Internal

Medicine I
16/Lecture # 4
Fever and Hyperthermia
Dr. Homer Uy Co 06/27/2014

Chapter 16: Fever and Hyperthermia

Lecture Objectives
1.
2.
3.
4.
5.

To discuss the physiology of body temperature regulation

To define fever
To define hyperthermia
To distinguish between fever and hyperthermia
To discuss how fever and hyperthermia are treated

Thermoregulation

TNF, IL-1, IL-6, ciliary neurotropic factor (CNTF),

IFN-a

TNF & IL-1 produce fever at low doses of 10-100

ng/kg; IL-6 (1-10ug/kg)

Elevation of the hypothalamic set point

By cytokines causing the increase in production of

prostaglandin E2 (PGE2)

By direct activation of Toll-like receptors by

microbial products resulting in PGE2 production

Hypothalamus (preoptic anterior and posterior hypothalamus)

Acts like a thermostat for the human body
o

o
o
o

The temperature of the blood that is contained in the

vessels gives the signal for the hypothalamus to adjust the
body temperature
Skin sensory organs
Needs an objective criterion Hypothalamic Set point
Core body temperature range: 36.5 37.5C (97.7-99.5F)
lowest levels at 6am and highest levels at 4-6 pm

Method for releasing Heat

Exhalation
Sweat
Vasodilatation

Method for Heat production

Shivering from muscles
Increase liver Metabolism
Vasoconstriction heat
conservation by shunting blood
away from the periphery to the
internal organs
Behavioral adjustments (eg.
Putting more clothing)

1. Fever electric oven

2 elements of fever (Should Present)
o Elevated Body Temperature
o Increase in Hypothalamic set point

Hyperpyrexia

Body temp greater than 41.5C

Most commonly occur in patients with severe infections

and with CNS hemorrahges

Hypothalamic fever elevated temperature caused by abnormal
hypothalamic function.

Pathogenesis of Fever:
o Pyrogens

Any substance that causes fever

Exogenous pyrogens

Endotoxin from gram negative

bacteria; highly pyrogenic molecule in
humans (2-3 ng/kg)

Enterotoxin from gram positive

bacteria

o Pyrogenic cytokines

Formerly called ENDOGENOUS PYROGENS

Figure 1 Flowchart of fever

o

Hyperthermia Brick oven

o Also called HEAT STROKE
o Uncontrolled increase in body temperature that
exceeds the bodys ability to lose heat
o There is no reported hyperthermia in cold
regions
o 2 mechanisms: Endogenous heat production
and Exogenous heat exposure
o Does not involve pyrogenic molecules

Clinical Manifestation
Fever
Shivering (This can only be seen

Hyperthermia
Manifestation depends on

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Internal Medicine I
16/Lecture # 4
Fever and Hyperthermia
Dr. Homer Uy Co 06/27/2014

in fever)
Body trying to produce or
conserve heat
Elevated body temperature (due
to infection and/or
inflammation)

etiology
Warm dry skin
Hallucination, delirium, pupil
dilation, muscle rigidity,
elevated creatinine
phosphokinase

Treatment: Fever
o Treat the underlying cause
o Objectives: first, to reduce the hypothalamic set point
(antipyretics) then facilitate heat loss (eg. Cooling
blankets)
o Examples of antipyretics:
Paracetamol (Inhibits COX3, CNS version of COX1
and COX2)
NSAIDs
Aspirin
Inhibition of prostaglandin formation
o Anticytokine therapy nice to know ;)

Treatment: Hpyerthermia
o Cool the patient
External cooling

Cooling with wet blankets

Cooling fan

Ice bath
Internal cooling

Gastric lavage

Peritoneal lavage tenchock, use

peritoneum to transfer heat

Hemodialysis cooling blood

Cardiopulmonary bypass with cooling

of blood
o IV fluid administration
o Remember:

Antipyretics are not effective in treating

hyperthermia.

Treat the underlying cause (see table 16-1)

10 item multiple choice quiz

1. A patient currently undergoing surgery suddenly manifested

increased Temp, HR, RR, pCO2 and muscle rigidity few minutes upon
induction of inhalation anesthetic, Halothane. What would be your
most probable diagnosis?
a.
Neuroleptic Malignant Syndrome
b. Severe Respiratory acidosis
c.
Malignant hyperthermia
d. Cardiopulmonary arrest

2. What would be your immediate intervention (in case #1)?
a.
Stop anesthesia, give antipyretic and cooling blanket
b. Stop anesthesia, increase O2
c.
Stop anesthesia, IV administration of Dantrolene s odium
d. Stop anesthesia, do CPR or defibrillation, give anti-
arrhythmic drug or calcium-channel blocker

3. PGE2 receptor involved in fever
a.
EP-1
b. EP-2
c.
EP-3
d. EP-4

4. Acetaminophen or oral ibuprofen, and not aspirin, is given to
children with fever because:

a.
Aspirin may cause ulceration of the gastric mucosa &

abdominal pain

b. Aspirin greatly affects platelet and may cause bleeding

c.
Aspirin is a poor COX inhibitor

d. Aspirin increases the risk of developing Reyes

syndrome



5. The following are TRUE regarding treatment of
fever/hyperpyrexia except:

a.
Routine treatment of fever with antipyretics does no

harm and does not slow the resolution of common viral

and bacterial infections.

b. Withholding antipyretic therapy can be helpful in

evaluating the effectiveness of a particular antibiotic.

c.
In treating hyperpyrexia, use of cooling blankets

facilitates reduction of temperature, thus, antipyretics

may not be given.
d. Routine use of antipyretics may mask an inadequately

treated bacterial infection



6. What is the preferred antipyretic drug to be used?

a.
Acetaminophen

b. Ibuprofen

c.
Aspirin



7. Tricyclic antidepressant overdose may cause drug-induced
hyperthermia. Treatment will include:

a.
Naloxone

b.
Physostigmine

c.
Curare

d. Dantrolene



8. This type/cause of hyperthermia is characterized by lead-pipe

rigidity:

a.
Neuroleptic Malignant syndrome
b. Malignant hyperthermia

c.
Serotonin syndrome

d.
Drug-induced hyperthermia



9. Serotonin syndrome can be differentiated with neuroleptic

malignant syndrome by the presence of the following except:

a.
Diarrhea

b. Tremor

c.
Myoclonus
d. Lead-pipe rigidity



10. Which of the following will most likely develop fever?

a.
30kg volunteer injected with 50ng of endotoxin

b. 70kg volunteer injected with 210ug of S. aureus

enterotoxin

c.
55kg volunteer injected with 400ng of IL-1

d. 60kg volunteer injected with 55ug of IL-6



Answers: C C C D C A B A D A

References:
Lecture
th
Harrisons Principle of Internal Mediciine 18 ed.

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