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: compazine / zosyn attending: chief complaint: nausea, labored breathing major surgical or invasive procedure: cardiac catheterization endocardial biopsy history of present illness: 35yf with multiple medical problems (including sle, restrictive lung disease, global cardiomyopathy with severely depressed systolic function, nephrotic syndrome), with recent admission for nausea, vomiting, and diarrhea, re-admitted with shortness of breath, tachycardia, and persistent nausea. her symptoms began in (after a recent hospitalization), when she developed diarrhea (which she relates to her metoprolol). the diarrhea (multiple times daily, non-bloody, brown in color) initially improved but then worsened again. she then developed nausea, vomiting, and dry heaves, without abdominal pain, and was admitted on . she also reported worsening shortness of breath, 3 pillow orthopnea, and episodes of paroxysmal nocturnal dyspnea. she was felt to be intravascularly dry, so she was given iv fluids. she had a thorough workup for causes of her diarrhea (infectious, structural, medication related etc.) and was scheduled for gi follow up on . during the admission, an echocardiogram was performed, demonstrating worsening systolic function (ef 15-20%), but she was felt to be intravascularly dry, so her lasix was held. given the patient's concern that her diarrhea started at the same time as metoprolol (75mg daily), this medication was also stopped (and switched to carvedilol 3.125mg ). she was to have close follow up with her cardiologist. she had acute on chronic renal failure which returned to close to baseline (1.5) with iv fluids; she had a renal biopsy during that admission, the results of which are still pending. her imuran was initially held during the last hospitalization but was restarted after a conversation with her rheumatologist. during that hospitalization, her nausea was not fully explained, but there was a possibility that restarting her imuran may have contributed. her presentation today is similar. she has nausea and dry heaves (non-bloody, non-bilious), along with worsening shortness of breath/pnd/orthopnea. her husband (who follows her vitals closely) has noted increased blood pressures and heart rates since she was discharged from the hospital. given her worsened nausea and tachycardia to the 120's, he brought her to the hospital. she denies any history of blood clot (but had iufd at 21wks recently). in the ed, triage vitals were t97.6f, hr 124, bp 126/109, rr 18, sat 100%. she was given 4mg iv ondansteron x 2, in addition to ceftriaxone and azithromycin given an equivocal chest x-ray. she was transferred to the floor for further evaluation. her respiratory rate was noted to be as high as 33. on review of systems, she reports nausea and vomiting, as well as shortness for breath and orthopnea as above. diarrhea is unchanged. she denies fevers, chills, chest pain (but perhaps some chest "heaviness"), palpitations, pleuritic chest pain, cough, weakness, numbness, tingling, abdominal pain, constipation, hematemesis, hematochezia, urinary symptoms. past medical history: - sle: diagnosed in , manifested by kidney disease (membranous nephropathy by report of biopsy), facial rash, sjogren's syndrome, raynaud's phenomenon, and pleuritis - gastritis - restrictive lung disease: followed by dr. , noted to be moderate to severe on pfts completed 5/. - history of pancytopenia associated with varicella zoster infection - history of persistent thrombocytopenia - baseline proteinuria (cr 0.8-0.9 pre-pregnancy) - intrauterine fetal demise (at gestational age ~21wks) - right- and left-sided cardiomyopathy (ef estimated 15-20% in ) social history: patient is a computer programer in and married. she was accompanied at presentation by her husband and sister. she denies tobacco or etoh. family history: adopted physical exam: vitals: t94.5f (oral, repeat axillary temp was 95.4f), bp 120/94, hr 120, rr 40, sat 95%ra general: moon facies, chronically ill-appearing, tachypneic, in mild respiratory distress; malar rash present heent: eomi, perrl, anicteric, op clear heart: tachycardic without murmurs lungs: clear to auscultation bilaterally, no crackles appreciated back: no cva tenderness, no spinal tenderness abd: soft, non-tender, non-distended, + bowel sounds, no hepatosplenomegaly extremities: no clubbing, cyanosis; 1+ dp pulses bilaterally; 2+ pitting edema in feet to mid-shin bilaterally (l>r) neuro: a&o x 3 pertinent results: urine: yellow, hazy, specgr 1.022, ph 6.0, sm leuk, sm blood, 500 prot, rbc, few bacteria, 0-2 epi na 133 k 4.3 cl 101 hco3 18 bun 33 creat 1.4 gluc 100 ck: 13 mb: notdone trop-t: 0.04 alt: 29 ast: 34 ap: 121 tbili: 0.3 lip: 64 probnp: wbc 5.6 n:81.3 l:12.8 m:5.3 e:0.4 bas:0.2 hgb 12.1 hct 37.5 plt 137 mcv 96 pt: 11.7 ptt: 24.4 inr: 1.0 cxr pa/lat (prelim): retrocardiac opacification which may represent atelectasis vs. pneumonia; bibasilar effusions and increased hilar infiltrates suggestive of volume overload; stable moderate cardiomegaly. ecg : sinus tachycardia. leftward axis, normal intervals. twf in i, ii, v5-v6 (interpreted as pseudonormalization in ed, but unimpressive). : the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. the right atrial pressure is indeterminate. left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is severe global left ventricular hypokinesis (lvef = 15-20 %). no masses or thrombi are seen in the left ventricle. there is no ventricular septal defect. rv with severe global free wall hypokinesis. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the lv cavity size has increased and the lvef is slightly lower (lvef overestimated on prior study). rv dysfunction is now more prominent. . the left atrium is elongated. left ventricular wall thicknesses and cavity size are normal. there is moderate global left ventricular hypokinesis. quantitative (biplane) lvef = 33 %. right ventricular chamber size is normal with borderline normal free wall systolic function. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. . left ventricular wall thicknesses are normal. the left ventricular cavity is mildly dilated. there is moderate to severe global left ventricular hypokinesis (lvef = 30 %). right ventricular chamber size is normal. with borderline normal free wall function. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is moderate thickening of the mitral valve chordae. moderate to severe (3+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. significant pulmonic regurgitation is seen. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular cavity size is smaller, global systolic function is improved (quantitative biplane lvef 30% on review of prior study), and the severity of mitral regurgitation and estimated pulmonary artery systolic pressure are reduced. brief hospital course: 35yf with multiple medical problems (including sle, restrictive lung disease, global cardiomyopathy with severely depressed systolic function, nephrotic syndrome), with recent admission for nausea, vomiting, and diarrhea, admitted with shortness of breath, tachycardia, and persistent nausea. . #) cardiomyopathy: pt was initially admitted to the hospitalist service but transferred for cath and endocardial biopsy in the setting of worsening ef. her cardiomyopathy was thought to be due to lupus. peripartum cardiomyopathy was also considered however given the timing of onset and biopsy showing immune complexes seen on endocardial biopsy, lupus cardiomyopathy was thought to be more likely. she was treated with steroids, cytoxan, plasmaphoresis, ivig and supportive care, and improved from an ef of 15 to 33%. it is unclear which therapy led to improvement. she did require temporary ccu transfer for milrinone given worsening ef, however was weaned after a few days and transferred back to the floor in stable condition. her mitral regurgitation and hypertension also contributed to her poor forward flow, and htn improved with diuresis, hydralazine, lisinopril and amlodipine. . #) schf, volume overload: on admission, pt was clearly tachypneic but satting well on room air. reported 3 pillow orthopnea and paroxysmal noctural dyspnea, in the setting of recent d/c lasix and ivf resuscitation, le edema also suggested fluid overload. bnp extremely elevated at 65,187. she also had non-specific sxs concerning for hf including throat tightness and gi sxs. her sxs improved with diuresis and symptomatic management and she was discharged on oral torsemide. she was also treated with bp control and bblocker therapy. given her sob and le edema r>l, a le us was performed and showed no le clot, therefore pe was thought to be unlikely. . #) sle. pt diagnosed in , manifested by kidney disease previously membranous nephropathy, facial rash, sjogren's syndrome, raynaud's phenomenon, and pleuritis. previously followed by dr. at b&w, however has requested to transfer her care to after this admission. initially contined on plaquenil and imuran, as well as prednisone. plaquenil dc'd per rheumatology recs. cardiomyopathy and renal failure on current admission were felt to be manifestation of underlying lupus. rheumatology was consulted and recommended aggressive therapy with steriods, cytoxan and plasmapheresis. received solumedrol 1g daily x 3 followed by solumedrol 30mg iv q12hrs, which was uptitrated to 60 q 12 hrs and subseuquently tapered and she was ultimately discharged on prednisone 60mg orally daily. she was also placed on atovaquone pcp prophylaxis in the setting of immunosuppression. she recieved 1 dose of cytoxan 750mg on with mesna, cell counts with nadir on . prior to cytoxan, she received 7.5mg lupron for ovarian protection with plans to pursue egg harvesting for fertility as an outpatient. received 5 cycles of plasmapheresis. 3 doses of ivig was also administered given that pts hf continued to worsen during the hospital stay. additional plasmaphoreis was considered but held due to her continued improvement. . #) nausea/diarrhea. initially thought secondary to restarting imuran, however pt and husband attributed to bblocker therapy. most likely due to gut edema in the setting of right hf. gi was consulted and agreed however recommended ruling out infectious etiology given her immunosuppression; w/u was negative. she improved with symptomatic tx and treatment of her hh. . #) thrombocytopenia: pt bleeding from hd site , improved with cryo, platelets, and surgicel. patient developed thrombocytopenia with nadir of 68, likely multifactorial related to dilution, imunnosupression, and possibly pheresis. heme consulted and recommended removing asa, nsaids, all heparin products, f/u lfts, fibrinogen. platelet drop was too quick to be related to cytoxan and likelihood of developping 4t score is 3. hit ab negative. fibrinogen nomralized. thrombocytopenia quickly improved, however then fluctuated in the setting of cytoxan use. igg and igm aca negative, so unlikely to have prothrombotic state. . #) acute on chronic rf: pt with h/o sle nephritis. pt previously with membranous nephropathy on prior biopsy. she had repeat biopsy showing type 3,4,5 lupus nephritis. worsening renal failure with creatinine increased to 3.7 up from 1.4 on admission. urine lytes indicative of prerenal ischemia (feurea < 0.02%) +/- evolving atn likely from poor cardiac output/ cardiorenal syndrome. renal u/s show's no obstruction. while her renal function showed some initial worsening with diuresis, diuresis was continued due to continued volume overload, and creatinine remained stable. . # htn: bps improved with uptitration of hydralazine and addition of lisinopril. pt concerned that hydralazine may be causing joint pain. given this and her improved renal function, lisinopril was uptitrated and hydralazine discontinued. blood pressures stable . # anemia: likely due to acute renal disease, cytoxan therapy. pt was given one unit of prbcs while in patient and started on epo with good improvement in her crit. . # joint pain: ? medication side effect (ivig, hydralazine) vs lupus flare, however pt has never had joint pain with lupus flares in the past. hydralazine was discontinued, symptomatic relief with tylenol, pt. medications on admission: pantoprazole 40 mg po bid prednisone 15 mg qam and 5 mg qpm vitamin d 400 units daily calcium 500 mg twice daily ferrous sulfate 325 mg once daily (not continued last admission) multivitamin one tablet once daily (not continued last admission) cyanocobalamin 1000 mcg injection once a month (not listed at last admission) folic acid 1mg daily furosemide 40 mg by mouth once daily (held after admission) plaquenil 200 mg by mouth once daily metoprolol 75 mg xl by mouth daily at bedtime (changed to carvedilol) carvedilol 3.125mg imuran 50 mg daily discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po once a day. 2. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 3. cholecalciferol (vitamin d3) 400 unit tablet sig: 2.5 tablets po daily (daily). 4. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain: please do not exceed 3000mg/day. 5. atovaquone 750 mg/5 ml suspension sig: two (2) 5ml teaspoons po daily (daily). disp:*300 ml* refills:*2* 6. ferrous sulfate 325 mg (65 mg iron) tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. epoetin alfa 4,000 unit/ml solution sig: one (1) injection injection qmowefr ( -wednesday-friday). disp:*12 injections* refills:*2* 8. carvedilol 12.5 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 9. nystatin 100,000 unit/ml suspension sig: five (5) ml po bid (2 times a day). disp:*300 ml(s)* refills:*2* 10. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 11. spironolactone 25 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 12. prednisone 20 mg tablet sig: three (3) tablet po once a day. disp:*90 tablet(s)* refills:*0* 13. hydrocortisone 2.5 % cream sig: one (1) appl rectal q day (). disp:*1 tube* refills:*2* 14. lisinopril 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 15. torsemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary systemic lupus erythematosus associated cardiomyopathy. . secondary systemic lupus erythematosus hypertension persistent thrombocytopenia discharge condition: stable, good, baseline ambulatory and mental status discharge instructions: you were admitted to the hospital because you were having nausea shortness of breath. you were found to have a lupus induced cardiomyopathy causing heart failure. you received immunosuppressive medications to control your immune system and your heart function improved as shown on serial echos. you received diuretics to remove the fluid that accumulated due to the heart failure, and medications to control your blood pressure. . the following changes were made to your medications. we stopped: plaquenil . we changed to: carvedilol 25mg twice a day vitamin d 1000mg daily . we added: lisinopril 20mg daily torsemide 20mg twice a day hydrocortisone 2.5% rectal cream 1 application per rectum daily with rectal pain spironolactone 25mg daily amlodipine 10mg daily ferrous sulphate 325mg daily erythropoeitin alfa 4000 unit sc injection mwf atovaquone suspension 1500mg daily while on prednisone nyastatin 5ml p.o as needed for oral thrush . weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: 1.provider: , md phone: date/time: 8:00 . 2.md: dr. specialty: pcp / time: thursday, at 3:15pm location: , , ma phone number: . 3.cardiology lab specialty: cardiology date/ time: , at 3:00pm location: , bldg , , ma phone number: . 4.md: dr. specialty: cardiology date/ time: , at 4:00pm location: , bldg , , ma phone number: procedure: venous catheterization, not elsewhere classified combined right and left heart cardiac catheterization coronary arteriography using two catheters hemodialysis venous catheterization for renal dialysis angiocardiography of right heart structures therapeutic plasmapheresis injection or infusion of immunoglobulin biopsy of heart diagnoses: chronic glomerulonephritis in diseases classified elsewhere other primary cardiomyopathies systemic lupus erythematosus hyperpotassemia anemia, unspecified mitral valve disorders congestive heart failure, unspecified acute and subacute necrosis of liver acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified hypopotassemia chronic kidney disease, unspecified alkalosis antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use acute on chronic systolic heart failure raynaud's syndrome other complications due to renal dialysis device, implant, and graft lung involvement in other diseases classified elsewhere sicca syndrome 

Answer: The patient is high likely exposed to