Diagnostic Assessment — Chronic Fatigue Syndrome
Example 1 of 1 · fictitious patient (Veteran AE)
Diagnostic Assessment
Chronic Fatigue Syndrome
BOP Code: 106 of 2021 (Chronic Fatigue Syndrome)
RH Code: 105 of 2021 (Chronic Fatigue Syndrome)
ADF History
Veteran AE, date of birth 04 October 1966, Australian Army, Vehicle Mechanic (Royal Australian Electrical and Mechanical Engineers), later Warrant Officer Class 2 and maintenance manager, enlisted as an Army apprentice 18 January 1982, medically discharged 14 November 2014. Operational service: Somalia, 12 January 1993 to 20 May 1993 (warlike); East Timor, 25 September 1999 to 10 February 2000 (warlike); Afghanistan, 06 February 2012 to 28 July 2012 (warlike).
Occupational History
Army vehicle mechanics maintain, repair and recover wheeled and tracked vehicles in workshops and in the field. The work involves heavy lifting, awkward postures under vehicles, exposure to fuels, solvents, exhaust and dust, and long hours in field conditions with limited hygiene, communal ablutions and field-prepared food and water. Recovery teams deploy with combat elements to retrieve damaged and bogged vehicles, often under threat.
In field training areas in northern and central Australia, soldiers live and work among cattle yards, paddocks and dusty tracks, with exposure to animal products, ticks, mosquitoes and contaminated water. On operations, maintenance recovery teams travel with patrols, work at the site of improvised explosive device strikes and are exposed to rocket and mortar attack on forward bases, with the associated risk of witnessing death and serious injury.
History
Veteran AE, a vehicle mechanic and warrant officer in the Australian Army, was abused as a 15-year-old Army apprentice and, in 2012, led a maintenance recovery team on warlike service in Afghanistan, where he came under attack and acquired Giardia infection. He developed chronic fatigue syndrome on 10 September 2012 with acute Q fever acquired on a field exercise in Queensland, and the condition worsened in 2013 when appropriate management was not provided.
Timeline
- 23 Sep 1982 — A health record from the Army apprentice school documented bruising to the back and buttocks and a disclosure by the 15-year-old apprentice of repeated beatings and sexual assault by an adult staff member and older apprentices since February 1982. He was moved to another accommodation block. The abuse was later reported to a Defence abuse response process, which accepted the account. "apprentice, disclosed assaults, bruising"
- 14 Apr 2012 — On warlike service in Uruzgan Province, Afghanistan, the veteran's recovery vehicle came under small arms and rocket-propelled grenade fire while recovering a vehicle damaged by an improvised explosive device. A grenade struck the vehicle beside his and he took cover for 40 minutes before the patrol withdrew. He reported being certain he would be killed. Rocket attacks on his forward operating base occurred several times a week throughout the deployment. "contact during recovery, RPG fire"
- 23 Jun 2012 — After an improvised explosive device destroyed an Afghan National Army vehicle, the veteran's team recovered the wreck. He saw two Afghan soldiers killed and helped lift a third, critically injured, onto a stretcher, and later cleared human remains from the vehicle before it was towed. Post-incident he was seen by the unit medical officer, who recorded acute stress symptoms that settled over three weeks. "IED strike, cleared remains"
- 02 Aug 2012 — At return-to-Australia screening the veteran reported loose stools, bloating and sulphurous belching since 18 July 2012 at the forward operating base, where water was drawn from a contaminated bore after a purification unit failed. Stool PCR was positive for Giardia lamblia. He was treated with a single dose of tinidazole and returned to duty after leave. "Giardia PCR positive, tinidazole"
- 14 Sep 2012 — During a peacetime field exercise in a central Queensland training area, where his workshop was set up beside cattle yards in dusty calving paddocks from 20 August 2012, he developed abrupt fever to 39.4 degrees, drenching sweats, severe headache, myalgia and overwhelming exhaustion from 10 September 2012. He was evacuated to the base health centre. Liver enzymes were raised, Coxiella burnetii phase II IgM was positive, and repeat stool PCR was again positive for Giardia lamblia. He had not been vaccinated against Q fever. "acute Q fever, Giardia persisting"
- 05 Oct 2012 — Convalescent serology showed a fourfold rise in Coxiella burnetii phase II IgG, confirming acute Q fever. Doxycycline was given for 14 days and nitazoxanide for the persisting giardiasis, with a negative stool test on 30 October 2012. The fever settled, but he remained exhausted after minimal activity, slept 12 hours without feeling refreshed and could not complete a half-day in the workshop. "Q fever confirmed, exhaustion persisting"
- 21 Mar 2013 — An infectious diseases physician diagnosed chronic fatigue syndrome after six months of severe, persisting fatigue not relieved by rest and worsened by exertion, with post-exertional malaise, unrefreshing sleep, poor concentration and memory, myalgia, arthralgia, new daily headaches and tender cervical nodes. Blood tests, echocardiography, polysomnography, MRI brain and a psychiatric assessment excluded other causes. The Bell disability scale score was 50. "chronic fatigue syndrome, Bell 50"
- 18 Nov 2013 — After his chain of command declined a specialist referral for graded management and required him to complete a two-week field exercise in October 2013, the veteran was housebound, spending most of the day in bed and needing help to shower. The Bell disability scale score had fallen from 50 to 20. He was placed on sick leave and referred to a medical employment classification review. "housebound, Bell 20, sick leave"
Symptoms
At onset the veteran had an abrupt febrile illness with sweats, headache, muscle aches and profound exhaustion. When the fever settled the exhaustion persisted: he slept 12 hours a night without feeling refreshed, could not concentrate on technical manuals, lost his train of thought in conversations, and after any physical effort was bedbound for two to three days with muscle and joint pain, headaches, tender neck glands and a recurrent sore throat.
After the worsening in late 2013 he became largely housebound. He now manages about two hours of light activity a day, uses a shower chair, does not drive more than 20 minutes, and relies on his wife for shopping and household tasks. Any attempt at sustained exertion is followed by several days of crash with pain and cognitive slowing.
Imaging
- 05 Oct 2012 — Transthoracic echocardiogram: "Structurally normal heart valves with no vegetations. Normal biventricular function."
- 08 Oct 2012 — Ultrasound abdomen: "Mild hepatomegaly with normal echotexture, consistent with resolving Q fever hepatitis. No focal lesion."
- 12 Feb 2013 — MRI brain: "Normal study. No white matter lesions, no structural abnormality."
Onset Date
The most likely date of onset of this condition is 10 Sep 2012.
At that date the veteran was serving full time as a warrant officer and maintenance manager on a peacetime field exercise in a central Queensland training area, six weeks after returning from warlike service in Afghanistan. His field workshop had been set up beside cattle yards in calving paddocks since 20 August 2012. On 10 September 2012 he developed the abrupt fever and overwhelming exhaustion of acute Q fever, while still infected with the Giardia lamblia acquired in Afghanistan, and the fatigue never resolved.
This date is appropriate because his post-deployment health assessment of 02 August 2012 and his fitness test of 15 August 2012 recorded normal energy and full physical capacity, and the first presentation with the illness was on 14 September 2012. The new and definitive onset of severe fatigue dates from 10 September 2012 and persisted for more than 6 consecutive months, satisfying the definition. The date falls within uninterrupted full-time service.
For the acute infection factors, both Coxiella burnetii and Giardia lamblia infection were present on 10 September 2012: Q fever was confirmed by phase II IgM and a fourfold IgG rise, and Giardia was positive on stool PCR on 02 August and 14 September 2012. For the hostile environment factor, the 6 months before onset run from 10 Mar 2012 to 10 Sep 2012; the veteran was on warlike service at a forward operating base under regular rocket attack and went on combat patrols from 10 March to 28 July 2012, more than 20 weeks. For the stressor factors, the 1 year before onset runs from 10 Sep 2011 to 10 Sep 2012, and contains the contact of 14 April 2012 and the improvised explosive device strike of 23 June 2012. The childhood abuse occurred in 1982, long before onset.
For the worsening, the documented worsening is 18 Nov 2013, when the Bell disability scale score had fallen from 50 to 20 after specialist management was refused and he was required to complete a field exercise in October 2013.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Chronic Fatigue Syndrome (ICD-10-AM G93.3), also known as myalgic encephalomyelitis, under the Statements of Principles concerning chronic fatigue syndrome, Balance of Probabilities No. 106 of 2021 and Reasonable Hypothesis No. 105 of 2021.
Chronic fatigue syndrome is a disabling illness defined by a new and definite onset of severe fatigue that is not relieved by rest, is worsened by physical or mental exertion, persists for at least six months and substantially reduces daily activity, accompanied by symptoms such as post-exertional malaise, unrefreshing sleep, impaired memory and concentration, muscle and joint pain, headaches, tender lymph nodes and sore throat. Other medical and psychiatric causes of fatigue must be excluded. A well-recognised pattern is onset after an acute infection, particularly Q fever, Epstein-Barr virus and Ross River virus, and the illness is also associated with severe stress and trauma.
