George C. Phillips, MD

Sports Medicine Rounds

May 20, 2004

Case #1

n   Preseason physicals, 19yo freshman male

n   Baseball player, negative orthopedic exam

n   Medical history unremarkable

n   Medical exam negative

n   Oh, by the way, how can I get tested for STDs, including HIV? 

Case #1

n   History of unprotected sexual activity during the summer, multiple partners

n   No knowledge of partners’ history for STI

n   Prior testing for STIs, including HIV, in high school was negative

n   No current symptoms

Case #2

n   20-year-old recreational athlete

n   Chief complaint of fatigue, mild cough

n   Symptoms of mostly upper respiratory illness, no bowel/bladder complaints

n   Typical college student hours balancing school, work, social life

n   Exam unremarkable except mild congestion

Case #2

n   Any other questions or concerns?

n   How can I get tested for STDs?

n   New partner recently, multiple partners in the past year, inconsistent use of condoms

n   No obvious symptoms

Sexually Transmitted Infections

n   Review basic infection information

n   Testing and treatment

n   Injury management – infectious risk?

n   Routine screening? 

STIs - Epidemiology

n   Approximately 15 million persons are annually infected with a STI

n   At any one time, 65 million persons are infected with an STI

n   Total medical costs for STI (not HIV)

u $10 Billion annually

u HIV alone costs $7 Billion annually

STIs

n    Chlamydia

n    Gonorrhea (GC)

n    Syphilis

n    Herpes simplex (HSV)

Chlamydia

n   Most prevalent bacterial STI

n   In women, 46% of cases occur between ages 15-19; 33% between ages 20-24

Chlamydia

n   Chlamydia (+) women are 3-5 times more likely to contract HIV if exposed

n   40% of women with untreated Chlamydia will suffer from pelvic inflammatory disease (PID)

Chlamydia

n   Pelvic Inflammatory Disease – ascending infection along the reproductive tract; injury to uterus, fallopian tubes, ovaries

n   20% of women with PID due to Chlamydia will suffer infertility

n   18% will experience chronic pain

n   9% will have an ectopic pregnancy

Chlamydia

n    Screening: all sexually active women <25; ³ 25 years old, test if risk factors

n    Treatment:  Zithromax 1 gram, one time

n    Health costs > $2 Billion annually

u  1 dollar test/treat = 12 dollars saved in costs

Gonorrhea (GC)

n   650,000 new cases of GC each year

n   50% of males have symptoms initially

u Burning with urination, yellow-white d/c, painful/swollen testicles

u Symptoms often occur within 2-5 days of infx

n   If females have any symptoms, they are mild and often mistaken for UTI 

Gonorrhea (GC)

n   75% of reported cases occur between ages 15-19

u Women 15-19; Men 20-24

n   GC can also cause PID in women

n   Test: Urine or culture swab

n   Treatment: Cipro 500 mg, one time

n   Complications include conjunctivits, arthritis

Syphilis

n   70,000 new cases each year

n   Primary syphilis:  chancre – firm, round, small, painless lesion; heals in 1-5 weeks

n   Secondary syphilis: rash on palms/soles, flu-like symptoms

n   Latent stage: no symptoms; systemic spread

Syphilis

n   If untreated, 1/3 of latent cases will progress to tertiary syphilis

n   CNS: loss of coordination, blindness, dementia, personality changes

n   CV: aneurysms, coronary artery thrombus, impotency

Syphilis

Human Papillomavirus (HPV)

n   Most common STI among young, sexually active persons

n   5.5 million new infections annually

n   At any given time, 20 million Americans are infected with HPV

Human Papillomavirus (HPV)

n   Risk factors include:

u Younger age at first intercourse

u Multiple sexual partners (serial monogamy)

n   By age 50, at least 80% of women will have acquired HPV

n   Most cases are asymptomatic

n   Some infections result in genital warts

Human Papillomavirus (HPV)

n   Persistent infection with a high-risk strain of HPV is the #1 risk factor for cervical cancer

u HPV type 16 accounts for more than one-half of all cervical cancers

u HPV 16, 18, 31, 45 account for 80%

n   Immune system can clear HPV infections, but reactivation or reinfection can occur

