Admittedly, clinical immunology is a very niche field with boundaries that at times can seem poorly defined. My opinion is that we should make ourselves useful to our colleagues as best we can so we can have good interdisciplinary relationships and work together as a team.

I plan to add a few posts over the coming months on what an immunologist can offer for different subspecialties. The format and tone might change but this first one is about what an immunologist can offer a respiratory physician.

Disclaimer: The content of this post is intended to be a referral guide where an immunologist might be able to support respiratory physicians. It is not intended to be clinical advice as each patient requires individual clinical assessment. All suggestions are subject to the relevant clinical guidelines. The best course of action is to refer your patient for a formal assessment.

Recurrent sinopulmonary infections

Reasons for referral

Assessment for an underlying immunodeficiency? (Primary: CVID, X-linked agammaglobulinaemia; Secondary: hypogammaglobulinaemia, HIV).

Diagnosis & Treatment

  • Immunoglobulin replacement (IVIg/SCIg)
  • Genetic testing with implications for family planning and prognosis
  • Monitoring for extrapulmonary complications of immunodeficiency

Tracheal stenosis

Reasons for referral

What is the underlying cause? (e.g. GPA, relapsing polychondritis). Screen for other organ involvement if systemic vasculitis is identified.

Treatment (if an immune-mediated pathology is present)

  • Immunosuppression with steroids
  • Cyclophosphamide
  • Biologics

Asthma + food allergy / eczema / allergic rhinitis

Reasons for referral

  • Diagnosis and management of food allergy and atopic eczema
  • Skin prick testing and specific IgE for aeroallergens and food allergens
  • EpiPen prescription if the patient is at risk of anaphylaxis
  • Allergen avoidance education
  • Dupilumab for severe eczema with concomitant benefit for asthma
  • Allergen immunotherapy (SCIT/SLIT) for allergic rhinitis can reduce severe asthma exacerbations

Chronic rhinosinusitis with nasal polyposis

Reasons for referral

  • Assess type 2 airway inflammation and biologic candidacy
  • Mepolizumab is indicated for CRS with NP
  • Allergy workup for aeroallergen sensitisation and treatment with immunotherapy if safe to do so

Adult onset asthma + sinusitis + eosinophilia

Reasons for referral

  • Investigate for EGPA (eosinophilic granulomatosis with polyangiitis)
  • ANCA testing (MPO/PR3 and interpretation of atypical patterns in the clinical context)
  • Systemic workup for other organ involvement (skin, peripheral nerves, kidneys, heart, GI)
  • Differentiate from other hypereosinophilic syndromes

Treatment

  • Steroids
  • Cyclophosphamide
  • Mepolizumab (for those without organ threatening manifestations)

Hypersensitivity pneumonitis

Reasons for referral

If antigen avoidance is not possible then treatment with steroids, mycophenolate may be indicated.

Interstitial lung disease

Reasons for referral

  • Autoimmune serology workup and interpretation (myositis antibodies, anti-synthetase panel, ANA, ENA, ANCA)
  • Systemic evaluation if connective tissue disease or vasculitis is suspected
  • Consensus on immunosuppression (steroids, mycophenolate, rituximab, IVIg)
  • Nailfold capillaroscopy (takes about 30 minutes)

Interpretation of immunopathology results

Reasons for referral

As a dual trained immunopathologist I am well equipped to interpret immunopathology results. I can help with this in general if it is required.

ANA-ENA discordance

e.g. the ANA is nucleolar but the ENA shows an SSA antibody which is typically associated with speckled pattern.

Myositis antibody relevance

Why might a particular myositis antibody be relevant to this patient's presentation?

Multiple positive results

Why does this patient have multiple positive results? (e.g. low level RF, dsDNA antibodies, low positive ENA/ANA/myositis antibodies may all be associated with an interfering factor such as a cryoglobulin). I can help evaluate for these and provide an interpretation of the tests/identify what if anything is relevant.