A Double Pathogen Strike: COVID-19 and Talaromycosis Co-infection in a Patient with Post-Tuberculosis Lung Disease

An 80-year-old woman from rural Guangxi with post-tuberculosis lung disease (PTLD) (hereinafter referred to as PTLD)presented with one month of cough and fever. One month prior, she had ingested raw rodent meat—a known exposure for Talaromyces marneffei. Chest HRCT showed bilateral tree-in-bud opacities superimposed on prior left lung destruction. Conventional microbiological tests, including acid-fast bacilli smears, were negative. A nasopharyngeal swab was positive for SARS-CoV-2 (cycle threshold 17). Metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid identified both T. marneffei and SARS-CoV-2. Her CD4+ count was 344/μL and HIV serology was negative. She received nirmatrelvir–ritonavir and sequential amphotericin B followed by voriconazole, with clinical and radiological improvement. This case illustrates that PTLD may serve as a local anatomical risk factor for talaromycosis even without systemic immunodeficiency.