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: patient recorded as having no known allergies to drugs attending: chief complaint: transfer to micu for management of persistent mental status changes major surgical or invasive procedure: s/p intubation s/p hd catheter placement history of present illness: 62 yo m h/o htn, etoh abuse, clbp initially admitted for back pain/mulitple spinal surgeries, followed by sicu service, transferred to micu for chronic post-op mental status changes. history obtained from daughter, , and chart, as pt presently not communicative. pt was in usoh until around when pt fell while carrying refrigerator. pt seen in ed c/o back pain. l spine with ? om. mri recommended, but pt refused and was discharged form the ed. pt again returned to (this admission) c/o back pain. mri performed, demonstrating epidural abscess l4, l2-3 and l3-4 discitis, l3 compression fx. started on ctx, vanc and flagyl and admitted to neurosurgery. on , pt started on 7 day course of vanc, flagyl, ctx. pt taken to or and had partial vertebrectomy of l2 and l3 and anterior fusion of l2-l4. pt subsequently followed in sicu until when he completed surgery with a total laminectomy of l4, multiple lumbar laminotomies l1-l5, and fusion l1-s1. since that time pt has been minimally interactive per the primary surgical team. he was extubated and has remained minimally responsive with difficulty following commands. of note pt had a abd u/s on which revealed reversal of flow in the main portal vein and small ascites. mri head on without evidence of acute infarct or abnormal enhancement. labs significant for persistently elevated ast, t bili, inr. ct head today negative. lp attempted on floor by surgical team was unsuccessful. given persistent mental status changes the pt is being transferred to the micu for further management. past medical history: hypertension alcohol abuse chronic low back pain liver disease likely due to alcohol social history: lives with daughter reports drinking >1 pint/day denies tobacco, denies drugs, denies ivdu family history: non-contributory physical exam: temp 100.1, tm 101.8 last night 2200) bp 162/70 pulse 88 resp 11 o2 sat 100% ra i/o for today 2100/4600 gen - somnolent, minimally rousable, intermittently follows simple commands heent - per sluggishly rl, +icterus b/l, mucous membranes slightly dry neck - no jvd chest - clear to auscultation bilaterally cv - normal s1/s2, rrr, no murmurs, rubs, or gallops abd - soft, nontender to deep palp, nondistended, with normoactive bowel sounds extr - 1+ pitting edemain le b/l. 2+ dp pulses bilaterally neuro - as above skin - no rash pertinent results: 05:36pm hiv pt-16.7* ptt-35.2* inr(pt)-1.5* lactate-2.8* glucose-125* urea n-6 creat-1.1 sodium-136 potassium-3.0* chloride-100 total co2-26 anion gap-13 alt(sgpt)-27 ast(sgot)-89* alk phos-315* tot bili-3.3* magnesium-1.2* hbsag-negative hbs ab-negative hbc ab-negative hcv ab-negative wbc-4.9 rbc-4.35* hgb-15.4 hct-45.5 mcv-105* mch-35.3* mchc-33.8 rdw-15.4 neuts-37.3* lymphs-50.0* monos-7.0 eos-4.1* basos-1.6 plt count-140* sed rate-60* . cerebrospinal fluid (csf) wbc-170 rbc-* polys-77 lymphs-6 monos-3 macroph-14 cerebrospinal fluid (csf) totprot-936* glucose-79 cerebrospinal fluid (csf) herpes simplex virus pcr- neg cerebrospinal fluid (csf) tuberculosis - pcr- neg . pep-unusual pa igg-2206* iga-754* igm-53 . urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg . 12:58 pm stool consistency: soft **final report ** clostridium difficile toxin assay (final ): reported by phone to r. pfeiffer, r.n. on at 0505. clostridium difficile. feces positive for c. difficile toxin by eia. . 07:20am alt-26 ast-56* ld(ldh)-243 alkphos-180* totbili-4.4* 07:20am wbc-9.9 rbc-3.22* hgb-11.0* hct-32.8* mcv-102* mch-34.2* mchc-33.6 rdw-17.8* plt ct-187 07:20am pt-22.7* ptt-43.5* inr(pt)-2.2* 07:20am glucose-99 urean-10 creat-0.9 na-135 k-3.8 cl-100 hco3-27 07:20am albumin-3.3* calcium-9.7 phos-2.9 mg-1.4* . . mr cervical spine -- impression: limited evaluation of the cervical spine due to lack of axial images, but degenerative changes which are likely causing moderate canal stenosis at c3/4 and c6/7. -- superior extent of the dorsal epidural phlegmon is the t12 level. multilevel areas of ligamentum flavum thickening without high-grade canal stenosis. . . pathology l3 diagnosis: 1. l3 bone (a-e): focal osteonecrosis with granulation tissue and fibrosis. features of acute osteomyelitis are not seen. bone remodelling and marrow with fibrosis with chronic inflammation. fibro- and hyaline-cartilage with reactive changes. 2. l3 vertebral body (f-i): bony remodelling and degenerated fibrocartilage. granulation tissue, fibrosis, fat necrosis in associated soft tissues. 3. l3-l4 disc (j): granulation tissue and bone with remodelling. . ct spine () impression: 1. status post posterior lumbar fusion; hardware intact and well positioned. destruction of l3 and l4 consistent with the given history of osteomyelitis. 