RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01131
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated from the Temporary Disability Retired List (TDRL) for “sarcoidosis” with a disability rating of 0%.  

CI CONTENTION:  “…I think I am owed a disability rating from the military because I have a disorder that was brought on by the negligent actions of an unsupervised corpsman.  I will have this disorder for the rest of my life with the possibility of continued progression.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 200500712	VARD - 20040903	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sarcoidosis	6846	0%	Sarcoidosis	6600	60%	20031022	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Sarcoidosis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s sarcoidosis condition began in August 2002 after a yellow fever vaccination and subsequent anaphylactic shock.  Surgical pathology on 28 October 2002 of a transbronchial lung biopsy showed lung parenchyma with focal interstitial thickening with fibrosis and occasional epithelioid type cells suggestive of sarcoidosis.  Special stains for acid-fast bacilli and fungal organisms were negative.  While the findings were suggestive of sarcoidosis, no distinct epithelioid granulomas were seen nor was there evidence of Langerhans giant cells.  The CI was treated with steroids and methotrexate (an immune suppressor medication), followed by Imuran (azathioprine, an immune suppressor medication).  By the time of TDRL placement in December 2003, lymphadenopathy had resolved based on radiographic examination and her ESR (erythrocyte sedimentation rate, a measure of inflammation) and ACE (angiotensin-converting enzyme, a marker of sarcoidosis) levels had returned to normal.  However, left-sided chest pain persisted and was treated with MS Contin (morphine sulfate, a narcotic), MSIR (morphine sulfate instant release), and methadone (a narcotic).  

The CI had an emergency room visit and a pulmonary consultation on 18 June 2004 where the impression was non-cardiac chest pain possibly related to sarcoidosis ongoing for 18 months.  Her ACE level on 11 September 2004 was slightly elevated. Calcium and alkaline phosphatase levels were within normal limits.  A bone scan on 10 December 2004 revealed a small focus of increased tracer activity at the costovertebral junction at the level of the mid and lower thoracic spine on the right which may have reflected inflammatory change.  There was also mild degenerative type uptake in the shoulders, knees, feet, hands, and wrists, likely due to an arthritic type uptake with a mild increased uptake in the sacroiliac joints.  

A sleep study on 12 January 2005 revealed significant obstructive sleep apnea requiring CPAP (continuous positive airway pressure).  A pulmonary function study on 10 February 2005 demonstrated no significant dynamic airway collapse or air trapping.  Pre-bronchodilator flow rates had a pattern consistent with minimal chronic obstructive pulmonary disease (emphysema), which was described as mostly just peripheral airway dysfunction; the post-bronchodilator showed no statistical significant change, although the study was in the normal range. The MVV (maximal voluntary ventilation known as maximum breathing capacity) was normal pre- and post-bronchodilator, and airway resistance was normal.  A CT scan of the thorax on 10 February 2005 demonstrated no adenopathy, no identified nodule, no pneumonia or atelectatic (collapse or closure of part or all of a lung) change, no pleural lesions, no bony lesions, and normal appearing adrenals.  A DEXA (dual-energy X-ray absorptiometry) scan (to determine bone density) on 15 March 2005 demonstrated probable osteopenia (loss of bone mineral content).  A pain management consultant noted the left chest pain may have been of a cardiac origin and a component was neuropathic.  

An echocardiogram on 14 April 2005 for chest pain was essentially unremarkable with an ejection fraction of 70% with normal left ventricular wall function, systolic function, and contractility, normal valves, and no regional wall motion abnormalities.  A transesophageal echocardiographic study the same day demonstrated findings of left ventricle obstructive subvalvular stenosis, a high adrenergic catecholamine state, asymmetric septal hypertrophy, and diminished left ventricular cavitary dimensions in systole and diastole.  The impression was an “essentially normal 4-chamber cardiac structure hyperdynamic, hyperkinetic, hypercontractility.”  A trial of beta-blockers was recommended.  A chest X-ray on 3 May 2005 revealed unchanged cardiac silhouette and pulmonary vascularity, both likely within normal limits.  There were no pleural effusions and no lung opacities or densities seen.  A cardiac catheterization on 12 May 2005 was normal.  

On 13 May 2005, a rheumatologist diagnosed fibromyalgia, which was felt to be the cause of most of her current aches and pains.  The CI continued to take MS Contin along with NitroQuick (nitroglycerin for chest pain, diltiazem (a calcium channel blocker for hypertension and chest pain), isosorbide (for chest pain), hydrochlorothiazide (a diuretic for hypertension), tramadol (an opioid-like medication), Neurontin (gabapentin for nerve pain), and albuterol (a bronchodilator), along with thyroid and estrogen replacement medications.  Prevacid (lansoprazole for upper gastrointestinal symptoms) and Ambien (zolpidem for sleep) were also taken.  Physical examination showed the CI’s vital signs to be:  blood pressure 146/88, pulse 82 beats/minute, respirations 20/minute, height 5’1”, and weight 184 pounds.  Her lungs were clear and the heart had a regular rate and rhythm without a murmur, gallop, rub, or arrhythmia. There was no peripheral edema and she moved all extremities well.  No focal motor or sensory deficits were appreciated.  

The 8 Jun 2005 TDRL removal NARSUM examination, 1 month prior to separation, noted complaints of sarcoidosis complicated by chronic chest pain.  The CI also reported pain in her hips.  She had a dull constant pain 5/10 (10 being the worst pain) and an intermittent sharp pain 9/10 precipitated by activities and partially relieved by rest and medications.  Electrocardiograms dated 1 July 2005 and 11 July 2005 were normal.  

At the 13 November 2003 VA Compensation and Pension (C&P) examination, 19 months before separation, the CI reported an occasional cough and dyspnea (shortness of breath) on exertion with a diagnosis of sarcoidosis.  Physical examination showed the CI to be comfortable and in no distress.  Vital signs were weight 181 pounds, heart rate 88 beats/minute, blood pressure 118/82, and oxygen saturation 95% on room air.  Examination of the chest revealed clear lung fields and normal heart sounds.  There was no peripheral edema, clubbing, or cyanosis.  Pulmonary function testing revealed mild restrictive ventilatory defect with mild obstructive ventilatory defect.  Diffusion capacity corrected to alveolar volume was normal.  A chest X-ray was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the sarcoidosis condition 0%, coded 6846 (sarcoidosis), citing no physiological impairment, although she had chest pains with exertion.  The VA rated the sarcoidosis condition 60%, coded 6846, based on the C&P examination, citing pulmonary involvement requiring systemic high dose (therapeutic) corticosteroids for control.

Panel members discussed the findings of the TDRL removal examination in depth.  The PEB assigned a 0% rating that requires “chronic hilar adenopathy or stable lung infiltrates without symptoms or physiologic impairment.”  CT and X-ray studies failed to demonstrate “pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids.”  Therefore, a 30% rating or higher, is not applicable using code 6846.  However, code 6846 indicates “or rate active disease or residuals as chronic bronchitis (DC 6600) and extra-pulmonary involvement under specific body system involved.”  Although there was no evidence of chronic bronchitis, there was a suggestion of mild chronic obstructive pulmonary disease (code 6604); however, there were no quantitative pulmonary function test measurements with which to determine a rating.  Nevertheless, the CI did report left sided chest pain, and a transesophageal echocardiographic study on 14 April 2005, in contrast to an echocardiogram that was performed on the same day and was unremarkable, demonstrated findings of left ventricle obstructive subvalvular stenosis, a high adrenergic catecholamine state, asymmetric septal hypertrophy, and diminished left ventricular cavitary dimensions in systole and diastole.  VASRD code 7000 (valvular heart disease) offers a 30% rating, which requires that “workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray.” Since the CI did have dyspnea and chest pain and the transesophageal echocardiogram did demonstrate subvalvular stenosis, asymmetric septal hypertrophy, and diminished cavitary dimensions in systole and diastole, members considered the 30% option to have credence.  A caveat to the results of the transesophageal echocardiogram was the report that a cardiac catheterization on 12 May 2005 was normal; however, no details of the examination were available for review, and it is therefore unclear whether the catheterization focused on the coronary vasculature and/or valves or encompassed the full spectrum of cardiac function.  Nonetheless, the CI was taking four medications to ameliorate her chest pain (angina) including nitroglycerin, isosorbide, diltiazem (which is also use to treat high blood pressure), and MS Contin.  Therefore, panel members recommend a 30% rating, and no higher in the absence of an ejection fraction of 30-50%, using code 6846-7000.  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 sarcoidosis with residual chest pain condition, coded 6846-7000.  
BOARD FINDINGS:  In the matter of the sarcoidosis condition, the panel recommends a disability rating of 30%, coded 6846-7000 IAW VASRD §4.97 and §4.104.  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 the date of medical separation:  

CONDITION	VASRD CODE	RATING	
Sarcoidosis	6846-7000	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007329, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure