Colon (small intestine) non tumor
Infectious colitis (enteritis)
Vibrio cholerae

Author: Elliot Weisenberg, M.D. (see Authors page)

Revised: 10 January 2017, last major update January 2017

Copyright: (c) 2003-2017, PathologyOutlines.com, Inc.

PubMed search: Vibrio cholerae [title] small intestine

Cite this page: Vibrio cholerae. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/colonvibrio.html. Accessed January 17th, 2017.
Definition / General
  • Infection by toxigenic strains of Vibrio cholerae O1 or V. cholerae O139
Essential Features
  • Infection is caused by ingestion of toxigenic bacteria in food or water
  • Most cases are asymptomatic or cause mild diarrhea
  • Severe disease consists of a precipitous onset of acute watery diarrhea that rapidly may lead to dehydration, shock, electrolyte disturbances, renal failure and death
  • Endemic and epidemic disease occurs
  • Public health measures to prevent disease are centered on providing safe water and sanitation with vaccination in disease "hotspots" and in high risk individuals
  • Oral rehydration is the mainstay of treatment; in severe cases intravenous fluid and antibiotics are also employed
ICD-10 coding
  • A00.9
Epidemiology
  • The World Health Organization estimates that there are between 1.3 and 4.0 million cases annually with from 21,000 to 143,000 deaths (WHO)
  • The Centers for Disease Control and Prevention estimates there are between 3 and 5 million cases annually with over 100,000 deaths (CDC)
  • V. Cholerae has an aquatic reservoir and attaches to algae, crustacean shells or zooplankton
  • It can be metabolically active or be dormant during adverse conditions
  • The bacteria may infect seafood or be spread to human water sources causing disease; fecal-oral spread also occurs
  • V. cholerae is killed by high temperatures and tolerates acid poorly
  • In the developed world Cholera is very rare
  • Endemic and epidemic disease occur
  • Endemic disease is defined as disease that occurs during 3 of the past 5 years where there is no evidence of imported disease
    • Cholera is endemic in around 50 countries mostly in Africa, South and Southeast Asia
  • Outbreaks or epidemics are defined by the occurrence of at least 1 confirmed case with endemic local transmission where the disease is not usually encountered
    • Epidemics emerge periodically; currently an epidemic is ongoing in Haiti (CDC)
    • The Haitian epidemic is related to an encampment of Nepalese peacekeepers sent there after a catastrophic earthquake who were based at a United Nations camp; the UN has recently taken responsibility for this epidemic (UN)


  • Endemic disease:
    • Affects populations with pre-existing immunity
    • More often affects children from 2 to 15 years old
    • May be spread by ingesting food or water or the fecal-oral route
    • Has an aquatic reservoir
    • Is more likely to be asymptomatic
  • Epidemic disease:
    • Affects all ages of a nonimmune population where the bacteria does not have a reservoir
    • Spread is fecal-oral with high secondary spread
    • Asymptomatic infection is less common
  • Disease is most common in the developing world; in the developed world disease is generally encountered in travelers and immigrants
  • Rarely disease occurs from ingesting contaminated seafood, a phenomenon rarely associated with seafood from the Gulf of Mexico
  • Hypochlorhydria caused by drugs or chronic Helicobacter pylori infection is a risk factor, as is HIV infection
  • Infection is more common in summer months
  • In endemic areas breast milk contains protective IgA antibodies
Sites
  • Small intestine
Pathophysiology
  • Symptomatology occurs due to production of an exotoxin encoded by a virulence phage that causes the small intestine to secrete fluids and electrolytes
  • V. cholerae is a noninvasive pathogen
  • The toxin has two A subunits and five B subunits
    • The two A subunits, A1 and A2 are linked by a di-sulfide bond
  • Through several steps intracellular cyclic adenosine monophosphate opens the cystic fibrosis transmembrane regulator and chloride ions are released into the lumen while chloride and sodium ion reabsorption is inhibited by c AMP
  • There is affinity of the toxin to the ganglioside receptor on enterocytes that is higher in patients with blood type O
  • Hemagglutinin is necessary for bacterial detachment and shedding in stool
Etiology
  • Infection by toxigenic strains of Vibrio cholerae O1 or V. cholerae O139
Clinical Features
  • Most cases are asymptomatic or cause mild diarrhea
  • Symptomatic cases have an incubation period of from 12 hours to 5 days
  • Severe disease is characterized by sudden onset of profuse watery diarrhea often described as having a "rice water" character sometimes preceded and usually followed by vomiting
  • Patients are anxious and rapidly become dehydrated with sunken eyes, dry mucous membranes, thirst and loss of skin turgor
  • Other signs and symptoms include tachycardia, hypotension and muscle cramps
  • Untreated cases may rapidly progress to electrolyte disturbances, renal failure, shock and death
  • Rarely "cholera sicca" occurs where patients have ileus and abdominal distention but lack diarrhea; fever is uncommon
  • Children may suffer from hypoglycemia, seizures, fever, and altered mental status
  • Coinfection with other pathogens may occur
Diagnosis
  • Microbiologic culture is the gold standard and may confirm other testing methods
  • PCR and real time nucleic acid sequencing are available
  • In epidemic settings bacteria have a characteristic chaotic movements when viewed by darkfield microscopy and an immunochromographic dipstick test is available
  • Testing to determine serotype and antibiotic sensitivity is necessary
  • In the United States all cell isolates should be sent to the CDC via state health departments
Prognostic Factors
  • Elderly and debilitated patients have a worse prognosis
  • Pregnant patients do worse and have a high rate of fetal loss
  • HIV infection confers an increased risk of acquiring disease
  • Subjects with blood group O are loser risk of acquiring disease, but it is worse when it occurs
Case Reports
Treatment
  • Most patients are successfully treated with oral rehydration solution (ORS); treatment should begin promptly
  • Patients with moderate to severe disease or who cannot tolerate ORS should receive intravenous hydration
  • With severe disease antibiotic treatment is indicated to reduce fluid requirements and disease duration
  • Quinolones, trimethoprim-sulfamethoxazole, tetracycline, doxycycline, erythromycin, and azithromycin have been used; antibiotic resistance is common and antimicrobial sensitivity should guide treatment
  • Three oral vaccines are effective; vaccinations should be given to populations in disease "hotspots" and travellers at high risk of acquiring disease
  • Zinc supplementation reduces disease severity in children in resource limited areas
Clinical Images
Images hosted on other servers:

Child with cholera

An adult with severe dehydration due to cholera

Gross Description
  • Gross changes are rarely encountered
Micro Description
  • Biopsy is rarely performed
  • Mucosa is normal or may show a mild neutrophilic infiltrate of the lamina propria
Videos


Small intestine - Cholera & Vibrio cholerae
Differential Diagnosis
  • Clinically mild to moderate disease mimics many types of gastroenteritis, but the precipitous onset of profuse watery diarrhea is very characteristic of severe cholera
Additional References
  • Robbins, Mandell, Odze