A Paediatric Case Study Report of Cholera in an Endemic Area of Cebu Province of Philippines

ZD, 2 years old male child from Cebu city Philippines with chief complaint of loose watery stools was admitted by his mother to a tertiary hospital. Five days prior to the admission, onset of the disease with three episodes (approximately 100 ml each) of non-foul smelling loose watery (yellow) stools was observed with moderately severe dehydration. However, it was observed that the patient was playful and with a good appetite. He was given 1 pack per day Vivalyte rehydration solution hence, the episode reduced to one time. One night prior to admission, an increase in bowel movement frequency was noted. The stool colour changed to yellowish to greenish with mucus. The patient turned anorexic and weak with sunken eyeballs. In the morning of the admission, the patient had another 2 episodes of the stools with formed particles. Patient also had 3 episodes of non-projectile vomiting (approximately 30 ml/ episode) irrelevant to the food intake timings.

At the Emergency Room, the patient was treated with IV Fluids of Normal Saline Solution (60 cc/ kg/ day); CBC showed thrombocytosis with neutrophilic predominance, serum electrolytes revealed hyponatremia and hypokalaemia. Stool Culture was done. Medications started were Zinc Sulphate at 20 mg per day and Oral rehydration solution. The patient was referred to an infectious specialist care with a primary impression or consideration of Cholera thus Erythromycin was started at 50 mg/kg/day (3 doses/ day).

Since the patient was under developed or did not match with the normal developmental milestones like no teething, open anterior fontanel, and deviation in the weight height ratio had developed as significant deviation in head circumference, chest circumference and abdominal girth due to the infused fluid volume overload. There might be chances of making wrong clinical diagnosis like viral diarrhoea complicated to give rise meningitis by primary care givers in absence of a confirmed laboratory results, an immediate initiation of an empirical treatment with fluid resuscitation and antibiotics undertaken, hence, the patient was referred to the care of a specialist of the infectious diseases for further evaluation and treatment.

At ward, the patient was observed awakened, irritable, without respiratory distress and tachycardia, with moderate dehydration and a positive fluid balance of 210 ml. Stool exam results showed 55-65 WBC per high power field. Intra Venous (IV) Fluid to correct the imbalance of electrolytes and medications were continued. Following days, the patient had 4 episodes of loose watery stools amounting to 100 - 200 ml per episode with passage of Ascaris. Patient was slightly irritable, with still sunken eyeballs, otherwise with good turgor, mobility and strong pulses. IV Hydration was continued. Albendazole (400 mg/ tab) single dose was given. Electrolyte imbalance was already corrected. However, the stool culture was positive for Vibrio cholerae. On the fifth hospital day, the patient got normal for all the symptoms and signs. Erythromycin was prescribed for 3 days at the rate of 50 mg/ kg/ day (3 doses/ day). Further, Zinc Sulphate tablets (20 mg/ tab) twice a day was also prescribed and then the Patient was discharged.

In absence of teething, Doxycycline as the drug of choice for the Cholera treatment might have been prescribed for a fast recovery. However, doxycycline is contraindicated in children less than 8 years of age due to the risk of yellow tooth discolouration and dental enamel hypoplasia. Generally, V. cholerae often becomes drug-resistant against multiple antibiotics through its enzymatic functions (HGT) that modify antibiotics chemically. Hence changing the antibiotic regimen remains the best strategy to get the best prognosis if the previously administered antibiotic doesn’t work properly. Another, before discharging, the condition of the patient might also have confirmed as normal through the required laboratory exams even if the patient was tolerating orally well. Moreover, the patient might have been referred to a paediatrician or called for an early follow up to reassess him and prescribe probiotics and other growth regulatory supplements for complete well-being of the patient.