Despite chemoprophylaxis, malaria remains a serious threat for large numbers of non-immune soldiers deployed in endemic areas. Five adult cases of severe falciparum malaria are reported. Three cases were complicated by multiorgan failure and one of these patients died from cerebral malaria. These cases serve to highlight issues, in an Australian intensive care unit, associated with the management of severe malaria, an uncommon disease in our country. The need for rapid diagnosis and commencement of appropriate treatment is paramount in preventing further morbidity and mortality. Understanding and management of malaria continues to evolve rapidly. The pathophysiology of acute lung injury, shock and brain injury associated with malaria are examined in light of recent research. This article discusses the current controversies of exchange blood transfusion and the use of the new artemisinin derivatives.