Diagnostic Assessment — Hypothyroidism
Example 1 of 1 · fictitious patient (Veteran CC)
Diagnostic Assessment
Hypothyroidism
BOP Code: 4 of 2022 (Hypothyroidism)
RH Code: 3 of 2022 (Hypothyroidism)
ADF History
Veteran CC, date of birth 05 May 1978, Australian Army, Communications Systems Operator (Signaller), enlisted 14 January 1997, medically discharged 30 November 2016. Operational service: East Timor, 20 September 1999 to 28 February 2000 (warlike); Afghanistan, 01 August 2010 to 08 January 2011 (warlike, ended by aeromedical evacuation); Middle East Area of Operations, 01 October 2013 to 14 February 2014 (warlike, ended by aeromedical evacuation).
Occupational History
As a signaller the veteran deployed with field headquarters and patrol bases, operating and maintaining radio and satellite equipment in vehicles and shelters, often for long periods away from main bases. Field postings meant living on combat ration packs and locally sourced food with non-iodised salt, drinking water treated with iodine purification tablets, and working long shifts in heat and cold.
Deployed personnel were exposed to motor vehicle accidents, emergency field medical care, extreme cold during winter operations in mountainous areas, and traumatic events. In forward locations specialist endocrine care, thyroid function testing and reliable resupply of prescribed medication were frequently unavailable.
History
Veteran CC, a signaller in the Australian Army, developed hypothyroidism that first presented as myxoedema coma on warlike service in Afghanistan on 06 January 2011, eleven months after childbirth complicated by Sheehan syndrome. It followed postpartum thyroiditis, amiodarone and iodinated contrast exposure, and a background of radiotherapy, radioactive iodine, hemithyroidectomy, sarcoidosis, thyroid carcinoma and other conditions, and it worsened with a second myxoedema coma on warlike service in the Middle East on 12 February 2014.
Timeline
- 11 Dec 1999 — During warlike service in East Timor the veteran was a passenger in a military vehicle that rolled on a mountain road, killing the driver. She sustained a ruptured spleen and was transfused four units of locally collected blood at a field hospital before splenectomy. A psychiatrist later diagnosed posttraumatic stress disorder related to the accident, and quetiapine 200 mg at night was commenced in 2006. Hepatitis C infection, acquired from the emergency transfusion, was confirmed in 2001 and remained chronic. "vehicle rollover, transfused, splenectomy"
- 14 Aug 2007 — The veteran had received mantle field radiotherapy of 36 Gy for Hodgkin lymphoma in 2003, with the thyroid in the field, and radioactive iodine-131 for Graves' hyperthyroidism in 2006 after carbimazole. A gastric stromal tumour was resected in 2005. On 14 August 2007 a left hemithyroidectomy was performed for a follicular adenoma, and the specimen showed non-caseating granulomas. Systemic sarcoidosis with thyroid involvement was confirmed in 2008. She remained euthyroid without replacement. "left hemithyroidectomy, sarcoid granulomas"
- 04 Mar 2010 — The veteran gave birth on 10 February 2010, complicated by a postpartum haemorrhage of 2.8 litres. Endocrine testing showed ACTH deficiency and a blunted TSH response to TRH, consistent with Sheehan syndrome, and hydrocortisone was commenced. Thyroid ultrasound and fine-needle aspiration confirmed a 7 mm papillary carcinoma in the right lobe, placed under active surveillance. BMI 33. "Sheehan syndrome, papillary microcarcinoma"
- 22 Jul 2010 — At her pre-deployment medical, after a painless thyrotoxic phase of postpartum thyroiditis in June 2010, thyroid function had returned to normal: TSH 1.9 mU/L and free T4 14 pmol/L. Thyroid peroxidase antibodies were negative. eGFR was 52 mL/min/1.73 m2 from sarcoid-related hypercalcaemic nephropathy, and BMI 33. She had taken minocycline 100 mg daily since 01 April 2010 for papulopustular rosacea. "TSH 1.9, free T4 14"
- 28 Dec 2010 — On warlike service in Afghanistan the veteran had lived on ration packs and local food with non-iodised salt from August, and urinary iodine was 64 micrograms per litre on 20 October 2010. Amiodarone 200 mg daily was commenced on 15 November 2010 for recurrent atrial fibrillation, and on 20 December 2010 she had a CT pulmonary angiogram with iodinated contrast. Urinary iodine on 28 December 2010 was 1,850 micrograms per litre. She was drinking water treated with iodine tablets at a patrol base. "urinary iodine 1,850, amiodarone"
- 06 Jan 2011 — Thirty hours after being stranded overnight in freezing conditions when her vehicle broke down on 04 to 05 January 2011, and with a developing right lower lobe pneumonia, the veteran was found drowsy and confused. At the role 3 hospital her GCS was 9, temperature 31.8 degrees, heart rate 42, sodium 124 mmol/L and glucose 2.9 mmol/L. TSH was 11 mU/L, inappropriately low for a free T4 below 3 pmol/L. An intensivist diagnosed myxoedema coma and commenced intravenous thyroid hormone and hydrocortisone. "myxoedema coma, GCS 9"
- 24 Feb 2011 — After aeromedical evacuation an endocrinologist confirmed hypothyroidism with combined primary and central components, due to postpartum and amiodarone-induced thyroiditis in a gland reduced by radiotherapy, radioactive iodine and hemithyroidectomy, with TSH deficiency from Sheehan syndrome. Levothyroxine 125 micrograms daily was commenced and titrated. "combined primary and central hypothyroidism"
- 12 Feb 2014 — On warlike service in the Middle East, eleven months after the birth of her second child on 15 March 2013, the veteran's levothyroxine supply ran out on 02 February 2014 and could not be resupplied. Pneumonia with septicaemia was diagnosed on 10 February 2014, and 36 hours later she was found obtunded with hypothermia, bradycardia and hyponatraemia. A second myxoedema coma was diagnosed, with free T4 below 3 pmol/L. Her replacement dose rose from 150 to 225 micrograms daily after recovery. "second myxoedema coma, supply exhausted"
Symptoms
Before onset the veteran had several weeks of fatigue, cold intolerance, weight gain, constipation, a hoarse voice and dry skin, which she attributed to the deployed conditions. At onset she had drowsiness progressing to confusion and reduced consciousness, with hypothermia, slow pulse, low sodium and low blood glucose.
She now reports persistent fatigue, cold intolerance, slowed thinking and poor concentration, weight gain and low mood despite replacement, with frequent dose adjustments, and she carries an emergency plan for hydrocortisone and thyroid hormone.
Imaging
- 04 Mar 2010 — Thyroid ultrasound and MRI pituitary: "Absent left thyroid lobe after hemithyroidectomy. Small, heterogeneous right lobe with a 7 mm hypoechoic nodule with microcalcifications (fine-needle aspiration: papillary carcinoma). Pituitary small with partial empty sella, consistent with Sheehan syndrome."
- 20 Dec 2010 — CT pulmonary angiogram with iodinated contrast: "No pulmonary embolus. Bilateral hilar lymphadenopathy consistent with sarcoidosis. Small, heterogeneous right thyroid lobe."
- 20 Jan 2014 — CT chest with iodinated contrast: "No pulmonary embolus. Stable hilar lymphadenopathy. Small, hypoenhancing right thyroid lobe with stable 7 mm nodule."
- 08 Apr 2014 — Thyroid ultrasound: "Small, diffusely hypoechoic and hypovascular right lobe consistent with destructive thyroiditis. Stable 7 mm papillary carcinoma under surveillance."
Onset Date
The most likely date of onset of this condition is 06 Jan 2011.
At that date the veteran was on warlike service in Afghanistan as a signaller at a patrol base, eleven months after childbirth. Thirty hours after being stranded overnight in freezing conditions, and with an evolving pneumonia, she was found with reduced consciousness, hypothermia, bradycardia, hyponatraemia and hypoglycaemia, and myxoedema coma was diagnosed the same day. The hypothyroidism first presented as myxoedema coma.
This date is appropriate because her pre-deployment thyroid function on 22 July 2010 was normal, and the deficiency of thyroid hormone was first confirmed when she presented on 06 January 2011. The earlier nonspecific symptoms on deployment were not investigated, and the date of the first presentation is the date on which the condition is established.
For the BoP iodine, contrast and drug factors, the 3 months before onset run from 06 Oct 2010 to 06 Jan 2011; the RH equivalents use the 6 months from 06 Jul 2010 to 06 Jan 2011. Her urinary iodine of 64 micrograms per litre on 20 October 2010, the contrast CT of 20 December 2010, the urinary iodine of 1,850 micrograms per litre on 28 December 2010, amiodarone from 15 November 2010 (7 weeks and 3 days) and nightly quetiapine all fall within both windows. For minocycline, the 9 months before onset run from 06 Apr 2010 to 06 Jan 2011, and she took it continuously from 01 April 2010. For amiodarone, the 1 year before onset runs from 06 Jan 2010 to 06 Jan 2011. For postpartum, 12 months after the birth on 10 Feb 2010 run to 10 Feb 2011. For obesity, the 5 years before onset run from 06 Jan 2006 to 06 Jan 2011, and her BMI was 30 or more from 2004. For the myxoedema coma factor, the 48 hours before onset run from 06 Jan 2011 back to 04 Jan 2011, which contain the cold exposure and the pneumonia.
