The neurologic basis of fever

Vagal immune-to-brain communication: a visceral chemosensory pathway

The immune system operates as a diffuse sensory system, detecting the presence of specific chemical constituents associated with dangerous micro-organisms, and then signalling the brain. In this way, immunosensation constitutes a chemosensory system. Several submodalities of this sensory system function as pathways conveying immune-related information, and can be classified as either primarily brain barrier associated or neural. The vagus nerve provides the major neural pathway identified to date. The initial chemosensory transduction events occur in immune cells, which respond to specific chemical components expressed by dangerous micro-organisms. These immune chemosensory cells release mediators, such as cytokines, to activate neural elements, including primary afferent neurons of the vagal sensory ganglia. Primary afferent activation initiates local reflexes (e.g. cardiovascular and gastrointestinal) that support host defense. In addition, at least three parallel pathways of ascending immune-related information activate specific components of the illness response. In this way, immunosensory systems represent highly organized and coherent pathways for activating host defense against infection.

Effects of vagotomy on lipopolysaccharide-induced brain interleukin-1beta protein in rats

The production of interleukin-1beta (IL-1beta) in brain is thought to be a critical step in the induction of central manifestations of the acute phase response, and the vagus nerve has been implicated in immune-to-brain communication. Thus, this study examined the effects of intraperitoneal (i.p.) injections of lipopolysaccharide (LPS) on brain IL-1beta protein levels in control and subdiaphragmatically vagotomized rats. In the first experiment, vagotomized and sham-operated male Sprague-Dawley rats were injected i.p. with one of three doses (10, 50, 100 microg/kg) of LPS or vehicle (sterile, pyrogen-free saline) and sacrificed 2 h after the injection. In the second experiment, vagotomized and sham-operated rats were injected i.p. with 100 microg/kg LPS or vehicle and sacrificed 1 h after the injection. The i.p. injection of LPS dose-dependently increased IL-1beta protein levels in the hypothalamus, hippocampus, dorsal vagal complex, cerebellum, posterior cortex, and pituitary 2 h after the injection. Brain and pituitary IL-1beta levels were also significantly increased 1 h after the injection of 100 microg/kg LPS. There were no significant differences in brain IL-1beta levels between sham-operated and vagotomized rats at either the 2 h or 1 h time points. The current data are consistent with previous studies showing increases in brain IL-1beta after peripheral injections of LPS, and support the notion that brain IL-1beta is a mediator in the illness-induction pathway. Furthermore, these data indicate that, at the doses and times tested, subdiaphragmatic vagal afferents are not crucial for LPS-induced brain IL-1beta protein.

Antipyretic effects of nimesulide, paracetamol and ibuprofen-paracetamol

The antipyretic effect of nimesulide has not been adequately compared with paracetamol and ibuprofen-paracetamol combination in children. Hence, a randomized, double blind, and parallel groups' design and multicenter study was conducted on children with respiratory tract infections. Eighty-nine patients with temperatures above 38.5 degrees C were randomly administered nimesulide (1.5 mg/kg/dose), paracetamol (10.0 mg/kg/dose), or ibuprofen-patients combination (10.0 mg/kg/dose), thrice daily for five days. The axillary temperature was recorded at the baseline and at different time intervals post administration of drugs. The hematological and biochemical investigations were performed at the basal level and at the end of the treatment period. The adverse drug reactions were monitored during the trial. All the drugs produced a significant fall in temperature as compared to their respective basal values (p < 0.001). However, on looking at the change in temperatures at different time intervals from the respective basal levels, no significant difference was found among all the drugs. Surprisingly, nimesulide had a tendency to raise serum glutamate pyruvate transaminase and serum glutamate oxaloacetate transaminase levels as compared to its baseline values. There was no marked adverse effect of the drugs on other hematological and biochemical parameters investigated. No other serious adverse reaction occurred in the study. Ibuprofen-paracetamol combination, nimesulide, and paracetamol had almost similar antipyretic effects in children.

Intrapartum fever and unexplained seizures in term infants

OBJECTIVE

Early-onset neonatal seizures are a strong predictor of later morbidity and mortality in term infants. Although an association of noninfectious intrapartum fever with neonatal seizures in term infants has been reported, it was based on only a small number of neonates with seizures. We therefore conducted a case control study to investigate this association further.

METHODS

All term infants with neonatal seizures born at Brigham and Women's Hospital between 1989 and 1996 were identified. For this study, cases consisted of all term neonates with a confirmed diagnosis of seizure born after a trial of labor for whom no proximal cause of seizure could be identified. Infants with sepsis or meningitis were excluded. Four controls matched by parity and date of birth were identified for each case. The rate of intrapartum maternal temperature >100.4 degrees F was compared for case infants and controls. Potential confounding was controlled in logistic regression analysis.

RESULTS

Cases comprised 38 term infants with unexplained seizures after a trial of labor. We identified 152 controls. Infants with seizures were more likely to be born to mothers who were febrile during labor (31.6% vs 9.2%). In almost all cases, the fever developed during labor (94.7% cases, 97.4% controls). At admission, mothers of infants with seizures were not significantly more likely to have factors associated with concern about infection such as a white blood cell count >15 000/mm(3) (28. 9% vs 19.1%) and premature rupture of the membranes (15.8% vs 17.8%). In a logistic regression analysis controlling for confounding factors, intrapartum fever was associated with a 3.4-fold increase in the risk of unexplained neonatal seizures (odds ratio = 3.4, 95% confidence interval = 1.03-10.9).

CONCLUSION

Our data indicate that intrapartum fever, even when unlikely to be caused by infection, is associated with a fourfold increase in the risk of unexplained, early-onset seizures in term infants.

Circulating cytokines as mediators of fever

The febrile response is thought to be mediated by endogenous mediators, generically called "endogenous pyrogens." In the classical model of pathogenesis, induction of fever is mediated by the release of pyrogenic cytokines such as tumor necrosis factor (TNF), interleukin (IL)-1, IL-6, and interferons into the bloodstream in response to exogenous pyrogens. These mediators act at the level of the organum vasculosum of the lamina terminalis in the central nervous system (CNS), inducing synthesis of prostaglandins, which are the central mediators of the coordinated responses leading to fever. However, analysis of recent data suggests that multiple pathways may be involved in the induction of fever by cytokines, such as local cytokine production leading to signaling through vagal fibers, release of cytokine-induced circulating mediators at the tissue level, the use of membrane-bound cytokines as mediators, or the local release of cytokines in the hypothalamus by circulating activated monocytes. In addition, certain bacterial products can stimulate cytokine production directly at the level of hypothalamus, probably by activation of Toll-like receptors. A multipathway mechanism for the induction of fever is therefore suggested.

