Citation Nr: 0947549 Decision Date: 12/16/09 Archive Date: 12/31/09 DOCKET NO. 06-11 173A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for flushing attack syndrome with associated difficulty swallowing (claimed as dysphagia); shortness of breath; and severe weakness/fatigue secondary to benzene exposure from jet fuel. 2. Entitlement to service connection for diabetes mellitus secondary to flushing syndrome. 3. Entitlement to service connection for coronary artery disease secondary to flushing syndrome. 4. Entitlement to service connection for hypertension secondary to flushing syndrome. 5. Entitlement to service connection for osteopenia secondary to flushing syndrome. 6. Entitlement to service connection for obstructive sleep apnea secondary to flushing syndrome. 7. Entitlement to service connection for hearing loss, including as secondary to benzene exposure from jet fuel. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD P. Childers, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from December 1961 to December 1965. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2008 the Veteran testified before the undersigned Acting Veterans Law Judge at a Travel Board hearing in Waco, Texas. The transcript of that hearing has been associated with the claims file. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's current flushing syndrome and associated symptomatology (including difficulty swallowing; shortness of breath; and severe weakness/fatigue) and his bilateral hearing loss disorder are both secondary to his contamination during service with jet engine fuel. 2. The Veteran's diabetes mellitus, coronary artery disease, hypertension, osteopenia, and obstructive sleep apnea are secondary to his flushing syndrome treatment regime, including systemic corticosteroids. CONCLUSIONS OF LAW 1. Flushing syndrome with associated difficulty swallowing (claimed as dysphagia); shortness of breath; and severe weakness/fatigue (flushing syndrome) was reasonably incurred during active military service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). 2. Diabetes mellitus is secondary to the Veteran's service- connected flushing syndrome. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2009). 3. Coronary artery disease is secondary to the Veteran's service-connected flushing syndrome. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2009). 4. Hypertension is secondary to the Veteran's service- connected flushing syndrome. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2009). 5. Osteopenia is secondary to the Veteran's service- connected flushing syndrome. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2009). 6. Obstructive sleep apnea is secondary to the Veteran's service-connected flushing syndrome. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2009). 7. Bilateral hearing loss was incurred during active military service. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). In this case, the Board is granting the benefits sought. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. The Veteran seeks service connection for a flushing disorder and hearing loss due to in-service exposure to benzene in jet fuel. He also seeks service connection for muscle weakness, shortness of breath, diabetes mellitus, coronary atherosclerotic disease, dysphagia, hypertension, osteopenia, and obstructive sleep apnea, which he says are all secondary to medications taken for his flushing disorder. According to the Veteran, while refueling a B-52 bomber the fuel hose broke. He says that high pressure JP-4 fuel sprayed at least 50 feet into the air, and that he was completely soaked. He adds that the incident was witnessed by the wing commander, and that the fire department was notified and responded. He further states that he attempted to hose down at the scene, but had to leave the base and go home to shower more completely with soap and water. Service personnel records confirm that the Veteran's work included refueling and defueling duties. Letters from military buddies and the Veteran's wife corroborate the Veteran's accounts of having been saturated with jet fuel during a fueling mishap. Legal Criteria Service connection will be granted if it is shown that the Veteran suffers from a disability contracted in the line of duty while in active military service. 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred during active military service. In addition, a disability that is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102. Medical Evidence In a letter dated in August 1994 a Mayo Clinic physician advised that the Veteran's fatigue was, in part, due to partial adrenal suppression from the long-acting steroids that were being used to help stop his flushing attacks. In a letter dated in May 2005 a private treating physician reported that the Veteran had received treatment at his clinic since 1988. He advised that in 1991 the Veteran began to experience symptoms of flushing in the neck and chest associated with a swelling sensation in the face, difficulty breathing, and severe fatigue. In a letter dated in April 2006 the physician averred that the Veteran's symptoms were consistent with a history of chronic benzene exposure. He further wrote as follows: Treatment for this condition has required multiple courses of corticosteroids which have now led to diabetes, hypertension, and coronary artery disease. Despite an extensive work-up by a myriad of physicians, no obvious diagnosis has ever been found that fully explains his symptoms and laboratory values. It has recently become evident that [the Veteran] had significant exposure to jet fuel while in the service, fuel that contained benzene, a known neurotoxin. Many studies have shown that this additive can, over prolonged and intense contact, cause degenerative neurological, physiological, and cognitive deficits. It may also trigger autoimmune and anaphylactic-type episodes similar to those experienced by [the Veteran]. Due to its deleterious health effects, benzene is no longer a significant component of jet fuel. In light of these recent findings, and given that most of [the Veteran's] symptoms are consistent with a history of chronic benzene exposure, it is my professional opinion that exposure to JP4 jet fuel with benzene while this patient was in the service was more likely than not the cause of his debilitating condition all these years. The physician reiterated his opinion in letters dated in November 2007 and October 2008. In June 2005 and again in May 2006 the Veteran was accorded a VA Compensation and Pension audiology examination. Pure tone threshold testing revealed a flat moderate-severe sensorineural hearing loss, bilaterally. According to the examiner, the Veteran's bilateral flat sensorineural hearing loss is not a pattern consistent with loud noise exposure. In a letter dated in August 2005 a private endocrinologist advised that he had treated the Veteran from May 2000 to March 2005. He indicated that while the Veteran's multiple flushing reactions were of uncertain etiology, they appeared to be allergic in nature. He advised that these reactions were treated with multiple supraphysiologic dosages of glucocorticoids such as prednisone and triamcinolone from 1987 to 1999, resulting in iatrogenic Cushing Syndrome. He then averred that the glococorticoids that were used to treat the flushing reactions had resulted in diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, hypogonadism, and osteopenia. In a letter dated in March 2006 a private audiologist noted the Veteran's report of "exposure to/saturation with" jet fuel during service. She also noted that the Veteran's hearing was normal at the time of his discharge from service; and the Veteran's reported absence of noise exposure after service. She advised that fuel at the time of the Veteran's contamination contained Benzene, which she said was a caustic and possibly carcinogenic agent that stays in the body once exposed to it. She added that research on Benzene and hearing loss had revealed that Benzene is one of the most potent known ototoxic organic solvents, and that hearing loss "appears progressive." She then opined that, based on the Veteran's service history of Benzene exposure and documented research regarding the ototoxic effects of this chemical, it is at least as likely as not that his hearing loss "was caused by, or contributed to by his exposure during his tour of duty in the service." In June 2006 the Veteran was accorded a VA Compensation and Pension ear examination. According to the ENT examiner, the Veteran "has a bilateral sensorineural hearing loss, which he feels is related to his service duties." He remarked that the Veteran did have references with regard to benzene and sensorineural hearing loss, and opined that based on this document, it is likely that the Veteran's hearing loss is related to service duties. He added that the Veteran's hearing loss was more than he would expect for a 65 year old patient. In August 2007, the Veteran was accorded a VA Compensation and Pension skin examination. The examiner opined that it was "within the realm of possibility" that the Veteran's exposure to jet fuel was the cause of the Veteran's flushing syndrome; however, based on the lack of definitive evidence of record and on his review of the medical literature it remained less likely than not that the Veteran's flushing syndrome was due to the exposure to jet fuel during service. He acknowledged the literature that the Veteran had submitted; however, he noted that the literature did not specifically address the condition of flushing syndrome, a carconoid-like anaphylactic type episodic reaction as experienced by the Veteran. The examiner concluded that the Veteran's specific case remained an enigma, an idiopathic condition, even though it has been extensively studied by experts. In August 2008 the Board referred the case for an independent medical opinion. In a letter dated in October 2009 the reviewing physician wrote as follows: The central issue is whether his flushing syndrome is related to exposure to jet fuel. Based on extensive diagnostic testing the answer to this question is not entirely conclusive. The patient was without symptoms for several years after exposure indicating at least that there was not an immediate relationship to exposure leading to flushing. The issue of delayed reaction to initial exposure manifesting itself as flushing many years later is possible but does not seem highly plausible. Based on his medical records, it is not possible to associate his flushings convincingly to his prior exposure to jet fuel. It is very likely that the treatment of his flushing at least partly has contributed to his diabetes, osteopenia, iatrogenic Cushing's syndrome and possible to coronary artery disease and sleep apnea. These illnesses could have been partly as a result of treatment with corticosteroids. Regarding his hearing loss it is very difficult to determine whether this was a result of exposure to jet fuel or could have resulted from long term exposure to noise and the effect of aging. Analysis The Veteran states that he was saturated with jet fuel during service, and the Board finds his assertion, which is supported by statements from multiple informants (including at least one military eyewitness), to be consistent with the circumstances of his service, which entailed refueling and defueling military aircraft. Moreover, medical evidence (including that from the Mayo Clinic and VA Compensation and Pension examiners) confirms that the Veteran has a flushing disorder (characterized by flushing in the neck and chest, swelling of the throat, shortness of breath/difficulty breathing, and severe fatigue/weakness) and a bilateral hearing loss disorder; and numerous physicians have opined that the Veteran's flushing attacks and bilateral hearing loss may be secondary to his in-service exposure to jet fuel benzene. Even the independent medical expert concedes that a link between the Veteran's in-service exposure to jet fuel and the post-service onset of flushing attacks and hearing loss is possible. Although a link between the current Veteran's flushing disorder and service was doubted by the 2007 VA Compensation and Pension examiner, he proffered no explanation for the Veteran's flushing disorder and related symptomatology, and simply concluded that the Veteran's specific case "remained an enigma, an idiopathic condition." The Board consequently finds that the evidence is at least in relative equipoise as relates to the Veteran's claims for service connection for a flushing disorder and a bilateral hearing loss disorder. Accordingly, and in accordance with 38 C.F.R. § 3.102, a grant of service connection for a flushing disorder and a bilateral hearing loss disorder is warranted. The record also contains evidence that the Veteran has incurred additional disabilities secondary to his flushing disorder. Medical records confirm that the Veteran's treatment for his flushing attacks includes systemic corticosteroids and sometimes subcutaneous epinephrine. According to the Veteran's endocrinologist, his diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, and osteopenia are attributed to the glucocorticoids used to treatment his flushing attacks. The Veteran's pulmonary specialist also opines that the Veteran's diabetes, hypertension, and coronary artery disease disorders are secondary to corticosteroids taken for treatment of the Veteran's flushing attacks; and the record contains no medical evidence to the contrary. In addition, the independent medical expert avers that these medications may have contributed, "at least partly," to the Veteran's development of sleep apnea; and there is no medical evidence to the contrary. Accordingly, with resolution of all reasonable doubt in favor of the Veteran, the Board finds that service connection for diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, osteopenia, and sleep apnea, secondary to the Veteran's service-connected flushing disorder, is also warranted. 38 C.F.R. §§ 3.102, 3.310. ORDER Service connection for a flushing syndrome, characterized by symptoms that include difficulty swallowing (claimed as dysphagia); shortness of breath; and severe weakness/fatigue, is granted. Service connection for diabetes mellitus is granted. Service connection for coronary artery disease is granted. Service connection for hypertension is granted. Service connection for osteopenia is granted. Service connection for obstructive sleep apnea is granted. Service connection for bilateral hearing loss is granted. ____________________________________________ ROBERT E. O'BRIEN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs