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 develops into bronchitis and seems to hang on forever. She is often awake at night, either coughing or having drenching night sweats. Finally, in April, she goes to her family practice physician to have it checked.

Her chest x-ray shows questionable cavitary lesions in her 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 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 should know good universal precautions technique, would develop a contagious disease.

Patient A, however, is the perfect candidate for infection. Working in a community with a large immigrant population from underdeveloped countries means she had a greater risk for exposure than other nurses. Although she worked on a surgical unit, many of the patients were possibly infected.

Her healthy immune system successfully suppressed the initial infection, but when the stressors in her life mounted, a breakdown occurred. 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 immune function and reactivation of latent TB. Any of these alone might have been insufficient to cause the immune system to fail, but grouped together, it was only a matter of time until the latent infection re-emerged. On antituberculous chemotherapy, proper nutrition, and a brief period of rest, she recovers without complication.