CHOLERA

ADRENALINE 4 C
Group 2 AND 3
 Group members
Group 2-C GROUP 3-C
1. BANDALA SAI TEJA YADAV 1. ABIRAJ HARINIVASH
2. BASAPURAM SUBRAHMANYESWARA RAO 2. AJITHAKUMARI PAULRAJ ASHA
3. ALBERT MARIA TERANCE GLATO
3. BUKKAPATNAM NAVEED HUSSAIN 4. JEYAKUMAR RAMYA
4. CHAUDHARY PRABIN 5. KANAGARAJ DINESH KUMAR
5. DEIVENDRAN MOUNICA 6. KANNAN GUHANRAJ
6. DIGUMARTHY MURALI KRISHNA 7. KRISHNAMOORTHY KOWSALYA
7. DAS KUNTAL 8. MANJINI VEERASAMY NITHIN KRISHNA
8. GHOSH SAGNIK 9. MISHRA DHEERENDRA
10. MURUGAN VIGNESH
9. GOSWAMI PUSHTI PRAMODGIRI 11. NOAH ERNEST
10. JAGANI JAYKISHANBHAI VALLABHBHAI 12. ODELI WEYIMI
11. JOSHI KOMAL DILIPBHAI 13. OHAJIONU CHIGOZIE
12. KAHAR PREYASI CHANDRAKANTBHAI (LEADER) 14. PANCHAL JAYMEEN ANILKUMAR
13. KUMAR ABHISHEK 15. RAVICHANDRAN POOJASRI
16. SELVARAJ GAYATHIRI
14. MAROJU SIDDHARTH VENKAT
17. SREEKUMAR BINDHUJA
15. PUDASAINI SOVANNA 18. STEGY GRAF
16. RATHOD KIRTAN PRAVINKUMAR 19. SUBBIAH NANDHAKUMARAN
17. RAY UJJWAL 20. VINAYAGAMOORTHY TABITHA
18. SARVAMTHOTA TEJASWINI
19. SHARMA SRITIY
20. STEPHEN NOYAL EDBERK
• Cholera is an acute diarrheal disease that can, in a
matter of hours, result in profound, rapidly progressive
dehydration and death
• Caused by bacteria : Vibrio. Cholera
Vibrio cholera
• Gram –ve curved Rod Enteric Tract bacilli
• Is a highly motile, oxidase positive,
facultative anaerobic with one or more
flagella
• Grows on : TCBS Agar
• Acid labile
• Live in Tidal rivers and bay with moderate
salinity
• Proliferate in summer months ( Temp >20c )
• Illness frequency increases during warm
months.

Mims' Medical Microbiology and Immunology

Goering, Richard V., BA MSc PhD; Dockrell, Hazel M., BA (Mod) PhD...Show all. Published January 1, 2019. Pages 265-
304. © 2019
Epidemiology
• Natural habitat of V.cholera is coastal sea water and brackish
estuaries, where organisms live in relation to plankton
• Can grow in freshwater with adequate nutrients and warmth
water.
• Serogroup : 01 and 0139 have epidemic potential
• Route of ingestion: Oral- Fecal
• No known animal reservoir
• High incidence of severe cholera occurs in O blood group
• Low risk in AB blood group
Epidemiology
• Cholera is native to the Ganges delta in the Indian subcontinent.
• Since 1817, seven global pandemics have occurred
• WHO- cholera cases reported annually
• >40%—— Africa
• >35%.—— Asia
• >20%. —— America
• 2-3 Million cases occur yearly but only ~200000 cases reported
annually to the WHO and these cases report >50k -100k Deaths
annually.
Whole-Genome Sequencing to
Characterize Cholera Across the
Americas Over a 40-Year Time
Span.
(Intercontinental introductions of
seventh pandemic V. cholerae El
Tor into Latin America in 1991
and 2010. The direct introduction
of the Latin American
transmission #2 sublineage from
South Asia or China or
introduction via Eastern Europe
in 1991 is uncertain and denoted Jekel's Epidemiology, Biostatistics, Preventive
by dashed lines. Medicine, and Public Health
Elmore, Joann G., MD, MPH; Wild, Dorothea M.G.,
MD, MPH...Show all. Published January 1,
2020. Pages 35-54.e1. © 2020.
Pathogenesis
• V.Cholera ingestion into
stomach through oral-fecal
Contamination of food and
water
• Shuts down protein
production to conserve
energy and nutrients to
survive in acidic environment
• Reaches intestine
Attaches to the mucosa by
fimbriae that attach to
ganglioside receptor in the
intestinal wall.
• Multiply and produces toxin
Electron microscopy shows :Adherence of Vibrio cholerae to M cells in human
ileal mucosa. (Courtesy of T. Yamamoto.)
Mims' Medical Microbiology and Immunology
Goering, Richard V., BA MSc PhD; Dockrell, Hazel M., BA (Mod) PhD...Show
all. Published January 1, 2019. Pages 111-128. © 2019.
o Releases cholera toxin - Main
Virulence Factor AB type toxin

Up regulates production of Gαs

cAMP by binding to and increasing
activating adenylate cyclase.

Then it will activate the GS

pathway. Activates GS, up-regulates
cAMP, Produces watery diarrhea
through an efflux of Cl and H2O Netter's Integrated Review of Medicine
Shinnar, Eliezer. Published January 1,
2021. Pages 503-505. © 2021. 
Mechanism of Secretory Diarrhea in Cholera.
Clinical manifestations
• Some patients are Asymptomatic or mild diarrhea only
• Cholera gravis - Explosive life threatening diarrhea
Reasons unknown but
 Pre existing Immunity
 Blood type
 Nutritional status play a major role

• In non-Immune patient, after 24-48hrs incubation period -> Painless

watery diarrhea develops and progresses to voluminous
• Patient often vomit
• Muscle cramps
Characteristics of Stool: a
nonbilious, gray, slightly cloudy
fluid with flecks of mucus, No
blood and a somewhat fishy,
inoffensive odor. It has been called
“rice-water” stool because of its
resemblance to the water in which
rice has been washed 
• Clinical symptoms parallel volume
contraction:
at losses of <5% of normal body weight, thirst
develops;
at 5–10%, postural hypotension, weakness,
tachycardia, and decreased skin turgor are
documented
at >10%, oliguria, weak or absent pulses,
sunken eyes (and, in infants, sunken
fontanelles), wrinkled (“washerwoman”) skin,
somnolence, and coma are characteristic.
• Severe volume depletion can lead to Renal Dennis, Mark, MBBS (Hons), PhD, DDU, FRACP, FSCMR; Bowen,
William Talbot, MBBS, MD...Show all. Published January 1,
failure due to Acute tubular necrosis. 2020. Pages 174-331. © 2020. 
A child with cholera showing decreased skin turgor From Sack DA,
Sack RB, Nair GB, et al. Cholera. Lancet 2004; 363: 223–
233.Kleigman et al., Nelson Textbook of Pediatrics, Chapter 201,
1400–1403.e1. © 2016 Elsevier.
Laboratory data
• CBC reveals :
elevated hematocrit (due to hemoconcentration ) in non-anemic patients
mild neutrophilic leukocytosis
• elevated levels of blood urea nitrogen
• creatinine consistent with prerenal azotemia
• normal sodium, potassium, and chloride levels
• a markedly reduced bicarbonate level (<15 mmol /L)
• an elevated anion gap (due to increases in serum lactate, protein, and
phosphate).
• Arterial pH is usually low (~7.2).
Diagnostic workup
• Cholera should be suspected when a patient ≥5 years of age develops
acute watery diarrhea in an area known to have cholera or develops
severe dehydration or dies from acute watery diarrhea, even in an
area where cholera is not known to be present.
• Stool examination
• Dark microscopy on wet mount of fresh stool
• Cholera dipstick – can detect cholera antigen. Used in the field or
where laboratory facilities are absent.
Treatment
• Death from cholera is due to hypovolemic shock; thus
treatment of individuals with cholera first and foremost
requires fluid resuscitation and management.
• oral rehydration solution (ORS) : takes advantage of the
hexose-Na+ co-transport mechanism to move Na+ across
the gut mucosa together with an actively transported
molecule such as glucose (or galactose). Cl– and water
follow.
ORS may be made by adding
safe water to prepackaged
sachets containing salts and
sugar
0.5 teaspoon (i.e., a small
spoonful) of table salt
+
6 level teaspoons (i.e., 6 small
spoonfuls) of table sugar
+
1 L of safe water.
Potassium intake in bananas
or green coconut water
should be encouraged.
Total fluid replacement
• In severely dehydrated patients (>10% of body weight) can be
replaced safely within the first 3–4 h of therapy, half within the first
hour
• Ringer’s lactate is the best choice among commercial products
• Transient muscle cramps and tetany are common.
• Thereafter, oral therapy can usually be initiated, with the goal of
maintaining fluid intake equal to fluid output.
• Severe hypokalemia – treated with oral or IV supplement
Antibiotics

Although not necessary for cure, the use of an antibiotic to which the
organism is susceptible diminishes the duration and volume of fluid loss
hastens clearance of the organism from the stool.
• Adjunctive antibiotics should therefore be administered to patients with
moderate or severe dehydration due to cholera. 
Adults Children

Erythromycin 250mg orally q.d for 3days 12.5mg dos.q.d for3days

Azithromycin Single 1g dos. 20mg/kg dos.

• Increasing resistance to tetracyclines is widespread; however, in areas with
confirmed susceptibility
Non pregnant adults Children >8yrs old
Tetracycline 500mg orally q.d for 3days 12.5mg/kg dos. q.d.
For3days
Doxycycline 300mg single dos. Single dose 4-6mg/kg dos.
• Similarly, increasing resistance to fluoroquinolone is being reported, but in
areas with confirmed susceptibility

Adults Children
• Oral administration500mg
Ciproflaxosin of supplemental
b.d. For3days zinc is associated
15mg/kg with decreased
b.d. 3days
volume and severity of diarrhea in young children, including in those with
cholera.

<6months >6-60months
Zinc 10mg daily for 10days 20mg daily for 10days
Cholera cot
Patients are best
managed using a
cholera cot, especially
in an epidemic
situation.

Conn's Current Therapy 2020

Pietroni, Mark, MD, MBA. Published January 1, 2020. Pages 538-
541. © 2020. 
Cholera cot.
Conn's Current Therapy 2020
Pietroni, Mark, MD, MBA. Published January 1, 2020. Pages 538-541. © 2020.
Conn's Current Therapy 2020
Pietroni, Mark, MD, MBA. Published January 1, 2020. Pages 538-541. © 2020.
Prevention

• Provision of safe water and of facilities for sanitary disposal of feces

• Improved nutrition
• Attention to food preparation and storage in the household can significantly
reduce the incidence of cholera.
• In an attempt to maximize mucosal responses, two types of oral cholera
vaccines such as oral killed vaccines and live attenuated vaccines were
developed.
Immunization

• Currently, three oral killed cholera vaccines have been prequalified by the
WHO and are available internationally.
• WC-rBS contains several biotypes and serotypes of V. cholerae O1
supplemented with 1 mg of recombinant cholera toxin B subunit per dose.
• BivWC contains several biotypes and serotypes of V. cholerae O1 and V.
cholerae O139 without supplemental cholera toxin B subunit. 
Immunization

• The vaccines are administered as a two- or three-dose regimen, with doses

usually separated by 14 days. 
• They provide ~60–85% protection for the first few months.
• Booster immunizations of WC-rBS are recommended after 2 years for
individuals ≥6 years of age and after 6 months for children 2–5 years of
age.
References
• Harrisons principles of Internal medicine 20th Edition
ILLUSTRATIONS & ALGORITHM
• Mims' Medical Microbiology and Immunology Goering, Richard V., BA MSc PhD;
Dockrell, Hazel M., BA (Mod) PhD...Show all. Published January 1,
2019. Pages 265-304. © 2019.
• Goldman Cecil medicine
• Jekel's Epidemiology, Biostatistics, Preventive Medicine, and Public Health
• Elmore, Joann G., MD, MPH; Wild, Dorothea M.G., MD, MPH...Show
all. Published January 1, 2020. Pages 35-54.e1. © 2020.
• Netter's Integrated Review of Medicine Shinnar, Eliezer. Published January 1,
2021. Pages 503-505. © 2021.Mechanism of Secretory Diarrhea in Cholera.
References
• Adherence of Vibrio cholerae to M cells in human ileal mucosa. (Courtesy of T. Yamamoto.)
Mims' Medical Microbiology and Immunology Goering, Richard V., BA MSc PhD; Dockrell,
Hazel M., BA (Mod) PhD...Show all. Published January 1, 2019. Pages 111-128. © 2019.
• Mims medical microbiology and immunology
• Dennis, Mark, MBBS (Hons), PhD, DDU, FRACP, FSCMR; Bowen, William Talbot, MBBS,
MD...Show all. Published January 1, 2020. Pages 174-331. © 2020
• Conn's Current Therapy 2020
• Pietroni, Mark, MD, MBA. Published January 1, 2020. Pages 538-541. © 2020. 
• Cholera cot.
• Conn's Current Therapy 2020
• Pietroni, Mark, MD, MBA. Published January 1, 2020. Pages 538-541. © 2020.
Thank you