Endogenous antipyretics

Fever is the hallmark of the stereotyped host response to microbial infection, although it is just one of a number of high-risk strategies employed by the infected host to clear itself of invading pathogens. The febrile response is accompanied by activation of multiple endogenous antipyretic systems that serve to suppress its magnitude or duration. These include neuroactive substances of neural and humoral origin, some of which (e.g., glucocorticoids, melanocortins, and IL-10) have broad-ranging anti-inflammatory actions. Glucocorticoids, vasopressin, and melanocortins appear to exert their antipyretic effects by acting on receptors within the brain, but beyond this the mechanisms involved are unknown. It is hypothesized, but not proven, that endogenous antipyretic systems protect the host against the destructive consequences of unchecked fever. Importantly, pharmacological blockade of the actions of endogenous antipyretic systems increases fevers of even low to moderate intensity. Therefore, in addition to protecting against catastrophic consequences of high fever, endogenous antipyretic systems seem to play a fundamental physiological role in determining the normal course of fever. Elucidating the neural and biochemical mechanisms involved in suppression of fever by physiological antipyretic systems will yield a rich benefit, both by advancing the basic understanding of host defense strategies, and by permitting the design of novel antipyretic and anti-inflammatory strategies for therapeutic intervention in human disease.

Effect of transection of various branches of the vagus nerve on lipopolysaccharide-induced synthesis of corticotropin-releasing hormone mRNA in the paraventricular nuclei of rat hypothalamus

Effects of selective transection of the gastric, celiac, and hepatic branches of the vagus nerve on expression of corticotropin-releasing hormone mRNA in small cell neurons of the hypothalamic paraventricular nuclei in rats administered with bacterial lipopolysaccharide were studied using in situ hybridization technique. Low doses of lipopolysaccharide stimulated expression of corticotropin-releasing hormone mRNA in rats subjected to axotomy of the gastric or celiac branches of the vagus nerve, but did not change the intensity of autoradiographic labeling in animals with transected hepatic branches. High doses of lipopolysaccharide enhanced expression of corticotropin-releasing hormone mRNA in vagotomized rats of all groups, which indicated the existence of a vagus-independent mechanism responsible for activation of paraventricular neurons mediating the effect of this hormone. The data suggest that the inflammation-dependent activation of stress-regulating neurons in the hypothalamus is controlled by several mechanisms, whose activation depends on the severity of inflammatory processes.

Distribution and function of prostanoid receptors: studies from knockout mice

Recent developments in the molecular biology of the prostanoid receptors has allowed the investigation of the physiological roles of each individual receptor type and subtype. The following article reports the prostanoid receptor distributions deduced from Northern blot and in situ hybridization analyses, summarizes the phenotypes of each receptor knockout mice, and discusses recent studies investigating the effects of each receptor deficiency on the inflammatory response and female reproductive processes. The combination of expression pattern and knockout analyses enabled us to determine which receptor expressed in a particular cell is important for the maintenance of normal and/or pathological physiology. The results from these analyses may be useful in the development of novel therapeutics that can selectively manipulate prostanoid-mediated actions.

Effects of vagotomy and bacterial lipopolysaccharide on food intake and expression of cyclooxygenase-2 mRNA in rat brain vessels

Effects of bilateral subdiaphragmatic vagotomy on food intake and expression of cyclooxygenase-2 mRNA in cerebral vessels in rats intraperitoneally injected with bacterial lipopolysaccharide were studied using in situ hybridization technique. Low doses of lipopolysaccharide decreased food intake in sham-operated animals, but did not affect this parameter in vagotomized rats. Comparison of hybridization signals in brain slices showed that low doses of endotoxin did not affect expression of cyclooxygenase-2 mRNA in vessels of control and experimental animals. High doses of lipopolysaccharide reduced food intake in vagotomized and sham-operated rats and elevated cyclooxygenase-2 mRNA expression in vascular endothelial cells of the brain parenchyma and meninges. The data suggest that the vagus nerve activates central structures responsible for manifestation of anorexia after intraperitoneal injection of low doses of lipopolysaccharide. High doses of endotoxin activate the vagus-independent mechanism of cyclooxygenase-2 synthesis in the endothelium of cerebral vessels. It is assumed that prostaglandins synthesized by cyclooxygenase-2 diffuse into the brain parenchyma and cause anorexia by activating target nerve structures.

Central CO-heme oxygenase pathway raises body temperature by a prostaglandin-independent way

Recently, the carbon monoxide (CO)-heme oxygenase pathway has been shown to play an important role in fever generation by acting on the central nervous system, but the mechanisms involved have not been assessed. Thus the present study was designed to determine whether prostagandins participate in the rise in body temperature (T(b)) observed after induction of the CO-heme oxygenase pathway in the central nervous system. Intracerebroventricular (ICV) injection of heme-lysinate (152 nmol/4 microl), which is known to induce the CO-heme oxygenase pathway, caused an increase in T(b) [thermal index (TI) = 5.3 +/- 0.5 degrees C. h], which was attenuated by ICV administration of the heme oxygenase inhibitor ZnDPBG (200 nmol/4 microl; TI = 2.5 +/- 1.7 degrees C. h; P < 0.05). No change in T(b) was observed after intraperitoneal injection of the cyclooxygenase inhibitor indomethacin (5 mg/kg), whereas indomethacin at the same dose attenuated the fever induced by ICV administration of lipopolysaccharide (LPS) (10 ng/2 microl) (vehicle/LPS: TI = 4.5 +/- 0.5 degrees C. h; indomethacin/LPS: TI = 1.7 +/- 1.0 degrees C. h; P < 0.05). Interestingly, indomethacin did not affect the rise in T(b) induced by heme-lysinate (152 nmol/4 microl) ICV injection (vehicle/heme: TI = 4.5 +/- 1.4 degrees C. h; indomethacin/heme: TI = 4.2 +/- 1.0 degrees C. h). Finally, PGE(2) (200 ng/2 microl) injected ICV evoked a rise in T(b) that lasted 1.5 h. The heme oxygenase inhibitor ZnDPBG (200 nmol/4 microl) failed to alter PGE(2)-induced fever. Taken together, these results indicate that the central CO-heme oxygenase pathway increases T(b) independently of prostaglandins.

Dose-dependent effects of endotoxin on human sleep

The role of the central nervous system in the host response to infection and inflammation and modulation of these responses by the hypothalamic-pituitary-adrenal system are well established. In animals, activation of host defense mechanisms increases non-rapid eye movement (NREM) sleep amount and intensity, which, in turn, are thought to support host defense, or the body's ability to defend itself against challenges to its immune system. In humans, the evidence is conflicting. Therefore, we investigated the effects of three placebo-controlled doses of endotoxin on host response, including nocturnal sleep in healthy volunteers. Administered before nocturnal sleep onset, endotoxin dose dependently increased rectal temperature, heart rate, and the plasma levels of tumor necrosis factor (TNF)-alpha, soluble TNF receptors, interleukin (IL)-1 receptor antagonist, IL-6, and cortisol. The lowest dose reliably increased circulating levels of cytokines and soluble cytokine receptors, but it did not affect rectal temperature, heart rate, or cortisol. This subtle host defense activation increased deep NREM sleep amount, often referred to as slow-wave sleep (stages 3 and 4), and intensity (delta power). Conversely, the highest dose of endotoxin disrupted sleep. Whereas it is well established that the endocrine and thermoregulatory systems are very sensitive to endotoxin, this study shows that human sleep-wake behavior is even more sensitive to activation of host defense mechanisms.

Fever in the ICU

Fever is a common problem in ICU patients. The presence of fever frequently results in the performance of diagnostic tests and procedures that significantly increase medical costs and expose the patient to unnecessary invasive diagnostic procedures and the inappropriate use of antibiotics. ICU patients frequently have multiple infectious and noninfectious causes of fever, necessitating a systematic and comprehensive diagnostic approach. Pneumonia, sinusitis, and blood stream infection are the most common infectious causes of fever. The urinary tract is unimportant in most ICU patients as a primary source of infection. Fever is a basic evolutionary response to infection, is an important host defense mechanism and, in the majority of patients, does not require treatment in itself. This article reviews the common infectious and noninfectious causes of fever in ICU patients and outlines a rational approach to the management of this problem.

Effects of vagotomy on serum endotoxin, cytokines, and corticosterone after intraperitoneal lipopolysaccharide

The vagus nerve appears to play a role in communicating cytokine signals to the central nervous system, but the exact extent of its involvement in cytokine-to-brain communication remains controversial. Recently, subdiaphragmatic vagotomy was shown to increase bacterial translocation across the gut barrier and thus may cause endotoxin tolerance. The current experiment tested whether or not vagotomized animals have similar systemic responses to endotoxin challenge as do sham-operated animals. Subdiaphragmatically vagotomized and sham-operated animals were injected intraperitoneally with one of three doses (10, 50, 100 microg/kg) of lipopolysaccharide (LPS) or vehicle, and blood samples were taken at 15, 30, 60, 90, and 120 min after the injection. The intraperitoneal injection of LPS increased circulating LPS levels at all time points examined. In addition, all three doses of LPS significantly increased serum interleukin (IL)-1beta, IL-6, and corticosterone in both control and vagotomized rats. In conclusion, vagotomy itself has no marked effect on circulating endotoxin levels or the production of IL-1beta, IL-6, or corticosterone in blood after an intraperitoneal injection of LPS.

Prostanoid receptors: structures, properties, and functions

Prostanoids are the cyclooxygenase metabolites of arachidonic acid and include prostaglandin (PG) D(2), PGE(2), PGF(2alpha), PGI(2), and thromboxne A(2). They are synthesized and released upon cell stimulation and act on cells in the vicinity of their synthesis to exert their actions. Receptors mediating the actions of prostanoids were recently identified and cloned. They are G protein-coupled receptors with seven transmembrane domains. There are eight types and subtypes of prostanoid receptors that are encoded by different genes but as a whole constitute a subfamily in the superfamily of the rhodopsin-type receptors. Each of the receptors was expressed in cultured cells, and its ligand-binding properties and signal transduction pathways were characterized. Moreover, domains and amino acid residues conferring the specificities of ligand binding and signal transduction are being clarified. Information also is accumulating as to the distribution of these receptors in the body. It is also becoming clear for some types of receptors how expression of their genes is regulated. Furthermore, the gene for each of the eight types of prostanoid receptor has been disrupted, and mice deficient in each type of receptor are being examined to identify and assess the roles played by each receptor under various physiological and pathophysiological conditions. In this article, we summarize these findings and attempt to give an overview of the current status of research on the prostanoid receptors.

Aetiology of fever in patients with acute stroke

OBJECTIVE

Fever in patients with acute stroke is usually related to infectious complications. In some cases, a focus of infection cannot be identified, fever does not respond to empirical antibiotic treatment and is thought to be due to the central nervous system lesion. The aim of this study was to determine the frequency and origin of fever in patients with acute stroke and the characteristics associated with the presence of fever.

DESIGN

A retrospective study of 36 months' duration.

SETTING

The study was carried out at 'Alexandra' Hospital, a tertiary care teaching centre in Athens, Greece.

SUBJECTS

A total of 330 patients hospitalized for acute stroke from June 1992 until July 1994.

RESULTS

In 37.6% of 330 patients, fever was noted; 22.7% had a documented infection and 14.8% had fever without a documented infection. In univariate analysis, older age was associated with the presence of fever (P = 0.001). The development of fever was associated with intracerebral haemorrhage versus ischaemic infarct (P < 0.001) and with the presence of mass effect (P < 0.001), transtentorial herniation (P < 0.001), intraventricular blood (P < 0. 001), and larger size of ischaemic infarct (P = 0.0001) and of haemorrhage (P = 0.0002). Patients with fever had lower scores on admission on the Glasgow Coma Scale (P = 0.0001) and the Scandinavian Stroke Scale (P = 0.0001). The development of fever was associated with prior use of an invasive technique (P < 0.001) and more specifically with urinary catheterization (P < 0.001), but not with the presence of risk factors for infection. Patients with fever had a worse outcome assessed by the Modified Rankin Scale (P = 0. 0001) and the Barthel Index (P = 0.0001). In multivariate analysis, age, Scandinavian Stroke Scale score and mass effect were found to be significantly associated with fever (P = 0.035, P = 0.0001 and P = 0.0004, respectively). Patients with fever without documented infection had an earlier onset of fever than those with infection (P = 0.0061). In a logistic regression analysis, the only factor predictive of fever without documented infection versus infection was earlier onset of fever (P = 0.029).

CONCLUSION

Patients with acute stroke who develop fever are older, suffer severe stroke, their fever is associated with the use of invasive techniques, and they have a poor outcome. In patients with fever without a focus of infection, the only characteristic that is different from patients with known infection is earlier onset of fever.

Carbon monoxide as a novel mediator of the febrile response in the central nervous system

Heme oxygenase catalyzes the metabolism of heme to biliverdin, free iron, and carbon monoxide (CO), which has been shown to be an important neuromodulatory agent. Recently, it has been demonstrated that lipopolysaccharide (LPS) can induce the enzyme heme oxygenase in glial cells. Therefore, the present study was designed to test the hypothesis that central CO plays a role in LPS-induced fever. Colonic body temperature (T(b)) was measured in awake, unrestrained rats (basal T(b) = 36.8 +/- 0.2 degrees C). Intracerebroventricular injection of zinc deuteroporphyrin 2,4-bis glycol (ZnDPBG; 75 nmol), a heme oxygenase inhibitor, caused no significant change in T(b), indicating that the central heme oxygenase pathway plays no tonic role in T(b) under the experimental conditions used. Intraperitoneal injections of LPS (50-100 microgram/kg) evoked dose-dependent increases in T(b). Intracerebroventricular injection of ZnDPBG in febrile rats attenuated LPS-induced fever (thermal index with ZnDPBG = 1.1 +/- 0. 2 degrees C, thermal index with vehicle = 2.3 +/- 0.4 degrees C), suggesting that the central heme oxygenase pathway plays a role in fever generation. The antipyretic effect of ZnDPBG could be reversed by intracerebroventricular administration of heme-lysinate or CO-saturated saline. Collectively, our data indicate that CO arising from heme oxygenase may play an important role in fever generation by acting on the central nervous system.

Research-overview article: membrane lipolysis and cholinergic priority

Cholinergic drugs and antigenic and toxicological challenges induced lipolysis in twelve sheep. A lipolytic end product, the PGF2alpha metabolite, was found to be a reliable non-specific cholinergic marker. The lipolytic membrane alterations supported the concept of a general priority of the cholinergic system. A main feature is the breaking of molecular stability in dynamic hydrogen-bond interactions. Both acetylcholine and dioxygen reactivity are apparently moderated by cholinesterases. Free radicals appeared to be normal intermediates of catabolism, serving to neutralize excess protons. Antioxidants regenerate molecular oxygen, and so counteract part of excess activated oxygen. Intrinsic reactivity against its own structures characterizes the immuno-cholinergic system. Genetic priority could be assumed for cholinergic constituents and constitutions. A broad spectrum of etiologies was suggested. Lasting or repeated challenges may cause heterochiral conversions of vital proteins. The priority aspect of cholinergism also suggested methods to rank among the multitude of secondary biomolecules.

Blood-borne, albumin-bound prostaglandin E2 may be involved in fever

Although the involvement of blood-borne PGE2 in fever has been hypothesized by several authors and has substantial experimental support, the current literature often rejects this hypothesis because several attempts to induce fever by a peripheral PGE2 failed. However, it is usually ignored that the amphipathic molecules of PGE2 are readily self-associating and that such an aggregation could have prevented the peripherally administered PGE2 (free form) from expressing its pyrogenic activity, thus leading to false negative results. To ensure disaggregation of PGE2, we prepared its complex within a carrier protein, human serum albumin (HSA). HSA was purified with activated charcoal and polymixin B-polyacrylamide gel and incubated with PGE2 for 1 h at 37 degrees C. Adult Chinchilla rabbits were injected intravenously with PGE2-HSA complex in either the higher (75 micrograms/kg PGE2:30 mg/kg HSA) or the lower (15 micrograms/kg:6 mg/kg) dose, and the rectal temperature (Tr) was measured. In the controls, either the ligand alone or the carrier alone was administered. At the higher dose, neither free PGE2 nor albumin alone was pyrogenic, whereas the PGE2-HSA complex produced a fever characterized by a short latency (<10 min) and a maximal Tr rise of 0.7 +/- 0.2 degrees C. At the lower dose, none of the substances affected the Tr. This study demonstrates a marked pyrogenic activity of the intravenous PGE2-HSA, but not of the free PGE2. Administration of a preformed complex may be more physiologically relevant than administration of the free ligand because of the ligand's disaggregation, protection from enzymatic degradation, and facilitated delivery to targets. Our study supports the hypothesis that peripheral PGE2 is involved in fever genesis.

Interleukin-1beta in immune cells of the abdominal vagus nerve: a link between the immune and nervous systems?

Intraperitoneal administration of the cytokine interleukin-1beta (IL-1beta) induces brain-mediated sickness symptoms that can be blocked by subdiaphragmatic vagotomy. Intraperitoneal IL-1beta also induces expression of the activation marker c-fos in vagal primary afferent neurons, suggesting that IL-1beta is a key component of vagally mediated immune-to-brain communication. The cellular sources of IL-1beta activating the vagus are unknown, but may reside in either blood or in the vagus nerve itself. We assayed IL-1beta protein after intraperitoneal endotoxin [lipopolysaccharide (LPS)] injection in abdominal vagus nerve, using both an ELISA and immunohistochemistry, and in blood plasma using ELISA. IL-1beta levels in abdominal vagus nerve increased by 45 min after LPS administration and were robust by 60 min. Plasma IL-1beta levels increased by 60 min, whereas little IL-1beta was detected in cervical vagus or sciatic nerve. IL-1beta-immunoreactivity (IR) was expressed in dendritic cells and macrophages within connective tissues associated with the abdominal vagus by 45 min after intraperitoneal LPS injection. By 60 min, some immune cells located within the nerve and vagal paraganglia also expressed IL-1beta-IR. Thus, intraperitoneal LPS induced IL-1beta protein within the vagus in a time-frame consistent with signaling of immune activation. These results suggest a novel mechanism by which IL-1beta may serve as a molecular link between the immune system and vagus nerve, and thus the CNS.

Do only circulating pyrogenic cytokines act as mediators in the febrile response? A hypothesis

The classical model of the pathogenesis of fever suggests that pyrogenic cytokines, produced by leucocytes in the bloodstream in response to exogenous pyrogens, represent the distal mediators of the febrile response. They are recognized at the level of the organum vasculosum of the lamina terminalis in the central nervous system, where they induce synthesis of prostaglandins representing the central mediators of the coordinated responses leading to fever. This classical model is challenged by studies showing inconsistencies between the febrile response and the cytokine pattern, as well as by data demonstrating paradoxical hyperfebrile reactions in knock-out mice lacking cytokines or cytokine receptors. Moreover, no measurable cytokine concentrations are to be found in a variety of specific patients groups with febrile conditions. There are recent data in the literature suggesting that alternative pathways may be involved in the induction of fever, ranging from the use of vagal fibres to transmit the signals leading to fever, to local production of cytokines at the level of the hypothalamus, or the use of membrane-bound cytokines as mediators. A multipathway mechanism for the induction of fever is suggested.

Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery

OBJECTIVES

This study investigated the association of intrapartum temperature elevation with cesarean delivery and assisted vaginal delivery.

METHODS

Participants were 1233 nulliparous women with singleton, term pregnancies in vertex presentations who had spontaneous labors and were afebrile (temperature: 99.5 degrees F [37.5 degrees C]) at admission for delivery. Rates of cesarean and assisted vaginal deliveries according to highest intrapartum temperature were examined by epidural status.

RESULTS

Women with maximum intrapartum temperatures higher than 99.5 degrees F were 3 times as likely to experience cesarean (25.2% vs 7.2%) or assisted vaginal delivery (25.2% vs 8.5%). The association was present in epidural users and nonusers and persisted after birthweight, epidural use, and labor length had been controlled. In adjusted analyses, temperature elevation was associated with a doubling in the risk of cesarean delivery (odds ratio [OR] = 2.3, 95% confidence interval [CI] = 1.5, 3.4) and assisted vaginal delivery (OR = 2.1, 95% CI = 1.4, 3.1).

CONCLUSIONS

Modest temperature elevation developing during labor was associated with higher rates of cesarean and assisted vaginal deliveries. More frequent temperature elevation among women with epidural analgesia may explain in part the higher rates of cesarean and assisted vaginal deliveries observed with epidural use.

Behavioral and neurochemical consequences of lipopolysaccharide in mice: anxiogenic-like effects

Systemic administration of lipopolysaccharide (LPS) induces sickness behaviors, as well as alterations of hypothalamic-pituitary-adrenal functioning commonly associated with stressors. In the present investigation, it was demonstrated that systemic LPS treatment induced a sickness-like behavioral profile (reduced active behaviors, soporific effects, piloerection, ptosis), which appeared to be dependent upon the novelty of the environmental context in which animals were tested. As well, LPS induced anxiogenic-like responses, including decreased time spent in the illuminated portion of a light-dark box, reduced open-arm entries in a plus-maze test, and decreased contact with a novel stimulus object in an open-field situation. The behavioral changes were accompanied by increased plasma ACTH and corticosterone levels. As well, LPS induced increased turnover of norepinephrine (NE), dopamine (DA) and serotonin (5-HT) in the paraventricular nucleus (PVN), median eminence plus arcuate nucleus, hippocampus, as well as NE turnover within the locus coeruleus and DA turnover within the nucleus accumbens. Although these neurochemical variations were reminiscent of those elicited by stressors, LPS was not particularly effective in modifying DA activity within the prefrontal cortex or NE within the amygdala, variations readily induced by stressors. Whether the LPS-induced anxiogenic-like responses were secondary to the illness engendered by the endotoxin remains to be determined. Nevertheless, it ought to be considered that bacterial endotoxin challenge, and the ensuing cytokine changes, may contribute to emotionality and perhaps even anxiety-related behavioral disturbances.

Glutamate release in the nucleus tractus solitarius induced by peripheral lipopolysaccharide and interleukin-1 beta

The involvement of vagal afferents in the communication pathway from the immune system to the brain was studied. Glutamate was measured in the nucleus tractus solitarius, the brain area receiving glutamatergic vagal afferents, after peripheral injection of lipopolysaccharide or interleukin-1 beta. Intraperitoneal or intravenous saline or intraperitoneal heat-inactivated interleukin-1 beta increased glutamate release, measured by brain microdialysis in freely-moving rats at 20 min (137 +/- 19%, 126 +/- 10% and 133 +/- 6%, respectively), without inducing any other change up to 3 h after injection. Intraperitoneal lipopolysaccharide (10 micrograms/rat) increased glutamate at 20 min (132 +/- 10%) and at 60 min (208 +/- 26%). To compare lipopolysaccharide effectiveness by the two routes, serum levels of interleukin-1 beta, interleukin-6 and tumour necrosis factor-alpha were measured. Intravenous lipopolysaccharide induced each cytokine more rapidly and efficiently than intraperitoneal lipopolysaccharide. Perfusion with tetrodotoxin (1 microM) in the dialysis probe decreased glutamate basal levels by approximately 20% and completely prevented lipopolysaccharide effects, showing the neuronal component of the glutamate measured. Except for the 20-min increase, intravenous lipopolysaccharide (10 micrograms/rat) did not affect glutamate release. Intraperitoneal interleukin-1 beta (4 micrograms/rat) increased glutamate release at 20 min (126 +/- 6%) and at 40 min (150 +/- 18%). These data indicate that vagal glutamatergic system in the nucleus tractus solitarius is activated by intraperitoneal injections of immunoactive compounds.

Individual variation in hypothalamus-pituitary-adrenal responsiveness of rats to endotoxin and interleukin-1 beta

Intraperitoneal (i.p.) administration of lipopolysaccharide (LPS) or interleukin (IL)-1 beta induces activation of the hypothalamus-pituitary-adrenal (HPA) axis. In some experiments, a marked individual variation has been observed in HPA responses to these stimuli. We reasoned that only parameters that correlate with this variability may reflect signals involved in HPA activation. Although IL-1 beta is found in the peritoneal cavity and has been implicated in the HPA response to i.p. LPS, IL-1 beta levels in peritoneal lavage fluid did not correlate with the variation in HPA responsiveness and neither did IL-1 beta concentrations in plasma. In contrast, IL-6 concentrations in plasma, but not in peritoneal lavage fluid, correlated with this variation to i.p. LPS or IL-1 beta. We conclude that IL-6 in the plasma represents a major determinant of the individual variation in HPA responses to i.p. LPS or IL-1 beta. Because of its positive correlation with Fos expression in various brain-stem nuclei, we suggest that circulating IL-6 may facilitate the generation of signals in vagal afferents or potentiate vagal information transfer to lower brain-stem nuclei.

Impaired febrile response in mice lacking the prostaglandin E receptor subtype EP3

Fever, a hallmark of disease, is elicited by exogenous pyrogens, that is, cellular components, such as lipopolysaccharide (LPS), of infectious organisms, as well as by non-infectious inflammatory insults. Both stimulate the production of cytokines, such as interleukin (IL)-1beta, that act on the brain as endogenous pyrogens. Fever can be suppressed by aspirin-like anti-inflammatory drugs. As these drugs share the ability to inhibit prostaglandin biosynthesis, it is thought that a prostaglandin is important in fever generation. Prostaglandin E2 (PGE2) may be a neural mediator of fever, but this has been much debated. PGE2 acts by interacting with four subtypes of PGE receptor, the EP1, EP2, EP3 and EP4 receptors. Here we generate mice lacking each of these receptors by homologous recombination. Only mice lacking the EP3 receptor fail to show a febrile response to PGE2 and to either IL-1beta or LPS. Our results establish that PGE2 mediates fever generation in response to both exogenous and endogenous pyrogens by acting at the EP3 receptor.

Thermogenic and corticosterone responses to intravenous cytokines (IL-1beta and TNF-alpha) are attenuated by subdiaphragmatic vagotomy

The brain orchestrates changes in behavior and physiology as a consequence of peripheral immune activation and infection. These changes require that the brain receives signals from the periphery that an immunological challenge has occurred. Previous research has established that cytokines play a role in signalling the brain. What remains unclear, however, is how peripheral cytokines signal the central nervous system. A recent proposal is that cytokines signal the brain by stimulating peripheral nerves. The hypothesis states that following infection and the release of cytokines such as IL-1beta into local tissue or microvasculature, IL-1beta stimulates IL-1 receptors on vagal afferent terminals, or more likely on cells of vagal paraganglia. Vagal afferents, in turn, signal the brain. Previous work has demonstrated that transection of the vagus below the level of the diaphragm blocks or attenuates many illness consequences of intraperitoneally (i.p.) administered lipopolysaccharide (LPS) or IL-1beta. The present studies extend these findings by examining the effect of subdiaphragmatic vagotomy on illness consequences following intravenously (i.v.) administered IL-1beta and TNF-alpha. Subdiaphragmatic vagotomy attenuated both the fever response and corticosterone response produced by i.v. administered cytokines. This effect was dose dependent. The results add support to the hypothesis that vagal afferents are involved in peripheral cytokine-to-brain communication.

Tumor necrosis factor-alpha, interleukin-6, and interleukin-8 secretion and the acute-phase response in patients with bacterial and tuberculous osteomyelitis

Osteomyelitis, or bone infection, is a major worldwide cause of morbidity. Treatment is frequently unsatisfactory, yet little is known about pathogenesis of infection. Plasma tumor necrosis factor (TNF), interleukin (IL)-6, and IL-8 concentrations were measured before and after lipopolysaccharide stimulation of whole blood from patients with bacterial and tuberculous osteomyelitis and from controls. Patients with bacterial and tuberculous osteomyelitis mounted an acute-phase response and were anemic and febrile. However, plasma IL-6 concentrations were significantly elevated in only tuberculous osteomyelitis patients (vs. controls, P < .05). IL-6 concentrations correlated with erythrocyte sedimentation rate, C-reactive protein level, and plasma albumin concentration, all acute-phase markers. There were no other correlations between cytokine concentrations and clinical data. Following ex vivo stimulation, TNF, IL-6, and IL-8 were secreted equally by patients and controls. In summary, tuberculous osteomyelitis is characterized by elevated systemic IL-6 concentrations associated with an acute-phase response. For further insight into immunopathology of osteomyelitis, studies on infected bone are required.

Effect of endotoxin and interleukin-1beta on corticotropin-releasing-factor and prostaglandin release by rat brainstem slices

This study investigated the effects of lipopolysaccharide (LPS) and interleukin-1beta (IL-1beta) on corticotropin releasing factor (CRF) and prostaglandin E2 (PGE2) release by brainstem slices in vitro. First, we characterized our experimental model and demonstrated that high potassium stimulates CRF release from rat brainstem slices in a calcium dependent way. The direct stimulation of brainstem slices with IL-1beta (3-25 pM) did not modify basal or potassium-stimulated CRF release, although IL-1beta at the dose of 25 pM increased PGE2 production. Peripheral injection (i.p.) of LPS (1-10 microg/kg) or IL-1beta (1-10 microg/kg) evoked a dose-related potentiation of the ex-vivo release of CRF and PGE2 from brainstem slices. However, central (i.c.v.) administration of LPS (10-500 ng/rat) potentiated the release of CRF and PGE2 only at the dose of 500 ng/rat, whereas IL-1beta (1-100 ng/rat) failed to modify significantly the ex vivo production of both CRF and PGE2. The results of the present study provide evidence that peripheral, rather than central, endotoxin and IL-1beta administration induce the activation of brainstem CRF and PGE2, supporting the hypothesis that peripheral cytokine signalling to the CNS is mediated by stimulation of peripheral afferents.

The role of the vagus nerve in cytokine-to-brain communication

Peripheral interleukin-1 beta (IL-beta) and inflammatory stimuli that induce the synthesis and release of IL-1 beta produce a variety of central nervous system responses. Most proposals designed to explain how peripheral IL-1 beta influences the CNS have focused on blood-borne routes of communication. We will review data that indicate that at least some of the CNS response to peripheral IL-1 beta are instead mediated by a neural route of communication between the periphery and the CNS. IL-1 beta activates afferent vagal fibers that terminate in the nucleus tractus solitarius, and communication via the vagus is responsible for much of the hyperalgesia, fever, anorexia, taste aversions, increased levels of plasma corticosteroid, and brain norepinephrine changes produced by intraperitoneal injections of IL-1 beta and LPS. Data extending this analysis to TNF-alpha and intravenous routes will be described.

Neurobiological Mechanisms of Fever

Increased body temperature (fever or hyperthermia) is a physiological response to many different stimuli. In fact, fever (a 1-4°C elevation of the body temperature) is not only a clinical symptom common to many infectious diseases but also a side effect of immunostimulating or antiviral therapies. Hyperthermic reactions, on the other hand, can be observed after treatment with antipsychotic drugs, 5-hydroxytryptamine-receptor agonists, and acetylcholinesterase inhibitors and as a reaction to anesthesia. Moreover, hyperthermic reactions can be related to particularly stressful emotional states, to the menstrual ovulatory cycle, and to pregnancy. Transient hyperthermia or fever is also a common consequence of cerebral ischemic events, and it is present during stress as well as intense physical exercise. This review focuses on fever, one of the main components of the systemic acute-phase reaction to external proinflammatory stimuli. Special emphasis is given to neuronal mechanisms of fever induction, in which the hypothalamus plays a crucial role in both control of the febrile response as well as other centrally mediated neurological signs of inflammation, such as increased sleep, activation of the hypothalamic-pituitary-adrenal axis, anorexia, and sickness behavior. This review pays particular attention to the role of proinflammatory cytokines as endogenous pyrogens. NEUROSCIENTIST 4:113-121, 1998

Mother's knowledge of, attitudes toward, and management of fever in preschool children in Italy

BACKGROUND

We examined mothers' knowledge of, attitudes toward, and management of fever in their children.

METHODS

Interviews of mothers of preschool children were performed using a structured questionnaire administered by interviewers with no specific medical competence.

RESULTS

Of a total of 1,237 mothers who were interviewed, data were analyzed for the 707 mothers who had coped with a febrile episode in their children during the previous month. Of these, 59% were concerned about fever in their children and 17% were very worried. At the onset of fever, 48% of the mothers gave their child an antipyretic and 18% called the physician immediately. In logistic regression analysis, five variables were significantly associated with mothers' concern: the absence of previous information on the management of fever, temperature > 39 degrees C, an only child, mother's low educational level, and mother's residency in the south of Italy. For the request for a physician's visit, of the variables entered, the only explanatory ones were the mother's concern and the absence of previous information on the management of fever.

CONCLUSIONS

These findings suggest that informing mothers on the definition, consequences, and treatment of fever can significantly improve their confidence in managing fever, as reflected by fewer requests for physicians' visits.

Pyretic and antipyretic signals within and without fever: a possible interplay

Current concepts on the pathogenesis of fever emphasize the importance of the cytokine-prostaglandin cascade. This humoral line mediates nonthermal signals to the brain, while the thermal signals supply feedback from the thermoreceptors. However, the humoral line cannot alone account for the whole febrile response. Here, we hypothesize that, besides this humoral mediatory mechanism, nonthermal neural signals of abdominal origin conveyed mainly by the vagus nerve are also important pro-pyretic factors. The pro-pyretic mechanisms are proposed to be in a dynamic balance with endogenous antipyretic mechanisms that also form an integral part of the normal reaction to pyrogens. Further, it is hypothesized that the role of such neural and humoral signals either for elevation or depression of body temperature is not limited to fever but has an important role also in nonfebrile thermoregulation.

TNF-alpha-induced corticosterone elevation but not serum protein or corticosteroid binding globulin reduction is vagally mediated

Immune activation leads to production of mediators such as cytokines, which act to induce both brain-mediated and peripheral defense processes. We used intraperitoneal administration of the cytokine tumor necrosis factor-alpha (TNF-alpha) to investigate whether defense processes induced by this cytokine are mediated by vagal afferents and/or interleukin-1 (IL-1) receptors. Because some effects of TNF-alpha are mediated, at least in part, by the brain [plasma corticosterone (CORT) elevation] and some are mediated by peripheral organs [reduction of serum protein and corticosteroid binding globulin (CBG)], we also investigated whether the effects of vagotomy are specific to those defense processes mediated by the brain. Both vagotomy and IL-1 receptor antagonist attenuated serum CORT elevation, but had no effects on serum protein or CBG reduction. These results support the idea that vagal afferents provide a true immune-to-brain pathway that may include IL-1 receptors.

Preprodynorphin mRNA-expressing neurones in the rat parabrachial nucleus: subnuclear localization, hypothalamic projections and colocalization with noxious-evoked fos-like immunoreactivity

The dorsal lateral subnucleus of the rat pontine parabrachial nucleus is a major target for ascending nociceptive information from the spinal cord. With in situ hybridization histochemistry, using a radiolabelled cRNA probe, we demonstrate that neurones in and near the dorsal lateral subnucleus express preprodynorphin mRNA. The cRNA probe was constructed from a PCR product amplified from rat genomic DNA. Sequencing of the PCR product revealed that it corresponded to the sequence 466-1101 of the rat preprodynorphin gene exon 4. Tract tracing experiments, using injection of cholera toxin subunit B into the hypothalamic median preoptic nucleus, showed a retrograde labelling pattern of neurones in the parabrachial nucleus that was almost identical to that of the preprodynorphin mRNA expressing neurones. Double-labelling, combining immunohistochemical detection of tracer and in situ hybridization, revealed that the retrogradely labelled neurones expressed preprodynorphin mRNA. A similar double-labelling, combining in situ hybridization with immunohistochemical detection of noxious-evoked fos following formalin injection into one hindpaw of awake animals, showed that almost all fos-immunoreactive neurones in the dorsal lateral parabrachial subnucleus also expressed preprodynorphin mRNA. Quantitative analysis suggested that the evoked fos immunoreactivity was accompanied by an increased preprodynorphin mRNA expression. The findings provide evidence that neurones in the dorsal lateral subnucleus produce dynorphin and project to the median preoptic nucleus, and that noxious stimulation in awake animals synaptically activates the dynorphinergic neurones in this subnucleus. These observations are consistent with the idea of a functional and chemical heterogeneity among different parabrachial subnuclei that serves to produce specific homeostatic responses to stimuli that changes the physiological status of the organism, including tissue damage.

Role of circulating endotoxin and interleukin-6 in the ACTH and corticosterone response to intraperitoneal LPS

Peripheral administration of lipopolysaccharide (LPS) may activate the hypothalamus-pituitary-adrenal (HPA) axis by way of both neural and humoral mechanisms. We have investigated whether biologically active endotoxin appears in the general circulation after intraperitoneal administration of LPS (5 or 100 micrograms/kg) to rats and whether this is a prerequisite for activation of this HPA axis. Within 15 min, endotoxin appeared in the general circulation, whereas elevations of plasma adrenocorticotropic hormone (ACTH), corticosterone, and interleukin (IL)-6 concentrations were not detected until 90 min after LPS injection. At this time, a marked interindividual variation was observed in plasma concentrations of endotoxin, ACTH, corticosterone, and IL-6. Elevated levels of plasma endotoxin were associated with elevated levels of ACTH, corticosterone, and IL-6. Intravenous administration of the LPS antagonist cationic antimicrobial protein 18 (5 mg/kg), which did not affect cytokine production in the peritoneal cavity, markedly reduced plasma ACTH, corticosterone, and IL-6 levels after 5 micrograms/kg LPS. Our results suggest that circulating endotoxin is required for the activation of the HPA axis. They also favor a role for circulating IL-6 in this response.

