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MALARIA SPECIFIC LEARNING

OBJECTIVES
• List different malarial parasites and their vectors.
• Describe the key stages of the parasitic life cycle in humans
and mosquitoes.
• Describe the pathogenesis of malaria
• List clinical features and sequelae of malaria
• Describe the different methods of lab diagnosis
• Compare and contrast malaria and babesia

CAUSATIVE AGENTS
WHAT IS MALARIA?

➔Malaria parasite belongs to

• Parasitic infection due to protozoa
Phylum- Apicomplexa
of genus Plasmodium transmitted by
Class- Sporozoa
the female anopheles mosquito.
Order- Eucoccidea
Suborder- Haemosporina

HOW MANY PLASMODIUM VECTOR

SPECIES CAUSING MALARIA?

• Plasmodium falciparum
Human malaria is transmitted by the
female Anopheles mosquito.
• Plasmodium vivax

• Plasmodium ovale

• Plasmodium malariae

• Plasmodium knowlesi

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LIFE CYCLE OF MALARIAL PARASITE

LIFE CYCLE
2 stages :
➔Asexual phase : humans
Asexual phase – called schizogony occurs in humans. In
➔Sexual phase : female anopheles mosquito humans schizogony occurs in RBC (erythrocytic schizogony) &
in the liver cells ( exo-erythrocytic schizogony or tissue phase).
 Definitive host : female anopheles mosquito
 Intermediate host : humans Sexual phase – called sporogony takes place in the female
anopheles mosquito.

HUMAN PHASE -PRE-ERYTHROCYTIC

SCHIZOGONY
Infected mosquito bites healthy humans.

Sporozoites are introduced into humans.

Sporozoites reach liver & enter hepatocytes where they multiply.

Pre erythrocytic schizont is formed.

LIFE CYCLE OF PLASMODIUM Schizont bursts & releases the pre erythrocytic merozoites.

Pre-erythrocytic Schizogony
In P.vivax & P.ovale , 2 kinds of sporozoites are seen ERYTHROCYTIC CYCLE
Some of which multiply inside the hepatocytes promptly & some
which remain dormant.
• P.vivax – primarily affects young erythrocytes

Hypnozoites are the dormant forms present in the hepatocytes • P. malariae- primarily affects old RBCs
which are activated from time to time to release merozoites , which
go on to infect the RBC's , producing clinical relapses
• P. falciparum infects RBCs of all ages

In P.falciparum & P. malariae no hypnozoites are formed )

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ERYTHROCYTIC STAGE :
MALARIAL PIGMENTS
Exo erythrocytic merozoites attach to RBC's by glycophorin
receptor.
• Parasites feed on hemoglobin.
• It doesn’t metabolize it completely.
RBC's engulf the merozoites by endocytosis.
• The excess protein, iron porphyrin and hematin left over
by parasite after metabolization of Hb, will combine to
form malarial pigment. (Haemozoin pigment) In the RBC's merozoites become rounded forming signet ring
like structure, called the early trophozoite.

Early trophozoite develops to form late trophozoite.

Schuffner’s dots/Maurer’s cleft
Further multiplication occurs to form the schizont with
erythrocytic merozoites.  During the amoeboidal growth of trophozoite, bits of
membrane from the developing parasite accumulate on
the surface of the RBC – appear as stippling or clefts
Erythrocytic schizont bursts & releases the erythrocytic on surface of the RBC, called Schuffner’s dots.
merozoites.

Most of the erythrocytic merozoites are destroyed by host

immune system . Some of them invade fresh RBC's & few of
them develop into gametocytes

RING STAGE:

P. vivax P. falciparum P. ovale

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GAMETOGONY
 Few erythrocytic merozoites develop into gametocytes in
internal organs like the spleen & the bone marrow.

 The macro- gametocytes or the female gametocytes & the

micro- gametocytes or the male gametocytes are formed.
P. vivax
 Macro gametocytes are larger in size while micro
gametocytes are smaller in size.

 These mature gametocytes appear in the peripheral

circulation.

GAMETOCYTES

❖The mature gametocytes are round in shape, except in P.

falciparum, in which they are crescent / sickle shaped.
❖ Female gametocyte (macrogametocyte) in all sp. has dark
blue cytoplasm with small compact deep red nucleus.
❖Male gametocyte (microgametocyte), cytoplasm stains pale
blue or pink, nucleus is larger and diffuse. GAMETOCYTES
❖Gametocytes do not produce any febrile reaction & individual P. vivax P. falciparum
harboring gametocytes are called Carrier

P. falciparum LIFE CYCLE OF PLASMODIUM

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THE MOSQUITO PHASE/ SPOROGONY/ SEXUAL .

