16.
LABORATORY DIAGNOSIS OF MALARIA
Exercise 16.1:
Clinical case: A case of fever with chills and rigors, splenomegaly
A 36-year-old female from Odisha presented with fever, chills and rigor for 5 days
with anemia. The patient developed seizures prior to admission. She was started on
ceftriaxone by a private medical practitioner and she did not improve. On physical
examination, splenomegaly was present and signs of meningeal irritation were absent. Her
blood sample was collected and sent to laboratory for peripheral blood smear examination
and for other laboratory investigations (Figure. A & B)
1. What is the clinical diagnosis and how you arrived at it?
Ans:-
The clinical diagnosis is a case of cerebral malaria due to Plasmodium falciparum because the
patient presented with the splenomegaly, anemia, fever with chills and rigor.
2. What is the host, infective form, and mode of transmission of the parasite?
Ans:-
Definitive host - Female Anopheles mosquito (sexual cycle)
Intermediate host – Man (asexual cycle)
Infective form- Sporozoites (or merozoites) act as the infective form.
Mode of Transmission and Infective Form
▰ Man acquires infection by the bite of female Anopheles mosquito
▰ Rarely, it can also be transmitted by blood transfusion or transplacental transmission.
3. What are the various complications seen?
Ans:-
Cerebral malaria, Pernicious anemia, Black water fever, Algid malaria, Septicemic malaria
Pulmonary edema and adult respiratory distress syndrome, Hypoglycemia, Renal failure
Bleeding/disseminated intravascular coagulation, severe jaundice, severe normochromic,
normocytic anemia, acidosis.
4. What are the various diagnostic modalities?
Ans:-
Microscopic tests:
Peripheral blood smear - gold standard
Thick smear - more sensitive
Thin smear - speciation can be done based on the following features:
P. vivax - amoeboid ring form and schizont.
Fluorescence microscopy (Kawamoto’s technique)
Quantitative buffy coat examination—parasitized RBCs appear as brilliant green dots.
Non-microscopic tests:
Antigen detection tests (RDTs) or ICTs - detect pan malarial Ag (LDH, aldolase),
falciparum specific Ag (HRP-II)
Culture - RPMI 1640 medium
Molecular diagnosis - PCR targeting 18S rDNA
5 How will you treat this clinical condition?
Ans:-
North-Eastern state: ACT-AL regimen-artemisinin combination therapy-artemether-
lumefantrine for 3 days plus Primaquine single dose on second day (to kill gametocytes of
P.faliciprum)
Other states: - ACT-SP regimen-artesunate for 3 days plus sulfadoxine/pyrimethamine given on
first day plus Primaquine single dose on second day
6. Draw labelled diagrams of common diagnostic forms of this parasite focused.
Ans:-
A B
A. P. falciparum ring forms such as multiple rings (blue arrow), accole form (red arrow) and
head phone-shaped ring form (black arrow)
B. Female gametocyte of P. falciparum
Exercise 16.2:
Clinical case: A case of fever with chills and rigors with splenomegaly and anemia
A 13-years-old boy from Mangaluru, presented with high grade fever rises every third day
with chills and rigor. His serum sample was subjected to a rapid diagnostic test (RDT) Fig
1. What is the clinical diagnosis and how you arrived at it?
Ans:-
The clinical diagnosis is a case of vivax malaria because the patient presented with the high
grade fever rises third day with chills and rigor. His serum sample was subjected to a rapid
diagnostic test (RDT) positive.
2. What is the host, infective form, and mode of transmission of the parasite?
Ans:-
Definitive host - Female anopheles mosquito (sexual cycle)
Intermediate host – Man (asexual cycle)
Infective form- Sporozoites (or merozoites) act as the infective form.
Mode of Transmission and Infective Form
▰ Man acquires infection by the bite of female Anopheles mosquito
3. What is relapse and how it is different than recrudescence?
Ans:-
Relapse and recrudescence in malaria
Relapse Recrudescence
Seen in Plasmodium vivax and P.ovale Although seen in all species, more common in P.
infections falciparum followed by P.malariae
Few sporozoites do not develop into pre- In falciparum malaria—recrudescence is due to
erythrocytic schizont, but remain dormant persistence of drug resistant parasites, even after
(known as hypnozoites) for 3 weeks to one the completion of treatment
year
Reactivation of hypnozoites leads to In P. malariae infection, long-term recrudescences
initiation of erythrocytic cycle and relapse are seen for as long as 60 years
of malaria This is due to long-term survival of erythrocytic
stages at a low undetectable level in blood
4. What are the various diagnostic modalities?
Ans:-
Microscopic tests:
Peripheral blood smear - gold standard
Thick smear - more sensitive
Thin smear - speciation can be done based on the following features:
P. vivax - amoeboid ring form and schizont.
Fluorescence microscopy (Kawamoto’s technique)
Quantitative buffy coat examination—parasitized RBCs appear as brilliant green dots.
Non-microscopic tests:
Antigen detection tests (RDTs) or ICTs - detect pan malarial Ag (LDH, aldolase),
falciparum specific Ag (HRP-II)
Culture - RPMI 1640 medium
Molecular diagnosis - PCR targeting 18S rDNA
5. How will you treat this clinical condition?
Ans:-
For vivax malaria: The recommended regimen is Chloroquine 25 mg/kg (divided over three days)
and primaquine 0.25mg/kg body weight daily for 14 days; to prevent relapse)
