Citation Nr: 0510160 Decision Date: 04/08/05 Archive Date: 04/21/05 DOCKET NO. 97-20 584 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for lymphoma, including as due to exposure to herbicides. 2. Entitlement to service connection for chronic fatigue syndrome, including as due to exposure to herbicides. 3. Entitlement to service connection for Epstein Barr virus (EBV)-related disease, including as due to exposure to herbicides. 4. Entitlement to service connection for peripheral neuropathy, including as due to exposure to herbicides. REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney at Law WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD Michael Holincheck, Counsel INTRODUCTION The veteran served on active duty from July 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. The Board previously denied the veteran's claims in March 2000. He appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). The veteran's attorney and VA's General Counsel filed a joint motion requesting that the Court vacate the Board's decision and remand the case to the Board for further development and re- adjudication in accordance with the directives of the joint motion. The Court granted the joint motion for remand in January 2001 and returned the case to the Board. The Board received a letter from the veteran's attorney in June 2001. She stated that she was requesting a 30-day extension to submit additional evidence in support of the veteran's claim. She said that she had not received an earlier letter from the Board. She also submitted a copy of her representation agreement. The Board wrote to the veteran's attorney in June 2001. The veteran, through his attorney, was advised that the Court returned the case to the Board. The Board acknowledged that an earlier letter was not sent. The veteran was further advised that he had 90 days to submit additional evidence or argument in support of his claim. The veteran's attorney submitted a request for a 45-day extension to submit additional argument/evidence in support of the veteran's claim in September 2001. The attorney later submitted additional evidence in November 2001. She also submitted a waiver of consideration by the agency of original jurisdiction (AOJ). The Board wrote to the veteran in January 2002. He was advised that the Veterans Law Judge who previously had conducted a hearing in the case was no longer employed at the Board. The veteran was provided an opportunity to have another hearing. The veteran responded in February 2002 that he did not want another hearing. The Board sent a letter to the veteran in February 2002 that acknowledged his decision that he no longer wanted a hearing. The Board wrote to the veteran in January 2003 and informed him that the Board would conduct additional development in his case. The veteran responded through his attorney in February 2003. He submitted a detailed statement on his behalf, along with additional evidence. In May 2004, the Board advised the veteran's attorney that an independent medical expert (IME) opinion was being sought in this case. The attorney was further informed that they would be given a copy of the opinion when it was received and afforded an opportunity to submit additional argument or evidence. The Board forwarded a copy of the IME opinion to the veteran's attorney in June 2004. She was advised that she had 60 days to submit additional argument or evidence in response to the opinion. The attorney contacted the Board in August 2004 and requested a 60-day extension of time. The Board again wrote to the veteran's attorney in August 2004. The letter informed the attorney that a waiver of consideration by the AOJ was necessary to allow the Board to consider the IME opinion in the first instance. The attorney was informed that she should respond within 60-days regarding the waiver. The attorney requested a 30-day extension of time in October 2004. The Board responded in November 2004 and provided a deadline of November 12, 2004. The veteran's attorney submitted a second request for an extension of time to respond in November 2004. She indicated that she was waiting for a medical opinion to submit on behalf of the veteran. The veteran's attorney submitted a medical opinion that was received at the Board on November 12, 2004. She also waived consideration of the additional evidence by the AOJ. The Board granted the attorney's request for an extension, first submitted in October 2004, as no prior specific response to her request had been provided. The attorney responded in November 2004 that she had submitted her evidence. She asked that the Board proceed with the appeal. In light of the attorney's multiple waivers of AOJ consideration of evidence submitted, and her expressed desire for the Board to proceed with the appeal, the Board finds that case is ready for appellate review. FINDINGS OF FACT 1. A lymphoma, including non-Hodgkin's lymphoma, has not been diagnosed. 2. Medical evidence of record establishes that chronic fatigue syndrome and chronic active Epstein Barr Virus infection clinically are indistinguishable. 3. The veteran's chronic fatigue syndrome and chronic active Epstein Barr Virus infection are not directly related to the veteran's military service and are not related to exposure to herbicides during service. 4. There is competent medical evidence of record to show that the veteran's service-connected post-traumatic stress disorder caused or contributed to his chronic fatigue syndrome and chronic Epstein Barr Virus infection. 5. The veteran does not have a peripheral neuropathy that is related to service or to exposure to Agent Orange. CONCLUSIONS OF LAW 1. The veteran does not have lymphoma that is the result of disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2004). 2. The veteran's chronic fatigue syndrome and chronic Epstein Barr Virus infection are proximately due to, or the result of, a service-connected disability. 38 U.S.C.A. §§ 1110, 1154(b), 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. 3. The veteran does not have peripheral neuropathy that is the result of disease or injury incurred in or aggravated by active military service or due to in-service herbicide exposure. 38 U.S.C.A. §§ 1110, 1154(b), 5107; 38 C.F.R. § 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Background The veteran served on active duty from July 1967 to May 1969. A review of his service medical records (SMRs) shows that the veteran was initially given an induction physical examination in May 1966. The physical examination report was negative. The veteran did provide a medical history of having had mumps, appendicitis, frequent or painful urination, and kidney stone or blood in the urine on his Report of Medical History (RMH). The examiner commented on the RMH that the veteran was treated for a right ear infection and urinary tract infection in 1965. The veteran underwent a preinduction physical examination in July 1967. Again, his physical examination report was negative for any abnormalities. On his RMH the veteran said that he was colorblind. He also listed having ear, nose, and throat troubles, pain or pressure in his chest, frequent or painful urination, kidney stone or blood in his urine, and a recent loss or gain of weight. A review of the prior examination report shows that the veteran's weight increased from 189 pounds to 208 pounds. The medical examiner said that the veteran had otitis of the right ear in 1965 with no residual or recurrence. The examiner also noted that the veteran had had gross hematuria with a negative intravenous pyelogram (IVP). The several clinical records in the SMRs show that the veteran was seen at an aid station in Vietnam in December 1968 and February 1969. The entries noted that there were no symptoms or complaints. The veteran was seen for otitis of the left ear in June 1968, prior to his service in Vietnam. He was also treated for a cold in February 1968. The veteran was given a separation examination in May 1969. No abnormalities were noted on the physical examination. The veteran again reported color blindness, appendicitis, frequent or painful urination, and kidney stone or blood in the urine on his RMH. The examiner commented only that the appendicitis occurred prior to service. The veteran's DD 214 reflects that he served 10 months and 13 days overseas, in this case, the Republic of Vietnam. The veteran was awarded the Combat Infantryman Badge (CIB). The Board notes that the veteran first submitted a claim for VA education benefits in May 1971. Evidence of record shows that he received benefits for several years between 1971 and 1976. The evidence also shows that the veteran submitted a VA Form 22-1995, Request for Change of Program or Place of Training, in August 1978. The veteran indicated that he wanted to pursue a degree in engineering, with an ultimate goal of a doctorate degree. The veteran reported that he was seeking a job change, but did not indicate why he was seeking the change. He said he would be attending Ball State University. The veteran anticipated a 12-credit-hour program beginning in September 1978. An enrollment certificate from the school was received in September 1978. It was reported that the veteran was enrolled for a school year from September 1978 to May 1979 with a 12-credit-hour program. Education benefits were awarded in October 1978. Notice was received in November 1979 that the veteran did not enroll for the winter quarter. No further information was provided. The veteran submitted his claim for disability compensation benefits in June 1996. The veteran did not specify any type of illness or injury on his claim form. He did say he was treated for "Agent Orange exposure" in service. He also reported treatment by two physicians for "Agent Orange exposure" after service. A Dr. Stricker from 1969 to 1988, and a Dr. Cummings from 1989 to the then present. The veteran also submitted a statement wherein he said he was submitting a claim for benefits based on his exposure to Agent Orange. He said that he had been unable to work since 1994. He said he could document his illness back to 1969 when he returned from Vietnam. The veteran said he was forced to quit a job in 1978, presumably from a lymphoma-like illness that he said he gradually recovered from to some degree. He said he visited a VA hospital in 1994 and that doctors there recognized that his illness could be related to Agent Orange. He said he was also told by one of the doctors not to make an application for benefits because he did not have one of the diseases on "their" list. The veteran stated that he now knew that he should have been receiving benefits since he left the Army in 1969 but wanted to apply for disability benefits back to 1978 when he became seriously disabled to the point of having to give up a good job. The RO wrote to the veteran in June 1996. He was informed that treatment records were being requested from Dr. Stricker and Dr. Cummings. The RO also wrote separately regarding the veteran's Agent Orange claim. The veteran was informed that he needed to specify a disability that he felt was the result of exposure to Agent Orange. He was told he should contact a local VA medical center (VAMC) to have a protocol examination. He was also informed that, if he had previously had such an examination, he should inform the RO so that a copy could be obtained for rating purposes. The veteran was also requested to provide information regarding his last employer since he had stated he was unable to work since 1994. The veteran failed to provide the requested information and did not authorize the RO to obtain the information directly from the employer. Records from Dr. Stricker were received in July 1996. They covered a period from June 1969 to July 1988. The records show that the veteran was first seen in June 1969 with complaints of a sore throat. A test for evidence of mononucleosis was negative at that time. The veteran was seen again for complaints of a sore throat in May 1970. Laboratory studies, to include another test for mononucleosis, were negative at the time. A kidney infection was suspected from September to December 1970 and the veteran was treated with antibiotics. The veteran was again treated for a cold and sore throat in August and December 1972. Laboratory studies, to include a test for mononucleosis, were reported as negative. The veteran was seen again for complaints of a sore throat in 1974 and 1975. In July 1977, the veteran complained of night sweats, cough, allergies, marital problems and anxiety. Several additional entries, dated in 1977, note that the veteran was also being treated by a Dr. Foster. An entry dated in June 1978 noted that the veteran was going to have a serum protein electrophoresis study. The results were reported as a "normal pattern." There is a three-year gap in entries until October 1981 when the veteran was seen for a physical examination for a skin diving class. The veteran was treated for a cold in 1987 and upper respiratory infection in 1988. A review of Dr. Stricker's records does not reveal any evidence of a diagnosis of chronic fatigue syndrome, Epstein- Barr virus (EBV) exposure, lymphoma, or peripheral neuropathy. The veteran was evaluated on a number of occasions for complaints of sore throat and a cold. A number of laboratory studies were conducted, to include for mononucleosis. The tests for mononucleosis were all negative and the clinical entries did not report any significance associated with any of the laboratory findings reported in the entries. Associated with the claims file are VA treatment records for the period from September 1994 to March 1995. A neurology clinic entry, dated in September 1994, reported that the veteran complained of fatigue, blurring of vision, night sweats, and headaches over the last six months. The veteran was also reported to have lost 30-40 pounds in the last 3-4 months in an effort to lose weight. The veteran also complained of joint pain in the interphalangeal joints, elbows and knees. The veteran also gave a history of exposure to Agent Orange. The veteran was to be evaluated for his complaints to include electromyograph (EMG) study. The physician noted that the veteran had been fully evaluated by private physicians six months earlier. An entry dated in December 1994 noted that the veteran was not seen at VA prior to August 1994 when he was referred for an Agent Orange examination with an elevated liver function test and protein in his urine. The veteran gave a history of having a "flu-like" illness with joint pain in January 1994. He was evaluated for possible Lyme disease but this was negative. He said he was referred to another physician where he was diagnosed with chronic fatigue with a positive Epstein-Barr value. The veteran was referred to VA by his company physician. The veteran had felt bad since January 1994 and had been off work since February 1994. The veteran gave a history of exposure to several chemicals at his current job and at past jobs. The assessment at that time was of elevated liver function test, malaise, night sweats, and fatigue. The veteran was scheduled for a number of laboratory studies, to include an Epstein-Barr nuclear antigen (EBNA), a computed tomography (CT) study and a return to the clinic after the studies. The veteran underwent EMG testing in December 1994. The results of the testing were interpreted as showing no electrodiagnostic evidence to suggest decremental response myasthenia gravis. The results of a January 1995 CT scan of the thorax and abdomen were reported to show a small bullae or bleb near the right hilum, otherwise an unremarkable CT scan of the chest and abdomen. A January 1995 neurology clinic assessment noted the results of the EMG and CT scan. The examiner said that the veteran's problems did not appear to be neurologically based on the normal clinical examination and the EMG results. The veteran was discharged from the neurology clinic. The veteran was seen in a different clinic in association with his Agent Orange complaints. The examiner noted the results of the neurology evaluation. The examiner also noted that the EBNA study was not done. The examiner ordered additional laboratory studies, to include an Epstein-Barr titer. The results of the several tests were written in the margin of the clinic note. Another entry, dated in March 1995, reviewed some of the January 1995 laboratory results. A protein electrophoresis was said to be within normal limits. The veteran was said to be followed by a private physician for his fatigue symptoms. The final assessment was elevated liver function test, resolving. The veteran was released from the clinic. Treatment records from M. Cummings, M.D., were received in August 1996. The records covered a period of treatment from November 1991 to August 1996. The earlier records document treatment for recurrent episodes of pharyngitis from December 1991 to February 1993. The next entry is dated in May 1994 when the veteran was seen with complaints of fatigue and weakness. The physical examination reported normal findings. The veteran was to get an Epstein-Barr titer and be seen afterwards. The titer was said to be positive. The veteran was referred to a Dr. R. Shadowen. The veteran was seen again in June 1994. The veteran was noted to have been seen by Dr. Shadowen, no results from the evaluation were given. The entry also noted that Dr. Cummings was going to proceed with an Agent Orange work-up and refer the veteran to VA. A July 1994 entry reported essentially the same physical findings - that there were no abnormalities. The veteran was to have a neurological consultation to rule out myasthenia. The veteran was evaluated again in October 1994 with complaints of fatigue and numbness in the right arm. The physical examination was reported as normal. The veteran underwent additional laboratory studies. He was noted to have hypertriglyceridemia. He was put on a diet. A November 1994 entry reported the same, essentially normal, physical findings as before. Dr. Cummings noted that he had a long discussion with the veteran about the long-term effects of his condition. The veteran was said to be having difficulty and had not been able to work. Entries in April and May 1995 reported the same physical findings. Dr. Cummings reported that he was going to get a Medline search on Agent Orange, chronic fatigue syndrome and Epstein- Barr virus from the hospital in November 1995. An October 1995 entry reported the same physical findings as before. The plan was no treatment necessary. It should be noted that, although the physical findings were reported as normal on the several outpatient visits, the veteran presented with complaints of chronic fatigue. There was no diagnosis of lymphoma or peripheral neuropathy from Dr. Cummings. The RO denied the veteran's claim for service connection for chronic fatigue syndrome/lymphoma in October 1996. The RO denied the veteran's claim on both a direct and presumptive basis. The veteran reported for a VA examination in January 1997. The veteran gave a history of symptoms of chronic fatigue going back to 1969. He said a Dr. Deshmukh found an enlarged lymph node in his groin and right axilla. A biopsy had been recommended but one had not been done. The veteran had not been diagnosed with lymphoma. The veteran said that he had been told by some doctors that his symptoms may have been caused by exposure to Agent Orange. The veteran appeared tired on physical examination. There was no finding of peripheral neuropathy reported. The diagnoses were chronic fatigue syndrome and elevated blood pressure on examination. No opinion was given as to the etiology of the chronic fatigue syndrome. The veteran submitted a statement in January 1997 wherein he referred to his VA examination. He said that he was asked very specifically by the VA examiner what he had been diagnosed with in the past. He said that one problem was that he sometimes forgot things. He also said that he had been diagnosed with peripheral neuropathy and that the diagnosis should be in his records. He submitted a copy of a report from R. D. Shadowen, M.D., a specialist in infectious diseases. The report, dated in June 1994, was prepared after a referral from Dr. Cummings. Dr. Shadowen said that the veteran had a 15-month history of weakness, joint soreness, migratory arthritis, fatigue, and fleeting rashes. She said that the veteran's Epstein-Barr virus serology was somewhat confusing but that his results represented old disease - longer than six months ago. She said that, since the veteran's illness began 15 months ago, she could not really say whether this was the inciting event or not, but that the results would classify the veteran as having chronic fatigue syndrome if indeed it were. She said that the veteran's nuclear antigen was positive at 1:40 and that meant that he had the disease at least six months earlier. She said that she could not place the disease beyond the six months in light of other test results. Dr. Shadowen also said that she would look for further evidence to support deep-seated streptococcal infection that would let them know the veteran had a post- rheumatic fever sequela. She recommended a magnetic resonance imaging (MRI) test of the head to rule out multiple sclerosis. Dr. Shadowen noted that the veteran had a peripheral neuropathy as evidenced by decreased vibratory sensation over his feet and felt that an EMG and possibly a lumbar puncture should be done to look for a demyelinating process. She also noted that the veteran had an indeterminate Lyme disease test in 1993. She recommended a repeat test. Dr. Shadowen reported that the veteran had decreased vibratory sensation over both of his toes with 100 percent representation at the ankles, 20 percent on the right toe and 10 percent at the left toe at the metatarsal head levels. It was also noted that the veteran had approximately 50 percent decrease in sensation to the wrist to the proximal phalanx of both hands. Her impression was of fatigue-like illness with various features that brought the possibilities of rheumatic fever, Jaccoud's arthritis, Lyme disease, fungal illnesses, and demyelinating processes. She did not include peripheral neuropathy as a specific condition in her list of impressions. The veteran submitted the first of what would be several statements and/or letters from P. R. Aaron, M.D., J.D., MPH, in April 1997. Dr. Aaron said that he was writing the letter because "we" believe that the veteran was exposed to Agent Orange and was suffering from the effects of that exposure. Dr. Aaron noted the veteran's negative medical history prior to service, the veteran's service in Vietnam, and the cold and sore throat symptoms reported soon after service. He noted that the veteran developed a flu-like illness in 1994. He also made a broad statement of the veteran's medical condition, not supported by the evidence of record, that the veteran had peripheral neuropathy in his extremities. Dr. Aaron also made mention of the veteran's daughters suffering from medical conditions that he implied could be the result of the veteran's exposure to Agent Orange. He noted that Dr. Shadowen had reported a decreased vibratory sensation in the toes. He also said that a neurologist, J. Oropilla, M.D., found the veteran's sensory examination was decreased 50 percent in the feet compared to the thigh and with a bilateral deficit in the upper extremities. Dr. Aaron noted that there was a list of diseases that the government believed were caused by exposure to Agent Orange. He concluded by saying that the veteran's findings were suggestive of Agent Orange exposure. Dr. Aaron did not provide an opinion that related any specific diagnosis to the veteran's military service, nor did he provide an opinion that related any specific diagnosis to exposure to Agent Orange. The veteran submitted a copy of a note written to him by a VA physician, Dr. D., in 1995. The VA physician had followed the veteran on his initial evaluation by VA for Agent Orange screening and authored several of the 1994 and 1995 VA treatment entries. The veteran had asked Dr. D. to comment on his EBV work-up. Dr. D. said that the EBV work-up might be supportive of chronic fatigue syndrome, not diagnostic for it. Dr. D. said that, per discussion with ear, nose, and throat (ENT) physicians, their feeling was if there was a neoplasm of ENT it should be present on physical examination - no additional tests to be done. He said that the veteran's physical examination precluded that diagnosis. Dr. D. said that, as for chronic infection, no sources were found nor at the time anything else suggesting tests for malignancy. The veteran was advised to show the note to his physicians. The veteran submitted a claim for entitlement to service connection for post-traumatic stress disorder (PTSD) and peripheral neuropathy, due to Agent Orange, in June 1997. The veteran was afforded a VA PTSD examination in October 1997. The veteran gave a history of fatigue-like syndrome. The examiner noted the report of Dr. Shadowen in the history portion of his report. He also noted the letter from Dr. Aaron. He noted several statements from the veteran that discussed his service in Vietnam and exposure to Agent Orange. The examiner did not provide a diagnosis of PTSD. Rather, he said that the Axis I diagnosis related to life circumstance problems. The examiner said that the veteran did not have a psychiatric problem. The veteran was afforded a VA neurology examination in October 1997. The examiner noted that the veteran complained of numbness and paresthesias in the upper extremities. The veteran related that this began in service. The veteran said he was told that this was secondary to when he was in Vietnam and carrying a 100-pound rucksack. The examiner noted that the veteran had been diagnosed with EBV syndrome and chronic fatigue syndrome in 1994. The examiner further noted that an EMG was negative for myasthenia gravis. The diagnoses given where chronic fatigue syndrome, EBV syndrome and bilateral paresthesias in the upper extremities. The examiner noted that there was no mention made of peripheral neuropathy in the 1994 EMG report. Dr. Aaron submitted another statement in October 1997. Dr. Aaron said that recent EBV literature suggested that there may be a long-term link between EBV, lymphoma, and nasopharyngeal carcinoma. He said that researchers now linked EBV as damaging to a person's immune system and suggest that a person with chronic EBV is someone whose immune system is compromised by other serious illnesses such as lymphoma or Agent Orange. He further noted that one test indicated that the veteran was infected with EBV at the time he became ill in 1994. Dr. Aaron noted that the Environmental Protection Agency (EPA) had issued a statement that said that immune and reproductive systems were most sensitive to dioxins. He went on to say that the veteran was at greater risk when he was exposed to EBV because of his prior exposure to dioxin. He concluded by saying that the veteran had chronic EBV, there was a link between EBV and dioxin and that EBV itself was not the cause of the veteran's diseases. He said that the role of EBV was secondary to dioxin's effect on the body's immune system. The veteran submitted a letter from an insurance company, Trans-General Group, in October 1997. The letter related to the veteran's claim with the company for long-term disability benefits. The letter detailed a number of items of medical evidence from a number of sources, to include Dr. Cummings and Dr. Aaron, as well as several other physicians. The letter concluded that, as a result of an audit, the company had determined that the veteran's symptoms related to chronic fatigue syndrome were caused or contributed to by his exposure to Agent Orange in service. The company then invoked a War clause to terminate the veteran's claim. In his statement, the veteran cited to the letter as proof of his assertion of exposure to Agent Orange. (The Board notes that the veteran was requested to either provide the records cited in the letter from the insurance company or authorize VA to obtain the records. He declined to do so as he felt that the record contained sufficient records to decide his claim.) The veteran testified at a Travel Board hearing in November 1998. The veteran said that he was in good health when he entered the service. There was testimony from the veteran about why he believed he was exposed to Agent Orange. The veteran said that he suffered from headaches and numbness in his hands and arms. He said that he talked to a field medic about it. He said that he noticed some allergies he never had before when he returned home. Because his problems were not debilitating at the time he did not worry about them. The veteran said that he had not worked since 1994 and was found to be disabled by the Social Security Administration (SSA). The veteran said he was not certain if Dr. Cummings was a relative but if he was, he was not a close relative. The veteran said he had been seeing Dr. Aaron for three years. The veteran testified that his illness eventually forced him to quit working. He received long-term disability benefits for a period of time. The benefits were terminated when the insurance carrier discontinued coverage because of a war clause. The veteran also testified that his three daughters had problems with a lower spinal abnormality. He had been in contact with the National Birth Defect Registry and was told that his daughters' problems were consistent with those whose parents were exposed to Agent Orange. The veteran submitted additional evidence at the hearing. Included was an October 1998 statement from Dr. Aaron. He repeated his prior assertions of the link between exposure to Agent Orange and its effect on the immune system. He also said that the veteran's peripheral neuropathy was caused by exposure to Agent Orange in Vietnam. He provided no support for this statement by way of a clinical diagnosis or scientific evidence to establish such a nexus. Dr. Aaron did submit a copy of an article from the Association of Birth Defect Children (ABDC). He also included copies of information regarding mononucleosis and EBV. The ABDC article noted that data from the National Birth Defect Registry raised the possibility that children of veterans exposed to Agent Orange were suffering from a pattern of disabilities caused by an impaired immune system. The veteran also submitted statements from friends and family members who knew him and either attested to his character or to both his character and his change in health after his military service. In addition, he included a statement from Dr. Stricker's office. The statement reported that attempts were made to locate additional medical records from Henry County Memorial Hospital and Dr. Foster but those records were destroyed after 10 years. The statement also indicated that Dr. Stricker's office retained clinic notes but destroyed other doctors' reports after 10 years. The veteran submitted two statements from Dr. Cummings. The first, dated in October 1994, said that the veteran was permanently disabled due to chronic fatigue secondary to complications with Agent Orange. The second statement, dated in January 1996, also addressed the veteran's overall disability status. The medical conditions included chronic fatigue syndrome, positive EBV syndrome, exposure to Agent Orange, and hypertriglyceridemia. Finally, the veteran included a copy of a notice of favorable decision from SSA in regard to a disability claim dated in July 1996. The decision noted that the veteran claimed exposure to Agent Orange in Vietnam. It was noted that the veteran developed fatigue and that the EBV was isolated. He was said to have developed dysthymia as a result of his physical condition. There was no further information. The Board notes that the veteran submitted a number of statements during the development of his claim to this point. He asserted that his health was good prior to being in the military and in Vietnam. He said that he experienced numbness and tingling in his arms in the field in Vietnam and talked to a medic about it. He said that he was told at the time that the problem was probably due to his carrying a heavy rucksack and that it would go away. The veteran also addressed how he developed colds, sore throats, and allergies soon after he returned home. He said he had worked for [redacted] [redacted] for a number of years but had to quit in 1978 when he was no longer physically able to do his job. He held several other jobs and was self-employed in the years after until he became too sick to work in February 1994. The veteran felt that his fatigue, EBV syndrome, and peripheral neuropathy were all related to his exposure to Agent Orange in Vietnam. The Board solicited a medical opinion from a Veterans Health Administration (VHA) medical professional in May 1999. An opinion was received in June 1999. The physician reviewed the veteran's SMRs, the records from Dr. Cummings, the statements from Dr. Aaron, and October 1997 VA neurology examination report. The opinion stated first that there was insufficient evidence or documentation by history, neurologic examination, or electrodiagnostic testing, to show that the veteran currently suffers, or has suffered in the past, from peripheral neuropathy. He said that the records did not indicate any basis for a diagnosis by Dr. Aaron or Dr. Cummings. He said there were no neurological findings to support a diagnosis of peripheral neuropathy. He also said that there was no diagnosis of peripheral neuropathy at the time of the October 1997 VA examination. The doctor found that it was not likely that the veteran's subjective complaints of paresthesia in his upper extremities were due to Agent Orange exposure during his military service. In support of this conclusion he said that there was no medical chart documentation that the veteran complained of, or showed clinical manifestations compatible with peripheral neuropathy. Next, the opinion stated that the SMRs or post-military records showed no indication that the veteran suffered from the symptoms or manifestations of chronic fatigue syndrome or Epstein-Barr infection until the early 1990's. The opinion stated that there was no medical literature, of which that doctor was aware, that established a causal relationship between Agent Orange exposure and the development of Epstein- Barr viral syndrome, or chronic fatigue syndrome. The physician said that it was not likely that the veteran developed chronic fatigue syndrome due to exposure to Agent Orange. He further stated that exposure to Agent Orange was not the cause of, nor did it lead to the development of Epstein-Barr viral syndrome. The Board wrote to the veteran's attorney of record at the time in July 1999. The attorney was provided a copy of the VHA opinion and given 60 days to submit argument or evidence in support of the veteran's claim. Unrelated to the Board's letter, the veteran submitted additional statements from himself, as well as other evidence to the Board in May and June 1999. The veteran submitted a copy of a letter from the ABDC. The letter provided no direct support of the veteran's claim. Rather, it addressed in general terms the effect of exposure to Agent Orange on a person's immune system. The letter noted that most people were exposed to EBV but that the EBV is held in check by the immune system, unless the immune system is compromised. The veteran also submitted another statement from Dr. Aaron, dated in May 1999. Dr. Aaron said that there was a definite link between the veteran's medical condition and his military service. He said that the veteran was healthy prior to service. While in service, particularly in Vietnam, the veteran experienced sore throats, headaches, peripheral neuropathy and loss of hair. He said he had shared in the veteran's care over the last several years and could attest to the veteran's recurrent symptoms. He acknowledged that the medical care from the 1970's did not isolate a medical condition to identify the veteran's health condition. Dr. Aaron said that records show that the veteran was forced to quit his job of 13 years because of health problems beginning in 1977. The Board notes that there are no records for this period of time to show any medical reason for the veteran's having to quit his job. Dr. Aaron concluded by saying that the veteran did not have his symptoms prior to service, that they developed in service, and that they continued to the present. The veteran's attorney, at the time, submitted additional argument and numerous evidentiary exhibits in June 1999. Many of the exhibits were duplicative of items previously submitted. This included statements from Dr. Aaron, Dr. Cummings, the veteran, as well as numerous medical treatise excerpts and articles. Also included were several additional excerpts regarding dioxin and the immune system. There was no medical opinion that addressed the applicability of the general information to the veteran's specific case. The Board remanded the veteran's case in August 1999. The remand directed the RO to review the evidence submitted directly to the Board by the veteran. In addition, the other evidence of record compiled since the last supplemental statement of the case (SSOC) was issued was to be reviewed. A new SSOC was to be issued if the claim was not granted. The veteran submitted a statement dated in May 1999, and received in August 1999, that was signed by him and Dr. Aaron. He again restated the evidence