Malaria

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Excellent content from Harrison's and Goldman-Cecil. I now have comprehensive material covering all aspects. Let me compile the full, detailed academic overview.

Malaria - Comprehensive Clinical & Academic Overview

Sources: Harrison's Principles of Internal Medicine 22E (2025), Goldman-Cecil Medicine, Robbins & Kumar Basic Pathology, Murray & Nadel's Respiratory Medicine, Katzung's Pharmacology

1. Etiology

Malaria is a protozoan disease caused by six species of the genus Plasmodium, transmitted by the bite of infected female Anopheles mosquitoes. Humans are the only natural reservoir for human-infecting species.

Species	Features
P. falciparum	Most dangerous; causes tertian malaria (48-h cycle); nearly all deaths; widespread chloroquine resistance
P. vivax	Common in Central/South America and Asia; forms hypnozoites (causes relapses)
P. ovale (curtisi & wallikeri)	Two morphologically identical sympatric species; hypnozoites present; mild disease
P. malariae	72-h (quartan) cycle; mild but can cause nephrotic syndrome; no hypnozoites
P. knowlesi	Simian malaria in Southeast Asia; 24-h cycle; can be fatal; morphologically resembles P. malariae
P. simium / P. cynomolgi	Rare zoonotic infections

"In 2022, there were an estimated 249 million cases in 85 malaria-endemic countries and 608,000 deaths (approximately 1,660 deaths each day)." - Harrison's Principles of Internal Medicine 22E, p. 1804

2. Life Cycle & Pathogenesis

Life cycle of P. falciparum showing hepatic and erythrocytic stages

Hepatic (Pre-erythrocytic) Phase - Clinically Silent

Female Anopheles mosquito injects sporozoites into the bloodstream during a blood meal
Sporozoites travel to the liver within minutes, binding to hepatocyte surface via thrombospondin-related adhesive protein and circumsporozoite protein (which bind heparan sulfate proteoglycans)
Sporozoites enter hepatocytes and undergo intrahepatic schizogony - one sporozoite produces 10,000-30,000 daughter merozoites
Infected hepatocytes burst, releasing merozoites into the bloodstream
In P. vivax and P. ovale, some forms become hypnozoites (dormant liver forms) - cause relapses weeks to over a year later

Erythrocytic Phase - Causes Disease

Merozoites bind to RBC surface via a lectin-like molecule binding sialidated glycophorin (a RBC transmembrane protein)
Merozoites invaginate into RBCs within a "digestive vacuole"
Intraerythrocytic organisms differentiate into ring trophozoites → trophozoites → schizonts
Schizonts express PfEMP1 (P. falciparum Erythrocyte Membrane Protein 1) on knob-like extensions on the RBC surface - this is the key virulence factor
PfEMP1 binds to endothelial adhesion molecules (ICAM-1, VCAM-1, CD36) causing sequestration of parasitized RBCs in capillary beds - central to severe disease
After several days, schizonts lyse RBCs and release new merozoites (every 48 h for P. falciparum; 72 h for P. malariae; 24 h for P. knowlesi)
Some trophozoites become gametocytes, which are taken up by a mosquito to restart the sexual cycle

In the Mosquito

Male gametocyte exflagellates into 8 motile male gametes; fuses with female gametocytes
Undergoes meiosis in the midgut, forming a zygote → ookinete → oocyst
Oocyst bursts to release sporozoites which migrate to the salivary glands

Key Pathogenic Mechanisms

Cytoadherence and sequestration: PfEMP1-mediated; causes microvascular obstruction in brain, lung, kidney, placenta
Inflammatory cytokines: TNF-alpha, IL-1, IL-6 cause fever and systemic effects
Hemolytic anemia: RBC lysis with each schizont burst; increased splenic clearance of both infected and uninfected RBCs
Hemozoin: Brown degradation product of hemoglobin produced by the parasite; found in macrophages; contributes to anemia and inflammation
Genetic protection: Sickle cell trait, thalassemia, G6PD deficiency, and Duffy antigen negativity all confer partial protection - reflecting thousands of years of co-evolution

3. Epidemiology

Geography: P. falciparum predominates in sub-Saharan Africa, New Guinea, and Hispaniola. P. vivax predominates in Central/South America and most of Asia. P. malariae is found in most endemic areas. P. knowlesi is restricted to Southeast Asia
Burden: 85 endemic countries; predominantly affects children <5 years old in sub-Saharan Africa
Transmission patterns: Stable (year-round, intense, e.g. coastal West Africa) vs. Unstable (seasonal/epidemic, all age groups susceptible)
Resistance trends: The WHO World Malaria Report 2025 highlights artemisinin partial resistance now confirmed or suspected in at least 8 African countries - the most important current threat to malaria control

4. Clinical Features

Uncomplicated Malaria

Incubation period: 7-30 days (longer with P. malariae)
Prodrome: Headache, myalgia, anorexia, fatigue
Classic malarial paroxysm (3 stages):
1. Cold stage: Rigors, shivering (1-2 h)
2. Hot stage: Fever 39-41°C, headache, nausea (2-6 h)
3. Sweating stage: Drenching sweats, defervescence, fatigue
Fever periodicity (corresponds to schizont rupture):
- Every 24 h (quotidian) - P. knowlesi
- Every 48 h (tertian) - P. falciparum, P. vivax, P. ovale
- Every 72 h (quartan) - P. malariae
- Note: Periodicity is unreliable, especially in P. falciparum
Splenomegaly: Almost universal in endemic areas; "big spleen disease" in chronically infected individuals

Severe Malaria (mainly P. falciparum)

WHO criteria for severe falciparum malaria include:

Complication	Notes
Cerebral malaria	Unarousable coma (GCS < 11); most common in children; diffuse encephalopathy from sequestration and cytokines
Severe anemia	Hb < 7 g/dL; commonest in children in high-transmission areas
Acute renal failure	"Blackwater fever" = massive intravascular hemolysis + hemoglobinuria + renal failure; mainly in adults
Acute pulmonary edema / ARDS	High mortality; more common in adults and pregnant women; can worsen with over-hydration
Hypoglycemia	Very common in children and pregnant women; caused by parasite glucose consumption and quinine-induced hyperinsulinemia
Metabolic lactic acidosis	Major cause of death; from sequestration impairing tissue perfusion
Algid malaria	Septicemic shock presentation
Abnormal bleeding / DIC	Rare but serious
Hyperparasitemia	>5% infected RBCs; high fatality risk
Convulsions	Especially in children

Complications vary by patient group (from Harrison's Table 231-4):

Children: Anemia, convulsions, hypoglycemia predominate
Adults: Jaundice, renal failure more prominent
Pregnant women: All complications amplified, especially hypoglycemia and pulmonary edema; fetal loss, low birth weight common

5. Diagnosis

Gold Standard: Blood Smear Microscopy

Thick smear: Screening - more sensitive for detecting parasites
Thin smear: Species identification, parasite count, morphology
Repeat smears every 12-24 h if initial negative but suspicion high

Rapid Diagnostic Tests (RDTs)

