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: bactrim attending: chief complaint: lymphoma major surgical or invasive procedure: dialysis catheter placement for cvvh central line placement history of present illness: 62 y.o. female w/ h.o. hl, hypothyroidism presented initially at osh w/ fatigue, insomnia found to be high grade lymphoma. transferred for further management from . admitted to the icu for cvvh for possible tumour lysis syndrome. pt states that 4 weeks ago she noted some jaw pain as well as total body weakness, malaise, "body burning sensation". she had also noted some decreased appetite to food and water, insomnia accompanied by a bloating sensation in her abdomen. she saw her pcp last for a check up and received bld work which was noted to be 'abnormal'. unfortunately she was not told what labs were abnormal, given her malaise she decided to come to the ed. in the ed she was noted to have a leukocytosis of 27.2, in addition to w/ creatinine of 2.2, plt 66, ldh 25, 348. she was initially given ceftriaxone for ?uti given appearance of her urine. 4+ bacteria, wbc were seen on a u/a that was notable for squamous cells. as part of her work up she underwent a ct torso which showed left subclavian node, retroperitoneal adenopathy, l hydronephrosis. she was then referred to the ed on day of admission. in the ed her initial vitals were noted to be t99.0, hr 110, bp 126/72, rr 14, sat 99%. her labs were notable for a leukocytosis of 28.4 with 29n, band 4, l 23, m14, e11, b1, meta5, myelos1, nrbcs5, other 12. bun/creatinine 38/2.4, glc 66. uric acid 26.3, ldh 26, 420, ast 211, alt 65, ca .4, k 3.8, ph 4.2, tuberculosis 1.6, alk phos 477. fibrinogen 266. oncology were consulted given the suspicion for lymphoma and obtained a bm bx, cytology was obtained from aspirate. review of systems: (+)ve: (-)ve: measured fevers, chest pain, palpitations, cough, nausea, vomiting, diarrhea, constipation past medical history: hypothyroidism hyperlipidemia social history: pt currently works as a system analyst at nhic. she denies any etoh, tobacco or ivdu history. family history: sister - cirrhosis, brother - dm, anterograde amnesia. denies any h.o. lymphoma or other malignancies physical exam: general: fatigued appearing caucasian female lying down in bned in nard heent: no scleral icterus, perrl, eomi. neck: no lad noted. cardiac: regular rhythm, tachy (110 bpm). normal s1, s2. no murmurs, rubs or . lungs: ctab, good air movement biaterally. abdomen: soft, distended, tender in the epigastric region. no hsm extremities: no edema noted. neuro: a&ox3. appropriate. cn 2-12 grossly intact. preserved sensation throughout. 5/5 strength throughout. psych: listens and responds to questions appropriately, pleasant pertinent results: labs on admission: fibrinoge-522* pt-14.9* ptt-24.4 inr(pt)-1.3* plt smr-low plt count-109* hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal neuts-29* bands-4 lymphs-23 monos-14* eos-11* basos-1 atyps-12* metas-5* myelos-1* nuc rbcs-5* other-0 wbc-28.4* rbc-3.67* hgb-10.9* hct-31.4* mcv-86 mch-29.8 mchc-34.8 rdw-14.5 haptoglob-7* calcium-11.4* phosphate-4.2 magnesium-2.1 uric acid-26.3* alt(sgpt)-65* ast(sgot)-211* ld(ldh)-* alk phos-477* tot bili-1.6* estgfr-using this glucose-66* urea n-38* creat-2.4* sodium-138 potassium-3.8 chloride-105 total co2-15* anion gap-22* bone marrow ipt-done bone marrow cd34-done cd3-done cd4-done cd8-done bone marrow -g-done cd33-done cd41-done cd56-done cd64-done cd71-done cd117-done cd45-done hla-dr a-done kappa-done cd2-done cd7-done cd10-done cd11c-done cd14-done cd15-done cd19-done cd20-done lambda-done cd5-done iron-done sed rate-62* fibrinoge-538* pt-15.5* ptt-23.1 inr(pt)-1.4* pep-no specifi crp-34.3* d-dimer-580* tot prot-5.0* calcium-10.6* phosphate-4.9* magnesium-2.2 ld(ldh)-* creat-2.9* potassium-3.4 hiv ab-negative calcium-10.6* phosphate-5.0* magnesium-2.1 ld(ldh)-* creat-2.8* sodium-134 potassium-3.5 chloride-93*flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, glycophorin a, kappa, lambda, and cd antigens 2, 3, 4, 5, 7, 8, 10, 11c, 14, 15, 19, 20, 33, 34, 41, 45, 56, 64, 71, 117. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. lymphoma cells comprise 20% of total gated events. t cells comprise 72% of lymphoid gated events, express mature lineage antigens, and have a helper-cytotoxic ratio of 1.6. no abnormal events are identified in the "blast gate." interpretation immunophenotypic findings consistent with involvement by a kappa restricted cd10 positive b-cell lymphoproliferative disorder. the immunophenotypic profile in concert with the morphologic features of the lymphoma on the bone marrow smear and core biopsy are consistent with burkitt's lymphoma. see s10- for correlation with morphology. specimen: bone marrow aspirate and core biopsy: diagnosis: hypercellular marrow entirely replaced by a high grade lymphoid tumor with morphologic and immunophenotypic features consistent with burkitt lymphoma (see note). microscopic description peripheral blood smear: erythrocytes appear decreased in number, and show mild anisocytosis. occasional polychromatophilic cells present. 13 nucleated rbcs per 100 wbcs present. the white blood cell count appears increased. there is absolute lymphocytosis. about 50% of the lymphocytes are medium to large, with an irregular nucleus with prominent one or more nucleoli. cytoplasm is deep basophilic and shows vacuoles. occasional neutrophil shows hypogranular cytoplasm with unsegmented nuclei. platelet count appears decreased. differential count shows 24% neutrophils, 1% bands, 2% monocytes, 52% lymphocytes, 17% eosinophils, 2% myelocytes, 2% metamyelocytes. aspirate smear: the aspirate material is adequate for evaluation. the m:e ratio cannot be reliably assessed since the marrow is replaced by a lymphoproliferative process. erythroid precursors are relatively reduced. myeloid precursors appear markedly decreased. megakaryocytes are present in decreased numbers. differential shows: <1% blasts, <1% promyelocytes, <1% myelocytes, <1% metamyelocytes, 4.2% bands/neutrophils, <!% plasma cells, 2.6% lymphocytes, 1.8% erythroid, 90% medium size blasts with basophilic cytoplasm with numerous vacuoles. clot section and biopsy slides: the biopsy material is adequate for evaluation, and consists of a core biopsy of paratrabecular bone measuring 2.2 cm. cellularity is 80%. the marrow is almost entirely replaced by a population of medium to large atypical lymphoid cells interspersed with tingible body macrophages. lymphoma cells exhibit nuclei with blastic chromatin with multiple nucleoli, and contain moderate amounts of amphophilic cytoplasm. normal hematopoietic elements greatly decreased. rare megakaryocytes are present. marrow clot section consists of bone marrow similar to biopsy and fibrocollagenous tissue. special stains: storage iron cannot be assessed due to absence of spicules and erythroblasts (marrow completely replaced by lymphoma cytogenetics pending as of cxr- impression: no acute cardiopulmonary process. low lung volumes tte: the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. there is no aortic valve stenosis. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: normal biventricular systolic function. mild pulmonary hypertension. liver or gallbladder us (single organ) port 1. no intra- or extra-hepatic biliary dilatation. cbd 2-mm. no evidence of cholecystitis. 2. as seen on recent outside hospital ct, several subcentimeter non- obstructing right renal calculi, and mild left hydronephrosis without left renal calculi. hydronephrosis is likely related to extensive retroperitoneal soft tissue density mass (likely nodes), seen on the outside hospital ct. 3. mild splenomegaly 3. incidentally noted, enlarged uterus csf ()- negative for malignant cells. flow cytometry ()- cell marker analysis demonstrates a t cell dominant lymphoid profile and diagnostic immunophenotypic features of involvement by a non-hodgkin b-cell lymphoma are not seen in specimen. a small population of cd45 (moderate) positive cells is noted comprising 3% of total analyzed cells. review of corresponding blood smear showed occasional immature-appearing mononuclear cells, morphologically consistent with blasts. flow cytometry ()- non-specific t cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. bm biopsy ()- - normocellular myeloid dominant marrow with myeloid left-shift, megakaryocytic hyperplasia and erythroid hypoplasia. - no diagnostic morphologic features of lymphoma seen. cytogenetics ()- no cytogenetic aberrations were identified in 20 metaphases analyzed from this unstimulated specimen. csf ()- negative for malignant cells. csf ()- negative for malignant cells. brief hospital course: ##. burkitt's lymphoma: pt was seen by heme/onc in ed, and bone marrow bx performed at that time. prelim read from heme-path suggesteded large cell lymphoma w/ vacuoles suggestive of possible burkitt's lymphoma. treatment was initiated with steroids. the patient began spontaneous tumor lysis prior to induction of chemotherapy. nephrology was consulted and patient was started on cvvh. pt received rasburicase for uric acid converion with good response as well as allopurinol. patient was then initiated on codox. received daily dexamethasone and cytoxan. she remained on cvvh with tumor lysis labs stable and ldh steadily trending down. dic labs remained wnl. ebv, cmv, hiv viral loads were negative. tte was done to evaluate baseline function prior to doxorubicin. doxorubicin and vincristine were administered on . methotrexate was given on , vincristine on and intrathecal cytarabine on . cytopathology-immunophenotyping from the csf fluid obtained on was positive for presence of lymphoma. she was started on acyclovir and received pentamidine for prophylaxis. she completed codox and was then started on ivac on . counts were slow to recover. ct scan showed bilateral pleural effusions (l>r). concern for methotraxate collecting in pleural fluid leading to persistent neutropenic and poor recovery of counts. interventional pulmonary team was consulted and drained 250cc of pleural fluid from left side on . no signs on infection were found in the fluid. patient's anc recovered almost immediately (- 0, - 129, - 594). repeat bm biopsy and csf studies showed no disease. while receiving ivac, she developed visual hallucinations, arm/leg tingling (no numbness) and increased anxiety. this was attributed to ifosphamide and, therefore, her 5th dose of the drug was not administered. her symptoms improved daily after ivac course was completed. she was on neupogen from . she received it methotrexate on and it-cytarabine on . her counts responded appropriately. plan after discharge is to begin codox-m therapy. she has an appointment scheduled with dr. (admitting physician) on / ##. rue thrombosis: the patient noted right upper extremity swelling. ultrasound was obtained, which demonstrated thrombosis in the right brachial and basilic veins. she was not anticoagulated given her significant thrombocytopenia. u/s repeated on which showed no progression of clot. picc line was kept in right arm but was eventually pulled due to vre-positive cultures (see below). ## c. difficile associated disease: she noted loose bowel movements, with c. diff antigen returning positive on . she was started on iv flagyl and po vanc. diarrhea eventually resolved. id was consulted re: duration of therapy. they recommended checking stool for c.diff antigen and if negative than to discontinue antibiotics. stool checked on was negative for c.diff so antibiotics were discontined on . she then developed recurrent diarrhea on and was empirically treated for c diff. she had 2 stool samples negative for c. diff at this time, but was treated with a course of oral vancomycin to be continued after discharge, at least until her next oncology appointment (scheduled for ). ## febrile neutropenia: she was noted to have a fever in the setting of neutropenia. she was started on vancomycin, cefepime, and micafungin. she developed a diffuse rash shortly after initiation of antibiotics. derm was consulted- performed biopsy which showed "intraepidermal vesicles and underlying linear track of ischemia with adjacent dermal inflammation with eosinophils". her rash was consistent with a drug eruption and cefepime was thought to be the culprit. cefepime was discontinued and patient was started on aztreonam (in addition to vancomycin). rash resolved shortly thereafter. the c. difficile antigen returned positive and she was started on flagyl. she was continued on antibiotics while neutropenic. antibiotics were discontinued as patient was afebrile and cultures remained negative. she again developed fevers on . cultures were drawn and grew back vre. patient was started on daptomycin and picc line was pulled. a central line (left ij) was placed after 48 hours. surveillance cultures were negative. daptomycin was continued until . upon discharge, she was no longer neutropenic and afebrile. ##. : likely due to uric acid stones and urate nephropathy, in additon to hydronephrosis due to external compression by retroperitoneal tumor. pt on cvvh during cytoxan treatment. renal function returned to baseline and remained stable off cvvh. ##. hematuria: patient began having hematuria after foley placement that worsened with initiation of cytoxan. she was also having bladder pain. she was started on continuous bladder irrigation for concern of hemorrhagic cystitis. hematuria eventually resolved as did pain. it seemed likely that patient passed uric acid stone. cbi was stopped and patient continued to make adequate urine. ##. tachycardia: on review of osh records pt has been persistently sinus tachycardic, likely related to her underlying lymphoma. she remained tachycardic (95-115) throughout her course here. she denied chest pain, palpitations, dizziness or syncope. ##. ?uti: pt was given iv ceftriaxone for ?uti however u/a was notable for several epi cells in addition to bacteria. no dysuria noted, urine appearance likely related to her . repeat urine cx neg x 2. pt was not further treated. ##. hypothyroidism: continued on home regimen of hypothyroidism. ##. anxiety- patient was quite anxious while here. it worsened after she received ifosphamide. standing clonazepam was added to her prn ativan ordered with good control of her anxiety. she was discharged on prn clonazepam but if anxiety is a problem in the future for her, she may need to be changed back to standing clonazepam. ##. fluid overload- patient received iv fluids with chemotherapy and became quite fluid-overloaded. weight was up to 210+ pounds with 3+ pitting edema in bilateral lower extremities. she received one-time doses of iv lasix and responded very well to them. she eventually began auto-diuresing and no longer required lasix. her weight on discharge was near 170 pounds with no signs of fluid overload on physical exam. medications on admission: levothyroxine 100mcg daily furosemide dose unknown daily lipitor unknown calcium vitamin d discharge medications: 1. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 2. acyclovir 400 mg tablet sig: one (1) tablet po q8h (every 8 hours). disp:*90 tablet(s)* refills:*2* 3. levothyroxine 100 mcg tablet sig: one (1) tablet po daily (daily). 4. clonazepam 0.5 mg tablet sig: one (1) tablet po tid (3 times a day) as needed for anxiety. disp:*90 tablet(s)* refills:*2* 5. vancomycin 125 mg capsule sig: one y five (125) mg po four times a day for 7 days. disp:*7 days* refills:*3* 6. potassium chloride 20 meq tab sust.rel. particle/crystal sig: two (2) tab sust.rel. particle/crystal po once a day. disp:*60 tab sust.rel. particle/crystal(s)* refills:*2* 7. bactrim 400-80 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna discharge diagnosis: primary diagnosis: burkitt's lymphoma secondary diagnosis: diarrhea acute renal failure (resolved) discharge condition: good. vital signs stable. discharge instructions: you presented to the hospital with altered mental status and confusion. you initally were admitted to the intensive care unit given your condition. you underwent hemodialysis and once you were stable, you were transferred to the hematologic malignancy service for the remainder of your stay. you completed a round of chemotherapy while here and tolerated it very well. your kidney function returned to and your most recent bone marrow was free of disease. upon discharge, you were stable and doing well. the following changes were made to your medications: 1. start taking fluconzole 200mg by mouth daily 2. start taking acyclovir 400mg by mouth three times per day 3. start taking vancomycin 125mg by mouth four times per day 4. start taking potassium chloride 40milliequivalents/day 5. start taking bactrim 1 single strength tablet daily 6. start taking clonazepam 0.5mg three times daily as needed for anxiety followup instructions: please follow-up in clinic. you have the following appointment scheduled: provider: . date/time: monday, at 11:00am location: of building, phone: procedure: hemodialysis venous catheterization for renal dialysis thoracentesis biopsy of bone marrow closed biopsy of skin and subcutaneous tissue injection or infusion of cancer chemotherapeutic substance diagnoses: acidosis acute kidney failure, unspecified unspecified acquired hypothyroidism other and unspecified hyperlipidemia anxiety state, unspecified other specified cardiac dysrhythmias bacteremia intestinal infection due to clostridium difficile dermatitis due to drugs and medicines taken internally streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] other specified antibiotics causing adverse effects in therapeutic use hematuria, unspecified neutropenia, unspecified fever presenting with conditions classified elsewhere burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites acute venous embolism and thrombosis of deep veins of upper extremity 

Answer: The patient is high likely exposed to