PLASMODIA SPECIES

Introduction
 Name malaria (mal bad, aria-air)- 18th century in Italy => foul emanations
from the marshy soil.
 Specific causative agent discovered in RBCs of a patient in 1880 by Alphonse
Laveran, a French army surgeon in Algeria.
 Romanowsky - Russia in 1891- staining method in blood films
 Blood parasites of the genus Plasmodium
 Most important parasitic disease of mankind.
 2018: estimated 228 million cases worldwide, deaths: 405 000.
 Kenya: 3.5 million new clinical cases and 10,700 deaths per year vs
approximately 2,000 cases each year in the US- returning travelers and
immigrants ("imported" malaria). Previously worldwide, now confined to tropical and
subtropical areas of Asia, Africa, South and C. America.
Classification
 Phylum-Apicomplexa Class-Sporozoea Order- Eucoccidea
 Genus Plasmodium- divided into 2 subgenera;
 Subgenus: Plasmodium-P. vivax, P. malariae and P. ovale
 Subgenus Laverania - P. falciparum ( differs from the other 3
spp)
 P. falciparum more related to bird malaria parasites, a
recent parasite of humans in evolutionary terms.
 ?For this reason causes the severest form of malaria +is responsible for nearly all fatal
cases.

Classification..
 Approx. 156 named species which infect various vertebrates.
 Above 4 -true parasites of humans – use humans almost Exclusively as a natural
intermediate host.
 Reports of simian malaria parasites being found in humans- P. knowlesi, considered
zoonotic. Others affecting monkeys: P.cyanomolgi, P.inui.
 Species infecting birds: P.gallinaceum and P.elongatum
Epidemiology
> Transmission does not occur at temperatures below 16°C, or above 33°C, and at altitudes
>2000m because development in the mosquito (sporogony) cannot take place.
> Optimum transmission conditions: high humidity and Temperatures between 20 and 30°C.
>Rainfall provides mosquito breeding sites though in Excess may wash away mosquito larvae
and pupae.
> Restricted to tropical and subtropical areas.
Epidemiology..Kenya
Endemic: altitudes ranging from 0- 1,300 metres around L. Victoria and in the coastal regions.
Rainfall, temperature and Humidity are the determinants of the perennial transmission.
Seasonal transmission: Arid and semi-arid areas of N and SE Parts of the country- short
periods of intense malaria Transmission during the rainfall seasons.
Epidemic outbreaks: T morbidity rates due to immune Status of the population in extreme
conditions ie. El nino. Wn Highlands.
Low risk malaria areas: central highlands of Kenya including Nairobi. Temperatures are
usually too low to allow completion Of the sporogonic cycle.
Epidemiology..
 P.falciparum-predominant worldwide.
 P. ovale -Sub-Saharan Africa and P. vivax in the other Areas; but their geographical
ranges do overlap.
 P. malariae -wide global distribution: S.America, Asia, And Africa, but it is less frequent
than P. falciparum in Terms of association with cases of infection
 P. knowlesi is found in S.E Asia.

Vectors
Human malaria: transmitted by the female Anopheles Mosquito- needs at least two blood meals
before the first Batch of eggs can be laid.
Male mosquito feeds exclusively on fruit juices.
Animal parasites (apes, monkeys, rodents- transmitted by
Anopheles, but bird malaria parasites are carried by Culex, Aedes and other genera of mosquitoes
Life Cycle
Two stages:
a) Asexual phase- in humans.
> 10-15 sporozoites are injected at a time, occasionally many hundreds. Many are destroyed by
the phagocytes, but some reach the liver within an hour.
> Parasite multiplies by division/splitting=> or splitting, schizogony (from schizo-to split, and
gone-generation). Also called thee vertebrate, intrinsic or endogenous phase.
> Occurs in 2 locations-RBC (erythrocytic schizogony) and in liver cells (exoerythrocytic
schizogony or tissue phase or pre-erythrocytic schizogony)
> The products of schizogony in both locations=>merozoites (meros-a part, zoon-animal).
Tissue Stage
▪️In 5.5 to 15 days the liver schizont matures and bursts, releasing thousands of merozoites.
Merozoites enter the bloodstream and infect RBCs by invagination.
▪️Interval between the entry of the sporozoites into the body and the first appearance of the
parasites in blood: prepatent period.
▪️Duration of pre-erythrocytic phase in the liver, size of mature schizont and number of
merozoites produced vary with the species.
▪️Only a few liver cells are infected- usually asymptomatic for the human host.
Tissue stage….
▪️In P.vivax and P. ovale: 2 kinds of sporozoites-those that form schizonts and others which
remain dormant.
▪️Latter forms => hypnozoites (from hypnos-sleep). Remain in hepatocytes as uninucleated
forms for long periods.
▪️From time-to-time, some are activated (after weeks to years) to become schizonts=> release
merozoites=> infect RBCs=> clinical relapses.
▪️In P.falciparum and P.malariae: no hypnozoites form but a small no. of erythrocytic parasites
persist in the bloodstream=> multiply with time to cause clinical disease (recrudescence or
short-term relapse).
▪️In falciparum-1-2 yrs, P.malariae long periods, even up to 50 years.
• In RBCs appear as
young annular
▪️Forms called ‘ring
forms/early
Trophozoites’.
▪️Feed on Hb but does
not Metabolise it
completely,so Leaves
behind as residue a
Haematin-globin
pigment=> Malaria pigment (formerly known As haemozoin pigment). Appearance differs in
species.
▪️ Ring form develops to an Irregular shaped stage amoeboid Form/late trophozoite.
• Suitable RBCs: P. vivax and P. Falciparum prefer younger ones And P. malariae prefers older
Cells.
• Nuclear division starts
and forms the
Schizont/meront
(formerly rosette Forms)
which eventually
releases Merozoites.
▪️Rupture of the mature
schizont Releases large
quantities of
Pyrogens=> febrile
paroxysms
▪️Interval between the
entry of Sporozoite into
the host and the earliest
manifestation of clinical
Illness: incubation
period.
▪️Schizogonic
periodicity: about Hours
in P.vivax, P. falciparum
and P. ovale while in
P.malariae it is 72 Hours.

Periodicity
> P.vivax: Benign tertian or BT malaria. (Tertian- fever recurs every 3rd day- Greek/ Roman
counting system). Benign- relatively less dangerous than falciparum malaria.
> P.falciparum: Malignant tertian or MT malaria. (Or subtertian). Poorly synchronised cycles
and febrile paroxysms recur at intervals of less than the expected 48 hours.
> P. ovale: Ovale tertian (Tertian periodicity and the irregular oval shape of infected RBCs).
> P. malariae: Quartan malaria- occurring every 4th day.
Gametogony
▪️After a few cycles of erythrocytic schizogony, some merozoites don't become schizonts but
develop into sexually differentiated forms, the gametocytes.
▪️Generally occurs in internal organs ie. spleen and bone marrow, and only the mature forms
appear in circulation.
▪️Mature gametocytes : round except P.falciparum- crescent- shaped.
▪️Female-larger (macrogametocyte),male-smaller (microgametocyte).
▪️A person with gametocytes in circulation is a carrier or reservoir.
▪️Do not cause any clinical illness .Do not develop further in the vertebrate, die in a few days if
not taken up by mosquito.
▪️A gametocyte concentration of 12 or more /mm³ of blood in the human host is necessary for
mosquitoes to become infected.
Mosquito phase
▪️Asexual forms are digested, gametocytes set free in the Stomach and undergo further
development.
▪️Male gametes form by division and exflagellation.
▪️Female gametocyte does not divide but matures to become Female gamete or macrogamete.
▪️Fertilization in half to two hours after the blood meal Zygote.
▪️Zygote- ookinete- penetrates stomach wall- oocyst- mature Oocyst has around 1000
sporozoites- ruptures- sporozoites
▪️Into salivary glands- salivary ducts- ready for injection.
▪️Sporogony in mosquito: 1-4 weeks.
The pathophysiology of Malaria results from:
1- Destruction of erythrocytes.
2- Liberation of the parasites & Erythrocytes material into Circulation and host reaction to
these events.
3- Erythrocytes sequestration in Microcirculation of vital organs Interfering with
microcirculatory Flow (P. falciparum)
Pathophysiology..
‫܀‬RBCs containing mature forms of P.falciparum adhere to Microvascular endothelium
(‘cytoadherence’) and thus disappear From the circulation. This process is known as
sequestration.
‫܀‬Tethering (the initial contact) is followed by rolling and then firm Adherence (stasis).
‫܀‬Once adherent, the parasitized cell remains stuck until schizogony and Even afterwards the
residual membranes remain attached to the vascular Endothelium.
‫܀‬Once infected red cells adhere, they do not enter the circulation Again, remaining stuck until
they rupture at merogony.
Cytoadherence
-Mediated by high molecular weight parasite-derived proteins termed P.falciparum erythrocyte
membrane protein 1 or PfEMP-1.57,141,150
- These variant surface antigen (VSA) proteins are encoded by ‘var’ Genes.
- Immunodominant surface Ag undergoes antigenic variation to ‘change its coat’ and avoid
immune mediated attack.
- Each P. falciparum var gene has different rates of switching on and Off.
- Sequestration of parasitized cells in microcirculation=> congestion, Hypoxia, blockage and
rupturing of small blood vessels

Rosettings
▪️RBCs containing mature Parasites also adhere to
Uninfected RBCs.
▪️Encourages cytoadherence by Reducing flow (shear rate), Which would enhance Anaerobic
glycolysis, reduce pH And facilitate adherence of Infected RBCS to venular Endothelium.

Clinical Features…Uncomplicated malaria

▪️Febrile paroxysm: 3 successive stages.
-Cold stage: 15-60 minutes. Intense cold and uncontrollable Shivering
▪️Hot stage: 2-6 hours.Intense heat, fevers up to 41°C or higher. Severe headache, nausea and
vomiting are common.
▪️Sweating stage: profuse sweating. Temperature drops rapidly, Patient falls into deep sleep, to
wake up refreshed.
Paroxysm usually begins early afternoon and lasts for 8- 12 hours.
▪️Myalgias, arthralgias, weakness and diarrhea, abdominal pain,, Irritability and refusal to feed.
May occur singly or in combination.
Clinical Features.
▪️Febrile paroxysms follow completion of erythrocytic Schizogony: mature schizont ruptures,
releasing red cell Fragments, merozoites, malarial pigment and other parasitic Debris.
▪️Macrophages and polymorphs phagocytose these and release Large quantities of endogenous
pyrogens=> high temperatures.
▪️High levels of parasitaemia=> activation of cytokines ie. TNF and IL-1 and the destruction of
many RBCs.
▪️Falciparum malaria parasitaemia can exceed more than 250000 parasites/l of blood.

Clinical Features..Severe malaria

-Altered level of consciousness
▪️Prostration
▪️Cerebral malaria
▪️Jaundice
▪️Respiratory distress (acidotic breathing)
▪️Multiple generalized convulsions
▪️Pulmonary oedema
▪️Shock (circulatory collapse, septicaemia)
▪️Abnormal bleeding (DIC)
▪️Haemoglobinuria (black water fever)
▪️Acute renal failure
▪️Severe anaemia (Hb<
5g/dl)
▪️Hypoglycaemia <
2.2.mmol/|)

Severe malaria
▪️Prostration: inability Or
difficulty to sit Upright,
stand or walk Without
support in a Child
normally able to Do so, or
inability to Drink in
children too Young to sit.
Cerebral Malaria
> CNS lesions: -
congestion of the
meninges and brain
-occlusion of capillaries
in brain
Causes?
- numerous petechial perivascular haemorrhages
- peripheral glial reaction (malarial granuloma) around occluded blood vessels.
 Characterised by hyperpyrexia, coma and paralysis.
Multiple Generalised Convulsions

