PLASMODIUM
Taxonomy
Phylum Apicomplexa
Subphylum Sporozoa
Genus Plasmodium
Disease Malaria
Geographical Tropical &
distribution Subtropical countries
Genus Plasmodium
2 subgenera
PLASMODIUM LAVERANIA
P.vivax
P. malariae P.
P. ovale falciparum
Landmarks in the evolution of Malaria
1880 – Laveran identified the malarial parasite in
an unstained smear
1885 – Golgi described the blood stage
(erythrocytic schizogony) of malarial
parasite – Golgi cycle
1898 – Amigo & Grassi described the life cycle
1891 – Romanowsky introduced the staining
method
1897 – Ronald Ross while in Calcutta, India,
demonstrated Anopheles sp. of
mosquitoes as
vectors of malaria.
Got Nobel prize for his work in 1902
Transmission & Life Cycle
Definitive host Female Anopheles mosquito
Intermediate host Man
Infective form Sporozoites
Portal of entry Skin
Mode of transmission Bite of an infected mosquito
Site of localization First in liver cells & then in
RBCs
Phases of Development in Man
2 phases of development
1. Inside the liver (tissue phase)
Pre- erythrocytic schizogony – no clinical
symptoms, no pathological damage
Exo- erythrocytic schizogony – cause of
relapse
2. Inside the RBCs (erythrocytic phase)
Erythrocytic schizogony – cause of
malarial paroxsyms
Gametogony – infects mosquito
Morphological forms seen in Humans
In liver:
1. Sporozoites
2. Pre erythrocytic schizonts
3. Merozoites – infect RBCs
In RBCs :
1. Trophozoites – ring form
2. Schizonts
3. Merozoites – released by the rupture of
schizonts – infect other RBCs
4. Gametocytes – micro and macro
gametocytes
Morphological forms seen in Mosquito
Further differentiation & development of
gametocytes take place in mosquito
1. Macro gametes (female gametes) – each
macro gametocyte develops in to one
macro gamete in the mid gut of mosquito
2. Micro gametes (male gametes) – one
micro gametocyte produces 6 to 8 micro
gametes by exflagellation.
3. Zygote – Ookinete – Oocyst – rupture –
release of Sporozoites – predilection to
salivary glands.
Other modes of transmission
Sporozoite- induced- malaria : injection of
an emulsion of salivary glands of mosquito
containing sporozoites
Trophozoite- induced- malaria : injection
of blood from a malarial patient containing
the asexual forms of erythrocytic
schizogony e.g.
1. Transfusion malaria – when persons with
latent infection are used as donors
2. Congenital malaria – transmission through
some placental defects (a healthy placenta
acts as a physiological barrier)
3. Drug addicts – by using same syringe
PATHOGENICITY
Infection causes intermittent fever – Malaria
Each of the 4 species causes a characteristic
fever:
1. P. vivax Benign tertian/ vivax
malaria
2. P. falciparum Malignant tertian/
falciparum malaria, black water fever
3. P. malariae Quartan malaria
4. P. ovale Tertian/ Ovale malaria
INCUBATION PERIOD is generally 9-30 days
Shortest in P. falciparum – 12 days
Longest in P. malariae – 28-30 days
In P.vivax and P.ovale – 13-17 days
Clinical Features
Series of febrile paroxysms – fever is
caused by the release of merozoites &
toxins from ruptured erythrocytic
schizont which in turn causes the release
of cytokines.
Quartan malaria – every 72 hrs
Tertian malaria - every 48 hrs
Febrile paroxysms
Shows 3 stages
1. cold stage- lasts for 15-60 min;characterised by
intense cold and uncontrolled shivering
2. hot stage- lasts 2-6hrs (high temp., body & joint
pains, vomiting & diarrhoea)
3. perspiration stage – lasts 2-3 hours(fall in
temp.)
Clinical Features
Anaemia – due to breakdown of RBCs,
particularly occurs in falciparum malaria
Splenomegaly – all forms
FALCIPARUM MALARIA
Most widespread
Accounts for 80% of malaria cases
worldwide
Most pathogenic of human malaria species
Untreated infections - severe disease & even
death, particularly in young children,
pregnant woman & non immune adults.
Complications of Falciparum malaria
Severe falciparum malaria is associated with
Pernicious malaria [malignant malaria]- is the
complication; clinically presented as follows
A. cerebral malaria – hyperpyrexia, convlsion, coma,
paralysis.
B. Algid malaria- characterised by cold and clammy
skin, peripheral circulatory failure, hypotension.
C. Blackwater fever
D. Anaemia
E. Hypoglycaemia
F. Hypotension
G. Complications in pregnancy
Pernicious Malaria
Def: refers to a series of phenomenon
occurring during infection with P.
falciparum which, if not effectively
treated, threatens the life of the patient
with in 1 to 3 days
In children & non immune adults, can
cause coma & death – Cerebral malaria.
Occurs as a result of capillary blockage.
Black Water Fever
Can also occur in non immune adults
with severe falciparum malaria, and
also as a complication of quinine
therapy.
A rare but acute condition
characterised by sudden & massive
hemolysis of parasitised & non
parasitised RBCs followed by fever and
haemoglobinuria.
Often fatal due to renal failure
Black Water Fever
Urine appears dark red to
brown black due to the
presence of free Hb.
Clinical features –
fever, rigor, aching pains in the loin,
icterus, bilious vomiting, circulatory
collapse, haemoglobinuria & acute renal
failure.
Treatment – Chloroquine, blood
transfusion, peritoneal dialysis in ARF.
Anaemia
Can be severe & occur rapidly, particularly
in young children
Occurs due to destruction of parasitised
RBCs – phagocytosis & destruction in the
spleen
Decreased production of RBCs in the bone
marrow.
Falciparum malaria in Pregnancy
Can result in:
Severe anemia
Low birth weight babies
Greatest risk in 1st pregnancy
Malaria caused by P.vivax,
P.ovale & P.malariae
Rarely life threatening
Relapses/ recurrences are a feature
Recurrences in Malaria
May result from – reinfection or
- due to certain events
related
to the parasite’s life
cycle
Recurrence of Malaria
Two types of recurrences known in
malaria:
1. Recrudescence –
seen in P. falciparum & P. malariae
due to persistence of blood infection (some
erythrocytic forms evade host immunity) even
after clinical illness has subsided.
The numbers may increase later, leading to
reappearance of clinical symptoms
Occur mostly up to one year or so but in P.
malariae, it can occur even after decades
Recurrence of Malaria
2. Relapse
Occurs due to a special form of parasites –
hypnozoites.[ sleeping sporozoites]
Hypnozoites are the sporozoites that
remain dormant after infecting liver
Activated from time to time to initiate pre
erythrocytic schizogony - Exoerythrocytic
schizogony
Occurs in P. vivax AND P. ovale
Genetic factors protecting
against Malaria
Sickle cell anaemia – sickle celled RBCs
are removed by the spleen before the
development of schizonts
Ovalocytosis – RBCs are rigid and they
resist parasitic invasion
Duffy blood group negative individuals –
duffy blood group Ag is the receptor for
the attachment of merozoites of P.vivax
Genetic factors protecting
against Malaria
Newborn infants – natural protection for 1st
few months of life due to high conc. of HbF
in their RBCs.
Beta thalassaemia – protects against
severe falciparum infection
LABORATORY DIAGNOSIS
Microscopy – detecting & identifying
malarial parasites in peripheral blood
films.
Concentrating parasites in venous
blood by centrifugation when they can
not be found in blood films
Using a rapid malaria Ag or enzyme
detection test
Other tests – Hb, PCV, Blood glucose,
total WBC & platelet count.
1. Examination of Blood film
Collection of blood
- best prepared directly from capillary
blood
- in EDTA bulb (used within 30 mins)
Time of collection
- as soon as possible if malaria is
suspected
- before administering antimalarials
- during pyrexial phase
Types of Blood film
Two types:
1. Thick films :
- 30 to 40 times more sensitive than
thin films
- more suitable for detection of malarial
parasite when they are few in
number
- blood is not fixed, RBCs are lysed
during staining (only parasitic forms
will be seen)
Types of Blood film
2. Thin films :
- to confirm the Plasmodium species
- assists in the identification of mixed
infections
- blood is fixed, parasites are seen
within the RBCs
- also helps in assessing the response
to treatment especially in areas
where drug resistance is suspected
(by counting the number of
parasitised RBCs before & after
the treatment)
Making of Thin & Thick films
Fixation & Staining
Fixation – thin films are fixed with absolute
alcohol for 1 to 2 mins.
