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 (sulfonamides) / aspirin / iodine / red dye / yellow dye / perfume ht52 attending: chief complaint: anemia and weakness major surgical or invasive procedure: bone marrow biopsy picc line placement bone marrow biopsy bronchoscopy transjugular liver biopsy tunneled central venous line placement tooth extraction history of present illness: ms. is a 49 year-old woman who was recently diagnosed with aplastic anemia. she notes increasing fatigue. she is being admitted to consider treatment. she was in her usual state of health until about last when she experience viral syndrome and associated w/ sore throat. she was put on multiple courses of antibiotics (amoxicillin, cipro, etc) for total of month. she was feeling generally well with her baseline amount of energy until when she noted increasing fatigue and was noted to be pancytopenic. she reported easy nose bleeds and gum bleeding at that time. she was seen at for evaluation. a bone marrow biopsy on revealed a hypocellular bone marrow with 5-10 % cellularity and no evidence of leukemia or other marrow infiltration. ebv igm was positive at that time with a low titer of igg. a repeat bone marrow evaluation on showed mildly hypocellular marrow with approximate cellularity of 30% and erythroid dominance. she was admitted to the - upon discharge, her counts remained stable and her anc has ranged from 300-500, platelets from 14-21,000, and hematocrit from 23.8-27.4 without transfusion support. she remains profoundly fatigued. she is not eating well and is drinking less than a liter of fluid per day. she states that she becomes dyspneic with minimal exertion and has been experiencing chest pain with this dyspnea. she notes nausea and dry heaves on a daily basis. she occasionally has headaches but denies focal neurologic deficits. she feels cold, but denies fevers or rigors. she previously had diarrhea, but now notes her stools are firmer and less frequent (approximately once daily). she notes occasional nose bleeds. past medical history: 1. hcv: she has received interferon and ribavirin in the past, though has not received any treatment for at least 1-2 years. her most recent hcv pcr was 12,600,000 copies on . 2. pancytopenia as noted above. social history: she is married and lives with her husband outside of . she has no children. she is currently on disability. denies alcohol, tobacco or drug use. quit tobacco in . quit ivdu in the early 80s. of noet the patient is a jehovah's witness family history: mother had ovarian cancer at age 65 and is alive and well. sister had squamous cell cancer of skin at age 41. brother is well, though has ankylosis spondylitis. physical exam: vital signs: blood pressure: 90/62, heart rate: 87, weight: 161 lbs, temperature: 97.7, resp. rate: 20, o2 saturation%: 100. general: tired and ill-appearing. no acute distress. sitting in wheelchair, accompanied by her husband. : sclera anicteric, oropharynx clear. neck: no thyromegaly. chest: clear to auscultation and percussion. abdomen: soft, nondistended. mild right and left upper quadrant discomfort. no definitive splenomegaly. extremities: no edema. skin: no jaundice. no purpura, ecchymosis, or petechiae. pertinent results: = = = = = = = = = = = ================================================================ bone marrow biopsy : normocellular, erythroid-dominant bone marrow with a striking trilineage dyspoiesis and a small population of blasts = = = = = = = = = = = ================================================================ liver core biopsy mild portal predominant mononuclear inflammation (grade 1). minimal steatosis. mild increased stainable iron (iron stain examined). mild portal fibrosis (stage 1) on trichrome stain. note: the overall features consistent with chronic viral hepatitis, grade 1 inflammation, stage 1 fibrosis. no lobular abscesses or viral inclusions. = = = = = = = = = = = ================================================================ spirometry within normal limits . echo the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 60%) there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is no pericardial effusion. . ct chest non-contrast 1. no ct evidence of thymoma. 2. scattered peribronchiolar nodular opacities and ground-glass attenuation, most likely due to an acute infectious etiology. 3. mild centrilobular emphysema. = = = = = = = = = = = ================================================================ bronchoalveolar lavage: gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~5000/ml oropharyngeal flora. legionella culture (final ): no legionella isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirvovecii (carinii). fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (final ): no mycobacteria isolated. viral culture (final ): no virus isolated. . cmv viral load: negative . mrsa screen: negative . varicella serologies: igg positive . hcv viral load (final ): 2,270,000 iu/ml. . blood culture : coag neg staph . blood culture : klebsiella pneumonia = = = = = = = = = = = ================================================================ . sputum cx: --> respiratory culture (preliminary): rare growth oropharyngeal flora. pseudomonas aeruginosa. moderate growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | amikacin-------------- 16 s cefepime-------------- 4 s ceftazidime----------- 4 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r imipenem-------------- 8 i meropenem------------- 8 i piperacillin---------- =>128 r piperacillin/tazo----- 64 s tobramycin------------ =>16 r brief hospital course: 50 yo female with a history of hepatitis c who presented with pancytopenia and was diagnosed with mds. . #pancytopenia, diagnosed as aml: throughout her hospital stay, the pt had profound pancytopenia and required intermittent transfusion support of red cells and platelets. parvovirus b19 and herpes virus 6 were both negative. pt was negative for pnh. antiplatelet antibody was positive while antigranulocyte antibody was negative. bone marrow biopsy was performed on and was interpreted as myelodysplastic syndrome evolving to an acute erythroid leukemia. pt was briefly on epogen 40,000 units per week, which was discontinued after the results of the bone marrow biopsy were finalized. the patient had multiple subsequent bone marrow biopsies which showed definate evolution to aml. there was concern that her hepatitis c virus was contributing to the marrow suppression; hepatology was consulted and felt this was not the case. the did recommend started ursodiol at the time of chemotherapy. she received 7+3 chemotherapy in preparation for an allosct with her brother as the donor. her transplant preparation was also repeated: lab tests, infectious serologies,echo and pft's. she was started on fluconazole and acyclovir for neutropenic prophylaxis. a bone marrow biopsy performed on , which showed an ablated marrow, and the patient was consented for her bone marrow transplant. the patient received busulfan from days -7 until day -4, and cytoxan from day -3 until day -2. she recieved her stem cell transplantation on day 0 without any complications. cyclosporine commenced on day -1, which will continue until day +49 for gvhd ppx for gvhd ppx. the patient received methotrexate on days +1, +3, +6, and +11. while in the the patient was placed on methylprednisolone and mycophenolate. her methylprednisolone was weaned by 5mg qweek, and her mycophenolate was eventually titrated up to 100mg tid. she was transferred to the floor and counts (particularly wbc) trended down, and her cellcept was held. . # bacteremia: the patient was found to be febrile on while neutropenic, at that time, cefepime was started. she was then found to be bacteremic on blood cultures with coagulase negative staph, which is oxacillin-resistant, and sensitive to vancomycin. vancomycin was started on , and her central line was left in place. all surveillance cultures are ngtd, as of . on , cefepime was discontinued, as she remained afebrile upon starting vancomycin. the patient spiked again on (day -6), at that time her blood and urine were cultured and cefepime was restarted. her cultures showed pan sensitive klebsiella. since this positive culture, her surveillance cultures have been negative for over 72 hours. flagyl and caspofungin were added on as the patient began to spike through her regimen of vancomycin and cefepime. iv vancomycin was discontinued on . . # hyponatremia: the patient was noted to have a sodium on 127 on day -1. at that time, fluid restriction to 1l was started, urine and urine electrolytes were obtained, which showed elevated urine sodium and and osmolality of 568. after 24 hours of fluid restriction, her sodium normalized to 134. based on her labs, it was thought to be secondary to cytoxan induced siadh. fluid restriction was stopped shortly afterward and her sodium remained normal. . # mucositis: the patient began to experience symptoms of mucositis on day+1, including mouth pain, abdominal pain and diarrhea. she was ruled out for c. diff infection. at that time, tpn was started, and the patient was started on a morphine pca. . # hepatitis c: patient has been a non-responder to interferon and ribaviron therapies. viral load was 12,600,000 in , then down to 2.27 million and after chemotherapy came up to 5 million. liver biospy was performed on , which showed grade 1, stage 1 hepatology following, liver biopsied, which was consistent with chronic viral hepatitis, grade 1 inflammation, stage 1 fibrosis. hepatology recommended followup as outpatient after completion of the sct. . #abnormal lung findings on ct: ct chest showed presence of ground glass opacities in bilateral lobes c/w infectious etiology. pt remained asymptomatic. galactomannan, b-d-glucan, crptococcal antigen, and histo antigen were all negative. pt had a bronchoscopy on , and bal studies are negative to date. . # dental pain: pt was evaluated by a dentist, who recommended extraction of tooth #19 prior to sct. the tooth was extracted on by oral surgeon dr. . after the extraction, pt developed intense pain at the site, radiating to her l frontal sinus and ear. as she was neutropenic, infection was suspected and she was started on unasyn. oral surgeon was re-evaluated the site of extraction and agreed with abx and also suggested a dressing for alveolar osteoitis if the pain does not resolve with abx. pt then became febrile and was switched to zosyn, completing a 7 day course. she was subsequently switched to levofloxacin and clindamycin; then just to levofloxacin as there was no evidence of further dental infection. she had no further tooth pain. . # depression/anxiety: the patient remained fatigued and weak and with some degree of emotional lability. her previous admission was marked by passive suicidal ideation, and she was well-known to the psychiatry consult service, which was consulted again this admission. ritalin was discussed with the patient, though she declined this and any other anti-depressant medications. she was continued on lorazepam prn. # gerd: pt continued on her home regimen of prevacid. . # hepatitis b: the patient was found to have a positive core antibody but a negative viral load. per gi reccs, the patient was started on lamivudine. but patient was unable to take lamivudine due to mucositis. . # rash: soon after starting chemotherapy, the patient developed a rash on her shins thought to be related to her chemotherapy. she was given sarna for palliation. she also had a similar rash on her lower abdomen, which then became more circular and localized with one particular area suggstive of ungal infection. given that she was laready on fluconazole and topical was added. in addition, she briefly developed a contact dermatitis under her breasts bilaterally secondary to the adhesive on ekg leads; hydrocortisone was prescribed to these areas only. . # hypertension: after starting cylosporine, the patient began having persisent high blood pressures. she was started on a calcium channel blocker to treat cylosporine-induced hypertension. in addition, her cyclosporine dose was decreased and then held due to supratherapeutic levels. during her stay, her antihypertensives were held initially. her blood pressures were high in the sbp's 160's-190's, particulary when agitated or stimulated. she was then started amlodipine 10mg daily and anti-anxiety medications, including zyprexa. her blood pressures subsequently normalized. . # acute renal failure: her creatinine began rising on and steadily climbed during her stay. she was initially on lasix for diuresis which was then held soon after her creatinine continued rising. on further analysis, her urine electrolytes did not show a pre-renal etiology and urine eosinophils were negative. the nephrology team was consulted and found significant muddy-brown casts on urine microscopy. she was diagnosed with atn secondary to cyclosporine toxicity. given her elevated cyclosporine levels, the dosages had already been substantially reduced. on diagnosis of atn, the cyclosporine was changed from continuous to dosing, and then were held. her creatinine peaked at 5.2 and then slowly began trending down. due to her arf and volume overload that was thought to be contributing to her failure to wean from the vent, cvvh was started on and continued through . rij dialysis line was discontinued on secondary to fever, and cvvh was not restarted as the patient was not volume overloaded and did not have electrolyte abnormalities necessitating dialysis. patient began having increased urine output on . her phosphate continued to increase to 9.0 on and she was begun on aluminum hydroxide phosphate binder. upon transfer to the floor, her renal function improved steadily off of hemodialysis, and she consistently produced approx 2l urine daily. . # respiratory failure: on , the patient began having respiratory distress and hypoxia. she was transferred to the and intubated for hypoxic respiratory failure. her cxr showed bilateral pulmonary infiltrates concerning for pcp, pna, pulmonary edema or diffuse alveolar hemorrhage. she was started on clindamycin and primaquine as well as steroids for empiric pcp treatment given recent failure to take pcp . she was also started on azithromycin. she was maintained on cefepime, vanc and caspofungin initially. vanc was intermittently stopped but then finally restarted and continued