Possible medical complications in athletes who exercise during an infective illness

Transcription

1 IOC Advanced Team Physician Course 2017, Antalya, Turkey Possible medical complications in athletes who exercise during an infective illness Prof. Martin Schwellnus Professor of Sport and Exercise Medicine, Faculty of Health Sciences, University of Pretoria, South Africa

2 Outline 1. The Basics 2. Acute infective illness and reduced exercise performance 3. Acute infective illness and risk of medical complications 1. Take home messages!

3 Athlete Infection / acute illness

4 Multi-system physiological response to exercise

5 Host (Athlete) response to infection Microbe invasion Microbe specific host response Non specific host response End organ / system tissue injury Immune response Cellular release of proinflammatory cytokines by macrophages and other cells Reduced exercise performance Medical complications

6 Non-specific response Acute Phase Response The acute phase response (APR) is a prominent systemic reaction of the organism to local or systemic disturbances in its homeostasis caused by infection (and tissue injury, trauma / surgery, neoplastic growth or immunological disorders) Gruys E, et al. J Zhejiang Univ, B(11)

7 Acute Phase Response to Infection Microbe invasion Endocrine / metabolic Skeletal muscle Neuromuscular CNS Brain / Brain Liver Altered motor endplate function Fatigue / malaise Muscle breakdown Negative nitrogen balance Altered thermoregulation Anorexia Pathogen opsonisation

8 Clinical manifestations (and biomarkers) of the APR Clinical assessment Anorexia Malaise (fatigue) Fever Dehydration Increased heart rate (rest and exercise) Altered muscle function: o Loss of muscle mass o Decreased muscle function o Reduced neuromuscular control o Reduced substrate availability for muscle during exercise Biomarkers of APR Increased plasma viscosity Raised ESR Increased CRP Increased procalcitonin (PCT)

9 Acute Phase Response and negative nitrogen balance (muscle breakdown) Viral Bacterial Parasitic Friman G, Wesslen L: Immunol Cell Biol; 2000, 78;

10 Hrs to 3 days Acute Phase Proteins Timing of Biomarkers

11 2. Microbe specific response - tissue injury Microbe specific host response 1. End organ / system tissue injury 2. Immune response Microbe invasion Microbe specific common infections in athletes 1. Respiratory / ENT 2. Gastrointestinal 3. Dermatological 4. Urogenital tract 1. Microbe specific 2. Single or multi organ (tissue) 3. Localised and/or systemic 4. Varied duration and severity of damage

12 Acute infective illness and exercise performance (lab studies) Decreased isometric strength by 5-15% Reduced substrate availability for working muscle Decreased muscle endurance 13-18% Reduced endurance capacity up to 25% Decreased neuromuscular control

13 DNF rate (per 100 runners in each group) Self reported acute pre-race (1-2 weeks) illness and race completion in > 6000 runners (systemic vs. localized infection) (Did not finish rate - % runners started) 3 2,5 2 1,5 1 0,5 *: Significantly different from CON group Runners with self-reported symptoms of systemic 1,3 illness had 2 X greater chance of not completing the race 2,1 2,4 * 0 CON (n=5 316) Localized (n=741) Systemic (n=450) Van Tonder A, Schwellnus M, et al; BJSM (15),

14 Physician diagnosed acute pre-race illness and race completion (localised vs. systemic) (Did not finish rate - % runners started) 1. Illness determinants and race perfromance: *: Significantly different from CON group localised vs. systemic time of diagnosis before the race 2. Runners with physician diagnosed systemic illness < 24 hours before the race had a 7 X greater chance of not completing the race * * Gordon L, Schwellnus M, et al; BJSM 2017;51:

15 Potential medical complications of an acute infective illness during exercise (APR and end organ injury) Thermoregulatory Altered set point Heatstroke Respiratory Prolonged illness Bronchial hyperreactivity Cardiovascular Viral myocarditis Myopericarditis Medication use Renal Rhabdomyolysis / Dehydration Acute renal injury / failure Other Organomegaly Chronic fatigue Neuromuscular Rhabomyolysis Joint, ligament, muscle injuries

16 Take home messages!! 1. Microbe invasion in an athlete results in: non specific systemic acute phase response (APR) microbe specific tissue injury 2. The systemic APR together with specific tissue injury: reduces exercise performance Increases the risk of medical complications 3. NB: Be aware of risk of medical complications during exercise with specific infections: Viral myocarditis and sudden death Infective illness and exertional heatstroke Rhabdomyolysis IM and splenic rupture Bronchial hyper- reactivity and respiratory illness Session 10: Wednesday Clinical assessment to reduce risk of medical complications Return to sport: Evaluate for APR Evaluate for suspected microbe specific tissue injury

17 Thank you for your attention 1. Acute phase 2. Microbe specific end organ injury Reduced exercise performance Microbe invasion Medical complications Endocrine / metabolic Neuromuscular Liver Skeletal muscle 1. Acute phase 2. Microbe specific end organ injury Altered motor endplate function Fatigue / malaise Altered thermoregulation Anorexia Pathogen opsonisation Breakdown