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UDOM CHAITHONG Ph.D. L’POOL
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OBJECTIVES : TO STUDY MORPHOLOGY LIFE CYCLE GEOGRAPHICAL DISTRIBUTION EPIDEMIOLOGY PATHOGENICITY DIAGNOSIS PREVENTION AND CONTROL
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OBJECTIVE :
Human Malaria Plasmodium malariae (Laveran,1880)
Plasmodium vivax (Grassi & Feletti,1890)
Plasmodium falciparum (Welch,1897)
Plasmodium ovale (Stephens,1922)
ZOONOSIS MALARIA
Plasmodium knowlesi Natural transmission of Plasmodium knowlesi to humans by Anopheles latens in Sarawak, Malaysia 2006
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Geographical Distribution
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HISTORY OF MALARIA
INDIA : AYURAVEDA
AIR, FIRE , WATER EARTH ,BREATH
MASAGAH IS VECTOR
GREEK : ILIAD (HOMER) “PYRETOS” ANOPHELES (HARMFUL) IS THE VECTOR
CHINA: HUANG TI HEADACHE CHILL FEVER “ YAU MU” QINGHAUSU
THAILAND ‘KASAI” FEVER ,CHILL
EGYPT “ AATA” MOSQUITO IS VECTOR
MALARIA HISTORY
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Geographical Distribution
P. malariae & P. vivax Tropical to Temperate Zone
P. falciparum Tropical & Subtropical Zone
P. ovale Tropical Africa & Eastern Asia
Thailand
P. falciparum > P. vivax > P. malariae > P.ovale
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MORPHOLOGY Base on thin blood film
1. Trophozoite 1.1 Early, young, trophozoite (ring form) -Infected red cell - Enlarge -Multiple infected - Common -Trophozoite - Signet ring -Cytoplasm - Light blue -Chromatin - 1 red dot
Plasmodium vivax
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1.2. Growing Trophozoite Form - Amoeboid
Cytoplasm - Light blue Chromatin - Red dot or thread Stippling - Schuffner’s dot Pink dot on cytoplasm Pigment - Fine yellow brown rodlets
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2. Schizont - Early - Chromatin 2 granules
- Growing - Chromatin 4 granules - Mature- Chromatin12-24merozoites - Schuffner’s dot - Pink dots - Pigments - Fine yellow brown
rodlets eccentric mass
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3. Gametocytes 3.1. Young - Cytoplasm - Light blue with no vacuole - Chromatin - Large piece of red dot - Schuffner’s dot - Pink dots - Pigment - Fine granules yellow brown rodlets
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3.2. Microgametocyte (Male gametocyte) Form - Spherical or oval Cytoplasm - Periphery pale blue Chromatin - Abundant or diffused pale pink Pigment - Fine yellow brown rodlets
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3.3.Macrogametocyte (Female gametocyte) Form - Spherical or oval Cytoplasm - Deep blue Chromatin - Compact eccentric pink Pigment - Coarse yellow brown Schuffner’s dot - Pink dots
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Ring form
Amoeboid form
Mature Schizont
Female gametocyte
Male gametocyte
Growing Schizont
WBC
WBC
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Plasmodium malariae 1.Trophozoite 1.1. Young , ring form Infected red cell - Normal Cytoplasm - Deep blue Chromatin - Large red dot compact ring
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1.2. Growing trophozoite 1.2.1.- Band form
Cytoplasm - Deepblue band across the cell Chromatin - Red dot or thread 12.2. - Compact form Cytoplasm - Deepblue compact ring Chromatin - Red dot Stippling Ziemann’s dot ( rare) 12.3. Erregular form
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2. Schizont Early - 2 red chromatin granules Growing - 4 red chromatin granules Late - 6 -12 merozoites (mature) ( rosset form ) Pigment Central blackbrownish mass
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3. Gametocyte
3.1. Microgametocyte Cytoplasm - Pale blue Chromatin - Abundant or diffused pinkish Pigment - Scattered coarse blackbrownish granules
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3.2. Macrogametocyte Cytoplasm - Deep blue Chromatin - Compact or eccentric pink Pigment - Coarse blackbrownish granules are crealy defined
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Ring form
Band form
Compact form
Mature Schizont
Female gametocyte
Male gametocyte
Female gametocyte
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Plasmodium falciparum 1. Trophozoite Infected red cell - Normal red cell Multiple infected - Very common Cytoplasm - Medium blue Chromatin - Red dot Frequently 2 signet rings 2 chromatins in one ring
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1.2. Growing trophozoite Cytoplasm - Medium blue Chromatin - Red dot Stippling - Maurer’s dot Pigment - Fine black granules
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2. Schizont
Early - 2 red dots chromatin
Growing - 4 red dots chromatin Mature - 16-24 merozoites Pigment - Central or eccentric solid fused dark brownish mass Early ,growing and mature are rarely seen in peripheral blood
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3. Gametocyte 3.1.Microgametocyte Form - Crescent, sausage or banana round end in shape Cytoplasm - Pale blue Chromatin - Central diffused pink Pigment - Dark brownish rodlets
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3.2. Macrogametocyte
Form - Crescent , sausage banana
pointed end Cytoplasm - Deep blue Chromatin - Compact eccentric red dot Pigment - scattered coarse granules are clearly defined in dark blackbrownish rodlets
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Ring form
Female gametocyte
Mature Schizont Male gametocyte
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Double chromatins
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Plasmodium ovale
1. Trophozoite
Infected red cell -Enlarge oval red blood cell 1.1. Early , ring Multiple infected - Rare Cytoplasm - Deep blue Chromatin - Large red dot
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1.2. Growing Trophozoite
Cytoplasm - Elongate or oval deep blue
Chromatin - Red dot or thread Pigment - Fine greenish brown granule Stippling - Schuffner’s dot - Pale bluish dots
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2. Schizont
Early - 2 red dots
Growing - 4 red dots Mature - 6-12 merozoites Pigment - Central or eccentric greenish brown mass
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3.Gametocyte 3.1. Microgametocyte Form - Oval or Tear dorp Cytoplasm - Pale blue Chromatin - Abundant diffuse pinkish Pigment - Fine greenish brown Schuffner’s dot - violet blueish dots
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3.2. Macrogametocyte
Form - Oval or Tear dorp
Cytoplasm - Deep blue Chromatin - Compact or eccentric red dot Pigment - Greenish brown granules
Schuffner’s dot - violet blueish dots
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Ring form
Female gametocyte Mature Schizont
Male gametocyte
Growing Schizont
Young gametocyte
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P. knowlesi in human infection could not easily differentiate with other Plasmodium species, especially for atypical form of P. vivax and P. malariae.
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LIFE CYCLE
1. EXOGENOUS PHASE OR MOSQUITO PHASE SEXUAL CYCLE OR SPOROGONY ANOPHELES MOSQUITOES 2. ENDOGENOUS PHASE OR HUMAN PHASE ASEXUAL PHASE OR SCHIZOGONY -A. EXO-ERYTHROCYTIC SCHIZOGONY
-B. ERYTHROCYTIC SCHIZOGONY
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ENDOGENOUS PHASE
A. EXOERYTHROCYTIC SCHIZOGONY
SPOROZOITES
BLOOD CERCULATION
PARENCHYMAL CELL
EXOERTHROCYTIC SCHIZOGONY HYPNOZOITES OR DORMOZOITES (TISSUE SCHIZOGONY)
EXOERYTHROCYTIC MEROZOITES
BLOOD CERCULATION
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B. ERYTHROCYTIC SCHIZOGONY
EXOERYTHROCYTIC MEROZOITES
RED BLOOD CELL
TROPHPZOITES
TROPHOZOITE
SCHIZONT
ERYTHROCYTIC
MEROZOITES
ASEXUAL CYCLE
YOUNG GAMETOCYTE
GAMETOCYTE
MICROGAMETOCYTE
MACROGAMETOCYTE
SEXUAL CYCLE
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EXOGENOUS PHASE
MACROGAMETOCYTE MICROGAMETOCYTE
MACROGAMETE MICROGAMETE
ZYGOTE
( EXFLAGELATION )
OOKINETE
PENETRATE TO MIDGUT WALL
OOCYST
SPOROZOITES
SPOROZOITES IN SALIVARY GLANDS
HUMAN
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Exogenous phase
Endogenous phase
Mosquito phase
Human phase
2 อาทิตย์ ที่ 25 o C
ต่่า กว่า 16 o C จะไม่เกิด Sporogony ในมาลาเรีย ทุกชนิด
Incubation period
PV 13 ( 12-17 ) PO 17 ( 16-18 ) PF 12 ( 9-14 ) PM 28 ( 18-40 )
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CLINICAL FEATURES AND PATHOLOGY THE CHARACTERISTIC FEATURE
OF MALARIA IS FEVER IT USUALLY OCCURS IN THREE STAGE
AS FOLLOWS: 1. COLD STAGE ; 15 - 60 Min. 2. HOT STAGE ; 2 - 6 Hrs. 3. SWEATING STAGE
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1. Cold stage : characterized by
- Rigor and headache
- Patients feel cold and shiver even
though their temperature are rising
- The skin pale and cyanotic
- Take 15 -60 Min.
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2. Hot stage.
The temperature rise to its maximum.
Severe frontal headache
Often vomiting and diarrhea
The skin becomes flushed
Take 2 - 6 Hrs.
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3. Sweating stage
The patient starts to sweat profusely and
usually begins to fell better.
Weak and exhausted and tend to asleep
The temperature is normal, headache and
other pains are relive until the next rigor
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Plasmodium vivax
P. ovale
Benign tertian malaria
Ovale tertian malaria
PERIODICITY P. vivax 48 Hrs. P. falciparum 36-48 Hrs. P. ovale 48 Hrs. P. malariae 72 Hrs.
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Plasmodium malrariae Quartian malarai
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P. vivax 48 Hrs. P. falciparum 36-48 Hrs. P. ovale 48 Hrs. P. malariae 72 Hrs.
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Plasmodium falciparum
Malignant tertian malaria
P. vivax 48 Hrs. P. falciparum 36-48 Hrs. P. ovale 48 Hrs. P. malariae 72 Hrs.
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PATHOGENESIS OF MALARIA
PARASITES DEVELOPMENT IN RBC
1. METABOLISM OF HEMOGLOBIN
2. LYSIS OF INFECTED CELLS 3. SURFACE CHANGES IN RBC
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1. METABOLISM OF HEMOGLOBIN
HEMOZOIN FORMATION
Fe STORE DEPLETION
ANEMIA
TISSUE ANOXIA
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2. LYSIS OF INFECTED CELLS
Stroma
Splenomegaly
(P.falciparum) Increased destruction
normal Rbc
Black-water fever Anuria
Hb
Hemoglobinaemia
Hemoglobinuria
Antigen
+ Antibody
( P.malariae ) Nephritis
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3. SURFACE CHANGES IN RBC
(P. falciparum) Agglutination of parasitized rbc
disseminated intravascular coagulation
localized decreased microcirculation Tissue anoxia
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1, 2, 3 Tissue anoxia
Adrenal Cerebral G I Hepatic Pulmonary Renal shock dysentery edema
hyperpyrexia , coma Jaundice Anuria
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ADDITIONAL ASPECTS OF MALARIA INFECTION
1. Mixed infection
Two species are endemic
PV. + PF. Thailand
PV. + PM . Srilanka, Malasia
PF. + PM . Africa
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2. Chronic malaria - Recrudescence + - Relapses + - Reinfections MALARIA CACHEXIA
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3. Congenital Malaria Infected malaria RBC
Placenta
Fetus 4. Symtompless Parasitaemia
A. Blood Donor B. Highly Endemic Areas
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5. Blood Induced Infections Contaminated -Needles or Syringes
6. Imported Malaria
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Diagnosis 1. DEFINITIVE DIAGNOSIS - Laboratory Diagnosis
2. CLINICAL DIAGNOSIS - Historic - Fever
1. THIN BLOOD FILM 2. THICK BLOOD FILM 3. STAINED - GEIMSA OR WRIGHT STAINED
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THE ENUMERATION OF MALARIA PARASITES OBJCTIVE : TO DEMONSTRATE THE CONCENTRATION IN THE BLOOD AT A PARTICULAR TIMES
1. THICK SMEARS 2. THIN SMEARS
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TREATMENTS
1. BLOOD SCHIZONTOCIDE - CHLOROQUIN, QUININE, MEFLOQUINE, - HALOFANTHRINE, SULFADOXINE, - PYRIMETHAMINE, ARTEMISININE 2. TISSUE SCHIZONTOCIDE - PRIMAQUINE 3. GAMETOCYTOCIDE - PRIMAQUINE 4. SPORONTOCIDE OR ANTISPORGENIC AGENT - PRIMAQUINE, PYRIMETHAMINE
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MOSQUITO VECTORS
Anopheles minimus An. dirus An. maculatus An. aconitus An. sundaicus An. pseudowillmori
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PREVENTION AND CONTROL
1. BLOCKING MAN-VECTOR CONTRACT
2. VECTOR CONTROL 3. TREATMENT OF MALARIA IN CASE 4. DRUG PROPHYLAXIS
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DEGREE OF ENDEMICITY
THE MOST IMPORTANT INTERRELATED FACTORS ARE
1. THE PREVALENCE OF INFECTION IN MAN
- RESERVOIR
2. THE SPECIES OF INDIGENOUS ANOPHELES - VECTORS
3. THE PRESENT OF SUSCEPTIBLE HUMAN POPULATION - NEW HOST
4. LOCAL CLIMATIC CONDITION - GEOGRAPHIC AND HYDROGRAPHIC
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Plasmodium
vivax Plasmodium
malariae Plasmodium
ovale Plasmodium
falciparum
GEOGRAPHIC
ZONES tropics
subtropics
temperate
subtropics
temperate East Asia
subtropics
temperate
tropics
subtropics
PERIODICITY 48 hour
benign tertian 72 hour
quartan 48 hour
tertian 48 hour
malignant
tertian
AGE OF
INVADED
RBC
Reticulocytes Older Cells Reticulocytes All Ages
SIZE AND
APPEARANCE
OF PARASITIZED
RBC
Enlarged Normal or
Small Enlarged
60% oval
20%
fimbriated
edges
Normal
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Plasmodium
vivax Plasmodium
malariae Plasmodium
ovale Plasmodium
falciparum
INCLUSIONS Schuffner's Dots
Ziemann's Dots (rare)
Schuffner's Dots
Mauer's Dots
(rare)
APPEARANCE
OF GROWING TROPHOZOITE
Ameboid Compact and Band Forms
Compact N/A
FORMS IN
PERIPHERAL BLOOD
All
All
All
Rings Gametocytes
NUMBER OF
MEROZOITES IN SCHIZONT
12-24 Ave.16
6-12 , Ave 8
16-24
6-12 , Ave 8