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: metformin attending: chief complaint: fever, neutropenia, hepatitis. major surgical or invasive procedure: skin biopsy. bone marrow biopsy. bone marrow biopsy. history of present illness: 51yo male with history of hypertension, hyperlipidemia, rheumatoid arthritis and diabetes mellitus who presents to osh after syncopal event on . . he awoke on and felt warm. his temperature at that time was 101.0 so he took two tylenol and went back to sleep. he awoke a few hours later and again felt warm and "flush" and found his temp to be 103.0. he got up to go to the bathroom and "the next thing (he) knew" he was on the floor. he was found by his wife after an unknown duration and came to quickly. denies any confusion. he his the right side of his face and has a large abrasion there now. he was taken to his local ed where he was admitted for further evaluation. . while at the osh, he underwent an extensive work-up for his syncope. during this process, he developed persistent fevers, thrombocytopenia, leukopenia, and liver failure. he was initially started on azithromycin and rocephin but was transitioned to vanco and cefotaxmin to cover for cns infection. neurology evaluated the patient given syncopal event and underwent negative eeg and ct head. no lp was done as there was no suspicion for on-going meningitis. he underwent an echo which some lvh with normal ef and no pulmonary htn. ct chest and ct sinus were negative for any infection and he satted about 92% on ra. . as mentioned, the patient was found to have acute elevation of his liver enzymes. on admission, alt was 89 and ast was 70. alt rose to 353 and then 1067 and ast rose to 472 and 1732. t-bili and alk phos remained within normal limits. hepatitis panel and monospot studies were negative. he had no abdominal pain, jaundice, nausea or vomiting. ruq u/s did not show any inflammation or ductal dilatation. . he also became leukopenic, which is of unclear etiology. there was some concern that it could be secondary to enabrel. wbc down from 3.2 to 0.8 with anc of 0.51. hct stayed within normal limits. in addition, thrombocytopenia develops as she went from 169 to 68. retic count was 1%, inr 1.1, fibrinogen 240, d-dimer 3360. smear showed leukopenia with left shift and normochromic, normocytic anemia. there was no evidence of schistocytes, acute leukemia, inclusion bodies or toxin granulation. . id was consulted given fevers and underlying marrow suppression. cultures were negative and ebv is pending. he was continued vancomycin and cefotaxime. of note the patient denies any recent travel, tick bites, or new rashes. . he is being transferred to for further evaluation. on arrival to , vital signs were t- 103.4, bp- 160/80, hr- 103, rr- 20, sao2- 95% on ra. the patient reports feeling warm but denies chest pain, shortness of breath, abdominal pain, dizziness, lh, or syncope. past medical history: 1. diabetes mellitus 2. hypertension 3. hyperlipidemia 4. ra 5. obesity 6. insomnia 7. osteoarthritis social history: married. does not smoke or use any drugs. denies regular alcohol use. family history: diabetes and hypertension on maternal side of his family. colon cancer- father. physical exam: admission exam: vs: t- 103.4, bp- 160/80, hr- 103, rr- 20, sao2- 95% on ra general: mildly distressed but resting. appropriate. heent: nc/at, eomi, sclerae anicteric, mmm, op clear. neck: supple, no jvd. heart: tachycardic, no mrg, nl s1-s2. lungs: cta bilat, no r/rh/wh, good air movement, resp unlabored. abdomen: soft/nt/nd, no masses or hsm, no rebound/guarding. extremities: wwp, no c/c/e, 2+ peripheral pulses. skin: no rashes or lesions. lymph: no cervical lad. neuro: awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, dtrs 2+ and symmetric, gait deferred. pertinent results: admission labs: 09:35am blood wbc-0.8* rbc-4.02* hgb-12.2* hct-34.7* mcv-86 mch-30.4 mchc-35.2* rdw-13.3 plt ct-30* 09:35am blood neuts-53 bands-8* lymphs-30 monos-5 eos-1 baso-0 atyps-0 metas-3* myelos-0 09:35am blood pt-13.7* ptt-47.8* inr(pt)-1.2* 05:10pm blood fibrino-155 09:35am blood ret aut-0.9* 09:35am blood glucose-148* urean-16 creat-1.0 na-133 k-3.7 cl-102 hco3-21* angap-14 09:35am blood calcium-7.1* phos-1.4* mg-1.7 05:15pm blood albumin-3.1* uricacd-2.7* iron-58 05:15pm blood caltibc-207* vitb12-1567* folate-19.0 hapto-76 ferritn-* trf-159* 05:10pm blood hiv ab-negative 09:35am blood acetmnp-neg . ct chest/abd/pelv: 1. mild gallbladder wall hyperenhancement with surrounding band of fat stranding, portocaval lymph nodes, and presence of peritoneal fluid might be explained by current episode of hepatitis. however, if cholecystitis remains a consideration clinically a right upper quadrant ultrasound might be considered. 2. small pulmonary nodules are non specific and ahould be followed up with a chest ct in 12 months as society guidelines if the patient has no history of smoking or malignancy. 3. small bilateral pleural effusions are observed. 4. mildly enlarged mediastinal lymph nodes were also present. 5. left lobe liver hypodensity is too small to characterize. . bmbx : hypercellular bone marrow with focal stromal damage, increased apoptosis and occasional hemophagocytic histiocyte. these findings, in the clinical setting of pancytopenia, hepatic , extreme hyperferritinemia, hypofibrinogenemia and hypertriglyceridemia are consistent with acquired hemophagocytic lymphohistiocytosis. . echo: lvef: 55% impression: suboptimal image quality. normal biventricular cavity sizes with preserved global left ventricular systolic function. mild right ventricular free wall hypokinesis. . lower extremity doppler u/s: impression: no evidence for dvt. . mri head: impression: normal mri of the head. . eeg: impression: these findings are consistent with initial non-convulsive status epilepticus, resolving with treatment (iv levetiracetam), and improvement in the background activity to moderate diffuse slowing consistent with a moderate diffuse encephalopathy. . ct head: findings: impression: normal study. . cxr: tip of the new right pic line is in the mid svc alongside a right internal jugular sheath. widening of the mediastinum is stable, and there is no tracheal displacement or other finding to suggest that there is any mediastinal bleeding. there is no pleural effusion and the lungs are clear. . 04:55am blood wbc-1.0*# rbc-3.18* hgb-9.8* hct-26.7* mcv-84 mch-30.8 mchc-36.7* rdw-13.5 plt ct-44* 03:49am blood neuts-69.4 lymphs-29.2 monos-1.0* eos-0.2 baso-0.2 09:30am blood pt-12.1 ptt-21.9* inr(pt)-1.0 09:30am blood fibrino-356 01:58am blood fibrino-104* 09:30am blood fibrino-356 03:49am blood ret aut-0.7* 09:32pm blood facviii-59 fact ix-41* fact -66 facxiii-normal 05:22am blood aca igg-3.8 aca igm-12.0 04:20pm blood cd3%-73.61 cd3abs-247 16/56%-0.49 16/56ab-2 04:55am blood glucose-117* urean-18 creat-0.5 na-135 k-3.9 cl-102 hco3-28 angap-9 04:55am blood calcium-7.9* phos-3.2 mg-1.8 05:04am blood albumin-2.7* calcium-7.8* phos-3.9 mg-2.1 iron-147 04:55am blood alt-81* ast-25 ld(ldh)-365* alkphos-110 totbili-1.4 05:50am blood alt-1211* ast-1850* ld(ldh)-2431* ck(cpk)-936* alkphos-93 totbili-0.5 04:50pm blood ck(cpk)-2685* 04:03am blood alt-111* ast-52* ld(ldh)-425* ck(cpk)-256 alkphos-111 totbili-1.1 09:30am blood ferritn-* 05:04am blood d-dimer-* 05:50am blood triglyc-344* 10:45am blood triglyc-276* 03:17am blood osmolal-322* 09:35am blood tsh-1.5 05:50am blood smooth-negative 10:00am blood psa-1.1 05:50am blood -negative 05:50am blood rheufac-234* crp-80.6* 05:32pm blood lactate-3.7* 12:58am blood lactate-1.2 05:08am blood freeca-1.08* 04:00pm blood freeca-1.15 brief hospital course: 51yo man with ra on etanercept, dm, and htn who is was foung to have , pancytopenia, fevers, hyperferritinemia, hypofibrinogenemia, and bmb confirming hemophagocytic lymphohistiocytosis (hlh). developed fever, pancytopenia, , transferred to . he was intubated for agitation and airway protection after becoming dyspneic, tachypneic, and having chest pain. ferritin was 57,602. bmb confirmed hlh. started high-dose steroids (dex 20mg iv daily), ivig 40g iv daily x4d, and on etoposide 150mg/m2 days 1,4,8,11. on he had 3 minutes of seizure-like activity which resolved with benzodiazapines. eeg initially showed frequent subclinical seizures. icu course was complicated by hypernatremia to 150 which improved with free water boluses, agitation/delerium which improved with levetiracetam and haloperidol, sinus tachycardia to hr 150, and steroid-induced hyperglycemia. extubated . mri head negative. he was transfused 5u prbcs, cryoprecipitate for hypofibrinogenemia. abx were stopped despite fevers (due to hlh). dramatic improvement over this week. . # febrile neutropenia - initially febrile when presented to outside hospital, and with wbc of 3. he was started on vanc and ceftriaxone. became neutropenic down to wbc 0.8 prior to transfer. on transfer he remained febrile up to 103 with relief only from cooling blankets due to inability to take acetaminophen or ibuprofen. hem/onc was consulted for further assistance and performed a bone marrow biopsy on which was repeated due to inadequate specimen. diagnosis hlh. his antibiotic course included: --vancomycin 1g q12hr - , ->approx. --cefepime 2g q8hr - ->approx. --doxycycline 100mg po q12hr - ->approx. --acyclovir 800mg q8hr - -> - ciprofloxacin po 750mg q12hr ->approx. . # anemia - initially his hematocrit was stable around 37 for most of his hospitalization, but on it dropped to 30 and then subsequently to 26 later that day. his ldh was up, but hapto was normal. this was assumed to be related to whatever process was causing his pancytopenia. . # thrombocytopenia - his platelet counts were initially normal at the osh and trended steadily downward to 60 on admission, and then remained around 30. transfusions: platelets - 1 bag - (for picc placement). . # hepatitis - his lfts were initially normal at the osh, and then began to increase, initially to alt/ast ~400, then ~1200 but stable for two days. then his alt increased to 1700 and ast to 4700. ldh continued to increase from to 2400 to 4300. bilirubin and coags remained normal. ferritin continued to elevate up to , likely acute phase reactant. liver was consulted for further evaluation. . # ra: held etanercept. initially concerned that this could contribute to his pancytopenia but rheumatology felt this unlikely. rheumatology was formally consulted and felt the most likely diagnosis was hlh, and recommended starting ivig, which he received once. . # diabetes: on u500 as an outpatient, with unclear glucose levels or insulin requirements. started on a regular insulin sliding scale on this admission. sugars initially well-controlled in the 100s, then began to increase into the 300s. . # hypertension: held atenolol and benicar in the setting of recent syncopal event and report of bradycardia at osh. maintained on telemetry. . # syncopal event- could have been vagal or secondary to hypotension given high fevers. ct head, echo, eeg all negative at osh. . micu course: patient transferred to micu given new respiratory symptoms and oxygen requirement. on arrival to the micu, he received ivig (40mg over 4 days). he did not tolerate increased rate and developed rigors and fevers, which could also have been secondary to underlying disease process. he was treated with tylenol and benadryl and tolerated the remained of the infusion. his respiratory remained stable overnight. bps were elevated to sbp of 190. he was initially treated with hydral 5mg iv x 2 with good response. given duration of illness and likelihood that sepsis would have declared itself, we resumed his beta-blockade with metoprolol 12.5mg with plans to resume if bps were stable on . he was started on ppi in the setting of recent hct drop and stools were guaiac-ed (results**). ruq u/s (with dopplers) showed no gallbladder pathology with normal hepatic vasculature. . heme/onc was consulted regarding his pancytopenia. a bone marrow biopsy was done which revealed hypercellular bone marrow with increased apoptosis and occasional hemophagocytic histiocyte. it was felt that this was c/w acquired hemophagocytic lymphohistiocytosis given his constellation of symptoms. he was then transfered to the for initation of chemotherapy. prior to transfer, the patient was noted to be acutely agitated and had to be intubated for airway protection. . during his stay in the , the patient was noted to have shaking episodes (low amplitude, all 4 extremities). an eeg was performed, which was concerning for seizure activity. neurology was consulted who felt that he may have been having subclinical seizures and he was started on antiepileptics. as his eeg monitoring continued, this activity stopped and his antiepileptics were discontinued. . his mental status also began to improve, albeit slowly. he was able to be extubated without incident. the patient had a fall out of bed that was unwitnessed. he was found at the side of his bed, sitting on the floor. he denied hitting his head, and there was no evidence of head trauma. a head ct was done which did not reveal any abnormalities. also during his icu stay, the patient required an insulin drip to adequately control his blood sugars. this was felt to most likely due to steroids and his dm. his insulin dose and sliding scale was uptitrated accordingly and the insulin gtt was discontinued. he was then transferred to the floor for further management. . # hlh: steroids started , ivig x4d finished , cycle #1 etoposide per hlh-94 regimen started , finished (days 1/4/8/11). completed 2wks dexamethasone 20mg, now on a slow taper. - continue etoposide 150mg/m2 qwk x6wks (mondays), last given . - continue dexamethasone 10mg (5mg/m2) daily x2wks, then 5mg (2.5mg/m2) x2wks, 2.5mg (1.25mg/m2) x1wk, then taper off over 1wk. - cyclosporine might be started week #9 pending re-evaluation. - follow cbc, fibrinogen, coags, ldh. - calcium and vitamin d to prevent bone loss while on steroids. - ppi while on steroids. - continue tmp/smx ppx. - tmp-smx for prophylaxis. . # pancytopenia: due to hlh and chemotherapy. transfused 1u plts . transfused 8u prbc previously and 2u prbc . trace positive stool guaic. avoid nsaids and heparin with low plts. . # coagulopathy: ptt up to 71 (with factor ix 41%) now normalized. transfused cryoprecipitate to keep fibrinogen >100. . # : due to hlh. hepatology consulted. normal hepatitis serologies from osh. lfts improving. . # diabetes: endocrinology consulted. added nph. holding insulin glargine until po intake stabilizes. increased sliding scale per endocrine. . # respiratory failure: extubated. off o2. . # seizure d/o and delirium: due to hlh. mri brain negative. eeg confirmed seizure. neurology consulted. resolved. continued levetiracetam for seizure. continued trazodone prn sleep. . # fever: due to hlh. id consulted. abx stopped . adenovirus pcr, analplasma (hge) ab, blastomycosis ab, coccidioides ab, hepatitis e ab, hhv-6 pcr, hsv-, histoplasma ab, leptospira ab, parvovirus b19 ab all negative. . # thigh hematoma: due to bm biopsy, coagulopathy, and pancytopenia. resolving. . # ra: holding etanercept for now. . # hypertension: restarted olmesartan (initially held due to syncope). increased metoprolol to 25mg . atenolol stopped. . # hypernatremia: due to osmotic diuresis with hyperglycemia, resolved. . # fen: regular diabetic diet. hypernatremia resolved with iv fluids. . # dvt prophylaxis: pneumatic boots. . # access: picc. . # precautions: fall. . # contact: wife. . # code: full. . transitional: # hlh: etoposide 150mg/m2 iv weekly x5 more weeks, then re-evaluate. . # pulmonary nodule: ct with scattered pulmonary nodules measuring up to 5 mm needs f/u ct in 12 months. medications on admission: 1. atenolol 25mg daily 2. lipitor 40mg daily 3. lasix 40mg daily 4. benicar 20mg daily 5. lovaza- 1gm- 2 cap in am, 2 in pm 6. vicotaz- 1.8u subcutaneous daily 7. u500 insulin- 14u in am, 13u in pm 8. tricor- 145mg po daily 9. enabrel discharge medications: 1. levetiracetam 500 mg tablet sig: two (2) tablet po bid. 2. calcium carbonate 200 mg calcium (500 mg) po bid. 3. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily. 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h. 5. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid. 6. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily. 7. prochlorperazine maleate 5 mg tablet sig: 1-2 tablets po q8hr prn nausea. 8. ondansetron hcl 4 mg tablet sig: 1-2 tablets po q8hr prn nausea. 9. nystatin 100,000 unit/ml suspension sig: five (5) ml po qid prn thrush. 10. oxycodone 5 mg tablet sig: one (1) tablet po q6h prn pain. 11. trazodone 50 mg tablet sig: 0.5 tablet po hs prn insomnia. 12. olmesartan 20 mg tablet sig: one (1) tablet po daily. 13. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid. 14. etoposide 20 mg/ml solution sig: one y (150) mg/m2 intravenous 1x/week (once per week) for 5 weeks: mondays x5 more weeks, then treatment to be determined. plan is to give this in dr. office. 15. dexamethasone 2 mg tablet sig: five (5) tablet po daily (daily): 10mg (5mg/m2) daily x2wks (finishing ), then 5mg x2wks, 2.5mg x1wk, then taper off over 1wk. 16. nph insulin human recomb 100 unit/ml sig: 12 units sc qam: with breakfast. 17. insulin regular human 100 unit/ml solution sig: per sliding scale sc qid. 18. miconazole nitrate 2 % powder sig: one (1) appl topical tid prn rash. discharge disposition: extended care facility: rehab discharge diagnosis: 1. syncope (fainting). 2. fever. 3. pancytopenia (low blood counts). 4. coagulopathy (bleeding disorder). 5. hemophagocytic lymphohistiocytosis (hlh), bone marrow disease. 6. (liver dysfunction, hepatitis). 7. altered mental status (delirium). 8. generalized weakness. 9. seizure disorder. 10. rheumatoid arthritis. 11. diabetes. 12. hypertension (high blood pressure). discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted to the hospital directly from another hospital due to fainting (syncope), pancytopenia (low blood counts), , altered mental state, and fever. you were seen by the infectious disease, rheumatology, neurology, endocrinology, hepatology (liver), dermatology, and hematology/oncology specialists. you needed transfusions of red blood cells, platelets, and clotting factors for a coagulopathy (bleeding disorder). dermatology performed a skin biopsy of a rash. hematology performed a bone marrow biopsy; this confirmed the diagnosis of hlh (hemophagocytic lymphohistiocytosis), a bone marrow disease that destroys blood cells. this was treated with etoposide (chemotherapy) and dexamethasone (steroids) and you will need to continue these as an outpatient. . while you were in the hospital, your confusion and agitation worsened when you were feeling short of breath. this required intubation (ventilator/breathing machine support). during this time, an eeg showed seizure activity, so you were started on a seizure medication, levetiracetam (keppra). as the steroids and chemotherapy continued, you began feeling better, you did not need the ventilator, fevers resolved, and the liver function tests normalized. your blood counts remain low, a result of the hlh and chemotherapy, and you are continuing to need frequent blood transfusions. . initially, you should have your blood counts (cbc) checked every other day and this can be spaced out if your need for transfusions declines. . medication changes: 1. etoposide chemotherapy weekly for at least the next 5 weeks, then additional therapy will be considered. 2. dexamethasone tapered over then next six weeks. 3. levetiracetam (keppra) for seizure disorder. 4. stop atenolol. 5. metoprolol 2x a day. 6. calcium and vitamin d supplements while you are on steroids (dexamethasone). 7. trimethoprim/sulfamethoxazole (bactrim) ss (single strength) once daily to prevent infections. followup instructions: hematology/oncology dr. catcher appointment: monday at 9:15am healthcare , , phone fax (attention: ) . department: hematology/oncology when: thursday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage . department: hematology/oncology when: thursday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage . department: neurology when: thursday at 3:30 am with: , md building: campus: east best parking: garage procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube biopsy of bone marrow biopsy of bone marrow closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: thrombocytopenia, unspecified anemia, unspecified pure hypercholesterolemia toxic encephalopathy unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver acute respiratory failure hypotension, unspecified disorders of phosphorus metabolism rheumatoid arthritis rash and other nonspecific skin eruption nontraumatic hematoma of soft tissue encephalopathy, unspecified hyperosmolality and/or hypernatremia other alteration of consciousness insomnia, unspecified neutropenia, unspecified nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] benign essential hypertension fever presenting with conditions classified elsewhere body mass index 40.0-44.9, adult generalized nonconvulsive epilepsy, without mention of intractable epilepsy lymphocytosis (symptomatic) dysphagia, oral phase hemophagocytic syndromes 

Answer: The patient is high likely exposed to