Referral guidelines clinical immunology and allergy - Newcastle Hospitals NHS Foundation Trust

Services available and accessing services

Outpatient clinics

Outpatient clinics are based at the Royal Victoria Infirmary (RVI). Clinics are held Monday – Friday.

Referrals from GPs

Referrals from GPs should be sent by e-referral. Referrals are screened by a consultant and patients are booked to be seen in problem-based clinics according to the identified clinical question.

Referrals from within the trust/other hospitals

Referrals from within the trust or other hospitals should be sent to the Immunology Department via this address:

Royal Victoria Infirmary
Newcastle upon Tyne
NE1 4LP

They can also be emailed to the immunology and allergy team. You can contact the secretaries on 0191 282 0669.

Please make sure we are made aware of additional needs, for example non-English speaking patient, or patient with learning difficulties.

Referral for children

Referral for children (<16) are not accepted and should be sent to Paediatric Allergy or Paediatric Immunology teams at the Great North Children’s Hospital or local hospitals where available depending on the clinical condition.

Advice and guidance

Advice and guidance can also be accessed via e-referral and most enquiries would be answered in 2 working days. For advice on patients already known to our service please contact the department directly.

Outreach clinics

Clinics are currently only being held in the RVI.

Who we are

We are a team of consultants, specialist nurses, junior doctors and nursing staff supported by a dietitian, health care assistants, receptionists and secretarial staff. You can find details of key staff members on our Allergy and Immunology pages.

Helpful information

American Academy of Allergy, Asthma & Immunology website Anaphylaxis website Allergy UK website British Society for Allergy & Clinical Immunology website JEXT website Epipen website NICE website

What to refer

Please see the table below – numbers in brackets refer to the numbered notes.

Immunodeficiency

What to refer*	What not to refer*
Known or suspected primary immunodeficiency (1)	HIV/AIDS (2)
Recurrent major infection (3)	Recurrent minor infection (4)
Recurrent severe boils (failed initial therapy; deep seated abscesses) (5)	Recurrent superficial abscess/boil hidradenitis suppurativa (5)
Unexplained periodic fevers / autoinflammatory conditions	Vasculitis/connective tissue disease (6) Arthritis (7)
Congenital asplenia (8)	Non-congenital asplenia (8)
Hereditary angioedema/acquired angioedema secondary to C1 esterase inhibitor deficiency	Recurrent shingles (9)
	Chronic fatigue/long COVID**

Allergy

What to refer*	What not to refer*
Anaphylaxis (10)	Asthma (11) Recurrent sensation of throat swelling without other features of allergy (12)
Recurrent angioedema in people NOT on ACE Inhibitors (13)	Angioedema in people taking ACE Inhibitors/Angiotensin receptor blockers (14); single episode of self-limiting angioedema
Seasonal or perennial rhinoconjunctivitis resistant to maximal conventional therapy (14)	Eczema (15); Periorbital oedema with scaly rash (15)
Venom allergy (16)
Immediate hypersensitivity reactions to medications including immediate reactions to antibiotics, local anaesthetic & vaccines (17)	Drug intolerance/recognised side-effects from medications, none immediate reactions e.g. DRESS, Stevens Johnson syndrome
General Anaesthetic allergy (18)
Latex allergy (19)
Food allergy (20)	Food intolerance, irritable bowel syndrome, eosinophilic oesophagitis (20)
Urticaria if severe and prolonged (21)	Urticaria if single episode, recent onset and/or mild (21)
	MCAS / mast cell activation syndrome (22)

See below for details and advice. If unsure whether to refer, please contact Department by telephone, fax or email or request Advice and Guidance via e-referral.

Notes

Known or suspected immunodeficiency: all need to be under care of immunologist.
Refer all HIV/AIDS to Adult Infectious Disease Service at Royal Victoria Infirmary (or to local Infectious Disease or GUM Service, outside of Newcastle)
Recurrent Major infection: please refer all of the following:
- Two major infections in 12 months (major = requires hospital admission).
- One 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.
- Unusual, recurrent or persistent fungal infections
Recurrent minor viral infections including recurrent, self-limiting COVID infections will not be due to immunodeficiency and referral is not necessary: exclude stress, inadequate diet, iron deficiency. Recurrent vaginal thrush is common and not an indicator of immunodeficiency.
Recurrent boils/abscesses: most are due to staphylococcal carriage or local disease (hidradenitis suppurativa – refer to dermatology or plastic surgery). 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, available on request. Refer only those carriers who fail decontamination. Refer all patients with deep-seated abscesses (liver, brain).
Acute vasculitis or connective tissue disease should be referred to Rheumatology.
Acute arthritis should be referred to Rheumatology.
Patients with secondary asplenia can be managed in primary care; guidance on immunisation can be found in The Green Book.
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 aciclovir (not topical). If episodes are very frequent, consider prophylaxis with aciclovir 200mg bd for 6 months.
Refer all patients with anaphylaxis (= allergic reaction with systemic features, hypotension, laryngospasm, bronchospasm). See NICE Guideline: http://guidance.nice.org.uk/CG134 .
Refer difficult to control asthma to Respiratory Medicine. Severe asthma is an exclusion criterion for immunotherapy.
Refer recurrent sensation of throat swelling/ closing (can be due to inducible laryngeal obstruction) to ENT.
Angioedema may be caused by ACE inhibitors (up to 5% of patients): stop drug and wait 3 months. Refer if angioedema persists. Other drugs which may cause angioedema include NSAIDs, PPIs and statins.
Refer only patients with allergic rhinconjunctivitis who fail to respond to maximal medical therapy (oral anti-histamines + nasal steroid + eye drops). Before referral please check specific IgE levels to common inhalants including grass pollen, tree pollen, house dust mite, and any animals they have regular exposure to. If negative results there is no evidence of allergic disease contributing and referral to ENT / ophthalmology for management of non allergic symptoms is suggested. Ensure that nasal steroids are used with head forward looking at feet. For management in primary care see BSACI primary care guideline.
Refer eczema and persistent periorbital oedema with scaling to Dermatology. In adults, food allergy rarely has a role to play in the generation of eczema. Investigation of dermatitis is by patch testing (available in Dermatology).
Venom immunotherapy should be offered to patients who have had a severe systemic reaction to a sting, or who have had a moderate reaction with one or more risk factors (raised mast cell tryptase, significant anxiety about further stings or high risk of further stings). See NICE guidance. Patients with large local reactions to stings/bites without systemic symptoms do not require assessment, even when swelling is very significant.
Refer patients with drug allergy only if clinically relevant and where testing will alter treatment. See NICE Guidelines on referring drug allergy from primary care.
Patients with penicillin allergy should only be referred where there is an ongoing need for a penicillin antibiotic e.g. underlying health condition such as diabetes, chronic lung disease, or where the allergy is associated with allergy to other antibiotics.
Refer patients with reactions to NSAIDS only where there is a clear ongoing need for this class of drugs.
True IgE-mediated allergy to local anaesthetics is very rare.
Patients with immediate onset of allergic symptoms after vaccine administration should be referred for consideration of testing where this is possible.
We do not normally recommend the carriage of adrenaline autoinjectors in drug-related reactions as medications can be avoided. A medic-Alert bracelet (or equivalent) is advisable.
General Anaesthetic allergy. The anaesthetist involved in the patient’s care at the time of reaction should refer the patient. The following documents and a copy of the anaesthetic chart should be completed and sent to Dr Henrietta Dawson, Consultant Anaesthetist, Anaesthetic Drug Allergy Clinic, Anaesthetic Department, Royal Victoria Infirmary or email Henrietta Dawson.
Refer all patients with significant immediate allergy to latex. Contact eczema to rubber should be referred to Dermatology for patch testing.
Refer all patients’ symptoms in keeping with an IgE mediated reaction reactions to foods. i.e. those people with reproducible symptoms of hives, swelling, shortness of breath etc. soon after exposure to a particular allergen. Non-specific symptoms including recurrent abdominal pain and bloating, non-specific rashes, fatigue after multiple foods are not in keeping with food allergy. Some patients may have been told that they have multiple food allergies after high street ‘allergy’ tests: many of these tests are unscientific and should not be recommended or results overinterpreted. Patients with eosinophilic esophagitis sometimes request allergy tests to guide food avoidance; this condition is not mediated via IgE and therefore specific IgE testing and skin prick testing is not recommended to guide dietary changes.
Chronic urticaria is rarely due to allergy. Most is due to physical urticaria (pressure, heat etc.), stress, chronic infection (dental, sinus, helicobacter, cholecystitis), and thyroid dysfunction; some may be spontaneous and can be affected by the former conditions. Iron deficiency can exacerbate symptoms in some patients. Exclude these before referral. Do not refer patients with a single or short-lived episode of urticaria as these episodes are common in general population. Management of urticaria may require high doses of antihistamines such as cetirizine in does up to 40 mg per day, or fexofenadine 360 mg bd; addition of montelukast 10 mg od is also recommended in Guidelines. Do not use continuous steroids. Do not use Piriton (chlorphenamine) during the daytime or for acute use (weak antihistamine, short duration of action and sedating). BSACI guidelines on managing Chronic spontaneous urticaria.
There is increasing use of the term Mast cell activation syndrome (MCAS) and there are an increasing number of referrals for us to diagnose people with this condition, many of whom are polysymptomatic with symptoms including fatigue, musculoskeletal pain/weakness, unexplained abdominal pain, pruritis and diarrhoea. In studies of patients suspected of having idiopathic MCAS, psychiatric morbidity is common and includes depression, anxiety, compulsive disorder, ADHD, somatisation disorder and bipolar affective disorder. Many score highly on HADS. The only test which may be of value would be to check a baseline tryptase and then during acute exacerbation of symptoms (maximum 4 hours after symptomatic episode). A rise of greater than 20% plus 2mg/L from baseline would indicate need for further assessment. Patients can have a trial of antihistamines (H1 and H2 blockers) and montelukast to see if benefit obtained; if there is not please discontinue these as these patients are at risk of polypharmacy. We would have nothing additional to offer in the clinic and therefore only refer patients if they have symptoms that would meet our acceptance criteria.