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: no known allergies / adverse drug reactions attending: chief complaint: fever of unknown origin, pancytopenia, acute hypoxemic respiratory failure, myelodysplasia major surgical or invasive procedure: bal placement of picc elective intubation history of present illness: attending admission note date: time: 22:45 the patient is an 82-year-old spanish-speaking female with hx of ulcerative colitis in remission s/p colectomy who was transferred from osh for hypoxemic respiratory failure in the setting of a new diagnosis of myelodysplasia and pancytopenia. the history was collected with assistance from daughter (hcp) who lives with the patient. per daughter, patient was in her usual state of health until early when she had back pain after making her bed. an x-ray of her back was taken and she was told she had a "pinched nerve" for which she was treated with one week of a prednisone taper and vicodin with good improvement. subsequently, on the week of , she began to complain of abdominal pain and general malaise. the following week, on , she had a fever at home as well as rash on her arms and legs, which was raised and painful to touch. she was seen by her pcp dr on ; cxr and blood tests were performed. per her daughter, she was feeling extremely weak and had poor po intake during these days. based on the results of the blood tests, she was referred to oncology. she was seen by dr on for her pancytopenia and admitted directly to the hospital as she appeared tachypneic and unwell. during her hospital admission, bone marrow biopsy was performed that showed 18% blasts concerning for high grade myelodysplastic syndrome as well as granulomas concerning for fungal infections. heme/onc was consulted who felt that initiating treatment for myelodysplasia was not warranted. id was also consulted as she had persistent fevers to 102-103, anc ranged 1000-1400. she was transferred to the icu for hypotension with intermittent fluid boluses to maintain bps. id was concerned for strep pharyngitis and recommended ceftriaxone (discouraged vanc/cefepime as these could worsen pancytopenia). infectious work-up included tte, ct abdomen/pelvis, bcxs and stool studies that were unremarkable. urine was weakly positive for histoplasmosis. she was given a dose of amphotericin that caused rigors and tachycardia. she was then placed on trial of iv solumedrol 80mg tid and fevers defervesced. on day of transfer to , she had worsening hypoxemia with increasing fio2 requirement. cxr showed diffuse bilateral pulmonary infiltrate, predominantely perihilar in distribution, and b/l pleural effusions. id had recommended that steroids be discontinued on transfer and amphotericin resumed (150mg daily). she was also given a dose of lasix for volume overload prior to transfer. on the floor, she reports that she is comfortable. she reports that her breathing has improved. she denies pain anywhere, including abdominal pain. she reports her diarrhea has resolved with immodium. + dry mouth, but was able to tollerate po in the icu. review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. denies chest pain, palpitations, orthopnea, dyspnea on exertion. denies shortness of breath, cough or wheezes. denies nausea, vomiting, heartburn, diarrhea, constipation, brbpr, melena, or abdominal pain. no dysuria, urinary frequency. denies arthralgias or myalgias. denies rashes. no increasing lower extremity swelling. no numbness/tingling or muscle weakness in extremities. no feelings of depression or anxiety. all other review of systems negative. past medical history: ulcerative colitis s/p total colectomy with ileoanal anastomosis recurrent small bowel obstructions s/p adhesiolysis , gerd hyperlipidemia osteoporosis social history: originally from republic; has been living in us for 27years. has 3 daughters. lives with oldest daughter . - : hx of social smoking. quit in the - alcohol: social etoh, glass of wine occasionally. - illicits: none family history: mother: mi (60s) brother: cv disease brother: emphysema physical exam: admission physical exam: vs: 98.1 ax, 129/66 110 22 96%2l; pain 0/10 gen: no apparent distress heent: no trauma, pupils round and reactive to light and accommodation, no lad, oropharynx clear, no exudates cv: regular rate and rhythm, no murmurs/gallops/rubs pulm: clear to auscultation bilaterally, no rales/crackles/rhonchi gi: soft, non-tender, non-distended; no guarding/rebound ext: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral iv present neuro: alert and oriented to person, place and situation; cn ii-xii intact, motor function globally derm: dark circular plaques over upper and lower extremities b/l, no longer raised or painful discharge