RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00679	
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070327		 

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty E-5 (Multiple Launch Rocket System/High Mobility Artillery Rocket System Crewmember) medically separated for erythema nodosa (EN) and obstructive sleep apnea (OSA) rated 0% and 0%, respectively.

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the 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/Naval 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 confined to review of medical records and all available evidence for application of the 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:  
   
IPEB – Dated 20061228	VA* - (~5 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Erythema Nodosa	7899-7806	0%	Erythema Nodosum	7899-7806	60%	20061028	
OSA, Mild Industrial Impairment	6847	0%	Sleep Apnea / Sarcoidosis / Moderate Obstructive Airway Disease	6699-6604	60%		
Hemochromatosis	Not Unfitting	Splenomegaly/
Hemochromatosis	7799-7704	40%		
Splenomegaly						
Other MEB/PEB Conditions x 0 (Not In Scope)	No Additional VA Conditions in Scope	
RATING:  0%	RATING:  90%	
*Derived from VA Rating Decision (VARD) dated 20070426.   

ANALYSIS SUMMARY:  

Erythema Nodosum (EN).  The service treatment record (STR) documents that the CI had a fever of unknown origin while deployed to Iraq.  He reported that he was hospitalized for 7 days and after 4 days developed skin lesions on his legs, and a rash on his left arm.  The CI was clinically diagnosed with EN and started on oral corticosteroids (Prednisone).  EN is a presumed delayed hypersensitivity reaction to antigens associated with the infectious agents, drugs, or diseases.  The diagnosis most frequently associated with EN is streptococcal pharyngitis (strep throat), but it is frequently idiopathic (unknown cause).  Eleven imaging studies (X-rays, CTs) of the chest and abdomen over 27 months showed splenomegaly (enlarged spleen) with no evidence of lymphadenopathy (enlarged lymph nodes).  An angiotensin converting enzyme (ACE) level, which can associated with sarcoidosis (a multisystem granulomatous disorder of unknown etiology), was modestly elevated.  A skin punch biopsy showed findings suggestive of EN.  General findings consistent with sarcoidosis were splenomegaly, an elevated ACE level, and EN, but findings of lymphadenopathy and granulomas (nodular masses of chronically inflamed tissue) were absent.  A dermatology evaluation reported that the CI had been clinically diagnosed with EN and been taking Prednisone daily for over 1-1/2 years.  The examiner opined that he had been initially started on Prednisone for a strong suspicion of sarcoidosis.  Sarcoidosis had not been confirmed and the dermatologist did not recommend continued corticosteroid treatment for clinical EN.  An internal medicine physician considered EN as a possible cutaneous manifestation of sarcoidosis.  It was not a definitive diagnosis as no granulomas (characteristic of sarcoidosis) were seen on biopsy.  The examiner recounted the negative evaluation by pulmonology (involved bronchoscopy and biopsy) and planned to slowly wean the CI off corticosteroids.  A right leg incisional wedge biopsy was consistent with EN but granulomas were absent.  In the narrative summary (NARSUM), 5 months before separation, the CI complained he was always tired, had difficulty breathing, and felt like he did not get a good solid night’s sleep.  The skin exam documented “The patient had several erythema nodosum rashes on his body.”  At a rheumatology consultation, the CI complained of arthralgias (diffuse joint pain) and arthritis, especially in the knees, and occasionally in the hands.  His main complaint was that he was “always tired, worn out, and sleepy.”  The exam documented “He does have erythema nodosum lesions over both lower extremities ….”  The assessment listed no diagnosis but the plan was for a trial of a corticosteroid-sparing and disease modifying agent (Imuran).  

At the Compensation and Pension (C&P) exam the CI complained of constant painful nodules on his lower legs with ulcer formation.  The skin exam documented “There is erythema nodosum skin condition present.  The skin condition located on the bilateral lower extremities and right lateral abdomen has the following characteristics: induration of less than six square inches.”  The skin lesion coverage relative to the whole body was 2% and 0% in the exposed area.  The MEB addendum reported in reference to the EN, “The dermatologist noted less than 5% of the patient's body surface area has involved lesions.  Currently the patient has two nodules on his right shin, one on his left shin, and one on his right abdomen.”  A rheumatology encounter documented “He says he is still having a great deal of aching and stiffness, and his nodules are returning … did notice increasing ACE levels.”  The assessment listed increased symptomatology and findings with a plan to continue Imuran and start another corticosteroid-sparing and disease modifying agent (Methotrexate).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the EN 0% (coded 7899-7806) citing affecting less than 5% of total body surface area.  The VA, citing the C&P exam 5 months before separation, rated the EN 60% (7899-7806) citing taking corticosteroids constantly for 12 months.  While the underlying etiology of the EN was never clearly established, systemic therapy with immunosuppressive drugs (corticosteroids and corticosteroid-sparing and disease modifying agents) was required for control.  While the skin lesions involved less than 5% of total body surface area, records showed constant systemic therapy with corticosteroids (Prednisone) or other immunosuppressive drugs (Imuran, Methotrexate) during the past 12-month period consistent with the 60% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the EN condition.

Obstructive Sleep Apnea (OSA).  The STR documents that the second night sleep study diagnosed OSA with need for a continuous positive airway pressure (CPAP) trial.  The NARSUM documented the CI underwent a sleep study, was found to be a candidate for CPAP, and had subsequently been using CPAP without concerns.  The MEB addendum by psychiatry recorded mild to moderate OSA.  The CI was placed on CPAP for one month and noticed no improvement in daytime hyper-somnolence.  The diagnosis listed breathing-related sleep disorder, in partial remission on CPAP.  The social and industrial impairment was listed as mild.  The C&P exam listed treatment with CPAP and no functional impairment resulting from the OSA condition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the OSA condition 0% (coded 6847) citing mild industrial impairment under the provisions of DoDI 1332.39, E2.A1.2.21.  The VARD included the sleep apnea condition with sarcoidosis and moderate obstructive airway disease and rated 60% (coded 6699-6604) citing pulmonary functions tests.  The second night sleep study diagnosed OSA and the CI was started on CPAP.  Initiation, and optimization, of CPAP pressure resulted in resolution of symptoms.  While not addressed in the commander’s statement, the OSA was implicated in the profile, MEB and PEB.  The PEB’s 0% rating for OSA was derived from DoDI 1332.39; however, IAW DoDI 6040.44, the Board’s rating recommendation must be derived from the VASRD.  VASRD §4.100 provides for a minimum rating of 50% for OSA requiring a breathing assistance device; and, the evidence establishes that the latter criterion was met in this case.  In consideration of these facts, the Board unanimously recommends a disability rating of 50% for the OSA condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hemochromatosis and splenomegaly conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Contended Hemochromatosis Condition.  A hematology evaluation diagnosed hemochromatosis (gene mutations resulting in increased intestinal iron absorption, overload, and tissue deposition) based upon genetic testing.  Additional genetic testing excluded other inherited disorders.  Labs did not demonstrate iron overload (ferritin [iron storage protein] equal 31.3 ng/ml [22.0-340.0]).  The hematologist recommended periodic phlebotomy (blood letting) of 500 cc of blood (to keep ferritin below 30) and annual surveillance with labs and imaging studies (liver ultrasound).  Typical clinical manifestations of iron overload include weakness, lethargy, and arthralgia.  Progressive iron deposition in the liver can be associated with hepatosplenomegaly (enlarged liver and spleen).  While serial computed tomography (CTs) found mild to moderate splenomegaly, there was no comment on hepatomegaly (enlarged liver).  Labs showed the CI was heterozygous (one gene mutation copy present) for the H63D gene mutation.  The clinical significance of the H63D genotype is uncertain as most will not have iron overload.  While genetic testing was consistent with hemochromatosis, serial comprehensive iron studies did not show iron overload.  Without overload, it is unlikely there would be excess iron deposition, and disease manifestation.  

Contended Splenomegaly Condition.  A normal adult spleen is less than 13 cm in the longest axis.  Serial CTs incidentally found mild to moderate splenomegaly with a maximum measured dimension of 14 cm.  Splenomegaly can be associated with many disorders to include hemochromatosis and sarcoidosis.  Typical clinical manifestations of symptomatic splenomegaly include a sense of fullness, early satiety, and pain.  While hemochromatosis and splenomegaly were profiled, they were not implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that the hemochromatosis and splenomegaly conditions significantly interfered with satisfactory duty performance.
BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board surmised from the record or PEB ruling in this case that prerogatives outside the VASRD were exercised.  In the matter of the EN condition, the Board unanimously recommends a disability rating of 60%, coded 7899-7806 IAW VASRD §4.71a.  In the matter of the OSA condition, the Board unanimously recommends a disability rating of 50%, coded 6847 IAW VASRD §4.71a.  In the matter of the contended hemochromatosis and splenomegaly conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration. 

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior to medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Erythema Nodosa	7899-7806	60%	
OSA, mild industrial impairment	6847	50%	
COMBINED	80%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, date received 06 Feb 2014, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAMR-RB																		

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX, AR20160003060 (PD201400679)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 80% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 80% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA