Infectious Disease in Sports Medicine

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Practices common to athletics. Athletes do many things together that contribute to the spread of disease among them.Consuming water and food from the same source, such as bottles or cupsClose personal contact, skin to skin, sweat to sweat and breath to breath.High likelihood of trauma to the skin

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Infectious Disease in Sports Medicine

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1. Infectious Disease in Sports Medicine Mark D. Harris, MD, MPH Family, Sports and Preventive Medicine

2. Practices common to athletics Athletes do many things together that contribute to the spread of disease among them. Consuming water and food from the same source, such as bottles or cups Close personal contact, skin to skin, sweat to sweat and breath to breath. High likelihood of trauma to the skin, an important barrier to infection, in contact and collision sports Crowded settings such as team buses Sharing personal items such as razors

3. Other high risk behaviors for infectious disease transmission Substance use Drug use less common in athletes College athletes drink more alcohol more often and have more drinking and driving than non athlete peers. Injections more common in athletes anabolic steroids intravenous vitamin complexes Sexual activity College-aged athletes have more sexual partners and less condom use than non athletes Anecdotally, athletes in the Olympic village and on road trips are notorious for unrestrained sexual contact

4. Effects of Acute Episodes of Vigorous Exercise on the Immune System (3-72 hrs) Cortisone induced neutrophilia, lymphopenia Decrease in NK cell cytotoxic activity Decrease in delayed hypersensitivity response Increase in plasma cytokines Decrease in nasal and salivary IgA concentration Decreased nasal neutrophil activity Impaired macrophage function (MHC 2 expression and antigen presentation)

5. Chronic Effects of Exercise on the Immune System Natural killer cell activity is increased in athletes compared to non-athletes Some epidemiologic studies indicate that athletes have a lower rate of URI than non-athletes.

6. Effects of Acute Infections on Exercise Fever impairs muscle strength, aerobic endurance, power, coordination, concentration, and fluid and temperature regulation Viral infections are associated with muscle protein catabolism, tissue wasting and negative nitrogen balance. Full recovery can take weeks to months Exercise after acute viral illness is a risk factor for rhabdomyolysis

7. Fever in Sports ? metabolism, caloric, and fluid requirements, ? pulmonary perfusion, concentric muscle strength, & cognitive function for every degree above 37°C , O2 consumption ? 13% promotes dehydration ? coordination/concentration ? endurance ? strength A well-known but rare complication of viral URIs is viral myocarditis. Coxsackie virus is perhaps the most common causative viral agent. Although there is no evidence to suggest that exercise during a viral infection increases the likelihood of myocarditis in humans, exertion does increase viral replication rates and severity of morbidity associated with myocarditis in murine models infected with Coxsackie virus [6]. Viral myocarditis has been associated with sudden cardiac death, and accounts for roughly 3% to 5% of known cases in young athletes [7]. The ability of common URI viruses to cause myocarditis and a potential lethal outcome remains a strong reminder of the risks of common viral infections; however, because any sudden death occurrence in a young athlete receives significant publicity, this association may be overvalued, and should not be the sole factor determining return to training activity.A well-known but rare complication of viral URIs is viral myocarditis. Coxsackie virus is perhaps the most common causative viral agent. Although there is no evidence to suggest that exercise during a viral infection increases the likelihood of myocarditis in humans, exertion does increase viral replication rates and severity of morbidity associated with myocarditis in murine models infected with Coxsackie virus [6]. Viral myocarditis has been associated with sudden cardiac death, and accounts for roughly 3% to 5% of known cases in young athletes [7]. The ability of common URI viruses to cause myocarditis and a potential lethal outcome remains a strong reminder of the risks of common viral infections; however, because any sudden death occurrence in a young athlete receives significant publicity, this association may be overvalued, and should not be the sole factor determining return to training activity.

8. Drug Therapy Effects on Performance Antibiotics – no direct effect on muscle power or endurance but indirect effects on performance through side effects such as diarrhea, nausea, rashes, or allergic reactions Doxycycline – photosensitivity, erosive esophagitis Quinolones – tendon rupture Some treatments used for acute infections may be regulated or banned - ephedrine

9. What infections are commonly seen in athletes? Hepatitis (A,B,C,D,E) Infectious mononucleosis Skin infections Viral - molluscum contagiosum, herpes (HSV), warts Bacterial – impetigo, folliculitis, otitis externa Fungal – tinea, onychomycosis, scabies, lice Respiratory illnesses Gastroenteritis, Traveler’s diarrhea

10. Infections in Athletes - AIS Study 98% of college athletes had >=1 illness during winter 2-month period 246/588 visits for medical problems URI most common chest infection viral syndrome Gastroenteritis Asthma/allergy Skin problems Fatigue Otitis externa A study of illness incidence among collegiate athletes [3] found that 98% of the athletes experienced at least one illness during a 2-month period in the winter. The overwhelming majority of the illnesses were classified as URIs.A study of illness incidence among collegiate athletes [3] found that 98% of the athletes experienced at least one illness during a 2-month period in the winter. The overwhelming majority of the illnesses were classified as URIs.

11. Blood Borne Infections

12. A Good News Story

13. Hepatitis transmission Direct transmission of HAV or HEV during sports has not been reported Outbreaks of HAV among athletes have been reported 90 members of a college football team contracted HAV after children contaminated the drinking water they used during practice Two reports of HBV transmission during contact sport One report of HBV transmission during non-contact sports No cases of HCV transmission during sport One case of HCV transmission after a fist fight when both cleaned the blood from their hands with the same handkerchief

14. Hepatitis

15. Hepatitis – clinical features SSx – fatigue, nausea, low grade fever, abdominal discomfort, jaundice, hepatomegaly (80%), splenomegaly (20%) Contact and collision sports should be avoided until organomegaly has resolved and the patient is asymptomatic. Chronic carriers can play sports as long as body fluid precautions are strictly enforced

16. NCAA RTP Guidelines - Hepatitis “If the student-athlete develops acute HBV illness, it is prudent to consider removal of the individual from combative, close contact sports (e.g. wrestling) until loss of infectivity is known. The best marker for infectivity is the HBV Ag, which may persist for 20 weeks.” “Student athletes in such sports who develop chronic HBV, especially if e-Ag+, should be removed from competition indefinitely, due to the risk of transmission”

17. Hepatitis – Treatment & Prevention

18. HIV Initial infection causes flu-like illness Very small risk of getting HIV from sporting field contact if carrier is actively bleeding or wearing bloodstained clothing (<1/million) No player actively bleeding can remain in play Medical staff must follow universal precautions No restrictions to play for healthy HIV+ athletes

19. Medical Team Responsibilities to Prevent Blood-Borne Pathogens Stop bleeding Cover open wounds Appropriate supplies Universal precautions Bloody jerseys should be changed Clean playing surface Wash uniforms after event Ensure first aid and infection control training

20. Dermatologic Infections

21. Skin Infections - HSV SSx – fever, malaise, painful lesions Mucosa – ulcers (herpes labialis) Skiers, others exposed to cold stress/high altitudes/UV radiation Skin - small vesicles, often on red bases or in dermatomal distribution Herpes gladiatorum (wrestlers) Herpes rugbeiorum (rugby – scrum pox) Eyes – conjunctivitis, blepharitis Treatment – acyclovir 5x/d, valacyclovir bid(no topicals) Prophylaxis – acyclovir bid, valacyclovir qd during season

22. HSV Outbreak Control 33% probability of transmission if herpes develops on a sparing partner in wrestling NCAA rules on wrestling RTP Athlete must be free of systemic sx Athlete must be free of new lesions for 24 hrs No moist lesions and all lesions must have a firm, adherent crust Antiviral medication for 120 hrs prior to competition Covering active lesions is not acceptable

23. NCAA Wrestling RTP Guidelines - HSV Primary infection No systemic symptoms No new blisters x 72 hours No moist lesions – crusts must be firm and adherent Completed 120 hrs of antiviral therapy Covering active herpetic lesions is not adequate Recurrent infection No moist lesions – crusts must be firm and adherent Completed 120 hrs of antiviral therapy Covering active herpetic lesions is not adequate

24. Skin Infections - Molluscum Contagiosum White to skin colored umbilicated papules 3-5 mm diameter Swimmers, gymnasts and wrestlers Asymptomatic, spread skin to skin contact Hands, forearms, and face Spontaneously resolves over months to years so LN treatment recommended Cover lesions while playing contact sports

25. Skin Infections - Warts Do not retain normal fingerprint lines on hands and feet like calluses do 10-15 pinpoint black spots which are thrombosed capillaries Low infectivity Transmission – skin to skin and fomites such as swimming pools decks and showers RTP after treatment but must be covered

26. NCAA RTP Wrestling Guidelines – Viral Molluscum Contagiosum Lesions must be curetted or removed before competition Solitary or localized, clustered lesions can be covered with a gas permeable membrane and tape Verrucae Wrestlers will be disqualified if facial lesions cannot be covered with a mask Multiple lesions must be adequately covered Solitary or scattered lesions can be curetted

27. Skin Infections - Impetigo Staph or strep, person to person spread Bullous – multiple fluid filled vesicles Non-bullous – “honey-crusted” lesions Afebrile but + lymphadenopathy Treatment Oral or topical antibiotics Local debridement with soap and water NCAA guidelines Antibiotics for 72 hrs prior to play No new skin lesions for 48 hrs

28. Skin Infections – Folliculitis & Furunculosis (S. Aureus) Folliculitis – superficial hair follicle infection, mildly tender papules/pustules w/erythema Hot tub folliculitis (pseudomonas) - Pustular rash, perineum, axilla, buttocks, self limiting 7-14 days, prevent w/ filtration/chlorination Folliculitis can also occur after massage, leg waxing or shaving Furunculosis – deeper infection of hair follicle, usually containing pus Erythematous, fluctuant nodules in areas of increased sweating/friction (buttock, belt line, thigh, axilla Treatment – anti-staph antibiotics 10-14 days

29. Skin Infections - MRSA Highest risk - football, rugby, wrestling, fencing Patients treated w/ antibiotics in the past few months are more likely to have MRSA Transmission – direct person to person (draining lesion or asymptomatic carrier) MSSA – 20-30% of general population MRSA – 5% of general population Colonization increasing

30. MRSA Risk Factors Close physical contact Exposure to contaminated objects Generalized lack of cleanliness Crowding Skin injury (including chafing from protective gear) Increased antimicrobial usage Sharing equipment, towels, water bottles, etc.

31. MRSA - clinical 2-3 cm diameter erythematous wounds w/ purulent center Evidence of prior trauma often noted Multiple infections – inadequate treatment, reinfection Treatment (culture all suspicious wounds) Debridement – drain wound, pack lightly w/ iodoform gauze, heals by secondary intention over 10-14 days. Change packing daily Abx (clindamycin, septra, vancomycin, zyvox)

32. MRSA - Prevention Everyone, including athletes, coaches, medical staff, etc uses good infection control practices Carefully target antibiotic use. Eliminate colonization w/ intranasal mupirocin x 5 d + chlorhexadine body wash Administrators ensure adequate equipment, supplies and support staff (i.e. housekeeping) Disease reporting – athletes w/ sx must report them.

33. MRSA and Elite Athletes Mike Gansey (basketball guard, Miami Heat) – knee and ankle chronic infections. Cut from team 2007. Ricky Lannetti (football, Lycoming College) – died of MRSA pneumonia 2003 http://sports.espn.go.com/espn/news/story?id=2800948

34. NCAA Wrestling RTP Guidelines – MRSA+ Bacterial infections No new skin lesions x 48 hours before competition No moist, exudative or purulent lesions at competition Covering purulent lesions is not adequate for play Hidradenitis Suppurativa No play with extensive or purulent draining lesions Covering purulent lesions is not adequate for play Pediculosis Athlete must be treated with pediculocide and reexamined for completeness of response before wrestling Scabies Athlete must have negative scabies prep at competition

35. Skin Infections – Tinea/Onycho Tinea pedis (athlete’s foot) and tinea cruris (jock itch) most common SSx – scaling, cracking skin in moist areas Tx - Topical antifungals 2-3x/d for 2-4 weeks Prevention – regular changes of socks, shorts and underwear, foot powders, regular cleaning of showers Onychomycosis – trichophyton, fungal infection of toenail bed, nail plate discolored/deformed Common in swimmers, people using communal showers, and those wearing occlusive footwear

36. Skin Infections – Scabies/Lice Scabies - Skin to skin contact, mites burrow into epidermis, severe itching Distribution - axilla, finger/toe web spaces, genitals, buttocks, lateral foot, periumbillicus, flexor wrist surface, extensor elbow/knee surface Tx - (Elimite, Acticin) and crotamiton (Eurax). Lice – pediculosis SSx – nighttime itching, 2-4 mm red papules on a red base Lindane, malathion, pyrethrins x1 and retreat in 7 d Wash and dry hot or discard all clothes, bed linen and sports equipment

37. NCAA RTP Guidelines - Tinea Minimum 72 hours of topical therapy is required for skin lesions Minimum 2 weeks of scalp therapy is required for scalp lesions Athletes with extensive and active lesions will be disqualified Those with solitary or closely clustered lesions will be disqualified if the lesions cannot be adequately covered

38. Respiratory Infections

39. URI URI is the most common infection in humans, caused by > 200 viruses and some bacteria Rhinovirus is estimated to cause almost 40% of URIs, peaking in fall and spring Coronavirus peaks in winter Enterovirus peaks in late summer/early fall Transmission – droplet, aerosol, saliva person to person and via fomites Intense exercise during the incubation period may result in more severe illness Intense exercise while infected with enterovirus increases risk for myocarditis

