Interstitial pneumonia in a glassblower: think to chronic beryllium disease!

Chronic beryllium disease (CBD) is an occupational illness with varying severity. In this report, we describe a 27 year old man, glassblower, who developed a fatal CBD after six months of unknown Beryllium's exposure. The diagnosis was suspected on histological examination and then consolidated by confirmation of Beryllium's exposure at the working area. Physicians should be aware of the potential risk to develop CBD in glassblowers. These workers should benefit from early medical surveillance using the Beryllium lymphocyte proliferation test (BeLPT) and therefore from suitable management.

An official American Thoracic Society statement: diagnosis and management of beryllium sensitivity and chronic beryllium disease

RATIONALE

Beryllium continues to have a wide range of industrial applications. Exposure to beryllium can lead to sensitization (BeS) and chronic beryllium disease (CBD).

OBJECTIVES

The purpose of this statement is to increase awareness and knowledge about beryllium exposure, BeS, and CBD.

METHODS

Evidence was identified by a search of MEDLINE. The committee then summarized the evidence, drew conclusions, and described their approach to diagnosis and management.

MAIN RESULTS

The beryllium lymphocyte proliferation test is the cornerstone of both medical surveillance and the diagnosis of BeS and CBD. A confirmed abnormal beryllium lymphocyte proliferation test without evidence of lung disease is diagnostic of BeS. BeS with evidence of a granulomatous inflammatory response in the lung is diagnostic of CBD. The determinants of progression from BeS to CBD are uncertain, but higher exposures and the presence of a genetic variant in the HLA-DP β chain appear to increase the risk. Periodic evaluation of affected individuals can detect disease progression (from BeS to CBD, or from mild CBD to more severe CBD). Corticosteroid therapy is typically administered when a patient with CBD exhibits evidence of significant lung function abnormality or decline.

CONCLUSIONS

Medical surveillance in workplaces that use beryllium-containing materials can identify individuals with BeS and at-risk groups of workers, which can help prioritize efforts to reduce inhalational and dermal exposures.

Unsuspected exposure to beryllium: potential implications for sarcoidosis diagnoses

Exposure to Beryllium (Be) can cause sensitization (BeS) and chronic beryllium disease (CBD) in some individuals.  Even relatively low exposures may be sufficient to generate an asymptomatic, or in some cases a symptomatic, immune response. Since the clinical presentation of CBD is similar to that of sarcoidosis, it is helpful to have information on exposure to beryllium in order to reduce misdiagnosis. The purpose of this pilot study is to explore the occurrence of Be surface deposits at worksites with little or no previous reported use of commercially available Be products.  The workplaces chosen for this study represent a convenience sample of businesses in eastern Iowa. One hundred thirty-six surface dust samples were collected from 27 businesses for analysis of Be. The results were then divided into categories by the amount of detected Be according to U.S. Department of Energy guidelines as described in 10 CFR 850.30 and 10 CFR 850.31. Overall, at least one of the samples at 78% of the work sites tested contained deposited Be above the analytical limit of quantitation (0.035 µg beryllium per sample).  Beryllium was detected in 46% of the samples collected. Twelve percent of the samples exceeded 0.2 µg/100 cm² and 4% of the samples exceeded a Be concentration of 3 µg/100 cm². The findings from this study suggest that there may be a wider range and greater number of work environments that have the potential for Be exposure than has been documented previously.  These findings could have implications for the accurate diagnosis of sarcoidosis.

Pneumoconioses

Occupational lung diseases are caused or made worse by exposure to harmful substances in the work-place. "Pneumoconiosis" is the term used for the diseases associated with inhalation of mineral dusts. While many of these broad-spectrum substances may be encountered in the general environment, many occur in the work-place for greater amounts as a result of industrial processes; therefore, a range of lung reactions may occur as a result of work-place exposure. Physicians in metropolitan cities are likely to encounter pneumoconiosis for two reasons: (i) patients coming to seek medical help from geographic areas where pneumoconiosis is common, and (ii) pneumoconiosis caused by unregulated small-scale industries that are housed in poorly ventilated sheds within the city. A sound knowledge about the various pneumoconioses and a high index of suspicion are necessary in order to make a diagnosis. Identifying the disease is important not only for treatment of the individual case but also to recognise and prevent similar disease in co-workers.

Chest wall shrapnel-induced beryllium-sensitization and associated pulmonary disease

Chronic beryllium disease (CBD) is an exposure-related granulomatous disease mimicking sarcoidosis. Beryllium exposure-associated disease occurs mainly via inhalation, but skin may also be a source of sensitization. A 65-year-old male with a history of war-related shrapnel wounds was initially diagnosed with pulmonary sarcoidosis. Twenty years later, the possibility of a metal-related etiology for the lung disease was raised. A beryllium lymphocyte proliferation test, elemental analysis of removed shrapnel, and genetic studies were consistent with a diagnosis of CBD. This case demonstrates that retained beryllium-containing foreign bodies can be linked to a pathophysiologic response in the lung consistent with CBD.

SELDI-TOF derived serum biomarkers failed to differentiate between patients with beryllium sensitisation and patients with chronic beryllium disease

BACKGROUND

People exposed to beryllium may develop beryllium sensitisation (BeS) and, in some cases, progress to chronic beryllium disease (CBD).

OBJECTIVES

The objective of this study was to test the ability of proteomic technology to identify patterns of serum protein biomarkers that allow differentiation between BeS and CBD and thus remove the need for invasive bronchoscopic procedures.

METHODS

Initially, SELDI-TOF methodology and analysis was performed on serum samples from 30 CBD and 31 BeS patients.

