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: mr. is a 36-year-old male with newly diagnosed hiv who was transferred from an outside hospital with acute renal failure, hemolytic anemic, thrombocytopenia, and transaminitis. the patient was originally admitted to on . the patient migrated originally from approximately three years ago and reported being in his usual state of good health until four days prior to admission. on the day of presentation, the patient reported he had the onset of sharp, non-radiating chest pain, chills, weakness, and a headache. ekg at that time upon presentation was significant for t wave inversion in v1-v6 and rsr prime in v1. white blood cell count upon admission was noted to be 1,800, hematocrit 35.2, platelet count 134,000 with creatinine 1.1. the patient was also noted to have elevated alkaline phosphatase at 153 and an elevated ast at 83. the patient was placed on respiratory precautions and was started on ceftazidime for neutropenia and fevers. the patient also complained of back pain and a bone scan was obtained where the results were negative. a transthoracic echocardiogram was also performed which revealed normal left ventricular function and no valvular abnormalities. a cd4 count was obtained which was found to be 15 and an hiv antibody test was sent which subsequently returned as positive. the patient was started on highly active antiretroviral therapy, bactrim prophylaxis, and neupogen at the outside hospital at that time. ceftazidime was subsequently discontinued on . the patient subsequently had a lumbar puncture and a bone marrow biopsy at the outside hospital. at , the patient's course was subsequently complicated by acute renal failure after the institution of haart therapy and also anti-tuberculous medication. the patient was also noted to have acute renal failure and hemolytic anemia with a positive coombs test. the patient was also noted to have elevated transaminases. the patient was subsequently transferred to for further workup and evaluation for possible hemolytic anemia syndrome/thrombocytopenia purpura and requiring possible plasmapheresis. past medical history: none reported. allergies: no known drug allergies. medications upon presentation: the patient was taking no medications as an outpatient. upon transfer to the medical intensive care unit, the patient was on iv ig 20 grams q. day four out of five, diflucan 400 mg iv q. day, phenergan 2 mg im q. 6 hours p.r.n., neupogen 200 mg subq. q. 24 hours, biaxin 500 mg p.o. q. 12 hours, pyridoxine 25 mg p.o. q. day, zantac 50 mg p.o. q. day, 3tc 40 mg p.o. b.i.d., d4t 150 mg p.o. b.i.d., ziagen 200 mg p.o. b.i.d., ethambutol 1000 mg p.o. q. day. family history: noncontributory. social history: the patient worked with chemicals. further details cannot be elicited. the patient has a 10 pack year history of smoking. the patient lives with his brother and sister in . he immigrated from approximately three years ago. physical examination on presentation: temperature was 102.3, blood pressure 113/51, heart rate 110, respiratory rate 30, saturating at 100% on 4 liters nasal cannula. in general, the patient was a cachectic male, tachypneic, in mild respiratory distress. heent examination was normocephalic, atraumatic. sclerae were icteric. oropharynx was dry. positive thrush and positive jaundice were noted underneath the tongue. pulmonary examination was clear to auscultation bilaterally. cardiac examination revealed tachycardia with no murmurs, rubs, or gallops. abdominal examination revealed positive hepatosplenomegaly, mild distention of the abdomen. extremity examination revealed no cyanosis, clubbing, or edema. pulse examination revealed 2+ dorsalis pedis and posterior tibialis pulses. on neurologic examination, the patient was alert and oriented times three. cranial nerves ii-xii were intact. no motor weakness was noted. deep tendon reflexes were 2+ in the biceps, triceps, brachioradialis, patella, and ankle. radiography: radiological studies from the outside hospital revealed ct of the abdomen, torso, and chest on showing lymphadenopathy 1-2 cm in diameter in the mediastinum. there was no lung or pleural disease. abdominal ct revealed hepatosplenomegaly. bone scan on was negative. chest x-ray on revealed minimal cardiomegaly. kub on revealed normal results. laboratory data: laboratory studies upon presentation to evidence white blood cell count , hemoglobin 6.6, hematocrit 19.4, platelets 24,000, mcv 77, rdw 13.2, pt 18.2, ptt 51.6, inr 1.2, sodium 125, potassium 5.7, chloride 89, bicarbonate 16, bun 80, creatinine 5.7, glucose 103, albumin 2.8, calcium 7.7, magnesium 2.6, phosphorus 2.7, alt 97, ast 590, alkaline phosphatase 549. ck enzyme revealed 2,159. arterial blood gas upon admission revealed ph 7.51, pco2 25, pao2 21. ekg revealed sinus tachycardia wave inversions in v1-v5. hospital course: this is a 36-year-old male with newly diagnosed hiv with a cd4 count of 15 and viral lode of 50,000 who presented from an outside hospital for further workup for his acute renal failure, hemolytic disease, thrombocytopenia, and transaminitis. neurologic: during the hospital course, the patient had an episode of mental status changes. given the fact that the patient was thrombocytopenic, a head ct was obtained to rule out intracranial bleed. no intracranial bleed was noted. a lumbar puncture was performed during the hospital course which was negative and did not reveal any evidence of infection. cardiac: upon transfer to , the patient was noted to be tachycardiac and he remained persistently tachycardiac and was noted on multiple ekgs to have sinus tachycardia. by ck enzymes, the patient had elevated cks up to the 1000s, however, did not rule in by ckmb indexes which were negative. during the hospital course, however, the patient remained in persistent tachycardia and chest x-ray revealed cardiomegaly. a cardiac echocardiogram was performed which subsequently revealed a small pericardial effusion with tamponade physiology on cardiac echocardiogram. the patient had collapse of his right ventricle, partial collapse of his right atrium, and regurgitant inflow from his mitral and tricuspid valves consistent with tamponade physiology. the cardiology service was consulted for further evaluation and their recommendation was to follow pulsus paradoxus and ekgs daily as the patient remained hemodynamically stable at this time. pulsus paradoxus was initially noted to be 6 mmhg and subsequently increased to 10 mmhg. at the time of this dictation, the patient remained hemodynamically stable with a pulsus paradoxus of approximately 10 mmhg and ekgs did not reveal electrical alternans and no clinical evidence of tamponade. the patient's blood pressure remained stable in the 150-160/90-100 range. the cardiology service was aware of the patient and if the patient becomes relatively more hemodynamically unstable or shows clinical evidence of tamponade physiology, the cardiology service should be reconsulted for pericardial drainage placement. pulmonary: upon presentation to , the patient had no pulmonary respiratory problems. was originally started on tuberculosis medications at which contributed to his transaminitis and also the acute renal failure. upon presentation to , these medications were subsequently discontinued. during the hospital course, the patient was intubated for several days in order to obtain multiple studies as the patient had mild respiratory distress. during this time, a lumbar puncture, mri of the head and abdomen, bone scan, bone marrow biopsy, and lymph node biopsy were all obtained. after all these studies were obtained, the patient was subsequently rapidly extubated and subsequently did well with face mask oxygen and subsequently titrated down to nasal cannula, then back down to room air. infectious disease: upon presentation to , the patient was noted to be pancytopenic. a ct scan revealed lymphadenopathy in the mediastinum. a cd4 count was obtained which revealed it was 15. hiv antibody test was obtained at - which returned positive and viral lode was obtained which revealed 50,000. the patient was started on highly active antiretroviral therapy at prior to transfer to . upon transfer to , given the fact that the patient was in acute renal failure and had transaminitis, all his highly active antiretroviral therapy medications were discontinued. despite this during the hospital course, the patient continued to spike high temperatures to 104 degrees farenheit and subsequently had to be placed on a cooling blanket. all blood cultures drawn at were negative to date. blood cultures drawn here at were negative to date. however during the hospital course, the bone marrow biopsy performed at on the fungal culture grew out yeast. here at , a lymph node biopsy on pathology revealed budding yeast and on fungal culture grew out yeast also as per the pathologist. the pathology of the yeast was consistent with histoplasmosis duboisii an african variant. histoplasmosis urine antigen was positive after being sent from . at this time, the patient was started on ambazone for treatment of disseminated histoplasmosis. forty-eight hours after initiation of ambazone therapy, the patient subsequently defervesced and remained afebrile during the hospital course. all of his blood cultures have been negative to date and all fungal cultures from the blood have been negative to date. the only positive cultures were from the lymph node biopsy done here at and also the bone marrow biopsy performed at - which grew out yeast. upon review by pathology, it was consistent with histoplasmosis duboisii. the patient will continue on ambazone at the current dose of 5 mg/kg intravenously while in the hospital. the patient may be able to change over to itraconazole orally upon discharge as per infectious disease recommendations. during the hospital course, the patient was followed closely by the infectious disease service. as mentioned before, the patient's blood cultures have been negative to date. the patient's lumbar puncture and csf cultures have been negative to date. bronchial alveolar lavage cultures have been negative to date for viruses and bacteria. the patient's urine cultures were also negative to date. at this time, the patient's infectious disease source was thought to be disseminated histoplasmosis given the positive lymph node biopsy and culture and also the positive bone marrow culture. in regards to the patient's hiv therapy, the patient will not be started on haart therapy until the patient's anemia, leukopenia, and thrombocytopenia are relatively resolved. hematology: upon presentation to , the patient was noted to be anemic, thrombocytopenic, and leukopenic. a bone marrow biopsy performed at was relatively negative. however after institution of the haart therapy and also anti-tuberculosis therapy, the patient subsequently became further pancytopenic and developed severe anemia. a coombs test performed at was positive and the patient was subsequently transferred to for possible workup for hemolytic uremia syndrome/thrombotic thrombocytopenic purpura. upon arrival at , the patient was admitted to the medical intensive care unit where the hematology/oncology service was consulted. upon extensive evaluation of the patient's blood smear/slides, there was no evidence of schistocytes. there was no evidence of hemolytic uremia syndrome. as per the hematologist/oncologist, the patient probably has hiv idiopathic thrombocytopenic purpura rather than hemolytic uremia syndrome. during the hospital course, the patient had an episode of mild disseminated intravascular coagulopathy which required transfusion of fresh frozen plasma, platelet support, and blood support. during the hospital course, the patient was supported with transfusion with multiple units of packed red blood cells, platelets, and also fresh frozen plasma. as per the hematology/oncology consult service, gcsf was started for the patient's leukopenia. the patient's white count subsequently improved and remained stable approximately at 7,000. the gcsf as per hematology recommendation will be continued until the white count is greater than 10,000 as after the gcsf is discontinued, the white count would drop by half. during the hospital course, the patient was also noted to have splenic infarction of unclear etiology. hemoglobin electrophoresis was obtained which revealed that the patient had a hemoglobin s trait. urine protein electrophoresis and serum protein electrophoresis which were obtained during the hospital course were negative to date. upon lymph node biopsy, the pathology results revealed that the patient had evidence of kaposi's sarcoma in his lymph nodes. however given the fact that the patient was severely ill at this time, no reinstitution of haart therapy or chemotherapy will be started. if the patient recovers from his disseminated histoplasmosis, the patient will probably require followup with the hematologist/oncologist for followup of the kaposi's sarcoma. the patient may follow up with dr. upon discharge. gastrointestinal: upon arrival to - outside hospital, the patient's liver function tests were noted to be relatively within normal limits. however after institution of multiple medications, the patient's liver function tests subsequently began to rise. upon transfer to , the patient's ck enzymes subsequently continued to rise and seemed to have peaked at 5,000. alkaline phosphatase subsequently continued to rise and peaked at 600. ast subsequently began to rise and peaked in the 100s and ldh subsequently rose and peaked in the 3,000 range. after institution of ambazone, the patient's liver function tests subsequently began to trend downward. the patient's liver function tests were consistent with disseminated histoplasmosis. hepatitis serologies were sent which revealed that the patient was exposed to hepatitis b in the past but there was no active hepatitis b infection. he was also exposed to hepatitis a in the past with no active hepatitis a infection. iron studies were obtained which did not reveal that the patient had any evidence of wilson's disease. an mri of the abdomen and also multiple ct scans were obtained which revealed the patient had hepatomegaly and splenomegaly. mri of the abdomen to rule out histoplasmosis abscess in the spleen or liver revealed that the patient had infarcts in the spleen and subsequent hemoglobin electrophoresis revealed that the patient had hemoglobin s trait. during the hospital course, the patient also had multiple episodes of loose bowel movements. clostridium difficile cultures were negative and stool cultures were negative and no etiologies were found for the patient's diarrhea. renal: upon arrival to , the patient had normal bun and creatinine and renal function. creatinine was noted to be 1.1. however during the hospital course at , the patient went into acute renal failure with subsequent rise in his creatinine to 5.0 and upon transfer to , the patient's creatinine remained at 5 and subsequently peaked at 5.5. the nephrology service was consulted for help in care of the patient. the patient's renal function subsequently improved with aggressive intravenous fluid hydration. the patient's acute renal failure was thought secondary to acute tubular necrosis from dehydration and medication insult state. abdominal ct revealed the patient had diffusely enlarged kidneys bilaterally which were consistent with hiv nephropathy versus disseminated histoplasmosis to the kidney. the patient's renal function subsequently declined and seemed to have reached a plateau of approximately 2.0 and remained chronically at this level. the patient probably has chronic renal insufficiency given his hiv status and also his disseminated histoplasmosis. the patient's renal function should be followed closely. fluids, electrolytes, and nutrition: upon transfer to , the patient was noted to be hyponatremic thought secondary to the patient's volume state. the patient was subsequently corrected in regards to his sodium status and during the hospital course, the patient became hypernatremic thought secondary to the patient's hypovolemic state from his fevers and also his excessive water losses. after aggressive fluid hydration, the patient's sodium was corrected back to within normal limits. during the hospital course, the patient was initiated on ambazone therapy. the patient's potassium, magnesium, and calcium were replaced aggressively. the patient also had poor nutritional status. the patient's albumin was noted to drift downward during the hospital course to 1.6 as the patient was unable to tolerate much p.o. and the patient had decreased appetite. the patient had a picc line placed and total parenteral nutrition was initiated for nutritional support. lines and access: the patient upon admission to had a right internal jugular triple lumen central line placed which remained in for approximately 10 days. after this, a left double lumen picc line was placed and the right internal jugular central line was removed. code status: upon admission at , the patient's code status was reported to remain full code, full care. given the fact that the patient has a poor prognosis from disseminated histoplasmosis and his multiple medical issues, the code status should be readdressed. an addendum to this stat dictation will be performed at a later date in regards to multiple issues in this complicated patient. , m.d. dictated by: medquist36 procedure: spinal tap incision of lung parenteral infusion of concentrated nutritional substances fiber-optic bronchoscopy biopsy of lymphatic structure diagnoses: congestive heart failure, unspecified acute kidney failure, unspecified hypopotassemia human immunodeficiency virus [hiv] disease kaposi's sarcoma, lymph nodes infection by histoplasma duboisii, other 

Answer: The patient is high likely exposed to