Deep Dive Into Mold Testing

• Diagnostic Solutions
• GI Map white paper
• GI-MAP Interpretative Guide
• Dr. Ruscio’s Additional Resources

Intro:

Welcome to Dr. Ruscio Radio discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit drruscio.com and sign up to receive weekly updates. That’s DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hi everyone. Today. I speak with Dr. Jill Crista author of Breaking the Mold. She’s been on the podcast in the past and Dr. Joe Mather, who has also been on the podcast in the past. We went deep into the tests that are available for mold. One of my concerns is that this is an area of lab assessment that is so early, still in its infancy, that it can be challenging to ascertain what tests to use, what tests not to use, which ones are accurate. So one of the chief objectives today was to get a better handle on that and also highlight some of the recent split test study results that Dr. Jill will be publishing. So just a forewarning, this is a fairly detailed, nuanced exploration of the different tests available to quantify one’s mold exposure, one’s body burden of mold, and/or their immune system reactivity to mold.

DrMR:

So that is what we will cover in detail today, the good news is outside of all of the nuance, it doesn’t seem to make a huge difference, at least ostensibly on patient outcome. As long as the clinician is keeping the bigger picture in mind, and, as I’ve said before, testing can be viewed as perhaps one-fourth of the data needed to make a clinical decision, then irrespective of if it’s the best test, the right test, the right time, you should still be able to achieve the end-point of seeing improvements in your or your patient’s health over time. I also want to point out that Dr. Joe is one of the doctors now in the expanded clinic, Austin Functional Medicine. I’m happy to announce that and as you’ll hear in this episode, Dr. Joe is very sharp and very well tuned in, and he’s one of the great minds that we have on board, all working collaboratively in the model that we’ve been working so hard to develop. If you are in need of personal health care, feel free to reach out to the clinic now under the name Austin Functional Medicine. There is now an offering beyond just me with much shorter wait times, and we’d be more than happy to kind of steward you down the path of cost-effective patient-centered, practical, and scientific, and evidence-based functional medicine. So with that, we will now go to the podcast on all the nuances of mold testing.

DrMR:

Hi, everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m back with both Dr. Jill Crista and Dr. Joe Mather, and we are going to be having a clinician’s round table on mold and mold testing. Really what I really want to get into is the two tests that we’ve discussed prior that seem to be the most accurate, pros and cons of each, and some updates in the data. If I’m being as simple as possible in this description, how do we best use these tests? How do we know when they’re accurate, when they’re not accurate, especially wanting to prevent people from seeing something in their urine and perhaps falsely concluding that this means mold. This is where there’s a lot of gray, and we may not be able to fully parse this into black and white today, but hopefully we can at least help establish some better boundaries for how we navigate some of this. As I’m sure the audience knows, one of the things that I really try to do is arm people with knowledge so that they don’t get pulled into what could be and instead can really focus on this is probably the thing or things that are most important to focus on. Basically getting a really clear signal and separating that out from a lot of the noise that that lab testing can sometimes be imbued with.

DrMR:

So with that long intro, Jill and Joe, welcome.

DrJC:

Thank you.

Accuracy & Interpretation of Mold Tests

DrMR:

You’ve both been on the podcast before, so I will refer people to those episodes that they wanted to familiarize themselves with your backgrounds. I want to get right into it though. One of the things that kind of spawned this conversation is this continual challenge I have, and I think every clinician has to some extent, with testing patients for mold and knowing if the tests are accurate and how to interpret them because this is a very new area of science and of laboratory evaluation. Jill recently did what we could call an in-office study, Jill correct me if I’m wrong there, but you have some findings that you’ve recently presented. So I thought we can start with those findings and then kind of unpack how we interpret those and how they impact clinical practice.

DrJC:

Yeah. I have had a lot of fun doing split sample testing through the years just to learn the answer to this question that you’re asking…

DrMR:

I’m sorry to interrupt, but can you explain what split testing is for people who may have heard it before?

DrJC:

Oh yeah. That’s a good point.

DrMR:

I love that you do that.

DrJC:

Well, it’s that curious mind of mine. We’re in an area with a paucity of research, so as a clinician, you’re experimenting on your patients. So yeah, a split sample is basically taking one urine sample and/or blood sample that you’ve collected in one collection. Ideally, we’re collecting the sample from the same vial, but that doesn’t always happen with blood testing. You’re trying to capture an identical moment in time and then split that sample in half. One goes off to one lab, one goes off to the other and we compare results. What I was trying to understand is not necessarily is the lab accurate but what I’m trying to understand with that split sample testing was what do I need to do with or to my patient before they give a sample so that we’re getting the best representation for the kind of testing that we’re doing? I get a lot of times, well, which tests do you prefer? And I say, that’s not really the right question. The question is if I’m going to test, and then when, and then how. It’s determining which method matches the question that we’re trying to answer. If we already know it’s mold and somebody knows they have mold in their house and many members of the family are sick. We will skip testing and go right to working on the house. Treating the cause. So the split sample testing is just basically trying to capture that single moment in time using different methods so I can learn about the techniques themselves and then about the prep time before the sample, and then ideally correlating that to what we find in their home.

DrMR:

Just for the audience really quick to orient people in case they’re a bit newer to this conversation. I think we’re all in agreement, and if not, please speak up. But I think we’re all in agreement that we want to start with dietary and lifestyle foundational aspects first. Again, they may sound trite, but making sure you’re sleeping enough, exercising enough, taking walks, getting time in nature, personalizing the diet to you. Definitely a foundation that we need to get in place first. So if you’re not doing those things, you should be. Second, I think we all agree here, at least generally speaking, that improving one’s gut health should kind of be the next endeavor. Then for those who have done all these things and have not responded adequately or only very partially, mold is then a consideration. So one of the things that comes up is, well, how do we quantify if mold is, or is not an issue, if there’s clear water damage and mold in a home, then I think what you’re saying here, Jill is we may not even need a test necessarily, but for people where it’s a bit more unclear, the testing can be helpful.

DrMR:

Is there anything there that you would modify in terms of how we kind of contextualize this for the audience?

DrJC:

No. I think you really wrapped it up that mold fits in that category, sort of like Lyme disease, the great imitator. So it can look like a lot of things and some of the cardinal keys that it may be a mold problem as you’ve done all the reasonable things and you don’t feel better. Because I think, you know, all three of us see people that when you correct lifestyle, it can seem really simplistic, but it’s profound. Good clean living keeps a lot of people out of our offices. So yeah, doing that and if, if things aren’t responding in the way that we would see in the majority of our patients that aren’t dealing with mold, then that’s the time to go looking. So, yeah, that’s the time to either test or I have a questionnaire because I do serve real people who have to pay cash for their care. And sometimes the questionnaire is what they can afford to do.

DrMR:

I love the mindfulness of being cost conscious. So if someone is in this category and they’re trying to get more definitive information to tell them, do I go into mold or perhaps not, this is where testing comes in. As you said earlier there really is a paucity of data here. So we’re kind of doing the best with what we have. You’ve done the split testing, which is something that I’ve done with stool testing. We’ve chronicled some case studies in our clinicians newsletter and on the podcast in the past where we should be careful with how much we derive in terms of conclusions from one stool study. More often find disagreement between split stool studies, then you do agreement, which doesn’t mean that the tests aren’t valid, but I think it just poses a good bridling of how literally we should interpret some of these tests. So you’re doing the same thing with mold testing. What is it that you found as you’ve gone through this wonderful exercise of split testing different labs, and also tell us a little bit more about the parameters of the split test. Was it purely preparation for the test or was it also, you use two different kind of somewhat tandem labs?

DrJC:

Split Testing

DrJC:

Oh, that’s a good point. So I try to make sure the prep was exactly the same as much as possible. I have a very unique situation where I have identical twin boys and that gives me an opportunity to rule out even one difference there, which would be genetic differences. Then one needed to be on a certain medication and one was not very good about taking that medication, which gave us another opportunity. So through time they’ve been my subjects for a lot of it because it’s hard to convince patients to pay for two tests, but in the cases where we’re using not my identical twin kids, we’ve tried to keep the test prep the same. This is so we can rule out the biggest challenge with excretion tests and mycotoxin tests, and it’s a distraction I think, intended to be there by insurance companies and people who don’t want to be paying for mold remediation and treatment.

DrJC:

But the biggest challenge is the assumption that if you find a mycotoxin in any of these methods, whether it’s urine or serum antibody testing, it’s because the person is eating it in their food, it has nothing to do with that water damaged building that they’re living or working in. So I tried to make sure that the prep part involves a low mold diet. Taking out things that either are fungus or that are commonly known to be contaminated with mycotoxins in a mass production sort of way. So one of those would be corn, grains, things that are done in mass production. So for the test prep, I try to take people off of that for 72 hours. Although, most come back and say, “I did pretty well”. I did about two days. So I figure I’m looking at a 48 hour low mold diet in most of the split sample testing that I did. For urine mycotoxin, there are two different methods being used. Then there is also serum antibody. Each of those has its strengths and its challenges. The strength of urine mycotoxin is that we’re able to see, and it depends on if you’re using ELISA or the mass spect method, each has its strengths as well. But we’re able to see a direct measure if you’re using mass spect they are seeing the mycotoxin in your urine. If you’re using the ELISA, that’s a little more complicated because it’s a little more indirect measure. With the serum antibody, the downside of those is they are excretion tests. So if the person is really bad at excreting, you may not be getting a good representation. So you could use a serum antibody, which tells not necessarily the mere presence of the mycotoxin, but what does the body think about it?

DrJC:

And it’s not relying on excretion to tell us that. So I’m trying to do, across the board, the ELISA, the two mass spect and the serum at the same time. That’s my next run. To try to do all four at the same time. I’m finding, much like you said, you can’t just take 6 to 10 split samples of different people, repeated throughout time and apply to all patients. I’m trying to repeat it with the same patients so that I can see their story but that’s not going to tell us population statistics. That’s not going to be something I can broadly apply to all patients. However, it has taught me some things like binders can affect how much you excrete in a urine mycotoxin test. I’m not sure if that makes a difference in a serum antibody test because I haven’t run those yet. I’ve also seen that provoking with glutathione may be underrepresenting your mycotoxin load in the mass spect method.

DrJC:

So someone has to be on glutathione, I use the ELISA method. I’ve also seen that if someone has having kidney disease, which is really calm and ochratoxin is incredibly hard on the kidneys possibly using the ELISA method is not ideal because it’s not controlled for creatanine. So there are all these little things that then make it really complicated for us as clinicians. Now I need a guide not only on my favorite test but also what are the conditions? That’s what I’m trying to create. An algorithm that just says what are the conditions that rule in or rule out this method? The problem with the serum antibody tests, for me clinically, is that I see that it’s useful to know that the IgG level is high. They do also IgE, which answers the question that urine mycotoxin can’t answer, which is, is this a now problem? Something that is only happening in this moment. Urine mycotoxin can’t really answer that question because someone could be detoxing, even though they’re out of the mold and still look like they have mold sickness, because they do, because they have mycotoxin load.

DrJC:

So the IgE serum is really great because you can see they’re reacting in the last two weeks. They’ve been exposed. The IgG can stay positive for up to six months. So that doesn’t give me a record of how am I doing on treatment? With urine mycotoxin, I’m able to see that those levels drop as we treat. There’s usually a bump up and then a drop. So I usually don’t retest any sooner than three months.

DrJoeMather:

Is there a particular lab you’re using for the serum antibody testing?

DrJC:

My Myco Lab is the lab I’m using for serum.

How Are We Testing?

DrMR:

I want to get into some of these details here in a second. But just to restate a few things to make sure we’re not losing anyone. Essentially from a high level there are antibodies that we can test for your blood and/or, we can use these together, there is urine testing that can look for the number of actual mycotoxins in the urine.

DrJC:

And there’s urine that can look at the antibody reaction to the mycotoxins, which what a urine ELISA is. Which is real time analysis.

DrMR:

So, okay. Thank you for that. So the urine ELISA – I thought that was an antibody test, which makes sense, obviously, if you know about the methodology. So the antibodies can be assessed via serum or via urine.

DrJC:

Yeah. I mean technically with the ELISA, the lab is choosing antigens. There’s a very well established use of this method for the last 15 years. The idea here is that due to the body’s ability to modify these mycotoxins, antigen detection is better than trying to do a molecular matching with the mass spect. Because you’re going to catch more metabolites and get a better view of the body burden. Well, that works as long as the lab is choosing the correct antigens. I think that we’re getting a much better idea as we move through. Each mycotoxin is so different. The biodiversity of these, if you looked at the chemical structure, for example, aflatoxins. Basically all different types of aflatoxins look a little bit alike. All the different types of Ochratoxins look a little bit alike, but if you were to compare them aflatoxin to ochratoxin to zearalenone, they have wide, wide biodiversity. So the trick with any kind of antibody testing is, are we picking the right antigen. And how much does the body modify that antigen through the process of detoxification? It gets very complicated.

DrMR:

It’s fine. So I’m going to keep kind of bringing this back to a high-level so we keep that our orientation and our “North star” in sight. Two high-level differences in methodologies: antibodies, which can be done in blood or in urine and excretion tests. And the excretion is exclusively via the mass spectrometry methodology or are excretion tests using any other type of methodology?

DrJC:

So all the urine ones could be considered an excretion test. The body’s excretion is what gets it to the urine. From that point, the method choices are either ELISA or mass spect. It does look like, when I’m looking at the studies and again, research labs have all the money in the world so they can use this very expensive mass spect machine. There’s a reason why it’s not necessarily easy to test this at every Quest lab. Specialty labs perform these tests because the machinery is incredibly expensive. But it appears, in the research that I’m reading, that the mass spect method, using liquid chromatography, with the tandem mass spect is going to be what they are considering the gold standard for a small molecule toxin-based detection. So big picture is 1) urine is all excretion and 2) there are two methods there. Alternatively, you could do serum antibody.

DrJM:

I would just also throw in VCS testing, which is sometimes helpful and is one of the things I am interested to hear everyone’s opinion on. I’m seeing about 50% of the time that it’s highly specific and will track with a mycotoxin load. As my patient improves their scores change. So I’m using that as just a low-cost screen and telling patients if we get a hit and it looks like it’s helpful, we’ll keep doing it. If it doesn’t, then we’ll just drop it because it’s just so low cost and easy to do.

DrMR:

And for the audience to the VCS test, I believe it was originally pioneered by Richard Shoemaker, stands for Visual Contrast Sensitivity. It essentially tracks things on the computer screen and looking at how well essentially your eyes can perform this test and I think it costs about $10. It’s something that we’ve been using in the clinic. I agree with you, Joe. I think it’s a very attractive test in the sense that it’s simple, easy, almost instantaneous in it’s turn around and it’s very cheap in terms of its cost. I do want to come to the correlation between testing and VCS, but before we go there….

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Test Methodology

DrMR:

I want to make sure we’ve kind of pinned down a couple of other questions regarding the tests. I’m assuming that both Real Time labs and Doctor’s Data, they’re both urine tests. Are they the same methodology or do they differ?

DrJM:

Well, the two labs that I’m primarily using are Great Plains, which is the mass spect.

