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, hypotension major surgical or invasive procedure: intubation history of present illness: mr. is a 66 year old man with h/o poems syndrome, s/p autosct , therapy-related mds, recently hospitalized and diagnosed with recurrence of poems syndrome, c1d18 of velcade/dexamethasone, who was admitted with fever and hypotension. the patient was discharged 2 days prior to admission () after hospitalization for febrile neutropenia, complicated by arf requiring hdx4 sessions and features of poems syndrome relapse. at home, the patient had a low grade temp yesterday to 100.3 with chills and then another fever to 101.2 this afternoon. the wife notes that he was complaining of increased pain in his lower extremities (neuropathy) and had decreased po intake. he became increasingly lethargic and weak to the point that they had difficulty getting him out of bed. his urine output decreased from 1100cc the day before to 400cc over 24h. foley was in place since last sunday (1 week). the wife called the bmt fellow on call, who referred the patient to the ed. in the field, the patient's bp was 60/40. ems placed a peripheral line and bolused him with ivf. in the ed, initial vs were: t 101.2 hr 120 bp 184/132 rr 18 o2sat 100% nrb. bp then dropped to 50/30 about 10 minutes after arrival. the patient was lethargic, but arousable to voice, complaining of generalized body pains. patient had brown, turbid urine in his foley. cxr showed persistent l basilar opacification. labs notable for hct 19.5, plt 8, hco3 18, cr 3.7. the patient was started on levophed, vanc, and cefepime. also given a dose of hydrocortisone given recent steroid use. given 4l ns. he was intubated in the ed without difficulty using the bougie, despite h/o tracheal stenosis, and started on fent/midaz for sedation. on transfer, levophed was running at 0.42mcg. vs: t 100 hr 119 bp 114/51 rr 18 o2sat 99% on fio250% tv450 peep4. on arrival to the micu, patient's vs t 98.6 hr 106 bp 127/84 rr 16 o2sat 98% on ac tv 450 rr 18 fio2 40% peep 5. the patient is intubated and sedated on fentanyl 100mcg/hr, midazolam 4mg/hr, levophed 0.32mcg/kg/min. past medical history: oncologic history: poems syndrome manifested by polycythemia, polyneuropathy, organomegaly, endocrinopathies including hypocalcemia, hypothyroidism, hypogonadism and elevated pth (diagnosed in ). in anasarca that eventually progressed to respiratory failure, treated with plasmapheresis and prednisone followed by 18 months of cyclophosphamide. /: bortezomib (1.3 mg/m2 days 1,4,8,11 and dexamethasone (20 mg days 1,2,4,5,8,9, 11, and 12) x three cycles discontinued due to painful lower extremity neuropathy. high dose cytoxan for stem cell mobilization () high dose melphalan with stem cell rescue () in remission since than. : bone marrow aspirate and biopsy showed dysplastic basophilic and polychromatophilic erythroblasts, a marked left shift and dysplastic myelopoiesis and abundant hyperchromic megakaryocytes, which initially were felt to be consistent with colchicine toxicity; however, chromosome studies performed on that bone marrow material revealed an abnormal karyotype 15/16 studied cells showed a complex clone with the following anomalies. he had deletion in the long arm of chromosome 5 between band 5q13 and 5q33, otherwise known as 5q minus. he had monosomy 13, monosomy 17, monosomy 20, and addition of an unidentified marker chromosome and double minute chromosomes. these were all consistent with a myeloid abnormality since there were not an increased number of blasts much more consistent with mds. other past medical history: 1. poems syndrome: first diagnosed in with treatment described above. his manifestations have been as follows: a. polyneuropathy - cidp in ; painful lower extremity sensory neuropathy and proprioception defects. b. organomegaly - splenomegaly c. endocrinopathy - hypothyroidism, hypogonadism, hypocalcemia related to hypoparathyroidism d. monoclonal gammopathy e. skin and nail changes - now resolving. f. pulmonary hypertension and restrictive lung disease. g. chronic renal insufficiency (which has now resolved with therapy) h. anasarca, now resolved. i. hyperuricemia and gout - now resolved j. polycythemia and thrombocythemia - now resolved 2. vitamin b12 deficiency 3. s/p compound fracture, 4. s/p tracheostomy 5. prostate cancer s/p brachytherapy 6. gout 7. pulmonary htn and restrictive lung disease 8. chronic kidney disease 9. c dif () 10. acute angle glaucoma () social history: pt is a ukrainian refugee who immigrated to the us in . he lives with his wife and they have two sons. cigarettes, very occasional alcohol. he works as a paint salesman for -. he is also a veteran. exposed to , which he believes is the etiology of his poems. family history: mother is alive and has sle, fibromyalgia. his father's medical history is unknown. half-sister with ovarian cancer. physical exam: admission exam vs: tm 98.7, tc 98.7, p 98 (98-106), bp 117/70 (117/70 - 127/84), rr 16 spo2: 98%, fio2: 40% ventilator mode: cmv/assist/autoflow, vt: 450 ml, rr : 18, peep: 5 cmh2o general: intubated, sedated heent: sclera anicteric, pupils minimally reactive to light, l>r neck: supple, jvp not elevated, no lad cv: tachycardic, s1 + s2, no murmurs, rubs, gallops lungs: clear to auscultation anteriorly with decreased breath sounds at the bases abdomen: soft, non-distended, bowel sounds present gu: foley with brown, turbid urine ext: warm, well perfused, 2+ pulses, 2+ generalized edema/anasarca neuro: sedated discharge physical exam: 98.1, 120/68, 74, 18, 98ra general: aaox3 in nad, appearing male older than stated age heent: pupils are asymmetric at baseline l>r neck: previous scar from trach is well healed, no elevated jvp no lad lungs: ctab moving good air bilaterally cv: rrr, 2/6 systolic murmur heard best at hte lusb not radiating abd: mildly protuberant, normoactive bowel sounds, soft, nontender, no palpable masses ext: warm, well perfused, trace peripheral edema bilaterally skin: two stage 1 ulcers. one located on the right buttock with some underlying edema, and one located on the right posterior posterior heel neuro: cn ii-xii intact. motor 3/6 strength in ue and le bilaterally. decreased proximal strength biltaerally int he lower extremiteis. sensation grossly intact and symmetric. occasional intentional tremulous not orthostatic, patient is symptomatic upon standing but by 5min patients vs are stable. pertinent results: admission labs 08:40pm blood wbc-3.4* rbc-2.16* hgb-6.3*# hct-19.5* mcv-90 mch-29.2 mchc-32.4 rdw-15.1 plt ct-10*# 08:40pm blood neuts-54 bands-10* lymphs-5* monos-30* eos-0 baso-0 atyps-0 metas-0 myelos-1* 08:40pm blood pt-13.5* ptt-22.8* inr(pt)-1.3* 08:40pm blood glucose-71 urean-75* creat-3.7*# na-133 k-4.2 cl-101 hco3-18* angap-18 08:40pm blood alt-47* ast-32 ld(ldh)-219 alkphos-272* totbili-1.1 08:40pm blood ctropnt-0.06* 04:24am blood ck-mb-4 ctropnt-0.07* 09:48am blood ck-mb-3 ctropnt-0.08* 08:40pm blood albumin-2.8* 04:24am blood calcium-6.5* phos-5.3*# mg-1.5* 09:08pm blood lactate-2.2* micro urine culture (final ): no growth. blood culture, routine (preliminary): staphylococcus species. aerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. blood culture, routine (pending): sputum source: endotracheal. gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (preliminary): rare growth commensal respiratory flora. blood culture: neg blood culture, neg blood culture, neg urine studies: 06:05am urine casthy-20* castbr-2* 02:09pm urine histoplasma antigen-test 04:57pm urine bk virus by pcr, urine-test 06:23am urine u-pep-multiple p ife-no monoclo 09:13am other body fluid wbc-650* rbc-* polys-2* bands-1* lymphs-12* monos-26* mesothe-1* macro-58* urine: 05:30pm urine color-yellow appear-clear sp -1.012 05:30pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-neg 05:30pm urine rbc-1 wbc-2 bacteri-none yeast-none epi-1 imaging chest (portable ap): persistent left basilar opacification may represent atelectasis, pneumonia or aspiration. moderate-sized left and small right bilateral pleural effusions. possible mild pulmonary vascular congestion, though evaluation is somewhat limited due to low lung volumes. chest (portable ap): there is an endotracheal tube and a feeding tube which are unchanged in position. there is also a right-sided central venous line with the distal lead tip in the cavoatrial junction, unchanged. there is unchanged cardiomegaly. there is a left retrocardiac opacity and left-sided pleural effusion which is stable. no overt pulmonary edema is identified. overall, there has been no significant change. : ct abd/pelvis: impression:1. no new fluid collection or source of intra-abdominal infection. 2. stable bilateral small to moderate partially loculated pleural effusions slightly improved since . : ruq u/s impression: 1. no evidence of portal venous thrombosis. 2. no hepatobiliary pathology. 3. borderline spleen size. : ct chest impression: 1. progression of left lower lobe consolidation, and increase in size in bilateral loculated pleural effusions with enhancing pleura, concerning for pneumonia and/or empyema. 2. cardiomegaly. 3. heterogeneous enhancement of the kidneys, bilateral, raises possibility of pyelonephritis or infarct, recommend correlation with ua. : bronchial washing: bronchial lavage: negative for malignant cells. pulmonary macrophages and blood. no viral cytopathic changes or fungal organisms are seen. : hip xray:views of both hips show minimal hypertrophic spurring with slight narrowing of the joint spaces bilaterally. multiple metallic seeds are seen in the region of the prostate. : ultrasound right buttock: persistent mild edema of the soft tissue overlying the right buttock. no drainable collection identified. discharge labs 12:00am blood wbc-2.3* rbc-2.37* hgb-7.2* hct-21.7* mcv-92 mch-30.3 mchc-33.1 rdw-14.3 plt ct-40* 12:00am blood neuts-30* bands-0 lymphs-47* monos-19* eos-0 baso-0 atyps-0 metas-0 myelos-4* 12:00am blood pt-10.3 ptt-22.7* inr(pt)-0.9 12:00am blood glucose-130* urean-37* creat-0.6 na-137 k-4.4 cl-101 hco3-28 angap-12 12:00am blood alt-52* ast-24 ld(ldh)-293* alkphos-391* totbili-0.4 12:00am blood calcium-8.6 phos-3.0 mg-1.8 brief hospital course: primary reason for admission: mr. is a 66 year old man with h/o poems syndrome, s/p autosct , therapy-related mds, recently hospitalized and diagnosed with recurrence of poems syndrome, s/p velcade/dexamethasone, who was admitted with fever and hypotension and requiring intubation initially who was found to have b+glucan hemoptysis and multiple episodes of febrile neutropenia requiring multiple icu stays who is currently hemodynamically stable and afebrile x 1 week still requiring occasinal blood transfusions/platelet transfusions at the time of discharge. active issues: #poems- patient with recent diagnosis of poems syndrome relapse velcade/dexameth (d1 ). during this admission he was initially treated with high dose short course of steroids. his pain was controlled with the addition of increased gabapentin, addition of methadone and oxycodone. as his pain would worsen when the steroids were weaned off, he was kepts on 3mg po dexamethasone as a stable dose for one week prior to discharge. while he was on a sliding scale due to being on steroids, he did nto require any insulin and therefore this was stopped at the time of discharge as he was on a stable regimen of steroids. -will require follow-up with dr. for ongoing care for this -will continue dexamethasone 3mg po bid #mds- patient has history of therapy related mds. his smear during this hospitalization continued to show atypical cells. during this hospitalization he required multiple blood transfusiosn and platelet transfusions and for a period of time was transfusion dependent. he had no adverse reactions to any of his blood product transfusions. he was started on revlimid on and tolerated this well. he will continue on this after he leaves. -will require frequent lab work to determine if transfusions are required -will continue revlimid 10mg po qday #dysuria- patient has significant dysruia and negative ua with unclear source of the pain. -continue methadone, oxycodone -continue oxybutinin, pyridium and urojets as needed for the pain -consider urology consult if persists neutropenic fevers- no clear source of his fevers. he was found to have hemoptysis and was bglucan positive so was started on voricanozole and continues this at the time of discharge.he was on iv vancomycin and meropenem and these were weaned off in the week prior to discharge and he was switched to ciprofloxacin 500mg po bid a few days prior to discharge and remained afebrile with stable wbc. -continue voricanozole -continue ciprofloxacin # respiratory failure: patient was intubated in the ed to allow for aggressive volume resuscitation. he was extubated without problem and has no oxygen requiremnet at the time of discharge. his lungs are clear on exam. . # acute kidney injury: patient had elevated cr to 3.7 at the beginning of his admission which was a combination of prerenal and atn. this responded to fluids and resolved prior to his discharge. . # elevated troponin: pt had three sets of elevated troponins (0.06, 0.07, 0.08) but ck-mbs were normal. he also had some initial ekg changes that resolved. he likely had some demand ischemia in the setting of . he was chest pain free throughout his course . # anemia: patient is transfusion-dependent to mds. hct 19.5 on admission, and was transfused 2 units prbcs with an appropriate bump in his hct, which subsequently trended down. he continued to require intermittent transfusions throughout his course. last platelet transfusion on last prbc transfusion on . # hyperbilirubinemia: t bili and direct bili were elevated. the rest of his lfts were unremarkable, demonstrating a cholestatic picture. a right upper quadrant u/s was performed that showed no evidence of cholestasis. his alk phos continued to uptrend during the end of his hosptial stay with no localizing symptoms. -this will be monitored by dr. office # volume overload: secondary to new left ventricular dysfunction and acute systolic heart failure as well as poems syndrome with likely capillary leak, hypoalbuminemia, and initial aggressive volume resuscitation. patient was grossly volume overload after his resuscitaion which had resolved at the time of discharge without an elevated jvp or peripehral edema. transitional issues: -patient to receive his own revlimid while at rehab 10mg po qday -pain control- patient is currently on methadone and oxycodone, please monitor for any changes needed - unclear source, on multiple medications medications on admission: ( d/c summary): levothyroxine 112mcg po daily acyclovir 400mg po qhs pyridoxine 100mg po daily doxazosin 8mg po daily vitamin b12 2000mcg po daily thiamine 100mg po daily oxycodone-acetaminophen 5-325mg 1-2tabs po q6h prn calcium carbonate 500mg po bid allopurinol 100mg po daily timolol maleate 0.5% 1gtt citalopram 10mg po daily sulfamethoxazole-trimethoprim 400-80mg po daily gabapentin 300mg po q12h discharge medications: 1. levothyroxine 112 mcg tablet sig: one (1) tablet po daily (daily). 2. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). 3. vitamin b-12 2,000 mcg tablet extended release sig: one (1) tablet extended release po once a day. 4. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 5. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po twice a day. 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 8. gabapentin 300 mg capsule sig: two (2) capsule po q12h (every 12 hours). 9. midodrine 2.5 mg tablet sig: one (1) tablet po tid (3 times a day). 10. dexamethasone 1.5 mg tablet sig: two (2) tablet po q12h (every 12 hours). 11. methadone 5 mg tablet sig: tablet po qam (once a day (in the morning)). 12. methadone 5 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)): give 12 hours after am methadone dose. 13. oxycodone 5 mg tablet sig: one (1) tablet po q2h (every 2 hours) as needed for severe pain: hold for sedation or rr<10. 14. phenazopyridine 100 mg tablet sig: one (1) tablet po tid (3 times a day) for 2 days. 15. oxybutynin chloride 5 mg tablet sig: one (1) tablet po tid (3 times a day). 16. lidocaine hcl 2 % gel sig: one (1) appl mucous membrane tid (3 times a day) as needed for penile pain. 17. terazosin 1 mg capsule sig: two (2) capsule po hs (at bedtime). 18. revlimid 10 mg capsule sig: one (1) capsule po daily (daily): patient to take own medication. 19. voriconazole 200 mg tablet sig: two (2) tablet po q12h (every 12 hours). 20. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 21. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 22. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 23. hydrocortisone 2.5 % cream sig: one (1) appl rectal daily (daily). 24. ondansetron 8 mg film sig: one (1) film po every 4-6 hours as needed for nausea. 25. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours). discharge disposition: extended care facility: - discharge diagnosis: primary: poems, severe sepsis, respiratory failure, mds secondary: bph, type ii diabetes mellitus discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , you were admitted to the hospital because you were very short of breath and having fevers. this required you to be in the icu, and after you improved you were transferred to the regular oncology floor. here we worked to help manage your pain and treat your fungal pneumonia with iv antibiotics. on a couple of occasions your blood pressure got low and you were feverish and were treated in the icu for this. as you were here for a prolonged hospitalization you will require intensive rehab to get your strength back and will do this at . while you were here you received multiple blood and platlet transfusions while your counts were low without problems. transitional issues: pending labs/studies: none medications started: voricanozole (antifungal) ciprofloxacin (antibiotic) revlimid dexamethasone oxycodone (as needed pain medication) methadone (pain medication twice a day) senna colace oxybutinin (help with bladder spasm) terazosin (help with bph) pyridium (help with pain on urinating) urojet (numbing medicine for pain with urinatng) midodrine- (for dizziness on standing) ondansetron- as needed for nausea medications changed: increased citalopram from 10mg once a day to 20mg once a day increased gabapentin from 300mg to 600 mg medications stopped: stopped allopurinol stopped doxazosin (on terazosin instead) stopped timolol eye drops (no longer needed) stopped percocets (on oxycodone and methadone instead) follow-up needed for: 1. determine course of antibiotics and antifungals (dr. 2. monitoring your blood counts and your liver function tests 3. you will need to follow-up with dr. to determine if you need your glaucoma drops again followup instructions: will we contact you with your appointment times and dates! if you do not hear from us within 48hours please contact us procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube insertion of endotracheal tube closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of bronchus injection or infusion of immunoglobulin diagnoses: pneumonia, organism unspecified acidosis obstructive sleep apnea (adult)(pediatric) other chronic pain esophageal reflux acute kidney failure with lesion of tubular necrosis urinary tract infection, site not specified congestive heart failure, unspecified long-term (current) use of steroids diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled severe sepsis unspecified acquired hypothyroidism other chronic pulmonary heart diseases peripheral stem cells replaced by transplant other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure septic shock antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use other diseases of lung, not elsewhere classified acute systolic heart failure other disorders of plasma protein metabolism delirium due to conditions classified elsewhere personal history of antineoplastic chemotherapy splenomegaly other chronic nonalcoholic liver disease staphylococcal septicemia, unspecified other and unspecified mycoses chronic inflammatory demyelinating polyneuritis other testicular hypofunction jaundice, unspecified, not of newborn nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] hypoparathyroidism polycythemia vera bloodstream infection due to central venous catheter monoclonal paraproteinemia other secondary thrombocytopenia other pancytopenia 

Answer: The patient is high likely exposed to