Difference between revisions of "Cholera"

(Created page for Cholera)
 
(References)
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==Background==
 
==Background==
* Endemic to Asia, Africa, and Central and South America
+
* 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
+
* 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>
 
==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)
+
* 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
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* Acidosis from loss of bicarbonate; muscle cramps from loss of K, Ca
 
* Acidosis from loss of bicarbonate; muscle cramps from loss of K, Ca
 
==Differential Diagnosis of Watery Diarrhea==
 
==Differential Diagnosis of Watery Diarrhea==
* Enterotoxigenic E. coli (most common cause of watery diarrhea)
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* Enterotoxigenic E. coli (most common cause of watery diarrhea)<ref>Marx et al.  “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”.  Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.</ref>
 
* Norovirus (often has prominent vomiting)
 
* Norovirus (often has prominent vomiting)
 
* Campylobacter
 
* Campylobacter
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* Diagnosis can be confirmed by stool cultures on TCBS medium (tell the lab cholera is suspected, so appropriate medium is used).
 
* Diagnosis can be confirmed by stool cultures on TCBS medium (tell the lab cholera is suspected, so appropriate medium is used).
 
==Management==
 
==Management==
* Aggressive volume repletion.  Usually can be given orally if mild/moderate volume depletion; give rehydration solution to replete electrolyte loss.
+
* 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>
 
* Oral rehydration solution includes in 1L of water: 2.6g NaCl, 2.9g Trisodium citrate, 1.5 g KCl, and 13.5 g glucose.
 
* 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.
 
:*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.   
 
* 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.   
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:*Alternatives: ciprofloxacin 1g single dose; doxycycline 300mg single dose; TMP-SMX double strength BID for 3 days; erythromycin 500 QID for 3 days.  <ref><ref>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref></ref>
* Give children Zinc and Vitamin A.
+
* Give children Zinc and Vitamin A. z
  
 
==Sources==
 
==Sources==
 
<references/>
 
<references/>
* Marx et al.  “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”.  Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
 
* Sack DA, et al. Cholera. Lancet 2004; 363:223.
 
* LaRocque R and Harris J.  “Overview of Cholera”, UpToDate.com
 
* LaRocque R and Pietroni M.  “Approach to the Adult with Acute Diarrhea in Developing Countries”.  UpToDate.com
 
* World Health Organization.  Cholera Fact Sheet.  Feb 2014
 
* http://www.ncbi.nlm.nih.gov/pubmed/24481887
 
* http://www.ncbi.nlm.nih.gov/pubmed/20372681
 
  
====Authors====
+
[[Category:ID]]
Kavita Joshi, MD and Alex Koyfman MD
 
<br />
 
Department of Emergency Medicine, UT Southwestern Medical Center / Parkland Memorial Hospital, Dallas, Texas, USA
 

Revision as of 12:49, 1 October 2014

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, which produces an enterotoxin which causes a secretory diarrhea[2]

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

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 depletion. However, most cases are mild.
  • Occasionally seen: sudden watery vomiting, borborygmi, abdominal cramping.

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”)
  • Acidosis from loss of bicarbonate; muscle cramps from loss of K, Ca

Differential Diagnosis of Watery Diarrhea

  • Enterotoxigenic E. coli (most common cause of watery diarrhea)[4]
  • Norovirus (often has prominent vomiting)
  • Campylobacter
  • Non-typhoidal Salmonella
  • Enteroaggregative E. coli (EAEC)
  • Enterotoxigenic Bacteroides fragilis

Workup

  • Diagnosis largely clinical presentation + epidemiological risk factors
  • Fecal smears will NOT show leukocytes or erythrocytes.
  • Diagnosis can be confirmed by stool cultures on TCBS medium (tell the lab cholera is suspected, so appropriate medium is used).

Management

  • 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>
  • 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. Cite error: Closing </ref> missing for <ref> tag</ref>
  • Give children Zinc and Vitamin A. z

Sources

  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.