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: ifosfamide attending: chief complaint: fever major surgical or invasive procedure: : bone marrow aspiration and biopsy. : open splenectomy, exploratory laparotomy, lysis of adhesions : drainage of splenectomy bed history of present illness: this is a 59 yom with hx of dm2, high-grade prostatic intraepithelial neoplasia, renal cell carcinoma, s/p l nephrectomy (), diffuse large b cell lymphoma (), s/p chop x 8 cycles and r-ice two cycles now s/p asct day 41 post transplant who presents from home with fevers. patient states he felt febrile this afteroon so he took his temperature and noted it to be elevated to 100.6. he called his oncologist who then referred him to the ed. the patient reports +fatigue over the past few days, +body aches today. he also reports +rhinorrhea with clear discharge. he denies any recent cough, sore throat, ear pain, sore throat, headache, cp, sob, n/v, diarrhea, abdominal pain, dysuria, hematuria, urinary frequncy, back pain, rashes, sick contacts or recent travel. . in the ed v/s: temp 100.6, bp 124/62, hr 120, rr 20 99% ra. patient received cefepime 2gm iv x 1, flu swab sent. cxr done showed no acute abnormality. 2l ivf given. blood cultures drawn and patient sent to the floor for further management. past medical history: 1. diabetes mellitus, type ii (diagnosed 10-11 years ago), treated with oral meds until chemotherapy, now on iss. 2. high-grade prostatic intraepithelial neoplasia (prostate biopsy , no treatment "no cancer") 3. diffuse large b-cell lymphoma (), s/p chop x 8 cycles and r-ice two cycles 4. renal cell carcinoma, s/p l nephrectomy () 5. eczema (severe) - no recent exacerbations 6. h/o c. difficile colitis (just completed po vanc course) 7. pneumonia, ~ - did not require hospitalization; treated with z-pack x 2 . past surgical hisory: 1. pyloric stenosis correction as neonate 2. vasectomy - complicated by infection, treated with antibiotics 3. left nephrectomy for renal cell carcinoma . -------------------- . oncologic history (per primary oncologist's note, dr. ): is a 59-year-old man who was diagnosed with a diffuse large b-cell lymphoma in and received 8 cycles of chop plus rituxan. at the time of this diagnosis, he was also diagnosed with a renal cell carcinoma for which he underwent unilateral left complete nephrectomy and this was thought to be curative therapy. in late , he again felt febrile and repeat ct of the abdomen revealed new or increased adenopathy in the left internal and external iliac groups, the largest area being 24 mm. he also had some liver lesions, which were suspicious for metastatic disease (lymphoma versus renal cell carcinoma) and splenomegaly. he was transferred to where he underwent a ct of the torso showing multiple abnormally enlarged lymph nodes in the retroperitoneum,extending to the left common and external iliac chains to the left inguinal ring, highly concerning for recurrent lymphoma. there are multiple ill-defined liver lesions, very symptomatic metastatic disease and small volume ascites. there is a thin band of enhancing soft tissue in the left nephrectomy bed, worrisome for locally recurrent renal cell carcinoma and a cluster of central lobular nodules in the left upper lobe measuring up to 7 mm in size. there was also a 4-mm right lower lobe pulmonary nodule seen. biopsy of a left iliac lymph node showed involvement by diffuse large b-cell lymphoma. the mib fraction was approximately 90%. cd20 was not immunoreactive and this was thought to be due to previous therapy with rituximab and therefore he was started on ice without rituxan due to the lack of cd20 positivity in the cells. his therapy was complicated by encephalopathy. he developed asterixis, negative myoclonus, inattentiveness and somnolence after the second dose of ifosfamide and third dose was delayed by one day. his third dose resulted in similar signs. this was cleared within 24 hours, the somnolence improved dramatically within 24 hours as well. he was discharged after this cycle on . he was readmitted with febrile neutropenia secondary to c. difficile colitis on , treated with oral vancomycin and flagyl, and discharged on . he was readmitted on for his second cycle of r+ice, but found to have c.diff colitis at that time and was discharged to home with po vancomycin. . other oncologic history: - ? prostate cancer - biopsy on revealed high-grade prostatic intraepithelial neoplasia - renal cell carcinoma - diagnosed after routine work-up including ct scan; s/p nephrectomy (considered curative) . other active problems: - pancytopenia - findings on ct concerning for locally recurrent renal cell carcinoma, recurrent lymphoma (retroperitoneal nodes extending down int/ext iliac chains), lesions in liver (? renal, ? lymphoma mets) social history: married, lives with wife in , . two daughters (one works as nurse and lives with him), one son. was a motor mechanic but could not tolerate the eczema. for the last thirty-five years he has worked as a computer technician, at first with . currently on disability. smoked until (11.5 ppd x 13 years) and does not presently drink (x 14 years), although did have history of heavy etoh use. family history: father died from mesothelioma (worked in fire department and as janitor, smoked), and had a pace-maker. mother had diabetes and breast cancer, still alive with "lazy blood cancer". osh documents describe his mother's "myelodysplastic syndrome, 5q minus syndrome and low-grade lymphoma involving bone marrow as well as monoclonal gammopathy consulted by dr. ". half-sister (by his mother) with diabetes, obesity and poor self-care, is deceased. daughter and two other children are well. physical exam: on admission: vs: temp 97.7, bp 90/56, hr 93, rr 18 98% ra gen: caucasian male in nad, lying in bed comfortably heent: ncat, no sinus tenderness, dry mm, op clear neck: no lad cv: +s1/s2, no m/r/g, rrr pulm: ctab, no wheezes crackles or ronchi abd: +bs, nt/nd, no gaurding limbs: no c/c/e, +2 pulses, left great toe bandaged appears soupy skin: no rashes pertinent results: on admission: 08:51pm lactate-1.0 08:35pm glucose-85 urea n-26* creat-1.7* sodium-140 potassium-4.5 chloride-105 total co2-25 anion gap-15 08:35pm calcium-8.8 phosphate-3.0 magnesium-2.0 08:35pm wbc-2.3* rbc-2.63* hgb-8.9* hct-25.2* mcv-96 mch-33.9* mchc-35.3* rdw-21.0* 08:35pm neuts-56 bands-1 lymphs-23 monos-16* eos-0 basos-0 atyps-4* metas-0 myelos-0 08:35pm hypochrom-normal anisocyt-2+ poikilocy-normal macrocyt-3+ microcyt-normal polychrom-occasional 08:35pm plt smr-very low plt count-24* 08:35pm pt-12.4 ptt-26.0 inr(pt)-1.0 micro: imaging: torso ct w/contrast: 1. no pathologically enlarged mediastinal, mesenteric or retroperitoneal lymphadenopathy that would be concerning for recurrence, with marked interval improvement of previously noted lymphadenopathy in retroperitoneum and left pelvic region as seen on ct from . 2. previously noted band of enhancing soft tissue in left nephrectomy bed on examinations from and is incompletely evaluated on this non-contrast examination with no gross enlargement. 3. slight thickening of the cecum. it is unclear if this is from underdistention, typhlitis, or infection/inflammation. liver/gallbladeer u/s: 1. cholelithiasis again noted within contracted gallbladder. possible sludge also. no biliary obstruction. 2. normal liver exam on ultrasound. again previously seen lesion in the liver on ct of is not visualized on ultrasound. mri abdomen w/o & w/contrast: 1. no abnormality identified to explain patient's persistent fevers. no fluid collections seen. 2. diffuse low signal intensity within the liver and spleen is consistent with iron deposition secondary to hemosiderosis. 3. massive splenomegaly. 4. enhancing linear soft tissue noted within the left nephrectomy bed which is unchanged from the recent ct, and again remains concering for disease recurrence. 5. mildly increased size of a left paraaortic lymph node. 6. abnormal marrow signal, possibly related to iron deposition but marrow infiltration by lymphoma, post-treatment changes, or marrow reconversion are not excluded. ct torso w/contrast: 1. slight increase in size of subcentimeter mediastinal lymph nodes, soft tissue thickening in the left nephrectomy bed, and soft tissue nodules/lymph node in the left paraaortic region,potentially concerning for recurrence of disease. 2.the spleen has increased by 4 cm in its length since , concerning for worsening of patient's lymphoma. 3. two stable pulmonary nodules as described. 4. small amount of free fluid in the pelvis, which is new, but not specific. 5. no intra-abdominal or pelvic collections. head ct w/o contrast: no acute intracranial process. no midline shift. ct abdomen w/o contrast: 1. no significant change in appearance of the right adrenal gland with no evidence of high attenuation to suggest spontaneous active adrenal hemorrhage. 2. overall no significant interval change in appearance of the abdomen with the previously noted soft tissue thickening in the left nephrectomy bed and left periaortic region stable, though incompletely characterized on this non-contrast examination. 3. splenomegaly with spleen measuring up to 22 cm. : ct chest/abd/pelvis: 1. new subtle ground-glass opacities in the bilateral lungs predominantly in the bases. although findings are nonspecific, differential diagnosis includes edema, infection, or drug reaction. 2. status post splenectomy with a small amount of fluid within the posterior splenectomy bed and mesenteric stranding. while these findings may represent post-surgical change, and underlying infection is not excluded. splenic vein thrombus which does not cross the midline. portal vein patent. 3. interval increase in some of mediastinal and retroperitoneal lymph nodes. 4. stable 3 mm left lower lobe nodule and tree-in- opacity. 5. enhancing tissue within the left nephrectomy bed very suspicious for rcc recurrence. : bone marrow biopsy: hypercellular marrow with extensive involvement by patient's known diffuse large b-cell lymphoma. : chest xray: no active disease in the chest. : liver ultrasound: the liver has a normal echotexture without focal hepatic lesions. there is no intra- or extra-hepatic biliary duct dilatation. the common bile duct is normal measuring 4 mm. there are multiple small non-obstructing gallstones. the portal vein is patent with normal hepatopetal flow. the patient is status post splenectomy. there is no ascites. : ct chest/abd/pelvis: 1. interval organization of fluid within the splenectomy bed, now with enhancing rim. infection is not excluded by imaging. splenic vein thrombus has not propagated; portal vein remains patent. 2. subtle diffuse ground-glass opacities in bilateral lungs with lower lobe predominance, similar to that seen on . findings again nonspecific, with differential including inflammatory or infectious processes. 3. status post left nephrectomy and adrenalectomy. stable enhancing soft tissue within the left nephrectomy bed. 4. minimal if any increase in size of retroperitoneal and mediastinal lymph nodes. 5. multiple tiny lung nodules and peribronchovascular nodular opacities, similar to that seen on . : chest xray: there is no pneumothorax. cardiomediastinal contours are normal. the lungs are clear. there is no pleural effusion. drain projects in the left upper quadrant. : non-contrast chest ct: 1. diffuse infectious process, likely viral in origin, with small bilateral pleural effusions. 2. slight increase in mediastinal lymphadenopathy. 3. soft tissue nodular thickening in the left nephrectomy bed, incompletely evaluated due to the lack of iv contrast. bal cytology: negative for malignant cells. numerous pulmonary macrophages, bronchial cells, lymphocytes and benign-appearing squamous cells. portable cxr: widespread ground-glass opacities are present throughout both lungs with some associated reticular, micronodular, and linear opacities. heart size and pulmonary vascularity have not appreciably changed. correlation with chest ct of demonstrates widespread abnormalities which have apparently progressed. observed findings are likely due to an evolving infection, either viral or pneumocystis. ct abd/pelvis: 1. marked interval progression of bilateral ground-glass opacity and tree-in- opacities in the lung bases with small bilateral pleural effusions concerning for worsening infectious disease process. 2. interval decrease in fluid collection within the left upper quadrant with drain in appropriate position. other areas of small amount of fluid within the perihepatic space along the right paracolic gutter are now identified. 3. mild gallbladder distention, unchanged. periportal edema, similar in appearance. 4. enhancing nodule within the left nephrectomy surgical bed concerning for recurrence. 5. multiple pathologically enlarged lymph nodes within the retroperitoneum, unchanged. 6. focal areas of wall thickening involving the cecum and sigmoid colon. dedicated visualization with colonoscopy is recommended given history of lymphoma. 7. persistant splenic vein thrombosis. portable cxr: as compared to the previous radiograph, the bilateral parenchymal opacities have further increased in extent and severity. the distribution and morphology of the opacities would be consistent with diffuse infection, or vascular permeability edema. increasing retrocardiac atelectasis, no evidence of pleural effusions. brief hospital course: 59 year old male with a history of type ii dm, high-grade prostatic intraepithelial neoplasia, renal cell carcinoma s/p l nephrectomy (), diffuse large b-cell lymphoma () s/p autologous sct admitted for febrile neutropenia. #. febrile neutropenia: there was initially no clear source based on cultures or imaging. he was started on vancomycin, cefepime, levoquin, and tamiflu. nasopharyngeal swab and culture were negative for viral infection, so the tamiflu was discontinued. he continued to have fevers to 103 so micafungin was added for fungal coverage while invasive marker of fungal infection were sent. bone marrow biopsy on did not show disease recurrence. there was concern for hepatic candidiasis given increased alk phos but hepatic mri was negative. he continued to spike fevers to 103 degrees, with no positive culture data. pet/ct on showed a massive, fdg avid spleen (22cm up 4cm since ) and some fdg-avid nodes, concerning for disease recurrence. he required daily platelet and blood tranfusions, thought to be to splenic consumption. general surgery was consulted, and the patient underwent splenectomy on (see below for course with general surgery). he was initially afebrile but again developed fevers on . ct torso on showed new subtle ground-glass opacities bilaterally, predominantly in the bases. he received pentamidine on for pcp . blood, urine, stool, and mycolytic cultures continued to be negative. repeat ct's on and showed worsening intrapulmonary processes, reported as likely infectious. antibiotic coverage was broadened to include daptomycin, zosyn, voriconazole, levaquin, and bactrim. the patient underwent bronchoscopy/bronchoalveolar lavage on and repeat on , both negative for organisms or pcp; bactrim was then discontinued on . the only culture positive data was from his jp drain fluid, which grew enteroccoccus; id felt this was more consistent with colonization than infection, but the patient was nonetheless continued on daptomycin. he was tranfused prbcs and platelets to keep his hct above 25 and his platelets above 10. sputum culture on grew gnrs, likely respiratory flora, but given persistent fevers, id recommended changing levofloxacin to gentamicin, and zosyn to meropenem. cxr and ct chest were consistent with progression of the patient's underlying lymphoma, and although he continued to be treated for infectious source, b lymphoma symptoms were also considered as contributing to his fevers. ultimately, he could continued to spike fevers with hypotension despite negative cultures. antibiotics were being changed to meet this fever curve, with the last major addition being daptomycin on . despite this, his cxr continued to reveal new opacities. this together with his fevers and history of recurrent lymphoma presenting with fevers, comfirmed a primary role for lymphoma. on , a family meeting was held wherein the patient would be made dnr and a transition to comfort care was initiated. he passed shortly thereafter #. respiratory distress: as above, the patient had worsening opacities on chest films and ct scans, concerning for infection. after his bronchoscopy on , the patient was breathing comfortably and satting well, intermittently wearing 1-2 liters by nasal cannula. the following day, he was found to be tachypnic, and abg revealed po2 of 69. on the morning of , he triggered for worsening hypoxia, tachypnea, and tachycardia. he was placed on a non-rebreather mask. abg revealed o2 of ~100, while on the nrb. stat chest x-ray revealed worsening opacities. he was transferred to the for further management. on arrival patient was tachypneic and tachycardic, and was intubated and placed on mechanical ventilation. bronchoscopy was performed which was negative x 2. bactrim was stopped, but he was otherwise continued on broad spectrum antibiotics. thoracic surgery declined to perform a vats biopsy given patients comorbidities. #. abdominal pain: the patient complained of the acute onset of abdominal pain on . ct abd/pel showed small peri-pancreatic fluid accumulations. concern was raised regarding whether or not this was a leak secondary to his surgery. surgery recommended watchful waiting. #. acute renal failure: his creatinine on admission was elevated from baseline creatinine. this was though to be likely due to dehydration and increased insensible loss. he was given ivf in the emergency department and on the floor and his creatinine returned to baseline. #. cholestasis transaminitis: patient developed an elevated alkaline phosphatase, bilirubin, and ggt following initiation of antibiotic therapy. azithromycin was stopped and the lfts improved. there was no sign of hepatitic candidiasis. he later again had elevated transaminitis and elevated alk phos with a normal bilirubin. tylenol was kept to a minimum and hepatotoxic drugs were stopped. it was felt that his elevated lfts may be due to his recurrent lymphoma. #. diffuse large b-cell lymphoma: he is s/p autologous sct. he was started on antibiotics on admission but after his infectious work-up was negative they were discontinued given concern for drug fever. he had a pet/ct, as above. after splenectomy on , splenic tissue showed involvement by non-hodgkin lymphoma, diffuse large b-cell type. he was restarted on rituxan and steroids on . he had a bm biopsy on which showed diffuse involvement by his known lymphoma. he underwent treated with nitrogen mustard on . #. post-operative splenectomy course: on , the patient underwent open splenectomy, exploratory laparotomy, and lysis of adhesions. after a brief, uneventful stay in the pacu, the patient was transferred to the ticu overnight and intubated. the patient was hemodynamically stable. he was extubated on pod#1, and later transferred to the floor. post-operative pain was controlled with the a dilaudid pca. jp amylase was sent in the evening of pod#6; the jp was discontinued on pod#7 as the output and amylase level were low. around pod 20-21, he began to complain of left-sided abdominal pain. ct abdomen/pelvis was done which showed an fluid collection at the splenectomy site with an enhancing rim and there was concern for infection given his recent fevers. this collection was drained by interventional radiology and gram stain and culture were negative to date. the fluid did have a very elevated amylase level which suggested pancreatic fistula/injury during the surgery. a drain was left in place, and it continued to collect about 20-80 cc of fluid/day, one month later. medications on admission: acyclovir - 400 mg tablet - 1 tablet(s) by mouth every 12 hrs levamir 24u sq qpm novolog sliding scale discharge medications: deceased discharge disposition: expired discharge diagnosis: primary: 1. febrile neutropenia 2. chronic thrombocytopenia and splenomegaly. 3. acute renal failure 4. large b cell lymphoma discharge condition: deceased discharge instructions: deceased followup instructions: deceased md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances percutaneous abdominal drainage biopsy of bone marrow biopsy of bone marrow closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus total splenectomy debridement of nail, nail bed, or nail fold injection or infusion of biological response modifier [brm] as an antineoplastic agent diagnoses: acidosis thrombocytopenia, unspecified diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute kidney failure, unspecified other malignant lymphomas, unspecified site, extranodal and solid organ sites peripheral stem cells replaced by transplant acute respiratory failure antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use other specified disorders of biliary tract other ascites diarrhea hypovolemia hyperosmolality and/or hypernatremia removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation drug induced neutropenia personal history of malignant neoplasm of kidney acquired absence of kidney persistent postoperative fistula fever presenting with conditions classified elsewhere dysplasia of prostate unspecified local infection of skin and subcutaneous tissue other specified aplastic anemias 

Answer: The patient is high likely exposed to