Lesson 5: SPOROZOA (Plasmodium spp.

and Babesia • from Italian word “mal’aria” which means “bad air”
spp.)
• Considered to be the most important parasitic
disease affecting man (Belizario, 2015)

CLASSIFICATION OF PROTOZOAN PARASITES Vector: female Anopheles mosquito

(CONT.) 1˚: Anopheles minimus var. flavirostris
 Phylum Apicomplexa Babesia spp. Others: Anopheles litoralis
- Cryptosporidium hominis
- Cyclospora cayetanesis Anopheles maculates
- Isospora belli
Anopheles mangyamus
- Plasmodium spp.
- Toxoplasma gondii Final Host: female Anopheles mosquito
 Phylum Microspora Enterocytozon bineusi
Intermediate Host: Man
- Encephalitozoon spp.
- Vittaforma cornea Infective stages: sporozoites (man)
- Pleistophora spp.
gametocytes (mosquito)
- Brachiola vesicularum
- Microsporidium spp. NOTE:

- Peak – rainy season

- Mostly affected:
 Plasmodium spp.
 Young children: Chronic malaria leads to
- Plasmodium falciparum
anemia, impaired physical and mental growth
- Plasmodium vivax
and development
- Plasmodium malariae
 Pregnant women: Anemia is a leading
- Plasmodium ovale
contributor of maternal morbidity and mortality
- Plasmodium knowlesi
 Babesia spp Sexual and Asexual Cycle of Plasmodium spp.:
- Babesia microti
- Babesia divergens - Sexual cycle occurs in the Anopheles mosquito, the
invertebrate and definitive host.
*Plasmodium falciparum and Plasmodium vivax are - Asexual stage occurs in human, the vertebrate and
responsible for 90% of all human malaria cases intermediate host.
* 5th human malaria parasite is Plasmodium knowlesi

* 1st reported case (Philippines) – 2006

* Microscopically Plasmodium knowlesi is
indistinguishable with Plasmodium malariae – can only
be differentiate using Polymerase Chain Reaction (PCR)
Source of Exposure to infection:
Vector-borne (Arthropodborne)
Other modes of transmission:

1. Imported malaria - acquired by visitors or

Malaria residents of countries with endemic disease
2. Transfusion malaria - blood transfusion from
- WHO – classified as one of the 3 major disease infected donors
threats along with HIV/AIDS and Tuberculosis 3. Mainline malaria - injection drug user who
- HIV/AID – viral share needles and syringes
- Tuberculosis – bactrerial 4. Congenital malaria – rare but possible
- Malaria - parasitic - Ex. Mother to baby
Vector Biology : Anopheles flavirostris  Macrogamete (Female)
- Remember : Plasmodium falciparum (unique)
Aquatic Habitat: slow flowing streams; shaded

streams

Adult biting: Night biting (indoor and outdoor)

Adult resting: inside walls

LIFE CYCLE OF MALARIA

1. Sporogonic Cycle
2. Pre-erythrocytic or Exoerythrocytic cycle
3. Erythrocytic cycle

 Gametogony: formation of gametocytes (happens

in human body)

Sporogony: sexual cycle in the mosquito which lead to

the formation of sporozoites (happens on the body of
 Schizogony: formation of merozoites
mosquito)

SPOROGONY/GAMETOGONY Process: A. Pre-erythrocytic or Exo-erythrocytic cycle

Microgamete + Macrogamete  Zygote  Ookinete  Sporozoite infect liver parenchymal cells

Oocyst (if ruptured)  Sporozoite (infective stage)


Schizont (inside the liver)

 Microgamete (Male)

- remember : Plasmodium falciparum (kidney
shape) Liver cells rupture releasing the merozoites

B. Erythrocytic cycle

Schizogony (Asexual Cycle)

B. Erythrocytic cycle DEVELOPING TROPHOZOITES

Merozoites invade RBC



Ring Form (young trophozoite)



Mature Trophozoite

Schizont


Rupture of RBC releasing the merozoites - Plasmodium malariae – it have band formation
or prominent chromatin band pattern

IMMATURE SCHIZONTS – on RBC
Develop into a micro or macrogamete

NOTE:

- Merozoites invade the RBC but some merozoites

of Plasmodium vivax and Plasmodiuam ovale re-
Sinvade the liver cells forming “hypnozoites”.
- These dormant exoerythroxytic forms may remain
for quite years.

RING FORMS (EARLY TROPHOZOITES)

MATURE SCHIZONTS

- Plasmodiuam falciparum – it have accole

formation (ring found at the margin or periphery
of RBCs)
COMPONENTS OF MALARIAL LIFE CYCLE Periodicity/ Febrile Cycle

Species Febrile cycle Interval Common

(hours) victims

Plasmodium *Malignant 36-48 All

falciparum tertian

Plasmodium Benign 48 Young

vivax tertian

Plasmodium Quartan 72 Adult

malariae

Plasmodium Ovale 48 Young

ovale tertian

 Mosquito bites (Gametozytemic person) * Aestivoautumnal malaria – associated to P. falciparum

Mosquito Vector NOTE:

 Undergo fertilization (Sporogonic cycle) – - P. falciparum, P. vivax and P. ovale: paroxysms

Mosquito vector
 Infective period
Human Host
 Pre-patent period: interval from sporozoite
injection to detection of parasites in the blood
Incubation period: time between sporozoite
injection and appearance of clinical symptoms
 Clinical Illness – period that you’re infected
with malaria
 Recovery
occur on alternate days or every second day
(TERTIAN MALARIA)
- P. malariae: paroxysms occur on days 1 and 4, or
every third day (QUARTAN)
- Aestivoautumnal malaria: occurs most commonly
in late summer and autumn in temperature
regions.
- Interval between attacks is determined by the
length of the erythrocytic cycle (rupture of
mature schizont)
AGE OF INFECTED ERYTHROCYTES

INTERVALS Species Age of Infected

Eryhrocytes
Species Prepatent Incubation
peroid period P. falciparum RBC of all stages

Plasmodium 11-14 days 8-15 days P. vivax Young RBC

falciparum P. malariae Aging RBC

Plasmodium 11-15 days 12-20 days P. ovale Young RBC

vivax P. knowlesi RBC of all stages

Plasmodium 3-4 weeks 18-40 days

malariae *Blackwater fever – kidney infected with P. falciparum
Plasmodium 14-26 days 11-16 days resulting to marked hemoglobinuria
ovale
(acute renal failure, tubular necrosis, nephrotic
syndrome DEATH)
 Paramet P. P. vivax P. P. ovale Trophozoite (band form)
er falciparu malaria
m e P. malariae
1. Size of Normal Enlarge Normal Normal
RBC d or sl. - sl.
smaller enlarge
d
2. Usually Ameboi Band fimbriat
Trophoz not d form ed
oite present
3. no. of 8-36 12-24 6-12 in 8
merozoit rosette
e in form Mature schizont
schizont
4. Maurers, Schuffn Ziemm Schuffn (P. falciparum)
Stippling Stephens er’s ans er’s
s , (James)
Christoph
er
5. Ring Single, single Single Single
forms multiple
6. Single, Single, Single Single
Chromati double dense,
n dot big
Macrogametocyte and
7. Present
Applique microgametocyte (P. falciparum)
or accole
8. Macro- Large, Large, Large,
Gametoc cresent round, round, round,
yte Micro- oval oval oval
banana,
sausage
shape
9. Stages Ring all all all
in forms Schizont (P. malariae)
peripher and
al gametoc
blood ytes

Trophozoite (ring form)

P. falciparum
Pathology
CLASSICAL MALARIA PAROXYSMS – attack or sudden
fever
a. Cold stage
- sudden coldness and apprehension
- mild shivering turns to teeth chattering and
shaking of the
- whole body
- may last for 15 to 60 minutes
b. Hot stage/ flush phase : best stage to collect blood
sample
- high temperature (40-41˚C), headache,
palpitations,
- epigastric discomfort, thirst, nausea and
vomiting
- patient is confused and delirious
- may last for 2 to 6 hours
c. Sweating stage (Defervescence or Diaphoresis)
- profuse sweating, temperature lowers and
symptoms
- diminishes
- may last for 2 to 4 hours
NOTE:
- There is no absolute clinical feature of malaria
except for regular paroxysms (sudden attack or
violent expression) of fever with asymptomatic
intervals.
Pathology
1. Recrudence – renewal of parasitemia or its clinical
features arising from persistent undetectable
asexual parasitemia in the absence of exo-
erythrocytic cycle
- (early stopping of medication)
NOTE:
- renewed outbreak of the disease, the disease is
reduced to the point where it is undetectable
but still persists in the body and reoccur
(generally due to stopping the treatment early)
after some days or weeks
2. Relapse – renewed asexual parasitemia following a
period in which the blood contains no detectable
parasites.
- common to P. vivax and P. ovale infections, as
result from the reactivation of hypnozoite
forms of the parasite in the liver
NOTE:
- suffering deterioration after a period of
improvement, premature stage of organism
resides in the body in dormant form causes
disease after recovering completely from
previous occurrence of the disease.
-
3. Cerebral Malaria – diffuse symmetric
encephalopathy, retinal hemorrhages, bruxism,
mild neck stiffness. If left untreated may lead
Diagnosis
1. Microscopy (Gold Standard) - “Thick and Thin Blood
Smear”
- stained with Giemsa or Wright’s stain
- perform multiple sets of blood films (blood
collected every 6 to 12 hours for up to 48 hours)
Manner of Reporting
A. Qualitative
+ = 1-10 parasite/100 thick field
++ = 11-100 parasite/100 thick field
+++ = 1-10 parasite/thick field
++++ = more than 10/ thick field
B. Quantitative
Malaria parasite/ uL =
no. of parasites x 8, 000
200 WBC
2. Quantitative Buffy Coat (QBC) – uses a special
capillary tube with acridine orange
(+) bright green and yellow under fluorescent
microscope
3. Rapid Diagnostic Test (RDT) – detects Plasmodium-
specific antigens in finger prick sample
A. Histidine-rich protein II (HRP II) – water
soluble CHON produced by trophozoites
and young gametocytes (e.g., Paracheck Pf
test, ParaHIT f test)
B. Plasmodium LDH – produced by both sexual
and asexual stages and can distinguish
between P. falciparum and non-P.
falciparum (Diamed Optimat IT)
4. Serologic Tests (IHA, IFAT, ELISA)
5. Molecular Methods through PCR (low cases and
mixed infection)
Treatment
a. Protective (Prophylactic) - used before
infection occurs or before it becomes
evident
b. Curative (Therapeutic) - action on
established infection
c. Preventive - deterrence of infection of
mosquitoes with the use of gametocidal
drugs to attack the gametocytes in the
human host
 Arthemether-Lumefantrine (Coartem TM) – first
line drug for confirmed P. falciparum cases. Not
recommended in pregnancy, lactation & infants
 Quinine (plus Tetracycline or Doxycycline) – second
line drug for confirmed P. falciparum cases which AL
fail or not available
 Quinine IV drip – drug of choice for complicated or
severe P. falciparum malaria
 In addition to AL and Q+T,D, Primaquine is given on
the 4th day as single dose to prevent transmission
Chemoprophylaxis: Mefloquine & Doxycyline
NOTE:
- Chloroquine: resistant to Plasmodium
falciparum but still sensitive to Plasmodium
vivax.
Prevention
1. Use of mosquito repellant
2. Use of Insecticide treated nets (ITN)
3. Take Prophylactic medication
4. Wearing of light-colored clothing which cover
most of the body
Control
1. Environmental cleanliness (stream cleaning to
speed up water flow and exposing to sunlight)
2. Indoor residual spraying
3. Zooprophylaxis – use of carabao to deviate
mosquitoes
4. Use of biologic control methods
a. Bacillus thuringiensis – larvicidal
b. Larviparous fishes (e.g., Oreochromis
niloticus)
Resistance to Malaria
1. Most Africans and American Blacks
(Duffy antigen negative)  Fy(a-b-)  Resistant
to P. vivax and P. knowlesi
2. Those with Hemoglobinopathies (S, C, E and
thallasemia)
3. G6PD deficient individuals
Plasmodium knowlesi
- A primate malarial parasite common in SEA
- Causes malaria in long tailed macaques (Macaca
fascicularis)
- May also infect humans
- The appearance of P. knowlesi is similar to that
of P. malariae.
- PCR assay and molecular characterization are
the most reliable methods for detecting and
diagnosing P. knowlesi infection
*however, P. vivax appears to interfere PCR testing
(cross-reactivity)
Babesia spp. Diagnosis
(Babesia microti & Babesia divergens) 1. Microscopy of the Giemsa-stained peripheral blood
smear
- First described to cause “Texas cattle fever or
A. Merozoites in Maltese cross arrangement
red water fever”  B. divergens
B. Ring form àmost frequent intraerthrocytic
- Blood parasites that cause malaria-like
form found
infections
2. PCR (gold standard)
- “Babesiosis” – pathology due to Babesia spp.
3. Immunofluorescent assays (IFA)
- Parasites divide through binary fission or
4. Immunochromatographic test (ICT)
budding
- Cycle in the tick is still uncertain

NOTE: Tick, Splenic or Nantucket fever Treatment

Vector: Ticks (Ixodes scapularis)
- Hard ticks
- Scapularis – capable of carrying
Borrelia burgdorferi  CA of Lyme disease
 Clindamycin – Drug of choice
 Drug combination: Clindamycin and Quinine or
Azithromycin and Atovaquone
 Chloroquine – former drug of choice (it only
improve the symptoms but not the degree of
the parasitemia)

Infective Stage: sporozoites In the Philippines: human babesiosis is not yet reported
however, it could be present in dogs. (B. canis)
Diagnostic stage: “Maltese cross” arrangement of the

merozoites and ring-form trophozoite

Prevention and Control
Primary host: Man
- avoidance of places where ticks are usually
Intermediate host/ vector: ticks
found
Other modes of transmission: - wearing of light-colored pants tucked into one’s
socks
- Blood transfusion - tick check (especially for children)
- Organ transplantation - Rodent population should be controlled
- Transplacental route

Pathology
- Associated with excessive pro-inflammatory
cytokines such as the tumor necrosis factor
(TNF)
- Most cases are subclinical and may occur as
self-limiting
- Headache, high-grade fever, chills, vomiting,
myalgia, DIC, hypotension, respiratory distress
and renal insufficiency.