Introduction Athletes at all levels of competition travel, including junior circuits, amateur leagues, and those in collegiate, professional, and international sports. Recently, realignment of collegiate athletic conferences; the introduction of name, image, and likeness (NIL); and the explosion of travel sports teams have amplified the burden of travel in athletes. Increased travel potentially exposes athletes to a wide range of infectious diseases, requiring timely recognition and prevention of specific risks by sports medicine providers. The four most afflicted systems during travel are the upper respiratory, dermatological, gastrointestinal, and pulmonary. Recent data highlight infectious outbreaks during popular televised events such as the Olympic Games and FIFA World Cup, reporting cases of legionellosis, norovirus, dengue, and Zika virus (1). Sport type also must be taken into consideration, as outdoor sports pose more risk compared with indoor sports (2). An example of such risk includes airborne fungal infections, the most common being Blastomycosis, Coccidioidomycosis, and Histoplasmosis within distinct geographic locations of the United States (2,3) (Fig. 1). According to the Centers for Disease Control and Prevention, reported cases of Coccidioidomycosis range between 10,000 and 20,000 annually in the United States, with most cases occurring in California and Arizona, with those over 60 years of age most at risk (3).Figure 1:: Geographical map of the United States showing fungal endemic regions. Adapted from Wisconsin Department of Health Services (4).Case We report a 33-year-old male advanced rock climber who attended a nonsport outdoor event in Kern County, CA, for 3 d. About 2 wk after the event, he exhibited nonspecific symptoms of fever and fatigue. His persistent symptoms prompted clinical evaluation, where he was diagnosed with community-acquired pneumonia after chest radiographs demonstrated a unilateral mass-like density in the upper left lung lobe with pleural effusion and lower lung consolidations. He was treated with antibiotics, which initially improved symptoms somewhat, but then progressed into wheezing and shortness of breath. He then revealed specific travel history to a region endemic for Coccidioidomycosis. As a result, additional imaging and fungal testing were recommended. His symptoms continued to worsen, ultimately requiring hospital admission. Empiric treatment for Coccidioidomycosis with 400 mg of oral fluconazole daily for 3 months was initiated, and serology eventually verified the presence of Coccidioides. While his treatment course was successful, delayed diagnosis and treatment resulted in appetite suppression, dehydration, muscle loss, and subsequent 15-lb weight loss. Persistent night cough impaired sleep, requiring an inhaler for relief. Repeat chest X-ray revealed significant radiographic improvement, correlating with his interval clinical recovery. Infectious disease consultation resulted in cessation of fluconazole after 3 months, rather than completing the full 6 months of treatment. Despite continued clinical improvement, he continued to experience challenges with his pulmonary function, raising concerns about the long-term impact on athletic performance. Discussion Emerging Infectious Risks in Traveling Athletes Athletes visiting areas where Coccidioidomycosis is common (Fig. 1) face a higher relative risk of contracting the disease through exposure to airborne fungal spores. These fungal spores, classically inhaled from dust, are disturbed by environmental factors such as storms and outdoor activities including construction, agricultural and archaeological work, and military training (2). The typical incubation period is 1 to 4 wk after exposure, necessitating high clinical suspicion in individuals with symptoms consistent with newly developed community-acquired pneumonia (5). The lack of epidemiological monitoring for fungal infections in athletes makes early clinical suspicion essential and of heightened importance given the morbidity of incurring such an infection. Diagnosis is typically confirmed through serologic testing, including enzyme immunoassay for antibodies and complement fixation testing. Treatment depends on disease severity, as mild cases are self-limited and require only observation. Antifungal treatment is recommended for patients who have a significantly debilitating illness. Usually, first-line treatment starts with 400 mg of oral fluconazole daily for 3 to 6 months. Disseminated disease often requires intravenous antimycotic therapy and an extended interval of treatment (5). Respiratory protection in dusty environments, preferably with an N95 mask rather than a standard surgical face mask due to limited protection in outdoor settings, enhanced hand hygiene, and avoidance of competition in high-exposure areas during peak dry seasons are examples of mitigating strategies (2,6). Upper respiratory infections (URIs) are the most common acute illnesses among traveling athletes, especially in the context of active training and prolonged or recurrent travel. While athletes experience a lower incidence of acute respiratory infections, estimated to be 1.8 per athlete per year compared with the general population, this rate is still significant when considering its potential impact on their training programs (6). The most common respiratory viruses are rhinovirus (common cold), coronavirus (seasonal and SARS-CoV-2), influenza viruses, and respiratory syncytial virus. Group A β-hemolytic Streptococcus (Streptococcus pyogenes) is a significant bacterial cause of acute pharyngitis in athletes whose risk increases in close-contact team settings, especially with shared equipment, poor ventilation, or during travel (2,6). URI prevention in athletes traveling to areas with known environmental risks starts with updated vaccinations for specific destinations. Additionally, mitigation requires adhering to strict hand hygiene, avoiding close contact with symptomatic individuals, and using face masks when clinically indicated, especially in high-risk settings such as crowding with suboptimal ventilation and/or enclosed arenas (6,7). While most