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: penicillins attending: chief complaint: found down unconscious major surgical or invasive procedure: none history of present illness: this is a 40 w with aids, last cd4 count of 8 in , who is non-compliant with f/u and not on haart, presented to the ed with lethargy, fever, hypotension, and a cough productive of thick greenish-yellow sputum. per ed records, the patient was noticed sitting on her doorstep, apparently unconscious, and a bystander called 911. . of note, patient is not cooperative with interview or examination. she refused to answer questions about her medical history or social situation and is uncooperative with physical exam. . in the ed patient was found to be febrile (101.9), hypotensive (80/50), tachycardiac, and severely anemic with hct 12, and guaiac positive. patient was transfused with 2 units prbcs and blood and urine cultures were sent. an lp was performed and patient was started on 2 grams ceftriaxone, 1 gram vanco, 500 mg iv flagyl, and decadron 10 mg iv. past medical history: aids itp hsv rash abnormal pap s/p leep for squamous intraepithelial lesions social history: the patient had been living with her 22-year-old daughter for the six months prior to the admission. before feburary , the patient had difficulty meeting her living expenses and spent some time in shelters. before being diagnosed with hiv, she worked at and was a notary public. she is estranged from her husband. family history: nc physical exam: vs: t: 99.2 hr: 71 bp: 101/63 gen: cachectic woman lying in bed, refusing to open her eyes, in nad heent: eyelid strength, otherwise unable to assess cv: rrr, no m/r/g chest: ctab no c/w/r abd: thin, unable to assess ext: no edema, + 2 distal pulses bl neuro: awake, uncooperative, answers to some questions appropriately pertinent results: 11:47pm cortisol-30.8* 11:47pm urine hours-random creat-118 sodium-31 08:45pm cerebrospinal fluid (csf) protein-27 glucose-64 08:45pm cerebrospinal fluid (csf) wbc-0 rbc-6* polys-0 lymphs-0 monos-0 04:00pm urine blood-sm nitrite-neg protein-tr glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 04:00pm urine rbc-0-2 wbc- bacteria-few yeast-none epi-0-2 04:00pm urine hyaline-* 01:11pm glucose-81 urea n-49* creat-2.0*# sodium-138 potassium-3.7 chloride-92* total co2-34* anion gap-16 01:33pm lactate-2.1* 01:11pm calcium-8.8 phosphate-4.7* magnesium-2.6 01:11pm wbc-3.9* rbc-1.59*# hgb-4.2*# hct-12.5*# mcv-79* mch-26.6*# mchc-33.8 rdw-18.5* 01:11pm plt count-407 01:11pm pt-12.3 ptt-29.6 inr(pt)-1.1 . cxr (): persistent bibasilar opacities. development of new opacity in the right upper lobe as described above. given the current clinical situation, multifocal pneumonia would be the likely cause. . mri (): impression. 1. no mass or abnormal enhancement in the brain or meninges. 2. findings consistent with bilateral mastoiditis and mucosal thickening in both sphenoid sinuses. 3. generalized brain atrophy. . eeg (): no focal abnormalities or epileptiform features were seen. . ct of head (): impression: severe destruction and fluid replacement of bilateral mastoid air cells, right greater than left. in the right petrous bone there is osseous destruction anteriorly that might indicate possible spread to the intracranial compartment. demineralization of the sigmoid plate is present posteriorly. we recommend mri of the brain and also mrv. . mri (): impression: 1. increased enhancement of bilateral mastoids and part of the petrous bones, opacified with complex fluid, most likely due to infection. 2. new small subdural complex fluid collections in bilateral frontal regions with meningeal enhancement. these findings are worrisome for meningeal spread of the infection. 3. no obvious intraparenchymal abnormality at this stage. . mri () impression: 1. acute left putaminal infarct, new in the interval. 2. unchanged appearance of bilateral mastoiditis with small bilateral subdural fluid collections, with enhancement of the surrounding meninges. . eeg: impression: markedly abnormal eeg due to the very frequent generalized sharp wave discharges with a left hemisphere predominance. these discharges were generally occurring every one to two seconds but not particularly rhythmically. the suppressed background suggests a widespread and severe encephalopathy affecting all areas. there was more cortical dysfunction on the right, with lower voltage activity, but the discharges suggest an area of increased cortical hypersynchrony on the left with epileptogenic potential. these discharges did not constitute a seizure at the time of the recording, but they are worrisome for seizures at other times. . eeg: this 24 hour video eeg telemetry demonstrated periodic lateralized sharp epileptiform discharges most prominantly seen over the left frontocentral and frontotemporal leads. the background also demonstrated a diffuse low voltage slowing. these findings are suggestive of a left hemispheric focus superimposed on a more widespread encephalopathy. . cxr: stable appearance of small bilateral pleural effusions and small bibasilar consolidation which could represent pneumonia or atelectasis. . mr head: impression: 1. bilateral extensive mastoid soft tissue changes. decrease in meningeal enhancement seen on the previous mri study. no new areas of signal abnormality or enhancement or fluid collection seen. 2. evolution of left putaminal infarct. 3. diffuse brain atrophy could be related to hiv encephalopathy. 4. no new areas of enhancement. . head ct impression: 1. no new infarct or hemorrhage. 2. status post right mastoidectomy with persistent opacification in the region of surgery. increased opacification in the left mastoid air cell/middle ear cavity consistent with worsening mastoiditis. . renal usn: increased echogenicity in relation to the kidneys bilaterally consistent with hiv nephropathy. brief hospital course: this is a 40 y.o. woman with aids admitted with hypotension, fever, pneumonia, anemia, uti, and acute renal failure. during this hospitalization, the patient was transferred to the micu on several occasions for hypotension. after a long hospital stay with a consistently declining status, the patient was made cmo and expired while on the wards. the following issues were addressed: . 1. infectious disease: the patient presented with b/l pna and developed a mastoiditis with extension into the subdural space. upon presentation an lp was done which was negative for meningitis. blood cultures, urine cultures, and ear drainage was cultured. viral cultures and stool cultures were also sent. the patient grew out mssa and pseudomonas from her sputum and coag negative staph from her r ear. a right mastoidectomy was performed. the patient was treated empirically with vanco, ceftazadime, caspofungin, and acyclovir. as viral and fungal cultures came back negative, the acyclovir and caspofungin were stopped. id was involved throughout the hospitalization and suggested a 4 week course of the vanco and ceftazadime from the time of debridement of the r mastoid. a repeat head ct on showed increasing l sided mastoiditis despite maximum medical therapy. on , all antibiotics were stopped as the patient had been anuric for three days and the antibiotics were contributing to fluid overload and respiratory distress. the patient was made cmo at that point and finally expired on . . a. pneumonia: the patient presented with cxr and ct findings consistent with a bilateral multi-focal pneumonia. a cavitary lung lesion was also seen in the right ll on chest ct. given patient's cd4 count of 8, and subsequent immunocompromised state, the patient was susceptible to opportunistic infections and the ddx was extremely broad and included bacterial, viral, fungal, parasitic infections. three consecutive induced sputum samples were negative for acid fast bacteria. culture of these sputum samples revealed pseudomonas aeruginosa, mssa, and yeast. her sputum was negative for pcp, , and nocardia. she was treated with an antibiotic regimen to cover gram +, gram -, particularly pseudomonas. as stated above she was treated with vancomycin, ceftazidime, and caspofungin. the patient was kept on bactrim for pcp . the patient also was found to have b/l pleural effusions after being fluid repleted in the icu. a thoracocentesis was considered but ultimately was not pursued as the patient was satting well and had an overall poor prognosis. as part of a workup for the cavitary rll lesion, anca was sent to r/o wegener's granulomatosis. the anca was found to be mildly positive with a pattern not typical of patient's with hiv. rheumatology was consulted and did not think a vasculitic process was likely given anca is commonly positive in aids and also in the setting of infection. no further workup or treatment was done for this finding. . b. bilateral otitis media/mastoiditis: patient was noted to have opacification of mastoid air cells on head ct. on the third day of her admission, her right ear drum ruptured and was oozing an opaque, thick fluid. her ear infections were noted to be bilateral. ent was consulted several times during the course of this admission. tympanostomy tubes were placed to drain any residual infection and to prevent intracranial infiltration. the drainage from her r ear was cultured and grew coag negative staph and some yeast. the patient was treated with vancomycin and caspofungin. a repeat mri showed bilateral fluid collections in the frontal region with meningeal enhancement that were concerning for meningeal spread of the infection. a right sided mastoidectomy was done to remove the fluid from the right mastoid cavity. a ct head on later showed increasing l sided mastoiditis despite the broad antibiotic coverage. ent was consulted but no further intervention was recommended. . c.uti: her uti was treated with the broad spectrum antibiotics (for pna and mastoiditis) and subsequent ua was negative as were urine cultures. . 2. seizures: on day six of her hospital admission, the patient had a witnessed tonic-clonic seizure. her antibiotics and antipsychotic medications that may have lowered the seizure threshold were stopped. neurology was consulted and the patient was started on phenytoin for seizure management (goal 15-20). the patient continued to have seizures and keppra was added. an eeg was done which showed seizure activity. by the end of her hospitalization, the seizures appeared to be controlled on phenytoin and keppra. however, non-convulsant seizures could not be ruled out. the patient was continued on the seizure prophylaxis while she was cmo. . 3. acute left putaminal infarct: this infarct was found s/p r mastoidectomy and thought to be secondary to a hypercoagulable state during surgery and/or hypotension during surgery. the patient exhibited diminished movement of her rue and was not seen to move her lower extremities. the patient was often uncooperative with the exam and it was unclear if these perceived motor deficits were secondary to a hemiparesis vs ms decline secondary to post-ictal states vs lack of voluntary cooperation by the patient. the patient was started on an aspirin and her hct was trended given her history of ob positive stool. . 4. pericardial effusion: for evaluation of the patient's tachycardia and hypotension, the patient had a ett which showed a pericardial effusion. cardiology was consulted and did not feel that the patient had clinical signs of tamponade (no jvd and pulsus= ). cardiology did not recommend pericardiocentesis. the fellow spoke to the daughter and she agreed not to pursue with the procedure. . 5. hyperchloremic metabolic acidosis: the patient developed a non-gap metabolic acidosis initially thought to be secondary to fluid boluses with ns used to keep the patient's bp wnl in addition to bicarb loss via diarrhea induced by the tube feeds. the boluses were changed to lr but the acidosis continued. a c.diff was ordered but the patient's status was changed to cmo before it was sent. . 6. hypothyroidism: the patient's thyroid function was initially wnl at the beginning of her hospitalization. thyroid function was reassessed when the patient developed hypothermia. the tsh was increased and t3 t4 were decreased, likely secondary to her infected state. this may have also contributed to her declining ms, pericardial effusion and le edema. the patient was started on levothyroxine 25 mcg qd without any improvement in her hypothermia or edema. . 7. ms changes: throughout the hospital stay her mental status fluctuated on a day to day basis. however, as the patient's overall condition worsened, her mental status declined. the ddx for this change includes the numerous seizures and a post-ictal state, the infarct, aids dementia, and overwhelming infection. . 8. hypotension: in the ed sbp transiently improved to 90's -low 100's with ivf. given the signs of infection, the hypotension was concerning for sepsis. the patient was normotensive for some time after transfer to the medicine service. she later developed hypotension in the setting of tachycardia and was transferred to the icu because of the concern for sepsis. she was treated with 4l iv normal saline. when her hypotension resolved, she was transferred back to the medicine service for management. after a few days on the medicine service, the patient again became hypotensive and had multiple seizures, requiring a dilantin load which tended to exacerbate the hypotension. the patient was again admitted to the icu, fluid repleted, and returned to the floor for further management. multiple blood cultures were drawn throughout the hospital stay. none of the blood cultures every grew out any organisms. . 9. anemia: while the patient's hct measured in the ed was 12.5, the patient received 3 units packed rbcs after which her hct stabilized to 28-29. gi was consulted, but the patient declined to have endoscopy performed. her stool was guaic + in the ed. the patient was transfused multiple times during her hospitalization to keep her hct>21. . 10. tcp: the patient's platelets began to drop during the admission. the ddx included bm suppression from her hiv and/or overwhelming infection. dic was also possible but thought to be less likely. drug toxicity was also considered possible and drugs causing tcp were stopped (protonix). given the patient was on heparin, hit was also deemed a possibility and sc heparin was stopped. pneumoboots were used instead. the patient did not show any signs of bleeding and never needed platelet transfusions. all lab draws were discontinued on secondary to her poor prognosis and the desire to move the patient to comfort care only. . 11. aids: not on haart non-compliance. pt was felt to be too ill/decompensated with multiple areas of infection to start haart as an inpatient. . 12. arf: her initial serum creatinine was 2.0. after receiving iv fluids, it resolved to 0.7, making it likely that her elevated creatinine was the result of dehydration. the patient's cr was stable throughout her admission. however, towards the end of the admission the patient's creatinine began to increase. urine lytes did not show a picture consistent with a pre-renal etiology as fena was 1.7%. renal usn did not show any signs of obstruction. med toxicity was considered and all nephrotoxic agents were stopped. the patient's vanco level was supratherapuetic and was held. there were no eos in her urine or peripherally. the patient's renal failure continued to progress and she eventually became anuric. it was decided that dialysis would not be pursued and no further workup would be done given her poor prognosis. the patient was anuric for >7 days prior to expiration. . 13. ppx: ppi and sc heparin were given until tcp developed and then pneumoboots were used thereafter. . 14. fen: an ngt was placed and the patient was started on tube feeds to improve nutrition. when the patient's code status was changed to comfort care only, the ngt was pulled and tube feeds were stopped. medications on admission: bactrim mvi discharge disposition: expired discharge diagnosis: expired discharge condition: expired md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified spinal tap incision of lung spinal tap incision of lung enteral infusion of concentrated nutritional substances transfusion of packed cells simple mastoidectomy myringotomy with insertion of tube diagnoses: acute kidney failure with lesion of tubular necrosis unspecified pleural effusion iron deficiency anemia secondary to blood loss (chronic) unspecified acquired hypothyroidism human immunodeficiency virus [hiv] disease unspecified disease of pericardium pneumonia due to pseudomonas methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site grand mal status methicillin susceptible pneumonia due to staphylococcus aureus other diseases of lung, not elsewhere classified dementia in conditions classified elsewhere without behavioral disturbance hemorrhage of gastrointestinal tract, unspecified intracranial abscess iatrogenic cerebrovascular infarction or hemorrhage cerebral thrombosis with cerebral infarction staphylococcal meningitis acute mastoiditis with other complications acute petrositis chronic mastoiditis acute nonsuppurative otitis media, unspecified 

Answer: The patient is high likely exposed to