Diagnostic Assessment — Left Thoracic Dermatome - Shingles (Herpes Zoster)
Example 1 of 1 · fictitious patient (Veteran DL)
Diagnostic Assessment
Left Thoracic Dermatome - Shingles (Herpes Zoster)
BOP Code: 28 of 2023 (Shingles and Postherpetic Neuralgia)
RH Code: 27 of 2023 (Shingles and Postherpetic Neuralgia)
ADF History
Veteran DL, date of birth 19 October 1979, Australian Army, Infantry Soldier (later Warrant Officer, Operations), enlisted 02 February 1998, medically discharged 17 March 2025. Operational service: East Timor, 10 October 1999 to 20 April 2000 (warlike); Afghanistan, 01 March 2010 to 15 October 2010 (warlike); South Sudan, 15 November 2023 to 28 May 2024 (non-warlike).
Occupational History
As an infantry soldier and later an operations warrant officer the veteran patrolled on foot with heavy loads, lived in crowded field accommodation and travelled in protected vehicles exposed to improvised explosive device blast. On United Nations service he lived and worked in an austere camp with shared facilities, limited medical support and long periods away from Australian health services.
Infantry soldiers have high rates of blast injury, traumatic brain injury, chest and abdominal trauma, dust and smoke exposure and psychological injury. Crowded living conditions on deployment expose them to outbreaks of respiratory and childhood infections, and remote postings limit access to vaccination and timely treatment.
History
Veteran DL, an infantry soldier and later an operations warrant officer in the Australian Army, developed shingles in the left T6 dermatome on United Nations service in South Sudan on 18 February 2024, five weeks after fracturing the left sixth and seventh ribs, while taking methotrexate and prednisolone for rheumatoid arthritis and after COVID-19 on deployment. He also had a moderate traumatic brain injury and splenectomy from a blast in Afghanistan, diabetes, depression and persistent asthma, and had been prevented from receiving recommended zoster vaccination. Postherpetic neuralgia followed and worsened in May 2024.
Timeline
- 04 Feb 1998 — At enlistment the veteran had no recorded history of chickenpox and varicella-zoster IgG was negative. He was given two doses of live attenuated varicella vaccine, on 04 February and 08 April 1998, under the recruit immunisation programme. "VZV IgG negative, varicella vaccine"
- 22 Jan 2000 — During warlike service in East Timor he developed fever and a generalised itchy vesicular rash during a varicella outbreak among local workers at the base. The medical officer diagnosed breakthrough chickenpox, with about 60 lesions, and he was isolated for seven days. "breakthrough chickenpox, isolated"
- 19 Jun 2010 — During warlike service in Afghanistan his vehicle struck an improvised explosive device. He lost consciousness for about two hours, had a Glasgow Coma Scale score of 9 and post-traumatic amnesia for four days, and CT showed bifrontal contusions. A ruptured spleen was removed at laparotomy at the role 3 hospital. A moderate traumatic brain injury was diagnosed. "moderate TBI, splenectomy"
- 14 Sep 2011 — A psychiatrist diagnosed major depressive disorder, recurrent, related to his blast injury and loss of colleagues, and commenced sertraline, continued thereafter. A respiratory physician diagnosed persistent asthma of moderate severity after deployment dust and burn pit smoke exposure, with daily symptoms, weekly night waking and an FEV1 of 68 per cent predicted, and commenced inhaled budesonide-formoterol. "depression, moderate persistent asthma"
- 05 Mar 2021 — A rheumatologist confirmed seropositive rheumatoid arthritis and continued methotrexate 20 mg weekly with prednisolone 15 mg daily, and recommended recombinant zoster vaccine because he was immunosuppressed. Type 2 diabetes, diagnosed in 2019, was being treated with metformin. Posted to an isolated training area in northern Australia, he could not obtain the vaccine before deploying, because it was not stocked there and he was not released for travel. The vaccine was still not given by March 2023. "zoster vaccine recommended, not given"
- 10 Jan 2024 — On United Nations service in South Sudan he fell from the rear of a vehicle onto a steel step and fractured the left sixth and seventh ribs posteriorly, confirmed on X-ray. He had COVID-19, confirmed by rapid antigen and PCR testing, from 20 December 2023. He continued methotrexate and prednisolone. "left rib 6-7 fractures"
- 20 Feb 2024 — He presented with burning pain around the left chest wall from 18 February 2024 and, from the next day, a band of grouped vesicles on a red base following the left T6 dermatome from the spine to the midline. PCR of vesicle fluid detected varicella-zoster virus, genotyped as the vaccine (Oka) strain. Valaciclovir was not available at the team site and was not started until 24 February 2024. "left T6 zoster, vaccine strain"
- 10 May 2024 — Pain in the left T6 dermatome had not settled after the rash healed and had become severe, with allodynia to clothing and a pain score rising from 4 to 9 out of 10, and a fresh crop of vesicles appeared in the same dermatome. Repeat PCR confirmed varicella-zoster virus. HbA1c was 8.6 per cent and he remained on methotrexate and prednisolone. Postherpetic neuralgia with recurrent zoster was diagnosed, and pregabalin and nortriptyline were commenced. "worsening postherpetic neuralgia, recurrence"
Symptoms
At onset the veteran had burning, stabbing pain around the left side of the chest at the level of the lower shoulder blade, followed by a band of painful blisters from the spine to the front of the chest, with fever and malaise. After the rash healed the pain persisted, with extreme sensitivity of the skin to touch and clothing, and it worsened in May 2024 with a further crop of blisters.
He now reports constant burning pain and electric shocks in the left T6 band, worse at night and with clothing, body armour or a seatbelt, poor sleep, low mood and difficulty concentrating, despite pregabalin and nortriptyline.
Imaging
- 19 Jun 2010 — CT brain: "Bifrontal haemorrhagic contusions with a small subdural haematoma. No midline shift."
- 10 Jan 2024 — X-ray left ribs: "Undisplaced fractures of the posterior left sixth and seventh ribs. No pneumothorax."
Onset Date
The most likely date of onset of this condition is 18 Feb 2024.
At that date the veteran was on non-warlike United Nations service in South Sudan as an operations warrant officer, recovering from left rib fractures, on methotrexate and prednisolone for rheumatoid arthritis, and recently recovered from COVID-19. Burning left chest wall pain began on 18 February 2024 and the dermatomal rash followed the next day.
This date is appropriate because the rib fracture review of 31 January 2024 recorded fracture pain only, with normal skin and no dermatomal burning pain, and he presented with the characteristic prodrome and rash on 20 February 2024, two days after the pain began. It falls within non-warlike service.
For the trauma factors, the 6 weeks before onset run from 07 Jan 2024 to 18 Feb 2024 and the 8 weeks before onset from 24 Dec 2023 to 18 Feb 2024, and the rib fractures occurred on 10 Jan 2024, 39 days before onset. For the vaccination factor, the period between 1 and 5 years before onset runs from 18 Feb 2019 to 18 Feb 2023, and recombinant zoster vaccine was recommended on 05 Mar 2021 and not available to him throughout the rest of that period. For the SARS-CoV-2 factor, the 6 months before onset run from 18 Aug 2023 to 18 Feb 2024, and COVID-19 began on 20 Dec 2023. Chickenpox (22 Jan 2000), live varicella vaccine (1998), splenectomy and moderate traumatic brain injury (19 Jun 2010), persistent asthma of moderate severity and depressive disorder (14 Sep 2011), diabetes mellitus (2019), rheumatoid arthritis and immunosuppression (from 2021) were all established before 18 Feb 2024 and present on that date.
For the worsening factors, the period after onset runs from 18 Feb 2024 to the documented worsening on 10 May 2024, during which methotrexate and prednisolone continued and diabetes was poorly controlled, with an HbA1c of 8.6 per cent at the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Left Thoracic Dermatome - Shingles (Herpes Zoster) of the left T6 dermatome, vaccine strain, complicated by postherpetic neuralgia (ICD-10 B02.2), under the Statements of Principles concerning shingles and postherpetic neuralgia, Balance of Probabilities No. 28 of 2023 and Reasonable Hypothesis No. 27 of 2023.
Shingles is caused by reactivation of varicella-zoster virus, which lies dormant in the sensory nerve ganglia after chickenpox or live varicella vaccination. When cell-mediated immunity falls, the virus travels down a sensory nerve and causes pain followed by a band of blisters in the area of skin supplied by that nerve, the dermatome. Risk rises with age, immunosuppressive drugs, diabetes, autoimmune disease, chronic illness, depression, trauma to the dermatome, splenectomy and recent COVID-19. Postherpetic neuralgia is nerve pain persisting after the rash has healed, and can be severe and long-lasting.
The condition began on 18 February 2024 on United Nations service in South Sudan, was confirmed by PCR on 20 February 2024, and worsened with severe postherpetic neuralgia and a recurrence on 10 May 2024.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
18 February 2024.
When did the veteran first present to a health / medical provider for this condition?
20 February 2024.
When was the condition confirmed / formally diagnosed?
20 February 2024.
When did the veteran first present to you (or your practice) for this condition?
14 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 on 20 February 2024 by the characteristic prodromal burning pain followed by grouped vesicles on a red base confined to the left T6 dermatome, and by PCR of vesicle fluid detecting varicella-zoster virus, genotyped as the vaccine (Oka) strain. This meets the Statement of Principles definition of shingles, and the vaccine-strain result confirms vaccine-strain shingles.
Postherpetic neuralgia was diagnosed on 10 May 2024, with severe pain and allodynia persisting in the same dermatome for more than two months after the rash had healed, and the recurrence in that dermatome was confirmed by repeat PCR.
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 18 February 2024, after 1 July 2004, during non-warlike service in South Sudan. 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 East Timor in 1999 to 2000, where he had chickenpox, in Afghanistan in 2010, where he sustained the brain injury and splenectomy and the asthma and depression arose, and his non-warlike service in South Sudan in 2023 to 2024, where the rib fractures, COVID-19, onset and worsening occurred. The Balance of Probabilities instrument applies to peacetime service.
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 Shingles and Postherpetic Neuralgia, No. 28 of 2023
Causative factors
Factor 9(1): having chickenpox before the clinical onset of shingles or postherpetic neuralgia; — MET
- The veteran had breakthrough chickenpox diagnosed by a medical officer on 22 January 2000, with fever and about 60 vesicular lesions, during an outbreak at his base, 24 years before onset. Varicella-zoster virus then lay latent in his sensory ganglia.
Factor 9(2): for vaccine strain shingles only, having live attenuated varicella vaccine before the clinical onset of shingles or postherpetic neuralgia; — MET
- PCR genotyping of vesicle fluid on 20 February 2024 identified the vaccine (Oka) strain. The veteran received two doses of live attenuated varicella vaccine on 04 February and 08 April 1998 under the recruit immunisation programme, 26 years before onset.
Factor 9(3): being prevented from accessing appropriate varicella-zoster vaccination in accordance with contemporary medical standards of the time, between 1 and 5 years before the clinical onset of shingles or postherpetic neuralgia; — MET
- On 05 March 2021 a rheumatologist recommended recombinant zoster vaccine because the veteran was immunosuppressed, in line with the national immunisation recommendations of that time for immunocompromised adults. Posted to an isolated training area where it was not stocked and not released for travel, he could not obtain it, and it had still not been given by March 2023. This was between 1 and 5 years before onset, from 18 February 2019 to 18 February 2023.
Factor 9(4): being in an immunocompromised state as specified at the time of the clinical onset of shingles or postherpetic neuralgia; — MET
- At onset on 18 February 2024 the veteran was taking methotrexate 20 mg weekly and prednisolone 15 mg daily for rheumatoid arthritis, immunosuppressive drugs that substantially suppress immune responses, as confirmed by the rheumatologist on 05 March 2021 and in his deployment medication record.
Factor 9(5)(a): having trauma, including surgery, involving: the dermatome affected by shingles or postherpetic neuralgia; within the 6 weeks before the clinical onset of shingles or postherpetic neuralgia; — MET
- On 10 January 2024 he fell onto a steel vehicle step and fractured the posterior left sixth and seventh ribs, blunt trauma to the left T6 dermatome, 39 days before onset, within the 6 weeks before onset from 07 January to 18 February 2024. The fall occurred in the course of his duties.
Factor 9(5)(b): having trauma, including surgery, involving: the nerve supply to the dermatome affected by shingles or postherpetic neuralgia; within the 6 weeks before the clinical onset of shingles or postherpetic neuralgia; — MET
- The left sixth intercostal nerve, which supplies the T6 dermatome, runs in the groove beneath the fractured left sixth rib, and the fracture of 10 January 2024 involved that nerve supply, 39 days before onset.
Factor 9(6): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of shingles or postherpetic neuralgia; — MET
- Seropositive rheumatoid arthritis, on the specified list of autoimmune diseases, was confirmed by a rheumatologist on 05 March 2021 and was active and treated at onset on 18 February 2024.
Worsening factors
Factor 9(7): being in an immunocompromised state as specified at the time of the clinical worsening of shingles or postherpetic neuralgia; — MET
- The veteran was still taking methotrexate 20 mg weekly and prednisolone 15 mg daily on 10 May 2024, when severe postherpetic neuralgia with a pain score rising from 4 to 9 out of 10 and a PCR-confirmed recurrence in the same dermatome were documented.
Factor 9(8): inability to obtain appropriate clinical management for shingles and postherpetic neuralgia. — MET
- Antiviral treatment for shingles should start within 72 hours of the rash. Valaciclovir was not available at his team site in South Sudan and was not started until 24 February 2024, five days after the rash appeared, and he had no access to pain specialist care until his return. Early antiviral treatment reduces the risk and severity of postherpetic neuralgia. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Shingles and Postherpetic Neuralgia, No. 27 of 2023
Causative factors
Factor 9(1): having chickenpox before the clinical onset of shingles or postherpetic neuralgia; — MET
- The veteran contracted breakthrough chickenpox during a varicella outbreak on warlike service in East Timor, diagnosed on 22 January 2000, 24 years before onset.
Factor 9(2): for vaccine strain shingles only, having live attenuated varicella vaccine before the clinical onset of shingles or postherpetic neuralgia; — MET
- The shingles was vaccine strain on PCR genotyping. He had received live attenuated varicella vaccine in 1998, and the latent vaccine virus reactivated during his non-warlike service in South Sudan while he was immunosuppressed.
Factor 9(3): being prevented from accessing appropriate varicella-zoster vaccination in accordance with contemporary medical standards of the time, between 1 and 5 years before the clinical onset of shingles or postherpetic neuralgia; — MET
- Recombinant zoster vaccine was recommended on 05 March 2021, but because of his posting to an isolated training area and his preparation for non-warlike service in South Sudan he was not able to receive it at any time up to February 2023, between 1 and 5 years before onset.
Factor 9(4): being in an immunocompromised state as specified at the time of the clinical onset of shingles or postherpetic neuralgia; — MET
- Methotrexate 20 mg weekly and prednisolone 15 mg daily were taken throughout his non-warlike service in South Sudan, including at onset on 18 February 2024.
Factor 9(5)(a): having trauma, including surgery, involving: the dermatome affected by shingles or postherpetic neuralgia; within the 8 weeks before the clinical onset of shingles or postherpetic neuralgia; — MET
- On non-warlike service in South Sudan on 10 January 2024 he fractured the left sixth and seventh ribs in a fall from a vehicle, trauma to the left T6 dermatome 39 days before onset, within the 8 weeks before onset from 24 December 2023 to 18 February 2024.
Factor 9(5)(b): having trauma, including surgery, involving: the nerve supply to the dermatome affected by shingles or postherpetic neuralgia; within the 8 weeks before the clinical onset of shingles or postherpetic neuralgia; — MET
- The fracture of the left sixth rib on non-warlike service on 10 January 2024 involved the left sixth intercostal nerve, the nerve supply to the T6 dermatome, 39 days before onset.
Factor 9(6): having diabetes mellitus at the time of the clinical onset of shingles or postherpetic neuralgia; — MET
- Type 2 diabetes mellitus was diagnosed in 2019, aggravated by long-term prednisolone, and was present on non-warlike service at onset, with an HbA1c of 8.1 per cent in January 2024.
Factor 9(7): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of shingles or postherpetic neuralgia; — MET
- Rheumatoid arthritis was active at onset on non-warlike service in South Sudan, with flares in the hands and wrists recorded on deployment.
Factor 9(8): having a depressive disorder at the time of the clinical onset of shingles or postherpetic neuralgia; — MET
- Major depressive disorder was diagnosed by a psychiatrist on 14 September 2011, arising from the blast and loss of colleagues on warlike service in Afghanistan, and was present and treated with sertraline at onset.
Factor 9(9): having a chronic medical condition from the specified list of chronic medical conditions before the clinical onset of shingles or postherpetic neuralgia; — MET
- Persistent asthma of moderate severity was diagnosed on 14 September 2011, with daily symptoms, weekly night-time symptoms and an FEV1 of 68 per cent predicted for more than six months, after dust and burn pit smoke exposure on warlike service in Afghanistan. It was present before onset.
Factor 9(10): having a moderate to severe traumatic brain injury before the clinical onset of shingles or postherpetic neuralgia; — MET
- A moderate traumatic brain injury, with loss of consciousness for two hours, a Glasgow Coma Scale score of 9, post-traumatic amnesia for four days and bifrontal contusions, was sustained in an improvised explosive device blast on warlike service in Afghanistan on 19 June 2010.
Factor 9(11): having a splenectomy before the clinical onset of shingles or postherpetic neuralgia; — MET
- His ruptured spleen was removed at laparotomy at the role 3 hospital after the blast on warlike service in Afghanistan on 19 June 2010, almost 14 years before onset.
Factor 9(12): having an active symptomatic infection resulting in SARS-CoV-2 within the 6 months before the clinical onset of shingles or postherpetic neuralgia; — MET
- Symptomatic COVID-19, confirmed by PCR and diagnosed by the medical officer, began on 20 December 2023 on non-warlike service in South Sudan, within the 6 months before onset from 18 August 2023 to 18 February 2024.
Worsening factors
Factor 9(13): being in an immunocompromised state as specified at the time of the clinical worsening of shingles or postherpetic neuralgia; — MET
- Methotrexate and prednisolone were continued on non-warlike service in South Sudan and were being taken at the worsening documented on 10 May 2024.
Factor 9(14): having diabetes mellitus at the time of the clinical worsening of shingles or postherpetic neuralgia; — MET
- Diabetes mellitus was present and poorly controlled at the worsening, with an HbA1c of 8.6 per cent on 10 May 2024, while he was still deployed in South Sudan.
Factor 9(15): inability to obtain appropriate clinical management for shingles and postherpetic neuralgia. — MET
- On non-warlike service in South Sudan valaciclovir was not available at his team site and was not started until five days after the rash, outside the 72-hour window, and specialist pain management was not available until his return. The postherpetic neuralgia became severe and the zoster recurred.
The % contribution of the causes is 100% and significant.
Sequelae
The shingles has been followed by postherpetic neuralgia in the left T6 dermatome, with chronic neuropathic pain, sleep disturbance and a worsening of his accepted depressive disorder, and by scarring of the skin in the dermatome. These should be considered for acceptance as sequelae.
Unintended Consequence
Met. The immunosuppression that allowed the virus to reactivate was caused by methotrexate and prednisolone prescribed and paid for by the Commonwealth while the veteran was serving, and the reactivating virus was the vaccine strain from the live varicella vaccine given under the recruit immunisation programme. Both 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. Antiviral treatment for shingles is most effective when started within 72 hours of the rash, particularly in immunosuppressed people, and reduces the risk of postherpetic neuralgia. On non-warlike service in South Sudan valaciclovir was not available at the veteran's team site and was not started until 24 February 2024, five days after the rash appeared, and he had no access to specialist pain management until his return. Recombinant zoster vaccine, recommended in March 2021, had also not been provided. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that delay time-critical antiviral treatment and recommended vaccination amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 04 Feb 1998, Enlistment medical examination and immunisation record, Medical Officer, Recruit health centre
- 22 Jan 2000, Outpatient health record, Medical Officer, East Timor
- 19 Jun 2010, Trauma admission, CT brain and operation report, Role 3 hospital, Afghanistan
- 14 Sep 2011, Psychiatric assessment, Consultant psychiatrist
- 14 Sep 2011, Respiratory function tests and specialist consultation, Respiratory physician
- 05 Mar 2021, Rheumatology consultation, Rheumatologist
- 20 Dec 2023, Outpatient health record and COVID-19 PCR, Medical Officer, South Sudan
- 10 Jan 2024, Outpatient health record and X-ray left ribs, Medical Officer, South Sudan
- 31 Jan 2024, Rib fracture review, Medical Officer, South Sudan
- 20 Feb 2024, Outpatient health record and VZV PCR with genotyping, Medical Officer and Pathologist
- 10 May 2024, Specialist review, Infectious diseases physician
- Statement of Principles concerning Shingles and Postherpetic Neuralgia (Balance of Probabilities) No. 28 of 2023, Repatriation Medical Authority
- Statement of Principles concerning Shingles and Postherpetic Neuralgia (Reasonable Hypothesis) No. 27 of 2023, Repatriation Medical Authority