DrMR:

Oh I’m sorry, yes, I meant Great Plains, not Doctor’s Data. Thank You

DrJM:

And Real Time Laboratories, which is the ELISA testing. So when I do a split sample, it’s with those two labs. Doctor’s Data does not have a mycotoxin test. I think part of where the rationale comes in that Dr. Neil Nathan has to run both these tests in tandem, because he wants to see both different excretion, urine methodologies, one from Real Time labs, one from Great Plains. Jill, do you agree with that general assertion from Dr. Nathan that using those two urine tests in tandem is well, I guess I just want to say is better. I think if we’re going to paint a picture, two tests would generally be better than one, but we have to weigh that against the additional costs. So all things considered, do you feel that that’s an advisable way of testing?

DrJC:

Again, it’s just a financial burden on the patients. I agree with him. In a perfect world, we would do both of those techniques and I would save and toss in a serum, in a perfect world because, again, the paucity of research. We don’t know if we’re seeing, ochratoxin using a mass spect method, which is a great way to see that. Can we infer other mycotoxin exposures that we might have to run an ELISA for? You know, we don’t know that yet. It would be nice to know that data. I would have a hunch that that would not be the case, that it would not be one of those cases where we can just run one. I used to do this with food sensitivity testing. You could kind of infer the other foods that they would be not tolerating and so I could run a shorter panel sometimes. I don’t think we’re able to infer different mycotoxin exposure when we see just one. So ideally yes, we would run both. There was a study out of China recently, it was not meant to be a comparison study of techniques, but rather a detection study because they were trying to find out how many men and women are exposed to these different mycotoxins. Is there a difference between men and women? The short answer to that is yes, but it’s not statistically significant. Their findings were that when you pair plasma testing and urine testing, there were differences between the type of mycotoxin and the gender for which method would be the best one to detect certain types of mycotoxins. So that leaves us with this question of now what do we do in practice?

DrJC:

You know, so it is sometimes good to get your building done, maybe even before you’re running your mycotoxins. I know that’s backwards. If you know the building has a problem, then why even test? But then you can know which ones you’re targeting and which, which lab to run. That’s possible. What I go for, actually, and what I’m finding in some of my split sample testing, comparing the two mass spect companies, I’m finding that the company that is really individualizing out the metabolites, I’m getting a more accurate picture related to what we’re finding in the building. And that would be Vibrant Wellness, their trouble with mass spect is that those mycotoxins, that do look similar peak in the same place. So you can get to kind of a cross-reactivity or double reporting. What we’re finding was the technique that’s being used that’s really pulling those peaks apart, is showing a better representation to what we know these patients have been exposed to. So it’s a tough one. Sorry, I answered that question with a yes, but…

DrMR:

And Joe, I do want to loop you in here more in a second and kind of get some of your clinical thoughts. So I’m not trying to keep you on the back burner here, but I’m trying to make sure I get all of these updates from Jill on the table here so we have all of this to look at and parse together. So Jill, maybe a more direct way of answering this question for the audience is asking them what testing regimen have you found to be most effective?

What Testing Regimen is Most Effective

DrJC:

Yeah, I’m with Joe that if I know that the person is coming in with neurological symptoms, that’s when the VCS is really helpful. That tells me how deep into the neurology has this problem gone. How far into central nervous system soaking have the mycotoxins come. Then that tells me how aggressively I need to go with that treatment, really addressing central nervous system, bone marrow the deep, deep structures. I think Joe’s number represents about what I’m seeing that people can have a negative VCS, it can be totally clear and they can still have mold sickness. So that one is a nice, cheap, easy way for me to know in practice, how aggressively we need to go, how pushy do I need to go at dosing? How pushy do I need to be about them changing their job or getting out of their home or, you know, devoting money to remediation?

DrJC:

Then I like to use the urine mycotoxin testing. I’m also using that just as one data point. There is no end all be all single test, but I have been using the Vibrant Wellness test more often lately, because again, I’m seeing that it’s representing what we’re finding in the home very accurately. Now, granted, I’m seeing patients who already have the diet on board. They’re already doing a lot of things that are helping them detoxify. So I think that I’m seeing an accurate picture of their ability to excrete. Certainly, there are going to be those patients that, because it’s an excretion test, they’re too sick to show me how sick they are on paper. And those are the people that, if they can’t go into the laundry detergent aisle at the grocery store, or they can’t drive too close behind another car because the exhaust bothers them, they can’t fill their own gas tank because they get a headache. I know that those are the people that relying on an excretion test without doing some pre homework on getting their body detoxified and nourished. We’re probably not going to see a representative sample on a urine mycotoxin test, no matter what method that we use. So I may also run a glutathione test either through Doctor’s Data, like RBC glutathione, so that I get an idea of how able are they to mobilize those things in tissue and get it to the liver or get it back to the bloodstream so the kidneys can actually filter and show us that that’s the problem.

DrMR:

And are you incorporating the blood antibody testing into the equation here?

DrJC:

I will use that very rarely, but I will use it when I have that super sensitive, toxic, toxic patient that I’m really concerned that they’re not going to be able to excrete. Then we shift gears to, well, let’s just look to see, is your body complaining about it? Now, that’s not going to be a good test for somebody who has an IG deficiency or immune deficiency. So in those cases, ideally, we would run a natural killer cell function test because mold is so immune suppressive, but it’s a very expensive test. So I’m careful if someone has insurance coverage and they’re past their deductible and we can get that, great. That tells me again, kind of like the VCS, how deep is this into the immune system? How much rewiring of the genetics of the immune system are we dealing with? And then how much support am I going to need to be doing to prevent all the secondary infections that can come or cancer for that matter? Those are kind of like my probably most common go tos other than a chem panel looking at liver enzymes, GGT, a high 125 vitamin D with a low 25 OH.

DrMR:

Oh, I’m sorry. Let me, let me interrupt you there cause I’d love to ask you this question based upon what Joe Pizzorno mentioned when he came on. For the audience, he wrote the book called The Toxin Solution, is one of the founding fathers of natural medicine. He feels that GGT is an adequate kind of high level of screening test for exposure to toxins. I believe his cut off, I may have the number wrong here, but I believe his cut off was above 20 considered positive where the lab range didn’t flag until maybe two or three times that level. Are you finding that same thing?

DrJC:

Yes. He was actually someone that taught me what I know. So yeah, I’m using a more functional level for the GGT.

DrMR:

And you’re finding correlation between, is it, 20 and above that you’re finding a good correlation? Is it when you see these mycotoxin patients, are you seeing GGT elevated most of the time? Is it rare? Give us a sense of how you’re seeing this present.

DrJC:

It is quite accurate when we’re also dealing with some blood sugar dysregulation syndrome. So metabolic syndrome, diabetes, that kind of thing. There is something about that tripping the inflammatory trigger in the liver. If I have somebody where I’m seeing a GGT of 15, and there isn’t any metabolic disorder going on, then I’m going to consider that as not something I’m hanging my hat on. I’m not saying “Oh, well you’re fine. You don’t have any toxic illness. No mycotoxins here”. But conversely, when someone does have some sort of metabolic syndrome, blood sugar dysregulation, and I see a GGT even in the low thirties or high twenties, then yes, that’s when I’m feeling like yes, this is the mold is now definitely affecting your inflammation to the point where it’s affecting your metabolism. Not just mitochondrial disorder, but blood sugar dysregulation.

DrJM:

I’ll just say, I actually recently ordered about a dozen of these and in my patient population I didn’t see that it lined up with mycotoxicity or toxic exposure. A few of those were heavy metals, but I ordered maybe 12 or so actually after your interview with Michael. I hadn’t ordered a GGT in a while and so I got excited. So at least here where I am, I hadn’t seen that correlation. I’m really interested in it.

DrJC:

Yeah. It makes sense because it’s one of the markers for nonalcoholic steatohepatitis. Well, people are breathing alcohols, aldehydes, VOCs, microbial VOCs when they’re in a moldy environment. So it’s more the chemical toxicity. So I would say that that’s also going to be in my patients that are actively being exposed, not the people that were exposed 10 years prior and are still sick because now they’re colonized. That’s not going to be the same situation.

DrJM:

I see. Interesting.

DrMR:

So one question that that’s interesting to me is, at least theoretically, and this is kind of tying back to one of our philosophical points that I’m always trying to kind of inculcate here on the podcast. Theoretically, it would make sense to me that looking to see how strongly the immune system is reacting against mold, maybe more important than the mold itself. Some of this ties into the mercury literature where, and it has been a few years since I’ve really dove deeply into this literature, but some of the analyses have found that it’s not necessarily about having any tissue burden of mercury, but rather the amount of immune reactivity against that mercury that may correlate with those who have problems after exposure versus those who don’t. So I’m drawing a little bit of a parallel analogy here, but how would you respond to that question, Jill, in terms of the immune system assessment not seemingly being as important as just a total burden that the body is exposed to.

DrJC:

I’m not sure how to answer that. That’s what I’m trying to suss out now adding the serum split sample testing. So I can understand is that a factor for the people who just don’t seem to get their resiliency back? So I do think that there’s a good argument there of, it’s not so much the mere presence of a mycotoxin, but what your body thinks about it, but I’m not sure if that’s correlating to their symptoms. I’m really curious to find that out. Sorry. That was a long way of saying, I don’t know.

DrMR:

It’s okay. I mean, there’s a lot here that we don’t know.

DrJC:

There’s a ton we don’t know.

Testing & Labs

DrMR:

So just to make sure, and let me apologize. I try to take notes for our notes section while I’m listening while I’m thinking about the next question. So sometimes I may have a bullet point here underneath the wrong spot, so correct me if I’m wrong. The Vibrant Wellness test is a urinary antibody profile using the ELISA methodology?

DrJC:

No, they did. They started with an ELISA. I didn’t use them at that time because I didn’t find the ELISA method that they were using was very effective. I think Dr. Nathan spoke to that. Now they’ve switched to the mass spect. So that’s what I’ve been using now because the particular mass spect that they’re using has that peak separation piece.

DrJM:

Do you know, when they switched over Jill?

DrJC:

Oh, I want to say maybe a year ago. So October, November 2019. I could be way wrong, but I remember thinking, “Oh, I don’t need to pop into that booth” at a conference I was at. Because I already knew what they’re doing and I’ve already tested with them. Then somebody mentioned that they use mass spect and I thought, no, they don’t, so I went over to learn more. I think it was November when I was that conference. It may have been before that they switched, but that’s when I discovered it.

DrJM:

So right now you’re currently using Great Plains and Vibrant for most of your testing or is this just for an office study?

