In vivo neutralization of bee venom lethality by IgY antibodies.

Bee venom is a complex mixture of molecules, among which melittin and phospholipase A2 (PLA2) are the toxic components involved in envenoming accidents with multiple honeybee stings. Traditionally, the treatment of envenomings has been based on the administration of specific antibodies to neutralize the deleterious effects of toxins. An alternative to mammalian polyclonal antibodies is the use of egg yolk immunoglobulins (IgY) due to their advantages regarding animal welfare and lower costs of production as compared to the conventional production methods. In this work, a novel composition containing specific IgY antibodies was developed. After four immunizations, IgY extracted from the egg yolks was able to recognize several components of the bee venom, including melittin and PLA2. The performance of IgY to neutralize the lethal activity was evaluated in a mouse model by using one median lethal dose (LD50) of the bee venom. The effective dose of the IgY extract was determined as 30.66 µg/mg. These results demonstrate the feasibility to produce IgY-based antivenoms to treat envenomings by multiple bee stings.

Functional traits linked to pathogen prevalence in wild bee communities.

Reports of pollinator declines have prompted efforts to understand contributing factors and protect vulnerable species. While pathogens can be widespread in bee communities, less is known about factors shaping pathogen prevalence among species. Functional traits are often used to predict susceptibility to stressors, including pathogens, in other species-rich communities. Here, we evaluated the relationship between bee functional traits (body size, phenology, nesting location, sociality, and foraging choice) and prevalence of trypanosomes, neogregarines, and the microsporidian Nosema ceranae in wild bee communities. For the most abundant bee species in our system, Bombus impatiens, we also evaluated the relationship between intra-specific size variation and pathogen prevalence. A trait-based model fit the neogregarine prevalence data better than a taxa-based model, while the taxonomic model provided a better model fit for N. ceranae prevalence, and there was no marked difference between the models for trypanosome prevalence. We found that Augochlorella aurata was more likely to harbor trypanosomes than many other bee taxa. Similarly, we found that bigger bees and those with peak activity later in the season were less likely to harbor trypanosomes, though the effect of size was largely driven by A. aurata. We found no clear intra-specific size patterns for pathogen prevalence in B. impatiens. These results indicate that functional traits are not always better than taxonomic affinity in predicting pathogen prevalence, but can help to explain prevalence depending on the pathogen in species-rich bee communities.

Role of Human Action in the Spread of Honey Bee (Hymenoptera: Apidae) Pathogens.

The increased annual losses in European honey bee (Apis mellifera) colonies in North America and some other countries is usually attributed to a range of factors including pathogens, poor nutrition, and insecticides. In this essay, I will argue that the global trade in honey bees and migratory beekeeping practices within countries has enabled pathogens to spread quickly. Beekeepers' management strategies have also contributed to the spread of pathogens as well as the development of resistance to miticides and antibiotics, and exacerbated by hobby beekeepers. The opportunities for arresting honey bee declines rest as strongly with individual beekeepers as they do with the dynamics of disease.

Approaches and Challenges to Managing Nosema (Microspora: Nosematidae) Parasites in Honey Bee (Hymenoptera: Apidae) Colonies.

UNLABELLED: The microsporidia Nosema apis (Zander) and Nosema ceranae (Fries) are common intestinal parasites in honey bee (Apis mellifera L.) colonies. Though globally prevalent, there are mixed reports of Nosema infection costs, with some regions reporting high parasite virulence and colony losses, while others REPORT: high Nosema prevalence but few costs. Basic and applied studies are urgently needed to help beekeepers effectively manage Nosema spp., ideally through an integrated pest management approach that allows beekeepers to deploy multiple strategies to control Nosema when Nosema is likely to cause damage to the colonies, rather than using prophylactic treatments. Beekeepers need practical and affordable technologies that facilitate disease diagnosis and science-backed guidelines that recommend when, if at all, to treat infections. In addition, new treatment methods are needed, as there are several problems associated with the chemical use of fumagillin (the only currently extensively studied, but not globally available treatment) to control Nosema parasites. Though selective breeding of Nosema-resistant or tolerant bees may offer a long-term, sustainable solution to Nosema management, other treatments are needed in the interim. Furthermore, the validation of alternative treatment efficacy in field settings is needed along with toxicology assays to ensure that treatments do not have unintended, adverse effects on honey bees or humans. Finally, given variation in Nosema virulence, development of regional management guidelines, rather than universal guidelines, may provide optimal and cost-effective Nosema management, though more research is needed before regional plans can be developed.

Allergenicity of Gramineae bee-collected pollen is proportional to its mass but is highly variable and depends on the members of the Gramineae family

BACKGROUND: Gramineae bee-collected pollen is identified as being at the origin of allergic accidents but the biological potency of Gramineae bee-collected pollen is not well known. Cereal grasses (e.g., Zea) and European wild forage grasses (FG) are contained in bee-collected pollen. METHOD: In this experiment, Zea-mass and FG-mass were identified in bee pollen mass and the proportion of Zea and of FG was calculated using the bee pollen melissopalynology spectrum. Skin reactivity to Zea and to FG were assessed by measuring wheal diameters (W) from skin prick tests using three serial dilutions of bee-collected pollen on 10 allergic patients to Gramineae, in order to calculate the relationship between Zea mass (Masszea) or FG mass (MassFG) in bee pollen and skin reactivity. RESULTS: The linear function Log10(WFG) = 0.24(Log10(MassFG)) + 0.33 (R = 0.99) was established using a bee pollen sample with 0.168 mg of FG pollen per mg. The linear function Log10(Wzea) = 0.23(Log10(Masszea)) + 0.14 (R = 0.99) was established using a bee pollen sample with 0.983 mg of Zea pollen per mg. Gramineae allergens seem to be little altered by bee secretions. Gramineae bee pollen retains its allergenic capacity but it depends on the members of the Gramineae family. CONCLUSIONS: To our knowledge this is the first time it has been shown that skin reactivity to Gramineae is proportional to the absolute Gramineae mass contained in the bee-collected pollen and that it depends on the members of the Gramineae family

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Adding Biotic Interactions into Paleodistribution Models: A Host-Cleptoparasite Complex of Neotropical Orchid Bees.

Orchid bees compose an exclusive Neotropical pollinators group, with bright body coloration. Several of those species build their own nests, while others are reported as nest cleptoparasites. Here, the objective was to evaluate whether the inclusion of a strong biotic interaction, such as the presence of a host species, improved the ability of species distribution models (SDMs) to predict the geographic range of the cleptoparasite species. The target species were Aglae caerulea and its host species Eulaema nigrita. Additionally, since A. caerulea is more frequently found in the Amazon rather than the Cerrado areas, a secondary objective was to evaluate whether this species is increasing or decreasing its distribution given South American past and current climatic conditions. SDMs methods (Maxent and Bioclim), in addition with current and past South American climatic conditions, as well as the occurrences for A. caerulea and E. nigrita were used to generate the distribution models. The distribution of A. caerulea was generated with and without the inclusion of the distribution of E. nigrita as a predictor variable. The results indicate A. caerulea was barely affected by past climatic conditions and the populations from the Cerrado savanna could be at least 21,000 years old (the last glacial maximum), as well as the Amazonian ones. On the other hand, in this study, the inclusion of the host-cleptoparasite interaction complex did not statistically improve the quality of the produced models, which means that the geographic range of this cleptoparasite species is mainly constrained by climate and not by the presence of the host species. Nonetheless, this could also be caused by unknown complexes of other Euglossini hosts with A. caerulea, which still are still needed to be described by science.

Tetracycline-resistance encoding plasmids from Paenibacillus larvae, the causal agent of American foulbrood disease, isolated from commercial honeys

Paenibacillus larvae, the causal agent of American foulbrood disease in honeybees, acquires tetracycline-resistance via native plasmids carrying known tetracycline-resistance determinants. From three P. larvae tetracycline-resistant strains isolated from honeys, 5-kb-circular plasmids with almost identical sequences, designated pPL373 in strain PL373, pPL374 in strain PL374, and pPL395 in strain PL395, were isolated. These plasmids were highly similar (99%) to small tetracycline-encoding plasmids (pMA67, pBHS24, pBSDMV46A, pDMV2, pSU1, pAST4, and pLS55) that replicate by the rolling circle mechanism. Nucleotide sequences comparisons showed that pPL373, pPL374, and pPL395 mainly differed from the previously reported P. larvae plasmid pMA67 in the oriT region and mob genes. These differences suggest alternative mobilization and/or conjugation capacities. Plasmids pPL373, pPL374, and pPL395 were individually transferred by electroporation and stably maintained in tetracycline-susceptible P. larvae NRRL B-14154, in which they autonomously replicated. The presence of nearly identical plasmids in five different genera of gram-positive bacteria, i.e., Bhargavaea, Bacillus, Lactobacillus, Paenibacillus, and Sporosarcina, inhabiting diverse ecological niches provides further evidence of the genetic transfer of tetracycline resistance among environmental bacteria from soils, food, and marine habitats and from pathogenic bacteria such as P. larvae (AU)

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Gut microbiota instead of host genotype drive the specificity in the interaction of a natural host-parasite system.

Specific interactions between parasite genotypes and host genotypes (G(p) × G(h)) are commonly found in invertebrate systems, but are largely lacking a mechanistic explanation. The genotype of invertebrate hosts can be complemented by the genomes of microorganisms living on or within the host ('microbiota'). We investigated whether the bacterial gut microbiota of bumble bees (Bombus terrestris) can account for the specificity of interactions between individuals from different colonies (previously taken as host genotype proxy) and genotypes of the parasite Crithidia bombi. For this, we transplanted the microbiota between individuals of six colonies. Both the general infection load and the specific success of different C. bombi genotypes were mostly driven by the microbiota, rather than by worker genotype. Variation in gut microbiota can therefore be responsible for specific immune phenotypes and the evolution of gut parasites may be driven by interactions with 'microbiota types' as well as with host genotypes.

Evaluación ecotoxicológica de dos derivados del Nim en lombriz de tierra y abejas / Ecotoxicological assessment of two Neem derivatives in earthworm and honey bees

La utilización de productos con bajo o nulo impacto en organismos circundantes y el ambiente, constituye parte del nuevo concepto de protección de cultivos. Los productos NeoNim 60 y OleoNim 80, obtenidos del árbol del Nim, están propuestos para su uso como insecticida, nematicida y acaricida. Con el objetivo de realizar la evaluación ecotoxicológica de estos productos, se realizaron los ensayos de toxicidad aguda en lombriz de tierra Eisenia andrei y de toxicidad aguda por contacto en abejas Apis mellifera. Cada ensayo contó con un grupo control y dos tratados. El ensayo en lombrices se realizó durante 14 días utilizando suelo artificial, realizando observaciones clínicas, conteo de animales y estudio del comportamiento de la biomasa. La prueba en abejas se prolongó por 48 horas, realizándose observaciones clínicas y conteo de animales. Se obtuvo un 100% de supervivencia en las lombrices de los grupos tratados, obteniendo en el NeoNim 60 valores de disminución de la biomasa significativamente inferiores al grupo control, mientras que el grupo tratado con OleoNim 80 mostró aumento en la biomasa del inicio al final del ensayo. En el ensayo en abejas, la comparación estadística no mostró diferencias entre grupos en cuanto a la mortalidad. Teniendo en cuenta el conjunto de los resultados obtenidos, se pudo concluir que los derivados del Nim NeoNim 60 y OleoNim 80 no producen efecto tóxico sobre las lombrices de tierra y las abejas (AU)

The use of products with low or null impact in surroundingorganisms and the environment constitutes part of the new concept of crop protection. The products NeoNim 60 and OleoNim 80, obtained from the Neem tree, are proposed for its use as insecticide, nematicide and acaricide. With the objective of perform the ecotoxicological assessment of these products, it were carried out the earthworm acute toxicity and the honey bee acute contact toxicity tests. For each assay two Treated and one Control group were established. The assay in earthworms Eisenia andrei was carried out during 14 days using artificial soil, with daily clinical observations, count of animals and study of the changes of the biomass. The test in honey bees Apis mellifera was prolonged for 48 hours, with daily clinical observations and count of animals. A survival of 100% was obtained in the earthworms of the Treated groups, obtaining in the NeoNim 60 group significative lower values of biomass when compared to the Control, while the group treated with OleoNim 80 showed an increase in the biomass from the beginning to the end of the assay. In the assay in bees, the statistical comparison didn't show differences among groups as for the mortality. Taken into account the obtained results, it could be concluded that the Neem derivatives NeoNim 60 and OleoNim 80 don't produce toxic effect on the earthworms and the honeybees (AU)

Short-sighted evolution of virulence in parasitic honeybee workers (Apis mellifera capensis Esch.).

The short-sighted selection hypothesis for parasite virulence predicts that winners of within-host competition are poorer at transmission to new hosts. Social parasitism by self-replicating, female-producing workers occurs in the Cape honeybee Apis mellifera capensis, and colonies of other honeybee subspecies are susceptible hosts. We found high within-host virulence but low transmission rates in a clone of social parasitic A. m. capensis workers invading the neighbouring subspecies A. m. scutellata. In contrast, parasitic workers from the endemic range of A. m. capensis showed low within-host virulence but high transmission rates. This suggests a short-sighted selection scenario for the host-parasite co-evolution in the invasive range of the Cape honeybee, probably facilitated by beekeeping-assisted parasite transmission in apiaries.

Bee and bee products allergy in Turkish beekeepers: determination of risk factors for systemic reactions / Alergia a la abeja y a los productos de la abeja en apicultores turcos: determinación de los factores de riesgo de reacciones sitémicas

Background: The prevalence of allergic reactions due to bee stings in beekeepers varies in different regions of the world. The aim of this study was to evaluate the characteristics of sting reactions and the risk factors for developing systemic reactions in Turkish beekeepers. Methods: A self-administered questionnaire was distributed to 1250 beekeepers to be completed in seven different cities of Turkey. A total of 494 (39.6 %) questionnaires were returned. Results: There were 444 subjects (89.9 %) with a history of sting exposure in the previous 12 months. Systemic reactions were present in 29 subjects (6.5 %) and nine (2 %) reactions were anaphylactic. Fifty-five percent of beekeepers reported more than 100 bee stings in the previous year. When systemic reactions were controlled by age and duration of beekeeping in a logistic regression model, seasonal rhinitis (OR: 4.4, 95 % CI: 1.2-11.5), perennial rhinitis (OR: 4.6, 95 % CI: 1.2-18.2), food allergy (OR:7.0, 95 % CI: 2.0-25.0), physician-diagnosed asthma (OR: 8.0, 95 % CI: 2.5-25.6), having an atopic disease of any type (OR: 3.3, 95 % CI: 1.2-8.7) and having two or more atopic diseases (OR: 10.9, 95 % CI: 3.5-33.8) were significantly associated with systemic reactions due to bee sting in the previous 12 months. Conclusion: The incidence of systemic reactions in Turkish beekeepers is low, which might be due to the protective effect of a high frequency of bee stings. The risk of systemic reactions increases approximately three-fold when one atopic disease is present and eleven-fold when two or more concurrent atopic diseases are present with respect to no atopic disease

Antecedentes: la prevalencia de las reacciones alérgicas por la picadura de abejas en los apicultores varia en las diferentes regiones del mundo. Este estudio está encaminado a evaluar las características de las reacciones a la picadura y los factores de riesgo para que tengan lugar reacciones sistémicas en los apicultores turcos. Métodos: Se envió un cuestionario a 1.250 apicultores de siete ciudades diferentes de Turquía, para que lo retornarán tras cumplimentarlo, lo que hicieron 494 (39,6%) de ellos. Resultados: En los 12 últimos meses, 444 (89,9%) de los apicultores habían sufrido picaduras. 29 (6,5%) habían tenido reacciones sistémicas, 9 de ellas (2%) reacciones anafilácticas. El 55% de los apicultores habían sido sufrido más de 100 picaduras en el último año. Cuando las reacciones sistémicas se controlaron en función de la edad y la duración de la apicultura en un modelo de regresión logística, la rinitis estacional (OR: 4.4, 95% CI:1.2-11.5), rinitis perenne (OR: 4.6, 95% CI:1.2-18.2), alergia alimentaria (OR: 7.0, 95% CI:2.0-25.0), asma diagnosticada por el médico (OR: 8.0, 95% CI: 2.5-25.6), tener una enfermedad atópica (OR: 3.3, 95% CI: 1.2-8.7), y tener dos o más enfermedades atópicas (OR: 10.9, 95% CI: 3.5-33.8), estaban asociadas significativamente con reacciones sistémicas causadas por picadura de abeja en al menos los últimos 12 meses. Conclusión: la incidencia de reacciones sistémicas en los apicultores turcos es baja, lo que puede deberse al efecto protector de la alta frecuencia de picaduras de abeja. El riesgo de reacciones sistémicas aumenta aproximadamente tres veces cuando el apicultor ya padece una enfermedad atópica y once veces cuando concurren dos o más enfermedades atópicas, en comparación con los apicultores que no padecen enfermedades de esta naturaleza

Bugged.

This was a great save. The crew could easily have missed the presentation of anaphylaxis and let the window for treatment with epinephrine slip away. This patient was in anaphylactic shock. There were no signs that supported a traumatic injury, and that, combined with diaphoresis, urticaria and tachycardic central pulse, contributed to the suspicion of anaphylaxis. Anaphylaxis is classified as distributive shock. This type of shock is caused by profound systemic vasodilation, and the heart is unable to increase output enough to maintain blood pressure. Other causes of distributive shock include sepsis and spinal cord injury. It is rare to have both hypotension and wheezing in such cases. In an anaphylactic reaction, an allergen, such as a food protein, medication, insect venom or latex, is introduced into the body. The mast cells of the immune system have a protein on their surface called IgE antibodies (Immunoglobulin E). The mast cells are filled with histamines [table: see text] and leukotrienes, which are chemical mediators. These are released when the allergen reacts with the IgE antibodies. When these mediators are released, they cause smooth-muscle constriction in the respiratory and gastrointestinal tracts, resulting in wheezing, stridor, nausea, vomiting and diarrhea. They also cause vascular dilation, leading to edema and urticaria. Most patients will present with either profound vascular effect (shock) or wheezing; this is a rather rare presentation of a patient having both. The medication best suited to counteract the effects of these medicators is epinephrine. Epinephrine is an alpha- and beta-agonist, acting to constrict the vasculature and dilate the smooth muscles in the bronchial tree. Antihistamines can alleviate symptoms of anaphylaxis, but should only be used in addition to epinephrine, not as a substitute. In life-threatening reactions, epinephrine must be given quickly and in a form that the body can distribute. Use of the subcutaneous route with a solution mixed at 1:1,000 dilution is appropriate in most patients, but if the patient is in profound shock and not perfusing the skin (pale, cold, clammy skin), then a more diluted concentration must be given i.v. at a slow rate (1 cc every minute of the 1:1,000 dilution) until the patient recovers. If i.v. access is delayed or not available, give the 1:1,000 dilution intramuscularly, in the tongue or down the endotracheal tube. Refer to your local protocols for dosage, but the usual dose of epinephrine is 0.3-0.5 mg, or 0.01 mg/kg in a child. There are more than 40 million people in the U.S. with allergic histories that place them at risk for developing anaphylaxis. Each year over 5,000 deaths are attributed to anaphylaxis. The risk of death from anaphylaxis increases with a more rapid onset of signs and symptoms. Up to 25% of patients will experience a biphasic reaction. This means there is a recurrence of symptoms several hours after the initial reaction, and it is prudent to observe patients for a period of time following their initial treatment.

Picadura masiva de abejas e insuficiencia renal aguda / Acute renal failure after massive bee stings in a boy

Introducción. La picadura masiva de abejas desencadena graves efectos tóxicos por la cantidad de veneno transmitido. Se reporta un caso en un niño mexicano haciendo énfasis en las complicaciones renales. Caso clínico. Escolar masculino de 11 años, del medio rural del estado de Jalisco, que fue picado por más de 1 000 abejas de tipo no especificado. Después de 24 horas presentó disminución en su uresis y retención de azoados, iniciando manejo con diálisis peritoneal aguda por 4 días, mientras que los indicadores de función renal se normalizaron a los 15 días de tratamiento. Conclusiones. En el paciente pediátrico que sufrió picadura masiva de abejas, se deberá mantener vigilancia estrecha de su función renal en las primeras 24 horas y en caso de presentar insuficiencia renal se deberá evaluar el manejo con diálisis peritoneal aguda.

