“Best Tests” For Suspected Toxic Indoor Mold Exposure: Pros & Limitations of Tests for the Body & for the Building

Let’s briefly discuss pros and limitations of mold testing for the body & the pros and limitations of mold testing of the home….here we go!

Starting to assess someone to see the burden from mold and mycotoxins on their body and to their home is a challenge to say the least.

Everyone always asks “what is the best mold/mycotoxin test?”

Short answer: there isn’t one (regardless if we’re talking about working up the body or the home!)

Reality: there is a bunch of puzzle pieces and nuances to consider when a person has possible signs and symptoms of mold/mycotoxin bioaccumulation that can lead to varying degrees of harm to the human body.

Here are considerations when looking at the options to assess the body for mold related illnesses:

1. VCS testing
Visual contrast sensitivity testing is a simple, free, online test to check contrast sensitivity in the eyes. When there is a positive test coupled with mold illness symptoms, there is an extreme likelihood of mold or other biotoxins altering normal eye function. The validity of this screening tool is well documented in medical literature. It does alone not diagnose any condition; it is just that: a screening tool but a good one and a free one.

2. Urine mycotoxin testing
This will detect mycotoxins in the urine. You must note that mycotoxins can be from any mold, which yes does include food; however food is hardly the culprit to mold illness and the amount that would need to be consumed is a lot per several studies; plus, avoiding moldy food will never be the stand alone solution to mold illness because it alone is ineffective; breathing in toxic indoor mold is the likely and realistic culprit as its ongoing, and so consequently much more detrimental. The amount of grains one would have to eat to become get mold sick from food is unrealistic: The average adult would have to eat over 14 pounds of oatmeal daily or 20 slices of bread daily (Sundheim L, Lillegaard IT, Faeste CK, Brantsaeter AL, Brodal G, Eriksen GS, 2017 Feb 4;9 (2):46).

So the urine mycotoxin test is one good screening tool as it will tell you the type of mycotoxin coming out in the urine but the source still needs founds and you have got to rule out the environment as environmental factors are almost always what contributes to mold illness(es). Note, I do view the values of mycotoxins in the urine as somewhat arbitrary; this doesn’t make it a bad test but just note it has limitations. What is nice about the test is it shows the mycotoxin(s) in the urine (so this confirms some sort of mold exposure from somewhere) and this almost always goes hand in hand with the mold in the air sample or an ERMI dust test. In my opinion it is not enough to do a VCS screening and CIRS panel to assess for mold impacting the body as these two tests alone dont 100% confirm mold as the culprit; Lyme or other biotoxins still need ruled out or ruled in when CIRS panels are positive. This is why I believe some sort of mycotoxin test is not a bad idea despite its limitations.

3. Serum mycotoxin antibody testing
This a blood test and is slightly more $ than the urine mycotoxin test; I like it as another option as it will show that the immune system is detecting mycotoxins. If mycotoxins are detected, it means the person is actively exposed to mold and/or colonized. Mycotoxin colonization can occur from older exposures and doesn’t always mean it being currently breathed in. The purpose of this test is to see if there is a mycotoxin burden to the body and then current environmental exposure needs ruled out or ruled in. It is thought that the serum mycotoxin antibody test does not “pick up” mold from food.

4. CIRS (Chronic Inflammatory Response Syndrome) Bloodwork
A CIRS panel is slew of biomarkers (MSH, MMP9, TgFbeta1, C4a, C3a, VEGF, ADH, Osmolality, Leptin). When multiple of these are abnormal (plus a HLA haplotype confirmed via genetic testing, plus positive for CIRS cluster symptoms plus positive VCS test plus known water damage exposure), then a diagnosis of CIRS-WDB (water damaged building) is confirmed. The limitation of a CIRS panel is that is alone does not rule out or rule in mold is the only problem; Other biotoxins can cause a chronic inflammatory state. This is why I also like to see a urine mycotoxin test and/or serum mycotoxin antibody testing as this confirms mold is at least part of the picture. CIRS is the downstream result of biotoxin exposure like toxic indoor mold and usually happens when the person in question has a specific HLA haplotype causing mold illness susceptibility (about 25% of the population). This is why some people get “more sick” living in mold versus other family members in the same house. A priming event (like getting the flu for example) is often what sets off the response.