RESULTS

This 'starter set' yielded two distinct biomarker pattern sets with eight candidate proteins. The first set differentiated between BeS and CBD with 83.3% sensitivity and 82.3% specificity, with 10-fold cross-validation of 75% and 79%, respectively. The second set of biomarkers yielded higher sensitivity (90.0%) and higher specificity (90.3%), with 10-fold cross-validation of 71.7% and 82.3%, respectively. Due to its greater sensitivity and specificity, the second set of biomarkers was used as the framework for differentiating between CBD and BeS in a second set of serum samples from 450 patients with BeS and CBD. When this larger set of samples was subjected to the biomarker framework in a blinded fashion, it yielded a sensitivity of 43.53% and a specificity of 38.93%.

CONCLUSIONS

Due to these low sensitivity and specificity values, we have concluded that, currently, the unique set of SELDI-TOF derived biomarkers does not possess the qualities that would allow it to differentiate between a CBD patient and a BeS patient using serum protein biomarkers. Future refinements in sample collection or proteomic technology may be needed to improve biomarker discovery.

Interpreting borderline BeLPT results

BACKGROUND

The beryllium lymphocyte proliferation test (BeLPT) identifies persons sensitized to beryllium (BeS) and thus at risk for chronic beryllium disease (CBD). BeLPT test results are abnormal (AB), borderline (BL), or normal (NL). This manuscript addresses the predictive value and interpretation of BL BeLPT results.

METHODS

The various three-result combinations that meet or exceed a nominal referral criteria of 1 AB + 1 BL are assessed with probability modeling and compared.

RESULTS

At 2% prevalence, the three-result combinations that meet or exceed this referral criteria and associated probabilities of BeS are: (a) 1 AB + 1 BL + 1 NL (72%); (b) 3 BL (91%); (c) 2 AB + 1 NL (95%); (d) 1 AB + 2 BL (99%); (e) 2 AB + 1 BL (100%); and (f) 3 AB (100%).

CONCLUSION

These results suggest that BL results are meaningful and that three BL results predict BeS across a broad range of population prevalences. An analysis of longitudinal BeLPT results and clinical findings from an actual surveillance program is warranted to confirm the model's predictions.

Progression from beryllium exposure to chronic beryllium disease: an analytic model

BACKGROUND

Understanding the progression from beryllium exposure (BeE) to chronic beryllium disease (CBD) is essential for optimizing screening and early intervention to prevent CBD.

METHODS

We developed an analytic markov model of progression to cbd that assigns annual probabilities for progression through three states: from BeE to beryllium sensitization and then to CBD. We used calculations of the number in each state over time to assess which of several alternative progression models are most consistent with the limited available empirical data on prevalence and incidence. We estimated cost-effectiveness of screening considering both incremental (cost/case) and cumulative program costs.

RESULTS

No combination of parameters for a simple model in which risk of progression remains constant over time can meet the empirical constraints of relatively frequent early cases and continuing development of new cases with long latencies. Modeling shows that the risk of progression is initially high and then declines over time. Also, it is likely that there are at least two populations that differ significantly in risk. The cost-effectiveness of repetitive screening declines over time, although new cases will still be found with long latencies. However, screening will be particularly cost-effective when applied to persons with long latencies who have not been previously screened.

CONCLUSIONS

To optimize use of resources, the intensity of screening should decrease over time. Estimation of lifetime cumulative CBD risk should consider the declining risk of progression over time.

Assessment of the Beryllium Lymphocyte Proliferation Test Using Statistical Process Control

Despite more than 20 years of surveillance and epidemiologic studies using the beryllium blood lymphocyte proliferation test (BeBLPT) as a measure of beryllium sensitization (BeS) and as an aid for diagnosing subclinical chronic beryllium disease (CBD), improvements in specific understanding of the inhalation toxicology of CBD have been limited. Although epidemiologic data suggest that BeS and CBD risks vary by process/work activity, it has proven difficult to reach specific conclusions regarding the dose-response relationship between workplace beryllium exposure and BeS or subclinical CBD. One possible reason for this uncertainty could be misclassification of BeS resulting from variation in BeBLPT testing performance. The reliability of the BeBLPT, a biological assay that measures beryllium sensitization, is unknown. To assess the performance of four laboratories that conducted this test, we used data from a medical surveillance program that offered testing for beryllium sensitization with the BeBLPT. The study population was workers exposed to beryllium at various facilities over a 10-year period (1992-2001). Workers with abnormal results were offered diagnostic workups for CBD. Our analyses used a standard statistical technique, statistical process control (SPC), to evaluate test reliability. The study design involved a repeated measures analysis of BeBLPT results generated from the company-wide, longitudinal testing. Analytical methods included use of (1) statistical process control charts that examined temporal patterns of variation for the stimulation index, a measure of cell reactivity to beryllium; (2) correlation analysis that compared prior perceptions of BeBLPT instability to the statistical measures of test variation; and (3) assessment of the variation in the proportion of missing test results and how time periods with more missing data influenced SPC findings. During the period of this study, all laboratories displayed variation in test results that were beyond what would be expected due to chance alone. Patterns of test results suggested that variations were systematic. We conclude that laboratories performing the BeBLPT or other similar biological assays of immunological response could benefit from a statistical approach such as SPC to improve quality management.

CD57 expression correlates with alveolitis severity in subjects with beryllium-induced disease

BACKGROUND

Despite numerous studies in human beings linking surface phenotype of blood T cells with their functional characteristics, little is known about this relationship on antigen-specific CD4(+) T cells residing in a target organ.

OBJECTIVE

The aims of this study were to determine the relationship between CD57 expression, a marker of T-cell senescence, and severity of chronic beryllium disease (CBD) and to determine the phenotypic and functional characteristics that differentiate beryllium-specific CD4(+) T cells in lung and blood.

METHODS

CD57 expression on beryllium-responsive IFN-gamma-expressing and IL-2-expressing CD4(+) T cells in blood and lung of 17 beryllium-sensitized and 20 CBD subjects was determined.

