Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: fever major surgical or invasive procedure: endotracheal intubation and percutaneous endoscopic gastrostomy (peg) history of present illness: mr. is a 67 year old male with history hiv on haart and colitis who presented to the ed on with severe abdominal pain for 3 days, was admitted to the surgical service for perforated diverticulum and is now s/p sigmoid colectomy, who represented for fever and was found to have multifocal pna and was transferred to the micu on with respiratory distress. he was intubated and underwent bal which was not revealing. he was treated for 14 days with linezolid, meropenem, and cipro and was extubated . his micu course was complicated by delirium after extubation and he developed diarrhea (neg for c. diff), was transferred to the floor on . his status declined and he was re-admitted to the micu on and reintubated on . he was extubated on and had peg placed for nutritional support on . the patient was stable on nasal cannula and therefore was called out to the floor in the afternoon on . vital signs prior to transfer were 96.5 99/75 81 32 97% 2l nc . on arrival to the floor patient denies any pain in chest, abdomen, extremities or elsewhere. he denies nausea or vomiting past medical history: cad with mi s/p stent in hiv since (last cd4 was 540 (2 wks prior to admission) and viral load was <75) crohn's vs. lymphocytic colitis diagnosed 6 month ago on colonoscopy esophagitis adrenal suppression primary open angle glaucoma mv insufficiency arthroscopic knee surgeries ankle sprain early sacral decubitus ulcer since last admission cataract surgery social history: 15 pack-year smoking quit 35yrs ago, social etoh 10 drinks/wk, occ marijuana. lives independently in , however had been in rehab since last hosp. retired from engineering supply business. family history: father with dm, panc cancer, mother with cancer, chf physical exam: admission physical exam: ========================= vitals: t:99.7 bp:116/72 p:93 r:33 o2: 95% on 70% high flow general: alert, oriented, no acute distress, some tachypnea and difficulty finishing sentences heent: sclera anicteric, mmm, high flow mask in place, crusted abrasion on l face neck: supple, jvp not elevated, no lad lungs: exp wheezes throughout, bibasilar crackels cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: open abd wound, with granulation tissue, no e/o drainage or errythema. colostomy bag in place. mild ttp on r side gu: no foley ext: warm, well perfused, 2+ pulses, 2+ edema to the mid calf bilaterally, no calf tenderness. bruising around l ankle. petechial rash on r foot neuro: a&ox3, cnii-xii intact, sensation and strength grossly intact in all extremities skin: dressed decubitus ulcer discharge physical exam: ======================== 97.6 140/70 101 24 97% on 2l nc general: a+ox1-2. patient with frequent periods of confusion with garbled speech. weak phonation but speech intelligible when patient is oriented and mouth appropriately lubricated. heent: sclera anicteric, mmm, nc in place neck: supple, jvp not elevated, no lad lungs: faint scattered crackles. tachypneic with rapid shallow breaths 20-30 times per minute. cv: tachycardic, hyperdynamic heart sounds. normal s1 + s2, no murmurs, rubs, gallops abdomen: peg in place. colostomy bag in place. surgical wound clean. nabs, no ttp ext: warm, well perfused, 2+ pulses, skin: dressed sacral decubitus ulcer pertinent results: admission labs: 06:15pm wbc-4.5 rbc-3.04* hgb-9.9* hct-28.5* mcv-94 mch-32.6* mchc-34.8 rdw-13.6 06:15pm neuts-76.1* lymphs-20.0 monos-3.3 eos-0.3 basos-0.3 06:15pm plt count-207 06:15pm pt-14.4* ptt-25.3 inr(pt)-1.2* 06:15pm glucose-122* urea n-17 creat-0.5 sodium-135 potassium-3.2* chloride-103 total co2-25 anion gap-10 06:50am albumin-1.8* calcium-6.2* phosphate-2.4* magnesium-1.7 09:03am urine color-yellow appear-clear sp -1.041* 09:03am urine blood-sm nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-neg 09:03am urine rbc-1 wbc-1 bacteria-none yeast-none epi-0 ct torso : impression: 1. multifocal opacities in the upper and lower lungs, consistent with diffuse pneumonia. new irregular gas containing cavities concerning for necrotizing pneumonia in the previously seen area of right lower lobe consolidation. 2. small bilateral pleural effusions, left greater than right. 3. moderate amount of free fluid in the abdomen with indeterminate attenuation values, likely representing post-surgical fluid. no confined collection within the abdomen or pelvis to suggest abscess. 4. normal post-surgical appearance of the hartmann's pouch and . no evidence of obstruction, perforation, or leak. echo: impression: no echocardiographic evidence of endocarditis, however cannot exclude due to subooptimal image quality. moderate focal left ventricular systolic dysfunction consistent with inferior/inferolateral infarction. mild mitral regurgitation. ct torso: impression: 1. interval worsening alveolar pulmonary opacities with crazy-paving pattern, which could be related to worsening pneumonitis versus pulmonary edema and developing adult respiratory distress syndrome. more organized and necrotic-appearing right lower lobe necrotizing pneumonia. worsening pleural effusions. 2. new moderate bilateral pleural effusions. 3. slight interval increase in abdominal and pelvic ascites. 4. worsening anasarca. 5. status post sigmoid colectomy and diverting colostomy. ct abdomen: 1. interval decrease in the size of a necrotic pneumonia in the right lung base measuring 3.5 x 3 cm today. 2. consolidation in the left lower lobe consistent with aspiration or pneumonia. 3. left greater than right moderate nonhemorrhagic effusions. 4. nonhemorrhagic ascitic fluid with foci of free air, likely related to recent peg insertion. micro data: : blood culture, routine (final ): no growth urine culture (final ): no growth. sputum: gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 2+ (1-5 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): moderate growth commensal respiratory flora. : direct influenza a antigen test (final ): negative for influenza a. direct influenza b antigen test (final ): negative for influenza b. sputum: gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): no growth. legionella culture (preliminary): no legionella isolated. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): stool culture: source: stool. **final report ** microsporidia stain (final ): no microsporidium seen. cyclospora stain (final ): no cyclospora seen. fecal culture (final ): no enteric gram negative rods found. no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). bronchial lavage lingula. **final report ** respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. rapid plasma reagin test (final ): nonreactive. reference range: non-reactive. 10:45 pm bronchoalveolar lavage bronchial lavage rll. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~7000/ml commensal respiratory flora. yeast. ~5000/ml. isolates are considered potential pathogens in amounts >=10,000 cfu/ml. legionella culture (final ): no legionella isolated. potassium hydroxide preparation (final ): test cancelled by laboratory. patient credited. this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (final ): yeast. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. viral culture: r/o cytomegalovirus (final ): test cancelled, patient credited. further of the culture will be performed on request only. refer to cmv early antigen test result for further information. cytomegalovirus early antigen test (shell vial method) (final ): reported to and read back by 2:39pm. positive for cytomegalovirus. early antigen detected by immunofluorescence. discharge labs: ================ 06:03am blood wbc-9.5 rbc-2.95* hgb-8.8* hct-27.5* mcv-93 mch-29.9 mchc-32.1 rdw-15.0 plt ct-313 06:03am blood neuts-69.1 lymphs-24.6 monos-4.7 eos-1.3 baso-0.3 05:29am blood pt-11.6 inr(pt)-1.1 06:03am blood glucose-115* urean-16 creat-0.4* na-143 k-3.5 cl-108 hco3-29 angap-10 06:03am blood albumin-2.4* calcium-8.1* phos-3.9 mg-2.0 brief hospital course: primary reason for hospitalization: ==================================== mr. is a 67 yo gentleman with history of hiv on haart, last cd4 ct >500 and vl undetectable, s/p recent colectomy on for perforated diverticulum who presented on with fever and was found to have multifocal pna on ct requiring intubation and an icu course that was complicated by delirium and malnutrition. . active issues: =============== # acute respiratory failure: due to bilateral, multifocal necrotizing pneumonia, worst in the rll. he was intially given vanc/levaquin. however, after ct scan results, he was broadened to vanc/cipro/meropenem given his recent hospitalization. shortly after transfer to the micu, the patient had worsening respiratory distress requiring intubation . he was maintained on ards net ventilation settings. antibiotic regimen was adjusted to linezolid/cipro/meropenem. he had worsening oxygenation, with bronchoscopy showing a lot of thick yellowish secretions. sputum and bal cultures were all negative. viral dfa negative, legionella urine antigen negative. acid-fast smears were negative x3. on patient found on repeat ct scan to have worsening bilateral r>l pleural effusions. 700cc of light-coloured fluid drained from the left side, with elevated ldh to suggest exudative effusion, but was considered to be transudative given bland cell count and gross appearance. on he was successfully extubated. he completed his antibiotic course on . on pt had respiratory decompensation and increased o2 requirement. he went from 99% on 1l the evening of to 85% on 3l the am of . he received nebs and lasix but continued to require 6l o2 on floor and had labored breathing with audible breath sounds at bedside. cxr showed diffuse hazy opacities bilaterally. ekg without ischemia or right axis dev but ?q wave in lead iii. he was transferred to micu for continued work of breathing and nursing concern. restarted vanc//cipro for suspicion of recurrent pneumonia. he was reintubated for increased work of breathing. he was extubated on and had peg placed for nutritional support on . since that time he has had a consistent 1.5 to 2 liter oxygen requirement. he continues to breath 20-30 times per minute with rapid shallow breathing, however this has been stable for over a week. the source of his continued breathing difficulties appears to be a combination of severe necrotizing pneumonia which is slow to heal as well as a possible component of respiratory muscle weakness due to cachexia. the neccessary duration of treatment for necrotizing pneumonia is not well established and depends on response to therapy. in consultation with thoracic surgery, a 6 week course of antibiotics was planned to be completed . if the patient continues to have respiratory difficulties at that point a repeat ct scan of the chest should be considered. because a causative organism was never identified he will require continued broad spectrum coverage with vancomycin, meropenem, ciprofloxacin, and micafungin. interventional pulmonology considered a tap of pleural fluid but felt that it was too risky given the small amount of fluid. . #. hcap/fevers/chills: thought to be due to necrotizing pneumonia. all blood and urine cultures were negative. recent cd4 ct >500 therefore unlikely opportunistic infection. given recent surgery were initially concerned for intra-abdominal infection, however no evidence of focal collection; moderate free-fluid in abdomen likely represents normal post-surgical changes. the surgery team followed along, but did not feel this was a post-surgical infection. tte did not show endocarditis. the id team was consulted. because of persistent fevers, fluconazole was added . urine crypto antigen negative and galactomannan negative. beta-glucan and hhv8 were positive however this was not considered clincially relevant by the infectious disease service given improving clinical status. , given continued fevers, vanco stopped and linezolid started. the cytology from his pleural effusion fluid showed "vesicular chromatin, irregular nuclear membranes and some plasmacytoid cell", raising the possibility of malignancy causing his continued fevers. the oncology team was consulted, who recommended multiple viral markers, but felt that his lung mass would be very atypical for a malignancy. cmv was positive in the bal. ultimately because of response to therapy, it was concluded that the fevers had been due to the pneumonia. the patient was afebrile for over 10 days prior to discharge with stable white count. . #. malnutrition, severe: patient has recent history of chronic diarrhea and weight loss from possible crohn's vs microscopic colitis. on admission had albumin 1.8, trended down to 1.2 despite initiating tube feeds. he was fed via dobhoff but he was displaced several times. there was difficulty replacing it even with endoscopy and he had a peg placed on . with tube feeds, albumin had trended up to 2.4 prior to discharge. urine protein to creatinine ratios were checked to look for an alternative explanation for hypoalbuminemia. these were elevated but not in nephrotic range and results can be falsely elevated in the setting of cachexia. no other evidence of synthetic dysfunction was found to suggest hepatic origin. -- if persistently hypoalbuminemic despite treatment of infection and appropriate nutritional support then should consider further gi workup to investigate protein losing enteropathy. . # acute metabolic encephalopathy: most likely related to prolonged severe illness. no evidence of cns infection. vbg ruled out co2 narcosis. patient has many obligate tethers. tsh and rpr are normal. - - small dose of trazodone qhs to help sleep wake cycle. . # possible zenker's seen on egd: - video speech and swallow when patient improved from respiratory standpoint . # s/p colectomy: patient had wound dehiscence, however the wound remained clean and dry with granulation tissue and evidence of adequate wound healing. - pouch change 2 x a week: monday/thursday - cleanse skin with warm water - pat dry - cut wafer to fit template pattern with supplies - apply seal to back of wafer - center pouch over stoma and apply to abdomen and hold in place x 2 minutes . # sacral decubitis: seen by wound care, has sacral coccygeal ulcer measuring 4 x 3 cm that is covered with a black eschar. treated with special bed and dressing changes. . #. anemia: lower than recent baseline, however pt does have anemia at baseline. be in part due to blood loss during surgery. studies were checked which showed anemia of chronic disease. he had brown guaic postive stools. endoscopy showed schatzki ring and non-bleeding duodenal ulcer. he was started on pantoprazole. his hct then trended up and has remained stable for several days. . chronic issues: =============== # hiv: continued home antiretrovirals, ritonavir 100 mg po bid and darunavir 600 mg po bid . # hld: continued rosuvastatin . # cad s/p nstemi in : rate well controlled. metoprolol held in setting of hypotension, but later restarted. continued aspirin and rosuvastatin. . # glaucoma: continued eye drops . transitional issues: ==================== -- 6 week total course of antibiotics planned, which is to be completed . if the patient continues to have respiratory difficulties at that point a repeat ct scan of the chest should be considered. -- video swallow when medically appropriate before starting anything po and also to investigate possible zenker's diveriticulum. -- gi follow-up outpatient to investigate protein losing enteropathy -- questions about ostomy should be referred to acute care surgery (dr. did the sigmoid colectomy) medications on admission: medications at rehab: nystatin s&s dorzolamide-timolol drops brimonidine eye drops darunavir 600mg ritonavir 100mg calcium carbonate aspirin 325 mv metoprolol succinate xl 12.5 daily tylenol oxycodone prn pain . medications on transfer: -piperacillin-tazobactam 4.5 g iv q8h -acetaminophen 325-650 mg po/ng q6h:prn pain -aspirin 325 mg po/ng daily -budesonide 3 mg po daily -rosuvastatin calcium 20 mg po daily -ciprofloxacin 400 mg iv q12h -ritonavir 100 mg po bid -darunavir 600 mg po bid -metoprolol succinate xl 12.5 mg po daily -vancomycin 1000 mg iv once -niacin 500 mg po bid -vancomycin 1000 mg iv q 12h discharge medications: 1. rosuvastatin 20 mg tablet : one (1) tablet po daily (daily). 2. niacin 500 mg tablet : one (1) tablet po twice a day. 3. ritonavir 80 mg/ml solution : one hundred (100) mg po bid (2 times a day). 4. darunavir 600 mg tablet : one (1) tablet po bid (2 times a day). 5. dorzolamide-timolol 2-0.5 % drops : one (1) drop ophthalmic (2 times a day). 6. brimonidine 0.15 % drops : one (1) drop ophthalmic (2 times a day). 7. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 8. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical tid (3 times a day) as needed for itchiness. 9. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain. 10. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day). 11. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q4h (every 4 hours) as needed for sob/wheeze. 12. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours) as needed for sob/wheeze. 13. aspirin 325 mg tablet : one (1) tablet po daily (daily). 14. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 15. trazodone 50 mg tablet : 0.25 tablet po hs (at bedtime). 16. vancomycin in d5w 1 gram/200 ml piggyback : 1000 (1000) mg intravenous q 12h (every 12 hours) for 13 days: last dose . 17. meropenem 500 mg recon soln : five hundred (500) mg intravenous q6h (every 6 hours): last dose . 18. micafungin 100 mg recon soln : one hundred (100) mg intravenous q24h (every 24 hours): last dose . 19. ciprofloxacin 750 mg tablet : one (1) tablet po every twelve (12) hours for 13 days: last dose . discharge disposition: extended care facility: discharge diagnosis: primary: - necrotizing pneumonia - acute on chronic systolic heart failure (ef 30-35%) - malnutrition - anemia - aspiration secondary: - coronary artery disease - hiv - hyperlipidemia - glaucoma discharge condition: respiratory rate 24-32 and spo2 in mid 90s on 1.5-2 l oxygen at recent baseline, stable for over one week. hr 80s to 100s stable for over 1 week mental status: confused - always. speech: garbled and hypophonic. improves with lubrication of oral cavity. level of consciousness: alert activity status: out of bed with assistance to chair or wheelchair. discharge instructions: mr. , it was a pleasure taking care of you here at . you were admitted to the hospital on because you were having fevers at rehab after your surgery. you were diagnosed with a very severe pneumonia and on two occassions you required a breathing tube to help you breathe. on you were able to be taken off of the breathing machine. you have been receiving a long course of multiple strong antibiotics. you will continue to receive these antibiotics when you go to rehab. followup instructions: questions about ostomy should be referred to acute care surgery (dr. did the sigmoid colectomy). if patient's breathing not improving after completing antibiotic course, consider repeating ct of the chest. procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances other endoscopy of small intestine diagnostic ultrasound of heart insertion of endotracheal tube insertion of endotracheal tube enteral infusion of concentrated nutritional substances thoracentesis other bronchoscopy percutaneous [endoscopic] gastrostomy [peg] arterial catheterization arterial catheterization arterial catheterization closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus injection or infusion of oxazolidinone class of antibiotics central venous catheter placement with guidance central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: anemia of other chronic disease hypocalcemia coronary atherosclerosis of native coronary artery mitral valve disorders unspecified pleural effusion congestive heart failure, unspecified toxic encephalopathy unspecified septicemia iron deficiency anemia secondary to blood loss (chronic) severe sepsis candidiasis of mouth diaphragmatic hernia without mention of obstruction or gangrene other and unspecified hyperlipidemia regional enteritis of unspecified site acute respiratory failure pneumonitis due to inhalation of food or vomitus cachexia old myocardial infarction abscess of lung pressure ulcer, lower back cocaine abuse, episodic other disorders of plasma protein metabolism hyperosmolality and/or hypernatremia acute on chronic systolic heart failure delirium due to conditions classified elsewhere leukocytosis, unspecified asymptomatic human immunodeficiency virus [hiv] infection status stricture and stenosis of esophagus colostomy status neutropenia, unspecified critical illness myopathy mixed acid-base balance disorder nutritional marasmus duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction body mass index less than 19, adult pressure ulcer, unstageable diverticulum of esophagus, acquired glaucoma stage, unspecified primary open angle glaucoma 

Answer: The patient is high likely exposed to