Multiple Sclerosis — DVA claim example

Diagnostic Assessment — Multiple Sclerosis

Example 1 of 1 · fictitious patient (Veteran AJ)

Diagnostic Assessment

Multiple Sclerosis

BOP Code: 12 of 2020 (Multiple Sclerosis)
RH Code: 11 of 2020 (Multiple Sclerosis)

ADF History

Veteran AJ, date of birth 22 April 1986, Royal Australian Air Force, Aircraft Technician (Aircraft Structural Fitter, later Maintenance Supervisor), enlisted 10 January 2005, medically discharged 14 July 2023. Operational service: Afghanistan, 05 October 2008 to 02 April 2009 (warlike); Middle East Area of Operations, 01 October 2010 to 30 September 2011 (warlike); Afghanistan, 10 March 2013 to 08 September 2013 (warlike); Iraq, 20 September 2021 to 22 November 2021 (warlike).

Occupational History

As an aircraft structural fitter the veteran repaired, stripped, primed and painted airframes in enclosed hangars and paint shops, using methyl ethyl ketone, toluene, acetone and other solvent-based cleaners, sealants and coatings daily, often with only gloves and a disposable mask. Flight line work exposed her to long hours of intense sun on deployment, jet fuel, exhaust and noise, while maintenance surges involved long night shifts and sleeping by day.

Aircraft maintenance trades carry recognised exposure to organic solvents, fuels and hydraulic fluids, shift work with disrupted sleep and reduced daylight exposure, and the physical and psychological demands of operational air bases, including indirect fire attacks. The crew rooms, accommodation and vehicles of the period were often shared with heavy smokers.

History

Veteran AJ, an aircraft structural fitter in the Royal Australian Air Force, developed relapsing-remitting multiple sclerosis on 10 April 2018 after infectious mononucleosis in initial training, years of daily solvent exposure, heavy smoking, a year of night-shift work without sunlight on deployment with vitamin D deficiency, obesity in her twenties, type 1 diabetes, adalimumab treatment and, finally, pembrolizumab for a service-related melanoma. The disease worsened after brain irradiation in 2018 and again, severely, on warlike service in Iraq in November 2021 after a rocket attack, the death of a close friend and COVID-19 pneumonia.

Timeline

• 21 Mar 2005 — During initial employment training the veteran presented with fever, severe sore throat, cervical lymphadenopathy and fatigue. The Monospot test was positive and Epstein-Barr virus VCA IgM was detected, confirming acute infectious mononucleosis. She was admitted to the base health facility for five days and placed on light duties for six weeks. "EBV IgM positive, glandular fever"
• 14 Nov 2011 — On return from 12 months in the Middle East working permanent night shifts on the flight line and sleeping by day in windowless accommodation, she remained on night-shift maintenance at an RAAF base in southern Victoria. Serum 25-hydroxyvitamin D was 36 nmol/L, after levels of 28 nmol/L on 15 January 2011 and 31 nmol/L on 20 July 2011. Weight 88 kg, height 1.66 m, BMI 31.9. She smoked 20 cigarettes a day. "vitamin D 36, BMI 31.9"
• 18 Jun 2014 — After a febrile enteroviral illness in the final weeks of her 2013 Afghanistan deployment she developed thirst, polyuria and weight loss. Fasting glucose was 14.2 mmol/L, HbA1c 9.8 per cent and GAD antibodies were strongly positive, and an endocrinologist diagnosed type 1 diabetes mellitus and commenced basal-bolus insulin. A rheumatologist was separately managing reactive spondyloarthritis that followed Campylobacter dysentery in Afghanistan in July 2013. "type 1 diabetes, GAD positive"
• 08 Mar 2016 — The rheumatologist commenced adalimumab 40 mg fortnightly for reactive spondyloarthritis that had failed to respond to two NSAIDs and sulfasalazine. Adalimumab continued until 10 December 2017, when it was stopped because melanoma had been diagnosed. Neurological examination was normal. "adalimumab 40 mg fortnightly commenced"
• 05 Mar 2018 — A 2.1 mm ulcerated melanoma on her upper back, a site exposed while working shirtless or in a singlet under body armour on the flight line in Afghanistan in 2008 and 2009, had been excised in October 2017 with a positive sentinel node (stage IIIB). Adjuvant pembrolizumab 200 mg three-weekly began on 15 January 2018. Staging MRI of the brain on 05 March 2018 showed a solitary 8 mm right frontal metastasis and no white matter lesions. "pembrolizumab, solitary brain metastasis"
• 17 Apr 2018 — She presented with a one-week history of numbness and tingling rising from both feet to the waist, electric shocks down the spine on neck flexion and urinary urgency, beginning on 10 April 2018. MRI showed multiple new periventricular, juxtacortical and infratentorial T2 lesions and a lesion at C4, with some enhancing and others not. CSF showed oligoclonal bands not present in serum. Pembrolizumab was given for the last time on 30 April 2018. "Lhermitte sign, multiple demyelinating lesions"
• 21 May 2018 — A neurologist diagnosed relapsing-remitting multiple sclerosis, with dissemination in space and in time under the 2017 McDonald criteria, and excluded neuromyelitis optica (aquaporin-4 and MOG antibodies negative). Whole-brain radiotherapy, 30 Gy in 10 fractions, was given from 04 June to 15 June 2018 for the enlarging metastasis, and interferon beta-1a 44 micrograms three times weekly was commenced on 02 July 2018. "relapsing-remitting MS, McDonald criteria"
• 20 Aug 2018 — She had a relapse with left optic neuritis and a brainstem syndrome with diplopia and ataxia. MRI on 22 August 2018 showed three new enhancing lesions within the irradiated brain. EDSS rose from 1.5 to 3.5, and she was treated with intravenous methylprednisolone. Total cholesterol was 6.4 mmol/L and atorvastatin was continued. "relapse, EDSS 1.5 to 3.5"
• 18 Nov 2021 — During warlike service in Iraq, five weeks after a rocket attack on 12 October 2021 that killed her close friend and section commander in front of her, and after COVID-19 pneumonia requiring high-flow oxygen from 25 October 2021, she developed a severe relapse with spastic paraparesis and loss of bladder control. Interferon had been missed for five weeks because of a refrigeration failure. She was aeromedically evacuated on 22 November 2021. MRI on 30 November 2021 showed new enhancing brain and thoracic cord lesions, and EDSS rose from 3.0 to 6.0. "severe relapse, EDSS 6.0, evacuated"

Symptoms

At onset the veteran had ascending numbness and tingling of both legs to the waist, Lhermitte phenomenon and urinary urgency. In August 2018 she developed blurred and painful vision in the left eye, double vision and unsteadiness, and in November 2021 weakness and stiffness of both legs, falls and urinary incontinence.

She now walks with a stick for up to 100 metres, has spasticity, fatigue, heat sensitivity, reduced vision in the left eye, urinary urgency and incontinence, and cognitive slowing, and she cannot work.

Imaging

• 05 Mar 2018 — MRI brain with contrast: "Solitary 8 mm enhancing metastasis in the right frontal lobe. No white matter lesions."
• 17 Apr 2018 — MRI brain and cervical spine with contrast: "Multiple ovoid T2 hyperintense lesions in periventricular, juxtacortical and infratentorial locations and a cervical cord lesion at C4, with simultaneous enhancing and non-enhancing lesions, consistent with demyelination disseminated in space and time."
• 22 Aug 2018 — MRI brain with contrast: "Three new enhancing lesions, including the left optic nerve and the pons, within the field of previous whole-brain radiotherapy."
• 30 Nov 2021 — MRI brain and whole spine with contrast: "New enhancing lesions in the corpus callosum and at T6 and T9 in the thoracic cord, with increased overall T2 lesion load."

Onset Date

The most likely date of onset of this condition is 10 Apr 2018.

At that date the veteran was serving full time as a maintenance supervisor at an RAAF base in Australia, on adjuvant pembrolizumab for stage IIIB melanoma, with type 1 diabetes on insulin. On 10 April 2018 numbness began in both feet and rose to the waist over the following days, with electric shocks down the spine on neck flexion.

This date is appropriate because the neurological examination of 08 March 2016 was normal and the MRI brain of 05 March 2018 showed no white matter lesions, and she first presented with the symptoms on 17 April 2018, one week after they began. It falls within uninterrupted full-time service.

For the infectious mononucleosis and type 1 diabetes factors, both were established before onset, on 21 Mar 2005 and 18 Jun 2014. For the smoking factors, she had smoked 20 cigarettes a day since 2002, about 16 pack-years by onset, 13 of them during service, and was still smoking. For the second-hand smoke factors, she had accumulated about 14 000 hours of enclosed exposure by onset. For the organic solvent factor, she used solvents daily from 01 Jul 2005 to 30 Jun 2010, well over the one continuous year required. For the sunlight factor, she could not meet the specified sunlight exposure levels from 01 Oct 2010 to 29 Feb 2012, a period of 17 months that ended more than two years before onset (the two years before onset run from 10 Apr 2016 to 10 Apr 2018). For the vitamin D factor, serum 25-hydroxyvitamin D was below 50 nmol/L from 15 Jan 2011 to 02 Feb 2012, a continuous period of more than one year, also more than two years before onset. For the overweight and obesity factors, her BMI was 30 or more from 2008 to 2014, ages 22 to 28, which falls before her thirtieth birthday on 22 Apr 2016 and within the 15 years before onset (10 Apr 2003 to 10 Apr 2018). For the tumour necrosis factor alpha antagonist factor, the two years before onset run from 10 Apr 2016 to 10 Apr 2018, and she took adalimumab from 08 Mar 2016 to 10 Dec 2017. For the immune checkpoint inhibitor factor, the four months before onset run from 10 Dec 2017 to 10 Apr 2018, and pembrolizumab was given from 15 Jan 2018.

Two clinical worsenings are documented. For the first, on 20 Aug 2018: the four months before run from 20 Apr 2018 to 20 Aug 2018 and the last pembrolizumab dose was on 30 Apr 2018; the one year before runs from 20 Aug 2017 to 20 Aug 2018 and adalimumab was taken until 10 Dec 2017; interferon beta-1a began on 02 Jul 2018, within the six months before; and whole-brain radiotherapy of 30 Gy was completed on 15 Jun 2018, before the worsening. For the second, on 18 Nov 2021, during warlike service in Iraq: the three months before run from 18 Aug 2021 to 18 Nov 2021 and the six months before from 18 May 2021 to 18 Nov 2021. Within those windows she underwent hormonal assisted reproductive therapy from 20 Aug to 06 Sep 2021, survived the rocket attack and saw her close friend killed on 12 Oct 2021, was socially isolated and in conflict at work on deployment, and had life-threatening COVID-19 pneumonia from 25 Oct 2021, which began 24 days before the worsening. She had stopped smoking on 15 Jan 2020, less than two years before the worsening, and was taking interferon beta-1a and atorvastatin.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Multiple Sclerosis, relapsing-remitting type (ICD-10 G35), under the Statements of Principles concerning multiple sclerosis, Balance of Probabilities No. 12 of 2020 and Reasonable Hypothesis No. 11 of 2020.

Multiple sclerosis is a chronic immune-mediated disease of the central nervous system in which the immune system attacks the myelin sheath around nerve fibres in the brain, optic nerves and spinal cord. Focal areas of inflammation and demyelination form plaques, which heal with scarring (gliosis), and new plaques form at different times and in different places. Symptoms depend on the site and include numbness, weakness, visual loss, double vision, imbalance, bladder disturbance, fatigue and cognitive change. Most people begin with a relapsing-remitting course, and many later develop progressive disability. Genetic susceptibility combines with environmental factors, including Epstein-Barr virus infection, smoking, low sunlight exposure and vitamin D, adolescent obesity and immune-modulating drugs.

The condition began on 10 April 2018, was diagnosed by a neurologist on 21 May 2018, and worsened on 20 August 2018 and again, severely, on warlike service in Iraq on 18 November 2021.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

10 April 2018.

When did the veteran first present to a health / medical provider for this condition?

17 April 2018.

When was the condition confirmed / formally diagnosed?

21 May 2018.

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 confirmed by a neurologist on 21 May 2018 on the clinical attack of April 2018 together with MRI of 17 April 2018, which showed T2 lesions in periventricular, juxtacortical, infratentorial and spinal cord locations (dissemination in space) with simultaneous enhancing and non-enhancing lesions (dissemination in time), and CSF-specific oligoclonal bands. This satisfies the 2017 McDonald criteria and the Statement of Principles definition of a chronic relapsing-remitting disorder with multiple focal regions of demyelination occurring on multiple occasions.

Neuromyelitis optica spectrum disorder and MOG antibody disease were excluded with negative aquaporin-4 and MOG antibodies, and the subsequent relapses of August 2018 and November 2021, each with new lesions on MRI, confirm that this is multiple sclerosis and not a clinically isolated syndrome or acute disseminated encephalomyelitis.

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 April 2018, 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. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2008 to 2009 and 2013, where the melanoma-causing sun exposure, the dysentery and reactive arthritis and the enteroviral illness occurred, in the Middle East in 2010 to 2011, where she worked a year of night shifts without sunlight, and in Iraq in 2021, where the condition severely 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 Multiple Sclerosis, No. 12 of 2020

Causative factors

Factor 9(1): having acute infectious mononucleosis before the clinical onset of multiple sclerosis; — MET

- Acute infectious mononucleosis was confirmed on 21 March 2005, during initial employment training, with a positive Monospot test and Epstein-Barr virus VCA IgM, and she was admitted to the base health facility for five days. It was contracted in crowded training accommodation, 13 years before the onset on 10 April 2018.

Factor 9(2): smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of multiple sclerosis, and where smoking has ceased, the clinical onset of multiple sclerosis has occurred within five years of cessation; — MET

- The veteran smoked 20 cigarettes a day from 2002, about 16 pack-years before onset, of which about 13 pack-years were smoked during service from January 2005, when cigarettes were cheap and smoking breaks were part of flight line routine. She was still smoking at onset on 10 April 2018 and did not stop until 15 January 2020.

Factor 9(3): being exposed to second-hand smoke for at least 10 000 hours before the clinical onset of multiple sclerosis; — MET

- From 2005 she spent about four hours of each working day in enclosed crew rooms, workshop offices and shared vehicles where colleagues smoked, and shared enclosed living quarters with smokers on deployment. Her occupational history records about 14 000 hours of enclosed second-hand smoke exposure before onset on 10 April 2018.

Factor 9(4): having vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 50 nanomoles per litre for a continuous period of at least one year before the clinical onset of multiple sclerosis, and where this vitamin D deficiency occurred more than two years before the clinical onset of multiple sclerosis; — MET

- Serum 25-hydroxyvitamin D was 28 nmol/L on 15 January 2011, 31 nmol/L on 20 July 2011, 36 nmol/L on 14 November 2011 and 44 nmol/L on 02 February 2012, below 50 nmol/L continuously for more than one year. The deficiency ended more than six years before onset, beyond the two years before onset from 10 April 2016 to 10 April 2018, and was caused by a year of night-shift work and continued night shifts at a southern base.

Factor 9(5): being obese for at least five years when aged less than 30 years before the clinical onset of multiple sclerosis, and where this five year period occurred within the 15 years before the clinical onset of multiple sclerosis; — MET

- Her BMI was 30.4 in 2008, 31.9 on 14 November 2011 and 30 or more at every annual health assessment until the weight loss of type 1 diabetes in 2014, a period of about six years from age 22 to 28. This fell before her thirtieth birthday on 22 April 2016 and within the 15 years before onset. The weight gain followed shift work, deployment rations and limited opportunity to exercise on night shifts.

Worsening factors

Factor 9(6): having onset of a viral or bacterial infection within the five weeks before, or the two weeks after, the clinical worsening of multiple sclerosis; — MET

- COVID-19 pneumonia began on 25 October 2021 while she was serving in Iraq, confirmed by PCR, 24 days before the severe relapse of 18 November 2021. Systemic infection is a well-recognised trigger of multiple sclerosis relapse.

Factor 9(7): smoking at least ten pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of multiple sclerosis, and where smoking has ceased, the clinical worsening of multiple sclerosis has occurred within five years of cessation; — MET

- The veteran had smoked about 16 pack-years by the first worsening on 20 August 2018, while still smoking, and about 18 pack-years when she stopped on 15 January 2020. The second worsening on 18 November 2021 occurred less than two years after cessation.