RESULTS

CD57 expression was significantly higher on bronchoalveolar lavage (BAL) than blood CD4(+) T cells in both beryllium-sensitized and CBD subjects. Expression of CD57 on BAL CD4(+) T cells was directly correlated with the lymphocytic alveolitis. In blood and BAL, higher CD57 expression was seen on more differentiated CD4(+) memory T-cell subsets. Although CD57 expression on blood and BAL cells was associated with a reduced proliferative potential, examination of beryllium-specific CD4(+) T cells in blood and lung revealed no difference in CD57 expression on cells that produced IFN-gamma only versus IFN-gamma and IL-2.

CONCLUSION

These data suggest that CD57 expression on CD4(+) T cells is an important phenotypic marker to assess lung inflammation and the functional competence of the CD4(+) T-cell compartment in CBD.

CLINICAL IMPLICATIONS

These findings suggest that CD57 is a marker of lung inflammation and potentially, disease severity.

Chronische Berylliose

Chronic Berylliosis (CB) is an occupational disorder which needs to be considered in the diagnostic work-up of granulomatous pulmonary diseases. Germany imports increasing amounts of beryllium which causes increased occupational exposure and this fact suggests that CB is underdiagnosed. Since CB is a perfect phenocopy of sarcoidosis, it is assumed that many cases are hidden in the cohort of sarcoidosis patients. This review presents the epidemiology, pathogenesis, diagnostics, and therapy of CB.

Comparative analysis between CFSE flow cytometric and tritiated thymidine incorporation tests for beryllium sensitivity

BACKGROUND

In this study, we evaluated alternative possibility for CFSE beryllium flow cytometric test against beryllium blood lymphocyte proliferation test (BeLPT) as a standard radioactive clinical screening method to identify sensitization to beryllium.

METHODS

Delta PD (the ratio of divided cell population to the total number of cells with subtracted counts of unstimulated cells) of specific beryllium-induced pathogenic CD3+ CD4+ T-lymphocytes and stimulation index (SI) in CFSE proliferation test was compared with delta counts per minute (mean test CPM minus mean control CPM) and SI in radioactive blood BeLPT.

RESULTS

Comparison analysis of CFSE and BeLPT demonstrated excellent agreement between delta PD and delta CPM (kappa = 0.845, P << 0.0001). We determined 6.8% positive subjects in the beryllium-exposed, Be-LPT-negative group. The decreased mean difference of these indexes to percentage of average and the long tail in the plot reflects increased sensitivity. CFSE/CD4+ T-cell proliferation assay has 100% specificity, significantly higher sensitivity and efficiency than BeLPT.

CONCLUSIONS

Both delta PD, measured by the precursor frequencies method in CFSE assay and delta CPM, defined by tritiated thymidine in BeLPT, can be used for the enumeration of beryllium specific CD4+ T-cell proliferation and may substantially improve the quality of the early diagnosis of beryllium hypersensitivity.

[State of broncho-pulmonary system in berylliosis patients on distant follow-up period]

The article presents results concerning evaluation of bronchopulmonary system in berylliosis patients on distant follow-up period. In accordance with work conditions, the authors defined two forms of berylliosis: granulomatous and interstitial. Granulomatous one was characterized by progressive course at early stages, with complications resulting in cardio-pulmonary failure. Interstitial one was benign in nature.

Chronic beryllium disease among dental technicians in Israel

BACKGROUND AND AIM

The potential risks of beryllium use in the dental industry have been recognized for some time. This is the first case series that focuses on the effect of a number of potentially harmful effects of substances that induce lung disease among dental technicians with emphasis on beryllium as a major risk factor in the work environment of dental technicians.

METHODS

All the dental technicians consecutively recruited to this study had past occupational exposure to beryllium. They were evaluated in order to confirm immunological evidence of beryllium exposure for differential diagnosis between sarcoidosis and chronic beryllium disease (CBD). They were tested for beryllium sensitization by the beryllium lymphocyte proliferation test (BeLPT), and underwent lung function and induced sputum (IS) studies. Each had earlier undergone a comprehensive evaluation that included high-resolution computerized tomography, bronchoscopy and transbronchial biopsy to establish the final diagnosis of their condition.

RESULTS

There were 24 enrollees (mean age 49.7 +/- 13.7 years, 17 males, 7 females) of whom 12 (50%) had positive BeLPT findings and were finally diagnosed as suffering from CBD, 7 (29%) had negative BeLPT findings and were diagnosed as suffering from another pulmonary pathology (sarcoidosis, chronic obstructive pulmonary disease, rejection of transplanted lung), and 5 (20.8%) had negative BeLPT findings and were diagnosed as being free of pulmonary disease.

CONCLUSION

This case series study demonstrates that dental technicians are exposed to beryllium and various other occupational dusts and chemicals and are at high risk of developing CBD and other lung diseases. Our findings emphasize the need for awareness of the medical community to detect occupation related diseases in this profession.

Use of Beryllium Lymphocyte Proliferation Testing for Screening of Asymptomatic Individuals: An Evidence-Based Assessment

OBJECTIVE

We reviewed published data describing use of beryllium lymphocyte proliferation testing (BeLPT) to determine the appropriateness of BeLPT for screening asymptomatic individuals.

METHODS

Published studies were identified by computerized literature searches and hand searches of relevant bibliographies and cited references. Critical assessment of evidence focused on five elements essential to judging effectiveness of preventive services: 1) burden of suffering, 2) accuracy and reliability of screening tests, 3) effectiveness of early detection, 4) harms of screening, and 5) benefits outweighing harms.

