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: abdominal pain and swelling major surgical or invasive procedure: paracentesis history of present illness: pt is a 64 yo male with cll, chronic hemolytic anemia, h/o pcp, is s/p recent chemo on (cytoxan, dexamethasone, vincristine, rituxan) who presents with abdominal pain. pt was discharged after being admitted for rituxan therapy, as he has had reactions in the past to it. he has had increasing abdominal pain and ascites for the past 10 days. per pt, paracentesis was attempted x 2 while he was an inpatient, both times failing. he was discharged home, and returned to the ed on with increasing abdominal pain described as "a pressure," and "like a pregnant woman," and was an . with pain medication, it came down to a 6/10. . + fevers at home prior to chemo last week, though pt did not measure them. +nausea and abdominal pain getting worse over past ten days. no vomiting. decreased appetite. +constipation. no bm x 3 days. +mild sob in association with ascites. . in the ed vs were: t: 98.7; hr: 115; bp: 105/64; rr:14; o2: 97 ra. a diagnostic paracentesis in the rlq was performed with minimal fluid taken off. pt was given ceftriaxone 2 mg iv, flagyl 500 mg iv, vancomycin 1 g iv, dexamethasone 10 mg iv, morphine (8 mg total), and 3 l ivf. he was hemodynamically stable. ct ab/pelvis showed increased intraabdominal ascites with increased nodularity in the omentum and peritoneum since recent () scan. past medical history: pmhx: 1. cll dx'ed -s/p three cycles of cytoxan/vincristine/prednisone, rituxan, and one cycle fludarabine, last in ; last prior to that . . 2. malignant r multiloculated and trabeculated pleural effusion s/p 1.5l thoracentesis , s/p right lung decortication . . 3. h/o pcp 4. autoimmune hemolytic anemia on chronic prednisone 5. hbv s/p blood transfusion 6. lipomas 7. splenomegaly social history: swimming coach @ college. married with two grown children. 10 packyear smoking history. occasional etoh. family history: mother died at age 86 of cll father died at age 76 two brothers alive and well physical exam: vs: t: 98.6; bp: 105/61; p: 97; rr:18; o2: 94% ra gen: cachectic male with large protruding abdomen, russian accent speaking in full sentences in nad heent: perrla; eomi; mild icteric sclera. dry mm. neck: jvd 7 cm at 45%. cv: rrr s1s2. prominent s2 with hyperdynamic precordium lungs: decreased bs at bases. no focal w/r. abd: markedly distended and firm. +fluid wave. +tenderness upon percussion throughout, without rebound or guarding. hypoactive bowel sounds. +spider telangectasias. no caput medusa. +angiomas. in left mid quadrant, soft large multi-cm protrusions from skin (? lipoma vs. hernia). non-reducible. ext: 2+ pitting edema b/l to midcalf. dp difficult to palpate. no cords appreciated. no asterixis. neuro: cn ii-xii tested and intact. ms throughout. a&o x 3. skin: as above. + 5 cm ecchymoses in mid-left upper back. pertinent results: 04:55pm pt-15.8* ptt-28.5 inr(pt)-1.7 04:55pm wbc-19.8* rbc-4.55* hgb-14.8 hct-44.1 mcv-97 mch-32.4* mchc-33.5 rdw-15.9* 04:55pm calcium-8.4 phosphate-3.4 magnesium-2.1 04:55pm alt(sgpt)-359* ast(sgot)-200* alk phos-133* amylase-36 tot bili-4.9* 04:55pm glucose-97 urea n-27* creat-1.0 sodium-141 potassium-4.0 chloride-102 total co2-26 anion gap-17 05:10pm lactate-4.8* 10:30pm ascites wbc-2740* rbc-1730* polys-80* lymphs-11* monos-2* atyps-1* other-6* 10:30pm ascites tot prot-0.9 glucose-77 ld(ldh)-108 amylase-24 albumin-less than radiology: - ct ab/pelvis with contrast: 1. interval increase in the amount of intra-abdominal ascites with increased nodularity in the omentum and peritoneum since the scan. this finding may represent sequelae from infected ascites versus peritoneal carcinomatosis, which would be uncommon in chronic lymphoid leukemia. 2.interval increase in the bilateral lung base pleural effusions with compressive atelectasis. 3. unchanged soft tissue nodule at the right lung base, which may represent sequelae from prior chest tube placement, however, metastatic disease cannot be excluded. interval near resolution of left lung base soft tissue nodule better appreciated on the examination. 4. stable appearance of intraabdominal and intrapelvic lymphadenopathy. 5. splenomegaly, unchanged. . -cxr ap- persistent blunting of the right costophrenic angle. there is interval development of slight blunting of the left costophrenic angle, possibly representing a small effusion . : us abdomen: abdomen ultrasound: limited evaluation was performed of the right upper quadrant. doppler analysis of the main portal vein demonstrates normal waveforms. aberrant color flow is seen in the proximal main portal vein, which is likely artifactual. of note, normal flow is seen in the main portal vein from ct of one day prior. normal color flow and waveforms are seen in the right and left portal veins and within the hepatic veins. . cursory examination of the abdomen reveals a significant interval decrease in the amount of ascites consistent with recent paracentesis. . : abdominal us impression: no portal venous thrombus identified . : peritoneal fluid: numerous lymphocytes, mesothelial cells, histiocytes, and neutrophils. hematopathology review by dr. (): lymphocytes present. with a history of cll, some lymphocytes may represent cll. flow cytometry may be useful to rule out cll in ascitic fluid, if clinically indicated . : paracentesis of abdomen: impression: successful paracentesis with removal of 3.25 liters of serous yellow ascites fluid, and with fluid sent for both microbiology, as well as chemistry and hematology examinations. . : us liver: impression: 1. interval complete reversal of portal vein flow, without intraluminal thrombus identified. 2. patent hepatic arteries and hepatic veins with normal phasicity. 3. moderate/large intra-abdominal ascites. 4. gallbladder sludge without evidence of cholecystitis. 5. splenomegaly. . mri abdomen: impression: 1. appropriate (hepatopetal) directional flow of the portal venous system. 2. moderate amount of ascites is present. 3. edematous/indurated appearance of the omentum, without definite infiltrative involvement. 4. right lower lobe lung nodule and bilateral atelectasis as previously described . microbiology data: : blood cultures: aerobic bottle (final ): escherichia coli. identification and sensitivities performed on culture # 194-3540p . anaerobic bottle (final ): escherichia coli. identification and sensitivities performed on culture # 194-3540p . . : blood cultures: aerobic bottle (final ): reported by phone to , r.n. on at 0620. escherichia coli. final sensitivities. trimethoprim/sulfa sensitivity available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ <=2 s ampicillin/sulbactam-- <=2 s cefazolin------------- <=4 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s cefuroxime------------ 4 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s imipenem-------------- <=1 s levofloxacin---------- =>8 r meropenem-------------<=0.25 s piperacillin---------- <=4 s piperacillin/tazo----- <=4 s tobramycin------------ <=1 s anaerobic bottle (final ): escherichia coli. . : hbv viral load hbv viral load (final ): greater than 38,000 iu/ml. performed by pcr. detection range: 60 - 38,000 iu/ml. . : cmv vl: <600 copies . complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 06:45am 21.5* 4.38* 14.0 42.4 97 31.9 32.9 16.7* 59* 06:40am 24.6* 4.31* 13.7* 42.0 97 31.7 32.6 16.0* 66* 06:25am 42.7* 4.54* 14.5 42.6 94 32.0 34.1 16.1* 78* 06:35am 47.8*# 4.11* 13.4* 38.2* 93 32.5* 35.0 15.6* 65* 06:30am 14.6*# 3.87* 12.5* 36.8* 95 32.3* 33.9 16.0* 47* 06:30am 7.7 3.75* 12.0* 36.0* 96 32.1* 33.5 15.8* 47* 03:59am 6.8 3.44* 10.9* 31.7* 92 31.8 34.4 15.4 42* 02:58pm 9.6 3.62* 11.4* 33.5* 93 31.6 34.2 15.4 50* 05:21am 7.2 3.28* 10.5* 31.7* 96 32.1* 33.3 15.5 47* 05:15am 6.4 3.76* 12.1* 36.2* 96 32.1* 33.3 15.9* 66* 12:30am 6.5# 3.97* 12.4* 37.6* 95 31.3 33.1 16.0* 75* 04:55pm 19.8* 4.55* 14.8 44.1 97 32.4* 33.5 15.9* 98 . differential neuts bands lymphs monos eos baso atyps metas myelos 06:30am 1.9* 0 95.5* 1.5* 0.2 1.0 03:59am 1.8* 97.0* 0.5* 0.2 0.4 05:15am 11* 3 84* 0 0 0 0 2* 0 12:30am 11* 2 80* 4 0 0 3* 0 0 04:55pm 2* 0 96* 0 0 0 2* 0 0 . renal & glucose glucose urean creat na k cl hco3 angap 06:45am 76 67* 3.7*# 128* 7.0* 92* 14* 29* 06:40am 69* 54* 2.3* 128* 6.6* 94* 16* 25* 06:25am 89 38* 1.3* 131* 5.4* 94* 23 19 06:35am 119* 31* 1.0 130* 5.0 96 23 16 06:30am 96 22* 0.9 133 4.7 97 27 14 06:30am 46* 19 0.7 134 4.9 99 25 15 03:59am 59* 20 0.7 135 4.5 101 21* 18 05:21am 95 20 0.7 138 4.1 105 24 13 05:15am 88 21* 0.8 140 4.2 110* 22 12 12:30am 72 24* 0.8 142 3.8 107 23 16 04:55pm 97 27* 1.0 141 4.0 102 26 17 . chemistry totprot albumin globuln calcium phos mg uricacd iron cholest 06:45am 8.0* 7.9* 2.7* 06:40am 8.6 6.5*# 2.6 06:25am 8.8 3.3 2.5 06:35am 8.6 2.2* 2.4 06:30am 8.2* 2.1* 2.2 06:30am 8.6 2.3* 03:59am 2.7*7.6* 1.6* 1.9 05:21am 2.5*7.5* 1.9* 1.9 05:15am 2.5*6.7* 3.2 3.0* 04:55pm 8.4 3.4 2.1 . blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph calhco3 base xs aado2 req o2 intubat comment 05:24pm art 36.7 63* 28* 7.37 17* -7 not intuba . lactate k 05:24pm 10.0*1 7.2*1 05:42am 3.6* 12:35am 3.5* 05:10pm 4.8*1 brief hospital course: impression/plan: 64 yo male with cll, with suspected infiltration to liver and spleen, s/p recent chemo and failed paracentesis attempts on prior admission, presents with 10 day history of abominal pain and increasing ascites. diagnostic paracentesis consistent with bacterial peritonitis. patient later found to have e coli bacteremia, worsening lymphocyte predominance from cll and positive hbv viral load. . # patient was initially admitted to intensive care unit, and was later transferred to the floor. . #. cll: pt is s/p chemo and rituxan administration while inpatient. pt finished a course of prednisone 75 mg for tls. anc 130. throughout this last hospitalization, the patient's wbc count rose from < 10 to the high 20s and once to >40 with lymphocytic predominance and many smudge cells. the patient's primary oncologist and covering oncologists on the floor discussed with the family on multiple occasions that there were no further treatment options available for this disease at this time. . # liver failure: - diagnosed on the basis of clinical condition (edema, pulmonary crackles, ascites), signs of portal hypertension as well as laboratory data. - the patinet had increased lfts (ast/alt), t. bili, and inr. - he had active hepatitis b viral infection by viral load >38,000 - this was only an estimate of his hepatitis b infection viral copies was the upper limit of normal. there was also the possibility of contributions from liver invasion by cll. he was started on adefovir to treat this. -u/s with dopplers showing patent vasculature on initial exam, but on , ultrasound showed complete reversal of blood flow in the liver. ct did not reveal any liver masses. mri on , however showed that the direction of blood flow has been returned to without any intervention. despite this, his lfts remained elevated and his total bilirubin continued to rise. in addition, on his initial presentation, patient had elevated lactate, which could have reflected sepsis/liver failure or cll. he initially presented with a lactate of 4.8 which dropeed to 3.6 on hod#2; however, by , his lactate continued to rise and was 10.0 on . it was felt that the patient may have had problems processing lactate due to worsening liver failure. . patient had moderate to large amounts of ascites in his abdomen. no free air was found by ct scan. for the ascites he was tapped in the ed and found to have bacterial peritonitis. this, as well as the possibility of sepsis on admission, was treated initially with vancomycin, ceftriaxone and flagl in the ed - then the antibiotic regimen was changed to cefepime and levofloxacin to double cover for pseudomonas and other gnrs. gram stain negative for organisms, however many lymphocytes were found in the fluid which could correlate with his cll. . also had therapeutic tap under ultrasound on where 4l was removed. his saag >1, so ascites likely secondary to portal htn +/- hbv reactivation +/- hepatic infiltration from cll. patient had 3-4l taken off on . there were 895 wbc in the fluid and albumin was 0.5. . his spleen also remained enlarged, as it was dueing his previous admission in . could have been attributed to portal hypertension or malignancy . patient was not a transplant candidate. a hepatology consultant was asked per family's wishes to reconfirm this. patient had a meld score of 28 which indicated that the patient had an extremely poor short term prognosis. hence, he was not a candidate for a liver transplant. . # renal failure: - from - patient's cr rose from 0.7 -> 3.7 - hepatorenal syndrome was considered to be high on the differential for this given liver failure. patient had decreasing urine output and renal service was asked to consult on how to improve urine output. it was felt from the medical team's standpoint that the patient's decreased uo was due to his low bp, hepatorenal syndrome and potential obstructive uropathy. dialysis was not felt to be an option at this time despite his high k. because of peaked t waves on ekg, he was given calcium gluconate to stabilize his myocardium. he was also given insulin. he could not be given oral kayexalate because of his poor mental status. . # e. coli bacteremia: likely source is gi causing bacterial peritonitis and spread to blood. - patient was treated with ceftazidime on the floor as the e coli was found to be sensitive to this. . # neutropenia- anc 300, on neutropenic precautions. patient was afebrile but was on high dose steroids. - patient has been chronically neutropenic; . during this admission, patient was found by nursing staff trying to climb out of bed and intermittently disoriented-- which along with his rising lfts indicated that patient was likely developing hepatic encephalopathy. as such, he was treated empirically with lactulose. despite this, his mental status continued to wane while he was on the floor. . #. hemolytic anemia- will continue prednisone 5 mg qday. hct stable, although decreased from baseline, likely cannot be fully explained by hemodilution. patient was transfused to stabilize hct as necessary. . #. ppx- pneumaboots and ppi. lactulose and rifaximin for hepatic encephalopathy. . #. fen- neutropenic diet. a nutrition consultant provided input regarding an appropriate diet for the patient. patient was given ivf as deemed necessary and with caution given chance of reaccumulating ascits. he also intermittently received albumin to try to maintain intravascular volume. po fluids were encouraged when patient was alert enough to take po. his electrolytes were repleted prn. . #. social: cpr not indicated in light of end-stage cll and worsening liver failure. this was discussed with the patient's wife while he remained in the intensive care unit. on the floor, pt was dnr/dni as per patient's wife - this was discussed with wife on multiple occasions with multile physicians. despite being dnr/dni, patient's wife asked for potential icu care for this patient; hence the icu team was notified and assessed patient and agreed to intervene if there were any acute changes in his condition. in addition, she felt at this time that if his bp < 65/45, that he should be placed on pressors. this goal of care was discordant with previous discussions and the ethics service was requested to help to correlate the goals of care of the family, the medical team and the consultant teams. at the end of this discussion, both the patient's wife and the medical team had a clear goal regarding this man's care that further aggressive management would be avoided and that we would only do things that would improve his long term prognosis and ease any current pain. . social work and palliative care services also spent considerable amounts of time with the family on this difficult end of life case in providing emotional support and in helping the patient to die with dignity and in comfort. it was decided to provide small doses of morphine to help the patient with pain; and the family was allowed to temper this in the event that they felt that it was too sedating. . in the early morning (2am) of , patient experienced respiratory distress. the family was notified and agreed that giving the patient morphine to decrease the work of breathing and to calm the patient would be appropriate. after this, patient continued to have agonal breathing per nursing reports. patient was found to be apneic and without signs of life at 5am on rn check in on patient. the covering night float intern was called and the patient was pronounced at 545am. the patient's family was called and made aware and arrived shortly thereafter. a partialy autopsy of his liver was requested. medications on admission: allopurinol 300 mg qday lasix 20 mg qday oxycodone 5 mg prn prednisone 75 qday x 4 days per chemo, last . otherwise prednisone 5 mg po qday. discharge medications: na discharge disposition: expired discharge diagnosis: cll liver failure discharge condition: deceased discharge instructions: na followup instructions: na procedure: percutaneous abdominal drainage transfusion of other serum diagnoses: cirrhosis of liver without mention of alcohol hepatorenal syndrome personal history of tobacco use cachexia bacteremia hepatic encephalopathy chronic lymphoid leukemia, without mention of having achieved remission autoimmune hemolytic anemias 

Answer: The patient is high likely exposed to