The Look, the Feel, of Cotton

1Legacy Health, Portland, OR

Meeting: Hospital Medicine 2015, March 29-April 1, National Harbor, Md.

Abstract number: 473


Case Presentation:

A 52 year-old woman presented with two days of chest and back pain. History was significant for treated Cryptococcus fungemia, multi drug resistant urinary tract infection, hepatitis c and intravenous illicit drug use. Physical exam was positive for temperature of 39.6 C, heart rate of 102, respiratory rate of 22, 2/6 systolic murmur and visible sites of recent drug injection.  Laboratory data showed a white blood cell count of 2,800 cells/ul and transaminases that were at baseline. Urinalysis and chest radiograph were negative. The patient was admitted with systemic inflammatory response syndrome (SIRS) and started on vancomycin and cefepine.  Her SIRS and pain resolved.  Work up revealed negative HIV, negative blood and urine cultures, negative MRI of the spine, and negative echocardiogram. Antibiotics were discontinued after 24 hours and the patient remained stable.  Infectious disease was consulted. Further history revealed the patient used rainwater and cigarette filters to strain her heroin prior to injection.  It was felt that the patient using a cigarette filter to prepare her heroin had precipitated cotton fever which accounted for the patient’s SIRS and subsequent negative work up.  The patient remained stable off antibiotics and was discharged home.


SIRS and drug abuse is a combination commonly encountered by the hospitalist.  Cotton fever is a self-limited process that mimics sepsis in intravenous drug abusers (IVDA).  It occurs when cotton fibers are used to filter a drug suspension.  Endotoxins in cotton are believed to cause this presentation.  Cotton fever can present with headache, malaise, chills, dyspnea, emesis, abdominal pain, back pain, and myalgias.  Physical exam can elicit fevers, tachycardia, tachypnea, abdominal tenderness and muscle tenderness.  Laboratory data may reveal leukocytosis and transaminitis.  Cultures and imaging are negative.  The syndrome typically resolves in 12-24 hours.  Given the potential infections an IVDA can have this is a diagnosis of exclusion.


This is a middle aged female with active intravenous drug use who presented with SIRS and a negative work up.  While care must be taken to evaluate for serious causes of SIRS in an IVDA, cotton fever should be on the differential diagnosis.  A point should be made to ascertain IVDA injection habits when completing a history.

To cite this abstract:

Chadaga S. The Look, the Feel, of Cotton. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 473. Journal of Hospital Medicine. 2015; 10 (suppl 2). Accessed September 20, 2019.

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