Blackwater Fever
▪️Or malarial haemoglobinuria. Syndrome seen in falciparum Malaria; repeated infections
inadequately treated with Quinine.
▪️Resumption of quinine therapy for new attack followed by Massive RBC destruction, fever,
haemoglobinuria and renal Failure.
▪️Clinical features: bilious vomiting and prostration, passage of Dark red or blackish urine
(blackwater).
▪️Pathogenesis: ? Autoimmune. Parasitized+quininized RBCs From previous infection=>
antierythrocyte autoAbs=> Subsequent Ix and quinine Rx=> destruction of RBCs.
▪️Rare because of replacement of quinine with other drugs.
▪️Can also occur in association with G6PD deficiency.
Blackwater fever.
A 25-year-old male with Severe malaria, Pulmonary oedema, Renal impairment and Massive
haemolysis.
Anaemia
-In all types of malaria, most pronounced in falciparum Infections.
▪️Haemolytic, normocytic/microcytic,
▪️Normochromic/hypochromic.
- Due to: a) Mechanical destruction of parasitized RBCs
b)Deformability of parasitized cells causing rapid
phagocytosis and destruction in spleen.
c) ↓ erythropoiesis in bone marrow
d) Lysis and phagocytosis of uninfected RBCs.
e) Autoimmune RBC destruction in a few with malignant
tertian malaria.
Acidosis
▪️Mainly a lactic acidosis, although ketoacidosis may predominate in Children.
▪️Lactic acidosis results from :
a) Tissue anaerobic glycolysis consequent upon microvascular Obstruction
b) Failure of hepatic and renal lactate clearance
c) Production of lactate by the parasite
▪️Acid-base assessment or venous lactate concentrations on or 4h After admission to hospital are
very good indicators of prognosis in Severe malaria.
Hypoglycemia
a. An increased peripheral requirement for glucose consequent Upon anaerobic glycolysis (the
Pasteur effect).
b. Increased metabolic demands of the febrile illness.
c. Obligatory demands of the parasites- use glucose as their major fuel (all of which demand)
d. Failure of hepatic gluconeogenesis and glycogenolysis (↓ supply).

Splenomegaly
Initial change- congestion=> leading to a soft enlargement.
⇓
Darkens due to accumulated malarial pigment.
⇓
Diffuse cellular hyperplasia, dilated sinusoids and Accumulation of macrophages.
⇓
Hardens due to fibrosis.

Tropical Splenomegaly Syndrome

-Hyper-reactive malarial splenomegaly (HMS).
-Due to immunological overstimulation to
Repeated malaria attacks over a long period of Time.
Hypersplenism features: anaemia, Thrombocytopenia
▪️↑ titres of circulating antimalarial Ab, Circulating immune complexes.
▪️A moderately enlarged liver and absence of Malaria parasites in peripheral blood smears.
▪️Difference from other tropical Splenomegalies?

Liver dysfunction
▪️Jaundice – common in adults with severe malaria.
▪️Reduced clotting factor synthesis.
▪️Reduced metabolic clearance of the antimalarial drugs
▪️Failure of gluconeogenesis – contributes to lactic acidosis and Hypoglycaemia.
Pulmonary oedema
▪️Results from a sudden increase in pulmonary capillary Permeability that is not reflected in
other vascular beds.
▪️Cause is not known, although the presence of sequestered PRBC and host leukocytes in
pulmonary capillaries may have a Role in causing pulmonary capillary endothelial cell
dysfunction.
Bacterial Infection
▪️Patients with severe malaria are vulnerable to bacterial Infections, Particularly of the lungs and
urinary tract (following Catheterization).
▪️Postpartum sepsis is also common.
▪️Spontaneous bacterial septicaemia esp. in children.
▪️Enteric bacteria- normal defences against bacterial invasion From the gut are compromised.
▪️Systemic non-typhoidal Salmonella infections in children Especially.

**Trophozoite/ Merozoite-induced Malaria

▪️Direct infection of RBCs without 1° and 20 exoerythrocytic schizogony.
a) Transfusion of blood from a patient with malaria=> transfusion malaria.
b) In utero transmission to foetus=> congenital malaria
c)Use of contaminated syringes in drug addicts.
d) Renal transplantation from an infected donor.
▪️Short incubation period and no associated relapse.
Immunopathology
▪️Malaria is known to produce some depression of the immune system.
▪️In endemic areas+ recurrent infection this is suggested to be responsible for Burkitt's
lymphoma in African children.
▪️Autoimmune phenomena in parasitized RBCs.
▪️Nephrotic syndrome in P.malariae. More in children.
Kidneys damaged following deposition of Ag-Ab complexes on glomerular basement
membrane. Oedema, marked proteinuria, and a serum albumin level.

