Cholerae
[Link] Selvan
Background
• cholera defined as ‘profuse watery diarrhoea with severe
dehydration’ during a cholera outbreak or a positive stool culture for
V. cholerae 01 or 0139
• Intestinal infection caused by Vibrio cholerae.
• Hallmark: profuse secretory diarrhea.
• Endemic, epidemic, or pandemic.
• Transmitted by the fecal-oral route.
Epidemiology
• Infective agent: Vibrio cholerae,highly motile, halophilic Gram-
negative, comma-shaped bacterium.
• Reservoirs: Human and water
• Based on 0-antigen lipopolysaccharide structure: 200 serogroups
• Only two (V. cholerae 01 and 0139) cause cholera epidemics .
• 2023,WHO reported a worldwide more than 700,000 cases and 4000
deaths in 30 countries.
• Global burden: 1.3-4 million cases and 21,000-143,000 deaths per
year.
Pathogenesis
Risk Factors
• Poor hygiene & sanitation
• Malnutrition/immunodeficiency
• Hydrochlorhydria or achlorhydria of any cause
• People with type O blood
Clinical Features
• Incubation period:1 to 5 days
• Asymptomatic disease to life-threatening dehydration:depending on
bacterial load, degree of background immunity and presence or
absence of malnutrition
• Mild cases: indistinguishable from other causes of diarrhoeal illness,
• Profound infection: vomiting and rapid loss of fluid and electrolytes
in ‘rice water’ stool at rates of 10–20 ml/kg/h.
• Cholera gravis: Severe hypovolaemia may occur within hours of
symptom onset, resulting in hypovolaemic shock, hypokalaemia, lactic
acidosis, acute renal failure and hypoglycaemic coma
Physical Examination
• 3-5% loss of normal body weight - Excessive thirst
• 5-8% loss of normal body weight - Postural hypotension, tachycardia,
weakness, fatigue, dry mucous membranes or dry mouth
• >10% loss of normal body weight - Oliguria; glassy or sunken eyes;
sunken fontanelles in infants; weak, thready, or absent pulse;
wrinkled "washerwoman" skin; somnolence; coma
Cholera sicca
• Old term, a rare, severe form of cholera that occurs in epidemic
cholera.
• Manifests as ileus and abdominal distention from massive outpouring
of fluid and electrolytes into dilated intestinal loops.
• Mortality is high, with death resulting from toxemia before the onset
of diarrhea and vomiting.
Diagnosis
• presumptively on the basis of clinical features.
• WHO standard case definition: a case of cholera is suspected when the
following conditions are met:
• [Link] an area where the disease is not known to be present, a patient aged 5
years or older develops severe dehydration or dies from acute watery diarrhea
• 2. In an area with a noted cholera epidemic, a patient aged 5 years or older
develops acute watery diarrhea, with or without vomiting
• confirmed by isolation of V. cholerae from stool cultures on specific media
(TCBS or TTGA agar).
Investigations
• Stool Examination: Gram stain/direct dark-field examination of the
stool/electron microscope: gram-negative curved bacillus, motile by
means of a single flagellum.
• PCR
Investigations
• Stool Culture on Alkaline enrichment media : large, smooth, round
yellow colonies
• Serotyping and Biotyping by immobilization tests by using specific
antiserum.
• Hematocrit, serum-specific gravity, and serum protein are elevated
• Leukocytosis
• Metabolic acidosis with elevated anion gap
• Hyponatremia
• Hypokalemia
Investigations
• Hypercalcemia
• Hypermagnesemia
• Elevated BUN
Treatment
• Rehydration
• Antibiotic therapy
Treatment
Treatment
Treatment
• The 2005 WHO guidelines listed tetracycline (12.5 mg/kg qid for 3
days) as the treatment of choice for children >2 years with severe
dehydration
• doxycycline, TMP-SMX, erythromycin and chloramphenicol alongside
zinc supplementation once vomiting has stopped
Prevention
• Rapid identification of cases and prompt treatment will limit further
spread of the disease.
• Drink water by boiling or adding chlorine.
• Sensitive surveillance and prompt reporting
• Education on specific hygiene practices
• Cholera vaccine
Steps in the treatment
• 1. Assess for dehydration
• 2. Rehydrate the patient and monitor frequently, then reassess hydration
status
• 3. Maintain hydration; replace ongoing fluid losses until diarrhea stops
• 4. Administer an oral antibiotic to the patient with severe dehydration
• 5. Feed the patient
