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: cefepime / vancomycin / allopurinol attending: chief complaint: bone/ thigh pain major surgical or invasive procedure: tunneled line removal picc line placement picc removal bone marrow biopsy history of present illness: 64-year-old man 51 days after a matched unrelated donor, non-myeloablative transplant for aml, after a history of polycythemia with myeloid metaplasia and myelofibrosis and previous splenectomy. patient presents after a morning episode where he developed gradual throbbing/ pulsating in his right thigh when he was walking. he rates the pain with walking and improved with putting his feet up. he has never had this sort of episode in the past. patient also endorses a single temperature f 99 and a brief episode of sweats, but no chest pain or shortness of breath, after walking around during this time. he sat down and noted that his stomach was queasy. he endorses a chronic runny nose, but otherwise has been asymptomatic with no localizing symptoms including no fevers, chills, neck stiffness, cough, dysuria, diarrhea. of note, patient was recently seen by dr. in clinic and had a ct torso with contrast. that evening, he developed a single fever of 100.3, called in, but was told to wait it out. past medical history: past oncologic history: longstanding history of polycythemia with myeloid metaplasia s/p splenectomy , previously treated with hydroxyurea and splenectomy. he was diagnosed with acute myelogenous leukemia on the , negative for npm mutation and for the flt 3 mutation, treated with induction chemotherapy of idarubicin and ara-c, but had persistent disease and was therefore reinduced with mitoxantrone, etoposide and ara-c on the . his hospital course was complicated by febrile neutropenia, e. coli and vre bacteremia, a questionable fungal pneumonia. he had a drug rash to cefepime. he developed a-fib with rapid ventricular response that was treated and resolved. he had significant edema and hypoxia, which at one point required an icu admission. he recovered from those, was discharged from the hospital on to complete a course of iv meropenem and daptomycin for his e. coli and vre bacteremia. a followup bone marrow showed him to have persistent fibrosis, but no evidence of leukemia. he did not have a sibling donor, but a matched unrelated donor was identified and the patient has agreed to participate in protocol 07-384, reduced intensity conditioning for an allo hematopoietic stem cell transplant using clofarabine, total lymphoid radiation and atg. . anklyosing spondylitis hypothyroidism social history: patient lives in . married with children. previously lived in . he is a retired schoolteacher (world and american history). he regularly spends 6 months of the year in in a retirement home. denies tobacco or drug use. rare social etoh use (none since transplant). family history: mother was a heavy smoker and passed away from lung cancer. father passed away from complications from dm. no thistory hematologic disorders. physical exam: admission exam: 100.3, 112/84, 94, 97% gen: pleasant, nad heent: no op erythema or exudate. no lad. pulm: ctab. cv: rrr. no m/r/g. abd: +bs. ntnd. no hsm. ext: no c/c/e. lines: hickman tunnelled line with scant dry blood. neuro: cn2-12 intact, 5/5 strength bilaterally. decreased le sensation. . floor->icu transfer exam gen ill-appearing fatigued diaphoretic, minimally verbal heent atraumatic but w/r lower check tender swollen fluctuant mass 2x2 cm, difficulty speaking and swallowing (new today), high soft voice (new x3 days), hearing loss (chronic), eomi, perrl, op otherwise clear neck supple no jvd no lad cv rrr nl s1 s2 no murmur chest ctab no r/r/w abd soft nontender nondistended +bs (no longer tender to palpation llq) ext wwp no edema, pulses palpable neuro aox3 cn intact except hearing loss, strength 4/5 symmetrically throughout, reflexes 2+ throughout. . icu->floor physical exam : vs t99.0 hr 107 bp 102/65 rr 17 02 96%/ra 24h urine outpu 2l icu los fluid balance +4l gen: gaunt, pale man resting in bed in nad, very hard-of-hearing heent: ncat eomi perrl op notable for large (2x3 cm) r retropharyngeal eschar w/no active bleeding, no tonsillomegaly, erythema or exudate neck: no edema, anatomic landmarks visible, no lad, no jvd pulm: good aeration, unlabored breathing, prominent l basilar rales; l cvl removed, site w/minor ecchymosis but nontender, no erythema cv: rrr, nl s1 s2, pmi nondisplaced, no m/r/g abd: flat, nontender nondistended, active bowel sounds, spleen/liver non-palpable