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Clinical Summary

Cholera is a severe diarrheal disease caused by Vibrio cholerae, a gram-negative bacterium, and is spread via the fecal-oral route. It is associated with poor hygiene and overcrowding, as well as the resultant contamination of food and water. Endemic disease is present in many areas of the world with occasional epidemics. Massive outbreaks in previously disease-free areas can occur following disasters or breakdowns in public health measures, such as seen in Haiti following the 2010 earthquake.

Cholera is characterized by massive, watery, gray, and painless diarrhea. The stool resembles “rice water” without blood or pus. Patients may have associated vomiting. Renal failure, hypotension, and circulatory collapse can occur within hours of diarrhea onset. Mortality rates as high as 20% to 50% among severe cases can be seen if adequate rehydration is not available. Death rates of less than 2% are seen with good case management.

FIGURE 21.12

Cholera. Severely dehydrated child during an outbreak in Uganda. Lethargy and sunken eyes are typical findings. IV fluids are typically reserved for severe cases. The child is on a typical cholera cot. (Photo contributor: Seth W. Wright, MD.)

FIGURE 21.13

Dehydration in Cholera. “Tenting” of the skin of a dehydrated cholera patient. The presence of tenting implies moderate to severe dehydration. (Photo contributor: Seth W. Wright, MD.)

Management and Disposition

The mainstay of treatment is hydration. Oral rehydration solutions are adequate for mild and moderate dehydration. Patients with severe dehydration are treated with IV lactated Ringer solution and oral rehydration. Per World Health Organization (WHO) guidelines, adult patients may require 10 to 15 L in the first 24 hours. Monitoring of electrolytes and renal function is ideal, but often not available in areas struck by cholera epidemics. Hypokalemia is common. Antibiotics are not required for recovery as the illness is self-limiting, but doxycycline may reduce the volume of diarrhea and shorten the duration of illness.


  1. Cholera, plague, and yellow fever are the three diseases internationally notifiable to WHO.

  2. John Snow’s removal of the Broad Street water pump handle during the 1854 cholera epidemic in London is considered to be the beginning of modern field epidemiology.

  3. Rapid cholera test kits are available and are essential for early confirmation of disease in the 1st suspected cases.

  4. An oral cholera vaccine is available but only confers short-term immunity and is not available in the United States.

FIGURE 21.14

Rice Water Stool. Typical “rice water” stool from cholera patient. Patients with cholera often lose a liter or more of watery stool an hour. (Photo contributor: Seth W. Wright, MD.)

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