CHOLERA AND DYSENTRIAE

MENIK HERDWIYANTI
INTERNIST RS PERTAMINA CIREBON
FAKULTAS KEDOKTERAN UNSWAGATI CIREBON

9 des 209
SEMESTER 3
 INFEKSI
Infeksi terjadi
akibat gangguan
dari trias
epidemiologi,
dimana:

Host yang rentan

mendapatkan
paparan agent
yang toxic di
lingkungan yang
mendukung
terjadinya
penyakit.
CHOLERA
Cholera
• Vibrio Cholera
•3-5 juta kasus  100.000 Meninggal
•Endemik di Negara berkembang : Asia,
Afrika, dan Timur Tengah.
•Tantangan saat ini : ditemukannya strain
–strain baru yang multidrug resistant

• Vibrio cholerae  200 serotipe lebih, O antigen pada permukaan

liposakarida. Hanya serotipe O1 dan O139 yang menyerang
manusia.
• V.cholerae O1 dibagi atas tipe clasic dan El Tor  berdasarkan
jumlah karakteristik biokimia
Major Virulence  CHOLERA TOXIN.

Elevation
Toxin
Cyclic AMP Increase Decrease Loss of
binding
within Cl- Na Fluid and
Enterocyte
intestinal Secretion Absorption Electrolytes
s
mucosa
CLINICAL MANIFESTATION
incubation period of cholera ranges from a few hours to five
days, with most cases presenting within one to three days

Incubation period is shortest among patients with a

high gastric pH and a high inoculum of ingested
organisms

Mild cholera cannot be reliably distinguished from

gastroenteritis caused by other pathogens.
• a few episodes of watery stools
• minimal mucus and no blood,
•may not have nausea and vomiting,
•may not become clinically dehydrated
CLINICAL MANIFESTATION
Diarrhea  suddenly or gradually

Stools watery with flecks of mucus,  "rice water" stools,

a mild "fishy" odor.

• abdominal cramping
• fever is infrequent
• a role of inflammation in the host response:
polymorphonuclear infiltrate in lamina propria
(ACUTE)
• Upregulation of proinflammatory cytokines
including IL-1beta and TNF alpha
CLINICAL MANIFESTATION
SEVERE
• Only after few hours
• Massive volume of 500 -1000 mL/ jam
• 10% body Water loss
• Diarrhea sever in 2-4 days
• Complication:
• Massive volume loss
• Massive Electrolyte Loss, esp. Hypokalemia
• Acute Renal Failure
• Arrythmia due to HypoK
• Hypoglycemia  poor prognostic  mental status
changes and Seizures
DIAGNOSIS
• should be considered in all cases of severe watery diarrhea and
vomiting, especially those with rapid, severe dehydration

• recent travel to areas endemic for cholera or where cholera

outbreaks are occurring, including Africa, Asia, or South and
Central America, or ingestion of undercooked or raw shellfish

treatment for suspected cholera

begins before laboratory identification
of the causative organism is available
DIAGNOSIS
• Stool specimens should be collected soon after the onset of diarrhea
and, if possible, before antibiotic treatment. Culture techniques consist
of plating samples from stool or rectal swabs directly onto a selective
medium such as thiosulfate citrate bile salts-sucrose agar (TCBS) or
tellurite taurocholate gelatin agar (TTGA)
DIAGNOSIS
• Gram stain/culture (augmented with methods for detection of
toxinogenic strains) and dark field microscopy

Vibrios can be detected by dark field or phase contrast

microscopy of stool. The organisms are motile and
resemble "shooting stars"

V. cholerae by polymerase chain reaction and antibody-based

tests including monoclonal antibody-based stool tests and
serologic tests peak seven days after infection.  confirm the
diagnosis of V. cholerae infection  not for ACUTE
TREATMENT
TREATMENT
 If the patient can drink, begin giving oral rehydration salt
solution (ORS) by mouth 
A homemade equivalent :
6 teaspoons of sugar+ 1 ½ teaspoon of salt
in 1 L water
Or
a half cup of orange juice or
Or
some mashed banana can provide potassium

WHO ORS contains the following:

Sodium – 75 mmol/L
Chloride – 65 mmol/L
Potassium – 20 mmol/L
Bicarbonate – 30 mmol/L
Glucose – 111 mmol/L
TREATMENT
Severe dehydration
Administer intravenous (IV) fluid immediately to
replace fluid deficit. 
older than 1 year,
100 mL/kg IV in 3
hours~30 mL/kg as rapidly
as possible (within 30 min)
then
70 mL/kg in the next 2
hours.
younger than 1 year,
100 mL/kg IV in 6
hours~30 mL/kg in the
first hour
then
70 mL/kg in the next 5
hours.
TREATMENT
HOLIDAY SEGAR (cc/hari)
• < 10 KG : 100 cc x KgBB
• 10-20 KG : 1000 cc + (50 cc x (KgBB – 10))
• > 20 KG : 1500 cc + (25 cc x (KgBB – 20))

ATAU
KEBUTUHAN CAIRAN HARIAN (M)+ KEHILANGAN CAIRAN (D)
M = 30 cc x KgBB
D= (30 cc x KgBB x LOSS%)

½ D + ½ M diberikan pada 6 jam pertama

½ D + ½ M diberikan pada 18 jam berikutnya
TREATMENT
 Prophylaxis of household contacts of patients with cholera can be
effective in limiting the spread of disease in endemic areas

Vaccination
Dukoral:
•inactivated monovalent whole-cell recombinant cholera toxin B subunit
•vaccine licensed in Europe for use in individuals ≥2 years of age
•given in two doses at intervals of ≥1 week (three doses at intervals of ≥1 week
for children 2 to 6 years of age);
•protection is obtained seven days after the second dose 

mORCVAX
•killed whole-cell vaccines containing 01 and 0139 serotypes
• licensed in India and Vietnam,
•safe and effective in endemic populations;

Vaxchora (PaxVax), a single-dose, oral, live-attenuated

cholera vaccine
Dysentriae
Dysentriae
Shigella species are a common cause of bacterial diarrhea worldwide,
especially in developing countries.

165 million cases occur annually worldwide, with 1 million associated

deaths

Shigella are nonmotile, facultatively anaerobic,

gram-negative rods.
family Enterobacteriaceae,
genus Shigella
four species of Shigella:
S. dysenteriae (serogroup A),
S. flexneri (serogroup B),
S. boydii (serogroup C), and
S. sonnei (serogroup D
 w ?
Ho UNWASHED HANDS ORAL PATHWAY

INFECTED WATER

STOMACH AND
INTESTINE
FOOD SYMPTION

FLY / COCKROACH
BLOODY STOOLS
DIARRHEA
FEVER

CONTAMINATED
STOOL
CONTAMINATION
CLINICAL MANIFESTATION
incubation period ranges from one to seven days, with an average
of three days

Shigella gastroenteritis typically present with high fever, abdominal

cramps, and bloody, mucoid diarrhea Tenesmus is a common complaint.

Stool frequency is typically 8 to 10 per day

Significant fluid loss is uncommon (average approximately 30
mL/kg per day

in contrast to small bowel infections, which are typified by

large volumes of watery diarrhea associated with abdominal
cramping, bloating, gas and weight loss
DIAGNOSIS
Shigella should be suspected in the
setting of: Definitive
• frequent, small volume, bloody stools, determination of the
• abdominal cramps, and tenesmus, infecting organism
• particularly if accompanied by fever requires stool culture
TREATMENT
Hydration is important to compensate for fluid
loss from the gastrointestinal tract
TREATMENT
 If the patient can drink, begin giving oral rehydration salt
solution (ORS) by mouth 
A homemade equivalent :
6 teaspoons of sugar+ 1 ½ teaspoon of salt
in 1 L water
Or
a half cup of orange juice or
Or
some mashed banana can provide potassium

WHO ORS contains the following:

Sodium – 75 mmol/L
Chloride – 65 mmol/L
Potassium – 20 mmol/L
Bicarbonate – 30 mmol/L
Glucose – 111 mmol/L
TREATMENT
Severe dehydration
Administer intravenous (IV) fluid immediately to
replace fluid deficit. 
older than 1 year,
100 mL/kg IV in 3
hours~30 mL/kg as rapidly
as possible (within 30 min)
then
70 mL/kg in the next 2
hours.
younger than 1 year,
100 mL/kg IV in 6
hours~30 mL/kg in the
first hour
then
70 mL/kg in the next 5
hours.
TREATMENT
HOLIDAY SEGAR (cc/hari)
• < 10 KG : 100 cc x KgBB
• 10-20 KG : 1000 cc + (50 cc x (KgBB – 10))
• > 20 KG : 1500 cc + (25 cc x (KgBB – 20))

ATAU
KEBUTUHAN CAIRAN HARIAN (M)+ KEHILANGAN CAIRAN (D)
M = 30 cc x KgBB
D= (30 cc x KgBB x LOSS%)

½ D + ½ M diberikan pada 6 jam pertama

½ D + ½ M diberikan pada 18 jam berikutnya
TREATMENT
 QUESTIONS?

Thank You