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: penicillins / cefepime / aztreonam attending: chief complaint: acute leukemia major surgical or invasive procedure: none history of present illness: this is a 64f with pmh mds, and new aml now day 44 s/p two rounds of chemotherapy, complicated by neutropenic fevers and multifocal pneumonia, who is being transferred to the for hypoxia and hypotension. the patient has had ongoing neutropenia spiking daily fevers with largely negative culture data with the exception of vre uti, and multifocal pneumonia and a right sided pleural effsuion. she has been persistently tachypneic with rr 20-30 and hypoxic and had o2 sat of 94% on 4l. she was given lasix 20mg iv x1 yesterrday morning with marginal improvement, and she was incontinent of urine so output was unable to be assessed. her effusion was also tapped yesterday, , with drainage of 800cc serosanguinous fluid, found to be an exudate. her tachyopnea improved and but her hypoxia remained stable, satting 96% on 6l. overnight her respiratory status slowly worsened, satting 93% on 100% facemask, and this morning she was found to be somnolent, with respiratory rate in the 30's and hypotensive with blood pressure 89/49. abg drawn on 100% facemask was 7.44/37/44, with o2 sat 93%. she was placed on nrb with marginal increase in o2 sat to 97%. she was also bolused 500cc of ivf with increase in blood pressure to 105/70, hr 80. abg on nrb was 7.46/33/109. the patient has pmh of developmental delay, and is a poor historian, but she is not reporting pain, discomfort, or dyspnea. per report from the team, over the past week she has also developed new bilateral lower extremrity weakness, attributed to deconditioning, and sside effect of daptomycin, and urinary and fecal incontinence. the urinary incontinence was attributed to a vre and bowel incontinence attributed to new diahrrea. per report, her neurology exam has beeen unchanged and non-focal. past medical history: ** mds dx after pt found to have sideroblastic anemia ** aml dx in after she had a bm biopsy showing acute myeloid leukemia. a csf with atypical blasts suspicious for cns involvement. ** l. breast cancer (dx ) s/p 2 lumpectomies with pathology showing dcis ** htn ** glaucoma ** shingles v1 distribution social history: denies smoking, etoh current or past. previously worked in a factory bottling various chemicals such as baby shampoo, retired. married and lives at home with husband. children. family history: n/c for cancer, cad, or dm physical exam: g: nad, wn, wd heent: clear op, mmm neck: supple, no lad, no jvd, + r carotid bruit lungs: bs bl, no w/r/c cardiac: rr, nl rate. nl s1s2. no murmurs abd: soft, nt, nd. nl bs. no hsm. ext: no edema. 2+ dp pulses bl. neuro: a&ox3. eomi, perrl. preserved facial muscle strength, tongue midline. no obvious dysarthria, unable to repeat 'no ifs, ands, or buts'. preserved sensation throughout. 1-2/5 strength on r upper and lower extremities. full 5/5 l side strength. gait assessment deferred. pertinent results: labs -- labs on admission -- 10:10pm blood wbc-183.1* rbc-2.45* hgb-7.5* hct-20.5* mcv-84 mch-30.6 mchc-36.5* rdw-19.4* plt ct-74* 10:10pm blood neuts-34* bands-4 lymphs-0 monos-1* eos-0 baso-0 atyps-0 metas-2* myelos-1* promyel-2* other-56* 10:10pm blood hypochr-normal anisocy-1+ poiklo-occasional macrocy-normal microcy-1+ polychr-normal target-occasional 10:10pm blood pt-14.1* ptt-25.4 inr(pt)-1.2* 10:10pm blood fibrino-455* 12:00am blood gran ct-* 10:10pm blood cd5-done cd33-done cd41-done cd56-done cd64-done cd71-done cd117-done cd45-done hla-dr a-done kappa-done cd2-done cd7-done cd10-done cd11c-done cd13-done cd14-done cd15-done cd19-done cd20-done lambda-done 10:10pm blood glucose-82 urean-24* creat-1.1 na-140 k-3.5 cl-106 hco3-26 angap-12 10:10pm blood alt-25 ast-42* ld(ldh)-687* alkphos-67 totbili-0.7 dirbili-0.2 indbili-0.5 10:10pm blood albumin-4.0 calcium-8.4 phos-2.7 mg-2.1 uricacd-4.2 10:10pm blood %hba1c-6.3* eag-134* 10:10pm blood edta ho-hold -- blood counts -- 10:10pm blood wbc-183.1* rbc-2.45* hgb-7.5* hct-20.5* mcv-84 mch-30.6 mchc-36.5* rdw-19.4* plt ct-74* 02:24am blood wbc-113.1* rbc-2.12* hgb-6.4* hct-17.8* mcv-84 mch-30.0 mchc-35.7* rdw-18.7* plt ct-46* 05:15am blood wbc-97.2* rbc-2.32* hgb-6.7* hct-19.4* mcv-83 mch-28.8 mchc-34.5 rdw-19.0* plt ct-44* 01:12pm blood wbc-81.9* rbc-2.80* hgb-8.2* hct-23.0* mcv-82 mch-29.2 mchc-35.6* rdw-17.3* plt ct-34* 10:25pm blood wbc-66.7* rbc-2.83* hgb-8.2* hct-23.6* mcv-83 mch-28.8 mchc-34.6 rdw-17.4* plt ct-25* 05:40pm blood wbc-48.0* rbc-2.60* hgb-7.6* hct-21.7* mcv-83 mch-29.2 mchc-35.0 rdw-17.0* plt ct-72* 05:51am blood hct-23.4* 12:00am blood wbc-21.9* rbc-3.10* hgb-8.9* hct-25.7* mcv-83 mch-28.8 mchc-34.7 rdw-16.9* plt ct-41* 11:45am blood wbc-16.1* rbc-3.25* hgb-9.5* hct-27.1* mcv-83 mch-29.4 mchc-35.2* rdw-16.3* plt ct-26* 02:44pm blood wbc-6.4 rbc-2.96* hgb-8.9* hct-25.5* mcv-86 mch-29.9 mchc-34.7 rdw-16.5* plt ct-47*# 12:37pm blood wbc-4.0 rbc-2.87* hgb-8.6* hct-24.5* mcv-85 mch-30.1 mchc-35.3* rdw-15.8* plt ct-16* 12:00am blood wbc-2.7* rbc-2.58* hgb-7.7* hct-22.0* mcv-85 mch-30.0 mchc-35.1* rdw-15.8* plt ct-9* 12:46am blood wbc-1.2*# rbc-2.65* hgb-8.0* hct-22.7* mcv-86 mch-30.2 mchc-35.3* rdw-15.3 plt ct-10*# 12:00am blood wbc-0.5*# rbc-2.70* hgb-8.2* hct-23.4* mcv-87 mch-30.4 mchc-35.1* rdw-15.1 plt ct-14*# 12:00am blood wbc-0.3* rbc-2.82* hgb-8.5* hct-23.9* mcv-85 mch-30.3 mchc-35.7* rdw-14.7 plt ct-9* 12:30am blood wbc-0.2* rbc-2.80* hgb-8.5* hct-23.7* mcv-85 mch-30.5 mchc-36.0* rdw-14.7 plt ct-27* 12:37am blood wbc-0.1* rbc-2.62* hgb-8.0* hct-22.2* mcv-85 mch-30.4 mchc-36.0* rdw-14.3 plt ct-36*# 12:00am blood wbc-0.2*# rbc-2.87* hgb-8.5* hct-23.9* mcv-83 mch-29.5 mchc-35.4* rdw-14.1 plt ct-33* 12:00am blood wbc-0.2*# rbc-2.98* hgb-8.8* hct-25.5* mcv-85 mch-29.5 mchc-34.6 rdw-13.8 plt ct-33* 12:00am blood wbc-0.1* rbc-2.94* hgb-8.6* hct-24.1* mcv-82 mch-29.3 mchc-35.7* rdw-13.4 plt ct-21* microbiology -- blood cultures -- all blood cultures were negative -- urine cultures -- urine culture no growth urine culture no growth -- stool cultures -- stool c diff negative stool c diff negative stool c diff negative cmv cxs negative respiratory viral cxs negative imaging -- chest x-rays -- heart is top normal size, pulmonary vasculature is engorged, but as yet there is no pulmonary edema and any pleural effusion is minimal. a suggestion of fullness in the thoracic inlet, slight rightward tracheal deviation could be due to enlarged thyroid or adenopathy in that location. tip of the right supraclavicular central venous catheter is unchanged in position in the mid svc. a slight lateral convexity in the course of the line as it passes under the right clavicle could be due to local swelling, but may also be spurious. slight indentation in the left wall of the trachea suggests the thyroid is enlarged. heart size top normal, exaggerated by low lung volumes, reflected in mild left basal atelectasis. pleural effusion is minimal if any. upper lungs clear. no pneumothorax. -- ultrasounds -- : rue u/s: no evidence of right upper extremity dvt -- ct scans & mris -- ct head w/o contrast study date of 10:46 pm 1. basal ganglia hyperdensities likely represent calcification. 2. hyperdensities in the cerebellar hemispheres slightly asymmetric probably also calcifications. however, in the absence of prior comparison studies this high-attenuation material could represent represent hemorrhage. in the appropriate clinical context, consider either a repeat ct or mri for further characterization. 3. retention cyst versus small polyp in the right maxillary sinus. mra neck, head and brain: study date of 3:26 pm 1. severe stenosis of the supraclinoid left ica of uncertain etiology with low flow with the left a1 and m1 segments. recommend cta for further evaluation. 2. acute deep white matter infarcts in the left centrum semiovale may be secondary to a low flow state or may be watershed infarcts. 3. diffusely hypointense bone marrow signal intensity may be secondary to anemia or neoplastic infiltration. 4. diffuse dural enhancement which may be secondary to an infectious or inflammatory etiology. neoplasia cannot be excluded. 5. microangiopathic ischemic white matter disease. 6. advanced central and cortical involutional changes. biopsies -- cytogenetics -- bone marrow - cytogenetics procedure date of karyotype: 46,xx interpretation: only 10 metaphase cells were obtained and analyzed from this specimen and no cytogenetic aberrations were identified. this limited/ incomplete study may not rule out mosaicism at a level that is standard for such an analysis. mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. nuc ish(eto,cbfb,aml1)x2 fish evaluation for an aml1-eto rearrangement was performed on nuclei with the lsi aml1/eto dual color, dual fusion translocation probe ( molecular) for eto at 8q22 and aml1 at 21q22 and is interpreted as normal. no rearrangement was observed in 98/100 nuclei, which is within the normal range (up to 1% dual rearrangement and 3% technical artifact) for this probe in our laboratory. a normal finding can result from absence of an aml1-eto rearrangement, from a variant aml1-eto rearrangement, or from an insufficient number of neoplastic cells in the specimen. fish evaluation for a cbfb rearrangement was performed on nuclei with the lsi cbfb dual color, break apart probe ( molecular) at 16q22 and is interpreted as normal. no rearrangement was observed in 99/100 nuclei, which is within the range of a normal hybridization pattern (up to 1% rearrangement) established for this probe in our laboratory. a normal cbfb fish finding can result from absence of a cbfb rearrangement, from a variant cbfb rearrangement, or from an insufficient number of neoplastic cells in the specimen. this test was developed and its performance determined by the cytogenetics laboratory as required by the clia ' regulations. it has not been cleared or approved by the u.s. food and drug administration. this test is used for clinical purposes. nuc ish(d5s23,d5s721,egr1,d7z1,d7s522,d20s108)x2 fish evaluation for a 5q deletion was performed with the vysis lsi egr1/d5s23, d5s721 dual color probe ( molecular) for egr1 at 5q31 and d5s721/d5s23 at 5p15.2 and is interpreted as normal two egr1 hybridization signals were observed in 97/100 nuclei examined, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 3% of cells in normal samples can show apparent 5q deletion using this probe set. a normal egr1 fish finding can result from absence of a 5q deletion, from a 5q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. fish evaluation for a 7q deletion was performed with the vysis d7s522/cep7 dual color probe ( molecular) for d7s522 at 7q31 and cep7 (d7z1) (chromosome 7 alpha satellite dna) at 7p11.1-q11.1 and is interpreted as normal. two d7s522 hybridization signals were observed in 98/100 nuclei, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 3% of cells in normal samples can show apparent 7q deletion using this probe set. a normal d7s522 fish finding can result from the absence of a 7q deletion, from a 7q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. fish evaluation for a 20q deletion was performed with the vysis lsi d20s108 probe ( molecular) at 20q12 and is interpreted as normal. two hybridization signals were observed in 95/100 nuclei examined, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 8% of cells in normal samples can show apparent 20q deletion using this probe set. a normal 20q fish finding can result from absence of a 20q deletion, from a 20q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. this test was developed and its performance determined by the cytogenetics laboratory as required by the clia ' regulations. it has not been cleared or approved by the u.s. food and drug administration. this test is used for clinical purposes. bone marrow - cytogenetics procedure date of date and time taken: 7:00 pm date processed: requesting physician: , location: inpatient karyotype: 46,xx interpretation: only 5 metaphase cells were obtained and analyzed from this specimen and no clonal cytogenetic aberrations were identified. this limited/incomplete study may not rule out mosaicism at a level that is standard for such an analysis. ****please see the online medical record for additional results which were not copied into this summary given large number of studies performed and lack of need to transfer care in the setting of death**** brief hospital course: this is a 64 year old female with history of mds presenting with acute leukemia, hospitalized for nearly 2 months for treatment and complications of disease, ultimately resulting in death. . #. aml: diagnosed on admission with aml. admitted with wbc of 183. pheresed on admission and given hydrea and allopurinol. leukocytosis resolved shortly after admission. treated with 7+3 regimen which she tolerated without significant complications. day 14 bone marrow showed residual blasts, so pt proceeded to hdac re-induction therapy. pt tolerated hdac well, was still neutropenic (anc = 0) by day 25, thus another bm bx was performed on which showed a hypoplastic marrow. patient remained with profound neutropenia and on was started on neupogen 300mcg daily. anc remained 0-20 and when patient started to develop high grade fever (see below), the g-csf was discontinued due to concern of drug fever. although transplantation was considered, deferred indefinitely due to persistent infectious complications. severe myelosuppression remained and patient required multiple transfusions with prbcs and platelets to maintain hct > 25 and plt > 10. . #. cns involvement: mild r-sided weakness thought recent cva vs cns involvement, thus it chemo was initiated. first csf has 1 atypical cell suspicous for blast, but subsequent ones were clear. her it mtx was held during hdac since it crosses blood/brain barrier. pt's last it mtx was on . . #. neutropenic fever: patient initially developed low grade fevers (tm 100.5) on without localizing sx. treated with aztreonam, vanco, micafungin (s/p fluconazole); allergic to cefepime initially. subsequently, developed acute onset r cheek swelling. ct neck confirmed salivary glad inflammation so per id recs, antibiotic regimen was altered to vanc, flagyl, levaquin and mica. although swelling improved significantly on regimen, low grade fevers persisted so aztreonem was added to antibiotic regimen on . secondary to the development of diffuse drug rash, aztreonam was discontinued on and meropenem was started. despite broad spectrum coverage with meropenem/ metronidazole/ micafungin/ vancomycin low grade fevers persisted. picc line removed due to superficial thrombophlebitis; no dvt found, and skin has improved. beginning on , the patient started spiking higher fevers to 102- 103 with occasional relative hypotension (sbp 80s), responsive to fluids. source thought to be most likely progressive multifocal pneumonia. extensive evaluation including bronchoscopy with bal on was unrevealing. on , patient developed progressive respiratory distress with tachypnea, increased work of breathing and hypoxia requiring 100% nrb. repeat cxr showed increase of right middle and lower lung opacities, from increased pulmonary edema and worsening consolidation. a diagnostic and therapeutic thoracentesis was performed with removal of 800cc fluid, temporarily ameliorating respiratory distress, however pt continued to be tachypnic, hypoxic and short of breath when not on high flow oxygen. . #. watershed infarct: during the week of , patient was noted to have increasing lower extremity weakness. she also had new bladder and bowel incontinence on presentation to the icu, correlating with a new frontal hypodensity that was subacute in nature attributed to leukostasis. on exam, she was noted to have worsening rue weakness/paresis which later evolved to paralysis. patient also noted to have new slight right-sided facial droop and rightward tongue deviation on tongue protrusion. these findings were concerning for cns involvement of the patient??????s malignancy versus ischemia. mri shows acute ischemia in the left mca as well as the aca territory to a lesser extent. overall, the pattern appeared to have an acute on chronic nature which together with her known supraclinoid ica stenosis is suggestive of ongoing embolic phenomena known as ??????stump embolus?????? syndrome. her goal platelets was > 50 to prevent conversion into a hemorrhagic stroke. her goal sbp is between 140??????160 to prevent continued poor perfusion to watershed infarct area. . #. hypoxia: likely multifactorial, related to fluid overload as well as infection. patient on broad spectrum antibiotics, consisting of ambisome, bactrim, flagyl, meropenem, and linezolid. pt is s/p thoracentesis with removal of ~1l of fluid, consistent with exudative effusion. respiratory status improved with that treatment, with patient able to lie flat, however she continued to have high oxygen requirements. . #. diarrhea: had intermittent ongoing diarrhea during hospitalization. c diffs repeatedly negative. likely chemo related. treated with immodium and resolved. . #. nosebleeds: had recurrent nosebleeds in the setting of thrombocytopenia. all of them were either self limited or resolved with platelet transfusions. . #. htn: hypertensive at first in setting of holding her home medications. blood pressures well controlled once home medications were started. . #. discoloration and coolness of right hallux: evaluated by vascular surgery, felt likely to be an embolic event. resolved over time. . #. avnrt: with onset of high fevers and septic-like phsyiology on , patient began to have episodes of svt with heart rate as high as 150-170s. tachyarrhthymias were unresponsive to fluid and patient remained asymptomatic with stable blood pressure. etiology of tachycardia was thought to be secondary to high output/ catecholaminergic state related to malignancy and underlying pulmonary infection. patient monitored continuously on telemetry. as per cardiology recommendations, patient was started on low dose b-blocker. over following hospital course, metoprolol and diltiazem were started and titrated to maintain a target heart rate of 80s-90s without causing hypotension. on with progression of sepsis and development of hypotension responsive to fluids, bblocker and ccb were discontinued, but were later reinitiated. the diltiazem was discontinued on so as to maintain higher bp and cerebral perfusion. rate remained relatively well-controlled. . #. transaminitis: elevated transaminitis developed after patient briefly placed on daptomycin and voriconazole. although rest of lfts have trended down, alp remained elevated. ct scan w/o contrast showed no abnormalities. abdominal u/s showed benign hepatic cysts, pleural effusions. . #. goals of care: after meeting between patient??????s family and dr. , it was decided that the patient will be dnr/dni. she was transferred to the bmt service on for comfort care. on the morning of , two days after transfer from the icu, pt passed. medications on admission: atenolol 25 mg po bid lisinopril 5 mg daily atenolol eye drops xalatan eye drops discharge medications: na discharge disposition: expired discharge diagnosis: na discharge condition: deceased discharge instructions: na followup instructions: na procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified injection or infusion of thrombolytic agent thoracentesis thoracentesis biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow closed [endoscopic] biopsy of bronchus injection or infusion of cancer chemotherapeutic substance injection of other agent into spinal canal therapeutic leukopheresis other diagnostic procedures on nasal sinuses diagnoses: pneumonia, organism unspecified unspecified pleural effusion urinary tract infection, site not specified unspecified essential hypertension unspecified septicemia personal history of malignant neoplasm of breast sepsis other specified cardiac dysrhythmias infection with microorganisms without mention of resistance to multiple drugs dermatitis due to drugs and medicines taken internally streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] cerebral embolism with cerebral infarction phlebitis and thrombophlebitis of superficial veins of upper extremities other and unspecified infection due to central venous catheter urinary incontinence, unspecified epistaxis neutropenia, unspecified anemia in neoplastic disease other drugs and medicinal substances causing adverse effects in therapeutic use sialoadenitis acute myeloid leukemia, without mention of having achieved remission paralysis, unspecified fever presenting with conditions classified elsewhere stomatitis and mucositis, unspecified 

Answer: The patient is high likely exposed to