Clinical Immunology and Allergy – Referral guidance

We also include guidance on the information to be included in referrals and management advice that can be progressed with in the community for some common presentations.

All referrals into our service must come from an NHS GP or specialist. Primary care referrals can only be accepted if sent by the NHS e-Referral system. Secondary care referrals can be sent by post, email (clinical.immunology@mft.nhs.uk) and all internal MFT referrals need to be submitted as an order in HIVE to “Outpatient Referral to Immunology – Adult Immunology”.

Clinical enquiries and queries can be sent by email also (the above address) from health care professionals. Please remember to seek patient consent if sending patient identifiable information.

Immunology

We offer a clinical service for primary and secondary immunodeficiency (not HIV) and hereditary or acquired angioedema.

We do not provide a clinical service for autoimmune or autoinflammatory diseases, but we would be able to discuss these cases with the GP or specialist to provide advice and guidance.

Immunodeficiency

Any referrals for suspected immunodeficiency should include details about the infections, including frequency, treatment response and microbiology results. We have an infection diary that can be used to record the details that help with referral triage. Ideally referrals should be accompanied by an infection diary. The warning signs of immunodeficiency in adults are listed below:

• Clinical features suggestive of immunodeficiency
• Four or more new ear infections within 1 year
• Two or more serious sinus infections within 1 year
• Two or more months on antibiotics with little effect
• Two or more pneumonias within 1 year
• Failure of an infant to gain weight or grow normally
• Recurrent, deep skin or organ abscesses
• Persistent thrush in mouth or elsewhere on skin
• Need for intravenous antibiotics to clear infections
• Two or more deep-seated infections
• A family history of primary immune deficiency

It is also useful to know in the referral if underlying causes for immunodeficiency have been considered and the relevant history, examination findings and investigation results to exclude these causes. The common causes for secondary immunodeficiency include:

• Medications
  • Immunosuppression including steroids
  • Anticonvulsants
  • Antipsychotics
• Haematological disease for example
  • MGUS
  • Myeloma
  • CLL
• Increased losses of antibody proteins for example
  • Proteinuria
  • Diarrhoea / malabsorption

Hereditary or acquired angioedema

Any referrals for suspected hereditary or acquired angioedema should include details on any relevant family history and describe the frequency and severity of events of swelling. It is important to note that urticaria is NOT a feature in patients with hereditary or acquired angioedema. Drug therapy should also be reviewed and any ACE inhibitors should be stopped / replaced with an alternative in all patients with angioedema of any cause. It is required to send a blood sample for complement C4 and C1 inhibitor levels prior to referral (unless there is a family history) and include the results in the referral. Please see later section on urticaria and angioedema also.

Allergy

We offer a clinical service for the diagnosis and management of various allergic conditions. We mainly focus on type I hypersensitivity (immediate hypersensitivity). Type I hypersensitivity is a very well described condition in which an individual will experience immediate (generally within an hour) onset symptoms (including but not limited to itching, urticaria, angioedema, difficulty breathing, hypotension, vomiting, diarrhoea) on exposure to the relevant allergen trigger. The symptoms only occur on exposure to the trigger, and if the trigger is avoided the symptoms do not occur. We have a diary that can help with collecting the appropriate clinical information to support a referral, and we would prefer if the diary accompanies any referrals.

We do not provide a clinical service for delayed contact hypersensitivity, intolerance, mast cell activation, but we would be able to discuss these cases with the GP or specialist to provide advice and guidance.

Food, drug, venom and latex allergy

In patients with suspected type I hypersensitivity to food, drug, venom or latex we can undertake diagnostic allergy testing and provide comprehensive allergy management planning including self injectable adrenaline training and desensitisation where required/applicable. It is important that any referrals are accompanied by a completed diary or equivalent clinical information to allow appropriate triage. We have additional information on suspected food allergy .

Please also consider the NICE guidance on drug allergy prior to any referral.

Referrals for anaesthetic anaphylaxis assessment should be sent to Dr Andrew Parkes (Department of Anaesthesia, Manchester Royal Infirmary) and should be made using the NAP6 referral form found on the NAP6 website. We provide a weekly joint Anaesthetic Reaction Clinic with Dr Parkes. The ARC is one of the longest standing joint clinics of its kind. For further information on the anaesthetic anaphylaxis service please contact the Department of Anaesthesia on 0161 901 1493.

Respiratory allergy

In patients with suspected respiratory allergy (mainly allergic rhinitis but we can also advise on atopic asthma, but not on the management of asthma itself), we can consider desensitisation therapy if the symptoms are refractory to medical management and there is evidence of appropriate allergic sensitisation. Before referral medical management should be trialled and there should be blood investigations for respiratory allergens. Please see linked guidance. We also have a symptom severity survey patients can complete while on appropriate medical therapy. It would be ideal to include a completed survey with any referrals where the patient has remained symptomatic despite therapy and has detectable allergic sensitisation. In the case of sensitisation to house dust mite we will often recommend an ENT review prior to assessment in the allergy clinic.

Urticaria and angioedema

We do not see patients routinely for spontaneous urticaria and angioedema in the MRI clinic. Please consider following the linked guidance. If patients do not respond to the measures in the guidance please do refer the patient to a specialist urticaria service such as that based in the Allergy Centre at Wythenshawe, or the Dermatology or Immunology service in Salford Royal. Please note the linked guidance also includes angioedema and ACE inhibitor related angioedema guidance. In patients with isolated angioedema a blood sample for complement C4 and C1 inhibitor levels should be sent prior to referral; please include the results in the referral. Please see earlier section on hereditary and acquired angioedema also.

Anaphylaxis

All cases of suspected anaphylaxis should be referred to an allergy service in line with the NICE guidance. Please include as much information about the suspected event ideally using our reaction diary . We also offer a rapid access anaphylaxis service please see the instruction, poster, referral form and patient information.

Mastocytosis

We see patients with confirmed mastocytosis to support the management of allergic complications, but we do not see patients with suspected mast cell activation syndrome. In these cases we recommend sending blood for serum mast cell tryptase and discussing the case with us by telephone.