Factor 9(8): being exposed to second-hand smoke for at least 10 000 hours before the clinical worsening of multiple sclerosis; — MET

- She had accumulated more than 14 000 hours of enclosed second-hand smoke exposure in crew rooms, vehicles and accommodation by the worsenings of 20 August 2018 and 18 November 2021.

Factor 9(9): undergoing a course of treatment with a tumour necrosis factor alpha antagonist within the one year before the clinical worsening of multiple sclerosis; — MET

- The veteran took adalimumab 40 mg fortnightly from 08 March 2016 to 10 December 2017 for reactive spondyloarthritis. The one year before the first worsening runs from 20 August 2017 to 20 August 2018, and she took adalimumab for almost four months of it. Tumour necrosis factor alpha antagonists are recognised to provoke demyelination.

Factor 9(10): undergoing a course of treatment with granulocyte colony-stimulating factor or interferon within the six months before the clinical worsening of multiple sclerosis; — MET

- Interferon beta-1a 44 micrograms three times weekly was commenced on 02 July 2018, within the six months before the worsening of 20 August 2018, and continued to the worsening of 18 November 2021, apart from five missed weeks on deployment.

Factor 9(11): undergoing a course of treatment with an immune checkpoint inhibitor within the four months before the clinical worsening of multiple sclerosis; — MET

- Pembrolizumab 200 mg three-weekly was given from 15 January 2018 to 30 April 2018 for stage IIIB melanoma. The four months before the first worsening run from 20 April 2018 to 20 August 2018, and the last dose was given on 30 April 2018.

Factor 9(12): experiencing the death of a significant other within the three months before the clinical worsening of multiple sclerosis; — MET

- Her section commander, a close friend of nine years who was important in her life, was killed in a rocket attack on the air base in Iraq on 12 October 2021, 37 days before the worsening of 18 November 2021.

Factor 9(13): experiencing a category 1A stressor within the three months before the clinical worsening of multiple sclerosis; — MET

- On 12 October 2021 the veteran was caught in the open during a rocket attack on the air base, with an impact about 30 metres away. This was a life-threatening event, 37 days before the worsening.

Factor 9(14): experiencing a category 1B stressor within the three months before the clinical worsening of multiple sclerosis; — MET

- In the same attack on 12 October 2021 she was an eyewitness to her section commander being killed and gave first aid to two critically injured colleagues, 37 days before the worsening.

Factor 9(15): experiencing a category 2 stressor within the three months before the clinical worsening of multiple sclerosis; — MET

- From late September 2021 she was the only woman in her maintenance section on deployment, socially isolated, and in ongoing conflict with a supervisor who questioned her fitness because of her multiple sclerosis, with stressful workloads after the attack. The mental health officer recorded ongoing distress on 04 November 2021, within the three months before the worsening.

Factor 9(16): having a medical illness or injury, other than multiple sclerosis, which is life-threatening or which results in serious physical or cognitive disability, within the three months before the clinical worsening of multiple sclerosis; — MET

- COVID-19 pneumonia from 25 October 2021 caused hypoxia with an oxygen saturation of 84 per cent on air, requiring high-flow oxygen at the role 3 hospital. This was a life-threatening illness within the three months before the worsening of 18 November 2021.

Factor 9(17): for women only, using hormonal assisted reproductive therapy within the three months before the clinical worsening of multiple sclerosis; — MET

- The veteran underwent an IVF cycle with follicle stimulating hormone, a gonadotrophin-releasing hormone antagonist and a chorionic gonadotrophin trigger from 20 August to 06 September 2021, timed to her pre-deployment leave so that embryos could be stored before she deployed. This was within the three months before the worsening of 18 November 2021.

Factor 9(18): undergoing a course of therapeutic radiation for cancer, where the affected site was in the field of radiation, before the clinical worsening of multiple sclerosis; — MET

- Whole-brain radiotherapy, 30 Gy in 10 fractions, was given from 04 June to 15 June 2018 for the melanoma brain metastasis. The whole brain, including the sites of the new optic nerve and pontine lesions of August 2018 and the corpus callosum lesion of November 2021, was in the field of radiation before both worsenings.

Factor 9(19): inability to obtain appropriate clinical management for multiple sclerosis. — MET

- On deployment in Iraq her interferon beta-1a supply was spoiled by a refrigeration failure and could not be replaced for five weeks, and when the relapse began on 18 November 2021 there was no neurologist, MRI or intravenous methylprednisolone available. She waited four days for aeromedical evacuation and nine days for MRI. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Multiple Sclerosis, No. 11 of 2020

Causative factors

Factor 9(1): having acute infectious mononucleosis before the clinical onset of multiple sclerosis; — MET

- Acute infectious mononucleosis was confirmed serologically on 21 March 2005, 13 years before onset. Epstein-Barr virus infection persisted and her latent infection was present throughout her warlike service in Afghanistan and the Middle East, where the later immune triggers occurred.

Factor 9(2): smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of multiple sclerosis, and where smoking has ceased, the clinical onset of multiple sclerosis has occurred within five years of cessation; — MET

- The veteran smoked about 16 pack-years before onset, including about three pack-years during her warlike deployments in 2008 to 2009, 2010 to 2011 and 2013, when her intake rose to 25 to 30 cigarettes a day on long shifts. She was still smoking at onset.

Factor 9(3): being exposed to second-hand smoke for at least 10 000 hours before the clinical onset of multiple sclerosis; — MET

- About 14 000 hours of enclosed second-hand smoke exposure were recorded before onset, including about 3 500 hours in shared crew tents, hardened shelters and accommodation on warlike service in Afghanistan and the Middle East.

Factor 9(4): inhaling an organic solvent or having cutaneous contact with an organic solvent on more days than not for a continuous period of at least one year before the clinical onset of multiple sclerosis; — MET

- As an aircraft structural fitter from 01 July 2005 to 30 June 2010 she used methyl ethyl ketone, toluene and acetone on almost every working day for stripping, degreasing and painting airframes in enclosed paint shops, with skin contact and inhalation. This continued during her warlike service in Afghanistan from October 2008 to April 2009, where she repaired battle-damaged airframes in a hangar with poor ventilation.

Factor 9(5): undergoing a course of treatment with a tumour necrosis factor alpha antagonist within the two years before the clinical onset of multiple sclerosis; — MET

- Adalimumab 40 mg fortnightly was given from 08 March 2016 to 10 December 2017 for reactive spondyloarthritis that followed Campylobacter dysentery contracted on warlike service in Afghanistan in July 2013. The two years before onset run from 10 April 2016 to 10 April 2018.

Factor 9(6): in the absence of supplemental ultraviolet light exposure, having an inability to meet the specified sunlight exposure levels for at least one year before the clinical onset of multiple sclerosis, and where this inability to meet the specified sunlight exposure levels occurred more than two years before the clinical onset of multiple sclerosis; — MET

- On warlike service in the Middle East from 01 October 2010 to 30 September 2011 she worked permanent night shifts on the flight line from 1900 to 0700 and slept by day in windowless accommodation, with almost no daylight exposure, and no supplemental ultraviolet light was provided. Night shifts continued at a southern Victorian base at about 38 degrees latitude until 29 February 2012. The 17-month period ended more than six years before onset.

Factor 9(7): having vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 50 nanomoles per litre for a continuous period of at least one year before the clinical onset of multiple sclerosis, and where this vitamin D deficiency occurred more than two years before the clinical onset of multiple sclerosis; — MET

- Serum 25-hydroxyvitamin D was below 50 nmol/L continuously from 15 January 2011, during her warlike service in the Middle East, to 02 February 2012, more than one year, and ended more than six years before onset. It resulted from the night-shift pattern of that deployment.

Factor 9(8): undergoing a course of treatment with an immune checkpoint inhibitor within the four months before the clinical onset of multiple sclerosis; — MET

- Pembrolizumab 200 mg three-weekly began on 15 January 2018 for a stage IIIB melanoma of the upper back, a site sunburnt repeatedly while working on the flight line on warlike service in Afghanistan in 2008 and 2009. The four months before onset run from 10 December 2017 to 10 April 2018.

Factor 9(9): being overweight for at least five years when aged less than 30 years before the clinical onset of multiple sclerosis, and where this five year period occurred within the 15 years before the clinical onset of multiple sclerosis; — MET

- Her BMI was 25 or more from 2007 and 30 or more from 2008 to 2014, more than five years between the ages of 21 and 28, within the 15 years before onset. Weight gain was greatest during the 12 months of night shifts on warlike service in the Middle East, when her BMI reached 31.9.

