Cholera where. Symptoms, diagnosis, consequences and treatment of cholera. Cholera Risk Factors

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Cholera is a very dangerous bacterial infection that is usually transmitted through contaminated water.

Cholera causes severe diarrhea and dehydration.

If left untreated, cholera can lead to death within a few hours or days.

Modern wastewater treatment methods have virtually eradicated cholera from developed countries. In the United States, the last major outbreak was recorded in 1911. But cholera still causes epidemics in Asia, Africa, Latin America, the Middle East and India. The risk of cholera is especially high among the poor, who live in crowded conditions without basic sanitation, as well as among refugees and victims of natural disasters.

Cholera is easy to treat if it is started on time. Death from cholera is usually the result of severe dehydration, which can be prevented with simple rehydration solutions.

Causes of cholera

Cholera is caused by a bacterium called Vibrio cholerae. Vibrio cholerae has two distinct life cycles - inside the human body and outside it.

1. Vibrio cholerae in the environment.

This bacterium naturally lives in coastal waters, where it attaches to small crustaceans and other organisms. Vibrio cholerae travels with its host as crustaceans migrate in search of food - algae. Algae grow intensively in warm coastal water, and urea, which is contained in wastewater, is especially conducive to their growth. This is why the risk of cholera increases during the warmer months, especially in areas contaminated by sewage.

2. Vibrio cholerae in the human body.

When a person ingests cholera bacteria, it can cause the disease itself, or it can simply multiply in the intestines and be excreted in the feces. When the feces of a cholera carrier get into drinking water or food, they become a dangerous source of infection.

The deadly effects of Vibrio cholerae on the body are associated with the powerful toxin CTX, which the bacterium secretes in the small intestine of the patient. CTX disrupts the normal flow of sodium and chloride in the intestinal wall. Because of this, a large amount of water accumulates in the lumen, causing watery diarrhea and a sharp loss of fluid and electrolytes. Contaminated water supplies are a major risk factor for cholera. Eating raw fish, unpeeled fruits and vegetables can also lead to contracting this dangerous infection.

In order for a person to get sick, more than a million bacteria must enter the body - approximately the same amount contained in one glass of contaminated water. Therefore, cholera is rarely transmitted through contact with a sick person.

So, the main sources of cholera are:

Water from natural sources, wells. Vibrio cholerae can live in water bodies for a long time. Water is the main source of major cholera outbreaks. People living in unsanitary conditions are at greatest risk.
. Seafood. It is very risky to consume raw or poorly processed seafood, especially shellfish from certain unsafe waters. For example, US authorities strongly recommend carefully preparing seafood from the Gulf of Mexico.
. Raw fruits and vegetables. The source of infection is often raw, unpeeled fruits or vegetables. In developing countries, manure fertilizers and dirty water for irrigating fields can lead to crop contamination. Therefore, you need to be especially careful about vegetables and fruits from third world countries.

Risk factors for cholera.

Everyone is susceptible to cholera, with the exception of infants, who have received immunity from mothers who have had the disease.

But there are several factors that increase a person's susceptibility to cholera:

Reduced or zero acidity of gastric juice. Vibrio cholerae cannot survive in an acidic environment - the usual environment of gastric juice. It is the stomach that should serve as a barrier to infection, as provided by evolution. But people with low acidity, as well as those who take medications against ulcers (H2-histamine blockers, proton pump inhibitors, antacids) are at risk.
. Blood type 0. But for unknown reasons, people with blood type 0 are twice as susceptible to cholera as people with other groups.

Symptoms of cholera

Most people exposed to Vibrio cholerae do not get cholera. They do not even suspect that they have been infected. But these people become carriers, shedding bacteria in their stool within 7-14 days after infection. In most patients, cholera causes mild to moderate symptoms, so without laboratory tests it sometimes cannot be distinguished from common food poisoning. Only one in 10 infected people develops the typical picture of cholera, with profuse watery diarrhea and rapid dehydration.

Symptoms of cholera include:

Diarrhea (diarrhea). With cholera, diarrhea occurs suddenly and can quickly lead to dehydration. In severe cases, a person loses up to 1 liter of fluid every hour. Feces have the appearance of water in which rice was washed - watery, whitish in color.
. Nausea and vomiting. These symptoms occur both early and late in the disease. Vomiting can exhaust the patient for several hours in a row.
. Dehydration (dehydration). Severe dehydration of the body develops during the first hours. The degree of dehydration depends on how much fluid the patient loses through stool and vomit, and how treatment is carried out. A loss of 10% of body weight corresponds to severe dehydration. Signs of dehydration in cholera are: irritability, drowsiness, thirst, sunken eyes, dry mouth, decreased skin turgor, decreased urine production, drop in blood pressure, arrhythmia, etc.

Dehydration is dangerous due to a sudden imbalance of minerals that play an important role in the body. This condition is called electrolyte imbalance. It requires urgent treatment, otherwise the patient may die.

Symptoms of electrolyte imbalance:

Muscle spasms and heart rhythm disturbances. As a result of the sudden loss of chlorides, potassium and other substances, muscle contractions, including the heart muscle, are disrupted (arrhythmia).
. Shock. This is one of the most serious consequences of dehydration. Shock occurs when insufficient circulating blood volume causes a drop in blood pressure. If help is not provided in time, hypovolemic shock leads to death within minutes.

The symptoms of cholera in children are generally similar to those in adult patients.

But in children the disease is more severe and they may experience the following symptoms:

Depression of consciousness, up to coma.
. High body temperature.
. Cramps.

When should you see a doctor?

The risk of cholera is very low in developed countries, and even in disadvantaged areas you are unlikely to get sick if you follow government advice and good hygiene. But sporadic cases of cholera still occur around the world. If you experience diarrhea after visiting a dangerous region, consult your doctor. If you have profuse, watery diarrhea and you suspect cholera, seek medical attention immediately. Remember that severe dehydration can develop within the first hours of illness. Don't waste time!

Diagnosis of cholera

In dangerous areas, doctors initially suspect cholera, so most likely there will be no problems with making a diagnosis. But in parts of the world where cholera is rarely found, it may take time for doctors to make a correct diagnosis.

Today it is not necessary to do a culture and wait to confirm this or that infection. In developed countries, special rapid tests are used to quickly identify cholera. Rapid diagnosis reduces mortality and helps prevent cholera outbreaks through timely intervention.

Treatment of cholera

Cholera requires immediate treatment.

Treatment methods are as follows:

Rehydration. The main task is to restore lost water and electrolytes. To do this, use simple salt solutions, such as the well-known drug Regidron. These products are sold in powder form, which are dissolved in water and taken in portions at certain intervals. In severe cases, the doctor may prescribe intravenous administration of special solutions. With proper rehydration, the mortality rate from cholera does not exceed 1%.
. Antibiotics. Surprisingly, antibiotics are not a major part of cholera treatment. In some cases, the antibiotic doxycycline (Doxibene, Unidox) or azithromycin (Sumamed) is actually prescribed. The dosage and duration of treatment is determined only by the doctor.
. Zinc preparations. Recent studies have shown that zinc may shorten the duration of diarrhea in children with cholera.

Complications of cholera

Cholera can quickly become fatal. In the most severe cases, this occurs within 2-3 hours, sometimes before the person is taken to the hospital. In other cases, death from dehydration may occur within a few days from the onset of the first symptoms.

In addition to the shock and severe dehydration mentioned above, cholera can cause the following complications:

Hypoglycemia (low blood sugar). If a person becomes so weak that they are unable to even eat, hypoglycemia may occur. A deficiency of sugar, an essential nutrient for cells, causes seizures, loss of consciousness, and even death. The risk of such complications is highest in children.
. Hypokalemia (low potassium levels). Cholera patients lose enormous amounts of electrolytes, including potassium. Very low potassium levels impair nerve function, cause arrhythmias, and can be life-threatening.
. Kidney failure. When the kidneys' filtering capacity is impaired, excess toxins and some electrolytes accumulate in the body. This condition can lead to death. In cholera patients, kidney failure is often combined with hypovolemic shock.

Konstantin Mokanov

Cholera is an acute infectious disease characterized by primary damage to the small intestine and manifests itself in the form of vomiting, diarrhea and severe dehydration. There are always outbreaks of disease that originate in India and spread throughout the world in the form of epidemics and pandemics.

The causative agent of cholera is bacteria of the species Vibrio cholerae, which enter the environment with the feces of a sick person or a healthy vibrio carrier. Bacteria enter the body through the fecal-oral route through contaminated water, contaminated food and unwashed hands.

Vibrio cholerae settles in the mucous membrane of the small intestine, multiplies and produces cholera toxin, which leads to the release of fluid into the intestinal lumen. The result is vomiting, dehydration, hypokalemia and other metabolic disorders.

Without treatment, a person quickly dies from complications of the disease: dehydration (hypovolemic shock), acute liver and kidney failure, cardiac arrest and neurological disorders. Modern treatment involves combating dehydration and metabolic disorders by drinking plenty of fluids with the addition of salts and minerals, intravenous saline and mineral solutions, destroying Vibrio cholerae using antibiotics, inactivating cholera toxin using enterosorbents, and concomitant therapy. With timely treatment, the prognosis is favorable, patients fully restore their ability to work within a month after the onset of the disease.

Prevention of cholera comes down to preventing the epidemic through a set of state and interstate sanitary and hygienic measures, observing personal hygiene rules, and vaccinating the population.

The source of Vibrio cholerae is a sick person or a healthy carrier who releases the bacteria into the environment along with feces and vomit.

Transmission routes:

• fecal-oral - through contaminated water (drinking, swallowing while diving), contaminated food products, in particular those that are not heat-treated before consumption (shrimp, shellfish, smoked fish, etc.);
• household contact, primarily through unwashed hands.

Symptoms and severity of cholera

The incubation period (from the moment of infection until the appearance of the first symptoms of cholera) lasts 1-2 days. 80% of infected people either do not get cholera or experience it in a mild to moderate form.

Here are the typical symptoms of cholera:

• acute onset;
• : heavy (up to 250 ml at a time) bowel movements up to 20 times a day. The stool is initially mushy, then liquid, white-gray in color, and finally colorless, odorless and bloody with floating flakes that resemble rice water;
• vomiting - first of food eaten, and then reminiscent of rice water;
• dehydration of the body, characterized by thirst, pointed facial features, sunken eyes, severe dryness of the skin and mucous membranes, etc.;
• decreased body temperature (up to 35 degrees) in severe cases; reduced blood pressure;
• little urination (oliguria) and complete cessation of urination (anuria);
• cramps of the masticatory and calf muscles;
• associated with hypokalemia.

There are 4 degrees of dehydration in cholera:

• I degree - the body loses up to 3% of its original body weight;
• II degree - loss of 4-6% of initial body weight;
• III degree - loss of 7-9% of initial body weight;
• IV degree - loss of more than 9% of initial body weight. In this case, due to severe dehydration and loss of salts (potassium and sodium chlorides, as well as bicarbonates), the so-called algid develops: low temperature, severe weakness, hypotension, oligo- and anuria, convulsions, cessation of stool, severe dry skin ( decrease in her turgor, “washerwoman’s hand”). You should know that algid also develops with.

The course of cholera is divided into 3 degrees of severity:

• mild degree - and vomiting (in half of the cases one-time). I degree of dehydration. Patients complain of weakness, thirst, dry mouth. Symptoms disappear after 2 days;
• moderate degree - acute onset with frequent bowel movements (up to 15 times per bowel movement). Dehydration of the second degree. Vomiting without previous nausea. Discomfort in the abdomen (feeling of “fluid transfusion”). Dryness, decreased skin turgor,... No abdominal pain. Spasms of the masticatory and calf muscles. Patients feel weakness, thirst, dry mouth;
• severe degree - manifested by III and IV degrees of dehydration. There are frequent, profuse stools resembling rice water, vomiting (also similar to rice water), pointed facial features and sunken eyes, hoarse voice, dry tongue, decreased skin turgor, the appearance of wrinkles and skin folds, a drop in temperature and blood pressure, oligo- and anuria , liver failure. Patients experience severe weakness and convulsions, as well as indomitable thirst. Without treatment, coma and death occur.

Diagnosis of cholera

The disease is diagnosed through questioning, examination and laboratory confirmation (microbiology).

Laboratory methods include bacteriological testing (identification of Vibrio cholerae in feces and vomit), as well as serological testing (determination of agglutinins and vibriocidal antibodies in the patient’s blood).

Treatment of cholera

In all cases, hospitalization of the patient and isolation from others is required.

First of all, they fight dehydration: they prescribe plenty of fluids with the addition of salts and minerals, and carry out intravenous rehydration, in particular, with the help of Ringer's solution. Potassium deficiency is corrected by separate administration of potassium supplements.

Antibacterial drugs are prescribed only for III and IV degrees of dehydration. Azithromycin, Co-trimoxazole, Erythromycin, Tetracycline and Doxycycline are used (the last 2 drugs are not recommended for children under 8 years of age).

To inactivate cholera toxin, enterosorbents are prescribed.

With timely comprehensive treatment, the prognosis is favorable - patients return to work in about a month. After recovery, the patient develops immunity, but infection with other serotypes of Vibrio cholerae is possible.

Includes state (interstate) and personal sanitary and hygienic measures, as well as vaccination of the population:

• prevention of the introduction of cholera vibrio from foci of infection;
• early detection and isolation of cholera patients and healthy carriers of Vibrio cholerae;
• disinfection of water bodies and public places;
• disinfection of water in everyday life (primarily boiling), frequent hand washing, thorough heat treatment of food, etc.;
• use of one of 3 types of oral cholera vaccine (WC/rBS vaccine, modified WC/rBS vaccine, CVD 103-HgR vaccine) and cholera toxoid.

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Cholera is an acute anthroponotic fecal-oral infection caused by Vibrio cholerae, occurring with symptoms of watery diarrhea, vomiting with the possible development of dehydration shock. Due to its severe course and the possibility of rapid epidemic and pandemic spread, cholera, according to the International Health Regulations, is classified as a particularly dangerous infection. Since ancient times, cholera pandemics have caused great loss of life. There are seven known cholera pandemics. The last one started in 1961.

Its peculiarity is the change of pathogen from true cholera classic to Vibrio El Tor, characterized by a relatively benign course of the disease with a high frequency of vibrio carriage. Currently, cholera diseases are registered in dozens of third world countries, from where this infection is annually imported into economically more developed countries, including Russia.

Etiology

The causative agent of cholera, Vibrio cholerae, is represented by two biovars: the biovar of cholera itself and El Tor. Both biovars are similar in morphological and tinctorial properties, are highly motile due to the presence of a flagellum, do not form spores, are gram-negative, and are cultivated in alkaline nutrient media. According to antigenic properties, cholera pathogens belong to serogroup 01. In recent years, it has been proven that vibrios 0139 have the ability to secrete an exotoxin identical to the known biovars of cholera vibrios and cause a clinically similar disease, the so-called cholera Bengal.

Pathogenesis

Vibrio cholerae enters the human body through the mouth with water or food. They must overcome the gastric barrier. This often occurs on an empty stomach, during a period of rest in the secretory activity of the stomach, when drinking plenty of water, which reduces the acidity of gastric juice, or in people suffering from achylia and chronic diseases of the stomach with reduced acid-forming function. Persons suffering from alcoholism and undergoing gastric resection are more often and more seriously ill. Cholera vibrios, having overcome the gastric barrier, multiply intensively in the small intestine. They form an exotoxin and the so-called permeability factor. Cholera toxins dramatically increase the permeability of blood vessels and cell membranes of the small intestine. As a result of frequent vomiting and diarrhea, the patient loses a large amount of fluid, isotonic plasma, electrolytes, primarily potassium, and bicarbonates in a short period. Along with the loss of electrolytes, dehydration should be considered as a leading link in the pathogenesis of cholera. The blood thickens, hemodynamics and kidney function are impaired, and convulsions appear. Acidosis and hypokalemia play a leading role in the genesis of seizures. The pathogenesis of cholera is the same when a person is infected with both classical cholera vibrio and El Tor vibrio. Clinic. The clinical picture is very diverse - from the mildest manifestations of enteritis to the most severe forms, occurring with severe dehydration and ending in death on the 1st-2nd day of the disease. The incubation period ranges from several hours to 5 days, more often 2-3 days. The onset of the disease is usually acute. Mild forms sometimes have a gradual onset. The disease usually begins with diarrhea, which occurs suddenly, often at night or in the morning. Most patients initially have watery stools, less often fecal stools, and then acquire a character typical of cholera - they resemble rice water. In some cases, with a mild course of the disease, the stool is fecal. Occasionally there is an admixture of mucus, and sometimes blood. The frequency of stool on the 1st day of illness is from 3 to 10 times, and in some cases it cannot be counted. Dehydration can develop after several bowel movements. In the first hours of the disease, pain and convulsive contractions occur in the calf and chewing muscles. Muscle weakness develops, often accompanied by dizziness and fainting. In most cholera patients, loose stools are followed by sudden repeated profuse vomiting. In some patients, it may precede diarrhea. Sometimes vomiting is observed without stool upset. Vomit may initially be mixed with food and bile, and then becomes watery and also resembles rice water. Vomiting in cholera is profuse, frequent, and erupts like a fountain. With vomit, patients lose a significant amount of electrolytes, especially chlorine. In almost half of the cases, abdominal pain is aching in nature, not intense. The abdomen of cholera patients is often retracted. As a result of the loss of large amounts of fluid and salts, a severe secondary disorder of the cardiovascular system and kidneys quickly develops. Diarrhea and vomiting stop, symptoms of dehydration appear: decreased skin turgor, cyanosis, dry skin and mucous membranes, hoarseness, even aphonia, convulsions, shortness of breath, hemodynamic disorders, anuria, hypothermia, which causes peripheral circulation disorders. At the same time, in most patients the rectal temperature is elevated. At the onset of the disease, some patients have a low-grade fever, and some people have a febrile temperature. Characterized by a decrease in arterial systolic and venous pressure and increased heart rate. With increasing dehydration, hypokalemia, acidosis, and blood thickening, hypovolemic shock and respiratory failure develop, and renal failure may occur. In accordance with the degree of dehydration, clinical forms are distinguished: mild, moderate, severe and very severe (algic). The mild form is characterized by grade I dehydration (fluid loss of up to 3% of body weight). Cholera of moderate severity is characterized by dehydration of the second degree (fluid loss up to 4-6% of body weight), an acute onset with the appearance of loose stools and the early addition of repeated vomiting with copious watery contents without previous nausea. Some patients experience cramps in the calf muscles, and less often in the hands and feet. The severe form of cholera is characterized by degree II dehydration (fluid loss of up to 7-9% of body weight), acute onset and development of all symptoms of dehydration in the first 10-12 hours of the disease. Weakness quickly increases, thirst, cyanosis of the skin, and muscle cramps of the limbs develop. Facial features become sharper. In the algic form of cholera, dehydration of the fourth degree is noted (fluid loss of up to 10% of body weight or more), the symptoms of dehydration are pronounced, the voice is silent, the skin, collected in folds, does not straighten out, the facial features are sharply pointed, the eyeballs are sunken, “washerwoman’s hands” , blood pressure decreases and then is not detected at all even in large arteries. Heart sounds are muffled, breathing is rapid and shallow, cyanosis is pronounced, convulsions become more frequent and widespread, and painful hiccups appear as a result of diaphragm convulsions. Body temperature drops to 35-34.5 °C. Diuresis sharply decreases or is absent (cholera anuria), diarrhea and vomiting stop, the patient loses consciousness, and cholera coma develops. The most severe clinical variants of the disease include the fulminant form and dry cholera. Vibrio carriage poses a great epidemiological danger. In the El Tor cholera foci, the ratio of vibrio carriers and manifest forms of cholera ranges from 10:1 to 100:1. Clinical, histomorphological, and immunological studies indicated the presence of an active infectious process with a subclinical course in bacteria carriers. Changes in peripheral blood in patients with cholera with stage I dehydration are insignificantly expressed. With degree II, there is a decrease in the number of red blood cells and hemoglobin level, which is obviously caused by the redistribution of fluid and its influx into the vascular bed due to progressive dehydration. ESR increases, especially with degree II of dehydration. With grade I dehydration, leukocytosis and leukopenia are recorded with equal frequency; in grades II-III, 50% of patients experience neutrophilic leukocytosis, which normalizes during the period of convalescence and is replaced by lymphocytosis. With II, III and IV degrees of dehydration, the content of erythrocytes and hemoglobin, despite the thickening of the blood (the relative density of plasma increases to 1028-1035), does not increase, which is probably due to the retention of erythrocytes in the depot and their subsequent destruction. At the same time, the number of leukocytes increases due to neutrophil granulocytes, especially young elements (band cells). Laboratory studies confirm the decompensated nature of the IV degree of dehydration. The relative density of plasma reaches 1032-1040 or more, the hematocrit increases to 65-70/l, and blood viscosity to 10-20 units. The volume of circulating plasma decreases, arterial blood pH drops to 7.2, significant electrolyte deficiency, severe metabolic acidosis, and hypoxia develop. As a result of deterioration of microcirculation, a violation of the blood coagulation system occurs (acceleration of phases I and II of blood coagulation with increased fibrionolysis and thrombocytopenia). Changes in urine are characteristic of the most severe degrees of dehydration and are expressed mainly in the appearance of proteinuria, erythrocytes, leukocytes, and hyaline casts. There is a decrease in the concentration function of the kidneys to 1010 and below. For rapid diagnosis of cholera, the fluorescent serological method can be used. Serological studies are used mainly for retrospective diagnosis. Of the laboratory methods, the main one is bacteriological examination of stool and vomit before the patient takes antibiotics.

Epidemiology

The source of infection is a patient with manifest or asymptomatic disease. The most active vibrio excretors are patients with severe disease, excreting up to 10 liters of feces per day, each milliliter of which contains up to 109 vibrios. At the same time, patients with asymptomatic and latent cholera, in the absence of timely diagnosis, release the pathogen into the external environment for a long time. The existence of chronic, sometimes lifelong, vibrio carriers is assumed. The mechanism of cholera infection is fecal-oral. Routes of transmission: water, nutritional, contact and household. The waterway is critical to the rapid epidemic and pandemic spread of cholera. Moreover, not only drinking water, but using it for household needs (washing vegetables, fruits, etc.) can lead to cholera infection. A temporary reserve factor for the pathogen can be fish, shrimp, and shellfish, which are capable of accumulating and preserving cholera vibrios. The most susceptible to cholera are immunocompromised people, people with hypo- and achlorhydria. The transferred disease leaves long-term immunity. Recurrent diseases are rare. As with all intestinal infections, cholera is characterized by a summer-autumn seasonality.

Clinic

The incubation period ranges from several hours to 5 days, averaging 2 days. There are typical and atypical forms of cholera. Typical cholera is classified into mild, moderate and severe.

The atypical form can occur as erased, “dry” and fulminant cholera. The typical form of cholera develops acutely - loose, watery stools appear, without tenesmus and abdominal pain, but with rumbling and a feeling of fullness in the intestines.

Body temperature is normal, sometimes low-grade fever is possible. On examination, dryness of the tongue and mucous membranes is revealed.

The abdomen is painless, rumbling is detected along the intestines. Diarrhea lasts 1-2 days and if the course is favorable, recovery occurs.

As the disease progresses, the frequency of stools can increase up to 20 times a day. The stool is watery in nature, in typical cases it looks like rice water.

There are also completely transparent or slightly bile-stained watery stools. The addition of repeated “gushing” vomiting significantly worsens the patient’s condition.

The volume of each portion of pathological stool and vomit is on average 250-300 ml and varies little from bowel movement to bowel movement. Dehydration and demineralization of the patient's body develops.

