Parasitol Res (2014) 113:801–809
DOI 10.1007/s00436-014-3804-1
REVIEW
The role of antioxidants treatment on the pathogenesis of malarial
infections: a review
Murtala Bindawa Isah & Mohammed Auwal Ibrahim
Received: 7 November 2013 / Accepted: 28 January 2014 / Published online: 13 February 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract Oxidative damage is one of the most important
pathological consequences of malarial infections. It affects vital
organs of the body manifesting in changes such as splenomeg-
aly, hepatomegaly, endothelial and cognitive damages. The
currently used antimalarials often leave traces of these damages
after therapy, as evident in memory impairment after cerebral
malaria. Hence, some research investigations have focused
attention on the use of antioxidants, alone or in combination
with antimalarials, as a viable therapeutic strategy aimed at
alleviating plasmodium-induced oxidative stress and its associ-
ated complications. However, the practical application of this
approach often yields conflicting outcomes because some anti-
malarials specifically act via induction of oxidative stress. This
article critically reviews most of the studies conducted on the
potential role of antioxidant therapy in malarial infections. The
most frequently investigated antioxidants are vitamins C and E,
N-acetylcystein, folate and desferroxamine. Some of the inves-
tigations measured the effects of direct administration of the
antioxidants on the plasmodium parasites while others per-
formed an adjunctive therapy with standard antimalarials. The
therapeutic application of each of the antioxidants in malaria
management depends on the targeted aspect of malarial pathol-
ogy. It is hoped that this article will provide an informed basis
for future research activities on the therapeutic role of antioxi-
dants on malarial pathogenesis.
M. B. Isah
Department of Biochemistry, Umaru Musa Yaradua University,
Katsina, Nigeria
M. A. Ibrahim (*)
Department of Biochemistry, Ahmadu Bello University, Zaria,
Nigeria
e-mail: mauwalibrahim@gmail.com
M. A. Ibrahim
e-mail: maibrahim@abu.edu.ng
Introduction
Malaria is one of the most important parasitic diseases world-
wide. Cartographic approach to estimating annual clinical bur-
den of the disease shows that it affects 451 million people in 87
endemic countries, with some 1.5 billion more at risk (Hay et al.
2010). The incidence of mortality as a result of the disease is
mostly among African children, where approximately 2000
deaths occur per day. In addition to the health-related burden,
malaria also causes huge economic loss in countries with high
reported cases (WHO 2010). The disease is caused by plasmo-
dium parasites among which five species that infect humans
have been identified (White 2008). However, researches on
malarial pathogenesis are mostly conducted with rodent malaria
parasites due to their similarity to the human parasite in genome
sequence and pathology (Carlton et al. 2002). A number of
complex mechanisms are involved in the pathogenesis of ma-
larial infections, but oxidative stress has been described as a
common mechanism that plays vital roles in most aspects of the
disease pathology (Postma et al. 1996). Thus, it is considered as
a promising rationale for antimalarial chemotherapy (Becker
et al. 2004).
The plasmodium parasite specifically targets the red blood
cells (RBCs) of its host, leading to complex and harmful
pathophysiologies (Dhangadamajhi et al. 2010). Upon entry
into the RBC, the parasite metabolizes the host’s hemoglobin
in its acidic food vacuole as a source of amino acids and to
regulate the osmotic pressure necessary for its growth (Lew
et al. 2004). This process leads to generation of reactive oxygen
species (ROS) (Guerra et al. 2004). Hemoglobin degradation
also results in increased intracellular iron levels which in turn
further increase the levels of H2O2 and OH˙ that may cause
molecular and cellular damage (Vander Jagt et al. 1992). In
addition to intraerythrocytic ROS production, some of the
parasites stimulate the generation of ROS by peripheral blood
monocytes and neutrophils (Kharazmi et al. 1987). Therefore,
802
the rapid growth of the parasites with concomitant elevation in
ROS production leads to an imbalance between plasma oxidants
and the antioxidant system of the host, resulting in oxidative
stress (Rashid et al. 2013). Consequently, the oxidative stress
leads to oxidation of membrane proteins and lipids, hemolysis of
the RBC as well as extensive damage to endothelial cells and
other vital organs of the body (Andrews and Lanzer 2002; Guha
et al. 2006; Chen et al. 2001; Nanda et al. 2004).
