RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02085
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20041026

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Services Journeyman, medically separated for “congenital hepatic fibrosis” with a disability rating of 10%.

CI CONTENTION:  “Review of all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20040728	VARD - 20050606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Congenital Hepatic Fibrosis…”	7312-7399	10%	Hepatic Cirrhosis with Suspected Budd-Chiari Syndrome, Aggravated by Isoniazid Medication Therapy (INH)	7312	50%	20050118	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Congenital Hepatic Fibrosis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s congenital hepatic fibrosis condition, by definition began at or near birth but was first noted at approximately age 13 when he had an enlarged liver and spleen which resulted in liver biopsy that he disclosed on his MEPS physical.  The CI’s liver disease came to light while deployed, he and 50 members at his deployed location had gastroenteritis.  When symptoms persisted, blood laboratory tests were obtained which showed an abnormally low white blood cell count and platelet count but essentially normal liver associated enzymes.  Due to concerns for bleeding because of the low platelet count, he was aeromedically evacuated to home station.  After an extensive medical workup it became clear that the CI’s congenital medical condition was not compatible with military service.  

Prior to his deployment, the CI was noted to have a positive tuberculosis (TB) skin test and was started on isoniazid (INH) to decrease the likelihood of reactivation of active TB later in life.  Laboratory tests obtained at that time (26 June 2003) revealed antibodies consistent with the CI having been immunized against hepatitis B and no evidence of hepatitis A or hepatitis C infection.  One of the liver associated enzymes (aspartate aminotransferase (AST)) was normal at 31 international units per liter of serum (U/L) with the normal range at that lab being 17-59.  

The 29 October 2003 abdominal computerized tomogram (CT) showed an enlarged spleen, 3 times the normal volume.  The hepatic veins were not visualized and there was an enlarged caudated lobe noted causing suspicion of severe portal venous hypertension (marked elevation of pressure within the veins of the liver).  During the 5 November 2003 transjugular liver biopsy venous pressures were found to be normal (no evidence of significant portal hypertension).  

A liver biopsy obtained 5 November 2003, 12 months prior to separation, found cirrhosis but no significant inflammation to the parenchyma (the functional substance of the liver).  There were abnormal bile ducts, additional bile ducts, many of which were plugged with bile and bridging fibrosis.  There was no evidence of excessive iron deposition.  The specimen was forwarded to the Armed Forces Institute of Pathology where the team for hepatic and GI pathology noted several fibrous septa of varied thickness transecting an otherwise normal parenchyma.  Numerous bile ducts were noted along and within the septa, some of which had an abnormal configuration.  Many of the smaller ducts contained congealed bile plugs.  The team noted that those changes were diagnostic for congenital hepatic fibrosis, a hereditary genetic condition.  

The 17 December 2003 esophagogastroduodenoscopy (EGD), 10 months prior to separation, noted grade 2 esophageal varices (dilated veins in the esophagus) that showed no stigmata of recent hemorrhage.  The varices were banded at that time to prevent future bleeding.  The CI was referred to a civilian gastroenterologist 9 June 2004, 5 months prior to separation, where the history was reviewed, the CI was examined and after review of all of the available data he opined, “Description of the liver biopsy reveals no evidence of an idiosyncratic reaction to INH and with the development of cirrhosis and portal hypertension, I suspect that he has had chronic liver disease for at least 1-2 decades and I conveyed this to him.”  The 29 April 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of fatigue.  Physical examination showed a soft abdomen that was not distended or tender.  The liver edge was palpable 2 cm below the edge of the ribs and the spleen was palpable.   

At the 18 January 2005 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported dyspnea on exertion with decreased stamina, 20 pound weight loss from October 2003 through July 2004 and continued monthly episodes of fever, shaking chills and night sweats.  Physical examination showed mild scleral icterus, no jugular venous distention.   The spleen was palpable 3 fingerbreadths below the left rib margin and the liver edge was palpable two fingerbreadths below the right rib margin.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the congenital hepatic fibrosis condition 10%, coded 7312-7399 (analogous to cirrhosis of the liver, primary biliary cirrhosis, or cirrhotic phase of sclerosing cholangitis), after a deduction of 40% based on the CI’s preexisting congenital condition citing an existing prior to service (EPTS) factor.  The PEB also cited current symptomology included hemorrhage from rectal varices and portal gastropathy which renders a 50 percent disability rating in and of themselves.  The VA rated the congenital hepatic fibrosis condition 50% coded 7312, based on the C&P examination 3 months after separation, citing cirrhosis with known esophageal varices.  

There was evidence of portal hypertension (as evidenced by the presence of esophageal varices) and spenomegaly with weakness, anorexia, abdominal pain, malaise, and the CI claimed at least minor weight loss to justify a 30% rating under VASRD code 7312.  Although there was a history of esophageal varices that were banded to prevent future bleeding, there was no evidence of hemorrhage from varices, one episode of ascites, hepatic encephalopathy or portal gastropathy to validate the criteria for the next higher 50% rating.  With respect to the deduction for the condition existing prior to service, a presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  Though the civilian gastroenterologist felt certain that the CI had liver disease for 1 to 2 decades, it is impossible to determine if the combination of the INH therapy with gastroenteritis and dehydration or any number of other service connected features may of accelerated liver scarring and by how much.  Additionally, at the time the CI entered active duty service a normal physical examination was noted and he was found fit even after disclosing his previous history of enlarged liver and spleen with liver biopsy.  As such, the panel does not recommend a deduction for the condition existing prior to service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the congenital hepatic fibrosis condition, coded 7312.  

BOARD FINDINGS:  In the matter of the congenital hepatic fibrosis condition, the panel majority recommends a disability rating of 30%, coded 7312 IAW VASRD §4.114.  The single voter for dissent recommended no change to the previously assigned rating and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Congenital Hepatic Fibrosis	7312	30%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20150728, 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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02085.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.
Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:  
Record of Proceedings