python3 -c " from docx import Document doc = Document('/tmp/workspace/attachments/257abe20-0586-43c1-a1ea-12246886ab5f/FOR CASE SUMMARY.docx') for p in doc.paragraphs: style = p.style.name if p.style else 'None' if p.text.strip(): print(f'[{style}] {p.text}') "

mkdir -p /tmp/workspace/case-summary && ls /tmp/workspace/case-summary/

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement import copy doc = Document() # ── Page margins ────────────────────────────────────────────────────────────── from docx.shared import Inches for section in doc.sections: section.top_margin = Inches(0.9) section.bottom_margin = Inches(0.9) section.left_margin = Inches(1.0) section.right_margin = Inches(1.0) # ── Base font ───────────────────────────────────────────────────────────────── normal_style = doc.styles["Normal"] normal_style.font.name = "Calibri" normal_style.font.size = Pt(10.5) # ── Helper: add a shaded table row ─────────────────────────────────────────── def shade_cell(cell, fill_hex): tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement("w:shd") shd.set(qn("w:val"), "clear") shd.set(qn("w:color"), "auto") shd.set(qn("w:fill"), fill_hex) tcPr.append(shd) def add_heading(doc, text, level=1, color=None): p = doc.add_heading(text, level=level) run = p.runs[0] if p.runs else p.add_run(text) if color: run.font.color.rgb = RGBColor(*color) return p def add_bold_para(doc, label, value, indent=False): p = doc.add_paragraph() if indent: p.paragraph_format.left_indent = Inches(0.25) run_label = p.add_run(f"{label}: ") run_label.bold = True run_label.font.size = Pt(10.5) run_val = p.add_run(value) run_val.font.size = Pt(10.5) return p def add_bullet(doc, text, level=0): p = doc.add_paragraph(text, style="List Bullet") p.paragraph_format.left_indent = Inches(0.25 + 0.2*level) return p def section_divider(doc): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(2) p.paragraph_format.space_after = Pt(2) pPr = p._p.get_or_add_pPr() pBdr = OxmlElement("w:pBdr") bottom = OxmlElement("w:bottom") bottom.set(qn("w:val"), "single") bottom.set(qn("w:sz"), "6") bottom.set(qn("w:space"), "1") bottom.set(qn("w:color"), "4472C4") pBdr.append(bottom) pPr.append(pBdr) return p # ═══════════════════════════════════════════════════════════════════════════════ # TITLE BLOCK # ═══════════════════════════════════════════════════════════════════════════════ title = doc.add_heading("CLINICAL CASE SUMMARY", 0) title.alignment = WD_ALIGN_PARAGRAPH.CENTER for run in title.runs: run.font.color.rgb = RGBColor(0x1F, 0x49, 0x7D) run.font.size = Pt(16) sub = doc.add_paragraph("Haploidentical PBSCT for Relapsed B-ALL | GVHD Management Emphasis") sub.alignment = WD_ALIGN_PARAGRAPH.CENTER for run in sub.runs: run.font.color.rgb = RGBColor(0x26, 0x86, 0xC2) run.font.bold = True run.font.size = Pt(11) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 1 – PATIENT DEMOGRAPHICS # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "1. PATIENT DEMOGRAPHICS", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) tbl = doc.add_table(rows=3, cols=4) tbl.style = "Table Grid" data = [ ["Patient", "Master X X Gupta", "Age at Diagnosis", "11 years (April 2020)"], ["Diagnosis", "B-ALL t(12;21) – Intermediate Risk", "Blood Group", "B Positive"], ["CMV Status","Positive (Recipient & Donor)", "Donor", "Mother (Dr. Abha), Age 49 – Haploidentical"], ] for r_idx, row_data in enumerate(data): row = tbl.rows[r_idx] for c_idx, val in enumerate(row_data): cell = row.cells[c_idx] cell.text = val run = cell.paragraphs[0].runs[0] run.font.size = Pt(10) if c_idx % 2 == 0: run.bold = True shade_cell(cell, "DEEAF1") doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 2 – DISEASE HISTORY AND PRE-TRANSPLANT COURSE # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "2. DISEASE HISTORY & PRE-TRANSPLANT COURSE", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) add_heading(doc, "2a. Initial Diagnosis and First-Line Treatment (April 2020 – March 2021)", 2, color=(0x26,0x86,0xC2)) events1 = [ ("April 2020", "Presented with fever, fatigue, epistaxis. CBC: Hb 7.6 g/dL, TLC 20,800, Plt 27,000. Diagnosed B-ALL t(12;21), Intermediate Risk. Initiated on BFM 95/2002 protocol (Aurangabad, in consultation with TMC Mumbai)."), ("Mid-2020", "Post-Induction Phase 1: BM MRD positive (0.37%). Received Induction Phase 2 + Consolidation."), ("December 2020", "BM MRD Negative. Received Re-induction Phase A and B (Dec 2020 - Mar 2021). IT Methotrexate (12.5 mg) x 12 doses throughout."), ("March 12, 2021","Initiated on Maintenance therapy: 6-Mercaptopurine + Methotrexate."), ] for date, text in events1: add_bold_para(doc, date, text) add_heading(doc, "2b. First Bone Marrow Relapse (August 2022)", 2, color=(0x26,0x86,0xC2)) events2 = [ ("January 2022", "Contracted COVID-19 infection."), ("August 2022", "Developed lethargy and fever after 17 months of maintenance. BM: 85% blasts — RELAPSE confirmed."), ("Sep–Oct 2022", "Received Inotuzumab ozogamicin x 6 doses + IT Methotrexate (12.5 mg) x 3 doses. Achieved remission — MRD Negative."), ("Oct 21, 2022", "Received Vincristine + Bortezomib + Dexamethasone."), ("Dec 2022", "Evaluated at DNSH; MRD Negative. Family reluctant for allogeneic BMT. Autologous stem cell harvest performed. Planned Blinatumomab maintenance (3 cycles, 4 wks on/8 wks off) as bridge. Interim BFM Maintenance initiated pending procurement."), ("June 2023", "Blinatumomab maintenance planned but delayed due to family issues; BFM maintenance continued at hometown."), ] for date, text in events2: add_bold_para(doc, date, text) add_heading(doc, "2c. Isolated CNS Relapse (November 2023)", 2, color=(0x26,0x86,0xC2)) events3 = [ ("November 2023", "Developed bilateral papilledema and blurring of vision. Diagnosed: ISOLATED CNS RELAPSE."), ("28 Nov – 22 Dec 2023", "IT Triple Chemotherapy (TIT: MTx + ARA-C + Hydrocort) x 6 doses."), ("24–27 Dec 2023", "High-Dose MTx + ARA-C (Cycle 1). Complicated by febrile neutropenia with PICC line infection — IV antibiotics given."), ("28 Jan 2024", "TIT Dose 7. CSF: 5% blasts persisting."), ("Early 2024", "Multi-institutional consultations (DNSH, TMH, MD Anderson). Options discussed: HyperCVAD + Blinatumomab + TIT + CSI + CAR-T (MDA); vs. HD-MTx/ARA-C + TIT x4 + Blinatumomab +/- CSI. CAR-T not feasible (pediatric, not eligible for TMH trial as BM-MRD negative)."), ("Early 2024", "Decision: Rituximab x 4 weekly + HD-MTx + L-Asp + Inotuzumab, followed by Blinatumomab, then Allogeneic HCT. Mother identified as best HLA-haploidentical donor."), ] for date, text in events3: add_bold_para(doc, date, text) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 3 – TRANSPLANT DETAILS # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "3. TRANSPLANT DETAILS", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) tbl2 = doc.add_table(rows=7, cols=2) tbl2.style = "Table Grid" transplant_data = [ ("Date of Transplant", "17 May 2024 (Day 0)"), ("Graft Source", "Haploidentical Peripheral Blood Stem Cells (PBSC) from Mother"), ("Cell Dose", "CD34: 6.37 x 10⁶/kg | CD3: 20.7 x 10⁷/kg"), ("Conditioning Regimen", "Fludarabine + Thiotepa + Melphalan (05–14 May 2024); Cranial Boost 2 Gy x 2 (15 May) + TBI 2 Gy (16 May 2024)"), ("GVHD Prophylaxis", "Per institutional haploidentical protocol (Cyclosporine / PTCy-based with institutional adaptations)"), ("Neutrophil Engraftment", ">500/µL on Day +14 | >1000/µL on Day +16"), ("Platelet Engraftment", ">20,000 on Day +11 | >50,000 on Day +12"), ] for r_idx, (label, val) in enumerate(transplant_data): row = tbl2.rows[r_idx] row.cells[0].text = label row.cells[1].text = val row.cells[0].paragraphs[0].runs[0].bold = True shade_cell(row.cells[0], "DEEAF1") for cell in row.cells: for run in cell.paragraphs[0].runs: run.font.size = Pt(10) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 4 – EARLY POST-TRANSPLANT COURSE (Day 0 to Day +30) # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "4. EARLY POST-TRANSPLANT COURSE (Day 0 to Day +30)", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) early_events = [ ("Day +3, +6", "SDP (platelet) transfusions x 2 units."), ("Day +4", "Loose stools — IV Metronidazole started (5 days, resolved). Acneiform lesions on scalp/face/trunk — IV Doxycycline added, Levocetirizine + Atarax for pruritus."), ("Day +8", "Prophylactic granulocyte infusion given for post-engraftment support."), ("Day +13", "Low-grade fever; antibiotics escalated to Avibactam + Aztreonam (continued till engraftment then de-escalated)."), ("Day +14/+16", "Neutrophil engraftment achieved (>500/µL Day +14; >1000/µL Day +16)."), ("Day +18", "Rise in transaminases (SGOT 90.7, SGPT 58.4). Started IV NAC infusion + Tab Heptral — gradual normalization."), ("Day +23", "Asymptomatic throat ulcers. Started IV Acyclovir + IVIG + Amphotret gargles — resolved."), ("Day +25 (discharge)", "Discharged in stable condition. CBC: Hb 9.7, TLC 4300, Plt 1.30 lac. LFTs mildly elevated. No GVHD, FDC confirmed."), ] for date, text in early_events: add_bold_para(doc, date, text) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 5 – ACUTE GVHD (DETAILED) # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "5. ACUTE GRAFT-VERSUS-HOST DISEASE (aGVHD)", 1, color=(0xC0,0x00,0x00)) section_divider(doc) p_intro = doc.add_paragraph() r = p_intro.add_run("This section details the development, escalation, and management of acute GVHD following haploidentical PBSCT.") r.font.italic = True r.font.size = Pt(10.5) add_heading(doc, "5a. Onset and Initial Presentation", 2, color=(0xC4,0x36,0x00)) agvhd_onset = [ ("Day +31", "CMV viremia detected (copy no. 1,085). Started IV Ganciclovir Day +33."), ("Day +32", "Re-admitted with fever ~102°F, periorbital edema, conjunctival congestion. Sepsis workup initiated; Meropenem + EDTA + Amikacin started."), ("Day +33", "Onset of loose stools. IV Metronidazole started. Stool BioFire: NEGATIVE. CRP not elevated. Differential: CMV colitis vs. GUT GvHD. Mild oral mucosal congestion noted. IV Methylprednisolone (Solumedrol) initiated — FIRST LINE aGVHD THERAPY."), ] for date, text in agvhd_onset: add_bold_para(doc, date, text) add_heading(doc, "5b. Escalation to Steroid-Refractory GI aGVHD (Grade IV)", 2, color=(0xC4,0x36,0x00)) agvhd_esc = [ ("Day +36", "Sigmoidoscopy + biopsy CONFIRMED ACUTE GUT GvHD (Grade II histologically). Steroid dose increased to 2 mg/kg IV Solumedrol."), ("Day +37", "Worsening stool volume and frequency. CT Abdomen: Diffuse colitis + intussusception in jejunal loop (GI consult — repeat CT in 72 h advised). After 3 days on steroids with no improvement: CLASSIFIED AS STEROID-REFRACTORY aGVHD (upstaged to Grade IV). Ruxolitinib (oral) initiated. Gut rest + Parenteral Nutrition started. Supportive: Racecadotril, IV Pantoprazole, IV NAC, FEN correction."), ("Day +37", "COSBL transfusion given."), ("Day +39", "Second-line: Basiliximab initiated (institutional protocol)."), ("Day +40", "Second-line: Infliximab initiated, repeated WEEKLY x 4 doses. IV Defibrotide started (Day +42) for endothelial protection (x 5 days). Steroid taper commenced Day +43 given refractoriness."), ("Day +41", "Institutional cellular therapy (donor-derived) from mother administered."), ("Day +43", "Steroid taper initiated."), ("Day +45", "Third-line: ECP planned and initiated. Lymphopheresis performed; product sent to Medanta (Gurgaon) for ECP processing. Octreotide infusion started to reduce GI secretions. Femoral access obtained by IR under sedation. Psychologist, nutritionist, and physiotherapist support initiated."), ] for date, text in agvhd_esc: add_bold_para(doc, date, text) add_heading(doc, "5c. Response to ECP and Partial Remission", 2, color=(0xC4,0x36,0x00)) agvhd_resp = [ ("Days +45–54", "Gradual reduction in stool volume and frequency following ECP. Initial schedule: alternate-day ECP, then revised to TWICE WEEKLY as response noted. After 3 weeks: improved stool consistency and reduced frequency. Mucosal congestion resolved."), ("Day +54", "PARTIAL REMISSION of aGVHD documented. ECP continued on scheduled basis."), ("Days +55–73", "ECP sessions continued (approx. biweekly). Concurrent management of CMV reactivation: IV Ganciclovir withheld (cytopenia) Day +42 → alternate-day IV Foscarnet x 2 wks → low-dose Ganciclovir reintroduced → discontinued Day +63 (persistent cytopenia) → Oral Artesunate + Acyclovir Day +63."), ("Day +66–67", "CMV reactivation (copy no. 13,970). Oral Valganciclovir initiated + IV Cidofovir administered. G-CSF support for cytopenia."), ("Day +80", "Wysolone and Jakavi doses tapered. ECP 11th session. BM aspiration done (reports awaited). IT chemotherapy administered."), ] for date, text in agvhd_resp: add_bold_para(doc, date, text) # Summary table for aGVHD treatment ladder doc.add_paragraph() p_lbl = doc.add_paragraph() r = p_lbl.add_run("aGVHD Treatment Escalation Ladder") r.bold = True r.font.size = Pt(11) r.font.color.rgb = RGBColor(0xC0,0x00,0x00) tbl3 = doc.add_table(rows=6, cols=4) tbl3.style = "Table Grid" headers = ["Line", "Agent / Intervention", "Day Initiated", "Response"] for c_idx, h in enumerate(headers): cell = tbl3.rows[0].cells[c_idx] cell.text = h run = cell.paragraphs[0].runs[0] run.bold = True run.font.size = Pt(10) shade_cell(cell, "C00000") run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) ladder_data = [ ["1st Line", "IV Methylprednisolone (escalated to 2 mg/kg)", "Day +33", "Insufficient — steroid refractory"], ["2nd Line", "Basiliximab (IL-2R blockade)", "Day +39", "Partial; escalation needed"], ["2nd Line", "Infliximab (anti-TNF) x 4 weekly doses", "Day +40", "Partial response"], ["Adjunct", "IV Defibrotide (endothelial protection)", "Day +42", "Supportive; x 5 days"], ["3rd Line", "Extracorporeal Photopheresis (ECP) — ongoing", "Day +45", "Partial Remission by Day +54; gradual improvement"], ] for r_idx, row_data in enumerate(ladder_data, start=1): for c_idx, val in enumerate(row_data): cell = tbl3.rows[r_idx].cells[c_idx] cell.text = val run = cell.paragraphs[0].runs[0] run.font.size = Pt(10) if r_idx % 2 == 0: shade_cell(cell, "FCE4D6") doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 6 – CHRONIC GVHD (DETAILED) # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "6. CHRONIC GRAFT-VERSUS-HOST DISEASE (cGVHD)", 1, color=(0x70,0x30,0xA0)) section_divider(doc) p_intro2 = doc.add_paragraph() r2 = p_intro2.add_run("Chronic GvHD developed from approximately Day +177 onwards with multi-organ involvement including skin, liver, joints/fascia, lungs, and oral mucosa.") r2.font.italic = True r2.font.size = Pt(10.5) add_heading(doc, "6a. Emerging Features (Day +177 – Day +263)", 2, color=(0x70,0x30,0xA0)) cgvhd_emerge = [ ("Day +100–177 (~3–6 months post-Tx)", "Serial ECP sessions continued (ECP 13th–16th). Transaminases progressively rising (SGOT 210→274 U/L by Day +177). LFTs suggest hepatic cGVHD component developing."), ("Dec 2024 (Day +221)", "Admitted with fever, generalized weakness, constipation. Mucoceles noted in palate, increase in skin lesions — early cutaneous cGVHD features. Also: Rhinovirus (respiratory BioFire) + Candida parapsilosis (blood PCR) — treated with Amphotericin B + Vancomycin. Tbili 3.14 mg/dL (conjugated 2.76), SGOT 472, SGPT 232, ALP 259 — significant hepatic involvement. ECP 19th session. G-CSF support for cytopenia."), ("Feb 2025 (Day +259–263)", "OPD visit: NEW COMPLAINT of proximal muscle weakness + pain in lower limbs with wasting. MRI: no significant pathology. Suspected: CHRONIC GVHD (musculoskeletal / fascial involvement). Initiated Rituximab (B-cell depletion for cGVHD). Improvement in backache and knee pain noted at Day +263."), ] for date, text in cgvhd_emerge: add_bold_para(doc, date, text) add_heading(doc, "6b. Established Chronic GVHD — Multi-organ Assessment (Mar 2025 – Mar 2026)", 2, color=(0x70,0x30,0xA0)) cgvhd_estab = [ ("March 2025 (Day ~+291–309)", "Rituximab continued (3rd and 4th doses). Improving ROM at knee joint, backache improving. LFTs trending down (SGOT 52 → 48 U/L)."), ("April 2025 (Day +323)", "SGOT 40.3 / SGPT 27.3 — significant LFT improvement. No active cGVHD features clinically documented."), ("May 2025 (Day +365 — 1-Year Post-Tx)", "BM aspiration + LP done. NO ACTIVE CHRONIC GVHD clinically. IVIG continued. Counts: Hb 11.1, TLC 4500, Plt 2.03 lac."), ("June–July 2025 (Day 1Y1M–1Y2M)", "Well, no active infection or cGVHD. LFTs mildly fluctuating (SGOT 59→191 July 2025 — likely drug/metabolic)."), ("November 2025 (Day 1Y6M)", "Mild restriction in movement of right elbow + periungual lesions noted — features of ACTIVE cGVHD. Vaccinated (Pneumovac + Influvac). BM + LP done."), ("Jan 2026 (Day 1Y8M)", "CBC normalising (Hb 14.2, TLC 8830, Plt 3.38 lac). LFTs near normal (SGOT 36, SGPT 34). Clinically well."), ] for date, text in cgvhd_estab: add_bold_para(doc, date, text) add_heading(doc, "6c. Active Chronic GVHD with Multi-organ Involvement (Mar 2026 – Present)", 2, color=(0x70,0x30,0xA0)) cgvhd_active = [ ("March 2026 (Day 1Y10M)", "FORMAL cGVHD ASSESSMENT: Skin ~50% softening (+), scarring (+). Joint/fascia ROM (R elbow/knee/wrist): improved ~50%. Mouth: better ~80%. PFT: FEV1 83%, FEV1/FVC 103%, RV 200%, RV/TLC 40% (obstructive/air-trapping pattern — lung cGVHD suspected). Moxifloxacin inhaler started + Candid M/P after each use."), ("April 2026 (Day 1Y11M)", "Skin softening ~60%, ROM better ~60%, mouth ~80% better. FEV1 89%, FEV1/FVC 101.3%, RV 205%. HRCT Chest: No significant abnormality. Bilateral thigh lipoatrophy (subcutaneous) suspected — confirmed on evaluation. Ruxolitinib (Jakavi) re-initiated + steroid taper. Sirolimus added. Mavicel (institutional cellular therapy) Dose 1 (50 x 10⁶ cells) given 22.04.2026."), ("May 2026 (Day 2Y)", "UVA1 therapy started 07 May 2026 (5 sessions by Day 2Y visit). Skin: patchy sclerosis — chest wall R side, abdomen, bilateral forearms, left leg. Lipoatrophy bilateral thighs: reduced. Nails + hands: resolved/better. Feet: better. Sirolimus taper + Jakavi dose increase. 2nd Mavicel dose (50 x 10⁶ cells) given 18.05.2026."), ("May 27, 2026", "Video consult: Tightness of left elbow + right forearm developing. Advised aqua therapy + Ayurvedic oil massage."), ("June 05, 2026", "Skin tightness increased per patient report. Patient emotionally distressed regarding appearance. Extensive counselling given; father advised to seek psychological support. Anti-GVHD escalation: Omnacortil 10 mg AM + 5 mg PM; Sirolimus/Jakavi/Rezurock (Belumosudil) continued. Thalidomide 50 mg OD at bedtime added for skin fibrosis. Ecosprin 75 mg added (antiplatelet with thalidomide). Topical Calcipotriol (PASI TREX) discussed with Dermatology. UVA1 therapy continued under Dermatologist supervision."), ("June 22, 2026", "OPD: Lungs-better, Liver-better, Joints/fascia-better (except ankle). Skin sclerosis improving. 2 new possible skin lesions + new lichenoid lesions on lipodystrophy area. ECP to be reconsidered if no improvement after 4 weeks of full-dose UVA1."), ("July 18, 2026 (Current)", "2Y2M post Haplo-HCT. Post 2 doses of Rituximab. Oral cGVHD: ok. Eyes: ok. Joints/fascia: stable. Skin sclerosis: tightness around abdomen and inner thighs persisting. UVA1 stopped (poor weather). PLAN: Initiate Ibrutinib, reduce Jakavi, discuss ECP in 4 weeks."), ] for date, text in cgvhd_active: add_bold_para(doc, date, text) # ── cGVHD Organ Summary Table ──────────────────────────────────────────────── doc.add_paragraph() p_lbl2 = doc.add_paragraph() r3 = p_lbl2.add_run("Chronic GVHD Organ Involvement Summary") r3.bold = True r3.font.size = Pt(11) r3.font.color.rgb = RGBColor(0x70,0x30,0xA0) tbl4 = doc.add_table(rows=8, cols=3) tbl4.style = "Table Grid" headers4 = ["Organ / System", "Features", "Current Status"] for c_idx, h in enumerate(headers4): cell = tbl4.rows[0].cells[c_idx] cell.text = h run = cell.paragraphs[0].runs[0] run.bold = True run.font.size = Pt(10) shade_cell(cell, "7030A0") run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) organ_data = [ ["Skin", "Sclerosis, mucoceles, acneiform lesions, periungual changes, skin scarring, new lichenoid lesions", "Partially improved (~60%); some areas of active sclerosis"], ["Liver", "Elevated transaminases & ALP (peak SGOT 472), hyperbilirubinemia, hypoalbuminemia", "Improving — near normal LFTs by Apr 2026; mild fluctuation"], ["Joints/Fascia", "Proximal muscle weakness, wasting, reduced ROM right elbow/knee/wrist", "Better ~60%; ankle still affected"], ["Oral Mucosa", "Mucoceles in palate, mucosal congestion", "~80% improved"], ["Lungs", "Air trapping (RV 200–205%, RV/TLC 40%), reduced peak flow, FEV1 83–89%", "Stable; HRCT no abnormality; spirometry 4x/day; Moxiflo inhaler"], ["Eyes", "Monitored", "No active disease"], ["Subcutaneous", "Bilateral thigh lipoatrophy", "Partially improving; under evaluation"], ["GI Tract", "Post-aGVHD; no active GI cGVHD documented", "Resolved"], ] for r_idx, row_data in enumerate(organ_data, start=1): for c_idx, val in enumerate(row_data): cell = tbl4.rows[r_idx].cells[c_idx] cell.text = val run = cell.paragraphs[0].runs[0] run.font.size = Pt(9.5) if r_idx % 2 == 0: shade_cell(cell, "EAD1FF") doc.add_paragraph() # ── cGVHD Treatment Ladder ─────────────────────────────────────────────────── p_lbl3 = doc.add_paragraph() r4 = p_lbl3.add_run("Chronic GVHD Treatment Summary") r4.bold = True r4.font.size = Pt(11) r4.font.color.rgb = RGBColor(0x70,0x30,0xA0) tbl5 = doc.add_table(rows=10, cols=3) tbl5.style = "Table Grid" headers5 = ["Agent", "Indication / Role", "Timing"] for c_idx, h in enumerate(headers5): cell = tbl5.rows[0].cells[c_idx] cell.text = h run = cell.paragraphs[0].runs[0] run.bold = True run.font.size = Pt(10) shade_cell(cell, "7030A0") run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) cgvhd_drugs = [ ["Corticosteroids (Methylpred / Wysolone / Omnacortil)", "Primary immunosuppression; titrated to response", "From Day +33 (aGVHD); ongoing with taper"], ["Ruxolitinib (Jakavi)", "JAK1/2 inhibitor; steroid-refractory GvHD", "Day +37 (aGVHD); re-initiated Apr 2026 for cGVHD"], ["ECP (Extracorporeal Photopheresis)", "3rd-line aGVHD; continued for cGVHD; 18+ sessions total", "Day +45 onwards"], ["Rituximab", "B-cell depletion for cGVHD (musculoskeletal)", "Feb–Mar 2025 (4 doses); resumed Jul 2026"], ["Sirolimus (mTOR inhibitor)", "Immunosuppression for cGVHD", "Started Apr 2026; being tapered"], ["Belumosudil (Rezurock)", "ROCK2 inhibitor; approved for cGVHD", "Current medication"], ["Thalidomide", "Anti-fibrotic for skin sclerosis", "Started Jun 2026 (50 mg OD)"], ["Ibrutinib (BTK inhibitor)", "Planned for skin/fascial cGVHD", "Planned Jul 2026"], ["Mavicel (Institutional Cellular Therapy)", "Regulatory T-cell / MSC product from donor", "Apr 2026 + May 2026 (2 doses)"], ["UVA1 Phototherapy", "Cutaneous sclerotic cGVHD", "Started May 2026; paused Jul 2026 (weather)"], ] for r_idx, row_data in enumerate(cgvhd_drugs, start=1): for c_idx, val in enumerate(row_data): cell = tbl5.rows[r_idx].cells[c_idx] cell.text = val run = cell.paragraphs[0].runs[0] run.font.size = Pt(9.5) if r_idx % 2 == 0: shade_cell(cell, "EAD1FF") doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 7 – INFECTIOUS COMPLICATIONS # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "7. INFECTIOUS COMPLICATIONS", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) infect = [ ("Pre-transplant (D-4)", "Shigella enterocolitis (stool BioFire +ve). Treated with Ofloxacin + Tazar/Amikacin/Minocycline. Melphalan dose modified. Resolved before Day 0."), ("D+4 to D+13", "Neutropenic fever; empirical Meropenem+EDTA + Amikacin. Granulocyte infusion D+8. Escalated to Avibactam/Aztreonam. Resolved post-engraftment."), ("D+31–67", "CMV Reactivation (serial): Initial copy 1,085 → Ganciclovir → withheld (cytopenia) → IV Foscarnet → Oral Artesunate → CMV reactivation D+66 (copy 13,970) → Valganciclovir + IV Cidofovir. G-CSF support."), ("D+32–52", "Recurrent septic episodes. Meropenem + Amikacin + Fosfomycin → escalated to Avibactam + Aztreonam. Resolved."), ("Dec 2024 (D+221)", "Rhinovirus (respiratory BioFire +ve, persistent). Candida parapsilosis (blood multiplex PCR +ve). Treated with IV Amphotericin B + Vancomycin. Responded in 5 days."), ("Dec 2024 onwards (prophylaxis)", "Tab Isuvaz (Isavuconazole) 200 mg OD started 18.02.2026. Tab Zovirax (Acyclovir) 400 mg TDS (reduced 07.08.2025). Bandy Plus monthly (antihelminthic)."), ] for date, text in infect: add_bold_para(doc, date, text) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 8 – COMPLETE TIMELINE # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "8. MASTER TIMELINE", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) timeline = [ ("Apr 2020", "Diagnosis: B-ALL t(12;21). Initiated BFM 95/2002 protocol."), ("Dec 2020", "MRD Negative. Re-induction Phase A+B initiated."), ("Mar 2021", "Maintenance: 6MP + MTx started."), ("Jan 2022", "COVID-19 infection."), ("Aug 2022", "BM RELAPSE (85% blasts). Inotuzumab x 6 + IT MTx x 3. MRD Negative."), ("Oct 2022", "VBD (Vincristine + Bortezomib + Dexa). Evaluated at DNSH."), ("Dec 2022", "Autologous stem cell harvest. Family discussed plan for allo-HCT vs. Blinatumomab maintenance."), ("Jun–Oct 2023", "Blinatumomab delayed; BFM Maintenance at hometown."), ("Nov 2023", "CNS RELAPSE — bilateral papilledema. TIT x 6 doses."), ("Dec 2023", "HD-MTx + ARA-C Cycle 1. Febrile neutropenia; IV antibiotics."), ("Jan 2024", "TIT Dose 7; CSF 5% blasts. Multi-institutional consultations."), ("Feb–Apr 2024", "Rituximab x 4 + HD-MTx + L-Asp + Inotuzumab. Blinatumomab pre-transplant. Hickman line 08.02.2024. Mother identified as haplo-donor."), ("05–16 May 2024", "CONDITIONING: Flu+TT+Mel + Cranial Boost + TBI."), ("17 May 2024", "TRANSPLANT DAY 0: Haplo-PBSCT (CD34 6.37×10⁶/kg)."), ("Day +14/+16", "Neutrophil engraftment. Platelet engraftment Day +11/+12."), ("Day +31", "CMV viremia detected. IV Ganciclovir D+33."), ("Day +33", "aGVHD ONSET: Loose stools + oral mucositis. IV Solumedrol started."), ("Day +36", "Sigmoidoscopy: CONFIRMED Acute Gut GvHD Grade II."), ("Day +37", "CT Abdomen: Diffuse colitis + intussusception. Classified Grade IV steroid-refractory. Ruxolitinib + Parenteral Nutrition."), ("Day +39–40", "Basiliximab + Infliximab (x4 weekly). Defibrotide D+42."), ("Day +41", "Institutional cellular therapy (donor-derived) from mother."), ("Day +45", "ECP initiated (3rd line). Octreotide. Lymphopheresis."), ("Day +54", "Partial Remission of aGVHD."), ("Day +66–67", "CMV re-activation (copy 13,970). Valganciclovir + Cidofovir."), ("Day +80–100", "Wysolone + Jakavi taper. ECP 11th–13th sessions. BM aspiration done."), ("Nov 2024–Jan 2025","ECP 16th–19th sessions. Mucocoles + skin lesions = cGVHD features emerging. Candida parapsilosis + Rhinovirus managed."), ("Feb 2025", "Proximal myopathy / fascial involvement. Rituximab started (1st dose cGVHD Rx)."), ("Mar–Apr 2025", "Rituximab 2nd–4th doses. Gradual LFT normalisation. ROM improving."), ("May 2025", "1-YEAR POST-TRANSPLANT: BM + LP done. No active cGVHD."), ("Nov 2025", "Mild R elbow restriction + periungual lesions — active cGVHD. Vaccinations."), ("Jan 2026", "CBC normalising (Hb 14.2, Plt 3.38 lac). LFTs near-normal."), ("Mar 2026", "cGVHD Assessment: Skin 50%, ROM 50%, Mouth 80% improved. PFT: lung involvement (RV↑). Moxiflo inhaler started."), ("Apr 2026", "Ruxolitinib re-initiated + Sirolimus added. Mavicel Dose 1. Lipoatrophy confirmed bilat. thighs."), ("May 2026", "2-YEAR POST-TRANSPLANT. UVA1 therapy started. Mavicel Dose 2. Sirolimus tapering."), ("Jun 2026", "Skin tightness worsened. Thalidomide added. Emotional distress — psychological support advised."), ("Jul 2026", "Post 2 doses Rituximab: Oral/eyes/joints stable. Skin inner thigh/abdo tightness. Ibrutinib planned. ECP to be discussed."), ] tbl6 = doc.add_table(rows=len(timeline)+1, cols=2) tbl6.style = "Table Grid" hdr_row = tbl6.rows[0] hdr_row.cells[0].text = "Date / Timepoint" hdr_row.cells[1].text = "Event" for cell in hdr_row.cells: run = cell.paragraphs[0].runs[0] run.bold = True run.font.size = Pt(10) shade_cell(cell, "1F497D") run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) for r_idx, (date, event) in enumerate(timeline, start=1): row = tbl6.rows[r_idx] row.cells[0].text = date row.cells[1].text = event for c_idx, cell in enumerate(row.cells): if cell.paragraphs[0].runs: run = cell.paragraphs[0].runs[0] run.font.size = Pt(9.5) if c_idx == 0: run.bold = True if r_idx % 2 == 0: shade_cell(row.cells[0], "DEEAF1") shade_cell(row.cells[1], "DEEAF1") doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # SECTION 9 – CURRENT STATUS & PLAN # ═══════════════════════════════════════════════════════════════════════════════ add_heading(doc, "9. CURRENT STATUS & ONGOING PLAN", 1, color=(0x1F,0x49,0x7D)) section_divider(doc) p_curr = doc.add_paragraph() r_c = p_curr.add_run("As of July 2026 (Day ~2Y2M post Haploidentical PBSCT):") r_c.bold = True r_c.font.size = Pt(10.5) status_items = [ "Disease Status: In remission (no active ALL). BM + LP last done at 2-year mark (May 2026).", "Acute GVHD: Resolved (achieved partial remission Day +54; complete resolution thereafter).", "Chronic GVHD: Active, multi-organ — skin sclerosis (partially improved), joint/fascia (stable), lungs (stable air trapping, HRCT clear), liver (improving), oral/eyes stable. Lipoatrophy bilateral thighs.", "Current Anti-GVHD Medications: Omnacortil + Sirolimus + Ruxolitinib (Jakavi) + Belumosudil (Rezurock) + Rituximab (recent 2 doses) + Thalidomide + UVA1 therapy (paused). Ibrutinib: PLANNED.", "CMV: Controlled; monitoring ongoing.", "Antimicrobial Prophylaxis: Isavuconazole (Isuvaz) + Acyclovir (Zovirax) + monthly Bandy Plus.", "Supportive: Monthly IVIG. Spirometry 4x/day. Physiotherapy + aqua therapy.", "Planned: ECP reconsideration in 4 weeks if no skin improvement with UVA1; 2-year formal BM + LP assessment.", "Psychological Support: Formal psychiatric / psychological referral advised due to emotional distress.", ] for item in status_items: add_bullet(doc, item) doc.add_paragraph() # ── Footer note ──────────────────────────────────────────────────────────────── p_footer = doc.add_paragraph() p_footer.alignment = WD_ALIGN_PARAGRAPH.CENTER r_f = p_footer.add_run("CONFIDENTIAL — Clinical Case Summary | Generated for Medical Use Only | Patient identity anonymised") r_f.font.size = Pt(8) r_f.font.color.rgb = RGBColor(0x80,0x80,0x80) r_f.font.italic = True # ── Save ────────────────────────────────────────────────────────────────────── out_path = "/tmp/workspace/case-summary/Clinical_Case_Summary_GVHD.docx" doc.save(out_path) print(f"Document saved: {out_path}") PYEOF

python3 << 'PYEOF' from docx import Document from docx.shared import Pt, Inches, RGBColor from docx.enum.text import WD_ALIGN_PARAGRAPH from docx.oxml.ns import qn from docx.oxml import OxmlElement doc = Document() # ── Page margins for section in doc.sections: section.top_margin = Inches(0.9) section.bottom_margin = Inches(0.9) section.left_margin = Inches(1.0) section.right_margin = Inches(1.0) normal_style = doc.styles["Normal"] normal_style.font.name = "Calibri" normal_style.font.size = Pt(10.5) def shade_cell(cell, fill_hex): tc = cell._tc tcPr = tc.get_or_add_tcPr() shd = OxmlElement("w:shd") shd.set(qn("w:val"), "clear") shd.set(qn("w:color"), "auto") shd.set(qn("w:fill"), fill_hex) tcPr.append(shd) def add_heading_colored(doc, text, level=1, rgb=(0x1F,0x49,0x7D)): p = doc.add_heading(text, level=level) if p.runs: p.runs[0].font.color.rgb = RGBColor(*rgb) return p def add_bold_para(doc, label, value): p = doc.add_paragraph() p.paragraph_format.space_after = Pt(3) run_label = p.add_run(f"{label}: ") run_label.bold = True run_label.font.size = Pt(10.5) run_val = p.add_run(value) run_val.font.size = Pt(10.5) return p def add_bullet(doc, text): p = doc.add_paragraph(style="List Bullet") p.paragraph_format.left_indent = Inches(0.25) p.paragraph_format.space_after = Pt(3) run = p.add_run(text) run.font.size = Pt(10.5) return p def section_divider(doc): p = doc.add_paragraph() p.paragraph_format.space_before = Pt(1) p.paragraph_format.space_after = Pt(4) pPr = p._p.get_or_add_pPr() pBdr = OxmlElement("w:pBdr") bottom = OxmlElement("w:bottom") bottom.set(qn("w:val"), "single") bottom.set(qn("w:sz"), "6") bottom.set(qn("w:space"), "1") bottom.set(qn("w:color"), "4472C4") pBdr.append(bottom) pPr.append(pBdr) def make_table(doc, headers, data_rows, header_fill="1F497D", alt_fill="DEEAF1", font_size=10): n_cols = len(headers) n_rows = len(data_rows) + 1 tbl = doc.add_table(rows=n_rows, cols=n_cols) tbl.style = "Table Grid" # header hrow = tbl.rows[0] for c_idx, h in enumerate(headers): cell = hrow.cells[c_idx] cell.text = h shade_cell(cell, header_fill) if cell.paragraphs[0].runs: run = cell.paragraphs[0].runs[0] run.bold = True run.font.size = Pt(font_size) run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) # data for r_idx, row_data in enumerate(data_rows, start=1): row = tbl.rows[r_idx] for c_idx, val in enumerate(row_data): cell = row.cells[c_idx] cell.text = str(val) if cell.paragraphs[0].runs: run = cell.paragraphs[0].runs[0] run.font.size = Pt(font_size) if r_idx % 2 == 0: shade_cell(cell, alt_fill) return tbl # ═══════════════════════════════════════════════════════════════════════════════ # TITLE # ═══════════════════════════════════════════════════════════════════════════════ title = doc.add_heading("CLINICAL CASE SUMMARY", 0) title.alignment = WD_ALIGN_PARAGRAPH.CENTER for run in title.runs: run.font.color.rgb = RGBColor(0x1F,0x49,0x7D) run.font.size = Pt(16) sub = doc.add_paragraph("Haploidentical PBSCT for Relapsed B-ALL | GVHD Management Emphasis") sub.alignment = WD_ALIGN_PARAGRAPH.CENTER for run in sub.runs: run.bold = True run.font.color.rgb = RGBColor(0x26,0x86,0xC2) run.font.size = Pt(11) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 1. DEMOGRAPHICS # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "1. PATIENT DEMOGRAPHICS", 1) section_divider(doc) make_table(doc, headers=["Parameter", "Detail", "Parameter", "Detail"], data_rows=[ ["Patient", "Master X X Gupta", "Age at Diagnosis", "11 years (April 2020)"], ["Diagnosis", "B-ALL t(12;21) — Intermediate Risk", "Blood Group", "B Positive"], ["CMV Status", "Positive (Recipient & Donor)", "Donor", "Mother (Dr. Abha), Age 49, Haploidentical"], ["HCT-CI", "1", "Transplant Date", "17 May 2024"], ], header_fill="1F497D", alt_fill="DEEAF1" ) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 2. DISEASE HISTORY # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "2. DISEASE HISTORY & PRE-TRANSPLANT COURSE", 1) section_divider(doc) add_heading_colored(doc, "2a. Initial Diagnosis and First-Line Therapy (April 2020 – March 2021)", 2, rgb=(0x26,0x86,0xC2)) for date, text in [ ("April 2020", "Fever, fatigue, epistaxis. CBC: Hb 7.6 g/dL, TLC 20,800, Plt 27,000. Diagnosed B-ALL t(12;21), Intermediate Risk. Initiated BFM 95/2002 protocol (Aurangabad / TMC Mumbai)."), ("Mid-2020", "Post-Induction Phase 1: BM MRD positive (0.37%). Received Induction Phase 2 + Consolidation."), ("December 2020", "BM MRD Negative. Re-induction Phase A and B (Dec 2020 – Mar 2021). IT Methotrexate (12.5 mg) x 12 doses throughout treatment."), ("March 12, 2021","Maintenance therapy started: 6-Mercaptopurine (6MP) + Methotrexate."), ]: add_bold_para(doc, date, text) add_heading_colored(doc, "2b. First Bone Marrow Relapse (August 2022)", 2, rgb=(0x26,0x86,0xC2)) for date, text in [ ("January 2022", "Contracted COVID-19 infection."), ("August 2022", "Lethargy and fever after 17 months of maintenance. BM: 85% blasts — RELAPSE confirmed."), ("Sep–Oct 2022", "Inotuzumab ozogamicin x 6 doses + IT Methotrexate x 3 doses. Achieved MRD Negative remission."), ("Oct 21, 2022", "VBD: Vincristine + Bortezomib + Dexamethasone. Evaluated at DNSH — MRD negative."), ("Dec 2022", "Autologous stem cell harvest. Family reluctant for allo-HCT. Plan: Blinatumomab maintenance (4 wks on / 8 wks off) x 3 cycles as bridge, with discussion of allografting at earliest opportunity. BFM Maintenance in interim."), ("Jun 2023", "Blinatumomab delayed (family/procurement issues). BFM Maintenance continued at hometown."), ]: add_bold_para(doc, date, text) add_heading_colored(doc, "2c. Isolated CNS Relapse (November 2023)", 2, rgb=(0x26,0x86,0xC2)) for date, text in [ ("November 2023", "Bilateral papilledema and blurring of vision. Diagnosed: ISOLATED CNS RELAPSE."), ("28 Nov–22 Dec 2023", "IT Triple Chemotherapy (TIT: MTx + ARA-C + Hydrocort) x 6 doses."), ("24–27 Dec 2023", "High-Dose MTx + ARA-C (Cycle 1). Complicated by febrile neutropenia with PICC line infection — IV antibiotics given."), ("28 Jan 2024", "TIT Dose 7. CSF: 5% blasts persisting."), ("Early 2024", "Consultations at DNSH, TMH, MD Anderson. Options evaluated: HyperCVAD + Blinatumomab + TIT + CSI + CAR-T (MDA) vs. HD-MTx/ARA-C + TIT x 4 + Blinatumomab +/- CSI. CAR-T not feasible (pediatric; BM-MRD negative, ineligible for TMH trial)."), ("Early 2024", "Decision: Rituximab x 4 weekly + HD-MTx + L-Asp + Inotuzumab, then Blinatumomab, then Allogeneic HCT. Mother (Dr. Abha) identified as best haploidentical donor. Hickman line inserted 08.02.2024."), ]: add_bold_para(doc, date, text) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 3. TRANSPLANT DETAILS # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "3. TRANSPLANT DETAILS", 1) section_divider(doc) make_table(doc, headers=["Parameter", "Details"], data_rows=[ ["Date of Transplant (Day 0)", "17 May 2024"], ["Graft Source", "Haploidentical Peripheral Blood Stem Cells (PBSC) — Mother"], ["CD34 Cell Dose", "6.37 x 10\u2076/kg"], ["CD3 Cell Dose", "20.7 x 10\u2077/kg"], ["Conditioning Regimen", "Fludarabine + Thiotepa + Melphalan (05–14 May); Cranial Boost 2 Gy x 2 (15 May); TBI 2 Gy (16 May)"], ["Donor Mobilisation", "G-CSF from D-4; PBSC collected via femoral venous access 17.05.2024"], ["Neutrophil Engraftment", ">500/\u00b5L on Day +14; >1000/\u00b5L on Day +16"], ["Platelet Engraftment", ">20,000 on Day +11; >50,000 on Day +12"], ], header_fill="1F497D", alt_fill="DEEAF1" ) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 4. EARLY POST-TRANSPLANT (Day 0 – Day +30) # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "4. EARLY POST-TRANSPLANT COURSE (Day 0 – Day +30)", 1) section_divider(doc) for date, text in [ ("Day +4", "Loose stools — IV Metronidazole (5 days, resolved). Acneiform lesions on scalp/face/trunk — IV Doxycycline + Levocetirizine/Atarax for pruritus; resolved."), ("Day +8", "Prophylactic granulocyte infusion given."), ("Day +13", "Low-grade fever; antibiotics escalated to Avibactam + Aztreonam (continued to engraftment, then de-escalated)."), ("Day +14/16", "Neutrophil engraftment achieved."), ("Day +18", "Rise in transaminases (SGOT 90.7, SGPT 58.4). IV NAC infusion + Tab Heptral — gradual normalisation."), ("Day +23", "Asymptomatic throat ulcers. IV Acyclovir + IVIG + Amphotret gargles — resolved."), ("Day +25", "Discharged: Hb 9.7, TLC 4300, Plt 1.30 lac. No GVHD. Full donor chimerism (FDC) confirmed."), ]: add_bold_para(doc, date, text) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 5. ACUTE GVHD # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "5. ACUTE GRAFT-VERSUS-HOST DISEASE (aGVHD)", 1, rgb=(0xC0,0x00,0x00)) section_divider(doc) p = doc.add_paragraph() r = p.add_run("This patient developed steroid-refractory Grade IV acute gut GvHD requiring sequential escalation through three lines of therapy, ultimately achieving partial remission with Extracorporeal Photopheresis.") r.font.italic = True; r.font.size = Pt(10.5) add_heading_colored(doc, "5a. Onset and First-Line Treatment", 2, rgb=(0xC4,0x36,0x00)) for date, text in [ ("Day +31 (17 Jun 2024)", "Post-transplant follow-up Day +31. CBC: Hb 11.6, TLC 5900, Plt 1.60 lac. CMV viremia detected (copy no. 1,085). IV Ganciclovir initiated Day +33."), ("Day +32 (18 Jun 2024)", "Re-admitted with fever 102\u00b0F, periorbital edema, conjunctival congestion (sepsis signs). Meropenem+EDTA + Amikacin started empirically."), ("Day +33", "Onset of loose stools. Stool BioFire: NEGATIVE. No CRP rise. Differential: CMV colitis vs. Gut GvHD. Mild oral mucosal congestion noted. FIRST-LINE: IV Methylprednisolone (Solumedrol) initiated."), ]: add_bold_para(doc, date, text) add_heading_colored(doc, "5b. Escalation to Steroid-Refractory aGVHD (Grade IV)", 2, rgb=(0xC4,0x36,0x00)) for date, text in [ ("Day +36", "Sigmoidoscopy + guided biopsy: CONFIRMED ACUTE GUT GvHD (Grade II histology). Steroid dose escalated to 2 mg/kg IV Solumedrol. Oral Ruxolitinib initiated. Gut rest + Parenteral Nutrition. Supportive: Racecadotril + IV Pantoprazole + IV NAC + FEN correction. COSBL transfusion."), ("Day +37", "Increased stool volume and frequency — worsening on Day 3 of steroids. CT Abdomen: Diffuse colitis + intussusception in jejunal loop. GI consult: repeat CT in 72 h. CLASSIFIED: STEROID-REFRACTORY aGVHD (upstaged to GRADE IV)."), ("Day +39", "SECOND LINE: Basiliximab initiated (IL-2R blockade, institutional protocol)."), ("Day +40", "SECOND LINE: Infliximab initiated (anti-TNF); repeated WEEKLY x 4 doses."), ("Day +41", "Institutional cellular therapy (donor-derived, from mother) administered."), ("Day +42", "IV Defibrotide initiated for endothelial protection (5 days)."), ("Day +43", "Steroid taper commenced in view of refractoriness."), ]: add_bold_para(doc, date, text) add_heading_colored(doc, "5c. Third-Line Therapy: ECP and Response", 2, rgb=(0xC4,0x36,0x00)) for date, text in [ ("Day +45", "THIRD LINE: Extracorporeal Photopheresis (ECP) planned. Lymphopheresis done; product sent to Medanta, Gurgaon. Femoral access obtained under IR + sedation. Octreotide infusion started. Multidisciplinary support: nutritionist, physiotherapist, psychologist."), ("Days +45–54", "Mild reduction in stool volume and frequency noted. ECP schedule: alternate-day initially, then twice-weekly as response observed. After 3 weeks: improved stool consistency, reduced frequency, resolved mucosal congestion."), ("Day +54", "PARTIAL REMISSION of acute GvHD documented."), ("Day +80", "Wysolone + Jakavi doses tapered. ECP 11th session. Continued monitoring."), ]: add_bold_para(doc, date, text) # aGVHD treatment ladder table p_lbl = doc.add_paragraph() p_lbl.add_run("aGVHD Treatment Escalation Ladder").bold = True p_lbl.runs[0].font.color.rgb = RGBColor(0xC0,0x00,0x00) p_lbl.runs[0].font.size = Pt(11) make_table(doc, headers=["Line", "Agent / Intervention", "Day Initiated", "Response"], data_rows=[ ["1st Line", "IV Methylprednisolone (escalated to 2 mg/kg)", "Day +33", "Insufficient — refractory within 3 days"], ["2nd Line", "Ruxolitinib (JAK1/2 inhibitor, oral)", "Day +36", "Partial; escalation required"], ["2nd Line", "Basiliximab (IL-2R antagonist)", "Day +39", "Partial; further escalation needed"], ["2nd Line", "Infliximab (anti-TNF) x 4 weekly doses", "Day +40", "Partial response; symptoms persisting"], ["Adjunct", "IV Defibrotide (endothelial protection)", "Day +42", "Supportive; 5 days"], ["Adjunct", "Institutional cellular therapy (donor-derived from mother)", "Day +41", "Supportive immunomodulation"], ["3rd Line", "ECP (Extracorporeal Photopheresis) — 18+ sessions total", "Day +45", "Partial Remission Day +54; gradual improvement"], ], header_fill="C00000", alt_fill="FCE4D6" ) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 6. CHRONIC GVHD # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "6. CHRONIC GRAFT-VERSUS-HOST DISEASE (cGVHD)", 1, rgb=(0x70,0x30,0xA0)) section_divider(doc) p2 = doc.add_paragraph() r2 = p2.add_run("Chronic GvHD developed from approximately Day +177 onwards with multi-organ involvement: skin, liver, joints/fascia, lungs, oral mucosa, and subcutaneous tissue (lipoatrophy).") r2.font.italic = True; r2.font.size = Pt(10.5) add_heading_colored(doc, "6a. Emerging Features (Day +177 – Day +263)", 2, rgb=(0x70,0x30,0xA0)) for date, text in [ ("Day +100–177", "Serial ECP sessions (13th–16th). Transaminases progressively rising (SGOT 136–274 U/L) — hepatic cGVHD component emerging."), ("Dec 2024 (D+221)", "Admitted: fever, weakness, constipation. Mucoceles in palate + increase in skin lesions — early CUTANEOUS cGVHD. Also: Rhinovirus (respiratory BioFire +ve) + Candida parapsilosis (blood PCR +ve) — treated Amphotericin B + Vancomycin. LFTs: Tbili 3.14 mg/dL, SGOT 472, SGPT 232, ALP 259 — HEPATIC cGVHD. Albumin 2.37 g/dL (low)."), ("Feb 2025 (D+259)", "NEW: Proximal muscle weakness + pain in lower limbs with wasting. MRI: no significant pathology. Suspected: MUSCULOSKELETAL / FASCIAL cGVHD. Rituximab (B-cell depletion) initiated — 1st dose for cGVHD."), ("D+263 (Feb 2025)", "Backache and knee pain improving. ROM at knee increasing. Rituximab course continued."), ]: add_bold_para(doc, date, text) add_heading_colored(doc, "6b. Established Chronic GVHD — Multi-organ (Mar 2025 – Nov 2025)", 2, rgb=(0x70,0x30,0xA0)) for date, text in [ ("Mar–Apr 2025", "Rituximab 2nd–4th doses. LFTs trending down (SGOT 52 → 40 U/L). ROM improving. Albumin normalising."), ("May 2025 (1-Year)","BM aspiration + LP done. NO ACTIVE CHRONIC GVHD clinically. Counts: Hb 11.1, TLC 4500, Plt 2.03 lac. IVIG continued monthly."), ("Jun–Jul 2025", "Well, no active cGVHD. LFTs mildly fluctuating (SGOT 59 → 191 Jul 2025 — drug/metabolic). Monthly IVIG and ECD sessions."), ("Nov 2025 (1Y6M)", "ACTIVE cGVHD features: mild R elbow restriction + periungual lesions. Vaccinated (Pneumovac + Influvac). BM + LP done."), ("Jan 2026 (1Y8M)", "CBC normalising: Hb 14.2, TLC 8830, Plt 3.38 lac. LFTs near-normal (SGOT 36, SGPT 34). Clinically well."), ]: add_bold_para(doc, date, text) add_heading_colored(doc, "6c. Active Chronic GVHD with Formal Assessment (Mar 2026 – Present)", 2, rgb=(0x70,0x30,0xA0)) for date, text in [ ("March 2026 (1Y10M)","FORMAL cGVHD ORGAN ASSESSMENT: Skin ~50% softening, scarring (+). Joint/fascia ROM (R elbow/knee/wrist) improved ~50%. Mouth ~80% better. PFT: FEV1 83%, FEV1/FVC 103%, RV 200%, RV/TLC 40% (air-trapping — LUNG cGVHD suspected). HRCT Chest: No significant abnormality. Moxifloxacin inhaler started."), ("April 2026 (1Y11M)","Skin softening ~60%, ROM ~60%, Mouth ~80%. FEV1 89%, RV 205%. Bilateral thigh subcutaneous lipoatrophy identified. Ruxolitinib re-initiated. Sirolimus added. Mavicel Dose 1 (50 x 10\u2076 cells, institutional cellular therapy) given 22.04.2026."), ("May 2026 (2Y)", "UVA1 therapy started 07.05.2026 (5 sessions). Skin: patchy sclerosis on chest wall R side, abdomen, bilateral forearms, left leg. Lipoatrophy bilateral thighs: reduced. Nails + hands: better/resolved. Feet: better. Sirolimus tapering. Jakavi dose increased. Mavicel Dose 2 (50 x 10\u2076 cells) given 18.05.2026."), ("Jun 05, 2026", "Skin tightness increased (patient report). Patient emotionally distressed regarding appearance. Extensive counselling; father advised to seek psychological support. ESCALATION: Omnacortil 10 mg AM + 5 mg PM. Continue Sirolimus/Jakavi/Rezurock. Added: Thalidomide 50 mg OD (anti-fibrotic for skin sclerosis) + Ecosprin 75 mg (with thalidomide). Topical Calcipotriol discussed with Dermatology. UVA1 continued."), ("Jun 22, 2026", "OPD: Lungs better, Liver better, Joints/fascia better except ankle. Skin sclerosis improving. 2 possible new skin lesions + new lichenoid lesions on lipoatrophic area. ECP to be reconsidered if no improvement after 4 weeks of full-dose UVA1."), ("Jul 18, 2026", "2Y2M Post Haplo-HCT. Post 2 doses Rituximab. Oral/eyes: ok. Joints/fascia: stable. Skin sclerosis: tightness persisting around abdomen and inner thighs. UVA1 stopped (poor weather). PLAN: Initiate Ibrutinib (BTK inhibitor); reduce Jakavi; discuss ECP in 4 weeks."), ]: add_bold_para(doc, date, text) # cGVHD Organ Table p_l2 = doc.add_paragraph() p_l2.add_run("Chronic GVHD — Organ Involvement Summary").bold = True p_l2.runs[0].font.color.rgb = RGBColor(0x70,0x30,0xA0) p_l2.runs[0].font.size = Pt(11) make_table(doc, headers=["Organ / System", "Key Features", "Current Status"], data_rows=[ ["Skin", "Sclerosis, mucocoles, acneiform lesions, periungual changes, scarring, lichenoid lesions", "Partially improved (~60%); patchy active sclerosis persisting"], ["Liver", "Elevated transaminases/ALP (peak SGOT 472), hyperbilirubinemia, hypoalbuminemia", "Improving — near-normal LFTs by Apr 2026; mild fluctuation"], ["Joints/Fascia", "Proximal muscle weakness, wasting, reduced ROM (R elbow/knee/wrist)", "Better ~60%; ankle still affected"], ["Oral Mucosa", "Mucocoles in palate, mucosal congestion", "~80% improved; stable"], ["Lungs", "Air trapping (RV 200–205%, RV/TLC 40%), low peak flow, FEV1 83–89%", "Stable; HRCT no abnormality; spirometry 4x/day; inhaler"], ["Eyes", "Monitored serially", "No active disease"], ["Subcutaneous", "Bilateral thigh lipoatrophy", "Partially improving; ongoing evaluation"], ["GI Tract", "Post-aGVHD; no active GI cGVHD documented", "Resolved"], ], header_fill="7030A0", alt_fill="EAD1FF", font_size=9 ) doc.add_paragraph() # cGVHD Treatment Table p_l3 = doc.add_paragraph() p_l3.add_run("Chronic GVHD — Treatment Summary").bold = True p_l3.runs[0].font.color.rgb = RGBColor(0x70,0x30,0xA0) p_l3.runs[0].font.size = Pt(11) make_table(doc, headers=["Agent", "Role / Indication", "Timing"], data_rows=[ ["Corticosteroids (Wysolone / Omnacortil)", "Primary immunosuppression; dose titrated per response", "D+33 onwards; ongoing taper"], ["Ruxolitinib (Jakavi — JAK1/2 inhibitor)", "Steroid-refractory aGVHD; re-used for cGVHD", "D+36 (aGVHD); re-initiated Apr 2026 (cGVHD)"], ["Basiliximab", "2nd-line aGVHD (IL-2R blockade)", "Day +39 (aGVHD only)"], ["Infliximab (anti-TNF)", "2nd-line aGVHD x 4 weekly doses", "Day +40 (aGVHD only)"], ["ECP (Extracorporeal Photopheresis)", "3rd-line aGVHD; continued for cGVHD; 18+ total sessions", "Day +45 onwards"], ["Rituximab", "B-cell depletion for musculoskeletal/skin cGVHD", "Feb–Mar 2025 (x4); resumed Jul 2026"], ["Sirolimus (mTOR inhibitor)", "Immunosuppression for cGVHD", "Started Apr 2026; being tapered"], ["Belumosudil (Rezurock — ROCK2 inhibitor)", "FDA-approved 3rd-line cGVHD", "Current medication"], ["Thalidomide (anti-fibrotic)", "Skin sclerosis (anti-fibrotic effect)", "Started Jun 2026 (50 mg OD)"], ["Ibrutinib (BTK inhibitor)", "Planned for skin/fascial cGVHD", "Planned Jul 2026"], ["Mavicel (Institutional Cellular Therapy)", "Regulatory T-cell/MSC product from donor", "Apr 2026 + May 2026 (2 doses)"], ["UVA1 Phototherapy", "Cutaneous sclerotic cGVHD", "Started May 2026; paused Jul 2026 (weather)"], ], header_fill="7030A0", alt_fill="EAD1FF", font_size=9 ) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 7. INFECTIOUS COMPLICATIONS # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "7. INFECTIOUS COMPLICATIONS", 1) section_divider(doc) for date, text in [ ("Pre-Tx (D-4)", "Shigella enterocolitis (stool BioFire +ve). IV Ofloxacin + Tazar/Amikacin/Minocycline. Melphalan dose modified. Resolved before Day 0."), ("D+4 – D+13", "Neutropenic fever. Empirical Meropenem+EDTA + Amikacin. G-CSF infusion D+8. Escalated to Avibactam/Aztreonam. Resolved post-engraftment."), ("D+31 – D+67", "CMV reactivation (serial): 1,085 copies D+31 -> IV Ganciclovir D+33 -> withheld D+42 (cytopenia) -> alternate-day IV Foscarnet x 2 wks -> low-dose Ganciclovir reintroduced -> discontinued D+63 -> Oral Artesunate + Acyclovir D+63 -> CMV reactivation D+66 (13,970 copies) -> Valganciclovir + IV Cidofovir D+67. G-CSF support throughout."), ("D+32 – D+52", "Recurrent septic episodes. Escalated: Meropenem + Amikacin + Fosfomycin -> Avibactam + Aztreonam. Resolved."), ("Dec 2024 (D+221)", "Rhinovirus (respiratory BioFire +ve, persistent) + Candida parapsilosis (blood multiplex PCR +ve). IV Amphotericin B + Vancomycin. Responded in 5 days."), ("Ongoing Prophylaxis", "Isavuconazole (Isuvaz) 200 mg OD (from 18.02.2026) + Acyclovir (Zovirax) 400 mg TDS + Bandy Plus monthly. Monthly IVIG 10–15 g."), ]: add_bold_para(doc, date, text) doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 8. MASTER TIMELINE # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "8. MASTER CLINICAL TIMELINE", 1) section_divider(doc) timeline = [ ("Apr 2020", "Diagnosis B-ALL t(12;21). BFM 95/2002 started."), ("Dec 2020", "BM MRD Negative. Re-induction Phase A+B."), ("Mar 2021", "Maintenance: 6MP + MTx."), ("Jan 2022", "COVID-19 infection."), ("Aug 2022", "BM RELAPSE (85% blasts). Inotuzumab x 6 + IT MTx x 3. MRD Negative."), ("Oct 2022", "VBD chemotherapy. Evaluated at DNSH."), ("Dec 2022", "Autologous stem cell harvest. Blinatumomab planned as bridge."), ("Jun–Oct 2023", "Blinatumomab delayed; BFM Maintenance at hometown."), ("Nov 2023", "ISOLATED CNS RELAPSE — bilateral papilledema. TIT x 6 doses."), ("Dec 2023", "HD-MTx + ARA-C Cycle 1. Febrile neutropenia."), ("Jan 2024", "TIT Dose 7; CSF 5% blasts. Multi-institutional consultations."), ("Feb–Apr 2024", "Rituximab x 4 + HD-MTx + L-Asp + Inotuzumab + Blinatumomab. Hickman line 08.02.2024."), ("05–16 May 2024", "CONDITIONING: Flu+TT+Mel + Cranial Boost 2Gy x 2 + TBI 2 Gy."), ("17 May 2024 (D0)", "TRANSPLANT: Haplo-PBSCT (CD34 6.37x10\u2076/kg). FDC confirmed."), ("D+14/16", "Neutrophil engraftment. Platelet engraftment D+11/12."), ("D+31", "CMV viremia (1,085 copies). IV Ganciclovir D+33."), ("D+33", "aGVHD ONSET: loose stools + oral mucositis. IV Solumedrol started."), ("D+36", "Sigmoidoscopy: CONFIRMED Acute Gut GvHD Grade II. Ruxolitinib + PN."), ("D+37", "CT Abdomen: diffuse colitis + intussusception. STEROID-REFRACTORY Grade IV."), ("D+39–40", "Basiliximab + Infliximab x 4 weekly. Defibrotide D+42."), ("D+41", "Institutional cellular therapy (donor-derived from mother)."), ("D+45", "ECP initiated (3rd line). Octreotide. Femoral access."), ("D+54", "PARTIAL REMISSION of aGVHD."), ("D+66–67", "CMV re-activation (13,970 copies). Valganciclovir + Cidofovir."), ("D+80–100", "Wysolone + Jakavi taper. ECP 11th–13th sessions. BM aspiration."), ("Nov 2024–Jan 2025","ECP 16th–19th sessions. Mucocoles + skin lesions (cGVHD emerging). Candida parapsilosis + Rhinovirus managed."), ("Feb 2025", "Proximal myopathy suspected cGVHD. Rituximab started."), ("Mar–Apr 2025", "Rituximab x 4 doses. LFT normalisation. ROM improving."), ("May 2025", "1-YEAR POST-TRANSPLANT: No active cGVHD. BM + LP done."), ("Nov 2025", "R elbow restriction + periungual lesions. Active cGVHD. Vaccinations."), ("Jan 2026", "CBC normalising (Hb 14.2, Plt 3.38 lac). LFTs near-normal."), ("Mar 2026", "cGVHD Assessment: Skin 50%, ROM 50%, Mouth 80% improved. Lung involvement (PFT). Moxiflo inhaler started."), ("Apr 2026", "Ruxolitinib + Sirolimus. Mavicel Dose 1. Lipoatrophy bilateral thighs confirmed."), ("May 2026", "2-YEAR POST-TRANSPLANT. UVA1 therapy started. Mavicel Dose 2. Sirolimus tapering."), ("Jun 2026", "Skin tightness worsened. Thalidomide added. Psychological support advised."), ("Jul 2026", "Post 2 Rituximab doses. Oral/eyes/joints stable. Skin inner thigh/abdomen tight. Ibrutinib planned. ECP to be discussed."), ] # Build timeline table row by row using add_row tbl6 = doc.add_table(rows=1, cols=2) tbl6.style = "Table Grid" # header hrow = tbl6.rows[0] for c_idx, h in enumerate(["Date / Timepoint", "Key Event"]): cell = hrow.cells[c_idx] cell.text = h shade_cell(cell, "1F497D") if cell.paragraphs[0].runs: run = cell.paragraphs[0].runs[0] run.bold = True run.font.size = Pt(10) run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF) for r_idx, (date, event) in enumerate(timeline, start=1): row = tbl6.add_row() row.cells[0].text = date row.cells[1].text = event for c_idx, cell in enumerate(row.cells): if cell.paragraphs[0].runs: run = cell.paragraphs[0].runs[0] run.font.size = Pt(9.5) if c_idx == 0: run.bold = True if r_idx % 2 == 0: shade_cell(row.cells[0], "DEEAF1") shade_cell(row.cells[1], "DEEAF1") doc.add_paragraph() # ═══════════════════════════════════════════════════════════════════════════════ # 9. CURRENT STATUS & PLAN # ═══════════════════════════════════════════════════════════════════════════════ add_heading_colored(doc, "9. CURRENT STATUS & ONGOING MANAGEMENT PLAN", 1) section_divider(doc) p_c = doc.add_paragraph() p_c.add_run("As of July 2026 (Day ~2 Years 2 Months post Haploidentical PBSCT):").bold = True for item in [ "Disease Status: In remission. BM + LP done at 2-year mark (May 2026).", "Acute GvHD: Resolved. Partial remission achieved Day +54; fully resolved by ~Day +100.", "Chronic GvHD: ACTIVE, multi-organ — skin sclerosis (partially improved), joint/fascia (stable/improving), lungs (stable air trapping; HRCT clear), liver (near-normal), oral/eyes stable, bilateral thigh lipoatrophy.", "Current Anti-GvHD Medications: Omnacortil + Sirolimus (taper) + Ruxolitinib (Jakavi, dose adjusting) + Belumosudil (Rezurock) + Rituximab + Thalidomide + UVA1 (paused). Ibrutinib: PLANNED.", "CMV: Controlled; monitoring ongoing.", "Antimicrobial Prophylaxis: Isavuconazole (Isuvaz) + Acyclovir (Zovirax) + monthly Bandy Plus.", "Supportive: Monthly IVIG 15 g. Spirometry 4x/day. Moxiflo inhaler + Candid M/P. Aqua therapy. Ayurvedic oil massage.", "Upcoming Plan: ECP reconsideration in 4 weeks if no skin improvement on UVA1; 2-year formal BM + LP assessment (June 2026).", "Psychological Support: Formal psychiatric/psychological referral advised due to emotional distress and concern regarding appearance.", ]: add_bullet(doc, item) doc.add_paragraph() # Footer p_f = doc.add_paragraph() p_f.alignment = WD_ALIGN_PARAGRAPH.CENTER r_f = p_f.add_run("CONFIDENTIAL — Clinical Case Summary | For Medical Use Only | Patient Identity Anonymised") r_f.font.size = Pt(8) r_f.font.color.rgb = RGBColor(0x80,0x80,0x80) r_f.font.italic = True out_path = "/tmp/workspace/case-summary/Clinical_Case_Summary_GVHD.docx" doc.save(out_path) print(f"SUCCESS: {out_path}") PYEOF