Detoxification of ROS is a challenge not only to the host
(Becker et al. 2004). However, plasmodium parasites possess
endogenous mechanisms for protection against oxidative
stress (Ahmad and Srivastava 2007). The parasite is further
protected by the host hemoglobin which quenches ROS that
would otherwise be harmful to the parasite (Sobolewski et al.
2005). In spite of these observations, oxidative stress still
represents a fundamental control strategy, because the parasite
is susceptible to excess of ROS (Ackerman et al. 2009). As
such, modulation of the ROS detoxification system of the
parasite is frequently of therapeutic importance (Ahmad and
Srivastava 2008). In fact, some antimalarials such as
artesunate specifically induce oxidative stress in erythrocytes,
and achieve appreciable success in retarding the proliferation
of the parasite (O’Neill et al. 2010).
However, excessive generation of ROS poses a risk of
serious complications to the host as well. These include micro-
vascular obstruction, cerebral pathology, respiratory distress,
placental pathology, sequestration of infected RBC to endothe-
lium and anemia (Becker et al. 2004). Indeed, anemia is a very
important pathological feature of the disease, accounting for
around one third of all deaths resulting from malarial infection
(Haldar and Mohandas 2009). Based on the foregoing, a num-
ber of research groups have focused attention on the application
of antioxidants to malaria therapy in order to alleviate the
oxidative stress-associated complications in the host.
Numerous studies on the involvement of antioxidant ther-
apy in malaria management have been reported. However, the
results are complex and often conflicting, with researchers
reporting both beneficial and deleterious effects. At present,
there is no harmonized review in the literature that compiles
the available data on the influence of antioxidants treatments
on malarial pathology. In this article, we review most of the
available studies on various antioxidants therapies used
against malarial infections with a view to provide the scientific
community and pharmaceutical industries an informed basis
for potential therapeutic applications of different antioxidants
on the pathogenesis of malarial infections.
Methodology
Relevant literature on the testing of different antioxidants in
the treatment of malaria was searched using the major scien-
tific databases including PubMed, Sciencedirect, Medline and
Parasitol Res (2014) 113:801–809
Google Scholar for different antioxidants tested in the treat-
ment of malaria. Some articles were found through tracking
citations from other publications or by directly accessing the
journal website. The keyword combinations for the search
were: malaria, plasmodium, vitamin, antioxidant and oxida-
tive stress.
Results and discussion
Eight different antioxidants were investigated for potential
application in malaria treatment. Different research strategies
were adopted for the studies using animals and human sub-
jects. Some of the investigations measured the effects of direct
administration of the antioxidants on the plasmodium para-
sites (Table 1) while others performed an adjunctive therapy
with standard antimalarials (Table 2). The direct effects of all
the antioxidants were reported, among which six were also
tested as adjunctive treatments. Seven studies involving two
antioxidants (N-acetylcystein [NAC] and folate) investigated
as adjunctive treatments were human-based (Table 2). A pilot
human-based study with desferroxamine (DFO) was also
reported. The role of one antioxidant, vitamin E, was investi-
gated through dietary and nutritional manipulations as well as
gene knockout studies. All of the studies were conducted with
various strains of four species of the parasite: the species are
Plasmodium falciparum, P. vivax, P. berghei and P. yoelii.
In order to provide a critical view of the potential role of
antioxidants on the malarial pathogenesis, findings on each
antioxidant are discussed under separate subheadings. The
antioxidants are discussed and arranged based on the types
of studies conducted and number of citations.
