Mold Allergy Follow-up

Updated: Sep 18, 2017
  • Author: Shih-Wen Huang, MD; Chief Editor: Harumi Jyonouchi, MD  more...
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Follow-up

Further Outpatient Care

Allergic rhinitis and allergic conjunctivitis

A skin test for environmental allergens should be performed to establish the diagnosis of mold allergy.

Once the diagnosis is made, the patient should be given instructions regarding home environmental care, pharmacotherapy, and possible indications for immunotherapy.

Pharmacotherapy should include an antihistamine with or without decongestant, antihistamine nasal spray, mast-cell stabilizer nasal spray, and, most likely, a corticosteroid nasal spray.

These patients should be monitored regularly, at least every 3 months.

Sinus radiography or CT scanning of paranasal sinuses may be needed if sinusitis fails to respond to a proper therapy.

Children with obstructive apnea should undergo rhinoscopy or lateral imaging to identify adenoid hypertrophy.

Allergic asthma

The diagnostic workup, including skin testing and pulmonary function testing, is performed on an outpatient basis.

Prescription of drugs depends on the patient's stage of asthma, as follows:

  • Mild intermittent - Short-acting bronchodilator inhaler or mast-cell stabilizer
  • Mild persistent - Short-acting bronchodilator for acute relief, long-acting bronchodilator for long coverage, especially at night, leukotriene antagonist at night, and corticosteroid inhaler as needed
  • Moderate persistent - Short-acting bronchodilator for relief, long-acting bronchodilator for long coverage, leukotriene antagonist at night, and corticosteroid inhaler on a regular basis
  • Severe persistent - Oral corticosteroid daily (The patient may be allowed to use a corticosteroid inhaler as the oral steroid drug is tapered.) short-acting bronchodilator for acute attack, perhaps the addition of long-acting bronchodilator, a daily leukotriene antagonist, and the option of adding theophylline

Spirometry is used at the clinic. A peak flow meter is used at home.

ABPA or ABPM

Diagnosis can be established on an outpatient basis by finding eosinophilia, elevated total serum IgE value, and a skin test positive for the suspected fungi; by finding precipitin antibody against suspected fungi; or by finding hyphae or positive sputum culture results for fungi.

Drug therapy begins with an oral corticosteroid followed by a corticosteroid inhaler if the condition improves. Patients should be monitored every 3 months with spirometer measurement of airflow.

AFS

For a patient with chronic sinusitis, use the same criteria for diagnosis as used for ABPA and ABPM listed above.

CT scans and sinus radiographs are needed on a regular basis.

Treatment should include sinus surgery and a prolonged course of an oral corticosteroid. If improvement occurs, a trial of a corticosteroid nasal spray to replace the oral steroid is appropriate.

Follow-up visits should occur every 3 months.

EAA

The diagnosis can be established on an outpatient basis with a carefully taken history regarding exposure, especially occupational exposure.

Chest radiography, pulmonary function testing, and lung scanning may be appropriate, depending on the clinical stage.

Treatment should begin with an oral corticosteroid for a lengthy period. Patients should remain in mold-free environments. An additional option of an inhaled corticosteroid or bronchodilator can be considered. In chronic stage disease, patients may need oxygen to avoid hypoxemia.

Pulmonary function should be tested on each clinic visit, which should occur every 3 months.

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Further Inpatient Care

Allergic rhinitis and allergic conjunctivitis

Inpatient care is rarely necessary unless patients develop complications, such as adenoid hypertrophy, chronic retention of effusion in the middle ear, or complications of sinusitis.

Allergic asthma

Most patients have relief with proper home-environmental control, pharmacotherapy, and perhaps immunotherapy (for a small number of patients). However, acute asthma attacks are often medical emergencies that require emergency care. Therefore, some patients may visit the emergency department frequently. Unless patients develop impending respiratory failure because of a recalcitrant asthma attack, they are most likely to be monitored in an outpatient setting.

