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: nifedipine attending: chief complaint: pancytopenia major surgical or invasive procedure: bone marrow biopsy lumbar puncture with infusion of ara-c lumbar puncture lumbar puncture history of present illness: 61 year old man with history of ph+ all s/p chemotherapy with dva, gleevec and s/p mud myeloablative allo-sct c/b gvd of liver, cmv viremia, right leg mucormycosis and aspergillus lung infections treated with ambisome/micafungin, presenting with persistent pancytopenia with concern for recurrence of disease. patient recently admitted with rsv pneumonia treated with ivig and empiric antibiotics. course was complicated by seizures leading to encephalopathy, controlled with levetiracetam. patient was seen in clinic on day of admission and found to have worsening thrombocytopenia in addition to immature cells on peripheral smear. patient denied worsening fatigue, shortness of breath or fever. he reported abdominal pain, worse with meals, with intermittent nausea. he also complained of cough, with headache, but without rhinorrhea. headache has been present for past 3-4 weeks occurring at night from 8-9pm. patient denies visual changes, numbness/weakness/tingling in extremities, or sudden loss of bladder/bowel control. he received 1 unit of platelets in clinic, with improvement in counts from 12 to 57. in addition, patient had a bone marrow biopsy to evaluate for potential recurrence of disease. he was admitted for further management of pancytopenia. review of systems: positive for occasional diarrhea (solid on day of admission). chills without fever or night sweats. he denies shortness of breath or chest pain. he denies nausea, vomiting, abdominal pain or constipation. he denies dysuria, urgency/frequency of urination or hematuria. past medical history: oncologic history - bone marrow biopsy c/w all, cytogenetic with bcr-abl translocation - started hypercvad part a and imatinib - febrile neutropenia with mrsa bacteremia, multifocal pna - repeat bone marrow biopsy with no evidence of leukemia, normal cytogenetics indicative of remission - rue dvt at picc site - / it methotrexate once weekly x 4 weeks - matched unrelated donor allosct with fludarabine / busulfan / atg conditioning - liver biopsy with evidence of gvhd and infectious cholangitis, in addition, evidence of gvh of gut improved w steroids - aspergillus in lungs - right leg mucor infection (started on ambisome/micafungin) . other past medical history: - chronic kidney disease - colon cancer - s/p r hemicolectomy with anastomosis - prostate cancer - sebaceous carcinoma status post removal - right thigh malignant mass, status post surgery - muir- syndrome - a subset of the syndrome which stems from msh2 deletion - hypertension - hypercholesteremia - left ventricular hypertrophy - hemorrhoids - ercp on and for blocked cbd, s/p sphincterotomy and stent placement - vre bacteremia on daptomycin - cmv viremia social history: lives in with his wife, who is his healthcare proxy. 2 adult daughters ( and ) and 5 grandchildren. worked as saw operator cutting aluminum, not currently working due to leukemia diagnosis. no history of alcohol intake, no smoking. denies chemical exposures. family history: multiple cancers in family including mother with uterine cancer, father who passed of lung cancer. one of his brothers passed of brain cancer at age 15. another brother has syndrome and colon cancer. one of his daughters did test positive for mutation. physical exam: admission physical exam: vs- t99.0 bp 144/82 hr 76 rr 20 o2 100% ra general- elderly male in nad heent- perrl, sclera anicteric, no conjunctival pallor, moist mucous membranes without lesions, exudate or erythema in oropharynx. adentulous on upper palate. no palpable lymphadenopathy cv- irregularly irregular rhythm, normal rate, normal s1/s2, no m/r/g appreciated pulm- course ronchi in bilateral upper lung fields, clear to ausculation without wheezes, ronchi, rales in lower lung fields. abd- +bs, soft, nontender, nondistended, no hepatosplenomegaly palpable ext- warm and well perfused, 3x3cm eschar overlying right tibial tuberosity with surrounding hyperpigmentation, no erythema or swelling. trace pedal edema. 1+ dp/pt pulses bilaterally neuro- alert and oriented x 2, cn ii-xii intact, strength 5/5 bilaterally in upper/lower extremities, sensation intact access- r picc c/d/i without tenderness or erythema discharge physical exam: patient expired during admission. pertinent results: admission labs: wbc 2.5 hgb 10.2 hct 29.3 plts 12 n:32 band:1 l:53 m:4 e:1 bas:0 atyps:2 metas:3 myelos:2 promyel:1 nrbc: 6 other: 1 . 137 106 25 -------------- 4.6 21 1.5 . ca: 9.0 mg: 1.7 p: 4.4 alt: 36 ast: 25 ap: 205 tbili: 0.7 ldh: 210 . labs - last labs checked prior to being made cmo: wbc-2.1* hgb-9.6* hct-29.3* mcv-97 plt ct-28* glucose-144* urean-89* creat-1.9* na-150* k-4.3 cl-115* hco3-25 alt-20 ast-33 ld(ldh)-180 alkphos-276* totbili-2.4* dirbili-1.8* . microbiology: beta glucan - 93 pg/ml beta glucan - 142 pg/ml beta glucan - 67 pg/ml . galactomannan - 0.1 . adenovirus - not detected ebv pcr - not detected hhv6 - < 500 bk virus pcr - 5824 h . cmv viral load - cmv dna not detected induced sputum - no mycobacteria isolated (preliminary) cmv viral load - cmv dna not detected blood culture - no growth rapid respiratory viral screen - positive for respiratory syncytial virus (rsv). blood fungal/afb culture -negative urine cmv, adeno - no growth on culture, no virus isolated urine bk virus h stool - negative for noro negative for c.diff no campylobacter found no enteric gram negative rods found. no salmonella or shigella found o+p negative x 3 (, , ) c.diff pcr - negative . csf : no growth, no malignant cells chemistry protein- 84 glucose- 65 csf wbc 0 rbc 2 poly 8 lymph 28 mono 24 eos macroph- 40 gram stain- no polymorphonuclear leukocytes seen. no microorganisms seen . csf : protein 57 glucose 62 wbc 2 pmn-40 lymph-58 mono-1 macro-1 rbc 6050 hsv pcr- negative cryptococcal antigen- not detected gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture: no growth fungal culture: no fungal isolated acid fast culture: no mycobacteria isolated viral culture: no virus isolated adenovirus pcr- negative hhv6 pcr- negative ebv pcr- negative vzv pcr- not detected toxoplasma pcr- negative virus- negative cmv pcr- not detected . csf : gram stain- no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (preliminary): no growth. fungal culture (preliminary): no fungus isolated. hsv pcr- negative hhv6 pcr- negative ebv pcr- negative vzv pcr- not detected cmv pcr- negative toxoplasma pcr- negative . bone marrow core biopsy - relapsed precursor b- acute lymphoblastic leukemia microscopic description peripheral blood smear: the smear is adequate for evaluation. red blood cells are reduced in number, normochromic with anisopoikilocytosis including occasional macroovalocytes and spherocytes seen. a nucleated red blood cell is seen on scan. the white blood cell count appears decreased. dysplastic hypogranulated and pelgeroid neutrophils are present. occasional hypersegmented forms are seen. large granular lymphocytes are seen. platelet count appears decreased; large and giant forms are seen. differential shows 50% neutrophils, 1% monocytes, 47% lymphocytes, 0% eosinophils, 1% basophil, 1% myelocytes. rare blasts are seen on scan, particularly in the thicker portions of the smear. aspirate smear: the aspirate material is adequate for evaluation and consists of hypercellular spicules with sheets of blasts. erythroid precursors are markedly decreased in number. myeloid precursors appear markedly decreased in number. megakaryocytes are present in markedly decreased numbers. differential (500 cells) shows: 80% blasts, 1% promyelocytes, 1% myelocytes, 1% metamyelocytes, <1% bands/neutrophils, 10% lymphocytes, 7% erythroid. clot section and biopsy slides: the biopsy material is adequate for evaluation. it consists of a 0.6 cm core biopsy of trabecular marrow with focal aspiration artifact with an overall cellularity of 70%. there is an interstitial infiltrate of immature mononuclear cells consistent with blasts occupying 70-80% of overall marrow cellularity. these blasts are medium-sized with small amount of cytoplasm, oval to irregular nuclei with moderately fine chromatin and distinctive nucleoli. in the remaining cellularity, scant trilineage hematopoiesis is noted including occasional dyspoietic erythroids. . imaging: cxr - right pic line passes as far as the low svc. opacification in the juxtamediastinal region above the right hilus could be due to either mediastinal widening or a new lung lesion. it is best evaluated with conventional radiographs, including a lordotic view if deemed necessary after conventional views have been obtained. there is also a suggestion of consolidation at the right lung base medially. left lung is grossly clear and there is no pleural effusion. heart size top normal. . ct chest - 1. slow progression right middle lobe consolidation over three months, probable low-grade infection, and a different pathogen than multiple small lung nodules, some cavitated, which have not changed over the same period of time. middle lobe lesions should be accessible to bronchoscopic sampling from a division of the medial segment of the right middle lobe. 2. no gross evidence of malignancy, large goiter, showing less severe tracheal narrowing than previously. 3. unexplained marrow infiltrative disorder, sternal manubrium, radiographically stable for at least a year. 4. increased small-to-moderate layering non-hemorrhagic right pleural effusion. stable small pericardial effusion. no evidence of tamponade. 5. persistence but continued improvement in widespread bronchocentric infiltrative abnormality, probably viral infection, ascribed to rsv. . transthoracic echocardiogram - the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. there is mild pulmonary artery systolic hypertension. there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study (images reviewed) of , no change (very small pericardial effusion was seen on prior). . ct sinuses - there is mild to moderate mucosal thickening and aerosolized secretions in the bilateral maxillary, sphenoid, and frontal sinuses. there is also mild mucosal thickening in the ethmoid air cells. there are no air-fluid levels. there is no high-density material. there is no bony erosion or sclerosis. the nasal septum is deviated slightly to the left. the ostiomeatal units are patent. the lamina papyracea are intact. impression: mild to moderate mucosal thickening in all paranasal sinuses. no fluid levels, high-density material or bony erosions to ongoing infection. . renal ultrasound - the left kidney measures 11.5 cm. the right kidney measures 12.3 cm. there is no hydronephrosis. no renal stone identified. there is a small simple cyst in the left kidney measuring 1.4 x 1 x 1.6 cm, unchanged. the urinary bladder appears within normal limits. there is enlarged prostate roughly measuring approximately 4.5 x 4 x 4.8 cm. impression: no hydronephrosis. prostatic enlargement. . mri right leg - no significant interval change in the appearance of the bilateral calves, including the right anterior knee skin lesion. no rim-enhancing collection to suggest an abscess and no evidence of osteomyelitis. . noncontrast head ct - 1. no acute intracranial process. 2. mild inflammatory disease involving the sphenoid and anterior ethmoidal air cells, and incompletely visualized maxillary sinuses, bilaterally; correlate clinically. . mri head - 1. no acute abnormality seen within the brain. the previously seen flair and t2 hyperintense foci in the subcortical white matter are unchanged compared to study on . 2. sinus disease is not changed compared to ct yesterday. . 20min eeg - this routinely acquired eeg is moderate to moderately severely encephalopathy. there is diffuse background slowing and there is more severe delta frequency slowing seen over frontal central regions. the latter activity often takes on epileptic features with sharp and spike like discharges. those also tend to be frontal and central in their location. these are seen independently in the two hemispheres as well as in short duration bilaterally synchronous discharges. . eeg - the recording showed often rhythmic and very persistent, approximately 2 hz, generalized sharp wave activity throughout most of the record with brief periods of diminished sharp wave activity, as described above. the background was disorganized. the record indicates an encephalopathy throughout, but the persistent rhythmic 2 hz sharp wave discharges. there is concern for non-convulsive seizure activity not correlated with clinical signs of seizure. the record did not change appreciably from beginning to end. . eeg - the continuous eeg showed rhythmic generalized 2 hz sharp wave discharges throughout most of the recording. the findings are consistent with generalized nonconvulsive status epilepticus. nevertheless, there was no evidence of clinical seizure or convulsion. no focal abnormalities were evident. there were a few breaks of several minutes at a time when discharges were far less frequent and an encephalopathic background was more prominent. . eeg - the recording showed rhythmic generalized 2 hz sharp wave discharges through midnight at the end of . there were occasional breaks for a second or two with a more slow and disorganized background even during that period. after midnight, there were longer periods of a slower disorganized background with intermittent sharp waves. the earlier parts of the recording indicate non-convulsive status epilepticus. there were shorter episodes after midnight, but the record changed to that of an encephalopathy at about 5:30 in the morning. . eeg - the background remained slow, disorganized, and indicative of an encephalopathy throughout. there were no prominent focal findings. there were very frequent and brief periods of rhythmic, generalized sharp wave discharges. these sharp waves were usually blunted and without following slowing and were usually not so rhythmic as to suggest ongoing seizures. no definite electrographic evidence of seizure. . ct chest w/o contrast - 1. peribronchial inflammation, in the lower lungs, left greater than right, increased since , could be function of aspiration, but i see no pneumonia. moderate enlarging right pleural effusion is responsible for more right basal atelectasis. 2. chronic lung infection responsible for small cavitary nodules is unchanged, but a subacute infection responsible for a larger nodule in the right middle lobe is decreasing. 3. chronic pericardial effusion increased slightly, now moderate in size. no evidence of tamponade. . cxr - right infrahilar consolidation and pleural effusion appear to be even more prominent than on the prior examination. heart size and mediastinum are stable. left lung is essentially clear. there is no left pleural effusion. right pleural effusion is at least moderate. there is no pneumothorax. narrowing of the proximal trachea due to thyroid enlargement is noted, better appreciated on the ct chest from . . cxr - there has been interval improvement of the right lower lung consolidation and decrease in size of the right pleural effusion. no left pleural effusion is detected. no pneumothorax or new focal consolidation is seen. heart and mediastinal contours are within normal limits. right picc courses along the expected location of the superior vena cava with tip likely in the region of the cavoatrial junction. mass effect on the proximal trachea is again noted, better evaluated on prior ct. . portable abdomen - no evidence of obstruction or perforation. . ruq ultrasound - gallbladder is distended, contains echogenic material in its lumen and shows some mild wall thickening. acute cholecystitis cannot be excluded. if this is a clinical concern, hida scan is recommended. the gallbladder distention is more pronounced compared to the previous ultrasound examination of . no dilated bile ducts. no focal liver lesion. . hida scan - 1. no acute cholecystitis. 2. chronic gallbladder dysfunction. . cxr - newly occurred right basal parenchymal opacity, in addition to a right pleural effusion. a reactive pleural effusion and accompanying pneumonia cannot be excluded. a wet read was delivered at the time of image acquisition. borderline size of the cardiac silhouette. no evidence of pulmonary edema. . cxr - cardiomegaly, pulmonary vascular congestion and mild perihilar edema are present, the latter slightly worse compared to the prior examination. large partially layering right pleural effusion is again demonstrated as well as a possible small left pleural effusion. brief hospital course: 61 year old man with a history of ph+ all s/p chemotherapy (dva, gleevec) and s/p mud myeloablative allo-bmt c/b gvhd of the liver, cmv viremia, r leg mucor infection treated with ambisome/micafungin, picc line thrombus and ckd presenting with worsening pancytopenia, found to have all recurrence. patient was made comfort measures only following 1 month of admission complicated by multiple medical issues (detailed below) and expired during admission. . # pancytopenia: patient has had persistent pancytopenia, but cbc on day of admission was notable for worsening thrombocytopenia and immature white cells in the periphery. bone marrow biopsy consistent with relapsed all with bcr-abl translocation. see below for management. . # all: s/p hypercvad and imatinib, s/p mud allogeneic sct, admitted with relapse as above. patient has had complicated course with gvhd, cmv viremia and mucor infection. patient was started on dasatinib 100mg po daily to target bcr-abl translocation. in addition, given headaches for several weeks and recent seizures, lp was repeated with infusion of intrathecal arac, and dexamethasone 4mg po bid. once seizures recurred (see below), dasatanib was held. it was briefly resumed when patient became more awake and alert, but again held as mental status worsened. given the severity of disease relapse in conjunction with multiple medical issues below, the patient's family transitioned him to comfort measures only. he expired during admission. . # seizures: on , patient's mental status was acutely changed, with decreased responsiveness and more irritability. keppra, which was held due to concern for myelosuppression, was restarted, and on , when the patient's mental status continued to rapidly decline, a 20 min eeg confirmed non-convulsive seizures. underlying cause of seizures was not clear. two lps were performed with no clear infectious source. nasopharyngeal rsv was positive so patient received pavalizumab, as this helped during last admission. however, patient is likely colonized with rsv, and seizures did not abate with pavalizumab administration. patient became less responsive, and per neuro-oncology, he was titrated up on keppra, with addition of lacosamide and eventually valproic acid. seizure activity was controlled by , as demonstrated on eeg. patient was somnolent for several more days, and anti-epileptics were titrated off, leaving valproic acid 750mg qid at therapeutic level (80-100). once anti-epileptics were reduced, patient slowly became more responsive and interactive. on , patient again became less responsive. valproic acid level remained therapeutic, and 24 hour eeg performed did not show further evidence of seizures. the's patient's family refused further eeg monitoring for patient's comfort. . # upper gib: on , the patient was transferred to the icu for an episode of hematemesis followed by bright red blood per rectum, associated with increasing tachycardia and mild hypotension. the patient was seen by gastroenterology, but did not undergo upper endoscopsy, as decided through a goals-of-care discussion with the family. he was transfused 2 units of prbcs, and returned to the floor. following this episode, the patient had multiple episodes of melena, symptomatically managed with transfusion. he was also continued on a ppi drip for gastritis or stress ulcer. . # pneumonia: as the patient's mental status declined, he suffered from a large right sided aspiration pneumonia. he began spiking high fevers, and was started on broad spectrum antibiotics. the patient was made comfort measures only during the course of his pneumonia, and antibiotics were discontinued. he passed away from fevers of 104 and dehydration in the setting of pneumonia. . # ruq tenderness: in the setting of ongoing gi bleed and sepsis from pneumonia, the patient began to experience right upper quadrant tenderness associated with worsening lfts in a cholestatic pattern. ruq ultrasound and hida were without evidence of obstruction. patient likely had tpn- or sepsis-induced cholestasis. pneumonia was treated as above. tpn was continued until the patient was made comfort measures only. . # right leg mucor infection: stable on ambisome, with no signs of active infection, only eschars remaining. saw general surgery as outpatient one week prior to admission who felt that debridement of eschars would increase risk of osteomyelitis. mri performed during admission showed no inflammation to suggest extension of mucor. patient was continued on ambisome and micafungin during admission. . # chronic gvhd: documented gvhd of liver and gi tract. on prednisone and budesonide. lfts within normal limits. prednisone was changed to methylprednisolone while patient not taking orals, and budesonide held. stool was consistently guaiac positive with stable hematocrit. . # chronic renal insufficiency: during previous admissions, patient has had acute on chronic injury secondary to tacrolimus/ambisome induced tubular toxicity and volume depletion. on admission, there was ongoing concern that ambisome may be worsening renal function following discontinuation of tacrolimus. patient was continued on ambisome during this admission, and with fluid resuscitation, creatinine improved. where possible, nephrotoxic medication was avoided. electrolytes were repleted as necessary, as patient had potassium wasting with elevated transtubular potassium gradient. . # cavitary lesions in lung: stable in size over serial imaging. likely related to mycobacterium kansaii which has been cultured from sputum repeatedly, but not treated due to significant hepatotoxicity associated with ripe regimen + ambisome. plan was to transition patient off of ambisome once able to take po so that he could be treated with the ripe regimen, but patient was transitioned to comfort measures only. . # history of picc-associated dvt: thrombocytopenic throughout admission. right picc functioned without issue. . # history of tachycardia: the patient has a history of wide complex tachycardia. on admission, the patient was off of metoprolol secondary to orthostatic hypotension, then restarted early in this admission. patient was given 5mg iv lopressor as needed for prolonged sinus tachycardia. late in his admission the patient had many episodes of atrial fibrillation with rapid ventricular response, treated with lopressor 5mg iv q6 hours. medications on admission: albuterol sulfate 90 mcg hfa inh q4-6h prn sob/wheezing and 2 puffs prior to pentamidine amphotericin b liposome 400mg iv q24h budesonide 3 mg po tod finasteride 5mg po daily levetiracetam 500mg po bid (d/c'ed by dr. on day of admission) lorazepam 1mg po q8h prn nausea, anxiety, insomnia magnesium sulfate 2g iv daily micafungin 100mg iv q24h ondansetron 8mg po q8 hours prn nausea oxybutynin chloride 5mg po bid prn bladder spasm oxycodone 5mg po q4h prn pain pentamidine 300mg inh qmonth potassium chloride 40meq iv daily potassium chloride 40meq er po bid prednisone 10mg po daily ursodiol 300mg po bid valganciclovir 450mg po daily docusate sodium 100mg po bid sennosides 8.6mg po bid prn constipation multivitamin discharge medications: not applicable discharge disposition: expired discharge diagnosis: # recurrent acute lymphocytic leukemia, chromosome positive # non-convulsive status epilepticus # mucor infection of the right leg # pneumonia # gastrointestinal bleed # chronic graft versus host disease discharge condition: patient expired during admission. procedure: venous catheterization, not elsewhere classified spinal tap incision of lung spinal tap incision of lung parenteral infusion of concentrated nutritional substances biopsy of bone marrow injection or infusion of cancer chemotherapeutic substance injection of other agent into spinal canal diagnoses: pneumonia, organism unspecified acidosis pure hypercholesterolemia unspecified pleural effusion acute posthemorrhagic anemia 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 other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pneumonitis due to inhalation of food or vomitus grand mal status long-term (current) use of anticoagulants personal history of malignant neoplasm of large intestine complications of transplanted bone marrow personal history of venous thrombosis and embolism diarrhea headache do not resuscitate status hemorrhage of gastrointestinal tract, unspecified hyperosmolality and/or hypernatremia tachycardia, unspecified aspergillosis other alteration of consciousness acute lymphoid leukemia, without mention of having achieved remission neutropenia, unspecified zygomycosis [phycomycosis or mucormycosis] other pancytopenia pulmonary diseases due to other mycobacteria graft-versus-host disease, unspecified other specified disorders of bladder 

Answer: The patient is high likely exposed to