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Infectious Disease in Sports

Infectious Disease in Sports. Britt Marcussen, MD Department of Family Medicine University of Iowa . UI Sports Medicine 6-0. Seeking Sponsorship ?. Influenza.

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Infectious Disease in Sports

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  1. Infectious Disease in Sports Britt Marcussen, MD Department of Family Medicine University of Iowa

  2. UI Sports Medicine 6-0

  3. Seeking Sponsorship ?

  4. Influenza • Definition: Influenza or “flu” is an infection caused by the influenza viruses. Influenza spreads around the world in seasonal epidemics that result in 250,000 to 500,000 deaths each year (41,000 on average in the US). Occasional pandemics occur when a particularly virulent and contagious strain of flu have been know to cause 50 million deaths.

  5. Classification There are three viral types: A/B/C A: The most virulent and responsible for all pandemics thus far. Mutates rapidly B: Not as virulent. Mutates slower. Humans have some baseline immunity. C: Much less common and usually only produces mild symptoms.

  6. Influenza Viral Structure • Envelope: Contains the glycoprotein's Hemaggutinin (binding) and Neuraminidase (release) and thus the H N classification. • Core: contains the RNA that contains the genes for protein coding • During viral replication because there are no RNA proofreading enzymes errors in transcription occur, thus altering the surface proteins. These mutations are what is responsible for “antigenic drift”.

  7. Signs and Symptoms • The typical presentation is fairly rapid onset of fever, chills and body aches. Other symptoms can include HA, cough, nasal congestion and sore throat. You can also get GI symptoms of nausea, vomiting and diarrhea especially in children. None of these clinical symptoms or signs are particularly specific and are common to most of the hundreds of known respiratory viruses

  8. Morbidity/Mortality • Increased in the young (<5), old (>65) and those with other co morbid conditions. • Death is usually the result of a secondary infection, usually pneumonia. • During pandemics the excess mortality is in younger patient population and is a result of the “cytokine storm” induced by the virus which leads to pulmonary edema and hemorrhage.

  9. Transmission • Possible mechanism of spread: • Direct transmission from hard surfaces • Direct transmission for large particle contact (up to 1 meter away) • Inhalation of suspended particle (5micrometer)?. • The virus can live on hard surfaces up three days and in mucus for up to two weeks!

  10. Testing • Rapid test for A/B are available and are reasonably accurate (sensitivity 50-70% and specificity of 90-95%). • They are most accurate during the first 4-5 days. • Test only when results will influence decision making( i.e., hospitalized patients, considering treatment of the individual or contacts/infection control). During outbreaks in patient with typical symptoms no testing is necessary.

  11. Treatment • Must start within 48 hours! • At best decreases the duration of illness by 1-2 days. • It is unclear whether treatment decreases the severity of symptoms, complications or mortality.

  12. Treatment • Agents: Amantidine, rimantidine, oseltamivir (Tamiflu), zanamivir (Relenza). • The adamantanes are not currently recommended due to high resistance rates, but this may change! • Most healthy adults with no risk factors for complications require no treatment.

  13. Treatment • High risk groups • Pregnancy up to two weeks postpartum • The young and old (<5 and >65) • Chronic medical conditions (CV/pulmonary disease, renal/hepatic disease, diabetes, immunosuppressed, 19 yo’s or younger on aspirin, obesity/BMI over 30 • Severe disease/pronounce lower respiratory tact symptoms. • Prophylaxis of close contacts is not generally recommended, especially if 48 hours has passed since the time of exposure.

  14. Prevention • The infectious period starts 24 hour prior to the onset of symptoms and at least for 24 hour after fever abates. • Stay home until fever free for 24 hours. For health care workers it’s or 7 days which ever is longer! • Patients on antiviral are considered infectious until they have completed at least 4 days of therapy. • Surgical masks are recommended for health care workers caring for suspected cases. • General Advise: Wash your hands, don’t pick your nose, avoid sick people, eat well, sleep well and avoid stress. • Medical offices: Triage/vaccination of staff/masking/designated waiting areas.

  15. Vaccination • Advised for everyone over 6 months of age. • This years vaccine will include H1N1, a seasonal H3N2 and a B component. • There are two vaccines available an inactivated injectable form and a live attenuated intranasal form • Why everyone: • An estimated 85% of the population has and indication for vaccination. • People under 50 do get ill and spread infection. • We are now able to supply the vaccine.

  16. Vaccination • Special populations and considerations • One dose if 8 and older, 2 dose 4 weeks apart if 8 and under and did not receive at least one dose of the 2009 H2N1 vaccine plus at least one dose of seasonal flu vaccine previousely. • No nasal vaccine for those under 2 or over 50. Pregnancy, age <19 and on aspirin, lung disease, diabetes, weakend immune system, kidney failure. • No vaccine at all if you have a severe egg allergy, history of Gillain-Barre’ within 6 weeks of previous vaccination. • Multidose vial contains Mercury. • 6-35 months get ½ dose. • Avoid Fluviron in those 8 and under due to fever and febrile seizure risk. • If 65 and older consider high dose Fluzone (4x the antigen). • Better immune response but ? better protection.

  17. Vaccination • NNT in Health Adults (Cochrane review) • Under ideal conditions (vaccine match) = 33 • Under usual conditions = 100 • One case of vaccine related Gillian Barre’/million vaccinated. • 15/36 studies were industry sponsored. • Vaccine effectiveness under the age of two is not yet established despite the guild lines. • may not need to change from year to year. New DNA vaccine to the inner less variable part of the HA protein shows some promise and -The are over 200 viruses that cause influenza like illness which represent about 90% of the circulating virus each year.

  18. Summary of Last Years Flu Season • Overall vaccination coverage was 41%, 27% for H1N1. • H1N1 was very wide spread peaking in June/July and again in October. • Deaths from April 09 to April 10 were approximately 12,470. 9,570 were in the 18-64 year age group! In an average year up to 40,000 deaths will be attributed to flu. • Hospitalizations were approximately 274,000 with 160,000 from the 18-64 age group.

  19. Summary of Last Years Flu • 2009 NEJM 369:1935-1944 • Looked at 272 hospitalized patients • 45% were <18; 50% were 18-65 • In a “usual year” 60% of the hospitalized patients will be >65. • New obesity link? • 45% of hospitalized patients were obese

  20. 1918 Pandemic Prospective • Mortality was 10-20% primarily young adults (cytokine storm-massive hemorrhage) • WW1 troop movement and close quarters help facilitate the spread • 3-6% of the global population died (50-100 million) • 500,000 to 700,000 died in the US (more than in the war). • In Samoa 90% of the population died. • The virus has been identified as an Avian H1N1 virus and sequenced from frozen remains in Alaska and preserved soldiers. • Will modern medicine help when this type of stain emerges again? Vaccination/antibiotics/better equipped hospitals.

  21. Influenza and Sports • Asian Youth Games 2009 (BJSM 2010 44:528-532). • 1210 athletes, 810 staff from 43 countries one week after WHO declared H1N1 a pandemic. • All athletes had twice daily temp. recorded • Any athlete with flu like symptoms was tested and if positive placed on medication put in isolation. Close contacts were placed on medication and quarantined. • Masks and thermometers were provided to all athletes and officials. • All confirmed cases of H1N1 were admitted to the Hospital for isolation after “special transport” was arranged. Close contacts were placed on medication and isolated at government quarantine facilities for 7 days. Close contact was defined as 2m for more than one hour. • Temperature scanners were place at strategic locations in the games village. • Medical care was made available 24/7 to all participants family and staff. With hot zone and cold zone triage. All medical staff in the hot zone were required to wear gloves/gowns/N95 masks. Mobile high efficiency air filter systems were installed in the hot zone. • 6 cases, 42 quarantined, no event outbreaks were identified.

  22. Case: Football team arrives and passes through thermal scans. After arrival 2 team members who did not make the trip due to illness are found to have H1N1. First match is the next day. What do you do?

  23. Emergency panel assembles and determines that all are “close contacts”. • All 21 team/team personal are screened. 4 are positive, the rest are quarantined.

  24. The Athlete and Influenza Athletes may be at higher risk during times of high training load and stress. Athletes may be at higher risk due to close contact with other athletes during training and competition. Athletes may be at higher risk due to there living/travel circumstances Athletes may be at higher risk due to sharing of water bottles towel and other personal items. Good hygiene and infectious control measure should be stressed.

  25. The Athlete and Influenza • We should do are best to recognizes the typical symptoms of flu in our athletes and staff (i.e., abrupt onset of f/c/HA/cough/ST/rhinnorhea) and treat if appropriate and minimize exposing others. PPV 79-88% • Not all need to be seen in the clinic as uncomplicated cases resolve in 3-7 days. • Cough and malaise can last several weeks so training loads may need adjusting. • We need to be aware of the incubation periods are 1-4 days. Viral shedding occurs for 24 hour prior to symptoms and lasts 5-10 days.

  26. Return to Play • Must be individualized based on: • Symptom severity • Fever/myalgia/severe cough warrant activity limitation (neck check) • Symptom duration/infectious period. • Sport and current demand • Must include monitoring for secondary infection/pneumonia.

  27. InfluenzaUpdate • Flu is sporadic in Iowa at the moment but increasing. • Both influenza A and B have been identified. • All strains so far (including H1N1) are covered by the vaccine.

  28. Mononucleosis in Athletes • Infectious Mononucleosis (IM) is a common medical condition effecting thousands of young athletes each year. • It an important clinical entity for the sports medicine team for several reasons: • It can have a profound and somewhat lasting effect on athletic performance. • There are a number of potentially serious complications including splenic rupture. • Therefore, there are often complex and difficult decisions for the medical team regarding return to play.

  29. Goals • Describe the etiology and pathophysiology of IM. • Describe the clinical presentation of IM. • Provide guidelines for making the diagnosis of IM. • Discuss the potential complications IM focusing on splenic rupture. • Discuss treatment and RTP.

  30. Epidemiology • IM is cause by Epstein Barr Virus (EBV) a herpes virus. • The peak incidence of clinical IM is in adolescents and young adults. • Between 30-70% of freshman remain vulnerable. • The risk of developing IM is between 1-3% per year. • In childhood it is often subclinical or difficult to distinguish from other respiratory illness. • It is more likely to be symptomatic and severe the older you are when you acquire the infection. • Eventually 90-95% of the adult population will show serologic evidence of infection. • The incidence clinical infection in the US is 30 times higher in whites compared to blacks.

  31. Transmission and Pathogenesis • EBV is transmitted primarily through saliva thus it’s popular description as the “kissing disease” • Other possible modes of spread include sexual contact, sneezing and the sharing cups and food. • Host cells include epithelial cells/monocytes/B lymphocytes and T lymphocytes. • The incubation is as long as 30-50 days. • The virus is shed for weeks to months. • There is evidence of intermittent shedding in oral secretions for decades. • Despite the bodies immune response to the virus it enters a dormant phase.

  32. Clinical Features • Sore throat (82%), fever (76%) and fatigue (76%) are the most common clinical symptoms • Clinical Findings/Signs • Lymphadenopathy: Posterior cervical chain>anterior. Auxiliary and inguinal nodes can be involved. Node are often large and tender. • Pharyngitis: Exudates are seen in 30-50% or more and can be white to gray. Hypertrophy may be impressive. Palatal petechiae can be present. Group A Strep can be present in up to 30%...colonization?

  33. Clinical Features • Fatigue • May be persistent and severe. • May have a fair amount of daily variability • Women seem to have more severe and more prolonged fatigue. • Usually resolves in one month but may last up to six. • Performance may lag for 3+ months. • A small subset of patients will have persistent fatigue. The reasons for this are unclear.

  34. Clinical Features • Skin: • a rash can be present and can be maculopapular to urticarial to petechial. • Rash development after administration of Amoxicillin (up to 95% of the time) is common but can occur with other antibiotics (40-60% with other beta lactams). • Petecial rash should alert you to check for hematologic complications (aplastic anemia, thrombocytopenia, hemolytic anemia, HUS, DIC) • Petechiae and any GI symptoms seems to predict a longer and more severe course. • Periorbital edema

  35. Clinical Features • Abdominal: • Splenomegaly • Probably occurs in most cases but clinically detectable in 15-65% as the sensitivity and specificity of the clinical exam is 20-70% and 69-100% respectively. This may be even worse in our athletes many of whom have well developed musculature making it even more difficult to detect. Be aware there are reported cases of rupture from too vigorous an examination! More to come…. • Hepatomegaly • Can occur but is much less common. Transaminases can be elevated but are not clinically important to follow. • Neurologic: These are rare occurring in only 1-5% of cases • Guillain-Barre, Facial Nerve Palsy, encephalitis, meningitis, transverse myelitis and other neuritis.

  36. Differential Diagnosis • HIV-rash, GI symptoms, cough, weight loss etc… • Group A Strep-Seasonal, no posterior chain nodes, no splenomegaly, less tonsillar hypertrophy, less fatigue more fever. • Cytomegalovirus-Usually minimal to no sore throat, otherwise can look very similar. • Toxoplasma Gondii-small anterior tender andenopathy. • Human Herpes Simplex 6/7

  37. Laboratory Testing • The most common lab finding with IM is lymphocytosis defined as >4500/mcl or >50%. Atypical Lymphocyte count of >10% on a peripheral smear. • The “monospot” test or the heterophile antibody test is a group of IgM antibodies that cross react with antigens found on sheep and horse blood cells. • Sensitivity increase through the first few weeks of illness with false negatives of 25% in the 1st week falling to 5% by week 3. • Once present the test can stay positive for up to 1 year. • In the presents of typical symptoms the test has a sensitivity of around 85% and a specificity of approximately 94% • Patients with HIV type 1/cancer/lupis can generate false positive results.

