Bohol, Mabelle D.

No.031

Plasmodium malariae

I. Description of the Organism Plasmodium malariae is a parasitic protozoa that causes malaria in humans. It is closely related to Plasmodium falciparum and Plasmodium vivax which are responsible for most malarial infection. While found worldwide, it is a so-called "benign malaria" and is not nearly as dangerous as that produced by P. falciparum or P. vivax. P. malariae causes fevers that recur at approximately three-day intervals (a quartan fever), longer than the two-day (tertian) intervals of the other malarial parasites, hence its alternate name quartan malaria. Plasmodium malariae has been recognized since the Greek and Roman civilizations over 2,000 years ago, with different patterns of fever described by the early Greeks. In 1880, Alphonse Laveran discovered that the causative agent of malaria is a parasite. Detailed work of Golgi in 1886 demonstrated that in some patients there was a relationship between the 72-hour life cycle of the parasite and the chill and fever patterns in the patient. The same observation was found for parasites with 48-hour cycles. Golgi concluded that there must be more than one species of malaria parasite responsible for these different patterns of infection. Each year, approximately 500 million people will be infected with malaria worldwide Of those infected, roughly two million will die from the disease. Malaria is caused by four Plasmodium species: Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale and Plasmodium malariae. At any one time, an estimated 300 million people are said to be infected with at least one of these Plasmodium species and so there is a great need for the development of effective treatments for decreasing the yearly mortality and morbidity rates. Arguably, P. malariae is the least studied of the four species that infect humans, in part because of its low prevalence and milder clinical manifestations compared to the three other species. It is widespread throughout sub-Saharan Africa, much of southeast Asia, Indonesia, on many of the islands of the western Pacific and in areas of the Amazon Basin of South America. In endemic regions, prevalence ranges from less than 4% to more than 20%, but there is evidence that P. malariae infections are vastly underreported.

II. Metabolism Life cycle P. malariae is the only human malaria parasite that causes fevers that recur at approximately three-day intervals (therefore occurring evey fourth day, a quartan fever), longer than the two-day (tertian) intervals of the other malarial parasites. Human infection Liver stage

In this stage, many thousands of merozoites are produced in each schizont. As the merozoites are released, they invade erythrocytes and initiate the erythrocytic cycle, where the parasite digests hemoglobin to obtain amino acids for protein synthesis. Erythrocytic cycle

The total length of the intraerythrocytic development is roughly 72 hours for P. malariae. At the schizont stage, after schizogonic division, there are roughly 68 parasite cells in the erythrocyte. Following the erythrocytic cycle, which lasts for seventy two hours on average, six to fourteen merozoites are released to reinvade other erythrocytes. Finally, some of the merozoites develop into either micro- or macrogametocytes. The two types of gametocytes are taken into the mosquito during feeding and the cycle is repeated. There are no animal reservoirs for P. malariae. Mosquito stage

Similar to the other human-infecting Plasmodium parasites, Plasmodium malariae has distinct developmental cycles in the Anopheles mosquito and in the human host. The mosquito serves as the definitive host and the human host is the intermediate. When the Anopheles mosquito takes a blood meal from an infected individual, gametocytes are ingested from the infected person. A process known as exflagellation of the microgametocyte soon ensues and up to eight mobile microgametes are formed.

Sexual stage

Following fertilization of the macrogamete, a mobile ookinete is formed, which penetrates the peritropic membrane surrounding the blood meal and travels to the outer wall of the mid-gut of the mosquito. The oocyst then develops under the basal membrane and after a period of two to three weeks a variable amount of sporozoites are produced within each oocyst. The number of sporozoites that are produced varies with temperature and can range from anywhere between many hundreds to a few thousand. Eventually, the oocyst ruptures and the sporozoites are released into the hemocoel of the mosquito. The sporozoites are then carried by the circulation of the hemolymph to the salivary glands, where they become concentrated in the acinal cells. A small number of sporozoites are introduced into the salivary duct and injected into the venules of the bitten human. This initiates the cycle in the human liver.

