Immunology

The clinical Immunology service comprises of two elements, both based at the Royal Infirmary of Edinburgh:

• the laboratory service and
• the clinical primary immune deficiency service.

Adults with suspected immune deficiencies are seen in the Clinical Immunology clinics. There are also joint transition clinics held at the RIE or the RHCYP, where adolescent / young patients are seen by both the Paediatric and Adult Immunology teams, as the steps for transitional care are made.

There is currently no adult clinical allergy service provided within the Clinical Immunology service in Lothian. There are no admitting facilities for Immunology.

Lothian has one Clinical Immunologist, and the large catchment area means that referral criteria are highly specific. The Clinical Immunologist can be contacted for advice about testing or results (see ‘how to refer’ below).

Clinical Immunology Laboratory Services

The Clinical Immunology laboratory processes blood testing for the investigation of patients suspected of autoimmunity, immune deficiency, and some forms of allergy. 
The service is provided to General Practitioners, clinics and hospitals in the Lothians and other health boards within Scotland. There are 3 distinct areas within the laboratory:

• Autoimmune serology:  Measurement of a number of autoantibodies found in a range of connective tissue diseases, endocrine disorders, primary vasculitides and other autoimmune disorders. 
• Allergy testing: Specific IgE measurements to various allergens, Total IgE measurements, mast cell tryptase measurement
• Immunochemistry: Complement protein analysis (e.g. C3 / C4)

Further details on the individual tests and the test repertoire are available in the test directory on the laboratory medicine website.

Autoantibodies testing is rarely ‘diagnostic’ for a particular condition, and therefore the testing is best clinically utilised when there is the presence of clinical symptoms/ signs to raise clinical concern of a particular autoimmune condition. In general, most autoimmune serological tests are not useful ‘screening tests’ as often false positive / equivocal results may be seen, highlighting that the presence of autoantibodies does not necessarily equate to the diagnosis / presence of autoimmune disease. Furthermore, in some patients with certain autoimmune conditions (e.g. rheumatoid arthritis), there may be ‘seronegative’ disease, where rheumatoid factor and/or CCP antibodies are not detected, although these patients do have the disease. Please see specific RefHelp guidelines on these tests / conditions for further information.

Other relevant RefHelp guides related to Immunology laboratory tests include:

• Testing complement
• Requesting allergy testing (specific IgE tests) in primary care
• Connective tissue disease (ANA testing)
• Vasculitides and ANCA testing
• Immunoglobulin results interpretation guide

Clinical Immunology Primary Immune Deficiency (PID) Service

This Clinical Immunology PID service involves the investigation, clinical assessment, treatment and holistic management of patients with suspected and established primary immunodeficiencies [PID] requiring life-long treatment. It is responsible for all clinical referrals for the Lothians, Fife, the Scottish Borders and some patients from Forth Valley.

PID disorders are rare conditions, and so sometimes it may be useful to email / discuss individual cases prior to referral.

The department looks after patients with a range of PID disorders. These include:

• Primary antibody deficiency (including Common Variable Immune Deficiency (CVID))
• X-linked Agammaglobulinaemia (XLA)
• Combined Immune Deficiency
• other complex PID syndromes, including C1 inhibitor deficiency (including Hereditary Angioedema (HAE)),
• some patients with secondary antibody deficiency who are on immunoglobulin replacement home therapy.   

Patients with primary immune deficiency commonly present with a clinical history of infections (usually bacterial) which are SPUR:

• Severe
• Persistent
• Unusual
• Recurrent

If there is clinical concern about primary immune deficiency, total immunoglobulins (IgG, IgA and IgM and electrophoresis) should be measured as first line tests and discussion with the clinical Consultant Immunologist is advised. Microbiological samples (e.g. sputum for culture) wherever possible, are very helpful in the clinical evaluation of these patients to define the types of infections being experienced. In general, urinary tract infections are not typically associated clinical features of systemic immune deficiency syndromes.

C.M. & C.C. 23-01-25