Fever is part of the presenting complaint in the majority of ED visits by IVDUs.51 1 I5 and 16 Fever is associated with infection in over two-thirds of patients. Prospective studies of febrile IVDUs have found bacteremia in up to 42 percent, pneumonia in 26 to 38 percent, and endocarditis in 6 to 13 percent. 1 I415 and 16 These studies found that neither clinical judgment nor derived predictive rules were reliable in identifying those with serious underlying causes of fever. 1 1415 and 16 While an elevated erythrocyte sedimentation rate (ESR) of greater that 100 mm/h is associated with serious infections in febrile IVDUs, a normal ESR does not reliably exclude serious disease.17

Noninfectious causes of fever in the IVDU include acute toxic reactions to substances of abuse, reactions to injected adulterants, and withdrawal syndromes. Cocaine and amphetamines can cause fevers acutely, occasionally in excess of 40°C (104°F). Adulterants used to dilute active substances can cause dramatic febrile reactions accompanied by alteration in mental status and leukocytosis.18 One syndrome, associated with the use of cotton balls as filters for drug suspensions, is called cotton fever.19 Patients with cotton fever develop high fever, chills, headache, dyspnea, myalgias, arthralgias, nausea, and vomiting within hours after injection. Physical findings may include tachypnea, tachycardia, abdominal pain, and inflammatory retinal nodules. Chest radiography may reveal inflammatory pulmonary granulomata. This is a self-limited syndrome that resolves completely within 24 h. While the cause of this syndrome remains unclear, it has been proposed that the acute symptoms are due to either endotoxin from gram-negative rods introduced by injection or the pyrogenic effect of injected cotton particulate matter. Patients withdrawing from barbiturates or heroin also may appear acutely ill, with chest and abdominal pain, diaphoresis, tachycardia, and fever.

Since there are no reliable markers excluding serious underlying disease in the febrile IVDU, common practice has been to obtain blood cultures and admit such patients for observation, awaiting culture results. In those patients for whom follow-up can be ensured and who appear clinically well, outpatient evaluation is reasonable as long as an adequate number of cultures are obtained.14

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