Mold Illness & CIRS (Shoemaker Protocol) — Environmental Medicine & Toxin Avoidance
Chronic Inflammatory Response Syndrome (CIRS) from water-damaged buildings — a genetically susceptible population's response to mold biotoxins, treated via the Shoemaker sequential treatment protocol.
Overview
CIRS is a multi-system illness affecting ~24% of the population who carry HLA-DR haplotypes that make them unable to adequately clear biotoxins from water-damaged buildings (WDB). Biotoxins from molds (Aspergillus, Stachybotrys, Chaetomium), bacteria (MARCoNS), and actinomycetes bind to innate immune receptors but cannot be tagged for elimination in susceptible individuals, triggering persistent inflammatory cytokine cascades. Dr. Ritchie Shoemaker developed an 11-step sequential treatment protocol validated in observational studies. Symptoms include extreme fatigue, cognitive impairment ('brain fog'), pain, shortness of breath, temperature dysregulation, and numerous other multi-system complaints. Diagnosis requires: positive ERMI (Environmental Relative Moldiness Index) in home, HLA-DR susceptibility genotype, VCS (Visual Contrast Sensitivity) testing, and pattern recognition on 11 lab markers (elevated TGF-β1, MMP-9, VEGF, reduced MSH, VIP, DHEA, abnormal osmolality). Cholestyramine (CSM) is the primary binder that interrupts biotoxin enterohepatic recirculation.
Indications
- Fatigue, brain fog, and multi-system symptoms following water-damaged building exposure
- CIRS diagnosis per Shoemaker criteria (HLA-DR genotype + VCS + clinical pattern)
- Resistant fatigue syndromes after ruling out other causes
Mechanism of Action
In susceptible HLA-DR genotypes, biotoxins bind innate immune receptors but cannot generate appropriate adaptive immunity — the biotoxins are not cleared and instead continuously stimulate innate immune cytokine production
Dosing
| Compound | Dose | Frequency | Notes |
|---|---|---|---|
| Cholestyramine (CSM) — Step 1 | 4g (1 packet) | 4 times daily (QID), 30 minutes before meals | Primary biotoxin binder; used 4-6 weeks before reassessing; prescription required (Questran brand or generic) |
| Welchol (colesevelam) — alternative binder | 625mg tablets, 6 tablets daily | Divided with meals | Better tolerated than CSM; tablets vs. powder; lower binding capacity; used for those who cannot tolerate CSM |
Evidence Grade
GRADE D
Safety & Contraindications
- CRITICAL: Relocate from or remediate the water-damaged building FIRST — no treatment works while exposure continues
- Cholestyramine (CSM) binds fat-soluble vitamins, medications, and thyroid hormone — take 1 hour apart from all medications; supplement fat-soluble vitamins (A, D, E, K)
- CSM is constipating — hydration and fiber essential during treatment
- MARCoNS (Multiple Antibiotic Resistant Coagulase Negative Staphylococci) nasal biofilm treatment requires compounded EDTA + BEG spray — requires physician prescription and lab confirmation
- Immune-modulating treatments (VIP intranasal) are investigational and should only be done in specialist hands