Factor 9(10): having type 1 diabetes mellitus before the clinical onset of multiple sclerosis; — MET

- Type 1 diabetes mellitus was diagnosed on 18 June 2014 with GAD antibodies, after a febrile enteroviral illness in the final weeks of her warlike service in Afghanistan in 2013. It was present for almost four years before onset.

Worsening factors

Factor 9(11): having onset of a viral or bacterial infection within the five weeks before, or the two weeks after, the clinical worsening of multiple sclerosis; — MET

- COVID-19 pneumonia began on warlike service in Iraq on 25 October 2021, 24 days before the worsening of 18 November 2021.

Factor 9(12): smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of multiple sclerosis, and where smoking has ceased, the clinical worsening of multiple sclerosis has occurred within five years of cessation; — MET

- About 18 pack-years had been smoked, including during her warlike deployments, when she stopped on 15 January 2020, and the worsening on warlike service in Iraq on 18 November 2021 was within five years of cessation.

Factor 9(13): being exposed to second-hand smoke for at least 10 000 hours before the clinical worsening of multiple sclerosis; — MET

- More than 14 000 hours of enclosed second-hand smoke exposure, including about 3 500 hours on warlike service, had accumulated before the worsenings of 2018 and 2021.

Factor 9(14): undergoing a course of treatment with a tumour necrosis factor alpha antagonist within the two years before the clinical worsening of multiple sclerosis; — MET

- Adalimumab, prescribed for reactive spondyloarthritis following dysentery on warlike service in Afghanistan, was taken until 10 December 2017, within the two years before the worsening of 20 August 2018.

Factor 9(15): undergoing a course of treatment with granulocyte colony-stimulating factor or interferon within the one year before the clinical worsening of multiple sclerosis; — MET

- Interferon beta-1a was taken from 02 July 2018, within the one year before the worsening of 20 August 2018, and was being taken, with interruption, during warlike service in Iraq before the worsening of 18 November 2021.

Factor 9(16): undergoing a course of treatment with an immune checkpoint inhibitor within the four months before the clinical worsening of multiple sclerosis; — MET

- Pembrolizumab for the melanoma caused by sun exposure on warlike service in Afghanistan was last given on 30 April 2018, within the four months before the worsening of 20 August 2018.

Factor 9(17): experiencing the death of a significant other within the six months before the clinical worsening of multiple sclerosis; — MET

- Her close friend and section commander was killed in a rocket attack on warlike service in Iraq on 12 October 2021, 37 days before the worsening.

Factor 9(18): experiencing a category 1A stressor within the six months before the clinical worsening of multiple sclerosis; — MET

- She survived the rocket attack of 12 October 2021 on warlike service in Iraq, a life-threatening event, 37 days before the worsening.

Factor 9(19): experiencing a category 1B stressor within the six months before the clinical worsening of multiple sclerosis; — MET

- On 12 October 2021 on warlike service in Iraq she was an eyewitness to her section commander being killed and gave first aid to critically injured casualties, 37 days before the worsening.

Factor 9(20): experiencing a category 2 stressor within the six months before the clinical worsening of multiple sclerosis; — MET

- On warlike service in Iraq from 20 September 2021 she was socially isolated and in ongoing conflict with a supervisor about her fitness to serve, with stressful workloads after the attack, causing ongoing distress recorded on 04 November 2021.

Factor 9(21): having a medical illness or injury, other than multiple sclerosis, which is life-threatening or which results in serious physical or cognitive disability, within the six months before the clinical worsening of multiple sclerosis; — MET

- Life-threatening COVID-19 pneumonia with hypoxia, contracted on warlike service in Iraq, began on 25 October 2021, 24 days before the worsening. Metastatic melanoma with a brain metastasis, a life-threatening illness, was also present within the six months before the worsening of 20 August 2018.

Factor 9(22): for women only, using hormonal assisted reproductive therapy within the three months before the clinical worsening of multiple sclerosis; — MET

- She used follicle stimulating hormone, a gonadotrophin-releasing hormone antagonist and chorionic gonadotrophin from 20 August to 06 September 2021 so that embryos could be stored before her warlike deployment to Iraq, within the three months before the worsening of 18 November 2021.

