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ESSENTIALS OF DIAGNOSIS

  • History of travel in endemic area or contact with infected person.

  • Voluminous diarrhea (up to 15 L/day).

  • Characteristic “rice water stool.”

  • Rapid development of marked dehydration.

  • Positive stool cultures and agglutination of vibrios with specific sera.

GENERAL CONSIDERATIONS

Cholera is an acute diarrheal illness caused by certain serotypes of Vibrio cholerae. The disease is toxin-mediated, and fever is unusual. The toxin activates adenylyl cyclase in intestinal epithelial cells of the small intestines, producing hypersecretion of water and chloride ion and a massive diarrhea of up to 15 L/day. Death results from profound hypovolemia. Cholera occurs in epidemics under conditions of crowding, war, and famine (eg, in refugee camps) and where sanitation is inadequate. Infection is acquired by ingestion of contaminated food or water. For over a century, cholera was rarely seen in the Western Hemisphere until an outbreak occurred in Peru, starting in the early 1990s and ending by 2001; the outbreak resulted in almost 400,000 cholera cases and more than 4000 deaths. Cholera again became a rare disease in the Western Hemisphere until late 2010, when there was a massive earthquake in Haiti followed by a cholera outbreak that resulted in thousands of deaths.

CLINICAL FINDINGS

Cholera is characterized by a sudden onset of severe, frequent watery diarrhea (up to 1 L/h). The liquid stool is gray; turbid; and without fecal odor, blood, or pus (“rice water stool”). Dehydration and hypotension develop rapidly. Stool cultures are positive, and agglutination of vibrios with specific sera can be demonstrated.

PREVENTION

A vaccine is available that confers short-lived, limited protection and may be required for entry into or reentry after travel to some countries. It is administered in two doses 1–4 weeks apart. A booster dose every 6 months is recommended for persons remaining in areas where cholera is a hazard.

Vaccination programs are expensive and not particularly effective in managing outbreaks of cholera. When outbreaks occur, efforts should be directed toward establishing clean water and food sources and proper waste disposal.

TREATMENT

Treatment is by replacement of fluids. In mild or moderate illness, oral rehydration usually is adequate. A simple oral replacement fluid can be made from 1 teaspoon of table salt and 4 heaping teaspoons of sugar added to 1 L of water. Intravenous fluids are indicated for persons with signs of severe hypovolemia and those who cannot take adequate fluids orally. Lactated Ringer infusion is satisfactory.

Antimicrobial therapy will shorten the course of illness. Antimicrobials active against V cholerae include tetracycline, ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, fluoroquinolones, and azithromycin. Multiple drug-resistant strains exist, so susceptibility testing, if available, is advisable. A single 1 g oral dose of azithromycin is effective for severe cholera caused by strains with reduced susceptibility to fluoroquinolones, but resistance is emerging to this drug as well.

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