14.00 IMMUNE SYSTEM (Adult Prior) IMMUNE SYSTEM DISORDERS (Adult Final)

Transcription

1 The following is a side-by-side chart comparing the pri adult immune system listings (left side) with the new adult immune system disders listings (right side). We have copied the text of the new listings on the right side. However, on the left side we have cut and pasted the introducty text of the pri listings beside the introducty text of the new listings that it parallels in meaning. The introducty text in the pri listings has many paragraphs that do not have paragraph headings numbers. Therefe, to assist the reader, we identify paragraphs without a designation in the current listings by placing its section letter and the number of its numerical der in that section in parenthesis at the beginning of the introducty text. In some cases, we have also identified sentences from a paragraph by their numerical der when we compare only part of the introducty text from a pri paragraph with the introducty text in a new paragraph IMMUNE SYSTEM (Adult Pri) IMMUNE SYSTEM DISORDERS (Adult Final) A. What disders do we evaluate under the immune system disders listings? A. Listed disders include impairments involving deficiency of one me components of the immune system (i.e., antibodyproducing B cells; a number of different types of cells associated with cell-mediated immunity including T-lymphocytes, macrophages and monocytes; and components of the complement system). (B. 6, sentence 1) These disders may preclude perfmance of any gainful activity by reason of serious loss of function because of disease affecting a single gan body system, lesser degrees of functional loss because of disease affecting two me gans/body systems associated with significant constitutional symptoms and signs of severe fatigue, fever, malaise, weight loss, and joint pain and stiffness. (14.00B, 6, sentence 1) 1. We evaluate immune system disders that cause dysfunction in one me components of your immune system. a. The dysfunction may be due to problems in antibody production, impaired cell-mediated immunity, a combined type of antibody/cellular deficiency, impaired phagocytosis, complement deficiency. b. Immune system disders may result in recurrent and unusual infections, inflammation and dysfunction of the body s own tissues. Immune system disders can cause a deficit in a single gan body system that results in extreme (that is, very serious) loss of function. They can also cause lesser degrees of limitations in two me gans body systems, and when associated with symptoms signs, such as severe fatigue, fever, malaise, diffuse musculoskeletal pain, involuntary weight loss, can also result in extreme limitation. 1

2 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) c. We ganize the discussions of immune system disders in three categies: Autoimmune disders; Immune deficiency disders, excluding human immunodeficiency virus (HIV) infection; and HIV infection. B. Dysregulation of the immune system may result in the development of a connective tissue disder. Connective tissue disders include several chronic multisystem disders that differ in their clinical manifestation, course, and outcome. They generally evolve and persist f months years, may result in loss of functional abilities, and may require long-term, repeated evaluation and management. 2. Autoimmune disders (14.00D). Autoimmune disders are caused by dysfunctional immune responses directed against the body s own tissues, resulting in chronic, multisystem impairments that differ in clinical manifestations, course, and outcome. They are sometimes referred to as rheumatic diseases, connective tissue disders, collagen vascular disders. Some of the features of autoimmune disders in adults differ from the features of the same disders in children. 3. Immune deficiency disders, excluding HIV infection (14.00E). Immune deficiency disders are characterized by recurrent unusual infections that respond poly to treatment, and are often associated with complications affecting other parts of the body. Immune deficiency disders are classified as either primary (congenital) acquired. Individuals with immune deficiency disders also have an increased risk of malignancies and of having autoimmune disders. D. Human immunodeficiency virus (HIV) infection. D.1. HIV infection is caused by a specific retrovirus and may be characterized by susceptibility to one me opptunistic diseases, cancers, other conditions, as described in Any individual with HIV infection, including one with a diagnosis of acquired immunodeficiency syndrome (AIDS), may be found disabled under this listing if his her impairment meets any of the criteria in is of equivalent severity to any impairment 4. Human immunodeficiency virus (HIV) infection (14.00F). HIV infection may be characterized by increased susceptibility to opptunistic infections, cancers, other conditions, as described in

3 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) in (B. 2, sentence 1) The documentation needed to establish the B. What infmation do we need to show that you have an existence of a connective tissue disder is medical histy, immune system disder? Generally, we need your medical physical examination, selected labaty studies, appropriate histy, a rept(s) of a physical examination, a rept(s) of medically acceptable imaging, and, in some instances, tissue labaty findings, and in some instances, appropriate medically biopsy. acceptable imaging tissue biopsy repts to show that you have an immune system disder. Therefe, we will make every reasonable efft to obtain your medical histy, medical findings, and results of labaty tests. We explain the infmation we need in me detail in the sections below. (B. 3) A longitudinal clinical recd of at least 3 months demonstrating active disease despite prescribed treatment during this period with the expectation that the disease will remain active f 12 months is necessary f assessment of severity and duration of impairment. D2. Definitions. In 14.08, the terms "resistant to treatment," "recurrent," and "disseminated" have the same general meaning as used by the medical community. The precise meaning of any of these terms will depend upon the specific disease condition in question, the body system affected, the usual course of the disder and its treatment, and the other circumstances of the case. (B. 3, sentence 2-5) Medically acceptable imaging includes, but is not limited to, x-ray imaging, computerized axial tomography (CAT scan) magnetic resonance imaging (MRI), with without contrast material, myelography, and radionuclear bone scans. "Appropriate" means that the technique used is the proper one to suppt the evaluation and diagnosis of the impairment. C. Definitions 1. Appropriate medically acceptable imaging includes, but is not limited to, angiography, x-ray imaging, computerized axial tomography (CAT scan) magnetic resonance imaging (MRI), with without contrast material, myelography, and radionuclear bone scans. Appropriate means that the technique used is the proper one to suppt the evaluation and diagnosis of the 3

4 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) However, the Social Security Administration will not purchase impairment. diagnostic tests procedures that may involve significant risk, such as biopsies angiograms. Generally, the existing medical evidence will contain this infmation. 2. Constitutional symptoms signs, as used in these listings, means severe fatigue, fever, malaise, involuntary weight loss. Severe fatigue means a frequent sense of exhaustion that results in significantly reduced physical activity mental function. Malaise means frequent feelings of illness, bodily discomft, lack of well-being that result in significantly reduced physical activity mental function. D.2. "Disseminated" means that a condition is spread widely over a considerable area body system(s). The type and extent of the spread will depend on the specific disease. 3. Disseminated means that a condition is spread over a considerable area. The type and extent of the spread will depend on your specific disease. 4. Dysfunction means that one me of the body regulaty mechanisms are impaired, causing either an excess deficiency of immunocompetent cells their products. 5. Extra-articular means other than the joints ; f example, an gan(s) such as the heart, lungs, kidneys, skin. B.6.b. The terms inability to ambulate effectively and inability to perfm fine and gross movements effectively in 14.09A have the same meaning as in 1.00B2b and 1.00B2c and must have lasted, be expected to last, f at least 12 months. B.6.a. In 14.09A, the term maj joints refers to the maj 6. Inability to ambulate effectively has the same meaning as in 1.00B2b. 7. Inability to perfm fine and gross movements effectively has the same meaning as in 1.00B2c. 8. Maj peripheral joints has the same meaning as in 4

5 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) peripheral joints, which are the hip, knee, shoulder, elbow, wristhand, and ankle-foot, as opposed to other peripheral joints (e.g., 1.00F. the joints of the hand fefoot) axial joints (i.e., the joints of the spine.) The wrist and hand are considered together as one maj joint, as are the ankle and foot. Since only the ankle joint, which consists of the juncture of the bones of the lower leg (tibia and fibula) with the hindfoot (tarsal bones), but not the fefoot, is crucial to weight bearing, the ankle and foot are considered separately in evaluating weight bearing. 9. Persistent means that a sign(s) symptom(s) has continued over time. The precise meaning will depend on the specific immune system disder, the usual course of the disder, and the other circumstances of your clinical course. (D.2. 3) "Recurrent" means that a condition that responded adequately to an appropriate course of treatment has returned after a period of remission regression. The extent of response ( remission) and the time periods involved will depend on the facts of the particular case. (D.2. 2) "Resistant to treatment" means that a condition did not respond adequately to an appropriate course of treatment. Whether a response is adequate, a course of treatment appropriate, will depend on the facts of the particular case. (B. 6, sentence 2) We use the term "severe" in these listings to 10. Recurrent means that a condition that previously responded adequately to an appropriate course of treatment returns after a period of remission regression. The precise meaning, such as the extent of response remission and the time periods involved, will depend on the specific disease condition you have, the body system affected, the usual course of the disder and its treatment, and the other facts of your particular case. 11. Resistant to treatment means that a condition did not respond adequately to an appropriate course of treatment. Whether a response is adequate a course of treatment is appropriate will depend on the specific disease condition you have, the body system affected, the usual course of the disder and its treatment, and the other facts of your particular case. 12. Severe means medical severity as used by the medical 5

6 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) describe medical severity; the term does not have the same community. The term does not have the same meaning as it does meaning as it does when we use it in connection with a finding at when we use it in connection with a finding at the second step of the second step of the sequential evaluation processes in the sequential evaluation processes in , , and , , and (B. 4) To permit appropriate application of a listing, the specific diagnostic features that should be documented in the clinical recd f each of the disders are summarized f systemic lupus erythematosus (SLE), systemic vasculitis, systemic sclerosis and scleroderma, polymyositis dermatomyositis, undifferentiated connective tissue disders, and the inflammaty arthritides. D. How do we document and evaluate the listed autoimmune disders? B.1. Systemic lupus erythematosus (14.02) This disease is characterized clinically by constitutional symptoms and signs (e.g., fever, fatigability, malaise, weight loss), multisystem involvement and, frequently, anemia, leukopenia, thrombocytopenia. Immunologically, an array of circulating serum auto-antibodies can occur, but are highly variable in pattern. Generally the medical evidence will show that patients with this disease will fulfill The 1982 Revised Criteria f the Classification of Systemic Lupus Erythematosus of the American College of Rheumatology. (Tan, E.M., et al., Arthritis Rheum. 25: , 1982). 1. Systemic lupus erythematosus (14.02). a. General. Systemic lupus erythematosus (SLE) is a chronic inflammaty disease that can affect any gan body system. It is frequently, but not always, accompanied by constitutional symptoms signs (severe fatigue, fever, malaise, involuntary weight loss). Maj gan body system involvement can include: Respiraty (pleuritis, pneumonitis), cardiovascular (endocarditis, myocarditis, pericarditis, vasculitis), renal (glomerulonephritis), hematologic (anemia, leukopenia, thrombocytopenia), skin (photosensitivity), neurologic (seizures), mental (anxiety, fluctuating cognition ( lupus fog ), mood disders, ganic brain syndrome, psychosis), immune system disders (inflammaty arthritis). Immunologically, there is an array of circulating serum auto-antibodies and pro- and anticoagulant proteins that may occur in a highly variable pattern. b. Documentation of SLE. Generally, but not always, the medical evidence will show that your SLE satisfies the criteria in 6

7 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) the current Criteria f the Classification of Systemic Lupus Erythematosus by the American College of Rheumatology found in the most recent edition of the Primer on the Rheumatic Diseases published by the Arthritis Foundation. B.2. (sentences 1-4) Systemic vasculitis (14.03) This disease occurs acutely in association with adverse drug reactions, certain chronic infections and, occasionally, malignancies. Me often it is idiopathic and chronic. There are several clinical patterns, including classical polyarteritis nodosa, atic arch arteritis, giant cell arteritis, Wegener's granulomatosis, and vasculitis associated with other connective tissue disders (e.g., rheumatoid arthritis, SLE, Sjögren's syndrome, cryoglobulinemia). Cutaneous vasculitis may may not be associated with systemic involvement and the patterns of vascular and ischemic involvement are highly variable. 2. Systemic vasculitis (14.03). a. General. (i) Vasculitis is an inflammation of blood vessels. It may occur acutely in association with adverse drug reactions, certain chronic infections, and occasionally, malignancies. Me often, it is chronic and the cause is unknown. Symptoms vary depending on which blood vessels are involved. Systemic vasculitis may also be associated with other autoimmune disders; f example, SLE dermatomyositis. (ii) There are several clinical patterns, including but not limited to polyarteritis nodosa, Takayasu s arteritis (atic arch arteritis), giant cell arteritis (tempal arteritis), and Wegener s granulomatosis. B.2. (sentences 5 &6) The diagnosis is confirmed by angiography tissue biopsy when the disease is suspected clinically. Most patients who are stated to have this disease will have the results of the confirmaty angiogram biopsy in their medical recds. B.3. (sentences 1-3) Systemic sclerosis and scleroderma (14.04) These disders constitute a spectrum of disease in b. Documentation of systemic vasculitis. Angiography tissue biopsy confirms a diagnosis of systemic vasculitis when the disease is suspected clinically. When you have had angiography tissue biopsy f systemic vasculitis, we will make every reasonable efft to obtain repts of the results of that procedure. However, we will not purchase angiography tissue biopsy. 3. Systemic sclerosis (scleroderma) (14.04). 7

8 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) which thickening of the skin is the clinical hallmark. Raynaud's a. General. Systemic sclerosis (scleroderma) constitutes a phenomena, often severe and progressive, are especially frequent spectrum of disease in which thickening of the skin is the clinical and may be the peripheral manifestation of a generalized hallmark. Raynaud's phenomenon, often medically severe and vasospastic abnmality in the heart, lungs, and kidneys. The progressive, is present frequently and may be the peripheral CREST syndrome (calcinosis, Raynaud's phenomena, esophageal manifestation of a vasospastic abnmality in the heart, lungs, and dysmotility, sclerodactyly, telangiectasia) is a variant that may kidneys. The CREST syndrome (calcinosis, Raynaud's slowly progress to the generalized process, systemic sclerosis, phenomenon, esophageal dysmotility, sclerodactyly, and over years. telangiectasia) is a variant that may slowly progress over years to the generalized process, systemic sclerosis. B.3. (sentences 4 & 5) In addition to skin and blood vessels, the maj gan/body system involvement includes the gastrointestinal tract, lungs, heart, kidneys, and muscle. Although arthritis can occur, joint dysfunction results primarily from soft tissue/cutaneous thickening, fibrosis, and contractures. (14.00.B.3, sentence 4) b. Diffuse cutaneous systemic sclerosis. In diffuse cutaneous systemic sclerosis (also known as diffuse scleroderma), maj gan systemic involvement can include the gastrointestinal tract, lungs, heart, kidneys, and muscle in addition to skin blood vessels. Although arthritis can occur, joint dysfunction results primarily from soft tissue/cutaneous thickening, fibrosis, and contractures. c. Localized scleroderma (linear scleroderma and mphea). (i) Localized scleroderma (linear scleroderma and mphea) is me common in children than in adults. However, this type of scleroderma can persist into adulthood. To assess the severity of the impairment, we need a description of the extent of involvement of linear scleroderma and the location of the lesions. F example, linear scleroderma involving the arm but not crossing any joints is not as functionally limiting as sclerodactyly (scleroderma localized to the fingers). Linear scleroderma of a lower extremity involving skin thickening and atrophy of underlying muscle bone can result in contractures and leg 8

9 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) length discrepancy. In such cases, we may evaluate your impairment under the musculoskeletal listings (1.00). (ii) When there is isolated mphea of the face causing facial disfigurement from unilateral hypoplasia of the mandible, maxilla, zygoma, bit, adjudication may be me appropriate under the criteria in the affected body system, such as special senses and speech (2.00) mental disders (12.00). (iii) Chronic variants of these syndromes include disseminated mphea, Shulman s disease (diffuse fasciitis with eosinophilia), and eosinophilia-myalgia syndrome (often associated with toxins such as toxic oil contaminated tryptophan), all of which can impose medically severe musculoskeletal dysfunction and may also lead to restrictive pulmonary disease. We evaluate these variants of the disease under the criteria in the musculoskeletal listings (1.00) respiraty system listings (3.00). d. Documentation of systemic sclerosis (scleroderma). Documentation involves differentiating the clinical features of systemic sclerosis (scleroderma) from other autoimmune disders. However, there may be an overlap. B.4. (sentences 1-3) Polymyositis dermatomyositis (14.05) This disder is primarily an inflammaty process in striated muscle, which can occur alone in association with other connective tissue disders malignancy. Weakness and, less frequently, pain and tenderness of the proximal limb-girdle musculature are the cardinal manifestations. Involvement of the cervical muscles, the cricopharyngeals, the intercostals, and 4. Polymyositis and dermatomyositis (14.05). a. General. Polymyositis and dermatomyositis are related disders that are characterized by an inflammaty process in striated muscle, occurring alone in association with other autoimmune disders malignancy. The most common manifestations are symmetric weakness, and less frequently, pain 9

