Vibrio Cholera

Aka: Vibrio Cholera, Cholera, Vibrio Cholerae

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II. History

  1. Various modern outbreaks
    1. Yemen as of 2016-2017 has the largest Cholera outbreak in history
    2. Bangladash (1993 post-monsoon potable water contamination)
    3. Latin America and South America (1991 improper sewage processing)
    4. Indonesia had onset in the 1960s of an ongoing Cholera epidemic
    5. Cholera was limited to Asia until 1817, when it spread to India and then globally
  2. London Physician John Snow (1813-1858)
    1. Famous role in public health history
    2. Linked Cholera outbreak to Broad Street Pump in 1854
      1. Proved Cholera to be a Waterborne Illness
      2. Ghost Map is a literary account of his epidemiological investigation
        1. https://en.wikipedia.org/wiki/The_Ghost_Map
      3. Concurrent epidemic in Italy in 1854
        1. Lead to identification of Vibrio Cholera organism by Filippo Pacini, a florence physician
    3. Snow was also a proponent of Anesthesia in childbirth
      1. Knighted by Queen Victoria on birth of seventh child

III. Pathophysiology

  1. Characteristics
    1. Vibrio Cholera is a facultative Anaerobic Gram Negative Rod in Vibrionaceae family
    2. All Vibrio genus Bacteria are curved (crescent shaped) and motile with a single polar flagellum
  2. Organism survival
    1. Not viable in pure water (stable in salt water)
    2. Survives up to 24 hours in sewerage
    3. Survives in impure water with organics for 6 weeks
    4. Withstands freezing for 3-4 days
    5. Readily killed by drying, heat, or disinfectants
  3. Pathogenesis
    1. Incubation: 4 hours to 5 days (average 1-2 days)
    2. Causes Toxigenic, Secretory Diarrhea (similar but more severe than Enterotoxigenic E. coli or ETEC)
      1. Enterotoxin adheres to intestinal epithelial cell (but does not invade)
      2. Severe fluid loss occurs in Small Bowel
      3. Large Intestine is overwhelmed by large fluid volume
        1. Unable to reabsorb majority of fluid losses
        2. Results in profuse, rice-water Diarrhea (up to 1 Liter/hour)
    3. Cholera Enterotoxin (Choleragen)
      1. Similar to Heat Labile (LT) toxin of Enterotoxigenic E. coli (ETEC)
      2. B-Subunits (5)
        1. Bind GM1 gangliosides on intestinal cell membranes
      3. A-Subunits (2)
        1. Acts at GTP-binding Protein (ADP-ribosylation)
        2. Activates membrane associated adenylate cyclase, converting ATP to cAMP
        3. Increased cAMP levels induce Sodium chloride (NaCl) secretion, and inhibit its reabsorption
        4. Results in osmotic water losses (as well as Electrolytes, e.g. bicarbonate and Potassium)
  4. Transmission
    1. Large infectious dose needed to cause disease
    2. Fecal contamination of food or water
      1. Waterborne Illness (most common)
      2. Foodborne Illness
    3. Heavily soiled hands or utensils
    4. Biological Weapon
      1. Infective aerosol dose: 10-500 organisms

IV. Symptoms

  1. Asymptomatic to severe sudden onset
    1. Only 1 symptomatic patient for every 400 infected
  2. Vomiting
  3. Headache
  4. Intestinal cramping
  5. Low grade fever or afebrile
  6. Painless voluminous Diarrhea
    1. Rice water stools
  7. Fluid losses: 5-10 liters per day (up to 15 liters per day)

V. Signs

  1. Severe Dehydration
  2. Hypovolemia to shock
  3. Manifestations of Electrolyte disturbance (e.g. Hypokalemia, Hypomagnesemia)

VI. Course

  1. Usual duration: 1 week
  2. Death may occur due to severe Dehydration if untreated
    1. Mortality rates approach 50% from Dehydration without aggressive Fluid Replacement
    2. Mortality 0.2% with aggressive rehydration (see below)

VII. Labs

  1. See Acute Diarrhea
  2. Enteric Pathogens Nucleic Acid Test Panels
  3. Stool microscopy
    1. Darting, motile short curved Gram Negative Rods
    2. No or minimal Fecal Occult Blood
    3. No or minimal Fecal Leukocytes
    4. Other microscopy modalities
      1. Darkfield microscopy
      2. Phase contrast microscopy

VIII. Management: General

  1. See Oral Rehydration Therapy
  2. Cholera has a high mortality, not via invasive disease, but via severe Dehydration
  3. Fluid and Electrolyte replacement
    1. Aggressive fluid and Electrolyte replacement is the key to effective management (drops mortality from 50% to 0.2%)
    2. Lactated Ringers is preferred crystalloid if IV hydration is required
    3. Replace Electrolytes (e.g. Potassium)

IX. Management: Antibiotics

  1. Indication: Moderate to severe disease
    1. May shorten the duration of Diarrhea
    2. Reduces Bacterial shedding
  2. Adult Preparations
    1. Tetracycline 500 mg four times daily for 3 days
    2. Doxycycline 300 mg x1 dose or 100 mg bid for 3 days
    3. Azithromycin 500 mg orally daily for 3 days (or 1 g for 1 dose)
    4. Erythromycin 250 mg orally three times daily for 3 days
    5. Ciprofloxacin 1 g orally for 1 dose
  3. Child Preparations
    1. Azithromycin 10 mg/kg/day orally daily for 3 days
    2. Erythromycin 30 mg/kg/day orally divided three times daily for 3 days
  4. References
    1. Gilbert (2016) Sanford Guide, accessed 9/12/2016

X. Prevention

  1. Water Disinfection
    1. Dry heat at 117 degrees C (steam or boiling)
    2. Short exposure to disinfectants
    3. Water chlorination
  2. Good Hygiene
    1. Frequent Hand Washing
    2. Exclusive use of safe water and food
  3. Licensed killed Cholera Vaccine
    1. Indicated during epidemics
    2. Efficacy: 50-86% protection lasts only 6 months
    3. Vaccine schedule
      1. Initial Doses: 0 and 4 weeks
      2. Booster Doses: every 6 months
    4. References
      1. Luquero (2014) N Engl J Med 370(22): 2111-20 +PMID: 24869721 [PubMed]

XI. Prognosis: Indicators of severe disease and worse outcomes

  1. Difficult access to medical services
  2. Blood Type O (45% of U.S. persons)
  3. Low gastric acidity
    1. Antacid therapy
    2. Partial gastrectomy

XII. Resources

  1. CDC Cholera
    1. http://www.cdc.gov/cholera/index.html
  2. WHO Cholera
    1. http://www.who.int/cholera/en/

XIII. References

  1. Harris (2012) Lancet 379(9835): 2466-76 +PMID:22748592 [PubMed]
  2. Lippi (2016) Microbiol Spectr 4(4) +PMID: 27726771 [PubMed]

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Related Studies

Ontology: Cholera (C0008354)

Definition (MEDLINEPLUS)

Cholera is a bacterial infection that causes diarrhea. The cholera bacterium is usually found in water or food contaminated by feces (poop). Cholera is rare in the US. You may get it if you travel to parts of the world with inadequate water treatment and poor sanitation, and lack of sewage treatment. Outbreaks can also happen after disasters. The disease is not likely to spread directly from one person to another.

Often the infection is mild or without symptoms, but sometimes it can be severe. Severe symptoms include profuse watery diarrhea, vomiting, and leg cramps. In severe cases, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.

Doctors diagnose cholera with a stool sample or rectal swab. Treatment includes replacing fluid and salts and sometimes antibiotics.

Anyone who thinks they may have cholera should seek medical attention immediately. Dehydration can be rapid so fluid replacement is essential.

