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Upper Respiratory Infection

Helpful Steps for Physicians

John W. O'Kane, MD

Practice Essentials Series Editors:
Kimberly G. Harmon, MD; Aaron Rubin, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 9 - SEPTEMBER 2002


In Brief: Upper respiratory infections (URIs) are extremely common in adults. Most adults have multiple URIs each year, with athletes being more or less susceptible, depending on training intensity. Most URIs are viral nasopharyngeal infections that will improve in 7 to 10 days with symptomatic treatment and result in little time lost from athletic participation. Physicians must recognize the symptoms consistent with bacterial pharyngitis, infectious mononucleosis, and sinusitis to provide appropriate diagnostic testing, treatment, and return-to-play recommendations.

Upper respiratory infections (URIs), including viral rhinitis (common cold), pharyngitis, and sinusitis, are among the most common medical complaints in most training room clinics. Tips for recognizing and treating these illnesses in athletes can aid practitioners.

The Exercise-URI Connection

Most URIs are caused by viruses. Athletes engaged in moderate regular training appear to have increased resistance to infection, while those engaged in heavy training are more susceptible to infection. A study by Nieman et al1 of 2,311 marathon runners revealed that those who trained more than 96 km/wk were twice as likely to have URI symptoms compared with those who trained less than 32 km/wk. In the week following the race, participants were nearly six times more likely to report URI symptoms than a control group of runners who did not run in a marathon. Similar results have been seen in other studies. Less evidence exists to show that moderate exercise protects against URIs, but small trials comparing walkers with sedentary controls have shown a lower incidence of URI symptoms among walkers.2

It is not known exactly how exercise affects immune function, although some evidence suggests that heavy training can reduce salivary immunoglobulin (Ig) A and IgM levels and the number of natural killer cells.3 In addition, reduction of certain salivary IgA subclasses in swimmers resulted in a higher number of URIs.4 Some evidence indicates that supplementation with carbohydrates, vitamin C, or glutamine may partly reduce immunosuppression associated with heavy training; however, additional study is needed, particularly for vitamin C and glutamine. Supplementation studies demonstrate an attenuation of cortisol elevation and an increased number of leukocytes and lymphocytes in distance runners who consumed a carbohydrate-containing beverage before and during prolonged bouts of endurance activity.5 Good evidence exists for increased immunosuppression induced by poor nutrition and increased psychological stress associated with heavy training.2

Infectious Rhinitis (Common Cold)

On average, adults have two to four colds each year, with most occurring during the winter.6 The two most likely methods of transmission are hand contact with infectious secretions, followed closely by inoculation through hand contact with the eyes or nose. Viruses can be spread directly through aerosolized droplets. Athletes who train in close quarters are susceptible to URIs. Cleaning shared equipment between users and improving ventilation can help prevent the spread of infection (See the Patient Adviser, "Coping With Upper Respiratory Infections").

Causes and treatment. Viruses cause most cases of infectious rhinitis, with rhinovirus being the most common agent. Typical symptoms include mild chills and fatigue followed within a day by clear rhinorrhea, mild sore or scratchy throat, congestion, cough, and headache. Sinus pain and pressure are common early symptoms. Severe sore throat, significant myalgias, high fever, and deep productive cough are uncommon. Rhinorrhea may become purulent, a finding that is not, by itself, an indication of bacterial superinfection. Symptoms generally improve after 5 to 7 days and abate within 10 to 14 days.

Common exam findings include normal vital signs, an occasional low-grade fever (<101°F), either clear or purulent rhinorrhea, mild sinus tenderness, mild throat erythema with or without postnasal drip, shotty cervical lymphadenopathy, and clear lungs. When characteristic symptoms are present, no further diagnostic workup is necessary. Antibiotics have no role in the treatment of viral rhinitis. Oral decongestants and acetaminophen, ibuprofen, or naproxen sodium are used primarily for symptomatic relief, but no evidence shows that they shorten the duration of infection.

