CHOLERA

Acute diarrheal disease

Profound secretory diarrhoea
Dehydration
Hypovolemic shock
Native to the Ganges delta

ETIOLOGY :
VIBRIO CHOLERA
Gram negative bacilli
0.20.4 um X 1.54 um

Serogroup :

V. cholera O1

V. cholera classic
V. cholera El Tor
V. cholera non O1 -> O2 . O139 Bengal
Serotype : Ogawa
Inaba
Hikojima

EPIDEMIOLOGY
Worldwide
Endemic, epidemic and pandemic
No animal reservoir
Transmission by ingestion of

contaminated water, food

Relatively high infectious dose
High risk : children, type O blood
group

THE CHRONOLOGY OF KING CHOLERA

At Home
to 1817 --------------------- Endemic to Indian subcontinent
The Historic Pandemic
1817-23 ----------------------------------------First Pandemic
1829-50 -------------------------------------Second Pandemic
1852-60 ---------------------------------------Third Pandemic
John Snow and the Broad Street pump (1854)
1863-79 -------------------------------------Fourth Pandemic
The Classical Pandemic
1881-96 ---------------------------------------Fifth Pandemic
Robert Koch and the comma bacillus (1883)
1899-1923 ------------------------------------Sixth Pandemic
The El Tor Pandemic
1961 to date -------------------------------Seventh Pandemic
O139 Bengal Pandemic
1993 to date ----------------------------------Eigth Pandemic

PATHOGENESIS

(1)

Ingestion of V. cholera
Transverse the acidic gastric

environment
Colonized in the upper small bowel
Attachment mediated by TCP (toxin
coregulated pilus)
Production of CT (cholera toxin)
Secretory diarrhoea dehydration
shock

PATHOGENESIS

.(2)

CT : subunit A (monomeric enzymatic)

subunit B (pentameric binding)

Subunit B bind to GMI ganglioside -
A subunit enter the cell activate
adenylate cyclase accumulation of
cAMP inhibit Na+ absorption,
activate Cl & HCO3 excretion NaCl
accumulation in lumen followed by
water

Mode of Action of Cholera

Toxin

IMMUNITY
Poorly understood
Antibacterial effect of mucosal

surface
Secretory IgA
Serum antibody is not protective

CLINICAL MANIFESTATIONS
Incubation period : 24 48 hours
Sudden onset of watery diarrhoea

voluminous diarrhoea (rice water

stool) and vomiting
Severe case: stool volume 250 ml/kg
Parallel to volume contraction
Dehydration hypovolemic shock
Electrolyte disturbances

CLINICAL MANIFESTATIONS
: electrolyte disturbances
Bicarbonate

metabolic acidosis
Kussmaul respiration
Potasium
weakness
electrocardiogram changes
paralytic ileus
cardiac arrythmia
cardiac arrest

CLINICAL MANIFESTATIONS
: volume depletion
Tachycardia, pulse

volume decreased
Hypotension
Respiratory rate
increased
Kussmaul resp.
Sunken eyes & cheeks
Dry mucous
membranes
Skin turgor decreased

Washer women hand

Scaphoid abdomen
Oliguria/anuria
Thirst
Altered mentation

(restlessness,
irritability, weakness.
lethargy, stupor)

Electrolyte composition of cholera stool and of fluids

used for hydration of patients with cholera
-----------------------------------------------------------------------------------------Electrolyte and glucose conc (mmol/liter)
Osmolality
Fluid
Na
Cl
K
HCO 3
Glucose or (mosmol/l)
Dextrose
-----------------------------------------------------------------------------------------Cholera stool
Adults
130
100
20
44
0
300
Children
100
90
33
30
0
300
WHO ORT
90
80
20
30
111
331
Intravenous solutions
Lactated Ringers 130
109
4
28
0
271
Dhaka
133
98
13
48
0
292
Normal saline
154
154
0
0
0
348

ELECTROLYTE COMPOSITION OF
CHOLERA STOOL AND PLASMA
Cholera stool

Plasma
(mmol/liter)

(mmol/liter)

Na+130
Cl K+
HCO3-

100
20
44

Na+136 145
Cl K+
HCO3-

96 - 106
3,5 5
22 - 31

LABORATORY FINDINGS
Elevated haematocrite
Increased plasma specific gravity
Elevated WBC count
Elevation of BUN and creatinine
Low arterial pH
Reduced bicarbonate level
Hypokalemia

DIAGNOSIS
Anamnesis
Physical examination
Laboratory
Culture :

transport media Carey-Blair

medium TCBS (thiosulfate-citratebile-salts)

DEHYDRATION

(1)

Based on:
Clinical findings : mild, moderate,
severe
score
Central venous pressure
Laboratory : plasma specific gravity
Na

DEHYDRATION
Mild dehydration (3-5 % BW)

.(2)

skin turgor decreased

tachycardia
thirst
Moderate dehydration (8 % BW)
skin turgor decreased
postural hypotension
tachycardia, weak pulse
inrease sensation of thirst

DEHYDRATION

(3)

Severe dehydration (> 10 % BW)

skin turgor markedly decreased

oliguria anuria
weak absent pulse
sunken eyes
wrinkled skin (washer women hand)
somnolence coma
shock

TREATMENT
Initial volume replacement
Score
------- X 0.1 X BW (kg) X 1 (liter)
15
Plasma SP 1.025
------------------- X BW (kg) X 4 ml
0.001

Antibiotics : tetracycline, doxycycline,

cotrimoxazole

DIFFERENTIAL DIAGNOSIS
Vibrio parahaemolitycus
Enteropathogenic E. coli
Enterotoxigenic E. coli
Rotavirus
Salmonella sp
Shigella sp
Campylobacteriosis
Malaria cholerica