THE MALARIA PARASITES

PLASMODIUM spp.

Nguyen Si Tuan, MD. PhD

Head department of Clinical Microbiology
Thongnhat General Hospital of Dongnai Province
INTRODUCTION
 Malaria is a mosquito-borne infection caused by protozoa
of the genus Plasmodium.
 Humans are commonly infected by four species:
1. Plasmodium malariae (Laveran, 1881)
2. Plasmodium vivax (Grassi and Feletti, 1890)
3. Plasmodium falciparum (Welch, 1897)
4. Plasmodium ovale Stephens, 1922

 Recently a 5th parasite was known to be able to infect

humans naturally: Plasmodium knowlesi, a simian parasite
described by Sinton and Mulligan in 1932.
SOME HISTORICAL HIGHLIGHTS
1880 Detection of parasites in patients’ blood (Laveran).

1891 Methylene blue-eosin stain (Romanowsky).

1897 Sexual stages of a malaria-like parasite in birds (MacCullum).

1897 Mosquitoes as malaria vectors (Ross).

1947 Tissues stages in the liver discovered (Shortt & Garnham).

1962 Persistence of hypnozoites in the liver (Krotoski).

1976 Continuous culture of erythrocytic stages (Trager & Jensen).

1993 Rapid Diagnostic Test for P. falciparum (Parasight-F test*).

2002 Genome sequence of P. falciparum completed.

EPIDEMIOLOGY AND TRANSMISSION (2013)
Estimated malaria cases and deaths, by
WHO region, 2000–2015
Estimated number of malaria deaths in children aged
under 5 years, by WHO region, 2015
Situation of Vietnam (2014)
Levels of endemicity
 Transmission of malaria can be evaluated by surveys among
children aged 2 to 9 years.

Level Spleen rates Parasite rates

≤ 10%, may be higher
Hypoendemic ≤ 10%
for part of the year

Mesoendemic 11-50% 11-50%

Constantly > 50%

Hyperendemic Constantly > 50%
high in adults (>25%)
Constantly > 75% Constantly > 75% among
Holoendemic
low in adults infants aged 0-11 months
Hackett’s classification of splenomegaly
0 Not palpable
1 Palpable on deep inspiration
2 Palpable but <½ the way to the
umbilicus
3 Not below the umbilicus
4 Below the umbilicus
5 >½ the way to the pubic symphysis.
 Classes 1, 2: mild splenomegaly,
 Class 3: moderate splenomegaly
 Classes 4, 5: massive splenomegaly
 Vectors of malaria

 Mosquitoes of the genus Anopheles.

 To be considered as vector of malaria, sporozoites must be
found in the salivary glands of the mosquito.
 Only 70/400 species of Anopheles mosquitoes in the world
are considered important malaria vectors.
 3 important vectors in Vietnam:
1. Anopheles minimus (forest areas),
2. Anopheles dirus (forest areas below latitude 20o N)
3. Anopheles epiroticus (brackish coastal area of Southern VN).
Anopheles spp.
LIFE CYCLE
MORPHOLOGY (PERIPHERAL BLOOD)
P. v. P. m. P. f. P. o.

Early trophozoites (ring forms)

Developing trophozoites

Immature schizonts

Mature schizonts

Microgametocytes (male)

Macrogametocytes (female)
Morphology of P. falciparum

Trophozoites

Schizonts

Gametocytes
Morphology of P. vivax

Trophozoites

Schizonts

Gametocytes
Morphology of P. malariae

Trophozoites

Schizonts

Gametocytes
Morphology of P. ovale

Trophozoites

Schizonts

Gametocytes
 Morphology of P. knowlesi

Note: accurate diagnosis can only be done by molecular technique (PCR)

 CLINICAL MANIFESTATIONS OF
UNCOMPLICATED MALARIA
 Symptomatic malaria without signs of severity or evidence
(clinical or laboratory) of vital organ dysfunction. The signs
and symptoms of uncomplicated malaria are nonspecific.
 Most frequent symptoms: fever and chills, ± headache,
myalgias, arthralgias, weakness, vomiting, and diarrhea.
 After a few days of onset, fever and chills can be periodic:
every 24 hrs. for P. f. (quotidian fever), every 48 hrs. (tertian
fever) for P. v., and every 72 hrs. (quartan fever) for P. m.
 Other clinical features: splenomegaly, anemia.
CLINICAL MANIFESTATIONS OF SEVERE
AND COMPLICATED MALARIA (WHO, 2010)
Clinical criteria Laboratory findings
 Impaired consciousness or  Hypoglycemia
unrousable coma (GCS < 9)*  Metabolic acidosis
 Prostration  Severe normocytic anemia
 Failure to feed  Hyperparasitemia
 Multiple convulsions  Hyperlactatemia
 Deep breathing, respiratory distress  Renal impairment
 Circulatory collapse or shock,
 Clinical jaundice
 Abnormal spontaneous bleeding
 Pulmonary edema * GSC: Glasgow Coma Score
PATHOLOGY
 Related to the rupture of infected erythrocytes and the
release of parasite material and metabolites, hemozoin
(malaria pigment) and cellular debris,
 Activity of RES (macrophages) ↑, TNF-α ↑, proinflammatory
cytokines ↑,
 Liver and spleen are often enlarged,
 Cytoadherence (due to “knobs” on parasitized RBCs) and
sequestration in deep vascular beds in vital organs (brain),
 Rosetting ⇒ large clumps of erythrocytes that restrict
microvascular flow.
IMMUNITY
 Premunition: immunity that is contingent upon the
pathogen being present,
 Genetic factors in human populations which confer
varying levels of resistance to malaria:
 Sickle-cell hemoglobin (HbS), HC LIỀM
 G6PD deficiency, CHỐNG OXY HÓA
 β-thalassemia,
 Ovalocytosis
 Duffy blood type negative (resistance to P. vivax).
 DRUG RESISTANCE
 Definition: “Ability of a parasite strain to survive and/or
multiply despite the administration and absorption of a drug
given in doses equal to or higher than those usually
recommended but within tolerance of the subject” (WHO,
1965, 1973).
 Therapeutic efficacy study (TES) ⇒ Adequate Clinical and
Parasitological Response - ACPR, Late Treatment Failure -
LTF (Late Clinical Failure - LCF, Late Parasitological Failure -
LPF), Early Treatment Failure - ETF.
 In vitro test (schizont maturation assay).
 Molecular markers (detection of gene mutations). [K13]
DIAGNOSIS

 Microscopy: presence of parasites in blood smear

(malaria species, stages, density),
 Rapid Diagnostic Tests (RDTs): presence of malaria
antigens (HRP2, pLDH, aldolase),
 Polymerase Chain Reaction (PCR, qPCR),
 Others abnormalities: anemia, low platelet count,
hyperbilirubinemia, hyper-alkaline phosphatasemia…
 RDTs

PCR technique

P. ovale

Microscopy P. falciparum

P. malariae

P. vivax
TREATMENT

 Plasmodium falciparum:
 1st line treatment: artemisinin combination therapy
(ACT) such as Dihydroartemisinin + Piperaquine
 2nd line treatment: quinine + doxycycline /clindamycin.
 Plasmodium vivax (P. m., P. o.): chloroquine
 Primaquine: gametocytocide (P. f.), anti-hypnozoite (P. v.)
 Chemoprophylaxis (not recommended in Vietnam).
Main strategies to prevent and treat malaria
PREVENTION AND CONTROL
 Reduce human-mosquito contact: impregnated bed-nets
and/or house spraying with insecticides, use of repellents,
protective clothing, house screens.
 Reduce vector density: environmental modification
(eliminating breeding sites of mosquito), larvicides
/insecticides (with pyrethroid compounds), biological
control (larvivorish fishes, Bacillus thuringiensis).
 Reduce the parasite reservoir: case detection and
treatment, chemoprophylaxis.