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 / sulfa (sulfonamide antibiotics) / vancomycin analogues / tape "x10yd / lisinopril / bactrim / pentamidine isethionate attending: chief complaint: dyspnea and chest pain major surgical or invasive procedure: dialysis kidney graft biopsy history of present illness: 66 yo f w/ h/o polycystic kidney dz s/p 2 nephrectomies and transplant in , c/b ureteral stricture and obstruction requiring nephrostomy tube and recent admission for cmv viremia, uti requiring re-initiation of hd (t/th/sa), p/w cp and sob. . patient presents w/ cp and sob x 1 day. she was seen by outpt on where she complained of fatigue and shortness of breath. she was in sinus rhythm. . of note patient recently d/c'd from (). she was admitted for cmv viremia, uti, worsening ri requiring restarting of dialysis. her cmv vl 70,000s, she was reated with iv ganciclovir then po valcyte. in regards to her uti, urine cx notable for vanc sensitive enterococcus and she was treated w/ linezolid. on that admission, she developed hypotension, afib w/ rvr and renal failure to atn in the setting of hypotension. . in the ed, initial vs were: t 98, hr 57, bp 129/71, rr 15, o2 98% 10l. on exam she was tachypneic. she desated to high 80s and was placed on a non-rebreather. her labs were notable for wbc 6, hct x, plt abd pmn 76.5% pmn, inr 1.3, cr 3.1, hco3 34, trop 0.06. cxr evidence for volume overload. past medical history: -pkd s/p b/l nephrectomy , ecd kidney transplant -htn -endometrial ca s/p tah/bso -afib/flutter on amiodarone and coumadin s/p cardioversion -primary hyperparathyroidism -c.difficile colitis -hypothyroidism -mitral and tricuspid regurgitation -systolic dysfunction with ef 40-45% (tte ) psh: - - ecd kidney transplant and vhr with mesh - - rue av fistulogram, balloon angioplasty - - b/l nephrectomies for pkd - - rue brachiocephalic av fistula - - appendectomy and incisional hernia repair with mesh - - tah/bso for endometrial ca - - hysteroscopy - - hemorrhoidectomy and drainage of perirectal hematoma - - r hemithyroidectomy and excision of r parathyroid adenoma, neck exploration social history: her daughter, son in law and 3 grandchildren (6yo, 18mo, 3mo) live with her. lives with daughter, husband died . 2 daughters. former middle school teacher. no tobacco, etoh or drugs. family history: father and daughter both with pkd. no fh of ovarian, colon, breast, or endometrial ca. no family history of early mi, arrhythmia, cardiomyopathies, or sudden cardiac death. physical exam: physical exam on admission: vitals: 97.1 56 135/66 18 100% on non-rebreather general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp elevated to mandible, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: crackles throughout abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly ext: 2+ edema to mid-calf, dopplerable pulses. physical exam on discharge: vitals: tm, tc 99.2, 95-121/45-79, 90-102, rr 20, 100% ra. 24 hr output: from nephrostomy tube: 620ml yellowish fluid, no blood. general: well-appearing woman, comfortable, nad heent: mucous membranes moist, perrl, no lad neck: no elevated jvp cardiac: irregularly irregular rhythm, tachycardic rate, nl s1, s2, no mrg lungs: ctab, no wheezes or rales abdomen: soft, nontender, nondistended, urostomy in place with dressing c/d/i, biopsy site mildly tender with dressing c/d/i. subcutaneous nodularity palpated in bilateral lower abdomen. back: no cva tenderness pertinent results: 01:15pm blood wbc-4.7 rbc-2.75* hgb-8.3* hct-26.6* mcv-97# mch-30.0 mchc-31.1 rdw-19.7* plt ct-96* 03:45am blood neuts-76.5* lymphs-21.9 monos-0.6* eos-0.8 baso-0.2 01:15pm blood pt-19.7* inr(pt)-1.8* 01:15pm blood urean-23* creat-3.1* na-140 k-4.4 cl-97 hco3-34* angap-13 01:15pm blood alt-12 ast-18 totbili-0.7 03:45am blood ck-mb-2 probnp-* 01:15pm blood albumin-3.3* calcium-9.7 phos-3.5 01:15pm blood tacrofk-7.6 pertinent results : bk virus, qn pcr no dna detected : heparin dependent antibodies equivocal ekgs: : baseline artifact. sinus bradycardia. q-t interval prolongation. st-t wave abnormalities. since the previous tracing there is no significant change.clinical correlation is suggested. imaging: cxr : impression: mild-to-moderate pulmonary edema. cxr : moderate cardiomegaly is accompanied by pulmonary vascular engorgement and worsening perihilar and basilar pulmonary edema, now moderate in severity. small-to-moderate bilateral pleural effusions are present, with worsening on the right in the interval. cxr : interval placement of endotracheal tube, with tip terminating about 6.5 cm above the carina. nasogastric tube courses below the diaphragm with tip outside of the field of view. cardiac silhouette is upper limits of normal in size. perihilar and basilar edema have slightly improved, and are accompanied by bilateral pleural effusions, moderate on the right and small-to-moderate on the left. tte : he left atrium is elongated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). the right ventricular cavity is mildly dilated with normal free wall contractility. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. the end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. there is a trivial/physiologic pericardial effusion. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. pulmonary artery hypertention. right ventricular cavity enlargement with preserved free wall motion. at least mild-moderate mitral regurgitation. compared with the prior study (images reviewed) of , the estimated pulmonary artery systolic pressure and the right ventricular cavity size are increased. the severity of mitral regurgitation is likely similar. if clinically indicated, a tee would be better able to assess the severity of mitral regurgitation. : 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). left atrial appendage doppler pattern is most consistent with atrial flutter. no atrial septal defect is seen by 2d or color doppler. right ventricular chamber size and free wall motion are normal. there are complex (>4mm, non-mobile) atheroma in the aortic arch. the aortic valve leaflets (3) are mildly thickened. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is no pericardial effusion. impression: mildly thickened mitral leaflets with moderate mitral regurgitation. complex, non-mobile, thoracic aortic atheroma. no thrombus, but atrial flutter functional pattern of the left atrial appendage. radiology chest (portable ap) comparison is made to prior study performed a day earlier. moderate pulmonary edema has improved. mild cardiomegaly is stable. engorgement of the vessels in the mediastinum has improved. right ij catheter tip is in the upper svc. bilateral pleural effusions, moderate on the right and small-to-moderate on the left have decreased. bibasilar atelectases have improved. there are no new lung abnormalities. needle kidney biopsy: conclusion: successful ultrasound-guided renal transplant biopsy. kidney biopsy pathology - pending micro: cmv viral load undetectable urine culture - mixed flora blood culture no growth blood culture no growth coag negative staph (only 1 bottle) brief hospital course: this is a 66 yo f w/ h/o polycystic kidney dz s/p 2 nephrectomies and transplant in , c/b ureteral stricture and obstruction requiring nephrostomy tube and recent admission for cmv viremia, uti requiring re-initiation of hd (t/th/sa), p/w cp and sob. . # respiratory distress: the cxr on admission was consistent with volume overload. she did not respond to lasix from the ed. pt was initially admitted to micu, started on hd and had a negative 3l. pt was therefore transferred to regular floor. however, the second day, pt developed acute respiratory distress, requiring immediate intubation and mechanical ventilation. she was admitted back to micu. the etiology for sudden respiratory distress was unclear. there was no evidence of acs, worsening valvular disease, pe, or pneumonia. given the lack of other explanations, flash pulmonary edema in the setting of a-fib was most likely. pt was treated with ultrafiltration for fluid removal. she had hypotension requiring pressor support. the hypotension appears to be associated with ultrafiltration. pt was extubated on micu day #4, and no oxygen requirement or respiratory complains on the medical floor. her symptoms were very likely caused by hypervolemia and perhaps flash pulmonary edema. . # pancytopenia: pt was found to have developed profound thrombocytopenia in the past two weeks. there is also evidnece of anemia and leukopenia, although to a less degree. the cause of her thrombocytopenia vs pancytopenia is unclear, but likely multifactorial. possible etiology includes medication, including linezolid, valganciclovir, cellcept, dapsone vs infectious from cmv or other unidentified viral etiology. workup was negative for intragraft hemolysis, ebv, and parvovirus. hit antibody was borderline positive (od0.421 with 6% supression with heparin). given the clinical context, hit was thought highly unlikely per hematology consult. we discontinued linezolid on , which was started for enterococcus uti. dapsone and ranitidine were also discontinued. her immunosuppressive medications were also reduced. her wbcs recovered to 6.3k, hct 24.8, and platelets recovered and were 290k on discharge. pt was discharged on her new lower dose of tacrolimus. her dapsone was restarted at her prior dose, but ranitidine was not restarted given her absence of symptoms and its possible contribution to her pancytopenia. she can continue to receive epogen at her dialysis unit as needed for her chronic anemia secondary to renal disease. . # atrial fibrillation: pt was found intermittently in a-fib rhythm. we continued her amiodarone, but initially beta-blocker given the concern of hypotension. her warfarin was stopped and she was treated with a heparin drip prior to her renal biopsy. given her chads2 score of 2, pt was restarted on warfarin without bridging after her biopsy. she remained tachycardic to 120s and her metoprolol tartrate was doubled from 12.5mg to 25mg po bid, which did lower her hr to 90s. this was continued on discharge and may be addressed by her cardiologist. pt's inr was not therapeutic on discharge at 1.1 and will need to be monitored closely in clinic. . # ckd s/p bilateral nephrectomy, ecd renal transplant: has recently been re-initiated on hd (t/th/sa). she was treated with tacrolimus and mycophenolate, both of which were renally dosed. we discontinued her dapsone in the setting of pancytopenia, but this was restarted on discharge (see above). her dose of tacrolimus was also lowered. throughout her course, pt continued to have good urine output from her renal graft / nephrostomy. a renal biopsy was performed on , with final path still pending. however, prelim path showed chronic inflammation and some scarring, although the cause of this (infectious vs acute rejection) remained unclear. pt vociferously stated dissatisfaction w/ the graft and made it very clear that her utis made her very ill and that she would prefer to have the graft removed since she has remained dialysis dependent. the team has postponed this step until pt can discuss the potential risks and benefits fully with dr. , her primary , and dr. , her transplant surgeon, which we have arranged for shortly after discharge. pt will be discharged with nephrostomy in place and reduced immunosuppressants (see above). . # hld: continued pravastatin 20 mg daily . # hypothyroidism: continued synthyroid. . transitional issues: -final pathology of renal biopsy is still pending. pt will need to have a discussion regarding her desire to have the graft removed with her and transplant surgeon. -pt's inr was not therapeutic on discharge. she was not bridged due to her low chads2 score. this will need to be followed closely until her inr is stably therapeutic. -pt's metoprolol was increased due to afib causing tachycardia to 120s. this may be difficult given her tendency to be hypotensive during dialysis. a discussion between her nephrologists and cardiologists may be helpful to determine the optimum dosing for rate control while avoiding hypotension. medications on admission: medications: from discharge summary amiodarone 200 mg daily dapsone 100 mg daily levothyroxine 75 mcg daily mycophenolate sodium 180 mg pravastatin 20 mg daily metoprolol tartrate 12.5 valganciclovir 450 mg every other day ranitidine hcl 150 mg daily linezolid 600 mg (???3 more days) warfarin 1 mg daily nephrocaps 1 mg daily nystatin qid tacrolimus 0.5 mg for 2 weeks then tacrolimus 1 mg ** per patient is taking 2.5mg zofran odt 4 mg prn discharge medications: 1. amiodarone 200 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 3. mycophenolate sodium 180 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po bid (2 times a day). 4. pravastatin 20 mg tablet sig: one (1) tablet po daily (daily). 5. valganciclovir 450 mg tablet sig: one (1) tablet po every other day. 6. tacrolimus 0.5 mg capsule sig: three (3) capsule po q12h (every 12 hours). disp:*90 capsule(s)* refills:*0* 7. nephrocaps 1 mg capsule sig: one (1) capsule po once a day. 8. nystatin 100,000 unit/ml suspension sig: five (5) ml po four times a day as needed for thrush: orally swish 4 times daily for thrust. 9. zofran odt 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po every eight (8) hours as needed for nausea. 10. dapsone 100 mg tablet sig: one (1) tablet po once a day. 11. warfarin 1 mg tablet sig: one (1) tablet po once daily at 4 pm. 12. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*0* 13. outpatient lab work please check inr on and during dialysis, and fax results to dr. , . discharge disposition: home discharge diagnosis: primary: -hypervolemia -acute on chronic renal failure -congestive heart failure secondary: -atrial fibrillation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: ms. , you came to the hospital because you had shortness of breath, chest pain, and an irregular heartbeat. you were found to have excessive fluid in your body, and this fluid was removed with dialysis. your condition may have been due to the function of your transplanted kidney. you had significant improvement once you started dialysis. you were also found to have low counts of white and red cells as well as platelets in your blood. this was thought to be due to several medications that you were receiving, including ranitidine and linezolid, and these were either stopped. your blood cell counts recovered after stopping the mediations in question and lowering your immunosuppressants. you had a renal biopsy, which showed that your kidney graft was damaged, but it remains unclear whether this is due to your prior infections or graft rejection. your kidney doctors will discuss your therapeutic options when you see them in clinic after they have thoroughly reviewed the final pathology studies, which have not yet been completed. you also had a mildly elevated heart rate. we increased your metoprolol, and you may wish to discuss this with your cardiologist dr. . your warfarin was held during your hospitalization prior to your renal biopsy and was restarted afterwards. you will need to have your inr checked during dialysis and have the results faxed to dr. office at . we have made the following changes to your medications: -stop ranitidine -decrease your tacrolimus to 0.5mg tablets, 3 tabs every 12 hours. -increase your metoprolol to 25 mg tablets, 1 tab every 12 hours please continue to take your other medications as previously prescribed. we have made follow-up appointments for you with your primary care physician, , and your transplant surgeon (see below). followup instructions: department: transplant center when: at 11:40 am with: , md building: lm campus: west best parking: garage department: - adult med when: wednesday at 12:50 pm with: , md building: (, ma) campus: off campus best parking: free parking on site dialysis phone: schedule: tue//sat *your will follow up with you for your hospitalization at your next dialysis. we are working on a follow up appointment of your hospitalization in transplant with dr. within 1 week. the office will contact you at home with an appointment. if you have not heard within 2 business days or have any questions or concerns. please call . md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours diagnostic ultrasound of heart hemodialysis closed [percutaneous] [needle] biopsy of kidney diagnoses: anemia in chronic kidney disease end stage renal disease mitral valve disorders urinary tract infection, site not specified unspecified acquired hypothyroidism atrial flutter acute respiratory failure other and unspecified angina pectoris antiviral drugs causing adverse effects in therapeutic use cardiogenic shock streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] acute on chronic systolic heart failure other specified antibiotics causing adverse effects in therapeutic use complications of transplanted kidney epistaxis hypotension of hemodialysis acute edema of lung, unspecified polycystic kidney, unspecified type other artificial opening of urinary tract status primary hyperparathyroidism hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage v or end stage renal disease other drug-induced pancytopenia antacids and antigastric secretion drugs causing adverse effects in therapeutic use 

Answer: The patient is high likely exposed to