Tsutsugamushi disease is an acute febrile illness caused by Orientia tsutsugamushi. It is characterized by fever, myalgia, lymphadenopathy, and rash. And it can be easily diagnosed by characteristic eschar and serologic testing. Nearly all of the patients with tsutsugamushi disease improve with antibiotics such as doxycycline. However, the fatality rate of untreated cases is seven to ten percent. The well-known causes of mortality are respiratory failure associated with pulmonary edema or adult respiratory distress syndrome. We report a case of tsutsugamushi disease complicated with acute respiratory distress syndrome and disseminated intravascular coagulopathy, despite of doxycycline treatment. A 78-year old woman was admitted to the hospital because of fever. Twelve days before admission she had suffered myalgia and some days later she developed a rash. Despite of management at a local clinic, her condition deteriorated and she was transferred to our hospital. On admission she presented with altered consciousness and two eschars on her right arm and right thigh. Under the initial diagnosis of scrub typhus, doxycycline was administered. Her fever subsided with the initiation of doxycycline. However, her hypoxia worsened progressively and she died on the fifth hospital day.