Enterobacter agglomerans—Associated Cotton Fever

Ferguson, R. L.; Feeney, Colin; Chirurgi, Valerie A.

doi:10.1001/archinte.1993.00410200109014

Cited by 33 publications

(21 citation statements)

References 6 publications

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“…Cases of peritonitis due to P. agglomerans have also been reported (15,31). Finally, P. agglomerans, which is known to colonize cotton and cotton plants heavily, is associated with cotton fever, a benign febrile syndrome seen in intravenous drug abusers (14).…”

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confidence: 97%

Phylogeny and Identification of Pantoea Species and Typing of Pantoea agglomerans Strains by Multilocus Gene Sequencing

Delétoile¹,

et al. 2009

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Pantoea agglomerans and other Pantoea species cause infections in humans and are also pathogenic to plants, but the diversity of Pantoea strains and their possible association with hosts and disease remain poorly known, and identification of Pantoea species is difficult. We characterized 36 Pantoea strains, including 28 strains of diverse origins initially identified as P. agglomerans, by multilocus gene sequencing based on six protein-coding genes, by biochemical tests, and by antimicrobial susceptibility testing. Phylogenetic analysis and comparison with other species of Enterobacteriaceae revealed that the genus Pantoea is highly diverse. Most strains initially identified as P. agglomerans by use of API 20E strips belonged to a compact sequence cluster together with the type strain, but other strains belonged to diverse phylogenetic branches corresponding to other species of Pantoea or Enterobacteriaceae and to probable novel species. Biochemical characteristics such as fosfomycin resistance and utilization of D-tartrate could differentiate P. agglomerans from other Pantoea species. All 20 strains of P. agglomerans could be distinguished by multilocus sequence typing, revealing the very high discrimination power of this method for strain typing and population structure in this species, which is subdivided into two phylogenetic groups. PCR detection of the repA gene, associated with pathogenicity in plants, was positive in all clinical strains of P. agglomerans, suggesting that clinical and plant-associated strains do not form distinct populations. We provide a multilocus gene sequencing method that is a powerful tool for Pantoea species delineation and identification and for strain tracking.The genus Pantoea includes several species that are generally associated with plants, either as epiphytes or as pathogens, and some species can cause disease in humans. Pantoea agglomerans, the Pantoea species most commonly isolated from humans, is widely distributed in nature and has been isolated from numerous ecological niches, including plants, water, soil, humans, and animals. It is frequently associated with plants as an epiphyte or an endophyte, and some isolates have been reported to be tumorogenic pathogens (20, 51). As an opportunistic human pathogen, P. agglomerans can occur sporadically or in outbreaks. At the beginning of the 1970s, P. agglomerans (then called Enterobacter agglomerans) was implicated in a large U.S. and Canadian outbreak of septicemia caused by contaminated closures on bottles of infusion fluids; 25 hospitals were involved, with 378 cases (34). Since then, P. agglomerans bacteremia has also been described in association with the contamination of intravenous fluid, parenteral nutrition, the anesthetic agent propofol, blood products, and transference tubes used for intravenous hydration (2-4, 22, 36). P. agglomerans has been recovered from joint fluids of patients with arthritis, synovitis, or osteomyelitis (7). Infection often occurs after injuries with plant thorns, wood slivers, or wooden spl...

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confidence: 97%

Phylogeny and Identification of Pantoea Species and Typing of Pantoea agglomerans Strains by Multilocus Gene Sequencing

Delétoile¹,

et al. 2009

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“…10 Further supporting this endotoxin theory, a case of cotton fever was described in conjunction with E. agglomerans bacteremia. 6 This current case represents a humbling reminder of the significant disparities in medical knowledge and cultural awareness between providers and their patients. Following an extensive inpatient evaluation for an occult infection in a febrile injection drug user, only the serendipitous insight from the patient ultimately led to the diagnosis of cotton fever.…”

Section: Discussionmentioning

confidence: 92%

“…While most often associated with injection of heroin, 6,7 cotton fever has also been described when injecting hydromophone 8 or a combination of pentazocine and methylphenidate. 9 The pathophysiology is poorly understood, but three pathogenic theories have been proposed.…”

Section: Discussionmentioning

confidence: 99%

“…Following an extensive inpatient evaluation for an occult infection in a febrile injection drug user, only the serendipitous insight from the patient ultimately led to the diagnosis of cotton fever. There are few publications addressing cotton fever [6][7][8][9]11 ; thus there is no epidemiological data on the incidence of cotton fever, highlighting the general lack of awareness of this clinical entity in current medical practice. However, there are multiple sources of information for injection drug users on Bdrugs forum^, Bopiophile^and BHeroin Helper^, leading to greater awareness of cotton fever amongst the injection drug user population compared to the medical community.…”

Section: Discussionmentioning

confidence: 99%

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Cotton Fever: Does the Patient Know Best?

2015

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Fever and leukocytosis have many possible etiologies in injection drug users. We present a case of a 22-year-old woman with fever and leukocytosis that were presumed secondary to cotton fever, a rarely recognized complication of injection drug use, after an extensive workup. Cotton fever is a benign, self-limited febrile syndrome characterized by fevers, leukocytosis, myalgias, nausea and vomiting, occurring in injection drug users who filter their drug suspensions through cotton balls. While this syndrome is commonly recognized amongst the injection drug user population, there is a paucity of data in the medical literature. We review the case presentation and available literature related to cotton fever. I njection drug use is associated with many infectious and non-infectious complications. The most common associated complications faced by managing physicians are soft-tissue infections, overdose, intoxication, and withdrawal.1 A frequent and challenging triage dilemma in this population is that of fever with active injection drug use. Despite numerous unsuccessful attempts to develop discriminating decision rules to guide ambulatory triage in these cases, clinicians are still unable to reliably exclude occult infections such as endocarditis and osteomyelitis. 2,3 This often results in short-term hospitalization of these patients, with accrual of health care expenditures. 4 An infrequently recognized cause of fever in injection drug users is cotton fever, a poorly characterized systemic febrile inflammatory syndrome seen in this population. Ironically, while there is a paucity of literature and awareness in the medical community, cotton fever is a wellrecognized syndrome amongst injection drug users. Originally coined in 1975, cotton fever was described as a benign selflimited febrile syndrome occurring in injection drug users who filtered their drug suspensions through cotton balls. 5 We present a case of presumed cotton fever in an active injection heroin user, in whom the diagnosis was only considered upon hearing the patient reference the syndrome after substantial workup had been completed. Additionally, a review of the medical literature and a discussion of the current theories about the pathophysiology of cotton fever are presented. CASE REPORTA 22-year-old woman presented to an outside hospital 4 hours after developing acute onset of fevers, headache, abdominal pain and radiating back pain, which began 20 minutes after injecting heroin. She did not endorse any visual symptoms, chest pain, dyspnea, or rashes. Initial vital signs were notable for a temperature of 39°C and heart rate of 102 beats per minute. At the time, the remainder of her exam was reported as normal except for diffuse abdominal tenderness. In the setting of acute back pain, a lumbar spine MRI was obtained and interpreted as consistent with an L3-S2 epidural abscess. Blood cultures were drawn, and the patient was started on vancomycin and ceftriaxone. Twelve hours after initiation of symptoms, the patient was transferred to our instituti...

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“…Symptoms usually resolve within 12 hours of onset. [2][3][4][5][6][7] Despite the benign course of cotton fever, it is important to rule out sources of sepsis, infective endocarditis, and other conditions associated with IV drug use, including HIV and hepatitis. Depending on the patient's presentation, IV antibiotics may be initiated until data from blood cultures is available.…”

Section: Discussionmentioning

confidence: 99%

Cotton Fever: A Condition Self-Diagnosed by IV Drug Users

Zerr

Kara

2016

The Journal of the American Board of Family Medicine

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The presentation of fever in an intravenous drug user prompts diagnostic testing targeted at identifying infectious etiologies. However, an alternate diagnosis exists in "cotton fever." While few reports describe this phenomenon in the peer-reviewed literature, the diagnosis is well recognized among the intravenous drug user community. Although its etiology is not well understood, cotton fever seems to be a self-limited, febrile response to the intravenous administration of a drug filtered through cotton. Educating clinicians regarding cotton fever may limit unnecessary hospital admissions and improve our ability to care for this population. (J Am Board Fam Med 2016;29:276 -279.)

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Enterobacter agglomerans—Associated Cotton Fever

Cited by 33 publications

References 6 publications

Phylogeny and Identification of Pantoea Species and Typing of Pantoea agglomerans Strains by Multilocus Gene Sequencing

Phylogeny and Identification of Pantoea Species and Typing of Pantoea agglomerans Strains by Multilocus Gene Sequencing

Cotton Fever: Does the Patient Know Best?

Cotton Fever: A Condition Self-Diagnosed by IV Drug Users

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