PARASITOLOGY

DEPARTMENT
 MALARIA

ĐOÀN VĂN QUYỀN, MD

 INTRODUCTION

Procozoan parasites characterized by the production

of spore like oocysts containing sporozoites were
known as sporozoan.
CLASSIFICATION

Malaria parasite belongs to:

• Phylum: Apicomplexa
• Class: Sporozoa
• Order: Hemosporida
• Genus: Plasmodium.
 CLASSIFICATION

The genus Plasmodium is classified into two subgenera:

• subgenus Plasmodium: P. vivax, P. malariae and P. ovale.
• subgenus Laverania: P. falciparum.
• P. knowlesi, a parasite of monkeys may also affect man.
 CAUSATIVE AGENTS OF HUMAN
MALARIA
• Plasmodium vivax: Benign tertian malaria.
• Plasmodium falciparum: Malignant daily (tertian) malaria.
• Plasmodium malariae: Benign quartan malaria.
• Plasmodium ovale: Benign tertian malaria.
• Plasmodium knowlesi: Benign quartan malaria. Like
Plasmodium malariae
 HISTORY
• Malaria has been known from ancient times. Seasonal
intermittent fevers with chills and shivering, recorded in
Indian, Chinese and Assyrian civilizations.
•The name malaria (mal: bad, aria: air) was given in the
18th century in Italy.
• The specific agent of malaria was discovered in red
blood cells of a patient in 1880 by Alphonse Laveran, a
French army surgeon in Algeria.
 HISTORY
• ln 1886, Golgi in Italy described the asexual development
of the parasite in RBC (erythrocytic schizogony), be called
as Golgi cycle
• In 1897, Ronald Ross in India identified the developing
stages of malaria parasites in mosquitoes.
• Both Ross (1902} and Laveran (1907) won the Nobel
Prize for their discoveries in malaria.
 DISTRIBUTION
The revalence of the four species of malaria varies in different
geographical regions
1. P. vivax is widely distributed in Asia, North Africa, and Central and
South America.
2. P. falciparum in Africa, Papua New Guinea and Haiti, is rapidly
spreading in South East Asia and India.
3. P. malariae is present in most places but is rare, except in Africa.
4. P. ovale is confined to West Africa.
DISTRIBUTION
 DISTRIBUTION
In India, malaria is a major public health threat. In India, about 27%
population lives in high transmission and about 58% in low transmission area.

The level classification of endemicity (WHO)

• Hypoendemic (transmission is low): Spleen or parasite rate less than10%
• Mesoendemic (transmission is moderate): Spleen or parasite rate 11-50%
• Hyperendemic (transmission is intense but seasonal): Spleen or parasite
rate 51-75%
• Holoendemic (transmission of high intensity):Spleen or parasite rate more
than 75%
 VECTOR
• Malaria is transmitted by over 60 species of female Anopheles
• The mosquito feeds exclusively on fruits and juices, but the female
mosquito needs at least two blood meals, before the first batch of eggs
can be laid.
• Out of 45 species of Anopheles in India, only few are regarded as
the vectors of malaria, e.g. An.culicifacies, An. fluviatilis, An.
stephensi, An. minimus, An. philippinensis, An. sundaicus,
MORPHOLOGY
 MORPHOLOGY

trophozoit
e Plasmodium vivax

schizont

gamatocyte
 MORPHOLOGY

trophozoit
e Plasmodium falciparum

schizont

gamatocyte
 MORPHOLOGY

trophozoit
e Plasmodium malariae

schizont

gamatocyte
 MORPHOLOGY

trophozoit
e
Plasmodium ovale

schizont

gamatocyte
 LIFE CYCLE

Malaria passes its life cycle in two hosts:

1. Definitive host: Female Anopheles.
2. Intermediate host: Man.
The life cycle of malarial comprises of two stages
1. An asexual phase occurring in humans,
2. A sexual phase occurring in mosquito
LIFE CYCLE
LIFE CYCLE
 PATHOGENESIS

• Clinical manifestations are caused by products of

erythrocytic schizogony and the host's reaction to them.
• The disease process occurs due to the local
or systemic response of the host to parasite antigens
and tissue hypoxia caused by reduced oxygen delivery
because of obstruction of blood flow by the parasitized
erythrocytes
 PATHOGENESIS
• Liver is enlarged and congested. Kupffers are
increased and filled with parasites. Hemozoin pigments are
also found in the parenchymal cells.
• Spleen is soft, moderately enlarged and congested in
acute infection. In chronic cases, spleen is hard.
• Kidneys are enlarged and congested. Glomeruli contain
pigments and tubules may contain hemoglobin casts
 PATHOGENESIS
• The brain in P. falciparum infection is congested.
Capillaries of the brain are plugged with parasilized RBCs.
The brain shows multiple punctiform hemorrhage.
• Anemia: Anemia is caused by destruction of large
number of red cells by autoimmune hemolysis. Spleen also
plays an active role by phagocytic removal of a large
number of both infected and uninfected RBCs
lo s
 PATHOGENESIS

• Cytokines like TF, interleukin {IL)-1 and interferon

(IFN)-gamma play an important role in the pathogenesis
of end-organ disease of malaria.
PATHOGENESIS
 CLINICAL FEATURES

Benign Malaria
• Incubation period: 12- 17 days.
• The typical clinical feature of malaria consists of
periodic bouts of fever with chill and rigor, followed
by anemia, splenomegaly and hepatomegaly.
 CLINICAL FEATURES
Benign Malaria
• Fever: The febrile paroxysm comprises of three stages
I . Cold stage: The patient feels incense cold with chill and rigor for
15 minutes to 1hour.
2. Hot stage: The patient feels intensely hot. The temperarure
mounts to 39 - 41•c for 2- 6 hours.
3. Sweating stage: Profuse sweating follows the hot stage and the
temperature comes down to normal. The skin is cool and moist.
 CLINICAL FEATURES

Benign Malaria
• The periodicity : According to species of parasites. It is
approximately 48 hours in tertian malaria (in P. vivax, P.
falciparum and P. ovale) and 72 hours in quartan malaria (in
P. malariae). Now, 24 hours (P. falciparum).
 CLINICAL FEATURES

Malignant Tertian Malaria

Incubation period: 8-14 days.
• The most serious and fatal type of malaria is malignant tertian
malaria caused by P. falciparum, if not treated timely or adequately
• Parasitic load is very high and more than 5% red cells are affected.
• The term pernicious malaria also have been applied to cerebral
malaria, blackwater fever, algid malaria and septicemic malaria
 CLINICAL FEATURES
Malignant Tertian Malaria
Cerebral malaria
• The initial symptoms are nonspecific with fever, headache,
backache, anorexia and nausea, anemia, hepatosplenomegaly,
thrombocytopenia.
• After 4- 5 days of high fever, cerebral malaria is manifested
by features of encephalopathy like headache, confusion,
increased muscle tone, seizures, paralysis and coma.
 CLINICAL FEATURES
Malignant Tertian Malaria
Blackwater fever
• Malarial hemoglobinuria is sometimes seen in P. falciparum,
particularly in patients, who get inadequate treatment with quinine.
An autoimmune mechanism has been suggested.
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency may
develop this condition after taking oxidant drugs, even in the
absence of malaria.
• Clinical manifestations: fever, prostration and hemoglobinuria
 CLINICAL FEATURES

Malignant Tertian Malaria

Algid malaria:
• Peripheral circulatory failure, rapid thready pulse with low
blood pressure and cold clammy skin.
• There may be severe abdominal pain, vomiting, diarrhea
and profound shock.
 CLINICAL FEATURES

Malignant Tertian Malaria

Septicemic malaria:
• It is characterized by high continuous fever with
dissemination of the parasite to various organs,
leading to multiorgan failure.
• Death occurs in 80% of the cases.
 CLINICAL FEATURES
Complications of P. falciparum
• Cerebral malaria • Hypoglycemia
• Algid malaria • Severe anemia
• Septicemic malaria • Hyperpyrexia
• Blackwater fever • Metabolic acidosis and shock
• Pulmonary edema • Bleeding disturbances
• Acute renal failure • Hyperparasitemia
 TRANSMISSION OF MALARIA
Sporozoite-induced Malaria
The natural infection is transmitted by sporozoites through the
bite of Anopheles.
Merozoite-induced Malaria
Injection of merozoites can lead to direct infection of red cells.
Such merozoite-induced malaria may occur in the following
situations:
• Transfusion malaria: Blood transfusion can accidentally
transmit malaria
 TRANSMISSION OF MALARIA

Merozoite-induced Malaria
• Congenital malaria: the parasite is transmitted
transplacentally from mother to fetus.
• Renal transplantation may lead to malaria if the donor
had parasitemia.
• Shared syringes among drug addicts may be responsible
 IMMUNITY
Immunity in malaria could be two types: innate
immunity and acquired immunity.
Innate Immunity
• It is the inherent, nonimmune mechanism of host
resistance against malarial parasite.
• Innate immunity could be due to: Duffy negative red
blood cells, Hemoglobin E , Glucose-6-phosphate
dehydrogenase deficiency, Human leukocyte a ntigen-
B53, iron deficiency.
• ,
 IMMUNITY
Acquired Immunity
Infection with malaria induces specific immunity involving
both humoral and cellular immunity.
• Humoral immunity: Circulating antibodies (IgM, lgG,IgA)
against asexual forms and sexual forms.
• Cellular immunity: Sensitized T cells release
cytokines that regulate macrophage activation and stimulate
B cells to produce antibodies.
 RECRUDESCENCE AND RELAPSE

Recrudescence
• In P. falciparum and P. malariae infections after the
• primary attack, sometimes there is a period of latency
without clinical illness. But parasites persist in
erythrocytes, although the level of parasitemia is below
the fever threshold or the microscopic threshold
• The parasites develop again, the patients get malarial
illness again.
 RECRUDESCENCE AND RELAPSE
Relapse
• In inadequately treated P. vivax and P. ovale infections.
• In both these species, some of sporozoites multiply
inside hepatocytes promptly to form schizonts and others remain
dormant be called hypnozoites (hypnos: sleep).
• Hypnozoites remain inside the hepatocytes for long periods.
• Reactivation of hypnozoites leads to initiation of fresh
erythrocytic cycles and new attacks of malarial fever
 LABORATORY
DIAGNOSIS

Demonstration of Parasite by Microscopy

• Diagnosis of malaria can be made by
demonstration of malarial parasite in the blood
• Two types of smears are prepared from the peripheral
blood are called thin smear and thick smear. (good)
 LABORATORY
DIAGNOSIS
Demonstration of Parasite by Microscopy

Plasmodium falciparum
 LABORATORY
DIAGNOSIS

Rapid antigen detection tests

Be based on the detection of antigens using
immunochromatographic methods (in 15 minutes)
Quantitative Buffy Coat(QBC) in 5 minutes.
Culture of Malaria Parasites for research
 TREATMENT
Antimalarial drugs are used with 4 objectives:
1. Clinical cure
2. Prevention of relapse
3. Prevention of transmission
4. Prophylaxis
 TREATMENT
Therapeutic
Objective is to eradicate the erythrocytic cycle and clinical cure.
Radical Cure
Objective is to eradicate the exoerythrocytic cycle in liver to prevent
relapse
Gametocidal
Objective is to destroy gametocytes to prevent mosquito transmission
and thereby reducing human reservoir
 TREATMENT
Chemoprophylaxis
Objective is to prevent infections in nonimmune person
visiting endemic areas.
 MALARIA VACCINE
Malaria vaccine is an area of intensive research. Over
past decades, there has been a significant progress in
malaria vaccine development. A completely effective
vaccine is not yet available for malaria.
 CONCLUSION
Malaria is a common disease globally, especially in
tropical regions, greatly affecting human health.