Infectious Disease and the Athlete

Infectious Disease and the Athlete Mark Peluso, MD Ann Cappellari, MD San Jose Medical Center Sports Medicine Fellowship Program 8/12/2008 Discussion Objectives 1. Review current theories on effects of exercise on immunity. 2. Review infectious diseases commonly seen in athletes 3. Review Vaccine Recommedations 8/12/2008 Effects of Intense - Exhaustive exercise on Immunity 8 1. NK cell count and activity burst / drop 2. Macrophage burst / drop 3. CD4: CD8 ratio drops 4. Impaired Neutrophil function 5. Effect on cytokine production unclear 6. IgA & IgG concentrations drop 8/12/2008 Effects of repeated moderate exercise on Immunity 8 1. NK cell count and activity increases 2. Macrophage function unchanged 3. CD4: CD8 ratio changes unknown 4. Neutrophil function unknown 5. Effect on cytokine production unclear 6. IgA & IgG concentrations unchanged 8/12/2008 Immunology Review & Exercise 8 8/12/2008 Theroy of Susceptibility vs. Exercise Intensity 8 8/12/2008 Effect of fever on the athletes performance 1 z z z z z z Decreased strength Decreased aerobic power Decreased endurance Decreased coordination Decreased concentration ALL CAN LEAD TO INJURY 8/12/2008 Effect of fever on the athlete’s physiology 1 z Increased cardiopulmonary effort with reduction in peak exercise capacity z Abnormal temperature regulation z Abnormal pulmonary function z Early muscle fatigue & decreased isometric strength z Decreased desire (psychological) 8/12/2008 General Recommendations for Febrile Athlete’s Participation 1 z Avoid strenuous conditioning and competition during the febrile state (100.4 F or 38 C) z Avoid strenuous conditioning and competition in presence of marked generalized symptoms (severe malaise, myalgias, SOB, weakness, cough, diarrhea, vomiting) z Level of exercise on return varies according to severity of illness and length of time away. 8/12/2008 “NECK CHECK” for stubborn athletes6 z Symptoms above the neck (rhinorrhea, headache, congestion, sore throat): athlete goes at 50% for a few minutes, if clears continue at 50% or gradually increase the intensity. z Symptoms below the neck (myalgia, arthralgia, vomiting, diarrhea, fever, cough) means do not train until symptoms resolve. 8/12/2008 Disease Commonly Seen in Athletes Sick Athlete Viral Infections Bacterial Infections Skin Diseases Infectious Mononucleosis Pneumonia Herpes Common URI Otitis Externa Tinea Viral Gastroenteritis Pharyngitis Molluscum Contagiosum Travellers Diarrhea 8/12/2008 Impetigo & Furuncles Upper Respiratory Infections z Sx: fever, chills, myalgia, sore throat, fatigue, cough z Etiology: rhinovirus, adenovirus, coxackievirus……. z Tx: rest, fluids, antipyretics, decongestants, cough suppressants z Emphasize handwashing z Return gradually once asymptomatic 8/12/2008 Infectious Mononucleosis (IM) I z 90% US citizens EBV(+) by age 30 z 25- 50% with syndrome ages 15-25 z oral:oral transmission, most cases with unknown contact z 30 - 50 day incubation period z Classic Prodrome: headache, fever, anorexia, malaise, myalgia, lasts 3-5 days 8/12/2008 Infectious Mononucleosis (IM) II Classic Syndrome 1. Fatigue 2. Fever / sweats 3. Sore throat 4. Exudatve tonsillits 33% 5. Cervical LAN 6. Jaundice (15%) 7. Palpable spleen (60%) 8. Last 5-15 days 8/12/2008 Infectious Mononucleosis 8/12/2008 Infectious Mononucleosis (IM) III Labs z Monospot test: IgM/ Heterophil antibody test * 15% adults don’t make the heterophil Ab. z Referral lab for IgM to EBV Capsid Ag; or CMV, HIV, mycoplasmam, adenovirus. z Rapid Strep test or throat culture. z WBC = 10,000 - 20,000 wbc/ hpf. z 50% lymphocytes, 10-20 % are atypical. z LFT’s = mild hepatitis picture. 8/12/2008 Infectious Mononucleosis (IM) IV Complications Airway Obstruction Concurrent Grp A Strep Pharyngitis (5-30%) Neurological Complication (GB, encephalitis) Possible increase susceptibility to head injury (due to decreased brain tissue compliance) z Protracted course z Splenic Rupture (0.1 - 0.2 %) z Myocarditis, Pancytopenia, Pneumonitis z z z z 8/12/2008 Infectious Mononucleosis (IM) V Splenic Rupture z Only w/ splenomegaly, but not all spleens are palpable (perform serial exams) z usually days 4-21 of acute phase z many occur with ADL’s or very minor trauma z LUQ pain w/ Kerr’s sign, hypovolemia z Prompt surgical referral 8/12/2008 Infectious Mononucleosis (IM) VI Treatment z NSAIDS for symptomatic care z Stool softeners to prevent splenic rupture z Corticosteroids for severe adenopathy, hepatitis, septic pattern, neurologic probs…. z Consider PCN or E-mycin for Strep infxn note: Ampicillin will cause a rash thus do not use in acute IM 8/12/2008 Infectious Mononucleosis (IM) VII Return to Play z Absence of splenomegaly & LUQ tenderness consider U/S if any question z Afebrile, pharyngitis &complications resolved z LFT’s normal (measrure only if hepatomegaly, RUQ tenderness or jaundice present in course) z Start with very gradual non-contact activities and progress slowly to full contact. 