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: pancytopenia major surgical or invasive procedure: subclavian central venous catheter placement and removal bone marrow biopsies - right subclavian triple lumen central venous catheter placement and removal - bone marrow biopsies (three) - lumbar puncture and intrathecal methotrexate history of present illness: 66yo m w/ pmh s/f htn, seasonal allergies, osteoarthritis s/p l tka and r tha who is transferred from outside hospital with pancytopenia, recent weight loss (semi-intentional), and found to have blasts on peripheral smear by osh hematologist. he reports feeling mostly well prior to admission. he developed headache last weekend that he felt was related to his sinuses, given his h/o seasonal allergies. he then developed a sore throat earlier this week. he went to the va to be evaluated for possible sinusitis/uri and cbc was checked which revealed wbc of 1.8. he was referred to osh for further management. he was evaluated in the ed and a hematologist was consulted who examined the peripheral smear. smear showed 50% lymphocytes, 28% blasts, 2% metamyelocytes, 5% nrbcs. no clear cut auer rods but some blasts with significant granularity. patient was transfused 2u prbcs, started on allopurinol, 1/2ns w/ bicarb and k at osh and transferred here for further diagnostic workup. of note, pt. travels often to west coast and spent 10 weeks in this spring, returning . he reports allergic symptoms and lots of dust. also of note, pt. reports trying to lose weight recently with 9-10lb weight loss in last 1-2 months. denies fever, chills, night sweats, fatigue, unintentional weight loss, lymphadenopathy. denies rash, joint pain, nausea, vomiting, productive cough, diarrhea, brbpr, melena. past medical history: osteoarthritis, s/p l tka, r tha h/o negative colonoscopy-last hypertension seasonal allergies gerd social history: never married, no children. lives alone. retired fireman. u.s.m.c. veteran. denies ever smoking, no etoh, no illicits. travelled to for 10 weeks, returning 4/. family history: thinks he had an uncle w/ liver cancer. father died of aaa, mother of ?chf. multiple family members w/ cva as cause of death. no known h/o hematologic malignancies. physical exam: vs: 99.4 132/90 115 18 94%ra 231lbs gen: alert, anxious m appearing stated age in nad heent: nc/at, perrl, eomi, op w/o exudate/erythema, mm moist, no oral lesions, good dentition, no scleral pallor neck: supple, no submental, submandibular, supraclavicular, ant/post cervical, pre/post auricular lad skin: no rash, well healed vertical incision over l knee, bandaid over l chest cor: tachycardic but regular, no murmurs/rubs/gallops, +s1/s2 lungs: ctab, good air entry b/l, no rales/rhonchi/wheezes abd: slightly firm, nontender, nondistended, +bs, no hepatosplenomegaly, no rebound or guarding extremities: warm, no clubbing or edema, +onychomycosis on all toenails pertinent results: admission labs: 05:48pm blood wbc-2.3* rbc-3.69* hgb-10.5* hct-31.8* mcv-86 mch-28.4 mchc-32.9 rdw-17.1* plt ct-30* 05:48pm blood neuts-16* bands-1 lymphs-20 monos-0 eos-2 baso-0 atyps-1* metas-0 myelos-0 blasts-60* nrbc-5* other-0 05:48pm blood hypochr-1+ anisocy-occasional poiklo-normal macrocy-occasional microcy-normal polychr-1+ ovalocy-2+ 05:48pm blood pt-13.2 ptt-24.6 inr(pt)-1.1 05:48pm blood fibrino-665* 12:04am blood fibrino-607* 03:30pm blood esr-45* 12:00am blood gran ct-163* 05:48pm blood glucose-102* urean-25* creat-1.0 na-141 k-4.4 cl-102 hco3-31 angap-12 05:48pm blood alt-47* ast-37 ld(ldh)-396* alkphos-125 totbili-1.1 05:48pm blood albumin-4.3 calcium-9.6 phos-4.3 mg-2.1 uricacd-5.2 06:00am blood tsh-1.5 06:00am blood -negative . discharge labs: . pathology: flow cytometry: flow cytometry immunophenotyping the following tests (antibodies) were performed: cd2, cd3, cd4, cd5, cd7, cd8, cd10, cd13, cd14, cd15, cd19, cd20, cd33, cd34, cd41, cd11c, cd56, cd64, hla-dr, kappa, lambda, cd71, glyca, cd45, cd117. results: three color gating is performed (light scatter vs. cd45) to optimize blast yield. an abnormal population of events cluster within the blast gate. they comprise of approximately 37% of all events. these 'blasts' express cd7, cd34, cd13 (dim), cd33, cd11c(dim) and cd71. cd19 expression is equivocal. they are negative for cd20, cd10, cd3 (and other t-cell markers except cd7), cd64, cd14 and cd56. lymphoid gated events are unremarkable. interpretation increased blasts with predominantly myeloid markers, consistent with acute myeloid leukemia. morphological review shows blasts (~58%) with high n:c ratio, rare auer rods, scant paucigranular cytoplasm, irregular nuclear contours, and open chromatin. findings discussed with dr. on . . - bone marrow: by morphology and immunophenotype, the blasts appear to be of early myeloid differentiation (fab m1-2). however, cytogenetics and other molecular findings are necessary and should be correlated for an appropriate current who based classification. microscopic description peripheral blood smear: the smear is adequate for evaluation. erythrocytes are decreased in number and are normochromic and normocytic with mild anisopoikilocytosis. occasional ovalocytes, dacrocytes and polychromatophilic cells seen, 2 nucleated rbcs, 100 nucleated cells seen. the white blood cell count appears decreased. there is a predominance of large, immature forms with high nuclear cytoplasm ratio, scant agranular cytoplasm, prominent nucleoli and fine chromatin consistent with blast forms. rare auer rod identified. platelet count appears decreased. large forms are seen. giant forms are not present. differential shows 6% neutrophils, 0% bands, 0% monocytes, 28% lymphocytes, 2% eosinophils, 0% basophils, 63% blasts seen. - aspirate smear: the aspirate material is adequate for evaluation. the m:e ratio is 1.9:1. erythroid precursors show normoblastic maturation with occasional megaloblastoid forms, irregular nuclear contours, and rare nuclear buds. myeloid precursors consist of a predominance of blast forms. megakaryocytes are present in decreased numbers; abnormal forms are seen and include small hypolobated forms. differential shows: 62% blasts, 0% promyelocytes, <1% myelocytes, 0% metamyelocytes, 0% bands/neutrophils, <1% plasma cells, 3% lymphocytes, 33% erythroid. blasts comprise 62% of the aspirate and are large with fine chromatin, prominent nucleoli and scant cytoplasm. clot section and biopsy slides: the biopsy material is adequate for evaluation. prominent aspiration artifact is present. the overall cellularity of ~ 70% with 80% blasts. the m:e ratio estimate is normal. erythroid precursors are decreased and exhibit normoblastic maturation. myeloid elements are decreased and consist of predominantly blasts, without maturing hematopoiesis. megakaryocytes are markedly decreased. marrow clot section is similar to the biopsy. special stains: iron stain is adequate for evaluation. storage iron is normal. sideroblasts are present. ringed sideroblasts are absent. . - cytogenetics: karyotype: 46,xy interpretation: no cytogenetic aberrations were identified in 20 metaphases analyzed from this unstimulated specimen. this normal result does not exclude a neoplastic proliferation. mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. -------------------interphase fish analysis, 100-300 cells------------------- nuc ish(d5s23,d5s721,egr1)x2,(d7z1,d7s522)x2, (d20s108x2) fish evaluation for a 5q deletion was performed with the vysis lsi egr1/d5s23, d5s721 dual color probe ( molecular) for egr1 at 5q31 and d5s721/d5s23 at 5p15.2 and is interpreted as normal. two egr1 hybridization signals were observed in 100/100 nuclei examined, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 3% of cells in normal samples can show apparent 5q deletion using this probe set. a normal egr1 fish finding can result from absence of a 5q deletion, from a 5q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. fish evaluation for a 7q deletion was performed with the vysis d7s522/cep7 dual color probe ( molecular) for d7s522 at 7q31 and cep7 (d7z1) (chromosome 7 alpha satellite dna) at 7p11.1-q11.1 and is interpreted as normal. two d7s522 hybridization signals were observed in 100/100 nuclei, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 3% of cells in normal samples can show apparent 7q deletion using this probe set. a normal d7s522 fish finding can result from the absence of a 7q deletion, from a 7q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. fish evaluation for a 20q deletion was performed with the vysis lsi d20s108 probe ( molecular) at 20q12 and is interpreted as normal. two hybridization signals were observed in 98/100 nuclei examined, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 8% of cells in normal samples can show apparent 20q deletion using this probe set. a normal 20q fish finding can result from absence of a 20q deletion, from a 20q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. . bone marrow : peripheral blood smear: the smear is adequate. erythrocytes are decreased and exhibit moderate anisocytosis and poikilocytosis. scattered microcytes, echinocytes, elliptocytes, dacrocytes and red cell fragments are seen. rare shistocytes are seen on scanning. the white blood cell count appears markedly decreased and includes large immature myeloid forms consistent with blasts. lymphocytes include small mature and large reactive forms. platelet count appears moderately decreased. large forms are seen. differential count shows 0% neutrophils, 0% bands, 4% monocytes, 89% lymphocytes, 0% eosinophils, 7% blasts. aspirate smear: the aspirate material is adequate for evaluation and is predominantly comprised of large atypical myeloid forms with one to several prominent nucleoli consistent with blasts. erythroid precursors are markedly decreased. rare maturing forms are present. maturing myeloid precursors are greatly decreased in number. megakaryocytes are present in normal numbers. differential (300 cells) shows: 72% blasts, 2% promyelocytes, <1% myelocytes, <1% metamyelocytes, <1% bands/neutrophils, 3% plasma cells, 18% lymphocytes, 5% erythroid. clot section and biopsy slides: the biopsy material is adequate for evaluation. the overall cellularity is approximately 40% and is comprised almost entirely of large blast forms present in large clusters. the blasts comprise 70-80% of overall marrow cellularity. the remainder of the cellular components are made up of lymphocytes, plasma cells and rare maturing myeloid and erythroid precursors. megakaryocytes are present. . - bone marrow : <<<< >>> . imaging: - tte: the left atrium is elongated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets are mildly thickened (?#). there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. impression: suboptimal image quality. mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. biatrial dilation. . - cxr: no previous images. there is some apparent hyperexpansion of the lungs suggesting some chronic pulmonary disease. however, no evidence of acute pneumonia, vascular congestion, or pleural effusion. right subclavian picc line extends to the mid portion of the svc. no evidenceof pneumothorax. . - cxr: aside from atelectasis in the left base the lungs are clear. there are low lung volumes. cardiomediastinal contours are normal. right picc tip is in the mid svc. . - ct chest w/o con: 4.5-mm right lower lobe nodule. suggest repeat examination in six months.multifocal subsegmental atelectasis, not obstructive. coronary calcification. . - ct chest/abd/pelvis: no abnormal interstitial lung process or site of infection identified. interval increase in number of mediastinal nodes extensively, but no single pathologically enlarged lymph node. . - cta chest: 1. limited ct examination due to respiratory artifact. no proximal or segmental pulmonary emboli identified. more distal branches obscured due to poor filling and breathing artifact. if a high clinical concern for embolus, a dedicated v/q scan could be obtained if patient is able to tolerate as the lungs. slightly increased linear atelectasis. 2. unchanged small mediastinal lymph nodes of uncertain etiology. 3. atherosclerotic calcification within the coronary vessels. small-to-moderate hiatal hernia. 4. stable right-sided pulmonary nodules as detailed above; can be followed in six months as suggested on initial ct chest. . - ct abdomen/pelvis: mild delayed right nephrogram with high-density filling defect within the posterior calices of the right upper pole, most consistent with underlying clot. there is mild right hydronephrosis and proximal-mid hydroureter with abrupt cutoff of contras column in the mid-distal ureter. this may reflect more distal intraureteral clot, although a focal obstructing lesion cannot be completely excluded. can consider correlation with follow up ct or further evaluation with dedicated mr urogram or ureteroscopy as needed. - bone marrow biopsy: markedly hypocellular bone marrow with features consistent with chemotherapy-induce marrow ablation. there is no morphologic evidence of involvement by acute myeloid leukemia. - renal u/s: mild to moderate right and mild left hydronephrosis. - mri c and t spine, brachial plexus: no abnormal cervical or thoracic spine enhancement. limited study by motion, but grossly normal mr appearance of the brachial plexus bilaterally. - ct chest w/o contrast: redemonstration of tiny pulmonary nodules as detailed above, the largest of which is approximately 5 mm. would recommend repeat evaluation with a dedicated ct of the chest in approximately six months. - bone marrow biopsy: hypocellular marrow with erythroid dominant elements. diagnostic features of involvement by acute myeloid leukemia are not seen, by immunohistochemical stains, cd34 reactive blasts comprised <5% of overall marrow cellularity. e-cadherin expression is present in scattered clusters of early erythroid precursors, while glycophorin a highlights numerous maturing erythroid forms. - urine cytology: rare cluster of atypical but degenerated urothelial cells. brief hospital course: 66yo m w/ unrelated pmh presented to osh, found to have pancytopenia w/ blasts in smear, transferred and found to have aml on flow cytometry and bone marrow biopsy. . # aml: patient was admitted and found to be pancytopenic but asymptomatic except a chronic non-productive cough that was attributed to seasonal allergies. he underwent tte which showed normal lvef. he underwent bone marrow biopsy on which confirmed diagnosis of aml. a triple lumen subclavian cvl was placed on . he was started on 7+3 induction therapy on . he tolerated the infusion well and his anc fell to 0 on . he was thrombocytopenic and developed gingival bleeding with plt in the 30s and was transfused as needed. he was also anemic and transfused as needed. repeat bone marrow showed hypercellularity. patient was started on mec therapy and tolerated it well. his anc remained 0. repeat bone marrow on d14 of mec showed hypocellularity. his counts gradually increased and antibiotics were discontinued, he had been on broad coverage with vancomycin, cefepime, and ambisome (spent a lot of time in ) and remained on these antibiotics until he was no longer neutropenic or febrile. counts continued to increase and at the time of discharge pt was no longer neutropenic and wbc was 4.1. bone marrow biopsy on showed no clonal cytogenetic aberrations and <5% blasts. however, skin biopsy for a purple-pink papular rash on both forearms with biopsy was consistent with leukemia cutis. considering his bone marrow response and the resolution of this rash, it was thought to be rseolved. he will followup with dr. for futher treatment. . # febrile neutropenia: as counts decreased, the patient was febrile without obvious source in urine or lungs and was started on cefepime and vancomycin and levofloxacin which had been prescribed for cough was discontinued. given the concern for hemorrhoids and possible minor anal mucosal tear, see below, flagyl was added. micafungin was added on day 4 after first spike given continued fevers. pt. felt well and was ambulatory, taking po during this time. patient clinically improved, but then developed high fevers, rigors, and whole-body rash, respiratory distress (see icu course below). he was pan-scanned again, and ct sinus showed sinusitis. coccidio, beta-glucan, galactmannan, histoplasmosis, legionella, blood fungal cultures were sent and were all eventually negative. id was consulted and suggested removing cefepime and micafungin as they might cause rash. he was placed on vancomycin, meropenem, and ambisome (for aspergillus and coccidiomycosis coverage). patient had risen lfts which eventually trended down. he improved clinically and antibiotic coverage was stopped on when patient had been afebrile for several days and anc >1000. beta glucan from was >500. id was consulted again and advised to recheck beta glucan, as it may have been an erroneous result, since he was asymptomatic and had stable lesions on chest ct from , and also requested a mycof/lytic culture. these results are to be followed up as an outpatient and no antifungal coverage or liver/spleen imaging were advised unlses the he spiked a fever, which he did not do. . # guaiac positive stool: patient reported hard and painful bm during induction therapy. bloody streaks were seen on stool, minimal blood in toilet. platelets transfused, hct stable. bowel regimen increased and further bms were guaiac neg and soft for the rest of his hospital course. #hematuria: noted to have hematuria in the setting of thrombocytopenia. ct abd/pelvis showed mild r hydronephrosis and proximal-mid hydroureter on . hematuria resolved as thrombocytopenia resolved, platelets were transfused for <10. f/u ultrasound showed bilateral hydronephrosis in the setting of increasing creatinine, urology was consulted concerning the hydronephrosis and advised that he follow up as an outpatient for a hematuria workup. . #thrombocytopenia: pt had low platelets as expected and was transfused prn for platelets <10. on , had urticarial reaction to crossmatched platelets that improved with tylenol, pra assay positive. thrombocytopenia improved without intervention as the rest of counts went up as well. #acute kidney injury: patient's creatinine was elevated starting from baseilne of 0.9 to 1.8 on despite removal of nephrotoxic vancomycin and ambisome on . renal was consulted and considering fena of 2.1, was thought to be due to ain, although it is unclear which medication caused this. he did have a drug rash earlier in his hospital course, thought to be related to micafungin or meropenem, but it is unclear what caused the ain. he will followup with renal service as an outpatient. #l 4th and 5th finger numbness: patient had noted this consistently for a week and mentioned it on . mri t and c spine and brachail plexus were ordered to eval for cns spread of disease, in addition lp was done. no lesions on mri and no evidence of cns disease. numbness may be ulnar neuropathy, he will follow up in neurology clinic and may get an emg. . icu course () hypoxia: pt with increased o2 demand and some respiratory distress which lead to his brief transfer from the onc service to the . pt was initially given nebs, changed from nc to facemask, and given iv lasix. he was redosed with lasix with good urine output. cxr showed no change and echo was obtained. pt o2 requirement stabilized and he was titrated down to lower dose nasal cannula. . febrile neutropenia: temp of 101.4 at time of icu transfer. broad spectrum antibiotics were continued but elevated lfts raised concern over the administration of fluconazole. because of the pts significant travel history to some fungal endemic regions it was determined to treat emperically with ambisome so this was started and fluconazole d/ced. near the end of the first ambisome infusion pt spiked a fever above 104 and had chills/rigors. this calmed down with demerol and tylenol and was thought likely due to the infusion vs an infectious cause. . pancytopenia: this was thought to aml and chemo with hgb low on icu presentation. over brief icu course 1 unit of prbc was initially given followed by 2 units prbc the next day. pt had mild temp at time of beginning of the 2nd transfusion but it was administered in spite of this. hct responded appropriately to these infusions. . medications on admission: home: diovan 80mg po daily aspirin 81mg po daily omeprazole 20mg po daily multiple vitamins, incl. mvi, b complex . on transfer: allopurinol 300mg po daily ambien 5mg po qhs prn insomnia colace 100mg po bid dulcolax 10mg po qam prn constipation milk of magnesia q6h prn constipation mylanta 30ml po q4h prn procardia xl 30mg po daily protonix 40mg po daily reglan 10mg iv q6h prn nausea robitussin 10ml po q4h prn cough tylenol 650mg po q6h prn zofran 4mg iv q8h prn nausea discharge medications: 1. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 2. acyclovir 400 mg tablet sig: one (1) tablet po q12h (every 12 hours). disp:*60 tablet(s)* refills:*2* 3. nifedipine 30 mg tablet extended rel 24 hr sig: one (1) tablet extended rel 24 hr po once a day. disp:*30 tablet extended rel 24 hr(s)* refills:*2* 4. guaifenesin 100 mg/5 ml syrup sig: 5-10 mls po q6h (every 6 hours) as needed for coughing. discharge disposition: home discharge diagnosis: primary: acute myelogenous leukemia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: mr. , you were admitted to the because you had low blood count. we obtained a bone marrow biopsy which showed that you had acute myelogenous leukemia. you were started on chemotherapy. your cell counts dropped as expected, and you developed a fever. we did ct scans of your sinus, chest, and abdomen to look for a source of infeciton. we treated you with many antibiotics. one of the antibiotics gave you a rash, which resolved after we stopped it. you had a repeat bone marrow biopsy which still showed leukemia, so you underwent a second round of chemotherapy. while you white blood cell counts were at their nadir, you have difficulty breathing and spiked high fevers with rigors for many days. we continued with medications to treat bacterial or fungal infections. you eventually got better and did not have any more fevers and your white blood cell counts increased (including neutrophil count) and we stopped your antibiotics. we did a final bone marrow biopsy which showed <5% blasts, indicating a good response. you will follow up with dr. on friday to discuss the next steps in your treatment. your creatinine was increasing (number that shows kidney function), which we think is likely due to acute interstitial nephritis (allergic reaction in your kidneys likely from medications). you should follow up with urology clinic and renal clinic about this and the blood in your urine you had a couple of weeks ago. you should also follow up in neurology clinic so they can check on the numbness in your left hand. your sutures can be taken out in one week (around ), this can be done at clinic. . we made the following changes to your medications: stop taking diovan start taking nifedipine (procardia) start taking acyclovir followup instructions: provider: . & phone: date/time: 4:00 (neurology-finger numbness) provider: , md phone: date/time: 3:00 (renal-kidneys) provider: , md phone: date/time: 2:00 (oncologist-leukemia) 02:00p , c. (urology, for blood in your urine) procedure: venous catheterization, not elsewhere classified injection or infusion of thrombolytic agent biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow biopsy of bone marrow closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance injection or infusion of cancer chemotherapeutic substance injection of other agent into spinal canal diagnoses: thrombocytopenia, unspecified coronary atherosclerosis of native coronary artery esophageal reflux acute kidney failure, unspecified pulmonary collapse dysthymic disorder other and unspecified hyperlipidemia acute respiratory failure antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use other constipation other diseases of lung, not elsewhere classified hypoxemia hemorrhage of gastrointestinal tract, unspecified hydronephrosis drug induced neutropenia knee joint replacement tachycardia, unspecified hematuria, unspecified other abnormal blood chemistry chronic maxillary sinusitis hip joint replacement anemia in neoplastic disease lesion of ulnar nerve displacement of lumbar intervertebral disc without myelopathy other specified disorders of skin acute myeloid leukemia, without mention of having achieved remission chronic sphenoidal sinusitis fever presenting with conditions classified elsewhere cough encounter for antineoplastic chemotherapy other specified periodontal diseases chronic ethmoidal sinusitis 

Answer: The patient is high likely exposed to