Sick Building Syndrome-A Wolf in Sheep's Clothing* Emu J Bardana, Jr, MD

Reprinted fran Annals c£Allergy, Asthma, & Immunology TO. 79, Number 3, September 1997

Review article Supported by a grant from Zeneca Pharmaceuticals Sick building syndrome-a wolf in sheep's clothing* EmU J Bardana, Jr, MD

Objective: Reading this article will acquaint the reader with possible outcomes and research began in Scandinavian associated with the diagnosis of "sick building syndrome." The definition, epide- countries and the United Kingdom in miology, and precipitating events of this symptom complex are distinguished fern the late 1970s.6 In 1983 at a World other defined building-related illnesses. Health Organization meeting in Ge- Data source: The author's experience with many patients presenting with, this neva, a new symptom complex "sick diagnostic label and selected studies ou indoor pollution and "sick building syn- building syndrome" was initially drome" arc carefully reviewed. coined? The complaints of afflicted of- Study selection: Pertinent scientific investigations on "sick building syndrome" fice workers included drynexs of the and previously published reviews on this arid related subjects that met the educa- skin and mucous membranes, mental tional objectives were critically reviewed. fatigue, headaches, general pruritus, Results: "Sick building syndrome" is a pseudodiagnosis composed of nonspe. and airway infections.8 Most involved cific. transient symptoms without proven biologic markers. Its application in the buildings were of a commercial nature clinical setting invites frequent subsequent linkage to other similar vague diagnoses and had in common the fact that they associated witti chronic debility and lack of therapeutic intervention. were heavily populated, carpeted, and Conclusion: The reader is encouraged to avoid the use of this term in favor of a either infrequently or poorly cleaned." Simpler, descriptive diagnosis (eg, transient office-related annoyance andAjr irrita- In the previous decade there has- tion) or if this seems inadequate, adoption of the diagnostic label of "idiopathic been increasing debate about the building intolerance." symptom complex of "side building Ann Allergy Asthma Frorounol l997;79:283-94. syndrome." The growing dissatisfac- tion with the term originates firm the INTRODUCTION it has become apparent that they do not total absence of consistent case defini- There is an increasing awareness that always achieve, this goal. Although tion of the "syndrome," the lack of biologic markers for most symptoms, poor indoor air quality may generate a there are no governmental health stan- or even groups of symptoms, and fail- variety of deleterious effects on human dards specifically applicable to com- ure to tind consistent associations be- health.' In recent years this has become mercial, buildings, the federal govern- tween "sick building syndrome "symp- a major publjc health concern. This is ment either directly or indirectly toms and any building contaminant^) nut surprising when one considers that regulates many products associated across a large number of buildings WE spend a majority of our time trav- whh indoor pollution.-1 There are vol- studied.'0-" It has been argued that uti- eling or working in a succession of untary guidelines within the Environ- lization of this term has not improved indoor mkroenvirontnems.2 Although mental Protection Agency's Building our understanding of the occurrence of buildings arc intended to provide rela- Air Quality guide.' in Europe, the these symptoms, and funher, that to tively safe and comfortable environ- World Health Organization has also ments for individuals to Jive and work, label an entire building as "sick" or developed indoor air quality guide- "healthy" has no scientific founda- lines? tion." Unfortunately, the media have Although the first modem building- often contributed to the problem by * From the Oregon Health Science* Univer- associated illnesses were recognized sity. Division of Allergy and Clinical Immunol- linking any building-associated com- ogy. Ponlind, Oregon. prior to I960, it was not until after the plaint under this misleading and some- Presented at iht November, '996 American Arab oil embargo of 1973 that com- times disquieting term.12 In the United College oF Allergy. Asthma and Immunology plaints of physical discomfort with as- States expanding litigation has sought Meeting in Boston. sociated irritant symptoms were re- Received for publication May 16. 1997. to link "sick building syndrome" with Accepted for publication in revised form Au- ported with increasing frequency in the an equally controversial and unscien- SUMn 1.1997- medical literature. Much of the interest tific symptom complex of "multiple

