Diagnostic Assessment — Left Thenar Eminence - Warts
Example 1 of 1 · fictitious patient
Diagnostic Assessment Left Thenar Eminence — Warts BOP Code: 8 of 2023 (Warts) RH Code: 7 of 2023 (Warts)
ADF History
The veteran, date of birth [withheld], Australian Army, Artilleryman, 25 September 1979 to 11 July 1986
History
The veteran had warts on both hands and wrists during ADF service, with the documented distribution encompassing the hand surfaces including the thenar eminence.
The thenar eminence is the fleshy mound at the base of the thumb on the palmar surface.
Two warts on the left thenar eminence were specifically documented on 10 December 1981, when liquid nitrogen was applied to them
Timeline
09 Dec 1981 — Warts on both hands and wrists recorded at an artillery regiment and referred for liquid nitrogen, which was applied on 10 December 1981. "Warts of hands and wrists" 10 Dec 1981 — Liquid nitrogen applied to warts: one on the right middle finger, two on the left thenar eminence and four on the left wrist. "x2 (L) thenar eminence" 26 Dec 1983 — Diathermy of warts on left hand under GA at RANH an artillery regiment. "Diathermy warts" 1 3.
Diagnosis, dates, confirmation: Left Thenar Eminence Warts — Viral Warts (ICD-10: B07.8).
Onset prior to 9 December 1981.
Confirmed clinically on 10 December 1981, when liquid nitrogen was applied to two warts on the left thenar eminence.
DRCA legislation.
Acquired in communal service environment.
100% service-related
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 23 December 1999 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 12 months before the clinical onset of warts — MET - Cutaneous warts are acquired from another person's wart virus, chiefly by direct skin contact, and are common among adolescents and young adults.
In the 12 months before 9 December 1981 the veteran, as a young adult and 18, lived and worked in close quarters with other young sailors on the survey ship an artillery regiment and then in an artillery regiment, working lines and handling steel cables and survey equipment alongside them; in such work and communal living, direct skin contact with shipmates' hands, without any barrier, is routine.
No specific contact is recorded, but that is not evidence that it did not occur, and it is reasonable to infer direct physical contact with another person's cutaneous warts within that period.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts affecting the anogenital region; the veteran's warts in this assessment affect the left thenar eminence.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's warts in this assessment affect the left thenar eminence.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 12 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's warts in this assessment affect the left thenar eminence, not the sole of the foot.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 12 months before the clinical onset of warts — NOT MET - Although the thenar eminence is part of the hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as an Artilleryman and Artilleryman do not include galley work.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the warts appeared in or before December 1981.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having direct physical contact with another person s cutaneous warts, within the 20 months before the clinical onset of warts — MET - In the 20 months before 9 December 1981 the veteran, as a young adult to 18, lived in shared accommodation as a recruit and trainee at naval establishments and then served in close quarters on the survey ship an artillery regiment and in an artillery regiment, working lines and cables alongside other young sailors, among whom cutaneous warts are common.
Direct skin contact with shipmates, without any barrier, is routine in that setting, and although no specific contact is recorded, it is reasonable to infer direct physical contact with another person's cutaneous warts within that period.
Factor 9(2): for warts affecting the cervix uteri only, having penetrative sexual intercourse with a person with genital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the cervix uteri and cannot apply to the veteran, who is a man.
Factor 9(3): for warts affecting the anogenital region only, having contact with the anogenital warts of another person within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts affecting the anogenital region; the veteran's warts in this assessment affect the left thenar eminence.
Factor 9(4): for warts affecting the oral cavity or the larynx only, having oral sex with a person with anogenital warts within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to warts of the oral cavity or larynx; the veteran's warts in this assessment affect the left thenar eminence.
Factor 9(5): for plantar warts only, using communal showering or bathing facilities within the 20 months before the clinical onset of warts — NOT MET - This factor applies only to plantar warts; the veteran's warts in this assessment affect the left thenar eminence, not the sole of the foot.
Factor 9(6): for warts on the hands only, using shared gloves or shared utensils on more days than not for 3 months in the preparation of meat, poultry or fish for consumption, within the 20 months before the clinical onset of warts — NOT MET - Although the thenar eminence is part of the hand, there is no record that the veteran prepared meat, poultry or fish with shared gloves or utensils, and his recorded duties as an Artilleryman and Artilleryman do not include galley work.
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical onset of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation, and nothing in his history suggests substantially lowered immune function when the warts appeared in or before December 1981.
Other Plausible Links to Service the veteran acquired and spread his warts while serving as a young Artilleryman and Artilleryman, living in close quarters on survey ships and at naval establishments with shared messes, ablutions and equipment.
His recorded duties included rope work and working ships' lines, lifting steel cables and cable drums (January 1981), scrubbing decks and diving on tide poles (1980), largely in the hot, humid climate of north Queensland.
Wet, abraded skin is more easily infected by the wart virus, which persists on shared ropes, tools and wet surfaces, and the wart clinic held by the sick bay of an artillery regiment in April 1983 suggests that warts were common in the Artilleryman.
These conditions of service plausibly contributed to the infection of his hands.
The left thenar eminence, the fleshy part of the palm at the base of the thumb, bears much of the grip and friction of hauling lines, rope work and handling cables and tools, and in the veteran, who is left-hand dominant, it takes the greater share of that load.
Friction and small abrasions at gripping surfaces favour inoculation of the wart virus and its spread from nearby warts, such as the large left wrist wart, which kept bumping against objects while he served in an artillery regiment and was excised on 8 February 1981.
On that basis the thenar eminence warts are most probably an extension of an in-service wart infection.
Conclusion the veteran's left thenar eminence warts are a human papillomavirus infection acquired during his naval service, most probably through direct contact with other personnel's warts in the close living and working conditions of ships and naval establishments (factor 9(1)) and by spread from his own earlier in-service warts, favoured by the grip and friction of rope and cable work on his dominant left palm.
After a single cryotherapy session in December 1981, warts of the left hand persisted and multiplied (factor 9(9)) until diathermy under general anaesthetic on 26 December 1983.
The warts therefore arose in the course of his service and were contributed to by its conditions.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's left thenar eminence warts are found not to have arisen out of his service, the following factors address whether service rendered after their clinical onset (on or before 9 December 1981) aggravated them or contributed to them in a material degree.
The two warts received liquid nitrogen on 10 December 1981; warts of the left hand then multiplied and required diathermy under general anaesthetic on 26 December 1983.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Warts, No.
8 of 2023) Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation while the warts persisted and spread between 1981 and 1983, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - The two warts on the left thenar eminence received one liquid nitrogen session on 10 December 1981 with no recorded review, although cryotherapy normally needs repeated sessions every two to three weeks until clearance.
No further treatment is recorded for 16 months, which included a November 1982 command signal suspecting him of malingering; by 7 April 1983 there were five warts on the left hand and arm, not located more precisely, and after two sessions that month and an artillery regiment's voyage in early 1983, warts of the left hand required diathermy under general anaesthetic on 26 December 1983.
Assessed objectively and subjectively under Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), this amounts to an inability to obtain appropriate clinical management.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Warts, No.
7 of 2023) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(8): being in an immunocompromised state as specified at the time of the clinical worsening of warts — NOT MET - There is no record of HIV infection, immunosuppressive drug treatment or renal transplantation while the warts persisted and spread between 1981 and 1983, and nothing in his history suggests substantially lowered immune function at that time.
Factor 9(9): inability to obtain appropriate clinical management for warts — MET - The two warts on the left thenar eminence received one liquid nitrogen session in December 1981 and no recorded follow-up for 16 months, which included a November 1982 command signal suspecting malingering; by April 1983 there were five warts on the left hand and arm, and warts of the left hand still required diathermy under general anaesthetic in January 1984.
Isolated treatments without specialist referral for two years amount to an inability to obtain appropriate clinical management as explained in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J)
Sequelae, Unintended Consequence, Inability
As per Left 5th Finger Warts
Date of Clinical Onset
Left thenar eminence warts are an infective condition.
Their date of clinical onset is the date on which they first appeared, which is no later than the date on which they were first recorded in the service medical records.
Later treatment, investigation or imaging does not alter the date of clinical onset.
First documented: 9 December 1981 — warts of the hands and wrists, with liquid nitrogen applied to two warts on the left thenar eminence the next day [ [CHART REVIEW document], pages 69 70].
As the condition was already present when it was first documented, its clinical onset was no later than that date.
Date of clinical onset: on or before 9 December 1981.
This date falls within the veteran's ADF service (25 September 1979 11 July 1986).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