Mechanisms of CNS response to systemic immune challenge: the febrile response

The acute-phase reaction is the multisystem response to acute inflammation. The central nervous system (CNS) mediates a coordinated set of autonomic, endocrine and behavioral responses that constitute the cerebral component of the acute-phase reaction. However, the mechanisms of immune signaling of the CNS remain controversial. Emerging evidence indicates that different parts of the acute-phase reaction are initiated by distinct mechanisms and in different brain regions. Cytokines produced as a result of local infections (for example, in the abdominal or thoracic cavities) might activate vagal sensory fibers, resulting in sickness behavior and fevers. Additionally, circulating immune stimuli might activate meningeal macrophages and perivascular microglia along the borders of the brain, eliciting the local production of prostaglandins and responses such as fever, anorexia, sleepiness, and activation of the hypothalamo-pituitary-adrenal (HPA) axis. The biological importance of these responses might favor the existence of multiple parallel CNS pathways that are engaged by cytokines.

Thermometer use among Mexican immigrant mothers in California

A community-based household survey was utilized to assess the relationship between thermometer use, home treatment and utilization of health care services. Using a cross-sectional design, the study surveyed 688 low income Mexican origin mothers of children between the ages of 8 and 16 months in San Diego County. Mothers were asked how they determine that their child has fever and how often they use a thermometer. Nearly 40% of low income Mexican mothers interviewed in San Diego county never used a thermometer for determining childhood fever. Approximately two-thirds (64.7%) relied either primarily or exclusively on embodied methods such as visual observation or touch to determine fever in their child. A multivariate logistic regression analysis determined that low education and a separated or divorced marital status decreased the odds of thermometer use, whereas regular contact with the health care system doubled the likelihood of thermometer use. Mothers who relied on embodied methods were more likely to use over-the-counter medications than those who relied on thermometers; however, no significant differences were found between groups using other methods of home treatment. Fever determination modalities can be used to screen for lack of access to care and to provide for other health care needs in a culturally appropriate manner. While clinicians' expectations may include parental experience with temperature taking, current pediatric literature questions the need for home-based thermometer use. Possible alternatives to the traditional rectal thermometer might include digital thermometers and color coded thermometer strips.

Intravenous lipopolysaccharide induces cyclooxygenase 2-like immunoreactivity in rat brain perivascular microglia and meningeal macrophages

Production of prostaglandins is a critical step in transducing immune stimuli into central nervous system (CNS) responses, but the cellular source of prostaglandins responsible for CNS signalling is unknown. Cyclooxygenase catalyzes the rate-limiting step in the synthesis of prostaglandins and exists in two isoforms. Regulation of the inducible isoform, cyclooxygenase 2, is thought to play a key role in the brain's response to acute inflammatory stimuli. In this paper, we report that intravenous lipopolysaccharide (LPS or endotoxin) induces cyclooxygenase 2-like immunoreactivity in cells closely associated with brain blood vessels and in cells in the meninges. Neuronal staining was not noticeably altered or induced in any brain region by endotoxin challenge. Furthermore, many of the cells also were stained with a perivascular microglial/macrophage-specific antibody, indicating that intravenous LPS induces cyclooxygenase in perivascular microglia along blood vessels and in meningeal macrophages at the edge of the brain. These findings suggest that perivascular microglia and meningeal macrophages throughout the brain may be the cellular source of prostaglandins following systemic immune challenge. We hypothesize that distinct components of the CNS response to immune system activation may be mediated by prostaglandins produced at specific intracranial sites such as the preoptic area (altered sleep and thermoregulation), medulla (adrenal corticosteroid response), and cerebral cortex (headache and encephalopathy).

Investigation of the influenza-like symptoms associated with recombinant human erythropoietin therapy

The mechanism by which fever and influenza-like symptoms occur, after the administration of recombinant human erythropoietin (rHuEPO) to patients on continuous ambulatory peritoneal dialysis, was investigated. Peripheral blood mononuclear cells, obtained from two patients with fever and/or influenza-like symptoms related to the administration of rHuEPO for the treatment of anaemia were cultured with or without rHuEPO (100, 200, and 300 U/ml). Production of interleukin-1 beta and tumour necrosis factor-alpha was higher in cultures with rHuEPO than in cultures without rHuEPO, although the dose relationships were not clear. These findings suggest that increased production of interleukin-1 beta and tumour necrosis factor-alpha 1, induced by administration of rHuEPO, may cause fever and influenza-like symptoms.

Blockade of lipopolysaccharide-induced fever by subdiaphragmatic vagotomy in guinea pigs

It is generally believed that fever is mediated by certain cytokines produced by immune cells activated by exogenous pyrogens, e.g., lipopolysaccharides (LPS), released into the circulation and transported to the brain There, the cytokines are thought to stimulate prostaglandin (PG) E2 production within the organum vasculosum laminae terminalis region. PGE2 then may act as a febrigenic mediator locally or in the surrounding preoptic area (POA). However, whereas the increases in preoptic PGE2 and body (core) temperature (Tc) following the intravenous (i.v.) administration of LPS correlate temporally, cytokine levels in blood lag both these increases. From recent data in the literature, we have conjectured that a possible, alternative communication pathway between the i.v. LPS-activated immune system and brain PGE2 may be provided by the vagi. To test this possibility, we measured the levels of PGE2 in the extracellular fluid of the POA (collected by microdialysis) of conscious, subdiaphragmatically vagotomized or sham-operated guinea pigs following LPS administration (2 micrograms/kg; i.v.); controls received pyrogen-free saline (PFS). The effluents from the microdialysis probes were collected over 30-min periods throughout the experiments and the samples analyzed by radioimmunoassay; Tc was monitored continuously using thermocouples inserted 5 cm into the colon. LPS induced a biphasic fall in Tc and failed to increase preoptic PGE2 levels in the vagotomized guinea pigs (n = 10), whereas in their sham-operated controls (n = 10) it induced increases in both preopitc PGE2 and Tc within 15 min after its injection; PFS (n = 13) had no effect on either variable. We postulate that peripheral immune cell-derived signals may be transmitted via the vagi to the medulla. From other data, we suggest further that they may be conveyed from here via the ventral noradrenergic bundle to the POA region, where the released norepinephrine induces the local synthesis of PGE2 and, hence, fever onset.