VOLUME 79. OCTOBER. IW7 2U3 Table 1. Definition of Terms Frequently Employed li Office Building-Related HeeHH use of pesticides or other intoxi- Problems cants.16-" These building-related ill- . Problem building nesses have clinical case definitions An ofoe building where worker complaints of ill health are more common than and can be diagnosed by objectively might be reasonably expected. measurable signs of illness. There is • Building-related Illness little controversy related to these ill- An office building In which one or more workers develop an accepted, well-defined nesses and they will not be dealt wih Illness for which a specific cause is found. The cause £ dsady related to the further in this review. building, eg< hypersensitivity pneumonitis. humidifierfever, Legionnaire's pneumonitis, etc, On the other hand, there has been an • Sick building syndrome increasing tendency to describe .symp- An office building in which an Ill-defined Illness develops In one cr more workers. toms that appear or are perceived to be The illness demonstrates great variability among the workers and no causative related lo the air quality of a building, agent is apparent or found despite significant evaluation but which exhaustive studies fail io • Tight building syndrome correlate with any identifiable problem Generally used to designate an engineering or architectural flaw as the cause for in the building, ft is this group of tran- either a building-related illness or a sick building syndrome. sient symptoms thai has composed the • Crisis building symptom complex called "side build- Skk building where repeated industrial hygiene surveys have failed to localize a ing syndrome" upon which this review ceuse for Ill-defined symptoms that precipitates a crisis of concern in the involved employees. Such buildings are frequently evacuated. will concentrate. Even those who utilize the lerrn (Adaptedfrom Bardana EJ. Building-related Illness in occupational asthma, Eds: Bardena EJ, "sick building syndrome"concede that MontanaroA O'Hollaren IvTT Philadelphia: Hantey& Belfus, 1992337-54). all investigators and scientific journals discussing this issue have a great re- sponsibility to Hafino terminology chemical sensitivity."13-1* This review dona of commonly employed renns are will, focus on the available sciendfic summarized in Table 1." It should be clearly."1-" One of the critical issues information on "sick building syn- pointed out that there continues to be often lost in distinguishing building- drome" and proposes an approach to some disagreement as to the use and related illness such as Legkmaire's the evaluation of nonspecific building- application of these labels. In evaluat- disease and "sick building syndrome" associated complaints for clinicians ing problem buildings, investigators is that the former biologically defined confronted with this problem. have identified a variety of buildinp- infection may persist even after an af- related illnesses that are clearly attrib- flicted individual is removed from the TERMINOLOGY utable to the building?." These include building, whereas the symptoms of Although air pollution in the setting of such diagnoses as hypersensitivity "sick building syndrome" should heavy industry bas been well recog- pneumonitis, humidifier fever, build- quickly abate upon leaving the build- nized for many centuries, indoor air ing-related asthma, toxic pneumonitis ing." It is often this distinction that quality issues in large commercial or organic dust toxic syndrome, a va- motivates a number of unconventional, buildings and their worker occupants riety of infectious syndromes (eg. Le- providers to seek linkage with other are relatively new developments in gionnaire's disease, Pontiac fever. Q- equally con trovers JaJ diagnoses to jus- tify the persistence of symptoms.70 In medicine.15 The terminology that has fever. tuberculosis), building-related arisen in this area has become some- dermatitis and ocular symptoms and doing this one loses even the ill-de- what confusing. The author's defini- rare intoxication syndromes, eg, mis- fined parameters of this toraisnt symptom complex.

EPIDEMIOLOGIC Commtrdtl buildings CONSIDERATIONS The prevalence of "sick building syn- I J i drome" remains largely unknown. Building* withouf Case definition for this symptom com- ProW*m tunning* tdcntiNod problems • 20.30% 70-60% plex remains very arbitrary since there are no biologic martens lo define it J J ! I precisely. It has bceri indicated that Buikrmg ntoat IdiopothK touiWtny Undetected He»Hhy this is partly attributable to inadequate »ine*« •- jrttotemwt •- probtom* • buUdingf analytical methods, and psrrjy related 5-10* 1D-2S* 10-20% 50-70% to the nonspeciflcity of many "sick Figure I.Schematic depiction of the dynamic continuum within commercial building stock focused building syndrome" symptoms." on the degradation of building performance (adopted from reference *22. with permission). Burge has observed that in the inves-

284 ANNALS OF ALLERGY. ASTHMA. & IMMUNOLOGY Tabte 2, Independent Health Factors ECONOMIC REPERCUSQONS tipiioi* conducted thus far there(does Identified by Respondents to Although symptoms related 10 indoor noi appear <° be one group of 'sick Questionnaires Related to "Sic* Building pollution may seem trivia;, it is asso- buildings and a separate group of un- Syndrome" aflcfieU buildings." Rather, there is a ciated with e disproportionate expen- continuum of problems from one • Upper respiratory symptoms diture of both financial and manpower Rhlnontiea resources. The economic impact of this building to another.31 In this respect, Nasal congestion Woods has hypothesized a dynamic problem can easily be overlooked in Sneezing the absence of a clear understanding of continuum within commercial building Sinus congestion bow widespread the problem is. The stock focused on the degradation of • Throat symptoms building performance (Fig J)-a Fur- Soreness numhcr of incriminated buildings and thermore, most studies of this issue Hoarseness their occupants is estimated lo be sub- have utilized a self-report instrument, Dry ness stantial. In the United States, Woods and there is neither a standard ques- • Lower respiratory symptoms has estimated these numbers to he be- tionnaire nor a general consensus on Cough tween 800.000 and l,200,000commer- ihc range of symptoms that are appro- Wheezing cial buildings with between 30 to 70 Dyspnea priate for inclusion.53 million exposed o"~* pants.37 For ex- Chest tightness The National Institute of Occupa- ample, if approximately half of EnvjJ • Ocular/cutaneous symptoms ronmental Protection Agency's em- lionul Safety and Health conducted nu- Dryness merous investigation? over the past (toft ployees reported headache fur the scvcr.il decades. By 1991 over 600 in- Tearing previous week with a duration of two door air quality studies bad been per- Blurred vision days, this" corresponds to 5,000 head- formed as pan of the health hazard Soreness/burning aches/wk among 5000 employees, or a program."04 It has been estimated Problems Wfti contact lenses quarter of a million headaches per ne.-irly a third of buildings world-wide • General year. If the cost of a headache is esti- have some problems with their heat- FBtigue/drowslness mated to vary between $1.50 and Chills/fever ing, ventilation, and air conditioning S8.00,?* then the cost <£ buijding-re- Nausea system precipitating worker com- lated headaches to the Eavironmcntal • Muscutosketetal Protection Agency as an organization pliiints. Jn 1989 the Honeywell Corpo- Myalgia ration conducted a random telephone Cervical spasm could be valued at between $375-000 .survey of 600 of its office workers. Lumbosacral spasm/pain and $2 million.36 If one adds the cost of Twenty percent perceived their work Numbness in hands/wrists workers' compensation actions and. in product hampered by poor indoor air Polyarthrelgia some instances, litigation against ar- quality.1'1 • Neurologic chitects, building managers, employers A number of large multi-building Headache and landlords, the cost of this problem studies covering thousands of office Reduced memory can reach astronomic proportions.'-1-4 w'.irkers have been conducted in North Difficulty in concentrating Depression America, the United Kingdom, and PRECIPITATING FACTORS IN Tension/nervousness I .'...-...*.» Ztt-i* A« :~.j:*...«a*l AU^tra n.trw I'WIkl^W, y"W jLlJt*t**U*\*l* MWV«*< ^«»w "SICK BU1LDCNG SYNDROME" liunnaires were noi standardized in Modified and adapted from references *32 My own experience as well as that of these investigations making any com- and #35, with permission. yihcr investigators in the area of "sick purisons problematic. As well, these building syndrome" indicates there are Mudic.s depended on self-reported three major reasons associated with the symptoms and subjective estimates of cy's BASE program suggests, how- unset of complaints in building occu- building condirions,«i^liy air, dusty ever, that symptom frequencies in a pants. They are (J) rapid new buildinp occupancy, (2) building renovation, c'.tndiiions. fresh paint odor, etc." The dozen buildings selected at random validity of these observations and ab- and (3) water or moisture incursion were often lower by a factor of two or with subsequent microbial contamina- sence of confirmation by objective more." The only finding common 10 measurements bns been n source of tion. The most common precipicocwr is the multiple studies performed to dale associated with the initiation of exten- significant criticism. The most com- wag the increased .symptom rates re- mon independent health factors identi- sive office building renovation thai is fied in these Urge cross sectional stud- ported by females.*1"3- Even this ob- conducted during nmirmi work hours ies of "sick building" workers are servation elicits debate because it may with incomplete isolation of the con- summarized in Table 2- There are no simply reflect workplace disparities, struction are*, and with little or no etiniparable data for these independent ie, lower pay scale, assignment of me- adjustment of the ventilation rate- health factors in unaffected buildings. nial tasks. unaliractive workspace, Painting, sheetrocking. plasicring, and ''Tic Environmental Protection Agen- etc.3* carpeting result in a variety of cherai-

U)I.UME 79. OCTOBER. ISX»7 285 cal emissions thai may adversely im- outlined in Table 2 has yet 10 be estab- In instances where emissions frym pact nearby employees. Airborne par- lished/5 Levels of volatile organic construction materials are nor the ini- ticulate and volatile chemical compounds in the indoor environment tiaJ trigger of symptoms, the next most contaminants are (he most frequently are attest alxegs well below thresh- acmncnly encountered problem is re- reported contaminants in.buildings un- old limit value standards published by lated either to a poorly maintained dergoing renovation."-" Volatile or- the American Conference of Govern- structure, or one that was poorly yr> ganic compounds in indoor air arise mental Industrial Hygienists. Il is al- defectively constructed with resultant from a wide variety of building mate- most impossible to calculate the cumu- intrusion of water and contamination rials, cleaners, office products and ma- lative effect of total, volatile organic with microbial and fungal growth. This chines, paints and furnishings. Exam- compounds when one considers the may be more problematic in certain ples of typical volatile organic potential synergistic effect of airborne geographic locations where warmer compounds found in office buildings particulate and other possible pollut- temperatures and high relative humid- ity result in condensation problems in include xylene, chloroform, etbyJben- ants.49 Where ventilation rales meet OK z«n.e, chlorobenzcnc, styrene, and tri- exceed the requirements of the Amer- air conditioned structures, In general. chloroethylene. Volatile organic com- ican Conference of Governmental In- older buildings are more susceptible to moisture problems than newer build- pounds frequently have annoying dustrial Hygienists; standard 62-1989, ings. Obvious fungal growth usually odors and their presence in tiie setting the total volatile organic compounds of significant renovation or new build- precipitates health concerns among of- are usually less than 1 mg/nv1 and con- ing occupancy is estimated at 70% to fice occupants. This results in the typ- centrations of individual volatile or- 80%. ical "moldy" or "mildew" odor that ganic compouads are well below (less ScvcraJ reviews and a number of accompanies such contamination. investigations have incriminated vola- than J %) any recognized occupational However, there is a paucity of scien- tile organic compounds in office build- exposure standard.45 tific information upon which building ings as a cause of annoyance and/or In addition to building renovation, engineers, industrial hygicnists and in- irritation to the eyes and mucous mem- rapid new building occupancy is volved clinicians can make sound brane of the respiratory tract.*0-4* It is equally likely to induce annoyance judgements. There are no generally ac- not yet scientifically known whether and/or irritative complaints in exposed cepted numerical guidelines that spec- exposure to low level concentrations of workers. The reasons are very similar ify "safe" exposure limits. More im- volatile organic compounds has any LO those noted above wj th building ren- portantly, there are no established significant adverse health effects. It is ovation, The same contamination with standard)) as lo what airborne levels clear that certain odors are attributable dusts and volatile organic compounds constitute a definite health hazard. to volatile organic compounds; how- occurs when newly constructed build- Similarly, there arc no environmental ever, whether or not they cause or con- ings are not left to "air out" and me- criteria for deciding whether a mea- tribute to the nonspecific symptoms ticulously cleaned prior to occupancy. sured airborne level of ftngi or bacte- ria is a ride factor for bypersensiu'vjty pneumonitis or other defined respira- tory disorders." Analytical results of air sampling for microorganisms ate useful in identifying indoor sites where fungi may be accumulating and ampli- fying. The same analytical results can- not, however, be used to predict or invoke adverse health effects.

