Objective To analyze the clinical characteristics and treatment schemes of patients with severe Japanese spotted fever (JSF), and provide a basis for the diagnosis and treatment of severe JSF. Methods Data of JSF patients who admitted to Yichang Central People’s Hospital from April 2022 to September 2024 were collected, and severe patients were selected for analysis. Epidemiological and clinical characteristics, as well as treatment schemes were investigated. Results A total of 19 JSF patients were admitted, including 10 mild cases and 9 severe cases. All 9 severe cases (100%) had a history of outdoor activities. All patients presented with multiple organ dysfunction besides symptoms such as fever, rash, fatigue, poor appetite, and scab. Laboratory examination results were as follows: white blood cell count and neutrophil percentage elevated in 5 (55.6%) and 9 (100%) cases, respectively; lymphocyte percentage and platelets decreased in 9 (100%) and 8 cases (88.9%), respectively; C-reactive protein increases significantly in 9 cases (100%); alanine aminotransferase and aspartate aminotransferase increased in 9 cases (100%) and 8 cases (88.9%), respectively; total protein, albumin, and albumin/globulin ratio decreased in 6 cases (66.7%) and 9 cases (100%), respectively; blood sodium and blood calcium decreased in 3 (33.3%) and 9 cases (100%), respectively; urea elevated in 8 cases (88.9%); creatinine, lactic dehydrogenase and α-hydroxybutyrate, and creatine kinase isoenzyme elevated in 6 (66.7%), 9 (100%), and 4 cases (44.4%), respectively. In terms of treatment, all patients were treated with doxycycline combined with other antimicrobial agents. Six patients (66.7%) received tracheal intubation for ventilator-assisted ventilation; 8 patients (88.9%) received infusion of blood products such as platelets and plasma; 9 patients (100%) received infusion of albumin and support treatment such as liver and stomach protection, water and electrolyte balance maintenance, et al; 6 patients (66.7%) were finally cured. Conclusion Severe JSF not only causes typical symptoms such as fever, rash, and scab, but also leads to multiple organ dysfunction. Timely application of doxycycline supportive treatment for various organs can help patients get through the critical period and receive effective treatment.