Malaria Identification

It is easier than you think!

Susan Flaker Johnson, MT(ASCP), MEPD
Malaria Identification
 The learner will be able to:

 Describe the symptoms of Malaria

 Determine areas of the world where Malaria is endemic

 Identify Malaria parasites within red blood cells

 Identify the species of Malaria present within red blood cells

What is Malaria?

 Italian for “Mala Aria” or Bad Air

 It was thought to be caused by breathing stale, warm,

humid air found around swamps

 It is the Mosquitoes, not the Bad Air

Why Malaria?
 3.3 billion people live in areas at risk for Malaria
 WHO estimates that in 2008 Malaria caused 190 - 331
million clinical episodes and nearly 1 million deaths
 89% of those who die are in Sub Saharan Africa, and the
majority of those are children
 It is the 5th leading cause of death from infectious diseases
worldwide (after respiratory infections, HIV/AIDS,
diarrheal diseases, and tuberculosis)
 It has increased in the last three decades

http://www.cdc.gov/malaria/about/facts.html
Malaria in the Western Hemisphere

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx
Malaria in the Eastern Hemisphere

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx
Malaria in the USA
 Anopheles mosquitoes are found in the USA
 ~ 1500 cases are reported every year
 1st and 2nd generation Americans returning to their “home”
countries are less likely to take prophylactic medication
 1957 – 2009, 63 outbreaks of locally transmitted Malaria
have occurred
 1963 – 2009, 96 cases of transfusion-transmitted Malaria
were reported

 http://www.cdc.gov/malaria/about/facts.html
Malaria in the USA

http://www.cdc.gov/malaria/features/2008_us_data.html
Common Symptoms of Uncomplicated
Malaria
 FEVER 100%

 Chills
 Headache
 Nausea and Vomiting
 Myalgia

 Thrombocytopenia
 Anemia
 Splenomegaly
 Hepatomegaly
Symptoms of Severe Malaria
 Seizures, impairment of consciousness, coma
 Severe anemia
 Hemoglobinuria
 Acute respiratory distress syndrome (ARDS)
 Coagulopathies
 Acute kidney failure
 Low blood pressure caused by cardiovascular collapse
Diagnosis of Malaria
 Patient Symptoms and Physical Findings
 Patient History
 Foreign Travel?
 Blood Transfusion?
 Laboratory Testing
 Rapid Diagnostic Tests
False Negatives with low parasitemia
Insufficient data on P. ovale and P. malariae
CDC recommends all positives be followed up with Microscopy
 PCR – Available through WSLH and CDC
Confirmatory, but there is a delay
 Microscopy – Confirmatory
Need for competent laboratory professionals

http://www.cdc.gov/malaria/diagnosis_treatment/rdt.html
Specimen Requirements for Microscopy

 FRESH EDTA whole blood

 Thick and Thin Blood Smears – made within ONE hour

 Giemsa stain is preferred

 Wright’s Stain is OK for thin smears

Malaria Cycles

SPECIES NAME RBC CYCLE PAROXYSM

CYCLE

P. vivax Benign Tertian 45 hours 8 – 12 hours

P. ovale Tertian 48 hours 8 – 12 hours

P. malariae Quartian72 hours 8 – 10 hours

P. falciparum Malignant Tertian 48 hours 16 – 36 hours

Species Distribution

 Plasmodium vivax 50%

 Plasmodium falciparum 43%

 Plasmodium malariae 7%

 Plasmodium ovale 2%
Plasmodium vivax

 Plasmodia in enlarged RBCs (retciulocytes)

 Plasmodia in RBCs with Schuffner’s dots

 Plasmodia with more than 12 chromatin masses

(usually 16 – 24)

 Trophozoite tends to be amoeboid

Plasmodium vivax
Plasmodium malariae

 Plasmodia in RBCs of normal size, usually in aging cells

 Plasmodia in band stage

 Plasmodia rarely have more than 12 chromatin masses

(usually 6 – 12) and in a rosette

 No Schuffner’s dots
Plasmodium malariae
Plasmodium ovale

 Relatively rare

 Infected RBCs tend to be oval or burred and of normal

size or in reticulocytes (slightly larger RBCs)

 Plasmodia with 8 chromatin masses (usually 6 – 10)

 Schuffner’s dots may be present

Plasmodium ovale
Plasmodium falciparum
 Plasmodia in the crescent (banana shape) stage

 Plasmodia in ring stage with 2 chromatin dots

 Plasmodia in RBCs in eclipse (accole) position

 More than one ring (trophozoite) per RBC

 Intermediate stages rarely seen, all plasmodia in film in

ring stage or gametocyte stage, but not both

 Plasmodia invade all stages of RBCs

Plasmodium falciparum
Now for the Test…..

 http://www.rph.wa.gov.au/malaria.html
Other Organisms to Consider

 Plasmodium knowlesi

 Babesia microti
Plasmodium knowlesi
 Emerging New Form of Malaria
 Monkey Malaria
 Found in South East Asia
 Malaysia
 Borneo
 Thailand – Burma border region
 Philippines
 Singapore
 24 hour reproductive cycle
 Potentially fatal
Plasmodium knowlesi
 Appearance in blood films similar to P malaria

http://www.cdc.gov/eid/content/15/9/1478-F1.htm
Plasmodium knowlesi

 Diagnosis
 Blood film screening – appears similar to P malariae
 Compact parasite – all stages
 Does not alter RBCs size
 Schizonts 8 – 10 merozoites, arranged in a rosette

 Rapid Diagnostic Tests may NOT recognize P knowlesi

 PCR – most reliable

Babesia microti

 Tick transmitted
 Found in USA
 Upper Midwest
 Wisconsin
 May be confused with P falciparum
Babesia microti

 Diagnosis
 Microscopy – Thick and Thin Blood Films
 Small, delicate parasites
 Multiple organisms within a single RBC
 Tetrads within a single RBC

 Antibody detection by indirect fluorescent antibody (IFA)

 Molecular Methods - PCR

Babesia microti

http://www.dpd.cdc.gov/DPDX/HTML/Babesiosis.htm