Advanced Diagnostic Tests in Malaria

Introduction The peripheral blood smear is no doubt the most popular diagnostic tool to detect malaria and to identify the causative organism; however, rapid diagnostic tests (RDTs) such as immunochromatographic tests are now being widely researched worldwide for the detection of malarial antigens because they are portable and do not need any power supply or pathological laboratory setup.

Immunochromatographic tests As of now, the existent immunochromatographic tests use polyclonal or monoclonal antibodies that bind with certain antigens of the parasite such as histidine-rich protein 2 of Plasmodium falciparum (PfHRP2) in the peripheral blood of the host. Other tests of the same type may be sensitive to specific enzymes like Plasmodium aldolase and parasite-specific lactate dehydrogenase.

PfHRP2, which is expressed on the surface of the erythrocytic membrane, is water-soluble in nature. Produced by the gametocytic and asexual forms of Plasmodium falciparum, this protein has been found to stay in the bloodstream for a month or longer once antimalarial treatment is commenced.

The enzyme Plasmodium aldolase is expressed as a result of the glycolytic pathway of practically all the malarial parasites in their blood stages. A combined immunochromatographic test for the falciparum as well as the vivax forms exists, which uses the pan-specificity of monoclonal antibodies in their reaction against Plasmodium aldolase, whilst also targeting PfHRP2 and the pan malarial antigen (PMA).

The red blood cells infected by the plasmodia are known to release a glycolytic enzyme called parasite lactate dehydrogenase (pLDH), which is produced by both the sexual as well as asexual forms of the malarial parasites. Distinct isomeric forms of pLDH exist for each of the 4 species of malaria that afflict humans. Various assays like the qualitative immunochromatographic

dipstick assay, immunodot assay, and quantitative immunocapture assay, have been devised to target this particular enzyme.

These days, PCR tests are also being done in real-time using the sample blood sample that was used for an RDT. In one such study, the identification of mixed infections was possible by using PCR on RDT in 2 out of 5 SDFK60 tests and 4 out of 5 OptiMAL tests.

Magneto Optical Test (MOT) This innovative diagnostic tool bio-physically detects the presence of haemozoin in a malaria patients blood sample. The specificity and sensitivity of the MOT is lower in comparison with RDTs and PCR; however, it can be used for screening a very large number of patients within a very short period of time, especially in areas where malaria is endemic.

Procalcitonin as a biomarker of severe falciparum malaria The occurrence of imported malaria is fairly rare in the developed nations. As a result of this, a number of physicians may find it difficult to clinically assess the severity of the disease and the treatment protocol per se. In one study, the level of procalcitonin (PCT) was found to correlate with the severity of falciparum malaria. However, the biggest drawback of this test is that concurrent bacterial infections or other species of malaria may cause false positive results.

Portable fluorescent microscopy Portable fluorescent microscopy is a simple and rapid diagnostic tool to detect malaria in remote or rural areas of the third world countries where even the supply of electricity may be a major issue. As compared to light microscopy, the specificity of fluorescent microscopy was certainly lower (<40%); however, its sensitivity in children was 86.7% and that in adults was 92.1%. With increased parasitemia, the specificity also seemed to rise by 15 to 25%. Although this appears to be an affordable option for mass screening, the incidence of frequent false positives may be a deterrent to its employment.