Weapons of Mass Destruction (WMD)

House of Representatives - Committee on the Judiciary

Hearing Regarding Compensation for Chronic Beryllium Disease

21 September 2000

My name is Lawrence Repsher. I am a pulmonary physician, who has specialized in environmental and occupational lung disease for 26 years. My curriculum vitae has already been supplied. I have diagnosed and treated patients with chronic beryllium disease or CBD since 1974. I have followed the clinical course of two patients for over 30 years and several patients for more than 25 years. I have either seen in person or have reviewed extensive records of approximately 150 patients, who have some form of CBD. This experience has given me an unusual degree of insight with regard to the diagnosis, clinical course, prognosis, and potential response to therapy of patients with CBD. I will deal with these aspects of CBD in order during the rest of my presentation.

It is important to distinguish three conditions: beryllium sensitization, subclinical CBD, and clinical CBD. Beryllium sensitization indicates that the patient has only a positive lymphocyte proliferation test (LPT), but no symptoms or evidence of functional impairment and no evidence of granulomas on lung biopsy. Subclinical CBD means that there are granulomas in addition to a positive LPT, but no symptoms or impairment. A diagnosis of clinical CBD requires positive LPT, granulomas on lung biopsy, and respiratory symptoms, along with evidence of pulmonary impairment.

There has been some suggestion that there has been a marked increase in the number of patients diagnosed with CBD since the early '90s. However, the vast majority of the recent cases since the early '90s have either been workers with beryllium sensitization or subclinical CBD and not true clinical CBD. There has probably been no actual increase in the number of true clinical CBD cases, because the apparent increase has consisted primarily of workers and other potentially exposed individuals, who have been identified through screening programs, utilizing the now reasonably sensitive and reasonably consistent LPT. Prior to this time patients with CBD were identified primarily because of symptoms or abnormal screening x-rays and/or pulmonary function tests; that is, only those patients with clinical CBD. Attachment A summarizes these three conditions, how they are diagnosed, and the advances in medical diagnostic technology that made the detection of subclinical CBD and beryllium sensitization possible.

It is true that some workers and other exposed individuals did become seriously ill and even die from CBD as a result of the very heavy exposures to beryllium prior to 1950. However, my experience with CBD patients, who were exposed at Coors Porcelain Co. during the '60s and early '70s and the Rocky Flats nuclear weapons plant beginning in the late '50s, has not been so pessimistic. Indeed, although I have had patients die with CBD, I have not had any patients die of CBD. Further, it has been my experience that only a few patients will progressively deteriorate. Rather, the vast majority will present with a wide range of physiologic impairment that remains stable. Finally, although there may be a modest initial improvement of function with steroid therapy, this is usually not maintained. However, pulmonary function will generally remain stable, regardless of therapy.

Having some form of CBD does not protect one from developing other lung and/or heart diseases, which can cause or contribute to shortness of breath and other chest symptoms and may ultimately even cause death. Thus, the evaluation of individual patients must take into account these comorbid conditions.

There are especial difficulties in diagnosing beryllium sensitization. Despite the significant improvements in the LPT, it remains a biologic test, subject to all the potential vagaries of any biologic test. Potential problems include minor variations in testing protocol and varying viability of the lymphocytes, as well as possible comorbid conditions. These have resulted in the well documented frequent discrepancies between laboratories and even between sequential tests in the same laboratory, which is summarized in the article by Deubner, et al. in Attachment B. Thus, it has generally been accepted that one must have two clearly positive LPT's to reliably diagnose beryllium sensitization.