Caracterización de las complicaciones de los pacientes diagnosticados con cólera en el Hospital Pediátrico de Centro Habana, 2013-2017 / Characterization of the complications of patients diagnosed with cholera in the Pediatric Hospital of Centro Habana, 2013-2017

Introducción: La séptima pandemia del cólera llegó a las Américas en 1991. En Cuba hacía más de 130 años no se registraba ningún caso. Objetivos: Identificar y caracterizar las complicaciones por cólera y su relación con características clínicas y de tratamiento. Métodos Se realizó un estudio descriptivo y prospectivo desde el año 2013-2017 a los pacientes a los que se les confirmó el V. cholerae como causa exclusiva de enfermedad diarreica aguda. Las variables cualitativas se describieron estadísticamente mediante frecuencias absolutas y relativas y para las variables cuantitativas se utilizó la media, la mediana, la desviación estándar y el rango intercuartílico como medidas de dispersión. Resultados: El 36,5 por ciento de los enfermos presentó complicaciones donde la deshidratación fue la más frecuente. El valor de la mediana del tiempo que medió entre la aparición de los síntomas y la atención en el centro fue menor en los pacientes con complicaciones comparado con el observado en los no complicados, pero la diferencia no fue significativa: (24 horas [RI: 24,0-72,0 horas] vs. 48 horas [RI: 24,0-72,0 horas], p= 0,355). Conclusiones: La mayoría de los enfermos no presentaron complicaciones y la más frecuente es la deshidratación ligera(AU)

Introduction: The seventh cholera pandemic arrived to the Americas in 1991. In Cuba for more than 130 years there were no case reports. Objectives: To identify and characterize the complications by cholera and its relation with clinical characteristics and treatment. Methods: A descriptive and prospective study was conducted from 2013 to 2017 to the patients who had been confirmed with V. cholerae as exclusive cause of acute diarrheal disease. The qualitative variables were described statistically using absolute and relative frequencies, and for the quantitative variables were used the average, medium, and standard deviation and the interquartile range as dispersion measures. Results: 36.5 percent of the patients presented complications where dehydration was the most frequent. The value of the median time between the onset of symptoms and attention in the center was lower in patients with complications in comparison with the observed in non-complicated patients, but the difference was not significant (24.0 h [RI: 24,0-72,0 h] vs. 48,0 h [RI: 24,0-72,0 h], p= 0.355). Conclusions: Most of the patients did not present complications and the most frequent is the slight dehydration (AU)

Bacteriemia por Vibrio cholerae no-O1/no-O139 que porta una región homóloga a la isla de patogenicidad VpaI-7 / Bacteremia caused by Vibrio cholerae non-O1/non-O139 carrying a region homologous to pathogenicity island VpaI-7

Resumen Presentamos un caso de bacteriemia por Vibrio cholerae no-O1/ no-O139 en una mujer de 81 años con un cuadro de dolor abdominal, fiebre, vómitos, diarrea, coluria e ictericia, mientras visitaba una zona rural sin acceso a agua potable. La identificación se realizó por la técnica de espectrometría de masa MALDI-TOF, confirmándose una cepa no toxigénica no-O1/no-139. La caracterización molecular del aislado demostró la ausencia del gen de la toxina del cólera (CTX), y pilus TCP; sin embargo, presentó cinco de los seis genes de virulencia presentes en la isla de patogenicidad homóloga denominada VPaI-7 del V. parahaemolyticus (vcs N2+, vcs C2+, vcs V2+,toxR-, vspD+, T vopF+). Además, el aislado presentó los genes de virulencia hylA y rtxA. Este es el primer caso reportado en Chile de una cepa clínica de V. cholerae no-O1, no-O139 aislada de hemocultivos portador de un segmento homólogo de la isla de patogenicidad denominada VPaI-7 de V. parahaemolyticus, el cual codifica para un sistema de secreción tipo III (TTSS), que probablemente contribuye a su virulencia.