Centers for Disease Control and Prevention
Definition (MSH) An acute diarrheal disease endemic in India and Southeast Asia whose causative agent is VIBRIO CHOLERAE. This condition can lead to severe dehydration in a matter of hours unless quickly treated.
Definition (CSP) acute diarrheal disease endemic in India and southeast Asia whose causative agent is Vibrio cholerae; can lead to severe dehydration in a matter of hours unless quickly treated.
Concepts Disease or Syndrome (T047)
MSH D002771
ICD9 001.9, 001.0, 001
ICD10 A00 , A00.9, A00.0
SnomedCT 186087007, 154269008, 61972007, 187267007, 186089005, 186088002, 63650001
English Choleras, Cholera due to Vibrio cholerae, Cholera - O1 group V cholerae, Cholera - O1 group Vibrio cholerae, Cholera - Vibrio cholerae, Cholera, unspecified, [X]Cholera, unspecified, cholera (diagnosis), cholera, cholera due to Vibrio cholerae, cholera due to Vibrio cholerae (diagnosis), Vibrio cholera gastroenteritis, Vibrio cholerae gastroenteritis, Unspecified cholera, Cholera NOS, Cholera d/t vib cholerae, Classical cholera, Cholera [Disease/Finding], asiatic cholera, choleras, epidemic cholera, Cholera due to vibrio cholerae, (Cholera) or (Vibrio cholerae), Vibrio cholerae, [X]Cholera, unspecified (disorder), Cholera - Vibrio cholerae (disorder), (Cholera) or (Vibrio cholerae) (disorder), Cholera due to Vibrio cholerae (disorder), Cholera NOS (disorder), Vibrio cholerae infection, Cholera (disorder), cholera; classical, classical; cholera, Vibrio cholerae 01; cholera, Cholera, NOS, Cholera
Dutch niet-gespecificeerde cholera, cholera door Vibrio cholerae, Vibrio cholerae-gastro-enteritis, cholera, niet-gespecificeerd, Vibrio cholerae gastro-enteritis, Vibrio cholerae 01; cholera, cholera; klassiek, klassiek; cholera, Cholera, niet gespecificeerd, cholera, Cholera
French Gastro-entérite à Vibrio cholera, Gastroentérite à Vibrio cholerae, Choléra, non précisé, Choléra non précisé, Choléra à Vibrio cholerae, Choléra
German Cholera, unspezifisch, unspezifische Cholera, Cholera, verursacht durch Vibrio cholerae, Vibrio cholera-Gastroenteritis, Vibrio cholerae-Gastroenteritis, Cholera, nicht naeher bezeichnet, Cholera
Italian Gastroenterite da Vibrio cholerae, Colera, non specificato, Colera non specificato, Colera da Vibrio cholerae, Colera
Portuguese Cólera NE, Gastrenterite por Vibrio cholerae, Cólera por Vibrio cholerae, Cólera
Spanish Cólera no especificado, Cólera por Vibrio cholerae, Gastroenteritis por Vibrio cholerae, Gastroenteritis por Vibrio cholera, cólera - Vibrio cholerae (trastorno), [X]cólera, no especificado (trastorno), cólera, SAI (trastorno), cólera, SAI, cólera por Vibrio cholerae (trastorno), cólera - Vibrio cholerae, [X]cólera, no especificado, cólera por Vibrio cholerae, cólera (trastorno), cólera, Cólera
Japanese コレラ、詳細不明, コレラ菌胃腸炎, コレラ, 詳細不明のコレラ, コレラ菌によるコレラ, ｺﾚﾗｼｮｳｻｲﾌﾒｲ, ｼｮｳｻｲﾌﾒｲﾉｺﾚﾗ, ｺﾚﾗｷﾝﾆﾖﾙｺﾚﾗ, ｺﾚﾗｷﾝｲﾁｮｳｴﾝ, ｺﾚﾗ
Swedish Kolera
Czech cholera, Cholera vyvolaná Vibrio cholerae, Cholera, Blíže neurčená cholera, Cholera, blíže neurčená, Gastroenteritida vyvolaná Vibrio cholerae
Finnish Kolera
Russian KHOLERA, ХОЛЕРА
Korean 상세불명의 콜레라, 콜레라
Polish Zakażenie Vibrio cholerae, Cholera
Hungarian nem meghatározott cholera, Vibrio cholerae okozta cholera, Vibrio cholerae gastroenteritis, cholera k.m.n., cholera, Vibrio cholerae által okozott gastroenteritis
Norwegian Kolera
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Vibrio cholerae (C0042629)

Definition (NCI_CDISC) Any bacterial organism that can be assigned to the species Vibrio cholerae.
Definition (NCI) A species of facultatively anaerobic, Gram negative, curved rod shaped bacteria assigned to the phylum Proteobacteria. This species is motile, oxidase and lipase positive, can use a wide variety of sugars as carbon sources, does not require salt for growth, and produces cholera toxin. V. cholerae is the causative agent of cholera.
Definition (CSP) etiologic agent of human Asiatic cholera; some strains produce a milder, cholera-like disease.
Definition (MSH) The etiologic agent of CHOLERA.
Concepts Bacterium (T007)
MSH D014734
SnomedCT 75953000
English Vibrio comma, V. cholerae, Vibrio cholerae Pacini 1854, cholerae vibrio, cholera vibrio, vibrio cholera, vibrio cholerae, v. cholerae, Bacillo virgola del Koch, Bacillus cholerae, Bacillus cholerae-asiaticae, Kommabacillus, Liquidivibrio cholerae, Microspira comma, Pacinia cholerae-asiaticae, Spirillum cholerae, Spirillum cholerae-asiaticae, Vibrio cholera, Vibrio cholerae-asiaticae, VIBRIO CHOLERAE, VIBRIO COMMA, Vibrio cholerae (organism), Vibrio cholerae
French Vibrion cholérique, Vibrio comma, Vibrio cholerae
Swedish Vibrio cholerae
Czech Vibrio cholerae
Finnish Vibrio cholerae
Italian Vibrio comma, Vibrio cholerae
Russian KHOLERNYE VIBRIONY, KHOLERY VOZBUDITEL', VIBRIO ALBENSIS, VIBRIO COMMA, VIBRIO ELTOR, VIBRIO PROTEUS, ХОЛЕРНЫЕ ВИБРИОНЫ, ХОЛЕРЫ ВОЗБУДИТЕЛЬ
Japanese コレラ菌, ビブリオ･コレレ, コンマ菌, ビブリオコレラ
Croatian VIBRIO CHOLERAE
Polish Vibrio cholerae, Przecinkowce cholery
Norwegian Vibrio cholerae, Vibrio comma
Spanish Vibrio cholerae (organismo), vibrión colérico, Vibrio cholerae, Vibrio comma
German Vibrio cholerae, Vibrio comma
Dutch Cholerabacil, Cholerabacterie, Vibrio cholerae, Vibrio comma
Portuguese Vibrio cholerae, Vibrio comma
Derived from the NIH UMLS (Unified Medical Language System)

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