Case Definition: Trichothecene Mycotoxin

Clinical description

The trichothecene mycotoxins are a group of toxins produced by multiple genera of fungi. Some of these substances may be present as contaminants from mold or may occur naturally in foodstuffs or in livestock feeds. Symptoms may occur among exposed humans or animals. The likelihood of developing adverse effects following exposure depends on such variables as: toxin type and purity, dose, and duration of exposure. Dermal exposure in some situations could lead to burning pain, redness, and blisters, and oral exposure may lead to vomiting and diarrhea. Ocular exposure might result in blurred vision, and inhalational exposure might cause nasal irritation and cough. Systemic symptoms can develop with all routes of exposure (especially inhalation) and might include weakness, ataxia, hypotension, coagulopathy, and death (1).

Laboratory criteria for diagnosis

• Biologic: Selected trichothecene mycotoxins can be detected in human urine to assess for exposure (2).
• Environmental: Detection of trichothecene mycotoxins (such as deoxynivalenol) in environmental samples; however there is no standard method of detection (3). FDA has established advisory levels of deoxynivalenol for safe foods and livestock feeds.

As a result of indoor air-quality investigations involving mold and potentially mold-related health effects, mycotoxin analyses of bulk environmental samples are now commercially available through environmental microbiology laboratories in the United States. Studies measuring background levels of trichothecene mycotoxins in non-moldy homes and office buildings or nonagricultural outdoor environments are limited. Therefore, the simple detection of trichothecene mycotoxins in environmental samples does not necessarily indicate an intentional contamination or a health threat.

Case classification

• Suspected: A case in which a potentially exposed person is being evaluated by health-care workers or public health officials for poisoning by a particular chemical agent, but no specific credible threat exists.
• Probable: A clinically compatible case in which a high index of suspicion (credible threat or patient history regarding location and time) exists for trichothecene mycotoxins exposure, or an epidemiologic link exists between this case and a laboratory-confirmed case.
• Confirmed: A clinically compatible case in which laboratory tests of environmental samples have confirmed exposure.

The case can be confirmed if laboratory testing was not performed because either a predominant amount of clinical and nonspecific laboratory evidence of a particular chemical was present or the etiology of the agent is known with 100% certainty.

Additional resources

1. Wannemacher RW Jr, Wiener SL. Trichothecene mycotoxins. In: Zajtchuk R, Bellamy RF, eds. Textbook of military medicine: medical aspects of chemical and biologic warfare. Washington, DC: Office of the Surgeon General at TMM Publications, Borden Institute, Walter Reed Army Medical Center; 1997:655-77.
2. Warth B, Sulyok M, Fruhmann P, Mikula H, Berthiller F, Schuhmacher R, Hametner C, Abia WA, Adam G, Fröhlich J, Krska R. Development and validation of a rapid multi-biomarker liquid chromatography/tandem mass spectrometry method to assess human exposure to mycotoxins. Rapid Commun Mass Spectrom 2012 Jul 15;26(13):1533-40.
3. Meneely J, Ricci F, Van Egmond HP, Elliot C. Current Methods for Analysis for the Determination of Trichothecene Mycotoxins in Food. Trends Anal Chem 2011;30:192-203.
4. Li Y, Wang Z, Beier RC, Shen J, De Smet D, De Saeger S, Zhang S. T-2 toxin, a trichothecene mycotoxin: review of toxicity, metabolism, and analytical methods. J Agric Food Chem 2011; 59(8):3441-53.
5. Tuomi T, Reijula K, Johnsson T, et al. Mycotoxins in crude building materials from water-damaged buildings. Appl Environ Microbiol 2000;66:1899-904.
6. Holstege CP, Bechtel LK, Reilly TH, Wispelwey BP, Dobmeier SG. Unusual but potential agents of terrorists. Emerg Med Clin North Am. 2007 May; 25(2):549-66.
7. NIOSH. NIOSH manual of analytical methods [online]. 2003. [cited 2013 Apr 5]. Available from URL: http://www.cdc.gov/niosh/docs/2003-154/.
8. OSHA. Sampling and analytical methods [online]. 2010. [cited 2013 Apr 5]. Available from URL: http://www.osha.gov/dts/sltc/methods/index.html.
9. FDA. Food: Laboratory methods [online]. 2013. [cited 2013 Apr 5]. Available from URL: http://www.fda.gov/Food/FoodScienceResearch/LaboratoryMethods/default.htm.
10. EPA. Selected analytical methods: chemical methods query [online]. 2013. [cited 2013 Apr 5]. Available from URL: http://www.epa.gov/sam/searchchem.htm.