Liver Transplant In India Information Guide.

Urine normally flows in one direction—down from the kidneys, through tubes called ureters, to the bladder. Vesicoureteric reflux is the abnormal flow of urine from the bladder back into the ureters.

Vesicoureteric reflux is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with UTI are found to have Vesicoureteric reflux. Vesicoureteric reflux can lead to infection because urine that remains in the child's urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of Vesicoureteric reflux.

There are two types of Vesicoureteric reflux. Primary Vesicoureteric reflux occurs when a child is born with an impaired valve where the ureter joins the bladder. This happens if the ureter did not grow long enough during the child's development in the womb. The valve does not close properly, so urine backs up (refluxes) from the bladder to the ureters, and eventually to the kidneys. This type of Vesicoureteric reflux can get better or disappear as the child gets older. The ureter gets longer as the child grows, and the function of the valve improves.

Secondary Vesicoureteric reflux occurs when there is a blockage anywhere in the urinary system. The blockage may be caused by an infection in the bladder that leads to swelling of the ureter. This also causes a reflux of urine to the kidneys.

Infection is the most common symptom of Vesicoureteric reflux. As the child gets older, other symptoms, such as bedwetting, high blood pressure, protein in the urine, and kidney failure, may appear.

Common tests to show the presence of urinary tract infection include urine tests and cultures.

Because no single test can tell everything about the urinary tract that might be important to know, more than one of the following imaging tests may be needed:

Kidney and bladder ultrasound: A test that uses sound waves to examine the kidney and bladder. This test shows shadows of the kidney and bladder that may point out certain abnormalities. The test cannot reveal all important urinary abnormalities or measure how well a kidney works.

Voiding cystourethrogram (VCUG): A test that examines the urethra and bladder while the bladder fills and empties. A liquid that can be seen on x rays is placed in the bladder through a catheter. Pictures are taken when the bladder is filled and when the child urinates. This test can reveal abnormalities of the inside of the urethra and bladder. The test can also determine whether the flow of urine is normal when the bladder empties.

Intravenous pyelogram: A test that examines the whole urinary tract. A liquid that can be seen on x rays is injected into a vein. The substance travels into the kidneys and bladder, revealing possible obstructions.

Nuclear scans: A number of tests using radioactive materials that are usually injected into a vein to show how well the kidneys work, their shape, and whether urine empties from the kidneys normally. Each kind of nuclear scan gives different information about the kidneys and bladder. Nuclear scans expose a child to about the same amount of radiation as a conventional x ray. At times, it can be even less.

The goal for treatment of Vesicoureteric reflux is to prevent any kidney damage from occurring. Infections should be treated at once with antibiotics to prevent the infection from moving into the kidneys. Antibiotic therapy usually corrects reflux caused by infection. Sometimes surgery is needed to correct primary Vesicoureteric reflux.

Infection is the most common symptom of Vesicoureteric reflux. As the child gets older, other symptoms, such as bedwetting, high blood pressure, protein in the urine, and kidney failure, may appear.

Common tests to show the presence of urinary tract infection include urine tests and cultures.

Because no single test can tell everything about the urinary tract that might be important to know, more than one of the following imaging tests may be needed:

URINARY INFECTIONS

What is a Urinary Tract Infection (UTI)?

The urinary tract makes and stores urine. Bacteria, a type of germ that gets into your urinary tract, cause a UTI. This infection can happen in parts of your urinary tract, like your kidneys, bladder, or urethra.

UTIs are far more common in women than men.

What causes urinary tract infections (UTIs) in women?

Many things can help to cause UTIs in women:

Wiping from back to front after a bowel movement (BM). Germs can get into your urethra, which has its opening in front of the vagina.

Having sexual intercourse. Germs in the vagina can be pushed into the urethra.

Waiting too long to pass urine. When urine stays in the bladder for a long time, more germs are made, and the worse a UTI can become.

Using a diaphragm for birth control, or spermicides with a diaphragm or on a condom.

Anything that makes it hard to completely empty your bladder, like a kidney stone.

Having diabetes, which makes it harder for your body to fight other health problems.

Loss of estrogen and changes in the vagina after menopause. Menopause is when you stop getting your period.

What are the signs of a urinary tract infection (UTI)?

There are signs if you have an infection:

Pain or stinging when you pass urine.

An urge to pass urine a lot.

Pressure in your lower belly.

Urine that smells bad or looks milky, cloudy, or reddish in color.

Feeling tired or shaky or having a fever.

How does a doctor find out I have a urinary tract infection (UTI)?

To find out if you have a UTI, your doctor will ask you to pass urine into a plastic cup. When you open the cup, don’t touch the inside of the lid or inside of the cup. Before you pass urine, wipe the area between the labium majora, or outer lips of the vagina, with a special tissue, given to you by your doctor. Then, pass a little bit of urine into the toilet and then into the cup.

How is a urinary tract infection (UTI) treated?

UTIs are treated with antibiotics, a medicine that kills the infection. Your doctor will tell you how long you need to take the medicine. Make sure you take all of your medicine, even if you feel better!

If you don't take medicine for a UTI, the UTI can hurt other parts of your body. Also, if you're pregnant and have signs of a UTI, see your doctor right away. A UTI could cause problems in your pregnancy, such as having your baby too early or getting high blood pressure.

Are there steps I can take to help prevent a urinary tract infection (UTI)?

These are steps you can take to try to prevent a UTI. But you may follow these steps and still get a UTI. If you have symptoms of a UTI, call your doctor.

Urinate when you need to. Don't hold it. Pass urine before and after sex. After you pass urine or have a bowel movement (BM), wipe from front to back.

Drink water every day and after sex.

Clean the outer lips of your vagina and anus each day. The anus is the place where a bowel movement leaves your body, located between the buttocks.

Don't use douches or feminine hygiene sprays.

If you get a lot of UTIs and use spermicides, or creams that kill sperm, talk to your doctor about using other forms of birth control.

Wear underwear with a cotton crotch.

URINARY INCONTINENCE IN WOMEN

What is urinary incontinence?

Urinary incontinence is when urine leaks out before you can get to a bathroom. If you have urinary incontinence, you're not alone. Millions of women have this problem.

What causes urinary incontinence?

There are many reasons why a woman may leak urine. Sometimes it's caused by an illness, in which case bladder control returns when the illness goes away. For example, bladder infections and infections in the vagina can cause incontinence for a short time. Being unable to have a bowel movement or taking certain medicines also may make it hard to control your bladder.

Sometimes incontinence is an ongoing problem, in which case the cause might be:

the bladder cannot empty completely

weakening of the muscles that help to hold or release urine

a blocked urinary passage

damage to the nerves that control the bladder

Sometimes, diseases such as arthritis make it hard to get to the bathroom in time and can make it even harder to control urine leakage.

How common is urinary incontinence?

More than 13 million Americans — male and female, young and old — have incontinence. Women are more likely to leak urine than men.

Older women have more bladder control problems than younger women. But loss of bladder control does not have to happen as you age. If you're leaking urine, talk to your doctor about it. Your doctor can help you.

Does having a baby cause urinary incontinence?

Yes. It can, but don't panic. If you lose bladder control after having a baby, the problem often goes away by itself. Your muscles may just need time to recover.

Being pregnant also can cause leakage due to:

pressure of the pregnancy on the bladder and pelvic muscles

vaginal delivery

episiotomy (the cut in the muscle that makes it easier for the baby to come out)

damage to bladder control nerves

If you still have bladder problems six weeks after having your baby, talk to your doctor. Without treatment, lost bladder control can become a long-term problem. Leaking can also result from some medical conditions, including neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging.

Sometimes bladder control problems show up years after you've had your baby. Some women do not have problems until later, often in their 40's.

Unborn babies push down on the bladder, urethra (tube that you urinate from) and pelvic muscles.

Does menopause affect urinary incontinence?

Yes. Some women have bladder control problems after they stop having periods (called menopause or change of life). After your periods end, your body stops making the female hormone estrogen. Some experts think this loss of estrogen weakens the vaginal tissue.

If you're leaking urine, talk to your doctor about it. Your doctor can help you.

Are there different types of urinary incontinence?

Yes.

Stress incontinence — leakage happens with coughing, sneezing, exercising, laughing, lifting heavy things, and other movements that put pressure on the bladder. It is the most common type of incontinence. It can be treated and sometimes cured.

Urge incontinence — this is sometimes called "overactive bladder." Leakage usually happens after a strong, sudden urge to urinate. The sudden urge may occur when you don't expect it, such as during sleep, after drinking water, or when you hear running water or touch it.

Functional incontinence — leaking because you can't get to a toilet in time. People with this type of incontinence may have problems thinking, moving, or speaking that keep them from reaching a toilet. For example, a person with Alzheimer's disease may not plan a trip to the bathroom in time to urinate. A person in a wheelchair may be unable to get to a toilet in time.

Overflow incontinence — leaking urine because the bladder doesn't empty completely. Overflow incontinence is less common in women.

Mixed incontinence — two or more types of incontinence together, most often stress and urge incontinence.

Transient incontinence — leaking urine for a short time due to an illness such as a bladder infection. Leaking stops when the illness is treated.

How do I talk to my doctor about urinary incontinence?

Most people don't want to talk to their doctor about such a personal topic. But keep in mind that urinary incontinence is a common medical problem. Millions of women have the same problem, so your doctor has probably heard many stories like yours.

Even if you feel shy, it is up to you to take the first step. Some doctors don't treat bladder control problems, so they may not think to ask about it. Others might expect you to bring up the subject. If your doctor doesn't treat bladder problems, ask for help finding a doctor who does.

Here are some questions to ask your doctor:

Could what I eat or drink cause bladder problems?

Could my medicines (prescription or over-the-counter) cause bladder problems?

Could other medical conditions cause loss of bladder control?

What are the treatments to regain bladder control? Which one is best for me?

What can I do about the odor and rash caused by urine?

It may help to write down when you leak urine. Be sure to note what you were doing at the time, for example, sneezing, coughing, laughing, or sleeping. Take this log with you when you visit your doctor.

How do I find out if I have urinary incontinence?

The first step is to see your doctor. If your doctor doesn't treat bladder problems, ask for help finding someone who does.

Your doctor will ask you about your symptoms and take a medical history. Your doctor will ask you:

how often you empty your bladder

how and when you leak urine

how much urine you leak

Your doctor will do a physical exam to look for signs of health problems that can cause incontinence. Your doctor also will do a test to figure out how well your bladder works and how much it can hold. For this test, you will drink water and urinate into a measuring pan, after which your doctor will measure any urine still in the bladder. Your doctor also may order one or more of the following other tests:

Stress test — while you cough or bear down, the doctor watches for loss of urine.

Urinalysis — you give a urine sample, which is tested for signs of infection and other causes of incontinence.

Blood test — you give a blood sample, which is sent to a lab where it is tested for signs of other causes of incontinence.

Ultrasound — sound waves are used to take a picture of the kidneys, bladder, and urethra. Your doctor will look to see if there are any problems in these areas that could cause incontinence.

Cystoscopy — a thin tube with a tiny camera is placed in the urethra to view the inside of the urethra and bladder.

Urodynamics — a thin tube is placed into your bladder and your bladder is filled with water. Your doctor measures the pressure in the bladder.

Your doctor may ask you to write down when you empty your bladder and how much urine you produce for a day or a week.

Is there anything I can do to prevent urinary incontinence?

Yes. Exercising your pelvic floor muscles regularly can help prevent bladder problems. These exercises are called Kegels.

How to do Kegel exercises:

It may be easier to begin practicing these exercises while lying down.

Squeeze the muscles in your genital area as if you were trying to stop the flow of urine or trying to stop from passing gas. Try not to squeeze the muscles in your belly or legs at the same time.

Relax. Squeeze the muscles again and hold for 3 seconds. Then relax for 3 seconds. Do this 8 more times. Work up to 5 sets of 10.

When your muscles get stronger, do your exercises sitting or standing. You can do these exercises any time, while sitting at your desk, in the car, waiting in line, doing the dishes, etc.

Be patient. It may take 3 to 6 weeks before you see results.

If you're not sure you're doing Kegel exercises right, ask your doctor or nurse to check you while you try to do them. If you aren't squeezing the right muscles, your doctor or nurse can teach you the right way to do the exercises. A pelvic floor physical therapist may be available in your area to help teach you how to strengthen these muscles or help you with other treatments.

How is urinary incontinence treated?

There are many ways to treat incontinence. Your doctor will work with you to find the best treatment for you.

