IMMUNOLOGY USERS GUIDE 2017

Transcription

1 IMMUNOLOGY USERS GUIDE 2017 Immunology Laboratory 2 nd Floor, Pathology & Pharmacy Building Royal London hospital 80 Newark Street, Whitechapel LONDON E1 2ES Tel Fax Lab

2 Contents Immunology Laboratory... 1 The Immunology Laboratory... 3 General Information... 3 Contact Details:... 3 Requesting Tests... 4 Specimen Collection... 4 Patient Consent... 5 Confidentiality and Information Governance... 5 Complaints... 5 Reporting... 5 Training, Quality and Audit... 6 Test Profiles... 7 Immunodeficiency... 7 Antibody Deficiency... 7 Neutrophil Disorders... 7 Complement Abnormalities... 7 Cellular Abnormalities... 7 Clinical Services... 8 Lymphocyte Subsets (CD4 counts)... 8 Autoimmune Serology... 8 Coeliac Serology... 8 Connective Tissue Disease... 9 Anti-cardiolipin antibodies:... 9 Rheumatology Test Protocols Investigation of Renal Failure and Vasculitis Allergy: Specific & Total IgE Anaphylaxis Angioedema Last updated May 2017 Page 2 of 23 Author: Chris SCOTT / Sorena KIANI

3 The Immunology Laboratory The Immunology Laboratory provides a full Consultant-led diagnostic service for the diagnosis and monitoring of patients with immunodeficiencies, autoimmune diseases and allergic conditions. The medical staff provide a consultative service for clinical and laboratory questions in addition to both outpatient and inpatient immunodeficiency services. The department is particularly well-equipped to diagnose and monitor immunodeficiency disorders and provides specialist investigations in this area. General Information Laboratory opening times: , Monday to Friday. For urgent Immunology enquiries outside normal working hours please contact the Duty Consultant Immunologist via the main switchboard. Contact Details: Immunology Laboratory Main Laboratory Tel: General Enquiries: Tel: Departmental Fax: Fax: Dr Sofia Grigoriadou, Consultant Immunologist Tel: sofia.grigoriadou@bartshealth.nhs.uk Dr Hilary Longhurst, Consultant Immunologist Tel: hilary.longhurst@bartshealth.nhs.uk Dr Sorena Kiani, Consultant Immunologist Tel: sorena.kiani@bartshealth.nhs.uk Chris Scott, BMS Advanced Practitioner Tel: Diane Macdonald, Chief BMS Autoimmune Serology Tel: Alaco Hickey Chief BMS (Immune deficiency) Tel: Mike Stevens Lead Clinical Scientist Tel: BHNT.Immunology@nhs.net Last updated May 2017 Page 3 of 23 Author: Chris SCOTT / Sorena KIANI

4 Requesting Tests All tests should be requested electronically via CRS for those departments who are CRS enabled. Manual requests are accepted on a standard internal request form. Name, date of birth, hospital number and/or NHS Number are essential for unique identification of your patient. Clearly writing Consultant name and/or code and ward or clinic will ensure prompt return of results. Please take the extra time to furnish clinical details and hazard information. When full clinical details are available, laboratory staff will select optimal tests as defined by existing protocols. This could mean that not all the tests requested are always performed or that extra indicated tests may be added, for example anti-dna antibodies after a positive ANA; this is only possible when full clinical details are given. If it is likely that the sample volume after venepuncture will be limited, please contact the laboratory before phlebotomy to discuss the absolute minimum volume requirements for the requested tests. Additional tests may also be performed on previously received specimens if a sufficient volume is available in storage. Samples are stored for 1 month. Contact the laboratory by telephone to see if this is possible. Please note that repeated serological requests within specified timeframes, samples with inadequate unique identifiers or incorrect specimens will not be processed. The report for these requests will identify the reason for not performing the test. Where possible specimens are kept for up to 1 month and you are encouraged to contact the lab if you would like to provide additional details that would facilitate performing the requested tests. Specimen Collection The normal portering and specimen collection services should be used for non-urgent specimens on all sites. Urgent specimens must be discussed with the laboratory and brought or couriered directly to the laboratory. Individual specimens should be placed in individual plastic bags with the request forms in an outer pocket. Severely haemolytic, icteric or lipaemic samples may be rejected as these interfere with a number of assays and may lead to an inaccurate result. All results are available on the CRS system or Cyberlab when approved depending on the hospital site, external results are posted or faxed if the external hospital provides the department with a safe haven fax number For optimum results and turn around times, please send the correct sample (see lists below). The following tests have special requirements: Last updated May 2017 Page 4 of 23 Author: Chris SCOTT / Sorena KIANI

5 Lymphocyte surface markers, CD4 counts, 4ml of blood in EDTA (vacutainer not Sarstedt tube) should be taken and sent directly to the laboratory. Samples should be kept at room temperature, never at 4 o C. Samples should reach the laboratory by hrs. Lymphocyte and neutrophil function tests are performed only after prior discussions with a consultant immunologist and may require special samples. Functional complement studies (CH100 & AP100): Samples should be placed in plain tubes and then stored on ice until they are collected for transport. They should reach the laboratory within 3 hours. C1 inhibitor should only be requested if C4 RLH) is low. Samples should reach the laboratory before 3pm. TSpot TB Testing: two lithium heparin samples are required. Samples should reach specimen reception [WXH/NGH/RLH] before 3pm. Samples arriving after this time will be unsuitable for testing. This test can only be performed on weekdays. Please do not send sample on weekends. Patient Consent RCPath guidance for patient consent can be found here. Confidentiality and Information Governance All staff members adhere to trust guidelines on confidentiality and are trained in information governance. Trust Guidelines for information governance are found here and guidelines for confidentiality are found here. Complaints Your complaint matters to us at Barts Health and we are committed to providing a high quality service for all our patients and end users, and will do everything possible to make sure that your visit to our hospital is as comfortable as possible. We are constantly developing the services we provide for patients and visitors, and would welcome your input. Details of how to complain can be found here Reporting A printed or electronic report will be despatched to the patient s location when all requested tests have been reported and authorised. If you require a sample to be processed urgently, please telephone the laboratory before Last updated May 2017 Page 5 of 23 Author: Chris SCOTT / Sorena KIANI

6 bleeding the patient. This way we can confirm that the correct sample is sent, organise a time for it to be processed and give you an expected date and time for the result. We endeavour to process all such requests as quickly as possible. The laboratory staff attempt to issue telephone results on all results deemed urgent. If you have a query about any result or its interpretation, please telephone for assistance. Training, Quality and Audit The laboratory participates in a comprehensive quality assurance programme, monitoring all aspects of the service. All investigations, laboratory and clerical procedures are governed by external quality requirements and in house validated standard operating procedures in addition to periodic laboratory and clinical audits. The department is approved by the Health Professions Council as a training department for Biomedical Scientists Standards of testing are maintained by the use of internal quality control and external UK National External Quality Assessment Schemes (UK NEQAS) schemes. Copies of the last year s participation certificate are available upon request for each of the following UK NEQAS Schemes: UK NEQAS for Nuclear Related Antigens UK NEQAS for General Autoimmune Serology UK NEQAS for Phospholipid Antibodies UK NEQAS for ANCA and GBM UK NEQAS for Bullous Dermatosis UK NEQAS for Coeliac Disease UK NEQAS for Fungal and related antigens UK NEQAS for Specific microbial antibodies UK NEQAS for Immune Monitoring UK NEQAS for Total IgE UK NEQAS for Allergen specific IgE UK NEQAS for C1 Inhibitor and functional Complement UK NEQAS for Intrinsic Factor Antibodies UK NEQAS for Paraneoplastic Antibodies UK NEQAS for Acetylcholine Receptor Antibodies UK NEQAS for Tryptase Last updated May 2017 Page 6 of 23 Author: Chris SCOTT / Sorena KIANI

7 Test Profiles Immunodeficiency Antibody Deficiency The nature of the infecting organisms gives a guide to the possible type of immunodeficiency. Antibody deficient patients are prone to bacterial infections of the respiratory tract, joints and skin. These patients should have IgG, IgA and IgM levels checked (Biochemistry) as a starting point. If these are normal, but there is still a high index of suspicion for an antibody deficiency, clinical immunologists investigate more subtle defects by checking IgG subclasses, and specific antibodies (Haemophilus, Tetanus and pneumococcal antibodies). Isolated low subclasses or specific antibody levels are not sufficient to diagnose immunodeficiency and requires follow up functional assays and interpretation by clinical immunologists. Neutrophil Disorders Patients with neutrophil disorders are prone to widespread deep-seated bacterial and fungal infection. If persistent or cyclic neutropenia has been ruled out, a search for neutrophil dysfunction may be made. We can measure neutrophil respiratory burst (Nitro Blue Tetrazolium (NBT) or dihydrorhodamine test) and neutrophil adhesion molecules after prior discussion. Complement Abnormalities Complement abnormalities manifest in two main forms. Patients with deficiency of terminal pathway factors (C5-C9) characteristically develop repeated episodes of Neisserial spp infections. Patients with recurrent meningitis should always have complement defects excluded. Complement deficiency may also cause SLE and glomerulonephritis. Measurement of the CH100 is the single most important assay; it is absent or extremely low in all such patients. Alternative pathway deficiencies are significantly rarer, but should be considered in e.g. atypical haematolytic uraemic syndrome or recurrent infections with X-linked inheritance patterns. Note: Routine C3 & C4 quantitation is carried out in Biochemistry. Cellular Abnormalities T cell dysfunction or reduction of T cell numbers can occur as a result of a spectrum of infections with both pathogenic and opportunistic organisms of all microbial genera. Patients should be discussed in detail so that the most appropriate lines of investigation can be planned. Measurement of the lymphocyte count, total immunoglobulin and specific antibody levels are good initial investigations. In infants with infections and a lymphocyte count below 4x10 9 /l, congenital immunodeficiency should be considered. Be aware that the normal range of lymphocyte counts is different for children than in adults. They should not be given live vaccines and blood transfusions should preferably be avoided until immunodeficiency has been excluded. These infants should be discussed with an immunologist and may need urgent referral to Great Ormond Street. Last updated May 2017 Page 7 of 23 Author: Chris SCOTT / Sorena KIANI

8 Clinical Services Diagnosis of immunodeficiency requires a low clinical threshold and specialist investigations. Clinical primary immunodeficiency services are available for adults and children at the Royal London. Lymphocyte Subsets (CD4 counts) CD4 counts are an excellent way of monitoring HIV infection but are not a substitute for HIV serology and cannot be used to diagnose HIV infection. There are also medico-legal reasons for the laboratory needing to be certain that patients receiving CD4 counts are known to be HIV infected and have given consent for such testing. Consequently, we require that, for patients receiving their first CD4 count, knowledge of HIV status is confirmed on the request form and consent for HIV testing is also documented before the CD4 count is done. We are happy to do CD4 counts for other indications, for example, during antithymocyte globulin administration, following bone marrow transplant and in the investigation of primary immunodeficiency, so long as these are clearly indicated on the request form. A same day service is available in this situation, provided we are warned by telephone ( ) and the sample is sent to The Royal London by courier before midday. Autoimmune Serology Coeliac Serology Tissue Transglutaminase (ttg) antibodies are the most useful screen for coeliac disease. Coeliac disease sometimes coexists with IgA deficiency, in which case IgG ttg antibodies may be the only positive result. It is important to realise that these assays may suggest coeliac disease, but a jejeunal biopsy is still required for confirmation. Our current protocol is as follows: Adults: Children: IgA ttg (if positive confirmed with IgA Endomysium). IgA ttg (if positive confirmed with IgA Endomysium). IgG ttg if IgA deficiency is suspected Children with a positive ttg antibody and endomysial antibody may benefit from HLA DQ2 and DQ8 haplotype testing. In situations where endoscopy and biopsy are not feasible or difficult to perform, if all three serological tests (ttg, EMA and HLA) are positive, biopsy may be avoided. HLA testing is performed in the clinical transplantation laboratory and requires an EDTA sample. Last updated May 2017 Page 8 of 23 Author: Chris SCOTT / Sorena KIANI

9 Connective Tissue Disease Multi-system diseases including SLE and rheumatoid arthritis are generally referred to as connective tissue diseases. While the clinical features are very important in diagnosing specific diseases in such patients, the Immunology Laboratory plays a very important role in assisting the diagnostic process and in monitoring disease activity. Anti-Nuclear Antibodies (ANA): Positive in most people with SLE but may also be present in other connective tissue diseases, autoimmune liver diseases, during infections, sometimes secondary to drugs and in some healthy individuals especially the elderly. If ANA is abnormal and/or the clinical condition is convincing, the following tests may be useful: Double-stranded DNA antibodies (dsdna abs): These are seen in SLE and may be used for disease activity monitoring. They may indicate a predisposition to renal/neurological involvement. They may be seen occasionally in autoimmune hepatitis. If ANA is negative, DNA antibodies will not be present. DNA antibodies are tested initially by ELISA and if positive an IIF (Crithidia Lucillae immunofluorescence test or CLIFT) is performed. Please note that other autoimmune disorders such as autoimmune hepatitis can result in high titre dsdna antibodies by ELISA that are negative by CLIFT. These antibodies are not diagnostic of SLE. Patients with SLE on treatment may also have discordant ELISA and CLIFT results, since the two assays measure different overlapping subtypes of dsdna antibodies. Extractable nuclear antigen antibodies (ENA abs): A variety of antibodies including those which may be useful in connective tissue disease classification or in assessing risk of particular complications: Repeat testing of ENA antibodies is unnecessary, unless there is a major change in clinical features. Note: Antibodies to ENA and dsdna are rare in patients who are ANA negative. If an ANA is positive the laboratory will add on appropriate ENA and dsdna antibody tests. SS-A (Ro) SS-B (La) Sm and RNP Scl-70 Jo-1 SLE with photosensitive rashes, congenital lupus/heart block, Sjogren s syndrome SLE and mixed connective tissue disease Diffuse Systemic Sclerosis Polymyositis / Dermatomyositis Additional extended ENA Ab testing is available on discussion with the laboratory. Anti-cardiolipin antibodies: These may be positive in the anti-phospholipid syndrome (apls) which predisposes a sub-group of connective tissue disease patients to arterial and venous thrombosis or recurrent miscarriage (secondary apls). Primary apls Last updated May 2017 Page 9 of 23 Author: Chris SCOTT / Sorena KIANI

10 without the presence of connective tissue disease can also be seen, although much less frequently. Haemolytic anaemia and thrombocytopenia may also be seen in the presence of this autoantibody. A required diagnostic criteria for diagnosis of antiphospholipid syndrome is when anticardiolipin antibodies (or lupus anticoagulant assayed in Haematology) are positive on 2 occasions with a 12 week interval. If the Anti Cardiolipin Screen test is positive we will automatically add on the following tests IgG Cardiolipin antibodies IgM Cardiolipin antibodies IgG Beta-2-glycoprotein1 antibodies IgM Beta-2-glycoprotein1 antibodies False positive anticardiolipin antibodies are seen in a range of infections. Guidelines for the diagnosis of anti-phospholipid syndrome require anticardiolipin antibodies (or lupus anticoagulant assayed in Haematology) to be positive on 2 occasions with a 12 week interval. Rheumatology Test Protocols In the laboratory, to increase efficiency and lower costs and turnaround times, rheumatology tests are selected according to the clinical details given. Joint pain?sle ANA and rheumatoid factor (Clinical Biochemistry) ANA, ENA, DNA (if ANA positive) Investigation of Renal Failure and Vasculitis Tests of value in the diagnosis of acute renal dysfunction include glomerular basement memberane (GBM) antibodies (positive in most cases of Goodpasture s disease) and Anti-neutrophil cytoplasmic antibodies (ANCA). These are characterised by immunofluorescence pattern as c-anca (positive in many patients with Wegener s granulomatosis) and p-anca antibodies (positive in many patients with pauci-immune glomerulonephritis). In some cases, these tests may be used for monitoring disease activity. Samples positive for ANCA by Immunofluorescence will be confirmed by testing for antibodies to proteinase-3 (PR3) and myeloperoxidase (MPO) Although inflammatory bowel disease can give rise to positive ANCA tests, these are of low sensitivity and specificity. We do not recommend ANCA testing in this setting. In both acute and chronic renal failure, a variety of other tests may be useful in identifying an immunological cause. These include a screen for an underlying connective tissue disease such as SLE, RA or scleroderma. Last updated May 2017 Page 10 of 23 Author: Chris SCOTT / Sorena KIANI

11 Primary (idiopathic) membranous nephropathy is associated with PLA2 Receptor antibodies and a quantitative assay is used for both prognostic and monitoring purposes. Allergy: Specific & Total IgE We can perform a spectrum of allergy tests, including total IgE and specific IgE for a wide range of allergens. These tests should be complementary to a careful history and, in most cases, skin prick testing should be performed first. Skin prick testing often provides an immediate answer to allergy questions and is more specific than specific IgE testing. Skin-prick testing should only be done by experienced personnel with adequate resuscitation facilities at hand. Tests for specific IgE are reserved for situations where such direct testing gives conflicting results or is contraindicated (very young children, severe eczema, recent use of antihistamines and steroids, history of anaphylaxis). An indication of the possible allergens should be given to the laboratory staff to assist in testing a useful panel. Blanket testing is not useful. Tests for molecular allergic determinants (a.k.a. component allergen testing) are available where appropriately commissioned and on discussion with the laboratory. In assessing results of specific IgE tests, it should be remembered that there is a well-recognised false positive and false negative rate with these tests and that the degree of positivity correlates with the likelihood of allergy but not with the degree of clinical sensitivity. The medical staff in this department are experienced in dealing with allergic patients and are happy to give clinical advice, if you wish. Results (kua/l) Grade < > PLEASE NOTE: Allergen specific IgE tests are not100% sensitive. They can also be found without clinical reactions, especially in atopic individuals. They are NOT proof of allergy and are not useful for screening. Suggest allergy referral for assessment if indicated. Anaphylaxis Mast Cell Tryptase is a useful test for the diagnosis of anaphylaxis. Samples should be collected as soon as possible after resuscitation and 4-6 hours after Last updated May 2017 Page 11 of 23 Author: Chris SCOTT / Sorena KIANI

12 the allergic reaction. The test should be repeated after 24 hours for baseline levels to confirm the diagnosis and rule out mastocytosis. Please indicate times of the reaction and the sample on form. A rise of mast cell tryptase level with a fall after 24 hours is suggestive of anaphylaxis. Be aware, however, that a positive rheumatoid factor or certain drugs such as opioids can cause an elevated serum mast cell tryptase level. These samples do not need special handling, as tryptase is stable in vitro. It is not necessary to separate these samples prior to dispatch to the laboratory. Angioedema Patients with recurring angioedema, in the absence of urticaria, may have C1 esterase inhibitor deficiency. In this case angioedema is usually non-pruritic and may affect airways and abdominal viscera (resulting in pain, vomiting or diarrhoea). Typically, the C1 inhibitor and C4 levels are low, while the C3 is normal. In a minority of familial cases a non-functional form of C1 inhibitor is produced so that the C1 inhibitor level may be normal, but the C4 is usually low in which case a test of C1 inhibitor function is required. C3/C4 should be sent to Clinical Biochemistry, but C1 inhibitor level and function tests are processed in this laboratory. The much more common condition of urticaria/angioedema tends to cause repeated episodes of intensely itchy swellings which last a shorter period of time, often no more than hours. No obvious trigger is detected in the majority of such cases and laboratory investigation is usually not helpful. Stool Tests Faecal calprotectin (FCP) is released from gut granulocytes when they are activated. Stool samples with high levels of FCP are seen in patients with inflammatory bowel disease and this is a useful test for risk stratifying patients with chronic diarrhoea and monitoring disease activity in patients with inflammatory bowel disease. Acute intercurrent infection (including of the gastrointestinal and respiratory tract) and any source of GI bleeding may give a positive result. Last updated May 2017 Page 12 of 23 Author: Chris SCOTT / Sorena KIANI

