ISEAI 2023 Mold Symposium

I had the honor of attending the ISEAI 2023 event "2023 Mold Symposium" on November 10-12, 2023.  

It has long been my opinion that many of the complex conditions we face today are the result of our external environment.  ISEAI is a leading organization sharing this message; as well as fostering collaboration and sharing solutions to improve the quality of our lives.

I strongly encourage practitioners working with complex, chronic illnesses to join ISEAI; become part of the conversation and ultimately the solution.

Disclaimer: Nothing in this text is intended to serve as medical advice. All medical decisions should be made only with the guidance of your own personal licensed medical authority.

Disclaimer: This information was taken as notes during the training course and may not represent the exact statements of the speakers. Errors and/or omissions may be present.

Note: As this information may be updated as any errors are found, I kindly request that you link to this single source of information rather than copying the content below. If any updates or corrections are made, this will help to ensure that anyone reading this is getting the most current and accurate information available.

Jonathan Vellinga, MD talked with Mark Su, MD and shared:

• MTHFR, mold, vector-borne infections emerge and become a focus for a period of time; then realize it is much more complex than what you anticipated
• Chronic illness is a complex mosaic of many complex factors
• There is no one single concept, idea, or protocol that works for everyone

Todd Maderis, ND spoke on "The Pathophysiology of Mold Illness” and shared:

• Mycotoxins are produced by mold spores; secondary metabolites for fungal survival and competitive advantage
• Modified mycotoxins are produced by parent mycotoxins and not detected with any available testing; can be more toxic than the parent mycotoxin
• Exposure to spores via inhalation, ingestion, and topically; mycotoxins just slightly larger than viruses
• Probably getting exposed more dietarily to mold spores and mycotoxins than we recognize
• Mold can colonize in the body and persist after someone has left the moldy environment
• Mold leads to oxidative damage
• Reference range for 8-OHdG is often too high; want < 4
• Mycotoxins can lead to oxidative stress in the nervous system
• Oxidative stress may lead to increases genotoxicity
• Phospholipids can repair cell and mitochondrial membranes; one of the most important treatments available
• DNA adducts can be formed when a toxin attacks DNA
• Deficient glutathione plays a role in mycotoxin-related illness; mycotoxins interfere with the production of glutathione
• Mold leads to immune dysregulation; it is more than just an inflammatory response
• Exposures lead to changes of cytokine and chemokine production
• Inhalation of mold spores impacts the innate immune system; inflammation in the hippocampus leading to increased pain and anxiety
• Symptoms above the neck are often inflammation in the brain
• Mycotoxins can lead to WBC death and immune system suppression
• Gliotoxin may trigger neuroinflammation and demyelination 
• Autoimmune conditions can likely be triggered by mold and mycotoxin exposure
• Mycotoxins increase Th17 which impacts the blood brain barrier
• Some mycotoxins can lead to increase in Th2
• Fungi, mold spores, and mycotoxins can induce mast cell degranulation
• Toxins and infections are the most common cause of mast cell degranulation
• Mold may lead to mitochondrial dysfunction 
• Healing from chronic illness is a whole body process that begins with the mitochondria
• Mold exposure may lead to antimitochondrial antibodies
• Mold can lead to neurological damage
• Ochratoxin A may play a role in neurodegeneration 
• Mycotoxins may play a role in targeting astrocytes and oligodendrocytes and lead to MS
• Mycotoxins may be a contributor to Parkinson’s disease; OTA may lead to a decrease in dopamine 
• Some speculate mycotoxins may lead to ALS
• Mycotoxins can increase intestinal permeability
• Recalcitrant cases of SIBO may be related to exposure to water-damaged buildings; may be SIFO
• More and more convinced that colonization of mold in the sinuses has a big role on symptoms and recovery potential
• Substantial deposition of Stachybotrys occurs in the nasal mucosa
• Mold should always be removed in a house; not killed
• Need to support detox, drainage, binders when using antifungals as more mycotoxins may be produced 
• Every MARCoNS test except or one patient was positive; does not change his approach to treating
• Uses a lot of IV PC which seems to be the best option; oral PC on days they do not have an IV
• Used MyMycoLab for 2-3 years and found it initially helpful for guiding antifungal therapy but moved back to largely using provoked urine mycotoxin testing over time
• Uses NasoNeb and compounding pharmacy for antifungal therapies

Nafysa Parpia, ND spoke on "Pre-Tox Protocol: Preparing the Body for Detoxification” and shared:

• Detoxification therapies can be premature in "wastebasket diagnoses"
• Want to open channels of elimination before doing cellular detoxification
• Remove the trigger and support organs of elimination
• Inflammation is a byproduct of detoxification; detoxification may further drive inflammation
• Detoxification when inflammation is already high is not appropriate
• Identify the driver and mediate it
• Modulate inflammation prior to initiating detoxification
• Consider gut, liver, kidneys, skin, and lungs
• Detox is premature: toxin overload, nutritional deficiency, detox SNPs, dysregulation of organs of elimination, emotions, structural integrity
• Treat prior to detox: constipation/GI issues, UTI, MCAS, nervous system, sleep, hyper/hypotension, headaches, hormonal imbalance, insomnia
• Nervous system needs to be in a parasympathetic state to detoxify efficiently
• Efficiency of detox impacted by genes, emotions
• Factors that impact efficiency of detox
  • High endotoxin load: infections, bacterial toxins, yeast/Candida, stress
  • Exotoxin load: metals, solvents, VOCs, pesticides, plastics, phthalates, parabens, mold/mycotoxins, EMFs, medications, diet
  • Reduce exposures before starting detoxification
  • Structural integrity: EDS, CCI, MCAS; take inflammatory burden off of lax ligaments; some patients may have tight tissues which will lead to issues with blood and lymphatic flow
• Preparation for Pre-Tox I
  • Take history
  • Run labs
  • Diagnose
  • Organic diet
  • Evaluate nutrients
  • Hydration
  • Sleep
  • GI Issues
  • Hormone balancing
  • Movement
  • Emotions
• Product ingredients do not have to be safe for a product to be on the market
• GI issues are often related to infections and nervous system dysregulation
• There are no straight lines in complex, chronic illness.
• Healing begins when a patient is believed and heard
• Most patients have emotional traumas from their illness; not from prior to it
• Likes Radiance Labs Long-haul panel
• Micro-clotting test from spike proteins is important to look at; want to treat before detoxing
• Likes Parasitology Center testing
• BiomeFX tests of GI MAP for microbiome exploration
• Microgen or Microbiology Dx for sinus colonization
• Viruses create inflammation and impact the nervous system
• IGeneX TBD Panel 10 and culture testing helpful
• Likes IGL for environmental toxin testing; Mosaic Labs also helpful

Georgina Hale, MD spoke on "Anti-Fungal Therapy: Is There a Place for it in Mold Illness?” and shared:

• Can have invasive fungal infection or colonization which are different entities
• Yeasts are single celled; like warm environments; reproduce by asexual budding or binary fission
• Molds are multi-cellular; reproduce by sexual or asexual spores; can grow in low temperatures
• Invasive fungal infection leads to immunosuppression; progressive and fatal, if untreated
• Mold illness is inflammatory; exposure to mycotoxins, immune dysfunction, dysbiosis, poor detoxification
• Yeasts: Candida, Cryptococcus, Pneumocystis
• Molds: Aspergillus, Mucorales, Mucormycoses, Fusarium
• Dimorphic fungi: Blastomyces, Coccidioides, Histoplasmosis, Penicillium, Sporothrix
• Invasive fungal infections largely Aspergillus and Candida; immunocompromised patients
• Risk factors: bone marrow suppression, cancers, HIV, steroids, diabetes, antibiotics, IV drug use, abnormal anatomy
• Aspergillus treated with Voriconazole, Posaconazole, Ampho B; Fusarium same but may use liposomal Ampho B; Penicillium with echinocandins and liposomal Ampho B; Mucormycosis with Voriconazole, Posaconazole, liposomal Ampho B; Candida with echinocandins, Fluconazole, liposomal Ampho B
• Colonization is not the same as invasive infection
• Can have an allergic Aspergillosis which may be treated with immune suppressants; does not need antifungal therapy
• Mold illness is from the mycotoxins from indoor mold
• Mycotoxins can be direct, potent mitochondrial toxins
• Those with EDS are more susceptible to mycotoxins and MCAS
• Treatment of mold illness is removing the mold, detoxification, inflammation, oxidative stress, immune support, MCAS, managing trauma, treating limbic system
• Non WDB sources: foods, in the body
• Do indoor molds colonize the gut or sinuses?  Data suggests yes
• Can mold colonization lead to clinically significant mycotoxins?  No clinical data; Dr. Dennis finds this is an issue
• Why are we using antifungals?  To reduce mycotoxins from colonized organisms?
• Treating MARCoNS may just create more resistant bacteria; probably not helpful
• Treating based on an OAT test is not scientific
• Itraconazole has become popular; more activity than Fluconazole
• Reasons for using Itraconazole are “a little flimsy”; what are we treating?
• Candida overgrowth is not the same as mold illness
• Itraconazole inhibits cytochrome P450 3A4 and 3A5; responsible for metabolism of numerous medications; interferes with bile acid detoxification
• Itraconazole covers some Aspergillus and most Candida
• Poor absorption orally and influenced by food intake and gastric acid
• Many reported side effects of Itraconazole
• Can Itraconazole harm mold illness patients?  Are we interfering with detoxification process or liver function?
• The more we use antimicrobials, the more epigenetic pressure we apply to the world of pathogens and more resistant pathogens emerge
• Not a good principle to treat colonization; treat by restoring balance, not worsening it
• Short term topicals/nasal antifungals are fine but not systemic antifungals
• Clear biofilms with Xylitol; sinuses with saline, probiotics/prebiotics; address gut health
• Effective for SIFO: oregano, thyme, sage, berberine, caprylic acid
• Itraconazole has a half-life of around 40 hours
• Colonization can lead to biofilms
• 1% of lower H2O2 douches or boric acid for vaginal fungal support
• Uses probiotics on a Qtip at night

Jill Carnahan, MD spoke on "Small Intestinal Bacterial and Fungal Overgrowth: Everything You Need to Know” and shared:

• Fungal dysbiosis is common and contributes to inflammation; increases food allergies and leaky gut, as well as immune suppression
• Carb cravings or white coating on the tongue are common signs of fungal dysbiosis
• Alcohol intolerance due to production of acetaldehyde; fills the bucket
• Risk factors for SIFO: antibiotics, diabetes, steroids, immune suppression, pregnancy/birth control pills, age, stress
• GI fungal dysbiosis can aggravate asthma
• Mycobiome varies by location in the body in terms of organisms more likely to be present
• Diagnose fungal dysbiosis: stool culture, organic acids (arabinose, citramalic acid, beta-keto glutaric acid), immune response (Candida IgG/A/M, Candida antigen)
• Related conditions: mood, PMS, MS, seizures, cancer, CFS, Interstitial Cystitis, autism, Alzheimer’s, SLE, FMS, Schizophrenia, Crohn’s, Ulcerative Colitis
• OAT: 2, 4, 5, 6, 9 for mold; 1, 3, 7, 8 for yeast
• Arabinose > 50 is significant
• 1, 3, 8 more general yeast and less specific to Candida
• Mold can directly create oxalates in the blood
• OAT does not replace urine mycotoxin testing
• Saccharomyces boulardii can be helpful, but Saccharomyces cerevisiae can be problematic; do not use Saccharomyces when positive antibodies are present
• OAT is one of the most clinically helpful tools she has in her toolbox
• TGFb1 can be produced from fungal dysbiosis
• Treatment: Fluconazole or Itraconazole, Nystatin, Ampho B; Undecylenic acid, Caprylic, Garlic, Uva Ursi, Oregano, Pau D’Arco, Olive Leaf
• Doesn’t feel avoiding mold in the diet is always necessary
• Oxalates can be from human production, plant sources, and internal mold
• Yeast, bacteria, and protozoa can create oxalates in the liver
• B6 can help with metabolism of excess oxalates to glycine
• Eliminating all oxalate foods can lead to oxalate dumping and make symptoms worse; reduce 10-20% at a time
• Oxalates: hydration, low oxalate diet, antifungals, calcium or magnesium citrate, chondroitin sulfate to prevent formation, B6 to degrade, excessive fats may increase oxalate absorption, probiotics may degrade in the intestines, Omega 3, E, selenium, arginine may minimize damage
• Herxheimer: reduce dose, add enzymes, hydration, sleep, neutralize toxins, activated charcoal
• Low plasma DAO can be used to diagnose histamine intolerance
• LPS causes mast cell degranulation; increases histamine 4-15 fold
• Lower histamine: Ascorbic acid (low if oxalates), B6, quercetin, luteolin, skullcap, medications
• Lactobacillus rhamnosus and Bifido can breakdown histamine
• DHPPA can be from beneficial bacteria
• SIBO breath testing; cannot diagnose SIBO through stool or urine
• Methanogen SIBO is now called IMO; intestinal methanogen overgrowth
• Evidence does not support FMT for SIBO
• Evidence points against the use of probiotics when treating SIBO; exception spore-based
• Bile is bacteriostatic; bitters can be very helpful
• Prolonged PPI use may lead to SIBO
• Restless legs common in SIBO
• E. coli, Klebsiella, Enterococcus, Strep are commonly seen in SIBO
• Low FODMAP diet can be helpful for 4-6 months after initial treatment; siboinfo.com combination of SCD/SIBO diet
• Treatment: Rifaximin, Metronidazole or Neomycin; prokinetics: LDN, erythromycin, prucalopride, Iberogast, ginger; herbs: berberine, oregano, garlic, neem
• 3-Oxoglutaric acid on OAT is related to oxalates 