We report a case of V. cholerae non-O1 / non-O139 bacteremia in an 81-year-old woman with abdominal pain, fever, vomiting, liquid stools, choluria and jaundice, while visiting a rural area without access to potable water. The identification was made by the MALDI-TOF mass spectrometry technique and subsequently the non-toxigenic non-O1 / non-139 strain was confirmed in the national reference laboratory. The molecular characterization demonstrated the absence of the cholera toxin gene (CTX), and the TCP pilus, however, presented 5 of 6 virulence genes present in an island of homologous pathogenicity named VPaI-7 of V. parahaemolyticus (vcs N2 +, vcs C2 +, vcs V2 +, toxR-, vspD +, T vopF +) and in addition it was positive for hylAy rtxA virulence genes recognized outside the island. This is the first case reported in Chile of a clinical strain of V. cholerae non-O1, non-O139 isolated from blood culture that carries in its genome a homologous segment of the pathogenicity island named VPaI-7 of V. parahaemolyticus, which codifies for a type III secretion system (TTSS) that probably contributes to his virulence.

Bacteremia por Vibrio cholerae NO-O1/NO-O139 en un paciente cirrótico: Primer reporte de caso en el Perú y revisión de la literatura / Vibrio cholerae NO-O1/NO-O139 bacteremia in a cirrhotic patient: First case report in Peru and literatura review

Vibrio cholerae serogrupo NO-O1/NO-O139 (VCNO) es causa infrecuente de gastroenteritis. Sin embargo, se le asocia a infección extra-intestinal severa en huéspedes inmunocomprometidos, y entre ellas, la bacteremia en pacientes con cirrosis hepática es digna de mención. A continuación, presentamos el caso de una mujer de 58 años, con el diagnóstico de cirrosis hepática de fondo, que desarrolló progresivamente choque séptico, disfunción orgánica múltiple y desenlace fatal al cuarto día de su admisión. Los resultados obtenidos post mortem, de los hemocultivos previamente tomados, aislaron bacilos gram negativos compatibles con Vibrio cholerae. Posteriormente, se identificó el serogrupo NO-O1/NO-O139, a través de aglutinación en placa y PCR negativo para el gen ctxA. El antibiograma mostró susceptibilidad conservada a ampicilina, cloranfenicol, tetraciclina y ciprofloxacino, con resistencia al trimetoprim-sulfametoxazol. El presente caso, descrito en el Hospital Nacional Dos de Mayo, es hasta la fecha, el primer reporte de bacteremia VCNO en el Perú.

Non-O1, non-O139 Vibrio cholerae (NOVC) strains are an uncommon cause of gastroenteritis. However, they have been recently associated with severe extraintestinal infections in immunocompromised hosts. Among them, bacteremia in cirrhotic patients is noteworthy. We present the case of a 58-year-old woman with cirrhosis that developed septic shock, multiple organ failure and died four days after admission. Blood cultures yielded Gram-negative rods identified as Vibrio cholerae. Further serogrouping by slide agglutination and a negative PCR for ctxA gen confirmed the strain to be NOVC. Antimicrobial susceptibility testing showed sensitivity to ampicillin, chloramphenicol, tetracycline and ciprofloxacin; and resistance to trimethoprim-sulfamethoxazole. To the best of our knowledge, this is first report in Peru, described in the Hospital Nacional Dos de Mayo, of NOVC bacteremia.

Control de foco de un brote de Cólera. Matanzas 2014 / Control of Focus in front of a Bud of Cholera. Matanzas 2014

Se presenta un estudio de control de foco de un brote de cólera, mediante la técnica observacional del tipo serie de casos, en el mes de julio de 2014 en el Municipio Matanzas, donde se describe, según el método epidemiológico, la relación de los casos detectados con el caso índice; se analiza el problema detectado teniendo en cuenta el enfoque de riesgo del cólera. Se realiza una evolución clínico-epidemiológica de los casos detectados y se analizan las medidas de control de foco aplicadas. Se revisan tanto las historias clínicas individuales en el consultorio del médico de la familia, como las encuestas epidemiológicas y el expediente de control de foco en el departamento de Epidemiología (AU).

A study of control of focus of a bud of cholera is presented, by means of the observational technique of the type series of cases, in the month of July of 2014 in the Municipality Matanzas, where it is described, according to the epidemic method, the relationship of the cases detected with the index case; the detected problem is analyzed keeping in mind the focus of risk of the cholera. He/she is carried out a clinical-epidemic evolution of the detected cases and of the applied measures of focus control. They are revised the clinical histories so much in the clinic of the doctor of the family, as the epidemic surveys and the file of focus control in the department of epidemiology (AU).

La epidemia de cólera en América Latina: reemergencia y morbimortalidad / The cholera epidemic in Latin America: reemergence, morbidity, and mortality

OBJETIVO: Identificar la morbilidad y la mortalidad por cólera entre distintos segmentos del período 1991-2011 en los países de América Latina. MÉTODO: Mediante el uso de fuentes de información provenientes de una búsqueda bibliográfica no sistemática de trabajos sobre epidemias del cólera, se realizó un estudio ecológico mixto dirigido a analizar series de tiempo de morbilidad, mortalidad y letalidad de estos eventos sanitarios ocurridos entre los años 1991 y 2011 en 18 países de América Latina. RESULTADOS: Durante el período 1991 y 2011 en América Latina se notificaron 1 839 037 casos de cólera, con 19 538 muertes y una letalidad de 1,06%. Los países más afectados fueron Perú entre 1991 y 2002 -con una incidencia acumulada anual máxima de 1 452,72 casos por 100 000 habitantes, pero con baja letalidad (0,72%)- y Haití entre 2010 y 2011, con una incidencia acumulada anual máxima de 3 319,13 por 100 000 habitantes y una letalidad de 1,32%. CONCLUSIONES: La epidemia de cólera ha provocado morbilidad, mortalidad y letalidad altas en algunos países de América Latina, debidas en gran medida a factores fundamentalmente socioeconómicos y climáticos. La reemergencia de esta enfermedad y la diversidad de factores relacionados con los comportamientos de sus brotes ameritan el desarrollo y el fortalecimiento de estrategias regionales de prevención y control en los países, junto con estudios de los determinantes que influyen en la emergencia y reemergencia de las enfermedades infecciosas en América Latina.

OBJECTIVE: To determine morbidity and mortality from cholera during different segments of the period 1991-2011 in the countries of Latin America. METHODS: Using information sources from a nonsystematic literature search for works on cholera epidemics, a mixed ecological study was conducted aimed at a time series analysis of morbidity, mortality, and case-fatality in cholera-related health events between 1991 and 2011 in 18 Latin American countries. RESULTS: During the period 1991-2011, 1 839 037 cases of cholera were reported in Latin America, with 19 538 deaths and a case fatality rate of 1.06%. The most affected countries were Peru between 1991 and 2002-with a maximum annual cumulative incidence of 1 452.72 cases per 100 000 population but a low case fatality rate (0.72%)-and Haiti between 2010 and 2011, with a maximum annual cumulative incidence of 3 319.13 per 100 000 population and a case fatality rate of 1.32%. CONCLUSIONS: The cholera epidemic has resulted in high morbidity, mortality, and case fatality in some Latin American countries, due largely to basically socioeconomic and climatic factors. The reemergence of this disease and the many factors related to how cholera outbreaks evolve call for the development and strengthening of regional prevention and control strategies in the countries as well as a study on the determinants that influence the emergence and reemergence of infectious diseases in Latin America.

A De in the life of cholera.

The 50-year commemoration of S.N. De’s seminal 1959 publication in Nature provides an opportunity to reflect on scientific discovery, recognition, and public health. De’s paper marked the first major conceptual advance in cholera research since 1884, when Robert Koch definitively identified Der Kommabazillus as the aetiological agent of cholera. Unfortunately, Koch reported that systemic toxinosis and multi-organ failure led to severe dehydrating diarrhoea, thereby mistaking cause for effect. As a consequence, while work on other microbial pathogens advanced into the development of vaccines and therapeutics, cholera research languished as scientists injected animals parenterally in decades of futile effort to develop an animal model of diarrhoea. This fundamental misconception in cholera pathogenesis was swept away when S.N. De used ligated loops of rabbit ileum to demonstrate lumenal fluid accumulation in the presence of Vibrio cholerae culture filtrates. After some delay, De’s observation of a diarrhoeagenic exotoxin became the founding principle of modern cholera research, vaccination, and treatment; and a burst of discovery saw V. cholerae transformed into the enteric pathogen best understood at the molecular level. The scientific basis for orally administering vaccines to induce mucosal immunity was established, and the success of oral rehydration, what has been described as one of the 20th century’s most important medical advances, was explained.Nobel laureate Joshua Lederberg wrote of De’s iconoclastic creativity, experimental skill, and observational mastery, and many other leaders in the field concurred. De was nominated for the Nobel Prize in Physiology or Medicine more than once. But despite the passage of half a century from De’s work, cholera remains a frustrating problem: we are clearly missing something. In reviewing the scientific and programmatic impact of S.N. De on cholera, it is clear that a defining victory against the disease is achievable, but only if basic scientific discoveries are relentlessly driven towards progress in public health.

Prevalence of acute diarrhoea in Kathmandu valley.

This retrospective study was conducted during January to September in the year 1997. Three hundred and forty nine stool samples were collected from diarrhoea patients from different places of Kathmandu valley and examined at National Public Health Laboratory (NPHL), Teku, Kathmandu. Acute diarrhoea becomes epidemic in rainy season and is a major public health problem of the city. In this study, people with poor hygiene practice and poor education were infected more than other people. Among the 349 patients with the gastrointestinal disease, 26.0% were found to have bacterial infection. Out of which, 88 (25.1%), one (0.28%), one (0.28%), and one (0.28%) were found to be Vibrio cholerae 01, Vibrio cholerae 0139, Shigella dysenteriae and Escherichia coli respectively. Cholera cases were found almost throughout the year in the city though the numbers increased during the rainy season. It was highest during July (34.6%) followed by August (32.35%), September 32% and June (6.89%). The uncommon species of Vibrio i.e. Vibrio cholerae 0139 was also found in the study. Higher prevalence was found in urban areas (83.52%) than in rural areas (16.48%). Antimicrobial susceptibility testing of bacterial isolates showed that Ciprofloxacin (97.85%) was found to be the most effective antibiotic followed by Tetracycline (92.34%), Erythromycin (92.34%), Norfloxacin (93.34%), Cholramphenicol, Ampicillim, but Cotrimoxazole were found to be resistant to all isolated Vibrio cholerae.

Standard WHO-ORS versus reduced-osmolarity ORS in the management of cholera patients.

The study compared the safety and efficacy of an oral rehydration salts (ORS) solution, containing 75 mmol/L of sodium and glucose each, with the standard World Health Organization (WHO)-ORS solution in the management of ongoing fluid losses, after initial intravenous rehydration to correct dehydration. The study was conducted among patients aged 12-60 years hospitalized with diarrhoea due to cholera. One hundred seventy-six patients who were hospitalized with acute diarrhoea and signs of severe dehydration were rehydrated intravenously and then randomly assigned to receive either standard ORS solution (311 mmol/L) or reduced-osmolarity ORS solution (245 mmol/L). Intakes and outputs were measured every six hours until the cessation of diarrhoea. During maintenance therapy, stool output, intake of ORS solution, duration of diarrhoea, and the need for unscheduled administration of intravenous fluids were similar in the two treatment groups. The type of ORS solution that the patients received did not affect the mean serum sodium concentration at 24 hours after randomization and the relative risk of development of hyponatraemia. However, patients treated with reduced-osmolarity ORS solution had a significantly lower volume of vomiting and significantly higher urine output than those treated with standard WHO-ORS solution. Reduced-osmolarity ORS solution was as efficacious as standard WHO-ORS solution in the management of cholera patients. The results indicate that reduced-osmolarity ORS solution is also as safe as standard WHO-ORS solution. However, because of the limited sample size in the study, the results will have to be confirmed in trials, involving a larger number of patients.