as he saw it. He recounted his health in service, and after. He opined about the effects of dioxin on the immune system and the role of EBV. Additional statements from the veteran and his attorney were received at the RO. Essentially, the arguments remained the same regarding the veteran's exposure in service and the subsequent development of health problems that the veteran felt were related to his military service. As noted in the Introduction, the veteran's claim was denied by the Board in March 2000. The Court vacated the Board's decision, based on an order granting the joint motion filed by the veteran's attorney and the VA's General Counsel, in January 2001. It was argued that the case should be remanded for the issuance of a statement of the case (SOC) in regard to a denial of the veteran's claim for service connection for PTSD. The joint motion also said that the case should be remanded because the Board failed to ensure compliance with its remand instructions under Stegall v. West, 11 Vet. App. 268 (1998). The joint motion said that the VA medical opinion was not styled as requested in the request for the opinion. Specifically, although the examiner stated that there was no connection between the veteran's exposure to Agent Orange and his claim for service-connected benefits, his opinion was deficient in that he did not use the term "at least as likely as not." Finally, the joint motion said that the Board had not clearly articulated the reason for concluding that the physician who supplied the VA medical opinion was more qualified than Dr. Aaron and Dr. Cummings. The veteran's attorney, in a letter dated in June 2001, noting that the Board allegedly mailed a notice letter in March 2001 but denying receipt of the letter, requested a 30- day extension to reply to the Board's letter. The Board responded to the veteran's attorney in June 2001. The veteran, through his attorney, was advised that the Court returned the case to the Board. He was further advised that he had 90 days to submit additional evidence or argument in support of his claim. Associated with the claims file is a claim for service connection for PTSD that was developed concurrently with the veteran's claim for the issues on appeal. The veteran's claim was received in August 2000. The veteran submitted two letters from physicians in support of his claim. The first letter, from Dr. Aaron, and dated in May 2000, noted that he found the veteran to be totally disabled. He said that he believed the problems were caused by exposure to Agent Orange which caused the veteran to have a damaged immune system and caused him to have peripheral neuropathy. He said that the veteran also suffered from PTSD. He noted the veteran's medical history. He said none of the veteran's physicians had been able to identify a disease which had compromised his immune system. Dr. Aaron opined that the veteran's immune system compromise was due to Agent Orange. He also said that the medical literature was replete with documentation that showed that PTSD could compromise the immune system (he did not cite to any such literature or provide any related documentation). He repeated his assertion that the veteran's medical problems were caused by his exposure to Agent Orange in service and PTSD. The second letter was from a M. K. Thompson, M.D. and dated in July 2000. Dr. Thompson said she first saw the veteran in July 2000. She noted the veteran's medical complaints by history only. She said that it was suggested that there was a possible connection between the veteran's physical problems and his psychiatric disorder. She said that there was no doubt that the veteran's physical condition, including the status of his immune system, was adversely affected by and related to his PTSD. She cited to several medical treatises in support of her assertion. She stated that her diagnostic impression was that the veteran suffered from chronic PTSD and that it was her belief that the disorder adversely affected his immune system. Dr. Thompson submitted a second letter, dated in September 2000, that attested to her belief that the veteran's Global Assessment of Functioning (GAF) score was a 25. This was in regard to an assessment of the veteran's mental health status. The veteran submitted additional statements on his behalf. Also associated with the claims file were several letters from the veteran to several senators and a congressional representative. The veteran continued to assert his basis for entitlement to service connection based on his exposure to Agent Orange. The veteran was afforded a VA PTSD examination in April 2001. The examiner provided a history of the veteran's past medical complaints and treatment. The examiner provided a diagnosis of PTSD specifically linked to the veteran's combat experiences in Vietnam. The veteran was granted service connection for PTSD in August 2001. He was assigned a 50 percent disability rating effective from August 29, 2000. The veteran's attorney faxed a letter to the Board in September 2001 wherein she requested an additional 45-day delay in submitting additional evidence. The attorney submitted additional evidence and argument to the Board in November 2001. She also specifically waived consideration of the evidence by the agency of original jurisdiction. Included in the submission was a duplicate copy of the May 2000 statement from Dr. Aaron, duplicate copies of the July 2000 and September 2000 letters from Dr. Thompson, and a duplicate copy of the April 2001 VA examination report. There were two new statements from Dr. Thompson. She provided additional support for her assessment of a GAF score of 25 and noted that she had reviewed the veteran's claims file. Also new to the record was a treatment record from Y. K. Deshmukh, from the Elizabethtown Hematology-Oncology, PLC, dated in December 2000. Dr. Deshmukh said he first saw the veteran in 1996. He said the veteran presented with peripheral neuropathy at that time. The veteran had a history of exposure to Agent Orange and several other chemicals. Dr. Deshmukh said that the peripheral neuropathy was presumably caused by some of the chemicals, including possibly Agent Orange. Dr. Deshmukh noted that he had found evidence of some small lymph nodes in the treoperitoneal and inguinal areas and had recommended a biopsy but that the veteran had declined. He said that the veteran had no significant illness except history of infectious mononucleosis and a chronic fatigue-like syndrome. The problem list included PTSD, depression, history of infectious mononucleosis and chronic fatigue-like syndrome. Dr. Deshmukh said that he had looked at records from Dr. Aaron and Dr. Thompson. He also said that it appeared that the veteran could very well have his symptoms because of his exposure to the chemicals during the war. He said that the veteran had nonspecific lymphadenopathy that required further exploration. He concluded by saying that the veteran should be given disability as most of his problems, if not directly related to the chemicals, were certainly indirectly related to the PTSD. The attorney also included a May 2001 medical opinion from C. N. Bash, M.D., who listed himself as an Associate Professor of Radiology and Nuclear Medicine at the Uniformed Services University of the Health Services. Dr. Bash said that he had reviewed the veteran's SMRs, post-service medical records, the SOC, the veteran's statements, and medical literature research. Dr. Bash began by stating that it was his opinion that it was likely that the veteran's fatigue syndrome "+/- " peripheral neuropathy were secondary to his exposure to Agent Orange during service. He proceeded to provide a recitation of facts he found to be of importance. Dr. Bash identified a fatigue-like illness as first occurring in 1994 in referring to Dr. Shadowen's records. He also noted a peripheral neuropathy from her records. He did not address any earlier medical evidence. Dr. Bash concluded that the veteran had a fatigue-like illness and "+/-" peripheral neuropathy that had not been specifically attributed to any illness process. He said that, without another firm diagnosis and giving the veteran the benefit of the doubt, the most likely cause was his exposure to Agent Orange. Dr. Bash went on to paraphrase several selections from published studies regarding diseases specifically found to be related to exposure to Agent Orange. Although Dr. Bash paraphrased the material, he used quotation marks to signify that he was quoting from the material. Unfortunately, Dr. Bash's "quotes" were incomplete, highly inaccurate, and conveyed the exact opposite view of the cited passages. In that regard the Board notes that Dr. Bash cited to a study by Peper et al, dealing with exposure to environmental polychlorinated dibenzofurans (PCDD)/PCDF) as demonstrating multiple neuropsychological changes. He used ellipses to include the word "fatigue" with the findings as supportive of the veteran's claim. This quotation was taken from the Veterans and Agent Orange, Update 1996, Institute of Medicine, National Academy Press, 1996 (Update 1996). Specifically, Dr. Bash cited to page 308 of the update. A review of the material shows that the topic discussed was cognitive and neuropsychiatric effects of exposure to Agent Orange. The beginning sentence of that section noted that a prior review had determined that "the literature was insufficient to determine whether an association existed between exposure to herbicides and related compounds and chronic cognitive or neuropsychiatric disorders." Update 1996, at 307. In regard to Dr. Bash's quote, the material was taken from a section entitled "Update of the Scientific Literature." In particular, the sentence cited by Dr. Bash noted that there were ". . . self-reports of memory problems, distractibility, irritability, and fatigue, and objective changes in verbal conceptualization skills, amnestic organization and psychomotor activity." Update 1996 at 308 (emphasis added). The passage did not relate to fatigue as an identifiable illness associated with exposure to herbicides. Finally, in the conclusion of the section relating to cognitive and neuropsychiatric effects of exposure to Agent Orange, the authors stated that "[t]here is inadequate or insufficient evidence of an association between exposure to the herbicides considered in this report and cognitive or neuropsychiatric disorders. The evidence regarding association is drawn from occupational and other studies in which subjects were exposed to a variety of herbicides and herbicide components." Id. In regard to Dr. Bash's opinion regarding peripheral neuropathy, he cited to an excerpt from the Veterans and Agent Orange, Update 1998, Institute of Medicine, National Academy Press, 1998 (Update 1998). Specifically, he cited a section that noted that acute peripheral neuropathies were reported following acute occupational exposure. He cited to Update 1998 at page 473. A review of that section shows that it relates to the study of acute and subacute transient peripheral neuropathy. (emphasis added). A more thorough review of the section shows that the committee determined that: Based on an analysis of the data from studies reviewed in VAO (Veterans and Agent Orange) and Update 1996, as well as those published more recently regarding occupational, environmental, and Vietnam veteran exposure to herbicides and herbicide components, this committee agrees with the conclusion of the last committee that there is limited/suggestive evidence of an association between exposure to certain herbicides used in Vietnam and the development of an acute or subacute transient peripheral neuropathy. Acute peripheral neuropathies have been reported following acute occupational exposure to 2, 4- dichlorophenoxyacetic acid (2,4-D) weed killer by several authors (Goldstein et al., 1959; Todd, 1962; Berkely and Magee, 1963). Affected patients had not been examined prior to exposure, but the temporal relationship between clinical disturbance and herbicide exposure was well documented. It remains possible, however, that the neuropathy was unrelated to the herbicide exposure and related to other disorders, such as Guillain- Barré syndrome. Update 1998 at 473. The summary of the section stated that: The committee is aware of no new publications that bear on this issue. If TCDD [2,3,7,8- tetrachlorodibenzo-p-dioxin] were associated with the development of transient acute and subacute peripheral neuropathy, the disorder would become evident shortly after exposure. The committee knows of no evidence that new cases developing long after service in Vietnam are associated with herbicide exposure. Update 1998 at 473. Dr. Bash went on to review the June 1999 VA medical opinion. He noted that the VA physician said that there was insufficient evidence to show that the veteran had peripheral neuropathy and that there was no medical literature that established a causal connection between exposure to Agent Orange and chronic fatigue. Dr. Bash said that he agreed with the VA physician that further diagnostic testing and documentation was necessary to clarify the veteran's peripheral neuropathy. He said that he disagreed with the VA opinion regarding the link between fatigue and Agent Orange. Dr. Bash said that there were several references in the both the 1996 and 1998 Updates. Dr. Bash concluded by saying that the VA physician did not provide any literature to support his opinion and that he did not provide an alternative diagnosis to explain the veteran's findings. In her argument, the veteran's attorney focused on Dr. Bash's opinion as evidence for why the veteran's claim for service connection should be granted for the issues on appeal. She also cited to Dr. Deshmukh's opinion that the veteran could have his symptoms because of his exposure to chemicals in service. She also noted that Dr. Deshmukh said that the findings could also be related to the veteran's PTSD. The Board wrote to the veteran in January 2002 to offer him an opportunity for another Board hearing. The veteran was advised that the Veterans Law Judge who previously conducted the November 1998 hearing was no longer at the Board. The veteran faxed a statement in response to the Board's letter in February 2002. He elected to not have another Board hearing. He asked that his statement be used in lieu of a hearing. In his statement the veteran restated his assertions for why service connection for his claimed disabilities was in order. In keeping with Board policy at the time, the Board issued a development memorandum to obtain additional evidence in the case in March 2002. The memorandum included contacting the veteran to have him provide either the treatment records from his sources of treatment or authorize VA to obtain the records; contacting the SSA to obtain the records pertinent to the veteran's SSA disability claim; obtaining the records, or authorization to obtain the records, from Trans-General Group; personnel and medical records pertaining to the veteran's employer in regard to the veteran's allegation that his health forced him to give up his job; and, information from the veteran pertaining to his daughters having birth defects related to his Agent Orange exposure. The records from the SSA were received in July 2002. The records show that the veteran was initially determined not to be totally disabled as the result of affective (mood) disorder in July 1995. A reconsideration of his case lead to a determination of total disability for chronic fatigue syndrome and dysthymia in July 1996. A review of the associated records shows that the veteran claimed that his chronic fatigue syndrome was due to his exposure to Agent Orange when he served in Vietnam. The veteran listed the physicians who treated him as a VA physician, Dr. Cummings, and a Dr. Marshall. All treatment began in 1994. There was no reference to any illness or treatment prior to 1994. Treatment records from Dr. Cummings were included in the SSA file. The records included the treatment records previously discussed, the report from Dr. Shadowen, a report from an ophthalmology consultation, as well as the results of several laboratory tests. A psychological evaluation, dated in May 1995, was included. The evaluation noted the veteran's medical condition only in passing and provided no pertinent information. Also included were records from J. B. Oropilla, M.D., PSC, dated in January and February 1997, respectively. Dr. Oropilla's letterhead identified him as a Diplomate of the American Board of Psychiatry and Neurology. In a January 1997 report, Dr. Oropilla said that the veteran was referred by Dr. Aaron. He noted a history from the veteran of his having had medical problems since his military service. Dr. Oropilla said that the veteran "saw a Dr. Chaudion [sic] in Bowling Green who noted that his vibration is decreased in his feet and made a diagnosis of peripheral neuropathy." He noted that the veteran did not bring any outside records with him. The veteran described having a lack of feeling in his hands. There was no numbness but there was a needles and pins sensation in his lower extremities. Dr. Oropilla said that the distribution of the numbness in the upper extremities extended from the shoulder to the hand. Dr. Oropilla noted a decrease in reflexes in the upper and lower extremities. He also noted a decrease in the sensory examination on the feet compared to the thighs. He said he wanted to review the previous work-up to avoid repetition and wanted to see the earlier EMG. He did not provide any impression, assessment or diagnosis. In a February 1997 evaluation report, Dr. Oropilla noted that the veteran again did not bring his medical records for review. The veteran complained of fatigue and headaches at this visit. Dr. Oropilla said that the veteran's past medical history was unremarkable except for a question of liver dysfunction, which the veteran said he was told that he had an overactive liver. He said that the veteran had an EBV syndrome for the past three years. He noted that the veteran was being followed by Dr. Deshmukh. In regard to the veteran's reflexes, Dr. Oropilla said that the reflexes were normoactive in the biceps, triceps, patellae with reinforcement as compared to the last examination. The reflexes of the ankles were said to be slightly decreased. Dr. Oropilla's impression was that the veteran had chronic fatigue syndrome of unknown etiology. He did not provide a diagnosis of peripheral neuropathy. The Board notes that the SSA records relied on by the Board consisted of the veteran's own private treatment records that were provided to the SSA on his behalf. The Board did not develop records not originated on behalf of the veteran. In fact, the veteran, and Dr. Aaron had referred to the records in several of their earlier submissions. The Board wrote to the veteran, and his attorney, and notified him that the Board would be doing additional development in his case in January 2003. The letter essentially followed the outline of the March 2002 development memorandum in asking the veteran to provide his private medical records from the several sources or authorize the Board to obtain them. He was further requested to provide records from his insurance company, and his employer regarding his having to terminate his employment due to illness. The veteran was also asked to submit additional evidence that his daughters suffered from a birth defect related to his exposure to Agent Orange. The veteran responded through his attorney in February 2003. The veteran declined to provide any additional medical record evidence or to authorize VA to obtain additional evidence. He also declined to provide the records from his insurance company or to authorize VA to request the records. He did not address the request for employment records. The veteran said that Dr. Aaron was the only physician he had seen since the prior Board decision. He felt that there was sufficient medical evidence of record to support his claim. In regard to his daughters, the veteran said that he never claimed that they were disabled. He said that he mentioned their health problems to add to the reasonable list of evidence supporting his exposure to Agent Orange and to get their condition on record so that VA could not say that there was no evidence of their illness in the future. The veteran included statements from friends and his brother who attested to his character or change in health after service. He also included a statement from his ex-wife who had been married to the veteran from 1979 to 1992. She said that the veteran had to quit his job in 1978 because of his health and should have gone on disability then but he did not want to. She said that the veteran saw a Dr. Jackson who suggested a link between his illness and stress from Vietnam. She said that the veteran stopped seeing the doctor and quit his job at [redacted]. The last item was an article about EBV infection, Jeffrey I. Cohen, M.D., Epstein-Barr Virus Infection, New England Journal of Medicine, Volume 343, Number 7, pp. 481-491. Of note, the article said that EBV was one of the most successful viruses and that it infected over 90 percent of humans and persisted for the lifetime of the person. The article went on to discuss the features of EBV, its latency period, the immune responses to EBV and evasion of the immune system by the virus, and clinical syndromes. The veteran wrote to the Board in December 2003. He noted the lack of records from his first years after service and pointed to the earlier statement that treatment records from Dr. Foster had been destroyed. He again asserted that his illness had its onset in Vietnam, whatever the exact cause. The veteran was granted a 100 percent rating for his service- connected PTSD by way of a rating decision dated in April 2004. The Board solicited an Independent Medical Expert (IME) opinion in May 2004. See 38 U.S.C.A. § 7109 (West 2002); 38 C.F.R. § 20.901(e) (2004). Included as enclosures to the request were copies of pertinent pages from Update 1996 and Update 1998, as well as the published notice in the Federal Register of Diseases Not Associated with Exposure to Certain Herbicide Agents. 67 Fed. Reg. 42,600-42,608 (June 24, 2002). The veteran, and his attorney, were advised of this action and informed they would be provided a copy of the report when it was received. The Board received an IME opinion from A. M. Ducatman, M.D., M.S., a Department Chair and Professor of Community Medicine at West Virginia University, in May 2004. The IME opinion was in response to the May 2004 request. Dr. Ducatman addressed three of the four questions put forward in the Board's request. He noted that the medical records did not reveal histopathologic or electrodiagnostic evidence of peripheral neuropathy. He also said that physical examination outcomes were not convincing. Dr. Ducatman said that there were no primary records to support the veteran's allegations of extremity numbness. He said that the report from Dr. Shadowen was indeterminate. He said it dated the onset of peripheral neuropathy type symptoms to 1993, many years after dioxin exposure in service. Dr. Ducatman stated that, in the absence of electrophysiologic confirmation, and in the absence of new or historic EMG confirmation, the existing record did not support a diagnosis of peripheral neuropathy related to the veteran's past exposure to dioxin. Dr. Ducatman also addressed an April 1997 comment from Dr. Aaron who had cited to a finding from Dr. Gropilla [sic] in 1997. Dr. Ducatman noted that the records from Dr. Gropilla [sic] were not at all supportive and no electrodiagnostic data were provided. In regard to EBV, Dr. Ducatman noted that Dr. Aaron had linked the veteran's diagnosis of chronic EBV to exposure to dioxin, as well as peripheral neuropathy, and chronic immune system compromise. Dr. Ducatman said that medical data were not provided to support "chronic" EBV infection, nor any associated abnormal performance of the immune system. He noted that studies had been done for detectable immunologic abnormalities in Vietnam veterans. He said that outcomes were not found. Dr. Ducatman also noted that Dr. Shadowen noted that the veteran's previous EBV infection was likely to have been well in the past but could not be pinpointed with certainty. Dr. Ducatman also stated that there was no evidence of surgical, biopsy, or histopathologic evidence of lymphoma in the medical records. Dr. Ducatman noted that the veteran first began to complain of chronic fatigue in 1993 or 1994. He said the veteran recalled having such symptoms back to his days in service. Dr. Ducatman said that medical records for the period from the 1970's to 1994, including SMRs and civilian records, did not clearly report fatigue as a significant complaint to the degree that it came to the attention of the veteran's physicians. Dr. Ducatman also addressed the opinion from Dr. Bash, noting that Dr. Bash attributed the veteran's chronic fatigue to dioxin exposure. He said that the opinion noted