CHAPTER 31 • INFECTIOUS DISEASE AND THE ATHLETE 177
- Pulmonary findings are variable and can range from
normal to diffuse rhonchi, and/or wheezing. Chest X-
rays are usually normal but may be useful to exclude
other diseases (Williamson, 1999).
- As in URIs and acute sinusitis, rest and hydration are
key. Bronchodilators such as albuterol (1–2 puffs
q 4–6 h) may be useful, especially in patients with
wheezing or cough that increases with activity.
- Antibiotics are often not indicated in the first 2 weeks
since most cases are viral.
- The decision to prescribe antibiotics may involve non-
medical factors such as upcoming competitions and
risk of deconditioning while monitoring the course of
illness.
- Antibiotic treatment should primarily target Bordetella
species (Gilbert, Moellering and Sande, 2002). The
first line choice is erythromycin estolate (500 mg qid
for 14 days). Second line choices include trimethoprim-
sulfamethoxazole-DS (1 bid for 14 days) or clari-
thromycin (500 mg bid for 7 days).
- During recovery, the healing bronchi are more sensitive
to changes with exercise such as increased minute ven-
tilation, increased inhalation of antigens and irritants,
and drying and cooling of inspired air. These can trig-
ger bronchospasm and impede training. The clinician
must provide considerable reassurance as complete
symptom resolution may take 4–5 weeks (Williamson,
1999). Management relies on avoiding irritant stimuli
and using bronchodilators such as albuterol (1–2 puffs
q 4–6 h). Inhaled corticosteroids such as fluticasone
(88–440 mcg bid), beclomethasone (2–4 puffs qid),
flunisolide (2–4 puffs bid), or triamcinolone (2–4 puffs
bid-qid) may be useful too (McDonald, 1997).
- Acute cough with a history of fever, sputum produc-
tion, myalgias, pleuritic chest pain, and shortness of
breath, and physical findings such as hypoxia, tachyp-
nea, and localized pulmonary rales or rhonchi, sug-
gest the diagnosis of community-acquired pneumonia
(Masters and Weitekemp, 1998).
- Chest X-rays often show localized or diffuse infiltrates,
but may not early in the course of disease. Sputum
gram stain and culture may provide clues to the
causative organism (Masters and Weitekemp, 1998).
•Healthy subjects can usually be treated as outpatients
(Levy and Kelly, 1999). Proper rest, hydration, and
nutrition are critical, as well as antibiotics to cover the
common bacterial pathogens (Streptococcus pneumo-
niae, Mycoplasma pneumoniae, Legionella pneumoniae,
Chlamydia pneumoniae, Haemophilus influenzae).
First line therapy includes azithromycin (500 mg for
one day then 250 mg a day for 4 days), or clar-
ithromycin (500 mg bid for 7–14 days). One may also
consider a flouroquinolone with increased S. pneumo-
niaeactivity such as levafloxacin (500 mg qd for
7–14 days), an oral second-generation cephalosporin
such as cefuroxime (250–500 mg bid for 7–14 days),
amoxicillin/clavulanate (875 mg bid for 7–14 days),
or doxycycline (100 mg bid for 7–14 days) (Gilbert,
Moellering, and Sande, 2002).
- Pneumonia patients, by virtue of their damaged pul-
monary parenchyma, will require more time to recover
and return to full training. Absolute rest while the
patient is symptomatic is critical to avoid prolonged
illness, pulmonary abscess, and empyema (McDonald,
1997).
SORE THROAT
- Common infectious causes of acute pharyngitis include
viral URIs, group A beta-hemolytic strep (GABHS),
infectious mononucleosis(IM), and enterovirus infec-
tions, like coxsackievirus, which have been linked to
infectious myocarditis (Perkins, 1997; Francis, 1995).
- History should cover time of onset, ill contacts, pres-
ence of cough and/or fever, difficulty swallowing, and
difficulty speaking.
- On examination look for tonsillar erythema and exu-
dates, asymmetric tonsillar swelling, ulcerations, palatal
petichiae, fever, cervical adenopathy, and splenomegaly.
- The most common etiology is viral (Perkins, 1997).
Symptomatic treatment with warm salt water gargles,
humidified air, throat lozenges, and analgesics is often
all that is needed.
•A rapid strep test gives a quick diagnosis of GABHS
pharyngitis. If negative, then a throat culture should be
done and the patient treated if positive (Perkins, 1997).
- The combination of sore throat, fever, cervical
adenopathy, tonsillar exudates, and absence of cough
suggests a greater than 50% likelihood of strep throat
and warrants empiric treatment (Perkins, 1997).
- Penicillin (500 mg bid for 10 days) remains the drug
of choice for GABHS. Second line choices include
azithromycin (500 mg qd for 1 day and then 250 mg
a day for 4 days) or erythromycin (250 mg qid for
10 days)(Perkins, 1997). Antibiotics hasten recovery,
render the patient noninfectious after 24 h, and protect
against rheumatic fever (McDonald, 1997).
- IM, caused by Ebstein-Barr virus(EBV), occurs most
commonly between ages 15 and 24 and affects 1–3%
of college students each year (Maki and Reich, 1982).
•Typical symptoms include a 3–5-day prodrome of
headache, anorexia, and malaise, followed by sore
throat, fever, lymphadenopathy, and fatigue lasting
typically 2 weeks. Anorexia, nausea, fatigue, and
malaise are often present for longer, and can lengthen
an athlete’s return to preillness training levels by up to
3 months (Maki and Reich, 1982).