physical exam: vs: gen: heent: cv: pulm: ext: neuro: skin: pertinent results: on admission to osh: wbc 1.9, hgb 10.2, hct 32, mcv 77, plts 80k. polys 50%, bands 40%, lymphs 8%, monos 2%, esr 105, alk phos 237 prior to transfer: wbc 1.8, hgb 9.6, hct 29, plts 71k, alk phos 254 abg ph 7.49, bicarb 19.6, pco2 26, po2 56, oxygen sat 89%5l on admission: 10:55pm glucose-141* urea n-33* creat-0.9 sodium-143 potassium-4.1 chloride-109* total co2-25 anion gap-13 10:55pm alt(sgpt)-29 ast(sgot)-36 ld(ldh)-307* alk phos-237* tot bili-0.7 10:55pm albumin-2.6* calcium-8.1* phosphate-3.3 magnesium-2.4 iron-74 10:55pm caltibc-202* haptoglob-300* ferritin-1283* trf-155* 10:55pm wbc-2.2* rbc-3.80* hgb-10.0* hct-30.5* mcv-80* mch-26.3* mchc-32.8 rdw-21.7* 10:55pm neuts-79* bands-2 lymphs-10* monos-2 eos-1 basos-0 atyps-1* metas-2* myelos-2* nuc rbcs-2* plasma-1* 10:55pm pt-14.0* ptt-22.8 inr(pt)-1.2* 10:55pm fibrinoge-305 pertinent labs: 05:35am blood wbc-1.9* rbc-3.65* hgb-9.7* hct-30.3* mcv-83 mch-26.6* mchc-32.1 rdw-21.2* plt ct-38* 04:34am blood wbc-3.0* rbc-4.26 hgb-11.6* hct-34.9* mcv-82 mch-27.1 mchc-33.1 rdw-20.8* plt ct-41* 04:37am blood wbc-3.1* rbc-3.29* hgb-8.8* hct-26.7* mcv-81* mch-26.7* mchc-32.9 rdw-20.6* plt ct-24* 04:34am blood pt-12.8 ptt-20.3* inr(pt)-1.1 04:37am blood pt-13.6* ptt-26.1 inr(pt)-1.2* 11:21am blood fdp-80-160* 04:57am blood fdp-40-80* 04:37am blood fdp-80-160* 05:35am blood gran ct-1653* 05:35am blood glucose-131* urean-36* creat-0.7 na-140 k-3.9 cl-107 hco3-24 angap-13 04:34am blood glucose-153* urean-36* creat-0.8 na-140 k-3.9 cl-104 hco3-23 angap-17 04:37am blood glucose-98 urean-28* creat-0.6 na-140 k-2.6* cl-108 hco3-25 angap-10 12:35am blood na-136 k-3.2* cl-106 10:55pm blood alt-29 ast-36 ld(ldh)-307* alkphos-237* totbili-0.7 04:34am blood albumin-3.0* calcium-8.0* phos-3.4 mg-2.2 05:35am blood tsh-0.41 04:34am blood anca-negative b 04:34am blood dsdna-negative 04:34am blood -positive * titer-pnd 07:23am blood vanco-6.4* bglucan 62 galactomannan 0.1 urine 08:34pm urine color-yellow appear-clear sp -1.011 08:34pm urine blood-tr nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 08:34pm urine rbc-1 wbc-2 bacteri-few yeast-none epi-<1 transe-<1 11:21pm urine casthy-57* studies: histoplasmosa antibody neg anti gbm neg anti histone neg histoplasma urine antigen neg bal cell differential 05:24pm other body fluid polys-13* lymphs-14* monos-0 eos-2* macro-71* images: echo the left atrium is mildly dilated. 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 ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. . cxr impression: ap chest compared to through 18: radiographically, there has been no change since in large areas of perihilar consolidation, left greater than right. in the interim, moderate bilateral pleural effusions have decreased. heart size is exaggerated by large hiatus hernia. much of the perihilar consolidation is probably pulmonary edema given the waxing and in the severity of at least the left upper lobe component between and . right picc line ends in the svc. no pneumothorax. radiology ct torso w/contrast 1. slight decrease in diffuse alveolar ground-glass opacities with a perihilar and lower lung predominance, likely secondary to either infection, drug reaction, or pulmonary edema. 2. moderate bilateral pleural effusions, right greater than left, not significantly changed in size compared to prior ct from , . 3. fluid within the endometrial cavity without other definite uterine abnormalities. followup of the uterus and endometrium should be performed with short-term ultrasound on a non-emergent basis. radiology unilat up ext veins us nonocclusive thrombus in the left brachial vein containing the peripheral catheter. images were obtained ~5 inches proximal to the antecubital fossa radiology chest (portable ap) cardiomegaly is stable. increase opacities in the lower lobes bilaterally greater on the right are a combination of atelectasis and large pleural effusions; part of the change is due to difference in position of the patient. cardiomegaly is stable. otherwise, perihilar opacities are unchanged. there is no evidence of pneumothorax. et tube is no longer present. radiology chest (portable ap) 1. new endotracheal tube terminating 2.5 cm above the carina. 2. bilateral pulmonary edema is essentially unchanged. lateral portion of the left hemithorax is excluded from the film. pathology tissue: slides referred for skin, left thigh, punch biopsy (consult from hospital s--11, , 1 h&e, 1 afb, 1 gms, 4 immunostains with neg controls): mild superficial to mid-dermal perivascular lymphocytic inflammation with focal mixed cell inflammation in the superficial subcutis. note: an underlying panniculitis is possible, however, the limited sampling of the subcutis precludes further classification of the inflammation within the panniculus. gms and afb stains are negative. c-kit stains a few mast cells and cd34 stains vessels. no leukemic infiltrate is identified. radiology ct chest w/o contrast 1. predominantly central perihilar opacities, in the setting of bilateral pleural effusions and mildly enlarged heart, these findings are most suggestive of pulmonary edema. no definite findings to suggest infection. 2. moderate-to-large hiatal hernia. 3. tip of the central catheter is at the junction of the brachiocephalic vein and the superior vena cava. radiology chest (portable ap) patient is not intubated, heart is mildly to moderately enlarged and small bilateral pleural effusions are present. the very symmetric perihilar pulmonary consolidation in both lungs could therefore be pulmonary edema rather than pneumonia. prior chest radiograph should be obtained to make a more knowledgeable assessment cardiology ecg , normal sinus rhythm. right bundle-branch block. no previous tracing available for comparison. osh studies: bone marrow flow cytometery: bone marrow shows 18% blasts, blasts expressing cd34, cd 117, and various myeloid antigens pathology report shows hypercellular bone marrow for age wtih trilineage dysopoiesis, increased blasts and granulomatous inflammation fungal cultures from bone marrow: no yeast or fungus afb bone marrow: afb stain showed no acid fast bacillus skin punch biopsy shows superficial and deep dermal perivascular inflammation extending into the superficial subcut skin biopsy: no growth seen, no neutrophils, no organisms ct abdomen/pelvis no acute inflammatory process, normal small bowel within right lower quadrant. no evidence of closed loop bowel or inflammation chest ct scan : bilateral central perihilar patchy ground glass infiltrates and small bilateral pleural effusions. . tte : the left ventricle is normal in size. there is normal left ventricular wall thickness. left ventricular systolic function is normal. ejection fraction 55-60%. there is mild mitral annular calcification. the mitral valve leaflets appear thickened, but open well. mild to moderate mitral regurgitation. mild tricuspid regurgitation. mild aortic regurgitation. no definitive valvular vegetation could be identified on this study. if there is future concern regarding possible endocarditis, consider tee. ekg : sinus rhythm. incomplete rbbb. microbiology bcx: pending x 2 bcx: no growth ucx: no growth 12:22 pm bone marrow precaution for histiplasmosis. fluid culture (preliminary): no growth. brucella culture (preliminary): no growth. fungal culture (preliminary): no fungus isolated. blood (ebv) - virus vca-igg ab-postive; - virus ebna igg ab-positive; - virus vca-igm ab-negativeinpatient blood (cmv ab) cmv igg antibody-positive; cmv igm antibody-negative inpatient serology/blood varicella-zoster igg serology-positive inpatient stool clostridium difficile toxin a & b test-negative final inpatient stool ova + parasites-negative inpatient sputum acid fast smear-preliminary; acid fast culture-negative inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-no growth. inpatient urine urine culture-no growth. final inpatient stool ova + parasites-negative final inpatient sputum acid fast smear-final; acid fast culture- negative inpatient resp bal cx: negative for pneumocystis jirovecii bronchoalveolar lavage gram stain-final; respiratory culture-final; immunoflourescent test for pneumocystis jirovecii (carinii)-final; fungal culture-preliminary; acid fast smear-final; acid fast culture-preliminary inpatient rapid respiratory viral screen & culture respiratory viral culture- no growth, <1000 cfu/ml; respiratory viral antigen screen-final inpatient bronchoalveolar lavage gram stain-final; respiratory culture-final; potassium hydroxide preparation-final; immunoflourescent test for pneumocystis jirovecii (carinii)-final; fungal culture-preliminary; acid fast smear-final; acid fast culture-preliminary inpatient blood culture ( myco/f lytic bottle) blood/fungal culture-preliminary; blood/afb culture-negative inpatient blood culture blood culture, routine-negative inpatient stool fecal culture-final; campylobacter culture-negative final; ova + parasites-final negative; fecal culture - r/o vibrio-final negative; fecal culture - r/o yersinia-final negative; fecal culture - r/o e.coli 0157:h7-final negative; microsporidia stain-final negative; cyclospora stain-final negative; cryptosporidium/giardia (dfa)-final negative; clostridium difficile toxin a & b test-final inpatient: feces negative for c.difficile toxin a & b by eia. serology/blood cryptococcal antigen-cryptococcal antigen not detected. final inpatient urine legionella urinary antigen -final inpatient blood culture blood culture, routine-no growth. inpatient mrsa screen: no mrsa isolated. urine urine culture-final {enterococcus sp.} inpatient brief hospital course: 82-year-old spanish-speaking female with hx of ulcerative colitis in remission s/p colectomy being transferred from osh for hypoxemic respiratory failure in setting of new diagnosis of myelodysplasia and pancytopenia. # hypoxemic respiratory distress: stable. she was transferred from osh with worsening respiratory distress satting mid 90's on nrb. cxr showed diffuse b/l pulmonary infiltrates and small pleural effusions. she was treated empirically for hcap with vancomycin, cefepime, and azithromycin. also continued on ambisome per id recs due to reports of positive histoplasmosis antigen from osh. she was diuresed with iv lasix approximately 4l prior to transfer to the floor. she was electively intubated for bronchoscopy on , and was successfull extubated the following day. as below, the bal returned bloody fluid. on , the again began to experience respiratory distress associated with borderline bp and a 10 point decrease in her hematocrit. she was again transferred to the icu for further monitoring. her blood pressures remained fluid responsive to both ivf and prbcs (1 unit). it was felt that the etiology of her hypoxia and hypotension was possible due to additional alveolar hemorrhage. her respiratory status and blood pressures improved during her icu stay and were stable prior to transfer back to the general medical floor. on the floor, she continued to do better. on one occasion on the night of , the patient spiked a fever after 48 hours of afebrile condition. a chest x-ray showed possible lul pneumonia, which was treated emperically with vanco/zosyn. on day of discharge, the patient's respiratory status was stable, requiring supplemental oxygen after exertion. # fever: she had persistent fevers at osh despite being on ceftriaxone and then amphotericin/itraconazole. work up at osh included ct abdomen, ct chest, tte, bcx, and stool studies which were been unremarkable. urine was weakly positive for histoplasma antigen at osh, and she was started on amphotericin. urine culture on admission grew 10-100k vse and bal returned bloody fluid. otherwise blood, urine, and bal cultures were unremarkable, including repeat urine culture. she continued to spike fevers, and ct a/p showed no source of infection, although did mention fluid in the endometrial cavity. she was ruled out x3 for tuberculosis. histoplasma and autoimmune serologies are negative. after transfer to the floor, patient was afebrile for 48 hours. spiked spontaneously on one evening, and initially the chest x-ray was concerning for lul pneumonia, and the patient was started on vancomycin/zosyn for treatment of ventilator acquired pna. in the interim, the patinet's urine culture grew out vre, only susceptible to linezolid. the patient was discharged on the remainder of a 3 day course of levaquin and voriconazole which she was to continue until final results of the histo pcr were complete. # pancytopenia: bone marrow biopsy from osh reportedly showed 18% blasts with myelodysplasia concerning for new diagnosis of aml. also with reported granulomas. heme/onc was consulted who reviewed outside smear, and recommended repeating smear with cultures performed. platelets continually dropped during stay in micu and patient received 1 unit of platelets. patient also received a unit of rbcs while on the floor and also while in the unit (2 units total). repeat bone marrow biopsy was consistent with mds as opposed to aml. the patient's white blood cell count continued to drop through the admission, and she did become neutropenic; her neutropenia was attributed to her underlying mds. the patient will need follow-up on an outpatient basis for monitoring, transufions of blood products as well as for treatment of underlying mds. transfusions goals are 1 unit for a hematocrit of less than 24 or platelets less than 30. # rash: initial presentation concerning for erythema nodosum. per osh records, biopsy was sent to life sciences for outside consultation. biopsy slides were arranged to be sent to our pathology department. pathology report also consistent with erythema nodosum. # diarrhea: she has chronic diarrhea, and arrived from osh with flexiseal in place. c. diff and stool cutlures were negative. she was treated symptomatcially with loperamide with good effect. during this hospitalization, c. diff antigen x 2 and pcr were all negative. flexiseal was discontinued during the admission. continue home loperamide as needed for diarrhea upon discharge from the hospital. # left ue dvt: left arm noted to be swollen during stay. ueni showed clot in left arm associated with picc line. line was pulled, and there was resolution of the erythema associated with the left upper extremity dvt. the patient was not started on anticoagulation given her thrombocytopenia. transitional issues: 1. continue on voriconazole as ordered until we receive final results of the histoplasmosis pcr, which we expect will be by wednesday, . if the results are negative we will stop the voriconazole. if the results are positive we will continue the voriconazole and schedule her for a follow up appointment with the infectious disease clinic at . 2. continue the levofloxacin for one more day, to end on wednesday, . 3. follow up appointment with dr. for further evaluation and management of her myelodysplastic syndrome. 4. check chem 10 and cbc on friday and follow up as needed including electrolyte repletions and blood and platelet transfusions if needed (for a hematocrit < 25 or platelets < 30). medications on admission: simvastatin 20mg daily alendronate 70mg weekly os-cal 2 tablets daily folic acid 400mg daily b12 500mg daily vitamin d 800 iu daily loperamide 2mg daily prn temazepam 15mg qhs prn discharge medications: 1. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily). 2. loperamide 2 mg capsule sig: two (2) capsule po tid (3 times a day) as needed for diarrhea. 3. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 4. calcium 500 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po once a day. 5. folic acid 1 mg tablet sig: one (1) tablet po once a day. 6. acetaminophen 500 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain or fever. 7. combivent 18-103 mcg/actuation aerosol sig: 1-2 puffs inhalation every 4-6 hours as needed for shortness of breath or wheezing. disp:*1 inhaler* refills:*0* 8. other home oxygen 9. alendronate 35 mg tablet sig: one (1) tablet po once a week. 10. voriconazole 200 mg tablet sig: one (1) tablet po twice a day: continue to take until directed to stop by your physician. 11. levofloxacin 750 mg tablet sig: one (1) tablet po once a day for 3 days. discharge disposition: extended care facility: the rehab discharge diagnosis: histoplasmosis (pending confirmation) mds pulmonary alveolar hemorrhage discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: dear ms. , it was a pleasure taking care of your during your hospitalization at . you presented to us with shortness of breath and fevers. while with us, we determined that you likely suffered the fevers from an infection infection. your shortness of breath was attributed to bleeding in your lungs, which stopped during your hospital . we also determined that you likely have myelodysplastic syndrome, which will require further workup and treatment as an outpatient. the following changes were made to your medication: added: - combivent inhaler 1-2 puffs as needed for shortness of breath/wheezing every 4 to 6 hours - levaquin which you should take for 3 days - voriconazole, which you should continue until we have final results of your test for histoplasmosis. we expect to have these results within the next week. you had a skin biopsy while you were here. you need to have your sutures removed two weeks after the biopsy which was , so the sutures should be removed on or around . one of your physicians at the facility you are going to can remove them. until then the dressing on the wound from your biopsy should be changed daily and the wound treated with vaseline. followup instructions: department: hematology/bmt when: tuesday at 3:00 pm with: , np building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 3:00 pm with: , md building: sc clinical ctr campus: east best parking: garage md, procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified parenteral infusion of concentrated nutritional substances insertion of endotracheal tube biopsy of bone marrow closed [endoscopic] biopsy of bronchus closed biopsy of skin and subcutaneous tissue diagnoses: acidosis thrombocytopenia, unspecified hypocalcemia esophageal reflux unspecified pleural effusion unspecified essential hypertension unspecified protein-calorie malnutrition hypopotassemia myelodysplastic syndrome, unspecified other and unspecified hyperlipidemia acute respiratory failure hypotension, unspecified disorders of phosphorus metabolism osteoporosis, unspecified fever, unspecified rash and other nonspecific skin eruption diarrhea drug induced neutropenia tachycardia, unspecified precipitous drop in hematocrit other and unspecified anti-infectives causing adverse effects in therapeutic use acute venous embolism and thrombosis of upper extremity, unspecified other pancytopenia histoplasmosis, unspecified, without mention of manifestation 

Answer: The patient is high likely exposed to