Andrew Maxwell, MD spoke on "Management of POTS in the Mold Patient” and shared:

• Every part of the body can be affected in a mold patient
• Genetic vulnerability or canary in the coal mine; first to become sick with toxin exposures; can be genetic variants in connective tissue, immune system, mast cells
• Mold and mold toxins, blue green algae, industrial toxins, stealth infections like Bartonella, EMFs
• Triggers may involve mast cells or have a direct toxic effect
• Mast cells may activate in locations far from the trigger
• Mast cells can secrete materials that break down connective tissues; elastase 2 and others; can lead to a hypermobile state
• Hypermobile conditions may be environmentally-induced; CCI, loss of airway
• COVID and COVID long haul may be very similar triggers
• Dysautonomic patients can have top-down assault, full body assault, or bottom-up assault 
• MCAS, EDS, and Dysautonomia are the “triad” and may be causal with one another
• 1/3 of his dysautonomia patients have MCAS and many also have hypermobility; generally more sick than those without
• MCAS can release TNF-a, elastase 2, histamine, heparin, tryptase, and more
• EDS may not show generalized hypermobility
• “Pentad Super Syndrome” is the triad plus autoimmunity and GI dysmotility
• Environmentally-exposed patients may start with MCAS vs a post-concussion patient that may have more dysautonomia
• CRPS and MCS are often associated with underlying MCAS
• Doesn’t matter how it starts; all roads lead to the “Pentad Super Syndrome”
• Dysautonomia can cause slow GI motility which can activate mast cells and inflammation of the vagus nerve
• EDS patients may damage the vagus nerve 
• Dysautonomia may arise from CCI loose ligaments at C1/C2 causing vein compression creating Pseudo-Eagle Syndrome and impacting drainage and blood flow
• Cranial nerves 9, 10, 11 can get injured together and create neurologic dysfunction
• Mold toxic person may lose control over latent viruses
• Vagus nerve is a cholinergic nerve
• Dysautonomia is dysfunction of the parasympathetic nervous system
• POTS is not dysautonomia; cannot diagnose as POTS unless > 6 months; heart rate rise of 30 or more points when standing in adults
• Some with POTS do not have anything wrong with their ANS; though they likely develop dysautonomia over time
• Aldosterone Paradox – pooling blood leads to inappropriate diuresis and worsening orthostatic intolerance, fatigue, brain fog, dyspnea, urinary frequency
• Sympathetic overdrive can lead to palpitations, racing heart, anxiety, insomnia, subtle hyperventilation; edge of a panic attack, migraines, brain fog
• Co2 in plasma is most important determinator of cerebral blood flow
• POTS is a saggy preload + sympathetic overdrive; proximal heart failure or pre-load failure
• POTS: hyperadrenergic (sympathetic overdrive), hypovolemic (aldosterone paradox predominant), neuropathic (small fiber neuropathy caused by diabetes or autoimmunity)
• Have to manage the entire pentad
• Have to tackle: genetics, triggers, metabolism, consequences, symptoms
• Therapies: improve autonomic function, support connective tissues, suppress sympathetic overdrive, optimize vascular volume, treat small fiber neuropathy, restore cholinergic activity
• Need to treat your body like a sports car
• Diet, 3/5 of a gallon to 1 gallon of electrolyte water per day, 7-8 grams of salt a day, sleep, exercise (aerobic, core strengthening, leg muscle strengthening) 
• Find a sweet spot with exercise  where symptoms reduce without being too sedentary or too intense
• Compression garments can be helpful
• Inclined bed therapy can change kidney physiology and lead to increased fluid during the day
• MCAS: low histamine diet, treat SIBO, DAO, methylation, block elastase 2, glutamine, cromolyn, Ketotifen
• Big 5 Treatments for Dysautonomia and POTS: Midodrine, Fludrocortisone, Pyridostigmine, Corlanor, Beta-blocker
• Elastase 2 inhibitors: Horse Chestnut Seed Extract, I3C, Streptochlorin
• Has not seen much benefit from vagal nerve stimulators
• Breaking up fascia can be a helpful strategy

Scott Rattigan, JD spoke on "Expanding Your Impact Legally: How to Safely Practice Telemedicine and Reach More Patients the Right Way” and shared:

• Book: The Practice of Telemedicine: A Complete Legal Guide for Licensed Healthcare Professionals
• A provider must be licensed in the state in which the patient is located during the visit
• Includes live encounters and emails/portal messaging
• Skype is not HIPPA compliant
• Need to be licensed and have malpractice coverage in states where patient is located
• Can do peer-to-peer consultation without licensure in a state
• Can get: special telemedicine only licenses or interstate licensure compacts 

Robert Naviaux, MD spoke on "The Mitochondrial Road to Recovery from Chronic Illness” and shared:

