Author: JOHN J. D'ORAZIO
Last saved by: BARKSDALE, JAMEILL M GS7 USAF SAF SAF/MRBE
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE NUMBER:  PD1201313
BRANCH OF SERVICE:  Army	BOARD DATE:  20130516
DATE OF PLACEMENT ON TDRL:  20000828
Date of Permanent SEPARATION:  20020530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SPC/E-4 (46Q/Public Affairs Specialist), medically separated for fatigue and depression as a residual of sarcoidosis.  The CI's symptoms began in 1996 upon her return from a 2 week annual training at Fort Polk where the CI was noted to have some cervical adenopathy, leading to a diagnosis of sarcoidosis.  The CI was deployed with her Public Affairs Unit to Bosnia in 1999 and soon thereafter she was evaluated at Landstuhl Army Medical Center because of her shortness of breath (SOB) and fatigue.  The CI continued to exhibit these problems and was also treated for anxiety disorder, depression and social phobia.  
Despite the numerous and extensive rheumatology, dermatology and physical therapy (PT) evaluations, the CI failed to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3/S3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “1.  Sarcoidosis causing joint aches and general fatigue; 2.  Axis I:  1. Major Depression related to her general medical condition and her inability to work and to function well because of fatigue. 2. Social phobia 3.  Acrophobia, mild. 3. Axis II:  Mixed personality disorder with obsessive-compulsive, passive-dependent and schizoid features.  Axis III:  1. Sarcoidosis 2.  Chronic Anemia 3.  Fatigue related to sarcoidosis and/or the anemia and/or the depression and/or chronic fatigue syndrome, possibly.  Axis IV:  1. Inability to function on the job 2.  Inability to function at home secondary to fatigue. Axis V:  60” were forwarded to the Informal Physical Evaluation Board (IPEB) IAW AR 40-501.  The IPEB adjudicated “sarcoidosis with associated excessive fatigue, depression and joint pain” as unfitting, rated 30% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was placed on the Temporary Disability Retired List (TDRL) on 28 August 2000.  The IPEB proceedings of 18 March 2002 removed the CI from the TDRL and she was permanently separated with a 10% disability for sarcoidosis with residual fatigue, depression.  The CI appealed to the Formal PEB (FPEB) which affirmed the IPEB finding and rating.  The CI rebutted the FPEB finding and the US Army Physical Disability Agency (USAPDA) affirmed the FPEB finding.  The CI made no appeals, and was medically discharged.

CI CONTENTION:  “The rating for sarcoidosis should be changed because it is alleged the condition preexisted.  There is no evidence the condition preexisted.  The posterior cervical lymphadenopathy appeared while on active duty.  It did not exist prior to my active duty time.  According to Dr. V---, it was reactive.  Even if the condition was present, it was dormant until the active duty time.  This constitutes “worsening of the condition.”  I have continued to suffer w/sarcoidosis SINCE that active duty time.  Never before.  That would constitute permanent worsening.  The condition has progressed to nuero sarcoidosis since that time.  I am required to take medication daily to maintain the illness.”
______________________________________________________________________________

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the sarcoidosis with residual fatigue and depression condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Final Service FPEB - 20020417 | VA (12 Mo. Post-TDRL Entry and 30 Mo. Post-TDRL exit)
On TDRL - 20000828 | Code | Rating | Condition | Code | Rating | Exam
Condition | | TDRL | Sep. | | | |
Sarcoidosis with associated Excessive Fatigue, Depression, and Joint Pain | 6846 | 30% | | Sarcoidosis | 6846 | Not Service Connected (NSC) | 20010818
| | | | Major Depression | 9434 | NSC | 20010818
Social Phobia;  Acrophobia, Mild; and Mixed personality Disorder | | Not Unfitting | | No VA Entry
Sarcoidosis with Residual Fatigue and Depression | 6846-9434 | | 10% | Sarcoidosis | 6846 | NSC | 20041030
| | | | Major Depression | 9434 | NSC | 20041030
Iron Deficiency Anemia | | | Not Unfitting | No VA entry
Combined:  30% → 10% | Combined: NSC