Allergic fungal sinusitis (AFS)

Patients are likely to be monitored on an outpatient basis while the condition is considered chronic sinusitis until the correct diagnosis is established. After the correct diagnosis is made, patients require sinus surgery, which may entail a short stay in the hospital. Treatment does not change while the patient is in the hospital.

Allergic bronchopulmonary aspergillosis (ABPA) and allergic bronchopulmonary mycosis (ABPM)

Most patients are initially monitored on an outpatient basis during diagnostic workup. Inpatient care is likely when the patients' conditions are unresponsive to adequate corticosteroid therapy. Frequent inpatient care is anticipated when patients' clinical conditions become chronic (stage lV or V). A superimposed infection notably compromises the respiratory system. Patients may require frequent, short hospital stays for pulmonary medical care. If the patient has an underlying condition, such as cystic fibrosis (CF), urgent inpatient care may be needed.

Extrinsic allergic alveolitis (EAA)

In the acute stage, inpatient care may be needed to establish the diagnosis. Otherwise, patients are likely to be seen regularly in the outpatient setting. However, as the disease continues to advance and respiratory function is compromised further, and with superimposed infection, the chance of inpatient care steadily increases. This is more apparent with change of heart condition, such as development of cor pulmonale or right heart failure. Whether these patients are candidates for lung transplantation remains uncertain.

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Inpatient & Outpatient Medications

General

Most mold allergy–related problems can be managed on an outpatient basis. If patients require inpatient care for acute conditions, the drugs used for outpatient care still apply.

Allergic rhinitis

Drugs are as follows:

  • Oral antihistamine (Claritin, Zyrtec, Allegra) or over-the-counter (OTC) drugs
  • Oral antihistamine-decongestant (Claritin D 12 h, Claritin D 24 h, Zyrtec D, Allegra D) or OTC drugs
  • Astelin nasal spray
  • Corticosteroid nasal spray (Flonase, Nasonex, Rhinocort, Nasarel, Nasalide)
  • NasalCrom or Atrovent nasal spray (if indicated)

Allergic conjunctivitis

Drugs are as follows:

  • Patanol eye drops
  • Oral antihistamine (Claritin, Zyrtec, Allegra)
  • OTC drugs with antihistamine effect
  • Corticosteroid eye drops (rarely needed)

Allergic asthma

Drugs are the same for inpatient care and outpatient care, as follows:

  • Mild intermittent - Cromolyn, Nedocromil, short-acting beta2-agonist bronchodilator
  • Mild persistent - Cromolyn, Nedocromil, short-acting beta2-agonist bronchodilator, long-acting beta2-agonist, corticosteroid inhaler, leukotriene antagonist
  • Moderate persistent - Long-acting beta2-agonist, leukotriene antagonist, corticosteroid inhaler
  • Severe persistent - Long-acting beta2-agonist, corticosteroid inhaler, oral corticosteroid, leukotriene antagonist, theophylline, anticholinergic inhaler

ABPA and ABPM

Drugs are the same for inpatient care and outpatient care. The drugs used for moderate persistent or severe persistent asthma may be added if the clinical picture resembles that of asthma. Oral corticosteroid and corticosteroid inhaler are indicated.

Allergic fungal sinusitis

Inpatient care is necessary for surgery. Drugs are the same for inpatient care and outpatient care, as follows:

  • Oral corticosteroid
  • Corticosteroid inhaler
  • Corticosteroid nasal spray
  • Oral decongestant

Extrinsic allergic alveolitis

Drugs are the same for inpatient and outpatient care, as follows:

  • Oral corticosteroid
  • Corticosteroid inhaler
  • Long-acting bronchodilator
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Transfer

Patients with allergic rhinitis and/or conjunctivitis, AFS, or allergic asthma do not require transfer.

Patients with ABPA, ABPM, or EAA, because of the relapsing nature of these diseases and their propensity to advance to a chronic stage in a subset of patients, may require transfer to a tertiary care medical center, in part for easy access to diagnostic procedures and greater expertise in dealing with these conditions.

