Severe Scrub Typhus Presenting With Multiorgan Dysfunction and Atypical Features: Two Case Reports From the Maldives

Scrub typhus, caused by the obligate intracellular bacterium <i>Orientia tsutsugamushi</i>, is an emerging cause of acute febrile illness with a broad clinical spectrum ranging from mild self-limited fever to life-threatening multiorgan dysfunction syndrome (MODS). We report two unusual, clinically severe cases from the Maldives illustrating the diagnostic challenges and systemic involvement characteristic of severe scrub typhus. The first case involved a 42-year-old previously healthy male who presented with fever, progressive respiratory distress, severe hyperglycemia, metabolic acidosis, and acute kidney injury initially suggestive of a diabetic emergency. Further evaluation revealed multiorgan involvement, including pulmonary infiltrates, hepatic dysfunction, and profound renal impairment, with serological confirmation of scrub typhus. The second case described a 22-year-old male presenting with fever and a painful axillary abscess concealing a probable eschar, complicated by severe pneumonia. Both patients had pulmonary infiltrates consistent with pneumonitis and required intensive supportive care, including mechanical ventilation and renal replacement therapy. Combined antimicrobial therapy with doxycycline and azithromycin was initiated, resulting in notable clinical improvement. These cases underscore the protean clinical manifestations of scrub typhus, particularly atypical presentations and absence of classic eschar, both of which complicate early diagnosis. The significant involvement of pulmonary, renal, hepatic, and metabolic systems highlights the need for high clinical suspicion, prompt serological testing, and aggressive management in endemic regions to mitigate morbidity and mortality.