Cotton Fever: Does the Patient Know Best?

Abstract

Fever and leukocytosis have many possible etiologies in injection drug users. We present a case of a 22-year-old woman with fever and leukocytosis that were presumed secondary to cotton fever, a rarely recognized complication of injection drug use, after an extensive workup. Cotton fever is a benign, self-limited febrile syndrome characterized by fevers, leukocytosis, myalgias, nausea and vomiting, occurring in injection drug users who filter their drug suspensions through cotton balls. While this syndrome is commonly recognized amongst the injection drug user population, there is a paucity of data in the medical literature. We review the case presentation and available literature related to cotton fever. I njection drug use is associated with many infectious and non-infectious complications. The most common associated complications faced by managing physicians are soft-tissue infections, overdose, intoxication, and withdrawal.1 A frequent and challenging triage dilemma in this population is that of fever with active injection drug use. Despite numerous unsuccessful attempts to develop discriminating decision rules to guide ambulatory triage in these cases, clinicians are still unable to reliably exclude occult infections such as endocarditis and osteomyelitis. 2,3 This often results in short-term hospitalization of these patients, with accrual of health care expenditures. 4 An infrequently recognized cause of fever in injection drug users is cotton fever, a poorly characterized systemic febrile inflammatory syndrome seen in this population. Ironically, while there is a paucity of literature and awareness in the medical community, cotton fever is a wellrecognized syndrome amongst injection drug users. Originally coined in 1975, cotton fever was described as a benign selflimited febrile syndrome occurring in injection drug users who filtered their drug suspensions through cotton balls. 5 We present a case of presumed cotton fever in an active injection heroin user, in whom the diagnosis was only considered upon hearing the patient reference the syndrome after substantial workup had been completed. Additionally, a review of the medical literature and a discussion of the current theories about the pathophysiology of cotton fever are presented. CASE REPORTA 22-year-old woman presented to an outside hospital 4 hours after developing acute onset of fevers, headache, abdominal pain and radiating back pain, which began 20 minutes after injecting heroin. She did not endorse any visual symptoms, chest pain, dyspnea, or rashes. Initial vital signs were notable for a temperature of 39°C and heart rate of 102 beats per minute. At the time, the remainder of her exam was reported as normal except for diffuse abdominal tenderness. In the setting of acute back pain, a lumbar spine MRI was obtained and interpreted as consistent with an L3-S2 epidural abscess. Blood cultures were drawn, and the patient was started on vancomycin and ceftriaxone. Twelve hours after initiation of symptoms, the patient was transferred to our instituti...

Cotton fever resulting in Enterobacter asburiae endocarditis

“…Due to multiple comorbidities associated with IDU, cotton fever is often a diagnosis of exclusion [15]. While early recognition of cotton fever has been shown to decrease the cost of secondary evaluations and minimize prolonged hospital stays, as the clinical course is typically benign and symptoms resolve within the first 12−48 hours of onset, serious infections such as bacteremia and endocarditis must be excluded [4,7]. This case emphasizes the need for clinicians to perform a thorough workup despite the typically benign and self-limited presentation of cotton fever.…”

“…The etiology of fever in these patients, whether it be infectious or induced by the type of drug injected, can be challenging for physicians to discern [3]. While the ailment of “Cotton Fever” is widely acknowledged amongst PWIDs, it is rarely recognized in the medical community and less than a dozen cases have been presented in peer-reviewed literature [[4], [5], [6], [7]].…”

“…1) which is the process of injecting trace amounts of drugs extracted from previously used cotton filters [8]. It is described as a transient elevation in core body temperature of 2–4℉ that occurs minutes after injection [7]. Other symptoms include rigors, headache, nausea, vomiting, and myalgias, similar to symptoms of opioid withdrawal.…”

Cotton Fever: A Condition Self-Diagnosed by IV Drug Users

“…Symptoms usually resolve within 12 hours of onset. [2][3][4][5][6][7] Despite the benign course of cotton fever, it is important to rule out sources of sepsis, infective endocarditis, and other conditions associated with IV drug use, including HIV and hepatitis. Depending on the patient's presentation, IV antibiotics may be initiated until data from blood cultures is available.…”

“…In another case report, upon discharge after a negative workup, a patient conjectured that she had cotton fever. 7 The first mention of cotton fever that we could locate in peer-reviewed publications was from 1975. 8 There have been fewer than a dozen total publications on this condition since then (Table 1).…”