Alternative Health

Mold Illness (CIRS) Protocol

Chronic Inflammatory Response Syndrome (CIRS) is a multi-system illness triggered by biotoxin exposure, most commonly from water-damaged buildings. Developed by Dr. Ritchie Shoemaker, the framework is clinically detailed but remains controversial in mainstream medicine.

Why This Is Controversial

Mainstream allergists and pulmonologists acknowledge mold allergy and hypersensitivity pneumonitis. What they dispute is the CIRS framework's claim that low-level chronic mycotoxin exposure causes a persistent inflammatory cascade in genetically susceptible individuals, independent of IgE-mediated allergy.

The evidence: Shoemaker has published peer-reviewed papers, but critics note small sample sizes, lack of independent replication, and biomarkers (like VIP, MSH, C4a) that are nonspecific. The clinical reality is that many patients improve dramatically with the protocol, but placebo- controlled trials are essentially nonexistent.

HLA-DR Genetic Susceptibility

The Shoemaker model proposes that approximately 24% of the population carries HLA-DR haplotypes that impair recognition and clearance of biotoxins. In these individuals, mycotoxins recirculate via enterohepatic cycling rather than being tagged for elimination.

HLA-DR testing is a blood test available through LabCorp or Quest. "Mold susceptible" haplotypes include 4-3-53, 11-3-52B, and others in Shoemaker's classification. The clinical utility of this testing is debated, but it provides context for why some household members get sick from mold and others don't.

Testing

Urine mycotoxin testing

RealTime Laboratories or Great Plains Laboratory (now Mosaic). Measures ochratoxin A, aflatoxins, trichothecenes, gliotoxin, and others in urine. Provoked (with glutathione challenge) vs unprovoked is debated. Critics argue these tests have high false-positive rates and that mycotoxins in urine may reflect dietary exposure (grains, coffee) rather than environmental.

Environmental testing (ERMI / HERTSMI-2)

ERMI (Environmental Relative Moldiness Index) uses PCR to quantify mold DNA in dust samples. HERTSMI-2 is a simplified version focusing on the 5 species most associated with water damage. Score above 11 suggests problematic environment. More objective than air sampling.

Shoemaker biomarker panel

Blood tests: TGF-beta 1, C4a, MMP-9, MSH (alpha-melanocyte stimulating hormone), VIP (vasoactive intestinal peptide), VEGF, leptin, ADH/osmolality. Abnormalities in 4+ markers with history of water-damaged building exposure supports CIRS diagnosis in Shoemaker's framework.

Treatment: Binders

Binders interrupt enterohepatic recirculation by binding mycotoxins in the GI tract so they are excreted in stool rather than reabsorbed:

  • Cholestyramine (CSM): prescription bile acid sequestrant. The primary binder in the Shoemaker protocol. 4g four times daily, taken away from food and other medications. Most evidence of any binder for CIRS. Side effects: constipation, nutrient binding.
  • Welchol (colesevelam): alternative prescription binder, better tolerated than CSM for some patients. Less evidence specifically for mycotoxins.
  • Activated charcoal: OTC, broad-spectrum binder. 500-1000 mg between meals. Also binds nutrients and medications, so timing matters.
  • Bentonite clay: binds aflatoxins well (animal agriculture data). Human evidence limited. 1 tsp in water between meals.
  • Modified citrus pectin: gentlest option, some evidence for heavy metals, limited for mycotoxins specifically.

All binders must be taken 2+ hours away from medications and supplements to avoid binding those instead.

Environmental Remediation

No protocol works if you remain in a contaminated environment. This is the step most patients resist because it's expensive and disruptive, but it's the most important.

  • Professional mold inspection (not just air sampling, which misses settled spores)
  • Source identification and remediation by certified professionals (IICRC S520 standard)
  • HEPA air filtration (IQAir, Austin Air, or equivalent true-HEPA units)
  • Porous materials in affected areas often need replacement (drywall, carpet, upholstered furniture)
  • Post-remediation ERMI/HERTSMI-2 verification

Shoemaker Protocol Steps

The full Shoemaker protocol is sequential. Each step must be completed before moving to the next:

  1. Remove from exposure (remediate or relocate)
  2. Cholestyramine or Welchol binder therapy
  3. Eradicate MARCoNS (nasal staph biofilm) if present -- BEG spray or alternatives
  4. Correct anti-gliadin antibodies (gluten-free diet if positive)
  5. Correct androgens if needed
  6. Correct ADH/osmolality with DDAVP if needed
  7. Correct C3a and C4a
  8. Correct TGF-beta 1
  9. Replace VIP (vasoactive intestinal peptide) nasal spray