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: no known allergies / adverse drug reactions attending: chief complaint: "altered mental status." major surgical or invasive procedure: lumbar puncture gastric tube placement history of present illness: mr. is a 52 y/o male with bipolar d/o well controlled on lithium who presented to hospital following 3 days of fever, cough and nausea. noted to have ams, garbled speech and was ataxic. denied toxic ingestions, substances of abuse. complained of diarrhea over 1 week. labs notable for acute renal failure, hyponatremia (126), metabolic acidosis and plt count of 40. a head ct was negative, cxr revealed a possible lll pna, and ct abd/pelvis was remarable for perinephric stranding and a thickened gb wall. lithium level was wnl. transferred to for further management. . on arrival to the ed here, the patient's vitals were 98.1 98 105/72 20 94% ra. an ecg showed nsr. laboratory studies were remarkable for hyponatermia, arf, wbc 2.9 with 18% bands, plt count of 40. a lumbar puncture was done with ptn 31 and glucose 74 (serum glucose 116). tox screen (-). the patient was given 2g ceftriaxone, 1g vanco, 500mg azithro for ? pneumonia, coverage for meningitis/encephalitis. no acyclovir given csf results. while in the ed, the patient spiked a fever to 101.1f. pressure droped to 85 systolic, 105-115's after 2l ivf in our ed, getting a 3rd on transfer. bp currently 91/55. had profuse, watery, greenish, profuse, guaiac positive diarrhea. sent for cdiff and culture. given concern for ttp, a smear was reviewed that showed bandemia but no schistocytes or other evidence of ttp/hus. concern for sepsis and admitted to the icu. . on arrival to the icu the patient's vitals were 97.9 90 96/76 16 95%. described some back pain but not other complaints at this time past medical history: bipolar disorder -new this admission nephrogenic diabetes insipitus to lithium persistent dysphagia and dysarthria to delayed lithium toxicity and ? cerebellar syndrome social history: lives alone and is independent. works part-time at stop & shop. brother is his gaurdian. smokes 1.5ppd. no etoh or other drug use. recieves most medical care at the va. family history: nc physical exam: admission vitals - 97.9 90 96/76 16 95% general - lying in bed in nad heent - perrla, anicteric, mm dry, op clear neck - supple, no jvd cv - tachycardic, s1 and s2 no m/r/g lung - decreased breath sounds with mild rhonci in lll. otherwise good air entry b/l abdomen - soft, nt/nd, bsx4, no organomegally ext- no gross deformity or edema. bunions on feet. dry skin. neuro - awake and alert. oriented x3. slurred speech. no focal neuro deficits. moving all extremities. discharge 99.6 109/75 86 18 96 ra i/o24-6135/4000 pain: none gen: aaox3 in nad heent: cn 2-12 grossly intact, mm dry, edentulous but wearing dentures neck: no lad cv: rrr, no rmg resp: ctab, no wrr abd: abdomen flat, active bs, no ttp, no hsm, g tube in place in epigastrum, cdi and non tender extr: wwp, 5/5 strength, sensation, pulses intact and equal derm: no obvious rashes neuro: cn intact, strength, sensation wnl, speech somewhat garbled but able to understand psych: mood and affect wnl pertinent results: radiology ct abdomen at osh from lung bases: the imaged lung bases are clear aside from mild dependent atelectasis. abdomen: the non-contrast appearance of the liver, spleen, gallbladder, pancreas, and both adrenal glands is normal. there is no hydronephrosis or kidney stones. bilateral perinephric stranding is nonspecific. the abdominal aorta is normal in course and caliber. no retroperitoneal or mesenteric lymphadenopathy is seen. no free air or free fluid is seen. the stomach and duodenum appear normal. pelvis: loops of small bowel demonstrate no signs of ileus or obstruction. the appendix is normal. there is no apparent thickening of the colon and no signs of diverticulosis. no free pelvic fluid. urinary bladder is distended appearing normal. no inguinal or pelvic lymphadenopathy. bones: no worrisome bony lesions are seen. impression: 1. nonspecific perinephric stranding. please correlate for possible infection. 2. no signs of colitis or bowel obstruction. ct head there is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. -white matter differentiation is preserved. ventricles are normal in size and configuration. imaged paranasal sinuses are clear. mastoid air cells are opacified on the left. left middle ear cavity, right middle ear cavity and right mastoid air cells are well aerated. the bony calvarium is intact. minimal mucosal thickening is noted along the paranasal sinuses. impression: opacification of the left mastoid air cells. no evidence of acute infarction or hemorrhage. consider mri to further assess as needed. cxr a small right subhilar region of heterogeneous opacity obscures the hemidiaphragmatic contour. dilation of the azygos vein and left atrium, in addition to mild pulmonary vascular congestion, is new. the lungs are otherwise clear. there is no pneumothorax or pleural effusion. impression: 1. persistent subhilar right lower lobe pneumonia. 2. elevated venous pressure consistent with hypervolemia. mr head w/o contrast study date of impression: 1. no obvious focus of slow diffusion to suggest an acute infarct. 2. increased signal intensity in the mastoid air cells, from fluid/mucosal thickening, left more than right. 3. nonspecific flair hyperintense foci in the cerebral white matter- etiology uncertain. followup can be considered as no prior studies are available with post-contrast images if necessary after clinical and lab correlation. chest (pa & lat) study date of impression: resolved right subhilar lower lobe pneumonia. video oropharyngeal swallow study date of video oropharyngeal swallow: video oropharyngeal swallow study was performed in conjunction with the speech and swallow team. multiple consistencies of barium were administered. there is aspiration with thin liquids. there is aspiration with nectar-thickened liquids, but somewhat less than with the thin liquids. there is a swallow delay and residuals within the vallecula. impression: aspiration with thin and nectar-thickened liquids. for complete report, please see speech and swallow note in omr. admission labs 04:30pm blood wbc-2.9* rbc-4.28* hgb-12.6* hct-37.1* mcv-87 mch-29.5 mchc-34.1 rdw-12.9 plt ct-40* 04:30pm blood neuts-65 bands-18* lymphs-8* monos-9 eos-0 baso-0 atyps-0 metas-0 myelos-0 04:30pm blood hypochr-normal anisocy-occasional poiklo-normal macrocy-normal microcy-normal polychr-normal 04:30pm blood glucose-116* urean-42* creat-2.4* na-131* k-3.7 cl-102 hco3-16* angap-17 04:30pm blood alt-32 ast-63* ld(ldh)-348* alkphos-56 totbili-0.3 04:30pm blood albumin-3.2* uricacd-11.2* 05:20am blood calcium-8.1* phos-2.5* mg-2.5 04:30pm blood hapto-374* 04:30pm blood asa-5.0 ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 04:49pm blood glucose-109* lactate-0.8 na-133 k-3.8 cl-106 calhco3-17* brief hospital course: mr. is a 52 y/o m with biploar presenting with sepsis, pancytopenia, , pna, diarrhea, ams. also has nephrogenic di lithium toxicity. cxr suggestive of pna. anaplasma pcr also positive. anaplasma likely major cause of his presentation. . ## anaplasmosis: mr. was found to have positive pcr for anaplasma at hospital, which was complicated by skin rash characterized by classic target lesions on his arms, leukopenia, and thrombocytopenia. given that he was septic on initial presentation with altered mental status, fever, tachycardia, and leukocytosis, he was admitted to the icu and treated initially with broad-spectrum antibiotics due to concern for pneumonia, which were later discontinued once he was confirmed to have anaplasmosis. he also had a lumbar puncture, which was unremarkable. he improved with doxycycline and was subsequently transferred out of the icu. he completed a 10-day course of doxycycline ending on . lyme and babesia studies were also negative. acute anaplasma serologies were negative and id felt there would be limited utility to repeat them. a repeat lyme serology was also checked and this was negative. . ## nephrogenic diabetes insipidus: patient has nephrogenic diabetes insipidus due to lithium use. he was interestingly hyponatremic on presentation, but this was likely due to diarrhea and hypovolemia with inadequate solute intake. when his access to free water was restricted, he maintained substantial urine output and quickly developed hypernatremia, which required d5w to correct. nephrology guided management with normalization of his sodium once he was able to match his urine output with oral water intake. his lithium has therefore been discontinued. on discharge his sodium was 145 and the patient is on free water flushes at 450 q2hours through his feeding pump. the patients 24 hour urine output has been around 4 l for several days. the patient should follow up with renal the first week of . ## acute on chronic renal failure: baseline cr is 1.4, but his admission cr was 2.4, which is likely due to lithium toxicity, as well as his acute anaplasma infection and resulting hypovolemia in the setting of sepsis with pre-renal injury. as stated above, his lithium has been held due to likely diabetes insipidus and possible cerebellar degeneration (see below). new baseline appears to be between 2.2 and 2.4 and on the day of discharge his creatinine was 2.4. ## thrombocytopenia, leukopenia: these were thought to be due to anaplasmosis and resolved with treatment ## dysarthria: developed new dysarthria during this admission, which persistent after his infection was treated and his sodium normalized. neurology was consulted and recommended mri of the brain to out a stroke. this was done and was negative for a stroke. neurology reviewed this and felt there was evidence of cerebellar degeneration. he has normal speech at baseline per family report. pt and speech therapy were also consulted. neurology did not feel that his mri indicated any specific pathological process. neurology nad psychiatry both felt that the dysarthria is probably due to lithium toxicity and resultant cerebellar degeneration and may take a long time (months to years) to resolve, if at all. although early disseminated lyme disease (with cns involvement) and a demyelinating process were considered, these were felt to be very unlikely per neurology given negative initial lyme serologies, and normal csf on lp, and an examination inconsistent with these syndromes. repeat lyme serologies (convalescent serologies) were ordered given that he may have been co-infected with lyme diesease with negative initial serologies, 21 days after the initial assay and was negative. ## bipolar disorder: lithium has been held due to its toxicity. he will continue on prolixin for now. psychiatry recommended continued followup with outpatient psychiatry providers, but no need to acutely start another mood stabilizer because he was calm and not manic during the hospitalization. seroquel was added to his guardianship documentation. cogentin was also added during this hospitalization. #generalized/weakness and ataxia: able to walk independently and work in grocery at baseline, but here he was somewhat unsteady and used a walker to ambulate. pt recommended that he was supervision level. his family was unable to provide 24/7 care so the patient was referred for placement at a . ##dysphagia: the patient also developed trouble eating while in house and speech and swallow evalauted the patient. they found that he was aspirating and unsafe to eat or drink. after discussion with his guardian and brother , as well as with him, elected to place a g tube. this was performed by interventional radiology on . the patient has been on isosource 1.5 at 55 cc/hr continous. this will likely be easier while the patient is requring free water flushes at 450 q2hours. if this requirement changes tf can be cycled or bolused. bolus recomendations are 2 cans of isosource tid via g-tube. cycle feeding recomendations are start at a rate of 50 ml/hr and increase rate by 20 ml/h to goal of isosource 1.5 at 110 ml/h for 12 hours (1800-0600). . transitional issues: -f/u with neurology clinic ( at , after discharge from the cooledge house) -f/u with outpatient psychiatry (your usual provider) -f/u with speech language pathology for repeat swallowing evaluation in weeks weeks the cooledge house medications on admission: lithium, dosage unknown fluphenazine 10mg po qhs discharge medications: 1. fluphenazine hcl 10 mg tablet sig: one (1) tablet po hs (at bedtime). 2. nystatin 100,000 unit/g cream sig: one (1) appl topical (2 times a day) as needed for fungal rash. 3. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day). 4. benztropine 1 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* discharge disposition: extended care facility: discharge diagnosis: anaplasmosis infection with sepsis and cytopenias nephrogenic diabetes insipidus due to lithium use with resultant hypernatremia dysarthria, dysphagia, and ataxia deconditioning acute on chronic renal failure discharge condition: mental status: clear and coherent, but dysarthric, so difficult to understand level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker) and stand-by to contact-guard assistance discharge instructions: you were admitted to the intensive care unit for treatment of an infection called anaplasmosis, which is a bacterial infection transmitted by a tick bite. you improved with appropriate antibiotic therapy. your lithium was stopped because it was harming your kidneys and possibly may have led to degeneration of the cerebellum (part of the brain that controls speech, movement coordination, and is involved in swallowing coordination. however, you still had trouble with your speech, so you had an mri, which did not indicate any specific problems with the exception of possibly some cerebellar atrophy per our neurology colleagues who evaluated you here in the hospital. you will need to continue to work on getting your speech back to normal which may take a while (months or years). you are advised to use a walker to ambulate. you were also found to have difficulty swallowing to the extent that you cannot eat or drink safely as we discussed. given this, we elected in discussion with you and and to place a gastric feeding tube (gtube) to protect you from aspirating large amounts of food or drink into your lung which could cause pneumonia and or respiratory failure. you will be sent to a rehabilitation facility on tube feeds and free water flushes. these should be continued until you follow up with renal physicians. you also need to be evaluated by speech and swallow in 2 weeks to see if you are safe to take things by mouth. medication changes: - stop taking lithium take all other medications as prescribed (see below) followup instructions: f/u with neurology clinic ( at , after discharge from the cooledge house) f/u with outpatient psychiatry (your usual provider) f/u with speech language pathology for repeat swallowing evaluation in weeks weeks the cooledge house procedure: spinal tap incision of lung enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] diagnoses: pneumonia, organism unspecified acidosis tobacco use disorder toxic encephalopathy acute kidney failure, unspecified hyposmolality and/or hyponatremia severe sepsis candidiasis of mouth chronic kidney disease, stage iii (moderate) other specified septicemias diarrhea dysarthria hypovolemia hyperosmolality and/or hypernatremia bipolar disorder, unspecified nephrogenic diabetes insipidus other psychotropic agents causing adverse effects in therapeutic use lack of coordination schizophrenic disorders, residual type, chronic essential and other specified forms of tremor dysphagia, unspecified polydipsia other pancytopenia other ehrlichiosis primary cerebellar degeneration 

Answer: The patient is high likely exposed to