ext: no cyanosis or edema, pulses palpable foley in place draining clear yellow urine l arm picc nontender, non-erythematous, dressing c/d/i neuro: alert, ox3, poor hearing to loud voice, cn otherwise intact, strength 3/5 throughout, reflexes intact, gait and cerebellar signs not assessed . discharge exam patient deceased pertinent results: admission labs 02:40pm blood wbc-14.5* rbc-3.21* hgb-10.9* hct-30.9* mcv-96 mch-33.8* mchc-35.2* rdw-18.1* plt ct-211 02:40pm blood neuts-69 bands-0 lymphs-15* monos-6 eos-3 baso-1 atyps-2* metas-2* myelos-0 promyel-1* blasts-1* nrbc-1* 12:00am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-2+ microcy-normal polychr-normal ovalocy-occasional target-occasional acantho-1+ 02:40pm blood pt-14.8* ptt-24.7 inr(pt)-1.3* 02:40pm blood glucose-96 urean-22* creat-1.2 na-139 k-4.2 cl-101 hco3-26 angap-16 02:40pm blood alt-9 ast-47* ld(ldh)-* ck(cpk)-26* alkphos-95 totbili-0.5 02:40pm blood albumin-4.3 calcium-10.5* phos-3.5 mg-1.6 02:40pm blood tsh-4.2 . other notable labs 01:28pm blood igg-609* 05:55am blood iga-55* igm-12* 12:00am blood hapto-280* 12:00am blood wbc-0.1* lymph-91* abs -91 cd3%-31 abs cd3-28* cd4%-28 abs cd4-26* cd8%-5 abs cd8-5* cd4/cd8-5.6* 12:00am blood cd3%-34.3 cd3abs-31 16/56%-11.6 16/56ab-11 07:19pm blood wbc-0.1* rbc-2.01* hgb-6.2* hct-19.6* mcv-98 mch-30.9 mchc-31.7 rdw-17.9* plt ct-35* 07:19pm blood neuts-0* bands-0 lymphs-80* monos-0 eos-0 baso-0 atyps-10* metas-0 myelos-0 blasts-10* 12:00am blood fibrino-781* 09:22pm blood lactate-1.5 . serial urinalysis 05:48pm urine mucous-rare 10:34pm urine castgr-1* casthy-1* 05:48pm urine rbc-<1 wbc-<1 bacteri-none yeast-none epi-<1 10:34pm urine rbc-1 wbc-<1 bacteri-none yeast-none epi-0 05:54pm urine rbc-<1 wbc-<1 bacteri-none yeast-none epi-0 05:48pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 10:34pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 05:54pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.5 leuks-neg 05:48pm urine color-yellow appear-clear sp -1.010 10:34pm urine color-yellow appear-clear sp -1.015 05:54pm urine color-yellow appear-clear sp -1.010 . pertinent micro: bcx negative viral swab negative c diff toxin (negative) (negative) (negative) 6:57 pm stool consistency: loose source: stool. **final report ** microsporidia stain (final ): no microsporidium seen. cyclospora stain (final ): no cyclospora seen. fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. . 4:48 am blood culture (x2 bottles) blood culture, routine: pseudomonas aeruginosa. final sensitivities. piperacillin/tazobactam sensitivity testing performed by . sensitivities: mic expressed in mcg/ml _______________________________________________________ pseudomonas aeruginosa | cefepime-------------- 8 s ceftazidime----------- 4 s ciprofloxacin--------- 1 s gentamicin------------ <=1 s meropenem------------- =>16 r piperacillin/tazo----- s tobramycin------------ <=1 s aerobic bottle gram stain (final ): gram negative rod(s). bcx: pseudomonas aeruginosa bcx: pseudomonas aeruginosa. bcx: no growth. picc tip cx: negative - blood cx: negative bal- gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. respiratory culture (final ): ~1000/ml commensal respiratory flora. legionella culture (final ): no legionella isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. fungal culture (final ): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. viral culture: r/o cytomegalovirus (preliminary): no cytomegalovirus (cmv) isolated. cytomegalovirus early antigen test (shell vial method): negative sputum cx gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and chains. 3+ (5-10 per 1000x field): gram negative rod(s). quality of specimen cannot be assessed. respiratory culture (final ): moderate growth commensal respiratory flora. pseudomonas aeruginosa. moderate growth. pseudomonas aeruginosa | cefepime-------------- 4 s ceftazidime----------- 4 s ciprofloxacin--------- 1 s gentamicin------------ 2 s meropenem------------- =>16 r piperacillin/tazo----- s tobramycin------------ <=1 s blood mycolytic cx: no fungus isolated. no mycobacteria isolated. stool cx negative for c.diff (repeat negative) , , urine culture - negative sputum gram stain (final ): <10 pmns and <10 epithelial cells/100x field. 4+ (>10 per 1000x field): gram negative rod(s). quality of specimen cannot be assessed. respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginose-mod growth _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 16 i ceftazidime----------- =>64 r ciprofloxacin--------- 1 s gentamicin------------ 2 s meropenem------------- =>16 r piperacillin/tazo----- r tobramycin------------ <=1 s . 11:26 pm swab source: soft palate mass. gram stain (final ): reported to and read back by dr. . on at 0450. 1+ (<1 per 1000x field): polymorphonuclear leukocytes. 4+ (>10 per 1000x field): gram negative rod(s). wound culture (preliminary): escherichia coli. moderate growth. piperacillin/tazobactam sensitivity testing available on request. pseudomonas aeruginosa. moderate growth. piperacillin/tazobactam sensitivity testing performed by . amikacin , doripenem and colistin sensitivities requested per dr. # . doripenem non-susceptible sensitivity testing performed by etest. mic interpretations are based on manufacturer's guidelines that are fda approved. escherichia coli. sparse growth #2. piperacillin/tazobactam sensitivity testing available on request. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | pseudomonas aeruginosa | | escherichia coli | | | amikacin-------------- <=2 s 16 s <=2 s ampicillin------------ =>32 r =>32 r ampicillin/sulbactam-- =>32 r =>32 r cefazolin------------- =>64 r =>64 r cefepime-------------- <=1 s =>64 r <=1 s ceftazidime----------- <=1 s =>64 r <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin--------- =>4 r =>4 r =>4 r gentamicin------------ =>16 r 8 i =>16 r meropenem-------------<=0.25 s =>16 r <=0.25 s piperacillin/tazo----- r tobramycin------------ =>16 r <=1 s =>16 r trimethoprim/sulfa---- =>16 r =>16 r . 1:29 pm blood culture source: line-picc. blood culture, routine (preliminary): gram negative rod(s). aerobic bottle gram stain (final ): reported to and read back by dr at 11:50. gram negative rod(s). . . viral/fungal studies: , , cmv viral load (negative) ( pending) , , , galactomannan negative ( pending) , , , , b glucan - negative ( pending) blood voriconazole level - wnl adenovirus pcr negative , ebv pcr negative hhv6 pcr <500 (negative) (repeat pending) . selected imaging, see omr for full collection . ct chest: findings: there is no pathologic enlargement of central lymph nodes by size criteria. tiny pericardial effusion is physiologic. apparent thickening along the right posterior costal pleural surface deep in the medial pleural gutter is more likely atelectasis. there is no pleural effusion. this study is not designed for subdiaphragmatic diagnosis, but shows there is no adrenal mass or lesions in the imaged portions of the unenhanced solid organs of the upper abdomen suspicious for malignancy. the spleen is absent, presumably resected. the previous multifocal opacities of various sizes in both lungs, have resolved leaving small areas of scarring and atelectasis. the lungs are otherwise clear. there is no evidence of active intrathoracic infection currently. impression: 1. no evidence of intrathoracic infection or malignancy. previous multifocal pulmonary abnormality, presumably infectious has resolved since . . ct abd/pelvis: ct of the abdomen: there is mild linear bibasilar atelectasis. the visualized heart and pericardium are unremarkable. the liver enhances homogeneously, without focal lesions or intrahepatic biliary duct dilatation. the gallbladder is collapsed compared to and contains several gallstones. the portal vein is patent. the pancreas does not show focal or diffuse abnormalities. there is no evidence of peripancreatic stranding or fluid collection. the patient is post splenectomy. the adrenal glands are unremarkable. the kidneys do not show solid or cystic lesions and present symmetric nephrograms and excretion of contrast. no pelvicaliceal dilatation or perinephric abnormalities are present. the intra-abdominal vasculature is unremarkable. there are no retroperitoneal or mesenteric lymph node enlargement. no ascites or abdominal wall hernias are noted. the stomach, duodenum and small bowel are within normal limits without evidence of wall thickening or obstruction. the appendix is not visualized but there is no evidence of appendicitis. examination of the sigmoid and descending colon including the splenic flexure demonstrates thickening of the bowel walls with areas of surrounding fat stranding as well as areas of mucosal enhancement. no fluid collection is identified. no free air is seen. there are multiple diverticula. no dilitation of the small or large bowel. pelvic ct: the urinary bladder and terminal ureters are normal. no pelvic wall or inguinal lymph node enlargement is seen. there is no pelvic free fluid. the prostate, seminal vesicles, and rectum are unremarkable. osseous structures: multilevel degenerative disease of the lumbar and thoracic spine. diffuse mixed sclerotic and lucent appearance of the bones which is unchanged. coronal and sagittal images were reviewed confirming the axial findings. impression: 1. thickening of the bowel wall including the entire sigmoid and descending colon including the splenic flexure with surrounding fat stranding and areas of mucosal enhancement may represent infectious, inflammatory, or ischemic etiology. given the extent of the involement, diverticulitis is unlikely. no evidence of perforation, obstruction, or abscess formation. 2. diffuse mixed sclerotic and lucent appearance of the bones which is unchanged and consistent with aml. . ct sinus findings: there is mucosal thickening of the ethmoid air cells as well as minimal mucosal thickening of the inferior left maxillary sinus and frontethmoidal recess on the left. no aerosolized secretions to suggest significant acute component are seen. no notable air-fluid levels except for minimal amount in the left maxillary sinus. there is s-shaped deviation of the nasal septum with a shallow bony spur on the left which does not cause significant occlusion of the middle meatus. there is mucosal thickening around the ostiomeatal units with obstruction of the infundibulum on the right. the olfactory fossae are type bilaterally with some demineralization of the cribriform plate and lateral lamellae; left cribriform plate is higher than right. the lamina papyracea are intact. the right anterior clinoid process is pneumatized. altered attenuation of some of the bones- c spine and mandibular condyles is noted and may relate to osteopenia/ underlying marrow disorder- inadequately imaged. impression: mucosal thickening of the ethmoid air cells with minimal mucosal thickening of the left frontoethmoidal recess and left maxillary sinus. no aerosolized secretions or notable air-fluid levels except for minimal amount in the left maxillary sinus. . ct chest 1. no evidence of intrathoracic malignancy or infection. 2. longstanding widespread blastic and lytic involvement of the entire chest cage. . ct abdomen 1. increased thickening of the bowel wall of the descending colon with increased fat stranding consistent with worsening colitis of unclear etiology. no evidence of perforation, obstruction or abscess formation. 2. diverticulosis of the sigmoid colon. 3. diffuse mixed sclerotic lucent appearance of the bones, which is unchanged and consistent with aml. . ct maxillofacial 1. extensive soft tissue swelling, which is centered in the right oropharyngeal mucosal space and palatine fossa, extends into the right pyriform sinus of the hypopharynx and likewise involves the right submandibular space and right neck soft tissue planes. while these changes likely represent diffuse phlegmon, there is no discrete or drainable abscess and no lymphadenopathy. 2. no ct evidence of odontogenic abscess or mandibular osteomyelitis. 3. unchanged predominantly ethmoid sinus disease. . mandible films there is amalgam, a metallic bridge and a dental implant in the incisor region. there is a lucency in the maxilla, seen on the lateral view, but it is unclear as to whether this represents some rarefaction in the normal trabecular markings or a frank abscess adjacent to the incisors. otherwise, no discrete abscess is seen subjacent to the lower mandible molars or incisors. . ct chest 1. rapidly progressive right upper lobe consolidation, consistent with pneumonia. 2. bibasilar atelectasis and/or infectious consolidation. 3. pulmonary arterial hypertension. consider echo for initial further evaluation if not already performed. 4. mild paraseptal emphysema. 5. multifocal lytic and sclerotic bone lesions, unchanged since . . ct sinus 1. extensive bilateral peripharyngeal soft tissue induration, markedly worse than three days ago, with no drainable abscess or fluid collection identified. the origin of the infection is unlikely to be from a sinus because of the lack of marked acute sinusitis seen on the prior study. 2. evidence of new right lung pneumonia and atelectasis, better evaluated by the chest ct performed on the same day. 3. new fluid opacification of the bilateral sphenoidal sinuses, which may represent acute infection or may be due to pooling of secretions after endotracheal intubation. . portable cxr left internal jugular line ends at mid svc. the endotracheal tube terminates approximately 5 cm above the carina and is appropriate. orogastric tube is seen to course below the diaphragm into the stomach; however, the distal end is beyond radiographic view. right upper lobe pneumonia, though unchanged since prior radiograph dated , is smaller as compared to radiographs through to . bilateral lower lung consolidations have also improved. no new lung opacities. no pleural effusion. or pneumothorax. cardiomediastinal contour is stable. . cxr compared with at 19:40 p.m. and allowing for differences in technique, the radiographic appearance is similar. the right apical opacity is grossly unchanged. again seen is some patchy opacity in the left infrahilar area and, to a lesser extent, in the right infrahilar area. these raise concern for multifocal pneumonic infiltrates or, possibly, areas of aspiration. the differential could include atypical pattern of fluid overload, but this is considered much less likely, as no upper zone redistribution is identified . pathology . bone marrow aspirate and core biopsy: diagnosis:increased blasts consistent with residual myeloid leukemia, see note. note: the findings are somewhat similar to that biopsy done previously. there are circulating blasts and marrow blasts are enumerated at 18%. the constellation of findings are suggestive of a residual acute myeloid leukemia. the dysplastic megakaryocytes are also suggestive of residual megakaryoblastic lineage, as discussed in the bmt conference on and . microscopic description peripheral blood smear: the peripheral smear is adequate for evaluation. erythrocytes are decreased in number, have marked poikilocytosis, including burr cells, red cell fragments, spherocytes, nucleated red blood cells, and inclusions (-jolly, pappenheimer). granulocytes are in normal numbers and are dysplastic (large elements, with vacuoles, toxic granulations, and polylobation). platelets are mildly decreased in number; large and giant forms are numerous. differential shows: 70% neutrophils, 13% lymphocytes, 4% monocytes, 4% eosinophils, 2% meta, 1% myelo, 4% blasts, 2% nrbc. aspirate smear: the aspirate is sub-optimal for evaluation. it contains no marrow spicules. erythroid precursors are virtually absent. myeloid precursors exhibit dysplastic maturation. erythroids are virtually absent, only rare orthonormoblasts are seen. granulocytes are markedly increased and are dysplastic. megakaryocytes are not seen. blasts focally constitute 20 to 30% of cellularity. touch preparations are similar. differential (500 cell): 18% blasts, 2% myelocytes, 5% metamyelocytes, 60% bands/neutrophils, 12% lymphocytes. clot section and biopsy slides: the core biopsy is adequate for evaluation. it consists of 12 mm long core of trabecular, cortical bone with some crush artifacts. overall, 80% of the marrow has an atypical cellular infiltrate with streaming of nuclear debris and histiocytes. the rest of the evaluable marrow has a 60% cellularity. the m:e ratio is increased. erythroid precursors are rare. myeloid precursors are decreased, are left shifted, and mildly dyspoietic. eosinophils are scattered. megakaryocytes and dysplastic forms are increased and loosely/tightly clustered. immature cells are present in clusters and singly and are estimated at 20-30% of marrow cells. : interpretation: 40~44,,(3)(p13),(5)(q12q32),-7,-8,-9,-13,-14,-15,de l(16)(q22),-17,-18,+-5/46,xy this abnormal karyotype is characteristic of a male with numerous structural and numerical chromosomal aberrations. small chromosome anomalies may not be detectable using the standard methods employed. this finding is similar to that previously reported on . . bm biopsy specimen: bone marrow aspirate and core biopsy. diagnosis: hypocellular marrow with extensive myelofibrosis and dysplastic hematopoiesis (see note). note: by immunohistochemistry, cd34 highlights blasts comprising 20-30% of marrow cellularity. cd42 highlights rare dysplastic megakaryocytes. overall, most of the findings are similar to those seen in a previous biopsy (s11-48147m; ). however, although the relative number of blasts is increased in comparison with the previous biopsy, the absolute number is lower. microscopic description peripheral blood smear: the peripheral smear is adequate for evaluation. erythrocytes are decreased in number and exhibit anisopoikilocytosis including targets, elliptocytes, dacrocytes, and occasional red cell fragments. -jolly bodies are seen. the white cell count is markedly decreased. neutrophils are absent. lymphocytes are markedly decreased, and include large granular forms. a rare immature monocyte is seen. platelets are decreased in number; large forms are not seen. blasts are not present. aspirate smear: the aspirate is inadequate for evaluation. in contains no marrow spicules. no hematopoietic precursors are seen. clot section and biopsy slides: the core biopsy is adequate for evaluation. it consists of 13 mm long core of trabecular marrow with focal aspiration artifact. the majority of marrow is replaced by fibrosis, with scattered dysplastic erythroid, myeloid, and megakaryocytic cells and overall cellularity not greater than 10%. as in the previous biopsy, extensive bone remodelling with woven bone formation is present. (rpt negative ) . 14:45 engraftment/chimerism test, post-transplant transplant information collected diagnosis transplant date donor last name donor sample --------- --------- --------------- --------------- -------------- aml id#0447-3457-2 engraftment/chimerism analysis collected sample type locus tested recipient sensitivity (%) blood se33 donor sensitivity (%) recipient results (%) donor results (%) 45 55 . bone marrow biopsy specimen: bone marrow aspirate and core biopsy. diagnosis: bone marrow with extensive involvement by patient's known leukemia, which exhibits extensive megakaryocytic differentiation. note: by immunohistochemistry cd34 highlights the majority of cells, including cells with obvious megakaryocyte differentiation. cd117 stains approximately 30% of all cells, which are predominantly mononuclear. cd42 stains differentiating magakaryocytes and many mononuclear cells. a similar pattern is observed with vwf. cd68 stains histiocytes as well as a small subset of mononuclear cells. cd33 stains a majority of cells. e-cadherin and glycophorin stain only rare small clusters of cells. combined these findings are consistent with acute myeloid leukemia with megakaryocytic differentiation. the findings in this biopsy are similar to those seen at first diagnosis of acute leukemia (see biopsy s11-25476m; ). . soft palate biopsy squamous mucosa and soft tissue with extensive necrosis and superinfection with mixed bacterial flora. no evidence of viral infection or lymphoid tumor seen in the sections examined (see note). blast trend 02:40pm blood neuts-69 bands-0 lymphs-15* monos-6 eos-3 baso-1 atyps-2* metas-2* myelos-0 promyel-1* blasts-1* nrbc-1* 12:00am blood neuts-69 bands-3 lymphs-14* monos-7 eos-3 baso-0 atyps-0 metas-0 myelos-0 blasts-4* 12:00am blood neuts-66 bands-1 lymphs-10* monos-3 eos-2 baso-1 atyps-0 metas-1* myelos-0 blasts-16* nrbc-1* 04:28pm blood neuts-63 bands-1 lymphs-17* monos-5 eos-3 baso-1 atyps-0 metas-0 myelos-0 blasts-10* 12:41am blood neuts-64 bands-1 lymphs-12* monos-2 eos-0 baso-0 atyps-0 metas-1* myelos-0 blasts-20* 06:43pm blood neuts-86* bands-0 lymphs-8* monos-2 eos-2 baso-0 atyps-0 metas-0 myelos-0 blasts-2* nrbc-7* 06:00am blood neuts-46* bands-0 lymphs-36 monos-10 eos-3 baso-1 atyps-0 metas-0 myelos-0 blasts-4* 12:00am blood neuts-26* bands-0 lymphs-42 monos-0 eos-2 baso-0 atyps-0 metas-0 myelos-0 blasts-30* 12:00am blood neuts-4* bands-0 lymphs-60* monos-0 eos-8* baso-0 atyps-0 metas-0 myelos-0 blasts-28* 10:40pm blood neuts-14* bands-0 lymphs-51* monos-14* eos-0 baso-0 atyps-0 metas-0 myelos-0 blasts-21* 12:00am blood neuts-0* bands-0 lymphs-87* monos-6 eos-0 baso-0 atyps-4* metas-0 myelos-0 blasts-3* 03:32pm blood neuts-0* bands-0 lymphs-80* monos-0 eos-0 baso-0 atyps-10* metas-0 myelos-0 blasts-10* 11:46pm blood neuts-0 bands-0 lymphs-65* monos-5 eos-0 baso-0 atyps-5* metas-0 myelos-0 blasts-25* 05:14pm blood neuts-84* bands-0 lymphs-0 monos-0 eos-0 baso-0 atyps-0 metas-10* myelos-0 blasts-6* 02:17am blood neuts-81* bands-4 lymphs-12* monos-3 eos-0 baso-0 atyps-0 metas-0 myelos-0 blasts-0 02:07am blood neuts-73* bands-1 lymphs-12* monos-6 eos-0 baso-0 atyps-1* metas-2* myelos-0 blasts-5* nrbc-3* 03:26am blood neuts-58 bands-0 lymphs-3* monos-0 eos-0 baso-0 atyps-0 metas-0 myelos-0 blasts-15* nrbc-2* other-24* 03:53am blood neuts-43* bands-1 lymphs-4* monos-3 eos-0 baso-1 atyps-4* metas-0 myelos-2* blasts-42* nrbc-1* other-0 12:00am blood neuts-37* bands-0 lymphs-2* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-0 blasts-59* nrbc-2* 12:15am blood neuts-30* bands-4 lymphs-9* monos-5 eos-0 baso-0 atyps-0 metas-0 myelos-0 blasts-52* 12:00am blood neuts-6* bands-0 lymphs-5* monos-0 eos-0 baso-0 atyps-1* metas-0 myelos-0 blasts-88* 12:52am blood neuts-2* bands-0 lymphs-3* monos-1* eos-0 baso-0 atyps-0 metas-0 myelos-0 blasts-94* brief hospital course: 64m with hx aml admitted w/r thigh pain, found during this admission to have relapsed aml after mud allo transplant and aml relapse after mec reinduction during this admission, hospital course complicated by febrile neutropenia, descending colitis/diarrhea, pseudomonas sepsis/pna, and r buccal inflammation requiring icr transfer & intubation with residual r retropharyngeal ulcer. given persistent relapse in face of overwhelming infection, patient was made dnr/dni and ultimately comfort measures only on . patient expired overnight from overwhelming pseudomonas sepsis secondary to refractory aml. . # relapsed aml patient was s/p mud transplant at time of admission. r thigh pain was imaged and seen to be c/w aml recurrence; bone marrow biopsy confirmed disease relapse. chimerism studies showed 50%/50% donor/host. given disease relapse after allotransplant, immunosuppression tapered off. he underwent mec reinduction d1 with hydroxyurea and . ldh elevation >4000 dropped markedly after mec & pt tolerated mec well, but initial post-treatment course was complicated by neutropenic fevers (see below). repeat bm bx on (day 15) and showed aml relapse again. blast count continued to rise to a maxium of 94% peripherally on . given persistent relapse in face of overwhelming infection, patient was made dnr/dni and ultimately comfort measures only on . # febrile neutropenia patient had fevers intermittently throughout admission. initially, given history of e. coli and vre bacteremia, he was empirically started on meropenem and daptomycin, then broadened to voriconazole given hx fungal pna. micro (including line cultures) and pan-ct scans were negative for sources of infection until on bcx grew gnr which speciated as pseudomonas auruginosa initially pan-sensitive except to meropenem. soon thereafter, he developed pna seen on chest imaging & bal sputum cx grew pseudomonas now with evolved resistances only sensitive to cipro/tobra/gent. neck soft tissue infection also likely contributed to fevers. in the icu, antibiotics were switched to tobra, linezolid, ambisome, zosyn. he was afebrile on at time of icu callout on dapto/cipro/vori. he became febrile again on ; at that time, possible infectious sources included pna and, although cultures remained negative, possible bacteremia from oral flora seeding from retropharyngeal ulcer site was considered an ongoing possibility. fever briefly subsided after restarting daptomycin, but returned shortly thereafter. pseudomonas from throat swab noted to have evolved resistance to ciprofloxacin along with mdr e. coli. patient was started on colistin on . fevers persisted and blood cutlures from showed gnr bacteremia. . # diarrhea/colitis diarrhea started . patient had hx pcr+ c diff so he was empirically started on po vancomycin. he also developed llq pain; a ct abd/pelvis obtained with concernf or tiflitis showed descending colitis. gastroenterology was consulted for question of infectious colitis vs gvh (especially off immunosuppression). he was made npo for bowel rest. tpn started . serial stool studies and cmv testing was negative. . # pseudomonas sepsis patient became septic with pseudomonal bacteremia from likely gi source. at time of icu transfer his urine output was wnl and he was mentating at baseline but he was having relative hypotension with bp ~15 pts below his baseline. briefly required levophed and vasopressin for bp support. he was persistently febrile even after blood pressure stabilized. . # right mandibular/tonsillar swelling, soft tissue infection pt developed acute-onset r buccal swelling and tenderness on the morning of which evolved rapidly throughout the subsequent 8 hours. swelling was intitially localized in right peri-molar buccal mucosa. there was initial question of whether the infection might have arisen from a r posterior molar, but omfs evaluation including ct face and panorex showed that the infection did not involve bone. urgent ent consult followed closely; no biopsy was performed given lack of drainable collection on imaging. as swelling evolved to includer peri-tonsillar soft tissue it caused airway obstruction which prompted icu transfer and intubation. repeated ct scans showed soft tissue swelling, no collection or abscess to drain. antibiotics were empirically broadened to tobra/linezolid/ ambisome/zosyn. soft tissue swelling gradually resolved but left residual r retropharyngeal ulcer after extubation persisted and was cleaned daily by ent. . # respiratory distress/intubation patient developed acute airway compromise neck/tonsillar soft tissue infection, with stridor on exam. intubated for airway protection for 11 days until patient had cuff leak, decreased secretions, and improvement in swelling. . #tonsillar necrosis/r retropharyngeal ulcer upon extubation necrosis of the right tonsil with open ulceration became apparent. tonsillar necrosis was treated supportively with normal saline washes and daily debridement by ent. ulcer continued to bleed at a low-level and patient was unable to manage oral secretions, so he required frequent suctioning. continued on daptomycin for gram positive coverage of oral bacteria, in case of translocation through necrotic tissue. flagyl was added for oral anaerobe coverage. given inability to swallow liquids or solids without aspirating, he was kept npo on tpn. . # pneumonia in the icu he developed a rul seen on cxr which was treated as ventilator associated pneumonia. sputum originally grew pseudomonas, with the same sensitivities as in blood, which was treated with zosyn with double coverage with tobramycin. sputum culture from showed that pseudomonas had evolved resistance to zosyn, at which time he was switched to ciprofloxacin. cxrs on the floor in setting of ongoing fevers showed persistent rul opacity c/w known pna. he continued to produce thick yellow-white sputum which was difficult to manage in combination with low-level bleeding from oral ulcer. repeat cultures from throat showed evolution of cipro resistance to the cipro and colistin was started as above. # tachycardia: patient with history of afib with rvr. patient was in sinus rhythym throughout this admission. ocasionally tachycardic in setting of fever but ekgs confirmed sinus tachycardia. became persistenly tachycardic with fevers and had two episodes of svt >200 on and broken by carotid massage. . # hx gerd: continued omeprazole 20 mg po daily, then transitioned to iv ppi once he was no longer tolerating pos. medications on admission: acyclovir 400 mg tablet tid cyclosporine modified 75 mg capsule q12h fluconazole 400 mg tablet qd folic acid 1 mg qd levothyroxine 75 mcg tablet qd metoprolol tartrate 12.5 mg daily mycophenolate mofetil 750 mg q 12 hours nystatin 100,000 unit/ml suspension 10 suspension(s) by mouth qid omeprazole 20 mg capsule daily saliva substitution combo no.2 solution 5 solution(s) qid sodium fluoride 1.1 % gel 1 gel(s) hs sulfamethoxazole-trimethoprim 400 mg-80 mg tablet qd ursodiol 300 mg capsule * otcs * aluminum hydroxide gel 600 mg/5 ml 30 suspensions q4h prn dyspepsia bisacodyl 10 mg tablet, delayed release (e.c.) qd prn constipation docusate sodium 100 mg capsule prn constipation magnesium oxide-mg aa chelate 133 mg tablet tid magnesium sulfate (bulk) 100 % crystals multivitamin tablet qd not taking: clotrimazole 10 mg troche 5x/day discharge medications: patient deceased discharge disposition: expired discharge diagnosis: primary: relapsed acute myelogenous leukemia, pseudomal septic shock secondary: polycythemia with myeloid metaplasia, ankylosing spondylitis, hypothyroidism discharge condition: deceased discharge instructions: n/a followup instructions: n/a procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow closed [endoscopic] biopsy of bronchus incision with removal of foreign body or device from skin and subcutaneous tissue nonexcisional debridement of wound, infection or burn injection or infusion of cancer chemotherapeutic substance injection or infusion of oxazolidinone class of antibiotics biopsy of uvula and soft palate diagnoses: acidosis esophageal reflux severe sepsis unspecified acquired hypothyroidism atrial fibrillation candidiasis of mouth hypopotassemia peripheral stem cells replaced by transplant other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure pneumonia due to pseudomonas other diseases of pharynx, not elsewhere classified septic shock do not resuscitate status hyperosmolality and/or hypernatremia ventilator associated pneumonia other and unspecified coagulation defects aseptic necrosis of head and neck of femur hypercalcemia neutropenia, unspecified jaundice, unspecified, not of newborn septicemia due to pseudomonas polycythemia vera infection with drug-resistant microorganisms, unspecified, with multiple drug resistance retropharyngeal abscess fever presenting with conditions classified elsewhere other diseases of respiratory system, not elsewhere classified cellulitis and abscess of neck enthesopathy of hip region ankylosing spondylitis other chronic disease of tonsils and adenoids acute myeloid leukemia, in relapse tumor lysis syndrome other pancytopenia intestinal infection due to other gram-negative bacteria myelofibrosis with myeloid metaplasia 

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