MEDICAL PARASITOLOGY

PLASMODIUM INFECTION (MALARIA)

DR. BONIFACIO/CABUDOY
OLFU • FUMC ½ COLLEGE OF MEDICINE
Ref: Medical Parasitology in the Philippines by: Belizario

• Malaria Hot Spots

Outline: o Apayao
• Human Infection o Quirino
§ Plasmodium falciparum o Sulu
§ Plasmodium vivax o Tawi tawi
§ Plasmodium malarae • Malaria FREE!
§ Plasmodium ovale o Cavite, Batangas, Marinduque, Catanduanes, Benguet,
§ Plasmodium knowlesi Romblon, Batanes,
• Non-Human Infection or Zoonic Infection o Albay, Sorsogon, Camarines Sur
§ Plasmodium cyanomolgi o Iloilo, Guimaras, Aklan, Capis, Bohol, Cebu, Siquijor,
§ Plasmodium simium Masbate
o Western Samar, Eastern Samar, Northern Samar,
INTRODUCTION Northern nd Southern Leyte
o Biliran, Camiguin, Surigao Del Norte, Dinagat Island
Epidemiology of Plasmodium
• Philippines: Malaria Prevalence ® 7.3/1,000 population (1974) Note: Malaria free
§ P. falciparum • Catanduanes, Bohol, Cebu, North and Southern Leyte ® 1st
o 67% to 70% provinces declared malaria free! Shutaca!
o Highest among prevalence
o Associated with mortality – common in Ph
• How about Palawan?
§ P. vivax
§ 5 cases of P. knowlesi (initially read as P. malariae)
o 30% to 33%
§ 5th human plasmodium infection
o Associated with benign manifestation
§ Natural host ® long-tailed macaque monkey
§ P. malariae
§ Cases were found in a wide geographic area, NOT just
o 0.01%
in municipalities near Malaysia
o Least ® transmission is intense but the
parasite is below 10%
o Associated with benign manifestation Transmission
§ P. ovale • Bite of infected female Anopheles mosquito
o Not thrive in country but common in African • Blood transfusion
country
• Accidental needle prick ® rare case
§ P. knowlesi
• Mother to fetus ® congenital malaria [vertical transmission]
o Also associated with mortality
• Geographic distribution
§ Tropics, Subtropics and Temperate regions
§ 1/3 world population (3.4 billion)
§ Incidence: 280 million
§ 10 million afflicted each year
§ 0.5 million die wah year

Life cycle
• Sporozoite
§ Infective stage to Man (intermediate host)
• Gametocytes
§ Infective stage to Mosquito (definitive host)

• WHO Malaria Report 2012

o 9552 reported cases of malaria (72@ of cases caused
by P. falciparum)
o 12 death from malaria (0.13%)
o 0.1 cases/1000 population/year
o 2.9% slide positivity rate
• Malaria cases and Deaths
o 2005
§ Number of cases ® 46,342
§ Number of deaths 1® 150
o 2013
§ Number of cases ® 7,720
§ Number of deaths ® 12

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 MEDICAL PARASITOLOGY
Plasmodium Infections (Malaria)
During blood meal, malaria-infected female Anopheles mosquito inoculated • Inside the mosquito
sporozoite into human host (liver organ) § The microgametocyte developed into 6 to 12
¯ microgametes in a process called exflagellation
Sporozoites infect liver cells and matures into schizonts, which rupture and while the macrogametocyte developed into
release merozoites (infective stage of malaria) microgamete
(Note: P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the § Microgamete fuses to macrogamete to produce
liver and cause release by invading the bloodstream weeks or ever years the zygote ® process called Syngamy/Fertilization
later) § From a zygote it will developed into ookinete then
¯ develops further into oocyte and will produce
After this initial replication in the liver (exo-erythrocytic schizogony), the thousands of sporozoite
parasite undergo asexual multiplication in the erythrocytes mature into § Then the oocyst burst or ruptures into the
schizonts, which rupture releasing merozoites mosquito’s gut, the sporozoites mixed with the
¯ saliva and readily to transmit to man during the
Some parasite differentiate into sexual erythrocyte stage (gametocytes) mosquito’s blood meal
[gametocyte observes in exo-erythrocytic schizogony]
¯ Morphology
Blood stage parasite are responsible for the clinical manifestations of the • Detected by: Thin and Thick Blood Smear – gold standard
disease

The gametocyte, male (microgametocytes) and female (macrogametocytes,

are ingested by an anopheles mosquito during blood meal
¯
The parasite multiplication in the mosquito is known as the Sporogonic cycle
¯
While in the mosquito’s stomach, the microgametes penetrated the
macrogametes generating zygote
¯
The zygote in turn become motile and elongated (ookinetes) [reproductive
stage] which invaded the midgut wall of the mosquito where they developed
into oocyst
¯
The oocysts grow, rupture, and release sporozoites, which make their way
to the mosquito’s salivary gland
¯
Inoculation of the sporozoites into a new human host perpetuated the
malaria life cycle

Recording: • Ring form – early trophozoites

• Asexual phase § Refers to ring appearance of the malarial parasite
§ Synonymous to schizogony following the invasion onto a previously healthy RBC
§ 2 type: iridocytic and hepatic schizogony § Blue – cytoplasmic circle
• Sexual phase § Red – chromatin dot (nucleus)
§ Also called Sporogonic phase ® that’s why § Space inside the rings – vacuoles
mosquito is the definitive host and NOT MAN
because, the sexual reproduction happens inside
the gut of the mosquito
• Sporozoite
§ Injected by infected mosquito ® once the
sporozoite is injected into the skin and circulation • Developing trophozoite
then now reach the liver ® once in the liver® the § Varies among the Plasmodium spp.
parasite now penetrates the parenchymal cell to § Remnants of the cytoplasmic circle and chromatin dot
develop into other stages § Pigment – primarily brown
§ In P. ovale and P. vivax ® has additional stage § The amount of RBC spaces invaded is significantly
which is Hypnozoites § more than that of the ring form
• Inside the Hepatocyte
§ Numerous merozoites is developed then finally
released in the circulation to form erythrocytic
schizogony
• Inside the RBC
§ Each of the merozoite developed into young • Immature Schizonts
trophozoite ® growing trophozoite ® matured § Unorganized, evidence of active chromatin replication
trophozoite stage is seen Visible cytoplasmic material surrounds growing
§ The chromatic dot spilt into two to form young chromatin
schizont ® then going to growing schizont ® § Continues to multiply, it expands and occupies more
matured schizont stage (this stage of parasite spaces within RBCs
readily to release the merozoite and continues the
cycle, then this merozoite differentiates into
microgametocyte and macrogametocyte to become
the infective stage of female anopheles’ mosquito

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 MEDICAL PARASITOLOGY
Plasmodium Infections (Malaria)
• Mature Schizonts PLASMODIUM FALCIPARUM
§ Characterized by emergence of the fully developed
stages of the asexual sporozoa trophozoites known as Incubation Period 2 weeks
merozoites Period of schizogony 36 to 48 hrs
Type of fever Malignant tertian / Sub-tertian
Stages seen in the PBS Young trophozoites and
gametocytes
Degree of parasitemia 100,00/cu mm
Number of chromatin dots in Mature 18 to 24 up to 32 cluster of
• Microgametocyte
schizont stage grapes
§ Typical shape: Roundish shape except P. falciparum
which is crescent / banana shaped Affected RBC Young and mature
§ Consist of large diffuse chromatin mass that stains pink Effect in the RBC Not enlarged
to purple and is surrounded by a colorless to pale halo Strippling Maurer’s / Cristoferr’s bodies
§ Pigment is usually visible
Rings: • Double chromatin
dots
• Accole forms
• Multiple infections in
same red cells
• Macrogametocyte
§ Shape: Round to oval except P. falciparum which is Trophozoites: • Compact (rare seen
crescent / banana shaped in peripheral blood)
§ Compact chromatin mass is partially to completely • Knob-like formation
surrounded by cytoplasmic material at the surface of
§ Pigment is also present infected red cells

Gametocyte • Mature (M)®

banana/crescent
shape
• Immature (I) ®
rarely seen in PBS

Schizonts • 8 to 24 merozoites
(rare in PBS)

PLASMODIUM VIVAX

Incubation Period 2 weeks

Period of schizogony 48 hours
Type of fever Benign tertian
Stages seen in the PBS All stages
Degree of parasitemia 50,000/cu mm
Number of chromatin dots in Mature 12 to 24 cluster of grapes
schizont stage
Affected RBC Young only
Effect in the RBC Enlarged
Strippling Schuffner’s dot

Rings

Trophozoites • Ameboid, deforms

the erythrocyte

Gametocyte • Round oval

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 MEDICAL PARASITOLOGY
Plasmodium Infections (Malaria)
Schizont • 12-24 merozoites PLASMODIUM KNOWLESI

Incubation period (vector) 12 to 12 days

Period of schizogony 24 hours
Type of fever Quotidian
Stages seen in the PBS All
Degree of parasitemia 500 to 300,000/mm3
Number of chromatic dots in 16 chromatin dots
PLASMODIUM MALARIAE mature schizont stage
Striplings None
IP 30 to 40 days RBC Not enlarged
Period of schizogony 72 hours
Type of fever Quartan • Diagnostic tool ® RT-PRC (gold standard)
Stages seen in the PBS All stages § Thin and thick ® misleading because the ring form is
Degree of parasitemia 15,000/cu mm similar to that P. falciparum while the other stages of
Number of chromatin dots in 6 to 12 cluster of grapes the parasite is seen similarly to P. malariae
Mature schizont stage
Affected RBC Mature only Recurrence of Paroxysms of Plasmodium
diameter, for long periods. Reactivation of hypnozoites leads The thick film is d
Effect in the RBC Not enlarged • Recrudescence
to intitiation of fresh erythrocytic cycles and new attacks 5–10 minutes for d
Strippling Ziemann’s dots §
of malarial P.fever.
falciparum
Such new (1year)
attacks of malaria, caused by It is not fixed in me
dormant P. malariae (30
§ exoerythrocytic to 40
forms, years) –usually
reactivated long dormant
from 24 exposure
Thick film is staine
Trophozoite • Compact • weeks to®5 years
Relapse resultsafter
ofthe primary attack
antigenic stimulation ofrelapses
are called The stained film is e
hypnozoites found
(Table 6.5). microscope.
• Typical band form in the liver The thick film is
§ 6.5:P.
Table Diffvivax (2 toBetween
erences 3 years)Recrudescence and by an experienced
Relapse
§ P. ovale 20–30 layers of blo
Thick film is more
Recrudescence Relapse
malarial parasite, p
Seen in P. falciparum and Seen in P. vivax and low as 20 parasites
P. malariae P. ovale
The dehemoglobi
Schizont • 6 to 12 merozoites Due to persistence of the Due to reactivation of not show any red ce
• Coarse, dark pigment parasite at a subclinical level in hypnozoites present in liver cells
present, the paras
circulation
distorted in form,
Occurs within a few weeks or Occurs usually 24 weeks to 5
in blood cells such
months of a previous attack years after the primary attack
cannot be made
Can be prevented by adequate Can be prevented by giving difficult.
drug therapy or use of newer primaquine to eradicate
antimalarial drugs in case of hypnozoites
Thin film is exam
Gametocyte • Round parasites are foun
drug resistance
• Coarse, dark pigment thick film. If paras
then thick film sho
Laboratory Diagnosis
Patience Suspected of Malaria It is recommende
should be examin
• History of chills, fever,
Demonstration of Parasiteand sweating
by Microscopy negative (Fig. 6.14
• History of blood
Diagnosis transfusion
of malaria can be within thedemonstration
made by past 6 mons of
• History ofparasite
malarial living in
in an
theendemic
blood. area for malaria for the past 2
yearsTwo types of smears are prepared from the peripheral
...summary... of Plasmodium spp found in Philippines blood. One is called thin smear and the other is called thick
smear. Temperature Chart
Falciparum Vivax/Ovale* Malariae
Thin smears: They are prepared from capillary blood
IP 2 weeks 2 weeks 30 to 40 days • P. malariae
of finger tip and spread over a good quality slide by
Period of 36 to 48 hrs 48 hours 72 hours aosecondFeverslideevery
held 4atdays ® quartan
an angle typefrom
of 30°–45° of fever
the
schizogony Spike
horizontal
o suchinterval is every
that a tail 72 hours (Period of schizogony)
is formed.
Type of fever Malignant tertian / Benign tertian Quartan • A properly made thin film will consist of an unbroken
P. vivax/ovale
Sub-tertian smear of a single layer of red cells, ending in a tongue,
Stages seen in Young trophozoites All stages All stages
o whichFever every 3 days ® benign tertian fever
stops a little short of the edge of the slide.
the PBS and gametocytes o ThinsSchizogonic
smears are period
air dried is rapidly,
every 48 hours
fixed in alcohol
Degree of 100,00/cu mm 50,000/cu mm 15,000/cu mm • P. falciparum
and stained by one of the Romanowsky stains such
parasitemia o as Leishman,
Temperature Giemesa,
is Fields, or JSB stain (named
after Jaswant Singh and Bhattacharjee).
Number of 18 to 24 up to 32 12 to 24 cluster of 6 to 12 cluster of irregular ®
chromatin dots cluster of grapes grapes grapes Thins smears are used for detecting the parasites
andmalignant/sub-
determining the species.
in Mature “rosette pattern” tertian They can be made on the same slide of
Thick smears:
schizont stage
malignant
thin smear fever
or separately.
Affected RBC Young and mature Young only Mature only lm, usually 3 drops of blood are spread Fig. 6.14: Malarial parasite, Plasm
Effect in the Not enlarged Enlarged Not enlarged
o In aPeriod
thick fiof
showing numerous ring stages
over a small area (about 10 mm).
RBC schizogony ® ground s
The amount of blood in thin smear is about 1–1.5 µL, Courtesy: Textbook of Pathology
Strippling Maurer’s / Schuffner’s dot Ziemann’s dots 36intoa 48
while hours
thick smear it is 3–4 µL. Brothe
Cristoferr’s bodies

