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: suspected hus- transfer from osh major surgical or invasive procedure: 1. temporary quinton catheter placement 2. picc placement x 2 3. tunnelled quinton catheter placement 4. intubation and bronchoscopy 5. tranesophageal echocardiogram 6. renal biopsy history of present illness: 49 yo m with a history of esrd, secondary to kidney transplant failure who was transferred from hospital for suspected ttp-hus. the patient reports that he has had six months of increasing shortness of breath, fatigue and intermittent blood-tinged productive cough. the shortness of breath has become acutely worse over the last few days and he has had symptoms of orthopnea. . the patient presented to the osh and was noted to have bilateral pleural effusions on chest ct, hct 20.5, k 7.8 cr 4.2 and glucose > 400. he received several boluses of insulin and was placed on an insulin gtt. he was also given an amp of d50, calcium chloride, and kayexalate with subsequent decrease in k to 5.9. he receieved 2 units of prbcs which bumped his hct to 24.7. he was placed on 4l nc for decreased o2 sat. hematology was consulted and felt that he needed plasmapheresis for hemolytic uremic syndrome. he was transferred to for further management. . ros: unable to obtain complete review, but denied cp or fevers past medical history: 1. l cadavaric kidney transplant () for renal failure presumed chronic glomerulonephritis 2. esrd, baseline cr 1.5 in 3. dm 4. restrictive lung disease 5. htn 6. interstitial pulmonary fibrosis 7. s/p l av fistula 8. hypercholesterolemia 9. gout social history: lives by himself, divorced; no etoh or tobacco family history: diabetes mellitus physical exam: vs: 97.1 84 160/77 26 97% on 6l nc gen: tachypnic, using accessory muscles to breath heent: perrl, mm slightly dry cor: irregularly irregular lungs: b/l crackles, wheezes abd: +bs, s/distended/no ttp ext: trace pitting edema, wwp, 2+ pulses throughout neuro: alert, somnolent, responds to questions slowly, eomi but sluggish, 4/5 strength in ue b/l skin: 1.5 cm healing linear incision on l forehead pertinent results: osh records: chest ct: chf, rll infiltrate bnp 896, rheumatoid factor 17 (0-13) pfts: fvc moderately reduce, fev1 mildly to moderately reduced/ fev1/fvc = normal, tlc moderately reduced. diffusion severely reduced. moderate restrictive disease w/ severe reduction in diffusion capacity. echo: ef 60-65%, mild concentric lvh, oderate biatrial enlargement; mildr tricuspid and trace pulmonic regurgitation. . renal transplant u/s: no hydronephrosis. normal vascularity throughout the transplanted renal parenchyma. . bronchial washings : negative for malignant cells. reactive bronchial epithelial cells, pulmonary macrophages, lymphocytes and neutrophils. . ct chest: 1. bilateral pleural effusions with atelectasis involving large portions of both lower lobes. the possibility of superimposed consolidation (reflecting pneumonia or aspiration) is difficult to exclude. 2. ascites and subcutaneous edema, consistent with diffuse third spacing of fluid. 3. small amount of hyperdense material within the gallbladder, which may represent stones or sludge. 4. tubes and lines positioned as described. 5. three rounded soft tissue density structures between posterior ribs near the spine as described, which may represent lymph nodes. tte: the left atrium is dilated. there is mild symmetric 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 are moderately thickened. there is mild to moderate aortic valve stenosis. trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is a trivialpericardial effusion. . bone marrow biopsy: peripheral blood granulocytic dysplasia, along with dysplasia of erythroid and megakaryocytic lineages in the bone marrow aspirate raises the possibility of myelodysplastic syndrome. blasts (peripheral blood and marrow) were enumerated at <1%. ringed sideroblasts were not identified. in the absence of myelotoxic or myelo-stimulatory therapy, the findings are suspicious for refractory cytopenia with multi-lineage dysplasia (rcmd) in the who classification. however, we note that the patient is critically ill, has end stage renal disease and is under several medications. clinical, pharmaco-therapeutic list and cytogenetic correlation is recommended. we further recommend a repeat biopsy for confirmation and evaluation for definitive diagnosis. . bronchial washings : negative for malignant cells. reactive pulmonary macrophages and scattered yeast forms some of which appear to be within cells. . r ue u/s: no evidence of deep vein thrombosis. . tee : 1 the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. 2. left ventricular wall thicknesses are normal. 3.the ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 4.the aortic valve leaflets are moderately thickened. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. 5.the mitral valve leaflets are mildly thickened. no mass or vegetation is seen on the mitral valve. physiologic mitral regurgitation is seen (within normal limits). 6.there is no pericardial effusion. . ct torso: 1. no evidence of retroperitoneal hemorrhage. 2. again seen are moderate sized bilateral pleural effusions with associated atelectasis. there is also some ascites. . renal u/s: no interval change in the appearance of the transplanted kidney in the left lower quadrant. no hydronephrosis. normal vascularity of the transplanted kidney. . transplant biopsy: 1. chronic allograft nephropathy. 2. diabetic nephropathy. 3. changes consistent with "acute tubular necrosis", see note. . repeat tee : the left atrium is normal in size. no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. the left atrial appendage emptying velocity is depressed (<0.2m/s). no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness abnd cavity size are normal. right ventricular chamber size and free wall motion are normal. there is a focal simple atheroma in the descending thoracic aorta. the aortic valve leaflets are moderately thickened. mild-moderate aortic stenosis is suggested (not quantified). trace aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild (1+) mitral regurgitation is seen. there is a trivial/physiologic pericardial effusion. brief hospital course: 49 yo m w/ esrd s/p kidney transplant on chronic immunosuppressive therapy, presenting with ams, thrombocytopenia, arf, hemolytic anemia and pancytopenia, and respiratory failure with bilateral pulmonary infiltrates, with mds on bm bx and persistent fevers of unknown origin, now on hd. . # hypoxic respiratory failure/pulmonary edema: likely secondary to volume overload in setting of esrd +/- possible ventilator associated pneumonia. ef by tte was normal at 60% so chf unlikely contributor. cultures revealed no growth and he completed a 7 day course of zosyn/vancomycin for possible ventilator associated pneumonia. he had some difficulty weaning off of peep believed to be secondary to volume overload in the setting of renal failure and his hd was increased to qd. following increased hd, he was able to be switched to pressure support on the ventilator and sedation was weaned. he was extubated on . however, he failed extubation after 2 hours with tachypnea and low tidal volumes and was reintubated. he underwent trach and peg without complication. he was slowly able to be weaned off the vent with gradual return of respiratory muscle strength. prior to discharge he had no mechanical ventilation requirements and was maintained on trach mask alone. . # fever: patient had been spiking fevers as high as 102 in the icu. he had a thorough work up for infection with all culture and serology negative except for a weakly positive igm for ehrlichia at igm ab + 1:80 titer. further studies were sent and he was started on doxycycline for presumed ehrlichia infection. urine, blood, stool, respiratory cultures remained negative except for some yeast which grew from bal and sputum cultures. because of persistent fevers his temporary dialysis catheter as well as his picc were pulled and tip cultures were negative. cmv serologies and viral load were drawn initially and were negative. they were then resent because of persistent fevers and were again negative. bk virus, cryptococcal ag, and babesia pcr were also drawn. bk virus was strongly positive in the urine but was negative in the serum suggesting renal transplant colonization. cryptococcus and babesia were negative. lp was negative for infection. tee was negative for valve vegetation. he completed a 7 day course of vancomycin/zosyn for possible ventilator associated pneumonia. following discontinuation of broad spectrum antibiotics, he remained afebrile on only doxycycline for presumed ehrlichia infection. he completed a 14 day course of doxycycline and then again spiked a fever with associated hypotension. he was restarted on vancomycin and zosyn as well as stress dose steroids with concern for sepsis. his hypotension responded to fluid boluses. blood cultures grew coag negative staph in blood culture bottles and his zosyn was d/c'ed. his fevers rapidly recovered as did his mental status. he completed a 7 day course of vancomycin and was then off all antibiotics. his steroids were tapered to baseline required for immunosuppresion for his renal transplant. a renal biopsy did not suggest transplant rejection as a cause of fevers. he also received a ct abdomen to evaluate for intrabdominal abscess, lymphoma, or other malignancy which was negative. there was no clear cause of his intermittent fevers throughout admission. however, at the time of discharge, patient had been afebrile off of all antibiotics. . # pancytopenia: there was evidence of hemolytic anemia based on admission hct, haptoglobin, and peripheral smear. however, per heme/onc and transfusion medicine, there were only few schistocytes on peripheral smear and was not believed to be consistent with ttp-hus. a direct coombs was negative. there was initially some concern that anemia could have been due to cyclosporin and it was stopped. however, bone marrow biopsy was obtained and was suggestive of mds and cyclosporin was restarted. he received a total of 6 units prbcs over the course of admission as well as 5 units of platelets. following cyclosporin restart, cell lines remained stable. he required no further transfusions after . parvovirus dna and ehrlichia serologies were drawn as above to work up possible contribution and ehrlichia was only weakly positive. however, he still completed a full course of doxycycline. his counts all rebounded to normal values at the time of discharge. hematology oncology recommended outpatient follow up to determine whether he required any further evaluation or treatment for possible mds. . # acute on cri - s/p renal transplant. patient has been on chronic immunosuppressive therapy. outside transplant physician had been increasing doses of cyclosporin over past several months. cyclosporine level was 89 on admission but concern for contribution to pancytopenia and was stopped as above. cyclosporin held briefly given concern that it was causing/contributing to pancytopenia, but restarted once bone marrow bx suggestive of mds. levels were followed and have remained low since restart with goal level ~75. however, levels never reached goal. he received a biopsy of his transplant kidney which showed no evidence of acute rejection. it was thought that his acute renal failure was most likely secondary to atn. due to this, his cyclosporin was stopped given risk for renal vasoconstriction. immunosuppression was maintained with prednisone and cellcept. he was initially managed with triweekly dialysis which was increased to daily dialysis to help improve respiratory status. his urine output eventually began to improve and his dialysis was again decreased to ~ 3 times a week as needed. he was initially dialyzed through his fistula. however, this clotted off and could not be opened by interventional radiology. therefore, prior to discharge, he received a tunneled quinton line for further dialysis after discharge while his atn continued to resolve. he should have 24 hour urine studies checked intermittently to determine need for further dialysis. . # hypertension - patient had been resistant to multiple medications as outpatient previously. prior to initiation of daily dialysis, patient was also extremely hypertensive on the floor. possibly secondary to steroids, although required high dose of beta blocker as outpatient. he was initially managed with diltiazem, nifedipine, labetolol, and hydralazine. blood pressures improved with initiation of daily dialysis and he blood pressure medications were cut back. following a hypotensive episode as described above, his bp medications were stopped. eventually he was restarted on labetolol with hydralazine as needed with good blood pressure control. diltiazem was also added for atrial fibrillation as described below. . # atrial fibrillation - he was initially found to be in atrial fibrillation on admission believed to be most likely secondary to adrenergic surge in the setting of sepsis. however, he quickly returned to nsr. however, towards the end of his admission, he once again converted to afib with rvr which required a diltiazem drip for adequate rate control. he was eventually transitioned to po diltiazem in addition to his labetolol with good heart rate control. he did not convert spontaneously and was started on a heparin drip for anticoagulation. he then had a repeat tee which verified that he had no clots in his atria. ep then recommended chemical cardioversion as they felt he would be high risk of reverting to afib in the setting of acute illness. he was therefore loaded with 6 grams of amiodarone at a dose of 400 mg po bid. following this loading dose he was decreased to 200 mg po bid which was set to be continued for 1 months time. his hrs were monitored with the start of amiodarone to determine the need for diltiazem weaning as the amiodarone took effect. he was also started on coumadin for transition off of heparin drip. . # diabetes. - patient was started on hydrocortisone for immunosuppression and had significant elevation in his blood sugars. also believed to be some contribution of possible infection. he required high doses of insulin sliding scale and was started on lantus which was uptitrated as high as 34 units qd. however, following resolution of his fevers, he had some episodes of hypoglycemia and his insulin was cut back. with return of his fevers and initiation of stress dose steroids in the setting of hypotension, his blood sugars once again elevated rapidly and he was started on an insulin drip. the drip was continued until his steroids were weaned back down to his maintenance dose for immunosuppression for his renal transplant. he was then converted to a subq regimen. . # diarrhea: patient had a significant amount of diarrhea throughout his icu stay. stool studies were all negative including cultures and c diff toxin a and b were negative throughout admission. banana flakes were added to be given in between tube feeds with some improvement in diarrhea. . # fen - nutren renal 3/4 strength; additives: beneprotein, 45 gm/day, banana flakes, 3 packets per day. goal: 40 ml/hr . # ppx - sc heparin followed by heparin drip followed by coumadin. pneumoboots. lansoprazole while on steroids. . # communication: hcp ; other, . # code: full code medications on admission: - lasix 80mg po qd - adalat 60mg po bid - atenolol 200mg po bid - lipitor 40mg po qd - niaspan 500mg po qd - gemfibrozil 600mg po bid - zetia 10mg po qd - neoral 175mg po bid - prednisone 5mg po qd - glipizide 20mg po bid - metformin 500mg po bid - sulindac 150mg po qd - terazosin 2mg po qd - allopurinol 100mg po bid - neurontin 400mg po qd - prilosec 20mg po qd - azathioprine 25mg po qd - cyclosporin 175 mg po qd . meds on transfer: - vanco 1g iv qd - zosyn 2.25g iv q6h - azithromycin 500mg iv q24h - zetia 10mg po qd - lopid 600mg po breakfast/dinner - protonix 40mg iv qd - simvistatin 80mg po qhs discharge medications: 1. senna 8.8 mg/5 ml syrup : 1-2 tablets po bid (2 times a day) as needed. 2. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 3. cyanocobalamin 100 mcg tablet : 0.5 tablet po daily (daily). 4. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical (2 times a day). 5. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed. 6. epoetin alfa 10,000 unit/ml solution : 10,000 units injection asdir (as directed): to be administered during dialysis. 7. labetalol 300 mg tablet : two (2) tablet po tid (3 times a day): hold for sbp<110, hr<60. 8. diltiazem hcl 90 mg tablet : one (1) tablet po qid (4 times a day): hold for sbp<110, hr<60. 9. albuterol-ipratropium 103-18 mcg/actuation aerosol : puffs inhalation q4h (every 4 hours). 10. amiodarone 200 mg tablet : two (2) tablet po tid (3 times a day) for 10 doses. 11. amiodarone 200 mg tablet : one (1) tablet po tid (3 times a day) for 1 months: to be started following completion of 400 mg po tid dosing of amiodarone. 12. warfarin 5 mg tablet : one (1) tablet po hs (at bedtime). 13. mycophenolate mofetil 250 mg capsule : two (2) capsule po bid (2 times a day). 14. ascorbic acid 500 mg tablet : one (1) tablet po bid (2 times a day). 15. zinc sulfate 220 (50) mg capsule : one (1) capsule po daily (daily). 16. prednisone 5 mg tablet : three (3) tablet po daily (daily). 17. insulin glargine 100 unit/ml solution : thirty (30) units subcutaneous at bedtime. disp:*1000 units* refills:*2* 18. heparin (porcine) in d5w 100 unit/ml parenteral solution : seven hundred (700) units/hr intravenous asdir (as directed): currently at 700units per hour to be titrated to ptt 60-80 per weight based protocol until inr therapeutic on coumadin. disp:*5000 units/hr* refills:*2* 19. insulin regular human 300 unit/3 ml insulin pen : units subcutaneous qid: please refer to attached sliding scale. disp:*qs qs* refills:*2* 20. heparin lock flush (porcine) 100 unit/ml syringe : two (2) ml intravenous daily (daily) as needed: 10 ml ns followed by 2 ml of 100 units/ml heparin (200 units heparin) each lumen daily and prn. inspect site every shift. discharge disposition: extended care facility: center discharge diagnosis: primary: 1. respiratory failure 2. fever of unknown origin 3. acute tubular necrosis 4. critical illness neuropathy 5. myelodysplastic syndrome 6. atrial fibrillation secondary: 1. end stage renal disease 2. diabetes 3. hypertension discharge condition: stable respiratory status on 40 % fio2 via trach mask. tolerating po diet with pmv in place. pleasant, conversant. full assist with transfers and adls. discharge instructions: please continue to take all medications as prescribed. you should be taking prednisone and cellcept once a day to protect your kidney transplant. you will need to continue to use a heparin drip until your coumadin levels are within goal. you are also taking amiodarone to attempt and alter and abnormal rhythm with your heart. please see below for follow up appointments. please continue with and dialysis at your facility. followup instructions: please follow up with dr. of cardiology on at 2:20 on the of on the of the building. phone: you should follow up with your outpatient nephrologist dr. in 1 month. you may call his office at ( to make an appointment. you will be working with the dialysis doctors at your facility. hematology/oncology will call you to schedule a follow-up appointment. you will be followed by dr. and dr. . you may call the clinic at with any questions. please follow up with dr. on at 3 pm for your first new patient primary care appointment. phone procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis percutaneous [endoscopic] gastrostomy [peg] biopsy of bone marrow temporary tracheostomy closed [endoscopic] biopsy of bronchus closed [percutaneous] [needle] biopsy of kidney diagnoses: pneumonia, organism unspecified acute kidney failure with lesion of tubular necrosis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified atrial fibrillation chronic kidney disease, unspecified myelodysplastic syndrome, unspecified acute respiratory failure other and unspecified complications of medical care, not elsewhere classified complications of transplanted kidney other complications due to renal dialysis device, implant, and graft diabetes with ketoacidosis, type ii or unspecified type, uncontrolled 

Answer: The patient is high likely exposed to