Factor 9(23): undergoing a course of therapeutic radiation for cancer, where the affected site was in the field of radiation, before the clinical worsening of multiple sclerosis; — MET

- Whole-brain radiotherapy for metastatic melanoma, a cancer arising from sun exposure on warlike service in Afghanistan, was completed on 15 June 2018, with the whole brain in the field, before the worsenings of 20 August 2018 and 18 November 2021.

Factor 9(24): having received a cumulative equivalent dose of at least 10 sieverts of ionising radiation to the affected site before the clinical worsening of multiple sclerosis; — MET

- The radiation oncology record shows a prescribed dose of 30 Gy to the whole brain, a cumulative equivalent dose of 30 sieverts to the sites of the new lesions, delivered before the worsenings of 2018 and 2021.

Factor 9(25): having dyslipidaemia at the time of the clinical worsening of multiple sclerosis; — MET

- Total cholesterol was 6.4 mmol/L on 20 August 2018, and the veteran was on regular atorvastatin to normalise her lipids, prescribed with her type 1 diabetes, at both worsenings.

Factor 9(26): inability to obtain appropriate clinical management for multiple sclerosis. — MET

- On warlike service in Iraq her interferon was spoiled by a refrigeration failure and could not be replaced for five weeks, and when the relapse began on 18 November 2021 no neurologist, MRI or intravenous methylprednisolone was available. Evacuation took four days and MRI nine days.

The % contribution of the causes is 100% and significant.

Sequelae

The multiple sclerosis has caused spastic paraparesis, neurogenic bladder with urge incontinence, left optic atrophy with reduced visual acuity, fatigue and cognitive impairment, and the veteran has developed a depressive disorder in response to her disability and loss of career. These are sequelae of the multiple sclerosis and should be considered for acceptance.

Unintended Consequence

Met. The adalimumab and pembrolizumab that preceded the onset, and the whole-brain radiotherapy that preceded the first worsening, were prescribed and paid for by the Commonwealth while the veteran was serving, for reactive spondyloarthritis and melanoma linked to her operational service. Their recognised effect in provoking or aggravating demyelination is an unintended consequence of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. On warlike service in Iraq the veteran's interferon beta-1a was spoiled by a refrigeration failure and could not be replaced for five weeks. When the severe relapse began on 18 November 2021 there was no neurologist, no MRI and no intravenous methylprednisolone at the air base, she waited four days for aeromedical evacuation and nine days for MRI, and her EDSS rose from 3.0 to 6.0 with incomplete recovery. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that interrupt disease-modifying treatment and delay relapse treatment amount to an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 21 Mar 2005, Inpatient record and serology, Medical Officer, Base health facility
2. 15 Jan 2011, Pathology report, serum 25-hydroxyvitamin D, deployed health facility, Middle East
3. 14 Nov 2011, Occupational health review, Medical Officer, RAAF base health centre
4. 18 Jun 2014, Endocrinology consultation, Endocrinologist
5. 08 Mar 2016, Rheumatology consultation, Rheumatologist
6. 17 Oct 2017, Histopathology report and surgical oncology letter, Surgical oncologist
7. 05 Mar 2018, MRI brain report, Radiologist
8. 17 Apr 2018, MRI brain and cervical spine report and CSF analysis, Radiologist and Pathologist
9. 21 May 2018, Neurology consultation, Neurologist
10. 15 Jun 2018, Radiotherapy treatment summary, Radiation oncologist
11. 22 Aug 2018, MRI brain report and neurology review, Neurologist
12. 08 Sep 2021, Fertility treatment summary, Fertility specialist
13. 04 Nov 2021, Mental health assessment, Mental Health Officer, Role 3 hospital, Iraq
14. 18 Nov 2021, Aeromedical evacuation record, Senior Medical Officer, Iraq
15. 30 Nov 2021, MRI brain and spine report and neurology admission, Neurologist
16. Statement of Principles concerning Multiple Sclerosis (Balance of Probabilities) No. 12 of 2020, Repatriation Medical Authority
17. Statement of Principles concerning Multiple Sclerosis (Reasonable Hypothesis) No. 11 of 2020, Repatriation Medical Authority