The described case concerns a 57-year-old man from a non-endemic area who was diagnosed with cavitary pulmonary tuberculosis using CT-guided biopsy, acid-fast staining and PCR for Mycobacterium tuberculosis. Despite standard antituberculosis treatment, high fever persisted. Metagenomic sequencing of the bronchoalveolar lavage revealed co-infection with the bacterium Orientia tsutsugamushi, which was also confirmed by a positive IgM test. After doxycycline was added to the treatment, there was rapid resolution of fever and improvement of symptoms. Control CT showed the reduction of the cavitary lesion, but also the emergence of new fibrotic changes. The patient was started maintenance treatment with pirfenidone and home oxygen therapy. The authors emphasize that Orientia tsutsugamushi co-infection should be considered in persistent fever in patients with tuberculosis even in areas without typical exposure. This case also points to the possibility of irreversible structural remodeling of the lung despite microbiological control of the infection.