary hemorrhage, based on fungal structures recovered from patient lung tissue. New scientific reports have verified the current state of knowledge and note that clinical significance of this fungus is exceedingly controversial. For these reasons, understanding S. chartarum requires reviewing the well-known toxigenic features and harmful factors associated with this fungus, by gathering the newest ones into a coherent whole. The research problem related to this fungus seems to be not overly publicized, and there is still a demand to truthfully define the real threats of S. chartarum and phylogenetically related species. The most important problem, which should be fully elucidated as soon as possible, remains the clarification of the pathogenicity of S. chartarum and related species. Maybe it is urgent time to ask a critical question, namely what exactly do we know 28 years after the outbreak of pulmonary hemorrhage in infants in Cleveland, Ohio, USA most likely caused by S. chartarum?

A novel approach to the diagnosis and treatment of hemoptysis in infants: A case series.

IntroductionHemoptysis in children is an uncommon presenting symptom but can be life‐threatening if massive. Cardiac catheterization and coil embolization of aorto‐pulmonary collateral vessels (APCs) is uncommon in pediatric hemoptysis patients without congenital heart disease.MethodsWe present a series of seven infants (≤12 months of age) with hemoptysis, all of whom underwent cardiac catheterization to look for and intervene upon APCs, if found. Only those patients who underwent both bronchoscopy as well as cardiac catheterization from January 1995 to January 2015 were included in this retrospective review.ResultsSeven patients met inclusion criteria, and three had a history of recurrent hemoptysis. The mean age was 3 months. Four had evidence of bleeding on bronchoscopy. All seven had respiratory distress which necessitated ICU admission; five required mechanical ventilation. Cardiac catheterization showed significant APCs (>2 mm) in six of the seven studied patients, all of which were coil embolized. One patient had no significant APCs and therefore, no embolization. All patients had complete resolution with no recurrences during the 10‐20‐year outpatient follow‐up period. Chest CT scans were not helpful in delineating the site or etiology of bleeding in any patient.ConclusionsAPCs should be considered as a differential diagnosis for pulmonary hemorrhage in infants after more common causes have been ruled out.

957 Use of Therapeutic Surfactant Lavage in a Preterm Infant with Massive Pulmonary Hemorrhage

Introduction: Pulmonary hemorrhage (PH) is a potentially life-threatening complication occurring in 10-16% of extremely low birth infants (ELBW), leading to chronic lung disease in 60% of cases. Surfactant is mainly used for early management of respiratory distress syndrome in preterm infants. Recently, therapeutic surfactant lavage with diluted surfactant has been proposed for the management of infants suffering from severe meconium aspiration syndrome (MAS). Case presentation: We report a case of a preterm infant (26 weeks GA) presenting with recurrent pulmonary hemorrhage in whom we performed a therapeutic lavage with diluted surfactant after an acute episode of massive bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10 x 2 ml) allowed for marked improvement in oxygenation allowing to reduce mean airway pressures during high frequency oscillatory ventilation rapidly. The infant showed further progressive improvement allowing switching from HFOV back to conventional ventilation and finally extubation within 25 days. Conclusion: Bronchoalveolar lavage with diluted surfactant might be beneficial in massive pulmonary hemorrhage in infants. Further investigations are needed to clarify the potential benefit of such a therapeutic intervention on outcome of infants suffering from life-threatening PH.

Testing antimicrobial cleaner efficacy on gypsum wallboard contaminated with Stachybotrys chartarum

Reducing occupant exposure to indoor mold is the goal of this research, through the efficacy testing of antimicrobial cleaners. Often mold contaminated building materials are not properly removed, but instead surface cleaners are applied in an attempt to alleviate the problem. The efficacy of antimicrobial cleaners to remove, eliminate or control mold growth on surfaces can easily be tested on non-porous surfaces. However, the testing of antimicrobial cleaner efficacy on porous surfaces, such as those found in the indoor environment such as gypsum board can be more complicated and prone to incorrect conclusions regarding residual organisms. The mold Stachybotrys chartarum has been found to be associated with idiopathic pulmonary hemorrhage in infants and has been studied for toxin production and its occurrence in water damaged buildings. Growth of S. chartarum on building materials such as gypsum wallboard has been frequently documented. Research to control S. chartarum growth using 13 separate antimicrobial cleaners on contaminated gypsum wallboard has been performed in laboratory testing. Popular brands of cleaning products were tested by following directions printed on the product packaging. A variety of gypsum wallboard surfaces were used to test these cleaning products at high relative humidity. The results indicate differences in antimicrobial efficacy for the six month period of testing. Results for the six types of GWB surfaces varied extensively. However, three cleaning products exhibited significantly better results than others. Lysol All-Purpose Cleaner-Orange Breeze (full strength) demonstrated results which ranked among the best in five of the six surfaces tested. Both Borax and Orange Glo Multipurpose Degreaser demonstrated results which ranked among the best in four of the six surfaces tested. The best antimicrobial cleaner to choose is often dependent on the type of surface to be cleaned of S. chartarum contamination. For Plain GWB, no paint, the best cleaners were Borax, Lysol All-Purpose Cleaner-Orange Breeze (full strength), Orange Glo Multipurpose Degreaser, and Fantastik Orange Action. These results are not meant to endorse the incomplete removal of mold contaminated building materials. However, it is recognized that complete removal may not always be possible and solutions to control mold regrowth may contribute to reduced occupant exposure. Current recommendations of removal and replacement of porous building materials should be followed. It is not the intension of this discussion to endorse any product. Reporting on the performance of these products under the stated conditions was and remains the only purpose.

