removed from the circulation by the spleen more rapidly than is normally the case. The loss of red blood cells from these various mechanisms is therefore generally greater than would be expected from parasitemia alone and often causes significant anemia.

When red blood cell losses are mild, anemia is well tolerated, but anemias can quickly become life-threatening in patients with high parasitemias (Phillips et al., 1986a; Molyneux et al., 1989a). There is no consensus about what constitutes “life-threatening” anemia in a malaria patient, and the only effective treatment currently available is blood transfusion. The administration of blood carries its own inherent risks, and these are compounded by the danger of transmitting AIDS in areas where a substantial proportion of the population is HIV seropositive. Once the parasitemia has cleared, bone marrow production of red blood cells resumes, and the red blood cell mass is gradually restored to its preillness level (Phillips et al., 1986a).

While the danger of contracting AIDS is a real problem for patients with malarial anemia who undergo transfusion, there is no evidence at the present time to suggest that HIV infection places individuals at increased risk of severe malaria. The possibility of such an association, however, warrants continued surveillance.

Other Clinical Features

In areas of the world where malaria transmission fluctuates, adults do not acquire significant immunity and may be at risk for developing a severe infection involving many organ systems (World Health Organization, 1990). Women who are pregnant for the first time appear to be particularly susceptible to this form of the disease (Looareesuwan et al., 1985).

Acute Clinical Complications Adults with severe malaria often require a higher level of supportive care than do children, including mechanical ventilation for pulmonary edema and hemodialysis or peritoneal dialysis for kidney failure, the two most frequent and serious noncerebral complications of the disease (World Health Organization, 1990).

The principles of antimalarial drug therapy in these settings are the same as for treating cerebral malaria in children. Special care should be taken in treating pregnant woman with intravenous quinine, since they are more likely than other adults to develop hyperinsulinemic hypoglycemia (Looareesuwan et al., 1985).

Pulmonary edema is a serious complication of falciparum malaria and is associated with a high mortality rate (World Health Organization, 1990). Its cause is unknown. Pulmonary edema resembles adult respiratory distress syndrome, with increased pulmonary vascular permeability.

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