• P. ovale
• Stripling is Jame’s dot
• P. knowlesi
• No stripling
• P. malariae
• Rosset pattern of chromatin dots

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 *Height of the fever Rupture schizonts__> merozoites mistaken
us as platelets
MEDICAL PARASITOLOGY
s,
4. Pathology, Clinical Symptoms, and Complications Plasmodium Infections (Malaria)
Pathology, Clinical Symptoms and Complication Note:
• In mid-day, the schizont is ruptured due to increase body
temperature ® “period of schizont”
• Cyclic paroxysm on Plasmodium spp.
§ Vivax – q 48 hours
§ Ovale – q 48 hours
m § Malariae – q 72 hours
§ Falciparum – q 36-48 hours
al
ly
e. Life Threatening Malaria
• Conditions:
he § Parasitemia
d o > 100,000/cu mm or multiple infection <5%
in PBS
o presence of mature schizont stage in PBS
§ Hemolysis
o Hgb >7%
o Hct >20%
§ Jaundice
§ Hemorrhage
• Profuse GIT bleeding ® DIC and liver-dependent coagulation § Hypoglycemia with blood sugar level of 60mg/dl or
factor defect less
nt • P. falciparum and Hemoglobinuria ® Black Water Fever § Cerebral malaria
Malarial Paroxysm
Syndrome § Clinical shock – Kidney failure
– Cold stage § Hyperthermia – 40 to 42oC with seizure
FeelingMalarial
of intense Paroxysm
cold
• Cold stageVigorous
– 15 to 60shivering
mins Clinical Features of Severe Malaria
Feeling
§ Lasts forof15-60
intense cold
minutes • Impaired consciousness
– Hot stage§ Vigorous shivering • Prostration
or
§ Intense heat® patient experience intense cold and
Last an hour • Multiple convulsions: more than 2 episodes within 24 hours
uncontrollable
Dry burning skin shivering • Deep breathing and respiratory distress (acidotic breathing)
g • Hot stage – 2 to 6 hours
Throbbing headache • Circulatory collapse or shock, systolic BP of (<80mmhg in adults
§ Intense hear dry burning skin and <50mmhg in children)
§
Usually mid-day
Throbbing headache • Acute kidney injury
§ Lasts formid-day
Usually, 2-6 hours
• Clinical jaundice plus evidence of other vital organ dysfunction
§ With temp peak 41 centigrade or higher
• Abnormal bleeding
§ Occurs on midday
§ Pathology
Note: Complication of Severe Malaria
o AssociatedPage
with2the
of peak
7 of the • Acute renal injury ® ­ BUN and Creatinine
temperature is the rupture of infected red
• Hypoglycemia
cells contains the mature schizont
o The ruptured rbc, the chromatin dots are • Pulmonary Edema
released and free in the circulation and this • Shock
called the merozoites “pathogenic stage of • Seizure
the parasite” • Metabolic Acidosis
• Sweating stage (hyperhidrosis) – 2 to 4 hours • Anemia
§ Profuse sweating
§ Declining temperature
G-6-PD in Malaria
§ Exhausted
• There are drugs that may trigger hemolysis in patients with G6PD
deficiency
Patients Who should be Hospitalized for Malaria
• Know the G6PD
• Positive for the asexual stage of P. falciparum
status of the patient
• Patients showing complications/life-threatening malaria
• Peripheral blood
• Children regardless of the strain of Plasmodia seen in the
smear - >20% HEINZ
peripheral blood smear
bodies significant for
• Pregnant women
diagnosis of G6PD
• Importance is that
Complication of Malaria
some anti-malarial
• (+) for P. falciparum + Drug resistance (R2 or R3) ® resistant
drug induce
against antimalarial drug
hemorrhage in some
• Life threatening condition biochemical
• Level of Drug Resistance (R): disorders
o R1 ® following treatment, parasitemia clears but • Malaria in
after 1 year there is recrudescence occurs Pregnancy ® avoid
o R2 ® following treatment, there is reduction of Primaquine since
parasitemia is not clear the drug might
o R3 ® following treatment there is no reduction of compromise the fetus
parasitemia

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 MEDICAL PARASITOLOGY
Plasmodium Infections (Malaria)
Congenital Malaria • Immunochromatography (malarial strips)
• Parasitemia within 7 days of life manifestation observed several § Similar to pregnancy test
weeks after pre-patent period • Serological examination
• Conatal or Neonatal Malaria § Note helpful because they do not differentiate
§ Observed during active labor between an activity of infection
§ Parasitemia after 7 days but no more than 28 days of • Blood Smears – still serve as the Gold Standard of Dx of malaria
life
§ Manifestation observed in the later course of the Clinical Assessment
disease • Notice the degree of anemia in Malaria ® palpebral are of the
eye
Malaria and Babesia 79 • Organomegaly observed during abdominal palpation in child with
acute malarial infection
eactivation of hypnozoites leads The thick film is dried and kept in a koplin jar for
rocytic cycles and new attacks 5–10 minutes for dehemoglobuliniation.
w attacks of malaria, caused by It is not fixed in methanol.
ms, reactivated usually from 24 Thick film is stained similar to thin film.
imary attack are called relapses The stained film is examined under the oil immersion
microscope.
The thick film is more sensitive, when examined
tween Recrudescence and by an experienced person, because it concentrates
20–30 layers of blood cells in a small area.
Thick film is more suitable for rapid detection of
Relapse
malarial parasite, particularly when they are few (as • Jaundice n patient with P. falciparum malaria
Seen in P. vivax and low as 20 parasites/µL).
P. ovale • Note: blackish discoloration of the urine in P. falciparum
The dehemoglobinized and stained thick film does
Due to reactivation of not show any red cells, but only leucocytes, and, when
hypnozoites present in liver cells
present, the parasites. But the parasites are often
distorted in form, and as the diagnostic changes
Occurs usually 24 weeks to 5
in blood cells such as enlargement and stippling
years after the primary attack
cannot be made out, species identification is
Can be prevented by giving difficult.
primaquine to eradicate Diagnosis
hypnozoites
Thin film is examined first at the tail end and if
• Thin and thick smear
parasites – gold
are found, standard
there is no need for examining
§ thickIndication: parasite
film. If parasites count
are not and malarial
detected in thin film,density
then thick film should be examined. • Black water fever syndrome
§ Note: single negative per blood smear cannot rule out
osis It is recommended that 200 oil immersion fields
malaria
should be examined before a thick film is declared o Rare but serious complication or malaria that is a
asite by Microscopy Best time
§ negative to collect: peak time of fever
(Fig. 6.14). consequence of antimalarial treatment (inadequate
be made by demonstration of treatment of quinine) blackish discoloration of urine
d.
e prepared from the peripheral o Presence of hemoglobinuria
ear and the other is called thick • Algid Malaria (shocked)
o Peripheral circulatory failure ® weak thready pulse
prepared from capillary blood
d over a good quality slide by and cold clammy skin
an angle of 30°–45° from the • Septicemic malaria
il is formed.
74 Textbook of Medical Parasitology o Death case of 80%
n film will consist of an unbroken
r of red cells, ending in a tongue, o High continuous fever with dissemination of malarial
hort of the edge of the slide. parasite in various organ leading to multi-organ failure
dried rapidly, fixed in alcohol
• Brain (cerebral malaria)
of the Romanowsky stains such
sa, Fields, or JSB stain (named o Clostridium tetani infection
and Bhattacharjee). § Signs and symptoms: headache,
ed for detecting the parasites hyperpyrexia, paralysis, confusion
e species.
be made on the same slide of § Gross: flattening of the gyri and narrowing
of sulci
ly 3 drops of blood are spread Fig. 6.14: Malarial parasite, Plasmodium falciparum, in the peripheral blood
showing numerous ring stages and a crescent of gametocyte. The back- § Histology: congestion of micro vessels
out 10 mm). • Quantitative buffyground coatshows(QBC)a normoblast.
d in thin smear is about 1–1.5 µL, Courtesy: Textbook of Pathology, Harsh Mohan, 6th ed. New Delhi: Jaypee containing numerous red cells some of it
r it is 3–4 µL. § Numerous immunofluorescent
Brothers, 2013(R), p. 314 elements in the buffy contains the parasite and hemozoin
coat represent the parasite pigment (pathognomonic sign of malaria)
§ Advantage: faster and more sensitive than thick blood • Liver
smear o Hepatomegaly
§ Disadvantage: less sensitive it is less sensitive than § Due to hypertrophy and hyperplasia of
thick film and is expensive Von-Kupffer cell
• Spleen
o Splenomegaly
Distended
§ stain,
Fig. 6.12: Plasmodium ovale stages of erythrocytic schizogony (Giemsa magn x 2000) splenic capsule
Mixed infection with P. vivax and P. falciparum is the
§ Precaution: gentle palpate the area
most common combination with a tendency for one or
the other to predominate
The clinical picture may be atypical with bouts of fever
occurring daily
Diagnosis may be made by demonstrating the
characteristic parasitic forms in thin blood smears.
The characteristics of the 4 species of plasmodia
infecting man are listed in Table 6.3.