10 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) diaphragm may occur in those with listing-level disease. and tenderness of the proximal limb-girdle (shoulder pelvic) musculature. There may also be involvement of the cervical, cricopharyngeal, esophageal, intercostal, and diaphragmatic muscles. B.4. (sentence 7) The diagnosis is suppted by elevated serum muscle enzymes (creatine phosphokinase (CPK), aminotransferases, aldolase), characteristic abnmalities on electromyography, and myositis on muscle biopsy. b. Documentation of polymyositis and dermatomyositis. Generally, but not always, polymyositis is associated with elevated serum muscle enzymes (creatine phosphokinase (CPK), aminotransferases, and aldolase), and characteristic abnmalities on electromyography and muscle biopsy. In dermatomyositis there are characteristic skin findings in addition to the findings of polymyositis. When you have had electromyography muscle biopsy f polymyositis dermatomyositis, we will make every reasonable efft to obtain repts of the results of that procedure. However, we will not purchase electromyography muscle biopsy. c. Additional infmation about how we evaluate polymyositis and dermatomyositis under the listings. B.4. (sentences 4 & 5)Weakness of the pelvic girdle, as contemplated in Listing 14.05A, may result in significant difficulty climbing stairs rising from a chair without use of the arms. Proximal limb weakness in the upper extremities may result in inability to lift objects, and interference with dressing and combing hair. (14.00.B.4, sentence 2) (i) Weakness of your pelvic girdle muscles that results in your inability to rise independently from a squatting sitting position to climb stairs may be an indication that you are unable to ambulate effectively. Weakness of your shoulder girdle muscles may result in your inability to perfm lifting, carrying, and reaching overhead, and also may seriously affect your ability to perfm activities requiring fine movements. We evaluate these limitations under 14.05A. (ii) We use the malignant neoplastic diseases listings (13.00ff) to evaluate malignancies associated with polymyositis 10

11 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) dermatomyositis. We evaluate the involvement of other gans/body systems under the criteria f the listings in the affected body system. B.4 (sentence 6) Weakness of the anteri neck flexs may impair the ability to lift the head from the pillow in bed. B.5. Undifferentiated connective tissue disder (14.06) This listing includes syndromes with clinical and immunologic features of several connective tissue disders, but that do not satisfy the criteria f any of the disders described; f instance, the individual may have clinical features of systemic lupus erythematosus and systemic vasculitis and the serologic findings of rheumatoid arthritis. It also includes overlap syndromes with clinical features of me than one established connective tissue disder. F example, the individual may have features of both rheumatoid arthritis and scleroderma. The crect designation of this disder is imptant f assessment of prognosis. 5. Undifferentiated and mixed connective tissue disease (14.06). a. General. This listing includes syndromes with clinical and immunologic features of several autoimmune disders, but which do not satisfy the criteria f any of the specific disders described. F example, you may have clinical features of SLE and systemic vasculitis, and the serologic (blood test) findings of rheumatoid arthritis. b. Documentation of undifferentiated and mixed connective tissue disease. Undifferentiated connective tissue disease is diagnosed when clinical features and serologic (blood test) findings, such as rheumatoid fact antinuclear antibody (consistent with an autoimmune disder) are present but do not satisfy the criteria f a specific disease. Mixed connective tissue disease (MCTD) is diagnosed when clinical features and serologic findings of two me autoimmune diseases overlap. 6. Inflammaty arthritis (14.09). B.6. (sentence 1) Inflammaty arthritis (14.09) includes a vast array of disders that differ in cause, course, and outcome. B.6. (sentence 4) Clinically, inflammation of maj joints may be a. General. The spectrum of inflammaty arthritis includes a vast array of disders that differ in cause, course, and outcome. Clinically, inflammation of maj peripheral joints may 11

12 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) the dominant problem causing difficulties with ambulation fine be the dominant manifestation causing difficulties with and gross movements, the arthritis may involve other joints ambulation fine and gross movements; there may be joint pain, cause less restriction of ambulation other movements but be swelling, and tenderness. The arthritis may affect other joints, complicated by extra-articular features that cumulatively result in cause less limitation in ambulation the perfmance of fine and serious functional deficit. gross movements. However, in combination with extra-articular features, including constitutional symptoms signs (severe fatigue, fever, malaise, involuntary weight loss), inflammaty arthritis may result in an extreme limitation. B.6. (sentence 2) F example, inflammaty spondyloarthropathies include ankylosing spondylitis, Reiter's syndrome and other reactive arthropathies, psiatic arthropathy, Behçet's disease, and Whipple's disease, as well as undifferentiated spondylitis. B.6. (sentence 3) Inflammaty arthritis of peripheral joints likewise comprises many disders, including rheumatoid arthritis, Sjögren's syndrome, psiatic arthritis, crystal deposition disders, and Lyme disease. b. Inflammaty arthritis involving the axial spine (spondyloarthropathy). In adults, inflammaty arthritis involving the axial spine may be associated with disders such as: (i) Reiter's syndrome; (ii) Ankylosing spondylitis; (iii) Psiatic arthritis; (iv) Whipple's disease; (v) Behçet's disease; and (vi) Inflammaty bowel disease. c. Inflammaty arthritis involving the peripheral joints. In adults, inflammaty arthritis involving peripheral joints may be associated with disders such as: (i) Rheumatoid arthritis; (ii) Sjögren s syndrome; (iii) Psiatic arthritis; (iv) Crystal deposition disders (gout and pseudogout); (v) Lyme disease; and (vi) Inflammaty bowel disease. 12

13 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) d. Documentation of inflammaty arthritis. Generally, but not always, the diagnosis of inflammaty arthritis is based on the clinical features and serologic findings described in the most recent edition of the Primer on the Rheumatic Diseases published by the Arthritis Foundation. e. How we evaluate inflammaty arthritis under the listings. B.6.c. Inability to ambulate effectively is implicit in 14.09B. Even though individuals who demonstrate the findings of 14.09B will not dinarily require bilateral upper limb assistance, the required ankylosis of the cervical dsolumbar spine will result in an extreme loss of the ability to see ahead, above, and to the side. B.6.d. (sentence 1-3) As in through 14.06, extra-articular features of an inflammaty arthritis may satisfy the criteria f a listing in an involved extra-articular body system. Such impairments may be found to meet a criterion of 14.09C. Extraarticular impairments of lesser severity should be evaluated under 14.09D and 14.09E (i) Listing-level severity in 14.09A and 14.09C1 is shown by an impairment that results in an extreme (very serious) limitation. In 14.09A, the criterion is satisfied with persistent inflammation defmity in one maj peripheral weightbearing joint resulting in the inability to ambulate effectively (as defined in 14.00C6) one maj peripheral joint in each upper extremity resulting in the inability to perfm fine and gross movements effectively (as defined in 14.00C7). In 14.09C1, if you have the required ankylosis (fixation) of your cervical dsolumbar spine, we will find that you have an extreme limitation in your ability to see in front of you, above you, and to the side. Therefe, inability to ambulate effectively is implicit in 14.09C1, even though you might not require bilateral upper limb assistance. (ii) Listing-level severity is shown in 14.09B, 14.09C2, and 14.09D by inflammaty arthritis that involves various combinations of complications of one me maj peripheral joints other joints, such as inflammation defmity, extraarticular features, repeated manifestations, and constitutional symptoms signs. Extra-articular impairments may also meet listings in other body systems. 13

14 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) B.6.d. (sentence 4). Commonly occurring extra-articular (iii) Extra-articular features of inflammaty arthritis may impairments include keratoconjunctivitis sicca, uveitis, involve any body system; f example: Musculoskeletal (heel iridocyclitis, pleuritis, pulmonary fibrosis nodules, restrictive enthesopathy), ophthalmologic (iridocyclitis, keratoconjunctivitis lung disease, pericarditis, myocarditis, cardiac arrhythmias, atic sicca, uveitis), pulmonary (pleuritis, pulmonary fibrosis valve insufficiency, conary arteritis, Raynaud's phenomena, nodules, restrictive lung disease), cardiovascular (atic valve systemic vasculitis, amyloidosis of the kidney, chronic anemia, insufficiency, arrhythmias, conary arteritis, myocarditis, thrombocytopenia, hypersplenism with compromised immune pericarditis, Raynaud's phenomenon, systemic vasculitis), renal competence (Felty's syndrome), peripheral neuropathy, (amyloidosis of the kidney), hematologic (chronic anemia, radiculopathy, spinal cd cauda equina compression with thrombocytopenia), neurologic (peripheral neuropathy, sensy and mot loss, and heel enthesopathy with functionally radiculopathy, spinal cd cauda equina compression with limiting pain. sensy and mot loss), mental (cognitive dysfunction, po memy), and immune system (Felty's syndrome (hypersplenism with compromised immune competence)). B.6. (sentence 5) When persistent defmity without ongoing inflammation is the dominant feature of the impairment, it should be evaluated under 1.02,, if there has been surgical reconstruction, e. The fact that an individual is dependent on steroids, any other drug, f the control of inflammaty arthritis is, in and of itself, insufficient to find disability. Advances in the treatment of inflammaty connective tissue disease and in the administration of steroids f its treatment have crected some of the previously disabling consequences of continuous steroid use. Therefe, each case must be evaluated on its own merits, taking into consideration the severity of the underlying impairment and any (iv) If both inflammation and chronic defmities are present, we evaluate your impairment under the criteria of any appropriate listing. 14

15 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) adverse effects of treatment. 7. Sjögren s syndrome (14.10). a. General. (i) Sjögren s syndrome is an immune-mediated disder of the exocrine glands. Involvement of the lacrimal and salivary glands is the hallmark feature, resulting in symptoms of dry eyes and dry mouth, and possible complications, such as cneal damage, blepharitis (eyelid inflammation), dysphagia (difficulty in swallowing), dental caries, and the inability to speak f extended periods of time. Involvement of the exocrine glands of the upper airways may result in persistent dry cough. (ii) Many other gan systems may be involved, including musculoskeletal (arthritis, myositis), respiraty (interstitial fibrosis), gastrointestinal (dysmotility, dysphagia, involuntary weight loss), genitourinary (interstitial cystitis, renal tubular acidosis), skin (purpura, vasculitis), neurologic (central nervous system disders, cranial and peripheral neuropathies), mental (cognitive dysfunction, po memy), and neoplastic (lymphoma). Severe fatigue and malaise are frequently repted. Sjögren s syndrome may be associated with other autoimmune disders (f example, rheumatoid arthritis SLE); usually the clinical features of the associated disder predominate. b. Documentation of Sjögren s syndrome. If you have Sjögren s syndrome, the medical evidence will generally, but not always, show that your disease satisfies the criteria in the current Criteria f the Classification of Sjögren s Syndrome by the American College of Rheumatology found in the most recent 15

16 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) edition of the Primer on the Rheumatic Diseases published by the Arthritis Foundation. E. How do we document and evaluate immune deficiency disders, excluding HIV infection? 1. General. a. Immune deficiency disders can be classified as: (i) Primary (congenital); f example, X-linked agammaglobulinemia, thymic hypoplasia (DiGege syndrome), severe combined immunodeficiency (SCID), chronic granulomatous disease (CGD), C1 esterase inhibit deficiency. (ii) Acquired; f example, medication-related. b. Primary immune deficiency disders are seen mainly in children. However, recent advances in the treatment of these disders have allowed many affected children to survive well into adulthood. Occasionally, these disders are first diagnosed in adolescence adulthood. 2. Documentation of immune deficiency disders. The medical evidence must include documentation of the specific type of immune deficiency. Documentation may be by labaty evidence by other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice. 3. Immune deficiency disders treated by stem cell transplantation. 16

17 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) a. Evaluation in the first 12 months. If you undergo stem cell transplantation f your immune deficiency disder, we will consider you disabled until at least 12 months from the date of the transplant. b. Evaluation after the 12-month period has elapsed. After the 12-month period has elapsed, we will consider any residuals of your immune deficiency disder as well as any residual impairment(s) resulting from the treatment, such as complications arising from: (i) Graft-versus-host (GVH) disease. (ii) Immunosuppressant therapy, such as frequent infections. (iii) Significant deteriation of other gan systems. 4. Medication-induced immune suppression. Medication effects can result in varying degrees of immune suppression, but most resolve when the medication is ceased. However, if you are prescribed medication f long-term immune suppression, such as after an gan transplant, we will evaluate: a. The frequency and severity of infections. b. Residuals from the gan transplant itself, after the 12- month period has elapsed. c. Significant deteriation of other gan systems. D. Human immunodeficiency virus (HIV) infection. F. How do we document and evaluate human immunodeficiency virus (HIV) infection? Any individual with HIV infection, including one with a diagnosis of acquired immune deficiency syndrome (AIDS), may be found disabled under if his her impairment meets the criteria in that 17

18 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) listing is medically equivalent to the criteria in that listing. D.3. Documentation of HIV infection. The medical evidence must include documentation of HIV infection. Documentation may be by labaty evidence by other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice. D.3.a. Documentation of HIV infection by definitive diagnosis. A definitive diagnosis of HIV infection is documented by one me of the following labaty tests: D.3.a.i..A serum specimen that contains HIV antibodies. HIV antibodies are usually detected by a screening test. The most commonly used screening test is the ELISA. Although this test is highly sensitive, it may yield false positive results. Therefe, positive results from an ELISA must be confirmed by a me definitive test (e.g., Western blot, immunofluescence assay). 1. Documentation of HIV infection. The medical evidence must include documentation of HIV infection. Documentation may be by labaty evidence by other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice. When you have had labaty testing f HIV infection, we will make every reasonable efft to obtain repts of the results of that testing. However, we will not purchase labaty testing to establish whether you have HIV infection. a. Definitive documentation of HIV infection. A definitive diagnosis of HIV infection is documented by one me of the following labaty tests: (i) HIV antibody tests. HIV antibodies are usually first detected by an ELISA screening test perfmed on serum. Because the ELISA can yield false positive results, confirmation is required using a me definitive test, such as a Western blot an immunofluescence assay. (ii) Positive viral load (VL) tests. These tests are nmally used to quantitate the amount of the virus present but also document HIV infection. Such tests include the quantitative plasma HIV RNA, quantitative plasma HIV branched DNA, and reverse transcriptase-polymerase chain reaction (RT-PCR).. (iii) HIV DNA detection by polymerase chain reaction (PCR). 18

19 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) D.3.a.ii. A specimen that contains HIV antigen (e.g., serum (iv) A specimen that contains HIV antigen (f example, specimen, lymphocyte culture, cerebrospinal fluid (CSF) serum specimen, lymphocyte culture, cerebrospinal fluid). specimen). (v) A positive viral culture f HIV from peripheral blood mononuclear cells (PBMC). D.3.a.iii. ( 1) Other test(s) that are highly specific f detection of HIV (e.g., polymerase chain reaction (PCR)), that are acceptable methods of detection consistent with the prevailing state of medical knowledge. (vi) Other tests that are highly specific f detection of HIV and that are consistent with the prevailing state of medical knowledge. D.3.a.iii. ( 2) When labaty testing f HIV infection has been perfmed, every reasonable efft must be made to obtain repts of the results of that testing. D.3.b. Other acceptable documentation of HIV infection. D.3.b ( 1) (HIV infection may also be documented without the definitive labaty evidence described in paragraph a, provided that such documentation is consistent with the prevailing state of medical knowledge and clinical practice and is consistent with the other evidence. If no definitive labaty evidence is available, HIV infection may be documented by the medical histy, clinical and labaty findings, and diagnosis(es) indicated in the medical evidence. F example, a diagnosis of HIV infection will be accepted without definitive labaty evidence if the individual has an opptunistic disease (e.g., toxoplasmosis of the brain, pneumocystis carinii pneumonia (PCP)) predictive of a defect in cell-mediated immunity, and there is no other known cause of diminished resistance to that disease (e.g., long-term steroid treatment, lymphoma). In such cases, every reasonable efft must be made to obtain full details of the histy, medical b. Other acceptable documentation of HIV infection. We may also document HIV infection without the definitive labaty evidence described in 14.00F1a, provided that such documentation is consistent with the prevailing state of medical knowledge and clinical practice and is consistent with the other evidence in your case recd. If no definitive labaty evidence is available, we may document HIV infection by the medical histy, clinical and labaty findings, and diagnosis(es) indicated in the medical evidence. F example, we will accept a diagnosis of HIV infection without definitive labaty evidence of the HIV infection if you have an opptunistic disease that is predictive of a defect in cell-mediated immunity (f example, toxoplasmosis of the brain, Pneumocystis pneumonia (PCP)), and there is no other known cause of diminished resistance to that disease (f example, long-term steroid treatment, lymphoma). In such cases, we will make every reasonable efft to obtain full 19

20 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) findings, and results of testing. details of the histy, medical findings, and results of testing. (D.3.a.iii 3) Individuals who have HIV infection other disders of the immune system may undergo tests to determine T-helper lymphocyte (CD4) counts. The extent of immune depression crelates with the level rate of decline of the CD4 count. In general, when the CD4 count is 200/mm [3] less (14 percent less), the susceptibility to opptunistic disease is considerably increased. However, a reduced CD4 count alone does not establish a definitive diagnosis of HIV infection, document the severity functional effects of HIV infection. (D.4.a 2) Although a reduced CD4 lymphocyte count may show that there is an increased susceptibility to opptunistic infections and diseases (see ) 3a, above), that alone does not establish the presence, severity, functional effects of a manifestation of HIV infection. D.4. Documentation of the manifestations of HIV infection. The medical evidence must also include documentation of the manifestations of HIV infection. Documentation may be by labaty evidence by other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice. D.4.a.. Documentation of the manifestations of HIV infection by definitive diagnosis. (D.4.a. 1) The definitive method of diagnosing opptunistic diseases conditions that are manifestations of HIV infection is by culture, serological test, microscopic examination of biopsied tissue other material (e.g., bronchial washings). Therefe, every reasonable efft must be made to obtain 2. CD4 tests. Individuals who have HIV infection other disders of the immune system may have tests showing a reduction of either the absolute count the percentage of their T- helper lymphocytes (CD4 cells). The extent of immune suppression crelates with the level rate of decline of the CD4 count. Generally, when the CD4 count is below 200/mm 3 ( below 14 percent of the total lymphocyte count) the susceptibility to opptunistic infection is greatly increased. Although a reduced CD4 count alone does not establish a definitive diagnosis of HIV infection, a CD4 count below 200 does offer supptive evidence when there are clinical findings, but not a definitive diagnosis of an opptunistic infection(s). However, a reduced CD4 count alone does not document the severity functional consequences of HIV infection. 3. Documentation of the manifestations of HIV infection. The medical evidence must also include documentation of the manifestations of HIV infection. Documentation may be by labaty evidence other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice. a. Definitive documentation of the manifestations of HIV infection. The definitive method of diagnosing opptunistic diseases conditions that are manifestations of HIV infection is by culture, serologic test, microscopic examination of biopsied tissue other material (f example, bronchial washings). We will make every reasonable efft to obtain specific labaty evidence of an opptunistic disease other condition whenever 20

21 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) specific labaty evidence of an opptunistic disease other this infmation is available. If a histologic other test has been condition whenever this infmation is available. If a histological perfmed, the evidence should include a copy of the appropriate other test has been perfmed, the evidence should include a rept. If we cannot obtain the rept, the summary of copy of the appropriate rept. If the rept is not obtainable, the hospitalization a rept from the treating source should include summary of hospitalization a rept from the treating source details of the findings and results of the diagnostic studies should include details of the findings and results of the diagnostic (including appropriate medically acceptable imaging studies) studies (including radiographic studies) microscopic microscopic examination of the appropriate tissues body fluids. examination of the appropriate tissues body fluids. (D.4.b.) Other acceptable documentation of the manifestations of HIV infection. (D.4.b. 1) Manifestations of HIV infection may also be documented without the definitive labaty evidence described in paragraph a, provided that such documentation is consistent with the prevailing state of medical knowledge and clinical practice and is consistent with the other evidence. If no definitive labaty evidence is available, manifestations of HIV infection may be documented by medical histy, clinical and labaty findings, and diagnosis(es) indicated in the medical evidence. In such cases, every reasonable efft must be made to obtain full details of the histy, medical findings, and results of testing. b. Other acceptable documentation of the manifestations of HIV infection. We may also document manifestations of HIV infection without the definitive labaty evidence described in 14.00F3a, provided that such documentation is consistent with the prevailing state of medical knowledge and clinical practice and is consistent with the other evidence in your case recd. F example, many conditions are now commonly diagnosed based on some all of the following: Medical histy, clinical manifestations, labaty findings (including appropriate medically acceptable imaging), and treatment responses. In such cases, we will make every reasonable efft to obtain full details of the histy, medical findings, and results of testing. The following are examples of how we may document manifestations of HIV infection with other appropriate evidence. (i) Although a definitive diagnosis of PCP requires identifying the ganism in bronchial washings, induced sputum, lung biopsy, these tests are frequently bypassed if PCP can be diagnosed presumptively. Supptive evidence may include: Fever, dyspnea, hypoxia, CD4 count below 200, and no evidence of bacterial pneumonia. Also supptive are bilateral lung interstitial infiltrates on x-ray, a typical pattern on CAT scan, a 21