Treatments include:

Pelvic Muscle Exercises (Kegel exercises) — easy exercises to make your pelvic muscles stronger. Doing these exercises every day can help reduce or cure stress leakage.

If you're not sure you're doing Kegel exercises right, ask your doctor or nurse to check you while you try to do them. If you aren't squeezing the right muscles, your doctor or nurse can teach you the right way to do the exercises. A pelvic floor physical therapist may be available in your area to help teach you how to strengthen these muscles or help you with other treatments listed below.

Electrical Stimulation — electrodes are placed in the vagina or rectum for a short time to stimulate nearby muscles and make them stronger. This treatment can reduce both stress incontinence and urge incontinence.

Biofeedback — biofeedback helps you learn how your body works. A therapist puts an electrical patch over your bladder and urethral muscles. A wire connected to the patch is linked to a TV screen. You and your therapist watch the screen to see when these muscles contract, so you can learn to control these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to help control stress incontinence and urge incontinence.

Timed Voiding or Bladder Retraining — there are two ways you can train your bladder to hold urine better. In timed voiding, you urinate at set times instead of waiting for a strong urge. To do bladder retraining, you slowly increase the time between your scheduled voiding times to train your bladder to hold urine better. These treatments can reduce urge incontinence and overflow incontinence. A doctor can tell you if these may help you.

Weight Loss — extra weight puts more pressure on your bladder and nearby muscles, which can cause bladder control problems. If you’re overweight, work with your doctor to plan a diet and exercise program that works for you.

Dietary Changes — certain foods and drinks can cause incontinence, such as caffeine (found in coffee, some sodas, and chocolate), tea, and alcohol. Limiting these foods and drinks can reduce incontinence.

Medications — medications can reduce some types of leakage. Talk to your doctor to see if medication is right for you.

Pessary — a pessary is a small device that fits in your vagina and helps hold it up. A pessary can help reduce leakage. Your doctor or nurse will decide which type and size of pessary is right for you and will check the pessary regularly.

Implants — your doctor may suggest injecting a material into the space around the urethra with a needle. This material thickens the area around the urethra so you can control your urine flow better.

Surgery — surgery can fix problems such as blocked areas. It can also support the bladder or the urethra to prevent loss of urine. A surgeon can also put a small device in the body that acts on nerves to control bladder activity.

Urethral Inserts — a urethral insert is a thin tube that you place inside the urethra that blocks urine from coming out. You take the tube out when you need to urinate and then put it back in until you need to urinate again.

External Urethral Barrier — this device is a small foam or gel disposable pad that you place over the opening of the urethra. The pad seals itself against your body, keeping you from leaking. When you go to the bathroom you take it off. After urinating you place a new pad over the urethra.

Catheters — if nothing else helps, the doctor may suggest catheters, thin tubes placed in the bladder by a doctor or by you. A catheter drains the bladder for you, sometimes into an attached bag.

SARCOIDOSIS

Sarcoidosis involves inflammation that produces tiny lumps of cells in various organs in your body. The lumps are called granulomas because they look like grains of sugar or sand. They are very small and can be seen only with a microscope.

These tiny granulomas can grow and clump together, making many large and small groups of lumps. If many granulomas form in an organ, they can affect how the organ works. This can cause symptoms of sarcoidosis.

Sarcoidosis can occur in almost any part of your body, although it usually affects some organs more than others. It usually starts in one of two places:

Lungs

Lymph nodes, especially the lymph nodes in your chest cavity.

Sarcoidosis also often affects your:

Skin

Eyes

Liver.

Less often, sarcoidosis affects your:

Spleen

Brain

Nerves

Heart

Tear glands

Salivary glands

Bones and joints.

Rarely, sarcoidosis affects other organs, including your:

Thyroid gland

Breasts

Kidneys

Reproductive organs.

Sarcoidosis almost always occurs in more than one organ at a time.

Sarcoidosis has an active and a nonactive phase:

In the active phase, the granulomas form and grow. In this phase, symptoms can develop, and scar tissue can form in the organs where the granulomas occur.

In the nonactive phase, the inflammation goes down, and the granulomas stay the same size or shrink. But the scars may remain and cause symptoms.

The course of the disease varies greatly among people.

In many people, sarcoidosis is mild. The inflammation that causes the granulomas may get better on its own. The granulomas may stop growing or shrink. Symptoms may go away within a few years.

In some people, the inflammation remains but doesn't get worse. You may also have symptoms or flare-ups and need treatment every now and then.

In other people, sarcoidosis slowly gets worse over the years and can cause permanent organ damage. Although treatment can help, sarcoidosis may leave scar tissue in the lungs, skin, eyes, or other organs. The scar tissue can affect how the organs work. Treatment usually does not affect scar tissue.

Changes in sarcoidosis usually occur slowly (e.g., over months). Sarcoidosis does not usually cause sudden illness. However, some symptoms may occur suddenly. They include:

Disturbed heart rhythms

Arthritis in the ankles

Eye symptoms.

In some serious cases in which vital organs are affected, sarcoidosis can result in death.

Sarcoidosis is not a form of cancer.

There is no known way to prevent sarcoidosis.

What Is Sarcoidosis?

Sarcoidosis can occur in almost any part of your body, although it usually affects some organs more than others. It usually starts in one of two places:

Lungs

Lymph nodes, especially the lymph nodes in your chest cavity.

Sarcoidosis also often affects your:

Skin

Eyes

Liver.

Less often, sarcoidosis affects your:

Spleen

Brain

Nerves

Heart

Tear glands

Salivary glands

Bones and joints.

Rarely, sarcoidosis affects other organs, including your:

Thyroid gland

Breasts

Kidneys

Reproductive organs.

Sarcoidosis almost always occurs in more than one organ at a time.

Sarcoidosis has an active and a nonactive phase:

In the active phase, the granulomas form and grow. In this phase, symptoms can develop, and scar tissue can form in the organs where the granulomas occur.

In the nonactive phase, the inflammation goes down, and the granulomas stay the same size or shrink. But the scars may remain and cause symptoms.

The course of the disease varies greatly among people.

In many people, sarcoidosis is mild. The inflammation that causes the granulomas may get better on its own. The granulomas may stop growing or shrink. Symptoms may go away within a few years.

In some people, the inflammation remains but doesn't get worse. You may also have symptoms or flare-ups and need treatment every now and then.

Changes in sarcoidosis usually occur slowly (e.g., over months). Sarcoidosis does not usually cause sudden illness. However, some symptoms may occur suddenly. They include:

Disturbed heart rhythms

Arthritis in the ankles

Eye symptoms.

In some serious cases in which vital organs are affected, sarcoidosis can result in death.

Sarcoidosis is not a form of cancer.

There is no known way to prevent sarcoidosis.

Sarcoidosis was once thought to be an uncommon condition. It's now known to affect tens of thousands of people throughout the United States. Because many people who have sarcoidosis have no symptoms, it's hard to know how many people have the condition.

Sarcoidosis was identified in the late 1860s. Since then, scientists have developed better tests to diagnose it and made advances in treating it.

What Causes Sarcoidosis?

The cause of sarcoidosis is not known. And, there may be more than one thing that causes it.

Scientists think that sarcoidosis develops when your immune system responds to something in the environment (e.g., bacteria, viruses, dust, chemicals) or perhaps to your own body tissue (autoimmunity).

Normally, your immune system defends your body against things that it sees as foreign and harmful. It does this by sending special cells to the organs that are being affected by these things. These cells release chemicals that produce inflammation around the foreign substance or substances to isolate and destroy them.

In sarcoidosis, this inflammation remains and leads to the development of granulomas or lumps.

Scientists have not yet identified the specific substance or substances that trigger the immune system response in the first place. They also think that sarcoidosis develops only if you have inherited a certain combination of genes.

You can't catch sarcoidosis from someone who has it.

More research is needed to discover what causes sarcoidosis.

Who Gets Sarcoidosis?

Sarcoidosis affects people of all ages and races worldwide.

It occurs mostly in:

Adults between the ages of 20 and 40

African Americans (especially women)

People of Asian, German, Irish, Puerto Rican, and Scandinavian origin.

In the United States, sarcoidosis affects African Americans somewhat more often and more severely than Caucasians.

Studies have shown that sarcoidosis is more likely to affect certain organs in certain populations. For example,

Sarcoidosis of the heart and eye appears to be more common in Japan.

Painful skin lumps on the legs occur more often in people from Northern Europe.

People who are more likely to get sarcoidosis include:

Health care workers

Nonsmokers

Elementary and secondary school teachers

People exposed to agricultural dust, insecticides, pesticides, or mold

Firefighters.

Brothers and sisters, parents, and children of people who have sarcoidosis are more likely than others to have sarcoidosis.

What Are the Signs and Symptoms of Sarcoidosis?

Many people who have sarcoidosis have no symptoms. Often, the condition is discovered by accident only because a person has a chest x ray for another reason, such as a pre-employment x ray.

Some people have very few symptoms, but others have many.

Symptoms usually depend on which organs the disease affects.

Lung Symptoms

Shortness of breath

A dry cough that doesn't bring up phlegm (flem), or mucus

Wheezing

Pain in the middle of your chest that gets worse when you breathe deeply or cough (rare).

Lymph Node Symptoms

Enlarged and sometimes tender lymph nodes—most often those in your neck and chest but sometimes those under your chin, in your arm pits, or in your groin.

Skin Symptoms

Various types of bumps, ulcers, or, rarely, flat areas of discolored skin, that appear mostly near your nose, eyes, back, arms, legs, and scalp. They usually itch but aren't painful. They usually last a long time.

Painful bumps that usually appear on your ankles and shins and can be warm, tender, red or purple-to-red in colour, and slightly raised. This is called erythema nodosum (er"i-the'mah nodo'sum). You may have fever and swollen ankles and joint pain along with the bumps. The bumps often are an early sign of sarcoidosis, but they occur in other diseases too. The bumps usually go away in weeks to months, even without treatment.

Disfiguring skin sores that may affect your nose, nasal passages, cheeks, ears, eyelids, and fingers. This is called lupus pernio (loo'pus per'nio). The sores tend to be ongoing and can return after treatment is over.

Eye Symptoms

Burning, itching, tearing, pain

Red eye

Sensitivity to light

Dryness

Floaters (i.e., seeing black spots)

Blurred vision

Reduced colour vision

Reduced visual clearness

Blindness (in rare cases).

Heart Symptoms

Shortness of breath

Swelling in your legs

Wheezing

Coughing

Irregular heartbeat, including palpitations (a fluttering feeling of rapid heartbeats) and skipped beats

Sudden loss of consciousness

Sudden death.

Joint and Muscle Symptoms

Joint stiffness or swelling—usually in your ankles, feet, and hands.

Joint pain.

Muscle aches (myalgias).

Muscle pain, a mass in a muscle, or muscle weakness.

Painful arthritis in your ankles that results from erythema nodosum. It may need treatment but usually clears up in several weeks.

Painless arthritis that can last for months or even years. It should be treated.

Bone Symptoms

Painless holes in your bones.

Painless swelling, most often in your fingers.

Anaemia that results from granulomas affecting your bone marrow. This usually should be treated.

Liver Symptoms

Fever

Fatigue

Itching

Pain in the upper right part of your abdomen, under the right ribs

Enlarged liver.

Parotid (pah-rot'id) and Other Salivary Gland Symptoms

Swelling, which makes your cheeks look puffy

Excessive dryness in your mouth and throat.

Blood, Urinary Tract, and Kidney Symptoms

Increased calcium in your blood or urine, which can lead to painful kidney stones

Confusion

Increased urination.

Nervous System Symptoms

Headaches.

Vision problems.

Weakness or numbness of an arm or leg.

Coma (rare).

Drooping of one side of your face that results from sarcoidosis affecting a facial nerve. This can be confused with Bell's palsy, a disorder that may be caused by a virus.

Paralysis of your arms or legs that results from sarcoidosis affecting your spinal cord.

Weakness, pain, or a "stinging needles" sensation in areas where many nerves are affected by sarcoidosis.

Pituitary (pi-tu'i-tar"e) Gland Symptoms (Rare)

Headaches

Vision problems

Weakness or numbness of an arm or leg

Coma (rare).

Other Symptoms

Nasal obstruction or frequent bouts of sinusitis.

Enlarged spleen, which leads to a decrease in platelets in your blood and pain in your upper left abdomen. Platelets are needed to help your blood clot.

Sarcoidosis may also cause more general symptoms, including:

Uneasiness, feeling sick (malaise), an overall feeling of ill health

Tiredness, fatigue, weakness

Loss of appetite or weight

Fever

Night sweats

Sleep problems

These general symptoms are often caused by other conditions. If you have these general symptoms but don't have symptoms from affected organs, you probably do not have sarcoidosis.

How Is Sarcoidosis Diagnosed?

Your doctor will find out if you have sarcoidosis by taking a detailed medical history and conducting a physical exam and several diagnostic tests. The purpose is to:

Identify the presence of granulomas in any of your organs

Rule out other causes of your symptoms

Determine the amount of damage to any of your affected organs

Determine whether you need treatment.

Medical History

Your doctor will ask you for a detailed medical history. He or she will want to know about any family history of sarcoidosis and what jobs you have had that may have increased your chances of getting sarcoidosis.

Your doctor may also ask whether you have ever been exposed to inhaled beryllium metal, which is used in aircraft and weapons manufacture, or organic dust from birds or hay. These things can produce granulomas in your lungs that look like the granulomas that are caused by sarcoidosis but are actually signs of other conditions.

Physical Exam

Your doctor will look for symptoms of sarcoidosis, such as red bumps on your skin; swollen lymph nodes; an enlarged liver, spleen, or salivary gland(s); or redness in your eyes. He or she will also listen for abnormal lung sounds or heart rhythm. Your doctor also will check for other likely causes of your symptoms.

Diagnostic Tests

There is no one specific test for diagnosing sarcoidosis. It is harder to diagnose sarcoidosis in some organs (e.g., heart, nervous system) than in others. Your doctor will probably conduct a variety of tests and procedures to help in the diagnosis.

These include:

Chest X Ray. A chest x ray takes a picture of your heart and lungs. It may show granulomas or enlarged lymph nodes in your chest. About 95 out of every 100 people who have sarcoidosis have an abnormal chest x ray.

Doctors usually use a staging system for chest x rays taken to detect sarcoidosis:

Stage 0: Normal chest x ray
Stage 1: Chest x ray showing enlarged lymph nodes but otherwise clear lungs
Stage 2: Chest x ray showing enlarged lymph nodes and shadows in your lungs
Stage 3: Chest x ray showing shadows in your lungs, but the lymph nodes are not enlarged
Stage 4: Chest x ray showing scars in the lung tissue.

In general, the higher the stage of the x ray, the worse your symptoms and lung function are. But there are a lot of differences among people. If your x-ray results show Stages 0, 1, 2, or 3, you may not have symptoms or need treatment, and you may get better and have normal chest x rays again over time.

Blood Tests. These tests can show the number and type of cells in your blood. They also will show whether there are increases in your calcium levels or changes in your liver, kidney, and bone marrow that can occur with sarcoidosis.

Lung Function Tests. One test uses a spirometer (spi-rom'e-ter), a device that measures how much and how fast you can blow air out of your lungs after taking a deep breath. If there is a lot of inflammation and/or scarring in your lungs, you will not be able to move normal amounts of air in and out.

Another test measures how much air your lungs can hold. Sarcoidosis can cause your lungs to shrink, and they will not be able to hold as much air as healthy lungs.

Electrocardiogram (ECG). This test will help show if your heart is affected by sarcoidosis.

Pulse Oximetry. A small clip attached to your finger tip can show how well your heart and lungs are moving oxygen into your blood.

Arterial Blood Gas Test. This test is more accurate than pulse oximetry for checking the level of oxygen in your bloodstream. Blood is taken from an artery (usually in your wrist). It is then analyzed for its oxygen and carbon dioxide levels.

Fiberoptic Bronchoscopy. In this procedure, your doctor inserts a long, narrow, flexible tube with a light on the end through your nose or mouth into your lungs to look at your airways. This tube is called a bronchoscope. You most likely would have this procedure as an outpatient in a hospital under local anaesthesia.

Bronchoalveolar Lavage (brong"ko-al-ve'o-lar lah-vaje') (BAL). During bronchoscopy, your doctor may inject a small amount of salt water (saline) through the bronchoscope into your lungs. This fluid washes the lungs and helps bring up cells and other material from the air sacs deep in your lungs where the inflammation usually starts to develop. The cells and fluid are then examined for signs of inflammation.

Biopsy. Your doctor may take a small sample of tissue from one of your affected organs. For example, when breathing tests or chest x rays show signs of sarcoidosis in your lungs, your doctor may do a fiberoptic bronchoscopy biopsy. This will help confirm the diagnosis. Your doctor inserts a tiny forceps through the bronchoscope to collect tissue that will be examined. Because the granulomas may be spread out in your lungs, the bronchoscope may miss some of them.

Biopsies of your skin and liver are sometimes done to detect granulomas in these organs.

You may have sarcoidosis in other organs as well and multiple biopsies may be necessary. However, every organ involved does not need to be biopsied for a diagnosis to be made.

Computerized Tomography (CT) Scan. This test provides a computer-generated image of your organs that has more detail than a regular chest x ray. It can provide more information about how sarcoidosis has affected an organ.

Your doctor may do a CT scan to:

Obtain more information about how much of your lung is affected by sarcoidosis.
Detect sarcoidosis in your liver. A CT scan of your abdomen will show if your liver is enlarged and if there is a pattern suggesting granulomas.

Magnetic Resonance (MR) Scan. This test is also called nuclear magnetic resonance (NMR) scanning or magnetic resonance imaging (MRI). This scan uses powerful magnets and radio waves to make images of some of your organs that your doctor doesn't want to risk doing a biopsy on. For example, an MR scan can be used to diagnose sarcoidosis in your brain, spinal cord, nerves, or heart.

Thallium and Gallium Scans. These scans are often done to see if sarcoidosis is affecting your heart. Thallium and gallium are radioactive elements. Your doctor injects a small amount of one of them into a vein in your arm. The elements collect at places in your body where there is inflammation. After awhile, your body is scanned for radioactivity. Increased radioactivity at any place may be a sign of inflammation.

This test gives information on the tissue in your body that has been affected by sarcoidosis and the amount of damage to it. But since this test shows all inflammation in your body, even inflammation caused by conditions other than sarcoidosis, it does not give a definite diagnosis of sarcoidosis.

Positron Emission Tomography (PET) Scan. This test also uses radioactive injections. It may be more sensitive than gallium in detecting areas of inflammation. Some doctors are using it instead of gallium scans.

Your doctor may not need to find every one of your organs affected by sarcoidosis, only those that cause symptoms. Often the organs affected by the condition continue to function well and don't need to be treated.

