The pulmonary toxicity of beryllium

Multisystemic Beryllium Disease: An Exceptional Case Revealed by a Urinary Tract Granulomatosis

Chronic beryllium disease (CBD), or berylliosis, is an interstitial lung disease caused by the chronic inhalation of finely particulate beryllium, frequently mistaken for sarcoidosis. It is rarely associated with skin nodular lesions, asymptomatic granulomatous hepatitis or calcium nephrolithiasis. To date, it has never been reported as a diffused multi-organ granulomatous disease. A 60-year-old Pakistani man, a former excavation worker with ancient history of suspected sarcoidosis, underwent a left nephroureterectomy for suspected papillary kidney carcinoma. The histopathological analysis showed a benign non-necrotic granulomatous infiltration of the renal pelvis and ureter. Six months later, he suffered from two consecutive episodes of acute kidney failure. Bladder biopsies found similar noncaseous granulomatosis and kidney biopsies showed interstitial nephritis. Known for suspected asthma, sleep apnea, and usual interstitial pneumonia, the patient would regularly consult for episodes of pyrexia, chills, nocturnal coughing, and wheezing. As kidney function gradually worsened, he ultimately started hemodialysis and was transferred to our facility. A positive blood beryllium lymphocyte proliferation test confirmed the diagnosis of CBD. This original report is the first description of multi-organ berylliosis with diffused urothelial granulomatosis and pseudo-tumor. The patient's pulmonary disease is minimal compared with renal and urinary tract involvement, eventually responsible for end-stage kidney disease. Berylliosis usually responds to glucocorticoids. This case report highlights the importance of evoking the diagnosis of CBD in the presence of any granulomatosis, even extra-thoracic, especially if associated with pulmonary symptoms, however atypical.

Chronic Beryllium Disease: Update on a Moving Target

Beryllium exposure remains an ongoing occupational health concern for workers worldwide. Since the initial Occupational Safety and Health Administration (OSHA) ruling on a permissible exposure limit (PEL) for beryllium in 1971, our understanding of the risks of beryllium sensitization and chronic beryllium disease (CBD) has evolved substantially. A new OSHA ruling released in early 2017 and implemented in late 2018 reduced the PEL for beryllium, increased requirements for medical screening and monitoring, and may ultimately enhance worker protection. This review highlights advances in our understanding of the pathway from beryllium exposure to sensitization and progression to CBD that guided the development of this OSHA ruling. Screening workers exposed to beryllium and management of CBD will also be discussed. Finally, we will discuss the role of beryllium as a cause of morbidity and mortality among exposed workers in this potentially preventable occupational lung disease.

Beryllium-associated diseases from a chemist’s point of view

Beryllium has long been considered the most toxic non-radioactive element to humans. However, it is shown that the acute toxicity of beryllium ions does not exceed that of other toxic cations like Cd2+, Ba2+, Hg2+ or As3+. The physiological mechanisms liable for the development of beryllium-associated diseases are discussed. Additionally an overview over proposed low-molecular model system for the beryllium species responsible for beryllioses is presented.

Understanding the Localization of Berylliosis: Interaction of Be2+ with Carbohydrates and Related Biomimetic Ligands

The interplay of metal ions with polysaccharides is important for the immune recognition in the lung. Due to the localization of beryllium associated diseases to the lung, it is likely that beryllium carbohydrate complexes play a vital role for the development of berylliosis. Herein, we present a detailed study on the interaction of Be2+ ions with fructose and glucose as well as simpler biomimetic ligands, which emulate binding motives of saccharides. Through NMR and IR spectroscopy as well as single-crystal X-ray diffraction, complemented by competition reactions we were able to determine a distinctive trend in the binding affinity of these ligands. This suggests that under physiological conditions beryllium ions are only bound irreversibly in glycoproteins or polysaccharides if a quasi ideal tetrahedral environment and κ4 -coordination is provided by the respective biomolecule. Furthermore, Lewis acid induced conversions of the ligands and an extreme increase in the Brønstedt acidity of the present OH-groups imply that upon enclosure of Be2+ , alterations may be induced by the metal ion in glycoproteins or polysaccharides. In addition the frequent formation of Be-O-heterocycles indicates that multinuclear beryllium compounds might be the actual trigger of berylliosis. This investigation on beryllium coordination chemistry was supplemented by binding studies of selected biomimetic ligands with Al3+ , Zn2+ , Mg2+ , and Li+ , which revealed that none of these beryllium related ions was tetrahedrally coordinated under the give conditions. Therefore, studies on the metabolization of beryllium compounds cannot be performed with other hard cations as a substitute for the hazardous Be2+ .

Repeated pulmonary exposures to zinc ions enhance inflammatory responses to subsequent metal exposures

AIM OF STUDY

Metal contaminants contribute to adverse human health effects via acute and chronic exposures. Acute metal exposures followed by prolonged secondary metal exposures may elicit exaggerated inflammatory responses in certain individuals. The aim of this study is to determine whether repeated pulmonary exposures to zinc chloride (ZnCl₂) alter subsequent responses to zinc or cerium exposures.

