RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02669
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Patient Administration Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “systemic lupus” with a disability rating of 10%.

CI CONTENTION:  Requested review of systemic lupus and hypertension along with additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 FPEB - 20040304	VARD - 20041018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Systemic Lupus	6350	10%	Bilateral Sjogren’s of the Eyes Associated with Systemic Lupus Erythematous [SLE]	6099-6025	20%	20040909	
			Multiple Joint Pain and Inflammatory Arthritis Associated with SLE	5099-5025	10%	20040830	
			Facial Photosensitivity and Lesions Associated with SLE	7899-7823	10%	20040910	
Hypertension	Not Unfitting	Hypertension	7101	0%	20000731	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Systemic Lupus.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was placed on to the TDRL on 10 May 2000 for systemic lupus with a history of lupus nephritis (kidney small blood vessel bacterial infection), which was successfully treated with Cytoxan (immunosuppressive medication).  She was able to taper off her other medications, prednisone and Plaquenil (anti-rheumatic agent), and successfully completed a pregnancy.  She continued to have periodic morning stiffness, joint pain, and intermittent ankle swelling that resolved with rest and elevation.  Arthralgias (joint pain) and myalgias (muscle aches) were treated with low dose nonsteroidal anti-inflammatory drugs and topical analgesic creams.  She noted occasional oral ulcers and continued fatigue, but remained off immunosuppressive medications post-partum. She denied sicca (dry mouth and dry eyes), chest pain, shortness of breath, rash, photosensitivity, active Raynaud’s syndrome symptoms (white or blue fingers in the cold), genitourinary or gastrointestinal complaints.  There was full range of motion (ROM) of the joints, no active synovitis (inflammation of the joints), and normal strength.  

The 15 October 2003 TDRL NARSUM examination, 5 months prior to TDRL removal, noted complaints of continued fatigue and musculoskeletal symptoms.  The CI achieved renal remission with cytotoxic therapy, continued to have stable renal function, and did not require anti-hypertensive therapy.  Physical examination showed no malar erythema (cheek redness in a butterfly pattern) and no oral or nasal ulcerations, but she had alopecia (patchy hair loss) over the top of scalp.  The examiner noted global improvement of the CI’s disease process, but that she continued to have periodic exacerbation of arthritis and alopecia.

At a rheumatology visit on 29 January 2004, Raynaud’s symptoms were reported to be stable.  During a primary care visit on 8 March 2004, 3 weeks before TDRL removal, the CI complained of sores in both nostrils and at the back of the mouth since November 2003.  On examination, there was bilateral interior nasal inflammation, but no pharynx mucosal lesions or exudates (fluid seeping from vessels or organs).  The neck was supple without any cervical lymphadenopathy.  At a dermatology appointment the same day, the CI reported nostril irritation, but no photosensitivity or thickening and/or scarring rashes.  The provider noted no nostril lesions, but documented right chest hyperpigmentation.  At an 18 March 2004 rheumatology appointment, the CI complained of hand joint pain, alopecia, and daily headaches.  She reported no rashes or photosensitivity, but did have sicca symptoms.  Physical examination was within normal limits with no synovitis, but there were superficial nasal septum ulcers.

The CI submitted a PEB decision rebuttal on 19 March 2004, and cited sources that defined flare and exacerbation to support a higher rating.  She stated that while physical examinations seemed to show her disease activity in remission, the periods between evaluations were not always disease-free but “unfortunately, I [CI] lack documentation to support this claim.”  She described symptoms that she felt could be characterized as an “exacerbation of my lupus” including hair loss and fatigue, and reported use of low-dose prednisone, Plaquenil, and artificial tears.

At a follow-up rheumatology visit on 25 March 2004, the CI complained of bilateral hand, wrist and knee joint pain, nasal ulcers, and alopecia.  She denied difficulty breathing, chest or abdominal pain, fever, chills, or cough.  There were superficial nasal septum ulcers, but no swollen cervical lymph nodes, sinus tenderness, oral ulcers, or joint swelling/warmth.  At a dermatology examination on 29 March 2004, a day before TDRL removal, the CI was seen for nose sores, and reported not taking steroids or Plaquenil.  Examination revealed scalp and mild bilateral nasolabial (skin indention on either side of the mouth) flaking.  The nasal passages had mild redness with no sores, and there were no skin lesions.  The examiner diagnosed seborrheic dermatitis.  At a 31 March 2004 optometry visit, the CI complained of a history of capped Meibomian glands (similar to a pimple on the eyelid edge) that she popped with a Q-tip, but had no other ocular or visual issues.  The provider noted a diagnosis of Sjogren’s syndrome (dry eyes and mouth) from an “outside rheumatologist” who prescribed artificial tears.  However, the CI had not been using the medication and wanted to get it through the VA.  Examination revealed bilateral capped Meibomian glands and myopia.  The examiner’s assessment was SLE with no ocular manifestations, although the CI was prescribed artificial tears.