CLINICAL SEQUELAE ASSOCIATED WITH MICROBIAL OVERGROWTH There are a variety of clinical Out- comes that may be associated with mi- crobial growth in a building (Fig 2). Annoyance Reactions Annoyance reactions occur in individ- Figure 2. Pntential clinical sequelae associated with fungal conuiminauon of 9 building. SBS = sick uals who possess a heightened sense of building syndrome. MCS * multiple chemical sensitivity, and ABPA = allergic bronchopulmoniiry olfactory awareness. Odor perception involves the most ftmdameiltal of

286 ANNALS OF ALLERGY. ASTHMA. & IMMUNOLOGY sense*. Eton a phylogenetic stand- have been observed to possess both inant cannot be directly identified with point, it may be the oldest of the per- inflammatory and adjuvant proper- a disease process in an occupant unless ceptual systems and is known to k— ties.60-*2 In this respect, it is of interest there is additional, evidence linking an valve the limbic system of the brain that Michel and associates recently •himrrilogic response to a specific whJch is the seat of emotions in hu- demonstrated that subjects sensitized building contaminant (as opposed roan mans and other animals.51 The ability to housedust mite develop severe alternative exposure, eg, home, bam, to tolerate a variety of non-irritating, asthma when simultaneously exposed vehicle, ±5). but. undesirable odors, is dependent on to housedust containing high concen- Respiraiory Infections trations of endotoxjn.*3 This supports a variety of genetic and acquired fac- Respiratory infections with common the theory that mite allergy (or other tors lhal affect olfartim. These factors pathogens such as viruses (eg, influ- may include the presence of allergic or allergens) act as an initialing environ- mental factor, whereas endotoxin acts enza, measles, common colds) and nonallergic rhinjtjs, infectious sinus- bacteria (eg, Legionnaire's disease. Q itis, nasal and paranasal polyposis. to- a? a triggering mechanism for increas- bacco use, and nasal instillation of ing the seventy of ihe basic disease. fever, tuberculosis) are certainly trans- missible by indoor air and have been over-the-counter, prescription and il- At the present time there arc very licil drugs, among otters. The percep- limited scientific data related to the reported moficebuildings.*7'** Only a few fungal species, however, can cause tion of an undesirable odor is one of detection of endotoxin, glucans, or the principal heralding complaints in other microbial constituents in office infections in otherwise healthy individ- uals (eg, Coccidioides immitis, His- instances of "sick buildiag syndrome." settings. A great deal more work will toplasma capsulation, Cryptococcus Frequently, a strong emotional re- be required before meir roles, if any, sponse is voiced by occupants, and of- can be determined with any accuracy neofnrmans). These are common to soil and the last two also occur in bird len. the complaints may continue de- in building-related illness.62 droppings that may contaminate air in- spite remediation of the source. As Sensitizarivn well, the emotional response of occu- take systems of buildings." Other fun- Sensitization is a highly unlikely pants of ten seems out of proportion to gal infections usually occur in the set- HBCTHnism to explain synptoros in the identified problem.5' This often be- ting of patients wirb significant defects most cases of "sick building syn- comes a difficult issue to solve, and a in cell-mediated immunity,'" and have drome." The symptom complex of sick costly experience for the building been reported JJD association wifla building syndrome often develops owner or manager.*1-0 The source of faulty heating, ventilation and air coc- acutely in individuals who have none repugnant odors in "sick building syn- ditioning systems,7'-73 eg, dissemi- of the hallmarks of allergic disease. As drome" is frequently associated with nated aspergillosis. the "mildew" or 'Yousty"odor of fun- well, (here arc relatively few chemicals with (he capacity of inducing dc novo Toxicosis gal growth which represents fungaj- immune hypersensitivity. Although Toxicosis results from chemical toxins specific volatile organic compounds. significant levels or" dust and microor- thai are generated by viable organisms. Irrhaiionol Symptoms ganisms have been found in public The irritant responses to endotoxin and Although conventional wisdom has at- buildings,144^ it is more likely that glucans have been discussed above. tributed the transient, nonspecific irri- these constituents contribute to symp- Endotoxin has also been associated tation of mucous membranes or respi- tomatology by either mechanical irri- with the development of "organic dust ratory tract to volatile organic tation, or by reactivity wfcfti volatile toxjc syndrome." The severity of compounds in office buildings, there is organic compounds associated with symptoms in this condition appears to a paucity of scientific data substantiat- microorganisms, than by de novo sen- correlate with the number of grim- ing this assertion/5-*1 It is possible that sitization.*' negative bacteria or endotoxin in the other factors-wlatuig-toJoial particu- In addition Jo IgEr specific inecha- environment.7'' Symptom generally lates. relative rumdLty, and tempera- nrans, hypersensitivity pneumonic)s commence four 10 eight hours after lure may play a role in these nonspe- naf result from Exposure to moder- exposure and include malaise, myal- cific symptoms. ately heavy concentrations of micro- gia-dyspnea, cough, headache, and In the absence of specific chemicals organisms.06 The true incidence of nausea. It differs from hypersensicwry or mixtures of chemicals, ic has been building-related Bypersensitiviry pneu- pneumonitis in that no prior sensitiza- suggested that indoor microbial con- monia's is not known. There is a pau- fcjan is required, chest radiograph is tamination could account for a portion city of scientific data related to ibe generally normal, and dircnic sequelae or the observed symptoms.55'59 Indoor actual dyse of bacterial or fungal ami-* do not occur." Symptoms usually sub- air contains a variety of bacterial and gen required for either sensitization or side in hours and tolerance often de- fungal species.5*-39 Certain cell wall devetopmentof oven symptoms. I can- velops despite continued exposure. constituents, particularly bacteria) en- not overemphasize that the mere pres- The latter may be lost over weekends D, glucans, and othw proteases ence of an airborne microbial contam- or vacations with reappearance upon

