1.

Malaria
• Malaria is caused by Plasmodium species (protozoan parasites) where there are more than 200
species that infect reptiles, birds, and mammals
• Common causes of human malaria are Plasmodium falciparum, P. vivax, P. ovale, P. malariae and P.
knowlesi
• P. knowlesi that commonly infects monkeys (Macaca fascicularis and Macaca nemestrina) in
Southeast Asian countries has also been identified from human infection and considered as fifth
human malaria parasite
• Plasmodium parasites, are transmitted to people by the bites of infected female Anopheles
mosquitoes (common mode of transmission), congenitally to fetus, blood transfusion, and
accidentally from contaminated laboratory materials (e.g. injecting needle)
• There are around 40 mosquito species that can transmit the malaria parasite to human
• Malaria disease can range from asymptomatic infection, mild acute febrile illness to severe
complications that can result fatality depending on the type of Plasmodium species
• Plasmodium falciparum is mainly a cause of severe disease (e.g. cerebral malaria) and death
• Malaria is a major public health problem in 84 countries (including Ethiopia) in tropical and
subtropical areas
• There were 247 million malaria cases and 619 000 deaths globally in the year 2022, death toll in
Africa was 593 000 out of the total and almost all deaths were caused by P. falciparum (over 95%)
• There were also 3575 P. knowlesi cases that are resulted 13 deaths

1
 Figure shows transmission and developmental cycle of Plasmodium falciparum

Pathogenesis of Malaria
• Depends on virulence of the parasite isolate and a variety host related factors such as host’s
immunity, genetic make-up, and physiology
• Waste substances released into the blood after rupture of erythrocytes and release of merozoites, such
as red blood cell membrane products, hemozoin pigment, plasmodial DNA , antigens & toxic factors
such as glycosylphosphatidylinositol (GPI)
• These waste substances activate macrophages and endothelial cells to secrete cytokines and
inflammatory mediators such as TNF, IFN-γ, IL-1, Il-6, IL-8, macrophage colony-stimulating factor,
lymphotoxin, superoxide and nitric oxide (NO)
• Hemozoin (a by-product of haemoglobin digestion by the parasite) is linked to the induction of
apoptosis in developing erythroid cells in the bone marrow which is related to anaemia
• Major changes occur in infecdted erythrocytes that alter their morphology and physiology. One of the
changes can be integration of parasite derived products into infected erythrocytes

2
 • In Plasmodium falciparum the P.f erythrocyte membrane protein-1 (PfEMP1) molecule is encoded
by approximately 60 var genes, each individual parasite expresses a single var gene at a time
• The PfEMP1 has knob like formation on the surface of infected erythrocytes and is responsible for
both immune evasion and cytoadherence to vascular endothelial surfaces
• PfEMP1 binds to receptors such as CD36, chondroitin sulfate A (CSA), thrombospondin, &
intercellular adhesion molecule 1 (ICAM-1)
• PfEMP1 adhesion to ICAM-1 on vascular endothelial cells in the brain is associated with cerebral
malaria
• PfEMP1 adhesion to chondroitin sulfate A (CSA) cells in the placenta is associated with severe
malaria in pregnant women
• Severe malaria involves mechanisms such as rosetting, cytoadherence, and sequestration (congestion)
of infected erythrocytes in the vital organs
• This results in blocking of blood flow, local oxygen supply, mitochondrial ATP synthesis, and
stimulating cytokine production resulting in various organ dysfunctions

Symptoms of Malaria
• Malaria symptoms occur either as mild (uncomplicated) or severe (complicated) disease

Clinical signs of mild malaria

• Mild malaria occurs as acute febrile illness and can be caused by all human malaria species
• Symptoms of mild (uncomplicated) malaria are nonspecific- a febrile illness with headache, tiredness
(fatigue), muscle, joint aches, abdominal pains, shivering, perspiration, nausea, anorexia, vomiting
and diarrhea
• Mild anaemia, jaundice, splenomegaly, and hepatomegaly

Clinical signs of severe malaria

• Cerebral malaria (Deep coma), multiple convulsions, acute renal failure, pulmonary edema, hepatic
dysfunction, disseminated intravascular coagulation, haemoglobinuria, retinal edema, lack of retinal
reflex, circulatory shock , severe anaemia
• These occurs almost always due to P. falciparum
Cerebral Malaria(CM)
• Due to cytoadherence, rosetting, and rigidity of infected erythrocytes, elevated TNFα, IL-5, IFNγ,
NO
• Manifested as seizure, coma, retinal hemorrhage, subconjuctival hemorrhage
• Duration of coma, 48 – 72 hrs which may be followed by death

• Brain:- swollen with multiple petechial hemorrhages in white matter, mid-zonal necrosis,
sequestration of
P.f parasites is higher in comatous patients.
• Long term effects:- heparesis, cerebellar ataxia, blindness, mental retardation, encephalopathy, and
others
3
 • In addition to the above cerebral malaria symptomatic manifestations the following complications
occur in other body parts

Severe Anaemia
• Due to bone marrow suppression (dyserythropoiesis), erythrophagocytosis, erythrocyte destruction
of both IE & Non-IE, sequestration of IE & iron, low plasma IL-10
• Rapidly occurs in patients with CM, more in young children, non- immune people
Lung
• Pulmonary edema, congestion of pulmonary capillaries, hyaline membrane formation, respiratory
distress, pneumonia (superimposed with bacterial infection)
Liver
• Sequestration occurs, perivenous ischaemia, necrosis, hepatomegaly, becomes gray color, increased
bilirubin, severe jaundice
Heart
• Minimal change, swollen & mononuclear cells infiltration, myocardial failure
Spleen
• splenomegaly, occasionally ruptures, color grey to black, congested with IE & Non-IE,
reticuloendothelial hyperplasia

Diagnosis
1. Microscopy
• Giemsa stained peripheral blood smear observed by light microscope 1000X magnification with oil
immersion

Early trophozoite (ring stage) in RBcs Mature trophozoites in RBCs

2. Rapid diagnostic test (RDT)

• A type of serological test

4
 • P.f Histidine rich protein-II (PfHRP-II) antigen (actively secreted from infected erythrocytes) and
Plasmodium Lactic dehydrogenase (pLDH) for specific detection of P. falciparum and P. vivax

3. Laboratory indicators (measurements) of severe malaria

• Sever anaemia Hct < 15%
• Renal failure No urine or < 400ml in 24 hr or 12ml/kg/24hr after rehydration or serum
creatinine n> 265 μmol/l (> 3 mg/dl)
• Hypoglycemia Blood sugar < 2.2mmol/l (40ml/dl)
• Shock- Systolic BP < 70mmHg in adult or <50mmHg in children
-
• Acidosis Arterial PH < 7.25 or plasma HCO < 15
3
• Hyperparasitaemia > 5% in non-immune, >100, 000/ µl (LTA) or >200, 000 / µl (HTA)
• Mature pigmented parasites in peripheral blood (>20% of parasites)
o
• Hyperpyrexia T > 40 C
5
 • Peripheral blood polymorphonuclear leukocytes(PMNL) > 12 000/ µl
• Malaria pigment In > 5% of PMNL
• High plasma lactate >6 mmol/l

NB. In addition to these laboratory diagnosis methods physical examinations are vital in determining
especially severe malaria

Treatment
• The Artemisinin derivative drugs:- Dihydroartemisinin (DHA), Artesunate, Artemether, and Arteether
can be used for P. falciparum treatment of malaria in combination with partner drugs
• Recommended combination therapies are:- Artemether/Lumefantrine, Artesunate/Amodiaquine,
Artesunate/Mefloqiune, Artesunate/Sulfadoxine-Pyrimethamine and Dihydroartemisinin/Piperaquine
for the treatment of uncomplicated P. falciparum malaria
• Artemether/Lumefantrine (AL), a fixed dose in a 1:6 ratio (20mg/120mg) approved as Coartem®,
now comprises nearly 75% of the 100 million or so Artemisinin based combination therapies (ACTs)
utilized by endemic countries including Ethiopia
• For severe malaria IV supplied Artesunate or Quinine are used

ACT drug (Coartem)

6
2. Toxoplasmosis
• This disease is caused by Toxoplasma gondii, it infects multiple types of animals in addition to
humans

• The parasite has various cellular stages, with distinct cellular morphology, biochemistry, and behavior.
• These stages include the tachyzoite, merozoite, bradyzoite (found in tissue cysts), sporozoites (found in
oocysts), and gametocytes (M & F)

• Tachyzoite: Motile, metabolically active and quickly multiplying stage, tachyzoites are responsible for
expanding the parasite in the host
• Bradyzoite: Bradyzoite is the slowly dividing and dormant stage of the parasite that remains encysted in
tissue. It is also an infective stage to mammalian hosts upon consuming raw meat (animal flesh)
containing encysted bradyzoites
• Merozoite: Formed in cat’s intestine and divides quickly by schizogony. Merozoites are responsible for
expanding parasite inside the cat intestine prior to sexual reproduction

7
• Sporozoite: Sporozoites are the stage of the parasite residing within oocysts
• Gametocytes: male and female gametocytes are formed during schizogonic phase in the cat’s intestine

• The only known definitive host for Toxoplasma gondii is domestic cat and its relatives in the family
Felidae
• Large numbers of unsporulated oocysts are shed in the cat’s feces. Oocysts take 1-5 days to sporulate in
the environment and become infective
• Intermediate hosts in nature (birds and mammals) become infected after ingesting soil, water or plant
material contaminated with mature Oocysts containing Sporozoites originally from cat’s feces
• Humans can become infected by any of several routes:- eating undercooked meat of animals harboring
bradyzoites in tissue cysts, or blood transfusion or organ transplantation, or transplacentally from mother
to fetus, or consuming food / water contaminated with Oocysts containing mature sporozoites
• T. gondii is an intracellular parasite which can actively enter any nucleated cell in the host body. It
disseminates through the host body with infected mobile cells, such as dendritic cells and monocytes.
• Using this Trojan horse strategy, it can even enter immunoprivileged organs, testes, the eyes, and
especially the brain

Infection/Diseases

 When Oocysts are ingested by human, sporozoites are released and infect intestinal epithelial cells then
change to the proliferative Tachyzoite stage
 Tachyzoites afterwards disseminate through blood and infect different tissues and organs
 In immunocompetent human host, the bradyzoites become encysted in tissues, most commonly in
skeletal muscle, myocardium, brain, and the eyes; these bradyzoite cysts may remain throughout the life
of the host
 Healthy people who become infected with T. gondii often do not have symptoms because their immune
system usually keeps the parasite from causing illness
 Serologic prevalence data indicated that toxoplasmosis is one of the most common human infections
throughout the world
 For example, survey of T. gondii seroprevalence showed results, in Latin America (50–80%), Parts of
Eastern and Central Europe (20–60%), Middle East (30-50%), Parts of Southeast Asia (20–60%), and
Parts of Africa (about 20–55%) among healthy individuals

8
 When acute illness occurs, it is usually mild with "flu-like" symptoms (e.g., swollen and tender lymph
nodes, muscle aches, general body pains etc.), splenomegaly, hepatomegaly that last for weeks and then
symptoms go away (i.e. self-healing)

 After symptoms disappear, the parasite remains in the body in an inactive state as bradyzoite and it can
become reactivated if the person becomes immunosuppressed at some point in life

 Infants, pregnant women and immunocompromised people, such as those with HIV/AIDS, those taking
immunosuppressive chemotherapy, or those who have recently received an organ transplant are
vulnerable and may develop severe toxoplasmosis

 In the case of severe toxoplasmosis, the parasite can cause encephalitis (with large foci of necrosis in
gray matter) and other neurologic diseases, pneumonia, myocarditis, and eye diseases

 The CNS complication (pathology) is a common cause of death in AIDS patients

 Infants infected before birth via placental transmission may be born with either of the above problems, or
with nasal malformations, intrauterine growth retardation, premature birth, brain growth or psychomotor
retardation, hydrocephalus or microcephalus, muscle atrophy and stillbirth can happen

 Pregnant women with HIV infection are with high risk of transmitting T. gondii to their fetus

Laboratory Diagnosis
• Diagnosis of toxoplasmosis in humans is made by Clinical(physical), serological, histological, or
molecular methods
• Serology (specific antibody detection from serum) is a routine method of diagnosis
• There are numerous serological methods available for the detection of T. gondii specific antibodies:-
these include, indirect haemagglutination assay (IHA), indirect fluorescent antibody assay (IFA), direct
agglutination test (DAT), the latex agglutination test (LAT), the enzyme-linked immunosorbent assay
(ELISA), enzyme immunoassay (EIA) and the immunosorbent agglutination assay test (IAAT)
• These serological tests are used to detect IgM and IgG antibodies from serum specific to T. gondii
• The IgM antibodies appear sooner after infection than the IgG antibodies and disappear faster than IgG
antibodies after recovery from symptoms
• Hence, the finding of these antibodies to T. gondii in a person’s serum sample helps to demonstrate acute
infection or if a person has been infected in the past
9
• Newborn infants suspected of congenital toxoplasmosis should be tested for presence of both IgM and
IgG by EIA (enzyme immunoassay) method
• Toxoplasma gondii can be isolated from patients by inoculation of body fluid specimens (secretions,
excretions) or tissues taken by biopsy into laboratory animals or tissue cultures for later microscopic
observation
 Bradyzoites in tissue cysts can be observed by microscope in biopsy specimens (histological preparation)
stained with periodic acid Schiff (PAS)
 In the case of severe diseases, microscopic observation of parasites (Tachyzoites) in patient’s specimens,
such as blood or other body fluids (e.g. bronchoalveolar lavage, cerebrospinal fluid (CSF)), lymph node
biopsy from immunocompromised patients is possible
 Ocular disease is diagnosed based on the appearance of the lesions in the eye, symptoms, course of
disease, and often serologic testing