supportive literature and the absence of other causes. Dr. Ducatman said that it was well known that chronic fatigue was equally found in ground troops in other wars without dioxin exposure and that Dr. Bash's conclusion was not supported by epidemiological data. Dr. Ducatman said a more encompassing diagnosis was provided by Dr. Thompson in July 2000. He said that she attributed the broad range of the veteran's findings to PTSD. He also said that it was not appropriate to emphasize a nonspecific diagnosis such as chronic fatigue when a patient has a specific diagnosis, such as PTSD, which can include the same outcomes. In conclusion, Dr. Ducatman said that Agent Orange was not a cause of EBV infection and it was not known to make any of the several potential outcomes of EBV infection worse. He repeated his statement that there was no evidence of lymphoma anywhere in the medical records. He noted the veteran's historic evidence of chronic fatigue. He said this diagnosis is based on history and does not have corroborative physical findings and did not meet the usual "falsifiable" tests of physical diagnosis. He said that the complaint of fatigue could be reliably dated to the early 1990's. He also noted that the veteran carried a diagnosis of PTSD and that this was an important neuropsychiatric syndrome. He said that the presence of PTSD overlapped with, and was more precise than chronic fatigue syndrome. He further opined that the veteran's obesity might also be a cause of chronic fatigue. He also stated that it was not clear that the veteran had peripheral neuropathy. Dr. Ducatman said that the best available neurologic examination suggested only inconsistencies of physical presentation. Supportive electrodiagnostic data was not present. Dr. Ducatman said that a diagnosis of peripheral neuropathy could not be advocated based on the records. He also related that, in studies of Vietnam veterans, only Ranch Hand units had documented findings of peripheral neuropathy and these were equivocal. The veteran, through his attorney, was provided a copy of Dr. Ducatman's opinion in June 2004 and was provided an opportunity to submit additional argument and/or evidence in his case. The veteran was advised that he had 60 days to submit the evidence and/or argument. The veteran's attorney requested a 60-day extension to submit additional evidence in August 2004. A second letter from the Board was sent in August 2004 that provided a 60-day period for submitting of additional argument and/or evidence. The veteran's attorney submitted a request for a 30-day extension of time in October 2004. The Board responded on November 8, 2004, and informed the veteran's attorney that a deadline of November 12, 2004, was in effect for the submission of any additional evidence and/or argument. The veteran's attorney faxed a copy of a medical opinion from James. L. Sublett, M.D., on November 12, 2004. Dr. Sublett identified himself as a board certified specialist in Allergy and Immunology and Clinical Professor and Section Chief of Allergy and Immunology at the University of Louisville School of Medicine. His opinion was dated in October 2004. Dr. Sublett said that he had reviewed the veteran's service and post-service records, as well as the opinion from Dr. Ducatman. Dr. Sublett began his report by stating facts that he believed were not contested. Those facts were: 1) the veteran served in the Army in Vietnam from 1968 to 1969; 2) the veteran had ground level exposure to Agent Orange during his service in Vietnam; 3) the veteran began to experience symptoms of headache and fatigue in Vietnam that he attributed to heat and stress; 4) after his return from Vietnam, the veteran continued to have chronic constitutional and physical symptoms which eventually resulted in his being diagnosed with PTSD. Dr. Sublett said that the veteran had been diagnosed by various primary care physicians as having chronic fatigue syndrome (CFS) and/or chronic active Epstein Barr Virus (CAEBV) infection. He said that the two diagnoses clinically were indistinguishable. He also cited to laboratory evidence in the claims file as confirming the diagnosis of CAEBV. He said that EBV was not recognized as the cause of acute infectious mononucleosis until 1968 and that the first cases of CAEBV were not reported until 1988. Therefore, it would not have been possible for a diagnosis of CAEBV during the first 20 years of the veteran's illness. Dr. Sublett said that CAEBV was rare and did not occur in all individuals that contracted EBV. He said that the immune defect in individuals that contract CAEBV was related to decreased activity of Interferon. Dr. Sublett also noted that Dr. Ducatman had said that Agent Orange had not been reported to have effects on immunological responses. Dr. Sublett said that other sources, including the EPA, related that dioxin had profound effect on immune function, particularly immune surveillance related to abnormal T-Cell function. Dr. Sublett said that he agreed with Dr. Aaron that the veteran was at a greater risk when he was exposed to EBV because of his immune suppression caused by dioxin. Dr. Sublett then noted that suppression of immune function had been reported in PTSD subjects, both military and civilian, that had not had exposure to Agent Orange. He referred to Dr. Thompson's July 2000 letter that confirmed the diagnosis of PTSD and referenced several recent articles in the medical literature that related to immune dysfunction in PTSD. He also referred to a source cited by Dr. Ducatman as relating psychological abnormalities in veterans exposed to Agent Orange. Dr. Sublett went on to cite to another medical article that addressed the connection between the immune system and persons with a past history of PTSD. Dr. Sublett concluded the following: 1) the veteran has been determined to have PTSD related to his combat service in Vietnam; 2) the veteran has CAEBV based on both laboratory data and his long history of medically documented complaints which were typical symptoms of the disease; 3) the cause of the veteran's CAEBV is primarily due to his PTSD; and, 4) the role of exposure to battlefield Agent Orange may also play an additive role in the veteran's immune dysfunction. Therefore he agreed with the December 2000 opinion of Dr. Deshmukh who related the veteran's condition to his Agent Orange exposure and/or PTSD. II. Analysis The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110, (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2004). In addition, certain chronic diseases, including organic diseases of the nervous system and malignant tumors, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2004). The chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the Court, lay observation is competent. Service connection may be established on the basis of 38 C.F.R. §3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to continued symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. Pond v. West, 12 Vet. App. 341, 346 (1999); accord Caluza v. Brown, 7 Vet. App. 498 (1995). Evidence of record shows that the veteran was awarded a Combat Infantryman Badge (CIB) for his service in Vietnam during his period of service from July 1967 to May 1969. The CIB is indicative of participation in combat. In that case, if an injury or disease is alleged to have been incurred or aggravated in combat, such incurrence or aggravation may be shown by satisfactory lay evidence, consistent with the circumstances, conditions, or hardships of combat, even if there is no official record of the incident. 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2004). "Satisfactory evidence" is credible evidence. Collette v. Brown, 82 F.3d 389, 392 (1996). Such evidence may be rebutted only by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Section 1154(b) allows combat veterans, in certain circumstances, to use lay evidence to establish the incurrence of a disease or injury in service. "However, the provisions of section 1154(b) do not provide a substitute for medical-nexus evidence. . ." Clyburn v. West, 12 Vet. App. 296, 303 (1999). Section 1154(b) serves only to relax the evidentiary burden to establish incurrence of a disease or injury in service. Id. A. Presumptive Basis - Herbicide Exposure Certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even though there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) (2004) are met. See 38 C.F.R. § 3.309(e) (2004). The term "herbicide agent" means a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. The diseases for which service connection may be presumed to be due to an association with herbicide agents include chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma; non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). See 38 C.F.R. § 3.309(e). In general, for service connection to be granted for one of these diseases, it must be manifested to a degree of 10 percent or more at any time after service. Chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy must be manifest to a degree of 10 percent within one year after the last date on which the veteran performed active military, naval, or air service in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. See C.F.R. § 3.307(a)(6)(ii) (2004); 68 Fed. Reg. 34,541 (June 10, 2003) amending 38 C.F.R. § 3.307(a)(6)(iii) implementing the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). A veteran who served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, will be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to the contrary. Id. Service in the Republic of Vietnam includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii) (2004). It is important to note that the diseases listed at 38 C.F.R. § 3.309(e) are based on findings provided from scientific data furnished by the National Academy of Sciences (NAS). Section 3 of the Agent Orange Act of 1991, Pub. L. 102-4, established the initial requirement that the Secretary enter into an agreement with the NAS to review available scientific evidence to determine if a particular disease is associated with exposure to herbicides. The NAS conducts studies to "summarize the scientific evidence concerning the association between exposure to herbicides used in support of military operations in Vietnam during the Vietnam era and each disease suspected to be associated with such exposure." 64 Fed. Reg. 59,232-59,243 (Nov. 2, 1999). Reports from NAS are submitted at two-year intervals to reflect the most recent findings. Based on input from the NAS reports, the Congress amends the statutory provisions of the Agent Orange Act found at 38 U.S.C.A. § 1116 and the Secretary promulgates the necessary regulatory changes to reflect the latest additions of diseases shown to be associated with exposure to herbicides. The findings of the biennial studies are published by the National Academy Press as noted above. The prior references to Update 1996 and Update 1998 reflect updates published subsequent to the original publication of study findings in 1994. The original edition was entitled Veterans and Agent Orange (VAO). Hardbound editions of updates for 2000 and 2002 have since been published during the pendency of the veteran's appeal. In this case, the latest notice regarding diseases not associated with exposure to certain herbicides was published in 2003. See 68 Fed. Reg. 27,630-27,641 (May 20, 2003). The update stated that the NAS noted in VAO and subsequent reports that there was inadequate or insufficient information to determine whether an association existed between exposure to herbicides and immune system disorders. The Secretary found that the credible evidence against an association between immune system disorders and herbicide exposure outweighed the credible evidence for such an association. The Secretary further determined that a positive association did not exist. See 68 Fed. Reg. 27,637. 1. Lymphoma There is no evidence of the veteran ever having been diagnosed with lymphoma at any time. The veteran was noted to have some enlarged lymph nodes in the past. A biopsy was recommended but there is no evidence one was ever done and the veteran does not claim that there is pathological evidence of lymphoma. In order for service connection to be granted for a claimed disability, there must be evidence of the current existence of such claimed disability. See Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). As there is no evidence to show that the veteran has ever been diagnosed with lymphoma of any type, his claim must be denied. 2. Chronic Fatigue Syndrome/Epstein Barr Virus Infection As noted above, the NAS, and the Secretary, have not found evidence of an association between exposure to herbicides, to include Agent Orange, and immune system disorders. The list of diseases found at 38 U.S.C.A. § 1116 and 38 C.F.R. § 3.309(e) do not include CFS and CAEBV infection. Accordingly, there is no basis to conclude that the veteran's CFS/CAEBV infection is presumptively related to his exposure to Agent Orange. Entitlement to service connection, on a presumptive basis, and based on exposure to Agent Orange, must be denied. 3. Peripheral Neuropathy In this case the veteran's SMRs are negative for any diagnosis of peripheral neuropathy at any time. The veteran has maintained that he complained of numbness in his arms while in the field in Vietnam and that he was told by a medic that it was probably related to carrying a heavy rucksack and that it would go away. The veteran did not list any complaints of numbness in his arms or legs at the time of his separation examination. In past examinations, he listed several conditions that had occurred in the past, to include at the time of his 1969 separation examination. However, he did not list peripheral neuropathy or numbness of any type at the time of his last RMH. The records from Dr. Stricker do not reflect any complaints of numbness in the extremities at any time. These records relate to treatment provided to the veteran from June 1969 to July 1988 and cover the immediate period of the veteran's return home from Vietnam. The requirements for service connection for acute or subacute peripheral neuropathy require that the illness be manifest to a compensable degree within one year after last performing active military service in the Republic of Vietnam. There is no objective evidence of record to show that the veteran did manifest peripheral neuropathy to a compensable degree within the required timeframe. In the absence of such evidence, the veteran's claim must be denied. B. Direct Basis 1. Lymphoma The same rationale applies in this circumstance as for presumptive service connection. There is no evidence of a current diagnosis of lymphoma. As such there is no basis to establish service connection for lymphoma. See Rabideau, supra. The veteran's claim on this basis is denied. 2. Chronic Fatigue Syndrome/Epstein Barr Virus There is no objective evidence to show that the veteran developed CFS/EBV in service. His SMRs are negative for any complaints. His discharge examination is also negative for any complaints. The veteran has said that he did experience fatigue in service and he is capable of providing information regarding his symptoms. However, "the capability of a witness to offer such evidence is different from the capability of a witness to offer evidence that requires medical knowledge..." Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The veteran cannot say that he had CFS or EBV infection in service. The early records from Dr. Stricker note that the veteran was evaluated for possible mononucleosis on several occasions, beginning in 1969. The several tests were reported as negative. The veteran submitted a number of statements from family and friends who attested to his health problems after service. He has also submitted a number of statements on his own behalf, as well as testified at a Board hearing. However, those statements have to be evaluated in conjunction with the concurrent medical evidence. The medical records, prior to 1994, do not show that the veteran suffered from CFS or EBV infection, or that he complained of fatigue. The Board notes that the veteran has alleged that his health was such that he had to quit a good paying job in 1978. He was asked to provide information regarding his having to quit the job but did not. The records from Dr. Stricker did not show any evidence of a health condition that required the veteran to terminate his employment. Further, the veteran enrolled in college in 1978, was awarded VA education benefits, and was noted to attend courses up to November 1979. He was later given a physical examination by Dr. Stricker in 1981 for the purposes of taking a skin diving class. The first objective evidence of complaints of fatigue and the presence of EBV is contained in the records from Dr. Cummings, beginning in 1994. The records of Dr. Cummings from 1991 to 1993 did not show any complaints related to fatigue. Dr. Aaron has provided several statements wherein he states that the veteran was healthy prior to service and demonstrated symptoms soon after service. Therefore, he contends that the veteran's illness was related to his military service. Such reasoning is not supported by the evidence cited above, to include the lack of evidence in the records from Dr. Stricker and Dr. Cummings prior to 1994. The veteran has submitted evidence from Dr. Aaron and Dr. Cummings, both of whom provide generalized statements of their belief of a connection between the veteran's exposure to Agent Orange and his CFS/EBV illness. In regard to Dr. Aaron, the Board notes that no treatment records from him are associated with the claims file, despite requests to the veteran to provide such records. Dr. Aaron has provided several written statements that summarize the veteran's medical condition and he has opined as to his belief of the origin of the veteran's medical conditions. Dr. Aaron cited to a statement from EPA that addressed the sensitivity of the immune system to dioxin. He opined that the veteran's exposure to Agent Orange weakened his immune system such that it could be attacked by EBV. Dr. Aaron provided a copy of an article from the ABDC in October 1998 that contained the same statement from EPA. However, the article related to children of veterans exposed to Agent Orange. The article did not address the effect of exposure to Agent Orange on Vietnam veterans, as did the multiple studies conducted by NAS. Despite Dr. Aaron's several emphatic statements of his belief that Agent Orange damaged the veteran's immune system and this lead to the development of CAEBV infection, he has not provided any support for his conclusions. Dr. Cummings made broad statements that the veteran's CFS was due to exposure to Agent Orange. He cited to no support for his conclusion. He also did not make this connection in any of his treatment records that covered a number of years of care for the veteran. Dr. Shadowen, an infectious disease specialist, did not associate the veteran's fatigue-like illness with exposure to Agent Orange. Dr. Deshmukh was equivocal in his assessment as to the etiology of the veteran's chronic fatigue-like syndrome and said that if the cause was not directly related to chemical exposure in service, it was certainly indirectly related to the veteran's PTSD. The June 1999 VHA opinion from Dr. S. was that there was no medical literature, that he was aware of, that established a causal relationship between Agent Orange exposure and the development of EBV or CFS. It was his opinion that it was not likely that the veteran developed CFS due to exposure to Agent Orange. He also said that the veteran's exposure to Agent Orange during service was not the cause of, nor did it lead to, the development of EBV syndrome. Dr. Bash cited to VAO updates to show that there was a positive association between exposure to herbicides and fatigue. However, as was shown in the Background section, the characterization of the findings was not accurate. Further, it has been clearly shown in subsequent VAO updates, that there is no association between exposure to herbicides, to include Agent Orange, and chronic fatigue or diseases of the immune system. Dr. Bash said that the veteran had a fatigue-like illness which had not been linked to any illness process. He said that, without another firm diagnosis, and giving the veteran the benefit of the doubt, the most likely cause was Agent Orange. He challenged the VHA opinion of Dr. S. for not providing an alternative diagnosis and for not citing to any literature in support of his opinion. The Board finds that Dr. Bash's opinion is of little probative value because of his mischaracterization of the Update 1996 findings. In fact Update 1996 and Update 1998 were the only sources of literature cited by Dr. Bash and neither source supports his conclusion. Moreover, as will be discussed later in this decision, there is another basis for the etiology of the veteran's CFS/EBV infection. Dr. Ducatman concluded that the veteran had encountered the EBV; however, he said that this was unrelated to previous exposure to Agent Orange. He said that Agent Orange was not a cause of EBV infection and was not known to make any of the several potential outcomes of EBV infection worse. Dr. Ducatman also said that there was no valid data to support dioxin exposure as a cause of chronic fatigue. He did say that the veteran's CFS should be "understood" in the context of his diagnosis of PTSD. Dr. Sublett stated that diagnoses of CFS and CAEBV infection were clinically indistinguishable. He said that the veteran had CAEBV that was primarily due to his (veteran's) PTSD. He also said that the role of the veteran's probable Agent Orange exposure may also play an additive role in his immune dysfunction. He said that he agreed with Dr. Desmukh's December 2000 opinion relating the veteran's condition to Agent Orange exposure and/or PTSD. In weighing the evidence of record, to include the several medical opinions, the known scientific literature on the subject, as evidenced by the original VAO study in 1994 with updates in 1996, 1998, 2000, and 2002, and that cited by Dr. Ducatman and Dr. Sublett, the Board concludes that evidence does not support a grant of service connection on the basis of exposure to Agent Orange. As noted above the opinions of Drs. Aaron, Cummings, and Deshmukh are not supported by medical literature. The reference to the EPA statement and the article from ABDC do not suffice to establish a connection that has not been established by the NAS after many years of study. Dr. Bash did not provide any support for his opinion other than the mischaracterization of the Update 1996 material and by challenging the lack of an alternative diagnosis by VA. Dr. Ducatman cited to, and provided a list of authorities, in support of his opinion. Dr. Sublett attributed the veteran's CFS and EBV primarily to the veteran's PTSD. On the other hand, the evidence of record does show that the veteran's CFS and CAEBV is at least as likely as not related to his service-connected PTSD. Dr. Thompson has provided several statements to that effect. She has also cited to medical literature in support of her opinion. Dr. Deshmukh, although equivocal, also said that the veteran's PTSD was indirectly involved. Dr. Ducatman's opinion was consistent with Dr. Thompson's assessment that the veteran's PTSD was related to his CFS. Dr. Sublett stated that the veteran's CAEBV (a diagnosis he said was clinically indistinguishable from CFS) was primarily due to his PTSD. Dr. Sublett provided a strong rationale for his opinion. In reviewing the evidence of record the Board finds that there is no basis to support service connection on a direct basis. However, the evidence does support a grant of service connection on a secondary basis. Accordingly, service connection for CFS/CAEBV infection is warranted as secondary to service-connected PTSD. 3. Peripheral Neuropathy The veteran's SMRs are negative for any evidence of a diagnosis of peripheral neuropathy in service. The first objective evidence of complaints of numbness was in the 1994 records from Dr. Cummings. The veteran was evaluated by VA physicians, to include an EMG, in 1994 and 1995. Peripheral neuropathy was not found. In fact, a VA neurologist opined that the veteran's problems did not appear to be neurological in light of normal examination, and the veteran was discharged from the neurology clinic as noted in a clinic entry dated in January 1995. The 1994 report from Dr. Shadowen did not provide a diagnosis of peripheral neuropathy. She did note symptoms of decreased vibratory sensations, and she did use the term peripheral neuropathy in describing the veteran's reported symptoms, but she did not list peripheral neuropathy in her assessment of the veteran's condition. She also wanted the veteran to have an EMG or to get the results of any EMG that was done. However, there is no indication that she was ever apprised of the result of the VA EMG. The SSA records contain a letter from her to the veteran