5% clinical and parasitologic response at 28 days.13 However, a larger recent trial in Papua New Guinea

of Cytoskeletal Signaling inhibitor 195 children with vivax malaria treated with different artemisinin-based combination therapies compared with conventional chloroquine-sulfadoxine-pyrimethamine (CQ-SP) demonstrated adequate clinical and parasitologic response of only 69% in the dihydroartemisinin-piperaquine group compared to 13% in the CQ-SP group.14 In summary, CRPV is emerging as a clinically significant issue among travelers with imported malaria. Awareness of epidemiology and a detailed travel exposure are critically important to the recognition of CRPV. Mefloquine is an effective treatment for patients potentially infected with CRPV, and treatment strategies for P. vivax may eventually need to be reconsidered if CRPV becomes more widespread. Further research is needed to elucidate the mechanisms of resistance and to validate better prospective assays for chloroquine resistance. Malaria prophylaxis for travel to destinations with CRPV may not require change if P. falciparum is the predominant clinical concern, but an expanded role for primaquine in prevention could be considered.15 Pre-travel advice to travelers going check details to such destinations should include discussion of CRPV and the risk of resistance and/or relapse. The authors state they have no conflicts of

interest to declare. “
“Splinter hemorrhages appear in a variety of conditions. One identified cause is ascent to altitude, but trauma and extreme conditions have Amino acid been thought to be responsible. We document the appearance of splinter hemorrhages in a group of adults during several days of easy touring at an altitude of 11,000 feet (3,350 m). Splinter hemorrhages are seen in conditions of varying severity

including (but not limited to) infective endocarditis, vasculitis, the antiphospholipid syndrome, chronic meningococcemia, ingestion of tyrosine kinase inhibitors, trauma,[1] and activities of daily living (especially in the elderly).[1, 2] Chronic[4] or acute[5, 6] exposure to high altitude has also been associated with this finding, but, in this scenario, extreme conditions and trauma have been thought to play a causative role. This report describes splinter hemorrhages associated solely with ascent to moderately high altitude and in the absence of associated trauma or extreme conditions. This 71-year-old physician presented for evaluation of numerous splinter hemorrhages (Figure 1). He denied fever, chills, muscle or joint pains, chest pain, difficulty breathing, or neurologic symptoms. He had no known heart murmur, and was in general good health, with hypertension, well controlled on hydrochlorthiazide and atenolol, and diabetes, well controlled on metformin 500 mg daily (hemoglobin A1c = 5.6). He had just returned from a 7-day trip to Peru where he spent 2 days in Cuzco (altitude 11,000 feet) and 1 day in Machu Picchu (altitude 8,000 feet).