DrJC:

For most of my testing, again, it’s looking at the patient and some of the challenges. So if somebody has to be on glutathione because of brain injury or they just feel bad off of it, then I will use the ELISA method with Real Time.

DrJM:

Yeah. I agree with that.

DrJC:

Then, you know, if someone doesn’t feel good off their binder, I might use the serum because then I don’t think that that’s really affecting the excretion at the moment. So that’s why I want to create an algorithm for clinicians that can say if this condition, then this is the better lab. But as far as if I’m just choosing like for a normal mold patient, if there is that, that isn’t super toxic and that I feel like there’s some level of confidence I have in their ability to excrete and they’re willing to go on a low mold diet before to do the prep. Then I will use Vibrant right now based on the split sample testing I did that seems to be a little bit better matching what we’re finding in the building. But again, that’s taking a very, very small sample set and applying it broadly. But if you’re using Great Plains, it might be better to stick with them. Meaning if you started testing with Great Plains, maybe stick with them for that one patient so you’re comparing the same methodology. Yeah.

DrJM:

Maybe, this might be interesting for clinicians to know, while we’re talking about mass spect, Great Plains had actually over the last six months changed their limits of detection. So about the beginning of March, I was finding a lot more negatives on their tests, even in patients that I knew were mycotoxic and had previous positive tests. Recently they changed their limits of detection back and we think that they’re going to be more accurate moving forward. But there were about six months where I was getting a lot of negatives on it. What I learned was that, as you alluded to, the mass spect machines are hugely complicated, expensive beasts that take a lot of technical care. I think small changes can really change the accuracy of what we’re seeing. So just to make a complicated situation, even more complicated, I think small tweaks in the instrumentation can potentially have more of an effect on mass spect than it would on ELISA technology, as you correctly mentioned, has been used pretty reliably for a host of diagnostics throughout medicine. So I think that’s one piece. I’ve actually been using a lot more of the Real Time ELISA tests lately. From my vantage, I’m seeing a wider array of mycotoxins from that test.

DrJC:

Interesting.

DrJM:

So that’s kind of my primary go-to at the moment. So it’s so interesting to hear your perspective, which I think is a little different, going more into the mass spect.

DrMR:

That’s a good, I guess, transition point to tell us a little bit more about what you’re using, what you’re finding. So we can kind of compare and contrast here. Before you answer, just really quick for the audience, this is one of the reasons why I harp on being very careful in terms of how much we glean from any single test here. We have a few clinicians and we’re all putting our heads together and we’re not able to come up with a consensus because in a lot of these areas there is a very limited amount of data. This is why when you see that lab paper with a high or low, don’t get too freaked out. Make sure you have a competent clinician analyze this for you because these tests shouldn’t always be looked at literally. ABut yeah, Joe, curious to hear more of what you’re finding and how you’re navigating this.

DrJM:

Before I answer that, I just wanted to point people to the November, 2019 Townsend letter. Dr. Shaw from Great Plains put out a study that the lab did showing mycotoxin amounts with a healthy group of controls and exposed patients. They showed significantly increased numbers in the exposed group. So there is some literature and data out there on these tests, when they should be positive or not. My approach comes from my observation that the lower the mycotoxin burden I can get on the body generally the better a patient is doing. It seems fairly direct and simple to me. I see things open up when I get patients say have a 25% drop in their mycotoxins. Then I start really seeing systems come online and people respond to treatments and I see some of the neurologic sequelae dropped down and maybe some of the tinnitus, which I think is a marker of central nervous system penetration.

Different Level of Toxicity, Different Approach

DrMR:

I think in a similar vein to the VCS testing. I think the degree to which we see that symptom is how far it’s wormed its way into the brain. What I do depends on how sick the patients in front of me. I think all of us who treat mycotoxic patients realize that there are patients who may be mild to moderately fatigued and have some odd symptoms and really need some work on reducing their exposure or remediating the home, but they’re not critically ill. Then we also see a group of horribly sensitive, critically ill patients with daily seizures. They’re on five foods, they can barely tolerate any medicines. They’ve got limbic dysfunction and MCAS and all the rest of it. Those patients are just so devastatingly sick that I don’t want to pull a punch and I don’t want to miss anything.

DrJM:

So for those patients, I’ll do a split Great Plains and Real Time. I tell patients that we’re looking for a coffee cup. And if I do that test, I’m going to see a coffee cup, but on one of the tests, I may see the handle and on the other one, I may not. I’ll see different ranges of toxins on different tests and I want to make sure that I’m binding all of those to the best of my ability. What I find generally is that when I use Great Plains test, about 90% of the time I’m seeing ochratoxin and its metabolites, the mycophenolic acid. And when I use Real Time, I don’t see ochratoxin as much, but I often see aflatoxin, gliotoxin, trichothecenes. So I want to make sure that if I can target the binders that I can do it so that we minimize the supplement burden for these patients, because they’re already having to usually be propped up with so much. That’s what I’m primarily using. Then I’m picking one to follow moving forward. That’s served me pretty well, but the more I do this, the more I’m just relying on the Real Time, because I think it gives me a little broader look and I’m just covering for the binders or better covering the ochratoxin. That’s kind of where I am in the moment. Did that help answer the question?

DrMR:

Yeah. Yeah. So your primary is the Real Time. And if you want to be more robust, you’ll pair the Real Time with the Great Plains.

