 Four species of Plasmodium are responsible for

malaria. These are-

- Plasmodium vivax causes benign tertian

malaria. (periodicity of fever is once in 48 hours,
i.e. recurs every third day)

PLASMODIUM - Plasmodium falciparum causes malignant

Dr.Fahmi iqbal tertian malaria. (severe malaria, periodicity of
Associate Professor
Dept. of Microbiology
fever is once in 48 hours, recurs every third day)

- Plasmodium malariae causes benign

Generic character of Plasmodium
quartan malaria. (periodicity of fever is once
 No organ of locomotion.
in 72 hours, i.e. recurs every fourth day)
 Alteration of generation and alteration of host-
- Plasmodium ovale causes ovale tertian - Asexual reproduction (Schizogony):
Occurs in vertebrate host (Man).
malaria. (periodicity of fever is once in 48
Product is merozoite.
hours, i.e. recurs every third day) - Sexual reproduction (Sporogony):
Occurs in invertebrate host (Mosquito).
Product is sporozoite.
 Geographical distribution

 Hilly region: Plasmodium falciparum

 Plain land: Plasmodium vivax

 Plasmodium malariae in the sub-tropical zone.

 Plasmodium ovale in the East and West Africa

and Philippines.

Malaria endemic zone in Bangladesh

The problem

 At risk: More than 40% of world population.

 Death: More than 2 million/year.
 Chemotherapy: Limited drugs and drug
resistance.
 Vaccination: An anti-gametocyte vaccine is
developed, which cannot prevent malaria
but can prevent transmission to others.
 Epidemiology Host factors

1. Higher susceptibility:
3 basic epidemiological factors are-
• Children above 6 months of age (around 25%

E
• Host

• Agent
vie in hyper-endemic areas).

• Pregnant lady.
• Environment
• Non-immune traveller.

2. Natural immunity: Agent factors

• People of West Africa are immune to 1. Parasite:
Plasmodium vivax due to duffy negative Fy-Fy
• Strain-specific different epidemiological features.
phenotype .
2. Vector biology:
• Sickle cell trait and G6PD deficient patients are
• Female anopheles mosquito. Female Anopheles
resistant to Plasmodium falciparum as RBCs
(Anopheline) mosquito is the definitive host
contain too little ATPase which cannot support
where the sexual cycle (sporogony) takes place.
the growth of Plasmodium falciparum.
 Environmental factors

1. Climate:
• Male Anopheles doesn’t feed on man and
• Rainy season: Intense transmission.
feeds exclusively on fruit juices, that's why
male Anopheles doesn’t transmit the disease. 2. Biological factors:

Whereas female Anopheles needs at least two • Micro-habitats of mosquito.

blood meals before laying eggs. 3. Socio-economic factors:

• Poverty.

Methods of transmission
Methods of transmission
Inoculative method
• Inoculative method
• Mode of transmission: Bite of female
• Other methods-
anopheles mosquito.
a. Blood transfusion
• Portal of entry: Skin.
b. Transplacental transmission
• Infective form: Sporozoite.
c. Needle sharing
• Site of localization: First in the skin and then
d. Therapeutic malaria in the erythrocytes.
 Methods of transmission Methods of transmission
Blood transfusion

• Infective form: Trophozoite. Therapeutic malaria

• Incubation period: Shorter. • Infection has been artificially induced for the
• Relapse: Absent. treatment of neurosyphilis.

• Radical cure: Not needed.

Incubation period Life cycle

10-14 days for
Asexual reproduction (In Human)
• Plasmodium vivax. A malaria-infected female Anopheles mosquito
inoculates sporozoites into the human host
• Plasmodium falciparum.

• Plasmodium ovale. Sporozoites infect liver cells

18 days for
mature into schizonts
• Plasmodium malariae.
 Schizonts rupture and release merozoites
Blood stage parasites are responsible for the
Merozoites infect red blood cells clinical manifestations of the disease.

