Ver el código de «Cholera»

==Background==	
*Endemic to Asia, Africa, and Central and South America	<ref>http://www.who.int/cholera/en/</ref>
*Occasionally seen on the Gulf Coast of US, due to inadequately cooked seafood.

===Pathophysiology===
*Usually Vibrio cholera (gram negative), which produces an enterotoxin which causes a secretory diarrhea<ref>LaRocque R and Pietroni M.  “Approach to the Adult with Acute Diarrhea in Developing Countries”.  UpToDate.com</ref>
**Toxin causes increase in cell cAMP leading to secretion of water and electrolytes into the gut lumen

===Natural History===
*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)<ref>Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41</ref>
*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

===Risk Factors===
* Persons with blood group O are more likely to have severe disease 

{{Vibrio species}}

==Clinical Features==
*Classic “rice water” diarrhea with fishy odor; usually painless
*Fluid losses can be significant, up to 1L/hr, leading to severe fluid and electrolyte depletion.  However, most cases are mild.
*Occasionally seen: sudden watery vomiting, borborygmi, abdominal cramping.
Later manifestations:
*Fluid loss 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 loss of K, Ca

==Differential Diagnosis==
{{Template:Diarrhea DDX}}

==Evaluation==
===Work-up===
*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)

===Evaluation===
*Diagnosis largely based on clinical presentation + epidemiological risk factors

===Labs===
*Non-specific abnormalities: hyponatremia, hypokalemia, hypoglycemia, increased hematocrit & plasma protein concentration (from water depletion)

==Management==
*Aggressive volume repletion (primary treatment)<ref>Sack DA, et al. Cholera. Lancet 2004; 363:223.</ref>
**Mild/moderate dehydration: [[oral rehydration solution]] 
**Severe dehydration: [[IV fluids]] - bolus lactated ringers 100ml/kg over 3 hrs
**May require more than 350ml/kg in first 24 hours
*Antibiotics (decreases severity and duration of disease)<ref>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref>
**Use local susceptibility to choose if available
**Option 1: [[doxycycline]] 300mg x 1 PO<ref name="Stanford">Stanford Guide to Antimicrobial Therapy 2014.</ref>
**Option 2: [[azithromycin]] 1 gm (20mg/kg) x 1 PO <ref name="Stanford" />^
**Option 3: [[erythromycin]] 500 QID x 3 days<ref name="Stanford" />^@
**Option 4: [[ciprofloxacin]] 1g x 1 PO
**Option 5: [[TMP-SMX]] DS BID s 3 days
*Give children Zinc and Vitamin A supplementation

:^Pregnant
:@Children

==Complications==
*Death
*Dysrhythmia from electrolyte imbalance
*Brain damage from prolonged hypoglycemia and failure of gluconeogenesis
*Aspiration pneumonia
*Paralytic ileus

==Disposition==
*Admit if hypotensive or hemodynamically unstable, severe electrolyte abnormalities

==See Also==
*[[Diarrhea]]
*[[Travel medicine]]

==References==
<references/>

[[Category:ID]]
[[Category:Tropical Medicine]]