Malaria
★ Malaria is the most important of all tropical parasitic disease ,causes death and debility
and is endemic throughout the tropics and subtropics. The main symptoms and signs are
periodic fever, headache ,anorexia and anemia.
★ Five species of malaria infect humans:
➔ Plasmodium falciparum
➔ Plasmodium vivax
➔ Plasmodium ovale
➔ Plasmodium malariae
➔ Plasmodium knowlesi
Epidemiology
Asexual Stage sporozoites are injected by an infected Anopheles Mosquito into the blood
of human and enter liver cells and will become schizonts then become
Merozoites whish release in the circulation and penetrate the Red Blood Cell
and cause the main pathology of the disease hemolysis and anemia . Some
parasites develop
into male and female Gametocyte
Sexual Stage male and female Gametocyte are taken up from the blood of an infected
human by biting mosquito .Further sexual development takes place in the
mosquito gut to produce SPOROZOITES.
Human to human transmission can occur by blood transfusion or vertical transmission across
the placenta.
Sporozoites in mosquito
saliva Mosquito bites uninfected
human
Sporozoites enter bloodstreem and
Mosquito bites infected migrate to liver, infecting hepatocytes
human
Merozoites released, infect
Symptoms occur erythrocytes (Fever results from escape
+ reinfection of Merozoites)
*It like to stay mainly in
Erythrocytes become sticky brain and kidney = coma and
renal failure
This video was shown by doctor mona so
we advise you to watch it :)
Life Cycle of Malaria:
*Time when rupture happens and the infected person starts to get FEVER
Plasmodium Malariae 72hrs quartan because at the fourth day they will have fever
Plasmodium Vivax & 48hrs tertian
Plasmodium Ovale
Plasmodium Falciparum Quotidian, tertian or irregular
(could have fever every 3 or 4 days or could be irregular)
Components of the Malaria Life Cycle:
Fever
Clinical Signs & Symptoms
Sw
ea
ills
tin
Ch
g
Malarial Paroxysm
Cold stage - Feeling of intense cold
- Vigorous shivering
- Lasts 15-60 minutes
Hot stage - Intense heat
- Dry burning skin
- Throbbing headache
- Lasts 2-6 hours
Sweating stage - Profuse sweating
- Declining temperature
- Exhausted and weak → sleep
- Lasts 2-4 hours
Pathogenesis of Malaria
Symptoms are due to:
- Hemolysis of Red Blood Cells :
with release of metabolites and pigments from Malaria parasite.
- Plugging of capillaries by parasitized erythrocytes : in P. falciparum
In cerebral malaria there is sequestration of parasites in central nervous system
capillaries.
Anemia
Tissue Anoxia
Localized decreased
microcirculation
Clinical Picture
Acute Disease Non severe acute febrile Severe malaria e.g.
Death
(in P. falciparum) disease cerebral malaria
Developmental
Chronic Asymptomatic
Chronic Disease Infection
Anemia Disorders;
Transfusions; Death
Low Birth weight
Infection During
Chronic Disease Pregnancy (very fatal)
Placental Malaria Increased Infant
Mortality
Complications of Severe Malaria
Severe malaria is defined as symptomatic malaria in a patient with P. falciparum with
one or more of the following complications:
Complication Description
- Generalized convulsions (> 2 episodes within 24 hours)
- Severe normocytic anemia (Ht<15% or Hb < 5 g/dl)
Cerebral Malaria
- Opisthotonos in an unrousable comatose child with cerebral
malaria. The CSF fluid count was normal
- In pregnancy can lead to abortion, stillbirth seen in tropical
africa.
Hypoglycemia and -Metabolic acidosis with respiratory distress (arterial pH < 7.35 or
Pulmonary Edema bicarbonate
< 15 mmol/l)
-Fluid and electrolyte disturbances
- Acute pulmonary edema and adult respiratory distress
syndrome
- Abnormal bleeding
Acute Renal - Jaundice
Failure - Haemoglobinuria (uncommon and malarial hemoglobinuria
(Black water usually presents in adults as severe disease with anemia and
fever) renal failure).
- Circulatory collapse, shock, septicaema (algid malaria)
- Hyperparasitaemia (>10% in non-immune; >20% in
semi-immune)
Tropical -
Splenomegaly
- It can present with other complications (Such as acidosis and
Severe Malaria respiratory distress) or alone with no other malaria
Anemia complications
- Usually seen with children?
Uncomplicated malaria is defined as: symptomatic infection with malaria parasitemia
without signs of severity and/ or evidence if vital organ dysfunction.
Diagnosis of Malaria
Two common methods are used which are
1. Light microscopy (thin & thick film) 2. Rapid diagnostic Tests (RDTs)
- Thick film → for screening - It is used to detect malaria antigens
- Thin film → for identifying the type It and there are number of different
is the gold standard for diagnosis of formats of this test:
Malaria - Plastic Cassette
- Parasite density - Card
- Species diagnosis - Dipstick
- Monitoring response to treatment - Hybrid Cassette-dipsticks
* When we have two ring stages inside one
The Malaria Parasite RBC this means its P. falciparum
Three development stages seen in blood film: This is the ring stage
1. Trophozoite (merozoite)
2. Schizont (a cell full of merozoite)
3. Gametocyte (male and female sitting in the RBCs) *
Anti-relapse (P.vivax) Sporontocides
- Primaquine - Primaquine
- Pyrimethamine
- Proguanil
Treatment
Blood Schizonticides Gametocide
- Chloroquine - Primaquine
- Sulfadoxine/Pyrim
ethamine
- Quinine
- Artemisinins
Tissue Schizonticides
- Primaquine
- Pyrimethamine
- Tetracycline
- Proguanil
Doctor’s Notes
- There are 5 species of malaria and plasmodium falciparum has the most severe
clinical picture, the most severe complications and the most fatal one.