5. HLA Genetic Testing for Mold Illness Susceptibility
The Intermediate Resolution HLA DR1/3/4/5, DQ test helps detect specific proteins, called human leukocyte antigens (HLA), on the surface of white blood cells. These HLAs play a critical role in immune system function. Depending upon your test results, there is a chart that then shows if you are mold susceptible, Post lyme treatment syndrome susceptible, both, or low risk. Knowing this information can help you determine your susceptibility for developing CIRS if/when exposed to a biotoxin.

6. Mold Allergy testing
Mold allergy testing actually has little to do with mold illness or CIRS from mold. An allergy is an allergy and an illness is an illness. Mold allergies when tested for and positive just mean you can/will have an allergenic response to mold when exposed; this is much different than the pathogenesis of CIRS as shown in the CIRS biotoxin pathway. Mold IgG testing and mold IgE testing are worthless when it comes to the conversation of mold illness. If you are allergic, yes you need to avoid mold so you don’t have allergenic reaction. But mold and mycotoxins are not just allergenic to the human body; mold and mycotoxins are carcinogenic, hepatoxic, neurotoxic, nephrotoxic, immunotoxic, iatrogenic, etc. Overall Western Medicine does a poor job at acknowledging the research that shows the harm mold can cause; this is why so many must turn to Integrative/Functional Medicine aligned practitioners.

7.OAT (Organic Acid Testing)
An Organic Acids Test (OAT) is a functional test that purports to detect metabolic imbalances and abnormalities in the body. This involves analyzing the levels of small molecules called organic acids in a urine sample. OAT provides the most sensitive and specific test for mitochondrial dysfunction, which mold assaults the mitochondria of cells. Some of you may remember learning about the Krebs Cycle in biology, a complex process of converting food and air into energy within the mitochondria, so the OAT test takes a look at metabolites that serve as important players in the these bodily processes that require specific nutrients and enzymes.  In addition to thee above, the OAT can give insight into microbial overgrowth. Toxic indoor mold is immunosuppressive and exposure lends itself candida overgrowth in the body.

As you can see it is an intricate puzzle piece to assess the human body when it comes to suspected or confirmed mold exposures. To summarize, the VCS and a mycotoxin test are often done as an initial screen. If both are “positive” and a person has CIRS symptoms, checking the home for mold is the next step and a CIRS panel.

TESTING THE HOME FOR MOLD
Same principle applies: there isn’t one best test, but rather a series of puzzle pieces. Multiple types of mold tests to check the home have pros and limitations. A “good” certified mold inspector will assess the home through multiple lenses. (If you are a renter, this is on your landlord to hire. If they refuse which is wrong, here are steps you can take).

1. Thermography: 
A device exists to detect temperature variations that might indicate hidden moisture problems behind walls or under floors. Remember moisture and/or water is/was always involved in mold growth. If moisture/water is found, mold is likely. (Preventing water or excess moisture is the way to prevent toxic indoor mold growth that can you make you sick).

2. Relative Humidity Screening:
Detecting elevated moisture levels and/or water damage in building materials, indicates potential mold growth areas. Organic materials plus water or moisture = mold growth typically within 24-48 hours. Moisture needs to been taken seriously as it is the gasoline to the mold fire. The source must be found and addressed, and remove the mold that did grow, when applicable. Preventatively speaking, dehumidifiers must be running at all times in every basement year round and in any environment that starts to go above 45% humidity. Un-encapsulated crawlspaces are notorious for dangerous mold growth and need encapsulated and a professional grade dehumidifier installed. Basements and attics are other common areas for excess moisture, leaks and poor breathability resulting in mold growth.

3. Air Sampling:
The EPA recommends air sampling as the gold standard and it can show air borne mold. It is one snap shot in time and doesn’t always pick up “heavy molds” that fall flat – like black mold. The CIRS medical community doesn’t advise air testing alone given this limitation and states the ERMI dust testing is more valid to gauge safety for someone with CIRS. A person with CIRS can get sick from “just a little bit of mold.” Note that one square inch can put off over 1 million spores…..per day! They must be much more careful and their mold inspector needs to be CIRS literate and understand the gravity of the genetics of those with specific HLA haplotypes. Research has shown that someone with CIRS gets better when the ERMI for someone with CIRS is less than 2 if their MSH is less than 35. If their C4a testing was >20,000 and MSH<35, then a safe ERMI is <-1. After remediation, once the HERTSMI-2 is <11, the building is safe to enter again. 

