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: patient recorded as having no known allergies to drugs attending: chief complaint: transfer from osh for further management of liver, renal, and vascular surgery issues major surgical or invasive procedure: dialysis lines skin biopsies x 2 history of present illness: this is a 58 year old man with a complicated history including cad, cardiomyopathy (ef 39%), afib, dm, who presented to an osh on with leg pain and swelling. history is obtained from the patient, his family, and osh medical records. mr. had apparently injured his r leg by bumping it while getting on his tractor in and developed a wound. he was diagnosed with cellulitis and treated with keflex for 2 weeks with no improvement. the wound was later debrided three times by vascular surgery at but still did not improve. he was then admitted in late /early to with l leg necrotic areas. biopsy revealed a thrombotic embolic process and he was started on vanco and ceftaz. . he was transfused several units prbc for anemia. blood cultures then returned with gram + bacteria and he was switched to unasyn. the patient was then noted to become jaundiced with total bili 5.2 and direct bili 3.8. gi was consulted. ruq u/s revealed multiple stones. ercp showed no stones in the ducts. lfts remained elevated. hcv antibody was positive, but viral load negative. cryoglobulins were checked on a previous admission (due to concern for vasculitis) but were negative. the patient was eventually discharged home on oral antibiotics for outpatient wound care. . within one week, his leg again became enlarged and swollen and the patient was referred to the ed and admitted on with r leg cellulitis and necrotic areas of the l leg. he was started on kefzol and dvt was ruled out. cultures of the leg came back positive for mrsa. question of coumadin skin necrosis was raised, but then felt unlikely as pt had been on coumadin for 5 years. per osh notes, transfer to a tertiary care center was first considered on for plastic surgery management of le wounds. . amiodarone was discontinued due to elevated lfts. ammonia level was in the 60s and lactulose was started. of note, the patient also developed hypoglycemia, believed to be due to oral dm meds. this improved when meds were held and d5w or d10w were given. the patient then developed hyponatremia that was felt due to these hypotonic fluids. nephrology was consulted for arf and hyponatremia. they suggested increasing doses of lasix along with albumin (pt's albumin level was 1.4 at this point) and switching to d10ns. . on the patient was noted to be wheezy. pulmonary was consulted due to concern for an upper-airway lesion. ct neck showed now airway compromise. pulmonary felt that wheezing was more likely than actual upper airway stridor. pfts and ct were recommended. not clear if ct was done at that time, but cta was done on and ruled out pe. did show a r base pna. on the patient was apparently transferred to the icu for a chf exacerbation. this is not well-documented in the notes, but the family notes that the patient was increasingly sob despite increasing doses of lasix. he was eventually put on a lasix gtt. . according to the report given to the nurse, the patient has undergone hemodialysis for the last 2 days ( & ), with 4.3l taken off yesterday and 5l today (this is not mentioned in osh records). the patient reports feeling much better respiratory-wise following dialysis. most recent abg by report was 7.34/48/69 on 2l nc. apparently hepatorenal syndrome has been considered as the etiology for worsening renal failure. today (), hct noted to be 24.4, and patietn was transfused 2u prbc prior to transfer. . according to the family, the reasons for transfer to (on ) are for vascular vs. plastic surgery evaluation for his legs, renal evalation for renal failure requiring hd, and liver transplant team evaluation, although they are aware he is not a transplant candidate at this time (obese and actively infected). past medical history: paroxysmal atrial fibrillation (on coumadin as outpt) chf/cardiomyopathy ef 39% htn obesity dm2 hypercholesterolemia cirrhosis (possibly hcv vs. fatty liver) chronic renal insufficiency (cr 2.6 in ) social history: retired, lives with wife and sons. nonsmoker, drinks 2-3 vodka and tonics a few times a week. family history: nc physical exam: vs: 99.6, hr 82, bp 128/58, rr 24, o2sat 100% on 3l nc gen: anxious appearing man in nad heent: perrl, +scleral icterus, mmm, op clear neck: supple lungs: few crackles at bases, r>l heart: rrr, soft ii/vi systolic murmur at apex abd: +bs, soft, obese, nt, mildly distended. extrem: 1+ edema b/l. necrotic ulcers over both pretibial regions. areas of black eschar r>l with also some smaller open areas draining serosanguinous fluid. mild surrounding erythema. neuro: alert and oriented to self, to "hospital". cn2-12 grossly intact. moving all 4 extremities. +asterixis. pertinent results: 11:22pm blood wbc-13.0* rbc-3.10* hgb-9.4* hct-28.6* mcv-92 mch-30.3 mchc-32.8 rdw-18.1* plt ct-137* 11:22pm blood neuts-90* bands-2 lymphs-2* monos-6 eos-0 baso-0 atyps-0 metas-0 myelos-0 11:22pm blood pt-30.4* ptt-49.9* inr(pt)-3.2* 11:22pm blood glucose-197* urean-53* creat-3.4* na-135 k-4.5 cl-100 hco3-28 angap-12 11:22pm blood alt-16 ast-50* ld(ldh)-166 alkphos-116 amylase-30 totbili-7.7* 11:22pm blood albumin-2.9* calcium-8.8 phos-3.0 mg-2.5 05:57am blood caltibc-65* ferritn-360 trf-50* 05:42pm blood cryoglb-no cryoglo 06:48am blood triglyc-147 hdl-19 chol/hd-7.4 ldlcalc-93 12:42pm blood pth-68* 11:22pm blood hbsag-negative hbsab-positive hbcab-negative igm hav-negative 06:14pm blood anca-negative 08:19am blood -negative 05:13pm blood crp-43.0* 06:48am blood igg-1713* 05:13pm blood c3-85* c4-12 .... abd us (): 1. coarsened and slightly nodular echotexture of the liver without focal liver lesions. trace amount of ascites. no varices. splenomegaly. 2. gallstones and gallbladder sludge. . cxr (): 1. left subclavian central line tip at distal svc/ra junction. no pneumothorax. 2. patchy opacity at both bases, question atelectasis versus infiltrate, in the setting of low inspiratory volumes. . tte-the left atrium is moderately dilated. the estimated right atrial pressure is 0-5mmhg. there is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. the right ventricular cavity is mildly dilated. free wall motion could not be assessed. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is no valvular aortic stenosis. the increased transaortic gradient is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve leaflets are structurally normal. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. moderate tricuspid regurgitation is seen. there is severe pulmonary artery systolic hypertension. there is no pericardial effusion. ... ct lower extremities: findings: extensive vascular calcifications are present throughout the pelvis and lower extremities including several of the smaller end arterioles. subcutaneous edema is present most notably about both knees as well as both ankles. no focal fluid collections are identified, however, evaluation for this entity is limited without intravenous contrast. there are no fractures, dislocations, or bone abnormalities. small joint effusion is present at the right knee. limited images through the contents of the pelvis demonstrate rectal and foley catheters. muscle atrophy is noted with fatty infiltration of the hamstring musculature as well as medial gastrocnemius muscles. impression: 1) extensive vascular calcification throughout the pelvis and lower extremities. this is a nonspecific findings and can be seen in calciphylaxis and extensive atherosclerotic disease. 2) subcutaneous edema in both lower extremities particularly about both knees and ankles without large skin defects or fluid collections. .... bone scan: impression: 1) uptake in the femoral vessels in the thighs bilaterally may represent residual blood pool activity or vascular calcifications. if indicated,urther evaluation with a noncontrast ct scan may be performed. 2) faint uptake posteriorly near the proximal left femur may represent degenerative change or soft tissue uptake/calcification. 3) no definite abnormal uptake in the calves. pathology examination name birthdate age sex pathology # , 58 male report to: dr. gross description by: dr. /mtd specimen submitted: 4 mm punch bx - right pretibia. procedure date tissue received report date diagnosed by dr. -/cma?????? ************this report contains an addendum*********** diagnosis skin, leg, right pretibial; punch biopsy (a): preliminary findings: vascular calcification involving larger caliber cutaneous vessels (see comment). comment: initial sections show a punch biopsy spanning the full thickness of the epidermis and dermis to include the more superficial portion of the panniculus. there is epidermal atrophy, dermal fibrosis and calcification of larger caliber vessels in the deep dermis and septae of the superficial subcutaneous fat. calcification of small to medium vessels in the adipose tissue lobules is not appreciated. however, given the placement of the biopsy site and the relatively small amount of panniculus available for evaluation, calciphylaxis cannot be excluded on the basis of this biopsy. if there is continuing clinical concern for calciphylaxis, re biopsy to include more panniculus may be appropriate as clinically indicated. there is no evidence of vasculitis in the levels so far examined. additional tissue levels and special stains will be performed and the results issued in a final report. reviewed by dr. . addendum: additional levels have been examined and the findings remain unchanged. no fungal organisms are identified on pas, pas-d or gms stains and bacterial organisms are not identified in the dermis or subcutis on gram staining. the initial findings were discussed with dr. on . pathology examination name birthdate age sex pathology # , 58 male report to: dr. gross description by: dr. -, ,/mtd specimen submitted: skin bx, left leg (1). procedure date tissue received report date diagnosed by dr. -/bef?????? previous biopsies: 4 mm punch bx - right pretibia. diagnosis: skin and subcutaneous tissue, left leg; biopsy (a-c): focal calcification within walls of small subcutaneous vessels (see comment). comment. initial and multiple additional tissue levels have been examined. there is focal calcification with a concentric pattern within the walls of a few subcutaneous vessels. these are present in panniculus which underlies an area of epidermal and dermal necrosis associated with acute inflammation. in the correct clinical setting these findings are suggestive of calciphylaxis. the calcification is not well developed in this biopsy. this may reflect placement of the biopsy site or alternatively, could represent an evolving lesion. in addition, there is calcification and partial occlusion of a much larger vessel in the subcutis which shows changes consistent with atherosclerosis. part of the included epidermis and superficial dermis is necrotic and associated with underlying acute inflammation. both fungal and bacterial forms are present on the surface of the necrotic epidermis, seen on gms and pas-d and gram stains, respectively. fungi also extend into the most superficial dermis. the findings are consistent with superficial colonization of the necrotic tissue. no stainable fungi or bacteria are identified within the acutely inflamed deeper dermis. clinical correlation is recommended. the preliminary findings were reviewed with dr. on . the final results were phoned to dr. by dr. on at approximately 1730 hrs. sections have been reviewed by dr. and dr. . ct abdomen w/o contrast 5:49 pm ct chest w/o contrast; ct abdomen w/o contrast reason: ct torso without contrast to evaluate for calcification of v medical condition: 58 year old man with ?calciphylaxis reason for this examination: ct torso without contrast to evaluate for calcification of vessels to kidneys/liver contraindications for iv contrast: renal failure indication: 58-year-old male with calciphylaxis. evaluate for calcification of vessels. comparison: none. technique: non-contrast multidetector ct acquired axial images of the chest, abdomen and pelvis from the thoracic inlet to the pubic symphysis. coronal and sagittal reformatted images were obtained. ct of the chest noncontrast: there is a small right pleural effusion and adjacent compressive atelectasis. consolidation is seen within the left lower lobe. the heart and great vessels are unremarkable. there is no pericardial effusion. note is made of soft tissue superior to the vocal cords on a single image, which is incompletely assessed and recommend correlation with clinical findings. no pathologically enlarged axillary or mediastinal nodes are apparent. ct of the abdomen without intravenous contrast: liver shows no focal lesions. a mildly distended gallbladder containing numerous gallstones is seen. there is no pericholecystic fluid or gallbladder wall edema to suggest cholecystitis. the adrenal glands, spleen, stomach, pancreas, intra-abdominal loops of large and small bowel are within normal limits. multiple low density lesions are seen within bilateral kidneys, too small to characterize but likely to represent cysts. residual contrast is seen within the kidneys and collecting system. there is no hydronephrosis or hydroureter. no intraabdominal free fluid or free air is detected. no enlarged retroperitoneal or mesenteric lymph nodes are evident. vascular calcifications are noted within the abdominal aorta, iliac arteries, celiac artery and branches. small foci of high attenuation is seen throughout the subcutaneous tissue of the abdomen, likely representing injection sites. note is made of a left subclavian central venous catheter with tip at the atriocaval junction. ct of the pelvis without intravenous contrast: the rectum and sigmoid colon are unremarkable. the bladder is decompressed. intrapelvic loops of small bowel are unremarkable. free fluid is seen within the pelvis. no pathologically enlarged pelvic or inguinal lymph nodes are appreciated. bony windows: no suspicious lytic or sclerotic lesion is identified. multilevel degenerative changes are seen throughout the thoracolumbar spine. impression: 1. small right pleural effusion and adjacent compressive atelectasis. consolidation in the left lung base, concernig for infectious etiology. 2. cholelithiasis without evidence of cholecystitis. 3. multiple hypodensities within bilateral kidneys, too small to charaterize, but most likely representing cysts. 4. soft tissue seen above the vocal cords on a single slice, incompletely assessed for which correlation with clinical findings is recommended. 