Spectrum of Noninfectious Health Effects From Molds

Molds are multicellular fungi that are ubiquitous in outdoor and indoor environments. For humans, they are both beneficial (for the production of antimicrobial agents, chemotherapeutic agents, and vitamins) and detrimental. Exposure to mold can occur through inhalation, ingestion, and touching moldy surfaces. Adverse health effects may occur through allergic, infectious, irritant, or toxic processes. The cause-and-effect relationship between mold exposure and allergic and infectious illnesses is well known. Exposures to toxins via the gastrointestinal tract also are well described. However, the cause-and-effect relationship between inhalational exposure to mold toxins and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) is controversial and requires additional investigation. In this report we examine evidence of fungal-related illnesses and the unique aspects of mold exposure to children. Mold-remediation procedures are also discussed.

Spectrum of Noninfectious Health Effects From Molds

Molds are eukaryotic (possessing a true nucleus) nonphotosynthetic organisms that flourish both indoors and outdoors. For humans, the link between mold exposure and asthma exacerbations, allergic rhinitis, infections, and toxicities from ingestion of mycotoxin-contaminated foods are well known. However, the cause-and-effect relationship between inhalational exposure to mold and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) requires additional investigation. Pediatricians play an important role in the education of families about mold, its adverse health effects, exposure prevention, and remediation procedures.

Acute Inflammatory Responses to Stachybotrys chartarum in the Lungs of Infant Rats: Time Course and Possible Mechanisms

Stachybotrys chartarum has been linked to building-related respiratory problems including pulmonary hemorrhage in infants. The macrocyclic trichothecenes produced by S. chartarum have been the primary focus of many investigations. However, in addition to trichothecenes this fungus is capable of producing other secondary metabolites and a number of protein factors. This study examines the effects of intact, autoclaved, and ethanol-extracted spores on the lungs of infant rats as an approach to differentiate between secondary metabolites and protein factors. Seven-day-old infant rats were exposed intratracheally to 1 x 10(5) spores/g body weight (toxic strain JS58-17) and sacrificed at various times up to 72 h. The inflammatory response was measured by morphometric analysis of the lungs and determination of inflammatory cells and cytokine concentrations in bronchoalveolar lavage (BAL) fluid. Alveolar space was greatly reduced in animals exposed to fungal spores compared to phosphate buffered saline (PBS)-treated controls. The largest effects were observed in pups treated with intact spores where alveolar space 24 h after treatment was 42.1% compared to 56.8% for autoclaved spores, 51.1% for ethanol-extracted spores, and 60.6% for PBS-treated controls. The effects of different spore preparations on inflammatory cells, cytokine, and protein concentrations in the BAL fluid can be ranked as intact > autoclaved > extracted. Tumor necrosis factor alfa (TNF-alpha), interleukin 1-beta (IL-1beta), and neutrophils were the most sensitive indicators of inflammation. The difference between autoclaved (100% trichothecene toxicity, denatured/enzymatically inactive proteins) and intact (100% trichothecene activity, unaltered/released proteins) spores indicates the involvement of fungal proteins in the inflammatory response to S. chartarum and sheds new light on the clinical importance of "nontoxic" strains.