You must understand though that the industry standard of sampling the air even though spore traps can only detect particles that are larger than 3 microns and therefore, miss over 99% of the inflammagens. Studies have shown that for every spore, there can be 100-500 inflammagen carrying fragments. The World Health Organization has stated that if one wants to do air sampling, it should be done in multiple locations per room which can become time consuming and cost prohibitive. It’s almost important to highlight that there are multiple techniques for doing air sampling like cavitation sampling (getting sample from behind the wall which is more accurate for that location).

Finally, only the ERMI and HERTSMI have been associated with sequential activation of innate immune responses, not air testing. I have seen numerous patients who have been told that their air tests were “normal” yet they had high ERMI or HERTSMI scores and their bloodwork shows persistent inflammation. This is not to say air testing is worthless; it absolutely has worth but generally captures a snapshot of data but it is definitely better than doing nothing and it is the industry standard which makes it challenging as it’s not the medical standard especially in the CIRS Shoemaker World – which is where a lot of the “back and forth” occurs in terms of arguing “who is right.”

Air sampling and ERMI dust testing are just measuring different things – one sample in time of the air and one sample in time of the the dust. You have to take both with a grain of salt. If the air sample is okay, but the patient has symptoms, has positive gene test, has a positive VCS test and has abnormal bloodwork, a deeper dive into the home may be needed and also ruling out Lyme or other types of endotoxins in the home making a person ill.

4. ERMI
ERMI (Kit 1) stands for environmental relative mold index; it is a dust sample that you can self order here (recommend ordering kit #1 if you want to check mold only and kit #8 if wanting to check mold, endotoxins and actinomycetes levels) quantifying the type and amount of mold and other endotoxins. Some argue it can just show a “dirty home” and maybe you only need small particle cleaning and don’t actually have water damage as the mold present in the test could be from a “normal amount of mold” comparable to what is outside, but the person just never dusts their home and mold has accumulated in the dust sample making it look falsely high. Given this test has the possibility to over diagnose, but also underdiagnose too depending upon user error and how and when the sample is collected, that is what can make the ERMI challenging. The air sampling also has been shown to underdiagnose and why it is just one tool. Another downside with ERMI too is if a patient is just doing this on their own, it doesn’t indicate what so ever the where and why and source; this is why I always recommend a certified mold inspector instead of an ERMI alone the whole home needs evaluated using multiple methods.

5.AMEA:
AMEA is a hybrid mold assessment test and I joke it is “half air sampling and half ERMI.” The mold inspector will agitate the dust in the home with a leaf blower so it becomes air borne and then do a longer air sample of an hour. Many are moving to doing AMEAs as a part of the assessment to capture both the air and dust levels.

Summary of Mold Inspection:
No one test alone to assess the living environment will replace the critical thinking of a certified mold inspector who takes into account the big picture. Because finding out that mold is present in the home is just half the battle. The other thing that is likely the most important is finding the source of the mold and why did it grow in the first place. Mold inspection and remediation is weak if you just treat and don’t put the preventative measures in place; otherwise it will grow right back.

Qualified mold literate practitioners and certified mold inspectors understand a lot of nuances in the “mold world” and can help guide the patient in assessing the body and the home, respectively. I wish there was one “best test” for both worlds but it is really a series of puzzle pieces that need gathered as unfortunately no one agrees 100% when it comes to assessing mold there are shades of gray given the pros and limitations to various types of test.

But even amidst the gray, we can’t just sit there and do nothing as mold is a potentially lethal biotoxin depending upon the amount and multiple other factors. Imperfect action always over burying head in the sand to the realities of mold illness. The ONE question to be asked is – does the person have possible signs and symptoms of mycotoxin/mold illness? Then start overturning the mold stones. Period.

The key to moving the needle of health in both healthcare and mold inspection world is being extremely thorough in testing and not guessing and considering multiple angles.

The next steps are then the proper interventions once found….read about interventions here for mold illness.

If you are not sure where to start and you need a step by step game connecting the dots from start to finish, register for my Healing from Mold Program.

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