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: codeine / sulfa (sulfonamides) attending: chief complaint: fever, neutropenia major surgical or invasive procedure: lumbar puncture x 3 picc line placement bone marrow biopsy x 2 itrathecal chemotherapy with methotrexate initiation of radiation therapy to right arm history of present illness: 35 y.o. woman with history of newly diagnosed t cell lymphoma () who presented on day 10 status post chop. she had been feeling well during the week prior to admission before having a temperature of 100.4 on . at that point she felt tired but otherwise well without localizing symptoms (shortness of breath, cough, chest pain, abdominal pain, dysuria, etc...). she awoke with a temperature of 102 f with chills as well as dizziness and "eyes burning." otherwise she reported constipation (ongoing) and some mouth sores. these complaints brought her in to the ed. . in the ed temp 102.7, hr 124, bp 98/52, rr 20, o2 sat 100% ra. she received cefepime 2gm iv, vanco 1gm iv, decadron 10mg iv, and tylenol. she also received 6l ivf. in the ed her lowest sbp was 86 and after fluid hr improved to 100. . on arrival to the floor she reported feeling thirsty as well as mild abdominal cramping and some mild headache. she denied photophobia, neck stiffness, sob, cp, diarrhea. she had just finished steroid taper and had been on levofloxacin for suppressive therapy. past medical history: peripheral t cell lymphoma: she presented with fevers and elevated lft's in the spring of . bone marrow biopsy at that time revealed t-cells. treatments so far include -high dose steroids -nitrogen mustard -chop . social history: she lives with her husband who is her health care power of attorney and her two and a half year old son. she denies using tobacco or alcohol. she rents space in a salon where she does manicures. family history: father has a history of benign adrenal mass and skin cancers removed. her mother has hyperparathyroidism and hypertension. physical exam: admission exam: t 98.6, hr 104, bp 96/58, 97% ra rr23 gen: well appearing nad heent: mm dry. palor. jvp 6cm. mild mucositis. no photophobia or nuchal rig cards: rrr no murmurs. physio split s2. resp: nl effort. ctab abd: bs+ mildly tender diffusely. no rebound or guarding. mild ruq tenderness. soft. no masses. ext: good pulses. no edema. no rashes. . on discharge: patient afebrile two days. vital signs all stable and within normal limits except for continued sinus tachycardia. at time of discharge she no longer had visible mucositis. no longer right upper quadrant tenderness. over course of hospitalization she had interval development of right wrist drop and decreased sensation in webspace of right hand. strength 5/5 in all other extremities and muscle groups. pertinent results: laboratory values ------------------ admission labs() wbc-0.8*# rbc-3.32* hgb-9.2* hct-27.5* mcv-83 mch-27.8 mchc-33.5 rdw-16.1* plt ct-185 ---pmns-52,bnds-2,l-39,mono-2,eos-2,atyp-3*,nrbc-1* pt-15.9* ptt-33.8 inr(pt)-1.4* glucose-195* urean-15 creat-0.8 na-135 k-4.5 cl-101 hco3-23 angap-16 alt-67* ast-51* alkphos-282* totbili-1.4 calcium-9.0 phos-3.0 mg-1.9 lactate-2.6* blood cultures: urine studies: color-yellow appear-clear sp -1.017 blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg rbc-0 wbc-0 bacteri-occ yeast-none epi-0-2 admission cxr: portable ap chest, one view: patient is in relative lordotic positioning. cardiomediastinal and hilar contours are normal. the lungs are clear without focal consolidation or pulmonary edema. there is no pleural effusion or pneumothorax. osseous structures are unremarkable. impression: no acute cardiopulmonary process. brief hospital course: mrs. is a 35 yo woman with peripheral t-cell lymphoma admitted for neutropenic fevers and hypotension between her first and second cycle of chop. . 1. t cell non-hodgkins lymphoma. despite fever patient was able to proceed to her second cycle of chop as scheduled on during this admission. she tolerated it well. because of bone marrow infarcts during her last cycle g-csf was held and her counts dropped. she later was treated with g-csf and her counts improved. however, her fevers returned and all her cultures were negative. given concern for advancing disease given continued fevers and no signs of infection she had a series of lp's. the second and third lp showed atypical cells that likely represented cns disease. therefore she was started on and it methotrexate with high dose methotrexate on day 10. she tolerated these therapies well with only some gi toxicity and mild mucositis after the methotrexate. after receiving high dose methotrexate she again began to have fevers and chills leading to another infectious work-up which was negative except for an enterococcal bacteremia (see below). she also had slightly elevated liver enzymes so repeat mri of the abdomen was obtained and showed no focal involvement of the liver. she ended up on broad spectrum antimicrobials for fevers as her neutropenia reached its nadir. at the same time work up of her right radial nerve palsy (see below) led to suspicion of progressive neurologic disease despite previous chemotherapy. thus as she began to recover from her nadir with the help of g-csf the plan was made to start steroid therapy for her suspected continued neurologic disease and proceed to it arac and eshap. the patient defervesced on steroid therapy and the plan was made to continue to it ara c in a few days and eshap in approximately a week of discharge. . 2.) fever: on presentation there were no localizing symptoms on imaging or testing so her fevers were thought to be non-infectious and probably due to bone marrow infarcts vs drug fever vs continued disease activity. thus she proceeded onto her second cycle of chop. after the fevers did not resolve after her second cycle of chop an additional fever work up was initiated which revealed likely cns involvement of her lymphoma(see above). her brain mr was negative for focal findings but additional work up with lumbar punctures revealed cns disease and required additional treatment with and intrathecal methotrexate on day 1 and high dose methotrexate on day 10. after high dose methotrexate she again became febrile and thus yet another infectious work up was initiated. this revealed an enterococcal urinary tract infection for which she was treated with vancomycin and then ampicillin after sensitivities returned. she never defervesced and as she became more neutropenic her coverage was broadened to include broad spectrum antibiotics as well as fungal coverage. despite this coverage she continued to be febrile. as her cytopenias resolved and a high suspicion of progressive neurologic lymphoma arose her antimicrobials were eventually decreased to levofloxacin and voriconazole, which she continued on discharge. at this point progressive lymphoma was considered the most likely etiology of her fevers but she was continued on antimicrobials given the inability to completely rule out infection. her fevers only resolved with the initiation of steroid therapy two days before discharge. . 3.) hypotension: she was admitted to the on presentation with hypotension as well as fever. she was treated empirically on admission with vancomycin and cefepime iv and remained hemodynamically stable overnight. her blood pressure responded to fluid bolus of 1l ns. a cortisol stim test was wnl on . it is unclear if the hypotension was due to sepsis of some infecting organism or some other etiology. this did not recur. . 4.) bone marrow infarction: around day +10 from her first cycle of chop and while on treatment with g-csf she developed rapidly rising ldh, severe bony pain, and fever. this was believed to be due to bm infarcts. she received supportive care with fluids, analgesia with a dilaudid pca, and fever control. she was easily weaned from the pca once the pain passed. her counts prior to her second cycle of chop were stable. the main complication of this was urinary retention requiring the placement of a foley catheter. her second cycle of chop was a reduced dose. she was continued on morphine sr for continued bone pain throughout her hospitalization and with this the pain was well managed. she was discharged on this medication. . 5 hsv active oral lesions on admission. received 7 days of therapeutic dosing of acyclovir. she was reduced to prophylaxis dose and maintained on that dose without complications thereafter. . 6.)neurologic symptoms: she had umn signs on the left early in admission and later weakness and lmn signs of right wrist and hand with decreased extension of her fingers. neurology was consulted and recommended imaging, but mri of brain, spine, and brachial plexus on both sides were essentially wnl. two lp's were obtained the first of which was normal and the second of which showed atypical cells. the left arm recovered during the second cycle of chop. the right arm problems started abound the time was started. she was also having intense pain in her right arm at this time. consideration was given to an inflammatory process vs a chemo induced or paraneoplastic neuropathy but no clear etiology was found. because of no improvement in the right arm symptoms with treatment with and high dose methotrexate, neuro-oncology was consulted and diagnosed a right radial nerve palsy. neuro-onc suspected neoplastic involvement of the nerve and mri of the right arm did demonstrate this. thus, radiation oncology was consulted and began xrt to the lesion in the right arm as the treating team proceeded to the more aggressive strategy of it arac and eshap. the patient had received only a few sessions of xrt at discharge and no interval change in right radial nerve palsy though in regards to function and pain it was much improved with use of a soft splint. . 7.) right upper quadrant tenderness. started acutely during the second cycle of chop and resolved for the most part within two days. there was a concomitant elevation in alk phos, ldh, and ggt. ct on showed possible gb wall edema. us on was essentially normal. lft improved since spike on . ultimately it was believed that this was due to liver involvement by lymphoma, which was a component of her original presentation. a further workup revealed a normal liver mr and her lft's resolved. . 8.) right pleural effusion: this was found incidentally on imaging and pulmonology was consulted and performed a pleurocentesis on . final results revealed normal fluid and this was resolved on her next ct scan. . 9.) bilateral neuropathic pain in lower extremities: this may have been due to lymphoma versus side effects of vincristine. the pain responded well to gabapentin and amitriptyline therapy and she was discharged on these medications. . 10.) hemorrhoids: the patient had dealt with hemorrhoids in the past. these flared with some incidents of diarrhea during her chemotherapy and had large inflamed hemorrhoids. given cytopenias were worsening these were observed and managed with baths and steroid cream with good improvement particularly as diarrhea resolved. . 11.) mucositis: had some mild mucositis during hd methotrexate therapy. this was managed with topical cares with good results. . 12.) access: the patient initially had a right sided picc line that developed pain and poor function. this was removed. a right upper extremity ultrasound on revealed a right cephalic vein thrombosis with no extension of time. she received local therapies for pain and this resolved. a left sided picc was then placed that functioned well for the remainder of the hospitalization and was present on discharge. . 13.) prophylaxis: patient received her inhaled pentamadine on for pcp . she ambulated for dvt prophylaxis. she remained on her home ppi throughout the hospitalization. antimicrobial prophylaxis was acyclovir as described above. she never received antibacterial prophylaxis as she was always was on treatment doses of antibiotics for fevers when she became neutropenic. . the patient was maintained on a neutropenic diet. she was full code. medications on admission: levofloxacin 500 daily zofran prn pantoprazole 40 daily senna allopurinol 100 daily ativan prn prednisone taper hydroxyzine 25 q4h prn colace 100 pentamidine qmonth discharge medications: 1. saline flush 5-10 cc saline flush to each lumen of picc daily 2. heparin flush 10 units/cc; 3-5 cc flush to each lumen daily after normal saline flush 3. dressing changes dressing change of picc site weekly and prn per critical care protocol 4. voriconazole 200 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 5. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 6. acyclovir 400 mg tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 8. morphine 30 mg tablet sustained release sig: one (1) tablet sustained release po every eight (8) hours. disp:*90 tablet sustained release(s)* refills:*0* 9. amitriptyline 10 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 10. gabapentin 300 mg capsule sig: two (2) capsule po tid (3 times a day). disp:*180 capsule(s)* refills:*2* 11. oral wound care products gel in packet sig: one (1) ml mucous membrane tid (3 times a day) as needed. 12. dexamethasone 4 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 1 weeks: please taper as instructed in the outpatient bmt area. . disp:*14 tablet(s)* refills:*0* 13. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. disp:*60 capsule(s)* refills:*2* 14. pentamidine 300 mg recon soln sig: one (1) dose inhalation once a month: last dose on . discharge disposition: home with service facility: critical care systems discharge diagnosis: primary diagnosis: -------------------- t-cell lymphoma neutropenic fever discharge condition: good, afebrile, tolerating po's discharge instructions: you were admitted to the hospital for very high fevers. your fevers were thought most likely related your lymphoma and your recent chemotherapy. you were found to have a urinary tract infection for which you received adequate treatment. we still thought it was most likely you had your fevers due to your underlying lymphoma. while you were admitted to the hospital, you also had severe bone pain which was controlled with narcotic pain medication and also thought due to your lymphoma. this pain improved significantly while you were in the hospital. . in the hospital you also had problems with nerve pain, which was thought due to your chemotherapy and possibly your lymphoma as well. you also had paralysis of one nerve and a scan of this area revealed involvement of your lymphoma. we put you on several medications for nerve pain with some improvement and you were also started on radiation therapy to attempt to help your nerve recover from the lymphoma involvement. you also received high dose methotrexate for your central nervous system disease. you tolerated this well with only some mouth sores as side effects. you were always able to tolerate food by mouth. you will also start intrathecal arac therapy with dr. from neurology. this will be arranged in the next week. . we have made the following changes to your medications. you have been started on gabapentin, ms contin, and amitryptyline to help manage your nerve pain. your allopurinol and ondansetron (zofran) have been stopped. you have also been started on dexamethasone to help manage your fevers and help your nerve recover. . please keep all follow up appointments as these are important to maintaining your health. . please seek immediate medical attention if you develop fevers > 100.4, shaking chills, night sweats, shortness of breath, chest pain, abdominal pain, worsening or changing bone pain. followup instructions: you have a ct/pet scan scheduled for this wednesday at 11:10 this will take place on 4 at the . . you have an appointment with the ophthalmologist , md on at 12:45 pm to assess for ocular involvement of your lymphoma. her office can be reached at . . after your ophthalmology appointment please report to the outpatient area of the bmt floor for evaluation by dr. , you will also be coordinated to receive your it chemo from dr. at some point in that afternoon. procedure: venous catheterization, not elsewhere classified spinal tap incision of lung thoracentesis biopsy of bone marrow biopsy of bone marrow transfusion of packed cells injection or infusion of cancer chemotherapeutic substance injection or infusion of cancer chemotherapeutic substance other radiotherapeutic procedure injection of other agent into spinal canal diagnoses: unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified other opiates and related narcotics causing adverse effects in therapeutic use constipation, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure brachial neuritis or radiculitis nos hypotension, unspecified other complications due to other vascular device, implant, and graft antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use retention of urine, unspecified nausea alone streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] dehydration drug induced neutropenia tachycardia, unspecified anemia in neoplastic disease other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms herpetic gingivostomatitis unspecified drug or medicinal substance causing adverse effects in therapeutic use polyneuropathy due to drugs unspecified hemorrhoids without mention of complication stomatitis and mucositis, unspecified peripheral t cell lymphoma, lymph nodes of multiple sites 

Answer: The patient is high likely exposed to