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: fever and chills with headache major surgical or invasive procedure: colonscopy transjugular liver biopsy bone marrow biopsy lumbar puncture history of present illness: mr. is a 59-year-old gentleman with a history of multiple myeloma nonsecretory type with free light chain disease, kappa predominating, who came to ed because of fever, chills. he is now s/p a matched cord blood nonmyeloablative transplant(about 50 days ago) with conditioning regimen of atg, fludarabine, melphalan, and methylprednisolone. . when he was hospitalized for allogeneic transplant in this , his hospital course was complicated by fever, with positive blood cultures with staph, coag(-)from his hickman. he was initially treated with vancomycin, cefepime and flagyl and was discharged home on vancomycin which completed on . he also had diarrhea in the hospital, which was c diff negative. this resolved when his counts recovered and he has had no signs of gvhd. his immune suppression is fk-506 and cellcept. he recently has been noted for a positive ebv viral load and bk virus in the urine. he has been having intermittent fever, chills over several weeks and has been followed by oncology as outpatient for those problem. recently has been noted for a positive ebv viral load and bk virus in the urine. given his increased ebv viral load, he was started on valcyte 50 mg twice per day. last night, he developed fever up to 101.6f. he came to ed. . in ed,vs t 100.6, bp 145/88, hr 135, rr 20, o2 sat 100% on ra. ed staff decided to admit him to bmt service for possible line infection. he received iv vanc and iv cipro in ed. . on the floor, he stated feeling okay. reported frequency for few weeks, denied ha, cough, sore throat, runny nose, diarrhea. past medical history: oncologic treatment history: 1. diagnosed in with non-secretory multiple myeloma with vertebral collapse and rod placement. surgery complicated by dvt, treated with coumadin for 18 months. bone marrow biopsy showed ~ 40% plasma cells and the presence of a hypogammaglobulinemia. he was also found to be mildly anemic with hematocrit of between 35 and 40. his beta-2 microglobulin was 2.3. he was initially treated with melphalan and prednisone 8 cycles, dexamethasone and thalidomide. 2. received intermittent doses of cytoxan followed by high-dose cytoxan on with stem cell mobilization and collection and status post high-dose chemotherapy with autologous stem cell transplant in 10/. 3. noted for disease progression on bm bx in and was treated on the multiple myeloma/dendritic cell vaccine trial in and taken off study due to progression of disease. 4. increasing back pain during this time but noted for new herniated disc and underwent surgery in 09/. 5. begin revlimid with dexamethasone but developed a rash at higher doses of 25 mg daily, then restarted a three-week cycle with increasing doses as of . his usual dose has been 15 mg daily for 21 days with dexamethasone on six days of the cycle. he is status post 13 cycles with his last cycle completed on . 6. noted for disease progression/persistence with bone marrow aspirate and biopsy revealing approximately 80% plasma cells. 7. status post one cycle of cytoxan, velcade and decadron initiated on . second cycle on , day 11 velcade held due to low counts. third cycle on with day 11 velcade held due to low counts. 8. bone marrow aspirate and biopsy from : normocellular erythroid dominant marrow with persistent involvement by patient's known plasma cell myeloma. the plasma cells comprise 7% of aspirate differential and 10-15% of the bone marrow core biopsy by cd138 immunohistochemical staining and are kappa restricted. 9. completed decadron 20 mg daily for two days in , repeated weekly x 2 in order to temporize his disease prior to his transplant. 10. bone marrow aspirate and biopsy from shows a normocellular erythroid dominant bone marrow with trilineage ematopoiesis with persistent involvement by known plasma cell myeloma. plasma cell distribution is variable on the aspirate smear ranging from 10% to focally as high as 30%), with cytologically typical forms. by immunohistochemistry, cd138 positive plasma cells ccount for 20-30% of marrow cellularity, and are kappa restricted by kappa and lambda light chain staining. 