Budding, A.E.

Korswagen, L.

Rozemeijer, W.

Voskuyl, A.E.

DSpace at VU

  EUROSURVEILLANCE  Vol .  14 ·  Issue 32 ·  13 August 2009 ·  www.eurosurveillance.org 1
R ap i d  com m uni ca ti on s
V i b r i o  c h o l e r a e  n o n -o1  n o n -o139  i n f e c t i o n  i n  a n 
i m m u n o c o m p r o m i s e d  pat i e n t  r e t u r n i n g  f r o m  s pa i n , 
J u ly  2009
W Rozemeijer (w.rozemeijer’vumc.nl)1, L A Korswagen2, A E Voskuyl2, A E Budding1
1. Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, the Netherlands
2. Department of Rheumatology, VU University Medical Center, Amsterdam, the Netherlands 
We describe a severe gastroenteritis with non-O1, non-O139 
Vibrio cholerae in an immunocompromised patient returning from 
a holiday in Spain in July 2009. Predisposing factors and possible 
cholera enterotoxin production could explain the unusually grave 
symptomatology. The patient recovered after doxycyclin treatment.
In July 2009, a Dutch man in his fifties presented to an 
emergency department in Amsterdam with profuse diarrhoea. He 
had recently been diagnosed with systemic sclerosis complicated 
by a renal crisis, myositis and reduced motility of the stomach and 
small bowel (especially the duodenum). His medication included 
prednisone and esomeprazole. 
The patient became ill the day before presentation with 
severe diarrhoea (more than 30 evacuations per day), vomiting 
and abdominal cramps. One day before onset of symptoms he 
had returned from Canary Islands, Spain. He had not swum in 
natural water nor eaten seafood during his stay. None of his family 
members who had accompanied him on his holiday had symptoms 
of gastroenteritis. On examination he was afebrile with normal pulse 
and blood pressure. He was severely dehydrated having lost more 
than 10% of his bodyweight. Laboratory tests showed an acidosis, 
hypokalaemia and elevated creatinine and C-reactive protein. He 
was hospitalised and treated with intravenous fluids and potassium.
A faecal culture was sent to the microbiology department. Its 
rice water appearance guided the technician to include testing for 
Vibrio cholerae. A lactase-negative, oxidase-positive, Gram-negative 
rod was identified by the Vitek system (Biomerieux, France) as 
V. cholerae. Serotyping classified it as non-O1, non-O139 serotype. 
Disk diffusion results showed susceptibility to cefotaxime, 
ciprofloxacin, trimethoprim-sulfamethoxazole and tetracycline.
When culture results became available six days later, the patient 
was still having diarrhoea (diminished to 10 evacuations a day) 
and was feeling unwell. Antibiotic treatment was started with oral 
doxycycline 100mg for three days and this led to quick recovery 
from his gastroenteritis. Further worsening of the systemic sclerosis 
prevented the patient from being discharged in the following days.
In contrast to V. cholerae serotype O1 and O139, the 
non-O1, non-O139 V. cholerae (NCV) are not associated with 
cholera epidemics but with sporadic cases or small outbreaks 
of gastrointestinal disease [1,2]. Occasionally these can cause 
extraintestinal disease including wound infections and septicaemia 
[1,2]. Few NCV strains produce cholera enterotoxin, the toxin 
responsible for massive dehydrating diarrhoea. Some strains 
can have other virulence genes leading to less severe intestinal 
symptoms [1,2]. The presence of typical choleric rice water stools 
and the extent of dehydration in our patient are uncommon in 
NCV infection and suggest cholera enterotoxin production [3]. The 
predisposition of this patient may have contributed to the severity 
of disease. He was on immunosuppressive medication, his gastric 
acid production was blocked by esomeprazole and the intestinal 
mobility was impaired [4,5].
NCVs are part of the normal bacterial ecosystem of estuaries and 
coastal areas and these strains seem to persist in the environment, 
similar to V. cholerae O1 and O139 strains [5]. NCVs are found 
in salt and fresh water in both the Mediterranean and temperate 
parts of Europe. Warm summer months favour Vibrio growth and 
it is in late summer and early fall that most cases occur, either 
through eating contaminated seafood or by direct contact with 
contaminated water [6-8]. A recent study in Italy, in a population 
with high dietary seafood intake, showed that 3.4% of the acute 
diarrhoea cases admitted to hospital were caused by NCV infection 
[7]. Most European countries do not routinely check for the 
presence of NCV in clinical samples, foodstuff or the environment. 
Our case underlines the importance of testing for V. cholerae in 
potentially exposed patients with acute diarrhoea, especially when 
predisposing factors like immunosuppression and acid-blocking 
medication are present.
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2  EUROSURVEILLANCE  Vol .  14 ·  Issue 32 ·  13 August 2009 ·  www.eurosurveillance.org
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This article was published on 13 August 2009.
Citation style for this article: Rozemeijer W, Korswagen LA, Voskuyl AE, Budding AE. 
Vibrio cholerae non-O1 non-O139 infection in an immunocompromised patient returning 
from Spain, July 2009. Euro Surveill. 2009;14(32):pii=19298. Available online: http://
www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19298 


Vibrio Cholerae Non-O1 Non-O139 Infection in An Immunocompromised Patient Returning from Spain, July 2009

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