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: cefepime / vancomycin / allopurinol attending: chief complaint: acute leukemia major surgical or invasive procedure: right subclavian cvl bone marrow biopsy x2 history of present illness: 63 yo m with hx polycythemia with myeloid metaplasia s/p splenectomy on hydroxyurea therapy, now with fevers and 49% other cells concerning for leukemic transformation. pt was in usoh until 7 days ago when he began to experience fevers on/off. fevers as high as 102. sx a/w muscle and joint aches located in knees and shoulders. he reports that his knees have been particularly bothering him r > l. pt denies cp, sob, cough, uri sx, diarrhea, abd pain, or any other complaints. he did go into osh ed in nh and cxr neg, u/a neg; he was sent home. of note, pt with labs drawn on with wbc 21 (stable) with relatively normal diff, plts 260, and dropping hct of 33. thus, dr. decreased hydroxyurea from 1500 qd to 1000 qd. today, pt returned to dr. office at where labs were drawn. he was thus sent here to ed. in ed, vitals were t 99.8, hr 72, bp 119/72, rr 16, o2 97% ra. cxr did not reveal any frank abnormalities; u/a was negative. wbc 24 with 49% other on diff. ldh 4000. pt given cefepime 2 g x 1. past medical history: polycythemia with myeloid metaplasia on hydroxyurea therapy. s/p splenectomy complicated by hemorrhage and portal vein thrombosis. anklyosing spondylitis hypothyroidism social history: patient lives in , denies alcohol or tobacco use. he is a retired schoolteacher. family history: mother with lung cancer, father with dm, no history of hematologic disorders physical exam: vitals: 99.5, 100/64, 84, 20, 96% ra gen: pleasant, nad heent: no op erythema or exudate. pulm: cta bilaterally. cv: rrr. no m/r/g. abd: +bs. ntnd. no hsm. ext: no edema. resolving left forearm papular rash. knees w/o warmth, erythema, or swelling. no pain pertinent results: 06:05pm wbc-24.8* rbc-2.35* hgb-9.2* hct-27.4* mcv-117* mch-39.2* mchc-33.7 rdw-20.3* 06:05pm neuts-28* bands-0 lymphs-17* monos-6 eos-0 basos-0 atyps-0 metas-0 myelos-0 nuc rbcs-7* other-49* 06:05pm hypochrom-normal anisocyt-2+ poikilocy-1+ macrocyt-3+ microcyt-normal polychrom-normal spherocyt-occasional ovalocyt-1+ teardrop-occasional how-jol-occasional fragment-occasional 06:05pm pt-33.9* ptt-32.0 inr(pt)-3.4* 06:05pm wbc-24.8* rbc-2.35* hgb-9.2* hct-27.4* mcv-117* mch-39.2* mchc-33.7 rdw-20.3* 07:00pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-2* ph-5.5 leuk-tr ==================== microbiology: 2:50 pm blood culture source: line-central. **final report ** blood culture, routine (final ): escherichia coli. final sensitivities. piperacillin/tazobactam sensitivity testing confirmed by . colistin and tigecycline requested by dr. . colistin <=2 mcg/ml, sensitivities performed by laboratories. sensitive to tigecycline @ 0.125 mcg/ml, mic interpretations are based on manufacturer's guidelines that are fda approved sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | amikacin-------------- <=2 s ampicillin------------ =>32 r ampicillin/sulbactam-- 16 i cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin--------- =>4 r gentamicin------------ =>16 r meropenem-------------<=0.25 s piperacillin/tazo----- <=4 s tobramycin------------ 8 i trimethoprim/sulfa---- =>16 r aerobic bottle gram stain (final ): reported to and read back by dr. pager# @ 0418 on . gram negative rod(s). anaerobic bottle gram stain (final ): gram negative rod(s). 7:32 am blood culture source: line-central line. **final report ** blood culture, routine (final ): enterococcus faecium. final sensitivities. daptomycin = 4 mcg/ml, sensitivity testing performed by etest. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: resistant to 1000mcg/ml of streptomycin. screen predicts no synergy with penicillins or vancomycin. consult id for treatment options. . sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecium | ampicillin------------ =>32 r daptomycin------------ s linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ =>32 r anaerobic bottle gram stain (final ): gram positive cocci in pairs and chains. reported to and read back by dr. 10:25am. aerobic bottle gram stain (final ): gram positive cocci in pairs and chains. 11:47 am bronchoalveolar lavage lll. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): 10,000-100,000 organisms/ml. commensal respiratory flora. legionella culture (preliminary): no legionella isolated. potassium hydroxide preparation (final ): test cancelled, patient credited. patient credited. this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (preliminary): no fungus isolated. nocardia culture (preliminary): no nocardia isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. viral culture: r/o cytomegalovirus (preliminary): no cytomegalovirus (cmv) isolated. ==================== imaging: knee x-ray : three views of the right knee show no fracture or dislocation. joint spaces are normal. note is made of mild tricompartmental osteophytosis. there is a small enthesophyte at the insertion of the quadriceps tendon. chest ct : 1. peribronchial infiltration and ground-glass opacity with bilateral lower lobe predominance may be infectious or inflammatory. leukemic infiltrate is considered less likely given the rapid development. appearance is not consistent with pulmonary edema. 2. several new nodules measuring up to 1 cm may be related to above process. recommend ct followup after resolution of acute symptoms. 3. diffuse abnormal bone mineralization related to patient's known aml. 4. probable hepatomegaly. 5. diverticuosis. bilateral le duplex : grayscale and color doppler son imaging was performed of the bilateral common femoral, superficial femoral, popliteal, peroneal, and posterior tibial veins. normal compressibility, flow, and augmentation was demonstrated. tte : normal biventricular cavity sizes with preserved global and regional biventricular systolic function. mild mitral regurgitation with normal valve morphology. mild pulmonary artery systolic hypertension. dilated aortic sinus. compared with the prior study (images reviewed) of , the findings are similar. discharge labs: 12:00am blood wbc-3.1* rbc-2.66* hgb-8.7* hct-25.6* mcv-96 mch-32.5* mchc-33.8 rdw-16.3* plt ct-388 12:00am blood neuts-57 bands-2 lymphs-17* monos-14* eos-0 baso-0 atyps-0 metas-4* myelos-4* blasts-2* nrbc-2* 12:00am blood plt smr-normal plt ct-388 01:56am blood fibrino-716* 12:00am blood gran ct-1829* 06:10am blood gran ct-1856* 12:00am blood glucose-93 urean-18 creat-0.6 na-139 k-4.8 cl-102 hco3-29 angap-13 12:00am blood alt-12 ast-16 ld(ldh)-198 alkphos-141* totbili-0.3 12:00am blood calcium-8.9 phos-3.5 mg-1.9 brief hospital course: 63 yom with pmh polycythemia with myeloid metaplasia s/p splenectomy on hydroxyurea therapy who is admitted with fever leukocytosis with 49% blasts, newly diagnosed aml, treated with 7+3 followed by mec, course complicated by vre, e. coli esbl, c. diff, drug rash.. # leukocytosis: persistently elevated wbc at 21k, last check on showed no blasts, now admitted with 49% blasts, concerning for leukemic conversion to aml, bone marrow biopsy was consistent with aml . echocardiogram prior to chemotherapy showed lvef 65% and was otherwise unremarkable. he was treated with 7+3 and reached his nadir (day 7). he then developed 18% peripheral blasts into recovery of his counts, so he was again induced with mec. on , repeat bm showed ablation of bone marrow with fibrosis. counts slowly recovered and anc >1800 prior to discharge. repeat bone marrow biopsy on pending. # fever: 3 episodes of febrile neutropenia. 1) admitted with spiking fevers to 102, chest x-ray showed left lobe infiltrate concerning for developing pneumonia. he was started on vancomycin, cefepime. levofloxacin was added in icu and later discontinued. micafungin was added for fungal coverage when patient continued to spike fevers on antibiotics. no culture growth, and fevers resolved with treatment of leukemia. 2) d10 of mec, spiked to 102 with tachycardia, tachypnea, sbp ~90s, started on vanc/ and aggressive ivf. sepsis resolved. cx with ecoli sensitive to meropenem. cx and with vre, on dapto. patient continued to spike daily fevers. ddx included drug fever, fungal pna (ct showing "tree-in-" lesions). bronchoscopy was performed and patient empirically started on voriconazole pending bal galactomanin results. patient also developed diarrhea, c. diff toxins were negative, but pcr positive, so patient started on po vancomycin. # drug rash: rash to cefepime, iv vancomycin, allopurinol per skin biopsy. diffuse erythematous rash spreading from central to distal, involving the face, mildly pruritic but otherwise asymptomatic. resolved over time with cessation of cefepime. cef was changed to aztreonam and during the course of his rash, which progressed on both antibiotics. eventually he was placed on cipro/tobra for gnr coverage; his e.coli cx from was resistant to cipro and intermediate to tobra. in consultation with derm and id, meropenem was felt okay to rechallenge. # afib: with rvr. asymptomatic, other than some "stomach queasiness". found in afib w rvr on routine physical exam one morning. given lopressor 5mg iv x2 with little response. started po lopressor and digoxin, which overnight caused second pauses. this was then d/c'd and changed to dilt po, which was increased to 90 qid. he spontaneously converted to sinus on after ~4-5 days in fib. in sinus rhythm on discharge but continuing dilt 90qid. would consider coumadin if afib recurs. # diffuse edema and pmr like joint pain: occurred suddenly after starting mec. diffuse edema in joints, severe pain bilaterally in tmjs, shoulder girdle, wrists/fingers, knees/ankles. placed on steroids for 2 days only, after which symptoms resolved. unclear cause. # hypoxia: was noted to be hypoxic to 80s while sleeping early into hospital course, placed on nonrebreather and transferred to icu for monitoring and management. repeat chest x-ray was suspicious for pneumonia vs. leukemic infiltrate vs. pulmonary edema, so his abx coverage was broadened to vancomycin, cefepime and levofloxacin and he was also given lasix. pt improved and was transferred back to bmt service. ct chest was done and showed ground glass opacity suspicious for infection vs. inflammation. # knee pain: he complained of right knee pain on admission, exam showed small effusion and did not show signs of infection. pain and swelling was believed to be related to possible leukemic infiltrate. pain controlled with lidocaine patch. resolved with treatment of leukemia. # history of portal vein thrombosis: occurred in the setting of spleenectomy which was complicated by portal vein thrombosis and hemorrheage. given expected thrombocytopenia with chemotherapy, and the need for urgent central line placement, warfarin was held and inr reversed with ffp and vitamin k. repeat ct abdomen showed resolution of portal vein thrombosis, so coumadin was not restarted on discharge. # hypothyroidism: continue levothyroxine. # transitional issues: follow up galactomanin from bal, if negative, plan to dc voriconazole and restart fluconazole. ertapenem/daptomycin last day . po vancomycin last day . follow up bone marrow biopsy result. reassess need to continue po diltiazem as patient remained in sinus rhythm since . medications on admission: allopurinol 150 qd furosemide 20 qd hydroxyurea 1000 mg qd omeprazole 20 qd levothyroxine 75 qd warfarin as directed discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 2. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 3. ertapenem 1 gram recon soln sig: one (1) g intravenous once a day for 9 doses: last day . disp:*9 g* refills:*0* 4. daptomycin 500 mg recon soln sig: four y (480) mg intravenous q24h (every 24 hours) for 9 days: last day . disp:*qs qs* refills:*0* 5. ativan 0.5 mg tablet sig: 1-2 tablets po twice a day as needed for nausa; anxiety. disp:*20 tablet(s)* refills:*0* 6. voriconazole 200 mg tablet sig: one (1) tablet po twice a day. disp:*10 tablet(s)* refills:*0* 7. acyclovir 400 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*0* 8. diltiazem hcl 90 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*0* 9. vancomycin 250 mg capsule sig: two (2) capsule po q6h (every 6 hours) for 23 days: last day . disp:*184 capsule(s)* refills:*0* 10. voriconazole 200 mg tablet sig: one (1) tablet po twice a day for 1 days. disp:*2 tablet(s)* refills:*0* discharge disposition: home with service facility: critical care systems discharge diagnosis: aml drug allergy c. dificile infection vancomycin-resistant enterococcal bacteremia e. coli (esbl) bacteremia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure to take care of you at during your hospital stay. you came to the hospital with fevers and was found to have leukemia. you were started on chemotherapy called "7+3" which you tolerated well. when you were just starting your chemotherapy, you were found to have low oxygen level in your blood. you were transferred to icu for a short time for monitoring of your oxygen levels while you were on supplemental oxygen. your bone marrow biopsy in the middle of chemotherapy showed no signs of malignant cells. you will need a repeat bone marrow biopsy soon as your cell counts are recovering. this will be done at follow up in the clinic. you can stop your hydroxyurea for polycythemia because these cells should be treated from the chemotherapy. please start acyclovir (antiviral) for prophylaxis. you had an irregular heart beat (atrial fibrillation) while you were sick. we started you on a heart rate control medication called diltiazem. your heart rhythm converted back to normal. if this irregular heart beat starts again, you may need anticoagulation with coumadin. please continue diltiazem and follow up with your doctors. you had intermittent fevers during this hospital stay. your blood grew e. coli and enterococcus (two types of bacteria) and you were treated with antibiotics through the vein. you developed rashes on your back and on your chest while you were on the antibiotics. dermatologists saw you and biopsied your rash, which showed allergic reaction to medications. you were taken off switched over to other antibiotics. you will continue on meropenem and daptomycin (antibiotics) until . your ct scan of your lung was concerning for fungal infection. we started you on voriconazole (antifungal). this may change depending on the final result of your bronchoscopy. please follow up with your doctor. you also had some loose stools while you were here, and we found a bacterial infection in your intestines. we treated you with oral antibiotic, and you will continue vancomycin till . we also stopped your lasix because your blood pressures were on the lower side and you do not have significant edema. we stopped your coumadin because your portal vein thrombosis is no longer present. medication change: start daptomycin (last day ) start ertapenem (last day ) start vancomycin (last day ) start acyclovir start voriconazole (may change depending on the final result from your bronchoscopy) start diltiazem 90mg three times a day stop coumadin stop hydroxyurea stop lasix stop allopurinol followup instructions: department: hematology/oncology when: friday at 10:15 am with: , md building: sc clinical ctr campus: east best parking: garage **please follow up galactomanin result from bal, if negative, plan to switch voriconazole to fluconazole for prophylaxis if a-fib recurs, may need anticoagulation. department: dermatology and laser when: friday at 9:30 am with: , md building: (, ma) campus: off campus best parking: free parking on site procedure: venous catheterization, not elsewhere classified biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow closed [endoscopic] biopsy of bronchus closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance central venous catheter placement with guidance diagnoses: urinary tract infection, site not specified unspecified acquired hypothyroidism atrial fibrillation candidiasis of mouth alkalosis bacteremia intestinal infection due to clostridium difficile antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use dermatitis due to drugs and medicines taken internally hypoxemia accidents occurring in residential institution drug induced neutropenia anemia in neoplastic disease cephalosporin group causing adverse effects in therapeutic use sialoadenitis polycythemia vera acute myeloid leukemia, without mention of having achieved remission effusion of joint, lower leg fever presenting with conditions classified elsewhere ankylosing spondylitis other secondary thrombocytopenia temporomandibular joint disorders, arthralgia of temporomandibular joint 

Answer: The patient is high likely exposed to