Commentary and update: Chemical pneumonia in workers extracting beryllium oxide1 Merril Eisenbud, Sc.D. Nearly 1,000 cases of beryllium-related disease have leading to much published information dealing been reported in the United States since the first three with the many ramifications of beryllium disease. cases were reported by VanOrdstrand and his associ- Although similar subject material in the Euro- ates in 1943. In addition to acute chemical pneumoni- pean literature had called attention to the occur- tis, beryllium exposure has also resulted in berylliosis, rence of a disease resembling chemical pneumo- a chronic granulomatous disease. The largest number nitis among workers employed in the extraction of berylliosis cases was reported in the fluorescent 1 lamp industry where beryllium was used in phosphors of beryllium, the reports lacked continuity and until 1949. Other cases occurred due to air pollution the etiologic factors given to explain the disease in the vicinity of beryllium-producing factories and were problematic. The publication in the January exposure of family members to beryllium dust brought 1943 issue of the CLEVELAND CLINIC QUARTERLY home on contaminated work clothes. Many of the pe- culiar epidemiologic features of both the acute and was the first published in the United States and chronic forms of beryllium disease can be explained was followed by publications in other journals, by its sensitizing characteristics. The standards that not only by VanOrdstrand and his associates, but were established for the control of beryllium disease in also by investigators from other parts of the the later 1940s have been remarkably effective and United States and Europe. Interest developed so have now been adopted worldwide. rapidly that the Sixth Saranac Symposium, which Index terms: Beryllium, adverse effects Occu- was held at the Trudeau Foundation in 1947, pational diseases was devoted almost completely to "the beryllium Cleve Clin Q 51:441-447, Summer 1984 problem" and attracted approximately 200 phy- sicians and scientists.2 Beryllium is the lightest of the metals and, with With the opening sentences of a paper written an atomic weight of 9.01, is the top element in more than 40 years ago, H. S. VanOrdstrand, group II of the periodic table. It was discovered Robert Hughes, and Morris G. Carmody raised in 1797 and given the name "glucinum" because the curtain on a new medical drama that would of the sweet taste of some of its salts. Until attract the attention of occupational disease spe- recently, beryllium was obtained from the min- cialists for decades to come. As this drama un- eral beryl, a beryllium aluminum silicate, of folded, the Cleveland Clinic became a worldwide which the gems aquamarine and emerald are center for clinical consultation and research, varieties. During the past decade, bertrandite, a silicate mineral, has also become an important source for this element. 1 From the Laboratory for Environmental Studies, New York Beryllium has proved to be useful in science University Medical Center, Institute of Environmental Medicine, New York. sb and industry. Its most widespread use is as a copper alloy, containing about 2.5% beryllium, 0009-8787/84/02/0441/07/$2.75/0 which is used for springs and diaphragms. Beryl- lium metal has a number of interesting nuclear Copyright © 1984, The Cleveland Clinic Foun- properties and, because it is practically transpar- dation. 441 Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. 2*442 Cleveland Clinic Quarterly Vol. 51, No. 2 ent to x rays, is widely used for x-ray-tube win- the authors called "delayed chemical pneumoni- dows. Neutron sources can be produced from tis," were known. They noted that "the distinctive capsules containing mixtures of beryllium and feature that separates the present group [of cases] alpha-emitting radionuclides such as radium 226 from previous reports in the literature is the usual or polonium 210. The metal can also be used to delay in onset following common exposure—and moderate or reflect neutrons and, for these rea- progression of the disease in spite of change in sons, has found limited application in certain environment." By this time, although the Hardy types of nuclear reactors. It has a high melting and Tabershaw paper was the only report of the point (1,285° C) and also has useful structural chronic form of beryllium disease, now generally properties that have led to its use in the aerospace known as "berylliosis," a number of other reports industry. Additionally, beryllium oxide has ex- of acute chemical pneumonitis had been reported cellent refractory properties. among beryllium workers in Pennsylvania, New During the early 1940s, when the first cases of Jersey, and Ohio. The Pennsylvania cases, which beryllium disease were reported, one of the most were described by the State's Director of Indus- important uses of this element was as a compo- trial Hygiene and which, like the first of the nent of fluorescent lamp phosphors. This use was VanOrdstrand cases, also occurred among work- discontinued in 1949 because of the toxicity of ers in a beryllium extraction plant, were believed the phosphors. by the authors to be due to the acid radicals The three cases of acute chemical pneumonitis associated with beryllium rather than to the be- 5 that were reported by VanOrdstrand et al in ryllium ion itself. This was not an unreasonable 1943 proved to be only a glimpse of a widespread position to take at the time because the early problem that was not fully understood for many European cases had been attributed to fluoride years. At about the same time, two women com- salts of beryllium. Moreover, a 1943 report on plaining of severe and disabling dyspnea were the toxicity of beryllium oxide in the rat, pub- admitted to a tuberculosis sanitarium in Massa- lished by the U.S. Public Health Service, had not 6 chusetts. An initial diagnosis of miliary tubercu- considered that compound to be toxic. losis was discarded after about two months of Even as late as 1946, people had difficulty study in lieu of a new diagnosis: pulmonary sar- accepting the fact that beryllium was harmful. coidosis. The fact that the two women worked in An element situated with magnesium and calcium the same building of a plant manufacturing flu- in group II of the periodic table was not expected orescent lamps did not appear particularly im- to be toxic. Some specialists continued to believe portant at the time. A postmortem examination that the acute conditions were caused by the of one patient seemed to confirm a diagnosis of anions with which beryllium was associated, and Boeck's sarcoid. As pointed out by Shipman3 in one prominent pathologist, LeRoy Gardner, who an early review of the history of beryllium dis- was a specialist in the etiology of the pneumocon- ease, the matter would have been concluded then ioses, even proposed that the chronic disease had not a third patient been admitted to the same might be due to some infectious organism that sanitarium with an identical history. A fourth somehow thrived in an environment that con- and fifth patient were soon treated, and upon tained beryllium.7 Moreover, general acceptance investigation, the Division of Occupational Hy- of the element's toxicity was made more difficult giene of the Massachusetts Department of Labor by the unusual clinical and epidemiologic fea- and Industries reported that the only unusual tures of the cases that were being reported. material used in the fluorescent lamp manufac- The etiology of new industrial diseases is gen- turing process was a compound of beryllium—a erally elucidated by epidemiologic studies that metal about which little was known. Thus, at the provide an understanding of the clinical and en- same time that the VanOrdstrand group was vironmental factors involved. One essential re- reporting the occurrence of acute chemical pneu- quirement for environmental studies is tech- monitis among beryllium workers, the Massachu- niques to sample the air in the workroom atmo- setts investigators were reporting a chronic de- sphere to establish the relationships between the bilitating sarcoid-like lung disease among work- degree of exposure and the observed effects. ers who were also exposed to this metal. After 1947, methods for the analysis of the trace When the first report of the Massachusetts amounts of beryllium in air samples had been cases was published by Hardy and Tabershaw4 in developed, and the Atomic Energy Commission September 1946, 17 cases of this disease, which then sponsored epidemiologic and environmen- Downloaded from www.ccjm.org on September 24, 2021. For personal use only. All other uses require permission. Summer 1984 Commentary 443 tal studies which led quickly to the gaining of mendation was borne out by the fact that 53 cases information needed to control the disease. of acute pneumonitis were reported in 1947; 28 in 1948; and only one in 1949. Fifteen cases were The acute disease noted between 1950 and 1968, all in beryllium The first three cases described by the Cleve- extraction plants.9 Most cases were associated land Clinic physicians involved workers from the with accidental massive releases during the start- Clifton Products Company, a small beryllium re- up of new plants. No instance of the disease has finery in Painesville, Ohio; these cases were fol- been reported since 1968, and no fatalities have lowed by additional ones involving patients both been recorded since 1947. from that plant and the Brush Beryllium Com- Here, it should be noted that the recom- pany plant in Lorain, Ohio, which used a differ- mended standard applied only to peak levels of ent extraction process. Cases from the Pennsyl- exposure. Establishment of a maximum allowable vania refinery, as noted previously, and from a daily average exposure also seemed necessary to plant that manufactured the phosphors used in control the chronic disease, but the prevalence fluorescent lamps were also reported.