11. this : matched cord blood nonmyeloablative transplant with conditioning regimen of atg, fludarabine, elphalan, and methylprednisolone. . past medical history: 1. multiple myeloma as outlined above 2. history of rosacea 3. question seizure history dating back to with 2 syncopal episodes. however most consistent with vaso vagal reaction. the patient insisted on continuing the neurontin as a "security". he was initially started on dilantin but this was tapered and discontinued in and he was put on neurontin. he was thoroughly evaluated and there was no evidence for seizures on eeg. his neurontin was tapered to 100 mg three times per day with no evidence for any seizure activity. this was discontinued at the beginning of this year. 4. spinal surgery with rod placement in at time of diagnosis. recent surgery for herniated disc in 9/. 5. h/o dvt in the setting of initial spinal surgery. 6. hypogammaglobulinemia, treated with ivig. 7. left inguinal hernia repair. . social history: mr. is divorced x 10 years, and lives alone in a apartment with his sister in law and her family living upstairs. his ex-wife is his main support and they seem to have a very good relationship. they have no children. has 3 brothers, 2 older and one younger. his mother is well and lives in . his father died many years ago. has worked the last 30 years as a librarian at the library and has a second job as a designer for ac . both jobs had been very supportive and flexible but in planning for his transplant, he has retired and is applying for ssdi. mr. is a nonsmoker and drinks rare alcohol. he denies any iv or recreational drug use. family history: no clear history of lymphoma, leukemia, or myeloma in the family. vague history of cancer on father's side mother: copd physical exam: vitals: t 99 hr 99, bp 128/80 rr 20 98%ra gen: well nourished comfortable man in nad heent: anicteric eyes, op clear with no lesions, no cervical or axillary chest: cta b/l heart: rrr no m/r/g abdomen: soft, nt, nd +bs extr:no edema 2+dps skin: no lesions neuro: a+ox3 cns intact. strength 5/5 ue and le b/l, gait intact, romberg negative, ftn intact pertinent results: specimen: bone marrow aspirate and core biopsy: diagnosis: 1. involvement by lambda-restricted plasma cell dyscrasia, immunoreactive, worrisome for post-transplant lymphoproliferative disorder (note: immunohistochemical stains show increased cd138-immunoreactive plasma cells, singly and in small clusters, occupying 10-15% of marrow cellularity. by immunoglobulin light chain staining these are lambda restricted. of note, the patient's prior marrows showed kappa restricted plasma cells. the differential diagnosis includes post-transplant lymphoproliferative disorder versus recurrence of his myeloma with the phenomenon of isotype switch.given the increased numbers of virus encoded rna () positive cells in this patients marrow, the former is favored. additionally, scattered histiocytes with ingested hematopoietic precursors are also seen (hemophagocytic histiocytes). please correlate with clinical and other laboratory findings). 2. hypercellular bone marrow for age with dyserythropoiesis and dysmegakaryopoiesis. brief hospital course: 59 year old gentleman with a history of multiple myeloma nonsecretory type with free light chain disease, kappa predominating who is s/p a matched unrelated double cord blood nonmyeloablative transplant with conditioning regimen of atg, fludarabine, melphalan, and methylprednisolone. he presented with with fever, chills, and headache. an lp was performed and was wnl. peripheral smear was notable for blasts and plasma cells, and a bone marrow biopsy was performed which showed involvement by lambda-restricted plasma cell dyscrasia, immunoreactive, worrisome for post-transplant lymphoproliferative disorder and hypercellular bone marrow. . 1. anemia/thromocytopenia. - hct decreased during admission and was difficult to maintain with transfusions. chimer studies showed the presence of both cord blood lines as well as the patient's own cells. the anemia was thought to be due to low grade bleeding from thrombocytopenia, melena that pt experienced later during the admission, and some hemolysis. haptoglobin was wnl early in the hospital stay but quickly dropped and coombs test was negative. there is a possibility that the anemia and thrombocytopenia are due to ptld / hemophagocytic lymphohistiocytosis. . 2. diarrhea: etiologies unclear. colonoscopy was benign. cdiff was negative. gvhd remained a possibility, but was unlikely given colonoscopy results. it was felt to be at least in part due to pt's low platelets and liver dysfunction leading to bleeding diathesis. tube feeds were begun for nutritional support, but stopped as pt began to have frankly melanotic stools. pt's hematocrit trended down as the frequency of melanotic stools increased. . 3. acute renal failure: etiology unclear. pt was admitted in renal failure which responded to fluids. he was then imaged with hydration and bicarb plus nac before and after the contrast. nevertheless he went into arf. it is possible - and even likely, that there was a combination of contrast nephropathy, mm, pre-renal, hepato-renal, and possibly even direct involvement by bk, ebv, or ptld. pt became anasarcic, anuric and required intermittent hemodialysis for fluid removal. this volume overload was thought to be contributing to his respiratory failure. however, with intermitten hemodialysis pt could not tolerate the abrupt shifts of fluid and electrolytes and became very tachycardic (hr 130-170s) and hypertensive, often reaching into the 180s and 190s systolic. he was placed on cvvh which he tolerated better, and effectively removed the extra fluid volume and helped to reverse his metabolic acidosis. . 4. acute hepatitis: biopsy showed diffuse involvement by large b cells consistent with ptld. liver enzymes continued to rise and pt became very thrombocytopenic/coagulopathic. pt showed signs of low-grade bleeding. gums were oozing blood and small amounts of dark blood was suctioned from the trachea. pt was transfused supportively to maintain plt>30 and inr<1.4-1.7. . 5. ptld. related to very high titers of ebv. treated with multidrug regimen. liver involvement was confirmed by biopsy. had questionable response to the drugs. clinically, the lymph nodes in the neck decreased in size however his liver enzymes continued to rise. spleen was also enlarged by ct and u/s. . 6. increasing o2 demand and respiratory failure: pt had increasing o2 demand in the context of bilateral infiltrates on ct and diffuse infiltrates. bronchoscopy showed lambda restricted b cells believed to be consistent with pulmonary involvement by ptld. the situation is complicated by arf and fluid overload. pt was intubated and transferred to icu on assist-control. pt was placed on intermittent hemodialysis, then on cvvh for fluid removal. pt had lactic acidosis and compensatory respiratory alkalosis. pt improved from respiratory perspective enough to be placed on pressure support however was not extubated due to concerns for what to do should re-intubation be necessary. . 7. bk cystitis. admitted with very high titers of bk in the urine with severe urinary urgency. the urinary urgency was treated only barely effectively with oxybutinin. this was discontinued and a foley was placed to facilitate intravesicular cidofavir. the procedure was tolerated well. . given questionable response of ptld to numerous drug regimens, and pt's poor prognosis, a consensus was reached between pt's oncologist, healthcare proxy, and the rest of the care team to make patient cmo. he was extubated and expired in the presence of family. medications on admission: clonazepam 1 mg tablet(s) at bedtime as needed for insomnia clotrimazole - 10 mg troche po four times a day as needed for thrush fluconazole - 200 mg tablet q 12h folic acid - 1 mg tablet daily heparin flush - 10 unit/ml kit - kit(s) q day and prn to each lumen daily and prn mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice a day oxybutynin chloride - 5 mg tablet once a day. increase to twice a day as needed. oxycodone - 5 mg tablet(s) every four hours as needed for pain pantoprazole - 40 mg tablet daily pentamidine - 300 mg recon soln - 1 inhaled once a month prochlorperazine maleate - 10 mg tablet every six hours as needed for nausea tacrolimus - 0.5 mg capsule one q am and one tab q pm triamcinolone acetonide - 0.025 % cream - apply to affected area twice a day ursodiol - 300 mg capsule - capsule(s) twice a day 1 tablet in the am, 2 tablets in the pm valganciclovir - 450 mg tablet - 1 (one) tablet(s) twice a day discharge disposition: expired discharge diagnosis: post-transplant lymphoproliferative disorder history of multiple myeloma multi-organ failure cardiopulmonary arrest discharge condition: pt expired discharge instructions: pt expired followup instructions: pt expired procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis closed (percutaneous) [needle] biopsy of liver venous catheterization for renal dialysis biopsy of bone marrow arterial catheterization closed [endoscopic] biopsy of bronchus closed [endoscopic] biopsy of large intestine injection or infusion of cancer chemotherapeutic substance diagnoses: pneumonia, organism unspecified acidosis urinary tract infection, site not specified acute kidney failure, unspecified other malignant lymphomas, unspecified site, extranodal and solid organ sites acute respiratory failure complications of transplanted bone marrow neutropenia, unspecified 

Answer: The patient is high likely exposed to