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Benign malaria: 3 stages----afebrile intervals-----periodicity of paroxysm of fever (tertian or quartan) Typical periodicity is absent in non-immune individuals Infection with-----P.vivax----chronic course with periodic relapse P. ovale------generally mild P. malariae-----less severe but may cause nephrotic syndrome in children
Cont..
1- Fever: probably due to IL-1 & TNF- released by macrophages 2- Anemia: parasite destroy large no. of RBCs---hemolytic anemia------results extreme fatigue and weakness Causes:- (a)haemolysis of infected & uninfected RBCs, (b) Dyserythropoiesis, (c) depletion of folate stores, (d) splenomegaly---erythrocyte sequestration & haemodilution
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3- Brown malarial pigment----Hb derivative--released from ruptured shizonts---discolors liver, spleen and bone marrow 4- Phagocytic defense mechanism-----marked hyperplasia of phagocytic cells throughout the body----splenomegalyalso liver in long standing cases 5- Immunity---gradually develops---untreated patient survive---episodes become less severe
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Plasmodia differ greatly in their ability to multiply in RBCs Pv--- prefer to invade young RBCs 1-2 % Pm---- prefer to invade older RBCs Pf---- invade all ages of RBCs 5-8% or even more
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Malignant Malaria----P.falciparum---if untreated life threatening complications develop Pernicious malaria---complex life threatening complications---occurs in heavy infections, >5% RBCs are infected.
Pathogeneis of P.falciparum
1- Erythrocytic schizogony---occurs in deeper capillaries of internal organs (brain, heart, liver, spleen, lungs, intestine, placenta and bone marrow)----obstruction & blood flow to organs
Cont.
2- Alteration on RBCs membrane---surface changes of deformed prasitised RBCs---make them sticky to adhere one another on capillary endothelium-----sequestration of infected RBCs in capillaries of internal organs------congestion, hypoxia, blockage & inflammation 3- High level parasitaemia----30-40% RBCs may infected.
Immunity
4- Ovalocytosis gene ; deletion of eryt. Band 3 gene---RBCs are rigid resistant to invasion 5- Malnutrition and Iron deficiency 6-Infants are immune coz fetal Hb (Hb-F)
Congenital malaria
Transplacental infection
Can be all 4 species Commonly P.v. and P.f. in endemic areas P.m. infections in nonendemic areas due to long persistence of species
Neonate can be diagnosed with parasitemia within 7 days of birth or longer if no other risk factors for malaria (mosquito exposure, blood transfusion) Fever, irritability, feeding problems, anemia, hepatosplenomegaly, and jaundice
Malaria Diagnosis
Clinical Diagnosis Malaria Blood Smear Fluorescent microscopy Antigen Detection Serology Polymerase Chain Reaction
Clinical Diagnosis
Hyperendemic and holoendemic areas Laboratory resources not needed Fever or history of fever Sensitivity ranges from poor to high Often has poor specificity and predictive values Overlap with other syndromes
Threshold of detection
thin film: 100 parasites/l thick film: 5 -20 parasites/l
Requirements: equipment, training, reagents, supervision Simple, inexpensive yet labor-intensive Accuracy depends on laboratorian skill
THIN FILM
fixed RBCs, single layer smaller volume 0.005 l blood/100 fields good species differentiation requires more time to read low density infections can be missed
lysed RBCs larger volume 0.25 l blood/100 fields blood elements more concentrated good screening test positive or negative parasite density more difficult to diagnose species
Blue cytoplasm
SCHIZONT
GAMETOCYTE
Ring form
Schizont
Trophozoite
Gametocytes
Plasmodium falciparum
Infected erythrocytes: normal size
Rings: double chromatin dots; appliqu forms; multiple infections in same red cell
Gametocytes: mature (M)and immature (I) forms (I is rarely seen in peripheral blood) Schizonts: 8-24 merozoites (rarely seen in peripheral blood)
Plasmodium vivax
Infected erythrocytes: enlarged up to 2X; deformed; (Schffners dots)
Plasmodium ovale
Infected erythrocytes: moderately enlarged (11/4 X); fimbriated; oval; (Schffners dots) malariae - like parasite in vivax - like erythrocyte
Trophozoites: compact Rings Schizonts: 6-14 merozoites; dark pigment; (rosettes) Gametocytes: round-oval
Plasmodium malariae
Infected erythrocytes: size normal to decreased (3/4X)
Trophozoite: compact
Trophozoites
Schizonts
Gametocytes
Fluorescent Microscopy
Modification of light microscopy Fluorescent dyes detect RNA and DNA that is contained in parasites Nucleic material not normally in mature RBCs Kawamoto technique
Stain thin film with acridine orange (AO) Requires special equipment fluorescent microscope Staining itself is cheap Sensitivities around 90%
Monoclonal and polyclonal antibodies used in antigen (Ag) capture test Species- and pan-specific Ab Cannot detect mixed infections Cross reactivity with rheumatoid factor reportedly corrected
A: HRP-2 (histidine-rich protein 2) (ICT) B: pLDH (parasite lactate dehydrogenase)(Flow) C: HRP-2 (histidine-rich protein 2) (PATH)
pLDH is found in sexual and Water-soluble protein is released from parasitized RBCs asexual forms
Differentiation between malarial species is based on antigenic differences between pLDH isoforms
Does not cross react with other Can differentiate between P.f. species P.v., P.o., P.m. and non-falciparum malaria Does not cross react with human LDH Positive only in viable parasites, potentially useful for monitoring success of treatment
Cannot detect mixed infections Cannot detect mixed infections Sensitivity and specificity decreases < 100 parasites/l Can remain positive up to 14 days post treatment, in spite of asexual and sexual parasite clearance, due to circulating antigens Sensitivity and specificity decreases < 100 parasites/l
Definitive species-specific diagnosis now possible Can identify mutations try to correlate to drug resistance Parasitemia not quantifiable May have use in epidemiologic studies Requires specialized equipment, reagents, and training
Real-Time PCR
New technique based on fluorescence Promising because it has potential to quantify parasitemia, decreases contamination, may detect multiple wavelengths in same tube identifying multiple species in one run, saves hands-on time
Treatment
Quinine Chloroquine Primaquin Pyrimethamine +salfadoxine Fanssidar Newer drugs; halofantrine, artemisinin
Vaccines Cont
2- Vaccines against asexual form; surface Ag of trophozoites and schizonts: characterized and cloned-----under trail 3- Antigametocyte vaccine; aim to control malaria transmission: under trial
Vaccines in use
1- Spf 66; widely tested synthetic vaccine :contains epitope of Ag present on sporozoite & asexual stage---moderate reduction in malaria during field trials in Colombia, Tanzania & Gambia 2- vaccines using candidate molecules including antigametocyte vaccine; breaking malaria transmission