A 14-year-old daughter of a dental technician has a cough, is wheezing, and has a low-grade fever.

The patient has developed a troublesome cough and sometimes at night cannot catch her breath. Her cough has recently worsened, with an increase in sputum production and chest discomfort. Last night she had a particularly rough time, but she had no wheezing or fever. Chart review reveals no known history of asthma or allergies. The patient's height and weight are appropriate for her age. Her two siblings, aged 6 and 12 years, are in good health. History of previous illness reveals three episodes of otitis media as a young child, but no other significant illness. She has no history of eczema or food intolerance.

In response to your questions, the mother tells you that her husband, a dental technician, has been diagnosed with sarcoidosis. He recently had flu-like symptoms similar to those of his daughter, including fatigue, nasal congestion, sneezing, and cough. Although her husband, who smokes cigarettes, has had a cough for several years, the mother states that her daughter developed symptoms a few days after her husband's latest bout. She wonders if her husband's sarcoidosis could have been transmitted to their daughter.

Examination reveals a cheerful girl in no acute distress. Her temperature today is 100ºF, respiratory rate is 24 breaths per minute, without retractions or audible wheezing, and her pulse is 90 beats per minute and regular. Significant findings include a mildly inflamed pharynx and anterior cervical lymph nodes that are slightly enlarged and mildly tender. Tympanic membranes are clear. Auscultation of the lungs reveals mild and diffuse expiratory wheezing with occasional rhonchi. Results of cardiac and abdominal examinations are normal. Chest radiograph shows minimal peribronchial thickening, but it is otherwise normal.

1. Construct a problem list and a differential diagnosis for the daughter.
2. What further questions might you ask about the father?
3. What is the most likely diagnosis for the daughter?
4. Could the father pass beryllium to other family members by contact or by coughing or sneezing?
5. What organ systems should be evaluated if beryllium exposure is suspected?
6. What steps would you take to evaluate the condition of the daughter in the case study?
7. What steps will be necessary to evaluate her father's condition?
8. The father's blood beryllium lymphocyte proliferation test (BeLPT) test was abnormal. It was repeated and was again abnormal, consistent with beryllium sensitization. What is appropriate treatment of the father's condition?

1. The patient's problem list includes productive cough, wheeze, and low-grade fever. The most likely causes to consider for this patient's condition are reactive airway disease, asthma, an infectious process (viral or bacterial bronchitis, sinusitis, or pneumonia), and chemical irritation (cigarette smoke or air pollution). Considerations in younger patients might also include bronchiectasis, congenital abnormalities, foreign-body aspiration, and cystic fibrosis.

   The information for this answer comes from section “How Should Patients Exposed to Beryllium Be Evaluated?”

2. Initially, you would want to know the father's general state of health, his full work history, smoking habits, and history of respiratory problems. You may also wish to explore his hobbies and home environment. As a dental laboratory technician, the father may be at risk of exposure to beryllium (during casting and grinding of alloys used in dental prostheses), as well as to mercury (during mixing of dental amalgams). Chronic cough is a common symptom of chronic beryllium disease, which can be misdiagnosed as sarcoidosis unless an immunological test specific to beryllium sensitization is used.

   The information for this answer comes from section “How Should Patients Exposed to Beryllium Be Evaluated?”

3. Asthma or bronchitis would both be high on your list. Wheezing, if present, could be a complication of bronchitis, or it could be a new onset of asthma triggered by infection or exacerbated by smoke from her father's cigarettes. Workers who cast or grind beryllium can bring the dust home on their hair, skin, and clothes, from which members of their households may be exposed. Such exposed household members have developed chronic beryllium disease. Based on her acute signs and symptoms, it is unlikely that the patient has a beryllium-related disease. However, if she visits her father's workplace, or if he does not change work clothes before leaving the workplace, she should be considered at risk

   The information for this answer comes from section “How Should Patients Exposed to Beryllium Be Evaluated?”

4. No evidence suggests that beryllium sensitization or disease can be passed on by body fluids, coughing, or sneezing. However, beryllium exposure of family members can occur via contaminated clothes. To ensure that beryllium is not brought home from the workplace through beryllium-contaminated clothes and skin, you should discuss with the father proper workplace hygiene, including changing clothes and showering before leaving the workplace

   The information for this answer comes from section “Who Is At Risk of Beryllium Exposure?”

5. Chronic beryllium disease manifests mainly in the lungs as a granulomatous interstitial pneumonitis. The skin should also be evaluated because beryllium can lead to dermatitis, ulceration, granuloma formation, and poor wound healing

   The information for this answer comes from section “What Other Tests Can Assist With Diagnosis of Beryllium-Related Disease?”

6. For the daughter, initial evaluation should include a careful history, thorough physical examination, and a chest radiograph. The history suggests the presence of an infectious process or asthma. Screening blood work or peak flow rates might be considered at this time, depending on the severity of symptoms. If her respiratory symptoms become chronic, she should be re-evaluated and possibly referred to a specialist. A blood BeLPT might be considered if you highly suspect beryllium exposure.

   The information for this answer comes from section “How Should Patients Exposed to Beryllium Be Evaluated?”

7. Due to proven beryllium exposure, the father is a candidate for a more complete evaluation for beryllium toxicity. Referral to a pulmonologist familiar with the workup of chronic beryllium disease would be appropriate at this time. An abnormal BeLPT would indicate a good likelihood that his pulmonary abnormalities are due to beryllium exposure

   The information for this answer comes from section “How Should Patients Exposed to Beryllium Be Evaluated?”

8. The father has beryllium sensitization based on two abnormal blood Beryllium Lymphocyte Proliferation Tests. The first therapeutic effort should be to remove him from further exposure to beryllium. Another important step for symptom relief may be to help the patient stop smoking.

   Bronchoscopy with bronchoalveolar lavage and biopsy may be performed by the pulmonologists to establish a diagnosis of chronic beryllium disease. The following baseline tests are often performed:

   • chest radiograph,
   • pulmonary function tests,
   • carbon monoxide diffusion, and
   • exercise physiology with arterial blood gases.

   The patient's health should be followed on a regular basis to monitor declines in physiology and development of symptoms.

   If appropriate, corticosteroid therapy may be instituted by the pulmonary physician managing this patient. The father should be re-evaluated periodically to assess his response to corticosteroids, and to taper the dose to the minimum needed to control symptoms and maintain physiologic improvement. He should also be monitored for potential long-term steroid side effects.

   Because the father may represent a sentinel case, the local health department should be notified. To prevent further exposures, the patient's workplace should be evaluated. Notification of the Occupational Safety and Health Administration or a patient request for a National Institute for Occupational Safety and Health (NIOSH) health hazard evaluation may be warranted.

   The information for this answer comes from section “How Should Patients Exposed to Beryllium Be Treated?”