Smear-Negative Pulmonary Tuberculosis with Cavitary Disease in a Young Immigrant Patient: A Diagnostic Challenge

Tuberculosis (TB) remains a public health concern in the United States, with most cases resulting from reactivation of latent infection. Smear-negative pulmonary TB (SNTB) presents a diagnostic challenge, often lacking classical radiographic findings or sputum smear positivity. Diagnosis in such cases depends on a high index of suspicion and the integration of clinical, radiographic, and epidemiologic information. We report the case of a 26-year-old male patient with no significant past medical history who presented with hemoptysis, fever, night sweats, and weight loss. He had immigrated from Cuba 18 months prior and worked in construction, with exposure to silica and aluminum dust. Chest imaging revealed cavitary pneumonia. Despite treatment for a presumed atypical pneumonia, his symptoms persisted. Immune-based testing ultimately supported a diagnosis of TB, and the patient improved after initiation of standard therapy. This case highlights the diagnostic complexity of SNTB, especially when radiographic findings are atypical and confounding serologic tests are present. His occupational exposure to silica likely contributed to disease susceptibility. He had experienced fever, cough, night sweats, weight loss, and hemoptysis for approximately one week prior to presentation, underscoring the importance of considering epidemiologic and occupational context in patients with acute respiratory symptoms. Early recognition of smear-negative disease is critical for timely treatment and public health control. As TB continues to affect urban U.S. areas with high immigration and occupational risk, early recognition of smear-negative disease is critical for timely treatment and public health control.