The cytokine-prostaglandin cascade in fever production: fact or fancy?

Modulation of the Acute Inflammatory Response Induced by the Escherichia coli Lipopolysaccharide through the Interaction of Pentoxifylline and Florfenicol in a Rabbit Model

BACKGROUND

Experimental reports have demonstrated that florfenicol (FFC) exerts potent anti-inflammatory effects, improving survival in a murine endotoxemia model. Considering the anti-inflammatory and immunomodulatory properties of pentoxifylline (PTX) as an adjuvant to enhance the efficacy of antibiotics, the anti-inflammatory effects of the interaction FFC/PTX over the E. coli Lipopolysaccharide (LPS)-induced acute inflammatory response was evaluated in rabbits.

METHODS

Twenty-five clinically healthy New Zealand rabbits (3.8 ± 0.2 kg body weight: bw), were distributed into five experimental groups. Group 1 (control): treated with 1 mL/4 kg bw of 0.9% saline solution (SS) intravenously (IV). Group 2 (LPS): treated with an IV dose of 5 µg/kg of LPS. Group 3 (pentoxifylline (PTX) + LPS): treated with an oral dose of 30 mg/kg PTX, followed by an IV dose of 5 µg/kg of LPS 45 min after PTX. Group 4 (Florfenicol (FFC) + LPS): treated with an IM dose of 20 mg/kg of FFC, followed by an IV dose of 5 µg/kg of LPS 45 min after FFC administration. Group 5 (PTX + FFC + LPS): treated with an oral dose of 30 mg/kg of PTX, followed by an IM dose of 20 mg/kg of FFC, and, 45 min after an IV dose of 5 µg/kg of LPS was administered. The anti-inflammatory response was evaluated through changes in plasma levels of interleukins (TNF-α, IL-1β and IL-6), C-reactive protein (CRP), and body temperature.

RESULTS

It has been shown that each drug produced a partial inhibition over the LPS-induced increase in TNF-α, IL-1β, and CRP. When both drugs were co-administered, a synergistic inhibitory effect on the IL-1β and CRP plasma concentrations was observed, associated with a synergic antipyretic effect. However, the co-administration of PTX/FFC failed to modify the LPS-induced increase in the TNF-α plasma concentrations.

CONCLUSIONS

We concluded that the combination of FFC and PTX in our LPS sepsis models demonstrates immunomodulatory effects. An apparent synergistic effect was observed for the IL-1β inhibition, which peaks at three hours and then decreases. At the same time, each drug alone was superior in reducing TNF-α levels, while the combination was inferior. However, the peak of TNF-α in this sepsis model was at 12 h. Therefore, in rabbits plasma IL-1β and TNF-α could be regulated independently, thus, further research is needed to explore the effects of this combination over a more prolonged period.

Role of thoracic and abdominal tomography in identifying a potential source of infection in patients with acute fever of unknown focus

OBJECTIVES

The objective of this study was to evaluate the relationship between clinical features and the presence of infection on thoracic and abdominal tomography (CT) scans in emergency department (ED) patients with acute febrile illness without apparent source.

METHODS

Patients aged 18 years and over who presented to ED with acute fever of unknown origin between January 1, 2020 and December 31, 2020 and underwent CT imaging (thoracic and abdomen) as a diagnostic test were included in the study retrospectively. Acute fever of unknown origin was defined as the absence of a history or physical examination finding that could explain the possible cause of fever, normal values of parameters that would suggest an infection in the urine analysis, and absence of infiltration on chest X-ray. The patients were divided into two groups according to the presence and absence of a source of infection on CT. The clinical and demographic data of the patients were evaluated. The effect of clinical factors on the presence of infection in CT scans was determined using the logistic regression analysis.

RESULTS

Among the 173 patients included in the study, the CT scans were positive for the source of infection in 31.2% (n = 54) and negative in 68.8% (n = 119). In the multiple logistic regression analysis, age ≥ 65 years [odds ratio (OR): 2.72, 95% confidence interval (CI):1.15-4.35, p < 0.001), presence of comorbidity (OR:2.37, 95%CI:1.08-4.14, p = 0.033), and procalcitonin positivity (PCT) (OR: 2.54, 95%CI: 1.29-4.95, p = 0.006) were identified as risk factors for the presence of infection in CT.

CONCLUSION

Patient's age, presence of comorbidity and PCT level should be considered when deciding on the use of CT in determining the source of infection in acute febrile patients without clinical clues.

Reverse Engineering the Febrile System

Fever, the elevation of core body temperature by behavioral or physiological means, is one of the most salient aspects of human sickness, yet there is debate regarding its functional role. In this paper, we demonstrate that the febrile system is an evolved adaptation shaped by natural selection to coordinate the immune system to fight pathogens. First, we show that previous arguments in favor of fever being an adaptation are epistemologically inadequate, and we describe how an adaptationist strategy addresses this issue more effectively. Second, we argue that the mechanisms producing fever provide clear indications of adaptation. Third, we demonstrate that there are many beneficial immune system responses activated during fever and that these responses are not mere byproducts of heat on chemical reactions. Rather, we show that natural selection appears to have modified several immune system effects to be coordinated by fever. Fourth, we argue that there are some adaptations that coordinate the febrile system with other important fitness components, particularly growth and reproduction. Finally, we discuss evidence that the febrile system may also have evolved an antitumor function, providing suggestions for future research into this area. This research informs the debate on the functional value of fever and antipyretic use.

Uterine Microbiota and Immune Parameters Associated with Fever in Dairy Cows with Metritis

OBJECTIVE

This study aimed to evaluate bacterial and host factors causing a fever in cows with metritis. For that, we investigated uterine microbiota using a metagenomic sequencing of the 16S rRNA gene (Study 1), and immune response parameters (Study 2) in metritic cows with and without a fever.

PRINCIPAL FINDINGS (STUDY1)

Bacterial communities were similar between the MNoFever and MFever groups based on distance metrics of relative abundance of bacteria. Metritic cows showed a greater prevalence of Bacteroidetes, and Bacteroides and Porphyromonas were the largest contributors to that difference. A comparison of relative abundance at the species level pointed to Bacteroides pyogenes as a fever-related species which was significantly abundant in the MFever than the MNoFever and Healthy groups; however, absolute abundance of Bacteroides pyogenes determined by droplet digital PCR (ddPCR) was similar between MFever and MNoFever groups, but higher than the Healthy group. The same trend was observed in the total number of bacteria.

PRINCIPAL FINDINGS (STUDY2)

The activity of polymorphonuclear leukocyte (PMN) and the production of TNFα, PGE2 metabolite, and PGE2 were evaluated in serum, before disease onset, at 0 and 3 DPP. Cows in the MNoFever had decreased proportion of PMN undergoing phagocytosis and oxidative burst compared with the MFever. The low PMN activity in the MNoFever was coupled with the low production of TNFα, but similar PGE2 metabolite and circulating PGE2.

CONCLUSION/SIGNIFICANCE

Our study is the first to show a similar microbiome between metritic cows with and without a fever, which indicates that the host response may be more important for fever development than the microbiome. Bacteroides pyogenes was identified as an important pathogen for the development of metritis but not fever. The decreased inflammatory response may explain the lack of a febrile response in the MNoFever group.

Mechanisms of fever production and lysis: lessons from experimental LPS fever

Fever is a cardinal symptom of infectious or inflammatory insults, but it can also arise from noninfectious causes. The fever-inducing agent that has been used most frequently in experimental studies designed to characterize the physiological, immunological and neuroendocrine processes and to identify the neuronal circuits that underlie the manifestation of the febrile response is lipopolysaccharide (LPS). Our knowledge of the mechanisms of fever production and lysis is largely based on this model. Fever is usually initiated in the periphery of the challenged host by the immediate activation of the innate immune system by LPS, specifically of the complement (C) cascade and Toll-like receptors. The first results in the immediate generation of the C component C5a and the subsequent rapid production of prostaglandin E2 (PGE2). The second, occurring after some delay, induces the further production of PGE2 by induction of its synthesizing enzymes and transcription and translation of proinflammatory cytokines. The Kupffer cells (Kc) of the liver seem to be essential for these initial processes. The subsequent transfer of the pyrogenic message from the periphery to the brain is achieved by neuronal and humoral mechanisms. These pathways subserve the genesis of early (neuronal signals) and late (humoral signals) phases of the characteristically biphasic febrile response to LPS. During the course of fever, counterinflammatory factors, "endogenous antipyretics," are elaborated peripherally and centrally to limit fever in strength and duration. The multiple interacting pro- and antipyretic signals and their mechanistic effects that underlie endotoxic fever are the subjects of this review.

The development of endotoxin tolerance, and the role of hypothalamo-pituitary-adrenal function and glucocorticoids in Pekin ducks

Endotoxin tolerance represents a state of abated immunological responsiveness to pyrogens, which, in mammals, leads to the decline or abolition of the fever response. The development of endotoxin tolerance in birds is not well understood; consequently, the impact of repeated pathogenic exposure on the avian febrile response, and thus on the ability of birds to fight recurrent infection, is not known. We determined the effect of repeated injections of lipopolysaccharide (LPS) on the febrile response of Pekin ducks. We gave ducks five injections of LPS, spaced 1, 4 or 10 days apart, and recorded their core body temperature with abdominally implanted temperature data loggers. Once we established that Pekin ducks developed endotoxin tolerance, we investigated the effect of repeated injections of LPS on the central and peripheral segments of the hypothalamo-pituitary-adrenal (HPA) axis in an attempt to elucidate the role of glucocorticoids in the modulation of the febrile response during the tolerant period. When our ducks became tolerant to LPS, they had significantly higher basal levels of plasma corticosterone (CORT, the principal glucocorticoid in birds), and their HPA response to treatment with LPS was blunted. We propose that the augmented levels of basal plasma CORT resulted from sensitized HPA function, and this, in turn, contributed to the development of endotoxin tolerance. Regulation of the circulating level of CORT might be a possible target for the re-establishment of appropriate immune responses in birds.

Heat, Athletes, and Immunity

During exercise, body temperature rises as a result of increased energy metabolism and heat absorbed from the environment. In response to this rise in body temperature, blood flow increases and stress hormones are released. Together, blood flow and stress hormones stimulate increases in the number of circulating leukocytes and alterations in various aspects of immune function, including cytokine production. The extent of changes in leukocyte numbers, cytokine concentrations, and immune cell function depends on how high body temperature rises and the intensity and duration of exercise. In general, increases in body temperature of ≤ 1.8° F (1° C) induce mild changes in immune function, and such changes are unlikely to increase the risk of illness in athletes, firefighters, and military personnel who regularly exercise in hot conditions. More severe immune disturbances during exercise in extreme heat (≥ 106° F or 41° C) may contribute to classical symptoms of heatstroke.

Molecular aspects of fever and hyperthermia

After defining hyperthermia and fever, this article describes the complete chain of events leading to the genesis of fever, starting with the lipopolysaccharide-induced formation of endogenous pyrogens (cytokines), their interactions with relevant targets in the brain, the induction of enzymes responsible for the formation of prostaglandin E2, the activation of descending neuronal pathways via the EP3 receptor, and the stimulation of thermogenesis via this pathway to support the febrile shift of the thermoregulatory set point. This article also summarizes an alternative hypothesis to account for a rapid induction of the early phase of lipopolysaccharide-induced fever before the release of larger amounts of cytokines into the bloodstream. Other topics discussed include malignant hypothermia, drug-induced hypothermia, and the heat stroke syndrome.

Blockade of prostaglandin E2-induced thermogenesis by unilateral microinjection of GABAA receptor antagonist into the preoptic area

Previous studies have demonstrated that pretreatment of rats with a GABA(A) receptor antagonist microinjected bilaterally into the preoptic area (POA) blocked cold- or lipopolysaccharide-induced thermogenesis. Here, the involvement of GABA(A) receptors in prostaglandin (PG)E2-induced fever was examined. Thermogenic, tachycardic, vasoconstrictive, and hyperthermic responses were elicited by the unilateral microinjection of 0.57-1.1 pmol PGE2 into the region adjacent to the organum vasculosum of the lamina terminalis in urethane-chloralose-anesthetized rats. All these responses were blocked 10 min after pretreatment of the rats with a GABA(A) receptor antagonist, bicuculline methiodide or gabazine (50-500 pmol), microinjected unilaterally into the POA; and recovery occurred at approximately 70 min. Though the antagonist treatment alone had no effect on the O2 consumption rate or colonic temperature, it did elicit a bradycardic response. Pretreatment with the vehicle, saline, had no effect on the PGE2-induced responses. However, the blocking action of bicuculline/gabazine was efficacious when the agent was administered unilaterally, but not necessarily bilaterally, into the POA either contralateral or ipsilateral to the PGE2 injection site. These results suggest that the PGE2-induced responses are not simply mediated by the GABAergic transmission from the PGE2-sensitive site to the thermoefferent structure in the POA, although a tonic inhibitory input to POA neurons has a permissive role for the full expression of PGE2-induced fever.

Molecular Aspects of Fever and Hyperthermia

A rise in core temperature during fever usually results from change in the thermocontroller characteristics, resulting in an elevation of the set point of body temperature. Time course and extent of natural fevers are variable, but an upper limit (41 degrees C in humans), at which core temperature is maintained for some time and reduced when the set point of body temperature returns to its normal level, rarely is exceeded. Although any rise in body temperature may result from fever, those rises that are not accompanied by supportive changes in thermoeffector activities are termed hyperthermia.

Endotoxic fever: New concepts of its regulation suggest new approaches to its management

Endotoxic fever is regulated by endogenous factors that provide pro- and anti-pyretic signals at different points along the febrigenic pathway, from the periphery to the brain. Current evidence indicates that the febrile response to invading Gram-negative bacteria and their products is initiated upon their arrival in the liver via the circulation and their uptake by Kupffer cells (Kc). These pathogens activate the complement cascade on contact, hence generating complement component 5a. It, in turn, very rapidly stimulates Kc to release prostaglandin (PG)E2. Pyrogenic cytokines (TNF-alpha, etc.) are produced later and are no longer considered to be the immediate triggers of fever. The Kc-generated PGE2 either (1) may be transported by the bloodstream to the ventromedial preoptic-anterior hypothalamus (POA, the locus of the temperature-regulating center), presumptively diffusing into it and acting on thermoregulatory neurons; PGE2 is thus taken to be the final, central fever mediator. Or (2) it may activate hepatic vagal afferents projecting to the medulla oblongata, thence to the POA via the ventral noradrenergic bundle. Norepinephrine consequently secreted stimulates alpha1-adrenoceptors on thermoregulatory neurons, rapidly evoking an initial rise in core temperature (Tc) not associated with any change in POA PGE2; this neural, PGE2-independent signaling pathway is quicker than the blood-borne route. Elevated POA PGE2 and a secondary Tc rise occur later, consequent to alpha2 stimulation. Endogenous counter-regulatory factors are also elaborated peripherally and centrally at different points during the course of the febrile response; they are, therefore, anti-pyretic. These multiple interacting pathways are the subject of this review.

Kupffer cell-generated PGE2triggers the febrile response of guinea pigs to intravenously injected LPS

Because the onset of fever induced by intravenously (iv) injected bacterial endotoxic lipopolysaccharides (LPS) precedes the appearance in the bloodstream of pyrogenic cytokines, the presumptive peripheral triggers of the febrile response, we have postulated previously that, in their stead, PGE2could be the peripheral fever trigger because it appears in blood coincidentally with the initial body core temperature (Tc) rise. To test this hypothesis, we injected Salmonella enteritidis LPS (2 μg/kg body wt iv) into conscious guinea pigs and measured their plasma levels of LPS, PGE2, TNF-α, IL-1β, and IL-6 before and 15, 30, 60, 90, and 120 min after LPS administration; Tcwas monitored continuously. The animals were untreated or Kupffer cell (KC) depleted; the essential involvement of KCs in LPS fever was shown previously. LPS very promptly (<10 min) induced a rise of Tcthat was temporally correlated with the elevation of plasma PGE2. KC depletion prevented the Tcand plasma PGE2rises and slowed the clearance of LPS from the blood. TNF-α was not detectable in plasma until 30 min and in IL-1β and IL-6 until 60 min after LPS injection. KC depletion did not alter the times of appearance or magnitudes of rises of these cytokines, except TNF-α, the maximal level of which was increased approximately twofold in the KC-depleted animals. In a follow-up experiment, PGE2antiserum administered iv 10 min before LPS significantly attenuated the febrile response to LPS. Together, these results support the view that, in guinea pigs, PGE2rather than pyrogenic cytokines is generated by KCs in immediate response to iv LPS and triggers the febrile response.

Pyrexia, anorexia, adipsia, and depressed motor activity in rats during systemic inflammation induced by the Toll-like receptors-2 and -6 agonists MALP-2 and FSL-1

Macrophage-activating lipopeptide-2 (MALP-2) from Mycoplasma fermentans has been identified as a pathogen-associated molecular pattern of Mycoplasmas that causes activation of the innate immune system through the activation of the heterodimeric Toll-like receptors (TLRs)-2 and -6. The aim of this study was to characterize the ability of MALP-2 and a synthetic analog fibroblast-stimulating lipopeptide-1 (FSL-1; represents the NH2-terminal sequence of a lipoprotein from M. salivarium) to act as exogenous pyrogens, to induce formation of cytokines (endogenous pyrogens), and to cause sickness behavior, such as depressed motor activity, anorexia, and adipsia. For this purpose, body temperature, activity, food intake, and water intake were recorded for 3 days by use of telemetry devices in several groups of rats treated with MALP-2/FSL-1 or the respective control solutions. Intraperitoneal injections of FSL-1 caused fever at doses of 10 or 100 microg/kg, which was preceded by a pronounced phase of hypothermia in response to a dose of 1,000 microg/kg. The maximal fever (a peak of 1.5 degrees C above baseline) was caused by the 100 microg/kg dose with almost identical responses to both MALP-2 and FSL-1. Fever was accompanied by pronounced rises of the proinflammatory cytokines TNF and IL-6 in plasma. Treatment with the TLR-2 and -6 agonists further induced a dose-dependent manifestation of anorexia and adipsia, as well as a reduction of motor activity. We could thus demonstrate that activation of TLR-2 and -6 can induce systemic inflammation in rats accompanied by the classical signs of brain-controlled illness responses.

Localized vs. systemic inflammation in guinea pigs: a role for prostaglandins at distinct points of the fever induction pathways?

In guinea pigs, dose-dependent febrile responses were induced by injection of a high (100 μg/kg) or a low (10 μg/kg) dose of bacterial lipopolysaccharide (LPS) into artificial subcutaneously implanted Teflon chambers. Both LPS doses further induced a pronounced formation of prostaglandin E2 (PGE2) at the site of localized subcutaneous inflammation. Administration of diclofenac, a nonselective cyclooxygenase (COX) inhibitor, at different doses (5, 50, 500, or 5,000 μg/kg) attenuated or abrogated LPS-induced fever and inhibited LPS-induced local PGE2 formation (5 or 500 μg/kg diclofenac). Even the lowest dose of diclofenac (5 μg/kg) attenuated fever in response to 10 μg/kg LPS, but only when administered directly into the subcutaneous chamber, and not into the site contralateral to the chamber. This observation indicated that a localized formation of PGE2 at the site of inflammation mediated a portion of the febrile response, which was induced by injection of 10 μg/kg LPS into the subcutaneous chamber. Further support for this hypothesis derived from the observation that we failed to detect elevated amounts of COX-2 mRNA in the brain of guinea pigs injected subcutaneously with 10 μg/kg LPS, whereas subcutaneous injections of 100 μg/kg LPS, as well as systemic injections of LPS (intra-arterial or intraperitoneal routes), readily caused expression of the COX-2 gene in the guinea pig brain, as demonstrated by in situ hybridization. Therefore, fever in response to subcutaneous injection of 10 μg/kg LPS may, in part, have been evoked by a neural, rather than a humoral, pathway from the local site of inflammation to the brain.

Cytokines, PGE2 and endotoxic fever: a re-assessment

The innate immune system serves as the first line of host defense against the deleterious effects of invading infectious pathogens. Fever is the hallmark among the defense mechanisms evoked by the entry into the body of such pathogens. The conventional view of the steps that lead to fever production is that they begin with the biosynthesis of pyrogenic cytokines by mononuclear phagocytes stimulated by the pathogens, their release into the circulation and transport to the thermoregulatory center in the preoptic area (POA) of the anterior hypothalamus, and their induction there of cyclooxygenase (COX)-2-dependent prostaglandin (PG)E(2), the putative final mediator of the febrile response. But data accumulated over the past 5 years have gradually challenged this classical concept, due mostly to the temporal incompatibility of the newer findings with this concatenation of events. Thus, the former studies generally overlooked that the production of cytokines and the transduction of their pyrogenic signals into fever-mediating PGE(2) proceed at relatively slow rates, significantly slower certainly than the onset latency of fever produced by the i.v. injection of bacterial endotoxic lipopolysaccharides (LPS). Here, we review the conflicts between the earlier and the more recent findings and summarize new data that reconcile many of the contradictions. A unified model based on these data explicating the generation and maintenance of the febrile response is presented. It postulates that the steps in the production of LPS fever occur in the following sequence: the immediate activation by LPS of the complement (C) cascade, the stimulation by the anaphylatoxic C component C5a of Kupffer cells, their consequent, virtually instantaneous release of PGE(2), its excitation of hepatic vagal afferents, their transmission of the induced signals to the POA via the ventral noradrenergic bundle, and the activation by the thus, locally released norepinephrine (NE) of neural alpha(1)- and glial alpha(2)-adrenoceptors. The activation of the first causes an immediate, PGE(2)-independent rise in core temperature (T(c)) [the early phase of fever; an antioxidant-sensitive PGE(2) rise, however, accompanies this first phase], and of the second a delayed, PGE(2)-dependent T(c) rise [the late phase of fever]. Meanwhile-generated pyrogenic cytokines and their consequent upregulation of blood-brain barrier cells COX-2 also contribute to the latter rise. The consecutive steps that initiate the febrile response to LPS would now appear, therefore, to occur in an order different than conceived originally.