Correspondence
priate approach to such situations should they
arise. However, we think that expecting airlines
to provide a complete set of medical supplies on
all commercial flights is not appropriate. A com-
mercial aircraft is, in fact, simply that a com-
mercial aircraft. Passengers must exercise good
judgment with regard to the advisability of air
travel if they have or expect to have illness or
injury that should preclude it. Of course, we
also understand that some events occur with-
out warning.
There is also the problem of training flight
attendants to use the supplies. In most instances,
the only training flight attendants receive in-
volves very basic first aid, which allows for only
limited interventions. Volunteer health care pro-
viders can provide assistance, but their range of
abilities may also limit care. Furthermore, an
airline assumes some liability by placing medi-
cal equipment on an aircraft that its personnel
are not sufficiently trained to use. If certain
equipment is mandated by law or a legitimate
standard of care exists, then the relevant equip-
Case 28-2015: A Man with Febrile Symptoms after Traveling
from Liberia
To the Editor: In the Case Record discussed by
Biddinger et al. (Sept. 10 issue),1 the authors de-
scribe the care of a febrile traveler who was re-
turning from an area in which malaria is highly
endemic and who was considered to be in the
low (but not zero) risk category for Ebola virus
disease (EVD).2 Modifications made to safely as-
sess the patient for EVD are reported, including
the use of only a rapid diagnostic test to diagnose
malaria. The Centers for Disease Control and
Prevention (CDC) recommends immediate micros-
copy of thin and thick blood smears for the diag-
nosis of malaria, which can be safely performed
by observing precautions against the transmis-
sion of EVD.3 Diagnosis by means of microscopy
allows for the identification of species and the
quantification of parasitemia, both of which are
needed to determine the most appropriate treat-
ment. Microscopy must always be performed af-
ter a rapid diagnostic test in order to confirm the
result and obtain this additional information.4
The patient discussed could have had undiag-
n engl j med 374;3nejm.org January 21, 2016
The New England Journal of Medicine
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Copyright 2016 Massachusetts Medical Society. All rights reserved.
ment or material must be provided. However, it
is important to bear in mind that in-flight
medical emergencies present a wide variety of
challenges that require not only the appropriate
equipment but also appropriate training in the
use of that equipment.
WilliamJ. Brady, M.D.
University of Virginia
Charlottesville, VA
BruceD. Gehle, J.D.
Piedmont Liability Trust
Charlottesville, VA
JoseV. Nable, M.D., N.R.P.
MedStar Georgetown University Hospital
Washington, DC
wb4z@virginia.edu
Since publication of their article, the authors report no fur-
ther potential conflict of interest.
1. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of
medical emergencies on commercial airline flights. N Engl J Med
2013;368:2075-83.
2. Federal Aviation Administration (FAA), DOT. Emergency
medical equipment: final rule. Fed Regist 2001;66:19028-46.
DOI: 10.1056/NEJMc1512716
nosed hyperparasitemia, which requires paren-
teral therapy. In addition, without identifying the
species by means of microscopy or polymerase-
chain-reaction assay, the authors may have missed
a mixed infection, which could have been treated
with primaquine, thereby preventing a 6-week
relapse. Correct determination of the initial in-
fecting species is preferred over the reliance on
knowledge of the geographic distribution of spe-
cies that cause relapsing malaria and the use of
empirical therapy with primaquine.
KathrineR. Tan, M.D., M.P.H.
KarenA. Cullen, Ph.D.
PaulM. Arguin, M.D.
Centers for Disease Control and Prevention
Atlanta, GA
ktan@cdc.gov
No potential conflict of interest relevant to this letter was re-
ported.
1. Case Records of the Massachusetts General Hospital (Case
28-2015). N Engl J Med 2015;373:1060-7.
2. Centers for Disease Control and Prevention. Guidance for
293
 The n e w e ng l a n d j o u r na l of m e dic i n e

have been desirable but not essential to the deter-

monitoring and movement of persons with potential Ebola
v irus exposure. October 2015 (http://www.cdc.gov/vhf/ebola/
mination of initial care. Severe malaria requiring
exposure/monitoring-and-movement-of-persons-with-exposure
.html). intravenous antimalarial therapy is distinguished
from uncomplicated malaria primarily by the
3. Centers for Disease Control and Prevention. Guidance for
malaria diagnosis in patients suspected of Ebola infection in
presence of dysfunction of vital organs.2 Smear
the United States. 2014 (http://www.cdc.gov/malaria/new_info/
2014/malaria_ebola.htm). preparation unnecessarily increases not only the
risk of a laboratory accident (glass slides are
4. Centers for Disease Control and Prevention. Malaria diag-
nosis (United States) (http://www.cdc.gov/malaria/d iagnosis_
sharp and can break) but also the complexity of
treatment/d iagnosis.html).
diagnosis, lengthening diagnostic turnaround
DOI: 10.1056/NEJMc1512873 time and diminishing the pool of adequately
trained technologists who can be available to
The discussants reply: After EVD had been perform testing 24 hours a day, 7 days a week.
ruled out in this case, blood smears were exam- JohnA. Branda, M.D.
ined to confirm the diagnosis of falciparum ma- GregoryK. Robbins, M.D., M.P.H.
laria and to assess the parasite burden. There DavidC. Hooper, M.D.
was no evidence of a mixed plasmodium infec- Massachusetts General Hospital
tion; thus, the patients relapse with nonfalci- Boston, MA
parum malaria would not have been predicted or Since publication of their article, the authors report no fur-
prevented if microscopy had been used initially. ther potential conflict of interest.
Our decision to rely on a rapid diagnostic test for
malaria at the time of initial presentation, which 1. Centers for Disease Control and Prevention. Guidance for
malaria diagnosis in patients suspected of Ebola infection in the
is acceptable according to CDC guidance,1 bal- United States. 2014 (http://www.cdc.gov/malaria/new_info/2014/
anced clinical needs with laboratory safety. After malaria_ebola.htm).
falciparum malaria was diagnosed with a rapid 2. White NJ, Pukrittayakamee S, Hien TT, et al. Malaria. Lancet
2014;383:723-35.
diagnostic test, measurement of the parasite
count or the detection of mixed infection would DOI: 10.1056/NEJMc1512873

More on PML in Patients Treated with Dimethyl Fumarate

To the Editor: Balak and Hajdarbegovic (Aug. 6
issue)1 discuss an old case of Kaposis sarcoma2
in a patient with psoriasis who was treated with
Fumaderm, a drug containing different fumaric
acid esters (FAE). The authors claim that the pa-
tient had normal total lymphocyte counts before
the diagnosis of Kaposis sarcoma, whereas the
original publication shows counts of 500 to 800
per cubic millimeter for more than 18 months.2
In the same issue of the Journal, van Kester
et al.3 report a case of suspected generalized
varicellazoster virus (VZV) infection in a
23-year-old patient with psoriasis who was treat-
ed with a compounded Dutch FAE preparation
for 2 months, without the development of lym-
phocytopenia. The authors conclude that FAE
treatment may reactivate VZV infection in the
absence of lymphocytopenia. However, from the
clinical picture and in the absence of IgG anti-
bodies to VZV, other interpretations need to be
considered, including adult chickenpox and
generalized zoster related to preexisting im-
mune deficiencies or irrespective of immunosup-
pression.
Both letters reference a report previously pub-
lished in the Journal of a case of progressive
multifocal leukoencephalopathy (PML) in a pa-
tient with psoriasis who was treated with a com-
pounded Dutch FAE preparation for approxi-
mately 2 years, which was reported to have
occurred without severe lymphocytopenia.4 Such
a conclusion is questionable, because lympho-
cytes were not monitored for 19 months before
the diagnosis of PML, and the extent of lympho-
cytopenia during that period is unknown.
We conclude that PML and other opportunis-
tic infections have not been observed during FAE
therapy without lymphocytopenia and in the
presence of appropriate monitoring and drug-
discontinuation rules.

294 n engl j med 374;3nejm.org January 21, 2016

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