Malaria Pathogenesis and Reason for drug resistant
May 11, 2015
Malaria Pathogenesis and Reason for drug resistant
Plasmodium species which infect humans
Plasmodium vivax (tertian)
Plasmodium ovale (tertian)
Plasmodium falciparum (tertian)
Plasmodium malariae (quartian)
Exo-erythrocytic (hepatic) cycle
Sporozoites
Mosquito Salivary Gland
Malaria Life CycleLife Cycle
Gametocytes
Oocyst
Erythrocytic Cycle
Zygote
Schizogony
Sporogony
Hypnozoites(for P. vivax and P. ovale)
Malaria Transmission Cycle
Parasite undergoes sexual reproduction in the mosquito
Some merozoites differentiate into male or female gametocyctes
Erythrocytic Cycle: Merozoites infect red blood cells to form schizonts
Dormant liver stages (hypnozoites) of P. vivax and P. ovale
Exo-erythrocytic (hepatic) Cycle: Sporozoites infect liver cells and develop into schizonts, which release merozoites into the blood
MOSQUITO HUMAN
Sporozoires injected into human host during blood meal
Parasites mature in mosquito midgut and migrate to salivary glands
Components of the Malaria Life Cycle
Mosquito Vector
Human Host
Sporogonic cycle
Infective Period
Mosquito bitesgametocytemic person
Mosquito bitesuninfected person
Prepatent Period
Incubation Period
Clinical Illness
Parasites visible
Recovery
Symptom onset
Exo-erythrocytic (tissue) phase
Blood is infected with sporozoites about 30 minutes after the mosquito bite
The sporozoites are eaten by macrophages or enter the liver cells where they multiply – pre-erythrocytic schizogeny
P. vivax and P. ovale sporozoites form parasites in the liver called hypnozoites
Exo-erythrocytic (tissue) phase
P. malariae or P. falciparum sporozoites do not form hypnozites, develop directly into pre-erythrocytic schizonts in the liver
Pre-erythrocytic schizogeny takes 6-16 days post infection
Schizonts rupture, releasing merozoites which invade red blood cells (RBC) in liver
Relapsing malaria
P. vivax and P. ovale hypnozoites remain dormant for months
They develop and undergoes pre-erythrocytic sporogeny
The schizonts rupture, releasing merozoites and produce clinical relapse
Exo-erythrocytic (hepatic) cycle
Sporozoites
Mosquito Salivary Gland
Malaria Life CycleLife Cycle
Gametocytes
Oocyst
Erythrocytic Cycle
Zygote
Schizogony
Sporogony
Hypnozoites(for P. vivax and P. ovale)
Exo-erythrocytic (tissue) phase
P. vivax and P. ovale hypnozoites remain dormant for months
They develop and undergoes pre-erythrocytic sporogeny
The schizonts rupture, releasing merozoites and producing clinical relapse
Erythrocytic phase
Pre-patent period – interval between date of infection and detection of parasites in peripheral blood
Incubation period – time between infection and first appearance of clinical symptoms
Merozoites from liver invade peripheral (RBC) and develop causing changes in the RBC
There is variability in all 3 of these features depending on species of malaria
Erythrocytic phasestages of parasite in RBC
Trophozoites are early stages with ring form the youngest
Tropohozoite nucleus and cytoplasm divide forming a schizont
Segmentation of schizont’s nucleus and cytoplasm forms merozoites
Schizogeny complete when schizont ruptures, releasing merozoites into blood stream, causing fever
These are asexual forms
Erythrocytic phasestages of parasite in RBC
Merozoites invade other RBCs and schizongeny is repeated
Parasite density increases until host’s immune response slows it down
Merozoites may develop into gametocytes, the sexual forms of the parasite
Schizogenic periodicity and fever patterns
Schizogenic periodicity is length of asexual erythrocytic phase 48 hours in P.f., P.v., and P.o. (tertian) 72 hours in P.m. (quartian)
Initially may not see characteristic fever pattern if schizogeny not synchronous
With synchrony, periods of fever or febrile paroxsyms assume a more definite 3 (tertian)- or 4 (quartian)- day pattern
RESISTANCE
DEFINITION
Drug resistance is the ability of the parasite species to survive and/or multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended but within the limit of tolerance.
The important factors that are associated with resistance are
Longer half-life. Single mutation for resistance. Poor compliance Host immunity. Number of people using these
drugs.
The characteristics of a drug that make it vulnerable to the development of resistance are:
a long terminal elimination half-life a shallow concentration-effect
relationship mutations that confer marked
reduction in susceptibility.
Drug resistance is most commonly seen in P. falciparum.
Only sporadic cases of resistance have been reported in vivax malaria.
Resistance to chloroquine is most prevalent
Degree of resistance
WHO has developed a simple scheme for estimating the degree of resistance that involves studying the parasitemia over 28 days.
Smears on day 2, 7 and 28 are done to grade the resistance as R1 to R3. In a case of normal response parasite count to fall to 25% of pre-treatment value by 48 hours and smear should be negative by 7 days.
Sensitive (S)
The asexual parasite count reduces to 25% of the pre-treatment level in 48 hours after starting the treatment and complete clearance after 7 days, without subsequent recrudescence - Complete Recovery.
RI, Delayed Recrudescence
The asexual parasitemia reduces to < 25% of pre-treatment level in 48 hours, but reappears between 2-4 weeks.
RI, Early Recrudescence
The asexual parasitemia reduces to < 25% of pre-treatment level in 48 hours, but reappears earlier.
RII Resistance
Marked reduction in asexual parasitemia (decrease >25% but <75%) in 48 hours, without complete clearance in 7 days.
RIII Resistance
Minimal reduction in asexual parasitemia, (decrease <25%) or an increase in parasitemia after 48 hours.
This classification however has some limitations
1. In endemic areas it is not easy to differentiate recrudescence from re-infection.
2. Recrudescence can occur beyond 28 days also.
3. Therapeutic failure could be due to other causes also.
4. RII is a very broad category. 5. Practical difficulties in following the patient
for 28 days. 6. Intermittent nature of parasitemia in the
blood
Prevention of drug resistance
Resistance develops most rapidly when a population of parasite encounters subtherapeutic concentration of antimalarial drugs.
.
The following points will be helpful in reducing the emergence of resistance:
Selection of drugs - Use conventional drugs first in uncomplicated cases. Greater the exposure, higher will be the emergence of resistance.
Avoid drugs with longer half-life if possible
Ensure compliance
Avoid basic antimalarials for non-malarial indications (e.g. Chloroquine for rheumatoid arthritis in a malarial endemic area).
Monitoring for resistance and early treatment of these cases to prevent their spread.
Clear policy of using newer antimalarials. Use of combinations to inhibit emergence
of resistance
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