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: cellulitis/dvt major surgical or invasive procedure: thoracentesis (x2) placement of chest tube pleurodesis abdominal paracentesis (x4) picc line placement history of present illness: this is a 78 year old man with history notable for extensive pulmonary asbestosis, atrial fibrillation, and rp fibrosis s/p ureterolysis and omental wrap who presented to an outside hospital on for elective hernia repair. the patient has long been awaiting repair of a large inguinal hernia and ventral hernia and had stopped taking his coumadin 10 days prior to presentation (he is on this for atrial fibrillation) in order to get these procedures completed. over the week prior to presentation he had also noted worsening left lower extremity edema and increasing abdominal girth with worsening of his preexisting vental hernia. other review of systems notable for some nonproductive cough as well as general fatigue and decreased mobility for the past month, which he largely attributed to his impressive hydrocele. he denied any fevers,chest pain, orthopnea, or pnd. at the outside hospital initial evaluation revealed abdominal wall erythema concerning for cellulitis as well as a swollen left lower extremity. ultrasound showed left common femoral vein dvt. he was transferred to for further management. on arrival he complained of fatigue and discomfort from his large hernias. no other issues. past medical history: -asbestosis -atrial fibrillation -ureterolysis -rp fibrosis (presumed idiopathic) -omental wrap social history: the patient worked as a steam engineer for over 40 years. he reports significant asbestos exposure over a period of several years. he lives with his wife of 58 years. he denies tob or drug use and says he drinks alcohol only very occasionally. family history: father died of complications of pernicious anemia, mother died at age 66 of ??????heart problems??????. brother died of an mi at age 53, both younger brothers died of cvd in their 40??????s. one sister died of complications of alcoholism at 66, another sister died at age 68 of cerebral hemorrhage. his one remaining sibling, a sister, is 77 and well. physical exam: on presentation: t=94.7 hr 60 bp 153/56 rr30 93% nrb physical exam general: pleasant, speaking in full sentences heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla. dry mmm. op clear. neck supple, no lad. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . no elevation of jvd lungs: decreased breath sounds in lower of right lung and poor air movement with crackles in the rest of the lung. abdomen: large ventral hernia, multiple large other hernias. nt, nd. +bs extremities: +2 edema to the sacrum. 1+ dorsalis pedis pulses bilaterally gu: very large scrotal hernia and scrotal edema skin: macular rash on abdomen and back neuro: a&ox3. appropriate. cn 2-12 intact. ue and le strength . psych: listens and responds to questions appropriately, pleasant, tangential speech. pertinent results: ===================== laboratory results ===================== blood ------ on presentation: wbc-11.5* rbc-4.20* hgb-11.4* hct-34.5* mcv-82 rdw-15.3 plt ct-452* ---neuts-84.8* lymphs-5.1* monos-8.7 eos-1.0 baso-0.4 pt-14.2* ptt-25.5 inr(pt)-1.2* glucose-105 urean-37* creat-2.0* na-140 k-5.5* cl-107 hco3-24 calcium-8.7 phos-4.1 mg-1.8 last full labs: wbc-16.1* rbc-3.82* hgb-10.4* hct-32.0* mcv-84 rdw-15.9* plt ct-649* ---neuts-86.8* lymphs-3.4* monos-8.6 eos-0.8 baso-0.4 pt-15.2* ptt-37.0* inr(pt)-1.3* glucose-121* urean-102* creat-2.0* na-136 k-4.2 cl-104 hco3-21* other important labs: 07:50am blood alt-10 ast-20 alkphos-60 totbili-0.2 07:15am blood triglyc-135 hdl-29 chol/hd-4.2 ldlcalc-67 03:50am blood tsh-4.1 03:50am blood cortsol-15.9 12:52pm blood psa-0.8 07:25am blood pep-no specific peak id's protein/albumins: 07:50am albumin-2.7* 07:15am totprot-6.4 albumin-3.5 07:25am totprot-6.2* 05:00am totprot-5.9* albumin-3.2* 05:37am albumin-3.3* 03:50am albumin-2.5* 05:56am totprot-4.3* albumin-2.2* urine ------ : color-yellow appear-hazy sp -1.017 blood-tr nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg rbc-2 wbc-1 bacteri-none yeast-none epi-1 transe-<1 castgr-18* pleural fluid --------------- wbc-190* rbc-5875* polys-11* lymphs-59* monos-18* eos-1* meso-11* totprot-3.6 glucose-129 ld(ldh)-116 cholest-75 triglyc-1120 wbc-1000* rbc-9333* polys-19* lymphs-55* monos-15* eos-1* meso-10* totprot-3.5 ld(ldh)-116 amylase-28 albumin-2.0 peritoneal fluid ----------------- wbc-1875* rbc-* polys-22* bands-1* lymphs-40* monos-0 macroph-37* ld(ldh)-120 albumin-2.0 triglyc-1304 adenosine deaminase: 6.4 (normal) wbc-740* rbc-3150* polys-8* lymphs-57* monos-33* mesothe-2* totpro-3.6 ld(ldh)-114 albumin-2.1 triglyc-815 wbc-570* rbc-720* polys-58* lymphs-27* monos-0 eos-1* plasma-2* mesothe-1* macroph-11* totpro-2.4 glucose-133 ld(ldh)-139 amylase-16 albumin-1.4 =============== microbiology =============== blood cultures *6: no growth urine cultures *4: no growth stool for c diff: negative peritoneal fluid culture *4: no growth pleural fluid culture*3: no growth =========== pathology =========== pleural fluid cytology from , , and : negative for malignant cells peritoneal fluid cytology from and : negative for malignant cells pleural fluid immunophenotyping: nterpretation non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. correlation with clinical findings and morphology (see c09-) is recommended. flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. =============== other studies =============== ecg : sinus bradycardia. otherwise, tracing is within normal limits ct abdomen and pelvis w/o contrast : impression and plan: 1. abnormal soft tissue encasing the retroperitoneal structures, surrounding the aorta and ivc, extending inferiorly along the presacral space. these findings are incompletely characterized without intravenous contrast. findings could reflect retroperitoneal fibrosis, though correlation with prior history or any prior imaging would be helpful. the attenuation of this material is not compatible with hemorrhage 2. complex ventral abdominal wall hernia containing fat, fluid and small bowel, without evidence of obstruction. 3. large left inguinal hernia, with herniation of fluid and sigmoid colon to the left scrotal sac. 4. large amount of ascites. 5. left external iliac, common femoral, and superficial femoral venous thrombosis. chest radiograph : impression: marked cardiac enlargement predominantly involving the left heart. extensive bilateral pleural changes including calcifications consistent with previous asbestos exposure. pulmonary vasculature demonstrates upper zone re-distribution pattern but no conclusive evidence for acute infiltrates. bilateral lower extremity ultrasounds : impression: 1. occlusive deep venous thrombosis in the common femoral vein extending into the greater saphenous and deep femoral veins. of note, the proximal extent of thrombus is not defined. 2. no right lower extremity deep venous thrombosis. spirometry : impression: marked restrictive ventilatory defect with a marked gas exchange defect. the reduced dlco suggests an interstitial process. there are no prior studies available for comparison. tte : conclusions the left atrium is moderately dilated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). there is no vsd seen. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened. there is a minimally increased gradient consistent with minimal aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is mild mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. abdominal ultrasound w/dopplers : impression: 1. normal portal venous, hepatic venous, and hepatic arterial flow to the liver. 2. large amount of ascites ct chest w/o contrast : impression: the constellation of findings including an increasing right pleural effusion which is moderately large, massive hiatal hernia, diffuse ground-glass opacities throughout the lungs probably infective or inflammatory, extensive calcification in multiple pleural plaques with extensive intra- abdominal ascites all contribute to the worsening respiratory status. the presence of an increasing pleural effusion with calcified and noncalcified pleural plaques in the setting of asbestos-related disease raises the remote possibility of mesothelioma. tte : impression: mild concentric hypertrophy with normal biventricular regional and global systolic function. moderate diastolic dysfunction with elevated pcwp. mild aortic regurgitation. moderate pulmonary hypertension. compared with the prior study (images reviewed) of , the findings are similar. a paramembranous vsd is not seen on either study (mentioned in initial report). the velocity across the aortic valve is now lower ct chest : impression: 1. large right-sided pleural effusion which has increased in size since the study performed five days prior. associated compressive atelectasis of the right lung base. also compressive atelectasis of the left lung base due to large hiatal hernia which is unchanged. 2. scattered ground-glass opacities throughout both lungs, stable, likely infectious or inflammatory in nature. no focal consolidations. no other significant changes since the prior study. renal ultrasound : impression: no hydronephrosis. non-diagnostic doppler evaluation due to patient's inability to hold breath. ct chest w/o contast : findings: there has been a slight decrease in size of the large right pleural effusion since the previous ct on with no pneumothorax. the right lower lobe compressive atelectasis remains similar and the large intrathoracic hiatal hernia now contains peripheral fluid tracking up from the extensive ascites. otherwise, no change since the ct torso on , and reference to the previous ct report is recommended for complete description of findings. kub : findings: in the left anterior mid abdomen in the expected location of the patients known ventral abdominal hernia, multiple air-filled and dilated bowel loops are seen, likely involving both small and large bowel. air is visualized in the rectum. ct is recommended to rule out large or small bowel obstruction. chest radiograph : findings: portable ap upright chest radiograph is compared with and . there is a large hiatal hernia. there is increase in the right mid lung opacification, which may be atelectasis or pneumonia. there is left basal atelectasis with increasing pleural effusion. within the left upper lung there is increased opacification, which may be secondary to infection. the right pigtail catheter is unchanged in position. there is atherosclerotic disease of the thoracic aorta. brief hospital course: this is a 78 year old male with history of paradoxical atrial fibrillation, pulmonary asbestosis, and idiopathic rp fibrosis presenting with cellulitis and increased abdominal distension found to have dvt and with progressive chylous ascites. 1)chylous ascites: the patient was noted to have a distended abdomen on presentation and imaging revealed a large amount of ascites. as the patient had not had a previous history of ascites this was worked up with liver ultrasound that revealed no parenchymal or vascular dysfunction. diagnostic paracentesis was obtained on that showed chylous ascites. this paracentesis also revealed >250 neutrophils so the patient was empirically started on a five day course of ceftriaxone though he remained afebrile and had no abdominal pain. after the chylous ascites was discovered primary concern was for a malignancy given the lack of liver disease. multiple imaging studies failed to show a mass, however, multiple fluid cytologies were negative, and the patient's ldh was within normal limits making lymphoma quite unlikely. therefore, most likely etiology of the development of chylous ascites was thought to be progressive lymphatic obstruction from rp fibrosis leading to increased hydrostatic pressure and leak into the peritoneal cavity. the patient had three therapeutic paracentesis on , and respectively removing 900 cc, 3l and 1 l of chylous fluid respectively. the second of these revealed a neutrophil count of 280 so led to a second course of five days of antibiotics with ciprofloxacin (as the patient was on cefepime/vanc when the paracentesis occured) which completed on . all cultures remained negative. unfortunately, the patient developed secondary chylothorax from fluid tracking up into the pleural space causing respiratory distress. attempts were made to slow accumulation of fluid with medical therapies including octreotide and low fat diet then low fat tpn but these were unsuccessful. general surgery was consulted twice and both times said that surgery to attempt to improve lymph drainage would be unsuccessful as structures are very small and diffuse and post-surgical scarring would likely be as damaging as initial insult. case was discussed with thoracic surgery who thought that without clear damage to thoracic duct there was no indication for procedural management. finally, the possibility of lymphangiogram was discussed extensively with a possible intervention and balloon dilation of cisterna chyli. unfortunately, planning mri would have been required and given patient's progressively poor respiratory status this would have required intubation. as lymphangiogram and balloon dilation are extremely uncommon procedures, odds of success were not considered high and risk of intubation and likely difficulty extubation was discussed with the family and patient and they elected to pursue comfort focused care. the possibility of disease modifying therapy for rp fibrosis was discussed with rheumatology, but they said there would be no role for the agents used (almost all of which are immune suppressants) in this acutely sick individual and these things would be unlikely to lead to quick turn-around. 2) chylothorax/hypoxic respiratory failure: the patient was initially noted to be hypoxic soon after admission with desats to the low 90's on room air. he was seen by pulmonary who attributed this to ascites and his large abdomen causing restrictive pathology in the setting of his underlying pulmonary asbestosis and plaques. this was supported by his initial pft's that showed a restrictive pattern. the patient then became progressively more hypoxic in the setting of an expanding right sided pleural effusion and a large amount of compressive atelectasis. he was desatting to the low 90's on 4l o2 by nasal cannula when he had his first thoracentesis on with considerable improvement after the procedure. by , however, he had reaccumulated almost completely and by was desaturating again so that an abg showed of o2 of around 53. therefore, he was transferred to the unit while he awaited a second thoracentesis. as he reaccumulated quickly again after that thoracentesis decision was made to place a pigtail catheter, which was placed on . over the ensuing days the patient continued to put out greater than one liter of chylous fluid per 24 hour period despite the various interventions meant to reduce chylous ascites mentioned (low fat diets, octreotide, etc...). on a pleurodesis was attempted in hopes of allowing eventual removal of the chest tube though interventional pulmonology thought this had a very low probability of being successful. after the second thoracentesis the patient remained dependent on at least 4l of oxygen by nasal cannula to keep sats> 90%. on he desaturated to the 80's on 6l in the context of worsening infiltrates bilaterally but this seemed to improve with holding tpn and was ultimately thought most likely due to volume overload. however, on the day of expected discharge (), his respiratory status worsened (oxygen saturation of 90-92% on non-rebreather) and he did not wish to use the mask. given that comfort was the goal, he was transitioned back to nasal cannula, and oxygen saturations were no longer followed. 3) nutrition/protein loss: initially the patient was allowed to eat a regular diet but in attempts at medical management he was converted to a low fat, high protein diet and then made npo with tpn. despite tpn his protein and albumin continued to fall presumably due to losses in the chest tube. after he became quite volume overloaded on and given the minimal reduction in fluid output seen even with the tpn modifications tpn was stopped as of and he was allowed to eat for comfort. he and his family understand he will ultimately continue to become malnourished and weaker but given poor toleration of tpn and comfort focused care this was considered acceptable by them. 4) health care associated pneumonia: the patient was noted to have intermittently elevated white counts and on had a right upper lobe infiltrate on chest radiograph and had purulent sputum. therefore, he received 9 days of cefepime/vancomycin with some improvement in his sputum production and stable chest radiograph findings. white count failed to trend reliably. he was never febrile. 5) lle dvt: he was initially on heparin gtt then transitioned to be therapeutic on coumadin. he was transferred back to heparin gtt once on the medical service and continued on this throughout his course there to make procedures feasible without needing a long warfarin wash-out. anticoagulation with medications other than unfractionated heparin (enoxaparin, warfarin) was not optimal given his renal failure and poor nutritional status. 6)cellulitis: the patient initially received a dose of penicillin then a few days of cefazolin with minimal improvement in his abdominal rash. he then received 10 days of vancomycin as well as steroid cream after dermatology thought the abdominal rash could be a contact dermatitis. this led to resolution of his abdominal rash. 7) likely drug rash: later in his hospitalization (around -15th) he developed a morbilliform eruption on his trunk in the context of receiving a dose of piperacillin-tazobactam in the icu. this medication was stopped an his rash resolved. 8) hypotension: the patient developed relative hypotension in the hospital. multiple blood cultures were negative and this seemed stable without mental status changes or end organ dysfunction (except some worsening of his ckd). this was thought likely due to poor cardiac return due to massive third spacing from his protein losses and perhaps external compression of the ivc by his abdomen. 9) acute kidney injury: the patient's baseline cr is unclear. at presentation cr was 2 then trended down to 1.5 before trending up again in the setting of worsening ascites and his general deterioration. renal was consulted twice and ultimately concluded this was likely due to poor preload and forward flow from the heart in the context of his third spacing and massive abdominal distension. he never became oliguric or anuric. 10) atrial fibrillation: the patient developed atrial fibrillation with rapid ventricular response while his nodal agents were being held. this broke with diltiazem and he was restarted on this medication with good rate control. 11) goals of care: after extensive discussion with the family and patient about the lack of options for reversing the patient's chylous ascites accumulation and subsequent respiratory compromise and progressive protein wasting they elected to pursue comfort focused care. reasonably benign interventions (i.e. antibiotics, pleurodesis through a preexisting chest tube) were pursued but other aggressive cares were not. similarly oral feeds were pursued even in the face of a possible sbo for the patient's comfort and happiness. his major goal was comfort and the family and patient understood his poor prognosis. when his respiratory status deteriorated on (as above), further diagnostics and interventions were not pursued, and he was given morphine. he passed away in the evening of , and his family was notified. autopsy was requested and will be performed at . medications on admission: 1. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. diltiazem hcl 300 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 3. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). 4. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 5. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 6. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 7. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). discharge medications: expired discharge disposition: expired discharge diagnosis: primary diagnoses ================== chylous ascites presumed secondary to retroperitoneal fibrosis secondary chylothorax hypoxic respiratory distress due to external compression hospital acquired pneumonia spontaneous bacterial peritonitis acute kidney injury cellulitis left lower extremity dvt secondary diagnoses ===================== paroxysmal atrial fibrillation pulmonary asbestosis large inguinal and ventral hernias discharge condition: expired discharge instructions: expired followup instructions: expired procedure: insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances thoracentesis thoracentesis thoracentesis percutaneous abdominal drainage percutaneous abdominal drainage percutaneous abdominal drainage percutaneous abdominal drainage injection into thoracic cavity diagnoses: pneumonia, organism unspecified anemia of other chronic disease cellulitis and abscess of trunk unspecified pleural effusion congestive heart failure, unspecified acute posthemorrhagic anemia acute kidney failure, unspecified atrial fibrillation pulmonary collapse chronic kidney disease, stage iii (moderate) acute respiratory failure hypotension, unspecified incisional hernia without mention of obstruction or gangrene paralytic ileus other inflammatory disorders of male genital organs pressure ulcer, lower back dermatitis due to drugs and medicines taken internally other ascites diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled acute venous embolism and thrombosis of deep vessels of proximal lower extremity dehydration asbestosis chronic diastolic heart failure mixed acid-base balance disorder pressure ulcer, stage ii spontaneous bacterial peritonitis inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) other noninfectious disorders of lymphatic channels hydrocele, unspecified contact dermatitis and other eczema, unspecified cause other ureteric obstruction penicillins causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to