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Cholera
Last reviewed: 05.07.2025
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Cholera is an acute infectious disease of the small intestine caused by Vibrio cholerae. This microorganism secretes a toxin that causes profuse watery (secretory) diarrhea, leading to dehydration, oliguria, and collapse. Infection typically occurs through contaminated water and seafood. Diagnosis of cholera is based on culture or serological testing. Treatment of cholera includes intensive rehydration and replacement of electrolyte losses with doxycycline therapy.
ICD-10 codes
- A00. Cholera.
- A00.0. Cholera caused by Vibrio cholerae 01, biovar cholerae.
- A00.1. Cholera caused by Vibrio cholerae 01, biovar eltor.
- A00.9. Cholera unspecified.
Causes of cholera
Cholera is caused by Vibrio cholerae serogroups 01 and 0139.
This organism is a short, curved, labile aerobic bacillus that produces an enterotoxin. Enterotoxin is a protein that causes hypersecretion of an isotonic electrolyte solution by the small intestinal mucosa. Both El Tor and classical biotypes of Vibrio cholerae can cause acute disease. However, mild or asymptomatic infection is much more common with the El Tor biotype.
Cholera is spread by consuming water, seafood, and other foods contaminated with the feces of people with or without symptoms of the infection. Cholera is endemic in parts of Asia, the Middle East, Africa, South and Central America, and the Gulf Coast of the United States. Infections have spread to Europe, Japan, and Australia, causing local outbreaks. In endemic areas, cholera outbreaks usually occur during warmer months. The disease is most common in children. In young areas, cholera epidemics may occur at any time of year, and susceptibility to the pathogen is similar in children and adults. A mild form of gastroenteritis is caused by non-cholera vibrios.
Sensitivity to infection may vary. It is higher in people with blood group I (ABO). Since the vibrio is sensitive to gastric acid, hypochlorhydria and achlorhydria are predisposing factors for the development of the disease. People living in endemic regions gradually acquire natural immunity.
[ What are the symptoms of cholera?
Cholera has an incubation period of 1–3 days. Cholera may be subclinical, mild, uncomplicated episodes of diarrhea, or fulminant, potentially fatal. Typically, the initial symptoms of cholera are sudden, painless, watery diarrhea and vomiting. Severe nausea is usually absent. Stool losses may reach 1 L per hour in adults, but are usually much less. This leads to acute water and electrolyte losses, causing intense thirst, oliguria, muscle cramps, weakness, and marked decrease in tissue turgor, accompanied by sunken eyeballs and wrinkling of the fingertips. Hypovolemia, hemoconcentration, oliguria, and anuria occur, as well as acute metabolic acidosis with a fall in ionized potassium levels (the concentration of sodium in the blood remains normal). If cholera is left untreated, circulatory collapse with cyanosis and stupor may follow. Prolonged hypovolemia may cause tubular necrosis.
Where does it hurt?
How is cholera diagnosed?
Diagnosis of cholera is made by stool culture and subsequent serotyping. Cholera is differentiated from similar diseases caused by enterotoxin-producing strains of E. coli and, occasionally, salmonella and shigella. Electrolyte levels, residual urea nitrogen, and creatinine should be measured.
What do need to examine?
How to examine?
What tests are needed?
Who to contact?
How is cholera treated?
Cholera is treated using the basic principle of fluid replacement. Moderate cases can be treated with standard oral replacement. Rapid correction of hypovolemia is vital. Prevention and correction of metabolic acidosis and hypokalemia are very important. Intravenous isotonic solutions are indicated in patients with hypovolemia and acute dehydration (see Replacement Therapy for details). Water should also be given freely by mouth. KCL 10-15 mEq/L or KHCO 1 mL/kg orally in a 100 g/L solution four times daily may be added to the intravenous solution to replace potassium losses. Potassium replacement is especially important in children, as they tolerate hypokalemia very poorly.
When volume replacement is required, the volume to replace ongoing losses must be carefully assessed based on stool losses. Adequacy of hydration is confirmed by frequent clinical assessment (pulse rate and strength, tissue turgor, urine output). Plasma, plasma expanders, and vasopressors should not be used in place of water and electrolytes. Oral glucose-saline solutions are effective in replacing stool losses. They can be used after initial intravenous rehydration and, in endemic areas where intravenous fluids are limited, they may be the sole source of rehydration. Patients who are mildly or moderately dehydrated and able to drink can be rehydrated solely with glucose-saline solutions (approximately 75 ml/kg over 4 hours). Patients with more severe dehydration require larger volumes of solutions, and placement of a nasogastric tube may be necessary. The oral solution recommended by WHO should contain 20 g glucose, 3.5 g NaCl, 2.9 g triple citrate and dihydrate (or 2.5 g NaHCO ), and 1.5 g potassium chloride per 1 liter of drinking water. These prescriptions should be continued as long as necessary {ad libitum) after rehydration in volumes adequate to losses with stool and vomiting. Solid food can be given to the patient only after vomiting has ceased and appetite has been restored.
Early treatment of cholera with an effective oral antibiotic eradicates the vibrio, reduces fecal losses by 50%, and stops diarrhea within 48 hours. The choice of antibiotic is based on the susceptibility testing of the cholera vibrio, provided that the latter has been isolated from the microbial community. Drugs effective against susceptible strains include doxycycline (a single dose of 300 mg orally for adults), furazolidone (100 mg orally 4 times daily for 72 hours for adults, 1.5 mg/kg 4 times daily for 72 hours for children), trimethoprim-sulfamethoxazole (2 tablets 2 times daily for adults, 5 mg/kg 2 times daily (trimethoprim) for children for 72 hours).
Most patients become free of V. cholerae within 2 weeks of cessation of diarrhea, but some become chronic biliary carriers.
How is cholera prevented?
Cholera is prevented by properly disposing of human excreta and ensuring that water supplies are clean. Drinking water should be boiled or chlorinated, and vegetables and fish should be thoroughly cooked.
Killed whole-cell oral B-subunit cholera vaccine (not available in the United States) provides 85% protection against serogroup B for 4 to 6 months. Protection lasts up to 3 years in adults but rapidly disappears in children. This protection is greater against the classical biotype than against El Tor. Cross-protection does not occur between serogroups 01 and 0139. Vaccines with proven efficacy against both groups are the hope of the future. Parenteral cholera vaccine provides only short-term partial protection and is therefore not recommended for use. Requisite prophylaxis with doxycycline 100 mg orally every 12 hours in adults (in children under 9 years of age, trimethoprim-sulfamethoxazole may be used for prophylaxis) may reduce the incidence of secondary cases in households with contact with a cholera patient, but mass prophylaxis of cholera is not practical, and some strains are resistant to these antibiotics.