2007 - Lung Abscess in A Professional Rugby Player - Castinel Et Al - BrJSportsMed

696
CASE REPORT
Lung abscess in a professional rugby player: an illustration of

overtraining syndrome?
Bernard H Castinel, Philippe Adam, Christophe Prat, Pierre Mourlanette
...................................................................................................................................
Br J Sports Med 2007;41:696–698. doi: 10.1136/bjsm.2007.035071
On 10 June 2006 he took part in the Top 14 competition final

As in other endurance sports, the intensity of training sessions
game. He had been treated for an infected cut on the ear
and the pace of competition has significantly increased since
3 weeks earlier but the wound seemed to have healed before
rugby union became a professional sport. The case history is
the game. The following day he experienced neck pain and felt
presented of a professional rugby player who was diagnosed very weak but was not hyperthermic.
with septicaemia and a lung abscess following an infected He was admitted to hospital on 13 June because of increasing
wound to the ear. The symptoms only resolved after a large pain in his neck and left arm. The cervicobrachial neuralgia
dose of antibiotics and 3 months of rest. It is hypothesised that persisted despite treatment with analgesics. A cervical MRI
this may be an example of overtraining syndrome, but scan revealed small hernia of the C5C6 and C6C7 intervertebral
complementary blood analyses would be necessary to confirm discs and, at this stage, these hernia were thought to be the
this. The case underlines the importance of clinically assessing cause of the pain. However, on 14 June his body temperature
the individual capacity of players to recover, in order to prevent started to increase steadily and further diagnostic tests were
overtraining and to maintain a high level of performance undertaken. Staphylococcus aureus (‘‘Méti S’’ strain) was isolated
during the whole season. by blood culture, suggesting that septicaemia had caused the
hyperthermia. Standard chest radiographs also showed a
discrete opacity in the basal area of the left lung (fig 1).
Despite antibiotic treatment with vancomycin infusion, he did
S
ince rugby union became a professional sport in 1995, it
has become more demanding with a longer playing not improve. On 19 June a CT scan of the thorax revealed the
season, more games, intense training sessions and requires presence of a circular apical mass 60 mm in diameter in the left
the commitment of players to give their best performance chest (fig 2). A transthoracic puncture of the mass was
during the whole season. This also implies that rugby players conducted under CT scan on the following day and confirmed
work at the edge of their physiological limits which can lead to the presence of an abscess. Antibiotic treatment with pristina-
chronic fatigue and immunodeficiency. We report the case of a mycin was then initiated for 15 days and the primary
professional rugby player who was diagnosed with septicaemia symptoms (neck pain, fatigue and hyperthermia) were rapidly
and a lung abscess following an infected wound to the ear. We attenuated. On 2 July a CT scan showed that the size of the
hypothesise that the combination of a long playing season with abscess had decreased to 40 mm in diameter (fig 3). CT scans
insufficient time for recovery was a major predisposing factor. on 31 July (fig 4) and 6 September (fig 5) showed retracting
scar tissue in place of the lung abscess. The symptoms had
entirely resolved by the end of July. The player resumed playing
CASE REPORT
rugby at the end of September when his clinical condition and
A 27-year-old man had been playing rugby for 10 years for a
serological markers of inflammation were normal and the scar
French professional club, either as a prop or a hooker. In
tissue was considered stable on the CT scan.
addition, he was selected for all of the games played by the
French national team during the 2005/6 international season.
His daily training load consisted of three sessions: specific DISCUSSION
weight training in the morning, interval or speed training in the It was apparent that the lung abscess associated with
afternoon, and a joint game session for the forward players in septicaemia in this patient was linked to chronic fatigue
the evening. following a long playing and hard training season combined
Figure 1 Chest radiograph on 14 June. The arrow indicates a zone of Figure 2 Axial CT scan of the thorax on 19 June. The arrow indicates the
opacity at the base of the left lung. zone of opacity (abscess).
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Lung abscess in a professional rugby player 697
Figure 3 Axial CT scan on 2 July showing that the size of the abscess Figure 5 Sagittal CT scan on 6 September showing a small apical scar
(arrow) has decreased considerably compared with the previous CT scan. (arrow) as the only sequel of the lung abscess.
with the stress generated by the final phase of the champion-

ship. Depression of the immune defences of the player (whose What is already known on this topic
HIV status was negative), presumably caused by cumulative
tiredness over the rugby union season, reduced his capacity to N The overtraining syndrome is well known as a condition
resolve a local infection. A heavy antibiotic regimen and of fatigue and underperformance which is often asso-
3 months of rest were required before the player was allowed ciated with frequent infections and depression and occurs
to play again for his team. Similar observations have been made following hard training sessions and competition.
in athletes with a systemic illness where immune deficiency
following periods of high physical activity considerably
N It has mainly been described in endurance athletes.
increased their risk of infection.1
A serious complication of an infected wound to the ear in an
apparently healthy athlete suggests the overtraining syndrome,
which is defined as a condition of fatigue and decreasing What this study adds
performance ‘‘often associated with frequent infections and
depression … following hard training and competition’’.2 A
number of factors may contribute to this degree of burnout or
N Rugby is a game where endurance and resistance
periods are linked during the game.
staleness,2 leading to a delay in recovery from intense training
and competition. It has been shown that chronic fatigue in N Infection of the lung following a simple infected cut
athletes can be assessed by blood analysis.2 For instance, a low resulted from the immunodeficiency of the player because
testosterone/cortisol ratio has been found to be a reliable of chronic fatigue with under-recovery following an
marker of overtraining.2 3 Serological markers of immunosup- excessively long season of hard training and competition.
pression were not investigated in the present case as cortisone
treatment was prescribed for the first diagnosis of cervicobra-
chial neuralgia. Other clinical analyses to investigate persistent
fatigue and recurrent infections in athletes have included and/or recurrent infections in immunodeficient players. Even
leucocyte counts4 and the use of thyroid hormones and serum though the epidemiological data reported here suggest an
immunoglobulins.1 overtraining syndrome, complementary blood analysis is
The intensity of training sessions has significantly increased, necessary to reinforce and confirm our hypothesis. We also
together with the pace of the competition. In order to meet the suggest that a more rational management of recovery periods,
expectations of sponsors and administrators, players have to assessed at the player level with clinical analyses, could help to
maintain a high level of physical performance during and also prevent situations of overtraining and ensure that endurance
between games. athletes such as rugby players maintain a high level of
As suggested by the present case report, intense competition performance during the whole season.
and hard training could explain the incidence of opportunistic
.......................
Authors’ affiliations
Figure 4 Axial CT scan on 31 July Bernard H Castinel, Philippe Adam, Pierre Mourlanette, Clinique des
showing scar tissue in place of the Cèdres, Cornebarrieu, France
lung abscess (arrow). Christophe Prat, Stade Toulousain Rugby, Toulouse, France
Competing interests: None.
Patient consent was obtained for publication.
Correspondence to: Dr Bernard H Castinel, Clinique des Cèdres, 31700

Cornebarrieu, France; [email protected]
Accepted 27 March 2007

Published Online First 4 May 2007
REFERENCES
1 Nieman DC. Risk of upper respiratory tract infection in athletes: an epidemiologic
and immunologic perspective. J Athl Train 1997;32:344–9.
www.bjsportmed.com
698 Castinel, Adam, Prat, et al
g y
2 Budgett R. Fatigue and underperformance in athlete: the overtraining syndrome. immunosuppression. A staphylococcal septicaemia, consequent
Br J Sports Med 1998;32:107–10. upon an infected skin lesion, ultimately localised to a CT proven
3 Maso F, Lac G, Filaire E, et al. Salivary testosterone and cortisol in rugby players:
correlation with psychological overtraining items. Br J Sports Med lung abscess. Excellent plain radiographs and CT images add to
2004;38:260–3. the discussion and confirm the focus of infection. However, if a
4 Reid VL, Gleeson M, Williams N, et al. Clinical Investigation of athletes with state of chronic fatigue and ‘‘competition stress’’ are postulated
persistent fatigue and/or recurrent infection. Br J Sports Med 2004;38:42–5.
as the cause of an ‘‘opportunistic’’ lung infection, objective
measures of daily training load would strengthen the argu-
ment. Several serological markers identified with ‘‘persistent
fatigue’’ are discussed but not quantified. Their tabulation
............... COMMENTARY ...............
would improve the presentation as would a finite list of the
‘‘return to play criteria’’. This case reminds us to consider a
The issue of altered immune status in highly trained athletes is systemic cause for failing adaptation in active patients.
widely reported and attributed to a number of factors. This case
study describes an interesting clinical case affecting a profes- David Gerrard
sional rugby player. The assumption is made that his University of Otago Medical School, Dunedin, New Zealand;
deteriorating clinical status was secondary to exercised induced [email protected]
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696

Lung abscess in a professional rugby player: an illustration of

Br J Sports Med 2007;41:696–698. doi: 10.1136/bjsm.2007.035071

On 10 June 2006 he took part in the Top 14 competition final

with the stress generated by the final phase of the champion-

Correspondence to: Dr Bernard H Castinel, Clinique des Cèdres, 31700

Accepted 27 March 2007

Save your favourite articles and useful searches

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