Enfermedades cutáneas producidas por algunos artrópodos en Chile / Cutaneous diseases caused by some arthropods in Chile

Existen muchos artrópodos que afectan al hombre y a animales. Algunos artrópodos sólo producen manifestaciones cutáneas o sistémicas, otros son vectores de diversas enfermedades. Las picaduras y mordeduras de artrópodos son un motivo de consulta muy frecuente en la práctica dermatológica diaria, la mayoría de diagnóstico y tratamiento fácil, sin complicaciones. A veces, sin embargo, las manifestaciones puden ser tan greves que producen la muerte. En ocaciones, por ejemplo, en pacientes que han viajado al extranjero, el diagnóstico de las lesiones puede ser difícil, y es necesario profundizar en los diagnósticos diferenciales. En este artículo revisamos las patologías cutáneas más frecuentes producidas por distintos artrópodos de las clases Insecta y Aracnida, tales como abejas, pulgas, moscas, chinches, vinchucas, arañas y escorpiones. Se describen con detalle las distintas manifestaciones cutáneas y sistémicas y se entregan algunos elementos teóricos en el tratamiento de éstas

Accidentes sistémicos por picadura de abeja / Systemic accidents for honey bee sting

La proliferación de la apicultura en la región, incrementó la población de riesgo a la anafilaxia por veneno de abeja. Objetivos: Presentar los resultados de los pacientes que pudieron ser evaluados al final de la inmunoterapia y la experiencia con los que la realizaron a distancia. Material y Métodos: Desde 1990 hasta 1995 consultaron 50 pacientes, 26 apicultores o familiares, por reacción sistémica ante picadura de abeja. Se efectuó IgE total y específica. Se testificó con veneno de abeja por intradermoreacción. Se trataron 33 pacientes. Terminaron el tratamiento 25 pacientes recibiendo 150 microgramos de veneno, cada 30 días, durante 3 años. A 20 pacientes se les proveía el veneno mensualmente. Culminando el tratamiento, 18 pacientes fueron testificados y a 9 de ellos se les efectuó IgG e IgE específica. Resultados: El 44 por ciento del total de pacientes eran atópicos. La mayoría sufrió anafilaxia por una picadura, dentro de los veinte minutos. En el accidente, sólo el 22 por ciento fue tratado correctamente. Hubo correlación positiva (88 por ciento) entre prueba cutánea e IgE específica. El 33 por ciento de los pacientes sufrieron provocaciones. La testificación se negativizó en 6 pacientes y la IgE específica en 3 pacientes. Manteniendo positivas la testificación y la IgE específica, dos pacientes fueron picados sin sufrir anafilaxia. Conclusiones: Fue válida la indicación de la inmunoterapia, aún sin reto diagnóstico con picadura. El tratamiento a distancia fue seguro. Si la testificación y la IgE específica permanecieran positivas, estaría indicado el reto con picadura; si ocurriera anafilaxia, se debería continuar el tratamiento

Accidentes sistémicos por picadura de abeja / Systemic accidents for honey bee sting

La proliferación de la apicultura en la región, incrementó la población de riesgo a la anafilaxia por veneno de abeja. Objetivos: Presentar los resultados de los pacientes que pudieron ser evaluados al final de la inmunoterapia y la experiencia con los que la realizaron a distancia. Material y Métodos: Desde 1990 hasta 1995 consultaron 50 pacientes, 26 apicultores o familiares, por reacción sistémica ante picadura de abeja. Se efectuó IgE total y específica. Se testificó con veneno de abeja por intradermoreacción. Se trataron 33 pacientes. Terminaron el tratamiento 25 pacientes recibiendo 150 microgramos de veneno, cada 30 días, durante 3 años. A 20 pacientes se les proveía el veneno mensualmente. Culminando el tratamiento, 18 pacientes fueron testificados y a 9 de ellos se les efectuó IgG e IgE específica. Resultados: El 44 por ciento del total de pacientes eran atópicos. La mayoría sufrió anafilaxia por una picadura, dentro de los veinte minutos. En el accidente, sólo el 22 por ciento fue tratado correctamente. Hubo correlación positiva (88 por ciento) entre prueba cutánea e IgE específica. El 33 por ciento de los pacientes sufrieron provocaciones. La testificación se negativizó en 6 pacientes y la IgE específica en 3 pacientes. Manteniendo positivas la testificación y la IgE específica, dos pacientes fueron picados sin sufrir anafilaxia. Conclusiones: Fue válida la indicación de la inmunoterapia, aún sin reto diagnóstico con picadura. El tratamiento a distancia fue seguro. Si la testificación y la IgE específica permanecieran positivas, estaría indicado el reto con picadura; si ocurriera anafilaxia, se debería continuar el tratamiento (AU)