Confounding illnesses. With chronic or remitting symptoms, allergic rhinitis enters the differential. The symptoms of allergic and infectious rhinitis overlap, but allergic rhinitis may involve a family history and seasonal or perennial symptoms. Other findings may include watery, itchy, or erythematous conjunctiva, atopic dermatitis, and asthma. Oral antihistamines are common first-line treatment for allergic rhinitis, although nasal corticosteroids treat congestion more effectively.7

Less common than allergic rhinitis, vasomotor rhinitis is not precipitated by allergies. Vasomotor rhinitis produces perennial symptoms, no other allergic symptoms, and nasal discharge free of eosinophils. Topical ipratropium may be effective for vasomotor rhinitis. If symptoms do not improve, one should also consider antimigraine treatments, as vasomotor rhinitis can fall within the spectrum of migraine-variant symptoms.

Acute bronchitis is characterized by a chronic productive cough lasting 1 week to 1 month, usually following typical URI symptoms. It is caused by infection of the lower respiratory tract with airway inflammation and edema but deserves mention because of its association with URIs. The etiology is nearly exclusively viral, although occasional Mycoplasma or Chlamydia pneumoniae are implicated. In healthy adults, little evidence shows that antibiotics are of any significant benefit, even in cases of Mycoplasma or C pneumoniae. In their meta-analysis of 8 trials, Bent et al8 did not find sufficient evidence to recommend antibiotic treatment. Inhaled albuterol for 7 days has shown to reduce the length and severity of cough.9

Rhinitis medicamentosa, a syndrome characterized by rebound congestion and rhinitis from prolonged topical nasal decongestant usage, should be included in the differential diagnosis. Topical decongestants should be reserved for athletes in whom excessive symptoms persist despite oral decongestants or for athletes experiencing excessive sympathetic side effects. These agents are also helpful for congested athletes with increased ear or sinus pressure who are flying to events. Use should be limited to 5 days or less. Overtraining syndrome should also be considered in athletes with chronic relapsing URI symptoms.

Return-to-play guidelines. Different sports governing bodies restrict the use of some prescription and nonprescription cold medications. Physicians caring for athletes must familiarize themselves with these regulations. In addition:

  • No restriction from participation is necessary with rhinitis. Symptomatic treatment will improve the athlete's sense of well-being and, possibly, performance.
  • A day or two of rest from heavy training early in the course of significant URI symptoms may result in more rapid improvement and limit the opportunity for viral transmission among athletes.
  • Athletes with systemic symptoms (fever, myalgias, significant fatigue) or lower respiratory symptoms (deep cough, wheezing, shortness of breath) should have participation restricted until the symptoms improve. Athletes are often reluctant to miss training for any reason, and they appreciate the physician's "permission" to rest and recover.

Pharyngitis

Viral rhinitis and viral pharyngitis have some overlapping symptoms and etiology. A common cold caused by rhinovirus, coronavirus, parainfluenza virus, or respiratory syncytial virus will often produce throat erythema, scratchiness, and mild pain. Significant pharyngeal pain and vesiculation are common with herpes simplex or coxsackievirus. Adenovirus causes high fever, significant pharyngeal erythema, and swelling (associated with conjunctivitis 50% of the time).6 Treatment and return-to-play recommendations are the same as those for viral rhinitis. Athletes with pharyngeal swelling sufficient to cause airway compromise should not participate.

Streptococcal infections. Group A streptococcus (GAS) is responsible for up to 20% of acute pharyngitis cases during its peak incidence in winter through early spring. Classic symptoms include significant sore throat, fever, and tender anterior cervical lymphadenopathy. Occasionally, nausea and abdominal pain are present, while cough, congestion, conjunctivitis, and diarrhea are usually absent. The throat often appears erythematous with exudate and, occasionally, petechiae. More than 50% of adults with pharyngitis and classic symptoms during the winter months will have GAS.10 Centor and Witherspoon11 demonstrated that 56% of those presenting with a sore throat and swollen tender anterior cervical nodes, lack of cough, history of fever, and tonsillar exudates will have a positive GAS culture. Likelihood of a positive culture drops to 32% in patients with three of these four findings, 15% in those with two of four findings, and to only 6% in those with one of four findings.

