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HelpTest Code LCMAL Malaria, Molecular Detection, PCR, Varies
Reporting Name
Malaria PCRUseful For
Detection of Plasmodium DNA and identification of the infecting species
An adjunct to conventional microscopy of Giemsa-stained films, particularly in cases of low percent parasitemia or suboptimal parasite morphology
Detection and confirmatory identification of Plasmodium species: Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi
This test should not be used to screen asymptomatic patients.
Testing Algorithm
For more information see Malaria Laboratory Testing Algorithm.
Method Name
Real-Time Polymerase Chain Reaction (PCR)/DNA Probe Hybridization
Performing Laboratory
Mayo Clinic Laboratories in Rochester
Specimen Type
VariesOrdering Guidance
1. This test is not performed on a STAT basis and, therefore, should not be used as a primary screening test for malaria.
2. This test is used primarily for confirmation of a presumptive malaria diagnosis and determination of infecting Plasmodium species-particularly when the parasite morphology on traditional blood films is suboptimal.
3. Clients in the Rochester, MN area who are seeking a primary test for malaria and who can deliver the specimen within 4 hours of collection should order MAL / Rapid Malaria/Babesia Smear, Varies.
4. Laboratories that are unable to deliver a specimen within 4 hours of collection should perform an initial screen for malaria and other blood parasites in their laboratory prior to sending a specimen to Mayo Clinic Laboratories.
5. This test does not include blood smear examination/calculation of parasitemia. If calculation of percent parasitemia is also desired for cases that are positive for Plasmodium species, clients should order LMALP / Malaria PCR with Parasitemia Reflex, Varies.
Specimen Required
Both blood specimens and slides are required.
Specimen Type: Blood
Container/Tube: Lavender top (EDTA)
Specimen Volume: 4 mL
Collection Instructions:
1. Invert several times to mix blood.
2. Send specimen in original tube. Do not aliquot.
Specimen Type: Blood films
Container/Tube: Clean, grease-free slides in plastic slide container
Specimen Volume: 2 thin blood films and 2 thick blood films
Collection Instructions:
1. Ideally, blood films should be made directly from uncoagulated blood acquired via fingerstick. However, EDTA anticoagulated blood is also acceptable.
2. Prepare thin blood films as follows:
a. Prepare a thin film with a "feathered edge" that is no more than a single cell thick.
b. Allow the film to thoroughly air dry and then fix by briefly immersing in either absolute or 95% methyl alcohol.
c. Allow to air dry after fixation.
3. Prepare thick blood films as follows:
a. Place a large drop of blood (approximately the size of a dime and preferably from a fingerstick) on a slide.
b. Using a corner of a second slide, spread the drop in a circular motion while applying firm pressure to literally scratch the blood onto the carrier slide. This technique allows the blood to dry quickly and adhere well to the slide. Use approximately 20 circular sweeps with the second slide. The drop of blood should be about the size of a quarter when finished.
c. Do not fix. Air dry thoroughly (approximately 45 minutes) before placing in transport container.
Specimen Minimum Volume
Blood: 1 mL
Slides: See Specimen Required.
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Varies | Refrigerated (preferred) | 7 days | |
| Ambient | 7 days |
Reject Due To
| Gross hemolysis | Reject |
| Gross lipemia | Reject |
Special Instructions
Reference Values
Negative
Day(s) Performed
Monday through Sunday
CPT Code Information
87798
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| LCMAL | Malaria PCR | 47260-5 |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| 87860 | Malaria PCR | 47260-5 |
Clinical Information
Malaria is a mosquito-transmitted disease caused by apicomplexan parasites in the genus Plasmodium. It is an important cause of morbidity and mortality worldwide, with the World Health Organization (WHO) estimating 219 million cases and 435,000 malaria-related deaths in 2017. Malaria disproportionately affects individuals living in Africa (90% of cases), with individuals living in southeast Asia and the eastern Mediterranean regions next most affected. Malaria is also encountered outside of endemic regions, such as the United States, usually in returning travelers.
Malaria is caused primarily by 4 species of the protozoa Plasmodium: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale. A fifth Plasmodium species, Plasmodium knowlesi, is a simian parasite that may be an important source of human infection in some regions of Southeast Asia. Differentiating P falciparum and P knowlesi from other species is important since both can cause life-threatening infections. In addition, P falciparum is typically resistant to many commonly used antimalarial agents, such as chloroquine.
Microscopy of Giemsa-stained thick and thin blood films is the standard laboratory method for diagnosis and differentiation of malaria parasites. Under optimal conditions, the sensitivity of the thick film microscopy is estimated to be 10 to 30 parasites per microliter of blood. However, microscopic diagnosis requires considerable expertise and may be insensitive or nonspecific when inadequate training and facilities are available. Furthermore, prolonged exposure to EDTA, transportation conditions, and prior use of antimalarial drugs may alter parasite morphology and negatively impact the ability to perform species identification by microscopy. Finally, Babesia parasites have a similar appearance to P falciparum ring forms (early trophozoites) on peripheral blood films, resulting in potential diagnostic confusion.
Polymerase chain reaction (PCR) analysis is an alternative method of malaria diagnosis that allows for sensitive and specific detection of Plasmodium species DNA from peripheral blood. PCR may be more sensitive than conventional microscopy in very low parasitemias and is more specific for species identification. It may be particularly useful when subjective microscopy does not permit certain identification of the species present. Malaria PCR can be used in conjunction with a traditional blood film or Babesia PCR when the clinical or morphologic differential includes both babesiosis and malaria. Examination of the thin film also allows for calculation of percent parasitemia, which can be used to predict prognosis and monitor response to treatment. This test does not include blood smear examination or calculation of parasitemia.
Interpretation
A positive result indicates the presence of Plasmodium nucleic acid and melting curve analysis indicates the infecting species.
Cautions
Malaria is potentially a life-threatening disease, and it is imperative to test for parasites as rapidly as possible. Therefore, this test is for confirmation only except for clients in the immediate Rochester, Minnesota area who can provide rapid delivery of specimens to Mayo Clinic Laboratories.
Assay may be negative in very low parasitemias.
Species of Plasmodium present in mixed infections may not be clearly delineated.
In some instances, the closely related species, Plasmodium ovale and Plasmodium vivax, cannot be differentiated from one another by this test. In this instance, results will be reported as "P vivax/P ovale." These 2 species have similar prognosis and treatment and can often be distinguished based on patient travel history.
This is a qualitative test only. If calculation of percent parasitemia is desired, order LMALP / Malaria PCR with Parasitemia Reflex, Varies.
This assay does not distinguish between residual nucleic acid (which may persist after adequate treatment) and viable intact parasites. It also does not distinguish between gametocytes (nonpathogenic forms that may be present in resolving infections) and virulent trophozoites.
Although the reference range is considered "negative" for individuals living in nonendemic areas, this assay may detect low-grade asymptomatic parasitemia from individuals exposed to malaria-endemic areas. However, this assay is designed to detect only Plasmodium species of clinical significance and is to be used for patients with a clinical history and symptoms consistent with malaria.
This polymerase chain reaction assay does not detect other parasites that may be present in the blood and have similar disease presentations including Babesia and Trypanosoma species.
Method Description
DNA from EDTA-anticoagulated whole blood is extracted and tested using real-time polymerase chain reaction on the LightCycler 2.0 instrument (Roche Applied Science) with primers and fluorescence resonance energy transfer (FRET) probes. A genus-specific primer set corresponding to 18S ribosomal RNA is used to amplify target sequence. One pair of FRET hybridization probes was designed for Plasmodium falciparum over a region containing base pair mismatches allowing for differentiation of other Plasmodium species by use of melting curve analysis, while a second probe set is specific for Plasmodium knowlesi.(Babady NE, Sloan LM, Rosenblatt JE, Pritt BS: Detection of Plasmodium knowlesi by real-time polymerase chain reaction. Am J Trop Med Hyg. 2009 Sept;81(3):516-518)