September 2020 — Clinical Microbiology, Hematology, Hematopathology, & Infectious Disease

A 46 year old male presented to an express care clinic with a 1-day history of fever, headache, chills, abdominal pain, nausea, and vomiting. He had returned 10 days prior to presentation from a 9 month trip to Ethiopia. To evaluate the patient for malaria, microscopic examination of Giemsa-stained thick and thin peripheral blood smears was performed, and the organisms shown in Images 1 and 2 were identified.

Image 1: Giemsa stained thin blood film showing an ameboid trophozoite (arrow) of Plasmodium vivax at 100x magnification. A second trophozoite is seen within a RBC to the right of the ameboid trophozoite. Note that both infected RBCs are molded to the countours of the neighboring RBCs. Extremely faint stippling is seen.
Image 2: Giemsa stained thin blood film showing a gametocyte at 100x magnification. More prominent stippling is seen within the cytoplasm of the infected RBC.

What is the Plasmodium species seen in these images?

  • Plasmodium knowlesi
  • Plasmodium malariae
  • Plasmodium vivax
  • Plasmodium falciparum

The correct answer is...

The correct answer is Plasmodium vivax.

Plasmodium vivax is the most widely distributed of all of the species causing human malaria, being found in areas of the tropics and subtropics worldwide, as well as some temperate climates. The regions with highest prevalence are Latin America and Southeast Asia. While majority (60-70%) of malaria cases in Ethiopia are contributed to Plasmodium falciparum, the remaining 30-40% of infections is caused by P. vivax, and infections due to Plasmodium ovale and Plasmodium malariae are rare (1). Plasmodium knowlesi is endemic to Southeast Asia and does not fit this case due to travel history. P. vivax has a low degree of infectivity compared to P. falciparum, which can rapidly progress to life-threatening disease. While all malaria species have an initial liver stage, only P. vivax and P. ovale have a dormant liver stage, where hypnozoites can persist in the liver and cause relapses by invasion into the blood stream weeks to months after initial infection is cleared (2).

The various Plasmodium species can be differentiated based on their appearance on Giemsa and Wright-Giemsa stained thin blood films. P. vivax and P. ovale preferentially infect immature red blood cells (RBCs), and thus the infected cells are larger than many of the surrounding uninfected cells. Intracytoplasmic inclusions (i.e., Schüffner’s stippling or ‘dots’) are also characteristic when the stain is at a neutral pH (7.0 – 7.2). In comparison, the size of the infected RBCs is usually normal or small in P. falciparum and P. malariae infections, and Schüffner’s dots are not seen. Differentiating P. vivax from P. ovale can be more challenging. In general, P. vivax late stage trophozoites have an ameboid shape (i.e., having pseudopod-like projections) whereas P. ovale late stage trophozoites are more compact. Additionally, P. vivax infected RBCs exhibit increased flexibility, causing them to mold to the countours of the neighboring cells. This is not seen in P. ovale infected red blood cells, which instead take on an overall ovoid shape (in approximately 1/3 of infected RBCs) and may have jagged (i.e., fimbriated) edges. Characteristic features of P. vivax can be seen in both of the images in this case. In Image 1, a late-stage trophozoite (arrow) has an ameboid shape, and both infected RBCs are partially molded to neighboring cells. In the second image, stippling can be seen in the gametocyte, and the parasite fills nearly the entire RBC. The infected cell is also partially molded to the neighboring RBC.


Photo of Allison Eberly, Ph.D. Allison Eberly, Ph.D.
Fellow, Clinical Microbiology
Mayo Clinic
Photo of Bobbi Pritt, M.D. Bobbi Pritt, M.D.
Division Chair, Clinical Microbiology
Mayo Clinic
Professor of Laboratory Medicine and Pathology
Mayo Clinic College of Medicine and Science
MCL Education (@mmledu)

MCL Education

This post was developed by our Education and Technical Publications Team.