Cotton Fever: Symptoms, Toxic Syndrome, & More

If you’ve heard the term “cotton fever” in relation to intravenous drug use, you might be feeling worried or confused. Perhaps you’re concerned about a loved one who has mentioned feeling feverish and unwell after injecting drugs.

In this article, we’ll clarify cotton fever, its signs, and ways to prevent and manage it. Empowering yourself with knowledge can make all the difference in supporting someone through this frightening yet often misunderstood condition.

What is Cotton Fever?

Cotton fever is a short-lived febrile illness primarily affecting intravenous drug users who inject substances filtered through cotton.

While well-known within the user community, this condition is often underrecognized by medical professionals. Despite its alarming symptoms, it typically resolves on its own within a day or two.

Cotton fever arises from the practice of filtering drug solutions through cotton, especially when reusing filters or extracting residual substances ("shooting the cottons"). This introduces particulate matter, including bacterial endotoxins, into the bloodstream.

What Causes Cotton Fever?

Many people use small pieces of cotton as filters when preparing drugs for injection. If the cotton is contaminated by bacteria—especially Pantoea agglomerans—its endotoxins can enter the bloodstream.

Once these bacterial toxins are in the body, the immune system reacts. Unlike a true bacterial infection, the bacteria usually don’t invade tissues; it’s the endotoxins that trigger the response.

Habits that could cause cotton fever include:

• Reusing or sharing cotton
• Using old or unsterile syringes
• Using unclean cookers and water
• Failing to sanitize injection sites or hands before injecting

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What are the Symptoms of Cotton Fever?

It can be tricky to distinguish cotton fever from other illnesses, especially given how closely it resembles the flu or bacterial infections. Awareness of its hallmark timing and presentation is key.

• High fever: Often ranging between 101 and 104°F.
• Chills and shaking: Users may feel intense shivering or trembling.
• Headache and body aches: Muscle, joint, or abdominal pain is common.
• Rapid heartbeat and rapid breathing: The body’s inflammatory response can accelerate heart and breathing rates.
• Nausea or vomiting: GI upset may accompany the fever.

These symptoms typically start within 20 to 60 minutes after injection and subside within 6 to 48 hours. Because they mimic bacterial infection (like sepsis), cotton fever can be frightening but is generally self-limiting.

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When Should You Call For Help?

If you think someone is experiencing cotton fever, contact a professional healthcare provider. If someone’s symptoms linger beyond 24 hours or intensify, it may signal a more serious infection that needs immediate medical evaluation. 

Compared to cotton fever, other conditions typically manifest as follows:

• Flu or cold: These typically develop more gradually, over several hours to days, not usually minutes after an injection.
• Sepsis: In sepsis, the bacteria actively grow in the bloodstream, and symptoms often get worse without antibiotics.
• Allergic reaction: This might include hives, wheezing, or severe swelling, which differ from standard cotton fever presentations.

How to Manage Cotton Fever

While cotton fever can be scary—especially for someone new to these symptoms—most cases clear up on their own with proper rest and hydration. 

However, prevention remains the gold standard, particularly if intravenous drug use is ongoing. 

If you or someone you know is experiencing cotton fever, here are things you can do to manage the symptoms:

• Hydration: Drinking water or electrolyte solutions helps flush out toxins and prevents dehydration from fever.
• Fever Management: Over-the-counter medications like acetaminophen or ibuprofen can lower fever and soothe headaches.
• Cool Compresses: Applying a cold towel on the forehead or back of the neck may offer temporary relief.
• Rest and Reassurance: Let the body recover; stress and physical exertion can worsen symptoms.

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How to Prevent Cotton Fever

To prevent cotton fever, the best thing to do is to stop using illicit drugs and seek treatment if you suspect an addiction. Here are other ways to prevent the condition:

• Use sterile equipment: Always choose new, sealed syringes, needles, and filters (like SteriFilts).
• Avoid reusing materials: Each injection should involve fresh cotton and clean cookers to prevent bacterial buildup.
• Practice good hygiene: Wash hands thoroughly, and cleanse the injection site with an alcohol pad.
• Reject makeshift filters: Cigarette filters or dirty cotton from random sources pose a high risk of bacterial contamination.
• Education and peer support: Learning correct injection techniques reduces the chance of missed shots, infections, and cotton fever.
• Keep naloxone available: While cotton fever isn’t an opioid overdose, having naloxone can save a life in case of an accidental overdose.
• Substance use treatment programs: Engaging with treatment can lower the frequency of risky injection practices, thereby reducing cotton fever episodes.

If you or someone you love is dealing with symptoms of cotton fever, remember that medical professionals can help confirm a diagnosis.

Practicing safer injection techniques—or, more importantly, seeking addiction support—can protect against future episodes and other complications. Every step toward safer practices is a step closer to better health and well-being.

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