from August 1994 wherein she noted that she had not heard back from the veteran. Dr. Oropilla also did not provide a diagnosis of peripheral neuropathy. In his January 1997 evaluation he did note Dr. Shadowen's initial evaluation and her finding of decreased vibratory sensation. He said that she made a diagnosis of peripheral neuropathy. In his February 1997 evaluation, Dr. Oropilla did not diagnose the veteran with peripheral neuropathy. The veteran was noted to complain of bilateral paresthesia in the upper extremities at the time of his October 1997 VA neurology examination. However, there was no diagnosis of peripheral neuropathy made at the time. In his VHA opinion, Dr. S. noted that there was insufficient evidence or documentation by history, neurologic examination, or by electrodiagnostic testing, that the veteran currently had or in the past had suffered from peripheral neuropathy. Dr. Bash made no association with the veteran's claimed peripheral neuropathy and his military service outside of exposure to Agent Orange. As noted above, chronic peripheral neuropathy has not been found to be associated with exposure to Agent Orange. The evidence of record does not support a finding that the veteran had either acute or subacute peripheral neuropathy in service or within one year after his last service in Vietnam. Dr. Ducatman said that it was not clear that the veteran had peripheral neuropathy. He said that the best available neurologic examination suggested only inconsistencies of physical presentation. He noted that there was no supportive electrodiagnostic data to confirm a diagnosis of peripheral neuropathy. Dr. Sublett did not address the issue in his opinion. The evidence of record does not support a conclusion that the veteran has a confirmed diagnosis of peripheral neuropathy. The VA physicians gave the veteran a thorough examination, to include an EMG. The conclusion was that his problems were not neurological in nature. Peripheral neuropathy was not found at the time of the October 1997 VA examination. Dr. Shadowen did not provide a diagnosis of peripheral neuropathy. She noted the veteran's decreased vibratory sensations. Dr. Oropilla, a neurologist, also did not diagnose the veteran with peripheral neuropathy based on his two evaluations of the veteran. Dr. Aaron has made multiple statements where he said the veteran had peripheral neuropathy that Dr. Aaron attributed to either the veteran's military service or Agent Orange exposure. However, Dr. Aaron did not provide any basis for his diagnosis, to include his own medical records that would document testing or evaluation to establish the diagnosis. Moreover, he did not address the VA records that found no evidence of peripheral neuropathy, or the lack of a diagnosis from Dr. Shadowen and Dr. Oropilla. Nor did he address the opinions from Dr. S. and Dr. Ducatman who both said that there was insufficient evidence in the record to say that the veteran ever had peripheral neuropathy and did not have a current diagnosis. In light of the considerable evidence of record that does not support a diagnosis of peripheral neuropathy, the Board concludes that there is no evidence of a current disability involving peripheral neuropathy, whether it be claimed as due to service or exposure to Agent Orange and manifest many years later. As the record does not support a finding of a current disability involving peripheral neuropathy, the veteran's claim is denied. See Rabideau, supra. In evaluating this appeal, the Board has considered for application 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d), which provides for proof of a claim by satisfactory lay, or other evidence, for combat veterans, under certain conditions. See Collette, supra. In this case, even conceding that the veteran experienced fatigue, and numbness in his extremities during service, the evidence does support a conclusion that his CFS/CAEBV infection is related to service or that he has a current diagnosis of peripheral neuropathy. This includes consideration of the statements from the veteran, and his testimony. As noted above, the first objective evidence of fatigue and complaints of numbness are recorded approximately 25 years after service. As noted above, the Court has held that 38 U.S.C.A. 1154(b) does not alter the fundamental requirement of a medical nexus to service. See Clyburn, supra; Libertine v. Brown, 9 Vet. App. 521, 524 (1996). As discussed above, the evidence does not support a finding that the veteran's CFS/CAEBV is related to service or that there is a current diagnosis of peripheral neuropathy. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting service connection for lymphoma, CFS/EBV infection, and peripheral neuropathy on either a direct or presumptive basis, to include exposure to Agent Orange. Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2001). The Board notes that 38 C.F.R. § 3.102 was amended in August 2001, effective as of November 9, 2000. See 66 Fed. Reg. 45,620-32 (Aug. 29, 2001). However, the change to 38 C.F.R. § 3.102 eliminated the reference to submitting evidence to establish a well-grounded claim and did not amend the provision as it pertains to the weighing of evidence and applying reasonable doubt. Accordingly, the amendment is not for application in this case. In so finding, the Board has considered the applicability of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106- 475, 114 Stat. 2096, (codified as amended at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)), and the implementing regulations codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2004). Under the VCAA, VA has a duty to notify the veteran and his representative of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103 (West 2002); 38 C.F.R. § 3.159(b) (2004). There is no outstanding information or evidence needed to substantiate a claim in this case. The veteran has provided the necessary information to complete his application for benefits. Under 38 U.S.C.A. § 5103, the Secretary is required to provide certain notices when in receipt of a complete or substantially complete application. The purpose of the first notice is to advise the claimant of any information, or any medical or lay evidence not previously provided to the Secretary that is necessary to substantiate the claim. The Secretary is to advise the claimant of the information and evidence that is to be provided by the claimant and that which is to be provided by the Secretary. 38 U.S.C.A. § 5103(a) (West 2002). In those cases where notice is provided to the claimant, a second notice is to be provided to advise that, if such information or evidence is not received within one year from the date of such notification, no benefit may be paid or furnished by reason of the claimant's application. 38 U.S.C.A. § 5103(b) (West 2002). In addition, 38 C.F.R. § 3.159(b), details the procedures by which VA will carry out its duty to assist by way of providing notice. The veteran's claims were submitted prior to the enactment of the VCAA. The RO wrote to the veteran in June 1996. He was advised on the overall claims adjudication process and how his claim would be developed. The veteran was also asked to provide information regarding his employment as he claimed that he was unemployable. The veteran responded with the necessary authorizations to obtain the records from Dr. Stricker and Dr. Cummings. The RO originally denied the veteran's claims via rating decisions dated in 1996, 1997, and 1998 respectively. Each decision provided an explanation for why the respective claim was denied. The veteran was informed of the basis for the decisions and why the evidence of record was not sufficient to substantiate his claim for service connection. A SOC was issued in the respective appeals of the several issues on appeal. In addition, multiple SSOCs were issued to address the considerable additional evidence added to the record throughout the development of the veteran's claim at the RO level. In addition, the Board remanded the veteran's case in August 1999 for consideration of additional evidence developed in the record and for evidence submitted by the veteran. A SSOC was issued in September 1999. The veteran continued to submit additional evidence that was addressed by subsequent SSOCs until the case was returned to the Board. The Board originally denied the veteran's claims in March 2000. The decision provided an explanation for the denial and why the evidence was not sufficient to establish service connection. The veteran appealed the Board's March 2000 decision. His joint motion for remand was granted by the Court in January 2001 and his case returned to the Board for further review and development. The veteran was informed that the Board was to do additional development in January 2003. The Board requested that the veteran identify certain evidence that would further substantiate his claims. In particular, the veteran was asked to either provide evidence from several private physicians or authorize the Board to obtain the records. He was also requested to provide information from his insurance company and employer. The veteran responded to the Board's letter in February 2003. He declined to provide any additional evidence as requested. He also declined to authorize the Board to obtain any additional evidence on his behalf. He stated that there was already considerable evidence of record to decide his case. He said that there was "nothing new to add and there is no reason to waste more months to gather more information or subjecting me to more experimentation." In reviewing the requirements regarding notice found at 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159(b), the Board cannot find any absence of notice in this case. As reviewed above, the veteran has been provided information regarding the type of evidence needed to substantiate his claim. In summary, the Board finds that no additional notice is required under the provisions of 38 U.S.C.A. § 5103 as enacted by the VCAA and 38 C.F.R. § 3.159(b). See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). (Although the notices provided by the RO were generally not provided until after the RO adjudicated the appellant's claims, this sequence of events does not amount to error on the part of the RO. Pelegrini v. Principi, 18 Vet. App. 112, 122 (2004). Consequently, the Board does not find that the late notice under the VCAA requires remand to the RO. Nothing about the evidence or the appellant's response to the RO's notifications suggests that the case must be re-adjudicated ab initio to satisfy the requirements of the VCAA.) The duty to assist claimants under the VCAA is codified under 38 U.S.C.A. § 5103A (West 2002) and established by regulation at 38 C.F.R. § 3.159(c)-(e). This section of the VCAA and regulation sets forth several duties for the Secretary in those cases where there is outstanding evidence to be obtained and reviewed in association with a claim for benefits. However, in this case there is no outstanding evidence to be obtained, either by the VA or the veteran. Extensive VA and private medical records have been obtained and associated with the claims file. The veteran has submitted multiple statements on his own behalf. He has also submitted multiple statements from family and friends. He has submitted medical treatise information, statements from his physicians, and two opinions from medical experts. The Board has developed the case for the veteran's SSA records and has also obtained medical opinions from two different experts. The veteran also testified at a Board hearing in 1998. He was offered an opportunity for a second hearing but declined. In addition, the veteran, through his attorney, has been afforded multiple extensions of time to submit additional argument/evidence in support of his case. The Board finds that every effort has been made to seek out evidence helpful to the veteran. The veteran has not alleged that there is any outstanding evidence that would support his contentions. The Board is not aware of any outstanding evidence. Therefore, the Board finds that the VA has complied with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e) (2004). ORDER Service connection for lymphoma is denied. Entitlement to service connection for chronic fatigue syndrome and chronic Epstein Barr Virus infection as secondary to the veteran's service-connected PTSD is granted. Service connection for peripheral neuropathy is denied. ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs