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I thank Lt Col A Banerjee for his thoughtful response to our letter.
Prolonged exposure over generations should select out a relatively immune population in endemic areas of falciparum malaria. The emergence of such immunity would restrict parasitemia, the patient becoming symptomatic once the degree of parasitemia increases. If hepatomegaly or splenomegaly occurs with low grade parasitemia, the patient should be considered immunologically unstable. The concept of immune tolerance for falciparum malaria is interesting but in that case the patient should be minimally symptomatic with increasing parasitemia. All our patients were severely symptomatic with a high degree of parasitemia which leads us to believe that either the strain is new or mutated, this of course can only be proved by studying the antigenic characteristics of the parasite.