RESULTS

Important gaps and deficiencies in the evidence were found. The prevalence of beryllium sensitization and chronic beryllium disease in asymptomatic individuals are unknown. The accuracy and reliability of BeLPT are uncertain. Marked intra- and interlaboratory variability has been reported. The clinical benefits of early intervention have not been confirmed or quantified in asymptomatic individuals.

CONCLUSIONS

There is currently insufficient scientific evidence to support the use of BeLPT for routine screening of asymptomatic individuals.

[Berylliosis in Italy: a case of "sarcoidosis" under the threshold limit value]

BACKGROUND

Berylliosis is caused by a chronic immune reaction to beryllium; in Italy the first case of beryllium exposure-related disease was described in 1935 by Fabroni-Marradi and two additional cases of beryllium disease were subsequently described by Ambrosi and co-workers in 1968. No case has since been recognized using the standardized criteria including immunological testing.

OBJECTIVES

To describe a case report of clinically significant berylliosis that occurred in a man exposed to beryllium for ten years in the workplace at concentrations below the permitted threshold limit value.

METHODS

The man complained of dyspnoea, dry cough, weakness and weight loss for the past year and was at first diagnosed as suffering from sarcoidosis because of increased angiotensin converting enzyme levels, alteration of hepatic and renal functional indexes, the presence of diffused reticulo-nodular lung abnormalities with high resolution computed tomography that also showed enlarged mediastinal lymph nodes, abnormal lung physiology with reduced diffusion capacity and a bronchial biopsy showing granulomatous lesions. Because of the occupational history immunological testing and high resolution HLA class II typing were performed.

RESULTS

The high response to beryllium in the lymphocytes proliferation test and the HLA typing which revealed the presence of the two susceptibility markers HLA-DPGlu69 and HLA-DRPhe47 led to a diagnosis of berylliosis.

CONCLUSIONS

The importance is stressed of suspecting a diagnosis of berylliosis in the proper occupational contexts and encouraging the use of immunological tests for diagnosis, and also the need for critical revision of the permitted threshold limit values.

Diagnoses of chronic beryllium disease within cohorts of sarcoidosis patients

An increase in chronic beryllium disease (CBD) has been suggested due to higher industrial use of beryllium alloys. Since occupational CBD is a perfect phenocopy of sarcoidosis, it might be misdiagnosed as sarcoidosis. In the current it was hypothesised that CBD exists in cohorts of sarcoidosis patients. In a prospective case study, sarcoidosis patients were evaluated for potential beryllium exposure. In those patients in whom beryllium exposure was confirmed and beryllium hypersensitivity demonstrated, the diagnosis of sarcoidosis was rejected and corrected to CBD. In 84 patients seen for re-evaluation or making a diagnosis of sarcoidosis, beryllium exposure was recognised and a diagnosis of CBD was made in 34 out of 84 patients. The time lag between clinical diagnosis of sarcoidosis and the final diagnosis of CBD ranged 0-18 yrs (median 3 yrs) and the mean (range) age at time of diagnosis of CBD was 43.9(25-80) yrs. Beryllium-contaminated workplaces causing disease encompassed a wide spectrum of industries and technical trades in which beryllium-exposure is generally not perceived as a health hazard. In conclusion, chronic beryllium disease still belongs to the spectrum of differential diagnoses of granulomatous disorders.

The BeLPT: algorithms and implications

BACKGROUND

The beryllium lymphocyte proliferation test (BeLPT) is used to identify persons with beryllium sensitization. The variability of laboratory results and lack of a "gold standard" have led to questions about the test's performance. Fortunately, a recently published study has credibly estimated standard epidemiologic parameters for the BeLPT.

METHODS

Information from this recent study was used to assess the performance of two common algorithms for BeLPT testing. Standard epidemiologic parameters were determined for two common algorithms and then compared.

RESULTS

One of the two algorithms was more sensitive than the other (86% vs. 66%). The specificity of both algorithms (99.8% or greater) was high. At an estimated 2% prevalence, the positive predictive value of both algorithms for beryllium sensitization remained high (90% or higher).

CONCLUSIONS

A priori characterization of the testing algorithm under consideration can enhance public health decision-making.

Beryllium exposure: dermal and immunological considerations

OBJECTIVE

People exposed to beryllium compounds are at increased risk of developing beryllium sensitization and chronic beryllium disease (CBD). The purpose of this short communication is to present information regarding the potential importance of skin exposure to beryllium, an exposure and alternate immune response pathway to the respiratory tract, which has been largely overlooked in epidemiologic and exposure assessment studies.

METHODS

We reviewed the published literature, including epidemiologic, immunologic, genetic, and laboratory-based studies of in vivo and in vitro models, to assess the state of knowledge concerning skin exposure to beryllium.

RESULTS

Reduction in inhalation exposure to beryllium has not resulted in a concomitant reduction in the occurrence of beryllium sensitization or CBD, suggesting that continued prevalence may be due, in part, to unchecked skin exposure to beryllium-containing particles.

CONCLUSIONS

Recent developments in our understanding of the multiple exposure pathways that may lead to beryllium sensitization and CBD suggest that a prudent approach to worker protection is to assess and minimize both skin and inhalation exposures to beryllium.

