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: no known allergies / adverse drug reactions attending: chief complaint: coughing up blood major surgical or invasive procedure: - vats for lung bx - renal biopsy - l renal arteriogram history of present illness: 66f with history of htn, cad s/p cabg and mechanical aortic valve 20 years ago on coumadin, recent +panca, presented for admission for reversal of inr and observation for upcoming lung biopsy for workup of potential wegners diagnosis. patient was admitted on for complaints of a progressive severe cough for 2 months with three days of coughing up blood tinged mucus mixed in with some clots. omr notes reveal anemia over past month with recent transfusion on thursday prior to admission. . per omr notes she was undergoing routine echo of the heart when an increased dilation of the aorta was noted. a ct scan was ordered which revealed a 4.8 cm thoracic aortic aneurysm. however, in addition, bilateral lung nodules were seen. pet ct showed multiple bilateral fdg avid nodules. she was seen by thoracic surgery for consideration of ebus versus open lung biopsy one month ago. in the interim, a panca level came back positive, along with an esr of 115 and a newly discovered anemia of 8.0, and she was seen by rheumatology, who facilitated elective admission to the hospital for further workup. . she was admitted to micu for monitoring in setting of blood loss, cxr appearance showing diffuse opacities, and concern for hemoptysis. she was transfused two unit prbc on & for decreasing hct 21.1. renal saw patient and noted: ua: 4+ blood, 2+ prot. urine microscopy: >50 wbc/hpf. >50 rbc/hpf - isosormophic. anca +, anti-gbm pending. +. rhumatology saw patient and recommened 3 pulse doses before lung biopsy. on , patient had video assisted thoracoscopic surgery, left upper lobe wedge resection, patient successfully extubated. chest tube removed on without complications. patient was put on 60mg po prednisone daily after vats. past medical history: - coronary artery disease with cabg in and additional placement of mechanical st. aortic valve - hypertension - hyperlipidemia - gout social history: ms. is originally from . she worked as an aid for people with mental retardation in group home for many years. she has also worked for a few years at itt doing a technology related role. denies any respiratory occupational exposures to dust or other inhalation exposure. she does not drink alcohol, does not smoke and has never smoked and denies any drug use. she has three children. she is currently retired and lives with her son. family history: there is no family history of autoimmune disease, lung or kidney disease. physical exam: on arrival to micu: vitals: 98.7, 73, 111/45, 96/ra general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated lungs: scattered wheezes but good air movement. cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . discharged exam: general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated lungs: bibasilar crackles, but other clear to auscultation bilaterally cv: regular rate and rhythm, mechanical valve sounds at rusb abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: deferred ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: on admission: : urine: wbcclump-many rbc-27* wbc-47* bacteria-few yeast-none epi-<1 urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.5 leuk-lg urine color-yellow appear-clear sp -1.005 plt count-406 neuts-86.0* lymphs-9.3* monos-3.1 eos-1.4 basos-0.2 wbc-11.8* rbc-3.16* hgb-9.1* hct-26.6* mcv-84 mch-28.7 mchc-34.0 rdw-15.3 albumin-3.9 alt(sgpt)-34 ast(sgot)-39 alk phos-117* tot bili-1.8* urine mucous-rare urea n-28* creat-1.4* sodium-137 potassium-3.8 chloride-97 total co2-26 anion gap-18 . labs on discharge: : blood wbc-6.0 rbc-3.06* hgb-9.0* hct-26.2* mcv-85 mch-29.3 mchc-34.4 rdw-16.8* plt ct-195 blood pt-24.9* ptt-24.4 inr(pt)-2.4* blood glucose-82 urean-31* creat-0.8 na-139 k-3.1* cl-102 hco3-29 angap-11 blood calcium-8.3* phos-2.5* mg-1.8 : blood hbsag-negative : blood anca-positive * . micro data: blood cultures, urine cultures negative. renal and lung biopsy negative for infectious agents . : confirmed diagnosis of anti- antibody. -antigen is a member of the blood group system. anti- antibody is clinically significant and capable of causing hemolytic transfusion reactions. in the future, the patient should continue to receive -antigen negative products for all red cell transfusions. approximately 90% of abo compatible blood will be -antigen negative. . cxr: bilateral ill-defined perihilar opacities, may represent alveolar hemorrhage. differential considerations include a diffuse infectious process. . renal us: 1. increased renal cortex echogenicity consistent with medical renal disease. 2. moderately increased resistive indices. . echo: the left atrium is mildly dilated. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef 65%). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. there are focal calcifications in the aortic arch. a bileaflet aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. . chest ct w/o contrast: 1. diffuse bilateral ground-glass opacities and consolidation are nonspecific. however, given the clinical and laboratory data for this patient, they are most consistent with widespread hemorrhage likely secondary to wegener's granulomatosis or other vasculitis. the extent of involvement has increased since , but the right lower lobe superior segment appears improved. 2. prosthetic aortic valve with dilatation of the ascending aorta to 4.8 cm, unchanged from . 3. possible calcified right renal artery pseudoaneurysm, less likely calcified lymph node anterior to the right kidney. . wedge biopsies of lung, three (see note): . i. left lower lobe segment superior segment: a) lung tissue with recent hemorrhage and focal organizing alveolar fibrin. b) focal capillaritis. c) focal organizing pneumonitis. d) no large vessel vasculitis. . ii. anterior left upper lobe: a) lung tissue with recent hemorrhage and focal organizing alveolar fibrin. b) focal capillaritis. c) focal organizing pneumonitis. d) no large vessel vasculitis. . iii. posterior segment, left upper lobe: a) lung tissue with recent hemorrhage and focal organizing alveolar fibrin. b) focal organizing pneumonitis. c) no large vessel vasculitis. . note: case was discussed with dr. . on . the findings are not specific. the typical findings of wegener's granulomatosis are not seen. the diagnosis of goodpasture syndrome should be considered. clinical correlation is recommended. . renal biopsy: necrotizing extracapillary (crescentic) glomerulonephritis ,pauci-immune type consistent with glomerulonephritis of the anca-associated vasculitic syndromes (see note). . note: sections reveal fragments of renal parenchyma containing approximately 30 glomeruli, two of which are globally sclerotic. about 20% of the others show cellular/fibrocellular crescents of varying sizes and associated with fibrinoid necrosis (the extent of involvement by crescents varies greatly from level to level, up to 50%). endocapillary proliferation is minimal. mild interstitial fibrosis and tubular atrophy are noted accompanied by chronic inflammation. focally the medulla shows an apparent capillaritis. arterioles/small interlobular arteries show mild fibrotic changes. larger arteries show focal /mild intimal fibroplasia. . immunofluorescence studies reveal 8 glomeruli to be present. no staining is seen with immunoglobulin (iga, igg, igm), kappa light chain, lambda light chain or c1q. c3 (+/-) stains vessels and tubular basement membranes. trace fibrin is noted in a crescent. albumin preparations are not contributory. electron microscopy results pending. . chest radiograph: impression: minimal improvement in the extent of the confluent opacities in the perihilar and basilar regions, likely due to pulmonary hemorrhage in the setting of hemoptysis. . ct abdomen and pelvis(non-contrast): impression: slight increase to the right lung infiltrates. no intra-abdominal or retroperitoneal bleed. right ovarian cyst which requires further assessment with ultrasound. . right upper quadrant ultrasound: 1. no evidence of focal or textural liver abnormalities. 2. tiny cholesterol polyps are visualized; otherwise, the gallbladder is within normal limits. 3. borderline enlarged spleen measuring 12.3 cm. . : ct abdomen and pelvis without contrast. interval large amount of hemorrhage in the left pararenal and perirenal spaces and subcapsular, with hematocrit effect and clot retraction, compatible with subacute hemorrhage. fat stranding extends inferiorly from the left pararenal spaces to the left pelvis. . : renal ultrasound with doppler 1. left renal subcapsular hematoma and perinephric hematoma. 2. echogenic kidneys suggesting medical renal disease. 3. normal flow in bilateral main renal arteries and veins. 4. elevated resistive indices bilaterally, which may be related to baseline medical renal disease. on the left, further increased resistive indices may be due to compression by hematomas. . : left renal arteriogram 1. no evidence of active bleeding on left renal arteriogram including segmental selective injections to the interpolar branch and inferior polar branch. 2. no evidence of pseudoaneurysm, av fistula, or free extravasation on left-sided lumbar arteriograms with selective injections of l2, l3 and l4 lumbar arteries. . : ct abdomen and pelvis without contrast 1. stable appearance of right perinephric and retroperitoneal hematoma without evidence of extension or new bleeding. 2. right lower lobe 4-mm pulmonary nodule. if patient is low risk, no further followup is warranted. if the patient is high risk, then consider ct chest. brief hospital course: 66yo woman with a h/o htn, cad s/p cabg and mechanical bileaflet aortic valve placed 20 years ago on coumadin, presented with hemoptysis, lung nodules, microscopic hematuria with positive p-anca, elevated esr, crp. renal biopsy showed necrotizing extracapillary (crescentic) glomerulonephritis, pauci-immune type consistent with glomerulonephritis of the anca-associated vasculitic syndrome. hospital course was complicated by a post renal biopsy perinephric bleed and then a larger more expansive retroperitoneal bleed which ultimately self tamponaded with no need for open surgery or ir guided interventions. . # hemoptysis/microscopic hematuria: patient presented with hemoptysis,lung nodules with +panca with working diagnosis of wegener's granulomatosis/microscopic polyangiitis and admission was facilitated by outpatient rhuematology for inr reversal and lung biopsy. due to worsening hemoptysis and anemia she was directly admittted to micu. she had ct chest consistent with widespread hemorrhage thought to be secondary to wegener's granulomatosis or other vasculitis given concurrent renal insufficiency and active urinary sediments. following discussions with renal, ip, thoracics, and rheumatology, it was decided to proceed with a biospy of the lung. it was felt that given the intensity of immunosuppressive therapy for vasculitis, it would be best to confirm the diagnosis with biopsy. in the meantime, she was started on prednisone 60 mg po. a complicating factor was her anticoagulation for her mechanical heart valve. her coumadin was held before lung biopsy and she was given vitamin k to speed inr reversal. lung biopsy results were non-diagnostic. she then had a renal biopsy on which confirmed diagnosis of anca associated vasculitis. she was started on monthly iv cytoxan. her course was complicated by an initial perinephric hematoma with bleeding and later by an expanding retroperotineal bleed after being re-bridged back to oral coumadin over a week after her surgery. throughout the later half of her hospital course she continued to have hematuria on urine studies but no gross hematuria appreciated. she had no recurrent bouts of hemoptysis after initial few days in the hospital and this issue appeared to have stabilized by time of discharge. . # /microscopic hematuria: on ua patient had microscopic hematuria and proteinuria with active sediments with a large amount of wbc and rbc and fat bodies. renal biopsy showed necrotizing extracapillary (crescentic) glomerulonephritis ,pauci-immune type consistent with glomerulonephritis of the anca-associated vasculitic syndromes. there was a maximum increase to cr 1.5 during mid- with potential pre-renal and intrinsic kidney damage to blame in the setting of known blood loss issues at that time. fortunately, the patient's cr remained stable and imroved down to 0.8-0.9 range at time of discharge which is essentially her normal cr baseline. of note, after she was started on iv cytoxan the first week in , it was noted that just after one week there was noticeable improvement in renal function as well as decrease in active urinary sediments. thus, this confirmed most of her kidney dysfunction could be blamed on anca vasculitis. . # perinephric and retroperitoneal bleeds: two days after renal biopsy patient was started on heparin bridge to coumadin. 7 days later, while waiting for the inr to become therapuetic she developed severe abdmominal pain with ct scan showing perinephric and subcapsular hematoma. her hematocrit intially dropped but then became stable after one unit of tranfusion. her heparin and coumadin was discontinued. she was hemodynamically stable and therefore did not require any procedures. three days after the bleed she was restarted on heparin bridge again. two days after being put on heparin she again developed worsening abdominal pain with hemodynamic instability and was found to have a worsened retroperitoneal bleed. she was transferred to the icu and received blood transfusions. she was taken to interventional radiology for embolization, but no active source of bleeding was found. after her hematocrit was stable for several days, she was restarted on heparin on . on she was restarted on coumadin since her hematocrit had remained stable. on the patient was transferred out of the micu. she remained stable while on the floor with hematocrits ranging from 24-26. she had a brief hematocrit drop on to 22.8, for which she was transfused an additional unit of blood and subsequently had a ct abdomen and pelvis which revealed no new bleeding source and stability of her perinephric bleed. her hematocrit on discharge on was 26.2. throughout her nearly 6 week hospital course, ms. received a total of 18 blood transfusions. . # anticoagulation: ms. has an aortic mechanical avr that was placed over 20 years ago at hospital. she has been on longstanding coumadin for her known mechanical valve. per echo and patient's cardiologist she has bileaflet mechanical valve with normal ef, no history of afib, or additonal hypercoagulable conditions. as outlined above, she needed to interrupt her usual coumadin dosing to be briefly held and then re-bridged alongside heparin gtt. in the setting of a pulmonary biopsy, then later for her renal biopsy. after realizing active intra-abdominal/rp bleeding with dropping hcts she also had her anticoagulation held in the icu setting later in her hospital course. after a brief icu stay in late with clear evidence of stable hcts for several days and stable vital signs her coumadin was restarted at a lower cautious dose on . heparin was briefly stopped given a small hematocrit drop on while inr was 1.8, but soon thereafter it was restarted with coumadin. she was discharged on coumadin dose of 4 mg/day and with an inr of 2.3. close follow-up arranged with vna and pcp for ongoing inr checks and hct monitoring. . #anemia: patient became anemic one month prior to presentation most likely in the setting of hemoptysis and microscopic hematuria. overall she received 18 units of prbcs transfusion spaced out over the course of her hospitalization. her reticulocyte was 1.3 on possibly from bone marrow suppresion most likely from new meds e.g cytoxan and bactrim. after discontinuing bactrim, her reticulocytes increased to around 5. however patient continued to be anemic. patient's iron studies as well as b12, and folate as well as hemolysis labs were normal. 10 days after the renal biopsy patient developed a retropertotenial bleed further contributing to her anemia. her hct on discharge was 26.2. plan at discharge was for vna and pcp to help check her hct within a few days of discharge to make sure it continued to remain stable. . # elevated lfts: during the hospital course patient had mild elevation in lfts and increased in d-bili most likely cholestasis from bactrim. ruq ultrasound did not show any biliary dilation. after discontinuing bactrim patient's lfts trended back to normal. . # leukopenia: wbc trended down to 1.5 on . most likely in the setting of cytoxan related bone marrow suppression and immune suppression effects. patient did not have any active signs or symptoms of infections. all blood and urine cultures during hospital course were unremarkable. briefly placed on neutropenic precautions during her wbc nadir, while slowly resolved. her wbc count returned to without any intervention by , and remained normal throughout the rest of her hospitalization. . # htn: blood pressure was initially on the low side and her captopril, lasix, spironolactone were held in the setting of low bp and rp/perinephric bleeding issues. several days after her active bleed seemed to have stabilized in the icu she had blood pressures adjusted again to include labetolol, tid captopril and amlodipine in order to ensure elevated blood pressures did not set off additional bleeding. team tried to keep goal sbps in the 120-140s range as much as possible, with several extra prn iv hydralazine doses during her hospital stay. by time of discharge patient had been put on a stable combination of labetalol, captopril and amlodipine. restarting of her lasix or spironolactone will be determined by her pcp at later date. . # cad: stable. patient did not complain of any chest pain during hospital course. aspirin was held in setting of numerous biopsies and then her bleeding complications. she was continued on usual home statin medication. . # hyperlipidemia: stable, patient continued on home pravastatin . # gout: no acute flares of her known gout during hospital course. she was continued on home dose of allopurinol. . transition of care: pcp will consider need to continue holding vs. restart former diuretics ( spironolactone and lasix) if deemed necessary. patient will follow up with her nephrologist dr. for her next planned iv cytoxan therapy over the next few weeks patient will have her inr monitored as outpatient by her pcp . . medications on admission: codeine-guaifenesin 10 mg-100 mg/5 ml oral liquid teaspoons by mouth at bedtime pravastatin 40 mg tab po daily allopurinol 300 mg tab 1 tablet(s) by mouth once a day captopril 25 mg tab 2 tablet(s) by mouth twice a day atenolol 50 mg tab 1 tablet(s) by mouth twice a day furosemide 40 mg tab 1 tablet(s) by mouth spironolactone 25 mg tab 1 tablet(s) by mouth twice a day warfarin 4 mg tab 1 tablet(s) by mouth discharge medications: 1. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 2. calcium 500 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po three times a day. disp:*90 tablet(s)* refills:*2* 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* 4. pravastatin 40 mg tablet sig: one (1) tablet po once a day. 5. outpatient lab work please check potassium, hematocrit and inr within 2 days after discharge ( on , ) and have records sent to your physician . (fax #: , phone #: ) so that your coumadin dose can be adjusted and labs can be monitored. 6. prednisone 20 mg tablet sig: three (3) tablet po once a day. disp:*90 tablet(s)* refills:*0* 7. labetalol 200 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 8. amlodipine 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 9. atovaquone 750 mg/5 ml suspension sig: two (2) po once a day. disp:*60 * refills:*0* 10. allopurinol 300 mg tablet sig: one (1) tablet po once a day. 11. multivitamin tablet sig: one (1) tablet po once a day. 12. captopril 25 mg tablet sig: three (3) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*0* 13. warfarin 3 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* discharge disposition: home with service facility: discharge diagnosis: primary diagnoses: anca-associated vasculitis, anemia secondary to perinephric hematoma and retroperitoneal bleed secondary diagnoses: hypertension, coronary artery disease, gout discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mrs. , it was an absolute pleasure taking care of you during your hospitalization at medical center. you were admitted to the hospital due to episodes of coughing up blood. you were directly admitted to the icu where your symptoms and blood levels were closely monitored. you had a lung biopsy on which was without clear diagnosis. therefore, at the recommendations of our rheumatology and renal teams, you underwent a kidney biopsy on which demonstrated inflammatory changes in your kidneys consistent with anca-associated vasculitis. after a multidisclplinary discussion between the renal, rheumatology, and medicine teams, you were started on cytoxan to treat your vasculitis. you received your first treatment of cytoxan on without experiencing any decreased white blood cell counts. your red blood cell counts decreased briefly, but returned back to their baseline levels. you were kept in the hospital to continue monitoring of your blood levels while waiting for your inr level to reach a therapeutic level. unfortunately, your red blood cell levels (hematocrit) decreased significantly due to a bleed around your kidneys which occurred after the renal biopsy. this bleeding complication was likely because your blood was thinned on recent anticoagulation medicine. this bleeding was in your abdomen and pelvic area (retroperitoneal space) and it was monitored on both abdominal ultrasounds and ct scans. your anti-coagulation medication was stopped and later restarted once your bleeding appeared to have stopped. you received several blood transfusions, but ultimately you were transferred to the icu for further management on . you eventually stabilized in the icu, and you were then transferred back to the general medical floor on where you fortunately did not have any further bleeding complications until your discharge on . at that time, your red blood cell counts and inr had stabilized to appropriate levels. on discharge, you will follow-up with dr. , your kidney doctor, on , . he will be organizing your monthly cytoxan therapy for your new diagnosis of anca-associated vasculitis. we also set up an appointment with your cardiologist dr. for wednesday, , who will be continuing to help manage your anti-coagulation therapy and inr test results now that you have a history of a significant bleed. in addition, we changed your medications to allow for better control of your new anca-associated diagnosis and blood pressure. those changes are listed below: we have made the following medication changes: - started labetalol 200 mg twice a day - started amlodipine 10 mg once a day - started monthly iv cytoxan - started prednisone 60 mg once a day - started atovaquone 1500 mg once a day - started calcium carbonate 500 mg once a day - started vitamin d 400 units once a day - started pantoprazole 40 mg once a day . - continue pravastatin 40 mg once a day - continue warfarin 3 mg once a day . - increased captopril to 75 mg three times a day . - decreased allopurinol to 150 mg once a day . - stopped lasix - stopped spironolactone - stopped codeine-guaifenesin - stopped atenolol . followup instructions: 1) w/ dr. 517 , phone: ( 2) at 11:15 am w/ dr. , , ma phone: fax: . md procedure: closed [percutaneous] [needle] biopsy of kidney arteriography of other specified sites arteriography of renal arteries injection or infusion of cancer chemotherapeutic substance thoracoscopic excision of lesion or tissue of lung diagnoses: acute posthemorrhagic anemia acute kidney failure, unspecified thoracic aneurysm without mention of rupture gout, unspecified aortocoronary bypass status other and unspecified hyperlipidemia heart valve replaced by other means hemorrhage complicating a procedure other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure long-term (current) use of anticoagulants other specified disorders of biliary tract hemoperitoneum (nontraumatic) sulfonamides causing adverse effects in therapeutic use other specified diseases of pulmonary circulation jaundice, unspecified, not of newborn leukocytopenia, unspecified benign essential hypertension other specified hypersensitivity angiitis hemoptysis, unspecified microscopic hematuria nephritis and nephropathy, not specified as acute or chronic, with lesion of rapidly progressive glomerulonephritis 

Answer: The patient is high likely exposed to