CASE 1 1.

According to the WHO, cholera is characterized by a sudden onset of acute watery diarrhea that can rapidly lead to death by severe dehydration. The disease is acquired by ingestion of water or food contaminated by Vibrio cholerae and has a short incubation period of two hours to five days. Cholera is an extremely virulent disease that affects both children and adults. Unlike other diarrheal diseases, it can kill healthy adults within hours. All cases of cholera should be treated immediately. If treatment is delayed or inadequate, death from dehydration and circulatory collapse may follow very shortly. Individuals with lower immunity, such as malnourished children or people living with AIDS, are at greater risk of death if infected by cholera. Among people developing symptoms, 80% present with mild to moderate acute watery diarrhea, while the other 20% develop rapidly severe dehydration leading to deaths. Utilizing a simple and inexpensive solution of sodium and glucose, ORS enhances sodium and fluid absorption in the small intestine, even in cases of enterotoxic diarrhea where fluid loss is often substantial. Potential problems with the standard ORS formulation are that it may not lower stool output or duration of diarrhea, which reduces its acceptance in many communities (Rabbani 2000). Alternative formulations, including those that use lower electrolyte concen- trations or replace glucose with complex carbohydrates such as rice powder, or both, have been introduced with the aim of re- ducing osmolarity to promote greater salt and water absorption in the small intestine. In a recent systematic review, reduced osmo- larity ORS was found to be safe and more effective when com- pared with standard ORS for treatment of diarrhea in children (Hahn 2001). Reduced osmolarity oral rehydration solution for treating cholera (Review) 2

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

2. The Actions of Cholera Toxin

Figure 1: Action of cholera toxin. See below for description. A, B (cholera toxin subunits); GM1 (GM1 ganglioside receptor); Gs (G protein); AC (adenylate cyclase); Gi (G protein); cAMP (cyclic AMP); CFTR (cystic fibrosis transmembrane conductance regulator).

When cholera toxin is released from the bacteria in the infected intestine, it binds to the intestinal cells known as enterocytes (epithelial cell in above

diagram) through the interaction of the pentameric B subunit of the toxin with the GM1 ganglioside receptor on the intestinal cell, triggering endocytosis of the toxin. Next, the A/B cholera toxin must undergo cleavage of the A1 domain from the A2 domain in order for A1 to become an active enzyme. Once inside the enterocyte, the enzymatic A1 fragment of the toxin A subunit enters the cytosol, where it activates the G protein Gsa through an ADP-ribosylation reaction that acts to lock the G protein in its GTP-bound form, thereby continually stimulating adenylate cyclase to produce cAMP. The high cAMP levels activate the cystic fibrosis transmembrane conductance regulator (CFTR), causing a dramatic efflux of ions and water from infected enterocytes, leading to watery diarrhoea. One area of anti-diarrhoea treatment lies in the stimulation of enkephalins, which regulate intestinal secretion by acting directly on enterocytes. Enkephalins bind to the opioid receptors on enterocytes, which act through G proteins to inhibit the stimulation of cAMP synthesis induced by cholera toxin, thereby directly controlling ion transport.

www.ebi.ac.uk/interpro/potm/2005_9/Page2.htm
3. V cholerae O1 and V cholerae O139 cause clinical disease by producing an enterotoxin that promotes the secretion of fluid and electrolytes into the lumen of the small intestine. The enterotoxin is a protein molecule composed of 5 B subunits and 2 A subunits. The B subunits are responsible for binding to a ganglioside (monosialosyl ganglioside, GM1) receptor located on the surface of the cells that line the intestinal mucosa. The activation of the A1 subunit by adenylate cyclase is responsible for the net increase in cyclic adenosine monophosphate (cAMP). cAMP blocks the absorption of sodium and chloride by the microvilli and promotes the secretion of chloride and water by the crypt cells.[3, 4] The result is watery diarrhea with

electrolyte concentrations isotonic to those of plasma. Fluid loss originates in the duodenum and upper jejunum; the ileum is less affected. The colon is usually in a state of absorption because it is relatively insensitive to the toxin. However, the large volume of fluid produced in the upper intestine overwhelms the absorptive capacity of the lower bowel, resulting in severe diarrhea. Unless the lost fluid and electrolytes are replaced adequately, the infected person may develop shock from profound dehydration and acidosis from loss of bicarbonate. The enterotoxin acts locally and does not invade the intestinal wall. As a result, few neutrophils are found in the stool. http://emedicine.medscape.com/article/962643-overview#a0104 4. Reason for adding up glucose in ORS. Oral rehydration therapy (ORT) using the WHO/UNICEF glucose-based Oral Rehydration Salts (ORS) solution is the preferred method for treating most children with dehydration due to diarrhoea (except those with severe dehydration); it has been used successfully in millions of cases worldwide. In many countries glucose-ORS solution is also recommended for home treatment of children with diarrhoea after they have been seen at a health facility, even when there are no signs of dehydration. Glucose-ORS solution works because glucose is rapidly absorbed by most patients with diarrhoea, and this causes salt and water also to be absorbed, thus replacing the faecal losses. Although glucose-ORS solution efficiently replaces faecal losses of water and salts, it has one important shortcoming: it does not reduce stool volume during diarrhoea or shorten the duration of the illness, which are the results that mothers and many health workers seek. If an ORS formulation could be developed that had the positive features of the standard glucose-ORS, including

low cost safety, and stability during prolonged storage, but also appreciably reduced the rate of stool loss during illness and/or the duration of diarrhoea, it could have considerable advantages over glucose-ORS. Most importantly, it could be promoted as having a true antidiarrhoeal effect, which should lead to increased acceptance and use of ORS by both health workers and mothers, and perhaps also to a reduction in the use of ineffective "antidiarrhoeal" drugs and inappropriate antibiotics. This would represent a major advance in efforts to control diarrhoeal morbidity and mortality through appropriate case management.

https://apps.who.int/chd/publications/newslet/update/updt-07.htm

Simply giving a saline solution (water plus Na+) by mouth has no beneficial effect because the normal mechanism by which Na+ is absorbed by the healthy intestinal wall is impaired in the diarrhoeal state and if the Na+ is not absorbed neither can the water be absorbed. In fact, excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens.

If glucose (also called dextrose) is added to a saline solution a new mechanism comes into play. The glucose molecules are absorbed through the intestinal wall through active transport - unaffected by the diarrheal disease state - and in conjunction sodium is carried through by a co-transport coupling mechanism. Experiments showed that each glucose molecule absorbed from the intestine into the bloodstream can "co-transport" one sodium atom (called a sodium "ion" when dissolved in water).

http://www.wanterfall.com/Travel-Health/Oral-Rehydration.htm Crane RK, Miller D & Bihler I, "The restrictions on possible mechanisms of intestinal transport of sugars", In: Membrane Transport and Metabolism. Proceedings of a Symposium held in Prague, August 22-27, 1960. Edited by A. Kleinzeller and A. Kotyk. Czech Academy of Sciences, Prague, 1961, pp. 439449.

5. Signs and symptoms of dehydration seen in the patient: Poor skin turgor BP 70/50 Pulse weak and rapid