RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03337
BRANCH OF SERVICE:  Army	BOARD DATE:  20150521
Separation Date:  20041012

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Cook) medically separated for recurrent staphylococcal furunculosis (skin infections/boils).  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The recurrent infectious condition characterized as “staphylococcal recurrent furunculosis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were forwarded for adjudication.  The Informal PEB adjudicated “recurrent staphylococcal furunculosis,” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 20040901	VA* - (11 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Staphylococcal Furunculosis	7820-7806	10%	Folliculitis Of The Buttocks, Abdomen, And Posterior Thighs	7820-7806	10%	20050921	
Other x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20050929 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Recurrent Staphylococcal Furunculosis (skin infection) Condition.  The CI developed multiple skin abscesses on his abdomen in March 2004.  Wound cultures and a nasal swab were all positive for staphylococcus aureus (bacterial colonization).  Multiple topical treatments and multiple oral (systemic) antibiotics for the skin infections were not effective in removing the bacteria, and the CI had recurrent skin infections.  An Infectious Disease Specialist noted that the CI had undergone several incision and drainage procedures on the abscesses (deep skin infections) and that the CI had taken (oral) antibiotics for these multiple infections.  There were physical exam findings of scattered red follicular lesions (superficial skin at the pockets where the hair grows) on the arms and legs, the trunk with well healed scars on the abdomen, and the back of the neck with a well healed scar.  The MEB narrative summary (NARSUM) Infectious Disease exam approximately 2 months prior to separation documented that the CI had a history of recurrent staphylococcal folliculitis (superficial infections), furunculosis and skin abscesses.  The CI reported that areas of friction with his clothing seemed to precipitate his outbreaks and were worst affected.  The examiner noted that the CI had been on chronic antibiotic therapy in an attempt to decolonize him; however, he had a relapse and was receiving a different course of antibiotics at the time of the MEB.  There were exam findings of well healed scars on the posterior right neck, abdomen and extremities and a follicular rash on the right lower extremity.  Treatment notes indicated the CI required a 30-day course of antibiotics beginning in March 2004, a 2-week course starting in May 2004, and was issued a 60-day supply of antibiotics (plus two refills) on 24 June 2004 “so that he could initiate therapy at the onset of skin lesions.”  The NARSUM stated that “as of the evaluation of the patient on 21 Jul in the infectious disease clinic, he had last used his Dicloxacillin (oral systemic antibiotic) the week prior to his appointment.”  The VA Compensation and Pension exam approximately 11 months after separation documented that when the CI had a flare of the folliculitis, he would take an oral antibiotic.  There were physical exam findings of “at least six transverse 1 cm long flat non tender scars on the abdomen and posterior neck” and folliculitis in the right upper quadrant of the abdominal wall and buttocks and posterior thighs.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the recurrent staphylococcal furunculosis condition as 7820 - Infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal and parasitic diseases) with 7806 (dermatitis or eczema) and rated at 10%.  The PEB disability description stated “active lesions minimal at this time and while on antibiotic therapy.”  The VA also coded the skin condition (folliculitis of the buttocks, abdomen, and posterior thighs) as 7820-7806 rated 10% citing “a history of intermittent systemic therapy during the past 12-month period.”  The 2004 VASRD indicated that disability code 7820 should be rated under the criteria for disfigurement, scars, or dermatitis depending on which is predominate.  There was no evidence of “two or more characteristics of disfigurement” for any rating above 10% under code 7800.  There was no indication of any unstable or tender scars for alternate or additional disability code rating consideration (IAW VASRD 2004 criteria), and disability code 7806 was adjudged as the predominate code for rating.  The Board deliberated whether the CI’s systemic antibiotic therapy use met the analogous criteria for “systemic therapy such as corticosteroids or other immunosuppressive drugs,” as well as the duration and frequency of treatment.  There was documentation throughout the service treatment record (STR) that the CI required systemic antibiotic therapy on a regular basis to eradicate the skin infection.  The Board discussed the fact that the CI’s skin condition was an infectious bacterial condition which required chronic systemic antibiotic therapy to eradicate the infections where steroids and immunosuppressive therapy would be contraindicated as contrasted with an inflammatory or immune reaction condition such as dermatitis or eczema.  Oral systemic antibiotic use was adjudged as systemic therapy meeting the analogous criteria under code 7806 (from 7820; infections of the skin).

The Board agreed that the CI’s need for chronic systemic antibiotic therapy at the time of separation exceeded the 10% rating criteria of “intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period.”  The Board then considered the 30% rating criteria of systemic therapy “required for a total duration of six weeks or more, but not constantly …” versus the 60% rating criteria of “constant or near-constant systemic therapy ….”  A review of the active medications throughout the STR demonstrated that the CI was on systemic antibiotic therapy for the skin infection condition for over 6 weeks in the 12 months preceding separation, and that only intermittent systemic therapy was required in the after separation timeframe prior to the VA exam (adjudged after separation improvement).  Although the CI was on constant or near-constant systemic therapy following his initial diagnosis for the 4 months prior to separation, systemic antibiotic therapy appeared to be intermittent (not “constant or near-constant systemic therapy ….”) for the 12-month period considered under rating for 7820 after separation.

The Board also considered the percent of the entire body or exposed areas affected for alternative rating.  There was no support for the exposed area affected being greater than 20%.  The service exam was not sufficiently detailed to reasonably calculate the total body area affected, and the Board adjudged that there was insufficient evidence for concluding that more than 40% of the entire body was affected for any rating higher than the 30% rating applying systemic therapy use criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the recurrent staphylococcal furunculosis condition IAW §4.118.

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 recurrent staphylococcal furunculosis condition, the Board unanimously recommends a disability rating of 30%, coded 7820-7806 IAW VASRD §4.118.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Recurrent Staphylococcal Furunculosis	7820-7806	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140628, 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 XXXXXXXXXX, AR20160003772 (PD201403337)

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 30% 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 30% 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