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Why sports can be a breeding ground for dangerous MRSA infections

NEW YORK -- Brandon Noble is 10 years removed from his seven-year NFL career and now works near Philadelphia as a financial adviser. But the former Dallas Cowboys and Washington Redskins defensive tackle wasn't surprised when a reporter tracked him down Wednesday to discuss New York Giants tight end Daniel Fells, who has become the latest athlete to be diagnosed with MRSA, a frightening, antibiotic-resistant staph infection that can result in multiple surgeries, amputations and, rarely, even death.

"I've been waiting for my phone to ring," said Noble, who was forced to retire from the Redskins in 2006 at age 31 after surviving two harrowing bouts with MRSA, the first after what was supposed to be a "minor" knee cleanup procedure.

"Until I had it, I'd never heard of it, I didn't have a clue," Noble said. "MRSA was relatively new to the general public. So when you're laying there in a hospital bed and they're telling you about it for the first time, that makes it even scarier. The look on the doctor's face lets you know it's really serious. Then when they tell you we don't know exactly what to do or what drugs will work to fight it, you really start sweating.

"The infectious disease doctor told me if I'd waited even 24 more hours to go to the hospital the first time, we'd be talking about you perhaps losing your leg."

Noble didn't lose his leg. But the MRSA scares and aftershocks didn't stop there.

"Typically, they can't tell for sure how you got it. They can't tell where you got it. Or if it might come back," he said. All told, Noble spent two years battling complications and bouncing in and out of surgeries. The second time he fell ill, he went to the emergency room on a Thursday; his wife went into the same hospital the next day and gave birth to their third child. It took a pitched fight to get doctors to reluctantly allow Noble to be present for the birth. Even then, he was forced to sit in a wheelchair under orders that he could only watch from the back of the delivery room.

Noble says he learned more than he ever wanted to know about how stealthily the infection works and how hard MRSA is to prevent, as the Giants are learning now.

On Monday, Giants head coach Tom Coughlin gathered the team together and placed a Skype call to Fells in his hospital room to remind the popular 32-year-old veteran that the team was thinking of him and to award Fells a game ball from New York's gritty last-minute 30-27 win over the San Francisco 49ers the night before.

"That [call] was emotional," Giants quarterback Eli Manning said Wednesday.

The Fells case -- like Noble's nearly a decade ago -- shows how particularly difficult it is to completely eradicate MRSA in sports settings and how hard the bug is to shake once it does get a foothold in someone's body.

The MRSA germ (methicillin-resistant Staphylococcus aureus) itself is a type of staph bacteria that is resistant to many antibiotics. According to the Centers for Disease Control and Prevention, staph bacteria exist in our everyday environment and can live on the skin or in the nose without causing illness (about one in three people carry staph, while two in 100 carry the MRSA strain). An infection can occur if there is a pathway for the bacteria to enter the body through an open wound, cut or abrasion -- all workaday features of being an athlete. If left untreated for too long, infections caused by MRSA can become dangerous and potentially life-threatening if they spread into muscle, blood, bones or the lungs.

The CDC says MRSA can also spread by skin-to-skin contact, exposure to contaminated surfaces used by a carrier or exposure to someone who already has a full-blown infection. Sports teams need to be especially vigilant about how they dress open wounds and about having athletes share shower and whirlpool facilities that could breed infections.

The first sign of a MRSA infection is usually a pus-filled pimple or skin boil that's often mistaken as an insect bite. The surrounding skin can be red, swollen and painful. Victims can feel feverish and weak. Draining the abscess and/or the right combination of antibiotics often successfully treats MRSA infections. But when they have spread, numerous surgeries -- and in rare, extreme cases, amputation -- might be needed to clean out areas that become infected and then re-infected. (Noble lost 34 pounds during his two-year battle.)

An NFL physicians survey determined there were 33 MRSA infections across the league from 2006-08 alone.

Washington owner Daniel Snyder was highly aggressive when five of his players, including Noble, were diagnosed by 2006.

"He basically nuked the building," Noble recalls, referring to how whirlpools were completely ripped out, ultraviolet lighting (which has been shown to kill MRSA and other germs) and sanitizers were installed, individual stools replaced shared benches in the locker room, and the entire building was disinfected.

"It's a very serious thing [and] has been that way in this league for quite a few years," Coughlin said this week. "Everyone has been very aware of it."

But the NFL is hardly the only sport affected. Studies like this one have shown that athletes in contact sports such as wrestling and rugby are at greater risk than the general population to get MRSA. And the CDC has said skin infections including MRSA have also been reported among athletes in soccer, basketball, field hockey, volleyball, rowing, martial arts and fencing.

Justin Turner of the Los Angeles Dodgers and infielder Freddy Galvis of the Philadelphia Phillies are two of the recently documented cases in Major League Baseball. The Yale Daily News recently reported that a member of the school's baseball team confirmed that a few of his teammates were being treated for MRSA.

USC is among the high-profile college football programs that have battled MRSA in the past. At the Division III level, Ricky Lannetti, a senior wide receiver at Lycoming College in Williamsport, Pennsylvania, died from MRSA in 2003.

The CDC has guidelines on its website explaining how shared facilities or equipment can host the bacteria, and other ways it can spread. The CDC has also issued this list of preventive tips.

"The Redskins said I got it at my doctor. The doctor said I got it at Washington's facility. But when you look at it, my doctor did [something like] 10,000 knee surgeries and never had a MRSA case. There were four other MRSA cases in Washington that year. You do the math."

Brandon Noble

The NFL and NFL Players Association have worked to better educate players and team staff and issue guidelines on how to combat MRSA since it began showing up in the league in the early 2000s.

But the league and union centralized their efforts even more -- formalizing a consulting relationship with Duke Infection Control Outreach Network last year rather than continuing to leave each team responsible for its own prevention efforts -- after MRSA struck three members of the Tampa Bay Buccaneers in 2013: kicker Lawrence Tynes, former All-Pro guard Carl Nicks and cornerback Johnthan Banks. The Bucs outbreak prompted talk about postponing an October home game against the Philadelphia Eagles and led to the embarrassing visual of the Atlanta Falcons bringing in a cleanup crew wearing hazmat suits a week later to disinfect the visitors' locker room after Tampa Bay played at the Georgia Dome.

Noble understands the concern. He's developed a Lady MacBeth-like impulse to wash his hands. He says tests have shown he's not a MRSA carrier, and yet he still fears about a reoccurrence or infecting his wife and three children.

"I've definitely become a bit of a germaphobe," he said. "It always dwells and lives on in the back of my mind that I could get it again."

Fells' case has prompted strong reactions as well.

Two sources familiar with Fells' condition say initial media reports overstated the imminent danger of Fells losing his foot or his life. (One erroneous report even said Fells had indeed already lost parts of one foot.) Both sources said their understanding is doctors believe Fells is responding well to treatment.

"Technically, you're always fighting this horrible thing until you're not, right?" one source said Wednesday. "But he's now put together five good days in a row where he's been able to rest comfortably. Everything is pointing in the right direction."

"My information is the doctors aren't fearing any loss of life or limb," the second source said. Arizona Cardinals tight end Darren Fells echoed the positive sentiment Thursday and said his brother's infection was "almost gone." Another source close to Daniel Fells, however, told ESPN.com late Thursday night that he had indeed been close to losing his foot.

There's been speculation that Fells, 32, might have become infected while getting a cortisone injection at a hospital for a chronic ankle problem, not at the Giants' facility. But it's often hard to know for sure.

"The unfortunate thing that happens when these cases come up,'" Noble said, "is everyone starting pointing fingers or saying, 'You didn't get it here. Didn't get it there.' The Redskins said I got it at my doctor. The doctor said I got it at Washington's facility. But when you look at it, my doctor did [something like] 10,000 knee surgeries and never had a MRSA case. There were four other MRSA cases in Washington that year. You do the math."

Noble's ordeal began when had arthroscopic surgery to clean out his right knee at a Charlotte, North Carolina, hospital in April 2005. After getting the stitches removed at the Redskins' training facility, he noticed a quarter-sized red "hot spot" and quickly developed a fever. "But being Tommy Tough football player, I figured it would just go away," he said.

Noble went to the hospital only after his mother-in-law, who is a registered nurse, visited him and his wife and told him to get to an emergency room immediately. And that's when he was diagnosed.

Noble's second case of MRSA showed up in December 2005 in his other knee, which he'd shredded during the 2003 preseason. Noble's doctors speculated stubborn bacteria that had been dwelling in the screws and plates that were inserted after his reconstructive surgery might have caused it.

"I tore my ACL, MCL and PCL the year before I had MRSA and came back from that to play the very next year -- which was quicker than I recovered from MRSA," Noble said. "It was MRSA that ended my career."

A number of staph infections, including MRSA cases, haunted the Cleveland Browns throughout the last decade and led to two lawsuits charging that the team did not properly sanitize its facility. The Browns eventually settled out of court with former offensive lineman LeCharles Bentley and receiver Joe Jurevicius, who both retired.

Jurevicius' denouement shows how cruel these outcomes can be. He contracted a MRSA infection following a 2008 procedure on his right knee and subsequently underwent six surgeries that year. He vowed to return the next season, but the Browns released him on March 11, 2009. He filed his lawsuit three months later, and a settlement was reached a year later. He never played again.

Tampa Bay reached a reported $3 million settlement with Nicks without going to court after he was forced to retire. Banks, now a third-year cornerback, didn't miss any playing time and remains with the team. But Tynes, whom the Bucs cut after he suffered an infected toe that developed a MRSA infection, is suing the team for $20 million.

Last month, U.S. District Judge James S. Moody Jr. ruled that Tynes' case can proceed in Florida state court, citing the Jurevicius case while rejecting the NFL's argument that Tynes' claim was preempted by the league's collective bargaining agreement.

"So far, the team hasn't expressed any interest in settling," said Matthew P. Weinshall, one of Tynes' attorneys. "So we're left to litigate in state court, which we're prepared to do. ... Lawrence deserves his day in court."

Noble was under the impression a decade ago that he didn't have legal recourse under Virginia or Washington D.C. law.

"In my case there was no settlement, nothing, it was just, 'Hey, sorry it happened; glad you walked out here,' and that was it," Noble said. "But I think it's a shame anyway when lawyers get involved. All that starts happening is blaming people when what we should be doing here is saying, 'Let's all get together and get rid of this horrible thing. How do we do it?'"

But total victory might not even be possible against bacteria as commonplace and virulent as MRSA. Continued vigilance is a key.

"I'm good now, but I've already had five knee surgeries for this and just figure I'm going to have knee replacements in my future," said Noble, evincing no trace of bitterness. "It's been a long time, but I still worry about it coming back or me infecting my wife and kids. I still wash my hands constantly now. Any time I walk by the sink, I use bit of hand sanitizer."

Asked what he'd say to Fells as he fights his battle with MRSA, Noble sighs and says, "Man, I just feel so badly for him. I really, really do."

So does the Giants' Manning.

"There was still a lot of uncertainty once we got to Saturday night before the game," Manning said. "A lot of us have been in touch with him [Fells].

"It was scary, knowing what he was going through."