• Mitochondria have rapid metabolism and are the canaries in the coal mine
• They create metabolic and epigenetic memory that cause the core symptoms of autism and other conditions to persist
• ASD, ME/CFS, long COVID and dozes of other complex disorders will persist 
• When ATP leaks out of the cell, it signals danger
• Exposure to environmental chemicals can delay the healing process
• Salugenesis is the creation of health from illness
• We don’t yet have salugenesis therapies in our quiver
• Follows 30 different complex disorders; all have increased since 1980s
• Golden Retrievers lived 16-17 years in 1970s; now live 10-12 years
• Millennials sicker than GenX and Baby Boomers
• Autism increased 417% since 2000
• A drop of blood is like a sample of water from a river or ocean ecosystem
• Chronic disease is the result of a recurrent systems abnormality; failure to complete the healing cycle
• CDR: ME/CFS, suicide, TBI, PTSD, aging, exercise, OCD, Gulf War, Lyme, Autism
• You can’t heal, learn, or fight off infections if your cells cannot change
• Anti-puringergic drugs are in pre-clinical testing
• eATP is an initiator; calcium propagates the signal and many cytokines and signaling molecules are engaged 
• Mitochondria must be reprogrammed from M1 to M0 to M2 
• If mitochondria do not return to health within 6 months after injury, infection, or stress, they are receiving signals that are telling them that danger persists and healing is incomplete
• CDR1 is an M1 type; CDR2 is M0; CDR3 and health are M2 mitochondrial phenotype
• CDR1 is inflammation; CDR2 is proliferation; CDR3 is remodeling
• Different cells and tissues will move through the cycles at different rates; when most of the cells move through the process, eATP reduces
• “Danger is gone” is a different single from “safe”
• Non-communicable diseases can be triggered by a communicable disease that activates the CDR
• Most chronic illness from 3 synergistic hits
  • Genetic or environmental predisposition
  • Pre-symptomatic period of multiple environmental exposures that trigger the CDR needed to heal; head trauma, COVID, etc.
  • Hypersensitivity to ATP signaling that inhibits or blocks completion of the healing cycle (disrupted salugenesis leads to progression) 
• No single gene is responsible for more than 1 in 200 cases of autism
• 14% of children with ASD had one of 134 ASD associated genes
• 86% of children with ASD did not have a causal DNA change
• Most ASD is the result of strong gene-environment interactions during critical window of development
• Autism is a pluricausal disease 
• ALS is also pluricausal and rising
• Ultimate cause is the cellular response to a variety of different stressors
• 90% of chronic illness is puricausal
• Most risk factors increase the risk of several different chronic illnesses
• Mitochondria are not damaged but persisting in performing functions that should be finished
• Early life stress and ACEs may crate chronic hypersensitivity to eATP signaling
• Prevention: environmental monitoring to reduce triggers and presymptomatic screening and early diagnosis to lessen future illness
• Treatment: turn off triggers, turn off danger signals, turn on safety signals
  • Remove triggers of the CDR
  • Desensitize short-distance cell danger; anti-purinergic therapies
  • Restore long-distance safety signals that connect CNS, organs, and mitochondria
• He mentioned some tools like Safe and Sound Protocol and others to send safety signals to the body
• You can learn all you want about pathogenesis, but after the insult has been cleared, we have a biological process that helps us to get better but we don’t know very much about it yet
• If in CDR1, some tools like phospholipids and plasmalogen precursors may not be supportive or could be potentially detrimental; we need to permit the inflammation to occur
• Vagal nerve stimulation, photobiomodulation, and other technologies are coming online and will be synergistic with metabolic interventions
• Limbic system interventions may be helpful for creating safety signals
• Need to turn off local cell danger responses and turn on the remote anti-inflammatory pathway is what we ultimately need to do
• EMF exposure is a problem but some are more sensitive than others

Nafysa Parpia, ND and Eric Gordon, MD spoke on "Applications of Cell Danger Response and Mitochondrial Road to Recovery in Clinical Practice” and shared:

• CDR is a story to understand where approaches may be helpful or not helpful for a patient
• Once the CDR is triggered, want to get the body to return to the health or healing cycle
• Treating the trigger works with acute issues but does not work in chronic illness
• If lactic acid is high compare to pyruvate, this could be an indicator of mitochondria that are stuck in CDR1
• Have to work on lowering inflammation but not adding a lot of mitochondrial support
• If mitochondria think there is danger, they won’t use supplements to make ATP
• This is a mosaic; not happening one way
• Different parts of the body can be in different stages of the CDR
• Chronic illness patients often require a broad collection of interventions
• Exposure to sun, grounding, nature, breath, subtle movement, sleep, nutrition
• Love will allow fear to ebb
• Being sensitive can be your superpower and your Achilles heel
• Clinical history is key for identifying triggers; patients will tell you

JW Biava spoke on “Part 1: Know Your Tools – Laboratory Factors and Their Impact on Clinical Validity” and shared:

• RealTime, Mosaic, and Vibrant partnered with ISEAI to better understand available testing
• Mycotoxin results are not comparable between laboratories; they test for different analytes with different technologies
• Best to pick one and stick with it over time for a given patient
• At least 300 mycotoxins exist; probably closer to 400
• No lab tests for all 300-400; nor are all common in indoor environments 
• Non-lab variables: environmental exposure, past exposure, colonization, diet, supplements, detox ability, stress, exercise, sweating, hydration, provocation (sauna, NAC, glutathione), collection of representative sample, proper sample handling
• Saw one case where a mushroom supplement was contaminated with Chaetomium
• Lab variables: reference standard preparation, extraction of reaction efficiency, matrix interferences, analytical variability, modification of mycotoxins (glutathione)
• Day to day variations are: +/- 30% based on diet, supplements, detox, metabolic stress, exercise, sweating, hydration; +/- 50% based on provocation; +/- 20% based on collection and handling of sample; +/- 20% based on the lab variables above
• Reduction or increase may not mean anything; have to consider the factors involved in expected variations
• Two testing technologies are in use today: ELISA and LC/MS/MS
• ELISA: uses specific antibodies to bind to mycotoxin of interest; must be repeated for each antigen tested; produces a color change analyzed with a microplate reader
• LC/MS/MS: urine is extracted and put into instrument for analysis; each toxin has its own fingerprint; very sensitive, very selective (not groups of compounds)
• Mosaic: LC/MS/MS; 11 mycotoxins (adding more); creatinine corrected to compensate for concentration of the urine; ranges are based on 100 healthy volunteers without known mold exposure using 95% confidence interval; adding to reference range population over time; provocation could result in LOWER results as modified mycotoxins may not be detected
• RealTime: ELISA; adding LC/MS/MS for additional mycotoxins; 16 mycotoxins tested in 5 groups; in use for 17 years; results are not adjusted for creatinine; not convinced that the correction is needed for a reference range across a population but may be helpful for a specific person; free and modified mycotoxins in the urine sample; LC/MS/MS can produce false negatives due to mycotoxin modification; up to 30% variation day to day for same patient; does not have a reference range related to clinical symptoms or population statistics; glutathione and NAC do not negatively impact ELISA (they may LC/MS/MS); methylene blue is an interferant and testing will need to be resampled; uses a detection limit and NOT a reference range
• Vibrant: LC/MS/MS; 29 mycotoxins tested; available 3-4 years; working to expand further; creatinine corrected; provocation could result in LOWER results (same as above); 10-20% error bar; reference range based on over 1000 patient samples; results reported using 75th and 95th percentiles
• Is the fishing net of what is tested for today adequate to determine what may be impacting a person’s health?
• Similar cost between the three labs
• All perform negative and positive controls
• We may not make antibodies to certain mycotoxins; which is a limitation of ELISA and why RealTime is adding an LC/MS/MS test in the near future
• None of the three labs are CLIA or FDA reviewed for the methods used
• Cannot compare results from one lab to the results of another
• Vibrant performs LC/MS/MS; they do not use a “lab on a chip” or proprietary micro-array 
• RealTime has 5 reported analytes; a separate analysis is required for each 
• All labs use in-house developed methodologies
• Mosaic and Vibrant use in-house developed reference ranges
• Urine mycotoxin testing should not be used exclusively for diagnosing mold illness
• Creatinine correction is very useful
• Would ideally perform three urine draws and analysis per patient in a perfect world; or could take 3 non-consecutive day draws and combine them

