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BERYLLIUM DISEASE by I Postgrad Med J: first published as 10.1136/pgmj.34.391.262 on 1 May 1958. Downloaded from 262 BERYLLIUM DISEASE By I. B. SNEDDON, M.B., Ch.B., F.R.C.P. Consultant Dermatologist, Rupert Hallam Department of Dermatology, Sheffield It is opportune in a symposium on sarcoidosis monary berylliosis which fulfilled the most to discuss beryllium disease because it mimics so stringent diagnostic criteria. closely the naturally occurring Boecks sarcoid and A beryllium case registry set up at the Massa- yet carries a far graver prognosis. chusetts General Hospital by Dr. Harriet Hardy Beryllium was first reported to possess toxic had collected by 1956 309 examples of the disease, properties by Weber and Englehardt (I933) in of whom 84 had died. The constant finding of Germany. They described bronchitis and acute beryllium in autopsy material from the fatal cases respiratory disease in workers extracting beryllium had proved beyond doubt the association between from ore. Similar observations were made by the granulomatous reaction and the metal. Marradi Fabroni (I935) in Italy and Gelman It is difficult to reconcile the paucity of accounts (I936) in Russia. Further reports came from of beryllium disease in this country with the large Germany in I942 where beryllium poisoning was amount of beryllium compounds which have been recognized as a compensatable disease. Towards used in the last ten The in the end of World War II the production and use years. only reports the medical literature are those of Agate (I948),copyright. of beryllium salts increased greatly in the United Sneddon (i955), and Rogers (1957), but several States, and in 1943 Van Ordstrand et al. reported others have reached public notice in the daily the first examples of chemical pneumonia in men press by reports of coroners' inquests and medico- extracting beryllium oxide from ore in Ohio. In legal actions. It is possible that there are others addition to the acute respiratory disease, it had undiagnosed which are at present labelled Boeck's also been recognized that an acute contact derma- sarcoidosis. titis and ulcers resembling chrome ulcers occurred workers in extraction amongst beryllium plants, http://pmj.bmj.com/ but it was not until 1946 that the first examples Pathology of delayed chemical pneumonitis were described The basic pathological change seen in material by Hardy and Tabershaw. from three autopsies by Chesner (1950) was an They drew attention to a slowly progressive intra-alveolar nodular granulomatous lesion which sarcoid-like change which involved the lungs, involved all the lung fields. The nodules were liver and other organs in workers who had been composed of a preponderance of large endothelial exposed sometimes for a very short time to cells with plasma cells, mononuclears and lympho- beryllium compounds. The striking feature of cytes. There was no caseation at any stage. on September 28, 2021 by guest. Protected the condition was the long latent period between Giant cells of both foreign body and Langhan's exposure to beryllium and the onset of symptoms. type were seen in large numbers. Inclusion This delay at first lead to doubt that beryllium bodies were seen within the giant cells in some itself was responsible for the pathological changes but not all cases. Spread occurred by aggregation and even as recently as I95I an annotation in the of nodules in a more diffuse fashion throughout Lancet suggested that the case against beryllium the alveolar septa. The diffuse reaction was at was not proven, though this was later contradicted first a polymorphous cellular one with later by Harriet Hardy (1951) who has so vigorously fibrosis and hyalinization. campaigned for better recognition of the danger. Hilar lymph nodes were invariably affected by It is in deference to her that the condition is the same granulomatous process. The liver was called beryllium disease in this article. involved in two of the three cases, but there were Since that time more and more cases have been no other visceral lesions. Similar granulomatous described in the United States of America. In reactions have been described in skin lesions I953 Denardi et al., in an authoritative review of associated with beryllium disease of the lung by the subject, reported 35 examples of chronic pul- Grier et al. (I948), who also gave the first account Postgrad Med J: first published as 10.1136/pgmj.34.391.262 on 1 May 1958. Downloaded from May 1958 SNEDDON: Beryllium Disease 263 of skin nodules due to accidental implantation of when attempting to differentiate the two con- beryllium in the skin. ditions. Lederer and Savage (1954), who have described Equally, respiratory function studies which the only example of beryllium granuloma of the show diminished vital capacity and slowing of skin in this country, noted pathological changes alveolar diffusion in beryllium disease are merely indistinguishable from sarcoidosis in part of the a measurement of the severity of the lung damage. lesion but extensive caseation in other areas. Impairment of respiratory function is, however, Although most investigators have failed to pro- found earlier and is more severe in beryllium duce pulmonary granulomata in animal experi- disease than in sarcoidosis. ments with beryllium compounds, Davies and Wilson (1948) has described the radiographic Harding (1950) succeeded in causing pulmonary appearance of the lungs as being in three stages: granulomata in rats after intra-tracheal injection (I) A fine ground-glass granularity through the of a mixture cf beryllium oxide and manganese whole of the lung fields; dioxide. (2) A superimposed recticular pattern; and (3) Very characteristic nodulation. The nodules Clinical Features varying in size from small to quite large, but not Symptoms may arise after a latent period from all cases progress through these stages. the last exposure to beryllium, of a few months Hilar gland enlargement does occur but never to over ten years, and the exposure time need without densities in the lung fields. It is note- only be a few weeks. Although the majority of worthy that the early changes may be so finely patients have worked in contact with beryllium granular that miniature mass radiography may compounds, Sterne and Eisenbud (I951) have not show them. recorded beryllium disease in residents in the near Many of the American articles do not refer to neighbourhood of beryllium extraction plants the results of tuberculin skin tests, but Hardy where the air contained less than ix±g. of beryllium states that in her series of cases, in contrast to million and was as low as sarcoidosis, the responses have not differed from per parts probably those of the On the other o.I ,ug. per million. The disease has also affected general population. copyright. relatives of beryllium workers whose only contact hand, Agate's patient showed a change from a was with soiled working clothes. positive Mantoux reaction of I/I,OOO to negative The onset is insidious with dyspnoea on exer- during the course of the illness, and in Rogers' tion, one of the first complaints. A dry paroxysmal (1957) patient and in two of the author's cases the cough, fatigue and loss of weight associated with Mantoux test was negative. anorexia are usual and periods of fever may occur. The Kveim test has only been performed on a As in sarcoidosis, quite advanced changes may few patients with beryllium disease, and the be present in the lungs without symptoms, and results have either been negative or a non-specific http://pmj.bmj.com/ such cases are discovered on routine chest radio- foreign body reaction. graphy. Biopsy of the liver may reveal a sarcoid-like Physical signs are usually minimal though club- granulomatous reaction indistinguishable from bing of the fingers and crackling rales throughout sarcoidosis. both lung fields and pleural friction have been The Differential described. Enlargement of the liver and spleen Diagnosis be but The differential diagnosis of beryllium disease may found, enlarged superficial lymph on September 28, 2021 by guest. Protected glands are very rare. Skin nodules of the same includes miliary tuberculosis, miliary carcino- type as those seen in sarcoidosis have occurred matosis, pneumoconiosis and haemosiderosis, but occasionally, and in the author's case linear sarcoid above all else it resembles Boeck's sarcoidosis and infiltrations in the site of previous skin damage the majority of reported cases were first thought by beryllium copper strip were a presenting and to be that condition. unusual feature. There are some differences between the two. For instance, no lesions of the eye, parotid or tonsil have been found in beryllium disease, and Investigative Procedure cervical and axillary node enlargement is rare. As Hardy (1956) has pointed out, many of the No cystic bone changes have ever been reported. laboratory procedures such as total serum proteins The course of beryllium disease tends to be more and globulin, electrophoretic pattern of serum, rapidly downhill than that of sarcoidosis, but these liver function studies, urinary and serum calcium slight differences are not of sufficient importance and urinary steroids may show abnormalities in to tip the scale when faced with a patient. beryllium disease just as they may in sarcoidosis, The original criteria of diagnosis of beryllium and therefore they are of little or no assistance disease established by American workers were: Postgrad Med J: first published as 10.1136/pgmj.34.391.262 on 1 May 1958. Downloaded from 264 POSTGRADUATE MEDICAL JOURNAL May 1958 (I) History of exposure to dusts and fumes of beryllium compounds. (2) Clinical course of the pulmonary syndrome including studies of pulmonary function. (3) Radiographic evidence of granuloma of the :":,;;.....::.,.. lung. (4) Lung biopsy and analysis for beryllium. In 1953, Denardi et al. reported the reliability of skin patch tests carried out with dilute solutions of beryllium salts in distinguishing between * .....
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