Anthony S. Fauci, MD
Eugene Braunwald, MD
Dennis L. Kasper, MD
Stephen L. Hauser, MD
Dan L. Longo, MD
J. Larry Jameson, MD, PhD
Joseph Loscalzo, MD
Harrison's Manual of Medicine, 17/e
Copyright © 2009, The McGraw-Hill Companies
Notice; Contributors
Preface
User Agreement

Unbound Platform Copyright © 2000-2009 Unbound Medicine, Inc. All rights reserved.

Editors

Anthony S. Fauci, MD, ScD(HON)
Chief, Laboratory of Immunoregulation;
Director, National Institute of Allergy and Infectious Diseases,
National Institutes of Health, Bethesda
Eugene Braunwald, MD, ScD(HON)
Distinguished Hersey Professor of Medicine,
Harvard Medical School;
Chairman, TIMI Study Group,
Brigham and Women's Hospital, Boston
Dennis L. Kasper, MD, MA(HON)
William Ellery Channing Professor of Medicine,
Professor of Microbiology and Molecular Genetics,
Harvard Medical School;
Director, Channing Laboratory,
Department of Mediciine,
Brigham and Women's Hospital, Boston
Stephen L. Hauser, MD
Robert A. Fishman Distinguished Professor and Chairman,
Department of Neurology
University of California, San Francisco,
San Francisco
Dan L. Longo, MD
Scientific Director,
National Institute on Aging,
National Institutes of Health,
Bethesda and Baltimore
J. Larry Jameson, MD, PhD
Professor of Medicine;
Vice President for Medical Affairs and Lewis Landsberg Dean,
Northwestern University Feinberg School of Medicine;
Chicago
Joseph Loscalzo, MD, PhD
Hersey Professor of the Theory and Practice of Medicine,
Harvard Medical School;
Chairman, Department of Medicine;
Physician-in-Chief,
Brigham and Women's Hospital, Boston
NOTE: Dr. Fauci's and Dr. Longo's works as editors and authors were performed outside the scope of their employment as U.S. government employees. These works represent their personal and professional views and not necessarily those of the U.S. government.

Copyright

Copyright © 2009, Published by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher. ISBN: 0-07-146315-1.

Notice

Medicine is an ever-changing science. As new research and clinical experience broadens our knowledge, changes in treatment and drug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this book is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is particularly important in connection with new or infrequently used drugs.

Contributors

Tamar F. Barlam, MD
Associate Professor of Medicine
Boston University School of Medicine
Boston
Anne R. Cappola, MD, SCM
Assistant Professor of Medicine
Division of Endocrinology, Diabetes, and Metabolism
University of Pennsylvania School of Medicine
Philadelphia
S. Andrew Josephson, MD
Assistant Professor of Neurology,
Director
Neurohospitalist Program
University of California, San Francisco
San Francisco
Carol A. Langford, MD, MHS
Director, Center for Vasculitis Care and Research,
Department of Rheumatic and Immunologic Diseases,
Cleveland Clinic Foundation,
Cleveland
Leonard S. Lilly, MD
Associate Professor of Medicine
Harvard Medical School
Chief, Brigham/Faulkner Cardiology
Brigham & Women's Hospital,
Boston
David B. Mount, MD
Assistant Professor of Medicine
Harvard Medical School
Associate Physician,
Brigham & Women's Hospital,
Renal Division Staff Physician,
VA Boston Healthcare Systerm,
Boston
Edwin K. Silverman,, MD, PhD
Associate Professor of Medicine
Channing Laboratory and Pulmonary and Critical Care Division
Department of Medicine, Brigham & Women's Hospital
Harvard Medical School,
Boston

Numbers indicate the chapters written or co-written by the contributor.
Tamar F. Barlam,MD
13,26,29,37,62,83-111,113-116,139,152,212
Eugene Braunwald, MD
11,12,14,33,46-49,117-124,126-131,134,143,144,217
Anne R. Cappola, MD, SCM
7,8,24,25,30,51,177-188,216
Anthony S. Fauci, MD
28,32,38,55,56,63,64,112,159-176
Stephen L. Hauser, MD
6,17-23,35,36,39-45,61,82,189-207,209,210,215
J. Larry Jameson, MD, PhD
1,3,4,7,8,24,25,30,31,51,60,125,177-188,208,211,216,218
S. Andrew Josephson, MD
6,17-23,35,36,39-45,61,82,189-207,209,210,215
Dennis L. Kasper, MD
13,26,29,37,62,83-111,113-116,139,152,212
Carol A. Langford, MD
28,32,38,55,56,63,64,112,159-176
Leonard S. Lilly, MD
11,33,117-124,127-133,213
Dan L. Longo
9,10,27,34,50,52-54,58,59,65-81,156-158,214
Joseph Loscalzo, MD, PhD
2,5,15,16,57,132,133,135-138,140-142,145-151,153-155
David B. Mount
2,57,145-151,153-155
Edwin K. Silverman, MD, PhD
5,15,16,135-138,140-142