Staining – films are stained with
Romanowsky stain: giemsa, field’s,
wright’s
Giemsa – 10% solution for 10 mins
Reporting of Blood film
Look for the different morphological
forms of parasite in blood smear:
1. Trophozoites / ring forms
2. Schizont
3. Gametocytes
Identify species – differences in the
characteristics of morphological forms in
different species
TROPHOZOITES / RING FORMS
Character P. vivax P. falciparum
Size 2.5µ (1/3rd of RBC) 1.25 to 1.5 µ
Cytoplasm Thick opposite to Uniform thickness
nucleus
Nucleus One/ ring Can have >1
Number of rings One ring/ RBC >1/ RBC
Location in Always inside Inside as well as on the
RBCs RBCs surface (accole’ forms)
Type of RBC Preferentially All types
infected young RBCs &
reticulocytes
Thin Blood Film Thick Blood Film
Ring Forms /
Trophozoites
SCHIZONT
Character P. vivax P. falciparum
Size of RBC Increases to Does not
twice its size change
No of 16 8 to 32
merozoites
Arrangement Symmetric in Asymmetrical
of merozoites form of rosette
Presence in Present Absent
peripheral
blood
P.falciparum
P. vivax
Gametocytes (male & female)
Character P. vivax P. falciparum
Shape – Male Spherical Cresentic
Female Spherical Sausage shaped
Nucleus - M Central, diffuse Central, diffuse
F Peripheral,small Central,compact
Infected RBC Enlarged Deformed, with
its membrane
stretched.
P.vivax P. falciparum
Counting the % age of
parasitised RBCs
On thin blood films
When falciparum malaria parasitemia is
high
Method of counting:
1. Select an area where no of RBCs is roughly
250.
2. Count the no of parasitised RBCs in 4 such
fields i.e. approximately 1000 RBCs.
3. Divide by 10 to obtain the percentage.
*WHO – if it is >5%, then the
parasitemia is heavy & prognosis is poor.
Buffy Coat preparation
To concentrate malarial parasite
Centrifuge EDTA anticoagulated venous
blood in a thin bore capillary tube
Buffy coat layer is formed between the RBCs
& the plasma.
Break the tube & transfer buffy coat & RBCs
to a slide - make a thin smear – air dry – fix
with ethanol – stain with Giemsa.
Quantitative Buffy Coat
Capillary tube is coated with anticoagulant &
Acridine orange fluorescent dye
After centrifugation, the tube can be used for
two purpose:
1. Complete blood count
2. Identification of malarial parasite using a
fluorescence microscope.
Quantitative Buffy Coat
Rapid Diagnostic tests
Developed to diagnose falciparum
malaria rapidly & without a microscope.
Can also detect vivax malaria
Three tests are available commercially
Detects either HRP2 Ag (Histidine rich
protein) or specific pLDH (parasite lactate
dehydrogenase)
Both HRP2 & pLDH are produced by the
parasites during their growth &
differentiation in RBCs.
Rapid Diagnostic tests
HRP2 tests
detection of P.falciparum
Two types of test – ParaSight F
- ICT Malaria Pf
pLDH test e.g. OptiMAL test
Detection of P.falciparum & P.vivax
Produced by all human malarial
parasites
Differentiation of species is based on
antigenic differences between pLDH
isoforms.
ParaSightF test
Optimal test
ICT Malaria Pf / Pv
Stage specificity of antimalarial drugs
Stage of malarial Antimalarial drug
parasite
Sporozoite Proguanil, Pyrimethamine
Hypnozoite Primaquine
Pre- erythrocytic Proguanil, Pyrimethamine
schizont
Blood schizont Chloroquine, Quinine,
Artemisinin
Gametocyte Primaquine
