RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-00493
BRANCH OF SERVICE:  NAVY                                                                   sEPARATION dATE:  20041214
DATE PLACED ON TDRL:  20041215                                       DATE REMOVED FROM TDRL:  20081015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Operations Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “membranous lupus nephritis” with a disability rating of 10%.

CI CONTENTION:  The CI’s conditions continue to worsen and negatively affect daily activities.  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20041215/20081015	VARD - 20050815	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
Severe case of Membranous Lupus Nephritis	7541	60%	10%	Systemic Lupus	6350	100%	100%	
				Residual Neck Scar, Post Blood Clot, Right Jugular
Associated with Systemic Lupus	7804	10%	10%	
				Residuals Scar Right Shoulder, Post Catheter Infection
Associated with Systemic Lupus	7804	10%	10%	
				Residuals Scars to Inner Arms From PICC Line and Left
Back SP Kidney Biopsy Associated with Systemic Lupus	7802	0%	0%	
COMBINED RATING:  60% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Membranous Lupus Nephritis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s membranous lupus nephritis condition began in July 2004 after the findings of elevated laboratory results for kidney disease (creatinine 3-4 range), which presented as severe suprapubic abdominal pain and facial swelling. During hospitalization the CI had nephrotic-range proteinuria, hematuria (blood in the urine), a positive ANA (to test for connective tissue disease), positive anti-double stranded DNA antibody tests, and a kidney biopsy confirmatory of World Health Organization Class V systemic lupus nephritis.  Treatment consisted of oral and intravenous corticosteroids along with several days of dialysis.  However, the disease progressed to severe lupus nephritis and Cytoxan (cyclophosphamide, an immunosuppressive medication) along with intravenous methylprednisolone (a steroid) and dialysis were instituted.  Additionally, medication to raise her red blood count (erythropoietin) and to treat hypertension and preserve renal function (Monopril (fosinopril), Bumex (bumetanide), and Adalat (nifedipine)) were added to the treatment regimen.   

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated August 2004, 4 months prior to TDRL placement, the CI reported shortness of breath and joint aches.  Physical examination revealed noticeable edema on her cheeks and dry, scaling eczematous skin throughout.  The NARSUM dated 11 August 2004, 4 months prior to Temporary Disability Retirement List (TDRL) placement, indicated her kidney function was approximately 10% of that of a normal person and she would require medical intensive therapy for at least 6 months.  On examination her blood pressure was 119/92 and pulse 94.  Pertinent physical findings included a central venous catheter in place on the right upper extremity and 4+ pitting edema from the feet to the thighs bilaterally.  The CI was discharged from the hospital on 25 August 2004, but thereafter lower extremity swelling and leakage of clear fluid was noted.  Cytoxan therapy was continued along with hemodialysis and her renal function improved and swelling decreased as her weight normalized.  The CI developed a catheter infection with an associated right internal jugular clot, which was treated with antibiotics.  By October 2004 urinalysis revealed the absence of hematuria or proteinuria and serum creatinine normalized by December 2004.  Kidney dialysis and/or kidney transplantation were future possible considerations; therefore she was referred to the PEB for TDRL placement.  

At the VA Compensation and Pension (C&P) examination on 28 March 2005, performed 3 months after TDRL placement, the CI reported pain in her hands, her heels, her feet, and her hips and a rash when in the sun and a history of alopecia prior to her diagnosis.  On examination her blood pressure was 129/58, 143/53 and 141/62.  She had some periorbital edema, stretch marks of the lower extremities, and no lower extremity edema.  X-rays on 28 March 2005 of the chest, sacroiliac joints, knees, feet, and bilateral tibia and fibula were normal.

The TDRL removal examination in June 2008 indicated the CI was started on Plaquenil (hydroxychloroquine) to treat the lupus erythematosus in the summer of 2006 and mycophenolate mofetil (an immunosuppressive medication) was initiated in September 2007 for alopecia and synovitis (inflammation of the joint(s)).  She also took iron sulfate, B12 injections monthly, and narcotics and nonsteroidal anti-inflammatory medication as needed.  She reported urinary frequency and feelings of urinary urgency with arthralgias (joint pains) in many of the joints and an erythematous malar rash (of the cheeks).  Physical examination was within normal limits as were laboratory studies for renal function.  The examiner indicated that following treatment with cyclophosphamide and corticosteroids, complete remission had been maintained for the prior 3.5 years as evidenced by the presence of normal renal function and the absence of hematuria or proteinuria.  Hypertension was absent and there was no leukopenia, anemia or thrombocytopenia.  However, although the nephritis remained in remission, her systemic lupus was active and required chronic immunosuppression with close laboratory monitoring and required clinical follow-up.  The examiner also noted that treatment placed her at increased risk for infections and malignancy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 60% rating under the 7541 code (Renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes), which is rated based on renal dysfunction, citing a severe case of membranous lupus nephritis.  
The VA assigned a 100% rating using 6350 code (lupus erythematosus, systemic (disseminated)) based on the VA C&P examination 3 months after separation, citing systemic lupus.  The VA also assigned a 10% rating using the 7804 code for a residual neck scar, post blood clot, right jugular associated with systemic lupus, a 10% rating using code 7804 for residuals scar right shoulder, post catheter infection associated with systemic lupus, and a 0% rating using code 7802 for residual scars to inner arms from PICC line and left back s/p kidney biopsy associated with systemic lupus.  However, none of the aforementioned scars were in the scope of review.

Board members discussed whether the CI warranted a rating higher than 60% at the time of TDRL placement.  There were insufficient clinical or laboratory findings or symptoms (persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion) to justify an 80% rating or higher using the 7541 code.  Board members noted the VA assigned a 100% rating using code 6350, which states:  “Not to be combined with ratings under DC 7809 Acute, with frequent exacerbations, producing severe impairment of health.”  However, at the time of separation, the lupus nephritis had improved significantly, although the CI reported arthralgias, a rash in the sun, and alopecia.  However, Board members noted that those symptoms of lupus erythematosus did not appear to rise to the level of a severe impairment of health or substantiate a rating of 100%. 

On TDRL removal the PEB assigned a 10% rating under the 7541 code (renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes: rate as renal dysfunction), citing severe case of membranous lupus nephritis.  
By the time of the TDRL removal examination the CI had not had a recurrence of the lupus nephritis for more than 3 years.  Furthermore, the record was very limited and there was no credible evidence of laboratory abnormalities, slight edema or hypertension sufficient to warrant a 30% rating using code 7541 (Albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension at least 10 percent disabling under diagnostic code 7101).  Board members considered a higher rating using the 6350 code; however, there was no evidence of exacerbations of the systemic lupus erythematosus lasting a week or more, two or three times per year to warrant a 60% rating.  Lastly, since the CI reported arthralgias of many joints, Board members discussed a possible rating using 5099-5002 (arthritis rheumatoid (atrophic), since rheumatoid arthritis and lupus erythematosus both have arthralgias, although X-rays of the CI’s joints were normal.  Furthermore, a 20% rating requires one or two exacerbations a year in a well-established diagnosis.  The record did not provide any evidence related to exacerbations; therefore, to rate using that code would be speculative. 
 
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the membranous lupus nephritis condition for either the TDRL placement or TDRL removal.  

BOARD FINDINGS:  In the matter of the membranous lupus nephritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140723, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 21 Sep 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  
XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel
					(Manpower & Reserve Affairs)