"rheumatologic emergencies" AND management

rheumatologic emergencies ACR EULAR guidelines 2024 2025 CAPS MAS vasculitis

"macrophage activation syndrome" AND treatment

"septic arthritis" AND management

mkdir -p /tmp/workspace/rheumatologic-emergencies && ls /tmp/workspace/rheumatologic-emergencies/

mkdir -p /tmp/workspace/rheumatologic-emergencies && python3 << 'PYEOF' from pptx import Presentation from pptx.util import Inches, Pt, Emu from pptx.dml.color import RGBColor from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.util import Inches, Pt import json, subprocess, base64, os from io import BytesIO prs = Presentation() prs.slide_width = Inches(13.333) prs.slide_height = Inches(7.5) # ── Colour palette ────────────────────────────────────────────────────────── NAVY = RGBColor(0x0A, 0x29, 0x5E) # dark-navy header/accent TEAL = RGBColor(0x00, 0x7B, 0x8A) # teal accent RED = RGBColor(0xC0, 0x00, 0x00) # alert / red-flag GOLD = RGBColor(0xD4, 0xA0, 0x17) # highlight WHITE = RGBColor(0xFF, 0xFF, 0xFF) LIGHT = RGBColor(0xE8, 0xF4, 0xF8) # very-light-blue background DARK = RGBColor(0x1A, 0x1A, 0x2E) GREY = RGBColor(0xF2, 0xF4, 0xF7) GREEN = RGBColor(0x1A, 0x7A, 0x4A) ORANGE = RGBColor(0xE0, 0x6C, 0x00) blank_layout = prs.slide_layouts[6] # fully blank # ── Helper: solid-fill background ─────────────────────────────────────────── from pptx.oxml.ns import qn from lxml import etree def set_bg(slide, rgb): bg = slide.background fill = bg.fill fill.solid() fill.fore_color.rgb = rgb # ── Helper: add rectangle shape ───────────────────────────────────────────── def add_rect(slide, l, t, w, h, fill_rgb=None, line_rgb=None, line_pt=0): shape = slide.shapes.add_shape(1, Inches(l), Inches(t), Inches(w), Inches(h)) if fill_rgb: shape.fill.solid(); shape.fill.fore_color.rgb = fill_rgb else: shape.fill.background() if line_rgb and line_pt: shape.line.color.rgb = line_rgb; shape.line.width = Pt(line_pt) else: shape.line.fill.background() return shape # ── Helper: add text-box ───────────────────────────────────────────────────── def add_tb(slide, text, l, t, w, h, size=18, bold=False, color=DARK, align=PP_ALIGN.LEFT, wrap=True, italic=False): tb = slide.shapes.add_textbox(Inches(l), Inches(t), Inches(w), Inches(h)) tf = tb.text_frame; tf.word_wrap = wrap tf.margin_left = tf.margin_right = tf.margin_top = tf.margin_bottom = 0 p = tf.paragraphs[0] p.alignment = align run = p.add_run(); run.text = text run.font.size = Pt(size); run.font.bold = bold run.font.color.rgb = color; run.font.italic = italic return tb, tf # ── Helper: multi-bullet text-frame (returns tf) ──────────────────────────── def add_bullets(slide, items, l, t, w, h, size=15, color=DARK, bold_first=False, symbol="•", heading=None, head_size=16, head_color=NAVY): tb = slide.shapes.add_textbox(Inches(l), Inches(t), Inches(w), Inches(h)) tf = tb.text_frame; tf.word_wrap = True tf.margin_left = Pt(4); tf.margin_right = Pt(4) tf.margin_top = Pt(2); tf.margin_bottom = Pt(2) first = True if heading: p = tf.paragraphs[0] if first else tf.add_paragraph() first = False p.alignment = PP_ALIGN.LEFT run = p.add_run(); run.text = heading run.font.size = Pt(head_size); run.font.bold = True run.font.color.rgb = head_color for item in items: p = tf.paragraphs[0] if (first and not heading) else tf.add_paragraph() first = False p.alignment = PP_ALIGN.LEFT p.space_before = Pt(2) if isinstance(item, tuple): sym, txt = item else: sym, txt = symbol, item run = p.add_run() run.text = f"{sym} {txt}" run.font.size = Pt(size) run.font.bold = bold_first and (item == items[0]) run.font.color.rgb = color return tf # ── Helper: slide header bar ──────────────────────────────────────────────── def header(slide, title, subtitle=None): add_rect(slide, 0, 0, 13.333, 1.1, fill_rgb=NAVY) add_tb(slide, title, 0.3, 0.08, 11, 0.65, size=28, bold=True, color=WHITE, align=PP_ALIGN.LEFT) if subtitle: add_tb(slide, subtitle, 0.3, 0.72, 11, 0.38, size=14, bold=False, color=GOLD, align=PP_ALIGN.LEFT) # thin accent line below header add_rect(slide, 0, 1.1, 13.333, 0.05, fill_rgb=TEAL) # ── Helper: slide number ──────────────────────────────────────────────────── def slide_num(slide, n): add_tb(slide, str(n), 12.8, 7.2, 0.5, 0.3, size=11, color=GREY, align=PP_ALIGN.RIGHT) # ── Helper: two-column layout ─────────────────────────────────────────────── def two_col(slide, left_items, right_items, l_head=None, r_head=None, top=1.2): add_bullets(slide, left_items, 0.3, top, 6.2, 6.0, heading=l_head, size=14) add_bullets(slide, right_items, 6.8, top, 6.2, 6.0, heading=r_head, size=14) # divider add_rect(slide, 6.6, top+0.1, 0.03, 5.8, fill_rgb=TEAL) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 1 – TITLE # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, NAVY) # big accent bar left add_rect(s, 0, 0, 0.35, 7.5, fill_rgb=TEAL) add_rect(s, 0.35, 2.2, 12.8, 0.07, fill_rgb=GOLD) add_rect(s, 0.35, 5.4, 12.8, 0.05, fill_rgb=TEAL) add_tb(s, "RHEUMATOLOGIC", 1.0, 1.0, 11.5, 1.1, size=50, bold=True, color=WHITE, align=PP_ALIGN.LEFT) add_tb(s, "EMERGENCIES", 1.0, 2.0, 11.5, 1.0, size=50, bold=True, color=GOLD, align=PP_ALIGN.LEFT) add_tb(s, "A Comprehensive Evidence-Based Review for Final Year MBBS", 1.0, 3.1, 11.5, 0.6, size=18, bold=False, color=LIGHT, align=PP_ALIGN.LEFT, italic=True) add_tb(s, "Department of General Medicine | Academic Seminar | 2026", 1.0, 3.8, 11.5, 0.5, size=15, bold=False, color=GOLD, align=PP_ALIGN.LEFT) add_tb(s, "Based on: Harrison's Principles