MATERIALS AND METHODS

Rats were intratracheally (IT) instilled with physiologic saline (n = 24) or 0.05 mg/kg ZnCl₂ (n = 16) twice weekly for 4 weeks. Four days after last dosing, the saline group was divided into three subgroups, each IT-instilled with either saline, ZnCl₂ or CeCl₃ (both at 0.1 mg/kg). The ZnCl₂ pre-instilled rats were divided into two subgroups, each instilled with 0.1 mg/kg ZnCl₂ or CeCl₃. Biomarkers of lung injury/inflammation were assessed in bronchoalveolar lavage (BAL) fluid collected 24 hours later. Oxidative stress was evaluated as total and reduced glutathione in BAL.

RESULTS

Increases in inflammatory cells, LDH, albumin, leptin, MCP-1, IP-10, fractalkine, TNFα and RANTES were observed in rats instilled with multiple PBS and then with 0.1 mg/kg ZnCl₂ and CeCl₃. However, rats pre-exposed repeatedly to 0.05 mg/kg ZnCl₂ and then challenged with 0.1 mg/kg ZnCl₂ or CeCl₃ showed even more eosinophils, lymphocytes, and increased concentrations of hemoglobin and MIP-1α. Significant reduction in GSH/GSSG ratios in BAL in response to all ZnCl₂ or CeCl₃ exposures indicated oxidative stress.

CONCLUSION

Previous exposure to zinc ions increases responsiveness to subsequent exposures to zinc and cerium ions. These findings suggest enhanced sensitization possibly due to a reduction in antioxidant defenses.

Sarcoidosis in iron-steel industry: mini case series

Sarcoidosis is a disease of unknown etiology. Despite the proposed connection between the development of sarcoidosis and exposure to environmental and toxic substances, no definitive associations could be established. Also, the role of silica and silicates in the etiology of this condition is currently unknown. Heat-treatment of silica results in the generation of tridymite and cristobalite forms and iron-steel industry represents one branch of industry in which silicone element is exposed to temperatures around 2000°C. Studies reporting on the incidence of sarcoidosis in the workers of iron-steel industry are scarce in number, and workers of this industrial branch are known to be exposed to silica in the form of cristobalite, nano-particulate silicone, metal oxides, and silicates. These substances, which have respiratory toxic properties and have been reported to be associated with autoimmune conditions, may also play a role in the pathogenesis of sarcoidosis. In our clinic, sarcoidosis was diagnosed in a total of 4 individuals, who works in the iron-steel industry. Through this report involving a series of patients with sarcoidosis, we also wanted to discuss the role of crystalline silica forms and silicates in the etiology of sarcoidosis, which is also considered to be an auto-immune condition. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 365-372).

Off the Beaten Track-A Hitchhiker's Guide to Beryllium Chemistry

This Minireview aims to give an introduction to beryllium chemistry for all less-experienced scientists in this field of research. Up to date information on the toxicity of beryllium and its compounds are reviewed and several basic and necessary guidelines for a safe and proper handling in modern chemical research laboratories are presented. Interesting phenomenological observations are described that are related directly to the uniqueness of this element, which are also put into historical context. Herein we combine the contributions and experiences of many scientist that work passionately in this field. We want to encourage fellow scientists to reconcile the long-standing reservations about beryllium and its compounds and motivate intense research on this spurned element. Who on earth should be able to deal with beryllium and its compounds if not chemists?

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.

Structural basis of metal hypersensitivity

Metal hypersensitivity is a common immune disorder. Human immune systems mount the allergic attacks on metal ions through skin contacts, lung inhalation and metal-containing artificial body implants. The consequences can be simple annoyances to life-threatening systemic illness. Allergic hyper-reactivities to nickel (Ni) and beryllium (Be) are the best-studied human metal hypersensitivities. Ni-contact dermatitis affects 10 % of the human population, whereas Be compounds are the culprits of chronic Be disease (CBD). αβ T cells (T cells) play a crucial role in these hypersensitivity reactions. Metal ions work as haptens and bind to the surface of major histocompatibility complex (MHC) and peptide complex. This modifies the binding surface of MHC and triggers the immune response of T cells. Metal-specific αβ T cell receptors (TCRs) are usually MHC restricted, especially MHC class II (MHCII) restricted. Numerous models have been proposed, yet the mechanisms and molecular basis of metal hypersensitivity remain elusive. Recently, we determined the crystal structures of the Ni and Be presenting human MHCII molecules, HLA-DR52c (DRA*0101, DRB3*0301) and HLA-DP2 (DPA1*0103, DPB1*0201). These structures revealed unusual features of MHCII molecules and shed light on how metal ions are recognized by T cells.

Recent advances in understanding the biomolecular basis of chronic beryllium disease: a review

In this review we summarize the work conducted over the past decade that has advanced our knowledge of pulmonary diseases associated with exposure to beryllium that has provided a molecular-based understanding of the chemistry, immunopathology, and immunogenetics of beryllium toxicity. Beryllium is a strong and lightweight metal that generates and reflects neutrons, resists corrosion, is transparent to X-rays, and conducts electricity. Beryllium is one of the most toxic elements on the periodic table, eliciting in susceptible humans (a) an allergic immune response known as beryllium sensitization (BeS); (b) acute beryllium disease, an acutely toxic, pneumonitis-like lung condition resulting from exposure to high beryllium concentrations that are rarely seen in modern industry; and (c) chronic beryllium disease (CBD) following either high or very low levels of exposure. Because of its exceptional strength, stability, and heat-absorbing capability, beryllium is used in many important technologies in the modern world. In the early 1940s, beryllium was recognized as posing an occupational hazard in manufacturing and production settings. Although acute beryllium disease is now rare, beryllium is an insidious poison with a latent toxicity and the risk of developing CBD persists. Chronic beryllium disease-a systemic granulomatous lung disorder caused by a specific delayed immune response to beryllium within a few months to several decades after exposure-has been called the "unrecognized epidemic". Although not a disease in itself, BeS, the innate immune response to beryllium identified by an abnormal beryllium lymphocyte proliferation test result, is a population-based predictor of CBD. Genetic susceptibility to CBD is associated with alleles of the major histocompatibility gene, human leukocyte antigen DP (HLA-DP) containing glutamic acid at the 69th position of the beta chain (HLA-DPbeta-E69). Other genes are likely to be involved in the disease process, and research on this issue is in progress. The current Occupational Safety & Health Administration permissible exposure limit of 2 microg/m3 has failed to protect workers from BeS/CBD. As a safe exposure limit that will not lead to BeS or CBD has not yet been determined, the realization that the risk of CBD persists has led to a renaissance in research on the effects of the metal on human health. Current data support further reductions in exposure levels to help minimize the incidence of CBD. Steps that would directly impact both the power of epidemiologic studies and the cost of surveillance would be to develop and validate improved screening and diagnostic tests, and to identify more genetic factors that affect either sensitization or disease process. The major focus of this review is the recent research on the cellular and molecular basis of beryllium sensitization and disease, using a multidisciplinary approach of bioinorganic chemistry and immunology. First we present a historical background of beryllium exposure and disease, followed by occurrence of beryllium in the environment, toxicokinetics, biological effects, beryllium lung disease, and other human health effects.

Immunology of chronic beryllium disease

PURPOSE OF REVIEW

This review discusses the immunology of chronic beryllium disease. It addresses the importance of the interaction between class II molecules and the T cells that recognize beryllium, along with the subsequent immune response that results in sensitization and disease, and genetic factors leading to variation in this response.

RECENT FINDINGS

HLA-DPB1 with a glutamic acid at amino acid position 69 (Glu69) confers increased risk of beryllium sensitization and is not specific for chronic beryllium disease. The degree of negative surface charge of the molecule may increase risk of chronic beryllium disease but not sensitization. In the absence of Glu69, HLA-DRB1 alleles may function in beryllium presentation, increasing the risk of chronic beryllium disease. The T-cell response as assessed by the beryllium lymphocyte proliferation test is dependent on central memory T-cells, while Th1 cytokine secretion leading to granulomatous inflammation and chronic beryllium disease is dependent on the activity of effector memory T cells. Polymorphisms in cytokine genes, such as the TGF-beta1 gene, also affect the risk of chronic beryllium disease and more severe disease.

SUMMARY

The current diagnostic criteria for sensitization and chronic beryllium disease rely on the beryllium lymphocyte proliferation test. By understanding the novel immunologic mechanisms and genetic factors associated with sensitization and chronic beryllium disease, we may improve our ability to detect beryllium health effects with new diagnostics, and hopefully refine therapies for disease.

Amelioration of beryllium induced alterations in hepatorenal biochemistry and ultramorphology by co-administration of tiferron and adjuvants

Influence of adjuvants i.e., alpha-tocopherol (25 mg/kg, p.o.) and piperine (10 mg/kg, p.o.) on therapeutic potential of chelator tiferron (300 mg/kg, i.p.) was evaluated to encounter toxicogenic events of beryllium exposure. Albino rats were exposed to beryllium nitrate (1 mg/kg, i.p.) daily for 28 days followed by treatment of aforesaid therapeutic agents for 5 consecutive days. Results were considered to be significant at p < or =0.01 and p < or =0.05. Exposure to beryllium increased its concentration in liver, kidney and serum causing significant alterations in the activity of CYP-450 2E1 system, microsomal lipid peroxidation and protein; alkaline phosphtase, lactate dehydrogenase, gamma-glutamyl transpeptidase, bilirubin, creatinine and urea in serum; activity of acid phosphatase, alkaline phosphatase, adenosine triphosphatase, glucose-6-phosphatase and succinic dehydrogenase in liver and kidney. Beryllium exposure also induced severe alterations in histopathology and ultramorphology of liver and kidney proving its toxic consequences at cellular level. Tiferron along with adjuvants dramatically reversed alterations of all variables more towards control rather than individual treatment. Study concluded that tiferron in combination with alpha-tocopherol and piperine respectively was beneficial in diluting beryllium induced systemic toxicity; however, combination of tiferron and piperine presented more pronounced therapeutic potential.

Bérylliose Pulmonaire Chronique : un modèle d’interaction entre environnement et prédisposition génétique (1re partie)

INTRODUCTION

The physico-chemical properties of beryllium (Be) are crucial for high technology industries. The inhalation of beryllium may cause, in certain individuals, a specific sensitisation (BeS) and lead, in some of them, to a pulmonary granulomatosis called chronic pulmonary berylliosis (CPB).

BACKGROUND

Although there is no linear relationship between the level of exposure to Be and the risks of BeS and CPB, the highest exposures are associated with an increased risk. The specific influences of the chemical composition, the solubility and different types of Be on the risk of BeS an CPB are poorly understood. Insoluble particles of small diameter are probably associated with an increased risk. Many studies have reported the role of a genetic predisposition in the risk of BeS and CPB. At present the role of HLA-DPB1 Glu69 in sensitisation to Be is the best studied.

CONCLUSION

Sensitisation to Be and CPB result from the combination of exposure and predisposing genetic polymorphisms. CPB is a model for the understanding of the pathology of certain ideopathic pulmonary granulomatoses such as sarcoidosis.

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.

Genetic and exposure risks for chronic beryllium disease

Exposure to beryllium results in beryllium sensitization, or development of a beryllium-specific, cell-mediated immune response, in 2% to 19% of exposed individuals. Sensitization usually precedes the development of the scarring lung disease, chronic beryllium disease. The development of granulomatous inflammation in patients with CBD is associated with the production of numerous inflammatory cytokines, including IFN-gamma, IL-2, and TNF-alpha (see Fig. 1). In some individuals this can result in increased granulomatous inflammation and a more severe form of the disease. Although the exposure response relationship in sensitization and disease is nonlinear, in some studies, higher exposures were associated with higher rates of sensitization and CBD. Machinists usually have higher levels of beryllium exposure and increased risk of developing sensitization and disease. The impact of the physicochemical properties of beryllium, such as form, solubility, and particle size, on the risk of sensitization and disease are less well understood. It is clear from numerous studies that genetic susceptibility affects risk of beryllium-related health effects. The role of HLA-DPB1 Glu69 in the proliferative response to beryllium and risk of sensitization has been the most well-studied. Some genes, such as Glu69, are important in the development of an antigen-specific, cell-mediated immune response to beryllium or sensitization, whereas others may be important in the development of beryllium-specific granulomatous inflammation or CBD (see Fig. 1). Two copies of the Glu69 gene may be a disease-specific genetic risk factor. The TNF-alpha -308 A variant is associated with beryllium-stimulated TNF-alpha production, which, in turn, is associated with more severe CBD. Whether the TNF-alpha -308 A is a genetic risk factor in CBD, sensitization, or more severe disease still needs to be determined. It is likely that sensitization and CBD are multigenetic processes, and that these genes interact with exposure to determine risk of disease. Current genetic markers are not ready for clinical use as a screening test for beryllium-related health effects because of the low specificity of the markers and the low prevalence of BeS and CBD.

Beryllium skin patch testing to analyze T cell stimulation and granulomatous inflammation in the lung

Chronic beryllium disease (CBD) is characterized by granulomatous inflammation and the accumulation of CD4(+) T cells in the lung. Patch testing of CBD patients with beryllium sulfate results in granulomatous inflammation in the skin. We investigated whether the T cell clonal populations present in the lung of CBD patients would also be present in the involved skin of a positive beryllium patch test and thus mirror the granulomatous process in the lung. CBD patients with clonal TCR expansions in bronchoalveolar lavage (BAL) were selected for study. All three CBD patients studied had a positive response to beryllium sulfate application and a negative patch test to normal saline. Immunohistochemistry showed extensive infiltration with CD4(+) T cells and few, if any, CD8(+) T cells both at 3 days and at later times when granulomas were apparent. T cell infiltration early after skin testing appeared to be nonspecific with the TCR repertoire of infiltrating T cells being distinct from that present in BAL. At later times when granulomas were present, T cell clones in skin overlapped with those in BAL in all patients tested. Total TCR matches in skin and BAL were as high as 40% in selected Vbeta T cell subsets. Studies of peripheral blood T cells before and after patch testing provided evidence for mobilization of large numbers of pathogenic beryllium-reactive T cells into the circulating pool. These studies using skin patch testing provide new insight into the dynamics of T cell influx and mobilization during granulomatous inflammation.

Chronic beryllium disease: a model interaction between innate and acquired immunity

Beryllium (Be) is a lightweight and durable metal useful to a variety of manufacturing processes. With the use of Be in industrial settings, a number of health effects were noted including acute pneumonitis, sensitization to Be, interstitial lung disease and dermatological disease. Interstitial mononuclear cell inflammation and granuloma formation are the primary processes that occur in the lungs of Be-exposed workers, resulting in chronic beryllium disease (CBD). Recent studies have begun to describe the role of Be in the pathogenesis of CBD. These studies reveal that the host's response to Be involves components of the innate immune system or inflammatory responses. Inflammatory responses to Be can establish a state of acquired, Be antigen-specific, cell-mediated immunity. Despite triggering both the innate and acquired immune responses, Be is not eliminated from the host. Rather, it establishes pathways leading to chronic granulomatous inflammation. We will examine recent studies describing the host's cellular and molecular responses to Be, responses that promote granuloma formation.

Gene expression profile in BALB/c-3T3 cells transformed with beryllium sulfate

Differential gene expression was studied to understand the potential molecular mechanism responsible for cell transformation and tumorigenesis induced by beryllium. Cell lines were derived from tumors developed in nude mice injected subcutaneously with BALB/c-3T3 cells morphologically transformed with beryllium sulfate. Using the Atlas mouse 1.2 cDNA expression microarray, the expression profiles of 1176 genes, belonging to several different functional categories, were studied in the tumor cells as well as in the nontransformed control cells. Expression of 18 genes belonging to two functional groups was found to be consistently and reproducibly different (at least twofold) in the tumor cells compared with the control cells. The functional groups and the differentially expressed genes are as follows: The cancer-related genes (nine genes) were the ets-related transcription factor activated by ras, colony-stimulating factor, A-myb, sky, cot1, c-fos, c-jun, c-myc, and R-ras proto-oncogenes. The DNA synthesis, repair, and recombination genes (nine genes) were the DNA replication licensing factor MCM4, the DNA replication licensing factor MCM5, the DNA mismatch repair gene PMS2, the DNA excision repair gene, the DNA mismatch repair gene MSH2, the ultraviolet excision repair gene Rad23 DNA ligase 1, Rad51, and Rad52. The differential gene expression profile was confirmed with reverse transcription-polymerase chain reaction using primers specific for the differentially expressed genes. In general, expression of the cancer-related genes was upregulated, while expression of genes involved in DNA synthesis, repair, and recombination was downregulated in the tumor cells compared with the control cells. Using c-fos and c-jun, two of the differentially expressed genes, as model genes, we have found that in the nontransformed BALB/c-3T3 cells, the beryllium-induced transcriptional activation of these genes was dependent on pathways of protein kinase C and mitogen-activated protein kinase and independent of reactive oxygen species. These results indicate that beryllium-induced cell transformation and tumorigenesis are accompanied by and are possibly a product of alterations in expression of genes related to cancer and to DNA synthesis, repair, and recombination.

Efficacy of serial medical surveillance for chronic beryllium disease in a beryllium machining plant

There is limited information on the use of the blood beryllium lymphocyte proliferation test (BeLPT) at regular intervals in medical surveillance. Employees of a beryllium machining plant were screened with the BeLPT biennially, and new employees were screened within 3 months of hire. Of 235 employees screened from 1995 to 1997, a total of 15 (6.4%) had confirmed abnormal BeLPT results indicating beryllium sensitization; nine of these employees were diagnosed with chronic beryllium disease. Four of the 15 cases were diagnosed within 3 months of first exposure. When 187 of the 235 employees participated in biennial screening in 1997 to 1999, seven more had developed beryllium sensitization or chronic beryllium disease, increasing the overall rate to 9.4% (22 of 235). The blood BeLPT should be used serially in beryllium disease surveillance to capture new or missed cases of sensitization and disease. Beryllium sensitization and chronic beryllium disease can occur within 50 days of first exposure in modern industry.

Beryllium disease

Berylliosis is an environmental chronic inflammatory disorder of the lung caused by inhalation of insoluble beryllium (Be) dusts and characterized by the accumulation of CD4+ T cells and macrophages in the lower respiratory tract. In response to Be inhalation, noncaseating granuloma formation and, eventually, fibrosis. The immunopathogenic process is maintained by Be-specific lung CD4+ T-lymphocytes. Consistent with the disease immunopathology, these Be-specific T cells have a T-helper 1 phenotype producing interleukin-2 and interferon-gamma, the macrophage-activating cytokine driving the granulomatous reaction. Previous studies have demonstrated that the glutamic acid in position 69 of the human leukocyte antigen class II b chain is strongly associated with increased susceptibility to Be in exposed workers, suggesting that human leukocyte antigen gene markers may be used as epidemiological probes to identify population groups at higher risk.

