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

V. cholera O1

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 HCO3 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
(mmol/liter)

Plasma
(mmol/liter)

Na+ Cl K+ HCO3-

130 100 20 44

Na+

136 145 Cl96 - 106 K+ 3,5 5 HCO322 - 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 .(2)
Mild dehydration (3-5 % BW)

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