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: history of present illness: a 32-year-old female with a systemic lupus erythematosus, positive double strand dna and positive with pan cytopenia who has a history of chylous ascites for the past five years who was transferred to for further management of her illness. the patient has had an extensive workup of her chylous ascites including numerous paracentesis with fluid analysis for malignancy and tuberculosis, abdominal ultrasounds with angiograms, peritoneal biopsies, exploratory laparotomies as well as transjugular liver biopsies, pet scans and mris which have all been negative. the patient has been treated with steroids, ivig, cyclosporin and octreotide in the past but continues to have problems with her chylous ascites. a bronchoscopy in the past also revealed goop. the patient has also had numerous bone marrow biopsies in the past for her pan cytopenia which have revealed hypocellular marrow with a left shift but have not elucidated the origins of her pan cytopenia. finally, patient has also had an egd which also had a negative small bowel biopsy in the past. patient was transferred to where she would be seen by the liver team under the care of dr. for a second opinion of her chylous ascites. the patient arrived at on , was stable and was noted to be neutropenic with an anc of 470, patient was hyperkalemic with ekg changes. patient was given calcium, insulin and glucose with resolution of her hyperkalemia. she was noted to be hyponatremic and was seen by the renal team here who decided to start the patient on lasix as well as to administered products secondary to the patient's intravascular volume depletion. the patient also had two paracenteses on the floor prior to micu admission where four liters of creamy fluid were taken off her abdomen on the day of admission and, once again, on day number three status post a second paracentesis, the patient developed low grade temperature and some diffuse abdominal pain. the patient was followed very closely by the hematology department. they reviewed the patient's bone marrow biopsies with pathology. they felt that these studies were within normal limits and there was nothing on the bone marrow biopsies that would explain the patient's recurrent condition. she was started on gcsf and epogen as well as iron on the floor. the patient was also followed by infectious disease consultants who sent off numerous cultures from the paracenteses looking for tuberculosis as well. the patient was seen by rheumatology and dermatology and, given her history of lupus in the past, she was found to be double strand dna negative here and her titer was 1:80. the rheumatologist felt that a rheumatologic process was not the primary cause of all her current concerns. she also had a derm biopsy taken of some erythematous macules noted on her tibial region which revealed panniculitis consistent with pancreatitis. the patient also had a ct of the abdomen prior to intensive care unit admission which revealed a large amount of ascites, no focal liver abnormalities and some contrast in the right renal collecting system which was nonspecific. the patient also had a right upper quadrant ultrasound prior to admission to the intensive care unit which did not reveal any intrahepatic biliary dilation and revealed patent portal and hepatic veins. of note, the ct of the abdomen did reveal some enlargement of the head of the pancreas as well as a very small splenic infarct. on the day of admission to the icu the patient's temperature spiked to 101.4 during a packed red cell transfusion. systolic pressure dropped to 70/40. a diagnostic paracentesis with 60 cc of fluid revealed purulent yellowish material which was sent to the laboratory for analysis. the patient was noted to be anuric for 12 hours prior to icu admission and patient was started on empiric antibiotics for sbp and transferred to the micu for hemodynamic instability as well as impending respiratory failure. laboratory on admission: white cell count 1.6 up from 0.6 on admission, hematocrit 29.6 from 26 status post one unit packed red cell transfusion. platelets 46. electrolytes: sodium 127, potassium 4.0, chloride 97, bicarbonate 19, bun 55, creatinine 1.3 up from 0.8 on admission, glucose 112, inr 1.2, ptt 26, alt 26, ast 31, ldh 100, alk phos 104, amylase 840, lipase 1,256, total bilirubin 9.4 up from 1.3 on admission, anc 1,340. paracentesis from the revealed the following values: 300 white cells, 5,425 red cells, 91% polys, 4% lymphocytes, 5% monocytes. albumin was less than 1. amylase was 328. ldh was 161, total protein 0.7, glucose 95. medical intensive care unit course: the patient was admitted to the icu on , for hypotension. she was started on stress dose steroids as well as neo-synephrine and vasopressin since it was thought that the patient was possibly septic. she was started empirically on antibiotics. the patient was given vancomycin, ceftazidime and flagyl empirically for sbp coverage. the patient was subsequently intubated on the 12th secondary to impending respiratory failure. the patient's respiratory failure was thought to be secondary to her loss of her renal function. the patient's loss of renal function caused an acute on chronic metabolic acidosis. the patient was forced to have respiratory compensation for this metabolic acidosis and due to her large restrictive process secondary to her chylous ascites she was forced to breathe at respiratory rates as high as 40 to 45 breaths a minute. the patient's abg revealed pseudo-normalization of her pco2 and it was thought that the patient should be intubated for impending respiratory failure at that time. the patient was treated for sbp and was followed very closely by the infectious disease team. numerous cultures were taken from her paracentesis as well as cultures, urine cultures and sputum cultures, all of which remained negative. sequentially, the vancomycin and flagyl were taken off the patient's antibiotic regimen and the patient was continued on ceftazidime. it was later thought that the patient's hypotensive episode and subsequent acute renal failure was most probably due to pancreatitis and the spacing of fluids as opposed to sbp since all culture data remained negative. subsequently, the patient's ceftazidime was stopped. the patient did not spike any temperatures off antibiotics and her hemodynamics continued to improved with aggressive volume hydration, episodic packed red cell infusion to facilitate intravascular volume repletion and q. day albumin according to the hepatology recommendations. the patient was taken off her neo-synephrine and vasopressin on the . her systolic pressures remained well but she was continued on stress dose steroids. another thought of component of her hypotension was considered. it was thought that the patient may have abdominal compartment syndrome given her large intra-abdominal pressures secondary to her chylous ascites. pre- and post-paracentesis bladder pressures were measured and it was deemed that the patient did not have significant abdominal compartment syndrome and the patient's hemodynamics did not improve markedly after paracenteses. the patient continued to do well off any pressors and did not have any problems with pressure subsequently. from a pulmonary standpoint, the patient was extubated on the but did have some problems with pulmonary edema status post extubation. the patient required one episode of noninvasive mask ventilation during which oxygenation and ventilation remained good but the patient's respiratory rate went up into the 30's. the patient was diuresed with 20 mg of intravenous lasix q. day for four days and this regimen was changed over to 40 mg of p.o. lasix until she was discharged from the hospital. subsequent chest x-rays revealed resolution of her pulmonary edema and subsequent pulmonary examinations revealed improvement in her lung sounds. the patient's pancreatitis continued to improve throughout her intensive care unit stay. on admission her amylase was 840 and lipase was 1,256 with a t. bili of 9.4. by the end of her micu stay after aggressive hydration, the patient's amylase and lipase were in the 230's and her total bilirubin came down to 3.2. the patient did not complain of any epigastric abdominal pain. she was continued on albumin, had a repeat ct which did not reveal very much secondary to difficulty visualizing the intra-abdominal structures secondary to her massive ascites. she had an mri done subsequently to rule out any pancreatic pseudocyst since she did have one episode of back pain. the mri revealed the following studies. it revealed that the patient's spleen, in fact, had a large splenic infarct and there was only sparing of the anterior pole. the adrenals and the kidneys were unremarkable. the pancreas was enlarged and the pancreatic head was noted to have a 5 x 5 x 4.4 cm hypoenhancement relative to the rest of the pancreas which was thought to be worrisome for ischemia. the patient's gallbladder was unremarkable. the portal vein was patent. the splenic vein was also unremarkable. there was noted to be some distended bowel loops and on ct's there was massive ascites discovered. due to these findings, the surgery team was consulted as to possibility for operative intervention given the patient's infarcted spleen. the surgery team saw the patient and determined that surgical intervention would be untenable given the patient's thrombocytopenia and relative neutropenia. they advised that further medical management would be the safest course of action. the patient's mean pressures were maintained above 70 to facilitate end organ perfusion and hypotensive insults were avoided. the patient had a repeat mri two days later which revealed that the ischemia of the pancreas was unchanged and that the infarcted spleen remained unchanged as well. throughout the hospital stay, it was thought that the patient should be treated for this infarcted spleen with vancomycin, zosyn and fluconazole to ensure that the patient did not have an intra-abdominal infection. infectious disease again was consulted on the case and repeated cultures were taken. cultures of the paracenteses were taken as well which revealed no growth. the patient did not have any abdominal pain or symptoms and it was subsequently decided that the vancomycin and fluconazole could be stopped once the second mri revealed no further signs of infection or bowel inflammation. the zosyn was continued at the time of discharge from the intensive care unit and infectious disease team continued to follow to ensure that the patient did not have any intra-abdominal infections. two diagnoses were considered for the patient's chylous ascites. the first was whipple's disease. the patient's biopsies of her egd were analyzed here and it was thought that the findings were not consistent with whipple's disease but pcr could not be performed on these studies. the second diagnosis that was considered was - syndrome. it was thought that some of the patient's presentation was consistent with - syndrome and the decision was made to start the patient on high dose steroids but it was decided to hold off on starting the patient on any other immunosuppressive agents since throughout the hospital stay there were numerous episodes in which it was thought that the patient might be infected. the patient's acute renal failure also played a role in holding off on starting any high dose immunosuppressives and, finally, the patient's persistent thrombocytopenia was also quite worrisome and it was decided that any cyclophosphamides or other immunosuppressives should be started when the patient is much more stable. of note, no histiocytes were noted on any marrow biopsies or in any peripheral cultures according to the liver team. from a renal standpoint, the patient did have acute renal failure secondary to a prerenal process since her __________ excreted sodium was less than 1% as well as an acute tubular necrosis. the patient's ____ were maintained above 70% and renal perfusion was maximized. all nephrotoxic agents were avoided and the patient's creatinine came down from 1.3 on admission down to 0.9 and the patient anuria resolved and the patient was making normal amounts of urine at the time of discharge from intensive care unit. as far as the patient's pan cytopenia, the patient's gcsf was continued. her white cell count was 0.6 on admission and rose to 5.7 at the time of discharge. a repeat bone marrow biopsy was considered but was held off since the hematology team felt that this would not add anything to the patient's management. the patient was also continued on iron supplements by epogen for stimulation of the patient's anemia. for the patient's thrombocytopenia, the patient was given approximately 20 bags of platelets throughout her icu stay. the patient continued to consume her platelets. her platelets at the time of admission were 47 but dropped down to 9 and as low as 5 throughout her icu stay. the patient did not have any overtly clinical signs of bleeding but did have petechiae that were new on her anterior thorax as well as a few area of petechiae over her abdomen. the hematology team sent off studies for antibodies to platelets which were negative. there were thoughts of giving the patient single donor platelets to improve the patient's response but the studies revealed that the patient did not have any antibodies to platelets and that multiple donor platelets would, in fact, the choice that should be preferred since the patient would possibly respond to one line. the patient was also started on high dose steroids at 2 mg/kg a day with the hope that not only would this possibly help her possible - syndrome but would hopefully help her thrombocytopenia. the patient's high dose steroids did not have any effect on the thrombocytopenia. at the time of discharge, the patient's platelets from micu were 7. it was also thought that the patient might be in dic. numerous dic screens were negative throughout her hospital stay and this was not thought to be the cause of her thrombocytopenia. as far as a nutrition standpoint, the patient was npo on admission to the intensive care unit but once she was extubated she was started on ___ and ppn. the patient could not be started on tpn throughout this hospital stay since we could not change the patient's central line over a wire to get improved venous access and since the patient could not have a picc line placed due to her thrombocytopenia. the nutritionist consulted on her case constantly and worked very closely with the hepatologists and the patient did have a nasojejunal feeding tube placed under fluoroscopy by interventional radiology and was started on on-live kosher supplements as well as _____ tube feeds at a goal rate of 80 cc/hour which was to be supplemented with 20 mg of promod and this regimen was to be supplemented by p.o. intake and the patient is quite aware of which foods she can and cannot take. the patient is to be on a low fat diet since this was thought to prevent stimulation of her chylous ascites. from a psychiatric standpoint, the patient was quite depressed about her icu stay and was quite concerned about her overall prognosis. the patient was seen and followed by a social worker numerous times and was started on zoloft for her situational depression. at the time of discharge from the icu the patient's spirits were much better since she was more mobile and was once again able to take p.o. intake. dr., 12-899 dictated by: medquist36 procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances percutaneous abdominal drainage closed biopsy of skin and subcutaneous tissue diagnoses: acute kidney failure with lesion of tubular necrosis unspecified protein-calorie malnutrition acute respiratory failure hypotension, unspecified acute pancreatitis other noninfectious disorders of lymphatic channels panniculitis, unspecified site other specified diffuse diseases of connective tissue 

Answer: The patient is high likely exposed to