Watery Diarrhea and Dehydration Case

Case Presentation
A 13 yo boy presents to the clinic that you are working at in Cameroon. According to his mother, he started having watery diarrhea earlier in the day and has proceeded to have at least ten large bowel movements since that time. He has had two episodes of non-bloody, non-bilious diarrhea and has had tactile fever. He has been too weak to take in much liquid but has had a few intermittent sips of water. He has become progressively more fatigued throughout the day and was brought into the clinic by his mother and a few other family members. He has had no cough, congestion, or complaints of headache. A few other people in his community have had similar symptoms over the past week including his aunt and uncle.  Of note, he has only urinated once since yesterday evening.
 
Vital signs
Temp: 99.4, HR: 138, RR: 15, BP: 90/60, Sats: 97% on room air

Photo Credit: ​http://cameroon-info.net/stories/0,29767,@,cholera-epidemic-persists-in-cameroon.html

Physical exam
General: arouses to stimulation but sleepy in appearance, can answer questions
HEENT: Normocephalic, sunken eyes bilaterally, TMs clear, nares clear without discharge, pharynx without erythema
Neck: no stiffness, full ROM
LAD: no cervical or axillary LAD
Respiratory: clear to auscultation bilaterally, no crackles, no retractions, no tachypnea
Cardiovascular: tachycardic, no murmur, peripheral pulses are rapid, no edema noted
GI: abdomen is non-distended, soft, mildly tender to palpation, hyperactive bowel sounds
Neuro: unable to walk without support, decreased strength in upper and lower extremities bilaterally

Differential Diagnosis
Escherichia coli
Vibrio cholerae
Campylobacter
Norovirus
Non-typhoidal Salmonella enterica 

​Labs
CMP
Stool studies
 
Discussion
Cholera is an intestinal infection that leads to secretory diarrhea and is caused by the gram-negative bacteria V. cholera. It has more than 200 serotypes and produces an enterotoxin that leads to large volumes of fluid loss from the duodenum and jejunum. The colon is unable to reabsorb this large volume of fluid and can cause prolific amounts of diarrhea. People primarily become infected with cholera through ingestion of contaminated food and water, by ingesting undercooked shellfish/oysters, and by living in conditions with poor sanitation, which are more likely to have contaminated water supplies. Many adults in a community where cholera is endemic can be asymptomatic carriers and shed the bacteria in the their stools for two to three weeks. The incubation period is typically 24-48 hours but can be up to five days.  Cholera is typically diagnosed clinically although stool studies and electrolyte panels can be sent to determine diagnosis and degree of dehydration and acidosis. Physical exam findings consistent with dehydration include sunken eyes, tachycardia, hypotension, poor skin turgor, delayed capillary refill, lethargy, and weak pulses. Management is focused on rehydration and correction of electrolyte abnormalities with fluid resuscitation. If rehydration is not performed in an adequate time frame, the disease can often be fatal.
 

Examples of cholera cots, for management of large volume diarrhea

Additional Resources
http://www.who.int/mediacentre/factsheets/fs107/en/
http://www.cdc.gov/cholera/index.html
​