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: compazine attending: chief complaint: fever, nausea/vomiting, joint and neck pain, seizures major surgical or invasive procedure: multiple lumbar punctures continuous eeg monitoring history of present illness: ms. is a 21 yo f with h/o mixed connective tissue disorder who is transferred to ed from lgh ed for workup of fever, nausea/vomiting, joint and neck pain, and 2 seizures yesterday. her story is relayed by her boyfriend and family as patient is too confused to provide a history. . patient was in her usual state of health until one week ago, when she spiked a fever to 103.7. she went to hospital, where she was given iv fluids, tylenol and compazine for nausea (which incidentally caused dystonic reaction). the following day, she was febrile to 100.7; this time it was associated with nausea, vomiting, and diffuse arthralgias and myalgias which were also present in her neck. over the next two days, her nausea/vomiting, fevers and diffuse arthralgias/myalgias persisted, and she also became quite somnolent and slept for >20 hours per day. . yesterday morning when she awoke at ~6:30 am, her boyfriend noted she was quite lethargic and speaking in broken phrases, not making any sense (e.g. would say "go to the garage" completely out of context to the conversation). she also had several episodes of "going blank" where she would be completely unresponsive. at 12 pm she had a 1 minute long episode of unresponsiveness during which her left hand opened and closed repeatedly (likely partial complex seizure). during this episode her pupils constricted and dilated repeatedly and her eyes twitched back and forth rapidly. she was also completely confused, and per her family was completely amnestic to all events within the past 4 weeks. . of note, patient has had multiple potential infectious exposures lately, including countless mosquito and flea bites. she has 2 new cats, and also helps out at a horse barn. she went canoeing for a week in earlier in , during which time her boyfriend had a one-day episode of nausea, vomiting and migraine headache. for other sick contacts, her mother had a ?viral uri one week ago. no known unusual ingestions recently. she is sexually monogamous with her boyfriend. . her family brought her to after this episode yesterday, where she was febrile to 101.0 on arrival. on her way to ct scanner, she became agitated, started vomiting, and had a 2-minute episode where her eyes rolled back in her head and all over her extremities shook violently (likely generalized tonic-clonic seizure). afterwards she had a 20-minute post-ictal period where she was somnolent and confused. her nchct at lgh was negative per report. an lp was performed which showed <1000 rbcs in both bottles, 13 wbcs (48% pmns), protein 54*, and normal glucose. she received dilantin load (unknown dose), ceftriaxone 2grams iv, acyclovir 800mg iv, and was transferred to for further workup. . on arrival to ed, vitals were 99.0 78 107/73. while in the ed she spiked to 101.1. she had multiple episodes of blank staring and unresponsiveness which i witnessed while taking her history. in between these episodes she was awake and alert but very confused. she knew her name and recognized her family members but did not know where she was and thought the ed curtain was a shower curtain. the episodes of unresponsiveness became more and more frequent in the ed, and were spaced <8 minutes apart right before she was transported upstairs. . neurologic ros is otherwise negative except for above. general ros is positive for dry cough. also positive for heavy vaginal bleeding at lgh (noted by mom), unusual given that lmp ended one week ago. no chills, night sweats, recent weight gain/loss, palpitations, diarrhea, dysuria, or rashes. . past medical history: past medical history: - mixed connective tissue disorder (characterized by joint aches/pains/swelling. followed at . was on prednisone + mtx in past social history: lives with boyfriend in ma. in college part-time but worked in a gardening shop. marijuana 2x/wk. social alcohol. denies tobacco, heroine, cocaine, and other ivdu. denies domestic violence or sexual abuse. family history: - mother: hypothyroidism, ovarian cysts (?pcos), cholecystectomy - father: inflammatory arthritis (?rheumatoid), b12 deficiency, restless leg syndome, a-fib, (in remission), cholecystectomy - mother's parents: heart disease, alcoholism - paternal grandmother: physical exam: exam on admission: vitals: 101.1 78 107/73 general: pale but non-toxic appearing young f in nad, wd/wn, looking expressionlessly around room. heent: nc/at. mmm. no oral lesions. neck: supple, no lad. subjective discomfort with neck flexion but no kernig/brudzinsky sign. pulm: ctabl cardiac: rrr, no murmurs abdomen: soft, nontender, nondistended, +bs, no hsm/masses extremities: wwp, no c/c/e, pulses 2+ bilaterally skin: no rashes or lesions noted. neurologic: -mental status: aaox1 (person, not place or time). flat affect. unable to relate history, responds "i don't know" in response to almost all questions. can say dow forward with some prompting, cannot say dow backward. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt. was able to name both high and low frequency objects. able to read without difficulty. speech was not dysarthric. able to follow both midline and appendicular commands. pt. was able to register 3 objects, but could recall 0/3 at 3 minutes, even with prompting. no knowledge of current events. no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: perrl 5 to 4mm and brisk. vff to confrontation. funduscopic exam without papilledema, exudates, or hemorrhages. iii, iv, vi: eomi with fast-beating nystagmus on resting position and in all directions. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, tone throughout. no pronator drift bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -sensory: no deficits to light touch throughout. -dtrs: tri pat ach l 3 3 3 3 2 r 3 3 3 3 2 plantar response was flexor bilaterally. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf or hks bilaterally. -gait: not tested in setting of multiple ?seizures physical exam : physical exam: gen: nad, comfortable resp: breathing comfortably vs t: af, 98.4 hr: 93 (93-125) bp: 106/81 rr: 20 sao2: 99% general: nad, lying in bed comfortably. - respiratory: nonlabored - skin: multifocal rash in areas that can be reached by patient's hands, pale base with erythematous rim consistent with excoriations neurologic examination: - mental status: awake, alert, oriented to being at . minimal recall of recent events. has learned the names of 2 residents that she has seen repeatedly but does not learn name of medical student after repeated coarching. moca performed again (see chart); 21/30 (points deducted for clock hand placement; fluency: 7 words starting with s with 4 words each repeated 3-4 times; when provided with explicit instructions not to repeat words, named 6 words starting wtih b with 2 repetitions; spontaneous recall improving to with category cueing and with list cueing); language fluent without dysarthria and with verbal comprehension. no paraphasic errors. normal prosody. no dysarthria. good ideomotor praxis. normal performance on simple executive function tests, including luria hand sequencing and go-no go test. on animal fluency test, named 9 animals with 10 repeats. on hand movement mirroring, good performance with only one right/left confusion error. complex figure performed: slowed but intact copy of figure. delayed recall: did not recall having drawn figure, when prompted drew a square. see attached for drawing. cranial nerves: vf full to number counting. funduscopy shows crisp disc margins, no papilledema. eom intact, no nystagmus. normal saccades v1-v3 without deficits to light touch bilaterally. pterygoids contract normally. no facial asymmetry. hearing intact to voice. palate elevation symmetric. ] scm strength 5/5 bilaterally. tongue midline. motor: normal bulk and tone. no pronation or drift. no tremor or asterixis. ] l 5 5 5 5 5 5 5 5 5 5 5 r 5 5 5 5 5 5 5 5 5 5 5 sensory: no deficits on stereognosis, graphesthesia, topognosis, direction sensing. intact warm/cold temperature discrimination. reflexes = ] l 2 2 2 2 2 r 2 2 2 2 2 plantar response extensor bilaterally. coordination: mildly ataxic on rebound, finger-to-nose, finger mirroring, and heel-knee-shin testing. dysdiadochokinesia of left but not right hand. gait: hesitant initiation. wide base, very unsteady, unable to take even one or two steps without support. unstable stance with feet together with eyes open and close. exam on discharge: vs: af 98.5f, bp 98/68, hr 89-133, rr 16, o2sat 100%ra gen: nad, comfortable, affect cheerful derm: still with multifocal excoriated rash, lesions with central pallor and red rim, also multiple erythematous papules around mouth cv: tachy but regular pulm: breathing nonlabored abd: scaphoid, normal bowel sounds, no tenderness/rigidity/guarding mental status: alert, oriented to self & place, registered words and recalled spontaneously and with category cueing cn: perrl 9->4mm brisk, visual fields full, eom intact w/end-beat nystagmus, good smooth pursuit, face/jaw opening/palate elevation symmetric, tongue midline & moves easily, scms strong motor: no pronator drift, full strength in upper & lower extremities proximally & distally in flexors & extensors coordination: no rebound sensation: intact to fine touch in extremities gait: continues to be impaired pertinent results: imaging: - ct head w/o contrast; outside films read only 2:28 am: study limited by technique. within this limitation no acute intracranial pathology. please note that mri is more sensitive for the detection of encephalitis and discrete masses and may be considered if there are no contraindications to the