Cholera: Difference between revisions
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* 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 | * 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 | * Acidosis from loss of bicarbonate | ||
* Muscle cramps from loss of K, Ca | |||
==Differential Diagnosis == | ==Differential Diagnosis == | ||
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==Diagnosis== | ==Diagnosis== | ||
===Work-up=== | |||
* 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 ( | * Diagnosis can be confirmed by stool cultures on TCBS medium (must inform lab cholera is suspected so appropriate medium is used) | ||
===Evaluation=== | |||
* Diagnosis largely based on clinical presentation + epidemiological risk factors | |||
==Management== | ==Management== | ||
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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>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref> | :*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. | * Give children Zinc and Vitamin A. | ||
==Disposition== | |||
*Admit if hypotensive or hemodynamically unstable, severe electrolyte abnormalities | |||
==See Also== | ==See Also== | ||
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*[[Travel Medicine]] | *[[Travel Medicine]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:ID]] | [[Category:ID]] | ||
[[Category:TropMed]] | [[Category:TropMed]] |
Revision as of 07:18, 18 August 2015
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
Acute diarrhea
Infectious
- Viral (e.g. rotavirus)
- Bacterial
- Campylobacter
- Shigella
- Salmonella (non-typhi)
- Escherichia coli
- E. coli 0157:H7
- Yersinia enterocolitica
- Vibrio cholerae
- Clostridium difficile
- Parasitic
- Toxin
Noninfectious
- GI Bleed
- Appendicitis
- Mesenteric Ischemia
- Diverticulitis
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
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
Traveler's Diarrhea
Diagnosis
Work-up
- 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)
Evaluation
- Diagnosis largely based on clinical presentation + epidemiological risk factors
Management
- Aggressive volume repletion. Usually can be given orally if mild/moderate volume depletion; give rehydration solution to replete electrolyte loss. [5]
- 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. [6]
- Give children Zinc and Vitamin A.
Disposition
- Admit if hypotensive or hemodynamically unstable, severe electrolyte abnormalities
See Also
References
- ↑ http://www.who.int/cholera/en/
- ↑ LaRocque R and Pietroni M. “Approach to the Adult with Acute Diarrhea in Developing Countries”. UpToDate.com
- ↑ Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41
- ↑ 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.
- ↑ Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6