Vitamin E (α-tocopherol)
Vitamin E is perhaps the most investigated antioxidant direct-
ed against malarial infections. Krungkrai and Yuthavong
(1987) reported the antimalarial activity of qinghaosu
(artemisinin) which was mediated via increased oxidative
stress. But the authors found that vitamin E reduced the
efficacy of qinghaosu in vitro because of the vitamin’s scav-
enging activity towards ROS. This is further supported by a
more recent study by Awodele et al. (2007), in which oral
treatment of P. berghei-infected mice with 100 mg/kg body
weight of vitamin E for 4 days was found to decrease the
parasite clearance ability of 2.5 mg/kg body weight daily
doses of artesunate. The vitamin also retarded the artesunate-
induced improvement of packed cell volume. Hence, it ap-
pears that vitamin E antagonizes the efficacy of artemisinine-
based antimalarials.
On the other hand, in a dietary manipulation based study,
vitamin E-deficient diet supplemented with menhaden-fish oil
(Levander et al. 1989a) or cod liver oil (Levander et al. 1989b)
Parasitol Res (2014) 113:801–809 803

Table 1 Effects of different antioxidants on plasmodium infections and its associated oxidative damage

Antioxidant Plasmodium species Effect on parasitemia Effect on oxidative damage Reference

Vitamin E P. berghei NE ↓ Ibrahim et al. (2012a)

Vitamin C P. berghei ND ↓ Iyawe and Onigbinde (2009)
P. falciparum ↑ ↑ Marva et al. (1989)
P. falciparum NE ND Soh et al. (2012)
N-Acetylcystein P. berghei ↓ ↓ Fitri et al. (2009)
P. berghei and P. yoelii NE ↓ Reis et al. (2010)
P. falciparum ND ↓ Nuchsongsin et al. (2007)
P. falciparum NE ND Soh et al. (2012)
Folate P. berghei ND ↓ Iyawe and Onigbinde (2010)
Desferroxamine P. falciparum ↓ ND Raventos-Suarez et al. (1982)
P. falciparum ↓ ND Pollack et al. (1987)
P. berghei ↓ ↓ Hershko and Peto (1988)
P. falciparum and P. vivax ↓ ND Bunnag et al. (1992)
P. falciparum ↓ ND Loyevsky et al. (1993)
P. falciparum ↓ ND Chevion et al. (1995)
P. berghei and P. yoelii NE ↓ Reis et al. (2010)
Dequalinium P. berghei ↓ ND Rodriguez and Gamboa (2007)
P. berghei ↓ ↓ Rodriguez and Gamboa (2009)
Vitamin A P. berghei ND ↓ Iribhogbe et al. (2013)
Melatonin P. yoelii ND ↓ Guha et al. (2007)

↓ Decrease, ↑ increase, ND not determined, NE no effect

protected mice against P. yoelii. The protective effects of a
vitamin E deficient diet supplemented with fish oil were then
further investigated in mice lacking antimalarial antibodies. B-
and T-cell deficient mice were fed for 4 weeks with a diet
containing the pro-oxidant menhaden fish oil, with and with-
out vitamin E. Infection of the mice with P. yoelii led to the
death of the vitamin E supplemented group whereas the
vitamin deficient group showed controlled parasite growth
and extended survival (Taylor et al. 1997). These indicate that
a diet-induced pro-oxidant condition confers resistance to
P. yoelii infection which is reversed by vitamin E. In a related
study, an experiment with α-tocopherol transfer protein (α-
TTP) knockout mice showed that serum deficiency of vitamin
E protects against cerebral malaria (Herbas et al. 2010). This
suggests that vitamin E is essential to the erythrocytic stage of
the parasite for normal growth. In fact, it has been shown that
vitamin E is synthesized in the intraerythrocytic stage of the
malarial parasite (Sussmann et al. 2011). This could explain,
at least in part, the ineffectiveness of the vitamin in retarding
the parasites’ proliferation despite its potent antioxidant activ-
ity in vivo.
The direct intraperitoneal administration of vitamin E on
malarial pathology was also investigated, both alone (Ibrahim
et al. 2012a) and in combination with vitamin C (Ibrahim et al.
2012b). At a dose of 1,000 IU/kg body weight, the vitamin
was found to ameliorate P. berghei-induced anemia, organ
weight changes and oxidative stress in mice. This result was
further improved in a combined therapy with 100 mg/kg body
weight of vitamin C (Ibrahim et al. 2012b). Interestingly, these
authors also reported the failure of the vitamin to lower
parasitemia levels in infected mice. Moreover, vitamin E also
increased membrane integrity of RBC (Iribhogbe et al. 2013)
which might reduce further infection of erythrocytes as well as
diminish the degree of anemia. Furthermore, the level of the
vitamin was observed to decrease in P. falciparum and P. vivax
infections with the corresponding increase in lipid peroxida-
tion (D’Souza and D’Souza 2006). The authors hypothesized
that the vitamin may provide protection against oxidative
stress in malaria (D’Souza and D’Souza 2006).
Based on the findings of the various studies mentioned
above, it seems that, in a pro-oxidant condition, vitamin E
deficiency offers protection against malaria. The vitamin also
antagonizes drugs that act via induction of oxidative stress on
the parasite, but could also protect malaria infected animals
against some of the deleterious effects of the disease. Hence,
the role of vitamin E in the pathogenesis of plasmodium
infections is situation-specific.
Vitamin C
The role of vitamin C in malaria management has been widely
investigated. High doses of the vitamin have been reported to
804 Parasitol Res (2014) 113:801–809

Table 2 The role of different antioxidants on the efficacy of anti-plasmodium agents

Antioxidant Plasmodium Anti-plasmodium Effect of antioxidant + Reference

species antiplasmodium

Vitamin E P. berghei Artesunate ↓ Awodele et al. (2007)

P. berghei Vitamin Ca ↑ Ibrahim et al. (2012b)
Vitamin C P. falciparum Coppera ↑ Marva et al. (1992)
P. falciparum Exofone +++ Winter et al. (1997)
P. berghei Benzophenone derivatives − Mahajan et al. (2005)
P. berghei Chloroquine ↑ Iyawe et al. (2006)
P. falciparum Ellagic acid ↓ Soh et al. (2012)
N-Acetylcystein P. falciparum Artesunate ↑ Treeprasertsuk et al. (2003)
P. falciparum Artesunate ↑ Arreesrisom et al. (2007)
P. falciparum Chloroquine − Arreesrisom et al. (2007)
P. falciparum Artesunate − Charunwatthana et al. (2009)
P. yoelii and P.berghei Desferroxamine and chloroquine/artesunate + Reis et al. (2010)
P. yoelii and P.berghei Desferroxamine + Reis et al. (2010)
P. falciparum Ellagic acid ↓ Soh et al. (2012)
Folate P. falciparum Sulfadoxine-pyrimethamine − Mbaye et al. (2006)
P. falciparum Sulfadoxine-pyrimethamine ↓ Carter et al. (2005)
P. falciparum Sulfadoxine-pyrimethamine ↓ Mulenga et al. (2006)
P. falciparum Atovaquone/proguanil − Mulenga et al. (2006)
P. falciparum Sulfadoxine-pyrimethamine ↓ Ouma et al. (2006)
P.berghei Chloroquine ↑ Iyawe and Onigbinde (2012)
Desferroxamine P. falciparum Chloroquine ↓ Vippagunta et al. (1999b)
P. yoelii Ellagic acid + Soh et al. (2012)
Dequalinium P.berghei Chloroquine ↑ Rodriguez and Gamboa (2007)

+++ Synergistic, + additive, − no effect, ↑ increased efficacy, ↓ reduced efficacy

a
Not an anti-plasmodium agent but were tested in adjunctive anti-plasmodium therapy

reverse the anti-plasmodium effects of cod liver oil, which
was known to induce oxidative stress on the parasite (Godfrey
1957). This was further explained by Marva et al. (1989) who
demonstrated that, in the presence of metal chelators, vitamin
C acts as an antioxidant and promotes P. falciparum growth.
However, the growth of the parasites was suppressed in both
infected glucose-6-phosphate dehydrogenase deficient
(G6PDH (−)) and G6PDH (+) erythrocytes treated with the
vitamin and copper. In the same report, treatment with the
vitamin alone suppressed parasites’ growth in G6PDH (−)
erythrocytes, while slight progression was observed in the
G6PDH (+) cells. These suggest that the vitamin acted as a
pro-oxidant in the presence of metal ions (Marva et al. 1989),
which is further supported with the observation that ascorbate
toxicity is aggravated with increasing iron availability (Higson
et al. 1988).
Subsequent research reported the detrimental effects of the
vitamin on the advanced forms of P. falciparum (Marva et al.
1992). This corresponds to the time of increased production of
redox active iron-containing compounds in the parasitized
erythrocytes. It thus appears that the pro-oxidant properties
of vitamin C are dependent on the growth stage of the parasite
and the availability of metal ions in the milieu of the host cell.
The in vivo synergistic antimalarial effect of some benzo-
phenone derivatives and vitamin C was investigated. Poor
synergism (5 %) was observed between the ketones and
vitamin C at a dose of 80 mg/kg body weight each. However,
at a subcutaneous dose of 180 mg/kg body weight, 25 % of
these benzophenone derivatives were active against P. berghei
in mice when given in mono therapy and 45 % were active
when co-administered with the iron chelator, rufigallol
(Mahajan et al. 2005). The lower doses of the ketones used
in the combined therapy may be the reason for the observed
poor synergism.
Contrary to these findings, vitamin C was reported to
augment the antimalarial effects of a different ketone,
exofone, against P. falciparum in vitro, with a possible pro-
oxidant activity (Winter et al. 1997). Furthermore, combined
administration of the vitamin with chloroquine at a dose of
25 mg/kg body weight each, restored oxidative stress in
female P. berghei-infected mice (Iyawe et al. 2006). The same
research group suggested that vitamin C is beneficial in the
Parasitol Res (2014) 113:801–809
management of oxidative stress and restores erythrocytes
fragility in P. berghei-infected mice (Iyawe and Onigbinde
2009). Also, co-administration of the vitamin with folate
significantly reduced lipid peroxidation in P. berghei infection
(Iyawe and Onigbinde 2011).
In a similar study, a dose of 100 mg/kg body weight of
vitamin C co-administered with vitamin E restored P. berghei-
induced organ weight alterations in mice (Ibrahim et al.
2012b). Although the treatment had no effect on the
parasitemia, it ameliorated the malaria-induced changes in
the oxidative stress markers as seen in the concentration of
malondialdehyde, and activities of catalase and superoxide
dismutase in the serum, liver and brain of the infected animals.
Thus, vitamin C was effective in the management of malaria
induced oxidative damage.
D’Souza and D’Souza (2006) reported the decrease in the
plasma level of both vitamins C and E in falciparum and vivax
malaria, suggesting their protective role during the infection.
The additive effects of these two vitamins could be explained
by the ability of vitamin C to regenerate α-tocopherol radicals
in the chain reaction of neutralizing free radicals by vitamin E
(Upston et al. 1999). From the above studies, it is evident that
vitamin C is beneficial in malaria management in conditions
that favor its pro-oxidant properties. It is also important in the
management of organ pathologies resulting from
plasmodium-induced oxidative stress.
N-Acetylcystein
This antioxidant has been popularly used as a safe treatment
for paracetamol overdose, due to its ability to stimulate the
synthesis of reduced glutathione which is necessary for de-
toxification of the generated radicals (Algren 2008).
Watt et al. (2002) carried out a placebo controlled adjunc-
tive therapy of NAC with quinine on P. falciparum infected
patients in Thailand. The NAC-treated group received a load-
ing dose of 150 mg/kg body weight NAC followed by 50 and
100 mg/kg body weight, 4 and 16 h later, respectively. All the
patients received intravenous quinine dihydrochloride before
the commencement of the NAC treatment. Findings from the
study revealed that, the raised serum lactate level, which is an
indicator for severe malaria, returned to normal twice faster in
NAC-treated patients than the placebo group. This suggests
that NAC accelerates recovery from severe malaria.
In another human-based study from Thailand, NAC treat-
ment at a loading dose of 140 mg/kg body weight over a 24-h
period was administered after a dose of artesunate followed by
eighteen 70 mg/kg body weight doses at a 4-h interval. This
resulted in a decreased mortality rate associated with severe
malaria (Treeprasertsuk et al. 2003). These studies seem to
suggest that NAC possess some additive effects on artesunate.
Contrary to these findings, in a larger study, 300 mg/kg
body weight of NAC administration was started 2 h after
805
artesunate and the NAC treatment had no effect on mortality,
serum lactate clearance or coma recovery (Charunwatthana
et al. 2009). Thus, in this study, NAC treatment seems to have
no effect on artesunate. Interestingly, Arreesrisom et al. (2007)
reported the antagonistic effects of NAC on artesunate when
incubated together for 6 h which was abolished after 24 h and
this interaction was not observed with quinine. Hence, the
additive effects of NAC on artesunate as observed by
Treeprasertsuk et al. (2003) and Watt et al. (2002) could be
due to the longer time of the NAC treatment and the different
drugs combination used. It is noteworthy that artesunate in-
duces oxidative stress in erythrocytes which may be countered
by NAC depending on the time of exposure. This suggests
that the two compounds could be antagonistic. This is further
supported by the observation that, ellagic acid, a drug that was
shown to possess antimalarial activity by interfering with
glutathione metabolism, was also antagonized by NAC (Soh
et al. 2012) possibly because the latter was known to replenish
in vivo glutathione levels (Algren 2008).
NAC was shown to restore RBC deformity caused by heme
products from the parasite under in vitro conditions
(Nuchsongsin et al. 2007). Furthermore, co-administration of
NAC and artemisinin reduced parasitemia and increased im-
mune response against P. berghei via enhanced interleukin-12
production more than the artemisinin alone (Fitri et al. 2009).
Hence, in addition to its antioxidant and glutathione
replenishing properties, NAC enhances the body’s natural
response to plasmodium infection.
In addition to these findings, other studies indicate that the
antioxidant property of NAC is important in the control of
pathologies such as cerebral malaria where oxidative stress is
a vital pathogenic mechanism. Experiments conducted with
mouse models of cerebral malaria revealed that treatment with
an antimalarial (either chloroquine or artesunate) and NAC/
DFO prevented both parasitemia and cognitive damage in-
duced by P. berghei and P. yoelii (Reis et al. 2010). Treatment
with either of the antimalarials alone did not prevent the
development of persistent cognitive damage. Likewise, NAC
and/or DFO did not prevent the progression of the parasite
proliferation in the infected mice. However, the combined
treatment resulted in the prevention of both parasite prolifer-
ation and signs of cognitive damage.
Thus, multiple studies of the NAC–malaria relationship
demonstrate that NAC is important in the management of
ROS-induced pathologies during malaria but may antagonize
the effects of antimalarials that act via induction of oxidative
stress or interfere with glutathione metabolism.
Folate
Although folate has been reported to be an effective free
radical scavenging agent (Joshi et al. 2001), its antioxidant
properties in malaria management have not received much
806
attention. One study demonstrated its effectiveness in allevi-
ating P. berghei-induced oxidative stress at a dose of 25 mg/kg
body weight (Iyawe and Onigbinde 2010). The same research
group also reported that folate improved the efficacy of chlo-
roquine and vitamin C treatment in P. berghei-infected mice
(Iyawe and Onigbinde 2012).
Apart from the reduction of oxidative stress, other effects of
folate administration in malaria management have been investi-
gated. Findings from folate supplementation study demonstrated
that the vitamin could improve malarial anemia (Mulenga et al.
2006) but concomitant supplementation with antifolates, such as
sulfadoxine-pyrimethamine to P. falciparum infected children
abolished those effects (van Hensbroek et al. 1995). Interesting-
ly, similar results were found in pregnant women where folate is
a routine supplement (Ouma et al. 2006). However, in contrast to
these observations, Mbaye et al. (2006) reported that folate does
not antagonize the efficacy of the antifolates in cases where there
is low resistance to the drugs.
In a more recent study, Salcedo-Sora et al. (2011) character-
ized two folate transporters in P. falciparum capable of re-
cycling the vitamin via the salvage pathway, in addition to its
de novo synthesis. This implies that the parasites, especially the
uninuclear trophozoites depend heavily on folate for DNA and
amino acid metabolism like most other rapidly dividing cells
(Dieckmann and Jung 1986; Nzila et al. 2005). It could thus be
deduced that although folate may be recommended in the man-
agement of anemia and oxidative stress, it can also aggravate the
proliferation of the parasite, which is detrimental to the host.
On the other hand, the administration of folate could be
beneficial to patients where the antimalarial is a non-antifolate
such as atovaquone/proguanil (AP). Mulenga et al. (2006)
reported a reduction in malarial anemia with folate and AP
treatments with no effect on parasitemia. On a general note, the
usefulness of folate administration during malaria appears to
depend on the type of treatment underway. Co-administration
of the vitamin with antifolates is generally not recommended
except in areas with low resistance to these drugs.
Desferroxamine
DFO, also known as desferrioxamine, is an iron chelator that
has anti-plasmodial activity independent of the iron status of
the host (Hershko and Peto 1988). It scavenges iron which is
necessary for the intraerythrocytic parasite growth and conse-
quently restricts the amount of the free metal ion, thereby
preventing a resulting ROS generation (Lytton et al. 1991).
It is thus considered as an antioxidant in vivo.
The sensitivity of plasmodia to iron deprivation was ini-
tially demonstrated by Raventos-Suarez et al. (1982), which
suggests that DFO and other iron chelators could be useful in
malaria chemotherapy. The authors demonstrated the in vitro
P. falciparum growth inhibition of DFO at a concentration of
60 μM, which is a tolerable dose in vivo. Pollack et al. (1987)
Parasitol Res (2014) 113:801–809
further reported the suppressive effects of continuous subcu-
taneous infusion of DFO on P. falciparum in aotus monkey.
To further assess the efficacy of the antimalarial effects of
DFO, a pilot study was conducted in P. falciparum and P. vivax
infected patients from Thailand (Bunnag et al. 1992). A 3-day
DFO daily treatment at 100 mg/kg body weight led to a total
clearance of the P. falciparum and P. vivax in 106 and 57 h,
respectively, in the infected patients. However, a relapse in all
the P. falciparum and 86 % of the P. vivax-infected patients
occurred 10 days after the commencement of the treatment
(Bunnag et al. 1992). These suggest that DFO is effective in
clearing Plasmodium parasites, but does not have an effect on
the gametocyte stage of the parasites.
The rate-limiting step for the action of DFO is permeation
into the plasmodium membrane. In one study, the membrane
permeability of DFO was improved via amino group modifica-
tion with N-methylanthranilate, and the derivative was taken up
faster than the free DFO (Loyevsky et al. 1993). Moreover, the
in vitro antimalarial action of the derivative was ten times greater
than free DFO. In a similar study, the erythrocyte membrane
permeability of DFO was found to be improved when it was
complexed with zinc (Chevion et al. 1995). This complex was
also effective in lowering the level of P. falciparum and inter-
fered with the life cycle of the parasite in vitro more than the free
compound, especially at lower concentrations.
These studies suggest that agents that modify DFO to
improve the membrane permeability might boost the efficacy
of DFO. Furthermore, co-administration of DFO with NAC
was observed to compliment both chloroquine and artesunate
in preventing oxidative stress-induced cognitive damage in
cerebral malaria caused by P. yoelii and P. berghei (Reis et al.
2010). Indeed, DFO was found to be necessary for the com-
bination to be effective in the prevention of cognitive damage.
The combined administration of DFO and ellagic acid on
P. yoelii infection was also reported (Soh et al. 2012). The
two compounds are interesting because they both possess
antimalarial and antioxidant activities and their combination
resulted in additive antimalarial effects.
DFO was also shown to interfere with hematin metabolism
in the plasmodium parasite (Baysal et al. 1990). Hence, it may
influence the effects of some antimalarials that target
hemazoin formation by the parasite, such as chloroquine
(Vippagunta et al. 1999a). Vippagunta et al. (1999b) demon-
strated the antagonistic effects of DFO against chloroquine in
P. falciparum trophozoites in vitro. On a general note, DFO
demonstrated promising results in adjunctive malaria therapy
but caution is needed when combining it with drugs that affect
hematin metabolism such as the quinines.
Other anti-oxidative agents
The influence of other antioxidants in malaria therapy has been
investigated to a lesser extent. Melatonin has been shown to
Parasitol Res (2014) 113:801–809
protect malaria-induced hepatocytes apoptosis through its anti-
oxidant activity. It acts via scavenging free radicals, maintaining
the level of glutathione and prevention of lipid peroxidation. At a
dose of 20 mg/kg body weight, the antioxidant improved liver
function of P. yoelii infected mice as manifested in the normal-
ization of indices of hepatic damage such as serum transami-
nases, alkaline phosphatase and bilirubin levels (Guha et al.
2007). However, melatonin may also act against plasmodium
parasites by a separate mechanism. Melatonin was shown to
interfere with mitochondrial Ca2+ homeostasis of plasmodia
(Gazarini and Garcia 2004), and this process leads to a disruption
in the intraerythrocytic cycle of the parasites (Hotta et al. 2000).
Another antioxidant, vitamin A, at a dose of 60 mg/kg body
weight, had good in vivo antioxidant activity and prevented
erythrocytes hemolysis caused by P. berghei (Iribhogbe et al.
2013). The serum level of vitamin A was found to be depleted
during falciparum malaria and tended to be restored with
recovery, which consequently resulted in improved liver func-
tion (Davis et al. 1994). This suggests the importance of vitamin
A in retarding organ pathologies during the malarial infection.
The antimalarial and antioxidant effects of dequalinium in
P. berghei were also investigated. Dequalinium was found to
restrict P. berghei proliferation in vitro via inhibition of
hemazoin formation and also through inhibition of the parasite
proteases involved in hemoglobin degradation (Rodriguez
and Gamboa 2007). Furthermore, dequalinium reduced
in vivo parasite proliferation in P. berghei-infected mice sim-
ilar to chloroquine and was found to augment the antimalarial
effects of the latter. Moreover, dequalinium remarkably mod-
ulated the oxidative status of P. berghei-infected erythrocytes
as manifested in increased superoxide dismutase activity and
decreased lipid peroxidation (Rodriguez and Gamboa 2009).
The activities of G6PDH, 6-phosphogluconate dehydroge-
nase, and the levels of glutathione-related enzymes were also
diminished by the compound. This effect on the primary
antioxidant defense system suggests that dequalinium in-
creases oxidative stress in the parasite but decreases lipid
peroxidation in the host cells. It is thus beneficial to the host
and detrimental to the parasite.
Conclusion
Modulation of plasmodium-induced oxidative stress is a
promising strategy in controlling parasitemia and the patho-
logical damage caused by oxidants. Antioxidants that act
strictly as free radical scavengers may ameliorate plasmodium-
induced organ pathology and cellular damage but unfortunately
tend to improve the survival of the mature parasite in the host.
Hence, the choice of which antioxidant to use in malaria therapy
depends on which aspect of malarial pathology one wishes to
target. For instance, the reported protective effects of antioxi-
dants on cognitive damage may stimulate antioxidant treatment
807
in cases where cerebral malaria is the primary concern. Com-
bined antimalarial treatment with antioxidants may also be
promising in combating oxidant pathological damage and
retarding the proliferation of the parasites. However, the right
combination of regimens is of utmost importance because in
addition to their antioxidant effects, some antioxidants possess
other mechanisms through which they interfere with the parasite
survival in the host. Other antioxidants interfere with the action
of antimalarial drugs. Combination of antioxidants that target
endothelium and antimalarials that specifically induce oxidative
stress within the parasite may be an optimum therapeutic strat-
egy in the treatment of malaria.
Acknowledgements We are grateful to Prof I. A. Umar for his valuable
comments during the initial preparation of the manuscript.
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