Cholera

Description:

Cholera (Latin cholera)  - the acute intestinal antroponozny infection caused by bacteria of a type of Vibrio cholerae. It is characterized by the fecal and oral mechanism of infection, damage of a small intestine, watery diarrhea, vomiting, bystreyshy loss by an organism of liquid and electrolytes with development of various degree of dehydration up to hypovolemic shock and death.
Extends, as a rule, in the form of epidemics. The local centers are located in Africa, Latin America, India (Southeast Asia).
Infection atriums is the digestive tract.  Cholera vibrioes often perish in a stomach owing to availability of hydrochloric (hydrochloric) acid there. The disease develops only when they break a gastric barrier and reach a small bowel where begin to breed and emit exotoxin intensively.

Cholera symptoms:

The incubation interval of cholera fluctuates of several hours to 5 days (the thicket is 2-3 days old). On expressiveness of clinical manifestations distinguish erased, easy, moderately severe, the heavy and very heavy forms which are defined by dehydration degree. V. I. Pokrovsky allocates the following degrees of dehydration: The I degree when patients lose the volume of liquid, equal 1-3% of body weight (erased and easy forms), the II degree - losses reach 4-6% (a moderately severe form). The III degree - 7-9% (heavy) and IV degree of dehydration with loss over 9% corresponds to very heavy course of cholera. Now the I degree of dehydration occurs at 50-60% of patients, II - at 20-25%, III - at 8-10%, IV - at 8-10%.
At the erased forms of cholera there can be only once liquid chair at good health of patients and absence of dehydration. In more expressed cases the disease begins sharply, without fever and the prodromal phenomena. The first clinical signs are a sudden desire on defecation and an otkhozhdeniye kashitseobrazny or, from the very beginning, watery excrements. In the subsequent these imperative desires repeat, they are not followed by pain. Excrements are allocated easily, intervals between defecations are reduced, and the volume of excrements increases each time. Excrements have an appearance of "rice water": translucent, rather turbid-white coloring, sometimes with floating flakes of gray color, inodorous or with a smell of fresh water. The patient notes rumbling and unpleasant feelings in umbilical area. At patients with an easy form of cholera defecation repeats not more often than 3-5 times per day, overall health remains at them satisfactory, feelings of weakness, thirst, dryness in a mouth are insignificant. Duration of a disease is limited for 1-2 days.
At moderately severe (dehydration of the II degree) the disease progresses, the vomiting accruing on frequency joins a diarrhea. Emetic masses has the same appearance of "rice broth", as well as excrements. It is characteristic that vomiting is not followed by any tension and nausea. With accession of vomiting dehydration - эксикоз - quickly progresses. Thirst becomes painful, language dry with "a cretaceous plaque", skin and mucous membranes of eyes and a stomatopharynx turn pale, turgor of skin decreases, the amount of urine decreases up to an anury. The chair to 10 times a day, plentiful, in volume does not decrease, and increases. There are single spasms of gastrocnemius muscles, brushes, feet, masseters, unstable cyanosis of lips and fingers of hands, hoarseness of a voice. Moderate tachycardia, hypotension, an oliguria, a hypopotassemia develops. The disease in this form lasts 4-5 days.
The severe form of cholera (the III degree of dehydration) is characterized by sharply expressed signs of an eksikoz owing to very plentiful (to 1-1,5 l for one defecation) a chair which becomes that from the first hours of a disease, and the same plentiful and repeated vomiting. Patients are disturbed by painful myotonia of extremities and muscles of a stomach which in process of a course of a disease pass from rare clonic in frequent and are even replaced by tonic spasms. The voice is weak, thin, often slightly audible. Turgor of skin decreases, the skin collected pleated long does not finish. Skin of brushes and feet becomes wrinkled - "beef-steak hand". The person takes a form, characteristic of cholera: the pointed features, the sunk-down eyes, cyanosis of lips, auricles, lobes of ears, a nose. At a palpation of a stomach