Cholera differential diagnosis: Difference between revisions

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==Overview==
==Overview==
Patients with cholera may give a history of consumption of contaminated food or water, and travel to an endemic area. The symptoms usually develop within 24-48 hour of consumption of contaminated food. Patient presents with sudden onset, painless, odorless, rice watery large volume stool, abdominal cramps, [[vomiting]] and [[fever]]. It should be differentiated from other infectious causes of [[diarrhea]] for e.g. [[rotavirus]], [[E.coli]], [[amoebic dysentry]] and [[giardiasis]]. It should also be differentiated from some non-infectious causes of diarrhea for e.g. [[VIPoma]], tubulovillous adenoma and [[food poisoning]].
Patients with cholera may have a history of consumption of contaminated food or water and/or travel to an [[endemic]] area. Symptoms of cholera usually develop within 24-48 hour of infection. Patient presents with sudden-onset, painless, odorless, rice-watery, large-volume stool; [[abdominal cramps]]; [[vomiting]]; and [[fever]]. Cholera should be differentiated from other infectious causes of [[diarrhea]] such as [[rotavirus]], [[E. coli]], [[amoebic dysentry]], and [[giardiasis]]. Cholera should also be differentiated from some non-infectious causes of diarrhea such as [[VIPoma]], tubulovillous [[adenoma]], and [[food poisoning]].<ref name="pmid14738797">{{cite journal| author=Sack DA, Sack RB, Nair GB, Siddique AK| title=Cholera. | journal=Lancet | year= 2004 | volume= 363 | issue= 9404 | pages= 223-33 | pmid=14738797 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14738797  }} </ref><ref name="pmid3035922">{{cite journal| author=Krejs GJ| title=VIPoma syndrome. | journal=Am J Med | year= 1987 | volume= 82 | issue= 5B | pages= 37-48 | pmid=3035922 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3035922  }} </ref><ref name=DIff-Chol>Guerrant RL, Van Gilder T, Steiner TS, et al.; Infectious Diseases Society of America. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32(3):331–351.</ref><ref name=DIF-Cholera>Scallan, Elaine, et al. "Foodborne illness acquired in the United States—unspecified agents." Emerg Infect Dis 17.1 (2011): 16-22.</ref>


==Differentiating Cholera from other Diseases==
==Differentiating Cholera from other Diseases==
===Infectious Diarrhea===
Cholera must be differentiated from other conditions associated with acute onset diarrhea, including:<ref name="pmid14738797">{{cite journal| author=Sack DA, Sack RB, Nair GB, Siddique AK| title=Cholera. | journal=Lancet | year= 2004 | volume= 363 | issue= 9404 | pages= 223-33 | pmid=14738797 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14738797  }} </ref><ref name="pmid3035922">{{cite journal| author=Krejs GJ| title=VIPoma syndrome. | journal=Am J Med | year= 1987 | volume= 82 | issue= 5B | pages= 37-48 | pmid=3035922 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3035922  }} </ref><ref name=DIff-Chol>Guerrant RL, Van Gilder T, Steiner TS, et al.; Infectious Diseases Society of America. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32(3):331–351.</ref><ref name=DIF-Cholera>Scallan, Elaine, et al. "Foodborne illness acquired in the United States—unspecified agents." Emerg Infect Dis 17.1 (2011): 16-22.</ref>
* It may be difficult to differentiate cholera from other infectious causes of diarrhea specially if it is mild and in early stages.
===Infectious causes of diarrhea===
* Fresh stool microscopy, stool culture, PCR and other techniques help to differentiate these conditions. Stool tests are useful, cheap and frequently used test to differentiate cholera from other infectious conditions. Other tests like [[PCR]], serotyping though sensitive and specific, may not be performed because of the cost or non-availability at many centers.
* It may be difficult to differentiate cholera from other infectious causes of diarrhea, especially if it is mild and in early stages.
====Shigella====
* Fresh stool [[microscopy]], [[stool culture]], [[PCR]], and other techniques help to differentiate these conditions. Stool tests are useful, cheap, and frequently used to differentiate cholera from other infectious conditions. Other tests (e.g., [[PCR]], serotyping), though sensitive and specific, may not be performed due to prohibitive cost or lack of availability at many healthcare centers.
* Shigella has acute bloody diarrhea whereas cholera has watery diarrhea
 
* Shigella causes invasive diarrhea thus presents with symptoms of fever, abdominal cramp and rectal pain. These symptoms are lacking in cholera.
====[[Shigella]]====
* Vomiting is usually absent in [[Shigella]] but is frequently seen in cholera.
* [[Shigella]] patients present with acute, bloody diarrhea, whereas cholera patients have watery [[diarrhea]].
====Amoebic Hemorrhagic E.coli Dysentery====
* [[Shigella]] causes invasive diarrhea and thus presents with symptoms of [[fever]], [[abdominal cramps]], and [[rectal pain]], which are not observed in patients with [[cholera]].
* Bloody diarrhea is not found in cholera and guides to a diagnosis of dysentery
* Vomiting is usually absent in [[shigella]] but is frequently seen in cholera.
* The volume of stool is not as high as seen with Cholera.
 
====Amoebic Hemorrhagic [[E. coli]] [[Dysentery]]====
* Bloody diarrhea, which is not seen in cholera, guides clinicians toward a diagnosis of [[dysentery]].
* The volume of stool is not as high as seen in cases of [[cholera]].


====Giardiasis====
====Giardiasis====
* The volume of stool is not as high as seen with Cholera.
* The volume of stool is not as high as in cases of cholera.
* Stool microscopy is used to detect eggs and parasite.
* Stool microscopy is used to detect eggs and parasites.
* Stool in giardiasis produce strong odour whereas cholera usually has odourless stools.
* The stool of [[giardiasis]] patients produces a strong odor, whereas cholera patients usually have odorless stools.
 
====Strongyloides====
====Strongyloides====
* The volume of stool is not as high as seen with Cholera.
* The volume of stool is not as high as in cases of cholera.
* Stool microscopy is used to detect eggs and parasite.
* Stool [[microscopy]] is used to detect eggs and parasites.
 
====Food poisoning====
====Food poisoning====
* The volume of stool is not as high as seen with Cholera.
* The volume of stool is not as high as in cases of cholera.
 
===Non-infectious causes of diarrhea===
====[[VIPoma]]====
* Patients present with a chronic history of [[diarrhea]]
* Volume of stool is not as high as in cases of [[cholera]]
* Negative stool examination and culture
* Fasting gut hormones confirm the diagnosis
 
====Tubulovillous [[adenoma]]====
* [[Colonoscopy]] and [[biopsy]] confirm the diagnosis
* Patients present with a chronic history of [[diarrhea]]
* Volume of stool is not as high as in cases of [[cholera]]
* Negative stool examination and culture
 
'''The table below summarizes the findings that differentiate watery causes of chronic diarrhea'''<ref name="pmid16151544">{{cite journal| author=Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR et al.| title=Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. | journal=Can J Gastroenterol | year= 2005 | volume= 19 Suppl A | issue=  | pages= 5A-36A | pmid=16151544 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16151544  }} </ref><ref name="pmid12135027">{{cite journal| author=Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D| title=Bowel habits and bile acid malabsorption in the months after cholecystectomy. | journal=Am J Gastroenterol | year= 2002 | volume= 97 | issue= 7 | pages= 1732-5 | pmid=12135027 | doi=10.1111/j.1572-0241.2002.05779.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12135027  }} </ref><ref name="pmid1702075">{{cite journal| author=Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R et al.| title=Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia. | journal=Gastroenterology | year= 1991 | volume= 100 | issue= 2 | pages= 359-69 | pmid=1702075 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1702075  }} </ref><ref name="pmid14439871">{{cite journal| author=RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC| title=Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue. | journal=Gastroenterology | year= 1960 | volume= 38 | issue=  | pages= 28-49 | pmid=14439871 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14439871  }} </ref>
<small>
{| class="wikitable"
! colspan="3" rowspan="2" |Cause
! colspan="2" |Osmotic gap
! rowspan="2" |History
! rowspan="2" |Physical exam
! rowspan="2" |Gold standard
! rowspan="2" |Treatment
|-
!< 50 mOsm per kg
!> 50 mOsm per kg*
|-
| rowspan="5" |Watery
| rowspan="3" |Secretory
|[[Crohns disease|Crohns]]
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* [[Abdominal pain]] followed by [[diarrhea]]
|
* [[Abdominal]] [[tenderness ]]when palpated in severe [[disease]]
* Blood seen on [[rectal exam]]
*[[Fever]]
*[[Tachycardia]]
*[[Hypotension]]
|
* [[Colonoscopy]] with [[biopsy]]
|
* Topical mucosamine and [[corticosteroids]] are preferred
* [[Mesalamine]] and [[sulfasalazine]] are used for remission
|-
|[[Hyperthyroidism]]
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|
* Excessive [[sweating]]
* Heat intolerance
* [[Hypermotility|Increased bowel movements]]
|
* Lump in the neck
* [[Proptosis]]
* [[Tremors]]
* Increased DTR
|
* [[TSH]] with [[T3]] and [[T4]]
|
* [[Carbimazole]]  and [[methimazole]]
* [[Beta blockers]] like [[propylthiouracil]]
* [[Iodine-131]]
|-
|[[VIPoma]]
|<nowiki>+</nowiki>
| -
|
* Watery [[diarrhea]]
* [[Dehydration]]  ([[thirst]], [[dry skin]], [[dry mouth]], [[tiredness]], [[headaches]], and [[dizziness]])
* [[Lethargy]], [[muscle weakness]]
* [[Nausea]], [[vomiting]]
* Crampy [[abdominal pain]]
* [[Weight loss]]
* [[Flushing]]
|
* [[Tachycardia]]
 
