PROTOZOA DARAH

(MALARIA)

dr. DWI HANDAYANI, MKes

Staf Bagian Parasitologi
Fakultas Kedokteran Unsri
 Curriculum Vitae
Personal Details
Name dr. Dwi Handayani, M. Kes
Phone +62 8127824209 / 089627007479
E-mail dwih.dr@gmail.com/ wie_dr@yahoo.com

Education
1999-2005 Medical Doctor (Sriwijaya University)
2010-2013 Biomedical Science Majoring Medical Parasitology
(Sriwijaya University)
Work
2009 – Now Lecture at Parasitology Department
WHY WE HAVE TO STUDY
PARASITOLOGY?
IS PARASITOLOGY SOMETHING FUN?
 Alumni FK Unhas
 Mengabdi di daerah
terpencil di Papua
 Meninggal akibat
terserang malaria
 15 May 2015

MAY ALLAH SWT BLESS HIM

 Today’s Learning Objectives
Malaria I :
to know the etiology of malaria
to know the life cycle of Plasmodium
to know morphology of Plasmodium
to know the epidemiology of malaria

to know the clinical symptoms of malaria

Malaria  Infectious disease
PlasmodiumP .falciparumP .malariae
P.vivaxP
.ovaleP .knowlesP
i.cynomolgi
Endemis di 105 negara di
dunia
40% of the world's population
lives in endemic areas
149-303 million clinical cases
peryear
236-635 thousands deaths
(WHO Report, 2015)

60% penduduk Indonesia

tinggal di daerah endemis 9
 MAP OF MALARIA ENDEMICITY AT
DISTRICT/MUNICIPALITY LEVEL IN INDONESIA, 2010

Source: DG of Disease Control and

(Yoes Prijatna Dachlan,2013)
Environmental Health, Ministry of Health
RI, 2011
Impact of malaria

 Malaria causes about 350-500 million

infections in humans and approximately one to
three million deaths annually.
 The vast majority of cases occur in children
under the age of 5.
 Pregnant women are also especially vulnerable.
Monkey plasmodium
 P. knowlesi
 1st report in Malaysia
 Kalimantan (2010)
 Similar as P. falciparum and P. malariae

 P. cynomolgi
 Plasmodium knowlesi

• The most commonly reported

primate malaria zoonosis in
Southeast Asia
• The most common and most
pathogenic form of human malaria
in Malaysia
• Main reservoir hosts are Macaques
and Leaf Monkeys
• Traditionally misdiagnosed as
other forms of human malaria
• The early sexual stages resemble
P. falciparum
• Mature parasites resemble P.
malariae (band forms)
• Molecular diagnosis is the only
sure way of confirming P.
knowlesi infection
Morphology:

- Chromatin
- Cytoplasm
- Pigment
- Granula
 Life cycle
- Intrinsic phase:
in the vertebrate host,
asexual  schizogony

 Extrinsic phase:
in the female
anopheles mosquito,
sexual  sporogony
Life cycle Plasmodium
 Life cycle ofP.vivaxorP.ovale
Man Female anopheles
In the liver
Hypnozoite sporozoite

Schizont

oocyst
merozoite

In RBC
TROPHOZOITE

SCHIZONT MEROZOITE ookinete

MAKROGAMETOCYTE makrogamete
zygote
MIKROGAMETOCYTE mikrogamete
 Life cycle in video

D:\Pict and Vid\Video\Malaria\The Malaria life cycle explained. Should interest

a lot of people..mp4
Physiology
Latent period in the body :
- P. falciparum : shortest
- P. malariae : longest

RBC: sumber energi untuk parasit

RBC: Heme (iron porphyrin) + Globin (protein)
Heme  toksik bagi parasit  polimerisasi 
hemozoin -> hematin (pigmen malaria)
 For survival the malarial parasites
need: CHO; PROTEIN; FAT

Besides they also need:

 Methionin
 Riboflavin
 Para-aminobenzoic acid
 Panthotenic acid
 Vit C
MORFOLOGI
 Trofozoit muda (Ring Form) Trofozoit tua

Gametosit
Skizon muda

Skizon
 Plasmodium vivax
menyebabkan malaria vivaks (malaria tersiana)

O Stadium trofozoit dalam darah

Perubahan pada eritrosit
- eritrosit membesar
- ada titik SchÜffner

O Trofozoit aktif, ameboid

Infeksi multipel (kadang-kadang)
Pigmen berwarna kuning tengguli
Plasmodium vivax
stadium trofozoit
Plasmodium vivax
Stadium trofozoit lanjut
Plasmodium vivax

 stadium skizon
- inti banyak (12 - menjadi
24) merozoit
- pigmen berkumpul
Plasmodium vivax

stadium makrogametosit
mikrogametosit

mikrogametosit

makroganetosit
 Plasmodiummalariae
Menyebabkan: malaria malariae (malaria quartana)

Perubahan pada eritrosit

- eritrosit tidak membesar
- adanya titik Ziemann
Trofozoit tidak aktif (kompak)

Bentuk pita: pigment tengguli tua, kasar

Plasmodium malariae
Stadium trofozoit

Stdium trofozoit
Plasmodium malariae
stadium trofozoit lanjut
Plasmodium malariae
 stadium skizon
- inti 8 - 12 buah bentuk bunga
serunai (inti = merozoit)
- pigmen berkumpul di tengah
Plasmodium malariae
stadium gametosit
mikrogametosit

makrogametosit
 P. falciparum

 Penyebab malaria tropika atau tertiana

 Penyebaran tinggi di daerah tropis
 Indonesia: frekuensi tinggi
 Komplikasi berat - kematian
P. falciparum

Gambaran darah tepi

 Stadium trofozoit muda

Sediaan darah tipis

Pulasan Giemsa
Ciri-ciri:
- eritrosit : tidak
membesar
- parasit di tepi eritrosit
(accole)
P. falciparum

 Stadium trofozoit muda

Sediaan darah tipis
Pulasan Giemsa
Ciri-ciri :
- eritrosit :
tidak
membesar
- parasit
bentuk
cincinhalus
- tampak lebih dari satu
parasit dalam sebuah
P. falciparum

 Stadium skizon muda

( Jarang ditemukan dalam darah tepi)
Sediaan darah tipis
Pulasan Giemsa
Ciri-ciri:
- Eritrosit tidak membesar
- Parasit: jumlah inti 2 - 6
- pigmen
sudah
menggumpal,
warnanya hitam
P. falciparum

 Stadium skizon matang

Sedian darah tipis
Pulasan Giemsa
Ciri-ciri:
- eritrosit : tidak membesar
- parasit :
> biasanya tidak mengisi
seluruh eritrosit
> jumlah inti 8-24
- pigmen menggumpal
warna hitam
 P. falciparum

 Stadium makrogametosit
Sediaan darah tipis
Pulasan Giemsa
Ciri-ciri :
- eritrosit tidak membesar
- Parasit:
*bentuk pisang agak
lonjong
* plasma biru
* inti padat, kecil
* pigmen di sekitar inti
 P. falciparum

 Stadium mikrogametosit
Stadium Mikrogametosit
sediaan darah tipis
Pulasan Giemsa
Ciri-ciri :
-eritrosit tidak membesar:
-parasit :
* bentuk sosis
* plasma merah muda
* inti tidak padat
* pigmen tersebar
Plasmodium ovale
Morfologi : menyerupai P.
vivax
Kelainan eritrosit:
- bentuknya oval
- ujungnya bergerigi
- adanya titik James
Trofozoit tidak aktif
 Epidemiology of malaria

60o

Equator
30o

2,770 m above sea level  Cochabamba

400 m bellow “ “  Dead sea basin
 Anopheles mosquitoes

Vectors in indonesia:
 Anopheles annularis
 Anopheles vagus
 Anopheles barbirostris
 Anopheles aconitus
 Anopheles sundaicus
 Anopheles maculatus
 Anopheles balabacensis
 Anopheles punctularis
 Anopheles subpictus
 Ano;heles indefinitus
 *(Epidemiology)
*Endemic : connotes natural transmission in an area so that
there are autochthonous, locally contracted cases

*Imported malaria: is acquired outside the area

*Introduced malaria : cases derived from Imported malaria

*Sporadic : cases are few and scattered

Term- related epidemiology of malaria
 Masapra-paten:
Waktu antara permulaan infeksi (sporozoit masuk)
sampai parasit malaria ditemukan dalam darah tepi

 Masa inkubasi/tunas instrinsik:

Waktu antara permulaan infeksi sampai timbul gejala
klinis/demam

 Masa tunas ekstrinsik:

Waktu antara gametosit masuk ke dalam tubuh
nyamuk sampai terbentuknya sporozoit dalam
kelenjar ludah nyamuk
Malaria endemicity:

•The prevailing frequency and intensity of

endemic malaria.

•Classification of endemicity:
Based on spleen index (%) of children in age group
2-9, and the spleen rate of adult
 Parasitic rate
 Sporozoite rate

47
Classification of endemicity:

1. Hypoendemic malaria : spleen rate in age

group 2-9 ≤ 10%
2. Mesoendemic malaria :
“ “ “ “ “ 2-9: 11-50%
3. Hyperendemic malaria :
“ “ “ “ “ 2- 9 > 50% and adult
spleen rate increase
4. Holoendemic malaria : spleen rate in age
group 2-9 > 75% but adult tolerance high and
adult spleen rate decrease
Symptomatology
1. The febrile paroxysm may be divided into 3
clinical stages:
- cold stage (15-16 minutes)
- host stage (about 2 hours: 39-40o C)
- sweating stage (about 1 hour)

2. Secondary anemia
3. Splenomegaly
 The attack of paroxysm

O P.vivaxandP.ovale : 48 hours
O P.falciparum : 24-48 (36-48) hours
O P.malariaae : 72 hours
 GEJALA KLINIS
 Demam :
Masa inkubasi bervariasi 9 - 30 hari
( P. vivax strain tertentu  10 bulan)
 Didahului dengan sakit kepala, lemah, nyeri
otot dan nyeri tulang
 Kemudian terjadi “demam menggigil”=
malaria paroxysm

52
 GEJALA KLINIS
Faktor yang mempengaruhi demam:

- hitung parasit  jumlah parasit/l

- ambang demam  respons
imun hospes

53
 PATOFISIOLOGI GEJALA KLINIS

Ruptured schizont released merozoit and waste substances

(RBC products, hemozoin, GPI and others)

Activate macrophages and endothelial cells

Secrete cytokines and inflammatory mediators

(TNF, interferon, IL-1, IL-6, IL-8, limfotoxin, superoxide, NO)

Systemic manifestations
54
 *GEJALA KLINIS
*Anemia

1. Hancurnya eritrosit yang mengandung parasit

*Red cell rigidity and deformability  increase splenic clearance
2. Eritrosit normal tidak dapat hidup lama
3. Depresi sumsum tulang (diseritropoesis) oleh
sitokin
4. Hemozoin-induced apoptosis in developing
erytroid cells

*Pada P.falciparum terjadi secara akut

pada P. vivax terjadi seca5r6a kronis
GEJALA KLINIS

 Splenomegali

- Limpa membesar dan dapat diraba dalam 1 -

2 minggu setelah demam,
limpa mengecil setelah serangan demam
berakhir.
- peregangan kapsul limpa menyebabkan nyeri
 ruptura limpa

57
Lanjutan…..

 Pembesaran limpa terutama pada infeksi P. vivax,

paling jarang pada P. malariae

 Setelah infeksi berkali-kali, limpa fibrotik

dan mengecil (mendekati normal)

 Sehingga di daerah endemisitas tinggi, limpa pada

orang dewasa berukuran normal

58
 Today’s Learning Objectives
Malaria II :
to know the pathology of malaria
to know the severe malaria
to know the treatment of malaria
to know about resistency
to know the immunity of malaria
Mode of infections:
1. Bitten by female anopheles
2. Congenital
3. Transfusion
4. Organ transplantation

PATHOLOGY
1. Vascular blockade of vascular by parasistized rbc
 Rosetting
 Sitoadherens
 Sequestrasi
2. Anoxia (organ)
3. Deposition of pigments
PATHOLOGY
Malaria rosette
 Incubation period:

Pmalariae : 12-14 days(18-40 days)

Pf.alciparum : 10-12 days (8-11 days)

P.ovale : 10-12 days

P.vivax : 14-17 days (10-17 days)

Relaps pada malaria :

 Penyakit dapat bersifat menahun dan menimbulkan

relaps
 Relaps ada :
- rekurens (long term relaps) P. vivax
- rekrudesensi (short term relaps)
P. falciparum & P. malariae
 Pernicious manifestation

Warning signs:
asexual parasitemia ≥ 5%, 10 %
with multiple rings in red cells and
schizonts in peripheral blood

66
Pernicious manifestation:

 Cerebral malaria
 Malaria with jaundice
 Diarrhoea, dysentery
 Renal failure
 Pulmonary edema
 Black water fever
 Algic malaria, shock
 Hyperpyrexia
Algic malaria

A condition analogous to cerebral

malaria, except that the gut and other
abdominal viscera are involved.

The skin is cold and clammy, but internal

temperature is high.
 (Algic malaria)
 Two types:

Gastric : with persistent vomiting

Dysenteric : with bloody, diarrheic stools
containing enormous numbers of
parasites.
Definition of severe malaria (WHO)
One or more of the following criteria + the presence of asexual
parasitaemia defines severe malaria

1. Cerebral malaria/unarousable coma

2. Severe anaemia
3. Renal failure
4. Pulmonary oedema/adult respiratory distress syndrome (ARDS)
5. Hypoglycaemia
6. Hypotension/shock
7. Bleeding/disseminated intravascular coagulation (DIC)
8. Convulsion
9. Acidosis/ Acidaemia
10. Macroscopic haemoglobinuria
 Pathophysiology of Cerebral malaria:


 It is exactly not known

Proposed hypotheses:
1. Permeability hypothesis (Maegraith and fletcher)
2. Toxic/cytokine hypothesis
3. Mechanical hypothesis
 Black water fever

 Haemoglobinuria
 fever
 Nausia & vomitus
 Icterus
Pamaquine
quinine
(qinghousu)
Death due to Renal failure
 Diagnosis

1. Thick film (DDR)

2. Thin film
3. Q.B.C. (Quantitative Buffy Coat)
4. I.R.M.A. (Immunoradiometric assay)
5. Elisa for Ag p. falcliparum
(HRP-2 = histidine Rich Protlein-2)
6. RNA probe
7. DNA Hybridization
8. Rapid Manuel test (P.falciparum)HRP-II
also available for vivax
9. Indirect fluorescence Assay (IFA)
10. Polymerase Chain Reaction (PCR)
 D:\Pict and Vid\Video\Malaria\Laboratory
Diagnosis of Malaria.mp4
Pengobatan
Chemoprophylaxis
 Chloroquine: 300 mg base weekly
 Sulfadoxine 1 g + Pyrimethamine 50 mg
every two weeks
 Sulfadoxine .1.5 g + Pyrimethamine 70 mg
every four weeks
 Mefloquine: 5 mg/kg BB/weekly
(250 mg/tablet base)
Suppressive treatment:

 Chloroquine: 0.5 g weekly

Resistance of asexual parasites (P. falciparum)
to schizontocidal drugs (4-aminoquinolines)

Resistance:
The ability of a parasite strain to
survive and /or to multiply despite
the administration and absorption of
a drug given in doses equal to or
higher than those usually
recommended but within the limits of
tolerance of the subject.
Resistensi

Mengubah kebijakan pengobatan

malaria

Rekomendasi WHO:
Artemisinin based combination therapy (ACT):
e.g.: Artesdiaquine (Artesunate 50 mg + amodiaquine 200 mg).
Resistensi
 Terkait perubahan gen Plasmodium
 Pfcrt, Pfmdr1, DHFR, DHPS
 2012: My friend and I did the research to know the
resistance of chloroquine at South Sumatera based
on molecular genotyping
 See my online journal at
http://dx.doi.org/10.13181/mji.v23i1.679
 Kemampuan strain parasit
untuk tetap hidup dan/ atau
berkembangbiak walaupun Penggunaan antimalaria
pemberian dan absorpsi obat secara monoterapi ,
sesuai dosis standar / lebih kombinasi yang tidak
tinggi dari dosis yang rasional , ketidakpatuhan
direkomendasikan tetapi dalam pengobatannya
masih dapat ditoleransi oleh
hospes

WHO:
Interaksi ETF
obat, parasit, RESISTENSI LTF
dan manusia
ACPR

Penyebaran malaria ke
Mutasi spontan pada level
daerah-baru, munculnya
molekul yang mempengaruhi
kembali pada daerah
struktur dan aktivitas target
yang telah dieradikasi,
obat atau mempengaruhi
terjadinya epidemik dan
access obat terhadap parasit
memberatnya
target
manifestasi penyakit
 Early treatment failure:
One or two condition occur as bellow
within the first 3 days of treatment

- Parasitemia with complication of severe

malaria on day 1, 2 and 3.
- Parasitemia on day 2 > that on day 0
- Parasit count on day 3 > 25% of day 0
- Or the axial temperature: > 37.5°
 Late treatment failure:
if the following conditions occur on day 4 – 28, divided into 2 sub group:

1. Late Clinical (and parasitological) Failure (LCF)

- Parasitemia (the same species with that of day

0) complicated with severe malaria after day 3.
- The axial temperature > 37° C with parasitemia between
day 4 - 28.

2. Late Parasitological Failure (LPF)

Parasitemia (the same species with day 0) on day 7, 14 or 28 without
rising of the axial temperature (< 37° C)
 Immunologi of malaria

In the liver of man: Well developed

P. vivax
In liver of
chimpanse: Not develop

P. berghei The liver of mouse: 1%

In the liver of a tree rodent: 50%

Immunologi of malaria
 Species specific
 Strain specific
 Stage specific
 Age-dependant
 Slow to develop
 Antigenic diversity
 The immunity of malaria
The combination of those mechanisms which:
1. Prevent infection
2. Prevent reinfection
3. Prevent super infection

With the outcome of:

 Destruction of the malarial parasites
 Hindrance of their multiplication,
 Modification of their effects and
 Helping specifically for the repairing of
tissues.
 (Immunity of malaria)


1. Innate:
Such as:
- G6PD deficiency
- Duffy factor negative
- Sickle cell anemia
- Thallasemia Hb & Hb E
- Hb foetus of human
- ATP deficiency

2. Acquired
- Passive
- Active:
1. concomitant
2. residual
 (Immunity of malaria):

1. Non specific
RES
2. Specific: Gamma globulin
 lysin
 Agglutinin
 Precipitin
 Opsonin
 Ablastin
 Complement-fixing
 Cytoplasm-modifying
 In high endemic area of malaria:

infant<4 4 months- 3 10 -15 years adult

month years
Relative High Low parasite Low parasite
resistant to parasite rate rate rate
malaria
 Macrophage ← P. falciparum


Low level High level
TNF

Patologi
Protection

Inhibition of Dyserythropoisis Cytoadherence Clinical
parasites in: -Erythro phagocytosis manfestations:
Adherence of *
The liver & parasitized rbc to Such as:
RBC vascular Headache
Anemia endothelium
Fever
Chill etc.
 Referensi

1. Parasitology Protozoology and Helmintology

2. Basic Clinical Parsitology: Brown & Belding
K.D. Chatterjee
3. Clinical Parasitology: Paul Chester Beaver c.s.
4. The immunology of Parasitic infection
omar o. Barriga
5. Faundation of Parasitology
Gerald D. Schmidt & L.S. ROBERT
6. Atlas of Medical Helmintology & Parasitology: Jeffrey & leach
7. Modern Parasitology : Edited by F.E.G. Cox
8. Medical Parasitology, Apractical Approach
Edited by S. H. Gillespie and P. M. Hawkey
9. Perubahan Radidkal dalam Pengobatan Malaria di Indonesia
P.N. Harijanto. Cermin Dunia Kedokteran, 2006
9. Internet
SUMMARY
 D:\Pict and Vid\Video\Malaria\Malaria -
Plasmodium.mp4

 D:\Pict and Vid\Video\Malaria\Pathophysiology

Malaria.mp4
95