THEME OF THE LESSON:

CHOLERA. URGENT CONDITIONS AT ACUTE INTESTINAL INFECTIONS.

The activator: cholera vibrio - Vibrio cholerae, last decades the biotype of El-Tor
cholera is allocated. 3 serological types: Ogava, Inaba and Gikoshima are present.
Vibrions, not agglutinating by cholera O-serum - so-called NAG-vibrions – are met.
Now it is established from above 60 serological O - groups of NAG-vibrions, some of
them can cause diseases, on severity not making a concession to cholera.
Source of an infection: sick man and vibriocarrier. The mechanism of infection is
fecal-oral, prevailing way is water.

Clinic

The Incubatory period is from several hours up to 5 days. In typical cases the
beginning of the disease is acute, without rise in temperature: a sudden desire on
defecation, stool like thin gruel which soon becomes plentiful, aqueous, colorless and
unfecal - as “rice-water”, with white - grey flakes of shedding epithelium of an intestine
and a smell of a crude potato. The painful syndrome is absent. At easy process the
patient loses up to 3 % from weight of a body, the moderate phenomena of dehydration,
or exsicosis (the first degrees) - dryness of a skin and mucous membranes are marked.
Middle heavy process of cholera is characterized by dehydration of the second degree
(loss of a liquid - from 4 up to 6 % from weight of a body) at which the listed symptoms
have the big expressiveness, except for that owing to loss of significant volume of water
and electrolytes spasms of muscles of extremities are joined. There is vomiting; the
structure of emetic masses corresponds to structure of excrements which have not time
to be evacuated by natural way (it is possible paresis of the intestine, caused by
hypopotassiemia); with connection of vomiting loss of electrolytes grows, especially -
chlorine; the condition of the patient is worsened. In pathogenesis of cholera there is no
inflammatory component, therefore the described phenomena do not name
gastroenteritis, it is only a stage of dehydration. Arterial pressure is progressively
reduced, pulse becomes frequent.
The heavy form of cholera is characterized by sharply expressed attributes of exsicosis:
spasms arise frequently, clonic spasms are replaced on tonic, turgor of the skin is
reduced (“a hand of the laundress”), the voice becomes weak - up to aphonia. Very
plentiful stool (up to 1-1,5 liters for one defecation) and repeated vomiting result in loss
of a liquid in volume of 7-9 % from initial weight of a body (the third degree of
dehydration). At this stage there are symptoms of hypovolemic shock that is connected
with organic insufficiency on a background of dehydration, disturbance of a nutrition
and hypoxia. Parameters of hemodynamic (decrease of maximal arterial pressure is less
than 90 mm of mercury column, dullness of cardiac tones), function of kidneys
(oligoanuria) are worsened, a body temperature is normal or reduced up to subnormal. In
process of increase of hypopotassemia there are disturbances of a cardiac rhythm,
paresis of an intestine and decrease of glomerular filtrations.
The heaviest form of cholera with dehydration of the fourth degree (loss more than 10 %
of weight of a body) early is named algidal as the body temperature becomes subnormal
- 34-35,5°С, integuments are cold. To anuria the dyspnea, even more significant
decrease of the arterial pressure, paresis of an intestine, the hiccups, disorder of
consciousness, disturbance of breath are joined, comes lethal outcome.
Complications: hypovolemic shock, disturbances of a cardiac rhythm and other
consequences of disorder of water-electrolytic exchange. The combination of cholera to
others infectious and infectious diseases results in gross disturbances and
decompensation of activity of internal organs.

Laboratory diagnostics

Microscopic research (smears) - will be carried out with the purpose of rough
diagnostics.
Bacteriological research of excrements and emetic masses with the purpose of
allocation of the activator are since the first days of the disease (prior to the beginning of
antibacterial therapy). The preliminary answer is in 6-10 hours, final - in 36-48 hours.
Serological diagnostics has the limited value and is applied with the purpose of
retrospective diagnostics at had been ill and vibriocarriers. A diagnostic titer in reaction
of passive hemagglutination is 1:40 - 1:80

Treatment

Intensive therapy begins with initial rehydration - restoration of the lost liquid and
electrolytes according to prospective volume (i.e. the diagnosed degree ofdehydration).
Use polyionic solutions - "Trisolum", "Quartasolum", "Acesolum" etc.; them enter
intravenously in warm kind (up to 38-40°С), with speed of 40 ml/minute at dehydration
of the second degree, up to 60,0 ml/minute - at dehydration of the third – the fourth
degrees. In conditions of the hospitals equipped with modern qualitative monitors,
allowing to supervise a level of electrolytes in a blood channel during intensive therapy,
introduction of water-salt solutions with speed of 80-120,0 ml/minute is possible. Initial
rehydration proceeds 1-1,5 (up to 6) hour.
Further it will be carried out corrective compensatory rehydration - in volume,
calculated at measurement of loss of a liquid with a stool, vomiting and urine for the 6-
hour period of supervision. Besides intravenously entered solutions, the patient receives
preparations of peroral rehydration - "Rehydronum", "Citroglucosolanum" (at absence
of vomiting).
Antibiotics reduce duration of clinical manifestations of cholera and accelerate
sanitation. Usually apply Doxycyclini hydrochloridum - 200 mg inside in the first day,
then on 100 mg (1 tab.) per day within 5-6 days. It is possible to use others tetracyclinic
preparations, Laevomycetinum, Furasolidonum, “Biseptolum”, Phtourhinolons.
Revealing of patients. In the center all patients with dysfunction of intestinal tract
are subject to active revealing, provisional hospitalization and bacteriological inspection
(three times prior to the beginning of antibacterial therapy).
Revealing of vibriocarriers
Volume of the work become in everyone concrete case by medical staff.
To obligatory inspection on vibriocarry are subject: contactive with patients and carriers
(three times during the first day), the persons coming in psychiatric and narcological
dispensaries, houses of aged, in establishments with special regimen (one time), serving
personnel of water-line and sewer constructions (one time).
Hospitalization: Patients with cholera (vibriocarriers) are subject to immediate
hospitalization in choleral hospital (ward).
On the contactive make lists with their addresses, places of work, study, time, degree
and character of contact. A character of dialogue, a level of sanitary culture of
communicating is especially taken into account.
The persons having close contact to ill (carrier) in a conditions of life, and also persons
from number of communicating, exposing to identical with ill (carrier) risk of infection
are subject to isolation. Indications to isolation are defined in view of a degree of
contact to the patient. Behind all contact medical supervision within 5 day is established,
under epidemiological indications one time bacterial research and prophylactic treatment
by antibiotics are carried out. Isolation of ill (carrier) is stopped after recovery,
completion of course of antibacterial therapy and reception of negative results of
bacterial researches.
Emergency prophylaxis in the focus: Doxycyclini hydrochlodis (a doze and
course rate - as for treatment).
Extraordinary measures on a cordon of the focus and observation driving off for it
borders are unnecessary. Limiting measures which are the most effective: interdiction of
using of individual river transport, unorganized fishing, bathing.

Urgent conditions at acute intestinal infections (hypovolemic shock).

Pathological processes.

1. Decompensating dehydration of the fourth degree - loss of a liquid in quantity

of 10 % and more to initial weight of a body, hypovolemic shock.
а) extracellular dehydration;
б) general dehydration.
2. Hemoconcentration, disturbance of hemocirculation, hypovolemia.
3. Metabolic acidosis.
4. Acute renal failure: oliguria, anuria, nitrogenemia.
 Diagnostics

Clinical criteria: the temperature is normal, more often - subnormal. The patient
is in consciousness, languid, apathetic, and indifferent. A voice is husky or aphonia.
There is absence of stool and vomiting after the period of plentiful excrements and
vomiting. Facies Hippocratica - the pointed features, cyanosis of a mucous of a mouth
and lips, dark circles under the eyes, sunk down eyeballs. Turgor of a skin is reduced,
folds of a skin are finish slowly, cyanosis of integuments, “a hand of the laundress”.
There are convulsive reductions of groups of muscles, especially musculus
gastrocnemius. Arterial pressure is sharply reduced or not defined, pulse is frequent,
small or not palpated, tones of heart are deaf, and there is dilatation of borders of heart.
Breath is frequent, superficial, and noisy. Urine is not eliminated.
Epidemiological criteria:
1. There is contact with source of an infection - the patient, vibriocarrier, the persons
staying in the centers of cholera;
2. Stay in the focus of cholera, AII with obscure etiology with high lethality, in places of
concentration or moving of the big weights of people.

Laboratory research

1. The analysis of blood;

- The general analysis of blood: erythremia, leukocytosis with rodonuclear shift;
- Hemoconcentration: density of plasma is 1,032 + 0,4 g/m3;
Index of hematocrit is 65,9 + 2,7;
- рН of capillary blood is 7,3 + 0,02;
- Hyposodiumemia is 135 meq/l;
- Hypopotassiemia is 3,5 meq/l;
- Hypochloremia is 96 meq/l;
- Acceleration of the 1st and the 2nd phases of coagulation of blood.
2. The bacteriological analysis of excrements and emetic masses;
3. The serological analysis: reaction of agglutination with pair serums, reaction of
passive hemagglutination - in dynamics.

Tactics

To place the patient in reanimation chamber on “choleric bed”, to warm the

patient with hot-water bottles, to calculate the quantity of a liquid necessary for initial
rehydration, in case of necessarity to separate a vein, to begin rehydration therapy.

Treatment

The phase of initial rehydration: intravenously - solutions "Trisolum",

"Chlosolum", "Acesolum", heated up to 30-40° with volumetric speed of 100-120 ml in
1 minute are entered so that within 1-1,5 hours to enter 4-6 litres of a liquid. At
restoration of pulse and the arterial pressure, occurrence of urine, improvement of a
condition the volumetric speed of introduction of a solution can be reduced up to 50 ml
in 1 minute.
The phase of correction: intravenous drop introduction of the above-stated
solutions with speed of 5-10 ml in one minute in the quantity equal to proceeding loss of
a liquid proceeds.
Occurrence of arrhythmias of a heart, feelings of obdormition of extremities,
feeling of crawling of shivers, decrease of tendinous reflexes - testifies about overdose
of potassium. In this case it is necessary to proceed to introduction of a solution of
which in 1 liter of apyrogenic water it is dissolved 6 g of chloride of sodium and 4 g of
bicarbonate of sodium.
At absence of the symptoms testifying about overdosage of potassium, enteral
reception of salts калия up to 15-20 days of treatment is recommended. At stoppage of
vomitings rehydration will be carried out per os.
Etiological therapy: parenterally – Morphocyclinum - 150 thousand units
intravenously or intramuscularly, 2 times per day, or Sygmamycinum 500 thousand
units are introdused intravenously or intramuscularly 4 times per day. Upon stoppage of
vomiting Tetracyclinum 100 thousand units is appointed intramuscularly 4 times per
day. Upon stoppage of vomiting Tetracyclinum for intake on 0,3 4 times per day within
5 days is appointed.
REALIZATION OF THE LESSON
The purpose is to learn to diagnose cholera and urgent conditions at AII
according to clinic, the epidemiological anamnesis and also to make the plan of
inspection and treatment.
Control questions to the beginning of the lesson.
1. Etiology of cholera.
2. Name a source of an infection.
3. List ways of transfer at cholera.
4. Name clinical forms of cholera.
5. Name complications.
6. What urgent conditions can be observed at acute intestinal infections?
7. What pathological mechanisms underlie an urgent condition at cholera and
others AII?
8. Clinical criteria of hypovolemic shock.
9. Methods and means of therapy of hypovolemia.
10. Clinical attributes of hypopotassiemia.
11. Tactics of initial rehydration and secondary correction of water-electrolytic
losses.
12. With what diseases it is necessary to differentiate cholera?
13. What laboratory methods of research are used at cholera?
 14. Principles of treatment of cholera.