Preface

Harrison's Principles of Internal Medicine (HPIM) provides a comprehensive body of information important to an understanding of the biological and clinical aspects of quality patient care. It remains the premier medical textbook for students and clinicians. With the rapidly expanding base of medical knowledge and the time constraints associated with heavy patientcare responsibilities in modern health care settings, it is not always possible to read a comprehensive account of diseases and their presentations, clinical manifestations, and treatments before or even immediately after encountering the patient. It was for these reasons, among others, that in 1988 the Editors first condensed the clinical portions of HPIM into a pocket-sized volume, Harrison's Manual of Medicine. Similar to the prior 6 editions, this new edition of the Manual, drawn from the 17th edition of HPIM, present the key features of the diagnosis, clinical manifestations, and treatment of the major diseases that are likely to be encountered on a medical service.

The Editors stress that the Manual should not substitute for in-depth analysis of the clinical problem, but should serve as a ready source of wellcrafted and informative summaries that will be useful "on-the-spot" and that will prepare the reader for a more in-depth analysis drawn from more extensive reading at a later time. The Manual has met with increasing popularity over the years; its popularity and value relate in part to its abbreviated format, which has proven to be extremely useful for initial diagnosis, brief description of pathogenesis, and outline of management in time-restricted clinical settings. The most obvious change in this new edition of the Manual is its appearance: full-color format will increase the speed with which readers can locate and use information within its chapters. The Manual has been written for easy and seamless reference to the full text of the 17th edition of HPIM, and the Editors recommend that the full textbook--or Harrison's On Line--be consulted as soon as time allows.

As with previous editions, this latest edition of the Manual attempts to keep up with the continual and sometimes rapid evolution of internal medicine practices. In this regard, every chapter has received a close review and has been updated from the prior edition, with substantial revisions and new chapters provided where appropriate. In Section 1 on Care of the Hospitalized Patient, a new chapter entitled "End-of-Life Care" has been added. Section 2 on Medical Emergencies now includes a chapter entitled "Spinal Cord Compression." Chapters on "Tremor and Movement Disorders" and "Generalized Fatigue" appear in Section 3 on Common Patient Presentations. In Section 7 on Infectious Diseases, the chapter on "HIV Infection and AIDS" has been extensively revised to reflect important advances in therapy since the last edition. In Section 8 on Cardiology, there are new chapters on "Noninvasive Examination of the Heart," "Congenital Heart Disease in the Adult," and "Metabolic Syndrome." In Section 9 on Pulmonology, there is a new chapter on "Sleep Apnea," and in Section 16 on Disease Prevention and Health Maintenance, there are important new chapters on "Cardiovascular Disease Prevention" and "Smoking Cessation."

In full recognition of the important role of digital information delivery in alleviating the increasing time demands put on clinicians, the last 3 editions of the Manual, including the current edition, have been made available in PDA format. In addition, a version of the Manual for use with the iPhone platform is available for the 17th edition.

In 2006, in recognition of the increasing use of electronic health records systems in hospitals, Harrison's Practice made its debut. This innovative, digital point-of-care resource delivers substantial clinical reference data to the bedside. Its outline format and telescopic nature make it an ideal tool for finding and employing complex medical reference information quickly. Taken as a complete portfolio, Harrison's is now available in a variety of formats designed to be suitable for all levels of medical training and for all varieties of health care settings.

Acknowledgments

The Editors and McGraw-Hill wish to thank their editorial staff whose assistance and patience made this edition come out in a timely manner:

From the Editors' offices: Pat Duffey; Gregory K. Folkers; Julie McCoy; Elizabeth Robbins, MD; Kathryn Saxon; Kristine Shontz; and Stephanie Tribuna.

From McGraw-Hill: James F. Shanahan, Mariapaz Ramos Englis, Catherine Saggese, M. Lorraine Andrews, and Eileen Scott who has been a part of HMOM since the 11th edition.

The Editors also wish to acknowledge contributors to past editions of this Manual, whose work formed the basis for many of the chapters herein: Joseph B. Martin, MD, PhD; Kurt Isselbacher, MD; Jean Wilson, MD; Daryl R. Gress, MD; Michael Sneller, MD; John W. Engstrom, MD; Kenneth Tyler, MD; Sophia Vinogradov, MD; Dan B. Evans, MD; Punit Chadha, MD; Glenn Chertow, MD; James Woodrow Weiss, MD.

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