Pathogenesis
All clinical manifestation in malaria are due to products of
erythrocytic schizogony and the host’s reaction to them.
The disease process in malaria occurs due to the local
or systemic response of the host to parasite antigens
• Florescent antibody test (FAT) and tissue hypoxia caused by reduced oxygen delivery
because of obstruction of blood flow by the parasitized
§ Platform that utilizes acridine orange dye in theerythrocytes.
Liver is enlarged and congested. Kupffer cells are
diagnosis of malaria increased and filled with parasites. Hemozoin pigments
are also found in the parenchymal cells (Fig. 6.13). Fig. 6.13: Major pathological changes in organs in malaria

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 80 Textbook of Medical Parasitology
MEDICAL PARASITOLOGY
Morphological feature of malaria The advantage of QBC is that it is faster and more
sensitive than thick blood smear. Plasmodium Infections (Malaria)
parasites in blood smear
The disadvantage of the test is that it is less sensitive
Malarial
In P. vivax, P. ovale,Density
and P./malariae
Malarial Count
all asexual forms • In parasitological confirmation is not readily available
than thick film and is expensive.
• Use
andthick peripheralcan
gametocytes bloodbesmear
seen in peripheral blood. In § make a blood film and start treatment of severe
A careful smear examination still remains as the
• Compute for theinfection,
P. falciparum degree ofonly parasitemia
ring form to alone
monitoror patient’s
with malaria on the basis of clinical presentation
‘gold standard’ in malaria diagnosis.
response to medication:
gametocytes can be seen.
Ring§ formsCount parasite
of all species while counting
appear 50 WBC
as streaks of using
blue theMicroconcentration
thick Note: NOT Techniqueto Give
cytoplasmsmearwith (# of parasite/50
detached nuclearWBCs)
dots. They are large • Steroid and Mannitol
Countintotal WBCP. (per cuand
mm)P. malariae, and In microconcentration technique, blood sample
These 2isagentscollected have NO ROLE in the treatment of
and§compact P. vivax, ovale, §
Totalwith
WBCs/50 quotient in microhematocrit tube and centrifuged at high
cerebral speed.
malaria
fine§ delicate double chromatin (head-phone
Multiply The sediment is mixed with normal serumCerebral malariaisin adults usually presents in mild
and smear
appearance).
§ In actual number multiple
P. falciparum, of parasites counted
rings with X §
prepared. Though it increases the positivity rate, it changes
‘accole’ forms are seen.
quotient neck stiffness WITHOUT neck rigidity and
the morphology of the parasite.
Gametocytes
§ Degree areofbanana-shaped
parasitemia /cu mm (crescents) in P. photophobia
falciparum and round in P. vivax, P. ovale, and P. malariae.
Enlarged RBCs with Malaria
intracellular coarse brick-red
Culture of Malaria Parasites
Estimated Density Chemoprophylaxis
• stippling (Schuffner’s
Done by Thick smear dots) are characteristic in P. Attempts to culture malaria • parasites
Non-Immune in vitro were started in
vivax. In P. falciparum, RBCs
++++ (+4) 11 toare
100normal
parasitein/HPF
