Pulmonary complications, including acute respiratory distress syndrome (ARDS), are well described in P. falciparum (PF) and to a lesser extent in other malaria species. In non-endemic areas, malaria diagnosis may be overlooked; if a thorough travel history is not obtained on all patients with acute febrile illness. Three patients with malaria associated respiratory distress were admitted to our intensive care unit. The diagnosis was delayed; however, all patients received artesunate and intensive therapy with a satisfactory outcome. One patient presented with respiratory disease while the others developed ARDS during or following appropriate therapy. Similarly, level of parasitemia was variable ranging from undetectable to over 5%. Variability in timing and severity of illness is exciting and gives emphasis to the different pathological processes contemplated in this complication.