Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: bactrim attending: chief complaint: cc:. hpi: 19 y/o male with all day 176 s/p mud allogenic stem cell transplant with gvhd of skin, gut/liver, and now possibly lung. he was admitted on eweek prior for new onset doe of about two weeks now. during workup last admission, cxr was abnormal with bilateral diffuse patchy infiltrates. high resolution ct showed tree in appearance in lower lobes consistant with infectious process. echo showed normal ef. he was seen by pulmonary, and bronchoscopy was done. bal was non contributory, negative for pcp. was negative. he was started on combivent and his pulmocort was changed to fluticasone. he was started on azithromycin to cover atypical pna, atovaquonefor pcp . he had 's checked on , which showed fev1 of 0.95 l. last bone marrow aspiration and biopsy showed a hypocellular marrow with a cellularity of less than 10%. no evidence of leukemia was seen and he was full donor chimerism. . he comes in today after being seen in the clinic with continued sob. he is being admitted for further workup and possibly open lung biopsy. . oncology history: he was diagnosed with pre-b-cell all in after presenting with fatigue, doe, dizziness, 20lb. weight loss, lymphadenopathy and splenomegaly. he was found to have pancytopenia with a hct of 15. following diagnosis he underwent induction therapy on the e-2993 protocol, with intrathecal methotrexate on day 24 as per protocol. his initial bone marrow aspiration and biopsy on day +24 showed resolution of most of his prior abnormal cytogenetics, but persistence of aneuploidy 4. he received phase ii of induction chemotherapy with cyclophosphamide, ara-c, 6-mp for 28 days. he received intensification with high-dose mtx, followed by consolidation therapy with cyclophosphamide and etoposide (ep-16). this was completed with the addition of dexamethasone and 6-tg in . in , he underwent a repeat bone marrow aspirate and biopsy. the bone marrow aspirate and biopsy showed karyotype 47,xyy, and no evidence by fish of the prior mentioned cytogenetic abnormalities. a recent bone marrow biopsy revealed mildly hypocellular marrow with maturing trilineage hematopoiesis and no evidence of all, but cytogenetic testing revealed aneuploidy of chromosome 4 in 12% of cells. he was admitted on and began repeat induction with the ecog-2993 protocol including daunarubicin, vincristine, prednisone, and l-asparaginase with intrathecal methotrexate on day 10. lp cytology results demonstrated no malignant cells in sampled csf. the patient's course of chemotherapy was complicated by hypomania secondary to high dose prednisone, hypofibrinogenemia secondary to therapy with l-asparaginase, neutropenic fever, and multiple lft abnormalities. the etiology of the rise in his transaminases was thought most likely to be due to a drug reaction. the viral testing was negative. given that he was scheduled to undergo an allogeneic transplant with cytoxan and tbi conditioning, he did undergo a liver biopsy to assess the degree of fibrosis as well as inflammation prior to proceeding with transplant. the liver biopsy showed moderate microvascular steatosis with mild bile duct injury and occasional apoptotic hepatocytes, consistent with drug injury. special stains for fungi, herpes simplex virus, and cmv were negative. however, given that his alt was still at 200, the transplant planned for was delayed until to try and reduce the risk of vod. bone marrow bx from showed markedly hypocellular marrow with early recovering trilineage hemopoesis, no residual all identified. pt was admitted on precondition with cytoxan and tbi for an allo transplant. last allo transplant complicated by gvh for which he was on steroids and cyclosporin. . past medical history: 1. relapsed pre b-cell all 2. asthma as a child that resolved by fourth grade. . allergies: bactrim . medications: multivitamin 1 cap po qd folic acid 1 mg po qd prednisone 60 mg po qd acyclovir 400 mg po q8 oxygen 1-2 l/minute as needed while ambulating cyclosporine modified 275 mg po bid fluticasone 110 mcg 2 puff inh azithromycin 250 mg po q24h albuterol-ipratropium 103-18 mcg 2 puff inh q4h atovaquone 1500 mg po qd fluconazole 200 mg po qd pentamidine inh last . social hx: no smoking, occ alcohol, no drugs . fam hx: mother with lymphoma . physical exam: gen: well appearing male not in respiratory distress t 98.4 hr 102 bp 118/80 rr 18 sat 94% ra heent: perrl, sclera anicteric, evidence of mucosal gvhd neck: no cervical lad chest: lungs with decreased breath sounds aat bases, better at apecies, bronchial throughout. small non tender node in right axilla. heart: mildly tach bur regular, no m/g/r. abd: + bs, soft, nt, nd, no masses. ext: no c/c/e. neuro: intact . labs: see bleow . ct scan: 1. diffuse predominantly ground-glass lung opacities with a predominantly peribronchiolar distribution with sparing of the lung periphery. this has progressed since . differential diagnosis given the time interval since transplant includes progressive opportunistic infection and noninfectious entities such as cryptogenic organizing pneumonia. 2. slight increase in bilateral pleural effusions. persistent small pericardial effusion. . echo: last admission had normal ef . a/p: 19 y/o m day 176 s/p ablative mud allogenic transplant with a recent admission for sob, now presenting with persistent symptoms for workup. . 1. doe: gvhd (peripheral eosinophilia, transaminitis) vs. infectious process - cont azithro, start levofloxacin - pulm consult - consider ct surgery consult for open lung biopsy if not improved - change fluconazole to voriconazole - continue prednisone 60mg po qd, cont csa at 275 mg po bid (last level 320) - o2 by nasal cannula to maintain o2>92% . 2. all: he is five months s/p allo transplant. he had gvhd of skin and liver. his counts are stable. . 3. thrombocytopenia: stable. no evidence of bleeding. . 4. anemia: mild anemia, not requiring transfusion. stable. . 5. transaminitis: likely due to liver gvhd. . 6. eosinophilia: likely due to gvhd. . eating. moving bowels without constipation or diarrhea. major surgical or invasive procedure: endotracheal intubation and mechanical ventilation, chest tube x 3, vats, r tunneled ij line placed history of present illness: bmt transfer accept note . cc:. hpi: 19 y/o male with all several months out from mud allogenic stem cell transplant complicated by gvhd of skin, gut/liver. he was admitted recently for new onset doe, workup up with bronchospopy which was negative for infectious cause, and discharged, on azithromycin for atypical pna and atovaquone for pcp prophylaxis, with room air saturation in the mid 90's with ambulation. he was readmitted after clinic visit showed no improvement in symptomes. his antibiotics were changed to vanco, cefepime, and levofloxacin. he underwent vats procedure for definitve diagnosis between boop/bo vs. infection. procedure went well, but post op course was complicated by chest tube related pneumothorax. . he reports feeling well currently with no sob, but with some left sided pain with inspiration, coughing. pain has been well controlled with morphine pca. he denies headache, dysuria, constipation or diarrhea. he has a good appetite. . oncology history: he was diagnosed with pre-b-cell all in after presenting with fatigue, doe, dizziness, 20lb. weight loss, lymphadenopathy and splenomegaly. he was found to have pancytopenia with a hct of 15. following diagnosis he underwent induction therapy on the e-2993 protocol, with intrathecal methotrexate on day 24 as per protocol. his initial bone marrow aspiration and biopsy on day +24 showed resolution of most of his prior abnormal cytogenetics, but persistence of aneuploidy 4. he received phase ii of induction chemotherapy with cyclophosphamide, ara-c, 6-mp for 28 days. he received intensification with high-dose mtx, followed by consolidation therapy with cyclophosphamide and etoposide (ep-16). this was completed with the addition of dexamethasone and 6-tg in . in , he underwent a repeat bone marrow aspirate and biopsy. the bone marrow aspirate and biopsy showed karyotype 47,xyy, and no evidence by fish of the prior mentioned cytogenetic abnormalities. a recent bone marrow biopsy revealed mildly hypocellular marrow with maturing trilineage hematopoiesis and no evidence of all, but cytogenetic testing revealed aneuploidy of chromosome 4 in 12% of cells. he was admitted on and began repeat induction with the ecog-2993 protocol including daunarubicin, vincristine, prednisone, and l-asparaginase with intrathecal methotrexate on day 10. lp cytology results demonstrated no malignant cells in sampled csf. the patient's course of chemotherapy was complicated by hypomania secondary to high dose prednisone, hypofibrinogenemia secondary to therapy with l-asparaginase, neutropenic fever, and multiple lft abnormalities. the etiology of the rise in his transaminases was thought most likely to be due to a drug reaction. the viral testing was negative. given that he was scheduled to undergo an allogeneic transplant with cytoxan and tbi conditioning, he did undergo a liver biopsy to assess the degree of fibrosis as well as inflammation prior to proceeding with transplant. the liver biopsy showed moderate microvascular steatosis with mild bile duct injury and occasional apoptotic hepatocytes, consistent with drug injury. special stains for fungi, herpes simplex virus, and cmv were negative. however, given that his alt was still at 200, the transplant planned for was delayed until to try and reduce the risk of vod. bone marrow bx from showed markedly hypocellular marrow with early recovering trilineage hemopoesis, no residual all identified. pt was admitted on precondition with cytoxan and tbi for an allo transplant. last allo transplant complicated by gvh for which he was on steroids and cyclosporin. . past medical history: 1. relapsed pre b-cell all 2. childhood asthma . allergies: bactrim . medications: multivitamin 1 cap po qd folic acid 1 mg po qd prednisone 60 mg po qd acyclovir 400 mg po q8 cyclosporine modified 200 mg po bid fluticasone 110 mcg 2 puff inh albuterol-ipratropium 103-18 mcg 2 puff inh q4h atovaquone 1500 mg po qd fluconazole 200 mg po qd cefipime 2g iv q12hours levofloxacin 500 mg po qd morphine sulfate pca protonix 40 mg po qd . vancomycin 1 g iv q12 . physcial exam: 97.3 94 128/82 22 100%on 4l nc gen: well appearing, not tachypneic, left sided chest tube in place heent: peerl, eomi, sclera anicteric neck: no lad chest: crackles on left side ant and posteriorly heart: noraml s1/s2. no m/g/r abd: nabs, soft, nt, nd, no masses ext: no edema or cyanosis neuro: intact . ct scan: 1. small left apical pneumothorax. 2. tip of the left chest tube located high within the lung apex. this tube should be retracted at least 3-4 cm. 3. no evidence of pulmonary embolus. 4. interval progression of perihilar and bibasilar patchy consolidation with relative sparing of the lung apices and periphery. this has significantly progressed since . given the time interval since transplant, differential diagnosis concerning for progressive opportunistic infection and less likely pulmonary edema. 5. stable appearance of large right and smaller left pleural effusion. moderate pericardial effusion. . cxr: a left-sided chest tube remains in place. a small left pneumothorax with apical and lateral components is again demonstrated, with slight decrease in the lateral component. cardiac and mediastinal contours are stable. bilateral alveolar opacities are without change allowing for differences in lung volumes. . a/p: 19 y/o m s/p ablative mud allogenic transplant, now s/p vats lung biopsy with left sided chest tube in place, getting worked up for boop/bo vs infection, on vanco, cefepime, levofloxacin. . 1. pulm: gvhd vs. infectious process. - cont levofloxacin, vancomycin, and cefipime - cont prednisone at 60 mg po qd and cont csa at 200 mg po bid (last level 345) - cont voriconazole, acyclovir, and atovaqone as prophylaxis po bid - o2 by nasal cannula to maintain o2>92%. - had chest tube pulled today, watch for sob . 2. all: he is five months s/p allo transplant. he had gvhd of skin and liver. his counts are stable. . 3. thrombocytopenia: mild. stable. no evidence of bleeding. . 4. anemia: mild anemia, not requiring transfusion. stable. . full code social history: lives with parents. no tobacco, no etoh, no drugs. family history: mother . physical exam: 99.6/99.6, 105-134, 92-111/60-67, 90-100% 10lnrb gen: increased work of breathing, mild respiratory distress, speaks in single words, using abdominal muscles for respiration heent: ncat, perrl cor: tachycardic, s1s2, no r/g/m pulm: decreased bs bilaterally, l sided chest tube in place with serosanguinous fluid draining abd: using abdominal muscles as above, soft, ntnd, +bs ext: no c/c/e, wwp, 2+ pt pulses bilaterally pertinent results: . cxr : moderate left pneumothorax with interval increase in size since recent radiograph of one day earlier. . cta chest 4/1:1. no evidence of pulmonary embolism or dissection. large right pleural effusion, stable. bilateral patchy opacifications appearing slightly more diffuse in location and less consolidative. echo: normal chamber sizes and wall thicknesses, elevated pa systolic pressure to 36-42. ef 65-70% . : lung bx: i. lung, left upper lobe, wedge biopsy (a - d): a. lung tissue with patchy chronic interstitial pneumonitis with accumulation of intra-alveolar macrophages. b. no viral inclusions, granuloma or malignancy identified. ii. lung, left lower lobe, wedge: a. lung tissue with patchy organizing and focally acute pneumonitis, with accumulation of intra-alveolar macrophages. b. no viral inclusion, granuloma or malignancy identified. . : bal negative for pcp, , influenza or other viral antigens . galactomannan negative . pfts with fev1 of 0.95, fvc 1.11 and ratio of 85% which suggest a restrictive pattern . last bone marrow aspiration and biopsy showed a hypocellular marrow with a cellularity of less than 10%. no evidence of leukemia was seen and he was full donor chimerism. . brief hospital course: was hospitalized from until the time of his death on . during this time he was cared for by the bmt team in the bmt unit, as well as by the team in the medical icu. he initially presented wiht tachypnea and dyspnea of unknown cause. original infectious workup was negative, including bal, and the patient underwent vats procedure. the lung biopsy was not pathognomonic but was consistent with gvhd of the lung, which was the presumed diagnosis. the patient was kept on steroids as well as cyclosporine to treat his pulmonary gvhd. vats was complicated by a left apical pneumothorax for which chest tube was placed and the patient was transferred to the . his breathing stabilized with chest tube and pneumothorax resolved. he was transferred back to the bmt floor, where he continued to worsen in pulmonary status, becoming tachypneic even with moving from bed to commode. the decision was made ot begin photopheresis for his gvhd and right internal jugular tunneled catheter was placed for this procedure. this was complicated by a venous air embolus which caused transient hypotension and hypoxia as well as tachycardia. the patient was again transferred to the , where he remained relatively stable although he did have an episode of what appeared to be atrial flutter, which was broken with valsalva. he was transferred back to the bmt floor, where his condition continued to worsen. he was started on treatment for broad infectious coverage (vanco, cefepime, levofloxacin, pentamidine later changed to atovaquone, voriconazole), including pneumocystis pneumonia treatment, but had no improvement and in fact cxr showed progression of infiltrates, particularly on the right side. he was found on the floor to have a spontaneous second pneumothorax on the left side for which chest tube was placed again and the patient was transferred back to the micu. his tachypnea continued to progress but abgs showed that the patient was not tiring for three days of respiratory rate of 40s-50s for most of the day. the running diagnosis at this time was more likely gvhd of the lung rather than infection and the patient had been started on cellcept in addition to his steroids and cyclosporine. he was not able to start photopheresis as he remained too ill to go to the pheresis lab. finally, on the patient's respiratory status continued to deteriorate, he was hypoxic to the high 80s and he was developing fatigue, and the decision was made to intubate the patient. the patient was extremely difficult to adequately ventillate and required paralysis in order to work with the ventilator. he went into rapid afib poorly responsive to beta blockers that lasted through the night. he also acutely spontaneously desaturated and was found to have a left tension pneumothorax despite l sided chest tube that was still in place and had been demonstrating air leak. the decision was made by the patient's family that he would not want to continue treatment in this way and he was extubated on at approximately 2:15pm. expired at 2:35pm on . his parents were in the room with him at this time. he was pronounced and post-mortem examination was declined by his family. medications on admission: multivitamin 1 cap po qd folic acid 1 mg po qd prednisone 60 mg po qd acyclovir 400 mg po q8 oxygen 1-2 l/minute as needed while ambulating cyclosporine modified 275 mg po bid fluticasone 110 mcg 2 puff inh azithromycin 250 mg po q24h albuterol-ipratropium 103-18 mcg 2 puff inh q4h atovaquone 1500 mg po qd fluconazole 200 mg po qd pentamidine inh last discharge medications: pt expired discharge disposition: expired discharge diagnosis: progressive pulmonary disease most c/w gvhd of the lung discharge condition: expired discharge instructions: expired followup instructions: expired md procedure: insertion of intercostal catheter for drainage insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances open biopsy of lung injection or infusion of biological response modifier [brm] as an antineoplastic agent diagnoses: hyperpotassemia thrombocytopenia, unspecified acute kidney failure with lesion of tubular necrosis long-term (current) use of steroids atrial fibrillation acute and chronic respiratory failure hypotension, unspecified iatrogenic pneumothorax bacteremia blood in stool other complications due to other vascular device, implant, and graft complications of transplanted bone marrow other diseases of lung, not elsewhere classified emphysema (subcutaneous) (surgical) resulting from procedure acute lymphoid leukemia, without mention of having achieved remission spontaneous tension pneumothorax other chronic bronchitis 

Answer: The patient is high likely exposed to