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: sulfa (sulfonamide antibiotics) / epinephrine / levofloxacin / penicillins / benadryl attending: chief complaint: dyspnea major surgical or invasive procedure: bronchoscopy history of present illness: 75 yo w with recurrent/refractory multiple myeloma presenting with several days of increased shortness of breath and cough/chest congestion, transferred to the for management of hypoxia. . she was recently admitted to the bmt service from where she received a number of antimicrobials to treat fever, cough, and uri symptoms ultimately attributed to parainflenza virus iii. the patient initially tested positive for parainfluenza on and failed outpatient treatment with a z-pack. during this last admission she also received ivig and a video swallow study to evaluate chronic aspiration attributed to hiatal hernia. on she started cytoxan/velcade/decadron with d8 of velcade on . . according to the patient, she has not experienced any fevers, chills, or night sweats since discharge. she felt her symptoms had improved dramatically, but not entirely resolved. after receiving chemo her symptoms returned and are now worse than before. she endorses worsening sputum production, now pink and occasional episodes of frank blood. no sick contacts or significant outdoor exposures. her dyspnea worsens with laying flat and is associated with l-sided pleuritic chest pain. she denies pnd or le swelling, hx of blood clots, hematuria, or rash. . she contact her oncologist and was sent to the ed for evaluation of potential post-viral pna. her initial vs on presentation were: 98.8, 76, 136/86, 20, 88% on ra. she was placed on a nrb and her o2 sats rose to 98%. cxr revealed b/l pleural effusions and opacification of the bases. she received vancomycin and cefepime. they attempted to wean her supplemental o2 to 40% fio2 on venturi mask; however, her oxygen saturations again dropped to the 80s. vitals prior to transfer were 141/94, 20, 99% nrb. . on admission to the , she appeared uncomfortable and tachypneic. she was tired, but willing to converse. she answered appropriately and expressed a need for pain medication to control her "rib pain." . . review of sytems: (+) per hpi, + n/v/d attributed to recent chemotherapy (-) denies fever, chills, night sweats. denies headache, sinus tenderness. denied chest pain or palpitations. denied constipation or abdominal pain. no dysuria. denied arthralgias or myalgias or rash. past medical history: past medical history: - vitiligo starting in - diverticulosis- found in colonoscopy . last had colonoscopy 6 months ago in . - atrial fibrillation - history of thyroidectomy - for benign cyst - history of radiation to her tonsils - history of radiation to a left clavicle plasmacytoma after a pathological fracture. - history of mitral valve prolapse - allergies - since stem cell transplant - chronic back pain - s/p 9 compression fractures related to multiple myeloma - restless leg syndrome - 30 yrs - auto. stem cell bone marrow transplant - multiple myeloma diagnosed in . . past oncologic history: "she is most recently status post five cycles of bendamustine with her fifth cycle on . she was noted for increasing lower back and right hip pain and underwent an mri of the thoracic and lumbar spine on , which showed unchanged extensive myelomatous involvement of the thoracic vertebrae with no evidence of an epidural soft tissue mass. there were chronic deformities of t7 through t12 and myelomatous involvement of the lumbar spine, particularly the left anterior aspect of l4. ms. developed increasing numbness of her right lower leg from the anterior ankle and up the shin with some disruption of her balance and gait due to this numbness. she had no changes in bowel or bladder functioning. she was initiated on decadron 4 mg four times per day on , and began radiation therapy on to the lower back in hopes of improving her symptoms. her decadron has been decreased to 4 mg three times per day on , 4 mg twice per day as of , 4 mg once per day on , and 2 mg daily as of . radiation therapy completed on . she also received weekly velcade while she was undergoing radiation therapy in order to continue to give her some systemic therapy during her treatment. she received a dose on , and . she required periodic platelet transfusions during this time. social history: retired former administrator for gte. lives in . 4 children who live in the area. she is a widow, now has male partner , with whom she does not live. no tobacco history. occasional social drinking. family history: no known family history of myeloma or other blood disorders. grandmother: breast cancer. father: mi. physical exam: admission physical exam: vitals: 98.2, 114, 151/96, 16, 95% on 4l nc and high flow mask general: alert, oriented, tachypneic, in no acute distress heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: diffuse rhonchi bilaterally cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops appreciated abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema discharge physical exam: afvss gen: well appearing, nad heent: sclera anicteric, mmm, oropharynx clear, plasmacytoma noted on scalp lungs: ctab except for decreased bs in lllf heart: regular, no m/r, +s3 abd: soft, nt, nd, with bs, no hsm ext: no c/c/e, wwp pertinent results: admission labs -wbc-4.2 rbc-2.84* hgb-9.1* hct-27.8* mcv-98 mch-32.1* mchc-32.9 rdw-16.3* plt ct-24*# neuts-92.8* lymphs-2.5* monos-3.7 eos-0.2 baso-0.8 -wbc-1.6*# rbc-2.50* hgb-8.4* hct-23.6* mcv-94 mch-33.8* mchc-35.8* rdw-17.0* plt ct-39* neuts-91.1* lymphs-5.6* monos-2.9 eos-0.3 baso-0.1 -wbc-0.8* rbc-2.71* hgb-8.9* hct-26.1* mcv-96 mch-32.8* mchc-34.1 rdw-16.7* plt ct-36* neuts-88* bands-1 lymphs-7* monos-3 eos-0 baso-0 atyps-0 metas-1* myelos-0 . -pt-13.5* ptt-24.8 inr(pt)-1.2* -glucose-146* urean-25* creat-1.4* na-141 k-3.7 cl-105 hco3-24 angap-16 -alt-19 ast-33 ld(ldh)-357* ck(cpk)-31 alkphos-112* totbili-0.3 . -glucose-186* urean-27* creat-1.5* na-141 k-4.2 cl-104 hco3-24 angap-17 -glucose-153* urean-29* creat-1.6* na-140 k-4.0 cl-102 hco3-28 angap-14 . ck-mb-4 ctropnt-0.09* ck-mb-5 ctropnt-0.27* probnp-* igg-632* imaging final ct chest 1. multifocal consolidations throughout all lung lobes. while consolidations in the right and left lower lobes are more consistent with bacterial pneumonia, the other consolidations are concerning for fungal infection, specifically invasive aspergillosis. 2. small bilateral pleural effusions, increased since ct of . 3. prominent main pulmonary artery which may be seen with pulmonary hypertension. 4. large hiatal hernia. cxr impression: ap chest compared to and : pulmonary vascular congestion and mild pulmonary edema have improved since . large area of consolidation at the right lung base and a smaller one at the left lateral to the large hiatus hernia have worsened, consistent with progressive pneumonia. moderate-to-severe cardiomegaly is longstanding. small bilateral pleural effusions are presumed. no pneumothorax. right subclavian infusion port ends in the svc. mr head impression: no acute infarcts. small vessel disease. bony abnormalities in the skull and cervical vertebrae as well as the clivus indicative of multiple myeloma. no significant epidural disease is seen, although evaluation is limited without gadolinium administration. ct chest impression: improving bilateral bronchocentric ground-glass opacities, right pulmonary consolidation and bilateral pleural effusions, consistent with a responding multifocal consolidation, angioinvasive aspergillosis is considered a probable explanation for the appearance on the prior ct. cardiac mr impression: 1. moderately dilated left ventricle with global left ventricular systolic dysfunction. the lvef was mildly depressed at 45%. the effective forward lvef was moderately depressed at 35%. no cmr evidence of myocardial edema. 2. normal right ventricular cavity size and systolic function. the rvef was normal at 57%. 3. moderate mitral regurgitation. 4. the indexed diameters of the ascending and descending thoracic aorta were normal. the main pulmonary artery diameter index was normal. 5. mild right atrial enlargement. 6. a note is made of bilateral pleural effusions and a hiatal hernia. microbiology respiratory virus screen 4:00 pm rapid respiratory viral screen & culture source: nasopharyngeal swab. respiratory viral culture (pending): respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. mycolytic blood cx 7:06 pm blood culture ( myco/f lytic bottle) source: line-poc. blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. bal 10:15 am bronchoalveolar lavage bronchial lavage. vic will also r/o cmv. reported to and read back by at 1320. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~/ml commensal respiratory flora. legionella culture (final ): no legionella isolated. potassium hydroxide preparation (final ): no fungal elements seen. this is a low yield procedure based on our in-house studies. koh performed per . immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (final ): yeast. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): afb grown in culture; additional information to follow. viral culture: r/o cytomegalovirus (final ): test cancelled, patient credited. please refer to viral culture for result. viral culture (preliminary): no virus isolated. sputum cx 12:25 pm sputum source: induced. gram stain (final ): pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): gram positive cocci. in pairs. respiratory culture (final ): sparse growth commensal respiratory flora. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (final ): yeast. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): reported to and read back by dr., and , @ 15:30, . afb grown in culture; additional information to follow. sent to state lab for further identification . - per verbal report from state lab, probe of plated organism + legionella negative **final report ** cmv igg antibody (final ): positive for cmv igg antibody by eia. 35 au/ml. reference range: negative < 4 au/ml, positive >= 6 au/ml. cmv igm antibody (final ): negative for cmv igm antibody by eia. interpretation: infection at undetermined time. a positive igg result generally indicates past exposure. infection with cmv once contracted remains latent and may reactivate when immunity is compromised. if current infection is suspected, submit follow-up serum in weeks. greatly elevated serum protein with igg levels > mg/dl may cause interference with cmv igm results. all blood cxs no growth/pending. discharge labs complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 05:26 5.0 2.84* 9.2* 27.3* 96 32.3* 33.6 17.9* 23* differential neuts bands lymphs monos eos baso atyps metas myelos nrbc 05:26 85* 0 4* 11 0 0 0 0 0 renal & glucose glucose urean creat na k cl hco3 angap 05:26 901 29* 1.7* 141 4.2 107 23 15 enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili indbili 05:26 24 23 243 142* 0.5 free kappa/lambda light chains pending brief hospital course: 75 yo w with recurrent/refractory multiple myeloma, recent parainfluenza virus infection, presenting with increased dyspnea, transferred to for management of hypoxia . # dyspnea/hypoxia: likely multifactorial in etiology. patient has an element of volume overload from acute congestive heart failure, supported by bnp of 33k, bilateral pleural effusions, and improvement with initial bipap and iv lasix boluses. she also demonstrated multifocal opacities on ct chest, concerning for bacterial pna (and potentially invasive aspergillus). given her immunocompromised state she was immediately started on broad antimicrobials (vancomycin, cefepime, and azithromycin) and extensive studies for bacterial, viral, and fungal pathogens were sent. respiratory culture was positive for parainfluenza iii. sputum grew gram positive cocci from one induced culture that were further speciated to respiratory flora. a bronchoscopy was performed and revealed alveolar hemorrhage. per infection control, pt needs to stay on droplet precautions until parainfluenza negative. . after stabilization, she was called out to the bmt floor. she received ivig x1 for the paraflu, and we continued her abx for a 14 day course. she did well and her oxygenation improved to the point that her ambulatory saturation did not dip below 91. the patient then started to have afb + cultures (x 3), and id was consulted. she was empirically started on a brief course of linezolid, imipenem, and clarithromycin as she will likely require chemotherapy soon for her myeloma. however, the state lab probed her cx which was + for , and her regimen was changed to rifabutin, ethambutol, and clarithromycin. she will require a baseline eye exam as an outpatient, and she has close f/u with oncology and infectious disease. . # acute congestive heart failure: patient presented with dyspnea and hypoxia (as above). cxr revealed b/l pleural effusions. bnp was elevated at 33k. echocardiogram revealed ef of 30% with severe hypokinesis of the inferior wall and basal 2/3rds of the septum and anterior wall, which was new from her prior echo in . cardiac biomarkers did not support acute coronary syndrome. cardiology was consulted and recommended starting low dose beta-blocker and uptitrating as needed to provide rate control and augment cardiac output. initiation of ace-inhibitor was deferred until hemodynamic stability was assured. the etiology of her cardiomyopathy is unclear. amyloid was considered (spep negative, upep was +), as well as parainfluenza virus, velcade (very rare), or a missed ischemic cardiac event. . out of concern that the echo showed coronary distribution hypokinesis, a cardiac mr was done which was c/w chemo induced cardiomyopathy, not a coronary issue. the repeat study showed an ef of ~ 45%. the cmr also did not show any signs of amyloid involvement. a cardiology c/s was recalled to assist with cm management, and metop was uptitrated to 37.5 potid, and lisinopril was started and titrated to 5 mg po daily, which she tolerated well. on discharge, her metop was changed to long acting toprol xl 100 mg po daily. . # multiple myeloma: diagnosed in and s/p auto sct in . currently on c1d1 of cytoxan/velcade/decadron on . had increase of lytic lesions while on prior bendamustine. anc on admission was approaching neutropenia, so the patient was placed on neutropenic precautions. hematolog/oncology followed closely and provided daily recommendations. we transfused to maintain platlets >20 and hct >25. she was continued on her prophylactic acyclovir, inhaled pentamidine (last dose 3/17), and current dexamethasone. per onc recs, her pentamidine was held. her pain and other symptoms were controlled. given the need for chemotherapy soon, she was placed on tx for mac (see above). she has close f/u with oncology scheduled. . # word finding difficulty: pt endorsed word finding difficulty a few hours after bronchoscopy. given concern for possible pulmonary/systemic fungal infection, aspergillosis or even mucor, vs acute embolic event, she was sent for mri wo contrast. neurological exam was negative for any focal findings. preliminary read on mri was negative for acute infarct, notable for chronic small vessel disease, mild atrophy, and skull deformities in l frontal/parietal/clivus/cervical vertebrae c/w known multiple myeloma. a neuro c/s was called, and as the patient improved, the thought was that this was toxic/metabolic causes from acute infection. the word finding difficulty resolved over time, and she was set up for outpatient f/u appointment in neurology. . # chronic kidney injury: related to multiple myeloma. cr currently uptrending in the setting of diuresis. baseline 1.4-1.8. trended and was stble throughout stay. all medications were renally dosed. . # prolonged pt: likely secondary to nutritional deficiency and/or recent antibiotic use. she was given 1 dose of po vitamin k 5 mg for repletion and inr improved. . # paroxysmal atrial fibrillation: held asa 81 daily given low plts and monitored on telemetry. pt was tachycardic and not on nodal blocking as outpatient. last ekg shows st with frequent pacs. troponins peaked (othwer biomarkers flat), likely heart failure/demand in setting of cki. per cards, started low dose bb. metoprolol 12.5 tid was started with subsequent improvement in rate and uptitrated to 25mg tid per cards rec. they attribute cardiomyopathy to chemotherapy and anticipate improvement w time. as above, these medications were continued to be titrated to metop succinate 100 po daily as well as lisinopril 5 mg for afterload reduction . # hypothyroidism: continued outpatient levothyroxine 112mcg daily. . # hiatal hernia: continued ranitidine 150 mg daily (home dosage unknown), to restart home dose at discharge (25 mg effervescent tab). medications on admission: -cetirizine 10 mg tab 1 (one) tablet(s) by mouth once a day -emla 2.5 %-2.5 % topical cream apply to poc site prior to blood draw -caltrate 600+d plus minerals 600 mg-400 unit tab 1 tablet(s) by mouth once a day -nystatin 100,000 unit/ml oral susp 5 cc(s) by mouth four times a day swish and spit as needed -vitamin c 500 mg tab 1 tablet(s) by mouth once a day will hold during radiation treatment -triamcinolone acetonide 0.1 % topical cream apply to affected area twice per day do not use on face. -aspirin 81 mg chewable tab 1 tablet(s) by mouth once a day -acetaminophen 325 mg tab 1 to 2 tablet(s) by mouth every hours as needed -ativan 0.5 mg tab tablet(s) by mouth q4-6 as needed for nausea, insomnia -milk of magnesia 400 mg/5 ml oral susp suspension(s) by mouth as needed for constipation -furosemide 20 mg tab 0.5 (one half) tablet(s) by mouth once a day in the morning. presently on hold per patient -alprazolam 0.5 mg tab 2 tablet(s) by mouth one hour before procedure. take additional 0.5 mg tablet if needed. -dexamethasone 4 mg tab 0.5 (one half) tablet(s) by mouth once a day icd-9 code: 203.00 -prochlorperazine maleate 5 mg tab tablet(s) by mouth every eight (8) hours as needed for nausea -promethazine 12.5 mg tab tablet(s) by mouth q 8 hours as needed for nausuea -anti-itch 0.5 %-0.5 % lotion apply to affected areas three times a day as needed for itching -colace 100 mg cap 1 capsule(s)(s) by mouth twice a day as needed for constipation levothyroxine 112 mcg tab 1 tablet(s) by mouth once a day -nebupent 300 mg solution for inhalation 300 mg(s) inhaled every month for 6 months diluted in 6 ml sterile water administered via aerosol. please administer 2 puffs of albuterol prior to treatment as needed. -oxycontin 10 mg 12 hr tab 1 to 2 tablet(s) by mouth every eight (8) hours -oxycodone 5 mg cap 1 - 2 capsule(s) by mouth every four (4) hours as needed for breakthrough pain -b complex cap one capsule(s) by mouth daily -acyclovir 400 mg tab 1 tablet(s) by mouth two times a day -folic acid 1 mg tab 1 tablet(s) by mouth once a day -ranitidine 25 mg effervescent tab -ondansetron hcl 4 mg tab 1 to 2 tablet(s) by mouth every eight (8) hours as needed for nausea icd-9 code: 203.00 -cetirizine 10 mg tab 1 (one) tablet(s) by mouth once a day discharge medications: 1. rifabutin 150 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 2. ethambutol 400 mg tablet sig: two (2) tablet po days (mo,we,fr). disp:*24 tablet(s)* refills:*2* 3. clarithromycin 250 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 5. toprol xl 100 mg tablet extended release 24 hr sig: one (1) tablet extended release 24 hr po once a day. disp:*30 tablet extended release 24 hr(s)* refills:*2* 6. caltrate 600 + d oral 7. nystatin 100,000 unit/ml suspension sig: five (5) cc po four times a day as needed for thrush. 8. vitamin c oral 9. triamcinolone acetonide 0.1 % cream sig: one (1) appl topical twice a day as needed for rash. 10. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever, pain. 11. ativan 0.5 mg tablet sig: 1-2 tablets po every 4-6 hours as needed for nausea or anxiety. 12. milk of magnesia 400 mg/5 ml suspension oral 13. dexamethasone 2 mg tablet sig: one (1) tablet po daily (daily). 14. emla topical 15. alprazolam 0.5 mg tablet sig: two (2) tablet po asdir as needed for before procedure: take 1 hr before procedure. 16. prochlorperazine maleate 5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 17. promethazine 12.5 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 18. sarna anti-itch topical 19. colace 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation. 20. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 21. nebupent 300 mg recon soln inhalation 22. oxycodone 10 mg tablet extended release 12 hr sig: tablet extended release 12 hrs po every eight (8) hours. 23. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 24. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 25. acyclovir 400 mg tablet sig: one (1) tablet po daily (daily). 26. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 27. ranitidine hcl 25 mg tablet, effervescent sig: one (1) tablet, effervescent po once a day. 28. zofran 4 mg tablet sig: 1-2 tablets po every eight (8) hours as needed for nausea. 29. cetirizine 10 mg capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: primary diagnosis pneumonia secondary diagnoses mycobacterium avium intracellulare multiple myeloma parainfluenza 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 during your hospitalization. you were admitted to with shortness of breath and were in the icu because you needed to have assistance with your breathing. you were treated with antibiotics for 14 days for a bacterial pneumonia, and you were given ivig because you were para-influenza positive. finally, we found acid-fast bacilli in your sputum multiple times which required you to stay on precautions while here. infectious disease saw you while you were here and they felt you could be discharged with three drugs to treat mac before your next round of chemo. we also had our cardiologists see you who added on medicine to keep your heart healthy. we also had our neurologists see you because of some word-finding difficulty, and they would like to see you in clinic. please make the following changes to your medications - stop taking lasix - stop taking aspirin - decrease your acyclovir to 400 mg by mouth daily - start taking rifabutin 150 mg by mouth daily - start taking ethambutol 800 mg by mouth every mon, wed, fri - start taking clarithromycin 250 mg by mouth daily - start taking metoprolol succinate (toprol xl) 100 mg by mouth daily - start taking lisinopril 5 mg by mouth daily please follow up with you physicians as indicated below followup instructions: you will be contact by the /bmt department regarding an appointment on monday with . **you should also schedule an eye exam in the next week since you are on ethambutol ** otherwise, these are the appointments for your follow up: department: when: wednesday at 1:45 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/bmt when: thursday at 1:30 pm with: , md building: sc clinical ctr campus: east best parking: garage department: neurology when: tuesday at 1:30 pm with: drs. & building: sc clinical ctr campus: east best parking: garage procedure: non-invasive mechanical ventilation closed [endoscopic] biopsy of bronchus diagnoses: other chronic pain abnormal coagulation profile mitral valve disorders congestive heart failure, unspecified acute kidney failure, unspecified unspecified acquired hypothyroidism atrial fibrillation candidiasis of mouth chronic kidney disease, unspecified diaphragmatic hernia without mention of obstruction or gangrene peripheral stem cells replaced by transplant acute respiratory failure primary pulmonary hypertension antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use acute systolic heart failure metabolic encephalopathy drug induced neutropenia backache, unspecified bacterial pneumonia, unspecified disseminated due to other mycobacteria other secondary thrombocytopenia secondary cardiomyopathy, unspecified 

Answer: The patient is high likely exposed to