Professional Documents
Culture Documents
IMMUNITY/
COMMUNICABLE DISEASE
Case Presentation
MUAMIR A. ALINGAN
BSN-4A
INTRODUCTION
• Cholera is an acute, bacterial, diarrheal disease with profuse watery stools,
occasional vomiting, and rapid dehydration.
• If untreated, circulatory collapse, renal failure and death may occur.
• More than 50% of untreated people with severe cholera die.
• It occurs worldwide, with periodic epidemics and pandemics.
• A recent Western Hemisphere cholera pandemic started in Peru in 1991. By 1994,
more than 950,000 cases had been reported in 21 countries in the Western
Hemisphere.
• Only 5 new U.S. cases were reported to the CDC in 2004. Most U.S. cases
involve the ingestion of raw or undercooked seafood (e.g., oysters) from the
coastal waters of Louisiana and Texas.
• The Philippines were infected in 1858.
• The 1902-1904 cholera epidemic claimed 200,000 lives in the Philippines.
• In the Philippines, there is an incidence rate of approximately one person in
86,241,697.
Short History
Cholera has killed millions of people since it emerged out of the filthy water and
living conditions of Calcutta India in the early 1800s. The Italian doctor Filippo Pacini
was the first to discover the cholera bacteria (Vibrio cholerae) in 1854 when cholera hit
Florence,Italy. Pacini became very interested in the disease. Immediately following the
death of cholera patients, he performed an autopsy and with his microscope, conducted
histological examinations of the intestinal mucosa. During such studies, Pacini first
discovered a comma-shaped bacillus which he described as a Vibrio. Three decades later,
unaware of the fact that Pacini had already done the same research at the University of
Florence and had obtained significant results, Robert Koch, one of the “fathers” of
microbiology and bacteriology, was also researching the microorganism causing
cholera,he went to different countries like in India which was a cholera hotspot and
performed analyses on the bodies of the victims of the disease and he found a bacillus,
the same one that Pacini had found, in the intestinal mucosa. The observations and
discoveries that Koch performed led him to become a hero in the field and for years, he
was given complete credit for the discovery and isolation of Vibrio cholera.
Etiologic agent.
Certain biotypes of Vibrio cholerae serogroup 01 which are curved, Gram-
negative bacilli that secrete an enterotoxin (a toxin that adversely affects cells in the
intestinal tract) called choleragen. Other Vibrio spp. (Vibrio parahaemolyticus, Vibrio
vulnificus) also cause diarrheal diseases. Vibrios are halophilic and are thus found in
marine environments.
Vibrio cholerae
Cholera Toxin.
The
delivery region (blue) binds membrane carbohydrates to get into cells. The toxic part
(red) is activated inside the cell .
Reservoirs and Mode of Transmission.
• Infected humans and aquatic reservoirs.
• Transmission is via the fecal-oral route, contact with feces or vomitus of infected
people, ingestion of fecally contaminated water and foods especially raw or
undercooked shellfish and other seafood and flies.
Diagnosis.
Rectal swabs or stool specimens should be inoculated onto thio-sulfate-
citrate-bile-sucrose (TCBS) agar; different Vibrio spp. produce different reactions on this
medium. Biochemical tests are used to identify the various species. Biotyping is
accomplished using commercially available antisera.
Laboratory Test:
darkfield/phase-contrast microscopy, which may yield a large quantity
of curved bacilli on examination of saline suspensions from fresh
stool samples. V cholerae are usually variable in size from 1 to 3
micrometres in length to 0.5 to 0.8 micrometres in diameter, with
single polar flagellum and typical shooting star motility.
Organs of the
Alimentary Canal
The
alimentary canal,
also called the
gastrointestinal
(GI) tract, is a
continuous,
coiled, hollow,
muscular tube that
winds through the
ventral body
cavity and is open
at both ends. Its
organs are the mouth, pharynx, esophagus, stomach, small intestine, and large intestine.
The large intestine leads to the terminal opening, or anus.
MOUTH
Food enters the digestive tract through the mouth, or oral cavity, a
mucous membrane-lined cavity. The lips (labia) protect its anterior opening, the cheeks
form its lateral walls, the hard palate forms its anterior roof, and the soft palate forms
its posterior roof. The uvula is a fleshy fingerlike projection of the soft palate, which
extends downward from its posterior edge. The space between the lips and cheek
externally and the teeth and gums internally is the vestibule.
The area contained by the teeth is the oral cavity proper. The muscular
tongue occupies the floor of the mouth. The tongue has several bony attachments-two of
these are to the hyoid bone and the styloid processes of the skull. The lingual frenulum,
a fold of mucous membrane, secures the tongue to the floor of the mouth and limits its
posterior movements.
At the posterior end of the oral cavity are paired masses of lymphatic
tissue, the palatine tonsils. The lingual tonsil covers the base of the tongue just beyond.
The tonsils, along with other lymphatic tissues, are part of the body’s defense system.
When the tonsils become inflamed and enlarged, they partially block the entrance into the
throat (pharynx), making swallowing difficult and painful.
PHARYNX
The pharynx or throat is a tubular structure that extends from the base of
the skull to the esophagus and is situated immediately in front of the cervical vertebrae.
The oropharynx and laryngopharynx are food passageways connecting the oral cavity
to the esophagus. No digestion takes place in the pharynx. Its only related function is
swallowing, the mechanical movement of food. When the bolus of food is pushed
backward by the tongue, the constrictor muscles of the pharynx contract as part of the
swallowing reflex.
ESOPHAGUS
The esophagus , or gullet, is a muscular tube of approximately 25cm in
length and 2cm in diameter. It extends from the pharynx to the stomach after passing
through an opening in the diaphragm. The esophagus functions primarily as a transport
medium between compartments.
The walls of the alimentary canal organs from the esophagus to the large intestine are
made up of the same four basic tissue layers, or tunics:
1. The mucosa is the innermost layer, a moist membrane that lines the cavity, or
lumen, of the organ. It consists primarily of a surface epithelium, plus a small
amount of connective tissue (lamina propria) and a scanty smooth muscle layer.
2. The submucosa is found just beneath the mucosa. It is a soft connective tissue
layer containing blood vessels, nerve endings, lymph nodules and lymphatic
vessels.
3. The muscularis externa is a muscle layer typically made up of an inner circular
layer and an outer longitudinal layer of smooth muscle cells.
4. The serosa is the outermost layer of the wall. It consists of a single layer of flat
serous fluid-producing cells, the visceral peritoneum. The visceral peritoneum is
continuous with the slick, slippery parietal peritoneum, which lines the
abdominopelvic cavity by way of a membrane extension, the mesentery.
STOMACH
The stomach is a C shaped expanded bag, located just left of the midline
between the esophagus and small intestine. It has two borders called the greater and
lesser curvatures. The first section is the cardia which surrounds the cardial orifice
where the esophagus enters the stomach. The fundus is the superior, dilated portion of
the stomach. The body is the largest section between the fundus and the curved portion of
the C.
The pylorus is the curved base of the stomach. Gastric contents are
expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the
stomach is contracted into numerous longitudinal folds called rugae. These allow the
stomach to stretch and expand when food enters.
The functions of the stomach include:
• The short-term storage of ingested food.
• Mechanical breakdown of food by churning and mixing motions.
• Chemical digestion of proteins by acids and enzymes.
• Stomach acid kills bugs and germs.
• Some absorption of substances such as alcohol.
SMALL INTESTINE
The small intestine is about 1 inch (2.5 cm) in diameter and approximately 20
feet (6m) long and extends from the stomach to the cecum of the large intestine.
The duodenum is the first 10 inches (25 cm) of the small intestine. The
jejunum is about 8 feet long, and the ileum is about 11 feet in length.
Digestion is completed in the small intestine, and the end products of
digestion are absorbed in the blood and lymph. The mucosa has simple columnar
epithelium that includes cells with microvilli and goblets cells that secretes mucos.
Enteroendocrine cells secrete the hormones of the small intestine. Lymph nodules called
peyer’s patches are especially abundant in the ileum to destroy absorbed pathogens.
LARGE INTESTINE
The large intestine is horse-shoe shaped and extends around the small
intestine like a frame. It consists of the appendix, cecum, ascending, transverse,
descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m
and a width of 7.5cm. The cecum is the expanded pouch that receives material from the
ileum and starts to compress food products into fecal material. Food then travels along
the colon. The wall of the colon is made up of several pouches (haustra) that are held
under tension by three thick bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold
fecal matter before it passes through the anorectal canal to the anus. Thick bands of
muscle, known as sphincters, control the passage of feces.
The functions of the large intestine can be summarized as:
• The accumulation of unabsorbed material to form feces.
• Some digestion by bacteria. The bacteria are responsible for the formation of
intestinal gas.
• Reabsorption of water, salts, sugar and vitamins
TEETH
The function of the teeth is chewing. This is the process that mechanically
breaks food into smaller pieces and mixes with saliva.
TONGUE
It is the principal organ of the sense of taste that also assist in the
mastication and deglutition of food.
PANCREAS
The pancreas is a lobular, pinkish-grey organ that lies behind the
stomach. Its head communicates with the duodenum and its tail extends to the spleen.
The organ is approximately 15cm in length with a long, slender body connecting the head
and tail segments. It is made up of numerous acini (small glands) that secrete contents
into ducts which eventually lead to the duodenum.
LIVER
The liver is a large, reddish-brown organ situated in the right upper
quadrant of the abdomen. It is divided into four lobes namely the right, left, caudate and
quadrate lobes. The liver has important functions. It acts as a mechanical filter by
filtering blood that travels from the intestinal system. It detoxifies several metabolites
including the breakdown of bilirubin and estrogen. In addition, the liver has synthetic
functions, producing albumin and blood clotting factors. However, its main roles in
digestion are in the production of bile and metabolism of nutrients.
GALL BLADDER
The gallbladder is a hollow, pear shaped organ that sits in a depression on
the posterior surface of the liver's right lobe. The main functions of the gall bladder are
storage and concentration of bile.
RISK FACTORS
Precipitating factors:
• Contaminated food and water (contact with flies, feces )
• Raw or undercooked seafood (e.g., shellfish)
• Poor hygiene and sanitation
• Overcrowding(e.g., refugee camps, impoverished countries, and areas devastated
by famine, war or natural disasters)
• Poverty
• Malnutrition
• Compromised Immunity
• Reduced or nonexistent stomach acid (hypochlorhydria or achlorhydria)
Predisposing factors:
• Age: children and older adults
• People who have had gastric surgery, who have untreated Helicobacter pylori
infection, or who are taking antacids, H-2 blockers or proton pump inhibitors for
ulcers
• Type O blood
• Household exposure
• International travel (Latin America, Africa, Asia, Gulf of Mexico, Middle East)
Entry of Vibrio cholerae through oral route
(entry) PATHOPHYSIOLOGY
Leads to
Survival of virulent organisms that pass through the
stomach and into the small intestine
Result in
Binding of toxin to the plasma membrane of
intestinal epithelial cells
CLINICAL MANIFESTATIONS
Stage 1: Diarrheal Stage
• Abrupt onset of painless, severe, watery diarrhea that is often voluminous, flecked
with mucus and dead cells, and has a pale, milky appearance that resembles water
in which rice has been rinsed (rice-water stool)
• Vomiting without nausea that may persist for hours at a time
• Muscle cramps
Stage 2: Dehydration Stage
• Dehydration
• Irritability
• Lethargy
• Sunken eyes
• Dry mouth
• Extreme thirst
• Dry, shriveled skin that's slow to bounce back when pinched into a fold
• Little or no urine output
• Low blood pressure
• Irregular heartbeat (arrhythmia)
• Shock
Prevention:
• Wash your hands. Frequent hand washing is the best way to control cholera
infection. Wash your hands thoroughly with hot, soapy water, especially before
eating or preparing food, after using the toilet, and when you return from public
places. Carry an alcohol-based hand sanitizer for times when water isn't available.
• Avoid untreated water. Contaminated drinking water is the most common
source of cholera infection. For that reason, drink only bottled water or water
you've boiled or disinfected yourself. Coffee, tea and other hot beverages, as well
as bottled or canned soft drinks, wine and beer, are generally safe. Carefully wipe
the outside of all bottles and cans before you open them and ask for drinks
without ice..
• Eat food that's completely cooked and hot. Cholera bacteria can survive on
room temperature food for up to five days and aren't destroyed by freezing. It's
best to avoid street vendor food, but if you do buy it, make sure your meal is
cooked in your presence and served hot.
• Avoid sushi. Don't eat raw or improperly cooked fish and seafood of any kind.
• Be careful with fruits and vegetables. When you're traveling, make sure that all
fruits and vegetables that you eat are cooked or have thick skins that you peel
yourself. Avoid lettuce in particular because it may have been rinsed in
contaminated water.
• Be wary of dairy foods. Avoid ice cream, which is often contaminated, and
unpasteurized milk.
• Cholera vaccine. Because travelers have a low risk of contracting cholera and
because the traditional injected vaccine offers minimal protection, no cholera
vaccine is currently available in the United States. A few countries offer two oral
vaccines that may provide longer and better immunity than the older versions did.
If you'd like more information about these vaccines, contact your doctor or local
office of public health. Keep in mind that no country requires immunization
against cholera as a condition for entry.
JOURNALS
Sari Cloth a Simple Sustainable Protector from Cholera
Five years later they conducted the follow-up study to determine whether
sari water filtration continued to be practiced by the same population of participants and,
if it were, whether there would continue to be a beneficial effect of reduced incidence of
cholera.
Over 7,000 village women collecting water daily for their households in
Bangladesh were selected from the same population used in the previous study. Survey
data showed that 31 percent continued to filter their water, of which 60 percent used a
sari. Additionally, they found that of the control group (the one that did not receive any
education or training in the first study) 26 percent of households now filter their water.
"This is a clear indication of both compliance with instructions and the
sustainability of the method, but it also shows the need for continuing education in the
appropriate use and benefits of simple filtration," says Colwell.
The researchers also looked at the incidence of cholera in households
during the 5-year follow-up period. While not statistically significant, they found the
incidence of hospitalizations for cholera during that period reduced by 25 percent.
"With the lower rate of filtration in this follow-up study, it is not
surprising that the observed reduction in disease rate was not as high as the 48 percent
observed in the original trial, suggesting that active reinforcement would have been
effective in ensuring higher protection," says Colwell.
They also found an indirect benefit. Households that did not filter their
water but were located in neighborhoods where water filtration was regularly practiced
by others also had a lower incidence of cholera.
"Results of the study showed that the practice of filtration not only was
accepted and sustained by the villagers but also benefited those who filtered their water,
as well as neighbors not filtering water for household use, in reducing the incidence of
cholera," says Colwell.
Untreated rodents contracted diseases quickly, but the mice who received
the plant-grown vaccines showed long-lasting immunity for more than 300 days
(equivalent to 50 human years).
Results from the National Institutes of Health-funded research are
published in this month's Plant Biotechnology, the top-ranked journal in the field.
Clinical trials are needed, and Daniell is hopeful that the results with mice
will translate to humans. It could be yet another example of plants delivering life-saving
medicines.
The dual vaccine follows a string of other "green" vaccines developed in
Daniell's lab. He's created vaccines against anthrax and black plague that generated a
congratulatory call from the top U.S. homeland security official and was featured on the
Discovery Channel. He's also successfully grown insulin in plants to find what could be a
long-lasting cure for diabetes. Daniell's team continues to research these vaccines and is
looking for investors to help fund clinical trials.
Producing vaccines in plants is less expensive than traditional methods
because it requires less labor and technology, Daniell said.
"We're talking about producing mass quantities for pennies on the dollar,"
he said. "And distribution to mass populations would be easy because it could be made
into a simple pill, like a vitamin, which many people routinely take now. There is no need
for expensive purification, cold storage, transportation or sterile delivery via injections."
For Daniell, his research is more than his day job. His passion to find
vaccines for the world's top 10 diseases as defined by the World Health Organization
comes from growing up in India. He watched many of his childhood friends contract
malaria, cholera and other diseases.
Daniell, a father of two, joined UCF's Burnett School of Biomedical
Sciences in the College of Medicine in 1998. His research led to the formation of the
university's first biotechnology company. Daniell also became only the 14th American in
the last 222 years to be elected the Italian National Academy of Sciences. In 2007 he was
named a Fellow of the American Association for the Advancement of Sciences.
"I'm not done yet," he said. "I still have more diseases to attack."