use of mri and if this is clinically warranted. - mr head w & w/o contrast 2:55 pm: findings: there is slight increase in signal within both hippocampi without enhancement or mass effect. no evidence for acute ischemia or hydrocephalus. no pathologic enhancement. the cerebellar tonsils are somewhat low lying, which may be in the spectrum of chiari malformation. flow voids are maintained. impression: slight increase in signal within both hippocampi, which can be seen as a post-ictal phenomenon, but possibility of viral encephalitis cannot be entirely excluded. clinical correlation is advised. the cerebellar tonsils are somewhat low lying, which may be in the spectrum of chiari malformation. - eeg : impression: this telemetry captured no pushbutton activations. the background is generally disorganized in wakefulness but included some alpha frequencies. there were very frequent left anterior quadrant spike and sharp wave discharges, particularly during sleep. there were no rapidly recurrent discharges or electrographic seizures. - pelvis, non-obstetric; pelvis u.s., transvaginal 3:01 pm: normal-appearing left and right ovaries, with incidental note of small amount of free fluid in the pelvis and around the right ovary - eeg : impression: this is an abnormal continuous video eeg recording with diffuse background slowing, focal slowing over right and left temporal and right central regions with admixed sharp features, sharp transients and sharp and slow wave interictal discharges seen. there were no clear electrographic seizures observed on this day's recording. this day's recording demonstrates improvement from prior days' recording. - eeg : impression: this is an abnormal continuous video eeg recording with diffuse theta background slowing, focal r>l delta slowing in central and temporal regions with admixed sharp features, sharp trnasients and sharp and slow wave interictal discharges seen. there were no clear electrographic seizures observed on this day's recording. - tte : findings left atrium: normal la size. right atrium/interatrial septum: normal ra size. left ventricle: normal lv wall thickness, cavity size and regional/global systolic function (lvef >55%). tdi e/e' < 8, suggesting normal pcwp (<12mmhg). doppler parameters are most consistent with normal lv diastolic function. no resting lvot gradient. right ventricle: normal rv chamber size and free wall motion. aorta: normal diameter of aorta at the sinus, ascending and arch levels. aortic valve: normal aortic valve leaflets (3). no as. no ar. mitral valve: mild mvp. late systolic mr jet. mild (1+) mr. normal lv inflow pattern for age. tricuspid valve: normal tricuspid valve leaflets. mild tr. normal pa systolic pressure. pulmonic valve/pulmonary artery: normal pulmonic valve leaflet. no ps. physiologic pr. pericardium: very small pericardial effusion. conclusions the left atrium is normal in size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). doppler parameters are most consistent with normal left ventricular diastolic function. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. there is mild bileaflet mitral valve prolapse. a late systolic jet of mild (1+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a very small pericardial effusion. impression: normal global and regional biventricular systolic function. normal diastolic function. mild mitral valve prolapse with mild mitral regurgitation. - eeg : impression: this is an abnormal continuous icu monitoring study because of the presence of a diffuse background slowing compatible with a diffuse encephalopathy affecting predominantly cortical neuronal systems. there is superimposed multifocal delta slowing suggesting potential multifocal cortical injury with occasional sharp and potential epileptic sharp activity. there were no clear electrographic seizures. - eeg : impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing, slow alpha rhythm, and runs of frontal intermittent rhythmic delta activity. these findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. firda can be seen in metabolic encephalopathies, as well as increased intracranial pressure, hydrocephalus, and deep midline structural lesions. there are no epileptiform discharges or electrographic seizures recorded. of note, the patient has sinus tachycardia throughout the recording. compared to the prior day's recording, there are no significant changes. cta findings: the thoracic aorta is normal in caliber without evidence of dissection. the pulmonary arterial vasculature is well visualized to the subsegmental level without filling defect to suggest pulmonary embolism. no pathologically enlarged axillary, mediastinal, or hilar lymph nodes are identified. the heart and great vessels are within normal limits without evidence of right heart strain. a tiny pericardial effusion is of no hemodynamic significance. a central venous catheter ends in the region of the cavoatrial junction. a nasogastric tube is in the esophagus. soft tissue density in the anterior mediastinum is thymic tissue in this young patient. there is no pleural effusion. lung window images demonstrate no worrisome nodule, mass, or consolidation. note, the upper lung zones and lung bases are not imaged. airways are patent to the subsegmental levels bilaterally. the study is not tailored for subdiaphragmatic evaluation, but the imaged portion of the liver is normal. bone windows: no bone finding suspicious for infection or malignancy is seen. impression: no acute aortic pathology or pulmonary embolism. eeg : impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing, slow alpha rhythm, and runs of frontal intermittent rhythmic delta activity. these findings are indicative of moderate diffuse cerebral dysfunction, which is etiologically nonspecific. firda can be seen in metabolic encephalopathies, as well as increased intracranial pressure, hydrocephalus, and deep midline structural lesions. there are no epileptiform discharges or electrographic seizures recorded. sinus tachycardia is present throughout the recording. there are 10 pushbutton events, but no clear clinical or eeg change during these episodes. compared to the prior day's recording, there are no significant changes. mri brain : final report noted is diffuse flair-hyperintensity in the sulci of both cerebral as well as the cerebellar hemispheres. this is likely "spurious," reflecting high fio2 (inspired oxygen concentration), as according to the mr note, and confirmed in conversation with dr. , this study was performed under general anesthesia with supplemental oxygen. along these lines, there is no pathologic leptomeningeal or dural focus of enhancement. however, there are now relatively symmetric multifocal parenchymal signal abnormalities, as follows: there is confluent t2-/flair-hyperintensity with corresponding t1-hypointensity involving both cerebellar hemispheres, left more than right, completely new. there is also now more confluent t2-/flair-hyperintensity involving the medial temporal lobes including the entirety of the hippocampal formations and parahippocampal gyri, with gyral swelling. this process is far more extensive than on the previous study. however, there is also now similar signal abnormality involving the lateral aspect of the left temporal lobe, while there is a more discrete rounded 11 mm signal abnormality in the mid-right temporal lobe, just anterior to that petrous apex. finally, less extensive and hyperintense paired signal abnormalities are seen in the immediate subcortical white matter of the right frontovertex and paramedian posterior parietal lobes. of note, none of these abnormalities demonstrates a corresponding abnormality of diffusion or pathologic enhancement. there is no associated susceptibility artifact to suggest hemorrhage, either at these sites or elsewhere in the brain. finally, there is no involvement of the deep matter structures of the internal capsule or thalamus, and the immediate periventricular white matter as well as the mid brain and brainstem also appear spared. again demonstrated is marked cerebellar tonsillar descent, at least 16 mm caudal to the plane of the foramen magnum, with a "peg-like" morphology. there is accompanying crowding at the foramen with slight angulation of the cervicomedullary junction. these findings are suggestive of underlying chiari i malformation, unrelated to the process, above. there is no evidence of central herniation. there is no space-occupying lesion, and the sella, parasellar region and remainder of the skull base are unremarkable. the orbits are unremarkable, and the mastoid air cells and included paranasal sinuses are clear. the principal intracranial vascular flow-voids, including those of the dural venous sinuses, are preserved and these structures enhance normally. there is normal flow-related enhancement in the included intracranial portions of both internal carotid and proximal middle and anterior cerebral arteries, bilaterally, there is normal, symmetric arborization of mca branches, without significant mural irregularity or flow-limiting stenosis. there is normal flow-related enhancement in the distal vertebral arteries, with dominant left vessel, and in the basilar and bilateral superior cerebellar and posterior cerebral arteries, without significant mural irregularity or flow-limiting stenosis. anterior and robust posterior communicating arteries are identified, with no aneurysm larger than 3 mm. incidentally noted is a so-called "patulous" basilar summit with conjoined origins of the scas and pcas, bilaterally. impression: markedly abnormal study, which has significantly progressed since the recent examination of , including: 1. symmetric signal abnormalities involving both cerebellar hemispheres and medial temporal lobes, the latter involving the limbic circuit, without enhancement, hemorrhage or diffusion abnormality. in this clinical setting, these findings suggest evolving severe limbic and rhombencephalitis. 2. there is also symmetric involvement of the fronto-parietovertex, as well as the lateral aspect of the left temporal lobe with sparing of the deep matter structures and the brainstem; while these findings may reflect more widespread involvement by the process in #1, above, they also might reflect the development of secondary pres. 3. no evidence of central herniation. 4. diffuse and uniform abnormality of the subarachnoid space, also new; however, this is likely "spurious" and related to study acquisition during high-flow oxygen therapy. use of 100% o2 during the examination has been confirmed by dr. , on review of more detailed notes by the anesthesia service. 5. underlying chiari i malformation, with no finding to specifically suggest syringohydromyelia involving the limited included upper cervical spinal cord; however, this would be better assessed with dedicated cervical spine study, mr study, on an elective basis. 6. unremarkable cranial mra, with no flow-limiting stenosis, evidence of vasculopathy or aneurysm larger than 3 mm. ct abdomen/pelvis : findings: abdomen: the lung bases demonstrate minimal dependent atelectasis. no pleural or pericardial effusion is seen. the liver, spleen, gallbladder, pancreas, adrenal glands, kidneys, visualized portions of the ureters, stomach, small bowel, colon, and appendix demonstrate no acute abnormalities. mild focal fatty infiltration in the liver about the enlarged mesenteric or retroperitoneal lymphadenopathy is detected. an enteric catheter courses into the proximal duodenum. visualized intra-abdominal vasculature is unremarkable. pelvis: the bladder, uterus, adnexa, and rectum are within normal limits. trace free fluid is seen in the pelvis, as seen on recent pelvic ultrasound. no enlarged intrapelvic or inguinal lymphadenopathy is detected. no concerning lytic or sclerotic osseous lesions are detected. impression: 1. no ct evidence for intra-abdominal or pelvic malignancy. 2. interval migration of enteric catheter into the proximal duodenum. eeg : impression: this is an abnormal continuous icu monitoring study. the background activity is slow mostly in theta and delta range, with frequent brief runs of frontal intermittent rhythmic delta activity (firda), suggestive of moderate encephalopathy. there are seven patient pushbutton events for body jerks; none are associated with any change in eeg background. there are no epileptiform discharges or electrographic seizures recorded. compared to the prior day's recording, there is no significant change. eeg : impression: this is an abnormal continuous icu monitoring study because of moderate diffuse background slowing and runs of frontal intermittent semirhythmic delta activity. these findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically non-specific. no electrographic seizures are present. compared to the prior day's study, there is no significant change. skin, right flank; punch biopsy (a): 1.focal parakeratosis with occasional dyskeratosis, mild spongiosis and very sparse superficial perivascular lymphocytic infiltrate (see comment). 2.no bacterial organisms seen on a tissue gram stain. 3.no fungal organisms seen on pas and gms stains. 4.no mycobacteria seen on an afb stain. 5.no herpes virus seen in multiple tissue levels examined or on an hsv-specific immunostain. comment. there is also focal upper dermal red blood cel extravasation and mild vascular ectasia. the findings in this biopsy are not well developed nor are they specifically diagnostic. they are compatible with a viral exanthem in the appropriate clinical setting, and the histologic differential diagnosis also includes a hypersensitivity reaction such as to a drug although per clinical discussion this is not favored. brief hospital course: 21f with history of mixed connective tissue disorder now in remission presents with 1 week history of fevers and worsening fatigue. tmax at home to 103.7, went to osh ed diagnosed with a viral illness and sent home with tylenol and compazine after ivf hydration. patient had a dystonic reaction which was attributed to prochlorperazine, she was brought back to the ed and given benadryl and more ivf and sent home. she had worsening fatigue, lethargy, nausea, vomiting, and ongoing fevers at home. began acting strangely, with loss of short-term memory, confusion, and increasing neck pain. she also had episodes of "spacing out" and repetitive bilateral finger/hand movements. had witnessed generalized tonic/clonic seizure at osh ed and was given phenytoin. lp performed was significant for elevated protein and ct head negative for bleed. empiric abx was started for meningitis, and she was transferred to for further workup and management. she transfered to icu as her symptoms were concerning for hsv encephalitis. #######first icu course: during the 2-day icu stay, infectious disease was consulted due to multiple potential exposures to infectious agents that can cause encephalitis, including arboviruses and bartonella. in addition, ebv or hsv could cause a similar picture and mri showed hyperintense areas in both hippocampi. she was started on vancomycin 1g iv, ceftriaxone 2 gm iv q 12h, doxycycline 100 mg iv q12h, rifampin 300 mg iv q12h and acyclovir 10 mg iv q8h as empiric therapy for infectious encephalitis on . vancomycin was discontinued on and ceftriaxone was discontinued on due to low suspicion of bacterial meningitis. to control seizure activity, phenytoin was changed to levetiracetem 750 mg on , but dose was increased to 1000mg and 1500mg on and 2000mg on . due to history of mctd and concern for autoimmune limbic encephalitis, she was started on methylprednisolone 1 gram iv on for total of 4 days. she was transferred to the neurology floor for further work-up. at the time of transfer, she was afebrile but still had problem with short term memory. - : polymorphic vt with low k, mg, ca. discontinued metoclopromide and ondansetron due to concern for qt prolongation - : 15 minute generalized seizure. 2g lorazepam given ##########second icu cource: in icu she did not develope seizure, she had sinus tachicardia and was on propranolol in that regard . - she did not develope fever. - the result for vzv and hsv came back negative, but id wanted to continue gancyclovir and negative pressure isolated room - as her status remained stable she was transfer to floor on . - at the time of transfer she still had problem with short term memory and she was disoriented to time. no focal deficit was found in motor, sensory or cranial nerve. ########################## after transfer back to floor: assessment: # neuro: 21f with history of mixed connective tissue disorder thought be in remission, who presented with fatigue, disorientation, amnesia and seizures concerning for limbic encephalitis; this developed a week after a prodromal sign of a febrile illness with nausea and vomiting. at the time of transfer back to floor, she has been afebrile for > 2 weeks, her seizures are now well controlled on levetiracetam and lacosamide but she continued to have dense anterograde and retrograde amnesia concerning for tissue damage in memory-forming areas. more recently, she has also developed bilateral ataxia and gait instability. the last days of her admission, pt's affect is much more cheerful than it has been. there is some evidence that her encoding is gradually improving but stably moderately poor performance on sequential mocas. causes of limbic encephalitis that remain on the differential include autoimmune vs. paraneoplastic vs infectious (likely viral). s/p 4-day methylprednisolone 1000 mg burst without improvement. - pertinent positives: temporal eeg spikes & sharp waves, mri findings of primarily bilateral temporolimbic involvement. patient had repeat mri on which suggested progressive severe limbic and rhombencephalitis with bilateral cerebellar involvement in addition to worsening in the previously affected areas. - negative/wnl: hiv ab & rna, cryptococcal ag, ebv ebna + & igg+, lyme ab, pelvic u/s and ct torso, dsdna, c3/4, anti-tpo, anti-tg, serum hsv ab, csf hsv pcr, csf enterovirus pcr, thick & thin smears for babesia, blood parasite smear, anti-, anti-ro, anti-la, bartonella henselae & , hme & hga, csf oligoclonal bands, serum & csf anti- - baseline high titers (1:1280), anti-rnp (unchanged compared to values) #neuro: 1) concern about encephalitis - finished ganciclovir 14 day course (day 1 = , day 14 = ) due to concern about possible cns varicella or hhv6 despite negative csf pcrs. - still awaiting results of csf paraneoplastic panel and anti-nmda ab - still awaiting results of arbovirus pcr - the remaining studies can be followed up in outpatient setting 2) seizures: newest eegs with encephalopathy but no seizure activity. - continue levetiracetam mg and lacosamide 200 mg . will try to wean off aeds in outpt setting after repeat eeg in months. prescribing folate 0.8 mg daily supplementation to prevent ntds in case of pregnancy. # id/rheum: - no signs of infection at time of discharge #cards: had autonomic dysregulation after her last seizure . now still w/occasional sinus tach - continue propranolol 40 mg tid to dampen sympathetic tone (can try to wean as outpt) #gi: significant nausea & vomiting during this admission, improved after initiation of tube feeds, indicating that previous severe nausea/vomiting may have been secondary to dysosmia and dysgeusia that pt was complaining of. on exam, dysosmia was replicated and smell testing elicited nausea. now still w/decreased but improving po intake. #derm: multifocal rash with differential of atypical-appearing vzv vs contact dermatitis vs secondary to scratching from neuropathic pruritus. derm biopsy nonspecific, viral studies negative. per family, itching precedes rash, and there is no rash until patient scratches, making neuropathic pruritus leading w/secondary prurigo a distinct possibility. - continue diphenhydramine 25 mg po q8h prn itching and gabapentin 300mg in am and at noon and 400 mg qhs for possible neuropathic pruritus - topically, continue pramoxine 1% up to five times daily. - prn cold packs - pt has derm follow up next week #heme: normocytic anemia, now resolved. medications on admission: ibuprofen prn pain discharge medications: 1. diphenhydramine 25 mg po q6h:prn nausea rx *diphenhydramine hcl 25 mg 1 tablet(s) by mouth as needed, up to every 6 hours disp #*60 tablet refills:*0 2. lacosamide 200 mg po bid rx *lacosamide 200 mg 1 tablet(s) by mouth twice daily disp #*60 tablet refills:*0 3. levetiracetam mg po bid rx *levetiracetam 1,000 mg 2 tablet(s) by mouth twice daily disp #*120 tablet refills:*0 4. ondansetron 4 mg po q8h:prn nausea rx *ondansetron 4 mg 1 tablet(s) by mouth as needed, up to every 8 hours disp #*45 tablet refills:*0 5. pramoxine *nf* 1 % topical five times daily as needed (prn) pruritic rash reason for ordering: recommended by dermatology consultants rx *pramoxine 1 % apply to affected itchy areas up to five times daily as needed disp #*1 tube refills:*1 6. propranolol 40 mg po tid hr > 120 hold for sbp<100, hr<60 rx *propranolol 40 mg 1 tablet(s) by mouth three times daily disp #*90 tablet refills:*0 7. sarna lotion 1 appl tp tid:prn pruritus rx *camphor-menthol 0.5 %-0.5 % apply to affected itchy areas up to three times daily disp #*1 tube refills:*1 8. gabapentin 300 mg po bid in am and midday rx *gabapentin 300 mg 1 capsule(s) by mouth in the morning and at noon disp #*60 capsule refills:*0 9. gabapentin 400 mg po hs rx *gabapentin 400 mg 1 capsule(s) by mouth in the evening disp #*30 capsule refills:*0 10. folic acid 0.8 mg po daily rx *folic acid 0.8 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*3 discharge disposition: extended care facility: hospital discharge diagnosis: limbic and rhombencephalitis of unknown etiology discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted because you developed confusion, seizures, memory problems (amnesia), and problems with coordination (ataxia). these were likely caused by an encephalitis (inflammation of the brain), specifically attacking the temporal lobes and cerebellum. this was evident on the mri of your brain. you also had inflammatory cells in your spinal fluid. although we sent many studies, up to this point we have not been able to determine what caused your encephalitis. however, some studies are still pending. we gave you a 4-day course of high-dose steroids but this did not help your condition. we were able to control your seizures with the following medications: levetiracetam (keppra) and lacosamide (vimpat). you were monitored on eeg for many days, and this showed epileptiform activity initially; however, newer studies showed no more epileptiform discharges. during your hospital stay, you also had significant problems with tachycardia (i.e., a rapid heart beat). for this, we prescribed you propranolol 40 mg three times daily. you also had significant problems with nausea and vomiting, and we gave you anti-nausea medications to control this. additionally, we had to give you nutrition via an ng tube for some time. some of this nausea was probably caused by abnormal smell function because you were better able to tolerate foods that went straight into your stomach, and because you misidentified smells when we tested them. this gradually resolved. another problem that you developed was a widespread itchy rash. initially, there was some concern that this could have been shingles; even though all the studies for this were negative, we treated you with a 14-day course of ganciclovir for varicella zoster virus. however, it appears that you develop itching, then you scratch, and only then do you develop a rash; thus it is possible that your itching is secondary to the brain inflammation (neuropathic pruritus). followup instructions: provider: , md date/time: 1pm. 2 (dermatology) provider: (rheum lmob) phone: date/time: 9:30 (rheumatology) provider: , md date/time: 1:30 (infectious disease) provider: . & chwalisz phone: date/time: 4:30 (neurology) md procedure: spinal tap incision of lung enteral infusion of concentrated nutritional substances closed biopsy of skin and subcutaneous tissue central venous catheter placement with guidance diagnoses: hyposmolality and/or hyponatremia hypopotassemia encephalopathy, unspecified unspecified diffuse connective tissue disease chronic ulcer of other specified sites edema generalized convulsive epilepsy, without mention of intractable epilepsy herpes zoster without mention of complication other pancytopenia other causes of encephalitis and encephalomyelitis 

Answer: The patient is high likely exposed to