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%