Mark Filidei, DO spoke on “Part 2: Issues in Clinical Interpretation” and shared:

• Has lectured that these mycotoxins can be from food
• Cannot diagnose mold illness based on urine mycotoxin testing alone
• Works with SPECT scans and then figures out why it looks like it does; mycotoxins are one of the possible explanations
• Mold can be allergic or toxic
• Brain fog and cognitive impairment or top symptoms
• Ochratoxin A may lead to Parkinson’s
• Alzheimer’s patients may have fungal DNA on autopsy that were not found in controls; Candida can cross BBB as well
• Did a 5 day M-F serial first morning urine test and kept a food log; same office, same house; not on a low mold diet; some markers were consistent and others were more highly varied; one day out of five showed high Chaetoglobosin A
• Judging progress by urine mycotoxin levels may be akin to chasing ghosts
• Mold exposures from: WDBs and food
• Food IS a problem for mold and mycotoxin exposure
• US is pretty high for mycotoxins in grains compared to other countries
• Sent a famous brand of coffee for mycotoxin testing and found none
• Can be ingested and then go to liver, organs, brain, kidneys
• Binders minimize re-uptake of mycotoxins
• Main foods with fungal metabolites: cereals, dried fruits, nuts, coffee, spices
• Up to 80% of foods may be contaminated with mycotoxins
• Mycotoxins have been found in water sources
• Most common mycotoxins found in food are deoxynivalenol, patulin, ochratoxin, and aflatoxin
• Should sample the urine or at least 24 hours in a perfect world
• In one study, citrinin was detected in 94% of all urine samples
• Food ingestion is the main source of mycotoxin exposure
• There are limited studies showing urine mycotoxins come from environmental exposure
• Current urine mycotoxin testing results reflect dietary intake
• Urine mycotoxin testing is of limited use for assessing environmental illness
• Some of the mycotoxins are less common in foods and thus may be relevant information if found in urine mycotoxin testing

A panel with Mary Ackerley MD, Jill Carnahan MD, Kelly McCann, MD, Mark Filidei DO, and JW Biava shared:

• Dr. Filidei feels that history and environmental testing are the most critical; Shoemaker labs are not specific to mold; does not think MARCoNS is a thing
• Dr. Ackerley has done 3000 MARCoNS tests; stopped doing them; 60% have it and attempting to get rid of it may just lead to more resistance; nose is very important and likes Xlear; testing MARCoNS every 6 months will likely see it come back in everyone regardless of prior treatment; likes Shoemaker labs (COVID and vaccines cause same elevations seen in mold); has seen TGFb1 up to 89K
• Dr. Carnahan shared we should not throw out the labs but need to know the limitations of the tools we have available; labs may be helpful for getting patient to understand there is a real issue; numerous food allergies can be a clue for intestinal permeability issues; detoxification efficiency impacts urine mycotoxin testing results; uses VCS testing, VEGF, TGFb1, MMP9, ADH/Osmo, MSH; it is a bucketful of toxins that need to be unloaded; patients have many toxins and infections; does not hang her hat on any specific test
• Dr. McCann shared sauna detoxes not just mycotoxins, but also metals, persistent organic pollutants; coffee enemas, colonics, PC, glutathione, binders; many tools are going to help many potential contributors; patients have symptoms and causes; address symptoms and identify causes; improve deficiencies and address toxicities
• Dr. Ackerley doesn’t generally test for fungus in the nose but does often use Xlear; not so much what you use but can you reach them when it comes to sinus treatment; may use LactoSinus; ENTs can be helpful for looking at fungus and some may need surgical interventions; changes in row E in VCS testing may represent VOC exposure; urine mycotoxin testing may get worse as a patient starts to detoxify
• 70% lower risk of dementia with regular sauna use
• There are some reports that silver gets into the brain; Dr. Ackerley became more cautious about long-term use of silver; also cautious about nasal ozone
• Dr. Carnahan uses GSE nasally for fungal support; patients get into limbic loops around mold; we all need daily detox habits long-term; we can’t be afraid of living in our world
• There is a ton of mold in Arizona
• People often need to be talked down from the mold hysteria
• There is no such thing as a dreaded gene; do not do HLA testing; the DR4 dreaded gene may have more resistance to COVID
• We are not just the mechanics of the physical body; healing occurs on many levels
• Dr. Carnahan noted that limbic looping does not mean it is all in your head; inhalation of toxicants drives a limbic response; very real physiologic response; 100% of her mold patients need to work with the limbic system as a part of their treatment plan
• Dr. Ackerley looks at the limbic system with NeuroQuant; it is in your brain, not in your mind; sympathetic overdrive negatively impacts detoxification 
• JW Biava suggests improving ventilation and filtration; we are working towards progress, not perfection
• Dr. Filidei feels that it may be more useful to check our food than our environment; fresh vegetables may be a good approach prior to testing to avoid the impact of food on urine mycotoxin testing
• Cannabis can be a source of mold exposure
• JW Biava talked about Actinos; Larry Schwartz is well-versed on it; mold makes multiple toxins; have always known bacteria is a problem; their plate testing looks for anomalies
• Dr. Ackerley suggested that Dr. Thrasher has said Actinos may be more of an issue than mold; the only treatment that is different is the environmental focus; certainly is more than mold but the treatment may be that different.
• Dr. Carnahan looks at SNPs to see what some may tolerate in terms of supplements
• Dr. Gray only ever used clay and charcoal; humic/fulvic may help per Dr. Ackerley; she may use Welchol; should be able to use all of the binders and not be stuck on one; consider if they are constipated or not in making a decision about which binder
• Dr. Filidei uses charcoal, clay, zeolite; some probiotics may deactivate mycotoxins in animals; does not use Cholestyramine much these days and certainly not at high doses; sticks to natural combo binders; sauna, NAC, glutathione
• Beta glucan may act as a binder
• Dr. Carnahan noted that clay and zeolite may be contaminated with metals; sodium bicarb may bind ochratoxin; steamed okra and cooked beets may be very effective 

Michael Schrantz, CEIC, CMI spoke on “ISEAI IEP Committee – Core Concepts for Clinicians and Patients from Published Documents” and “Use of the ERMI Score in Clinical Practice” and shared:

• IEP Committee are all volunteers
• Endorse ANSI/IICRC S520 standard for remediation; backbone is physical removal
• Have created an environmental consensus statement on ERMI score
• Have a directory of professionals on the ISEAI website under “Get Help”
• Have numerous PDF resources such as the Mold Testing Guide
• Have a Remediation Factsheet available on the ISEAI website
• Dead or alive mold can trigger symptoms
• Remediation should focus on physical removal; not killing or fogging alone
• Mold that is hidden can still impact the living space
• Hidden mold is commonly found inside walls
• It is never just mold; bacteria, mycotoxins, mVOCs, and more
• Root causes must be identified and fixed
• Skipping a formal inspection and going right to remediation often misses key steps
• Not all water-damage is obvious or known to the occupant
• Sensitive patients should be served by those remediators that work with IICRC S520 standard; ISEAI goes above and beyond IICRC S520
• Do not have remediation company do the inspection; conflict of interest
• Small particle cleaning after remediation is generally needed
• DIY testing is often less than ideal; can be a useful screening
• Have created a 2023 ERMI Consensus Statement; ERMI and HERTSMI-2 should not be used as the sole piece of information for making major decisions
• ERMI can be elevated when the sample had active mold growth along with the dust or includes soil in the sample
• ERMI can look normal in the presence of mold; inhibitors, frequent cleaning
• Bill Weber likes one ERMI inside and one outside; with a single family home, one ERMI per 500-750 square feet, one in basement, one in crawlspace, one in attic, one outside
• ERMI can be valuable but has to be interpreted in context

Bill Weber, GC, CR, CIEC, CMRS spoke on “Indoor Air – How Clean is Enough?” and shared:

• Has worked with crime scenes, fire losses, water losses
• Human eye can see only 10 microns or higher with perfect vision and right lighting
• Mold, bacteria, Actinos cannot be seen
• Generally need 3 passes for cleaning for effective small particle cleaning or medical-sensitive people
• Recommends exceeding the ANSI/IICRC S520 standards
• ISEAI standard is the “three pass” cleaning for effective small particle removal
• Only need to remove about 1mm of a surface before cleaning; physical removal + abrasive cleaning
• Two rounds of damp cleaning with microfiber and 3-5 drops of dish soap per quart of water; then dry wipe with electrostatic cloth
• Can then check for soapy residue using blue tape test; if the tape does not stick, there is a residue left
• After cleaning, wet a Qtip and use in corners and edges; if brown or black, it is not clean enough
• May use a Mycometer swab or Pathways swab or similar to check
• Outdoor determinants include: outdoor soil, spores in outside air, bodies of water, standing water, other buildings
• In Central Valley in California, many are struggling with the outside air
• Stachybotrys loves growing on wet hay and straw
• When contamination cannot be avoided, consider filtration, cleaning, HEPA vacuum, electrostatic cloths
• Not a good idea to start remediation based off an ERMI or other single test without a complete IEP assessment 
• Removing all dust will remove most particle-based contamination

Tim Taylor, PMP, MAC spoke on “Beyond Mold – Understanding the Next Most Common Contributors to Indoor Air Contamination” and shared:

• VOCs or off-gassing
• Indoor pollutants are 2.5x higher than outdoors
• VOC levels can be 1000s of times higher from paint or household cleaners
• Furniture contains glue and chemicals
• Gasoline in cars and other devices can off-gas VOCs
• With a respirator, need the correct cartridge for the type of chemical you are exposed to
• Need carbon or charcoal filter specific to chemicals and VOCs with air filters
• Can use a non-toxic sealant on surfaces that are off-gassing
• Best to buy small amounts of paints and other products and throw away when done
• Carbon monoxide results from incomplete combustion of carbon-containing fuels
• Don’t want to let a car idle in an attached garage
• Carbon dioxide: humans and animals exhale; active mold growth can cause; can be high in an enclosed automobile within 30 minutes
• Radon is naturally released from rocks, soils, and water; can cause lung cancer; heavier than air; settles in basements
• Ventilate with ERV or HRV; ERVs transfer heat and moisture; HRV transfers heat
• Turn on all ventilation fans to pull in air from outside or open a window and position a fan to blow out the window
• Humidity should be monitored; optimal is 35-45%
• Place $10 humidity gauges throughout the house
• uHoo, Purple Air, Airthings are good monitors; handheld meters can be very helpful as well

Linda Eicher is an IEP who shared:

• Offers virtual consults where the person is guided through what they would normally do if the IEP were physically there
• Avoid environments with musty smells or visible water damage
• House Hunting Guide: https://www.esgcarolinas.com/blog/househunting 
• For gasoline in a garage, prefer a separate detached garage or store chemicals in a shed; can weather strip the door from the garage into the home; exhaust fans create negative pressure that then pulls air from the garage into the living space; can add a ventilation system from the garage to the outside
• Indoor air is more positive ions; want a balance of positive and negative that matches outside; PCO without ozone can be very helpful
• After fixing the problem, cleaning is required to address residual
• Ventilation, air purification, cleaning processes all important or long-term health
• Don’t let cleaning companies bring their own equipment into your home; use only your own vacuum cleaner
• Use products without fragrances
• Look for evidence of mold in toilet tanks
• Likes vacuums with bags and not open cannisters (or dump outside)
• Clean electrostatic cloths / Swiffer’s separate from anything else when washing and drying
• There is no standard for “normal fungal ecology”
• For small areas of mold in a shower or similar, may want to clean with white vinegar
• Clear aerators on faucets 
• Bleach does not break through biofilms

Mary Ackerley, MD spoke on “Neuropsychiatric Effects of Mast Cell Activation with NeuroQuant” and shared:

• Treated mainly Lyme and mold for over a decade
• Mast cells are first responders against pathogens
• 10-17% of population; 60-70% in her patients have MCAS
• Since COVID, MCAS may be 25% of the general population
• Mast cells can release TGFb1
• Mast cells are found in the brain and limbic system
• Can lead to suicidal ideation within minutes of walking into a water-damaged building
• MCAS/EDS/POTS/GI/Autoimmunity are the “pentad”
• Trauma is central to lack of recovery in chronic illness patients
• Amygdala contains mast cells
• Brain itself produces histamine; involved in normal cognition and sleep/wake regulation
• You can over-medicate people with antihistamines
• Conditions associated with mast cells: Fibromyalgia, migraines, neuropathic pain, CRPS, vulvodynia, autism, MS, Alzheimer’s, Parkinson’s, neurofibromatosis
• Pupil dilation seen in sympathetic dominance
• Sympathetic is the accelerator; parasympathetic is the brakes
• Cell Danger Response can be released with social engagement, connection, compassion 
• “Flight” is common with patients running from their moldy homes in fear; often moving to their next moldy home
• “Freeze” is when the emergency brake is pulled and CDR engages; chronic fatigue, depression, disassociation 
• Adverse childhood events (ACEs) impact neurodevelopment, immunity, and gene expression 
• Trauma plays a more significant role in chronic illness than most recognize
• May be that 80-90% of patients with chronic illness have a high ACE score
• NeuroQuant can be used as a window into limbic dysregulation and mast cells
• A sense of real safety in the body is at the heart of normalizing autonomic nervous system function 
• NeuroQuant: Sea of blue = mold and mast cells and limbic system
• Limbic: thalamus, amygdala, hippocampus, ventral diencephalon, anterior cingulate
• Sympathetic arousal brain: limbic activation and lopping
• Looks at the Triage Brain Atrophy Report (TBAR)
• Oxygen therapies have a big role in treating gray matter atrophy
• IGeneX or Galaxy-diagnosed Bartonella may have temporal pole inflammation; possibly related to Bartonella vasculitis
• Red on NQ is neurodegeneration 
• Decreased blood flow to the brain with POTS, MCAS, and small fiber neuropathy
• ACEs may predispose some to Alzheimer’s 

Mary Ackerley, MD spoke on “Oxytocin: The Love Hormone” and shared:

• A biological metaphor for safety 
• Helps to regulate the nervous system
• May help with frequent urination related to low ADH
• Oxytocin: brain, ANS, cognition, cardiovascular, metabolic syndrome, diabetes, osteoporosis, protecting against breast and ovarian cancer
• Oxytocin is profoundly anti-inflammatory
• Oxytocin is a cardiovascular hormone; can help with POTS by reducing urinary frequency; decreases need for compression garments and electrolyte fluids
• May increase cardiac stem cells
• Appears to be a mast cell stabilizer for cardiac cells
• Body naturally increase oxytocin release when stimulated by histamine; antihistamines may decrease natural oxytocin release
• Oxytocin regulates and is regulated by the glia and immune system
• Can be useful in the treatment of neuroinflammation 
• Oxytocin increases bone formation 
• Oxytocin may lower the risk of breast cancer
• Oxytocin improves energy metabolism and may lead to weight loss ***
• May prevent skin aging
• May be helpful in PTSD, obesity, weight loss, addiction, withdrawal, hypoactive sexual desire disorder
• May support and calm the amygdala
• Dr. Sue Carter, wife of Stephen Porges, has studied and published on oxytocin 
• Embodiment of safety and love requires both oxytocin and ADH
• Oral is effective and easier than nasal or injection
• Has a very short half-life; effects may be due to impact on the ANS
• Does not cause dependency
• Can stimulate vagal tone
• Could be relate to prostate cancer but may be higher as a response to response to inflammation more than being causal
• Some may have a paradoxical response
• LDN can be synergistic with oxytocin
• LDN + alpha lipoic acid can help with neuropathy
• May have benefits with long COVID
• Dissolvable, troches, nasal start and stop quickly; long-acting also available
• Has been the most beneficial thing she has found in working with mold patients
• No withdrawal effects observed
• Acts as a mast cell stabilizer
• Vagal devices can burn you and don’t seem to be a top tool
• Likes the Primal Trust program; people don’t feel they are fighting the program
• Creates an internal peacefulness without sedation 
• Vagal tone is not a high; it’s a good day at the beach

Dale Bredesen, MD spoke on “How Mold is Making Alzherimer’s Optional” and shared:

• Mycotoxins are making Alzheimer’s optional
• Recent patient did well for 6 years, started drifting down; found sleep apnea, new mycotoxin exposures, and sinus infections with Cryptococcus; addressing these put her back on an improved path
• Alzheimer’s, Parkinson’s, ALS, macular degeneration all have supply and demand issues related to a specific system; higher demand than supply lead to development of these conditions
• Nutritional for Longevity creates food that supports the KetoFLEX 12/3 diet
• Professor Rick Johnson’s work with fructose mechanism; can line up with what happens in Alzheimer’s; fructose may be one of the more important mechanisms; can get to same pathway with fructose, glucose, or salt
• Newer blood tests: p-tau 181 and 217, Abeta 42:30, NfL, GFAP; should all know our p-tau 181 and GFAP
• Precision Medicine Program for Neurodegenerative Diseases being created
• Treatment for viral illnesses, cancers; new drugs that work with virus and assembly machine; has for all viral illnesses including COVID, RSV, flu, etc.; Vishwanath R. Lingappa; https://prosetta.com/antiviral-programs 
• Might there be specific mycotoxins associated with specific cognitive symptoms?
• 1/3 with cognitive decline are non-amnestic; very common with mycotoxin exposure; early depression, apoE4 negative think mycotoxins or vascular disease, apoE4 positive have amnestic and non-amnestic symptoms
• Aducanumab, Lecanemab, Donanemab only slow progression; they do not stop or lead to improvement
• Mild Cognitive Impairment is a late stage; not early; Asymptomatic -> SCI (10+ years) -> MCI -> Alzheimer’s 
• Master switch is APP; Abeta is a superb marker but a terrible therapeutic target
• Vast majority of Alzheimer’s is innate immunity too high and energetics too low
• Abeta is an antimicrobial peptide 
• Fasting in frail people will make them worse; giving more may make their insulin resistance worse; can add exogenous ketones early on
• May eventually be able to combine root cause with effector targeting such as APP-selective BACE inhibitors or ApoE4 post-translational modification to make ApoE4 act as ApoE3
• Lewy Body can also be associated with mycotoxins

Kat Toups, MD and Ann Hathaway, MD spoke on “Cognitive Decline Investigator’s Panel with Case Studies” and shared:

• Research Paper: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9484109
• Did a trial with 25 patients with MCI and early dementia using a broad ReCODE protocol
• Dr. Hathaway had two patients without reported cognitive improvements; they both were living in a moldy environment
• It is an uphill battle if mold and mycotoxins are not addressed
• In their second study, they now require inspection and potentially remediation based on testing results
• ApoE4 is not your destiny, but you have to try harder

Q&A with Dr. Bredesen and Dr. Toups shared:

• Get long-term care insurance before testing
• GFAP is non-specific but very sensitive; increases years before any cognitive change
• P-Tau 217 is specific for Alzheimer’s but not early stage 
• P-Tau 181 is available through LabCorp
• Tests are available through NeuroCode; https://neurocode.com 
• One of the most common contributors to Alzheimer’s is mold and mycotoxins; 70-80% of cases
• Missing the ball if you don’t explore infections and toxins
• Dr. Toups had 7 of 10 patients tested that had Lyme-related infections; the patients had no idea
• They check hormones and use BHRT at any age, if needed
• Using Oura ring in latest study
• The immune response is a big factor in dementia
• Uses LDN as an immune modulator
• Energetics: blood flow, SPO2, mitochondria, ketone levels
• With COVID, people died of cytokine storm; with Alzheimer’s, it is a cytokine dribble
• More about the innate immune system than adaptive 
• COVID will likely lead to many more cases of Alzheimer’s in the future
• They use LDN with autoimmunity; resolvins with non-autoimmune inflammation 
• She uses the Dr. Todd Born viral protocol with gemmotherapy and copper/gold/silver; also monolaurin/lysine/olive leaf
• She uses Beyond Balance herbs; easier to titrate drops; Cryptolepis can be helpful for Lyme persisters
• Dr. Bredesen said Methylene blue may be more helpful for Parkinson’s than Alzheimer’s as it helps with Complex I.  

During the extended question and answer period, the following points were shared:

• Dr. Maxwell shared: 
  • Vagal nerve issues -> MCAS -> hypermobility; small fiber neuropathy may occur from toxins, sugar (diabetes); if dysautonomia leads to slow motility and leaky gut and autoantibodies, might explore tools for autoimmunity; IVIG is a last resort after trying several other interventions first; IVIG helps dysautonomia in less than 50%; IVIG expert Jill Schofield, MD
  • Neuropathic subtype of POTS: less common in younger people where other types of POTS are seen; diabetes or longstanding toxic exposure in neuropathic POTS; may overlap with small fiber neuropathy; remove the toxin; the environmental toxin may be mold or something else; can be best to do a location sabbatical; may eventually get to IVIG
  • Nicotine is on Dr. Maxwell’s list to avoid but may be helpful in COVID which may include dysautonomia; there may still be medical application of nicotine such as patch
  • H3 blocker is Pitolisant/Wakix but not readily available as only for narcolepsy at present
  • Dr. Tessier mentioned magnolia bark can work with H3 receptors.  
  • Designs for Health Vessel Forte or horse chestnut seed may help as an H3 blocker based on comments from Dr. Ackerley
  • Dr. Maxwell has mixed feelings about Xolair; potential for inducing a mast cell reaction as much as blocking; don’t know until it is in the patient and then there for at least a month; may help a patient quite a bit or may cause a major flare; generally best done with an allergist
  • Ketotifen may have anti-cholingergic effects but has not been problematic with GI motility; one of the best mast cell stabilizers; Dr. Maxwell often starts with Gastrocrom and then may do liquid Ketotifen
• Larry Schwartz, CIEC shared:
  • No one ever lives in a clean room
  • Goal is to keep levels below what triggers each unique person
  • You want the levels to be low enough that air purifiers can then be helpful; higher levels may require additional ventilation strategies
  • If air filters are helping, levels of toxicants are probably at lower levels
  • Purification technologies include filtration and ionization
  • Ions have a charge; can help purify the air; may be better for chemicals/gases/VOCs
  • Likes to see some of both methods provided no ozone is created 
  • Some of his favorites include: IQAir, IntelliPure, AirDoctor
  • Dr. Tessier likes the IQAir HealthPro
  • Simple cleaning protocols work better than many of the products promoted to reduce mold and mycotoxins in the environment
  • Fogging is a way to kill mold; we don’t want to kill it; dead or alive mold causes health problems
  • Best to do SPC on items outside as the cleaning itself can release particles into the air 
  • Porous items that have no visible or identified growth may be able to be air washed outside; sufficient or 75-80% of clients; sensitive clients may not be able to tolerate and may need to dispose of
  • When moving from a moldy environment to a new space, some can have filters changed and easily cleaned; if the unit is harder to clean, you may not want to take it with you
  • Mini-split units need filters changes and regular cleaning
  • Standalone dehumidifier have coils inside of them and need regular cleaning
  • Working on a study on the effect of airborne beta glucans in the home on patient's health

Disclaimer: While I attempted to accurately represent the statements of the various speakers, it is possible that the above contains errors or inaccuracies. If you have any corrections to the content listed above, please Contact Me.