79. OCTOBER. 1997 287 re-exposure, ie, "Monday nnming c/wrrcrum and other fungi, there is no for this transition, but it must be rec- misery." This conditiai has been re- direct scientific evidence substantiat- ognized that when this occurs, the fened W under a variety of labels in- ing this asserticn. There are no con- synpton complex no longer repre- cluding humidifier fever, grain fever. fumed cases of Stachybotrys-induced sents what has been traditionally re- toxic dust syndrome, etc." hcmorrbagic alveolitis in adults.7* It ferred to as "sick building syndrone." Mycotoxicosis as a poten.ti.aj cause has been speculated that infants ana In tins respect, some patients may find cf "sick building syndrome.' remains ncKB susceptible because their lungs the theories of clinical ecology com- essentially undocumented. It would be are developing rapidly.79 This usually forting and useful, and as a matter of a consideration only in instances of occurs in the setting of very significant course are also labeled as having %"- florid contamination. Recently there water damage. It is highly doubtful tiple chemical sensitivity." ft this has been increased concern about that this organism plays a significant point they have acquired two homes water-damaged as a result of role in the induction of what has been pseudodiagnostic labels defined only flooding. This would rarely be a prob- characterized as "sick building syn- by nonspecific symptoms and con- lem in a conunercial building setting. drome." Aflaioxin from Aspergillus founded by a confusing nomenclature Stachybotrys chartarum (curd) and flavus is a mycotoxin associated with and considerable scientific contro- its toxic metabolites (satratoxins) have increased cancer risk, but an unlikely versy. Hence, the adage vf this re- been linked to life-threatening pulmo- participant in the nonspecific symp- view . . ."a wolf in sheep's doBnng." nary hemorrhage in a cluster of ten toms associated wjth "sick building In effect, many individuals who foliar infants in Cleveland.7* AQ. ten were syndrome." in this transition can be said to suffer a hospitalized and pibnciazy hemor- form of toxic agoraphobia usually trig- rhages recurred in five infants shortly j&ss Psychogenic Illness gered by an odor or the pT^'liTi of after discharge finn hospital. Informal Psychogeruc and social factors play a an exposure, ie. a form of cacosmia or surveillance for pulmonary hemor- significant role in the evolution of parosmia. Kurt believes this symptom rhage by the Centers for Disease Con- many cases of "sick building syn- complex is analogous to the manifes- trol and Prevention following the drome." There are insufficient scien- tations of panic disorder as defined by Cleveland report uncovered an addi- tific data to state how often this occurs. DSM-rV-R,** This belief is supported tional 32 cases in Chio and 47 cases The origin of the problem develops by two recent investigations.KM among infants in the rest of the coun- firm an initiaj lack of scientific infor- try.77 Unfortunately, in the latter re- mation, dissemination of misinforma- ASSOCIATION OF "SICK ports investigators wens unable to do tioi, or providers who unequivocally BUILDING SYNDROME" WITH any confirmatory studies. There ap- diagnose an evolving pathologic state OTHER CONTROVERSIAL pears to be a synergistic effect between that has not been scientifically demon- DIAGNOSES exposure to £ charturum and the pres- strated.*3 Frequently, the media add to Traditionally the symptom complex of ence of tobacco smoke.78'" Thus far all the confusion. Unfortunately, the use "sick building syndrome" has implied reported cases io humans have oc- cf "sick building syndrome" as a sur- the development of transient annoy- curred in inf>r*« less than 1 year of rogate €or a bonafide diagnosis con- ance and/or im'tationaJ symptom that age.79 tributes little to clarify the clinical sit- are temporally related to a building or Although there have been reports of uation. With the suggestion of a specific area of a building. The key Stachybotrys-induced disease in farm "dangerous" microbial aerosols in the issue lending credibility to this "diag- workers handling heavily contami- workplace, patients understandably be- nosis" has always been the striking nated hay, (be absence of appropriate come concerned about their long-term temporality of symptoms within the confirmatory studies makes the linkage health. Inappropriate belief spstsns building. Symptoms regress upon exit- tenuous.10 Similar concerns surround may become entrenched in situations ing the building and resume upon re- the report by Croft et al regardirtg-a— where office-workers are frustrated in turning. The obvious solution io any Chicago family with a heraorrbagjc al- their attempts to correct a perceived such patient bas been to change the veolitis presumed to be related to tri- problem and ignored by their employ- work station to an alternative site. In chotheeene toxicosis." Johanning et al ers and physicians.1* those affected patients where such so- reported on the results of a question- In my experience analyzing in- lutions appear to be elusive, there is a naire survey among 53 New York of- stances of "Sick building syndrome" gradual evoJutjon to a permanence of fice workers who were exposed to fun- there Frequently is ari evolution to symptoms beyond tte envelope of the gaj contaminants as a result of water chronic complaints from wbat origi- building. The reaacn for this subtle incursion from a faulty storm drain.*2 nated as transient building-related transform ation is not always evident. Although these authors conclude that symptoms. Frqucnrly. the spectrum of Because many of these patients k- wader symptoms and subtle immuno- odors or irritants precipitating symp- come engaged in one form or another logicchanges in the complainants were toms expands without plausible ratio- of legal action (eg, Workers' Compen- the result of exposure to toxigenic 5. nale. There are no physiologic reasons sation, Americans mfti Disabilities

28* ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY ganisation has recommended a new Sick Building name, "idiopathic environmental intol- 8yndn>fl» erance," to stress the fact that environ- Fatigue (BO) fatigue (93) mental chemicals have not been Confusion (20) Memoiy Loss (77) proven to cause "multiple chemical UriablMyfZO) Memory Lots (90) Confusion (73) Eye Irritation (90) Confusion (90) IrtteWKytST) sensitivity" synptons,! would submit Headache (100) HW

APPROACH TO PATENTS Firtgue (100) WITH IDIOEKEHICBrjIIDINS Memory Low (63) Contort*) (64) INTOLERANCE IrrittbiOty (50) Building-associated illness often pre- Headache (83) sents a major diagnostic challenge to the clinician. The patient often arrives Kiturc 3. Similarity rfcore pympiom? in four controversial disorders frequently associated with one with deeply entrenched perceptions re- mother i adapted Mid modified from references #12, 18, and 87. used with penmssioi). MCS = multiple garding the absolute Linkage of their chemical sensitivity. synptons to poor air quality in tteir work environment. Three major pit- falls arise in the evaluation of possible ACL Fair Housing Amendments Act, served that 69% to 86% claimed total attribution of any sjnptcm complex to Toxic Tort Litigation, etc), ffie concept disability.9'-*3 a particular workplace, domicile or of a sen-limited symptom complex is In selected patients with "sick build- product. These are (l)faUure to recog- never as forbearing as a condition that ing syndrome" or "multiple chemical nize an explanatory preexisting medi- has permanence and is all encompass- sensitivity" there is a furtherproclivity caL disorder, (2) failure to diagnose on ing. Vl< Accordingly, one occasionally to associate with other ill-defined, underlying condition masquerading as observes a tendency to lode "sick chronic disorders with overlapping "sick building syndrome, "and (3) in- building syndrome" with the develop- symptoms. These include chronic fa- appropriate patient advocacy in the ab- ment a i other chronic disorders, many tigue syndrome and fj.bromyalfia.87 It sence of credible scientific substantia- c£ which suffer a similar paucity of has been proposed that chronic fatigue tion. In evaluating any patient with biologic markers and an absence of syndrome and fibromyalgia are simi- such problems I recommend a strati- an effective therapeutic intervention." lar, if aor identical disorders.9*95 All fied approach beginning with a com- Disability among such patients is these conditions share a preponderance prehensive history and physical exam- considerable. cf female patients wirh similar mean ination to eliminate the first two "Multiple chemical sensitivity" is ages at presentation, marital status, ed- pjtfalb. In obtaining the medical his- frequently invoked as the natural out- ucational level, employment rai£, and tory, it is essential that attention be come of "sick building sprhrne." duration of illness (Fig S)."*-93 Re- given to the details of the patients' The latter serves as the environmental cently, there have also been claims as- workplace and non-workplace expo- trigger for "multiple chemical sensitiv- sociatangthe "chemical" basis of "mul- sores. Frequently, one sees a reason- hy."2" Core symptoms of these pro- tiple chemical sensitivity" with the ably complete description of the work- period symptom complexes are simi- induction of porphyria.** This pur- place and its exposures without similar lar. ie. skin and/or mucous membrane ported association is based principally attention to the home, avocations, so- T headache. onfresults fromVsingJe reference lab- ciaj habits, recreational activities, type cognitive impairment, etc11'*'7 (Fig 3). oratory utilizing a fundamentally of vehicle driven, etc. Supplementation Symptoms are not the result of tissue flawed assay .firerythrocyte copropor- of the madicBl history with an exten- damage rhat can be observed or mea- phyrin oxidase.*6 sive questionnaire that can be checked sured by physical examination or lab- Based on these observations, the cli- at the time of examination can be ex- oratory studies.""90 Once the transition nician should be extremely cautious tremely useful"1 As well, the examiner i-1. established, the patient feels justified about accepting or applying "sick must make every effort to obtain as in the expression of chronic synplons building syndrome" as a bunafide di- many previous medica! records as is fur which there is little hope of any agnosis. This frequently triggers a di- possible. effective therapeutic intervention.*1"93 agnostic domino effect leading to an Laboratory tests for biologic mark- Previous studies of patients with "mul- unintended clinical outcome. Just as a ers of building exposures are seldom liple chemical sensitivity" have ob- recent panel of The World Health Or- helpful, except in the case of environ.-

