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SASTM Newsflash - Cholera, diarrhea and dysentery update: Italy ex Cuba

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SASTM NEWSFLASH

 

CHOLERA, DIARRHEA AND DYSENTERY UPDATE:

ITALY ex CUBA, DOMINICAN REPUBLIC

 

Cholera with severe renal failure in an Italian tourist returning from Cuba, July 2013

 

An Italian man in his late 40s with cholera was hospitalized in Trieste, Italy, in July 2013. He had returned from Cuba, where he had spent 2 weeks in Havana. He did not seek medical advice before traveling. While in Cuba, he drank tap water and ate fruits and vegetables washed with tap water. He reported no direct contact with sick individuals there. On the last day of his stay, he ate raw seafood including sea urchin and crabs, which he caught himself, along the coast of Havana. The following day, during the flight to Italy, he developed watery diarrhea, severe weakness, tachycardia, muscle cramps, dizziness, abdominal pain, nausea and vomiting.

 

The day after his return, he was admitted to hospital with watery diarrhea, dehydration, loss of 10 kg (22 pounds) of body weight, low blood pressure and severe renal failure. He underwent continuous intravenous hydration and correction of metabolic acidosis and low blood potassium level. He also had a hemodialysis session and started empirical antibiotic therapy with ciprofloxacin (200 mg twice daily for 7 days).

 

The patient's condition progressively improved, the laboratory test abnormalities returned to normal values and he was discharged 10 days after admission. The patient's travel companion had consumed the same meals during their stay in Cuba, except for the raw seafood. The companion did not develop any symptoms.

 

_Vibrio cholerae_ was isolated from the patient's stool samples taken on the 1st day of hospitalization. The serogroup and serotype were confirmed by slide agglutination in polyvalent O1 and mono-specific Inaba and Ogawa antisera (Oxoid Ltd, United Kingdom) as _V. cholerae_

O1 serotype Ogawa. Double mismatch amplification mutation assay

(DMAMA) polymerase chain reaction (PCR) was performed in order to discriminate between the classical, El Tor, and Haitian type of ctxB allele (encoding cholera toxin B subunit) .

 

Antimicrobial drug susceptibility testing of the isolated _V.cholerae_ strain was performed by the disk diffusion method, according to the Clinical and Laboratory Standards Institute (CLSI) , and by Etest (Oxoid Ltd, United Kingdom), for phenotypic characterization of the isolate.

 

The strain was positive for the Haitian type of ctxB allele: it displayed resistance to sulfonamide, streptomycin, trimethoprim/sulfamethoxazole, nalidixic acid and ceftazidime, and susceptibility to cefotaxime, tetracycline, ampicillin, chloramphenicol and gentamicin. The strain showed also reduced susceptibility to ciprofloxacin (minimum inhibitory concentration: 0.25-0.5 mg/L). Genotyping was performed by pulsed-field gel electrophoresis (PFGE) analysis using the restriction enzymes NotI and SfiI according to the PulseNet United States protocol. The PFGE patterns were defined as KZGS12.0097(SfiI) and KZGN11.0124 (NotI), corresponding to those currently observed in most _V. cholerae_ strains from Haiti .

 

Background

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Cholera is an acute, secretory diarrhea caused by ingestion of food or water contaminated with the bacterium, _V cholerae_. The clinical presentation of infection may range from mild illness to massive watery diarrhea, shortly progressing to severe volume and electrolyte depletion, severe hypotension and renal failure, with death occurring within hours.

 

In 2012, the World Health Organization (WHO) recorded 245 393 cholera cases and 3034 deaths globally, with a case fatality rate of 1.2 percent, representing a 58 percent decrease in number of cases compared with the previous year. However, the actual number of cases is known to be much higher than those reported. In 2012, Cuba reported a cholera outbreak following a major outbreak in Haiti and the Dominican Republic that began at the end of 2010. A total of 500 cases were recorded in Cuba by the end of 2012. This was the 1st cholera outbreak in Cuba since the mid-19th century . Another outbreak of cholera occurred in Havana in January 2013: on 14 Jan, 51 cases of infection with _V. cholerae_ serogroup O1, serotype Ogawa, biotype El Tor were confirmed in Havana .

 

Cuba is an important tourist destination. It is estimated that in 2010, more than 2.5 million tourists visited Cuba, of whom around 32 percent were European residents, mostly from Italy, Spain and Germany.

 

Cases of imported cholera in Italy are very rare: the last confirmed case was in 2006. After the Hispaniola cholera epidemic started in Haiti in 2010, no cases of imported cholera have been reported in Italy.

 

Discussion

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Cholera can be a life-threatening disease. Early recognition, based on travel history and clinical features, is the cornerstone of successful patient management. Renal dysfunction can be present in the course of the disease, as occurred in our patient, can be a potential complication of the infection itself or secondary to volume depletion. Taken together, the phenotypic and genetic characterization of _V. cholerae_ O1 isolated from our patient shows its relationship with Haitian epidemic strains.

 

On 9 Aug 2013, another 4 cases of cholera in persons returning from travel to Cuba were reported to WHO, 2 from Venezuela and 2 from Chile . On 23 Aug 2013, the Pan American Health Organization (PAHO) reported 7 cases of cholera in persons who had travelled to Cuba from Europe: 2 from Germany, 3 from Italy (1 of whom was our patient, who had been reported in the PAHO update of 14 August), 1 from Netherlands and 2 from Spain.

 

In January 2013, the risk of cholera in travellers visiting Cuba was considered to be low. However, the risk has increased, given the outbreak in January 2013, the recent imported cholera cases and the high number of tourists visiting Cuba. Travelers to Cuba should seek advice from travel medicine clinics in order to assess their personal risk and to be aware of preventive hygiene measures. On 23 Aug 13, Cuba reported that there have been 163 cases of cholera in 2013 in the province of Havana, Santiago de Cuba and Camaguey, as well as in other municipalities. Public health awareness campaigns were intensified during the summer .

 

Physicians should consider the diagnosis of cholera in patients returning from Cuba who present with acute watery diarrhea.

 

Communicated by: Promed Mail

 


 

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