Cotton fever is a temporary health condition that is seen among people who use cotton as a filter before injecting their intravenous drugs. Symptoms appear quickly and usually last 12-24 hours. A fever and high white blood cell count (leukocytosis) are the most common symptoms, similar to a sepsis infection. Symptoms usually resolve without interventions but can also be treated with fluids, antibiotics, and fever-reducer medication.

What is Cotton Fever?

Cotton fever is a condition that can happen to someone who has used cotton as a drug filter before injecting intravenous drugs. Its primary symptoms are an acute-onset fever and high white blood cell count. It causes a systemic inflammatory response within minutes of the intravenous (IV) drug use. Cotton fever is a well-recognized condition among people who inject drugs (PWID) but is less known among healthcare providers. This results in frequent misdiagnosis and unnecessary medical tests and treatment.

What Causes Cotton Fever?

Intravenous drugs can be heated before being drawn into a syringe for injection. Once the drug is heated, it can be drawn through a cotton ball into the syringe as an inexpensive way to filter the drug.[1] Some users will even remove what has been filtered out in the cotton ball to use later, especially if their supply is running low. This is called “shooting the cottons”.

There are a few theories as to why cotton fever happens. One theory is that despite the cotton being there to filter out contaminates, it is not a medically sterile filter. Cotton contaminants can be drawn into the syringe and injected. Injecting the cotton contaminants can result in the sepsis-like symptoms of cotton fever.[2] A second theory is that some people have preformed antibodies to cotton while others do not. A third theory is that cotton fever may result from an endotoxin caused by bacteria such as Enterobacter agglomerans living in cotton plants.[3]

What Are The Symptoms of Cotton Fever?

Symptoms of cotton fever begin 15–30 minutes following injection and normally last six to twelve hours, but they can extend for 24-48 hours.[4]  Symptoms usually resolve on their own with no intervention.

Common cotton fever symptoms include :[5]

• Fever (peaks at 101.3–104.5 °F)
• Extreme chills & uncontrollable shivering
• Gastrointestinal symptoms, including abdominal pain, nausea and vomiting
• Headache
• Muscle pains
• Back and kidney pain (can be dull, sharp, piercing, or burning)
• Excessive sweating
• General weakness and malaise
• Shortness of breath
• Tachycardia
• Chest pain

Less common cotton fever symptoms include: [6]

• Leg pain
• Joint pain
• Heart palpitations
• Dysphoria
• Fear of death

How Is Cotton Fever Treated?

There are no established medical guidelines for managing and treating cotton fever.[7] Cotton fever is a short-term, non-lethal condition that often resolves without intervention. However, PWIDs are at a higher risk for developing severe infections and sepsis, and therefore, broad-spectrum antibiotics can be administered to help fight off any potential infections.  Most people’s symptoms will improve with receiving fluids and medications to reduce their fever. Severe cases may result in a short-term hospital stay for observation.

Many medical professionals are unfamiliar with cotton fever. Because its symptoms resemble sepsis, when someone presents at the emergency department with cotton fever, they require a lot of resources, as their symptoms are similar to life-threatening conditions. If medical personnel are educated on cotton fever and patients are forthcoming about their drug use, it would eliminate unnecessary medical tests and procedures for a short-term, self-resolving condition.

The best treatments for cotton fever are IV fluids, fever-reducing medications, antibiotics, and, if needed, vasopressors.[8]

Complications from Cotton Fever

Most complications people experience are a result of infection from their injection drug use. Infections can include:[9]

• Sepsis: an infection that has caused a full body response to the infection, resulting in organ failure, tissue damage, and death.
• Infective endocarditis: a bacterial infection that enters the bloodstream and settles in the heart lining, a heart valve, or blood vessels.
• Spinal epidural abscess: a central nervous system infection with a collection of pus and infectious materials causing an abscess along the spine.
• Other infections:  People who inject drugs are susceptible to multiple different infections, including HIV/AIDS, hepatitis, and other bacterial and fungal infections.

One direct complication of cotton fever is the potential for infection and sepsis from Enterobacter agglomerans and Pantoea agglomerans. This can be a serious health issue as these bacteria from the cotton plant can be resistant to standard antibiotics such as amoxicillin and cephalosporins.

Cotton Fever and Drug Addiction

If you or a loved one has experienced cotton fever and may be struggling with an addiction to intravenous drugs, there are treatment options. Treatment often starts with detox, which can help you through the uncomfortable withdrawal symptoms. After that, most people begin a rehab program that may include inpatient or outpatient treatment. Program admission staff who can explain how the different programs work, what may be the best fit for you, and help you determine if your insurance will cover treatment. Treatment programs focus on meeting the person’s needs, supporting their recovery, and repairing or maintaining their family relationships and work obligations.