Whether or not to perform a rapid antigen test or throat culture is a matter of debate. In general, the recommendation suggests testing only for patients who present with classic symptoms. Patients with suggestive symptoms may begin antibiotic therapy, pending test results, but should stop treatment if tests for GAS are negative. Most authorities tend to discourage empiric treatment without testing, even when suggestive symptoms are present, since nearly half of patients with symptoms will not have GAS.12

Rapid antigen tests for GAS have a sensitivity of up to 90%, although some studies have suggested lower sensitivities in clinical practice.13 Culture of samples from throat swabs on sheep blood agar is the gold standard for diagnosis. The 1997 AAP Red Book suggests that a positive antigen test suffices for diagnosis but that a negative test result should trigger a throat culture.14 Alternative bacterial causes of pharyngitis in high school and college athletes include groups C and G streptococcus and mycoplasma—and herpes simplex virus, chlamydia, and gonorrhea if athletes are sexually active.

Treatments and testing. Penicillin VK (1 g/day, divided bid or qid) for 10 days continues to be the drug of choice for GAS, but amoxicillin (250 to 500 mg tid) may be substituted. Macrolides are the traditional alternatives if patients are allergic to penicillin, and these drugs can also be used to treat mycoplasma and chlamydia infection. Treatment should be instituted to decrease the length of symptoms and contagious period as well as to decrease the likelihood of rare GAS nonsuppurative complications, acute rheumatic fever, and poststreptococcal glomerulonephritis. Historically, acute rheumatic fever occurred in about 3% of patients with untreated GAS pharyngitis,15 although antibiotics have lowered the incidence significantly. Rarely, nephritogenic strains of GAS cause glomerulonephritis about 10 days after the onset of pharyngitis. Epidemiologic studies suggest that the frequency of the disorder is decreasing with early antibiotic treatment of pharyngitis.16

Athletes presenting with pharyngitis and suggestive symptoms should have a rapid antigen test. If initial tests are negative, follow-up culture is warranted. Penicillin VK (500 mg bid) can be started at the initial encounter but should be discontinued if the culture is negative. Regardless of the patient's streptococcal status, symptomatic treatment including acetaminophen, ibuprofen, or naproxen and throat lozenges is often helpful. If the pharyngitis is not improved after 10 to 14 days, physicians should reconsider the possibility of mononucleosis (see the next section) and consider empiric treatment with a macrolide for possible atypical bacterial pharyngitis.

Return-to-play guidelines. For confirmed cases of GAS pharyngitis, athletes should be restricted from participation until they are afebrile and have been taking antibiotics for 24 hours. People who have been in close contact have a 20% to 50% chance of becoming infected based on studies within families,17 so the quarantine is as much for the team as for the ill athlete. Contacts who are symptomatic may be treated without culture and should be separated from the team, if possible, for the first 24 hours of therapy. Prevention should also focus on hand washing and not sharing oral items, including water bottles, mouthguards, and toothbrushes.

Infectious Mononucleosis

One additional viral cause of pharyngitis that deserves some mention is infectious mononucleosis due to Epstein-Barr virus (EBV) or, less commonly, cytomegalovirus (CMV) infection. Classic presenting symptoms include sore throat with tonsillar hypertrophy and exudate, significant lymphadenopathy, and fatigue. Some athletes also complain of left-sided abdominal discomfort from splenomegaly. Pharyngitis generally resolves by 2 weeks, and constitutional symptoms, with the exception of fatigue, resolve by 1 month. Fatigue commonly persists for at least 2 months with gradual improvement over 6 months; 90% of patients are asymptomatic after 6 months.18

Concerns for athletes. Multiple rare complications can occur and will not be presented here (see "Infectious Mononucleosis: Ensuring a Safe Return to Sport"), but two complications relevant for athlete care are severe tonsillar hypertrophy that may cause airway compromise and splenic rupture. If splenic rupture occurs, it usually does so between weeks 2 and 4 of the illness. Rupture, however, is rare, with a reported incidence of 1 in 1,000 cases, although clinical experience suggests a lower incidence.19 Splenic rupture usually occurs without trauma, but there is a risk of injury with contact sports when the spleen is enlarged.

