An Evaluation of Alternate Means to Diagnose Chronic Inflammatory Response Syndrome and Determine Prevalence
Author: Scott W. McMahon
Dr. McMahon wrote an incredible article dealing with the diagnosis of Chronic Inflammatory Response Syndrome (CIRS). There’s been a lot of dissension in the legal community on cause and effect of CIRS. Toxic mold is often responsible for the start of this deadly illness. BIg money is also involved; the insurance industry has done everything in its power to eliminate itself from the equation, inserting riders into insurance renewals so that they won’t be on the hook for expensive remediation of mold-damaged buildings.
Attorneys have argued for years that since we cannot pin a specific fungal species on causing the myriad problems, nor linked specific symptoms with specific fungi, there would be “no proof of causality”; in other words without these links, we cannot prove that the illnesses were CAUSED by the mold or water-damaged building (WDB).
CIRS is such a complex disease, it’s a host response, not a dose response! 25% of the population carry a Human Leukocyte Antigen (HLA, inherited from our parents) that leave them susceptible to CIRS. Once CIRS is present, it can create problems in virtually every organ system.
Now we have a new way to categorize patients with CIRS; a simpler way to define the illness and prove that the patient does indeed suffer from CIRS.
Dr. McMahon reviewed the charts of hundreds of his pediatric patients. He came up with an incidence of >7% meeting his new criteria based on;
- 13 CIRS Symptom Clusters
- 2 physical exam screens (VCS testing and shoulder anti-gravity muscle testing)
- 37 Symptoms
- Visual Contrast Screening (VCS) testing
- Standard CIRS Lab testing
- For children < 11 years, 4 abnormal tests were considered diagnostic.
- For patients 11 years or older, 5 abnormal lab tests were considered diagnostic.
These criteria are easily determined in a routine office visit in which the patient has an opportunity to do the VCS test and have labs drawn.
Re-evaluating the 1061 charts using Clusters plus Labs or Screens confirmed an additional 302 patients with CIRS, raising the total to 673 from 371. Of these additional patients, 67 were children and 235 were adults.
- This generates an astonishing minimum pediatric prevalence of 7.01%.
- Minimum is emphasized because most of the 3511 were not screened for CIRS and many were only seen once (often for a 2 month well check – long before CIRS symptoms manifest).
- Since the HLA susceptibility rate runs at 25%, most of these children have not yet had time to experience the exposure that triggered the CIRS onset.
- Astonishing is emphasized because the calculated minimum prevalence of pediatric CIRS is on the order of pediatric asthma, the most common chronic illness in children.
- Since CIRS is a progressive disease and since 7.01% is the minimum prevalence for the studied pediatric population, it is assumed that the prevalence in adults is at least 7.01%.
The most important “take-home” of this relates to the sensitivity and specificity of Dr. McMahon’s proposed testing:
- Sensitivity determines how many individuals in a given population actually have the disease (low rate of false-negatives).
- Specificity determines how many of these individuals actually DO HAVE the disease and not something similar (low rate of false-positives).
- Having few Clusters suggests a patient is unlikely to have CIRS (high sensitivity).
- Having 3 of 3 abnormal Screens is a better indicator than 2 of 3 abnormal Screens.
- Having 3 of 3 abnormal Screens or 4 abnormal Labs (<11 years) or 5 abnormal labs 11 years) suggests a patient is unlikely to have a different disease (high specificity).
- Combining these approaches by evaluating Clusters Plus Screens or Clusters Plus Labs provides high sensitivity with high specificity.
- When statistical calculations were performed, a prevalence rate was unknown.
- Using different prevalence rates provides different p-values (probability of chance explaining the outcome).
- Calculations were made at the highest possible prevalence of 25% (unpublished data calculated from the population prevalence of HLA frequencies obtained from the National Marrow Donor Program, at http://bioimformatics.nmdp and 1%.
- The p-values for Clusters plus 3 Screens, for all ages combined, at these two prevalence rates were 3.97 X 10-147 and 0.0011, respectively. (10*-3 means one in a thousand, a value of 10*-147 is HUGE/hard to comprehend!)
- This method of testing is VERY specific and sensitive
- For Clusters Plus labs the p-values were 7.36 X 10-96 and 0.0010, respectively.
- These data demonstrate that using Clusters Plus Labs or Clusters Plus Screens even at a prevalence of 1% are indistinguishable from using case definitions for diagnosing CIRS.