13 Test Autoimmune Serology: Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Anti-nuclear antibody (Hep-2) Plain Negative (<1/160) <7 SLE, Sjogren s, Systemic Sclerosis, Myositis, MCTD Extractable Nuclear Antigens: RNP/Sm/Ro/La/Jo-1/Scl- 70/Ribosomal P [Extended ENA testing available on request.] Plain Negative <7 Connective tissue diseases as for ANA. (Note: Normally only tested if ANA Positive, repeat testing only indicated if clinical symptoms change) dsdna antibodies ELISA Crithidia Lucillae IIF Plain <25 ku/l Negative <7 Monitoring SLE, renal lupus (Note: Normally only tested if ANA Positive, repeat testing only indicated if monitoring lupus flare) Histone antibodies Plain 0 40 Referral Positive in 95% of drug induced Lupus Cases as well as 50-70% of SLE patient [Only tested if ANA Positive] Anti C1q antibodies Plain <15 ku/l Referral Correlates with presence with Lupus Nephritis and Urticarial Vasculitis. Citrullinated Protein Antibodies Plain <10 ku/l <7 Rheumatoid Arthritis Last updated April 2015 Page 13 of 23 Chris SCOTT / Matthew BUCKLAND

14 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Autoantibody screen: Gastric parietal cell Mitochondria Liver Kidney Microsomes Smooth Muscle Plain Negative (<1/40) <7 Pernicious anaemia Primary Biliary Cirrhosis Autoimmune Hepatitis Type 1 Autoimmune Hepatitis Type 2 Thyroid Peroxidase (TPO) antibody Plain Negative <50 ku/l Borderline ku/l Positive >180 ku/l <7 Autoimmune thyroid disease (Hashimoto s, Grave s disease, autoimmune hypothyroidism) Thyroid Stimulating Receptor Antibody Plain ku/l <14 Pregnant women with Grave s disease Anticardiolipin antibodies Screen Anti-Cardiolipin IgG Anti-Cardiolipin IgM Beta-2-Glycoprotein-1 IgG Beta-2-Glycoprotein-1 IgM Plain Negative IgG <10 ku/l IgM <10 ku/l IgG <7 ku/l IgM <7 ku/l <7 Recurrent thrombosis & miscarriage Revised Sapporo Criteria ANCA Screen Myeloperoxidase (MPO) Plain Negative <3.5 ku/l <4 [Urgent testing can be Small vessel vasculitis, Wegener s granulomatosis. [MPO/PR3 will be tested if Screen is positive or if monitoring a known Last updated August 2016 Page 14 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

15 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Proteinase 3 (PR3) <2.0 ku/l arranged by contacting the laboratory directly] Some Indications vasculitic patient. ] GBM Antibodies (Glomerular Basement Membrane) Plain <6 ku/l <7 Goodpasture s syndrome PLA2 Receptor Antibodies (Phospholipase 2 Receptor abs) Plain <14 ku/l <14 Primary (idiopathic) membranous nephropathy Coeliac Antibodies IgA ttg antibodies IgG ttg antibodies** IgA Endomysial abs Plain <5 ku/l <7 ku/l Negative <7 Coeliac disease (**only indicated if IgA deficient) Faecal Calprotectin Stool <50 ug/g [ ug/g Borderline range] <14 Differentiation of irritable vs inflammatory bowel Monitoring of patients with inflammatory bowel disease Skin antibodies Plain Negative <14 Pemphigus / Pemphigoid [Positive screens are quantified for desmoglein (DSG1/3) or bullous pemphigoid Last updated August 2016 Page 15 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

16 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications antigen (BP120/180) as appropriate] Intrinsic factor antibodies Plain <6 ku/l <14 Pernicious anaemia, generally only tested if patient has gastric parietal cell antibodies Myocardial antibodies Plain Negative Referral Dressler s syndrome, rheumatic Fever Islet cell antibodies Plain Negative <14 Early insulin dependent diabetes GAD antibodies Plain <5 ku/l <14 Stiff Man Syndrome / To assist in differentiating between Type 1 and Type 2 Diabetes Mellitus IgG Insulin antibodies Plain <5 ku/l Referral Insulin dependent diabetes Steroid cell [Ovarian/Testicular] antibodies Plain Negative <14 Premature menopause / infertility. Enterocyte antibodies Plain Negative Referral Autoimmune enteropathy Last updated August 2016 Page 16 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

17 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Adrenal Antibodies Plain Negative <14 Addisons Disease NeuroImmunology: Acetylcholine Receptor ab Plain <0.45 nmol/l [Borderline ] <14 Myasthenia Gravis Aquaporin 4 Antibodies Plain Negative Referral Neuromyelitis Optica (NMO) Amphiphysin Antibodies Plain Negative Referral Paraneoplastic Stiff Person Syndrome Anti-MuSK Antibodies Plain Negative Referral AchR Ab Negative Myasthenia Gravis Basal Ganglia Antibodies Plain Negative Referral Post infectious Chorea Ganglioside Antibodies Plain Negative Referral Peripheral Neuropathy/ Miller Fisher Syndrome/Guillan Barre Myelin Associated Glycoprotein Plain Negative Referral Peripheral Neuropathy Last updated August 2016 Page 17 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

18 Test (MAG) Antibodies Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Neuronal abs (Hu/Ri/Yo) [Ma, Ta, CV2 antibodies if required] Plain Negative <14 Paraneoplastic Syndromes NMDA Receptor antibodies Plain Negative Referral Limbic Encephalitis Striated muscle antibody Plain Negative Referral Myasthenia gravis, thymoma Voltage Gated Calcium Channel antibodies Plain Negative Referral AchR Ab Negative Myasthenia Gravis/ Paraneoplastic MG Voltage Gated Potassium antibodies Plain Negative Referral Neuromyotonia, Limbic Encephalitis and Morvan Syndrome Natalizumab antibodies Plain Negative <14 MS patients Natalizumab. Blood samples must arrive within 2 hours of venepuncture or as frozen serum. Infliximab antibodies/titre Infliximab levels Adalimumab antibodies/titre Adalimumab levels <10 ng/ml >2 ug/ml <10 ng/ml >5 ug/ml Biologicals monitoring Last updated August 2016 Page 18 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

19 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Anti IgA Antibodies Plain Negative Referral Some Indications Can be checked in patients with IgA deficiency to predict future risk of transfusion reactions. Allergy: Total IgE Plain 0 81 ku/l Adult Range [Age dependent reference range] <7 Diagnosis of atopy in conjunction with specific IgE Specific IgE (For details of the repertoire of specific allergens contact the laboratory) Plain Class 0 (<0.35 kau/l) <14 Diagnosis of allergic sensitisation (only useful in association with history) Tryptase [Acute, 2 hour and convalescent samples please] Plain 2-14 ug/l <7 Diagnosis of Mastocytosis, anaphylaxis / anaphylactoid reactions Precipitins Aspergillus fumigatus Microsporium faeni Avian Precipitins Candida Preciptins Plain <25 Negative Negative Negative <14 Referral Test Referral Test Referral Test Extrinsic allergic alveolitis, Farmer s Lung Bird Fanciers Lung Last updated August 2016 Page 19 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

20 Test Immunodeficiency: Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Complement Function CH100 AP100 Plain: to arrive on ice units % <21 Only by prior arrangement with the department. Complement deficiency Complement C1q Complement C2 Complement C3 Nephritic Factor Plain Negative Referral Test Referral Test Referral Test C1q and C2 deficiency is associated with an increased risk of Autoimmune diseases and Lupus C3 Nephritic Factor is only indicated if C3 absent. It is associated with Membrano-proliferative Glomerulonephritis. Individual Complement Components Complement C5-C9 Complement Factor B, H, I Plain: to arrive on ice On request Referral Only by prior consultation with clinician. Complement deficiency Mannan Binding Lectin Plain >1300 ug/l <21 Investigation of recurrent infection by paediatric or adult immunologist <75 ug/l: Correlates with homozygous variant alleles and non-functional MBL which is Last updated August 2016 Page 20 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

21 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications associated with the greatest risk of infection ug/l: Correlates with functional MBL deficiency associated with increased risk of infection ug/l: Correlates with heterozygous variant alleles and may show mild deficiency associated with some increased risk of infection. >1300 ug/l: Correlates with wild type alleles showing no deficiency. C1 inhibitor (Antigenic) C1 inhibitor (Functional) Plain mg/l % <21 <21 Hereditary & Acquired angioedema if low or absent C4 complement IgG subclasses Plain Age Specific [Contact the laboratory for further details] <7 Recurrent infections [IgG4 only for IgG4 Related Disease] Haemophilus antibodies: Plain >0.15 mg/l <14 Investigation of recurrent infections Tetanus antibodies: Plain >0.01 ku/l ** Serotype specific ranges <14 Referral Investigation of recurrent infections ** Basic Protection Full protective Level >1 Long term protection Pneumococcal Serotype Specific antibodies: Plain Serotype specific ranges Referral Investigation of recurrent infections Last updated August 2016 Page 21 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

22 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Lymphocyte subsets (CD3, 4, 8) EDTA [Store at room temperature] Age Specific [Contact the laboratory for further details] <3 HIV monitoring. Immunodeficiency Panel (CD3, 4, 8, 19 & 56) EDTA [Store at room temperature] Age Specific [Contact the laboratory for further details] <3 Diagnosis of primary immunodeficiency. Monitoring immunosuppressant therapy. Check with laboratory for appropriate indications for testing. B Cell Subpopulation EDTA [Store at room temperature] Interpretive clinical comment <7 Classification of CVID. Only by prior arrangement with consultant. Memory / Naïve T Cells EDTA Only with prior arrangement with consultant Immunologist. <7 Diagnosis of immunodeficiency T cell function (CFSE) Heparin Only with prior arrangement with consultant Immunologist. <28 Diagnosis of immunodeficiency. Only by prior arrangement with consultant. Neutrophil function (NBT Oxidative Burst) EDTA Only with prior arrangement with consultant Immunologist. <7 Chronic Granulomatous Disease (CGD) & other 1 o immunodeficiency Last updated August 2016 Page 22 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER

23 Test Specimen Requirement Normal Adult Range Turnaround Time Days [95% reported within] Some Indications Neutrophil Adhesion CD11a CD18 EDTA Only with prior arrangement with consultant Immunologist. <7 Diagnosis of Leucocyte Adhesion Deficiency Gamma Interferon Release Assays: TSpot Heparin Negative <7 Latent TB Immunochemistry: Please note that the following immunochemistry tests have been centralised in Clinical Biochemistry: Immunoglobulins (IgG, IgA & IgM) Complement C3 & C4 C Reactive Protein (CRP) Rheumatoid Factor (RF) Referral Tests: Specialist / Isoteric Testing service are available and referred to the appropriate specialist centre. For further details about these tests or for any other enquiries relating to Immunology contact the department on , or externally (020) Last updated August 2016 Page 23 of 23 Chris SCOTT / Sameer BAHAL / Emily ZINSER