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: amoxicillin attending: chief complaint: altered mental status, fever and myalgias major surgical or invasive procedure: none history of present illness: 29 year old man with no significant past medical history who presents with altered mental status, fever and myalgias after recent trip to . as part of business school trip, and approximately 150 classmates went to from to . prior to leaving he went to travel clinic and received vaccination for yellow fever and a few others which he cannot recall. he received all the immunizations that were recommended to him. while there he stayed at hotels and drank bottled water for most of the trip. he does report that he used ice and drank some tap water on the last day of his trip. he reports that he and other travelers had bug bites, but does not recall any ticks or other animal exposures. he 2 days worth of malaria prophylaxis while there, but self d/ced the medication being told the area he was in was low risk. overall he reports having no symptoms other than exhaustion and a ? of heat rash throughout his stay in . the day after returning home, he noted that his muscles felt very sore as if he had been working out. he attended class but was feeling ill and therefore went to uhs at the recommendation of a friend. the physician there sent labs and returned home. he reports not sleeping well overnight and waking up on tuesday morning with confusion. his muscle pain was gone, but he was "incoherent". he called the uhs physician which he said took him 6-7 minutes as he was disoriented and found it difficult to dial the numbers. per report, the uhs physician was very concerned about how he sounded and called ems. at , temp was 101, and per records he was found to be disoriented with expressive aphasia. ct and mri/mra were normal, utox negative, blood smear negative for malaria or babesia. lp performed with 6 wbc, 5 rbc, glucose 68, protein 48. he was started empirically on ceftriaxone, vancomycin, acyclovir, and dexamethasone. transferred to for further workup. he was initially on the hospital medicine service but was promptly transferred to icu due to deteriorating mental status. id was consulted. as he had no signs of bacterial meningitis, his antibiotic regimen was tailored to acyclovir (for possible hsv) and doxycycline (for tick-borne pathogens). he was transferred to the hospital medicine service on the , where he reported feeling better and felt his mental status was improved to 80-90% of baseline. his muscle pain completely resolved. he has a lingering headache but no other current symptoms. ros: denies current fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, brbpr, melena, hematochezia, dysuria, hematuria. otherwise negative. past medical history: eczema wisdom tooth extraction social history: he is a first year hbs student. he lives with his fiance in . he is sexually active only with his fiance, does not use condoms and had a negative hiv test 6 years ago when he first started dating her. he does not regularly smoke, but he smokes cigars per year. he drinks 1 alcoholic beverage per night; typically has 1 glass of wine nightly with dinner. he was raised as scientist and did not have any immunizations until age 20 when he fell and was told to get a tetanus shot. at that point in time he decided to get all of his immunizations and believes he is up to date. he has traveled all througout europe, studied in new and , and went to and for work in . he went to travel clinic before his trip to and received all immunizations recommended at that time. family history: father has skin cancer, grandmother with dementia, and grandfather with multiple mis. physical exam: on presentation: t: 99.9 p: 92 r: 16 bp: 144/90, o2sat 100% 2l, 97% ra general: somnolent but arousable, diaphoretic, agitated with any disturbance, non-verbal in nad heent: ncat, perrl on limited exam due to non-cooperative, op clear without exudates/lesions on limited exam neck: no lad/jvd lungs: cta b heart: rrr, no m/r/g abdom: +bs, nt, nd, soft extrem: no edema, all joints without effusion or erythema gu: normal male genitalia, no discharge, foley in. external inspection of anus with small piece of toilet paper at anal verge, otherwise no discharge or erythema neuro: ocassional moans with nonsensical word eruptions, does not follow commands but eyes tracking examiner movement. no cn abnorm, but exam limited by not cooperation. strength 5/5 both distal/proximal muscles all extrem but again limited as not following commands. dtr 3+ b patella and bicep, no clonus. skin: no rash . on transfer to floor: physical exam: general: in nad, comfortable, lying in bed, appears stated age heent: normocephalic, atraumatic, perrl, eomi, no lymphadenopathy appreciated cardiac: rrr, nl s1/s2, no murmurs, rubs or gallops appreciated, no carotid bruits lung: ctab, no crackles or wheezing abdomen: +bs, nontender to palpation, nondistended ext: warm to palpation, pulses palpable bilaterally, no edema or erythema. neuro: alert and oriented x 3; good fund of knowledge. able to name high and low frequency objects. good attention - able to recite days of the week backwards. cn intact, full strength in ue and le. dtrs 2+ in patellas bilaterally. downgoing toes. difficulty only with using proximal muscles to sit up. derm: no rash appreciated pertinent results: - wbc-6.1 rbc-4.14* hgb-13.1* hct-38.2* mcv-92 mch-31.6 mchc-34.2 rdw-13.2 plt ct-186 - glucose-116* urean-18 creat-1.3* na-144 k-3.6 cl-106 hco3-27 angap-15 - hbsag-negative hbsab-positive hbcab-negative hav ab-positive - -negative - hiv ab-negative - hcv ab-negative - dengue-pnd - lp from osh: negative culture, hsv 1&2 negative brief hospital course: 29 yo man with no past medical history presented with altered mental status after a trip to , with concern for encephalitis. infectious work up thus far has been negative and patient clinically improved back to baseline mental status. he was discharged in stable condition with new pcp and infectious disease follow up. micu course: the patient was sent from to the ed at . given his altered mental status he was admitted to the micu for further monitoring. upon arrival he was placed on vancomycin, ampicillin, ceftriaxone, acyclovir, and doxycylcine. lp had been performed at and csf culture was preliminarily negative. infectious disease and neurology was consulted. mri was performed and was negative for acute pathology. clinically he was not oriented to person, place, or time, and was very inattentive and mumbled his words. he was hemodynamically stable. the chief concern was for viral encephalitis. multiple serologies and pcr were sent. however, within 24hrs his mental status cleared markedly. repeat lp and mri were deferred. he was subsequently tranferred to the medical floor. # viral encephalitis: as noted, lp results did not suggest a bacterial meningitis and he was changed to only iv acyclovir and iv doxycycline. his mental status rapidly improved and he was transferred to the floor. a number of tests were ordered including , hepatitis a/b/c, hiv, rpr, measles, mumps, and rubella; all negative. his csf from had a gram stain with no pmns and no organisms seen. his csf culture has no growth to date. csf cryptococcal antigen was negative and hsv pcr was undetectable. pending tests include csf vzv, dengue, west , eee, ebv, hhv6, cmv, and enterovirus. # acute renal failure: on hospital day 3, creatinine was elevated from 1.0 to 1.3. there was associated increase in bun from 7 to 13 and hyperphosphatemia. he had not been taking adequate po fluids and his iv infiltrated, so it was assumed to be prerenal secondary to volume depletion. cpk was checked to rule out rhabdomyolysis and was normal. repeat creatinine was 1.4 then 1.3. medications on admission: topical cream for eczema sudafed prn zyrtec for seasonal allergies discharge medications: 1. acetaminophen 500 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 2. doxycycline hyclate 100 mg capsule sig: one (1) capsule po q12h (every 12 hours) for 11 days: be sure complete medication regimen. disp:*22 capsule(s)* refills:*0* 3. outpatient lab work please draw blood for creatinine and bun and send results to primary care physician. discharge disposition: home discharge diagnosis: primary: encephalitis of undetermined etiology mild prerenal acute renal failure attributed to hypovolemia discharge condition: stable, tolerating po, o2 sat >95%, ambulating, mental status improved and close to baseline. discharge instructions: it was a pleasure taking care of you at the . you were transferred here from with altered mental status and fever. you underwent multiple imaging tests including mri/mra, ct, and chest xray all of which were normal. there was no evidence of seizures. you had a lumbar puncture which showed signs of inflammation likely due to a viral infection. laboratory tests were sent on your cerebrospinal fluid as well as blood; none of the returned tests have identified the organism causing the infection. please avoid ibuprofen and continue to take your antibiotic, doxycycline, two times per day for two weeks. it is critically important that you complete this regimen. return to the hospital if you notice fevers, chills, confusion, stiff neck, nausea, vomiting, rash, or any other concerning symptoms. followup instructions: please follow-up at infectious disease clinic. , md phone: date/time: 9:30 please follow-up with your new primary care provider, . . , md phone: date/time: 8:30 md procedure: magnetic resonance imaging of brain and brain stem diagnoses: acute kidney failure, unspecified unspecified causes of encephalitis, myelitis, and encephalomyelitis 

Answer: The patient is high likely exposed to