DrJM:

Yeah. I’ll make the Great Plains optional. I’ll say, “Hey, I really think you should do the Real Time. If you’ve got another 300 bucks and your remediation is already taken care of, go ahead and order the Great Plains so we don’t miss anything”. You’ll get a little different perspective, but if cash is tight, then sometimes I’ll skip it altogether and say, Hey, look, you need to get that bathroom torn apart” or whatever the problem area is.

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DrMR:

In terms of agreement between either one of these tests and the VCS test, it sounds like there may not be the primary agreement there. It’s more so that the VCS test tracks with neurological symptoms. Would you modify that at all?

DrJC:

I don’t think I have done the VCS enough to give you a read on neurologic versus other symptoms. Although I bet Jill, you’re exactly correct and that’s what it would be more useful for, patients with primary neurologic issues. It seems like a coin toss, whether or not it’s positive in a mold toxic patient in my early observation. But when it is, it seems to track with treatment.

Mold Remediation

DrMR:

Now, something else. I know your thoughts on this, Joe, I’m curious to kind of get your take, Jill. Regarding remediation, I’m becoming progressively more convinced that just like a patient shouldn’t go online and order their own testing, because the likelihood that they are going to order the wrong tests that tell them more about the thing that is irrelevant to them, or in many cases, unfortunately, a thing that is totally invalid, the same thing applies for assessing contaminants and toxins in the home. We shouldn’t just go to a mold testing service. We should have an indoor environmental pollution specialist who really kind of quarterbacks the charge. Jill, is that something that you’re also finding to be the most efficient way to help prevent patients from getting sucked into the “well, I had three different companies come in and run three different sets of tests; I got three different sets of positives and I have no objective filter to kind of help me determine what here is really the most important to act upon”?

DrJC:

Yeah, absolutely. That’s been one of the things that, when you write a book on mold and you teach doctors about mold you get known as the mold lady. But I started in this in environmental medicine just broadly. I ended up in a factory town near two lead mines. So I got pretty good at factory based environmental toxins and heavy metals. And I’m downstream from a couple paper mills. We have dioxin and atrazine, all kinds of fun things. What I learned with my mold patients is that, you know, sometimes people are coming to me saying I’ve got mold. I have a mold problem. When the environmental inspector goes in, they actually had been poisoning themselves with moth balls or in one case, there was a gas leak. You just need somebody that’s doesn’t have mold goggles on. I think that’s really important for us. When you get known for the thing you treat, you can often get goggles on for that one thing. Keeping a broad view on all the potential impacts on a human body, it’s much bigger than one thing, always. Even a water damaged building, isn’t just about mold. We see in studies from out of Katrina and different hurricanes studies that a water damaged building, yes, there’s mold there, but there’s also bacteria there. In one of my patients, we had more of an endotoxin load than we did a mycotoxin load. So, it’s important to have somebody that has a broader view and experience.

Episode Wrap-Up

DrMR:

So there was a lot there with testing that we picked apart, Jill, I really hope you will keep us abreast of the algorithm as you continue to kind of develop it. In that vein, what was the conclusion, in case we obfuscated it, with all the details, what was the conclusion from your split test study and the kind of the presentation findings?

DrJC:

Again, that’s why I’m using Vibrant currently for my patients based on this split sample testing that I was doing comparing the three different ways types of urine testing. I’m finding that the technique of mass spect is, in most patient cases that are able to do the prep, tracking with their symptoms. I 100% agree with Joe that as mycotoxins go up, people get sicker, as they go down, people tend to be feeling better. So I feel like the urine is really helpful that way, that it seems to correlate and track symptoms. The Vibrant test is pulling out the peaks and they’re choosing multiple metabolites. So I think Great Plains is also doing this, but they’re not reporting what the metabolites are. So with Vibrant, they’re showing you which metabolites they’re testing, and then they lump them together and say, these three together mean this mycotoxin. That’s nice to know as a clinician and they also are reporting creatinine. I have yet to get Great Plains, after many requests, to report creatinine levels on their lab results so that we, as clinicians, can see how someone is clearing. Then with the Real Time test, I’m using that with people that need to be on certain treatment and medications.

DrMR:

Gotcha. Thank you. That’s very helpful. Joe, I want to open up the floor to you if you have any, any further questions for Jill.

DrJM:

So are you saying that the Vibrant ELISA test is giving you a better window onto the environment? Did I hear you say that it matches more to the environment?

DrJC:

The Vibrant mass spect. I didn’t like the Vibrant ELISA which they are not doing anymore. Vibrant is using mass spect and I’m finding that it is correlating better to what we’re finding in people’s buildings that are actively being exposed. That’s the hard part about any of these excretion tests is we don’t know if this is a “now” problem or a “was” problem. Is it current or past? But when I’m correlating the split sample testing that I’m doing, I’m trying to do it on people that I know, at the time currently are being exposed and we had building testing. This way we can see, for example, in one situation, there was someone exposed to fusarium in the HVAC system and it was picked up on Vibrant but it was not picked up on Great Plains. That surprised me because I shifted away from the Real Time ELISA based on cost, because again, I live in an area where cost is really a factor for my patients. So I got used to the mass spect method that Great Plains is using and found it quite reliable. But I do think that they’re honing in on what is a normal value or normal amount. I think that’s really helpful. And I’m glad that they’re doing their own independent testing so we can figure that out. But I’m just finding right now with the few, I think it’s six to 10, that I have done on actively exposed patients where I’m tracking through time, a year apart now that I’ve been able to watch a patient. The latest one, I was able to add the Vibrant test and compare with building information. I’m seeing that the building versus patient lab correlation was stronger in the Vibrant mass spect.

DrJM:

Got it. My thought on that had been that it just seemed like such a big black box between what someone’s being exposed to versus what they’re able to metabolize versus if they have colonization or not as to what will actually come out into the urine. So my thinking was just kind of skip trying to correlate any sort of mycotoxin urinary test to the environment and let that be the dust testing. Let that be the inspector, let them do that and then use whatever tests seem to best correlate with body burden, because that’s what I see most tightly connects to clinical results. Do you think that Vibrant gives a better idea on body burden? Or do you still think it’s better at reflecting the environmental exposure?

DrJC:

I’m not sure about that because I haven’t done any where I know the person is out of the mold now, so that’s to be determined later. I think that we’re here splitting hairs. Both of us are getting results. I think that we’re able to split hairs like this because we see enough patients that we have to answer these thought questions that come up in practice. I don’t think that there are any bad ways to test for mycotoxins. Because you’re still seeing some evidence. I don’t think we’re missing a ton when someone is actively being exposed to a water damaged building.

DrJM:

Yes, I would agree with that.

DrJC:

I think where it gets tricky is the person that is now out of the mold and they’re excreting and now you are faced with, as a clinician, is this a now problem or a past problem? And then to what degree is this the thing making this person sick? And that’s the part I don’t think we know yet. I certainly don’t know.

Episode Wrap-Up

DrMR:

I’m glad you guys just kind of came to that agreement there to hopefully allay any of the confusion or feelings of being overwhelmed that clinicians or patients listening to this are likely feeling. If you zoom way out, you know, these details probably don’t matter a whole lot. I mean, sure details do matter. But as long as you’re, again, having a larger perspective on this, making sure that you proceed through the algorithm, foundational steps upward, and we’ve discussed ad nauseam the ways to kind of tackle mold. For those who are really reactive, you might have to start with limbic retraining and mast cell stabilizing therapies, and then go to binders and potentially use antimicrobials. We’ve discussed this Jill, and in your book, you do an amazing job of kind of laying out an algorithm also. So maybe to zoom people out, you know, past the nuances of the testing, as long as the clinician is being attentive to the patient, their reactions, their symptoms, and stewarding them through the process over time, they should be able to see a slow gradual improvement in how they’re feeling. Sure. There may be some reactions along the way, but there should be this general trend line of improving. Is that a fair conclusion for me to kind of put on the table here?

DrJC:

Yeah, I think so.

DrJM:

I agree.

DrJC:

Yeah. I mean, sometimes it’s just using the tool that you have a comfort with, and that is just fine. You know, if you’ve done enough of them, you start to see certain trends and you can expect certain responses. The bigger question sometimes is how long will it take doc? You know, how long is this going to take before I feel better? Sometimes if you use too many different methods and measures, it doesn’t really give you that experience in practice to be able to give a realistic timeframe to people. So the jumping around can sometimes be harder.

DrMR:

I couldn’t agree more.

DrJC:

Yeah. I’m hoping to create something that they can help us clinically for the picking and choosing, but I love hearing Joe’s experience. I think this is really important. Thank you for allowing us to have this conversation.

DrJM:

This has been fun.

DrMR:

Yeah. Well, thank you guys for being, willing to kind of discuss these things. I know you’re both very objective and open-minded, so I knew we’d have a good productive discussion, but in speaking with both of you via email, as I’m kind of wrestling with these things myself, you had different perspectives. So I figured it’d be fun and insightful to share these differences. This is an area where there’s still a lot to be learned but I’m appreciative of you guys sharing your perspectives and Jill, the research that you’re you’re putting out there. Jill, do you want to leave people with any closing thoughts and will you also remind them of your book and your website? And then Joe, I’ll ask you the same question.

DrJC:

Yeah. Closing thoughts is just to remember this conversation could have been very panic stricken, and overwhelming for people, but you can get better from this. I see it all the time. I’m sure Joe does too. Just, you know, stick with it and keep up the energetic fight. You can get better from this.

DrMR:

Love it. And your book and website again?

DrMR:

The website is drcrista.com. My book is Break The Mold. You can get from Amazon and soon to be from my website, because we’ve had a lot of requests for not supporting Amazon. So we’re working that out. Give me some time. I also have a practitioner training course called Are You Missing Mold Illness? And that’s for primary care trained practitioners that see patients. You’d be surprised how many mold patients you’re actually missing.

DrMR:

Awesome. Awesome. And Joe?

DrJM:

All right, well, I don’t have a book, so I’ll just plug Jill’s because I recommend it to my patients and it’s really well done. So everyone go read Jill’s book. You can Google me. It’s doctormather.com.

DrMR:

Awesome. Well guys, thank you. I really appreciate your attention to trying to untangle this Gordian knot. We will all keep our attention on this and try to improve the standard of care for patients. So just love what you guys are both doing and thank you again for taking the time.

Outro:

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