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: cefepime / aztreonam / levaquin attending: chief complaint: reinduction mec therapy major surgical or invasive procedure: none history of present illness: is a 38-year-old chinese-speaking female with a history of secondary aml from her treatment for breast cancer, is currently day 165 status post allogeneic stem cell transplant from an unrelated donor for tbi and cytoxan for conditioning regimen. the donor was noted to be an antigen b mismatch, noted to have an antigen mismatch as well as to b core positive hepatitis b. the donor had a negative viral load. ms. had been on lamivudine prophylactically. the patient had been doing very well as an outpatient until a couple of weeks ago when she is noted to have some blasts in the peripheral smear. bone marrow biopsy and aspirate revealed full both morphological and cytogenetic evidence of disease relapse, noted at that to be 98% donor. she was rapidly tapered off immunosuppression in order to stimulate the donor t cells to hopefully initiated graft versus leukemia effect. she has had no clear evidence of gvh at this time, did develop a maculopapular rash and spotty areas around the neck, back, torso, arms, and legs, which was very pruritic, was evaluated by dermatology who thought that perhaps it was an eczematous process possibly brought on by mri contrast and was not thought to be gvh, treated empirically initially with lidex ointment and then switched to triamcinolone cream with almost complete resolution of the rash. . she has required periodic blood and platelet support since her relapse. she recently has not had any evidence of circulating blasts in her peripheral smear. she did have a bone marrow biopsy and aspirate last week; the results are currently pending. the patient reports that the rash had almost completely resolved until a day or so ago when she had recrudescence of some of her symptoms, started to use the triamcinolone cream again and her symptoms have improved. she does continue to have some mild pruritus in her chest and back. she notes that over the last couple of days her eyes felt tired and dry. she notes some pressure behind her right eye and has not really had any headaches over the last couple of days but did have some headaches a few weeks ago. we did an mri which was essentially negative. she continues to report significant fatigue and lack of appetite. she denies any further back pain. otherwise, denies any nausea, vomiting, diarrhea, or constipation. denies any bleeding or bruising difficulties. denies any fever, chills, or night sweats. denies any cough, shortness of breath, chest pain, palpitations, or any other cardiac or respiratory difficulties. denies any lightheadedness or dizziness. . past medical history: past medical history: secondary aml 11q23 mutation breast ca graves' disease status post radioactive iodine treatment on with subsequent hypothyroidism. . onc hx: she was diagnosed with stage i (t1c, n0, m0) of right breast diagnosed in and ductal in situ of the left breast diagnosed in .(lvi negative, er positive, her-2/neu negative) she underwent wide excision with sentinel lymph node procedure on the right along with wide excision of the left breast. she also received four cycles of adriamycin and cytoxan chemotherapy (completed in ). bilateral mastectomies were performed in . tamoxifen was initiated in though was taken off at time of diagnosis of aml. social history: she is originally from , moved here in . she lives in with her parents. she denies tobacco, alcohol or illicit drug use. she does not have children and is single. family history: sister with dm, no history of malignancy physical exam: pe: young asain woman in nad vs: t 98.6 bp 120/65 hr 97 rr 18 97%ra heent: perrl, op clear neck: no lad lungs: ctab cards: tachycardic, regular rhythm, 2/6 sem at lusb abd: +bs, scaphoid, nd, tender to deep palpation mcburney's pt, no rebound, no guarding. ext: +2 pulses, no edema neuro: nonfocal, 5/5 strength, sensation intact skin: no visible rashes pertinent results: notable admission labs: wbc 0.6 anc 110 hgb/hct: 11.1/30.4 plts 9 bone marrow biopsy note: myeloblasts in the aspirate account for 70% of the marrow cellularity. . microscopic description peripheral blood smears: the smear is adequate for evaluation. erythrocytes show anisopoikilocytosis with ovalocytes, dacrocytes. the white blood cell count appears decreased. hypogranular neutrophils are present. platelet count appears normal. large forms are seen. giant forms are not present. the differential shows: 13% neutrophils, 1% bands, 2% monocytes, 90% lymphocytes, <1% eosinophils, <1% basophils, 3% blasts. . aspirate smears the aspirated material is adequate for evaluation. the m:e ratio is 3.6. erythroid precursors are markedly decreased with megaloblastic changes. myeloid precursors appear markedly decreased in number and show a left-shift in maturation. megakaryocytes are virtually absent. the differential shows: 70% blasts, 4% promyelocytes, 4% myelocytes, 2% metamyelocytes, 1% bands/neutrophils, 2% plasma cells, 11% lymphocytes, 3% erythroid, 3% of promonocytes/monocytes. . clot section and biopsy slides the biopsy material is adequate for evaluation. the marrow cellularity is approximately 10-20%. hemosiderin-laden macrophages are noted. the predominant population consists of interstitial blasts greater than 70% of the marrow cellularity. erythroid precursors are decreased and present in small clusters. myeloid elements are decreased. maturing myeloid elements are greatly decreased. megakaryocytes are decreased with hypolobated forms and cells with disjointed nuclei. marrow clot section is not submitted. touch prep is not submitted. . tte : the left atrium is normal in size. there is borderline left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). 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 regurgitation. the mitral valve leaflets are mildly thickened. no mitral regurgitation is seen. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. compared with the prior study images reviewed) of , there is now a small pericardial effusion. . ct head : 1. no intracranial hemorrhage or mass effect. 2. persistent opacification of the right frontal sinus, anterior right ethmoid air cell, and right maxillary sinus, the latter of which is not completely included in the field of view. . cta : no evidence of pe. large pericardial and pleural effusion. . echo : moderate circumferential pericardial effusion with evidence of mildly increased pericardial pressures and global biventricular hypokinesis. mild mitral regurgitation. compared with the prior study (images reviewed) of , the pericardial effusion is larger (previously very small) and global biventricular systolic dysfunction are now evident. these findings are suggestive of myopericarditis or other diffuse process. serial evaluation is suggested. . echo : the estimated right atrial pressure is 5-10 mmhg. lv systolic function appears depressed. right ventricular chamber size and free wall motion are normal. there is a moderate sized pericardial effusion (maximal posteriorly @ 1.9 cm, minimal anteriorly at 0.8 cm). no right ventricular diastolic collapse is seen. there is brief right atrial collapse, consistent with low filling pressures or early tamponade. compared to the prior study dated , there is no change. these findings are suggestive of elevated intrapericardial pressures. given the samll ivc size and normal respirophasic variation, a component of intravascular volume depletion should be considered. brief hospital course: . # relapsed aml: given the extent of disease involvement the patient was admitted to the hospital to reinduce her with mec in order to cytoreduce her disease prior to receiving dli. the patient received 5 days of mec therapy which she tolerated well. she had an echo prior to starting treatment which showed normal lv function. she has been pancytopenic and has required platelet and blood transfusions to keep her crit > 25 and plt > . after mec a bone marrow was performed which showed a hypocellular marrow with 85-90% blasts. despite the aggressive nature of the disease, a discussion was made with the family to continue with dli. dli was not given after the patient became hemodynamically unstable pericardial tamponade and bilateral pulmonary edema. a decision was made to make the patient comfort measures and not pursue further aggressive treatment given worsening bilateral pleural effusions and persistent tamponade in the setting of disease recurrence. the patient passed away peacefully with family at bedside. . # febrile neutopenia: granulocyte count of 110 on admission. patient remained neutropenic thoughout this admission and started to spike fever >102 on and was started on vancomycin and meropenem. she was already on fluconazole and acyclovir already for prophylaxis given her neutropenia. all culture data has been negative to date except for a urine cx with 10,000-100,000 proteus mirabilis microorganisms. repeat urine cultures have been negative. on , pt developed a rash and it was thought to be due to meropenem although the patient had meropenem in the past without problem. of note she does have rash with aztreonam. she was taken off meropenem and started on gentamicin. the rash was still present but not getting worse. on gentamycin was stopped and meropenem was restarted to better cover gram negative bacteria as the patient was still spiking fevers. on , the patient developed diarrhea and c dif cultures were sent and are pending. at that time, pt was started on flagyl. in addition, head ct showed some opacification of ethmoid and frontal sinuses. fungal cx sent and is pending. cmv viral loads sent weekly have been negative. the patient was switched briefly to aztreonam but this too worsened her rash and she was switched back to gentamicin for gram negative coverage. her left subclavian line was discontinued given that it was thought to be contributing to her fevers but the patient continued to spike despite the line being removed. she was eventually broadened to posaconazole/gentamicin/vancomycin/flagyl but continued to spike fevers of unclear etiology despite multiple blood cultures. upon transfer to the for pericardial tamponade, the patient continued to spike fevers up to 102. voriconazole was added for empiric fungal coverage. voriconazole was switched to posaconazole for mucor coverage by id recommendation and switching vancomycin to daptomycin to avoid renal toxicity. a repeat bone marrow biopsy was performed when the patient's counts showed no signs of recovery. she was found to have recurrent disease in her bone marrow. no source was identified for her fevers. a discussion with the patient and her family was held and a decision was made to make the patient comfort care given her aggressive disease and worsening clinical course with worsening respiratory distress from her pulmonary edema and pericardial tamponade. she was given standing tylenol to prevent fevers and make the patient comfortable. she passed peacefully with family at bedside. . # skin rash- thought to be due to meropenem which was stopped and restarted on for better gram neg coverage as she was still spiking temps. she was briefly switched to aztreonam which also seemed to worsen the rash. dermatology saw the patient and a biopsy showed spongiotic changes which were thought to be more likely consistent with drug rash although gvhd could not be ruled out. she was given triamcinolone cream for symptomatic relief and the rash slowly improved when she was switched off meropenem/aztreonam to gentamicin. . # mucositis- patient developed mucositis after reinduction with mec. she was given mouth care with nystatin, caphasol, clotrimazole troches prior to mucositis. she was also being covered for viral and fungal causes with fluconazole and acyclovir. the fluconazole was switched to caspofungin when she was still spiking fevers. her pain was well-controlled with a fentanyl pca and improved during her stay. patient was start on tpn since it was difficult for her to eat mouth pain. . # hypothyroidism- continued on home dose of levothyroxine. . # history of hep b positive donor- continued prophylaxis with lamivudine. her hepatitis b viral load was negative. this was checked as her lfts were elevated with mec. they trended down to normal after mec was completed. . # epistaxis- this occured in setting of plt count < 20 k. she was given plts to keep goal > 35,000 and afrin nasal spray. ent consulted and nose was never packed. this did not happen again during this admission. . # pericardial effusion and tamponade physiology: on the day of transfer to the , the patient was found to have increased sob and increasing o2 requirement. a chest ct showed evidence of a pericardial effusion and tte showing ra/rv collapse in diastole. in the , the patient was monitored with serial echos which showed persistent evidence of tamponade physiology. the etiology of her pericardial effusion was unclear. the fluid collection was not thought to be drainable given its posterior location. she was diuresed as needed for volume overload demonstrated on cxr. ambisome was added for empiric fungal coverage. her echo continued to show evidence of worsening tamponade physiology. upon transfer back to the floor, the patient's respiratory status worsened with tachycardia to the 150s, severe pulmonary edema and increased o2 requirement despite diuresis. a discussion with the patient and her family was held and the patient did not want to return to the icu. instead, comfort care measures were pursued. the patient was eventually placed on a fentanyl gtt for respiratory distress and made comfortable. she passed away peacefully with family at bedside. . # dispo: please see above for details of hospital course. the patient was found to have aggressive disease with recurrence of aml in the marrow after the patient underwent mec. concurrently, a large pericardial effusion was identified with tamponade physiology and worsening pulmonary edema. a discussion with the patient and her family was held and a decision was made to make the patient comfort measures. she was made comfortable on a fentanyl gtt and passed peacefully with her family at bedside. . medications on admission: levothyroxine lamivudine discharge medications: n/a discharge disposition: home discharge diagnosis: primary 1. secondary aml 2. h/o breast cancer 3. pancytopenia 4. pericardial effusion and tamponade 5. pleural effusions . secondary 1. hypothyroidism discharge condition: patient passed away peacefully with her family at bedside. procedure: parenteral infusion of concentrated nutritional substances biopsy of bone marrow transfusion of packed cells closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance transfusion of platelets injection or infusion of oxazolidinone class of antibiotics diagnoses: urinary tract infection, site not specified congestive heart failure, unspecified unspecified acquired hypothyroidism personal history of malignant neoplasm of breast peripheral stem cells replaced by transplant unspecified disease of pericardium acute respiratory failure dermatitis due to drugs and medicines taken internally diarrhea other specified antibiotics causing adverse effects in therapeutic use epistaxis anemia in neoplastic disease unspecified sinusitis (chronic) hepatitis b carrier acute myeloid leukemia, without mention of having achieved remission contact dermatitis and other eczema, unspecified cause pain in or around eye encounter for antineoplastic chemotherapy other neutropenia 

Answer: The patient is high likely exposed to