The Pathogenicity of Stachybotrys chartarum

Stachybotrys chartarum is a dematiaceous fungus that is ubiquitous in our living environment. This fungus has long been regarded as non-pathogenic and its inhalation effect on humans has been scarcely studied. Recently, however, epidemiologic studies on acute idiopathic pulmonary hemorrhage in infants suggested that the fungus might be potentially pathogenic to humans. To determine the pathogenicity of this fungus, its interaction with the host defense system was studied using polymorphonuclear leukocytes (PMNs) and macrophages. Histopathological analysis of mice intratracheally injected with this fungus was also performed. The results disclosed that the conidia of S. chartarum were resistant to the antifungal activities of alveolar macrophages in terms of phagocytosis, killing and inhibition of germination. However, the conidia could not survive in the lungs of mice when injected intratracheally. Lavage fluid of mycelia that contained the dark slimy material coating the surface of conidia showed cytotoxic activity against macrophages and PMNs. Intratracheal injection of conidia in mice resulted in intraalveolar infiltration of PMNs. When using multiple injections during a 3-week period, strong eosinophilic infiltration into the proximal alveoli and perivascular tissues was observed. Our results suggest that inhalation of conidia may cause serious damage to the human lung, particularly when repeated.

Management with High Frequency Ventilation of Acute Idiopathic Pulmonary Hemorrhage in Infants

Acute idiopathic pulmonary hemorrhage in infants (AIPHI) is characterized by a sudden onset of pulmonary hemorrhage in previous healthy infants. Evidence of pulmonary hemorrhage may present as hemoptysis or a finding of blood in the nose or airway with no evidence of upper respiratory or gastrointestinal bleeding. Patients presenting with acute, severe respiratory distress or failure, and those requiring mechanical ventilation and often demonstrate bilateral infiltrates by chest radiography. We report a case of AIPHI which developed during the induction of anesthesia. A 3-month-old male infant received right herniorraphy under general endotracheal anesthesia. After intubation, blood tinged fluid was aspirated using an endotracheal tube during operation. Chest radiography showed bilateral ground glass opacity. We transferred the patient to the ICU and applied conventional mechanical ventilation. However hypoxemia and respiratory acidosis were persisted. We then switched to a high frequency ventilator (HFV), the hypoxemia and respiratory acidosis were corrected. The patient was transferred to the general ward on the 7th postoperative day.

Localization of satratoxin-G in Stachybotrys chartarum spores and spore-impacted mouse lung using immunocytochemistry.

Satratoxin-G (SG) is the major macrocyclic trichothecene mycotoxin produced by Stachybotrys chartarum (atra) and has been implicated as a cause of a number of animal and human health problems including pulmonary hemorrhage in infants. However, there is little understanding where this toxin is localized in the spores and mycelial fragments of this species or in the lung impacted by SG-sequestered spores. The purpose of this study was to evaluate the distribution of SG in S. chartarum spores and mycelium in culture, and spore-impacted mouse lung in vivo, using immunocytochemistry. SG was localized predominately in S. chartarum spores with moderate labelling of the phialide-apex walls. Labelling was primarily along the outer plasmalemma surface and in the inner wall layer. Only modest labelling was observed in hyphae. Toxin localization at these sites supports the position that spores contain the highest satratoxin concentrations and that the toxin is constitutively produced. In impacted mouse lung, highest SG labelling was detected in lysosomes, along the inside of the nuclear membrane in nuclear heterochromatin and RER within alveolar macrophages. Alveolar type II cells also showed modest labelling of the nuclear heterochromatin and RER. There was no evidence that the toxin accumulated in the neutrophils, fibroblasts, or other cells associated with the granulomas surrounding spores or mycelial fragments. These observations indicate that SG displays a high degree of cellular specificity with respect to its uptake in mouse lung. They further indicate that the alveolar macrophages play an important role in the sequestration and immobilization of low concentrations of the toxin.

Stachybotrys.

Stachybotrys is a toxin-producing fungus that grows indoors when both water and cellulose are available. Epidemiologic evidence has demonstrated an association between acute pulmonary hemorrhage in infants and exposure to Stachybotrys and other fungi in water-damaged home environments. In recent years, advances in understanding of this association have occurred in six major areas: animal models, biologic mechanism of lung injury, dose-response relationship, isolation from diseased patients, detection methods, and intervention. The association demonstrates strength, consistency, coherence, and specificity. While additional data are gathered, a preventive approach to reducing the exposure of infants with pulmonary hemorrhage is suggested.

IgE-reactive proteins from Stachybotrys chartarum

Stachybotrys chartarum has been associated with idiopathic pulmonary hemorrhage in infants. This is thought to be mycotoxin-related. There are increasing numbers of reports linking this fungus to the indoor environment of patients with other pulmonary problems, including allergies and asthma. Given the potential significance of this fungus as a pulmonary pathogen, this work evaluates the antigenic proteins of S. chartarum as to their molecular size and the prevalence of immunoglobulin (Ig)E and IgG directed against them in the general population. S. chartarum was isolated from a local home. S. chartarum for extract production was grown on minimum salts and glucose. Plasma from 132 healthy individuals was evaluated for IgE and IgG directed against S. chartarum using direct and inhibition enzyme immunoassay. The number and molecular size of those proteins that were bound by IgE from pooled sera known to contain IgE to S. chartarum were determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting. Enzyme immunoassay indicated 65 of 132 (49.2%) sera tested contained IgG against S. chartarum and 13 of 139 (9.4%) sera tested contained IgE against S. chartarum. Pooled sera identified two IgE-binding proteins from extracts of S. chartarum spores and mycelia. These proteins are 34 and 52 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblot. We conclude sensitivity to S. chartarum is potentially much more widespread than previously appreciated. This fungus may impact the asthmatic and allergic population through both immunologic and toxic mechanisms. Its significance in the milieu of allergenic fungi may need to be re-evaluated.

Characterization of Stachybotrys from Water-Damaged Buildings Based on Morphology, Growth, and Metabolite Production

Stachybotrys was found to be associated with idiopathic pulmonary hemorrhage in infants in Cleveland, Ohio. Since that time, considerable effort has been put into finding the toxic components responsible for the disease. The name Stachybotrys chartarum has been applied to most of these isolates, but inconsistent toxicity results and taxonomic confusion prompted the present study. In this study, 122 Stachybotrys isolates, mainly from water-damaged buildings, were characterized and identified by combining three different approaches: morphology, colony characteristics, and metabolite production. Two different Stachybotrys taxa, S. chartarum and one undescribed species, were found in water-damaged buildings regardless of whether the buildings were in Denmark, Finland, or the USA. Furthermore, two chemotypes could be distinguished in S. chartarum. One chemotype produced atranones, whereas the other was a macrocyclic trichothecene-producer. The second undescribed taxon produced atranones and could be differentiated from S. chartarum by its growth characteristics and pigment production. Our results correlate with different inflammatory and toxicological properties reported for these same isolates and show that the three taxa/chemotypes should be treated separately. The co-occurrence of these three taxa/chemotypes in water-damaged buildings explains the inconsistent results in the literature concerning toxicity of Stachybotrys isolated from that environment.

Characterization of Stachybotrys from water-damaged buildings based on morphology, growth, and metabolite production

Stachybotrys was found to be associated with idiopathic pulmonary hemorrhage in infants in Cleveland, Ohio. Since that time, considerable effort has been put into finding the toxic components responsible for the disease. The name Stachybotrys chartarum has been applied to most of these isolates, but inconsistent toxicity results and taxonomic confusion prompted the present study. In this study, 122 Stachybotrys isolates, mainly from water-damaged buildings, were characterized and identified by combining three different approaches: morphology, colony characteristics, and metabolite production. Two different Stachybotrys taxa, S. chartarum and one undescribed species, were found in water-damaged buildings regardless of whether the buildings were in Denmark, Finland, or the USA. Furthermore, two chemotypes could be distinguished in S. chartarum. One chemotype produced atranones, whereas the other was a macrocyclic trichothecene-producer. The second undescribed taxon produced atranones and could be differentiated from S. chartarum by its growth characteristics and pigment production. Our results correlate with different inflammatory and toxicological properties reported for these same isolates and show that the three taxa/chemotypes should be treated separately. The co-occurrence of these three taxa/chemotypes in water-damaged buildings explains the inconsistent results in the literature concerning toxicity of Stachybotrys isolated from that environment.

Infant animal model of pulmonary mycotoxicosis induced by Stachybotrys chartarum.

In recent years cases of often fatal pulmonary hemorrhage in infants have been associated with water damaged homes and the toxigenic fungus Stachybotrys chartarum. The fungal spores contain mycotoxins which could be injurious to the rapidly developing lung. In order to understand the developmental pathophysiology of this disease we developed an infant rat model of stachybotrytoxicosis describing the effects of fungal spores on survival, growth, histopathology of the lung and respiration. Conidia of S. chartarum were instilled intratracheally (1.0-8.0 x 10(5)/gm wt.) in 4-d old Sprague-Dawley rat pups. Two control groups received either sterile PBS or a suspension of spores extensively extracted with ethanol to remove toxins. Lethal dose response was determined (LD50 = 2.7 x 10(5) spores/gm wt.). All dead pups had extensively hemorrhagic lungs. Growth of surviving animals was impaired in a dose-dependent manner. Changes of pulmonary function parameters in rats treated with 1.1 x 10(5) spores/g were consistent with an increased respiratory resistance. Histology of lungs revealed fresh hemorrhage, sparse hemosiderin-laden macrophages, and evidence of inflammation including thickened alveolar septa infiltrated by lymphocytes and mononuclear cells and intra-alveolar macrophages. Significant increases (p = 0.001) in numbers of macrophages (2-fold), lymphocytes (5-fold) and neutrophils (7-fold) were found in BAL fluid. Hemoglobin was elevated 2-fold (p = 0.004). Proinflammatory mediator IL-1beta increased more than 6-fold and TNF-alpha 30-fold (p = 0.001). Extracted spores had a minimal effect on all examined parameters in BAL fluid indicating that mycotoxins are primarily responsible for the hemorrhagic and inflammatory response.