Detect malaria antigens (HRP-2 for P. falciparum; pLDH for all species)
Fast (15-20 min), no microscopy needed
Note: HRP-2 deletions in P. falciparum in some regions may give false-negative RDTs

PCR

Most sensitive; can detect mixed infections and low-density parasitemia
Used for research, surveillance, and when other tests ambiguous

Other Labs

FBC: Anemia, thrombocytopenia (almost universal in malaria)
Blood film: May show hemolytic picture (raised bilirubin, raised LDH, reduced haptoglobin)
Renal function, glucose, lactate (assess severity)
Peripheral blood smear findings by species:

Species	Smear Findings
P. falciparum	Ring forms only (schizonts sequestered); multiple rings per RBC; "appliqué" forms; banana-shaped gametocytes
P. vivax	Enlarged RBCs; Schüffner's dots; ameboid trophozoites; all stages present
P. ovale	Enlarged, oval-fimbriated RBCs; Schüffner's dots
P. malariae	"Band-form" trophozoites; rosette schizonts; normal-sized RBCs
P. knowlesi	Resembles P. malariae on smear - PCR needed to distinguish

6. Treatment

Uncomplicated P. falciparum (or Unknown Species from Endemic Area)

First-line: Artemisinin-Based Combination Therapy (ACT)

ACT consists of an artemisinin derivative (artesunate, artemether, or dihydroartemisinin) combined with a longer-acting partner drug in a 3-day regimen. Recommended ACTs include:

Artemether-lumefantrine (Coartem) - the only ACT approved in the USA; widely used in Africa
Artesunate-amodiaquine - common in Africa
Artesunate-mefloquine - used in Southeast Asia
Dihydroartemisinin-piperaquine - effective but P. falciparum resistance emerging in SE Asia

In chloroquine-sensitive areas (Central America, Caribbean, parts of Middle East):

Chloroquine phosphate remains effective

P. vivax / P. ovale Treatment

Chloroquine for blood-stage parasites (where sensitive)
Primaquine or tafenoquine to eradicate hypnozoites and prevent relapse
- Check G6PD status before primaquine/tafenoquine - can cause severe hemolysis in G6PD deficiency
- Contraindicated in pregnancy

P. malariae

Chloroquine alone (no hypnozoites, no relapse concern)

Severe Malaria (Any Species)

IV artesunate - first-line globally; superior to quinine in trials (lower mortality, fewer side effects)
Quinine (IV) with doxycycline - alternative if artesunate unavailable
Important: Monitor blood glucose (hypoglycemia risk with quinine)
Manage complications: Fluids (cautiously), anticonvulsants, exchange transfusion for hyperparasitemia (controversial)

Drug Pharmacology Summary

Drug Class	Mechanism	Key Drugs	Notes
Artemisinins	Free radical generation from endoperoxide bridge; kills all intraerythrocytic stages	Artesunate, artemether, dihydroartemisinin	Short half-life (used in combination); delayed hemolysis possible
Aminoquinolines	Concentrate in parasite digestive vacuole; inhibit heme detoxification (prevent hemozoin formation)	Chloroquine, amodiaquine, piperaquine	Chloroquine resistance via PfCRT mutation
Antifolates	Inhibit dihydrofolate reductase (DHFR) and dihydropteroate synthase (DHPS)	Pyrimethamine, sulfadoxine-pyrimethamine	Resistance common; used in IPT in pregnancy
8-Aminoquinolines	Kills hypnozoites and gametocytes; mechanism not fully clear	Primaquine, tafenoquine	G6PD testing mandatory before use
Naphthoquinone	Inhibits mitochondrial electron transport (Cyt bc1 complex)	Atovaquone (with proguanil = Malarone)	Used for treatment and prophylaxis; expensive
Antibiotics	Various; slow-acting	Doxycycline, clindamycin	Used as partner drugs; not monotherapy

7. Prevention & Prophylaxis

Personal Protection

Insecticide-treated bed nets (ITNs) - highly effective
Residual indoor spraying (IRS) with insecticides
Repellents (DEET, picaridin)
Protective clothing

Chemoprophylaxis for Travelers

Choice depends on destination and resistance pattern:

Atovaquone-proguanil (Malarone): Daily; good for short trips; excellent tolerability
Doxycycline: Daily; cheap; photosensitivity and GI side effects; good for SE Asia
Mefloquine: Weekly; not recommended in areas with mefloquine-resistant P. falciparum (SE Asia); neuropsychiatric side effects in some
Chloroquine: Weekly; only for chloroquine-sensitive areas (limited use)

Intermittent Preventive Treatment (IPT)

IPTp (in pregnancy): Sulfadoxine-pyrimethamine at each antenatal visit; reduces maternal malaria and low birth weight
IPTi (in infants): SP at immunization contacts
SMC (Seasonal Malaria Chemoprevention): Amodiaquine + SP monthly in children during high-transmission season in the Sahel

Vaccines

RTS,S/AS01 (Mosquirix) and R21/Matrix-M: Pre-erythrocytic vaccines targeting circumsporozoite protein; WHO-recommended for children in high-transmission areas. The November 2024 WHO guidelines update includes updated recommendations on malaria vaccines. Efficacy is moderate (~36-75% reduction in clinical malaria in trials) but significant public health impact when combined with other measures.

8. Complications in Detail

Cerebral Malaria

Unarousable coma; more common in African children
CT/MRI may show cerebral edema
High mortality (~15-30% even with treatment); neurological sequelae in survivors (up to 25% of children)
Pathology: Sequestration of parasitized RBCs in cerebral microvessels; Durck granulomas (ring hemorrhages) on autopsy

Malarial Anemia

Multifactorial: Hemolysis of infected and uninfected RBCs, bone marrow dyserythropoiesis, increased splenic clearance
Severe anemia (Hb <7 g/dL) is a leading cause of death in children

Pulmonary Complications

From minimal cough to ARDS
Bilateral pulmonary edema visible on CXR (resembles cardiogenic edema)
Children, pregnant women, non-immune travelers most susceptible
Alveolar macrophages may contain hemozoin

Renal Failure

Acute tubular necrosis; "blackwater fever" (massive hemolysis + hemoglobinuria)
More common in adults; responds to dialysis

Malaria in Pregnancy

P. falciparum accumulates in the placenta via CSA (chondroitin sulfate A) binding of infected RBCs
Causes: Fetal growth restriction, low birth weight, premature labor, stillbirth, maternal death
Primigravid and secundigravid women most at risk in high-transmission settings
Congenital malaria: <5% of neonates of infected mothers

9. Antimicrobial Resistance (Current Threat)

This is the most pressing clinical challenge in malaria today:

Artemisinin partial resistance: Emerging in sub-Saharan Africa (Rwanda, Uganda, Eritrea) - due to kelch13 gene mutations (K13 propeller domain); manifests as delayed parasite clearance
ACT partner drug resistance: Resistance to piperaquine (combined with dihydroartemisinin) in SE Asia causes high treatment failure rates
Chloroquine resistance: Near-universal in P. falciparum outside Central America/Caribbean; mediated by PfCRT (chloroquine resistance transporter) mutations
Antifolate resistance: Widespread DHFR and DHPS mutations

Recent systematic reviews highlight ongoing spread of artemisinin resistance markers across Africa (PMID 39769406; PMID 38574550). The WHO World Malaria Report 2025 calls this the most serious current threat to malaria control progress.

10. Quick Summary: Species Comparison

Feature	P. falciparum	P. vivax	P. ovale	P. malariae	P. knowlesi
Fever periodicity	48 h (tertian)	48 h	48 h	72 h (quartan)	24 h
Hypnozoites	No	Yes	Yes	No	No
RBC preference	All ages	Reticulocytes	Reticulocytes	Old RBCs	All ages
Max parasitemia	Very high	Moderate	Low	Low	High
Severity	+++++	++	+	+	+++
Geographic focus	Africa	Americas, Asia	Africa	Worldwide	SE Asia
Chloroquine sensitivity	Resistant (mostly)	Sensitive (mostly)	Sensitive	Sensitive	Sensitive

Key references:

Harrison's Principles of Internal Medicine 22E (2025), Chapter 231 "Malaria," pp. 1804-1876
Goldman-Cecil Medicine, Chapter 316 "Antimalarial Drug Treatment," pp. 3380-3381
Robbins & Kumar Basic Pathology, Chapter 10, pp. 392-393
Murray & Nadel's Textbook of Respiratory Medicine, Chapter 58, p. 1352
WHO World Malaria Report 2025 - highlights artemisinin resistance threat
WHO Guidelines for Malaria, updated August 2025

Make a presentation on severe malaria management for clinical staff

Reading File

Running Command

mkdir -p /tmp/workspace/severe-malaria-pptx && ls /tmp/workspace/severe-malaria-pptx

Writing File

~/severe-malaria-pptx/build_pptx.py

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.enum.dml import MSO_THEME_COLOR
from pptx.oxml.ns import qn
from pptx.util import Inches, Pt
import copy
from lxml import etree
from io import BytesIO

# ── Colour Palette ────────────────────────────────────────────────
C_DARK_RED   = RGBColor(0xB0, 0x1E, 0x28)   # deep red – header bars
C_MID_RED    = RGBColor(0xD9, 0x3A, 0x2F)   # medium red – accents
C_LIGHT_RED  = RGBColor(0xF9, 0xE8, 0xE8)   # pale red tint – content bg
C_WHITE      = RGBColor(0xFF, 0xFF, 0xFF)
C_DARK_GRAY  = RGBColor(0x1A, 0x1A, 0x2E)   # near-black text
C_MID_GRAY   = RGBColor(0x4A, 0x4A, 0x6A)
C_LIGHT_GRAY = RGBColor(0xF4, 0xF4, 0xF8)
C_ORANGE     = RGBColor(0xE8, 0x6A, 0x1A)   # warning accent
C_GREEN      = RGBColor(0x1A, 0x7A, 0x40)   # safe/good accent
C_YELLOW_BG  = RGBColor(0xFF, 0xF5, 0xCC)
C_TABLE_HEAD = RGBColor(0x7B, 0x0D, 0x14)

prs = Presentation()
prs.slide_width  = Inches(13.333)
prs.slide_height = Inches(7.5)
blank = prs.slide_layouts[6]

# ── Helper functions ──────────────────────────────────────────────

def solid_bg(slide, color):
    bg = slide.background
    bg.fill.solid()
    bg.fill.fore_color.rgb = color

def add_rect(slide, left, top, width, height, fill_color, line_color=None, line_width_pt=0):
    from pptx.util import Pt as pPt
    shape = slide.shapes.add_shape(1, left, top, width, height)  # MSO_SHAPE.RECTANGLE
    shape.fill.solid()
    shape.fill.fore_color.rgb = fill_color
    if line_color:
        shape.line.color.rgb = line_color
        shape.line.width = Pt(line_width_pt)
    else:
        shape.line.fill.background()
    return shape

def add_textbox(slide, left, top, width, height, text, font_size, bold=False,
                color=None, align=PP_ALIGN.LEFT, italic=False, word_wrap=True,
                v_anchor=MSO_ANCHOR.TOP, margin_l=Inches(0.1), margin_t=Inches(0.05)):
    tb = slide.shapes.add_textbox(left, top, width, height)
    tf = tb.text_frame
    tf.word_wrap = word_wrap
    tf.vertical_anchor = v_anchor
    tf.margin_left = margin_l
    tf.margin_top = margin_t
    tf.margin_right = Inches(0.05)
    tf.margin_bottom = Inches(0.05)
    p = tf.paragraphs[0]
    p.alignment = align
    run = p.add_run()
    run.text = text
    run.font.size = Pt(font_size)
    run.font.bold = bold
    run.font.italic = italic
    if color:
        run.font.color.rgb = color
    return tb

def add_bullet_textbox(slide, left, top, width, height, items, font_size=13,
                       color=None, bullet_char="▸", indent=0.18,
                       line_spacing_pt=None, title=None, title_size=14):
    from pptx.oxml import parse_xml
    from pptx.oxml.ns import nsmap
    tb = slide.shapes.add_textbox(left, top, width, height)
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = Inches(0.1)
    tf.margin_top = Inches(0.06)
    tf.margin_right = Inches(0.1)
    tf.margin_bottom = Inches(0.06)

    first = True
    if title:
        p = tf.paragraphs[0] if first else tf.add_paragraph()
        first = False
        p.alignment = PP_ALIGN.LEFT
        r = p.add_run()
        r.text = title
        r.font.bold = True
        r.font.size = Pt(title_size)
        if color:
            r.font.color.rgb = color

    for item in items:
        p = tf.paragraphs[0] if (first and not title) else tf.add_paragraph()
        first = False
        p.alignment = PP_ALIGN.LEFT
        # indentation
        p.level = 0
        pPr = p._pPr
        if pPr is None:
            pPr = p._p.get_or_add_pPr()
        from pptx.oxml.ns import qn as _qn
        buNone_el = pPr.find(_qn('a:buNone'))
        if buNone_el is not None:
            pPr.remove(buNone_el)
        r = p.add_run()
        r.text = f"{bullet_char}  {item}"
        r.font.size = Pt(font_size)
        if color:
            r.font.color.rgb = color
        if line_spacing_pt:
            from pptx.oxml.ns import qn as _qn
            lnSpc = etree.SubElement(pPr, _qn('a:lnSpc'))
            spcPts = etree.SubElement(lnSpc, _qn('a:spcPts'))
            spcPts.set('val', str(int(line_spacing_pt * 100)))
    return tb

def header_bar(slide, title, subtitle=None):
    # Dark red top bar
    add_rect(slide, 0, 0, prs.slide_width, Inches(1.15), C_DARK_RED)
    # Thin accent line below header
    add_rect(slide, 0, Inches(1.15), prs.slide_width, Inches(0.06), C_MID_RED)
    # Title text
    add_textbox(slide, Inches(0.4), Inches(0.1), Inches(12.5), Inches(0.7),
                title, 28, bold=True, color=C_WHITE, align=PP_ALIGN.LEFT,
                v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.15))
    if subtitle:
        add_textbox(slide, Inches(0.4), Inches(0.72), Inches(12.5), Inches(0.38),
                    subtitle, 13, bold=False, color=RGBColor(0xFF, 0xCC, 0xCC),
                    align=PP_ALIGN.LEFT, margin_l=Inches(0.15))

