RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00805
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20040106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Aircraft Electronic & Environmental Systems Journeyman, medically separated for “idiopathic anaphylaxis with angioedema” with a disability rating of 20%.  

CI CONTENTION:  Evidence supports a higher rating.  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 - 20031014	VARD - 20040128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Idiopathic Anaphylaxis with Angioedema	7118-7199	20%	Idiopathic Anaphylaxis with Angioedema, Right Inguinal Hernia Repair and Depression	7118-8911	100%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:

Idiopathic Anaphylaxis with Angioedema.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s angioedema (swelling beneath skin surface) condition began in January 2002 with swelling in his hands and feet.  He was treated with medications, but had recurrent symptoms without an identifiable cause.  On 16 March 2002, he was hospitalized for gastroenterology, otolaryngology, and dermatology evaluations as well as radiographic and serological (blood) testing, which failed to reveal an etiology for the angioedema.  A 10 April 2002 rheumatology workup was normal. 

At a 6 August 2002, primary care visit, the CI reported feeling dizzy and that he would “pass out.”  During a neurology consult on 27 February 2003, he recounted periodic episodes of vertigo (sensation of spinning) since January 2002, previously associated with the angioedema.  The clinical examination was normal and provocative maneuvers negative.  Despite medication, the CI’s symptoms continued.  An 11 March 2003 infectious disease evaluation was unremarkable.  On 10 April 2003, the CI fainted at work and was evaluated by paramedics; at the time of their arrival, he was asymptomatic and refused transport.  A brain MRI 2 days later was normal.  Subsequently, he reported chest pain with his syncope (loss of consciousness) as well as dizziness.  A 24-hour cardiac monitor (ambulatory electrocardiogram) showed a normal rhythm.

At an 18 April 2003 cardiology visit, the CI reported five “full-blown” syncopal episodes with loss of consciousness over the previous month.  The cardiac evaluation was normal including an exercise tolerance test, an unremarkable echocardiogram, and physical examination.  The CI was referred for a 30 April 2003 neurology evaluation which noted a history consistent with migraines on several occasions.  The examiner opined that the CI’s episodes of dizziness were not seizures, and noted that neurological and vestibular testing remained normal. 

A 5 May 2003 cardiology visit revealed no pathology and that symptoms had improved after discontinuation of several medications (not specified).  Subsequently, the CI reported recurrent angioedema with respiratory compromise and was referred to Walter Reed Army Medical Center and the National Institutes of Health in June 2003.  Evaluations found no evidence of mastocytosis (mast cell disorder) and a neurology consult indicated symptoms were not consistent with migraines or seizures.  The CI remained symptomatic, primarily from episodes of dizziness, and frequently used epinephrine (EpiPen) for subjective difficulty with breathing.  

On 18 August 2003, the CI was hospitalized for treatment of abdominal pain, which he reported had been present for 2 years.  Despite extensive evaluation, no etiology was found for this condition, and the examiner opined that that his pain was out of proportion to his examination.  The CI was asymptomatic from angioedema at that time.  

During the 23 September 2003 MEB NARSUM examination, 4 months prior to separation, the examiner noted the CI’s mixed response to medications with improvement either when a prescription was added or stopped.  He was diagnosed with idiopathic angioedema and anaphylaxis but no seizure disorder.  The physical examination was normal.  The CI again experienced difficulty with syncope in October 2003 but a neurology evaluation was unremarkable other than apparent swelling of the optic discs.  A repeat brain MRI and electro-encephalogram (EEG) were normal.  In December 2003, a neurologist stated that none of the CI’s syncopal episodes had been witnessed in a hospital.  

The CI was medically separated on 6 January 2004 and seen in neurology on 19 February 2004 where he was diagnosed with a seizure disorder.  This diagnosis appeared in part to be based on the medical history he provided, and not entirely consistent with the STR.   He reported continued daily edema and dizziness.  An EEG (awake and sleep deprived) was normal.  The examiner noted that the episodes of angioedema lasted several hours.  There was no VA Compensation and Pension evaluation in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the anaphylaxis with angioedema condition 20%, analogously coded 7118-7199 (angioneurotic edema-angioedema, anaphylaxis), citing continuing symptoms and that “frequent use of an epipen is preventative in nature, rather than in response to laryngeal involvement.”  The VA rated the anaphylaxis with angioedema condition 100%, analogously coded 7118-8911 (angioneurotic edema- angioedema, anaphylaxis-epilepsy, petit mal), based on the CI’s STR, citing “unstabilized condition with severe disability” which was combined with a history of “right inguinal hernia repair and depression.”  The relative contribution of each to the rating was not addressed.  

The panel directed attention to its rating recommendation based on the above evidence.  The criteria for a higher 40% rating under code 7118 requires “attacks without laryngeal involvement lasting of 1-7 days or longer and occurring more than 8 times a year, or; attacks with laryngeal involvement of any duration occurring more than twice a year.”  While the CI reported frequent anaphylactic attacks, the duration of these episodes was not well documented throughout the STR; however, the 19 February 2004 neurology evaluation, 5 weeks after separation, noted that they lasted several hours.  The panel observed that on some occasions the CI felt that his upper airways were constricted; however, on direct examination, these were patent and without swelling (edema).  On at least one occasion, an otolaryngologist documented a normal examination while the CI was symptomatic.  Upon deliberation, members agreed that a rating higher than the 20% assigned by the PEB was not supported in this case.  The panel also noted that only angioedema and anaphylaxis were considered by the MEB and PEB.  While numerous other diagnoses were discussed in the STR, none are within the scope of review.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the anaphylaxis with angioedema condition.

BOARD FINDINGS:  In the matter of the anaphylaxis with angioedema condition and IAW VASRD §4.104, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160912, 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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00805.

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 appropriate.  The Board recommended no re-characterization or modification of your separation.

I carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings