A modified γ-retrovirus vector for X-linked severe combined immunodeficiency.

BACKGROUND: In previous clinical trials involving children with X-linked severe combined immunodeficiency (SCID-X1), a Moloney murine leukemia virus-based γ-retrovirus vector expressing interleukin-2 receptor γ-chain (γc) complementary DNA successfully restored immunity in most patients but resulted in vector-induced leukemia through enhancer-mediated mutagenesis in 25% of patients. We assessed the efficacy and safety of a self-inactivating retrovirus for the treatment of SCID-X1. METHODS: We enrolled nine boys with SCID-X1 in parallel trials in Europe and the United States to evaluate treatment with a self-inactivating (SIN) γ-retrovirus vector containing deletions in viral enhancer sequences expressing γc (SIN-γc). RESULTS: All patients received bone marrow-derived CD34+ cells transduced with the SIN-γc vector, without preparative conditioning. After 12.1 to 38.7 months of follow-up, eight of the nine children were still alive. One patient died from an overwhelming adenoviral infection before reconstitution with genetically modified T cells. Of the remaining eight patients, seven had recovery of peripheral-blood T cells that were functional and led to resolution of infections. The patients remained healthy thereafter. The kinetics of CD3+ T-cell recovery was not significantly different from that observed in previous trials. Assessment of insertion sites in peripheral blood from patients in the current trial as compared with those in previous trials revealed significantly less clustering of insertion sites within LMO2, MECOM, and other lymphoid proto-oncogenes in our patients. CONCLUSIONS: This modified γ-retrovirus vector was found to retain efficacy in the treatment of SCID-X1. The long-term effect of this therapy on leukemogenesis remains unknown. (Funded by the National Institutes of Health and others; ClinicalTrials.gov numbers, NCT01410019, NCT01175239, and NCT01129544.).

Green tea polyphenol extract in vivo attenuates inflammatory features of neutrophils from obese rats.

PURPOSE: Our study aimed to evaluate whether obesity induced by cafeteria diet changes the neutrophil effector/inflammatory function and whether treatment with green tea extract (GT) can improve neutrophil function. METHODS: Male Wistar rats were treated with GT by gavage (12 weeks/5 days/week; 500 mg/kg of body weight), and obesity was induced by cafeteria diet (8 weeks). Neutrophils were obtained from the peritoneal cavity (injection of oyster glycogen). The following analyses were performed: phagocytic capacity, chemotaxis, myeloperoxidase activity (MPO), hypochlorous acid (HOCl), superoxide anion (O 2 (·-) ), hydrogen peroxide (H2O2), IL-1ß, IL-6 and TNFα, mRNA levels of inflammatory genes, calcium mobilisation, activities of antioxidant enzymes, hexokinase and G6PDH. RESULTS: Neutrophils from obese rats showed a significant decrease in migration capacity, H2O2 and HOCl production, MPO activity and O 2 (·-) production. Phagocytosis and CD11b mRNA levels were increased, while inflammatory cytokines release remained unmodified. mRNA levels of TLR4 and IκK were enhanced. Treatment of obese rats with GT increased neutrophil migration, MPO activity, H2O2, HOCl and O 2 (·-) production, whereas TNF-α and IL-6 were decreased (versus obese). Similar reductions in TLR4, IκK and CD11b mRNA were observed. Catalase and hexokinase were increased by obesity, while SOD and G6PDH were decreased. Treatment with GT reduced catalase and increased the GSH/GSSG ratio. CONCLUSION: In response to a cafeteria diet, we found a decreased chemotaxis, H2O2 release, MPO activity and HOCl production. We also showed a significant immunomodulatory effect of GT on the obese condition recovering some of these factors such H2O2 and HOCl production, also reducing the levels of inflammatory cytokines.

[APPLICATION OF NEGATIVE PRESSURE THERAPY].

Negative pressure therapy is gradually taking an increasingly important role in the treatment of chronic wound healing because of its simple application in hospital or outpatient setting and good comfort with no pain for the patient. Chronic wound healing is accelerated in comparison with other conservative treatments. The level of negative pressure is between 40 and 125 mm Hg below ambient. Direct and indirect effect of the negative pressure therapy helps in wound healing and provides good preparation for definitive surgical management of wounds.

[BASIC PRINCIPLES OF SURGICAL TREATMENT OF CHRONIC WOUNDS ­ SHARP DEBRIDEMENT].

The ever improving health standards in terms of quality and more efficient health care result in an increase in life expectancy, thus increasing the number of elderly people in the population. A higher level of activity in elderly population leads to greater incidence of injuries, and on the other hand, there is an increasing number of comorbidities. Circulatory disorders, diabetes mellitus, metabolic imbalances, etc. and a reduced biological potential of tissue regeneration result in an increased number of chronic wounds that pose a significant health, social and economic burden on the society. These conditions require significant involvement of medical and non-medical staff in pre-hospital institutions. Significant material and other health care resources are allocated for the treatment of chronic wounds. These conditions result in a lower quality of life of patients and their families and caregivers. Debridement is a crucial medical procedure for the treatment of acute and chronic wounds. The result of debridement is removal of all barriers within and around the wound that obstruct physiological processes of wound healing. Debridement is a repeating process when indicated. There are several types of debridement, each with its advantages and disadvantages. The method of debridement should be determined by the physician or other professional trained person on the basis of wound characteristics and in accordance with their expertise and capabilities. In the same wound, we can combine different types of debridement, all with the goal of faster and better wound healing.

Microstructural alterations of femoral head articular cartilage and subchondral bone in osteoarthritis and osteoporosis.

OBJECTIVE: Explore whether osteoporosis (OP) in humans influences the morphological status of the articular cartilage and the subchondral bone. Explore the relationship between the macroscopic aspect of the articular surface and the rate of microscopic changes of both the cartilage and the subchondral bone in OP and osteoarthritis (OA). METHODS: Femoral heads after total hip replacement were obtained from patients with OP or hip OA (OP, n = 56; OA, n = 12). Cartilage degeneration was assessed using the Mankin grading system whereas subchondral bone was evaluated using histomorphometry and Micro-computed Tomography (µCT) scanning system. Thickness of the cartilage layers and subchondral cortical bone (SCB) was measured. RESULTS: Samples with higher total Mankin score have significantly reduced cartilage thickness. Mankin score differed between all OP specimens. In OP samples with lower Mankin scores the thickness of SCB shows a trend of an increase caused by increased levels of bone remodeling. In OP samples with higher Mankin scores we observed thinning of SCB. Structural indices of subchondral trabecular bone (STB) were significantly lower in OP than in OA samples. CONCLUSION: Thinning of SCB, found in OP samples with higher Mankin scores could be related with the progression of the cartilage degeneration indicating an early-stage OA. Increased levels of bone remodeling and evidently changed morphology of subchondral bone found in OP samples with lower Mankin score indicated that bony bed level must have a role in the progression of the cartilage degeneration.

Green tea catechins alone or in combination alter functional parameters of human neutrophils via suppressing the activation of TLR-4/NFκB p65 signal pathway.

The purpose of this study was to evaluate the potential of a mixture containing the four main catechins found in green tea, as well it separately, as modulators of the functional parameters of human neutrophils. The cells were obtained from peripheral blood of healthy individuals isolated and cultured with a mix: 30 µM of EGCG, 3 µM of EGC, 2 µM of ECG and 1.4 µM of EC, as well as each one alone. We evaluated the cytotoxicity of catechins, production of several reactive oxygen species (ROS), antioxidant enzymes (SOD, CAT, GPx and GR), Nrf2, TLR4/IKK/NFκB, CD11b mRNA levels, intracellular calcium release, chemotactic and phagocytic capacity, myeloperoxidase (MPO), and G6PDH activities, hypochlorous acid (HOCl) and pro-inflammatory cytokines release, protein levels of TLR4, p38 MAPK, iNOS and p-65 NFκB. The actions of the catechins were evidenced by the reduction in inflammatory parameters, including the suppression of TLR4, NFκB and iNOS protein expression, decreased release of TNF-α, IL-1ß and IL-6, migration capacity, MPO activity and HOCl production and the suppression of ROS, nitric oxide and peroxynitrite production, while inducing antioxidant enzyme activities and Nrf2 mRNA levels, phagocytic capacity and calcium release. Our results demonstrate that catechins present marked immunomodulatory actions, either alone or in combination.

Should we abandon regional anesthesia in open inguinal hernia repair in adults?

Inguinal hernia repair is a common worldwide surgical procedure usually done in the outpatient setting. The purpose of this systematic review is to make an evidence-based meta-analysis to determine the possible benefits of regional (neuraxial block) anesthesia compared to general anesthesia in open inguinal hernia repair in adults. Cochrane Library, Medline, EMBASE, CINAHL, SCI-EXPANDED, SCOPUS as well as trial registries, conference proceedings and reference lists were searched. Only randomized controlled trials (RCT) that compare neuraxial block (spinal or/and epidural) anesthesia (NABA) and general anesthesia (GA) were included. Main outcome measures were postoperative complications, urinary retention and postoperative pain. Seven RCTs were included in this review. A total of 308 patients were analyzed with 154 patients in each group. Overall complications were evenly distributed in NABA and in GA group [OR 1.17, 95 % CI (0.52-2.66)]. Urinary retention was statistically less frequent in GA group compared to NABA group [OR 0.25, 95 % CI (0.08-0.74)]. Movement-associated pain score 24 h after surgery was significantly lower in NABA group [SMD 5.59, 95 % CI (3.69-7.50)]. Time of first analgesia application was shorter in GA group [SMD 8.99, 95 % CI 6.10-11.89]. Compared to GA, NABA appears to be a more adequate technique in terms of postoperative pain control. However, when GA is applied, patients seem to have less voiding problems.

Stereologic parameters of nuclear ultrastructure as markers of the steroid receptor status in breast cancer epithelium.

The nuclear specific surface density (Sv/Vv), mean nuclear area (A) and numerical density (Nv) of tumor cell nuclei from 30 primary invasive female breast carcinomas with known concentrations of estrogen and progesterone receptors (ER and PR), were morphometrically analyzed at the ultrastructural level. It was found that carcinomas with concordant positive ER and PR status contained significantly higher number of smaller nuclei per volume unit of epithelium (mean Nv = 1.5 x 10(6) mm-3, mean A = 27 microns 2), than carcinomas of negative concordant receptor status (mean Nv = 0.8 x 10(6) mm-3, mean = 37 microns 2). Tumor cell nuclei of the former frequently displayed an elliptic shape (mean Sv/Vv = 1.16 microns-1), and had deeply invaginated surfaces, whereas nuclei of the latter were more frequently ball-shaped and exhibited a smooth-surface (mean Sv/Vv = 0.88 microns-1). The numerical density Nv (NUC/EPI) of tumor cell nuclei turned out to be a most reliable morphological marker of the concordant ER and PR status (overall efficiency = 84%, p < 0.01). The nuclear surface and volume ratio and mean nuclear area also appear to be reliable markers for terminal stages of the biochemical differentiation of breast carcinoma (overall efficiency = 79%, p < 0.05).

Position specific morphological characteristics of top-level male handball players.

With the aim of determining the common morphological features of senior male handball players and of analyzing their specificities i.e. the probable variation between the four playing positions (back court players, wings, pivots, goalkeepers), 25 anthropometric measures were applied to the sample of 49 players, members of three top-quality handball teams. The basic descriptive parameters were calculated and then an analysis of variance and a cluster analysis were performed. A mesomorphic, athletic body- type was obtained with a marked longitudinal skeleton dimensionality, but also with a balanced ratio between the skeletal system and muscle mass and with low values of subcutaneous fat tissue. Back court players and goalkeepers are superior in terms of outstanding skeletal dimensions and circumferences. Line players, i.e. wings and pivots, have somewhat lower longitudinal measures, whereas pronounced voluminosity and a slightly higher fat tissue value differentiate pivots from players in other positions. Cluster analysis revealed a greater homogeneity in the morphological profiles of the samples of line players (wings and pivots) than in the profiles of backs or goalkeepers. The obtained position-related differences in morphological characteristics of players suggest that the experienced players from the sample were earlier successfully subjected to the selection process and oriented to a particular playing position because of the observed correspondence between their body-type and specific kinesiological demands of the position in question. Therefore, in top-quality team-handball it would be recommendable to select players whose morphological profiles are as compatible as possible with positional specificities in the demand for the game.

Anthropometric characteristics of high level European junior basketball players.

The purpose of the research was to assess anthropometric status of European high-level junior basketball players and to determine anthropometric differences between the players playing in different game positions (guards, forwards, centers). The sample consisted of 132 young basketball players, participants of the European Junior Basketball Championship, Zadar, 2000. Participants were measured with 31 measures (anthropometric variables), on the basis of which two body composition measures (BMI and relative body fat) and somatotype were calculated. The basic statistical parameters were computed. The analysis of variance and discriminant canonical analysis were employed to determine the differences between positions in play. Results indicate that prominent longitudinal and transversal skeletal dimensions as well as circumference measures characterize players on the position of centers, but they do not have significantly larger skinfold measures in relation to forwards. Centers are also predominantly ectomorphic compared with other players. Guards achieved significantly lower values in all spaces and they are predominantly mesomorphic. Further investigations are necessary in order to assess potential changes in status of these parameters when the participants will reach the age of senior players and afterwards, as well as to determine relations between anthropometric status and skill related variables.

Tratamiento del asma severo con omalizumab: experiencia pediátrica en Chile y revisión de la literatura / Omalizumab treatment on severe asthma patients: pediatric experience in Chile and literature review

This paper presents clinical experience with Omalizumab treatment in 8 pediatric patients in Chile. All children presented difficult to control asthma despite receiving high intensity treatment, with low quality of life. All patients were studied in order to discard errors in asthma diagnosis and to evaluate asthma treatment adherence and inhalation technique. After evaluation, patients proven to have severe therapy resistant asthma were indicated treatment with Omalizumab. Significant clinical improvement was observed, with reduced asthma symptoms and number of exacerbations, as well as an improved quality of life. Omalizumab showed a good safety profile with mild and transient adverse reactions in 6 administrations of a total of 122.

Se presenta la experiencia clínica con el uso de Omalizumab en 8 pacientes pediátricos en nuestro país. Todos los pacientes presentaban asma sin control a pesar de recibir terapia de alta intensidad, asociado a una muy deficiente calidad de vida. La totalidad de los pacientes fueron sometidos en cada centro a un estudio exhaustivo para poder descartar error en el diagnóstico y se evaluó la adherencia y la técnica inhalada. Al comprobarse que estos pacientes tenían asma severo resistente a tratamiento se indicó Omalizumab, el cual produjo una mejoría clínica significativa. Se observó una reducción de las exacerbaciones y de los síntomas de asma acompañado de una mejoría de la calidad de vida, asociado a un buen perfil de seguridad. Se observaron reacciones adversas leves y transitorias en 6 administraciones de un total de 122.

Inmunodeficiencias y su relación con enfermedades autoinmunes / Immunodeficiencies and their relation with autoinmune diseases

Aunque pueda parecer paradójico, las inmunodeficiencias primarias y la secundaria a infección por VIH frecuentemente se complican con enfermedades autoinmunes. Esto debido a la desregulación del sistema inmune y a la activación policlonal debida a infecciones recurrentes. Se revisan diversas enfermedades autoinmunes y autoanticuerpos asociados con ambos tipos de inmunodeficiencias. Las enfermedades autoinmunes pueden ser la primera manifestación de una inmunodeficiencia, por lo que deben estudiarse especialmente si la enfermedad autoinmune es atípica. Las patologías más frecuentemente asociadas son las citopenias autoinmunes y los enfermedades reumatológicas. Debe realizarse una exclusión completa de las infecciones coincidentes o posiblemente causantes de complicaciones autoinmunes antes de iniciar tratamientos específicos para ellas.

Although it may seem paradoxical, primary immunodeficiencies and HIV immunodeficiency are frecuently complicated by autoimmune conditions. This is because of the immune system disregulation and polyclonal activation due to recurrent infections. We review various autoimmune diseases and autoantibodies associated with both types of immunodeficiencies. Autoimmune diseases my be the first manifestation of an immunodeficiency, so we should screen for it, specially if this autoimmune disease is atypical. The most frecuent disease associated with immunodeficiencies are autoimmune cytopenias and rheumatologic disorders. A through exclusion of infections coincident with or possibly causative of autoimmune complication should be undertaken before initiating specific treatments for autoimmune disease in this patients.

[Immunotherapy against hymenoptera venom: report of ten patients]. / Inmunoterapia con veneno de himenópteros: presentación de diez casos clínicos.

BACKGROUND: Immunotherapy can be used to treat allergic reactions to insect stings, specially bees and wasps. AIM: To report the experience with immunotherapy with aqueous extracts of hymenoptera venoms (bees and wasps). MATERIAL AND METHODS: Ten patients aged 6 to 58 years were treated in an allergy center of a University Clinical Hospital. The medical indication for this treatment was, in all patients, anaphylactic reactions after hymenoptera stings. Immunotherapy was carried out using standardized vaccines (Aqueous extracts Venomvac LETI, Spain), applied in a traditional protocol, with subcutaneous injections. This protocol had two phases: a buildup phase (between weeks 1 and 13) and a monthly maintenance phase, from the 13th week. The monthly maintenance dose was 100 fig of hymenoptera specific venom extract. RESULTS: Six patients had adverse reactions of different severity, during the treatment protocols and all had a good response to immediate therapeutic measures. After these events, they followed the protocol without problems. Two patients, treated with bee vaccines, suffered an accidental bee sting during the maintenance phase and they developed only local reactions. CONCLUSIONS: The lack of adverse reactions to bee stings in these two patients indicates the acquisition of clinical tolerance.

[Antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis associated to the use of propylthiouracil. Report of four cases]. / Vasculitis ANCA-positivo en pacientes hipertiroideos usuarios de propiltiouracilo: Report of four cases.

Antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis is an uncommon complication of the use of propylthiouracil. When it occurs, it affects multiple organs as any systemic vasculitis. We report three females and one male, aged 30, 40, 43 and 41 years respectively, that after a lapse of 12 to 28 months of propylthiouracil use, presented clinical signs of vasculitis. All had high titers of ANCA against myeloperoxidase. In three patients, a skin biopsy confirmed the diagnosis. The condition subsided when propylthiouracil was discontinued, but one female patient required the use of prednisone.

[Immune modulating effect of intravenous gamma globulin in a patient with overlapping syndrome]. / Efecto inmunomodulador de gamaglobulina endovenosa en un caso de síndrome de sobreposición.

We report a 46 years old woman with a diagnosis of systemic lupus erythematosus and scleroderma overlapping syndrome. During treatment with steroids and azathioprine, the appearance of paresthesias and a progressive invalidating proximal weakness was interpreted as a steroidal myopathy. Steroidal treatment was progressively discontinued, but lupic activity and esophageal involvement exacerbated. Therefore, the use of immune modulating doses of intravenous gamma globulin (2 g/kg/total dose) was decided. The patient received this dose in two consecutive days and, 48 hours later, a notable improvement in esophageal function and general condition was verified. After six months of follow up, the disease remains inactive.

[Characteristics of hospitalization of patients with rheumatic diseases admitted to a tertiary care hospital]. / Características de la hospitalización reumatológica en un hospital de nivel terciario.

BACKGROUND: The diagnostic profile of patients with rheumatic diseases admitted to a general hospital is variable. AIM: To report the epidemiological profile of patients with rheumatic diseases admitted to a tertiary care hospital. MATERIAL AND METHODS: All admissions to a Medicine ward of a general hospital and seen by the Rheumatology team were prospectively registered during one year in 1999. Patients were classified as primarily admitted for a rheumatic disease or admitted for other cause that required a consultation with the Rheumatology team. RESULTS: One hundred forty five admissions due to rheumatic diseases were registered. Of these, 82 were due to primary rheumatic diseases. Systemic lupus erythematosus, rheumatoid arthritis and vasculitis were the main diagnoses and the mean hospital stay was 18.5 days. Sixty three patients required a consultation with the Rheumatology team specially due to osteoarthritis and crystal induced diseases. CONCLUSIONS: Admissions due to rheumatic diseases are prolonged, correspond to 0.46% of all admissions and the main responsible disease is systemic lupus erythematosus.

Tumour necrosis factor alpha and nuclear factor kappaB inhibit transcription of human TFF3 encoding a gastrointestinal healing peptide.

