[vc_row][vc_column][vc_column_text css=””]Intravenous (IV) drug use is incredibly dangerous, and while all types of illicit substance abuse have risks, injecting drugs, also known as “shooting up,” is especially hazardous. Regardless of which drug a person is using, injecting drugs can produce a variety of adverse side effects. A few of the risks associated with IV drug use include addiction, overdose, skin infections, collapsed veins, and infections of all kinds.
One of the lesser-known risks of IV drug use is a condition called cotton fever. Cotton fever is characterized by a sudden onset of flu-like symptoms that occur 15-30 minutes after shooting up.
What is Cotton Fever?
Cotton fever is a benign illness that happens to some people after injecting drugs as a result of bacteria being injected into the body. It is often called a benign febrile syndrome because although it causes symptoms like fever, chills, abdominal pain, and weakness, it doesn’t typically require antibiotics or hospital care unless symptoms persist or worsen. Benign febrile syndrome is a general medical term used to describe a short-lived fever that is not caused by a serious underlying condition and typically resolves on its own without complications.
This short-term flu-like illness is generally caused by bacteria entering the bloodstream through reused cotton, dirty needles, or other non-sterile injection equipment.
According to the National Library of Medicine, the bacteria most often linked to cotton fever is Enterobacter agglomerans, which is found in cotton plants and can survive on cotton fibers used as filters during injection. While usually harmless in healthy individuals, it can cause infections when introduced into sterile areas of the body, such as the bloodstream. In the case of intravenous drug use, Enterobacter agglomerans can survive on cotton fibers that are used as makeshift filters.
Cotton Fever Symptoms
Cotton fever symptoms typically start within 30 minutes after injecting a substance. These include:
- Headache
- Nausea
- Extreme chills
- Abdominal pain
- Chest pain
- Muscle pain
- Extreme joint pain
- Elevated heart rate (tachycardia)
- Acute onset fever
- Weakness
- Skin flushing
- A general feeling of malaise
The severity of these symptoms may depend on the type of bacteria injected, the amount of contaminated cotton/drugs that were injected, and a person’s individual immune response.
Although there is no treatment, cure, or vaccine for the condition, it is generally not serious or life-threatening. It may feel like the flu, which can be frustrating when an IV user is expecting to get high but ends up getting sick; however, symptoms can usually be managed with an over-the-counter fever reducer.
Do Cotton Balls Cause Cotton Fever?
The exact cause of cotton fever is not fully understood. Some people believe that the condition is caused by bacteria that live on cotton balls, which are sometimes used to filter the drug before injection. Others believe that the fever is caused by the drug itself or by other contaminants in the drug. The most popular theory is that it is caused by accidentally injecting bacteria found in cotton filters.
Intravenous drug abusers typically pull small pieces of cotton from cotton balls or Q-Tips to use as a filter that makes it easier to suck liquid drugs into a needle and syringe. As an alternative to cotton, some people use cigarette filters, but the risks are the same.
Although cotton itself does not cause cotton fever, cotton, particularly reused cotton, can carry certain bacteria. If these bacteria get into the bloodstream directly after injection, people may begin to feel sick.
Exposure to the Enterobacter agglomerans bacteria triggers a benign febrile syndrome known as cotton fever, marked by acute onset fever, muscle pain, chills, and abdominal discomfort.
In a 2019 case study published in ScienceDirect, cotton fever was linked to a case of Enterobacter asburiae endocarditis after IV drug use, further suggesting bacteria on injection materials may be the true culprit behind this flu-like illness.
Other Causes of Cotton Fever: Bacteria, Immune Reactions & Chemical Interactions
The bacteria that cause cotton fever doesn’t always come from cotton, either. The symptoms can appear if bacteria get into the bloodstream through any means. Bacteria could be on the spoon, in the drugs, or in the needle used for injection.
There are multiple theories as to what causes cotton fever, and while bacteria is the most accepted theory, other researchers believe that the condition can arise from:
- An immune response – The immune system is responsible for detecting and reacting to foreign particles in the body. Cotton is a foreign particle, so it is possible that if cotton particles get into the bloodstream and are detected by the immune system, an immune response (fever and other symptoms) is generated.
- Chemical reactions – Some researchers believe that it is possible that cotton particles can react with certain chemicals associated with illicit drugs and their adulterants. These interactions may produce fever and other related symptoms.
How Long Does Cotton Fever Last?
Most cases of cotton fever resolve within 6 to 12 hours. Symptoms tend to peak early and fade as the body clears the foreign material or bacteria. However, if symptoms last longer than 24 hours, or include severe chest pain, confusion, or difficulty breathing, seek medical treatment right away, especially to rule out more serious conditions.
Cotton Fever vs. Infective Endocarditis (IE)
Cotton fever symptoms can mimic infective endocarditis (IE), a potentially life-threatening infection of the heart’s inner lining. IE is more common among people who inject drugs, with some studies showing they are 4–6 times more likely to develop the condition than the general population.
Symptoms of IE include:
- Fatigue
- Aching joints and muscles
- Swelling of the legs or feet
- Blood in the urine
- Persistent fever
Unlike cotton fever, infective endocarditis requires antibiotic treatment and can lead to serious complications if left untreated.
Without treatment with broad spectrum antibiotics, IE can result in life-threatening complications.
How to Prevent Cotton Fever and Other IV Drug Use Complications
The only way to completely avoid cotton fever and other risks of injecting drugs is to avoid IV drug use altogether. However, harm reduction strategies can lower your risk:
- Always use sterile syringes and needles
- Never reuse cotton filters or other injection equipment
- Use proper filtration tools like sterile micron filters designed for IV use
- Avoid sharing equipment
Many cities have syringe exchange programs or harm reduction centers that provide sterile supplies.
How are Symptoms of Cotton Fever Treated?
If you or someone you love develops cotton fever, there are several treatment options available to you. This is a self-limiting condition, which means symptoms will resolve on their own without any treatment, but treatment can make the symptoms more manageable. Some of the most effective treatments include:
- Placing a cool rag on the neck or forehead to provide comfort during a fever
- Over-the-counter anti-inflammatory medications to help reduce fever and headaches
- Drinking plenty of water and electrolytes to stay hydrated
- Getting plenty of sleep
- Eating a nutritious diet
Other Risks of Intravenous Drug Abuse
Intravenous drug users inject drugs directly into a vein using a needle and syringe. This method of drug use is often associated with higher risks than other methods, as the drug enters the bloodstream quickly and can produce intense effects. Aside from cotton fever, there are several additional risks associated with IV drug abuse, including:[3]
- Infection
- Overdose
- Organ damage
- Bloodborne diseases
- Skin problems
- Mental health problems
- Legal problems
- Serious infections
In addition to these risks, the intravenous administration of drugs can also have a significant impact on a person’s personal and professional life. It can strain relationships with family and friends, interfere with work or school, and lead to financial problems. The stigma associated with drug abuse can also make it difficult for individuals to seek help and support.
Frequently Asked Questions (FAQ) About Cotton Fever and IV Drug Use
Is cotton fever dangerous?
In most cases, cotton fever is not dangerous. It is considered a self-limiting condition and rarely leads to serious infections. However, symptoms can sometimes resemble more severe conditions like infective endocarditis, so it’s important to monitor your health and seek medical attention if symptoms worsen or persist beyond 12–24 hours.
How can I treat cotton fever?
If you’re experiencing cotton fever, home remedies can help manage symptoms:
- Rest and hydrate
- Use a fever reducer like ibuprofen or acetaminophen
- Apply cool compresses or take a warm bath for comfort
- Get plenty of sleep
- Eat nourishing food if you can tolerate it
In severe cases, or if symptoms persist, visit the emergency department for evaluation. IV fluids and broad spectrum antibiotics may be administered if a more serious bacterial infection is suspected.
When should I seek medical attention for cotton fever?
- You should seek medical attention if:
- Symptoms last longer than 12–24 hours
- You experience kidney pain, confusion, or difficulty breathing
- Your initial vital signs show very low or high blood pressure
- You have a history of heart issues or are at risk for infective endocarditis
A physical exam, blood cultures, and follow-up testing may be needed to rule out severe infections.
Can a case of cotton fever lead to infective endocarditis?
Yes. Although cotton fever itself is usually harmless, intravenous drug abusers are at high risk for infective endocarditis, a serious infection involving the heart valves. The two conditions share overlapping symptoms like fever, muscle pain, and abdominal pain, but infective endocarditis typically requires medical treatment with broad-spectrum antibiotics and sometimes surgery.
Positive blood cultures and abnormal findings on an echocardiogram often help the medical community distinguish between a case of cotton fever and something more dangerous.
Is cotton fever recognized by healthcare providers?
Yes, but it’s often a condition self-diagnosed by narcotic addicts or IV drug users who have experienced it before. Because symptoms are short-lived and mimic infection, it may not always be well-documented in general internal medicine settings. However, literature reviews and case reports increasingly acknowledge cotton fever as a real and recurring issue in the IV drug use population.
Drug Addiction Treatment
If you or a loved one are shooting up drugs, it’s important to realize that there is no safe way to inject drugs and that addiction is likely. Continuing injection drug use can seriously affect your health and even cost you your life. The best thing you can do is to seek professional treatment and begin your recovery journey as soon as possible.
At Moving Mountains Recovery, we have helped hundreds of people just like you get their lives back on track. To learn more about our substance abuse treatment programs or to find help for yourself or a loved one, please contact us today.
References:
- National Library of Medicine: Cotton Fever: Does the Patient Know Best?, Retrieved June 2025 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803705/
- Science Direct: Cotton fever resulting in Enterobacter asburiae endocarditis, Retrieved June 2025 from https://www.sciencedirect.com/science/article/pii/S2214250919303270
- National Institute of Health (NIH): Pantoea agglomerans, a Plant Pathogen Causing Human Disease. Retrieved June 2025 from https://pmc.ncbi.nlm.nih.gov/articles/PMC1933083/
- NIH: Enterobacter agglomerans, an uncommon cause of community-acquired bacterial infection in neonates. Retrieved June 2025 from https://pubmed.ncbi.nlm.nih.gov/36228308/
- National Library of Medicine: Intravenous Drug Use–Related Complications of the Hand and Upper Extremity, Retrieved June 2025 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416137/
- Centers for Disease Control and Prevention (CDC): HIV and Injection Drug Use. Retrieved June 2025 from https://www.cdc.gov/hepatitis-c/media/pdfs/factsheet-pwid.pdf
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