Cholera: Symptoms, Causes, Treatment, and Diagnosis

Cholera is an acute, infectious water-borne disease characterized by severe diarrhea and dehydration which could be fatal if not treated timely.

There has been no reporting of cholera outbreak in US since 1911 and the disease has been almost completely eradicated, thanks to modern sewage and water treatment.

However, cases of cholera still present a serious health issue in Africa, Southeast Asia, Haiti and central Mexico. People who live in crowded conditions with poor sanitation are at the highest risk of cholera.

Cholera can be treated easily and a simple and inexpensive rehydration solution can save lives of many suffering from cholera.

Symptoms of cholera infection

Diarrhea: Sudden diarrhea with massive and dangerous fluid loss as much as a quart (about 1 liter) an hour. The color of the stool resembles that of rice water, hence the name rice-water stool.
Nausea and vomiting: Persistent nausea and vomiting occur at early stages of cholera.
Dehydration: Dehydration occurs within hours after the symptoms of cholera become apparent. Dehydration can range from mild to severe depending upon the amount of water and electrolytes lost due to diarrhea.

Signs and symptoms of cholera dehydration

Irritability, lethargy, sunken eyes, a dry mouth, extreme thirst, dry, wrinkled skin with reduced elasticity, little or no urine output, low blood pressure, and an irregular heartbeat (arrhythmia). Dehydration may lead to a rapid loss of electrolytes causing an electrolyte imbalance.
Electrolyte imbalance: Proper fluid balance in the body is maintained by optimum concentrations of various electrolytes in the body. An electrolyte imbalance is characterized by serious signs and symptoms like:
Muscle cramps: This occurs due to loss of major electrolytes like sodium, potassium and others.
Shock: Shock (hypovolemic shock) is a state in which there is dangerous drop in blood volume, blood pressure and amount of oxygen in the body. If untreated, severe hypovolemic shock can cause death in a matter of minutes.

Signs and symptoms of cholera in children

Children and adults present almost the same set of symptoms during cholera but children are more prone to low blood sugar (hypoglycemia) due to fluid loss. Hypoglycemia in children can cause:
An altered state of consciousness
Seizures
Coma

When to see a doctor

See your doctor if you develop severe diarrhea after returning from cholera-prone areas or if you suspect you have been exposed to the cholera bacteria. Note that severe dehydration is a medical emergency that requires immediate medical attention, no matter what the cause is.

The main cause of Cholera is a bacteria named Vibrio cholerae which produces a potent toxin called CTX in the small intestine. After binding to intestinal walls, it causes disturbances in the normal flow of sodium and chloride. As a result, the body secretes a very large amount of water, leading to diarrhea and a rapid loss of fluids and electrolytes.

The major source of this deadly bacteria is contaminated water although the bacteria may also be found in raw shellfish, uncooked fruits and vegetables.

Cholera bacteria have two distinct life cycles- one in the environment and one in humans.

Cholera bacteria in the environment

Coastal waters are a natural habitat for the cholera bacteria, where they attach to tiny crustaceans called copepods. The cholera bacteria move wherever their host moves. The host moves to various parts in search of the food that comprises of certain types of algae. Algae growth is enhanced by urea found in sewage. So, cholera bacteria is more likely to be found on sewage water.

Cholera bacteria in people

Humans who harbor cholera bacteria, may not show signs of illness but they can still pass the bacteria in their stool. Food or water supplies contaminated by human feces provide ideal environment for growth of cholera bacteria.

The most common sources of cholera infection are standing water and certain types of food, including seafood, raw fruits and vegetables, and grains.

If you suspect you are suffering from cholera, talk to your doctor to receive a diagnosis.

If you develop severe diarrhea or vomiting and are in or have very recently returned from cholera prevalent place, seek immediate medical help.

Here are some tips that might help diagnosis and hence optimize the treatment:

Make a list of symptoms and their duration.
Mention the conditions/situations that might have exposed you to the infection.
Make a list of your key medical information, current health condition
Any medications, vitamins or supplements you're currently taking.

Questions to ask your doctor

Is my condition really cholera or something else?
Are there any test for confirming cholera?
What are possible treatments?
Are there any possible side effects from the medications I'll be taking?
How long will it take for me to get fully recovered?
Am I at risk of any long-term complications from cholera?
Can I spread it to others? If yes, how can I minimize the risk?
Ask to your doctor about any query that might arise during the conversdation.
What to expect from your doctor?

Your doctor may ask you questions like:

What are your symptoms?
Have you recently traveled to cholera prevalent region?
When did you first notice the symptoms?
Have you had watery diarrhea? How severe? How is the stool consistency?
Have you been vomiting?
Are there any symptoms of dehydration, such as intense thirst, muscle cramps or fatigue?
Have you recently eaten raw shellfish, such as oysters?
Are you pregnant? What is your blood type, if you know it?
Are you being treated for any other medical conditions?
Are you currently taking any medications?

