MALARIA

HISTORY OF “Malaria” = Mal (bad) + aria (air)

MALARIA
Earlier believed to spread through bad air from marshy land

Alphonse Laveran (1880) – Discovered Plasmodium in RBC

Ronald Ross (1897) – Mosquito transmission proved (India)

TU Youyou (2015) – Discovered Artemisinin

CAUSATIVE AGENT
MALARIA LIFECYCLE
ROLL NO 35
 HOST :- Plasmodium Completes Its Lifecycle In Two Hosts
1. Definitive Host – Female Anopheles Mosquito (Sexual Cycle)
2. Intermediate Host – Man (Asexual Cycle)
Anopheles Culicifacies In Rural Areas, Anophelese Stephensi In Urban
Areas
 Human Cycle
• By Bite Of Female Anopheles sporozoites (Infective Form)
Enters Blood Circulation
• It Can Rarely Transmit Through Blood Transfusion
• In Humans Asexual Cycle Occurs Which Consists Of
1. Pre Erythrocytic Schizogony (In Liver)
2. Erythrocytic Schizogony (In Rbc)
3. Gametogony
 PRE ERYTHROCYTIC STAGE
• Occurs In Liver
• No Liver Injury Occurs As Only Few Cells Are Affected
• Hypnozoites – Some Sporozoites Of P. Vivax And P. Ovale Do Not
Develop Further And Remain in Liver As Hypnozoites And Cause
Relapse Of Malaria After Many Years
 ERYTHROCYTIC SCHIZOGONY
• Merozoites Attack Rbc
• Merozoites Enter RBC And Get Transformed Into Trophozoites
• Trophozoites Have Different Stages – Early(signet Ring) And Late
(Amoeboid Form)
• Late Trophozoites Undergo Schizogony And Produce 6-30 Merozoites
• Rbs Ruptures To Release Daughter Merozoites Dur To Which Fever In
Seen
• After A Series Of Erythrocytic Cycles Some Merozoites Transform Into
Sexual Forms Called Gametocytes (Male And Female)
• Intra Erythrocytic Life Cycle Takes 48-72 Hours
 MOSQUITO CYCLE
• Gametocytes Enter Into Mosquito With Blood Meal
• Male Gametocyte Undergo Exflagellation And Form Microgametes
• Female Develop Into Macrogamete.
• Fertilisation Occurs And Zygote Form Which Further Develops Into
Ookinete And The Oocyst
• Oocyst Undergoes Sporogony (Meiosis) To Produce 4 Spindle
Sporozoites.
• The Time Required To Complete Life Cycle In Mosquito Time Required
Is 1-4 Weeks.
 PATHOGENESIS
AND
CLINICAL FEATURES
Incubation Period
• The incubation period: the time between infection and appearance of the first
symptom
• It varies between the species-
1. P. vivax: 14 days
2. P. falciparum: 12 days
3. P. malariae: 28 days
4. P. ovale: 17 days
Benign Malaria
• Milder in nature
• Can be caused by all four species

Febrile Paroxysm

Anemia Splenomegaly
Febrile paroxysm
• Fever comes intermittently depending on the species. The appearance of
paroxysm corresponds to the release of the successive broods of merozoites into
the bloodstream, at the end of each RBC cycle
• Febrile episodes occur:
• every third day (48 hours cycle for P. vivax, P. falciparum, and P. ovspecies) and
• every fourth day (72 hours cycle for P. malariae).
• Each paroxysm of fever is comprised of three stages such as—
• cold stage
• hot stage
• sweating stage.
Anemia & Splenomegaly
1. Anemia: It results from the lysis of RBCs due to the release of merozoites.
• Anemia is severe in most cases of P. falciparum as it infects RBCs of all age
groups
• P. vivax and P. ovale infect the young RBCs and reticulocytes
• P. malariae infects old RBCs.

2. Splenomegaly: It occurs due to the massive proliferation of macrophages

inside the spleen to remove the parasitized and nonparasitized coated RBCs.
Falciparum Malaria (Malignant Tertian Malaria)
• Sequestration of the parasites: ability to sequester (holding back) the parasites
in the blood vessels of deep visceral organs like brain, kidneys, etc.
• This leads to blockage of vessels, congestion, and hypoxia of internal organs.
• Sequestration is mediated by:
• Cytoadherence: It refers to the binding of infected erythrocytes to
endothelial cells. It is mediated by a specialized antigen called as falciparum
erythrocyte membrane protein-1 (PfEMP-1), which binds to specific receptors
present on the vascular endothelium of deep organs
• PfEMP-1 also helps in binding of infected RBCs to uninfected RBCs by a
process called rosetting
• Since the parasites are sequestrated back in deep vessels, they can avoid
frequent spleen passage, and hence can escape splenic clearance.
Plasmodium falciparum rosetting
(a) Rosetting in a Plasmodium falciparum in-vitro culture, observed after preparation of a Giemsa-stained
thin smear and light microscopy.
(b) Schematic representation of P. falciparum rosette formation in the microvasculature.
Complications of Falciparum Malaria
1. Cerebral malaria: most serious complication seen in falciparum malaria. It
results due to the plugging of brain capillaries by the sequestered parasitized
RBCs leading to vascular occlusion and cerebral anoxia
2. Pernicious malaria: It is characterized by black water fever, algid malaria, and
septicemic malaria
3. Blackwater fever: This syndrome is characterized by sudden intravascular
hemolysis followed by fever, hemoglobinuria, and dark urine.
4. Algid malaria: Characterized by cold clammy skin, hypotension, peripheral
circulatory failure, and profound shock
5. Other complications: Pulmonary edema and adult respiratory distress
syndrome, hypoglycemia, renal failure, bleeding/disseminated intravascular
coagulation, severe jaundice, severe normochromic and normocytic anemia
Blackwater Urine
Chronic Complications of Malaria
1. Tropical splenomegaly syndrome: It results from an abnormal immunologic
response repeated malaria infections and is characterized by— elevated IgM
and massive splenomegaly
2. Quartan malarial nephropathy: It is seen with P. malariae, characterized by
nephrotic syndrome due to immune complexes mediated injury of renal
glomeruli
3. Promotes Burkitt’s lymphoma: Malaria-induced severe immunosuppression in
African child provokes Epstein-Barr virus infection to develop Burkitt’s
lymphoma.
Transfusion Malaria
• Malaria can be transmitted by blood transfusion, needle stick injury, or organ
transplantation. The clinical features are same as for mosquito-borne malaria, but
differs in many other ways:
1. Infective form may be RBC forms such as merozoites, trophozoites or
schizonts but not sporozoites.
2. There is no liver stage and no relapse, therefore radical chemotherapy with
primaquine is unnecessary.
3. The incubation period is often short.
Malaria in Pregnancy
• Malaria during pregnancy increases the risk of fetal distress and can result in
premature labor, low birth weight and stillbirth.
• In areas with high malaria transmission, pregnant women are particularly
vulnerable to severe anemia, hypoglycemia, and acute pulmonary edema.
Why Laboratory Diagnosis is Essential
Clinical features like fever, chills, headache are non-specific, so confirmation requires laboratory testing.
Specimen Collection
Sample Best timing

•Peripheral blood •During fever spike or just before it

Types of samples
• Finger-prick capillary blood (field)
• Venous blood with EDTA (hospital)

Repeat sampling

If first smear is negative:

• Repeat every 6–12 hours × 3 samples

Microscopy (Gold Standard)
Microscopic examination of blood smear remains the gold standard.

1. Thick Blood Smear 2. Thin Blood Smear

Purpose:Detection of malaria parasite and More sensitive Purpose:Species identification and Parasite morphology
Why more sensitive? Advantages:RBC morphology preserved
• Blood is concentrated (RBCs are lysed) Allows identification of:Species
• Parasites are easier to find • Stage of parasite
Advantages: • Parasitemia %

• Detects low parasitemia (as low as 5–10 parasites/µL) Disadvantage:

Disadvantage: • Less sensitive than thick smear
• Species identification is difficult

Staining Method
Most commonly:

• Giemsa stain
• Parasite cytoplasm → blue
• Chromatin → red/purple
Rapid Diagnostic Tests (RDTs)
Used when microscopy is unavailable.

Principle:

Immunochromatographic detection of parasite antigens.

Quantitative Buffy Coat (QBC)
Principle:

• Blood centrifuged in capillary tube

• Parasites concentrated in buffy coat
• Stained with acridine orange
• Seen under fluorescence microscope
Molecular Diagnosis (PCR)
Uses:

• Low parasitemia cases

• Mixed infections
• Research and confirmation
Diagnostic Approach
01 02 03

Suspected malaria case: If smear negative but suspicion Severe/complicated case

high
• Peripheral smear microscopy • Parasite count
• Thick smear → detection • Repeat smear • PCR if needed
• Thin smear → species • Do RDT
 LEISHMANIASIS

ROLL NO.-47
 INTRODUCTION
• Hemoflagellates are the flagellated protozoa that are found in
peripheral blood circulation.
• Examples include Leishmania and Trypanosoma; both are
transmitted by the bite of the insect vector.
• They have an oval to elongated body, nucleus, and a single
flagellum arising from kinetoplast.
• Kinetoplast represents multiple copies of mitochondrial DNA. The
intracellular portion (root) of the flagellum is called as the
axoneme.
• Based upon the arrangement of the flagellum, they exist in four
morphological stages :
1. Amastigote form: Round to oval, lacks flagellum .
2. Promastigote form: Lanceolate shaped; kinetoplast is anterior
to nucleus and flagellum arises from the anterior end .
3. Epimastigote form: Elongated, kinetoplast is placed close to the
nucleus. Flagellum arises from the lateral side .
4. Trypomastigote form: Elongated, kinetoplast lies near the
posterior end. Flagellum arises posteriorly.
• In Leishmania amastigote and promastigote forms are seen.
❑ Amastigotes are diagnostic form, found in man .
❑ Promastigotes are infective stage to man, found in insect vector

• Apurba Sastry
 LEISHMANIASIS
• Leishmaniasis is caused by an obligatory intracellular protozoa of
the genus Leishmania, which primarily affects the reticulo-
endothelial system of the host.
❖ Vector: Female sandfly
❖ Clinical forms:
❑ Visceral leishmaniasis(VL)
❑ Post-kala-azar dermal leishmaniasis(PKDL)
❑ Cutaneous forms: Occurs in various forms such as cutaneous
leishmaniasis (CL), diffuse cutaneous leishmaniasis (DCL),
leishmaniasis recidivans (LR) and mucocutaneous leishmaniasis
(MCL) .
❖ Subgenera: L. Leishmania (L.L.) and L. Viannia (L.V.).
 CLASSIFICATION
➢ Old and New World: Depending up on the geographical
distribution, leishmaniasis is classified into two groups :
 VISCERAL
LEISHMANIASIS
 cause of VISCERAL LEISHMANIASIS

OLD WORLD SPECIES NEW WORLD SPECIES

• LEISHMANIA INFANTUM • LEISHMANIA CHAGASI

• LEISHMANIADONOVANI
(most common)
 LIFE CYCLE
VERTEBRATE:MAN,DOG ,RODENTS

TWO HOSTS
INVERTEBRATES : FEMALE SANDFLY

INFECTIVE FORM : PROMASTIGOTE (FOUND IN ALIMENTARY CANAL OF FEMALE SANDFLY)

 PATHOGENESIS

Infected female sandfly bite (Phlebotomus spp.)

Inoculation of PROMASTIGOTES into human skin

Promastigotes are phagocytosed by macrophages & dendritic cells

Inside macrophages → transformaƟon into AMASTIGOTES (Leishman–Donovan bodies)

Amastigotes multiply by binary fission within macrophages

Rupture of infected macrophage

Release of amastigotes → infection of new macrophages

Dissemination through reticuloendothelial system (RES)

 PHAGOCYTOSIS IS FACILITATED BY
SURAFEANTIGENS

GP-63 (glycoprotein-63) LPG (lipophosphoglycan)

• LPG VIRULENCE FACTOR

PREVENT PHAGOSOME MATURATION AND PROTECT PARASITE AGAINT HYDROLYTC ENZYMES

• GLYCOSYL-PHOSPHATIDYL-INOSITOL (GPI) MAJOR SURFACE PROTIEN

PROTECT PARASITE FROM PHAGOLYSOSOMAL ATTACK
 CLINICAL FEATURES
• INCUBATION PERIOD:2-6MONTHS

PENTAD

FEVER PROGRESSIVE HEPATOSPLENOMEGALY HYPERGAMMAGLOBULINEMIA PANCYTOPENIA

WEIGHT LOSS

• FEVER : abrupt in onset , moderate to high and associated with chills and rigor
• SPLENOMEGALY : most consistent sign , enlarged (soft nontender friable)
• Lymphadenopathy : African ENDEMIC REIGON , inguinal and femoral
• HYPERPIGMENTATION:INDIAN VL , face feet and abdomen
• PEDAL EDEMA AND ASCITES
• MUCOSAL LEISON
• LEISHMANOMA : nodular skin lesion, seen in African case only
HEMATOLOGICAL ABNORMALITY : pancytopenia and hypergammaglobulinemia
•
Post-kala-azar Dermal Leishmaniasis (PKDL):
• chronic, non-ulcerative skin manifestation that appears after treatment of
visceral leishmaniasis (VL) caused by Leishmania donovani.
• Occurs in 2–50% of Treated VL Patients (After Antimonials)
• Usually 6 months – 5 years after treated VL.
• Geographical Distribution:India (especially Bihar, Jharkhand, West
Bengal),Bangladesh,Nepal,Sudan and East African countries.
• Vector involved: Phlebotomus argentipes (India)

• PATHOGENESIS: After VL treatment-

• Parasites are cleared from viscera
• Some remain in skin macrophages
• Immune response shifts (↓ Th1, ↑ IL-10)
• Parasites multiply in dermis
• Skin lesions appear
• Evolution of Skin Lesions:

• Can Occur Without History of VL.

• Diagnosis: By detection of amastigotes in the nodular lesions and by
serological tests such as direct agglutination test (DAT) and antibodies to
rK39 antigen; positive in most of the cases

Amphotericin B is the drug of choice, given for 4 months.

 Leishmaniasis with HIV Co-infection
• Co-infection reported from:Southern Europe (France, Italy, Spain, Portugal),
Africa (Ethiopia, Sudan),Brazil,India (Bihar, sub-Himalayan region, North India)

🔁 Mutual Interaction
[Link] of Leishmania on HIV: 2. Effect of HIV on Leishmania:
• Leishmania infection activates macrophages • HIV suppresses Th1 response
• Increases expression of CCR5 receptors • Promotes Th2 dominance
• Reactivates latent HIV • Reduced IFN-γ production
• Increases HIV viral replication • Poor macrophage killing ability
• 👉 Disease progression of HIV becomes faster. • 👉 Leads to:Severe disease,Atypical
presentation,Frequent relapse.
Clinical Features:
In HIV co-infected patients, apart from the
classical features of VL, other forms such as
CL, MCL, PKDL, and atypical presentation
such as chronic diarrhea and pleural effusion
may be observed .

Diagnosis:
• Antibody detection tests are usually negative .
• Amastigotes are demonstrated from unusual sites such
bronchoalveolar lavage fluid and buffy coat region of blood.
 Laboratory Diagnosis :
1. Microscopy
When to Suspect VL?
In endemic area, suspect VL if: [Link]
• Fever > 2 weeks [Link] Detection
• Splenomegaly [Link] Detection
• Weight loss 5. Molecular Methods
• Pancytopenia 6. Leishmanin Test (Montenegro Test)
→ Laboratory confirmation is essential 7. Animal Inoculation
[Link] Tests
 • MICROSCOPY(Gold Standard):
• Demonstration of amastigotes inside macrophages(Leishman-Donovan bodies / LD
bodies)
• Stains used:Leishman stain,giemsa stain,wright stain

SPECIMENS:
• Splenic aspiration → Most sensitive
• Bone marrow aspiration → Most common specimen
• Lymph node aspiration
• Liver biopsy
• Peripheral blood smear (especially in HIV patients)
• Biopsy of various organs (in HIV patients)
• 🔎 Finding:
Macrophage filled with amastigotes (LD bodies)
• CULTURE:
Detects: Promastigote forms
• Used for:
-Species identification
-Drug sensitivity testing
• Media used:
-NNN medium
-Schneider’s liquid medium

• ANTIBODY DETECTION :
• Detect antibodies in serum:
• ELISA
• IFA
• Direct Agglutination Test (DAT)
• ICT using rK39 or rKE16 antigens
• ⚠️Usually positive in classical VL
• ⚠️May be negative in HIV co-infection
 • Leishmanin Test (Montenegro Test)
It is a skin test to detect delayed hypersensitivity to a
suspension of killed L. donovani promastigote injected
intradermally.

