Phylum Apicomplexa (Sporozoa)

By Dagmawi W. (MSc Medical Parasitology)

Phylum Apicomplexa (Sporozoa)
• Seven species infect humans.

• Members of the apicomplexa either invade or attach to host

cells.

• Composed almost entirely of parasitic (ie, no free-living) species

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 Classification

Phylum – Apicomplexa

Class –
Class - Coccidea Hematozoea

Order - Order –
Order – Hemos Piropla
Eimerida porida smida

Plasmo
dium Babesia

Cryptospo Cyclospor Toxopl Sarcocy Isospo

ridium a asma stis ra
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 Malaria

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 Terms in malaria
• Prepatent period: the time from inoculation of sporozoites until
asexual erythrocytic stage parasites are demonstrated in the blood
stream.

• Incubation period: the time from inoculation of sporozoites until the

individual first manifests symptoms or signs of malaria.

• Recurrence: repeat infection causing malaria that is result of a

relapse, recrudescence, or reinfection.

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 Terms in malaria

Sporogonic cycle

Infective Period

Mosquito bites
uninfected
person Mosquito Vector

Parasites visible Human Host

Mosquito bites
gametocytemic
Prepatent Period Symptom onset
person
Recovery

Incubation Period
Clinical Illness
 Relapse: a recurrent infection caused by full development of
hypnozoites from the liver. E.g. P. v, & P. o

 Recrudescence: a recurrent infection caused by full development of a

blood stage infection in which parasitaemia declined below the level of
detection and then rose above the level of detection.

Exacerbation of persistent undetectable parasitemia, due to survival

of erythrocytic forms, no exo-erythrocytic cycle (P.f., P.m.)

Occurs most commonly after inadequate treatment as a result of

drug resistance, unusual pharmacokinetics, incomplete dosage, or in
immunocompromised individuals

 Reinfection: a recurrent infection caused by a new exposure to infected

Anopheles mosquitoes (all species)
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 Life cycle
1. Sexual Reproduction (In the Mosquito)
 Transformation of male and female gametes of Plasmodium
falciparumto sporozoites within salivary glands and stomach of
female Anopheles mosquito.
 Duration of process: 2 weeks.
2. Pre-(Exo-) Erythrocytic Phase:
 Following a mosquito bite, the injected sporozoiteshead for the
human liver via the blood stream.
 During the next 10-15 days within the liver hepatocytes, the
sporozoitesare transformed into merozoites.
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3. Erythrocytic Phase (Asexual Reproduction):
 Merozoitesleave the liver hepatocytesto invade the red blood cells.
 Schizogony= Transformation of Merozoitesto Schizonts.
 Duration of Schizogony:
– 36-48 hours (P. falciparum).
– 48 hours (P. ovale/ vivax).
– 72 hours (P. malariae).
4. Post Erythrocytic Phase:
 Rupture of RBCs leads to the release of transformed schizontsas
male and female gametesinto the blood stream, where they cause
the syptoms of malaria (fever, rigors etc).
 Rupture of RBCs occur when the concentration of Schizonts within
the RBCsreach a critical minimum. The RBCs rupture in synchrony
and produce the clinical symptoms of malaria.

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• Life cycle video……….

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 Sporogony

Oocyst

Sporozoites

Mosquito Salivary
Zygote Gland

Hypnozoites
Exo- (for P. vivax
and P. ovale)
erythrocytic
(hepatic) cycle
Gametocytes

Erythrocytic
Cycle

Schizogony
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Hemoglobin Metabolism
• The malaria parasite requires amino acids for the synthesis of its
proteins.

• The three sources of amino acids are:

1. De novo synthesis
2. Import from host plasma

3. Digestion of host hemoglobin

• Hemoglobin serves as the major source of amino acids for the

parasite

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 Clinical features
Malaria severity in small proportion of individuals:
 Infective dose
 Nutritional status
 Level of acquired immunity
 Host genetic factors
 Parasite features
Growth rate
Drug resistance
The early symptoms are non-specific
 Lack of a sense of well – being, headache, fatigue,
 Abdominal discomfort, and muscle aches followed by fever
Nausea, vomiting, and hypotension common

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 Clinical features
Three Phases:

1. Cold stage (sensation of cold, shivering)

2. Hot stage (fever, headaches, vomiting; seizures in young children) ,

fever up to 40 0C)

3. Sweating stage (sweats, return to normal temperature, tiredness)

Paroxysms coincides synchronous rupture of Schizont

Elevated TNF - 

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 Malaria Paroxysm
• paroxysms associated with
synchrony of merozoite
release
• between paroxysms
temperature is normal and
patient feels well
• falciparum may not exhibit
classic paroxysms
• continuous fever
• 24 hr periodicity
tertian malaria
quartan malaria

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 Clinical features
Tertian Malaria , where paroxysms of malaria is repeated after 48 hrs
or fever occurs every third day.

o It is feature of P.falciparum, P.ovale and P.vivax

Quartan Malaria , where paroxysms occurs after every 72 hour or fever

occurs every fourth day.

o It is seen in P.malariae

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 Pathogenecity of P.
falciparum
1.Higher Parasitemia in Falciparum
Malaria
• all erythrocytes invaded
• up to 36 merozoites
• Pv/Po = reticulocytes
• Pm = senescent RBC
P.falciparum.
-Up to 30-40% of RBC
- sever if > 50% RBC are infected.
P.vivax & P.ovale rarely exceeds 2%
P. malariae. Usually < 1%

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 Severe Falciparum Malaria
Features Indicating Poor
Complications Prognosis
cerebral malaria Impaired consciousness
Black water fever Repeated convulsions
anemia Respiratory distress
hypoglycemia Shock
GI and liver syndromes Acidosis/hyperlactemia
pulmonary edema Hypoglycemia
Jaundice or other liver
malfunctions
Renal impairment
High parasitemia
(>500,000/mm3)
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 Sever Pf malaria
• Approximately 10% of falciparum malaria cases will develop into complicated
or severe disease with a mortality of 10-50%.

• The high parasitemia and sequestration can result in various complications

and severe malaria encompasses a complex syndrome affecting many organs
resulting in biochemical and hematological abnormalities.

• Patients will often exhibit several of these manifestations either

simultaneously or sequentially.

• The three most common syndromes associated with severe

malaria and most often correlated with death are: cerebral
malaria, severe anemia, and respiratory distress

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 Cerebral malaria
• Cerebral malaria is characterized by an impaired consciousness
and other neurological symptoms .

• Patients typically present with fever for several days followed by

a loss of consciousness.

• The presenting symptoms are usually severe headache followed

by drowsiness, confusion, and ultimately an unrousable coma.

• Convulsions, vomiting, and respiratory distress are also

frequently associated with cerebral malaria, especially in
children.

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 Pathophysiology of cerebral malaria.
• Early observations of the pathology of cerebral malaria suggested
a relationship between large numbers of infected erythrocytes in
the microvasculature and the development of the syndrome .

• Initially it was assumed that the cytoadherence would lead to a

mechanical blockage (i.e., cerebral ischemia) and subsequently
hypoxia.

• In addition, the parasite exhibits a high level of glycolysis which

could cause localized metabolic effects such as hypoglycemia and
lactic acidosis.

• Hypoxia and metabolic effects lead to coma and death.

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 Sequestration
Hypothesis
cytoadherence

cerebral ischemia

hypoxia, metabolic effects

coma

death

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 Diagnosis
1. Clinical Criteria
 Most widely used
 Feasible in many situations (rural areas, periphery of health care
systems)
 Symptoms very non – specific (overlap)
 Clinical criteria varies from area to area:
 Intensity of transmission,
 Other prevailing causes of fever
 Health service infrastructure

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 2. Parasitological or confirmatory diagnosis

 Microscopy

 Rapid diagnostic tests (RDTs)

 Detection of antibodies to parasites

 Detection of parasite DNA

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 2.1 Microscopic Examination

 Established method – “Gold standard” with:

 Careful examination

 Expert microscopist

 Well prepared and stained blood film

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 2.2 Malaria Identification: Parts

• Giemsa stain colors each part of a malaria parasite differently.

Cytoplasm (blue)

Chromatin (red)

Pigment (golden
brown to black)

Vacuole (clear)
Host red
blood cell
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 2.3 Malaria Identification: Stages
1. Trophozoite “Ring”:

• Most commonly seen

• Small to quite large

• Usually one chromatin dot

• Different shape cytoplasm (fine ring to ameboid)

• As it grows pigments appear

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 2.3 Malaria Identification: Stages
2. Schizont:

• Begins when:

• Trophozoite has reached its full capacity, and

• Chromatin divides into two

• Merozoites produced by asexual reproduction

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 2.3 Malaria Identification: Stages
3. Gametocyte:
• Round or banana shaped

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 2.4 Malaria Identification: Speciation

P. falciparum P. vivax P. ovale P. malariae

Numerous rings Enlarged Similar to P. vivax Compact
erythrocyte parasite
Smaller rings Schuffner’s dots Compact Merozoites in
trophozoite rosette
No trophozoite Amoeboid Fewer merozoites
or schizont trophozoite in schizont
Crescent – Elongated
shaped erythrocytes
gametocytes

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 2.5 Malaria Quantification

Importance:
– To know Severity
– To know Response to Treatment

• Methods

1. Number of parasites/µL of blood (thick film)

2. Number of parasites/µL of blood (thin film)

3. Proportion of parasitized RBCs (thin film)

4. Semi quantitative count (thick film)

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2.5 Malaria Quantification
4. Semi – Quantitative Count (thick film)
• Very quick but less accurate

• Reporting:

o+ - 1-10 asexual/ 100 thick film fields

o ++ - 11-100 asexual/ 100 thick film fields

o +++ - 1-10 asexual/ single thick film field

o ++++ - > 10 asexual/ single thick film field

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 Immunochromatographic tests for malaria antigens

 based on capture of the parasite antigens from peripheral blood

 Uses either monoclonal or polyclonal antibodies against the
parasite antigen targets.
 RDTs do not require a laboratory, electricity, or any special
equipment
Targets
1. Histidine-rich protein 2 of P. Falciparum,
2. Parasite specific lactate dehydrogenase(pldh)
 1. Histidine-rich protein 2 of P. falciparum (PfHRP2)

 Protein produced by the asexual stages and gametocytes of P.

falciparum,

 Remain in the blood for at least 28 days after the initiation of

antimalarial therapy

 Several RDTs targeting PfHRP2 have been developed.

 2. Parasite lactate dehydrogenase (pLDH)
 Is a soluble glycolytic enzyme produced by the asexual and sexual
stages of the live parasites

 Present in and released from the parasite infected erythrocytes

 Found in all 4 human malaria speceis, and different isomers of pLDH

for each of the 4 species exist with pLDH as the target
RDTS procedures

1. 50 µl of blood from finger prick

 A blood specimen is mixed in a buffer
 The labeled Ag – Ab complex migrates up the test strip
Reporting BF Results

• If positive, indicate:

• The stage

• Mixed infection

• The species

• Density

• If negative, after at least 100x thick fields:

• No parasite/hemo-parasite found

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 Chemoprophylaxis & Treatment
Chloroquine
 Widespread resistance has now rendered it virtually useless
against P. falciparum
Amodiaquine
 Effective against some Chloroquine-resistant strains of P.
falciparum
Pyrimethamine in combination with a sulfonamide
 Effective against all four human malarias
 But resistance has emerged rapidly
Mefloquine - effective against all forms of malaria
Artemisinin - active against all Plasmodium species
Lumefantrine - highly effective against multidrug -resistant P.
falciparum
Primaquine is effective against intrahepatic forms of all types of
malaria parasite
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 Prevention & Control
Prevention and Control
Factors to take into account:
 Biological, anthropological, cultural, and social characteristics of
the population
 Intensity and periodicity of malaria transmission
 Species of malaria parasites and their sensitivity to antimalarial
drugs
 Species of the mosquito vector, their behavior, and their
susceptibility to insecticides
 Presence of social and ecological change
 characteristics of the existing health services

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Three essential elements of malaria control (WHO):

Selective application of vector control

Early diagnosis and effective and prompt treatment of malarial

disease

Early detection or forecasting of epidemics

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 Thank you

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