Chronic beryllium disease and sensitization at a beryllium processing facility

We conducted a medical screening for beryllium disease of 577 former workers from a beryllium processing facility. The screening included a medical and work history questionnaire, a chest radiograph, and blood lymphocyte proliferation testing for beryllium. A task exposure and a job exposure matrix were constructed to examine the association between exposure to beryllium and the development of beryllium disease. More than 90% of the cohort completed the questionnaire, and 74% completed the blood and radiograph component of the screening. Forty-four (7.6%) individuals had definite or probable chronic beryllium disease (CBD), and another 40 (7.0%) were sensitized to beryllium. The prevalence of CBD and sensitization in our cohort was greater than the prevalence reported in studies of other beryllium-exposed cohorts. Various exposure measures evaluated included duration; first decade worked; last decade worked; cumulative, mean, and highest job; and highest task exposure to beryllium (to both soluble and nonsoluble forms). Soluble cumulative and mean exposure levels were lower in individuals with CBD. Sensitized individuals had shorter duration of exposure, began work later, last worked longer ago, and had lower cumulative and peak exposures and lower nonsoluble cumulative and mean exposures. A possible explanation for the exposure-response findings of our study may be an interaction between genetic predisposition and a decreased permanence of soluble beryllium in the body. Both CBD and sensitization occurred in former workers whose mean daily working lifetime average exposures were lower than the current allowable Occupational Safety and Health Administration workplace air level of 2 microg/m3 and the Department of Energy guideline of 0.2 microg/m3.

Bérylliose pulmonaire chronique (2e partie)

INTRODUCTION

Chronic beryllium disease (CBD) is an occupational lung disease caused by the inhalation of beryllium dust, fumes or metallic salts.

CURRENT DATA

Beryllium affects the lungs via particles deposited in the pulmonary alveoli. These are ingested by alveolar macrophages which act as antigen presenting cells to CD4+ T lymphocytes. T lymphocytes proliferate in response to beryllium antigens and combined with macrophages produce numerous epithelioid granulomas with the release of inflammatory cytokines (IFNgamma, IL-2, TNFalpha and IL6) and growth factors. Beryllium induces macrophage apoptosis which reduces its clearance from the lung which in turn contributes to the host's continual re-exposure and thus a chronic granulomatous disorder. Pulmonary granulomatous inflammation is the primary manifestation of CBD, but the disease occasionally involves other organs such as the liver, spleen, lymph nodes and bone marrow. The clinical, radiological, and histopathological features of CBD can be difficult to distinguish from sarcoidosis. The Beryllium lymphocyte proliferation test (BeLPT) demonstrates a beryllium specific immune response, confirms the diagnosis of CBD, and excludes sarcoidosis.

CONCLUSIONS AND PERSPECTIVES

CBD provides a human model of pulmonary granulomatous disease produced by an occupational exposure, occurring more frequently in those with a genetic pre-disposition. It can be differentiated from sarcoidosis by specific immunological testing.

Function associated transforming growth factor-beta gene polymorphism in chronic beryllium disease

Chronic beryllium disease (CBD) is a rare occupational, granulomatous lung disease clinically resembling sarcoidosis. The immune response to beryllium is thought to depend on genetic susceptibility. Although a glutamic acid in position 69 of the human leukocyte antigen-DP beta chain (HLA-DPB1-Glu69) is associated with the development of CBD, it cannot fully explain susceptibility. It is likely that additionally other genes are involved in regulating the immune and inflammatory response in the pathogenesis of this disease. Functional gene polymorphisms (PMs) of the tumor necrosis factor (TNF)A and transforming growth factor (TGF) beta(1) genes are suspected to modify the course of granulomatous disorders. We analyzed the TGF-beta(1) (codon 25) PM in 59 patients with CBD and 164 matched healthy controls, from two groups of European/Israeli and United States origin. Additionally, patients were genotyped for HLA class II gene variants and the TNFA (-308) PM. The most significant results were found for the TGF-beta(1) (codon 25) PM with a shift towards the low producing non-GG genotypes in the subgroup of European and Israeli patients with CBD (62.50% vs. 13.82% in healthy controls; P<0.001). This phenomenon was not observed in the group from the United States. Moreover, TGF-beta(1) (codon 25) PM genotype frequencies from United States CBD patients differed significantly from those of European and Israeli patients. In contrast, increased frequencies for the high producing TNFA2 allele were found only in the patients from the United States (28.20% vs. 8.96% in healthy controls; P<0.005) but not in the group of Europe and Israel. In conclusion, the increase in TGF-beta(1) (codon 25) PM genotype frequency associated with a low TGF-beta release suggests that immunoregulatory cytokines such as TGF-beta are involved in the pathogenesis of CBD. Moreover, based on the interaction of gene PMs associated with the control of the immune response, such as TNF-alpha and TGF-beta(1), with a specific immune response gene such as HLA-DPB1-Glu69 or other HLA-class II PMs driving the immune response to Be, the present data suggest that a combination of different genetic backgrounds determine susceptibility for the same immunopathological reaction and disease.

The beryllium lymphocyte proliferation test: Relevant issues in beryllium health surveillance

BACKGROUND

The beryllium lymphocyte proliferation test (Be-LPT) measures beryllium-specific cellular immune response, and is useful in medical surveillance of beryllium sensitivity and chronic beryllium disease (CBD).

METHODS

Current and former employees (n = 12,194) of 18 United States Department of Energy (DOE) sites were tested for beryllium sensitization at four laboratories with Be-LPT expertise. Beryllium sensitized individuals were offered evaluations for CBD. The sensitivity, specificity, and positive predictive value (PPV) of the Be-LPT were determined, as was inter- and intra-laboratory agreement.

RESULTS

False positives were calculated to be 1.09%, with a laboratory range of 0.00-3.35% for the 10-year investigation. Be-LPTs performed on inter-laboratory split blood specimens from sensitized individuals showed a false negative rate of 31.7%. The intra-laboratory repeatability of abnormal Be-LPT results ranged from 80.4-91.9%. The sensitivity of the Be-LPT was determined to be 0.683, with a specificity of 0.969. The PPV of one abnormal Be-LPT was 0.253.

CONCLUSIONS

The Be-LPT is efficacious in medical surveillance of beryllium-exposed individuals. The PPV of the Be-LPT is comparable to other widely accepted medical tests. Confirmation of an abnormal result is recommended to assure appropriate referral for CBD medical evaluation.

Screening for beryllium disease among construction trade workers at Department of Energy nuclear sites

BACKGROUND

To determine whether current and former construction workers are at significant risk for occupational illnesses from work at the Department of Energy's (DOE) nuclear weapons facilities, screening programs were undertaken at the Hanford Nuclear Reservation, Oak Ridge Reservation, and the Savannah River Site.

METHODS

Medical examination for beryllium disease used a medical history and a beryllium blood lymphocyte proliferation test (BeLPT). Stratified and multivariate logistic regression analyses were used to explore the risk of disease by age, race, sex, trade, duration of DOE employment, reported work in buildings where beryllium was used, and time since last DOE site employment.

RESULTS

Of the 3,842 workers included in this study, 34% reported exposure to beryllium. Overall, 2.2% of workers had at least one abnormal BeLPT test, and 1.4% were also abnormal on a second test. Regression analyses demonstrated increased risk of having at least one abnormal BeLPT to be associated with ever working in a site building where beryllium activities had taken place.

CONCLUSIONS

The prevalence of beryllium sensitivity and chronic beryllium disease (CBD) in construction workers is described and the positive predictive value of the BeLPT in a population with less intense exposure to beryllium than other populations that have been screened is discussed. The BeLPT findings and finding of cases of CBD demonstrate that some of these workers had significant exposure, most likely, during maintenance, repair, renovation, or demolition in facilities where beryllium was used.

Beryllium Medical Surveillance at a Former Nuclear Weapons Facility During Cleanup Operations

Despite increasing need to remediate beryllium-contaminated buildings in industry, little is known about the magnitude of risk associated with beryllium abatement or the merits of beryllium medical surveillance for cleanup workers. We examined beryllium lymphocyte proliferation tests and reviewed medical evaluations on workers at a nuclear weapons facility during the process of decontamination and decommissioning. Of 2,221 workers, 19 (0.8%) were beryllium sensitized based on two or more abnormal beryllium lymphocyte proliferation tests. Eight of 19 sensitized individuals underwent full clinical evaluation, of whom two were diagnosed with chronic beryllium disease (CBD). Notably, seven beryllium sensitized and CBD cases were hired after the start of cleanup operations. Beryllium medical surveillance detects sensitization and CBD in cleanup workers. Exposure controls and medical surveillance need to be 'broad-based' to include all cleanup workers involved in beryllium-contaminated building remediation.

Ethical aspects of genetic testing in the workplace

The European Group on Ethics and New Technologies, which advises the European Commission, has published an opinion paper on ethical aspects of genetic testing in the workplace. The paper goes well beyond the usual ethical issues, presenting a summary of genetic testing in the workplace in the United States and Europe and criteria for appropriate testing. Unlike many other documents on ethics, it pays close attention to the problem of false-positive and false-negative test results. Although no genetic tests are currently appropriate for screening workers or applicants for jobs in which occupational hazards exist, inappropriate testing has occurred and regulations are needed to ensure that only appropriate testing is used in the future. Workers or their representatives should be involved in deciding when and how genetic testing in the workplace is done.

[Rationale for choice of safety criteria during accidents while working with metallic beryllium]

The paper systematizes experimental studies evaluating the toxicity of beryllium compounds. The parameters required to choose safety criteria when accidents occur while working with metallic beryllium are determined.

Case series: use of induced sputum in the evaluation of occupational lung diseases

The authors recently reported that analysis of induced sputum may reveal the status of hazardous dust exposure (e.g., silica, hard metals) as effectively as does bronchoalveolar lavage. In the current study, the authors describe how induced sputum can assist in the evaluation and diagnosis of suspected occupational lung diseases. The 3 patients who underwent induced sputum testing included a miner with silicosis, a dental technician with berylliosis, and a teacher who suffered from undefined interstitial fibrosis and in whom induced sputum analysis revealed the presence of a high burden of calcium sulfate and silica. The data reported indicate that induced sputum--a known safe and simple procedure--can serve as a useful tool in the evaluation of patients with suspected occupational lung diseases.

Summary of historical beryllium uses and airborne concentration levels at Los Alamos National Laboratory

Beryllium operations and accompanying medical surveillance of workers at Los Alamos National Laboratory began in the 1940s. In 1999 a Former Workers Medical Surveillance Program that includes screening for chronic beryllium disease was initiated. As part of this program, historical beryllium exposure conditions were reconstructed from archived paper and electronic industrial hygiene data sources to improve understanding of past beryllium uses and airborne concentration levels. Archived industrial hygiene sampling reports indicated beryllium was principally used in technical areas-01 and -03, primarily being machined. Beryllium was also used at 15 other technical areas in activities that ranged from explosives detonation to the manufacture of X-ray windows. A total of 4528 personal breathing zone and area air samples for beryllium, combined for purposes of calculating summary statistics, were identified during the records review phase. The geometric mean airborne beryllium concentration for the period 1949-1989 for all technical areas was 0.04 microg Be/m(3) with 97 percent of all sample below the 2.0 microg Be/m(3) occupational exposure limit (OEL). Average beryllium concentrations per decade were less than 1 microg Be/m(3) and annual geometric mean concentrations in technical area-03, the largest user of beryllium, were generally below 0.1 microg Be/m(3), indicating exposure was generally well-controlled, that is, below the OEL. Typical of many retrospective exposure assessments, not all archived data could be extracted and summarized. Despite this, we report a reasonable summary of potential beryllium uses and airborne concentration levels a worker may have encountered from 1949-1989. These data can be used to more effectively identify former worker populations at potential risk for chronic beryllium disease and to offer these workers screening as part of the Former Worker Medical Surveillance Program, and in the event that a case is diagnosed, help to understand historical exposure conditions.

Is chronic beryllium disease sarcoidosis of known etiology?