- It’s caused by a protozoa so it’s unicellular
- The mosquito has the ability to drink as much blood is it want when it bite a human
bc it has anticoagulant
- Main pathology of malaria? RBCs
- The sporozoites are found in the salivary gland of the mosquito
- Main transmission? mosquito bite but it could occur by blood transfusion and human
to human
- Infective stage for human? Sporozoites
- Infective stage for anopheles? Gametocyte
- Vector? Female anopheles mosquito
- Stages:
1. asexual stage (intermediate hots) → human
a. After getting a bite from the mosquito it will introduce sporozoites into the human
blood → they immediately go to the liver → become schizonts then multiplied to
become merozoite → the merozoite go to the circulation and attack RBCs and
make them undergo hemolysis and causes anemia
i. Inside the RBCs the merozoite will divide till it rupture the cell (this process
takes 48 hours in P. falciparum, P. vivax & P. ovale / 72 hours in P. malariae / 24
hours in P. knowlesi)
ii. Why this process is important? Bc in case of P. falciparum, every 2 days the RBCs
will rupture and here is when the person will start feeling the fever
iii. Some sprotozite would hide in the form of hypnozoites in the hepatocytes for 10
months then get activated and invade the RBCs (relapse)
iv. In case of P. falciparum the RBCs filled with merozoite would get attached to the
capillaries of specific organs mainly kidney and brain → this cause sequestration
and the blood won’t be able to reach the kidney so result in renal failure & in
case of brain it will result in coma and death
- Also in P. falciparum the replication is very fast and infect more RBCs
v. Some merozoite will become gametocyte (male & female) within the RBCs
2. sexual stage (definitive host) → anopheles mosquito
a. When another uninfected mosquito bite someone who’s infected → it will take
gametocyte from the blood and become infected
Doctor’s Notes
- How to differentiate between TB and malaria from the symptoms? TB doesn’t
cause chills before the fever
- What's the pathogenesis of malaria? Symptoms occur when the RBCs rupture
- What's the most affected organ? RBCs
- The main complication of P. falciparum? Renal failure or black water fever
- Diagnosis:
- In light microscopy: first we take a blood sample and by using the thick film
we will be able to tell if this person has malaria or not → then we will use the
thin film on the same sample to identify the type
Summary
Malaria
Human: sporozoites
Infective stage Vector: Female Anopheles Intermediate host Human
Mosquito: Gametocyte
(definitive host) Mosquito
1-Hemolysis of RBCs Sporozoites are injected into the blood and enter liver cells
2-Plugging of capillaries and will become schizonts → Merozoites penetrate the RBCs
by parasitized and → hemolysis and anemia. Some develop into male and
Main erythrocytes (mainly in P. Life cycle:
female Gametocyte → they are taken up mosquito →
pathology falciparum)
Further sexual development in the mosquito to produce
sporozoites.
Symptoms Malarial Paroxysm (feeling of cold followed by heat then sweating)
periodic fever, headache ,anorexia and anemia.
Species Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium Plasmodium
malariae knowlesi
Type of fever Quotidian, tertian or 48h (tertian) 72h quartan -
irregular
Clinically Acute Disease Chronic Disease
Severe malaria: Non-severe Acute Infection during Chronic
symptomatic malaria Febrile disease Pregnancy lead to placental malaria Asymptomatic
caused by P. falciparum →Low Birth weight →Infant Mortality Infection lead to
with one complications anemia
or more
● Acute renal failure
(blackwater fever)
● Cerebral malaria
● Hypo-glycaemia and
Complications - - - -
pulmonary edema in
pregnancy can lead to
abortion
● Tropical splenomegaly.
● Light microscopy: (gold standard)
-Thin film: for different spices identification.
Diagnosis -Thick film: for screening.
● Rapid diagnostic tests (RDTs).
● serology
● PCR
Treatment Primaquine - Chloroquine
MCQs: 4- Which of the following could lead to
blackwater fever ?
A- P.knowlesi.
1- What is the main organ affected in malaria B- P.malariae.
infection? C- P.falciparum.
A- Liver. D- P.vivax.
B- kidney.
C- RBCs. 5-What is the gold standard method to diagnose
D- intestine. malaria ?
A- RDTs.
2- Patient comes to the ER complaining of B- Light microscope.
headache, fever that comes and goes every 3 C- PCR .
days. She most likely have which of the D- Serology.
following pathogen?
A- Plasmodium falciparum.
B- Plasmodium malariae. 6- Which of the following cause malaria infection
C- Plasmodium vivax. to human and mosquito ?
D- Plasmodium ovale. A- Sporozoites only.
B- Sporozoites,Gametocyte .
3- Sporozoites when injected into the human C- Gametocyte ,Sporozoites.
skin it migrates to? D- Gametocyte only.
A- Hepatocytes.
B- Intestinal wall.
C- Macrophages.
D-Lymphocytes.
6-B 3-A
SAQ:
5-B 2-B
4-C 1-C
- A patient presented with hemoglobinuria, convulsions and respiratory distress. Microscope
examination show schizont.
1- What is your diagnosis?
Malaria
2- What is the pathogen ?
P.falciparum
3- How do you confirm which type of pathogen?
By light microscope using thin film
4- Mention other test you could do to confirm your diagnosis?
Rapid diagnostic tests (RDTs).
serology
PCR
5- mention other complication?
Acute renal failure ( blackwater fever) - Tropical splenomegaly - Acute pulmonary edema
6- Treatment ?
Primaquine - Chloroquine
ALANOUD AL-MANSOUR & KHALED AL-OQEELY
ASEEL BADUKHON
NADA AL-OBAID
REEM AL-QAHTANI
SARA AL-SULTAN
