Clinicians are increasingly confronted with diagnosis and management of malarial complications. In nonfalciparum malaria, severe complications usually involve the spleen, most notably among them the condition termed spontaneous splenic rupture. A case of infection due to Plasmodium malariae resulting in a symptomatic splenic hematoma is presented. Malarial splenic enlargement and pathology are reviewed, as well as splenic complications such as spontaneous rupture, hematoma, hyperreactive malarial syndrome, hypersplenism, ectopic spleen, torsion, and formation of cysts. Also evaluated are the 11 reported cases of spontaneous splenic rupture in malaria in the English-language literature from 1960 to 1991. Most cases of spontaneous splenic rupture in malaria occur during acute infection and are associated with Plasmodium vivax. Lack of prior immunity to malaria appears to be a major predisposing factor. Increasingly, splenic complications are managed by supportive care and spleen-conserving procedures to avoid postoperative and asplenic morbidity.