Plasmodium

25/02/2019 SS NGHOSHI
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 Objectives
• Discuss the classification of medically important
flagellates.
• Discuss the pathogenesis and clinical aspects of
infections.
• Describe the general epidemiological aspects and
transmission patterns of diseases caused by intestinal
and hemoflagellates.
• Identify the methods and procedures of laboratory
diagnosis of pathogenic amoeba in clinical specimens.
• Discuss treatment options for flagellates.
• Implement the preventive and control measures.
 Terminologies
• Trophozoites - growing forms of parasite in
RBCs, include ring forms.
• Schizont- form of sexual multiplication, it
mature when completed & immature when
multiplication starts.
• Schizogony- asexual reproduction in which
nucleus divides to many subsidiary parts
spontaneously, part is called merozoite & the
process takes place in liver & RBCs of man.
 Terminologies Cont.
• Sporogony- sexual reproduction resulting in the
formation of sporozoites, takes place in mosquito.
• Sporozoite- infective form of parasite for man.
• Gametocyte- Stage containing gametes. Gametes
contain male & female Xsomes & when they fuse form a
zygote.
• Ookinate- zygote capable of moving.
• Oocyst-settled down zygote
• Haemocoele- body cavity functioning as a vascular
system in an insect.
 Malaria
• Malaria (latin word: mala aria — "bad air"; formerly called ague
or marsh fever)
• Is an infectious disease that is widespread in many tropical &
subtropical regions caused by plasmodium.
• Four species
– Plasmodium vivax
– Plasmodium ovale
– Plasmodium falciparum
– Plasmodium malariae
– Plasmodium Kwnolesii
• Transmitted by infected female anopheles mosquito as a vector.
 Epidemiology
• About 3.2 billion people are at risk
• Malaria caused about 212 million infections
last year & approx. 429,000 deaths
• About 66% of deaths are for children under 5
• And 91% of all deaths occur in Sub-saharan
Africa (about one death every 2 minutes)!
• The vast majority of cases occur in children
under the age of 5 & pregnant women.
 Life cycle
• Two stages
– Final or definitive (invertebrate) Host - e.g.
Anopheline mosquito.
– Intermediate (vertebrate) Host - e.g. Man
• Firstly sporozoites enter the bloodstream as
mosquito takes its blood meal.
• Rapidly transported to the liver, & penetrate
hepatocytes
• Develop into exoerythrocytic schizonts.
Life Cycle of Plasmodium
 Life cycle cont.
• In P. vivax & P. ovale invasion of the hepatocyte, the dev”t of
schizont is retarded, & a Hypnozoite, is formed.
• Hypnozoites may later go on to develop giving recrudescences
(2mo) after treatment & clearance of bloodstream forms of the
parasite.
• There are two cycles of schizogony in the liver.
• The primary tissue schizont, formed directly by the sporozoite, (pre-
erythrocytic schizont) & secondary tissue schizont (exo-erythrocytic
schizont, & absent in P. falciparum ), formed from merozoites
derived from the primary tissue schizont.
• Both of these schizont stages release numerous merozoites, capable
of infecting RBCs & generating the bloodstream forms of the
parasite. This is repeated every 48 hours (P. falciparum, P. vivax & P.
Ovale -tertian) or 72 hours or longer (P. malariae - quartun)
 Life cycle cont.
• The blood stream forms of the malaria parasite consist of
– Early Trophozoite form, also a 'ring' form
– Late Trophozoite form, with a single nucleus
– early Schizont form,nucleus has started to undergo division
– Late Schizont form,cytoplasm has rounded up around the individual nuclei,
forming individual merozoites- merozoit form.
• All above forms are intracellular, late schizont bursts releasing
merozoites (No. varies between species, but is between 8 & 24).
• Episodes of fever are associated with rupture of the mature schizont
releasing merozoites & toxic metabolic breakdown of the malarial
metabolism.
• On infection of new RBCs, instead of forming trophozoites the
parasites may grow into immature gametocytes.
 Life cycle cont.
• To develop, merozoites are taken up in the blood meal of a
mosquito.
• Inside mosquito gametocytes mature to micro- & macrogametes.
• Male microgametes then undergoes exflagellation, (long motile
filaments develop).
• Fertilizes occurs, forming a zygote.
• Zygote forms an ookinete, which penetrates the midgut wall of the
mosquito, forming an oocyst.
• Within an oocyst asexual repdn.takes place, with the formation of
numerous sporozoites.
• When mature, the oocyst bursts open releasing sporozoites, which
migrate to insects salivary glands.
 Modes of transmission
• Mosquito bite
• Blood transfusion
• Transplacental
• Use of contaminated syringes & needles.
 Pathogenesis
• Parasite is protected from immune system because it’s within
liver & RBCs.
• Infected RBCs are destroyed in the spleen reading to
anaemia.
• P. falciparum has surface adhesive proteins (PfEMP1) which
have about 60 variations, the parasite switches between
many proteins, ( staying ahead immune system).
• P. falciparum parasite displays adhesive proteins on the
surface of the infected RBCs, causing cells to stick to the walls
of small blood vessels, thereby sequestering the parasite
from passage thru the general circulation & the spleen..
 Pathogenesis
• This "stickiness" causes hemorrhagic cplxs of
malaria.
• High endothelial venules can be occluded by the
infected RBCs, e.g. placental & cerebrum.
• In cerebral malaria the sequestrated RBCs affect
the integrity of BBB leading to coma.
• Blackwater fever
• Hypoglycemia
• High fever
 Clinical Findings
• Cough
• Fatigue
• Malaise
• Shaking chills
• Arthralgia
• Myalgia
• Paroxysm of fever, shaking chills, & sweats i. e, 48 h
for P falciparum, P vivax, & P ovale [or tertian fever]
; 72 h for P malariae [or quartan fever])
 Diagnosis
• Microscopy
– Thick & thin blood smears stained with Giemsa, Field’s, or Leishman or
Wrights stains.
– Asexual forms & gametocytes seen in P. Ovale, P. vivax & P. malariae but
not in P. falciparum which shows ring forms & gametocytes.
• Serology: IHA,ELISA
• Rapid diagnostic tests;
• HRP-II (histidine-rich protein) used for P. falciparum only,
• pLDH (parasite lactate dehydrogenase) detects live parasites.
• pAldo (Fructose-bisphosphate aldolase)
• Molecular methods; DNA probe, RNA probe, PCR, dot blot assay.
Diagnosis cont
Diagnosis cont.
Diagnosis cont.
Diagnosis cont
 Treatment
• Derivatives of Chinese shrub Artemesia anhua,
Coartem( Artemethinin+ Lumafantrin),
• Fansidar (Sulphadoxine + pyrimethamine),
• Halofantrine, mefloquin,
• Primaquin for radical cure
• Quinine.
• Doxycycline
• Resistance is evolving fast!
 Prevention.
• Proper treatment of cases
• Avoidance of mosquito bites
– Insecticide-impregnated bed nets,
• Vector control
– Spraying houses with residual insecticides,
– Envir’tal mgt to minimize potential mosquito
breeding sites or to make aquatic sites unsuitable
for the development of mosquito larvae.
 Prevention cont
• Prophylaxis
– chloroquine + proguanil, or mefloquine,
doxycycline, or sulphadoxine-pyrimethamine in
areas where chloroquine-resistant parasites are
found.
– IPT
• No prophylactic drug can guarantee full
protection.
• Vaccine is being developed
 Malaria vaccine- RTS,S
• Recently developed recombinant vaccine
• Consists of the P. falciparum circumsporozoite
protein from the pre-erythrocytic stage.
• CSP antigen causes the production of Abs
capable of preventing invasion of hepatocytes
& additionally elicits a cellular response
enabling the destruction of infected
hepatocytes
 BABESIA
• Babesia are small pyriform protozoan
parasites found in erythrocytes.
• Important species include Babesia bovis, B.
divergens & B. microti.
• Babesiosis is transmitted by ticks of the genera
Ixodes & Dermacentor.
• But it may also be transmitted through blood
transfusion.
• Incubation period is 1-2 weeks.
• B. microti is infective for man.
• B. gibsoni has also been reported in the USA in
a splenectomized soldier.
• Human babesiosis is more severe in the
elderly than in young.
• Splenectomized persons are particularly
affected & may develop progressive
haemolytic anemia, jaundice & renal
insufficiency with prolonged parasitaemia.
 Diagnosis
• Microscopic demonstration of babesia
parasites in stained blood smears.
• Staining can be done by Giemsa, Leishman
stains.
Diagnosis
 Treatment
• I.V clindamycin & oral quinine or I.V
atovaquone & I.V azithromycin to avoid acute
renal failure