The pathogenesis of beryllium-induced pulmonary granulomatosis. A scanning secondary ion analytical microscopy study

Chronic granulomatous pneumonitis was induced in rats with beryllium to study the pathogenesis of that disease, by identifying and localizing the beryllium in histological sections of the pulmonary tissues. This was done with scanning secondary ion mass spectrometry (SIMS). Thus, our observations suggest that the route of the Be from the site of injection into the lung, passes first by the blood, through the vascular wall and into the surrounding pulmonary tissues where Be was phagocytized by macrophages. There resulted in acute vasculitis throughout the lung. It was noted that the granuloma were focal inflammatory sites, solely observed within the vascular wall, distributed along the course of the affected vessel. These findings raise the question as to whether pulmonary granulomatous lesions of other origins are also localized within the vascular wall.

Beryllium-stimulated production of tumor necrosis factor-alpha by a mouse hybrid macrophage cell line

Chronic beryllium disease (CBD) results from exposure to the light-weight metal beryllium (Be). In vitro stimulation of bronchoalveolar lavage cells from CBD subjects causes the production of high levels of TNF-alpha, IFN-gamma and IL-6. We tested the hypothesis that Be-stimulation might induce the production of TNF-alpha by macrophage cell lines. We observed that H36.12j cells (12j), a mouse hybrid macrophage cell line, but not other mouse and human macrophage cell lines, produced TNF-alpha upon Be-stimulation. The response was maximal at 100 microM BeSO4 and did not occur when 12j cells were stimulated with either aluminum sulfate or cobalt sulfate. Beryllium-stimulated the production of 725+/-25 pg/ml (mean +/- SEM) TNF-alpha protein by 12j cells as measured by ELISA of culture supernatants after 24 h. As measured by RT-PCR, Be-stimulated 12j cell TNF-alpha protein production was accompanied by an increased intracellular TNF-alpha mRNA at 3 and 24 h. The addition of 10U or 100U of rMu-IFN-gamma to Be-stimulated 12j cells further increased TNF-alpha production 1.5-4 fold (1.6+/-0.1 ng/ml) respectively. Bacterial lipopolysaccharide (LPS, 1 microg/ml) stimulated production of TNF-alpha in 12j culture supernatants after 6 h (515+/-151 pg/ml). This early versus late TNF-alpha production suggests that LPS and Be both stimulate 12j cell TNF-alpha synthesis, but through different pathways. We report for the first time, the direct effects of Be stimulation on the ability of 12j cells to produce TNF-alpha. The 12j cell line, contrasted with other macrophage hybrids that do not respond to Be-stimulation, may provide a useful tool to evaluate the mechanisms by which Be stimulates macrophage cytokine production, and by which T cell derived IFN-gamma amplifies TNF-alpha production in granulomatous diseases.

Increased glutathione and glutathione peroxidase in lungs of individuals with chronic beryllium disease

Reactive oxygen species (ROS) are mediators of chronic tissue damage and fibrosis. Endogenous antioxidants may increase in response to oxidants and reduce tissue injury. We investigated the antioxidant response of the lungs to the chronic release of ROS, as occurs in the immune-specific granulomatous inflammation of chronic beryllium disease (CBD), and compared it with that in healthy controls and individuals exposed to cigarette smoke. The antioxidants superoxide dismutase (SOD), catalase, glutathione peroxidase (GPx), and glutathione (GSH) were quantitated in lung epithelial lining fluid (ELF) and serum from control subjects (n = 10), cigarette smokers (n = 8), and individuals with CBD (n = 9). GPx activity and extracellular GPx (eGPx) protein were increased in the ELF of subjects with CBD in comparison with that of control subjects and smokers (eGPx in ELF: controls, 1.3 +/- 0.2 microgram/ml, smokers, 1.9 +/- 0.3 microgram/ml, CBD, 3.8 +/- 0.8 microgram/ml; p = 0.002; GPx U/ml ELF, controls 1.4 +/- 0.3, smokers 1.8 +/- 0.4, CBD, 4.5 +/- 1, p = 0.02). Smokers' ELF had higher levels of GSH than that of controls, but CBD patients' ELF contained much more GSH than that of either controls or smokers (p < 0.001). Increases in GSH were correlated with eGPx, indicating similar inducing mechanisms for these antioxidants. Thus, coordinate augmentation of the glutathione antioxidant system occurs in granulomatous lung inflammation.