Tests and treatment. Laboratory evaluation generally reveals a white blood cell count of 10,000 to 20,000/mm3 with increased atypical lymphocytes and, generally, mild elevations in alanine transaminase and aspartate transaminase levels. A positive heterophile antibody (Monospot) test is diagnostic and is positive in nearly 90% of patients by the third week of symptoms, but the test is positive only 40% of the time in the first week of symptoms.20 Serologic tests for EBV and CMV IgM and IgG can provide direct evidence of acute or prior infection. EBV IgM is present in the serum of more than 90% of individuals in the first week of infection.

Treatment is generally a minimum of 3 to 4 weeks relative rest from symptom onset, with gradual return to activity as tolerated. Corticosteroids are not usually recommended except with airway compromise, when the drugs can significantly decrease tonsillar hypertrophy.

Return-to-play guidelines. Physicians can ensure that athletes can have a safe return to sports by following these rules:

  • Athletes are generally restricted from training and competition for 3 to 4 weeks. In addition, returning athletes should have elevated transaminase levels returning to normal, other systemic symptoms improving, and spleens of normal size by clinical exam.
  • Traumatic splenic rupture is the most feared complication of premature return to sports. As a result, most authorities suggest that return to collision sports should be delayed for 4 to 6 weeks. In this setting, a "confirmatory ultrasound" to document a normal spleen may be helpful.
  • In endurance sports, it is not uncommon for athletes to be unable to train for 2 months or more. This is very frustrating for elite athletes, and an early return often worsens fatigue. It is helpful to meet weekly with athletes until they have fully recovered to monitor their progress and to encourage a gradual return to training.

Sinusitis

Sinusitis implies bacterial infection of one of the paranasal sinuses, usually maxillary or less commonly ethmoidal. Viral infection or allergy causes mucosal thickening with osteomeatal obstruction. Air is then absorbed from the sinus, and the resulting negative pressure causes retrograde flow of mucosal secretions and bacteria, creating an ideal environment for bacterial proliferation. Temporary osteomeatal obstruction resulting in computed tomography (CT)-confirmed fluid accumulation in the sinuses is a normal response to viral rhinitis in 87% of cases,21 but if sufficient bacterial proliferation occurs, prolonged bacterial sinusitis is the result.

Symptoms. Sinusitis most often manifests as "cold" symptoms that persist longer than normal. Generally, sinusitis should not be diagnosed in the first 5 days of symptoms. If fever and symptoms are increasing after 5 to 7 days or are no better after 10 days, sinusitis becomes more likely. Symptoms consistent with bacterial sinusitis include a history of purulent rhinorrhea, URI symptom improvement followed by relapse, unilateral sinus pain, periorbital pain with leaning forward, purulent postnasal drip on exam, poor response to decongestants, and maxillary toothache. A clinical diagnosis is 55% to 75% accurate when based on the preceding symptoms.22 The gold standard for diagnosis is percutaneous sinus aspiration and culture, an impractical procedure for routine diagnostic use.

Tests and treatments. Because sinusitis is a clinical diagnosis, imaging is not routinely needed, but CT and plain radiography have a role in recurrent and chronic disease or when the diagnosis is in question. X-ray findings consistent with sinusitis include mucosal thickening greater than 4 to 6 mm, altered air-fluid levels, and sinus opacification. Traditionally, four x-ray views are used, but a Veteran Administration study23 demonstrated comparable sensitivity of 88% using only a Water's view. CT allows better visualization of the sinuses and is better for assessing chronic disease, especially if surgery is being considered.24

Antibiotics are the initial treatment for bacterial sinusitis, although more than 60% of cases will resolve without such therapy.6 In adolescents and adults, acute sinusitis is generally caused by S pneumoniae, M catarrhalis, and Haemophilus influenzae, while chronic sinusitis is caused by a broader spectrum of organisms, including anaerobes. The traditional antibiotic course is 2 weeks, although some studies have suggested that shorter courses may be sufficient.25 Amoxicillin (250 to 500 mg tid or 40 mg/kg/day divided tid) is the standard first-line treatment, although some physicians prefer to use trimethoprim-sulfamethoxazole for its extended coverage of Gram-negative organisms and more favorable dosing schedule (bid). Increasing resistance among S pneumoniae isolates has led some to recommend amoxicillin at double the standard dose, amoxicillin plus amoxicillin-clavulanate, a second- or third-generation cephalosporin, or a second-generation fluoroquinolone as the second-line treatment, or even as first-line therapy in settings of documented high resistance.

Other therapy and diagnoses. Adjunctive therapy for sinusitis includes analgesics, antihistamines, nasal corticosteroids, and decongestants. Analgesics and decongestants both help with symptoms, but neither has been shown to shorten illness course or to prevent bacterial superinfection in the setting of viral rhinitis. Some concern exists about mucous thickening with antihistamines, a condition that could worsen sinus obstruction. Topical corticosteroids are often recommended, although the evidence suggests they are only beneficial if allergic rhinitis is a contributing factor.

Bacterial sinusitis is unlikely unless symptoms have been present for at least 7 days, so "sinus symptoms" should initially be treated as viral rhinitis. If the symptoms do not improve between 7 to 10 days and are consistent with sinusitis, consider antibiotics. If symptoms do not improve after a week of treatment, review the history and exam for allergy or asthma symptoms, consider a chest x-ray for a productive cough with shortness of breath, and order a Water's view if sinusitis is still likely. If sinusitis is detected on the x-ray, consider second-line antibiotics. Antibiotic failures with recurring episodes of sinusitis are often caused by inadequately treated underlying allergies or anatomic abnormalities that prevent normal sinus drainage.

Return-to-play guidelines. Recommendations are not significantly different than those for viral rhinitis and include:

  • Athletes can participate provided they do not exhibit significant systemic symptoms.
  • Anecdotal reports show that both nasal corticosteroids and decongestants can reduce sinus pressure during air travel.
  • Scuba diving should be restricted until sinus symptoms have resolved because of the risk of barotrauma.

The Current State of Affairs

URIs are exceedingly common in sports and, fortunately for the athlete, are usually a short-term aggravation rather than a significant medical limitation. Symptomatic treatment with continued participation is the rule, but athletes with systemic viral symptoms should avoid excessive exertion. Persistent rhinitis should alert physicians to the possibility of allergies or other nonviral causes of rhinitis. Pharyngitis consistent with GAS or mononucleosis should be evaluated expeditiously, then treated appropriately. Antibiotics should not be used presumptively or as prophylaxis for viral URIs, but when prolonged and characteristic symptoms are present, bacterial sinusitis should be considered.