size with 1912 by Bass and Johns, who obtained o limited Personmultiplication
travelling to an endemic area
large red dots (Maurer’s 1dots)
+++ (+3) to 10and sometimes,
parasite / HPF with of human plasmodia. The • breakthrough
Semi-Immune came in 1976 with
basophilic stippling. Careful search in blood should the discovery of a simple methodoby Trager Thoseand who Jensen
came for in an endemic area but have been
++ (+2) 11 to 100 parasites / 100HPF
be made for mixed infections. the continuous culture of P. falciparum.away The technique
for more that has5 years
+ (+1) 1 to 10 parasite / 100HPF
been extended to culture • other species also.
Primigravid
The original method of petridish culture employed
o Living in an endemic area for malaria
a candle jar to provide an atmosphere of 3% oxygen
Quantification of parasites and 10% carbondioxide and a relatively simple culture
Prevention and Control
Quantification of parasites can be done by thick smear. medium supplemented with human, rabbit, or calf
• Health education
serum to maintain infected erythrocytes. Fresh red cells
The counting of parasites are done to an approximate
number in the following method. were added periodically • Eradication
for continuation of mosquitoes
of the growth
+ = 1–10 parasite per 100 thick film fields §
and multiplication of plasmodia. The continuous flow Insecticide
++ = 11–100 parasite per 100 thick film method devised by Trager §enables Repellant
the prolonged
+++ = 1–10 parasite per thick film field maintenance of stock cultures.§ Mosquito nets
++++ = More than 10 parasite per thick film field. Computer-controlled culture systems, introduced
Note: a steady abundant supply of
subsequently, provide
parasites. Several culture • Iflines
patient
havepresented headache, muscle pain, fever and chills
been established
QuantitativePitfall:BuffyMissing
Coat,the Smear
Diagnosis from blood of infected Aotus and monkey
excessiveorsweating directly ® from consider P. falciparum followed by
• The Ask about:
Quantitative buffy coat (QBC) test developed by Becton- human patients. laboratory test Malaria and Babesia 75
§ USA
Dickinson, Areais aofnew
residence
simplified method for diagnosing Schizogony proceeds normally in culture. Gametocytes
Table 6.3: Comparison of the Characteristics of Plasmodia Causing Human Malaria
Travel
malaria,§wherein history:
a small local and
quantity international,
of blood µL) ofand are formed infrequently. Pre-erythrocytic
(50–110leisure P. vivax
stages of
P. falciparum P. malariae P. ovale
blood is spunworkin QBC centrifuge at 12,000 revolutions per some species have been obtained
Hypnozoites Yes
in tissue Nocultures. No Yes

minutes§for 5History
minutes. of blood transfusion Plasmodia retainErythrocyte
theirpreference
infectivityReticulocytes
in culture. Young erythrocytes, but Old erythrocytes Reticulocytes
can infect all stages
Exposure to
§ containing
RBC contaminated
malaria parasites needles
are less dense than Culture of plasmodia provides
Stages found in peripheral
a source Onlyofrings and
Rings, trophozoites,
the As in vivax As in vivax

