ACSM Infectious Disease in Athletes : Harris, M. D. (2011). Infectious disease in athletes. Current Sports Medicine Reports, 10(2), 84–89. doi.org/10.1249/jsr.0b013e3182142381.
Effects of Exercise on the Immune System
- Moderate exercise, commonly defined as exercise for 5 to 60 min within a range of 40% to 60% of maximum heart rate (MHR), improves many aspects of immunity due to the increase in neutrophil and NK counts as well as salivary IgA concentrations and secretion rates
- Intense exercise, defined as 5 to 60 min of exercise at 70% to 80% of MHR, and prolonged exercise, often defined as greater than 60 min, have detrimental effects on the immune system. As the body’s requirement for oxygen increases, the athlete transitions from nose to mouth breathing, which bypasses the nasal hairs and leads to disruption of the mucociliary elevator. Ultimately, this leads to more deposition of foreign particles in lower airways and diminished ability to remove them.
- For several infectious diseases, extreme exercisers are at the highest risk for infection, followed by sedentary individuals and then those who exercise moderately.
BJSM COVID Return to Play
- Elliott, N., Martin, R., Heron, N., Elliott, J., Grimstead, D., & Biswas, A. (2020). Infographic. graduated return to play guidance following covid-19 infection. British Journal of Sports Medicine, 54(19), 1174–1175. doi.org/10.1136/bjsports-2020-102637.
NFHS Cardiopulmonary Guidance for COVID19
- Drezner, J. A., Heinz, W. M., Asif, I. M., Batten, C. G., Fields, K. B., Raukar, N. P., Valentine, V. D., Walter, K. D., & Baggish, A. L. (2022). Cardiopulmonary considerations for high school student-athletes during the COVID-19 pandemic: Update to the NFHS-AMSSM guidance statement. Sports Health: A Multidisciplinary Approach, 194173812210771. doi.org/10.1177/19417381221077138.
Preparticipation:
- AAP strongly recommends that all people who are eligible should receive the primary series of the COVID-19 vaccine, receive a booster dose when recommended, and continue to follow transmission mitigation recommendations as described by the CDC.
Return to Play:
- Children and adolescents should be encouraged to begin a gradual return to physical activity if they have not participated in consistent physical activity for more than 1 month
- Children and adolescents should start at 25% of their usual volume and intensity of activity and consider every-other-day exercise. An increase of volume of 10% per week is recommended until the desired volume is achieved. Next, intensity of the desired exercise can be increased by 10% per week until the desired intensity is reached.
General
Herpes simplex infection (herpes gladitorium, labialis, sycosis, whitlow, keratitis)
CDC- Herpes
- Centers for Disease Control and Prevention. (2021, July 22). Std Facts – genital herpes (detailed version). Centers for Disease Control and Prevention. Retrieved May 26, 2022, from https://www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm
AAFP HSV Infections
- Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010 Nov 1;82(9):1075-82. PMID: 21121552.
Etiology and Pathogenesis:
- Non-genital rash due to herpes simplex virus infection
- Commonly seen in wrestler athletes
- Spread via skin-to-skin contact or mucous membranes→ virus transmits from skin to neuron and lies dormant in dorsal sensory root ganglion
- Primary infection appears 2-20 days after contact with infected person
- Often presents as prodrome of fever and hyperesthesia or paresthesia sensations followed by lesions of a particular area
- Rash described as maculopapular, vesicular rash with erythematous base and coalescing lesions
- Clinical diagnosis can be difficult as other rashes can resemble herpes infection. Can utilize viral culture or PCR
Management
- Primary infection: Valacyclovir 1000mg BID for 7-10 days (20mg/kg TID for pediatric patients less than 20kg)
- Recurrent infection: valacyclovir 500-1000mg BID for 7 days (or 2g BID for one day) or acyclovir 400mg TID for 5 days
- Prophylactic dosing: valacyclovir 500mg PO daily or acyclovir 400mg BID
Return to sport guidelines differ between NCAA and NFHS but in general:
- Lesions must be crusted over without new lesions for 72+ hours
- Athlete must be on antiviral therapy for 120+ hours
- No systemic symptoms or evidence of secondary bacterial infection
Tinea infections
AAFP Diagnosis and Management of Tinea Infections
- Ely, J. W., Rosenfeld, S., & Seabury Stone, M. (2014). Diagnosis and management of tinea infections. American family physician, 90(10), 702–710.
Etiology and Pathogenesis
- Tinea infections can occur essentially anywhere on the body (cruris, capitis, pedis, unguium, etc…)
- Rash typically described as an annular lesion with well-defined, scaly, often reddish margins. Rash is commonly pruritic
Management:
- Tinea capitis: 1% or 2.5% selenium sulfide shampoo or 2% ketoconazole shampoo should be used for the first two weeks. Can also use terbinafine or fluconazole
- Tinea pedis or cruris can be treated with topical azoles or allylamines
- Tinea unguium: Choosing Wisely campaign recommends not treating until confirmed infection via KOH prep. Topical agents are typically not successful
- Topical ciclopirox BID or topical azoles
Lyme Disease
AAFP Diagnosis and Management of Lyme Disease
- Wright, W. F., Riedel, D. J., Talwani, R., & Gilliam, B. L. (2012). Diagnosis and management of Lyme disease. American family physician, 85(11), 1086–1093.
Etiology and Pathogenesis
- Caused by bacteria, Borrelia burgdorferi which is transmitted through the bite of an infected deer tick (Ixodes scapularis)
- Diagnosis is clinical with the appropriate history of a tick bite and presence of an erythema migrans rash, described as a red macule with central clearing in a “bull’s-eye pattern.”
- Symptoms of secondary or tertiary lyme disease include arthralgias, myalgias, or potentially meningitis or myelitis. Other complications include carditis in the form of first or second degree atrioventricular block.
Management:
- Treatment preference is doxycycline 100mg BID for 10-21 days (contraindicated in pregnancy, breastfeeding, and children less than 8 years of age). Alternative options are macrolides such as azithromycin 500mg PO daily for 14-21 days or amoxicillin 500mg TID for 7-10 days.
- Return to play is guided by severity of symptoms, keeping in mind the late stage manifestations of secondary or tertiary Lyme.
Swimmer’s Ear
Otitis Externa AAFP
- Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician. 2012 Dec 1;86(11):1055-61. PMID: 23198673.
Etiology and Pathogenesis
- Otitis externa typically caused by Pseudomonas aeruginosa or Staphylococcus aureus infections
- Rapid onset of ear pain, itching, canal erythema and edema.
- Often occurs following swimming or minor trauma
Management:
- Treatment is with topical antimicrobial otic preparations
- Otic antibiotics: Ciprofloxacin BID, neomycin/polymyxin B 3-4 times daily,, ofloxacin 1-3 times daily
- A topical corticosteroid can be added to antibiotics for faster resolution of symptoms
- Treatment duration is for 7-10 days
Infectious Mononucleosis
AAFP Review on Infectious Mononucleosis
- Womack J, Jimenez M. Common questions about infectious mononucleosis. Am Fam Physician. 2015 Mar 15;91(6):372-6. PMID: 25822555.
Exercise in Athlete with Infectious Mononucleosis
- Shephard, Roy J. CM, MBBS, MD, PhD, DPE, LLD, DSc, FACSM, FFIMS Exercise and the Athlete With Infectious Mononucleosis, Clinical Journal of Sport Medicine: March 2017 – Volume 27 – Issue 2 – p 168-178 doi: 10.1097/JSM.0000000000000330
Splenic Rupture and Infectious Mononucleosis: Return to Play Recommendations
- Sylvester, J. E., Buchanan, B. K., Paradise, S. L., Yauger, J. J., & Beutler, A. I. (2019). Association of Splenic Rupture and Infectious Mononucleosis: A Retrospective Analysis and Review of Return-to-Play Recommendations. Sports health, 11(6), 543–549. https://doi.org/10.1177/1941738119873665
Etiology and Pathogenesis:
- Common in adolescents and young adults, 10-30 years of age
- Typical features are fever, pharyngitis, adenopathy, maliaise, and atypical lymphocytosis (at least 20%)
- Diagnosis can be made by positive heterophile antibody test
- False negative results of heterophile antibody tests are common in the early course of the infection
Management:
- Supportive and includes hydration, analgesics, antipyretics, and rest
- Athlete’s energy level should guide return to play and activity
- AAFP does not recommend corticosteroids, acyclovir, or antihistamines
- Fatigue, myalgias, and malaise may persist for months
- Major complication is of splenomegaly and resulting splenic rupture
- This can occur regardless of trauma or contact injury
- Greatest risk appears to be in the first 3 weeks of infection so generally recommend return to play 3-4 weeks after infection onset.
Cardiac (Myocarditis, Pericarditis)
Management and Treatment of Myocarditis in Athletes
- Hurwitz, B., & Issa, O. (2020). Management and treatment of myocarditis in athletes. Current Treatment Options in Cardiovascular Medicine, 22(12). doi.org/10.1007/s11936-020-00875-1.
AHA/ACC Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities
- Maron, B. J., Zipes, D. P., & Kovacs, R. J. (2015). Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Preamble, principles, and general considerations. Journal of the American College of Cardiology, 66(21), 2343–2349. doi.org/10.1016/j.jacc.2015.09.032.
EAPC Position Statement: Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis
- Pelliccia, A., Solberg, E. E., Papadakis, M., Adami, P. E., Biffi, A., Caselli, S., La Gerche, A., Niebauer, J., Pressler, A., Schmied, C. M., Serratosa, L., Halle, M., Van Buuren, F., Borjesson, M., Carrè, F., Panhuyzen-Goedkoop, N. M., Heidbuchel, H., Olivotto, I., Corrado, D., … Sharma, S. (2018). Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: Position statement of the sport cardiology section of the European Association of Preventive Cardiology (EAPC). European Heart Journal, 40(1), 19–33. doi.org/10.1093/eurheartj/ehy730.
Etiology and Pathogenesis:
- Pericarditis is an inflammation of the pericardium
- Myocarditis is an inflammation of the myocardium and can often be associated with cardiac dysfunction and arrhythmias, and is even one of the leading causes for sudden cardiac death (SCD) in athletes
- Most common (viral) causes: enterovirus, adenovirus, influenza viruses, human herpes virus-6, cytomegalovirus, parvovirus B19, Epstein-Barr virus and Covid-19
- Myocarditis from bacterial, fungal, and protozoal infections occurs much less frequently
- Clinical manifestations:
- Preceding viral illness: highly variable symptoms and may include fevers, chills, diarrhea, or decreased appetite.
- Cardiac symptoms tend to take up to days to develop and include chest pain, dyspnea, and palpitations, atypical chest pain aggravated when leaning the upper body forward, decline in physical performance, fatigue, muscle soreness, dizziness, or new onset atrial or ventricular arrhythmias.
- Diagnosis: Elevations in serum inflammatory markers (erythrocyte sedimentation rate, Creactive protein) and cardiac enzymes (troponin, creatine-kinase, natriuretic peptides), electrocardiogram (ST deviation, PR depression, arrhythmias) or echocardiogram (depressed left or right ventricular ejection fraction, regional wall motion abnormalities, pericardial effusion)
- Cardiac magnetic resonance (CMR) is becoming more widely recommended as part of a more comprehensive approach to the diagnosis and management of suspected myocarditis
Management:
- Mainstay of therapy for patients with acute myocarditis should focus on guideline-directed medical treatment of heart failure and arrhythmias. However, in most cases infectious myocarditis appears to resolve spontaneously with little treatment and has a favorable prognosis
- Before returning to competitive sports, the guidelines continue to recommend a resting echocardiogram, 24-h Holter monitoring, and an exercise ECG no less than 3 to 6 months after the initial illness
- Pericarditis treatment: Nonsteroidal anti-inflammatory drugs and colchicine
Upper Respiratory Tract Infections
Treatment of the Common Cold
- DeGeorge, K., Ring, D., & Dalrymple, S (2019). Treatment of the common cold. Am Fam Physician. 2019;100(5):281-289.
Etiology and pathogenesis:
- Acute upper respiratory tract infection (URI), also called the common cold, is the most common acute illness in the United States and typically presents with nasal congestion, rhinorrhea, sore throat, cough, general malaise, and/or low-grade fever.
- Viruses such as rhinovirus are the predominant cause
- Important to distinguish from allergic rhinitis, isolated pharyngitis, acute bronchitis, influenza, bacterial sinusitis, and pertussis
- Symptoms are self-limited, often lasting up to 10 days as compared to acute bronchitis which generally has a longer duration, with a mean of 18 days in adults and 12 days in children
- A 1989 Runner’s World survey revealed that 61% of runners reported fewer upper respiratory tract infections after starting running, whereas only 4% reported more. Some studies suggest that the incidence of URTI drops 20% to 30% in moderate exercisers compared with sedentary people.
Management:
- Use of hand sanitizer or handwashing is the most effective preventative method
- Symptomatic treatment with OTC analgesics and decongestants
- Avoid antibiotics
Acute Bronchitis
Acute Bronchitis
- Kinkade, S., & Long, K (2016). Acute bronchitis. Am Fam Physician. 2016 Oct 1;94(7):560-565.
