Imagine a battle in which an armys troops become confused and attack each other, rather than their enemy. In war, mistakenly attacking an ally is called friendly fire. When that nightmarish scenario happens inside the human body, its called an autoimmune disease.


In such a disease, millions of tiny white blood cells, which normally protect the body by killing outside invaders, or germs, start attacking the bodys own organs and tissues. Depending on the type of autoimmune disease, the bodys joints, skin, connective tissues, internal organs, nerves, muscles, endocrine system, and digestive system can be damaged. Such diseases can cause inflammation, change organ function, and destroy tissue.


Advancements in the understanding of autoimmune diseases in recent years have helped doctors to diagnose patients more accurately, but even now, for every patient who is diagnosed quickly with a particular disease, there are five patients who dont receive a definitive diagnosis, says Dr. Craig Wiesenhutter, of the Coeur dAlene Arthritis Clinic.


Autoimmune disease is the result of miscommunication in the bodys immune system, Wiesenhutter says. Cells are getting false information that there are bugs in tissues, then the generals inappropriately send out troops to fight a battle they shouldnt fight.


There are more than 80 types of autoimmune diseases, the U.S. Department of Health and Human Services says. Autoimmune diseases are chronic, and some afflict women far more often than men, at least in documented cases.


For instance, rheumatoid arthritis, which is the most common autoimmune joint disease, strikes women three times as often as men, Wiesenhutter says. Lupus, a connective-tissue autoimmune disease that can harm the skin, joints, kidneys, and other organs, occurs in women nine times as often as in men, he says.


Other common autoimmune connective-tissue diseases are scleroderma, which causes the skin and internal organs to thicken, and Sjogrens Syndrome, which attacks the bodys moisture-producing glands, says Dr. Gary Craig, of Spokanes Arthritis Northwest PLLC. Both diseases afflict women more often than men.


Perhaps the most common neuromuscular autoimmune disease is multiple sclerosis, or MS, which strikes the central nervous system, says the U.S. Department of Health and Human Services. Common autoimmune diseases of the endocrine system include hypothyroidism, Graves disease, and Type 1 Diabetes.


Diagnosing an autoimmune disease is difficult partly because the symptoms of different diseases often overlap and mimic each other, Craig says. In addition, since the bodys immune system is constantly changing in response to new threats, autoimmune diseases evolve as well. A patient whose affliction might not be clear when a disease first strike can develop into a full-blown case of the disease in two or three years, he says. Diseases can go into remission or flare up, and over time a patient can develop additional autoimmune diseases.


Ive watched people smolder away with a disease for 25 years, while for others, things can change overnight, Wiesenhutter says. The immune system is mutating all the time.


When patients who have such diseases first arrive at a doctors office, typically they complain about fatigue and joint pain and swelling. Some patients who are convinced they have rheumatoid arthritis actually have a chronic pain disorder called fibromyalgia, which isnt an autoimmune disease, but has some of the same symptoms, Craig says. Its thought to result from a reduced production of new neurotransmitters that control feelings of depression and pain tolerance, he says.


Fibromyalgia people used to be told it was all in their head, but its going to pan out as something thats very important, Wiesenhutter says. With all of these diseases, people shouldnt feel theyre hypochondriacs, because if youre healthy you shouldnt have pain and fatigue every day.


Doctors rely heavily on physical examinations and a patients medical and family history to make a diagnosis, Craig says. Rather than focusing solely on joint pain, a doctor will investigate a patients other systems and organ functions. Patients also undergo laboratory tests and scans. With rheumatoid arthritis, X-rays are helpful because they show damaged bones and joints.


Patients who suffer autoimmune-related symptoms also undergo a broad screening to rule out any other diseases, Wiesenhutter says. For example, Hepatitis C symptoms, at their outset, look very similar to those of rheumatoid arthritis, he says. Wiesenhutter says he now sees at least one new patient every month who turns out to have Hepatitis C instead of arthritis.


Despite the difficulty in diagnosing autoimmune diseases, its still possible to place the maladies in a category of disease, which helps when deciding on a treatment, he says.


It shows that medicine is an art rather than a science to some extent, because people never present like the textbook, says Dr. Anne Lee, of Spokanes Rockwood Clinic PS. To patients, she says,Its important to not expect youre going to get a diagnosis the first time you show up, because you might not.


Lee, Craig, and Wiesenhutter all say that while a lack of a precise diagnosis can be frustrating, new drugs have emerged that are helping to improve disease management and in some cases to stop the progression of a disease. Some drugs are used to target certain diseases, while others cover a broader spectrum.


Some of these drugs are life changing, Lee says. I do think theres hope out there for people with autoimmune diseases.


To treat joint pain, doctors typically prescribe strong anti-inflammatory drugs, Craig says. During flare-ups, steroids are used as a short-term rescue therapy, but typically arent as a long-term treatment, he says.


Disease modifying anti-rheumatic drugs (DMARDs) can help slow or stop damage to joints from autoimmune diseases. Plaquenil, a drug used to treat malaria, is a milder DMARD that reduces joint pain, rashes, and other problems, and may deter new symptoms, he says. TNF inhibitors, which include Enbrel, Remicade, and Humira, are a new category of arthritis drugs that appear to prevent joint damage better than older drugs. Such drugs also, however, carry a greater risk of infection, he says.


Another group of DMARD drugs, known as immunosuppressants, include methotrexate, cytoxan, and cellcept, among others, and are the most powerful drugs used for connective-tissue disease therapy, Craig says. Such drugs, however, can lower resistance to infection and cause toxicity, he says.


Rituxan, a drug that has been used to treat lymphomas, was approved by the U.S. Food and Drug Administration a year ago for use in treating rheumatoid arthritis, and now is used to treat lupus, he says.


For patients with neuromuscular or endocrine autoimmune diseases, specialists in those fields oversee treatment, which can involve anti-inflammatory drugs, insulin injections, and thyroid hormone replacement or removal, among others, the U.S. Department of Health and Human Services says.


Fatigue is a major problem for many autoimmune patients, both because the body is fighting itself and because sore joints disrupt sleep, Craig says. As a result, patients sometimes stop exercising, which worsens fatigue. Lee, Craig, and Wiesenhutter all emphasize the need to exercise as one of the most important aspects of disease management.


Stress is a known trigger for autoimmune diseases, so doctors also advise that patients seek to reduce their stress. Infections also can prompt flare-ups.


People can have good disease control, and then all hell will break loose, Craig says.


The causes of autoimmune diseases are unknown. So are the reasons why some of them strike women so often, but hormones are considered a contributing factor, Lee says.


Craig says one new theory is that women might be more susceptible to autoimmune diseases because they retain cells from their children that their bodies assimilated during pregnancy. The womans immune cells become confused about whether to kill these foreign cells, which perhaps triggers an autoimmune response. Other possible triggers for autoimmune disease could be viral infections and genetic factors that predispose people to such disorders, he says.


Awareness of autoimmune disorders has been increasing, resulting in more patients seeking medical help and more primary-care physicians referring patients to specialists, Lee says. Women, in particular, often dismiss pain and fatigue as the result of taking care of their kids, and dont talk to their doctors about it. Catching autoimmune diseases early is important, since some progress faster than others, and the path to diagnosis can be long, she says.


Contact Emily Brandler at (509) 344-1265 or via e-mail at emilyb@spokanejournal.com.