CHOLERA
Highly dangerous quarantine infection
ETIOLOGY
• Vibrio cholerae
• Curved, rod shaped
• Gram –
• Without spore and capsule
• Motile (single polar flagellum and
pili)
• Facultative anaerobe
AG STRUCTURE
• Somatic O-antigen, heat stable
• More than 200 types
• The most famous serotypes O1 and O139
• Flagellar H- antigen, heat labile
VIRULENCE FACTORS
1- Flagella
2- Adhesive proteins: hemagglutinin and surface proteins
3- Enzymes: fibrinolysin, neuraminidase, hyaluronidase
4- Toxins: Exotoxin- Choleragen (the main factor of diarrhea, consist of 2
subunits: A(action) and B (binding).
Mechanism of toxin- activation of adenylate cyclase, hyperproduction of cAMP,
excretion of electrolytes and water into small intestine
Endotoxin
EPIDEMIOLOGY
• Source of infection- infected human
• Transmission mechanism- fecal-oral
• Way-watery, alimentary, contact
• Factors – contaminated food, water, hands
• Susceptible population- all ages(especially- human with hypoacidity)
• Season-summer-autumn
• Immunity- not prolonged(1-3years)
• Outbreaks- in countries with poor sanitation
MARCH 2023 – 18 COUNTRIES
PATHOGENESIS
• Contamination of water
• Entering the GIT
• Producing of toxin in small intestine
• Penetrating of toxin into the enterocytes
• Disease
WHAT TOXIN DO IN ENTEROCYTES
1-Choleragen’s B subunit binds to GM1 receptors on enterocytes
2- A-subunit enters the cytoplasm and activates the G-protein (blocks the
adenylate cyclase)
3-production of c AMP
4- opens the channels, active secretion of Na, Cl with blocking their
reabsorption
5- Fluid, bicarbonates, K are lost with osmotic pull of the NaCl as it travels
down the intestine
CLASSIFICATION
• By type: typical
• Atypical: mild, subclinical, dry, hemorrhagic, fulminant forms
• By severity: mild, moderate, severe
• By outcomes: with complication, without complication
CLINICAL MANIFESTATION
• Incubation period- 1-6 days
• Onset- acute
• Normal body temperature!!!!
• Frequent watery diarrhea
• Vomiting
• Increasing of HR and RR, hypotension, oligo-anuria.
DIARRHEA FEATURES
• Acute
• Profuse (1 l\hour)
• Watery (without the feces)
• Painless
• Yellowish-whitish color
• “Rice-water” diarrhea
• Mucous +, blood and pus - abs
RICE WATER DIARRHEA
SPECIFIC SYMPTOMS OF CHOLERA WITH
DEHYDRATION
• Facies Hippocratic
• Spasmodic contraction of muscles of hands
• Spasmodic contraction of muscles of foot
• Sunken eyes with turned up eyeballs
• Laundress hand
FACIES HIPPOCRATICUS
LAUNDRESS HANDS
SPASM OF MUSCLES OF HANDS
SEVERITY CRITERIA
• Frequency of diarrhea\day
• Frequency of Vomiting \day
• Thirsty
• Diuresis
• Seizures
• General appearance(condition)
• Skin turgor
• Mucous membrane
• Respiration
• Cyanosis
• BP, pulse
• Blood pH
MILD CHOLERA (UNDERWEIGHT 1-3 %)
• Frequency of diarrhea- less than 10 times\day
• Thirsty, dryness of oral mucous membrane
MODERATE CHOLERA (4-6 %)
• Diarrhea – 10-20 times\day
• Vomiting
• Thirsty, dryness of tongue
• Elasticity of skin
• Cyanosis of lips and fingers
• Tachycardia, hypotension, hypoionemia
SEVERE CHOLERA (UNDERWEIGHT 7-10%)
• Diarrhea more than 20 times\day
• Vomiting (profuse and frequent)
• Seizures
• Changing of voice
• Facies Hippocratic
• Laundress hands
• Oliguria
• Tachycardia
• Tachypnea
CHOLERA ALGID (10%)
• Continiously diarrhea and vomiting
• Lethargy
• Hypotension(
• Anuria
• Hypothermia
• Ashy skin tone, cold, sticky skin, skin pinch retracts slowly
COMPLICATIONS
• Specific
• Hypovolemic shock
• Cholera algid
• Acute renal failure
• Non specific
• Secondary bacterial infection
• Cardiovascular complications
DIAGNOSIS
• Anamnesis
• Symptoms
• CBC- hematocrit may increase
• IONS- hypoionemia, ARF- creatinine, N, urea
• Culture of feces or vomiting products- fresh feces, dishes for culture do not
clean with solutions
• Serology
• PCR
TREATMENT
• Hospitalization!!!!(quarantine infection)
• Diet
• Etiologic
• Pathogenic-rehydration
• Symptomatic
ANTIBACTERIAL TREATMENT
• Doxycycline 200 mg- 5 days oral or i\v
• Ciprofloxacin 250mg- 2 times- 5 days
ORAL REHYDRATION
1 step (treatment of underweight)within 6 hours
• Dehydration I (mild cholera) 40-50 ml\kg
• Dehydration II (moderate cholera) 80-90 ml\kg
2 step (supportive treatment)
• 80-100 ml\kg\ day
INFUSION (NO EFFECTS OF ORAL
REHYDRATION)
• Dehydration I ( mild cholera)- 30-50 ml\kg\day
• Dehydration II- 60-90 ml\kg\day
• Dehydration III- 100-150 ml\kg\day
