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: no known allergies / adverse drug reactions attending: chief complaint: fever, altered mental status major surgical or invasive procedure: intubation - extubation - lumbar punctures - and picc line placement history of present illness: 57 y/o on cellcept + rapamune s/p renal transplant for pkd as well as other pmh including htn, hld and polycytemia, who was discharged from in for presumed bacterial meningitis, who presents with fever and ams with high suspicion of bacterial meningitis. . the patient was at home this morning, when he began to feel unwell and developed a fever. he called his sister to inform her that he felt feverish, and when she arrived to see him, she reports that he had an excruciating headache and exhibited profound shaking chills. concerned, she immediately brought him to the ed. . in the ed, initial vs were: t 102, hr 91, bp 88/57, map 65, rr 14, o2sat of 100 on tidal volume of 500, with a peep of 5. the patient was intubated, administered 1000 mg vancomycin, 2g ceftriaxone, ampicillin, acyclovir, and 10 mg decadron. an lp was performed and released turbid csf fluid, which was shown to contain > wbcs, 270 rbcs, protein of 490, and glucose of 3. gram stain analysis revealed 2+ gram negative diplococci. the patient was then admitted to the micu. . on arrival to the micu, patient's vs were: t 101, hr 100, bp 105/68, rr 32, o2sat 99% on tidal volume of 500, with a peep of 5. . past medical history: 1) admitted to for a presumed bacterial meningitis in 2) s/p living-related renal transplant from his wife in of , secondary to polycystic kidney disease (baseline cre ~1.3-1.5) 3) post-transplant was complicated by polyoma (bk) virus infection. 4) hypertension 5) hypercholesterolemia 6) polycytemia (baseline hct ~50) social history: social history: lives alone. has 30 y/o daughter. habits: 1 cigar a daily, rare alcohol. family history: family history: brother and sister both have polycystic kidney disease. hypertension effects many members of his family as well. physical exam: admission exam vitals: t 101, hr 100, bp 105/68, rr 32, o2sat 99% on tidal volume of 500, with a peep of 5. general: intubated heent: sclera anicteric, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi abdomen: soft, non-distended, bowel sounds present gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: sedated . discharge exam: 97.9, 132/87, 88, 18, 99ra general: well nad heent: sclera anicteric, perrla, eomi neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi,l slight crepitus noted on anterior left chest wall abdomen: firm, markedly distented with not pain to palpation, bowel sounds present ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: admission results: 10:33am blood wbc-14.6*# rbc-6.44* hgb-17.1 hct-54.3*# mcv-84 mch 26.5* mchc-31.5# rdw-14.1 plt ct-208 10:33am blood neuts-94.9* lymphs-3.7* monos-0.7* eos-0.4 baso-0.2 10:33am blood pt-10.4 ptt-27.7 inr(pt)-1.0 10:33am blood glucose-132* urean-23* creat-1.6* na-137 k-4.2 cl-103 hco3-22 angap-16 10:33am blood alt-20 ast-21 alkphos-60 totbili-0.6 11:04pm blood calcium-7.5* phos-1.8* mg-1.2* 11:14am blood type-art rates-14/2 tidal v-500 peep-5 fio2-100 po2-216* pco2-39 ph-7.31* caltco2-21 base xs--6 aado2-458 req o2-78 -assist/con intubat-intubated 10:40am blood lactate-2.2* csf studies: 12:50pm cerebrospinal fluid (csf) wbc-7050 rbc-325* polys-100 lymphs-0 monos-0 12:50pm cerebrospinal fluid (csf) wbc- rbc-270* polys-97 bands-2 lymphs-0 monos-0 eos-1 12:50pm cerebrospinal fluid (csf) totprot-490* glucose-3 repeat csf studies (): 03:41pm cerebrospinal fluid (csf) wbc-150 rbc-675* polys-40 lymphs-9 monos-0 macroph-51 03:41pm cerebrospinal fluid (csf) wbc-100 rbc-325* polys-63 lymphs-5 monos-0 nrbc-1 macroph-31 03:41pm cerebrospinal fluid (csf) totprot-121* glucose-33 : 03:53pm blood fibrino-817* 03:53pm blood ld(ldh)-218 ck(cpk)-294 03:27am blood alt-19 ast-25 ld(ldh)-196 ck(cpk)-236 alkphos-69 totbili-0.4 05:01am blood lipase-17 03:53pm blood hapto-331* drug levels: 04:11pm blood rapmycn-8.4 01:56am blood rapmycn-9.2 03:27am blood rapmycn-6.0 02:40am blood rapmycn-11.2 05:50am blood rapmycn-3.9* . 12:15am blood genta-6.6 01:05am blood genta-1.2* 02:10pm blood genta-0.6* 07:44am blood genta-3.1* 02:33am blood genta-0.7* 07:21am blood genta-0.7* discharge labs: 05:50am blood wbc-4.7 rbc-4.81 hgb-13.2* hct-41.6 mcv-86 mch-27.5 mchc-31.9 rdw-14.6 plt ct-231 05:50am blood glucose-87 urean-17 creat-1.4* na-137 k-3.2* cl-105 hco3-22 angap-13 microbiology: 1. blood cultures (): _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s daptomycin------------ s penicillin g---------- 4 s vancomycin------------ 2 s 2. csf gram stain and culture (): gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 2+ (1-5 per 1000x field): gram negative diplococci. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. previously reported as (@1523, ). 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram negative diplococci. fluid culture (final ): enterococcus faecalis. sparse growth. _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s daptomycin------------ s vancomycin------------ 2 s fungal culture (preliminary): no fungus isolated. cryptococcal antigen (final ): cryptococcal antigen not detected. (reference range-negative). performed by latex agglutination. results should be evaluated in light of culture results and clinical presentation. 12:50pm cerebrospinal fluid (csf) herpes simplex virus pcr-test name 8:31 am stool consistency: not applicable c. difficile dna amplification assay (final ): negative for toxigenic c. difficile by the illumigene dna amplification assay. ct abdomen and pelvis (): 1. stable appearance of polycystic kidney disease with stable hemorrhagic cysts; decrease in size of multiple hepatic cysts. 2. left anterior pneumothorax with chest tube in the posterior costophrenic sulcus. 3. no evidence of intra-abdominal fluid collection. 4. status post right pelvic transplant kidney without evidence of hydronephrosis or perinephric fluid collection. 5. sigmoid diverticulosis without diverticulitis. tee (): no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. right atrial appendage ejection velocity is good (>20 cm/s). no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 30 cm from the incisors. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no valvular pathology or pathologic flow identified. no evidence of endocarditis seen. cxr : lordotic positioning and low inspiratory volumes. an et tube is present, tip lies approximately 5 cm above the carina. an ng tube is present -- the tip is not well delineated but appears to overlie the stomach. a left-sided chest tube is present at the left lung base. left subclavian central line tip overlies the proximal svc. the cardiomediastinal silhouette is prominent, but likely accentuated by low inspiratory volumes. there is upper zone redistribution, pulmonary vascular plethora, and vascular blurring, suggesting chf, but likely also accentuated by technique. there is patchy retrocardiac opacity. the right hemidiaphragm is elevated, with slight atelectasis at the right base. no gross effusion identified. no pneumothorax detected. subcutaneous emphysema noted along the left chest wall. compared with at 3:42 a.m., the vascular plethora is worse. retrocardiac density may also be slightly worse. cxr am: patient has been extubated but overall the lung volumes, though small, are maintained, with persistent left lower lobe atelectasis. mild cardiomegaly is stable. within them atelectasis lungs are essentially clear. minimal left pleural effusion extends into the major fissure. no pneumothorax nor, basal left basal pleural tube in place. persistent subcutaneous emphysema in the left chest wall has not changed appreciably in extent. left subclavian line ends in the mid svc. cxr pm: findings: the tip of left subclavian line ends at mid svc. left chest tube have been removed. mild-to-moderate sized left-sided pneumothorax is essentially new since prior radiograph. both lung volumes persistently remain low. top normal heart size is similar. lower lung opacity due to a combination of minimal atelectasis and presumed small pleural effusion is stable. no new lung opacities of concern. subcutaneous emphysema along left lateral thoracic wall extending up to the axilla and supraclavicular regions is persisting, unchanged in extent and distribution. subclavian line tip lies at mid svc. no other significant interval changes in the chest since prior radiograph acquired six hours apart. impression new mild to moderate left pneumothorax. unchange left lung base opacity from small effusion and atelectasis brief hospital course: 57 y/o on cellcept + rapamune s/p renal transplant for pkd, htn, hld and polycythemia, who was discharged from in for presumed bacterial meningitis, who presented with fever and ams and was found to have enterococcal faecalis meningitis and bacteremia. . #. severe sepsis due to enterococcus faecalis meningitis and bacteremia: he presented with ams and sepsis from bacterial meningitis in the setting of immunosuppresion for his kidney transplant. his peripheral blood revealed a leukocytosis at 14.6 with 94.9% pmns. csf studies revealed a wbc count of with 97% pmns and 2% bands, protein of 490 and glucose of 3. csf and blood cultures ultimately grew enterococcus faecalis. id was involved upon arrival. he was intubated, started on propofol and fentanyl drips, and a left subclavian line was placed. line placement was complicated by a pneumothorax, requiring chest tube placement. he was initially treated with ceftriaxone, vancomycin, ampicillin, acyclovir and dexamethasone. several antibiotic changes were made throughout his icu stay but he was ultimately treated with ampicillin and gentamicin. gentamicin levels were monitored carefully throughout his hospitalization. a repeat lumbar puncture on hospital day 3 revealed a wbc count of 100 with protein of 121 and glucose of 33. tee was negative for endocarditis. a ct of the abdomen and pelvis was negative for evidence of an intra-abdominal infection. his peripheral blood wbc count also improved to 9 but after several days into his icu stay it trended back up to 11.1 and he developed a fever to 101.8, at which time id recommended the addition of linezolid. this was then discontinued due to concern from the renal transplant team for interaction with immune suppressant regimen. decision was made not to preform additional neurologic imaging to search for a possible menigeal focus of infection and instead treat with an erradicative regimen of extended antibiotics. the infectious disease team recommended long-term antibiotic therapy with 2 total weeks of gentamicin dosed at 420 mg q48h, ampacilin 2g iv q4h for a total of 6 week course. patient was discharged home to complete antibiotics via home infusion company with q48h gent/creatinine checks and qweekly cbc/chem 7 checked for ampacilin duration with results faxed to the clinic. . #. hypotension: he was initially hypotensive with systolic blood pressures in the 80s. his blood pressure improved with fluid administration and antibiotics. he briefly required norepinephrine on for blood pressure support. following discontinuation of norepinephrine, he became hypertensive. . #. subclavian line placement complicated by pneumothorax: his left subclavian line placement was complicated by a small pneumothorax. a chest tube was subsequently placed and set to suction. following extubation, his chest tube was removed on , although a small pneumothorax remained. this was followed by cxr without full resolution. the patient had no further respiratory distress, and it was anticipated that the pneumothorax would continue to self-resolve. there was no air leak detected at the former chest tube site. . #. hypertension: although initially hypotensive, he gradually became hypertensive after several days of treatment of his infection. his home regimen of metoprolol tartrate 100 mg tid and lisinopril 15 mg daily were held upon presention. with the gradual development of his hypertension, he was started on hydralazine 50 mg po q6h while he was intubated. it was felt that his hypertension was in part due to agitation so he was switched from propofol to dexmedetomidine, with some improvement in his blood pressure. following extubation, metoprolol was restarted at 50 mg po tid, changed to labetalol. his lisinopril continued to be held given concerns for potential renal injury in setting of gentamicin administration. . #. pkd s/p renal transplant: he received a living donor renal transplant in and has been immune suppressed on cellcept and rapamune. his creatinine on admission was close to baseline range of 1.3-1.5 and remained so throughout his icu stay. his rapamune and cellcept were held on admission as there was significantly more concern for complications from his infection than for rejection of his transplanted kidney. his rapamycin was restarted on hospital day 2 but was adjusted by the transplant nephrology service, who followed him throughout admission. cellcept was restarted on as the patient continued to improve, although at a reduced dose. patient's rapamycin dose was increased to 2 mg daily while on reduced cellcept dosing with plan to reduce dose when reassed by transplant nephrology. lisinopril continued to be held to allow for full renal recovery. . #. hypercholesterolemia: chronic issue, continued pravastatin. transitional issues: - rapamycin dose increased to 2 mg daily - cellcept dose decreased to 250 mg twice daily - d/c'd home on gentamicin q48h dosing and q4h amp with survailence labs sent to the clinic - patient is a full code - lisinopril was held at the time discharge - would consider surgical evaluation for removal cystic kidneys as possible source of recurrent infections. medications on admission: 1. sirolimus 1 mg po qdaily 2. pravastatin 80 po qdaily 3. mycophenolate mofetil 500 mg po bid 4. lisinopril 10 mg po qdaily 5. fosamax 70 mg po qweekly 6. omeprazole 20 mg po qdaily 7. metoprolol tartrate 100 mg po tid 8. multivitamin po qdaily discharge medications: 1. pravastatin 80 mg tablet sig: one (1) tablet po once a day. 2. fosamax 70 mg tablet sig: one (1) tablet po once a week. 3. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 4. labetalol 200 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*0* 5. multiple vitamins tablet sig: one (1) tablet po once a day. 6. mycophenolate mofetil 250 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 7. gentamicin 40 mg/ml solution sig: four y (420) mg injection q48h (every 48 hours) for 1 weeks: until . disp:*qs * refills:*0* 8. ampicillin sodium 2 gram recon soln sig: two (2) grams injection q4h (every 4 hours) for 5 weeks. disp:*420 grams* refills:*0* 9. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 10. outpatient lab work q72h gentamicin trough (drawn before gentamicin dose) and rapamycin level (prior to morning dose), bun and creatinine for 1 week. fax results to clinic icd-9 321 (menigitis other organisms) 11. outpatient lab work weekly cbc with differential and complete metabolic profile for 6 weeks fax results to clinic , icd-9 321 (menigitis other organisms) 12. sirolimus 1 mg tablet sig: two (2) tablet po once a day: for total of 2 mg of sirolimus daily. discharge disposition: home with service facility: home health care discharge diagnosis: primary -enteroccocus menigitis -enterococcus bacteremia -polycystic kidney disease status post renal transplant secondary: -hypertension -hypercholesterolemia -polycythemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: it was a pleasure taking care of you at . you came to the hospital with fever and confusion. you had previously been treated for meningitis, and you were found to have recurrence of this infection. you were intubated and sedated for several days. you were treated with iv antibiotics with good effect, and your infection rapidly cleared. you will need to continue iv antibiotics for additional 5 weeks. you have a long-term iv line placed to allow for this therapy; it will be removed when your treatment is complete. you will receive iv antibiotics at home through a visiting iv medication company that will also draw weekly labs that will be sent to our infectious disease experts. we made the following changes to your medications: - stop lisinopril until you have completed iv antibiotics - stop metoprolol - start labetalol 200 mg three times a day, a drug related to metoprolol - start ampacillin 2 g iv every 4 hours for 5 additional weeks - start gentamicin 420 mg every 48 hours for 1 week - reduce your dose of cellcept to 250 mg twice daily until you have completed iv antibiotics - increase your sirolimus to 2 mg daily from 1 mg daily please follow-up with your physicians as listed below. followup instructions: department: infectious disease when: wednesday at 10:00 am with: , md building: lm campus: west best parking: garage department: infectious disease when: wednesday at 10:00 am with: , md building: lm bldg () campus: west best parking: garage department: otolaryngology (ent) when: wednesday at 1 pm with: , au.d. building: lm campus: west best parking: . garage department: primary care name: dr. when: please call the office of dr. to schedule a hospital follow up appointment for 4-8 days after your discharge. address: , , phone: department: nephrology name: dr. when: thursday at 2:00 pm location: medical care, p.c. address: , ste 125e, , phone: department: otolaryngology (ent) when: wednesday at 1 pm with: , au.d. building: lm campus: west best parking: . garage md procedure: insertion of intercostal catheter for drainage continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung spinal tap incision of lung diagnostic ultrasound of heart injection or infusion of oxazolidinone class of antibiotics diagnoses: anemia of other chronic disease pure hypercholesterolemia unspecified essential hypertension other pulmonary insufficiency, not elsewhere classified severe sepsis other and unspecified hyperlipidemia iatrogenic pneumothorax septic shock surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation emphysema (subcutaneous) (surgical) resulting from procedure encephalopathy, unspecified ventilator associated pneumonia streptococcal septicemia examination of participant in clinical trial streptococcal meningitis kidney replaced by transplant polycythemia vera 

Answer: The patient is high likely exposed to