2. asymmetrically enlarged left psoas muscle, a new finding from the mri of , concerning for an evolving abscess or postsurgical hematoma. this could be further evaluated by a dedicated abdominal ct. 3. no evidence of focal osteolysis to suggest advanced osteomyelitis within the thoracic spine, though see prior mri for more sensitive assessment. 4. ct provides suboptimal intrathecal detail and cannot exclude an intrathecal hematoma or epidural abscess. see prior mri. 5. bilateral pleural effusions with associated atelectasis/consolidation. 6. thoracic spondylosis as described above. . ct head () comparison with the prior study of as well as a preceding examination from reveals no new intracranial hemorrhage, mass effect, or shift of normally midline structures. once again, a small left frontal lobe hypodense region is seen, consistent with a chronic lacunar infarct. considering patient age, there is mild peripheral cerebral atrophy detected. the surrounding osseous and soft tissue regions disclose moderate mucosal thickening within the sphenoid sinus, and to a minor extent within the posterior ethmoid sinuses. an air-fluid level is seen within the right maxillary sinus. these findings may relate to the intubated status of the patient, as would the noted mild opacification of both mastoid sinus complexes. conclusion: no intracranial hemorrhage. see above report . liver us () 1. no evidence of acute cholecystitis. unchanged appearance of single large gallstone within the gallbladder. 2. reversal of portal flow likely reflective of underlying cirrhotic pathology. clinical correlation is recommended. findings were discussed with dr. . at approximately 10:20 p.m. on . spine mri () - limited study secondary to both patient motion and metallic susceptibility artifact. - probable large right paracentral disc protrusion/herniation at c3-c4 with probable severe stenosis along the right c3-c4 neural foramen. - fluid within and tracking away from the left iliac bone graft harvest site demonstrates hematocrit effect and likely represents hematoma. the finding is unchanged in size when compared to . - persistent left-sided pleural effusion. - cervical, thoracic, and lumbar spondylosis without evidence of spondylolisthesis. - osseous destruction of the c3 and c4 vertebral bodies, seen on recent ct examination, not well assessed secondary to magnetic susceptibility artifact. the findings are again concordant with patient's history of osteomyelitis. . abdominal us () 1. hematoma in left flank corresponding to area of clinical concern. 2. as seen , ultrasound, a small amount of ascites, reversal of flow in the main portal vein, and gallstones. . head mri () 1. no evidence of acute infarct or abnormal enhancement. 2. mild brain atrophy and small vessel disease. 3. extensive soft tissue changes in the sphenoid sinus and mastoid air cells. 4. prominent csf around the optic nerves bilaterally could be an incidental finding, but clinical correlation recommended to exclude papilledema. . brief hospital course: surgical course: patient was taken to operating room on for l3 fracture and spondylosis. procedure: 1. partial vertebrectomy of l2 and l3. 2. anterior fusion l2-l4. 3. anterior debridement. 4. autograft, allograft, bone morphogenic protein. no immediate post-op complications encountered. patient was again taken to operating room on where the following procedures were performed: 1. total laminectomy of l4. 2. multiple lumbar laminotomies l1-l5. 3. fusion l1-s1. 4. segmental instrumentation l1-s1. 5. autograft. tissue was sent to pathology for evaluation. patient had no immediate perioperative complications. patient stayed in the surgical intensive care unit and had complicated extubation course secondary to delirium. patient was transferred to the medical intensive care unit for workup of altered mental status. micu course: altered mental status: hepatic encephalopathy vs. viral meningitis vs. seizure. neuro recommended fluoro-guided cervical tap and eeg. pt started on lactulose and low-protein tube feeds, ammonia levels were followed. pt was intubated to undergo these procedures, not for respiratory distress, so extubated following completion of procedures. csf findings complicated by apparent traumatic tap but also showed large protein and significant wbcs. id recommended starting vanco, ceftaz, ampicillin, as well as acyclovir b/c of concern for hsv. csf sent for hsv pcr and tuberculosis pcr, brucellosis antibodies also sent. ampicillin was d/c'd early, but flagyl added, and other abx continued pending cultures. eeg non-diagnostic. pt was extubated on with no change in mental status post-extubation. . fever: presentation concerning for pneumonia given cxr findings vs. viral meningitis vs. evolution of left psoas fluid collection. pt was pan-cultured, one bottle blood cx growing gram positive cocci in clusters. ct abdomen/pelvis to assess left psoas collection. ir obtained sample from left psoas and flank/abdominal wall collections under ct-guidance, gram stain showed pmns but cultures had no growth. infectious diseases was actively involved and guided team through prolonged workup. only klebsiella oxytoca was isolated from sputum culture and was believed to be ventilator associated. final workup did not reveal any pathogens including for negative tissue pathology from presumed epidural abscess. . elevated liver enzymes: found during prolonged hospitalization and concerning for history of long standing alcohol abuse. us findings suggested mild cirrhosis with portal hypertension and reversal of flow. liver function was followed and continued to improve. . coagulopathy: most likely secondary to liver disease. patient was given vitamin k with no response. his inr was adjusted with ffp as needed for procedures with significant bleeding risk. . hypertension: we manage blood pressure with beta-blocker and episodic hydralazine. . fluids, electrolytes and nutrition: while intubated, patient received tube feeds, but was able to resume a regular diet without difficulty. prophylaxis: heparin sc, ppi, thiamine, folate, mvi were given throughout admission. access: multiple central and arterial lines were used while in surgical service and intensive care unit. patient was only maintained with peripheral iv access in floor. communication: daughter/hcp (c) course on medicine floor on the medicine floor all medications that could be contributing to change in mental status were discontinued including scopolamine and oxycodone. hepatic encephalopathy was treated with rifaximin and lactulose. antibiotics were discontinued because the only positive culture was sparse growth of klebsiella on sputum culture. pt began to recover with decreasing need for supplemental o2, decreasing respiratory secretions, and improved mental status. mental status improved to alert and oriented times 2. pt started pulling out ng tube, so put on tpn for 2 days, then passed speech and swallow and tpn was discontinued. also while on the floor the pt developed diarrhea, and c. dif toxin was positive. he was started on flagyl and treated for c. dif colitis. his lactulose was held given his diarrhea, but he was continued on rifaximin. he is incontinent of stool so it is difficult to assess his bowel movements but his wbc count was normal as of . his mental status has remained slowly improved. the current assessment of his ams is a likely combination of a mild hepatic encephalopathy with strong degree of delirium, most likely secondary to prolonged hospitalization. 1. gammopathy: as part of workup for fracture, serum and urine electrophoresis were performed. though urine protein electrophoresis only revealed albumin, serum study showed a polyclonal gammopathy with increases in igg and iga but not igm. findings discussed with clinical pathology who felt these were consistent with critical illness and may represent monoclonal gammopathy of unknown significance (mgus). this condition can create a reactive polyclonal antibody pattern that can be elucidated with kappa to lambda ratio. in this case however, suspicion for malignancy is very low and we will defer any further investigation at this point. -- patient will need to have follow-up spep in 6 months. 2. hypomagnesemia: patient has required replacement every days, possibly secondary to increased stooling from lactulose. prescribed replacement orally every 4 days, he will need primary care physician to monitor as an outpatient when decision to continue or stop lactulose will be made. . medications on admission: meds on transfer: tylenol prn ablbuterol famotidine folate thiamine hep sc hydral 10 mg iv q6h iss spironolactone 25 mg daily metoprolol 50 mg tid . meds at home: aldactazide, asa, metoprolol, valium prn, vicodin prn, viagra prn discharge disposition: home with service facility: homecare discharge diagnosis: primary: epidural abscess and discitis . secondary altered mental status alcoholic liver disease discharge condition: improved procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances lumbar and lumbosacral fusion of the anterior column, posterior technique excision of intervertebral disc excision of bone for graft, other bones transfusion of packed cells repair of vertebral fracture lumbar and lumbosacral fusion of the anterior column, anterior technique transfusion of other serum transfusion of platelets aspiration of other soft tissue fusion or refusion of 2-3 vertebrae fusion or refusion of 4-8 vertebrae insertion of recombinant bone morphogenetic protein diagnoses: tobacco use disorder unspecified essential hypertension alcoholic cirrhosis of liver acquired coagulation factor deficiency portal hypertension hematoma complicating a procedure pulmonary collapse osteoporosis, unspecified intestinal infection due to clostridium difficile hepatic encephalopathy intraspinal abscess other and unspecified disc disorder, lumbar region closed fracture of lumbar vertebra without mention of spinal cord injury other and unspecified alcohol dependence, unspecified delirium due to conditions classified elsewhere disorders of magnesium metabolism lumbosacral spondylosis without myelopathy alcohol withdrawal chronic osteomyelitis, other specified sites malnutrition of moderate degree major osseous defects unspecified disorder of plasma protein metabolism 

Answer: The patient is high likely exposed to