Cotton fever: A case report and review of the literature

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. 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. 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.