Cholera differential diagnosis

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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.

Differentiating Cholera from other Diseases

Cholera must be differentiated from other conditions associated with acute onset diarrhea, including:

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

• Shigella patients present with acute, bloody diarrhea, whereas cholera patients have watery diarrhea.
• Shigella causes invasive diarrhea and thus presents with symptoms of fever, abdominal cramps, and rectal pain, which are not observed in patients with cholera.
• Vomiting is usually absent in shigella but is frequently seen in 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

• 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

Cause			Osmotic gap		History	Physical exam	Gold standard	Treatment
			< 50 mOsm per kg	> 50 mOsm per kg*
Watery	Secretory	Crohns	+	-	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	+	-	Excessive sweating Heat intolerance 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	+	-	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
	Osmotic	Lactose intolerance	-	+	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	-	+	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 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 movements are loose stools History of straining is also common	Abdominal tenderness Hard stool in the rectal vault	Clinical diagnosis ROME III criteria Pharmacologic studies based criteria	High dietary fiber Osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose Antispasmodic drugs (e.g. anticholinergics such as hyoscyamine or dicyclomine)

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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