VOUUME 79. OCTOBER. 1997 289 mental tobacco smoke. More com- to upper airway obstruction cr voice several alternative mechanisms may monly than not, laboratory studies are disorders such as hoarseness, laryngi- apply. The often used pscudodiagnosis TOpg Jjkely lo assist in the elucidation tis, or persistent throat pain ascribed to of "sickbuilding syndrome" is avoided of alternative disease processes. The poor air quality may lead to an alter- entirely with the hope that the patient clinician should consider selecting rel- native diagnosis, eg, vocal cord dys- will be reassured, and armed with a atively high yield, low cost tests (eg. function. Similarly, referral to a der- scientific medical perspective, proceed complete blood count, chemistry matologist or psychiatrisr can prove to cope with the issues at hand without screen, screening computerized LO- invaluable in shedding light on associ- adverse impact on their psychologic mography of sinuses, selected allergy ated cutaneous or cognitive problems. stability, their employment, or their ca- skin testing, putacnaiy function stud- The initial process of evaluation reer. In this respect, the physician owes ies, etc) before proceeding to more ex- should focus on the differential diag- each patient his or her advocacy, bur pensive evaluations less likely to yield nostic process, It is imperative to con- this patronage must always be tem- useful information (eg, autoimmune sider Ac common medical and psycho- pered by the overriding responsibility scrology, airborne bacterial/mold de- logic conditions chat may present as to scientific veracity. terminations, toxicology screens, lym- perceived toxicity or hypersensitivity In summary, "sick building syn- phocyte surface marker studies, etc).9" caused by indoor pollution. Five gen- drome" is a pseudodiagnosis com- The appropriate use of consultants eral groups of disorders have been posed of nonspecific, transient synp- can prove invaluable in the assessment identified in patients who present with tomS Without kllOWn biologic TttnJaara of building-associated symptoms. For building-related illness (Table 3). Its application in the clinical setting example, collaboration with an otolar- Upon completion of this initial invites frequent subsequent linkage to yngoJogist 10 assess symptoms relating phase of differential diagnosis, the sec- other similar vague diagnoses associ- ond step relates lo developing an as- ated with chronic debility and lack of Table 3. Diagnostic Groupings of Medical sessment of the most likely cause for effective therapeutic interventions, eg. Conditions Commonly Confused with the patient's complaints. ID this re- "multiple chemical sensitivity,'1 fibro- Toxicity or HypersensWvrty 10 Indoor spect, collaboration with a knowledge- myalgia, chronic fatigue syndrome, Pollution able industrial hygienist or building among others. Hence, the thrust of this engineer is invaluable. When possible review is to encourage the reader lo infectious diseases Acute/chronic sinusitis and practical, the clinician should al- avoid use of this term in favor of a Pharyngitis ways lake the opportunity to visit and simpler, descriptive diagnosis (eg, Tonsillitis inspect the building- A number of ex- transient annoyance and/or irritation) Bronchitis cellent protocols have been developed or if this is not appealing, adopt the Allergic/inflammatory disorders as guidelines in the investigation of diagnostic label of "idiopathicbuilding Allergic rhinitis indoor air quality. AD of these proto- intolerance" instead. Bronchia) asthma cols share a flexible approach and em- Contact dermatitis phasize general observations over ac- REFERENCES Idiopathic urticaria/angloedema tual measurements of pollutants.*2-*9-100 1. Samet J. Environmental centrals and Hypereensrtivlty pneumonitis Jung disease. 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292 ANNALS OF ALLERGY. ASTHMA, A IMMUNOLOGY chemical sensitivities. Arch Inter Med 93. American College ofPhyf icjans. Clin- Jnc. 1996:351-85. 1994:154:2049-53. ical ecology: position statement Ann 98. Bardana El. Montanaro A. "Cbemical- 88. Tea SL. Multiple chemical sensitivi- Intern Med 1989:111:168-78. ly sensitive'' patients: avoiding the pit. ties syndrome. IramunoJ Allergy Clin 94. Goldenberg DL, Slmrns RW, Geiger Mis. J Respir Dis 1989; 10:32-45. N Am 1992;12:897-908. A. et al. High frequency of fibrornyal- 99. Light EN, Presam N. Investigation of 89. Terr Al. Tmmunological issues in gia in patients with chronic fatigue indoor air quality complaints. Irnmu- "multiple cbejnica] sensitivities." Reg seen in a primary care practice. Arthri- nol Allergy Clin N Am 1994; 14: Tcodofl PhanMcon 993:18:54-60. tis Rheum 199033:381-7. 659-78. 90. Tor IA. Multiple chemical sensitivi- 95. Bohr T. Problems with royofascjal 100. Quintan P, Mucker JM, AHvantis LE, ties. In: Bardana ET, Montanaro A. eds pain syndrome and fibromvsJgia syn- et al. Batumi for the comprehensive Indoor Air Pollution and Health. New drome. Neurology 1996;46:393-7. evaluation cf building-associated ill- York: Msrccl PeWcer, Inc, 1996; 96. Haha M. Bonjcoysky HL. Multiple ness. State Art Rev Occupal Med 267-83. chemical sensitivity syndrome and 1989;4:771-$. 91. Terr AL Environmental illness: a clin- porphyria. Arch Intero Med 1997;157: ical review of 50 cases. Arch Intern 281-5. Requests far reprints thould k addressed tu: Med 1986:146:145-9. 97. Bardana El. Assessment or patients EmUJ Bardana. Jr. MD 92. Black DW. R»tbe A, Goldstein RB. with claims of illness due to indoor Oregon Health Sciences University Environmental illness: .a conirolled pollution. In; Bwdana EJ, Montanaro Division qf Allergy 4 Clinical tmmunalaxy study of 26 subjects with 20th Century A. cds Indoor Air Pollution and 1181 SWSam Jackson Park RtL PV 320 Disease. JAMA 19902643166-70. Health. New York: MweeJ Dekker, Portland. OR97ZQ1

