CIRS / Shoemaker Protocol

Chronic inflammatory conditions come in different shapes and sizes.  They can have different exogenous triggers that are in turn mediated by endogenous characteristics, such as deficiencies/excesses, whether we are glycotoxic, our microbiome, how good our vascular health might be, auto-immunity and of course genetics.  

Chronic Inflammatory Response Syndrome (CIRS) was first used as a term in the 1990s to describe a multi-symptom, multi-system chronic illness. Exposure to certain environmental ‘inflammagens’ and pathogenic organisms (which can collectively be termed ‘biotoxins’) is understood to trigger this chronic inflammatory response in the body. The work of Dr. Shoemaker, who applied the term CIRS in 1997 to an illness specific to the human response to exposure to Pfiesteria in the Pocomoke river, specifies the following as being key considerations for triggering a chronic inflammatory response:

  • Post Lyme syndrome (CIRS-PLS) which occurs beyond the acute phase of Lyme disease in around 20% of Lyme patients.
  • Ciguatera poisoning (CIRS-Ciguatera) which is a fish borne dinoflagellate that can trigger neurologic and gastrointestinal symptoms when consumed.  Around 5% of cases are thought to become chronic.
  • Cyanobacteria (CIRS-Cyanobacteria) is a blue-green algae that can produce toxic substances, and that can have hepato and neuro-toxic effects.
  • A bite from a brown recluse spider is also known to be a trigger of the same chronic immune response.

Whilst mould and exposure to water-damaged buildings (CIRS-WDB) are probably the most well-known in Europe, it is important to understand that the toxic soup found in a water damaged building may not be the only trigger.

The 2008 Government Accountability Office (GAO) case definition cites 4 criteria for CIRS.  Firstly, demonstration of exposure to water damaged building(s).  Secondly, signs and symptoms consistent with exposure.  Thirdly, laboratory testing consistent with results seen in published studies and lastly, improvement with appropriate therapy.

Dr. Shoemaker’s work is intimately connected with Dr. Dale Bredesen’s work on cognitive decline and both indicate that exposure to biotoxins can be part of the pathway that leads to cognitive decline. Both Doctors also agree that resulting inflammation and eventual hypo-metabolism are the net result of inflammatory exposures, contributing to changes in brain function. CIRS can, therefore, be seen as very much part of the cognitive decline jigsaw. Once CIRS has been identified, the Shoemaker protocol can be undertaken in a pyramid fashion.  Starting from the bottom, the steps are followed until the top is reached. The first step and most important is the removal of exposure to the biotoxin.  Whether the exposure is school, home, work, a frequently visited service or gym, it is important to prevent exposure to inhaled contaminants.  If this is not achieved, the inflammatory cycle may not be arrested.  To check an environment, the most used tests are Environmental Relative Moldiness Index (ERMI) and Health Effects Roster of Type Specific Formers of Mycotoxins and Inflammagens (HERTSMI 2), utilising dust sample collection.  Eradicating MARCoNs comes next and re-balancing all other out of normal range markers from laboratory testing follows until all re-tests are normal.  Colabs offer all these tests.

With volumetric MRI tests we can now see changes consistent with exposure to CIRS-PLS and CIRS-WDB reflected in the brain.  Different parts of the brain can show oedema or atrophy consistent with lab work.  Improvements can also therefore be tracked with repeat scans.  The work that Dr Shoemaker has published on brain changes ties in with the work of Dale Bredesen on cognitive decline, such that he has defined CIRS as being part of the pathology of type 3 Alzheimer’s.

The future of CIRS is now expanding into transcriptomics with new tests such as the genomic expression by Nanostring: inflammation explained (GENIE) revealing signature changes in gene expression, protein production and cellular activity.

For practitioners wishing to find out more about becoming a Proficiency Partner of Surviving Mold/Dr Shoemaker or becoming fully Certified please visit this link.

Colabs cover all aspects of the Shoemaker Approach as we offer:

  • Basic Training in the approach
  • Relevant blood tests that are from laboratories used in CIRS studies so the results can be contextualised
  • Technical support for laboratory results
  • Support with accessing MRI volumetric brain scans
  • Direct access to the GENIE transcriptomics test
Full CIRS Panel

This panel allows for an evaluation of those patients with a suspected mould / biotoxin component to their inflammatory picture

Markers included: ACTH, Total IgE, Osmolality, VIP, Cortisol AM, Anti Cardiolipin antibodies, VEGF, C4a, Copeptin, Leptin, MMP9, TGFb1, aMSH

There are add-ons that can be considered with this panel for completeness depending on a client’s individual requirements

MARCoNS Full Nasal Swab

This test considers evaluation of the nasal biome, particularly considering bacteria, fungus and biofilm


The GENIE transcriptomics test considers 20 different gene signalling pathways for an understanding of hypo-metabolism, inflammatory processes, and resulting metabolic process changes such as coagulopathies


Home dust swab testing can be useful to establish possible biotoxin exposure in the home, car or workplace for example.  Actinomycetes and Endotoxins can also be tested