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EDITORIALS: Christopher J M Whitty, Evelyn Ansah, and Hugh Reyburn Treating severe malaria BMJ 2005; 330: 317-318 [Full text]

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A very interesting and timely article.

Dr. V K Pandey   (11 February 2005)

Rescue of Cerebral Malaria

Arie Eisenman   (14 February 2005)

‘SMALL SPLEEN’ OF MALARIA

Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD, FAIMS., Dr. Akhilesh Kumar Singh. MBBS, MD. Dr. Parul Kushwah. MBBS, MISMCD.   (6 May 2005)

A very interesting and timely article. 11 February 2005
Dr. V K Pandey, Consultant Paediatrician Konkola Copper mines Plc., Chingola, Zambia Send response to journal: Re: A very interesting and timely article.	Sir, Kudos to authors of this article. It is a very timely article epecially when the malaria is staging a come back in Sub-Saharan Africa. On Copperbelt in Zambia, Konkola Copper Mines Plc. started Roll Back Malaria programme 3 years ago by spraying all household in the mining towns of Chingola and Chililabombwe. The programme had excellent results in first two years with the malaria incidence rates dropping dramatically. This year we are witnessing increasing number of patients admitted with malaria in our hospital. What is intersting as well as troubling is the fact that almost 70% of these patients have hyperparasitaemia (Blood slde 3+ or above). We suspect that two years of relative freedom from malaria has lowered the immunity in the population of these towns. As a result when they travel out side the mining towns to the areas of high incidence and are affected with malaria, they are not able to fight the infection with the same efficiency as they used to before Roll-Back era. As such we have a large number of severe malaria patients to treat. This article gives us alternative modality, which is easier and cheaper, for treatment which is welcome. Competing interests: None declared
Rescue of Cerebral Malaria 14 February 2005
Arie Eisenman, head of medical section, the emergency department The Western Galilee Hospital, POB 21 ,Naharia, 22100, Israel Send response to journal: Re: Rescue of Cerebral Malaria	Dear Editor, I have read Christopher et al's editorial with a great interest. Malaria is still a major problem in developing countries and cerebral malaria is the most dreadful form of the disease with high mortality due to high parasitemic level. The problem with whatever drug therapy used for cerebral malaria is its relatively slow activity. The patient often dies before even the drug starts acting. It seems to me that the only effective means to reduce the parasitemic level as quickly as possible without farther endangering the patient is by an urgent blood exchange. This rescue procedure is relatively simple, cheap, and in my opinion, should be adapted as the rescue procedure of choice by hospitals and health authorities in endemic countries. . 1. Christopher J M Whitty, Evelyn Ansah, and Hugh Reyburn Treating severe malaria. BMJ 2005; 330: 317-31 2. Eisenman A, Baruch Y, Shechter Y, Oren I.Blood exchange -a rescue procedure for complicated falciparum malaria. Vox Sang. 1995;68:19-21 Competing interests: None declared
‘SMALL SPLEEN’ OF MALARIA 6 May 2005
Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD, FAIMS., Consultant, Family Medicine & Communicable Diseases. 309/9 Avas Vikas Colony, Sikandra, AGRA -282007. INDIA, Dr. Akhilesh Kumar Singh. MBBS, MD. Dr. Parul Kushwah. MBBS, MISMCD. Send response to journal: Re: ‘SMALL SPLEEN’ OF MALARIA	Dear Editor, Having read the excellent, first-rate editorial by Whitty CJM et al [1] about the everlasting problem of malaria, I am prompted to bring to your notice that in cases who have been afflicted by the P. falciparum malaria, the splenic size decreases to below normal [2]. Similar decrease is evident in the residential population of P. falciparum endemic area [2], which I have also witnessed in certain real tall and stout healthy males as well of Northern Botswana. This shrinkage of spleen following clinical falciparum malaria, as also with the sub-clinical infections (premonition) that go unnoticed in residential population provides certain amount of immunity to malaria. In a hospital setting, this ‘small spleen’ can be easily picked up by ultrasonography in 2 to 5 minutes [2]. The smallest spleen noticed was of just 7.8 cm in a 30 year old healthy 68 kg adult male, who had a height of 1.71 m. Similarly this again was the smallest spleen size picked up in one of the adults from endemic malarial zone [2]. The splenic size following P. vivax malaria also decreases, but not as significantly as with those having suffered clinical or sub-clinical episodes of P. falciparum malaria. Once sickle cell disease is ruled out, if one were to find a ‘small spleen’ while dealing with malaria, it should be taken as a sign of acquired immunity for malaria. Given that malarial immunity is never complete, such individuals will require anti-malarial therapy, but the response shall be comparatively rapid and a lower total dose shall be required [3,4]. Individuals from endemic falciparum zones having a ‘small spleen’ would also not require anti-malarial prophylaxis [3]. Travelers who have been infected once by P. falciparum malaria may similarly not require any prophylaxis while returning to an endemic zone, if they have a ‘small spleen’ [4,5]. Likewise in cases of rapid induction of troops, or in cases of mass relief operations, ultrasonography of spleen has the potential of detecting individuals who will not require anti-malarial prophylaxis, thus saving on costs and unwarranted side effects. The choice of anti-malarials to be used depends on the availability, cost versus adverse effects and the status of established drug resistance [6]. Regards. Dr. Rajesh Chauhan MBBS, DFM, FCGP, ADHA, FISCD, FAIMS. Consultant, Family Medicine & Communicable Diseases. Dr. Akhilesh Kumar Singh. MBBS, MD. Dr. Parul Kushwah. MBBS, MISMCD. References: 1. Whitty CJM, Ansah E, Reyburn H. Treating severe malaria. BMJ 2005;330:317-18. 2. Chauhan R, Kapoor V, Vohra PA, Jhala PJ, Upadhyaya AK, Pathak KJ.The 'Small Spleen' in Malaria. J Assoc Physicians India. 1996 Jul;44(7):483-85. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9282611 3. The Small Spleen: Harbinger of malarial immunity (an original study). Rajesh Chauhan, Grover H, Bora D, Chauhan P, Singh AK, Kushwah M. In: Joint Annual Conference of Indian Society for Malaria & other communicable diseases & Indian Association of Epidemiologists. 09-11 Nov 2002, SCOPE convention Centre New Delhi. Page 25. Abstract serial 2.8 at page 25. 4. Unique experience with ultrasonography in malaria- a pilot study. Chauhan R, Tilak VW, Chowdhary HS, Kapoor V. In: Joint Annual Conference of Indian Society for Malaria & other communicable diseases & Indian Association of Epidemiologists. 30 Oct – 01 Nov 1998, SCOPE convention Centre New Delhi. Abstract serial 45 at page 25. 5. Moore DAJ, Jennings RM, Doherty TF, Lockwood DN, Chiodini PL, Wright SG, et al. Assessing the severity of malaria. BMJ 2003; 326: 808- 09. 6. Baird JK. Effectiveness of Antimalarial Drugs. NEJM 2005; 352(15): 1565-77. Competing interests: None declared