Rytands Murmur

Occasionally in patients with complete atrioventricular heart block, a mid-diastolic murmur is

heard at the apex (Rytands murmur) and may be confused with mitral stenosis. The slow heart
rate, variable duration of the murmur, changing intensity of the S1, and lack of opening snap
are helpful findings for the differential diagnosis. The mechanism of Rytands murmur is not
clear, but increased flow due to slow heart rate and increased antegrade flow with atrial
contraction, which occurs randomly, may be contributory.

17.29 Common causes of end-stage renal failure

Disease
Congenital and inherited
Renal artery stenosis
Hypertension
Glomerular diseases
Interstitial diseases
Systemic inflammatory
diseases
Diabetes mellitus
Unknown
Alport's syndrome

Proportio
n
5%
5%
5-20%
10-20%
20-30%
5-10%
20-40%
5-20%

Comments
E.g. polycystic kidney disease, Alport's
syndrome

IgA nephropathy is most common

e.g. SLE, vasculitis
Large racial and geographical differences

X-linked recessive disorder, affecting type IV collagen formation. Abnormal collagen

results in a progressive degeneration of the GBM. Associated with sensorineural
deafness and ocular abnormalities.

Major Causes of Chronic Diarrhea According to Predominant Pathophysiologic

Mechanism
Secretory causes

Inflammatory causes

Exogenous stimulant laxatives

Idiopathic inflammatory bowel

disease (Crohn's, chronic ulcerative
colitis)

Chronic ethanol ingestion

Lymphocytic and collagenous colitis

Other drugs and toxins

Endogenous laxatives (dihydroxy bile acids)
Idiopathic secretory diarrhea

Immune-related mucosal disease

(1 or 2 immunodeficiencies, food
allergy, eosinophilic gastroenteritis,
graft-vs-host disease)

Certain bacterial infections

Bowel resection, disease, or fistula ( absorption)
Partial bowel obstruction or fecal impaction
Hormone-producing tumors (carcinoid, VIPoma,
medullary cancer of thyroid, mastocytosis,
gastrinoma, colorectal villous adenoma)

Infections (invasive bacteria,

viruses, and parasites, Brainerd
diarrhea)
Radiation injury Gastrointestinal
malignancies
Dysmotile causes
Irritable bowel syndrome (including
postinfectious IBS)

Addison's disease
Congenital electrolyte absorption defects
Osmotic causes

Visceral neuromyopathies
Hyperthyroidism

2+

Osmotic laxatives (Mg , PO4 , SO4

Lactase and other disaccharide deficiencies

Nonabsorbable carbohydrates (sorbitol, lactulose,
polyethylene glycol)
Steatorrheal causes
Intraluminal maldigestion (pancreatic exocrine
insufficiency, bacterial overgrowth, bariatric
surgery, liver disease)

Drugs (prokinetic agents)

Postvagotomy
Factitial causes
Munchausen
Eating disorders
Iatrogenic causes
Cholecystectomy

Mucosal malabsorption (celiac sprue, Whipple's

disease, infections, abetalipoproteinemia, ischemia)
Postmucosal obstruction (1 or 2 lymphatic
obstruction)

Ileal resection
Bariatric surgery
Vagotomy, fundoplication

13.23

Causes of chronic diarrhoea in the tropics

Giardia lamblia
Strongyloidiasis
Hypolactasia (primary and secondary)
Enteropathic E. coli
Tropical sprue
Chronic calcific pancreatitis
HIV enteropathy
Intestinal flukes
Chronic intestinal schistosomiasis

Infectious mononucleosis (IM) and Epstein-Barr virus (EBV)

IM is an acute viral illness characterised by pharyngitis, cervical lymphadenopathy, fever and
lymphocytosis. A variety of medical complications may ensue. It is most often caused by EBV
infection, but a variety of other viral infections (CMV, HHV-6, HIV-1) and toxoplasmosis can
produce a similar clinical syndrome.
Complications of infectious mononucleosis
Common

Severe pharyngeal
oedema
Antibiotic-induced
rash (80-90% with
ampicillin)
Prolonged post-viral
fatigue (10%)
Hepatitis (80%)
Jaundice (< 10%)

Uncommon
Neurological

Cranial nerve palsies

Polyneuritis
Transverse myelitis
Meningoencephalitis
Haematological
Haemolytic anaemia
Thrombocytopenia
Cardiac
Myocarditis
ECG abnormalities
Pericarditis
Rare
Ruptured spleen
Respiratory
obstruction
Agranulocytosis

X-linked
lymphoproliferative
syndrome
EBV-associated
malignancy
Nasopharyngeal
carcinoma
Burkitt's lymphoma
Primary CNS
lymphoma
Hodgkin's disease
(certain subtypes
only)
Lymphoproliferative
disease in
immunocompromised
Oral hairy leucoplakia
(AIDS patients)