III. Virulence Factors The human malaria parasite Plasmodium malariae, one of the world's most devastating pathogens, has an astonishing array of sequences and genes that play key roles in pathogenesis and immune evasion. We must understand the functions of these elements if the chronicity and unpredictable virulence of Plasmodium is to be explained. Despite intensive efforts over the last century to understand and control malaria, the causative agent of the most severe form of the disease - Plasmodium malariae - remains firmly entrenched as a leading cause of morbidity and mortality in humans. Approximately 300-500 million clinical episodes and 2.7 million deaths are attributed to P. malariae infections each year and, with the emergence of widespread drug-resistant parasite populations and insecticide-resistant mosquitoes, this situation is predicted to worsen. New cost-effective strategies for controlling malaria, such as the development of a vaccine, are urgently required. The complete sequence of the 14 linear chromosomes that comprise the P. malariae genome has recently been determined. It is perhaps not surprising for such a successful pathogen that these studies have revealed that a high proportion of the 5,300 predicted genes encode proteins known or predicted to play a role in pathogenic processes, such as invasion of red blood cells, cytoadherence and immune evasion. We have reviewed elsewhere the impact of the genome sequence on

red blood cell invasion; in this article, we comment on our increased understanding of the virulence genes that encode proteins involved in cytoadherence and immune evasion. Insight into the function, diversity and regulation of these genes promises to reveal new strategies for fighting malarial disease. IV. Toxins produce Malaria, caused by an intracellular protozoan parasite of the genus Plasmodium, is responsible for 23 million deaths and 300500 acute illnesses annually. A major morbidity factor is cerebral malaria, characterized by enhanced blood-brain barrier permeability, leukocyte infiltration and/or activation, and neuronal dropout. The pathogenesis of cerebral malaria remains unknown. Hemozoin, a by-product of intraerythrocytic parasite mediated hemoglobin catabolism, is released when the parasite lyses the host erythrocyte. This potential toxin is found in the brain parenchyma of cerebral malaria cases. The effects, if any, of hemozoin on human brain cells has not been studied in detail. Our data demonstrates that astrocytes actively phagocytize hemozoin, resulting in a time and concentration dependent toxicity and loss of viability. Further analysis demonstrated a secondary loss of neurons in astrocyte-neuron co-cultures. Morphologic characteristics of apoptosis such as membrane blebbing were observed in astrocytes exposed to hemozoin. Apoptosis was subsequently corroborated via Western blot analyses and TUNEL confocal microscopy. Taken together, our results suggests that hemozoin can induce significant pathogenic responses in CNS cells that can contribute to the development of cerebral malaria. V. Pathology Plasmodium malariae causes a chronic infection that in some cases can last a lifetime. The P. malariae parasite has several differences between it and the other Plasmodium parasites, one being that maximum parasite counts are usually low compared to those in patients infected with P. falciparum or P. vivax. The reason for this can be accounted for by the lower number of merozoites produced per erythrocytic cycle, the longer 72-hour developmental cycle (compared to the 48-hour cycle of P. vivax and P. falciparum), the preference for development in older erythrocytes and the resulting earlier development of immunity by the human host. Another defining feature of P. malariae is that the fever manifestations of the parasite are more moderate relative to those of P. falciparum and P. vivax and fevers show quartan periodicity. Along with bouts of fever and more general

clinical symptoms such as chills and nausea, the presence of edema and the nephrotic syndrome has been documented with some P. malariae infections. It has been suggested that immune complexes may cause structural glomerular damage and that renal disease may also occur. Although P. malariae alone has a low morbidity rate, it does contribute to the total morbidity caused by all Plasmodium species, as manifested in the incidences of anemia, low birth rate and reduced resistance to other infections. VI. Diagnostics The preferable method for diagnosis of P. malariae is through the examination of peripheral blood films stained with Giemsa stain. PCR techniques are also commonly used for diagnoses confirmation as well as to separate mixed Plasmodium infections. Even with these techniques, however, it may still be impossible to differentiate infections, as is the case in areas of South America where humans and monkeys coexist and P. malariae and P. brasilianum are not easily distinguishable. Basic guidelines A. Capillary blood should be obtained by fingerstick, or venous blood should be obtained by venipuncture. B. Blood smears, at least two thick and two thin, should be prepared as soon as possible after collection. Delay in preparation of the smears can result in changes in parasite morphol-ogy and staining characteristics. C. Schffners dots can be demonstrated in Giemsa stain, which is preferred to Wright or Wright-Giemsa stains. In P. malariae infections, red blood cells (rbcs) are normal or smaller than normal (3/4) in size. 1. Rings P. malariae rings have sturdy cytoplasm and a large chromatin dot.

