Volume 1 FAQ

85 Total Items

Question Volume 1

Do you order the same labs on children that we see on your physician’s order sheet?

Answer

No, see the labs we almost always obtain in kids in the IACFS paper on this site. HLA, MSH, C4a, MMP9, TGF beta-1, CD4+CD25++CD127 lo/- (NB this is a test only obtained from Quest Baltimore), AGA, ACLA.

Question Volume 1

I am trying to interpret my first few ERMI’s and nasal swabs – first, do the actual individual numbers on the ERMI for the various fungi mean anything (for example, Aureobasidium pullulans 16000, Cladosporium herbarum 44000) or is it just the ERMI itself that is the important value? And secondly, what constitutes a positive nasal culture – number of resistant organisms or types (ie pen R versus oxacillin R)? If it is the number of resistant organisms, how many? Thank you.

Answer

Please take a look at the ERMI articles available on the site. Review as well the PowerPoints (1) on SAIIE; and (2) SAIIE meets ERMI. There is a huge amount of discussion that we could share on this topic. The talk I did last week at the International Mold meetings may be of interest. The “HERTSMI-2″ score looks at 5 organisms from group I in ERMI and assigns weight to the values. Any score over 10 is a problem; with moldy buildings routinely having scores of over 16.This construct thankfully ignores Cladosporium and Aureobasidium. The key issue in nasal cultures is the resistance patterns. Count the number of distinct classes of antibiotic resistance. If two or more, statistically that is an organism that must be eradicated. The oxacillin (read this one as methicillin) resistance is quite common in these organisms.

Question Volume 1

Can the ERMI be used to assess remediation success? If so, is there a protocol such as how long to wait after the floors are cleaned before the test can be run again?

Answer

Yes. I use ERMI exclusively to assess effects of remediation. Wait one month to six weeks before repeating ERMI.

Question Volume 1

I’ve had a number of patients with high ERMI scores, but mold inspectors can’t find the source. What are some areas that are frequently overlooked?

Answer

Good question. I will ask the inspector what they did. If they didn’t do a survey with a moisture meter I tell the patient that the job was incomplete. The inspection has to be thorough.

Question Volume 1

When using the ERMI for post-remediation testing, does the carpet near the bed and couch simply need to be well-vacuumed before waiting 4-6 week to collect the post-remediation dust or does it need to be cleaned in a certain way to avoid re-sampling the pre-remediation dust?

Answer

Carpets are usually trash. I know of no method to reliably clean them. The published literature here is sketchy at best, however.

Question Volume 1

I have one case in which the ERMI score was high and the inspector didn’t find anything except that it was the dustiest house he had ever seen. Could the dust alone be the source of mold exposure?

Answer

The distribution of the ERMI tells what is making the problem. Sort the ERMI by Aw, water saturation, looking for the likely types of problems. Wallemia in HVAC is the big player in what appears to an intact building envelope. Dust itself has not been the source in any of my cases to date. I suppose if the dust were wet enough it could support fungal growth if there were cellulose in the dust too.

Question Volume 1

I’ve had a few cases in which mold inspectors said the reason why my patients’ ERMI scores were high was because mold was brought in from the outside, especially moldy decks, via footsteps onto the carpet. Have you found this to be true at times?

Answer

It is more the proximity to the door than what is tracked in by people or pets. I don’t know anyway to decide which is which however if the areas outdoors are tested and are similar to what is indoors.

Question Volume 1

Would you say that sampling areas close to exterior doors can cause a falsely elevated ERMI? Are there other conditions that can lead to falsely elevated ERMIs?

Answer

ERMI was standardized in master bedroom and living room. There should be good reason to sample other places. The standard was designed to be done on about 5 grams of dust. Technically the results should be independent of total grams, but if an area with a lot of dust dominates the sample, then it could skew the results as deposition of dust is not random in all areas.

Question Volume 1

Will the use of a HEPA filter affect the accuracy and usefulness of the ERMI test? For example, if someone is in a WDB, will HEPA filtration lower the ERMI score? If the ERMI is less than 0, is the building safe at least for the time being?

Answer

Cleaning will lower ERMI all reservoirs in air, wall and floor coverings and possessions. HEPA will prevent addition of inflammagen burden to dust but won’t correct the ERMI values in the dust.

Question Volume 1

How would you approach the following ERMI in a person with a confirmed mold illness (C4a>20,000) with an ERMI of 6 and HERTSMI-2 of 10? Group I: 21.66 Group II: 15.64 ERMI: 6 Asp Pen: 210 Asp versi: 1 Chaetomium: 1 Stachy: ND Wallemia: 240 HERTSMI: 10

Answer

Such high C4a is of concern. At 10, his HERTSMI-2 says he won’t get ill with re-exposure. I would have the C4a lowered significantly before re-exposing him and I would do a reexposure trial before I said the home was safe.

Question Volume 1

Based on the water sats, what parts of the house should there be focus on?

Answer

Still with the focus on fungi and water sats known, where we really need to go is to the genomics. I hope your office is included in the new PAXgene program. Call the office here if you are not.

Question Volume 1

What does one do if the HERTSMI-2 appears good, but the ERMI appears high?

Answer

HERTSMI-2 is trying to eliminate the problems of aureobasidium and some of the Aspergillus. It is important to see what the total ERMI is; what group I plus group II is as well (NIOSH likes that calculation and says that anything over 30 is a problem).

Question Volume 1

An industrial hygienist recently wrote the following to me regarding the ERMI: “I really do not know how to better explain the ERMI test than this: an ERMI test is NOT a mold test; it is a mold DNA test that measures POTENTIAL only. Mold DNA is common to all environments. However, only inhaled mold spores, from fully-developed mold mycelium, are a health hazard. If you have high ERMI scores, it is only a measure of potential mold growth in the future and not necessarily that actual mold growth exists.” “Below is just one of hundreds of links that caution the use of ERMI tests as a definitive measure of actual mold growth: http://ezinearticles.com/?Beware,-The-E ... ome-For-Mo ld-Is-Misleading! &id=619115″ How would you respond? Is there a good article that may help convince him to be more open to the use of an ERMI?

Answer

The statement makes no sense. The fungal DNA is collected in dust, not some phantasm of potential dust, whatever that is. Gorny and Cho have both published on fungal fragments being up to 500 time greater source of toxins and inflammagens than intact spores. I actually would discard the comment from the CIH about spores as being less than currently informed.

Question Volume 1

Does the ERMI primarily measure the DNA of mold, mold spores, or both?

Answer

DNA is found in mold fragments and intact spores.

Question Volume 1

Are any of the species of mold used in the HERTSMI-2 exclusively found in indoor environments and never outdoors?

Answer

No, but Chaetomium and A. penicilloides and A. versicolor are quite rare to be reported in outdoor samples. Having said that I have seen an occasional report of Chaetomium in outdoor samples from Washington State and Florida.

Question Volume 1

I have a question about ERMI and acceptable mold levels. I have a patient with biotoxin illness, just starting on Welchol, very chemically sensitive, very sick. She had made the decision to move into a new home and bought it and had it fixed up, with new flooring, etc. Then I come along with all my new knowledge and have her get an ERMI on her old home (still there) and new one. The old home ERMI is 3.7, HERTSM-2 4. The new home, she plans to move into soon, has an ERMI of 8.9, but HERTSMI2 is only 6. There is, however, a small amount of Stachybotrys (28) on the ERMI of the new house. That is the only HERTSMI-2 mold high enough to score points. Do they need to keep searching for mold damage? (The only thing found so far was a small leak under kitchen sink, had cabinet and wood all replaced). Is the Stachybotrys a big deal by itself, at that level, from your experience? (I know there are no guarantees.)

Answer

Stachy of 28 says there is a leak somewhere to create a water saturation (Aw) of 90-100. I would spend a good bit of time trying to find the source as ongoing leaks will take an ERMI of 4 and make it 14 over time.

Question Volume 1

I just learned from one of my patients that Mycometrics is now offering a 5 species ERMI based on the HERTSMI-2 for only $125. Given your experience with the HERTSMI-2, do you think the 5 species version is good enough in most cases?

Answer

Mycometrics consistently has a better detection limit than other companies when done side to side. I don't know why that is. The use of HERTSMI-2 was designed for assessing risk of known patients for illness from re-exposure. It is not the same as asking IF the person is exposed. ERMI gives Group I and II that NIOSH adds together. If the number is over 30, then that is not good. The total ERMI is quite helpful looking at total fungal burden as well, so I get those at baseline and when I have confirmed the illness then I can see saving a lot of money by just asking for HERTSMI-2.

Question Volume 1

If someone presents with +VCS, + labs, multisusceptible haplotype, and Lyme WB falsely negative and I treat presumptively as mold with CSM, can the VCS, C4a, and symptoms still improve? If so, are there any clues to the undetected Lyme?

Answer

A priori, how do we know the WB is falsely negative? There is great argument about use of antibody testing in Lyme and if used, which labs? One might ask if I have a Lyme patient, can I treat successfully without antibiotics. NO! Look for elevated C3a at baseline to help sort Lyme (will have elevated C3a) from mold (won’t have high C3a). I don’t use procalcitonin BTW, as some have advocated, as it is negative in most of my Lyme patients. Those with no recollection of a tick bite, no ECM, low C3a, low C4a and neg WB that have Lyme are rare, but they do exist. There are times you just don’t know. The best approach is due diligence in differential diagnosis. If VCS is not improving with CSM like it should, challenge the diagnosis you have made.

Question Volume 1

If someone presents with +VCS, + labs, multisusceptible haplotype, Lyme WB positive, and negative home ERMI, but undetected mold exposure at work and I treat presumptively as Lyme with antibiotics then CSM/Actos, can the VCS, C4a, and symptoms still improve? If so, are there any clues to the undetected mold?

Answer

Yes, the CSM will help both Lyme and mold. The best clue to ongoing occult mold exposure will be rapid reacquisition of illness after CSM is stopped.

Question Volume 1

Have you ever seen a case of post-Lyme with a normal C4a?

Answer

Yes, especially if the nasal culture is positive.