CHOLERA

(Vibrio cholerae)

 Essentials of Diagnosis Patients may have associated vomiting. Anuria,

 Acute diarrheal illness leading to renal failure, hypotension, and circulatory
profound hypovolemia and death if not collapse can occur within hours of diarrhea onset.
addressed promptly Mortality rates as high as 20% to 50% among
 History of travel to endemic area or severe cases can be seen if adequate rehydration
contact with infected person is not available. Death rates of less than 2% are
 Occurs in epidemics under conditions of seen with good case management.
crowding and famine; acquired via
ingestion of contaminated food or water Emergency Department Treatment and
 Sudden onset of frequent, high-volume Disposition
diarrhea The mainstay of treatment is adequate hydration.
 Liquid (“rice water”) stool is gray, turbid Oral rehydration solutions are adequate for mild
and moderate dehydration. Patients with severe
 Rapid development of hypotension,
dehydration are treated with IV lactated Ringer
marked dehydration, acidosis, and
solution and oral rehydration. Adult patients may
hypokalemia
require 10 to 15 L in the first 24 hours. Monitoring
 Positive stool culture confirmatory;
of electrolytes and renal function is ideal, but
serologic testing useful after first week
often not available in areas struck by cholera
epidemics. Hypokalemia is common. Antibiotics
 Differential Diagnosis
are not required for recovery as the illness is self-
 Other small intestinal diarrheal illness
limiting, but doxycycline may reduce the volume of
(eg, salmonellosis, enterotoxigenic E.
diarrhea and shorten the duration of illness.
coli)
 Viral gastroenteritis
 Vasoactive intestinal peptide (VIP)–
producing pancreatic tumor (pancreatic
cholera)

 Treatment
 Vaccine less than 50% effective and is no
longer recommended for travelers
 Rapid replacement of fluid and
electrolytes, especially potassium; can
be done either orally or intravenously
 Cola beverages inhibit cyclic adenosine
monophosphate (cAMP) and reduce
diarrhea, adjunctive to standard volume
repletion Figure 1. Severely dehydrated child during an outbreak in
 Tetracycline and many other antibiotics Uganda. Lethargy and sunken eyes are typical findings. IV
may shorten duration of Vibrio excretion fluids are typically reserved for severe cases. The child is
on a typical cholera cot.
Clinical Summary
Cholera is a severe diarrheal disease caused by
Vibrio cholerae, a gram-negative bacterium. It is
spread via the fecal-oral route and is seen in areas
of poor hygiene and overcrowding. Contamination
of food and water are principle modes of infection.
Endemic disease is present in many areas of the
world with occasional epidemics. Incidence of
disease decreases with age.
Cholera is characterized by massive,
watery, gray, and painless diarrhea. The stool
resembles "rice water" without blood or pus.

Figure 2. Dehydration in Cholera. "Tenting" of the skin of
a dehydrated cholera patient. The presence of tenting
implies moderate to severe dehydration.
Figure 3. Rice Water Stool. Typical "rice water" stool from
cholera patient. Patients with cholera often lose a liter or
more of watery stool an hour.
Figure 4. Cholera Cot. Patient on cholera cot. Use of the
cholera cot allows for monitoring of fluid output and
allows for easier waste control in patients too weak to
leave the bed.
Pearls
1. Cholera is one of only three diseases, along
with plague and yellow fever, that are
internationally notifiable to the World Health
Organization.
2. John Snow's removal of the Broad Street
water pump handle during the 1854 cholera
epidemic in London is considered to be the
beginning of modern field epidemiology.
3. People with blood group O are nine times as
likely to develop life-threatening symptoms.
4. Rapid cholera test kits are available and are
essential for early confirmation of disease in
the first suspected cases.
Deaths in epidemics do not come from toxicity,
but rather from the effects of severe
dehydration, including hyperviscosity and
venous thrombosis.