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: bactrim attending: chief complaint: rising bilirubin major surgical or invasive procedure: none history of present illness: mr. is a 62 year old male with a history of multiple myeloma s/p multiple treatments, including numerous chemotherapy regimens, autologous transplant in , mini-mud allogeneic transplant in , and dli x4, most recently on , presenting from clinic after his bili was found to be increasing. . of note, mr. was recently admitted for dli in , and during that admission was found to have gvhd of the liver on biopsy. he was started on mmf and prednisone and was being managed as an outpatient. however, his numbers continue to rise, and he now appears to have eye and skin involvement. he was recently seen by ophthamology and started on drops for gvhd of the eye. he has, blurry vision in the left eye, grittiness and photosensitivity, but limited pain. his skin feels like "its burning down his legs." . otherwise, he feels well. he denies any nausea, vomiting, diarrhea (one loose stool yesterday), fever, chills, itchiness. his appettite is improving. he denies any pain. he is otherwise asymtpomatic. past medical history: past oncologic history: # : diagnosed with multiple myeloma after admission for arf (creatinine 3.0), anemia, hypercalcemia, bence- proteinuria, multiple lytic lesions, and 20-22% bm involvement. # : vad x4 # : micro fracture of right hip, s/p im rodding r femur # : pulse cytoxan # : cytoxan for stem cell mobilization # : autologous stem cell transplant # : enrolled in dendritic cell fusion vaccine protocol (04-240) after demonstrating progressive disease # : thalidomide max dose 200 mg/day, stopped due to increasing bence protein # : velcade/dexamethasone x2 cycles with disease progression # : cytoxan/dexamethasone # : xrt to left hip and femur # : revlimid/dexamethasone x2 cycles on expanded access and continued on this through (stopped for pancytopenia) # : admitted for allogeneic stem cell transplant (mini-mud) with campath as conditioning regimen. donor = a antigen mismatch. # , : dli c/b gvhd --> disease stability. started revlimid at low dose, then found to have plasmacytoma in frontal bone. # : mri c-spine shows extensive myelomatous infiltration of left lateral mass of c1 with cortical breakthrough; radiation to c-spine, frontal mass; started on velcade, steroids. # : dli (3rd infusion), weekly velcade # : increased velcade to twice weekly # : admitted for , resolved with hydration # : dli (4th infusion) . past medical history: # coronary artery disease - stenting x2 in # dvt - during auto transplant # gerd - decreased in severity recently # hypertension - has been less of an issue - now on amlodipine alone # hypothyroidism # osteoporosis # compression fracture # depression # c diff infection . past surgical history: # rod internal fixation of the right hip - fracture in . # open cholecystectomy social history: social history: he worked as a general contractor prior to his illness. he is married and has two children. tobacco: never smoked. alcohol: drank alcohol socially prior to chemo, none since. drugs: denies illicit drug use. . family history: family history: his mother died of myocardial infarction at age 59. his maternal uncle died of myocardial infarction at age 65. his father is alive at 86 with cad s/p recent cabg and valve surgery. . physical exam: vitals: t: 97.3 bp: 160/80 p: 54 r: 20 o2: 99% ra general: alert, oriented, no acute distress heent: sclera icteric, mmm, oropharynx clear, no mucositis, left eye erythematous, perrl, eomi neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi, few bibasilar crackles cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, palpable liver tip ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ pitting edema bilaterally skin: erythema along the back of his neck and back, as well as jaundice neuro: cnii-xii in tact, 5/5 strength, normal gait pertinent results: admission labs: 12:30pm blood wbc-5.0 rbc-3.18* hgb-11.2* hct-34.4* mcv-108* mch-35.3* mchc-32.6 rdw-23.6* plt ct-113* 12:30pm blood neuts-88* bands-0 lymphs-6* monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 12:30pm blood plt smr-low plt ct-113* 07:00pm blood pt-13.7* ptt-26.3 inr(pt)-1.2* 12:30pm blood urean-26* creat-0.7 na-139 k-3.2* cl-107 hco3-26 angap-9 12:30pm blood alt-411* ast-195* ld(ldh)-287* alkphos-646* totbili-12.5* dirbili-9.9* indbili-2.6 12:30pm blood calcium-8.0* phos-2.3* mg-1.7 chemistries: 12:30am blood glucose-123* urean-39* creat-0.8 na-129* k-3.6 cl-101 hco3-20* angap-12 06:24pm blood glucose-117* urean-72* creat-1.4* na-144 k-3.1* cl-118* hco3-15* angap-14 11:20am blood alt-385* ast-155* ld(ldh)-253* alkphos-639* totbili-10.6* dirbili-8.5* indbili-2.1 01:30am blood alt-207* ast-74* ld(ldh)-329* alkphos-655* totbili-29.0* 05:41am blood alt-146* ast-74* alkphos-659* totbili-27.3* 12:00am blood pep-hypogammag igg-321* iga-10* igm-38* 11:09am blood pep-hypogammag igg-476* iga-15* igm-29* 06:24pm blood b2micro-5.8* 09:16am blood cyclspr-less than 10:30am blood cyclspr-239 09:30am blood cyclspr-388 05:41am blood cyclspr-248 12:07pm blood lactate-2.6* 02:22pm blood lactate-4.5* 02:22pm blood type-art po2-39* pco2-23* ph-7.38 caltco2-14* base xs--9 cbc: 11:20am blood wbc-4.7 rbc-3.14* hgb-10.8* hct-33.0* mcv-105* mch-34.4* mchc-32.7 rdw-23.5* plt ct-108* 05:06pm blood wbc-3.6* rbc-2.49* hgb-9.2* hct-27.6* mcv-111* mch-36.9* mchc-33.4 rdw-26.0* plt ct-44* 06:24pm blood wbc-0.4* rbc-2.09* hgb-7.7* hct-23.2* mcv-111* mch-36.7* mchc-33.0 rdw-24.7* plt ct-61*# images: duplex dop abd/pel limited study date of 8:07 am the appearance of the liver is unchanged compared to the prior study. the hepatic veins, portal veins, and hepatic artery are patent. intrahepatic biliary ducts are not dilated. the chd measures 1.9 mm in diameter. the patient is status post cholecystectomy. impression: no evidence of biliary obstruction. chest (portable ap) study date of 3:21 pm impression: worsening pneumonia in the left lung, now involving the basal segments of the left lower lobe. apparent increase in right lower lung opacity which may reflect pneumonia. small bilateral pleural effusions, possibly increased on the left. diffuse bony changes compatible with known multiple myeloma. ct chest w/o contrast study date of 10:51 pm impression: left upper and lower lobe acute pneumonia. ct chest w/o contrast study date of 9:36 am impression: 1. worsening of left lower lobe pneumonia especially superior segment. 2. additional infectious sites in left upper lobe/right lung base unchanged. 3. small effusions/atelectasis unchanged. mr head w & w/o contrast study date of 5:43 pm impression: 1. no evidence of acute infarct, mass effect, or hydrocephalus. 2. no enhancing brain lesions. 3. multiple calvarial lesions consistent with patient's history of multiple myeloma. 4. new extensive opacification of bilateral mastoid air cells and middle ears. clinical correlation recommended. brief hospital course: assessment and plan: 62 year old male with a pmh of multiple myeloma with multiple therapies and auto and allo tx s/p dli x4 most recently in , now with gvhd of the liver and skin. . # gvhd: mr. was recently admitted in for dli. in he was found to have gvhd of the liver on biopsy. he was discharged on prednisone and mmf. he was being managed as an outpatient, but appeared to have eye involvement and skin involvement. his bilirubin continued to rise and was 12.5 on admission. we started him on solumedrol 30mg iv bid, cylosporine 50mg , and continued him on his mmf and budesonide. a ruq ultrasound was done and showed no evidence of thrombosis or obstruction. he required a switch from po to iv cyclosporin because he was not registering a detectable level while on po. it was thought to be in the setting of absorption issues with active gvhd. he was started on 100mg iv bid and reached a peak level of 388 on . hepatology was consulted in the setting of his acutely elevated bilirubin (peak 29.0 on ) without response to iv steroids, mmf, and csa. his transaminases began to downtrend , and initially thought the bilirubin would lag for 4-5 days. however, it continued to remain elevated in the mid to high 20s. at that point he had a fever and was diagnosed with a left lower lobe pneumonia. the continued elevation in bilirubin was thought to be in part caused by infection. he had been on acyclovir, atovaquone, and micafungin ppx. in light of his fever, he was started on cefepime and vancomycin. he was found to have a pneumonia on chest x-ray (see below). liver recommended a re-biopsy of the liver, which was scheduled, and ultimately postponed on the afternoon of because he went into a-fib with rvr and was transferred to the unit. . # multifactorial metabolic encephalopathy: overnight from , mr. became acutely confused, and began having hallucinations, confusion, word finding difficulty with severe asterixis. possible etiologies of his encephalopathy were csa toxicity (peak level of 388 at the time of his change in ms) hepatic encephalopathy, polypharmacy, infection, and worsening primary disease (myeloma). his csa was decreased and eventually stopped on and levels were followed. he was started on lactulose, and his other possible psychoactive medications were held. his infection was being treated with cefepime (which switched to meropenem on ) vancomycin and micafungin, which was changed to ambisome on . he had an lp done on which had elevated protein, but no white or red cells. viral pcrs were sent and were unremarkable. he remained altered on transfer to the icu, without a clear etiology. . # pneumonia: on mr. a fever, and a chest x-ray revealed a new left lower mid lung field pneumonia. a ct scan was done and showed a superior left lower lobe pneumonia. he was started on cefepime and vancomycin, and was continued on treatment with micafungin. id was consulted as well as pulmonology. he underwent bronchoscopy to evaluate for fungal pneumonia. his galactomanan came back negative from his bal, and his beta-glucan could not be interpreted because of his bilirubin level. he had a repeat chest ct scan on because of his change in mental status, and it showed an interval increase in size of his left lower lobe pneumonia. he maintained oxygen saturations of greater than 95% on ra. his fever curve decreased and he defervesced (although he remained on high levels of immunosuppression). on he went into a-fib with rvr, and a chest x-ray was checked to evaluate for fluid overload as possible cause of his rvr. the chest x-ray showed a worsening of his pneumonia. he was transferred to the icu for further management . his initial bronchoscopy had abnormal plasma cells reported. . # a-fib with rvr: he does not have any history of atrial fibrillation, and on he was noted to be tachycardic to 113, and irregular. an ekg was checked and he was in a-fib with rvr at 139 bpms. he was put on telemetry and found to be consistently between 140-160 bpms. 5mg iv metoprolol x 3 was given with no effect. a lactate was checked and found to be 2.6. he became hypotensive to 95/60 transiently. his bp remained 110-130/60-75. he was transferred to the icu for further management shortly thereafter. . # multiple myeloma: status post dli #4. his imuunoglobulin levels were all low, and his disease was thought to have been under good control. however, the abnormal plasma cells on bal were concerning. similarly, the elevated protein in his csf raised suspicion for csf involvement, although there were no cells. . # hypertension: he was initially continued on his home dose of amlodipine 5mg po daily which was subsequently increased to 10mg. ultimately it was held in the setting of his liver dysfunction. . # pain: pain from his multiple myeloma was controlled on oxycontin 30mg and oxydcodone for breakthrough pain, which was his home regimen. he was tapered off of his oxycontin and was not requiring any pain medication as his pain level was zero. he was given stool softeners for constipation. course patient presented with atrial fibrillation with rvr not responsive to iv beta blockade. he was initially given iv diltiazem followed by initiation of ditiazem drip and digoxin load. afib became rate controlled on this regimen with hr <100 consistently. his mental status was significantly compromised, differential included cyclosporin toxicity and/or worsening hepatic encephalopathy secondary to gvhd. his cyclosporin was held during his course. lactulose was stopped and rifaximin was started. he was continued on mycophenalate and steroids. despite continuation of broad spectrum antibiotics for his worsening bilateral mulitfocal pneumonia, he developed worsening hypoxic respiratory failure and was intubated. bronchoscopy was completed which showed gram negative rods for which tobramycin (for double negative coverage) and ciprofloxacin (atypical coverage) were added to his vancomycin and meropenum. he was also switched from micafungin to amphotericin for empiric fungal coverage. his beta 2 microglobulin levels were high, but no plasma cells were seen on bal. he became pancytopenic and neutropenic after intubation and was started on neupogen and received several transfusions of platelets. despite this treatment he progressed into septic shock and required full doses of phenylephrine and levophed. with worsening pressures, his family voiced that he would not have wanted to continue with aggressive treatment considering his grave prognosis. he was terminally extubated the evening of and passed away 30 minutes later with cardiopulmonary collapse. his family was at his bedside at the time of death. the family was called regarding grief counseling services (phone for counseling ), and his pcp . was notified of his passing. medications on admission: 1. mycophenolate mofetil 500 po tid 2. acyclovir 400 mg po q12h 3. amlodipine 5 mg po daily 4. atovaquone 1500 po daily 5. budesonide 3 mg capsule, sust. release po bid 6. folic acid 1 mg po daily 7. gabapentin 200 mg po tid 8. levothyroxine 50 mcg po daily 9. lorazepam 0.5 mg 1-2 tablets po every four (4)hours as needed for insomnia. 10. neomycin-polymyxin-hc 3.5-10,000-1 mg-unit/ml-% drops 4 drop otic 11. omeprazole 20 mg po daily 12. oxycodone 30 mg tablet sustained release po q12h 13. oxycodone 5 mg tablet po q4 hours as needed for pain. 14. prednisone 30 mg tablet po daily 15. sertraline 50 mg po daily 16. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic prn (as needed) as needed for dry eyes. 17. white petroleum-mineral oil -lacrilube 1 dab qid 18. dexamethasone 0.5 mg/5 ml elixir sig: five (5) ml po tid 19. triamcinolone acetonide 0.1 % ointmentappl tid as needed for rash 20. docusate sodium 100 mg po bid as needed for constipation 21. senna 8.6 mg po bid as needed for daily bms discharge disposition: expired discharge diagnosis: n/a discharge condition: n/a discharge instructions: n/a followup instructions: n/a md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified spinal tap incision of lung insertion of endotracheal tube arterial catheterization closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus diagnoses: pneumonia, organism unspecified coronary atherosclerosis of native coronary artery unspecified essential hypertension acute kidney failure, unspecified unspecified septicemia hyposmolality and/or hyponatremia severe sepsis unspecified acquired hypothyroidism atrial fibrillation percutaneous transluminal coronary angioplasty status 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 osteoporosis, unspecified septic shock multiple myeloma, without mention of having achieved remission complications of transplanted bone marrow encounter for palliative care hepatic encephalopathy metabolic encephalopathy other specified visual disturbances other and unspecified coagulation defects delirium due to conditions classified elsewhere personal history of antineoplastic chemotherapy jaundice, unspecified, not of newborn other specified disorders of skin personal history of pathologic fracture acute on chronic graft-versus-host disease other specified disorders of eye and adnexa 

Answer: The patient is high likely exposed to