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: bactrim attending: chief complaint: altered mental status and diarrhea major surgical or invasive procedure: central line placement lumbar puncture history of present illness: this is a 57-year-old gentleman with cll and large cell transformation, s/p antigen mismatched urd sct on (now day +164), recently discharged from to rehab on and now re-admitted to 7 from clinic for diarrhea, waxing/ mental status, and electrolyte abnormalities. as per physician at , patient had been having voluminous diarrhea, and was overall "not doing well." . mr. was last admitted on (tax day, as he likes to remind everyone) and went for antigen mismatched urd sct after busulfan/ cytoxan conditioning regimen. although he tolerated the transplant well, mr. subsequent 5 hospital course was complicated by gvhd of liver and gi tract, continous slow gib, hematuria with bk viruria, adenoviremia, altered mental status, and extreme deconditioning. all of his acute issues had resolved by the time of discharge, and mr. was transferred to for continued rehabilitation. . in clinic pt appeared comfortable although depressed. his vitals were stable. labs are at baseline except for lytes which will be repleted. on arrival to the floor pt appears tired but otherwise has no distress. past medical history: past medical history: hypertension hypercholesterolemia (diet controlled) s/p tonsillectomy cll (see below) . past oncologic history (per clinic note): pt presented with his disease back in with an elevated white count and ldh. he was without any splenomegaly or any cytopenias at that time. he did have some bulky lymphadenopathy. over the course of six months, his white count began to rise and essentially doubled to approximately 130,000 with a rising in his ldh of up to 1400, and he also was noted to have worsening palpable lymphadenopathy. he then completed four cycles of fcr therapy, which he completed back in 09/. he had an excellent response to therapy and was monitored off treatment for approximately two years. he then presented in with a rising white count, approximately 50% lymphocytes, and a mildly elevated ldh. he also had some mild worsening palpable lymphadenopathy. he then received four cycles of pcr, but did not have much in the way of response and his treatment regimen was switched to r-cvp of which he received two cycles. he did again not have a significant response, though continued to have an excellent performance status, and he was ultimately switched to campath therapy. he did have resolution of his lymphocytosis, and his white count has come down nicely, but did not have much in the way of response in terms of reducing his bulky lymphadenopathy. he had received chemotherapy initially through 06/. we had decided to observe him off treatment, and ultimately, we had decided to move forward with an allogeneic stem cell transplant; however, back at the end of the summer, his donor had backed out. he also had return of his disease, and we reinitiated campath regimen. this, however, ultimately was cut short on due to question of an infection versus pe for which he was ruled out. he has been followed closely by id and has been treated on augmentin since that time through therapy. he then was restarted back on campath and completed six weeks of treatment dose as previously his cycles have been interrupted. he again had normalization of his white count and also no longer had any lymphocytosis. however, he again did not have much in the way of significant response to his lymphadenopathy. he then eventually had developed an enlarging left cervical node which was biopsied and was found to have transformation. he was admitted on for . this was overall well tolerated. he completed his first course of eshap on , and tolerated this well. . four cycles of fcr (fludarabine, cytoxan, rituxan) completed on , four cycles of pcr (pentostatin, cytoxan, rituxan) completed on , two cycles of r-cvp completed on , campath treatment subcutaneously initiated on and stopped on , reinitiated on and stopped on , restarted on and completed approximately six weeks of therapy which he completed on . reinitiated therapy due to transformation with treatment (continuous infusion of etoposide, adriamycin, and vincristine on days , oral prednisone on days , and cytoxan on day 5) in 02/. d/t inadequate disease response from regimen was switched to eshap (bolus of etoposide on days , cisplatin continuous infusion on days , methylprednisolone iv on days , cytarabine 2g/m2 iv over 2 hours on day 5 only). patient underwent allo sct on from mud (, mismatch at one hla-a allele). the patient underwent a busulfan/cytoxan conditioning regimen which did not cause neutropenia and he tolerated it with only mild diarrhea. his initial transplant proceeded without incident. his post-transplant course was complicated by severe gvhd, febrile neutropenia, and viremia. social history: has been married for 30 years. he works as a software engineer. he does not smoke and drinks occasional alcohol he has one daughter who is 20-years-old. family history: notable for father who died of prostate cancer, with question of lung involvement at the end. his mother had a history of ms and one of his brothers is obese. an uncle with pancreatic cancer and an aunt with breast cancer. physical exam: physical exam: 98.4, 138/90, 92/min, 20/min, general: appears comfortable at rest, no apparent distress neck: supple, no jvd cardiac: rrr, frequent pvc, no murmurs, rubs, or gallops reduced air entry bilaterally abdomen: distended, but soft, no rebound/guarding/regidity extremities: 1+ edema bilaterally exam: gen: intubated, sedated ill-appearing edematous gentleman, not responsive to voice commands or painful stimuli. heent: marked chemiosis bilaterall and extensive bilateral scleral icterus, pupils equal and reactive to light cv: regular rate, no murmurs appreciated lungs: coarse, ventilated breath sounds b/l, poor air mvmnt in bases abd: markedly distended, hypoactive bowel sounds, soft ext: 4+ pitting edema b/l ue and le up to sacrum, c/w anasarca gu: extensive scrotal edema, foley in place w/ hematuria draining skin: multiple areas of skin breakdown, skin oozing clear serous fluid in upper extremities, multiple scattered ulcerations pertinent results: 03:15pm glucose-206* urea n-19 creat-0.5 sodium-134 potassium-3.2* chloride-103 total co2-20* anion gap-14 03:15pm alt(sgpt)-139* ast(sgot)-62* ld(ldh)-487* alk phos-511* tot bili-6.6* dir bili-4.9* indir bil-1.7 03:15pm albumin-2.5* calcium-8.7 phosphate-1.8* magnesium-1.9 03:15pm tsh-0.15* 03:15pm t4-4.2* t3-35* free t4-1.2 03:15pm wbc-6.3 rbc-2.56* hgb-8.8* hct-25.4* mcv-99* mch-34.2* mchc-34.6 rdw-26.1* 03:15pm neuts-87* bands-5 lymphs-1* monos-4 eos-0 basos-0 atyps-0 metas-1* myelos-2* mri : unchanged mildly compressive bilateral subdural collections which appears simple based on signal characteristics. no acute infarct or abnormal intracranial enhancement brief hospital course: mr. is a 57-year-old gentleman with cll and large cell transformation () s/p murd sct on , recently discharged from to rehab, now readmitted for increased diarrhea, abdominal pain, and waxing/ mental status. he was admitted to the intensive care unit following pea arrest. altered mental status: altered mental status was thought to be of infectious etiology, though the csf was negative for bk virus, virus, cmv, hsv, herpes 6, and toxoplasma. adenovirus was detected in the blood, less than 50,000 copies, and bk virus was highly positive in the blood. due to deterioration in mental status and persistent altered state, the patient was started on empiric cidofovir therapy at 5mg/kg iv weekly with oral probenecid for renal protection, per id recommendations, for possible bk encephalitis pending the csf results. an ng tube was placed in the icu for probenecid administration. his acyclovir was discontinued since cidofovir was reinstituted. patient was also started on thiamine and folate. he received 2 doses of cidofovir on the and . neurology was consulted for altered mental status and once patient was released from icu he underwent 24-hour video monitored eeg. eeg was negative for seizure activity. despite treatment with cidofovir, mental status continued to wax and wane. after which infectious disease recommended not to continue therapy for bk viremia. patient had periods of extreme agitation during which time he would thrash around in bed and strike his head against the side-rails. he would moan and cry out--however when asked if he was in pain, mr. would always shake his head "no." during this time, patient required extensive sedation with anti-psychotics, benzodiazepines, and pain medication. he was also restrained in bed. by the time of transfer to the icu on , mr. had become almost unresponsive. on , he sustained pea arrest and was intubated, then sent to the (see course below). bilateral subdural hematomas: a ct head from showed small bilateral hematomas. most likely from trauma due to thrashing around in bed with low platelets. a repeat head ct on showed no interval change in the hematomas. neurosurgery recommended no intervention at this time. . bk viremia: mr. continued to have persistent bk viremia. despite two treatments with cidofovir, bk viral load increased to 200,000. we began lowering immunosuppression, in hopes that mr. could fight off the virus. another bk viral load is pending. . #hypothermia-thought to be secondary to infection. patient has displayed this physiology with prior viral infectious. possibly secondary to an endocrine source, but patient is on steroids and a cortisol stimulation test would be inaccurate. thyroid studies were consistent with a sick euthyroid picture. he was treated on broad spectrum antibiotics in case this was a bacterial sepsis picture. he was given warming blankets to maintain appropriate temperatures. the patient was readmitted to the icu from for hypothermia, confirmed to 92.8 degrees farenheit by rectal temperature. he was warmed with a bair-hugger. cll s/p ricther's transformation with allo sct in : disease in remission. immunosuppression continued, bmt team closely following. gi bleeding: patient with long-standing heme positive stool, however, gi bleeding increased in early . his hematocrit remained stable during these bleeding episodes. he underwent flex sigmoidoscopy, which indicated bleeding from above the level of the transverse colon. no other pathology was found at the time. gi bleeding abated on its own. . #elevated lfts/tbili: related to gvhd, medications, and chronic viral infection. . #anemia/thrombocytopenia: secondary to immunosuppresion/infection/gvhd. patient's hematocrit remained in the low 20s throughout admission, and he was transfused on a "as needed" basis. we tried to keep his platelets above 30-40 in light of gi bleeding and subdural hematomas. . #decreased urine output: during first icu course, patient had mild decrease in urine output. he appeared intravascularly depleted and was give fluid boluses throughout the day and night. his urine output increased appropriately. #htn: metoprolol was continued throughout admission. . course (): patient transferred to the icu for hypothermia, with an axillary temperature approx. 89of on the floor, he had previously been hypothermic with prior infections. he was transferred to the icu for rectal temperature monitoring and rewarming. overnight he was placed on a bair hugger and his temperature increased to the 96 range rectally. the rectal temperature probe was discontinued when he was found to be newly neutropenic. after his initial warming his temperature remained around 96 on the bair hugger and he was deemed medically stable for transfer back to the floor. during his icu stay he continued to have worsening mental status, he was oriented to place, but extremely agitated. course ( ): early morning , the patient was found to have cheynne respirations and quickly lost a pulse. epinephrine was given once per acls protocol, and compressions were initiated on the floor. once the patient was identified as dnr, but intubation and pressors okay, the compressions were stopped. the patient returned to afib in the 150s with pulse. he was intubated and transfered to the . finger bs was in the 130s. he was briefly started on norepinephrine for blood pressure support. in the icu, the patient was started on phenylephrine and vasopressin and titrated off the norepinephrine due to atrial fibrillation. he was started on an amiodarone drip, and he quickly converted back to sinus rhythm. pan-ct showed new consolidation seen at the right and left upper lobes near the apices, consistent with pneumonia, bilateral small pleural effusions, left greater than right, with right being new, small-to-moderate amount of free fluid within the abdomen and diffuse anasarca. he was intubated for inability to protect his airway and started on broad spectrum antibiotics for coverage of pneumonia. throughout the remainder of his course, his waxing and mental status became a significant barrier to extubation. the underlying etiology of his altered mental status was unknown, as multiple blood and urine cultures exihibited no microbial growth. head cts repeated on and showed no interval change in his subdural hematomas and no new intracranial hemorrhage. his mental status was inconsistent and extubation was considered given his good fio2 but concerns were his inability to protect his airway. he was able to be extubated since he seemed to have some improvement in mental status, with some alertness and responsiveness to voice commands. his wife had noted that over a period of a few hours he was able to say "yes" and "no." unforunately, on he developed progressive bradycardia, followed by pea arrest and was re-intubated by anesthesia, who suctioned a mucus plus. after the 1st mg of epinephrine, he regained his pulse. the arrest was thought to be due to mucous plugging, although he had normal o2 sat prior to arrest. he had a few episodes of bradycardia throughout the night and received atropine. his neurologic function continued to deteriorate without an obvious cause during his course. he suffered from hematuria and melena and was seen by urology and gastroenterology respectively. a full infectious work-up for mental status change revealed no acute pathology so mri was performed. mri done on did not reveal any additional abnormalities. neurology was consulted, repeat eeg was done on but this showed low voltage background consisting of diffuse slow polymorphic delta activity. there were no focal lateralizing lesions or epileptiform features noted that would be consistent with seizure like activity. neurosurgery was consulted regarding subdural hematomas and whether there was utility in draining them by burr hole; however, the risks of the procedure given mr. underlying comorbidities were far too great. due to his deteriorating clinical course and grim prognosis, several family meetings were held and he was made comfort measures only on . a morphine drip was started and patient was maintained on propofol for sedation and comfort. he was extubated and passed in the presence of his family members, including devoted wife and daughter on at 14:33. medications on admission: 1. nystatin 100,000 unit/ml suspension sig: ten (10) ml po qid (4 times a day). 2. saliva substitution combo no.2 solution sig: one (1) ml mucous membrane qid (4 times a day). 3. oral wound care products gel in packet sig: one (1) ml mucous membrane qid (4 times a day) as needed for mouth pain. 4. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed for itching. 5. white petrolatum-mineral oil cream sig: one (1) appl topical qid (4 times a day) as needed for gvhd. 6. atovaquone 750 mg/5 ml suspension sig: one (1) po daily (daily). 7. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed): please see attached sliding scale. 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheeze. 9. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). 10. ergocalciferol (vitamin d2) 50,000 unit capsule sig: one (1) capsule po qsun (). 11. acetaminophen 325 mg tablet sig: two (2) tablet po asdir (as directed). 12. diphenhydramine hcl 25 mg capsule sig: one (1) capsule po asdir (as directed). 13. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). 14. acyclovir 200 mg capsule sig: two (2) capsule po bid (2 times a day). 15. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 16. budesonide 3 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po tid (3 times a day). 17. mycophenolate mofetil 500 mg tablet sig: 1.5 tablets po q 8h (every 8 hours). 18. potassium & sodium phosphates 280-160-250 mg powder in packet sig: one (1) powder in packet po once (once) for 1 doses. 19. micafungin 100 mg recon soln sig: one (1) recon soln intravenous daily (daily). 20. rituximab 10 mg/ml concentrate sig: seven hundred-fifteen (715) mg intravenous give dose #4 (last dose) on for 1 doses: please give 715mg on . 21. methylprednisolone sodium succ 40 mg/ml recon soln sig: twenty five (25) mg injection qam : please give 25mg of methylprednisolone sodium succ every morning. 22. methylprednisolone sodium succ 40 mg/ml recon soln sig: twenty (20) mg injection q pm: please give 20mg of methylprednisolone sodium succ every night. discharge disposition: expired discharge diagnosis: expired discharge condition: expired md procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances insertion of endotracheal tube insertion of endotracheal tube fiber-optic bronchoscopy arterial catheterization closed [endoscopic] biopsy of large intestine cardiopulmonary resuscitation, not otherwise specified injection or infusion of oxazolidinone class of antibiotics diagnoses: acidosis thrombocytopenia, unspecified anemia of other chronic disease unspecified pleural effusion unspecified septicemia severe sepsis atrial fibrillation paroxysmal ventricular tachycardia other malignant lymphomas, unspecified site, extranodal and solid organ sites acute respiratory failure pneumonitis due to inhalation of food or vomitus cardiac arrest cardiogenic shock unspecified accident other ascites other encephalopathy diarrhea gross hematuria hemorrhage of gastrointestinal tract, unspecified surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation neutropenia, unspecified toxoplasmosis, unspecified chronic lymphoid leukemia, in remission foreign body in respiratory tree, unspecified other specified non-arthropod-borne viral diseases of central nervous system hypoglycemia, unspecified euthyroid sick syndrome hypothermia not associated with low environmental temperature chronic graft-versus-host disease viremia, unspecified 

Answer: The patient is high likely exposed to