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Editor,—Caffarelli et alcomment on several immunological mechanisms by which gastrointestinal symptoms could occur in asthma.1 They do not comment on whether they excluded cystic fibrosis (CF). This is relevant as there are an increasing number of mild phenotypes of CF presenting as asthma.2 CF could be a unifying diagnosis in the “asthmatic” with gastrointestinal symptoms.
The important clinical message is to consider a diagnosis of CF in difficult cases of asthma.
Drs Caffarelli and Atherton comment:
We appreciate the comments made by Dr Furness, and we would certainly concur with his view that one must consider a diagnosis of CF in any child presenting with the combination of asthma and gastrointestinal symptoms.
We accept that a diagnosis of CF may not always be obvious on clinical criteria alone, but it remains the case that there is no simple cheap screening test for CF, and we must therefore continue to test only those children in whom there is at least some clinical basis for suspecting this diagnosis. We believe that we did adequately consider CF in the children that participated in our study according to clinical criteria, but sweat testing was not undertaken routinely, nor did we screen for CF mutations. While it is possible that we may have missed a child in whom the combination of asthma and respiratory symptoms was due to CF, we consider it exceedingly improbable that such omission would have substantially prejudiced our results.
The finding that gastrointestinal symptoms, for most of which there was no simple explanation, are common both in children with atopic eczema and in children with asthma, suggests that these symptoms are a reflection of the patients' atopic status itself, and undiagnosed CF is unlikely to be a significant contributory factor. Neither do we believe that these symptoms can merely be dismissed as being due to food allergy, any more than one could dismiss either atopic eczema or asthma themselves as being caused exclusively by food allergies. The precise aetiologies of these conditions remain to be clarified.