of Internal Medicine 21e • Kumar & Clark's Clinical Medicine 10e\n" "Oxford Handbook of Clinical Medicine 10e • ACR/EULAR Guidelines 2022–2025", 1.0, 4.7, 11.5, 0.9, size=12, bold=False, color=LIGHT, align=PP_ALIGN.LEFT, italic=True) add_tb(s, "Slide 1 of 20", 1.0, 6.8, 4.0, 0.4, size=11, color=RGBColor(0x88,0xAA,0xCC), align=PP_ALIGN.LEFT) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 2 – LEARNING OBJECTIVES # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Learning Objectives", "By the end of this seminar, you should be able to:") slide_num(s, 2) objectives = [ "Define rheumatologic emergencies and identify their spectrum", "Recognise red-flag clinical features demanding immediate intervention", "Construct a systematic diagnostic workup (labs + imaging)", "Describe pathophysiology and management of Septic Arthritis, CAPS, SRC, DAH", "Manage vasculitic emergencies including GCA and ANCA-associated vasculitis", "Diagnose and treat Macrophage Activation Syndrome (MAS / HLH)", "Recognise Neuropsychiatric SLE and Acute Transverse Myelitis", "List indications for ICU admission and biological/immunosuppressive therapies", "Apply recent ACR/EULAR 2022–2025 guideline updates in clinical practice", "Discuss common viva & MBBS examination high-yield points", ] for i, obj in enumerate(objectives, 1): add_rect(s, 0.35, 1.15 + (i-1)*0.55, 0.45, 0.42, fill_rgb=TEAL if i % 2 == 1 else NAVY) add_tb(s, str(i), 0.38, 1.18 + (i-1)*0.55, 0.4, 0.4, size=14, bold=True, color=WHITE, align=PP_ALIGN.CENTER) add_tb(s, obj, 0.9, 1.18 + (i-1)*0.55, 12.0, 0.42, size=13.5, bold=False, color=DARK) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 3 – INTRODUCTION & DEFINITION # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Introduction & Definition") slide_num(s, 3) # definition box add_rect(s, 0.3, 1.2, 12.7, 1.15, fill_rgb=NAVY) add_tb(s, "DEFINITION: Rheumatologic emergencies are acute life- or organ-threatening " "manifestations of rheumatic diseases requiring immediate diagnosis and intervention " "to prevent irreversible organ damage or death.", 0.5, 1.25, 12.3, 1.05, size=14, bold=False, color=WHITE) left = [ "Incidence: ~5–10% of rheumatic patients experience ≥1 life-threatening event", "Mortality: Up to 30–50% in conditions like CAPS, MAS, DAH without prompt Rx", "Often occur as first presentation or during disease flare", "Frequently under-recognised due to overlapping features with other conditions", "Require multidisciplinary approach: Rheumatology + ICU + Nephrology + Resp", ] right = [ "Common triggers: Infection, surgery, drugs, stress, pregnancy", "Underlying conditions: SLE, RA, Systemic Sclerosis, Vasculitis, APS", "Key principle: Treat the emergency FIRST, confirm diagnosis SECOND", "Time-sensitivity rivals ACS and stroke in some conditions (GCA → blindness)", "Always ask: 'Could this be rheumatologic?' in unexplained multiorgan failure", ] two_col(s, left, right, "Key Epidemiological Facts", "Clinical Pearls", top=2.45) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 4 – CLASSIFICATION & INITIAL APPROACH # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Classification & Initial Clinical Approach", "Rheumatologic Emergencies by Organ System") slide_num(s, 4) categories = [ (NAVY, "JOINT", "Septic Arthritis, Acute Crystal Arthritis (Gout/CPPD), Haemarthrosis"), (TEAL, "RENAL", "Lupus Nephritis (Class III/IV), Scleroderma Renal Crisis, ANCA Vasculitis"), (RED, "PULMONARY", "Diffuse Alveolar Hemorrhage, Acute Lupus Pneumonitis, ILD Exacerbation"), (GREEN, "VASCULAR", "CAPS, Giant Cell Arteritis (vision loss), Takayasu, Antiphospholipid Syndrome"), (ORANGE, "NEUROLOGICAL","NP-SLE, Acute Transverse Myelitis, Cervical Spine Instability (RA), CNS Vasculitis"), (NAVY, "HAEMATOLOGIC","MAS/HLH, Thrombotic Microangiopathy, Immune Thrombocytopenia"), (TEAL, "CARDIAC", "Myocarditis (SLE/Myositis), Pericardial Tamponade, Libman-Sacks Endocarditis"), (GREEN, "SYSTEMIC", "Cytokine Storm, Severe Drug Reactions (e.g. MTX toxicity, biologics)"), ] for i, (col, cat, desc) in enumerate(categories): row = i // 2; ccol = i % 2 xl = 0.3 + ccol * 6.55; yt = 1.25 + row * 1.4 add_rect(s, xl, yt, 0.6, 1.1, fill_rgb=col) add_tb(s, cat, xl+0.02, yt+0.28, 0.58, 0.55, size=8.5, bold=True, color=WHITE, align=PP_ALIGN.CENTER) add_rect(s, xl+0.62, yt, 5.8, 1.1, fill_rgb=LIGHT, line_rgb=col, line_pt=1.2) add_tb(s, desc, xl+0.72, yt+0.25, 5.55, 0.65, size=12.5, bold=False, color=DARK) add_rect(s, 0.3, 6.65, 12.7, 0.62, fill_rgb=GOLD) add_tb(s, "Initial Approach: ABCDE + IV access + Bloods (FBC, U&E, CRP, ESR, ANA, ANCA, complement) " "+ Cultures (blood/synovial) + Imaging (CXR, USS, CT) + Rheumatology referral", 0.5, 6.68, 12.3, 0.58, size=12, bold=True, color=NAVY) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 5 – PATHOPHYSIOLOGY # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Pathophysiology", "Unifying Mechanisms Behind Rheumatologic Emergencies") slide_num(s, 5) # central box add_rect(s, 4.9, 3.2, 3.5, 1.1, fill_rgb=NAVY) add_tb(s, "IMMUNE\nDYSREGULATION", 4.92, 3.22, 3.46, 1.06, size=15, bold=True, color=WHITE, align=PP_ALIGN.CENTER) arrows = [ (0.35, 1.3, 5.5, 1.4, TEAL, "Autoantibody\nFormation\n(ANA, ANCA,\naPL, RF)"), (0.35, 3.2, 5.5, 3.7, NAVY, "Complement\nActivation\n(C3/C4↓,\nMAC deposition)"), (0.35, 5.1, 5.5, 5.5, GREEN, "Cytokine Storm\n(IL-1, IL-6,\nTNF-α, IFN-γ)"), (8.5, 1.3, 8.5, 1.4, ORANGE,"Direct\nTissue Injury\n(Vasculitis,\nNephritis)"), (8.5, 3.2, 