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: sulfa(sulfonamide antibiotics) attending: chief complaint: fever, back pain major surgical or invasive procedure: 1. l2 bilateral hemilaminotomy. 2. l3 laminectomy without facetectomy. 3. l4 laminectomy with far lateral decompression, psoas debridement. 4. l5 laminectomy. 5. s1 laminectomy. 6. removal of intraspinal abscess. 7. deep biopsy, bone. 8. fluoroscopic-guided abscess drainage x2 history of present illness: pt is a 57y f with hx of sle on prednisone 10mg daily at baseline who is transferred from with low back pain and bilateral le weakness. history is obtained from pt and what is available from outside records. she states that for the past 3 months, she has experienced increased fatigue, anorexia, malaise, and an approximate 20lb unintentional weight loss. she also notes that she has increased back pain. on , she received an epidural injection for back pain and, per report, received an additional 2 injections the week before . since , she has been having weakness of her bilateral le and dull (not burning) pain in her thighs that has been getting progressively worse. the pain is now in intensity with movement; she denies any bowel or bladder incontenance or anesthesia. . she went to on where an mri showed a fluid epidural collection l5-s1 causing lateral recess stenosis at s1; ddx included hematoma vs. abscess. she was admitted to on where neurosurgery, ir, and id all felt that the risks of draining the collection outweighed the benefits; neurosurgery thought that the collections were a result of the injections themselves and not abscesses. after receiving iv abx(per her report), she was discharged on the 10th. the patient was, by her report, admitted again from - and had a repeat mri which showed "interval significant decreasein the size of bilateral epidural fluid collections at the s1 level. the degree of stenosis is markedly reduced. however, there is slight residual encroachment on the s1 nerve root. clinical correlation is suggested." she was given pain control and again discharged without any other interventions. she saw her rheumatologist as an outpatient who both said her pain and fluid collection was not the result of sle and did not change any medications. she represented to lgh on for pain control and weakness. her prednisone was increased from 20 to 40mg daily. emg confirmed an extensive sensorimotor neuropathy. she received blood cultures and an echo out of concern for occult infection and was transferred to for rheum consult and a second opinion. of note, she states that she had a temp of 102 at the beginning of , temps 99-100 throughout the month, and was noted to have a t of 101.3 at the time of transfer. she also notes "fogginess" in her thinking and times where her "mind goes blank" which has been going on through the past 3 months and she thinks is caused by her increased stress. she has no auditory or visual hallucinations and only minor tension headaches for the past 3-4 months. her thinking has not improved on prednisone. on arrival to , she is requesting to take a shower and has pain. she states that her pain was initially well-controlled with msir 15mg po before transfer. review of systems: (+) per hpi, chronic, mild, diffuse, abdominal pain and diarrhea after abx which has now stopped (-) denies chills, night sweats, recent weight gain. denies blurry vision, diplopia, loss of vision, photophobia. denies sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations, lower extremity edema, pnd. denies cough, shortness of breath, or wheezes. denies nausea, vomiting, constipation, melena, hematemesis, hematochezia. denies dysuria, stool or urine incontinence. denies arthralgias or myalgias. denies rashes or skin breakdown. no numbness/tingling in extremities. no si, overwhelming anxiety, or anhedonia. all other systems negative. past medical history: sle diagnosed in ex-lap in for menorrhagia skin grafts to le in secondary to medication reaction total teeth extraction social history: lives with her husband in , etoh/day, smokes 1 pack per day x 10 years, no illegal drugs. family history: no connective tissue diseases known; sister had leukemia, father had lymphoma physical exam: admission exam: vs: 97.4 bp 120/65 hr 51 rr 17 sao2 100ra gen: frail, cachectic, slightly fatigued, awake, alert, head bobbing while talking which she states has been going on for years for unknown reasons heent: eomi, sclera anicteric, conjunctivae clear, op moist and without lesion; bruise on bridge of nose neck: supple, no jvd cv: reg rate and rhythm, normal s1, s2. no m/r/g. chest: resp unlabored, no accessory muscle use. ctab, no crackles, wheezes or rhonchi. abd: soft, nt, nd, no hsm, bowel sounds present msk: normal muscle tone and bulk spine: point tenderness near l5 ext: no c/c/e, 2+ dp/pt bilaterally skin: no rash, warm skin neuro: oriented x 3, cn ii-xii intact, 5/5 strength throughout, intact sensation to light touch psych: tangential thought process at times, normal thought content, appropriate, slightly flat affect on discharge she was afebrile, blood pressure stable at 90s-100s/40s-50s. no neurologic deficits. pertinent results: admission labs: 10:45pm glucose-105* urea n-19 creat-0.6 sodium-133 potassium-4.5 chloride-92* total co2-29 anion gap-17 10:45pm alt(sgpt)-18 ast(sgot)-24 ld(ldh)-152 alk phos-64 tot bili-0.3 10:45pm albumin-3.6 calcium-9.5 phosphate-3.9 magnesium-1.6 10:45pm crp-195.2* 10:45pm wbc-11.8* rbc-3.79* hgb-11.8* hct-34.6* mcv-91 mch-31.2 mchc-34.2 rdw-12.3 10:45pm neuts-89.9* lymphs-6.1* monos-3.1 eos-0.8 basos-0.1 10:45pm plt count-403 10:45pm pt-11.1 ptt-29.9 inr(pt)-1.0 10:45pm sed rate-105* 10:45pm blood crp-195.2* 04:03am blood -positive * titer-1:80 02:05pm blood dsdna-positive * cardiac enzymes 08:32pm blood ck-mb-10 mb indx-13.2* ctropnt-0.25* 02:14am blood ck-mb-14* mb indx-8.0* ctropnt-0.41* 12:02pm blood ck-mb-12* mb indx-7.4* ctropnt-0.20* 07:28pm blood ck-mb-7 ctropnt-0.14* 03:34am blood ck-mb-5 ctropnt-0.09* csf 08:14am cerebrospinal fluid (csf) wbc-110 rbc-20* polys-74 lymphs-15 monos-11 08:14am cerebrospinal fluid (csf) wbc-105 rbc-35* polys-84 lymphs-13 monos-3 08:14am cerebrospinal fluid (csf) totprot-252* glucose-71 ld(ldh)-91 anemia studies: 05:57am blood caltibc-222* vitb12-288 folate-6.7 hapto-173 ferritn-373* trf-171* hypercoagulability studies: 10:00pm blood thrombn-43.8* 05:25am blood qg6pd-9.6 05:12am blood b2micro-1.5 05:12am blood aca igg-1.6 aca igm-4.8 rheum studies: 10:45pm blood esr-105* 02:05pm blood dsdna-positive * 04:03am blood -positive * titer-1:80 10:45pm blood crp-195.2* 05:30am blood c3-123 c4-20 stim testing: 06:20am blood cortsol-7.9 06:36am blood cortsol-15.0 08:39am blood cortsol-18.2 microbiology: **lumbar epidural abscess swab final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): nocardia farcinica. sparse growth. identified by laboratories . acid fast smear (final ): no acid fast bacilli seen on direct smear. fungal culture (final ): a swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. a negative result should be interpreted with caution. whenever possible tissue biopsy or aspirated fluid should be submitted. nocardia farcinica. identified in acid fast culture. potassium hydroxide preparation (final ): test cancelled by laboratory. patient credited. inappropriate specimen collection (swab) for fungal smear (koh). acid fast culture (final ): a swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. a negative result should be interpreted with caution. whenever possible tissue biopsy or aspirated fluid should be submitted. . no mycobacteria isolated. due to overgrowth of nocardia farcinica unable to continue monitoring for afb for 8 weeks. nocardia farcinica. identified by laboratories . sensitivities performed by laboratories (). final sensitivities. sensitive to amox/clav (mic: mcg/ml). resistant to cefepime (mic: >32 mcg/ml). resistant to ceftriaxone (mic: >64 mcg/ml). sensitive to imipenem (mic: 4 mcg/ml). sensitive to ciprofloxacin (mic: 1 mcg/ml). mic: <= 0.25 mcg/ml: no interpretation available. resistant to clarithromycin (mic: > 16 mcg/ml). sensitive to amikacin (mic: <= 1 mcg/ml). resistant to tobramycin (mic: > 16 mcg/ml). intermediate to: doxycycline (mic: 4 mcg/ml). intermediate to: minocycline (mic: 4 mcg/ml). sensitive to tmp/smx (mic: <= 0.25/4.75 mcg/ml). sensitive to linezolid (mic: 2 mcg/ml). anaerobic culture (final ): no anaerobes isolated. 8:14 am csf;spinal fluid source: lp,tube#3. **final report ** cryptococcal antigen (final ): cryptococcal antigen not detected. (reference range-negative). performed by latex agglutination. results should be evaluated in light of culture results and clinical presentation. 8:14 am csf;spinal fluid source: lp,tube#3. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast culture (preliminary): the sensitivity of an afb smear on csf is very low.. if present, afb may take 3-8 weeks to grow.. no mycobacteria isolated. gram positive rods. branching rods. viral culture (preliminary): no virus isolated. 9:00 am abscess source: epidural. gram stain (final ): 3+ (5-10 per 1000x field): polymorphonuclear leukocytes. 1+ (<1 per 1000x field): gram positive rod(s). smear reviewed; results confirmed. fluid culture (final ): nocardia species. sparse growth. nocardia farcinica. identification performed on culture # 343-5173g (). anaerobic culture (final ): no anaerobes isolated. fungal culture (final ): nocardia farcinica. identification performed on culture # . acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. nocardia farcinica. identification and sensitivities performed on culture # 343-5173g, . 3:45 pm abscess source: epidural abscess. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. mri l spine impression: 1. large extensive spinal abscess involving the inferior aspect to the thoracic spine and lumbar spine ,involving the epidural and intradural spaces with anterior displacement of the terminal spinal cord and nerve roots.the findings in the intradural space may represent arachnoiditis with loculated collections. there is associated arachnoiditis and extension of the abscess into the right psoas muscle. findings are significantly worse since the prior exam. 2. complex fluid collection with rim enhancement involving the left posterior paraspinal soft tissues, suspicious for an abscess. there is extensive edema and soft tissue inflammation in the posterior paraspinal soft tissues, worse on the left. mri spine impression: 1. there is no evidence of focal or diffuse lesions throughout the cervical or thoracic spinal cord to indicate a spinal cord edema or cord expansion, there is no evidence of spinal cord compression. 2. minimal degenerative changes identified at c7/t1, consistent with posterior disc bulge, causing mild right side neural foraminal narrowing. apparently, there is no evidence of abnormal enhancement throughout the cervical and thoracic spine, however, the examination is limited due to patient motion. 3. the patient is status post abscess removal and drainage in the lumbar region with laminectomies from l2 through l5/s1 levels as described above, fluid collection is noted posteriorly in the surgical bed, possibly consistent with a post-surgical fluid/phlegmon, formally a csf leak cannot be completely excluded, persistent focus with fluid and air noted in the right psoas, with a far lateral surgical change and pattern of enhancement surrounding the thecal sac, possibly consistent with residual abscess formation, close followup is advised, the previously noted abscess in the left paraspinal musculature has been reduced in size. head ct impression: large bilateral thalamic hypodensities, bilateral occipital pole hypodensities, and possible left frontal hypodensity. the differential diagnosis includes venous ischemia, perhaps due to deep cerebral vein or dural sinus thrombosis; vasculitis caused by meningitis; basilar tip thrombosis, or pres. mri may help clarify the nature of the abnormalities and determine patency of the veins and sinuses. . brain mri/mra/mrv impression: 1. extensive increased t2 flair signal involving bilateral thalami as well as the parieto-occipital white matter with areas of slow diffusion in the bilateral thalami and just posterior to the left occipital representing ischemia/infarct. differential diagnosis includes press versus less likely venous ischemia. mrv sequences demonstrate a questionable filling defect in the posterior aspect of the superior sagittal sinus, but with likely artifact since the post-contrast mprage demonstrates normal venous enhancement in this region. 2. global dural enhancement also present in the prior exam, which may be related to recent lumbar puncture versus inflammatory/infectious meningitis. brain mri : 1. decrease in the previously noted flair hyperintense areas in the periventricular white matter, with near-complete resolution of the flair hyperintense areas involving the thalami and adjacent parenchyma. correlate clinically and f/u as clinically indicated- etiology uncertain and includes pres/seizure related changes/ other etiology. 2. interval development of increased signal in the transverse and sigmoid sinuses on some of the sequences, question slow flow/artifact/related to venous sinus thrombosis. consider mr venogram for better assessment, as the present study is limited due to motion artifacts. 3. interval development of small bilateral subdural fluid collections, ? related to intracranial hypotension given the h/o recent cisternal puncture. correlate clinically and consider followup. brain mrv : no evidence of dural venous sinus thrombosis. mr : 1. redemonstration of a large fluid collection in the posterior spinous soft tissues, which is irregular in shape, in close proximity to the thecal sac margins at some levels. this is mildly decreased in some areas; however, no significant change is noted. assessment is somewhat limited due to motion-related artifacts. the possibilities include simple fluid collection/abscess/pseudomeningocele. correlate clinically to decide on the need for further workup. there is also reactive edema to changes noted in the posterior spinous soft tissues in the lower thoracic and in the lumbar and in the sacral regions. 2. decrease in the areas of fluid collection/abscess in the right psoas muscle. 3. unchanged appearance of the thickened cauda equina nerves related to arachnoiditis. 4. renal lesions- likely cysts- correlate with prior studies/us tte : the left atrium and right atrium are normal in cavity size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). right ventricular chamber size and free wall motion 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 no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is no pericardial effusion. impression: normal biventricular cavity sizes with preserved global and regional biventricular systolic function. increased pcpw. compared with the prior study (images reviewed) of , the findings are similar. clinical implications: based on aha endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is not recommended. clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. brief hospital course: primary reason for hospitalization: 57yof with a h/o sle on prednisone transferred from osh with fever and lumbar epidural abscess active issues: # lumbar epidural abcess: pt was transferred from osh due to concern for lumbar epidural abscess given her fevers and worsening epidural fluid collection on mri with extension to the psoas and paraspinal soft tissue. on she underwent l3-s1 laminectomy, incision and drainage and was transferred to the ortho spine service. the infectious disease service was consulted and she was initially treated with iv vancomycin and cefepime. intraoperative cultures subsequently grew beaded gram positive rods and partial acid-fast bacilli concerning for either non-tuberculin mycobacteria vs nocardia, and her antibiotics were changed to imipinem, linezolid, and amikacin. on her course was complicated by intractable nausea/vomiting and mental status changed, then had 3 generalized tonic-clonic seizures. she was given iv ativan and keppra load and was transferred to the medical icu. her seizures were felt most likely imipinem but also raised concern for possible cns involvement of her infection. imipenem was discontinued and her seizures resolved, however she continued to have altered mental status. she was electively intubated to obtain an mri/mra/mrv which showed thalamic and white matter changes of unclear etiology as well as dural enhancement, felt most c/w press. csf sample was obtained from a sub-cisternal puncture and initially showed no organisms, wbc 110, prot 252, gluc 71. she was empirically started on iv acyclovir, which was then discontinued once csf hsv pcr returned negative. repeat cultures of the epidural abscess were obtained by fluoroscopic drainage on , gram stain showed gram positive rods. cultures were sent to for speciation and ultimately the organism was identified as nocardia farcinica. sensitivity data showed susceptibility to bactrim and fluoroquinolones. given her sulfa allergy, she required monitored bactrim desensitization in the icu, which she tolerated well. she was transitioned to iv bactrim and po , and will likely require several months of antibiotic therapy. there was discussion of repeating surgical washout of the abscess, however given her clinical improvement the risk of the surgery was felt to outweigh the benefit. she is scheduled to follow up in the infectious disease clinic and orthopedic clinic. she should have labs monitored closely while on antibiotics, including cbc, electrolytes, and lfts with results faxed to the infectious disease rns. mri prior to d/c showed a worsening psoas abscess. after discussion with ortho spine and infectious disease, it was felt surgery would not be an effective treatment for this patient and may make the infection worse. she will be treated with iv antibiotics for now with close ortho-spine and id follow up. # seizures: as noted above, hospital course was complicated by seizure activity requiring icu transfer. this was felt most likely imipenem. her seizure activity resolved after starting keppra and stopping imipenem. per state law, she is prohibited from driving for the next 6 months. she is scheduled to follow up in neurology clinic. # ekg changes with elevated troponin: in the context of the patient's seizures, she had elevated cardiac enzymes with troponin-t peaking at 0.41. she was also noted to have ekg changes with depressions in the lateral and inferior leads and a <1mm elevation in v3-v4. these findings were felt most likely seizure activity. her cardiac enzymes were trended and returned to . later in her hospital course she had an episode of orthostatic hypotension, complained of "indigestion" (had just eaten) and was noted to have st elevations (appearing like jpoint elevations) on telemetry and on v3-v5 on 12 lead ekg. she was otherwise hemodynamically stable. her symptoms improved with maalox and the st changes resolved. repeat ekg later in her hospitalization showed q waves in lead ii, which were not seen previously. cardiac enzymes were again cycled and were normal. she had a tte which showed preserved systolic function and no focal wall motion abnormality. she never endorsed chest pain or pressure during her hospitalization, although at times c/o "indigestion" associated with meals. on discharge, she was started on asa 81mg daily. she was not started on a statin given her expected long course of antibiotic therapy. would recommend further cardiac evaluation within the next month as an outpatient with a stress echo once her functional status improves. #ha: pt c/o frequent headache which is worse with standing after her subcisternal puncture, felt c/w post-lp headache. blood patch was considered but given infectious risk this was deferred. she was treated with fioricet as needed. #sle on chronic steroids: pt has taken prednisone 10mg daily for sle for many years. she received stress dose hydrocortisone peri-operatively and then was rapidly tapered. she later received additional stress dose steroids in micu due to her seizure activity and acute deterioration, and was again tapered to prednisone 10mg daily after she clinically improved. she developed orthostatic hypotension which raised concern for possible adrenal insufficiency, however stim test was reassuring. the endocrinology service was consulted and did not feel there was indication to increase her steroid regimen. she was continued on her home prednisone 10mg daily at discharge. # pleural effusion: pt had small left sided pleural effusion incidentally noted on chest x-ray on . she denied dyspnea, hypoxia, or chest pain. repeat cxr on showed stability of the effusion. given that she was asymptomatic, thoracentesis was deferred. would recommend repeat cxr in weeks to monitor for change. transitional issues: - she was discharged on iv bactrim and po , likely require several months of antibiotics. she is scheduled to f/u in clinic and ortho clinic. - she was discharged on po keppra for seizure activity during her hospitalization. per ma state law she cannot drive for 6 months. she is sched to f/u in neurology clinic. - given ekg changes during hospitalization, she was started on asa 81mg daily. statin was deferred due her expected prolonged course of antibiotics. would recommend further cardiac eval with exercise stress testing in the outpatient setting once her functional status improves. - she should have repeat cxr to monitor small left pleural effusion - f/u r femur sclerotic lesion seen on xray - full code medications on admission: prednisone 10mg po daily naprosen prn pain percocet 1 tab q4 prn pain discharge medications: 1. levetiracetam 1,000 mg tablet sig: one (1) tablet po twice a day. 2. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for pain: max dose 3g daily. 3. butalbital-acetaminophen-caff 50-325-40 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for headache: max acetaminophen 3 gm day . 4. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). 5. 400 mg tablet sig: one (1) tablet po daily (). 6. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 7. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 8. sulfamethoxazole-trimethoprim 400-80 mg/5 ml solution sig: two hundred (200) mg intravenous q8h (every 8 hours). discharge disposition: extended care facility: nursing & rehabilitation center - discharge diagnosis: lumbar epidural abscess seizure orthostatic hypotension discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , you were admitted to because of an infection in your spine. you had surgery to wash out the infection and were started on antibiotics. you will need to continue the antibiotics for several weeks after leaving the hospital. you should follow up with the infectious disease service and the orthopedic surgery service for continued monitoring and treatment of your infection. while you were here, you had a seizure requiring monitoring in the intensive care unit. this likely happened because of antibiotic you were taking for your infection. you are no longer taking that antibiotic, and you were started on medication to prevent further seizures. according to state law, you cannot drive for 6 months after your seizure. we have scheduled an appointment for you to follow up in the neurology clinic. please note the following changes to your medications: -start bactrim 200mg by iv every 8 hours -start 400mg by mouth daily -start fioricet 1 tab every 6 hours as needed for headache -start aspirin 81mg daily -start levetiracetam (keppra) 1000mg twice daily -start omeprazole 20mg once daily you should also continue your prednisone 10mg daily. please see below for your currently scheduled follow up appointments. it has been a pleasure taking care of you at and we wish you a speedy recovery. followup instructions: department: orthopedics (spine center) name: dr. when: dr. office is working on a follow up appointment for 9-15 days after your hospital discharge. if you have not heard from dr. office in 2 business days please call the office number listed below. location: orthopedics address: , 2, , phone: department: infectious disease when: thursday at 11:30 am with: , md building: lm bldg () campus: west best parking: garage department: neurology when: friday at 1 pm with: drs. / haerents building: sc clinical ctr campus: east best parking: garage md procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours spinal tap incision of lung spinal tap incision of lung imageless computer assisted surgery excision or destruction of lesion of spinal cord or spinal meninges other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal other exploration and decompression of spinal canal biopsy of bone, other bones cisternal puncture other incision of conjunctiva diagnoses: systemic lupus erythematosus cellulitis and abscess of trunk unspecified pleural effusion long-term (current) use of steroids need for desensitization to allergens other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure loss of weight cachexia other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation encephalopathy, unspecified intraspinal abscess other specified antibiotics causing adverse effects in therapeutic use orthostatic hypotension nutritional marasmus infection following other infusion, injection, transfusion, or vaccination psoas muscle abscess generalized convulsive epilepsy, without mention of intractable epilepsy reaction to spinal or lumbar puncture body mass index less than 19, adult persistent vomiting meningitis due to other specified bacteria 

Answer: The patient is high likely exposed to