How Is Sarcoidosis Treated?

The goals of treatment are to:

Improve how the organs affected by sarcoidosis work

Relieve symptoms

Shrink the granulomas.

Treatment may shrink the granulomas and even cause them to disappear, but this may take many months. If scars have formed, treatment may not help, and you may have ongoing symptoms.

Your treatment depends on:

What symptoms you have

How severe your symptoms are

Whether any of your vital organs (e.g., your lungs, eyes, heart, or brain) are affected

How the organ is affected.

Some organs must be treated, regardless of your symptoms. Others may not need to be treated. Usually, if you don't have symptoms, you don't need treatment, and you probably will recover in time.

Drugs

The main treatment for sarcoidosis is prednisone. Prednisone is a corticosteroid, or anti-inflammatory drug. Sometimes it is used with other drugs. Sometimes other corticosteroids are used.

Prednisone almost always relieves symptoms of inflammation. If a symptom doesn't improve with prednisone treatment within a couple of months, consult your physician.

Prednisone is usually given for many months, sometimes for a year or more.

Low doses of prednisone can often relieve symptoms without causing major side effects.

When used at high doses, prednisone can cause serious side effects.

Side effects can include:

Weight gain.

Diabetes.

High blood pressure.

Mood swings (depression).

Difficulty sleeping at night.

Heartburn.

Acne.

Thinning of the skin and bones (called osteoporosis).

Cataracts.

Glaucoma.

Adrenal gland insufficiency, which occurs when these glands don't make enough of certain hormones. This requires treatment by an endocrinologist (en"do-kri-nol'o-jist), a doctor who specializes in the diagnosis and treatment of the endocrine glands. The endocrine glands include your adrenal and pituitary glands.

Aseptic (a-sep'tik) or avascular (ah-vas'ku-lar) necrosis (ne-kro'sis) of the hip, the development of cysts and hardened and dead tissue in the hip.

Your doctor can usually help you manage these side effects.

When it is time to stop taking prednisone, you should cut back slowly, with your doctor's help. This will help prevent flare-ups of sarcoidosis and allow your body to adjust to life without the drug.

You may also want to see an endocrinologist to make sure that your endocrine glands are making enough hormones. The endocrinologist may prescribe certain hormones for you to take until your endocrine glands are working well again.

Other Drugs Used To Treat Sarcoidosis

Other drugs are sometimes used to treat sarcoidosis. Your doctor may prescribe one of them if:

Your condition gets worse while you are taking prednisone

You can't stand the side effects of prednisone.

Most of these other drugs are immune system suppressants. This means that they prevent your immune system from fighting things like bacteria and viruses. As a result, you may have a greater chance of getting infections.

Most of these drugs also can cause serious side effects. Some also could increase your chances of getting cancer, especially if you take them at high doses.

You and your doctor must weigh living with the symptoms of sarcoidosis against the side effects of the drugs.

Some drugs work better than others for different people.

You may be given more than one drug.

Some drugs used to treat sarcoidosis are taken by mouth. Others are applied locally to an affected area.

Local therapy is the safest way to treat sarcoidosis. The drug is applied directly to the affected area. As a result, only small amounts of the drug reach other parts of your body.

Drugs used for local therapy include:

Eye drops

Inhaled drugs for your lungs

Skin creams.

Drugs can be used locally only if the affected area is easily reached. For instance, inhaled steroids can ease coughing and wheezing in the upper airways, but they don't seem to relieve these symptoms when the affected lung tissue is deep within your chest.

Talk with your doctor about these treatments and the side effects that may occur.

The other drugs used to treat sarcoidosis include:

Hydroxychloroquine (Plaquenil). This drug can usually help people who have sarcoidosis in the skin or a high level of calcium in their blood. This drug can irritate your stomach.

It also can cause eye problems. Before starting on this drug, you should see an ophthalmologist (of"thal-mol'o-jist), or eye doctor, for some baseline tests. Once you start taking it, you should have your eyes examined every 6 months.

Methotrexate. This drug is taken once a week by mouth or injection and usually takes up to 6 months to relieve symptoms.

This drug may cause side effects, especially if you take high doses. These include:

Nausea.
Mouth sores.
A decrease in infection-fighting white blood cells. You then have a greater chance of getting an infection. If you take this drug, you should have regular blood tests to check the levels of your white blood cells.
An allergic reaction in your lungs that goes away when you stop taking the drug. This is extremely rare.
Liver damage. This is the most serious side effect. If you take methotrexate you should be followed regularly by your physician.

If you are pregnant, you should not take this drug.

Taking folic acid can help you reduce your chances of having bad side effects from methotrexate.

Azathioprine (Imuran). This drug may work in about half of the people who have sarcoidosis. You usually take it for at least 6 months. Side effects include:

Nausea
Reduced white blood cell levels, which increases your chances of getting an infection.

This drug has caused cancer in some people, especially when they have taken it at high doses.

If you are pregnant, you should not take this drug.

Cyclophosphamide (Cytoxan). This is a very toxic drug. It is rarely used to treat sarcoidosis. It is given only to people who have serious forms of sarcoidosis, such as sarcoidosis in their central nervous system (neurosarcoidosis).

This drug is more likely to cause nausea and reduce your white blood cell levels than either methotrexate or azathioprine. Your doctor should check your white blood cell levels often while you are taking this drug to make sure you have a high enough level to fight infection.

Cyclophosphamide can also irritate your bladder. Some people who have taken it for more than 2 years have developed bladder cancer.

If you are pregnant, you should not take this drug.

Cyclophosphamide can be given intravenously (through one of your veins), which lessens some of its side effects, but this doesn't reduce the risk of cancer.

Treatments for Specific Types of Sarcoidosis

Eyes. Sarcoidosis in your eyes almost always responds well to treatment. Often, the only treatment you need is eye drops containing corticosteroids. You should have yearly eye exams, even if you think your eyes are doing well.

Spleen. Sarcoidosis can cause your spleen to become larger. This can lead to a decrease in your red or white blood cells or platelets and increase your chances of infection and blood clotting disorders. Treatment is usually given to increase the number of your blood cells and ease your pain. In rare cases, your spleen may need to be removed.

Liver. Sarcoidosis rarely causes permanent liver damage. As a result, your liver usually isn't treated unless it's causing major symptoms (e.g., fever). Drug treatment can usually reduce granulomas in your liver. Liver transplantation has been successful in those rare cases in which the condition has become worse.

Followup care includes regular blood tests to find out how well your liver is working. You should check with your doctor to find out how often you need these tests.

Nervous system. Sarcoidosis in your nervous system (neurosarcoidosis) usually needs treatment. Nerve tissue heals slowly, so treatment often takes a long time. You may need to take several drugs at high doses.

Erythema nodosum. These painful bumps on your shins often go away in weeks to months without treatment. Your doctor probably will not give you medication unless you are very uncomfortable. Aspirin or ibuprofen, an anti-inflammatory drug that you can buy without a prescription, will usually help.

Heart. Sarcoidosis in your heart is usually treated with steroids. You may also be given heart drugs to improve your heart's pumping ability or to correct a disturbed heart rhythm.

If you have a severe heart rhythm disturbance, your doctor may prescribe one of these devices:

A cardiac pacemaker, a small battery-operated device, often put under your skin, that regulates your heartbeat
A defibrillator, an implanted device that shocks your heart into a normal heartbeat or, if it has stopped, into beating.

If your heart is severely affected and doesn't respond to treatment, a transplant may be done. But this is rarely needed.

Lupus Pernio. This rash on your face, especially your cheeks and nose, can be distressing because it's in a very visible area. It often occurs with loss of your sense of smell, nasal stuffiness, and sinus infections.

Options for treatment include:

Local treatment with skin creams
Oral drugs (plaquenil or prednisone, for example)
Local injections of steroid preparations.

Lupus pernio is often treated by dermatologists, doctors who specialize in skin diseases, working with a sarcoidosis specialist.

Because sarcoidosis varies so much among different people, your doctor may find it hard to tell whether the treatment is helping.

Other Drugs Being Studied for Possible Use in Treating Sarcoidosis

Scientists also are studying drugs that are used for other conditions to see if they can help people who have sarcoidosis. These drugs include:

Etanercept (Enbrel). This drug is an immune system suppressant. It's injected under the skin to reduce symptoms of rheumatoid arthritis. It may also be used to treat psoriasis (so-ri'ah-sis) or ankylosing spondylitis (ang"ki-lo'sing spon"di-li'tis), a type of arthritis that affects the joints in the spine. Early studies suggest that it will not be useful in treating sarcoidosis, but research is ongoing.

Infliximab (Remicaide). This drug is an immune system suppressant. It's injected into a vein in your arm. It's used to treat Crohn's Disease, rheumatoid arthritis, and ankylosing spondylitis. Some studies have shown it to help sarcoidosis patients who also have lupus pernio, eye disease, or neurosarcoidosis. This drug has serious side effects but may improve lung function in some people who aren't helped by corticosteroids. More research is needed.

Pentoxifylline. This drug is an immune system suppressant. Stomach and gastrointestinal side effects are common. Early studies show that it has helped some people who have sarcoidosis in their lungs reduce their doses of prednisone while taking it. More research is needed.

Tetracycline. Tetracycline antibiotics are used to treat Lyme disease, some types of pneumonia, and acne. A few small studies suggest that they may help in treating sarcoidosis in the skin. Research is ongoing.

Thalidomide. This immune system suppressant can cause bad side effects. It is effective against other conditions that involve granulomas of the skin (e.g., leprosy, tuberculosis). Scientists are studying this drug to see if it can be used to treat sarcoidosis in the skin. More studies are needed.

What Does the Future Hold?

Scientists worldwide are trying to learn more about sarcoidosis and how to improve its diagnosis and treatment. Some recent studies have led to possible new treatments, which, in turn, are being studied. Current research includes studies of:

The agent or agents that cause sarcoidosis

Why sarcoidosis seems to act differently in people of different races

Why sarcoidosis appears in some families

How genes, passed from one generation to another, may make some people more likely than others to develop sarcoidosis

How cells act and communicate with each other to cause sarcoidosis symptoms.

Living With Sarcoidosis

You should take steps to stay healthy. This includes:

Don't smoke.

Avoid substances like dusts and chemicals that can harm your lungs.

Try to follow a healthy eating plan.

Be as active as you can but don't strain yourself.

Joining a patient support group may help you adjust to living with sarcoidosis. Talking to others who have the same symptoms can help you see how they have coped with them.

Your regular doctor may be able to diagnose and treat your sarcoidosis, but diagnosis and treatment by a doctor who specializes in sarcoidosis is recommended. If you prefer to use your regular doctor, you should see a doctor who specializes in the organs that are affected by your sarcoidosis at least once. For example, see an ophthalmologist if your eyes are affected or a pulmonologist if you have sarcoidosis in your lungs. These specialists are often found at major medical centers. They will work with your regular doctor to help make a diagnosis, develop a treatment plan, and schedule periodic exams and lab tests. .

Pregnancy

Many women give birth to healthy babies while being treated for sarcoidosis. Pregnancy usually doesn't affect the course of sarcoidosis, and you can continue corticosteroid treatment through your pregnancy. None of the other drugs are recommended for use during pregnancy.

Sometimes your sarcoidosis may get worse after the baby is delivered.

Women with severe sarcoidosis, especially if they are older, may have trouble becoming pregnant.

It's important for you to discuss this issue with your doctor. If you become pregnant, you should be sure to get both good prenatal care and regular sarcoidosis checkups during and after pregnancy.

Followup Care

Regular followup care is important, even if you aren't taking medication for your sarcoidosis. New symptoms can occur at any time, and your condition can get worse slowly, without your noticing.

Followup exams usually include:

A review of your symptoms

A physical exam

A chest x ray and CT scan

Breathing tests

An eye exam

Blood tests

An electrocardiogram (EKG).

How often you have your examinations and tests depends on:

How severe your symptoms are

Which organs were affected at diagnosis

What treatment you are using

Any complications that may develop during treatment.

You will probably need routine followup care for several years. Whether you see your regular doctor or a sarcoidosis specialist for this depends on your symptoms during the first year of followup.

Here are some examples of how your followup care can be managed. They are based on either your condition when you were diagnosed with sarcoidosis or the treatment used.

Followup After Initial Diagnosis

If at diagnosis, you have no symptoms, a normal breathing test, and an abnormal chest x ray:

You should plan on having a followup exam every 6 to12 months until your condition is stable or improving.

Your breathing test may need to be repeated. The need to repeat it depends on your symptoms and ability to be active.

If at your first followup visit, you have no new symptoms and your chest x ray is normal, you can go to your regular doctor for future followup care.

If at diagnosis, you have some symptoms, an abnormal chest x ray, but you don't need treatment:

You should plan on having a followup exam in 3 to 6 months.

If at your followup exam, your condition has gotten worse (i.e., you now have more symptoms, an abnormal x ray, or abnormal lab tests) you may need treatment.

If treatment is started, you may need followup tests more often.

Followup Based on Your Drug Treatment

If treatment is begun with prednisone:

You should be checked for the side effects of high blood pressure, too much weight gain, diabetes, loss of calcium from your bones, and pain in one or both hips.

If treatment is begun with hydroxychloroquine:

You should have an eye exam every 6 months while taking this drug.

If treatment is begun with methotrexate:

You should have blood tests every month or every other month to see if you have anaemia, low white blood cell or platelet levels, or liver inflammation.

Other Followup Tests

Depending on how serious your condition is and what organs are affected, you may also need to have certain tests done regularly.

Eye Tests

Everyone who is diagnosed with sarcoidosis, even if they don't have eye symptoms, should see an ophthalmologist (eye doctor) for eye tests. This is important because you may have eye damage even if you don't have symptoms.

These tests may include:

A slit lamp examination. Your doctor uses an instrument with a high-intensity light source to look at the front of your eyes.

A visual fields examination. Your doctor will ask you to you to look at a light through an instrument.

Inspection of your retina and optic nerve.

If you develop eye symptoms, your doctor will have you repeat the tests.

You should also have regular eye exams if you are being treated with:

Chloroquine or hydroxycholoroquine (Plaquenil)

Corticosteroids.

Breathing Tests

These tests are used to check the course of sarcoidosis in your lungs. The results are compared over time.

Blood Tests

A blood test for calcium should be done. If your calcium level is high, you probably will need to be treated. You also should not take vitamin and mineral supplements containing calcium or vitamin D, and you should avoid too much exposure to the sun.

Electrocardiogram

This test is needed to make sure that your heart is still not affected by sarcoidosis. The heart can be affected at any time if the sarcoidosis is active.

Key Points

Sarcoidosis involves inflammation that produces tiny lumps of cells called granulomas in various organs in your body. These granulomas can grow and clump together, making many large and small groups of lumps. If many granulomas form in an organ, they may affect how the organ works and cause symptoms.

Sarcoidosis can occur in almost any part of your body, although it usually starts in either your lungs or lymph nodes. It also often affects your skin, eyes, and liver.

Sarcoidosis can also affect your spleen, brain, nerves, and heart.

The course of sarcoidosis varies greatly among people. Sometimes, it's mild, and the symptoms may go away within a few years, even without treatment. But sometimes sarcoidosis slowly gets worse over the years and can cause permanent organ damage.

The cause of sarcoidosis is unknown. Doctors think that it may result when your immune system overreacts to some kind of foreign substance. Scientists also think that your immune system acts this way only if you have inherited a certain mix of genes.

Sarcoidosis affects men and women of all ages and races worldwide. It occurs mostly in people ages 20 to 40; African Americans, especially women; and people of Asian, German, Irish, Puerto Rican, and Scandinavian origin.

Many people with sarcoidosis have no symptoms. Symptoms usually depend on which organs the disease affects. Symptoms from sarcoidosis in the lungs and lymph nodes include shortness of breath, a dry cough, wheezing, and enlarged and sometimes tender lymph nodes.

Your doctor will determine if you have sarcoidosis by taking a detailed medical history and conducting a physical exam and several tests. The tests may include a chest x ray, blood and lung function tests, an electrocardiogram, magnetic resonance scan, and scans using radioactive elements.

Your doctor may also insert a long, narrow, flexible tube with a light on the end, called a bronchoscope, through your nose or mouth into your lungs to look at your airways and to obtain samples of cells and other tissue for examination under a microscope. You most likely would have this procedure as an outpatient in a hospital under local anaesthesia.

Treatment for sarcoidosis depends on your symptoms and how severe they are, whether any of your critical organs (e.g., your lungs, eyes, heart, brain) are affected, and how they are affected.

The main treatment for sarcoidosis is prednisone, a corticosteroid or anti-inflammatory drug. It's usually given for many months, sometimes even for a year or two. When used for a long time at high doses, prednisone can cause serious side effects, including diabetes, high blood pressure, depression, heartburn, acne, osteoporosis, cataracts, and glaucoma. It can also affect the body's production of certain hormones.

Other drugs may be used to treat sarcoidosis if your condition gets worse while you are taking prednisone or you can't stand its side effects. Most of these other drugs are immune system suppressants that can cause serious side effects.

Local therapy is the safest way to treat sarcoidosis. Localized drugs include eye drops, inhaled drugs for your lungs, and skin creams.

Research is being done to improve the diagnosis and treatment of sarcoidosis. Scientists are studying drugs that are used for other conditions to see if they can help people who have sarcoidosis. These drugs include several strong immune system suppressants, tetracycline antibiotics, and thalidomide.

Scientists also are conducting research to find out more about what causes sarcoidosis, why it seems to act differently in people of different races, and what genes are involved.

If you have sarcoidosis, you should take steps to stay healthy, including don't smoke, avoid substances like dusts and chemicals that can harm your lungs, follow a healthy eating plan, and be as active as you can without straining yourself.

Joining a patient support group may help you adjust to living with sarcoidosis.

Your regular doctor may be able to diagnose and treat your sarcoidosis, but diagnosis and treatment by a doctor who specializes in sarcoidosis is recommended. These specialists are often found at major medical centers. Even if you want to be treated mainly by your regular doctor, you should see a doctor who specializes in the organs that are affected by your sarcoidosis at least once. He or she can work with your regular doctor to make sure you have a good treatment plan.

If you are thinking about getting pregnant, you should talk to your doctor about how sarcoidosis may affect your pregnancy. Pregnancy usually doesn't affect the course of sarcoidosis, but it may flare up after delivery. You can continue taking corticosteroids during your pregnancy. None of the other drugs that are used to treat sarcoidosis are recommended for use then.

If you are pregnant, you should have good prenatal care and sarcoidosis checkups during and after pregnancy.

Regular followup care is important, even if you aren't taking medication, as new symptoms can occur at any time, and your condition can get worse slowly, without your noticing.