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Sarcoidosis with associated Excessive Fatigue, Depression, and Joint Pain Condition.  The CI’s condition was well documented in the numerous service treatment records.  The CI first presented with symptoms of bilateral cervical adenopathy in 1995.  A cervical node biopsy was performed in November 1995 and pathology confirmed the diagnosis of sarcoidosis.  In 1997, the CI underwent the biopsy of lesions on her face-lip area which were consistent with sarcoidosis.  The CI was seen by dermatology in 1999 for sarcoid lesions, internal medicine for iron deficiency anemia, and gynecology for bilateral breast lesions.  The rheumatologist noted profound fatigue and that the CI had developed significant problems with depression after treatment with Prednisone since the onset of the sarcoidosis.  A pulmonary function test (PFT) demonstrated a mild to moderate lung disease.  A cardiology consult was negative for sarcoid involvement.  The rheumatologist in November 1999 noted a depressed affect.  The internist noted chronic fatigue, mild lymphadenopathy and depression.

The CI was initially referred to mental health in 1999 for a history of anxiety which increased with stress in social situations and she was diagnosed with social phobia.  The CI was followed extensively by a psychiatric social worker and a psychiatrist for a mood disorder due to a general medical condition (sarcoidosis).  The commander’s statement noted that the CI's chronic fatigue, sarcoidosis, depression, and SOB interfered with her performing the duties required of her MOS.  The MEB history and physical exam approximately 6 months prior to TDRL entrance noted that the CI had suicidal ideation when she was in Bosnia; however, the examiner opined that “it would appear that the general medical condition is what incapacitates her and that the depression is secondary” and “if she is to be medically discharged from the Army it would not be appropriate to do that from a psychiatric point of view, but to tie her discharge to her general medical condition.”  The MEB narrative summary (NARSUM) exam approximately 5 months prior to TDRL entrance noted that the CI continued to have chronic and unrelenting fatigue and SOB with slight and frequent joint pain.  A PFT demonstrated moderate obstructive defect in small airways.  At the time of the MEB NARSUM, the CI was currently taking an anti-inflammatory medicine, hydroxychloroquine sulfate (Plaquenil) 200 mgs 2 per day, Prozac, and iron tablets for treatment of a chronic iron deficiency anemia.  The CI was given a P3/S3 permanent profile for sarcoidosis and major depression.  The CI was referred to PT with joint pains for quadriceps and hamstring strengthening.  The CI was placed on TDRL in August 2000.

The Board directs attention to its rating recommendation at TDRL entry based on the above evidence.  At TDRL entry, the PEB coded the sarcoidosis with associated excessive fatigue, depression, and joint pain as 6846.  The TDRL entry IPEB rated the condition at 30% based on pulmonary involvement with persistent symptoms requiring chronic low dose (maintenance) or intermittent corticosteroids.  Based on a review of treatment records, the VA determined that 6846 sarcoidosis was not service-connected (NSC) based on the finding that it had existed prior to service (EPTS) and it had not been permanently worsened as a result of service.  The VA also determined that 9434 depression was NSC because the records did not show any treatment for depression and it could not be shown that this condition was either incurred in or aggravated by military service.  The MEB NARSUM exam approximately 6 months prior to TDRL entrance noted that the CI continued to have chronic and unrelenting fatigue and SOB with slight and frequent joint pain.  At the time of TDRL entry, the CI had a well-documented history of SOB and dyspnea.  While Plaquenil is not a corticosteroid but an antimalarial medication, it is used to reduce inflammation in rheumatologic diseases instead of corticosteroids and can be considered similar for rating purposes.  With continued symptoms and chronic use of this medication, the CI exceeded the requirements for the 0% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends no recharacterization of the TDRL entry rating decision of 30%.

The Board turned its attention to the accompanying symptoms of depression and discussed the possibility of rating this as a separately unfitting condition.  The rheumatologist in November 1999 noted a depressed affect.  The internist noted chronic fatigue, mild lymphadenopathy, and depression.  The CI was initially referred to mental health in June 1999 for a history of anxiety that increased with stress in social situations and she was diagnosed with social phobia.  The CI was followed extensively by a psychiatric social worker and a psychiatrist for a mood disorder due to a general medical condition (sarcoidosis).  The CI was seen by mental health who, in November 2000, noted that she was diagnosed with social phobia and depression as a result of her tour in Bosnia.  The following month a psychiatrist opined that although the CI had “severe major depression (may or may not be due to sarcoidosis).”  The MEB NARSUM psychiatric addendum approximately 8 months prior to TDRL entrance noted that the CI had suicidal ideation when she was in Bosnia.  However, the examiner opined, “it would appear that the general medical condition is what incapacitates her and that the depression is secondary” and “if she is to be medically discharged from the Army it would not be appropriate to do that from a psychiatric point of view, but to tie her discharge to her general medical condition.”  The Board reviewed the above evidence and concluded that based on the preponderance of evidence, the depression was an inherent as part of the CI’s sarcoidosis and it was not separately unfitting.

While on the TDRL, the CI continued to have intermittent fatigue, joint arthralgias, anemia, depression, and flares of new sarcoid lesions.  Her medications included Plaquenil, an anti-depressant, a series of corticosteroids, and a NSAID.  Two PFT’s demonstrated a moderate obstructive defect in the small airways.  A chest X-ray in December 2001 indicated increased interstitial markings consistent with sarcoidosis.  A repeat chest X-ray 2 months later noted chronic changes in both perihilar regions, more prominent on the right and probably secondary to sarcoidosis.  The CI continued to have rheumatology evaluations for arthralgias and dyspnea and dermatology evaluations for ongoing skin lesions.  At the MEB TDRL exit NARSUM approximately 6 months prior to final separation, the CI had stopped taking Plaquenil against medical advice.  She had not received any prescriptions for corticosteroids in the previous year, had no emergency room visits, and had not been using any inhalers.  She was using an NSAID for joint pain a few times a week and had periodic steroid injections for skin lesions.  She was working 40 hours per week and she stated she was “exhausted” after an 8 hour day.  The physical examination noted only multiple 2 cm anterior and posterior cervical and submandibular lymph nodes that were all soft and mobile.  The pulmonary exam was clear and PFTs in November 2001 documented no change with a bronchodilator, a very mild decrease in diffusion, no obstruction, and no restriction.  As depression was a residual of the CI’s sarcoidosis, it was evaluated by both the VA and the service.  The VA psychiatric C&P examination approximately 9.5 months prior to permanent separation noted a Global Assessment of Functioning (GAF) of 70 (some mild symptoms).  The examiner opined that the CI’s “depression was aggravated by her military service from 26 February 1999 to 11 July 1999.  The MEB TDRL exit psychiatric addendum exam approximately 3 months prior to permanent separation, noted that the depression was in full remission with daily Prozac and regular outpatient psychiatric treatment.  There is documentation in the STR that the CI continued to be followed by mental health and there was an exacerbation of the depression.  She was advised to double the anti-depressant dosage and return to the clinic in a week for a reevaluation.  The CI continued to be monitored by mental health and had a GAF of 50 (serious symptoms) at VA outpatient appointments in both May and July 2002.  There was minimal information about her functioning at work was available although in July 2002 the CI reported, “work is going okay.”

The Board directs attention to its permanent separation rating recommendation at TDRL exit based on the above evidence.  The IPEB rated the sarcoidosis with residual fatigue and depression as 6846 sarcoidosis with 9434 major depression.  A 10% disability rating was assigned based on the 9434 code and a “mild social and industrial impairment.”  The CI appealed and both a FPEB and USAPDA affirmed the 10% disability rating.  In December 2001, the VA determined that both sarcoidosis and depression had EPTS and neither had been aggravated by service.  Therefore, neither condition was service-connected.  The VA cited evidence that sarcoidosis originated in August 1995, 4 years prior to service, and that while the etiology of sarcoidosis is unknown, it was unlikely to have resulted from the CI’s military service.  The VA had previously denied service-connection of depression based on lack of a diagnosis.  However, at the time of this rating decision, it had obtained evidence the CI had been treated for depression prior to service in August 1998 and that the depression had not been permanently aggravated by military service.  The evidence shows the CI had little to no pulmonary problems and was no longer taking Plaquenil or any chronic or intermittent corticosteroids at the time of the TDRL exit NARSUM.  Therefore, if 6846 sarcoidosis alone was used for rating, a disability rating greater than 0% would not be warranted.  However, if the general rating formula for mental disorders is applied to rate the depression as an extra-pulmonary residual of sarcoidosis, a 10% rating can be assigned based on the diagnosis of depression with symptoms controlled with medication.  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 permanent separation rating of 10% for the sarcoidosis with residual fatigue and depression condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the sarcoidosis with residual fatigue and depression condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication for TDRL entry rating or the permanent separation rating.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION | VASRD CODE | RATING
| | TDRL | PERMANENT
Sarcoidosis with Residual Fatigue and Depression | 6846-9434 | 30% | 10%
COMBINED | 30% | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130012146 (PD201201313)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD1201313