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Deterrence/Prevention

Total avoidance of airborne mold allergens is virtually impossible; however, minimizing exposure should be encouraged. Measures may include the following:

  • Remove the individual from the mold-infested area.
  • Reduce indoor humidity.
  • Remove mold stains on the walls, especially from wet surfaces.
  • Apply fungicidal agents for cleaning.
  • Remove carpet from cement floors.
  • Avoid raking leaves or hay.
  • Avoid exposure to outside air on foggy days.
  • Use an air cleaner with a high-efficiency particulate air (HEPA) filter and regularly maintain it.

In indoor settings, an effort should be made to reduce mold growth by decreasing excessive moisture. A dehumidifier or fan should be considered to improve circulation in a room or building.

An air cleaner with a HEPA filter may help remove floating mold spores indoors. Several studies indicate that, with proper education on how to maintain the machine, an air cleaner with a HEPA filter benefits patients, especially those with allergic rhinitis, conjunctivitis, or allergic asthma.

One study indicated that an air-conditioning unit in an automobile can be a source of mold infestation when cars are left in hot environments. Patients are advised not to roll up the car windows until the air conditioning unit has been in full operation for 10 minutes.

Other pollution factors can always aggravate mold allergy symptoms. Cigarette smoking is especially harmful for susceptible individuals.

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Complications

Allergic rhinitis and/or conjunctivitis

Long-term complications among persons who consistently breathe through their mouths include adenoid hypertrophy, adenoiditis, and recurrent sinus infections, all of which can lead to poor quality of sleep. Some individuals may develop obstructive sleep apnea. Chronic sinus drainage can cause bronchitis, pneumonia, or bronchiectasis. For some children, sinusitis can lead to orbital or periorbital cellulitis.

Allergic asthma

Poorly treated mold allergy asthma can have the same clinical results as any other form of allergic asthma. This includes status asthmaticus, which can lead to acute death. Other acute complications include pneumothorax and pneumomediastinum. Chronic relapsing asthma can lead to cor pulmonale or right heart failure, which may lead to death. In children, chronic asthma may lead to chest deformity such as a pigeon breast or barrel chest.

AFS

Poorly managed cases can result in chronic sinusitis, bronchitis, asthma, pneumonia, or bronchiectasis.

ABPA and ABPM

Poorly treated cases gradually develop into stage IV disease, which is steroid dependent. As a result, the patient may develop signs of hypercorticism and metabolic changes. When patients develop stage V disease (fibrosis), the condition is generally considered irreversible. Patients may advance to cor pulmonale, right heart failure, and death.

EAA

In patients whose conditions are poorly managed, chronic disease, characterized by pulmonary fibrosis, may develop. Patients are liable to develop cor pulmonale and right heart failure and possibly die.

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Prognosis

Allergic rhinitis and/or conjunctivitis

With the advent of oral nonsedating long-term antihistamine, antihistamine nasal spray, and various corticosteroid nasal sprays, many options are available for treating patients with differing degrees of symptom severity. With improvement of environmental care and immunotherapy available to those in whom it is indicated, the prognosis is good for most patients. The newer eye drops available should also help those with allergic conjunctivitis.

Allergic asthma

With the advent of revised national guidelines of asthma education and management the NIH sponsored and professional organizations supported, asthma can now be classified into 4 stages. Treatments are recommended for each stage. The availability of anti-inflammatory inhalers, long-acting bronchodilators, leukotriene antagonists, and other treatments should improve the outcome for patients with asthma.

The annual death rate has not declined, especially among teenagers in locations such as inner cities; this suggests that death can occur because of multiple factors, such as poor access to medical facilities, poor environmental control, and poor adherence to medical treatment. Given the number of people with asthma in the general population, strong public education is needed for asthma care. Another concern is that primary care physicians have not aggressively prescribed anti-inflammatory inhalers, especially to patients who already have moderate persistent asthma.

AFS

The prognosis for people with AFS is generally good if the treatment combines the surgical removal of allergic mucin, opening of breakage at the ostium of sinus tracts, and the use of a systemic corticosteroid. If poorly treated, AFS may cause chronic damage to the sinus cavity, which leads to chronic sinusitis.

ABPA and ABPM

According to a Northwestern University follow-up study, if patients' conditions are properly diagnosed and treated, especially with a systemic corticosteroid, most should not progress beyond stage IV clinical disease. [30, 31] However, once patients enter stage V (fibrosis), the condition is almost irreversible. Those patients may also develop emphysema, cor pulmonale, and right heart failure. Early and aggressive treatment with a corticosteroid is critical in preventing advancement of the disease. Whether adding an antifungal agent improves the prognosis is debatable.

EAA

If the diagnosis is delayed or the patient remains in the mold-contaminated environment, the disease is liable to become chronic. No data are available regarding the prognosis for people with EAA. One might assume that those with chronic disease are likely to develop cor pulmonale followed by right heart failure.

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Patient Education

General

Avoidance of mold exposure and adherence to medical treatment should be the main themes of patient education for each of the clinical disorders related to mold allergy.

Allergic rhinitis and/or conjunctivitis

Try to reduce humidity in the home environment. Use a dehumidifier in the house or turn up the air conditioner, changing the air filter frequently.

Remove any visible mold stains from the surface of wet areas, such as the bathroom, with a fungicidal agent.

Fix leaky roofs and/or wet walls.

Consider removing carpet from cement floors.

Do not rake leaves or hay.

Consider using an air cleaner with a HEPA filter in the bedroom. Make sure the machine is well maintained.

Do not allow children to lie on the carpet at home.

Make sure all rooms in the house or workplace are well ventilated.

Remember that air conditioning units in cars can harbor molds. Allow the air conditioner to run for 10 minutes before rolling up the windows.

Clean the air-duct system in the house or building periodically, especially in humid regions.

Smoking cessation among family members or workers is crucial. Never smoke in the house, a building, or the car.

Allergic asthma

All of the avoidance measures listed above apply.

Use national guidelines for asthma education and treatment sponsored by the NIH as a guide to treat each patient. Encourage adherence to medical advice.

Do not be afraid to use an anti-inflammatory (corticosteroid) inhaler, even in early stage asthma. Rinse your mouth after each use.

Maintain a good rapport with medical professionals about asthma care.

Exercise moderately to physical capability. Do not overexert. Ensure proper hydration.

AFS

All of the avoidance measures listed for allergic rhinitis apply.

Adhere to medical advice. Do not be afraid to take a systemic corticosteroid. This is the treatment of choice.

Report any adverse effects of medication to the physician.

ABPA and ABPM

Patients with ABPA should be advised of the source of Aspergillus in the environment. Decomposing organic matter serves as a substrate for the growth of Aspergillus species. Also, Aspergillus species have been recovered from potting soil, wood chips, mulches, freshly cut grass, decaying vegetation, crawl spaces, and sewage treatment facilities, as well as from outdoor air. Aspergillus spores also grow in excreta from birds.

The same information should be given to patients who develop ABPM from exposure to specific fungi.

EAA

This group of patients becomes sensitized against a mold or molds in the work environment exclusively through exposure. The list of fungi includes thermophilic actinomycetes and Alternaria, Aspergillus, Aureobasidium, Cephalosporium, Cryptostroma, Mucor, Penicillium, Saccharomonospora, Streptomyces, Sporobolomyces, and Trichosporon species.

Individuals should be educated that in some professions they may develop precipitin antibodies against fungi along with abnormal pulmonary function tests or radiographic findings suggestive of mold-related disease even though they are still asymptomatic. These patients, especially those with symptoms in a particular environment, require regular checkups.

For excellent patient education resources, see eMedicineHealth's Asthma Center. Also, visit eMedicineHealth's patient education articles, Asthma, Asthma FAQ, Occupational Asthma, and Asthma Medications.

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