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For further information, see CMDT Part 33-20: Cholera

Key Features

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

General Considerations

  • An acute diarrheal illness caused by certain serotypes of Vibrio cholerae

  • 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

  • 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


  • Rarely seen in the Western Hemisphere until an outbreak occurred in Peru in the early 1990s, resulting in thousands of deaths before it ended in 2001

  • Rarely seen in the Western Hemisphere between 2001 and 2010, until an ongoing outbreak erupted in Haiti in 2010 after an earthquake, resulting in thousands of deaths

Clinical Findings

Symptoms and Signs

  • See Table 30–3

  • 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

  • The disease is toxin mediated, and fever is unusual

Table 30–3.Acute bacterial diarrheas and "food poisoning" (listed in alphabetical order).

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