Citation Nr: 1318876 Decision Date: 06/10/13 Archive Date: 06/21/13 DOCKET NO. 10-06 913 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to service connection for Addison's disease. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). The Veteran served on active duty from June 1943 to February 1946. This matter initially came before the Board of Veterans' Appeals (Board) from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York which denied the Veteran's application to reopen the claim of entitlement to service connection for Addison's disease. After receiving new and material evidence within the appeal period, the RO continued this denial in July 2009. In the December 2009 statement of the case, the RO granted the application to reopen but denied the underlying claim, on the merits. In August 2011, the Veteran testified during a Travel Board hearing before a Veterans Law Judge; a transcript of that hearing is of record. When informed that the judge who conducted the hearing was no longer with the Board, the Veteran requested a new Travel Board hearing. In May 2012, the Board determined that reopening of the claim was warranted and remanded the reopened claim to the RO. In August 2012, the Veteran testified during a Travel Board hearing before the undersigned; a transcript of that hearing is of record. In April 2013, the Board remanded the claim to the RO, via the Appeals Management Center (AMC) for additional development, specifically, readjudication of the claim. As the readjudication was accomplished in the AMC's May 2013 supplemental statement of the case, the RO/AMC complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. Addison's disease did not manifest in service and is unrelated to service. 2. Addison's disease was not caused or aggravated by service-connected disease or injury. CONCLUSION OF LAW Addison's disease was not incurred in or aggravated by service, and it is not proximately due to, the result of, or aggravated by a service connected disorder. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VCAA The requirements of 38 U.S.C.A. §§ 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in an April 2005 letter of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The case was most recently readjudicated in May 2013. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. An opinion was obtained from a specialist pursuant to Veterans Health Administration Directive 2010-044, along with a clarifying addendum, as discussed below. There is no evidence that additional records have yet to be requested, or that additional examinations are in order. As noted in the Board's April 2013 remand, the Veteran wrote in a statement that he was "appealing your rejection until I receive the medical examination by a VA specialist as promised ... [(at) the August 2012 hearing]." The undersigned did not "promise" a medical examination, but, rather, asked whether the Veteran was willing to report to such examination if one were found necessary. See August 2012 Hearing Transcript, at 19. For the reasons stated below, the evidence including the above noted specialist opinion and addendum is sufficient to decide the claim and an additional VA examination is not in order. The Board will therefore proceed to the merits of the appeal. Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Veteran does not claim entitlement to service connection for disability due to a disease identified as chronic in the relevant statute and regulation; 38 C.F.R. § 3.303(b) is therefore inapplicable. In any event, the Veteran did not claim a continuity of symptomatology, as he testified that the first symptom he experienced was high blood pressure around 1957, more than ten years after service, and the evidence does not indicate otherwise. Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(b). This latter provision was added as part of an amendment intended conform VA regulations to Allen v. Brown, 7 Vet. App. 439 (1995), and also limited the circumstances in which VA would concede aggravation. See 71 Fed. Reg. 52,744 (Sept. 7, 2006) (codified at 38 C.F.R. § 3.310(b)). As the new regulation, which took effect on October 10, 2006, after the Veteran filed his February 2005 claim, is more restrictive, the former regulation is applicable. In any event, the Board will find below that there is no aggravation. The Veteran is currently service connected for bilateral hearing loss, psychoneurosis anxiety reaction, eczemoid dermatitis of the hands, feet, scalp, and face; tinnitus; hypertension; and malaria. In his written statements and Board hearing testimony, the Veteran has indicated that he was involved in a motor vehicle accident during service in which he injured his left ear, left sided ribs, left knee, and left kidney. Such accident is not referenced in the service treatment records, but the Veteran indicated that he did not receive treatment until months later because his unit had no medical personnel at his base camp. The Veteran is, however, competent to report his injury and his statements are supported by a March 1999 statement from a former Congressman who was a member of the Veteran's unit. In addition, the February 1946 separation examination report indicates that a kidney disorder began in July 1944, which is the time when the Veteran alleges the accident occurred, and the appellant was hospitalized in November 1945. The Board therefore finds the Veteran's testimony in this regard to be competent, credible, and consistent with the circumstances of his service. He has therefore met the in-service injury requirement. See 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a) (each disabling condition for which a veteran seeks service connection must be considered based on factors including the basis of places, types, and circumstances of service as shown by service record). As to whether the Veteran's Addison's disease is related to this in-service injury, there are multiple, conflicting medical opinions. As recounted by the Veteran, he began to experience high blood pressure around 1957, although his physicians were unable to identify the cause. Subsequently, a large growth around his left kidney, according to the Veteran on his left adrenal gland, was removed and he was diagnosed with hyperaldosteronism. The medical records show an April 1953 VA medical examination performed in connection with an application for hospital treatment or domiciliary care that revealed large glands. A June 1969 statement from Dr. Rothfeld indicated that the Veteran had previously undergone removal of a renal cyst. A December 1998 statement from Dr. Rosenburg noted a 1973 left renalcystectomy and a long history of hypokalemia, diagnosed as hyperaldosteronemia. A February 2002 VA hypertension examination report contains diagnoses of hypertension and Addison's disease. A February 2002 VA genitourinary examination report contains diagnoses of a history of renal trauma in the 1940s and a history of a left renal cyst. A February 2002 VA endocrine examination report noted a past medical history of left renal cyst resection in 1961 and a left suprarenal gland resection in 1986 for hyperaldosteronism with hypokalemia and hypertension. The VA examiner noted that the resection caused the Veteran's Addison's disease. In a June 2002 memorandum, the February 2002 VA examiner noted that, while the Veteran had previously testified that the cause of his hematuria was a kidney laceration, there was no indication of any complaint of hematuria or any reference to a kidney disease in the Veteran's service treatment records. He further noted that the only corroboration of the Veteran's alleged in-service motor vehicle accident was a letter from John Foley, as noted above. The VA examiner acknowledged, however, that a separation examination report, which he did not review, mentioned a kidney disorder and an abnormal urinalysis. Thus, he opined that the Veteran was, in fact, involved in a motor vehicle accident in 1944 and suffered a kidney contusion, but not a laceration, which would have led to immediate exsanguination. The VA examiner indicated that the contusion had manifested as flak and back pain, and hematuria. The VA examiner further opined that the Veteran's renal cysts were unrelated to his in-service kidney contusion because simple renal cysts are very common among the adult population. He also opined that the hyperaldosteronemia resulted from a hyperfunctioning suprarenal gland, and because it manifested over 40 years after the alleged trauma, it had no relationship to the in-service kidney trauma. With regard to the Veteran's Addison's disease, the VA examiner opined that whether or not this disability is related to the in-service kidney trauma depended on the side of the suprarenal gland resection. If the right suprarenal gland was the one resected, the subsequent development of Addison's disease would imply that the left gland was non-functioning, and the lack of function in the left gland would be as likely as not the result of his left flank trauma during service. If, however, it was the left suprarenal gland that was resected, then it would imply that the right one was non-functioning, which would indicate that the Addison's disease has no relationship to his in-service left-side trauma. The VA examiner indicated that he could not determine which suprarenal gland was resected in 1986. A February 2000 letter from Dr. Geiss to Dr. Klein indicated that the Veteran was evaluated for a laparoscopic left adrenalectomy. Medical treatment records show that, in February 2000, the Veteran underwent a laparoscopic left adrenalectomy for primary hyperaldosteronism. A September 2001 letter from Dr. Klein indicated that the Veteran was seen approximately 19 months following the removal of an aldosterone-producing adenoma. Based on his symptoms and laboratory studies, this physician believed it was possible to confirm a diagnosis of adrenal insufficiency. Dr. Klein opined that the Veteran would benefit from replacement therapy. A December 2003 VA endocrine examination report noted the Veteran's past medical history of a lacerated left kidney with a partial resection in 1963 and a left adrenal gland resection. It was also noted that there was a 1994 left adrenalectomy, but it is unclear whether this is the same operation as the left adrenal resection. The Veteran was diagnosed with, among others, status post left nephrectomy, 1963; Addison's disease; status post left adrenalectomy, 1994; colon cancer, status post partial colectomy; and hypertension, under treatment. This VA examiner, who was the same examiner as the one in February 2002, opined that the Veteran developed clinical Addison's disease after a left adrenalectomy in 1994, which meant that he had a non-functioning right adrenal gland at that time. This VA examiner indicated that a congenital lack of an adrenal gland is exceedingly rare. The possibility that the right - and to some extent, the left - adrenal gland was affected by his service-connected tuberculosis was likely. As this is a well-known complication of tuberculosis, it was this VA examiner's opinion that the Veteran had at least a non-functioning right adrenal gland, and when the left was resected, it was also involved with a tuberculosis process, and his Addison's disease became manifest and steroid-dependent. In a handwritten January 2004 note, however, the December 2003 VA examiner noted that his December 2003 opinion was incorrect as he had mistakenly believed at the time that the Veteran had tuberculosis that was service-connected, when the Veteran in fact does not have tuberculosis. Therefore, the December 2003 VA examiner indicated that the Veteran's hypo-adrenalism was not service-connected in any way. In October 2009, the Veteran's private physician, Dr. Rosenberg, submitted a letter indicating that the Veteran's hypokalemia may well have resulted from his in-service injury. Dr. Rosenberg indicated that he has been treating the Veteran since December 1985. He noted that the Veteran's in-service injuries included a left-sided concussion, fractured left-sided ribs with laceration of his left kidney, and presumably, damage to the adrenal gland. He also noted that, subsequent to discharge, contrast radiologic studies confirmed the presence of a giant renal cyst, prompting a left renal cystectomy, and this condition has required continued administration of potassium and Spironolactone. Dr. Rosenberg also noted that, at the time of surgery for colon cancer, a large tumor was found on the left adrenal gland, for which surgery was performed. Dr. Rosenberg indicated that it would appear that the initial event for this condition was the traumatic injury sustained in service. Given the above conflicting and somewhat unclear opinions, both with regard to the relationship between the Veteran's suprarenal gland resection and his Addison's disease, and the etiology of the Addison's disease, the Board found that a specialist opinion from an endocrinologist was required to resolve the issue of etiology with regard to the Veteran's kidney and adrenal gland disabilities, including kidney cysts, hypokalemia, hyperaldosteronism, and Addison's disease. The Board requested such an opinion pursuant to Veterans Health Administration Directive 2010-044 and one was provided in November 2011. The VA endocrinologist recounted the evidence of record, including the above medical opinions. The endocrinologist opined that "it is not at all likely that the Veteran's adrenal insufficiency is related to his service." Her reasons were as follows. First a diagnosis of tuberculosis was either never made or not thought to be related to service, and tuberculosis is one of the few medical conditions other than autoimmune disease, that causes adrenal insufficiency. Second, although left sided trauma caused by the motor vehicle accident could have damaged the left adrenal gland, it could not have caused an aldosterone producing tumor, which is the reason that the left adrenal gland was removed. Third, it is impossible to make a connection between the motor vehicle accident and adrenal insufficiency of Addison's disease because the Veteran's chart referenced adrenalectomies in 1986, 1994, and February 2000, and there are only two adrenal glands in the body. Fourth, when the Veteran was seen in a VA clinic in July 2006, his chart indicated diagnoses of both adrenal insufficiency and hypertension, but blood pressure was 140/80 and he was taking only 5 milligrams of prednisone. Moreover, the Veteran was not taking any Florinef. While 5 milligrams of prednisone may represent adequate glucocorticoid replacement for a man of the Veteran's weight and age, the fact that there are no references in his chart to abnormal potassium levels and that his blood pressure was high rather than low in the absence of any mineralocorticoid replacement argues against the diagnosis of Addison's disease altogether. The endocrinologist noted that Addison's disease is an autoimmune condition where there is total or near total loss of adrenal gland hormone production and, if the Veteran had post surgical adrenal insufficiency from having both adrenal glands removed, he would need Flourinef, at least in a low dose, to maintain normal potassium and blood pressure levels. The examiner also noted that there can be no rational connection between the motor vehicle accident and removal of the right adrenal gland because, if the Veteran were one of the exceedingly rare people born without a right adrenal gland, he could not have needed two or three surgical procedures to remove the remaining left adrenal gland. In November 2012, noting the Veteran's argument that portions of the November 2011 opinion were inadequate, in particular that he had not had his right adrenal gland removed and had not undergone three surgeries for adrenal gland removal. The Board noted that while the record contained multiple references to left adrenalectomies, the only report of record definitively documenting a left adrenalectomy was from February 2000. The Board asked the endocrinologist to provide a new opinion in which she assumed that the Veteran's right adrenal gland had not been removed and that he underwent a left adrenalectomy only in February 2000, with no prior adrenal gland surgeries. In January 2013, the endocrinologist responded, noting that she was provided a copy of the Veteran's comments and that she was to assume that he only had his left adrenal gland removed in 2000, that he had been treated by Dr. Klein for a high potassium level of 6.1 or 6.2 and this potassium level would be consistent with a diagnosis of adrenal insufficiency, and to assume that the Veteran's right adrenal gland had not been removed. The endocrinologist noted a 1949 VA examination that indicated that the Veteran's service-connected disabilities included a skin condition, nervous condition, malaria, and hemorrhoids. She also noted that a November 2012 cover letter to her indicated that the Veteran was hospitalized in November for a kidney disorder that began in July 1944, when the Veteran reported the motor vehicle accident had occurred. She also noted that the cover letter indicated that the Veteran underwent laparoscopic left adrenalectomy for primary hyperaldosteronism. The endocrinologist then opined that it was not at all likely that the reported 1944 motor vehicle accident caused any type of adrenal problem. She noted that this was because primary hyperaldosteronism results from a typically very small collection of adrenal gland cells that overproduce the hormone Aldosterone. High levels of this hormone cause hypertension that is very difficult to control and often cause very low potassium levels, which is the reason that the Veteran was treated with Spironolactone, that is , a medication that blocks the effects of Aldosterone, as well as potassium prior to the removal of the left adrenal gland in February of 2000. According to the endocrinologist, there was simply no logical explanation from a medical standpoint that would link trauma to the adrenal gland in 1944 (if sustained in the motor vehicle accident) to the development of an adrenal tumor that was removed over 50 years later. In addition, the removal of one adrenal gland does not cause post surgical Addison's disease or adrenal