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: 5 months of sob, fatigue, fevers to 102, night sweats, weight fluctuations major surgical or invasive procedure: - : endobronchial ultrasound with ultrasound-guided transbronchial needle aspiration (ebus-tbna) by thoracic surgery - : right cervical lymph node biopsy - : bone marrow biopsy by heme/onc - : renal biopsy by nephrology - : right video-assisted thoracoscopic (vats) lung biopsy, limited thoracotomy and mediastinal lymph node biopsy by thoracic surgery history of present illness: patient is a 55yof with a h/o hodgkin's lymphoma dx in treated with 6 cycles of chemotherapy - (no radiation), and asthma who presents with 5 months of b-symptoms (afternoon fevers to 102, chills, night sweats, progressive shortness of breath, easy bruising). she notes these are the same exact symptoms she had when she was first diagnosed with lymphoma in . she was first evaluated for these symptoms in at , where a ct scan showed mediastinal lymphadenopathy. approximately 1 month ago, she underwent a bone marrow biopsy and mediastinoscopy with subcarinal node biopsy that were, per the patient's report, unrevealing. she established care here at with dr. shortly after these studies, and underwent rigid bronchoscopy for lymph node biopsy (around the rll). the day of her procedure she was npo all day, and only received 700cc fluid in the or. she did well immediately post-op, but in the pacu developed tachycardia to the 140s, tachypnia to the high 30s, hypotensive to the high 80s systolic and febrile to 102, concerning for a sirs response. she complained of chest tightness and so an ekg, chest xray, and labs were sent she was monitored. the ekg showed sinus tachycardia and the first trop was negative. she was given demerol and tylenol for rigors, started on vanc and zosyn, then sent to the micu. there, she was continued on the vancomycin (lymph node gram stain showed gpcs) and rehydrated with mulitple liters of fluid. in the micu she was noted to be coughing up blood tinged sputum, was given nebulizers, and required o2 only when asleep. when her tachycardia resolved and her blood pressure stabilized, she was sent to the floor. as for recent infections, she was treated at for pna in , and was treated with a z-pack without resolution of symptoms. she went to with persistent symptoms, and was diagnosed with ebv. it was during this hospitalization that she had a ct chest/abd/pelvis showing mediastinal and abdominal lad, prompting the above work up. ros: reports fluctuations in weight over the last few months, chronic constipation, and recent ha which she describes as throbbing, are focal and can occur anywhere in her head, happen any time of the day, have associated white spots in her visual fields, and are relieved by 2 tablets of alieve. patient also has a baseline cough of clear sputum cup/day. denies sinus tenderness, rhinorrhea, congestion, nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes. **of note, she has port in place from from , which has not been accessed since her chemotherapy treatments finished. it has been accessed here by and works and can be used. but , we need records from nwh with information about the port (we know it's not a power port, but need lot number, refrence number, type of port). currently these records are in storage; nwh is in the process of collecting these records, and will fax them to the micu and to directly. past medical history: past medical history: 1. lymphocyte depleted hodgkins lymphoma s/p 6 cycles of abvd in 2. asthma 3. pulmonary fibrosis 4. chronic history of mild anemia - sickle cell trait +/- thalassemia per oncology records 5. depression past surgical history: 1. hysterectomy due to uterine fibroids in . social history: she quit smoking a few weeks ago after smoking pack per day for 30 years. she does not drink alcohol. she has two daughters and a son. she is single and lives with her son. she formally worked as a school bus dispatcher, but says that she is now too weak to continue to work. family history: mother died from ovarian cancer. father is living. she had nine siblings, three of which have passed away, one from hepatitis, one for murder and one from unclear causes. she has two other siblings with diabetes and a son with sarcoid. she knows of no other cancers or blood diseases within the family. physical exam: admission physical exam: vitals: t: 102 bp: 112/70 p: 122 r: 31 18 o2: 98 general: alert, oriented, no acute distress very pleasant heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: crackles at the bases abdomen: soft, non-tender, non-distended, bowel sounds present gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation discahrge physical exam: pertinent results: admission labs: 05:09pm urine color-dkamb appear-hazy sp -1.014 05:09pm urine blood-mod nitrite-neg protein-300 glucose-tr ketone-neg bilirubin-sm urobilngn-4* ph-6.0 leuk-neg 05:09pm urine rbc-1 wbc-5 bacteria-few yeast-none epi-2 05:09pm urine hyaline-15* 05:09pm urine mucous-rare 03:35pm glucose-100 urea n-30* creat-1.5* sodium-136 potassium-4.3 chloride-108 total co2-22 anion gap-10 03:35pm ck(cpk)-101 03:35pm ck-mb-2 ctropnt-<0.01 03:35pm calcium-7.5* phosphate-3.7 magnesium-2.1 03:35pm wbc-3.5* rbc-4.19* hgb-10.4* hct-33.1* mcv-79* mch-24.8* mchc-31.4 rdw-16.1* 03:35pm plt smr-very low plt count-40* 04:31am blood alt-65* ast-222* ld(ldh)-1520* alkphos-429* totbili-1.6* 04:31am blood albumin-1.7* calcium-6.6* phos-3.4 mg-2.0 uricacd-5.1 discharge labs: 12:10am blood wbc-6.9 rbc-3.02* hgb-7.9* hct-24.7* mcv-82 mch-26.0* mchc-31.8 rdw-20.3* plt ct-93* 12:10am blood neuts-42* bands-0 lymphs-51* monos-5 eos-0 baso-0 atyps-2* metas-0 myelos-0 12:10am blood pt-10.9 ptt-38.6* inr(pt)-1.0 12:10am blood glucose-107* urean-25* creat-1.3* na-129* k-3.8 cl-100 hco3-23 angap-10 12:10am blood alt-57* ast-203* ld(ldh)-514* alkphos-490* totbili-1.5 12:10am blood albumin-1.5* calcium-6.8* phos-3.1 mg-2.0 12:00am blood ferritn-5119* 12:00am blood pep-no specifi igg-772 iga-24* igm-7* ife-no monoclo pathology: pathology tissue: right lower lobe. flow cytometry report interpretation: non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. correlation with clinical findings and concurrent morphology (see cytology report) is recommended. flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. cytology ebus tbna level 7 lymph node (level 7), ebus-tbna: negative for malignant cells.bronchial epithelial cells and polymorphous lymphocytes consistent with lymph node sampling (see note). pathology tissue: right cervical lymph node specimen: right cervical lymph node, biopsy. diagnosis: tissue with extensive hemorrhage and necrosis, infiltration by macrophages and sparse lymphoid infiltrate. see note. note: the findings are concerning for infections, particularly mycobacterial or fungal. alternatively, the findings may represent ??????steroid-treated?????? lymphoma. special stains for mycobacterial ( and afb), and fungal (pas, mucicarmine and gms) organisms are negative. microscopic description: slides reveal fibrous tissue with a vaguely nodular cellular infiltrate comprised of histiocytes and lymphocytes. few giant cells are present. there is extensive hemorrhage and liquefactive necrosis between the histiocytic nodules. focal fibrosis is also present. the pattern of necrosis overall is suggestive of therapy effect or infection, rather than tumor necrosis. vessels are focally prominent. the sparse lymphoid infiltrate is made up of small and mature appearing lymphocytes, with rare intermixed immunoblasts, and many interspersed foamy histiocytes. by immunohistochemistry, the lymphoid component is predominantly composed of cd3 and cd5 positive t cells. only rare cells exhibit immunoreactivity for cd20, bcl6, mum1, or cd30. cd10 highlights stromal elements. cd45 and cd68 highlight histiocyte groups and clusters, including some in the nonviable areas. cd15 is negative. mib1 stains only scattered cells. pathology tissue: bone marrow core biopsy specimen: bone marrow aspirate and core biopsy. diagnosis:cellular bone marrow with maturing trilineage hematopoiesis and no morphologic evidence of involvement by lymphoma, see note. note: the findings of increased macrophages with ingestion of cells and debris, as well as an increased cytotoxic t cell infiltrate with concurrent markedly elevated ferritin level, raise the possibility of a primary, or more likely secondary, macrophage activation syndrome. nevertheless, lymphoma remains a strong consideration and procurement of adequate tissue from the pet avid mediastinal mass may represent the best chance for a definitive diagnosis. of note, recently ebv viremia has documented. ebv viremia increases the risk of both macrophage activation syndrome and b cell lymphoma. imaging: ekg : sinus tachycardia @128 nl axis, pr 150, qrs 98, qtc413 no stemi, no st dep, good r-r progression, no q waves imaging studies: cxr - no previous radiographs available. no evidence of pneumothorax following surgery. cardiac silhouette is within normal limits. bibasilar opacification most likely reflects a combination of atelectasis and effusion. in the appropriate clinical setting, pneumonia would have to be considered. central catheter probably extends to the upper portion of the right atrium. cardiovascular echo the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. 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 mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal global and regional biventricular systolic function. mild pulmonary hypertension. radiology abdomen u.s. findings: evaluation was limited due to poor acoustic penetration. the liver is mildly echogenic consistent with fatty infiltration. the portal vein is patent with hepatopetal flow. no intra or extrahepatic biliary duct dilatation. the common bile duct measures 4 mm and is normal. the gallbladder is collapsed with a mildly thickened wall, but no son was present. no cholelithiasis noted. there is a small right pleural effusion. the right kidney measures 10.4 cm and no stones or hydronephrosis is noted. the left kidney measures 11.6 cm and is normal. the spleen measures 11.5 cm but was not completely imaged. the visualized ivc is unremarkable. the aorta and pancreas were not adequately imaged due to body habitus. a prominent portal lymph node is noted measuring 9 mm. impression: 1. echogenic liver consistent with fatty infiltration. other forms of liver disease or more advanced liver disease cannot be excluded. 2. prominent 9-mm portal venous lymph node is non-specific and may relate to underlying lymphoma or liver disease. radiology chest findings: as compared to previous radiograph, there is no relevant change. likely small bilateral pleural effusions, reactive bilateral basal areas of atelectasis, but no newly appeared parenchymal opacity suggesting pneumonia. moderate cardiomegaly, known right-sided port-a-cath. pulmonary spirometry, lung volumes, dlco mechanics: the fvc is moderately reduced. the fev1 is mildly reduced. the fev1/fvc ratio is elevated. flow-volume loop: moderate restrictive pattern with an abrupt and early termination of exhalation and a starting hesitation. lung volumes: the tlc is mildly to moderately reduced. the frc and rv are moderately reduced. the rv/tlc ratio is normal. dlco: the diffusing capacity corrected for hemoglobin is moderately reduced. impression: mild to moderate restrictive ventilatory defect with a moderate gas exchange defect. the dlco is reduced out of proportion to the reduction in tlc which is consistent with an interstitial process. the fvc is likely underestimated due to an early termination of exhalation. there are no prior studies available for comparison. radiology unilat lower ext veins findings: evaluation is limited due to patient body habitus and overlying edema. grayscale and doppler son of bilateral common femoral, right superficial femoral, and right popliteal veins were performed. there is normal compressibility, flow, and augmentation. the right calf veins were not visualized due to edema in the calf. please note several of the images were mislabelled as to the side being evaluated. impression: limited study demonstrates edema with no evidence of right lower extremity dvt. right calf veins were not clearly visualized. radiology ct chest w/contrast impression: 1. multiple enlarged mediastinal lymph nodes in the paratracheal, precarinal, subcarinal, and right hilar stations, unchanged from the prior study. 2. diffuse interstitial lung abnormality with traction bronchiectasis and fibrosis which is may be due to nsip is similar compared to the prior study except for new bilateral pulmonary nodules. these nodules are most likely infectious given the rapid development, however could also be due to lymphoma and less likely other neoplasms. 3. new right pleural effusion. 4. spleen with multiple hypodense lesions is slightly smaller compared to the prior, although this is incompletely imaged. 5. enlarged main pulmonary artery suggestive of pulmonary artery hypertension. : right middle lobe biopsy pathology report the poor viability and presence of extensive necrosis and histiocytic infiltrate makes assessment difficult. given the extensive necrosis, presence of immunoblasts and scattered large lmp-1 immunoreactive cells, a diagnostic consideration is an infectious lymphadenitis, such as due to persistent ebv infection ( pending). however, in patients with a known prior history of hodgkin lymphoma, the presence of a scattered large cells also raises the concern for possible lymphoma with histological appearance modified by intercurrent therapy (steroids, etc); the strong cd20 immunoreactivity in a majority, albeit rare, large cells, and the absence of convincing cd30-immunoreactivity in the rs-like cells precludes an unequivocal diagnosis of lymphoma. the findings are similar to those present on a previous biopsy of a right cervical lymph node (s12-31209a). brief hospital course: patient is a 55yof with a h/o hodgkin's lymphoma diagnosed in , treated with 6 cycles of chemotherapy - (no radiation), and asthma who presents with 5 months of b-symptoms (afternoon fevers to 102, chills, night sweats, progressive shortness of breath, easy bruising); admitted after developing tachycardia, hypotension, and fever in the pacu status post rigid bronchoscopy for mediastinal ln biopsy. following extensive work up, patient was found to have hypogammaglobulinemia and prolonged ebv viremia, possibly resulting in her abnormal lfts, nephrotic syndrome, and macrophage activation syndrome. active diagnoses: # macrophage activating syndrome: cellular debris within macrophages on bone marrow biopsy, admission ferritin 11k. etiology is unclear, possibly due to lymphoma or ebv infection. extensive w/u including multiple lymph node biopsies all inconclusive. bone marrow showed cellular bone marrow with maturing trilineage hematopoiesis and no morphological evidence of lymphoma, but with evidence of mas. ferritin down - trend ebv pcr on mondays # malignancy work up: history of lymphoma, presented with b-symptoms and lymphadenopathy on ct torso concerning for underlying malignant process. however, extensive work up as detailed below did not yield clear diagnosis. mediastinal lymph node biopsy was inconclusive, for lymphoma vs infectious lymphadenitis (ebv). cervical node biopsy results were similarly inconclusive. spep, upep, free light chains were negative. bone marrow biopsy showed cellular debris in macrophages consistent with macrophage activation syndrome but no evidence of malignancy. -patient had persistent pleural effusion following video-assisted thoracoscopic surgery. chest tube was removed for decreased drainage, but drainage persisted for days after but had resolved by time of discharge. surgical inscisions were healing well without signs of infection as well. post-surgical effusion was slow to resorb due to underlying nephrotic syndrome causing hypoalbuminemia. -patient has an appointment with thoracic surgery for follow up and suture removal. # ebv viremia: vl was obtained given prolonged fevers and liver abnormalities. ebv vl noted to be initialy but weekly titers showed persistent viremia at >1k copies. id followed, cmv, histoplasma, aspergillus, beta glucan, gallactomannan and quanttb were all negative, blood cultures were negative throughout hospital course, hepatitis panel, hivab, hiv viral load were all negative as well. - weekly ebv viral load as outpatient (last was , vl 1469) # nephrotic syndrome: focal segmental glomerular sclerosis on biopsy, likely related to ebv viremia vs macrophage activation syndrome. patient with on admission (cr 1.5), developed extensive anasarca with 24 hr urine protein 8 grams and hypoalbuminemia. she was not anticoagulated for the increased risk of thrombosis associated with nephrotic syndrome because of concurrent thrombocytopenia. she did have one isolated episode of leg pain, ultrasound with doppler did not show dvt, leg edema remained symmetric. anca, , dsdna, c3, c4 were all negative. renal was consulted, advised treatment with lasix and lisinopril. - continue lisinopril 5mg, hold for sbp <100 - continue diuresis with 40 po lasix , hold for sbp <90 - elevate legs, wrap as needed - follow up with nephrology as scheduled # hypogammaglobulinemia: acquired vs. inherited, possible common variable immune deficiency (cvid). normal igg, low iga and igm, no response to pneumococcal vaccine given . h flu immune, meningococcal igg consistent with pre-vaccination reference ranges. immunology was consulted, agreed with trial of monthly ivig infusion with goal of eradicating ebv viremia. had two infusions of ivig, 15mg each on and . - monthly ivig to be determined by outpatient heme/onc # abnormal lfts - most likley ebv-induced vs macrophage activating syndrom vs nash, other infections, malignancy, or drug reactions, autoimmune less likley following extensive work up. patient presented with transaminitis and hyperbilirubinemia, abnormalities dating back at least to or upon presentation to . ruq ultrasound remarkable for fatty liver infiltration and splenomegaly, hepatitis serologies were negative. - patient should avoid hepatotoxic medications and alcohol # pancytopenia: most likely related to ebv or macrophage activation syndrome. cbc was trended, she required transfusion of platelets only on one occasion and transfusion of prbc on two occasions. discharge cbc as listed in dedicated discharge summary section. chronic issues: #asthma: patient was treated with albuterol and ipratroprium nebs. she was treated with supplimental o2 as needed. o2 requirement had resolved at time of discharge. # pulmonary fibrosis s/p bleomycin: pulmonary function testing was performed which showed mild to moderate restrictive ventilatory defect with a moderate gas exchange defect. the dlco was reduced out of proportion to the reduction in tlc, consistent with an interstitial process, likely due to bleomycin toxicity. confirmation of fibrosis on biopsy this admission. transitional issues: # outpatient follow up with dr. to discuss possible initiation of steroids # will have outpatient follow up with renal # monthly ivig infusion at heme/onc clinic # access: hickman catheter in place- 10 years per hx # patient has been spiking low grade temps likely related to her underlying disease process, please call dr. office at if temperature above 101f or change in clinical status. medications on admission: preadmission medications listed are correct and complete. information was obtained from patientwebomr. 1. albuterol inhaler 2 puff ih q4h:prn wheeze 2. acetaminophen 325-650 mg po q6h:prn pain 3. oxycodone (immediate release) 5 mg po q4h:prn pain 4. fluticasone propionate 110mcg 2 puff ih 5. vitamin d 1000 unit po daily 6. naproxen 500 mg po q8h:prn pain discharge medications: 1. albuterol inhaler 2 puff ih q4h:prn wheeze 2. fluticasone propionate 110mcg 2 puff ih 3. vitamin d 1000 unit po daily 4. furosemide 40 mg po bid hold for sbp <90 5. lisinopril 5 mg po daily hold for sbp<100 6. guaifenesin ml po q6h:prn cough 7. polyethylene glycol 17 g po daily:prn constipation 8. senna 1 tab po bid:prn constipation 9. simethicone 40-80 mg po qid:prn gas 10. oxycodone sr (oxycontin) 10 mg po q12h hold for somnolence or rr <10 11. morphine sulfate 2-4 mg iv q2h:prn pain for severe surgical site pain. please hold for somnolence or rr <10 12. docusate sodium 100 mg po bid hold for loose stools 13. oxycodone (immediate release) 5-10 mg po q3h:prn pain please hold for somnolence or rr<10 discharge disposition: home discharge diagnosis: primary diagnosis: - viremia, macrophage activation syndrome secondary diagnosis: abnormal liver function test nephrotic syndrome hypogammaglobulinemia asthma 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 mrs. , it was a pleasure taking part in your care during your hospitalization at . you presented with fevers, sweats and shortness of breath along with enlarged lymph nodes on ct scan of your chest and abdomen. you had a procedure called a bronchoscopy to obtain a biopsy of your enlarged lymph nodes, following which you had low blood pressures and difficulty breathing, for which you required a brief stay in the intensive care unit. to further investigate the cause of your symptoms you underwent biopsies of your bone marrow, kidney and lymph nodes in your lung and neck. you were found to be suffering from an immune deficiency (low antibodies) that may have allowed an infection with - virus to affect your blood cells, liver, and kidneys. you were treated with a medicine called ivig to give you extra antibodies, and were stable to be discharged to a rehabilitation facility to improve your strength. please use caution and do not take any substances that may further harm your kidneys or liver, such as alcohol, tylenol, or nsaids (like ibuprofen or advil). you should continue to take the lisinopril and lasix as directed in your medication list to decrease the swelling in your legs, and follow up with the kidney doctors . your surgeons have advised you to do the following: * monitor your surgical incision carefully and call your surgeon, dr. , if you see increasing redness, pus, or separation of the incision * shower daily. wash incision with mild soap & water, rinse, pat dry * no tub bathing, swimming or hot tubs until incision healed * no lotions or creams to incision site * walk 4-5 times a day and gradually increase your activity as you can tolerate. followup instructions: please follow up with your oncologist, dr. within the next week. someone from his office will call you to notify you of the time and date of your appointment. if you do not hear from someone by tuesday (), please call (. department: thoracic surgery when: thursday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage please report 30 minutes prior to your appointment to the radiology department on the of the clinical center for a chest xray. for concerns related to your lung biopsy surgery, please call dr. office at . department: nephrology - west clinic when: wednesday at 11:00 am with: , m.d. building: de building ( complex) campus: west best parking: garage procedure: biopsy of bone marrow closed [percutaneous] [needle] biopsy of kidney closed endoscopic biopsy of lung biopsy of lymphatic structure biopsy of lymphatic structure biopsy of lymphatic structure injection or infusion of immunoglobulin thoracoscopic excision of lesion or tissue of lung diagnoses: thrombocytopenia, unspecified anemia, unspecified unspecified pleural effusion acute kidney failure, unspecified hyposmolality and/or hyponatremia cardiac complications, not elsewhere classified asthma, unspecified type, unspecified personal history of tobacco use hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites postinflammatory pulmonary fibrosis systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction thoracoscopic surgical procedure converted to open procedure hypogammaglobulinemia, unspecified other fluid overload infectious mononucleosis nephrotic syndrome in diseases classified elsewhere other pancytopenia hepatitis in viral diseases classified elsewhere hemophagocytic syndromes 

Answer: The patient is high likely exposed to