** About **

Title Page

Harrison’s Manual of Medicine, 20th Edition
Copyright © 2020 by McGraw Hill Inc. All rights reserved.
Editors
Contributors
Preface
Acknowledgments
Notices and Disclaimers
Unbound™ mobile platform © 2000-2020 Unbound Medicine, Inc. All rights reserved.

Editors

J. Larry Jameson, MD, PhD
Robert G. Dunlop Professor of Medicine
Dean, Raymond and Ruth Perelman School of Medicine
Executive Vice President, University of Pennsylvania for the Health System
Philadelphia, Pennsylvania

Anthony S. Fauci, MD
Chief, Laboratory of Immunoregulation
Director, National Institute of Allergy and Infectious Diseases
National Institutes of Health
Bethesda, Maryland

Dennis L. Kasper, MD
William Ellery Channing Professor of Medicine
Professor of Immunology
Department of Immunology
Harvard Medical School
Boston, Massachusetts

Stephen L. Hauser, MD
Robert A. Fishman Distinguished Professor
Department of Neurology
Director, UCSF Weill Institute for Neurosciences
University of California, San Francisco
San Francisco, California

Dan L. Longo, MD
Professor of Medicine
Harvard Medical School
Senior Physician, Brigham and Women’s Hospital
Deputy Editor, New England Journal of Medicine
Boston, Massachusetts

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, Massachusetts

Contributors

ASSOCIATE EDITORS

S. ANDREW JOSEPHSON, MD
Professor and Chair, Department of Neurology, University of California,
San Francisco, San Francisco, California

CAROL A. LANGFORD, MD, MHS
Harold C. Schott Endowed Chair; Director, Center for Vasculitis Care and Research,
Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio

LEONARD S. LILLY, MD
Professor of Medicine, Harvard Medical School; Chief, Brigham and Women’s/
Faulkner Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts

DAVID B. MOUNT, MD
Assistant Professor of Medicine, Harvard Medical School; Renal Division, Brigham
and Women’s Hospital, Renal Division, Boston VA Healthcare System, Boston, Massachusetts

EDWIN K. SILVERMAN, MD, PhD
Professor of Medicine, Harvard Medical School; Chief, Channing Division of
Network Medicine, Department of Medicine, Brigham and Women’s Hospital,
Boston, Massachusetts

NEERAJ K. SURANA, MD, PhD
Assistant Professor in Pediatrics, Molecular Genetics and Microbiology, and
Immunology, Duke University School of Medicine, Durham, North Carolina

Numbers indicate the chapters written or co-written by the contributor.

ANTHONY S. FAUCI, MD
Chief, Laboratory of Immunoregulation; Director, National Institute of Allergy and
Infectious Diseases, National Institutes of Health, Bethesda, Maryland
28, 44, 45, 49, 60, 61, 107, 153–170

GREGORY K. FOLKERS, MPH
Chief of Staff, Office of the Director, National Institute of Allergy and Infectious
Diseases, National Institutes of Health, Bethesda, Maryland
107, 165

STEPHEN L. HAUSER, MD
Robert A. Fishman Distinguished Professor, Department of Neurology; Director,
UCSF Weill Institute for Neurosciences, University of California, San Francisco,
San Francisco, California
4, 6, 13, 18–24, 50–58, 75, 79, 183–204, 209

J. LARRY JAMESON, MD, PhD
Robert G. Dunlop Professor of Medicine; Dean, Raymond and Ruth Perelman School
of Medicine; Executive Vice President, University of Pennsylvania for the Health
System, Philadelphia, Pennsylvania
3, 4, 7, 8, 25, 26, 31, 32, 120, 171–182, 205, 210

S. ANDREW JOSEPHSON, MD
Professor and Chair, Department of Neurology, University of California,
San Francisco, San Francisco, California
18-21, 23, 51-54, 57, 183–184, 187, 189, 196–202, 209

DENNIS L. KASPER, MD
William Ellery Channing Professor of Medicine;
Professor of Immunology, Department of Immunology, Harvard Medical School,
Boston, Massachusetts
14, 29, 30, 59, 80–106, 108–111, 134, 147, 206

CAROL A. LANGFORD, MD
Harold C. Schott Endowed Chair; Director, Center for Vasculitis Care and Research,
Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland,
Ohio
28, 44, 45, 49, 60, 61, 107, 153–170

LEONARD S. LILLY, MD
Professor of Medicine, Harvard Medical School; Chief, Brigham and Women’s/
Faulkner Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
11, 12, 15, 33, 34, 36, 112–119, 121–129, 207

DAN L. LONGO, MD
Professor of Medicine, Harvard Medical School; Senior Physician, Brigham
and Women’s Hospital; Deputy Editor, New England Journal of Medicine, Boston,
Massachusetts
9, 10, 27, 39–43, 46, 47, 62–74, 76–78, 150–152, 208

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, Massachusetts
1, 2, 5, 11, 12, 15–17, 33–38, 48, 112–119, 121–146, 148, 149, 207, 211

DAVID B. MOUNT, MD
Assistant Professor of Medicine, Harvard Medical School; Renal Division, Brigham
and Women’s Hospital, Renal Division, Boston VA Healthcare System, Boston,
Massachusetts
1, 2, 38, 48, 141–146, 148, 149

EDWIN K. SILVERMAN, MD, PhD
Professor of Medicine, Harvard Medical School; Chief, Channing Division of
Network Medicine, Department of Medicine, Brigham and Women’s Hospital,
Boston, Massachusetts
5, 16, 17, 35, 37, 130–133, 135–140

NEERAJ K. SURANA, MD, PhD
Assistant Professor in Pediatrics, Molecular Genetics and Microbiology, and
Immunology, Duke University School of Medicine, Durham, North Carolina
14, 29, 30, 59, 80–106, 108–111, 134, 147, 206

Preface

Harrison’s Principles of Internal Medicine (HPIM), the premier medical textbook for students and clinicians, provides a comprehensive resource for understanding of the biological and clinical aspects of quality patient care. Harrison’s Manual of Medicine aims to fulfill a different need: As a concise, fact-rich resource for point-of-care, the Manual presents clinical information drawn from the 20th edition of HPIM, covering the key features of the diagnosis, clinical manifestations, and treatment of the major diseases that are likely to be encountered on a medical inpatient service and in the clinic.

First published 30 years ago, the Manual is well established as a trusted resource for rapid access to clinically practical information. With each edition, it is updated by experts and has become ever more useful with the rapid expansion of medical knowledge and the increasing time constraints associated with heavy patient-care responsibilities in modern health care settings. The Manual’s popularity and value reflect its abbreviated format, which has proven extremely useful for initial diagnosis and management in time-restricted clinical settings. In particular, the book’s full-color format allows readers to locate and use information quickly.

In addition, numerous tables and graphics facilitate decisions at the point of care. Although not a substitute for in-depth analysis of clinical problems, the Manual serves as a ready source of informative summaries that will be useful “on the spot” and that will prepare the reader for more in-depth analysis through more extensive reading at a later time. Of note, McGraw-Hill’s Access Medicine website (www.accessmedicine.com) provides online access to both the Manual and Harrison’s Principles of Internal Medicine, making it very easy to seek additional information when needed. The Manual is also available in a variety of eBook and app formats.

Like previous editions, this latest edition of the Manual is intended to keep up with the continual evolution of internal medicine practices. To this end, every chapter from the prior edition has been closely reviewed and updated, with substantial revisions and new chapters provided where appropriate. The Editors learned much in the process of updating the Manual and we hope that you will find this edition uniquely valuable as a clinical and educational resource.

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: Patricia Duffey; Gregory K. Folkers; Andrew Josephson, MD; H. Clifford Lane, MD; Carol A. Langford, MD; Julie B. McCoy; Anita Ortiz; Elizabeth Robbins, MD; Marie E. Scurti; and Stephanie Tribuna.

From McGraw-Hill: James F. Shanahan, Kim J. Davis, and Catherine H. Saggese.

The Editors also wish to acknowledge contributors to past editions of this Manual, whose work formed the basis for many of the chapters herein: Tamar F. Barlam, MD; Gerhard P. Baumann, MD; Eugene Braunwald, MD; Punit Chadha, MD; Joseph B. Martin, MD, PhD; Michael Sneller, MD; Kenneth Tyler, MD; Sophia Vinogradov, MD; and Jean Wilson, MD.

Notices and Disclaimers

Harrison’s Manual of Medicine, 20th Edition (the "Content") is a publication of McGraw Hill Education ("PUBLISHER"), and copyright © 2020, by McGraw Hill Education.

The Unbound™ handheld platform is copyright © 2000-2020 Unbound Medicine, Inc. All rights reserved.

The user is receiving only a limited right to use the Content and Unbound Platform (jointly referred to as the "Service") for user’s own internal or personal use. The user may not reproduce, forward, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the Service or in any way commingle the Service with other third party content, without PUBLISHER’s or Unbound Medicine’s consent.