when her wbc bumped with each attempt to wean off vanc. a bronchoscopy was performed. there was no purulent material or gross blood noted - making diffuse alveolar hemorrhage less likely. bal did not reveal any wbc's, rbc's, bacterial culture, fungal culture, viral culture negative and nocardia negative. because of the lack of evidence for a bacterial pna, cefepime was discontinued on . pcp was negative as well. after determining that she was pcp negative, the and primaquine were discontinued; she was placed on atovquone prophylaxis. she was intially kept on steroids to reduce gvhd (not for pcp) but then tapered off. histoplasma, mycoplasma and legionella were also negative; azithromycin was discontinued. respiratory viral antigens were also negative. she was changed from caspofungin to posaconazole when one isolate of pithomyces (diamacious fungus)grew from her pleural cultures. posaconazole was eventually discontinued given the lack of suspicion for fungal infection; she was switched to prophylactic fluconazole. because of the concern for pulmonary edema, she was agressively diuresed. a chest ct showed significant improvement suggestive of either resolving infection or decreasing pulmonary edema. when bun and cr began increasing, lasix was stopped. her chest x-ray then worsenened, and radiology was once again concerned about alveolar hemorrhage versus infection. a repeat bronchoscopy was performed which showed gross purulent material on the et tube but no blood. given the concern for ventilator associate pneumonia, she was re-started on cefepime, and cipro was added. in addition, cvvh was intiated for aggressive diuresis to treat pulmonary edema. further cultures showed two colonies of pseudomonas, cefepime was switched to zosyn and cipro was continued. she continued to have an elevated wbc despite this treatment. sensitivities of the cultures showed that they only were mutually sensitive to meropenem, so her cipro and zosyn were discontinued and she was started on meropenem. attempts at weaning the patient were complicated by agitation, tachycardia, and tachypnea. she was transitioned to an ativan/methadone weaning protocol which was not effective. she was next transitioned to fentanyl boluses to aid in weaning her off the vent. this was also ineffective. the patient had a trach and peg placed on , after being on the vent for nearly three weeks. after tracheostomy was placed, the patient was able to ventilate on her own and was able to verbally communicate. she was still undergoing treatment for pseudomonas vap, and is currently day of meropenem. ceftazidime was added on for sputum culture results showing intermediate resistance to meropenem. . #cmv viremia: cmv pcr from detected viral load of 658. repeat cmv pcr on detected over 9,000 copies. patient was started on gancyclovir on . the dose has fluctuated given her changing renal status, from 1.25mg/kg q24 to 1.25mg/kg 3xweek. . #coag neg staph: patient had coag neg staph grow from tip culture on . given her changing creatinine clearance, her vancomycin levels were checked daily and vancomycin dosed accordingly. vancomycin was d/c'd on . . # leukocytosis: the patient had leukocytosis during her stay. pna, infectious diarrhea and line infections were considered. diarrhea was persistently negative for c.diff. she was also being treated for possible pna. at each attempt to discontinue vanc, her leukocytosis re-appeared suggesting a mrsa or gram positive infection - possible line infection. she was given a picc in order to discontinue the central line. a dialysis line was an additional port was placed with the plan of removing the hickman. however, she was then found to have purulent material in her et tube suggestive of a bacterial, vap that could be the source of the leukocytosis. she was treated with cefepime and cipro until the gram stain only showed oralpharyngeal flora. the hickman was pulled on by dr . as above, she continued to have an elevated white count despite double pseudomonal coverage. when the sensitivies were found to be resistent to the zosyn and cipro, she was changed to meropenem per sensitivities. her leukocytosis gradually decreased coinciding with tapering of her methylprednisolone. however, wbc dropped to 1.5 on and medications were examined for potential myelosuppression. cellcept was held at that time. also vancomycin was discontinued. . #hyponatremia: na 135->129/130 since starting cvvh - cvvh removing fluids vs extravascular free water now returning to intravascular space and causing a dilutional effect? per renal, fluid re-administered during cvvh is relatively hyponatremic. their recomendations are to reduce any free water sources (meds, flushes etc) . * course * 50 y.o. woman s/p 7+3, and s/p allogenic bone marrow transplant on , transferred to the micu after tonic clonic seizure and hypoxic respiratory failure. . # respiratory failure - patient experienced acute desaturation following bone marrow biopsy and lp. responded to suction and was switched from ps to ac. because patient overbreathing the vent with nasal flaring, restarted propofol. acute worsening of cxr likely due to dependent shift of phlegm. underlying problem: pna v. pulmonary hemorrorhage in setting of seizure with platelets of 17 v aspiration pneumonitis. bronchoscopy revealed numerous blood clots, likley old blood from tracheostomy placement. patient continued to be tachypneic with rates from 30-40, along with abg showing relative hypercarbia and hypoxia despite vent changes. clinical picture suggestive of severe airway disease. her ceftazidime was continued, along with the addition of colistin for pseudomonas vap. an end tidal co2 was also performed: 16 - > shunt 50%. on , after several days on the ventilator, the patient was made cmo according to her wishes. this decision was made after discussion with her husband, the attending, and the attending. she passed away on . . # seizure and depressed mental status -patient experienced tonic clonic seizure on on bmt floor in setting of pancytopenia and low platelet count. initial concern for intracranial bleeding. she was administered ativan and dilantin loaded. ct did not show evidence of bleeding. mri c/w posterior reversible encephalopathy syndrome. her meropenem was discontinued, as it was thought to precipitate her seizures. the patient remained unresponsive overnight, however eeg did not reveal any seizure activity. the following morning the patient was responsive. she was continued on dilantin and did not experience any further seizures. lp was conducted which did not show any signs of infection. cultures were unrevealing. her blood presssure was maintained sbp's < 140 on lopressor. . # pancytopenia - thought to be drug effect v. loss of engraftment. her meropenem and mycophelate were discontinued. bone marrow biopsy was not consistent with loss of graft, and she was continued on neupogen . #cmv viremia-viremia detected from pcr, repeat pcr showing increased viremia. has been dosed according to renal function, previously considered discontinuing in setting of seizure and pancytopenia, however decided to continue gancyclovir with concurrent administration of neupogen. cmv viral load 2160 copies. . # aml: the patient was initially admitted with pancytopenia, and was found to have aml. she has undergone a long preparation for allogenic bmt including 7+3 induction chemotherapy, completion of abx for a tooth extraction, liver biopsy for history of hepatits c/b and initiation of lamivudine prophylaxis, and bronchoscopy for findings of ground glass opacities on chest ct. she received a stem cell marrow transplantation on without any immediate complications. mtx day +1, +3, +6, +11 for gvhd ppx with leucovorin rescue. cyclosporin d/c'd because of renal failure. the patient was continued on methylprednisolone, diflucan, and ursodiol. medications on admission: lorazepam, prevacid. discharge disposition: expired discharge diagnosis: acute myelogenous leukemia hepatitis b&c cytomegaloviremia discharge condition: patient deceased. discharge instructions: patient deceased. followup instructions: patient deceased. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis thoracentesis thoracentesis percutaneous [endoscopic] gastrostomy [peg] biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow temporary tracheostomy closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus incision with removal of foreign body or device from skin and subcutaneous tissue extraction of other tooth injection or infusion of cancer chemotherapeutic substance allogeneic bone marrow transplant without purging injection or infusion of biological response modifier [brm] as an antineoplastic agent transjugular liver biopsy diagnoses: acute kidney failure with lesion of tubular necrosis unspecified pleural effusion unspecified viral hepatitis c without hepatic coma other convulsions hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute and chronic respiratory failure pneumonia due to pseudomonas bacteremia dermatitis due to drugs and medicines taken internally complications of transplanted bone marrow other and unspecified infection due to central venous catheter cytomegaloviral disease neutropenia, unspecified chronic ulcer of other specified sites acute myeloid leukemia, without mention of having achieved remission unspecified drug or medicinal substance causing adverse effects in therapeutic use unspecified disorder of the teeth and supporting structures contact with or exposure to other viral diseases stomatitis and mucositis, unspecified 

Answer: The patient is high likely exposed to