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: penicillins / iodine / adenosine attending: chief complaint: fuo major surgical or invasive procedure: joint tap of the wrist history of present illness: 67 female with a history of cad s/p stent, dm, and esrd on hd, who presented to center on with bilateral foot pain. the patient reports a mechanical fall 2 weeks ago onto her left hip, then a second fall onto that same hip a few days later. she had significant ecchymoses and was told to use hot compresses by her hd physicians. the next day (), she developed severe left foot pain, followed by left wrist pain, then right foot pain, all characterized as burning and associated with erythema. she presented to the ed for evaluation and was discharged without intervention. the next day, her pain was so severe she could not rise to the bathroom so was biba to on . she was afebrile at that time but started on vancomycin and colchicine for a question of cellulitis v. gout without improvement. she was then started on neurontin on . she remained afebrile until several days later, with her first documented fever of 102.2 on . levofloxacin was started. ortho tapped her wrist, cx returned neg; no crystals sent. she remained febrile, so wrist and ankle films and a bone scan were done on which showed some increased uptake in bilateral feet and left wrist and lumbar spine, but appeared to be degenerative pattern. on , her right ij hd line was removed and a tunnelled left ij line was placed. tee was performed and no vegetations seen. on , her levofloxacin was discontinued. her fever work-up so far has been notable for leukocytosis, esr 100 -> 130 on , crp 31 on . negative studies have included serial bcx (ngtd), cath tip cx (ngtd), ucx, cxr, left wrist joint fluid cx, mrsa screen, lyme ab, hep b and c serologies, rf, and . . pt was accept for transfer here for further work-up of her fevers, with a concern for id v. rheum process. prior to her transfer this evening, the covering md (dr. was called to evaluate the pt for acute ms changes. per her daughters, she received some medications including dilaudid and became very difficult to arouse with confused speech. per her daughters, she had been "loopy" with narcotics in the past few days but not to this extent. she was noted to have a fever of 103. she received narcan around 6:30pm without improvement and a tylenol suppository at 7:30pm. around 9:30pm, the pt "woke up," and returned almost back to baseline. the md her, she seemed debilitated, listless, and lethargic but was not confused on his evaluation; she responded to voice without difficulty and neuro exam was grossly nonfoccal. abg did not show hypercarbia. he did order a stat ct head which only noted cerebral atrophy on prelim read. a cbc was repeated at time which showed an increase in wbc from 10 to 18.5 with 87% polys. . summary of hospital course: : to ed with left wrist and left foot pain, admitted. vanco and colchicine started. t99.4. : hd. neurontin started. cxr neg. : t99.3. : hd. t100.1. : t102.2. levofloxacin iv started. wrist tap done by ortho, sent for culture. : t100.4. hd. wrist and ankle films done and had a bone scan - some increased uptake in bilateral feet and left wrist and lumbar spine, but appeared to be degenerative pattern. : t99.7, tmax 101.9r ij hd line removed, tunnelled l ij hd line placed. tee performed, no vegetations seen. : t101.7. hd. : levofloxacin dced. tmax 103.4. . on the floor, patient currently is "much better" per her daughters. although her speech is still a little slurred, she is oriented x 3 and able to provide a good history. she complains only of burning wrist and bilateral foot/lower leg pain, worse with movement, which is unchanged. . her daughters note that she had a recent admission in for fuo which resolved after several days. per the osh notes, this admission was from to for febrile illness with 4 days of fever up to 103.7 but negative infectious workup (neg blood cultures, urine cultures, cdiff, cxr). oral hsv was questioned as the etiology at that time. she was started on ceftaz and given oral valtrex. notes state she completed 5 days of iv azithromycin and ceftriaxone and was discharged on 2 more days of azithro and vantin. . review of systems: denies recent weight loss or gain. denies headache or sinus tenderness, does have mild jaw pain when chewing. no rhinorrhea or congestion. denies neck pain or stiffness. denies cough, shortness of breath. denies chest pain or tightness, palpitations. denies nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. intermittent dysuria. back soreness "from lying in bed." no new rash other than erythema of left wrist and ble. up to date on routine cancer screening with recent normal mammogram, pap smear, and colonoscopy (within past couple years per daughter). pt tested negative for hiv in the past year. no new medications other than antibiotics (pt reports has not been on vanco in the past). past medical history: hypertension hyperlipidemia dm cad s/p pci with unknown type of stent (?bms), . esrd secondary to diabetes on hd mwf s/p cataract removal gerd anemia social history: she lives with her 2nd husband. she is a retired school teacher. she quit smoking over 40 years ago. she denies alcohol, drug, or herbal medicine use. family history: mother had htn and cad in her 80s. her mother died at 87 and her father at 93 of "old age." she has one sister who died after esophageal bleed and one sister with breast cancer in her 60s and bladder cancer in her 80s, still living. she also had an aunt with breast cancer in her 60s. she has two healthy daughters. family history of connective tissue disease. physical exam: vitals: t 102.1, bp 129/53, p 92, rr 20, o2sat 92 ra, fsg 155 general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, no focal c-spine tenderness, jvp not elevated, no lad back: diffuse tenderness over lumbar region involving l4-s1 spine and paraspinal muscles. lungs: minimal crackles at the bases, improved with coughing, otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, +systolic mm loudest at base, no rubs or gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly ext: warm, well perfused, 2+ pulses. left wrist and hand swollen with erythema and ttp but able to move. erythema and ?increased warmth over bilateral feet with patch over lower shin, superficial tenderness extending over pedal/dorsal foot and shin. minimal edema of both feet, nonpitting. tenderness on palpation of right 1st-4th pips with pain on movement of right ankle but not left ankle. + calf tenderness b/l. neuro: lethargic but easily arousable and responds appropriately to questions, oriented to person, hospital (initially but recalled when requestioned later), and date. speech clear at times, slightly gargled when drifting off to sleep. cn ii-xii grossly intact, ue strength 5/5, le strength. unable to maintain outstretched arms (l worse than r) with ?asterixis but no clear pronator drift. sensation to lt intact b/l (?hyperesthesia of le as noted above). patellar reflexes symmetric. negative kernig and brudzinski. gait not assessed. pertinent results: other notable osh labs: wbc max 15.5 on , although reportedly 18.5 on prior to transfer ferritin 1619 crp 31 on esr 100 on -> >130 on rf 13 (negative) on negative on lyme ab negative on heb b sab, sag, cab negative fe 21, tibc 155 on lfts all normal on (except albumin 2.6) ua : 3+ protein, >100 wbcs, rbcs, >15 epis hgba1c 5.8 on . micro: blood cultures: x2, x2, x1, all ngtd cath tip culture ngtd urine culture < 10k mixed skin flora; < 10k mixed skin flora l wrist joint fluid ngtd mrsa screen negative . images: tee : ef 60-65%. mild concentric lvh. trace ai, mild mr, mild tr. no vegetations. . tte : ef 60-65%. mac, mild mr. technically difficult study. . wrist films : extensive vascular calcifications. no evidence for osteomyelitis. . foot films : diffuse osteopenia. vascular calcifications. mild left sided soft tissue swelling. no osteomyelitis seen. . ankle films : no fracture. no radiographic evidence of osteomyelitis. . bone scan : abnormal uptake in both feet, predomiantly involving the hindfoot and midfoot regions. no clear focal area of radiotracer accumulation within the visualized tarsal bones. findings are probably degenerative rather than being secondaryh to multifocal osteomyelitis. degenerative appearing uptake in the visualized left wrist and lumbar spine. . portable cxr : r sided cathter. heart size upper normal. clear lungs. some r hemidiaphragm elevation (unchanged from prior) brief hospital course: 68 yo f with ckd on hd, cad, dm presents with bilateral foot and left wrist pain, persistant fevers, with waxing and mental status and elevated inflammatory markers transferred back to floors from micu. . # gout: rheumatology patient and did repeat wrist tap that revealed small amount of crystal negative fluid. however, presentation, signs and symptoms were highly consistent with gout. initially fever work up was conducted (see below) and steroids were held. patient treated w/ narcotics, but developed ams (see below) which were then held. infectious w/o was negative and fevers were thought to be secondary to gout. patient was ultimately started on prednisone taper from 30mg->20mg->10mg->5mg over 12 days. patient improved with steroid therapy. . # fevers: on transfer patient had persistant fevers with a leukocytosis that was downtrending. inflammatory markers esr and crp were elevated. further infectious work was undertaken and unrevealing. lfts were normal, hep serologies were repeated and negative, hiv ab and viral load, cmv, fungal cx and blood cx were neg. septic arthritis was felt to be unlikely given negative work up at osh. mri spine that was unrevealing for infectious process. patient had episodes of ams (see below), however given the lack of meningeal signs and symptoms and resolution of mental status with holding of narcotics lp was not performed. patient had unrevealing spep. leni's were checked bilaterally and were negative. hematology also consulted, who thought bm biopsy was unlikely to yield diagnosis. rheumatology was consulted and tapped the left wrist, crystals were not identified but given presentation rheumatology felt that the likely etiology to the fevers was gout. other rheumatologic markers , rf, anca were negative. patient defervesced with gout treatment see above. . # ams: on transfer patient appeared somnolent with ams. on patient triggered for ams, head ct was normal, and abg was unremarkable. patient was transferred to the micu. mri head was w/o any acute findings, mri c/t/l spine w/o evidence of cord compression or epidural abcess though the study was limited by motion artifact, and eeg w/o epileptiform acitivity. tsh within normal limits. b12/folate normal. ams resolved by holding narcotics and patient was transferred to the floors where she remained a&ox3 throughout. . # esrd: on transfer patient arrived with a tunneled hd line, that was left in place to allow for maturation of her fistula line. she was continued on her hd sessions m/w/f and continued on calcium acetate, nephrocaps. - tunnelled line to be d/c'd by outpatient nephrologist, pending maturation of fistula . # cad: pt remained chest pain free. osh tee was unremarkable. plavix was held at osh given concern for serum sickness, however this was restarted. she was continued on asa 81, imdur, statin, carvedilol. . # htn: continued home carvedilol and imdur. hydral, dilt, and lisinopril had been held at osh however these were restarted. . # hl: continued statin and fenofibrate . # dm: continue hiss. medications on admission: medications at home (per osh records): b complex-vitamin c-folic acid once a day calcium acetate 667 mg capsules - 3 tabs tid with meals carvedilol 3.125 mg twice a day clopidogrel 75 mg once a day diltiazem hcl 240 mg, sust. release fenofibrate 145 mg once a day fluvastatin 40 mg every other day hydralazine - 100 mg tablet insulin lispro sl sc as needed isosorbide mononitrate 30 mg once daily lisinopril 30 mg once a day aspirin 81 mg once a day darvocet n100 1 tab q6h prn omeprazole 20 mg daily . medications (on transfer): heparin 5000 unit sc tid insulin sc (per insulin flowsheet) acetaminophen 325-650 mg po/ng q4h:prn pain, fever isosorbide mononitrate (extended release) 30 mg po daily aspirin 81 mg po/ng daily nephrocaps 1 cap po daily calcium acetate mg po tid w/meals omeprazole 20 mg po daily carvedilol 3.125 mg po/ng pravastatin 40 mg po qodhs docusate sodium 100 mg po senna 1 tab po/ng :prn fenofibric acid *nf* 145 mg oral daily discharge disposition: extended care facility: discharge diagnosis: primary: gout flare ams secondary to narcotics discharge condition: reduced functional mobility and activity tolerance secondary to pain. oriented times three discharge instructions: we had the pleasure of taking care of you at for your foot pain and fevers. these were secondary to your gout flare. we treated you with prednisone and tylenol. while you were here you became confused and we performed imaging of your brain and spine that did not show any acute changes. we also performed an infectious work up which did not show any sign of infection in your body. we believe your confusion was from the narcotics and you improved when we stopped your narcotics. we have made the following changes to your medications: 1. we have started you on prednisone. you should take 20mg fri (), sat (), sun (); 10mg mon (), tues (), wed (); 5mg thurs (), fri (), sat (). 2. we have also started you on stool softners senna/colace to be taken as needed for constipation. 3. we have stopped darvocet, you can take tylenol instead. followup instructions: please follow up with rheumatology: at 10am in clinic with please schedule an appointment with your pcp and nephrologist. your nephrologist will decide when your temporary hemodialysis line can come out. procedure: hemodialysis arthrocentesis diagnoses: hyperpotassemia anemia in chronic kidney disease end stage renal disease nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere coronary atherosclerosis of native coronary artery esophageal reflux hyposmolality and/or hyponatremia depressive disorder, not elsewhere classified percutaneous transluminal coronary angioplasty status hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease other and unspecified hyperlipidemia anxiety state, unspecified fever, unspecified altered mental status unspecified sedatives and hypnotics causing adverse effects in therapeutic use diabetes with renal manifestations, type ii or unspecified type, not stated as uncontrolled gouty arthropathy, unspecified 

Answer: The patient is high likely exposed to