* [[Rash]]
* [[Facial flushing]]
* [[Abdominal distention]]
* [[Abdominal tenderness]] in the right upper abdominal quadrant
|
* Elevated [[VIP]] levels
* Followed by imaging
|
* [[Sandostatin]] or [[chemotherapy]]  for [[malignant tumors]]
* Surgical removal of the [[tumor]]
|-
| rowspan="2" |[[Osmotic]]
|[[Lactose intolerance]]
| -
|<nowiki>+</nowiki>
|
:* [[Abdominal pain]]
:* [[Bloating]]
:* [[Diarrhea]]
:* [[Flatulence]]
|
* [[Abdominal tenderness]]
|
* Intestinal [[biopsy]]
|
* Avoidance of dietary [[lactose]]
* Substitution to maintain nutrient intake
* Regulation of [[calcium]] intake
* Use of [[enzyme]] [[lactase]]
|-
|[[Celiac disease (patient information)|Celiac disease]]
| -
| +
|
* May be asymptomatic
* Vague [[abdominal pain]]
* [[Diarrhea]]
* [[Weight loss]]
* [[Malabsorption]] / [[steatorrhea]]
* Bloatedness
|
* [[Abdominal pain]] and [[cramping]]
* [[Abdominal distention]]
* [[Tetany]]
* [[Mouth ulcers]]
* [[Dermatitis herpetiformis]]
* Signs of the fat-soluble [[Vitamin A|vitamins A]], D, E, and K deficiency
|
* [[IgA]] tissue [[transglutaminase]] Ab
|
* [[Gluten-free diet]]
|-
|
|Functional
|[[Irritable bowel syndrome]]
| -
| -
|
[[Abdominal pain]] or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:
* Improves with [[defecation]]
 
* Onset associated with change in frequency of [[stool]]
 
* Onset associated with change in appearance of stool
 
* 25% of [[Bowel movement|bowel movements]] are loose stools
History of straining is also common
|
* [[Abdominal tenderness]]
* Hard stool in the rectal vault
|
* [[Diagnosis|Clinical diagnosis]]
** ROME III criteria
** [[Pharmacological|Pharmacologic]] studies based criteria
|
* High [[dietary fiber]]
* [[Osmotic]] [[laxatives]] such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]]
* [[Antispasmodic]] drugs (e.g. [[Anticholinergic|anticholinergics]] such as [[hyoscyamine]] or [[dicyclomine]])
|}{{WikiDoc Help Menu}} {{WikiDoc Sources}}
 


===Non-infectious causes===
==Differential Diagnosis by Organ System==
====VIPoma====
* Chronic history of diarrhea
* Volume of stool is not as high as seen with Cholera.
* Negative stool examination and culture.
* Fasting gut hormones are confirmatory for the diagnosis.
====Tubulovillous adenoma====
* [[Colonoscopy]] and [[biopsy]] are confirmatory for the diagnosis.
* Chronic history of diarrhea
* Volume of stool is not as high as seen with Cholera.
* Negative stool examination and culture.
(By organ system)
{|style="width:75%; height:100px" border="1"
{|style="width:75%; height:100px" border="1"
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular'''
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Gastroenterologic'''
| '''Gastroenterologic'''
|bgcolor="Beige"| [[VIPoma]], Tubulovillous adenoma, [[Food poisoning]]
|bgcolor="Beige"| [[VIPoma]], Tubulovillous [[adenoma]], [[Food poisoning]]
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
Line 86: Line 239:
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Infectious Disease'''
| '''Infectious Disease'''
|bgcolor="Beige"| [[Giardiasis]], [[Amoebic dysentry]], [[E.coli]], [[Strongyloides]],
|bgcolor="Beige"| [[Giardiasis]], [[Amoebic dysentry]], [[E. coli]], [[Strongyloides]],
|-
|-
|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
Line 152: Line 305:
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Neurotoxins]]
 
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[[Category:Bacterial diseases]]
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[[Category:Overview complete]]
[[Category:Infectious disease]]
{{WikiDoc Help Menu}}
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
{{WikiDoc Sources}}
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Gastroenterology]]
[[Category:Pediatrics]]

Latest revision as of 20:55, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]

Overview

Patients with cholera may have a history of consumption of contaminated food or water and/or travel to an endemic area. Symptoms of cholera usually develop within 24-48 hour of infection. Patient presents with sudden-onset, painless, odorless, rice-watery, large-volume stool; abdominal cramps; vomiting; and fever. Cholera should be differentiated from other infectious causes of diarrhea such as rotavirus, E. coli, amoebic dysentry, and giardiasis. Cholera should also be differentiated from some non-infectious causes of diarrhea such as VIPoma, tubulovillous adenoma, and food poisoning.[1][2][3][4]

Differentiating Cholera from other Diseases

Cholera must be differentiated from other conditions associated with acute onset diarrhea, including:[1][2][3][4]

Infectious causes of diarrhea

  • It may be difficult to differentiate cholera from other infectious causes of diarrhea, especially if it is mild and in early stages.
  • Fresh stool microscopy, stool culture, PCR, and other techniques help to differentiate these conditions. Stool tests are useful, cheap, and frequently used to differentiate cholera from other infectious conditions. Other tests (e.g., PCR, serotyping), though sensitive and specific, may not be performed due to prohibitive cost or lack of availability at many healthcare centers.

Shigella

Amoebic Hemorrhagic E. coli Dysentery

  • Bloody diarrhea, which is not seen in cholera, guides clinicians toward a diagnosis of dysentery.
  • The volume of stool is not as high as seen in cases of cholera.

Giardiasis

  • The volume of stool is not as high as in cases of cholera.
  • Stool microscopy is used to detect eggs and parasites.
  • The stool of giardiasis patients produces a strong odor, whereas cholera patients usually have odorless stools.

Strongyloides

  • The volume of stool is not as high as in cases of cholera.
  • Stool microscopy is used to detect eggs and parasites.

Food poisoning

  • The volume of stool is not as high as in cases of cholera.

Non-infectious causes of diarrhea

VIPoma

  • Patients present with a chronic history of diarrhea
  • Volume of stool is not as high as in cases of cholera
  • Negative stool examination and culture
  • Fasting gut hormones confirm the diagnosis

Tubulovillous adenoma

  • Colonoscopy and biopsy confirm the diagnosis
  • Patients present with a chronic history of diarrhea
  • Volume of stool is not as high as in cases of cholera
  • Negative stool examination and culture

The table below summarizes the findings that differentiate watery causes of chronic diarrhea[5][6][7][8]

Cause Osmotic gap History Physical exam Gold standard Treatment
< 50 mOsm per kg > 50 mOsm per kg*
Watery Secretory Crohns + -
Hyperthyroidism + -
VIPoma + -
  • Elevated VIP levels
  • Followed by imaging
Osmotic Lactose intolerance - +
Celiac disease - +
Functional Irritable bowel syndrome - -

Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following:

  • Onset associated with change in frequency of stool
  • Onset associated with change in appearance of stool

History of straining is also common

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Differential Diagnosis by Organ System

Cardiovascular No underlying causes
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic VIPoma, Tubulovillous adenoma, Food poisoning
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease Giardiasis, Amoebic dysentry, E. coli, Strongyloides,
Musculoskeletal / Ortho No underlying causes
Neurologic No underlying causes
Nutritional / Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy No underlying causes
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous No underlying causes

References

  1. ↑ 1.0 1.1 Sack DA, Sack RB, Nair GB, Siddique AK (2004). "Cholera". Lancet. 363 (9404): 223–33. PMID 14738797.
  2. ↑ 2.0 2.1 Krejs GJ (1987). "VIPoma syndrome". Am J Med. 82 (5B): 37–48. PMID 3035922.
  3. ↑ 3.0 3.1 Guerrant RL, Van Gilder T, Steiner TS, et al.; Infectious Diseases Society of America. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32(3):331–351.
  4. ↑ 4.0 4.1 Scallan, Elaine, et al. "Foodborne illness acquired in the United States—unspecified agents." Emerg Infect Dis 17.1 (2011): 16-22.
  5. ↑ Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR; et al. (2005). "Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology". Can J Gastroenterol. 19 Suppl A: 5A–36A. PMID 16151544.
  6. ↑ Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D (2002). "Bowel habits and bile acid malabsorption in the months after cholecystectomy". Am J Gastroenterol. 97 (7): 1732–5. doi:10.1111/j.1572-0241.2002.05779.x. PMID 12135027.
  7. ↑ Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R; et al. (1991). "Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia". Gastroenterology. 100 (2): 359–69. PMID 1702075.
  8. ↑ RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC (1960). "Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue". Gastroenterology. 38: 28–49. PMID 14439871.


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