The ring stage trophozoites mature into The gametocytes, male (microgametocytes) and
schizonts, which rupture releasing merozoites female (macrogametocytes), are ingested by
an Anopheles mosquito during a blood meal
Some parasites differentiate into sexual
erythrocytic stages (gametocytes)

Sexual reproduction (In mosquito) which invade the midgut wall of the mosquito
The parasites’ multiplication in the mosquito is where they develop into oocysts
known as the sporogonic cycle
The oocysts grow, rupture, and release
While in the mosquito’s stomach, the sporozoites
microgametes penetrate the macrogametes
generating zygotes which make their way to the mosquito’s salivary
glands. Inoculation of the sporozoites
The zygotes in turn become motile and
elongated (ookinetes) into a new human host perpetuates the malaria
life cycle.
 A few related terms
Stages of human cycle
 Relapse: Means persistence of exo -erythrocytic cycle
in the liver in which erythrocytic schizogony
 Cycles inside the liver: -

commences again. It is a feature of P. vivax and

-
1. Pre-erythrocytic schizogony. probably of P. ovale and P. malariae infections .
2. Exo -erythrocytic schizogony.  Recrudescence: Means recurrence of parasitaemia
-

 Cycles inside RBCs: from a low level of persistent blood infection. It is

-

1. Erythrocytic schizogony. seen in P. falciparum up to 1-2 years and in P.

2. Gametogony. malariae even up to 40 years.

 Re-infection: Means infection with different parasite.

-
 Prepatent period
Trophozoite
 Soon the pear shaped hepatic merozoites  Ring forms are the first asexual form that can
-

round up, lose their internal organelle and

- -
be demonstrated in the peripheral blood. The
transform into trophozoites
time interval between the entry of the parasite
 Ring form: Early trophozoite form is known as
-
ring form. It is annular or signet ring into man and demonstration of the parasite in
appearance containing a central vacuole and
the peripheral blood is called as prepatent
peripheral thin rim of cytoplasm and a nucleus.
Ring form occupies one third of RBC except in period. It varies between the species:
P. falciparum, where it occupies one sixth of
RBC.  P. vivax—8 days
 P. falciparum—5 days

Malarial pigment Mixed infection

 Plasmodium feeds on hemoglobin. The undigested  Different species of Plasmodium can infect
product of hemoglobin metabolism like hematin, the same mosquito which in turn can
excess protein and iron porphyrin combine to form
transmit mixed infections to man, accounts
malarial pigment (hemozoin pigment).
for 4–8% of total infection.
 The appearance of malarial pigment varies, mostly it
is brown black in color and numerous (except in P.
vivax it is yellowish brown in color and in P.
falciparum, it is few in number).
 Malarial pathology 2 important features in pathogenesis
Invasion of RBCs
 Hyperplasia of RE system.  Young RBCs by P. vivax.

 Parasitized RBCs filling capillaries of internal  RSCs of all ages by P. falciparum.

 Involves ligand-receptor interaction.
organs.
 Congestion and dilation of sinusoidal vessels. Lysis of RBC
 Stimulates production and release of
 Degenerative changes of parenchymal cells.
cytokines by macrophages. TNF-α and IL-1
 Pigmentation of organs. are responsible for fever, chill etc.

 Immunosuppression leading to infection.

Clinical features of malaria Febrile paroxysm

 Fever comes intermittently depending on the
3 cardinal features are-
species. It occurs every fourth day (72 hour
 Febrile paroxysm. cycle for P. malariae) and every third day (48
 Rapid development of anaemia. hour cycle for other three species).
 Splenomegaly.  Paroxysm corresponds to the release of the
successive broods of merozoites into the
bloodstream, at the end of RBC cycle.
Each paroxysm of fever is comprised of 3 stages—  Sweating stage: Fever comes down with
(1) cold stage (2) hot stage and (3) sweating profuse sweating. Skin becomes cold and
stage. moist. Patient feels relieved and often asleep.
Cold stage: Lasts for 15 minutes to 1 hour. The This stage lasts for 2–4 hours.
patient feels lassitude, headache, nausea,  In P. falciparum, the fever is more irregular or
intense cold, chill and rigor. even continuous with marked prostration,
Hot stage: Patient develops high grade fever of headache and nausea
39–41°C and dry burning skin. Headache
persists but nausea diminishes.

Anemia 3. Increased peripheral destruction of RBCs by

 After a few paroxysms of fever, patient spleen.

develops a normocytic normochromic 4. Depletion of folate store to meet up the

anemia. Various factors can attribute to the demand for increased synthesis of RBCs.
development of anemia such as: 5. Bone marrow suppression leading to
1. Haemolysis of infected RBCs. decrease RBC production.
2. Suppression of erythropoiesis by cytokines 6. Increased fragility of RBCs.
such as TNF-α, IL-1 and others. 7. Autoimmune lysis of coated RBCs.
 Splenomegaly WHO classification of malaria

After a few weeks of febrile paroxysms, spleen

1. Uncomplicated malaria: Mostly due to P.
gets enlarged and becomes palpable.
vivax.
Splenomegaly is due to massive proliferation
of macrophages that engulf parasitized and 2. Treatment failure malaria: History related

nonparasitized coated RBCs. diagnosis.

3. Severe malaria: It is a medical emergency.

Severe malaria
Severe malaria
Asexual form of P. falciparum in blood with any
one or more of the following- Clinical features
 Marked agitation.
Cerebral Bleeding (DIC) Extreme weakness  Hyperventilation.
malaria
 Hypothermia.
Severe Haemoglobinuria Hyperparasitaemia
 Bleeding.
anaemia
 Deep coma.
Acute renal Lactic acidosis Hyperpyrexia
 Repeated convulsion.
failure
 Anuria.
Hypoglycaemia Jaundice
 Shock.
Convulsion Impaired
consciousness
 Other complications
Severe malaria  Aspiration pneumonia.

Complications
 Anaemia. If patient remains unconscious for more then 3
 Convulsion.
days-
 Hypoglycaemia.  Chest infection.
 Jaundice.
 Catheter induced UTI.
 Renal failure.
 Pulmonary oedema.  Septicaemia.

Laboratory diagnosis
Chronic Complications of Malaria Parasitological diagnosis
 Hyperparasitaemia: Increased mortality at
1,00,000/µl and high mortality at 5,00,000/µl.
 Tropical splenomegaly syndrome (hyper- Haematological diagnosis
 Leukocytosis (>12,000/µl).
active malarial splenomegaly).
 Severe anaemia (PCV <15%).
 Coagulopathy: Decreased platelet count
 Quartan malarial nephropathy. (<50,000/µl) and prolonged prothrombin time(>3
seconds).
 Promotes Burkitt’s lymphoma: severe Biochemical diagnosis
 Hypoglycaemia (<2.2 m. mol/L).
immunosuppression in African children
 Acidosis (arterial PH <7.3 and serum HCO3- <15 m.
provoke Epstein-Barr virus. mol/L).
 Elevated serum creatinine and bilirubin, liver and
muscle enzymes.
 Causes of hypoglycaemia in malaria
Transfusion malaria
1. Decreased oral intake.  Malaria can be transmitted by blood
2. Depletion of liver glycogen. transfusion, needle-stick injury, or organ
3. Consumption of glucose by parasites. transplantation.

4. Release of insulin by the influence of  The infective form is trophozoite.

quinine.  There is no pre-erythrocytic stage of
5. Inhibition of gluconeogenesis by TNF-α and development and no relapse.
IL-1.  The incubation period is often short.

Pernicious malaria
Malaria in pregnancy It is a series of phenomena occurring during

 Malaria during pregnancy increases the risk the course of P. falciparum infection which if

of fetal distress and can result in premature not treated, threatens the life of the patient

labor, low birth weight and still birth. within 1-3 days.
 Clinical types-
1. Cerebral malaria.
2. Algid malaria.
3. Septicaemic malaria.
 Cerebral malaria Cerebral malaria
Clinical features Pathogenesis

 Coma.  Sequestration of P. Falciparum parasitized RBC in the

 Focal neurological signs are unusual. microvasculature of the brain leading to

microvascular obstruction, impaired perfusion of
 Fundoscopy reveals retinal haemorrhage,
brain and impaired consciousness.
retinal opacification and papilloedema.
 Interaction between cytoadherent parasitized RBCs
 Convulsion usually generalized and repeated. and microvascular endothelium causes release of
 Fatality: 20% among adults and 15% among TNF-α, IL-1 and nitric oxide.

children.

 TNF-α and IL-1 induce receptor ICA-1 on

endothelium which interacts with PFEMP-1
Plasmodium falciparum erythrocyte membrane protein 1
(receptor-ligand interaction) and block
microvasculature. Increased cytokine level
leads to more devastating changes.
Algid malaria Septicaemic malaria
 It is characterized by cold, clammy skin with
Characterized by-
vascular collapse leading to peripheral
 High continued temperature.
circulatory collapse.
 Bilious remittent fever.
 Types of Algid malaria-
 Pneumonia.
1. Gastric type: Associated with vomiting.
 Cardiac syncope.
2. Choleric type: Associated with diarrhoea.
3. Dysenteric type: Associated with bloody
diarrhoea.