• Important
normaldifferentials:
RBCs and concentrate just below the buffy coat parasites for study
blood
of their antigenic structure,
schizonts, gametocytes gametocytes
in
Ring stage Large, 2.5 µm, usually Delicate, small, 1.5 µm, Similar to vivax, but Similar to vivax, more
of Sepsis at the top of the erythrocytic column.
§ leucocytes seroepidemiologic surveys, drug single,sensitivity
prominent tests, and and thicker
double chromatin, compact
chromatin multiple rings common,
CNS infection(bacterial
Pre-coating
§ of the tube with and viral)
acridine orange studies in immunoprophylaxis. Accole forms found.
Late trophozoite Large irregular, actively Compact, seldom seen in Band form characteristic Compact, coarse pigment
induces
§ a fluorescence on the parasites, which can
Hepatitis amoeboid, prominent blood smear

readily visualized under the oil immersion Serodiagnosis Schizont

vacuole
then
§ be
Leptospirosis Large filling red cell Small, compact, seldom Medium size Medium size
microscope
§ Severe because
pneumonia the parasite contains DNA, Serodiagnosis is not helpful in clinical diagnosisseen because
in blood smear
Number of merozoites 12–24 in irregular grape- 8–24 grape-like cluster 6–12 in daisy-head or 6–12 irregularly arranged
but
§ the mature RBCs do not contain DNA and RNA.
Dengue they will not differentiate between like an
cluster active and past rosette pattern

The Typhoidof the parasite is detected by acridine infection. It is usedMicrogametocyte

§ nucleus mainly for seroepidemiological survey
Spherical, compact, pale Sausage or banana-
blue cytoplasm, diffuse shaped pale blue or pink
As in vivax As in vivax

orange stains and appears as fluorescing greenish- and to identify the infected donorsnucleus in transfusioncytoplasm, malaria.
nucleus
large diffuse

yellow against
Drugs red background.
for Severe Malaria (First-Line) The tests used are indirect hemagglutination
Macrogametocyte Large, spherical, deep (IHA),
Crescentic, deep blue As in vivax As in vivax
blue cytoplasm, compact cytoplasm, compact
• WHO guidelines nucleus nucleus
Infected erythrocyte Enlarged, pale, with Normal size, Maurer’s Normal, occasionally Enlarged, oval fimbriated,
§ Artesunate Schuffner’s dots clefts, sometimes Ziemann’s stippling prominent Schuffner’s
basophilic stippling dots
• Philippine Guidelines Duration of schizogony 2 2 3 2
§ Quinine given as 20mg salt/kg on administration then (days)
Prepatent period (days) 8 5 13 9
10mg/kg q 8 hours Average incubation period 14 12 30 14
§ If Quinine has to be given IM, inject on the anterior (days)
Appearance of gametocyte 4–5 10–12 11–14 5–6
thigh, NOT to buttock ® lead to sciatic nerve injury after parasite patency (days)
Duration of sporogony in 9–10 10–12 25–28 14–16
• Pregnant Women: mosquito (25 C) (days) o

§ Full dose without delay, whatever the stage of the Average duration of
untreated infection (years)
4 2 40 4

pregnancy
Parenchymal cells show fatty degeneration, atrophy, The brain in P. falciparum infection is congested.
and centrilobular necrosis. end Capillaries of the brain are plugged with parasitized
Evolution of Treatment Spleen is soft, moderately enlarged, and congested RBCs. The cut surface of the brain shows slate grey cortex
in acute infection. In chronic cases, spleen is hard with multiple punctiform hemorrhage in subcortical
• Chloroquine and Sulfadoxine + Pyrimethamine (CQ+SP) with a thick capsule and slate grey or dark brown or white matter.
even black in color due to dilated sinusoids, pigment Anemia is caused by destruction of large number of
• Primaquine ® if the patient developed resistance to CQ+SP accumulation, and fibrosis (Fig. 6.13). red cells by complement-mediated and autoimmune
• Quinine (QN) in combination with either Tetracycline or Kidneys are enlarged and congested. Glomeruli
frequently contain malarial pigments and tubules may
hemolysis. Spleen also plays an active role by destroying
a large number of unparasitized erythrocytes. There is
Doxycycline or Clindamycin contain hemoglobin casts (Fig. 6.13). also decreased erythropoiesis in bore marrow due to

• Artemisinin (ACT) ® all Plasmodium species, mixed infections

§ Artemether-Lumefantrine (AL)
§ Artesunate (AS) suppository ® given if oral is not
tolerated

Antimalarials for Severe Malaria

• Use parenteral antimalarial for a minimum of 24 hours
• Replace with oral medications as soon as these can be tolerated

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