are determined transfusion of liquid by intestines, the strengthened rumbling, liquid capotement. The palpation is painless. The liver, a spleen are not increased. There is a tachypnea, tachycardia to 110-120 beats/min accrues. Pulse of weak filling ("threadlike"), cardiac sounds deafs, the ABP progressively falls lower than 90 mm of mercury. at first maximum, then minimum and pulse. Body temperature is normal, the mocheotdeleniye decreases and soon stops. The pachemia is expressed moderately. Indicators of relative density of plasma, an index of a hematocrit and viscosity of blood on the upper bound of norm or are moderately increased. The hypopotassemia of plasma and erythrocytes, a hypochloraemia, a moderate compensatory hypernatremia of plasma and erythrocytes are expressed.
Very severe form of cholera (which was earlier called algidny) differs in a rough sudden course of a disease, beginning with massive continuous defecations and plentiful vomiting. In 3-12 h at the patient serious condition of an algid which is characterized by decrease in body temperature to 34-35,5 °C, an extreme obezvozhennost (patients lose up to 12% of body weight - dehydration of the IV degree), an asthma, an anury and disturbances of a hemodynamics as hypovolemic shock develops. By the time of arrival of patients in a hospital they develop paresis of muscles of a stomach and intestines owing to which at patients vomiting stops (is replaced by a convulsive hiccups) and a diarrhea (the gaping anus, the free expiration of "intestinal water" from an anal orifice at easy pressing with a front abdominal wall). The diarrhea and vomiting arise against the background of or after the termination of a regidratation again. Patients are in a condition of prostration, drowsiness passes into a sopor, further into a coma. Disorder of consciousness matches on time breath disturbance - from frequent breath, superficial to pathological types (Cheyna-Stokes, the Biota). Coloring of skin gets an ashy shade (total cyanosis) from such patients, "dark glasses around eyes", the eyes which sank down of a sclera dim appear, the unwinking gaze, a voice is absent. Skin cold and sticky to the touch, the body is cramped by spasms (a pose of "fighter" or "gladiator" as a result of the general tonic spasms). The stomach is pulled in, at a palpation convulsive reduction of direct muscles of a stomach is defined. Spasms painfully amplify even at an easy palpation of a stomach that causes concern of patients. The expressed haemo concentration is observed - a leukocytosis (to 20-109/l), the relative density of a blood plasma reaches 1,035-1,050, an index of a hematocrit of 0,65-0,7 l/l. Level of potassium, sodium and chlorine is considerably reduced (a hypopotassemia to 2,5 mmol/l), a decompensated metabolic acidosis. Severe forms are more often noted at the beginning and in epidemic heat. At the end of flash and in interepidemic time lungs and the erased forms, low-distinguishable from ponos of other etiology prevail.
At children under 3 years cholera proceeds most hard. Children have dehydration worse. Besides, they have a secondary damage of the central nervous system: the adynamia, clonic spasms, convulsions, disturbance of consciousness up to development of a coma are observed. At children it is difficult to define initial degree of dehydration. At them it is impossible to be guided by the relative density of plasma owing to the relative large extracellular volume of liquid. Reasonablly therefore at the time of receipt to weigh children for the most reliable definition of dehydration degree at them. The clinical picture of cholera at children has some features: frequent fervescence, more expressed apathy, an adynamia, tendency to epileptiform attacks owing to bystry development of a hypopotassemia. Duration of a disease fluctuates from 3 to 10 days, its subsequent manifestations depend on adequacy of replaceable treatment by electrolytes. At the emergency compensation of losses of liquid and electrolytes normalization of physiological functions happens quickly enough and lethal outcomes meet seldom. The main reasons for death at inadequate treatment of patients is a hypovolemic shock, a metabolic acidosis and uraemia as a result of an acute necrosis of tubules.
When finding patients in zones of the high temperatures promoting considerable loss of liquid and electrolytes with then and also in the conditions of reduced water consumption because of damage or poisoning of sources of water supply, as well as at other similar reasons of dehydration of the person, cholera proceeds most hard owing to development of the mixed mechanism of dehydration arising because of a combination of the extracellular (isotonic) dehydration characteristic of cholera, to intracellular (hypertensive) dehydration. In these cases chair frequency not always corresponds to weight of a disease. Clinical signs of dehydration develop at not numerous defecations, and quite often considerable degree of dehydration, life-threatening the patient in a short space of time develops.
Massive fecal pollution of water sources, the use of a significant amount of the infected water by people which are in a condition of psychological shock (stress) or thermal overheating, starvation and influence of other factors reducing resistance of an organism to intestinal infections promote development mixed инфекцияй: cholera in combination with a shigellosis, an amebiasis, a viral hepatitis, tifoparatifozny and other diseases. Cholera has heavier current at patients with various accompanying bacterial infections which are followed by a toxaemia. Owing to a pachemia and reduction of a mocheotdeleniye concentration of bacterial toxins becomes higher that causes the expressed clinical symptomatology of the combined infectious process. So, at a cholera combination to a shigellosis into the forefront clinical signs of a coloenteritis and intoxication - colicy pains in a stomach and fervescence to febrile or subfebrile figures act. Defecation usually is followed by tenesmus, in excrements impurity of slime and blood ("a rusty chair"). The syndrome of acute distal colitis is expressed, the spasm, consolidation and morbidity of a sigmoid gut are noted. At a rektoromanoskopiya in these cases catarral and hemorrhagic manifestations, characteristic of dysentery, come to light. However in several hours the volume of excrements which take a form of "meat slops" promptly increases. In most cases the accompanying shigellezny infection burdens the course of cholera, but at certain patients both infections can favorably proceed. At a cholera combination to an amebiasis the diagnosis of an intestinal amebiasis is verified by finding of fabric forms of a dysenteric amoeba in excrements.
The main clinical feature of a course of a disease in these cases is duration of diarrhea which in the absence of antiparasitic therapy makes, as a rule, up to 2-3 weeks. Weighting of cholera is noted when it arises at suffering from an intestinal chronic form of an amebiasis with a recurrent current. At these patients already at receipt symptoms of amoebic colitis in the form of abdominal distention, pains in the right ileal area, morbidity at a palpation of a reinforced caecum, flakes of vitreous slime and impurity of blood in excrements are defined.
Heavy disease is observed also at the cholera which arose at the patient with a tifoparatifozny disease. Emergence of intensive diarrhea for the 10-18th day of a disease is dangerous to the patient in connection with threat of intestinal bleeding and perforation of ulcers in ileal and blind guts with the subsequent development of purulent peritonitis.
Developing of cholera at eggs with different types of insufficiency of food and negative balance of liquid conducts to a course of a disease which features are the frequency of a chair, smaller in comparison with a usual current of monoinfection, and its moderate volumes, as well as the moderate number of emetic masses, acceleration of process of a hypovolemia (shock!), azotemias (anury!), hypopotassemias, hypochlorhydrias, other heavy disturbances of electrolytic balance, acidosis.
At the blood losses caused by various injuries of a surgical profile at cholera patients occur the accelerated pachemia (blood losses!), decrease in the central blood-groove, disturbance of microcirculation, developing of a renal failure and subsequent azotemia, and also acidosis. Clinically these processes are characterized by progressive falling of arterial pressure, the termination of a mocheotdeleniye, the expressed pallor of integuments and mucous membranes, high thirst and all symptoms of dehydration, in the subsequent - disorder of consciousness and pathological type
breath.

