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Yingda Xie, MD, Bailey A. Pope, MD, and Alan J. Hunter, MD, FACP

Bailey A. Pope

Department of Medicine, Oregon health & science University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR 97239-2997 USA


Alan J. Hunter

Department the Medicine, Oregon wellness & scientific research University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR 97239-2997 USA


Department that Medicine, Oregon health and wellness & scientific research University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR 97239-2997 USA
Corresponding author.

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Fever and leukocytosis have many feasible etiologies in injection medicine users. We existing a situation of a 22-year-old woman with fever and also leukocytosis that were presumed secondary to noodle fever, a rarely known complication that injection medicine use, after substantial workup. Cotton heat is a benign, self-limited febrile syndrome identified by fevers, leukocytosis, myalgias, nausea and also vomiting, emerging in injection drug users who filter their drug suspensions through cotton balls. When this syndrome is commonly recognized amongst the injection drug user population, there is a paucity the data in the medical literature. We evaluation the situation presentation and accessible literature regarded cotton fever.


KEY WORDS: cotton fever, medicine abuse, situation report, intravenous drug abuse

Injection drug usage is linked with plenty of infectious and non-infectious complications. The most common connected complications faced by regulating physicians room soft-tissue infections, overdose, intoxication, and also withdrawal.1 A constant and challenging triage dilemma in this population is the of heat with energetic injection drug use. Despite numerous unsuccessful do the efforts to build discriminating decision rule to overview ambulatory triage in this cases, clinicians room still can not to reliably exclude occult epidemic such together endocarditis and osteomyelitis.2,3 This frequently results in momentary hospitalization of this patients, with accrual the health care expenditures.4 one infrequently recognized reason of fever in injection drug customers is noodle fever, a poorly defined systemic febrile inflammatory syndrome viewed in this population. Ironically, while there is a paucity of literature and also awareness in the medical community, cotton fever is a well-recognized syndrome amongst injection medicine users. Initially coined in 1975, cotton fever was described as a benign self-limited febrile syndrome occurring in injection drug users who filtered their drug suspensions v cotton balls.5 We current a situation of presumed cotton heat in an active injection heroin user, in whom the diagnosis was only considered upon hearing the patient referral the syndrome after comprehensive workup had been completed. Additionally, a review of the medical literature and a conversation of the current theories around the pathophysiology of noodle fever room presented.


CASE REPORT

A 22-year-old woman presented come an external hospital 4 hrs after occurring acute start of fevers, headache, ab pain and radiating earlier pain, which began 20 minutes after injecting heroin. She did no endorse any type of visual symptoms, chest pain, dyspnea, or rashes. Initial an essential signs were noteworthy for a temperature the 39°C and heart rate of 102 beats every minute. At the time, the remainder that her test was reported as normal other than for diffuse abdominal tenderness. In the setup of acute ago pain, a lumbar spine MRI to be obtained and interpreted as consistent with an L3-S2 epidural abscess. Blood societies were drawn, and the patient was started on vancomycin and ceftriaxone. Twelve hrs after initiation of symptoms, the patient was transferred to our school for factor to consider of neurosurgical treatment for presumed epidural abscess. By the time of arrival, the patient’s fever had actually resolved and also her abdominal muscle pain had actually improved. On examination, she heart price was 101 beats every minute, blood press was 106/64 mmHg, and also temperature was 37.6 °C. Her cardiac exam revealed a II/VI systolic crescendo-decrescendo murmur ideal heard in ~ the left reduced sternal border. She abdomen to be diffusely tender without peritoneal signs, and also she showed lower back allodynia. She had actually numerous new and old injection monitor on her arms, yet no other rashes or stigmata of endocarditis. Her fundus test revealed a clean vitreous there is no hemorrhages or Roth spots. Her neck was supple and also her pulmonary and neurologic examinations to be unremarkable.

On transfer, the patient had actually a white blood cell counting of 22.6 × 109/L there is no a left shift; the remainder that her activities values; including chemistries, urinalysis and also cerebrospinal fluid, were every normal. Blood societies were redrawn and she was continued on broad-spectrum antibiotics. A transthoracic echocardiogram confirmed no proof of vegetations and only map tricuspid insufficiency. Her initial MRI to be reviewed by our neuroradiologists, who did not determine findings continual with epidural abscess or osteomyelitis and felt the the original enhancement was most likely a typical variant.

Twenty-four hours complying with transfer, she leukocytosis and ab pain resolved. Within two days, her back pain briskly improved and also she was able to ambulate fluidly. Together her blood cultures at both hospitals remained an unfavorable and she remained afebrile, antibiotic therapy was discontinued. Through no clear diagnosis yet with continuous clinical improvement, to plan were created discharge. On the work of discharge, she was overheard pointing out aloud to she friend; “I think I had a bad case of noodle fever.” adhering to a subsequent literary works review of noodle fever and also with the exclusion of other infectious etiologies because that the patient’s fever and also leukocytosis, a presumed diagnosis that cotton fever was made.


DISCUSSION

While ours patient’s symptoms, signs, and clinical food were initially worrisome because that infection, she rapidly improved and also infectious causes were rule out. Thus, she clinical photo was believed to be continual with a diagnosis of noodle fever. Cotton heat is a diagnosis the exclusion and is identified by acute beginning of fever and also leukocytosis automatically following intravenous medicine injection as soon as filtering v cotton. Symptoms start 15–30 minutes adhering to injection, and are regularly accompanied by shortness the breath, chills, headache, myalgia, abdominal muscle pain, nausea, vomiting and tachycardia. Return cotton fever is self-limited and also normally big 6 come 12 hours, that can proceed for approximately 24 come 48 hours.

While many often connected with injection the heroin,6,7 cotton heat has likewise been explained when injecting hydromophone8 or a combination of pentazocine and also methylphenidate.9 The pathophysiology is poorly understood, but three pathogenic theories have actually been proposed.9 The pharmacologic concept hypothesizes the the extracts of noodle contain water-soluble, steam-labile substances through pyrogenic activity. The immunologic concept proposes that civilization may have antibodies to cotton itself. However, no evidence has been discovered to assistance the immunologic or pharmacologic theory. Finally, the endotoxin theory suggests that cotton heat may result from the relax of endotoxins from Gram negative bacilli such as Enterobacter agglomerans, which has actually been displayed to routinely colonize cotton.10 further supporting this endotoxin theory, a case of cotton heat was described in conjunction with E. Agglomerans bacteremia.6

This current situation represents a humbling reminder that the significant disparities in medical knowledge and social awareness in between providers and also their patients. Following substantial inpatient evaluation for an occult infection in a febrile injection medicine user, only the serendipitous insight from the patient eventually led to the diagnosis of cotton fever. Over there are few publications addressing cotton fever6–9,11; thus there is no epidemiological data top top the incidence of noodle fever, highlighting the general lack that awareness of this clinical entity in present medical practice. However, there space multiple sources of details for injection drug individuals on “drugs forum”, “opiophile” and also “Heroin Helper”, top to greater awareness of noodle fever amongst the injection medicine user population compared come the medical community. One emergency medicine physician approximates that he sees approximately one together patient every month.7 However, injection drug individuals estimate the incidence the cotton heat to around 5 % per year that use.12 together this is a poorly characterized disease and a diagnosis that exclusion, the true incidence is likely much an ext common than well-known by the medical community.

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The review of a febrile injection medicine user proceeds to existing diagnostic challenges for providers. When the majority of injection drug individuals will have a conveniently identifiable resource of fever such together pneumonia or cellulitis, over there is a subset of patients in i beg your pardon the cause of their heat is not readily identifiable, and about 8–11 % are uncovered to have actually serious infections such together endocarditis.3,13,14 as the presentation of cotton fever and endocarditis are similar, it is necessary to consider endocarditis before making the diagnosis of cotton fever. The incidence that endocarditis in injection drug customers is approximated to it is in 1.5–3.3 instances per 1000 injection drug users per year.15–17 This hazard is more increased in the presence of concurrent HIV, which is yearly estimated come be present in 6.6 per 1000 injection drug users; this number mirrors a dramatic reduction because the arrival of highly energetic anti-retroviral therapies.18 one more rare complication of injection drug usage is osteomyelitis, which need to be thought about in the ideal clinical context.3

Despite the recognized burden that disease, the testimonial of a febrile injection medicine user can be costly and also difficult. Attempts at arising triage and diagnosis algorithms because that febrile injection medicine users have actually been unsuccessful in correctly predicting who will and also who will not have actually endocarditis.2,3 Therefore, we still recommend observing febrile injection medicine users, who often are can not or do not want to monitor up, till blood cultures are negative.13

In our patient, who eventually had a self-limited illness, the initially worrying interpretation the the lumbar MRI in the setting of fever, leukocytosis and recent injection medicine use, prompted considerable yet ideal diagnostic evaluation. Back cotton heat is a diagnosis the exclusion, an increased awareness that this problem would likely improve providers’ ability to administer supportive treatment while ruling out illness with boosted morbidity such as endocarditis and also osteomyelitis.