Black-water fever Black-water fever

 It is a manifestation of P. falciparum malaria, Pathogenesis-
 Intravascular haemolysis.
characterized by sudden intravascular haemolysis
Effects of intravascular haemolysis-
followed by fever and Haemoglobinuria.  Methaemalbuminaemia.
 Aetiology-  Hyperbilirubinaemia.
 Haemoglobinuria.
1. Infection with P. falciparum.
Clinical features-
2. Non-immune individual.  Fever with rigor.
 Haemoglobinuria.
3. Patient who have had inadequate dose of quinine.
 Jaundice.
 Vomiting.
 Renal failure.
 Laboratory diagnosis of malaria

 Microscopic examination-
Black-water fever
1. Peripheral blood film study.
Complications- 2. Fluorescent microscopy.
 Renal failure.
3. Quantitative buffy coat (QBC) test.
 Acute liver failure.
 Non-microscopic methods-
 Circulatory collapse.
1. Antigen detection.
Treatment-
 Chloroquine is the drug of choice. 2. Detection of malarial antibody.
 Dialysis for the treatment of renal failure. 3. PCR.

Laboratory diagnosis of malaria

Specimen
Light microscopy-
 Time for taking blood: Blood should be  Stains-
collected few hours after the height of the 1. Giemsa stain.
2. Wright’s stain.
paroxysm of fever and before taking
3. Leishman stain.
antimalarial drugs. Parasite density is 4. Field’s stain.
maximum during this period  Blood films-
1. Thick film
 Frequency: Smears should be examined at
2. Thin film
least twice daily until parasites are detected.
Laboratory diagnosis of malaria  For thick smear, a big drop of blood is spread
over half inch square area on a clean glass
Blood films- slide.
Thick film
 30-40 times  For thin smear, a small drop of blood is taken
concentration. on a corner of a slide. It is spread by another
 Rapid diagnosis of malaria.
slide at an angle of 45ᵒ and then is lowered to
Thin film-
 Species diagnosis. an angle of 30ᵒ and is pushed gently to the
left, till the blood is exhausted.

P. falciparum vs. P. vivax under microscope

P. falciparum P. vivax

RBC not enlarged. RBC enlarged.

Usually only ring forms are Single large ring in a single

present. >1 rings in a single RBC, Trophozoite and other
RBC. There are two chromatin developing forms are found.
dots. Marginal forms present.

Gametocytes are crescentric Gametocytes are spherical or

or banana shaped. globular.

Maurer’s dots present. Schuffner’s dot present.

Black or dark brown solid Yellow brown, fine granular

P. falciparum P. vivax
blocks of malarial pigments malaria pigment
 The plus system
Laboratory diagnosis of malaria
Parasite count-
+ = 1-10 parasites in 100 fields
There are two methods
1. Method I: Parasite/µl of blood
++ = 11-100 parasites in 100 fields
2. Method II: The plus system +++ = 1-10 parasites/field
Parasite/µl of blood = ++++ = > 10 parasites/field
Thick smear:
Number of parasites counted per 100 WBCs x Total WBC count
(8000)/100
Thin smear:
Number of parasites counted per 100 RBCs x Total RBC count
/100

Quantitative Buffy Coat Examination

Laboratory diagnosis of malaria
Antigen detection-
 The quantitative buffy coat (QBC) malaria
 Detects histidine -rich protein of P. falciparum/ P.
test is an advanced microscopic technique. vivax (HPR II) through ICT.
 P. falciparum/ P. vivax specific lactate
It consists of three basic steps— dehydrogenase.
(1) concentration of blood by centrifugation, Detection of malarial antibody-
 RIA
(2) staining with acridine orange stain  Immunofluorescence
 EIA
(3) examination under ultraviolet (UV) light
PCR.
source.
 Antibody Detection ICT test
 ELISA (enzyme-linked immunosorbent assay)
 IFA (indirect fluorescent antibody test)
 IHA (indirect hemagglutination test)

other Nonspecific Tests  Prolonged prothrombin and partial

thromboplastin time in severe infection.
 Normochromic and normocytic hemolytic
 Decreased antithrombin III levels in mild
anemia.
infection.
 Leucopenia: Due to decrease in
 Metabolic acidosis.
granulocytes and lymphocytes.
 Hypoglycemia.
 Raised erythrocyte sedimentation rate
(ESR).
 Raised serum C reactive protein.
 Severe falciparum malaria is also associated
Treatment of malaria
with low plasma concentrations of sodium,
Available drugs are- In pregnancy-
calcium, magnesium and albumin; and high
 Chloroquine.  Chloroquine.
levels of lactate, creatinine, muscle and liver  Mefloquine.  Quinine.
 Primaquine.  Mefloquine.
enzymes, and conjugated & unconjugated
 Halofantrine.
bilirubin.  Artemisinin.
 Tetracycline.
 Hypergammaglobulinemia.
 Dapson.