Cholera reasons:

More than 140 serogroups of Vibrio cholerae are known; they are divided on agglutinated standard cholera O1 serum (V. cholerae O1) and on not agglutinated standard cholera O1 serum (V. cholerae non 01).
"Classical" cholera is caused by a cholera vibrio of a serogroup of O1 (Vibrio cholerae O1). Distinguish two biopitch (biotype) of this serogroup: classical (Vibrio cholerae biovar cholerae) and Vibrio cholerae biovar eltor.

Treatment of Cholera:

The basic principles of therapy of patients with cholera are:
a) recovery of volume of the circulating blood;
b) recovery of electrolytic composition of fabrics;
c) influence on the activator.

Treatment should be begun during the first hours from an onset of the illness. At a heavy hypovolemia it is necessary to carry out immediately a regidratation by intravascular administration of isotonic polyionic solutions. Therapy of patients with cholera includes primary regidratation (replenishment of water and the salts lost prior to treatment) and a corrective compensatory regidratation (correction of the continuing losses of water and electrolytes). Regidratation is considered as a resuscitation action. The patients with a severe form of cholera needing acute management are sent to rehydration department or chamber at once, passing reception. Within the first 5 min. at the patient it is necessary to define pulse rate and breath, the ABP, body weight, to take blood for determination of relative density of a blood plasma, a hematocrit, content of electrolytes, acidosis degrees, and then to begin jet introduction of saline solution.
For treatment use various polyionic solutions. Trisol solution (solution 5, 4, 1 or solution No. 1) is the most approved. For preparation of solution take the depyrogenized bidistilled water on which 1 l 5 g of sodium of chloride, 4 g of Natrii hydrocarbonas and 1 g of potassium of chloride add. More effective the Kvartasol solution containing on the I l of water 4,75 g of sodium of chloride, 1,5 g of potassium of chloride, 2,6 g of sodium of acetate and 1 g of Natrii hydrocarbonas is considered now. It is possible to use Acesolum solution - on 1 l of depyrogenized water of 5 g of sodium of chloride, 2 g of sodium of acetate, 1 g of potassium of chloride; Hlosol solution - on 1 l of depyrogenized water of 4,75 g of sodium of chloride, 3,6 g of sodium of acetate and 1,5 g of potassium of chloride and the Laktosol solution containing on 1 l of depyrogenized water 6,1 g of sodium of chloride, 3,4 g of sodium of a lactate, 0,3 g of Natrii hydrocarbonas, 0,3 g of potassium of chloride, 0,16 g of Calcii chloridum and 0,1 g of magnesium of chloride. The World Health Organization recommended "solution of WHO" - for 1 l of depyrogenized water of 4 g of sodium of chloride, 1 g of potassium of chloride, 5,4 g of sodium of a lactate and 8 g of glucose.
Polyionic solutions enter intravenously, 40 °C which are previously warmed up to 38 ~, with a speed at the II degree of dehydration of 40-48 ml/min., at heavy and very severe forms (dehydration of the III-IV degree) begin administration of solutions with a speed of 80-120 ml/min. The volume of a regidratation is defined by the initial losses of liquid calculated on degree of dehydration and body weight, clinical symptomatology and dynamics of the main clinical indicators characterizing a hemodynamics. During 1 - 1,5 h carry out primary regidratation. After introduction of 2 l of solution further introduction is carried out more slowly, gradually reducing speed to 10 ml/min.
To enter liquid with a necessary speed, sometimes it is necessary to use at the same time two and more systems for one-time transfusion of liquid and to enter solutions into veins of hands and legs. In the presence of the corresponding conditions and skills to the patient put a kavakateter or carry out catheterization of other veins. At impossibility of a venipuncture do venesection. Administration of solutions is decisive in therapy of seriously ill patients. Cardiacs during this period are not shown, and administration of pressor amines (adrenaline, a phenylephine hydrochloride, etc.) contraindicated. As a rule, in 15-25 min. after the beginning of administration of solutions at the patient begin to be defined pulse and the ABP, and in 30-45 min. an asthma disappears, cyanosis decreases, grow warm lips, the voice appears. In 4-6 h the condition of the patient considerably improves. He begins to drink independently. By this time the volume of the entered liquid makes usually 6-10 l. At long administration of Trisol solution the metabolic alkalosis and a hyperpotassemia can develop. If necessary to continue infusional therapy it has to be carried out by Kvartasol, Hlosol or Atsesol solutions. The patient appoint potassium the oro-Tat or Pananginum on 1-2 tablet 3 times a day, 10% solutions of sodium of acetate or citrate on 1 tablespoon 3 times a day.
