Gametocytemia and fever in human malaria infections

We examine the charts of 408 malaria-naive neurosyphilis patients given malaria therapy at the South Carolina USPHS facility, with daily records encompassing at least 93% of the duration of infection, and focus on the 152 patients infected with the St. Elizabeth strain of Plasmodium vivax, 82 with the McLendon strain of Plasmodium filciparum, 36 with the USPHS strain of Plasmodium malariae, and 15 with the Donaldson strain of Plasmodium ovale in whom gametocytes appeared before drug, or other, intervention. In P. vivax infections, fever and parasitemia were higher after gametocytes were first detected than before; in P. malariae infections, parasitemia was higher. In P. ovale infections, fever and parasitemia were similar before and after. In P. falciparum infections, fever, parasitemia, and fever frequency were lower after gametocytes were first detected than before. Parasitemia and temperature correlated in P. vivax infections, before and after gametocytes were first detected; parasitemia and temperature at first fever were not correlated in infections with any species. Gametocyte density correlated with parasitemia in P. malariae and sporozoite-induced P. falciparum and P. vivax infections. Fevers and detected gametocytemia coincided more often than expected by chance with P. vivax and P. ovale; fever temperature and gametocyte density were not correlated in infections with any species.     

Plasmodium species mixed infections in two areas of Manhiça district, Mozambique

We compared the distribution patterns of individual Plasmodium species and mixed-species infections in two geographically close endemic areas, but showing environmental differences. Comparisons concerned circulating Plasmodium infections in both human and mosquito vector populations in the dry and wet seasons, at a micro-epidemiological level (households). Both areas revealed a very high overall prevalence of infection, all year-round and in all age groups. Plasmodium falciparum was the predominant species, being found in the vast majority of infected individuals regardless of the presence of other species. Plasmodium malariae and Plasmodium ovale occurred almost exclusively in mixed infections. Seasonal variation in P. malariae prevalence was observed in one area but not in the other. A decrease in P. malariae prevalence concurred with a marked increase of P. falciparum prevalence. However this was strongly dependent on age and when analysing infections at the individual level, a different pattern between co-infecting species was unveiled. Regarding transmission patterns, in both areas, P. falciparum gametocytes predominated in single infections regardless of age and P. malariae gametocyte carriage increased when its overall prevalence decreased.     

Relapsing malaria infection acquired in Kenya

An American physician-traveler to East Africa presented with manifestations of cerebral malaria and was treated with intravenous quinidine for chloroquine-resistant falciparum malaria. He later relapsed with Plasmodium ovale infection, despite previous primaquine therapy. Treatment of chloroquine-resistant malaria is discussed. The difficulty in diagnosing P. ovale infections and the predominance of this malaria species over P. vivax in East Africa are reviewed.     

Plasmodium ovale in Bangladesh: genetic diversity and the first known evidence of the sympatric distribution of Plasmodium ovale curtisi and Plasmodium ovale wallikeri in southern Asia

In spite of the high prevalence of malaria in Bangladesh and other southern Asian countries, there remains a substantial shortage of knowledge about the less common human malaria parasites. Recent studies indicate that Plasmodium ovale is made up of two species, namely Plasmodium ovale wallikeri and Plasmodium ovale curtisi. Genus- and species-specific nested PCR analyses of the ssrRNA gene was used to detect P. ovale infections among 2,246 diagnostic samples. Plasmodium ovale infections were further differentiated by nested PCR of the potra gene and multilocus sequence analysis of the cox1, porbp2 and the ssrRNA genes. Both P. ovale curtisi and P. ovale wallikeri occur sympatrically in the Chittagong Hill Tracts, Bangladesh and all patients presented with a mild or asymptomatic symptom complex at the time of diagnosis. The pathogens can be differentiated by nested PCRs targeting the ssrRNA and potra genes, and display dimorphism in multilocus sequence analyses. We believe that we report the first evidence of sympatric P. ovale curtisi and P. ovale wallikeri in southern Asia within a relatively confined study area of less than 5,000 km(2). High rates of mixed infections, the emergence of "new" human malaria parasite species and the evidence of zoonotic capability call for optimised diagnostic strategies for a new era of eradication.     

Plasmodium malariae and Plasmodium ovale--the "bashful" malaria parasites

Although Plasmodium malariae was first described as an infectious disease of humans by Golgi in 1886 and Plasmodium ovale identified by Stevens in 1922, there are still large gaps in our knowledge of the importance of these infections as causes of malaria in different parts of the world. They have traditionally been thought of as mild illnesses that are caused by rare and, in case of P. ovale, short-lived parasites. However, recent advances in sensitive PCR diagnosis are causing a re-evaluation of this assumption. Low-level infection seems to be common across malaria-endemic areas, often as complex mixed infections. The potential interactions of P. malariae and P. ovale with Plasmodium falciparum and Plasmodium vivax might explain some basic questions of malaria epidemiology, and understanding these interactions could have an important influence on the deployment of interventions such as malaria vaccines.     

Usefulness of genus-specific PCR and Southern blot species-specific hybridization for the detection of imported malaria cases in Italy

A PCR method involving a genus-specific oligonucleotides set and Southern blot hybridization with four species-specific probes to P. falciparum, P. vivax, P. malariae and P. ovale was evaluated for the detection of malaria parasites in blood samples from 101 patients with clinically suspect malaria infection imported to Italy. Plasmodium falciparum was the main species detected. As determined by microscopy, 53 (52.4%) patients had malaria and of these: 40 (75.5%) were infected with P. falciparum; 7 (13.2%) with P. vivax; 1 (1.9%) with P. ovale; 3 (5.7%) with P. malariae; 1 (1.9%) with P. vivax or P. ovale; and 1 (1.9%) with P. falciparum or P. vivax. Ninety-seven out 101 blood samples were submitted to ParaSight-F test which showed a sensitivity of 94.73%, and a specificity of 93.22%, as compared to microscopy. The PCR assay using the genus-specific oligonucleotide primer set (pg-PCR) was able to detect 53 (52.4%) infections and showed a sensitivity of 100% and a specificity of 100%, when compared to microscopy. The parasite species were identified by Southern blot hybridization using species-specific probes and 40 (75.5%) samples were P. falciparum positive, 5 (9.4%) P. vivax positive, 4 (7.5%) P. ovale positive, and 2 (3.8%) P. malariae positive. When the Southern blot results were compared to those of blood-film diagnosis, we observed some disagreement. In particular, compared to Southern blot, microscopy underestimated P. ovale infection; blood film analysis recognised only 1 P. ovale sample, whereas Southern blot recognised 4 P. ovale positive samples (by microscopy, 2 of these were detected as P. vivax, 1 as P. ovale or P. vivax, and the other as P. falciparum or P. vivax). Southern blot hybridization was unable to identify one P. falciparum and one P. vivax positive case detected by microscopy. We also plan to use a reference nested-PCR assay to clarify the disagreement observed between microscopy and Southern blot hybridization.     

Evolutionary relatedness of some primate models of Plasmodium

Primate--and, specifically, monkey--malaria infections are commonly used for understanding the pathology of and immune response to the human disease because they are thought to resemble most closely the host-parasite relationship found in humans. Plasmodium cynomolgi is used extensively as a model for the human parasite, P. vivax, and P. knowlesi is used primarily as a model for the development of erythrocytic-stage vaccines. Both of these simian parasites can naturally infect man, resulting in mildly symptomatic episodes of the disease. The phylogenetic relationship between these two simian parasites and previously characterized Plasmodium species, including P. vivax, was examined by comparison of the asexually expressed small- subunit ribosomal RNA genes. Our analysis confirmed that P. vivax is most closely related to P. cynomolgi and that it remains an appropriate model of the human pathogen. Furthermore, with P. knowlesi and P. fragile, these two species form a group of closely related species, distant from other Plasmodium species. What is considered to be the most ancient of the human malaria pathogens, P. malariae, was also included in the analysis and does not group at all with other simian or human parasites.      

Evaluation of a new plate hybridization assay for the laboratory diagnosis of imported malaria in Italy

A new molecular diagnostic method "Malaria-IBRIDOGEN" (Amplimedical S.p.A.--Bioline Division, Turin, Italy) based on a plate-hybridization assay for the simultaneous detection and identification of human malaria parasites was evaluated in this study. A target DNA sequence of the plasmodial 18S ribosomal RNA gene was amplified by polymerase chain reaction (PCR) and hybridized in microtiter wells with five biotinylated probes each specific for Plasmodium falciparum, P. vivax, P. malariae, P. ovale and the beta-globine human gene, respectively. Compared to the nested-PCR actually used in our laboratory for the molecular diagnosis of malaria, "Malaria-IBRIDOGEN" revealed an overall sensitivity of 100% (51/51) for the four human Plasmodium species testing 100 whole blood samples from people with malaria-like symptoms and fever. Specificity was 92% (45/49) considering four discordant samples as "false positive" by "Malaria-IBRIDOGEN". The assay showed a threshold of parasite density (detection limit) of 0.07 P. falciparum parasites/microliter, 0.15-1.5 P. vivax parasites/microliter, 0.3 P. malariae parasites/microliter and 0.4 P. ovale parasites/microliter of whole blood, respectively. This assay could be successfully applied to the laboratory diagnosis of malaria as a useful aid to microscopy.     

The blood-stage dynamics of mixed Plasmodium malariae-Plasmodium falciparum infections.

We present the first mathematical model of the within-host dynamics of a mixed-species malaria infection in a human: the blood-stage population dynamics of a dual infection with Plasmodium malariae and Plasmodium falciparum. Our results reproduce several important features of such infections in nature, including the asymmetry of species asexual-form densities, inter-specific suppression through interactions with the human immune system, and seasonal alternations in species prevalence. Most importantly, our results suggest that an existing P. malariae infection can reduce the peak parasitemia of a subsequent P. falciparum superinfection by as much as 50%. This result integrates numerous empirical observations and supports the hypothesis that clinical outcomes of P. falciparum infections may be influenced by the presence of a congener.     

Comparative structural analysis and kinetic properties of lactate dehydrogenases from the four species of human malarial parasites

Parasite lactate dehydrogenase (pLDH) is a potential drug target for new antimalarials owing to parasite dependence on glycolysis for ATP production. The pLDH from all four species of human malarial parasites were cloned, expressed, and analyzed for structural and kinetic properties that might be exploited for drug development. pLDH from Plasmodium vivax, malariae, and ovale exhibit 90-92% identity to pLDH from Plasmodium falciparum. Catalytic residues are identical. Resides I250 and T246, conserved in most LDH, are replaced by proline in all pLDH. The pLDH contain the same five-amino acid insert (DKEWN) in the substrate specificity loops. Within the cofactor site, pLDH from P. falciparum and P. malariae are identical, while pLDH from P. vivax and P. ovale have one substitution. Homology modeling of pLDH from P. vivax, ovale, and malariae with the crystal structure of pLDH from P. falciparum gave nearly identical structures. Nevertheless, the kinetic properties and sensitivities to inhibitors targeted to the cofactor binding site differ significantly. Michaelis constants for pyruvate and lactate differ 8-9-fold; Michaelis constants for NADH, NAD(+), and the NAD(+) analogue 3-acetylpyridine adenine dinucleotide differ up to 4-fold. Dissociation constants for the inhibitors differ up to 21-fold. Molecular docking studies of the binding of the inhibitors to the cofactor sites of all four pLDH predict similar orientations, with the docked ligands positioned at the nicotinamide end of the cofactor site. pH studies indicate that inhibitor binding is independent of pH in the pH 6-8 range, suggesting that differences in dissociation constants for a specific inhibitor are not due to altered active site pK values among the four pLDH.     

Minor liver profile dysfunctions in Plasmodium vivax, P. malaria and P. ovale patients and normalization after treatment

Liver function tests were performed in 61 vivax, 54 malariae and 15 ovale malaria patients who were admitted to Bangkok Hospital for Tropical Diseases between 2001 and 2004. The objective of the study was to evaluate changes in hepatic biochemical indices before and after treatment with artemisinin derivatives. On admission and prior to treatment, hepatic dysfunction was found among the 3 groups. Serum liver function tests and physical examinations were performed weekly during the 28-day follow-up period. Initially elevated serum bilirubin and diminished albumin returned to normal within 2 weeks of treatment. Serum alkaline phosphatase and aminotransferases returned to within normal limits within 3 weeks. We conclude that patients with Plasmodium vivax, P. malariae and P. ovale infections had slightly elevated serum bilirubin, aminotransferase and alkaline phosphatase levels, and hypoalbuminemia. These minor abnormalities returned to normal within a few weeks after treatment with therapies based on artemisinin derivatives.     

Can mosquitoes help to unravel the community structure of Plasmodium species?

There has been a recent revival in attempts to understand changes in patterns of abundance of Plasmodium spp. that infect humans. This has been driven by the purportedly beneficial effects of co-infection on clinical pathology and the recognition of Plasmodium vivax as a public health problem in its own right. In contrast to the attention given to mixed-species infections in humans, parasite infections and interactions within the mosquito vector remain poorly documented, even though the distribution of vector-borne parasites such as Plasmodium spp. depends on vector-vertebrate and, crucially, vector-parasite interactions. To understand malaria epidemiology and to design appropriate control measures, this gap must be re-addressed.     

Why do we need to know more about mixed Plasmodium species infections in humans?

Four Plasmodium species cause malaria in humans. Most malaria-endemic regions feature mixed infections involving two or more of these species. Factors contributing to heterogeneous parasite species and disease distribution include differences in genetic polymorphisms underlying parasite drug resistance and host susceptibility, mosquito vector ecology and transmission seasonality. It is suggested that unknown factors limit mixed Plasmodium species infections, and that mixed-species infections protect against severe Plasmodium falciparum malaria. Careful examination of methods used to detect these parasites and interpretation of individual- and population-based data are necessary to understand the influence of mixed Plasmodium species infections on malarial disease. This should ensure that deployment of future antimalarial vaccines and drugs will be conducted in a safe and timely manner.     

Some Observations on the Sporogonic Cycle of Plasmodium schwetzi, P. vivax and P. ovale in Five Species of Anopheles

SYNOPSIS. The sporogonic cycles of Plasmodium schwetzi, P. vivax and P. ovale are distinctly different with regard to rate of sporozoite development and median oocyst diameter. Differences in the oocyst structure, particularly with regard to the presence of inclusions in those of P. schwetzi , were noted. These findings tend to support the continued designation of these parasites as distinct and separate species.     

Haemostatic alterations in malaria correlate to parasitaemia

Fibrin(ogen) degradation products, platelet counts, antithrombin III, and the components of the Factor VIII complex were studied in a total of 80 patients with Plasmodium falciparum, Plasmodium vivax or Plasmodium ovale infections. The haemostatic findings were correlated to the numbers of parasitized erythrocytes and to each other. The results indicate that haemostatic changes in malaria correlate with the degree of parasitaemia. Evidence for moderate hyperfibrinolysis was found in patients with high P. falciparum parasitaemias only. Thrombocytopenia closely corresponded to parasitaemia and to von Willebrand factor levels, but appeared not to be linked to a consumption of coagulation factors. It was concluded that thrombocytopenia in malaria is not indicative of disseminated intravascular coagulation (DIC) but may relate to endothelial damage.     

Experimental infection of Anopheles farauti with different species of Plasmodium

Studies were conducted to determine the susceptibility of Anopheles farauti to different species and strains of Plasmodium. Mosquitoes were infected by feeding on animals or cultures infected with different strains of P. vivax, P. falciparum, P. ovale, P. coatneyi, P. gonderi, P. simiovale, P. knowlesi, and P. brasilianum. Infections of P. vivax and P. coatneyi were transmitted via sporozoites from An. farauti to monkeys. Comparative infection studies indicated that An. farauti was less susceptible to infection than An. stephensi, An. gambiae, An. freeborni, and An. dirus with the Salvador I strain of P. vivax, but more susceptible than An. stephensi and An. gambiae to infection with the coindigenous Indonesian XIX strain.     

On cytoadhesion of Plasmodium vivax: raison d'être?

It is generally accepted that Plasmodium vivax, the most widely distributed human malaria parasite, causes mild disease and that this species does not sequester in the deep capillaries of internal organs. Recent evidence, however, has demonstrated that there is severe disease, sometimes resulting in death, exclusively associated with P. vivax and that P. vivax-infected reticulocytes are able to cytoadhere in vitro to different endothelial cells and placental cryosections. Here, we review the scarce and preliminary data on cytoadherence in P. vivax, reinforcing the importance of this phenomenon in this species and highlighting the avenues that it opens for our understanding of the pathology of this neglected human malaria parasite.     

Cross-species regulation of Plasmodium parasitemia in semi-immune children from Papua New Guinea

Malariologists have long been fascinated by the question of whether Plasmodium spp. interact in the human host. The first genetic study of the longitudinal dynamics of multiple Plasmodium spp. and genotypes in humans has been completed in Papua New Guinea, where all four Plasmodium spp. that infect humans are present. The broad implications of the data from this study are covered here and they show that the total parasite density of Plasmodium species oscillates around a threshold and that peaks of infection with each species do not coincide. It is proposed that malaria parasitemia is controlled in a density-dependent manner in these semi-immune children and that a cross-species mechanism of parasite regulation exists. A model of how multiple immune responses could act in concert to explain these within-host dynamics are discussed here in relation to observed epidemiological patterns of mixed-species infections.     

Rare quadruple malaria infection in Irian Jaya Indonesia.

We report an exceptional finding from a blood slide collected in a remote area in the western half of New Guinea Island (Irian Jaya Province, Indonesia). One adolescent patient was found patently coinfected with all 4 known human malaria species, Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale. Diagnostic erythrocytic stages of all 4 species were clearly seen in the peripheral blood. A nested polymerase chain reaction, using species-specific primer pairs to detect DNA, helped substantiate this finding. Previous reports from Africa, Thailand, and New Guinea have detected all 4 species in a population but not simultaneously in an individual with a patent, microscopically detectable infection. We believe this quadruple infection represents the first reported natural case of all 4 human malaria parasites observed concurrently in the peripheral blood from a single Giemsa-stained slide.