Disclaimer of Warranties

THE SERVICE IS PROVIDED ON AN "AS IS" BASIS. NEITHER PUBLISHER, UNBOUND MEDICINE NOR ITS LICENSORS MAKE ANY GUARANTEES OR WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OR USE AS TO THE SERVICE OR THE INFORMATION THEREIN OR ANY WARRANTIES AS TO THE ACCURACY, COMPLETENESS, CURRENTNESS, OR RESULTS TO BE OBTAINED FROM, ACCESSING OR USING THE SERVICE, OR ANY MATERIAL REFERENCED IN SUCH SERVICE OR ANY INFORMATION ENTERED INTO THE SERVICE BY USERS OR OTHER PERSONS AND/OR ANY MATERIAL AVAILABLE ON OR THAT CAN BE ACCESSED THROUGH THE SERVICE (INCLUDING VIA ANY HYPERLINK OR OTHERWISE) OR AS TO NON-INFRINGEMENT OF THIRD PARTY RIGHTS. ANY WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, ARE DISCLAIMED. ANY MATERIAL OR DATA OBTAINED THROUGH USE OF THE SERVICE IS AT YOUR OWN DISCRETION AND RISK AND USER UNDERSTANDS THAT IT WILL BE SOLELY RESPONSIBLE FOR ANY RESULTING DAMAGE TO ITS COMPUTER SYSTEM OR LOSS OF DATA.

Disclaimers

MEDICINE IS AN EVER-CHANGING SCIENCE. AS NEW RESEARCH AND CLINICAL EXPERIENCE BROADEN OUT KNOWLEDGE, CHANGES IN TREATMENT AND DRUG THERAPY ARE REQUIRED. IN VIEW OF THE POSSIBILITY OF HUMAN ERROR OR CHANGES IN MEDICAL SCIENCES, NEITHER PUBLISHER, UNBOUND MEDICINE NOR ITS LICENSORS WARRANTS THAT THE INFORMATION CONTAINED IN THE SERVICE 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. USERS ARE ENCOURAGED TO CONFIRM THE INFORMATION CONTAINED IN THE SERVICE WITH OTHER SOURCES. FOR EXAMPLE, AND IN PARTICULAR, USERS 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 THE PUBLISHER CONTENT 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. NEITHER PUBLISHER NOR ITS LICENSORS SHALL BE LIABLE TO SUBSCRIBER OR TO ANY USER OR ANYONE ELSE FOR ANY INACCURACY, DELAY, INTERRUPTION IN SERVICE, ERROR OR OMISSION, REGARDLESS OF CAUSE, OR FOR ANY DAMAGES RESULTING THEREFROM.

Limitation of Liability

IN NO EVENT WILL PUBLISHER, UNBOUND MEDICINE OR ITS LICENSORS, BE LIABLE FOR ANY INDIRECT, SPECIAL OR CONSEQUENTIAL DAMAGES, INCLUDING BUT NOT LIMITED TO, LOST TIME, LOST MONEY, LOST PROFITS OR GOOD WILL, WHETHER IN CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE, AND WHETHER OR NOT SUCH DAMAGES ARE FORESEEN OR UNFORESEEN ARISING FROM OR RELATING TO: (i) YOUR USE OF THE SERVICE OR USE OF THE SERVICE THROUGH YOUR ACCOUNT BY ANYONE ELSE; (ii) THE COST OF PROCUREMENT OF SUBSTITUTE DATA, INFORMATION OR SERVICES; (iii) UNAUTHORIZED ACCESS TO OR ALTERATION OF YOUR TRANSMISSIONS OR DATA; OR (iv) ANY OTHER MATTER RELATING TO THE SERVICE. UNBOUND’S TOTAL CUMULATIVE LIABILITY TO YOU AND ANYONE WHO USES THE SERVICE THROUGH YOUR ACCOUNT, FOR ANY AND ALL CLAIMS UNDER ANY THEORY OF LAW, WILL NOT EXCEED THE UNUSED PORTION OF FEES PAID FOR THE SERVICE. IF, NOTWITHSTANDING THE OTHER TERMS OF THIS AGREEMENT, UNBOUND SHOULD HAVE ANY LIABILITY TO YOU OR ANY THIRD PARTY FOR ANY LOSS, HARM OR DAMAGE, YOU AND UNBOUND AGREE THAT SUCH LIABILITY SHALL UNDER NO CIRCUMSTANCES EXCEED THE LESSER OF $1,000 OR THE FEES YOU PAID US DURING THE THREE (3) MONTHS IMMEDIATELY PRECEDING THE DAY THE ACT OR OMISSION OCCURRED THAT GAVE RISE TO YOUR CLAIM. YOU AND UNBOUND AGREE THAT THE FOREGOING LIMITATION OF LIABILITY IS AN AGREED ALLOCATION OF RISK BETWEEN YOU AND US AND REFLECTS THE FEES, IF ANY, UNBOUND CHARGE YOU TO USE THE SITE AND THE SERVICES. YOU ACKNOWLEDGE THAT ABSENT YOUR AGREEMENT TO THIS LIMITATION OF LIABILITY, UNBOUND WOULD NOT PROVIDE THE SITE OR SERVICES TO YOU.

** About ** is a sample topic from the Harrison's Manual of Medicine.

To view other topics, please or purchase a subscription.

Harrison’s Manual of Medicine 20th edition provides 600+ internal medicine topics in a rapid-access format. Download Harrison’s App to iPhone, iPad, and Android smartphone and tablet. Complete Product Information.