• PCR molecular technique is also a useful diagnostic method, especially in detecting parasite's DNA in
amniotic fluid for possible mother-to-fetus then to newborn (congenital) transmission

Treatment
• Treatment is often only recommended for people with serious health problems, such as people with
HIV whose CD4 counts are under 200
• Treatment is very important for recently infected pregnant women, to prevent infection of the fetus
• Trimethoprim/Sulfamethoxazole is the drug of choice as prophylaxis to prevent toxoplasmosis
• Atovaquone — an antibiotic that is used to kill Toxoplasma cysts in latent case inside AIDS patients,
sometimes in combination with Clindamycin
• Pyrimethamine /Sulfadiazine — for treatment of acute/active toxoplasmosis
• Spiramycin — an antibiotic used most often for pregnant women to prevent the infection of their
fetus

10
3. Cysticercosis (Neurocysticercosis)
 It is caused by larva of the tapeworm species Taenia solium, which is called Cysticercus
cellulosae

Figure shows transmission and developmental cycle of Taenia solium

• The Cysticercus (Plural- Cysticerci) larva measures 5 to 10 mm in length and 5 mm in diameter

Transmission/Infection
11
 • Human is normally infected by eating raw or undercooked pork containing the Cysticercus
cellulosae larva, which results in development of adult worm in the small intestine
• In this case human serves as definitive host by harboring the adult worm in the small intestine
• Pig is considered as the only intermediate host where it carries tissue(organs) or muscle infection by
Cysticercus cellulosae larva
• Human can get infection by the larva as an intermediate host by accidentally ingesting the eggs in
contaminated food or water or by internal autoinfection when the eggs are carried by reverse
peristalsis back to the duodenum or stomach from existing adult worm infection in the small intestine

Diseases
 Larvae are often located in subcutaneous and intermuscular tissues, the eye, the brain (in 60- 90% of
patients)
 Ocular cysticercosis- larvae location in subretinal space, vitreous, and conjunctiva are most
common sites
 In the eye there occurs severe pain, blurred or lost vision
 Cutaneous and muscular- acute myositis, subcutaneous nodules
 Neurocysticercosis (NCC), is most common cause of epilepsy in endemic areas in 1/3 of patients
 Convulsion and/or seizures, intracranial hypertension, psychiatric disturbances, meningitis, and
encephalitis
 Brain - larval location and subsequent problems
 Parenchymal: epilepsy in most cases
 Ventricular: hydrocephalus
 Meningeal: meningitis, mental deterioration, psychomotor abnormalities

Figure shows Cysticerci with granuloma and

calcification in brain tissue

Laboratory Diagnosis
12
1. Lumbar puncture fluid analysis-
 Protein level(High), glucose level(Low), cell counts(Eosinophilia), Identifying Cyst
2. Histological examination-
 Biopsy of subcutaneous nodules (cyst 10- 20 mm), surrounded by inflammatory cells
3. Imaging-
 Radiography- can depict calcified larval cysts
 CT scan- can depict laraval cysts 5- 20mm diameter
 MRI- is superior to the others
4. Immunological-
 Enzyme Linked Immunotransfer Blot (ETIB) or ELISA is 100% specific & 90 % sensitive
for tests done on CSF and serum
5. Ocular- direct observation of larva in the eye with magnifying apparatus

Treatment
• Drug of choice against adult worm intestinal infection are Niclosamide and Praziquantel
• Albendazole or Praziquantel with high dose of steroids to reduce inflammation can be used against
larval tissue infection (cysticercosis)
• Treatment of cysticercosis must be monitored carefully for aggravated inflammatory reactions due to
dead cysticerci after drug therapy, especially if they are present in the brain
• Cysticerci in some parts of the body can be surgically removed as a means of treatment

13