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 major surgical or invasive procedure: lumbar puncture ivc filter placement history of present illness: 52 y/o m w/ hx of ph + all d 91 double cord transplant who was on his way from an appt when he scraped his left leg on the step of the shuttle. he was treated with wound care, vancomycin iv and d/c home on . he presented today to osh with fever 100.4 concerning for neutropenic fever. earlier in the morning he felt warm and measured his temp to 99.8, and later to 100.4. at the ed, his temp. was 100.6, other vitals stable. the patient was transferred to for further evaluation and management. he feels well other than fevers. he denies headaches, dizziness, cough, shortness of breath, uri symptoms, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, joint pains, bony pains, urinary symptoms. he does have persisting pain over the left leg/shin wound, but without worsening redness, swelling, tenderness or warmth. he denies any other rashes. review of systems: fever chills night sweats fatigue nausea vomiting diarrhea weight loss food intolerance cough doe since discharge sob at rest chest pain palpitation skin rash-psoriasis remains improved neuropathy past medical history: past oncologic history (from , confirmed with patient and wife): treatment history: * - hypercvad, part a. also started on gleevec 300 mg twice per day. * it cytarabine on * - hypercvad, part b with it methotrexate on . difficult time with this lp with resulting headache. * - high dose methotrexate * bone marrow biopsy without evidence for all * - high dose methotrexate * - hypercvad, part a. it methotrexate on under ir with resulting headache. d 8 it cytarabine held due to previous difficult lp. d 11 vincristine held d/t previously elevated bilirubin. * admitted on with fever, neutropenia and paronychia of left great toe. treated with iv abx and discharged on keflex * - hypercvad, part b. * - admitted with fevers and neutropenia. treated for pneumonia with persistent fevers and night sweats. workup negative for infection and bm biopsy with no evidence for all. discharged on . * - hypercvad, part a, it methotrexate on . * - admitted for headaches and lightheadedness. ct head negative. improved with ivf's and transfusions. discharged on . * - hypercvad, part b. gleevec on hold with lower blood counts. * - admitted with fever and neutropenia; no infectious etiology found * - presented to ew with abdominal pain and increased creatinine to 1.8. noted for kidney stones. pain resolved; creatinine now normal. * - started sprycel 100 mg daily; held on due to increasing diarrhea. * - started gleevac and discontinued on . post transplant course: d 0 . long complicated post transplant course with prolonged admission. developed acute mental status changes in setting of + hhv6 viremia and csf involvement treated with foscarnet induction with recovery of mental status. hhv6 viremia never decreased in the setting of treatment with foscarnet. also noted cmv viremia with peak cmv vl in the 700-800 range. currently on valganciclovir with most recent cmv viral load undetectable. ready for discharge on but developed orthostatic hypotension felt related to autonomic insufficiency. started on florinef with improvement in symptoms and blood pressure. discharged to local apartments on ; returned home as of . past medical/surgical history: 1. non-insulin-dependent diabetes type 2, previously on metformin/glyburide, now on glyburide and insulin - 2. hypertension - 3. hyperlipidemia - 4. hypothyroidism - 5. cervical djd/osteoarthritis - 6. cad status post stenting x1 in 7. status post cholecystectomy in . 8. psoriasis, controlled with topicals in the past - dx'ed atage 29 social history: living situation: has returned to own home isolation: continues with post transplant restricitons is married and lives with his wife. they have 2 children ages 19 (daughter in nursing school) and son 14. he ran the park/rec dept in , ma and worked part time at but is currently not working. etoh: none tobacco: never. illicits: denies, no h/o ivdu diet/exercise: no regular exercise, tries to follow cardiac/diabetic diet pets: 1 cat family history: from discharge summary no known hematologic malignancies daughter with disease physical exam: admission physical exam gen: middle-aged male, fatigued-appearing, lying comfortably in bed, nad conjunctiva: not injected oral mucosa: no oral lesions, moist neck: supple, no masses lungs: ctab, no wheezes, rhonchi, or rales cor: normal rate, regular rhythm, nl s1s2 no mrg abd: obese, soft, non-tender, nondistended, with normal bowel sounds and without hepatosplenomegaly. scattered superficial ecchymoses. line: central venous line dressing clean and site non-tender ext: 1+ edema, mostly non-pitting, with dark ruddy confluent areas with flaking skin. rle wrapped in bandages, laceration with marked surrounding erythema unclear if changed from prior skin: dry skin on scalp. mild erythema of psoriatic patches on back; minimal patches on abdomen and chest. neuro - awake, a&ox3, cns ii-xii grossly intact, muscle strength throughout, sensation grossly intact throughout, dtrs 2+ and symmetric discharge physical exam: vitals - tm 99.7 tc 98.3 bp 118-130/78-82 p 81-100 r 18 o2 96-99%ra gen: awake, alert, oriented, appropriate heent: mmm, no ulcers. small white ulcer on right side of lower lip. skin: diffuse areas of hypopigmentation on back, hyperpigmented, hyperepithelialized lower extremities lungs: decreased breath sounds in all lung fields, shallow breathing, no use of accessory muscles cardiac: normal rate, regular rhythm, nl s1s2 no mrg abd: nabs, nontender ext: trace edema bilateral lower extremities. exam: healing abrasions without surrounding warmth, erythema, or fluctuance. area of moist granulation tissue, but no drainage or bleeding on lower shin. skin: right lateral shin has 1cm black nodule with regular borders, non-tender, non pruritic neuro - cns ii-xii grossly intact, moving all limbs spontaneously, mild tremor bilaterally, no asterixis. access: hickman central line; dressing clean and site non-tender pertinent results: **********admission labs********** 06:48pm wbc-3.3*# rbc-2.97* hgb-10.2* hct-28.2* mcv-95 mch-34.3* mchc-36.2* rdw-17.0* 06:48pm neuts-87.1* lymphs-11.2* monos-1.4* eos-0.1 basos-0.1 06:48pm plt count-47* 06:48pm pt-10.8 ptt-28.6 inr(pt)-1.0 06:48pm glucose-254* urea n-19 creat-0.8 sodium-137 potassium-3.7 chloride-104 total co2-24 anion gap-13 06:48pm calcium-8.2* phosphate-3.1 magnesium-1.7 *********discharge labs********* 12:00am blood wbc-2.9* rbc-2.82* hgb-9.0* hct-25.4* mcv-90 mch-32.0 mchc-35.5* rdw-16.1* plt ct-58* 12:00am blood neuts-67 bands-1 lymphs-11* monos-18* eos-0 baso-0 atyps-3* metas-0 myelos-0 nrbc-1* 12:00am blood hypochr-normal anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-normal 10:30am blood plt ct-94*# 12:00am blood glucose-135* urean-12 creat-1.0 na-136 k-3.5 cl-101 hco3-25 angap-14 12:00am blood alt-22 ast-19 ld(ldh)-415* alkphos-62 totbili-0.4 12:00am blood calcium-8.3* phos-3.1 mg-1.6 **********microbiology********** ebv viral load < 200 on , , , cmv viral load = 746 copies = 649 cmv viral load (final ): 796 copies/ml. cmv viral load (final ): 765 copies/ml. cmv viral load , , negative cmv viral load (final ): 989 copies/ml. hhv6 serology - - hhv6 1,980,591 - herpes virus 6 dna, qn - herpes virus 6 dna, qn pcr > h - herpes virus 6 dna, qn multiple negative blood cultures, urine cultures, c. diff **********csf studies*********** total protein, csf 76* 15 - 45 mg/dl glucose, csf 70 mg/dl lactate dehydrogenase, csf 21 iu/l hhv6, ebv pcr, hsv - not detected ************imaging****************** tib-fib x-ray : 1. no acute fracture. 2. extensive vascular calcifications. # cxr: findings: as compared to the previous radiograph, there is no relevant change. borderline size of the cardiac silhouette. no evidence of pneumonia. known scar at the bases of the right upper lobe. no pleural effusions. no pneumothorax. double-lumen right central venous catheter in unchanged position. # head ct: there is no ct evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. there is preservation of -white matter differentiation. the basal cisterns appear patent. the ventricles and sulci are normal in caliber and configuration for patient's age. the visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. no acute bony abnormality is detected. # ct head impression: no ct evidence for acute intracranial abnormality. # tte the left atrium is elongated. 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). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. 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 pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. impression: normal biventricular cavity sizes with preserved regional and global biventricular systolic function. compared with the prior study (images reviewed) of , the findings are similar. # cta chest 1. occlusive right main pulmonary artery embolus with extension into the lobar and segmental vessels in the right upper and lower lobes. no evidence of right ventricular dysfunction. 2. small bilateral effusions with associated atelectasis. # transthroacic echocardiogram left ventricular systolic function is hyperdynamic (ef>75%). the right ventricular cavity is mildly dilated there is a very small pericardial effusion located along the infero-lateral left ventricular wall. there are no echocardiographic signs of tamponade. compared with the prior complete study (images reviewed) of , visualization of the right ventricle is suboptimal. with this limitation, the rv appears slightly more dilated. rv systolic function is probably similar. left ventricular systolic function is more vigorous. the very small pericardial effusion was present on the prior study. # lower extremity ultrasound: bilateral dvt, occlusive on the left, near-occlusive on the right. # tte no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (lvef>70%). the right ventricular cavity is mildly dilated with mild global free wall hypokinesis. the mitral valve appears structurally normal with trivial mitral regurgitation. the pulmonary artery systolic pressure could not be determined. there is a very small pericardial effusion. there are no echocardiographic signs of tamponade. impression: mildly dilated right ventricle with mild global wall hypokinesis. mild symmetric left ventricular hypertrophy with normal global systolic function. very small pericardial effusion without echocardiographic tamponade. ********* pathology ************ bone marrow biopsy : hypocellular erythroid-dominant marrow with erythroid and megakaryocytic dyspoiesis. no diagnostic morphologic features of involvement by leukemia seen. brief hospital course: 52 year old male with hx of ph + all d +96 (on admission ) double cord transplant, with history of hhv6 encephalitis, diabetes, adrenal insufficiency & orthostatic hypotension (on fludocortisone), who presented as a transfer for fever to 100.6. on days prior to this admission, he was admitted after he scraped his right shin on a shuttle bus. he got ivig, and was discharged on . on this admission, he presented fever and was empirically started on vancomycin and cefepime. he developed a headache on hd2, which was initially thought to be related to ivig. on hd3, he was somnolent / confused, so an lp was done on . csf studies revealed elevated protein, concerning for viral / aseptic meningitis. he was started on foscarnet empirically on , but this was stopped when csf studies came back negative for hhv6. his mental status improved and the etiology of headache and altered mental status remains unclear to date. he developed acute hypoxemia and was discovered to have an acute pulmonary embolus, provoked by prolonged immobilization and inability to anticoagulate because of thrombocytopenia. # submassive pulmonary embolus - the patient developed acute hypoxemia on , was found to have a large pulmonary embolus involving the right main with extension into the upper, middle, and lower segmental arteries, and was started on a heparin drip. leni showed bilateral deep venous thrombi, so he was brought emergently to the cath lab for ivc filter placement. he was brought to the ccu after his thrombectomy and did well. he he was maintained on heparin drip because of thrombocytopenia. once he was able to maintain his platelet count with every other day platelet transfusions, he was started on subcutaneous lovenox. he developed bleeding complications and was found to be supratherapeutic with the 1mg/kg dosing of enoxaparin, so he was placed on 1mg/kg daily enoxaparin, and factor xa levels were appropriate. - anticoagulation should be continued for 6 months for provoked pulmonary embolus, and ivc filter should be removed at the same time (around ) # fever - had one isolated fever 101.3 on . he was started empirically on vancomycin, cefepime. no definitive source was identified. possible localizing sources: cns, line infection, cellulitis (however left lower extremity appeared to be healing well and did not appear to be infected or cellulitic), gi (had watery diarrhea on the day he spiked a fever). most concerning was hhv6 encephalitis, so he was started empirically on foscarnet as described below. csf studies were negative for hhv6, ebv, hsv. also possible is foscarnet reaction (has previously had fever & diarrhea with foscarnet). because he remained afebrile and his wbc counts recovered, antibiotics were stopped on , and he remained afebrile. # ph + allo s/p double cord transplant: on protocol #11-085, reduced intensity conditioning with fludarabine, melphalan, and low dose tbi followed by double umblical cord blood sct (d 0 ). treatment has been complicated by , mucositis, neutropenic fever, hhv6 infection with cns involvement, giardiasis, mild gvhd of the gut following engraftment, and cmv viremia. maximun grade ii gvhd of the gi tract while hospitalized, biopsy-proven from egd , now resolved. no other evidence for gvhd. discharged on after a prolonged hospitalization and is recovering slowly. counts remain low and seem to fluctuate somewhat in the setting of his medications and infections. - we continued his anti-rejection regimen with methylprednisolone, sirolimus, and tacrolimus. methylprednisolone was tapered. - prophylaxis was continued with atovaquone, fluconazole. valgancyclovir held while on foscarnet. he receives monthly ivig, last received . - scheduled bone marrow biopsy from revealed no evidence of leukemia but hypocellular marrow with erythroid & megakaryocytic dyspoiesis # pancytopenia: chronic pancytopenia likely due to hypoproliferation and recurrent infections. he got neupogen on and for downtrending wbcs with good response. # altered mental status / headache / concern for viral encephalitis - originally presented with headache which improved with ivf, thought most likely related to ivig received . ct head was negative for hemorrhage. the patient had altered mental status . there was concern for hhv6 encephalitis because the patient has a personal history of hhv6 encephalitis and a persistently elevated hhv6 viral load. lumbar puncture was performed. csf studies were positive for elevated protein, consistent with possible aseptic meningitis, so he was started on foscarnet, but was discontinued when csf hhv6 was confirmed negative. headache and altered mental status improved. etiology remains unclear. # cmv viremia - he is on valgancyclovir prophylaxis at home. valgancyclovir was held in the setting of pancytopenia to allow counts to recover. he developed a positive cmv viral load. he was seen by infectious diseases and was discharged on a suppressive dose of valgancyclovir with infectious disease follow-up. # orthostatic hypotension: the patient has a h/o orthostatic hypotension on fludrocortisone at home. orthostatic hypotension was unresponsive to iv fluids which suggests he has a degree of adrenal insufficiency. of note, methylprednisone has been tapered as he is now > 100 days out from transplant. # cad/hypertension: continued home nifedipine. # diabetes: patient developed hypoglycemia while tapering methylprednisone, so home glargine was decreased from 30u to 4u, and he was maintained on a sliding scale with humalog. transition of care - please keep platelets > 60,000 while on lovenox - cmv levels should be drawn on friday, , and the dose of valgancyclovir may be changed accordingly - continue lovenox for 6 months after provoked pulmonary embolus (until ) - ivc filter should be removed in 6 months by interventional cardiology (around ) medication changes - decrease dose of tacrolimus to 0.5 mg twice daily - decrease dose of methylprednisone to 2mg daily - decrease dose of glargine insulin to 4u each night - start enoxaparin injections 90mg daily for 6 months (until ) - start pantoprazole 40mg daily to protect your stomach from bleeding while you are on lovenox medications on admission: the preadmission medication list is accurate and complete. 1. atovaquone suspension 1500 mg po daily 2. calcipotriene 0.005% cream 1 appl tp daily apply to affected area 3. clobetasol propionate 0.05% ointment 1 appl tp do not put on face. 4. fluconazole 400 mg po q24h 5. fludrocortisone acetate 0.1 mg po daily 6. folic acid 1 mg po daily 7. glargine 30 units bedtime insulin sc sliding scale using hum insulin 8. levothyroxine sodium 100 mcg po 4x/week (mo,tu,we,th) 9. levothyroxine sodium 200 mcg po 3x/week (,fr,sa) 10. methylprednisolone 8 mg po daily 11. nifedipine cr 30 mg po daily hold for sbp <100 hr <60 12. ondansetron 8 mg po q8h:prn nausea 13. sirolimus 1 mg po daily daily dose to be administered at 6am 14. tacrolimus 1.5 mg po q12h 15. valganciclovir 900 mg po bid 16. potassium chloride 40 meq po tid duration: 24 hours hold for k > 5.5 17. magnesium sulfate 4 gm iv 4x/week (,tu,th,sa) hold for mg>2.6 18. hydromorphone (dilaudid) 2-4 mg po q4h:prn pain hold for sedation, rr<12 discharge medications: 1. enoxaparin sodium 90 mg sc daily pulmonary embolus duration: 6 months rx *enoxaparin 100 mg/ml inject 90ml twice a day disp #*60 syringe refills:*5 2. calcipotriene 0.005% cream 1 appl tp daily apply to affected area 3. atovaquone suspension 1500 mg po daily 4. fluconazole 400 mg po q24h 5. fludrocortisone acetate 0.1 mg po daily 6. folic acid 1 mg po daily 7. hydromorphone (dilaudid) 2-4 mg po q4h:prn pain hold for sedation, rr<12 8. levothyroxine sodium 100 mcg po 4x/week (mo,tu,we,th) 9. levothyroxine sodium 200 mcg po 3x/week (,fr,sa) 10. magnesium sulfate 4 gm iv 4x/week (,tu,th,sa) hold for mg>2.6 11. nifedipine cr 30 mg po daily hold for sbp <100 hr <60 12. potassium chloride 40 meq po tid duration: 24 hours hold for k > 5.5 13. ondansetron 8 mg po q8h:prn nausea 14. methylprednisolone 2 mg po daily rx *methylprednisolone 4 mg 0.5 (one half) tablet(s) by mouth daily disp #*30 tablet refills:*0 15. tacrolimus 0.5 mg po q12h rx *tacrolimus 0.5 mg 1 capsule(s) by mouth twice a day disp #*60 capsule refills:*0 16. valganciclovir 900 mg po q12h rx *valganciclovir 450 mg 2 tablet(s) by mouth twice a day disp #*120 tablet refills:*0 17. sirolimus 1 mg po daily daily dose to be administered at 6am 18. glargine 4 units bedtime insulin sc sliding scale using hum insulin 19. pantoprazole 40 mg po q24h rx *pantoprazole 40 mg 1 tablet(s) by mouth daily disp #*30 tablet refills:*0 discharge disposition: home with service facility: vna discharge diagnosis: primary: acute lymphocytic leukemia secondary: pulmonary embolus, altered mental status, headaches, adrenal insufficiency, diabetes mellitus, hypertension 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: it was a pleasure caring for you during your recent hospitalization. you came in with a fever and were neutropenic so we started you on antibiotics. we did not identify a clear source of your fevers but they resolved without antibiotics upon discharge. early in your hospitalization, you complained of headaches and we were concerned that you seemed a bit confused, so you got a lumbar puncture because you have a history of hhv6 encephalitis. you were treated briefly with foscarnet but the spinal fluid did not grow hhv6, so we stopped the foscarnet. your headaches improved upon discharge. one week into your hospitalization, your oxygen levels dropped and we discovered that you have a large clot in your lungs, which was most likely caused by your prolonged hospitalization which made it difficult for you to walk around. you developed blood clots in your legs, which can travel to your lungs. the treatment for pulmonary embolus is anticoagulation with heparin. you were placed on a heparin iv until your platelet counts were adequate, then we started you on enoxaparin (lovenox) shots. you were seen by dermatology for a skin rash on your right shin. they felt it was a simple hematoma (bruise). nonetheless you should follow-up in dermatology clinic as an outpatient. it is very important that you keep the following appointments we have made for you. transition of care - please keep platelets > 60,000 while on lovenox - continue lovenox for 6 months after provoked pulmonary embolus (until ~) - ivc filter should be removed in 6 months by interventional cardiology (~ ) - cmv levels should be drawn on friday, , and the dose of valgancyclovir may be changed accordingly medication changes - decrease dose of tacrolimus to 0.5 mg twice daily - decrease dose of methylprednisone to 2mg daily - decrease dose of glargine insulin to 4u each night - start enoxaparin injections 90mg daily for 6 months - start pantoprazole 40mg daily to protect your stomach from bleeding while you are on lovenox followup instructions: department: bmt chairs & rooms when: friday at 9:30 am department: hematology/oncology when: friday at 9:30 am with: , bsn building: sc clinical ctr campus: east best parking: garage department: hematology/bmt when: friday at 10:00 am with: , np building: sc clinical ctr campus: east best parking: garage please make a follow-up appointment in the dermatology clinic 1-2 weeks after discharge or earlier if the rash on your right shin does not resolve. please call to make an appointment. test for consideration post-discharge: bnp, cmv vl (friday ), mri procedure: spinal tap incision of lung interruption of the vena cava biopsy of bone marrow angiocardiography of venae cavae diagnoses: abnormal coagulation profile coronary atherosclerosis of native coronary artery unspecified essential hypertension unspecified acquired hypothyroidism unspecified fall percutaneous transluminal coronary angioplasty status other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure diabetes with other specified manifestations, type ii or unspecified type, not stated as uncontrolled long-term (current) use of insulin complications of transplanted bone marrow unspecified accident abdominal pain, left lower quadrant diarrhea altered mental status headache acute venous embolism and thrombosis of deep vessels of proximal lower extremity cytomegaloviral disease other psoriasis examination of participant in clinical trial other pulmonary embolism and infarction personal history of antineoplastic chemotherapy epistaxis acute lymphoid leukemia, without mention of having achieved remission cervical spondylosis without myelopathy orthostatic hypotension heart disease, unspecified other fluid overload abrasion or friction burn of hip, thigh, leg, and ankle, without mention of infection gamma globulin causing adverse effects in therapeutic use other pancytopenia chronic graft-versus-host disease blister of hip, thigh, leg, and ankle, without mention of infection 

Answer: The patient is high likely exposed to