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: heparin agents attending: chief complaint: diarrhea major surgical or invasive procedure: ileocolectomy central venous line foley catheter bone marrow biopsy history of present illness: 52-year-old female with history of hypothyroidism and inflammatory spondyloarthropathy on sulfasalazine since , presented with diarrhea and fever for two week duration on to , found to have agranulocytosis with fever, tachycardia, hyponatremia, and thrush, transferred to for further management and bmt evaluation. . per discharge summary from , she had progressive weakness, malaise, fevers, oral ulcers, nausea, vomiting, and diarrhea over the 2 weeks prior to presentation. the patient states that she had been having large volume, multiple episode, watery, nonbloody diarrhea up to 5 and 6 times per day for 2 weeks, progressively worsening, associated with nausea, poor p.o. intake and 4 to 5 bouts of vomiting during the past week. she states last week she vomited only once "during sleep." she denies any sick contacts, recent illnesses other than her inflammatory arthritis. she had been taking sulfasalazine 1000 mg t.i.d. since approximately after seeing dr. for arthralgias and diarrhea. she was told on to discontinue the medication for these complaints of malaise and weakness as well as diarrhea; however, she did not decrease its use. she arrived in the emergency room and was found to be neutropenic with a wbc of 0.17; febrile to 103, hypotensive to 90/45, tachycardiac to 160s. she was given vanc/ceftaz/flagyl/mica and fluids in the ed and was admitted to the micu for further management. . osh course, she initially required 6l of ivf was transiently on levophed and vasopressin, subsequently weaned off. she was treated with flagyl 500 q8hr, ceftazidime 2 gm q8hr, micafungin 100 mg q24h, vancomycin 1.25 mg q12hr for neutropenic fever. nystatin 5 ml p.o. q.i.d. for the esophagitis. culture so far was positive klebsiella (sensitive to ampicillin/sulbactam, cefazolin, ciprofloxacin, gentamicin, levofloxacin, piperacillin-tazobactam, tobramycin and trimethoprim sulfa). all repeat cultures have been negative. pt is still having copious watery diarrhea and spiking fevers. bone marrow biopsy showed aplastic anemia, neupogen was started on . inr elevated to 3.8, responded to oral vitamin k. she was transfused for a threshold hct of 25 and plts of 20. . imagining studies: - echo showed left ventricle systolic function is normal with an ef of 60-65% with no regional wall motion abnormalities with trace mr, trace tr, pulmonary pressures within normal limits. - ct chest showed some pleural effusions with partial atelectasis of both lungs. - ct abdomen and pelvis showed pancolitis with inflammatory changes more prominent in cecum and sigmoid colon with adjacent pericolonic inflammatory stranding, no abdominal abscesses or fluid collection. -ct head on showed no acute bleeding or ischemia. . id: swab from tongue and perianal area are negative for hsv. legionella urine antigen was negative. patient's ebv negative, cmv viral load and parvo b19 were still pending. blood cmv pcr is negative. . on arrival to the icu, she appears to be in good condition, tachycardia and febrile but no other abnormalities. . see hospital course for update. past medical history: hypothyroidism inflammatory spondyloarthropathy status post cholecystectomy in social history: the patient has never married. she states that she has been sexually active in the past; however, she has been celibate for the last 10-15 years. she denies any risk factors for hiv such as multiple partners or iv drug use. she denies that she has ever had hsv infection. she is a previous smoker, quitting in . at that time she was smoking approximately 10 cigarettes per day. prior to that for many, many years she smoked approximately a pack a day. she denies any alcohol use or iv drug use. family history: her mother is deceased in her 70s from copd. her father lives with her. he lives on the of a 3-family. the patient has been responsible for his care in the past. she has a sister, , who is otherwise healthy and who she names as her health care proxy: she has a brother who is otherwise healthy. physical exam: vitals: t:101.8 bp: 114/60 p:115 r:23 o2: 97% general: alert, oriented, no acute distress heent: sclera anicteric, dmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema dischare exam: pertinent results: micro: from : bcx from : klebsiella pneumoniae ampicillin r >16 amp/sulbac s <= cefazolin s <=8 ciprofloxacin s <=1 gentamicin s <=4 levofloxacin s <=2 pip/tazo s <=16 tetracycline r >8 tobramycin s <=4 trim/sulfa s <=2/38 . images: from osh: . echo (osh): the left atrial size is normal. the right atrial size is normal. the left ventricular size is normal, left ventricular wall thickness is normal, and overall left ventricular systolic function is normal, with an estimated ejection fraction of 60-65% and no regional wall motion abnormalities seen. the right ventricular size and function are both normal. the aortic valve is trileaflet and minimally calcified with no aortic stenosis or aortic regurgitation. the mitral valve is minimally thickened with trace mitral regurgitation. there is trace tricuspid regurgitation. pulmonary pressures are within normal limits. there is a small pericardial effusion with no evidence of tamponade physiology. . head ct: impression: no ct evidence for acute hemorrhag or acute large vessel territorial infarct; if there is concern for n acute ischemic event, mri is recommended for better assessment. minimal sinus disease, as above. . ct abd pelvis: impression: 1. pancolitis, with inflammatory changes most prominent in the cecum and sigmoid colon. there is adjacent pericolonic inflammatory stranding, but no intra-abdominal abscess or fluid collection. 2. small right greater left pleural effusions with associated partial atelectasis of both lower lobes. 3. slight increase in the size of a pericardial effusion since . . bone marrow: diagnosis: hypocellular marrow with marked myeloid hypoplasia and increased megakaryocytes, see note. note: there is almost complete absence of myeloid precursors and evidence of marrow injury. marked increase in macrophages with ingested cellular debris is evident. the differential diagnosis includes agranulocytosis due to severe toxic injury, drugs, infections or auto-immune disorders, and hemophagocytic syndrome. agranulocytosis due to sulfasalazine toxicity is favored. hemophagocytosis can be observed as a secondary phenomenon in agranulocytosis. by immunohistochemistry with cd20 and cd3, the single lymphoid aggregate is a mixture of b and t cells. cd34 highlights a rare cell. mpo positive cells are absent, confirming agranulocytosis. glycophorin stains erythroblasts, individually and in clusters, which account for a significant part of the residual cellularity. e-cadherin stain small clusters of pronormoblasts. cd138 highlights scattered plasma cells accounting for less than 5% of marrow cellularity, which appear polyclonal by kappa/lambda staining. stains for cmv, ebv (lmp1) and parvovirus are all negative. microscopic description peripheral blood smear: the smear is adequate for evaluation. red blood cells are reduced in number hypochromic with anisopoikilocytosis including occasional elliptocytes seen. the white blood cell count appears markedly decreased, and neutrophils are absent. platelet count appears mildly increased, large and giant forms are seen. platelet clumps are seen. differential (100 cell) shows: 0% neutrophils, 0% bands, 0% monocytes, 100% lymphocytes, 0% eosinophils, 0% basophils. aspirate smear: the aspirate material is inadequate for evaluation due to lack of spicules and hemodilution. scattered macrophages, platelet clumps, megakaryocytes and hemophagocytic histiocytes are present. clot section and biopsy slides: the core biopsy material is adequate for evaluation. it consists three fragments of trabecular marrow measuring 0.6, 0.2 and 0.2 cm with a cellularity of 40%. significant marrow changes included numerous macrophages with ingested cellular debris, focal stromal changes consistent with serous atrophy-like changes and relative paucity of hematopoietic elements most notably myeloid precursors. erythroid precursors are also decreased and comprised almost entirely of intermediate and late erythroblasts. megakaryocytes are increased in number with focal loose clustering and include abnormal small hypolobated forms as well as large forms with complex nuclei. there is a medium sized non-paratrabecular interstitial lymphoid aggregate comprised of small lymphocytes occupying 10% of marrow cellularity. special stains: iron stain on the core shows no significant stainable iron. reticulin stain shows mild increase in reticulin fibrosis (who grade 1 of 3) which may be attributable to stromal collapse secondary to marrow insult. . gi biopsy: colon (sigmoid), mucosal biopsy: colonic mucosa with focal reactive / regenerative features, focal superficial edema, recent hemorrhage and epithelial injury with a rare dilated atrophic-appearing gland. (see note.) note: the differential diagnosis includes infection, drug reaction, ischemic type injury, etc. clinical correlation is needed. additional levels have been examined. an immunohistochemical stain for cmv will be reported in an addendum. addendum: a cmv immunohistochemical stain is nonreactive. . tte: impression: small circumferential pericardial effusion without evidence for hemodynamic compromise. normal biventricular cavity sizes with preserved global and regional biventricular systolic function. . ct : impression: 1. thickening of small and large bowel, including the entire colon and much of the small bowel worrisome for a severe form of enterocolitis; to some extent bowel wall changes may reflect superimposed peritonitis associated with bowel perforation. 2. discontinuity of enhancement along cecal mucosa with few extra luminal gas bubbles and enhancement of the peritoneum in proximity, as well as an extraluminal interloop fluid collection in the right mid abdomen and extravasation of enteric contrast consistent with recent or ongoing bowel perforation. these finding are worrisome for severe ischemia or necrosis of the cecal wall and perforation although the main site of perforation may be elsewhere. 3. proximal small bowel dilation with tapering to smaller caliber distally and no definite transition point; although partial small bowel obstruction is not excluded, this appearance may reflect an ileus associated with a severe inflammatory process. 5. multiple small subcentimeter splenic hypoattenuating lesions. given the patient's history that might represent opportunistic infection such as could be seen with fungal infections including candidiasis. 6. uterus anomaly with unchanged fibroid. . transfusion reaction report: icd9 code: 999.89) indication for consult: investigation of transfusion reaction indications for consult: investigation of transfusion reaction clinical/lab data: mrs. is a 52 year-old female with a history of spondyloarthropathy treated with sulfasalazine, pancytopenia, and pancolitis. she is status-post an ileocolectomy performed on for cecal perforation. on a unit of abo matched packed red blood cells was requested. pre-transfusion vitals were as follows: t=99.7f, bp=99/50, hr=133, rr=16. ten minutes into the transfusion the patient's body temperature increased to 101.1f. the transfusion was stopped 10 minutes later. the patient received approximately 50 ml of the unit. no other symptoms were reported. there were no significant changes in blood pressure, heart rate, or respiratory rate during the transfusion. of note the patient has been having fevers throughout her hospital stay as well as tachycardia. she has remained febrile with a tmax of 102.3f on . the transfusion medicine service was consulted regarding a possible febrile non-hemolytic transfusion reaction (fnhtr). a routine clerical check revealed no errors. laboratory testing: patient abo/rh: group o, rh positive red cell product (#04z) abo/rh: group o, rh positive post transfusion plasma: yellow, clear, dat negative transfusion history: the patient recieved one prior non-reactive red cell transfusion at on . she does not have a history of transfusion reactions. diagnosis, assessment and recommendations: mrs. experienced a mild temperature increase of 1.4 degrees f ten minutes into transfusion of a leukocyte reduced abo compatible red blood cell transfusion. laboratory workup revealed no evidence of hemolysis and the patient has had fevers during her hospital course outside the setting of transfusion. given that leukocyte reduction significantly decreases the incidence of febrile non-hemolytic transfusion reactions, and that only approximately 50 ml of the unit was transfused, the patient's fever is most likely due to underlying illness and not the transfusion. no change in transfusion practice is recommended at this time in this patient. ordering/attending md: dr. diagnosed by: dr. consulting physician: . . tte : the left ventricular cavity is unusually small. overall left ventricular systolic function is normal/hyperdynamic (lvef>65%). right ventricular chamber size and free wall motion are normal. there is a small to moderate sized pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. there is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. the respirophasic variation may be a sign of tamponade; however this variation may be largely explained by hypovolemia and ventilation. . tte : there is a small to moderate sized pericardial effusion. biventricular systolic function is now normal. post-pericardiocentesis the residual pericardial effusion appears small in an apical view. . ct : impression: 1. large fluid collection in the right lower quadrant adjacent to a suture line is concerning for an abscess/leak. a second large collection in the pelvis superior to the bladder may connect to the right lower quadrant collection. both of these collections are amenable for ct-guided catheter drainage. a small third collection at the inferior tip of the right hepatic lobe would be accessible to aspiration if warranted. 2. extensive bowel wall edema likely representing inflammatory changes from the intraperitoneal infection. 3. multiple hypodense lesions in the spleen are increased in size from and are concerning for a fungal infection. 4. small filling defect in the right internal jugular vein raises concern for dvt. further evaluation with ultrasound is recommended. . ct : impression: 1. redemonstration of intra-abdominal and intra-pelvic fluid collections, all of which have decreased from the comparison exam. 2. extensive large and small bowel mural thickening, in a pattern similar to that seen most recently. 3. innumerable splenic hypodensities which have increased substantially since , though are minimally changed since and raise the possibility of splenic abscesses. 4. unchanged filling defect in the right internal jugular vein, suggesting a nonocclusive deep venous thrombosis. this could be corroborated via ultrasound. . 3:07 pm abscess source: abdomen. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): enterococcus sp.. sparse growth. identification and sensitivities performed on culture # (). anaerobic culture (final ): no anaerobes isolated. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. wound culture (final ): escherichia coli. <15 colonies. piperacillin/tazobactam requested by dr pending. piperacillin/tazobactam sensitivity testing performed by . escherichia coli. <15 colonies. second morphology. piperacillin/tazobactam requested by dr pending. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | escherichia coli | | ampicillin------------ =>32 r =>32 r ampicillin/sulbactam-- =>32 r =>32 r cefazolin------------- =>64 r =>64 r cefepime-------------- <=1 s 4 s ceftazidime----------- <=1 s 16 r ceftriaxone----------- =>64 r =>64 r ciprofloxacin--------- =>4 r =>4 r gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s piperacillin/tazo----- s s tobramycin------------ =>16 r =>16 r trimethoprim/sulfa---- =>16 r =>16 r brief hospital course: 52 yof with hypothyroidism, inflammatory spondyloarthropathy who was on sulfasalazine and presented with fever and diarrhea for 1 week and found to have agranulocytosis due to sulfasalazine toxicity, admitted to the icu at osh for sepsis with klebsiella bacteremia and neutropenic fever, transferred to for evaluation. hospital course complicated by bowel perforation and necrosis requiring ileocolectomy, cardiac tamponade s/p pericardiocentesis, persistent fevers, tachycardia, splenic lesions, intrabdominal fluid collections, and hit+ antibody with subsequently negative sra. she was initially admitted to bmt but was transferred from the bmt service to medicine as her counts were recovering and her agranulocytosis was thought secondary to sulfasalazine toxicity (via bone marrow biopsy review). on the floor, she remained tachycardic, tachypneic with normotension. on the floor she had multiple episodes of bilious emesis. kub was performed that showed gastric dilation with distended loops of small bowel. an ngt was placed with ~2.5l of bilious emesis over 24 hour period. a ct abdomen was performed that showed a small bowel ileus with evidence of cecal necrosis with possible perforation. in spite of this, her abdominal exam was relatively benign, only notable for mild tenderness to palpation and mild distention without peritoneal signs. surgery was consulted, who brought the patient for an ex-lap on , which demonstrated a necrotic cecum with an intraloop abcess. an ileocecectomy with ileostomy and pouch were performed. postoperatively she was transferred to the t-sicu where she remained intubated for several days and her course was marked by a pericardial effusion with signs of tamponande. she underwent an urgent heart catheterization and pericardiocentesis which returned 150cc straw colored fluid. this drain remained in place until pod#7 when daily output decreased to <30cc. her tachycardia declined as her blood pressure improved. she had recurrent fevers postoperatively, and a ct abdomen demonstrated a fluid collection near the staple line. the collection was drained by 2 ir placed drains which were later removed. other issues are reviewed by problem: thrombocytopenia: she was found to be positive for heparin antibodies. heparin was stopped and fondaparinux was initiated, however this was subsequently discontinued when her sra came back negative, ruling out hit. her thrombocytopenia is most likely secondary to sulfasalazine marrow toxicity. klebsiella bacteremia, abdominal fluid collections, abdominal wound growing enterococcus: she was continued on vancomycin, cefipime and flagyl in setting of sepsis, leukocytosis, fevers and colitis with klebsiella bacterimia. she was treated with cefipime/flagyl for klebsiella until , however she continued spiking fevers and was found to have vre growing from her abdominal wound, as well as intraabdominal fluid collections on ct. she was also found to have splenic abscesses, presumed hepatosplenic candidiasis. id recommended treating with tigacycline and fluconazole, course to be determined by them in postop followup (likely 4 weeks of tigecycline and 2 months of fluconazole). she will need followup imaging prior to stopping fluconazole. transitional issues: -patient will need colonoscopy after taking down ostomy (i.e. in about a year) -surgery follow up of her ostomy -hematology follow up regarding her pancytopenia -ebv/cmv pending at time of discharge medications on admission: home medication: levothyroxine 0.15 once a day prilosec 20 once a day sulfasalazine 500 two tabs t.i.d. . medication on transfer: levothyroxine 150mcg daily omeprazole 20mg daily nystatin suspension 5ml qid (day 1 ) mag 2 g prn calcium gluconate prn kcl 20meq prn tylenol 650mg q4h prn neupogen 480mcg qd (day 1 , prior was on 300mg started on ) acyclovir 500mg q8h (day 1 ) micafungin 100mg q24h (day 1 ) vancomycin 1250mg q12h (day 1 ) ceftazidime 2g q8h (day 1 ) flagyl 500 mg q8h (day 1 ) vit k 5mg x2 tobramycin 100mg x3 doses () discharge medications: 1. olanzapine 5 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po qhs (once a day (at bedtime)). 2. levothyroxine 150 mcg tablet sig: one (1) tablet po once a day. 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. tigecycline 50 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours) for 1 months: last day . 5. fluconazole 200 mg tablet sig: two (2) tablet po once a day. 6. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 7. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 8. psyllium 1.7 g wafer sig: one (1) wafer po tid (3 times a day). 9. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 10. acetaminophen 650 mg tablet sig: one (1) tablet po every six (6) hours as needed for fever or pain. discharge disposition: extended care facility: - discharge diagnosis: infectious colitis bowel necrosis s/p ileocolectomy agranulocytosis thrombocytopenia hypothyroidism discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital with a blood stream infection and your hospital course was complicated by bowel necrosis requiring resection and ostomy, persistent fevers, cardiac tamponade, tachycardia, high ostomy output, and low platelets. you were followed by multiple specialists while you were here including surgery, gi, hematology, and infectious disease. by discharge, many of your acute issues had resolved. you continued to have fevers, for which you will continue tigacycline and fluconazole based on id recommendations. our surgeons will follow your ostomy. hematology will follow your blood counts. you will be discharged on many new medications. please see your med list for the full compilation. . please follow-up with your appointments as scheduled. followup instructions: name: , : internal medicine location: address: , , phone: **please discuss with the staff at the facility the need for a follow up appointment with your pcp when you are ready for discharge** department: hematology/oncology when: tuesday at 10:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: general surgery/ when: thursday at 1:15 pm with: , md building: lm bldg () campus: west best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances pericardiocentesis percutaneous abdominal drainage temporary ileostomy open and other right hemicolectomy closed [endoscopic] biopsy of large intestine right heart cardiac catheterization biopsy of mouth, unspecified structure intracardiac echocardiography diagnoses: acidosis unspecified protein-calorie malnutrition hyposmolality and/or hyponatremia severe sepsis unspecified acquired hypothyroidism perforation of intestine unspecified disease of pericardium infection with microorganisms without mention of resistance to multiple drugs disseminated candidiasis other septicemia due to gram-negative organisms other ascites acute vascular insufficiency of intestine other and unspecified coagulation defects other and unspecified diseases of the oral soft tissues sulfonamides causing adverse effects in therapeutic use candidal esophagitis chronic ulcer of other specified sites cardiac tamponade unspecified inflammatory spondylopathy abscess of intestine other specified aplastic anemias disease of spleen, unspecified 

Answer: The patient is high likely exposed to