Cholera is an epidemic secretory diarrheal disease caused by Vibrio cholerae. V cholerae releases a toxin that stimulates adenylate cyclase in intestinal cells. Cholera is usually a disease of poverty but is also well described in returning travelers.
Classically, patients present passing large quantities (liters) of rice-water stools.
Basic laboratory tests are nonspecific. Culture of the organism is definitive, and rapid dipstick tests are available.
Most patients will recover if the effects of the ensuing profound volume depletion are combated by oral and/or intravenous rehydration.
Antibiotics shorten duration and severity of disease, but rising rates of bacterial resistance are becoming problematic.
A secretory diarrheal illness caused by the gram-negative bacterium Vibrio cholerae. Secretion of the cholera enterotoxin leads to continued activity of adenylate cyclase in intestinal epithelial cells and secretion of water and accompanying salts into the gut lumen.
History and exam
Key diagnostic factors
- copious watery diarrhea
- evidence of volume depletion
Other diagnostic factors
- age <5 years
- ingestion of shellfish
- family history of recent, severe, cholera-like illness
- abdominal pain
- lethargy or coma
- ingestion of contaminated water
- ingestion of contaminated food
- inadequate sanitation
- recent heavy rains and flooding
- decreased gastric acid secretion
- blood group O
- HIV infection
- lack of breast-feeding
1st investigations to order
- serum electrolytes
- serum BUN and creatinine
- serum lactate
- darkfield/phase-contrast microscopy of stool
- rapid dipstick testing of stool
Investigations to consider
- Gram stain of stool
- stool culture of liquid stool, fecal suspension, or rectal swab
- serogroup confirmation using antisera
- antibiogram (sensitivities)
- CXR and abdominal x-ray
- enzyme-linked immunosorbent assay (ELISA) assay of stool
- molecular testing of stool
- loop-mediated isothermal amplification (LAMP) assay of stool
mild-moderate volume depletion: without vomiting
vomiting or severe volume depletion
Marcus Eder, MD (Inf Diseases & Microbiology), MRCP, MRCPath, MSc, DTM&H
Swissnoso (National Center for Infection Control)
ME declares that he has no competing interests.
Rekha Lopez, BSc, MBBS, MRCP, MSc, FRCPath
East and North Hertfordshire NHS Trust
RL declares that she has no competing interests.
Dr Marcus Eder and Dr Rekha Lopez would like to gratefully acknowledge Dr Justin Green, a previous contributor to this topic.
JG is employed by, and holds stock in, GlaxoSmithKline (GSK). GSK has had no involvement in the preparation of this document, and the views expressed are those of the author.
David Sack, MD
Department of International Health
Johns Hopkins Bloomberg School of Public Health
DS is an author of some studies referenced in this topic.
Nur H. Alam, MD
Clinical Sciences Division
International Centre for Diarrhoeal Disease Research
NHA is co-author of a study referenced in this topic.
Jaya Shankar Kaushik, MD
Department of Pediatrics
University College of Medical Sciences
JSK is the author of a reference cited in this topic.
- Other infectious diarrhea
- Amebic dysentery
- Strongyloides and other intestinal helminths
- Recommendations for the use of antibiotics for the treatment of cholera
- First steps for managing an outbreak of acute diarrhoea
Diarrhea in adults
Diarrhea in childrenMore Patient leaflets
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