Human Papillomavirus (HPV)

n   Testing:  Pap screen for women

u No test available for men

u Uncircumcised males may have increased risk

n   Treatment:  No cure

u Treat genital warts, abnormal cervical tissue

Herpes Simplex Virus (HSV)

n   From the late 1970s to the early 1990s, HSV prevalence increased 30% 

n   An estimated 19% of persons 14-49 years old are infected with HSV-2

n   Approximately 1 million new infections with HSV-2 occur each year

Herpes Simplex Virus (HSV)

n   Initial infection may result in painful ulcers

n   Most persons with HSV have no symptoms

n   HSV-1 (“Cold sores”) can also cause genital herpes

n   HSV-2 infections may have 4-5 recurrences each year

Herpes Simplex Virus (HSV)

n   Increases risk of acquiring HIV

n   Increases infectivity of person with HIV

n   Risk of neonatal infection, including meningitis

n   Testing:  Fluid from ulcer; body fluid/tissue

n   Treatment:  Anti-virals 7-10 days for initial infection (2-5x/day); 5 days for recurrence

Hepatitis B Virus

n   120,000 sexually acquired infections/year

n   Chronic infection associated with liver cancer

n   Universal immunization became part of routine schedule in 1991

u Freshman class of 2009

STIs in Iowa

HIV/AIDS in Iowa

n   Currently 1202 persons with HIV/AIDS in Iowa – 466 HIV(+) only, 736 with AIDS

n   Feb. 1983 to Mar. 2004, 1583 AIDS cases in Iowa

n   90% of persons with HIV are diagnosed between 20-49 years of age

u 23% ages 20-29

HIV/AIDS in Iowa

n   Annually, about 95-100 new HIV cases

n   Approximately 75-80 new diagnoses of AIDS each year

n   About 25-30 deaths each year

n   Jan-Mar 2004, 21 new diagnoses of HIV

u 7 cases in patients over age 49

STI Prevention

n   Abstinence and condoms

n   Early condom education is highly effective

u Sexually active teens ages 14-17

u Talk w/parent before sex – 3 times more likely to use at first intercourse

u Use condom at first intercourse – 20 times more likely to use with future intercourse

STI Prevention

n   UC-Berkley Study

u Date vignette in one of four relationships:

u One-night stand; First date; Casual non-committed relationship; Committed relationship

u 50/50 males/females; 50/50 virgin/non-virgin

u What happens next?

STI Prevention

n   For all four vignettes, only ¼ subjects said any talk about condoms would occur

n   Why not? 

u ½ said it would break the mood

n   Who would ask?

u 90% all respondents said the woman

STI Prevention

STI Prevention

n   Denver STD Clinic study of 100% condom users

n   61% of females, 53% of males had errors in condom use

n   Breakage, slippage, sex before putting on

STI Prevention

u New partner increases error rate 70%

u Multiple partners increases error rate 100%

STI Prevention

Preseason Screening

n    Common wisdom – no utility in PPE screen

n    J Adol Health 2003 – 636 high school students in New Orleans for sports exam

u  Overall prevalence 4.6% (3.2% men, 7.5% women)

u  75.9% received documented treatment at school

Risk of Contagion in Sport

n   HSV – herpes gladiatorum

u Increased risk HIV transmission via HSV lesion? 

n   Hepatitis B – Multiple cases on Japanese wrestling team

n   HIV – Only 1 case report of transmission in sport, head-to-head collision in soccer

u Non-athletic activity not ruled out as cause

Case #3

n   21-year-old male Division I athlete

n   Prior to departure for away game, reports recurrence of “fever blister” at corner of mouth; reports use of ointment in the past

n   Denies current symptoms

n   Exam consistent with oral HSV lesion

n   Considerations? 

Case #3

n   Water bottle

n   Towels on the bench

n   Potential of spread to others? 

n   What’s in the medical bag? 

Medical Bag

n    Amoxicillin

n    OM/Pneumonia

n    HSV

n    GC