Sarcoidosis is a granulomatosis that predominantly affects the lungs and is of unknown etiology. Chronic beryllium disease is a granulomatosis that predominantly affects the lungs and is due to a hypersensitivity response to beryllium. Similarities and differences between these two disorders are reviewed and lessons for both sarcoidosis and chronic beryllium disease are discussed.

Misdiagnosis of sarcoidosis in patients with chronic beryllium disease

BACKGROUND AND AIM

Sarcoidosis (SA) is a chronic systemic disorder characterized by infiltration of inflammatory cells in affected organs, resulting in the formation of granulomas. Granulomas are observed in numerous infectious diseases and hypersensitivity reactions (e.g., beryllium). Chronic beryllium disease (CBD) is a multisystem entity caused by dust, fumes or mists of beryllium metal or its salts. Although beryllium has been used for years by several industries in Israel, no case of CBD had ever been reported until recently when we described a 21-year-old female dental technician with CBD who was originally diagnosed as having SA. We launched the current investigation to test the hypothesis that other cases of CBD in Israel were not previously reported because these patients were misdiagnosed as having SA.

METHODS

Forty-seven patients with confirmed-SA from our outpatient clinic were recalled in order to reevaluate their occupational exposure history. We performed the beryllium lymphocyte transformation test (BeLTT) on each patient with a potentially positive environmental exposure anamnesis to beryllium (14/47).

RESULTS

Two of the 14 patients with evidence of granulomas in lung tissue (pulmonary involvement) and 1/14 with extrapulmonary involvement who all had a positive occupational exposure to beryllium and a positive BeLTT test had been erroneously diagnosed as having SA instead of CBD.

CONCLUSION

Our findings emphasize the vital importance of taking a comprehensive occupational history in the clinical evaluation of patients suspected of having SA.

Beryllium-stimulated neopterin as a diagnostic adjunct in chronic beryllium disease

BACKGROUND

The diagnosis of chronic beryllium disease (CBD) relies on the beryllium lymphocyte proliferation test (BeLPT) to demonstrate a Be specific immune response. This test has improved early diagnosis, but cannot discriminate beryllium sensitization (BeS) from CBD. We previously found high neopterin levels in CBD patients' serum and questioned whether Be-stimulated neopterin production by peripheral blood cells in vitro might be useful in the diagnosis of CBD.

METHODS

CBD, BeS, Be exposed workers without disease (Be-exp) normal controls and sarcoidosis subjects were enrolled. Peripheral blood mononuclear cells (PBMN) were cultured in the presence and absence of beryllium sulfate. Neopterin levels were determined from cell supernatants by enzyme linked immunosorbent assay (ELISA). Clinical evaluation of CBD subjects included chest radiography, pulmonary function testing, exercise testing, and the BeLPT.

RESULTS

CBD patients produced higher levels of neopterin in both unstimulated and Be-stimulated conditions compared to all other subjects (P < 0.0001). Unstimulated neopterin mononuclear cell levels overlapped among groups, however, Be-stimulated neopterin levels in CBD showed little overlap. Using a neopterin concentration of 2.5 ng/ml as a cutoff, Be-stimulated neopterin had a sensitivity of 80% and specificity of 100% for CBD and was able to differentiate CBD from BeS. Be-stimulated neopterin was inversely related to measures of pulmonary function, exercise capacity, and gas exchange.

CONCLUSIONS

Neopterin may be a useful diagnostic adjunct in the non-invasive assessment of CBD, differentiating CBD from BeS. Further studies will be required to determine how it performs in workplace screening.

Measurement of beryllium in lung tissue of a chronic beryllium disease case and cases with sarcoidosis

BACKGROUND

The clinical features of chronic beryllium disease (CBD) are similar to many other chronic lung diseases. In particular, it may be difficult to distinguish it from pulmonary sarcoidosis since the two conditions may be very alike in clinical, pathological and radiological features. Aim To determine if the amount of beryllium found in the lungs could be used to differentiate CBD from sarcoidosis and controls.

METHODS

Analyses for beryllium in the autopsied lung tissues of 29 cases and controls were carried out. The cases included one CBD, three confirmed sarcoidosis and 25 controls. Blocks of formalin-fixed tissues were analysed by an atomic absorption spectrophotometer equipped with a graphite furnace. A method for analysis of beryllium in air was modified to permit tissue analysis.

RESULTS

The CBD case had a much higher average beryllium level, but some individual results were similar to controls and patients with sarcoidosis.

CONCLUSION

The CBD case had beryllium levels within the range of values reported in the literature. The differentiation between CBD and sarcoidosis could not be made with reasonable assurance based only on the analytic result. Occupational history is very important in making a diagnosis of CBD, along with the analysis of tissues. Tissue analysis helped confirm the diagnosis of compensatable CBD in this particular case.

[Asthma, alveolitis, aspergillosis, berylliosis. What to do when there is allergic reaction of the lung?]

Among the major allergic pulmonary disorders are bronchial asthma, extrinsic allergic alveolitis, allergic aspergillosis and berylliosis. Asthma is diagnosed on the basis of clinical symptoms (wheezing, respiratory distress, tight chest, coughing) and lung function tests possibly supplemented by allergic and provocative testing. Asthma treatment is differentiated into long-term medication and as-required medication. Specific immunotherapy is considered the sole causal therapy. Extrinsic allergic alveolitis is work- or hobby-related (farmer's/cheese worker's/bird-fancier's lung) and manifests as diffuse pneumonitis with dyspnea, coughing and fever. For the diagnosis, the antigen provocative test in particular plays a major role. In the main, treatment comprises strict avoidance of allergens. The diagnosis of allergic pulmonary aspergillosis is based on the history, clinical findings, skin tests, serology and radiography. Treatment is stage-related by means of immunosuppressive agents. In terms of radiographic and pulmonary function findings, berylliosis is similar to sarcoidosis. Here, too, immunosuppressive agents are to the fore.

