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 / percocet attending: chief complaint: osh transfer for evaluation and treatment of ttp major surgical or invasive procedure: intubation and extubation bone marrow biopsy hd line placed and removed liver biopsy history of present illness: patient is a 59 yo male who recently was hospitalized at after diagnosis of ttp. at that time no underlying cause could be identified, he was treated with plasmapharesis and steroids, and ultimately improved however remained hd dependant. on the day of presentation patient fellt ill, and "passed out". he was transferred to hospital. . in the osh patient was found to be profoundly anemic and hypocoaguable. he was given 4 units of ffp and transferred to . in the ed, initial vs were: t 97.7 p 102 bp 134/92 r 22 o2 sat 95%4l. ed discussed the case with bmt fellow, 125 solumedrol was given, 2 units of prbc were recomended by heme fellow, non cont abd contrast for abd pain obtainedm, 2mg iv morphine, and 10 mg of vit k given. . . patient reports that he felt overall well up until the day of his presentation. he endorses no uop over the past 8 hours. he denies any fever/chills, or diarrhea, but endorses nausea and abdominal pain. past medical history: - asthma - hypercholesterolemia - ttp unclear etiology - renal failure, was on hd tue/th/sat - hemophagocytic lymphohistiocytosis social history: married and lives with his wife. retired from working as a case manager. he denies chemical exposure. - tobacco: 25 pack year history, quit in - alcohol: rare family history: throat cancer in mom and uncle. physical exam: vitals: t: 98.6 bp: 135/86 p: 103 r: 30 o2:92% general: alert, oriented, tired appearing heent: sclera icteric, mmm, oropharynx with no ulcers or lesions neck: supple, jvp moderately elevated, no lad lungs: slight bibasilar crackles cv: sinus rhythm, nl s1s2, no s3s4, no murmurs, rubs, gallops abdomen: soft, non tender, non-distended, bowel sounds present, no rebound tenderness or guarding, ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, with minimal dependent edema 1+ and pitting around the ankles neuro: cn ii-xii intact, upper extremitites shoulder shrug, deltoid extension, bicep and tricep flexion and extension b/l, lower extremities hip flexion, knee flexion/extension, ankle flexion/dorsiflexion b/l psych: mood and attitude appropriate pertinent results: data from last admission: ========================= blood cultures - , , - no growth cmv ab - - igm negative, igg positive catheter tip - - no growth cmv viral load - negative . leptospirosis - negative lyme serologies - negative sputum (osh) - pseudomanoas cultures, pan-sensitive to levofloxacin, meropenem, ceftriaxone, ceftazidime, r to aztreonam stool cultures - negative for salmonella, shigella, yersinia, e. coli o157:h7 - negatve b glucan - negative galactomannan - negative hiv - negative . urine gonorrhea/chlamydia pcr - negative urine culture - enterococcus species (but contaminated sample), - coag negative staph repeat urine cultures from , negative . hepatitis titers: hep b sab - negative hep b sab - positive hep c ab - negative hep a igg - positive, igm - negative . parvovirus igg positive, igm negative . 02:07pm blood parst s-negative . 07:31pm blood herpes simplex (hsv) 2, igg- negative 07:31pm blood herpes simplex (hsv) 1, igg- postive . ppd normal from , read on . rheumatologic work-up: anti-gbm ab: negative , anca - negative ceruloplasm - negative . 11:24am blood lupus-neg 03:36am blood aca igg-4.1 aca igm-9.6 11:23am blood anca-negative b 07:31pm blood smooth-negative 02:38pm blood -negative 07:31pm blood igg-780 igm-75 04:39am blood c3-93 c4-13 . miscellaneous: adamts13 activity and inhibitor: 38% 01:19am blood fibrino-246 . serum tox screen: 12:40am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg . 01:01am blood copper (serum)- normal hereditary hemochromatosis: negative . admission labs: ================ 10:05pm blood wbc-8.8 rbc-1.95*# hgb-6.2*# hct-17.8*# mcv-91 mch-36.8*# mchc-34.7 rdw-16.1* plt ct-53*# 10:05pm blood neuts-77* bands-3 lymphs-17* monos-1* eos-1 baso-0 atyps-1* metas-0 myelos-0 nrbc-1* 10:05pm blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-normal microcy-normal polychr-normal schisto-1+ stipple-occasional tear dr 1+ 10:05pm blood pt-23.6* ptt-55.1* inr(pt)-2.2* 10:05pm blood fibrino-81*# 04:06am blood fibrino-118* 04:06am blood fdp-* 04:06am blood qg6pd-11.5 04:55pm blood gran ct-1044* 10:40pm blood gran ct-1512* 03:00am blood gran ct-328* 04:06am blood ret aut-3.2 10:05pm blood glucose-94 urean-59* creat-3.4*# na-132* k-4.7 cl-94* hco3-18* angap-25* 10:05pm blood alt-262* ast-614* ld(ldh)-3850* alkphos-288* totbili-17.6* dirbili-8.3* indbili-9.3 02:56am blood alt-1393* ast-2319* ld(ldh)-5860* alkphos-271* totbili-30.7* 08:03pm blood alt-1652* ast-2896* alkphos-411* totbili-27.1* 10:05pm blood lipase-211* 04:06am blood lipase-585* 02:56am blood lipase-2627* 01:37pm blood lipase-1399* 01:57am blood lipase-669* 04:06am blood calcium-8.2* phos-4.0# mg-1.5* 04:06am blood hapto-73 ferritn-* 04:42am blood ferritn-* 04:06am blood hbsag-negative hbsab-positive igm hav-negative 09:03am blood hbsag-negative hbsab-positive hbcab-negative igm hbc-negative igm hav-negative 01:37pm blood anca-negative b 01:37pm blood -negative 02:44pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:06am blood hcv ab-negative 04:24am blood lactate-7.2* 09:15pm blood freeca-0.83* microbiology: ============== # aspergillus galactomannan antigen: negative test result reference range/units aspergillus antigen 0.1 <0.5 (sera with an index <0.5 are considered to be negative) # b-glucan- no result test ---- fungitell (tm) assay for (1,3)-b-d-glucans results reference ranges ------- ---------------- no result * negative less than 60 pg/ml indeterminate 60 - 79 pg/ml positive > or equal to 80 pg/ml # rubeola antibody, igm: negative test result reference range/units measles antibody, (igm) <1:10 <1:10 titer # adenovirus pcr: negative (no dna detected) # herpes 6 dna pcr, quantitative: <500 #herpes simplex virus 1 and 2 antibody igm test name in range out of range reference range --------- -------- ------------ --------------- herpes simplex virus (hsv) igm ab, ifa (serum) hsv 1 igm, ifa <1:20 <1:20 hsv 2 igm, ifa <1:20 <1:20 interpretive criteria <1:20 antibody not detected > or = 1:20 antibody detected #herpes simplex (hsv) 1, igg test result reference range/units hsv 1 igg type specific ab >5.00 h index hsv 2 igg type specific ab <0.90 index # 4:03 am mrsa screen nasal swab. mrsa screen (final ): no mrsa isolated. # 4:06 am blood culture blood culture, routine (final ): no growth. . . # 8:48 pm blood (cmv ab) source: line-aline. cmv igg antibody (final ): positive for cmv igg antibody by eia. 227 au/ml. . . # 8:48 pm blood (ebv) source: line-aline. - virus vca-igg ab (final ): test canceled and patient credited due to a prior ebv panel sent on indicating evidence of past infection (ebv vca-igg positive, ebna igg positive and ebv vca-igm negative). a repeat panel is unlikely to detect ebv reactivation. serum will be held for 3months. . # 8:48 pm immunology (cmv) source: line-aline. cmv viral load (final ): 650 copies/ml. . . # 11:11 pm blood culture ( myco/f lytic bottle) blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. # 10:15 pm sputum source: endotracheal. **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. . # 2:56 am blood culture ( myco/f lytic bottle) source: line-aline. blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. . # 9:43 am serology/blood chem # 09480w . **final report ** varicella-zoster igg serology (final ): positive by eia. a positive igg result generally indicates past exposure and/or immunity. icteric specimen. effect patient results. interpret results with caution. # 10:08 am rapid respiratory viral screen & culture site: nasopharyngeal swab **final report ** respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. # 3:29 pm immunology source: line-a-line. hbv viral load (final ): hbv dna not detected. . # 9:24 am urine source: catheter. urine culture (final ): no growth. . # 12:37 pm immunology (cmv) source: line-a-line. cmv viral load (final ): cmv dna not detected. . # 10:49 am blood culture source: line-hd line set #2. blood culture, routine (pending): # 14:30 ebv pcr, quantitative, whole blood results pending # 11:32 am sputum source: expectorated. gram stain (final ): pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. respiratory culture (final ): test cancelled, patient credited. fungal culture (preliminary): gram stain of this specimen indicates contamination with oropharyngeal secretions and invalidates results. specimen is only screened for cryptococcus species. new specimen is recommended. # cmv viral load (final ): 1,260 copies/ml. # 09:45am blood wbc-6.2 rbc-2.86* hgb-9.0* hct-26.5* mcv-92 mch-31.4 mchc-34.0 rdw-23.5* plt ct-63* # 03:20pm blood na-129* k-4.7 cl-95* # 08:03pm blood alt-1652* ast-2896* alkphos-411* totbili-27.1* 09:45am blood alt-202* ast-50* alkphos-466* totbili-4.8* # 04:42am blood ferritn-* 04:06am blood hapto-73 ferritn-* # 09:45am blood cyclspr-33* images/studies: =============== 10:07:34 pm normal sinus rhythm. possible left ventricular hypertrophy. non-specific st-t wave abnormalities. compared to the previous tracing of qrs voltage in the left lateral leads has increased raising the possibility of left ventricular hypertrophy. suggest clinical correlation and repeat tracing. intervals axes rate pr qrs qt/qtc p qrs t 96 136 82 350/413 66 62 91 . # 2:32:34 pm atrial fibrillation with rapid ventricular response. left ventricular hypertrophy. diffuse non-specific st-t wave changes. compared to the previous tracing of atrial fibrillation with a rapid ventricular response and diffuse st-t wave flattening have appeared. tracing #1 intervals axes rate pr qrs qt/qtc p qrs t 108 0 88 0 . #atrial fibrillation with rapid ventricular response. diffuse non-specific st-t wave flattening. compared to the previous tracing of no diagnostic interim change. tracing #2 intervals axes rate pr qrs qt/qtc p qrs t 115 0 86 342/438 0 67 80 # chest (pa & lat) study date of 10:37 pma double-lumen catheter is seen with tip in the lower svc. heart size is enlarged with the vascular pedicle more prominent than on . there is an ill-defined opacificity overlying the right mid lung. there is no pleural effusion or pneumothorax. impression: 1. new cardiomegaly and enlarged vascular pedicle, suggestive of fluid overload. 2. ill-defined opacity in the right mid lung could be pneumonia or pulmonary hemorrhage in the appropriate clinical context. . #pathology: difficult crossmatch and/or evaluation of irregular antibodies study date of (icd9 code: 999.7) indication for consult: difficult crossmatch and/or evaluation of irregular antibodies indications for consult: difficult crossmatch and/or evaluation of irregular antibody (s) clinical/lab data: mr. is a 59 year old male who was admitted with renal and hepatic dysfunction, as well as a picture concerning for sepsis/dic. a blood sample was sent for type and screen. laboratory data: patient abo/rh: group o, rh positive antibody screen: positive dat: 3+ igg, 1+ c3 eluate: panagglutination of all cells antibody identity: panagglutinating antibody (); anti-jkb identified by the american red cross reference laboratory after performing heterologous adsorption antigen phenotype: performed - e, k, jkb, fya, fyb-antigen negative transfusion history: 7 non-reactive red cell transfusions during previous admission (5 of 7 units retrospectively determined to be positive for jkb) previous non-reactive plasma transfusions: 123 (in setting of plasmapheresis) previous non-reactive platelet transfusions: 2 diagnosis, assessment and recommendations: mr. has a new diagnosis of anti-jkb antibody, in addition to his known warm autoantibody. jkb-antigen is a member of the kidd blood group system. jkb-antibody is clinically significant and capable of causing hemolytic transfusion reactions. during his last admission , mr. received 5 units of jkb positive blood. these units will likely be cleared more quickly than jkb negative units. the icu team was made aware that delayed hemolysis could be taking place, although it will be difficult to assess in the face of his other lab abnormalities. in the future, mr. should receive jkb-antigen negative products for all red cell transfusions. approximately 26% of all abo compatible blood will be jkb-antigen negative. a wallet card and a letter stating the above will be sent to the patient. . # echo : the left atrium is mildly dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. there is mild global left ventricular hypokinesis (lvef = 40-45 %). there is no ventricular septal defect. with depressed free wall contractility. the ascending aorta is mildly dilated. 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 mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , biventricular systolic function now appears mildly depressed. . #ct of the abdomen/pelvis w/o intravenous contrast: in the visualized thorax, there is septal thickening in the left lower lobe that is consistent with pulmonary edema. proximally there are small nodular densities. there is mild basilar atelectasis, worse on the left. there is no pleural effusion or pneumothorax. the visualized heart is normal in size with a trace pericardial effusion. relative attenuation of the ventricles relative to muscle suggests anemia. evaluation of the solid organs in the abdomen is limited without intravenous contrast. calcific foci are seen within the liver and spleen suggesting prior granulomatous insult. a sliver of fluid is seen between the hepatic parenchyma and the gallbladder (series 2, image 25). there is no pericholecystic fat stranding. the pancreas and adrenals appear normal. there is a 1.7-cm diameter hypodensity within the lower pole of the left kidney and a second 1.2-cm hypodensity in the interpolar region, incompetely characterized. abdominal loops of small bowel appear normal without distension or pericolonic fat stranding. there is moderate fecal loading of the large bowel. the appendix is not clearly visualized, but there are no secondary signs to suggest appendicitis. there is no abdominal free air, free fluid, or pathologic lymphadenopathy. pelvic loops of bowel appear normal. the bladder and distal ureters appear normal. the prostate measures to 5 cm. musculoskeletal: there is no suspicious osteolytic or osteoblastic lesion. multilevel degenerative changes are seen with prominent schmorl's nodes at l3-l4. impression: 1. sliver of pericholecystic fluid adjacent to the hepatic wall may reflect liver pathology rather than acute cholecystitis given no definitive gallbladder wall edema or adjacent fat stranding. nonetheless recommend us for further characterization. 2. left renal cysts are incompletely characterized. these can be evaluated concurrently with gallbladder 3. left lower lobe septal thickening and proximal nodularity are consistent with focal edema and an inflammatory/infectious process. 3. moderate fecal loading. 4. enlarged prostate. 5. anemia . # 2:17 pm liver or gallbladder us (singl; duplex dopp abd/pel) comparison is made to prior ct examination dated . the echotexture of the liver is unremarkable except for a 1.1-cm slightly hyperechoic lesion in segment viii of the liver. a similarly hyperechoic region is seen more medially in segment viii. this measures 1.3 cm. these areas do not demonstrate color flow consistent with hemangiomas. there is gallbladder wall edema; however, the gallbladder is not distended. there are no stones in the gallbladder. no pericholecystic fluid is noted. the gallbladder wall edema causes wall thickening up to 6.5 mm. on color flow and doppler images, there is normal flow in the main portal vein. adequate flow is also identified in the left portal vein. there is normal flow visualized in the hepatic veins, although it was difficult to obtain waveforms as the patient was unable to hold his breath for a sufficiently long period of time. impression: 1. portal vein and its branches as well as hepatic veins are patent. 2. gallbladder wall edema, the presence of a non-distended gallbladder most consistent with hypoalbuminemia or liver disease. 3. too small hyperechoic lesions in the liver are most consistent with hemangiomas. . # 4:08 am chest (portable ap) cardiomediastinal contours are unchanged. lungs are grossly clear except for a patchy area of opacity in the left retrocardiac region, which has slightly improved when compared to an earlier radiograph of 15th at 5:43 a.m. this is most likely atelectasis and less likely an infectious pneumonia. . # 11:15 am chest (portable ap): new poorly well-defined round opacities and right mid and left lower lung, concerning for infection such as septic emboli or fungal organisms. consider chest ct for confirmation and further characterization. . # ct chest w/o contrast: there has been partial resolution of the diffuse ground-glass opacities since the previous ct with residual well-demarcated ground-glass opacities which are predominantly in the right upper lobe (2.27) and the right lung base, to a lesser extent. the appearances of these abnormalities are similar to the previous ct with no newly affected areas. pleural surfaces are smooth with no pleural effusion. linear atelectasis is new and mild in the lower lobes bilaterally with thickening of the left major fissure due to mild atelectasis. several lung cysts which were accentuated by the ground-glass opacities in the prior study are now separate to the lung abnormality; these may represent sequelae of previous hemorrhage, i.e. prior hematoceles. paraseptal emphysema is mild. the pulmonary artery is enlarged at 37 mm, slightly larger than on the previous study suggesting pulmonary arterial hypertension. the caliber of the aorta and heart size is normal,no pericardial effusion. relative hypodensity in the cardiac in comparison to the myocardium suggests anemia. although this examination was not designed for subdiaphragmatic evaluation. review of the upper abdominal organs is unremarkable. punctate calcification in the liver and spleen in addition to several calcified mediastinal lymph nodes suggest prior granulomatous exposure. no destructive or sclerotic bone lesions are concerning for malignancy. impression: 1)partial resolution of the diffuse ground-glass opacities which are predominantly in the right upper lobe and right lower lobe to a lesser extent. these abnormalities appear to have cleared over several intervening chest radiographs and suggest recurrent pulmonary hemorrhage, particularly given the coexistent thrombocytopenia, other causes such as infection (pcp) are less likely. 2)liver, splenic and mediastinal lymph node calcifications suggest prior granulomatous exposure. . # ct head w/o contrast: there is no intracranial hemorrhage, edema, mass effect, or other ct sign of acute major vascular territorial infarction. the ventricles and sulci are normal in size and configuration. there are fluid levels within the left maxillary, right frontal and bilateral sphenoid sinuses, as well as complete opacification of left frontal sinus. aeration of the ethmoid air cells has improved since the prior study. wall thickening in the sphenoid and possibly also frontal sinuses suggests chronic sinusitis. high-density material within the paranasal sinuses suggests inspissated secretions, hemorrhagic secretions, or fungal colonization. it is not clear whether there are postsurgical changes in the incompletely evaluated nasal cavity. impression: 1. no intracranial hemorrhage or evidence of other acute intracranial abnormalities. 2. chronic sinusitis. fluid in the paranasal sinuses may indicate the presence of an acute component. high density contents within the sinuses may reflect inspissated secretions, hemorrhagic secretions, or fungal colonization. labs results on 2 days prior to discharge: 10:22a na 132 k4.9 cl100 cl 100 bun 35 k 4.9 hco3 100 creat 1 ca: 7.9 mg: 1.8 p: 3.0 cwbc 7.8 hct 27.6 plts 60 cyclspr: 70 alt: 245 ap: 466 tbili: 5.3 alb: 2.7 ast: 50 brief hospital course: # hlh: clinical scenario consistent with hlh. pt was admitted with severe anemia and thrombocytopenia. he has had 4 days of atg, which was stopped early due to neutropenia - he later received the 5th dose when neutropenia resolved. pt was also placed on high dose iv steriods, initially solumedrol 120mg that were ultimately tapered to prednisone 40mg by beginning of . only possible cause of hlh that could be identified was ? of cmv infection with two different viral load tests showing positive viral load. pt ended up getting two bone marrow biopsies ( and ) which both showed evidence of some hemophagycytosis. the liver biopsy on showed no evidence of malignancy, necrosis, or infections. the pathology present was predominantly cholestatic and most consistent with drug induced changes. pt was held off other chemotherapeutic regimens for the first 6 weeks of the hospitalization because of his combined renal failure and liver cholestasis. once pt recovered renal function and was declared by nephrology to no longer required hemodialysis, he was started on low dose cyclosporine 50 mg on the evening of . initial trough value was very low (<30) two days later. his cyclosporine was gradually increased in dose with the most recent dose being 175mg po bid. cyclosporine goal trough is 150-200 and should next be checked on and should be checked every 48 hrs. lab results should be faxed every 48 hrs as soon as test results come back to dr. and to dr. . along with these you can fax cbc and chem 10 pls obtain as detailed on order sheet. pt started on standing magnesium given cyclosporine results in magnesium wasting. pt is also on predisone 40mg . throughout admission pt continued to show evidence of red cell and plt destruction on laboratory data (hgb/plts would drift down, haptoglobin low, retics high). initially numerous prbc and platelet transfusions were needed to stabilize pt while in the icu. once he recovered enough to be on the floor, pt was intermittently given prbcs when his hct was low enough that there was concern for it causing symptoms. he only received plts on the floor one time per ir before they pulled out the hd catheter. he was followed closely by hematology while in the hospital who recommend the following treatment for his hlh: unfortunately with hlh the patient's prognosis over the next year is very poor. # sepsis/dic: mr. presented with hypotension, elevated wbc, elevated lactate, decreased haptoglobin, elevated pt/ptt, and elevated fibrinogen. no clear infectious source, possible liver or lung. upon presentation pt was treated empirically with meropenem, levofloxacin from hap with gn coverage since pt had been hospitalized and was on immunosuppression. he ultimately completed a 14 day course of meropenem. culture data was ultimately all negative with the only positive micro test being a low cmv vl. id started pt on gancyclovir for ppx, and initial acyclovir was stopped. pt then suffered from neutropenia thought possible related to gancyclovir vs atg. repeat cmv vls were negative and gancyclovir was stopped. histo was negative so also okay to stop ambisome. pt had been on bactrim as an outpatient for pcp prophylaxis while on steroids, but this was changed to atovaquone due patients liver injury and concerns for bactrim involvement. later in hospital course, pt was restarted on acyclovir for prophylaxis while on the steroids. repeat cmv vl from was positive for 1,630 copies and he was restarted on valganciclovir 900 mg po bid with a plan for 3 weeks of treatment total after discharge. his cbc will need to be monitored daily to look for neutropenia, but has remained stable after 4 days of treatment. # respiratory failure: electively intubated on and extubated on . post extubation maintained oxygen sats on nasal cannula and then on room air. throughout admission pt continued to have cough, occasionally productive, and somewhat congested chest, but no evidence of infection was found and pt was not treated with abx for pna after initial presentation. pt has hx of asthma and was previously on advair. so neb tx and advair were given throughout hospitalization. pt had ct of chest for f/u of new poorly well-defined round opacities and right mid and left lower lung, concerning for infection such as septic emboli or fungal. ct scans shows areas of opacity overall improving when compared to prior image in . as per above, id added atovaquone for pcp given that bactrim can cause bm suppression and liver damage. # atrial fibrillation (afib): pt developed a-fib on which then resolved on . this was likely related infection and respiratory distress. he was started on metoprolol 25mg , he converted to sinus. currently nsr. metoprolol 25mg po bid was continued throughout admission although pt did not have any more incidences of documented afib while on hospital. # elevated lfts: uncertain about etiology initially, but after liver bx results were final the leading likelyhood is cholestatic drug induced liver injury to bactrim. overall improvement in lft??????s, but t.bili was significantly elevated (38 at one point). tbili slowly came down over course of the next month although alt and alk phos remained stably somewhat elevated. the lft improvement that was noted initially dis seem to correlate with atg treatment. # anemia: hemolyzing. schistocytes previously seen on smear. hemophagocytosis seen in bm. pt was intermittently transfused as noted above when hct would get around 21 or when there was concern that pt was getting symptomatic from his anemia. epogen was given with hd while pt was on dialysis. once dialysis was discontinued, it was given mwf (4k units). as pt clinically stabilized, he was kept in the hospital by the concern that he continued to show evidence of red cell destruction. # thrombocytopenia: pt required plt transfusions in the icu as initially his plts were low and somewhat labile. he was also transfused for liver biopsy. once the patient was stable enough for the floor his plts ranged from 20k-80k. on the floor he was transfused plts once when ir took out the hd cath, but otherwise his transfusion parameter was set at spontaneous bleeding. the exact etiology of the low plts was never completely clear but it is likely multifactorial and related to hlh, medications, and overall health. # neutropenia: pt became neutropnic after 4 doses of atg and 2 doses of gancyclovir which may have caused bm suppression. counts quickly resolving after stopping offending meds. once count improved pt was given last dose of atg. gancyclovir was kept off until when a repeat cmv viral load was again suddenly positive. low dose gancyclovir was restarted and wbc counts should be monitored daily. pt was then swtiched to galvancyclovir as per id and his wbc have been monitored and have been stable. will monitor his wbc while in rehab to watch for recurrence of the neutropenia # coagulopathy: related to liver disease, infection, hlh. pt did not need ffp. pt was given vit k x 3 days early in admission. inr was stable around 1 for most of admission. # renal failure: received cvvhx 3 days. this was stopped on . he then had microfiltration on the same day to help with diureses for extubation. he was started on hd . stayed on hd until with slow improvement of kidney function. after hd was stopped, cr was observed for a few days and when it continued to show improvement down below 2, and pt continued to make very good urine output, his hd line was pulled by ir on . renal followed throughout course of disease and helped manage electrolytes and guide hd therapy. #hyponatremia: mr. developed hyponatremia on when he was autodiuresis after his kidney recovered from his arf. his hyponatremia and autodiuresis is likely also related to poor glc control. he made up to 6.5l of urine 3 days prior to discharge. please fluid restrict to 2.5l daily as his sodium improved with free water fluid restriction. # hypertension: pt had elevated bp that was worse with atg infusion. he initially required nitro drip for better bp control. this was discontinued quickly once control was achieved and he was restarted on his home dose of amlodipine 7.5mg which was then increased dose to 10mg qday. hd also helped with bp control. some additional control was provided by the metoprolol on which the patient was kept to control afib. #hyperglycemia: pt not a diabetic, but glucose was elevated in the setting of high dose steroids and tube feeds. managed with nph of varying am and pm doses with humalog iss. once tube feeds were stopped and oral intake restarted he again had to adjust nph and iss to keep sugars in an acceptable range. he is being discharged on nph and an iss. # delerium: after patient was transferred to the floor from the icu he developed delirium over the first weekend which manifested as inappropriate and sometimes violent actions with pt attempting to hit staff and spitting on staff. pt had to be restrained with leather restraints for parts of two days because he was able to break out of the soft restraints despite his deconditioning. the first night this occurred pt had to be given haloperidol and ativan. psych was then involved in care and recommended giving quitiapene qhs with extra prn doses as needed. pt was on this regimen, with slow tapering of the qhs dose for the next two weeks, although delirium never again was an issue. pt was intermittently mildly depressed about his body weakness and how long he had been in the hospital. . # lung nodule: new poorly well-defined round opacities and right mid and left lower lung, concerning for infection such as septic emboli or fungal organisms. chest ct showed areas of opacity overall improving when compared to prior image in (when he was previously admitted for what was thought to be ttp). this was thought to be related to prior pulmonary hemorrhage that is now resolving. nodule will need follow-up as an outpatient after discharge. # ha: early in admission, pt c/o bilateral frontal ha with no focal neurological deficits found on exam, however this was a new finding and given low platelet count this was concerning for head bleed. head ct showed no ic bleeding or other acute process. ha resolved over next few days and was not an issue for the rest of admission. # chest pain: pt had two episodes of epigastric pain which raised concerns for chest pain. at each time ekgs were unremarkable and cardiac enzymes did not show evidence of acute mi (although troponin was stably elevated in context of renal failure). pt described pain as not unlike the gerd pain he occasionally had in the past, and both times pain seemed to resolve with a gi cocktail. # insomnia: he had difficulty with sleeping during his hospital course and was started on trazodone qhs with good effect. medications on admission: 1. pantoprazole 40 mg po once a day. 2. zyprexa 5 mg po at bedtime: while on steroids. 3. fexofenadine 60 mg po bid 4. sulfamethoxazole-trimethoprim 800-160 mg one tablet po mwf 5. montelukast 10 mg po daily 6. prednisone 50 mg po daily 7. fluticasone-salmeterol 500-50 8. b complex-vitamin c-folic acid 1 mg capsule 9. calcium acetate 667 mg capsule sig: two (2) capsule po tid w/meals 10. amlodipine 7.5 mg po daily 11. docusate sodium 100 mg po bid 12. polyethylene glycol as needed for constipation. discharge medications: 1. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 2. folic acid 1 mg tablet sig: five (5) tablet po daily (daily). 3. morphine 15 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain: hold for sedation or rr<12. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation every four (4) hours as needed for wheeze. 5. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily): hold for sbp<110. 6. atovaquone 750 mg/5 ml suspension sig: two (2) servings (total 1500mg) po daily (daily). 7. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 8. tramadol 50 mg tablet sig: 0.5 tablet po q6h (every 6 hours) as needed for moderate pain. 9. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours) as needed for gerd symptoms. 10. labs and heme follow up most recent dose being 175mg po bid. cyclosporine goal trough is 150-200 and should next be checked on and should be checked every 48 hrs. check 1/2 hr prior to am dose but give am dose after. lab results including cbc and chem 10 should be faxed every 48 hrs as soon as test results come back to dr. and to dr. . 11. follow up needs transportation arranged for appointment at with dr. on at 1:15pm needs transportation arranged for appointment with dr. / at on at 2:30pm needs transportation arranged for infectious disease appointment at on 12. cmv viral load plase check cmv viral viral load each thursday, pls check cbc three x a week and chem 7 every other day for the next week and then once weekly. pls fax cmv viral load and three x a week cbc and once a week to infectious disease at or her rns at ( all questions regarding outpatient antibiotics should be directed to the infectious disease r.ns. at ( 13. cyclosporine modified 25 mg capsule sig: three (3) capsule po q12h (every 12 hours). 14. cyclosporine modified 100 mg capsule sig: one (1) capsule po q12h (every 12 hours). 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day): hold loose stool. 16. epoetin alfa 4,000 unit/ml solution sig: one (1) dose injection qmowefr (monday -wednesday-friday). 17. maalox 15ml po tid prn for gerd sx 18. ondansetron 8 mg iv q8h:prn nausea 19. prednisone 20 mg tablet sig: two (2) tablet po bid (2 times a day). 20. insulin pls continue attached insulin ss, am nph increased from 26-28 to start on 21. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 22. quetiapine 25 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for delerium and agitation: has not been needing recently. 23. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical daily (daily) as needed for pruritis. 24. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 25. valganciclovir 450 mg tablet sig: two (2) tablet po bid (2 times a day): last dose expected to be unless told otherwise by infectious disease doctor. 26. magnesium 300 mg capsule sig: one (1) capsule po twice a day: pls increase dosing if magnesium is low. discharge disposition: extended care facility: hospital - discharge diagnosis: primary diagnosis: -hemophagocytic lymphohistiocytosis -acute on chronic renal failure -liver failure due to drug rxn -cytomegalovirus secondary diagnosis: - asthma - allergies - hypercholesterolemia discharge condition: alert and oriented x3 unable to ambulate independently full code discharge instructions: mr. as you know you had a difficult hospital course but we are very pleased that you are well enough now to go to rehab. you originally came in with low blood pressure, bleeding, renal failure, liver failure, and hemolysis (destruction of your red blood cells and platelets. you required intubation in the intensive care unit and transfusions of blood and platelets. your liver biopsy ultimately showed your liver problems were due to a drug reaction, likely bactrim so you were changed from bactrim to atovaquone. your liver has been slowly recovering. your kidney function has improved and you no longer require hemodialysis. you are urinating a lot as a result of your improved renal function which caused your sodium levels to decrease. this improved with getting iv fluids. you had 2 bone marrow biopsies that ultimately diagnosed hemophagocytic lymphohistiocytosis which as you know is a very serious disease. you were originally treated with atg and steroids but later switched to cyclosporine. our hematologists will give your rehab advice on how to continue treatment with cyclosporine. you are also going to on monday for a second opinion which we encourage you to do. you have this appointment on . you currently have an infection called cmv which is being treated with valgancyclovir which you will continue atleast until . please take only those medications found on the attached list followup instructions: please let mrs. and the inpatient team know that i have arranged for mr. to be seen at by (expert in hlh wrote the uptodate card) on at 1:15, of phone: . *we are working on an appointment for you to be seen in our dermatology department. the office will contact you with an appointment. please call ( if you do not hear from them. department: hematology/oncology when: thursday at 2:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: thursday at 2:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: infectious disease when: thursday at 11:30 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 enteral infusion of concentrated nutritional substances hemodialysis biopsy of bone marrow arterial catheterization incision with removal of foreign body or device from skin and subcutaneous tissue transjugular liver biopsy diagnoses: pneumonia, organism unspecified acidosis hyperpotassemia thrombocytopenia, unspecified anemia in chronic kidney disease anemia of other chronic disease renal dialysis status esophageal reflux pure hypercholesterolemia adrenal cortical steroids causing adverse effects in therapeutic use acute and subacute necrosis of liver acute kidney failure, unspecified hyposmolality and/or hyponatremia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation asthma, unspecified type, unspecified chronic kidney disease, unspecified constipation, unspecified acute respiratory failure antiviral drugs causing adverse effects in therapeutic use disorders of phosphorus metabolism other diseases of lung, not elsewhere classified headache drug induced neutropenia other and unspecified coagulation defects cytomegaloviral disease delirium due to conditions classified elsewhere acute pancreatitis insomnia, unspecified sulfonamides causing adverse effects in therapeutic use polyuria suicidal ideation secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified hemophagocytic syndromes 

Answer: The patient is high likely exposed to