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Chapter 15 : Cholera: Pathophysiology, Clinical Features, and Treatment

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Abstract:

This chapter reviews the pathophysiology of cholera, focusing on the most common and important complication, dehydration; describes the clinical features of patients with cholera; and outlines treatment for patients with this disease. The major effects of O1 infection are to increase active chloride and bicarbonate secretion into the intestinal lumen by crypt cells and to decrease villous absorption of sodium chloride. The majority of children with cholera and hypoglycemia have neither frank marasmus nor kwashiorkor and resemble other cholera patients in their general clinical features. Severe dehydration produces such distinctive and pronounced features that cholera is one of the few diseases in adults that can be accurately diagnosed at first sight. The major laboratory abnormalities in patients with cholera are alterations in the concentration of serum electrolytes and creatinine and the effects of hemoconcentration on other blood constituents. Although replacement of fluid lost in cholera stool remains the crucial element of treatment of cholera patients, antimicrobial therapy is an important adjunctive therapy, especially in patients with high purging rates. Antimicrobial therapy of cholera is complicated by the marked increase in multiply antibiotic-resistant strains during the last 20 years. Currently in Bangladesh, more than 90% of O1 isolates are resistant to tetracycline, ampicillin, and trimethoprim-sulfamethoxazole. When epidemics occur in rural areas, it is often necessary to establish temporary cholera treatment centers. The supplies required for such temporary facilities are quite straightforward, and the costs not great.

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
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Figure 1

A syringe containing the characteristic rice water stool of cholera. Reprinted with permission (G. T. Keusch and M. L. Bennish, p. 601, R. D. Feigin and J. D. Cherry, ed., , 1992).

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
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Image of Figure 2
Figure 2

Characteristic clinical features of cholera. (A) A Bangladeshi woman in her early twenties with severe dehydration due to cholera who exhibits many of the features described by O'Shaughnessy 150 years ago. She appears "superannuated," she "uttered no moan, gave no expression of pain," "her eyes were sunk deep into her sockets," "all pulse was gone at the wrist," and "a tenacious sweat moistened her bosom." (B) A young girl with cholera. This young girl is severely dehydrated, as can be seen from her sunken eyes, somnolence, and increased skin tenting in response to pinching of the skin. Panel B is reprinted with permission (G. T. Keusch and M. L. Bennish, p. 601, R. D. Feigin and J. D. Cherry, ed., , 1992).

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
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Image of Figure 3
Figure 3

Cholera cots used for children and adults with diarrhea. This plastic-lined cot contains a hole in the middle (A) that allows stool to drain into a calibrated bucket (B) and facilitates recording of the volume of stool losses. Panel B is reprinted with permission (G. T. Keusch and M. L. Bennish, p. 603, R. D. Feigin and J. D. Cherry, ed., 1992).

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
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Image of Figure 4
Figure 4

Prepackaged sachets of standard oral rehydration solution from different countries. These packages are available for sale from pharmacists. The contents are dissolved in water and administered to patients.

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
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Tables

Generic image for table
Table 1

Electrolyte composition of cholera stool and of fluids used for hydration of patients with cholera

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
Generic image for table
Table 2

Changes in plasma electrolytes, creatinine, and total protein following rapid, 4-h rehydration of children with cholera

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
Generic image for table
Table 3

Classification of dehydration and fluid deficit based on clinical findings

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
Generic image for table
Table 4

Principles of fluid therapy in cholera patients

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
Generic image for table
Table 5

Research accomplishments from 1947 to 1970 crucial to developing effective intravenous and oral fluid therapies for cholera

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
Generic image for table
Table 6

Options for antimicrobial therapy of persons infected with serogroup O1

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15
Generic image for table
Table 7

Supplies required for the treatment of cholera in field facilities

Citation: Bennish M. 1994. Cholera: Pathophysiology, Clinical Features, and Treatment, p 229-255. In Wachsmuth I, Blake P, Olsvik Ø (ed), and Cholera. ASM Press, Washington, DC. doi: 10.1128/9781555818364.ch15

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