™ Positive test (induration of >5 mm in 72 hours) indicates

prior exposure to Leishmania antigens. Therefore, it is
useful for epidemiological survey to estimate the burden
of the disease.

™ It is positive in people with good CMI: Asymptomatic

individuals, cutaneous leishmaniasis, after recovery from
VL and leishmaniasis recidivans

™ However, this test is negative when CMI is low: Such as

in case of active VL and diffuse CL.
 Treatment:
• Pentavalent antimonials
• Liposomal Amphotericin B
• Miltefosine
• Paromomycin
• Immunotherapy (Interferon-γ)
FILARIASIS
Roll no. 39
Learning objective
• Introduction
• Epidemiology
• Life cycle and pathogenesis
• Clinical features
• Laboratory diagnosis
• Prevention and Elimination
• Treatment
FILARIAL NEMATODE
• Vector borne parasite
• Common agents – W. bancrofti , B. malayi ,Loa Loa ,Manosonella ,
Onchocerca volvulus
• Reside in lymphatic system , skin , subcutaneous tissue
• Clinical manifestation are lymphatic filariasis and cutaneous and ocular
filariasis
• Morphology
Adult worm – long , slender , cylindrical , dioecious
Larvae –four larval stage , delicate transparent body
Microfilariae – diagnostic form in blood
Filariform larva – infective form to man
LYMPHATIC FILARIASIS
• Causative agent – Wuchereria Bancrofti
Brugia malayi
Burgia timori
• Transmitted by mosquitoes
• Feature – chronic obstruction , fibrosis of lymphatics , hydrocele ,
elephantiasis
EPIDEMIOLOGY
• 893 Million people affected in 49 countries
• Majorly in south and South & Southeast Asia ,Sub-Saharan Africa ,
Western Pacific , Parts of Latin America
• In India - common in UP , Bihar , Jharkhand , Odisha
- 40% Of global burden
 LIFE CYCLE
• Definitive host – Man
• Intermediate host – Mosquito

• vector - Culex quinquefasciatus ( main)

- Anopheles
- Aedes ( rare )
PATHOGENESIS and PATHOLOGY
• Adult worm blocks lymphatic vessels
• Lymphatic inflammation
• Lymphedema and elephantiasis
• Enhanced granulomatous reaction and fibrosis of lymph vessels

• Factors responsible for pathologic change

Adult worm into lymphatics
Antigen and toxic metabolite from adult worm
Hosts inflammatory response
CLINICAL FEATURES
• Incubation period 8-16 month
• Asymptomatic microfilaremia - no symptoms
- microfilariae in peripheral blood
- microscopic hematuria
• Acute filariasis - filarial fever
-lymphatic inflammation
-transient local edema
-dermatolymphangitis
• Chronic filariasis – 10-15 yr after infection
- granuloma formation and fibrosis of lymph
vessels
- lymphatic obstruction and pedal edema
- common manifestations elephantiasis and
hydrocele
- chyluria
• Tropical pulmonary eosinophilia
-hypersensitivity reaction to microfilaria
trapped in lungs initiating allergic response
 LABORATORY DIAGNOSIS
• Microscopy – direct wet mount , peripheral blood smear
• Antigen detection – monoclonal antibody against Og4c3 and AD12 is
used
• Antibody detection
Flow through assay – IgG antibody to recombinant filarial
WbSXP antigen
Luciferase immunoprecipitation system- detects
antibody against by using Wb123 antigen
• Imaging methods – ultrasound ,X-ray
• Molecular method – PCR and real-time PCR
• other method – eosinophilia, elevated IgE , Biopsy of enlarged lymph
node
 PREVENTION
• Vector control
- anti larval measures – mosquito larvicidal oil ,
pyrethrum oil , fenthion oil
- anti adult measures – pyrethrum spray
• Personal protective measure
• Lymphatic filariasis elimination
- National vector borne disease control programme
- WHO recommended Mass drug administration
TREATMENT
• Diethylcarbamazine (for 12 days) - kill both adult worm and
microfilariae
• Albendazole ( for 21 days) – active against adult worm and
microfilariae
• Ivermectin – can kill microfilariae but no effect on adult worm
KEY TAKEAWAYS
• Main cause [Link]
• Main transmission by culex mosquito
• Chronic case – elephantiasis and hydrocele
• Prevention - Vector control
• Treatment - diethylcarbamazine
THANK YOU