Diagnostic Assessment — Seronegative Polyarthritis
Example 1 of 1 · fictitious patient (Veteran DS)
Diagnostic Assessment
Seronegative Polyarthritis
BOP Code: 51 of 2017 (Rheumatoid Arthritis)
RH Code: 50 of 2017 (Rheumatoid Arthritis)
ADF History
Veteran DS, date of birth 11 May 1972, Australian Army, Combat Engineer (later Plant Operator), enlisted 22 January 1990, medically discharged 27 March 2015. Operational service: Somalia, 12 January 1993 to 20 May 1993 (warlike); East Timor, 25 October 1999 to 30 April 2000 (warlike); Afghanistan, 15 October 2006 to 28 May 2007 (warlike).
Occupational History
Combat engineers and plant operators build roads, airfields, bases and defensive works, drilling, cutting, grinding and blasting concrete and rock and operating earthmoving equipment, with heavy exposure to respirable crystalline silica dust, diesel exhaust, noise and vibration. Work on operations is often done without effective dust control or respiratory protection.
Engineers also provide first aid to casualties, with exposure to blood and body fluids, and serve long field postings with limited dental care, irregular diets and high rates of smoking.
History
Veteran DS, a combat engineer and plant operator in the Australian Army with heavy silica exposure and 25 pack-years of smoking, developed seronegative rheumatoid polyarthritis on 03 March 2010, eleven weeks after starting peginterferon for hepatitis C acquired on warlike service in Somalia. The condition worsened with new erosions in July 2013 after methotrexate was stopped abruptly and interferon was restarted.
Timeline
- 18 Mar 1993 — During warlike service in Somalia the veteran gave first aid to a civilian with a gunshot wound and had the casualty's blood splashed into his eyes and an open cut on his hand. No post-exposure testing was available in the field. He smoked about 40 cigarettes a day during the deployment. "blood splash, open cut, first aid"
- 08 Aug 2006 — A Defence dentist diagnosed generalised chronic periodontitis with pocket depths of 5 to 7 mm. His BMI was 32.0, and he had been obese since March 2004. He was preparing to deploy to Afghanistan with a reconstruction task force to build patrol bases and roads. "chronic periodontitis, pockets 7 mm"
- 15 May 2007 — On warlike service in Afghanistan, testing for fatigue showed a 25(OH)D of 29 nmol/L, after 32 nmol/L in November 2006. He reported daily cutting and drilling of concrete in dust and drinking about 750 mL a day of American soft drinks from the coalition exchange store. "vitamin D 29 nmol/L"
- 12 Nov 2009 — Chronic hepatitis C, genotype 1a, had been diagnosed in 2008. At the pre-treatment examination his joints were normal, with no synovitis, and ESR and CRP were normal. An occupational hygiene review that year estimated about 750 hours a year of silica dust exposure since 2000. Serial vitamin D results to December 2007 had all been below 50 nmol/L. Peginterferon and ribavirin treatment was planned. "joints normal, pre-treatment"
- 10 Mar 2010 — The veteran presented with a week of painful swelling of both hands and wrists and morning stiffness lasting two hours, beginning on 03 March 2010, eleven weeks after starting peginterferon on 14 December 2009. Examination showed symmetrical synovitis of the second and third metacarpophalangeal joints, both wrists and the metatarsophalangeal joints. CRP was 38 mg/L. "symmetrical MCP and wrist synovitis"
- 21 Apr 2010 — A rheumatologist found persisting symmetrical polyarthritis for seven weeks, with 12 swollen and 14 tender joints. Rheumatoid factor and anti-CCP antibodies were negative, and ultrasound showed synovitis with power Doppler signal. Seronegative rheumatoid arthritis was diagnosed. Methotrexate was recommended. "seronegative RA, 12 swollen joints"
- 15 Jul 2013 — After hepatitis C relapse, peginterferon was restarted on 10 June 2013, methotrexate, taken continuously since 01 June 2010, was stopped abruptly the same day and iron dextran was infused on 25 June 2013 for iron-deficiency anaemia from NSAID-related blood loss. On 15 July 2013 he had a severe flare, with DAS28 rising from 3.1 to 5.8 and 18 swollen joints. He had stopped smoking on 01 February 2012. "severe flare, DAS28 5.8"
- 30 Sep 2013 — Hand and foot X-rays showed new erosions at the right second and third metacarpophalangeal joints and the left fifth metatarsophalangeal joint, absent in 2010. Rheumatology review had been delayed by ten weeks. Adalimumab was approved in December 2013. "new erosions MCP and MTP"
Symptoms
At onset the veteran had painful swelling and stiffness of the small joints of both hands, both wrists and the forefeet, with morning stiffness lasting two hours, fatigue and difficulty gripping tools.
He now has chronic pain and stiffness in the hands, wrists and feet, reduced grip strength, deformity of the right second and third metacarpophalangeal joints, and fatigue, and he cannot operate machinery or perform heavy manual work.
Imaging
- 21 Apr 2010 — X-rays of hands and feet: "Periarticular osteopenia at the metacarpophalangeal joints. No erosions."
- 21 Apr 2010 — Ultrasound of hands and wrists: "Grey-scale synovitis with power Doppler signal at both wrists and the second and third metacarpophalangeal joints bilaterally."
- 30 Sep 2013 — X-rays of hands and feet: "New marginal erosions at the right second and third metacarpophalangeal joints and the left fifth metatarsophalangeal joint, with joint space narrowing."
Onset Date
The most likely date of onset of this condition is 03 Mar 2010.
At that date the veteran was serving full time as a plant operator in an engineer regiment in Australia. He had started peginterferon and ribavirin for hepatitis C on 14 December 2009. From 03 March 2010 he developed painful swelling and stiffness of both hands, wrists and forefeet.
This date is appropriate because the pre-treatment examination of 12 November 2009 recorded normal joints and normal inflammatory markers, and he first presented on 10 March 2010, one week after onset, with the polyarthritis persisting for more than six weeks and confirmed by a rheumatologist on 21 April 2010. It falls within continuous full-time service.
For the drug factors, the eight weeks before onset run from 06 Jan 2010 to 03 Mar 2010, throughout which he took weekly peginterferon. For the periodontitis factor, the three months before onset run from 03 Dec 2009 to 03 Mar 2010, throughout which periodontitis was active. For the silica, obesity and vitamin D factors, the ten years before onset run from 03 Mar 2000 to 03 Mar 2010, containing about 7,500 hours of silica exposure (2000 to 2009), obesity from March 2004, and vitamin D deficiency from November 2006 to December 2007. For the sweetened beverage factor, the five years before onset run from 03 Mar 2005 to 03 Mar 2010, containing his intake from January 2007. He was still smoking at onset, with about 25 pack-years.
For the worsening factors, the period after onset runs from 03 Mar 2010 to the documented worsening on 15 Jul 2013. The eight weeks before the worsening run from 20 May 2013 to 15 Jul 2013 and contain the restarted peginterferon (from 10 Jun 2013) and the iron dextran infusion (25 Jun 2013). The six months before the worsening run from 15 Jan 2013 and contain the abrupt cessation of methotrexate on 10 Jun 2013. The ten years before the worsening run from 15 Jul 2003 and contain about 5,250 hours of silica exposure, and the worsening was within two years of his stopping smoking on 01 Feb 2012.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Seronegative Polyarthritis, seronegative rheumatoid arthritis (ICD-10-AM M06.0), under the Statements of Principles concerning rheumatoid arthritis, Balance of Probabilities No. 51 of 2017 and Reasonable Hypothesis No. 50 of 2017.
Rheumatoid arthritis is a chronic autoimmune disease causing symmetrical inflammation of the synovium of the peripheral joints, typically the small joints of the hands, wrists and feet. About a quarter of patients have no rheumatoid factor or anti-CCP antibodies and are described as seronegative, but have the same pattern of synovitis and can develop the same erosive joint damage. Smoking, silica dust, periodontitis, obesity and immune-stimulating drugs such as interferon-alpha trigger or worsen the disease, and sudden withdrawal of disease-modifying treatment causes flares.
The diagnosis followed heavy silica exposure, smoking and periodontitis during service, and began eleven weeks after interferon treatment for hepatitis C acquired on warlike service. It began on 03 March 2010, was confirmed by a rheumatologist on 21 April 2010 and worsened with new erosions in 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
03 March 2010.
When did the veteran first present to a health / medical provider for this condition?
10 March 2010.
When was the condition confirmed / formally diagnosed?
21 April 2010.
When did the veteran first present to you (or your practice) for this condition?
02 October 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 rheumatologist on 21 April 2010 on a symmetrical inflammatory polyarthritis of the metacarpophalangeal, wrist and metatarsophalangeal joints persisting for seven weeks, with synovitis on ultrasound and raised inflammatory markers. This meets the Statement of Principles definition: a symmetric, inflammatory, peripheral polyarthritis persisting for at least six weeks, characterised by inflammatory synovitis.
Rheumatoid factor and anti-CCP antibodies were negative. Psoriatic arthritis, viral polyarthritis, systemic lupus erythematosus and gout were excluded on examination, serology and joint aspiration. New erosions on X-ray on 30 September 2013 confirmed established erosive disease after the worsening.
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 03 March 2010, 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 Reasonable Hypothesis instrument applies to the veteran's warlike service in Somalia in 1993, where the hepatitis C was acquired, and in East Timor and Afghanistan, where his silica exposure, smoking, periodontitis, sweetened drink intake and vitamin D deficiency were increased. The Balance of Probabilities instrument applies to his peacetime service, including most of his silica exposure.
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 Rheumatoid Arthritis, No. 51 of 2017
Causative factors
Factor 9(1): smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of rheumatoid arthritis, and where smoking has ceased, the clinical onset of rheumatoid arthritis has occurred within ten years of cessation; — MET
- The veteran smoked 25 cigarettes a day from 1990 and was still smoking at onset on 03 March 2010, a total of about 25 pack-years, far more than five. The habit began in recruit training and was sustained throughout his service, including on deployments where cigarettes were cheap and widely shared.
Factor 9(2): inhaling respirable crystalline silica dust, at the time material containing crystalline silica was being: (a) produced; (b) excavated; (c) drilled, cut or ground; or (d) used in construction, manufacturing, cleaning or blasting; for a cumulative period of at least 5 000 hours within the ten years before the clinical onset of rheumatoid arthritis; — MET
- As a combat engineer and plant operator from January 2000 to December 2009 the veteran drilled, cut and ground concrete and rock, operated rock breakers and quarried road base, with an estimated 750 hours a year in visible dust, recorded in his trade log and in a 2009 occupational hygiene review. This is about 7,500 hours within the ten years before onset, which run from 03 March 2000 to 03 March 2010, well over 5,000 hours.
Factor 9(3): being treated with a drug from the specified list of drugs within the eight weeks before the clinical onset of rheumatoid arthritis; — MET
- The veteran started peginterferon alfa-2a 180 micrograms weekly with ribavirin on 14 December 2009 for chronic hepatitis C, and was taking it weekly throughout the eight weeks before onset, from 06 January 2010 to 03 March 2010. Interferon-alpha is on the specified list. The hepatitis C was acquired from blood exposure while giving first aid to casualties during his service.
Factor 9(4): having periodontitis for at least the three months before the clinical onset of rheumatoid arthritis; — MET
- A Defence dentist diagnosed generalised chronic periodontitis on 08 August 2006, with pocket depths of 5 to 7 mm and bleeding on probing, and it remained active, despite scaling, throughout the three months before onset, from 03 December 2009 to 03 March 2010. Prolonged field postings without dental care contributed.
Factor 9(5): being obese for at least five years within the ten years before the clinical onset of rheumatoid arthritis; — MET
- The veteran's BMI was 31.4 in March 2004 and 30 or more at every periodic health examination to 2010 (33.2 in November 2009), so he was obese for more than five years within the ten years before onset, which run from 03 March 2000 to 03 March 2010.
Worsening factors
Factor 9(6): smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of rheumatoid arthritis, and where smoking has ceased, the clinical worsening of rheumatoid arthritis has occurred within two years of cessation; — MET
- He smoked about 27 pack-years before stopping on 01 February 2012, and the worsening on 15 July 2013 occurred 1 year and 5 months after cessation, within two years.
Factor 9(7): inhaling respirable crystalline silica dust, at the time material containing crystalline silica was being: (a) produced; (b) excavated; (c) drilled, cut or ground; or (d) used in construction, manufacturing, cleaning or blasting; for a cumulative period of at least 5 000 hours within the ten years before the clinical worsening of rheumatoid arthritis; — MET
- Between 03 July 2003 and December 2009 the veteran accumulated about 5,250 hours of crystalline silica exposure while drilling, cutting and grinding concrete and rock, more than 5,000 hours within the ten years before the worsening.
Factor 9(8): being treated with a drug from the specified list of drugs within the eight weeks before the clinical worsening of rheumatoid arthritis; — MET
- Hepatitis C relapsed and peginterferon alfa-2a was restarted on 10 June 2013, and given weekly throughout the eight weeks before the worsening, from 20 May 2013 to 15 July 2013.
Factor 9(9): suddenly discontinuing treatment with a disease modifying antirheumatic drug after undergoing continuous disease modifying antirheumatic drug treatment for at least six months, within the six months before the clinical worsening of rheumatoid arthritis; — MET
- Methotrexate 20 mg weekly had been taken continuously from 01 June 2010. On 10 June 2013 it was stopped abruptly, without a taper or substitute, because of hepatotoxicity concerns when interferon was restarted. This sudden discontinuation after nearly three years of continuous treatment was within the six months before the worsening on 15 July 2013.
