Citation Nr: 1320448 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 09-21 414 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to service connection for post-operative constrictive pericarditis, claimed as a heart condition due to histoplasmosis. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran had active service from September 1954 to September 1957. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision by the Regional Office (RO) that denied the Veteran's request to reopen the previously denied claim of entitlement to service connection for pericarditis constrictive, post-operative residuals, claimed as a heart condition due to histoplasmosis. In February 2012, the Board granted the Veteran's claim to reopen and remanded the service connection issue, on the merits, for further development. In January 2013, the Board sought a medical opinion from the Veterans Health Administration (VHA). 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). FINDINGS OF FACT The most probative evidence supports a finding that the Veteran's current heart condition, resulting from post operative constrictive pericarditis, is due to histoplasmosis, which was contracted during service. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for heart disability due to post-operative constrictive pericarditis and histoplasmosis have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In light of the favorable disposition of the claim herein decided, the Board finds that a discussion as to whether VA duties pursuant to the Veterans Claims Assistance Act of 2000 have been satisfied is not required. The Board finds that no further notification or assistance is necessary, and that deciding the appeal at this time is not prejudicial to the Veteran. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a Veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and heart disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). The Board has reviewed all the evidence in the appellant's claims file and electronic Virtual VA file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran asserts that his current heart disability, resulting from post operative constrictive pericarditis, is due to histoplasmosis which he contracted during the performance of his duties in service while stationed in Virginia. Specifically, he claims he contracted histoplasmosis prior to discharge from service when he came in contact with bird droppings. Reportedly, within days of service discharge he developed flu-like symptoms. The Veteran asserts that these symptoms were a manifestation of histoplasma infection. Due to histoplasmosis, he developed constrictive pericarditis which caused his current heart disability. After a careful review of the claims folder, the Board finds that the pertinent evidence of record indicates that it is at least as likely as not that the Veteran's current heart condition, resulting from post operative constrictive pericarditis, is due to histoplasmosis contracted during service. Service treatment records are negative for diagnosis or treatment for histoplasmosis. There is one in-service complaint of chest pain in December 1954 described as pain in the heart after marching, with no findings and no further complaint or treatment during the remainder of service. The Veteran's separation examination in July 1957 was normal, including the chest x-ray, but he did not leave service until September 7, 1957. In statements and at a personal hearing in March 1988 the Veteran has consistently maintained that he became sick with flu-like symptoms immediately after leaving service. He stated that he was discharged on a Saturday and was ill when starting his new job the following Monday. He testified that he believed he had a common cold and upon seeking treatment he was told at the time that he had the Asiatic flu. Additionally, in witness statements in February 2012, the Veteran's spouse and sister reported that after the Veteran was discharged from service he was sick for approximately 3 weeks with a high fever. June 1966 private treatment notes show treatment for constrictive pericarditis, with a history of calcifications being noted 4 years earlier. It was noted that there was no history of tuberculosis. It was stated that the Veteran served his army time in Virginia and that "[t]he possibility of coccidiomyocis, histoplasmosis or blastomycosis is the etiological agent is considered." The final diagnosis was "calcific constrictive pericarditis-probably due to histoplasmosis." Chest x-rays in July 1981 revealed findings which a clinician noted were consistent with an old inflammatory disease. In January 2008, Dr. S.D.S., the Veteran's private physician, reviewed the Veteran's treatment records from 1966 and noted that at the time the Veteran underwent pericardectomy for an illness that started in 1957. Dr. S.D.S. indicated that a review of the data showed that pericardial effusion and calcified lymphadenpathy were attributed to histoplasmosis. In a subsequent statement in March 2008, Dr. S.D.S. stated that it appeared the Veteran must have been exposed to histoplasmosis when he got sick in 1957 before being discharged from service. Histoplasmosis could cause progressive scarring resulting in constrictive pericarditis as diagnosed in 1966. Dr. S.D.S. indicated that recent CT scans of the chest supported this conclusion. In an April 2008 report, Dr. D.T.A., the Veteran's infectious disease physician, noted the Veteran's report of becoming very ill after working in an area where there was a great deal of bird droppings prior to discharge from service. He stated that he became sick following service discharge in 1957, and spent 3 weeks with a cold and chest discomfort. Reportedly, at that time he was told he had the flu. However, over the years the Veteran's symptoms, to include shortness of breath, increased. In 1961 it was determined that the Veteran had calcifications throughout his heart and was diagnosed with constrictive pericarditis. He also had tested positive for histoplasmosis. Dr. D.T.A. determined that the Veteran's constrictive pericarditis was most likely due to an infectious agent and most likely due to histoplasmosis to which the Veteran was exposed while he was in service. In June 2008 Dr. J.S.S. reported that the Veteran had been under treatment for atrial fibrillation for several years. Dr. J.S.S. noted a history of constrictive pericarditis, status post-stripping in the 1960's, which the Veteran's pulmonologist and infectious disease specialist felt was related to histoplasmosis acquired in the 1950's during service. Dr. J.S.S. opined that Veteran's pericardial calcifications had played a role in triggering and complicating the Veteran's atrial arrhythmias. The Veteran underwent a VA examination in March 2012. He reported having a cold upon being discharged from service followed by the flu. He was sick for a month. The examiner noted that in 1966 the Veteran had undergone pericardiectomy for calcific constrictive pericarditis due to histoplasmosis, which the Veteran reportedly contracted in service. The VA examiner confirmed