Updated: 12/22/2021

Cholera

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  • Snapshot
    • A 20-year-old woman presents to a local travel clinic. She reports that she will be traveling throughout Africa on a medical mission and subsequent safari vacation. She is concerned about disease endemic to the area, including cholera. Her physician reassures her that there is a vaccine available for cholera, as long as she takes it ten days prior to traveling.
  • Introduction
    • Classification
      • Vibrio cholerae
        • a comma-shaped, flagellated, and gram - rod
        • oxidase + and produces cholera toxin
      • transmission
        • fecal-oral via water or uncooked food
    • Prevention
      • live-attenuated oral cholera vaccine
        • indication
          • adults traveling to endemic areas
          • > 10 days prior to travel
  • Epidemiology
    • Incidence
      • rare in the United States
    • Demographics
      • endemic in developing countries
      • most severe in children
    • Risk factors
      • raw seafood
      • contaminated water
      • travel
  • ETIOLOGY
    • Pathogenesis
      • acid-labile enterotoxin activates Gs and overactivates adenylate cyclase, causing ↑ cAMP
        • requires large inoculum or decreased acidity in the host’s stomach
        • causes ↑ chloride secretion, resulting in secretory diarrhea and water efflux
        • this results in loss of potassium and bicarbonate
  • Presentation
    • Symptoms
      • may be asymptomatic
      • acute onset
        • painless rice-water secretory diarrhea
        • nausea
        • vomiting
    • Physical exam
      • dehydration
        • sunken eyes
        • dry mucous membranes
        • decreased skin turgor
  • Studies
    • Labs
      • stool culture in alkaline media
        • definitive diagnosis but not always necessary
        • no white blood cells in stool
      • electrolyte abnormalities
        • hypokalemia
        • hyponatremia
        • metabolic acidosis
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Norovirus diarrhea
      • distinguishing factors
        • often associated with cruise ships, child care centers, or other crowded condition
        • typically self-limited
        • no association with geographic locations unlike cholera
    • Campylobacter jejuni-associated diarrhea
      • distinguishing factors
        • bloody diarrhea
        • comma-shaped but does not grow in alkaline media
        • white blood cells in stool
  • Treatment
    • Management approach
      • management is centered around rapid rehydration
    • Conservative
      • oral rehydration
        • indication
          • all patients
      • intravenous hydration
        • indication
          • severe dehydration
    • Medical
      • antibiotics
        • indication
          • severe dehydration
        • drugs
          • doxycycline
          • tetracycline
          • ciprofloxacin
  • Complications
    • Rapid dehydration
    • Hypovolemic shock
    • Death
  • Prognosis
    • If untreated, mortality is > 50%
    • If treated, mortality is < 1%
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