- Endemic to Asia, Africa, and Central and South America 
- Occasionally seen on the Gulf Coast of US, due to inadequately cooked seafood.
- Usually Vibrio cholera (gram negative), which produces an enterotoxin which causes a secretory diarrhea
- Toxin causes increase in cell cAMP leading to secretion of water and electrolytes into the gut lumen
- Transmission via ingestion of contaminated food or water, usually undercooked seafood
- Incubation period between hours to 5 days, depending on size of inoculum (usually 1-2 days)
- Most people are asymptomatic, and simply have bacteria in their feces for 7-14 days
- Diarrhea is most severe in days 1-2, usually resolves in 7 days
- Persons with blood group O are more likely to have severe disease
- Classic “rice water” diarrhea with fishy odor; usually painless
- Fluid losses can be significant, up to 1L/hr, leading to severe fluid and electrolyte abnormalities. However, most cases are mild.
- Occasionally seen: sudden watery vomiting, borborygmi, abdominal cramping.
- Dehydration] may lead to → sunken eyes, dry mouth, cold clammy skin, decreased skin turgor, or wrinkled hands and feet (also known as “washer woman’s hands”)
- Acidosis from loss of bicarbonate
- Muscle cramps from hypokalemia, hypocalcemia
- Arrhythmia from electrolyte imbalance
- Brain damage from prolonged hypoglycemia and failure of gluconeogenesis
- Aspiration pneumonia
- Paralytic ileus
- Viral (e.g. rotavirus)
- GI Bleed
- Mesenteric Ischemia
- Adrenal Crisis
- Thyroid Storm
- Toxicologic exposures
- Antibiotic or drug-associated
- Enterotoxigenic E. coli (most common cause of watery diarrhea)
- Norovirus (often has prominent vomiting)
- Non-typhoidal Salmonella
- Enteroaggregative E. coli (EAEC)
- Enterotoxigenic Bacteroides fragilis
- Diagnosis largely based on clinical presentation + epidemiological risk factors
- Fecal smears will NOT show leukocytes or erythrocytes.
- Diagnosis can be confirmed by stool cultures on TCBS medium (must inform lab cholera is suspected so appropriate medium is used)
- Labs; non-specific abnormalities:
- Aggressive volume repletion (primary treatment)
- Antibiotics (decreases severity and duration of disease)
- Give children Zinc and Vitamin A supplementation
- LaRocque R and Pietroni M. “Approach to the Adult with Acute Diarrhea in Developing Countries”. UpToDate.com
- Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41
- Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
- Sack DA, et al. Cholera. Lancet 2004; 363:223.
- Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6
- Stanford Guide to Antimicrobial Therapy 2014.