Falciparum malaria in pregnancy

- Normal immune responses:in pregnancy.
-Intense sequestration of P. falciparum infected RBCs in the placenta, local activation of pro-
inflammatory cytokine production, and maternal anaemia.
▪️Leads to cellular infiltration and thickening of the syncytiotrophoblast and placental
insufficiency.
▪️In areas of stable malaria transmission, partial immunity protects against serious clinical
falciparum malaria but not prevent heavy parasitic infection of the placenta and anaemia=>
LBW babies.
-In areas of unstable malaria transmission, pregnant women lack protective immunity => at risk
of severe life-threatening malaria. Abortion, still-birth, premature labour or LBW.

Genetic factors that protect against malaria

▪️P. vivax: rare in W. Africa or other places where RBCs lack the Duffy blood group antigens
Fya and Fyb needed for attachment to And invasion of RBCs.
• HbAS: once invaded the AS cells sickle readily, facilitating their Clearance by RES before the
parasites can develop into schizonts.
Sickle cell anaemia (HbSS) is not protective and can cause fatalities In young children with
falciparum malaria.
▪️Newborns- ↑ HbF levels in their RBCs 1st few months of life.
Malaria parasites do not grow well in red cells containing HbF.
Genetic factors that protect against malaria..
▪️Thalassaemias or glucose-6-phosphate dehydrogenase (G6PD) Deficiency (which share a
geographical distribution with malaria) Also protective though generally weaker.
• Persons with ovalocytosis ie. In P.N.Guinea and S.E.Asia have Lower parasite densities of P.
falciparum and P. vivax. Elliptical Red cells resist parasitic invasion.
▪️Possession of certain human leucocyte antigens (HLA) ie.class I Ag HLA-BW53 and class II
antigen HLA-DRB1* 1302 are protective Against severe malaria.
Laboratory Diagnosis
1. Microscopy- standard method :
▪️Thick smear- presence of organism + quantification and can Be used to monitor response to
treatment.
▪️Thin smear- speciate.
▪️Stained with Giemsa, Wright, or Wright-Giemsa stains.
▪️Giemsa preferred, allows for detection of certain Morphological features eg. Schüffner’s dots
Maurer’s clefts
Differences between thick and thin smears?
Parasite Quantification
Report the approximate numbers of parasites (trophozoites, schizonts, And gametocytes) and
also whether malaria pigment is present in White cells (always mention when the pigment is in
neutrophils).
Parasites
1-10 per 100 high power fields……
11-100 per 100 high power fields
1-10 in every high power field . . . . . .+++
More than 10 in every high power field. .+++
.++
Laboratory Diagnosis..
2. Molecular tests:
PCR- species differentiation and to detect parasites in specimens Where the parasitemia may be
below the detectable level of blood Film examination.
Highly sensitive and v.useful for detecting mixed infections, In particular at low parasite
densities.
Mainly used in drug efficacy studies. Neither PCR nor serology Is used for clinical management.
Laboratory Diagnosis...

3. Antibody detection
▪️Indirect fluorescent Ab test using Plasmodium schizonts (meronts) as the Ag.
▪️Non-specific
▪️Not practical for routine diagnosis of acute Malaria.
▪️For screening blood donors involved in cases of transfusion-induced malaria when the
donor's parasitemia may be below the detectable level of blood film examination
▪️For testing a recently treated patient in whom the diagnosis is questioned Cross reactions
between Plasmodium species and Babesia species.
Laboratory Diagnosis...
4.Antigen Tests: Rapid diagnostic tests (RDTs) - specific parasite Ags or enzymatic activity
detected using immunochromatographic methods.
-Uses dipstick or test strip bearing monoclonal Abs.
- Detect histidine-rich protein 2 (HRP2) specific for P.falciparum while those that detect
parasite lactate dehydrogenase (pLDH) or aldolase have the ability to differentiate between
P.falciparum and non-P.falciparum malaria (vivax, malariae and ovale).
- Not recommended for f/up- most of the tests remain positive for between 2-3 weeks following
effective antimalarial' treatment and clearance of parasites.
- Cannot be used to determine parasite density.
TREATMENT
▪️First line treatment in all age groups.
▪️For uncomplicated malaria in Kenya- artemether-lumefantrine (AL) (20 mg artemether and 120
mg lumefantrine) Administered as a 6-dose regimen given over three days.
• Second line treatment for uncomplicated malaria: dihydroartemisinin-piperaquine (DHA-PPQ)
• Confirmed cases of Rx failure: use 2nd line.
• Rx failure: poor adherence to Rx, unusual pharmacokinetic properties in that individual or drug
resistance.
• Suspected if patient deteriorates clinically at any time or symptoms persists 3 - 14 days after
initiation of drug therapy
TREATMENT OF UNCOMPLICATED VIVAX MALARIA
-Recommended treatment for vivax malaria is AL.
- However, to achieve a radical cure and prevent relapses, primaquine, must also be given.
- Causes abdominal discomfort when taken on an empty stomach- should always be taken with
food.
- May also cause haemolysis in patients with glucose-6-phosphatase dehydrogenase (G6PD)
deficiency.
TREATMENT OF SEVERE MALARIA
-Parenteral quinine or parenteral artemisinins (artesunate or Artemether).
- Preferred route of administration: IV; IM if not feasible.
- Hypoglycaemia- potential S/E of quinine administration Particularly in pregnant women.
Administer in a glucose Containing infusion.
- Loading dose of quinine 20mg/kg (maximum 1200mg) over 4hrs, Then 10mg/kg every 8hrs till
patient can take orally up to 7 days, Thereafter a complete course of artemether-lumefantrine
(AL) or Oral quinine is given in combination with clindamycin or Doxycycline also for 7 days.

Control and prevention of malaria

- Accessible malaria diagnostic facilities and affordable, accessible, Effective drugs.
• Public awareness/education.
• Avoiding mosquito bites – ITNs, screening windows and doors with Mosquito netting,
protective clothing, mosquito repellants.
• Preventing the breeding of mosquitoes: removing surface water, Filling in ponds, drainage
ditches, potholes etc; altering breeding sites, Spraying breeding sites and destroying adult
mosquitoes using effective Chemicals.
PROPHYLAXIS
Mefloquine
Proguanil
Atovaquone-proguanil
Doxycycline
Dosage? Frequency? Duration? Caution- A/Es?
Malaria Vaccines
▪️RTS-S acts against P. falciparum, most prevalent in Africa.
▪️Targets the circumsporozoite protein on the sporozoite surface of Parasites before they
infect liver cells=> a pre-erythrocytic vaccine.
▪️Among children who received 4 doses in large-scale clinical trials, it Prevented approximately
4 in 10 cases of malaria over a 4-year Period.
▪️Three countries – Ghana, Kenya and Malawi – began introducing The vaccine in selected areas
of moderate and high malaria Transmission in 2019.
▪️Vaccinations are being provided through each country’s routine Immunization programme.
Summary
Species
Factors favouring transmission
Tertian vs quartan malaria
Malaria vaccines
Life Cycle
Pathogenesis
Severe malaria features
Protective individual attributes
Laboratory diagnosis
Treatment of uncomplicated vs complicated malaria
Prevention: vector, PrEP, Vaccines
REFERENCES
• MOH National Treatment Guidelines for Diagnosis. Treatment and Prevention of
Malaria in Kenya (2016)
• Guideline WHO Guidelines for malaria – 16 February 2021
▪️Mathieu Rougemont, Madeleine Van Saanen, Roland Sahli, Hans Peter Hinrikson,
Jacques Bille and Katia Jaton. Detection of 4 Plasmodium Species in Blood from
Humans by 18S rRNA Gene Subunit-Based and Species-Specific Real-Time PCR
Assays. J. Clin. Microbiol. 2004, 42(12):5636.
▪️Snounou G, Viriyakosol S, Zhu XP, et al. High sensitivity detection of human Malaria
parasites by the use of nested polymerase chain reaction. Mol Biochem Parasitol 1993;61:315-
320.
• Sulzer AJ, and Wilson M. The fluorescent antibody test for malaria. Crit Rev Clin Lab Sci
1971;2:601-609.