Identification of an abnormal beryllium lymphocyte proliferation test

The potential hazards from exposure to beryllium or beryllium compounds in the workplace were first reported in the 1930s. The tritiated thymidine beryllium lymphocyte proliferation test (BeLPT) is an in vitro blood test that is widely used to screen beryllium exposed workers in the nuclear industry for sensitivity to beryllium. The clinical significance of the BeLPT was described and a standard protocol was developed in the late 1980s. Cell proliferation is measured by the incorporation of tritiated thymidine into dividing cells on two culture dates and using three concentrations of beryllium sulfate. Results are expressed as a 'stimulation index' (SI) which is the ratio of the amount of tritiated thymidine (measured by beta counts) in the simulated cells divided by the counts for the unstimulated cells on the same culture day. Several statistical methods for use in the routine analysis of the BeLPT were proposed in the early 1990s. The least absolute values (LAV) method was recommended for routine analysis of the BeLPT. This report further evaluates the LAV method using new data, and proposes a new method for identification of an abnormal or borderline test. This new statistical-biological positive (SBP) method reflects the clinical judgment that: (i) at least two SIs show a 'positive' response to beryllium; and (ii) that the maximum of the six SIs must exceed a cut-point that is determined from a reference data set of normal individuals whose blood has been tested by the same method in the same serum. The new data is from the Y-12 National Security Complex in Oak Ridge (Y-12) and consists of 1080 workers and 33 non-exposed control BeLPTs (all tested in the same serum). Graphical results are presented to explain the statistical method, and the new SBP method is applied to the Y-12 group. The true positive rate and specificity of the new method were estimated to be 86% and 97%, respectively. An electronic notebook that is accessible via the Internet was used in this work and contains background information and details not included in the paper.

Clinical approach to chronic beryllium disease and other nonpneumoconiotic interstitial lung diseases

Exposures in the workplace result in a diverse set of diseases ranging from the pneumoconiosis to other interstitial lung diseases to acute lung injury. Physician awareness of the potential disease manifestations associated with specific exposures is important in defining these diseases and in preventing additional disease. Most occupational diseases mimic other forms of lung disease, including pulmonary fibrosis, sarcoidosis, adult respiratory distress syndrome (ARDS), and bronchiolitis. A "sarcoidosis"-like syndrome, usually limited to the lungs, may result from exposure to bioaerosols and a number of metals. Exposure to beryllium in the workplace produces a granulomatous lung disease clinically indistinguishable from sarcoidosis, chronic beryllium disease (CBD). Beryllium's ability to produce a beryllium-specific immune response is used in the beryllium lymphocyte proliferation tests to confirm a diagnosis of CBD and exclude sarcoidosis. Exposure to other metals must also be considered in the differential diagnosis of sarcoidosis. When an individual presents acutely with ARDS or acute lung injury, an acute inhalational exposure must be considered. Exposure to a number of irritant substances at high levels may cause a "chemical pneumonitis" or acute lung injury, depending on the solubility and physicochemical properties of the substance. Some of the most notable agents include nitrogen and sulfur oxides, phosgene, and smoke breakdown products. Ingestion of paraquat may also result in an ARDS syndrome, with pulmonary fibrosis eventually resulting. Bronchiolitis is a rare manifestation of inhalational exposures but must also be considered in the clinical evaluation of inhalational exposure.

[Beryllium--underestimated occupational health hazard in Poland]

Beryllium is a metal used in different branches of industry. Inhalation is the most common way of exposure. Beryllium shows a high affinity to the lung tissue. It may act as toxic, carcinogenic and immunological agent. Chronic beryllium disease (CDB) is very difficult to diagnose because of its similarity to sarcoidosis. The lymphocyte proliferation assay is a very helpful test in CBD diagnosis. It seems reasonable to include this test into the body of the standard diagnostic procedures in workers exposed to beryllium. Early detection of hypersensitivity to beryllium, before CBD symptoms occur will allow to minimize adverse health effects.

Introduction to Beryllium: Uses, Regulatory History, and Disease

Beryllium is an ubiquitous element in the environment, and it has many commercial applications. Because of its strength, electrical and thermal conductivity, corrosion resistance, and nuclear properties, beryllium products are used in the aerospace, automotive, energy, medical, and electronics industries. What eventually came to be known as chronic beryllium disease (CBD) was first identified in the 1940s, when a cluster of cases was observed in workers from the fluorescent light industry. The U.S. Atomic Energy Commission recommended the first 8-hour occupational exposure limit (OEL) for beryllium of 2.0 microg/m3 in 1949, which was later reviewed and accepted by the American Conference of Governmental Industrial Hygienists (ACGIH), the American Industrial Hygiene Association (AIHA), the American National Standards Institute (ANSI), the Occupational Safety and Health Administration (OSHA), and the vast majority of countries and standard-setting bodies worldwide. The 2.0 microg/m3 standard has been in use by the beryllium industry for more than 50 years and has been considered adequate to protect workers against clinical CBD. Recently, improved diagnostic techniques, including immunological testing and safer bronchoscopy, have enhanced our ability to identify subclinical CBD cases that would have formerly remained unidentified. Some recent epidemiological studies have suggested that some workers may develop CBD at exposures less than 2.0 microg/m3. ACGIH is currently reevaluating the adequacy of the current 2.0 microg/m3 guideline, and a plethora of research initiatives are under way to provide a better understanding of the cause of CBD. The research is focusing on the risk factors and exposure metrics that could be associated with CBD, as well as on efforts to better characterize the natural history of CBD. There is growing evidence that particle size and chemical form may be important factors that influence the risk of developing CBD. These research efforts are expected to provide data that will help identify a scientifically based OEL that will protect workers against CBD.