to the editor: I read with great interest the article, “Prevention of Malaria in Travelers”¹ in the August 1, 2003 issue of American Family Physician. The authors provide an excellent introduction to prophylactic measures against malaria in nonimmune travelers, with a special emphasis on protective gear, chemoprophylaxis, and patient education.

Because of global travel, family physicians in the United States must have an increasingly high index of suspicion for malaria. Two groups of persons should be considered with regard to imported malaria:persons who are nonimmune and immigrants to the United States. Persons not previously exposed (i.e., nonimmune) have an atypical clinical picture that often leads to delays in diagnosis. In an atypical clinical presentation, patients may present with symptoms of diarrhea, cough, and myalgias; the classic tertian (fever occurring every 48 hours) or quartan (occurring every 72 hours) pattern rarely will be present; and they will have a delayed onset of symptoms after travel to an endemic area. In addition, the use of over-the-counter medication may blunt the fever and other symptoms. The atypical presentation of malaria in the nonimmune population should prompt early examination of blood smears in any patient with fever and a history of travel. Plasmodium falciparum malaria in a nonimmune patient should be treated as an emergency, because without treatment this type of malaria can be lethal in only hours.²

It also is increasingly common for immigrants to present to the emergency department seeking care for typical malaria symptoms. These patients may tell the physicians that they have malaria. Promptly performing a blood smear in these patients will save time and unnecessary testing.³