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Nerdarchy > Dungeons & Dragons  > D&D Ideas – Pestilence
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D&D Ideas – Pestilence

Adding More Divine Presence 5e D&D
D&D Ideas -- Famine

Welcome once again to the weekly newsletter. This week’s topic is Pestilence, which we discussed in our weekly live chat. We hangout every Monday evening at 8 p.m. EST at Nerdarchy the YouTube channel talk about D&D, RPGs, gaming, life and whatever nerdy stuff comes up.


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Delving Dave’s Dungeon

Last week we covered famine in previous newsletters we’ve done death and war. So it is time for the first Horseman of Apocalypse to ride forth. That horseman is called Pestilence, and is associated with infectious disease and plague. Looking through D&D Beyond I can find three primary sources for diseases, the contagion spell in the Player’s Handbook, Dungeon Master’s Guide, and monsters spread out over different D&D books.

That gives us 8 named diseases and 12 monsters ranging from CR ⅛ to CR 10. Half of which are solidly tier 1 monsters. Tier 2 starts at 5th level. You get access to Lay on Hands at 2nd level and lesser restoration at 3rd level. An adventure that heavily draws on themes of pestilence could prove to be quite deadly even in 5th Edition Dungeons and Dragons. I don’t know that a lot of players prepare lesser restoration which could prove to be a fatal oversight if you throw a lot of disease the players way.

To be clear not all diseases are created equally. A few are minor inconveniences but most are quite deadly. Think about a simple quest to clear rats from sewers. The players could be successful in driving off and slaying the rats to only have to worry about succumbing to the disease they carry later.

If you really wanted to lean into the theme of pestilence, imagine making the diseases more contagious. Any person coming in contact with an infected person needs to make a con save or get infected themselves. A successful save gives immunity for 24 hours after that you become susceptible to infection. A party with access to lay on hands and lesser restoration might find themselves going through those resources rapidly. I like the idea of a pestilence curse that is making diseases so much deadlier. This could be because of the Pestilence the Horseman, a god of plagues, or some other threat that needs to be dealt with before the diseases themselves can be countered.

Here is a list of diseases and their sources:

Diseases from the Contagion Spell in the Player’s Handbook

Filth Fever

Flesh Rot



Slimy Doom

Dungeon Master’s Guide Sample Diseases

Cackle Fever

Sewer Plague

Sight Rot

Monsters That Cause Disease

Otyugh CR 5

Gas Spore CR 1/2

Death Dog CR 1

Diseased Giant Rat CR ⅛

Buleza CR 3

Swarm of Maggots CR 2

Swarm of Diseased Giant Rats CR ½

Tlacatecolo CR 5

Blue Slaad CR 7

Rutterkin CR 2

Red Slaad CR 5

Aboleth CR 10

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From Ted’s Head

This last piece of the puzzle rounds out the four horsemen of the apocalypse. We spread it out over a lot of time and you can certainly do a lot with that concept, should you so desire. But of the 4 Horsemen, I feel that Pestilence is the easiest to implement.

War can be a tricky to run campaign as you are dealing with mass combat. Yes it can be an easy backdrop for a whole campaign or just part of it. Death easily looms over the heads of most player characters who constantly go into danger. If you focus on death as a concept it can be a very brutal and emotional story, so hard on players and DM alike. Famine which we covered last week is great for a backdrop as well but can easily be bypassed with the right spellcasters and spell selection. Afterall a single 1st level spell provides nourishment for up to 10 people for 1 day. Start training more druids I say.

But when we start to look at pestilence, we can see a different picture. Without going hard into the real world, we see disease spread and easily in our world. Even things that have cures or vaccines. In a fantasy world where common folk might not have access to the same levels of cleanliness disease can easily run rampant if not stopped. But when you put an active face on someone spreading disease it can get out of hand quickly. Clerics and paladins can spend all their resources trying to remove it, and unless they get everyone it will only keep spreading as people go about their normal lives.

Now we talked about some of the big monsters that can be used to spread disease and pestilence in the chat on Monday night. (by the way we are going to move those to Sunday for the time being). In my research I saw the carrion ogre and thought it a fun little monster to play with. But what if we wanted to scale that up? Keep the ridiculousness of the ogre, but as opposed to joining it with a carrion crawler, what if it was merged with a disease ridden Otyugh?

Allow me to introduce the Ogryugh.

Ogryughs are created by demons, evil divine beings, or creatures of great power that want to spread disease. The large nature of an ogre and an otyugh make them hard to bring down. The dull nature of the ogre allows them to be easily manipulated and the willingness to go anywhere and eat anything of an otyugh make for a perfect combination for malign beings.

An Ogryugh stands roughly 10 feet tall and has the general structure of an ogre. 2 arms and 2 legs. But instead of a normal head the massive maw of an otyugh bursts forth from its upper torso. Numerous oddly shaped eyes protrude from the top of the creature allowing it to see in all directions. Several massive tentacles grow out of this bizarre creature’s back that end in long spiked pads. The stench of decay and offal surround such a creature. On occasion an ogryugh will walk around on all 4 limbs waving its back tentacles around. When it does this some think that it looks like an oversized otyugh with an extra limb.


Large Aberration, Neutral

Armor Class 14 (natural armor)

Hit Points 126 (12d10 + 60)

Speed 30 ft.

STR: 18 (+4)

DEX: 11 (+0)

CON: 20 (+5)

INT: 7 (-2)

WIS: 11 (+0)

CHA: 6 (-2)

Saving Throws CON +7

Senses Darkvision 120 ft., Passive Perception 10

Damage resistance: Poison

Condition immunities: Disease

Languages Otyugh, Giant

Challenge 5 (1,800 XP)

Proficiency Bonus +3

Limited Telepathy. The ogryugh can magically transmit simple messages and images to any creature within 120 feet of it that can understand a language. This form of telepathy doesn’t allow the receiving creature to telepathically respond.

Disease Ridden. The Ogryugh is prone to carrying 1 or more diseases. While an Ogryugh is immune to their effects then can pass such diseases onto those it comes in contact with. Roll 1d3 for the number of diseases it currently carries. At each contact it can spread one disease randomly determined with each contact.


Multiattack. The otyugh makes three attacks: one with its bite and two with its tentacles.

Bite. Melee Weapon Attack: +6 to hit, reach 5 ft., one target. Hit: 12 (2d8 + 3) piercing damage. If the target is a creature, it must succeed on a DC 15 Constitution saving throw against disease or become poisoned until the disease is cured. Every 24 hours that elapse, the target must repeat the saving throw, reducing its hit point maximum by 5 (1d10) on a failure. The disease is cured on a success. The target dies if the disease reduces its hit point maximum to 0. This reduction to the target’s hit point maximum lasts until the disease is cured.

Tentacle. Melee Weapon Attack: +6 to hit, reach 10 ft., one target. Hit: 7 (1d8 + 3) bludgeoning damage plus 4 (1d8) piercing damage. If the target is Medium or smaller, it is grappled (escape DC 13) and restrained until the grapple ends. The otyugh has two tentacles, each of which can grapple one target.

Tentacle Slam. The otyugh slams creatures grappled by it into each other or a solid surface. Each creature must succeed on a DC 14 Constitution saving throw or take 10 (2d6 + 3) bludgeoning damage and be stunned until the end of the otyugh’s next turn. On a successful save, the target takes half the bludgeoning damage and isn’t stunned.

Nerdarchy staff

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