RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01780
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20060710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Quartermaster) medically separated for “reactive arthritis (Reiter's syndrome).”  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty Rating.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “Reiter's Syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded three other conditions (unspecified essential hypertension, disturbance of skin sensation and intermittent paresthesias) for PEB adjudication.  The Informal PEB adjudicated “reactive arthritis (Reiter's Syndrome)” as unfitting, rated 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Of the remaining conditions lower and upper extremity paresthesias and intermittent paresthesias were determined to be Category II (conditions contributing to unfitting condition) and hypertension was determined  to be Category III (a condition not separately unfitting and not contributing to the unfitting condition).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant asserts he has several conditions related to Reiter’s Syndrome or reactive arthritis as well as other conditions not addressed by the service, rated at 90 percent by the VA.  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 20060404	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reactive Arthritis (Reiter's Syndrome)	5299-5002	20%	Reiter's Syndrome	5009	20%	STR	
Lower and Upper Extremity Paresthesias	Cat II	Intermittent Paresthesias of the Upper and Lower Extremities	8099-8018	NSC	STR	
Intermittent Paresthesias	Cat II					
Hypertension	Not Unfitting / 
Cat III	Hypertension	7101	0%	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0 	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070703 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  
Reactive Arthritis (Reiter's Syndrome) Condition. The earliest note in the service treatment record (STR) dated 27 December 2004 indicated the CI had nausea and aches throughout the body.  A stool culture in 8 March 2005 revealed salmonella.  An evaluation on 23 June 2005 indicated the CI had periodic pain in both knees and left ankle as well as a first metatarsal joint pain for months raising the possibility of gout versus osteomyelitis.  The STR complemented and supported the findings of the narrative summary (NARSUM), which noted the CI presented to rheumatology in August 2005 complaining of pain and swelling in multiple joints including his knees, ankles, and hands.  Five months earlier he had salmonella dysentery that was treated and resolved.  An extensive work-up was positive for HLA-B27, but negative for rheumatoid factor, Lyme titer, ANA screen and uric acid.  Magnetic Resonance Imaging (MRI) in July 2005 of his left foot was suggestive of enthesopathy (inflammation at the point of attachment of a tendon or ligament to bone), which was clinically confirmed on the left second toe along with swelling of the left ankle and pain in his hands and knees.  Treatment with sulfasalazine (used to treat ulcerative colitis and rheumatoid arthritis) and Mobic (meloxicam, a nonsteroidal anti-inflammatory drug) was instituted and the dose of sulfasalazine was increased to 1 gram twice a day; however, fatigue and pain persisted in his hands, knees, left ankle, and first left metatarsal phalangeal joint (1st MTP).  X-rays of the sacroiliac joints revealed findings consistent with a right sacroiliitis.  Enbrel (etanercept, a tumor necrosis factor (TNF) blocker) was added and the CI did well until November 2005 when he developed recurrent furuncles (boils) consistent with a community acquired methicillin-resistant staphylococcus aureus (MRSA).  Discontinuation of the Enbrel and treatment with Septra (an antibiotic combination of sulfamethoxazole and trimethoprim) and Rifampin (rifampicin, an antibiotic) for 10 days along with showering with Hibiclens (chlorhexidine, an antiseptic) and a topical antibiotic for use in the nose resolved the furuncles, but his joint symptoms increased in the hands and knees.  Once the Enbrel and sulfasalazine were reinstituted, he did remarkably well with the reactive arthritis with no complaints of pain or swelling.  In January 2006, he complained of episodes of numbness and paresthesias (abnormal sensations tingling, burning or prickling like “pins and needles”) of his lower legs that lasted approximately 15 minutes without obvious triggers or affected by activity or position   (see below).  The NARSUM examination revealed no evidence of enthesopathies, synovitis (inflammation of the fluid or covering around a joint), or joint swelling, but had the CI bilateral crepitus (a grating sound) of the knees.  A neurologic examination was within normal limits.  In March 2006 he noted an intermittent brief pruritic (itchy) rash that lasted 1-2 hours that involved various areas of the body particularly the hands and legs.  He continued to have mild aches of the hands and knee pain and joints that clicked and popped.  The rheumatologist raised the possibility that the neurological symptoms (see below) may be related to the Enbrel and could also be caused as a result of a “a class effect” from Humira (adalimumab, a TNF anti-inflammatory drug) as well, nevertheless Enbrel was replaced by Humira.  The impression of reactive arthritis (Reiter’s syndrome) was made by the findings of a positive HLA-B27, right sacroiliitis, enthesopathy, and a history of salmonella dysentery and conjunctivitis (pinkeye).  Because of the cost of the Enbrel, the need for refrigeration, and the concern that the TNF inhibitor may need to be replaced due to side effects, the CI was unable to deploy.
Lower and Upper Extremity Paresthesias and Intermittent Paresthesias.  The CI with reactive arthritis was referred for neurologic evaluation for a possible Enbrel associated demyelinating disorder.  The neurologist noted on 24 January 2006 that the CI had been taking Enbrel since September 2005 and had a 1.5 month history of waist down paresthesias with some tingling, which started in his lower legs, ascended into the upper legs and sometimes involved his whole body.  The episodes lasted 15-30 minutes and the CI was fine in between episodes.  At the time of the visit he had tingling in the left shoulder, but was fine below the waist.  Physical examination was normal.  An MRI of the brain in February 2006 was unremarkable.  The neurologist doubted the Enbrel, which was discontinued and replaced by Humira, was the cause of the paresthesias, but was unable to find any other cause for the intermittent paresthesias even after extensive laboratory studies were normal.  He recommended the CI return if symptoms persisted or worsened at which time he would perform a lumbar puncture and spinal imaging.  A neurologic opinion on 14 March 2006 indicated there was no impact on duty from the paresthesias, although the condition was not stable and the prognosis was uncertain.
Limited duty (LIMDU) was authorized on 29 September 2005 for 6 months for reactive arthritis with limitations of no OCONUS, no deployment or sea commands and no physical readiness training; and the CI must be near a MTF with rheumatology.  At the MEB examination dated 9 March 2006, the CI reported on DD Form 2807-1 he was diagnosed with Reiter’s syndrome and paresthesias, while the MEB examiner noted on DD Form 2808, the CI had Reiter’s syndrome with pain in the hands and knees bilaterally and paresthesias of the left shoulder and lower extremities.   

No VA Compensation and Pension (C&P) examination was performed proximate to separation; however, at a temporally remote examination performed on 30 June 2011, approximately 60 months after separation, the CI reported pain, stiffness, weakness and some clicking in the knees and small joints of his hands with moderate flareups weekly after overuse.  On examination, the CI had an antalgic gait with tenderness of the knees along the joint lines.  Range-of-motion (ROM) was 135 degrees for each knee with extension normal bilaterally and no pain or limitation of motion after repetitions.  He was able to fully flex his hands with all eight fingers contacting the transverse palmar creases.  Grip strength was not strong but was nevertheless 5/5.  X-rays of the cervical and lumbar spine including the SI joints were normal as were X-rays of the hands and knees.  As a result of the reactive arthritis, the CI had problems with lifting, carrying, reaching and decreased strength of the upper extremities.  Examination of the back dated 28 December 2012 revealed full ROMs.

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 20% rating using code 5099-5002 for the Category I condition reactive arthritis (formerly known as Reiter’s Syndrome) and considered lower and upper extremity paresthesias and intermittent paresthesias as related Category II diagnoses.  The VA assigned a 20% rating using code 5009 (arthritis, other types) for Reiter’s Syndrome and used code 8099-8018 (multiple sclerosis) for intermittent paresthesias of the upper extremities, which it indicated was not service connected.  There are similarities between reactive arthritis and ankylosing spondylitis, which uses VASRD code 5240.  However, the CI had no clinical evidence of cervical or thoracolumbar spine involvement at the time of separation or any ROM measurements necessary for rating, but the VASRD code 5009 for other types of arthritis is rated according to code 5002 for active rheumatoid arthritis. However, the CI did not have symptom combinations productive of definite impairment of health objectively supported by examination since he was effectively treated with a combination of medications at the time of separation nor did he have incapacitating exacerbations occurring three or more times a year to warrant a 40% or higher rating.  Furthermore, with treatment at the time of separation he did not have any significant functional limitations, chronic arthritis residuals, or compensable limitation(s) of motion of the joints of either the upper or lower extremities to warrant separate ratings. 

The etiology of the lower and upper extremity paresthesias and the intermittent paresthesias was not determined, but although subjectively notable, had no impact on function and were determined to be probably related to the reactive arthritis or its treatment, but at the time of separation had insufficient features of being separately unfitting and, therefore, are not independently ratable, although the PEB determined the paresthesias to be Category II conditions related to the Category I condition, reactive arthritis.  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 reactive arthritis and paresthesias conditions.  

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension was 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.  The hypertension was not addressed by the LIMDU.  A nephrologist found the CI to be normotensive on 7 February 2006, although he had borderline blood pressure readings at some rheumatology clinic visits.  A problem list noted dated 16 March 2006 indicated the CI had no documented hypertension since he was seen by the examiner.   The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that hypertension 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 fitness determination for the hypertension and so no additional disability rating is 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 Category I reactive arthritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication nor does it recommend a change in the PEB adjudication of the Category II paresthesias, and therefore, no additional disability rating can be recommended.  In the matter of the contended hypertension condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140424, w/atchs
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 6 Jan 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:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- JXXXXXXXXXXXXXXX, former USMC  
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN

					   XXXXXXXXXXXXXXX
	     				  Assistant General Counsel
					 (Manpower & Reserve Affairs)