Expansions of T-cell subsets expressing particular T-cell receptor variable regions in chronic beryllium disease

Chronic beryllium disease (CBD) is a granulomatous disorder characterized by the presence of noncaseating granulomas and mononuclear cell inflammation, occurring in 1 to 5% of people exposed to beryllium in the workplace. In the lungs of affected patients, CD4(+) T cells accumulate. Using anti-T-cell receptor (TCR) monoclonal antibodies, we investigated the TCR beta and alpha variable (Vbeta and Valpha, respectively) repertoire in the bronchoalveolar lavage (BAL) and blood of both CBD patients and healthy controls. There was marked heterogeneity within the BAL CD4(+) T-cell repertoire in both patients and controls. However, 11 of the 28 CBD patients demonstrated 16 different T-cell subset expansions within the BAL as compared with only one expansion in ten healthy controls. Five of the 16 expansions in CBD patients expressed Vbeta3. Altered TCR expression within the BAL T-cell repertoire appeared to persist over time in patients who underwent repeat evaluation. After in vitro stimulation of BAL T cells with beryllium sulfate and interleukin-2, we noted further alteration of the BAL TCR repertoire in some individuals. These results provide additional insight into the involvement of CD4(+) T cells in this disease and form the basis for studies to examine the nature of the stimulating antigen.

Assessment of the sensitization potential of five metal salts in the murine local lymph node assay

The murine local lymph node assay (LLNA) has been proposed as a predictive test for the identification of sensitizing agents. We used this test to compare the sensitization potential of NiSO4, K2Cr2O7, CoCl2, Na2PtCl6 and BeSO4, salts of metals which have all been associated with allergic contact dermatitis and either bronchial asthma orinterstitial lung disease, by either humoral or cell-mediated allergic mechanisms. BALB/c mice (n = 3 per concentration studied, three concentrations studied per metal) received three daily applications of the metal salt (in DMSO) on the dorsum of both ears. On the fourth day the draining auricular lymph nodes were removed and the incorporation of [3H]-thymidine in the lymphocytes in culture was compared to that of concurrent vehicle-treated control mice, thus enabling to derive a stimulation index (SI), indicative of immunological sensitization potential. Each experiment was performed three times. Oxazolone and toluene diisocyanate, chosen as positive controls, yielded strongly positive SI values (> 20 and > 30 respectively). Na2PtCl6 (SI 2.6 +/- 1.0 at 2.5%), CoCl2 (SI 2.8 +/- 0.5 at 5%) and possibly also K2Cr2O7 (SI 2.1 +/- 1.2 at 0.5%) were positive in the LLNA, whereas NiSO4 (SI 0.9 +/- 0.2 at 5%) and BeSO4 (SI 1.3 +/- 0.6 at 4%) were negative. Although our results are still limited by the fact that only one mice strain was tested, they indicate that there is no strict relationship between the sensitization potential of metal salts, as evaluated in the murine LLNA, and their potential to cause either respiratory or dermal allergic disease. Consequently, caution should be exercised before proposing the murine LLNA as a valid test to predict the sensitization potential of low molecular weight chemicals.

Absence of skin sensitivity to oxides of aluminium, silicon, titanium or zirconium in patients with Crohn's disease

BACKGROUND

Some metallic compounds, especially of zirconium, can cause cell mediated granulomatous inflammation of the skin. Pigment granules containing compounds of aluminium, silicon, and titanium have been observed within macrophages in the wall of the small intestine in health and in Crohn's disease. Zirconium compounds can be ingested in toothpaste.

AIM

To determine in a pilot study if granulomatous sensitivity can be detected to compounds of these metals or silicon after injection into the skin of patients with Crohn's disease.

SUBJECTS

Eight patients with Crohn's disease known to have had granulomata in the intestine and not currently treated with corticosteroids, and two healthy controls.

METHOD

Two intradermal injections each of 0.1 ml of a 0.02% suspension of one of the compounds made in the abdominal wall of each subject. The site was marked and full thickness skin biopsy performed six weeks later.

RESULT

A foreign body granuloma was observed on histological examination of two biopsy specimens but no evidence of a cell mediated response in any subject.

CONCLUSION

No support was found for the hypothesis that Crohn's disease is due to a specific sensitivity to ingested metallic or silicon compounds.

Respiratory allergy: Clinical aspects

Human expression of pulmonary disease after exposure to chemicals is highly dependent on the locale and circumstances of the exposure. Most of the information about environmental hazards that is currently available has been obtained from epidemiological investigations. Chemical agents in the workplace have received considerable attention because the workplace is an ideal mini-epidemiological model of air pollution. Many instances of pulmonary immunotoxicology are engendered by adverse reactions to drugs but of necessity these can only be studied on a case-by-case basis. Although the overall expression of pathological processes in the anatomical structures of the respiratory system is limited, many of the clinicopathological features induced by chemicals present with features that are characteristic enough to suggest that several stimulus-response paradigms may be applicable. In this review the immunotoxicological impact of chemicals on the major anatomical components of the lung (the conducting airways, the alveolar, interstitial and capillary compartments, the pleura and the pulmonary vasculature) is considered. The two major classes of hypersensitivity induced in humans by chemicals are those involving IgE humoral and cell-mediated immune responses. Although other isotypic antibodies (IgM, IgG, IgA), as well as complement activation, have been demonstrated after specific types of exposure, the role of these immune components in the pathogenesis of disease does not appear to be of major importance. Chemicals with a special propensity for IgE sensitization and effects on the airways include polyisocyanates, acid anhydrides and platinum salts. Conditions that involve the lung parenchyma are exemplified by hypersensitivity pneumonitis, drug-induced pneumonia and berylliosis.

