Citation Nr: 1608300 Decision Date: 03/01/16 Archive Date: 03/09/16 DOCKET NO. 05-07 048 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUE Entitlement to service connection for Still's disease. REPRESENTATION Veteran represented by: Walter C. Spiegel, Attorney ATTORNEY FOR THE BOARD M. Scott Walker, Counsel INTRODUCTION The Veteran served on active duty from February 1997 to January 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire. The appeal was remanded by the Board for further development in May 2007. FINDING OF FACT The evidence of record is in relative equipoise as to whether Still's disease had its initial onset during the Veteran's period of active service. CONCLUSION OF LAW Still's disease was incurred during active service. 38 U.S.C.A. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran claims that he is entitled to service connection for Still's disease, juvenile onset rheumatoid arthritis, because he feels that certain symptoms he experienced during active duty were actually an early manifestation of this condition. Specifically, the Veteran contends that in-service episodes of anemia, fevers, rashes, and joint pain represented the initial manifestations of his claimed disorder. To that end, the U.S. Court of Appeal for Veterans Claims (Court) held that, in order to prevail on the issue of service connection on the merits, there must be medical evidence of (1) a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See generally Hickson v. West, 12 Vet. App. 247, 253 (1999). Turning to the evidence of record, the Veteran has a current diagnosis of Still's disease which was originally diagnosed in April 2003 (less than 1.5 years following separation from active duty). While the Veteran's service treatment reports were, of course, silent for such a diagnosis, he reported on several occasions with joint pain, fever, rashes, sore throat, and fatigue. The RO, in its denial, noted that his various joint complaints were the result of acute injuries, that his rash was diagnosed as dermatitis and tinea corpus, and that he was treated for varicose veins. As noted by the Veteran's private provider, discussed in detail below, the Veteran's in-service fevers and myalgias were associated with gastrointestinal symptoms and an elevated white cell count in January 1998 and May 2001. In February 1997, the Veteran reported with "burning" feet. In March 1997, he was seen for an itching rash on the back of his hands. In March 1999, x-ray evidence revealed degenerative changes of the first metatarsophalangeal joint. Post-service, a VA medical opinion dated in January 2004 stated that service treatment records do not indicate that the Veteran experienced inflammatory joint disease, such as Still's disease, while serving in the military. The VA examiner discussed the symptoms that the Veteran experienced in service, but he neither provided a concise opinion nor drew any conclusion regarding the likelihood that the Veteran's current diagnosis of Still's disease was related to his military service. Subsequently, the Veteran submitted a March 2004 letter from a private physician which stated that adult onset Still's disease is a difficult diagnosis to make, as it is often a diagnosis of exclusion. In the Veteran's case, consults from infectious disease, hematology, dermatology, and gastroenterology were required before a diagnosis was finally made. She opined that the Veteran's episodes of rashes and myalgias during his military service "may have been connected with this diagnosis." A statement from the Veteran's VA provider, authored in October 2007, indicated that Still's disease is characterized by fevers, rashes, and eventually joint pain (which was often absent in the early stages). While in the service, the Veteran presented with unexplained anemia, fevers, a rash, and some joint pain. The VA provider opined that it was likely that such in-service manifestations represented the onset of Still's disease. He added that, while the rash was clinically-diagnosed as tinea, it did not respond to therapy. Although not diagnosed at the time, the VA provider noted that it was likely not even considered in the differential diagnosis due to the rare incidence of the condition. In August 2008, the VA examiner who provided the January 2004 examination, which essentially resulted in a non-opinion, authored a supplemental statement in response to the Veteran's private physician. It was noted that the Veteran's rashes had been established as tinea, and that myalgias while in service are not uncommon in military personnel. The examiner also referenced an April 2003 medical report in which the Veteran presented with a rash on his ankles, legs, and hands, at which time he noted pain in those areas and denied a similar rash in the past. The examiner stated that "the opinion I provided in my January 8, 2004 report continues to be my present opinion, based on available medical facts as presented in the medical records. I do not speculate in one direction or another concerning this opinion." An additional private report, authored by a physician with an extensive military background, found that the Veteran's Still's diagnosis was more likely than not related to his period of service. In support, the physician pointed out that the Veteran experienced a number of medical problems during his period of active service, and that these manifestations represented the early symptoms of Still's disease. Such early signs may include arthralgias, sore throat, fatigue, fever, arthritic signs, rash, and elevated white cell count. As discussed briefly above, the physician noted in-service reports of fevers and myalgias, often associated with gastrointestinal symptoms and elevated white cell counts, in January 1998 and May 2001. The Veteran's rash and joint pains during his period of service were noted, as was the Veteran's varicose veins which required surgical intervention. The physician indicated that pain symptoms reported during a VA/QTC examination from November 2001 were clearly arthritic in nature and unrelated to popliteal varicosities. This led the examiner to conclude that these complaints were an early prelude to the full onset of Still's disease (as were complaints of left shoulder arthralgias of three months duration with positive physical findings). Because Still's can present initially with a mono-arthralgia or a partial syndrome or symptoms complex, it was clear to the physician that these symptoms, which the Veteran suffered from during active duty, represented the onset of his claimed disorder. It was further noted that this diagnosis could not have been made at the time, as more time was required for the development of the clinical picture of this particular disease. In September and October 2015, the VA examiner of record produced two more documents. The former noted discrepancies in the private opinions supporting the Veteran's claim, notably that the Veteran's shoulder complaints were deemed to be non-inflammatory, and that right knee pain was linked to varicose veins. He then stated that the interpretation of symptomatology at the time that symptoms are revealed is more apt to be fundamentally correct than its interpretation years later when the symptoms have been given a whole new meaning. The Board notes, however, that the most recent private opinion indicated that such a diagnosis required a long timeframe to come to fruition, as such a disorder could not have been diagnosed at the time of initial onset. The VA examiner did not actually refute to this assertion, and he even conceded that such was within the realm of speculation. In his October 2015 statement, the VA examiner stated that speculation becomes a very plausible conclusion regarding etiology, and that such an assumption was highly-speculative with a non-traumatic onset and a medical condition that is unrelated very much to all aspects of military life. In the final analysis, he was unable to state without resorting to mere speculation as to whether it was at least as likely as not that the Veteran's disorder was etiologically-related to his period of service. As such, after four separate analyses, the VA examiner had yet to provide a negative opinion in this case (or an opinion at all). Taking all reports into account, the Board finds that the evidence in this case is at least so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. As the evidence here is, at worst, in relative equipoise, meaning that the evidence for and against the Veteran's claim is essentially equal, entitlement to service connection for Still's disease is granted. In light of this result, a detailed discussion of VA's various duties to notify and assist is unnecessary (because any potential failure of VA in fulfilling these duties is harmless error). ORDER Service connection for Still's disease is granted. ____________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs