Citation Nr: 1539118 Decision Date: 09/14/15 Archive Date: 09/24/15 DOCKET NO. 12-05 645 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for scleroderma, to include as due to exposure to contaminated water at Camp Lejeune, North Carolina. 2. Entitlement to service connection for rheumatoid arthritis, to include as secondary to scleroderma. 3. Entitlement to service connection for gastroesophageal reflux disease (GERD) with Barrett's esophagus, to include as secondary to scleroderma. 4. Entitlement to service connection for small vessel vasculitis, to include as secondary to scleroderma. 5. Entitlement to service connection for Raynaud's syndrome, bilateral upper and lower extremities, to include as secondary to scleroderma. REPRESENTATION Veteran represented by: Angela K. Drake, Attorney ATTORNEY FOR THE BOARD M. C. Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1974 to December 1976 and May 1981 to May 1984, which included service at Camp Lejeune, North Carolina (Camp Lejeune). These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision that was issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction over these claims has since been transferred to the RO in Louisville, Kentucky. In April 2015, the Veteran withdrew his request to testify at a hearing before a Veterans Law Judge. In light of the evidence, the Board has recharacterized the Veteran's claim of service connection for Barrett's syndrome as a claim of service connection for gastroesophageal reflux disease (GERD) with Barrett's esophagus, as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). In June 2015 written argument, the Veteran's asserted entitlement to a total rating due to individual unemployability. This issue is referred to the RO for appropriate action. FINDINGS OF FACT 1. Resolving all doubt in favor of the Veteran, he currently suffers from scleroderma due to his military service. 2. The Veteran developed rheumatoid arthritis secondary to scleroderma. 3. The Veteran's GERD had onset during service and this condition was subsequently aggravated by his scleroderma. 4. The Veteran developed small vessel vasculitis secondary to scleroderma. 5. The Veteran developed Raynaud's syndrome, bilateral upper and lower extremities, secondary to scleroderma. CONCLUSIONS OF LAW 1. The criteria for service connection for scleroderma have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 1710, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 17.400 (2015). 2. The criteria for service connection for rheumatoid arthritis have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 3. The criteria for service connection for gastroesophageal reflux disease with Barrett's esophagus have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 4. The criteria for service connection for small vessel vasculitis have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). 5. The criteria for service connection for Raynaud's syndrome, bilateral upper and lower extremities, have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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). In addition, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected and compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability. 38 C.F.R. § 3.310 (2015); Allen v. Brown, 7 Vet. App. 439 (1995). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a) (West 2014); 38 C.F.R. § 3.303(a) (2015). The Veteran was diagnosed with scleroderma (systemic sclerosis) in 2000, which he contends is due to exposure to contaminated water at Camp Lejeune. His service personnel records confirm that he was stationed at Camp Lejeune from May 1981 to August 1981 and from April 1982 until at least August 1982. Thus, since he served on active duty for more than 30 consecutive days at Camp Lejeune between 1957 and 1987, he is presumed to have been exposed to contaminated drinking water. See 38 U.S.C.A. § 1710(e) (West 2014); 38 C.F.R. § 17.400 (2015). Service treatment records do not show complaints, diagnosis or treatment for scleroderma or another autoimmune disorder during service. There is no other record of the Veteran being diagnosed with or treated for scleroderma for many years thereafter, and the Veteran does not contend otherwise. VA has acknowledged that there was contamination of the ground water at Camp Lejeune from 1957-1987. Specifically, two on-base water-supply systems were contaminated with the volatile organic compounds (VOCs) trichloroethylene (TCE), and perchloroethylene (PCE). See VBA Training Letter 11-03 (November 2011). These water systems served housing, administrative, and recreational facilities, as well as the base hospital. In its 2009 report, "Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects," the National Academy of Sciences' (NAS) National Research Council (NRC) provided an assessment of the potential association between certain diseases and exposure to the chemical contaminants. This report indicates that there is "limited/suggestive evidence of an association" with contaminants found in the water at Camp Lejeune and scleroderma. See Training Letter 11-03, Appendix B. "NRC uses the category 'limited/suggestive evidence of an association' when the evidence is 'limited by the inability to rule out chance and bias, including confounding, with confidence' . . . ." Id. While scleroderma is not presumptively associated with service at Camp Lejeune, manifestation of this disease is considered to be sufficient to conduct a VA medical examination and request an opinion regarding its relationship to Camp Lejeune service. In an October 2009 statement, non-VA rheumatologist Dr. A.A. reported that the Veteran has progressive systemic sclerosis that is manifested by sclerodactyly, Raynaud's, arthritis and arthralgia, and small vessel vasculitis, and includes gastrointestinal complications with reflux esophagitis. Dr. A.A. reported that the Veteran has a history of Barrett's esophagus. This rheumatologist documented the Veteran's report of contaminated water at Camp Lejeune and indicated that the Veteran's systemic sclerosis/scleroderma could be related to service. In November 2009, a VA examiner opined that the Veteran's scleroderma has caused rheumatoid arthritis, small vessel vasculitis, GERD/Barrett's esophagus, and Raynaud's phenomenon. Notably, the November 2009 examiner also reported that the Veteran's GERD started with reflux in service, but has been made worse with scleroderma. This observation is corroborated by the Veteran's service treatment records, which include December 1982 notes that document the Veteran's report of a long history of abdominal upset, heart burn, and stomach problems for a year. In April 2010, VA obtained another medical opinion from the physician who conducted the Veteran's November 2009 examination. This physician reiterated that a study showed that there is limited/suggestive evidence of an association or causal relationship between TCE, PCE, or solvent mixtures and scleroderma, and there was no outcome found to be of sufficient evidence for an association or causal relationship. The physician reported that it could not be determined, with any reliability, whether diseases and disorders experienced by former residents and workers at Camp Lejeune were associated with their exposure to contaminants in the water supply. The physician reported that "[i]t seems clear that [the Veteran] was exposed to TCE/PCE albeit at levels below those usually seen in work environments," but noted that she could not provide an opinion as to whether the Veteran's scleroderma was directly caused by his exposure to toxins in the water supply at Camp Lejeune without resorting to mere speculation. In a statement that was received in April 2010, non-VA rheumatologist Dr. R.A., who has treated the Veteran since August 1999 and diagnosed the Veteran with scleroderma in April 2000, reported that he has obtained information from the Veteran regarding risk factors for scleroderma, including genetics and exposures. In July 2010, Dr. R.A. concluded that the Veteran has no other known risk factors to precipitate scleroderma except for his exposure to contaminated water at Camp Lejeune. Dr. R.A. opined that, based on his personal experience and medical literature, it is more likely than not that the Veteran's exposure to contaminated water at Camp Lejeune caused him to develop scleroderma. Dr. R.A. supported his opinion with statistical data and citations to various studies. In December 2011 and September 2012, a VA clinician opined that the Veteran's scleroderma is less likely than not proximately due to or the result of his service. This clinician supported her position by noting that the Veteran's scleroderma is idiopathic in nature and there is no definitive scientific literature stating that drinking contaminated water subsequently results in scleroderma. In March 2014, VA obtained an opinion from a "Camp Lejeune Contaminated Water Project" subject matter expert who noted that the etiology of scleroderma is unknown, but exposure to environmental triggers, including viruses or certain toxins, may lead to variable disease expression in genetically susceptible hosts. Nevertheless, this physician opined that it was less likely than not that the Veteran's scleroderma was caused by or the result of exposure to contaminated water. The physician reported that exposure from drinking water is very different than being exposed to contaminated water in occupational, industrial settings, and workers generally have exposure over many years, which is not the case for the Veteran. Workers in industrial settings are considered to be exposed to higher levels of toxins than people who drink contaminated water and, nonetheless, a causal relationship between working with these chemicals and scleroderma has not been established. Thereafter, in September 2014, VA implemented 38 C.F.R. § 17.400, which provides that VA will "assume" that certain enumerated diseases of Camp Lejeune veterans "are attributable to the veteran's active duty . . . unless it is clinically determined . . . that such an illness or condition is not attributable to the veteran's service." 38 C.F.R. § 17.400(c). The list of enumerated diseases under this regulation includes scleroderma. See 38 C.F.R. § 17.400(d)(1)(xiii). Although this regulation's scope is limited to determining whether Camp Lejeune veterans are entitled to hospital care and medical services for enumerated diseases such as scleroderma, the Board finds VA's recognition of scleroderma as an illness that is attributable to service at Camp Lejeune highly probative with regard to the Veteran's present claim for service connection. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) ("the Board retains discretion to make credibility determinations and otherwise weigh the evidence submitted"). In March 2015, the Veteran submitted a medical opinion from non-VA rheumatologist Dr. R.S. who, after review of the Veteran's medical records, reported that the Veteran has the following manifestations of scleroderma: Raynaud's phenomenon, digital tip ulcers, sclerodactyly, telangiectasias, arthritis, myositis, esophagitis, trigeminal neuralgia, interstitial lung disease, and positive ANA with anti-Scl70 auto-antibodies. Additionally, Dr. R.S. stated the following: "With regard to solvent exposure and the risk of scleroderma, there is extensive medical literature to support such an association. Our group reported a large case-control series showing that occupational exposure to solvents (TCE, TCA, benzene, etc.) was associated with a statistically significant higher risk of scleroderma. This association with solvent exposure was strongest in men and in patients with the anti-Scl70 auto-antibody, as in the case of [the Veteran] . . . . Subsequent case-control studies have generally confirmed our observations on solvent exposure and risk of scleroderma." Dr. R.S. reported that the cumulative exposure to organic solvents in the water at Camp Lejeune is associated with an increased risk of the development of scleroderma. He concluded that, in the absence of other known risk factors, the Veteran's exposure to organic solvents at Camp Lejeune was as likely as not the cause of his scleroderma. In light of the foregoing, the Board finds that the evidence stands in equipoise concerning whether the Veteran's scleroderma may be attributed to his active service and, resolving any doubt in the Veteran's favor, finds that service connection for scleroderma is warranted. Consequently, the benefit sought on appeal is granted. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). Additionally, the Board finds that service connection is also warranted for rheumatoid arthritis, small vessel vasculitis, and Raynaud's syndrome secondary to the Veteran's service-connected scleroderma. As the November 2009 examiner indicated that the Veteran's GERD was shown during service and subsequently aggravated by scleroderma, the Board finds that service connection is warranted for GERD with Barrett's esophagus as well. ORDER Service connection for scleroderma is granted. Service connection for rheumatoid arthritis is granted. Service connection for gastroesophageal reflux disease with Barrett's esophagus is granted. Service connection for small vessel vasculitis is granted. Service connection for Raynaud's syndrome, bilateral upper and lower extremities, is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs