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 (sulfonamides) / iodine attending: chief complaint: here for allogeneic transplant for refractory multiple myeloma major surgical or invasive procedure: central line placement and removal chemotherapy with cytoxan and busulfan allogeneic bome marrow transplant picc line placement vats/pleurodeisis history of present illness: 39 yo male with multiple myeloma diagnosed in he was initially treated with decadron alone and then began treatment with thalidomide and dexamethasone, which was started in 09/. he also underwent radiation therapy to the sacral area in 11/. his course was complicated by a dvt and pe at the time of his diagnosis, and he was on anticoagulation particularly while receiving thalidomide and decadron. he was noted for a very good response to his treatment with a repeat bone marrow biopsy in showing 5% plasma cells as well as marked improvement in his lesion in the sacral area. in /05, he was noted to have a drop in his white blood count, and repeat bone marrow biopsy showed increasing plasma cells with 20% involvement. his igg level had also increased with a concern for more refractory disease. he received a cycle of dvd chemotherapy on . following this therapy, he had increasing pain with increasing igg levels and spep with a poor response to therapy, he was switched to treatment with velcade and decadron. he was given four cycles of this therapy. a repeat bone marrow aspirate and biopsy revealed cd138 staining of plasma cells for approximately 10% of the cellularity. his igg level had decreased to a low of 1680. his spep had also decreased to 1100 mg/dl of the total protein. he then received high-dose cytoxan on in preparation for stem cell mobilization with his stem cell collections completed during the week of . he then was admitted on for high-dose chemotherapy with melphalan followed by stem cell transplant. followup evaluation of his disease at 2 months post-transplant at the end of showed approximately 10% involvement by plasma cells by cd138 staining. this was essentially stable, and he was continued to be monitored. his igg level had decreased to 1314 following his transplant. on , pt has increasing pain in the left groin area. an x-ray of the area did not show any evidence for fracture or lesion. he did undergo an mri as well, which showed a lesion near the groin area with no pathologic fracture. he received radiation therapy to this area. also in this setting, his igg level had now increased to almost 4 g. he underwent a bone marrow aspirate and biopsy by his local oncologist, dr. , which revealed extensive relapsed disease with plasma cell myeloma accounting for 80-90% of the core biopsy specimen. as a result of this, it was felt that mr. required more systemic therapy in addition to continuing the radiation therapy to the groin area, he was started velcade with decadron . he had been requiring increasing platelet transfusion support prior to beginning velcade as well as during the course of velcade with a platelet count less than 20,000 as well as red blood cell transfusion support, his igg level had increased to 7 g with his spep now representing 50% or 4900 mg/dl of the total protein. he was started on more aggressive chemotherapy with d-pace on . within one week, he was noted for an increase of his igg to over 6 g. as he clearly had an agressive refractory myeloma, he is being admitted for with a myeloablative transplant with cytoxan and busulfan conditioning. mr. is being admitted today to begin his allogeniec transplant. past medical history: 1. multiple myeloma as described above. 2. history of dvt and pe while receiving thalidomide, status post 6 months of anticoagulation. 3. recent pneumonia treated with a 14-day course of levofloxacin in 02/. social history: mr. previously worked as a florist but is currently unemployed. he does coach a girls basketball team and tries to keep active although since his most recent admission, he has not been keeping up with this. he denies any history of tobacco or alcohol use. he is married with a very supportive wife and has two young children, ages 4 and 1-year-old. family history: mr. has no hematologic malignancies in his family. there is type 2 diabetes in the family with elevated cholesterol. his mother died of a cerebrovascular accident. he has a brother and sister, both of whom have been hla typed and do not match him. he currently has a non-related hla match physical exam: admission: vs: t 97.6 bp108/65 hr110 o2sat97%ra gen: young aa male lying in bed in flat affect heent: anicteric sclera, mmm, op clear neck: supple. no lad. cardio: rrr, nl s1 s2, no m/r/g lungs: ctab no rrw abd: soft, nt, nd +bs, no hepatosplenomegaly ext: 2+pulses. no edema. . neuro: a&ox 3 back: no point tenderness to palpation pertinent results: . cxr: slight improvement in the multiple patchy opacities which may be consistent with improving multifocal pneumonia . line placement 1: successful placement of a 7-french triple lumen central line through the left internal jugular vein with the tip in the superior vena cava. the line is ready for use . line placement 2: successful placement of a 29 cm cuff-to-tip 10 french double- lumen tunneled catheter with the tip in the superior vena cava. the line is ready for use. . echo: the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. overall left ventricular systolic function is low normal (lvef 50-55%). tissue velocity imaging demonstrates an e/e' <8 suggesting a normal left ventricular filling pressure. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular systolic function now appears slightly more vigorous. . ecg: sinus tachycardia. normal ecg except for rate . cxr: stable appearance of multiple airspace opacities within the bilateral lungs which may represent multifocal pneumonia . ecg: sinus tachycardia. diffuse st-t changes are nonspecific . transfusion reaction investigation: mr had diffuse trunk and arm pain, tachycardia, mild hypertension and difficulty breathing while undergoing a transfusion of compatible red cells. although there are a few laboratory parameters that are suspicious for hemolysis (mildy elevated ldh), other labs (negative dat, normal haptoglobin) are not supportive of hemolysis, nor is his clinical picture. we feel that this reaction is an atypical non-hemolytic transfusion reaction that does not have a clear underlying cause. at this time we do not recommend changes in transfusion practice in this patient except careful monitoring during future transfusions. . ecg: sinus rhythm. non-specific diffuse t wave changes. compared to the previous tracing of no significant diagnostic change. . us liver: no evidence of liver, gallbladder, or biliary tree pathology to explain the patient's symptoms. tiny 2 mm polyp or non-shadowing stone in the gallbladder lumen. small bilateral pleural effusions. . cxr: the bilateral central venous lines are in stable position. there is no pneumothorax. there is persistent left lower lobe opacity presumably atelectasis which appears slightly increased with the medial diaphragm obscured. no new areas of consolidation or effusion are identified. . ct cap: 1. interval development of large left and smaller right pleural effusions. a new focal area of consolidation is seen at the left lung base which may represent atelectasis or possible pneumonia. 2. resolving multifocal areas of peribronchovascular nodular opacification. 3. progressive areas of soft tissue density in the paraspinal, pleural/extrapleural bases and left pelvis. multifocal skeletal lesions are relatively unchanged and most severe at t11 with associated wedge compression fracture and in the left scapula. 4. no radiographic findings to explain the patient's abdominal pain. . echo: 1. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). 2. compared with the prior study (images reviewed) of , there is no significant change. transthoracic echocardiogram: no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size, and systolic function are normal (lvef 70%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the pulmonary artery systolic pressure could not be determined. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. there is a small pericardial effusion. the effusion appears loculated around the right atrial free wall. there are no echocardiographic signs of cardiac tamponade, although there is brief right atrial diastolic invagination. compared with the findings of the prior study (images reviewed) of , the loculated pericardial effusion appears somewhat larger. cxr:impression: markedly increased right pleural effusion, compared to the prior study, worrisome for hemothorax in this patient with recent thoracentesis if it was on the right side. edema in the right lung. opacity in right lower lobe, which may be due to atelectasis, however, the evaluation is somewhat limited on this portable exam. : ct chest before and after contrast: impression: 1. large pleural fluid accumulation in the right hemithorax, with findings suggestive of clot in the inferior aspect. no definite extravasating vessel identified. stable appearance of left pleural effusion. 2. no pulmonary embolism. 3. otherwise, no significant interval change since examination of : chest ap: impression: stable pulmonary edema. tiny right apical pneumothorax. worsening left lower lobe consolidation, which could represent atelectasis or pneumonia. : right upper quadrant ultrasound: impression: unremarkable abdominal ultrasound. normal liver doppler vascular examination. : cxr - interstitial edema has cleared though pulmonary vascular redistribution persists. left lower lobe has been consolidated since at least and could be either persistent atelectatic or infected. right pleural tube still in place, but there is no pneumothorax or appreciable right pleural effusion. tip of the left pic catheter projects over the svc. heart size top normal, midline. right upper extremity ultrasound: impression: no evidence of left upper extremity dvt. cxr: findings: comparison is made to prior study from . the right apical pneumothorax is no longer visualized. the heart size is upper limits of normal and unchanged. there is a persistent left retrocardiac opacity and bilateral pleural effusion, which are stable. there is no overt pulmonary edema. cxr upright ap view of the chest: a left picc is present with tip in the distal svc. the heart is normal in size. the mediastinal and hilar contours are normal. the lungs are clear, and there are no pleural effusions or pneumothorax. pulmonary vascularity is normal. the osseous structures are unremarkable. . echo: conclusions: 1. the left atrium is mildly dilated. 2. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. 3. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. 4. there is moderate pulmonary artery systolic hypertension. 5.there is a small pericardial effusion with fibrin deposits on the surface of the heart. 6. compared with the prior study (images reviewed) of , there is no significant change. . eeg: impression: abnormal portable eeg due to the slow and disorganized background and bursts of generalized slowing. these findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures. medications, metabolic disturbances, and infection are among the most common causes. there were no areas of persistent focal slowing, and there were no epileptiform features. . diagnosis, assessment and recommendations: mr. has a clinically significant red cell alloantibody, anti-s. s is a member of the mns blood group system. anti-s can cause hemolytic transfusion reactions. in the future he should receive s negative red cells for transfusion. he is also restricted to irradiated and leukoreduced red cells. . ruq u/s impression: no son abnormalities in the right upper quadrant. . mri of c-spine and t-spine: conclusion: t11 vertebral body collapse, unchanged since , . c5-6 disc protrusion to the right with indentation on the spinal cord and occlusion of the neural foramen. no evidence of epidural abscess. . ct chest w/o contrast: impression: 1. persistent small right pneumothorax, as seen on an earlier radiograph of the same day. 2. improvement in bilateral pleural effusions, with small residual left effusion. 3. improved aeration of the right lung since the prior ct, although the entire right lung remains involved with heterogeneous consolidations. 4. worsening consolidations throughout the left lung. 5. similar prominent soft tissue densities in the left pelvic side wall, probably lymphadenopathy. brief hospital course: mr was admitted for a mud allogeneic bmt with cytoxan and busulfan conditioning. he was treated according to the transplant protocal. he was transfused to keep his hct>25 and plt>10. he had one suspected transfusion reaction to prbcs, and an investigation was performed. he received additional units of prbcs without further reaction. after the allogeneic bmt, he had febrile neutropenia. on blood cultures grew mrsa. he was started on vancomycin, cefepime and then caspofungin was added. he was persistently febrile to 104-105 degrees. he had a chest x-ray and ct scan that demonstrated bilateral pleural effusions, left greater than right. he was diuresed with some decrease in effusion size, although left sided effusion was still large. on , given the persistent, high fevers, and consolidation within the left pleural effusion, there was a concern for empyema. interventional pulmonary was contact. platelets were transfused to keep > 50 prior to procedure. they attempted thoracentesis on left, but were unable to drain any fluid despite being able to visualize fluid on ultrasound. ultrasound was performed on the right side and effusion was seen. thoracentesis was performed on the right side and very small amount of fluid was drained. approximately 10 hours after the procedure, patient noted severe substernal chest pain, difficulty breathing. he was tachycardic to 130's. pain responded to iv morphine. a chest x-ray was performed and demonstrated new right pleural effusion. his hematocrit had decreased to 15 (approx 8 point decrease) and concern for hemothorax. the medical icu team was contact. was transferred to the icu. a contrast ct chest/abdomen/pelvis was performed. given concern for contrast administration in patient with multiple myeloma, he was given 4 doses of mucomyst immediately following the ct scans. thoracics was contact and placed a chest tube on on the right which drained bloody fluid. patient was feeling much better after the chest tube was placed. his lfts were noted to be increasing, and especially his bilirubin (direct bilirubinemia). there was a concern for -occlusive disease. his weight had not been increasing, though. an ultrasound with dopplers was performed on and was normal with normal blood flow. his lfts started trending down and chest tube output was decreasing. he was transferred back to oncology floors on . chest tube was removed by thoracics surgery on . he continued to have serosanguinous drainage from chest tube site while he was neutropenic, but this stopped when his blood counts started rising. on , patient was noted to be diaphoretic and complained of not feeling well. in the afternoon he underwent a sharp decline in mental status, becoming confused and then increasingly somnolent. an abg on the bmt floor showed hypercarbia (abg: 7.27/58/89/28) with stable vital signs and a pe notable for poor respiratory excursion. he was given 125mg solumedrol and 1u plts/1u blood were transfused. when the icu team arrived the pt was noted to be stuporous. pt was given 0.8mg narcan-- > became more alert for a couple of minutes and then again lapsed obtunded state, had tonic clonic sz activity, and was noted to have loc, disconjugated gaze and bowel incontinence. he was intubated on floor for airway protection and transferred back to the icu. . in the , patient was noted to be in hypercarbic resp failure as above. his vent settings were titrated as needed to maintain normal pco2. his ms appeared to have improved. his seizure/ms changes as above were thought due to his hypercarbia and no aeds were initiated as per the neurology c/s service. it was felt that his hypercarbic resp failure was due to dah, and he received he was noted to develop arf with his cr rising to 2.0 from 1.0 over the span of a few days. it was thought that this was likely iatrogenic in nature rather than prerenal azotemia as he was fluid overloaded on exam, with nml vital signs and urine lytes c/w atn. his acyclovir was held and his csa dose was decreased to prevent further nephrotoxicity. he was steadily weaned from the vent until am when he was noted to have a sudden increase in oxygen requirement. he was bronched () and was noted to have progressive bloody return on bal, concerning for recurrent diffuse alveolar hemorrhage. he continued to intermittently spike and was pan-cultured. . from to , mr. mental status deteriorated such that he was no longer awake and responsive. his oxygen requirements continued to go up such that he was on 100% fio2 and was satting in the low 90s and was persistently tachypneic in the 30s-40s. he also continued to spike fevers of unknown origin and had rising cr. on the night of , in light of increasing oxygen requirements/decreasing sats and upon consultation with the bmt team and his wife, the decision was made to withdraw life support due to dismal prognosis and his wife's feeling that he had fought and suffered long enough. he died at 2359 on . . fever & neutropenia: while in the icu, the patient was continued on vancomycin and meropenem given his prior mrsa bacteremia and neutropenic fever. his caspofungin was initially changed to ambisome but given his rise in creatinine, he was switched back to caspofungin and then back to ambisome once his bili and ast/alt began to rise. two thansthoracic echocardiograms were performed looking for valvular vegetations but none seen. he was maintained on his acyclovir ppx until his creatinine rose to 1.8, and this was held. . back pain: mr has chronic back pain secondary to his myeloma. he was continued on mssr, with a dose increase to 60 , and covered for breakthrough pain with prn msir. . peripheral neuropathy: he was usually on neurontin and b6, but these were held for high dose chemotherapy given unknown durg-drug interactions with high dose chemotherapy. . fen: he was on a neutropenic, cardiac diet, with prn repletion of electrolytes and ivf per protocol. tpn was started on given poor po intake, low albumin. . ppx: he was on a ppi and a bowel regimen. . full code *** of note, he has a bactrim allergy, so he will need to have pentamidine as pcp . medications on admission: lexapro has been dicontinued neurontin 400 mg t.i.d. b6 vitamin 50 mg daily ms contin 15 mg b.i.d. msir 15 to 30 mg q.4-6h. p.r.n. protonix 40 mg daily acyclovir 400 mg t.i.d. aerosolized pentamidine q. monthly last given on discharge disposition: home with service discharge diagnosis: multiple myeloma mrsa bacteremia bilateral pleural effusions hemothorax discharge condition: death discharge instructions: none followup instructions: none procedure: insertion of intercostal catheter for drainage venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube enteral infusion of concentrated nutritional substances thoracentesis thoracentesis other intubation of respiratory tract decortication of lung temporary tracheostomy closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus transfusion of packed cells injection or infusion of cancer chemotherapeutic substance transfusion of platelets injection or infusion of oxazolidinone class of antibiotics allogeneic bone marrow transplant without purging injection or infusion of biological response modifier [brm] as an antineoplastic agent transplant from live non-related donor diagnoses: congestive heart failure, unspecified long-term (current) use of steroids acute posthemorrhagic anemia acute kidney failure, unspecified unspecified septicemia severe sepsis other convulsions chronic kidney disease, unspecified acute and chronic respiratory failure iatrogenic pneumothorax multiple myeloma, without mention of having achieved remission streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] unspecified hereditary and idiopathic peripheral neuropathy empyema without mention of fistula jaundice, unspecified, not of newborn pneumonia due to other streptococcus nonspecific abnormal findings in cerebrospinal fluid 

Answer: The patient is high likely exposed to