Cotton fever: A case report and review of the literature

Background

The term “cotton fever” describes a benign, self-limited febrile response within minutes following cotton filter use with intravenous (IV) drug injection. We present a case of Pantoea species (previously Enterobacter agglomerans) bacteremia related to injection of solubilized oxycodone.

Case report

A 33-year-old male solubilized half of an oxycodone 5 mg tablet in tap water, filtered it with cotton and injected it intravenously. He immediately felt unwell. Initial vital signs included a temperature of 40.5 ​°C, blood pressure 150/107 ​mmHg, heart rate 170 bpm, respiratory rate 28 bpm, and SpO2 of 98% on room air. His physical exam was notable only for rigors. Initial laboratory studies demonstrated a serum lactate of 2.7 mmol/L without leukocytosis. He was treated with vancomycin and piperacillin/tazobactam for two days with resolution of fever. Blood cultures were positive for Pantoea species resistant to ampicillin and cefazolin. He continued piperacillin/tazobactam for three additional days then transitioned to oral levofloxacin for seven days upon discharge.

Why should an emergency physician be aware of this?

Cotton fever describes an acute, febrile response following IV injection using cotton as a filter. The initial febrile reaction could be due to pyrogens or preformed endotoxins. Bacteremia from Enterobacter agglomerans (now Pantoea species) is possible and is frequently resistant to amoxicillin and first- and second-generation cephalosporins.