For the worsening factors, the documented worsening was the second myxoedema coma on 12 Feb 2014. The 3 months before it run from 12 Nov 2013 to 12 Feb 2014 and the 6 months from 12 Aug 2013 to 12 Feb 2014; the 9 months for minocycline run from 12 May 2013; the 1 year for amiodarone from 12 Feb 2013; and the 12 months postpartum after the birth on 15 Mar 2013 run to 15 Mar 2014. The 48 hours before the worsening contain the diagnosis of pneumonia with septicaemia on 10 Feb 2014.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Hypothyroidism, combined primary and central, first presenting as myxoedema coma (ICD-10-AM E03.8, with myxoedema coma E03.5), under the Statements of Principles concerning hypothyroidism, Balance of Probabilities No. 4 of 2022 and Reasonable Hypothesis No. 3 of 2022.
Hypothyroidism is a functional disorder in which there is a deficiency of thyroid hormone producing clinical symptoms and signs or warranting treatment. Primary hypothyroidism results from failure of the thyroid gland, from thyroiditis, iodine imbalance, drugs, radiation, surgery or infiltrative disease. Central hypothyroidism results from deficient pituitary TSH, for example after pituitary infarction from postpartum haemorrhage. Symptoms include fatigue, cold intolerance, weight gain, constipation, voice change and dry skin. Myxoedema coma is the life-threatening decompensated form, with reduced consciousness, hypothermia, bradycardia, hyponatraemia and hypoglycaemia, usually triggered by an acute event such as infection, cold exposure or interruption of treatment. Hashimoto thyroiditis is excluded from these instruments, and her thyroid antibodies were negative.
The condition first presented as myxoedema coma on warlike service in Afghanistan on 06 January 2011, was confirmed by an endocrinologist on 24 February 2011, and worsened with a second myxoedema coma on warlike service in the Middle East on 12 February 2014.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
06 January 2011.
When did the veteran first present to a health / medical provider for this condition?
06 January 2011.
When was the condition confirmed / formally diagnosed?
06 January 2011.
When did the veteran first present to you (or your practice) for this condition?
03 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 on 06 January 2011 by an intensivist at a role 3 hospital, on a free T4 below 3 pmol/L with an inappropriately low TSH of 11 mU/L, together with reduced consciousness, hypothermia of 31.8 degrees, bradycardia, hyponatraemia and hypoglycaemia. This meets the Statement of Principles definition of hypothyroidism, a deficiency of thyroid hormone producing clinical symptoms and signs and warranting treatment, including primary and central forms, and the dictionary definition of myxoedema coma.
An endocrinologist confirmed combined primary and central hypothyroidism on 24 February 2011. Thyroid peroxidase antibodies were negative, excluding Hashimoto thyroiditis, and the severity and persistence of the deficiency exclude subclinical hypothyroidism and sick euthyroid syndrome. The worsening was confirmed by a second myxoedema coma on 12 February 2014 and a 50 per cent increase in her replacement dose.
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 06 January 2011, after 1 July 2004, during warlike service in Afghanistan. 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. The Reasonable Hypothesis instrument applies to her warlike service in East Timor in 1999 and 2000, where she acquired posttraumatic stress disorder and hepatitis C, in Afghanistan in 2010 and 2011, where the condition began, and in the Middle East in 2013 and 2014, where it worsened.
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 Hypothyroidism, No. 4 of 2022
Causative factors
Factor 9(1): having iodine deficiency within the 3 months before the clinical onset of hypothyroidism; — MET
- From August 2010 the veteran lived on ration packs and local food prepared with non-iodised salt, and her urinary iodine on 20 October 2010 was 64 micrograms per litre, below the 100 micrograms per litre in the definition. This was within the 3 months before onset, from 06 October 2010 to 06 January 2011, and arose from deployed feeding arrangements.
Factor 9(2): having iodine excess within the 3 months before the clinical onset of hypothyroidism; — MET
- After amiodarone, iodinated contrast and iodine-treated drinking water, her urinary iodine on 28 December 2010 was 1,850 micrograms per litre, above the 300 micrograms per litre in the definition, within the 3 months before onset.
Factor 9(3): being administered an iodine-containing radiographic contrast agent within the 3 months before the clinical onset of hypothyroidism; — MET
- She received iodinated contrast for a CT pulmonary angiogram on 20 December 2010, ordered by a Defence medical officer for breathlessness, 17 days before onset.
Factor 9(4): taking a drug from the specified list of drugs within the 3 months before the clinical onset of hypothyroidism; — MET
- She took quetiapine 200 mg nightly, prescribed for service-related posttraumatic stress disorder, throughout the 3 months before onset. Quetiapine is on the specified list.
