Eschar, enigma, and encephalopathy: a case series of atypical and fatal presentations of scrub typhus in young adults from Northern India.

Scrub typhus is a re-emerging but often underdiagnosed tropical zoonosis in India. Its clinical heterogeneity, serological overlap with other endemic infections, and frequent absence of pathognomonic signs contribute to delayed diagnosis and high complication rates. Central nervous system, pulmonary, and renal involvement signify severe disease and are associated with considerable morbidity and mortality. We describe three cases of previously healthy young adult males (ages 24-32) who presented with severe, organ-threatening complications of scrub typhus: acute encephalitis syndrome (AES), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI). All patients had evidence of systemic inflammation, thrombocytopenia, and multiorgan dysfunction. Eschars-although present in all cases-were initially missed or overlooked, delaying causal diagnosis. Serologic cross-reactivity with dengue, chikungunya, and leptospira further complicated early recognition. Despite early initiation of doxycycline upon clinical suspicion, one patient with ARDS succumbed to progressive hypoxemia and multiorgan failure. These cases underscore the protean and fulminant nature of scrub typhus and highlight the diagnostic importance of thorough skin examination in febrile patients with unexplained CNS, pulmonary, or renal involvement. In endemic settings, empiric doxycycline should be considered early, even in the absence of classical signs. Early recognition and treatment remain the most critical determinants of survival. Our experience reinforces that scrub typhus, though elusive, is a potentially treatable cause of severe febrile illness when promptly identified.