There are 4 degrees of dehydration: Dehydration I degree - loss of fluid in the amount of 1-3% of body weight. The condition of patients during this period suffers little.

The main complaint is thirst. Dehydration of the second degree - loss of 4-6% of body weight is characterized by a moderate decrease in the volume of circulating plasma.

This is accompanied by increased thirst, weakness, dry mucous membranes, tachycardia, and a tendency to decrease systolic blood pressure and diuresis. Dehydration of the third degree is characterized by a loss of 7-9% of body weight.

At the same time, the volume of circulating plasma and intercellular fluid decreases significantly, renal blood flow is disrupted, and metabolic disorders appear: acidosis with accumulation of lactic acid. Cramps of the calf muscles, feet and hands occur, skin turgor is reduced, tachycardia, hoarseness, cyanosis.

Due to severe dehydration, facial features become sharpened, eyes become sunken, the “symptom of dark glasses”, “fades cholerica” is noted, and wrinkling of the skin of the hands determines the symptom of “washerwoman’s hands”. Hypotension, hypokalemia, acidosis, oliguria, characteristic of stage III dehydration, can be relieved with adequate therapy.

In its absence, IV degree of dehydration (loss of more than 10% of body weight) leads to the development of deep dehydration shock. Body temperature drops below normal (cholera algid), shortness of breath increases, aphonia, severe hypotension, anuria, and muscle fibrillations appear.

Decompensated metabolic acidosis and signs of severe tissue hypoxia develop. The latter include impaired consciousness in some patients, up to cerebral coma, and paralysis of the respiratory center, leading to asphyxia.

Only emergency prehospital and hospital therapy can save the patient. An even more rapid development of dehydration is possible.

In cases where dehydration shock develops within several hours (one day), the form of the disease is called fulminant. Dry cholera occurs without diarrhea and vomiting, but with signs of rapid development of dehydration shock - a sharp drop in blood pressure, the development of tachypnea, shortness of breath, aphonia, anuria, and convulsions.

In children, cholera often takes on a rapidly progressive course with the development of decompensated dehydration, anuria and signs of encephalopathy.

Differential diagnosis

Differential diagnosis. Cholera is differentiated from acute gastroenteritis caused by salmonella, Shigella Sonne, rotaviruses, as well as non-infectious gastroenteritis, mushroom poisoning (toadstool) and some pesticides. The differential diagnosis between cholera and gastroenteritis of salmonella etiology presents great difficulties. This is due to the fact that dehydration is typical for both diseases and only the degree of dehydration has diagnostic significance. With salmonellosis it rarely reaches grades III and IV.

In addition, in patients with salmonellosis, symptoms of intoxication (headache, fever with chills, nausea) precede vomiting and diarrhea or occur simultaneously with them. Cholera most often begins with diarrhea, followed by vomiting and the rapid development of dehydration. With salmonellosis, uncolored stools are rarely observed, stools are usually less frequent than with cholera, and there is an admixture of mucus in the stool. Sigmoidoscopy in patients with salmonellosis reveals focal changes in the mucous membrane (point hemorrhages, erosions), while in cholera, catarrhal changes in the mucous membrane of the colon are diffuse.

Hepatolienal syndrome is often observed in patients with salmonellosis. Due to the peculiarities of the course of El Tor cholera, there is a need to differentiate it from acute dysentery, especially caused by Shigella Sonne. Dysentery is characterized by scanty stool mixed with mucus and blood, tenesmus, abdominal pain, chills, and increased body temperature. Sigmoidoscopy reveals various forms of proctosigmoiditis.

Severe symptoms of dehydration and impaired renal function are not typical. The greatest difficulties for differential diagnosis with cholera are cases of rotavirus gastroenteritis. Both diseases begin with diarrhea and vomiting, but unlike cholera, with rotavirus gastroenteritis, abdominal pain is more intense, defecation is accompanied by loud rumbling, stool is profuse, foamy, bright yellow in color with a pungent odor. Important differential diagnostic symptoms are granularity, hyperemia, and swelling of the mucous membrane of the soft palate, which are detected in almost all patients.

The phenomena of dehydration characteristic of cholera are extremely rarely observed in patients with rotavirus gastroenteritis. While patients with cholera often experience tachycardia at the onset of the disease, rotavirus gastroenteritis is characterized by bradycardia. The most likely airborne mechanism of infection is rotavirus gastroenteritis, as evidenced by the concentration of diseases in close proximity to sources of infection. Mushroom poisoning (toadstool) causes a picture similar to a very severe form of cholera, but it is characterized by severe abdominal pain and the development of jaundice.

Anamnestic data and the absence of indications of a connection with the source of cholera infection allow us to doubt the diagnosis of cholera, and then reject it. The diagnosis of the first cases of cholera is of particular importance, since the official registration of cholera entails, in addition to medical measures, the introduction of restrictive measures in a given territory. Thus, with any combination of clinical and epidemiological data, the final diagnosis of the first cases of cholera must necessarily be confirmed by isolation of the pathogen from patients. At the same time, with an already developed epidemic, the mildest intestinal disease should be regarded as suspicious for cholera, and the patient must be subject to provisional hospitalization.

The specified approach and diagnostic tactics during an epidemiological outbreak of cholera are implemented through active identification of patients during door-to-door (door-to-door) and provisional hospitalization.

Prevention

Cases of cholera in the tropics (especially in Africa) oblige visitors to strictly observe personal prevention measures for cholera and other intestinal infections (typhoid, paratyphoid, bacterial dysentery, polio, etc.). Infection with intestinal infections occurs through dirty hands, food, flies and water. Clinical manifestations of cholera in some individuals are very minor or non-existent. Therefore, infection can often occur from practically “healthy” individuals. In patients with moderate cholera, there is a large loss of fluid through feces and vomiting (dehydration), convulsions, and loss of consciousness. Prevention of cholera should be strictly carried out in countries where there have been massive cases of this disease (Indonesia, Malaysia, the Philippines, Burma, Thailand, India, Pakistan, Afghanistan, Iran, African countries of the tropical zone, etc.), since the improvement of the territory cannot be carried out in short periods of time, and the danger of cholera infection remains for some time after epidemic outbreaks. The sanitary and hygienic level of the countries of the tropical zone is not always at the required level, and the control over the quality of water and products, the cleanliness of restaurants, bars and shops is unreliable. Therefore, those arriving in the tropics must rely on themselves and create conditions at home that prevent intestinal infections from infecting the family (cleanliness of the kitchen, dishes and food, boiling water for drinking, eliminating flies, personal hygiene). Those traveling to countries with an unfavorable epidemiological situation, as well as those living in them, are vaccinated against cholera. If necessary, vaccination is repeated. Measures to prevent cholera and other intestinal infections are important both for maintaining personal health and for preventing their import into the country of residence.

Diagnostics

The totality of clinical and epidemiological data is essential for diagnosis. In conditions of possible importation of cholera, in each clinically “suspicious” case (watery diarrhea without fever and abdominal pain), a laboratory examination with provisional hospitalization should be carried out. In laboratory diagnostics, bacterioscopic examination of feces and vomit is possible, which has an approximate value. The decisive method is to isolate the pathogen by inoculating feces in 1% alkaline peptone water, Hottinger agar and other media. An answer in the presence of vibrio can be obtained after 18-24 hours (a negative answer after 36 hours). Among the express diagnostic methods: RIF, ELISA, etc.

Treatment

All patients with cholera or suspected of having it are subject to mandatory hospitalization. The immediate treatment is to replenish the deficiency of water and electrolytes with oral rehydration solutions. In the presence of vomiting, as well as in patients with severe disease, polyionic solutions are administered intravenously.

The basic principle of treating cholera patients is immediate rehydration upon first contact with the patient at home, in an ambulance and in a hospital. For mild to moderate cases, oral rehydration should be performed.

The WHO Expert Committee recommends the following composition for oral rehydration: sodium chloride - 3.5 g, sodium bicarbonate - 2.5 g, potassium chloride - 1.5 g, glucose - 20 g, boiled water - 1 l. In Russia, this solution is more often called “Oralit”.

The addition of glucose promotes the absorption of sodium and water in the intestines. WHO recommends the use of a standard glucose-saline solution for oral rehydration for many acute intestinal infections, regardless of the etiology and age of the patients.

WHO experts have also proposed another rehydration solution, in which bicarbonate is replaced by a more stable sodium citrate (“re-hydron”). In Russia, a drug called citroglucosolan has been developed, which is identical to the WHO glucose-saline solution.

If it is impossible to accurately account for fluid losses with vomit and feces, it is recommended that children drink 50-150 ml of glucose-saline solution after each bowel movement (at a rate of 1 teaspoon - 1 dessert spoon per 1 minute), adults 200-250 ml (1 tablespoon in 1 minute). Along with the glucose-saline solution, an additional volume of plain boiled water, tea, rosehip decoction and other liquids is recommended.

Patients, and especially children, with frequent bowel movements in an unfavorable cholera situation should be examined every 12 hours or daily due to the possible rapid progression of the disease. In situations where observation is impossible, provisional hospitalization is indicated.

This is especially important in cases where during the first 6 hours oral fluid intake is ineffective and dehydration occurs. Often, such patients should immediately, starting from the prehospital stage, be given intravenous electrolyte solutions.

The calculation of the necessary solutions for rehydration in children depends on the child’s body weight and the degree of dehydration. In adults, oral rehydration fluid is calculated based on fluid loss in stool.

Oral rehydration is continued until diarrhea completely subsides. In case of severe cholera and in the presence of vomiting, polyionic solutions are administered intravenously: trisol, disol, acesol, quartasol, lactasol.

More often than others, trisol (Phillips solution No. 1) is used, containing sodium chloride 5 g, sodium bicarbonate 4 g, potassium chloride 1 g per 1 liter of pyrogen-free double-distilled water (5-4-1). If they are absent, Ringer's solution is used first.

Attention! The described treatment does not guarantee a positive result. For more reliable information, ALWAYS consult a specialist.

Cholera is an acute intestinal infection that primarily affects the small intestine, disrupting water-salt metabolism with varying degrees of dehydration due to loss of fluid with copious watery stools and vomiting. Cholera is a particularly dangerous infection, as an epidemic may occur.

What causes cholera and how do you get it?

The causative agent of cholera is Vibrio cholerae. This is a curved, non-spore forming rod with one flagellum. There are two main types of Vibrio cholerae - classic (the causative agent of Asian cholera) and El Tor.

Basic cholera infection route- water, when drinking unboiled water from open reservoirs.

After passing the stomach, vibrios enter the small intestine and colonize the surface of the intestinal epithelium. But in patients with cholera, vibrio can be found throughout the gastrointestinal tract.

Having multiplied to a certain concentration, the pathogen causes disease.

Advanced disease accompanied by a large loss of fluid and ions of sodium, potassium, chlorides, and bicarbonates. People of any age are susceptible to Vibrio cholerae. The disease occurs more often and more severely in people who abuse alcohol or have undergone surgery to remove part of the stomach.

How does cholera manifest?

The period from infection to illness with cholera varies from several hours to 5 days, but usually 2-3 days. For those people who took antibiotics for prophylactic purposes and, despite this, fell ill, this period can increase to 9-10 days.

The disease is characterized by a sudden onset. The first, most pronounced manifestation of cholera is diarrhea. Typical cholera stool is a watery, cloudy-white liquid in which flakes float, resembles rice water in appearance, and is odorless. Early signs of cholera also include muscle weakness and cramps in the calf muscles. Subsequently, profuse and repeated vomiting appears against the background of loose stools.

Degrees and stages of dehydration in cholera

I degree. Characterized by a loss of body weight of 1-3%. The frequency of diarrhea and vomiting ranges from 2-3 to 5-6 times a day, they last 1-3 days. Patients' health is most often satisfactory, but mild general weakness, thirst, and dry mouth may bother them. The color of the skin and mucous membranes is not changed, pulse, blood pressure, urine output are within normal limits. Patients with this degree usually do not seek medical help.

At II degree body weight loss is 4-6%. The frequency of stools reaches 15-20 times or more per day, moderate pain in the epigastric region, as well as frequent vomiting, may appear. General and muscle weakness increases, the skin and mucous membranes are dry, the tongue is dry and covered with a white coating. A constant blue discoloration of the mucous membranes of the lips appears, the voice becomes hoarse and decreases. In some cases, short-term cramps of the masticatory muscles and muscles of the legs, feet and hands appear. Most patients experience increased heart rate, decreased blood pressure, and decreased urination.

At III degree dehydration loss of body weight is 7-9%. The frequency of stools can exceed 25-35 times a day, and repeated vomiting is observed. This degree is characterized by severe general weakness, uncontrollable thirst, frequent painful spasms of the muscles of the arms, legs, abdomen, etc. There is a constant blue discoloration of the skin and mucous membranes. The skin becomes cold to the touch. The patient has a hoarse, almost silent voice. Body temperature can drop to 35.5 °C. Blood pressure is sharply reduced, rapid heartbeat, shortness of breath are observed, and there is practically no urination. Facial features become sharper, cheeks and eyes become sunken.

At IV degree dehydration (cholera algide) more than 10% of body weight is lost. Signs of cholera develop rapidly with severe diarrhea and vomiting. The condition of the patients becomes extremely serious. Signs of dehydration are most pronounced in the form of sharpening of facial features, cyanosis of the skin and mucous membranes, which become cold to the touch and covered with cold, sticky sweat. Characterized by severe cyanosis around the eyes (“a symptom of glasses”), “washerwoman’s hands”, a pained expression on the face, frequently repeated painful cramps of all muscle groups, a decrease in body temperature less than 35 C, absence of voice, a sharp disruption of the cardiovascular system: rapid heartbeat, pulse and blood pressure are not determined, shortness of breath increases.

Treatment of cholera

All people sick with cholera must be hospitalized. In addition to treatment aimed at replenishing fluid, both orally and intravenously, patients with cholera are shown antibiotics that reduce the duration of diarrhea and replenish water-salt losses. Doxycycline, tetracycline, chloramphenicol, erythromycin, furazolidone or ciprofloxacin are prescribed orally. The duration of antibacterial treatment is on average 3-5 days.

Internal administration of antibiotics is advisable after eliminating dehydration and stopping vomiting, which in most cases is achieved after 4-6 hours of treatment. In case of severe dehydration of the III-IV degree, tetracycline and chloramphenicol are administered intravenously in the first hour of therapy, and only then they switch to oral administration of the drug.

More

Residents of developed countries have long forgotten what cholera is, where the standard of living is quite high, prevention of cholera in the event of an epidemic risk is carried out quickly, and the quality of medical care is at the proper level.

However, not everything is so rosy on a global scale. Europe is not afraid of an outbreak of the disease within itself, but it is afraid (and not unreasonably) of its movement from exotic countries. That is why it is important to know the causes of cholera, its main manifestations and rules of behavior in such a situation.

Plague, cholera and anthrax are considered long-forgotten diseases that caused terrible epidemics. Their victims numbered in the tens of thousands. If plague and anthrax have recently been extremely rare, in isolated cases, then from cholera every year from 3 to 5 million people suffer and up to 150 thousand die.

Cholera is a dangerous infectious disease that affects the mucous membranes of the small intestine. The causative agent of cholera is Vibrio cholerae, Vibrio cholerae.

The pathogenesis of cholera is determined by the structure of the pathogenic microorganism, which has the following features:

• The presence of a flagellum that ensures the motility of the bacterium;
• purposefulness in movement towards nutrients;
• releases exotoxin - cholerogens, which activates chemical reactions in the intestines. Leads to diarrhea with extreme dehydration;
• enzymes released during vital activity destroy the integrity of the mucous layer and allow bacteria to enter the muscular layer of the intestine;
• The cholera vibrio has pili - a kind of suckers that help it to gain a foothold on the intestinal walls, multiply and colonize.

The causative agent of cholera, entering the human body, overcomes the gastric barrier and enters the small intestine. It is here that it is activated, releasing toxins that trigger the development of cholera symptoms.

It should be noted that the causative agent of the disease does not form spores or capsules. But despite the lack of protective functions, it is quite stable in the external environment. It can remain active in ice and river water for up to a month, and in sea water for up to a month and a half. In the feces of a sick person - up to 3 days, in soil - up to 3 months.

However, high temperatures (boiling or processing vegetables and fruits with boiling water kills instantly), drying, exposure to sunlight, treatment with antiseptics and disinfectant solutions lead to the death of vibrio.

Routes of infection

Cholera, as an infectious disease, threatens all inhabitants of the earth. Until 1817, it “lived” only in India, but then it spread beyond its borders. Now it is recorded in 90 countries around the world.

The unsanitary conditions in which people live in the countries of Latin America, Africa, and Southeast Asia provoke outbreaks of the disease every year.

There is a risk of contracting the disease among tourists who prefer to holiday in the Dominican Republic, Cuba, Haiti and Martinique.

Social cataclysms, earthquakes and other natural disasters that leave people without quality drinking water become the cause of the disease. The last cholera epidemic was registered in 2010, when there were more than 200 thousand cases.

The source of infection is a sick person or a carrier. The transmission mechanism is exclusively fecal-oral. Feces during this period do not have a specific smell or color, so they may go unnoticed. The disease is not transmitted by airborne droplets.

Transmission routes:

• Through contaminated water into which wastewater enters. In such water the concentration of the pathogen is very high, it is dangerous to wash with it, use it for cooking or drink;
• household contact infection occurs through objects;
• food - through seafood, algae, dairy products, fruits and vegetables, fish and meat that have not been subjected to heat treatment. Bacteria on these products can come from either the source or be carried by flies.

Risk factors for developing cholera infection include:

• Use of water from reservoirs contaminated by sewage. This “liquid” cannot be used for hygiene or household needs;
• seafood that has not been sufficiently cooked (especially raw shellfish and seaweed);
• travel to “third world” countries where the standard of living is low and SanPiN rules are not observed;
• refugee camps where there are no basic living conditions (sewage, drinking water);
  military operations and epicenters of natural or social disasters.

Also at risk are people with diseases of the digestive system (low acidity of gastric juice or problems with the functioning of the organ that produces hydrochloric acid).

Clinical picture

Symptoms of cholera are usually moderate with an average pathology development. The incubation period can last either several hours (with the fulminant form) or 3-5 days. During this time, the vibrio colonizes the intestines and begins its life activity.

The signs of cholera are as follows:

• Begins suddenly with morning or night frequent urge to defecate;
• temperature indicators remain within normal limits or do not increase significantly;
• then comes gushing vomiting without pain or nausea;
• there is rumbling and discomfort in the lower abdomen and in the navel area;
• the stool is frequent, at first just liquid, then it takes on the consistency and appearance of rice water, without any particular odor or with a slight fish or potato aroma;
• loss of appetite, muscle weakness and constant strong thirst;
• increased heart rate due to decreased blood pressure;
• dry skin and mucous membranes in the mouth. In some cases, the skin may take on a bluish tint.

With further development without adequate treatment, stool becomes even more frequent, due to dehydration, cramps appear in the muscles of the legs and arms, and the amount of urine excreted decreases until it is completely absent. The voice becomes hoarse. Loose stools are observed from several hours to 1-2 days - with timely seeking help and adequate therapy.

The cholera clinic will differ depending on the severity of the pathology.

A mild degree is the most favorable scenario for the course of the disease, ending with complete recovery without consequences for the body. The symptoms are as follows:

• General weakness, thirst and dry mouth;
• diarrhea up to 10 times a day;
• may occur without vomiting or with rare manifestations;
• fluid loss up to 3% of body weight in adults and up to 2% in children.

All these symptoms disappear within two to three days.

There is a version that with frequent and regular fluid intake during this period, cure is possible even without taking medications.

Moderate severity is characterized by the following clinical manifestations:

• The onset is rapid, loose stools up to 20 times a day;
• gushing frequent vomiting without nausea or discomfort;
• the organ (intestines) is not painful;
• general weakness, constant thirst, provoked by the second degree of dehydration, cramps of the calf muscles.

The severe form is characterized by a stool frequency of more than 20 times per bowel movement, uncontrollable vomiting, and the third degree of dehydration (fluid loss of more than 10% of the total body weight, critical for the human body).

All other symptoms are very pronounced and increase over time. If assistance is not provided in a timely manner, in 60% of cases the disease ends in death.

Cholera in children is most often observed between the ages of 3 and 5 years and is severe. Older children, especially those who have been vaccinated, get sick less often and in a mild form. In newborns, most cases are fatal.

Note: Children whose mothers have suffered from cholera have a strong immunity to the disease and even in infancy, if they get sick, it is in a mild form with a complete recovery without any complications.

The algic form of cholera (or rather, the period of pathology) is the most difficult period, during which mortality is noted.

Diagnosis and treatment

If there is no epidemic or at its very beginning, when isolated cases of intestinal infections are identified, the diagnosis is made in stages.

An anamnesis is collected based on the patient’s complaints and symptoms. The circle of his contacts over the past few days is revealed. This makes it possible to observe people who are sick, either carriers or potential patients.

Next, laboratory diagnostics of cholera is carried out - examination of vomit and feces. The material is collected immediately before the analysis. If the necessary research cannot be carried out within 3 hours, the material is placed in an alkaline environment. It is often possible to identify the pathogen within 36 hours, and in specialized laboratories – within 5 hours, which is very important for treatment.

As an auxiliary method, a serological test is used to detect antibodies in the blood.

Treatment for cholera includes:

• Relieve symptoms through rehydration. For mild and moderate severity - orally, for moderate and severe severity - intravenously;
• restoration of water-mineral balance through intravenous administration of appropriate drugs;
• prescribing choleretic drugs - narrow-spectrum antibiotics (acting specifically on Vibrio cholerae), but sometimes broad-spectrum antibacterial drugs are prescribed. Therapy is carried out for at least 5 days.

When improvement begins and a person can eat, experts do not recommend adhering to any special diets. Dishes should not be too fatty, spicy or salty. Meals are fractional and frequent, but in small portions. There are no special restrictions on products.

Preventive actions

Cholera prevention is carried out in countries where there is a risk of an epidemic outbreak or cases of the disease have been reported. Such measures can be divided into planned and emergency.

1. Directly at the place where the disease is detected, it is prohibited to swim in open water or drink raw water. Water is disinfected with special reagents.
2. Patients are strictly isolated until complete recovery.
3. People who had contact with the patient are being monitored. They are also examined for infection within five days.
4. It is imperative to wash your hands with soap and other antiseptics, treat dishes and food with hot water and, if possible, disinfectants.

In European countries, for preventive purposes, people returning from countries where cases of cholera were reported during their stay are monitored for 5 days.

Vaccination against cholera is a specific preventive measure. Modern research has proven that injectable vaccines should only be used in an emergency. According to epidemiological indicators, no earlier than 3 months later, revaccination can be carried out, providing one hundred percent protection against the disease.

But the use of oral vaccines, of which there are three types, is more justified. They are recommended for those who plan to visit potentially dangerous regions. But this must be done in advance (about 10-14 days before the planned trip).

The disadvantage of such vaccination is that it protects against the disease for a short time - from several months to six months, no more.

Complications of cholera, especially if treatment was started at the wrong time or was carried out using inadequate methods, may be as follows:

• With weak immunity and the presence of concomitant diseases, abscesses and phlegmon may develop;
• sepsis has recently become extremely rare, but still occurs in countries with low living standards;
• with severe pathology and fourth degree dehydration, dehydration shock may develop - blueing of certain areas of the skin, decreased body temperature, loss of voice, tachycardia and a decrease in blood pressure to critical levels;
• disturbances in the functioning of the brain and, as a result, coma.

One should not think that cholera is somewhere far away and not with us. As the last epidemic in 2010 showed, such a disaster can overtake a person in any country in the world.