Ring in a thick blood smear.

Rings in thin blood smears.

2. Trophozoites P. malariae trophozoites have compact cytoplasm and a large chromatin dot. Occasional band forms and/or basket forms with coarse, dark-brown pigment can be seen.

Trophozoite in a thick blood smear.

Band-form trophozoites in thin blood smears

Trophozoite in a thick smear.

Band-form trophozoites in thin blood smears

Basket-form trophozoite in a thin

Basket-form trophozoites in a thin smear.

Trophozoites in thin blood smears. These images show variations on the basket-form.

3. Schizonts P. malariae schizonts have 6 to 12 merozoites with large nuclei, clustered around a mass of coarse, dark-brown pigment. Merozoites can occasionally be arranged as a rosette pattern. 4. Gametocytes P. malariae gametocytes are round to oval with scattered brown pigment; they may almost fill the infected red blood cell. Diagnosis: 1. Examination of thin and thick smears (100ox) of blood, under oil immersion magnification, reveals the trophozoites and schizonts within the erythrocytes. Sometimes the gametocytes can be visualized. 2. Fluorescently labeled antibodies may be used to identify the responsible species. VII. Treatment Three main factors determine treatments: the infecting species of Plasmodium parasite, the clinical situation of the patient (for example, adult, child, or pregnant female with either mild or severe malaria), and the drug susceptibility of the infecting parasites. Drug susceptibility is determined by the geographic area where the infection was acquired. Different areas of the world have malaria types that are resistant to certain medications. The correct drugs for each type of malaria must be prescribed by a doctor who is familiar with malaria treatment protocols. Since people infected with P. falciparum

malaria can die (often because of delayed treatment), immediate treatment for P. falciparum malaria is necessary. Mild malaria can be treated with oral medication; severe malaria (one or more symptoms of either impaired consciousness/coma, severe anemia, renal failure, pulmonary edema, acute respiratory distress syndrome, shock, disseminated intravascular coagulation, spontaneous bleeding, acidosis, hemoglobinuria [hemoglobin in the urine], jaundice, repeated generalized convulsions, and/or parasitemia [parasites in the blood] of > 5%) requires intravenous (IV) drug treatment and fluids in the hospital. Drug treatment of malaria is not always easy. Chloroquine phosphate (Aralen) is the drug of choice for all malarial parasites except for chloroquine-resistant Plasmodium strains. Although almost all strains of P. malariae are susceptible to chloroquine, P. falciparum, P. vivax, and even some P. ovale strains have been reported as resistant to chloroquine. Unfortunately, resistance is usually noted by drug-treatment failure in the individual patient. There are, however, multiple drug-treatment protocols for treatment of drug-resistant Plasmodium strains (for example, quinine sulfate plus doxycycline [Vibramycin, Oracea, Adoxa, Atridox] or tetracycline [Achromycin], or clindamycin [Cleocin], or atovaquone-proguanil [Malarone]). There are specialized labs that can test the patient's parasites for resistance, but this is not done frequently. Consequently, treatment is usually based on the majority of Plasmodium species diagnosed and its general drugresistance pattern for the country or world region where the patient became infested. For example, P. falciparum acquired in the Middle East countries is usually susceptible to chloroquine, but if it's acquired in sub-Sahara African countries, it's usually resistant to chloroquine. The WHO's treatment policy, recently established in 2006, is to treat all cases of uncomplicated P. falciparum malaria with artemisinin-derived combination therapy (ACTs). ACTs are drug combinations (for example, artesunate-amodiaquine, artesunate-mefloquine, artesunate-pyronaridine, dihydroartemisinin-piperaquine, and chlorproguanil-dapsoneartesunate) used to treat drug-resistant P. falciparum. Unfortunately, as of 2009, a number of P. falciparum-infected individuals have parasites resistant to ACT drugs. New drug treatments of malaria are currently under study because Plasmodium species continue to produce resistant strains that frequently spread to other areas. One promising drug class

under investigation is the spiroindolones, which have been effective in stopping P. falciparum experimental infections. VIII. Other related studies List of parasites (human) Malaria Plasmodium falciparum Plasmodium vivax Plasmodium ovale