Cholera el tor

Asiatic Cholera / Epidemic Cholera

Vibrio cholerae has 2 biotypes ( on the basis of several phenotypic char )

*Classic

*El tor biotype

Cholera vibrios are facultative anaerobes. The optimum growth temp is 37oC and
growth is arrested below 14oC and above 42oC. The organism grow rapidly on
alkaline media at pH 6 9 .

Test to differentiate the two biotypes:

1. Direct Hemagglutination test

Classic (-) ; El tor (+) agglutinates sheep RBC / chicken red cells

2. Sensitivity to Polymyxin B

Classic (+) sensitive; El tor (-) resistant

3. Hemolysis test

Classic (-) ; El tor (+) hemolytic/hemolysis on blood agar

4. Sensitivity to Cholera Phage IV ( Murkerjee )

Classic (+) sensitive; El tor (-) resistant

 5. Voges Proskauer

Classic (-) ; El tor : purple & pink color

Serotypes due to minor difference in O antigen

1. Inaba or original type : antigen A, C

2. Ogawa or variant type: antigen A, B

3. Hikojima or middle type: antigen A, B,C

The 1st two are distinct from one another and the last is related to both types.

Infective dose: 102 103

Pathogenicity
: enterotoxin choleragen :binds to a receptor and a surface of cell &
activates intracellular adenylate cyclase to convert ATP into cyclic adenosine
monophosphate (cAMP)

Increased cAMP activates a secretory mechanism which blocks Na + absorption and

promotes excretion of water and chlorides. This mechanism is the prototype for all
toxigenic diarrheas. The toxin acts through an intact epithelium on the vasculature of the
bowel, with resultant outpouring of intestinal fluids.
Cholera red test / Nitroso indole rxn:
tryptophanase
In peptone medium with tryptophan

releases indole group and also reduces NO3 nitrosoreductase NO2; upon addn of H2SO4 red
color of nitrosoindole is visible described as cholera red.

Oxidase test: dark purple color on the paper within 10 sec

Mucoid test / String test:

Suspend an 18 to 24 hr growth from MEA (Meat Extract Agar), GA (Gelatin Agar) or TTGA
(Taurocholate Tellurite Gelatin Agar) or Kleigers Iron Agar slant - in a drop of 0.5%
aq. soln. of sodium desoxycholate on a slide.

If positive (+) the suspension immediately loses turbidity and becomes mucoid (as with
all vibrios). A mucoid string forms when the loop is drawn slowly away from the
suspension.

Cause of Death (COD) : hypovolemic shock; uncompensated metabolic acidosis and

renal failure .

Clinical symptoms in cholera:

aphonia - voice is high pitched and inaudible

sunken eyes, wrinkled skin

muscle cramps
 metabolic acidosis which starts from: diarrhea

-rice watery stool rich in H2O,HCO3 &

glucose.

- rice watery stools contains

109vibrios/mL

acidosis results due to loss of large volumes of bicarbonate rich stools.

hypokalemia - due to continous potassium loss muscle cramps mostly located in the
fingers, toes & lower extremities.

All signs, symptoms & metabolic derangements in cholera result from the loss of
isotonic , watery stools rich in electrolytes such as Na+,Cl-,HCO3 & K+ from the
gut. These losses result from the hypersecretion of the isotonic electrolyte soln by
an intact small bowel mucosa. It is caused by a heat labile enterotoxin known as
choleragen.

dehydration: signs of severe dehydration occur rapidly such as sunken fontanel (in
infants) and eyeballs (in adults), loss of turgor and elasticity of the skin, (+)
skin fold sign with wrinkling of the fingertips washerwomans hands, cold
clammy sweat & decrease bp, scaphoid abdomen-vomitting, increased exhaustion,
oliguria and even anuria.

Uremia accumulation of waste products like urea in the blood to toxic limits.

- due to tubular necrosis.

Vibrio cholerae can be detected directly by Dark field microscopy on a wet mount of a
fresh stool, & its serotype can be discerned by immobilization with Inaba or Ogawa
specific anti-serum.
Best selective medium : TCBS agar on which the organism grows as a typical opaque
yellow colonies.

If a delay in sample processing is expected : Carey Blair transport medium

and/or alkaline-peptone-water-enrichment medium should be inoculated as well.

Stool smears stained by fuchsin soln when examined microscopically occur in groups
similar to shoals of fish.

Adequacy of hydration is confirmed by frequent clinical evaluation:

Pulse rate and strength

Skin turgor

Urine output

Over-hydration: observation of neck veins auscultation of lungs

Ideal bed for patients with cholera el tor cholera cot

Cholera Vaccine: a sterile suspension of killed Vibrio cholerae of the Inaba and Ogawa
strains in NSS or suitable diluent. It contains about 8 billion cholera vibrios per mL killed
and preserved by the addn of 0.5% phenol.

Remarks: Immunity lasts for 6 months or less.

Protection depends largely on booster doses.

Acceptable Composition:

Glucose - 20 g/L

NaCl - 4 g/L

NaHCO3 4 g/L

KChloride - 1 g/L