CYCLE SPOROGONY

Healthy female anopheles mosquito bites infected person.

Macrogamete fuses with microgamete to produce zygote.

It ingests parasitized erythrocytes along with blood.

Zygote elongates & becomes motile, this form is called

Asexual forms are digested. ookinete.

The male & female gametocytes develop inside the stomach of the mosquito
Ookinete penetrates the epithelial lining of the stomach
Male gametocyte divide to form microgametes & female gametocyte mature wall of the mosquito to form the Oocyst.
to form macrogamete

DIFFERENTIAL CHARACTERISTICS OF
MALARIAL PARASITES
Oocyst ruptures & releases sporozoites. P. vivax P. P. P. ovale
falciparum malariae
Duration of 48 hrs 48 hrs 72 hrs 48 hrs
phase
Enter salivary duct Forms of Trophozoites, Ring forms and As in vivax As in vivax
parasite in schizonts, crescent shaped
peripheral gametocytes gametocytes
blood
Ring form in Large, single ring Multiple ring forms Same as in vivax Same as in
Mosquito is now infective to humans. RBC form & Accole forms (thicker ) vivax, more
compact
Gametocytes Spherical/globular Crescentic / sickle As in vivax As in vivax
SPOROGONY shaped

Infected RBCs Enlarged, Normal size, Normal Slightly

Schuffner’s dots Maurer’s dots Ziemann’s enlarged
stipling Schuffner’s dots

Incubation 14 days 12 days 30 days 14 days

PATHOGENESIS & CLINICAL FEATURES:

CLINICAL FEATURES

All clinical manifestations are due to the rupture of mature

• Incubation period ranges from 9days – 30 days.
schizonts from RBCs – releases merozoites
Benign malaria consists of :
malarial pigment and toxins into circulation
❖ Periodic bouts of fever with rigor

❖ Anaemia (haemolytic) the host reaction

❖ Splenomegaly
Febrile malarial paroxysm.

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CLINICAL FEATURES-FEBRILE FEVER SPIKES

PAROXYSOMES

I. Cold stage: The patient feels intense cold with chill and rigor along • Different species Fever spikes
with headache and nausea.This stage lasts for 15 minutes to I hour. • P. ovale and vivax – tertian malaria------Every 48hrs

• P. malariae – Quartan malaria-----------Every 72hrs

2. Hot stage: The patient feels intensely hot. The temperature mounts to
105 fehernite or higher. Headache persists but nausea commonly • P. falciparum – Malignant tertian malaria—Every 48 hrs
diminishes.This stage lasts for 2- 6 hours.
• P.knowlesi----Quatidian malaria--------Irregular

3. Sweating stage: Profuse sweating follows the hot stage and the
temperature comes down to normal.The skin is cool and moist.

RELAPSE & RECRUDESCENCE:

CAUSES FOR ANEMIA:

❖Haemolysis of infected red cells ➢RELAPSES : In P. vivax & P. ovale infections the
parasites may survive as hypnozoites or dormant forms in
❖Haemolysis of uninfected red cells liver cells .

❖Dyserythropoiesis
➢Reactivation of hypnozoites – initiation of erythrocytic
schizogony & new attack of malarial fever.
❖Splenomegaly, erythrocyte sequestration and
hemodilution

➢24 weeks to 5 years after primary attack

❖Recrudescence: The occurrence of clinical malaria

caused by Plasmodium persisting in the circulation Malignant Tertian Malaria
at a subclinical level following a previous attack. Sequestration
❖Can be caused by all the four sp. ; more commonly Cytoadherence- mediated by P. falciparum
by P. falciparum & P.malariae erythrocyte membrane protein-1 (PfEMP-1).
❖Can occur due to:
ROSETTING: binding of infected RBCs to uninfected
• Waning immunity of the host RBCs.
• Antigenic variation in parasite
Escape splenic clearance
• Inadequate drug therapy
Blockage of vessels, congestion, hypoxia of
• Drug resistance
internal organs.

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MALIGNANT TERTIAN MALARIA

Rosetting &
COMPLICATIONS - FALCIPARUM MALARIA
sequestration

Severe form, with Parasitemia >100,000

parasites/microL of blood,
>5-10% parasitized RBCs
Cerebral malaria-coma, confusion
Pernicious malaria

PERNICIOUS MALARIA: PERNICIOUS MALARIA:

• life threatening complications

Due to: • Algid malaria – hypotension, cold skin & shock .
❖Alteration of red cell membrane- deformed RBCs • Septicemia
become sticky- adhere – sequestration of red cells in
capillaries- block • Black water fever- malarial haemoglobinuria in
❖ High level parasitaemia – 30-40% red cells which patients may pass dark red or black urine
affected. due to intravascular haemolysis.

EXAMINATION OF
LABORATORY DIAGNOSIS : PERIPHERAL BLOOD SMEAR
• 2 types of blood films are prepared for
examination:
•The most important method for the diagnosis of malaria is the
demonstration of the parasite in the blood.
• Thick blood films : for quantitative estimate of the
parasite.
•The parasites are most abundant - few hrs after the peak of the • Thin blood films : for species identification.
fever-Ideal time for collection.

Stains : Leishman’s, Giemsa and

Field’s,Wright’s or JSB stain

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DIFFERENTIAL CHARACTERISTICS OF
MALARIAL PARASITES-PBS
P. vivax P. P. P. ovale
falciparum malariae
Forms of Trophozoites, Ring forms and As in vivax As in vivax
parasite in schizonts, crescent shaped
peripheral gametocytes gametocytes
blood
Ring form in Large, single ring Multiple ring forms Same as in vivax Same as in
RBC form & Accole forms (thicker ) vivax, more
compact
Gametocytes Spherical/globular Crescentic / sickle As in vivax As in vivax
shaped

Infected RBCs Enlarged, Normal size, Normal Slightly

Schuffner’s dots Maurer’s dots Ziemann’s enlarged
stipling Schuffner’s dots

QUANTITATIVE BUFFY QBC capillary

COAT EXAMINATION tube
Red blood cell
containing
• Blood (60 µL) is collected in a capillary tube coated malaria parasites
internally with acridine orange.
• Capillary tube is centrifuged - causes separation of
components of blood -RBCs, WBCs, lymphocytes and
platelets
• Examination of capillary tube at the buffy coat region
under the fluorescent microscope.

ANTIGEN DETECTION BY ANTIGEN DETECTION BY

RAPID DIAGNOSTIC TESTS RAPID DIAGNOSTIC TESTS

• Parasite lactate dehydrogenase (pLDH): trophozoites

and gametocytes of all Plasmodium species.

• Parasite aldolase: all Plasmodium species.

• Plasmodium falciparum specific histidine rich protein-2

(Pf-HRP-II): trophozoites and young gametocytes of P.
falciparum

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VECTOR CONTROL STRATEGIES VECTOR CONTROL STRATEGIES

(CONT..)
▰ Anti-larval measures
▰ Anti-adult measures ➢ Larvicide: Use of mineral oil or Paris green to kill mosquito larvae and
➢ Residual insecticide spraying: Dichloro pupae
diphenyltrichloroethane (DDT), malathion and fenitrothion is ➢ Source reduction (mosquito breeding sites): Includes environmental
highly effective against adult mosquito sanitation, water management and improvement of the drainage
➢ Space application of pesticide in the form of fog system.

➢ Individual protection: by using insecticide treated bed nets, ➢ Biological larvicide: Gambusia affinis (fish) and Bacillus thuringiensis
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repellents and protective clothing. (bacteria) can be used to kill the mosquito larva.

BABESIOSIS

 Malaria like illness seen in cattle and sheep.

 B. microti - most common species, others being B. bovis and B.

divergens.

 It is similar to malaria parasite in its life cycle and pathogenesis

BABESIOSIS except for the following differences:

➢ Hard tick (Ixodes scapularis) is the primary vector (definitive
51 host) of the parasite. 52

BABESIOSIS (CONT..) BABESIOSIS (CONT..)

❖ No liver-stage, sporozoites enter directly into RBCs ➢ Diagnosis: Peripheral blood smear examination reveals ring
forms inside RBC arranged in pair or tetrads (called as
❖ Clinical feature: It differs from falciparum malaria being less Maltese cross forms)

severe, low parasitemia, no cerebral involvement, less severe ➢ Confused with the multiple ring forms of P. falciparum

anemia and no periodicity seen in fever cycle. ➢ Differentiated by lack of pigments and lack of crescentic
gametocytes.
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BABESIOSIS (CONT..)

Giemsa stained blood smear showing Maltese cross form: A. Schematic diagram;
B. Peripheral blood smear
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