To support the reached state, carry out correction of the continuing losses of water and electrolytes. It is necessary to enter such amount of solutions how many the patient loses with excrements, the emetic masses, urine, besides, consider that per day the adult loses with breath and through skin of 1-1,5 l of liquid. For this purpose will organize collecting and measurement of all allocations. Within 1 days it is necessary to enter up to 10-15 l of solution and more, and in 3-5 days of treatment - to 20-60 l. To control the treatment course, systematically define and bring the relative density of plasma on the card of an intensive care; hematocrit indicator, expressiveness of acidosis, etc.
At emergence of the pyrogenic reactions (a fever, fervescence) administration of solution is not stopped. Add 1% to solution Dimedrol solution (1-2 ml) or Pipolphenum. At sharply expressed reactions appoint Prednisolonum (30-60 mg/days).
It is impossible to carry out therapy by isotonic solution of sodium of chloride as he does not compensate deficit of potassium and Natrii hydrocarbonas, can lead to a plasma giperosmotichnost with secondary dehydration of cells. Introduction of large numbers of 5% of solution of glucose is wrong that not only does not eliminate deficit of electrolytes, and, on the contrary, reduces their concentration in plasma. Also hemotransfusion and blood substitutes is not shown. Use of colloidal solutions for rehydration therapy is inadmissible.
Patients with cholera who have no vomiting have to receive in the form of drink of Glyukosol (Regidron) of the following structure: sodium of chloride of-3,5 g, sodium of bicarbonate-2,5 of, potassium of chloride-1,5 of, glucose-20 of on 1 l of drinking water. Glucose improves absorption of electrolytes in a small intestine. It is reasonable to prepare hinge plates of salts and glucose in advance; they should be dissolved in water at a temperature of 40-42 °C right in front of the dacha by the patient.
In field conditions the oral regidratation can be used by sugar saline solution for what add 2 teaspoons of table salt to 1 l of boiled water and 8 teaspoons of sugar. The total amount of glyukozo-saline solutions for an oral regidratation has to exceed by 1,5 times quantity lost with vomiting, excrements and perspiration of water (to 5-10% of body weight).
At children up to 2 years the regidratation is carried out drop infusion and 6-8 h continue, and in the first hour enter only 40% of the liquid volume, necessary for a regidratation. At small children compensation of losses can be provided with injection of solution by means of the nazogastralny probe.
Children with moderate diarrhea can give drinking solution in which on 1 l of water 4 sugar teaspoons, 3/4 teaspoons of table salt and 1 teaspoon of baking soda with pineapple or orange juice. In case of vomiting solution is given to a thicket and small portions.
Water-salt therapy is stopped after emergence of excrements of fecal character in the absence of vomiting and dominance of amount of urine over quantity of excrements in the last by 6-12 h.
Antibiotics, being an additional tool, reduce duration of clinical displays of cholera and accelerate clarification from vibrioes. Appoint tetracycline on 0,3-0,5 g in 6 h within 3-5 days or doxycycline of 300 mg once. In the absence of them or at their intolerance it is possible to carry out treatment by Trimethoprimum with sulf-metaksazoly (co-trimoxazole) on 160 and 800 mg twice a day within 3 days or furasolidone on 0,1 g in 6 h within 3-5 days. To children appoint Trimethoprimum-suljfometaksazol on 5 and 25 mg/kg of body weight
2 times a day within 3 days. Are perspective at treatment of cholera of a ftorkhinolona, in particular the ofloxacin (таривид) which is widely applied now at intestinal infections which causative agents are steady against traditionally applied antibiotics. It is appointed on 200 mg inside twice a day within 3-5 days. Vibriononositelyam conduct a five-day course of an antibioticotherapia. Taking into account positive experience of military physicians of the USA applying in Vietnam streptomycin inside at a persistent vibriovydeleniye it is possible to recommend in these cases intake of Kanamycinum on 0,5 g 4 times a day during 5 days.
The special diet for patients with cholera is not required. Had cholera in a severe form in the period of reconvalescence the products containing potassium salts (dried apricots, tomatoes, potatoes) are shown.
The patients who had cholera, and also vibriononositel are written out from a hospital after clinical recovery and three negative bacteriological researches of excrements. Investigate excrements in 24-36 h after the end of antibiotic treatment within 3 days in a row. Bile (portions In and C) investigate once. At employees of the food industry, water supply, nurseries and treatment and prevention facilities of an excrement investigate fivefold (for five days) and bile once.