Factor 9(5): taking a drug containing at least 10 milligrams of iodine daily for a continuous period of at least 4 weeks within the 3 months before the clinical onset of hypothyroidism; — MET
- Amiodarone 200 mg contains about 75 mg of iodine. She took it daily from 15 November 2010 to onset, a continuous 7 weeks and 3 days within the 3 months before onset, prescribed by a Defence medical officer for atrial fibrillation.
Factor 9(6): taking amiodarone for a continuous period of at least 2 weeks within the 1 year before the clinical onset of hypothyroidism; — MET
- Amiodarone was taken continuously from 15 November 2010 to 06 January 2011, more than 2 weeks within the 1 year before onset, from 06 January 2010 to 06 January 2011.
Factor 9(7): being pregnant or within the 12 months postpartum at the time of the clinical onset of hypothyroidism; — MET
- The veteran gave birth on 10 February 2010 while serving, and the onset on 06 January 2011 was 10 months and 27 days postpartum.
Factor 9(8): having a form of thyroiditis from the specified list of forms of thyroiditis at the time of the clinical onset of hypothyroidism; — MET
- She had postpartum thyroiditis, a form of silent thyroiditis on the specified list, with a painless thyrotoxic phase in June 2010 and negative antibodies, followed by the hypothyroid phase, and amiodarone-induced (drug-induced) thyroiditis from November 2010. Both were present at onset.
Factor 9(9): undergoing a course of therapeutic radiation for cancer, where the thyroid gland was in the field of radiation, before the clinical onset of hypothyroidism; — MET
- She received mantle field radiotherapy of 36 Gy for Hodgkin lymphoma in 2003, with the thyroid gland in the field, while serving and under Defence-funded oncology care.
Factor 9(10): having received iodine-131 (radioactive iodine) treatment before the clinical onset of hypothyroidism; — MET
- She received iodine-131 for Graves' hyperthyroidism in 2006, arranged by a Defence-funded endocrinologist, before the onset in 2011.
Factor 9(11): having subtotal or total thyroidectomy, or neck surgery involving the thyroid gland, before the clinical onset of hypothyroidism; — MET
- A left hemithyroidectomy was performed on 14 August 2007 for a follicular adenoma, while she was serving, before the onset.
Factor 9(12): having a disease involving the thyroid gland from the specified list of diseases at the time of the clinical onset of hypothyroidism; — MET
- Sarcoidosis, on the specified list, involved the thyroid, with non-caseating granulomas in the 2007 thyroid specimen and systemic disease confirmed in 2008, and was active at onset with hilar lymphadenopathy on CT on 20 December 2010.
Factor 9(13): having a primary or secondary malignant neoplasm of the thyroid gland at the time of the clinical onset of hypothyroidism; — MET
- A 7 mm papillary carcinoma of the right thyroid lobe was confirmed on fine-needle aspiration on 04 March 2010 and was under active surveillance, present at onset.
Factor 9(14): having a type 3 deiodinase-overexpressing neoplasm before the clinical onset of hypothyroidism; — MET
- A gastric gastrointestinal stromal tumour, a recognised type 3 deiodinase-overexpressing neoplasm, was resected in 2005, before onset.
Factor 9(15): having hypopituitarism involving deficiency of thyroid-stimulating hormone at the time of the clinical onset of hypothyroidism; — MET
- Sheehan syndrome after the postpartum haemorrhage of 10 February 2010 caused hypopituitarism with ACTH deficiency and a blunted TSH response to TRH, and the TSH of 11 mU/L at onset was inappropriately low for a free T4 below 3 pmol/L. The TSH deficiency was present at onset.
Factor 9(16): being obese for at least 5 years before the clinical onset of hypothyroidism; — MET
- Her BMI was 30 or more from 2004, rising to 33 in 2010, throughout the 5 years before onset, from 06 January 2006 to 06 January 2011. Weight gain followed steroid treatment for lymphoma and quetiapine for service-related posttraumatic stress disorder.
Factor 9(17): for hypothyroidism first presenting as myxoedema coma only, having an acute precipitating event within the 48 hours before the clinical onset of hypothyroidism; — MET
- The hypothyroidism first presented as myxoedema coma on 06 January 2011. Within the preceding 48 hours she was exposed overnight to freezing temperatures on 04 to 05 January 2011 when her vehicle broke down on a service task, causing hypothermia, and developed right lower lobe pneumonia. Hypothermia and infection are acute precipitating events.
Worsening factors
Factor 9(18): having iodine deficiency within the 3 months before the clinical worsening of hypothyroidism; — MET
- On deployment her urinary iodine was 70 micrograms per litre on 18 November 2013, within the 3 months before the worsening, from 12 November 2013 to 12 February 2014, on ration packs and non-iodised local food.
Factor 9(19): having iodine excess within the 3 months before the clinical worsening of hypothyroidism; — MET
- Urinary iodine was 2,100 micrograms per litre on 30 January 2014, after amiodarone was restarted and contrast given, within the 3 months before the worsening.
Factor 9(20): being administered an iodine-containing radiographic contrast agent within the 3 months before the clinical worsening of hypothyroidism; — MET
- She received iodinated contrast for a CT chest on 20 January 2014, 23 days before the worsening.
Factor 9(21): taking a drug from the specified list of drugs within the 3 months before the clinical worsening of hypothyroidism; — MET
- Quetiapine 200 mg nightly for posttraumatic stress disorder continued throughout the 3 months before the worsening.
Factor 9(22): taking a drug containing at least 10 milligrams of iodine daily for a continuous period of at least 4 weeks within the 3 months before the clinical worsening of hypothyroidism; — MET
- Amiodarone 200 mg daily, about 75 mg of iodine, was restarted on 01 December 2013 for recurrent atrial fibrillation and taken continuously for 10 weeks and 2 days to the worsening.
Factor 9(23): taking amiodarone for a continuous period of at least 2 weeks within the 1 year before the clinical worsening of hypothyroidism; — MET
- Amiodarone was taken continuously from 01 December 2013 to 12 February 2014, within the 1 year before the worsening.
Factor 9(24): taking a drug that increases the requirement of thyroid hormone replacement therapy at the time of the clinical worsening of hypothyroidism; — MET
- At the worsening she was taking ferrous sulphate and calcium carbonate for postpartum anaemia and omeprazole, all prescribed by Defence medical officers, which reduce levothyroxine absorption and increase the replacement requirement. Her dose rose from 150 to 225 micrograms daily after the worsening.
Factor 9(25): being pregnant or within the 12 months postpartum at the time of the clinical worsening of hypothyroidism; — MET
- Her second child was born on 15 March 2013, and the worsening on 12 February 2014 was 10 months and 28 days postpartum.
Factor 9(26): having a form of thyroiditis from the specified list of forms of thyroiditis at the time of the clinical worsening of hypothyroidism; — MET
- Amiodarone-induced destructive thyroiditis, a drug-induced thyroiditis, was present at the worsening, with a hypovascular, hypoechoic right lobe on ultrasound on 08 April 2014.
Factor 9(27): undergoing a course of therapeutic radiation for cancer, where the thyroid gland was in the field of radiation, before the clinical worsening of hypothyroidism; — MET
- The 2003 mantle field radiotherapy, with the thyroid in the field, preceded the worsening.
Factor 9(28): having received iodine-131 (radioactive iodine) treatment before the clinical worsening of hypothyroidism; — MET
- The 2006 iodine-131 treatment preceded the worsening.
Factor 9(29): having subtotal or total thyroidectomy, or neck surgery involving the thyroid gland, before the clinical worsening of hypothyroidism; — MET
- The left hemithyroidectomy of 14 August 2007 preceded the worsening.
Factor 9(30): having a disease involving the thyroid gland from the specified list of diseases at the time of the clinical worsening of hypothyroidism; — MET
- Sarcoidosis remained active at the worsening, with stable hilar lymphadenopathy on CT on 20 January 2014.
Factor 9(31): having a primary or secondary malignant neoplasm of the thyroid gland at the time of the clinical worsening of hypothyroidism; — MET
- The 7 mm papillary carcinoma remained under surveillance and was present at the worsening.
Factor 9(32): having a type 3 deiodinase-overexpressing neoplasm before the clinical worsening of hypothyroidism; — MET
- The gastrointestinal stromal tumour resected in 2005 preceded the worsening.
Factor 9(33): having hypopituitarism involving deficiency of thyroid-stimulating hormone at the time of the clinical worsening of hypothyroidism; — MET
- Hypopituitarism with TSH deficiency from Sheehan syndrome persisted at the worsening.
Factor 9(34): being obese for at least 5 years before the clinical worsening of hypothyroidism; — MET
- Her BMI was 30 or more throughout the 5 years before the worsening, from 12 February 2009 to 12 February 2014, and 35 in 2013.
Factor 9(35): for myxoedema coma only, having an acute precipitating event within the 48 hours before that clinical worsening of hypothyroidism; — MET
- The worsening presented as a second myxoedema coma on 12 February 2014, 36 hours after the diagnosis of pneumonia with septicaemia on 10 February 2014, which is an acute precipitating event.
Factor 9(36): inability to obtain appropriate clinical management for hypothyroidism. — MET
- Her levothyroxine supply ran out on 02 February 2014 at a forward location and could not be resupplied for ten days, and no thyroid function testing or endocrine advice was available. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management, and it preceded the second myxoedema coma.
Reasonable Hypothesis — Statement of Principles concerning Hypothyroidism, No. 3 of 2022
Causative factors
Factor 9(1): having iodine deficiency within the 6 months before the clinical onset of hypothyroidism; — MET
- The urinary iodine of 64 micrograms per litre on 20 October 2010 resulted from ration packs and non-iodised local food on warlike service in Afghanistan, within the 6 months before onset, from 06 July 2010 to 06 January 2011.
Factor 9(2): having iodine excess within the 6 months before the clinical onset of hypothyroidism; — MET
- The urinary iodine of 1,850 micrograms per litre on 28 December 2010 followed amiodarone, contrast and iodine-treated water on warlike service in Afghanistan, within the 6 months before onset.
Factor 9(3): being administered an iodine-containing radiographic contrast agent within the 6 months before the clinical onset of hypothyroidism; — MET
- The CT pulmonary angiogram with iodinated contrast on 20 December 2010 was performed at a role 3 hospital on warlike service in Afghanistan.
Factor 9(4): taking a drug from the specified list of drugs within the 6 months before the clinical onset of hypothyroidism; — MET
- Quetiapine, on the specified list, was taken nightly throughout the 6 months before onset for posttraumatic stress disorder arising from the fatal vehicle rollover on warlike service in East Timor.
Factor 9(5): taking minocycline for at least 6 months within the 9 months before the clinical onset of hypothyroidism; — MET
- Minocycline 100 mg daily was taken continuously from 01 April 2010 to onset, more than 9 months, covering the 9 months before onset from 06 April 2010 to 06 January 2011. It was continued through her warlike service in Afghanistan, where heat and sun exposure aggravated the rosacea.
Factor 9(6): taking a drug containing at least 10 milligrams of iodine daily for a continuous period of at least 4 weeks within the 6 months before the clinical onset of hypothyroidism; — MET
- Amiodarone, containing about 75 mg of iodine per 200 mg tablet, was taken daily for 7 weeks and 3 days from 15 November 2010 on warlike service in Afghanistan.
Factor 9(7): taking amiodarone for a continuous period of at least 2 weeks within the 1 year before the clinical onset of hypothyroidism; — MET
- Amiodarone was commenced on warlike service in Afghanistan on 15 November 2010 and taken continuously to onset.
Factor 9(8): being pregnant or within the 12 months postpartum at the time of the clinical onset of hypothyroidism; — MET
- The veteran was 10 months and 27 days postpartum at onset on warlike service in Afghanistan.
Factor 9(9): having a form of thyroiditis from the specified list of forms of thyroiditis at the time of the clinical onset of hypothyroidism; — MET
- Postpartum thyroiditis and amiodarone-induced thyroiditis, the latter from amiodarone started on warlike service in Afghanistan, were present at onset.
Factor 9(10): undergoing a course of therapeutic radiation for cancer, where the thyroid gland was in the field of radiation, before the clinical onset of hypothyroidism; — MET
- Mantle field radiotherapy including the thyroid was given in 2003, before the onset on warlike service in Afghanistan.
Factor 9(11): having received iodine-131 (radioactive iodine) treatment before the clinical onset of hypothyroidism; — MET
- Iodine-131 was given in 2006, before the onset on warlike service in Afghanistan.
Factor 9(12): having subtotal or total thyroidectomy, or neck surgery involving the thyroid gland, before the clinical onset of hypothyroidism; — MET
- The left hemithyroidectomy of 14 August 2007 preceded the onset on warlike service in Afghanistan.
Factor 9(13): having a disease involving the thyroid gland from the specified list of diseases at the time of the clinical onset of hypothyroidism; — MET
- Sarcoidosis involving the thyroid was active at onset, with hilar lymphadenopathy on the CT performed on warlike service on 20 December 2010.
Factor 9(14): having a primary or secondary malignant neoplasm of the thyroid gland at the time of the clinical onset of hypothyroidism; — MET
- The 7 mm papillary thyroid carcinoma was present at onset; surveillance ultrasound was not available on deployment.
Factor 9(15): having a type 3 deiodinase-overexpressing neoplasm before the clinical onset of hypothyroidism; — MET
- The gastrointestinal stromal tumour resected in 2005 preceded the onset.
Factor 9(16): having hypopituitarism involving deficiency of thyroid-stimulating hormone at the time of the clinical onset of hypothyroidism; — MET
- Hypopituitarism with TSH deficiency from Sheehan syndrome was present at onset on warlike service in Afghanistan.
Factor 9(17): having chronic kidney disease at the time of the clinical onset of hypothyroidism; — MET
- Chronic kidney disease stage 3, with an eGFR of 52 mL/min/1.73 m2 in July 2010 and 48 at onset, from sarcoid-related hypercalcaemic nephropathy, was present at onset.
Factor 9(18): having hepatitis C virus infection at the time of the clinical onset of hypothyroidism; — MET
- Chronic hepatitis C, acquired from emergency transfusion of locally collected blood after the vehicle rollover on warlike service in East Timor on 11 December 1999, was present at onset, with detectable HCV RNA in 2010.
Factor 9(19): being obese for at least 5 years before the clinical onset of hypothyroidism; — MET
- Her BMI was 30 or more from 2004, throughout the 5 years before onset, with weight gain from quetiapine for posttraumatic stress disorder arising from warlike service in East Timor.
Factor 9(20): having posttraumatic stress disorder at the time of the clinical onset of hypothyroidism; — MET
- Posttraumatic stress disorder from the fatal vehicle rollover on warlike service in East Timor was diagnosed by a psychiatrist and was present at onset.
Factor 9(21): for hypothyroidism first presenting as myxoedema coma only, having an acute precipitating event within the 48 hours before the clinical onset of hypothyroidism; — MET
- The overnight cold exposure of 04 to 05 January 2011 and the pneumonia that followed occurred on warlike service in Afghanistan within the 48 hours before the myxoedema coma on 06 January 2011.
Worsening factors
Factor 9(22): having iodine deficiency within the 6 months before the clinical worsening of hypothyroidism; — MET
- Urinary iodine of 70 micrograms per litre on 18 November 2013 resulted from deployed feeding on warlike service in the Middle East, within the 6 months before the worsening, from 12 August 2013 to 12 February 2014.
Factor 9(23): having iodine excess within the 6 months before the clinical worsening of hypothyroidism; — MET
- Urinary iodine of 2,100 micrograms per litre on 30 January 2014, on warlike service in the Middle East, was within the 6 months before the worsening.
Factor 9(24): being administered an iodine-containing radiographic contrast agent within the 6 months before the clinical worsening of hypothyroidism; — MET
- Contrast was given for the CT chest at a role 3 hospital on warlike service in the Middle East on 20 January 2014.
Factor 9(25): taking a drug from the specified list of drugs within the 6 months before the clinical worsening of hypothyroidism; — MET
- Quetiapine for posttraumatic stress disorder from warlike service in East Timor continued throughout the 6 months before the worsening.
Factor 9(26): taking minocycline for at least 6 months within the 9 months before the clinical worsening of hypothyroidism; — MET
- Minocycline was restarted on 01 June 2013 and taken continuously for 8 months and 11 days to the worsening, within the 9 months from 12 May 2013 to 12 February 2014, including on warlike service in the Middle East.
Factor 9(27): taking a drug containing at least 10 milligrams of iodine daily for a continuous period of at least 4 weeks within the 6 months before the clinical worsening of hypothyroidism; — MET
- Amiodarone, restarted on warlike service in the Middle East on 01 December 2013, was taken daily for 10 weeks and 2 days to the worsening.
Factor 9(28): taking amiodarone for a continuous period of at least 2 weeks within the 1 year before the clinical worsening of hypothyroidism; — MET
- Amiodarone was taken continuously from 01 December 2013 on warlike service in the Middle East, within the 1 year before the worsening.
Factor 9(29): taking a drug that increases the requirement of thyroid hormone replacement therapy at the time of the clinical worsening of hypothyroidism; — MET
- Ferrous sulphate, calcium carbonate and omeprazole, prescribed on warlike service in the Middle East, were being taken at the worsening and reduced levothyroxine absorption.
Factor 9(30): being pregnant or within the 12 months postpartum at the time of the clinical worsening of hypothyroidism; — MET
- The veteran was 10 months and 28 days postpartum at the worsening on warlike service in the Middle East.
Factor 9(31): having a form of thyroiditis from the specified list of forms of thyroiditis at the time of the clinical worsening of hypothyroidism; — MET
- Amiodarone-induced thyroiditis, from amiodarone restarted on warlike service, was present at the worsening.
Factor 9(32): undergoing a course of therapeutic radiation for cancer, where the thyroid gland was in the field of radiation, before the clinical worsening of hypothyroidism; — MET
- The 2003 mantle radiotherapy including the thyroid preceded the worsening on warlike service in the Middle East.
Factor 9(33): having received iodine-131 (radioactive iodine) treatment before the clinical worsening of hypothyroidism; — MET
- The 2006 iodine-131 treatment preceded the worsening on warlike service in the Middle East.
Factor 9(34): having subtotal or total thyroidectomy, or neck surgery involving the thyroid gland, before the clinical worsening of hypothyroidism; — MET
- The 2007 left hemithyroidectomy preceded the worsening on warlike service in the Middle East.
Factor 9(35): having a disease involving the thyroid gland from the specified list of diseases at the time of the clinical worsening of hypothyroidism; — MET
- Sarcoidosis involving the thyroid remained active at the worsening on warlike service in the Middle East.
Factor 9(36): having a primary or secondary malignant neoplasm of the thyroid gland at the time of the clinical worsening of hypothyroidism; — MET
- The papillary thyroid carcinoma was present at the worsening on warlike service in the Middle East.
Factor 9(37): having a type 3 deiodinase-overexpressing neoplasm before the clinical worsening of hypothyroidism; — MET
- The gastrointestinal stromal tumour of 2005 preceded the worsening.
Factor 9(38): having hypopituitarism involving deficiency of thyroid-stimulating hormone at the time of the clinical worsening of hypothyroidism; — MET
- TSH deficiency from Sheehan syndrome persisted at the worsening on warlike service in the Middle East.
Factor 9(39): having chronic kidney disease at the time of the clinical worsening of hypothyroidism; — MET
- Chronic kidney disease stage 3, with an eGFR of 45 mL/min/1.73 m2 in January 2014, was present at the worsening.
Factor 9(40): having hepatitis C virus infection at the time of the clinical worsening of hypothyroidism; — MET
- Chronic hepatitis C acquired on warlike service in East Timor remained untreated and present at the worsening.
Factor 9(41): being obese for at least 5 years before the clinical worsening of hypothyroidism; — MET
- Her BMI was 30 or more throughout the 5 years before the worsening, from 12 February 2009 to 12 February 2014.
Factor 9(42): having posttraumatic stress disorder at the time of the clinical worsening of hypothyroidism; — MET
- Posttraumatic stress disorder from warlike service in East Timor was present at the worsening and had been aggravated by her deployment to the Middle East.
Factor 9(43): for myxoedema coma only, having an acute precipitating event within the 48 hours before that clinical worsening of hypothyroidism; — MET
- Pneumonia with septicaemia, diagnosed on warlike service in the Middle East on 10 February 2014, preceded the second myxoedema coma by 36 hours.
Factor 9(44): inability to obtain appropriate clinical management for hypothyroidism. — MET
- On warlike service in the Middle East her levothyroxine ran out on 02 February 2014 and could not be resupplied to her forward location for ten days, with no thyroid testing or endocrine advice available, and the condition worsened to a second myxoedema coma.
The % contribution of the causes is 100% and significant.
Sequelae
The hypothyroidism is a sequela of the veteran's accepted posttraumatic stress disorder, through quetiapine, and of the amiodarone, iodinated contrast and iodine exposures on warlike service in Afghanistan. In turn it has contributed to weight gain, fatigue, depressed mood and dyslipidaemia, and the two episodes of myxoedema coma required intensive care.
Unintended Consequence
Met. The amiodarone-induced thyroiditis and the iodine load from contrast are unintended consequences of amiodarone and a CT pulmonary angiogram provided by Defence medical officers while the veteran was serving, and the reduced absorption of levothyroxine at the worsening was an unintended consequence of iron, calcium and omeprazole prescribed on deployment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On warlike service in the Middle East the veteran's levothyroxine supply ran out on 02 February 2014 and could not be resupplied to her forward location for ten days, and no thyroid function testing or endocrine advice was available. Without replacement, and with pneumonia, she developed a second myxoedema coma on 12 February 2014. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the interruption of prescribed treatment because of her service circumstances amounts to an inability to obtain appropriate clinical management. The lack of thyroid function testing on deployment in Afghanistan in late 2010, despite symptoms and amiodarone treatment, also delayed the diagnosis until she presented in myxoedema coma.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 11 Dec 1999, Field hospital admission and operation report, Field hospital, East Timor
- 14 Aug 2007, Operation and histopathology report, Endocrine surgeon
- 04 Mar 2010, Endocrinology consultation, thyroid ultrasound and cytology report, Endocrinologist
- 22 Jul 2010, Pre-deployment medical examination and pathology, Medical Officer, Garrison health centre
- 20 Oct 2010, Deployed health record and urinary iodine result, Medical Officer, Afghanistan
- 20 Dec 2010, CT pulmonary angiogram report, Role 3 hospital, Afghanistan
- 06 Jan 2011, Intensive care admission record, Intensivist, Role 3 hospital, Afghanistan
- 24 Feb 2011, Specialist consultation, Endocrinologist
- 20 Jan 2014, CT chest report, Role 3 hospital, Middle East
- 12 Feb 2014, Deployed intensive care record, Intensivist, Role 3 hospital, Middle East
- 08 Apr 2014, Thyroid ultrasound report and endocrinology review, Radiologist and Endocrinologist
- Statement of Principles concerning Hypothyroidism (Balance of Probabilities) No. 4 of 2022, Repatriation Medical Authority
- Statement of Principles concerning Hypothyroidism (Reasonable Hypothesis) No. 3 of 2022, Repatriation Medical Authority
