Parasitology: Malaria
PLASMODIA
>Sub-order Hemosporina ; Causes Malaria
>Medically significant species: P. falciparum, P. ovale, P. vivax, P. malariae,
P. knowlesii, initially found in Southeast Asia(Malaysia), in macaque monkeys
EPIDEMIOLOGY
>WHO, in 2020, 241 million cases worldwide
>95% in Africa ; 627000 deaths, 98% in Africa, 80% in children <5y/o
>Transmission: Bites of Anopheles; Blood transfusion & placental transfer
WORLD ENDEMIC PLACES
>Africa andAsia ; Central and SouthAmerica ; Haiti and the DominicanRepublic;
some parts of the Middle East ; some of the Pacific Islands
PHILIPPINE DATA
>Philippines,2019: 12M at risk (13%) ;malaria-free in 2030 ; 95% cases –from
Palawan ; 5% -rest of thecountry
>58 out of 80 provinces are declared malaria-free
>4,870 cases, 4 deaths(2018)
>Endemic places (DOH,2019): Palawan, Sulu , Mindoro Occi , Sultan Kudarat
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VECTOR : Anopheles mosquito
>Species found in Philippines: Anopheles mangyanus; A. balabacensis; A.
maculatus ; A. litorensis
>2 most common: A. flavirostris ; A.minimus
>Anopheles -Resting : Abdomen points upward; Feeding: Abdomen straighten
>Aedes, Culex- Resting: Abdomen downward/parallel to surface
Anopheles
>ONLY females feed on blood -> needs hemoglobin for eggs
>Males feed on nectar
>Night feeders(4 pm- 4 am); Eggs laid on shaded slow running, clean,fresh H20
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Life cycle
>Obligate intracellular parasites
>2 stages: Sporogony–sexual phase ; Schizogony–asexual phase
>2 hosts :Man –intermediate host ; Mosquito –definitive host (sexual phase)
>Extrinsic phase aka: Invertebrate phase , Sporogony
>Intrinsic phase aka: Vertebrate phase, Asexual cycle ; Occurs in MAN
INTRINSIC PHASE
>Exo-Erythrocytic Schizogony
*Mosquito bites -> Injects sporozoite ->Invades liver cells -> Transforms to
trophozoite ->Divides into many schizont by binary fission -> Each schizont
becomes a merozoite -> Liver cell ruptures releasing merozoites -> Some of
this merozoite becomes hypnozoite (true for vivax and ovale)
*Hypnozoite- source of reinfection in vivid and ovale
>Erythrocytic schizogony (ES)
*Merozoite released to blood -> Infect RBC via specific receptors ->Once
inside, transforms into young trophozoite with chromatin dot & cytoplasm ring->
Growing trophozoite consumes Hgb ->Uses globin as food and heme as
pigments ->RBC changes can be seen at this stage + Knobs or stippling seen
>Young schizont– 1 chromatin dot becomes 2
>Growing schizont–more than 1 but less than that of mature schizont
>Mature schizont–each species hast different number of chromatin:
*P. vivax, ovale 12 –24 ; *P. malariae 6 –12 ;*P falciparum 18 -24
>Once mature -> RBC ruptures -> Merozoites release to infect other RBC = one
ES cycle
>Time it takes for 1 ES cycle: P vivax & ovale 48 hrs ; P malariae 72 hrs ; P
falciparum 36 –48 hrs
>After 2 or more ES cycle, some merozoites undergo gametogenesis
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Gametogenesis
>Macrogametocyte–female ; Microgametocyte –male
>Infects the mosquito to begin Extrinsic phase/Sporogony/Sexual phase
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Sporogony Cycle
>Drop in temp causes gametocyte to transform into macro (has pole) &
microgametes(has flagella)
>They fuse to become a zygote (Macro + Micro = Zygote)
>Zygote becomes amoeboid, a ookinete
>Caused outpouching of gut wall to form an oocyst
>Inside oocyst, parasite divide to become sporocysts
>Sporocyst rupture &release sporozoite ->Sporozoite travels to salivary glands
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Clinical Manifestations:
>Incubation period -9 to 14days
>fever, headache, chills and shivers, nausea and/or vomiting
>severe forms -vomiting, diarrhea, seizure, coma,death
>Common manifestations: Anemia ,Splenomegaly ,Hepatomegaly ,Fever
1.Fever - When RBC ruptures, release pyrogens
>Fever pattern specific for each species (must know):
▪Tertian malaria /Every 3 days (48hrs) –P vivax, ovale and falciparum
▪Quartan malaria / Every 4 days (72hrs) –P malariae
>Atypical pattern maybe seen
>Malarial Paroxysm: Chills ->Fever->Sweating
2.Anemia
>Plasmodium requires hemoglobin for nutrition and growth
>Hgb (Hgb F) &blood cell abnormalities(G6PD, sickle cell anemia, thalassemia)
=Protective/Resistant of malaria
>RBC rupture & loss of iron causes anemia in patients
>Thus severity of anemia depends on severity of infection
>Anemia more often in P. falciparum & less common in P. malariae
3.Splenomegaly
*Abnormalities in the blood may cause splenomegaly
*Abnormal morphology of RBC, like knobs
*Hemozoin may also cause splenomegaly
4.Hepatomegaly - Secondary to the splenomegaly
5.Blackwater fever - Seen in P. falciparum infections
>Massive hemolysis= hemoglobinemia, hemoglobinuria & acute renal failure
>Tea colored urine hence the name
6.Cerebral Malaria - Most serious neurological complication
>Severe infection of the CNS ; Seizure, coma and death
>Long term neuroproblems in survivors ; Pathogenesis poorly understood
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Pathogenesis of Malaria
>RBC destruction by the spleen and the merozoite plus loss of iron = anemia
>Change in cell morphology, causing increase stickyness of RBC causes vessel
obstruction and hemorrhage = tissue anoxia
>Shock and DIC - Severe cases
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Lab Diagnosis
>History (travel, nature of fever) ; PE (S/S, urine color) ; Serology ; PCR ; RDT
(Rapid diagnostic test); Blood film exam (GOLD STANDARD)
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Blood Smear
>Timing of collection; Prefer 1hr before onset of fever (parasite is still inside
the RBC; Mature trophozoite form)
>Collection sample ; Prefer capillary sample/ fingerprick! (abnormal RBC
accumulate in capillary region)
*Reporting of Results:
>Degree of Infection
1.Thin film = # of infected cells / 1000 RBC x 100
2.Thick film = # of parasite / 100 WBC x 100
>Report: % infection, Genus and species, Stages of devt
*Next step after getting the % infection:
>Absolute count: % infection x RBC ct = infected cells/ mm3
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Prevention
>Vector control: Mosquito nets, Insecticides, Insect repellant
>Medication: Prophylactic anti-malarial drugs
>Vaccine - WHO recommends RTS vaccine to be given to Children in areas of
moderate to severe P. falciparum infections
Treatment: Anti malarial drug activity
>Tissue schizonticides ; Blood schizonticides ; Gametocytocides
Drugs in Malaria
>Blood schizonticides kill parasite in the blood
*Chloroquine, quinine, pyrimethamine, etc.
*Chloroquine is the drug of choice for P. falciparum
>Gametocytocides kill sexual forms of the parasite, preventing transmission
*Chloroquine, quinine are also gametocytocides for P. ovale and vivax but not
for P. falciparum
*Primaquine can be used for P. falciparum
PJMC- 2A