  38. Laboratory Continued • Specific IgM and IgG to viral capsid antigens (VCA) can be measure when the diagnosis is in doubt. Sensitivity and specificity for IM is 97% and 94% respectively. • IgG takes weeks to appear and indicates in most cases old infection. • IgM appears early in the disease usually disappears by 3-6 months but can persist in up to 20%. • IgG to the nuclear antigen (EBNA) can also be measured. This can be detected starting around 6-12 weeks and indicates that the virus is entering the latent phase. Therefore, it can be used to help exclude an acute infection. • All of these tests are useful primarily in cases when the diagnosis is in question or you suspect a false negative monospot.

  39. Immune Response

  40. Laboratory • Many patients with IM will have a mild hepatitis. Liver Function tests can be mildly elevated. • There is no correlation of LFT elevation and spleen size. • There is no evidence to support the use of serially monitoring as a guild to clinical improvement or return to play.

  41. Laboratory Summary • Patients with a clinical picture consistent with IM should have a CBC and a herterophile test • If the heterophile test is positive then no more testing is needed. • If the heterophile test is negative and the clinical suspicion is high then a repeat test can be performed in a week. • If the clinical syndrome is prolonged or symptoms are atypical then VCA IgM and IgG and EBNA IgG can be measured.

  42. Complications • Most patients who contract IM have an uncomplicated and often subclinical course thus require only supportive care. • Severe complications occur in less than 5% and include: • Airway obstruction • Dehydration • Splenic rupture • Aplastic anemia/thrombocytopenia • Neurologic-GB/Meningitis, encephalitis • Myocarditis • Lymphoma • HUS • DIC • Chronic Fatigue Syndrome?

  43. Treatment • Antiviral medication • 5 randomized trials of acyclovir have show decrease viral shedding during treatment only. No significant effect on clinical symptoms or duration of illness has been demonstrated • One small trial (20 patients) with valacyclovir did show a reduction in the number and severity of symptoms scores.

  44. Treatment • Corticosteroids (Cochrane review 2010) • 17 studies most with low patient numbers and widely varying methodology. • Return to work/school-2 studies no change • There may be an early effect of reduced severity of ST at 12-24 hours, but this effect is lost 36 hours. • In one study using both steroid and acyclovir showed diminished symptoms at 2 and 4 days. Furthermore, the ST was gone at 7 days in the treatment group and 9 days in the placebo group but no statistic significance was reported.

  45. Treatment • Fatigue-2 studies and no change with steroid use was noted. • Steroid plus valacyclovir showed slight improvement but the study was underpowered. • Fever • Steroids in three trials found modest reduction in the number of days of fever. • One trial of steroids and acyclovir showed no difference.

  46. Treatment • None of the studies systematically tracked complications that may have resulted from corticosteroid treatment • Corticosteroid use suppresses the hosts immune response and predisposes to secondary infections. • In these studies there was one reported case of acute diabetes, one peri-tonsillar cellulites and one empyema. • It is unknown what effect using an immunomodulator will have on the risk of EBV associated malignancies.

  47. Treatment • The conclusion is that there is not enough data to recommend corticosteroids or antivirals for the treatment of uncomplicated IM. • It is probably reasonable to use corticosteroids in cases in which significant respiratory, neurologic or hematologic complications arise.

  48. Treatment • Vaccines • Trails using vaccine developed against the glycoprotein subunit of the virus did not appear to protect against acquiring infection but were less likely to have symptoms.

  49. EBV Autoimmune Disorders and Cancer • Association of symptomatic EBV infections and various autoimmune processes and cancers have been identified including • Burkitt’s Lymphoma-virtually all African patients with BL have high titers of EBV • Hodgkin’s Lymphoma-EBV nucleic acids in 20-40%. • Nasopharyngeal carcinoma • Multiple Sclerosis

  50. Airway Obstruction/Complicated Cases • This is a result of marked tonsillar enlargement, autoimmune processes and lymphoid infiltration. • Can be treated with corticosteroids (i.e., prednisone at 40-80 mg/day) +/- antivirals. • Clinical expert opinion still favors their use of corticosteroids in cases of severe tonsillar hypertrophy with upper airway obstruction and in cases involving hemolytic anemia, thrombocytopenia or myocarditis.

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