Pulmonary Hemorrhage in Infants

Pulmonary Hemorrhage in Infants

Pulmonary Hemorrhage in Infants

Pulmonary Hemorrhage in Infants

Sick Building Syndrome. III. Stachybotrys chartarum

Increasingly, physicians are being asked to evaluate patients with putative environmentally associated illnesses. These can include a variety of problems, including infectious illnesses (Legionnaire's disease), chemical exposure in the workplace, and sick building syndromes. The latter has been an issue particularly in asthma because of the association of mold and increased bronchial responsiveness. Recently, attention has been focused on the mold Stachybotrys in human disease. Stachybotrys was first identified more than 60 years ago following an epidemic of stomatitis, rhinitis, conjunctivitis, pancytopenia, neurologic disorders, and death in horses. Since then, Stachybotrys has been identified in several outbreaks of disease in animals. It has also attracted attention as a possible agent in idiopathic pulmonary hemorrhage in infants. Stachybotrys is a relatively uncommon fungus but has been isolated from a variety of sources, including contaminated grains, tobacco, indoor air, insulator foams, and water-damaged buildings with high humidity. This fungus is particularly important because it is one of a series of fungi that produces trichothecenes mycotoxins; these mycotoxins are biologically active and can produce a variety of physiological and pathologic changes in humans and animals, including modulation of inflammation and altered alveolar surfactant phospholipid concentrations. The presence of Stachybotrys in a building does not necessarily imply a cause-and-effect relationship with illness, but should alert physicians and healthcare professionals to do more vigorous environmental testing. Guidelines are presented herein for intervention measures in the maintenance of heating, ventilation, and air-conditioning systems.

Infant Pulmonary Hemorrhage in a Suburban Home with Water Damage and Mold (Stachybotrys atra)

The American Academy of Pediatrics recently issued guidelines regarding the potential toxic effect of indoor molds. We now report another case of an infant with pulmonary hemorrhage whose residential environmental assessment revealed the presence of the toxigenic mold Stachybotrys atra. We used a questionnaire to identify environmental factors that could predispose the home to fungal contamination. We collected air samples from multiple locations in the home that we felt would reflect areas of relevant exposure. Surface samples were collected with a piece of transparent tape for semiquantitative measurement of spores present. We classified spores into their respective genera based on shape, size, and color. We also measured mycotoxin levels. Air sampling revealed significantly elevated total spore counts in the patient's bedroom and in the attic. Aspergillus/Penicillium species were predominant. Stachybotrys spores were found in the air sampled in the patient's bedroom, as well as from surfaces sampled in the patient's closet and the attic ceiling. Additionally, a small patch of Stachybotrys-contaminated area in the closet ceiling was sent for mycotoxin analysis. This material proved to be highly toxigenic. As the link between the presence of Stachybotrys in the home and pulmonary hemorrhage in infants increases, further efforts should be made to educate physicians, health care providers, and new parents about the potential toxic effects of this mold.

Stachybotrys chartarum (atra) contamination of the indoor environment: Health implications

In 1998, widespread contamination of water-damaged school portables with the toxigenic mold Stachybotrys chartarum was detected in the province of Ontario. This mold may cause human disease through direct irritation, type 1 hypersensitivity or the production of toxins. A variety of respiratory, dermatological, eye and constitutional symptoms have been associated with heavy and prolonged exposure to S chartarum. S chartarum has also been potentially implicated as a rare cause of idiopathic pulmonary hemorrhage in infants. Ingestion of food heavily contaminated with toxin-producing molds, including S chartarum, can cause bone marrow suppression and immunotoxicity. However, the level of toxin exposure that occurs following inhalation of S chartarum is very low; consequently, serious adverse health effects from such an exposure are extremely unlikely. In a child with symptoms felt to be temporally related to the school environment, an assessment of the child's school should be carried out by the public health authorities so that potential irritants and allergens can be identified. Avoidance of exposure is the most effective mode of therapy. Buildings found to be heavily contaminated with molds, particularly S chartarum, should undergo thorough cleaning and repair to remove the offending agent(s), and prevent further water damage and mold overgrowth.