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Key Features

Essentials of Diagnosis

  • Sudden onset of severe watery diarrhea

  • Persistent vomiting without nausea or fever

  • Extreme and rapid dehydration and electrolyte loss, with rapid development of vascular collapse

  • Contact with a case of cholera or with shellfish, or the presence of cholera in the community

  • Diagnosis confirmed by stool culture

General Considerations

  • Caused by the gram-negative organism Vibrio cholerae

  • Transmitted by contaminated water or food, especially contaminated shellfish

  • Epidemics are common in impoverished areas where hygiene and safe water supply are limited

  • Typical disease is generally so dramatic that in endemic areas the diagnosis is obvious

  • Individuals with mild illness and young children may play an important role in transmission of the infection

  • Incubation period is short, usually 1–3 days

  • Asymptomatic infection is far more common than clinical disease

  • Disease is unusual in infancy

  • Age-specific attack rate is highest in children younger than age 5 years and declines with age


  • Endemic in India and southern and Southeast Asia and in parts of Africa

  • Epidemic cholera spread in Central and South America, with a total of 1 million cases and 9500 deaths reported through 1994

  • A severe cholera outbreak in Haiti began in October 2010; more than 500,000 cases and 6000 deaths are estimated

  • Infection occurs in the United States occurs after foreign travel or as a result of consumption of contaminated imported food

Clinical Findings

  • Many patients have mild disease

  • Severe diarrhea

    • Develops in 1–2% of patients

    • Sudden onset of massive, frequent, watery stools, generally light gray in color (so-called rice-water stools) and containing some mucus but no pus

    • Vomiting may be projectile and is not accompanied by nausea

    • Within 2–3 hours, the tremendous loss of fluids results in life-threatening dehydration, hypochloremia, and hypokalemia, with marked weakness and collapse

    • Illness lasts 1–7 days and is shortened by appropriate antibiotic therapy


  • Markedly elevated hemoglobin (20 g/dL)

  • Marked acidosis, hypochloremia, and hyponatremia

  • Stool sodium concentration may range from 80 mEq/L to 120 mEq/L

  • Culture confirmation requires specific media and takes 16–18 hours for a presumptive diagnosis and 36–48 hours for a definitive bacteriologic diagnosis


  • Physiologic saline or lactated Ringer solution should be administered intravenously in large amounts to restore blood volume and urinary output and to prevent irreversible shock

  • Potassium supplements are required

  • Sodium bicarbonate, given intravenously, may be needed initially to overcome profound metabolic acidosis from bicarbonate loss in the stool

  • Moderate dehydration and acidosis

    • Can be corrected in 3–6 hours by oral therapy alone because the active glucose transport system of the small bowel is normally functional

    • Optimal composition of the oral solution (mEq/L): Na+, 90; Cl-, 80; and K+, 20 (with glucose, 110 mmol/L)

  • Tetracycline ...

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