40. URI (2) Tx – symptomatic Beware medication side effects and banned substances (i.e. Ephedra) RTP – NECK CHECK Sx only above the neck – OK to play a few days after sx resolve Sx below the neck – OK to play 10-14 days after sx resolve

41. Respiratory Infection - Influenza SSx – respiratory sx, fever, myalgia, prostration Pulmonary function is abnormal for weeks after acute infection Tx – Oseltamivir/zanamivir, if resistance low amantidine/rimantidine, <36 hrs post sx onset Prevention – seasonal vaccination Injection site soreness – 25-50% Myalgias, fevers – 1% Contraindication – egg allergy

42. Respiratory Infections – Sinusitis/Bronchitis/Pneumonia Sinusitis Swimming, diving, surfing, water polo 30% of cases allergic or viral RTP – “neck check”, no scuba diving Bronchitis Albuterol often much more helpful than abx Beware impaired respiratory flow dynamics – consider peak flow monitoring Intense exercise may impair mucociliary clearance Pneumonia Much greater insult to pulmonary function than bronchitis 30-50% viral, mycoplasma, S. pneumoniae Antibiotics often indicated

43. Pneumococcus

44. Respiratory Infections - SARS Severe Acute Respiratory Syndrome Incubation – 2-7 days SSx Prodrome – Temp > 38C, chills, rigors, myalgia, malaise, headache Lower respiratory sx 3-7 days Complications – 10-20% hypoxemia needing assisted ventilation Lab Decreased WBC and platelets Elevated CK and transaminases Tx – respiratory isolation, supportive

45. Infectious Mononucleosis Incubation – 30-50 days Transmission – person to person via saliva, blood Attack rate – 25-50% among people 15-25 SSx Prodrome (3-5d) - headache, fatigue, loss of appetite, malaise, myalgia Classic - sore throat, fever, tonsillar enlargement, cervical adenopathy, splenomegaly (50-75%), jaundice (10-15%)

46. Infectious Mononucleosis (2) Monospot Positive in 85-90% of patients w/ mono Often negative in the 1st week after infection, repeat weekly (diagnostic certainty is important) 5% to 30% GABHS coinfection – test Lymphocytosis, elevated LFTs Complications (<5% of cases) – splenic rupture (<0.2%), hepatitis, aplastic anemia, myelitis, nephritis, myocarditis

47. Infectious Mononucleosis (3) Acute sx resolution – usually < 6 weeks Elite athletes may take 3-6 months to regain full performance Treatment – supportive Return to play Non-contact exercise program when asymptomatic, progressing to activity Contact sports when asymptomatic and >3 wks after sx onset

48. Otitis Media/Externa OM Normal ssx and therapy RTP - Avoid diving until typanogram is normal, and TM should be intact before returning to activity OE Pseudomonas or S. Aureus, usually in swimmers SSx – Ear drainage, itch and/or pain w/ traction on ear tragus, debris in auditory canal Treatment - Corticosporin drops Prevent recurrences Drying agents (5% acetic acid) Water resistant ear plugs Shaking water out of ear after swimming Drying ear with hair dryer

49. Conjunctivitis Usually viral (i.e. adeno), highly contagious and can occur in outbreaks Tx – antibiotics for bacterial Consider neisseria gonorrhea and HSV in any sexually active adolescent or young adult with purulent discharge RTP – no wrestling, rugby or other high contact sport until tx completed and sx cleared Adenovirus can be transmitted in pool water, so swimmers should be held out of play as well

50. Myocarditis Coxsackie virus, usually summer/early fall epidemics SSx – fatigue, chest pain, dyspnea, palpitations, subclinical

51. Pericarditis Chest pain worse lying down, better sitting up T wave inversions, ST segment elevations

52. Myocarditis - Bethesda 36 Athletes w/ probable or definite myocarditis should withdraw from all competitive sports and convalesce at least 6 months. RTP Echocardiogram normal EKG, Holter and GXT normal Serum markers of inflammation and heart failure normal

53. Meningitis Aseptic – usually enterovirus, fecal-oral spread Most prevalent summer and early fall Bacterial – n. meningitidis, s. pneumo SSx – fever, headache, neck stiffness (only ½ of patients > 16 present with classic triad

54. Gastroenteritis Treatment Fluid replacement Sport Drink WHO formula Antibiotics as indicated Bismuth subsalicylate Loperamide Relative Contact Isolation Good Hand Washing

55. Gastroenteritis and RTP: Case study

56. Questions? Other Resources

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