Abraham U. Morales-Primo
Facultad de Medicina, Universidad Nacional Autónoma de México, Hospital General de México, Mexico City, Mexico.
Email: aump.puma (at) gmail (dot) com
FromSoftware’s 2022 seminal work Elden Ring explores themes such as war, betrayal, and moral confrontations with the status quo in the Lands Between. These conflicts are deeply influenced by divine entities, specifically the Outer Gods, who seek to impose their will upon the continent. Their influence extends beyond shaping the social dynamics of the townsfolk and their leaders, affecting even their mental and physical health.
One such manifestation of divine interference is the Scarlet Rot, a persistent affliction that ravages all living beings. Not limited to humans, the Scarlet Rot also permeates the ecosystem, corrupting other animals and flora alike. This ailment has been spreading for an untold length of time, reaching every corner of the Lands Between, even forming landmarks characterized by oozing rot. Despite its catastrophic consequences, the disease has been neglected, leaving entire towns derelict and their inhabitants unattended. Furthermore, with its varied clinical manifestations and cosmic origins, treating and curing those afflicted is an immense challenge. However, we can infer the disease dynamics by drawing parallels between the Scarlet Rot and real-world pathogens, offering insight into its destructive power in the Lands Between.
ETIOLOGY AND PATHOLOGY OF THE SCARLET ROT
The Scarlet Rot is the physical manifestation of the Outer God of Rot’s will upon the Lands Between, a force that transcends mere diseases. While its presence is most notably felt during the events of Elden Ring, its influence stretches back to ancient times. Historically, the Scarlet Rot was not always viewed as purely destructive. In some cultures, the bodily decay caused by the rot was considered a sacred process, integral to rituals of rebirth and transformation. Although there are no clear examples of diseases being revered in human history, they were often interpreted as divine intervention or retribution (Krzysztofik, 2022).
The Scarlet Rot’s infamous reputation intensified when the demigod Malenia, Blade of Miquella, cursed with the Scarlet Rot from birth, spread the miasma throughout the region of Caelid. She accomplished this by blooming into a gigantic scarlet flower, unleashing the Rot across the land (Figure 1). This eruption of Scarlet Rot caused devastating symptoms in the population, including open skin wounds, gangrenous and necrotic lesions, the loss of limbs, and ultimately, death (Figure 2).
Some animals exhibited gigantism, as evidenced by the enormous dogs, crows, and scorpion-spider chimeras roaming the affected lands. Additionally, fungi sprouts and other vegetal growths began to emerge from the bodies of the afflicted. Even the flora was not spared, as the same fungus-like growths appeared on plants and trees, emphasizing the destructive nature of the Rot. Finally, as their minds and bodies succumbed to the ailment, the sick descended into madness, exhibiting violent, erratic behavior until they were completely overtaken. The following sessions explain how the Scarlet Rot affects humans, plants, and arthropods.
HUMANS
In biological terms, Scarlet Rot is a disease that is transmitted by direct contact with an affected individual, for example through physical damage, by airborne transmission via inhalation of the miasma or spores, and by waterborne transmission, as it can contaminate bodies of water such as lakes or rivers. This multifaceted method of transmission highlights the difficulties of containing such a prevalent disease.
Empirical observations suggest that the Scarlet Rot may possess a plant or fungal origin. Both plants and fungi release compounds as defense mechanisms against pathogens and predators or to aid in colonization and infection (Kocyigit et al., 2023). Fungi, in particular, produce secondary metabolites called mycotoxins, which can cause serious health conditions, while plants produce similar compounds known as phytotoxins (Kocyigit et al., 2023). Phytotoxins are commonly ingested for them to cause symptoms in a patient, also known as plant poisoning (Abhilash et al., 2021; Kerchner & Farkas, 2020).
Given that the Scarlet Rot is spread through the blooming of a flower, pollen may be a potential causal agent. Pollen is a well-known allergen that triggers conditions such as allergic rhinitis, asthma, conjunctivitis, and dermatitis (Guryanova et al., 2022). While these allergies can be life-threatening in extreme cases, their symptoms are not as severe or grotesque as those observed with the Scarlet Rot. However, pollen from certain poisonous plants may provide a closer analogy to the dramatic effects of the Scarlet Rot. Hippomane mancinella (commonly known as the manchineel tree) and Nerium oleander (known as oleander or rosebay) are prime examples of plants with highly toxic properties (Figure 3). H. mancinella produces toxins such as phorbol esters and terpenoids, which can cause severe skin irritation, blistering, and even respiratory issues when inhaled or contacted (USDA, 2004; Andreu & Friedman, 2012). Similarly, N. oleander contains potent cardiac glycosides like oleandrin, which can cause arrhythmias, nausea, and fatal heart conditions if ingested or inhaled in significant quantities (Anadón et al., 2018). Though the pollen of these plants is less commonly studied as a direct vector of poisoning, any contact with these plants, including inhaling the air around them, can provoke serious allergic or toxic reactions.
Pollen is also capable of carrying mycotoxins and mycotoxin-producing fungi (Kostić et al., 2019). Some mycotoxins found in pollen, such as aflatoxins, ochratoxins, and fumonisins, are known to cause kidney and liver failure, hypersensitivity, muscle pain, respiratory impairment, and, in some cases, neurological symptoms such as difficulty with movement, delirium, or dementia (Kraft et al., 2021; Kostić et al., 2019). These mycotoxins are primarily produced by opportunistic species of the genera Aspergillus, Penicillium, and Fusarium, which can cause various diseases in vertebrates and plants (Kostić et al., 2019). Additionally, pollen can harbor toxic and opportunistic fungi species from the genera above, as well as Mucor, Cladosporium, Alternaria, and Trichoderma, which are primarily plant pathogens but can infect immunocompromised people (Kostić et al., 2019). This exemplifies how pollen not only acts as an allergen but also as a vector for mycotoxins and a carrier for harmful fungi, potentially mirroring the spread of the Scarlet Rot, as it infiltrates both the environment and living organisms through airborne and contact-based transmission.
On the other hand, some fungi utilize pollination as a means of dispersal and infection. Claviceps purpurea, commonly known as ergot, is a species of Ascomycota fungus that causes ergotism, a disease resulting from the ingestion of contaminated grains, particularly rye (Webster & Weber, 2009) (Figure 4). The life cycle of C. purpurea (Figure 4b) begins when a spore germinates in the flower’s ovary, replacing it with a fungal structure known as a stroma that produces haploid cells called conidia (Miedaner & Geiger, 2015). This stroma secretes a syrup-like substance, or honeydew, which attracts insects that transfer the fungus to other plants, helping to preserve and spread the infection (Miedaner & Geiger, 2015). Additionally, water droplets aid in fungal dispersion. Once the stroma dries and darkens, it matures into a structure called a sclerotium or ergot, which, under optimal conditions, produces new fruiting bodies that continue the fungus’s life cycle (Miedaner & Geiger, 2015).
Ingestion of the sclerotium via contaminated cereals will lead to the development of ergotism. Historically, ergotism, previously known as St. Anthony’s fire, has had a close relationship with humans, with cases reported as early as 600 BC, causing epidemics in the Middle Ages (Cervellin et al., 2021). St. Anthony’s fire manifests in two clinical forms: (1) Gangrenous ergotism, characterized by burning sensations in the limbs (hence the name), followed by desensitization, edema, drying and blackening of affected areas, and in severe cases, loss of the limb without bleeding; and (2) Convulsive ergotism, where patients exhibit twitching, spasms, hallucinations, paranoia, and convulsions (Cervellin et al., 2021; Haarmann et al., 2009).
The main source of toxicity of C. purpurea lies in the alkaloids found in the ergot. These ergot alkaloids, such as ergotamine, ergocryptine, and related ergopeptine alkaloids, are responsible for the vasoconstrictive and neurotoxic effects that lead to the symptoms of ergotism (Haarmann et al., 2009). These compounds interfere with neurotransmitter systems and blood flow, particularly affecting the extremities and nervous system, causing the gangrenous and convulsive manifestations of the disease (Cervellin et al., 2021; Liegl & McGrath, 2016). The gangrenous tissue damage and erratic behavior bear a striking resemblance to the symptoms caused by the Scarlet Rot, linking the two conditions in terms of their debilitating impact on the human body.
PLANTS
The Scarlet Rot’s effects on the landscape and vegetation are displayed in the environments of Caelid, the Lake of Rot, and the Church of Bud (Figure 5). The land in Caelid appears arid and lifeless, characterized by desiccated trees, eroded soil, and a notable absence of healthy plant life (Figure 5a). Instead, fungi thrive ubiquitously, with some gigantic flower buds growing from the dead vegetation. At the heart of this blighted region lies a contaminated body of water, precisely where Malenia’s bloom occurred. The Lake of Rot, where the God of Rot is sealed, bears similar signs of fungal infestation, with the added feature of a vast, corrupted lake and cascading water (Figure 5b). The Church of Bud and its surroundings display the same devastating patterns, though with a peculiar twist: flower buds of varying sizes carpet the floor of the church’s hall (Figure 5c).
Regarding fungi, we observe four distinct kinds of fruiting bodies that resemble real-life organisms (Figure 6). (1) Clusters of gray/red apothecia, similar to ascomycete fungi from the genus Sarcoscypha (Figure 6a). (2) Aggregates of flat-capped mushrooms that resemble Laetiporus (Figure 6b). (3) Pinecone-like structures that grow near or on top of mushrooms that share similarities with the fruiting bodies of Arcyria slime molds (Figure 6c), though slime molds are not technically fungi. (4) Long, single stems covered in capped-ended, branch-like projections, resembling an uncapped Dendrocollybia fruiting body (Figure 6d). All of these organisms are saprophytic, which is fitting given the degraded state of these lands and the themes of rebirth from dead organic matter (Arora, 1986). Furthermore, given the enormous size of the fungi, it is easy to infer that the weakened flora succumbed to the fungi’s nutritional demands, much like how many fungal diseases can ultimately kill their hosts (Jain et al., 2019). Interestingly, the sclerotium of C. purpurea resembles the structures previously described, solidifying the possibility that the Scarlet Rot shares similar traits with this group.
Lastly, the flower buds appear as large and bulbous with overlapping, thick, petal-like scales or tepals. They have green, sharp-edged bracts, giving the flowers an overall armored appearance, and the reddish-pink hue suggests a mature bloom ready to open. This description aligns with flowers of the Protea genus (Figure 6e). However, unlike Protea plants, which have a bushy growth habit, these Scarlet Rot buds appear epiphytic (SANBI, 2024).
Additionally, certain fungi can alter plant physiology to facilitate their own reproduction. Gibberella fujikuroi is a parasitic fungus that alters the growth of infected rice plants by producing gibberellins, a growth hormone, causing the plants to grow taller than others, which aids in the fungus’s spread (Cuali-Álvarez et al., 2011). Puccinia monoica, a parasitic rust fungus of mustard plants, dramatically alters plant physiology. It induces the formation of pseudoflowers that bear the fungal reproductive cells. These pseudoflowers produce nectar that attracts pollinators, which transfer the cells to a recipient fungal hypha on another infected plant, thus maintaining the fungus’s life cycle (Roy, 1994). These examples suggest that similar mechanisms could be at play in the context of the Scarlet Rot, where fungal strategies may be driving abnormal growth and reproduction in the affected flora, paralleling real-world biological interactions.
ARTHROPODS
Although the Scarlet Rot is harmful to vertebrates and plants, arthropod-like creatures appear immune, even forming symbiotic relationships with the rot. The Kindred of Rot, a race of anthropomorphic, centipede-like beings, praise the Rot, believing themselves to be its offspring (Figure 7a).
It is suspected that before the arrival of the God of Rot, they were mere bugs, elevated to their current form through a deep connection with the Rot. Entomopathogenic fungi from the Ophiocordyceps genus are well-known for altering insect behavior, although being detrimental to the host. For instance, infected ants experience spasms and are forced to leave their nests, climbing vegetation and clamping their jaws onto high surfaces to facilitate spore dispersal (de Bekker, 2019).
Conversely, some insects have developed mutualistic relationships with fungi. One such phenomenon is known as fungiculture. Attine ants and ambrosia beetles, for instance, depend on this relationship. These insects “farm” the fungus, spreading and caring for it (even secreting antibiotics to protect it), while the fungus concentrates nutrients from wood to nurture the arthropods (You et al., 2015; Currie et al., 2006). These examples show how fungi form symbiotic relationships with arthropods, improving their fitness, similar to how the Scarlet Rot benefits certain arthropod-like creatures.
Butterflies also symbolize the Scarlet Rot’s presence. Although butterflies are found in every biome across the Lands Between, the Aeonian and Scarlet butterflies thrive in Scarlet Rot-affected lands. These butterflies are believed to have been part of the God of Rot wings. The Rotten Butterflies incantation even uses these butterflies to cause Scarlet Rot buildup, suggesting these arthropods are vectors for the disease (Figure 7b). Members of the order Lepidoptera (butterflies and moths) are not considered a threat to human health like other insects. Toxicity in Lepidoptera depends on various factors such as the stages of development (some larvae have urticant hairs) and the source food (ingestion of some compounds such as alkaloids from plants, which are then stored in the insect’s tissues), however only direct contact or ingestion triggers symptoms (Rothschild et al., 1970). Interestingly, some butterflies can carry fungi as part of their microbiome in every stage of their life cycle, granting them a role as fungi spreaders (Harrison et al., 2016). Indeed, some butterflies are vectors for fungal plant diseases such as Ustilago maydis, also known as corn smut or huitlacoche (Jennersten, 1983).
These mutualistic relationships may be explained by the belief that the God of Rot possesses arthropod-like characteristics, specifically resembling a scorpion, solidifying the bond between the rot and arthropod life. Interestingly, it appears that the host’s willingness to receive the Scarlet Rot significantly influences the outcomes of the affliction. Romina, Saint of the Bud, who was once human, embraced the rot fully, resulting in her transformation into a chimera. While retaining her human appearance, she grew butterfly wings from her back, with a giant centipede and a scorpion tail protruding from her waist (Figure 7c). Even though some mycotoxins are mutagenic, such as the aflatoxin from Aspergillus, none cause such dramatic changes in the host (McCullough et al., 2019). Nonetheless, this transformation reinforces the powerful connection between arthropods and the Scarlet Rot, while also highlighting the thematic elements of rebirth and metamorphosis that the Rot conveys.
TREATMENTS
Despite the severe consequences of the Scarlet Rot on a patient, the disease can be resolved if treated quickly. Therefore, Scarlet Rot can be classified into acute and chronic stages. For the Tarnished (the playable character) to become afflicted with the Rot, they must come into contact with a source of Scarlet Rot and exceed a resistance threshold. Once afflicted, the Tarnished’s health points will rapidly decrease until either they succumb to the rot or use one of the tools available to cure it. To treat Scarlet Rot, the Tarnished have several options (Figure 8): consuming “Preserving Boluses”, inserting an unalloyed gold needle into their body, or casting the “Flame, Cleanse Me” incantation.
Magic or mystical techniques to treat sickness lack reproducibility and scientific evidence. However, in the case of the flame incantation (Figure 8a), fire — or more specifically, heat — has been used in various treatments throughout history. Cauterization is an ancient technique involving the direct application of heat through fire or heated materials to close wounds or remove undesired skin (Nayab, 2017). Similarly, hyperthermia is an adjuvant cancer treatment that involves applying heat (40–48 °C) to kill cancerous cells and reduce tumor size, locally or systemically, depending on the cancer stage (Behrouzkia et al., 2016). Additionally, some researchers have proposed using hyperthermia to treat infections, as it can deactivate pathogens and enhance immune responses, though with the risk of harming the patient (Markota et al., 2023).
Preserving boluses are a consumable item that alleviates the Scarlet Rot buildup and cures the rot (Figure 8b). They are crafted from natural ingredients such as buds, herbs, and moss. Natural remedies and traditional medicine have long been seen as potential treatments for various afflictions, including infections. Since we infer that the Scarlet Rot is similar to fungal diseases, plant derivatives such as eucalyptol, camphor, and tea tree oil exhibit fungicidal properties alone or in combination with other compounds (Stojković et al., 2022).
Finally, inserting an unalloyed gold needle (also known as Miquella’s needle; Figure 8c) not only cures Scarlet Rot but also severs any connection with the Outer Gods. This mechanism is similar to implantable drug delivery systems used in diabetes and cancer treatments (Greatbatch & Holmes, 1991). These devices are surgically placed in the patient’s tissue to control the timing, rate, and location of drug release (Fayzullin et al., 2021). Additionally, antibiotic-coated implants have been used to treat infections during orthopedic procedures (Gimeno et al., 2015). These modern implants are made from biodegradable materials and metals that, with the aid of antibiotics, prevent pathogen growth (Xi et al., 2021).
CONCLUSION
Scarlet Rot is an insidious disease that plagues the world of Elden Ring, akin to real-world fungal diseases, particularly those belonging to the Ascomycota phylum. Its characteristics resemble the fungus Claviceps purpurea (ergot), as the Rot causes symptoms similar to ergotism, characterized by gangrenous decay and hallucinations. Moreover, the fruiting bodies that emerge from Rot-infected plants are reminiscent of the fungal growths seen in ergot infections and other colonizing fungi. However, unlike ergot’s detrimental impact on plants and animals in the real world, the Scarlet Rot has a unique, symbiotic relationship with certain arthropods. Creatures such as the Kindred of Rot not only appear immune to the Rot’s effects but have adapted to thrive alongside it, elevating their in-game status and forming a mutualistic bond with the disease.
Scarlet Rot treatments also echo real-world medical practices. For example, consuming Preserving Boluses, crafted from natural ingredients, mirrors the use of plant-derived compounds that exhibit antifungal properties. The “Flame, Cleanse Me” incantation, while mystical, emulates the historical use of heat in medical treatments to combat infections. Meanwhile, Miquella’s needle evokes modern implantable drug delivery systems.
In summary, the Scarlet Rot can be interpreted through the lens of both fungal biology and medical science, blending real-world principles of disease, symbiosis, and treatment with the rich lore of Elden Ring.
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Acknowledgments
This work was partly supported by using OpenAI’s GPT for drafting and editing assistance, and Grammarly for grammar and style suggestions. The author reviewed, edited, and revised the AI-generated texts and suggestions to his liking and takes ultimate responsibility for the content of this publication.
About the author
MSc. Abraham U. Morales-Primo is a Mexican biologist specializing in the role of NETs in leishmaniasis. A proud geek, he explores the immunological and epidemiological mechanisms of diseases — even in video games. Just as NETs combat pathogens, Abraham spends his free time facing formidable foes like Malenia and Radahn, often emerging victorious (barely). He’s happiest with a good playlist, tacos, and the company of his wife and daughter.