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: nafcillin / penicillins attending: chief complaint: weakness, paresthesias major surgical or invasive procedure: lumbar puncture picc line placement sural nerve biopsy history of present illness: per admitting resident: 57 rhf w/ hx mmp inlcuding morbid obesity, dm, htn, oa, chronic pain, multiple skin infections and uti's, admitted twice over the past ~month to hosp. the first admission was for progressive weakness and parasthesiae initially only in the le with preserved ue strength and reflexes. she received mri of the c- and t-spine, initially without gad, and then later with, all of which were reportedly unremarkable. both had to be done at hosp to accommodate her girth. she received an lp under fluoro that showed normal cell counts, protein, and glucose. she received an emg, which, although technically difficult, demonstrated preserved f-waves, which was felt to argue against an inflammatory neuropathy. she was diagnosed with a presumptive transverse myelitis and was treated with 3 days iv soumedrol (1 g per day), w/ perhaps mild improvement in sensation, but no change in strength. she was discharged to rehab , but returned with fever to 104 f and altered mental status. lp was re-attempted but failed. ua was suggestive of uti, and she was treated with kefzol, nystatin, and macrobid. blood cx's have been neg to date. mental status returned to after she defeveresced, but when neurology was asked to re-examine her, it seemed that her weakness had progressed and involved her ue as well, and was described as a flaccid quadraplegia. she was given a repeat trial of iv solumedrol 1 g per day x 3 days without effect. on ros, she denied any ha or vc. she denied any gi or respiratory illness or any recent vaccines in the weeks to months prior to the onset of this weakness. she does endorse hoarseness of her voice which she feels has been present for about 10 days. past medical history: dm htn recurrent cellulitis of the abdomen an incarcerated ventral hernia requiring surgery followed by a dvt in , s/p ivc filter osteoarthritis of the knee and back with chronic pain chronic fungal infections of her pannus obesity, s/p gastric bypass gerd folate deficiency iron deficiency social history: denies tobacco or drugs. drinks ~3 beers per day on weekends. married, 2 grown kids. family history: denies physical exam: exam at time of admission: t- 97.7f bp- 152/80 hr- 107 rr- 18 o2sat 97% on 2l nc gen: morbidly obese woman, lying in bed, nad heent: nc/at, very dry oral mucosa neck: no tenderness to palpation, normal rom, supple, no carotid or vertebral bruit cv: rrr, nl s1 and s2, no murmurs/gallops/rubs lung: clear to auscultation bilaterally abd: +bs soft, nontender ext: no c/c/e; equal radial and pedal pulses b/l. skin: multiple hematomas thoughout ue b/l and abd. blistering lesions on le b/l with appearance of cellulitis changes on le b/l. neurologic examination: mental status: awake and alert, cooperative with exam, normal affect. oriented to person, place, and date. attentive, says dow backwards. speech is fluent with normal comprehension and repetition; naming intact. no dysarthria. intact. no right left confusion. no evidence of apraxia or neglect. cranial nerves: pupils equally round and reactive to light, 4 to 2 mm bilaterally. retinas with sharp disc margins b/l. visual fields are full to confrontation via moving finger test. extraocular movements intact bilaterally, no nystagmus. sensation intact v1-v3. facial movement symmetric. hearing intact to finger rub bilaterally. palate elevation symmetrical. sternocleidomastoid and trapezius normal bilaterally. tongue midline, movements intact motor: normal bulk bilaterally. tone normal. no observed myoclonus or tremor tri wf we fe ff ip h q df pf te tf r 3 2 2 1 1 1 1 0 0 0 0 0 0 0 l 3 2 2 1 1 1 1 0 0 0 0 0 0 0 in le, there is some subtle flickers of b/l abduction movement, but otherwise no mvmt whatsoever. sensation: decreased to light touch and pinprick throughout with some improvement superiorally (near shoulders and clavicle) without clear sensory level. very poor proprioception thoughout. reflexes: 0 and symmetric throughout. toes mute bilaterally pertinent results: labs on admission: 06:59pm blood wbc-6.0 rbc-3.07*# hgb-11.3* hct-34.1* mcv-111*# mch-36.9*# mchc-33.2 rdw-15.3 plt ct-523*# 06:59pm blood pt-12.4 ptt-22.6 inr(pt)-1.0 06:59pm blood glucose-76 urean-15 creat-0.4 na-136 k-3.9 cl-98 hco3-31 angap-11 06:59pm blood ck(cpk)-39 06:59pm blood ck-mb-notdone ctropnt-<0.01 06:59pm blood calcium-8.4 phos-2.4* mg-2.3 06:59pm blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 09:34am blood type-art temp-37.2 o2 flow-2 po2-88 pco2-43 ph-7.46* caltco2-32* base xs-5 intubat-not intuba urine studies: 06:38pm urine rbc-9* wbc-31* bacteri-mod yeast-many epi-1 transe-<1 06:38pm urine blood-tr nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-lg 06:38pm urine color-yellow appear-hazy sp -1.010 microbiology: ucx; yeast () bcx; 1/6 bottles mrsa. () catheter tip culture neg cdif neg x2 ------ labs during hospital course; esr 9 homocysteine 13 b12 297 folate 10.2 ferritin 342 tsh 6.6, t4 5.5, ft4 1.1 iga 240 hiv ab neg u tox + opiates copper 77 ceruloplasmin 16 (nl range 18-53) methylmalonic acid 518 (nl range 87-318) vitamin k 689 vitamin a 20 (nl range 38-98) vitamin d 1,25 13 (nl range 18-72) vitamin b1 279 (normal) porphyrins < 1 mycoplasma pneumonia igg 3.18, iga 19 anti antibody neg cmv igg +, igm neg pending studies; ace, b6, b1, cv2 ab, heavy metal screen ------- csf chemistry protein 23 glucose 57 source: lp; #1 csf wbc 0 rbc 18 poly 20 lymph 52 mono 28 eos none emg ; limited, markedly abnormal study. there is electrophysiologic evidence for a severe generalized denervating process of at least three weeks in duration. based on the single motor nerve conduction study, there is no clear evidence for primary demyelination, as would be expected in - syndrome. nonetheless, a primary demyelinating process cannot be entirely excluded. there is also no evidence for a presynaptic disorder of neuromuscular transmission. ------- results from outside hospital prior to admission; total prot 5.6 alb 2.8 t bili 1.7 alk phos 228 alt 18 ast 28 ldh 213 dbili 0.7 csf ; glucose 56, prot 16, 0 wbc, 90 rbc rpr neg aldolase 5.7 ace 52 1:40 parvo b19 igg 4.3, igm 0.06 igg serum 968, igg csf 1.3 albumin csf 7 albumin 2.41 alpha-1 0.53 alpha-2 0.79 gamma 1.03 beta 0.74 igg 926 iga 563 igm 71 mri spine; unremarkable brief hospital course: ms. is a 57-year-old right-handed feamle with history of morbid obesity s/p roux-en-y gastric bypass in , dm, htn, oa, chronic pain, multiple skin infections and uti's, admitted twice over the past month to hosp for progressive weakness and parasthesias. her clinical course of progressive weakness, sensory problems and loss of reflexes was clinically most suggestive of a demyelinating polyneuropathy, similar to . her prior negative lp and emg results were completed only 1 week into her symptoms. she was treated for transverse myelitis at osh wigh high dose solumedrol without clinical improvement. on admissiong to , patient was noted to be more tachypneic and her nifs and vcs declined to -30 and 1.0. given this, she was transferred to neuro icu. neuro. her re-examination showed only minimal movements of her fingers and no movements at wrist. she had proprioceptive loss to hip b/l and to elbows in ues, as well as loss of pp to l1 and c4 in les and ues respectively. she underwent a repeat lp which showed normal protein, glucose and no cells. repeat emg showed denervation, without ellicitable f waves due to no motor response. given all of the above, whe most likely had a gbs-type polyneuropathy and was started on ivig x 5 days on . she completed 4 days of ivig but developed fevers prior to infusion on day #5 and this was not completed. she did perhaps have slight improvement following the ivig course. other studies investigating the etiology of her symptoms have been negative including hiv, porphyrins, anti antibody, etc... (please see results section for all studies). a ct torso was also unrevealing for any underlying malignancy or lymphoproliferative process. current pending studies include ace level, b6, b1, cv2 ab, and heavy metal screen as well as vitamin b2, b7, carotene, vitamin c, and vitamin e. (due to a lab error the heavy metal screen was unable to be processed and re-sent ). the patient underwent a sural nerve biposy which revealed widespread denervation and axonal loss but no signs of inflammation. the final pathology report is still pending at the time of discharge. while the clinical course did appear consistent with an acute-demyelinating polyneuropathy, several aspects of her history did not appear consistent with . her second emg was more conistent with an axonal pathology and both csf analyses were unremarkable, and she had no proceeding illness able to be identified. given her history of a roux-en-y gastric bypass in , it was considered that her presentation may be a manifestation of a nutritional deficiency complicated by this procedure. her b12 level was 297, methylamlonic acid was elevated, vitamin a and vitamin d levels were low. she was started on multivitamins, thiamine, b12, folic acid, and vitamin a and vitamin d supplements. several cases of a similar polyneuropathy years after a gastric bypass procedure have been reported in the literatuere which is thought to mimic gbs clinically. this is usually not identified with any specific nutritional deficiencies. case reports have not shown conclusive improvement from nutritional repletion. it was considered if reversing the patient's gastric bypass could be considered and this was discussed with dr. (bariatric surgery) who did not believe she was a surgical candidate and did not believe reversal of the bypass would result in clinical improvement. further courses of ivig and/or plasmapheresis were also discussed. as she did not show much improvement from the first course of ivig and there was no evidence of an autoimmune process, it was thought that the risks of further treatments would outweight the benefits. the patient also reported painful paresthesias intermittently throughout the hospital course. her neurontin was titrated up and was continued on cymbalta for treatment of her neuropathic pain. she was also admitted on amitryptiline which was weaned off due to concern it may have been contributing to sedation and trileptal was also weaned off during the hospital course. ultram was added as needed for breakthrough pain which has been effective. at the time of discharge the patient had shown moderate improvement. her facial weakness is only moderate and she is less hypophonic. her strength has improved, with what appears to be 4-/5 triceps, biceps, wrist extension, finger extension and flexion bilaterally. iliopsoas is , hip abductors and adductors are , hamstrings and quads are , dorsiflexors 0/5, plantarflexors . pulm. abg on admission showed metabolic alkalosis. patient had multiple nifs and vc checked which were concerning for respiratory muscle weakness. her vc were consistently 800cc-1000cc early in the hospital course, promting several transfers to the icu. it was thought these values may have been effort-dependent and also limited by her facial muscle weakness. her nifs and vc remained poor however without showing other evidence of respiratory compromise. she never required intubation. she was however started on bipap at night for sleep apnea and was tolerating this well. cv. no active issues. she was treated with lasix for her edema. antihypertensive regimen (lisinopril) was held due to intermittent hypotension and autonomic nervous system instability, presumably due to her polyneuropathy. her blood pressure, pulse, and fluid balance have been stable for several days at the time of discharge. id. the patient spiked a temperature of 102 prior to day #5 of ivig treatment. she ultimately grew out 1 of 6 bottles positive for mrsa and was treated with a seven-day course of vancomycin. no obvious infectious source was identified (including catheter tip from picc line which was subsequently removed). f/e/n. the patient was started on continuous tube feeds and also supplemented with multivitamins, thiamine, folate, vitamin a, vitamin d, and b12. she was cleared for a nectar-thick liquid and pureed diet. she was not taking in adeuqate po intake and therefore continuous feeds were changed to cycled feeds at night from 6 pm to 6 am in hopes of improving appetite during the day. it is hoped that she will be able to transition to po intake over the next two weeks. medications on admission: (at time of transfer) tylenol 650 mg q4hrs prn pain, fever mom 30 ml qday lisinopril 2.5 mg qday lasix 20 mg morphine 1 mg iv prn pain percocet 1 tab q6hrs prn pain miralax 17 g qhs prn constipation amytriptyline 50 mg qhs gabapentin 600 mg qhs fentanyl 100 mcg patch q72hrs cymbalta 60 mg qday trileptal 300 mg colace 100 mg protonix 40 mg qday discharge medications: 1. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 2. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 3. therapeutic multivitamin liquid sig: one (1) tablet po daily (daily). 4. famotidine 20 mg tablet sig: one (1) tablet po q12h (every 12 hours). 5. papain powder sig: one (1) ml miscellaneous mrx1 () as needed for ngt clogging. 6. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 7. vitamin a 10,000 unit capsule sig: five (5) capsule po daily (daily). 8. acetaminophen 160 mg/5 ml solution sig: twenty (20) ml po q6h (every 6 hours) as needed for pain. 9. miconazole nitrate 2 % powder sig: one (1) appl topical tid (3 times a day) as needed for fungal infection. 10. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po 1x/week (tu). 11. tramadol 50 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain. 12. gabapentin 250 mg/5 ml solution sig: twenty (20) ml po q8h (every 8 hours). 13. thiamine hcl 100 mg/ml solution sig: one (1) ml injection daily (daily) for 7 days. 14. cyanocobalamin 1,000 mcg/ml solution sig: one (1) ml injection once a month. discharge disposition: extended care facility: - discharge diagnosis: subacute motor and sensory polyneuropathy, possibly secondary to nutritional deficiency and/or prior gastric bypass surgery discharge condition: awake, alert, follows commands. mild bifacial weakness. 4-/5 strength in triceps, in biceps, in wrist extensors, in finger extensors and flexors. in hip adductors and abductors, in hamstrings, quadriceps, in dorsiflexors, in plantarflexors, bilaterally. sensation decreased to light tough throughout. discharge instructions: patient is to be discharged to rehabilitation facility for further care. please continue your medications as prescribed and continue with physical therapy. followup instructions: please follow up with dr. (pulmonary) in the wednesday am sleep clinic in months. he can be reached at (. please follow up in neurology clinic with dr. and dr. . at appointment has been scheduled for you on at 2:30 pm at building () . please call ( with any questions or concerns. md, procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified spinal tap incision of lung enteral infusion of concentrated nutritional substances arterial catheterization open biopsy of soft tissue open biopsy of cranial or peripheral nerve or ganglion splenotomy injection or infusion of immunoglobulin diagnoses: obstructive sleep apnea (adult)(pediatric) urinary tract infection, site not specified unspecified essential hypertension diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute respiratory failure alkalosis bacteremia morbid obesity pressure ulcer, lower back methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site encephalopathy, unspecified quadriplegia, unspecified bariatric surgery status pressure ulcer, unspecified stage spondylosis of unspecified site, without mention of myelopathy polyneuropathy in other diseases classified elsewhere osteoarthrosis, localized, not specified whether primary or secondary, lower leg unspecified nutritional deficiency 

Answer: The patient is high likely exposed to