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Since the presentation and publication of our report numerous verbal reports have been received of persons with apparent hypersensitivity to pancreatin powder. The condition is evidently not rare and should be suspected in patients with cystic fibrosis as well as relatives exposed to these enzymes. Dr. Abernathy's letter raises the issue of the value and limitations of scratch and intradermal testing as an aid for identifying a causative allergen. Our reluctance to rely on a skin test in the diagnosis of pancreatin hypersensitivity in our patient was not limited to concern about anaphylaxis.

Allergic Bronchopulmonary Aspergillosis (ABPA) is not rare. A diagnosis of "clinically probable ARPA" should be suspected in asthmatics who are not well controlled on adequate bronchodilators, who are steroid dependent or who have recurrent pulmonary infiltrates, and who also have a positive skin test with a separate aspergillus extract. Suspicion should also stimulate pursuit of this diagnosis in asthmatics with a total eosinophil count over 500 cellsl mm 3 or a total serum IgE level over 1,000 IUlm!. Early detection in office practice is feasible, practical, and may be critical to avoidance of permanent pulmonary damage. Allergic BronchopulmonaryAspergillosis (ABPA) was first described by Hinson, Moon, and Plummer I in Great Britain in 1952 and subsequently further characterized by McCarthy and Pepys.2.3 A marked peripheral eosinophilia is a hallmark of the disease and should serve to raise one's index of suspicioQ for making the diagnosis.Patterson and co-workers described the first case of ABPA in the U.S. in 1968,4 a full 16 years after it was NER Allergy Proc.described in Britain and the condition was then considered to be a rarity in this country. The first two cases of ABPA were recognized in New England in 1972. We would like to describe complications sustained by one of our two original patients and summarize clinical data on an additional eight patients identified in an office practice. It is suggested that ABPA is not rare and an increased number of cases may be found if actively sought in allergy practice, Case Report: A.P., a 29 year old man, had asthma since the age of 2 years. ABPA was diagnosed at the age of 17 years on the basis of the following: The presence of asthma and peripheral eosinophilia, a strongly positive prick and intradermal immediate IgE skin test with Aspergillus fumigatus extract, an arthus skin reaction 6 hours after skin testing with the same extract, positive precipitating antibodies to aspergillus, recurrent pulmonary infiltrates, central bronchiectasis with a normal distal bronchial tree, and the demonstration of Aspergillus hyphae in a mucus plug obtained at bronchoscopy. A bronchial challenge with Aspergillus f. extract demonstrated a dual obstructive airways response, an elevation of the patient's temperature and rises in the total WBC and eosinophil count accompanying the late response. Steroid therapy was instituted and gradually tapered over an 18 month period. Chest X-rays demonstrated complete clearing of all pulmonary infiltrates, and the patient enjoyed a 7 year remission during which he was free of asthma and off all medications. In May of 1981, he presented with frank hemoptysis. He complained of mild symptoms of asthma, headache, 367

A 25-year-old woman with obstructive, reversible pulmonary and nasal hypersensitivity apparently induced by casual, repeated inhalation of pancreatin powder (desiccated pork pancreas) is described. The powder was being employed as a dietary supplement for the patient's son, diagnosed as having cystic fibrosis. Two challenges of the patient by reproducing home use of the powder resulted in repetition of a hypersensitivity symptom complex on both occasions. Vitalometry demonstrated an immediate and late response. Avoidance of pancreatin powder exposure resulted in subsidence of symptoms. Immunologic mechanisms are suggested but not proven.

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