#4 malaria identification
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Malaria IdentificationIt is easier than you think!
Susan Flaker Johnson, MT(ASCP), MEPD
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Malaria Identification The learner will be able to:
Describe the symptoms of Malaria
Determine areas of the world where Malaria is endemic
Identify Malaria parasites within red blood cells
Identify the species of Malaria present within red blood cells
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What is Malaria?
Italian for “Mala Aria” or Bad Air
It was thought to be caused by breathing stale, warm, humid air found around swamps
It is the Mosquitoes, not the Bad Air
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Why Malaria? 3.3 billion people live in areas at risk for Malaria WHO estimates that in 2008 Malaria caused 190
- 331 million clinical episodes and nearly 1 million deaths
89% of those who die are in Sub Saharan Africa, and the majority of those are children
It is the 5th leading cause of death from infectious diseases worldwide (after respiratory infections, HIV/AIDS, diarrheal diseases, and tuberculosis)
It has increased in the last three decades
http://www.cdc.gov/malaria/about/facts.html
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Malaria in the Western Hemisphere
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx
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Malaria in the Eastern Hemisphere
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx
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Malaria in the USA Anopheles mosquitoes are found in the USA ~ 1500 cases are reported every year 1st and 2nd generation Americans returning to
their “home” countries are less likely to take prophylactic medication
1957 – 2009, 63 outbreaks of locally transmitted Malaria have occurred
1963 – 2009, 96 cases of transfusion-transmitted Malaria were reported
http://www.cdc.gov/malaria/about/facts.html
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Malaria in the USA
http://www.cdc.gov/malaria/features/2008_us_data.html
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Common Symptoms of Uncomplicated Malaria FEVER 100%
Chills Headache Nausea and Vomiting Myalgia
Thrombocytopenia Anemia Splenomegaly Hepatomegaly
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Symptoms of Severe Malaria Seizures, impairment of consciousness, coma Severe anemia Hemoglobinuria Acute respiratory distress syndrome (ARDS) Coagulopathies Acute kidney failure Low blood pressure caused by cardiovascular
collapse
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Diagnosis of Malaria Patient Symptoms and Physical Findings Patient History
Foreign Travel? Blood Transfusion?
Laboratory Testing Rapid Diagnostic Tests
False Negatives with low parasitemiaInsufficient data on P. ovale and P. malariaeCDC recommends all positives be followed up with Microscopy
PCR – Available through WSLH and CDCConfirmatory, but there is a delay
Microscopy – ConfirmatoryNeed for competent laboratory professionals
http://www.cdc.gov/malaria/diagnosis_treatment/rdt.html
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Specimen Requirements for Microscopy
FRESH EDTA whole blood
Thick and Thin Blood Smears – made within ONE hour
Giemsa stain is preferred
Wright’s Stain is OK for thin smears
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Malaria Cycles
SPECIES NAME RBC CYCLE PAROXYSM
CYCLE
P. vivax Benign Tertian 45 hours 8 – 12 hours
P. ovale Tertian 48 hours 8 – 12 hours
P. malariae Quartian 72 hours 8 – 10 hours
P. falciparum Malignant Tertian 48 hours 16 – 36 hours
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Species Distribution
Plasmodium vivax 50%
Plasmodium falciparum 43%
Plasmodium malariae 7%
Plasmodium ovale 2%
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Plasmodium vivax
Plasmodia in enlarged RBCs (retciulocytes)
Plasmodia in RBCs with Schuffner’s dots
Plasmodia with more than 12 chromatin masses
(usually 16 – 24)
Trophozoite tends to be amoeboid
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Plasmodium vivax
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Plasmodium malariae
Plasmodia in RBCs of normal size, usually in aging cells
Plasmodia in band stage
Plasmodia rarely have more than 12 chromatin masses (usually 6 – 12) and in a rosette
No Schuffner’s dots
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Plasmodium malariae
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Plasmodium ovale
Relatively rare
Infected RBCs tend to be oval or burred and of normal size or in reticulocytes (slightly larger RBCs)
Plasmodia with 8 chromatin masses (usually 6 – 10)
Schuffner’s dots may be present
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Plasmodium ovale
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Plasmodium falciparum Plasmodia in the crescent (banana shape) stage
Plasmodia in ring stage with 2 chromatin dots
Plasmodia in RBCs in eclipse (accole) position
More than one ring (trophozoite) per RBC
Intermediate stages rarely seen, all plasmodia in film in
ring stage or gametocyte stage, but not both
Plasmodia invade all stages of RBCs
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Plasmodium falciparum
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Now for the Test…..
http://www.rph.wa.gov.au/malaria.html
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Other Organisms to Consider
Plasmodium knowlesi
Babesia microti
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Plasmodium knowlesi Emerging New Form of Malaria Monkey Malaria Found in South East Asia
Malaysia Borneo Thailand – Burma border region Philippines Singapore
24 hour reproductive cycle Potentially fatal
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Plasmodium knowlesi Appearance in blood films similar to P malaria
http://www.cdc.gov/eid/content/15/9/1478-F1.htm
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Plasmodium knowlesi
Diagnosis Blood film screening – appears similar to P
malariae Compact parasite – all stages Does not alter RBCs size Schizonts 8 – 10 merozoites, arranged in a rosette
Rapid Diagnostic Tests may NOT recognize P knowlesi
PCR – most reliable
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Babesia microti
Tick transmitted Found in USA
Upper Midwest Wisconsin
May be confused with P falciparum
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Babesia microti
Diagnosis Microscopy – Thick and Thin Blood Films
Small, delicate parasites Multiple organisms within a single RBC Tetrads within a single RBC
Antibody detection by indirect fluorescent antibody (IFA)
Molecular Methods - PCR
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Babesia microti
http://www.dpd.cdc.gov/DPDX/HTML/Babesiosis.htm