An 82-year-old man presented after being “found down.” One week earlier, he had returned from a 1-month visit to Chad, his country of birth, and had started having weakness. His body temperature was 37.4°C, and his blood pressure was 88/47 mm Hg. The physical examination was notable for confusion. Laboratory studies showed a hemoglobin level of 12 g per deciliter (reference range, 13.5 to 17), an elevated lactate dehydrogenase level, thrombocytopenia, metabolic acidosis, and acute kidney injury. A peripheral-blood smear is shown. Which of the following is the most appropriate next step in management?一名 82 岁男性在被人发现“倒地不起”后送医。1 周前，他刚结束在其出生国为期 1 个月的探亲并返回，此后开始出现乏力。体温为 37.4°C，血压为 88/47 mmHg。体格检查的突出表现为意识模糊。实验室检查显示：血红蛋白 12 g/dL（参考范围：13.5～17 g/dL）、乳酸脱氢酶升高、血小板减少、代谢性酸中毒以及急性肾损伤。外周血涂片如下图所示。以下哪项是最恰当的下一步治疗措施？
A. Chloroquine phosphate磷酸氯喹
B. Exchange transfusion交换输血
C. Oral artemether-lumefantrine口服蒿甲醚–苯芴醇
D. Oral atovaquone-proguanil口服阿托伐醌–丙胍
E. Parenteral artesunate静脉或肌内注射青蒿琥酯
答案解析：
外周血涂片显示红细胞内可见环状体滋养体，估算原虫血症水平为 50.7%。部分红细胞内可见多个环状体（箭头所示），这是恶性疟原虫（Plasmodium falciparum）感染的高度特征性表现。
该患者符合重症疟疾的诊断标准，包括意识障碍、酸中毒、肾功能损害以及原虫血症水平超过 10%。无论感染的是何种疟原虫，重症疟疾均应首选胃肠外给予青蒿琥酯作为初始治疗。
正确答案：E
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