Contact sensitization assays in guinea-pigs: are they predictive of the potential for systemic allergic reactions?

Guinea-pig assays have been used extensively to detect contact sensitizers. In contrast, almost no reliable assays are available to detect the potential for low-molecular-weight drugs and chemicals to induce systemic allergic reactions in humans. Based on clinical data, and, to some extent, on recent immunological findings, it is proposed that guinea-pig assays can predict the hazard for systemic allergic reactions in man. Seventy drugs and chemicals were compared from published results in guinea-pig assays and in the clinic. A close correlation was found with 43 substances and a relatively good one with 16 substances. Conflicting results were found with 11 substances only. However, substances known to induce systemic allergic reactions in man were all detected as weak sensitizers, at least in guinea-pigs. Guinea-pig contact sensitization assays may therefore prove useful until more suitable and specific assays are available to predict the risk for systemic allergic reactions.

HLA-DPB1 glutamate 69: a genetic marker of beryllium disease

Chronic beryllium disease (CBD) is a lung disorder related to beryllium exposure and is characterized by the accumulation in the lung of beryllium-specific CD4+ major histocompatibility complex (MHC) class II-restricted T lymphocytes. Evaluation of MHC class II genes in 33 CBD cases and 44 controls has shown a negative association with HLA-DPB1*0401 (P < 0.001) and a positive association with HLA-DPB1*0201 (P < 0.05) alleles, which differ at residues 36, 55 to 56, and 69 of the beta 1 chain. Among CBD cases, 97 percent expressed the HLA-DPB1*0201-associated glutamic acid (unaffected population, 30 percent; P < 0.001) at residue 69, a position involved in susceptibility to autoimmune disorders. This suggests that HLA-DP has a role in conferring susceptibility and that residue 69 of HLA-DPB1 could be used in risk assessment for CBD.

Lung diseases in the tropics. Part 1: Tropical granulomatous disorders of the lung: diagnosis and management

International travel, student and cultural exchanges and changing immigration patterns are insidiously transforming the face of medicine in the United States, Europe and other developed countries. It is essential that the practising clinician be aware of the increasing prevalence of various new and exotic tropical lung diseases. The definitive diagnosis of the pulmonary granulomas that constitute the bulk of lung disorders in the tropics is important since the treatment varies significantly. At the same time, recent developments in molecular biology, immunology and biochemistry have increased the diagnostic accuracy and therapeutic effectiveness related to tropical granulomatous disorders. Clinicians in the developing countries can now supplement their clinical acumen with rapid advances in immunology and histopathology enabling them to grasp the fundamental mechanisms of granuloma formation. Mycobacterial, fungal, parasitic, spirochetal and other infections must be differentiated from a variety of non-infectious granulomas including sarcoidosis, hypersensitivity pneumonitis, drug reaction and generalized vasculitis since therapy is vastly different. The treatment, if inappropriate, may not only be worthless but, in many cases, extremely harmful and even fatal.

Chronic beryllium disease in a dental laboratory technician

Workers involved in the manufacture of dental prostheses are exposed to a number of potentially harmful substances capable of inducing lung disease. In this report, we describe a dental laboratory technician who developed chronic beryllium disease as a result of exposure in the workplace. The diagnosis of chronic beryllium disease was suspected from the clinical, radiographic, and histologic features and confirmed by the in vitro proliferation of lung lymphocytes to beryllium salts. The potential risks of beryllium use in the dental industry have been recognized for some time, but this is the first documentation of chronic beryllium disease in this population of workers. Since chronic beryllium disease may be easily confused with sarcoidosis, awareness of this occupational association is essential in preventing misdiagnosis and in providing appropriate management.

Nonoccupational beryllium disease masquerading as sarcoidosis: identification by blood lymphocyte proliferative response to beryllium

Chronic granulomatous lung disease caused by industrial exposure to beryllium continues to occur, but no community cases have been reported in more than 30 yr. With the advent of a blood screening test that detects beryllium sensitization, physicians can discriminate chronic beryllium disease from sarcoidosis. A 56-yr-old woman in whom sarcoidosis was diagnosed had an unremarkable occupational history, but her husband was a beryllium production worker. Blood and bronchoalveolar lavage lymphocyte transformation tests, measuring the beryllium-specific cellular immune response, were abnormal, confirming a diagnosis of chronic beryllium disease. Chronic beryllium disease continues to occur in the nonoccupational setting and among bystanders in industry, masquerading as sarcoidosis. Because even transient or possibly low levels of exposure may cause disease, this case has important implications for how clinicians, industry, and government agencies define the populations at risk of chronic beryllium disease.