SummaryThe rationale for exchange blood transfusion (ET) in severe falciparum malaria is threefold: reduction of parasitaemia, reduction of presumptive 'toxic' factors, and improvement of the rheological quality of the blood. We evaluated the records of 61 patients treated with ET to describe the present status of malaria treatment in Germany, Austria and Switzerland and to assess the efficacy of ET. Clinical data of 61 patients treated with ET were compared to data of 63 patients treated in 2 hospitals where ETs were generally not performed. We found that exchange transfusion is applied according to the clinician's subjective impression rather than strict guidelines. Logistic regression analysis adjusting for the differences in clinical parameters between patients treated with or without ET did not identify treatment as a prognostic indicator (odds ratio for relative risk of death with ET: 1.3; 95% CI: 0.4-4.9). Exchange transfusion did not significantly improve the unfavourable prognosis in cases of severe falciparum malaria. However, failure to reach statistical significance may be due to the retrospective design of the study and therefore non-systematic approach.keywords malaria, Plasmodium falciparum, treatment, exchange blood transfusion correspondence Dr Gerd-Dieter Burchard, Bernhard

Intrasplenic lesions can cause diagnostic difficulties because malignant diseases can be excluded only by histologic examination. We present the cases of two patients with splenic manifestations of loiasis. Both patients had visited central Africa. Several years later, intrasplenic lesions were found during routine examinations (for chest trauma and employment, respectively). Both patients underwent splenectomies because malignant lymphoma was suspected. In both cases, histologic examination of the spleen showed eosinophilic granulomata with multiple Loa loa microfilariae.

Our fax numbers: 617-739-9864 and 617-734-4457 Our e-mail address: letters@nejm.orgWe cannot acknowledge receipt of your letter, but we will notify you when we have made a decision about publication. We are unable to provide prepublication proofs. Please enclose a stamped, self-addressed envelope if you want unpublished material returned to you. Financial associations or other possible conflicts of interest must be disclosed. Submission of a letter constitutes permission for the Massachusetts Medical Society, its licensees, and its assignees to use it in the Journal 's various editions (print, data base, and optical disk) and in anthologies, revisions, and any other form or medium. Correspondence Prednisone and Aspirin in Women with Recurrent Fetal LossTo the Editor: We applaud Laskin et al. (July 17 issue) 1 for completing a large trial of prednisone and aspirin in women with autoantibodies and unexplained recurrent fetal loss. We believe, however, that several aspects of the study deserve comment.First, 22 percent of the women had had only two pregnancy losses and therefore did not meet the traditional criteria (three or more pregnancy losses, with no more than one live birth) for the diagnosis of recurrent pregnancy loss. In addition, the women had a mixture of preembryonic, embryonic, and fetal losses. It is also unclear whether all the women were tested for other causes of pregnancy loss, although women with known conditions were excluded from the study.Second, the proportions of women with positive tests for lupus anticoagulant were high in both the treatment and control groups (38 and 36 percent, respectively), as compared with the proportions in other studies. 2 This difference raises a question about the specificity and validity of the assay used. The level of anticardiolipin-antibody positivity is not specified, and some women may have had low titers of questionable clinical importance. 3 Thus, the total number of women meeting the laboratory criteria for the antiphospholipid-antibody syndrome in the study may have been very small.Third, the autoantibodies tested were a diverse and heterogeneous group. Antinuclear antibodies have been associated with recurrent pregnancy loss in a few retrospective studies, but their presence does not increase the risk of subsequent fetal loss. 4 Anti-single-stranded DNA antibodies, anti-double-stranded DNA antibodies, and antilymphocyte antibodies are not associated with pregnancy loss, and it is therefore unclear why women with these dissimilar antibodies were included.Finally, the large number of women with repeatedly positive tests for at least one antibody (385 of the 773 women, or 50 percent) diminishes the biologic plausibility of the notion that these antibodies are of clinical importance. Is it possible that some women did not have autoimmune-mediated pregnancy loss and did not require any treatment?The issues raised by this trial, one of the best efforts of its kind, serve to underscore the difficulty of studying autoimmune-mediated pregnancy loss and the n...

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