Ramli S.R.Hii S.Y.F.Zainal Abidin S.Lee K.S.Ng T.K.Misnan N.A.Abdad M.Y.Mahidol University2026-01-022026-01-022025-12-01Plos Neglected Tropical Diseases Vol.19 No.12 (2025) , e0013156https://repository.li.mahidol.ac.th/handle/123456789/113714Scrub typhus (ST), an often-underdiagnosed zoonotic infection, poses significant diagnostic and management challenges, particularly in regions with endemic tropical infections like Malaysia. We report three fatal cases of ST in central region West Malaysia, highlighting diagnostic pitfalls and implications for clinical management. Three fatal cases of ST presented with respiratory distress and multiorgan failure were reported in this study. Laboratory investigations confirmed by positive Orientia tsutsugamushi (OT) PCR results. All three cases exhibited low PCR cycle threshold (Ct) values, suggesting high bacterial loads linked to severe disease. Phylogenetic analysis indicated two distinct genotypes, underscoring diverse circulating strains in Malaysia. Eschars were present but not initially detected in two cases. These cases emphasize critical diagnostic challenges in ST due to its nonspecific presentation and reliance on clinical recognition of eschar. Early identification and molecular confirmation are vital to improve diagnostic accuracy and reduce morbidity and mortality of ST.MedicineArticleSCOPUS10.1371/journal.pntd.00131562-s2.0-1050257336321935273541433254