Plasmodium

The malarial parasites of man are species of the Genus Plasmodium, a name which means a multinucleated mass and in which the asexual cycle (schizogony) takes place in the red blood cells of vertebrates and the sexual cycle (sporogony) in mosquitoes

Stages of development

Trophozoite

This is the earliest stage with one nucleus living inside the red cell. The early trophozoite is ring-shaped with a red chromatin dot small amount of blue cytoplasm when stained with Giemsa or Wrights stain.

Schizont

This stage is provided with nucleus divided into 8 24 nuclei. Each nucleus enclosed by some cytoplasm forming a merozoites.

Gametocytes

Sexual forms with one large compact and round or elongated nucleus.

Plasmodium falciparum
Malignant Tertian Malaria

Young trophozoite

Mature trophozoite

Mature trophozoite

Schizont

Schizont

Merozoites

Gametocyte

Gametocyte

Maurers dot

Plasmodium vivax
Benign Tertian Malaria

Young trophozoite

Young trophozoite

Mature trophozoite

Schizonts

Merozoites

Gametocyte

Shuffners dots

Plasmodium ovale
Benign tertian malaria

Young trophozoite

Mature trophozoite

Schizont

Gametocyte

Plasmodium malariae
Quartan malaria

Young trophozoite

Schizonts

Gametocyte

Life cycle

The life cycle of Plasmodium is passed in two hosts, a vertebrate host and a mosquito. The asexual cycle in the vertebrate host like humans consists of schizogony, which leads to formation of merozoites and gametony, which leads to the formation of gametocytes.

The sexual cycle in mosquito is sporogony, which leads to the formation of sporozoites.

Asexual phase in man (Schizogony)

Pre-erythrocytic schizogony

The infectious sporozoites from the salivary glands of an infected female Anopheles enters a liver parenchymal cell undergo nuclear division and cytoplasmic division and give rise to merozoites.

The duration of the preerythrocytic phase

Plasmodium falciparum = 5 7 days Plasmodium vivax = 6 8 days Plasmodium ovale = 5 days Plasmodium malariae = 13 16 days merozoites to initiate the erythrocytic cycle.

Exo-erythrocytic schizogony

In P. vivax and P. ovale, not all liberated merozoites from the liver parenchymal cells infect the red blood cells. Some infect other liver cells and continue the process of schizogony as the exo-erythrocytic cycle.

The merozoites formed are responsible for the relapse in cases of infection with these species of Plasmodium. Some schizonts called hypnozoites even become dormant and when activated by still unknown factors cause relapse even after a long period of time.

Erythrocytic schizogony

The merozoites formed in the preerythrocytic cycle invade red blood cells through the erythrocytic surface receptors. These released merozoites and other metabolites cause the typical intermittent chills, fever and sweating.

Inside the red blood cells, there is development into trophozoites, then schizont, the rupturing of the cell and the re-invasion of new cells.

Gametony

Some of the merozoites released from the red blood cells do not undergo schizogony nor infect more red blood cells, but they develop into male and female gametocytes which are infective to the mosquito.

Sexual phase in mosquito (Sporogony)

The male and female gametocytes sucked in by the mosquito during blood meal undergo maturation and differentiate into microgametes (male) and macrogametes (female). The microgamete exflagellates and produce 8 sperm like microgametes, fertilizes the macrogametes, producing zygote.

The zygote becomes motile and penetrates the mosquitos gut as an ookinete, Develops into oocyst. Oocyst undergoes division (sporogony), giving rise to many sporozoites, which is the infective stage to man.

When an infected mosquito bites man, the sporozoites from its salivary glands are inoculated through the skin into the circulation. The entire developmental cycle in mosquito takes 8 35 days.

Pathology

The appearance of clinical manifestations in cases of malaria is 8 40 days depending of the species involved. The clinical incubation for the different species is as follows: P. falciparum = 8 15 days P. vivax = 12 20 days P. ovale = 11 16 days P. malariae = 18 40 days

Prodromal symptoms

Include a feeling of weakness and exhaustion; aching toes, limbs and back; a desire to stretch and yawn; loss of appetite; headache; nausea and vomiting.

Malaria is characterized by malarial paroxysm, which occur at the end of the schizogonic cycle, when the merozoites of the mature schizonts are released from infected RBC into the blood circulation.

Three stages of malarial paroxysm

Cold stage (chill) The cold stage starts with a sudden feeling of cold, mild shivering that quickly turns into violent teeth chattering and shaking of the whole body. The peripheral blood vessels are constricted and these stage usually last for 15 minutes to 1 hour.

Hot stage (fever) The patient becomes hot wherein the body temperature increases up to 103F to 106C F ( 39 to 41C). Other manifestations include nausea, vomiting, headache, rapid pulse, hot skin, flushed face and the patient may become confused or delirious. This phase last for 2 to 6 hours.

Wet stage (sweating) Patient perspires profusely.

The interval between attacks is determined by the length of the erythrocytic cycle

P. malariae, 72 hours, causing paroxysms on days 1 and 4, hence the term quartan malaria P. falciparum, it is 48 hours P. vivax and P. ovale, paroxysms occur on alternate days, hence the term tertian malaria.

Plasmodium falciparum is the cause of virtually all fatalities due to vascular obstruction. The infected RBC has the tendency to stick to the endothelium of blood vessels and to each other The ability of P. falciparum to infect red blood cells of all ages and thus produce a high parasitemia.

P. falciparum may enter the kidney, brain and liver. Kidney involvement, known as black water fever, usually results in marked hemoglobinuria, caused by P. falciparuminduced red cell destruction. Acute renal failure, tubular necrosis, nephrotic syndrome and death may result.

P. vivax and P. ovale invade only the young or immature RBC P. malariae can infect mature or older RBC.

Diagnosis

P. falciparum it is 11 14 days; P. malariae, 3 4 weeks; P. ovale, 14 26 days P. vivax, 11 t0 15 days. The interval of time from sporozoite inoculation to detection of parasites in the blood is dependent on the prepatent period

Thick and thin blood smears stained with Giemsa or Wrights stain is examined microscopically for Plasmodium. Blood maybe collected any time.

Serological tests

IHA and ELISA. The Quantitative Buffy Coat (QBC) method uses a specially prepared capillary tube coated with acridine orange. Malaria parasites take up this stain and appear bright green and yellow when viewed under a fluorescent microscope.

The ParaSight F test is a dipstick test for the simple and rapid diagnosis of P. falciparum infection.

Treatment

The drug of choice for the treatment of malaria is Chloroquine. Pyrimethamine/sulfadoxine combination or quinine maybe used in areas where there maybe higher levels of resistance to chloroquine. Treatment also includes general and supportive measures. If fluid replacement or blood transfusion is necessary, it must be administered with care to avoid pulmonary edema.