RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03383
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Food Service Specialist, medically separated for “chronic autoimmune urticaria,” with a disability rating of 10%.

CI CONTENTION:  The CI requests the Board consider all conditions.  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 confined to 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 - 20040909	VARD - 20050321	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Autoimmune Urticaria	7825	10%	Cold Urticaria/Pressure Induced Urticaria; Idiopathic Urticaria 	7825	10%	20050124	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Urticaria.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the urticaria (hives) symptoms began approximately a year prior to referral for MEB.  The CI presented to the emergency department (ED) complaining lower lip swelling for 2 hours.  She reported 3-4 days of daily urticaria involving the arms and trunk.  The assessment listed urticaria.  She was prescribed a sedating histamine-1 (H1) receptor antihistamine (Benadryl) and a course of corticosteroids (Prednisone).  At an allergy and immunology encounter, the CI expressed concerns for increased symptoms with "swelling" when exposed to cold weather.  Symptoms occurred after a few minutes of cold with small bumps that increased in size to "burning warm" lesions.  Lesions started on exposed areas and progressed to involve clothed areas.  Lesions typically lasted for 1-2 hours if untreated.  Evening Benadryl prevented symptoms and improved them when they occurred.  Symptoms occurred daily with cold temperatures (< 50F) and more frequently in the evenings.  Symptoms began over the past year, starting in the cold winter, with no symptoms over the spring and summer.  She endorsed one episode of lip and tongue swelling causing her to present to the ED a month prior.  The skin exam revealed no rashes, lesions, or dermatographism (rapid onset of wheal and flare reaction to skin pressure).  Skin testing was performed with an ice cube test (urticarial weal induced by ice cube on skin).  The test was negative at the arm site where the ice was placed but raised, pruritic lesions occurred on the right ankle and arm consistent with hives.  The assessment listed cold-induced urticaria (subtype of physical urticaria induced by cold exposure) and chronic idiopathic urticaria (presence of urticaria on most days of week for longer than 6 weeks).  The examiner started a non-sedating histamine-2 (H2) receptor antihistamine (Allegra) every day during the cold season and continued Benadryl as need for exacerbations.  Two months later, the CI presented again to the ED for lower lip swelling with a preceding rash.  She denied any tongue swelling, drooling, difficulty swallowing, difficulty breathing, or a history of an anaphylactic reaction (serious and rapid allergic or hypersensitivity reaction that may cause death).  The physical exam revealed mild lower lip swelling with an urticarial rash on the upper extremities and trunk.  The CI was treated with an H1 receptor antihistamine (Benadryl), an H2 receptor antihistamine (Pepcid), and a corticosteroid (Decadron).  The CI was observed in the ED over several hours.  On recheck, her lip swelling and rash had resolved, and she was discharged home.  The impression listed resolved acute angioedema (self-limited localized subcutaneous/submucosal swelling from fluid extravasation).  

An allergy and immunology follow-up documented overall marked improvement since the weather was warmer.  The CI experienced exacerbations in air-conditioned rooms that were very cold but was not taking any antihistamines.  The assessment listed cold urticaria.  Two months later, an allergy and immunology follow-up documented increasing frequency of symptoms.  The CI complained of daily hives/angioedema despite warmer weather and recently experienced symptoms resulting from areas of tight clothing.  The skin exam documented no dermatographia wheal.  A serum test was positive suggesting an autoantibody to the FcER1 receptor as the cause of her hives.  Her cold ice test was negative at 10 minutes and was without edema upon rewarming.  The examiner opined that use of antihistamines could have altered the test or she may have transitioned from a physical urticaria to an autoimmune urticaria.  The assessment listed idiopathic urticaria, cold urticaria, and pressure-induced urticaria.  The examiner documented that the CI had severe daily symptoms that were not responsive to non-sedating antihistamines.  He opined that the CI might benefit from sedating antihistamines and recommended a trial an immunosuppressant (Cyclosporine).  The NARSUM examination, 4 months before separation, recounted the history and interventions.  The CI was unable to tolerate the Cyclosporine secondary to nausea, vertigo, and increasing hives and it was discontinued.  Active medications were an H1 receptor (Benadryl) and an H2 receptor (Atarax) antihistamine.  The CI complained of frequent episodes cause by tight fitting clothes that involved the bra line, neckline, panty lines, underarms, inside elbows, behind knees, and feet.  The physical exam documented “Her general physical examination was completely normal today.  She had no hives in any place.”  The diagnosis listed autoimmune urticaria. 

At the VA Compensation and Pension (C&P) examination in January 2005, performed 2 months after separation recounted the history and interventions.  It documented the CI developed symptoms of urticaria on exposure to cold and was found to have cold urticaria with a positive ice cube test.  She had symptoms consistent with pressure urticaria with hives under the belt, and delayed pressure urticaria with swelling on the soles after elevating her legs.  It recorded the diagnosis of idiopathic angioedema with no significant cold exposure related episodes.  The examiner recounted that an autologous skin test was positive for chronic idiopathic urticaria.  The CI had been unable to tolerate Cyclosporine and active medications were Benadryl and Atarax.  The physical exam documented “The skin, including appendages, is normal.”  The impression listed cold urticaria, pressure urticaria, delayed pressure urticaria, and idiopathic angioedema.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under code 7825 (urticaria) citing chronic autoimmune urticaria not requiring systemic immuno-suppressive therapy.  The VA assigned a 10% rating under code 7825 based on the VA C&P exam 2 months after separation.  The VA cited cold urticaria, pressure-induced urticaria, and idiopathic urticaria treated on several occasions, and involving multiple areas.  While the CI received corticosteroids the two times she presented to the ED, this was to treat the potentially life threatening angioedema, and not the hives.  While the CI attempted Cyclosporine, it was discontinued in less than a month.  Chronic medications were antiihistimines.  The proximate exams (allergy, NARSUM and C&P) documented normal skin exams.  The board agreed the overall clinical picture more closely approximated the 10% rating of recurrent episodes occurring at least four times during the past 12-month period, and; responding to treatment with antihistamines or sympathomimetics.  The higher 30% rating would require recurrent debilitating episodes occurring at least four times during the past 12-month period, and; requiring intermittent systemic immunosuppressive therapy for control.  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 urticaria condition.  

BOARD FINDINGS:  In the matter of the urticaria condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  There were no other conditions within the Board’s scope of review for consideration.  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 20140428, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008003 (PD201403383)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (DoD PDBR) recommendation and record of proceedings pertaining to the
subject individual. Under the authority of Title 10, United States Code, section 1554a,
I accept the Board's recommendation and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA