Fatal Rickettsial Multiorgan Dysfunction in an Adolescent Despite Standard Antimicrobial Therapy: A Case Report

Rickettsial diseases have re-emerged as significant causes of acute febrile illness in India and can occasionally evolve into rickettsial endovasculitis, characterized by widespread endothelial infection and vascular inflammation, leading to increased vascular permeability, tissue ischemia, and multiorgan dysfunction. Early diagnosis remains challenging because the initial clinical presentation is often nonspecific, and rapid diagnostic facilities are not uniformly available in many healthcare settings.

We describe a 17-year-old previously healthy female who presented after 10 days of fever and rapidly deteriorated, developing Acute Respiratory Distress Syndrome (ARDS), Acute Kidney Injury (AKI), hepatic impairment, and myocardial involvement. Serological testing demonstrated a positive Weil-Felix OX-K titer (OX-K ≥ 1:160), supporting a rickettsial etiology. Despite prompt doxycycline therapy, adjunctive corticosteroids for ARDS, renal replacement therapy, and lung-protective mechanical ventilation, the patient developed refractory hypoxemia (PaO₂ < 60 mmHg despite optimized ventilatory support) and circulatory collapse, resulting in death on the fifth hospital day. This case demonstrates a rapidly progressive, severe vasculitic form of rickettsial disease culminating in severe multiorgan dysfunction (severe ARDS, acute renal impairment, and myocarditis). The lack of classical clinical markers, such as eschar, along with significant overlap with other endemic tropical infections, likely delayed definitive diagnosis.

In rickettsial-endemic settings, clinicians should retain a high index of suspicion for these infections in patients presenting with undifferentiated febrile illness. Prompt initiation of doxycycline, improved access to rapid diagnostic tools, and early escalation to intensive care are essential strategies to reduce mortality and prevent fatal complications.