Cotton Fever: Symptoms, Causes, and When to Seek Help

Cotton fever can be a very unpleasant surprise. And as harmless as its name sounds, anyone who has experienced it knows how confusing and alarming it can be. Understanding where the term comes from, what we know about it, and when symptoms require immediate medical attention is valuable information to know.

What Is Cotton Fever?

Cotton fever is a common name for a flu-like syndrome that is actually the body’s inflammation response that happens after people inject drugs.[1] This illness is called “cotton fever” because it is known to happen after people use a piece of cotton, like a cotton ball or swab, to filter out debris after preparing the drug so it doesn’t end up in the syringe.

The exact cause of cotton fever is still not fully understood, but many researchers have theories that include:

• Bacterial endotoxins. A 2019 study discussing the prevalence of bacterial and fungal infections in people who inject drugs concluded that cotton fever is believed to result from injected bacterial endotoxins, immune responses triggered by cotton antigens, or pyrogenic proteins in filter materials.[2]
• Pantoea agglomerans. This is a type of bacteria found in plants (including cotton). Researchers believe that when someone introduces bacterial products from cotton into their body, it may elicit both fever and an inflammatory response.[3]
• Cotton fibers or debris entering into the bloodstream
• Other foreign cotton-based materials entering the bloodstream and triggering the body’s immune response.
• Contamination from drug preparation introduced while injecting.

 

While cotton fever itself is not likely to leave lasting damage, its symptoms are very close to those of potentially deadly bloodstream infections. If someone assumes their symptoms are from the cotton and waits for them to pass, this may cause a life-threatening delay in seeking treatment for infections like sepsis or endocarditis.

Cotton fever has primarily been studied in relation to heroin injection.[4] Case studies have also documented cotton fever-like symptoms after injecting other drugs.[5]

Cotton Fever Symptoms

Symptoms of cotton fever typically develop quickly after someone injects drugs and are consistent with a sudden-onset flu, including:

• Fever
• Chills
• Shaking
• Muscle pain
• Headache
• Back and abdominal pain, other general body aches
• Nausea and vomiting
• Elevated heart rate
• Shortness of breath
• Chest tightness
• Anxiety

These symptoms also mirror the symptoms of serious infections, so attempting to diagnose the condition at home may put you at risk for undetected life-threatening complications.

How Quickly Do Cotton Fever Symptoms Start?

Symptoms of cotton fever can develop quickly, sometimes within hours or even minutes after drug use.

Case studies documenting cotton fever that resembled sepsis reported that the fever began approximately 30 minutes after the person injected heroin through a reused cotton filter.[6]

How Long Do Cotton Fever Symptoms Last?

Typically, cotton fever symptoms resolve within 12 to 48 hours.

However, if symptoms last longer than expected or worsen over time, seek medical assistance immediately. If you or someone you’re with has a recurring fever, chronic illness, skin lesions, fever, wounds, rapid heartbeat, unconsciousness, or otherwise becomes increasingly debilitated shortly after injecting a drug, suspect endocarditis and get medical help immediately.

Can You Die From Cotton Fever?

Cotton fever isn’t usually life-threatening on its own. But if someone misdiagnoses themselves with cotton fever when they actually have endocarditis, sepsis, pneumonia, cellulitis, or another condition, that could ultimately prove fatal.

When people who inject drugs develop a fever, doctors can usually trace it to common infections like pneumonia or cellulitis. However, studies show that in 8 to 11% of cases, the fever is actually caused by endocarditis, which is a severe, life-threatening infection of the heart valve.[7]

Sepsis can also happen. Sepsis is an overwhelming reaction to infection that can result in tissue damage and/or organ failure, leading to death.[8] Both conditions start with the same presenting symptoms as cotton fever: high fever, aches, chills, rapid pulse, and fatigue. This is what makes a correct diagnosis so important.

Cotton Fever vs. Sepsis

Cotton fever and sepsis look similar at first, but sepsis also involves:

• Fever or low body temperature
• Confusion
• Severe weakness
• Fast breathing
• Fast heart rate
• Low blood pressure
• Worsening symptoms
• Organ dysfunction

Cotton Fever vs. Endocarditis

Endocarditis happens when bacteria is transmitted into the bloodstream and attaches to and colonizes either the cardiac valves or the interior surfaces of the heart chambers. Because intravenous drug use can easily introduce bacteria into the body via unsterilized needles, contaminated skin, or tainted supplies, people who inject drugs have a significantly higher risk of contracting endocarditis than the general population.[9]

Potential symptoms of endocarditis include:

• High fever
• Cold sweat
• Nighttime sweats
• Fatigue
• Shortness of breath
• Chest pain
• New or changing heart murmur
• Leg swelling
• Chronic or recurring illness
• Lower back pain
• Skin lesions or changes

Cotton fever is generally resolved relatively quickly, but endocarditis requires diagnostic confirmation and treatment, typically through intravenous antibiotics and possibly surgical intervention.

 

How Is Cotton Fever Diagnosed?

Cotton fever is diagnosed by exclusion, meaning ruling out more ominous causes for symptoms before considering the possibility of cotton fever.

Evaluation may include:

• Your medical history
• Your last injection date and history
• Vital signs
• Injection-site inspection
• Blood culture analysis
• Laboratory tests (e.g., complete blood counts and comprehensive metabolic panels)
• Urine tests
• Chest X-ray if symptoms include shortness of breath
• Cardiac assessment if endocarditis is suspected

There are no established home tests for diagnosing cotton fever. Someone who has experienced cotton fever before cannot be certain that the next instance is cotton fever again and not something more serious. Medical evaluation is recommended for any flu-like symptoms that follow intravenous drug use.

Cotton Fever Treatment

There is no specific medication for cotton fever. Instead, treatment focuses on providing supportive care once it has been determined that there is no underlying serious infection contributing to symptoms.

This might include:

• Bed rest
• Hydration
• Monitoring of symptoms
• Fever reducers
• Anti-nausea medication and support

Some people are prescribed antibiotics while awaiting laboratory test results if sepsis or endocarditis are suspected.

Prescribing antibiotics should be done under direction of a qualified healthcare provider and not performed as casual experimentation or by sharing antibiotic prescriptions between friends or users. Attempting to treat yourself at home when displaying severe symptoms or when symptoms fail to improve can pose significant risks, especially since fever following injection drug use can indicate a life-threatening condition.

When Should I Go to the Emergency Room for Cotton Fever?

Call 911 or visit an emergency room immediately for:

• Difficulty breathing or chest pain
• Dizziness or fainting
• Blue lips or blue fingers
• Debilitating weakness, seizure activity, or persistent vomiting
• High-grade fever or symptoms persisting longer than expected (more than 24 hours)
• Extremely fast heartbeat, low blood pressure, or blood pressure drop symptoms
• Intense lower back pain, increased swelling, redness, heat, or pus at injection site
• Appearance of new rash or skin lesion changes
• Multiple episodes of fever after injections
• Concerns regarding overdose or possible infection

When Cotton Fever Points to an Even Bigger Risk

If you have experienced cotton fever more than once, it may be a sign that your drug use is putting your overall health at risk.

If you recognize the following signs, it’s time to reach out for help:

• Reusing supplies.
• Experience cotton fever multiple times.
• Abscesses or skin infections.
• Withdrawal symptoms if you stop or reduce drug use.
• Using fentanyl, heroin, or methamphetamine.
• You have overdosed before.
• You have tried to stop and cannot.
• You are avoiding medical care due to fear, stigma, or guilt.

Seeking professional support can address issues related to cravings, withdrawals, mental health, preventing relapses, and establishing a foundation for regaining stability in your life.

Start Healing Today

If drug use is affecting your physical and mental health, help is available. Aura Recovery provides addiction rehab and detoxification services in a therapeutic setting designed to build the foundation for recovery and build positive habits.

Reach out today. We’ll guide you through your treatment options and help you take your first step on your journey towards healing.

 

Frequently Asked Questions About Cotton Fever