CHAPTER 31 • INFECTIOUS DISEASE AND THE ATHLETE 179- If indicated by the algorithm in Fig. 31-2, ultrasound
measurement of the spleen to left kidney ratio (Loftus
and Metreweli, 1998) every two weeks can be useful,
especially in athletes at the extremes of body habitus.
A ratio of less than 1.25 is normal.
ACUTE DIARRHEA
- Diarrhea is >3 loose stools a day for up to 7 days
(Mayer and Wanke, 1999) and is most often caused by
a viral infection. Other causes to consider include
hyperthyroidism, inflammatory bowel disease, bacte-
rial colitis, and antibiotic-induced colitis. - The history should focus on travel, hobbies, animal con-
tacts, antibiotic usage, dietary habits, and ill contacts.
The review of systems should cover stool appearance
(mucous, bloody, or watery), fever, weight loss (acute
and chronic), and abdominal pain (Mayer and Wanke,
1999). - Stool examination for fecal leukocytes, ova and par-
asites, and occult blood and C. difficiletoxin (if
indicated),are helpful in identifying the cause. Five
or more fecal leukocytes per high-powered field sug-
gests bacterial colitis (Mayer and Wanke, 1999). - Most cases can be treated with oral rehydration, but
severe cases may require intravenous hydration
(Mayer and Wanke, 1999). - Antidiarrheal agents may be used, and include lop-
eramide (4 mg ×1, then 2 mg after each loose stool,
maximum 16 mg a day), and bismuth subsalicylate
(262 mg, 2 qid prn). Loperamide should be avoided in
patients who are toxic, febrile, or are having bloody
diarrhea. Lomotil contains atropine and causes anti-
cholinergic side effects (Fenton, 2000). - The decision to use antibiotics empirically remains in
the hands of the provider. Bacterial colitis (Salmonella,
Shigella, E. coli, Campylobacter) can be treated
with ciprofloxacin (500 mg bid) or trimethoprim-
sulfamethoxazole DS (1 bid) for 3–5 days. Salmonella
should not be treated unless the illness is severe or the
patient is immunocompromised as antibiotic treatment
may prolong the carrier state. C. difficileis treated with
metronidazole (500 mg tid) or vancomycin (125 mg
orally qid) for 10–14 days (Gilbert, Moellering, and
Sande, 2002).
HIV INFECTION
- In HIV+ patients, moderate and high intensity aero-
bic exercise programs do not change leukocyte,
lymphocyte,CD4, and CD8 counts or the CD4:CD8
ratio (Terry, Sprinz and Ribeiro, 1999). Progressive
resistance training increases lean body mass and
physical functioning in patients with HIV-associated
wasting (Roubenoff and Wilson, 2001). Regular exer-
cise is associated with slower progression to AIDS
and decreased short-term mortality (Mustafa, 1999).
•Patients with a CD4 count <200 or an AIDS defining-
infection, however, should be limited to moderate
exercise (Stringer, 1999).- Documented sports transmission of HIV is exceed-
ingly rare. The risk of HIV transmission in profes-
sional football is estimated at one in 85 million game
contacts (Feller and Flanigan, 1997). - In 1995, the American Medical Society for Sports
Medicine (AMSSM) and the American Academy of
Sports Medicine (AASM) stated that mandatory HIV
testing should not be a requirement for competitive
sports participation, though they strongly encourage
counseling and voluntary testing in individuals at high
risk (AMSSM and AASM, 1995). - The National Collegiate Athletic Association (NCAA)
mandates removal of bloody uniforms and covering
open wounds prior to returning to competition.
Universal precautions are the norm in dealing with
any blood or body fluid (Feller and Flanigan, 1997).
RETURN TO PLAY- Experimental rhinovirus infection does not decrease
pulmonary function tests, VO2max, or submaximal
exercise testing (Weidner et al, 1997). Exercise during
such an infection does not alter its length or severity
(Weidner et al, 1998). Other respiratory viruses, such
as influenza virus (Blair et al, 1976; O’Connor et al,
1979), however, have been shown to impair pul-
monary function. - The “neck check” (Eichner, 1993; Primos, 1996)
helps guide return to play decisions. If symptoms are
above the neck (i.e., runny nose, nasal congestion,
sore throat, or sneezing) and not associated with
below the neck symptoms (i.e., fever, myalgias,
arthralgias, severe cough, GI symptoms), then the ath-
lete may train at half intensity for 10 min. If symp-
toms do not worsen, then the workout may continue as
tolerated. If symptoms worsen, the workout should
end and the athlete should rest until symptoms
improve. Exercise should be delayed until below the
neck symptoms have resolved (Eichner, 1993). - When resuming training after recovering from an ill-
ness, the athlete should start at a 50% intensity and grad-
ually increase to preillness training levels over 1–2 days
for every training day missed (Primos, 1996).
•Training delay serves three purposes. First, training
with below the neck symptoms hampers the workout
and limits desired training effects. Second, without a
medical evaluation athletes may not realize the severity