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: history of present illness: patient is a 50-year-old woman with a history of breast cancer status post autologous bone marrow transplant in , who was readmitted to for an allo mud bmt on . subsequent to her mud bmt, she developed subsequent febrile neutropenia, tachypnea with respiratory distress, acute renal failure, requiring intubation and admission to the intensive care unit on . patient was admitted for allo-mud bmt and subsequently developed congestive heart failure with an ef of 20% per echocardiogram on . this was not felt to be ischemic, but was questioned secondary to medication? patient also experienced acute episodes of shortness of breath, which were treated with lasix, nitrates, and hydralazine, however, patient became persistently tachypneic, and hypoxic, and was subsequently intubated on . she had been experiencing increasing renal insufficiency since her date of transplant with a rise in creatinine from 0.5 to 3.9 on day of admission to icu. her oliguria became anuria upon admission on . at that time, she was also acidotic with hyponatremia as well. past medical history: 1. breast cancer diagnosed in as inflammatory stage iii treated with mastectomy, xrt, and bone marrow transplant #1 which was autologous. also treated with adriamycin at that time. 2. patient with a history of clostridium difficile infection to treated with p.o. vancomycin. 3. hyperlipidemia. 4. status post cholecystectomy. 5. status post total abdominal hysterectomy. 6. history of ulcerative proctitis with perirectal abscess in of ' treated with flagyl and cipro. 7. myelodysplastic syndrome secondary to regional bone marrow transplant. allergies: 1. sulfa. 2. flagyl. family history: an aunt with chronic lymphocytic leukemia and mother with breast cancer. social history: patient is a nurse with no children. she is married. has a 15 pack year history of tobacco and occasional alcohol use. physical examination: on admission to the intensive care unit, temperature 104.4, blood pressure 100/60, respiratory rate 32. patient is sating 100% on bipap. general appearance: pursed-lipped female in moderate respiratory distress using all accessory muscles including abdominal muscles. heent: extraocular movements are intact. pupils are equal, round, and reactive to light. oropharynx is clear. neck is supple, no lymphadenopathy, positive jvd. skin: warm, erythematous in face. cardiovascular examination: regular, rate, and rhythm, tachycardic, no murmurs, rubs, or gallops. chest: crackles at right base, decreased breath sounds at right base with bilateral wheezing. abdomen is soft, distended with positive bowel sounds. neurologic examination: alert and oriented times three, yet lethargic. responds to commands, moving all extremities. laboratory data: echocardiogram with ef 20% and severe global hk, no valvular abnormalities, and moderately dilated left ventricle. echocardiogram : ef 30-35% with borderline pulmonary hypertension and trivial mr . cbc upon admission to the icu: white count 0.1, hematocrit 25.7, platelets 36. sodium 126, potassium 4.3, bicarb 13, chloride 101, bun 56, creatinine 3.9, glucose 145. normal lfts. lactate 2.2. abg: 7.30 ph, paco2 of 30 mm hg, pao2 148 mm hg on 100% bipap. summary of icu course: 1. respiratory failure: patient was admitted to intensive care unit with respiratory distress and metabolic acidosis. the patient continued to hyperventilate, but showed fatigue and was subsequently intubated on a.m. by anesthesia. intubation was uneventful without complications. patient remained ventilated for approximately three weeks with subsequent extubation on . patient's respiratory failure was thought secondary to congestive heart failure from cardiomyopathy of unclear etiology and decreased diastolic function in combination with metabolic acidosis and increased respiratory drive, as well as acute renal failure and volume overload. patient also had febrile neutropenia and was covered with broad-spectrum antibiotics at this time including acyclovir, caspofungin, meropenem, vancomycin, cipro to cover patient broadly given neutropenic status, volume overload with questioned pneumonia and respiratory failure. upon extubation, the patient did extremely well sating 98-100% on room air with clear lungs and no evidence of congestive heart failure. at time of transfer to medical floor, patient is without active respiratory issues. 2. acute renal failure: etiology unclear. however, patient did required cvvh for approximately one week to treat her anuric atn. upon discontinuation of dialysis, the patient's renal function continued to improve and at time of transfer to floor, she had a creatinine of 0.8, bun of 65. patient's urine output is excellent off any type of diuretics. of note, the patient had anasarca after weeks in the icu with volume repletion and was placed on natrecor for a short while to assist with diuresis (there is a question of a sulfa allergy, thus lasix was not given). natrecor was discontinued on , and the patient subsequently autodiuresed very well with excellent urine output and currently has no renal issues except for elevated bun, which is improving daily. 3. chf: patient with cardiomyopathy of unclear etiology, however, not ischemic. ef of 20%, subsequently improved to 35% on and patient had repeat echocardiogram on , which revealed an ef of approximately 40%. the left ventricular cavity was moderately dilated and mild global left ventricular hypokinesis was noted. a focal wall motion abnormality was not excluded due to suboptimal technical quality. there was no valvular abnormalities except for 1+ mitral regurgitation. of note, the patient had a repeat echocardiogram on , which was suboptimal in quality as well. her left and right atrium were normal. her right ventricle was normal, 1+ mr persisted, however, the left ventricular systolic function could not be adequately assessed due to technical quality, however, it appeared at least mildly impaired. rv chamber size and free wall motion was preserved. thus, at time of transfer to floor, the patient had no clinical evidence of congestive heart failure, yet it is likely that her left ventricular ejection fraction is mildly reduced and a repeat echocardiogram is recommended to assess systolic function. 4. anemia: patient is status post matched-unrelated donor allogenic bone marrow transplant on . after weeks of intubation, patient was finally extubated, however, her hematocrit was not stable. she was found to have coomb's negative hemolytic anemia with elevated ldh and total bilirubin. ldh peaked approximately 3500 with t bilirubin peak of approximately 4.3. the patient had numerous schistocytes on peripheral blood smear as well as thrombocytopenia and delta ms. blood smear was reviewed and patient was felt to have ttp (of note, the patient never spiked fever or had recurrent acute renal failure). given persistent hemolytic anemia, patient was ultimately placed on plasmapheresis for likely ttp thought to be due to cyclosporin. there had been case reports of cyclosporin-induced ttp and after thorough review by the bone marrow transplant service by dr. and staff, the patient was treated for ttp with plasmapheresis, which began on . her hemolytic anemia persists despite treatment, which she is still undergoing at time of transfer to the floor. her hematocrit has been stable between 21 and 26. transfusion parameters are for hematocrit less than 22. at time of transfer to the floor, patient's ldh and total bilirubin are trending down. active ......... should be maintained at all times. 5. thrombocytopenia: patient with persistent thrombocytopenia as well as microangiopathic hemolytic anemia concerning for ttp. patient did require multiple platelet transfusions over her four week icu course. however, upon development of ttp during the last 10 days or so of her icu stay, she did not require any platelet transfusions. platelet count stable between 12 and 26,000. no evidence of gross bleeding. of note aside from ttp, it was felt that her persistent thrombocytopenia could be due to lack of engraftment of platelets and failure of new bone marrow to produce new platelets. platelet transfusion parameters are for platelet count less than 10,000 or evidence of gross bleeding. despite a diagnosis of ttp, it was felt safe to transfuse patient with platelets for less than 10,000 or evidence of gross bleed, however, the patient did not require any platelet transfusions since her diagnosis of ttp upon time of transfer to medical floor. 6. mental status: status post extubation, the patient was felt to be very obtunded and unresponsive. her electrolyte abnormalities had improved and cause of mental status change was unclear. a head ct was obtained to rule out an acute bleed; the ct of the head had returned negative for any acute process. subsequently, a mr head was performed with diffusion-weighted imaging to rule out other acute process. no acute process was found. patient had received iv ativan, however, her hepatic and renal appearance was almost normal and this was unlikely the cause of her persistent mental status changes and obtundation for greater than 36 hours. ultimately, when the question of ttp was raised by dr. , her cyclosporin was discontinued as this was thought to be the cause of ttp, and patient's mental status improved significantly after discontinuation of cyclosporin. patient's mental status improved daily and was virtually at baseline upon transfer to medical floor. of note, patient is on high dosed steroids, and this seems to have made the patient very anxious and somewhat restless. she has not exhibited frank psychosis, however, her high dosed steroids have seem to interfere somewhat with her normal baseline mental status. otherwise, the patient is clear and oriented at time of transfer to floor. 7. icu myopathy: patient was noted to have bilateral symmetric upper extremity paralysis after extubation. neurology was consulted, and emg was obtained, which revealed axonal loss consistent with icu neuromyopathy. it is felt that there is nothing to do except aggressive rehab and to treat patient's underlying problem. patient's lower extremity muscle strength is currently 3-4/5 and appears to be improving on a daily basis. neurology should be reconsulted if there is a question of prognosis or course of therapy. 8. ttp: as noted above, patient with coomb's negative hemolytic anemia, thrombocytopenia, delta ms. febrile or with recurrent acute renal failure. peripheral blood smear with fragmented schistocytes consistent with microangiopathic hemolytic anemia and ttp. patient subsequently started on plasmapheresis on . cyclosporin was discontinued approximately , and patient's mental status improved significantly. of note, the patient's first plasmapheresis session was complicated by an acute allergic reaction with diffuse hives on her upper trunk and neck as well as mild bronchospasm, and tachypnea, as well as tachycardia. the patient remained hemodynamically stable throughout with stable oxygen saturations. she was treated with solu-medrol 125 iv x1, benadryl 50 mg iv x1, benadryl 25 mg p.o. x1. since initial episode of allergic reaction, patient has received the same above premedication prior to plasmapheresis every morning. she has done very well on this regimen, and this should be continued for premedication every day that she is plasmapheresed. of note, the patient also does well with 1 mg of versed for angiolysis prior to plasmapheresis. 9. graft-versus-host disease: patient was originally on steroids and cyclosporin, however, it is currently felt that the cyclosporin has precipitated ttp. since there is cross-reactivity with other immunosuppressants, it is not felt safe to initiate other agents such as fk-506 or cellcept. patient is continued on high dosed solu-medrol 40 mg iv b.i.d. for immunosuppression and prevention of graft-versus-host disease. she is followed closely by dr. and the bone marrow transplant attendings and at present steroids are her only immunosuppressant. plan per bmt. 10. id: patient presented with febrile neutropenia seven days post bmt. she was covered with broad-spectrum antibiotics and antivirals as well as antifungals. she subsequently defervesced after weeks and had no active infectious disease issue upon her last 10 days in the icu. of note on , she did have positive blood cultures for ampicillin-sensitive enterococcus from her hickman catheter. patient exhibited no clinical evidence of bacteremia such as hypotension, tachycardia, fevers, or decreased urine output/sepsis. patient received vancomycin for three days until her sensitivities returned as amp-sensitive enterococcus. the patient subsequently changed to ampicillin 2 grams iv q.8. for treatment of presumed line colonization. i do not believe patient was ever bacteremic. she has been receiving q.24-48 hour surveillance blood cultures to assess for bacteremia. none of these subsequent cultures have returned positive. patient should receive ampicillin through hickman line for 14 days for treatment of line contamination. should patient spike temperature, it is imperative that this hickman be recultured and possibly recited. given patient's poor access, this was not optimal, thus patient was treated through the line and seems to be doing clinically very well. 11. access: the patient had left subclavian quad placed upon arrival to intensive care unit which was subsequently changed over to a left subclavian plasmapheresis line with a side port for tpn by dr. on . she has a right subclavian hickman, which was placed by dr. on . these lines are active and working at time of transfer to the floor. patient has no peripheral iv access given anasarca and difficult stick. 12. nutrition: patient was given tpn for nutrition throughout her icu stay given her ventilatory status. upon extubation, patient was unable to take p.o. for approximately four days until she passed her speech and swallow. at time of transfer, patient is able to swallow, however, due to lack of appetite, weakness, and epigastric discomfort, patient's p.o. intake is suboptimal to obtain a decent nutritional status. thus, she is continued on tpn for nutrition until her p.o. intake is adequate. 13. psychiatric: patient with a history of anxiety and depression, and was on paxil prior to bmt. as all medications were discontinued for bone marrow transplant, patient has been off this angiolytic since early . she has experienced significant anxiety regarding her very difficult icu course and multiple procedures and interventions. she has done well on klonopin and ativan. would recommend restarting paxil as soon as possible once medically stable. patient appears to do better with short-acting benzodiazepines such as versed as against ativan which appears to make patient somewhat confused for long periods of time. it is important to note that her steroids seemed to have played a significant role in her anxiety and mental status as well. although she is alert and oriented x3 and very interactive, the patient has displayed anxious behavior and states that she is feeling very anxious and would like to go back on her paxil, that the steroids make her feel very "jacked up and anxious." 14. code: patient is full code. 15. communication: husband, mr. has been extremely involved in patient's care and at patient's bedside multiple times per day. he is well aware of patient's icu course and was present upon transfer to medical floor. discharge diagnoses: 1. respiratory failure. 2. acute renal failure. 3. metabolic acidosis. 4. neutropenic fever. 5. ttp. 6. graft-versus-host disease status post allogenic matched unrelated donor bone marrow transplant. 7. anxiety. 8. gastroesophageal reflux disease/gastritis. 9. intensive care unit myopathy with upper extremity paralysis bilaterally. discharge disposition: patient is transferred from fenard icu to 4 bmt service. discharge condition: fair. discharge medications: 1. caspofungin 35 mg iv q.d. 2. acyclovir 400 mg iv b.i.d. 3. solu-medrol 40 mg iv b.i.d. 4. metoprolol 25 mg p.o. b.i.d. 5. ativan 1 mg iv q.4-6h. prn. 6. nexium 40 mg p.o. b.i.d. 7. nystatin swish and swallow. 8. peridex mouthwash. 9. ampicillin 2 grams iv q.8. , m.d. dictated by: medquist36 procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances hemodialysis injection or infusion of thrombolytic agent venous catheterization for renal dialysis therapeutic plasmapheresis transfusion of packed cells closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance transfusion of platelets injection or infusion of nesiritide allogeneic bone marrow transplant without purging injection or infusion of biological response modifier [brm] as an antineoplastic agent removal of other device from thorax diagnoses: acute kidney failure with lesion of tubular necrosis congestive heart failure, unspecified acute respiratory failure pneumonitis due to inhalation of food or vomitus complications of transplanted bone marrow thrombotic microangiopathy aspergillosis critical illness myopathy acute myeloid leukemia, without mention of having achieved remission 

Answer: The patient is high likely exposed to