RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01546
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20011022	DATE REMOVED FROM TDRL:  20061010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard O2, Signal Officer, medically separated from the Temporary Disability Retired List (TDRL) for “history of disseminated coccidioidomycosis,” with a disability rating of 10%.  

CI CONTENTION:  The CI was not evaluated for his osteomyelitis, hypertension, and recurrent gastric ulcers with hemorrhage conditions during his TDRL period.  His 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 on 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 – 20011022/20061010	VARD - 20030227	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Disseminated 
Coccidioidomycosis	6835-5000	30%	10%	Disseminated 
Coccidioidomycosis	6835	50%	50%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Disseminated Coccidioidomycosis.  The service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 3 May 2001 indicated the CI developed a nonproductive cough, fever and headache after a 3-week field exercise in March 2000.  Those symptoms resolved in about 2 weeks.  In September 2000 the CI reported right groin pain and intermittent bilateral hip pain and low back pain with ambulation.  Over the next several weeks he developed a 2 x 2 cm lesion of the right iliac crest along with drenching night sweats.  A bone scan revealed uptake in the right iliac wing and the L2 and L4 vertebrae.  Computed axial tomography (CT scan) showed an 8 mm poorly defined lesion in the area of the left hip and two 1.5 cm destructive lesions of the right iliac crest, which were biopsied.  Pathology and culture proved Coccidioides immitis, a pathogenic fungus, as the etiology of the lesions and Coccidioides antibodies were positive 1:4 as well.  Initial antifungal treatment consisted of fluconazole, which was switched to itraconazole, but the CI had worsening right hip and low back pain.  The CI was then admitted to the hospital with a diagnosis of progressive coccidioidomycosis and was treated a more potent antifungal medication, Abelcet (a lipid associated amphotericin), from which he developed acute renal insufficiency that resolved with its discontinuation.  After a hiatus the medication was reintroduced without complication.  Debridement of the right iliac lesion was carried out along with drainage of an abscess of the right iliac spine area; the two lumbar vertebral lesions were treated medically without surgery.  The NARSUM author noted the CI would need lifelong suppressive therapy with itraconazole.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 4 August 2001, 3 months prior to separation, the CI reported debridement of a fistula and the right posterior iliac spine and he was treated for disseminated coccidioidomycosis.  The physical exam revealed a 4 cm healed scar of the right lower lumbar area post debridement and a slightly tender mid lower lumbar area.  No mass was present at the debridement site.  The CI’s range of motion (ROM) was full.  Reflexes were 2+ and straight leg raising (to determine nerve root irritation) was negative.  A CT scan in September 2001 demonstrated all the bone lesions noted previously appeared stable and without Interval progress.  The subcutaneous soft tissue abscess showed an interval decrease in size.  

At the 14 March 2002 VA Compensation and Pension (C&P) evaluation,  performed 4 months before TDRL placement, the CI reported a lot of pain around his hips and low back and was treated for coccidioidomycosis as well as uveitis (inflammation of the middle layer of the eye) and iritis (inflammation of the colored ring surrounding the pupil).  The CI had a mild cough and chest pain in the mid sternal area for the prior 5 months, which came and went and hurt when he moved.  Although he no longer had fever and chills, he occasionally had night sweats, headaches three times a month, and muscle stiffness of the “whole” back, hips and groin area as well as the neck and shoulder, but he did not have a rash.  On examination there was a vertical scar 6 cm x 2 cm to the right of L2-5 vertebrae and posterior and superior to the right iliac crest and two drainage scars 2 cm x 0.5 cm above the anterior iliac crest.  His gait was normal.  Straight leg raising was negative.  All functions and motions of both hips were normal with pain on motion.  The CI’s back was tender at L3, but there was no deformity, swelling, or muscle spasm.  Flexion was 0-82 degrees, extension 30 degrees, right and left lateral flexion 45 degrees, and right and left lateral rotation 47 degrees; all motions were with pain.  With fatigue flexion increased to 85 degrees and extension to 37 degrees.  A chest X-ray was “entirely normal” as were X-rays of the pelvis and X-rays of the lumbar spine were normal.  Laboratory studies of liver status were “entirely normal.”  The examiner’s diagnosis was disseminated coccidioidomycosis, “presently still under treatment with very strong antifungal medications.”

At an interim TDRL examination in July 2003 the CI complained of right hip pain with a good ROM, although he expressed some pain to the inguinal area as well as the sacrum and his sacroiliac joint as well.  Magnetic resonance imaging (MRI) on 7 August 2003 continued to show signal abnormalities involving L2 and L4 vertebral bodies anteriorly and the right acetabulum of the hip, sacrum and left acetabulum.  Continued lifetime itraconazole was recommended.  At the periodic TDRL examination dated 14 June 2004 the examiner noted inflammation markers, C-reactive protein and sedimentation rate were normal.  A CT scan continued to show some L4 vertebral body radiolucency, but no lytic or blastic lesions.  The examiner’s opinion was that the CI would require lifelong itraconazole therapy to suppress his disseminated coccidioidomycosis.  
At the TDRL removal examination dated 28 March 2006 the CI complained of intermittent, stable low-grade achy low back pain and intermittent left groin pain exacerbated by the work environment, particularly with lifting and strenuous activity.  He denied bowel or bladder dysfunction or radicular symptoms, although he suffered intermittent exacerbations of pain ranging from 2-7/10 (10 being the worst pain), which was controlled with intermittent use of ibuprofen, a nonsteroidal anti-inflammatory drug, occasional tramadol, an opioid-like medication, and Elavil (amitriptyline for nerve pain) at bedtime.  On examination the CI’s spine was symmetric and nontender, and he had a full ROM.  There was no pain with straight-leg raising.  Examination of the hips revealed no pain on eversion or inversion and there was a full ROM.  Neurologic evaluation was unremarkable.  A CT scan of the pelvic lumbar area on 29 December 2005 revealed stable lytic lesions in the inferior left of the L4 vertebral body and the right iliac wing.  No lesion was noted in the L2 vertebra where disease was previously present.  These findings were unchanged from a prior CT scan dated 13 July 2004 and the results felt to be consistent with quiescent disease.  The examiner noted the CI was on chronic suppressive itraconazole therapy without evidence of relapse of his underlying infection.  However, the CI had chronic low back pain and hip pain related to lytic lesions in the bones that limited his ability to perform manual labor on a regular basis, particularly activities requiring use of back such as heavy lifting.  The examiner recommended continuation of itraconazole indefinitely for chronic lifelong suppression of the disseminated coccidioidomycosis to reduce the risk of relapse.  

The Board directed attention to its rating recommendation based on the above evidence.  For TDRL placement the PEB rated the condition 30% coded 6835-5000 (coccidioidomycosis-osteomyelitis, acute, subacute, or chronic: of the pelvis, vertebrae, or extending into major joints, or with multiple localization . . .) for disseminated coccidioidomycosis involving the right iliac wing and L2 and L4 and was rated as osteomyelitis as there was no evidence of pulmonary disease.  The VA assigned rated the condition 50% coded 6835 (disseminated coccidioidomycosis) and a 0% rating coded 7802 for (drainage scars), which were not in the scope of review.  The PEB continued the CI’s TDRL and 30% rating in September 2003 and November 2004.  However, at TDRL removal in October 2006 the PEB assigned a 10% rating using code 6835-5000 for the history of disseminated coccidioidomycosis currently “without evidence of relapse or [the] underlying infection.”  

The Board noted the PEB used code 6835-5000 for rating at the time of TDRL placement and in subsequent proceedings including TDRL removal.  While osteomyelitis (infection of the bone) caused by Coccidioides immitis was present and localized by scans to the pelvis and lumbar vertebrae, the CI’s disease was disseminated coccidioidomycosis, and although atypical by not having a pulmonary component or a rash, it nevertheless, was extensive and required aggressive antifungal therapy prior to TDRL placement and continued, uninterrupted antifungal therapy, which each subsequent TDRL examiner noted should be for lifelong suppression of the disseminated coccidioidomycosis to reduce the risk of relapse.  Therefore, Board members felt the analogous code 6899-6835 (or 5000-6835) is more applicable since it is specific for coccidioidomycosis, albeit the General Rating Formula for Mycotic Lung Disease addresses pulmonary symptomatology, though it does highlight the requirement for suppressive therapy, which is clearly in concert with the CI’s continued use of antifungal medication.  For those reasons, Board members discussed a 50% rating for TDRL placement which requires “[c]hronic pulmonary mycosis requiring suppressive therapy with no more than minimal symptoms such as occasional minor hemoptysis or productive cough.  However, use of an analogous code would appropriately read “chronic osseous (bone) mycosis requiring suppressive therapy with no more than minimal symptoms such as occasional joint pain of the lower back and hip ameliorated by pain medication.”  

While at TDRL placement, the disease was clinically quiescent, nonetheless, suppressive antifungal therapy was continued and the intermittent back and hip pain likewise continued problematic enough to limit heavy lifting.  Therefore, a 50% rating at TDRL removal is also reasonable since a 30% rating using code 6899-6835 (or 5000-6835) does not require suppressive therapy, and although the lesions of the bone appear to be stable radiologically, the CI has back and hip symptoms and remained on suppressive therapy with itraconazole.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for TDRL placement for the disseminated coccidioidomycosis condition and a disability rating of 50% for TDRL removal for the disseminated coccidioidomycosis condition.  

BOARD FINDINGS:  In the matter of the disseminated coccidioidomycosis condition, the Board unanimously recommends a disability rating of 50%, coded 6899-6835 IAW VASRD §4.97 for TDRL placement and a disability rating of 50%, coded 6899-6835 IAW VASRD §4.97 for TDRL removal.  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:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Disseminated Coccidioidomycosis	6899-6835 	50%	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140401, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
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 XXXXXXXXXXXXXXXXXX AR20160013304 (PD201401546)

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 place the individual on the Temporary Disability Retired List (TDRL) at 50% rather than 30% disability rating for the period October 23, 2001 to October 9, 2006 and then following this period recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 50%.

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 temporary disability 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 day following the TDRL period.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 50% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 50% effective the day following the constructive TDRL period.  

	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:

 

CF: 
(  ) DoD PDBR
(  ) DVA