def footer_bar(slide, note="Source: Harrison's 22E · WHO Guidelines 2025 · Goldman-Cecil Medicine"):
    add_rect(slide, 0, Inches(7.18), prs.slide_width, Inches(0.32), C_DARK_GRAY)
    add_textbox(slide, Inches(0.3), Inches(7.19), Inches(12.7), Inches(0.3),
                note, 8, color=RGBColor(0xBB, 0xBB, 0xCC),
                align=PP_ALIGN.LEFT, margin_l=Inches(0.1), margin_t=Inches(0.02))

def section_card(slide, left, top, width, height, heading, items, heading_color=C_DARK_RED,
                 bg_color=C_LIGHT_RED, font_size=12.5, heading_size=13.5, bullet="▸"):
    add_rect(slide, left, top, width, Inches(0.38), heading_color)
    add_textbox(slide, left + Inches(0.1), top, width - Inches(0.2), Inches(0.38),
                heading, heading_size, bold=True, color=C_WHITE,
                v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.1), margin_t=0)
    add_rect(slide, left, top + Inches(0.38), width, height - Inches(0.38), bg_color)
    add_bullet_textbox(slide, left + Inches(0.1), top + Inches(0.42),
                       width - Inches(0.2), height - Inches(0.5),
                       items, font_size=font_size, color=C_DARK_GRAY, bullet_char=bullet)

# ════════════════════════════════════════════════════════════════════
# SLIDE 1 – Title Slide
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_DARK_GRAY)

# Big red accent bar left side
add_rect(slide, 0, 0, Inches(0.5), prs.slide_height, C_DARK_RED)
add_rect(slide, Inches(0.5), 0, Inches(0.12), prs.slide_height, C_MID_RED)

# Central content
add_textbox(slide, Inches(1.2), Inches(1.4), Inches(11), Inches(0.7),
            "SEVERE MALARIA", 46, bold=True, color=C_WHITE,
            align=PP_ALIGN.LEFT, v_anchor=MSO_ANCHOR.MIDDLE)
add_rect(slide, Inches(1.2), Inches(2.18), Inches(6), Inches(0.07), C_MID_RED)
add_textbox(slide, Inches(1.2), Inches(2.3), Inches(11), Inches(0.55),
            "Recognition, Assessment & Management", 22, bold=False,
            color=RGBColor(0xFF, 0xCC, 0xCC), align=PP_ALIGN.LEFT)
add_textbox(slide, Inches(1.2), Inches(2.95), Inches(10), Inches(0.45),
            "A Clinical Practice Guide for Healthcare Professionals", 14,
            color=RGBColor(0xAA, 0xAA, 0xBB), align=PP_ALIGN.LEFT, italic=True)

# Key stats box
add_rect(slide, Inches(1.2), Inches(3.7), Inches(10.8), Inches(1.55),
         RGBColor(0x2A, 0x2A, 0x44))
add_textbox(slide, Inches(1.4), Inches(3.82), Inches(3.2), Inches(0.4),
            "249 million", 26, bold=True, color=C_MID_RED)
add_textbox(slide, Inches(1.4), Inches(4.22), Inches(3.2), Inches(0.45),
            "cases globally (2022)", 12, color=RGBColor(0xCC, 0xCC, 0xDD))

add_rect(slide, Inches(4.8), Inches(3.82), Inches(0.04), Inches(1.1), RGBColor(0x55, 0x55, 0x77))
add_textbox(slide, Inches(5.1), Inches(3.82), Inches(3.2), Inches(0.4),
            "608,000", 26, bold=True, color=C_ORANGE)
add_textbox(slide, Inches(5.1), Inches(4.22), Inches(3.2), Inches(0.45),
            "deaths/year (~1,660/day)", 12, color=RGBColor(0xCC, 0xCC, 0xDD))

add_rect(slide, Inches(8.5), Inches(3.82), Inches(0.04), Inches(1.1), RGBColor(0x55, 0x55, 0x77))
add_textbox(slide, Inches(8.8), Inches(3.82), Inches(3.2), Inches(0.4),
            "P. falciparum", 22, bold=True, color=RGBColor(0xFF, 0xCC, 0xCC), italic=True)
add_textbox(slide, Inches(8.8), Inches(4.22), Inches(3.2), Inches(0.45),
            "responsible for most deaths", 12, color=RGBColor(0xCC, 0xCC, 0xDD))

add_textbox(slide, Inches(1.2), Inches(5.5), Inches(10), Inches(0.4),
            "WHO 2025  |  Harrison's Principles of Internal Medicine 22E  |  Goldman-Cecil Medicine",
            10, color=RGBColor(0x88, 0x88, 0x99), italic=True)

# ════════════════════════════════════════════════════════════════════
# SLIDE 2 – WHO Criteria for Severe Malaria
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "WHO Criteria for Severe Malaria",
           "Any ONE of the following in a patient with confirmed malaria = Severe Disease → Admit to HDU/ICU")
footer_bar(slide)

criteria_left = [
    "Unarousable coma (GCS < 11) – Cerebral malaria",
    "Prostration / extreme weakness",
    "Multiple convulsions (>2 in 24 h)",
    "Respiratory distress / deep breathing (acidotic breathing)",
    "Acute pulmonary oedema / ARDS",
    "Circulatory collapse / shock (algid malaria)",
]
criteria_right = [
    "Abnormal bleeding / DIC",
    "Jaundice + evidence of vital organ dysfunction",
    "Haemoglobinuria (blackwater fever)",
    "Severe anaemia (Hb < 7 g/dL)",
    "Hypoglycaemia (BGL < 2.2 mmol/L)",
    "Hyperparasitaemia (>5% infected RBCs)",
    "Acute kidney injury (creatinine > 265 µmol/L)",
]

section_card(slide, Inches(0.3), Inches(1.3), Inches(6.2), Inches(5.5),
             "Clinical / Neurological", criteria_left, font_size=12.5)
section_card(slide, Inches(6.7), Inches(1.3), Inches(6.3), Inches(5.5),
             "Metabolic / Laboratory", criteria_right, font_size=12.5)

# Red warning box at bottom
add_rect(slide, Inches(0.3), Inches(6.75), Inches(12.7), Inches(0.34),
         RGBColor(0xFF, 0xF0, 0xC8))
add_textbox(slide, Inches(0.45), Inches(6.76), Inches(12.4), Inches(0.33),
            "⚠  If uncertain, treat as severe — delay is fatal. Most deaths in non-endemic countries are due to delayed diagnosis.",
            11, bold=True, color=RGBColor(0x7A, 0x4A, 0x00))

# ════════════════════════════════════════════════════════════════════
# SLIDE 3 – Immediate Assessment
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Immediate Assessment on Presentation",
           "Parallel assessment and management — do not wait for all results before starting treatment")
footer_bar(slide)

# 3-column layout
cols = [
    ("HISTORY", [
        "Travel to endemic region (dates, locations)",
        "Symptoms onset & duration",
        "Prior malaria / antimalarial prophylaxis",
        "Pregnancy status",
        "HIV / immunosuppression status",
        "G6PD deficiency history",
    ]),
    ("EXAMINATION", [
        "GCS / conscious level",
        "Vital signs: HR, BP, RR, SpO₂, Temp",
        "Signs of jaundice / hepatomegaly",
        "Splenomegaly",
        "Respiratory signs (crackles, work of breathing)",
        "Urinary output / colour (haemoglobinuria?)",
    ]),
    ("URGENT INVESTIGATIONS", [
        "Thick & thin blood films (STAT)",
        "Malaria RDT if microscopy delayed",
        "FBC, blood film, reticulocytes",
        "U&E, creatinine, LFTs, bilirubin",
        "Blood glucose (repeat 1-2 hourly)",
        "Blood cultures (bacteraemia in 6% of children)",
        "Lactate, ABG/VBG",
        "Coagulation screen",
        "Urinalysis + urine output",
    ]),
]

col_width = Inches(4.1)
for i, (heading, items) in enumerate(cols):
    left = Inches(0.25) + i * (col_width + Inches(0.12))
    section_card(slide, left, Inches(1.3), col_width, Inches(5.6),
                 heading, items, font_size=11.5, heading_size=13)

# ════════════════════════════════════════════════════════════════════
# SLIDE 4 – First-Line Treatment (Pharmacotherapy)
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "First-Line Pharmacotherapy: IV Artesunate",
           "IV artesunate is superior to quinine for severe malaria — lower mortality, faster parasite clearance, better tolerability")
footer_bar(slide)

# Main big card – IV Artesunate
add_rect(slide, Inches(0.3), Inches(1.3), Inches(7.8), Inches(5.6), C_LIGHT_RED)
add_rect(slide, Inches(0.3), Inches(1.3), Inches(7.8), Inches(0.42), C_DARK_RED)
add_textbox(slide, Inches(0.45), Inches(1.3), Inches(7.5), Inches(0.42),
            "FIRST-LINE:  IV Artesunate", 15, bold=True, color=C_WHITE,
            v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.1), margin_t=0)

artesunate_details = [
    ("Dose", "2.4 mg/kg IV at 0, 12, 24 h — then every 24 h (max 7 days)"),
    ("Paediatric", "2.4 mg/kg IV (same weight-based dose as adults)"),
    ("Pregnancy", "IV artesunate preferred in 2nd/3rd trimester"),
    ("Duration", "Minimum 24 h IV, then switch to oral ACT (e.g. artemether-lumefantrine) to complete 3-day course"),
    ("Monitoring", "Glucose every 1–2 h; parasite count every 12–24 h; haematology at 28 days (delayed haemolysis)"),
    ("Key SE", "Delayed haemolytic anaemia (post-treatment days 7–30) — check Hb at 28 days post-treatment"),
]
y_pos = Inches(1.82)
for label, detail in artesunate_details:
    add_rect(slide, Inches(0.4), y_pos, Inches(1.5), Inches(0.56), RGBColor(0xD9, 0x3A, 0x2F))
    add_textbox(slide, Inches(0.42), y_pos + Inches(0.04), Inches(1.46), Inches(0.5),
                label, 11, bold=True, color=C_WHITE, v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.06), margin_t=0)
    add_rect(slide, Inches(1.9), y_pos, Inches(6.0), Inches(0.56), RGBColor(0xFC, 0xF0, 0xF0))
    add_textbox(slide, Inches(2.0), y_pos + Inches(0.04), Inches(5.9), Inches(0.5),
                detail, 11, color=C_DARK_GRAY, v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.06), margin_t=0)
    y_pos += Inches(0.62)

# Right side – alternative & special notes
right_x = Inches(8.4)
add_rect(slide, right_x, Inches(1.3), Inches(4.6), Inches(2.6), RGBColor(0xFD, 0xF5, 0xE8))
add_rect(slide, right_x, Inches(1.3), Inches(4.6), Inches(0.38), C_ORANGE)
add_textbox(slide, right_x + Inches(0.1), Inches(1.3), Inches(4.4), Inches(0.38),
            "IF IV ARTESUNATE UNAVAILABLE", 12, bold=True, color=C_WHITE,
            v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.1), margin_t=0)
add_bullet_textbox(slide, right_x + Inches(0.1), Inches(1.72), Inches(4.4), Inches(2.1),
    [
        "IV Quinine: 20 mg/kg loading dose over 4 h → 10 mg/kg every 8 h",
        "Give with doxycycline or clindamycin (pregnant/children)",
        "Monitor ECG (QTc prolongation, hypoglycaemia)",
        "IM artemether: 3.2 mg/kg loading, then 1.6 mg/kg daily — if IV unavailable",
    ], font_size=11, color=C_DARK_GRAY)

add_rect(slide, right_x, Inches(4.1), Inches(4.6), Inches(2.7), RGBColor(0xE8, 0xF8, 0xEE))
add_rect(slide, right_x, Inches(4.1), Inches(4.6), Inches(0.38), C_GREEN)
add_textbox(slide, right_x + Inches(0.1), Inches(4.1), Inches(4.4), Inches(0.38),
            "PRE-REFERRAL (LIMITED SETTINGS)", 12, bold=True, color=C_WHITE,
            v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.1), margin_t=0)
add_bullet_textbox(slide, right_x + Inches(0.1), Inches(4.52), Inches(4.4), Inches(2.2),
    [
        "Rectal artesunate (10 mg/kg) — if parenteral route unavailable",
        "Single pre-referral dose buys time; refer urgently",
        "Do NOT delay transfer for full treatment course",
        "WHO recommends pre-referral artesunate in children under 6",
    ], font_size=11, color=C_DARK_GRAY)

# ════════════════════════════════════════════════════════════════════
# SLIDE 5 – Cerebral Malaria Management
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Cerebral Malaria: Recognition & Management",
           "Unarousable coma (GCS <11) in confirmed malaria — most common in children in sub-Saharan Africa")
footer_bar(slide)

add_rect(slide, Inches(0.3), Inches(1.28), Inches(12.7), Inches(0.38),
         RGBColor(0xFF, 0xF3, 0xCD))
add_textbox(slide, Inches(0.5), Inches(1.28), Inches(12.3), Inches(0.38),
            "⚠  Rule out hypoglycaemia FIRST — check BGL immediately in every comatose malaria patient",
            12, bold=True, color=RGBColor(0x7A, 0x4A, 0x00), v_anchor=MSO_ANCHOR.MIDDLE)

recog_items = [
    "Unarousable coma: no purposeful response to pain",
    "Exclude other causes: hypoglycaemia, meningitis, encephalitis",
    "Fundoscopy: malarial retinopathy (pathognomonic) — whitening, vessel changes, haemorrhages",
    "Seizures may precede coma (esp. children)",
    "Prognosis: ~15–25% mortality even with treatment; up to 25% neurological sequelae in children",
]
mgmt_items = [
    "START IV artesunate IMMEDIATELY — do not wait for LP",
    "Secure airway — intubate if GCS ≤8 or airway unprotected",
    "IV access × 2; blood glucose STAT — treat hypoglycaemia with 50% dextrose IV",
    "Maintain lateral decubitus position; seizure precautions",
    "Treat seizures: IV diazepam 0.15 mg/kg or lorazepam (NOT prophylactic phenobarbitone)",
    "Avoid dexamethasone — HARMFUL in cerebral malaria (increases coma duration, GI bleeding)",
    "Monitor GCS hourly; parasite count 12–24 hourly",
    "Fever control: paracetamol (tepid sponging); avoid NSAIDs",
    "Fluid management: cautious (avoid pulmonary oedema)",
]

section_card(slide, Inches(0.3), Inches(1.75), Inches(5.6), Inches(5.05),
             "RECOGNITION", recog_items, font_size=12)
section_card(slide, Inches(6.1), Inches(1.75), Inches(6.9), Inches(5.05),
             "MANAGEMENT PRIORITIES", mgmt_items, font_size=11.5)

# ════════════════════════════════════════════════════════════════════
# SLIDE 6 – Complication Management
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Managing Key Complications",
           "Anticipate and proactively manage — many complications develop or worsen during treatment")
footer_bar(slide)

comp_data = [
    ("SEVERE ANAEMIA\n(Hb < 7 g/dL)", C_DARK_RED, [
        "Transfuse: Hb <7 (or <10 if respiratory distress)",
        "Use leuco-depleted, screened blood",
        "Children: 10 mL/kg packed RBCs over 3–4 h",
        "Monitor for fluid overload",
    ]),
    ("HYPOGLYCAEMIA\n(BGL < 2.2 mmol/L)", C_DARK_RED, [
        "50% dextrose 1 mL/kg IV (children: 2 mL/kg of 10%)",
        "Follow with 10% dextrose infusion",
        "Monitor glucose 1–2 hourly (esp. with quinine)",
        "Quinine stimulates insulin → refractory hypoglycaemia",
    ]),
    ("PULMONARY OEDEMA / ARDS", C_DARK_RED, [
        "Prop up 45°; restrict IV fluids aggressively",
        "High-flow O₂ → CPAP/NIV → intubation if needed",
        "Furosemide only if fluid overloaded",
        "Mortality >50% — early ITU involvement essential",
    ]),
    ("ACUTE KIDNEY INJURY", C_DARK_RED, [
        "Strict fluid balance; avoid nephrotoxins",
        "Haemofiltration/dialysis for oliguria unresponsive to fluids",
        "'Blackwater fever': IV fluids + prompt dialysis",
        "Avoid ACE inhibitors; dose-adjust all renally-cleared drugs",
    ]),
    ("METABOLIC ACIDOSIS", C_DARK_RED, [
        "Treat underlying cause: anaemia, hypovolaemia, sepsis",
        "Fluids cautiously — boluses of 10 mL/kg crystalloid",
        "Bicarbonate NOT recommended (treat cause)",
        "Lactate >5 mmol/L = very high mortality risk",
    ]),
    ("HYPERPARASITAEMIA\n(> 5%)", C_DARK_RED, [
        "IV artesunate clears parasites rapidly",
        "Exchange transfusion: controversial, not routinely recommended",
        "Monitor parasite count 12-hourly",
        "Consider ITU transfer urgently",
    ]),
]

cols_per_row = 3
card_w = Inches(4.1)
card_h = Inches(2.5)
gap = Inches(0.15)
for idx, (heading, hcolor, items) in enumerate(comp_data):
    row = idx // cols_per_row
    col = idx % cols_per_row
    left = Inches(0.25) + col * (card_w + gap)
    top  = Inches(1.32) + row * (card_h + gap)
    section_card(slide, left, top, card_w, card_h, heading, items,
                 heading_color=hcolor, font_size=11, heading_size=12)

# ════════════════════════════════════════════════════════════════════
# SLIDE 7 – Malaria in Pregnancy
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Severe Malaria in Pregnancy",
           "High-risk group — complications are amplified; fetal loss, pulmonary oedema, hypoglycaemia especially common")
footer_bar(slide)

risks = [
    "Primigravid & secundigravid most susceptible in stable transmission areas",
    "P. falciparum accumulates in placenta via CSA binding",
    "Fetal growth restriction, preterm labour, stillbirth, low birth weight",
    "Hypoglycaemia more frequent and severe (parasite + quinine effect)",
    "Pulmonary oedema risk greatly increased",
    "Maternal mortality from anaemia, haemorrhage, severe infection",
    "Congenital malaria in <5% of neonates of infected mothers",
    "HIV co-infection amplifies all risks",
]
treatment = [
    "IV artesunate: PREFERRED in 2nd and 3rd trimester",
    "1st trimester: IV artesunate still preferred if benefits outweigh risk (WHO 2024)",
    "Quinine + clindamycin: alternative if artesunate unavailable",
    "Monitor blood glucose every 1–2 h (hypoglycaemia very common)",
    "Careful fluid management — very low threshold for pulmonary oedema",
    "Fetal monitoring: cardiotocography if viable fetus",
    "Do NOT use primaquine or tafenoquine (haemolytic in fetus)",
    "Doxycycline CONTRAINDICATED in pregnancy — use clindamycin",
    "Delivery: only if necessary for maternal condition; malaria itself not indication for C/S",
]

section_card(slide, Inches(0.3), Inches(1.3), Inches(5.8), Inches(5.6),
             "RISKS & COMPLICATIONS", risks, font_size=12)
section_card(slide, Inches(6.3), Inches(1.3), Inches(6.7), Inches(5.6),
             "TREATMENT CONSIDERATIONS", treatment, font_size=12)

# ════════════════════════════════════════════════════════════════════
# SLIDE 8 – Monitoring & Response to Treatment
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Monitoring & Response to Treatment",
           "Regular monitoring guides treatment decisions — parasitaemia should fall within 24–48 h of IV artesunate")
footer_bar(slide)

monitor_items = [
    ("PARAMETER", "FREQUENCY", "ACTION THRESHOLD"),
    ("Blood glucose", "Every 1–2 hours", "BGL < 2.2 mmol/L → IV dextrose STAT"),
    ("GCS / neurology", "Every 1 hour (comatose)", "No improvement in 48 h → CT / LP"),
    ("Parasite count", "Every 12–24 hours", ">5% at 48 h → review treatment / resistance"),
    ("Temperature", "Every 4 hours", "Persistent fever >72 h despite Rx → consider resistance"),
    ("Fluid balance / urine output", "Hourly (IDC)", "UO <0.5 mL/kg/h → assess for AKI"),
    ("FBC / Haemoglobin", "Daily then Day 7, 28", "Post-treatment Hb fall day 7–30 = delayed haemolysis"),
    ("Respiratory rate / SpO₂", "Every 1–2 hours", "SpO₂ <94% / RR rising → ARDS screen"),
    ("Blood pressure", "Every 1–4 hours", "MAP <65 → fluid bolus, vasopressors, sepsis screen"),
    ("LFTs / Bilirubin", "Every 24–48 hours", "Rising bilirubin + coagulopathy = poor prognosis"),
]

# Draw table
table_left = Inches(0.3)
table_top = Inches(1.32)
table_w = Inches(12.7)
row_h = Inches(0.53)
col_widths = [Inches(2.8), Inches(2.8), Inches(7.0)]

for r_idx, row in enumerate(monitor_items):
    y = table_top + r_idx * row_h
    for c_idx, (text, cw) in enumerate(zip(row, col_widths)):
        x = table_left + sum(col_widths[:c_idx])
        if r_idx == 0:
            bg = C_TABLE_HEAD
            fc = C_WHITE
            bold = True
            fsize = 12
        elif r_idx % 2 == 0:
            bg = RGBColor(0xEE, 0xEE, 0xF8)
            fc = C_DARK_GRAY
            bold = False
            fsize = 11
        else:
            bg = C_WHITE
            fc = C_DARK_GRAY
            bold = False
            fsize = 11
        add_rect(slide, x, y, cw, row_h, bg, line_color=RGBColor(0xCC, 0xCC, 0xDD), line_width_pt=0.5)
        add_textbox(slide, x + Inches(0.08), y + Inches(0.04), cw - Inches(0.12), row_h - Inches(0.08),
                    text, fsize, bold=bold, color=fc,
                    v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.06), margin_t=0)

# ════════════════════════════════════════════════════════════════════
# SLIDE 9 – Antimicrobial Resistance Alert
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Antimicrobial Resistance: A Growing Threat",
           "WHO World Malaria Report 2025: Artemisinin partial resistance now confirmed or suspected in ≥8 African countries")
footer_bar(slide)

add_rect(slide, Inches(0.3), Inches(1.28), Inches(12.7), Inches(0.45),
         RGBColor(0xFF, 0xEE, 0xCC))
add_textbox(slide, Inches(0.5), Inches(1.28), Inches(12.3), Inches(0.45),
            "⚠  If parasite clearance is delayed (>48–72 h on IV artesunate), consider partial artemisinin resistance — review travel history, consult infectious diseases",
            11.5, bold=True, color=RGBColor(0x7A, 0x4A, 0x00), v_anchor=MSO_ANCHOR.MIDDLE)

resist_types = [
    ("CHLOROQUINE RESISTANCE", C_DARK_RED, [
        "Near-universal in P. falciparum globally",
        "Mediated by PfCRT gene mutations",
        "Only use chloroquine in Central America / Caribbean",
        "P. vivax resistance in parts of SE Asia & Oceania",
    ]),
    ("ARTEMISININ PARTIAL RESISTANCE", C_DARK_RED, [
        "Kelch13 (K13) gene mutations — key marker",
        "Manifests as delayed parasite clearance (not full failure)",
        "Emerged in SE Asia; now spreading to Africa (Rwanda, Uganda, Eritrea)",
        "WHO 2025 report: declining ACT partner drug efficacy in some regions",
        "CLINICAL: Parasitaemia still present >48–72 h after IV artesunate",
    ]),
    ("CLINICAL RESPONSE TO RESISTANCE", C_DARK_RED, [
        "Do NOT switch from artesunate prematurely (still most effective available)",
        "Extend IV artesunate duration to 7 days if clearance delayed",
        "Add or switch partner drug if confirmed ACT failure",
        "Report suspected resistance to national health authority",
        "Travel history essential — note specific country/region",
        "Consult infectious diseases / tropical medicine specialist",
    ]),
]

cw = Inches(4.1)
gap = Inches(0.15)
for idx, (heading, hcolor, items) in enumerate(resist_types):
    left = Inches(0.25) + idx * (cw + gap)
    section_card(slide, left, Inches(1.82), cw, Inches(4.95),
                 heading, items, heading_color=hcolor, font_size=11.5)

# ════════════════════════════════════════════════════════════════════
# SLIDE 10 – Step-Down Oral Therapy & Discharge
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Step-Down Oral Therapy & Discharge Planning",
           "Switch to oral ACT once patient can tolerate oral medications and parasitaemia is falling")
footer_bar(slide)

stepdown = [
    ("STEP-DOWN CRITERIA", C_GREEN, [
        "Patient conscious and able to swallow",
        "Tolerating oral fluids / medications",
        "Parasitaemia falling (ideally <1%)",
        "No active severe complication",
        "Minimum 24 h of IV artesunate completed",
    ]),
    ("ORAL ACT REGIMENS", C_GREEN, [
        "Artemether-lumefantrine (Coartem): 6-dose regimen over 3 days with fatty food",
        "Dihydroartemisinin-piperaquine: 3-day regimen (once daily)",
        "Artesunate-mefloquine: used in SE Asia",
        "Complete full 3-day course regardless of symptom resolution",
    ]),
    ("HYPNOZOITE ERADICATION\n(P. vivax / P. ovale)", C_MID_RED, [
        "Must add anti-relapse therapy after blood-stage treatment",
        "Primaquine 0.25–0.5 mg/kg/day × 14 days",
        "Or tafenoquine (single dose) — adults only",
        "CHECK G6PD STATUS FIRST — can cause fatal haemolysis",
        "Contraindicated in pregnancy — defer until postpartum",
    ]),
]

cw2 = Inches(4.1)
for idx, (heading, hcolor, items) in enumerate(stepdown):
    left = Inches(0.25) + idx * (cw2 + gap)
    section_card(slide, left, Inches(1.3), cw2, Inches(4.2),
                 heading, items, heading_color=hcolor, font_size=12)

# Discharge checklist
add_rect(slide, Inches(0.25), Inches(5.65), Inches(12.7), Inches(0.38), C_DARK_RED)
add_textbox(slide, Inches(0.4), Inches(5.65), Inches(12.5), Inches(0.38),
            "DISCHARGE CHECKLIST", 13, bold=True, color=C_WHITE,
            v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.1), margin_t=0)
add_rect(slide, Inches(0.25), Inches(6.03), Inches(12.7), Inches(0.95), RGBColor(0xF0, 0xF8, 0xF0))
discharge_items = "  ✓ Full oral ACT course complete   ✓ Haemoglobin checked (and at Day 28)   ✓ G6PD tested (if vivax/ovale)   ✓ Written treatment summary   ✓ Return precautions explained   ✓ Notification to public health (notifiable disease)"
add_textbox(slide, Inches(0.4), Inches(6.06), Inches(12.4), Inches(0.9),
            discharge_items, 12, color=C_DARK_GRAY, word_wrap=True,
            margin_l=Inches(0.1), margin_t=Inches(0.05))

# ════════════════════════════════════════════════════════════════════
# SLIDE 11 – Paediatric Considerations
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_LIGHT_GRAY)
header_bar(slide, "Paediatric Considerations",
           "Children <5 years in sub-Saharan Africa bear the greatest malaria mortality burden — unique clinical features and dosing")
footer_bar(slide)

paed_l = [
    ("CLINICAL DIFFERENCES IN CHILDREN", C_DARK_RED, [
        "Severe anaemia more common than renal failure",
        "Convulsions very frequent (febrile seizures common)",
        "Hypoglycaemia more severe — monitor aggressively",
        "Cerebral malaria: worse neurological outcomes",
        "Respiratory distress from acidosis (not just pulmonary oedema)",
        "Rapid deterioration — reassess frequently",
        "Malaria commonly coexists with bacterial sepsis",
    ]),
    ("DOSING (WEIGHT-BASED)", C_DARK_RED, [
        "IV artesunate: 2.4 mg/kg (same as adults — weight-based)",
        "50% dextrose (hypoglycaemia): 1 mL/kg IV",
        "Diazepam (seizures): 0.15–0.3 mg/kg IV or 0.5 mg/kg rectal",
        "Paracetamol: 15 mg/kg every 4–6 h (fever)",
        "Blood transfusion: 10 mL/kg pRBCs over 3–4 h",
        "Pre-referral rectal artesunate: 10 mg/kg (if <6 years old)",
    ]),
]

for idx, (heading, hcolor, items) in enumerate(paed_l):
    left = Inches(0.3) + idx * (Inches(6.3) + gap)
    section_card(slide, left, Inches(1.3), Inches(6.3), Inches(5.6),
                 heading, items, heading_color=hcolor, font_size=12)

# ════════════════════════════════════════════════════════════════════
# SLIDE 12 – Quick Reference Summary
# ════════════════════════════════════════════════════════════════════
slide = prs.slides.add_slide(blank)
solid_bg(slide, C_DARK_GRAY)
# Top bar
add_rect(slide, 0, 0, prs.slide_width, Inches(1.0), C_DARK_RED)
add_rect(slide, 0, Inches(1.0), prs.slide_width, Inches(0.06), C_MID_RED)
add_textbox(slide, Inches(0.4), Inches(0.1), Inches(12.5), Inches(0.82),
            "SEVERE MALARIA: Quick Reference Card", 24, bold=True,
            color=C_WHITE, align=PP_ALIGN.LEFT, v_anchor=MSO_ANCHOR.MIDDLE,
            margin_l=Inches(0.15))

# 4 summary cards on dark background
summary_cards = [
    ("DIAGNOSE", C_DARK_RED, [
        "Blood film (thick + thin) — STAT",
        "RDT if microscopy delayed",
        "ANY 1 WHO severity criterion = Severe",
        "Check glucose immediately",
    ]),
    ("TREAT", RGBColor(0x7B, 0x1D, 0x1D), [
        "IV artesunate 2.4 mg/kg at 0, 12, 24 h",
        "Then every 24 h (min 24 h IV)",
        "Switch to oral ACT when tolerating",
        "Complete full 3-day oral course",
    ]),
    ("MONITOR", RGBColor(0x4A, 0x2A, 0x6A), [
        "Glucose every 1–2 h",
        "GCS hourly (if comatose)",
        "Parasite count every 12–24 h",
        "Daily Hb; check at Day 28",
    ]),
    ("AVOID", RGBColor(0x1A, 0x4A, 0x2A), [
        "✗ Dexamethasone (harmful in cerebral malaria)",
        "✗ Prophylactic anticonvulsants",
        "✗ Primaquine in pregnancy",
        "✗ Doxycycline in pregnancy",
        "✗ Excessive IV fluids (ARDS risk)",
    ]),
]

card_w3 = Inches(3.0)
for idx, (heading, hcolor, items) in enumerate(summary_cards):
    left = Inches(0.25) + idx * (card_w3 + Inches(0.15))
    top = Inches(1.2)
    h = Inches(5.8)
    add_rect(slide, left, top, card_w3, h, RGBColor(0x2A, 0x2A, 0x44))
    add_rect(slide, left, top, card_w3, Inches(0.45), hcolor)
    add_textbox(slide, left + Inches(0.1), top, card_w3, Inches(0.45),
                heading, 14, bold=True, color=C_WHITE,
                v_anchor=MSO_ANCHOR.MIDDLE, margin_l=Inches(0.1), margin_t=0)
    add_bullet_textbox(slide, left + Inches(0.12), top + Inches(0.5),
                       card_w3 - Inches(0.2), h - Inches(0.65),
                       items, font_size=12, color=RGBColor(0xDD, 0xDD, 0xEE),
                       bullet_char="▸")

footer_note = "Harrison's Principles of Internal Medicine 22E (2025)  ·  WHO Guidelines for Malaria (Aug 2025)  ·  Goldman-Cecil Medicine  ·  Katzung Pharmacology 16E"
add_rect(slide, 0, Inches(7.18), prs.slide_width, Inches(0.32), RGBColor(0x11, 0x11, 0x22))
add_textbox(slide, Inches(0.3), Inches(7.19), Inches(12.7), Inches(0.3),
            footer_note, 8, color=RGBColor(0x88, 0x88, 0x99),
            align=PP_ALIGN.CENTER, margin_l=Inches(0.1), margin_t=Inches(0.02))

# ── Save ────────────────────────────────────────────────────────────
out_path = "/tmp/workspace/severe-malaria-pptx/Severe_Malaria_Management.pptx"
buf = BytesIO()
prs.save(buf)
with open(out_path, "wb") as f:
    f.write(buf.getvalue())
print(f"Saved to {out_path}")

Running Command

cd /tmp/workspace/severe-malaria-pptx && python build_pptx.py 2>&1

Running Command

ls -lh /tmp/workspace/severe-malaria-pptx/Severe_Malaria_Management.pptx

Your presentation is ready:

Severe Malaria Management

Presentation · PPTX

What's in the deck (12 slides)

Slide	Content
1. Title	Global burden stats (249M cases, 608K deaths) with dark red/charcoal design
2. WHO Severity Criteria	All clinical + lab criteria laid out in two columns; warning box on delayed diagnosis
3. Immediate Assessment	3-column layout: History / Examination / Urgent investigations
4. First-Line Treatment	IV artesunate dosing table (with dose, paediatric, pregnancy, monitoring); quinine fallback; pre-referral rectal artesunate
5. Cerebral Malaria	Recognition checklist + management priorities; warning on dexamethasone (harmful)
6. Complication Management	6-card grid: anaemia, hypoglycaemia, ARDS, AKI, acidosis, hyperparasitaemia
7. Malaria in Pregnancy	Risks + treatment modifications; G6PD note; contraindicated drugs
8. Monitoring Table	9-parameter table with frequency and action thresholds
9. Antimicrobial Resistance	Chloroquine resistance + artemisinin partial resistance (kelch13/K13); clinical response
10. Step-Down & Discharge	Oral ACT criteria + regimens; primaquine/tafenoquine for hypnozoites; discharge checklist
11. Paediatric Considerations	Clinical differences in children + weight-based dosing
12. Quick Reference Card	Dark-background 4-card summary: Diagnose / Treat / Monitor / Avoid

Colour scheme: Deep red headers, pale red content cards, with orange/green safety callouts. All sourced from Harrison's 22E (2025), WHO Guidelines 2025, Goldman-Cecil Medicine, and Katzung Pharmacology 16E.

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