Cholera
ہیضہ
Dr. Sehar Afshan Naz
[Link]., PhD
Assistant Professor
Department of Microbiology
Federal Urdu University of Arts, Science and
Technology, Karachi
Cholera
• Cholera is an infectious disease caused by
eating food or drinking water contaminated
with a bacterium called Vibrio cholerae.
• This organism secrete an enterotoxin which
causes severe watery diarrhea, which can
lead to dehydration and even death if
untreated.
• Cholera outbreaks are still a serious
problem in some parts of the world.
• The disease is most common in places with
poor sanitation, crowding, war, and famine.
Common locations include parts of Africa,
south Asia, and Latin America.
• The World Health Organization reports that
there are 1.3 million to 4 million cases each
year.
• Vibrio cholerae, the bacterium that causes cholera,
is usually found in food or water contaminated by
feces from a person with the infection. Common
sources include:
• Municipal water supplies
• Ice made from municipal water
• Foods and drinks sold by street vendors
• Vegetables grown with water containing human
wastes
• Raw or undercooked fish and seafood caught in
waters polluted with sewage
Etiology
• Vibrio cholerae is the major causative agent of
Cholera
• Gram-negative
• Curved or comma-shaped rods
• Highly motile with a single polar flagellum.
• Non sporing
• Non capsulated
• Vibrio cholerae was first isolated in pure culture
by Robert Koch in 1883.
• Other species of genus Vibrio includes V.
parahemolyticus and [Link]
Growth Characteristics
• Characteristically grow well at very high pH (8.5-
9.5) and rapidly kills by acids
• Killed at 55℃ for 10 minutes
• Sensitive to chemicals
• Sensitive to dessication
• Survive for 4-7 days over surfaces of vegetables
and fruits
•
• Grows well on simple media such as Nutrient
agar and produce smooth round translucent
colonies.
On Blood agar it gives beta hemolysis
• On selective media such as MacConkey`s
agar or EMB agar it produces non lactose
fermenter colourless colonies
• Another selective media, Thiosulfate Citrate Bile Salt
Sucrose agar (TCBS) having pH 8.6-9.5, is used
widely for its selective isolation from stool specimen.
• On this media it produces sucrose fermenter yellow
colonies.
Antigenic Structures
• Heat-labile flagellar H antigen.
• Somatic O antigen –lipopolysaccharides
antigen. Because of this lipopolysaccharide
it has 140 serogroups.
• Serogroup O1 and O139- cause classic
cholera.
• Others cause cholera like diseases.
• Antibodies against O antigen gives protection
against infection.
Virulence Factors
Toxins:
[Link] serotype 01 produces two type of
toxins
• Endotoxin
• Exotoxin
Endotoxin
• Lipopolysaccharide present in cell wall
• Released upon lysis of cell
• Pyrogenic (fever producing)
Exotoxin
Enterotoxin or Choleragen
• [Link] serotype 01 during its growth
produces an exotoxin known as enterotoxin or
Choleragen which is responsible for the loss of
fluid in Cholera
• This is AB toxin, consisting of two subunits
• Sub unit B also known as Choleragenoid binds
to mucosal receptors and promotes entry of sub
unit A into the cell.
• A subunit is the main toxic part responsible for
biological activity of choleragen
Pathogenesis
• Transmission is usually through the fecal-oral
route of contaminated food or water caused
by poor sanitation.
• High infectious dose i.e. 108-109 is
required to initiate the infection because this
bacilli is susceptible to gastric acids
• About 100 million bacteria must typically be
ingested to cause cholera in a normal
healthy adult
• Cholera is not an invasive infection.
• The organism do not reach blood stream but only remain
within the intestinal tract.
• The organisms survived from gastric acids enters the
intestine and attach to microvilli of the brush borders of
epithelial cells.
• The Vibrio bacilli infects the host using two major
virulence factors: the toxin-coregulated pilus (TCP) and
cholera toxin (CT). TCP is important for colonization of the
host gut mucosal layer where CT is released and passes
through the gastroendothelial wall..
• In addition to Cholera toxin (Choleragen), the Vibrio also
liberate mucinases and endotoxins
• This Cholera toxin elevates the production of cyclic AMP
which in turn produces massive secretion of fluids into
the lumen of intestine.
Clinical picture
• Incubation period is 24-48 hours.
• Symptoms begin with sudden onset of watery
diarrhea, which may be followed by vomiting. Fever is
typically absent.
• The diarrhea has fishy odor in the beginning, but
became less smelly & like “rice water” in few hours
due to presence of mucus, epithelial cells and large
number of vibrio bacilli.
• Sunken eyes and hollow cheeks
• In severe cases stool volume exceeds 250 ml /kg
leading to severe dehydration, shock & death if
untreated.
• Patient if survive, recovers slowly.
Classical cases of Cholera
Laboratory Diagnosis
Collection of Specimen:
• Stool sample
• Rectal swab
• Vomitus
Direct Microscopy:
Presence of large number of curved
shaped bacilli in Gram stained smear
of stool sample indicates probability of
Vibrios.
Dark Field microscopy may
demonstrate motility of vibrios
• Primary Isolation:
• Alkaline Peptone water is used for the enrichment of
Vibrio in stool sample.
• After incubation, the clinical specimens can be
streaked on different appropriate media for primary
isolation
Blood agar
MacConkeys Agar
Thiosulfate Citrate Bile Salts Sucrose agar (TC
• Grows well on simple media such as Nutrient
agar and produce smooth round translucent
colonies.
On Blood agar it gives beta hemolysis
• On selective media such as MacConkey`s
agar or EMB agar it produces non lactose
fermenter colourless colonies
• Another selective media, Thiosulfate Citrate Bile Salt
Sucrose agar (TCBS) having pH 8.6-9.5, is used
widely for its selective isolation from stool specimen.
• On this media it produces sucrose fermenter yellow
colonies.
Identification
• The isolates are identified on the basis of
following tests
• Catalase test
• Oxidase Test
• Indole
• TSI reaction
• Sugar Fermentation
Serodiagnosis
Vibrio Cholerae can be classified by slide
agglutination tests by using anti O group O-1
and O-139 antibodies.
Treatment
• Water and electrolyte replacement by giving
ORS to cure severe dehydration
*ORS (Oral rehydration Salts contain NaCl,
KCl, glucose etc)
• Oral Tetracycline is drug of choice
• Erythromycin or Chloromphenicol can be
uses in case of tetracycline resistance.
Prevention
• Improve Sanitation
• Public health awareness
• Prophylaxis:
• A killed vaccine is
available which is
effective in stimulating
partial protection of
short duration (6
months).
