So do we call them extreme infections?

It’s no secret that the “extreme athlete” industry continues to steamroll mainstream athletics. This isn’t a new trend, as evidenced by the fact that this review article is from 2007. Sorry for making everyone feel old by reminding them that CrossFit® is now 14 years old.

Anyway, extreme athletics involves taking classic sports and making them longer distances, more difficult, in austere locations, or combining multiple events into one. You also are required by law to say “extreme” in a loud, guttural voice. Due to the terrains, climates, and exotic locales involved in these sports, the extreme athlete is exposed to infections the typical (normal?) athlete isn’t. These are broken down in the article into parasitic, aquatic, tick-borne, and zoonotic infections. It’s not an exhaustive list, but is fairly extensive and thus only the surface will be scratched here.

Parasitic infections are important because diarrheal illness obtained almost everywhere except Southeast Asia is more likely to be parasitic than bacterial. Malaria gets emphasized by the article and should certainly never be missed. Certainly, fever and eosiniphilia in any returning traveller needs to be investigated further for all parasites. Other causative agents described are amebae, nematodes, and cutaneous larvae. The last one is interesting, as athletes are more likely to have broken skin and thus be susceptible to myiasis than typical tourists. An important point is that you must be aware of the endemic parasites where the athlete is intending to travel, and understand prevention, diagnosis, and treatment.

Ingested water can also be problematic, as Giardia, Cryptosporidium, and Schistosoma are common in the surface water of many areas. Since the incubation period can be as long as 40 days, good history taking is important. Schistosoma in particular can be nasty, with pulmonary, urologic, hepatic, and even neurologic manifestations, so one does not want to miss this infection. Again, treatment is organism specific.

Aquatic infections are common as well. These can come from any break in the skin that is exposed to water, including but not limited to bites, coral injuries, and stings. These must all be irrigated copiously, but empiric antibiotics should not be started. If a secondary infection does occur, due to atypical organisms, cultures should be obtained before giving antibiotics. They mention considering delayed wound closure, but this is falling out of favor in the years since the article and I wouldn’t recommend it unless there is serious contamination and no irrigation media available.

Tick-borne diseases, such as Lyme, Rocky Mountain Spotted Fever, babesiosis, and ehrlichiosis are yet another problem the extreme athlete has to consider. Using DEET is probably your best prevention, and whole body examination after potential exposure is a must. Infection usually takes 24-48 hours of attachment, so early detection is key. Just don’t do anything silly like use gasoline, KY, or fire to remove the tick. Use forceps, and get all of it. And as has been discussed, you should prophylax with 200 mg doxycycline if you remove a tick from someone in Lyme endemic areas.

The last grouping of infections is the zoonoses, but only 2 types are mentioned. The first, leptospirosis, can be found in many farm animals and rodents. As it is shed in their urine, it can be acquired from contaminated groundwater. They mention two specific outbreaks, one Illinois triathlon where 12% of the participants (98/834) contracted the disease, and an Eco-Challenge in Malaysia where a whopping 44% of athletes (69/158) had symptoms consistent with leptospirosis. Hantaviruses, usually associated with campers, are mentioned for what is presumably completeness sake. Treatment is supportive at best, although they mention ribavirin treatment based on only one reference.

They finish the article with sound advice on insect repellent, treating drinking water, and obtaining evacuation insurance. It seems as if the authors wanted to ride the “extreme” sports wave by merely discussing tropical and subtropical diseases, as none of these are unique to extreme sports. Sadly, they were trying to be too encompassing and became overly bloated at 15 pages with references. It’s not a bad review article for someone not familiar with travel medicine.

Young CC, Niedfeldt MW, Gottschlich LM, Peterson CS, Gammons MR. Infectious disease and the extreme sport athlete. Clin Sports Med. 2007 Jul;26(3):473-87. [PMID 17826196]