RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX					           CASE:  PD-2014-01611
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20070423

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Computer System Operations Journeyman) medically separated for diabetes insipidus.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty.  He was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  Central diabetes insipidus was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated central diabetes insipidus as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated pes planus as a Category II condition (can be unfit, but not compensable/ratable) and hyperlipidemia as a Category III condition (not separately unfit & compensable/ratable).  The CI made no appeals and was medically separated.

CI CONTENTION:  The symptoms of Central Diabetes Insipidus include polyuria and fatigue.  He was not evaluated for hypogonadism and infertility.  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 20070302	VA* - (~7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Central Diabetes Insipidus	7909	20%	Central Diabetes Insipidus	7909	20%	20071129	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080225 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Central Diabetes Insipidus Condition.   The documentation in the service treatment record supports and complements the MEB narrative summary dated 30 November 2006.  On 21 October 2004 a private endocrinologist noted the CI had the onset of symptoms of progressive polyuria (excess urination), polydipsia (excess thirst), and nocturia (awakening at night to urinate) that began when he was deployed 2 years earlier, which progressed up to 16 liters per day of urine output according to the CI.  He was diagnosed with diabetes insipidus with the condition in 2004 when his laboratory studies were elevated for serum sodium (146 ml/L [normal 135-145]) and osmolality (299 milliosmoles/kg [normal 280-295]).  The vasopressin (antidiuretic hormone (ADH)-regulates retention of water in the body) was low (0.9 picograms/ml) and urine volume was 5850 ml/24 hours (normal 800-1800).  An magnetic resonance image (MRI) in December 2004 revealed a slightly prominent pituitary stalk measuring 0.3-0.4 cm (normal 0.2 cm) and eosinophilic granuloma was raised as a rare possible etiology.  Additionally, the private endocrinologist ordered a spectrum of laboratory studies to determine whether any other endocrine abnormalities such as thyroid, adrenal or growth excess or deficiency were present.  Treatment of the diabetes insipidus, although the etiology was unknown, was with desmopressin acetate (DDAVP) 0.01% intranasal spray twice a day. The CI rarely had headaches, had no visual field defects, and had polyuria if he did no use the DDAVP.  To evaluate the etiology of the diabetes insipidus, a series of imaging studies were performed.  A radiologic report in November 2006 noted a sessile osteochondroma (cartilage/bony projection) of the distal right femur without worrisome features, while a bone scan performed December 2006 of the right femur showed no evidence for a primary malignant bone tumor or evidence for metastatic skeletal disease revealed an area with a benign appearance that could be consistent with eosinophilic granulomata noted on recent plain films; and a chest X-ray in January 2007 was negative.  On examination the CI weighed 228.5 pounds.  There was no proptosis (protruding eyes), visual field cuts or papilledema.  Gynecomastia was noted and the abdomen was protuberant with violaceous striae (stretch marks) on the lower abdomen.

A revised permanent P4 profile was issued on 29 November 2006 for central diabetes insipidus.  He appeared to be able to perform his current duties without restriction as long as he was taking his medication, but was not deployable and not worldwide qualified since he would be at risk for rapid dehydration and death if he did not have access to his medication and/or large amounts of potable water.  The commander’s statement dated 14 December 2006 indicated his condition did allow him to perform all primary in-garrison military duties without restrictions, limitations or work-a-rounds.  He deployed with this condition in the past and perhaps could deploy in the future (“C1” coded); however, if he could not deploy at all, then he would affect an AEF mission substantially.  

At the VA Compensation and Pension examination dated 29 November 2007, performed 7 months after separation, the CI reported that in November 2002, he started developing increased thirst and urination and would drink up to 2 gallons of water per day and voiding approximately the same amount.  He did not have the problem evaluated until he noticed he was having a problem with an erection and testing revealed low testosterone levels (see below).  Work up by an endocrinologist revealed an MRI finding of the CI’s pituitary stalk was a bit prominent at 3-4 mm in size (normal 2 mm) and was thought to  be the cause of the central diabetes insipidus and the hypogonadism (see below).  Treatment with DDAVP nasal spray controlled the diabetes insipidus. 

The Board directed attention to its rating recommendation based on the above evidence. Both the PEB and the VA assigned a 20% rating using code 7909 (Diabetes insipidus-polyuria with near-continuous thirst) for central diabetes insipidus.  The Board sought a route to a higher rating keeping in mind that only diabetes insipidus was in the scope of review.  However, the record did not document any episodes of dehydration in the year prior to separation or post-separation.  Therefore, a rating of 40% or higher is not applicable.  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 central diabetes insipidus condition.

Contended Conditions.  The Board’s main charge is to assess the fairness whether the PEB might have determined the contended conditions of hypogonadism and/or infertility were unfitting since they were thought to arise from pathology related to the pituitary stalk as was the central diabetes insipidus (discussed above).  The Board’s threshold for fitness determination requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Neither the hypogonadism nor the infertility was profiled or implicated in the commander’s statement and neither was judged to fail retention standards. However, the CI did not have his symptoms of polyuria, polydipsia and nocturia evaluated until he noticed he was having a problem with an erection.  Testing revealed low testosterone, LH (luteinizing hormone) and FSH (follicle-stimulating hormone) levels confirming the diagnosis of hypogonadotropic hypogonadism, which was marked clinically by low libido, decreased size of the testicles, and erectile dysfunction.  An MRI finding of the CI’s pituitary stalk was a bit prominent was thought to be the cause of the central diabetes insipidus and the hypogonadism.  The hypogonadotropic hypogonadism was effectively treated with transdermal testosterone (Androgel) 1% daily, which normalized his testosterone level and improved his erectile function.   The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the hypogonadism and infertility conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB’s lack of determination of either fitness or unfitness for the hypogonadism and infertility contended conditions and so no additional disability ratings are recommended.

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 did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the central diabetes insipidus condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypogonadism and infertility, the Board unanimously recommends no change from the PEB’s lack of determinations of either fitness or unfitness.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140327, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01611.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

			  XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings