Patient A is a registered nurse, 40 years of age, working in southern California at a large medical center. The hospital is located in an area with a large population of immigrants from southeast Asia, so she has cared for many of these patients during her 12 years of work on the surgical floor.

However, she decides to transfer to the hospital's home health agency to work with hospice patients. She had suffered through her mother's death from breast cancer only months before, and she is also hoping to get more regular hours to be able to spend more time with her teenage son.

About the same time, her husband is "downsized out" of his job as an aerospace engineer. It is a difficult time for the entire family, but Patient A feels perhaps the greatest stress of all. She is trying to overcome her grief for her mother; give attention to her father, son, and husband; do well in her new position; and work extra hours when necessary to help with their financial woes. There never seems to be any time for her to relax.

In December, Patient A gets a cold that progresses to bronchitis and seems to hang on for weeks. She develops a productive cough, sleeps poorly, and has periodic drenching night sweats. Finally, she goes to her family practice physician for help.

Her chest x-ray shows a questionable cavitary lesion in the right upper lobe. Although Patient A's first panicky fear is that she has cancer, her physician investigates further, ordering a TB skin test and sputum smear and stain for acid-fast bacilli. Both tests are positive.

She is started on INH (300 mg/day), RIF (600 mg/day), ethambutol (800 mg/day), and PZA (1,000 mg/day). She is shocked by her diagnosis and embarrassed to tell her friends that she, a nurse who practices good Universal Precautions, has developed a contagious disease.

Patient A, however, is a good candidate for having developed latent tuberculous infection sometime in the past. For years she has been working on a surgical unit in a busy community hospital with a large immigrant population, many of whom moved to here from developing countries. Thus, she had been at greater risk for exposure to TB than the average nurse.

Her healthy immune system had successfully suppressed the initial infection, likely for years, but mounting stressors in her life could have contributed to a breakdown in control of latent infection. Perhaps the combined effect of a parent's death, change in financial status, family concerns, new job demands, and lack of sufficient rest led, in time, to a subtle depression in cellular immune function sufficient for reactivation of latent TB. Any of these alone might have been insufficient to disrupt immune control, but grouped together, it became only a matter of time until the latent infection re-emerged. Antituberculous chemotherapy combined with proper nutrition and a brief period of rest enabled her to recover without complication.