Diagnosis of mixed Plasmodium malariae and P. vivax infection in a development aid volunteer by examination of bone-marrow specimens by real-time PCR

Mixed Plasmodium malariae and P. vivax infections in humans are reported very infrequently. The case of a 27-year-old male who sustained malaria quartana/tertiana caused by an unbalanced mixed P. malariae-P. vivax infection is reported here. Conventional tests and serology for malarial parasites were uniformly negative. Identification and quantification of the parasites were accomplished by examining bone-marrow specimens using specific real-time TaqMan PCR.     

Comparison of the OptiMAL Test with PCR for Diagnosis of Malaria in Immigrants

The OptiMAL test (Flow Inc., Portland, Oreg.), which detects a malaria parasite lactate dehydrogenase (pLDH) antigen, has not been evaluated for its sensitivity in the diagnosis of malaria infection in various epidemiological settings. Using microscopy and a PCR as reference standards, we performed a comparison of these assays with the OptiMAL test for the detection of Plasmodium falciparum and Plasmodium vivax infection in 550 immigrants who had come from areas where malaria is endemic to reside in Kuwait, where malaria is not endemic. As determined by microscopy, 125 (23%) patients had malaria, and of these, 84 (67%) were infected with P. vivax and 36 were infected with P. falciparum; in 5 cases the parasite species could not be determined due to a paucity of the parasites. The PCR detected malaria infection in 145 (26%) patients; 102 (70%) of the patients had P. vivax infection and 43 had P. falciparum infection. Of the five cases undetermined by microscopy, the PCR detected P. falciparum infection in two cases, P. vivax infection in two cases, and mixed (P. falciparum plus P. vivax) infection in one case. Correspondingly, the OptiMAL test detected malaria infection in 95 patients (17%); of these, 70 (74%) had P. vivax infection and 25 were infected with P. falciparum. In this study, 61 (49%) of the 125 malaria cases, as confirmed by microscopy, had a degree of parasitemia of <100 parasites per microl, and 23 (18%) of the cases had a degree of <50 parasites per microl. Our results show that the sensitivity of the OptiMAL test is high (97%) at a high level of parasitemia (>100 parasites/microl) but drops to 59% when the level is <100 parasites/microl and to 39% when it is <50 parasites/microl. In addition, the OptiMAL test failed to identify four patients whose blood smears contained P. falciparum gametocytes only. We conclude that the sensitivity and specificity of the OptiMAL test are comparable to those of microscopy in detecting malaria infection at a parasitemia level of >100 parasites/microl; however, the test failed to identify more than half of the patients with a parasitemia level of <50 parasites/microl. Thus, the OptiMAL test should be used with great caution, and it should not replace conventional microscopy in the diagnosis of malaria infection.     

Epitope-specific humoral immunity to Plasmodium vivax Duffy binding protein

Erythrocyte invasion by Plasmodium vivax is completely dependent on binding to the Duffy blood group antigen by the parasite Duffy binding protein (DBP). The receptor-binding domain of this protein lies within a cysteine-rich region referred to as region II (DBPII). To examine whether antibody responses to DBP correlate with age-acquired immunity to P. vivax, antibodies to recombinant DBP (rDBP) were measured in 551 individuals residing in a village endemic for P. vivax in Papua New Guinea, and linear epitopes mapped in the critical binding region of DBPII. Antibody levels to rDBP(II) increased with age. Four dominant linear epitopes were identified, and the number of linear epitopes recognized by semi-immune individuals increased with age, suggesting greater recognition with repeated infection. Some individuals had antibodies to rDBP(II) but not to the linear epitopes, indicating the presence of conformational epitopes. This occurred in younger individuals or subjects acutely infected for the first time with P. vivax, indicating that repeated infection is required for recognition of linear epitopes. All four dominant B-cell epitopes contained polymorphic residues, three of which showed variant-specific serologic responses in over 10% of subjects examined. In conclusion, these results demonstrate age-dependent and variant-specific antibody responses to DBPII and implicate this molecule in partial acquired immunity to P. vivax in populations in endemic areas.     

A reduced risk of infection with Plasmodium vivax and clinical protection against malaria are associated with antibodies against the N terminus but not the C terminus of merozoite surface protein 1

Progress towards the development of a malaria vaccine against Plasmodium vivax, the most widely distributed human malaria parasite, will require a better understanding of the immune responses that confer clinical protection to patients in regions where malaria is endemic. The occurrence of clinical protection in P. vivax malaria in Brazil was first reported among residents of the riverine community of Portuchuelo, in Rond?nia, western Amazon. We thus analyzed immune sera from this same human population to determine if naturally acquired humoral immune responses against the merozoite surface protein 1 of P. vivax, PvMSP1, could be associated with reduced risk of infection and/or clinical protection. Our results demonstrated that this association could be established with anti-PvMSP1 antibodies predominantly of the immunoglobulin G3 subclass directed against the N terminus but not against the C terminus, in spite of the latter being more immunogenic and capable of natural boosting. This is the first report of a prospective study of P. vivax malaria demonstrating an association of reduced risk of infection and clinical protection with antibodies against an antigen of this parasite.     

Response to anaemia in experimental Trypanosoma vivax infection of sheep

Trypanosoma vivax produced a progressive macrocytic normochromic anaemia in sheep during the acute phase of infection. Reticulocytes were absent from the blood of healthy sheep and of sheep with T. vivax-induced anaemia. However, anaemia induced artificially (AHA) in sheep by in vitro heat treatment of red cells, which was comparable in classification and degree to the anaemia of T. vivax infection, produced a reticulocytosis of 1.5 +/- 1.0 per cent. When plasma from the anaemic blood of sheep infected with T. vivax for two and four weeks was inoculated subcutaneously into mice, the reticulocyte response was similar to that of mice that received no sheep plasma and inferior to that elicited by normal sheep plasma. The anaemic plasma from sheep infected with T. vivax for three weeks induced a moderate reticulocyte response in mice which was, however, less intense than that induced by plasma from sheep with artificially induced anaemia of comparable intensity. These results indicate that, although the macrocytosis suggests that T. vivax-induced anaemia in sheep is slightly responsive, this response is suboptimal since reticulocytes were lacking in the blood of the sheep and their plasma was weakly erythrogenic in mice. This contrasts with the mild reticulocytosis in sheep with AHA of the same intensity and classification, whose plasma also stimulated considerable erythropoiesis in mice. The poor stimulation by plasma from T. vivax-infected sheep at two and four weeks post-infection suggests subnormal erythropoietin at these periods of infection.     

Comparison of two commercial assays with expert microscopy for confirmation of symptomatically diagnosed malaria

Conventional light microscopy has been the established method for malaria diagnosis. However, recently several nonmicroscopic rapid diagnostic tests have been developed for situations in which reliable microscopy may not be available. This study was conducted to evaluate the diagnostic performance of a recently introduced ICT Malaria Pf/Pv test. This assay detects Plasmodium falciparum histidine-rich protein 2 antigen (PfHRP-2) for P. falciparum diagnosis and pan-malarial antigen for P. vivax diagnosis. In this study we compared the performance of ICT Malaria Pf/Pv with microscopy of Giemsa-stained blood films and with an OptiMAL test that detects Plasmodium lactate dehydrogenase (pLDH) antigen. A total of 750 clinically suspected malaria patients were examined at local health centers in Kuwait. Both the antigen tests had a high degree of specificity (>98%) for detection of malaria infection. However, they were less sensitive than microscopy. Compared with microscopy the ICT Malaria PF/pf test failed to detect malaria infection in 93 (34%) of 271 malaria patients (11% of patients with P. falciparum and 37% of patients with P. vivax) and the OptiMAL test failed to detect malaria infection in 41 (15%) of 271 malaria patients (7% of patients with P. falciparum and 13% of patients with P. vivax). The sensitivities of the ICT Malaria Pf/Pv and OptiMAL tests for detection of P. falciparum infection were 81 and 87%, and those for detecting P. vivax were 58 to 79%, respectively. The sensitivity of the ICT Malaria Pf/Pv and OptiMAL tests decreased significantly to 23 and 44%, respectively, at parasite densities of <500/ micro l. Both of the tests also produced a number of false-positive results. Overall, the performance of the OptiMAL test was better than that of the ICT Malaria Pf/Pv test. However, our results raise particular concern over the sensitivity of the ICT Malaria Pf/Pv test for detection of P. vivax infection. Further developments appear necessary to improve the performance of the ICT Malaria Pf/Pv test.     

Characterization of peripheral blood lymphocyte subsets in patients with acute Plasmodium falciparum and P. vivax malaria infections at Wonji Sugar Estate, Ethiopia

We investigated the absolute counts of CD4+, CD8+, B, NK, and CD3+ cells and total lymphocytes in patients with acute Plasmodium falciparum and Plasmodium vivax malaria. Three-color flow cytometry was used for enumerating the immune cells. After slide smears were stained with 3% Giemsa stain, parasite species were detected using light microscopy. Data were analyzed using STATA and SPSS software. A total of 204 adults of both sexes (age, >15 years) were included in the study. One hundred fifty-eight were acute malaria patients, of whom 79 (50%) were infected with P. falciparum, 76 (48.1%) were infected with P. vivax, and 3 (1.9%) were infected with both malaria parasites. The remaining 46 subjects were healthy controls. The leukocyte count in P. falciparum patients was lower than that in controls (P=0.015). Absolute counts of CD4+, CD8+, B, and CD3+ cells and total lymphocytes were decreased very significantly during both P. falciparum (P<0.0001) and P. vivax (P<0.0001) infections. However, the NK cell count was an exception in that it was not affected by either P. falciparum or P. vivax malaria. No difference was found in the percentages of CD4, CD8, and CD3 cells in P. falciparum or P. vivax patients compared to controls. In summary, acute malaria infection causes a depletion of lymphocyte populations in the peripheral blood. Thus, special steps should be taken in dealing with malaria patients, including enumeration of peripheral lymphocyte cells for diagnostic purposes and research on peripheral blood to evaluate the immune status of patients.     

Evaluation of rapid immunocapture assays for diagnosis of Plasmodium vivax in Korea

The rapid immunocapture assays, OptiMal and ICT, were evaluated from 87 individuals for the diagnosis of malaria infections directly from whole blood. A total of 87 individuals was examined for malaria parasites by microscopic examination of Giemsa-stained blood smears, and 65 cases were positive for Plasmodium vivax by microscopy. Correspondingly, the OptiMal test identified malaria infection in 45 cases (69.2%) of microscopy positive cases. Of these, two cases were misinterpreted as Plasmodium falciparum, whereas ICT detected P. vivax infection in 29 (44.6%) patients. We would like to propose that rapid immuno capture assays are an easy method that can serve as a useful tool in addition to microscopy for the diagnosis of malaria, but sensitivity is not yet satisfactory for diagnosis of P. vivax in Korea.     

Experimental Infection with a Haemorrhage-Causing Trypanosoma vivax in N'Dama and Boran Cattle

N'Dama cattle control experimental infections with clones of Trypanosoma congolense of varying degrees of virulence, but nothing is known about their capacity to control infections caused by highly virulent. East African stocks of T. vivax. Thus four N'Damas and four trypanosusceptible Borans were infected with a tsetse-transmitted stock of T. vivax. IL2337. In Ayrshire cattle this stock is known to cause severe haemorrhagic disease.
No differences were observed in the parasitaemia between the two groups. Both groups became anaemic. The mean packed cell volume fell to 16.8 ± 5.0% in the N'Dama cattle and to 24.2 ± 2.2% in the Borans on day 26 post infection. These differences were not significant. Antibody responses to invariant trypanosome antigens were analysed. No differences were observed between the groups in the pattern of recognition or the isotype elicited. Antibody bound to the surface of erythrocytes was occasionally detected. No anti-platelet activity was observed.
The results show that N'Dama cattle, which are known to be resistant to disease caused by T. congolense and by T. vivax stocks from West Africa, were highly susceptible to an infection of T. vivax which causes acute haemorrhagic disease.     

云南微小按蚊饲养观察及其人工感染间日疟原虫初步观察

为了建立实验室云南微小按蚊饲养品系,以观察该蚊生长发育情况及其人工感染间日疟原虫的敏感性,采用常规人工方法饲养微小按蚊和直接叮咬吸血法进行人工感染间日疟原虫观察.实验表明微小按蚊在室温26～28℃、相对湿度60%～75%、水温23～25℃,每日光照12 h的实验室条件下,其孵化率、化蛹率、羽化率分别为83.1%、78.2%、92.6%,并观察10批次微小按蚊,他们间的孵化率、化蛹率及羽化率无统计学差异;人工感染6例间日疟患者中,3例感染者微小按蚊蚊胃卵囊阳性,它们的卵囊感染率分别为61.6%、87.5%和100.0%.结果表明云南微小按蚊饲养条件在26～28℃、相对湿度60%～75%、水温23～25℃下生长发育较好,同时,该蚊对间日疟原虫仍然敏感.     

Erythrocyte Fy antigen phenotyping helps differentiate so-called benign tertian malarias

Isolated cases of malaria are increasing in frequency in nonendemic countries. Blood film examination remains a mainstay of diagnosis of these sporadic cases because immunologic and molecular methods are unavailable, expensive, and problematic. Two tertian malarial species, Plasmodium vivax and Plasmodium ovale, may appear to be similar morphologically. Plasmodium ovale infection is infrequent, and misdiagnosis of this species is common. Plasmodium vivax infection can be ruled out, however, if a patient's erythrocytes phenotype as Fy(a-b-), because these cells completely resist entry by the latter species.     

Isolation and serological characterization of a Plasmodium vivax recombinant antigen.

A genomic library for Plasmodium vivax was constructed in lambda gt11 and immunologically screened with pooled serum samples from vivax patients. Six seroreactive clones were isolated, and one clone, denoted PV9, was studied further. This clone has an unusual base composition (65% G + C), does not share any homology with P. falciparum, and codes for an entirely new antigenic determinant. Antibodies (immunoglobulin G type) against the PV9-encoded polypeptide were produced in all vivax patients older than 15 years. This seroreactivity was lower among patients younger than 15 years (53%). The antigenic epitope(s) of the PV9-encoded polypeptide was recognized at a similar rate by serum samples from P. vivax patients who were living 350 to 973 km apart. Fifty percent of uninfected Indian adults were also seropositive, whereas all European and American (United States) sera tested were negative, suggesting that anti-PV9 antibodies persist after infection. The seroreactivity pattern of this antigen is similar to that of the immunity developed in malaria after repeated infections.     

Real-time PCR for detection and identification of Plasmodium spp

Rapid and accurate detection of malaria parasites in blood is needed to institute proper therapy. We developed and used a real-time PCR assay to detect and distinguish four Plasmodium spp. that cause human disease by using a single amplification reaction and melting curve analysis. Consensus primers were used to amplify a species-specific region of the multicopy 18S rRNA gene, and SYBR Green was used for detection in a LightCycler instrument. Patient specimens infected at 0.01 to 0.02% parasitemia densities were detected, and analytical sensitivity was estimated to be 0.2 genome equivalent per reaction. Melting curve analysis based on nucleotide variations within the amplicons provided a basis for accurate differentiation of Plasmodium falciparum, P. vivax, P. ovale, and P. malariae. For assay validation, 358 patient blood samples from the National University Hospital in Singapore and Evanston Northwestern Healthcare in Illinois were analyzed. Of 76 blinded patient samples with a microscopic diagnosis of P. falciparum, P. vivax, or P. ovale infection, 74 (97.4%) were detected by real-time PCR, including three specimens containing mixed P. falciparum-P. vivax infections. No Plasmodium DNA was amplified in any of the 82 specimens sent for malaria testing but that were microscopically negative for Plasmodium infection. In addition, 200 blood samples from patients whose blood was collected for reasons other than malaria testing were also determined to be negative by real-time PCR. Real-time PCR with melting curve analysis could be a rapid and objective supplement to the examination of Giemsa-stained blood smears and may replace microscopy following further validation.     

套式/多重PCR检测疟疾感染的应用研究

目的了解标签引物-套式/多重PCR技术在检测疟疾感染中的现场应用价值。方法随机采取我省疟疾流行区有发热症状的居民及家庭成员的耳垂血79份,同时制作厚血片和滤纸血样本各1份,用标签引物-套式/多重PCR检测所采集滤纸血样本中的疟原虫,并与镜检法进行比较。结果79份样本中,用标签引物-套式/多重PCR技术检出间日疟原虫阳性6例,镜检初检出10例间日疟原虫阳性,经复查血片后有4例排除了疟疾感染。镜检复核阳性的6例样本PCR均为阳性。以镜检复核为标准,两法阳性和阴性符合率为100%。结论标签引物-套式/多重PCR检测疟疾感染具高度敏感性和特异性,对疟疾鉴别诊断和明确诊断具有重要价值。     

Alleles -308A and -1031C in the TNF-alpha gene promoter do not increase the risk but associated with circulating levels of TNF-alpha and clinical features of vivax malaria in Indian patients

The biological significance of TNF promoter polymorphism and infectious disease association prompted us to investigate whether TNF-alpha -308 G/A and -1031 T/C promoter polymorphisms are associated with Plasmodium vivax infection, cellular TNF-alpha level and possibly with clinical symptoms by employing PCR-RFLP methods. An overall significant elevation of serum TNF-alpha, IL-6 content (p=0.0002, p=0.002, respectively), whereas highly significant depletion of IL-10 content (p=0.0001) was observed in vivax patients. In addition, TNF-alpha concentration in patients with and without fever were found to be significant (p=0.0001, p=0.0004, respectively). The genotypic distribution for -308 G/A and -1031 T/C positions were found non significant, but it was clinically potent to observe statistically significant distribution of genotypes (p=0.032) in patients with and without fever. Furthermore, the TNF-alpha level in TNF1 and TNF2 genotype for -308 position was significantly higher (p=0.010, p=0.006 respectively). In case of -1031 position TNF-alpha level was significant in ancestral (TT) genotype (p=0.0007) in patients compared to healthy subjects and significantly higher in rare (CC) genotype (p=0.021) as compared to ancestral genotype. In addition, the two polymorphisms 308G/A and -1031T/C were in highly significant LD (D'=0.7992, r(2)=0.6005, p=0.0001) in the patients as well as it is interesting to report that the distribution of novel 308A: 1031C alleles associated haplotypes are nearly the same in patients (0.2610) and in healthy subjects (0.2636). In view of present observation of promoter polymorphism with TNF-alpha level and other clinical parameters of vivax infection, we suggest that evaluation of TNF level and its polymorphisms in the promoter region may be considered to be reliable molecular and immunological markers, possess promising rational for diagnostic potential and immunotherapeutic interventions in clinical vivax malaria. Genetic variation in the promoter region is of biological significance and may play important roles in host defense mechanisms against vivax infection by enhancing cell-mediated immunity and stimulating the protective immunological cascade.     

Structural studies on Plasmodium vivax merozoite surface protein-1

Plasmodium vivax infection is the second most common cause of malaria throughout the world. Like other Plasmodium species, P. vivax has a large protein complex, MSP-1, located on the merozoite surface. The C-terminal MSP-1 sub-unit, MSP-1(42), is cleaved during red blood cell invasion, causing the majority of the complex to be shed and leaving only a small 15kDa sub-unit, MSP-1(19), on the merozite surface. MSP-1(19) is considered a strong vaccine candidate. We have determined the solution structure of MSP-1(19) from P. vivax using nuclear magnetic resonance (NMR) and show that, like in other Plasmodium species, it consists of two EGF-like domains that are oriented head-to-tail. The protein has a flat, disk-like shape with a highly charged surface. When MSP-1(19) is part of the larger MSP-1(42) precursor it exists as an independent domain with no stable contacts to the rest of the sub-unit. Gel filtration and analytical ultracentrifugation experiments indicate that P. vivax MSP-1(42) exists as a dimer in solution. MSP-1(19) itself is a monomer, however, 35 amino-acids immediately upstream of its N-terminus are sufficient to cause dimerization. Our data suggest that if MSP-1(42) exists as a dimer in vivo, secondary processing would cause the dissociation of two tightly linked MSP-1(19) proteins on the merozoite surface just prior to invasion.     

Evaluation of Plasmodium vivax isolates in Thailand using polymorphic markers Plasmodium merozoite surface protein (PvMSP) 1 and PvMSP3

Parasitology Research - Malaria is a significant public health problem in several tropical countries including Thailand. The prevalence of Plasmodium vivax infection has been increasing in the past...     

Plasmodium vivax polymorphism in a clinical drug trial

Data from a double-blind randomized clinical drug trial were analyzed to find the comparative responses of two antirelapse drugs, bulaquine and primaquine, against different relapsing forms of Plasmodium vivax infection. A 1-year follow-up study strongly suggests that the duration of preerythrocytic development of P. vivax is a polymorphic characteristic, exhibited by two strains of hypnozoites responsible for early and late manifestations after primary infection. Short-term relapses were significantly higher in the first half year than long-term relapses, and the reverse was true in the second half year. Clinical drug response data showed that the hypnozoites characterized for short-term relapse were not susceptible to either of the antirelapse drugs in the currently administered dose, whereas hypnozoites characterized for long incubation were significantly susceptible.     

Effects of MAO-A and CYP450 on primaquine metabolism in healthy volunteers

Parasitology Research - Eliminating the Plasmodium vivax malaria parasite infection remains challenging. One of the main problems is its capacity to form hypnozoites that potentially lead to...     

Interpretation of low-level Plasmodium infection rates determined by ELISA for anophelines (Diptera: Culicidae) from Egyptian oases

Plasmodium infection rates determined by enzyme-linked immunosorbent assay (ELISA) were compared for Anopheles sergentii (Theobald) and An. multicolor Cambouliu in Siwa Oasis, Egypt, an area with low-level Plasmodium vivax transmission, and in Bahariya and Farafra, two other Egyptian oases which appear to be free of malaria. Initial testing indicated that 4.4% (23 of 518) and 0.8% (4 of 518) of the An. sergentii were positive for P. vivax and P. falciparum, respectively, and that 1.4% (1 of 71) of the An. multicolor were positive for P. falciparum. However, after two confirmational tests, only 1.2% (6 of 518) of the An. sergentii remained consistently positive for P. vivax. Initial ELISA absorbance was not a useful predictor of potential false positive reactions in the P. vivax assay. Paradoxically, the six ELISA-positive An. sergentii were from the two malaria-free oases. This study raises the question of whether ELISA-positive reactions for anopheline vector species provides unequivocal evidence for transmission in areas of low malaria endemicity.