What you can do in the meantime

Stay well-hydrated in the time leading up to your appointment.
For diarrhea and vomiting possibly due to cholera, common drinks such as water, juice and soda are not of much help in replenishing the fluid and electrolytes. Instead, use an oral rehydration solution such as RecoverORS for adults or Pedialyte for children. In most developing countries, WHO recommended ORS powders are available. Reconstitute the powder as directed.
In case you cannot access ORS in the market, make your own by combining 1 quart (about 1 liter) of bottled or boiled water with 6 level teaspoons (about 30 milliliters) of table sugar and 1/2 level teaspoon (about 2.5 milliliters) of table salt.

Though signs and symptoms of cholera are definitive, stool examination for the bacteria provides confirmation. Rapid cholera dipstick tests enable health care providers in remote areas to confirm diagnosis of cholera earlier. Rapid confirmation helps to decrease death rates.

Cholera requires immediate treatment because the disease is often fatal and can cause death within hours.

Rehydration: Rehydration is aimed at replenishing lost fluids and electrolytes using a simple rehydration solution, oral rehydration salts (ORS) to avoid dehydration and associated complications. Without timely rehydration, approximately half the people with cholera die while death rate drops to less than 1 percent when prompt action is taken to rehydrate the patient. Intravenous fluids may be required when the patients are severely dehydrated and need immediate replenishment of fluids and electrolytes.
Antibiotics: Antibiotics are not used for curing cholera but drugs like doxycycline (Monodox, Oracea, Vibramycin) or azithromycin (Zithromax, Zmax) may can be used to reduce both the amount and duration of cholera-related diarrhea.
Zinc supplements: Zinc supplements may shorten the duration of diarrhea in children with cholera.

Follow these tips to prevent cholera, especially when traveling to cholera prevalent areas:

Frequent hand washing with soap and water, especially after using the toilet and before handling food, reduces your chances of contracting the bacteria. Rub soapy, wet hands together for at least 15 seconds before rinsing. If soap and water aren't available, use an alcohol-based hand sanitizer.
Drink only safe water, including bottled water or water you've boiled or disinfected yourself.
Use bottled water even to brush your teeth. Hot beverages are generally safe, as are canned or bottled drinks, but wipe the outside before you open them.
Eat food that's completely cooked and hot and avoid street vendor food, if possible. If you buy a meal from a street vendor, make sure it's cooked in your presence and served hot.
Avoid sushi, as well as raw or improperly cooked fish and seafood of any kind.
Stick to fruits and vegetables that you can peel yourself, such as bananas, oranges and avocados.
Stay away from salads and fruits that can't be peeled, such as grapes and berries.
Be careful with dairy foods, including ice cream, which is often contaminated, and unpasteurized milk.

Cholera vaccine

No cholera vaccine is currently available in the United States. Advanced oral vaccines offering longer protection are available in few countries.

Contact your doctor or local office of public health for further facilities available.

Note that no country requires immunization against cholera as an essential criteria before entering the country

There are several risks and complications associated with Cholera. Risks inlude:

Poor sanitary conditions: Cholera bacteria flourishes in poor sanitation areas like refugee camps, impoverished countries, and areas devastated by famine, war or natural disasters.
Reduced or nonexistent stomach acid (hypochlorhydria or achlorhydria): Cholera bacteria cannot survive in the acidic environment of stomach. People with low levels of stomach acid such as children, older adults, or those taking antacids, H2 blockers or proton pump inhibitors are at greater risk of contracting the bacteria.
Household exposure: Living with a person suffering from Cholera naturally increase your risk of catching the disease.
Type O blood: Type O blood are twice as likely to develop cholera as are people with other blood types. The reasons are still unknown.
Raw or undercooked shellfish: Intake of shellfish from contaminated waters greatly increases your risk.

Cholera can lead to death in a very short period of time if prompt action is not taken. Severe cholera can lead to death within two to three hours. Shock and severe dehydration are the two major complications of cholera. If left untreated, less severe cholera may lead to death within hours to days.

Some other complications of cholera are:

Low blood sugar (hypoglycemia): When people cannot take food due to severe illness, the blood sugar levels may drop down dangerously. Low blood sugar problems are common among children and often leads to seizures, unconsciousness and even death.
Low potassium levels (hypokalemia): Severe diarrhea results in extreme loss of fluids and electrolytes, including potassium. Very low potassium affects cardiac and nerve functions.
Kidney (renal) failure: In patients with cholera, kidney failure owing to accumulation of toxic substances in the body, results in life threatening situations.