BACKGROUND: and aims: Tumour necrosis factor alpha (TNF-alpha) induction of nuclear factor kappaB (NFkappaB) activation plays a major role in the pathogenesis of inflammatory bowel disease (IBD). Trefoil factor family peptides TFF1, TFF2, and TFF3 exert protective, curative, and tumour suppressive functions in the gastrointestinal tract. In this study, we investigated effects of the TNF-alpha/NFkappaB regulatory pathway by TNF-alpha on expression of TFFs. METHODS: After TNF-alpha stimulation, expression of TFF genes was analysed by quantitative real time polymerase chain reaction and by reporter gene assays in the gastrointestinal tumour cell lines HT-29 and KATO III. Additionally, NFkappaB subunits and a constitutive repressive form of inhibitory factor kappaB (IkappaB) were transiently coexpressed. In vivo, morphological changes and expression of TFF3, mucins, and NFkappaB were monitored by immunohistochemistry in a rat model of 2,4,6-trinitrobenzene sulphonic acid induced colitis. RESULTS: TNF-alpha stimulation evoked up to 10-fold reduction of TFF3 expression in the colon tumour cell line HT-29. Downregulation of reporter gene transcription of TFF3 was observed with both TNF-alpha and NFkappaB, and was reversible by IkappaB. In vivo, the increase in epithelial expression of NFkappaB coincided with reduced TFF3 expression during the acute phase of experimental colitis. CONCLUSIONS: Downregulation of intestinal trefoil factor TFF3 is caused by repression of transcription through TNF-alpha and NFkappaB activation in vitro. In IBD, perpetual activation of NFkappaB activity may contribute to ulceration and decreased wound healing through reduced TFF3.

Inmunopatogenia de la arteritis de la temporal / Immunopathogenesis of temporal arteritis

La arteritis de la temporal, clasificada como una vasculitis que compromete vasos de gran y mediano calibre, debe ser considerada como una emergencia médica, dado el potencial de causar ceguera y accidentes vasculares. La lesión típica corresponde a granulomas en la pared vascular, los que están constituidos por macrófagos y célulasT CD4+. Éstos se activan en la adventicia, luego de interactuar con las células dendríticas nativas. La injuria tisular es mediada por diversos subtipos de macrófagos, los que ejercen las diferentes funciones efectoras. El daño que domina en la capa media resulta del estrés oxidativo y determina la apoptosis de las células musculares lisas y la nitración de las endoteliales. Por otro lado, factores de crecimiento derivados de macrófagos determinan la hiperplasia intimal y la consecuente oclusión luminal. Las manifestaciones clínicas se relacionan estrechamente con el sitio isquémico. El tratamiento de elección son los corticoides sistémicos, los cuales pueden asociarse a inmunosupresores como también con agentes biológicos.

Temporal arthritis, which is classified as a large-and medium-caliber vessel vasculitis, should be considered as a medical emergency, given its potential to cause blindness and strokes. The injury typically corresponds to granulomas in the vascular wall, which are composed of macrophages and CD4+ T cells. They are activated in the adventitia, after interacting with native dendritic cells. Immunopathological mechanisms involve different subtypes of macrophaesges, which exert different effector functions. Damage that prevails within the median layer is secondary to oxidative stress and triggers apoptosis of smooth muscle cells and nitration of endothelial cells. On the other hand, growth factors derived from macrophages determine intimal hyperplasia and subsequent luminal occlusion. Clinical manifestations are closely related to the ischemic site. The treatment of choice is systemic corticosteroids, which can be associated with immunosuppressive drugs as well as biological agents.

Inmunoterapia con veneno de himenópteros: presentación de diez casos clínicos / Immunotherapy against hymenoptera venom: Report of ten patients

Background: Immunotherapy can be used to treat allergic reactions to insect stings, specially bees and wasps. Aim: To report the experience with immunotherapy with aqueous extracts of hymenoptera venoms (bees and wasps). Material and methods: Ten patients aged 6 to 58 years were treated in an allergy center of a University Clinical Hospital. The medical indication for this treatment was, in all patients, anaphylactic reactions after hymenoptera stings. Immunotherapy was carried out using standardized vaccines (Aqueous extracts Venomvac LETI, Spain), applied in a traditional protocol, with subcutaneous injections. This protocol had two phases: a buildup phase (between weeks 1 and 13) and a monthly maintenance phase, from the 13th week. The monthly maintenance dose was 100 fig of hymenoptera specific venom extract. Results: Six patients had adverse reactions of different severity, during the treatment protocols and all had a good response to immediate therapeutic measures. After these events, they followed the protocol without problems. Two patients, treated with bee vaccines, suffered an accidental bee sting during the maintenance phase and they developed only local reactions. Conclusions: The lack of adverse reactions to bee stings in these two patients indicates the acquisition of clinical tolerance.