8.5, 3.7, RED, "Thrombosis\n(APS, CAPS,\nTMA, DIC)"), (8.5, 5.1, 8.5, 5.5, TEAL, "Macrophage\nActivation\n(Haemophago-\ncytosis, MAS)"), ] for xl, yt, _, _, col, txt in arrows: add_rect(s, xl, yt, 3.8, 1.5, fill_rgb=col, line_rgb=WHITE, line_pt=0.5) add_tb(s, txt, xl+0.1, yt+0.1, 3.6, 1.35, size=12, bold=False, color=WHITE, align=PP_ALIGN.CENTER) add_tb(s, "Trigger (Infection / Stress / Drugs / Surgery / Pregnancy)", 0.3, 6.9, 12.7, 0.5, size=13, bold=True, color=RED, align=PP_ALIGN.CENTER) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 6 – CLINICAL FEATURES & RED FLAGS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Clinical Features & Red Flags", "Warning signs that demand immediate action") slide_num(s, 6) red_flags = [ "Sudden visual loss / amaurosis fugax → GCA until proven otherwise", "Acute monoarthritis + fever + rigors → Septic Arthritis until proven otherwise", "Haemoptysis + haematuria + ANCA+ → Pulmonary-Renal Syndrome (Vasculitis/DAH)", "Hypertensive crisis + rising creatinine in Scleroderma → Scleroderma Renal Crisis", "Fever + pancytopenia + ferritin >10,000 µg/L → MAS/HLH", "Multi-organ thrombosis + aPL+ → Catastrophic APS (CAPS)", "Neck pain + upper limb weakness in RA → Cervical Spine Instability", "Altered consciousness + seizures in SLE → Neuropsychiatric SLE", "Paraplegia/paraparesis onset <4 hrs → Acute Transverse Myelitis", ] general = [ "Unexplained fever >38.5°C in immunosuppressed patient", "New rash (purpura, livedo, malar) + systemic symptoms", "Dyspnoea + bilateral infiltrates → consider DAH", "Oliguria + haematuria + casts → renal vasculitis/nephritis", "Peripheral neuropathy + weight loss → vasculitis", "Dysphagia + proximal weakness → Myositis crisis", ] add_rect(s, 0.3, 1.2, 6.9, 0.5, fill_rgb=RED) add_tb(s, " ⚠ ABSOLUTE RED FLAGS (Act within minutes–hours)", 0.32, 1.22, 6.85, 0.46, size=14, bold=True, color=WHITE) add_rect(s, 0.3, 1.7, 6.9, 5.55, fill_rgb=RGBColor(0xFF,0xF0,0xF0), line_rgb=RED, line_pt=1) add_bullets(s, red_flags, 0.45, 1.75, 6.65, 5.4, size=12.5, color=DARK, symbol="⚠") add_rect(s, 7.45, 1.2, 5.55, 0.5, fill_rgb=ORANGE) add_tb(s, " General Warning Features", 7.47, 1.22, 5.5, 0.46, size=14, bold=True, color=WHITE) add_rect(s, 7.45, 1.7, 5.55, 3.4, fill_rgb=RGBColor(0xFF,0xF5,0xE6), line_rgb=ORANGE, line_pt=1) add_bullets(s, general, 7.6, 1.75, 5.3, 3.3, size=12.5, color=DARK, symbol="→") # MBBS viva box add_rect(s, 7.45, 5.3, 5.55, 1.95, fill_rgb=NAVY) add_tb(s, "VIVA POINTS:\n" "Q: Most common cause of acute monoarthritis in young adults? A: Septic arthritis\n" "Q: Hallmark of SRC? A: Normotensive or hypertensive crisis in diffuse SSc\n" "Q: Ferritin level in MAS? A: >10,000 µg/L (diagnostic threshold per 2016 criteria)", 7.6, 5.35, 5.3, 1.85, size=11, bold=False, color=GOLD) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 7 – DIAGNOSTIC WORKUP # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Diagnostic Workup", "Laboratory Investigations + Imaging Algorithm") slide_num(s, 7) labs_tier1 = [ "FBC: leucocytosis (infection), pancytopenia (MAS/SLE)", "ESR, CRP, Procalcitonin: infection vs. inflammation", "U&E, Creatinine: renal involvement (SRC, nephritis)", "LFTs, LDH, Uric acid: MAS, gout, crystal arthropathy", "Coagulation (PT, aPTT, D-dimer, fibrinogen): CAPS/DIC", "Urinalysis + microscopy: casts → nephritis/vasculitis", ] labs_tier2 = [ "ANA, anti-dsDNA, complement (C3/C4): SLE", "ANCA (pANCA/cANCA, MPO/PR3): Vasculitis", "aPL (aCL, anti-β2GP1, Lupus anticoagulant): APS/CAPS", "RF, anti-CCP: Rheumatoid Arthritis", "Ferritin (>10,000 → MAS), Triglycerides ↑", "Blood cultures × 2 + Synovial fluid C&S", ] imaging = [ "X-ray joints: baseline, erosions, calcification", "USS joints: effusion detection, guided aspiration", "MRI spine: cord compression (RA), transverse myelitis", "CT chest/abdomen: vasculitis, ILD, renal infarcts", "CXR: bilateral infiltrates (DAH, pneumonitis)", "Echo: Libman-Sacks, pericardial effusion, PHTN", "PET-CT/MRA: large-vessel vasculitis (GCA, Takayasu)", ] add_rect(s, 0.3, 1.2, 4.0, 0.45, fill_rgb=TEAL) add_tb(s, " Tier 1 – Urgent Bloods", 0.32, 1.22, 3.95, 0.42, size=13, bold=True, color=WHITE) add_rect(s, 0.3, 1.65, 4.0, 5.6, fill_rgb=LIGHT, line_rgb=TEAL, line_pt=1) add_bullets(s, labs_tier1, 0.45, 1.7, 3.8, 5.5, size=12.5, color=DARK, symbol="•") add_rect(s, 4.6, 1.2, 4.0, 0.45, fill_rgb=NAVY) add_tb(s, " Tier 2 – Immunology", 4.62, 1.22, 3.95, 0.42, size=13, bold=True, color=WHITE) add_rect(s, 4.6, 1.65, 4.0, 5.6, fill_rgb=LIGHT, line_rgb=NAVY, line_pt=1) add_bullets(s, labs_tier2, 4.75, 1.7, 3.8, 5.5, size=12.5, color=DARK, symbol="•") add_rect(s, 8.9, 1.2, 4.13, 0.45, fill_rgb=GREEN) add_tb(s, " Imaging", 8.92, 1.22, 4.08, 0.42, size=13, bold=True, color=WHITE) add_rect(s, 8.9, 1.65, 4.13, 5.6, fill_rgb=LIGHT, line_rgb=GREEN, line_pt=1) add_bullets(s, imaging, 9.05, 1.7, 3.93, 5.5, size=12.5, color=DARK, symbol="•") add_rect(s, 0.3, 7.15, 12.7, 0.28, fill_rgb=GOLD) add_tb(s, "SYNOVIAL FLUID: WBC >50,000/mm³ + >90% PMN = Septic Arthritis | " "Negatively birefringent = Gout | Positively birefringent = CPPD", 0.45, 7.17, 12.4, 0.24, size=10.5, bold=True, color=NAVY, align=PP_ALIGN.CENTER) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 8 – SEPTIC ARTHRITIS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Septic Arthritis", "Most common rheumatologic emergency | Orthopaedic urgency") slide_num(s, 8) col1 = [ "Incidence: 2–10/100,000/year; mortality 6–11%", "Risk factors: DM, RA, joint prosthesis, IVDU, immunosuppression", "Most common organism: Staphylococcus aureus (>50%)", "Neisseria gonorrhoeae: commonest in sexually active adults <35 yrs", "Route: Haematogenous (most common) > direct inoculation", "Most common joint: Knee > hip > shoulder > wrist", ] col2 = [ "Features: Acute monoarthritis + fever + erythema + severe pain", "Synovial WBC >50,000/mm³ (>90% PMN) strongly suggests infection", "Blood cultures positive in 50%; synovial culture positive in 70–80%", "Imaging: USS for effusion; MRI for early osteomyelitis", "X-ray: normal early; erosions/destruction in 7–10 days if untreated", ] two_col(s, col1, col2, "Epidemiology & Microbiology", "Diagnosis", top=1.25) # Management flowchart (text-based) add_rect(s, 0.3, 5.55, 12.7, 0.38, fill_rgb=RED) add_tb(s, " MANAGEMENT ALGORITHM", 0.45, 5.57, 12.4, 0.34, size=14, bold=True, color=WHITE) steps = [ ("ASPIRATION", "Joint aspiration BEFORE antibiotics | C&S, Gram stain, WBC", TEAL), ("ANTIBIOTICS", "IV Flucloxacillin 2g QDS (MRSA risk → Vancomycin) | IV then oral 4–6 weeks", NAVY), ("DRAINAGE", "Repeated aspiration or arthroscopic washout | Open surgery if hip/prosthesis", GREEN), ("MONITORING", "Daily WBC, CRP, ESR | Physiotherapy post-acute | Repeat aspiration prn", ORANGE), ] for i, (step, desc, col) in enumerate(steps): xl = 0.35 + i * 3.2 add_rect(s, xl, 5.95, 3.0, 0.52, fill_rgb=col) add_tb(s, step, xl+0.05, 5.97, 2.9, 0.28, size=11, bold=True, color=WHITE) add_tb(s, desc, xl+0.05, 6.23, 2.9, 0.32, size=9.5, bold=False, color=WHITE) if i < 3: add_tb(s, "→", xl+3.02, 6.1, 0.25, 0.35, size=14, bold=True, color=NAVY) add_rect(s, 0.3, 6.92, 12.7, 0.48, fill_rgb=LIGHT, line_rgb=NAVY, line_pt=0.8) add_tb(s, "MBBS EXAM KEY POINT: Joint aspiration is BOTH diagnostic AND therapeutic | " "Never delay IV antibiotics >1 hour after cultures | " "Gram-negative cover if elderly, immunocompromised, or IVDU", 0.5, 6.94, 12.3, 0.44, size=11.5, bold=False, color=NAVY) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 9 – CAPS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Catastrophic Antiphospholipid Syndrome (CAPS)", "Asherson Syndrome | Mortality ~37% even with treatment") slide_num(s, 9) left = [ "Definition: ≥3 organ thromboses over <1 week + aPL antibodies", "Prevalence: <1% of APS patients; most devastating APS variant", "Trigger: Infection (most common ~22%), surgery, OCP, anticoagulant withdrawal", "Organs: Kidney (78%), Lung (66%), CNS (56%), Heart (50%), Skin (50%)", "Lab: Thrombocytopenia, haemolytic anaemia, elevated D-dimer", "Distinguish from TTP: CAPS has aPL+; TTP has ADAMTS13 deficiency", "Diagnosis: ISTH CAPS criteria (2003): ≥3 organs + biopsy +aPL+", ] right = [ "TRIPLE THERAPY (Standard of Care):", "1. Anticoagulation: IV unfractionated heparin → warfarin (INR 3–4)", "2. Glucocorticoids: Methylprednisolone 1g/day × 3 days (IV pulse)", "3. Plasma exchange (PE): 5 sessions or IVIG 400mg/kg/day × 5 days", "", "Refractory CAPS: Rituximab 375mg/m² × 4 cycles", "Complement-mediated: Eculizumab (anti-C5) — evidence from case series", "Treat precipitating infection aggressively with antibiotics", "Lifelong anticoagulation after CAPS episode", ] two_col(s, left, right, "Pathophysiology & Diagnosis", "Management – Triple Therapy", top=1.25) add_rect(s, 0.3, 6.88, 12.7, 0.52, fill_rgb=NAVY) add_tb(s, "VIVA: Triple therapy = Anticoagulation + Steroids + Plasma exchange/IVIG | " "aPL antibodies: Lupus anticoagulant, anti-Cardiolipin IgG/IgM, anti-β2GP1 | " "Lab paradox: aPTT prolonged but patient is PROTHROMBOTIC", 0.5, 6.90, 12.3, 0.48, size=11.5, bold=False, color=GOLD) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 10 – SCLERODERMA RENAL CRISIS (SRC) # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Scleroderma Renal Crisis (SRC)", "Hypertensive emergency in Systemic Sclerosis | Treat with ACE inhibitors") slide_num(s, 10) facts = [ "Incidence: 2–15% of SSc patients; most in diffuse cutaneous SSc", "Risk factors: Anti-RNA polymerase III Ab+ (~25× risk), high-dose steroids (>15mg/day prednisolone)", "Early diffuse SSc (<4 yrs) = highest risk; rarely in limited SSc", "Pathology: Intimal proliferation + onion-skin lesions of renal arterioles", "BP: Usually >150/85 mmHg (but 10% normotensive SRC = worse prognosis!)", "Features: Headache, blurred vision, seizures, MAHA, oliguria, raised creatinine", "Urine: Haematuria, proteinuria, granular casts; MAHA on blood film", "Investigations: Renal biopsy (confirm) + echo (PHTN screen) + urinalysis", ] add_bullets(s, facts, 0.3, 1.2, 7.2, 5.8, size=13, color=DARK, symbol="•") # Management box add_rect(s, 7.65, 1.2, 5.35, 5.8, fill_rgb=LIGHT, line_rgb=TEAL, line_pt=1.5) add_tb(s, "MANAGEMENT", 7.75, 1.25, 5.15, 0.4, size=14, bold=True, color=TEAL) mgmt = [ "ACE Inhibitor: FIRST-LINE (e.g. Captopril 6.25mg TDS, titrate rapidly)", "Target: Systolic BP ↓ 20 mmHg/24 hr (avoid sudden hypotension)", "NEVER use ARBs as initial therapy (inferior evidence)", "Add CCB, ARB, endothelin antagonist if ACEi inadequate", "Haemodialysis if severe renal failure; continue ACEi during dialysis", "Kidney may recover up to 6–12 months after SRC → delay transplant", "AVOID high-dose corticosteroids (precipitates SRC)", "Prostacyclin (IV iloprost) for severe vascular involvement", "5-year survival: ~70% with ACEi; <20% before ACEi era", ] add_bullets(s, mgmt, 7.75, 1.65, 5.1, 5.25, size=11.5, color=DARK, symbol="→") add_rect(s, 0.3, 7.05, 12.7, 