Learning objectives

By the end of this Unit you should:

• recognize the importance of malaria as a disease
• be able to recognize the common clinical signs and
symptoms of malaria
• know that some people can have malaria without
clinical symptoms
• know that malaria is caused by the presence of
parasites in a patient’s blood
• know that a female anopheline mosquito can
transmit malaria to people
, you must be able to find and identify parasites in a
stained blood film examined under the microscope
 Malarial Parasites

Malaria is caused by protozoa of the Plasmodium species.

There are 4 species which infect both humans and animals
 Plasmodium malariae (quartian malaria),
 Plasmodium vivax (benign tertian malaria),
 Plasmodium falciparum (malignant tertian malaria, subtertian
malaria)

 Plasmodium ovale (ovale tertian malaria).

 Diagram of Malaria Infection
Infection is by mosquito bite

Infects liver, then

blood cells
• How Plasmodium
protozoa infect a human
host:
1. The bite of a female
Anopholes mosquito injects
Plasmodium protozoa into a
human host.
2. Plasmodium travel through
the bloodstream to the liver.
 • The released
3. In the liver, parasites (yellow),
Plasmodium multiply which go on to
infect new cells or
asexually. are ingested by
4. Plasmodium reenter the another mosquito.
• Blood cells with
bloodstream, multiply the malaria
in red blood cells, and parasite within the
then burst out, infecting cells.
new cells and • Red blood cells
that have ruptured
producing malaria
symptoms.
5. Plasmodium are ingested
by another mosquito, and
the life cycle begins again.
6. Inside the mosquito, male
and female forms of
Plasmodium reproduce
sexually, resulting in
thousands of genetically
varied offspring.
Life Cycle:
• The malaria parasite life cycle involves two hosts.  During a
blood meal, a malaria-infected female Anopheles mosquito
inoculates sporozoites into the human host . 
• Sporozoites infect liver cells and mature into schizonts ,
which rupture and release merozoites .  (Of note, in P. vivax
and P. ovale a dormant stage [hypnozoites] can persist in
the liver and cause relapses by invading the bloodstream
weeks, or even years later.) 
• After this initial replication in the liver (exo-erythrocytic
schizogony ), the parasites undergo asexual multiplication in
the erythrocytes (erythrocytic schizogony ). 
• Merozoites infect red blood cells .  The ring stage
trophozoites mature into schizonts, which rupture releasing
merozoites . 
• Some parasites differentiate into sexual erythrocytic stages
(gametocytes) .  Blood stage parasites are responsible for
the clinical manifestations of the disease. 
 Life cycle cont
• The gametocytes, male (microgametocytes) and female
(macrogametocytes), are ingested by an Anopheles
mosquito during a blood meal . 
• The parasites’ multiplication in the mosquito is known as
the sporogonic cycle .  While in the mosquito's stomach,
the microgametes penetrate the macrogametes
generating zygotes . 
• The zygotes in turn become motile and elongated
(ookinetes) which invade the midgut wall of the
mosquito where they develop into oocysts . 
• The oocysts grow, rupture, and release sporozoites ,
which make their way to the mosquito's salivary glands. 
Inoculation of the sporozoites into a new human host
perpetuates the malaria life cycle
By light microscopic observations of parasites
in circulating red blood cells.
 Chills
 Fever
 Sweating
 Headaches
 Nausea
 Vomiting
 Flu-like symptoms
 Diarrhea
 Jaundice (yellow fever)
 Myalgia (muscle pain)
Malarial Parasites
Malarial Parasites
Malarial Parasites
 Shock, liver or kidney
failures*
 Coma*
 Seizures*
*May occur depending on
type of plasmodium

Symptoms may develop

later.
 Diagnosis of malaria

Peripheral smear study

serological assay
Antibody Detection
Indirect Fluorescent Antibody
Enzyme immunoassays
Antigen Detection
Immunochromatographic
PCR
Diagnosis
 Antigen Detection
Malaria Immunochromatographic
Dipstick
OptiMAL Assay

P. falciparum
specific
monoclonal
antibody Control
Plasmodium pan specific
monoclonal antibody
 Antigen Detection
Malaria Immunochromatographic Dipstick

Problems

• Low sensitivity with parasites density <100/ml

• Currently only useful for detection of P.
falciparum infections
 Antibody Detection

+ =

Antigen- *-labeled antibody to Antigen-antibody-

antibody
complex
human antibody * antibody
complex
 Indirect Fluorescent Antibody
(IFA)

Microscope slide
 Malaria IFA Test
Initial detection of antibodies

• Parasitemia precedes antibody

– P. vivax 2-6 days
– P. falciparum and P. malariae 4-6 days
• If parasitemia is suppressed by
treatment, may develop detectable
antibody
 Enzyme Immunoassay
(EIA/ELISA)
substrate
enzyme
+

_
ELISA
 Antigen Detection

+ =

Monoclonal Antigen in Antigen-antibody

antibody patient’s serum complex
Sensitivity of Tools for
Diagnosis of Malarial
Infection
1. Most sensitive:
Antibody detection
2. PCR
3. Blood film examination
 Diagnosis of
Untreated Acute Malaria

• Blood film examination

• PCR
 Diagnosis of
Treated Recent Malaria

• Serology
• Blood film examination
• PCR
 Diagnosis of
Chronic Malaria

• Screen with serology

If IFA positive:
• May do blood film examination
• May do PCR
 Malaria review: multiple forms
• Trophozoites (=ring forms): most numerous form to see in
peripheral blood, ring like structure (<1/2 diameter of cell),
progressively enlarge and mature to…
• Schizont: multinuclear structure, appear as intraerythrocytic
collection of merozoites (each with its own nucleus)
• Gametocyte: mononuclear structure occupying >1/2 the red
cell, usually amoeboid in shape and nearly fills entire RBC
 P. falciparum
• Malignant tertian fever because potentially lethal
• Must be identified
• Usually only early ring forms and gametocytes
seen
– Ring forms: may have double chromatin dots, may be
multiply infected; accole or applique forms present;
less than 1/5 size of RBC
– Gametocytes: banana shaped
• Infected red cells NOT enlarged, infects RBCs of
all stages of maturation
 P. falciparum
• Acute intravascular hemolysis with
hemoglobinuria (“blackwater fever”)
• Infected RBCs have “sticky knobs” leading
to sludging, infarcts of brain, kidneys
• With no treatment, patients either die or
spontaneously resolve within one year
P. falciparum
 P. vivax and P. ovale
• Benign tertian fever
• Morphologically very similar
• P. ovale very rare, confined to Western
Africa
• Both infect young RBCs and appear
enlarged and pale
• All stages seen (early and developing
rings, schizonts, gametocytes)
 P. vivax and P. ovale
• Schuffner’s dots may be present
• Gametocytes are amoeboid shaped, not
banana
• Schizonts have 12-14 merozoites
 P. malariae
• Associated with nephrotic syndrome
• Infects older erythrocytes, normal to small sized
RBCs
• No Schuffner’s dots
• All stages seen
• Schizonts have 6-12 merozoites, rosette pattern
• Coarse pigment may be present
• Occasional band forms (trophozoite form) seen
• Low grade cryptic infections can occur up to 40 y
P. malariae
 DIAGNOSIS
 Gold standard:
Multiple thick and thin
smears
 Dip stick tests
 CBC
– Anemia
– Leukopenia, or
leukocytosis
– No eosinophilia
Plasmodium falciparum
PF
 Summary
• Mosquito-borne infectious disease
• Tropics, subtropics
• P. falciparum, vivax, ovale, malariae
• Incubation period nearly two weeks
• Cyclic paroxysms
• Fever
• Thick and think blood smears for diagnosis
• Drug resistance is increasing
• Chemoprophylaxis can prevent infection