Concurrent infection with S.typhi and V. cholerae--a case report".

An eight year old male child presented with symptoms of diarrhoea, vomiting & fever with signs of moderate dehydration. He was treated with tetracyline and fluid replacement therapy. Inspite of treatment and control of diarrhoea and vomiting patient developed gastrointestinal bleeding and tenesmus with continued fever. Deterioration in patient's condition to suspicion of another infection. High level of suspicion and appropriate microbial investigations revealed dual infection with S. typhi and V. cholerae.

Cólera y embarazo: reporte de un caso y revisión bibliográfica / Cholera and pregnancy: case report

Hasta enero de 1991 América Latina era la única parte del mundo que no había sido afectada por el brote epidémico delcólera de la séptima pandemia asiática, se determinó que el agente causal era el Vivrio Cholerae biotipo El Tor y existen extensos informes sobre la pandemia desde el punto de vista clínico y microbiológico, pero poco es lo publicado hasta la fecha sobre los efectos de la toxina colérica en pacientes embarazadas

Transtornos cardiovasculares en pacientes con cólera / Cardiovascular disorders in cholera patients

Se realizó un estudio analítico en pacientes con cólera, con deshidratación moderada y severa en el Hospital Nacional Edgardo Rebagliati M. (Diciembre 92-Marzo 93), buscando relacionar los niveles de potasio sérico y las alteraciones cardiovasculares. De 54 pacientes que cumplieron los criterios de inclusión se encontró deshidratación moderada en el 56 por ciento y severa en el 44 por ciento; de éstos, 6 tuvieron shok hipovolémico. Los signos clínicos más relevantes fueron: Hipotensión arterial (PA sistól nes séricas de potasio en la mayoría (55 por ciento) estuvieron en límites normales y sólo en 15 por ciento se halló hipokalemia no encontrándose relación significativa con la severidad de la deshidratación y los trastornos cardiacos. Taquicardia sinusal fue el hallasgo electrocardiográfico mas frecuente, además de aplanamiento e inversión de la onda T, presencia de onda U, arritmia supraventricular; siendo la fibrilación auricular con respuesta ventricular elevada la de mayor presentación. Podemos concluir que los niveles séricos de potasio no se correlacionan directamente con las alteraciones cardiovasculares y electrocardiográficas.

Clinical profile of cholera in young children--a hospital based report.

Clinical profile of cholera was studied in children attending Diarrhea Training and Treatment Unit from January-December 1993. Out of a total 8714 cases of acute watery diarrhea, 64 children (0.7%) were suspected to have cholera on the basis of acute onset loose water/rice watery stools, high purge rate with or without excessive vomiting and/or severe dehydration. Stool culture was positive for cholera in 33 cases (51.6%). All the isolates were V. cholerae 01 biotype El Tor serotype Ogawa. Sixty four per cent of stool culture positive cases were below 5 years of age. The results assume importance because out of 28 children < 2 years with clinical suspicion of cholera, 11 cases (39.3%) were culture positive for V. cholerae, youngest child being 3 months old. Comparison of various parameters revealed that presence of vomiting > 4 episodes/ day (p < 0.005), frequency of stools >12/24 hours (p <0.002), rice watery stools (p < 0.01) and presence of severe dehydration (p < 0.01) were significant parameters associated with positive stool culture. Beside examination of stool sample by hanging drop method was an excellent diagnostic tool (p < 0.001) with a sensitivity of 51.5%, specificity 100% and positive predictive value of 100%. The isolates of V. cholerae were susceptible to furazolidone, cephelexin, nalidixic acid, norfloxacin and gentamicin. Our observations indicate that cholera is not uncommon in infants and young children. Like children in the older age group, acute onset diarrhea with watery/rice watery stools and high purge rate with or without excessive vomiting and/or rapid development of severe dehydration should arouse suspicion of cholera in younger children also. They should be investigated for cholera even in non-endemic areas and in the absence of cholera outbreaks.

Pathologic changes of gut in non-01 Vibrio cholerae infection.

A 14-year-old girl who had beta-thalassemia hemoglobin E disease was infected by bacteriologically proven non-01 Vibrio cholerae at 2 months postsplenectomy and died 37 hours after onset of the malady. Postmortem examination disclosed congestion, edema, and hemorrhagic foci of the mucosa of the small and large intestines. The gut mucosa was focally eroded. The gut wall was infiltrated by leucocytes, especially neutrophils, in all coats representing acute purulent and hemorrhagic enterocolitis. There was hyperplasia of lymphoid follicles in the gut mucosa and lymph nodes. It is suggested that morphologic change of the gut in non-01 Vibrio cholerae infection is more severe than in infection caused by Vibrio cholerae.

Clinical features of infantile diarrhea associated with single or multiple enteric pathognes

Clinical features of infantile diarrhea were studied among 603 infants from birth to 12 months of age to determine the predominant clinical feature[s] seen in infantile diarrhea associated with a specific enteric pathogen. Among the major clinical features, fever was most often seen in diarrhea due to Yersinia spp. [61.5%] followed by that in rotavirus [26.1%]. Vomiting was mostly associated with Vibrio cholerae infection [90.9%] and shigellosis [64.6%]. Dehydration was predominant in Vibrio cholerae [90.9%] and Salmonella [84.9%] infections. Bloody diarrhea was mostly due to Shigella infection [74.3%]. As regards diarrhea with multiple pathogens, vomiting and dehydration were most frequent with Campylobacter+Enteropathogenic Escherichia coli [EPEC] [88.9% and 77.8%, respectively], while fever was more common with rotavirus+Shigella+Escherichia coli and rotavirus+Giardia. Infection with invasive organisms lead to vomiting, 4-10 stools per day and dehydration significantly more often as compared to infections with non-invasive organisms. Similarly more stools of patients infected with invasive organisms showed presence of blood and more than 5 leukocytes/HPF as compared to those infected with non-invasive organisms

Vibrio cholera non-01 septicaemia

Vibrio cholerae serogroup non-01 may cause a cholera-like illness but may also cause septicaemia in the compromised host, especially in people with hepatic cirrhosis. This organism was isolated from the blood in a patient presenting at the armed forces hospital with fever who was known to have cirrhosis of the liver. Over the next 5 months he had two further septicaemia episodes with vibrio cholerae non-01, suggesting the possibility of a chronic carrier state. Liver cirrhosis is common in oman and this diagnosis should be considered as a cause of fever in such patients

Complicaciones y tratamiento del cólera durante el embarazo / Cholera complications and treatment during pregnancy

A nivel mundial se vive la séptima pandemia de cólera. Desde el año de 1991 México se ha visto afectado por esta pandemia. Cerca de 20 por ciento de los casos habidos en nuestro país se han presentado en mujeres en edad fértil, por lo que la asociación del cólera con el embarazo es una posibilidad que se encuentra latente. Se presenta el caso clínico de una paciente que en el tercer trimestre de su embarazo cursó con un cuadro de cólera, desarrollando un parto pretérmino. Por otra parte se revisa la literatura médica a cerca de los principales generales del tratamiento del cólera y de la asociación de este con el embarazo