5. vascular calcifications within the aorta, iliac artery, celiac artery and branches.these findings are reviewed in light of the patients diagnosis of calciphylaxis.i have reviewed the literature for information on the distribution of calcium deposits in calciphylaxis. on the current ct images, we cannot reliably differentiate mural and medial calcification, but the distribution in this case is unusual, as there is almost complate sparing of the aorta and sma with severe involvement elsewhere.in addition, there appears to be little "soft plaque" or non-calcified plaque suggesting that this is predominantly a non-atherosclerotic process.if i find any further information in the literature i will issue an addendum brief hospital course: a/p: this is a 58 year old man with chf, afib, possible hcv, le cellulitis who is transferred from an osh for further management of le cellulitis and ulcers, acute on chronic renal failure, and cirrhosis. . # le cellulitis/ulcers: vasculitis vs. dm ulcer. +mrsa at osh. biopsy done at osh apparently showed vessel thrombosis. coumadin skin necrosis was considered a possibility, but unlikely since pt has been on coumadin several years. cryoglobulins negative (in setting of positive hcv ab). dvt ruled out at osh. further evaluation by consulting services felt that the appearance and history was consistent with calciphylaxis. and in review of the records, it appears that the patient had several days of elevated corrected calcium at the outside hospital preceeding his renal failure which could have contributed to his current condition. in this thought, the patient was continued on vancomycin (dosed by level after dialysis) for prophylaxis of the previously know mrsa colinization. since it is also sensitive to bactrim, patient could be continued on this as outpatient prophylaxis. initial biopsy was done on which was indeterminate, but a second biopsy eventually showed calciphylaxis. he was started on sodium thiosulfate treatment on days of dialysis. . # hepatic dysfxn: thought by hepatology to be secondary to decompensated nash though alcoholic hepatitis cannot be ruled out. patient's synthetic continued to worsen. patient carries diagnosis of cirrhosis, etiology not clear, and never had liver bx or u/s findings c/w cirrhosis. ultrasound showed fatty infiltration of liver. lfts have been mildly elevated, bili more so (now 7.7). albumin is low at 2.9, inr elevated. hepatitis serolgies were performed and negative. additionally patient did not have lab support of autoimmune hepatitis. patient was maintianed on vitamin k, lactulose with some improvement. as well patient received octreotide, midodrine and albumin for treatment of possible hepatorenal syndrome. . # acute on chronic renal failure: recent baseline creatinine 2.0-2.6 in . 3.4 on admission (post-hd) and now 4.8. s/p hd at osh. hepatorenal syndrome has been raised as a possible etiology, however, no definite evidence at this time. more likely prerenal w/ atn also possible, particularly in the setting of aggressive lasix diuresis. also had cta at osh w/ dye load; however, unclear if prior to or after hd initiated. patient received 2u prbc prior to transfer, which should help with hydration. abd u/s at osh showed no obstructive uropathy. patient continued on dialysis. . # pneumonia: patient had sob and was in icu at osh for most likely chf exacerbation. r base consolidation noted on cta at osh (wet read). pnemumonia was empirically treated with levo and flagyl and improved after >10 day course. . # chf: was in icu at osh for apparent chf exacerbation. improved s/p hd. renal following, but no acute indication for hd currently. currently stable. holding lasix for now. . # afib: h/o paf. previously on coumadin, but now on hold due to question of coumadin skin necrosis as well as liver failure and auto-anticoagulation. currently in sr. continue bb (at decreased dose). holding amiodarone due to abnormal lfts. . pt. continued to have worsening liver failure and on was hypotensive at dialysis so dialysis had to be stopped. the next day he became more and more tachypneic with e/o metabolic acidosis. he had abg of 7.19*/ 45/42, thought to be anion gap metabolic acidosis from sodium thiosulfate in addition to resiratory acidosis tiring. he was initially transferred to icu, but soon thereafter, family meeting was convened and decision was made to transition to comfort measures only. pt. had all meds d/c'd other than morphine drip and scopolamine. he passed away peacefully that evening of respiratory failure with the proximal cuase being liver and renal failure medications on admission: amiodarone 200 daily amaryl 2mg daily percocet prn lopressor 100mg lasix 40 discharge medications: none discharge disposition: extended care discharge diagnosis: liver failure renal failure . diabetes calciphylaxis discharge condition: deceased discharge instructions: none followup instructions: none procedure: hemodialysis closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue diagnoses: other primary cardiomyopathies pure hypercholesterolemia congestive heart failure, unspecified cirrhosis of liver without mention of alcohol diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver acute kidney failure, unspecified hepatorenal syndrome hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation chronic kidney disease, unspecified cellulitis and abscess of leg, except foot morbid obesity hepatic encephalopathy other disorders of calcium metabolism ulcer of calf 

Answer: The patient is high likely exposed to