CME Examination No 007-009 Questions 1-20, Bardana EL I997;79:283-94. CME Test Questions may be suffering adverse health C. Are usually well below TLV effects due to poor indoor air qual- standards published by the 1. AJI the following diagnoses be- ity is: American Conference of Gov- long in the category of building- A. 2 million. ernmental Industrial Hygien- related illnesses except: A. Hypersensitivity pneumonitis B. 5 million. ists B. Humidifier fever C. 10 million. D. Are usually less than 1% of C. Tuberculosis D. 20 million. any recognized occupational D. Q fever E. 50 million. exposure standard E. Vocal cord dysfunction syn- 5. All of the following are precipita- E. Arc definite respiratory irri- drome tors of "sick building syndrome" tants 2. A building where studies have except: 7- Obvious mold growth in commer- failed to localize a cause for ill- A. Preparation <£ food or bever- cial ofice buildings is usually as- defined symptoms in occupants ages sociated with all of the following with resultant fear and eventual B. Occupancy of a new building except: evacuation is termed a: before final completion A. Poor maintenance of the heat- A. tight building. C. Renovation of any commercial ing, ventilation, and air condi- B. problem building. building during normal work- tioning system C. crisis building. shift? B. Intrusion of water ~Dnroubled building. ~ " ~D. Water or moisture incursion C. Typical "mildew" odor 3. The estimated number of commer- 6. True statements related to indoor D. Health concerns among build- cial buildings with nalfunctLcning levels of volatile organic com- ing occupants heating, ventilation and air condi- pounds in commercial buildings E. Adverse health effects tioning systems is: include all cf the following ex- 8. All of the following oorxiitions A. 10% cept may impact how a building occu- B. 25% A. Associated with annoying pant responds to an undesirable C. 33% odors odor except: D. 50% B. Bnanate from paints, carpet A. Allergic rhinitis E 65% adhesives, plastering com- B. Chronic sinusitis 4. The approximate number of af- pounds . etc. C. Cigarette smoking fected building occupants who D. Cocaine abuse

VOLUME 79. OCTOBER 1997 293 E. Migraine headaches A. Preexisting atopic disease tant as information about which of 9. The source of the typical "mil- B. The lay media the following: dew" or "moldy" odor emanating C Misinformation A. Private residence from fungal overgrowth is related D. Lack of information to which constituents produced by B. Motor vehicle driven E Uninformed, alarmist provid- C. Avocations fungi: ers A. Endotoxin D. Social habits 14 r/iemcKt sigoificant trigger result- E. HI of the above B. Proteases ing in me development of toxic C. Volatile organic compounds 18. An example cf a relatively high agoraphobia in sick building syn- yield, low cost test in the evalua- D. Glucans drome is: E. Mycotoxins A. An upper respiratory infection tion of patients with building-re- 10- Fungal species associated vitti B. Poor acoustical qualities lated symptoms include: systemic infections in health indi- C. Unacceptable room tempera- A. Complete blood count viduals include all of the feiLkw- tures B. Computerised tomography screen ing except: D. Perception of some maiodor of sinuses A. Coccutioides imm'ais E. Inadetjuafe illumination C. Pulmonary function studies B. Histoplasma capsulatum 15. Conditions frequently associated D. Selected allergy skin tests C. Penidllium notation with "sick building Syndrome"in- E. All of the above D. Crypiococcus neoformans clude all of the following except: 19. In evaluating building-retted 11. Organic dust toxic syndrome is A. Multiple chemical sensitivity complaints the clinician should usually caused by which of the B. Chronic fatigue syndrome make every attempt to: following: C. FibromyaJgia A. Compare prevalence of symp- A. Thermoactinomyceies vulgaris D. Porphyria tom in similar buildings B. Endotoxin E Polymyalgia rheumatica B. Examine fce rate of absentee- C. Candida albicans 16. Three nHJcrpttfells that should be ism in all occupants D. Aspergillus flauus considered before attribution of C. Make a visit to the building E. Stachyboirys chartarum (atra) any symptom complex to a build- D. Perform allergy testing in aU 12. Aflatoxk is a carcinogenic nyco- ing include aD of the following occupants toxin derived from which of the except: 20. Which building-specific issue following species? A. Age of the building should be considered h evaluating A. Aureobaaidium pullulans B. Failure to recognize apreexist- the adequacy of any building: E. Alternaria tenuis ing medical disorder A. ftniH-JTvj age and design C. Sitaphilus granarius C. Failure to diagnose a condition B. Heating, ventilation and air D. Aspergillus flavus masquerading as "side build- conditioning design and main- E. Merulius lacrymans ing sjndrxne" tenance 13. Building-related psychogenic ill- D. Inappropriate patient advocacy C. Renovation ness has its inception m aD of the 17. Historically, information about the D. Management philosophy following except: patient's workplace is as impor- E. Ml of the above

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