Letters Section Editor: Robert M. Golub, MD, Senior Editor.
In Reply: We agree with Dr Hanson and colleagues that the presence of features indicative of severe malaria, such as acidosis and the presence of end-stage organ dysfunction, is crucial in the decision-making process related to malaria case management. This is why we included the presence of signs of severe malaria in our list of 5 questions to be addressed, as well as in our proposed treatment algorithm. For example, the presence of hyperparasitemia or the presence of adverse prognostic features indicative of severe disease would dictate the need for aggressive treatment with parenteral antimalarial drugs or consideration of exchange transfusion. We do not think that this advice falsely assures clinicians who have patients with signs of severe malaria, even if their patient's parasite count is low. The point that 2 patients with the same peripheral parasitemia may have a 100-fold difference in total parasite burden, depending on the stage of the parasites' life cycle, is certainly important.
Parise ME, Griffith K, Mali S, Lewis L. Malaria Treatment in the United States—Reply. JAMA. 2007;298(12):1396–1397. doi:10.1001/jama.298.12.1396-b
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