that the Veteran now had, or has a history of, myocardial infarction (2002), coronary artery disease (diagnosed in 2002), congestive heart failure (CHF) (diagnosed in 2002), supraventricular arrhythmia (diagnosed in 2001), ventricular arrhythmia (diagnosed in 2010), implanted cardiac pacemaker and automatic implantable cardioverter defibrillator (2010), infectious heart condition - pericarditis (1966), and pericardial adhesions (1966). The examiner also confirmed that the Veteran still had residual calcified constrictive pericarditis. The examiner went on to state that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The basis for this opinion was that the in-service complaint was a single episode in December 1954 and the examination at that time was negative. The examiner also noted that there were no other findings of chest pain during military service and the Veteran was able to fulfill his duties from 1954 to 1957 without other documented complaints of chest pain. As to the specific questions asked by the Board, the examiner provided a lengthy explanation, but failed to fully address the Board's questions. First, the examiner indeed opined that it was at least as likely as not that the current heart disabilities were due to histoplasmosis. The reasoning for this was that the Veteran had congestive heart failure, atrial fibrillation and coronary artery disease that were secondary to the post-operative constrictive pericarditis. The chronic congestive heart failure, according to the examiner, was caused by calcified constrictive pericarditis, due to alteration of the cardiac volume and contractility of the myocardium. This, according to the examiner, was the only logical explanation for the development of congestive heart failure at age 28. Atrial fibrillation was noted as caused by the scarring and calcification of the pericardium, with penetration of the plaques at atria and ventricles, which was documented on the May 26, 1966, operative report. And, coronary artery disease was caused by the extensive and gradual fibrosis of the surface of the coronary arteries after the pericardiectomy and due to the healing process of the myocardial surface. Finally, the examiner explained that histoplasmosis was not infrequent in the 1960's, and that the most common cause of calcified constrictive pericarditis in the 1960's was tuberculosis, but that another causative agent was histoplasmosis. The surgeon who operated on the Veteran in 1966 diagnosed histoplasmosis as the cause of the Veteran's calcified constrictive pericarditis in the operative note, and did not mention tuberculosis as a factor. The examiner determined that there was no reason to dispute the credible conclusion of the surgeon as to the likely diagnosis, and that "the private cardiologist and infectious disease specialist concur with this conclusion." The examiner, however, did not address the likelihood that the Veteran contracted histoplasmosis in service. As such, the Board sought an expert opinion from the VHA in January 2013. Significantly, on the question of medical causation the competent medical evidence supports the Veteran's claim. In an opinion in February 2013, the reviewing VHA physician opined that most likely the Veteran contracted histoplasmosis during active duty. Histoplasmosis had been documented in the western part of Virginia, where the Veteran had been stationed prior to service discharge. Histoplasma infection, when symptomatic, usually manifested as mild influenza-like symptoms, and had an incubation period of 7 to 21 days with most individuals exhibiting symptoms after 14 days. The VHA physician explained that the Veteran's description of "flu-like" symptoms immediately following discharge from service may have actually been a manifestation of the histoplasmosis infection. The Veteran's report of cleaning bird droppings approximately 14 days prior to the onset of an influenza-like illness that had a protracted course for several weeks was consistent the incubation period for pulmonary histoplasmosis. It was further noted that the Veteran reported ongoing respiratory symptoms following service discharge leading up to treatment in 1966. A significant fungal exposure could have lead to a more severe and prolonged acute infection productive of marked inflammation of the mediastinum and pericardium resulting in the calcific pericarditis as seen during surgery 9 years after discharge from service. The VHA physician noted that while a lot of information was circumstantial given the lack of confirmatory pathological and serological data, the most likely scenario was consistent with the Veteran contracting acute histoplasmosis infection during the last few weeks of active duty service. Accordingly, the VHA physician's opinion supports the Veteran's claim for service connection for a heart condition due to histoplasmosis. The February 2013 VHA physician's opinion is of great probative value. The opinion was rendered after a review of the claims file, to include the service treatment records, VA medical opinions, and post-service private treatment records, and contained a detailed analysis of the evidence of record and medical principles. The opinion is also consistent with the evidence of record and a rationale in support of the opinion was provided. Moreover, it is consistent with the medical opinion of the Veteran's private treating physicians, to include his pulmonologist and infectious disease expert. Significantly, there is no competent evidence that contradicts the opinion of the VHA physician's opinion report. For the foregoing reasons, entitlement to service connection for a heart condition due to histoplasmosis is warranted. 38 C.F.R. § 3.303(d). In sum, the medical evidence shows that the Veteran is currently diagnosed with a heart disability that has been etiologically related to an infectious disease, histoplasmosis. An histoplasma infection is manifested by flu-like symptoms and has an incubation period of 7 to 21. Further, the Board finds the Veteran competent and credible to report that he experienced flu-like symptoms immediately following discharge from service as those symptoms are capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Significantly, the competent medical evidence supports his assertion that he contracted histoplasmosis prior to service discharge. Based on the foregoing, the Board finds that the evidence supports the Veteran's claim for service connection for pericarditis constrictive, post-operative residuals, claimed as a heart condition due to histoplasmosis. As the competent medical evidence of record etiologically links the Veteran's disability to service, the Board finds that the evidence is at least in equipoise such that reasonable doubt may be resolved in favor of the Veteran, and service connection for post-operative constrictive pericarditis, claimed as a heart condition due to histoplasmosis, is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for heart disability due to post-operative constrictive pericarditis and histoplasmosis is granted. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs