RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01195
BRANCH OF SERVICE:  Army	
DATE PLACED ON TDRL:  20040617	
DATE REMOVED FROM TDRL:  20060404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Senior Personnel Sergeant, medically separated from the Temporary Disability Retired List (TDRL)  for “history of systemic erythematosus…”, with a disability rating of 10%.

CI CONTENTION:  The CI referenced the “Wounded Warrior Care Act” for review of her application.  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 – 20031104/20051201	VARD - 20040813	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Systemic Lupus Erythematosus	6350	60%	10%	Systemic Lupus Erythematosus with Lupus Nephritis and with Hypertension	6350	100%	20040421	
COMBINED RATING:  60% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Systemic Lupus Erythematosus.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), symptoms concerning for systemic lupus erythematosus (SLE) began approximately 1 year prior to referral for MEB.  Systemic lupus erythematosus (SLE) is a chronic inflammatory disease of unknown cause that can affect virtually any organ of the body.  It is characterized by immunologic abnormalities, especially the production of a number of antinuclear antibodies (ANA).  At a nephrology encounter, the CI complained of recurrent bilateral lower extremity edema, bilateral knee arthritis, excessive hair loss, and itchy and hyper-pigmented rashes.  Urinalysis revealed proteinuria (excess protein in urine).  A nephrology lab evaluation was concerning for SLE.  The CI underwent a kidney biopsy which revealed lupus nephritis (kidney inflammation).  The nephrologist started pulse therapy with an immunosuppressant (Cytoxan) for 2 years with a plan to convert to chronic therapy with another immunosuppressant (CellCept).  At a rheumatology evaluation, the CI complained of 8 months of polyarthralgia (multi-joint pain), hyper-pigmented pruritic (itchy) rashes on both wrists, and symptoms of Raynaud’s syndrome (recurrent finger and toe vasospasm in response to cold or stress).  Clinical, pathology, and lab findings consistent with SLE were Raynaud’s syndrome, polyarthalgia, renal biopsy, positive ANA, proteinuria, leukopenia (low white cell count), and anemia (low red cell count).  The assessment listed SLE and lupus nephritis.  The rheumatologist planned to start the disease-modifying anti-rheumatic drug (DMARD) Plaquenil.  

The 15 August 2003 NARSUM, 10 months before TDRL placement, recounted the history and interventions.  The CI complained of bilateral leg swelling from her groin to her feet.  Leg pain was 2-3/10 at baseline with exacerbations to 8/10.  She reported fatigue and intermittent knee, wrist, elbow, and finger pain.  Symptoms were exacerbated by activity and stress and somewhat relieved by rest, elevating her legs, and Motrin.  Medications were Cytoxan, Plaquenil, and a corticosteroid (Prednisone).  The physical examination revealed hyper-pigmented erythematous (red) rashes on her wrists and 2+ pitting edema (excess tissue fluid swelling) from the knees to the ankles.  The remainder of the physical examination was normal.  The examiner cited the finding from the nephrology and rheumatology consultations.  The diagnosis listed lupus nephritis.  Serial nephrology and rheumatology encounters continued the pulse Cytoxan therapy, Plaquenil, and Prednisone taper.  A nephrology encounter reported the CI had active lupus nephritis and was undergoing a 2-year period of pulse Cytoxan immunosuppressive therapy.  Upon completion of the pulse therapy, she was to be placed on maintenance immunosuppressive therapy.  The nephrologist cited a recent study which showed that kidney survival at 1 year in African American women with lupus nephritis was 79%, and at 5 years decreased to 58%.  The examiner opined that the CI’s illness portended a poor prognosis with a high chance for kidney failure requiring dialysis and/or transplantation.  He documented “Because of the intensity of medical therapy and the need for frequent follow-up, I have recommended that the patient be granted total disability for the duration of this intense treatment.”  A nephrology addendum documented the CI “… has SLE nephritis that is acute with frequent exacerbations producing severe impairment of health.  She is at high risk of progression to chronic kidney disease and loss of kidney function.  She is receiving pulse Cytoxan which is a systemic chemotherapeutic agent.  This is potentially life-threatening therapy.”  

The 21 April 2004 Compensation and Pension (C&P) examination, 2 months before TDRL placement, recounted the history and interventions.  The CI endorsed a history of recurrent severe swelling and proteinuria which led to a renal biopsy and the diagnosis of lupus nephritis.  She complained of getting pain mainly in the legs and neck, and becoming tired very easily with exertion.  The CI could not sustain heavy physical activities without immediate distress.  She reported one sister was diagnosed with SLE and was in advanced renal failure on dialysis.  Medications were Cytoxan, Plaquenil, and Prednisone.  The physical examination revealed a normal oral cavity examination and the skin was healthy in appearance and texture with no disfiguring scars.  The balance of the examination was unremarkable.  The diagnoses listed lupus nephritis, hypertension, bilateral knee and foot pain, and Raynaud’s syndrome.  The examiner opined that the nephritis, hypertension, arthralgias, and Raynaud’s syndrome represented “… the inexorable progress of the central condition of lupus erythematosus, an autoimmune disorder in which the body tissues are reacting against themselves in several parts of the body structure.”  The examiner documented the CI “… has been on a vast array of powerful medication in order to forestall the progress of lupus erythematosus which is currently associated with a serious complication of renal failure.”

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of TDRL placement.  The PEB assigned a 60% rating under the 6350 code (systemic lupus erythematosus) citing SLE with lupus nephritis, nephropathology showed mixed membranous and focal segmental lupus glomerulonephritis, condition was active and ongoing, lower extremity 2+ edema, and therapy with Prednisone and monthly intravenous Cytoxan.  The VA assigned a 100% rating under the 6350 code based on the VA C&P examination 2 months before TDRL placement.  The VA cited SLE with lupus nephritis based on kidney biopsy, proteinuria, hypertension, frequent exacerbations of SLE nephritis, frequent exacerbations of recurrent rash and multi-joint pain and swelling, lower extremity swelling, myalgia’s (muscle pain), neck pain, leg pain, fatigue, high risk for progression to chronic kidney disease and loss of kidney function, large variety of medications to forestall progression of SLE and renal failure, high dose Prednisone, and potentially life-threatening monthly intravenous Cytoxan.  Board members agreed the SLE condition did not approach the 100% rating (acute, with frequent exacerbations, producing severe impairment of health).  The Board did not find evidence to support a higher rating than the 60% (exacerbations lasting a week or more, 2 or 3 times per year) adjudicated by the PEB at the time of TDRL placement.  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 adjudications for the SLE at TDRL placement.

The 1 September 2005 TDRL evaluation, 7 months before TDRL removal, recounted the history and interventions.  Since initial presentation, the CI had developed symptoms of SLE.  Her activity was limited by joint pain, which she developed after 5-30 minutes on a treadmill.  The CI had completed 6 months of Prednisone and 2 years of pulse Cytoxan.  Active medications were an immunosuppressant (CellCept) and a DMARD (Plaquenil).  The physical examination revealed no ankle edema and the balance of the examination was unremarkable.  The diagnosis listed SLE with lupus nephritis.  The examiner documented “This is a life-long condition.  She is currently stable, but in any patient who had renal involvement from SLE the condition worsens with time.”  The examiner recommended discontinuation of TDRL status.  A rheumatology consultation documented that while the CI’s SLE was fairly stable on CellCept and Plaquenil, SLE was not curable.  The CI had a definite risk of progression to loss of renal function and would need to be followed indefinitely by nephrology and rheumatology.  CellCept, and her tendency to have a low white blood cell count, increased her risk of infection.  The rheumatologist documented “It is not recommended that she ever be put back into the military.  She will never be deployable.  On her medications she will always have to be careful of exposure to infections and viruses.”  

The Board directed attention to its rating recommendation based on the above evidence.  The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  There was no C&P examination proximate to the time of removal from TDRL, therefore the Board relied on the TDRL evaluation for its rating recommendation at the time of permanent disability separation.  The 1 December 2005 PEB, 4 months before TDRL removal, assigned a 10% rating under the 6350 code (systemic lupus erythematosus).  The PEB cited SLE, biopsy proven nephritis, symptomatic during the last two years, worked full time, considered stable, normal physical exam, well developed, well nourished, no apparent distress, no ankle edema, BUN of 8, creatinine of 0.7, and an essentially normal urinalysis.  While the rheumatologist documented the CI’s SLE was fairly stable on medication, it was not curable, and she would need to be followed indefinitely by nephrology and rheumatology.  There was also risk of progression to loss of renal function, and increased risk of infection.  Based upon exams and labs there was no disability for consideration under 7809 (discoid or subacute cutaneous lupus erythematosus), 7806 (dermatitis or eczema), 7541 (renal involvement in SLE), or 7101 (hypertensive vascular disease).  While the CI’s SLE was fairly stable on medication, the Board considered the chronicity of SLE, intensity of medical therapy, poor prognosis, and the high likelihood of kidney failure requiring dialysis and/or transplantation.  Board members agreed the SLE condition did not approach the 100% rating (acute, with frequent exacerbations, producing severe impairment of health).  The constellation of findings more closely approximated the 60% rating (exacerbations lasting a week or more, 2 or 3 times per year) and were not consistent with the 10% rating (exacerbations once or twice a year or symptomatic during the past 2 years).  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 SLE condition at the time of TDRL removal.

BOARD FINDINGS:  In the matter of the SLE condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement and a disability rating of 60% at permanent disability disposition, coded 6350 IAW VASRD §4.71a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Systemic Lupus Erythematosus	6350	60%	60%	
COMBINED	60%	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140117, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160010868 (PD201401195)

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 reo
characterize the individual's separation as a permanent disability retirement with the
combined disability rating of 60% 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
60% 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