At the 30 August 2004 VA Compensation and Pension (C&P) general examination, 5 months after TDRL removal, the CI reported fatigue, anemia, and dry eyes and mouth.  The examiner noted tenderness, painful motion, and joint weakness.  Ankle range of motion (ROM) was normal bilaterally.  Hip flexion was to 110 degrees (normal 125) on the right and 120 degrees on the left, bilateral extension was to 30 degrees (normal), and abduction was to 40 degrees (normal 45) on the right and 50 degrees on the left.  Bilateral external rotation was to 55 degrees (normal 60).

At the 9 September 2004 C&P infectious, immune, and nutritional disability examination, 5 months after TDRL removal, the CI reported fatigue every 3 days and that her arthritis “acted up” intermittently every 2 weeks.  She also complained of joint pain, gritty eyes, and difficulty swallowing at times.  Physical examination showed the head, eyes, ears, heart and abdomen within normal limits.  There was no cyanosis (bluish skin discoloration), clubbing (finger end enlargement) or swelling.  Femur, hip, and hand X-rays showed no significant changes.  

At the 10 September 2004 C&P dermatology examination, the provider noted the CI did not have lupus signs for the previous several months.  There were multiple facial and forehead areas of hypo- and hyperpigmentation (1-2 mm), but no malar erythema or signs of discoid lupus (coin-shaped skin lesion).  There was mild scalp scaling without redness, and 0.5 x 1.0 cm area of alopecia on the posterior crown where the scalp appeared normal.  There was a band of post-inflammatory hyperpigmentation and keratosis pilaris (coarse skin) across the mid-back extending around the right chest wall to the right inframammary area but not to the left.  The palms were dry with no specific lesions.  The provider noted approximately 70% of exposed areas of the face was affected with the small areas of hypo- and hyperpigmentation, and approximately 15% of the total body area, including the trunk and the scalp and face were involved.  The only component of the CI’s condition specifically suggestive of SLE was the photosensitivity and lesions on the face, which occurred with sun exposure.  However, she did not go out in the sun without sunscreen on her face.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the systemic lupus condition 10%, coded 6350 (lupus erythematosus, systemic (disseminated)), citing no current medications use or exacerbations in the past year.  The VA initially rated the SLE 10%, coded 6350, based on the C&P examination, citing the condition could be rated as a single disease, or based on the affected systems.  The VA subsequently withdrew the 10% rating, choosing to rate based on the affected systems, and thus rated bilateral Sjogren’s of the eyes associated with SLE 20%, analogously coded 6099-6025 (disorders of the lacrimal apparatus (epiphora, dacryocystitis, etc.), based on the C&P examination, citing epiphora (interference with the lachrymal glands, or tear ducts), which affected both eyes with grittiness and dryness.  The VA also rated bilateral multiple joint pain and inflammatory arthritis associated with SLE 10%, analogously coded 5099-5025 (fibromyalgia (fibrositis, primary fibromyalgia syndrome)), citing widespread musculoskeletal pain and tender points requiring medication for control.  The VA additionally rated facial photosensitivity and lesions associated with SLE 10%, analogously coded 7899-7823 (vitiligo with exposed areas affected), citing multiple small photosensitive lesions over 70% of the face, back, and left side of the chest.  

The panel reviewed the clinical and laboratory findings in depth and noted that while the CI still had SLE, she had significantly improved while on TDRL with the main involvement related to joint pain and fatigue.  There was no STR or VA examination showing exacerbations lasting a week or more, 2 or 3 times per year, and furthermore, the CI noted that she had no documentation to support the aforementioned duration or frequency of exacerbations.  

The panel also considered the VA’s separate lupus symptom ratings.  Although the VA rated for bilateral Sjogren’s of the eyes, and facial photosensitivity and lesions associated with SLE, the members noted that only the joint pain was documented in the STR.  During the TDRL removal examination, the CI reported no sicca symptoms, but during a VA examination she reported having dry eyes and was subsequently diagnosed with Sjogren’s.  The optometry examination showed no evidence of dry eyes, although she reported a rheumatologist diagnosis of Sjogren’s and was prescribed artificial tears.  Furthermore, she denied photosensitivity since she used a sunscreen.  The VA dermatologist noted no malar rash and minimal findings of post inflammatory changes of forehead and cheeks.  The VA rated the joint pains using an analogous code for fibromyalgia, but the CI reported joint pain rather than widespread musculoskeletal pain.  The panel determined that code 6350 was more appropriate for rating purposes rather than rating residuals, which must be supported by a preponderance of evidence, the threshold of which was not achieved.  Members agreed that the 10% rating adjudicated by the PEB at TDRL removal was reasonable and appropriate.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the systemic lupus condition.  

Contended PEB Condition:  Hypertension.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the systemic lupus condition and IAW VASRD §4.88b, the panel recommends no change in the PEB adjudication.  In the matter of the contended hypertension condition, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20170313, w/atchs
Exhibit B.  Service Treatment Record	
Exhibit C.  Department of Veterans Affairs Record 

AR20190007049, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.
 
	A copy of this decision has been provided to the counsel you listed on your application, Veterans of Foreign Wars (VFW), 31 Hopkins Plaza, Suite 1226, Baltimore, MD 21201.