0.38, fill_rgb=RED) add_tb(s, "KEY EXAM POINT: ACE inhibitor MANDATORY even if renal function worsens initially | " "High-dose steroids are a PRECIPITANT of SRC — reduce/avoid | " "Normotensive SRC exists and has WORSE prognosis", 0.5, 7.07, 12.3, 0.34, size=11, bold=True, color=WHITE, align=PP_ALIGN.LEFT) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 11 – DAH & LUPUS NEPHRITIS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Diffuse Alveolar Hemorrhage (DAH) & Lupus Nephritis", "Life-threatening pulmonary + renal complications of SLE") slide_num(s, 11) dah = [ "Incidence: 1.5–4% of SLE patients; mortality 50–90% without treatment", "Triad: Haemoptysis + Bilateral infiltrates + ↓Haemoglobin", "NB: Haemoptysis absent in up to 30%; CXR shows 'bat-wing' infiltrates", "Diagnosis: BAL showing progressively bloodier returns (haemosiderin-laden macrophages)", "Other causes: AAV (ANCA+), Goodpasture (anti-GBM+), Myositis, MCTD", "Treatment: Methylprednisolone 1g/day IV × 3–5 days + Cyclophosphamide", "Add Rituximab or Plasma exchange in refractory cases", "Mechanical ventilation/ECMO if respiratory failure", ] ln = [ "ISN/RPS Classification: Class I–VI (III/IV most severe)", "Class III: Focal proliferative; Class IV: Diffuse proliferative (>50% glomeruli)", "Features: Haematuria, proteinuria, red cell casts, rising creatinine, hypertension", "Induction: Methylprednisolone + Mycophenolate mofetil (MMF) OR IV Cyclophosphamide", "Maintenance: MMF 2g/day OR Azathioprine 2mg/kg/day", "Belimumab/Voclosporin: approved add-on therapy (2021–2023)", "Targets: Proteinuria <0.5g/24hr; creatinine normalisation", "ESRD risk: ~10–20% over 10 years in class IV without treatment", ] two_col(s, dah, ln, "Diffuse Alveolar Hemorrhage (DAH)", "Lupus Nephritis (LN)", top=1.25) add_rect(s, 0.3, 6.9, 12.7, 0.5, fill_rgb=NAVY) add_tb(s, "PULMONARY-RENAL SYNDROME = DAH + Nephritis → Think: AAV, SLE, Goodpasture, CAPS | " "Check: ANA, anti-dsDNA, ANCA, anti-GBM, complement | Biopsy both if safe", 0.5, 6.92, 12.3, 0.46, size=12, bold=False, color=GOLD) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 12 – VASCULITIC EMERGENCIES # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Vasculitic Emergencies", "Giant Cell Arteritis (GCA) | ANCA-Associated Vasculitis (AAV)") slide_num(s, 12) gca = [ "Age >50 years (average 72 yrs); F:M = 3:1; commonest large-vessel vasculitis", "Symptoms: Temporal headache, jaw claudication, scalp tenderness, PMR", "EMERGENCY: Sudden painless monocular visual loss (anterior ischaemic optic neuropathy)", "Lab: ESR >50 mm/hr, CRP ↑ (ESR can be normal in 4%)", "Diagnosis: Temporal artery biopsy (gold standard; skip lesions → bilateral biopsy)", "USS temporal/axillary: 'Halo sign' (non-compressible hypoechoic wall thickening)", "PET-CT: Aorta + branches involvement", "TREATMENT: Prednisolone 40–60mg/day IMMEDIATELY (do not wait for biopsy)", "Visual loss risk: Start HIGH-DOSE steroids within HOURS of diagnosis", "Tocilizumab (IL-6R inhibitor): steroid-sparing agent (GIACTA trial 2017)", ] aav = [ "Types: GPA (Granulomatosis with Polyangiitis), MPA, EGPA", "GPA: saddle-nose deformity, sinusitis, haemoptysis, haematuria", "Lab: cANCA/PR3 (GPA), pANCA/MPO (MPA, EGPA)", "Pulmonary-Renal Syndrome in AAV = EMERGENCY: mortality 25–30% if untreated", "Induction: Rituximab 375mg/m²×4 (preferred) OR IV Cyclophosphamide + Methylprednisolone", "RAVE/RITUXVAS trials: Rituximab non-inferior to cyclophosphamide", "Plasma exchange: PEXIVAS trial (2020) – no mortality benefit; still used in severe", "Maintenance: Rituximab 500mg every 6 months (2020 EULAR recommendation)", "EGPA: IL-5 inhibitor Mepolizumab approved (2017) for remission", ] two_col(s, gca, aav, "Giant Cell Arteritis (GCA)", "ANCA-Associated Vasculitis (AAV)", top=1.25) add_rect(s, 0.3, 6.88, 12.7, 0.52, fill_rgb=GOLD) add_tb(s, "GCA VIVA: Treat BEFORE biopsy | Biopsy valid up to 2 weeks after steroids | " "AAV VIVA: Rituximab preferred over cyclophosphamide in GPA/MPA (RAVE trial) | " "EGPA = Asthma + Eosinophilia + Vasculitis", 0.5, 6.90, 12.3, 0.48, size=11.5, bold=True, color=NAVY) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 13 – NP-SLE & ACUTE TRANSVERSE MYELITIS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Neuropsychiatric SLE (NP-SLE) & Acute Transverse Myelitis", "CNS emergencies in autoimmune disease") slide_num(s, 13) npsle = [ "Prevalence: 25–70% of SLE patients experience ≥1 NP manifestation", "Attributed to SLE in ~28% (ACR nomenclature 19 NP syndromes)", "Mechanisms: Antibody-mediated (anti-NMDAR, anti-ribosomal P), vasculitis, thrombosis (aPL)", "Seizures: ~10%; Status epilepticus → IV lorazepam/phenytoin + high-dose steroids", "Cerebral vasculitis/stroke: Anti-phospholipid → anticoagulate; vasculitis → immunosuppression", "Cognitive dysfunction: Most common NP-SLE; assess with neurocognitive testing", "Psychosis in SLE: Exclude infection/steroid-induced; treat with steroids + antipsychotics", "MRI brain: white matter lesions, infarcts, diffuse cerebritis", "CSF: pleocytosis, elevated protein, normal glucose in SLE", "Treatment: IV methylprednisolone + cyclophosphamide for severe NP-SLE", ] atm = [ "ATM in SLE/APS: Rare but severe; T4–T6 most common level", "Onset: Acute/subacute bilateral weakness + sensory level + bladder dysfunction", "MRI spine: T2 hyperintensity spanning ≥3 vertebral segments (longitudinally extensive)", "NMO spectrum disorder (AQP4-IgG): Must be excluded", "Treatment: IV