infections do not impair long-term performance, acute viral syndromes have been shown to reduce strength and recovery capacity (6). For bacterial URIs, athletes can typically return to training 24 hours after initiating antibiotics, once fever and systemic symptoms resolve (2). Similarly, vector-borne diseases like dengue and Zika virus remain concerning in tropical and subtropical regions (1). Athletes presenting with fever, rash, arthralgia, or conjunctivitis require close clinical monitoring. Diagnosis involves reverse transcription polymerase chain reaction testing in the early symptomatic stages and serological assays. Treatment is mostly conservative, consisting of hydration, rest, and symptom control (8). Prevention involves insect repellents containing DEET (N,N‐diethyl‐meta‐toluamide) long-sleeved clothing, and insecticide-treated bed nets. Return-to-play requires athletes to be afebrile and without systemic symptoms (6). Gastrointestinal infections such as traveler’s diarrhea due to Escherichia coli, Campylobacter, and norovirus are most common in athletes (9). Specifically, norovirus has been reported at large sporting events with increased frequency when sharing team living quarters or accommodations, thereby increasing transmission risks (10). Diagnosis is clinical, often based on recent travel history and symptoms such as watery diarrhea, abdominal cramps, and fatigue. Management includes hydration, antidiarrhea medications, and antibiotics if necessary (9). Recommended preventative practices include strict hygiene protocols and avoidance of tap water, ice, open buffets, fresh salads, unpeeled fruits, and undercooked meats. Safer options consist of sealed bottled water, boiled water, and hot, well-cooked foods. Athletes may consider returning to play once afebrile, rehydrated, and with normal bowel function (9). In the United States, dermatological infections account for 8.5% to 20% of all medical consultations among high school and college wrestlers, due to frequent skin-to-skin contact (11). Staphylococcus aureus and Streptococcus spp. are the most frequently reported bacterial infections, leading to folliculitis, erysipelas, furuncles, and impetigo. Fungal infections such as tinea gladiatorum were reported in at least one athlete in 84% of wrestling teams within the United States (11). Diagnosis is primarily clinical, based on lesion appearance and patient history, but sometimes may require other forms of testing (12). Management strategies include topical or systemic antibiotics for bacterial infections and topical or oral antifungal agents for fungal infections (11,12). Particularly in contact sports, key prevention strategies include daily showering, avoidance of shared personal items, and prompt evaluation of any skin lesions (11). Return to play often requires strict protocols dependent on the timing of symptomatic onset and treatment (12) (Fig. 2).Figure 2:: Return-to-play protocols for select travel-related infections.Impact of Travel on Immune Function Sleep adequacy plays a key role in athletic performance, influencing training capacity, cognitive performance, emotional regulation, injury risk, and recovery (13). Poor, impaired, and/or inadequate sleep has been linked to increased susceptibility to injuries, particularly concussions, and prolonged recovery timelines (14). The optimal range of sleep is between 7 and 9 h per 24 h for adults, whereas adolescents and teens require 8 to 10 h of high-quality sleep every 24 h (13,14). However, recent research shows that less than 50% of elite athletes attain 7 to 8 h of adequate restorative sleep regardless of age (15). Mental health vulnerabilities in athletes, including anxiety and depression, are exacerbated by chronic sleep disturbance and stressors such as performance pressure and frequent travel (14). It is hypothesized that circadian rhythm disruption results in decreased recovery and increased susceptibility to infection and illness (14,16). Eastward travel is more disruptive than westward travel, as such requires advancement of the circadian clock to the newly arrived time zone, which biologically is more difficult to achieve (16). Particularly in athletes with recurrent and prolonged travel, jet lag also affects both sleep quality and quantity (17). Studies demonstrate that delaying sleep initiation by 3.5 h and reducing sleep duration by 3.6 h resulted in less-than-optimal ranges of sleep (14). Disrupted sleep schedules and high-intensity training in elite athletes may reduce immune function, potentially due to prolonged fatigue caused by chronically elevated cortisol levels (13,14). An increase in URI occurrences, similarly, seen in overtraining syndrome, is often the sentinel event (7). Implementing strategies such as sleep optimization, hydration before travel, and time zone adaptation via caffeine avoidance before sleep may be beneficial. Additionally, eye masks and oral supplements may enhance sleep quantity and quality, potentially improving immune function (14). However, current sleep assessment tools are unsuitable for elite athletes, leading to the development of the more accurate Athlete Sleep Screening Questionnaire (18). Conclusion Management of infectious diseases and immune function is critical in traveling athletes, where high physical demands and close-contact environments are commonly encountered. This article highlights challenges posed by travel-related infections such as Coccidioidomycosis, while also underscoring the importance of timely diagnosis and appropriate treatment in traveling athletes. Although athletes are often in optimal health, they are still susceptible to infections and decreased performance, especially with travel-related stressors and risks. Pretravel planning should include preventive strategies such as vaccination, proper hygiene, environmental awareness, and sleep management to decrease infection risk and to limit group transmission. Return-to-play protocols should be individualized, taking into consideration the type of infection and severity. The authors declare no conflict of interest and do not have any financial disclosures.
Gallegos et al. (Wed,) studied this question.