Cholera: symptoms

Cholera has an incubation period that lasts from several hours to 5 days, usually 2-3 days, after which typical cholera symptoms appear.

Symptoms of cholera give the basis to divide the cholera into the following forms: erased, light, of medium severity, heavy and very heavy, determined by the degree of dehydration.

IN AND. Pokrovsky identifies the following degrees of dehydration:

• I degree, when patients lose a volume of fluid equal to 1-3% of body weight (erased and light forms);
• II degree - losses reach 4-6% (form of medium gravity);
• III degree - 7-9% (heavy);
• IV degree of dehydration with a loss of more than 9% corresponds to very severe cholera flow.

Currently, I degree of dehydration occurs in 50-60% of patients, II - in 20-25%, III - in 8-10%, IV - in 8-10%.

Assessment of the severity of dehydration in adults and children

	Stunted and light	Medium gravity	Heavy	Very heavy
	1-3	4-6	7-9	10 and more
Chair	Up to (0 times	Up to 20 times	More than 20 times	Without an account
Vomiting	Up to 5 times	Up to 10 times	Up to 20 times	Multiple (indomitable)
Thirst	Weak	Moderate	Strongly expressed	Unquenchable (or can not drink)
Diuresis	Norm	Decreased	Oliguria	Anuria

It is believed that the symptoms of cholera do not fundamentally depend on the type of pathogen (its serotype and biovar), however, as evidenced by observations, the biologist El-Tor V cholerae more often causes lighter forms of the disease.

Features of the clinical course of cholera depending on the biologist of the pathogen

Clinical forms	V. Cholerae
	Classica (asiatica)	El Tor
Heavy	Eleven%	2%
Mediocrity	15%	5%
Lungs	15%	18%
Innovative	59%	75%

With cholera, various clinical forms of the disease development are observed - from asymptomatic vibrio-carrying and subclinical forms to extremely severe and even lightning-fast forms with rapidly developing dehydration and possible death of patients within 4-6 hours from the onset of the disease.

In some cases (10-15%), the acute onset of the disease is preceded by the prodromal symptoms of cholera, which last from a few hours to a day. During this period, patients note the appearance of weakness, malaise, dizziness, headache, vegetative disorders in the form of sweating, palpitations, cold extremities.

In typical cases, cholera begins acutely, without fever and prodromal phenomena. The first symptoms of cholera are a sudden urge to defecate and leave the mitesy or from the very beginning of watery stools. In the future, these imperative desires are repeated. Stools lose their fecal character and often look like rice decoction: translucent, cloudy white, sometimes with floating flakes of gray color, odorless or with the smell of fresh water. The patient notes rumbling and unpleasant sensations in the umbilical region.

In patients with mild cholera, defecation is repeated no more than 3-5 times a day, overall health remains satisfactory, feelings of weakness, thirst, dry mouth are insignificant. Duration of the disease is limited to 1-2 days.

At moderate severity (dehydration of grade II), the disease progresses, vomiting, increasing in frequency, joins diarrhea. Vomit has the same kind of rice decoction as stool. It is characteristic that vomiting is not accompanied by any tension and nausea. With the addition of vomiting, exsicosis rapidly progresses. Thirst becomes painful, the tongue is dry, with a "chalky coating", the skin, mucous membranes of the eyes and oropharynx pale, the skin turgor decreases. Stool up to 10 times a day, plentiful, in volume does not decrease, but increases. There are single spasms of gastrocnemius muscles, hands, feet, chewing muscles, unstable cyanosis of the lips and fingers, hoarseness of the voice. Develop a moderate tachycardia, hypotension, oliguria, hypokalemia.

Cholera in this form lasts 4-5 days. Severe form of cholera (the third degree of dehydration) is characterized by pronounced signs of exsicosis due to the abundant (up to 1-1.5 liters per defecation) stool, which has become so since the first hours of the disease, and the same profuse and repeated vomiting. Patients are concerned about painful cramps in the muscles of the limbs and abdomen, which, as the disease progresses, pass from rare clonic to frequent and even give way to tonic cramps. The voice is weak, thin, often barely audible. The skin turgor is reduced, the skin is not folded for a long time. The skin of the hands and feet becomes wrinkled (the "hand of the laundress"). The face takes on a characteristic of cholera: sharpened features, sunken eyes, cyanosis of the lips, ear shells, ear lobes, nose.

When palpation of the abdomen is determined by the transfusion of liquid through the intestine, the splash of the liquid. Palpation is painless. Appears tachypnea, tachycardia increases to 110-120 per minute. Pulse of weak filling ("filiform"), heart sounds are deaf. The arterial pressure progressively drops below 90 mm Hg, at first the maximum, then the minimal and pulse. Body temperature is normal, urination decreases and soon stops. Condensation of the blood is expressed moderately. Indices of relative plasma density, hematocrit index and blood viscosity at the upper limit of the norm or moderately increased. Expressed hypokalemia of plasma and erythrocytes, hypochlora, moderate compensatory hypernatremia of plasma and erythrocytes.

A very severe form of cholera (formerly called algid) is characterized by a rapid sudden development of the disease, beginning with massive continuous defecations and profuse vomiting. After 3-12 hours, the patient develops a severe condition of the algid, which is characterized by a decrease in body temperature to 34-35.5 ° C, extreme dehydration (patients lose up to 12% of body weight - grade IV dehydration), dyspnea, anuria and hemodynamic disorders by type hypovolemic shock. By the time patients enter the hospital, they develop a paresis of the muscles of the stomach and intestines, which causes vomiting (replaced by convulsive hiccough) and diarrhea (a gaping anus, free outflow of "intestinal water" from the anus with a slight pressure on the anterior abdominal wall). Diarrhea and vomiting occur again on the background or after the end of rehydration. Patients are in a state of prostration. Breathing is frequent, superficial, in some cases Kussmaul's breathing is observed. Skin coloring in such patients acquires an ashy shade (total cyanosis). There are "dark glasses around the eyes," eyes sunk, sclera dull. The look is unblinking, the voice is missing. The skin is cold and sticky to the touch, it is easy to fold and for a long time (sometimes for an hour) does not straighten ("cholera fold").

Heavy forms of cholera are more often noted at the beginning and in the midst of the epidemic. At the end of the outbreak and during the interepidemic period, light and erased forms predominate, hardly distinguishable from diarrhea of another etiology. In children under 3 years of age, the symptoms of cholera occur most severely: they tolerate dehydration worse. In addition, children develop secondary CNS damage: observed adynamia, clonic convulsions, impaired consciousness, right up to the development of coma. It is difficult to determine the initial degree of dehydration in children. In such cases it is impossible to be guided by the relative density of the plasma due to the large extracellular volume of the liquid. It is therefore advisable to weigh the patients at the time of admission to determine the degree of dehydration most reliably. The clinical picture of cholera in children has some peculiarities: the body temperature often rises, apathy, adynamia, propensity to epileptiform fits due to the rapid development of hypokalemia are more pronounced.

The duration of the disease varies from 3 to 10 days, the subsequent manifestations of it depend on the adequacy of substitution treatment with electrolytes.

Since the most important primary clinical signs of cholera are liquid watery stools and vomiting, leading to dehydration of the body, the severity of the course and the prognosis of the disease are determined by the degree of its severity. One of the main signs of cholera is the rapid development of dehydration, which is not characteristic of other acute diarrheal infectious diseases. Dehydration IV degree can develop in patients already during the first day of the disease.

At present, clinical classification of cholera, proposed by V.I. Pokrovsky with co-workers. (1978), according to which four (I-IV) degrees of dehydration are distinguished, depending on the magnitude of water losses relative to body weight and, accordingly, reflecting the severity of the course of the disease.

Dehydration of the 1st degree. The level of fluid loss does not exceed 3% of body weight. Patients note a sudden appearance of a urge to defecate, accompanied by a mushy or watery stool. In the future, similar desires are repeated, but there are no painful sensations from the intestine. Most often the rate of defecation at the I degree of dehydration does not exceed 5-10 times a day. Vomiting is recorded in not more than half of patients and does not exceed 1-2 times a day. Patients notice only dry mouth, thirst and a slight weakness, their general condition and state of health remain satisfactory.

Dehydration of the II degree. Loss of fluid is in the range of 4 to 6% of body weight. The presence of more intensive water-electrolyte losses is manifested by a frequent watery stool (more than 10 times a day) and repeated vomiting (from 5 to 10 times a day). Typical stools of the type of rice broth are registered in not more than 1/3 of patients. In some cases, vomiting can dominate the clinical picture, while the stool in these patients will remain fecal.

Patients complain of the following symptoms of cholera: dryness of the mucous membranes of the oropharynx, expressed thirst, weakness. At objective survey the pallor of integuments is revealed, and in a quarter of cases cyanosis of the nasolabial triangle and acrocyanosis. The tongue is dry, coated with bloom. There are tachycardia, lowering blood pressure, oliguria. Approximately in a third of cases, patients experience short-term convulsive twitching of the limb muscles.

Dehydration of the third degree. Loss of fluid corresponds to 7-9% of body weight. Since water-electrolyte losses occur already at the expense of the vascular bed, the clinical signs of dehydration in such patients are sharply expressed. In view of maintaining the life-supporting functions of the cardiovascular system at a minimum, this stage is sometimes referred to as subcompensated.

Already from the first hours of the disease, patients have an abundant multiple stool and indomitable vomiting, which quickly lead to dehydration of the body. Early, long, repetitive painful cramps in the limbs appear with a possible transition to other muscle groups (for example, the muscles of the abdominal wall). In view of the decrease in bcc there is a progressive decrease in arterial pressure, tachycardia, development of oligoanuria.

Dehydration of the IV degree. The severity of water-electrolyte disorders is maximal, the fluid loss corresponds to 10% or more of the body weight. The variant of cholera flow with IV degree dehydration is characterized by a very rapid development of the clinical picture of the disease, as a result of which the growing signs of dehydration in most patients are detected within 6-12 hours from the moment of onset of the disease. Previously, this degree of dehydration was classified as an algid because of hypothermia in patients. The condition of the patients is extremely difficult. Due to electrolyte disorders, the paresis of the smooth muscles of the gastrointestinal tract sometimes develops, accompanied by the cessation of vomiting and the appearance of hiccups. The decrease in the tone of the anus is manifested by the free flow of the intestinal fluid, which increases even with mild palpation of the abdomen. Typical generalized convulsions. In the first hours with the IV degree of dehydration, the patients are conscious, but they are sleepy, apathetic, verbal contact with them is hampered by severe weakness and aphonia. As the introduction-electrolytic and acid-alkaline disorders progress, they may develop a sopor that goes to a coma. Despite the fact that the patients have critical electrolyte losses, manifested by a sharp drop in blood pressure, lack of pulse on the peripheral arteries, anuria, all changes are reversible, and the success of treatment depends on the timing of initiation of rehydration therapy and its adequacy.

In addition to clinically manifested forms, when the symptoms of cholera are pronounced, the disease can occur in subclinical form and in the form of vibrio-carrying. Vibrio-carrying can be convalescent (after the transferred clinically manifested or subclinical forms) and "asymptomatic", in which the development of the infectious process is limited only to the formation of carrier. Clinical and laboratory examination of "asymptomatic" carriers shows that in the overwhelming majority of cases (95%) patients have a subclinical form of the disease.

Clinical and epidemiological features of cholera caused by the biotype of El-Tor:

• increase in the number of erased, subclinical forms and vibrio-carrying;
• prolongation of the period of convalescence;
• a decrease in the effectiveness of etiotrolal therapy due to the growth of antibiotic resistance of vibrio strains .

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Complications of cholera

Due to violations of hemostasis and microcirculation in patients of older age groups, myocardial infarction, mesenteric thrombosis, acute cerebral circulatory insufficiency are observed. Phlebitis are possible (with catheterization of veins), severe pneumonia often occurs in severe patients.

[10], [11], [12], [13], [14], [15], [16]