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: patient recorded as having no known allergies to drugs attending: chief complaint: altered mental status major surgical or invasive procedure: - endotracheal tube intubation - left ij central venous line - left radial arterial line - endotracheal tube extubation - removal of left ij cvl - removal of left radial arterial line history of present illness: 66 yo m with neuroendocrine small cell carcinoma (merckel's) s/p l craniotomy for tumor resection of l parietal/temporal mass on s/p wbi, recent h/o serratia meningoencephalitis (completed a 2 week course of ceftriaxone from ), c diff colitis p/w admitted for altered mental status from , found to have recurrent meningities in ed, and seizure on the floor requiring ativan now being transferred to for further management. of note pt underwent tumor resection (), readmitted () for pansensitive serratia marcescens meningitis (tx w/ ceftriaxone ), c diff colitis, and le dvt (tx w/ lovenox). per wife, had an episode of ?seizure on that admission, though no documentation in omr. pt readmitted for ich in the region of his prior tumor resection, lovenox stopped and repeat lenis negative for clot. since then pt has been at , being treated w/ po vanc for recurrent c diff. morning of admission, pt w/ emesis, h/a, neck stiffness, and unresponsive brought to ed. in the ed, vs 98.6 (rectal temp 102) 111 127/80 20 97% 102. pt unresponsive, w/ episode of agitation. labs: lactate of 3.1, k 3.4, mg 1.8, hct 36, abg 7.56/24/120. head ct showed reduced area of ich. lp revealed yellow, cloudy fluid w 6350 wbcs and 13 rbcs (93% polys), glu. he was given cefriaxone, vanc, acyclovir, ampicillin, 1l ns. neurosurgery evaluated pt, nothing to do. on arrival to the floor, pt tachy to low 100s, sbp 120, rectal temp 103.1. he was unresponsive. he had episode of upper body shaking, and disconjugate gaze, thought to be seizure w/ improvement of ativan 2mg x2. neuro consulted recommended keppra loading (20mg/kg) x1. currently, patient is non-responsive. past medical history: # neuroendocrine small cell cancer likely cell: - diagnosed in after patient incidentally found a left axillary lymph node. fna was positive for malignant cells, positive for cytokeratin (ae1/3/cam 5.2), ck20, synaptophysin, and chromogranin, negative for cd45, ck7, ttf-1, and s-100. the immunophenotype suggested a neuroendocrine carcinoma. imaging studies showed fdg-avid enlarged left axillary lymph node without other concerning nodes or masses. - /: 4 cycles of cisplatin and etoposide - /: received radiation - : imaging study showed no evidence of recurrence of - : several weeks of ams --> large l temporo/parietal/occipital lesion s/p craniotomy by dr. , biopsy consistent with cell cancer #. : s/p left parietal-occipital craniotomy for mass resection. pathology report was consistent with a neuroendocrine tumor. #. treated for recent uti and epididymitis as an outpatient prior to admission #. basal cell carcinoma #. left hip pain #. h/o shooting pain to the left lower extremity after a fall in college #. pan-sensitive serratia marcescens meningitis treated with ceftriaxone #. c. diff #. vre ? rectal swab social history: (from omr) married. works as a dentist, likes to be called "doc". no smoking history. family history: unable to obtain. (from omr) his father did have melanoma and developed brain metastases. he mother had thyroid disease and congestive heart failure. he has two sisters, all healthy. history of malignant melanoma in his maternal aunt. physical exam: physical exam on admission to tcurrent: 39.3??????c, hr: 110 bpm, bp: 128/59 mmhg, rr: 24 insp/min, spo2: 96% general: unresponsive, laying in bed, no current seizure activity neuro: unresponsive, horizontal nystagmus preferntially to the left, pt grimaces, normal muscle bulk/tone, equivical babinski, no clonus heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: coarse anterior breath sounds cv: tachy, 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 in place ext: cool extremities, palpable peripheral pulses, no clubbing, cyanosis or edema pertinent results: labs upon admission: 12:25pm blood wbc-9.9 rbc-4.13* hgb-13.2* hct-36.0* mcv-87 mch-31.8 mchc-36.5* rdw-18.0* plt ct-252 12:25pm blood neuts-94.6* lymphs-3.7* monos-1.2* eos-0.2 baso-0.4 03:04am blood hypochr-normal anisocy-1+ poiklo-2+ macrocy-1+ microcy-1+ polychr-normal spheroc-1+ ovalocy-1+ burr-1+ tear dr 12:25pm blood pt-12.8 ptt-24.3 inr(pt)-1.1 11:51am blood fibrino-839* 12:25pm blood glucose-133* urean-13 creat-0.5 na-136 k-3.4 cl-100 hco3-21* angap-18 10:37pm blood alt-28 ast-15 ck(cpk)-23* alkphos-49 totbili-0.6 12:25pm blood calcium-8.5 phos-3.3 mg-1.8 03:04am blood caltibc-113* vitb12-254 folate-11.7 hapto-268* ferritn-* trf-87* 03:00am blood genta-1.1* 01:39am blood osmolal-275 12:31pm blood type-art temp-37.0 rates-/26 po2-120* pco2-24* ph-7.56* caltco2-22 base xs-1 intubat-not intuba comment-green top 12:31pm blood glucose-127* lactate-3.1* na-135 k-3.2* cl-100 01:14am blood freeca-1.08* microbiology: csf: serratia marcescens - rare growth | cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s crypotcoccal antigen: negative fungal culture: negative blood cultures: : no growth c.diff : negative urine : no growth sputum : yeast csf: : 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (preliminary): no growth. imaging: ct head : 1. progressive decreased size of left occipitoparietal intracranial hemorrhage with surrounding edema. no new definite areas of hemorrhage. 2. evaluation for possible intracranial infection is limited on this study and if there is clinical concern for an infection, mri with contrast should be performed. 3. stable configuration of the ventricles with enlargement of the left temporal . mri/mrv head : 1. dramatic interval change, characterized by new confluent foci of slow diffusion with extensive leptomeningeal enhancement in both frontal lobes with pachymeningeal enhancement in the left temporal pole in keeping with meningoencephalitis and early cerebritis, consistent with clinical course and recent csf results. 2. large left temporoparieto-occipital surgical cavity with nodular margins appears slightly more prominent since the recent studies. the presence of blood products in the cavity makes it difficult to exclude superinfection with abscess formation at this site. however, the overall appearance is not much changed, with no increase in associatd flair-signal abnormality indicative of further edema, as might be expected with pyogenic infection. 3. ependymal enhancement in the occipital of left lateral ventricle, unchanged and likely related to persistent tumor at this site, with no finding to suggest ventriculitis, elsewhere. 4. no evidence of cerebral venous thrombosis. mri spine : 1. no evidence of infection or tumor dissemination in the entire spine. 2. extensive abnormal but amorphous stir-hyperintensity in the deep dorsal and the interspinous and supraspinous soft tissues from l2 to l4-l5 level, likely related to multiple recent attempts at lumbar puncture; correlate clinically. 3. small disc-spondylotic ridges at c5-c6 and c6-c7 levels, without canal compromise. cxr : right picc has been withdrawn. now the tip is in the distal svc. right lower lobe atelectasis has improved. left lower lobe opacities consistent with atelectasis are unchanged. if any there are small bilateral pleural effusions. cardiomediastinal silhouette is unchanged. right perihilar opacities have resolved. eeg : this is an abnormal video eeg telemetry due to generalized slowing with a maximum 4 hz posterior predominant rhythm as well as bursts of generalized delta slowing, left more than right. this represents a severe encephalopathy such as can be seen with diffuse ischemia, toxic/ metabolic changes, infections, or medication effects. there were no clear epileptiform discharges or electrographic seizures noted. brief hospital course: 66 y/o m with merckel's cell carcinoma s/p l craniotomy () c/b post-op serratia meningitis tx w/ 2wk course of ceftriaxone () and iph now p/w ams. # recurrent serratia meningoencephalitis: complicated by associated seizure activity, altered mental status (comatose initially) and history of recent craniotomy and intracranial bleed. head ct showed interval improvement in iph and lack of abscess. he had a very high fever of 104 that was very difficult to control with antipyretics and cooling measures. he was intubated for airway protection in anticipation of mri/mrv and risk for aspiration when laying flat for a prolonged period. mri/mrv showed meningoencephalitis, slightly more prominent margins of his surgical cavity where an abscess/infection could not be ruled out, and no cavernous sinus thrombi. he was started on antibiotics gentamicin and meropenem with vancomycin po for c. diff prophylaxis on . meropenem was chosen because of good bbb penetration and does not lower seizure threshold as much as imipenem, and gentamicin is useful in combination therapy for fastidious gram negatives. lp was repeated on and showed significant decrease in wbc count indicating positive antibiotic effect. his mental status improved gradually throughout his stay in the icu, although not yet back to baseline per his family. he was followed by the neurooncology team and infectious disease while in the icu. he was transferred to omed. his first csf culture grew out pan sensitive serratia whereas repeat csf culture (performed after he was started on antibiotics) had no growth. the gentamicin was stopped . he will be continued on meropenem until . blood cx negative x 3. mri showed evidence of progressive leptomeningeal disease and stable surgical cavity. eeg showed evidence of moderate to severe encephalopathy with no evidence of seizure activity. # seizure. he had a seizure while on the medical floor likely due to underlying serratia meningoencephalitis that was responsive to ativan. he was given keppra maintenance dose 750 mg q12 with dexamethasone 4 mg q12 and kept on seizure precautions per neuro-onc. continuous eeg monitoring in the icu showed no seizure activity. dexamethasone was tapered down and keppra was continued. he had no further episodes of seizure activity during his hospital course. he will be dsicharged on keppra and dexamethasone. # resp alkalosis: abg was also notable for hypocapnea and respiratory alkalosis very likely centrally mediated in the setting of meningoencephalitis. patient also presented with elevated lactate and ag of 14 likely secondary to his infection. treatment with antibiotics and fluids improved his respiratory status. no respiratory complaints. normal oxygen saturation on room air. # history of c. diff. he had a history of cdiff while at . cdiff was negative during this admission. he was placed on c. diff prophylaxis using vancomycin po per id recommendations. the plan is to continue prophylaxis 8 days after completion of antibiotics for serratia. #transient hypotension: shortly after mri, he had transient hypotension requiring intermittent pressor support and placement of an a-line and lij cvl. most likely this was secondary to sedation boluses of versed and fentanyl that he received during the imaging study, but sepsis secondary to meningoencephalitis was considered. pressors were weaned within 8 hours of onset of hypotension and there were no signs of end-organ ischemia. bp stable for rest of hospital course # neuroendocrine small cell carcinoma: patient is s/p tumor recention, c/b meningitis and recent rebleed. has completed wbi. he was continued on dexamethasone throughout his stay. he was started on bactrim for pcp prophylaxis while on steroids. further treatment for his cancer will be deferred until resolution of meningoencephalitis. # anemia: his hematocrit has steadily declined, but remained stable in the low to mid 30s. b12 and folate were normal. iron studies revealed anemia of chronic inflammation. his stool was guaiac + on the medical wards. this may be explained by hemmorrhoids or diverticulosis that were seen on previous colonoscopy. he did not require blood transfusions during his hospital stay. he was given an iv ppi for ulcer prophylaxis. he was started on oxycontin 10 mg for pain control. the patient was full code for this admission. he was evaluated by speech and swallow and nutrition services and is taking adequate pos of soft diet upon discharge. medications on admission: medication on transfer to : mvi aquaphor colace decadron 2mg po bid desonide fragmin 5000u daily keppra 500mg po bid miralax mom prilosec 20 questram 4g po bid roxicodone 2.5 q4 prn pain apap prn vancomycin 125 mg po q6h () regular insulin sliding scale discharge medications: 1. meropenem 1 gram recon soln sig: two (2) g intravenous q8h (every 8 hours) for 13 days. disp:*78 g* refills:*0* 2. multivitamin oral 3. aquaphor topical 4. colace oral 5. decadron sig: two (2) mg twice a day. 6. desonide topical 7. fragmin 5,000 unit/0.2 ml syringe sig: one (1) syringe subcutaneous once a day. 8. keppra 500 mg tablet sig: one (1) tablet po twice a day. 9. miralax oral 10. milk of magnesia oral 11. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po twice a day. 12. questram sig: four (4) mg twice a day. 13. oxycontin 10 mg tablet sustained release 12 hr sig: one (1) tablet sustained release 12 hr po every twelve (12) hours. disp:*60 tablet sustained release 12 hr(s)* refills:*2* 14. tylenol oral 15. insulin regular human subcutaneous 16. sulfamethoxazole-trimethoprim 800-160 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 17. vancomycin 125 mg capsule sig: one (1) capsule po q6h (every 6 hours) for 21 days. disp:*84 capsule(s)* refills:*0* 18. omeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po twice a day. discharge disposition: extended care facility: - discharge diagnosis: serratia meningitis neuroendocrine small cell carcinoma s/p resection history of c diff anemia 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 for altered mental status. you were found to have meningitis and you were treated with antibiotics. you were admitted to the icu after a seizure where you were put on a breathing machine, you were disconnected from the breathing machine and did not have any evidence of further seizures. please make the following changes to your medications: start meropenem mg intravenous every 8 hours until for meningitis. start vancomycin oral liquid 125 mg every 6 hours until for c.diff prophylaxis start sulfameth/trimethoprim ds 1 tab daily for pneumonia prophylaxis start oxycontin 10 mg twice a day for pain stop roxicodone for pain please continue your other home medications. followup instructions: the following appointments have been made for you. please also see your primary care physician and your oncologist as needed. department: infectious disease when: thursday at 3:10 pm with: , m.d. building: lm campus: west best parking: garage department: infectious disease when: friday at 11:00 am with: , md building: lm bldg () campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified spinal tap incision of lung spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization arterial catheterization video and radio-telemetered electroencephalographic monitoring diagnoses: anemia, unspecified urinary tract infection, site not specified unspecified septicemia severe sepsis hematoma complicating a procedure other convulsions intracerebral hemorrhage other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure other specified cardiac dysrhythmias personal history of other malignant neoplasm of skin secondary malignant neoplasm of brain and spinal cord alkalosis intestinal infection due to clostridium difficile pressure ulcer, lower back personal history of venous thrombosis and embolism other encephalopathy personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health diverticulosis of colon (without mention of hemorrhage) pseudomonas infection in conditions classified elsewhere and of unspecified site coma personal history of colonic polyps pressure ulcer, stage ii history of fall meningitis due to gram-negative bacteria, not elsewhere classified unspecified hemorrhoids without mention of complication personal history of malignant neuroendocrine tumor 

Answer: The patient is high likely exposed to