The test
1. Toxins of vibrio cholera are:
1. Exotoxin
2. Endotoxin
3. Enzymes
4. Lowmolecular metabolites
5. Prostanoids
2. Consequences of dehydration at cholera are:
1. Hypovolemia
2. Hemoconcentration
3. Disturbances of microcirculation
4. Metabolic acidosis
5. Tissue hypoxia
3. Initial manifestations of cholera are:
1. Diarrhea
2. High fever
3. Spastic pains in an abdomen
4. Repeated vomiting
5. Convulses
4. The basic clinical attributes of cholera are:
1. The beginning of the disease from diarrhea
2. Vomiting without nausea, "fountain"
3. Plentiful stool irrespective of frequency of defecations
4. Absence of the expressed pains in an abdomen
5. Normal or subfebrile body temperature
5. Clinical attributes of dehydration of the 4th degree:
1. Generalized cyanosis
2. Aphonia
3. Hypothermia
4. Anuria
5. Collapse
6. Clinical attributes of dehydration of the 2nd degree:
1. Decrease of weight of a body more than on 9 %
2. Normal or slightly reduced turgor of a skin
3. Normal body temperature
4. Moderate changes of hemodynamic
5. Repeated vomiting
7. Cholera is differentiated with:
1. Shigellosises
2. Food toxicoinfections, salmonellosis
 3. Poisonings with heavy metals and mushrooms
4. Rotaviral gastroenteritis
5. Escherichiosises
8. The final diagnosis of a cholera put on the basis of positive results of laboratory
researches:
1. Bacterioscopic
2. Bacteriological
3. Serological
4. Immunological
5. Biochemical
9. At treatment of cholera there are used:
1. Intravenous injections of colloid solutions
2. Intravenous injections of isotonic polyionic crystalloid solutions
3. Vasopressore amines
4. Etiological therapy
5. Glucocorticoids
10. Indications to the termination of intravenous rehydration at cholera are:
1. Stabilization of hemodynamics
2. Proof stoppage of vomiting
3. Prevalence of volume of urine over volume of excrements
4. Defecations are rare
5. Reduction of volume of excrements, occurrence of fecal masses in them

For discussion of a theme of the lesson the students study a clinical problem. At
the decision of problems students write in writing-books the clinical diagnosis in view of
the form and severity of the disease, the plan of laboratory-instrumental inspection of the
patient, the plan of treatment with prescription in Latin language of preparations of
antibacterial and pathogenetic action.

PROBLEM
Patient S., 52 years, the bookkeeper. He is hospitalized 10/VIII for the third day
of the disease.
Complaints: in connection with a heavy condition of the patient to collect data on
complaints and development of the disease it was not possible.
The History of disease: (from words of the wife) the patient was ill 8/VIII. On
dawn the liquid stool has appeared, some times, with everyone defecation his condition
became worse; he weakened more and more and more. Temperature is 36,0°. In second
half of day (17 hours) at the patient vomiting has appeared, he already could not rise
from bed and use a bucket. Both the stool and vomiting were plentiful, aqueous. Spasms
have appeared. The urinary excretion is seldom and scanty. In subsequent time diarrhea
and vomiting have stopped, but the condition of the patient became even worse, the
voice was gone, features have become aggravated, there were spasms in the upper and
lower extremities.
Epidemiological anamnesis: 6 days prior to disease he was in the Astrakhan area
in Bitchkovo within 10 days. All free time he carried out on the river Volga: bathed,
dived, fished, floated by a steamship. In the local market bought fruit and vegetables,
sometimes eat not washed.
The objective data: a condition the heaviest. Features are pointed, eyes sunk
down. Integuments are covered cold sticky sweat. Mucous membranes of a mouth are
dry, cyanotic. The upper extremities and a skin of the upper half of trunk are cyanotic.
There is aphonia. There are frequent spasms of extremities. A dyspnea is 26-32 breathes
in one minute. Pulse is threadlike, 126 in one minute. Tones of heart are almost not
listened; the arterial pressure is not defined. At palpation the abdomen is involved and
painless, temperature is 35,6° C.
1. What disease is the most probable?
2. What tactics of the local doctor?