to the editor: We read this article with great interest, and we appreciate the authors highlighting three major sources of fever in the returning traveler. Given the continued steady increase in reported cases of malaria, especially from travelers to sub-Saharan Africa,¹ we would like to make a few points regarding recognition and treatment of this disease.

First, diagnostic studies should be promptly performed, with a low threshold for starting parenteral treatment when there is concern for severe infection. Intensive treatment should not be delayed while awaiting test results.² Although rapid testing can be performed, it should not replace direct microscopy, because testing for confirmation of infection and parasite density are needed to follow response to treatment.² For help with diagnosis or management, clinicians may call the Centers for Disease Control and Prevention's (CDC's) Malaria Hotline at 770-488-7788 (Monday through Friday, 9 a.m. to 5 p.m. Eastern time) or 770-488-7100 (emergency consultation after hours).

Second, patients with severe infection who may have been exposed to Plasmodium falciparum should be given artesunate or quinidine, not chloroquine (Aralen), because patients with P. falciparum malaria infection may deteriorate rapidly if improperly treated.^2,3 Worldwide, P. falciparum resistance to chloroquine is quite high outside of Latin America and the Middle East, which makes it a poor first choice, especially if there was recent travel to Africa.⁴ The CDC's online malaria map provides resistance characteristics for the area of travel (http://www.cdc.gov/malaria/map/).

For less severe infections in recent travelers to Africa or areas where the level of chloroquine resistance is unknown, clinicians should treat with atovaquone/proguanil (Malarone) or artemether/lumefantrine (Coartem) instead of the more cumbersome combination of quinine with doxycycline, tetracycline, or clindamycin.⁴ Mefloquine should be used only as a last resort because of neuropsychiatric reactions. A table of treatment recommendations from the CDC is available at http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf.

in reply: I thank Drs. Gibbs and Creech for their interest in our article. First, I agree that malaria smears may need to be performed right away. At our hospital, results are usually available in less than one hour. If results are delayed and the possibility of severe P. falciparum infection is high, then empiric therapy should be started. Second, as stated in the article, many areas in the world have chloroquine-resistant malaria; thus, knowing the area of exposure is needed to choose effective malaria therapy. Lastly, the fixed-dose combination artemether/lumefantrine is an additional first-line option to treat chloroquine-resistant malaria.