Etiology and pathogenesis:
- Acute bronchitis is a clinical diagnosis characterized by cough due to acute inflammation of the trachea and large airways without evidence of pneumonia
- Acute bronchitis is most often caused by a viral infection.The most commonly identified viruses are rhinovirus, enterovirus, influenza A and B, parainfluenza, coronavirus, human metapneumovirus, and respiratory syncytial virus.Bacteria are detected in 1% to 10% of cases of acute bronchitis.
- Clinical manifestations: Cough (predominant symptom), sputum production, dyspnea, nasal congestion, headache, and fever
Management:
- Supportive care and symptomatic treatment with OTC antihistamines and antitussives, proper hydration
- Avoid prescribing antibiotics for uncomplicated acute bronchitis
- Avoid using beta2 agonists for the routine treatment of acute bronchitis unless wheezing is present. Notable consideration for athletes with exercise-induced asthma.
- Indications for CXR (to rule out PNA):
- Dyspnea, bloody sputum or rusty sputum color; Pulse > 100 bpm, RR > 24 bpm or febrile; focal consolidation, egophony or fremitus on lung exam
Meningitis
Meningitis in the Athlete
- Ewald, A. J., & McKeag, D. B. (2008). Meningitis in the athlete. Current Sports Medicine Reports, 7(1), 22–27. doi.org/10.1097/01.csmr.0000308668.22688.0d.
Etiology and pathogenesis:
- Meningitis is defined as inflammation of the meninges, the dual membranes (pia and dura mater) lining the brain and spinal cord.
- Majority of reported cases of meningitis in athletes are viral in etiology but bacterial meningitis, most commonly caused by Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis (meningococcus), is associated with significant mortality and potentially devastating neurological sequelae.
- Frequent physical contact and close travel arrangements associated with many team sports may put athletes at even greater risk than the general population.
- In the reported outbreaks of viral meningitis in high school football teams, the rate of transmission among the members of the team was felt to have exceeded the infection rate not only in the community, but also in other athletic teams at the school, among students not involved in athletics, and in opposing teams.
- Clinical manifestation: fever, headache, meningismus (neck stiffness) as well as nausea, vomiting, photophobia, malaise, and drowsiness.
- Diagnosis: CSF analysis via lumbar puncture
Management:
- Treatment:
- Supportive care for viral meningitis
- In the case of disseminated meningococcal infection, the circulating load of bacteria and endotoxin is estimated to double in 30-45 min so pre-hospital treatment with intramuscular benzylpenicillin or ceftriaxone should be given, if available, into the quadriceps muscle
- Once intravenous (IV) access is established, the recommended regimen for children older than 3 months and adults younger than 50 yr of age is a third generation cephalosporin (ceftriaxone or cefotaxime), plus vancomycin.
- Encourage immunization of collegiate student athletes who may be at increased risk for infection as a result of their living in close quarters
Blood borne pathogens in the context of sports participation
- McGrew, C., MacCallum, D.-S., Narducci, D., Nuti, R., Calabrese, L., Dimeff, R., Paul, S., Poddar, S. K., Rao, A., & McKeag, D. (2019). AMSSM position statement update: blood borne pathogens in the context of sports participation. Clinical Journal of Sport Medicine. doi.org/10.1097/jsm.0000000000000738.
General
- Confirmed transmission of BBPs during sport is exceedingly rare with no well-documented reports
- Mandatory screening for BBP is not medically justified as a condition for athletic participation or competition given the low risks of infection and transmission
- Competitive athletes and non-athletes should follow appropriate general public health agency recommendations for screening for BBPs, considering their individual risk factors and exposures
- Adherence to basic hygiene and standard precautions against blood borne pathogens is appropriate for all athletic settings, including those providing care to athletes.
General
Etiology and pathogenesis:
- Acute onset of monoarticular joint pain, erythema, heat, and immobility should raise suspicion of sepsis as well as constitutional symptoms such as fever, chills, and rigors.
- In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50,000 per mm3.
- Isolation of the causative agent through synovial fluid culture is not only definitive but also essential before selecting antibiotic therapy. Synovial fluid analysis is also useful to help distinguish crystal arthropathy from infectious arthritis, although the two occasionally coexist.
- Septic arthritis is caused by nongonococcal pathogens (most commonly Staphylococcus species) in more than 80 percent of patients.
Management:
- Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods.
