Abstract Introduction In low-incidence countries, tuberculosis (TB) screening programs for healthcare workers rely on periodic IGRA testing and passive symptom reporting. However, transient clinicians, such as locum and home-health nurses, often operate across multiple care environments and may fall outside consistent occupational surveillance systems. In such settings, prior negative screening may create false diagnostic reassurance, even in the presence of evolving symptoms. We describe a case of advanced cavitary pulmonary TB in a locum nurse with repeated prior TB clearance and multiple missed opportunities for early diagnosis in primary care. Case Presentation A 40-year-old Filipino-born male working as a locum/home-health nurse presented with 3 months of dark-brown sputum, one episode of hemoptysis, intermittent fevers, pleuritic chest pain, decreased appetite, and ½-pack/day smoking history. He reported travel to Mexico 1 year earlier and multiple negative IGRA tests 2-3 years prior for employment clearance.Despite several prior outpatient visits for persistent cough, fever, fatigue, and myalgias, he was repeatedly diagnosed with “viral URI” and received only symptomatic therapy.On admission, he was febrile with WBC 15 K/µL and newly identified uncontrolled diabetes (glucose 315 mg/dL; HbA1c 11.9%). CXR showed a dense left-upper-lobe infiltrate; CT revealed cavitary consolidation with multifocal nodularity. Empiric broad-spectrum therapy for presumed bacterial pneumonia was initiated. On hospital day 3, sputum smear demonstrated 36 AFB/HPF. RIPE therapy was started for 56 days, all other antibiotics discontinued. Discussion This case reflects diagnostic drift and anchoring driven by prior negative occupational TB screens and low-index suspicion in a low-incidence environment. Repeated mislabeling as URI in primary care, despite systemic symptoms and prolonged cough, delayed diagnosis. Newly unmasked diabetes likely facilitated reactivation. Importantly, his locum nurse role—providing care across multiple facilities and households—posed a significant unrecognized transmission threat, revealing a vulnerable point in TB control systems. Conclusion TB can occur despite recent occupational screening and may be repeatedly misdiagnosed in primary-care settings when clinical suspicion is low. Locum healthcare workers represent a unique surveillance challenge due to fragmented screening oversight and broad patient contact networks. Enhanced TB vigilance, symptom-triggered re-testing, and public-health tracking mechanisms for transient healthcare staff are critical to prevent delayed diagnosis and potential healthcare-associated spread This abstract is funded by: None
Gollamandala et al. (2026) studied this question.