Cholera: Difference between revisions

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==Background==
==Background==
* Endemic to Asia, Africa, and Central and South America <ref>http://www.who.int/cholera/en/</ref>
*Endemic to Asia, Africa, and Central and South America <ref>http://www.who.int/cholera/en/</ref>
* Occasionally seen on the Gulf Coast of US, due to inadequately cooked seafood.
*Occasionally seen on the Gulf Coast of US, due to inadequately cooked seafood.


===Pathophysiology===
===Pathophysiology===
* Usually Vibrio cholera, which produces an enterotoxin which causes a secretory diarrhea<ref>LaRocque R and Pietroni M.  “Approach to the Adult with Acute Diarrhea in Developing Countries”.  UpToDate.com</ref>
*Usually Vibrio cholera (gram negative), which produces an enterotoxin which causes a secretory diarrhea<ref>LaRocque R and Pietroni M.  “Approach to the Adult with Acute Diarrhea in Developing Countries”.  UpToDate.com</ref>
**Toxin causes increase in cell cAMP leading to secretion of water and electrolytes into the gut lumen


===Natural History===
===Natural History===
* Transmission via ingestion of contaminated food or water, usually undercooked seafood
*Transmission via ingestion of contaminated food or water, usually undercooked seafood
* Incubation period between hours to 5 days, depending on size of inoculum (usually 1-2 days)<ref>Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41</ref>
*Incubation period between hours to 5 days, depending on size of inoculum (usually 1-2 days)<ref>Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41</ref>
* Most people are asymptomatic, and simply have bacteria in their feces for 7-14 days
*Most people are asymptomatic, and simply have bacteria in their feces for 7-14 days
* Diarrhea is most severe in days 1-2, usually resolves in 7 days
*[[Diarrhea]] is most severe in days 1-2, usually resolves in 7 days
 
===Risk Factors===
*Persons with blood group O are more likely to have severe disease
 
{{Vibrio species}}


==Clinical Features==
==Clinical Features==
* Classic “rice water” diarrhea with fishy odor; usually painless
*Classic “rice water” [[diarrhea]] with fishy odor; usually painless
* Fluid losses can be significant, up to 1L/hr, leading to severe fluid and electrolyte depletion.  However, most cases are mild.
*Fluid losses can be significant, up to 1L/hr, leading to severe fluid and [[electrolyte abnormalities]].  However, most cases are mild.
* Occasionally seen: sudden watery vomiting, borborygmi, abdominal cramping.
*Occasionally seen: sudden watery [[vomiting]], borborygmi, abdominal cramping.
Later manifestations:
Later manifestations:
* Fluid loss may lead to → sunken eyes, dry mouth, cold clammy skin, decreased skin turgor, or wrinkled hands and feet (also known as “washer woman’s hands”)
*[[Dehydration]]] may lead to → sunken eyes, dry mouth, cold clammy skin, decreased skin turgor, or wrinkled hands and feet (also known as “washer woman’s hands”)
* Acidosis from loss of bicarbonate
*[[Acidosis]] from loss of bicarbonate
* Muscle cramps from loss of K, Ca
*Muscle cramps from [[hypokalemia]], [[hypocalcemia]]
 
===Complications===
*Death
*[[Arrhythmia]] from [[electrolyte imbalance]]
*Brain damage from prolonged [[hypoglycemia]] and failure of gluconeogenesis
*Aspiration [[pneumonia]]
*Paralytic [[ileus]]


==Differential Diagnosis ==
==Differential Diagnosis==
{{Template:Diarrhea DDX}}
{{Template:Diarrhea DDX}}


==Diagnosis==
==Evaluation==
===Work-up===
*Diagnosis largely based on clinical presentation + epidemiological risk factors
* Fecal smears will NOT show leukocytes or erythrocytes.   
*Fecal smears will NOT show leukocytes or erythrocytes.   
* Diagnosis can be confirmed by stool cultures on TCBS medium (must inform lab cholera is suspected so appropriate medium is used)
*Diagnosis can be confirmed by stool cultures on TCBS medium (must inform lab cholera is suspected so appropriate medium is used)
*Labs; non-specific abnormalities:
**[[hyponatremia]]
**[[hypokalemia]]
**[[hypoglycemia]]
**hemoconcentration (increased hematocrit & plasma protein concentration) from water depletion)


===Evaluation===
==Management==
* Diagnosis largely based on clinical presentation + epidemiological risk factors
*Aggressive volume repletion (primary treatment)<ref>Sack DA, et al. Cholera. Lancet 2004; 363:223.</ref>
**Mild/moderate dehydration: [[oral rehydration solution]]
**Severe dehydration: [[IV fluids]] - bolus lactated ringers 100ml/kg over 3 hrs
**May require more than 350ml/kg in first 24 hours
*Antibiotics (decreases severity and duration of disease)<ref>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref>
**Use local susceptibility to choose if available
**Option 1: [[doxycycline]] 300mg x 1 PO<ref name="Stanford">Stanford Guide to Antimicrobial Therapy 2014.</ref>
**Option 2: [[azithromycin]] 1 gm (20mg/kg) x 1 PO <ref name="Stanford" />^
**Option 3: [[erythromycin]] 500 QID x 3 days<ref name="Stanford" />^@
**Option 4: [[ciprofloxacin]] 1g x 1 PO
**Option 5: [[TMP-SMX]] DS BID s 3 days
*Give children Zinc and Vitamin A supplementation


==Management==
:^Pregnant
* Aggressive volume repletion.  Usually can be given orally if mild/moderate volume depletion; give rehydration solution to replete electrolyte loss. <ref>Sack DA, et al. Cholera. Lancet 2004; 363:223.</ref>
:@Children
* Oral rehydration solution includes in 1L of water: 2.6g NaCl, 2.9g Trisodium citrate, 1.5 g KCl, and 13.5 g glucose.
:*If severe dehydration, bolus with 100 ml/kg over 3 hrs.  LR is solution of choice.  May require more than 350 ml/kg in first 24 hours.
* Antibiotic treatment decreases severity and duration of disease.  Antibiotic resistance patterns are changing constantly.  Most recommended currently is azithromycin 20mg/kg single dose. 
:*Alternatives: [[ciprofloxacin]] 1g single dose; [[doxycycline]] 300mg single dose; [[TMP-SMX]] double strength BID for 3 days; [[erythromycin]] 500 QID for 3 days.  <ref>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref>
* Give children Zinc and Vitamin A.


==Disposition==
==Disposition==
*Admit if hypotensive or hemodynamically unstable, severe electrolyte abnormalities
*Admit if [[hypotensive]] or hemodynamically unstable, severe [[electrolyte abnormalities]]
 


==See Also==
==See Also==
*[[Diarrhea]]
*[[Diarrhea]]
*[[Travel Medicine]]
*[[Travel medicine]]


==References==
==References==
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[[Category:ID]]
[[Category:ID]]
[[Category:TropMed]]
[[Category:Tropical Medicine]]

Revision as of 17:13, 28 August 2019

Background

  • Endemic to Asia, Africa, and Central and South America [1]
  • Occasionally seen on the Gulf Coast of US, due to inadequately cooked seafood.

Pathophysiology

  • Usually Vibrio cholera (gram negative), which produces an enterotoxin which causes a secretory diarrhea[2]
    • Toxin causes increase in cell cAMP leading to secretion of water and electrolytes into the gut lumen

Natural History

  • Transmission via ingestion of contaminated food or water, usually undercooked seafood
  • Incubation period between hours to 5 days, depending on size of inoculum (usually 1-2 days)[3]
  • Most people are asymptomatic, and simply have bacteria in their feces for 7-14 days
  • Diarrhea is most severe in days 1-2, usually resolves in 7 days

Risk Factors

  • Persons with blood group O are more likely to have severe disease

Vibrio species

Clinical Features

  • Classic “rice water” diarrhea with fishy odor; usually painless
  • Fluid losses can be significant, up to 1L/hr, leading to severe fluid and electrolyte abnormalities. However, most cases are mild.
  • Occasionally seen: sudden watery vomiting, borborygmi, abdominal cramping.

Later manifestations:

  • Dehydration] may lead to → sunken eyes, dry mouth, cold clammy skin, decreased skin turgor, or wrinkled hands and feet (also known as “washer woman’s hands”)
  • Acidosis from loss of bicarbonate
  • Muscle cramps from hypokalemia, hypocalcemia

Complications

Differential Diagnosis

Acute diarrhea

Infectious

Noninfectious

Watery Diarrhea

Traveler's Diarrhea

Evaluation

  • Diagnosis largely based on clinical presentation + epidemiological risk factors
  • Fecal smears will NOT show leukocytes or erythrocytes.
  • Diagnosis can be confirmed by stool cultures on TCBS medium (must inform lab cholera is suspected so appropriate medium is used)
  • Labs; non-specific abnormalities:

Management

  • Aggressive volume repletion (primary treatment)[5]
    • Mild/moderate dehydration: oral rehydration solution
    • Severe dehydration: IV fluids - bolus lactated ringers 100ml/kg over 3 hrs
    • May require more than 350ml/kg in first 24 hours
  • Antibiotics (decreases severity and duration of disease)[6]
  • Give children Zinc and Vitamin A supplementation
^Pregnant
@Children

Disposition


See Also

References

  1. ↑ http://www.who.int/cholera/en/
  2. ↑ LaRocque R and Pietroni M. “Approach to the Adult with Acute Diarrhea in Developing Countries”. UpToDate.com
  3. ↑ Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41
  4. ↑ Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  5. ↑ Sack DA, et al. Cholera. Lancet 2004; 363:223.
  6. ↑ Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6
  7. ↑ 7.0 7.1 7.2 Stanford Guide to Antimicrobial Therapy 2014.
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