Severe falciparum malaria is a medical emergency with high mortality rate. HIV co-infection not only adds to the severity of illness and mortality but also contributes to the decreased effectiveness of the treatment. We report 40 year old male of severe falciparum malaria with HIV co-infection, who presented with altered sensorium, severe intravascular hemolysis and acute renal failure with parasite index of more than 10%. Although, he was treated with artesunate, clindamycin and hemodialysis, he succumbed to his illness.