Citation Nr: 0004644 Decision Date: 02/23/00 Archive Date: 09/08/00 DOCKET NO. 97-17 453 DATE FEB 23, 2000 On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for systemic lupus erythematosus (SLE). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Tsopei Robinson, Associate Counsel INTRODUCTION The veteran had active duty from January 1978 to February 1990. This matter comes before the Board of Veterans' Appeals (Board) from a November 1996 rating determination of a Department of Veterans Affairs (VA) Regional Office (RO). FINDING OF FACT The veteran's SLE is not in any way related to service, service- connected hypertension, or any other service connected disability. CONCLUSION OF LAW SLE was not incurred in service and is not proximately due to or the result of a service-connected disease or injury. 38 U.S.C.A. 1110, 1131, 5107 (West 1991); 38 C.F.R. 3.310 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background Service medical records are negative for complaints, treatment, or findings referable to SLE. The records show that the veteran received Isoniazid therapy in 1978 for a period of six months. The records suggest that she developed arterial hypertension which was treated with hydrochlorothiazide in 1988. - 2 - VA outpatient treatment records dated from June 1990 to August 1994 show that the veteran was on Hydrochlorothiazide for hypertension. There are no treatment records for lupus noted. The veteran has been service-connected for hypertension, since January 1991. In May 1996, the veteran was diagnosed with SLE. She was suspected of having mild nephritis. The veteran underwent a VA general medical examination in June 1996. At that time, she reported a history of hypertension since 1989. The veteran reported that she was prescribed hydrochlorothiazide, but it was discontinued because it was assumed that it was causing her lupus condition. The diagnosis was hypertension reasonably well controlled with medication. The veteran submitted the following literature: Lupus Fact Sheet, Lupus Foundation of America, Neil Duane, Drug-Induced Lupus Mimics Real SLE, The American Writers' Association, and Elliot Chartash, M.D., Cardiopulmonary Disease and Lupus. VA outpatient treatment records dated from August 1996 to May 1997 show treatment for lupus. The veteran's lupus was reported to be reasonably controlled with Prednisone and Plaquenil. The veteran underwent a VA general medical examination in March 1997. It was noted that she had developed arterial hypertension in 1988 and had taken medication since that time. There was no complication of stroke or heart disease. It was also noted that the veteran developed generalized musculoskeletal aching especially about the shoulders in April 1996. In May 1996, an antinuclear antibody (ANA) was positive for lupus. The impression was systemic lupus erythematosus with arthralgia, and lupus nephritis. The examiner expressed the opinion that hypervascular disease might have been caused by the nephritis, however the first ANA was done in May 1996, and was not worked up for lupus prior to May 1 996. - 3 - The examiner opined that it was possible and probable that the hypertension was secondary to the lupus rather than the other way around. He further commented that systemic lupus, might be drug induced, and that the veteran was taking antihypertensive medication before lupus was diagnosed. The medications included Hydrochlorothiazide and Methysergide. The veteran was also on Isoniazid (INH) in 1978. The examiner stated that there was a definite association with Hydralazine, Procainamide, Quinidine, and Isoniazid, and noted that the veteran did take Isoniazid. There was no association with Hydrochlorothiazide. The examiner opined that Methysergide was unlikely to cause lupus. Additionally, he opined that the veteran's SLE was unlikely to be caused by drugs because nephritis features were not ordinarily present, complement levels were not depressed, antibodies to native deoxyribonucleic acid (DNA) were absent. The clinical features of the laboratory abnormality were often normal when the offending drug was withdrawn. These features separated it from the spontaneously occurring disease. The veteran was accorded a personal hearing in August 1997. At that time, she testified that she was diagnosed with hypertension in 1988 and lupus in 1996. The veteran testified that she was told that high blood pressure was a symptom of lupus. She also noted that the 1997 VA examiner suggested a causal relationship with his statement that hypertension was possible and probably secondary to lupus. The veteran testified that the examiner's statement suggest an in-service origin of lupus. In response to a VA memorandum, the March 1997 VA examiner, reviewed the claims folder including service medical records. He noted that the veteran received INH therapy in 1978, a medication that can cause lupus. In 1988, the veteran developed arterial hypertension, treated with hydrochlorothiazide, a drug which is unlikely to cause lupus. In May 1996, the veteran developed lupus with arthralgia, and positive ANA. The examiner noted that the hypertension preceded the diagnosis of lupus by a period of eight years. He opined that in all likelihood the hypertension was not - 4 - related to the lupus, but rather a separate problem. It was noted that lupus could cause hypertension, but usually there were renal and cardiac findings. The veteran's cardiac findings questionable pericarditis and cardiomegaly had been mild with normal creatinine, and normal creatinine clearance. The INH might have induced lupus, but usually with withdrawal of @, lupus symptoms and signs subsided. It was noted that the veteran had a long standing history of musculoskeletal complaints. The examiner opined that it was possible that the musculoskeletal pains were the prodrome for the definite diagnosis of lupus in 1996. Finally, he opined that probably the arterial hypertension and the lupus were not related. The musculoskeletal complaints were possibly the earliest signs of lupus but the diagnosis was not made until May 1996. In sum, without definite evidence of lupus during active service, hypertension and lupus were probably not related. In April 1999, the Board requested a Veteran's Health Administration (VHA) opinion. In June 1999, the requested response was received. In response to the question of whether it was as least as likely as not that INH therapy received in 1978 caused the veteran's SLE. The examiner reported that it was not likely that the patient's SLE was caused by medications prescribed to her. INH is a definite cause of SLE, but this drug was administered more than 20 years earlier and would not be expected to cause SLE at a later date. Hydrochlorothiazide was a "possible" cause of SLE, but several factors suggest that it was not an etiologic agent here. First, This drug was discontinued several years earlier. Drug-induced SLE usually wanes and often disappears after an offending drug is discontinued. This did not happen to the veteran. Second, the veteran had, not only anti-histone antibodies, which are characteristic of drug-induced and spontaneous lupus, but also anti DNA antibodies, which are rare in the drug- induced syndrome. 5 - In response to the question of whether it was at least as likely as not that SLE caused the veteran's hypertension. The examiner reported that is was not likely that SLE caused the veteran's hypertension. Hypertension was first diagnosed in 1988, 8 years prior to the diagnosis of SLE. The most common kidney disorders caused by SLE were nephritis and nephrosis. Although the veteran did abnormal amounts of urinary protein excretion, she does not have nephrotic range proteinuria. Further, there was no evidence of active nephritis, despite continued hypertension. Finally, drug- induced SLE is not usually associated with renal effects. In response to the question of whether it was as least as likely as not that the veteran's musculoskeletal complaints were the worry prodrome for SLE. The examiner reported that it was unlikely that the veteran's lower back pain and sciatica were related to SLE. It was likely, however, that the veteran experienced pain in the joints or muscles prior to the diagnosis of SLE in May 1996. It was possible that her knee pain was a prodrome of SLE. SLE commonly presents with symmetrical arthritis and arthralgia. Commonly, the pain is out of proportion to the physical findings. As above, however, drug-induced SLE usually wanes after cessation of the offending agent. To the extent that the veteran's SLE continued unabated, it was unlikely to have been caused by hydrochlorothiazide. Analysis The threshold question that must be resolved with regard to this claim is whether the veteran has presented evidence that his claim is well grounded. 38 U.S. C.A. 5107(a); Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997). A well grounded claim is a plausible claim, meaning a claim that appears to be meritorious on its own or capable of substantiation. Epps. An allegation that a disorder is service- connected is not sufficient; the veteran must submit evidence in support of the claim that would "justify a belief by a fair and impartial individual that the claim is plausible." Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). The quality and quantity of the evidence required to meet this statutory burden depends upon the issue presented by the claim. Grottveit v. Brown, 5 Vet. App. 91, 92-93 (1993). - 6 - In order for a claim for service connection to be well grounded, there must be a medical diagnosis of a current disability, medical or lay evidence of the incurrence of a disease or injury in service, and medical evidence of a nexus between the in- service disease or injury and the current disability. Epps, at 1468. A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. Therefore, if the determinant issue is one of medical etiology or a medical diagnosis, competent medical evidence must be submitted to make the claim well grounded. See Grottveit, 5 Vet. App. at 93. A lay person is, however, competent to provide evidence on the occurrence of observable symptoms during and following service. If the claimed disability is manifested by observable symptoms, lay evidence of symptomatology may be adequate to show the nexus between the current disability and the in-service disease or injury. Nevertheless, medical evidence is required to show a relationship between the reported symptomatology and the current disability, unless the relationship is one to which a lay person's observations are competent. See Savage v. Gober, 10 Vet. App. 488, 497 (1997). Service connection is granted for disabilities resulting from disease or injury during service. 38 U.S.C.A. 101(16), 1110, 1131 (West 1991). Under the provisions of 38 C.F.R. 3.310, service connection will also be granted for disabilities which are proximately due to or the result of a service connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Continuous service for 90 days or more during a period of war, or after December 31, 1946, and post-service development of a presumptive disease, including systemic lupus erythematosus, to a degree of 10 percent within one year from the date of termination of such service, establishes a presumption that the disease was incurred in service. 38 U.S.C.A. 1112 (West 1991); 38 C.F.R. 3.307, 3.309 (1999). A secondary service connection claim is well grounded only if there is medical evidence to connect the asserted secondary condition to the service-connected disability. Velez v. West, 11 Vet. App. 148, 158 (1998); see Locher v. Brown, 9 Vet. App. 535, 538-39 (1996) (citing Reiber v. Brown, 7 Vet. App. 513, 516-17 - 7 - (1995), for the proposition that lay evidence linking a fall to a service-connected weakened leg sufficed on that point as long as there was "medical evidence connecting a currently diagnosed back disability to the fall"); Jones (Wayne) v. Brown, 7 Vet. App. 134, 136-37 (1994) (lay testimony that one condition was caused by a service-connected condition was insufficient to well ground a claim). Read in a light most favorable to the veteran the 1997 VA examiner's opinion could be seen as linking SLE to the service connected hypertension or inservice drug therapy. Accordingly, the Board has concluded that the claim is well grounded. The Board also concludes that VA has complied with its duty to assist the veteran with the development of her claim. It has sought all known pertinent treatment records, has afforded her the opportunity for examinations, and has sought the opinion of an independent medical expert. The question then becomes whether the evidence is in the veteran's favor or at least in equipoise, in which case the claim is allowed, or whether the preponderance of the evidence is against the claim, in which case the claim must be denied. The evidence in favor of the veteran's claim consists of her contentions and the equivocal opinions of the 1997 VA examiner. The evidence against the veteran's claim includes that fact that SLE was not identified in the service medical records, the absence of any record of treatment for SLE within the initial post service year, and the reasoned VHA opinion. The VHA opinion is the most persuasive piece of evidence since it was the product of a review of the claims folder, was specific, and provided reasons for its conclusions. The June 1999 reviewer specifically found that it was unlikely that the veteran's SLE was caused by INH which was administered during service, unlikely that SLC caused hypertension, and that it was unlikely that the service-connected lower back and sciatica were related to SLE. These conclusions are also consistent with the ultimate conclusions of the VA examiner who conducted the March 1997 examination. 8 - Based upon the foregoing, the Board must conclude that the preponderance of the evidence is against the veteran's claim for service connection for SLE. The most thorough and informed opinion is to the effect that there is no relationship between the SLE and the service connected disabilities or inservice drug therapy. The 1997 opinion was equivocal, in that it noted that it was possible or probable that hypertension was secondary to the lupus nephritis. Inasmuch as the 1999 reviewer considered the 1997 opinion and provided a complete explanation for his conclusions, the Board finds it to be more probative. Accordingly, the Board concludes that the preponderance of the evidence is against the veteran's claim for service connection for a SLE. ORDER Service connection for SLE is denied. Mark D. Hindin Member, Board of Veterans' Appeals 9 -