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Last reviewed: 30 Oct 2023
Last updated: 20 Sep 2022



History and exam

Key diagnostic factors

  • recurrent infection
  • infection with Streptococcus pneumoniae or Haemophilus species
  • infection with atypical pathogens
  • repeated antibiotic use
  • respiratory crackles, high-pitched inspiratory squeaks, rhonchi
More key diagnostic factors

Other diagnostic factors

  • absence from school/work
  • failure to thrive
  • diarrhea
  • sinusitis
  • pallor
  • tympanic membrane perforation
  • illness after live vaccines
  • weight loss, night sweats, fevers
  • edema
  • alopecia, goiter, vitiligo
  • eczema
  • small/absent tonsils
  • lymphadenopathy and hepatosplenomegaly
  • history of celiac disease or transfusion reactions
  • muscle fatigability, ptosis, diplopia (if thymoma present)
  • dysmorphic features
  • neurologic involvement
Other diagnostic factors

Risk factors

  • male sex
  • positive family history of primary immunodeficiency
  • severe protein-losing state
  • hematologic malignancy
  • anticonvulsant and immunosuppressive drugs
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC
  • serum IgG
  • serum IgA
  • serum IgM
  • serum and urine electrophoresis
  • serum free light chains
  • urine dipstick
  • serum creatinine
  • serum albumin
  • LFTs
  • sputum culture
  • stool culture
  • chest x-ray
More 1st investigations to order

Investigations to consider

  • flow cytometry: lymphocyte subsets
  • specific antimicrobial antibodies
  • test immunization response
  • IgG subclasses
  • flow cytometry: protein expression
  • genetic testing
  • enzyme assays
  • abdominal ultrasound
  • CT chest/sinuses
  • CT abdomen
  • pulmonary function test
  • lymph node biopsy
  • small- and large-bowel biopsy
  • polymerase chain reaction (PCR) for viral infection
  • hepatitis B surface antigen, hepatitis B and C PCR
More investigations to consider

Treatment algorithm


primary hypogammaglobulinemia

secondary hypogammaglobulinemia



Sara Barmettler, MD

Allergy and Clinical Immunology Unit

Division of Rheumatology, Allergy & Immunology

Massachusetts General Hospital




SB is an author of some references cited in this topic. SB was on a scientific advisory board for CSL Behring.


Dr Sara Barmettler would like to gratefully acknowledge Dr Mohammed Yousuf Karim, Dr Patrick Yong, and Dr Zoe Adhya, previous contributors to this topic.


MYK serves on the advisory board for Allergy Therapeutics. PY and ZA declare that they have no competing interests.

Peer reviewers

John B. Ziegler, MD

Associate Professor of Pediatrics

University of New South Wales

Department of Immunology and Infectious Diseases

Sydney Children's Hospital





JBZ declares that he has no competing interests.

Charlotte Cunningham-Rundles, MD, PhD

Professor of Medicine and Pediatrics

Immunology Institute

Mount Sinai School of Medicine

New York



CCR is an author of several references cited in this topic.

David Webster, MD, FRCP, FRCPath

Honorary Clinical Scientist

UCL Centre for Primary Immunodeficiency

University College London Medical School

Department of Immunology

Royal Free Hospital




DW declares that he has no competing interests.

  • Differentials

    • Specific antibody deficiency
    • Hyposplenism
    • Complement deficiency
    More Differentials
  • Guidelines

    • Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: a Work Group report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees
    • Criteria for the clinical use of intravenous immunoglobulin in Australia
    More Guidelines
  • Patient leaflets


    Pneumonia: do I need a vaccine?

    More Patient leaflets
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