Factor 9(10): having periodontitis for at least the three months before the clinical worsening of rheumatoid arthritis; — MET
- Periodontitis remained active, with tooth loss in 2012, throughout the three months before the worsening, from 15 April 2013 to 15 July 2013.
Factor 9(11): being obese for at least five years within the ten years before the clinical worsening of rheumatoid arthritis; — MET
- He remained obese, with a BMI of 34.0 in 2013 after prednisolone treatment, from 2004 to the worsening, more than five years within the ten years before it.
Factor 9(12): inability to obtain appropriate clinical management for rheumatoid arthritis. — MET
- After the flare began, an urgent rheumatology review and an alternative to methotrexate were requested, but the veteran waited ten weeks for review and biological therapy was not approved until December 2013. Uncontrolled synovitis produced new erosions on X-ray on 30 September 2013. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Rheumatoid Arthritis, No. 50 of 2017
Causative factors
Factor 9(1): smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of rheumatoid arthritis, and where smoking has ceased, the clinical onset of rheumatoid arthritis has occurred within 20 years of cessation; — MET
- The veteran had smoked about 25 pack-years by onset and was still smoking. His intake rose to 40 a day on warlike service in Somalia in 1993, East Timor in 1999 to 2000 and Afghanistan in 2006 to 2007.
Factor 9(2): inhaling respirable crystalline silica dust, at the time material containing crystalline silica was being: (a) produced; (b) excavated; (c) drilled, cut or ground; or (d) used in construction, manufacturing, cleaning or blasting; for a cumulative period of at least 2 500 hours within a continuous period of ten years, before the clinical onset of rheumatoid arthritis; — MET
- The veteran inhaled crystalline silica dust while drilling, cutting and grinding concrete and rock and excavating road base for more than 2,500 hours within the continuous period from 2000 to 2009, including construction tasks on warlike service in East Timor in 2000 and with a reconstruction task force in Afghanistan from October 2006 to May 2007.
Factor 9(3): being treated with a drug from Specified List 1 of drugs within the eight weeks before the clinical onset of rheumatoid arthritis; — MET
- Peginterferon alfa-2a, an interferon-alpha on Specified List 1, was given weekly from 14 December 2009, throughout the eight weeks before onset, for hepatitis C acquired from a casualty's blood while giving first aid on warlike service in Somalia in March 1993.
Factor 9(4): having periodontitis for at least the three months before the clinical onset of rheumatoid arthritis; — MET
- Chronic periodontitis, diagnosed on 08 August 2006, progressed during warlike service in Afghanistan from October 2006 to May 2007 without dental access and was active throughout the three months before onset.
Factor 9(5): being obese for at least five years within the ten years before the clinical onset of rheumatoid arthritis; — MET
- He was obese from March 2004 to onset, more than five years within the ten years before it, with weight gain after a knee injury and reduced training following warlike service in East Timor.
Factor 9(6): consuming an average of at least 400 millilitres per day of beverages sweetened with high fructose corn syrup, for a period of at least one year within the five years before the clinical onset of rheumatoid arthritis; — MET
- From January 2007 to December 2010 the veteran drank about 750 millilitres a day of American-made cola and energy drinks sweetened with high fructose corn syrup. He began drinking them from coalition dining facilities and exchange stores on warlike service in Afghanistan, and continued with imported brands at home. This is more than one year within the five years before onset.
Factor 9(7): having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre, for a continuous period of at least one year within the ten years before the clinical onset of rheumatoid arthritis; — MET
- Serum 25(OH)D was 32 nmol/L on 20 November 2006, 29 nmol/L on 15 May 2007 and 41 nmol/L on 14 December 2007, with no result of 50 nmol/L or more in between, a continuous period of more than one year within the ten years before onset. The deficiency began during warlike service in Afghanistan, working in winter and in full protective clothing.
Worsening factors
Factor 9(8): smoking at least five pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical worsening of rheumatoid arthritis, and where smoking has ceased, the clinical worsening of rheumatoid arthritis has occurred within five years of cessation; — MET
- About 27 pack-years were smoked, much of it on warlike deployments, and the worsening on 15 July 2013 occurred within five years of cessation on 01 February 2012.
Factor 9(9): inhaling respirable crystalline silica dust, at the time material containing crystalline silica was being: (a) produced; (b) excavated; (c) drilled, cut or ground; or (d) used in construction, manufacturing, cleaning or blasting; for a cumulative period of at least 2 500 hours within a continuous period of ten years, before the clinical worsening of rheumatoid arthritis; — MET
- His silica exposure exceeded 2,500 hours within the ten years before the worsening, including construction work on warlike service in Afghanistan in 2006 to 2007.
Factor 9(10): being treated with a drug from Specified List 2 of drugs within the eight weeks before the clinical worsening of rheumatoid arthritis; — MET
- Peginterferon alfa-2a (interferon-alpha) was restarted on 10 June 2013 for relapse of the hepatitis C acquired on warlike service in Somalia, and intravenous iron dextran was infused on 25 June 2013 for iron-deficiency anaemia. Both are on Specified List 2 and both were within the eight weeks before the worsening.
Factor 9(11): suddenly discontinuing treatment with a disease modifying antirheumatic drug after undergoing continuous disease modifying antirheumatic drug treatment for at least six months, within the six months before the clinical worsening of rheumatoid arthritis; — MET
- Methotrexate, taken continuously from 01 June 2010, was stopped suddenly on 10 June 2013 when interferon was restarted for hepatitis C acquired on warlike service, within the six months before the worsening.
Factor 9(12): having periodontitis for at least the three months before the clinical worsening of rheumatoid arthritis; — MET
- Periodontitis that progressed during warlike service remained active throughout the three months before the worsening.
Factor 9(13): being obese for at least five years within the ten years before the clinical worsening of rheumatoid arthritis; — MET
- He was obese for more than five years within the ten years before the worsening, from 2004 to 2013.
Factor 9(14): consuming an average of at least 400 millilitres per day of beverages sweetened with high fructose corn syrup, for a period of at least one year within the five years before the clinical worsening of rheumatoid arthritis; — MET
- His daily intake of about 750 millilitres of high fructose corn syrup-sweetened drinks from January 2007 to December 2010, which began on warlike service in Afghanistan, included more than one year within the five years before the worsening, which run from 15 July 2008.
Factor 9(15): having vitamin D deficiency, with a serum 25(OH)D level of less than 50 nanomoles per litre, for a continuous period of at least one year within the ten years before the clinical worsening of rheumatoid arthritis; — MET
- The continuous vitamin D deficiency of November 2006 to December 2007 fell within the ten years before the worsening, which run from 15 July 2003.
Factor 9(16): inability to obtain appropriate clinical management for rheumatoid arthritis. — MET
- Urgent rheumatology review and replacement therapy were not available for ten weeks after methotrexate was stopped, and new erosions developed by September 2013.
The % contribution of the causes is 100% and significant.
Sequelae
The seronegative polyarthritis is a sequela of the veteran's service exposures to silica dust and tobacco, of his service-related periodontitis, and of the interferon treatment of hepatitis C acquired on warlike service in Somalia. Its own sequelae include erosive joint damage and deformity of the hands, and iron-deficiency anaemia from anti-inflammatory treatment.
Unintended Consequence
Met. The onset followed peginterferon prescribed by Defence for service-related hepatitis C, and the worsening followed the restarting of peginterferon, the abrupt withdrawal of methotrexate and an iron dextran infusion, all directed by Defence health services. These are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. When methotrexate was stopped on 10 June 2013 no substitute disease-modifying drug was provided, and the urgent rheumatology review requested after the flare took ten weeks to obtain, with biological therapy not approved until December 2013. During that time the disease was uncontrolled and new erosions appeared. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the veteran sought appropriate treatment and could not obtain it in time, which is an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 18 Mar 1993, Field medical record, Medical Officer, Somalia
- 08 Aug 2006, Dental examination, Dental Officer
- 15 May 2007, Deployed health record and pathology, Medical Officer, Afghanistan
- 12 Nov 2009, Pre-treatment examination, Gastroenterologist
- 15 Jun 2009, Occupational hygiene review, Occupational hygienist
- 10 Mar 2010, Outpatient health record, Medical Officer, Base medical centre
- 21 Apr 2010, Rheumatology consultation, X-rays and ultrasound, Rheumatologist
- 10 Jun 2013, Hepatitis C retreatment plan, Gastroenterologist
- 15 Jul 2013, Outpatient health record, Medical Officer, Base medical centre
- 30 Sep 2013, X-rays of hands and feet and rheumatology review, Rheumatologist
- Statement of Principles concerning Rheumatoid Arthritis (Balance of Probabilities) No. 51 of 2017, Repatriation Medical Authority
- Statement of Principles concerning Rheumatoid Arthritis (Reasonable Hypothesis) No. 50 of 2017, Repatriation Medical Authority