8/12/2008 z Most well 4-6 weeks, some 3-6 months. Pneumonia z Sx: fever, chills, productive cough, SOB, fatigue, chest pain. z Ex: Viral v Mycoplasma v S. pneumonia v TB z Dx: Exam, CXR, WBC, Sputum smear & Cx. z Tx: Emycin, Biaxin, Procaine Pen G. z Tx: Fluids, rest, antipyretics, cough suppressn. z Return: once afebrile, SOB/ DOE resolved. 8/12/2008 Pharyngitis z Signs & Sx: fever, sore throat, swollen/ exudative tonsils, anterior cervical LAN z Group A beta-hemolytic Strep z Rapid Strep tests 85-90% accurate z Throat Culture 95% accurate z Tx: PCN, E-Mycin, or Clinda; fluids, rest, analgesics z Return once afebrile & on antibiotics 8/12/2008 Pharyngitis 8/12/2008 Pharyngitis vs Mononucleosis z z z z Exudative tonsillitis Lymphadenopathy Myalgias Lab tests 8/12/2008 Otitis Externa: Swimmer’s Ear z Sx: otalgia, drainage, decreased hearing z Ex: Fungi, Pseudomonas aeruginosa z Dx: macerated/ swollen canal w/ drainage (make sure to see if TM perforated) z Tx: Cortisporin Otic Suspension 4gtt QID x 7-10 days, disp 10 ml bottle z keep ear dry, ear plugs once resolved z Return once sx mild (depends on sport) 8/12/2008 Gastroenteritis z Sx: Nausea, vomiting, diarrhea, abdominal cramps, fever, myalgias z Ex: Rota/Entero/Norwalk, Bacterial, Giardia z Dx: clinical v. stool culture w/ O&P z Tx: supportive (PREVENT DEHYDRATION) z Traveler’s Diarrhea: Bactrim DS bid & peptobismol, avoid antimotility drugs. z Return: sx resolved, rehydrated (handwashing) 8/12/2008 Gastroenteritis 8/12/2008 Skin Rash 8/12/2008 Herpes gladiatorum z 1-2mm vessicles on red base lasting 2-3 days then rupture & crust x 7days. Prodrome! z Tx: Acyclovir 400 mg TID x 10d (5d for recurrances, BID for prevention. z Quarrantine until no draining vessicles 4-6d. 8/12/2008 Molluscum Contagiosum z Raised firm umbilicated papules, 2-4 mm, groups/along scratches. z Wrestlers, swimmers or “partners” in direct contact z Tx: cryoablation z quarantine until lesions treated 8/12/2008 Impetigo z Staph or Strep infxn z vessicles -> bullae -> crusts with yellow fluid z Dx: remove crust & culture exudate z PCN (prevent PSGN) &/or topical Bactroban z No H2O or contact sports until lesions heal 8/12/2008 Tinea Pedis z Moist environment promotes infection z DDx: tinea, dyshydrotic eczema, contact dermatitis z 4th toe web diagnostic? z Topical antifungals, shower footwear, dry feet, powders (Zeasorb). 8/12/2008 Tinea Corporis and Capitis 8/12/2008 Pitted Keratolysis (aka “Toxic Sock Syndrome”) z Malodorous! z Hyperhydrosis leads to Corynebacterium infxn z 1-3mm erosions on plantar surface z Tx: Drysol (20% AlCl), frequent sock changes, topical or oral Emycin. 8/12/2008 Blood-Bourne Infections z HIV, Hepatitis B &C z Protection z Risk of transmission 8/12/2008 Immunizations6 z Tetanus: Booster every 10 years, or give if has wound and > 5 years since last booster. z Influenza: annually if supplies adequate, no contraindications, lasts 1 yr in healthy people, 25-50% sore @ site, 1% fever & myalgias. z Measles: outbreaks recurring! See guidelines. z Hepatitis B: no clear recommendation for athletes 8/12/2008 Prevention of illness: guidelines6 z z z z z z z Eat a well balanced diet. Keep life stresses to a minimum. Avoid overtraining & chronic fatigue. Keep Immunizations up to date. Avoid ill people (rashes included). Space out vigorous workouts & competitions. Get adequate sleep (avg 8 hours/ day). 8/12/2008 Conclusions: the take to clinic message….. z Athletic activity may cause both transient harmful & longterm beneficial effects on immunity. z Ill athletes must be recognized and counseled appropriately regarding participation while ill. z By following basic, common-sense guidelines, many illnesses can be prevented. 8/12/2008 References 1. Mellion, MB, The Team Physician’s Handbok 2nd ed, Mosby, 1997. 2. Strauss, RH; Sports Medicine 2nd ed, WB Saunders, 1991. 3. Eichner, RE; Infectious Mononucleosis Recognizing the Condition, Reactivating the Patient, Phys Spor Med, 24:4, 1996, p 49-54. 4. Oski, FA; Management of a Football Player with Infectious Mononucleosis, Ped Infect Dis Journal, 13:10, 1994 p 938-939. 5. Eichner RE, Calabrese LH, Immunology and Exercise, Med Clin Nor Amer, 78:2, 1994, p 377387. 6. Sevier TL; Infectious Disease in Athletes, Med Clin Nor Amer, 78:2, 1994, p 389 - 412. 7. Nieman DC; Exercise Infection and Immunity, Int J Sports Med, 15, 1994, p S131 - S141. 8. Shepard RJ, Shek PN; Exercise Immunity and Susceptibility to Infection: A J-Shaped Relationship?, Phys Spor Med, 27:6, 1999, p 47 - 66. 9. Shepard RJ, Shek PN, Brenner IK, Infection in Athletes, Sports Med, 1994 Feb;17(2):86-107. 10. Habif TB, Clinical Dermatology 3rd ed, Mosby, 1996. 8/12/2008