Malaria chemoprophylaxis Chemoprophylaxis in pregnancy

 Tab. Chloroquine 2 tab. Weekly + Tab.  Tab. Mafloquine 250 mg weekly- start one
Proguanil 2 tab daily- start one week week before journey and continue for four
before journey and continue 6 weeks after weeks after return.
return.
 Daily regimen: Doxycycline 100 mg. Daily
regimen should be started 1 day before
the travel.
 Antimalarial Drug Resistance Mechanism of drug resistance
Falciparum malaria:  Chloroquine resistance in Plasmodium
Drug resistance in P. falciparum is widespread. falciparum: Occurs due to mutations in the

 Chloroquine resistant. genes encoding the transporter proteins such

as PfCRT (P. falciparum Chloroquine
 Sulfadoxine -pyrimethamine resistance.
transporter) and PfMDR1 (P. falciparum
 Mefloquine resistance.
multidrug resistance gene 1).

These proteins help in Chloroquine influx into

the parasitic food vacuoles. Such mutation Prevention of malaria
results in impaired transport of Chloroquine.  Long sleeve dress.
 Mosquito control measure.
 Resistance to antifolates such as
 Using insecticide treated net.
Sulfadoxine, pyrimethamine and Proguanil  Intermittent chemoprophylaxis
for pregnant women.
is due to point mutation in DHFR  Chemoprophylaxis for non-
(dihydrofolate reductase) gene. immune travellers.
 WHAT IS TOXOPLASMOSIS
• Toxoplasmosis is an infection that is caused by a
TOXOPLASMOSIS microscopic parasite called Toxoplasma gondii.

• T. gondii is a coccidian protozoan that multiplies

only in living cells, tissue cysts, may contain
thousands of parasites and remain in tissues,
especially the CNS and skeletal and heart muscle,
for the life of the host.

• Latent encysted organisms persist in the host

In immunologically normal children: throughout life in immunocompromised
• Acute acquired infection may be infants or children.
asymptomatic. • Signs or symptoms related to the central
• lymphadenopathy, or affect almost any organ. nervous system (CNS)Congenital infection.
 HOW DO PEOPLE GET
• Toxoplasma infection is one of the most TOXOPLASMOSIS?
common latent infections of humans throughout • Contact with infected cat feces.
the world. • Contaminated raw or undercooked meat.
• In many areas of the world, approximately 3– • Contaminated unwashed fruits or vegetables.
35% of pork, 7–60% of lamb, and 0–9% of beef
• Vertical transmission.
contain T. gondii organisms.
• Organ transplant or blood transfusion.

Acquired Toxoplasmosis • Fever, stiff neck, myalgia, arthralgia,

• Immunocompetent children who acquire maculopapular rash that spares the palms and

infection postnatally: Asymptomatic. soles, localized or generalized lymphadenopathy,

• Symptomatic infection: lymphadenopathy, fever, hepatomegaly, hepatitis, reactive lymphocytosis,

and Hepatosplenomegaly. meningitis, brain abscess, encephalitis, confusion,

• Disseminated infection, including myocarditis, malaise, pneumonia, polymyositis, pericarditis,

pneumonia, and CNS toxoplasmosis, is more pericardial effusion, and myocarditis.

common among immunocompromised persons. • Chorioretinitis, usually unilateral.
 WHAT IS CONGENTIAL Congenital infection:
TOXOPLASMOSIS
Mild signs: premature birth, small size for
• When a pregnant woman gets the infection
gestational age, retinal scars, persistent jaundice,
during pregnancy and passes it on to her fetus.
mild thrombocytopenia, CSF pleocytosis.
Women who get toxoplasmosis before conception
More severe signs: Psychomotor retardation and
hardly ever pass the infection during pregnancy.
resulting low IQ, Seizures / Blindness, sometimes
Babies that get infected during the first trimester
deafness, Severe disease and death.
show to have the most severe symptoms.

TREATMENT
• CONGENTIAL TOXOPLASMOSIS:
• Acquired Toxoplasmosis and lymphadenopathy
Characteristic triad of Chorioretinitis,
do not need specific treatment unless they have
hydrocephalus, and cerebral calcifications.
More than half of congenitally infected infants severe and persistent symptoms or evidence of
damage to vital organs. If such signs and
• DIAGNOSIS:
symptoms occur, treatment with pyrimethamine,
- Culture.
- Serologic Testing sulfadiazine, and leukovorin should be initiated.
- PCR
 TREATMENT
Congenital Toxoplasmosis :
• All newborns infected with T. gondii should be
treated whether or not they have clinical
manifestations of the infection because treatment
may be effective in interrupting acute disease that
damages vital organs. Infants should be treated for
1 year with pyrimethamine, sulfadiazine and
leukovorin.