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Author: Bailey Pope, Oregon Health &
Science University School of Medicine, Class of 2013
Introduction: The evaluation of a febrile
intravenous drug user presents a difficult challenge for
clinicians. While the majority of intravenous drug users will have
a readily identifiable source of fever, up to 36% will have an
occult infection. Although exhaustive evaluations of these patients
may be warranted, recognition of benign causes of fever in
intravenous drug users may attenuate expensive workups. Thus we
present a case of cotton fever, an infrequently recognized
febrile reaction in intravenous drug users.
Case Presentation: A 24-year-old woman
presented to the emergency department for acute onset lower back
pain, fever, nausea, vomiting, abdominal pain, and anorexia four
hours after injecting heroin. On exam the patient was febrile,
normotensive, and tachycardic. Her cardiac exam revealed a soft
crescendo decrescendo murmur heard at the lower left sternal
border, while her pulmonary, abdominal, neurological, and cutaneous
exams were normal. Laboratory assessment revealed leukocytosis to
22.6 K/cu and an elevated C-reactive protein of 9.8 mg/dl (normal
< 0.6 mg/dl). Initial MRI imaging was suggestive of an L3 to S2
epidural abscess, but on further review this was interpreted as
normal epidural fat. A transthoracic echocardiogram revealed no
evidence of endocarditis. Cerebrospinal fluid analysis was
unremarkable, and all cultures were negative. Given the negative
infectious evaluation, no objective findings on physical
examination or diagnostic imaging to support further work up, the
patient was processed for discharge. Upon returning for
pre-discharge patient education, she was overheard talking to her
partner stating "I think I had 'cotton fever'". She later
acknowledged filtering her heroin through cotton prior to
Discussion: Cotton fever is a benign
self limited febrile syndrome typically presenting with fever,
dyspnea, headache, palpitations, back pain, and rigors immediately
following drug injection when filtering through cotton. Although
there have only been four case reports of cotton fever in the
medical literature, it is a common term among intravenous drug
users. There are two proposed theories of the mechanism of disease
for cotton fever. One suggests that a pyrogenic substance in
cotton, released during the drug cooking and filtration process,
triggers an inflammatory hypersensitivity reaction. The second is
that cotton fever is caused by injecting the bacteria
Enterobacter agglomerans, which commonly colonizes cotton. The
management of cotton fever is sportive, and the syndrome typically
resolves with in 24hrs.
Febrile intravenous drug users require a thorough evaluation for
both overt and occult etiologies of their fever. Awareness of
inflammatory syndromes such as the cotton fever, may allow
providers to minimize diagnostic and therapeutic interventions.
This case also highlights the knowledge and cultural gaps that
exist between our patients and their providers.
June 2012 Issue of IMpact