methylprednisolone 1g/day × 3–5 days", "Add IV cyclophosphamide for NP-SLE-associated ATM", "Plasma exchange for steroid-refractory cases", "Long-term: Azathioprine or MMF maintenance", "Prognosis: Full recovery in <30%; significant disability common", "VIVA: 'Sensory level' below lesion level is pathognomonic", ] two_col(s, npsle, atm, "Neuropsychiatric SLE (NP-SLE)", "Acute Transverse Myelitis (ATM)", top=1.25) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 14 – MACROPHAGE ACTIVATION SYNDROME (MAS) # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Macrophage Activation Syndrome (MAS)", "= Secondary HLH | Cytokine Storm | Mortality 20–30% | 2022 EULAR/ACR Guidelines") slide_num(s, 14) facts14 = [ "Definition: Life-threatening hyperinflammatory syndrome with macrophage/T-cell activation", "Associated with: sJIA (most common), Adult-onset Still's disease, SLE, infections, malignancy", "2016 Classification Criteria (for MAS in sJIA):", " Ferritin >684 µg/L + any 2 of:", " • Platelets ≤181×10⁹/L • AST >48 U/L", " • Triglycerides >156 mg/dL • Fibrinogen ≤360 mg/dL", "HScore: ≥169 → >93% probability of HLH/MAS", "Typical lab: Ferritin >10,000 µg/L, pancytopenia, ↑LDH, ↑transaminases, low fibrinogen", "Bone marrow biopsy: Haemophagocytosis (macrophages engulfing RBC/WBC/platelets)", ] mgmt14 = [ "2022 EULAR/ACR Points to Consider (PMID 37487610):", "Step 1: Treat underlying trigger (infection → antibiotics; malignancy → chemo)", "Step 2: High-dose glucocorticoids – IV methylprednisolone 2–8mg/kg/day", "Step 3: Cyclosporin A 3–4 mg/kg/day (especially sJIA-related MAS)", "Step 4: Anakinra (IL-1R antagonist) – HIGH DOSE 2–8mg/kg/day (rapidly effective)", "Step 5: Emapalumab (anti-IFN-γ) – FDA approved for refractory primary HLH (2018)", "Step 6: Ruxolitinib (JAK1/2 inhibitor) – promising in refractory cases", "Etoposide: For fulminant/malignancy-associated cases (HLH-94 protocol)", "IVIG: 1–2g/kg adjunct in severe cases", "Supportive: ICU, DVT prophylaxis, G-CSF avoided (worsens MAS)", ] two_col(s, facts14, mgmt14, "Pathophysiology & Diagnosis", "Management (Step-wise)", top=1.25) add_rect(s, 0.3, 6.9, 12.7, 0.5, fill_rgb=TEAL) add_tb(s, "VIVA: MAS vs Sepsis: ferritin >10,000 + falling ESR (fibrinogen consumed) favours MAS | " "2022 EULAR/ACR: Rule out HLH EARLY in unexplained fever + cytopenias | " "Never delay anakinra while awaiting bone marrow result", 0.5, 6.92, 12.3, 0.46, size=11.5, bold=False, color=WHITE) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 15 – CERVICAL SPINE INSTABILITY IN RA & CRYSTAL ARTHRITIS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Cervical Spine Instability in RA & Acute Crystal Arthritis", "Two distinct but important rheumatologic emergencies") slide_num(s, 15) csi = [ "Prevalence: ~25–40% of longstanding RA have cervical spine involvement", "Most common: C1–C2 (atlantoaxial) subluxation > subaxial subluxation", "Mechanism: Pannus formation erodes transverse ligament of atlas", "Trigger: Neck manipulation, intubation, falls, trauma", "Symptoms: Occipital headache, L'Hermitte's sign, upper limb weakness, gait ataxia", "EMERGENCY SIGN: New-onset myelopathy in RA = cord compression", "Diagnosis: Flexion–Extension X-ray (ADI >3mm = abnormal, >9mm = unstable)", "MRI: cord compression, pannus, signal change in cord", "Management: Rigid collar IMMEDIATELY, neurosurgical referral", "Surgery: Posterior C1–C2 fusion (wire/screw fixation)", "ANAESTHETIC WARNING: Avoid neck extension during intubation", ] crystal = [ "GOUT (Acute Gouty Arthritis):", " Serum urate >7 mg/dL (solubility threshold)", " Negatively birefringent, needle-shaped MSU crystals", " First MTP joint (podagra) in 50%; knee, ankle also common", " Treatment: NSAIDs (1st line) OR Colchicine 500µg BD-TDS", " Steroids: intra-articular or oral if NSAIDs contraindicated", " Add IL-1 inhibitor (Anakinra/Canakinumab) if refractory", "", "CPPD (Pseudogout):", " Positively birefringent, rhomboid-shaped calcium pyrophosphate crystals", " Knee most common; check calcium, Mg, PTH, haemochromatosis", " Treatment: Aspiration + NSAIDs/colchicine/steroids", " Consider underlying metabolic cause", ] two_col(s, csi, crystal, "Cervical Spine Instability (RA)", "Acute Crystal Arthropathy", top=1.25) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 16 – EMERGENCY MANAGEMENT PRINCIPLES & DRUG THERAPY # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Emergency Management Principles & Drug Therapy", "Immunosuppressive and biological agents in rheumatologic emergencies") slide_num(s, 16) # Drug table drugs = [ ("Methylprednisolone (IV pulse)", "1g/day × 3 days", "SLE flare, DAH, NP-SLE, MAS, Vasculitis", "Infection, hyperglycaemia, psychosis"), ("Cyclophosphamide (IV)", "750mg/m² monthly", "LN class III/IV, AAV, NP-SLE, DAH", "Haemorrhagic cystitis, myelosuppression"), ("Rituximab", "375mg/m² × 4 doses", "GPA/MPA, refractory SLE, CAPS, RA", "PML (rare), infusion reaction, PCP"), ("Anakinra (IL-1Ri)", "1–8 mg/kg/day SC/IV", "MAS/HLH, acute gout, Still's disease", "Injection site reaction, infection"), ("Tocilizumab (IL-6Ri)", "8mg/kg IV q4wk", "GCA (steroid-sparing), RA, Myositis", "GI perforation, LFT elevation"), ("Captopril / ACE inhibitor", "6.25mg TDS titrate", "Scleroderma Renal Crisis", "Hypotension, angioedema, renal failure"), ("Plasma Exchange (PE)", "5–7 sessions", "CAPS, DAH, TTP-like, AAV", "Hypocalcaemia, line sepsis"), ("IV Immunoglobulin (IVIG)", "1–2 g/kg total", "MAS, CAPS adjunct, immune thrombocytopenia", "Headache, renal failure, thrombosis"), ("Colchicine", "500µg BD–TDS", "Acute gout, CPPD, pericarditis", "Diarrhoea, myopathy, myelosuppression"), ("Heparin (UFH)", "IV infusion", "CAPS, APS thrombosis, DVT", "Bleeding, HIT"), ] headers_row = ["Drug", "Dose", "Indication", "Key Side Effects"] col_widths = [3.0, 2.3, 3.9, 3.7] col_starts = [0.3, 3.32, 5.64, 9.56] yt = 1.2 # Header row for ci, (hdr, w, xl) in enumerate(zip(headers_row, col_widths, col_starts)): add_rect(s, xl, yt, w-0.05, 0.42, fill_rgb=NAVY) add_tb(s, hdr, xl+0.06, yt+0.04, w-0.12, 0.36, size=12, bold=True, color=WHITE, align=PP_ALIGN.CENTER) for ri, (drug, dose, ind, se) in enumerate(drugs): yt = 1.62 + ri * 0.51 bg = LIGHT if ri % 2 == 0 else WHITE row_data = [drug, dose, ind, se] for ci, (val, w, xl) in enumerate(zip(row_data, col_widths, col_starts)): add_rect(s, xl, yt, w-0.05, 0.49, fill_rgb=bg, line_rgb=RGBColor(0xCC,0xCC,0xCC), line_pt=0.4) add_tb(s, val, xl+0.05, yt+0.04, w-0.12, 0.44, size=9.8, bold=(ci==0), color=NAVY if ci==0 else DARK) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 17 – ICU INDICATIONS, COMPLICATIONS & PROGNOSIS # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "ICU Indications, Complications & Prognosis", "When to escalate care | Monitoring | Outcomes") slide_num(s, 17) icu_ind = [ "Respiratory failure (DAH, severe pneumonitis, ILD exacerbation): SpO₂ <88%", "Cardiovascular instability: refractory hypertension (SRC), cardiac tamponade", "Neurological emergency: status epilepticus, GCS <10, acute cord compression", "Renal failure requiring urgent dialysis (SRC, CAPS, Vasculitis)", "CAPS / MAS / HLH: multi-organ failure, haemodynamic compromise", "Septic shock complicating septic arthritis or immunosuppression", "Post-operative complications (spinal surgery for RA)", "Severe thrombocytopenia (<20×10⁹/L) with active bleeding", ] complications = [ "Infection: Most common complication of immunosuppression (PCP, aspergillus, CMV)", "Steroid side effects: Cushing's, osteoporosis, avascular necrosis, psychosis", "Cyclophosphamide: haemorrhagic cystitis, malignancy (MESNA co-prescription)", "Biological agents: Reactivation TB (screen before anti-TNF), PML (rituximab)", "CAPS: Stroke, limb ischaemia, adrenal insufficiency, ARDS", "Septic arthritis: Osteomyelitis, avascular necrosis, joint destruction", "GCA: Permanent blindness (5–20%), aortic aneurysm (17×↑risk)", "Prognosis (PMID 41196392): ICU mortality in rheumatic diseases 20–40%", ] two_col(s, icu_ind, complications, "ICU Admission Criteria", "Complications & Prognosis", top=1.25) add_rect(s, 0.3, 6.9, 12.7, 0.5, fill_rgb=NAVY) add_tb(s, "ALWAYS screen for infection before escalating immunosuppression | " "TB screening (IGRA/TST) before biologics | PCP prophylaxis (Co-trimoxazole) when prednisolone >15mg/day", 0.5, 6.92, 12.3, 0.46, size=12, bold=False, color=GOLD) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 18 – RECENT ADVANCES & CURRENT GUIDELINES # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, WHITE) header(s, "Recent Advances & Current Guidelines (2020–2025)", "Biologics, Targeted Therapies & Guideline Updates") slide_num(s, 18) advances = [ ("2020", "PEXIVAS Trial", "Plasma exchange adds NO mortality benefit in ANCA vasculitis (NEJM 2020)"), ("2021", "Belimumab for LN", "FDA/EMA approved belimumab (anti-BLyS) for active lupus nephritis"), ("2022", "EULAR/ACR MAS", "2022 Points to Consider for early HLH/MAS diagnosis and management (PMID 37487610)"), ("2022", "Voclosporin + LN", "Voclosporin (calcineurin inhibitor) approved for active lupus nephritis (AURORA trial)"), ("2023", "EULAR AAV Guidelines", "Updated maintenance with rituximab every 6 months; avacopan approved for AAV"), ("2023", "Avacopan (C5aR1i)", "Oral complement inhibitor; non-inferior to high-dose prednisolone in ANCA vasculitis"), ("2024", "EULAR Still's/sJIA", "2024 EULAR/PReS recommendations: Biologic-first approach in sJIA with MAS features (PMID 39317417)"), ("2025", "EULAR RA Update", "2025 EULAR RA recommendations: 9 principles; JAK inhibitors with nuanced CV/malignancy guidance"), ("2025", "ERS/EULAR CTD-ILD", "CTD-ILD guidelines: nintedanib for SSc-ILD; antifibrotics evidence expanded"), ("2026", "Emerging", "Deucravacitinib (TYK2i), Upadacitinib (JAK1i) in SLE/PsA trials ongoing"), ] yt = 1.2 add_rect(s, 0.3, yt, 1.1, 0.42, fill_rgb=NAVY) add_rect(s, 1.42, yt, 2.5, 0.42, fill_rgb=TEAL) add_rect(s, 3.94, yt, 9.1, 0.42, fill_rgb=NAVY) add_tb(s, "Year", 0.32, yt+0.05, 1.05, 0.34, size=12, bold=True, color=WHITE, align=PP_ALIGN.CENTER) add_tb(s, "Advance", 1.44, yt+0.05, 2.45, 0.34, size=12, bold=True, color=WHITE) add_tb(s, "Clinical Significance", 3.96, yt+0.05, 9.05, 0.34, size=12, bold=True, color=WHITE) for i, (yr, adv, sig) in enumerate(advances): yt2 = 1.62 + i * 0.52 bg = LIGHT if i % 2 == 0 else WHITE add_rect(s, 0.3, yt2, 1.1, 0.5, fill_rgb=bg, line_rgb=RGBColor(0xCC,0xCC,0xCC), line_pt=0.4) add_rect(s, 1.42, yt2, 2.5, 0.5, fill_rgb=bg, line_rgb=RGBColor(0xCC,0xCC,0xCC), line_pt=0.4) add_rect(s, 3.94, yt2, 9.1, 0.5, fill_rgb=bg, line_rgb=RGBColor(0xCC,0xCC,0xCC), line_pt=0.4) add_tb(s, yr, 0.32, yt2+0.09, 1.05, 0.38, size=11.5, bold=True, color=TEAL, align=PP_ALIGN.CENTER) add_tb(s, adv, 1.47, yt2+0.09, 2.4, 0.38, size=11, bold=True, color=NAVY) add_tb(s, sig, 3.99, yt2+0.09, 9.0, 0.38, size=11, bold=False, color=DARK) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 19 – CLINICAL CASE SCENARIO # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, GREY) header(s, "Clinical Case Scenario", "Integrated diagnostic approach — exam-style reasoning") slide_num(s, 19) # Case box add_rect(s, 0.3, 1.2, 12.7, 2.1, fill_rgb=NAVY) add_tb(s, "CASE: A 28-year-old woman with known SLE (on hydroxychloroquine) presents with:\n" " • 4-day history of HIGH fever (39.2°C), severe fatigue, and generalised lymphadenopathy\n" " • Haemoglobin 7.4 g/dL, WBC 2.1×10⁹/L, Platelets 65×10⁹/L (3 days ago they were normal)\n" " • Ferritin: 24,600 µg/L | LDH: 1,840 U/L | Triglycerides: 3.8 mmol/L | Fibrinogen: 1.1 g/L", 0.5, 1.25, 12.3, 2.0, size=13.5, bold=False, color=WHITE) # diagnostic steps steps2 = [ ("RECOGNISE", "Pancytopenia + Hyperferritinaemia + High Triglycerides + Low Fibrinogen\n→ STRONGLY suggests MAS/HLH in a known SLE patient", TEAL), ("CONFIRM", "HScore ≥169 (>93% probability HLH) | 2016 MAS criteria met\nBone marrow aspiration: haemophagocytosis | Check EBV, CMV, parvovirus B19", NAVY), ("EXCLUDE", "Sepsis (cultures negative) | SLE flare alone (ferritin very high for SLE flare)\nMalignancy-associated HLH (lymphoma screen: CT chest/abdomen/pelvis)", GREEN), ("MANAGE", "IV methylprednisolone 2mg/kg/day → Cyclosporin A 3mg/kg/day\nAnakinra 2–4 mg/kg/day SC | ICU admission | Etoposide if fulminant", RED), ] for i, (step, desc, col) in enumerate(steps2): xl = 0.35 + i * 3.22 add_rect(s, xl, 3.42, 3.05, 0.4, fill_rgb=col) add_tb(s, f"STEP {i+1}: {step}", xl+0.07, 3.44, 2.92, 0.36, size=12, bold=True, color=WHITE) add_rect(s, xl, 3.82, 3.05, 2.4, fill_rgb=LIGHT, line_rgb=col, line_pt=1.2) add_tb(s, desc, xl+0.08, 3.88, 2.9, 2.3, size=11.5, bold=False, color=DARK) if i < 3: add_tb(s, "▶", xl+3.07, 4.55, 0.22, 0.5, size=16, bold=True, color=col) add_rect(s, 0.3, 6.35, 12.7, 1.05, fill_rgb=GOLD) add_tb(s, "LEARNING POINTS FROM THIS CASE:\n" "• Falling ESR (fibrinogen consumed) + rising ferritin = hallmark of MAS within SLE\n" "• 2022 EULAR/ACR: Suspect HLH/MAS EARLY — don't wait for bone marrow result to start treatment\n" "• Anakinra acts within 24–48 hrs and is now preferred first-line in sJIA-MAS and adult Still's MAS", 0.5, 6.38, 12.3, 1.0, size=12, bold=False, color=NAVY) # ───────────────────────────────────────────────────────────────────────────── # SLIDE 20 – KEY TAKE-HOME MESSAGES & REFERENCES # ───────────────────────────────────────────────────────────────────────────── s = prs.slides.add_slide(blank_layout); set_bg(s, NAVY) add_rect(s, 0, 0, 0.3, 7.5, fill_rgb=GOLD) add_rect(s, 0.3, 0, 12.7+0.3, 0.12, fill_rgb=TEAL) add_tb(s, "Key Take-Home Messages", 0.5, 0.12, 12.5, 0.75, size=30, bold=True, color=WHITE) add_tb(s, "References (Vancouver Style)", 0.5, 5.45, 12.5, 0.5, size=18, bold=True, color=GOLD) msgs = [ "Rheumatologic emergencies are time-critical: ABCDE first, then targeted immunosuppression", "Septic arthritis = aspirate + culture BEFORE antibiotics | IV flucloxacillin/vancomycin + drainage", "CAPS = Triple therapy: Anticoagulation + Steroids + Plasma exchange/IVIG", "Scleroderma Renal Crisis = ACEi MANDATORY even with rising creatinine; AVOID steroids", "GCA = IMMEDIATE high-dose prednisolone (40–60mg/day); do not wait for biopsy", "MAS: Ferritin >10,000 + pancytopenia → start anakinra early; use HScore", "PEXIVAS (2020): plasma exchange no longer routine in ANCA vasculitis", "2022 EULAR/ACR MAS guidelines + 2023 EULAR AAV + 2025 EULAR RA are high-yield for exams", ] for i, msg in enumerate(msgs): add_rect(s, 0.45, 0.95 + i*0.54, 0.4, 0.42, fill_rgb=TEAL if i % 2 == 0 else GOLD) add_tb(s, str(i+1), 0.47, 0.97 + i*0.54, 0.37, 0.38, size=13, bold=True, color=NAVY, align=PP_ALIGN.CENTER) add_tb(s, msg, 0.92, 0.97 + i*0.54, 12.0, 0.45, size=12.5, bold=False, color=WHITE) refs = [ "1. Loscalzo J et al. Harrison's Principles of Internal Medicine. 21st ed. McGraw-Hill; 2022.", "2. Feather A et al. Kumar & Clark's Clinical Medicine. 10th ed. Elsevier; 2021.", "3. Wilkinson I et al. Oxford Handbook of Clinical Medicine. 10th ed. OUP; 2017.", "4. Firestein GS et al. Firestein & Kelley's Textbook of Rheumatology. 11th ed. Elsevier; 2021.", "5. Shakoory B et al. 2022 EULAR/ACR points to consider for HLH/MAS. Ann Rheum Dis. 2023;82(10):1271–1285. PMID: 37487610.", "6. Walsh M et al. (PEXIVAS). Plasma exchange and glucocorticoids in severe ANCA-associated vasculitis. NEJM. 2020;382:622–631.", "7. Fautrel B et al. 2024 EULAR/PReS recommendations for Still's disease. Ann Rheum Dis. 2024. PMID: 39317417.", ] for i, ref in enumerate(refs): add_tb(s, ref, 0.5, 5.95 + i * 0.22, 12.5, 0.22, size=9.5, bold=False, color=LIGHT) add_tb(s, "Slide 20 of 20 | Department of General Medicine | 2026", 0.5, 7.28, 12.5, 0.2, size=9.5, bold=False, color=RGBColor(0x88,0xAA,0xCC), italic=True) # ── Save ──────────────────────────────────────────────────────────────────── out = "/tmp/workspace/rheumatologic-emergencies/Rheumatologic_Emergencies_MBBS.pptx" prs.save(out) print(f"Saved: {out}") import os; print(f"Size: {os.path.getsize(out):,} bytes") PYEOF

python3 -c " from pptx import Presentation prs = Presentation('/tmp/workspace/rheumatologic-emergencies/Rheumatologic_Emergencies_MBBS.pptx') print(f'Total slides: {len(prs.slides)}') for i, slide in enumerate(prs.slides, 1): texts = [sh.text_frame.text.strip()[:60] for sh in slide.shapes if sh.has_text_frame and sh.text_frame.text.strip()] title_candidate = texts[0] if texts else '(no text)' print(f' Slide {i:2d}: {title_candidate}') "