Malaria

Prof. Ahmed A Adeel

Malaria Species

• Four species of malaria :

– Plasmodium falciparum: malignant tertian malaria

– Plasmodium vivax: benign tertian malaria– Plasmodium ovale : benign tertian malaria– Plasmodium malariae: quartan malaria

Estimated incidence malaria episodes(caused by any species)

resulting from local transmission, country level averages, 2004

Exo-erythrocytic (hepatic) cycle

Hypnozoites

Sporozoites

Salivary Gland

LIFE CYCLE OF MALARIALIFE CYCLE OF MALARIA

Gametocytes

Erythrocytic Cycle

Zygote

Oocyst

Stomach Wall

Pre-erythrocytic (hepatic) cycle

sporozoites

Components of the Malaria Life CycleComponents of the Malaria Life Cycle

Mosquito Vector

Human Host

Sporogonic cycle

Infective Period

Mosquito bitesgametocytemic person

Mosquito bitesuninfected person

PrepatentPeriod

Incubation Period

Clinical Illness

Parasites visible

Recovery

Symptom onset

CLINICAL SIGNS & SYMPTOMSCLINICAL SIGNS & SYMPTOMS

Hot stage

Cold stage

Sweating

Plasmodium falciparum::

Plasmodium vivax,

Plasmodium ovale

Plasmodium malariae\:

Chronic Disease

Chronic Asymptomatic

Infection

PlacentalMalariaAnemia

InfectionDuring

Pregnancy

Developmental Disorders;

Transfusions;Death

LowBirth weight

IncreasedInfant

Mortality

Acute DiseaseAcute Disease

Non-severeAcute Febrile

disease

CerebralMalaria

Death

CLINICAL PICTURECLINICAL PICTURE

Uncomplicated malaria

• Uncomplicated malaria is defined as: Symptomatic infection with malaria parasitemia without signs of severity and/or evidence of vital organ dysfunction .

Malarial Paroxysm

cold stage•feeling of intense cold •vigorous shivering •lasts 15-60 minutes

hot stage •intense heat •dry burning skin •throbbing headache •lasts 2-6 hours

  sweating stage •profuse sweating •declining temperature •exhausted and weak → sleep •lasts 2-4 hours

Severe malaria • Severe malaria is defined as symptomatic malaria in a patient with P. falciparum

asexual parasitaemia with one or more of the following complications:– Cerebral malaria (unrousable coma not attributable to other causes). – Generalised convulsions (> 2 episodes within 24 hours) – Severe normocytic anaemia (Ht<15% or Hb < 5 g/dl)– Hypoglycaemia (glood glucose < 2.2 mmol/l or 40 mg/dl )– Metabolic acidosis with respiratory distress (arterial pH < 7.35 or bicarbonate < 15

mmol/l) – Fluid and electrolyte disturbances– Acute renal failure (urine <400 ml/24 h in adults; 12 ml/kg/24 h in children) – Acute pulmonary oedema and adult respiratory distress syndrome– Abnormal bleeding– Jaundice– Haemoglobinuria– Circulatory collapse, shock, septicaema (algid malaria)– Hyperparasitaemia (>10% in non-immune; >20% in semi-immune)

Complications of malaria :

Cerebral malaria

Complications of malaria :

Pulmonary oedema

Child with severe malaria anaemia and no other malaria complication

Complications of malaria :

anaemia

Child with severe malaria anaemia in conjunction with acidosis and respiratory

distress

Clinical Picture :

Patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency may develop intravascular haemolysis and haemoglobinuria precipitated by primaquine and other oxidant drugs, even in the absence of malaria. Haemoglobinuria associated with malaria (“blackwater fever”) is uncommon and malarial haemoglobinuria usually presents in adults as severe disease with anaemia and renal failure.

Malarial haemoglobinuria

Laboratory diagnosis of malaria

Laboratory diagnosis of malariaLaboratory diagnosis of malaria

Laboratory diagnosis of malariaLaboratory diagnosis of malaria

CCMOVBD Plasmodium falciparum CCMOVBD Plasmodium vivax

CCMOVBD Plasmodium malariae Malaria Tutorials, Wellcome Trust Plasmodium ovale

Laboratory diagnosis of malariaLaboratory diagnosis of malaria

Features of Plasmodium

CCMOVBD

Nucleus/chromatin dot

Cytoplasm

Stippling

Vacuole

Laboratory diagnosis of malaria

3. Gametocyte

The Malaria Parasite

Three developmental

stages seen in blood

films:

1. Trophozoite

2. Schizont

CCMOVBD CCMOVBD

Trophozoites

CCMOVBD

GametocyteSchizont

CCMOVBD

Laboratory diagnosis of malaria

Plasmodium falciparum (trophozoite stage)

Diagnostic Points:• Small, regular, fine to fleshy

cytoplasm• Infected RBCs not enlarged• Numerous, multiple infection

is common• Ring, comma, marginal or

accole forms are seen; often have double chromatin dots

• Maurer’s dots not clearly visible

CCMOVBD

Multiple infection

Double chromatin

Marginal form

Laboratory diagnosis of malaria

Plasmodium facliparum

Laboratory diagnosis of malaria

Rapid diagnostic tests detect malaria antigens

Laboratory diagnosis of malaria

Plastic cassette format of RDT

Rapid diagnostic tests detect malaria antigens

Rapid diagnostic tests detect malaria antigens

ACTION OF ANTIMALARIAL DRUG IN THE DIFFERENT LIFE ACTION OF ANTIMALARIAL DRUG IN THE DIFFERENT LIFE STAGES OF THE MALARIA PARASITESTAGES OF THE MALARIA PARASITE

Wellcome Trust (Modified)

Tissue SchizontocidesTissue Schizontocides•PrimaquinePrimaquine•PyrimethaminePyrimethamine•TetracyclineTetracycline•ProguanilProguanil

Anti-relapse (P.vivax)•primaquine

Blood Schizontocides•Chloroquine•Sulfadoxine/Pyrimethamine•Quinine•Quinidine•Artemisinins

GametocyideGametocyidePrimaquinePrimaquine

SporontocidesSporontocides•PrimaquinePrimaquine•PyrimethaminePyrimethamine•ProguanilProguanil

Main Malaria Control Measures

1. Early diagnosis and treatment of cases

2. Vector control : • adult mosquitoes :insecticides • mosquito larvae: draining

breeding sites 3. Reducing vector-human contact: bed nets

, repellents

4. Early detection and control of epidemics

Malaria Prevention in Travelers:

(1) Specific chemoprophylaxis( http://www.who.int/ith/en/ )

(2) Avoiding contact with malaria vectors ( repellents , bed nets)

(3) Stand-by treatment , early diagnosis and treatment