References

  1. Nieman DC, Johanssen LM, Lee JW, et al: Infectious episodes in runners before and after the Los Angeles Marathon. J Sports Med Phys Fitness 1990;30(3):316-328
  2. Nieman DC: Exercise and resistance to infection. Can J Physiol Pharmacol 1998;76(5):573-580
  3. Gleeson M, McDonald WA, Pyne DB, et al: Immune status and respiratory illness for elite swimmers during a 12-week training cycle. Int J Sports Med 2000;21(4):302-307
  4. Gleeson M, Hall ST, McDonald WA, et al: Salivary IgA subclasses and infection risk in elite swimmers. Immunol Cell Biol 1999;77(4):351-355
  5. Nehlsen-Cannarella SL, Fagoaga OR, Nieman DC, et al: Carbohydrate and the cytokine response to 2.5 h of running. J Appl Physiol 1997;82(5):1662-1667
  6. White CB, Foshee WS: Upper respiratory tract infections in adolescents. Adolesc Med 2000;11(2):225-249
  7. Dykewicz MS, Fineman S, Skoner DP, et al: Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 1998;81(5 pt 2):478-518
  8. Bent S, Saint S, Vittinghoff E, et al: Antibiotics in acute bronchitis: a meta-analysis. Am J Med 1999;107(1):62-67
  9. Hueston WJ: Albuterol delivered by metered-dosed inhaler to treat acute bronchitis. J Fam Pract 1994;39(5):437-440
  10. Wald ER, Green MD, Schwartz B, et al: A streptococcal score card revisited. Pediatr Emerg Care 1998;14(2):109-111
  11. Centor RM, Witherspoon JM: Treating sore throats in the emergency room: the importance of follow-up and decision making. Med Decis Making 1982;2(4):463-469
  12. Bisno AL, Gerber NM, Gwaltney JM Jr, et al: Diagnosis and management of group A streptococcal pharyngitis: a practice guideline. Infectious Diseases Society of America. Clin Infect Dis 1997;25(3):574-583
  13. Dowell SF, Schwartz B, Phillips WR: Appropriate use of antibiotics for URIs in children: part 2. cough, pharyngitis and the common cold. The Pediatric URI Consensus Team. Am Fam Physician 1998;58(6):1335-1342, 1345
  14. Peter G: Group A streptococcal infections, in Red Book: Report of the Committee on Infectious Diseases, ed 23. Elk Grove Village, IL, American Academy of Pediatrics, 1994, pp 483-494
  15. Kaplan EL: Rheumatic fever, in Fauci AS, Braunwald E, Isselbacher KJ, et al (eds): Harrison's Principles of Internal Medicine, ed 14. New York City, McGraw-Hill, 1998, pp 1309-1310
  16. Brady BR, O'Meara YM, Brenner BM: The major glomerulopathies, in Fauci AS, Braunwald E, Isselbacher KJ, et al (eds): Harrison's Principles of Internal Medicine, ed 14. New York City, McGraw-Hill, 1998, pp 1537-1538
  17. Bass JW: Antibiotic management of group A streptococcal pharyngotonsillitis. Pediatr Infect Dis J 1991;10(10 suppl):S43-S49
  18. Rea TD, Russo JE, Katon W, et al: Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract 2001;14(4):234-242
  19. Eichner ER: Infectious mononucleosis: recognizing the condition, 'reactivating' the patient. Phys Sportsmed 1996;24(4):49-54
  20. Cohen JI: Epstein-Barr virus infections, including infectious mononucleosis, in Fauci AS, Braunwald E, Isselbacher KJ, et al (eds): Harrison's Principles of Internal Medicine, ed 14. New York City, McGraw-Hill, 1998, pp 1089-1091
  21. Gwaltney JM Jr, Phillips CD, Miller RD, et al: Computed tomographic study of the common cold. N Engl J Med 1994;330(1):25-30
  22. Fagnan LJ: Acute sinusitis: a cost-effective approach to diagnosis and treatment. Am Fam Physician 1998;58(8):1795-1802, 1805-1806
  23. Williams JW Jr, Roberts L Jr, Distell B, et al: Diagnosing sinusitis by x-ray: is a single Waters view accurate? J Gen Intern Med 1992;7(5):481-485
  24. Parsons DS: Chronic sinusitis: a medical or surgical disease? Otolaryngol Clin North Am 1996;29(1):1-9
  25. Williams JW Jr, Holleman DR Jr, Samsa GP, et al: Randomized controlled trial of 3 vs 10 days of trimethoprim/sulfamethoxazole for acute maxillary sinusitis. JAMA 1995;273(13):1015-1021

Dr O'Kane is an assistant professor in the department of orthopedics and sports medicine and head team physician at the University of Washington in Seattle. Address correspondence to John W. O'Kane, MD, University of Washington Sports Medicine, Box 354060, Seattle, WA 98195-4060; e-mail to [email protected].

Disclosure information: Dr O'Kane discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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