22 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) gallium scan positive f pulmonary uptake. Response to anti- PCP therapy usually requires 5-7 days, and such a response can be supptive of the diagnosis. (D.4.b. 2) Documentation of cytomegalovirus (CMV) disease (14.08D) presents special problems because diagnosis requires identification of viral inclusion bodies a positive culture from the affected gan, and the absence of any other infectious agent. A positive serology test identifies infection with the virus, but does not confirm a disease process. With the exception of chietinitis (which may be diagnosed by an ophthalmologist), documentation of CMV disease requires confirmation by biopsy other generally acceptable methods consistent with the prevailing state of medical knowledge and clinical practice. (ii) Documentation of Cytomegalovirus (CMV) disease (14.08D) may present special problems because definitive diagnosis (except f chietinitis, which may be diagnosed by an ophthalmologist optometrist on funduscopic examination) requires identification of viral inclusion bodies a positive culture from the affected gan and the absence of any other infectious agent likely to be causing the disease. A positive serology test does not establish a definitive diagnosis of CMV disease, but does offer supptive evidence of a presumptive diagnosis of CMV disease. Other clinical findings that suppt a presumptive diagnosis of CMV may include: Fever, urinary culture positive f CMV, and CD4 count below 200. A clear response to anti-cmv therapy also suppts a diagnosis. (iii) A definitive diagnosis of toxoplasmosis of the brain is based on brain biopsy, but this procedure carries significant risk and is not commonly perfmed. This condition is usually diagnosed presumptively based on symptoms signs of fever, headache, focal neurologic deficits, seizures, typical lesions on brain imaging, and a positive serology test. (iv) Candidiasis of the esophagus (also known as Candida esophagitis) may be presumptively diagnosed based on symptoms of retrosternal pain on swallowing (odynophagia) and either opharyngeal thrush (white patches plaques) diagnosed on physical examination by microscopic documentation of Candida fungal elements from a noncultured specimen scraped 22

23 14.00 IMMUNE SYSTEM (Pri Adult) IMMUNE SYSTEM DISORDERS (Final Adult) from the al mucosa. Treatment with al (systemic) antifungal agents usually produces improvement after 5 me days of therapy, and such a response can be supptive of the diagnosis. 4. HIV infection manifestations specific to women. (D.5. 1) Manifestations specific to women. Most women with severe immunosuppression secondary to HIV infection exhibit the typical opptunistic infections and other conditions, such as pneumocystis carinii pneumonia (PCP), candida esophagitis, wasting syndrome, cryptococcosis, and toxoplasmosis. However, HIV infection may have different manifestations in women than in men. Adjudicats must carefully scrutinize the medical evidence and be alert to the variety of medical conditions specific to common in women with HIV infection that may affect their ability to function in the wkplace. (D. 5. 2) Many of these manifestations (e.g. vulvovaginal candidiasis, pelvic inflammaty disease) occur in women with without HIV infection, but can be me severe resistant to treatment, occur me frequently in a woman whose immune system is suppressed. Therefe, when evaluating the claim of a woman with HIV infection, it is imptant to consider gynecologic and other problems specific to women, including any associated symptoms (e.g., pelvic pain), in assessing the severity of the impairment and resulting functional limitations. Manifestations of HIV infection in women may be evaluated under the specific criteria (e.g., cervical cancer under 14.08E), under an applicable general categy (e.g., pelvic inflammaty disease under 14.08A5), in appropriate cases, under 14.08N. a. General. Most women with severe immunosuppression secondary to HIV infection exhibit the typical opptunistic infections and other conditions, such as PCP, Candida esophagitis, wasting syndrome, cryptococcosis, and toxoplasmosis. However, HIV infection may have different manifestations in women than in men. Adjudicats must carefully scrutinize the medical evidence and be alert to the variety of medical conditions specific to, common in, women with HIV infection that may affect their ability to function in the wkplace. b. Additional considerations f evaluating HIV infection in women. Many of these manifestations (f example, vulvovaginal candidiasis, pelvic inflammaty disease) occur in women with without HIV infection, but can be me severe resistant to treatment, occur me frequently in a woman whose immune system is suppressed. Therefe, when evaluating the claim of a woman with HIV infection, it is imptant to consider gynecologic and other problems specific to women, including any associated symptoms (f example, pelvic pain), in assessing the severity of the impairment and resulting functional limitations. We may evaluate manifestations of HIV infection in women under the specific criteria (f example, cervical cancer under 14.08E), under an applicable general categy (f example, pelvic inflammaty disease under 14.08A4), in 23