We describe a case of fatal falciparum malaria, with severe pulmonary insufficiency in the absence of fluid overload or cardiac failure. At autopsy the most striking change was a marked pulmonary interstitial edema. The endothelial cell was the most altered structure, showing marked cytoplasmic swelling which narrowed the capillary lumen. Monocytes were also found occupying the capillary lumen. The edematous interstitium also showed macrophages with endocytes and malarial pigment. There was no disseminated intravascular coagulation or other terminal complications. The patient's respiratory insufficiency seems not to have derived from the complications usually associated with the fatal malaria but from malaria-induced alveolar septal changes.