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Fever and production of cytokines in response to repeated injections of muramyl dipeptide in guinea-pigs.

Fever and systemic plasma levels of the cytokines tumour necrosis factor alpha (TNF) and interleukin-6 (IL-6) were measured in guinea-pigs in response to single or repeated intramuscular injections of 100 micrograms/kg muramyl-dipeptide (MDP). In a pilot study (experiment 1), MDP-induced fever was monitored for 8 h. The first fever phase 90-360 min after injection of MDP was followed by the second phase which continued beyond the duration of this experiment. High circulating levels of TNF and IL-6 were detected just before body core temperature started to rise. Within the next 90 min TNF declined again by more than 90% while IL-6 remained elevated. In experiment 2, the effects of repeated injections of MDP (5 times at intervals of 3 days) on the same parameters were investigated. In this paradigm, the febrile response started earlier (60 min after injection) and the first phase of fever remained manifest until 360 min after injection, while the late phase, measured 360-720 min after injection, was attenuated. Circulating, bioactive TNF and IL-6, measured 60 and 180 min after MDP was administered, were the same in response to the first, third, and fifth injection. In experiment 3, the influence of five repeated MDP injections on the abdominal temperature was measured for 22 h, and circulating cytokines were analysed before (360 min after injection) and during (480 min after injection) the late phase of MDP-induced fever. The late phase of MDP-induced fever 7-22 h after injection was attenuated in response to the second and further administrations of this pyrogen. At 6 h after the first, third, and fifth administration of MDP, only traces of TNF alpha were measured, 2 h later no bioactive TNF was detected at all. At these times also IL-6 declined again, compared with the activity of this cytokine measured during the early phase of MDP fever, but was still present in elevated amounts. Compared with the values measured in response to the third and fifth injections of MDP, circulating IL-6 was higher 360 min and 480 min after the first injection. It remains speculative whether the longer duration of elevated IL-6 in plasma is related to the development of the long-lasting, late phase of MDP-induced fever, which was only observed after the first of five repeated injections of MDP at intervals of 3 days.

Abdomen↗

Electrical stimulation of the paraventricular nucleus attenuates pyrogen fever in the rabbit.

Arginine vasopressin (AVP) perfused within the ventral septal area (VSA) suppresses fever normally evoked by pyrogenic substances, including Salmonella abortus equi (SAE). Neurons containing AVP and located within the paraventricular nucleus (PVN) or the nearby bed nucleus of the stria terminalis (BnST) are believed to have projections to this septal region. A series of experiments was undertaken to determine whether electrical stimulation of these areas, which might be expected to cause the release of AVP within the VSA, would affect similarly the pathogenesis of fever. A stainless steel cannula was implanted surgically in each of 22 male New Zealand White rabbits and a monopolar electrode was lowered through this guide cannula to the PVN or BnST areas. Electrical stimulation (20 Hz, 10 s on, 10 s off, 2.6-3.2 V) was initiated 30 min prior to and was continued until 90 min after the intravenous (i.v.) administration of 0.1-1.0 micrograms of SAE (1.0 ml carrier vehicle). While afebrile body temperature remained unchanged, electrical stimulation of sites located in the rostral extension of the PVN effectively attenuated the pyrogen-induced fever. Stimulation of sites outside these areas did not affect either the absolute magnitude or the duration of the fever. Although the reduction in fever was most pronounced during the period of electrical stimulation, in some cases the fever remained suppressed beyond the application of the current. These experiments provide the first evidence that electrical stimulation of paraventricular areas with AVP-containing cell bodies is effective in suppressing a fever evoked by systemic administration of a pyrogen. Although untested, it is possible that a stimulus-induced release of AVP within the VSA is responsible for the attenuation of the fever.

Animals↗

Arbovirus infections and viral haemorrhagic fevers in Uganda: a serological survey in Karamoja district, 1984.

Sera collected in May 1984 from 132 adult residents of Karamoja district, Uganda, were examined by haemagglutination inhibition tests for antibodies against selected arboviruses, namely Chikungunya and Semliki Forest alphaviruses (Togaviridae); dengue type 2, Wesselsbron, West Nile, yellow fever and Zika flaviviruses (Flaviviridae); Bunyamwera, Ilesha and Tahyna bunyaviruses (Bunyaviridae); and Sicilian sandfly fever phlebovirus (Bunyaviridae); and by immunofluorescence tests against certain haemorrhagic fever viruses, Lassa fever arenavirus (Arenaviridae), Ebola-Sudan, Ebola-Zaïre and Marburg filoviruses (Filoviridae), Crimean-Congo haemorrhagic fever nairovirus and Rift Valley fever phlebovirus (Bunyaviridae). Antibodies against Chikungunya virus were the most prevalent (47%), followed by flavivirus antibodies (16%), which were probably due mainly to West Nile virus. No evidence of yellow fever or dengue virus circulation was observed. A few individuals had antibodies against Crimean-Congo haemorrhagic fever, Lassa, Ebola and Marburg viruses, suggesting that these viruses all circulate in the area.

Adult↗

Macrophage inflammatory protein-1: unique action on the hypothalamus to evoke fever.

Macrophage inflammatory protein (MIP-1) administered systemically causes a fever not blocked by a prostaglandin (PGE) synthesis inhibitor. The purpose of this study was to examine the central mechanism of pyrexic action of this cytokine in the unrestrained rat. After guide cannulae for microinjection were implanted stereotaxically just above the anterior hypothalamic preoptic area (AH/POA), the body temperature of each rat was monitored by a colonic thermistor probe. Saline control vehicle or MIP-1 was microinjected into the AH/POA in one of eight concentrations ranging from 0.0028-9.0 ng per 0.5 mu 1 volume. MIP-1 induced a biphasic or monophasic fever of short latency characterized by an inverse dose-response curve. The potency of MIP-1 was in the femtomolar (10(-15)) range with the lowest dose of 0.028 ng producing a fever of over 2.0 degrees C with a latency of 15 min or less. To determine whether a PGE mediates MIP-1 fever, indomethacin was administered either intraperitoneally in a dose of 5.0 mg/kg or directly into the MIP-1 injection site in a dose of 0.5 microgram/0.5 mu 1, both injected 15 min before MIP-1. Pretreatment of the injection site in the AH/POA with indomethacin failed to prevent the febrile response evoked by MIP-1 injected at the same locus. Further, the dose of systemic indomethacin, which blocks PGE-induced fever in the rat, attenuated only partially the MIP-1 fever. The results demonstrate that MIP-1 is the most potent endopyrogen discovered thus far, and that its action is directly in the region of the hypothalamus which contains both thermosensitive and pyrogen-sensitive neurons. The local action of MIP-1 on cells of the AH/POA in evoking fever is unaffected by the PGE inhibitor which indicates, therefore, that a cellular mechanism operates in the hypothalamus to evoke fever independently of the central synthesis of a PGE.

Animals↗

Fever of unknown origin: chronic lymphatic leukemia versus lymphoma (Richter's transformation).

Currently, malignancies are more common than infections as a cause of fever of unknown origin (FUO) in adults. Many malignant disorders are associated with fever, which may either be of the hectic-septic variety resembling an infectious disease or prolonged and low-grade. Neoplasms with either kind of fever may present as an FUO. The malignancies usually associated with fever are lymphoreticular malignancies involving the blood, liver, spleen, or bone marrow. Most malignancies do not have fever, e.g., chronic lymphatic leukemia (CLL), as part of their clinical presentation. We present a case of long-standing CLL in an elderly woman who presented with an FUO. Initially, it was thought that her FUO was caused by CLL or a CLL-related opportunistic infection. The naprosyn test was used in this patient with CLL and FUO to differentiate a malignant from an infectious etiology. Her response to naprosyn indicated that the etiology of her FUO was neoplastic rather than infectious. The absence of tonsillar enlargement and peripheral adenopathy, as well as the presence of fever, argued against CLL as the cause of her fever. Computed axial tomography scans showed central adenopathy in addition to splenomegaly. The presence of fever, splenomegaly, and central adenopathy indicated that the cause of her FUO was a lymphoma (Richter's transformation) and not CLL.

Aged, 80 and over↗

Serological diagnosis and follow-up of asymptomatic and acute Q fever infections.

During an outbreak of Q fever at a farmer's market in Soest (North Rhine-Westphalia, Germany) in 2003, we examined 263 serum samples of presumably infected persons for Q fever antibodies. One hundred and seventy-one of these patients were tested positive for acute Q fever infection. Furthermore, 29 persons of certain risk groups like pregnant women (n=11) or patients with valvular heart disease (n=18) were examined. Among these, in four pregnant women and two heart patients an acute but asymptomatic infection could be diagnosed. With 30 patients we performed a serological follow-up for 8-60 weeks. In our study, phase 2 (PH2)-IgM antibodies as a marker for acute infection were present in all 30 patients 3-4 weeks after onset of clinical signs and disappeared 3-4 months later. Six weeks to three months after clinical manifestation, all patients developed PH1-IgG antibodies in low levels with no clinical signs of chronic Q fever. Three patients, including one pregnant woman showed high-level titres and were treated for chronic Q fever. Eleven patients with low PH1-IgG antibodies and all three patients with high titres developed IgA antibodies from 10 weeks after clinical manifestation; therefore PH1-IgA cannot be used as the only serological marker for chronic Q fever. Chronic infections were indicated only by a continuous increase of PH1 antibodies and a high persistence of PH2-IgG. We therefore conclude that the exclusion of chronic Q fever infection by a single serological examination cannot be done. At least three consecutive tests should be performed, that is 3, 6, and 9 months after initial Q fever infection.

Acute Disease↗

Timing and intensity of early fevers and the development of allergies and asthma.

BACKGROUND: Early childhood fevers appear to protect against later allergies and asthma. What is not known is the time in which fevers exert this effect and whether the degree of temperature increase is important. OBJECTIVE: We sought to examine the relationship between the time and degree of early fevers and later allergies and asthma. METHODS: Eight hundred thirty-five children from southeast Michigan were enrolled at birth. Clinic records from their first 2 years were abstracted for episodes of fever. At age 6 to 7 years, children underwent allergy testing. We examined fevers occurring within 6-month intervals in the first 2 years of life and outcomes at age 6 to 7 years. The primary outcome measures were allergic sensitization, asthma, asthma with allergic sensitization, and asthma without allergic sensitization. RESULTS: In the unadjusted analysis each episode of fever between 7 and 12 months of age was associated with a lower odds of allergic sensitization (odds ratio [OR], 0.71; 95% CI, 0.54-0.93) and asthma with allergic sensitization (OR, 0.43; 95% CI, 0.21-0.90) at age 6 to 7 years. Likewise, every 1 degrees C increase in the maximum temperature between 7 and 12 months was associated with a lower odds of allergic sensitization (OR, 0.77; 95% CI, 0.61-0.96) and asthma with allergic sensitization (OR, 0.62; 95% CI, 0.40-0.94). After adjusting for potential confounders, each episode of fever between 7 and 12 months was associated with a lower likelihood of asthma with allergic sensitization (adjusted OR, 0.33; 95% CI, 0.11-0.94) at age 6 to 7 years. CONCLUSIONS: Both the timing and intensity of childhood fevers appear to be important factors in the development of allergies and asthma.

Asthma↗

The value of follow-up after acute Q fever infection.

This is a case report of a 53-year-old woman involved in an outbreak of Q fever, in whom Q fever endocarditis was diagnosed 18 months after acute Q fever infection. At the time of diagnosis, she was completely asymptomatic and without screening for chronic Q fever, this severe potentially life-threatening infection would probably not have been recognised until significant valvular destruction had taken place. Early diagnosis enabled prompt, potentially curative medical treatment to start without the need for valvular heart surgery. The authors advocate that serological monitoring should be carried out every 4 months for a period of 2 years after acute Q fever and patients with high phase 1 IgG titres (>800) be investigated further and/or followed more closely depending on the clinical scenario. The case report also discusses the use of complement fixation testing in the diagnosis of Q fever endocarditis. The authors recommend that in cases of culture negative endocarditis, a single negative complement fixation test is not sufficient to exclude the diagnosis of Q fever endocarditis. Micro-immunofluorescence or repeat complement fixation testing is recommended when Q fever endocarditis is suspected clinically.

Anti-Bacterial Agents↗

The early diagnosis of typhoid fever prior to the Widal test and bacteriological culture results.

In an attempt to evaluate various clinical and laboratory features available within 24 h of admission, prior to the Widal test and bacteriological culture results as potential diagnostic aids in typhoid fever, we undertook a retrospective unit-based case control study in 90 febrile adult and paediatric patients admitted to King Edward VIII Hospital, Durban, South Africa with an initial diagnosis of typhoid fever. A total of 30 blood culture-proven typhoid fever patients (cases) were matched to 60 patients confirmed as not having typhoid fever (controls) by age, sex, race and severity of illness on admission. Features significantly associated with a final diagnosis of typhoid fever were: a pre-admission duration of fever > or = 7 days (odds ratio (OR) 6.9); hepatomegaly (OR 3.2); a normal leucocyte count (OR 10.8); a leucocyte count of < 10.0 x 10(3)/mm3 (OR 30.2); and leucopenia due to absolute neutropenia with a relative lymphocytosis (OR 11.8). Although the sensitivity, specificity and predictive values of any of these features cannot be used reliably to distinguish typhoid fever from other non-typhoidal febrile illness, it is concluded that leucopenia due to absolute neutropenia with relative lymphocytosis, when present, is highly suggestive of typhoid fever. A leucocyte count of > 10.0 x 10(3)/mm3 (OR 0.03) provides strong presumptive evidence against such a diagnosis.

Adolescent↗

Fever duration in hospitalized acute pyelonephritis patients.

PURPOSE: To study persistence of fever in treated pyelonephritis with respect to guidelines recommending investigation and modification of therapy after 2 to 3 days of fever. PATIENTS AND METHODS: A retrospective chart review was made of 70 patients hospitalized for febrile pyelonephritis at a community hospital in Canada. RESULTS: Median duration of fever was 34 hours; persistence of fever at 48 and 72 hours was 26% and 13%, respectively. No patients had complications such as intrarenal or perirenal abscess. Prolonged fever was independently associated with increasing baseline creatinine (P = 0.0001), younger age (P = 0.027), and increasing total leukocyte count (P = 0.026). Results of ultrasonography and intravenous urograms were not predictors of fever duration. CONCLUSION: Fever in treated pyelonephritis can take 4 days to resolve, and routine urologic investigation after 2 to 3 days of fever may be unwarranted.

Acute Disease↗

Relative association of fever and injury with hypermetabolism in critically ill patients.

The purpose of this study was to determine the association of injury type (trauma, surgery, medical disease), systemic inflammatory response syndrome (SIRS) and fever with the degree of hypermetabolism in critically ill patients. Medical records of 204 critically ill, mechanically ventilated injured, surgical and medical patients were reviewed for indirect calorimetry and associated data. Analysis of variance and covariance was used to test the effects of injury, fever and SIRS on the degree of hypermetabolism. All injury types were found to be hypermetabolic. Analysis of variance of hypermetabolism with injury type and presence of fever as main effects revealed a significant increase in hypermetabolic response from fever, of similar magnitude across all injury types. Subjects with SIRS were significantly more hypermetabolic than subjects without SIRS. However, analysis of variance indicated no effect for SIRS but a significant effect for fever in increasing the hypermetabolic response. It is concluded that fever portends a magnification of the hypermetabolic response, being similar across injury types. SIRS does not identify hypermetabolic patients independent of fever. The host response to injury, not the injury itself, determines metabolic rate in critically ill patients. Neither SIRS nor injury type should be used to classify hypermetabolic states without stratifying for presence of fever.

Adult↗

Fever and infection early after ischemic stroke.

Previous studies showed that elevated body temperature early after ischemic stroke is associated with severe neurological deficit and a poor outcome. The aim of this study was to analyse the prevalence and putative etiology of febrile body temperature (>/=38.0 degrees C) early after stroke and to investigate the association between body temperature, stroke severity and outcome. We investigated 119 consecutive patients who were admitted within 24 h after ischemic stroke. Patients were examined for infection before ischemia using a standardized questionnaire and received daily clinical examination after stroke. In case of fever, standardized radiological and microbiological examinations were performed. Fever within 48 h after stroke was observed in 30 (25.2%) patients. The probable cause of fever was infective or chemical aspiration pneumonia (n=12), other respiratory tract infection (n=7), urinary tract infection (n=4), viral infections (n=3) or insufficiently defined (n=5). (One patient had two potential causes of fever.) In thirteen of these patients, infection was most probably acquired before stroke. Fever newly developed more often during day 1 to 2 than day 3 to 7 after stroke (P=0.016). Fever was associated with a more severe deficit on admission independent from age, vascular diseases and risk factors (odds ratio 9.6; 95% confidence interval 3.1-29). Fever is a frequent complication early after stroke and in the majority of cases, it can be explained by infection or chemical aspiration pneumonia. In about half of the infected patients, infection was most probably acquired before stroke. Fever was associated with a more severe neurological deficit on admission.

Aged↗

Renal intrapelvic pressure during percutaneous nephrolithotomy and its correlation with the development of postoperative fever.

PURPOSE: Systemic absorption of irrigation fluid containing bacteria or endotoxin may lead to fever and urosepsis after percutaneous nephrolithotomy. Although to our knowledge the exact method of absorption is undefined, intrapelvic pressure greater than 30 mm. Hg has been shown to result in pyelovenous-lymphatic backflow. We measured intrapelvic pressure during percutaneous nephrolithotomy and correlated pressure with postoperative fever and operative technique. MATERIALS AND METHODS: Intrarenal pressure was measured with a transurethral 7Fr ureteral occlusion balloon catheter and a urodynamic system during percutaneous renal access, rigid and flexible nephroscopy, and intracorporeal lithotripsy. Postoperative fever was correlated with elevated intrarenal pressure, stone type and surgical technique. RESULTS: Enrolled in this study were 18 women and 13 men. Pressure greater than 30 mm. Hg was recorded in 8 patients (26%). Elevated pressure occurred under 2 conditions, namely incomplete positioning of the nephroscopy sheath within the collecting system and endoscopy through a narrow infundibulum. In 13 cases (42%) a fever of 38C or greater developed postoperatively. Elevated pressure did not correlate with fever. However, of those undergoing percutaneous nephrolithotomy for the removal of infection versus noninfection stones 64% and 24%, respectively, had fever postoperatively. CONCLUSIONS: Renal intrapelvic pressure generally remains low during percutaneous nephrolithotomy. Elevated pressure was associated with incomplete nephroscopy sheath positioning within the collecting system and endoscopy through an infundibular narrowing. There was no association of renal pressure greater than 30 mm. Hg with fever but postoperative fever and percutaneous nephrolithotomy done for infection related stones correlated significantly.

Adult↗

Prostaglandin E2-induced fever in young and old Long-Evans rats.

Aging is associated with a blunted or absent fever response to naturally occurring infections or to the peripheral administration of bacterial products and proinflammatory cytokines. We have recently shown that old Long-Evans rats are not defective in their capacity to develop a fever in response to brain administration of interleukin-1beta (IL-1beta). Here, we investigated the fever response of young (3-5-month) and old (24-26-month) Long-Evans rats to the intracerebroventricular (i.c.v.) microinfusion of prostaglandin E2 (PGE2), a final common mediator for the production of fever in the brain. Core body temperature was monitored by telemetry in freely moving rats. i.c.v. administered PGE2 (100 ng) induced comparable increases in body temperature in young and old Long-Evans rats. In the two groups, PGE2-induced fever was similar both in latency-to-peak fever and maximal fever response. These data, and the previous data on IL-1beta, demonstrate that the brains of old and young rats are similar with respect to fever generation in response to the i.c.v. administration of two classes of immunomodulators.

Aging↗

Fever in pregnancy and risk of fetal death: a cohort study.

BACKGROUND: Hyperthermia acts as a teratogen in some animals where it can induce resorption of the fetus and fetal death. Fever during pregnancy, especially in the period of embryogenesis, is also suspected as being a risk factor for fetal death in human beings. We did a large cohort study in Denmark to investigate this possibility. METHODS: We interviewed 24040 women who were recruited in the first half of pregnancy to the Danish National Birth Cohort Study, and obtained information on the number of fever incidents during the first 16 weeks of pregnancy. For each fever episode, the highest measured body temperature, duration of incident, and gestational age were recorded. Outcomes of pregnancies were identified through linkage with the Civil Registration System and the National Discharge Registry. Cox's regression with time-dependent variables was used to estimate the relative risk of fetal death, taking delayed entry into account. FINDINGS: 1145 pregnancies resulted in a miscarriage or stillbirth (4.8%). During the first 16 pregnancy weeks 18.5% of the women experienced at least one episode of fever. However, we found no association between fever in pregnancy and fetal death before or after adjustment for known risk factors of fetal death (relative risk 0.95 [95% CI 0.80-1.13]). This finding was consistent irrespective of measured maximum temperature, duration and number of fever incidents, or the gestational time of the fever incident, and was observed for fetal death in all three trimesters of pregnancy. INTERPRETATION: We found no evidence that fever in the first 16 weeks of pregnancy is associated with the risk of fetal death in clinically recognised pregnancies.

Abortion, Spontaneous↗

Urbanisation of yellow fever in Santa Cruz, Bolivia.

BACKGROUND: Reinvasion by Aedes aegypti of cities in the Americas poses a threat of urbanisation of yellow fever. After detection of yellow-fever infection in a resident of the city of Santa Cruz, Bolivia, in December, 1997, we investigated all subsequent suspected cases. METHODS: We introduced active surveillance of yellow fever in the Santa Cruz area. Hospitals and selected urban and rural health centres reported all suspected cases. Patients were serologically screened for yellow fever, dengue, hepatitis A and B, and leptospirosis. We collected clinical and epidemiological information from patients' records and through interviews. We also carried out a population-based serosurvey in the neighbourhood of one case. FINDINGS: Between December, 1997, and June, 1998, symptomatic yellow-fever infection was confirmed in six residents of Santa Cruz, five of whom died. Five lived in the southern sector of the city. Two had not left the city during the incubation period, and one had visited only an area in which sylvatic transmission was deemed impossible. Of the 281 people covered in the serosurvey 16 (6%) were positive for IgM antibody to yellow fever. Among five people for whom this result could not be explained by recent vaccination, there were two pairs of neighbours. INTERPRETATION: Urban transmission of yellow fever in Santa Cruz was limited in space and time. Low yellow-fever immunisation coverage and high infestation with A. aegypti in the city, and the existence of endemic areas in the region present a risk for future urban outbreaks. We recommend immediate large-scale immunisation of the urban population, as well as tightened surveillance and appropriate vector control.

Adult↗

Fever: causes and consequences.

The present review distinguishes pathogenic, neurogenic, and psychogenic fever, but focuses largely on pathogenic fever, the hallmark of infectious disease. The data presented show that a complex cascade of events underlies pathogenic fever, which in broad outline - and with frank disregard of contradictory data - can be described as follows. An invading microorganism releases endotoxin that stimulates macrophages to synthesize a variety of pyrogenic compounds called cytokines. Carried in blood, these cytokines reach the perivascular spaces of the organum vasculosum laminae terminalis (OVLT) and other regions near the brain where they promote the synthesis and release of prostaglandin (PGE2). This prostaglandin then penetrates the blood-brain barrier to evoke the autonomic and behavioral responses characteristic of fever. But then once expressed, fever does not continue unchecked; endogenous antipyretics likely act on the septum to limit the rise in body temperature. The present review also examines fever-resistance in neonates, the blunting of fever in the aged, and the behaviorally induced rise in body temperature following infection in ectotherms. And finally it takes up the question of whether fever enhances immune responsiveness, and through such enhancement contributes to host survival.

Animals↗

Resolution of fever in Staphylococcus aureus septicaemia--retrospective analysis by means of Cusum plot.

The treatment of Staphylococcus aureus septicaemia continues to be an important clinical challenge. Spikes of fever during antibiotic therapy complicate assessment of the response. In an attempt to analyse response to treatment in terms of resolution of fever we have retrospectively studied 17 patients with microbiologically proven S. aureus septicaemia. The data from temperature charts of such patients were converted to Cusum plots and analysed in order to estimate time to defervescence of fever and time to abolition of fever following the start of antibiotic therapy. Compared with conventional temperature charts, the Cusum data allowed defervescence of fever to be clearly seen. When the Cusum data were used, the time to defervescence of fever from the onset of antibiotic treatment was 21.7 h (range 8-96 h) and to abolition of fever 58.3 h (range 12-180 h). Antibiotic treatment was changed in 61% of patients on the basis of continued fever shown on the conventional temperature chart. In all of these patients, however, the Cusum plot showed clear evidence of response.

Adult↗