How To Get Rid Of Cotton Fever

NOT JUST COTTON FEVER: SEPTIC SHOCK IN PERSON WHO INJECTS DRUGS

Katie Raffel, MD ^*, UCSF, San Francisco, CA;Bridget Keenan, MD, University of California San Francisco, San Francisco, CA and Scott Steiger, MD, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA

Case Presentation:

A 58 year-old woman with end stage liver disease due to hepatitis C virus (HCV), human immunodeficiency virus (HIV) with intermittent adherence to anti-retroviral regimen and who injects heroin presented to the emergency department with malaise and diffuse abdominal pain of two days duration.

On admission, the patient had a temperature of 38°C, hypotension (65/34 mmHg), tachycardia (139/min) and tachypnea (22/min). Her abdominal exam showed diffuse tenderness and mild distention. Her initial laboratory data showed a white blood cell count of 3.1 x 10⁹/liter (93% neutrophils) and baseline hemoglobin and platelets. Chemistry panel was notable for hypokalemia and hypomagnesemia. Her liver function tests were abnormal but at baseline. CD4 count was 25 cells/mm3 with 20% CD4 and HIV viral load was 40,538 copies/ml. Chest X-ray was normal. Urine and blood cultures were sent.

Her septic shock was treated with intravenous fluids, vasopressors, and broad-spectrum antibiotics (vancomycin and cefepime). CT abdomen/pelvis demonstrated ascites and diffuse bowel edema without a source of infection. A paracentesis could not be performed safely.

On the second day of hospitalization, blood cultures grew Pantoea agglomerans. Urine culture remained without growth. The patient's antibiotic coverage was narrowed to ceftriaxone, and clinically she improved. No clear source was identified.

Discussion:

Pantoea agglomerans, formerly known as Enterobacter agglomerans, is an uncommon cause of sepsis. It has been described in patients with indwelling venous catheters, cancer, and in neonates. P. agglomerans is also a contaminant of cotton filters used to remove particulate material from heroin and is the suspected pathogen in the entity of "cotton fever." Cotton fever is a systemic inflammatory reaction causing fever, hypotension and leukocytosis in response to the endotoxin of P. agglomerans. Cotton fever is typically self-limited and without documented bacteremia. Although rarely reported, it appears in this case that immunocompromised patients with injection drug use can develop septic shock from exposure to this pathogen.

Conclusions:

Upon further questioning after discharge, the patient described re-using old, moist cotton to filter her heroin prior to injection. She was counseled on the infectious risk of cotton re-use and was referred to needle exchange programs to receive fresh cotton swabs.

The association between injection drug use and the patient's septic shock due to Pantoea agglomerans was not initially recognized, and inpatient providers missed opportunities to decrease recurrence of bacteremia or other sequelae of opioid use disorder. A thorough history of drug use techniques allows providers to counsel patients on avoiding risky practices, while initiation of opioid replacement therapy during hospitalization may improve engagement with outpatient maintenance treatment.

To cite this abstract:

Raffel, K; Keenan, B; Steiger, S.

NOT JUST COTTON FEVER: SEPTIC SHOCK IN PERSON WHO INJECTS DRUGS.

Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev..

Abstract 663

Journal of Hospital Medicine Volume 12 Suppl 2.

https://shmabstracts.org/abstract/not-just-cotton-fever-septic-shock-in-person-who-injects-drugs/.

November 20th 2021.

<< Go back

Page load link