The diagnosis followed the veteran's childhood abuse as an Army apprentice, his 2012 warlike service in Afghanistan with exposure to combat, rocket attack and death, and Giardia infection acquired on that deployment. It began on 10 September 2012 with acute Q fever acquired on a field exercise, was diagnosed on 21 March 2013 and worsened in late 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
10 September 2012.
When did the veteran first present to a health / medical provider for this condition?
14 September 2012.
When was the condition confirmed / formally diagnosed?
21 March 2013.
When did the veteran first present to you (or your practice) for this condition?
08 April 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made by an infectious diseases physician on 21 March 2013, applying criteria equivalent to those adopted in the Statement of Principles. The veteran had a new and definite onset of severe fatigue on 10 September 2012, not improved by bed rest and worsened by physical and mental exertion, persisting for more than 6 consecutive months, not due to ongoing exertion, and substantially interfering with his work and daily activities. He had seven of the eight listed symptoms concurrently: post-exertional malaise lasting more than 24 hours, unrefreshing sleep, impaired short-term memory and concentration, muscle pain, joint pain without swelling, new daily headaches and tender cervical lymph nodes, none of which preceded the fatigue.
Other causes of fatigue were excluded: full blood count, iron studies, thyroid function, cortisol, coeliac serology, HbA1c, liver and renal function and inflammatory markers were normal after the acute illness; echocardiography excluded Q fever endocarditis; polysomnography excluded sleep apnoea; MRI brain was normal; and a psychiatrist found no depressive, anxiety, alcohol or substance use disorder (PHQ-9 score 4). The Bell disability scale score was 50 at diagnosis and 20 at the documented worsening on 18 November 2013.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 10 September 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the field exercise in Queensland where the Q fever was acquired. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan from 06 February to 28 July 2012, where he lived in a hostile environment, experienced severe traumatic events and acquired Giardia infection.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Chronic Fatigue Syndrome, No. 106 of 2021
Causative factors
Factor 9(1): having an acute infection from the specified list of infections at the time of the clinical onset of chronic fatigue syndrome; — MET
- The veteran had acute Q fever (Coxiella burnetii) at the time of onset on 10 September 2012. Coxiella burnetii phase II IgM was positive on 14 September 2012 and phase II IgG rose fourfold by 05 October 2012, with fever, hepatitis and hepatomegaly. The infection was acquired on a peacetime field exercise in a central Queensland training area, where his workshop was set up beside cattle yards in dusty calving paddocks from 20 August 2012, an exposure that arose directly from his duties. He had not been offered Q fever vaccination. The fatigue began with the acute infection and never resolved.
Worsening factors
Factor 9(2): inability to obtain appropriate clinical management for chronic fatigue syndrome. — MET
- After the diagnosis on 21 March 2013 the infectious diseases physician recommended referral to a specialist fatigue service for activity pacing and graded management and a period of modified duties. His chain of command declined the referral, citing cost and the absence of a Defence-contracted service, and in October 2013 he was required to complete a two-week field exercise. The condition worsened, with the Bell disability scale score falling from 50 to 20 by 18 November 2013. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Chronic Fatigue Syndrome, No. 105 of 2021
Causative factors
Factor 9(1): having an acute infection from the specified list of infections at the time of the clinical onset of chronic fatigue syndrome; — MET
- Giardia lamblia, on the Reasonable Hypothesis specified list, was acquired on warlike service in Afghanistan, where the forward operating base drew water from a contaminated bore after its purification unit failed. Symptoms began on 18 July 2012, stool PCR was positive on 02 August 2012, a single dose of tinidazole failed, and repeat stool PCR on 14 September 2012 was again positive, so the infection was active at onset on 10 September 2012. It cleared only after nitazoxanide, with a negative stool test on 30 October 2012. Acute Q fever, also on the list, was present at onset as well.
Factor 9(2): living or working in a hostile or life-threatening environment for a period of at least 4 weeks within the 6 months before the clinical onset of chronic fatigue syndrome; — MET
- From 06 February to 28 July 2012 the veteran was on warlike service at a forward operating base in Uruzgan Province, which came under rocket attack several times a week, and he went on combat patrols with his maintenance recovery team to recover vehicles struck by improvised explosive devices. The part of this service within the 6 months before onset, from 10 March to 28 July 2012, lasted more than 20 weeks, well over the 4 weeks required.
Factor 9(3): experiencing severe childhood abuse before the clinical onset of chronic fatigue syndrome; — MET
- From February to September 1982, while he was a 15-year-old Army apprentice, the veteran was repeatedly beaten and sexually assaulted by an adult staff member and older apprentices, documented in his apprentice school health record of 23 September 1982 and accepted by a Defence abuse response process. The abuse was perpetrated by an adult working with him while he was under 16, in the course of his service, and occurred long before onset. Its effect on his stress response was compounded by the traumatic events of his warlike service in 2012.
Factor 9(4): experiencing a category 1A stressor within the 1 year before the clinical onset of chronic fatigue syndrome; — MET
- On 14 April 2012, on warlike service in Afghanistan, his recovery team came under small arms and rocket-propelled grenade fire, and a grenade struck the vehicle beside his. He took cover for 40 minutes and believed he would be killed. This was a life-threatening event five months before onset, within the 1 year from 10 September 2011 to 10 September 2012.
Factor 9(5): experiencing a category 1B stressor within the 1 year before the clinical onset of chronic fatigue syndrome; — MET
- On 23 June 2012, on warlike service, the veteran saw two Afghan soldiers killed by an improvised explosive device, helped lift a critically injured soldier onto a stretcher and cleared human remains from the destroyed vehicle. He was an eyewitness to persons being killed and critically injured and participated in the clearance of corpses and a critically injured casualty, less than three months before onset.
Worsening factors
Factor 9(6): inability to obtain appropriate clinical management for chronic fatigue syndrome. — MET
- The Giardia infection acquired on warlike service could not be diagnosed or treated at the forward operating base, which had no laboratory, and was undertreated on return, so it remained active when the fatigue began. After the diagnosis on 21 March 2013 the recommended specialist fatigue management and modified duties were refused, and he was required to complete a field exercise in October 2013. The Bell disability scale score fell from 50 to 20 by 18 November 2013.
The % contribution of the causes is 100% and significant.
Sequelae
The chronic fatigue syndrome is a sequela of the acute Q fever acquired on a peacetime field exercise and of the Giardia infection acquired on warlike service in Afghanistan, both accepted infections arising from his duties. In turn, the chronic fatigue syndrome has caused deconditioning, loss of employment through medical discharge on 14 November 2014 and reduced capacity for household and community activities.
Unintended Consequence
Not met. No treatment provided or funded by the Commonwealth caused the chronic fatigue syndrome. The refusal of specialist management and the requirement to complete a field exercise are addressed under inability to obtain appropriate clinical management.
Inability to Attain Appropriate Medical Management
MET. After chronic fatigue syndrome was diagnosed on 21 March 2013, the treating infectious diseases physician recommended referral to a specialist fatigue service for activity pacing and graded management, with modified duties. The referral was declined and in October 2013 the veteran was required to complete a two-week field exercise, after which his Bell disability scale score fell from 50 to 20 and he became housebound. The Giardia infection acquired on warlike service had also gone undiagnosed at the forward operating base and was undertreated on return. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the refusal of recommended specialist management and the imposition of duties contrary to medical advice amount to an inability to obtain appropriate clinical management. The six-month interval between onset in September 2012 and the specialist diagnosis in March 2013 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 23 Sep 1982, Health record, Medical Officer, Army apprentice school
- 14 Apr 2012, Incident report and post-contact health record, Unit Medical Officer, Afghanistan
- 23 Jun 2012, Post-incident health record, Unit Medical Officer, Afghanistan
- 02 Aug 2012, Return to Australia psychological and medical screening, Medical Officer
- 15 Aug 2012, Physical fitness assessment record, Unit
- 14 Sep 2012, Outpatient health record and pathology, Medical Officer, Garrison health centre
- 05 Oct 2012, Serology, echocardiogram and infectious diseases consultation, Infectious diseases physician
- 08 Oct 2012, Ultrasound abdomen, Radiologist
- 12 Feb 2013, MRI brain, Radiologist
- 28 Feb 2013, Diagnostic polysomnography report, Sleep physician
- 07 Mar 2013, Psychiatric assessment, Consultant psychiatrist
- 21 Mar 2013, Specialist consultation, Infectious diseases physician
- 18 Nov 2013, Outpatient health record, Medical Officer, Garrison health centre
- Statement of Principles concerning Chronic Fatigue Syndrome (Balance of Probabilities) No. 106 of 2021, Repatriation Medical Authority
- Statement of Principles concerning Chronic Fatigue Syndrome (Reasonable Hypothesis) No. 105 of 2021, Repatriation Medical Authority