insufficiency. If the left gland were removed and the Veteran truly developed adrenal insufficiency thereafter, this would mean that the Veteran's right adrenal gland was somehow defective. The examiner opined that there was no way to connect a right adrenal gland problem to an accident that caused only left sided damage to the Veteran's body. The endocrinologist noted the small (less than 50 percent) possibility that the motor vehicle accident could have caused or worsened hypertension if the left renal artery was injured in the accident. If scarring occurred in the renal artery over the next several months after the accident, this could directly cause renovascular hypertension. Because, however, hypertension due to renal artery stenosis would present itself fairly soon after the accident, and hypertension was not noted on the separation examination report or in the 1949 VA examination report, hypertension due to the motor vehicle accident was unlikely, even though hypertension has been found to be service connected. As to whether the kidney or adrenal gland disorders were aggravated by in-service kidney trauma or service connected disorders including hypertension, the endocrinologist found that kidney or adrenal trauma in 1944 could not have led to the development of a left sided adrenal tumor 55 years later because a damaged kidney is not able to effect an adrenal gland. If he truly had his left kidney removed in 1963, as indicated in the letter to her, then there was no link between trauma in 1944 to surgery needed 19 years later. Noting that she was not a nephrologist, the endocrinologist stated that, clearly, if the Veteran had only one kidney and hypertension, he would be at higher risk of chronic kidney disease, but no mention of such is made in the chart. Finally, the endocrinologist noted that the removal of a kidney due to trauma could aggravate a kidney disorder, but healthy people donate kidneys every day and still have normal kidney function and a normal lifespan. She could not think of any way that hypertension would aggravate an adrenal problem. She noted that, multiple adrenal problems can cause or worsen hypertension, but the reverse is not true to the best of her knowledge. Based on the above, the Board finds that the evidence weighs against the claim. The probative value of a medical opinion primarily comes from its reasoning; threshold considerations whether the person opining is suitably qualified and sufficiently informed. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the most thoroughly reasoned opinion is that of the VA endocrinologist, who also had the most relevant expertise. She explained her reasons based an accurate characterization of the evidence of record and modified her opinion when given factual corrections noted by the Veteran in his response to the opinion. She considered the nature of the in-service accident and the medical evidence of the disease processes experienced by the Veteran since service in concluding that the current disability was neither caused by the in-service kidney trauma nor aggravated by the service connected diseases of hypertension and/or malaria. The February 2002 VA examiner noted that the 1986 resection caused the Addison's disease, and that the Veteran suffered a kidney contusion in the in-service accident, but found the cysts unrelated because of their common nature and the hyperaldosteronism to be unrelated to the kidney contusion because of its manifestation over 40 years later. He did not offer an opinion as to whether Addison's disease was related to in-service kidney trauma because he could not determine which suprarenal gland was resected in 1986 and his opinion therefore provides neither positive nor negative support for service connection. See Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009) ( "The examiner's statement, which recites the inability to come to an opinion, provides neither positive nor negative support for service connection"). Moreover, although the December 2003 VA examiner initially concluded there was a relationship between Addison's disease and the Veteran's tuberculosis, he changed his opinion after realizing that the appellant did not have tuberculosis, and concluded hypo-adrenalism was not service-connected in any way. The only remaining opinion is that of Dr. Rosenberg. His opinion that the Veteran's hypokalemia may well have resulted from the in-service injury is entitled to some probative weight, as he explained the reasons for his conclusion. His reasoning, however, was not as thorough as that of the VA endocrinologist. He noted the in-service injury and presumed damage to the adrenal gland, but did not give a reason for this presumption. He also noted the post service renal cyst and left adrenal tumor, positing that the initial event appeared to be the traumatic injury in service but without explaining why he came to this conclusion. Based on the above, the Board concludes that the preponderance of the most probative medical evidence weighs against the claim. The only remaining opinion is that of the Veteran. Lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). As shown above, the medical issues in this case are complex, and the Veteran's testimony as to the development of Addison's disease and related kidney and/or adrenal gland disorders after service and possible relationship to service is testimony as to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). The Veteran's testimony in this regard is not competent and, to the extent that it is, the Board finds that the probative value of the specific, thoroughly reasoned opinion of the VA endocrinologist is of greater value than the Veteran's more general lay assertions, even when combined with Dr. Rosenberg's opinion. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for Addison's disease. The benefit-of-the-doubt doctrine is therefore not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Fagan, 573 F.3d at 1287 (Fed. Cir. 2009). ORDER Entitlement to service connection for Addison's disease is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs