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: codeine / nsaids / lamotrigine attending: chief complaint: seizures major surgical or invasive procedure: dr. craniotomy for open brain biopsy history of present illness: the pt is a 74 yom with a history of complex partial seizure and sometimes secondary generalization. presented with by his wife with mental status change, at 11am was confused with slurred speech, there noted to be hypertensive 210/106 (patient not taking medications as prescribed), nchct was normal and then admitted for management of seizures and htn. zonegran was decreased to 100mg daily, continue keppra and started topamax 25mg daily, eeg showed pleds every 1- 1.5 seconds followed by generalized slowing, --> thought to be in partial complex status, keppra 500mg and loaded with dilantin 250mg iv and 200mg po. topamax was further increased to 50mg . was called and patient transferred for further management. past medical history: seizure hx: multiple complex partial seizures sometimes with secondary generalization: 1st sz , semiology: garbled speech, disorientation, currently on: keppra, zonegran, aeds in past: lamictal --> d/c tremors t8-t9 extramedullary intradural thoracic meningioma sp resection in c/b seroma at the site of his surgical incision found to be growing mrsa. dvt in ; ? pe (no documentation) ? pres : (mri of the brain that showed increased t2 hyperintensities in the bilateral occipital and posterior right parietal lobe consistent with posterior reversible encephalopathy syndrome) vertebral artery stenoses (b/l) tremor (thought to be medication related and not parkinsonian, large amplitude) neuropathy: burning in toes bilaterally htn - amitriptyline hl - lipitor, pvd - left leg bypass done by dr. in for 65% stenosis of a right leg artery. hx of asystole 30secs, requiring chest compressions social history: he finished high school. he was a former butcher. he is retired. he is married to . does not smoke cigarettes, drink alcohol, or use any illegal drugs. he did skip the first grade. he had no learning disabilities. family history: his maternal uncle had 2 children and both of these cousins had epilepsy. the patient himself has no history of birth complications, or head trauma. physical exam: at admission: vitals: t: afebrile p: 76 r: 16 bp: 142/72 sao2: 96%ra general: alert, comfortable, confused and perseverative heent: nc/at, no scleral icterus noted, mmm, no lesions noted in oropharynx neck: supple, no carotid bruits appreciated. no nuchal rigidity pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented to person only. not able to relate history given perseveration and confusion. attentive but not able to follow commands "stick out your tongue, show me your teeth". language is fluent with impaired repetition and impaired comprehension. pt. was not able to name both high and low frequency objects. speech was not dysarthric. not able to follow both midline and appendicular commands. memory was not assessed. apraxia / neglect could not be assessed. -cranial nerves: i: olfaction not tested. ii: perrl 3 to 2mm and brisk. vff to confrontation. funduscopic exam revealed no papilledema, exudates, or hemorrhages. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: normal bulk, tone throughout. low frequency tremor in the right finger/hand, also demonstrated intermittent larger amplitude low frequency rhythmic jerking in his rle. pronator drift could not be assessed. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 5 5 5 5 5 5 5 5 5 5 5 5 r 4- 4+ 4 na na na 5 5 5 5 5 5 5 -sensory: no deficits to light touch or noxious stimuli. no extinction to dss. -dtrs: tri pat ach l 2 2 2 2 1 r could not be assessed given the ongoing rhythmic activity plantar response was extensor on the right and flexor on the left. -coordination: defered -gait: defered pertinent results: 05:39pm blood wbc-7.9 rbc-4.81 hgb-14.9 hct-45.3 mcv-94 mch-30.9 mchc-32.8 rdw-13.0 plt ct-156 05:39pm blood pt-28.7* ptt-37.7* inr(pt)-2.8* 05:39pm blood glucose-121* urean-25* creat-1.5* na-141 k-4.3 cl-106 hco3-25 angap-14 05:51am blood glucose-154* urean-19 creat-1.3* na-137 k-6.0* cl-104 hco3-22 angap-17 05:20am blood glucose-141* urean-13 creat-1.3* na-143 k-3.7 cl-105 hco3-28 angap-14 05:39pm blood alt-27 ast-20 ld(ldh)-168 alkphos-73 totbili-0.8 05:39pm blood calcium-10.5* phos-2.3* mg-2.0 07:30pm blood albumin-4.1 08:38am blood caltibc-160* trf-123* 05:39pm blood phenyto-7.7* 03:44pm blood lactate-1.7 08:38am blood prealbumin-test 04:58am blood vgkc antibody -pnd 04:58am blood glutamic acid decarboxylase-pnd 05:38pm urine color-yellow appear-hazy sp -1.018 05:38pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-7.0 leuks-tr 05:38pm urine rbc-50* wbc-1 bacteri-few yeast-none epi-<1 transe-<1 01:37pm urine hours-random creat-52 na-63 k-10 cl-58 12:30pm cerebrospinal fluid (csf) wbc-3 rbc-4* polys-0 lymphs-67 monos-26 macroph-7 12:30pm cerebrospinal fluid (csf) totprot-69* glucose-121 12:30pm cerebrospinal fluid (csf) 14-3-3-pnd 12:30pm cerebrospinal fluid (csf) herpes simplex virus pcr-test name 11:37 am csf;spinal fluid source: lp tube #3. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. fluid culture (final ): no growth. viral culture (preliminary): no virus isolated. 3:13 pm urine source: catheter. **final report ** urine culture (final ): citrobacter koseri. 10,000-100,000 organisms/ml.. identification and sensitivities performed on culture # , . enterococcus sp.. 10,000-100,000 organisms/ml.. identification and sensitivities performed on culture # 347-5871c, . 11:39 am urine source: catheter. **final report ** urine culture (final ): citrobacter koseri. >100,000 organisms/ml.. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. enterococcus sp.. 10,000-100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter koseri | enterococcus sp. | | ampicillin------------ <=2 s cefepime-------------- <=1 s ceftazidime----------- <=1 s ceftriaxone----------- <=1 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s nitrofurantoin-------- 32 s <=16 s tetracycline---------- =>16 r tobramycin------------ <=1 s trimethoprim/sulfa---- <=1 s vancomycin------------ 1 s 5:38 pm mrsa screen source: nasal swab. **final report ** mrsa screen (final ): positive for methicillin resistant staph aureus. eeg: : impression: this is an abnormal continuous icu monitoring study because of the diffuse encephalopathic features with focal and multifocal features. there is diffuse background slowing but also asymmetric slowing in the left parieto-occipital region and independently in the right parietal area. superimposed upon the leftsided slow wave activity is an exceptionally active paroxysmal epileptiform transient with a frequency of 0.5-1 hz. this appears to have both an electrical field effect in the right occipital pole as well as synaptic transmission to the right parietal-occipital region. there were several events that appear to be clonic seizures of the right leg but no clear electrographic correlate. : impression: this is an abnormal continuous icu monitoring study because of diffuse encephalopathic slowing seen as a widely distributed abnormality but superimposed structural features in the left posterior quadrant and independently in the right central parietal regions. there is extremely active paroxysmal interictal discharge in the posterior quadrant on the left maximum at the o1 electrode. no sustained electrographic seizures or clinical events were reported or recorded. : impression: this is an abnormal continuous icu monitoring study because of the persistent diffuse encephalopathy with superimposed more significant left hemisphere abnormality suggesting structural pathology in the more posterior aspects of the left hemisphere and possible independent structural pathology in the right parietal central region. superimposed upon this is a very active interictal epileptic discharge in the left occipital pole. no sustained seizures were identified. : impression: this is an abnormal continuous icu monitoring study because of diffuse encephalopathic changes and multifocal independent structural pathologic left greater than right. there continues to be an extremely active paroxysmal interictal epileptic discharge in the left occipital pole. : impression: this is an abnormal continuous icu monitoring study because of both diffuse encephalopathic features as well as multifocal slow wave abnormalites suggesting multifocal structural pathology. the left hemisphere appears more involved than the right. there continues to be paroxysmal interictal epileptiform activity in the left occipital pole. : impression: this is an abnormal continuous icu monitoring study because of a diffuse encephalopathy with multifocal superimposed slow wave features. this activity is over the left occipital parietal and the right central parietal regions. there continues to be an active interictal epileptiform transient in the left occipital pole. mr head with and without contrast: impression: restricted diffusion constrained to the left parietal and temporal cortical grey matter. the differential diagnosis for this pattern is broad and it is most commonly caused by vascular ischemia, however, in a patient with complex partial seizures originating from this location, post-ictal changes may present similarly. the findings of left cerebral atrophy and possible crossed cerebellar diaschisis is suggestive of syndrome. this can be further explored using mri spectroscopy, perfusion, and tractography. viral etiology must also be considered. the clinical significance of the relatively new microhemorrhages at these loci is unclear. carotid us: impression: although there is plaque involving the proximal internal carotid arteries bilaterally, no hemodynamically significant stenosis noted. flow in the vertebral arteries is prograde. tte: conclusions left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is no ventricular septal defect. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. physiologic mitral regurgitation is seen (within normal limits). the pulmonary artery systolic pressure could not be determined. there is an anterior space which most likely represents a prominent fat pad. impression: suboptimal image quality due to body habitus. no cardiac source of embolus seen. left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. the right ventricle is not well seen. no significant valvular abnormality. unable to assess pulmonary artery systolic pressure. paraneoplastic autoantibody eval, s interpretive comments no informative autoantibodies were detected in this evaluation. however, a negative result does not exclude neurological autoimmunity with or without associated neoplasia. anti-neuronal nuclear ab, type 1 -1, s negative titer <1:240 anti-neuronal nuclear ab, type 2 -2, s negative titer <1:240 anti-neuronal nuclear ab, type 3 -3, s negative titer <1:240 anti-glial nuclear ab, type 1 agna-1, s negative titer <1:240 purkinge cell cytoplasmic ab type 1 pca-1, s negative titer <1:240 purkinge cell cytoplasmic ab type 2 pca-2, s negative titer <1:240 purkinge cell cytoplasmic ab type tr pca-tr, s negative titer <1:240 amphiphysin ab, s negative titer <1:240 crmp-5-igg, s negative titer --reference value-- negative at <1:240 titers lower than 1:240 may be detectable by recombinant crmp-5 western blot analysis. crmp-5 western blot analysis will be done by request on stored serum (held 4 weeks). this supplemental testing is recommended in cases of chorea, vision loss, cranial neuropathy and myelopathy. contact laboratory inquiry at 1- (internally ) to add-on crmp-5-igg western blot, serum. striational (striated muscle) ab, s negative titer <1:60 p/q-type calcium channel ab 0.00 nmol/l <=0.02 n-type calcium channel ab 0.00 nmol/l <=0.03 ach receptor (muscle) binding ab 0.00 nmol/l <=0.02 achr ganglionic neuronal ab, s 0.00 nmol/l <=0.02 neuronal (v-g) k+ channel ab, s 0.00 nmol/l <=0.02 test performed at: medical laboratories, sw, , complete report on file in the laboratory. comment: paraneoplastic panel anti nmda ab anti-nmda negative 14-3-3 negative anti-gad negative hiv ab negative hcv ab negative brief hospital course: 74yom h/o complex partial seizures, dvt and pvd on warfarin, pres, bilateral vertebral artery stenoses, thoracic meningioma, and htn p/w suspected complex partial status epilepticus with right arm and leg myoclonus. . seizures/encephalopathy - the patient presented initially to an osh with confusion, hypertension, and right arm and leg myoclonus superimposed on his baseline right thumb/finger flexion tremor. his medications were altered with the cessation of zns, initiation of tpx, and increased doses of lev. his seizures did not abate, and so tpx and lev were increased and pht was added. when this did not control his seizures, he was transferred to for further care. he was initially noted to be very inattentive, perseverative, and unable to follow complex commands (with perseveration of motor tasks). he also had a fluent aphasia. he had an extensive investigation including laboratory data, infectious workup (which did not reveal any signs of infection, including of the csf) with empiric treatment for meningitis and encephalitis, and reimaging of the brain which revealed interval atrophy of the left cerebral hemisphere. this raised the question of possible atypical encephalitis versus another in inflammatory encephalitis that might cause seizures. he was monitored on cveeg which only showed one clear clinical seizure with several subclinical seizures while asleep. he was continued on lev, pht (with levels monitored) and standing lzp. a brain biopsy was performed by neurosurgery on which only showed reactive changes without clear specificity in diagnosis. given the concern for inflammatory encephalitis, he was given an empiric treatment of 5 days of iv methylprednisolone (1 gram) which correlated with some improvement in his seizures and clinical exam, though this also occurred simultaneously with an increase in his lzp from 0.25 to 0.5 tid. due to concerns for oversedation, his lzp was changed to clonazepam 0.5 . with limited improvement observed with iv corticosteroids, he also underwent 5 days of ivig for treatment of presumed auto-immune or paraneoplastic inflammatory encephalitis. his clinical condition has gradually improved with hopes that his clinical condition will continue to improve as the effect of corticosteroids and ivig may be delayed by days to weeks. . chronic dvt - he was maintained on a continuous infusion of heparin for chronic dvt and was transitioned back to warfarin. . htn - his lisinopril had to be stopped due to in the setting of concurrent acyclovir therapy. he was switched to amlodipine alongside his metoprolol tartrate. . uti - on his ucx grew citrobacter and enterococcus which was treated with ctx 1 gm q24h x 7 days. . pending studies: anti-nmda serum antibody anti- serum antibody hhv6 csf antibody . transitional care issues: neurology - please monitor his seizure frequency. please consider additional testing for etiologic investigation of his progressive epilepsy. please adjust his phenytoin, levetiracetam, and clonazepam doses. neurology - consider outpatient plasmapheresis or additional ivig treatments if his condition is still thought to be secondary to autoantibody-mediated inflammatory encephalitis. anticoagulation - please maintain his inr between with adjustments to his warfarin dose. wound care - please continue silvadene/xeroform dressing changes to his left arm ulcer. . wound care: site: left forearm type: traumatic ulcer / skin tear change dressing: comment: silvadene and xeroform per plastic surgery medications on admission: amitriptyline 10mg qhs atorvastatin 80mg qhs colchicine eszopiclone (lunesta) 3mg tab qhs keppra 1500 lisinopril 20mg lorazepam 0.5 daily prn anxiety metoprolol tartrate 50mg omeprazole 20mg ec daily vitamin d3 warfarin 5mg daily zonegran 100mg otc: b12 flaxeed folic acid 0.4 qam vit e 400 unit turmeric root discharge medications: 1. acetaminophen 650 mg po q6h:prn pain 2. amlodipine 10 mg po daily hold for sbp < 110 3. atorvastatin 80 mg po daily 4. phenytoin infatab 150 mg po q8am and q4pm 5. phenytoin infatab 200 mg po hs 6. senna 1 tab po bid constipation hold for loose stools 7. docusate sodium 100 mg po bid 8. clonazepam 0.5 mg po bid 9. levetiracetam 1500 mg po bid 10. metoprolol tartrate 50 mg po bid hold for sbp<100 and hr<55 11. silver sulfadiazine 1% cream 1 appl tp left arm ulcer 12. warfarin 5 mg po daily16 13. famotidine 20 mg po q12h 14. vitamin d 400 unit po daily 15. colchicine 0.6 mg po daily discharge disposition: extended care facility: - discharge diagnosis: primary diagnosis: seizure, encephalopathy/inflammatory encephalitis secondary diagnosis: hypertension, chronic deep venous thrombosis discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , you were hospitalized due to symptoms of right arm and leg shaking and confusion resulting from seizures. the brain is the part of your body that controls and directs all the other parts of your body. it normally communicates with electrical signals. when an abnormal electrical signal develops and forms a short circuit, this produces a seizure. seizures produce many different symptoms and can occur again. in particular, seizures that cause loss of consciousness (even if only temporary) can endanger you and place you at risk of harm. accordingly, we would like to help you prevent the recurrence of seizures. we are changing your medications as follows: 1. please take phenytoin 150 mg in the morning, 150 mg in the afternoon, and 200 mg at night. 2. please take levetiracetam 1500 mg in the morning and 1500 mg at night. 3. please take clonazepam 0.5 mg in the morning and 0.5 mg at night. 4. please take warfarin 5 mg each day (with goal inr ). this should be checked by the rehab facility and your primary care physician. please take your other medications as prescribed. please followup with neurology and your primary care physician as listed below. if you experience any of the symptoms below, please seek medical attention. because of the risk of future seizures, you must take the following seizure precautions: - you cannot drive a motor vehicle for at least 6 months after your last seizure during which you had impairment of consciousness (a staring spell or full loss of consciousness). - avoid swimming in a pool or body of water unattended. - when using the bathroom at home, please do not lock the door (so that if you have a seizure someone can reach you). - do not climb to high heights (e.g. trees, ladders, etc.). - do not engage in activities where temporary impairment of consciousness might cause you to fall or be placed in a dangerous position. it was a pleasure providing you with care during this hospitalization. followup instructions: neurology provider: , md phone: date/time: 1:00pm, , , , ma procedure: spinal tap incision of lung open biopsy of brain central venous catheter placement with guidance diagnoses: urinary tract infection, site not specified acute kidney failure, unspecified hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified peripheral vascular disease, unspecified mononeuritis of lower limb, unspecified chronic kidney disease, stage iii (moderate) antiviral drugs causing adverse effects in therapeutic use personal history of venous thrombosis and embolism streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group d [enterococcus] encephalopathy, unspecified hyperosmolality and/or hypernatremia accidents occurring in residential institution occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction aphasia other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms epilepsia partialis continua, without mention of intractable epilepsy abnormal involuntary movements cerebral degeneration, unspecified other causes of encephalitis and encephalomyelitis 

Answer: The patient is high likely exposed to