Cholera

Cholera is a toxinfection of the small intestine by certain strains of the gram-negative, comma-shaped bacterium Vibrio cholerae or vibrio vibrio. The condition can present without any symptoms, in mild or severe form. The classic symptom is profuse diarrhea, often complicated with acidosis, hypokalemia, muscle cramps, and vomiting, lasting a couple of days. The diarrhea can be so severe that it can lead to severe dehydration and electrolyte imbalance within hours. This can result in sunken eyes, cold skin, decreased skin elasticity, and wrinkling of the hands and feet. Dehydration can cause cyanosis, a bluish color of the skin. Symptoms begin two hours to five days after exposure.

Cholera is caused by a number of types of Vibrio cholerae, and some types are capable of causing more severe illness than others. These bacteria mostly develop in water and food that has been contaminated with human feces containing bacteria. Inadequately cooked seafood is also a common source. Humans are the only ones affected by these pathogens. Risk factors for the disease include poor hygiene and inadequate availability of drinking water. Cholera can be diagnosed by a stool test. A rapid test is also available, but it is not as accurate.

Prevention consists of providing adequate sanitation and providing access to clean water. Orally administered cholera vaccines provide reasonable protection for about six months and have the advantage of also protecting against E. coli infection. The primary treatment is oral rehydration therapy, which is the replacement of fluids with mildly sweet and salty solutions. Rice-based solutions are preferred. Zinc supplementation is helpful in children. In severe cases, intravenous fluids, such as Ringer’s lactate, may be required, and antibiotics may provide benefit. Testing to highlight which type of antibiotic is most effective in dealing with the infection can help in choosing the optimal treatment.

Cholera affects approximately 3 to 5 million people worldwide and had caused between 58,000 and 130,000 deaths in 2010. Although it is currently classified as a pandemic, it is very rare in the developed world. Children are the most likely to become infected. Cholera occurs both as a localized epidemic and as a chronic endemic in some areas. Areas that have a permanent risk of the disease include Africa and Southeast Asia. Although the risk of death among infected people is usually less than 5%, this figure can be as high as 50% in some groups that do not have access to treatment. Some historical descriptions of cholera are found as early as the 5th century BC in some Sanskrit writings. English physician John Snow’s study of the disease between 1849 and 1854 led to significant advances in the field of epidemiology. The bacterium was first identified in 1854 by Italian anatomist Filippo Pacini and studied in detail in 1884 by German physician Robert Koch. The name comes from the Greek choléra (cholé = bile) and indicated the disease that violently discharged the body’s humors and the consequent state of mind: anger.

Symptoms

The manifestations of cholera are variable from an asymptomatic state to one of profuse diarrhea, in the absence of abdominal pain and rectal tenesmus, which appears after 24-48 hours of incubation. In this case it can be up to a loss of one liter of feces in one hour with consequent state of dehydration that can culminate in a state of hypovolemic shock. The discharges are short (50-150 ml eliminated per discharge) and frequent (50 to 100 discharges daily). The person presents with thirst, weakness, rarely sensory dulling without delirium, hypotension, tachycardia, and tachypnea.

The skin is clammy and cold (due to acidosis and hypokalemia) and the mucous membranes are dry. Potassium loss may result in the development of muscle cramps. Fluid depletions greater than 10% of the individual’s weight can lead to oligo-anuria (there may be the possibility of acute tubular necrosis resulting in renal failure), filiform pulse, marked hypotension, tachycardia with filiform pulse, eye dimpling, wrinkling of the skin (“mummy facies”), and drowsiness to coma.

The loss of bicarbonate with the feces generates a state of metabolic acidosis to which are added alterations of electrolytes and increased hematocrit (due to increased blood concentration caused by water loss).

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