Mold illness & CIRS

In Dr. Hoffman’s words

What mold illness is

Mold illness is better described as chronic inflammatory response syndrome (CIRS), first described by Dr. Ritchie Shoemaker in the late 1990s. It is an inflammatory response to biotoxins, most often from water-damaged buildings: fungi with their mycotoxins, bacteria with endotoxins, actinomycetes, mycobacteria, beta glucans and volatile organic compounds. Mold accounts for about 80 percent of the CIRS illness burden; Lyme disease, dinoflagellates such as ciguatera, freshwater cyanobacteria and recluse spider bites account for the rest. Mycotoxins are extremely small, fat-soluble molecules that pass straight through cell membranes, which makes them very hard for the immune system to identify.

Why some people get sick and others do not

About 75 percent of people have an immune system that recognises and clears these toxins. Those with particular HLA genes cannot identify them, so they cannot eliminate them, and the innate immune system keeps producing inflammation that can reach every organ. It has been estimated that about 25 percent of people are susceptible; in my experience it is more than that. Not everyone exposed develops CIRS, and some only get allergy-type symptoms. Mold allergy is an IgE antibody response to spores. CIRS is chronic innate immune activation with downstream effects on hormones, so a negative mold IgE does not rule it out.

The symptoms

Headaches, brain fog and memory problems, fatigue, muscle and joint pain, numbness and tingling, light sensitivity, asthma and sinus trouble, vertigo, a metallic taste, night sweats, excessive thirst and urination, appetite changes and abdominal pain. Dr. Shoemaker has identified 37 symptoms in all, grouped into clusters, and because they seem unrelated many people endure years of misdiagnosis or are told the illness is psychosomatic.

How I investigate exposure

I work in layers. First the CIRS symptom questionnaire: more than eight symptoms in more than six of the subtypes puts mold in the differential. Then the visual contrast sensitivity (VCS) test, which about 92 percent of people with CIRS fail. Then the exposure itself: the history, a proper home inspection and ERMI testing. Then the Shoemaker labs: HLA genes, MSH, C4a, TGF beta-1, MMP-9, VEGF, ADH and osmolality, and a deep nasal swab for MARCoNS. A urine mycotoxin test cannot make the diagnosis: many healthy controls have mycotoxins in their urine, foods such as oats, corn and peanuts contain them, and the test cannot show when the exposure happened.

Testing and fixing the building

The best test of a building is the ERMI, a quantitative PCR analysis of 36 mold species in dust, or its shorter five-species version, HERTSMI-2, where a score of 10 or less is the cutoff for someone previously sickened. Air sampling is not a substitute: over 99 percent of the particles that carry inflammagens are smaller than 3 microns, and spore traps only detect particles larger than that. A good inspector works from attic to basement with an infrared camera or moisture meter. Remediation means correcting every source of water entry, replacing moldy wood, drywall and wet carpet rather than cleaning them, HEPA vacuuming and cleaning everything that remains, keeping indoor humidity below 50 percent, and filtering the air down to 0.1 microns. When the mold is affecting your health, the only real alternative is moving.

Treatment, in order

The Shoemaker protocol follows a fixed sequence: remove the exposure, bind the biotoxins with cholestyramine or Welchol, clear MARCoNS with BEG nasal spray, then correct anti-gliadin antibodies, androgens, ADH and osmolality, MMP-9, VEGF, C3a, C4a and TGF beta-1, with VIP nasal spray last, only once exposure has ended, VCS is normal and MARCoNS is gone. In the complex patient I do not reach for cholestyramine first. When total lipid content on the red cell membrane test is low it can crash the patient, so cell membrane repair comes before binders; I screen for POTS and mast cell activation; and I establish trust and self-regulation first, because someone stuck in fight-or-flight cannot tolerate a complex protocol. CIRS is an innate immune response, not chemical toxicity, so detoxification and chelation on their own will not resolve it.

On the evidence

The 2002 ACOEM and 2006 AAAAI guidelines, which stated that mold exposure could not cause human illness, rested largely on opinion papers by consultants in water-damaged building litigation and cited no human studies. There are no long-term randomised trials of the Shoemaker approach, so it has not met Level I criteria, but it is patient-centred and documents quantifiable, reproducible responses to care, which is where evidence-based medicine is supposed to begin.