RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04138
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20030706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Field Artillery Cannoneer, medically separated for “status post sickle cell crisis ” and “sickle cell trait,” rated 10% and existed prior to service (EPTS) respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requested consideration of 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 based upon a 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 -20030425	VARD - 20030429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Sickle Cell Crisis	7707-7399-7301	10%	Residuals, Status Post Sickle Cell Crisis	7799-7714	10%	20030530	
Sickle Cell Trait	EPTS	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Status Post Sickle Cell Crisis.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s sickle cell crisis condition began in January 2002 while training for cold weather mountain warfare when he ascended to 9800 feet and developed severe left upper quadrant pain.  Emergency treatment consisted of morphine (a narcotic) and IV fluids.  During hospitalization the CI had a left costophrenic angle infiltrate on a chest X-ray series and abdominal computed tomography (CT scan) revealed findings suspicious for splenic peripheral infarcts with sympathetic effusions and ascites (fluid in the abdomen).  A repeat chest X-ray series demonstrated a small left pleural effusion.  While hospitalized he was continued on intravenous fluids, supplemental oxygen, and medication (Demerol (meperidine, a narcotic)) for the severe abdominal pain.  Prior to discharge the CI was switched to Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) orally and was vaccinated against encapsulated organisms to include H. influenza, meningococcus, and pneumococcus.  On 23 Jan 2002 the CI’s sickle cell screen was positive with hemoglobin (Hgb) A1 51.9% (normal 57.6-65.1), Hgb A2 4.1% (normal 3.3-4.5), and Hgb S 42.5% (normal 34.9-42.4).   On 30 January 2002 G6PD (glucose 6 phosphatase) was normal and Hgb A1 was 50.6, Hgb A2 3.4, Hgb S 44.3, and Hgb F 1.7.  A hematology consultant raised the possibility of a rare heterozygous state of hemoglobin S.     

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 3 May 2002, 14 months prior to separation, the CI reported he was “not in current good health because of my sickle cell condition and unable to carry on with the Marines like I once did.”  The examiner checked normal for clinical evaluation of the lungs and noted a soft non-distended abdomen without rebound, rigidity or guarding but with tenderness to palpation of the left upper quadrant, which was described as sore with a severity of 6-8/10 (10 being the worst pain).  Bowel sounds were normal.  

At the 15 May 2002 NARSUM examination his abdomen was soft with left upper quadrant tenderness to palpation without rebound, rigidity or guarding along with mild enlargement of the spleen.    The CI had another episode of left upper quadrant pain in December 2002.  As a result of the sickle cell crisis he was unable to run due to pain, had exercise intolerance, and was unable to lift weights due to weakness.   Despite prolonged rest, he was unable to perform duties of a Marine.  

An MEB addendum dated 4 September 2002 indicated the CI suffered a vaso-occlusive crisis during high altitude mountain training when he was noted to have an abrupt onset of shortness of breath and left upper quadrant abdominal pain, which was made worse by coughing.  Post hospitalization the CI experienced a pain crisis after exercising during hot weather.  Thereafter, he developed shortness of breath and abdominal pain with moderate exercise.  Laboratory data revealed a Hgb A1 value of 54.9 and Hgb S value of 40.1; and a glucose 6-phosphate dehydrogenase deficit.  Lab data revealed hemoglobin and hematocrit remained stable from February 2002 through December 2002 with no red blood cell sickling reported.  A CT scan of the abdomen on 15 January 2003 revealed an unremarkable spleen without evidence of splenic infarctions and mild prominence of the biliary system throughout the liver.  

At the VA Compensation and Pension (C&P) examination on 30 May 2003, performed approximately 1 month before separation, the CI reported he still experienced symptoms of sickle cell crisis if involved in strenuous exertion. He still took pain medication and noted occasional use of oxygen therapy since he had episodes of shortness of breath from the time of the sickle cell crisis in 2002.  On examination the CI’s breath sounds were clear and the abdominal examination was negative except for mild tenderness on palpation of the mid and left upper quadrant.  There was no sign of enlargement of the liver or spleen.  On pulmonary function testing the CI had mild obstructive changes that improved with a bronchodilator.  The VA examiner’s diagnosis was status post sickle cell crisis related to sickle cell trait (see below) with residuals of splenic infarcts and recurring abdominal pain.  The episodic reactive airway disease associated with the sickle cell crisis appeared to have resolved.    

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB (FPEB) assigned an EPTS rating for sickle cell trait (see below) and a 10% rating under an analogous 7707-7399-7301 code (spleen, injury of, healed-peritoneum adhesions), citing aggravation of a pre-service condition based on clinical findings as well as testimony, documentation, and articles from the medical literature.  

The VA assigned a 10% rating using an analogous 7799-7714 code (sickle cell anemia) based on the VA C&P examination approximately 2 months before  separation, citing residuals, status post sickle cell crisis.  Board members agreed based on evidence in the STR that the sickle cell trait (see below) was an EPTS condition and that it was service aggravated giving rise to the sickle cell crisis, which was unfitting and rated accordingly.  Therefore, no subtraction is warranted from the sickle cell crisis rating.  Board members discussed whether the CI’s condition rose to a 30% rating or higher at the time of separation.  While the CI did have a second bout of pain after exercising during hot weather post hospitalization, following that episode there were no further documented episodes of continued impairment of health.  A CT scan showed resolution of the infarctions and respiratory symptoms had resolved by the time of the VA examination, which was prior to separation.  The CI did continue to note RUQ pain with moderate exertion or stress and respiratory symptoms.  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 status post sickle cell crisis condition.  

Sickle Cell Trait.  The CI was diagnosed upon enlistment as having sickle cell trait on 11 August 1999 with 41.8% Hgb-S, 52.4% Hgb-A, 4.4% Hgb-A2, and 1.4% Hgb-F and on a retest annotated in the STR dated 1 January 2002.  It is a genetic, hereditary defect that usually does not cause problems in the heterozygous state, but can be associated with a vaso-occlusive crisis under periods of extreme stress.  Altitude exposure during training triggered development of a sickle cell crisis marked by abdominal pain and splenic infarction, which is documented above. 

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB assigned an EPTS rating for sickle cell trait.  Board members agreed based on evidence in the STR that the sickle cell trait was an EPTS condition and that it was service aggravated giving rise to the sickle cell crisis, which was unfitting and rated accordingly as noted above.  Therefore, no subtraction is warranted from the sickle cell crisis rating, but no independent rating is warranted since according to the VASRD “Sickle cell trait alone, without a history of directly attributable pathological findings, is not a ratable disability.”  However, the VA Rating Decision (VARD) did not explicitly address the sickle cell trait, but did rate for residuals, status post sickle cell crisis using code 7799-7714; and, even if the Board could do so, it would invoke VASRD §4.14 (avoidance of pyramiding), which is to be avoided.

BOARD FINDINGS:  In the matter of the status post sickle cell crisis and the sickle trait conditions and IAW VASRD §4.117, the Board unanimously recommends no change in the PEB adjudication.  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 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 19 Sep 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:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC