Difference between revisions of "Cholera"

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==Background==
 
==Background==
* Endemic to Asia, Africa, and Central and South America <ref>http://www.who.int/cholera/en/</ref>
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*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.
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*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>
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*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
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*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>
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*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
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*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
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*Diarrhea is most severe in days 1-2, usually resolves in 7 days
  
 
{{Vibrio species}}
 
{{Vibrio species}}
  
 
==Clinical Features==
 
==Clinical Features==
* Classic “rice water” diarrhea with fishy odor; usually painless
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*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.
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*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.
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*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”)
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*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
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*Acidosis from loss of bicarbonate
* Muscle cramps from loss of K, Ca
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*Muscle cramps from loss of K, Ca
  
 
==Differential Diagnosis ==
 
==Differential Diagnosis ==
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==Diagnosis==
 
==Diagnosis==
 
===Work-up===
 
===Work-up===
* Fecal smears will NOT show leukocytes or erythrocytes.   
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*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)
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*Diagnosis can be confirmed by stool cultures on TCBS medium (must inform lab cholera is suspected so appropriate medium is used)
  
 
===Evaluation===
 
===Evaluation===
* Diagnosis largely based on clinical presentation + epidemiological risk factors
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*Diagnosis largely based on clinical presentation + epidemiological risk factors
  
 
==Management==
 
==Management==

Revision as of 18:13, 5 July 2016

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

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 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

Noninfectious

Watery Diarrhea

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

  1. Aggressive volume repletion (primary treatment)[5]
  2. Antibiotics (decreases severity and duration of disease)[6]
  3. Give children Zinc and Vitamin A supplementation
^Pregnant
@Children

Disposition

  • Admit if hypotensive or hemodynamically unstable, severe electrolyte abnormalities

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. Stanford Guide to Antimicrobial Therapy 2014.
  8. Stanford Guide to Antimicrobial Therapy 2014.
  9. Stanford Guide to Antimicrobial Therapy 2014.