Immunology is the branch of biomedical science focused on studying the immune system's structure, function, and disorders. It covers how the body defends itself against infections (bacteria, viruses) and cancer, utilizing both innate (general) and adaptive (specific) responses. It also addresses allergies, autoimmunity, and transplant rejection. 

This page describes the monitoring that can occur in primary care and when a referral to secondary care is appropriate, as well as how best to refer.  Clinical judgement is always beneficial, and Advice and Guidance is always recommended and available prior to any referral.  

The Immunology Department at Castle Hill Hospital provide: 

• A general immunology clinic for autoimmune conditions, immunodeficiencies and hereditary angioedema 
• Hospital-based immunoglobulin replacement therapy for patients with antibody deficiency 
• Home immunoglobulin therapy training for patients with a diagnosed antibody deficiency who wish to self-administer treatment

Absent immunoglobulins or undetectable (all isotypes) – discuss if in-patient for sepsis, requiring immediate immunoglobulin replacement therapy

Asplenia is the absence of normal splenic function, either through surgical removal (splenectomy), trauma, or congenital causes, leading to high risks of overwhelming infections (OPSI) from encapsulated bacteria. It requires lifelong vigilance, including specialized vaccinations (pneumococcal, Hib, Meningococcal) and prophylactic antibiotics to prevent rapid, severe illness.GP practices should maintain their own practice register of asplenia patients for annual follow-up. 

Guidelines for the management of asplenia are available from the Department. Or Information for patients with an absent or dysfunctional spleen - GOV.UK  

Recurrent ‘shingles’ is very rare in the absence of severe and obvious immunodeficiency (e.g. lymphoma, leukaemia, AIDS, chemotherapy) and the usual cause of recurrent lesions similar to shingles (VZV) is actually recurrent Herpes simplex infection.  Treat with oral acyclovir (not topical). If episodes are very frequent, consider prophylaxis with acyclovir 200mg bd for 6 months. 

Recurrent boils/abscesses: most are due to staphylococcal carriage or local disease (hidradenitis suppurativa). Rarely may be due to neutrophil or antibody deficiency. Check blood glucose, TFTs and nasal swabs for staphylococci. The Department has a regime for decontamination of staphylococcal carriers 

Refer only those carriers who fail decontamination. 

Hypogammaglobulinemia 

The differential diagnosis of hypogammaglobulinemia (low antibodies) may include lymphoproliferative condition, protein loss through the gastrointestinal or renal tracts but more often drug-induced (including systemic and high-dose inhaled steroids) suppression of antibody production. Borderline low immunoglobulins are also common in old age, and this is thought to reflect immunological senescence. 

In the absence of any recurrent, severe or unusual infections no investigations in the Immunology Clinic or long-term monitoring of immunoglobulin levels would be recommended. 

Action to take:  

1. please consider reviewing the patient in the GP surgery to assess for clinical signs which may be associated with lymphoproliferative condition or protein loss.  
2. if there is a clinical suspicion of B cell malignancy; please refer to Clinical Haematology. 

Hypergammaglobulinemia  

The differential diagnosis of polyclonal gammopathy or polyclonal hypergammaglobulinemia (high antibodies) may include chronic infections (bacterial, viral, malaria), liver diseases, autoimmune disorders (rheumatoid arthritis, SLE etc). 

In the absence of any recurrent, severe or unusual infections no investigations in the Immunology Clinic or long-term monitoring of immunoglobulin levels would be recommended.

Action to take:  

1. please consider reviewing the patient in the GP surgery to assess for clinical signs which may be associated with lymphoproliferative condition or protein loss.  
2. if there is a clinical suspicion of B cell malignancy; please refer to Clinical Haematology. 

Hypergammaglobulinemia  

The differential diagnosis of polyclonal gammopathy or polyclonal hypergammaglobulinemia (high antibodies) may include chronic infections (bacterial, viral, malaria), liver diseases, autoimmune disorders (rheumatoid arthritis, SLE etc). 

In the absence of any recurrent, severe or unusual infections no investigations in the Immunology Clinic or long-term monitoring of immunoglobulin levels would be recommended. 

Action to take:  

1. please consider reviewing the patient in the GP surgery to assess for clinical signs which may be associated with infections, or autoimmunity.  
2. please send a urine sample to check for Bence Jones protein. 

DO NOT REFER

• Recurrent minor viral infections will not be due to immunodeficiency and referral is not necessary: exclude (recent or ongoing) stress, inadequate diet, iron deficiency. 
• Patients with selective IgA deficiency do not need referral unless there is a history of severe infections, allergies or autoimmune disorders - please see Information on referrals for suspected mast cell activation syndrome (MCAS) regarding this.   
• The Immunology clinic does not see patients with chronic fatigue syndrome/ myalgic encephalitis / non-clonal mast cell disorders (MCAS) 
• Referral is for Immunodeficiency disorders including hereditary angioedema (C1-inhibitor deficiency) and suspected periodic fevers.   

The Department will see  

• suspected vasculitis 
• complex autoimmunity and CTD especially where there are unusual immunological features (e.g., multiple autoimmune diseases with enteropathy & low antibody levels) 
• asplenia patients who fail to respond to recommended vaccines or who cannot or will not tolerate continuous antibiotics 
• those with congenital asplenia 
• patients with deep-seated organ abscesses (liver, brain). 

Recurrent Major infection 

Please refer any of the following: 

• 2 major infections in 12 months (major = requires hospital admission). 
• 1 major + 2 minor (minor = microbiologically proven and needs oral antibiotic) in 12 months. 
• Second episode of bacterial meningitis ever. 
• Infections (major or minor) in relative of patient with known primary immunodeficiency. 
• Patients with unexplained bronchiectasis and/or sinusitis. 
• Suspected secondary immunodeficiency: e.g., CLL on treatment, vasculitis previously treated with Rituximab etc 

Referrals should be completed by a Health care professional via the NHS e-Referrals Service (ERS).  Advice and Guidance (A&G) is also available as a first contact if required. 

Guidance on using the advice and guidance element of ERS is available below 

• Enhanced advice and guidance overview 
• Managing advice and guidance requests 

The service is listed as Immunology and Allergy under Hull University Teaching Hospitals NHS Trust (RWA) and choose either A&G or referrals.  An A&G can also be revised to a referral following discussion with the Immunologist through the system, so please ensure that option is available.  

For a routine referral, please send a referral letter, including patient details (name, address, DoB, NHS number, history and reason for referral, including background and any medications) and the practice details through NHS eRS to Immunology and Allergy.     

Patients will be contacted to arrange appointments by the Trust and information on and following the appointment will be confirmed with the patient and their GP.

Information on referrals for suspected mast cell activation syndrome

Guidance_Staphylococcal Decontamination

• Hull University Teaching Hospitals