Attention: This bulletin has been superseded and is inactive.
EEOICPA BULLETIN NO. 02-17
Subject: New interpretation in the use of the Bronchoalveolar Lavage Beryllium Lymphocyte Proliferation Test (BAL BeLPT) in diagnosing chronic beryllium disease (CBD).
Background: To establish eligibility for benefits under the EEOICPA for diagnoses of CBD confirmed on or after January 1, 1993, the covered employee must first prove sensitization with a positive beryllium lymphocyte proliferation test (BeLPT) performed on either blood or lung lavage cells. Secondly, the covered employee must provide lung pathology consistent with CBD that includes one of the following:
(a) A lung biopsy showing granulomas, or a lymphocytic process consistent with CBD;
(b) A computerized axial tomography (CAT) scan showing changes consistent with CBD;
(c) Pulmonary function or exercise testing showing pulmonary deficits consistent with CBD.
Guidance on interpreting a lung biopsy showing granulomas, or a lymphocytic process consistent with CBD was obtained through a consult with Dr. Lee Newman of the National Jewish Medical and Research Center. Dr. Newman explained that a lymphocytic process consistent with CBD can be measured in the lungs by any one of the following methods: (1) biopsies showing lymphocytes (part of the population of so called mononuclear cells) in bronchial or interstitial (alveolar) lung tissue; (2) biopsies showing the non-caseating granuloma; (3) bronchoalveolar lavage (BAL) showing an increase in the percentage of lymphocytes in the differential cell count (typically >10% lymphocytes is considered a BAL lymphocytosis); (4) BAL Beryllium Lymphocyte Proliferation Test (BeLPT) showing that the lymphocytes washed from the lungs show a pathologic ability to respond to beryllium salts.
Dr. Newman interpreted the term lung biopsy as any sampling of lung tissue. He indicated that acceptable lung tissue samples directly indicative of lung pathology may include any one of the following:
(a) Lung tissue obtained from whole lung specimens at the time of autopsy;
(b) Lung tissue obtained by open or video-assisted thoracotomy;
(c) Lung tissue obtained by bronchoscopic transbronchial biopsy;
(d) Lung tissue obtained by bronchoalveolar lavage (which includes alveolar and bronchial epithelial cells, macrophages, lymphocytes, neutrophils, eosinophils, and other lung cells).
Tissue samples obtained by any one of these methods can be used to document a lymphocytic process consistent with CBD.
Reference EEOICPA: EEOICPA Section 7384l(13)(A)
Purpose: To notify the office of procedures for handling certain claims for CBD.
Applicability: All staff.
1. CE’s should review all incoming and pending cases for CBD for evidence of a BAL and/or BAL BeLPT consistent with a lymphocytic process consistent with CBD.
2. The file must contain a narrative report from a physician that contains an evaluation of the BAL BeLPT and a discussion of how it relates to CBD. This is especially important when the BAL BeLPT is the only test used in the diagnosis.
3. The Blood Lymphocyte Proliferation Test (BeLPT) is defined as a laboratory test that examines how a type of disease-fighting blood cell called a lymphocyte reacts to beryllium. The blood cells’ reaction to beryllium determines whether the test results are normal or abnormal. If the cells do not react very strongly to beryllium, the test is normal. If the cells react very strongly, the test is abnormal.
The Bronchoalveolar Lavage Beryllium Lymphocyte Proliferation Test (BAL BeLPT) is defined as a laboratory test performed on lung tissue that is washed from the lungs. The lung wash contains lung tissue that is obtained via intranasal insertion of a bronchoscope into the lung. When the bronchoscope is lowered into the lower lung, a saline solution is washed into the airways and retrieved (lung washing). The retrieved solution is cultured in the presence of beryllium salts. A reaction/response to the beryllium salts represents a lymphocytic process.
An abnormal BeLPT test performed on either blood or lung lavage cells and lung tissue obtained through a positive BAL BeLPT showing a lymphocytic process and established by a physician as being consistent with CBD, are sufficient to support the diagnosis of CBD. The CE may not use a positive BAL BeLPT solely to support a claim for CBD on or after January 1, 1993.
4. In claims that contain a normal or borderline LPT and the lung tissue biopsy confirms the presence of granulomas consistent with CBD, the CE may accept the claim for CBD. The lung biopsy is considered the “gold standard.” However, the following steps must be followed before accepting a claim in this manner.
(1) If the claimant is living, the CE should contact the treating physician and obtain a detailed narrative report detailing the past history of the claimant’s LPT results (if possible). Specifically, the physician should address whether the claimant has a past history of positive LPT’s with recent normal or borderline LPT results. The CE should note that if the claimant has a history of steroid use, this may cause a false negative on the LPT result.
(2) If the claimant is deceased, the CE should try to obtain as much information as possible on past LPT results and possible steroid use. If exhaustive efforts produce little or no results and the claim contains the normal/borderline LPT result along with a biopsy of the lung tissue showing the presence of granulomas, the CE may accept the claim.
(3) If there is no LPT and the lung tissue biopsy confirm the presence of granulomas consistent with CBD, the CE may accept the claim.
In these instances, the tissue evidence must be very obvious and the recommended decision must address all the statutory requirements for CBD claims in a well-reasoned manner. (i.e. LPT negative due to steroid medication giving a “false negative”).
Disposition: Retain until incorporated into the Procedure Manual.
Peter M. Turcic
Director, Division of Energy Employees
Occupational Illness Compensation
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